hysical

FIFTH

EDITION

eha biIitation

'11'<111 B. (1',,,111\.111. PT. 1 liD Proh........ lIf .3nJ Ch,ur Departl11l'nt I PI 'Ilall her,,!, St:hl\(lll,j

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F. A. DAVI~ COMPANY. PhiladelphIa

Preface \Vith rhe fifth edllion 01 Phnical Rl,JllIhiliralwfl. we continue 3 traditIon 01' ,tri\ ing for excellence that began more lhan 20 ) eaT'. ago. \Ve are gratified b~ the cOllllOumg \\ Ide acceptance of Phy.\lcul RdwhililUfl011 b~ both faculty and

,rudenl", prO\lde a cOl11prehen~i\'e approach patient.... A ... ~uch. II ., Inlended lO ,ene •.1'- J primal") textbook for prole ...The

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de ... 'gned

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rehJtnht~l(IOl1l11anagemen( of adult

'Iclnal-le\el rh~"'lcallherJr~ ..Iudenl'.. Jnd a.. an imporlam re ..ource lor pral.:tiung therapl'" a... \\ell a... for other rehat'lJlllatlon prole"lonal,. Thl' flflh edition recognize ... the

continuing gn.1\\ 111 III the profe...... lOn and integrate" ha'lc and applied ..:hnKJI re carch to gUIde and mforrn t.'\'idenceba.. ed clinical practl\.:e. Ii abo IIltegrate... tenninolog)_ prac-

lice pattern,. ,pc=clfll.. k' "and mea,ure". and mten enlion... pre...enled III the Amaican Ph~ ...a:al Theri.tp: A"Nx.:I,lIion ... GIi1Jt 10 Phn/c (/ TI rap/\! P, /1 ticc Ph.\ \/c 111 Rc 11<1lu II .!/(II/ I i;lrganizeu lOl.) four v'llon ... SecTJon One ,Ch,lpl"r J Pfnl\!I? ....111 r,t,.)dU 'l1nn !O pallent Lare and lIh lude.. rll.l.rt':r~ nn 1..·!iTll\.. ..l1 de I' .... TllaJ..ing. P"'.~LhtNX'Ii.ll fJllnr, m.l \..1.,1 e.... ';cdlm TI,'.(1 ~Cll,~rl -1-1 ~ I f.t. Applu.:atloll ot mpt',niJl1I (IIntepl I promoted through l
thai wmmarize and critically appraise research focu\ed on a particular topic or intervention relevant to the chapter content. OUf hope is that the boxes may provide a model for readers to continue to critically examine clinical practice using validated clinical methodologies. We also hope il wi II inspire enthusiasm about the imponance of continuou\. lifelong self-directed learning. without which practice may become rapidly and dangerously out·of-date. The visual illustrations have been substantially enhanced ...... Ith the addition of many new line drawings and photograph.... Changes in design and the introduction of a twocolor fonnal provide a more reader-friendly environmem as \~ ell a... augment understanding of content. \Vilhou{ question. our greatest asset in preparing the 5th echuon of PhySical Rehabilitation has been an outstanding group of contributing authors. We are most fortunate [Q hm e th" group of talented individuals whose breadth and .l·ope of profes,ional "'nowledge and experience seems llnparillleled. These individuals are recognized experts f om d \anety of ~pecially areas who have graciously : .·:eL! their "-nO\\ ledge and clinical practice expertise by Jl '" pIIng relevant. up-to-date. and practical information :thin the-Ir respective content areas. Ihe Illth edition has also benefited from the input of il'llTIr:fOlh indiViduals engaged in both academic and c1ini· \ d rractlct' ...ettmgs who have used and reviewed the conlent \\l: arc grateful for their consrructive feedback and h~\'e m~{itu(ed many of their suggestions and changes. As .1I . . . a)\\. \\e welcome sugge~tions for improvements from l)Ur colleagues and ":>tudenls. \ ... ph) \ical therapists continue to tale on more and g.re it a pt:rpetual "\\orl in progre:>s:' \Ve are gratetul for the opportunlt) to contnbute 10 the acaJemiL' literature III ph) ...ical therap) as \\ell a... to the profes"tmal development of tho"le prepanng to enter a career de\ott'd to Impro\lIlg the qualir) of hte of tho"le \\c ... ene We
Susan B. O'Sulh\an Thorn...... J Sdmlllz

,

Aclrnowledgtnents The on-go1Og development of Phnicol RehahilitatlOn has been 10 all a"lpech a collaboratl\e \enture. It~ fruition made pO.... lhlc only through the e\perti ..e and graciou'l contnbutlon"l of l11an) talented II1dl\ idual"l. Our appreciation i... con"lderahle Hearttelt thank. .. are e\tended to our nmtributtng author.. , Each ha.. hrought a ul1lque body of 1-.110\\ ledge a", \\ell a.. JI ... III1l't cllllical practICe c\pertt ..e to their re"lpecII\!:> chapter.. Then l'ommllment to ph) ..ical therap"'t education I" colle\.:lI\el~ di .. pla)eJ 111 (on tent pre...entation" Ihat (Jretull~ retlect the "'l.:npe ot k.l1ll\\ ledge and ...k.Iib reqUlr~d of a d) l1<.uniL', e\'l)I\'ing physiL'al therapy practice em Ironment. We are e\tremd~ graldul to each of our L·ontnhutor.. a, \\ til a... heartc-nt'd 1:1) ht {"\(elle-ncl' the) bring 10 the fltth c'I..1It U'lll. Our gr.llilude .tl) t"\lended ,0 our gUt'"" eUllOt dod re\ le\\ l'r.... Th\,; I r . . llil t1\ e L per i -.c l~n 1\ idt·J L ri t IL' al Il'pUt Junng 'an 'u h ~. 1..\1 }t'd J \e tlpl1len~ \\ .. tl\.uhrh j (I t, .. He lr th:': .. I,L n· ,ilg~ pedJgtlgh.a n hl'>..oJ j U· \,.lll1Jl1It n l. i' 1 lb~\' 11 .to I· the academiC r Ir....... It· t , nh\ ('Jl -, _l'f.ll· ... tdd 'll \\e thank h'hC n<.l \ Ju. I aIlLI... ,p, • 1trihutt:d le\\ ~hl hLr.J.~h tu tile In I' {1,Jal... I ~ 11. tu h J .1110\' j.h 'r pho;, I~ r It,h t I..... thlhC patient J eP' u'led throughnul tht te\1 Our apprci Jutlon glle ... 10 th J\.'dlL3ted pmt JOnal"l j( FA D..t\ I Compan~, Phll..I,klphia. P:\.. targ.tret 1. Blhlh, Publi...her. Jennlter Pine lX\colnpmr.=ntL\1 Edlh.)1 Bol' But ler. ProdUI:t1on \1ani.lger, and Ron f\lo~er. \hr"-eting Manager The ...e Indl\ idui.ll"l arc recoglllLed for their continued ",uppon. em:ouragement and uIl\\i.I\eling t:ommltment to

excellence. \Ve \"ould also like to thank Jean·Francols Vilaln. Former PubiJ,her, FA Davi" for hIs support throughout previou" editions of this te.1(t. Thanks also are extended to Berta Steiner. Director of Production, Bermedica Production Ltd. and to Deborah Lynam for her considerable talents In preparing many of the new line illustrations. We \\ i'h to thank the numerous students. faculty. and clinicians who over the years have used Physical Rehabilitation and pro\·ided u, with meaningful and constructive comments that ha\·e greatly enhanced thIS edition. It is our sincere hope that thi~ feedback will continue with the fifth edition. Our thank'" go also to the following individuals who proVided a",,,,i<.:.tance during different phases of the project: Diana Ago,ton. Elizabeth Bias, Ryanne Glasper, Ellen God" in. Kim Harris, Cristiana Kahl Collins, Katherine Li. \lar) Maloney, Eileen McAulay, Michele Mills, Evangelos Pappa,. Alexander Rosado, Alexis Sams, and Gideon F. ShapIro, A p3.nlcular note of thanks is extended to Stephen ",-, Caronia \\ ho contributed several Evidence SummaI) Boxe<.:. a... \\ ell a'> 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:'

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273

Ponne) OPT PhD, f APTA

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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 deu<'llln mal..lng') 1. De..cribe the ,,&:) .. tep' in the patient/diem management proce,' J. Define the malor re .. pon"lbtillie, of the phy<;ical therapl"( In plJJlning eftecli\ e treatment... ~. Idenlll) pOlenllal problem... thai could ad\er..el} aNec! the ph) "lloal therapi"t', clinical rea<;oning. 5. DI"cu",,, ,trategle 10 en"UTe p;ltienl participation In the plan 01 car~. 6. D... cu .... the Imponmen.... of ph) 'Icallherap) dC'k:Umenlati(m. S. Differentiate ~t\\ cen ex~n \cr"u<., 00\ ice therapl,t c1imlJ.1 decl IOn making_

9. AnaJ\1c and mterpret patiem/chent data. foml~lale n:ali .. lic gllJ,J.. and OOlcome.... and de\l~lop a plan of care \\ h~n presented \\ Ith a

Clinical Decision Making Susan B. O'Sullhan,

PT. EdO

OUTLINE ( h01Lal Rt.'asnning. CilO1L.J1 Dcll,ion la..,lIlg. 3

DtlLumCl1.lll<~n Hi Problem-Oriented \ledital Record 19

Sh:p n Patl nt( I nt \l.tnagl:.'ment -l Step 1. E"Ul1IOation 4 Step 2. E\aluation 7 Stcpt Dlagno\i\ 10 Stcp 4 Progno\i\ and Plan of Care 11 SICP 5. Inlcncnlion 1..Step 6. OullOlnc\ 1..-

Chnu:al DcU'i101l \1.I~lng E pert er u ()\ ILC ~o Kno\\ ledge Base and bpcricnl.:c :20 Cogniti\e Procel;<,mg SI)le.. :!() Self-\1onitoTlng Strategic" 21 Communication and Teathmg S~II'" :! I

PInt P.J.r111':W 11011 III Plannm' I"

Summary 21

clin"al ca"t.' tud).

Clinical Reasoning/Clinical Decision l\1aking rea~onin~ i....1 mu\tFlhn~~n ... ioIl31 prllt. 1,.' ~ thai m\oh·e... a ""Ide range ot lll_l1l1ivc .. hill .. pll}"'} <11 lh~!"api ...", u~e to pnxe ... InfomlalillO reach d·~ . . i... lon ..., and dctcmllnL action,. Rea oning can lx \ II wed a, em jOlt.'mal Jialogu~ that one contmuou,l) emplo}s \\ hlle mt"t"lin~ thl.' L'ha)lenge... of dall) life: cllmcal n.:a,oning fonn' the has!'.; of paUentAlIent management A number ot factors intlucm:e the chnH,:al rea...onmg pnxe ...,. The clinician \ goal-.. \ alue, and belief. p...),ho...Ot:lal ...k II b, knolA-ledge ba ...e and eXpt"nl-.e prohlem-')oh 109 "'lrategies, and pf()(:edural ,kilb all Imp..1L"t on c1illleal re'honmg. Man} of the~e factor, art=' the lc)(us of dl cu "'lOn JIllala chapters In thl'> le"t, ClJl1Jcal rca...onlng I a) 0 IOlluenc.;ed by patient/client charat:!en~uc... tgoal \dlut' and be IIt:h. ph}\ILal, psydlo...oual, educalIonal and luhural LJLlOr~1 a~ lA-ell as t'0\ Ironmenl.1I fat:!or, IdlOKal pradlt:~ em Ironment, O\erall re,ource~. IIIne k\el (,I llnanllal uppon k\d 01 M'k.lal ~uPPOI1), E\pcnent..:c:d or eX(kn lhnillan, It:nd to ullllze a jtJIll'un/ tl'(/,\(JI""~ J11f1( u.s In IAhlLh Lhe:: dUlILliln I' ilblc 10 rc:t'o!!nlzc: lue,
Clinical

<.Ire fomlulated based on intuition, Hypothe... i<., tC<.,ling I... not Iypically verbalized. Thus. actions are ba<.,ed on pattern recognition and experiential clinical knowledge. In contra...t, a hachmrds reasoning process (also tenned hypothetil.:odeductive process) is likely 10 be utilized by the nm Ice or 1I1c\perienced clinician, Thi" involves identit) Ing cue.... propo"'lng a hypothesis. galhering ~upportmg dala and e\aluating the hypothesis. and detennining appropriate action... E\pert~ may u"e hy pothesis-(e~ting method, \\ hen rouline problem recognition fails or they are practicmg out of their Mea of e\perti~e,I Rorh ...tem and Echtemach de\ elopC'J
4

Phl,ical R<-hahilitation

the- IherapI"'!'''' U.llllcdure ~h "l thl' (.;~lU ...e Prnbkm... arl' deimed 10 teml ... of hl1l1..IIOIMlllmII.IlHln ... , \ "!l0' rc"'roll't," 10 an~ (It the quc ... llon ... ,,{'...cd III ~11l .Il!!orlthm I'" .111 IIldKi.l tlon h.lr ree\ aluallllllllf lhe "1~lbllll~ 01 lhc h~ pOlhe...c gener~llcd .1Ild rel.:on"'ldcrall0ll 01 the dCrl'loll ... madc In u"'lIlg HO-\C II 31" a J1lodcllor (:llllKJI dCU\101l lllill..lIlg. Ih(' therapl ... t al ...o dl .... lIlgu"he... belween (,\I\t1ng prohlem ... and anllClpaled problcl1h. defined ~h oeliclt\ lh ..ll <11"(' lll..cly to occur it an internmllOIl i... not u...ed lor prc'velliion The \alue of all algorithm" thai II gUloe ... Ihe therapl"·... oeu1,,101"" and prO' ide all outline of the deci ...lon ... 1lli.10e See Chapter 20. Figure 20.8 10 20.1 n. for e\ample\ 01 prohlemcentered algonlhm . Chnicu! JCd.\ioll\ are the outcome... 01 the dlllil.:al rea",olllllg proce...... , Ph) ~Ical therapI ...t... IOda~ pradH.:e 10 comple\ em Ironl1lent~ and are called upon to re;Kh illcrea~ingl) comple\ decision ... under "'Ignllicillli practICe con ... trailll~. For example. the therapi ...t may be rcqull\'d to detennine a plan of care for the complicalt'd p;.11ll:nt \\ Itll multiple comorbiditie~ within 7'2 hour... of adl1ll ...... ltlll to ~I rehabilitation facilit). Reduced level of trt'ulllll;nl Jutho! ization \\ ith shorter and ~horter ...ta\, in rehahihtatlcr 11 I"' complicate the deci~lon makmg prOl'e....... 'I(l\ II':\; pi tltjoners can ea~i1y become o\'ef\\ helmed 1 hi... 'b 11k, introduces a frameworl.. for patient/client nUll I~ i C'11 tl,.l~ can assist in organizing and pnoritizing data allo in 1'1', ,ning effective treatment~ compatIble \\ ilh th~ nt.·...' d... dl'd goals of the patient/client and member~ of the i1l'alth C.lfC team. The disablement model ha~ been widely incorporated into physical therapy practice and into th\; GuiJe III Physical Therapi~t Practice:~ It prO\ ide~ an Important frame\\
Steps in Patient/Client Management Steps in patient/client management include: () examination of the patient; (2) evaluation of the data and identificalion of problems; (3) delennination of the diagnosis; (4) detennination of the prognosis and plan of care (POC); (5) implementation of the POC; and (6) reexamination of Ihe patient and evaluation of treatment outcomes (Fig. I.).

Step 1. Examination Ex.amination involves identifying and defining the patient's problem(s) and the resources available 1O

dt:llrmllll:: "pprnpTl.ne mtenellllon It lnll I t l,1 Ihr UHllpOnl'nt Ihe pJtle1l1 h, tory I re\ile III r I tnt tl'1ll .•md tt? t .Inil me I ur s f .lmmJllnn III th p.llient relcrr.11 or mlll,,1 entr), Ind <..:nntmuc t In nngoIIlg prn<..:c' throup:hout the <..:nur e of reh,thillt.ltlon Ree'ilmlnatlon al1(l\\ ... the thcrJpl ( to e\i.lluclle prnl!r
History Inlnmlatlon ahoul the patient' pJ t hi InT) ,lI1d current health ...tatu ... I'" nblalllcd lrom re\ 1("\\ nl the medlCJ) rel:nrd .1Ilt! mten 11.:\\ The medKdl reulrt! pro.. Ides dd.Jl1ed report" lnllll memlx'r 01 the health l.lfe team. prnce mg the-.e repmh require....111 untkr t,mdmg of til C<.l"t:' .md InJuT). met.!lcal tcn11lno!ogy dlttcrl'ntl,11 JI.lgnn I ).IMraton and other dlagnr"'tll: te ...h. and medll,ll m.magemcnl. The u.. e of re"'OllfL't' matcndl or prnte lol1.l1 con... ultatlOn l:Jn a...... i<;1 rhe 11m 1":1.' \;'111111.:1.\11, The typt' III d,lta that mi.l~ he generated lmlll <.i rallenl hl""'w\ an,; pn.~ tnled 111 Figure I 2 ! h 'l1er I '\\ I ,\r 1ll1rtlrtJ.nt t 01 u ed to nhtJm mfor,I!lllll di., tr\\m the p.1t1 nl f.1l11l1) Igmli\;ant mhef\. Ir ther mt r' d pt:r on The therapl t a k... il n dt;;' ~e lc r.11 t lfmatlOn mdudmg pa~t HJ "'~fl JIl'al ... nJilllO ... pmphlath.1O. mecham,m IlJUr:. I "Iflr j ",:- "ltl,tl,: lnMglllg te ...ung. medKatlOn.... "v '~r ...)T ,IJI I tI .lI1d thcf'lr\ hl ...tnr: The patient I'" a~ked t II· ... ,·~ "t_ III t'r ht:r l un'cnt L:,lIHJltioniproblc1l1\ . . 1and pnmal·) COi,ll"];,Ulll (rt:a...lUl for n:ferral w ph)"'IL:al therapy). T:picJ.l'~ tll ... r~l1lent ;,\ III t1e"'\;'nhe hi'" or her dlnil2'ultle . . 111 kllll'" pt funL:ti,mal hmit.Hlflll'" IJr di ...ablliue .... The patient I'" then J.... l..eJ J. ... cri~ ... ot 4ue.. tlllll ... de"'lgned to delmeJtc the nature and hl ...tof\ llf the current conditiorL primar) l2'omplaint. The thefapt...r al ...o neeo ... 10 dctennine the patlent\ age. gender. ethIllL'it:. prlmar: language. cultural background, cu~tom\ or religiou ... belief... that might affect care. educational le\'e!. ...ociallhealth hablh (e.g mol..mg histo~. alcohol u~e. e'(efi.:i~e like., and ol... like fre4uenc) and intensity of regular acti"ity). and famil) hi.,tor). Sample interview que~tion~ are included 111 8m.. 1.1. Pertinent information can abo be obtamed from the patient's famil) or carcgi\'er. For e\ample. patienb \\lth central nervou~ ~) ...(em deficit and ...e"ere coglllU\C and/or communication deficits or pediatric pali("nt~ \\ III be unable . .. to accuratel) comll1Ulllcate th· elr e'l~tll1g problems . The family member/caregiver then a~~ull1es the pnmar) role. of a~sisting the therapist in identifying problems and prO\'lding relevant aspcct~ of Ihe histol"). . The therapi~1 should be sensitive to difference~ ,m cullUre and elhnicity Ihat may .lilt1uenee how the patient. or family member responds during lhe interview or e'\anllnation proces". Different beliefs and attitude., 1O\...ard ~eahh care may .IIlfluence how coopera t·IVe the patient \... 111 be. During lhe lIlterVIC\\. Ihe therapisl should li,ten careful!) 10 what the patient says. The patienl should be obsened for

Chap.er I Clinical Decision ~ DIAGNOSIS Both the process and Ihe end result of evaluating examinatIOn data, which the physical therapist organizes Into defined clusters, syndromes, or categories to help determine the prognosIs (Including the plan of care) and the most appropriate interventIOn strategies. EVALUATION

PROGNOSIS (Including P1en of e-I Determination of the level of optimal improvement that may be attained through Intervention and the amount at time required to reach that level. The plan of care specifies the intervenhons to be used and their timing and frequency.

A dynamic process in whIch the physical therapist makes clinical Judgments based on data gathered dUring the examlnat1On. ThIs process also may identify possible problems that require consultation wIth or referral 10 another provider

INTERVENTION

EXAMINATION The process of obtaining a history. perlorming a systems review, and selecting and administering tests and measures to gather data about the pattenUchent. The imtlal examinatIon is a comprehensive screening and specIfic

testing process that leads to a diagnostic ctasslt.cat,on. The examination process also m.ay identify possible problems that require consultation with or re1erralto ano:h::T provider.

')UTCOMES ;E~u.b

';"

:Ji oati':.rlt'client mar,agement,

i·~r. 1:1C'

'Je

~np

impact of physical In the fOllowmg ~""I d~n:'~ •.Ja·hopliys'olagy (l,.. SP.1S f)rIjEf. C conditl)n), 1m" "'ii~i'~1 • hJ'1'~~' - ,.. I limitations. and rjlScibll", 1::: .... r:~'l reduL,l'Jniprevention; t'ea,li) lJelln~ss, and fitness; societal r€:S"uree::;; and patient/client tU..i ~~\' ". ~~ (;;"ono:::

Purposeful and skilled Interaction of the physical therapist With the patient/client and, If appropriate, with other mdivlduals involved in care of the patient/client, using various physical therapy methods and techmques to produce changes in the condition that are conSIstent with the diagnOSIs and prognosis. The physical therapist conducts a reexamination to determine changes in patient/client status and to modify or redirect intervention. The deCIsion to reexamine may be based on new clinical findings or on lack of patient/client progress, The process of reexamination also may Identify the need for consultation With or referral to another provider.

satlsfac~lon.

Figure 1.1 Element'> of pauent management k:...dlOg tll optimal .~ "ith penni "ion.,

outcome~.

IFrom APT.\. Guide

for Ph)"ical Therapl,>t 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 <11 ...0 u'\ed for health) population~. For e"ample. the phy...ical theri.lpi ... t can ...creen indhiduals 10 identify fish. I'actor~ for di ...ea'e ~llch as decreased activily kveb. stre". and obesity. Screening is also conducted 111 the ca...e 01 pediatric clien.... (e.g., scoliosis ...crcening). geriatTic client... (e.g.• to Idenltf) fall ri ... h. f",ctor~) ...uhlele~

6

Ph) \ical Rl'habilitalion General Demographics

Medical Surgical History • Cardiovascular o EndOCrine metaboliC o Gaslrolntp-stlnal o Genitourinary o GynecologIcal • Integumentary o Musculoskeletal • Neuromuscular o Obstetrical • Prior hospltahzatlons. surgeries. and preexisting medical and other health related condlltons • Psychological • Pulmonary

• Age o Sex o Race ethOlclty • Primary language o Education

Social History Cultural beliefs and behaviors o Family and caregiver resources • Social Interactions. social activities. and support system o

EmploymenlWork (Job School Play) • Current and pnor work Uob school play), community. and leisure actions. tasks, or actiVities

Current Condtion(s) Chief Complaint(s) Concerns that led the patient client to sePok the services of a phYSical !h .;rapist · Cone rns or needs of patIent client "ho r ~U!rt's tr,e ser/lces of a phySical t!"erap _t •C tl erapeut c interventions • i' '-r s of n ury or disease. c . . :1"- of enset ana course of r- I:::"'t n31. and pa!terrls of symptoms • t ~ E'f1f :tlen: fa:nlly s gnlTlcant other arlO ca:eglver expectatIons and goals for the therapeutIc Intervention • Previous occ:urence of chief compldJnt(s) • Prior therapeutIc interventJons

Growth and Development o Developmental history • Hand dominance Living Environment Devices and eqUIpment (eg. assistive, adaptive, orthotiC. protective, supportive, prosthetic) o Living environment and community characteristics • Projected dIscharge destinations o

General Health Status (Self-Report, Family Report, Caregiver Report) o General health perception o Physical functton (eg, mobility. sleep patterns, restricted bed days) o Psychological function (eg, memory, reasoning ability, depression, anxIety) o Role function (eg, community, leisure, social, work) • Social function (eg, social activity, social interaction, social support)

Functional Status and Activity Level • Current and prior functJonal status In self-care and home management. Including actiVities of dally hVlng (ADL) and Instrumental actIVItIes of darry liVing (IADL) • Current and prror functional status in work Uob/School/play). community, and leisure actions. tasks, or actlVltres

Social/health Habits (Past and Current) • General health perception • Physical function (eg, mobility, sleep patterns, restricted bed days) • Psychological function (eg, memory, reasoning ability, depression, anxiety) • Role function (eg, community, leisure, social, work) • Social function (eg, social activity, social interactIOn, social support)

Medications • Medications for current condition • Medications prevrously taken for current conditIOn • Medlcatrons for other conditions Other Clinical Tests • Laboratory and diagnostic tests • Review of available records (eg. medical, education, surgical) • Review of other clinical findings (eg, nutrition and hydration)

Family History • Familial health risks

Figure 1.2 Types of dala thai rna) be generated from palient Physical Therapist Practice." P 16 wilh permission.)

11I'\IOr),

(From AIYfA Guide for

Chapter 1 Clinical Deciaioa M

Box 1 . 1 Sample Inte rview Questions I. Inlerv lcw que'tl on ~ de!llgned 10 identify the nature and hl'lory althe current problem( s): Wha t problem s bnng you (0 therapy? When did the problem(:,) begm? What happened 10 precipitate the problem("i)'J How long ha~ the problem(s) e~ l ~ted ? Ho\\ are you lilk.mg care o f the prob lem(s)?

What make:-. the problem(s) beller? What l11ake~ the problcl1l(s) worse? What a re your goals and expectat io n') for phy~icaJ IherJp) ? II

Are you ::;ee mg anyone else for the problem( ~)'! InterView que~uoJ1l) designed (0 ident ify deSi red ou t·

•

le.g .. pre·perfo mlance exam.), and working adullll (c.",1D ide ntify the ri sk of musc ul os keletal injuries in the wodtplace). T hese scree ns can in volve a ny of the above stepl: observatio n. chart review. oral hi story. a nd/or a brief examination . Additional scree ning exam s may be mandated by institu tio na l sellings. Fo r exa mpl e. in a long-term care fa c ility the therapi st may be a.sked to rev iew the c hart for indica tions of changes in fun c tional statu s o r need for ph ys ica l the rapy. based on a review o f the discha rge noles fro m the prior ac ute ca re settin g. T he the rapist make s a determination of the need for furthe r physicaJ the ra py services based o n an eva luaLio n of the in fonna ti o n obt ained from the scree nin g exam. 6

comes in tenns of essential functional activi tie s

Tests and Measures

include: \¥hal actl\'1tie ... df! you nannull y do al home/ workl

More definitive tes ts and meas ures are used to provide objective dat a to accurately detennine the degree of specific functio n a nd dysfunction (e.g., manual muscle teSt

"chool ? \Vha! aCllvitlc " are ) OU unable to do? What aC t!\ IUC S are done diffe re nt I) and how are the) different (i.e .. ex trJ tIme . extra effort. dilfere nt <;; traleg) I" \Vh al aCLivl tie!> do) ou need help 10 perron n that you ,",ould rJ lher do ourself'l What Ie l ~u re :Jdiville .. ale Impnrf . .ml III :,«ill? HO\~

III

r;

can I help

lOU

PI.' more

ifl.;~~>e.ldl."ut')

lnten Ie,", 4uestion~ de"lgned r) I(kl~dy em irOn'11CllLtJ l'l.)ndiu(lfl~ in '-I.hich patienl <11.:U I'':'' r:P~"u ... " 1 indud~'

De . . cribe \! lUr hfJme.\ch~ f'j, ! I-.. Ho,", Oil \ llJ men :tfOund J,- .':\,

,\, r" .!~:.t: If'

III

or,

lJ.t'. batilrO(lm p~Gr"oln. 'r:ler,!:... J:ld c,., 'F th, home ') Hv\ afe \.II) ~ nu! ~ Ho\\ d( V IU mo .. e ifOUl1d/a\. .. e...;", "i!.Je.l~ In tiil' l, '1[muml. n. workpIr 'ilaif l:ur~'i. ralnp'» ')

Huw ~aIc do \ ou f~el"! qUI!~tion~ de" lgneu If' idlnlity :n-:1113hlt> !'>ociaJ !->uPPOI1" lIlcludt.:. \\rna 1I,es With you') Who aS~ ht !'> 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 <.: e ·)

Iv lntenie\l,

lntervie", qUc!oLion\ de ~ll?ne d to Identity the patient '", I-..nowlc:dge I) f pottnual di ,>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
IMMT]. range·of· motion [ROM] test, oxygen consump· tion, and so fo rth). Adequate training and skill in perform· ing specific tes ts a nd m eas ures are c rucial in ensuring both

validit y and reliability of the tests. Failure to correctly per· fo rm an examination procedure can lead to the gatherin g of in acc urate data and the fo nnation of an inappropria re p lan of c are . Later chapters focus o n specific tests and meas ures

and dt>c u>s issues of validit y and reliability. The use of Jisabil it y-specific standardized instruments (e.g., for indio vtdual. with stroke, the Fugl·Meyer Assessment of Physical Performance) can fac ilitate the examination but may not aJways be appropriate for each indi-

pnJc("s~

vidual pa tient. The therap ist needs to carefull y review the unique problems of the patient to de te nnine the approprimene<"s ..lIld sensitivity of an instrument. Therapists should res i ~t the te ndency (Q gather excessive a nd extraneo us data in th e mt~ tak.en belief (hat more infonnation is better. U nnece:-.sary data will only co n fuse (he picture. rendering clmical deci.sion making more difficult and unnece ssarily ra i~ Jng the cost of care. Lf problems arise thaI are not initiall ) identilied in the hisLOry o r sys te m s review. or if (he data o btained are incons isten t. additional tests or measures may be indicated. Con1>u itarion wi th an experienced (heraPI:,t can provide an Important means fa cianfy inconsi"'tenC le() and detem,ine the appropriarene:,s o f spec iti.c rests and tnei:lsure~ . Box I .::! p re:-..e nt s the c3tego ri es for tests and meas ure., Identified In the GUide (Q PhY~lc

Step 2. Evaluation Da ta garhered Irom th e 100ltai t:'xa l1l1narion mUM the n ~ all~lI} lI!J and orgml lu'd . Phy..,k,l.l therapl"h IllU"t co n ~ l Jer .1 number u l tactor", \\ hen t'\ta luJlIng d'.lta. induJ ing th~ lL'v~J 01 Illlp.\trlnent .... th<.;.~ deg ree 01 lun<.;.~ lI onu l l o!\~ anu dl~­ ab ility th.: patlent\ U\'~rall ht".tlth anti J<.;.~ ll \ JI ) Ic\el. a\'wl~Ibdlly III "uci •.tI . , uppnll "y..,tenh. li Ving, em Itorunem. and potelllt,1I dl,,"h .. u g,,· i.h.~"lJni.Ull)1l f\ lult l,,}\tt"m Ifi\ol\'emenl.

8

Ph~

ical RC'habililalion

Box 1.2 Calegorie. ror Te,lS and Measure. -\en"'''II.

C.lr.l\.ll~ lndul,llll.l'

-\nthn-'Ip"llll'trll. Ch,lr,lllI.:n II\. Arou'al. IlI.:ntlllll, ,1Ild CO!:"!IlllUlIl .\ I tI\ c and .\daptl\ l.: Dn lll.." CIRulallon ( \111'nal. \enou', l}mph.HIl) Cranial ,md PCrlpher,11 I\Icr\l" Integnl) Em lronllll.'ntal" I-tt'llll'", and \\('Ir"- Iloh/SchoflL PIJ~ l R:"lTTl('r~ Ergl'lnOmll"' .md B(x1~ \ ItXIl.lllll' Galt, Lt.x{... mot,oll, and Balanl"C

lntegumentaJ) Integnl) Joml Inlegrll)
Ih.\I Ilrlglll.lll Irom olhl'f ! It'm .. fhl Y t prl\' 1 11l1~ 1I11pdlTlnl'l1t<; flr lht

Thcfi.lPI~1

PraClltC

severe impairment and functIOnal loss. extended time 01 involvement (chronicity). comorbid condition\. and medical stability of the patient are importanl parameter" thai

increase the difficulty and ,hape the deci'lOn making process. 4

Disablement Tenninology agi used the tenn, patholog) {pathophy,iolog). Impairment, functional limitation. and disability to de\cribe health status. 7- 9 These tenn~ can be used to categorize clinical observations systematically. Disease is "a pathological condition of the body or abnonnal entity with a characteristic group of signs and symptoms that affect the body"-1 Jlf,Kh Etiology can be known or unknown. Signs are directl} observable or measurable evidence of physical abnonnality while symptoms are the more subjective reactions 10 the physical abnormality. Impairments (direct) are the result of pathology or disease states and include any loss or abnonnality of physiologic, anatomic, or psychologic structure or function,4 For a patient with stroke, examples of impairments that are the direct result of pathology mighl include sensory loss, paresis, dyspraxia, and hemianopsia. Impairments mayor may nOl be permanent. Secondary impairments (indirect) are the sequelae or complication"

t:

,\11 fI

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lh lllnllulll Ih.llllllur \\lIh rrfllfln~t'd 11l,H.tl\ll~ I.u k fl' .tdl1l'renu:: III ugl!C It'd Ir.lll'clt' 'mien nlliln ,lIllJlelf ( !I\l' pL11l 01 ,If\.: or 1.llk 01 r,'h.thdll.!llfln Inl r' enllltn r .ll11ph" 1\1 Indlrnt Il11r.tlrment 1Il1.11Iri. tit r ,I t d I
"r dall., Ii, in~

El \01 If I II _ hath,"" I, or in,trumental ac.hitie, of daih tiline, I \OL "llU~­

lie,

lk JIlII' pr p,mn m P p Ir._ I I ph lOin::" m<.tn.l~In' fm3n... 11 I ) torth I U tur n-1.l Ilffill.ltlnn ur lnd a

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mah lit. to r~rtorm 01 ,idl n . ta,k,. and til lilt'" \. j Ifl pt: It l oClal role ... that are l LI .. o'llar t lr h.. Illd \ I Ilial ll( xp,x:ted hlr [ht: per...on"" ... t,t ':_ or rol· III a rl d.K "I.Ki(llultliral \,"lln[C'\t ,tnJ phy"'lL'al em ironl It.llt. C.HCb0rtt' ut r Ililfed mit: IIlcluOc-d are ...(' I-laft:. homc manu-=, l1leot \or!.. lOt" l'h\)ol pl,ly J. and LOl1lmunit:!1l:I ... tIfl' fllll tht: IIldl\ h.lual I'" lln.lble 10 a\"lUllle ... ocietal role ...... u\.11 a... \H'Irk.mg, parenting gOlllg 10 "'Ll1ool Jtlt..ndmg churl'h (lr lltht'r gnHlp .IUI\ Itlc- .... or par· lll'lpatlng in Il'i ... ure ,1Cti\ Hie... "'porr... ret.TeatlOn. mp.... and l; I

I',

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11

...0 !cmh l. The AmeriLan Ph}'lCal TherJ.p} -\......ouJtlon L-\PT-\l, 111 the Guid(' to Ph_'-\lCUI Tht'l"df'i.\t Pl"d( 1l4t -I .I'" "ell J'" other profc ...... ional boole... (;'\atlon.tl -\0\ I ... or: Board on \!kdiLal RehabililatlOn Re,earch"'), h~l\e .ldopteo \'agl\ tCfll1Jnology trame\\ ork. The \\"orlll He..l1th OrgamzJl1on !la... publt ... hc-d a re\ i ed c1a...... lt"'it:allon of It... temllllolog}. the Intcmational Cla"l iflCalion of lmpaimlenh, DI ...JPllltlc.".... and Handil'ap... (ICIDH-2).~ Bo," 1.3 pre ...enh a guide 10 DI ... ablement Tenninolog) and i... a t:ompllation of {he~~ t\\-o ...ource\. Clinical e\.ample... and appllC'~ltlon... ot thl' terminology for deci"lion making of patient... \\ IIh orthopedtC and neurological dysfunction are e\ Idem In the ph)"'lCal therapy literature.I(}...]-1 Data obtained from functional e'\
Chapter 1 Clinical Decision ADMISSION'

Box 1.3 Disablement Tenninology

,

OISCHAIIGE" _

SELF-CARE

Activily: the nalUre and extent of functiomng at the level of the person. Activities may be limited in nature. duration. and qualily.Q

Conte,.t: includes the features. a~pects. attributes of. or objects. stnJctun:s. human-made organization, servi.ce ~ro­ VI~lon. and agencies in. the physical. social. and attltudmal environmenl in which people live and conduct their lives.'> 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'Iychosocial ac;pecb of the pallent's life. Participation: the extent of a person\ Jnvolvement In life ~ltuallom in relation lO impaimlcllls, aCllvities, health condition. and contextual factor~. Panicipation may be re~tntted m nature. duration and quali[y.~ Secondar~ impairment (indirect): ...equelae or complications that ongmalc from other ,,>ystems. the re...ull of preexIstmg unpillnnents or expandmg multJsystem dyslunclion. Signs: directly ob...ervable or measurable changes III an mdivldual\ organs or system~ as a re ...ult 01 pathology or dlsease.~ ~}mptoms: ubjecllve tVldem:e 01 physll:al abnorrnt:~ 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
Makiac

'

A. Eating

B. Grooming

C. Bathing 0, Dressing

~

Upper

E. Dressmg - lower F. ToHeting

SPHINCTER CONTROL G. Bladder H, Bowel

TRANSFERS I. Bed, Chair, Wheelchair

J. Toilet K. Tub, Shower

LOCOMOTION L WalkIWheelchair M. Stairs

COMMUNICATION ~J.

(1n[lrehenSlOn

0, hpresslOn

SOCIAL CCGNITION P. Social InteractIOn

n, Problem Solving R. Memory

B BB

~

W-Walk C~Wheelchaif

B-Both

~ ~

B~~,~B V-Visual B-Both

BB~BB

~

V-Vocal N-Nonvocal B-Both

B B

~ ~

... Leave no blanks. Enter 1if not testable due to risk.

F1M LEVELS No Helper 1 Complete Independence (Timely, Safety) 6 Modified Independence (DeVIce) Helper~ Modified Dependence 5 Supervision (Subject =100%) 4 Minimal ASSistance (Sublect = 75% or more) 3 Moderate Assistance (Sublect =50% or more) Helper ~ Complete Dependence 2 MaXimal Assistance (Sublect = 25% or morel 1 Total ASSistance or not testable {Subject less than 25%1

Figure 1.3 UDSmr"l\l FHvt"l\l lI1 \lrUmenl. (Repnnted \\ith per111l'.... Hm 01 Ih~ Unlionn Data Sy"tC'1ll lor Medical Rehabillt'lllon, .1 dl\I\IOIl 01 U B Foundallon ACIIVlllt''I, 11K. lUDSmr~l\ll, Copyright 1\.)1.)6. GUide lor the Unllonn Data Set Illr Medll~al Rell.lbllJldlllm llllcllllling lhe FIM'II\I lll~trulllentJ. Vep>lon 5,0, Bulldl\), NY: State UrllVer~ll} nl Ne\\ Yllrl.. at Bullalo, 1996.l

1.lulll'!.' III Ihl' lllliul .... 1.11t. .1Il1l I" II, I.lI ul 111111 1111" lJ1 Ch.lr1l·' II klll~I" "Ul!~l,l ttl,.lt'I!I. I11l III n l '.Ill(\r .Ind hllllef hould ~ t:\.llu.Hl·J HI.: ddllll di~ahlem('nf ri't.. rat. l(Jr~ J' tx-h.l\ Iflf'...H1nt'lull ,. nl lll\ mmll1l'l1t.11 IIlll1ll III that lIllrl'.l'l the lhal1u.:' (\1 dl.\llnrIl1C lInpllfl11llll lunll'l"\nal Ilmll.lIH)n,. 01 dl'Jt'llltl\ \\ hl'll III lnd, ,dll.ll dellwn"rah: all Jlll\e patholol!\ I nf e ,ll11rll 111 lIldl \ldu.11 mJ\ Jemon,trJIl' rr\.'dl r(l'II1~ "-'1.1f.ll 11.:1 , tIl (negall\\.' allell. r'Hhl"PU.1I m,t.lhdl1 y l. dCIl1(lgf.lphll (Il1nlled Imanual/heJlth re,nun.l·'. llllllll'd cduldtlonl. ,oUJI and t yle talll'''' (,n.l(.kllu~lll' 1~1I1111~ "Ul'pOIl. dl . . engaged llfe·'t y lel. (1f f(',lnl.ll\(' ('11\ If(1nnh?TlI fnul11l."I ou, af(h'te(tuf~11 bJrner,) Buffer'. (In the nlhl'l' h.lIld. .Ire defined a, lhe al"llon, or 1I1ll~l'\elltl(ln, (1I1 Ihl' p.1I1 III the lI1dl\ Idual 10 re ... l... t the de\('lnrment 01 lJllr~lIrlllcllt funcllollJI 1lJ11ltJI,on,. or dl",lhlllt) r(lf t~\alllpk .111 lIHIl \iduJI may adopt beha\ lor'
'''e..

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Step 3. Diagnosis -"\ /IIf'rllI II/i/itl " f"kr!1l !Ill 1,kn11l1 Illlln t'.l"l' (II ,pr(kl tlf l(llldllllln r,llh"l, _ r ,Ih"ph b\ t:\ illl,I'"l Ih(.: rfl n{lr' I n m tim J.lhtll.Jtllf f ull Ilr It m.. nl II lIul.lf P II te m (Ii.lcnn tJ t, I n I

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The u,e l)( JI.J..;n\I't11.. l.atq;l)nl.·' 'Pl·l.lf"i..: II.) rh~'I..-J1 lhaJpy t"kllir,ttC', ,W...·l.·l''''tul rl.?mlhur,eml.'nl \\ hl.?n hnke'J w lunctlonal l)llh.:ome, and enh.lI1l.·t..', Jlfe'd Jl.·(e" \.'1 I'h: "leal IherJr~ ,en ICt',. The dlaglllhll\.' rroee" ll1l'!ude' 1I1tl'~rJtll1g :md e\ Jlu.. ulIlg the uala ootaliled dunng rhe e\~U11lnJllOn 10 ,k,('nbe tht' patient/clicnt conuiuon 111 tenll' tlut \\ III ~uide Ihe pro~nl.'­ "i"'.thc plan of care. and lIlh:'nentlon ,trategle,. The ClIit/t' r{l PlIy.H·cu! Thera/".,r Pracrice organllL" lh.lgno,tic cutegonc, by l:lrefcrrcd Practice Patterns. 4 There arL' four mum Guegorie\ of condition... : l\1u,culo,j"elelal. Neuromu,cular. Cardiova...culaf/pulmonaf). i.U1U Integument~u: \\ ilh preferred pracli('l' p..lltcm... identified In t'ach (AppendL\ ..-\l. The pattern... are de,cnbed full) accorull1g [Q the fi\e elelllt..'nh of paliel1l/c1iel1l management Each pallern abo includt..'.. ree\· amination to evaluate progre....... glob." oUlCOl11e~. and en lena for lemlination of ph)~ical the rap) ~f\ ice~. lnclu~ion and exclusion criteria for [he praclice panem and criteria for multiple-pauem c1as~it'icalion are abo pre~el1led. The pat· terns repre~11I the collaborative etlon of e:-..perienced ph) ~l­ cal Iherapisls \\ 110 delailed Ihe broad c:uegorie~ of probklll' commonly seen by ph) ~ical therapi:-'h \\ ithin Ihe ~eope of

Chapter 1 Clinical Decision their lnowledge. experience. and experti . . e. E\pert t:onl.,en\u ... wa~ thu u"ed to develop and define the preferred pratlice pJ.llem nll~ prullary focul., 01 prelerred ~ractlce pallCml., i" al the level OflmpJlnllent" ~lJ1d functional limitation.... Thl~ 1\ a far more appropn:lte level for clinical decll.,ion I11J"lng. b) phY\lcaJ thempl"" Ihan the medical dlagnosl\. Therapll.,t~ ullable (0 dcten11llle an II.JenllliJble practice pallem when J retemng 10 the Guide 10 PhnU"ol TheraplJI p,.lIuice \\ III need (0 plan IIltervenllon... ba.;"ed on the speCific deficitl., Identified. ThCf3pl"'" al ...o need (0 identif) the ICD~9-CM codes related to the preferred practice pallcm. aho liMed In the Gwde to Pln.Hnll Therapl,H PrauU"e,J The coding 1\ from the World Health Organizatlon'~ International CIlli."lfication of Dl ...ea...e". The ...e code ... are needed tor billing purpo... e~ for . . orne pa)ef\. mcluding Medicare.

Step 4. Prognosis and Plan of Care The lenn prognosis rcft~r" to "the predicted optimal le\'el ollmprO\ emenl m functIon and amount of time needed to reach that le\'cl "J r J " An accurate progno:-.i:-. rna) be determilled at the on ...et 01 treatment tor ..,ome patient\. For other. more compllcJted patiel1ll;, ""lth exten\i\'c di ...abilil) and Illulti ...y ...tem 111\ nh'cment .. ut.h a the patient ""ith se\'ere lraumatll hrain lIljur). a IlflJgno i.. . or pr~dlction 01 le\'el olnnprO\l.'llll'llt can bi. d~tcmlilled only at \'3riuus Incremcnh dunng the lOur.. l.' 01 rehab;litcharge

Anticipated Goal~ and Expected Outcome~

An Important flr~t \tep In the dc\'eloplnent 01 the POC I .. the detenTiinatllJn 01 anticipated gnal~ and txpecled outcome!') Goal and outt:Oll1e .,tatcmenh addre ...., predllttd {;hangt~ In lInpalflllcn' .... lUIl(.. lIon.t1 limitation .... and dp",abllltlc!). They t:..tn dbo addrc ... ~ predicted lhange ... III

MakiIotI

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overall health. ri5." reduction and prevention. wellne i.lJ1d fitne., .... and oplimization of patient/chent satisfac· lion. All delllleate the intended re5.ult~ of palienl/client l11anagement. The difference is in teml~ of lime frame. OulCOme., define the patient\ expected level at the conclu"'lon 01 the epi ...ode of care or rehabilitation ...tay while goab define the interim stepl., that are necessary to achieve expected outcome~.J Goal and outcome Matemem~ 5.hould be objecllve. measurable. and time limited. There are four essential elements:

I. Indil'idua/: \Vho will perfonn the ~pecific behavior or a~pect of care? Goals and outcomes are focused on the pllliem (individuals who receive direct care physical therap) services). or the diem (individuals who benefit from consultation and advice. or services focused on promoting, health. wellness . and fitness). Goals can al ...o be focused on family members or caregivers. for example. the parent of a child with a developmental di,ability_ .., Behavior/Activity: What is the specific behavior or acti" ity the person will demonstrate? Goals and out(;ome~ include changes in impainnents (e.g.. ROM, qrcngth. balance) and changes in functional limitations or dl\ability {e.g., transfers. ambulation. activities of daily living [ADLsD_ 3. Condition: What are the conditions under which the patient \" behavior is mea~ured? The goal or outcome . . tatemcnl specifies the ~pecific conditions Or measures reqllired for successful achievement. for example, distallct.' achieved, required time 10 perfonn the activity. the specific number of successful attempLs out of a specific number of trials. Statements focused on functional ch
12

Ph) ic 1 Rehahilitation ~,"d

Intervention",

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Ihl\ lllultiple go.l1\ and tlUllOllll". (IO.tI ... 111(1) be Illlked 10 the ... uu'c\\ful ~llt.llnm('l1l 01 Illore Ih.lI1 ol1e outcollle, I'or e\'-1I11rle .•Itlallling RO\I III dnl" Ilk wn 1\ cntn:al 10 the lunliional OUI((lllll' of IIllkl'l.'ndl.'l1ll' 111 tran\fer... al1d ill1lbuliltlon. The ... ucl"t? ...... ful ~tll.tll1ll1l'nl 01 an outl.:ome i\ ill ... o dcpendent on adm>\ IIlg .1 l1umher 01 dlfterenl goal\ For e\Jmple, Independenl amI1111.111nll (the outcome) 1\ dependent on lIlaea"'lI1g ... Irength RO~1. and balance ... kllh. In formulJ.llng a POC the ther· apl,t need\ (0 ilCl:uralel) Identll) the rel.lllon,hlp bel\\een goa).., and OUlcome, alld tn ...eqUl'lllC' thcm appropriate I) 80\ l,.t pre\ent ... ('\ample\ of oUlcome .md goal slatemen..... The POC ... hould al,o Illclude a \Iatemenl regardlllg thl

patient's 0\ erall rehabilitation potential Till' i\ 1\ pIGllh a one-word ...tatement: e\(ellen!. good, fair, or pt.lor, Thl LherapI~t will need to con"'ldcr multiple factor, \\ hen ddl'r mining rehabilltiltion potential ~uch a ... the r~ltlcnt' ... cllnJl tion and on!-.et date. comorbidlt)'. mechant\m of inlUr) un baseline data. 1:!

Coordination and Communication ( .l"'l' lll.ln,ICt:01clll reqUIre Ih,lr.h r Ipl I be Ihle t 'm lllUllll.llc ('!tn.ll\- 'l~ \ Ith III rne-mher (II f r h Ihllltatt n IC,llll dlfl.'l1l) ~lr mJlreul f lr 1( Impl t e Ih'rJpl lllllllllllllll.ltc \\ nh othl'r pr te I n 11 I 'nfer l.'llles te.lnl mectlllg I ,r round r thf(lu~,", J K.:umentatllm 1Il lhl' mt:ll!c II rc ord. ~fte 11\ )mmum Jt on nhanee loll.lht'r,ltlon ,Ind Jnt.h:r tandm_ r he-LIPI I ,If' 3.1 n f p4 n Ibl r He Jt l11.lJl~ dille! nl I d The ttpprorn~le .1 I t of tn; ll'nenf to r \ tant r <1ldc I h th r pI I (oor lmat r r t IOllal ,r f I'll r .!ardll1~ ,I f':

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Box 1.4 Examples of Outcome and Goal Statements The following are examples of ex.peeted outcomes. ~11l to he achieved within lhe anticipaled rehab ...tay: The patient will be independenl and ...afe in ambulation usmg an ankle·fool onho<:,i" and a quad cane on level \urface... for unlimited communily distances and for all dail) aCli\ Hie... within 8 .... eeks. The patient'" III demomtrate modified dependence wilh c1o,e supervIsion in wheelchair propuhlon for limited hou ...ehold distances (up to 50 feel) within 8 weeks. The patient will demom,trale modified dependence with mmi· mum assistance of one person for all transfer aClivitles in the home em Iromnent withm 6 "'eeks. The patient will demonstrate IIldependence m basic ac(i\ltie~ of daily livmg (BADLs) Wllh minimal set up and equipment (use of a reacher) .... lthm 6 weeks. The patient and family Will demonslrate enhanced deci... lon making skl1h regardlllg the health of the patient and use of heallh care resource!> 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

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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<::tpeutlc modal

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Skilled phy!'>ical therapy includes a wide variety of procedural interventions. which can be broadly classified into three main group". Restorative interventions are directed toward rcmediating or improving the patient's status in term~ of impairments.. functionallimitation~.and recovery of function. The involved ...egments are targeted for inter\'ention. For example. the patient with incomplete spinal cord II1Jury undergoe... locomotor training using body \\elgh. ,upport and a treadmill (BWSTfj to improve gait. Patienh \\ ith chronic progre\\ive palhology (e.g., the patient with Parkin':>on\ di ...ease) may not respond to rc..,toralin: inlervenlion-., aimed at re~olving direct impairment..,: intervention ... aimed at re~loring or optimizing flllll.::tlon and modif) ing indirect impairmenb can. howevt'f. h'l\e a po..,iti\·e outcome. Compensatory intervention.., are dirccted to\\ ' If<.1 promoting optimal function lI . . lIlg re ... ldu.11 abilitie\. The actl\'it) or ta..,k j~ adapted in order to adllC\e fum.:llon and the unimolyed ...egmem':> are I.lrget.:-d Illl' lIlten enlion. For e\ample. the patient with kit hl:'llllrkgl<.1 It:..lfIh 10 drc ... .., U'llllg the right upper . .·\l'·Cllllt~ tht' patll.':nt \\ ith l..'t1l11plete TI paraplegia learns t~, I ,II lI . . lng upper l'\trt.·mitie.., and momentum. LII\ Inllll1ll.:l1t~1l adaptatloll" arc- al,o u... ed to facilitale f\,.1c II Jllll!..' {ll lunctlOnal . . kill.., and optimal perfornlance. hlr ex til pk the p:llIc-nt \~ Ilh Iraunutlc brall1 injur} i... abk' 10 drl..'... 1"'1\ . . elcctlng d~lthll1g tromcolor-coded dra\\e:- ('III1I'l..'11 .Hor~ II1tcnl..·1111011 .... can be u.. . ed III conJunct1l1l1 \\ Ith rc .... lpr.lll\C II1ICl"\l:'lltlOlh 10 m~l\imize function or hl'll !\.· .... hn.HI\I..· Il1tt:nt:t1110Ih are unrt:all ... tic or un'ltl(ll.. .... lui Pn'\l'ntali\r inltnrntion.., are dlret,.tt'J lO\\ard III III 11 II I 1I1l ~ P~)I\. 1l1l~t1 1III pOi I rlllt.·nh. tu IKtll)llJ.1 Ii III Jlatlon~. ,tlld Lli ,Ihllllll..· .... and IIUIIl(dlnlng ht.·~lIlh. For e\.<.lll1ple. l..',lrl~ I'l""Umj1llon o! upright ... t;tIldlng lI . . lng i.l tilt lable 11111111111/1.· .... tlh' 11 . . "- lit rllt'Ul1lnnl~1 bone.' Ith"', and renal caltult III Ihe p,t1I\"'l\t \\ IIh .... plll,t1t,.~Hd inillr)

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con ultation \\llh c pert t:hmuan ... ,\ an ellC(.flve Il1C~lI1'" oj Mlping the II1c\penenced IhcrilpI\' "'ort through the COI11pie h.sues Involved 111 del'i""oll I1liJ~ing. c~pcci"lIy when comphl~.,ting tactor... lI1tervcnc. For example. a COIll.,ulli.ltion "ould be beneficial 101 the lIlc,pencm.:ed therapl"" wllh a patient \\ 110 ,\ chrolllcally III. ha... multIple comnrbldlfle\ or complication .... 1I111xllred cognitIOn, lI1i.ldcquate

social o;;upporh. and/or severe functionallimit
hO\\ often the patient will receive ~"-.illed care: this is typically defined in temlS of the number of time, per week treatment will be given (e.g.. three time\' per week). or the number of visits before a ~pecific date. Intensity: what are the prescribed number of repetition", of exercises or activities (e.g.. 10 quad sets). Time (duration): how long the patient will receive skilled care; this is typically defined in terms of days or weeks (e.g.. three times per week for 7 weeks). The duration of an anticipated individual treatment ~er.,r.,ion should also be defined (e.g.. 30-minute sessions). Type of intervention: what are the specific treatment strategies or procedural intervemions used (e.g.. neuromuscular electrical slimulation [NMES J to right dorsiflexors to increase dorsiflexor contraction). Another example of a schema developed by Sullivan and Markos 25 identifies the specific components of a therapeutic exercise intervention. The components can be delineated by: Posture and activity: a description of the specific posture and activity the patient must perfoml (e.g.. \'itting, weight shifting or slanding, modified planligrade, reaching). Technique used: mode of therapist action or intervention used (guided, active-assisted, or resisted movement), or specific technique (e.g., rhythmic stabilization, slow reversals, and so forth). Required elements: those components necessary to assist the patient in the exercise or activity (e.g., verbal commands, manual contacto;, or equipment such as elastic band resistance. therapy ball, and so forth).

An example of this schema for the patient with stroke with poor dynamic sitting balance is: sitting, weight-shifting (position/activity). aClive-assisted reaching (mode of intervention), with verbal cueing and assisted '\tabilization of die Iffected upper eXlremity (required elements). The therapist should ideally choo~e interventions that

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more than one goal and are linked 10 the OUIaJmes.1lte inlerventions should be effectively to ~ key problem\ fir~t and to achieve

OplllllUIll 11101l\l~lt10IlJI effect). IIller'\patlllg lhe marL dlfficull or uncomtort<.lhlc prm:edurer., with ea"tlcr one.,. The therapi"'l ... hould include ta<;k", lhat en... ure <.;u(;ces<; dunng the treatment "'cv,um and. whenever po"i''1lble....hould end cath '("">1011 011 a pO\ltlve note. Thl ... help' the patIent retain ~l PO'ltI\C lcelmg of weee.....; and look forward to the next Ircalment.

Step 5. Intervention The therapl\t 111u,t take IIlto "Kcount ,I numher of fauors III r.,tructuring an cffc(;t1vC treatment c ...... lon. The patient's comfort and optimal pertormance hould oe a priority. The environment r.,hould be . . tructured appropnatel} to reduce di,tracllon" and foeu ... the palu:nt·... allentlon on the ta ... k. Patient pTI\aq· ... l1ould be re,peL·teU. ""lth adequate draping and PO'lIlOl1l1lg. ThL therap'\t ...hould con'llder good body ml'chanKs. etlectlH~ U'lC of gravIty and po... ition. and correLl application 01 tethlllquc., and modalities. An) equipment :'\hould ot" ~athcr d pnnr to treatment and be III good \\or"-.lIlg order \1I ,.lfet~ rr~LJutlOn, mu<"t be

ob,crvcd. The patl~J1I's pn. 1 1'.:atlllt:f'.! "\c! of IUllltlOll or inllial 'late .. PI'lild he .1It.Jull\ d ~ (jen...ral ....dte orgamzatin" 01 lhe cClllr I '1.. lli'''~ l nd hllml?o,tatic balance of the "OJl1tltl 1'1\1 'Il. II f) 1 \ terns iJ.rt. Important dcter1ll1l13nh 'H IW1\ a I"!!:em IlLl\ r(",pond III treatment. StocknH:yer=fI PO:l1l' l'ut that a "Ide range of intlllcnces. from emotional h) cog,nltln: tll o'-ganh,:. m~l) affect ho\\ a patient n..; ,ll.:b 10 .1 partl\.u J treatment. Patient.. \\lIh allered homeo\tatit. mt.·('hanl'm .. (e.g .. the patient \\lth traumatlc brain I1lJury \\ IIh ~ithL"r htgh or 10" arou ...all can be expected to n:act to treatment in unpredH.:table "ay~. Rc\pon<"es to treatment ",hould be carefull) monitored throughout the cour,c 01 rehabilltallon. and treatment modifications implemented a ......oon a... needed to en.. ure ~ucces~ful perfoflllance. Therapl..,h de\clop the "art of clinical practice" by learning to adjll\t their Input (e.g.. verbal command\. manual contach. and ...0 forth) in re\pon",e to the patient. Treatment thu\ become... a d) narrllC and interactive proce!)... bet\\.een patient and therapist. Shaping of behavior can be further enhanced b) careful orientation to the purpose of the tash and how they meet the patient"\ need!). thereb) en\uring optimal cooperation and motivation.

Step 6. Outcomes This la~t step is ongoing and involves continuou~ rcexam-. ination of the patient and a determination of the efficae) 01 treatment. The progress report .,ummarizes ree\aminatwn findings. and evaluation of the patient's abilities in tenns of the anticipated goals and expected outcomes set forth in the POCo A determination is made as to whether Ihe goal ... and outcomes are reasonable given the patient"-. diagno.. I"I and progrcvi made. If the patient attain, (he de ..ired level

Chapter 1 Clinical Decision Makinl

l.:ollll~tenu: lor the \IJh:d goa". reVI"lon"

lhe poe ,Ire IIH.ht.Hed_ II the pallenl altalll .. lhc de"'lred le\ocl of com· IX'ICIK': lor Ihe .:xpeLlcd oU(t"()IllC\. dl'lchi.lrge 1\ l.:on"ldcrcd. It Ihe pallcnl fad .. 10 i.Ichlc,"c Ihe .. lalcd goah or out· t:OIllC\. Ihe Ihcfi.lpl'" mu\1 detenllll1c why_ Were the goalo;; and oult'ome'" n:i1h .. IK gl\cn the di.lIabao;;e? Were lhe Il1ler\cnllOI1'" 'lelcued al 1.111 i.lppropnalc Ic\el In challenge Ihe pallcnl. or \\cre lhe) 100 ea\) or 100 dllfit:ull'! \\'a ... lhe pallenl .. ufliuCIlII) 111011\ aled'! Werc IIllen ':Illng and con.. tra1l1lng faclor .. (ch\ahlcIl1CIlI n ... 1.. taclor.. ) Idenlilicd'! II Ihe 1111en.:nl1011" \\ere nol appropriale, additional infoll11a· lion I'" ...ought. goal ... 1ll00011lied. and dllierentirealment Il1ter\enIUl1l" ...eIedeu, Re\ 1"101l 111 the POC I'" 1.11\0 indicaled If the pillll'nt progre ......e ... Illore rJpldl) or ... 10\\ I) Ihan C\JlCctcd. F~ll'h lllolhfirJIIOn 1ll1l ... 1 he C\ alliated 111 tenn ... 01 II ... (nerall cfll't'l 011 Ihe POC Tllll\ the plan hct'ome ... i.I fluid ",alelllcni 01 110\\ the rallCnl I'" progn:~"lIlg alld \\ here he or he I'" gOll1g, II'< o\cl'all .. uct·e ...... depcl1lh 011 the Ihcra1'1 ...1 ong()I11~ tllllll.:.l! deu"'lol1 lllal-.lIlg \1-.111 ... and on engagll1g tht' p.llh:-nl· ... l'oopt.·rallon and mOII\aliol1, Patient 01

In

Jdherent"(· to Ihl' POC ... hnuld be uOt'umentcu DI ...charge planlllll~ I'" IIli1lated carl) III the rehahllltalIon rroce ...... dUrlll~ thL' d~l1d colk(:tIOIl ph~hc and II1ll·I1 .... lie ... a... goal and e\pct"ll'd nutcollll· ... arc clo"l' 10 lx-ing rcarhl'd, DI char~l· pl.mning IllJ\ .dq) ht' 1I11tlJted il the ralJelll rl.'fu\t' lunha ·rl'
I , ....\Jlb

ttlr

lIl'" ()'lln'l!a

!lon 01 "'l~1\ Ill''''llllhl hL tlTl tull} dOI..'Uilll'tlll'tl. COIlI110!~:IJt, 01 an dkdl\e di,tharg:c..· plan 1I11,:lud l \ n Hiell! tam:l ()f

larl.'~l\ cr

etlll ,Itll n I ~ pl.m

lafe OT rckrralto i.tlloth

~ O1c.:l,.'lll·\

e\erel c plan
I'"

('\.1,\1

, .. tr

It'on

11."111

dl ...char1:!e dalc

III

PI'll a ...... ume~ the role of experl and sole planner, establishing the rules. regulation .... and in~truclion., for rehabilitation. Rather, it i... important to empower individual., to a .....ume a key role in planning and ens.ure the plan fits their Iife-\t) Ie for life-long self-management. The patient's abilIt) and 1110tl\'aliol1 to participate in planning does vary. The 1110re III the patient. the le.,s likely he or she will want to be aclively involved in planning. As the illness resolves and Ihe palient begin~ to feel better. the more likely he or she \\ ill \lvant 10 be engaged in planning the treatment. Also the more difficult the problem~ encountered, the more likely patient' are to put their lrust in "the ex pens" and the less Iil-.el) they are to trust their own abilities 10 reach effective deci ... ioJ1\, The therapiSol needs to guard against promoting dep.::ndence on Ihe expert and the patient's feelings of percC1\ed hclple\\nes~ in order to assist in developing the pat1'..'nt ... 0\\ n deci~ion making abilities. ()7l·" t.'t ,tl.'~ address these issues in an excellent refer-

.t.... (/,'.l

orJer to t.:ll ... urL' In) traillJJl~ In U"l

'-1,.,' 1 Teel Approllch. The authors suggest asking

the p, tlCut a qTie~ of prohillK questions to engage patients 111 the 11l."lImcnt planning process (Box] .5).

I..

,'I,.'J

Iu

\J"I~l e.....

",!'ln~in~l

hould hI,.' (lrdcn.·u b('li'l

t'ptit1ed 7""'Olment Planning for Rehabilitation--A

Til\' 11.'\ '1 of participatIOn in thIs. process may start out

I t'l,"l

IIllx.l fll,lt,

01 thl' home 1'1l\Ifllnml nl In .,'" I tIll... r.lIllnt

home, L: ...... ('nl1al l'LjUI(lIllUH

plete trml\etllon of the cervical ~plllal cord}. Thai arne patient may have cloolabli ... hed a very different ~t of per...onal go.l1 ... and expectallon.. (e.g .. return to walkll1g). For many pallen", for whom complete recovery iloo not expected. lhe overall "goal of any rehabilitation program mus.t be 10 incrc
1:- nrr< ," t.ll ~ . " ,~

15

':1('

',; LJ

'0

bt.: expected 10 expand as the collaborative cllI1tinucd. A Le\'els of Participation Scale can i..10

tl1 e\ aluate and document patient participation in

Hie p"lllnll1g proce~s (Box 1.6). In detennining what level

I,lj

mallltenann;' , tomplt'led The therarl't hould " I ) mcludt.: thl.: di charge pr0J:!,no,i... [: rIG.!II) a OIlL'~\\ nrJ re pon e lIlh.l c\tdknt ~nt.J lair.

01

poor II rl.:'tlcl' I

the tht:rarl"''-'" ,ud~lllent III the pcttll'nl .... ahilil) to maintain the le\cl 01 fUIll"tIlUl adlll.:'\l:d at the ('nd 01 rehabililatJOn v.llhout LOIllIllUl.'d .. I-.dled 11ll1.'l"\'Cllllon.·-l

Box 1.5 Questions Designed to Engage the Patient in the Treatment Planning Process Wh,lI are your concern... ? ~ Whi.lI i.. )our grei.lle-:.Il.:oncern·)

Patient Participation in Planning Il1\oh IllS;! the palll'nt alld t
\\11,11 \\Quld )OU lil..e 10 ... ee happen 1 What \\ould male )Oll fed Ih;.!l )OU are n1<1llllg prllgn:,;.. III dealing \\ ilh your chie! cOI1l:em'? What are your goals? 4. Whal 1'1 your . . penlle goal? 5. Wh,lI r('~lIlt .. have yOll achieved" h What I)rohkm ... do ) 011 11<\\ e? What qlle.'ltlOn.'l do ) ou hav~?

Wh.lI \\Ollid )OU lile 10 'lee ill"Comph.'lhed thilt ",ould nul..e you teel Ihal )OU Me mal-.lI1g 'lome progrelis in de~lllI1g With )our greale.')1 cont'~rn'! I-rom 01cr M, Pa)IOn 0, Nd\on C Trclilmelll Planning Il)r R~h,lhlhIJllun: A P,llient Centered Approa\.h I\kGnm-Hlll l\ie\\ 'or'"

,WOO I'll n •.od Nt. \\llh permh\h\n.

' .

16

Ph ical Rehabilitation

Box 1.6

I.e,·el. of Participation Scale

FREE CHOICE- The lherarl I .I"k an orcn-cn"~d queshon. The patient t.: plore . . and ...ded the an .. v.cr (what) and further "rel:lhe~ \".. hac'l and 10 \\hal degree"~ B = MULTIPLE CHOICE- The IIH~rapl"l a... b llw: .. llon.... pro\ide ugge\IIOn, (three option,). The pJIICll1 ..deu, one chOKe from (he J.hcmauve, rre'ented

C = CO. FIRMED CHOICE, The thccJp"t J,k, ~ucs­ lion. pro\ Ide.. a TYI.:t.1mmendalH,m «(lilt" chou:e) .tnd 3"'" for agreement. The pallent put'-. Into ha\ been \CIC(led

D

0'" n

,..'OTd.. \\ hat

= FORCED CHOICE' The
provide, a recoillmendation (one option): the: pallent agree'> (or di"lgrees) With what ha, been \elcl'led. E = 1'\0 CHOICE: The therapIst prescnbe... doe... not ask. the pal lent IS compliant (or noncompliant), From Ozer \1. Pa)IOn O. !\ehon C. Treatment Planmng tor Rehabililauon: A Patienl-Cenlered Appro..1ch \1cGra\\-HI1L 'e\'o York. 2000. p 44. \\ ith pennis~ion.

the patient is functioning at, the therapist start~ al the upper end of the scale (free choice) and mo\'e~ dm\-n Ihe ...cale a, necess3T). The lowest le\·el of participation I~ recO! led. For most patients. the lowest level of participation is ('ptlmally Level B Multiple Choice. Patients" Ith '1gnifilant cognitive or communication deficits (e.g., thc palient with traumatic brain injury) typically will require lower levels of participation. The goal. ho\\ever, as the patient recover\ and progresses in rehabilitation, is to increasingly invol\e the patient in the planning process. to \'vhatcvcr c\.tent po...· sible. [n these situations. the therapist can document improving levels of participation as evidence of rcco\ery.

Evidence-Based Practice The analysis of research evidence paired with the physical therapist's experience and expertise provides a powerful tool to guide clinical decision making. There are numerous areas of practice in physical therapy that lack rigorou~ examination and evidence. Therapists use some intervenlions all the time simply becau"e they are in widespread use. Wolrl< cautions again~t empiricism. that is, continuing to use a treatment simply because It has \\orked in the past. Therapi\t\ may also elect to use intervention"i because they are new and different or becau"ie they are the focus of "anecdotal testimonials" in continuing education courses. For example, nonstandard therapies have been described that are based on Iheories incongruent with anatomic or physiological funcllon or have been proposed for a broad IWlJC of diagnoses ",Ilhout adequate scientific evidence In pec:r-reviewed joumah (e.g.. myofa~cjal release. cran-

los,h..r,ll mohlll/,Jtmn). H.trns PO ll1t nul th,lt th r pon I hlllt) to deliver c\'ldcnce h,l cd tr Itm nl technlqu re \\ Ith all ph sKal thcrapi t p I To th It tnd the Amcrl(dn Ph~ Il.ell Therapy As O<.latlon f APTA) ha developed teon ha ... been expanded into e\idence-ba~ed practice IEBP, to enl·ompa a hroader rang ot health prote... Ion. The e enlla! "tep fit ERP an.; o

Step 1: A clim II pfi hlt-'m Idcnt tied .and an an"y,erable quc-.tlOn .... I rlJl , ul"t~d Stl'p: A ')-~,t.:111JI' I III r· lur re' It'\~ t\ t.:onducted and I.'\'iden('(' colk't,.l(' uknu: . . f' a: y anal~ led for ih • E I'~ Impa t '11 C!I t S, I 4 1 h~ I". I!'l 1.1, ""\1 , h-: ll~d anti Integrated .' Hr, {'" JlIlI·I"· t X.f ,..tl,e an.. [ c patient", unique ci13r•.l l:lt:rl\!lC\ :1t. \ alll!.: Slu) 5: The elfcct1\en.:,"i ,tlll1 i.:.Til:ienc~ of the \tep" in the l'\',dcl1cc-ha\cJ pwce...... are e\i.lIuated.

A. \\ell huilt rt'.H'(f/ch ejw'stiol1 coTllall1" three elemenh: ( J ) a ,pecific patient/client group or population. (~) (he \peclfK II1tenentlon\ or e\po... ure .. to he ,tudled. and tJI the outcome"i adlie\ed. For e\ample. a pubh\hed ,tud~ 16 examined intcneotion... commonl) applied for 10\\ back pam (therapeutic exercise. TE~S, thermo{herap), ultrasound, ma\~age, E-\tim. tracoon) uSing outcome .. Idenu· ficd a\ important to the patient (pall1. functIOn. patient global as~e,smcnt. qualil} of life. and return to \"orld. Sntcl1laric' rC\"fC'l1' (SR) i... a comprehcn"'l\e e\anllnation of t1;e literature. The re~earcher detennine ... ke~ re ...ource~ to provide the e\ idence. These include ( I) peer-re\ le\\ ed and evidence-based journab. (2) online seT\. lCe~ (e.g.. Cochrane Reviews, Database of Abstracts of Revic\\ s of Effecll\'ene~" or DARE. Phy,iotherapy-Evidence Databa,e or Pedro). and (3) ,earch engine, (e.g.. PubMed. Sum Search). B~S 1.7 Provides a brief i1~t of ESP Internet resources. SpeCific (nteria are de\eloped for the lI1c!uslOn and e,c!u"'lon of'he { research studies \elected for re\ie\\. Studic"i emplo)lng dlf· ferent designs Illa} be analyzed indi\ iduall) or compared qualitativel); 1'ItlIdle~ of Similar design ma)' be combined quamit<.ltively (e.g" meta-analysis).ll.\~ , ' d Critical analy\is of research finding, invohe"l dewde examination ot the methodology, re"ull .... and conclu\,lon.... The clinician 'thould be able 10 ans\\er the follo\\ Ing que'{Ion...: (I) What I'" lhe le\el ot e\ Idenee'''; (2) ,.. lhe e\ I·

Chapler 1 Clinical Dec. . .

Box 1 7 E"idence-Based Practice: internet Resources hUp ~,,""nd:'ll nlln mhe:o\ Pul'l\kJ hllr II\\. \\ \\.,nh l.rd)or~ 'll..u~ J.lft:hp.hlm IUlp:f/", \\. \\. .urJ.llt: ,"111\~.lrl.~.I.I\m/uxhrancl hl1r:llhlru,m..:Ill..... tcr.I..I~ (xhr.lnc-!l.cnl..:f iC..tnadl'!n hu p:l/.. Ul1hc..trl. h uth"I.'J ,cdU/"CJTI. hloml-l5. htm hllpj/rt\~ \\ \\.xl.h... u.. )d.cllu.Ju/pcuwl http://",\\\\ ... hel.JI.. .1IJ,J-..l.:harT/l rA:nn:. him I 1111 r:lkl.'bm .Jr 2.U\ ..11.:. u"-kal ..I.d Ical ...hlm I hllp:/keom, Ir2.0\ ...11..' .uJ,Jdo<:../II..·\ cl .. ,him I hup: in:hm.uloronhua! hup: Illm"on· l.llc:mcnI.Org hilI': /cn..:ac.ncli 1,14 Imcla·anal) ..t,,/mcla·anal) ..".hlm

t.!elll.:l' \Jllt.!·~; Jnt.! f.~) Are the re ..ult .. lInportanl Jnd c1l1lil'alh rek\ . t il!') Thu .. IIllerpretalJon .lnd ...) nthe ... l... of the ~\ Ilj~nc~ I11U"1 l.1~ l'l1l1 .. iden:t.! \\ IlhJl1 the conlcxl 01 the "p~l"1fil' pallCIJI/cllcllt problem. E\.Lll11l1lallOll bcgin~ with Ihl.' purpl"'e 01 IhL' .. tut.!~, \\hl(h ..hould be c1earl) ...Ialed, ..lJ1J lht.' re\ le\\ (l! IItcrature, \I, hKh .. houlJ he rclt:\ ant in Il'nll' (1' the "pl.·nlll.. ljue... uon .1... keJ. The l11e-thoJ.. !de"'lgn ..hould be . . ·h"'el~ e\Jmln~d, Dt'''I~n [\PI? ... \.lT~ greatl~ Jnd l.',lI1 be 1."\ ;Jlu;Jtt'J III tt.'nll'" of It:\ 1..1 )f e Jt:lh..:e \I, jth grad~ ol re-U'll11l11l. llbtwn In or kr I nw t til iea.. t ng(lTllU l n l I \wd \ II u ie J ot ;.t dd1l1111g l'haratleTl ..tic le.g., GlI1cer) and lornpared tu ;.lJ1otha "lIllllar group \\ ithoul lhe definlllg lhi.lratll'n~t1l to tlch:rmlne If a \ . lfli.lble (e.g. ~moklllg) h a\!'ooi.:lakd \'. IIh the con<.J!t10n, fhe "rutlie~ . Ire retro(ktll\t: JO thai lhe) C':-.amlne outl;ome~ to a previou ... t'xpo\urc!intCT\cl1llOll or cau ... al tauor SIIlg.le-ca"e de"'lgn Ill\olve~ one ... ubJl:ct evalualt:t1 over tllnc. Varying uc"gn ... (A B A. or A B A B) allow l:ompan ..oll 01 Ihe lI1kT\ClltlOn period (B) 10 a ba...clJlle period 01 no Inter\1:n1ion IAJ. Ll \l'l 4 \lIull< \ lI1tlude ta'>C·:"ICnc~ and poor qualll) cohort und ta'lot:~(;omrol ~Iudlc':l. Thc:"IC ...Iudlt:~ are li.lfgcl) de tnpllvl: SUbJl:t.:h ",nh i.I (;ondltlon 01 lI1tCfc!'ot an: e:-..u1""lIned O\er

l\t tree

pu~lt....

an:h engme

daw~a e: a~ lTaCI pi rehabilitation eft...;."._

Cochrane LibraI') Canadian O..x:hr.rnc Cenler ~kta-"eaf(,:h

cnglOe MedhnC', DARE

phy'llolher.lp> 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 \\ The evidence

18

Ph)''iical Rehabilitation

Table 1.1 Evidence Based Practice: Level. of Evidence and Grades of Rec01nmendat.ion

~~

G

of

Recoiiamen"st' ...

a SA of multiple ACTs (with homogenlclty. large N) b Individual RCT with narrow confldence Interval

A

2

a SA (with homogeneity) of cohort studies b Individual cohort study or low quality ACT (small N) c: Outcomes research

B

3

a SA (with homogeneity) of case-control studies b Individual case-control study

B

4

Case·senes and poor quality cohort and case·control studies

C

5

Expert opinion without explicit cntlcal appraisal or based on physiology. bench research or first principles

D

SR = Systematic review (Including meta-analysIs): a revIew In which the pnmary \udles are summarized, critIcally appraIsed. and statistically combined. usually quantltatll/p. natu ~ th speclf c Incrusionfexclusion criteria RCT Randomized controlled trial: an experimental study In which ~art'c p ,ot are retncK n y assIgned to either an experimental or control group to receive dlffl;!r Interver.tlon r i ar:ebo Cohort study A prospective (forward-in-time) study: a group of r 1rt Ip rt cnr rt a a condition is followed for a defined period of time; comparison S rr lc I, rn ,"'0 hal cloes not have the condition Homogeneity SR free of variations (heterogeneity) In Ihe cjir~( IS f'jPqr,., I e b'?: ..... ee individual studies. N = Number of subjects. Case control study A retrospectIVe (backward-m-time) study
r

then translated into EBCPG~ by reviewing key Olltcomc"l and deciding whether the intervention had clinical henclil. Categories of absolute and relative benefit were u...ed. The panel established a clinical improvement of 15 percent or more relative to the control as an acceptable level of C\ 1dence. Recommendation~ were graded based on le\'el"l (methodological quality) of the studies. Grade A or B recommendations were required to demon~trate clinically important changes and statistical significance. The panel"~ positive recommendations were then sent to 324 clinical practitioners for their feedback. The panel revie\l,:ed practltioner~' feedback and revised their recommendation\ accordmgly. In the low back pain study, the panel recommended the following EBCPG" (I) the use of therapeullc exercises for chronic. subacute. and post-surgery low back pain and (2) continuation of nonnal activities for acute low back pain. TIle panel found lack of evidence regarding efficacy for the use of other mlerventlon\ (e.g., thennotherapy, therapeutic ultra\ound. ma\\age, electrical stimulation). A similar proce~\ wa,:> u\ed to develop EBCPGs for rehabilitation of palienh wIth knee pain n and shoulder paln.~1\ According 10 Roth,:>tcll1, the~e \lUdie~ are clinically impor.

tant in that the) "are not telling u... \\ h,lI i... "-.l1ml, nand 1,1, hat 1\ not lnm\ n, hut what I'" \upporteu h~ C\ IdcllI.:c .. U1<.1 \\ hat I'" not 'lupporhxl b) e\idence:'jq p lb~) The gUlddmc... pro\ Ide U"l \\ Ilh a 'lummatlon of ix'... t po...... lhk C\ Idt"nu~ for u...e tn clinical practice.

Documentation Docul11enl,lIion 1\ an e......enllal rCLJulrt"I11CnI lor 1l11lel) rClmhur\emcnt of \en"ice\ and (OI11I11Unl(aIiOn among Ihe rehabilitation team member.... Wriuell dtxumentaliO n I" formally done at the time of adml'l'.. ion and uI'lcharge. and al penodic 1I11ervab dunng the cour....e 01 rehabdUJtlon (Il1terim or progress notes). The fonnat and 1I11Hng 01 not~ ... Will vary accordll1g to the regul'ltor) reLJulrel11ent ... \peCIfled by In<;titulional policy and third-party payer~. D.lla Included in the medical record \hould be me3nlllgful (Irnporlanl. nOI just nice to have), complelc and arcurJ!e (valid and reliable), timely (recorded prompll)), ,Illd ...) .... tcmallc (regularly recorded). All handwrittell enme'"

Chapter 1 Clinical DeciAion

Makinc

19

Guidelines from the APTA's Guide to Physical Box 1.8 Documentat.ion . P raclJce .• The..-aplst Ol.XUmellf3110n .. hould

lion 'WIth pallcnl/t:henl. family member""can:giver'I.OI' other provider...

Indude'

Appropnalc ldentllil.'aiton 01 the patient'", fulln3mc and ldenlllic.1tIOn number. II applicable "'I

TIle dale and the pro\ lder'", full name and de\lgnallon (I.e., PT or PTA). Senll..'c, pro\lded by ... Iudelll'. ... hould Include Iho~e de,ignaIIOll\ (I.c .. SPT or SIYfAl "nd ,holiid be co- ... igned b) a Ilcen..cd phpiicaJ therupi..,1.

-" The manner

III

"hich rhY~lcallherapy 'lcrVlce ...Ire iIllIHU-

cd (Le .. referral, direct acce..s) .. hOlild be indicated.

4. The re . . uh'l of the hl'aory...y..tems review, and adlllllli ..lralion of appropriale IC'iih ,md measure.'). The rewlt.., from a fe\ le\\ of communication. affect. cognition. language. and Ieammg <"1) Ie I" .11"0 included.

.5. The e\3Iu3Iion. diagno'll .... and prognosi ... TIw, includes Ihe Identlficalion of Pretcrred Pr.lclice Pattern" and ICD-9C\1 code.... ~ "" -:"- -"

a~

appropriate

POe IOcluding anticlp.lled goah. e\.pecled oult,:ome". and mtenentllln... Thi 11so mclude~ palient!clienl and famil~ caregi\er eJul:ational £ual ... and .lrrr\)prJ.lt~ l..'ollaboration and coordinalion )t lare with otha protc ...... ional .../ ... tT'o H.l'"....

b The

7 Re... ult-. of inlen ntlon or en 1l'e:-. pnl\ itied, 1i1c1~11.1111g change" in patient '"!atu ... Ix fHugre<;.;,. 17 r~r'rl~s,,·t1i1 Do(,.'umcJ1Iation ot mJi\ It.lual \ isih ... lhlUld i I:lude patlellt/dient ...eI11. pOJ1 "'r('~'ifi(. l:lh:-i'Vc';' JJI pflli~kd lfrequenq. 101e1l il) dUJ.illOll ,to ;,p;"ropli·.... lljlll i lfllo 111 pro\ ded. aJ.er<;L; Klion... to lhl'" II :-r- (;',,1,011. II induded are an. Ia-Llor... that mig! t ,~( II tit lH~",(q· lion aT' rwgrt" '0\10 ard intelldeJ ~ oJ.' Il.I.;. 1'.:.1 .1 cu.ihert:nu; t, 10 tru..tion J nd Lommun,.,
hould he 111 Ink kglhle anJ J~lleJ" i1h a It:~·tl .... ~'ll.ltun .• Chartlllg t:rrOf houlJ ~ ~orr~...· teJ h) a ...ingll' 11I1ethrough tht: error "'ith lIlitlalmg and datmg JIfl'ctl) ahmethe error Lrror houlJ not IX' t:ra...cd or l:O\efl~d \\ ith correU](m flUid, EleLtfOllH.; entnc ...... hould l"ompl) "'!th appro· pnate prO\I!o.lon~ tor !o.cturlt) alld l'lll1luJentiallt). See Box I ,x h,r JO...· ulllt:ntatlon gUH..Ielint:",

Problem-Oriented Medical Record Tht /JI"I)" /Il-/Ii/ulf£'d I11l'lJUlIlll'1 tJld (POMRI, orig.ln.tll) Oe\ c:I/ JP":o 0)- Vveed and Zlllln). ha ... heen adopted 0) man) III tllutllm 41 The piJtJelll Ircalllleill pnK.'e ...... I.. . dl\ Ilh,:o 11110 10UI phot 1: Pha.'ie I nit: fl,rrnallonol il d<.tldh..t'lt: Indudll1g hi 1(1). ph) ... l'-dl t).aJlUIl<.t(JOIl. anli Iahor.tlill') dud olher IL....I Ic ... UI!, Ph 2: IJl:ntJIlLiJliOn 01 a fk:llll!.. prohh:m Ihl lro/lltht: U1krprc;l<.tlIlJO vi lhl.: JiJtiJhiJ ...t: Indudll1g ">Jkllill. IHip.tlr In III "llunl.lIon (ph) ILll. Ih)dlOlogll.i.t1 "Ol'l.tI dllO (lI.,.iJ(H,niJl, re ultmg IIlIm the lh~ed...e prlKe ...... or IWIll uJlld..1ry Illlp"lIrllll:lll

8.

Re~ult\ of reexammatlon and reevaJuation. DocumenlabOD ... hould mclude an updating of fhe patient' /cllent's tatu; inlerpretatlon of tindmg~: and any reVi\IOm in lhe goals. outcomes. or POe.

9. SummatIon at Ihe conclu~ion of the episode of care (dilicharge note). Documentallon ~hould Include the critena for di~chargc: (I) anticipated goal':' and outcomes have been achieved: (2) patient/client. caregiver or guardian decline~ to continue intervention; (3) patient/client unable to conllOue due to medical or p<;ychosocial problems: or (4) patlcnt/client will no longer benefit from physicaltherapy service.:,. Abo IOciuded are a detemunation of the palienl's current physical and functional ~tatus, the degree to which the goals and outcomes have been achie\'ed. and the rea!o.on\ why the goals and outcomes were nO( achieved. The discharge note must also include the discharge plan related to the patient/client's continuing care needs. for ex.ample. referral<. for home program . additional sef\ ite"i. follow-up physical therapy <;ef\ice. continuJng famil) "nd caregiver lraining. and a statement of any equipment prmided. 10 unly :\L:t:cptablc medical tenninology ...hould be used in the medlcal record. Confusing abbreviations should be avoidt:J. Generally, a facility will have an approved list of abbre\ i<Jti·m.... Physical therapisb should eno;;ure that notes are '.UlJer<..tand...ble to all who read and use the medical record.

111\

is referred 10 the GUidelines for Physical Therap) -Lt~ and the Documentation Template~ lor Ph)' ~i ... ;ll Therapist Patient/Client '-'1anagement.':· pp "1n7_11<J r,'dtkr

Dn.:un,Cm.111()n~ Pr

Pha,e 3: Identificallon of a ,peclfic POC that include' inten e-ntion... for each of the problems described; e\'aluiHI\ ~ and progre.. . "i note!-, are included for each problem. Pha\e -l: Det~nnination of the effectiveness of the POC and ... uh\cquent change\ a"i a re\ult of patient progres\. The POMR thu, highlighh the rel'llion,hip of the databa'e to the POC and allow~ the \peeltle patient problem\ to become Iht.: cenlral foeu\ of planning. Computerization of the POMR I'" i.\\"i.lllabk to \tor~ va... t '1I110Ullt~ of data and r~late. . the 11lformauon to i.l r'lI1ge 01 pO ...... lble diagno\e\ and a\i.lliahle ll1ani.lg~ment OptlOlh.

Documentation Using SOAP Fonnal Progrc ...... nol~ ... are \\ rinen III the ... ubJec(I\c. obJel.:tl\e. a......e\... menl. plo.in (SO\P) lonnal SlIh,Ci.fln finding\ (S) are \" h.tt the p,uienl .md h, ... or her Lur\ll~ tell thl? ther.lpht

.lbtlUl Ih..' l'um:nt L:olldlllon ...khlt.:'t l·ompiJil1l .... lunL'llonal ,t.ltll,,>/,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

If;

1 H.( hnh.Il'atlOn

.,

1111 nt, nll.'n Ifl .11 n IIll hl,11 d (,)lIplllH:: till p.111 III 11,1' I h 1I lIlg lIm:ll ljunlc.:-~ 1ll.1 h ,h Ill" I Ill•. 1I111H.!.11I1 \ I III ((lml" "'(lllll 111lt.11l11,lIH'1l (I.' g I dnn', I1lC'd PI fhl'll n('Lhlll~ \\ ron!! \\ Ilh I11l ')_ f\kdU.,11 1l1lnnlldllnn nht.l1lll d IWIll Iht.: rJl1c.:-111 lh.H1 l,lIl ,II nne IIldudul IIl1dll.1 l mC1l1 !'t:ClU"'t.: Ihl. lhl"rdrl t 11.1 nnl dlft'lll nh ('I" il Ihl

,h ,r. r

011

I I'll

Illd II

nil

"

to l III"

~

I

tl,"

I'

I ,rn j (l'

IOn I m

n I

III

1

III

n,

rill 111111

"t

fu

I

Ii

Ifl

Imdlll!!

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<..nowledge ba"e is multidimen"lonal and patient-centered. Their clinical rea"oning is reflective. and focu"ed. Expert clinician~ collaborate effectively with palielll" and colleague",. The novice therapl..,t. on the other hand, may colleu "iml1ar data. but '" unable to organize

ndl\ idllal

,~, It ,!;enerall~

he t ~ J u"'p(,lll.h luJ~ment until JIl

li'lle datJ are gal h..-: rt.:'d. The data art.? ,1Ilal~ led inJI\ IJUJl1) ,mJ ('01leCli\ch belort' a final detenmn.lllon I nl.1J~ 01 h{l\\ to orgi.lIlll~ and u...e them The,",e .lInt..' indl IJuah arl.' "lei) to:ldort a ... ) 1I.~l1latiL· rrlx'C'","'ll1g "'I~ k m \\ hlch .1 melhoJical ... tep-b~ - It'p arprt.'.l\;h i... u"'I.'lL I'I.'mrk'Ilng I.lne ,rep befor..-: progn:- ing to tht' ne\t. COnlra... ung ... I~ Ie....m~ percepli\(' and IIltuili\e. The indl\ldui.ll \\ho lIfIillC" ~\ per("('{'{hi' cla/(l-~(Ilh('ril/'<: stylc \\ III ... eek. ..mJ re,pond W ongolllg ('uc", and pattern..,. defining JnJ organizll1g pwblem ear". Infomli.uion proce...... JI1g \... l.lrgel~ Il1tult1\co. Thu Ihe ... ~ l'Ill1iL·ian.., are abk 10 rt' ... ponJ III J large number 01 ... lI1null a... the\ on:lIr and con"'lder 1I11tiatiOn 01 coJ.r1) Ireatment OpliOlh.-.\~·Re...earch ... ugge~h Ihat ... t) le lTI~l) di~': fer b) expert group. Ma) and Dt'nni... -1-.\ and Jen t'll C'I <11 found Ihal clinician... \\ ith ('\perll ...e in orthopedic'" It'ndcod to lIlJ lilt' i.l rel'cptl\ e/...) ... tt'l11alic ...t) Ie. generating h) pOlhe..,e.., on" after J methodical and ordered ...earch ot d~1tJ· Elllbre)~ el al-l 1 found lhat pedlalric e\pert dinlchUl'" tended to utilize a pcrcepti\e data-galhering ..,t}1e and proce",~ information intuitivel}. Thus the) responded rapldl) (0 cue.., and pallern., (mo\emenl . . l'flpIS) and l~hallgc'" thaI occurred \\-ithlll lhe trealment .,e..,..,iol1. P...)cho...ocii.ll ... en'l~ li\ It) \....1.., a l..e) factor III directing e\penenced peJhltflC rl1

Chapter 1 Clinical DecUion

clinicians during the physical therapy se:-.sions. Novice therapistS were less re~ponsive to the psycho~ocial needs of the children and kept their attention focused on procedural matters. May and Dennis 44 reported that practitioners experienced in cardiopulmonary and neurological phy~ical therapy also tended to respond more favorably to the perceptive/intuitive style. Thus the differences noted in terms of the types of cognitive strategies reported appear 10 be evoked by specific problem structure and domain.

Self-Monitoring Strategies Important differences exist between expert versus novice clinicians in the area of self-monitoring. Expert clinicians were found to frequently and effectively utilize self-assessment to modify and redefine their clinical decisions. This reflecti\e aspect of practice resulted in improved improvi~ational perf0n11ance. the actions that occur when therapi~h are actually treating patienb. They were better able to control the lreatment situation (i.e., constant interruptions. the demand ... of many :-.cheduled patients. multiple ta:-.k:-.. and ...0 forth). and the time allotted. Conver:-.ely. novice therapi"'h demon ...trated ...elf-monJtoring. but \vere less able 10 utilize (he I11f0n11ation effectively to control the situation. The) reacted more to external .;timuli and the confu..,Ion of competing demands and '\'ere less able to offer alternate inten'ention ..;trategic.... Sclt-mo!'I~DflTis was \le\~ed :1', a po.. iti\,e e-.xperience by the experts !\~l-":C :." often a... b~ 110\ ilC therapi"'h. an inJic:ltlOJ1 that tilt IlIr.'penenced Iherapl,t<; were "'en'Hlve f,J their IImitatlon. Tile' expert... \~t're also JlllrC v..illl.lf to [al;.~ ri,J,'> 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 <.llltJ kll at home ascending the ... laIT' Ollhllk the Ironl dooT, Shl' was admitted to the ho"'pllal after ,u"ti.lIllJng J tr,IIl\U'r\ 1

cal. intracap\ular fracture of the nght femur, The patient fl\allOn (ORIF) rnx:edun: of the RLE to redm.:e and pin the trauure.

had an open reduction IIHemal

PAST MEDICAL HISTORY Patient I ' a \er~ Ihlll \\oman (9X pound ... ) \\ltl1 longstanding problem... \\ Ilh o,teoporo,i... (On medication lor X

) ear... ). She ha... a hl ...tor~ of fall'-.. three In the la.. . l )ear alone. ApproXimate!) 3 ) car... ago ...he had a m~ocardial infarction. and pre...ented \\ ilh third-degree heart hlod~. requiring Implantation of a pennanenl pacemaker Sh~ underwent cillara,t ... urger) \\ilh implantation:2 )car <.le-0: the left eye

I'" ...cheduled

I h~ ur ... t.ur... siceplllg Mea I'" <.:Iuth.:rcu nh ],lrl!C he,lVy IUrllJlun: The wumd floor hathroom is sm,111. \l,lth a high old luh ,lI1d pClle~t.ll feet and a lip. Th~rc IS no added t; qUI Pllll'llt.

PHYSICAL THERAPY fX MI ATIO I \lent Ii SIJIII \ lert .II1U oflcnted 3 Pica ant. coopcrati\e artil"ulate o .tpp,m:nt memory dcticit (,oot! prohlelll solVing ,lIlO salety d\"drenc prccJutlOr _

(

rt

l tl.l

Ie' [nll

aboul hlp

BPI 0'7';

m SOB with 20 mm 01 aUl\ It)

l

J

for ... imilar ... urger).

,

\

MEDICAL DIAGNOSES Coronary artery d"ea,e (CAD). hyperten,ion {IIT:\1. mitral ,al,e prolap,e. ,/p pemlanent heart pacer. '/p right cataract ""ith Implant. o~teoporo~l~ (moderate to severe

gla~

...

F l S

'1.

. RO I I.U BLb WFL Aflt'lled RLE.

Fosamax 70 mg weeki)

He 0 to X5 ht T \bd 0 to 20 \dd T II{. ~R T Righi knce' anu ankle- \\ FL

Atenolol ~4 mg po '1d MYI \\. nh Fe tab po '1d Metamucil tb, pm po '1d. Colace 100 mg po bid Tylenol no. 3 tab pm/mild pam

SOCIAL SUPPORTIENVIRONMENT The patient 1'\ a retired \choolteacher \\ ho \\ a... recentl~ \\ido\\ed from her hu ...band of'+X ~ear.... She ha ... t\\() on... and one daughter and tour grandchildren. all of \\ hom Ij\e \\ithin an hour"... urn lI1g dl'\tance "l\\a~. Gnl' 01 ha children \ ''''Ih e\C:f) \\eekcnd She ha a ramhUIK·1I0U ... black Labrador PUpP) that.... month olll and \\a... gl\l..·n to her "'-or compan) .. at Ihe lime hl'r hu ...hand lhed. She was walking Ihl' dog at the lime 01 lhl' aCl:Idenl She I'" .11l active participant 10 ;1 garden duh. Yo hlch meet... 1\\ Ice a month and in ",cd.l) e\ l'nh at the 10l:al ...enlor n:nler PrevIously she \\;1 dr" 109 her l.:ar lor all communlt)

_me. Sbe live alone in a large old 'e\\ England tamlhou e bome has an entr) \\ ilh tour ...Iair", and no rail (n"'H.k 14 room on 2 floor.... The do\\ n... lalr Ii\ 109 area

down mto the (amil) room \\lIh no rail. There 14 ..... to che ond floor \\uh raih on euher ... ide

IIlt:lLt

Incl ... ll.ln 1S he tied I J \Aell Ipproxl11Hltcd \';c·" bd"te",1 TED, '1 am /l "k;

ankle fracture (2 year~ ago). urinar} stress incontiOl..'IKe.

MEDICATIONS

ptll 1 Illpa I'" I

BL

II

111

the ,pine, hIp"~ and peh"j. o;teoarthriti' with mild pain in right knee. ,/p left elbo\\. lracture (I year ago). lett

r.. n:.

.11 m

(

tn.. *1~1 h

LU·. HI E . \\ H \lIellcd I{L.E (I,p ne, T' not te ted) H,p e t T H,p .,lxl T I\.nl.'''' c\.t -t .:' \n~k 01 -I '; PI" -I"

I

(Jo,lun.'

o h 11 ",cd hop' l'U. "'looped po...tur", mOl.h:r.ltc .... ) r 0...1.... l.: ,mo "'-nec.. E u...c ... \l,ct!I'e \.. hen I lIll."h leg length ... honeOing on "l r'- • ~

r~k

... \tllng \ 111d rc ..t1ng head tremor

"'t. Ibl.l1h.'I..· SlIlIng balal1l:e. WFL

:as

Chapte. 1 Clinical Decision Maklq

1 I. Pali""1 b llill,hly ~IOlinll"d

Slam.lmg h,t1
begllh

... lItlllg dO\~n· ...ale

month motion ch~\ atc ...eat of J...ILl"hen

"J ,","<Jnt 10 gel 111) life bacJ... rogether. get my dog home agam \0 I can taJ...e care of him."

PRIMARY INSURANCE

L' ...c'" 2-im.:h IOi.111l l"u hlon.. 10

dl.llr and li\mg roollll"h,lIr

Medicare

GUIDING QUESTIONS

9. I·UlH.:tiol1ill \lohility PallCJ1l \\a .. l·olllplclel) IIldcpendent (I) before her fi.lli. Re ... ul.... of lunl"llOnal a......e.....mcnt:

I ocd mobil II) I trall .. fcr..; ullahle 10 do IUb tran ... fer.. at pre ...ent I alllbulalion \\ Ilh ..talldard \\all--er X 200 feel 011 level ..urfacc.... partial \\Clghl·he.uing RLE Inaea...cd Il~\lOn of I--nee... and dor... al \pine

lone flight of ... t•.Ilr... \\ ith rail and SBQC

1. Identif} and categorize the patient'\ impairments into direct or mdirect. ""l Identif) her functional limitation~. dl~abihties. and a~~eh.

3. \Vhat are your concern,> regarding potential

10

Ill. \1)/.'

di~able­

ment ri~k factor~? 4. \Vhat i~ her rehabilitation prognosis? 5. Write t\\
direct he< POc.

6. Identify two treatment interventions you might include

I dre...... mg.. reqUire ... mlllimal

.I

ht

(\1mA) of home

111

hcalth aide for "'pong.e bath ... Require ... J11llderJIC a...... i ... tancc (\lodA) of home health aide for hOJ11cl11a"cr •.Il'ti\ illt" ...

her POc. What precaution; ;hould you observe?

7. \Vhat le~t\ and measures will you use to determine ~ucce~~ful attainment of outcomes? X. What precautions are important to observe?

References J Ib~l... l l'1 ,II L\r'rtl~~ It. Ph~ ,J TIi r BUllt.:r\\lmh Iklllt'I1Mnn. Hoq(ln Ii N Rlllh'1t:Il1, J\1. ,tnJ I I1Il'm.ll.h. II H. pllrh( -1'1:"1 lor dlnl~l;Jtl .\ IIll'lhoJ hlr e\;JIU,ltlllll and In ,llmu I I d' TI1l'r nfl, I ·:...x. 14\t Roth kill J\1 F I1krn h. JL ;Jrh.1 RIJdk Dl 1 n\; lnt"/l l'd 011 lndun lur I nlLl:m 111110 'I.e II t1" I n m;JnJ,.:c:ml'1lt PtJ Ild:-; .~'i'i, 200 ~ ..... mc:n~;rn Ph Il;J] I h r;Jp\ -\ "'1;J')On (juldo; I I 1) Thn;Jrl I p. IJ~ j Ph\ rht:r Itt I ~nll RandJ.II""l: j 1~l""cn·II<\\n1IO. IJe'll tnkrc: tu 1111.1 ..0011 PI Til.; ) ''-' ~III~J I, C hc=n n nlll O( IT \IJ":;J71Ot" J.m 1)- " IKI. ;J~l " [)I hUll and RdlJ.blln.: I Ohl St:.lk L 111\ (' C Iumhu ljI,

11, 1{C";)\lt';lt. J. Di\abilil)' and our id~nlit). Phy<, Ther 74:375. 199-t. 1 S;'l1"lll:llill. S: Dl,lgno... i\ b) tht" phy\ical therapi<'h prerequt... ite for lr\;,'l111Clll, I !)\ IheroS:170.1, 19XR P""_ '\: [ha!IlOt,[\; Defilllng Ihe Icon. Ph)', Ther69:162. 1989. ... \. Ilia;;thhb and c1a\\illcation by ph) . . icallherapi:.t'i: A <,pe-

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B.l 11111 t)'} Iklln J: IJ~,ntll)lIlg pT\lhlt'm~ in dlllll'.11 problem 'l)hing. Ph), Ihcrh'i:\lf'l

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"" ')hfl.l..lIl<.)<.r ') lllllllJI Jt'~hl~ln rn.tI..mg b.1'l'J llO hOtneo.. I.ltl~ \;l\ll<.l·pl In \\\11t ') Inll· L'lItl1lal [)..xi,lun fl.t.I"'Ill~ II) Ph''''I(JI I hCl.lp\ I -\ D..I\ h PhllaJdphl.t. !9S" p N ~ . ()l I \I P.t\ltlll o. d\llTJ. C Irc:,lImt:nl Pl.lOnlll!..: Illr Kdl.lhlltl,IIl\'1J ..... P;Jllelll.c(lltc:rc:d "prw.it.h fl.kL'r.I\\-HIII. • \\ 'I'rl.. ::'1I0tl 1S \\,111 ~ (11111•.11 D':~I\IUn \1.ll..ln.!! III Ph\"'I~.L1 Thl'r.t(l) FA D.t\h. l~hll.ldl·lllhl.1 11.11'1." ') Hm\ "huulJ Ir..-;Illl1enh l't.. ~llIlllu<,'d II,r"ll'tHIII~ ml·rt! Ihcr7hl7" 11'1119%. \() (HI.. t1I1Ih; \ l'llld kill fl.1 E:1l.,,11l S llull.,11 r..... t:.ulI' .Il!cnd.l h'r I'h~ "'1~.t1 thlr,lp\ Ph) 1 hl'l ;..:u:-tl}t) "I~. ::'1)(10 ~l \,I~I...11 I)..tllt! Il.l~IIC"'. H I \ Ilk tilt: B.t'l'd I\Ie.tlllne 111m III Pr.u..ll.e .tlill k.llh I Bl\l cd 1 <. hurdull-Ll\ 1Il~~1l1.ll' Nl'\\ '\111... :OOt.l 1 i 11\\ fl.llnlJ: hllkou..· H.I\L·d R~'h.lhllll.lllnll "i1,1.1.. Ihtlllllan: J IIMI} , • 1\1 II.UII I'h~

Appendix A: Preferred Practice Patterns: APTA Guide to Physical Therapist Practice4 Pattern G: lmpaired Motor Function and Sen5.ory Integrity Associated with Acute or Chronic Polyneuropathies

MUSCULOSKELETAL Palft.'rn -\: PrimJr} Prevenlion/Ri~k Reduction for

Pattfrn H: Impaired Motor Function, Peripheral Nerve Integrity, and Sensory Integrity A~socjated with Nonprogressive Disorders of the Spinal Cord

S"'eJelal Dellllneralization Pattern H. Impaired

PO~lUre

Patlt'rn ( : Impaired Mu"clc Performance Palll'rn [) Imprllfed Joint l\1obilll). Motor Funclioll. \1u . . c1e Perfonl1Jnce. Jnd Range of Mallon A.....,ocialed \\ ilh Connccmc Ti ...."uc D) ,JunctIon

Pattt'rn F: Impam'd

J01l1l

Mohllll). MOIor Function.

~1u"c1e

Perfonllance. ilnd RJnge 01 Motion A~\oclatcd \\ lIh LOl..'allled Inflammation

Patll-rn f Imp
CARDIOVASCULAR/PULMONARY Pattern .\: Primary PreventionlRisk Reduclion for Cardio\'a~cular/PulmonaryDisorders

Pattern n· Impaired Aerobic Capacity/Endurance A ... ~ociated with Deconditioning

Path.:rn «.; Imr~llred Jl.)lnl \1llbilit). \1ol11r Funuion. \Iu\de PeJ1omlarh:e Range of \fotillll .\"",(XIJlcU v. il.h h,tcture

Impaired J0ll11 Motllllty. Motor FUIlL"tl(JIl. '\1u...c1e PertonnallL't." R,lIlgl.... 01 \1.11ion \ ....... l\I..·lated \ I!~I Jaml \nhmpb I) Paltt.'r11 H

Palh:rn I Impam:J J 11111 '1uhlln 101111 FUi'l I', Mu...ck Per1onnafll..C . R..lIl1.'l' \..)1 \'011011 '\""lll'I;" l 1),1111 BOil) or Sot! Ti, ue Sur~el') '·atft>rn I Impaned \111lnr fundvlI1. \lu ... (k Pertunnalll..l;' Kange 01 \1011011. li,lit. Ll.K 'nH>l1I111 I Balance A...... llll
I'aftern I: Impaired Arousal, Range of Motion, and Motor Control Associated with Coma, Near Coma, or Vegetative Stale

I t II ( : Impaired Ventilation. Respiration/Gas F'.l'hange. ami Aerobic Capacity/Endurance Associated \' tl~ Alf\\ ay Clearance Dy ... function

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Impaired Aerohic Capacity/Endurance _d \\ ith CardiO\.a~clllar Pump Dysfunction or

:;,~

Imraired Vemildlion. Respiration/Gas Exchange \1,1111 Vt'ntilalory Pump Dysfunction or Failure

II ~:

Imp,lIrell \ellllialloll. Re;piration/Ga; I \.dl.lil~t: -\~'(lcialt:d \\ ilh Re~plrator) Failure

j, (."

. ELRO 1 S(CL\k

I, jlt Impaired Ventilation. Respiration/Gas 1 \ :langc and Aerohic Capacity/Endurance As~ociated \-\ lIh Rl'",plr,uor) Failure 111 the Neona[e

Pattt-rll \ Pnmar) Pre\t:ntlill1/R.I ... l r<'edUl.:llon 101 1.0....' oj Halallll;' al1d ~alhl1g

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1,Ifh'rn \ Primar) Pre\entlon!Rl ... l RcduclIon for Inh:gulllt'IlIJry [)I ... ordt."r.'

~&.IIIt'rn U

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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<;abilit\ and IlIne ...... 9. Underst;nd the common Jeftn ... j\ e rcactiol ... t·1 disabilit\. 10. Under.. t~nd ho\\ boJ~ IIl1.lge Illa:- .'le i""Cytt"J by di... abiJit~ and \\hat u ph:- ... i.. al th.:rapl II.:JII do to addre..., bod) Ima~e 1"'jUe\. 11. Recognize the \\anllng "Ipl' of fllh'll)] lin traumatIC sire" di ord~12. De.,cribe Ihe general a:.Lpl.!tiC' ~ ndrome. It:-. alms. u,e~. and potential JJ.n~l·roll'" l'U{I.:Omc'. 13. Identif~ cri",i~ POint-. in the reh thll1l3tlOn proce '). 14. Lnder tand the p... ~cho,r~Clal teLhlUlIues to fal:llltale cllent·cenlered lh\:rap} 15. Lht ...trategle, and re,uurl.:t' .. tor pre\ enuon, \\ellne~.. , and p~)cho\()(;lal educatIOn,

Influence of Psychosocial Factors on Rehabilitation Pat Predn,

OTR/L. MS. ABD

OUTLINE Suicide 47

P,\(,:hlhoual Adaptation 21.) G;ief. \1ouming. and Sorro", 29 Ph..N : \1odel\ of P'ycho!'>ocial Adaptation 30 Chromc IIIne..') and DI"abillly' Difference' In Adaptation 32 Po,ttraumatic Rehatlilltation 32 P":Nmalit:- md Corln~ 51) k, '\3

Sub"lance Abu'ie .+8 Substance Abuse and Rehabihtatlon 48 Treating Patients Who Abuse Subslance!'! 49 Educallon on Substance Abuse 49 When 10 \1ake a Referral for Substance Abu...e 49

PI:r-.onalit~ Typ..:~

Agitation and Violence 51

33

PeN)naht~

Dl,order... .3 ~ ('nrlll~ SI:-Ie... 35 Dl '

\. llI11'non

lI\l' I{.l:

DblhlJil \1 'h:t~

H) per'exuaJity 51 Psychosocial Wellness 52 Bamer<, to Wellness for People .... lIh Disabilttie.. 52 Social Support 52

_In, tl'

:'>

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.('
p~)thO~OCtal ractor~ pert
de\elopmenl 01 an Indl\iduJlln relallonlo 111'.. or her ~ol:lal en"m>nment P\)lho!'>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<.10r~ lIlciude prelnorbllj mel1li.ll 1IIne\\l· .... I~r­ (malll) \1) le~. lopmg ')lrakgle\, detclhe mClhi.tnl\llh. and t:mollonal reattlon\ to dl\abllll) Uthel ... 1Il1l11de plrlluallty, \alue~. t:m IlOl1mell1 adJu\tlTIent. l'ognlll\l'

abJlitie~.

III

Rehabilitation 52

Integratlllg P,ychosocial Faclor~ into Rchabilitauon: Case Example 53

d

Ie \ DI orJer I

Wellne.. !'>

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",ychoso<.:lal problemli.-' Patienl' "ith physical dl'iabdltle", may fall to respond to treatment If a promll1enl ps)cho'iocial i"... ue i... affecting them as \vell. Palienl~' perception, of their rehabilitation role influences trealment oUICOl11e~. Patienls who believe Ihal they possess control regarding their trealment and feel re"'rec1ed by staff lend to e\perience beller health outcomc~,-1-~ El11powennent, educalion. inclu...ion in goal ...etling. and a high le\'el of engagement are important factor... thai po"-\tively influence recover). The mind and the body are h,ghly connected.' Becau,e of their reciprocal innuence. psychosocial and physical issues should be addressed simultaneou~ly to best 1acilltalc recovery. A slow recovery ma) cause or prolnng dq're ... sian. which may in lum further delay the n:h.11,)Jht.j ;1 period. Watts belie\es that mental healIh 11It. ,en, en should be provided to all rehab,IItatlon pat,enl.. ,kalIl' outcomes tend to be poor and prolonged \\ h...·11 r\, ..:Ih)\'~· cial problems remain unaddressed.' Physical therapists regularly encounter patient:-. who have psychiatric illnesses. Psychiatric condition:.. occur WIth some frequency in the general population (Table 2.1 l. but

Table 2.1 Lifetime World Prevalence of the Most Common Psychiatric and Personality Disorders'

~

Paydaiatric or Dilanler

Alzheimer's (85 + years old)

-

Lifetime World Prevalence (%) 16-25

Alcohol abuse or dependence

15

Major depression

10

Marijuana abuse or dependence

5

Schizotypal personality disorder

3

Dependent personality disorder

3

Obsesslv~ompulsive

2.5

(lUlIr ill an cven higher rat In rcht.lhllUalJon ttm}! Fllr 1I1 ... 1 \\ell: the longer one po~ ...e:-.:-.e:-. :-.OI11C f0I111 ot menial heallh concern. Ihe gre~ter Ihe ri ...l... for de\'eloping a ph) ... ical dIne" .... Depre...... ion I~ ~ ri ...k factor for heart ol",ea...e and pO"I-...trol...e mortality. Heinemann et al found alcohol-relaled automobile .leeldent'-. re",polhlble for a "lgll1ficanl number of ",pll1JI cord injurie\. and Zegan'i reported thai p"')l'hologlcJI probk~~ can be e\acerbaled b) ph) ...ical dine ...... or ll1june'. Anxiely can also incrc~"e (he ri ..." 01 cardlo\a...eubr div .

dIsorder

Histnonic personalIty disorder

2.3

Borderline personality disorder

2

AntisocIal personality disorder

2

Panic disorder

1 2

SChizophrenIa

1

'I

ca...e and hyperten~lon." _ . ' 'd Although the co-occun'ence of ph) "leal ul ....tbdllle' .111 .. menial illne:>J'" '" high. the rate 01 - lreatment f or Inental Ill· I ·b·l· I \ In 1997 ' .00\ nes", among people- \\ Ith u",a I Ille... '" 0\ -_ " percenl 01 aduhs \\ IIh dcpre"''ilon. ~' percenl \\ Ilh JIl\ -. let} disorder". Jnd ~7 percent \\ 1111 "enou", men I.1 I IIlne"

"

recel."ed tre..ltmenl. . . _ h I £u.'JI A thorough exalllin:.lllon 01 Ihe pallenl·... p... )C 00 'b 'ficaoll) 10 iI b"",'md ...ocial functioning call conln ule "lglll II ., . . --Ie l.Ind C'lpa I tel' undCrSIJlltilng of need lear.... all\u.:: I '. Ihe IIC:>J. a~ '''ell a... funll'~h e entlal Infonnatlon JboU~ IJJ. d l abllu,. ';)"eh I . all n' Pallent"" emotion;)1 J djU'ilmCn '0 ... II\C fum.:II00l c nl d blllllc.... per...onallt) "truclUre. an 4.:og ~

Chapter 2 Influence of Psychosocial Factors on Reha •

Box 2.1

Major Areas of Consideration in a Mental Health Examination

• Pre~ent and premorbld mtellectual. emotional. and copmg function1ll2 • Present and pre morbid psychopathologies and personality 'itructure ilnd dIagnosis of levels of depressIon. anxiety. and other mental disabilities . • DeterminatIon of suicidal fendencies. decompen~atlOn. and other ri'\"'s • Degree of orgalllCII) and cognitl\;e disability and its relationship to the patient\ rehabilitatl\-e capacity • ymbolic meanml! of the disability and loss. Jnd the c~mpensator: re"~f\ es that can be elicited • Fru,tratlon tolerance. motl\ation. and <;econdary gam interference - Levels of pain. stre...s. and tolerance • Determinauon of \-ocational interesl\ and bad.ground. and present functioning capacity • Se\Ual altitude" and dysfunction • Detennination of pre...ent and prc·morbid family structure and interaction. social and economic statu". and [he natural "uPPOI1 network. (environmt:ntal upport s)"tcms)

The ...e l:an then p~ u... ed h."' better under land the.: patient"" emotIOnal barner... and h~h3\ IOr;}1 ,.fffiL·ullle'i that can impede ren)\cn \lthllugh not mc,u ... 1 t' Ho\ 2 I highlight'-. the maJor al ... of L Jf"idl r li\~n il1 J 111 .... nt.· health e\ammatil)1l \\ hether pi h.. I fht'rapi t h, l'ld add~ :. . r jd' 1)ual I ut' iur._ t t' If 1.:1 '11 rl"f .... P"\C'lll"J~1 tid) lmpaut'd p tier{ tht.:l ptot \( '1.1 01 . ' eral \aT1abl~ I thl; \ rII thl.: ,...tJ .I t .)('1,11 I ue' 2 the I ~ nfl rt Ilh \\I1IL'" tl "11 !LaJ therapl t L.iP .l41dn: I) I. htl ()I.: .11 pn hlt:lll 111.1 th ... paticnt ...blll! 10 rugre In reh.lhilJt th l It ll'-'t! P )Lho ~ual I Ut: .He nut .tJdn.·~. . cd. PilIit' ~If nil!.... to v. h"rn rekrral Ill<.t~ ht: mallL tor .HJdltlOnal p.. .yLhn . . ocial 1Il1t:f\elltlon include hut '-1ft: nol limited to p )l"i1Iatri'h. p ~dlOl{Jght P )l'hli1lr1L nur L' , OLtupational thcrapi'ih. ou31 y.orh.Cf In':''illl\e i1r1~ tht:rapi h. \Olatlonal Loun~1(Jr rc::h<.thlht<..ttlon LClUn5.l'Ior uh talll:t' ahu . . l.:· prote'i100al and pa toriJl LOUlhdors

Psychosocial Adaptation fhe C(Jlnhin<.tlil,n olllltt::n,e Ih)th"loglLi11 "tn:ss, lInu~n,un pH,gno 1 prolonged trei1tlllt:nt dilL! IlIlc,:dt'Il':IK"e ""Ilh dad alii IIle l:.1I1 grt:dtl) IIllp<.tLt the rt:h.thrlll'1I10n 01 pall nt \\lth ill ahilltlt: iJod LhHlIlIC Illnes e /Jt:whllt/\ I' I It IJr dlnllill licd abllll) to dorlll [leU"" MH.I.tl r lIt,nliiJlly rll:ut=J 01 tht: p.lllt-1l1 /J\\{ hOH'{ Iti/ lJ hl/lla/IiUl tit til ahllll\. dlld lillO/ilL 111,1'"... I .111 111l1:!011l ' J

dynamic. evolving process through which a patient trivea to attain an optimal Mate of function within his or her environment. 2:! Succes~ful psychosocial adaptation may be characterized by a sense of (I) personal maslery: (2) participation in social, recreational, or vocational pursuit: (3) successful negotiation of the environment; and (4) a realistic awareness of one's current strengths. deficits. and functional capacities.2-~ AdjuMment is the final phase in adaptation and includes striving to achieve life goals. feeling self-confident and having positive self-esteem, possessing a positive attitude toward one's disability. forming emotional connections to others, and establishing a community member role. 24 The processes of adaptation and adjustment are influenced by whether or not a chronic illness or disability is congenital or adventitious. of sudden onset or gradually progressive. and stable or unstable. Patients born with a physical disability and those who acquire them as a result of accident or disease later in life have substantial psychological differences. 2S Children born with a physical disability have only experienced life with their impainnent the development of their self-identity commonly mirrors that of chIldren without disabilities. In contrast. patients with adventitious disabilities often experience acute loss and grief. Patients with gradual1} progressive di~eases or disabilities of sudden onset often e\perience anxiety and shock when first becoming aware of theiT condition. Such anxiety and shock is often followed by rtl1ger and depression. as patients realize the magnitude and (lll,\equences of their diagnosis. 12 Disabilities of sudItn oll~e[ (e.g .. injuries or accidents) are usually experier.ced J:'\ cri e~ that will change the lives of patient~ and their famihe for all time.

Grief, Mourning, and Sorrow p~):chological ...tate of di~tress re . . ulting from a ... lg11lticant lo~ ..... In reaction to a di~abdi(). grief rna) emerge from lost function. bro"-en rclalion'ihip .... the 10 ... of one\ familiar ...elf-identlty. and di ... rupled fole~. Gncf I .... l'harat:tenzed by preol'L"upatioll \\ Ith Ith... and feeltng\ of \\urthle' ... ne ....... or helple ...... ne ....... Speufil: . . ) mplOm ... II1dude k~llI1g... 01 tlghtne:... ... ot the throat. mU"'L"ular \\ea"-ne ........ I!lllptllle 111 the abLiomen an\let) th~H I'" de ...cribed . h p.lIntul honnr ...... ot breath and dlO"-lI1g. and p~riod1L \\a\c ... 01 ph)sn.:al dl ... tl~""'" la'itlng up tn all hour Otht:'r . . ymplOm ... m
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ence prolonged feelings of guilt. anger. and ,adne" th't inhibit function and adaptation, It is important to recognize that grief can be an allencompassing experience that take~ time and energy ~l\\ a) from rehabilitation. but rehabilitation may not progrc ... ~ without it. Physical therapists must understand gne\ing. mourning. and sorrow so that a patient's lack of progre... \ or motivation is not misinterpreted as malingering.

Phase Models of Psychosocial Adaptation

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The literature regarding psychosocial adaptation to chronic

disability and illness falls into two oppo,ing theorie, 01 adaptation--one in which adaptation occurs as a 'let 01 nonsequential and independent patterns of behavior. and the other in which adaptation occurs progre~si\el) through a series of phases. Pha~e models suggest that a patient'S reaction to chronic

disability or illness follows a stable sequence of phase" or stages, that are hierarchically and temporally ordered, ThIS progression is gradual, linear, and involves the psychological assimilation of changes to one's body image and selfconcept. The most frequently identified phases in rhe adaptation to chronic disability and disease are shock. anxiety, denial, depression, internalized anger, externali7ed hostility. acknowledgment, and final adjustment. 22

Shock Shock usually occurs as the initial reaction to a psycholocieal trauma or severe and sudden physical injury. It

An..xiety Once the magnitude 01 the tTaUlllaOt.: e\ent .......·l1l11prehe-nded. i.u1\iet\ 111 the fonn of a Pi.lOlt.:-...trIt.:"en rcoad10n (ommonl) oc·cur... and .... mar"'eJ b~ l-llmpul ...,\e J.dl\lt~. conlu"'lon. ele\i.ucu pube rate. difti...:ult) brearhlllg. and cogllltl\e flooding. SJlUallOn... that actl\ate the ... ~ mp.ltheUl nerH1US \)- ... tem through repc-ateJ aLtnll or l..'hwOlI..· ...Ift'" may alter ...ynaptic (ran~mi...... ion and lead to depre"lon;ll1d malfunction of nonnal bod) ...) ...tem .... It ~hould be noted that the ph)~iological ;.lI1J p.. . ) . ,. hO.. logical reaction to ~tn?~~ are not limited (0 ci.lta...(rophK conditions. An e\ten~i\e bod) 01 re ...eardl ..,ho,,' . . Ire'''' reaction~ to be present in in(h\ idua"" under conl.!ltlOIl' IhJI may not be traumatic but ne\crthele...... per... l...telll and JI'~ 1J ruptive. Everyday life fru ... tri.ltion .... Illternal i.lllde\.(cn 'I'" , '1"ll1'1IorcI;\11"~ conflict"). and change~ III I e com Ilion"', I... '" e~ of the stress reaction thaI. over IlIlle. ha\e 1.1 J~ktcn" Olilo. effect on a per<;;on·... function alld he'llth. Ph) . . II'.Il

Chapter 2 Innuence of Psychosocial Facton on hhaW..•..' therapl ... h ... hould be cognizant thai even t~ough a patient"" emergency ,llUallon 1\ ovcr. a \tre\ ... reaction rna) continue to be pre ...ellt.

Denial

Denial I' often u...cd J'" a dcfcll"e mechalll~m to alienate the all\.lety and pa1l1 a\\oclilted \,,\th a di~abdllY or I1lne....... Denial occur... a\ a "Ipcclfic pha\e early 10 the adaptallon procc,\ and protect... Ihe per\onfrom having to confront the o\cn... hehlllng Impllcation\ 01 I1lne~~ or 1I1jury al onc~. In\tead. denial allow ... a gradual a""imilallon of on~\ ... allercd rcalll). Brcznltl Idcnllfied "even t)pe of delllal : I. Denial of threatcllIng lIlfollnation (u ... ing electivc 1I1attenllon and partial a\\arcne"q ~. Denial of \ ulnerabilit) (e\.crt1l1g control and maximizIIlg per\onal ... trength ) . . 3. Denial of urgenC) (u ing method", to ...ee the . . llUation a... Ie...... pre...... lIlg Ihan II i ) -to Denial of affect (reduction of emotional Impactl 5. Del1lal of affcu rele\ance (dl\erting attention to other i......ue ... Jnd belic\ing Ihat an emollon is coming from an unrelated cau e) 6. Denial of per onal relc\Jnce lattribut1l1g. difficultic ... to a benign cau...e and blaming othcr... when \11\ ol\'emcnl wa ... one'~ own) 7. DeniJI of all infOllll,1tion {creating a barrier hel\\l't'J} e\lemal rcalll) alld tllle\ p"')The rc..,ulting in tala! di ... belief of haYIng an J1lne ....·~ or dj~ilbilit})

It

internalized anger can re!,ull m depres~ion. suicidll telldcnclc..... or psychosomatic compla1l1ls---panicularly in people \.. ho ha\e a chronic condition. Vi There are man) rea~on"i why patients may nol expre 5 anger: fear of lo... mg lo....ed oneo;; or o;;ocial i...olation. cultural rc...tram..... lat~ of av.'areness. fear of 10liing conlrol, or belief Ihat exprc~... ing anger i!o. inappropriate or dangerouo;;. Repres...cd anger not only affect ... a patient\ p'iychological well-being. but ma) also ... Iow rehabilitation. It I.. . important for phy!o.ical therapist... to encourage expres~ion of angry feelmg ... by providing a safe environment for patients to verbalize their anger in appropriate way'i. Therapists might 'itate thai anger ill a nomlal emotion--especially under the patient\ circumstances--offer reason~ why it is Important 10 el\pres~ anger. and provide anger management technique.... It is equally important for therapisls to under...tand Ihat while a patient's anger may be directed al lhe therapi ...t. ... uch anger morc often reflects the patient's own projected feeling~ regarding his or her disability.

C:.L\C....

Externalized Hostility

Patienh in thc ... Iage 01 d~nlal rna) "elt"l'lIvel) ath~I'l to the em ironment. choo... t fact ... that ~upport illtir belJeh ;.Dl'lH them"elve ... and their condition. and Ignor~ fat '... lhat rern1l1d them of theIr nc\\ chalJenge~. They ma) hah ,!n,f'ali~llc and", I\hful goal ... lor recm ery anti m:.l) he ... ~t.;11 a ... mdlfferent and alool.

E.\terllali:ed hostility is anger directed toward other people or object... in the environment and is an attempt to retaliate again'lt functional limitations. Challenges encountered dunng rehabilitation may trigger externalized hostility. As time from the onset of the disability passes, externalized ilO rdily tcnd~ to become more apparentY Signs include ra ~ive-aggressive behaviors that obstruct rehabilitation. aggre ...,ive act~. hypercriticism. demanding or antagonistic b>2h<.\Vior.... fal ...ely blaming others. and abusive accusations. Patients \\ ho express anger aggressively through physical or \'crbal abu ...e. sarcasm, or controlling behaviors need the hclp o! the entire tcam to redirect their anger into producti\e therapeutic activities that further their rehabilitation g()<11\.

Depression

Acknowledgment

The pha...e 01 depre\\lon occur a... denial le~ ...en allo\.. mg a grealer a'" arene...... 01 one \ )o C'l. DeprcsslOll i a reactive re~pon'le of bt:rea\ement lor Impending death.... uffenng. or the lo~~ oj bod) functIOn. ~eurO<.:hemical and bIOlogical change... re...ultmg from dl ...abJlit) or di ...ease. premorbld per~onaIJt) and larml) hl"tor). and reallion to ~tre...", have all been identified a... n,,~ f actor", tor depre ion. U l
Ac~no\\ ledgment i" the first sign that the patient has accepted or recognized the permanency of the condition and il\ future implication~. The patient begins to integrate functional limitations into his or her self-concept. During thi ... pha\e. the patient accepts him- or her...elf a\ a person \\ Ith a di ...abilit). develop ... a ne\\ ~elf-concept. reassesses value .... and ...earche,:> for ne\\ goal<, and meaning.

Internalized Anger

Adjustment

Anger occur\ In r~allion 10 anxiety, ml"lperception, threat ... 01 abandonment. leellllg... of helple ...... ne~ .... or fear 01 IO"'lIlg <.:ontral Charaueri'lllc.:... 01 anger lI1<.:1ude hO"'lility, re\CntrnellI. or hatred. AnMer, I'" a re"pon",e 10 10...... and it nOI expre~ ...ed I... tenned lIIternuh:ed UllMer. Internaliled anger 1\ a......Ol:ialed With ~If-blame and ,... a manlfe"wtion of ...elt-dlreued hilterne~" and re"enlmenl. Sign... of Internalized anger II1dudc manipulation, ...abolage, and pa...... lve-aggre ...... ive behaVior. Sometime... anger emerge when a patient attribute hi'" or hel own behaVior" 10 the on el 01 dl ...abihly or disea e. In ...uch

AOjll'ltment 1\ the final pha~e in adaptation and In"ohe\ the development of new \\ays of interacting 'lll<.:ce ... \lully \.. Ith others and one· . . em ironment. The per..on .... no\\ adju~ted to the olll\ide world after havIng tully a ...... imilaled hI'" or her functional limllations lrom di ability InIO a new, cohe~ive ...elf. In this phase, the per on rcgain~ 'lelt-woflh. under\Hlnd\ that new pOlenlial ... are po~\ible. pllr:-'lIe~ vocational and ~ocial goal ... , and overcumc~ ob ... tacle ... that arise in the anain. menl 01 goal ....

..12

Ph", ical Rehabilitation

There I'" C'\ IJullC thallhl: ph~,... t.: model 01 ~tdlu 11111:11110 lhronJl dl,a""ltl~ (ll dlnc ...... I ' nOnllllt.:.lr 11111ltu.hl11cn 10n.11 and progre I\C Ph.,"'C' model ... lend tn h.l\c I () cOl11mon a...... umrlH'n 11: People l11il) ,I-..Ip one or 1110re ph~,"'e ... or I11i.\) regrc ... 10 an earher phi.l"'c. but ~ldJrla"On I'" not IrrC\('r Iblc , The r~'le and "'TUl'lUrc of adapt.lllOn CJIl nc II1flUCIKCd b) c\lemal e\ ent\ or II11en ell lion ... (e.g .. CI1\ lronl11cnla I change ... or coun eltng) )el are 111'-11111) dCICll1l111Cd b) internal proce......e . 3. ot e\er) one achieye ... ~ldJu"'l11C'nl. ...ome ll\ate al earlier pha\e.... -t Adaplation i... an unfoldlllg. d) IMI11IC proee thai graduall) ...hifts from 1I11tiai experience... of di ...trc to " ...... 1111ilalion of loss and reconciliation, 5. The adaptation process i... initiated by "'Ignificant and pemlanent changes in the body\" functional capm:llic... and appearance. \\hich Jre u,ually follo\\ed hy Jlteration of self-concept and body image. 6. The amount of lime spent in each phase vanc ... and 11M) be detennined by a combinatiol1 of the following tactors: ~ocial support. financial and human re ...ourn:.... past exposure to crises. age at ono,et. ...eYerit)'. natur~ 01 the disability or illness. and premorbid peNmalll) 7. Psychological maturity and growth occur a\ the paticJ1l progresses through the phases. 8. Psychological reequilibrium occurs through gradual adaptation and reintegration to the perceived mi~for­ tune. 9. Human variability and uniquene\') have a ...trong influence on the temporal ordering of phases-the sequence of phases is not universal. 10. Occasionally, phases may overlap. be nondiscrete. or fluctuate, causing palients to experience more than one reaction at a time.

Chronic Illness and Disability: Differences in Adaptation There are marked differences in the way that people adapt psychosocially to a disability associated with a traumatic event-such as traumatic brain injury-versu!) a chronic illness-such as multiple sclerosis. The onset of disability in a traumatic event is sudden, and medical stability may be achieved shortly after. The onset of a chronic illness is usually insidious and gradual; its course is often uncertain and marked by stales of remission and deterioration. 1K In chronic Illness each onset of symptoms can be experienced as a new Illness. Shock may not be experienced by people WIlh gradually deteriorating medical conditions (e.g., Parkinson's disease. rheumatoid anhritis, or diabetes mellitu ... ). bUI is u... ually experienced following a lrauma (e.g.. traumatic brain • myocardial mfarclion. amput3110n. or ~plnal cord ). Shock may be pre\ent but not as ~trong In people

\ Ith Itl thrc \ltnll1l! or end 1.1' til Col t: (e ~ I[J l.lIllcr Ilr ~lm\otrflphll I.Her.1I lIt,Tt) I I. fhe ph.1 of dnxlety and dcprc ... UHl rt.:ldte more tn the p:.t I. uth J gnC\lI1.L! OVCI the 10...... III premorhul tum.tlnning. In d l/1f()I)1l dine ...... <1I1'(ICI) dnd deprt: Ifln rel.lte mfxe to the future rl .L! • tc.lr 01 dc,lIh. lcchn\! I)t hnpele ne lIld lear ot tht' unknO\\nl I The ,tl~no ledg:menr .lntl .ldlu t~ ment pha e'" n1.l)- ht~ mort dl~ti( ult til .ll.;.hlc.:v 111 chronl(. ldc-thrcatcnlllg lfmdllion th.1I rCl/uln lhe Il1tema1l1atlrm 01 and Clcn'plant:t: Ihat the lfll1dltlllJ1 may \l"flr"Cn and re ult III dl'<.Ilh

Posttraumatic Rehabilitation The plhllraUl11atll pcnlld mil~ Inl Iud. phd c of an"ety. ~ll1d extemaltzed hlhl1ll1, mcntloned e.trilcr .1l1J i'i u uall the time: dunn!! '" hieh l1lulh. I nol InO t (t tht: rC'hahlll.1t H IJ1lenellllon lal-..c... I'i.u.t.:. Ii I I 0 h l'n d ..mrlll \hKh the p\)t.:hoIn';"ll"l} ttL:<. t, ,t I un .It pc I' e i1fe more "'ITOngl) I 'It h\ {, n,l·i~nt. It, '1'1 hi, flll' r )choln<;llwal defem\.' ... antI fl.;.'" jhlll. r:,,, It'_.tl1' t'LlH.llry durin~ the initial {Jcrn~"'''f)n. denial. intefll,tlllt..:U .In\.!er

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'"

Chapter 2 lnOuena- of P5,cbosoci.al Facto

member 01 "OClcly 1\ J dlffi<.:lllt adju"tment and can result m dIl\.Iet). depre ...... lon. and poor "ociaI1l1Iegration ..:!.:!··c Phy,,\cal therapl ...h ...hould help patlcn", prepare p,,)thologlcaH) lor dl"charge and rellHcgrallon 11110 ~ociet). Some of the I.,~ue~ that pat len'" mJ) tear mdude negatl\c reaclion.,to their dl"abllll). leelings 01 madequac). ha\ 1I1g to ldentlf) new "octal "uppon .... recel\ mg help 111 the home en\'ironment. Jnd adju:--llng to a ne\\ bod) Image. Bod\' unu.t!( mclude" judgment about one \ appearance. an a\\a~ene:--:-- 01 boundarie" and per~onal "'pace. judgment about one \ bodil) re"pon.,e'l. perception of one'~ body part" and Ulelr mO\ement. and an a\\'arene.,~ of phy.,ical plea.. ure and pam. Body image i'l mtllnatel) related to .,elfconcept and ..elf-e"teem. It affect"> not only a per~on'~ functional abllllle:-,. cognition. perceptlOn~. allitudes. and emotion... but abo the reaction" of others 10 one.,elf. Becau...e Ix>d) Image change... throughout life. it I'" thought III be both d)llarmc and de\elopmentall) ba...ed. Dlfticultie brought on b) a di ...abJllty-'Iu<.:h a... functional 1I111l1allon and rain and di . . tiguremcnt-alter body Image and threaten ih ...tabJlu). Patienh mu ...t then rel'on ... lruct their !:xxi) Image and ..elf-perception to adapt 10 lhi~ ph) ,,I(al c.:-hangeFi"lher ha... IdcnlJficd the follo\\ II1g pattenl''' in pallen.... who e\perit.'IKed ..hilt-. in l:xx.t~ image after di~ahilit~ (II denying tht" e'l h~nle ot one' bI.>d~ (~ ta.nta..iling ahout a IlJq or damap:d hod. raJ11xIIl~ ll1a~h.all~ ~rlal( ... or hr'alth~: nl eoneentrJtmg ...< lel~ ll!l nonmJured bod) P;U1\ il ordt;,r to dell) 1I11palrment )1 tht' lffelled area: and (.f C\r" liCnC1!l.;.1 pe:nod 01 dden \erle fdll'\\t;d 0) graul''''} 'K< t;jl1 If 'l llil' <.1 11l111",llon of tht"lf t red I ) hi:." rh~ I 'al 'J,,,,p I comton Ic:\d I1h t 1 Tit ph.. lea, dl ...ahilit) :.t,1· 1 1t: therapht" attl'Ill10n to thL ,ift ctt'd hod) rJ.rt 1lI.1) l.t p Ih .. patient teel Ie a hamed a )f ut :-xx.i~ . . han~,,;

Per~onalit)

and (oping Styles

Tht: mort: a pi1Uellt h<.1 e\ohed "'llCl,lll) and p"')<.:hologll:ally. the beller he (Ir he y, III be at u...mg adapti\t: ml·thlxb to deal y, nh In'>t:~. Hl:lll"t::. a patient '" nh a health) premorbid pcr!!lonalil) but a k\ere ph\~llal dl"laolilt\ ma\ do beller m rc'haolhtauIl1l 'hall one \l,.llh a It: S c'\l:rc'dl ablllt) and a pathoh)g:llal prenu,rhld pt;r')l)Jlallt~ 44 \\.- hen ay, are ollhclT palienh' JkNmaht) M)les php,lci.ll thcri.lpl ...h \1,."1 be mOTe adept at dc\dfJpIllg trealment plWh Mraltgl/lllg Inh~rVel1lIOlh. ;.tnd JOOllVallllg and gUldmg patient through ll:habillt..lllon

Personality Types A.lrh(Jut-!h ei.lth Jkr (JIlalll] I UIl14UC. IkrMJIl ..t111It'l'> ha\c' been t
00

Rehabilitalioa

lodl\ Iduah y, Ilh tyP( 4. pu.wflulwn ha\.e a compulsive need to be achiever... 111 all a"peu\ of I1fe. They are extremely ll1dependent and producllve. The\C quaJnie also ~erve al:l delen ...e again"'l lo\\- "Ielf-e\teem and mterve~al conOlct... The e people u... uall) derive ~atl~factlon from being ~trong II1dividual" \\oho can help other.,. If lhey can no longer participate In Ihl" role. they may become depre~.,ed becau~e of a percei\'ed mabillly to confinn their \\onh through altrui~tlc actl\'1tle~. Phy~ical therapi~t~ can u\e thc~e qualllie\ in patient... \\-lIh t)-pe A per..,onalltie~ to mOtlvate their intere')\ in rehabtlitatlon. Becau~e they are often \elf-\tarter... and take initiative for their own learning. the) can u,ually be depended upon to independently practice home exerci')e program~, Indi\'iduals with perj"euio"isric personalities uphold high <.,tandard') in order to mailllain self-esteem, These indl\'iduab judge them ...elves by inOexible and po~sibly unachievable criteria and may not be able to tolerate slow progress dunng rehabilitation. Physical therapists may aid these patient'> by helping them derive pleasure from simple thing\. 'iuch as a meal. a sunset. a new shin. or interesting infonnation, Helping them di\co\'er value in these things offer... them source~ of self-e":>teem other than meeting illlpo~"lbl) high .,tandard\. Individual", with aut!loriratire personalities need to be III l:onlP)1 and need things 10 be done in a particular way bet'au~e of ngid perceptions regarding values, rules. and the n mner in \\ hich others should behave. They are often Cf~:ll."\,;'m... u \\'ith statu". tend 10 be judgmental, and have JilL .. VIt. clnpathlLing with olhers. During rehabilitation. ~Ii~ p'HIPllh may try to dictate their treatment and :r:;.Ir.:... Ifl i.I poy, cr ...truggle with their physical therapists, P;ttiellh \I, Ith authoritative personalities have difficulty 'flilll\!. to dl"labilit) which often requires acceptance ~tfl'j l ,m"1" llTIl"'C', They may require alternati\'e Mrategies Iv "01' ~ y,hal ma) have been perceived as an unsoh'able plOhlem, PhY~l<.:al therapish should engage patients in problem solving to generate "trategies to meet Iheir goals. Indi\ Iduab \\ ith pass;\·e-aggresshe personalities e\prc''' ho...tilit) b) u"lmg pa\"Iive techniques such as prolTa"lination. resi\lance....tubbomness. and intentlonal ineffiCiency. The:-,c pcr~onalilie" react to aUlhority negativel) and ha\c difficult) \\or"-ing. with other.,. Phy~ical therapi"lh llli.l) \\or"- more effiL·lentl) v\ ith pa... \l\'e-aggre ... ~l\e pallen.... b) pli.ll:lng the re\ponslbllu) for progres~ onto thclTI. Patlenh can be in"ltruued 10 ma"-e uecislOns about th":l!" trealment "hene\ er p(h~lble and then summarize their progr..:\s alter eath \C"I"'lon. Thi ... deempha"llzes the ph) "'H,:al therapI ... l"" role a.....tn
Personality Disorders Whl:ll ~111 Indl\ ItllI..11 "I per...on..lllI) ...1) Ie dt"\ lale ... lrom l'ullut ..11 norlll~ 0\1.'1 a long peTluLl 01 tlllle. 1"1 Infh:\lble or per\, ..I ... lv..: lau ...e... d ....lre" ... h) one ...ell ;.tlld olher..., and lead"l to

J4

Ph, ic I RehAhilitation

ful1l'IIOnaI1l11J'JmllCnl, that rel'(lnall1) 'Iyk I lon Illcn.:d 0 Pcr'oI1Jhl) d"oHk'r' h.IH~ becn thm oughl) (b"llll:d The) I1ldlldc parJllold. ilJ1II,(KI.II (,11,0 reterred to a, '\)("Iop..lth 01 p'ychopalh). hordcrlll1c. hl,tnollll, l1arci,... i~tic, 3\Oldalll, d~pC'lldclll, ob.. e''',lve 'ompul'lvc \chizOld, and \chizolyp..11 per'oIlJlllle .... Fre1<.IIllJ.1l cl ill ...tate that dl'abillt) e\acerbate' pree\I'lIng patholo!.!} meanmg that the 'arc\"... at dealing \\ Ith a ph)"dl.:.ll IlInc ... ' - per...onalit) dl'order' e\en more prolloum.:e d '< can make Patien \\ l1h fJUrcmoid 1'(.,-\011£11", (!ison.f£ r II1lcrpret the moti\e of other... a ... male\ oicilt \\ hen the) llla) not be TIlis resulb from a pattern of ~u\rlcioll... neS\ and dl ...tru,1. These patient~ believe Ihat other are Irying 10 explOIt. decei\e. or hann them. Because of ueh mi\tru,t. they ma) discharge themsel\-e ... from treatmen!. Ph) ..,teal Iherap"" should look for beha\ lor.., that mdicate paranoid thought, such as hostile reactions. guardedne ...s. argumellli.ltJon. and ~tubbomness, and encourage patients to expre,.., thclr thoughts at that momenl. If the patient seems paranoid. the to ~ d) ,tunl'tlonal

physical therapist should help him or her to better understand the reality of a specific situation. For il1\tance. if Iht: patient complains about being forced to participate III ~lll elaborate intervention so that. in his or her 'vie\\. the therapist can make more money. the therapt~t ~hould rene\\ th\.' pros and cons of various treatments and di~cu..,.'l the clmical reasoning involved. Literature can be very convinclI1g since it does not come directly from the therapi\l. Patients with antisocial personality frequently engage in deceit and manipulation. In rehabilitation. they rna) U"le an alias, lie to the staff. or malinger. They are irre... pon~ible and often fail to comply with self-care procedure5. ~uch a ... hygiene and home maintenance. They seek OUI and take advantage of weaker staff members. often u~ll1g wit and

chann. When they do not receive what they wanl. the) commonly become irritable and violent, especially when staff members attempt to impose restrictions. They frequently cause disruption to others in rehabilitation. These patients require a cohesive team approach with immediate and strong intercommunication to minimize di~rupti\'e behaviors and refocus on rehabilitation goals. Patients with borderline personaliry disorder have instability in emotions, relationships, and self-image; are impulsive; use primitive defense mechanisms such as splitting and devaluation; and tend to engage in self-destructive behaviors such as abusing drugs or self-mutilation. On the surface, they may appear critical of others but these are signs of deep vulnerability and should be treated as such. Therapists should respond .... ith understanding and empathy instead of anger, and should emphasize strenglhs and strategies for ongoing work. Self-mutilating behaviors, such as repetitive cutting with razor blade:-., pin pricking, or cigarette burning, :-.hould be immedia1ely reported to a doctor and referral made to a psychiatrist. Patienl~ with his'rlonic personall" disorder ...eeJ... anention via excessive emotionality. Since the"e patient~ respond well to audiences, therapists should provide ... ltua1ion, in

\\ hllh p.ltlcnl l.1Il g.lln po III e Ittcn1lf11l Irllm dOH1 II n Ph lui th, T.lpl t h(luld 1 ht1un1l.lfl I help p.ltlcnl' 41Lhll'VI.: d h.tl.lIlle hel n thur nee-d Ir c\pn.'. " Ihem chc .1I1d t1K'lr I1ced tn locu," on Ih r,lpeU!JL 1I11L·r\Cntllm,. A <.:.l1m and logllill appnl,l<.:h tn rch,thlllld!Jon help, \"cttlC' IIllcn C ClnOIlOlh Referr.lls can t'f m'lde I d~lllLl' mll'l<.: at1 or draln.l thcrapl t to meet nngllll1c need tor attcnllon Jnd clt-c\prCti.\lnn rt:h,lhlllt.ltllll1

,,,,'w, r'"

,,"alll d, ortln .Ire c 11P.1I1cnh \\ lth l1an dC'l.:cndlllg and h.l\ (' J need lor Jtlmlf,llIon IOd fechnt! of \upcnont) II .\11 Illnc..,., <':4111 cs i.l redliLlion 111 Ihl'i Imai!e. the) ..... 111 rC<.jllJn: help Irom their ph} \l.:Jl thcrJpht\ to Identll) 'trenglh, and teel c1l.:lcptJhle. Patu:nt, \\ Jth \1 fll:md {Jt n(llw!lh til ""rtl, r h.ne a flat affect. or 11Illlted range 01 emotion.ll e'<pre Ion .•tnd are dct.ll·hed Imm ,(\<':ial mter.Ktlon The Therapl t hould attend ll' th~ r.Jtu:m ~ ro,;:h.lhdllatl0n \\lthnut tf)-1I1g to cnga~ 111m or ha In .1 ~re,lt de.ll of tl(lal 1I1teractl0n. It tht dt ...order h,I' h<.: en Inng-,tJnd1l1g_ tht.: ri.lllem \-\.llIlikel) teel lInl.:omrort~lhl(" "loL·iahlln!!. Palll r t w!th \" hi:u!.'jJ·1 flt"" Illalt{\. dHordn have C... l ..'n!JlL 'ha Hlr,1 erl'..:'r'"Jal Llr C(l~llll\e Lh,tOt1lOn'. and m;.r~,' ~t iii 1.11" f}lln h p The lxial mtlmaC) JI~'~ pl--I. .......! ~rr dh)n <.: I re \111 lI10n en\1ronment InJ\ .... J.., '1 I Sl(l Ul h ... d Inlcgratlon mto the tht.: ;'tX'Il{· ... , .• , III i~ hl' cyum.;d. A,k1l1g patient' \\he-ther thf'lr . . ; \ , \)1 ,t~ an: ,lL<.:UT,He nl.l~ help them remam focu'<,C"d nn nell I ..." in~ reh~lhiilt~ltl.)n gllak Patient' .\ it!1 .1 ('ld.U11 1'('1"\1 nali, h\onla ,uffer from "lo(.:ial inhibif1('lI, ecllllg ollllaJcqu..h.), and h)per,emlti'it) to ("fitici~m. Ph~ lI.al therapl"" ,h\luld rCJ, ... ure (he-..e pat len"" that the) are J 11lg \\ ell
Chapter 2 Influence of Psychosocial Factors on Rehabilitatiea

Coping Styles Coplllg qyle~ are ways Ihal people deal \.... ilh ~Iress and mclude behavioral. emollona!. and cognitive efforts to cope \'':Ith Internal and external challenges thai stram ordinal) re~ources.46 TheoTle~ of copmg :')uggest Ihat II is not \\ hal happens 10 people that IS Important. bUI rather how the\ react. .... Variou~ COpll1£ strategies have been identified 11 111 the literature and ~ummarized by Livneh and Antonak. The) mclude plannmg. problem "iolving. wishful thinking. a\'OIding. mll1lmizing. "ieeling social support. searching for meaning. emoting feelings. blaming. accepling. negotiating. dl:')ellgaging. and lurning to religion. These and others can be categorized into Ihree different Iypes of coping: (I) ... eekin£ \"er"iW, :l\Olding control and infon11ation: (2) e\pre"... ing \ersu ... repre"l"ling emotional reactions: and (J) ... eekll1g \'er"u~ \\ ithdra\\ 111£ from social interactions and net\\orJ...". Coplllg ... Iralegle... ha\ e heen found to be of great importance 10 rehabilitation. Pallent ... \\ ilh higher leyel coping ...J...ilb can more coL"illy Identif~ and report symptom..... make treatment decl ... ion.... cOl11pl~ \\ Ilh Inten·entlon. and accept ...upport. Patient \nth good problem "'01\ lIlg ... kill~ and po... UI\C altitude h3\e been found to make more positi\"c adju ... tment ... III their di abilitlc than patients with low sclfe ...teem and poor ...elf- onccrl Cupll1g ... tyle" often delermine \\ hether l'r not ratiC'nt ·eJ.. medIcal help and follow Jd\lI... e.

SO(JJI inllucT'I.t''' t ) .. .1 IOgll']] ch.lrartcl'''''til . '1.nd health hdids ha\C he 11\ n 1,) modify tl1e ifl1rad of di ... ahilu 'nd eO).: til ,ul !ttu ,I So,,·i.t1 ael.\! ...lr po ItJ\C It I.e-pI 1 t G I J fm.!t, .. i1 '-Cl "-I~'.l hd\·e I.. '1... \ III JI .lbl.t\. hlJUce predlLted ('\elkr h, H and R he luu I..I:t ishlP J<..t'\ee'l aJju .. tt, \..111 ,llld per onah p4 tal. 11 '4 finJ tn... t PII..,JI .. \ .\1ue el11 11 .11.. n ar 't IT lat _J \\ IIh Llpt"'·ll'f outlorne dapt e l ~ .n.=I ~ th t re tilt 111 o . . lIivc out... Jme t Jf pc Jpl~ \\-lil ul.thllltlt: utili/C pthltl\e direlt aldiiltl\e prohlern Ili\lllg tlllal..,uppoTt ...\.?'eklng. and lI1fllfT')J.tlon eekmg. \1.J.tadJ.pli\e cuplng ... 1) Ie.., thai lead to unfa\orahle adaplatJIll1 lIutcome"l melutlc "Iclt'blame: nundlrt:l"t, pa...... ih: and c...capc/a\oldance mode ... oj u,plng; and uh...tance ahu..,c LfJ/ U\ oIl /Jilfiol I... a helle! about one"" abllll} to conlrol Iitel:Ondlllltn and e\t:J1I P~tlh~nl'" \1,. Jth an eXlernal locu"l lit I..l,mrol bdle\'c that olher people or oUhlde L.lllor"l ddt:'rmmt" IJUIUJlTIe Patlt:J1I~ "" Ith an Internal 10l:u.., 01 • ntrolt~tle re pon Ihtlny l"rl..hange hcl:i.1u"c Ihe} hche\e the Cdn ..lt1e1..t their 0\\ n l: IrL um l..lnu:\, The latta Ieatl.., 10 g al-dm.;ued ..llllVJI} ..lnd al..tl\t: Loping • TIle uhlluy to IntenUlJnJ.lI) d1..lnge the rcl~111\e Impor· tane (,I event IhJ.1 (Jl..cur III IIlle \ Ilk re4ulres I..lm I.ml p7"d.lll e It ha heen htl" n Ih.lt patient v..llh eXlern.t! IU... 1 f Jfllllli expe-nt:nl:t" tre .mtJ .IIUlcl\ In rehablluallon. IlIk: pJ.II III \\ Jlh IIllt:m.d lOll 01 l:o;ltrol ha\l~ qult.J,cr ,eriC; h<'ttt:r III!JllV.tlllllJ IIllJr!..' hope and 111m.... cnl:rg)

Coping style~ can be e:~.amlned through intervw:ws observations. self-repon \urvey .... checkli~ts. and information from Ihe family. Treatment based on the"Oe findings should Include emphasl!
These protective factors and processes help people with disabilities during turning points in their lives. Analysio;; f)f turning point"i revealed three major way~ Ihat patients maintained meaning in their lives: through doing, belonging. and under\tanding themsel\·es in relation~hip to the \\-'orld. Domg m\'ol\"e~ participating in activities that are fulfilling ~md facilitate competency. Belongmg mvo"e~ percei\cd acceptance by others or membership in a \'alued group. LJnde"'landmg oneself in relation ...hip to the larger \\orlLl pro\ Ide~ a ..,en.. .e of identity and ...ometimc~ purpo...e.

Common Defense Reactions to Disability Deji'Il\!' mi'clwllI.\ms are coping ... I} Ie.., that people u...e 10

defend agi.t1n ... t lnlt'rnal and c\lernal ... Ire......or.... The) h'lppen aUlomi.lllcall~ ami uncon"'L'iOlhl~ Some Indl\'ldu.ll ... u ~ man} tlltlen:rll dcfen ...e mech.HlI ... m ... thrnughl)ut their 11\ (' . bUI nlthl lend ttl ullliLe onl) one ..)1' 1\\ o. The goal I'" nl'l h.l i:hangt' or nwdlf) Ihe...e dt'ten ...e ll1~dl~lnl"'Ill"', but t..) iJ...~n~ 111\ them In order 10 untlt:'f... I~lIld Ihl~ patient .... p"')I..·hl)lllgll..al pmt:e.., 1.''' IIMI undl.'flie l·ert~1II1 o...~h.t\ lor" .\Ill! n:"'1 lan,:c. L..nder"t~u1...lIng, Ihl.''''l' bdM\ lor... I.'.tll hdp ph\ ... 11...11 thf:rapl I 10 111011\.\1e nr n:dlll'l.t paltt:'nl... dunn!:! UI!lh.:UIt 11m In Ihl'JI reh.lhlllt.tIHlIl The d....ten ...e lllel..h~U1I ... m" de'l,,'Tibed 10 I3l)\ 2.2 ..11 . .· uHll11H)II 1f:~ll.thm ... 10 lll"'~lblill .md lan bt

.\6

Ph~ .. ic

I Re-hobilitot'on

Box 2.2 Common Defense Meehanisn,. ctinl! Oul In..tead 01 e pre mg !t.:clln£'

\crb.lIl~. Ihe

ra1lt.:1l1 II e, .llIulll 10 relea...e ... In.~""" For ("\;.1111pll.·. a palH:1l1 ,... anglY \\ Ilh the m.. uranl"e l'ompall) lor 1101 lund1llg an athkt'l' \\heckhalr. "'0 rclu ..e.. 10 u..e Ihe 'Iandard \\heekhiur /\lIIIl!2 OUI ouun. bel3u ..e certain feelm!!, ... ulh a, an~(', ,md hurl arc too dIll! lull to e\pre..... \er!:laJl) Lne\pre .....ed kellng bUIld an ,el) unt,1 the) are relea..eJ IhfllUgh al!lon. The IhtTJpJ'1 ...hould JJentlt) the kehng behllld the allmg out beha\ lor b) a''''1n!! Ihe ratient \\11) he or he beha\'ed III that \\'3) For m')tann;. the therapl ...t \\ould a the I1r"'l patient abme 3boUI u,mg the \... heclchair The patienl\ re\pon...e ... ""III e\'entuall) trace bac'" to the origmalune'pre......ed fecllllg. Through que...llomng. the therap"'l ~nng" to the pallen..... ;l\\arene....., the link bet\\een the feelmp. and the aellOn, The patient can nm\ \erbalize and dl ...cu ..... the feeling. In the <.:a')c alxl\e, the patient rna) be more \\ lIhng to U
Altruislll The patient become~ dedicaled to helping other... in order to manage his or her m,>n stres!). An altrui ...tic palient rna) Shlp treannent to help eveT) one else 111 the treatment worn. in ... lu.:! JOg the therapist. Such a patient receive... gratifil.:allon thf
tn.:.llm III (' 1Il1lllt proc d he or h III uld rlrrJ(f)a p~)lhnl(l.k!1 , tn C rlnre ",11.11 til Ihlllly III tn 10 hi I)r h r lullm: IIle

()c"aluatioll I hI.: p.ltH.:nt I ' mer!) tntllallllnlht>r md "I hIm or her elf and m.l~ lll... ult Ihn,tpl I .lI1d othtr pn onnel The thera ...Iwuld not la~e Ut h 111 ult .. per nn.lIl\; hut hould 'ff r mpa. th) and ~Illdne" "htl..h u tl,dl rtp:lTea e,J dluatlon md build rarrxlrt. Once.1 p.ltJenl trll t the the-rapl t he fIr he rna) dl'lU...... In''ietunlle., and Ie.tr 1l1"ilt',lIJ fit defendmg: <1gam'" them through f.:lllici'lll. Illhe thcrapl,t he, O11le anlln- \,\,1Ih the p..\llent. the lll"ldh u'uall) ht,'l,;ome \l.nr~c .md.J ~p;I"'er ,truggle ma~ en tit: ni~placcmcllt r.Jtl~nt trail I r I re Dlln<;e t or fe lin hout one IhJef.:t ontn .1 Ie hrt:..ltt'nln nl'll.:lt I m mmll F ,r e'\ample_ a p:lrient ma) ~ ane'! "lin J pou." O! dn\ In?" the (' If redks\l~ and h,l\ ing all .l~udt'lli hUI lJ.f ~ tht: .1Il~cf lut on the rh~ . . il:~11 therari'l. In thi, lIualllln nn nllt be 'ak or helpful I,lr h p. III e ('I em t th puu e. \,\, ho 01 rt mJ.\ ':'\..' P t

TIle

'1

7h:' 'npl 1 ~t t

'r 1'_101,1

'ull . I'

n ... pla(ed ndl mended. , b kn me patienT a )ngll1 I 1 .1nt!t:r

1 1

t

r

Autistic Fantasy The patient engages in excessive daydreammg in...tead of pursuing human relationships in order to decrease stn~ ... s. The patient may have difficulty following directions. rna) appear to be in another world. but happil} so, and may bet orne emotional and ten ..e when returned to reality, If asked v.hat he or she is Ihink.mg about. the patient may describe hI'" or her fan· tasies, which can be a rich source of wishes and de ... lres thai can be used by the therapi .. t to motivate the patient to v.ork. on short-term goals. For instance, a male patient relate~ a ranta~y of dating his favorite teen idol. However. in order 10 engage in daling. he must first develop interpersonal Skllb and practice them in simulated and real-life setlmgs.

Denial Demal prolects the ego from bemg overwhelmed by pam through an unrelenling process of disbelief. In Ihe ca'ie of disability, denial may be used to protect the patient from reminders of an altered external reality and Ihe resultant sense of )0%. Therefore. the patient may refuse 10 acknowl· edge an emollonally pamful condlllon or :'ltuallOIl that is apparent to other.... The patient oflen denies the se\'eril) of a new disability. behe\'mg he or she can relUrn to pre\'iou ... jo~ or roles. despite reallt} le~tmg from Ihe Iheraplst. The patient may refuse rehabilllation. c1almlllg lhal he or she just want') to leave the hospital III order to care lor hIS or her

children It it. Important to help the patlenl work Ihrough denial IIowly in order to 3\01d depreSSion, which may occur If the ....... become av.are of IllS or her reallt) betore p..yeho!ogl· to ac<.:ept It. It Ihe patients demall sO great lhal

.aty read)'

)i-,'(H:iadtHl pall' lIt tk.jj \I, ltn qft" t! r lllt;h a hr ~d'" 10\\ n 111 memof) lX·rc 'pfji'n. I.\>lh '11.)U\nt·", 1 m It f kha\ lor. The patll:nl tx·come-... I...khtd t"OlI \ h t h ppt:mng In Ihl..' moment beCIU,L' J! I II.Xi pill'}l I fI.1 enl m.l~ [OP pc;ak109 Ilr panif.::p,ltmg 10 ther.lp) and £.Ir hL.lnk intI ,pal.:e for up 10 "'t·\ eral m1l1ulc'" \\ itlhlur rnrl.llll.hn~ 10 thl..' em Ironment. Afterward, the patient mo.!) not he .\\\. 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 <.:an be u...ed 10 lllminllle 'Ire.... hy h1i!hlighllng Ihl.' Ironic or amusmf! a"'peel'" ul it ... 1ft>.... 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"it<., can rel.!te tC' such patients by IIltel1eclu3.lizlll~ \\ ith thun. In t'l~ precedin!= ca,,~. the thempl\! ma~ ..;peal.. atl. ut th... lXlll t Iv.: 3d ,rljurv n terms of c;ciem::e and t31.:1 In tead 0 m I(,n

bolation of \ike' lOf

ur

Rcpre~sion

or thoughts from consciousness in order to decrease stre~s. For example, a patient finds an endearing letter to a spouse from a student and forgets to mention it because the possibihty of the spouse haVing an affair is painful. Repressed material can be dangerous because it remains in the unconscious. Encouraging the patient to express his or her feelings. both good and bad. help~ free him or her of these feelings and any possible negati- e urges to act upon them. ~J'lliltillg A P<.ttlt:nt ... ic\\-s a per'lon or event through a positive or nega-

A patIent <.eparal ... tel'h ~:u

action"i are driven by o;ound motives. when he may truly be unsure, A fa.mily member caring for a relative with conge\ti'Ve heart failure a~ks for a do nOI re~uscllate (D. -R) "ilatus. citing extenSive re~earch 5tudies. The family member states that the relative Will die ~oon anyway. thereby concealing her real and less acceptable reason for seeking the DNR status-to relieve herself from caregiving responsibilities.

A patient unconsciously erases negative experiences, wishes.

charge plan... can be made.

and dl

Rationalization

I,.

~

r0

.~ J·· n (~i '.'Jl

t

e }.

I,ll

'\ ..

j·'·c IeI.S at any gi\en point III time. Later, the patient may nip hI ('I' her feelings to the opposite end of the spectrum

patient feel ...r act a It he or he l'i better than other 10 guard agam I ft:eLmg 01 madequ31.) For m~tance. a pallent j()O~ do", n on other pallent ... Yt Ith di~abilitle~ became he does not \10 ani to Jo.ee him"ielf a ... dl ...abled. A therapl~t might ob~erve cmicI~m and devaluation of extemal object.... braggmg ,,-bout accompli hmenh or kills. conceit. and grandiosi. t The therapt l could usc thl defen\e mechanl m to motivate the patient to gd Ot:tter lfi urder to a\old ktlmg mtenor

regal I 19 ~h,--~ arne per"ion or 'iituation. acting In this manner bl:'ca' he or he ha"i difficulty intcgratmg ambivalent feelLng!'> SOIl1~ patients Will often attempt (Q split staff, identify~ ing one staff member with unrealistic positive attribute ..., "hile identifymg another !'>Iaff member with unrealistic negall\~ tjualitie .... The staff member who ha... been identified 30; negatl\ e has u"iually denied some desire the patient requested. The par lent rna) approach the positi\ely identified thera· pist and complain that the first therapi!'>t 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~ <1 latec n ttl a\oid ree penel1\. ng t';.t'm. ihl:r t"'IS!'I sJ )'IJJ I .:Ip the patient mtegrate ee I ~ ahout m eH~lll ,1ft t.. ('II he memon I IT Thl n " ... hl ed b) 11lg' the pall at ho\\ h or he feel abou1 I.en m aspc...l<s 01 'he e\ell! '" hile tallmg about Jl

Omnil>otence A

\\ hen p.tlilonh Iran"itoml unal·Io;·Cptahle 1~1.t1I~ au.t:pl.tl"lk adlun FIn ~ am un!;l") lbtllli hi r,,'lo;enl dl\llr", mol be Iv l".\pr !'i. Ihm... kelln~!'i. 1~lr kat uf losm lIIhl

o 2 2 t. ommon n

1. (h;lnl m

It'n"'.

"-lupprl·......iOlI III ,It lllrhill '" Ir OfIt r t, Ju \\ h n In ( talk to hi or h r lila pi I lhl. I th t ~TllU ht hUll I. I'i hablll1 lion thl.: pdtli I uprr 11 [urbmg Ihl)ught 1'1cr; pI t \.an r t r r.IlICIiI I, r l r1 \ plllt:llllllh.ntlllll,llI) [J.\llti

lluaOnn e per em

Iher,_pl I Ie g

turtht'r e rlored

I

thnu hI

r r'wbh. ITt

11

d.lIlu IllU I.... .lrl. Ih,II11.1. I1r p,

1Il

Ir

tht' Dh/t:m"rll lliid '(a1l\l

I I

th r
aJ \1.11

Cau e of nxiet.)

( f \It "'al D1 \0Ii.1t. n.

nt ~

.

Anxietv The experience of (1I1.\/e'-\ \ aric ... 1Il ultlerent pallt"nt'. \\"hen ~omeone l~ nenou, (lndicatll1g a moderate Ic\'c-l 01 an\let y ) he or she may experience an up...et ... tomadl or headi.ll:he. Vv'hen ~omeone i... experiencing a paille attal'~ linuH:Jtlllg a high le\el of an\iet~). he or ...he ma) feel Impcnd1l1g dnom and terror. A \y mptom of an\lety In one patient rna) be heart palpitation~. \\ hile JJ1 another it may l~ ... hortne" ot breath. What i~ anxiety-producing to one patient may C
II

n II

d !>eha I

III l~t

I

ha Ii r t

rh

I

I

mJlvlJluli In ed md 01 ditlon \ar u anJ at"(' d One III the be e !fulfil! \.Rahe ,~e Appendi\ AI, \dlich qu..tl1t1tJ the e n JI Ilk LhJng~" on ... tre" and IlL'alth. Slh.:h m' Llfes ot Itle c\ent a ,um~ a relati\cl) glllh..d Impal: and J.~e mt) ... mOl n \ thl) ~ item Ii teu. A.lthou.!h thdl.... I JU tltlC' .llldit. m ul.h an approach. thae e\1 ~t pot~ntlall) more I.."n ItI I.." anJ \ ;lhJ mea ... ure,. one ot \\ hh.:h I the H..I Ie Sl.alcThe Ila.\.I/<'.\ Seal< (\ppenJI\ BJ. Lk\eloped n) "ann« et al"" re4ulre ... ,ubjeeh to iuentlfy tht." Irrit..uing and tru"· lrallnn demanu, of e\ C'f\da\ tran action' \\ llh the en\ lron~ menl.~Thi ... approadl t:l~e~ inhl ,h.:..:ount rhe inJI\ Idual'.. perl:eptiOn 01 C'\enh bdie\eu to p\l"<e ~l thrt.~at. It I'< ('on... I"tent \\ ilh the theoretical a...... umpllon that chrol1lf.: "rrugglt' may tax COplllg. abilitle ... and lead 10 greater dlftkult) 111 the management 01 dail) Itlc- e\enh. COlhldering the enOf~ mou, change... III a pc-r,on', function \\ hen JI ....lbill~~ occur,. pallenh are mort: h~el) to e\re......in In..:re~l"e III daily hJv..le, anJ ,trC' ,or,. Dt."alll1g \\ Ilh life becom~" more 1a\ll1g \\ hen ul ablll1g circum... tan\.·e ... blo('(.. l)ne" coping "'lyle. cau~lllg a gap bel\\l:'C-1l the pcr"'OI1 and hi'" or her Iii within the \\orld. Repeal occurrClll'e... of "tre and lhe cOI1IJJ1ual need 10 adjll ... t to I1C\\ ,ituiltlOlh can rt.· ult In repet it ion of the tight -or-night rC'Jllm ...e. \\ hich C.II1. 0\ er time. re ... ult in high bh.xxl pre"lIre leaJing to heart i.1tl~K\r.. or ~tro(..e.:?l

na

Chapter 2 Influence of P~ychosocial Factors on Rehabilitation

39

Table 2.2 Signs and Symptoms Associated with Low, Moderate, and High Levels of Anxiety Low.LeveI Anxiety Moderate·Level Anxiety High Lnel Agitation

Abdominal dIstress

Chest pains

Apprehension

Aches

Depersonalization

DIstress

Chills

De·realization (feeling unreal)

lrntabihty

Decreased concentration

Difficulty sleeping

Motor restlessness

Diarrhea

Dizziness

Muscle tension

Fear

Dread

Nervousness

Feeling light-headed. unsteady or faint

Helplessness

Worry

Fever

Horror Hyper·vigilance

Heart palpitations

-----------=--------Increased sensitivity to pain

Hof flashes

Increased heart rate Mlsperceptlon

Nausea

------------Paresthesia

Shaking or frembling Sh0rtness of breath Sweating

\nxiel) and Rehabilitation )iftcrenlll'\ds dm..let ha\c dint'l'n~ c:it: on J..'dtlCnts anxiery 1:-. mp ete(\ ..lh ent pat It m \ no Oc L If ated te J hie\!.: Irc:1lrn t e l hll an'{i~'\ Clf' h ,~ allng If dlrcl.. ed ( ehabllit.:.ll on" SCHr.: nx' y 1..',,"

e'l.."alate quit:J..ly i.md IInpalf all a... pects of the patient"s life. Including rehabilitation outcome~, by intensifying the perception of pain. inhibiting immunosuppression. and prolonging reco\cf) time,61 I t>1 Patient... who had difficulty managing mXlcly prior to ph} ... ical illne....., ,... ill probabl) ha\"c more difficult) managing "Ire:...., brought on b) di~abllily.

Table 2.3 Beha,ior> As.ocuted with Lo\\, Moderate, and High Le'el. of \nxiet) ---------Low Le'cl >\nxletl ~, oderate-l e,e1 Anxiel)

High.Le,·el

Anxie~

Avoiding stressful situatIons

Going to the bathroom frequently

Holding hand over heart

Bltmg IpS

Incessant talking

Reacting to Irrelevant cues

Drumming fingers on a table top

Mumbling

Throwing up

Fidgeting

Overactlvlty

Nail bIting

Sfarlng blankly

PaclIlg

Verbalizing somatic preoccupations

PUlling or tWIrling hatr Rubbing an object such as worry beads Shaking legs Sighing heavily

Tapping feet

n pall nl I n IOU Ihou oft n om r u e:d Oil Ih n I I mid nf ph Ilh r, p ullmg In d rl \"c. I nJ1U.'nlr 1111111 fl f I II un mg rna\ l'C "", uHd \\ hU1 ~t r.llil nl IS UI1.• bh, lo ... on... 11 lrat nn the: IhlTlr' t' llllWlllnll Thl 1',1111..111111,1 h unatll to perfonn tllllh'r 1.\ J.. Ih II rlqulf 111l11llpl te:r dire II J1 PilOT ull1 ('ntT IIlt l l1 .. III 11 I rc lilt tn II tv n k Ih 1'1111,,111 ~Ilt('nillm m.t I .,ltun tine NI een thl: n I~I~ 100 the: oem.lIld t1! ll:h.lndll.ltIOI1 Tel II'P .Ir fUJ1dlnn.lI. the r~IIICllt 111.1\ lr~ In rl:rhlflll .1 1.1 ~ 11.1\ IIlg heard (:lI1h rarl Ilf thL thU"~IJ1I"'1 111 IrulilPn SUlil J r.tllentl1la~ JaIl III ulld~r Lind om:( tH'J1 gl\CIl n) 11ll: Ihl:f~ pi t and ma~ 11(11 r ahle th.ll hl: or hl: 1111 "d Import.tnt tnhlrnUlInll. Sh:r nM~ ~ J..lrreo ano .1 r.ltll:nt m~\\ Jump ahl. d too \.Iul ... ldy. rl: ultlng In II1lunc In tht~ r,IIICnt (lr other... , II 1'3tICIlh bel,.ome learful becau ...e 01 ~tn\let)t the~ may a\(lld ("ertall1 beha\ lor In an attempl tn dn'rea e theIr fear. Feartul. an\iou patlenh are relUdant tn try ne\l. thing" They may refu e treatment. remain in their room .... reque.... a bedpan \\ hen the) ilre capahle nl u"'ln!= the commode. or be reluctant to progre~~ to the J1ext ... kp 111 therap). Such patient... \\111 commonly ma~(" ...tale-l11ent... 'ueh a . '"I can'l I don't feel \\ell. I"m 100 IIred. Le3\e me alone 01 no\\, 1"11 do 11 later I"m afraid. )ou Lan'l help me. You don't look 'trong enough. I'm gOlnc tall." Patients who express anxiety through overacli\'it) may allempt to progress too qUickly through rehabJiilalion. They often want to achieve everything at once and appea' Impallent. They tend to rush through each ",,,on \\ ithout mastenng each step. Such patients frequently talk of d,,charge before 11 IS an option. They may make rash deCIsions regarding major life changes, such as purchasing new cars or planning vacations when neither would be in their best interest. Such behaviors may provide Immediate rehef from anxiety for both patients and their famlhes yet eau,e more distress in the long run. When anxiety causes misperception, patients may perceive their level of dysfunction and improvement differently than do their therapists. They often leave therapy sessions with an unrealistic opimon concerning any progress or gains made. Such patients may beheve they perfonned at a hIgher level than they actually did. Watching a patient experience a panic auack for the first time can be frightening. It may not be immediately evident to either the patient or physical therapist if the patient has never experienced one before. Pattents experiencing a panic attack usually report fear of immedtate death. They may slart to hypervenillate, then suffer shortness of brealh. Sometimes they believe they are haVing a heart attack as a result of chest pain, heart palpitations, UId increased heart rale. Terror and panic ensue, and Ihe dICnp"1 may call a code or, If in a clinic, rush the patient II) die hoapnaJ.

Ho

lo,\ddr

n • I

11 th Tlpl t n d I ) h Ip r Itl In rrou 11 llh IT .llmUll liCl,1I III til U Ihur Ie IT ph. I Illh f,lpl l! In u he

Ph Ih.,.

1

nen

,It,; ~h Ilfl U IIh th pall nt Iflg r h III oUr!!T ( t 0 Ihlng )OU 11<1,00c m.) h 'ppen' md 0 f rth Ph Iher,Ir l I l:all or~ \\ Ilh p.ltlenl til hell' d fu e lrl I t u 109 ("~III'"'( n \/r/ll ru,.,,,~ Of the re h,'ptn 01 the pallent's thought ,mli"':h I reg "din' Ih fe red event For c •• mpi<. a therapl t I11I;hl help the pat..nll en age III re.lllt) Ic ling t'1~ a I tll1~ the patient to under laoc th I the O(lUrrenl,;e of Ihe teared t"\ent I unl1ke Pi.llh..'nh \\ Ilh n.:.11 .tnll Immll1t,;nt n rna henetil trom a...... I't.IIKC \\ Ilh rrllhit'm "(11\ me hlluld rhelr 'hor t~ca; e I,.cn.lflO (lnur ulh p Ihkm 11\111_ Ctr help patlen to t.:It \e that t1' \ an un \e nd h e memm;lul Itve lk rile th ( '-lIrr n f f ar ent er p Ilent ha\e e pre "t:d thel tee !l~ th pi t J.n help them segue mto Irt':ttmel t and tr n f If 11 lh~lr ~n It I '0 lIlt l ph\ h.. at aU1\'tty. It llOLJld he [II tl J n h1 rho e and cannot tul' 11tK1I1.... he u d n )t t>e enLouri.lged 10 j h\ 11 h rap. e Ion tJ. telle I .l! 0 ps ':10 amaliL l:omplum t Ire t "', 1 \. r lln re~ardll1g their an\lelie, Fnl'; .ell' II JI. "\ x, 'll t .l help to L'onduct f";..t' ,..'Il~ m J. t Il_ fan I U ,,31m .md ... omfoTL1ble II L1·lf~.ulllltar d io_ I ) ubtlOn In the em troJlmL'lIt Ill. m.tn.. ret..' Ie (lr t{)(.. mu... h nm Ii: li.1l1 mL:rea.~ an\~ It:l) Iud It m~ \ he rtul ( rei nent patlen" to the therapy room and (II rr .t!mcnt ('\pl'd,lllllO ...~aL:h 'e......IOll--tO allo\', them to kel .1 grl?':tte-f I,;n (" ot control. Ph) ,iell thcr.lpl Is hl.luld L:h(llht' .1 purro...eful ad1\ It) \\-ith the- patient, an\lct} in mind, Some- anxiou, pauenb ha\ e been kno\\ n to re pond to :.ll,.'[i\ itle-' that con,i.. t of one repetitive motor action. a... rh) thmic motion help'" to calm Ihem,b:! Gro~ . . motor mo\emenh help decrea"e th~ phySIcal symptom ... of anxle-t) uch a" mu ...c1e- ache.... agitation. and re~tle...~ne"is. Therapi t... ,hould bC'gin by ll1\ohing patient'l In a therapeutic aclJ\ it) that I'" ea"'ll) perforn1ed and then tncrea ...e the comple\lt) of the fa'l.. on(~ the patient has gained confidence, Anxious pUlIcnh who may Interrupt rhe physicaJ Ih~ra­ pist while he or she b v.;irh other patients may be rea....·• ured that they will be I)een on a certain date and lime. Ph) . . Kal therapl~ts ~hould ignore. \\ ithout anger. aLI ... ub...equenl intrusions. Setllng Iimlh 111 thi ... filshion help'" p~lllenl" improve theIr frustrallon tolerance. VeT) an\IOU'" peopk . l;jel by (lerupl I 1-'''''C'IU''~ often welcome clear boundanes ...t... l"• s they have difficulty selllllg limits for them ...elve . · ,UlJ SIress management technique"i are u...eful be tore after a l;jes"iion Techl1lques !
th...

Chapter 2 Influence of Psychosocial Factors on Rehabilitation rela\~llion. "tretching....tre ...... management diaries. identifying ...tre"'''01·''. blofecdback.. nutrition. prioritizing. problem IIlg. deci ... ion I11Jk.lI1g. anger management. Reiki. l1lu ... ic ~herap). therapeutic l11a ..."age. and prayer have been ,ho\\'n to l111prO\e both the ph) ... ical and emotional aspecls of pJtlt~nt,.t>~-n<; Some of the ...e techniques work more effecti\eh for ...ome patielll... than other.... Choosing one depends on the amount of time a\ ailable. materials required. and the patient', preference.

41

ten'-live drugs. Lower blood pressure leads to lower risk for atherosclerosis and related diseases.

. . 01,

Relaxation Response "niche' er "tre"" managemelll technique l~ -.elected. the o\eraJl coal I" t() teach patient" ho\\ to e\penence the reltHlmOfl n ~'rt 1J\t and replicate 11 independentl~ during tTe......ful "lIuatlon -\tter "tuJ~ 111£ the relaxation re...pon e for 20 \ ear . Dr. He~rt Ben l,)n Identitied t\\O e ......ential comr",)~enh that elK it the rc'pon"e: ( II repetition of a ...ound. \\l-)rd. phra..e pra\l.'r. llr mu ..... ular acti\ity: and (21 di ... re('IJ.fdin~ dl tr.1...· t n!:: th U~hh .U1J returning to the rt'petltion. Ben.. o~ ;1\t' l1l.: illk \~n_ te... , nJ4uc", _\r patient-.. I(l u...-." ~ .

eh,

p r e "orJ. 0r prjJ cr that i... part of ~ our tern

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I (l! ohm... \.? \\old 'JI hale II Ircll- 1!l~ tlou ...., b Ic: tlllg thUTI lUI' In \ a e, on the ( .iIl _ urplr I: \\ora urpr;t~...r ~O rn ,ut lOlite 11 v. 10:;- \ our thuught to rdurn ur e \ t flf dllolher minult' tx-for~ n1

Brea! PI'.. er

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be

Th Ire t

d i n re iX'0 h prO' en to be et1C:L11\ c: 10 "eo- headal.he h pencn I n amdl:t~. LardlJL rh) Ihm

d and muderak 'il:pn: Ion and prt'mt'n· fhe rela all on rt' pun t' v.ork. h) I' Ie r te t t bre~(hm~. ffidahulJ III ralt' n umptl md arbon dlO IUt' ehmm;JlJoll _tnd e reDummQ the K1 4 heahtu r hJI.uIU~· \.nell \\ Ithlll made hc'l\l,ec:n hlooJ pre lIrt' U Ile-- th moe aloremeJllJunl;;u ,",e... ,. III a efiJge \ toll .... hltHIJ t dlUPP d IIUIll 146 to In 111111 r ur dropped Ir>m \J I 'i '0 X 'I I nil' am hange I II rdJ. dlHl1l hill pI ur thrill! II l«IUII 011

n

m

III II\; He

till

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01 IIlllh f ,

L1IHIt

)' I III

Guided Imagery Another mtervention is guided tnlOgel)'. frequently used as a Mandard of care in multiple institution\ to improve rehabilitation through relaxation. Guided imagery is said to work by decreasing the levels of cortisol that can inh.bit the Immune system and slow tissue repair.f,~ As In eliciting the relaxation response, the patient should be guided to a state in which the mind is silent and calm. Through use of a tape. video. or therapy guide, the patient is "ked to imagine a special place (e.g., the ocean, a forest. a sunset) and focus on vivid details using the five senses. By focusing on this location for increasing lengths of time, patients learn to gain relief from constant worry by releasing concerns for a period of time and returning to a place of relaxation and peace. Guided imagery enhances the mindbod}-'pIrlt connection through 'he induction of an altered ...tate in which the mind communicates more effectively '''th the bod}.'" The u'e of guided imagery has achieved improved out::ome~ of care through significant reductions in pain, blood rr~s,urc. stress. side effects of treatments. headaches. uncert.l!nty. depression. insomnia. blood glucose levels. and hi... tJminc response to allergies. Significant enhancement or the Immune system and wound and bone healing ha ... also been noted. 69 Because music may trigger emotional 1{·...rOthes by influencing the limbic system when used \\ nh Imagery. music u~ed with guided imagery has been . . ho""n to decrease pain lhrough mereasing endorphin rl'lea ...e.- 1 I Guided imagery with mu ... ic ha ... also been founJ to reduce the need for large dO'les of medication and reduCt' recover) Iime. flO

Desensitization One out of e\ el) eight AmenL:'an aJult ... report ... ha\ mg phobia . . e\ere enough to illlerfere \\lth dJil) fundionIIlg. Patit'nl uttering trom phobia . . th.1t mtt'rtere \\ Ilh treatment rna) re-quire- til \ifJ\I1I:11tlOIl tethmqul'\ JI . . l) l-Jlh:J HllItltW/llll e\f'0~un t'\ I"{ He hlr e .lmpk, \\ heell-h~t1r·bt.lunJ pJlient \\uh.t k.tr (It ek\.lh)r \\h() .11\\ ) U ~J tau prillI' tll Inlun nll\\ re\.june hdp In ...'(Ipmf! \\ Ilh the-Ir le_trs In a lllrnlllrt~thh.', l31111 tre~t(11lent em Irllnm..-nt far tWill n de\~ttllr th\. ph} Il. I th .... r.lpl I l-J.1l h.I\I,; the pall 111 heg1l1 to un.. tDlltil helllgn.t ped' llt dL'\dll-lr Ie "hat Iht:) IUlIllJ"'e "her\.' thq .m:·ll~.II..-d _1111..1 h__ man Hour _II 11\ lht: hliIIJule). \\ htle tht" p,tll..-111 I .t11 \\enn 1 Iii e tlu 11110 Ih ph\ 1....lllh 1.11'1 I hOlild lkkllllill the p 111("111 s kVt"1 tit In lel\ \\ h.1I pe Itl ... l'l U It:g.lrdlltg th t:k\ tlUI I Iii plllf[li til l-li III' \\hl;;l1 111 til 11 r an I I Ill'i.".~1 l IIlh p.t1It:1ll h.1 11l1l.h )(OI!x·,,·111I1\. !llt'lun IOU III III 1.1111 I 111.1) .1 lo. IIhlft: .HI Ill\ pr\lllulin "I" II m u.. lI, 110\\111'111 Ih t'!\.lhll l-llilll'.' Ilhrean (t

emergency phone?" • An.: \OU mOh: !eartul 01 '''''Ing .111 Ie ator h) )our'cll or \'I,h a ullwd of pL'(lrk and ",hy"!"' Ha e you l'\('f 1.I"CI1 .111 eln.llor hclore and 11 <';0, whal happened'l" The thcI.lpl,1 . . hould C0l1tll111C to exam me the patlent"<.; It~\ el of.1I1 ICt) dUring que<.;tioning. <.;topping lu ...1 before the p.ltit.:lll' ,\11 let) re •.! lhe...
Cognitive-Behavioral Therapy Cognl!h'e-heharioral !"erapy (or cognitive restructunng) can help decrease anxiety by changing maladaptive thought patterns and modifying unhealthy behaviors." Before unhealthy behaviOrs can be modilled, they must fir!'!t be identified and c1a",slfied. Because many patient... are not cono:-,cious of their anxiety. an mitial step when u')ing cognitive-beha\ioral therap} i\ to help patient" recog1l1Le arn.iet). Detennme what the patient .... fir':>t signs of !'ltres"" tend to be. Many \\ ill repl) that the) react se\ erely to ~tre..,s. stating •. ) thro..... up:' or "1 cannot breathe:' In these cases. therapI\ls <.;hould a..,k about the exi~tence of les"" severe signs, ... u<.:h as nail biting or leg !'lhakmg. ext, pallenh ... hould count hov. many times a da) the) experience <.;tres<.;, recon..llOg these in a journal Physical therapi"'h should help patients look for pattern\ 10 their anxiety. Aft~ patients more am, IOU'" 10 the morning or evening. \\hen Ihe) anend thcrap), or \\hen faml!} members vi it) The more pallcnl (ao Identl") pattern.., of ao'\ICty the more they lao antll':lpalC It and prepare for an\lel} before It lK(ur . Theraplsl'" ... hould cl1l:ourage palll:nh to tre manage-menl le(hni~uc... a......oon a<.; Ihe} C\perlence the first sign of ,Ire..., so Ihal their all'\let) doc ... not : : : ' Keepmg a tress managcment Journal l:.U1 !!I\e 1ft Ighl mto ho\\ Ihelr lhnughh atte(1 their hcha\: arch has shown that lognlliH'-heha\ ioral ther.tp)' effecu 8S medilallon. E\ idenle Summar)'

Box 2.1 pre~cnt ... a ..,ummary of re~ear(,;h data eXamining tht: ellclls 01 cognitive therapy ver,u,> u"e of antldepre _ "'.lIlt, lor dcprcs'Ion

Treatment for Panic Attacks It the therapist knows that a patient ha a hi tory of panic alta<.:k..,. the follOWing technique.:; can he helpful Have the patient de...crihe the fir..t "'Ign'i of di c(lmfort dUTlng the attack. ImmedIately help him or her to breathe long deep. and \Iow breaths. Thl'" may reqUIre the U';C of a brown p1:I.per bag held by the patient over the mouth"" hile breathing mto lito ,1o\\- the inhalation rate. It i... beneficIal £0 acknowledge that a panic attack IS occumng and that the pallent will be all fight If he or she contmues (Q focu'i on breathmg ...Iov.ly and deeply. The panic attack can become ..evere v.lthm minute... and pass Ju ...t as qUIckly. The patient rno<.;1 likely \\ III be scated or lying do"n throughout the panic attack. ~ It mil) render him or her incapable of doing anythmg el<,e. P1fienls are u\uall} embarra...sed after an attack and rna~ a\01\1 all situation"> 111 \\hich they believe one may Ol:l.:ur. Tht.:} rna) "'11 on the end of the aisle \\-hile v.atching a movie, may aVOId cro..... lI .... or 111 c:-:treme cases. stop leavin!! their hom--..... entirely (reterred to a... agoraphobia I. Thl:ra·'l i') Lan help patienb Yo ho experience panic attacks tll ,Khl ·v.: <1 mor productivt' bfe b) teaching them techniQ'll" to Lonllol the tHtal·k ... betore the} become ",everc. l~anilhl;'" and palh:n''', ...hould be educated to under:-.tand that panIC attad..... invol\\::: a real phy ... iological reaction. tend to ia...t unly <.;cveral minute .... and often recur without further Intt'rn~nlion. Patients with evere. continuous panic attacks 'ihould hL' referred 10 a p }chiatrist for possible medil:ation managemenl.

When to Make a Referral for Anxiety In many ca...es. medication doe... not full) alleviate patlen~~' anxiety. However. it rna) decrease it ... ufticientl) enough lor pat lent ... to begl1l e:-:pre...... lllg their fear, anti Implementing ...trategie... to decrease \fres .... Becomlllg familiar .\\'th antlanxiet) medici.ltions rna) help ph)'lcal thera.pl ...b Identify patients suffering from an\lety, e,peclall) II a. dlagno" ... of an'\iet) i\ not documented III a patient ... chan. Freyuentl} pre..,cribed antian\iet) meoK.ulon ... are lI.. ted to

80'\ 2.4. . h h' \e i\lulllple referrah rna) be necessar). P.luenh \\ 0 J ran it, attat·ks ...hou Id be re l erft~ d to a ps)chlatn't for med· '."I·on Generalized an'\let) c.ln be treatcd \\ Ith nlt'dIl'J' .... . . d he pfl.lI~ "lion; hcnce. a referral to a p...)chlatn...t \\oul a~pro h I.. and IIltt'rlcn:'" \\It If the al1\lct) 10.1<';1<.; more th an J \\ee . . . c \Io-ho(;on • Ihe pallent\ perfonll ..lIll:e In re h a h IIII a I1n0Tho. .. . h b I· . . pltc dc">C'I1'IU _ tmue 10 e\pencn(e ..In\lct) Imm r 0 I,l'" (; l: h Id Ix rekrn:d to a P') /1.111011 thcrap) ..lIul medKallo l1 ' ou . A lora lion of Ihclr fcars. dwlo!!1'1 lor ..t more in- d ept h e\p .' s 10 referral to ..1 p...)\.·hnlogl . . t ... m(;hl'alcd It lhe ~n~~l'() he a dl'l'pl) rooh.·d characlen...Ul· of the- pallt:nl PL'

.:7':iIY,

Chapter 2 Influence of ~)cho§,ociaJ Factors on RehabiliIaIioB

Evidence Summary Box 2.3 Research Examining the Effects of Cognitive Therapy versus Antidepressants for Depression Design/ Reference

Subjects

Inteo'ention

Duration

Results

('ommenh

Beck." 2004

Depressed (nonblpolar and nonpsychollc) or dysthymiC oulpalienls 72.]00 female; Mean age 271

RandomIZed treatment-outcome study comparing two groups: cognltlve Iherapy (N ~ 18) and cognrtive Iherapy piUS anlide· pressanl treatment (amitriptyline) (N = IS)

12 weeks ollherapy and/or med· Icatlon in a clinic

Cognrtive group became depressed again dUring a one year period following intervention vs 18°0 of the cogmtlve plus antJdepressant group. a non-slgnrtlcant difference (p > .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<..,. A certain degree of depression is normal in respon",c to life's events, but when depression lasts :2 or more week.;, and affech occupational and social functioning, It is considered to be major depression. Depression may occur ~..... a biochemical imbalance in the brain. which ma) be triggered by \tress. or in rc\ponse to internal confitch or life c\'cnh. For example. the rate of depression in

people \\ ith 'pmal cord injury is fi,e times higher than that (ala lIC'phllmg I mterph:lln .... an expe It.nLt- ,I ( veri) lhrealenll1~J. rna\ t I III '" h l .11 \,.llnditlon (JI\e 1 the high lorlOrbldlt\ '" J'T\[) nd chmnit.. rnin. pip I II therapl t ~h( uJd U11me 'at 'nl \\ It'l P r T) for tt' ' I tenet." 01 chroOl\. Dam. The}, P'JIi IW' r"w 1 r 1/1/ Itflt!1f or tl'e M((J Ou 11 CJ.. ;)l' .dn,in 1 tere PT) 11 ..

Mn Srre

PT

J)

( t

sen ItI ral d e IU 'lleh 1m Ihtma Chat r 2 fu a n: d t U 1)1' 01 m'il U1r nl J I_ned mea ur pall The III e Ired uutcom t Irtatm~nt for JYI Sf) huulrl l- eoga_cment 1Il h t!th\ atl'-I) mg nt."c~ .tr~. :.11.11\ \tle I he ph) Ila1 thl:'rapl I lan help patic.=nt 10 hudd po ltlve dl etlicae) through t:oglllll\e re trullurin~, de: elflJlIllt'lIt oj heiJlth) lllplllg J.III and 1~i.lll1ing to u... ~ the fr Ia alllln Ie pO/he all III ~t prl.'lllLtahle, :-oak 1'1l\ 11011. m Ilt ledllll4ut: u ed to heir dl'lle;he t:ata'ill'ophillng nd IJ.IlICC lIIduue JlU;j1JOI1.t1 e).pu... urL' l'\erl.l'il' III III II d :.trhtrJ and Illtllou.·ptl\l' e\po")un: e\!.:'11.I l" u h a r lllllllig III pble or plllnlllg 1Il adulT). I r~ ptl e I" ure e t:fl.l ~ hdp p.ltlent I.upe \~lth n mfonCjhk ph. 11l1ogll....1 en ,tlloll Ihat nl.l) pI l"\\.·nt an 'pallon III aUI\ lilt' f lIliJlh Ihe thrrapi I hlluld PIO lh patlenl tuu\,.athHI h:gardlllg lu," IYfSD ,U1d p.UlI la IIUdt CJ.\h lltht"r dnd Ie ult III .1\OIU.llh.l \ p.utll r II m III II "lIh ~1\,.1I\1l1\. llll.f.t l lO-UllUTJlllg dl til d u.. !I .. tkpre 1I1f1 .HI Id~ p.llIll and !t.uh 1.Il11l

1

of the gencr.Li population.~<) \\omcn \\ ith di . . abilities are more prone to depression (10 percent \ than \\ omen without di\abillties (8 percent).

men" ith oi,abi! itie, (26 percent). and the general popub.tion (7 percent) according to Healthy People 2010.1.' Other re earcher", ",uppon the finding that women with di :lhihtl~"" t~nd to experience depres\ion morc common. th.m til if Illale counterpar...... In their analysi", of -t,B WOl~lt'n wllh ol . . ahtlitJc"'. Hughcs ct al found deprc\"'lon to he ~I fn:qut.:ntly ol'curring . . econd
9."'

Ph, i£ I Rchjthilitatinn

Tabl 2.4

SiK'" dod S. mptom

\

o
Anqer

Decreased solf ASfeem

Anguish

AnXiety

Despair

Change In appetite and weight

Decreased concentration

Despondence

Decreased sex dnve

Depressed mood

ExcessIve gUilt

Desperation

IndecIsIveness

Fearfulness

Feeling overwhelmed

Intrusive thoughts

Inadequacy

Helplessness

Irritability

Sensitivity

Hopelessness

-----

Lethargy

Insomnia or exceSSive sleep

Loneliness

Recurrent thoughts of sUIcide

Neediness

Wurthlessness

Sadness

'ad and mournful. Jf patient~ reac.:h out to fnl'nd, and exprc",s their feelIngs. they can alleviate feelIng' of lonl'li ne~' and i!;olation that commonly occur in re~pon't' to II) However. If patients do not take ~tep~ (0 expre~~ (heir fccl mg~. the downward ~piral of depres~ion may continue. Over time, patients may lose interc,t in activities and remain at home. They may lack the energy or motivation to attend to their responsibilities. and feelings of guilt ma) ensue. A decrease in role participation usually lead... to decreased ~elf-esteem and feeling ... of \\orthle~sne\s. bentually. people SlOp canng about their h) glene. The) may avoid social contact and become increa\ingly lonely. At this poim, ~taying in bed becomes a welcome allernati,e to dealing with the outside world and the painful feelings it may incur.

Depression and Rehabilitation GIVen the signs and symptoms of depression (Table 2.4) and it~ associated behaviors (Table 2.5). depression may negatively affect the outcome of treatment. Depre~sed patient"; may have difficulty geltlllg out of bed and may not be 1110ti\ated to attend therapy. If they do attend treatment. the) rna) di~pla) pS.H'Iwmotor retardation and lack energy and interest; the} may aha \erbali7e self-deprecating remarks. feel cnticized. and behe\'e that they arc progre~~mg m3dequateIy. It may be difficult for phY~lcal therapI\t~ to leave depressed patient!') unattended \\hile working with other~ because the depre~~ed patient may not engage in the prescribed exerCise!'). Patient<.; may feel guilty that the) arc in the hospital in\tcad of t:ll..lIlg care ot their children. v.orling to eun mane) for theIr famil). or engaging in othc.:r lite ro}e~. Depre ion u\uall) attects pcrtorman\:c negati\cl) [)repressed patients rna) not want to make gain, in rehabih-

he\: III l:C 1 t1V,Jllon .md lad.. of plea-,ure ill I k n,,, ~'h \ th
Treating Patients with Depression Deprc:-.\cd patienh require ,b\isrance \\ith mot/\JUo n. Phy,ical therapl\ls can facilllalC moti\alJon b) pro\ldll1g. a ·noco po:-'Irt\e encouragement, emphasizll1g "ltrengt I1'. allen . , ' 'I t goal feedback. addre:-.:-.ing value~. and mobihzlI1£ gUi t, 1110 ~ acqul\ltlon. Empo\\ering patienlS b} pro\ idlllg aCU\lue . . thai offer oppol1ul1ltie~ for self-control and ,ucce~s ha\ e been sho\\ n to decrea...e depres:-'lOn. .:, Depre...,ed patient... experience a naITO\\ ing of pen.:eplion. The) hJ\e dIfficulty ,eeing alternate solution.. to

Chapter 2 Influence of Ps)'cho'iociaJ Factors on Rehabilitation

47

Table 2.5 Behaviors Associated with Mild, Moderate, and Severe Depression all activIties

Bemg easily frustrated

Crying

Decreased Interest

Difficulty planmng ahead

Feeling pessimistic about the future

Lack of personal hygIene

Obsessmg about tasks

Having difficulty making decisions

StayIng in bed all day

SItting alone

Making frequent self-deprecating remarks

Suicide (or sUIcide attempt)

In

Over dependence Reacting strongly to criticism Reporting psychosomatic symptoms Ruminating about problems Ruminating about the past Social withdraw-a~I:----':---------------------

tlOn i":. unique. as is the recovery penod. Most pallents cannot "~nap out of it" as many family members desire.

When to Make a Referral for Depression It uepre"ion i, 'lI,pected. the phy"ca! therapISt 'holiid <.ktCnlline if the riuient is currently being treated for depres"'Ion or ha ... received treatment in the past. If the patient has 1l t: r l.x:'el1 treated for depres:-.ion and is experiencing suicid.J ie,llIon l t:e . .el:tion on Sui<.:ide beIO\\) or ...) rnptoms of depr Ion th;.t[ nMr"'edl) Imlxur life role.... the therapl ... t h u J n:k'r the p.ltll'nt to a p"')l'hi,:nri"'Jt for po...... ble medx manJ"':l'nlenl. ~kdi<.:,ltilln l'an enable patlenls 10 T 1<.1 tht: al mllTe Tl'aJII) JI l·U ..... problem.... anJ ~ pre .. l r u t i1r. 'S Being tamlllar \\ uh the namt: ot meJII lion uS(" j tll tn.'.!t Jepre "'lon rna) help thaapl h iJentit r 1I1l.:'nt \\ Hh Jl·pre:-. ilm. e... ~t.:I.tll) if a p... ) l:hl~\trli.: diag1111 h I not IIldil..tll·d In Ihelr <.:hart. Frelfuentl) prc-"'l.'ribed anlld pre 'S~tJlt IlH.Jll..tlion... .lTt: h ... h:d III Bo :!.o P tlc-nt \\J1h h; st:\t."r~ )lnptlHn.. "hll,tre nlll UII.. iJal ".In It: n:d h~ do P \I.)hl!,lgl I fl\r \(.~rb<.,1 ther.11' It d pal I t 'Jlr~ 1011 (,:~ tDt ~ "-JU J b) tlnul tU!TTl\U! ..t r rr.tl It U l I y.olker fl r ..tllllh IIHef\,entllm (.111 ~ mild Pallen1 \\hl. hu\(' Ulfth.uh erball Ill' their t eI Ir. l n to< rei tJ t ) tl Lre III\e 11 ther.tlll 1101.1 Ilu.t[ pre Ion lhrou'l 11\111\(' r.;.tl Ilu:au 1I h.1 InU Il tllll"Jl 01 t1ldJll t \ rC'h::rral ttl ,111 ,"-L'up.Ullln.11 tht:f.tpt I to: til he." IIIJ.Jc; hi ht:lp p,tliclll r '.un tUlldll\f1 111 d.1I1 II h.rldt: Ih II ... \(' II l.h ruph.:d h d pre hIll

uicid E

Bo 2.6 Commonlv P.....cribed

ntidepl"E'~sant Medication"

:

:::~~~hydmchl(lnd lEla ( ndlnl

11

(

llloltnn I apml prarmne h\dn hlllnd ( I'rrr.mlln)

Do

h)dn: hl(lndc.: tSm('4u.Ul. Zlm.lliml Au flO (Prn 31. S.lra~ m) Au\o amm ILu tl ) ImlpramlIlc h\ d hll'n.1 (Tolr.tnlll In

Imlrramlne ramoat I urlx't .lZ1d I I rr1.m Mapn"lldme t t ulililmlli

efazodone

~,' crzone)

ortnpl\ hn h~ dnx hlonde 1 A\ ent\ I. Pamelnr) Pam eune (Pa 10 ertrahne (Zoll'fl \ Phendzme ( ardlll

Prompt lin\' (\ "adll Tran~ Ie) rrommf' (Pamale) T razodl'nl.: (IX ) I'd I Tnmipranunl: maleale (Sumlomill \enlata ine (Etfexor) "ote: Brand name" are "hO\·\n in parenthe"e\

that may go unreported due to complications n:g.Ullillg the cause of death. 2(', More people lose their Ii\'e~ to suicide than to any other cause, with the exception of cancer and cardiovascular disease. Suicide is often a re~ult of poor ~ocial support, low self-esteem, ineffective coping skills, and the inability to see a solution to difficult ... itualion~. Ri~k factors include serious illness, previous suicide attempts, family history of suicide, alcohol and substance abuse/dependence, loss of a loved one through rejection or death, prolonged depression. and financial

difficult,.,. Recognizing the warning signs of possible suicide n-,k is important for its prevention. The most frequent \igns 01 suicide n",k melude: • Direct comment!o. about suicide, such as. "1 ju~t want to die" • Indirect comments about suiCide, such a:-.. "My mother will not have to worry about me anymore" • A plan to commit suicide • Writing a -,uicide note • Preoccupation with death • A sudden flight into happine5.s or relief after a long depre~­

sion • Excessive risk taking (e.g., driving while mebriated) and • careless attitude • Fmal preparations (e.g.. compo\ing a y.ill, giving away penonaI possession~, repairing broken relation ...hip", or wntlII8 revealing letters I

:.MIred

• Ch.lI1gc tn pcr s on,t1 ,lpr' Ir,lnl:C e ItJn h,thll u I dnve !cl'p p,lltcrns, men tru.d cycle hchJ Hlr (e g In,lhlllt) to t,:oncentr,lte or dl IOtcrc t In IOI\"ll1e J r u on
• \ k patient them t'he

Lt lhe)

drc Ihmkm~ ot hunmf: or kJlhng

• Li ten to patient without ex-pre 102' hock "uhout dl _ "fI.-dlllng \\ hat they y lnd v.ithout de\'alutn!:'! their teelmg TakL :111 suiCid 'me it en)U ly ~.. en 1 you do not hl h~\ them dt tht: urn • R .,. m I co pati.:nt ·... Ith emp.tth) and under tandlOg; I • t 0\\ much .It ut them and that )OU I' II. !anle to h"'lp them t ,.. '!H thmk. \,A ....ltemal es. (liter chOICes ba....ed on )t,l 1'1 v. ~ ige .ll"l0ut 'ht: rdllcnt .... life. rather than generH III ~ n, th.lt
Substance Abuse Suhstance abu ...e <X:cur... \\ hen an Indi\' idual demonstrate" <1 dysfunctional pattern of drug and/or alcohol u..e character· i;ed by recurrent and ~igniticam ad\erse comequence.. Sub... tance" rna} include. but are not limited to. alcohol. amphetamine". caffeine. marijuana. cocaine. haJlucmog en " inhalanh, opioid"J. or ~edalJ\"c",.~

Substance Abuse and Rehabilitation If clien'" come to the clinic under the mOuent:e of drug"IN alcohol, thc) may be inappropnate, argumentame. Imtab:~ . . I and \\111 ha\e dill' dl"Jmhibned. stubborn. IJloglca . or ang[') .., 71 culty follol,\.ing treatment plan", (...ce Table .lf1d BO\J~ ~ They may also dl ...rurb othcr clients. "orne 01 \\ horn m . For rhc-se n:'a,,(m... in their o\', n ...ub..tance abuse reco.. c[') _ nt .1 Illto\lcJred clients "hould be e",cOI1Cu ou t of the rre.ltJllt' area and referred bad. to their ...ubstance ..I bu...e prol!rJJ1l'" -~ he with a call to their sub...tance abuse pro.. ldc-r JesLTlbillg r

::!.?

Chapter 2 Influence of Ps~chosocial Factor~ on Rehabilitation

Box 2.7 Behaviors Associated with Substance Abuse • A"ClCIJlmg onl) \\ilh olher ,ub,lance abu,er\ • Chealmg • Compul'I\(' u,e of drug... • Decrea,ed abilit) to manage ...Ire" • De,.:rea,ed abilit) to manage time • DIHicuh) holding a .lob • DI'conllOuatwn of u,ual aCII\ lIie ... • Drug '("('''lOg and u...ing bcha\ ioT'• Falling • Inahlllt) 10 conlrol drug U'l' • Inat'lll11) 10 lulfil11llajor life role' ·I,olallon • L)mg • :\t'l pJ) Ing ('Ille', bill, • P(l~'r h) giene • "flCndmg all Ilwne) tl" drug' • SIJ) Inf' IIp al. night '\Il'ahnp

Physical therapists can help patients III recovery by providing opportunities that allow them to gain control Over their live~ again, Such assistance may include opportunilies to practice setting boundaries. regulating emotions. and tolerating frustration. Physical therapists can emphasize healthy activities that provide pleasure and decrease cravings. Strcs~ management, time management. activities

of daily living (ADLs). and social skills are usually necessary

e

o nol perle'l\e Ihelr nl.:C I n gle I to tollo\\ prt:Llu \,.Ihlam Jt i. h.lrgt.' Ix tort.'"

ut tall

rhlllill

It

skill~

to promote recovery.

Education on Substance Abuse

10m

etbu

are no longer abusing sub~tance~, The\e patients tend to have poor boundaTle~. They can be intrusive. flirtatious. or deal-seekmg m order to obtam what they want. :!Iuch as alcohol. cigarettes. or extra medication,

Treating Patients Who Abuse Substances

m...,d~' thall \"urred. IfthC') are t lurrentl. engdged m a u!l tan\,.(: J. ~ pr gram J. refcrrJJ ould he madl.: nallcm Me n und r the 11 f n I.: Juring tr('~llml.'nt. !lut Me m~ dPl T k at DIll', the\ mJ. mi ...... h...hilitat )J1 tired. tre tml:nt cen l ati'1n lIld UTihun~ r tahle nOD II '11 t'XI er \ II nl t enl.:e el

t

49

Phy ... ical thcrapi~ts. patients. and patients' family members l"hould be aware that substance abuse is an illness. Like ph) ... ical or menial Illness. it causes a decrease in function, require, ...killed intervention for recovery. results m denca ...ed role performance. and can affect anyone. Paticnh '" ith a diagnosis of sub~tance abuse usually cannot ...top 1"lI1g drug~ and alcohol on their own. They need help. and r~covery is a life-long process that includes Je\elopll1g ... k.ills 10 manage cravings. dealing with stress III healthy \\i1Y~. expressing feeling~. participating in 12-step progr.11lh. and engaging in drug-free activities.

When to Make a Referral for Substance Abuse If the patlt'nt I' gomg through \\lthdra\'.al. me ph) Kal lherapi t ,h()uld Immediatel~ refer the patient to a ph) '1I,,;lan. Sl~n, ot \\ Ithdra\\ al can mclude ... \\ealing. tmpalred leep. 'COI/ure.... Impaired motor l:oordination. faulty judg0lC'1lI an\lt't~. ,haklJ1g. ,Iurred ...pe-el"h. tlucmaung le\el, ot t. on \,.: ltlU ... ne ....... and \ I... ual Jnd tal'lIle halluunatlon ... Atta tahilillllg the patient. the ph~"'Il'1"1n rna) Iri.l.Il,ter hun or ht.'r 10 a Jcoh)\Itit.·;..ltlon Unit It the patient I' not C'\pt.'nenl'ln~ \\ lIhdra\\ <11 and I' nol ~llread) in ,1 ... lIb.. ti1IKe Jbll'l' trt.·,lImenl pl'llgmm. ph) 'h.·al Iherapl~l ... ("an make .1 rdcrr,d hi ,I.n .lppillpnate tre,tlment I.'enter Such treJtmeni l'l'nll'r, Ill" ludl: 2~ ·J,l~ Inp,IlIt'n1 reh.lbllll.ltion t.'elll('r . h_ln~ It'nll II hi I ~ )t'.lr... ) inp,ltlt.'"nllht'rapt:'ulIl· n)t1lI111I111 lie' . 12 h.·p pr()!!r.lm... tor I.'ommulllt) -d\\eliing outp.ltll.·nh. ~lnLl du.tl dl.t~fhl I progr.tllh h)r p.lIIt'nh \\hl) hJ.\~ II II tx'"t'n L11J.I!-IlU eLi \\ Ith menl.ll Illn P.tltt'1I1 \\h,' h,l\l' b<'en ahu III 1 UP I.ln... l' hi lOll 1 ~f lOll ~lt LlIIlt' h~lulJ ~ letllll:ll hi .l IlUlnll~,"1 t hIt phirlC'r dld,lI) re 'UI.t1hlll Pin h.. tl Ihd.tp., p.tllt.nl hl) h;J\ he' 11 ,lhu Illg uh 1.1Ilt. ('... tIl h4.: r h:nu.1 hi ( t.upa !Ioll.11 Ihl,;l.IIH I hi .h.IJrl: S IlgUI.UlIl I ll1l\Hhlfl IIln

Table 2.6 Signs and Symptoms Associated with Substance Abuse/Dependence

P'YChOJo~g~i~ca~J~::::::::~;::~~~~g~~~

"cal Abnormal blood pressure

Peripheral neuropathy

Cognitive deficits

Isolation

Alcohol on breath

Abnormal pupillary response

Perspiration

Denial

Loneliness

Belligerence

Bulging ocular veins

Poor concentration

Depression

---+--~ Low frustration tOle~creased role performance

Chills

Psychomotor disturbances

DIsinhibition

Low self-esteem

Cravmgs

Red nose

Olsturbar,l;€S II"' behavior

Enlarged heart

Sensory losses

Gastrointestinal bleeding

ShinY ears

HalluCinations

t

Olsturbant;us of

j

t.;;!rDerSOfldl

1"~tC2pt:(j1l

Paranoia

...

Impaired Judgment

Poor boundanes

EIl.utl:.Jnal I ~l Ility

Thought dIsturbances

Grarld;os't~

Tnggers

ImpulsIvity

+-

IrritabIlity Poor hygIene

Hyperactivity

VIolence

Hypertension

Ulcers

Liver damage

Visible track marks

Loss of consciousness

Withdrawal

Malnutrition

Yellow, brittle nalls, half and teeth

Nervousness

Drug paraphernalia

...

1

Chapter 2 Influence of Psychosocial Factors on Reh.bilitation

and m.lll1tall1lng appropriate boundarie~. tolerating fr~~ lrallon. mal1L1~,1ng '"nc. obt.llnlng . . oclal 'll...dh. and regall1 lilt! Ilccc........lr\ J({I\ 111c", ol d.lIl) hnng.OccupallonallheraPI:h 0.11.,0 CJ~ help pallcl1t . . learn that health) .lCllvltIC\ call be plea... ur,lbll'. Ihrough IJ'l1... group" lI1\\hlCh p..l lienh choo...e. engage 111. and di.,cu'l" health) actl\ IIle'l. A ... oclal \\orl... referral call be made If Ihe pallent requm~ ... COI11I11UJ1It) Inlegrallon. fJmll) II1len enuon. or .,ocial ",uprorl~.

Agitation and Violence Ph\ ...il.."al IherJpl"'h l11a) IxlieH' that patlcnh \\ III not del:"on ...tratc ...e"ual. aggrc......i\c, or \ IOlent hehanor.... yet mo,t ha\ (' \\ 1IIh~ ......ed "'Udl bella\ ior., at lea... t once. Thcrapl"''' ...llOUld Ieam h(l\\ to prcdict 'Iolenee. identlf) "'l~n III e...calatlon.l1l,magc aggn:: ......i\c patienh. and \crbalI) -re pt1nd to thrcah, \ J(llt'nce I'" not ah\J)'" predil"tahlc. hut the nlOft' therari ..." unda...tand ih ...Ign.... the better equipped the) \\ III Ix tll handll.? a dangcn1u'" ... ituatlOll. All IIllllal ...Il.?p IIl\(lhe... recognllJllg the early "'Ign, 01 JgltJtwn. '\gllatJ(lll u",u<1l1) doe ... not Jill1l11i ...h on ih 0\\ 11. In...tead. It mJ~ hul1d to a \crhal altercation llr ph) ...il.:al i.Kt. Some "'Ign... (l! ,Igllallnn m,l) IIldude l.lt:nching tJ"'h. pJCmg bacl... and INth. mal...lIlg angr) faLlal exrre...... ioll~. gruntmg. gWJ.nll1~ .... \\ (',mng t..lppll1g J fom. ~rjtt11lg n.'. tu"'1I1g 10 engagt.' 111 th.. . I".lp\ thrn\\ 11lg ohjl:c!s Jlld b.IIl~lng \\Clghh or (Hha Ihl'r.lpcutll. 1..'4uipment. .\lter Ol"'l'l"\ JIlg I,£Ih of a~itall0n. ph\ <.11 trl r.l\lI ... 1\ ...houlJ Idt'ntllj Ihl' IlUrlt.' oj the agitation In or...kl hd It:r umtmlll \\ hlh.. 11MB) Iluatll)Jl ... l"alll"atl~l. l-1tl\)l1. It I Imronant w rUllelllht r thJt eH:nh that J.)..':ltiU '1111 pl:r on ma~ ha\t' nn rlleL! 0n <4Ilother: It \el lro ·' •.illon \aT) trom per l. n to pa (lil. P '('ple \\ nh \llhclllh;'1 di ...· ea e 1ll3\ bcullne agitated 1lt:1o. au i.' the~ l.anJh 1 ~l~ ,Ill thl.: name of .illllllar obJed lJr rememher familiar lOlnl pbn Th IllJ helh.:\t. th~1 t t1l11h 'lll:rnner are hill" _ c to them del 1\ In_ them c,r
51

Violence aho can happen wllhout wamlOg. Many therapl... h \\"orking on inpatient Unil\ have been hlllen. kicked. punched. or ...cratchcd. Patient~ may feci that they are being forced to participate III ther'-lpy Ihey do not need. or Ihat they arc bemg Ireated lIke children. They may believe thai "ltaff member~ have as~umed control over their lives. To a\OId humiliating the patient therapist" can use a c1ieOlcentered therapy approach in which patients are offered n:: ... peci and IIlcluded III goal ~etllllg and treatment planning. If eflorh to deru~e the patient's agitation do not work and he or ~he becomes violent. the physical therapist should remove all other patient~ from the area. then leave and call for help. After an act of violence. members of the rehabilitation team ~hould examine what occurred to learn trom the incident. prevent a future recurrence. and provide ... upport and education to tho~e mvolved. In reviewing the mCldenL the physical therapist should address the followmg 4ue"tions: What wa... the patient's potential for aggression? Wh~lt were the signs of escalating anger? Did the patient have a history of violence? If so. under \\ hat circum ... tances? How did Iherapists and patients respond to the aggressor before. during. and after the act? What could have been done differently during the incident'? In addition to managing an agitated or violent patient. phY~II,;i.l1 therapi ...ts need to recognize when a patient is llmh::rgnlllg abuse. It is estimated that 10 percent of women \'.illl til abilitie... experience ~exuaL physical, or disabilityrd.lteO \iolellce.',l", Abu!)e ha~ been related to decreased '1~l..lal ",uprol1. IIlcrea...ed ...ocial isolation. and elevated leveb of dt.."pn: ...., ion and 'ltre....... '*' \Vomen with disabilitie... may be I.'\('n morl' ... u...ceptible to abu ...e. due to their dual minont) ... taW ....\\ people \\ ith di ...abilitie\ and a... women. A... comp.lrl..·d III "omen Without di ...abilitie.... \\omen ha\ IIlg di ...abilitll..·... e"perieneed longer pen(xb of abu ...e and abu ...e from a gre.lter number of perpelrator.... <1 "Jo...el-.. et al h,l\e ident1f"ied 1..'\ cr,ll lactor, that prediu \\ ith ~O percent .Kcural.·) \\ hether or not a \\oman ha, e"perienced abu ...e \\ uhll1 the pa... t )ear. I hI.' l.' IIldude decrea...ed mobiht~. 1..)('1.,1 I ... obtion. depre......hln, ,lI1d J 1,11.."l-.. 01 edULJtion. E",lIll1nation for ahll"'c ,hould tk: l..lln Idered Illr \\omcn \\ Ith d' ...,lbilitle.... o... el-.. et 31 dncl0JX'd ,1 tllllr-Il~111 ...I..rel.'nlng tl\I,)I, the \hl \l ~"t'"mt'JJf \1 Il t.'I"I-f),\aln!l" l.\ .\5-0). Ih.1I e",ll11l1le......e"lI,ll, ph\ "'11...11 .IIlJ dh~lhl1ll~-rcbteJ,lbll...e 111 till.." p,l ... t )('.If

Hypersexuality Ih

1..' U.allt\ I a tne llt ht.·Il!hlt.'llI:d "'1..' 1I.11 .tr\lll ,11 thai he' .ll..l..lllllp.ll1ll.·d h~ \1..·lh.1I llr ph~"'II...11 .lggle... hlll I he'" (' hell.l\ lor 1...\11 hI.." I.. ,lu ... l..·d h) Ill.HlId dlddlw.. lt..1 'to uat dhu"'l' III hl.llil d.II11,\!.!I..' 1\1111..'1\1'" 111,1\ dt."lll' .1I1t.·ntlllll, 10 rk.·1

1lI.1\

pro\o,,"e. to e\eTI power mer olher,. to 1I11pfe,... olher-i. III 10 ... ho\\ ott Verbal "'I~n ... 01 h)per...e\uaht) ('an lIlcludl' \\ Iw"tllllg. \ er!:lallllllg "'C\ lIal ue'lre ... or a... klllg for phY"'1l al l.:lo...ene phone numher.... or date .... Ph) "'Kal heh~l\ lOr... mdude Ianng. plIlchlllg. bru ...hlllg up agam ...t .mother .... hod). toud1111g. "'i ......1I1g. C\po"'1I1g genitalia. ma...turhallllt!. and bhxklllg another .... e\lt from a rool11. There are ...e\ eral "a) \ to proceed \\ hen ~l patlcnt e hibl"" hyper\e ual hehanor If the therapl ... t leel ... threatened. he or ... he ... hould lea\e Ihe area and oht,lIn a...... I"-lance. If the pallent·... h)per...e\ual hehanor I ... a ne\\ I) ob ...ened beha\ lor. Ihe therapI\t can tle cnhe the be.ha\ lor to the pallent and finnl) ...tate that It I in.lppropnate and \\111 nOI be toleraled. If Ihe therapl'1 helie\e, that the patIent I ... e"hlbitlllg ...ymptom' ot mania or h~ r o mama. referral ,hould be IInmedlately made to a p \chlatrist. Holding a multidi ...cipllllar) team l'ollferenl'~ nl .. help Ihe palient undeNand thai hype"e,u," b<:h3\'" are not tolerated III the clinic.

hl"i.Illh prohlem". and "oual IS( I, I ., E ' <.I 1(1l1 Ull1(Jmlc d \ antagl' ma\ he due tn \tres~-lOdullng ,. I ' ,lIJl ,UTI from puhlll programs. h<.l\ 109 less ed. Y henefi . . ulall(m th,1n 1 111i.l It:: (ountcrparts v,lth dl'\ahllu . d h " Ie an aVJng a hltlh hkcll!lOod of hemg unemplnv"d ' e. ... or unmarned. p \\llh plIlal l:ord IIlJur) tSCI, report d higher level O:'IPIt d per. . ~ m .In women wuh SC I tend In ha\e a higher le\cl of pcrl:elved tre men "Jlh SCI. thilIl u.'l\t,'d ... tre ...... than thl: {!eneraJ pnpu!atl(

Social Support uI l !1 f1 r/ I efltll.;al In mall1tallllllg or aehle" 109 p j_ ehp\.oLlal 'Aellne SOLial \.upport 1 ddined a, the availJhal t\ f ptha pt'T nn 111 the em tnmment \\ho can offer tlonul uppert. tinanL dl or matenal help. a h...tenme .!UHj n e r encouragemenr SOLial upport has bee~ cwo cd \\ tt- JIlGe<.t cd ~elf·e tecT'l eoplllg. and adJu.stt tl I' 11 UJl \\-!th dl abl1l11e . E\ Ide nee ",ugoeS[< \ II II/I

Psychosocial Wellness According to Donatelle and Davis. \\'ellne ...... 1:-- ~. lhni.llllic process in which people altempt to fully develo[- the'il emotional, social. environmental. phy~ical. spirilual. and intellectual health. loo Donatelle and Davis de'crihc a "ell individual as someone who can forgive Ihem ...ehc... and others. learn from miMakes. appreciate all thing ... hoth grand and small, develop a realistic sen,e of 'elf and the environment, achieve a balance III life role ... and dail\ activities, respect 01 hers and maintain health} relation ships, feel a sense of life satisfaction. under:-.tand one .... needs and express emotions appropriate I}. and function in his or her communit). Achieving this definition of wellness may require ~ubstantjal effort for someone \\!th a disability who rna) experience multiple barrier... to wellness. J

_

Barriers to Wellness for People with Disabilities Heal,hy People 2010 has identified gaps and disparities ,n the health and "'ell ness of Americans \\ ith disabiliries. I l They found that 56 percent of Americans with di~abilille... did not engage in ph)sicalleisure activity. only 10 percent panicipated in one organized health acti\it). 68 percent maintained a weight considered to be unhealth). and 33 percelll smoked cigarelles. Barriers to "'ell ness for people Wllh disabilitie~ Include ~tre...s. IO\\- self-esteem. multiple secondary condltlon~. and decrea;;ed social ~upport. Women With di abillties experience higher leveh 01 IITUS than do male With disabilities. po...sibly owing to incidence... of poverty, violence, abu':le. chronic

\ I

rlon ria)

-<

"

a trung pre\entatl\e and paIII l..: r In i.l ...... 30;(' ot ph~ ... Ieal and medical con\1 t 1.... RIntala ~ ound that the amount ot oeial supporr ,a 01 e . . II related W ..t ... en ...e at life atl . . factlon and \\ lll- ",lIlg 1 patient ... v, Ih "'pmal cord mjur). HdrJ~ el al and K,Jplan found that hIgh . . ocial . . uppon wa ... prcdlctl\'C of a return to \ ocationaJ functIOning after rehabilitation I ~ (1:\ )

Rl' ...carcher.. . have ... ugge ... ted that failure 10 recover from depre"'''lon "remmmg from dl\abilit) ma~ correlate to a lal:k of adequate :--oeial ... upparl. Social i...olatlon i a frequentl)- encountered condition a......ocialed \.\. Ith dl abillt~ Phy ... ical re ... triction" ... uch a pain and mobi!lt~ IImlratlon.. ma) dl ...caurage connection with other.... The combmanon of dlllllni"hed ...ocial opporlunitie.... negative ...ocletal pe(cepuon.... and multiple environmental harrier... rna) re,ult 10 i...olallon and a lac,," of emotional inuman SOCial ...upport can be u...ed to enhan~e treatment and promote patient compliance. The ph) ... lcJ.llherapl',t can u~ adaptl\ e equipment and em ironmenlal de\ Ice to Impro\e a patient .... acce~ ... to ...ocial nemor!... ... and ocializauon AppendiX C contain~ ~,eraJ internet re...ource" regarchn~ a, ...i...li\e technolog), di ...abllit) periodlcab and re..earch. and mforrnation needed to a......ure acce..." to hOU"'IO£· emplo)ment. recreational facihlle~, health and ...ocial..ef\Ice .... transportation. and ... upport group~.

Wellness in Rehabilitation n"'flenl~e P...) cho'oclal \.\. ellnes~ reqUIre ... thai pallen,... C\,,_ J ':lucce...... 111 both .. hort-tenn rehabllU31lon aUt\ Ille...m long-lem1 relalionshlp'!i and role;" Short-I,cnn rehahl!llil11"11 .... ill, flOn J.l.:tl\!IIC..... hould engage rhe patlcllI Jl1 f um.:110 , (e.g .. funcllon.1I mobility) and mealllngful c\'cnl'" thJI

Chapter 2 Influence of Psychosocial Facton on Reh...iIi. . . . fo,ler \(Kializallon (e.g.. pia) Ing \\ heelchair ba\k.etball \\ Ilh olher pallenh). Long-Ienn relallolllihlp, and role\ II1dude hell1!! a 'pou,e, parent. \\orker. and Inend. Read,u,tmenllO the~e long·lenll rale\ can be facllllaled b) p"')Cholog,,'" \ocial "ork.er,. and occupatIOnal therapll.,b. BOlh ,hort-Ienll reh'lblltlal ion ;:tell" IlIe, and long·teml relallon,hlp' and role~ \hould prO\ide a sense of conlentment. happll1es~. and well·bell1g. Ph) ~ical therapl\tl., can pro\ Ide opportul1lties for pallenh 10 choo,e and engage in meanll1gful aCli\ ilie, thai promote psychosocial \\'ellnes\. ~:llIe~ll' \\ ho spend a great deal of time dwelling on Ihe pa..,t and \\orrying aboul Ihe future are unable 10 be fully cognizanl of the present moment. The ability to become ab~orbed In Ihe present momenl can decrease anxiety COIlcerning Ihe pa';l or future-the palient's emotional energy I;;; focu . . ed on his or her immediale activities, Each inMance in \\ hich a patient can focus on the present offers him or her Ihe po\\ er to change, 10 break through old habit\. 10 'Ie\\ C1rcum\tance\ differentl). and lO recognize a\ ailable chOIce.... Ph) \ical therapi\h can help patienh remain focul.,ed on the pre . . ent moment b) selecting acti\ itie~ that are both meaningful to and congruenl with the patient \ g031\ for rehabilitation. Ha\ II1g J dail) balance of \\ork..lel,ure. and \ocial aCli\ltJe\ I'" impot1ant to ,\u:>.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: <.tctl\iry thar: patle' .\ lill depre\\ion. '!>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<.:t1\ it) illlere I un e ... are u:...ed tl galh,~r In 11 mation aOnut the t~pe of Il·1 ure fur ui", pi :l.:'nh PIC'\I ou\l) engaged 111. "hu.h IC'I lIrt' pur Ult... the) ...t.rrcnt!\ hold lI1tere:...1 Ill. and v.hlLh leI un: all!\j(Il'') the) \\oLdJ l!ke to pur'ue JI1 the future, A negall\t' outlouk IIlI11hlts P )l'ho")oual \\ellnc\s. Ph) "Lal therapl\h l.:an ht:lp palient... \\- ilh negative per"peul\c\ 10 P0:>.lIl\el} dlter their expecL.ttion ... through gOJI settlllg. idtlltlfylng optiml\ll(: option . uSJI1g <.:ogllltlve-behavlOral teL:hnlyue ... that <.:haJlenge the vaiJdlly 01 negative perceptlon:--, or refernng Ihe patlenl to a p...ychologlst for longer term Intervention.

~ntegrating Psychosocial Factors mto Rehabilitation: Case Example !:illl a I~ )'l:ar·old \Ioho Wa .. lrallllng 10 be

OI}lllpll' gymn t u (;uned a SCI In i.1 llloton.:yLll: ~tLLllh:lll Bill had de\.:I(Jped..l. trong oual bUpport y kill •.tnd p,lItll' lpdled In a \laru:::ly (Jj t::~tr,llUinlul.tr atll\illu:, lit "..I.' tng4Jgcd to be married, parlltlp..l.lt:d on hi, l:ollcgl.' ~ynll1d II(; It:alfl and wor~ ed a:>. .ill .tthh:ll<.: loun'.l'hll III ,111

lhe ..,ummer Ci.tTllp he had allended ,ince age seven. 1be SCI he \u\I<.t1ned ci.lu\ed a 10\\ of funcllon from hiS ehe I down. All of Bill", energy is now focu\ed on getting lhrough each day. He doe... not vie,," hlm~elf a\ able 10 work or attend \chool The accident has changed his expectallon\ for the future. hi\ outlook on life. h1\ environmental challenges. and hl\ ~ocial suppon l)ystem. HIS depres~lon wa\ compounded by his broken marriage engagement, and Bill no longer meets. his. friend,; for social events; in fact. he rarely leave~ his home other than to attend rehabilitation. Just when he was becoming independent of his parents, Bill has now become dependent upon them again. He observes his younger sisters and brotherl) progressing in their live~ and feels stagnant, angry, depressed, and ashamed. His self·esleem, which was once high, il) now severely dimini,;hed and he has 10<.:.1 hi~ familiar identity. As part of his rehabilitation, the therapist should provide a safe \Va) for Bill to express his anger; referral to a psychologi\l is also warranted. The Iherapist can help him to better underMand his physical limitations and capabilities. Based on Bill's strengths and limitations, the therapist s.hould help him to redefine interests that could emerge into new roles and a new identity. For instance, it might be helpful if Bill could identify a meaningful activity that could take the place of his athletic training (such as coaching a children" gymnastic team). InfOtmation about college and distance-learning could also be beneficiaL The therapist also can ""ist Bill and his family in the understanding of SCI an"i reasonable expectations for Ihe future.

------------------

Suggestions for Rehabilitative Intervention Table 2,7 olf~r:-- a Ii~t of beha\'ior~ that suggest lIlappropriate and pathologic response pattern, to disabilll). Tht' list i 1101 m~ant to be fully II1clu ... ive, bUI rUlher indicates area rCylllflng funher con:--ideralion. It i... important 10 under... tand Ihal even mild e\pre"':-'lOn... of pathological respon:--e pallern\ can become chronic and \\or,en in ...everily over tlllle. Table ~.8 l(.Ientlfie ... patient bella\ lor~ lhat \I. arrant a mental health con:>.ull. Human rCatllon ..., re'polhe pattern... , ..11lL! lhe ad<\pI<.ltion proces\ are vanable and IIldl\ Iduah\lll, Each pi.ltient Il1U\t be approalhe<.lllnlqllt~·I)- and Ireatment goal, ... hould inl,:1..1rporale the p.HICnt\ IIldl\'ldu,t1 per...on,lIll) Charal'lefl\lIl·..., respon:...c ... ,IIlU need.... An Imptlrl,1Il1 l'omponent l)1 rehJblllIallon 1:-- Ihe p.tllent-pr.tl"lllllUler rel.ltIllll ... hlp, Ph~ 11.• •11 Ihcr..tpl"" l",tll t' l.ihll',h ;.t tha,IJX'uIll' .t111w,pht>re 01 ull1l· IllUIl1l.',lt 1011 , unLlcr"t,lndlllg .1Ilt! LllLlper;Hh1n \\ IIh p.t1Il:lll \\hll.h l ..iIl :...enl'.1 11ll' IOUllltHlol1 ne":c ........tr\ III plOdul.'l~ pO...1I1\ l.' rch.tbllll,HIlIIl lHllnHne" Thel '-'pi I \. an M)lllc!lllll':-- hHgl'l lhl:' P"l\\CI lui IIllhu.'lll't' Ihe ha\C' In 'tHing till' Will" \11 1111, 1Il1,,'I.llllnn I hl:' \('1) ... lrul·lure and

Table 2.7 8eha,io" SUf(l(e'tinf( Pathuluf(i.al Re'I'Of"e Pallem "e~i~g:;:h7Ie:-n:-e:-d;----".:-:,;..~igh-;-le-n-ed--"--Pn .ihilily for ~ulc.d Gne '"9 for actual or perceIved Impair· ment of functioning or actual loss IS nor mal and e'pecled. but the following might serve as clues to a more severe reaction: Denial ot problem or Its seventy ExaggeratIon or IdealIZing the loss ObsessIon with the past or the preloss state Obsession wllh gUilt relaled to loss Regression DIfficulty with concen· tratlon Loss of interest in activities and events Lability of mood Inability to discuss loss Fear of being left alone Acting out behaviors (tantrums, sUicidal gestures, promiscu* ity) Angry stance

f

Flat affect (showmg ht tie emollon) Very low energy levels Manic energy and behavIor Psychomotor retardatIon (slowIng down of movement and action) Ruminating about negative thoughts Change In ealing and sleeping patterns (insomnia or hypersomnia) Regression Social withdrawal Self-destructive behaviors Loss of Interest in environment. peo· pie. and events Self-blame and selfcriticism

Isol~flon

from

~oclal

Dpprpsslon GIving aWriy POSSPS Self ·destructlvP Sions behavior Hoardlnq, hIding mprjInablilly 10 sustain eye tr:atlons I')r potential contact wpapon Inability to accept Wnllng $1lI( de nolp praise Updating Will Judgmental atiliude Verbalizing lonellnes~ Self-deprecallng an j 1)1 h)p Ie snes self-cnttcal 51 t me t rpg
atmosphere of service delivery and the per.,onalil} and type of communication given by the practitioner exert a strong influence on patient participation and re:-.ponsc to rehabilitation efforts.

Optimizing Patient Involvement Patients should be involved as fully as pos:-'Ible in their own treatment. This includes IIlvolvement in goal selling and treatment planning, as well as ill the ongoing evalualion of progre~s. Patient cooperalion is abo dependent on the therapisl's clear e"planauon of the patient's siluallOn. pos5ible inlerventions. and e"pected outcomes. Relatmg to the patient as a partner in therapy can engender cooperation and trust in the therapeutIC relationship. When patients feel a heightened sense of control and abililY (i.e.,

Po ihilily for "IQlence Low Ihreo:;hold for ringer Depression HIgh an)(lety state M0torll: agitation Self-mutilation OversenSItive Argumentative Inability to express f",ehngs Feal'4i of abandon· ment H qh , dependent Drsassoclallve states

10cU', of conlroll. feeling ... of de",pi.lIr i.md helple ..... ne..... can be Illlligaled. Therapi",t-., ",hould <.11 ...0 mainlalfl a recepll\e e.lf 10 pJtienr concel11:-. and enl.:ourage communication. LI ..[enlng caretull~ to pariellb in a nonjlldgm~n[al manner \\ ill allo\\ Ihem to re\cal concem ... and I., ..ue... rhe} rna} olher\\ I..e feel um.~om­ fonable di ..cu",.,mg. Clear and i.U1iculale communication. however. can be dl.,rupted b) emolion. uncertaim~. or Pl)\\er di!oicrcpancie, that eXI.,1 \vhen patlen", become P.'b~l\e reclpien'" of service. While il rna} somelimc:-. appear easier 10 do for palients than 10 Winle.,s lheir struggle---particularl} \\ hen palienh assume a pa:-'':>I\'e role in rehabllitation-promonng . emenl self-reliance and independence fosler:, patients engag and re,ponslbility III Iheir recove!). A110\\ ing patienh 10 mainlain a passive role FOSler.:> hetple..... ne~ .... dependenc~. and slows progress in the long lenn.

(hapter 2 Influence of

~)chosocia1 Factors

on Rehabilitation

Table 2.8 Palienl Beha.iors Warranting a MenIal Health Consull Regression

RegreSSion Involves reverting to earlier. more Immature patterns of functioning ThIs may be more commonly observed In children but mIght be observed In adults as well. For example, children may revert back to suckIng theIr thumb. or may appear to have lost their tOilet training skills. RegreSSion In adults may generally be seen In lost skills and abilities and/or even In the extreme behavior of reverting to taking a fetal position.

D,sonentatlon

DISOrientation IS confUSion as 10 time. place activity, self·ldentlty, or Identity of others. Occasional, transient diSOrientation is not wholly uncommon tn the average person, yet persistence In frequency or duration of occurrence IS cause for examinatIon and intervention. Any more extreme confused behaViors and thought processes need to be carefully examined

Delusional thinking

DelUSional thinking refers to faulty and mistaken beliefs and, although related to Inaccurate interpretation of environment, is distinguished by the persistence of this belief system. This can run the gamut from delusions of grandeur or of persecution, to deluSions about the nature and scope of a disabihty. These delUSions hold up and persIst In the face of contrary information.

Inaccurate mterpretatlon of environment

ThIs IS the broadest category in this list. but fortunately is also the most readily understood category. Clearly when a patient significantly miSinterprets and misunderstands the objective situation and reality about them, it is probably most readily noted by non-mental health practitioners In its many expressions. This should draw attention and Intervention. not only In ItS extreme form of a psychotic break, but also In Its minor form If small. repeated episodes of misinterpretations

Inappr lpnate 3ffel t

Affect refers to the mood state displayed by the patient, where feelings such as jay, sad'les<"" fear ,md so forth are reflected in body language, facial expression, and verbalizat n.... Inappropriate affect can be seen in an affective expression alien to the situation; for xampll rl lonstrating and expressing joy upon hearing bad news. It also refers to a ,pill between displayed affect and verbalization; for example, the verbal expression of 10ur,1lng :lnd condolence offered while smiling brightly and Jumping for joyc." _

Hvp "

J- yoo\jQ:lance I be noted In a patient being oblivious to his or her surroundings and e\', iJl fj Ifl'm socially. as well as physically. Hypervigilance refers to an nle f cus ~ d alert ·ss to social and physical surrounds. Each of these have difs lall tical. 'r11eanlng to the mental health team. Suffice It to say that a is either extreme IS approached . .:>\..-It !=I t

t

xpenpru p ctl..nges n mood, yet hopefully, most of the time these changes r 1. tlvply al proprlate reactions to external determinants, such as the receIpt of t: c.. al j f0rrnatlo' or to changing occurrences and circumstances in our environnet A lhl (h changeable. moods are generally persistent and stable. When mood hltlS either to extremes and/or with some frequency, it suggests either instability or trdt mood IS being driven predominantly by internal rather than external factors. I\i

it;

Self-destructive behavlor~

Normal behaviors taken to extremes

Any self-destructive behaVior, particularly ones that persist, are cause for serious ('()Ocern, Self-destructIve behaViors can run the gamut from subtle, difficult to detect signs to very clear and frightening overt signs. Subtle signs can Include noncompliance WIth treatment regimen, poor self-maintenance actlvlttes such as not eating, overeat· Ing. diminishment of personal care, and hygiene, or carelessness in negotiating the environment Clearer signs can include self-inflicted wounds and suicidal Ideation and expressions Normal human behavior enjoys a Wide latitude of response repertoire before draWing attention as being out of expected bounds. This latltude must usually be extended further when dealing with someone undergOing a more extreme, traumattc, or stressful experience, Someone confronted With a disability would be expected to naturally focus their attention. concerns, and anxiety around thiS issue. The level of focus on a left leg given by someone preparing to have that leg amputated would be considered obsessive in a healthy ambulatory person, yet normal here. Care in judgment is required by the clinician when determining behavior expressions. That said, Issues such as obsessiveness, extreme distractibility, Immobilization In the face of routine decisions, and unexpected egocentricity or self-denigration may reqUIre a consult. An overly compliant patient, an extremely calm patlent, as well as an overly contentious, argumentative, or extremely anxIous or hysterical patient also promotes concern. Any response (verbal or behaVioral) that appears unwarranted to the stimuli should draw attention. Overreactions In opposite dIrections or any behaVior which appears to be at an extreme. uSing reasonable judgment, deserves attention.

-----'

55

ofJargon and Lab

,~

hilUld I..htrhh.rll II rmph: 1nd t~.l , hllllllkr 1.1Ild 1.1Ill.!ll.l~ th.1t mall. ht.::s the I I ntll\e k\et I'l the p,ltlt.:l1l. Till lie flt l1l'I1111l1. 1·IQHl" 1lld 1;j~1.:1 h(lUld 1 ."olded \\hell pc.lkmg \\1111 p.lllt:nt . Pltl nt thCTlpl1 ll'11111lUnh.ltlOl1

b.

Jnd el11ntl(llhlll~ d,\r.llien.... trom therapi ... r-.. SimIlar]). \,hen patient'

l1onn.ll ph I1nl11 nnn .ll1d r fr,lIn from rc pondm em tl III to the p.tlh::nt unlon CIOU t ')(lafIOn Rather the Ih r,lpl t hould lontmue tn nulIJ d re peltful relatIOn h p \\lth Ihe p Hlcnt th.tl.m tIIne. III demon tr te to the pall th.11 hi or ht.:r llr t lmpres Inn ere ml perl ptlOn

11 ltllpedt.'\ r.lllCI1I lI11dCf',t.ll1dlllg

•1

t.Ul\"1..

Ill,1T therapl\h r('felTlng to tellO\\ palicnh h) then dlagnoI . Ihe) recei\ e the mc......age 111.11 p.lllcnh an~ nothlllg Tllore lh.l.O dl :lbllitle SUdl pral..'tll.:c ...hnuld lx- .1\Ollkd Jnd. t" f(lf

tead. therapl t hould u"'e language that rence.... rc"ped the ratient"" dlgOlt) and unique hie C1n.:um ... lal1l.·c ....

Rehabilitation Team Members' Self-Awareness Finall). and perhap!\ mo\t importantly. therapl\h need to be a\\are of their own feeling~. motivation~, and re~pon~­ e~. Such self-awarene~~ i~ critical for theraplsh 10 unucr~tand their own reaction~ 10 patienh. It is nomlal for people to re:-.pond to other... based on consciou\ or uncon ~iou" memone~. Sometimes patienh can remlOd thl'rapi t of "igniflCant other~. such a~ ~iblll1g.... parenh. spou...e . or emplo)er~. Howe\er. when theraplsb react to patIent... based on unconscious associations to other.;,. the) can mi'lperceive patient needs and re~pond inappropriatel]. For example, unconsciou~ reactions to patients can cau...e therapists to become overprotective or, at the other extreme, become frustrated with patient<., without recognizing that their own reactions have more to do with other relationship, than with the patient at hand. Generall}. "hen therapists feel a heightened sense of emotion in response to a particular patient il rna} often serve as a cue that such emotions stem from unconscious associations to others. When this occurs, it is imponanl for therapists to step back and evaluate Iheir own feelings in order to discern the connection between their reaction to the palient and how the patient may be triggering unconscious emolions. The converse is also true; patients will re~pond to therapists based on their own unconsciou<., associations with significant others who have similar personality characteristics to tho...e of the therapist. Therapish must be aware of this

Questions

for

Summary It I" Important lor ph\ SKoil thcr,lpl t'S tn IJ~nrlt ilnd under. ...tand the II1UI\ luu.1I p )\..ho l)(':l,tl t..tLlor that enhance fiT II1hlhJl the rch.lhtlttatlon of their patient. dnd Il1ter.ene alcordingl) Suu.:c ful mte'rv tl m J~pel1d on ",ehle\ mg a ullnplete p \' ho X JI und t.mdtn~ of eal:h patient mLludmg per on.11 lard c lpmg' kills h ommon defem,e L nda t.ll1uin~ hov, to re.ngm mechani ...m ... that p.ltif'nt U 1] r bllll<.lllqn. UnJerstimJing tht' t w of JJ Llptalion to di....Inllit~ <.Inti h >IPIIII:'" P ;Jt.:nt J=f It,. \\n adju...tment. l ntIff Dndl'1/:, to Id .m I d pre Ion. and ,u~stan(e bL. t t J. Jdre the~ p tk n \. :, ) pna e rderral tr)th r rl:,ltn I n l mg a ...1 ·lh. "'I llatlon \\ hereb} \.. ~T :h Jl ... ,.Jmpa.""'lon. thempl"" d 'mlJlI [~at... Empo'Wering parlent, and t Ull Lt:: th, l.(;h p~}cho"oclal education. and we-lines" and pre cnllnn techI1l4Ue~. Helping patienh dt:\'elop In..:.ltmcilt goal Ihilt match th~ir current need",. \alues. and level of tunclioning. Collaboratmg \\ irh patienh and other Ireatment team member... m the identifil"iltlon and lmpk'mcntation of appropriate inter. entlOn.... Utilizing a tcam approal:h and making ref~rra1, a.. necessar}.

Acknowledgments The editors \"'I~h to acknowledge iUld graciou",l) (hank Dr Sharon A. Gutman and Dr. Anne Hiller Scott for th~ \'I~lon. expenise. and wi"c msighb the) prm ided a... gue~t editon. of thi\ chapter.

Review

1. Identify five psycho5.ocial facLOrs and state how each factor may inOuence rehabilitation. 2. Give examples or interventions lor each psychoo.,ocial lactor that may Impair rehabilitatIOn. 3. Identify the different mental health profeS\lOnals who can treat pallent... \\.ith psycho...ocial i...... ues and ~tate their roles. 4. De'Crihe the tep u\ed to calm an agitated pallent. 5. De'Cribe a method for managll1g a "iolent pallcm and how to anal) le an act of VIOlence after it has (X'curred.

6. List \ign ... of and method ... 10 addre~s hyperse'Xualu}< 7. List and de ...cribe the phase ... of p~ychosoclal adaplation to disability. 8. Discus... three coping strategies that have been found effective In the psychOSOCial "ldaptation to chronic disability and Illness. 9. De...,cribe fi\e common defcn"e mechal1l"m" that paucnh u'le 111 re<.,ponse to dl,abllil). 10. Slate Ihe "'Ign... and s)lnptom, of po... ttraumall\.. ...tre ...... d'<.,order.

Chapter 2

11. De,alOe ho\\ to recognize \\h~n l10nnal re~.u.:tlon ... of ~ne\ log and deprc ...... ion ha\e become pathological. 12. De.. ,n~ ,e\eral \\a) ... to optlllllZe pauent lI1\ohemcnt 111

13 State the Importance of client-centered therapy and techlllque ... to achieve thi ... type 01 IOteraction. 14. De... cnbe the general adaptation ...yndrome.

the rehabilitation procc~... and promote ...elf-rellance.

Cas c

Study

The patient I'" a 6 -)ear-old Cauca... ian female. admitted 10 an II1patlcnt unH 2 da), afler "'U",ti.lIll1ng a hlp fracture from falling down her b<.l ...ement ",tam•. Prior to her fall. ,he \loa... In faIr health bUI wa" experiencing declining eye..ight. poor ,hort-teml memory. and o ... leoporo... i.... Her hip fradure ha' placed her at high ri,"- for further dccondl1I0nin£! and 10..... of lunctlon. The patient .... hu ...band had .. uffer;d a prolonged IlIne''': the patient cared for hun dunng the la,t 5 )ear until he pa,...ed 3\\<.1). She ha", a ...on \\hom ,he rarel) ee.... a... he I'" married \\ IIh children and h\lng 111 another pari of the country Her he ...t friend no\\ !i\e\ III Florida and the re ... t of her friend ... have died. The patient .... embarra,...ed to be ,cen 10 puhltc in a \\heelchatr. GI\en the death of her hu..,b· nd nd fnend .... and gl\cn her recent aU':-ldent. till p.luent 1... ltv\', \cr:- dll\IOU ah Lit her O\\n O1ortalit) tor lhc 111' t lIIn 11 her jife Sr.\? i...

preoccupied with her husband's death "'lOce he wm, ...0 much a part of her life. She feels that she ha; no future and nothing to look forward to. She no longer knows who she is and long.s to "be reunited with" her husband.

GUIDING QUESTIONS I. Identify the psychosocIal factors apparent in thIS case \ludy. :!. \Vhat relevant questions about the patient remain unan",wered? 3. How might the patient's emotional condition affect rchabi litarion? -1-. List the patient's assets and limitations. 5. E,tablish reasonable goals that are measurable and tlme-"'pecltiC. b. Formlllat~ an approach to plan of care. 7 hkntJlv appropnate referrals to other team members.

Reference \\eb"le:r c:\\ \\ d t)h.. I n II men an Ene J Prenllle-Ha.lL Lpper S.tdd RJ\ r J 1988 :! \a.J1ldfll. GF Adaptillion 10 Lite I.inl·, Blu\\ll 80 Ion 1 ., \\ld,rama~kera, I. ct al: \ppiJed p )lhurh)~iqlug} A bndgc: bet'Aeen the biomedlc,t1model and Ihe blllp,ydH1,Oll:\[ model in lamll) mcdlClne. Prot P')l.:hol Rc~ Pr 27:221. 14%. 4 Liebenn.m. A. Llcbennan. \1B. and Reichherg LlChcmlJ.n, B P )cho oualuJncumilanh to dl~abllil\ ;Jnd rchallllit.tlll'n, In' O·Sulh\dfl. SB Sr.;hmill. rJ. Ph)"K.tI-Rl:hablht;JIIIJn: \"e... ,~~nl and Tre.lImenl ed 4 fA D.t\I', Phlbddphia, 2001. pill. S Siegel. B L.o\c. \1edlune: .Ind \tlrade') Harpc:r Culluh 'C\\ Yort-

14Xk

'

fl ~l koch. P Happ) C\t'r l.tughter. P... )dlO\ roda) 2(.U2. \996.

7 \\att~. R 1 rauma {;Oun,c!Jng and rehahilitallon J Appl Rehab Coumelmg 2K:X, 11.)()7 K Gleck.man. AD. and Brill. S. The ImpiKt 01 brain llljury on jamil} lunltl(Jnln~' Implu.:atlfllh lor wbal.:U!l: n:habilllillion program,. Bram InJ I.J 1X). jljq';. l.J ~mcnc1Jl P )lhl.tlfl<.: A ... IlU.tllun: Ulil~no'lll imd St.tI ....IIl.:al dfluC J.lllung <.IpplJl.lIlh lor \()lil tlund) rchdblhtdtlon t.c:T\ ILC J Re:hablj lilAH. 11;J94 II fontd),dnd. J. .tnd '\'1l("011. M DI:-'dbilll} .tnd t1epre::-.... lOil Somc: ell u\ogl(;i11 lOINderutum:-.. SOl SrI Med 14 W\ IYY2 12. Turner. RJ . and .1 • , Bci"r'M.M.· ilJor ucpre::-,:-,ulIl ilnd depn:...... i"'e ~}'lllp tCJmdlolon am1mg the ph} .... L.tIJ}' d.....tblcd A ... :-.t::-,.,lng llit' fll!e: 01 lhrlJOll tfe, J ~e"" MCnl 01 I7X''\41 19l"1 L S J) . . . p epartmcn! (,I Hcallh .tnd HUln.tll Sen IlCllo Ilc.thh) Cllpl~ llJlfJ under l.tlldlllg ilnd IlIlprmlllu lIe:alth c.l"") \\a hI I Of' e · u ... 2fJlJlJ II! un . I S (Jo\Crnml:n! Pnnllng (JUIle: "imemtlt:r

14. 15.

16.

17

IX

Pijl'\UCCl, S. et al: PO:-.l ...troke depre~:-.ion and it-. role in rehabilitatllln oj mpatlent.... Arch Ph>" 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<)~.

19 Heinemann, A. et ill: Sub'lanl'e ahu\e b} per...on.. wilh re..:ent ..pinill cord HljUrie.... Rehabil P...ychol 35:2\7. 1990. 20 :legan... J: The embodied "ell": Integral ion in heahh imll illne...... Ad\ J In,t Al!\J.nl.:e Heahh 7(3t2l}, Il,ll}\ 21 Benwn. H Thc Rela\alion Re: ...pon...e, Haf'J":rCollin.. e\\ 'IOrk. 1974 n L I\neh. H, J.nd -\n1onak, RF: P...\..:ho'OLlal -\l!.lptJIIOn 10 ChhlOl...· JUne:...... and D.....lbilit) A ... pen. Gallher-..burg \10. 1\>47 H t\c.IIl~. h.C .ilul Glued,aul. Rl DI"',lbihh .mJ \Jlue: lh.lOec,. -\n O\t:nle:" .tnd .1lMI} ... i.. oj .u.:,c:ptance 0110..... lhe:or) R,·h.lb;1 P...)dlOl 3X: 199. \9l}'\. 24 Jal'ob..on, AM. t:l al Adhcr,'Il":1: among lhlldr,·n ilHd .ldok'l·e:nl' 'A IIh in,ulin·dependent dlilbctc:, melhlU' O\l'r a ll)ur-\e:.lT loneltu· dln,lllnllLl\\ -up: I Thl: inlluln.. e 01 p.uiellt l'oping i\~d .Idlu't~cnl J Pcdliltr P'}lhul 1-;:-; II. 1990. 2". ur/t"lak, R( .I.nl! I-Illok 0-\ \ bnd hhtl)r~ \11 p ~,holhlrap\ .tnl! ph} I... .tl III ,Ihdlt\, \11\ J P,\ holhe:r 4. 2~t1 I\)\)4 ~h Dun.llclh.: RJ. .tnl! 0:1\1 .Iti ~ u: ..., h\ IIl.llth e:d ('l -\ll\n WId B.l\on 'l'\:dh.llll ~ki~hh M \ ,:'000

(,(,

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66

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(,u dnl 1m,." r tor !l H din" \nE ~ntlaJ \O\on( "ic.klnl,", Ilne '\ \\orIJ Llhra~

~()\';jl{l. (' \. 2000 Dlh"C). 8\1: HolhtK mod.dlll' & he\tlm' morn 'n'" .... m J ~ur,

910\(0):44. II)l)S.

70. h"cnmall. A. and Coh..:-n B: \IU'IL lht''fap) tor patlcnt undergoing n.'glonal J.nc,thl"la AOR .... J h2:9.J . !YlJ] 71. White. J: "'u,it. Iher"p): -\n intt:r.cnl1111l (0 r('dul.<,: an'\lcl) In the ffi)o{;ardlal intarc1i{m patlenL ('lin 'ur Src:uah'l 6 lilt 1l.N2 e\\, )orl lQ9() 7"2. Bum ... 0: The Fe-dmg Good HJ.ndOtltlJ.. Plum 71. Beck. AT: Co~nition and P )lhorht'rap) t'd 2. Spnnger. York 2004. 74. Blackhum 1\1. and \loomead. S: L pdalt' In .. O,!n1II\c." (hcrap~ for depre...... IOIl. J Cogn P... ~LhothC'r I~I~) ~1I';; ~0I111

'to'"

. . OlIo&. K

Stress coping. and heahh behavior. In:

.

'3::~PM:::'-~ BK (cd). Health Behavior l!! SaP Fnocioco. 1997. P 113.

ID: ........ Disease. Butterworth: ReadlO(!:.

iiiEe:~:Jtarrhn'ocin'

copmg" lis1(1 Importance MiaIl/IIody Mcdi<:1Il< ):46. 1995. dID ... ~UU""Sbetween paIiD _ Am J Pbys Mcd

':::::~"'Iife after III - ._Jusbllent Poyd>oJ 43 118

75. Miller. 1\\. et a1: C'o!!mtl\elbcha\ltlural therap\ anJ phannacOlheraft) \10 Ilh chrome. d~g-retraetol) derre -.ed lnpalll:nl 0\ nole ot opllml...m. Beha\ P ~cholher I ~(~): ~~O. 19M';; 76. Bo\loc". WA- Treannenl of depre......ed in-patient-. C'ogmll\e!hera· P) plu~ medlcallon. rela'\atlon plu, medu.atJon and mC'(bcahOO alone. Dr J Ps\Ch 156:73 1qq(1. 77. Gloaguen. V ~t al: A meta-anal)"I" 01 the effects of cog:ml1\'C' Iher apy m deprel>~ 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
Am'"

8 bMIIIIItIC Geiuer ME.

"=:1be;"'~:hriftndri~:~p:"'="':""r:i):i:i .... i5::~:~.

.. cIiIDrder'-

Chapter 2 Influence of Psycbosocial Factors on Rehabilitation R6 Blake. DD. et al A clinician ratmg ,cale for a,..e<;,ing. currenl and lifellmePTSD: theCAPS·l BchavTher 13:187. 1990. R7 Weathcf'o. FW. et ,11: The PTSD Checkli ... t (PCL): Reliability. valldll). and dlagno"tic utility. Annual Meelmgof the Inlemational Society for TraumatIc Slre<;... Studies. San Antonio. Texa<;. 1993. ~g Oti,. JD. el ,11: An exammalion of the relatlOn<;hip between chronic pain and po...t-traumalic ,Ire.., di ...order. J Rehabil Re' Dev 40f51:3Q7.2003. HQ. Boekamp. JR. el al Depre...<;ion follov.ing. ,I \pmal cord inJUry. Inl J P,).:hiatr \1ed 26(3):.129. 1996. QO HU2he,. RB. el al: Characleri\l1C' 01 depre...,ed and nondeprev,ed 'A(l~len 'AIlh phy<;Kal di<;abililie'. Arch Ph) .. Med Rehabil i'\fl(J):4T~. 2005 ql Hu~he,. RB. CI al: Depre\\ion and women v.ith ,>pinal cord injury Top Spinal Cord Inl Rehabil 7f I ): 16. 200 I <)~ McGralh. E. el al: Women and Deprc . . ,ion: Ri,k Factor, and Treatment I...... ue': Final Report of the American P<,ychological A>.;\ociation·\ ....;.Ilional Ta\k Force on Women and Oepre".. ion. American P\)lhoIClgical A\\ociation. \Va\hmgton. DC. 1990.
'e"

Supplemental

96. Heinemann. AW: Sub"tance Abu\e and Phy..ical Di\abllily. Haworth. New York. 1993. 97 McFarlane. et al: Abuse A.....e..."ment Screen-DI ...abiliIY (AAS-D): Mea..unng frequency. type. and perpelrator of abuse toward women wilh physical di ..abilities. J Women'.. Health Gend B~ed Med 10086 J. 200 J. 98. No<;ek. MA, et al: National study of women with phy<;ical di ..abili ties: Final report Sex Disabll 19( 1):5, 2001. 99. Nosek. MA. el ,11: Vulnerabilities for abu~e among women With disabilities. Sex Disabil 19:177.2001. 100. Jacobs. K. and Jacobs. L: Quick reference diclionary for occupatlonallherapy. Slack. Thorofare. NJ. 2001. 101. Nosek. MA, and Hughes. RB: Psychosocial issues of women with phy\ical disabilities: The continuing gender debate. RCB 46(4)0224.2003. 102. Rinlala. DH. et al: Perceived ..Ire.." in individuals with spmal cord Injury. In Kroloski, OM, Mosek, MA, and Turk. MA (eds): Women with Physical Disabilities: Achieving and Maintaining Health and Well-being. Brookes, Baltimore. 1996, p 223. 103. Rintala. DI Lei al: Social support and the well-being of persons wllh \pinal cord injury living In the community. Rehabil Psychol 370155.1992. I ()..J. Hardy, C el al: The role of ~ocial <;upport in the life stressjinjury relation\hip. Sport Psychologi<;t 5:128.1991. 105. Kaplan, SP: Psycho<;ocial adju"lment three years after traumatic brain inJUry. C1in NeuropsychoI5:360. 1991. 106. Loy, DP, el al: Dimensions of leisure and depre..sion symptoms alter "pmal cord mjury. Annu Ther Recreal 11 :43. 106. 2002.

Recl.Jl1]1!,~

.--------------

Ann'lrong '-11. and fitzgerald. MH Culture and dl ...abilit.•!udlt,:'. An amhropological per<;~lCcme. Rehabil Edul: 10:2-4-7 !'::N(I. Ben\on. H TlIllelev~, Healing: The Po.... er and Bllliogy 01 Belit'f. Flfe\lde. 'ew York. 1997. Ben~n. H, and Friedman. R: Hame,,\ing the power at Ihe plw.:ebo dfect and renJJnlllg II 'remembered "ell ness" Annu Re\' \1ed 47'193. 19%. BocNna. K. and Limon. 5J Screening to identify patlcnt:. at ri\k Profiles oj p\)l:hologlcal ri\k factor\ lor early. intervention. Clin J Pam 2 If Il:3X. 2005. Brenes GA d al: TIlt: mfluence 01 anxiety on the progre\'llOn 01 di'lahillty JAm Genatr SOl 53( 1):14,2005 larl\on. J: E\alualmg patiell1 moti'allon in phy\il:al di\abilitit:, practiu: !>enlllgs AmJOnupTher51 347.19lJ6 LJrl;lllh. ED. d al r.. y{;ho<;ollal Aspccl\ 01 I-h:alth Care. Prcmice Hall (Pl;ar~l)n E::.dulatlOn. Inc). l ppt'r Saddle Ri"cr, NJ. 2003. Elt Inlm. M t:t al Rdi.lllOllS ~t""t:en coping 'tr.tlt:gIC' and health-rdat I:d 4Ui.l111) ell hk 10 patlcllls" nh ...pllli.11 {;()rd It'sion, J Rchabil M'<.I

"'7c I rLJ. 2()/J5.

S9

I:

Lthu LJ. Mt:dlvit I a. nd P"')l: 1lO.,IXla I ASl>ells 01 (hronic . I) !llnes\ and I ahtll\). 3rd cd Jlme\ ,lIld Banlt-It Puhli,hl'f\,. Sudhll~ MA "'XI< I'HUl ""-E dB, . 'J' ,_.J . . an l(xJ."a). JA r'l)d1UlnglLal A<;",C'l<;llleru 'lTld Managt:rncrtt In Kottke. r·J i.lnd LehmJlln Jf Kru\en', ;hlldhool,JI Ph) lLal Ml;dlline and Rt:habilitauon. 4lh ed. Ptuladdl;hl.t· ""- B Sdunud 1990. p 153 . ( ,r t"lIhergt:r. I). dlld Padc'l-y ( MUll! (her Mood ( Turf 1995 JUlllllld Pn:.... , Ne ....

IIcda):t, RJ: undeN,mding Biological P...ychiatf). Nonon, New York. 1995. llellrich. C. ct al: Volition a... narrative: Under...landing motivation in chronic lllne..,. Am J Occup Ther 4-8:J II. 199-4-. Hughe\. RB, et al: Stre\.. and women \\ Ilh phy\ical di\abilitie,: Identifying correlale\. Women Health h\ue 15( I): 14-. :2005. Kemp. JK: Psychological care of Ihe older rehabilitalion patient. Geriatr Rehabil 9:S41, ]l19J. Ko[t. GS, and Ander\on, MB (ed,): P\ycholog) in the Phy\ical and Manual Tberapie .... ChurcblllllvlIlg\tone, NY. .::!OO·~. f\1iller. JF: Coping v.ith Chroni<." IIIne's: Overcoming Po"erle\sne,s. 3rd ed. FA Da\ j,. Plu[adelphi:t. 2000. \1oldo\'cr, JE, ct at: Depre ...<;iotl alter traumatic bram injury: a re\ie\\ of c\ idenn: lor clinical hClerog.ent'it). Neurop\ycho[ Re" 1-4-(J): I-4-J.

)(XW Ryhala. IIJ, et al: rUllctioll
pp ndo A: Holmes-Rahe Social Readjustment Sale Rank 1

2 3 4 5 6 7

8 9 10 11

12 13 14

15 16 17 18 19

20 21

22 23 24 25 26 27

28 29 30 31

32 33 34 35

36 37 38 39

40 41

42 43

Ufe f.>en! Death of spouse DIvorce Marital separation Jail term Death of close family member Personal Injury or illness Marriage fired at work Marital reconciliation Retirement Change in health of family member Pregnancy Sex difficulties Gam of new family membc Business readjustment Change in financial slale Death of close frieod Change to different :;nu "" Jr!<, Change In number of arq ",,,01 h '. Mortgage over $10,000 Foreclosure of mortgage Ul loan Change in responsibil:tics.11 lork Son or daughter leaving home Trouble with In-laws Outstanding personal achievement Wife begin or stop work Begin or end school Change in living conditions Revision of personal habits Trouble with boss Change in work hours or conditions Change in residence Change in schools

\tean Value 100

73 65 63 63 53 50

47 45 45 44

40 39 39 39 38 37

36 uUS

35 31

30 29 29 29 28 26 26 25 24 23 20 20 20

Vacation Christmas

19 19 18 17 16 15 15 13 12

Minor violations of the law

11

Change in recreation Change in church activities Change in social activities

Mortgage or loan less than $10,000 Change in sleeping habits Change in number of family get-togethers Change in eatmg habits

From Holmes. T, and Rahe, R,58 with permission

\1 1 'ndi

B:

h· I .

.I

Appendix C: Internet Resources for Improving Community Accessibility Independent Li\ ing Center.-http://W\\\\i.senloroutlook.com Lmled Ad,ert"mg Publication,. Searche, o,er 40.000 apartment commumlles for people" IIh d"ahlhtles. Includes Virtual lOur\. searches b) distance. photos and floor plans. Contain'" Information on m...urance. storage. home mortgage." mo.. . -

mg. t) pe, of housing facilllie, and a glossary of housing terms. Updated weekly. Lmk, to Cenler; for Independent Living-hup://w" w.abledata.cnm Includes information on and links to periodicals and research on di ahtl;t) fessionals. The DeSign Linc-hup://"" ".designlinc.comicentersJ.hto, Provides product information and design tips for famllie . con I'm'

nd

,I

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I

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I TU r:

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of health care pro-

people Yo!th di ... ablhue .

C 11.\ PTE

llARNINC

OBJECllVEI

hknlll~ "h.lt a \alue:' lund hl)\l. It lilTed human lx'h..l\ lor

Rc-u1gnlJ'1' hO\\ hum.In'i '''.:'lum: \Jlue .., Idenlll} hll\\- "tlue' mtluencc the I..hoice.. 01 pallen"'. r.:llcnb. and ht.:Jlth proh:"'~lonJh.

" D.,tl1lgul\h Ix'lwcen \-'.llue-dircI:ICd behavior thai e~hJnr.:e, healing Jnd \alue-direC:led lleha\lllr that .... Iike]\ 10 Interfere: with

Influence of Values on Patient Care: Foundation for Decision Making Carol M. Da\ is,

PT. EdD. \IS. FWTA

hcallOg

De . .cribe t:\ample... of ethICal di tre..... Ihat 3l'COmpan~ health CJIe'

I..:,m: pro\ Ided h~ m;maged

OUlllNE

organization .

Learn a (IIm(..11 rea oomg prol.:e .. III ;.lId

In

I Ii. nc- M

Ir

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11

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t I lhh

r

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f"

II I

J.

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Rel,ol\'ing Ethical or Moral Dilemma:.

in Practice 72 ReactIve ven~us Proactive Deci ..ion Making 74 Value Decision:. and \1anaged Care 74 Values Inherent 10 Delegatmg to Supponi\-'e Per-.onnel 75 Value Decic;ion~ m Triage SituJtlons 75 Summar. '5

" , Ben,'litl.'nlt' Fttlll,; 01

Imualh. one ffilS"ht 1..1.: t1 nth. I!h.. \It ItKludl g a ch.. pter on \alue~ In a ext rdak'( to m:"'!ia~L'" ~l \ • •.dull rehabilitation patiLnt i'le fae I.., (hat thl Crl Ire book j~ de\ oted 10 edw..:ating thl' rt'3der about the proper ded!>.JOn~ to make in the rehabilitauon proce!>.~. and value!>. playa cntil:al role in most deci:'lion makmg. It is therefore important to con~ider thl~ a~pel·t of del-I..,lon mal-.mg. PrO'idmg an operating definition of a l'tJluc i~ ~ome­ thmg of a t.:hallenge. \ian) interpretation') have been of1ered. and different author~ ha\e provided a variet} of definition~.1 S For the purpm.e~ of thi~ chapter. a ,'alue J~ defined a!o> an inner forte that provide~ the ~tandards by which chOJce~ are made. For example. if people value the

,"ltl> 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<'

Benevolence: The

Care 72

tir\t ha~ to do I/o. ith kno" ledge or cognition. the second I/o. ith values or attitudes. ThiS tex:t is aimed at teaching the "knowing" a~pect; this chapter, however. is de\'oted to elucidating the value aspect in choosing. Most choices are value based; some decisions seem morc difficult to make than others . Difficult) may arise when the therapis( must re~oh'e a value\ dilemma. \\ hen two seemingly equal goab or choices compete \\ Ilh one another. Difficulty abo rna} arise \\ hen the therapist"" value\ conflict \\-ith the values of the patient. the pi.lIien(\ famil) , colleague~. the larger health care "'yslem. and/or ~ociety. This chapler further define\ values. de\cnbe ... how we acquire our value\. and illu\tr
66

Ph i.-AI Rt"hahilitation

Process of Decision Making Hou I..'htlj(t', ~lrc m.ldc I' dlltcn:nt from II hat dlO1C(,~ ~lrC made. Thc I.ltlt'r I..an Ix \Ic\\cd.l the ~1Il'\\C'r or the ,olu rion: the hmllcr de'l..Tlbe .1 procc . DCC!'l(m ll1a~111g or choo,mg 111 rehanlhtatwn I' ..(lmcllmc.. cOll1ptl'cd 01 noth109 more than a re-actne. lIl'l1nctne ..l1mulu.. re pon c effon. or haphalard tn.\I-.md-error gue,.. mg. But mort:" often. maklllg the right decl'lon. choo.. mg the he,t altematne. re'ult lrom profe "lon~llJ) educated problem "01\ 111g One t)pe of problem 01\ IIlg in health care i.. . tenned clinical reasoning. E\en I:lefore the therapl ...t fir..t ..ee.. . a patlcnt. the proce...... of clinICal rea,oning begm..... On re\ ie\\ mg patient infonnation. hypothe . . e.. are generated ~md \ ..l TIOU' questions are as"-ed m . . equence to examine the patient' problem full) and. IOc\'ltabl). to decIde on the dlagno I that will guide phy . . lcal therapy treatment. Further rca,oniog results 10 a deci . . lon about the mo...t appropriate treat ment for this particular per.. .on at this point In time. \\ht.:never possible verified by evidence in the literature. The greater pan of profes.. . ional education in health l:are is devoted to developing good clinical re~oner.... The t>t:.. . t instructors bravely refuse to give the "right'" an.. . \\er Jnd encourage students to learn the proces~ of dbcovery. In thi, way. students rise above the technical level of training:. They are encouraged to become profe,,;onals capahle 01 responding to complex patient situations by carefully read ing the literature. questioning. touching, testing. and listening with the "third ear" to what is said as well as to what IS left unsaid. Problem solving is fundamental to our daily lives a... humans. We often do not realize we are problem ...olving because the process is so habitual, so subconsciow•. Ju . . t deciding what to have for breakfaM can involve an intricate multistep process: What shall I have for breakfa>"

What's in the kitchen? Cereal, eggs, bacon, pancakes. juice. toast. H0\1 hW1RI}'

am I'

Sta",ed! HOl1' much lime do I /im'e? Thiny minute"i.

What did the scale say? Five pounds over. That does it .. juice and dry' (oas1.' The amwer to thi') problem solving process was ba\ed on identifying the imponance of one value over other..... The fact that the scale revealed 5 exees... pounds became a determining facror for making the final choice. Another persall nugbt have made the same choice but for a different rea..on:

_.

much time do I have?

,.....10_'

I'll have loa"t and juice and eal it on the \"ay~

Tt; lilt trom pnllTllllmg dllt fh m r ,Ihout nur v
1\1n I dlflll..l

\\l~ ~nO\\

ur

r n beL ' p r I n.i1 . part 01 the PIlltl~ flJ.1 1~llll'.llh n rn. m,,~ the aJoptlon of v.tlu\..' tha ~uali O' ...rl.\p \\ th ur per nnal 'alue.... At IllllC:-) I Cl\\\. l.:'r. the) m ...ht ... mtll uh them. Profe..... lOnal n~',r\)nslhll!ty 'c le(.lm. requ r th,11 \\ie pUI the pallen'''' nLcos hcf\)rt· uu O\A n ~llld act in \A~ly" that ,how v.e deserve the patient ... tm ...' Le lh take .1 clo'er look at \\hat a valuC' i and hO\\i \\\.' obtalll our pa..onal and profc ...,ional \allle . Ill' !

t

Values and Valuing A \alue cannot be ...een dinxth. anu it l:;lnnot be mea . . ured. Value.. are con ... trucl ... (moml '"l:hcme' I Ihat are made up 01 beliel"'" emotion... and attttude' aboul \\ hal i, be,t and \\hat I.. not good.\ \\'e can \ ie\\ \alue, onl~ IOdlredl~ b} a..."-lIlg people \\hlll the~ \alue. or e\en more Impon.UlI. b} \\ ..Hlhing another per"on \, beha\ lor \.lluc, .1re relleded 10 our action... e... pel:iall~ Ihe pauem of our .lL·!I0n, O\er lime. TllU.. one might <.;a)."1 \alue hone ..t):· but \\e mighl \\Onder hO\\ mut:h that".. true \\ hen the per,oll lm.l\\ ,"gl~ lheah on Income tax relUm ... -\nother \ alue ob\ lou,l~ ha'" priOnl} over hone l) for thi .. per...on. At tune .. value cooperate .•1Ild .11 other IImc" 'l~nllll,;t \\ ith eal:h other. A dilemma exi ...t, "heon \\e h,l\c dltllt..: uh ) choo"'lI1g \\ hil'h value ... hould ha\l~ prioTlt}. For C\,1Il1pk. re"lpeLl for lile 1"1 Ihe central \alue for .ldHX.:.lIC'" 01 .1 \voman'" right to choo..e aborllon 1.1"1 well a' lor thll"l.·' oppo...ed to abol1ion. The dlllerellce III 0p"llon amI t><1Ic1 01 thc.. .c (\\0 group'" i~ not o"er the \i.1lue 01 life b1I t (he impol1i.lm;c of the mother'" life mer the kill' 'lIk .Ih\ne ,til

Chapter 3 Influence of Values on Patient Care

con...'deralion.... Reproducllve freedom ad\'ocale~ empha... ize Ihe primac) of Ihe mother .... choice for the quahty of her life and re~lq out... ide Interference to her Tight to ChO(he. The TIght 10 life acti\ ist ... value the life of the unhorn fetu \\ ho require ... an advocate. 6 Resoh ing dilemma . . 10\01\(· a ~peCial foml of chnical reasoning that will be e\.plamed later. People are not born \\ Ith \ alue .... but the) arc born with lO ... tIOC.... and need~. Value.. are acquired from those who ...(X'ialile u.... primaril) parenh and ramil), and, for many, religIOn. The 1Illtiai learning of values take5. the fonn of ''fo~O\\ IIlg Ihe rule ..... that parent\ believe will minimize per"'l'Jlal pam and conflict. ll1a\imize pleasure and mcanmg. and protllote hannon) and peace in the home. In f('l.'cnt ) ear.... It can be ... aid thaI television. video game~, film. and mu ... a.: ha\ e pia) cd an increa..ingl) large part in tonlllng rhe \ alue of adole"'l'cnh and young adults. Adole"'l'enh. a a pan 01 natural maturation, le~t the \alue ... ot the home /:1) hreaklllg rule ... and trying forbidden Ixha\ or... , Thl... pr<X'e...... mark ... tht:' r.eginning of a tran..,formatlop. III \\ ~Il.h \ alue-ha eJ rule tollo\ ed to 1\ Old pun1 hrnt.'nt tx~l.ome JIlternalileJ and. 'Il renecHon. are adopted a llnc..' Yon 10 treopleenJup \l,lthtt ... .:"lu \Jlue very Imllar II t~at of [heir pJ.renI Ho\,.(' r tor nn"(.. the;; dltferl"'l.elf'th~\\J. th~\ pn rhzC'th.lr\~':..Ie li ~ adi tJnLlng het\\l'ep. them t; l ~nd Ct; !<:In h' nl"'( Ont: t"\ample of lh)lJ n pm ntizlIlg tne," \ til J·fter entl) from their p.tr..:nh! thl. m,J[ d:~L 1}1 \ 'I') 1:-1 n-,e fir t in four ~eneratl( Os not hI tl d\ \- IJ who del de n( t t ) g to c Ikgc: 'lot all The \aIue f th nr pn nt) fr I the f pe Ie e pr mat) I f Ll rk pic dlreLlI t mate bJel L keg,- up I d pia • be: n e turc-d that ,ne t the leo. ltlJkrelll.( that JI till _UI pr found! dift nt pe lail I tur eXdmpk ph lliltherJp t \\ osepr..tlll h",-uesun rkJrt ...-rd.lkJ nJune patient y,ho an: y,ell but inlUrl'OJ trolll ththt" t d· t l."ml and ph t lunal Ii I dH n I in 1 part ul th ph I It. rapl I un I r' a Itt) aH. h ut It I nl I I II uwm' Itl II It ,t Yo) r III pr

67

Code of Ethics The set of moral norms adopted by a profes5.ional group to direct value-laden choice~ III a way consi5.tent With professional responsibility is tenned a code of ethics (Box 3,1), Most codes of ethics of the profes~ions are composed of statements that have at their core one of four value principles-autonomy, beneficence, nonmalefi· cence, and justice-and three rules that follow from these four principles: (I) veracity, (2) confidenliality and pnvacy, and (3) fidelily' (Box 3.2). One might follow their code withoul internalizing it, just as small children follow the "rule~ of the house," For the code of ethics to function as a set of professional values, one must reflect on it and decide that it. indeed. fonn5. a values complex around which one is willing to organize professional choices. Thu~, a50 was previously stated, reflection is necessary to the internalization of values to make them truly one's own."\ ~ The choices that then follow this interr.alization are likely to be consistent with one \; basic beliefs, show coherencc. he authentic or genuine. and be adequate to the task of deci~ion making. Those who make the smoothest tran· ~itJon 1010 professional practice are likely tl) be those \\ ho... e per...onal values and priorities ~ignificantly overlap \",ith the \alues inherent 10 their cho...en professional prac1ic(~ Given that one \ basic human ~urvi\'al needs ar~ met. the mort one reflect~ on one \ choices and on which choil'CS rt.-..,ult in a good and meaningful life, the more one i... apt [0 experience con~istent reward from opportunitle....

The Values of Patients as a Factor in Care Palll'nh llHnl' to ph) ...Il:al tht'rap) .h \\ hllie per on 10 need ot pwk lonal help and guidanl't'. -\11 ~ople (an ~ \ Ie 'oe'd ;J... p(,.h e' lOg ti\ e area... ot need th,Hl'llmpn ...e the' \'o hlll('"' thl?" ph) Il-JI. th~ IIltdledual. the' e'motionJI. [he ...lX·I.IL and (hI.' ...pmtual II ululJ tlt" ... ald (h.H a more' Hh:.lfilOgtul and pc..:.llV tul lite rc ... ulh \\hen l:hoil't'''' are' m.llk that re"'pc..lnu e'lIu.lIl) 10 the tleIlli.lnu ... 01 all tour qUJlil.ln(.., ot need. Cl~ntr.11 tl) thl.' \\or" 01 Carl Jung '" thl' lx'lId th.ll .1 hc'alth) pl'r..,oll.lli(\ rt"...ult . . lnlll\ .1I,:hll'\ Ing.! b.illllll t be-t\\t"t'n thinkin~ .\Ild ttllIng .trlJ h..:l\\lcn 1Il[Ultll)l) lUlU ~('n ,Ilillll. P.ttll'nt lllllh." III ph~ ll.al thl.'r,lp" II \.ll"Il1l1 1,1 e In thCII 11\ t' •.tIlJ \\ Hh a ullIqu III h1n \,t h,t\ IIlg 11I.IJe (h u ;Jnd lIt dhlh,e U\er tllile the th r lpl t om to all that llUl po.all('ul III pl., .. 1 pall 11101 Clio. ;J.ntn tul t,; n I kill \\ II thuu 'hl l ut I.hoh.: thl: re JJ Ii f l-dr fll-IOU Ill1lh. 11 reJ unnr ani d tu N d ha I r Oltell pall III II 1.: h JI ha.. .II II r mdlr hwu 111 lh III 10 th raJ 1 ,r th \\lIh 4u dupl 'I;J ho Jro \\hil Tlm1.: 1 pall lit pn,hl m III 1110\ n III nu tUII II n lh II 1

68

Ph, ..ic.,1 Rehahilil'llinn

BOll

3

1 Code of Ethics of the American Physical Therapy Association Principlc ()

Preamhle Thl ... Code ot Bhk......el'- lonh pnllCiple ... for Ihe ethlc.11 pr.1l tlJ:C 01 ph~ "'leal Iherap~. All ph~ "'IGII therapl ...h are n,;"'pon"'lhle hlr mamtaining and promolmg t'thKal prill IKe. To Ihl'" end the ph) ... Kal therapi"'l ...hall ,ll'I III the he.. t 1I1lere...1 01 lhe patient/chene Thi .. Code 01 LlhK'" ... hall be bmdlll!! on .111 ph) "leal Iherapl"h,

A ph) Il.tllhcfapi ,I hall mamt.ull ,lIltl promote hl~h t,111 dard... tor ph)- ..1C.lllhcrap.... t pradll.. e 1Ul.;.ltlon. and rc...carch.

PJinciplc 7 A ph) ... Ie.ll thcr,lpl ... t ... hall ,cd.. (101)' urh n,'munemtion de ...en-ed .lnd rca... on.lhle for phy Ic.11 thef.tpy S~f\-H.:C3,

<.1'\

I

Plillciplc 1 A phy ... icalllu.'rapl.. t ... hall re"'pl'l"t the righh i.lI1d dignity 01 al1

mdivlduah and .. hall provide compa..... ionilte care.

Principle :2 A ph)\IGlllhcrapl ... 1 ... hall act m.\ lnl... tworthy manner

palienhlcllcnh. and practICe,

10

\(l\.. ,lId...

all other a...pech 01 ph~ \,,;,11 thcr,lp)

Principlc '" A physicallherari ... 1.. haH provide
PI;nciplt <) A phy 1 I. c

Principlc .1

from meth

A ph)"lcallherapl... t ... hal1 compl~ \\lIh h\\\ ...md rt.'gulallt\ll'i. gmemll1g ph)"'lCal therap~ and ... hall "tri\e to etred ch.muC's lhal benetit patJenhlchenh.

Principl \

ha

the prole Ion

I. n

1(

h

e health need

Principle .. A ph)"'lCal therapl ...t ...hall ncrJ:l"e "'(lund profc...... inn.tl i udgml.:l1L

Pnllcil

Principle 5

-\

A ph) ...ical Iherapi\1 ... hall achlc\ C and maintain profcs IOn. I competenl'c. Adopted

h~

1

I

rh~,,1\.

,•

\l,ledge and

I

Kills oj c II

the Hou...e 01 Dell'gatl'''', June :!ooO. If'rom the \men\; 10 Ph.. II al rho.;fap) \

\l.:1.1l1 In

~

Ih

pC'

11

n I

Bo 3.2 Moral Principles and Rules lhat Form the Foundations of Health Care Ethics' Principle""

Ethical Huh.:... that lollo\\ Thc"'l.' Print:ipll.:...

'\utonom~: The patll:nt"... n~ht to

I.hl)O C' for pne lite .:lIld 10 \OH.:e that chllll.:e hlr a.. lnn~;j pn ... Iblt" Beneficence: Domg \\h<.lt 1 Ix... l lor onl."· ... patient Contr.l h \\1Ih patemah ... m or patftll111lng, Bent:rl(enll.~ I ..I mOfdl o\:lhgalllln 01 all health care pralllllllne,,_ \\e lllu ... 1 ad \\ Itll bcnctllenl.:e \\hcn \\e an: a\\dre 01 the fa!.:h .1Ild Illl:: pdtlel1t I... al ... lgl1llil:dlll n ... k 01 hdnn or 1m md our .ll'tilln I'" needed tn prc\ elll that hdrm or Illv \\c l1lU,t .lI..'l \\ IIh bcnchl.l'n",e Illhe benellt to thL' p.lIlconl nUI\\t."I~h ... thl' pntl'ntlal h.mn tI) thl." h ,11th I..arco pradliioner 'onmah:fi<.:ence: Oil nil haml [)Il not Inlure \11 ahl Of kill ,I I ~n. 11r undcmlln a "on' repulatltm phlpcn ..

~racih

1\:1.:

Iell he truth do n t I nnllpl of iluton m olnd hc'nefil Olt." UI.. I h,\I, lTlu"h 01 th Iruth tt, tdlm \I~"

'Ihl' JI

11 lx'llI II

n~

("unfidt'nlialit.\ and Prh.H:,\ hom Ih. pnnllpk (11 hcnelt\;tll';C Ik,lIlh l.lrl..' pr.lllllIOI1l'r, dfl' IlIOT,dJ) 11hhct."d to r...l'l'P\;t1f1 ttdl.'nt .tll II1lornl.lllOn ltllll..Crrllll' p.llll'flh c..'\l"!1 ii/wI rl..'quc..'slcd pl'llfil.lIh. (PI \dl r1 10 dll ..\) \\Puld

hnnl! h,Jnll ttl mnlllC'1l1 p opl ttl hi lh p.ltll·nl 1fl P>-tl11.; nt 'l.I\ III n..:ht h r... 11 PfI\.11 ,Ill" II1hlml.l1l 11.'1 ~lc\aJH hI their l Jrc 1- idt:lih f m thl; pnn", pie t hcneh I. Ho,:J.hhlJ prlllltu.m oIlll. n nd Ireatmcn~ "'III r m;sm faithful Ihc.:lr p.au Ilt nd 10 Ihe-lf lollC'3$u(") C'\cn \lohen lh dl~ rt"C' \lollh Ihelr ... )Jka u

.0

tnootuXt III all mem up for p n u 11t.:

phabell

\

hom thl,:

I ordC'r

Chapter 3 Influence of Values on Patient Care

t"n('ountered 10 rehabilitation are not the result of "fate:' but re~ult from a lifetime 01 cholce~ that placed other values .md need... at a higher prionty than physical health. or than Lht" pre\ enllon of I line'" and mJury. The more physical theraj:lI'.. b become aware of ho\\ much control people actually ha\ e ('1\ er their ... tate ot \\ ellne'" and health. the morc dlffi1.:UIt It become... for ...ome therarl'1S to rcmalll nonJudgmental ab\"lut their pauenh, It i... exceedingly difficult tor ..,ome \.:11 n II.: Ian"'. t('lr example. to remain 110n.ludgmental while treJ.tm~ a t.:"hronh. ...moker for em ph) ...ema or a tremendow;1) \)~ ...e patient tor hip and knee .I0ll1t problem .... It I'" Import.lIlt. IKl\\C'\·Cr. to remember that \I,.e are Il1t)ralh .U1d eth1l'alh \"l\)unJ 1O ,£1\ e to all patienh the hl£:he ~ '1ua1lt) Clt \..;);e ~l lree trom Judgment and 1.11<.1 ... a... 1~le Thl I hen.: ~J.Janl.t:' 111 J.1l ("If our area ... ot need ht: r u II our'1cc-d arC' helT1~ met 1I1 all tl\ e area (ph) ...k.l1 :1tc- ]edu.ll emotl\lI1al. \Kla!. .tnd ... pintuall. \I,.C fccl t: ru trated ~d JT' ned h, per onal trc ...... and can ntere.m er ble t remam non.ludgmental e th ompa IOn. n 1 1o:p.trate that the llll.

r;

lfl

..

The Influence of Values on the Primary Goal of Patient Care When health practitioners expenence feelings of cntici m and negative Judgment toward a patient. they must be aware of it and consciously work not to let it affect their hehavior. The primary goal of health practitIOners is to help all people recover or mamtam their health '0 that day to day they may functIOn at the most autonomous level po",ble. If the primary goal IS to achieve optunal health and healing, certam values seem to promote that goal more than other~. One way to a~certain values that promote health and healtng is to deSCribe behaVior between a therap"t and patIent that does the very opposite. or that mterIcre, with health and healing. Puttmg yourself 10 the place 01 the patient. what therap"t behaVIOrs would /ll/elfere '''th your progre" toward gettmg well or healing' Table ~ I pre...enh a ...ample li...t of \ery ob\'iou~ behaVior... that would detract trom a patient's ahlltty to function optimally in .1 therapeutic ...euing. Abo mcluded is a list of po......ible 1lt.'!!iJt!\C \"alue ... that might umlerhe each of these behavInr Rc-ha\-wr .1I1U unuerl)lI1g \alue... thatJil lllrare healing ml,ht he de ,TI""d a' the e,ad oppo'lte 01 tho e that J trall trt\m ht:.L1l1lg (Tahle _"' ..::!L The... e therapi t behu\IOf hl-Ir rt: ... h\re a patH:nt .... hope. promote progre to\\.anJ r e LIlLi.1 I t \\Ith a\..·hlc\ Ing the hlghe t po Ible d~pend\"'nt hlO\,. tlOI1.

1m of u \h,.) \\1\uIJ reaJ the 11 (\\t ncgaU\e t'teh:.l\Ol r f.thle '\ II th.lt . k tr.td twm hL"aling \\\\uIJ re pnnd. I J nt: d tx-h.l\t: 10 u\..·h a \\.1\ \\IIh patll:nl '" But. In d d h ..!e .! ...,. e 1 t net \~C'n lrllJ\\ Ing the nght thtn= to nUn In J .. l It and ..Ktualh JOIO; II E la h d 111 r~urh . u e C't ell 1 the \,.ap • II tee! l"umpa ...... ion h\r th\) ~ \\ hn urter .t IOn I IU t dllkre'nl tfilln pit\ "here a per n I rr I 1 lh I \ \. ar Ie t .rtull te The m malUr h Jllh pr I I mal' ta I d hill! t n n \hal I P Ible lion III

tn,

III

tlJ

r

PI

p

pel:t1ve

IlIIa IIUti

·It.lran pol,al a th pi t Ih r I th Jpl I ,L1enl.ti
I

It h

o

Ph

ical RchlthilitMlO1l

T. Ie 3.1 Therapisl Beha> ion and Po"ible Underl ing Valu"s Ihal D Ira I from Ihe Healing Process

l

~;~;BeIuM;;~on that Interfe~ or

lillhl ior

&om the Healin, Pn>.,."..

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 \\<.1.., In "good health" on her arTival to the rehabilitation center You have been lreatlllg her tor ...everal weeks. havlIlg begun therapy from her adml ......lon to the rehabilitation center where you ",ork. Preoperau\e tramlllg ",a') gi\en III

the acute ctting. You h•.l\-e a...... l ... tt:d hcr \\ till pre-pro"lheth.· traming, trengthenlng. prm.thetlc tTamlng and i.lcceptance. and gall training. She ha... been progre"'''lIlg \\ell Joyce i... mtelligent and inqui ... itl\c. jet ...omc\\hat ... tubborn. Two wee","", before discharge )Oll notice an lIlcrea"'lllg tendency on her part 10 be careles... and to lake lInnece.......u") ri\k~. like hoppmg on one foot rather than uonmng her pro!O'thesi .... In adthtlon. she admit ... to thlllklllg thai her daily ')trenglhcnlllg exerci...c ...
Chapter 3 Influence of Value(, on Patient Care

71

Table 3.2 Therapist Behaviors and Possible Underlying Values that Facilitate the Healing Process Therapist BehavioR thai Facilitate or

Promote the Healing Proce.. Offenng you (the patient) the same amount of attention offered other patients. so it balances out from day-to-day. 2. Accepting your weaknesses along with your

Positive Valua that MiPt Underlie Each Betumor 1 Justice the quality of impartiality or fairness

2. Unconditional positive regard; acceptance.

strengths and verbally reinforcing the desired behavlors::.. _ 3. Always treating you as a person with feelings and being sensitive to those feelings each day.

3. a. Respect: the act of giving particular atlention to a person; worthy of high regard. b. Compassion: sympathetic consciousness of another's situation and the desire to be of effective help in relieving a painful situation.

4. Explaining things at your level. not oversimplifyIng or making things too complex.

4. a. Respect. b. Accurate and sensitive communication.

5 Always reachable yet never fostenng dependence; encouraging Independent activity.

5. a. Autonomy: a quality or state of selfgovernance; independence. b. Dignity: the quality of being worthy, honored, esteemed; to have distinction as a person,

6, Never uSing humor mappropnafelv never laughIng at you but encouraging you to be able to laugh sometimes even at yourself.

6. Appropriate humor, nondefensive humor.

7 Always keeping your confidence

7 Confidentiality: keeping another person's trust private and secret. ---------8. Autonomy.

8 Fostenng your own Independent activity w t:,out Ie mg you feel stranded

9 Real zing when tne ad'~lce of someone else is needed and asking for ~elp in a timely fashion. 10. Making you feel special, chenshed. and unique; showing Individual concern for you and your progress.

and rnanlpulall\l: HL'r rl'lu ...allo lO()pL'rale "'llh ~()ur ug· oge lion anger ~ou; ~ou kd Ih.u her ha Il Ia/ine 11\ fe-que lmg d \\ heddl•.t1r l.:'\htc-ni.:e represl,·n.......euhng for a 4uallt~ 01 hie that I Ie than tlplllllal .tnl! elli ... h. \ou Icel a 11 flU have 1.1I1cd 10 help ha reall/\.' hlT lull potential a y"t:ll a O\'l:r In:s~t:d \\nh thl' demand ... 01 Jour ",ork. ()nu.:' thl' pallt'nt l.,lfI: da) 11.1... hegun thl.:'rap"".... \eldolll tlnd )r 1a Ihe tmll.: III rL'llt'd lin 11lL" L.trgl:r "" ... w:.... tho"'L" thai lamer on Ihe fnnge ul the "ork UlIl')UOU\ness In...IL'.ld. lherapi 1 tend hi 10(1I Oil the IInm~l!l.lIl.: ~IlUalltlll in Imnl If them 4uh.kl) gathe-nng d..la and prohlem huh In!! a... th y gu. Jo}<.:e·s grm\lIlg pruhlel1l 01 rclultanlt' l(lulJ hi: I y.ed as a pt:npheralls~ue alllr~t, ont" Ihe Iher.tp""l hoped "" uld pa "llhOUI needing 10 be t:onlronkd BUI.,h her ti harge tWle l lUll; dl)SCr Ih ther,tpl t I hHled 10 re pond ttl \\ h.t! lIPI 10 r grc~ 1\ t' ~ha\ lor

9 Recognizing the limits to one's knowiedge, knowing when to get help or to refer; honesty. 10. a. Compassion. b. Sensitivity to your uniqueness.

The therapi ... t \ re"'pon",e ma) reveal one or more of ...e\'('ral thought... and ret'ling E... peciall) \\ hen under ...Ire....... Onl'l11a) bL'l'Ol1lt' Impatient am.! angf) i.lnd leclure Jo)ce (0 "grO\\ up." Thl' Ihaapi t mil) fcC'1 pC'p"onal failure and fru ...Ir.ltlon and. 111 a conde cending \\a). lei her I-..nO\\ far morC' f('Vt ard \\ a... l'\pected tor the eflort... placed in her ... ul·ce ...... tul rL'lli1hllitallon. Thl''''(' are often reaclh e. i.lulomi.uic. emolionb.t cd re ...,wn...e... ba...ed on a \altle of, or need for, "'pont.lncou hont' I) ,mJ IhL" righl 10 e\pre...... teeling... rq!J.rJle- ...... 01 tht: IInp.1l1 lh.u Ihe t' pre"'\Ion rna) haH' on olhl:l"'.. Thl.: Ihcl,tp""l I'" unhapp) .\nu \\anI-. the ... UtI.lllon III l'h.mge but dut' ... nOI h.110\\ I1m\ h) l:hangt' it 0 Ihe theri.tpi...1 dl"'pla\ ... poor Il1lpuhe l'ontroJ and aggre- I\t'ly "1t'1 ... olt '>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

-

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to the ,oclal \\or"er for P') chologlcal ,upport and l'<'un seling. If nece",ary. onjud,gmental concern and under...tanding in.: found~\·

lIOn, of heal mg. In additIon. health profe,,,onal' C.lnl g If adults must accept that occasionall) they v. ill l~IlC(lUnter , patient who is unwilling to cooperate with their <';Ilggotl m, and \\ ho re~ist~ theu attempts to offer therape'L.l II.: ..:-ar J:ld ad\ ice. \Vith the value of patient autonom\ In nllr d. fll... professional"s role is not to assume a paternait'tlL 't~mc... indicating "I know what's better for you than you do."' hut instead to outline as clearly, creatively, and accuratd~ a,

poSSIble the predictable results of the choices the patient

j,

making. Patients must have control over lhetr 0\\ n lh e... to the greatest extent possible. 6 .7 But in the end . we cannol and should not force patients to undergo treatment when the)

haye simply refused. It is their autonomous right to refu,e care and \\ e must honor that. These guidelines exist in their purest sense when therapists are treating adult patients who are not suffering from confusion, mental or intellectual disorders. or stgnificant depression. \Vith children or adults who are experiencing the conditions mentioned, therapists must aim for the greatest extent of autonomous choice possible and focus appropriate attention on parents and family caregivers.

Beneficence versus Benevolence: The Ethic of Care Mary Romanello. a physical therapist, and her colleague v. rotc an II1tcresling piece enutled. "The' Ethic of Care' in Physical Therapy Practice and Education: Challenges and Opportunities:'I~ in which she reinforce, the point made carher. that an Nhlc of canng goe... be}ond Simple beneficence. dOlllg v. hat IS good because that IS our dut). or bene\olcm:e. belllg kmd becau...e that I'" abo our dut}. Caring tor our pallenh ll1\iolves somethlllg greater than lhis. B"f ht m'\ lilt 1/(.(' lal" \//(lf"f of till ((1m 0/ (,(lI"t' ,IIal ulll M \ IItlllf}, (Urt prtlt IIflOml"\ '(0 fr/lll ul/(l I 011\1\-

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The <.Iuthnr tres tht ch tmctlOn hetw dut to not hann ,I p,IIt rt lnd on del"pe tjon~lI ethl'- 01 !w.lr\.: Ithough the author de not u tcnn<.;. ha"K<.III~ the\ 111cll..e a recommend,tllnn for Ie ,ltm moml ,",cn'iHi\'lty (the .Ihdlt to lIntlerst.md ho" one ill tl0n PM\ Jtl d lin lther anc- mor 11 Judcm nr he at! It) to all~ll}l j 1 J ton n m Ik d ~f~ moral decllOo tn mm<.tl Dltinn ha I (In 111 crhl'- 01 care The Importance of d('vclor1l10" thl". I\. II f II t mn mJ raj mg attention ~Hld thl..: r Ie nl ctl at nt·Lcnrered care {"sst. i The r ttpn t dhl, a} he at the Lilt 01 til l t e l . In ... h I lIlt Ir"m Thl demand lime :l'[('1 lila tl-Je rUIT f h alth Lire c1ima(e j" not y,illtJ (1\ ~ a' But t e rat n p all tloner relatIOn hIp ~

t) eal v.lth n '" that proE pcrienl'e alone ""ill not t(J tl,;,r JI1 flh. \'f l...lre ClmU:I<.l.n~ ,md dlnlcal educator~ rnu \ t \Ch lir!,; 't! d.pout thl mor~1 rhilo... oph~. and pomt It Ollt Ir l
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Resolving Ethical or Moral Dilemmas in Practice Ethical suuOl/om differ from ethical prohlt·nu. and both differ from an ethical dilemma. Ethical s,!lla(/ems are \\ ith u' e\'cn da\'. An c\amplc \\ auld be (he ... ilUatlon \\ here a ph} v ical ~her;pl"( I~ cautioned lo be careful al:x1ut d(Xumen(mg _patlenr.. . .• 0\ erL·h·~""'"lJn0 It I' accurate charge~ tor to a\Olu
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12oal .. or . . pendlng Ihe lime required 10 mdividuallze care Patre~h are not \\ell-~ened \\hen Ihe quanlil) 01 palienl<;; . . een or the profit of the praclice ta-"..e~ precedenc~ ove~ the qualil) of palienl care and Ihe profe!o.... ional ... er~lce ol.the practlce. \Ve /...no" the 1I11portance 01 therapeutic reJatlon... hlp.... and \\hen \I.e . . acrdice Ihem tor profit we arc re .. ponding 10 an ethical problem 111 an unelhlcal way. BUI rhl" doe .. nol con..lllute a true dilemma. for loyall) to our pallenh l11uq laJ...e precedence over our employer~.l~ Thl .. I" di ..cu....ed III more delail laler 111 lhl!o. chapter. A....peelal /...lI1d 01 clilllcal rea ...onlllg ,.. required \\ hen one confrollh a true moral or ethical dilemma, tn the pre..ence of an ethKa] dilemma. \\ hen the be .. t action elude~ U'). it help" 10 refleci III a ..) ... ,ematic \\ i.1). and then con...ult \\ ith a fellO\\ prole.....ional or ...omeone ..J...illcd in dilemma rC!o.olulion (So\. 3.31' In re...oh ing moral or ethical dilemma... in heallh l.:are. the be... t de-I..·I ... ion u... ualI) re .. ulh onl) when the facio, or conte\.1 ofthL' "Ilualion are delineated i.h clearly and a... rreu ..el) a... po.... ible. \\11c.~. ther )OU del' ide to rc ...ohe the dilemma It It'o[or;:i( all_, (del'iding \\ hal the be.. t outcome \\0uld be Ilor the grcateq number. for e\.amplej) or "1'011I [ :;:tl aI., 1\\ elghmg the t\\ 0 or more \ alue ... that ...eem to be tightlllg \\ IIh e.lch other. and decH.JlIlg \\ hll'h I'" the "hlghi'r" or "more nwral" 3C1ion in thi ... ranil'ular (,·a...c \\ ith tht: e rarth. ubr tad J. the ~ t I..k.... I... 1ll1l I.,<m ~ made onl) \\ 1Ih c.lTeful thl)ught. 8m. 3. ~ oullinl.·... a prol'c...... 01 rea\OIlIOf th;,it l..3.n ~uldc }OLi m re 01\ Ilo! ethll.:31 dilelllilU if' \ our pral. !I.e ) lU roulc'x: tit: DIU tl1) ~ our fin I 1..1 Ion 1'0\ e\plallling lxlth )our ethilll rt'a ... onin~ "ron:'~'" md VI.. Lr U.m I.llU \\el~hU1g Il \ IlL. 0 r J.I1ltb.. In til it 11\ Po \Ioell re-a 0111.. ,moral J"i..i lOll I ""a ......\ ... \.1 bl tion ot ne \ I ue y te 1 (J I.. n l"1f'nll • b on l r th l Je of ·.. tlth

["Am,'nce nf\alue on Pa[ient C~

Let'~ take a rather ... imple but familiar example in physIcal therapy. A 90-year-old man had recently had a revision of hi,) Iranstlbial (belo", knee) amputation to a transfemoral (above knee) amputation, The surgeon requested the physical therapist teach the patient exercises for home. but not to prepare him for a new transfemoral prosthesis becauo;,e the literature mdicated that his age did not pennit a ... ucceso;,ful outcome with a prosthesis, The physical therapist kne", the patient well. and disagreed with the physician"'" decision. The patient had exercised all his life and had e:xcelJent cardiopulmonary fitness. Can you identify the values at war with each other in this dilemma? The dilemma was between beneficence (doing what is good for the palient) and autonom) (the patient clearly hoped to get a new limb). ver.,us fidelity to the physician colleague. After di cussing this with a supervisor. and with the super\i ...or\ upport. the therapist fabricated a pylon, This allO\vcd the patient to succes...fully begin ambulation, The therapist invitcd the surgeon to watch the patient in the parallel bars. and ba...ed on thi", new infonnation. the surgeon facilitalcd thc proce~s of \ecuring a new limb. Hence by u... ing creative c1mical reasoning. what seemed to be an either/or ... uumion (an ethical dilemma) was turned into a "third \\ ay" rC!o.olution for the good of the patient. SometJlne~ thi ... i... not pm.... ible. however. Sometimes a dilemma J",I ha, to be r",olved with weighing all of the fal'h .II1J \alues. and chooslIlg the highe\t or most right ternati\t; gl\ en the context of the ...ituation. An example l~ relul"tJIltl)- agreeing to honor an older patient"s III 01 m t t:4ue ...t to remain at home in spite of the fact ,il he lth 3r~ proft:...... ional ... and famil)- members ha\e d<:af t:\ I knee that the patient .... balance i... compromi!)ed dl:J It I JU... t.1 rn . ttld of tlrot' until a fall and injur) occur.

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Reactive ,·ersus Proactive Oed ion taking R~alll\~ (an.~. dl.lra(t~n7ed by 011 lhe-\pot problem \olvlIlg and deCI'iIOn making. 1\ an unavoidable pa.rt 01 reh~­

billtation Ho\\e\'er. the greater the number of OUI' declthat are b,N~d on reaction rather Ihan on proaction or \\1.:11 thought out altematl\'e~. the more Idlo\yncratic. Inn.ln"'l ... tent. and erratic our ~IM\ ior "ill '>eem. It wa~ ugge ...ted that to ...top. breathe. and center is a u...eful way to a\old reactne Judgment. Stopping to breathe \",11 help bnng about more proacti\e decl ... ion~, rather than reactive one.... Part of prote",\ional re ... ponsibllit) i", to anticipate po ...""ble problem ... and to think through alternatives in ad\ance. Likev"·i,,,e. the more that therapists base their deci~ion'i on ...cientific evidence and the more that they reflect on the \alues behind alternative choices. the more apt they are to e\.perience con~istent. scientific-based decisions retlectl\e of the highest professional care. These decisions are me\ itabl, more conducive to heal1l1g. "'1\)11'"

Value Decisions and Managed Care Corporate health care, managed competition, capitation.

and prepaid health organizations (PPOs) in many cases have been limiting patient access to physical and occupational therapist~, and limiting the therapists' choice of and duration of reimbursed treatments. Under managed

care. ph}sical therapIsts have both professional obligat1on~ (Q

treat patients and may also have contractual obligation~ to managed care organizations (MCOs). It is Important that health care professionals be able to carefull) anal)ze their patients' needs and use sound moral rea",ol1lng and ethical dilemma resolution skill~ to decide on appropriate care when there is a shortage of profes..ional care available, or when there is inadequate reimbursement for needed care. 14 Remember that until recently, managed care corporatlon>, 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" <.:ontra(l. ThiS can result in ethical (t,sth \\ "hen }ou kno" the ~\1 thmg to do, but are prohlhuc-d from domg It h) the orgJnl7allOn "'llhll1 ",hll.:h you pradllC' '\ For l:\Jl11ple. If the .... x \.1"lIt .. proVided by an MCO under J lapltatum agreemcnt do not .. ullicc to reach the anl1upated goal ... "'I.:t "Itll the pallent al the initial anunatlOn th ht.:alth Gm: prok...... lnnal n ..." ... 1x1l1g held habl for abandnnm nt It hI.: or he dl lharge the patient prematureh "nh the lnmment 'hmr lCO hlld ml.: I had are Th bu Int.\ t cmn t dl ratt II (J he'llllh pro/r,ui<_JI ... h n I d ( nllnll IItulmem '\ \leO do not

tt.:ll profe<;"'lOn~\I'i \I. hen tn top l:.lr hut Imply h Ih III no long r p.l\ for (are f'mle Ion tI Ir oblljZat d t pro Ide needed L.lre Llke\ I prole Ion tl h,t the n t to maIl11.1\n ,10 adequ
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Chapter 3 I n 8 _ (.:olhdc.:. ah'ay rcmcmner that clhKally beneficence and .lUtnn(\my mu ...t oUI\\elgh elf-inlerc t ( ce 80"< ~.2). If profe... ,ion.tl \\ere enga!!cd only in bu,inc~ .... there \\-Quld be no dilemma. But health carc profe.,...lOnaJ... are bound by codes of ethlC~ of ...en ice. nOI profit. thai mandate advocac} for patlcnh \\ ho come 10 them becau...e they have both the .educalIOn and (he commitment to help them. To usc patients for our own benefit beyond service literally destroys the profe...."lon. 1I

Values Inherent in Delegating to Supportive Personnel .-\ ma.loril) of ... tate, no\\ pro\ ide direct access to the ser\,i(e... of ph) sical therapi ... h. A ... the profession of physical therap) advance ... to a... ~ume more autonomous respom,ibilit\ for the prevention. diagnosis. and management of prob1;01' \\ ithin the human movement system. the role of the profe,...ional become... more centcred on diagnosis and plannmg for appropnate treatmenL and health and commum I) edu(3tion. In day -to-da) patient care it 1 becoming more important 0 delegate treatment to other \\ ho are qualified to carr) out care at Ie c"
Value Decisions in Triage Situations T

alwo.t Involve v
.VaI_

I. An RO-year-old. frail elderly _ I ::~: admitted following surgery to repatr • Ii Room 300. 2. A 30-year-old man with severe low back poun ..ClII.... , to possible herniated disk. Room 20t. 3. A 53-year-old woman who had a mild heart attack bw weeks ago. admilled for cardiac rehabilitation. Room 302. How would you decide. at 8 AM. which of these three patients to see firM? What facls seem to make a difference? The patient's age? His or her location in the hospital (closest vs farthest away from where you are now)? Your existing patienl load and schedule? Your subconscious or con. scious aversion to certain palients. such as those with low back pain. worker's compensation patients. or elderly patients' If our primary goal 10 rehabilitation is to help patients recover their health so that they might function at the highest. most independent level possible. how can we use this goal to help direct our choices? Putting the patient's needs first by way of autonomy and beneficence seems to be critical to this decision. The therapISt's choice should not be based solely on personal convenience or self-interest. What additional facts are neededo l6 PUlling oneself in the place of the patient. one comes to realize that the existence of certain factors requires our immediate attention. One factor that readily comes to mind that demands immediate consideration is re ... ponding to patients in pain. Pain can totally consume one \ attention and will take immediate priority in our t:hoice.... Re.'lponding first to patients in severe discomfort seems ver~ Important in sequencing the order of treatments. The therapist needs to find out which of these three lJ1ui"Jduals may have had a difficult night and is most in need uf allention for relief of pam.

Summary Profes...ional rehabilitalive care requires cltnH:al decision mal...ing that i\o proactive. evidence-ba...ed. and demonstrates a t:on ... i...tent. con\ocious \'alue of choo... ing behavior Ihat is l.:onduci\ e to healing. Clinici.m... rou ...t become '·infonned re.l\Oners" \\.ho ha\e ... y... tematicall} g.uhe-reJ the facts. h.l\t' nxognized potemiil! chOice- and \alue ... dilemmas. anu have l,tl...en the time to \\l'lgh \\ h""'h choice is most conducive to the hei\ling prfKe....... Central to thi ... proce...s i... tht"' cour,tge (0 l.:ontronl seemIngly peripher.ll tal·tor... that rher,lpish are tempted to hope \\111 go il\\a), .t'l \\t'll ,\... rhe \... illlJ1gness (0 pUI oneself an Iht' pl.u.:e- of the pal lent. Pellegnnll lK laulions us not 10 be ~o egoU:nrfll.1 to tlt.".tt l)ther... "'Imply as we would like to Ile.II«1 In te,1l1. he ugge I thaI the Golden Rule h .lIlh clre- hllllid he lire 1l~/1/ of t'u( h ""'I nl" UI lit I "f'ed\ f l'ft!t fUll \: The heallh care pnlfeuiiol'" IIt'" I III .... "uld co ~d Imalar sensluvllY If he lo.h UIIlt" th wit" the pallenl

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1. A per\on\ \"alue'l are difficult 10 Idclltlfy. Ho\\ l"all one kIlo\\ \\hal a per'lon \alue ...·1 2. Ho". are \alue~ relaled to beha\ior J 3. A behef I') not a \ alue. bUI beiler... dln?l:t our \ alur .... If a per!,on believe... fairne~\ I.., good, "hat \'alue ... GUl you predict the IIldi\'idual will hold'! 4. \Vhat is the difference bel\\een a moral and a nonmoral \'alue? 5. Whal four per~onal value!' make up 1110..,1 code ... oj ethics in the profe...... ion... ? 6. Gi\e an example of a nonmoral value chOICe and a moral value choice. 7. What is Ihe difference belween behavior that agree... with a code of ethics and behavior that is value-ba cd?

Case

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ha... 1 d~cl 1( n II re, IhlhtatlUn l i~ our )bll~at Il tt. pilei "hen hi or her lll"urane~ nn lone 'r nlVt:: ur l,,;,ire drd e agreed upon goal ... have nOI becn mct') 11. De"l"fibc the e .....entlal JIHerem;c bet\\ cen moral benelkenu: and moral L uing.

10. \\'hal

Study

You are a physical therapi!o>l specializing in hand Iherap) and ha\"e been working for 5 years. You have decided Ihal the Lime is righl 10 establi!o>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 \\ce"- for J \\ed..,. You \end a COP) of) our nOle ... 10 Ihe \i.tcationing ph}"\ician.\Vhcn the ph)-",ician return ... 10 the office, he reads your corre~pondence and 11lll1lediately call.., you and says. "Who gave you the aUlhorilY 10 rel1lo\e Ihe splml from thi~ palient\ hand'! I "ant you to calilhe pallent and tell hlln that you made a mi ... la"-e, to pUI the spllnl back on, and ~end hllll to me Immediatel)-. I \\ ill remove it if I feel it should come oft." He Ihen bangs the phone down in your ear.

Chapter 3 Influence of VaJues on Patient Care

77

3. Li"ll your profe!)"olonal dulle.....

GUIDING QUESTIONS

I LI~t the facb affecting this '1IuatlOn.

4. Li ... t the practical feature ... that Impact tl1l\ '!luation. 5. Come to a final decl"ion that you can jU~lIty bc=cau\e you are acting on the higher value in thl\ \Iluation.

~ Identif) the element-. of the dilemma and value~ at war \\ Jlh each Olher (ethical principle!o. In\olved).

Thl\ ca<,e 31"0 appear.. In Da",j ... (\1: Wht,:n the lOlere..' of IYf and pallent collide: Habit of thought. PT Magazine January: 71. 199:"

ole: Bo\ 3.1 can ...ene ~ a guide to )our problem \01\ Ing.

• On (he one hand: • On the other hand:

References

2 .~ 4

,

Punl!O. RB. and Ca.....el. C)( Ethical Dlmen<,Hln .. In the Heallh Prole '1(\0\. S3undel", PhIladelphia. IQX! \\ehI3l:!e'. G. and Lod.,,",,lOd. AL. 'foral relatl\ I ... m and \alue.. educatlon.~ln: Purpel. D. and R~an. t.;: led... l: \1t1ral Education: It Come... \'1th the Temton. \kCulChen. Berl.ele~. CA. 1976. P ~ _ ~n . \1omtl. RL Tea'l-hlng: \'alue.. In Collc~c Jth... e~-Ba ....... San Francl"<;o. 191010 Bed... C' A philo.. ophlCal \ ie~ 01 \alue.. and \ aJue educalltJn In Hcnne...... ~. T ledl \alue.. and \1oral Dt·\elopment. Pauli ..., Pre....... '\ev. York. Jl~-6. P 1.~ Rath . LE \aJue and Teachlll£. Charlt:'... E \1C'mll C lumou .... OH.

,-

Ex'")C"nennal \1.:muaJ C! P~dlC'1t PraLlltl mer InteradlOn l.t... 1"'1 ~ tare .I. for Dc\el pm:=- the.\n f HC'alth Care e-d 10<; Pelle;nno ED What Pelleg:nn\ ER t I TA. and Zemban& S t"v. '1orL 14U l r I Jf n lpl< t B. q BC'auchamp TL. and C Ijdr lrk Jo~q ed ~ Ox!ord l n1\cn> Pr t> Da\ 1

-------------------------,

upplemE:uta Bldt.. IT r J Eth ... J.

1et1

J

10. Jung. CG: The Structure and D}namlCS ot the P~yche. Pantheon. '\C" Yorl... 1960 II Da\ i.... C\1: The Illnuence of \alue.. on patIent care. In Payton. OD fed): P...)cho\OCial A<.,pect5 of Climcal Practice. Churchill Ll\lllg,>tone. '\e" York. 1986. p 119. 12. Pent·c. GE: Can compa ......ion he taught'> J Med Ethics 9: 189. 1983. 13. Romanello M. and Knight-Abowit7 K: The "ethic of care" in physical therapy prat{lt:e and education: challenges and opponunities. J Ph~ ... Ther Edue l~n):20. 2000. 14 Pellegrino. ED The t:ommodification of medical and health care: The moral c n"t'4oence~ of a paradigm \hlft from a professional (0 a market thll;. J \1ed Philos 240):243. 1999. 1"i. 5", 'u. R Challenge.. in profe\\lonal ethics. Sympo~ium of Annual Su \leetlllg:. American Ph)<.,ical Therap) Association. San [) gu. CA. June. 11)97 \\ ( Ta.. k anJI~'>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

_~·<;I.~OOO

Caplan Moral t.mer TEallc.11 j." u n 1c:du:ule and the Lite Si,;lenC John \\ II ew 'I (Irk CIano C 1. and Brcxh H \l.md ed c JC'k,1I or Hyde JAMA ~-i~ ~ 10.. l'N5 . Cuom. LL \\n) good pt'oplc dl bdd thlllg ... ","ur"'lllg Mana!!ement ~"':bJ I'IYf, Galamhos C Re 01\ 111!-, C'thltJ.luJIlfllCt III a managed care em iron· man Health Sue \\orl. ~4IJ):llll 11J4lJ H.t.l.l RT <\n IntrodUi.:tlOII [0 Health Care (jr~alll;allUnal EthltS O ...lurd llll rr It. Pre;' "'e.... )uri.. 2000. Hal. 1edlcdJ deciSIon ~Jng An arguOle;'nt I"r niiITdtl\e;' OInd mebphor Theor 1cd HlUeth~, If"i'; 1f1o~ He (Ethlt:al decl IUCi mal.mg: Pre ure .md unt:e-nOlint) a compllalln fiKtof H....."ld Soc \\orl18 t4t.243 20m Klr hner KL StO<..kmg:. ( \\OIgner LB. Jou)e SL OInd Su~g.lcr. M Ethl dll ue Idenutu:d h~ rehdbllLtalllln t:lulIr..l<.tlh. Art:h Ph) ... Med I<' abd 2S:!·f.; 20111 (Jdd( Aft H~dlthr..drl dhlt . A pdtlent·L~nlcrt:d d~{;l..,ion model J Bu... Etill _4125 211111

BJ: Carllatlon on trial. California \1edicine 7:25.1996. on JC Tht' poll lit: ... 01 managed t:ompelition: Public abuse of the pm· ,Itt 1OIere..,t. J Heahh Polit Poli') La" 28:341. 200::1 Hnd"1n \1/\: \1t'diune. \loney and '1orah, Oxford l'ni\e.....it) Pre~~.

I i<

n

t-111

'\~" Yor~. 199.~

Scot!. R: Profe......HlIlal Ethio: A GUide lor Rehabilitation Proles~ionab.. V!(h"Y. 51. LOlli .... 1998 Sct'dhou...e. D: Commillllt'llI to health: A ...hared bond bel\\een profe~­ "'Ion... , J Interprol CUt" 16(3):249.2002. Sharp. H~' Ethical dC'd ...ion-mai..ing in interdi..,ciphnolr) te-olm care. C1dt Palate Cramol.1r.. J J2:495. \995 It:l.e. 1\.T EthKJ.llmphr..·<.tllon.. ot l'anng In rehabilllJtion. ~ur Clin onh Am 3312 )::!:n. IINl'l. llnr..h. C\, S()C'i..en 1\.L. and \11I1er.~: EthKal t:onfllt:1 a ...txlated" Ith m.tna!!ed t,lrt' \'1"'"'" 01 nu .....e prao.:tllioncr.., u..... RC' ... 52<-:;): 16~. 200.1. \\t'IIt'. J\' The reJ,ltlon . . hlp beme-en ml;"du;lOe·... Internal ml\r,\lit~ ,llld n:hglon. Chn . . l1t:ltlr.... Califomlil ~lethnne 7:2Q, 1990

J

7 I

7 I

CII.\ f''fI':R

4 l f AR N I • CO. Jf C:..:..T.:...'.:...'..;:.f.:;.I

_

I. Ix nlx'lhe- lalllm"k IN llldudllt{! \11..11 "'go nl\:d"un:' In the pillleill c),.10110aIIUO 2. F\pl.1lI1thC' 1~ll·\.anc(" of \ Ital "gnl" d:H;t 111 dllllutlluJ~llllnh related 10 il ..."gnlllg.1 dl.lgno"llc lahd. d('lennllullg the pn)~nll\i .... dod c.. .l:tbll"h

mg a plan

\If l.:ar~,

.\ Re,,(\~OI/e th~ Illllx11,.IllCC' 01 Vll.11 \l!!n" d.tl.l III

delcmllolrlg ph)''tlolnglcl\\ rc,pon'lc l(llrl~all1lelll .J.ml t\JIUallllg pJllc-nt rro~rc..... ... Ot·..lTlh.: the pr,x('durc for mUnllonng le.mperatun:'. pu!-.('. rc"pm.llioll. and blood prc .....un:. ~. D,fkn:nh,llc hcl"ccl1 nomlal and
\alue\ ur range.. for each \'Ilal ,.go. ~

Melli If) the nonn;lll\(' \anal1('ln .... lll \Ilill :"Ign..

and the tal"lor'. thai Influence Ihe..e l'h;mge". 7 Itlclltlf} thC' dinK'lI applil:;\tion of pub,.. m:lnWI~ ,n "l'lct'mng for h~I)()\l"llli;\. .K LX..crlht the )"tl.;ommcnded clemen" for doc.:u, menL.UIlm of \ Ital \1£0\ d.lt.t.

Vital Signs Thomas J. Schmitz, .' r. PhO OUTllNf Procedure for Mi)1ll10nllg Pu]<.,c 9R Rel.lled Me.l... urc.. 101

\lll'lalllllh III VIt,11 Sip'''' D.lI.1 x~ O\cr\ il'\\o of Innuentlal \'arHlble.. 82 Culture and Elhmcil) 8:!

\h'llll

lI,lIll'nl Ol'..,! \;lliUIl K.l "1ca.. unll~

BlI,-l~

lCIllpt'rJlun..

The Themloregululory S) ..Iem

~n 8~

AbnonnululC\ in Bod~ Temper:llure K7

Factor-.: Innu('Jl(:lIlg Boo)' Temrx:raturc 89 T, pes 01 ThcnnOll1Cler, Xl) Procedure for ~le:buring Boo) Tcmperdlurc 92 r...1tllllltlnll~

Pul . .c

114

Rh)lhm 95

Qualll) 96 '·:KlOr... Influencing Pul"c 96

MedlCallon" 97

Rt'lllr 11 '", RI.: ull

S) ·;teml(: or LOl:al Heat 97

with imporL.ult infoml<.ty·' ph)'lological ~latu~ and re ...pon ...e to ph~ \Iell aui, 11) l'llvironm~ntal condition.... and emotional In' ...or.... they are l·ollectivel) reI en-cd 10 a... vilal ... i~n, In addJllon although not (,oll\ldcred .1 pTlmar) vital "'Ign. pulw o'\imet .. ~ I ... all Il11pOnant related mCibllTt: lhal pro\ Idt:' infonnalion on al1en~11 blood oxygen ~alUration le\ch Pol..., 0 tllletr) d.lt~ i.lllc.w. th~ Iherap"l to \crcen ..nd IlItHHtor for 'n'Pwo11ftl ollcn J ... ~oualed \\ ilh pul 11l011Jr) JI\ordt:l ... lh~\l impJlr v~nfilalion ollhc lungs (e.g.• plll'Ulllllnl,1 dlfllllll' Olhlflll.:li"e pulmonar) di",eaw « OI-JDI .tlU'IllIJ re"'pirawf) mu,t:le "ea"-nc"", ilnd un:u·

':l...cular/pulrnon:l,!

IaIOT) 11ilThllnllt,,'nt,j

Jhi (,'uidt Itl PhnH uJ 1 hnOI,t,\' PraUH (' IIldude:-. (:\.101111<1.11011 (11 \ \lal "Ign~ IC.g,. bh\'kl rle~,un.·• ht'.lrt r,lk

105

Me3~llnng Brachial Blood Pre.,... ure 114 Procedure for Mea'lunng Popliteal tThigh) Blood Prc\\ure 116

Ex,cn.:i ...e 96

xammatlon of bod} temperalure, pul,e rate. re,pirator) ral~, and blood pre~~ure pfl1vid~ the ph) !llcal lher'lpi,t

Re~plratlon

Procedure for

Emollon /SI1-c..... 96

E

Factor;; Innuencing

Parameters of RC~PJf;tlion 106 PalICm\ of Respiration 107 Procedure for lollltonng Rc!'>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.'
97

Illl

SUllllll:Jn 117

re~pir;:\lory

rate)

III

the cardio,"uscular/pulmonary

~)-s­

[em~

review for each of the four major categories of praclice pallCrnl,. Vital ~ign~ arc also identified among

the lesb and mea... ure.. used to characterize or quantify

clfculmory ~1
0\< 'gII a d,af"" I" I. 1 nd I. ,f n \\ ,thin B lfic.: r lJee p tt m ~ Detmmne ~ pro' ' I 0<'1'1 n of m~ identifi 3(1("1\ of anth..lf'OllOO I nd C'Oflle". and Jccll n t (X'l..lfll.- 1m f\ nU .1. balua.. rail nl !'"'fTl" Ih",ugh am," I"", 1 pert odK intCI"\3h during an epl...ooe of care. 4 E\3luare the effect1\ene I; of ...cleLtcd mtC'f\cnlil..'O" m achie\ 109 anticipated £J'JI, and e pt'dt.'1l l'uh.'. "ome, (chan~e, 1n Impalmlent. fun('l!onallmlll.ltli)n .... and 01 abllil1t and change... 111 health. \\ ellne.. , .mJ time: ... ) 5. Detenmfle If a referral to another prJClIUClflef J') J.r.

r""

ranted

fam a C' 11m rrol~'" ll'lnat tkm nor the mfl. mla.lltll1 II rff'l' tte,t m ur calml~ ~ rlam 10 the path:nt that. PU 10" \31u nd thai H'lU Ul( ('I nllOn 1{l

1Ir

,n

ph~ 11.."3.1

(hemp.,." dmical Judgment \\ deterrome Yo hlch 'Ital ign'\ \hould be mea.....urcd and the fre· The

quenc) of mei15urement for an mdi\,idual pauem \\ l1h1l1 a

Alterations in Vital Sign Data

,peclfic contc\.t (e.g.. ,elf-paced ambulation on le\cl ... urfaces

\'~

Mair climbing). Although takmg vilal ,ign mea...·

ures rna) be delegated to a phy~ical IherJ.pl"it assi ... lant (PTAI or other suppon per
m Table 4.1 These data represem average value for the age-specific population from \\hich the) \\ere derhed. onnative values pro\ Ide the physical therapist \\ 1m a general reference for comparison during evaluation of clinical findings. However. nonnative "alues should be used cautiously as a global reference, as considerable dis· crepanc~

exists in the literature about the exact boundaries

of the range of nonnal values. h is also important to note lhat normal values are specific to an individuaL Some individuals typically displa) values different from those represented by nonnalh'c figures. This iIluslrares the i.mportance of monitoring vilal signs as a serial process. Vital sign measurements yield the most useful informa·

Overview of Influential Variables Se\cral hfe\1)Ie panem ... tml.ldtfiablci and patlen! (haD:ten... uc~ (nonm,,-1ditlabk) tntluence \ Hal ""!:-'ll nh,'.;L'll.ft Life~t) Ie paltems mc1ude~ hut are fk){ lunn<'d (('I. CatlC:l~ intake. tobJCCO u"-t'. diet. alcohol con'umplh'o. re f'l"'"ln-..e [0 stre.s~. obe,it). ph)' icaJ "ldl\.lI) Ie, el. medlcauon,. and u of L1legal drug,. \ Patient chJ.racteri ...tJc... mdude honmmJl statu.... age. gender...U1d famtl~ hbtOf). Other \,1rIJf:'tIe, thJI affect "ital ... ign mea~ure!\ lIlciude lime of d~l)'. ume of ltJ( month (menstrual cycle). general health statu",. anJ pJln. Infom13tiol1 about life~t)'le p:lltem~ and patient ch:trJc!er· iSlics is gathered from the patient ht ... lOl). the 'l~ I,{t'm.. re\ iew. and tests and mea"ure~. Factor; Identified ::J.'l mooifiable hould become the focu~ of pattenH-elated Ul.:-lJUl,,·· lion (e.g.. current condition. ri,k factor reduction. h~Jltb promotion). Spectfic faclOnt innuencing each \.'ltall>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: n~c to ...tre ...... I) plcally ... har~d hy ")Ih~~,"", \\ ho hrm.' t\ dc('p·\ealed di"llll''ll of Americ:J11 Iwalth care practkr.... Thl'l ",WallOn ,,,ould dearly affecl lhe accurJ(\ {)f the \llal "gil IlIca,ure .... elllllm reler... 10 an Il1Iegra-llon 01 learned" beha, iOT'" (nol hlologically Inherited) l"haT:lCleri,uc 01 a '<.l('iel~. It i, J 'tel 01 ..haTed behavIOral ...tanJanh thm meludc ... fundamentill value..., belief.... and ~u ...tom..... lIlduding Iho'C related to hcahh carc and illnes,..1 F'/flue", I' defined a.... an affili~Hion \\ Ith a group of people \\hn ~h~ a common cultural ongin or background. or Cl)mmon racial. n~tionJI. rellgiou",. linguis.tic. or cultura.! Lhnrw.':lcristics. ~ Recent demographic change~ In the United Slate, haw crcated greater l",ocietal diversity and have helghtencd the need for heahh care providcrs 10 ~ddress mc"t: js,uc,- during e\amination procedures and treatment mlcf\'enllon~. Culture and ethnicit) directly impact the atti~ tudt" held hy an mdivlduaJ toward health care.6 Metzgar" and FitzgeraJd 1 ofi"er the follo'\\ ing general sugge~tion~ for IIlt~raction "nh a culturally di\ Cf"iC patienl populalion: ;I ...

i1prc~lr" J.l1\ IOU" or

•

For additional infomlation on the impact of cultural dlver"lty 1I1 health care. the reader is referred 10 the work of Spector.6 PumelJ and Paulanka. 1l Lynch and Han~on.9 Galanati. lU Lud.man and Nobels. 11 and Huff and Kline. I .:!

Patient Observation Pnor to a IOnllaJ exammation of vitaJ ~igns, careful ~ys­ tt:miJ1H.: ob!..crvatlon of the patient can reveal important pre11IllJII~U) data. Ob~erviJlion alone will not provide definit1\C dlJgno">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) Irre<;;pectlve of skin color. Central cyanosis is indicative of marled arterial desatumtion. Peripheral qano'iis I~ obsef'ied "lin color change\ in the earlobes. no.. .e. lips. and toes. Il is usually transienl. occurs secondary 10 vasoconlitriction. and is typically rellevcd by warming the area. The skin should be observed for changes in texture and hair growth. Patients with diabetc~ mellitus or atherosclerosis typically lack hair growth on the legs and display 'hickening of 'he nail> of 'he fingers and 'oes. Skin tc\ture also varies with age and poor nutritional status. Diaphoresis (profuse perspiration) often indicates that the body is working to compensate for a reduced cardiac output. II is as\ociated with a variety of diagnostic categories mcluding myocardial infarction, h}'potension. and shock. Abnormal sitting postures may be suggestive of pain or structural abnonnalities of the pectoral or vertebral regions thaI may interfere with respiratory patterns. Use of accessory muscles of breathing may be indicative of cardiac or pulmonary impairmenls. Peripheral extremities should be observed for the presence of edema or clubbing. Clubbing is a bulbous swelling al the distal fingers and loes accompanied by a loss of 'he normal angle be'ween the nailbed and 'he skin. h develops gradually over time and is as ociated with diagnoses imposing 10ng-sl3nding h) poxia and cyanosis. such as congenital heart defects and pulmonary disorders. Peripheral edema is typically associated with right heart failurc or venous insufficiency.

a"

•

•

•

I. Stereotype, ,hould be aVOIded. Although a patien, may

share characleristic!' with other, of the same cuhure. each patient will also have unique. individual differences. 2. Respect culiuraJ inferences and individual differences in bcileb and attitudes toward health care. 3. FOl..:uS on de\-eloping the patient's truSI and rappon. ~ Remajn aware th31 one's own personal values and belief. may distort the examination of a patient from a dIfferent baCkground. 5. Be cautiow.. not to imerpret elhnic or cultural preference. in dress, manner. and physical appearance as abnomlal behavior or psychological disorder.

83

• •

During this initial observation. use of well-structured. impairment-specific questions will assist development of an initial database of patient infornlation. Depending on individual patient needs, data may be gathered from the pattent, family member. or caregiver. Box 4.1 presents a sample of clinical indicators that typically v.-arram monitonng of vital !'igns. Beloy. each clinical indicator are am. pie guiding slatement", or questions designed to facilitate history taking during initjal observation of the patient. Associated test !
Measuring Body Temperature Body ,emperature repre"'nLS a balance between the heat produced or acqulfed by the body and the amount lost. Be~au\e human~ are wann-blooded. or homoiothermic. body

, 84

Ph}sical RehabiJitation

Box 4.1 Sample of Clinical Indicators tbat Typically Warrant Detennination of Vital Sign Measures Below each dinical indicator arc ,ample gUiding \ti.lIcments or que ...tlono; dc ...igned to facilitate hl\tory taking dUTlng millal oi)"cn3I1on of the pallent prior 10. or dUring. gatheTlng: of Vital "gn data, It warranted by the c1mical indICator. speCific area" of needed ob\ervation and \ 11al <:.ign measures beyond tlU' .~ra"dClrd arc noted.

• Does the patient "eme \~Ipred heah nr expeflt'nce a sen<;ation that the heart i\ raung l • \\"hat provoke....mtl alll""ialc\ the Irr ular heart heat') • Rc\.ic", medical ion<.; the patient i" t.lkinf!.

Clinical Indicator Cyano\l ...

Clinical Indicator D) ..pnea <<;;hon:ness 01 hrealh. breathlessnes.... uncomforuble a\.";lrenes.. 01 one\ ..en,alion of breathlessness).

Sample Statement.., or Qucl'\tions • Ohtain a description of lhe dy...pnea. • What provoke.. it? • What allevli.ltes it? • Docs the d) spnea have a sudden or gradual olhet? • Doe.. po.. ition affect it? • Doe.. tllne of day aflect it'! • Re\.iew medications patient IS taking.

.\reas of ~ Teedt:d OlhLn-atioJl • Cenlral Cjilno I": oh en b) II ('Cdl !! [h~ mucou<; membranc.::s; mdiGtll's l,in.. n!1 "" 01 dl'i": ... nateJ hlood 10 the arterial c:ircu!;JflOiI. ,·1 hI,. t' a111ITn? the extremities; • Periphl:ral C:y;HlO ,i.. ob l~"'X:I~lfell \v 'il .1 ... lIon 1'1 rt: -JA: h, to cold and is U u
"h

( hi Il:al Indk· ,tlr Int.:nnit!cnt I,ll· nrr"al

I!.. !~.I. 'I

,.,

JlJ.

~ ... l.1rs

Ydth activity

Clinical Indicator Fatigue (weakness) amI ...)ncope

'"):HPJ!tc

Yital

Sample St.atement., or

Quc~tjon~

• Obtam a dc...criplion 01 the fatigue (\\ealne • What provoke~ the on<;et'? • What alleviates the fatigue and \yncope'? • Review medication\ patient is taking.

·Otlti.lll .. de~ulr{: Sl

J.nd "yn.:opc

Clinical Indicator ChC'it pain (dIscomfort).

Sample Statemcnt5J 01" Quc~tion~ • Obtain a description of the che~l di'icomfort. • Where is the discomfort located? • Identify the severity of the discomfort on a scale of I to 10. • What provoke .. the d ....comfort? • \Vhat aJle\. iates II? • Has the dl'icomfort occurred before? • Doel, re~1 \lOP the di.,comfort'! • Doe') the di ..comfort radiate (move) in any direction? • Is the dl\comlort sudden nr graJual III onscr" • Review medlcatlon~ patient is tallOg

Clinical Illdicator Im:gular heartbeat (palpitations).

Sample StatclllClll.. or \'itaJ Si~n ~Ic:.t~urc

QlIc~tion~ and

Spl::cific

• Obtain a de...l·riptloll nlthe palpIlJllon". • Idl'nlll~ h~art rh)lhm .\di.lpted lrom l.c\\I .... PS. \\.llh

Staknh.::nt....

fl'

IJCl:· ~(.f

:md Specific

~tg!l ~_I~·.h1l1·cs

It

IC,,:'''' 1Il.

• Ln.• _ .. h; c t ~nin • E ,n.I'e r nora!. popiH..:.tJ. Ill' pedal pulses. • F ,amine sk.in . : ulor ,mJ li.:r,1~·r;.Hurc of kg:-.. • \\ hat pro\'oke~ Ihe rain" • \\'h~1 allc\.iate~ thl:' pain 1 • E"an'lne 'e\f:ril~ of th~ pam on J call.' I I 10 10. • Examme 4ualily of the pain • Rc\.ic\\. medications the patient i ... [,lling.

Clinical Indicator Pedal edema (,welling of the feet and Ilmer leg.. ).

.\rca, of :\"ccdcd Oh,cnation and Specific \·i"tl Sign ~Iea'!'urc~ • Examine femoral, popliteal. and pedal pul'>es. • Exanllnc skin condition ,ll1d color. • Ob~erve edema. Note the e\tent of edema III Ihe (I\Sue (i,e.. from loe\ to ankle). To detennine plltmg edema. genii) touch edematous Il"'uc. In 15-"iecond mien al'>. ob\en-e hO\\ long It lakc... the ,lin 10 return to a nonnal \Iale. A lime mlen-al of 0 10 15 \econd'i I' 1+ cdem.t. 16 10 _'0 \econd.. I' :! + c.::dcma. 11 to -l5 ~econds is J + edema. and greater than 46 'icconds i\ 4+ edema. Piltlllg edelllJ can ,,)<.;\1 be c',Ulllned by deplh u,ing a .. mall ruler ..uch that 1+ edema - 2 mm ft mm dCplh, depth. :!+ cd~ma 4 mm dl'pth. 1'1"- edema and 4 T ~dl'ma ~ mm or grealer deplh

~mll ... \lon.

tempcr:.lture remall1 ... relatl\.d) con.. tanl. despite changc\ in the c\h:mal em Ironment Thl ... 1\ III l:ontrJ... t 10 l:0Id hlooded. or I'OIl..tlotluTfIIf(', aIlllnJls bUl:h 0..1 ... reptlle\) III \\ Illdl bod) tempcrJlure \.Jrie... \\ 1111 thai ollhelr em Ironment.

The Thermoregulatory System

4

The purpo\e 01 the lhcnnoregu1i.lWI) ")'h:m I.. 10 mJlnlJln a reiallH~I) l·on... tant mtern.ll bod) temper"lun: Thl" ,) .. tel1l

(·hapte ... " Vital Sign

..y"lcm.IU-l The: cutaneous Ihermorcceplor~ dcmon ...trate a largerdi . . trlbulion of cold 10 wamlth receptor't and are ...cn"Hive to rJpH.1 change.. 111 lempcrJlUrc.l~ Signal... from Ihese rcceplo,,", enter the "plllal cord Ihrough afferent nerves and Irmcl 10 Lhe hypothalamus via the laleral o"pll1OlhJlamlc

Ambient Air Temperature

... Thermoreceptors • Skm • Abdominal Organs • Nervous system

+-

tracl. The cenlral Ihenl1oreCeplOr"l are located in the hypothalamus and are sensllive to temperature chang~s in blood perfu\lI1g lhe hypothalamu .... These cells also can 1011late responses to either conserve or dl~ ... ipate heal. They are partlcularl) sen~lti\e 10 core temperature changes and monitOring body warll1th.l~

... Hypothalamus: Temperature Regulating Center SET POINT

...

Regulating Center

Effector Responses • Vasomotor • Shivering • PiloereclIOn • AlteralIOn In metabolic rate • Voluntary muscle activity • SweatIng

... Body Temperature • Normal • Hypothermia • HyperthermIa

I--

Figure 4.1 Thennorcgulator)' re.. pon..e~ n,,_ Ih~l1T\(m::ce! tIV'~ provide lllput rcgardin,l!. chJJlges In body It'lI1ptlulur..: l11a: ~lt.' ',1 the preoptic nucleus ollhe h~polh:llamu", Th, .. ph\\")l,;!:,,..-..I themlOsla! compare\ inl"\)ming ~lgnJls {~f .u.;IU;J1 b(I\J~' Ie!"'£"-' .1!U: \\ IIh Ihe ~I polnl \'aluL. II boJ~ lemper
lemperature

I~

higher than the

85

\el

point

\;,tl'lt. r.t".H 1(J~" m.:~

't'

1..-

ni!>ms 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 "<;;et" value and lOCOO1lOg mfonnation, mechanisms may be activated either 10 conserve or dissipale heal. 14 Peripheral and central thermoreceplor~ proVide afferent lemperature II1pUI to the regulating cenler. The penpheral receptor~, composed primarily of free nerve endmgs, have a high dlstnbution in the skin (culaneou~ thermoreceplOrs). TIley are al~o localed in the abdominal orgall"l and nervous

The temperalUre-regulating center of Ihe body is located in the hypothalamus. The hypothalamuli functions 10 coordinale the heat production and loss processes. much like a thermoSlat. ensuring an essentially constant and stable body tempernture. By influencing the effector organ~. Ihe hypothalamus achieves a relatively precise balance bet" een heat production and heat loss. In a healthy indi· vidual. the hypothalamic Ihermostat is set and carefully maint.:.tined at 98.6° ::!: 1.8°F 07 ± I C),IS In siluations in which Illput frvm lhermoreccptors indicates a drop in te01p.;rature behJw the ....el.. value. mechanisms are aClivated to con.. t.:fVt.: ht":It. Conversdy. ~ rise in temperature will ",.11' dh mecllall: . . rn !O clSSlpate heat. Mechanisms to dis"JVf.ll? hf"1.1 a:-e fl:~'llcularl) Import"n! during strenuous f"xe!d ...c. Fig.ur~ ../.,:. ~ummaril~s the primary physiologll'al a~Ju,.rlnt fl,S 10 e;(C~'\ !se (If incred~c. . in em ifllnmental tcmrr..·..~ .I.r... fhat V\.\"!" dllrIng h\,.'.H acclimation (the phy:-.iolog:11 a·..:Jpi:.;ion'- t:1..1, 1111Pro~C tolerance to hean. These fI "'p()n . . ~~ :In..' aCli"ated (hrough Ii) pothLiJamlC comrol over Ihe effl:ClOr \.Jfg:llIs Input 10 tlw effectur org'lns is transmined tl.:-0ugh den'ouo,; pathways of rnlth the somallC and auto)p-ornic ntJ..\('..... \ "'lcm~,l l'l

Eff..... tor Organs Thl... effector 0r6 ,,\Il:-' respond 10 both increases and decreases in kll1pt:'raturt' The prim:.lfv effeclor o;;y<.;tem<.; include vascular. m\,.tabolic sKeletdl muscle re~pon"es (shi\cnng). anJ ~weall11g. Thc ...e eff~lim ~Y'ltems funttion eithel to increa't~ or to di~~lpate bo<.i) heat Conservation and Productiun of Bod~ Heat When body temperalure is lowered. mel'hanlsms are activaled 10 coO\cn e he.ll and IOcrease heat production. The follow 109 are t1e"cnptions of heat ron"ef\auon and pro duclion mel:hilnlsms. 4

Vasuconstriction oj Blood Vessels. The hypothalamus aClivates sympalhelil: nerves, i.ln acrion that results in "a"ocon'tlriction of cutaneous \es~els throughout the body. This sigOlficantly reduces the lumen of the \e~sels and decrea~es blood 110\\ near the surface of the 'tkm \\ here the blood would n0n11ally be cooled. Tllll" the amoun! of heat losl (0 the environment is decreased.

Ph" icaJ Rehab.JitalJon NOf~1

Blood Temperature SET POINT

986 FIJ7C)

Inl

flon of exercise or

nc;re. . . In envIronmental temperature

,

y

~~oraK1v

'loInCtJOn of hypoth ( fromhypOl

y _YUHI. """.....0<1 c.\I1.II,_n

Ihe tolln" In' arc ~low Jrrro lmJlel~ 9, ,il F 37 d nrtlOn of heat produd lln n I.hlOl m

Chapter 4 Vital Signs

Conduction.

The transfer of heat from one object to another through a liquid. ~olid. or gas lakes place by con· duct ion. This lype of heal transfer requires direci molecular contact between 1\\'0 obJecl~. as when a person is sitling on a cold surface. or when heat is lost in a cool swimming pool. Heat is also lost by conduction to air.

Table 4.2 Primary Clinical Manifestations of Hyperthermia Presented by Body System FJI'eds Cardiovascular

Heart rate may Increase by 8.5 beats/min for each 33.8c F we) rise in temperature during fever, and up to 25 beats/min in other forms of hyperthermia. Decreased perfusion and high metabolic rate promote metabolic acidosis.

Nervous

Febrile seizures occur in 2-4% of young children with high temperatures. Hypoxia and decreased perfusion result in sleepiness and confusion in lower·grade fevers and in delirium, stupor, or coma in extreme hyperthermia.

Resp!~8:tory

Increased metabolic rate and activation of heat loss mechanisms induces hypoxia and respiratory alkalosis.

Rer~l

Increased metabolic rate and dehydration promote electrolyte imbal· al1ces and accumulation of metaboliC wastes in the blood (azotemia). Thermal injUry to muscle may cause rhabdomyolysis (release of myoglobin), which obstructs renal tubules.

HemntOiljglc

Dehydration results III hemoconcentration. Disseminated intravascular coagulation can occur secondary to tissue injury.

COII)'ect;o". The Irall\fer of heat b) movemenl of air or liquid (water) is achieved by conveclion. This fonn of heat loss is accomplished secondary to conduclion. Once the heat is conducted to the air. lhe air is then moved away from Ihe body by convection currellis. Use of a fan or a cool breeze provides conveclion currents. Heat loss by convection is mo\t effective when the air or liquid surrounding the bod) is conlinuall) moved away and replaced. El'aporal;ml. Di.. sipauon of body heal by the convcr.. lon

of a liqUId 10 a \apor occur<; b~ evaporation. This fonn of heal loss occurs on a continual ba"'J:-. through thc re'r1rJlor)' tracl and Ihrough per..piration trom the skm Evaporation prm ides the major mechan, ...m c.f ht:.H ioss during hea\~ exerci...e. Profu ..e s\\eating rrf'\"Ide ... ~t ignifican! coohng effeci on tht: sk.in as II cvapor~,I'''' In addllion. this coolmg 0: the .-.kin fum:tions 10 fUrlh:..:r l'ool the blood a... il i...... hunteJ from imcmal struuur..· s to UliillC.lU:areas,

Abnonnalities in Body TempemtUl e Increased Bod Temperature An elevation in bod) temperature i.. gellerally r,1.'lil'\cd to assi . . l Ihe body III fightIng disca~e or intedjr'n. Pyr... ltia i... the elevation of nonnal body tt"lIlper3ture. ml)f~ ClllJll1lonl) referred 10 a~ fe\·cr. H~ perpyr(''(1a and h) penhenlllJ arc tenns that de'ocnbe an c\lremel) high fever. generall) above J()6-F (-11.1 Cl.~u The pnmar~ clinical manlfl'..Ic mechanl ..m.. rai"e body tCIllpc-falUre 10 the nc\\, Illght'r \;alue over a penad of ..cveral hours, Thus a fc\cr. or febrile state. b produced. The dlllical ..ign'> 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
POlllt 01 highest ele\atlon 01 the lc\er. Once ma\unum

88

Ph}'sicaJ Rehabilitation

Box 4.2

Common t) pe'" of fe\er pre"ented

Types of Fe"er

Intermitlent: Bod~ 1,'mpt'l.Iture alternate.. al ~gul;Jr Inter· \al bet ~een ~nlld 01 Ic\tr and period 01 n(lml.al temperature,.

temperature i... rea(hed. Jl remain' rebll\ch t. b F f"r ., ...u<"tained: ~J...1I1 rna) Ix "ann and <.Irrear f1L. h~d. • Dtfa\ csa/l(( ltenlllnalJon re,olut10n J 1d III ti he period during \\hlCh the te,er 'ub'ldt: 3;ld ,. r.-pc: ......

Table 4.3 Primary Clinical Manifestation

E\p0 ure tn e,lreme cold produLe ,I lo\\ered body (em. L.,lIed h pothermia \\ ith prolonged np(hUre (0 1.:01.1 there 1.... 1 leLr~:l'>e In metiJf'\ohl rate. and bod) temperature- ~radli.dly ••111 \, cooling of the bram CKcu,.,. th .. r' sa Jt'prt." Lon nt the Iht:nnoregulJlOry center The tun\. tll'l1 nf ,I-. !hem1 regul~.roT] ct"nter hecomes ,;eriou~l} 100r •.I1fLJ \\ Ilt n hod ft:moer.jture fJlls below appro"matel} 9-t ~. (~-l."'l ( mJ I', l 1l1plt'lel~ 1o,,' \\llh temperature~ hcll\~' }-,':II.1 Cl, 4T'" tore,thcblxly'"heatTegulatory and rr t:(lqn n, h J 111 I III t S)mplOmS of hypotherm hi !lJt!{ tkne.l -'ul d plratoT) rates. cold and per.ltuTt~

aN)' e normal Relap.. in~ Period ot Iner are mter re"ed \\ llh ntlrm~l temperature thai 1.1'1 al It'a"! \lOe da); al<-o l.:al\e~i re II,. rl nl te\ocr. Con~tant Blxl) h:mrer.llure ., (:f'ln .. tanlh elevated \\ 11h flUl..tuatlOn'i Ie...... than ltl'F (::!Tl

muialed during thl ... pha...e

Iy

tutanel'U'" sensatIOn. depre~.

Kin ..)
"I m

II I

L

11.1

UJ'u,," +,1 j II..

Bo"\ 4.2. mclude

Lo ,ered Bod, Temperature

Remittent. Ele\3ted ):l.:ll.h h:mperd.ture that Oucw.u mure that 3.('; F f 2 C) 'A lthm a ~.J hour pennd hut kmalO

mo,"e toward nomlal. Thi drpp In leml-eTal ...uddenl) (en'I"" or g-riJduJ.ll) I~ \. r ,..\\ a.m~

10

IIIttrnu1tt'lt. reml1lell1. rdurqn~, and (·ol1ual11.~.lJ

I ~r: ml. c:n.uall 'he IWf'L: !"I'

kJ.ln. Th JJ~

pn:

pen '. and drowslJIe'ii'ii. If hypothenma IS left I,...~ vmptoms rna} lead [0 iani e I'lon.. of hypothenma

lJj:.rr

001:1.

1'1

Ta Ie '+.3.

f Hfpothenllia Pre ~n' '
Body System

m----~F.~tt~e<:-tJ

Cardiovascular

Decreased perfusion results from increased blood VIscosity and denaturatlon (loss of function) of serum proteins, VasoconSh iCl!l)n further decreases peripheral perfusion. promoting injUry of periph· eral tissues with freezing (frostt..lte). LactIC aCidoSIS develops. FIrst tachycardia then bradycardia is r)e typical cardIac rhythm. Decreased cardiac perfusion produces electrocardiographIc changes. including Osborne (J) waves following the ORS complex. and lengthen,ng at the PR. ORS. and OT Intervals. Blood pressure drops. Atrial and ventncular dysrhythmlas are induced by myocardial hypoxia Asystole occurs at temperatures below 82.4°F (28°C)

Nervous

Hypothalamic heat gain mechanisms are activated early. including vasoconstnctlon. shivering, and Increased metabolic rate. Shlvenng stops with moderate hypothermia as muscles stiffen. Stupor and coma occur with reduced cerebral perfusion. Pupils become nonreactive, and reflexes disappear. Response to paIn decreases. Electroencephalogram may be flat with severe hypothermia.

Respiratory

Respiratory rate IS initially Increased but soon decreases as oxygen consumption declines. Arterial blood gas values obtained from hypothermic patients are unreliable. A 50% decrease in CO 2 production occurs with a decrease of 46.4°F (SoC) in temperature. Bronchorrhea and cough suppression are apparent at first, followed by pulmonary edema. Hypothermia shifts the oxyhemoglobin dissociation curve to the left, decreasing oxygen delivery 10 tissues.

Renal

Cold·induced diuresis occurs. Renal acid excretion IS impaired. Glycosuria and electrolyte imbalances develop.

Hematologic

Hematocrit increases 2% for each 33.8"F POC) decline in temperature, contributing to hypercoagulability. Cold directly inhibits the clotting cascade. Production of thromboxane B2 by platelets declines, and thrombocytopenia results from bone marrow suppression and hepatic sequestration.

From Hansen, MJ,9 P 227, with permission.

Chapter 4 Vital S;gns

89

Menstrual Cycle

Factors Influencing Body Temperature A \tall"-lical average or normal temperature of 98.6' F (37' C) taken orally has been e\labli.. hed for body temperalUre In an adult populallon. However. bod) temperature is

Increased levels of progesterone dunng ovulation cause 0 0 body temperature 10 rise 0,5 to O,9°F (0.3 to O.5°C): :~is ~hght elevation i~ maintained ulllil just prior to the mltlalion of men~trualion. at which time It returns to normal

mo\' accurately pre...ented as a range. A range of values

leve"".

j("

more repre..ent:1ti\'e of nannal bod) temperature becau"ic certain everyda) circumstancc~ (e.g.. lime of day) or activities (e.g.. c:-.crcbc) influence the body's temperature. In addition. Ilome indi\'iduab typically run a slightly higher or lou'e" body temperature than the stati!o>tical average. Therefore. devial10ns from the 3\.erage will be apparent from indl\'iduallO mdividual. a~ well as between measures taken from a single subject under varYing circumstances.

lime of Day The ternl circadian rh) thm describes a 24-hour cycle of nonnal \-ariation~ In body temperature. Certain predictable and regular change~ in temperature occur on a daily basb. Body temperature tends to be lo\\-'e~t between 4 and 6 AM. and highe~t between -t and 8 PM. These regular changes in body temperature are influenced significantly by both digestive proces!tes and the level of skeletal muscle activity. For individuals v.ho work at night. thl'S pattern i, usually Inverted,l" "

Age Compared with adult'l, infants demon,trate a higher ow mal temperature 0\\ ing to the immaturity uf the thermoregulator)' S) stem (see Table 4_ t). Infanl'> are particu larl)' susceptible to em Ironmental temper... ulre Chall!;\: ~ and their bod) temperatun: \\ III Ouctuale Jcconh't:h Young children at')o averagl.' higher nOnT1<.t! tl?mperatllh ~ because of the heat prodm:lion associated \\ Ith Iill.r _io\"..:1 metabolic rate and high physical actlvlt~ Itvels Eldt:rly populations tend to demOIl'-lr3ie lo\\er t11an 3\'t'rage b(\(.l) temperatures. 0\\ 109 to a \a.l~(' of f.l(,.'tor.... includin~ 10'· t·'metabolic rates. decreased ~ub...·ul:lIle()u') t.... 'Sue ma'iS (which nonnall)' lIl'Sulates the b(ld\ again t heal j.\ ). decreased ph)-sl(;al acti\-it) kvd and lnJ.dequate diet

Pregnancy Because of increased metabolic activity, body temperature remains elevated by approximately O.9°F (0.5°C). Temperature returns to nonnal after parturition.

External Emironment Generally. wann weather tends to increase body temperature, and cold weather decreases body temperature. Environmenlal condilions innuence the body's ability to maintain constant temperatures. For example, in hot, humid environments the effectiveness of evaporative cooling i.. severely diminished becau'ic the air is already heavily moisture laden. Other fonns of heat dis'iipation are also dependent on environmental factors such as movement of air currents (convection). Clothing also can be an important external consideration because it can function both to con..erve and to facilitate retea...e of body heat. The amount and type of clothing I'S Important. To di'Ssipate heat. ah...orbenl. loose-tllting. iighh.:otored clothing is mo~t etfecti\e. To con"iervc heat. sev~r,ll layer~ of lightY-eight c!oth;ng to I,ap air and to Im,,'at.: the body are recomml~nded,

'vl"asur.. ment <;; te R d) Icmp"ratUle<; \Jf) IP)<'.,g boJ) parts. ReLla! and t, npal1u ';'.11"1 rr:~tnhlane i ...··npe ,Iture....tfe fwm 0.5 to f)S F (0.3 Ii) r,yc) r.tghei tnan or:t1 tl."mperatllre\. axil1,1TV ter"p~raturc~ Mt: 'llJrrc,xilll;.ttely 1 I r (0.6 ~C) lower tii In 01<.1 tempt'IJ1Urt -:-Ik' nonnaii\t~ \alue (lr tlral temp :tture 111 a heailh) ..dll i p\)pul ..uil..'fi I ~~n~r;lll) ('on... iJcor\;"': 9~.(~ f \ )7.,,~<") H'U for rertJ.l ,lnO l..\mp,lnit: memheme lemlxTlturC'~ ltl~ \ 'llu~ I 9,) 5 F \ 3 7 5 C I Bemg an ('\um-J m... '~urt", tht."(,(lll
Emotions/Stress Stimulation of the ympathetic nenllU", sy\lcm caU"'l increa\ed production of ermephrine .Jnd non:pinephnn(; "lIh a -,ub~equent mcrea..e 10 metabolic rale

Exercise The ejject~ of exen.:i\e on body temperature;: an: an important con ..ideration for phy~it:al ulerapi ...ts. Stn:nuous e\.t·r· ci\e \Igmlicantly IIlcrease'S body temperature hecau e 01 Il1crea,ed metabolic rate. Acti\e mu ...L!e contraction are an Important and potent \OURe ot heat produdllm. During exercise. bod) temperature lI1crea\e~ are proportIOnal to the relatIve intensity of the workload VigoTOu\ e\erCI'lL' can Increase the metabolil.' rate b) " .. mUL'h a... :W to 25 lime ... Ihat of the ba...al le\ d.

Inge too of "ann or Cold F

ds

(JfJI t"mflt'rmurc III be alt .. dt.. d b: oral imah..e. 1Il\.'ludlllg mpkin~~ P..llJen.... hllulu '-dr,ulI from moklllg or eating fm at It:.lst 1S min'lh.s (prdt"l.lhly 30 minute ... ) prior to an ural (empemture reading.

Types of Thermometers Glass \tercUl) fhennometerTradithlllall). tC'mpl:r.lture~ h.l\e h\.'(.'n taken \IJ .t gla ... tht'mlomt:tL'r, whit:h U)Jbl"'h 01 a gla...... tu~ \\ lth a bulbou~ lip 1I1kLl \\Ith mert:ur~. OneL' (he bulh 1\ in ...·ontal'l With holly h(';.I1. the- me-n:ur~ e\pJIlt.... ~md ri ...c ... 111 the g1.l...... column to n:gl tL'r blld\ tt:mpcratun:. Renu \,)1 mert:ur~ d0\\ n

Chapter" Vit.l1 Sign

"a Ion. Influencing Body Temperalure ,

f'

1.111 ttl.

tI

<.) I.u..

It

or nOnll.ll h:mrx=r.lIun: (,I l..)~.h r IIra\l, h.l l'\ct:n c:,tJ,hlt,hC'J lor ~lt.I~ l~m~r­ ! ('T.I '(

atun.: In all It.tull p'lpuIJl1llll, Hm",~\("r. rw.x1) lC:ITIJl';"TalUrc I

010'" 3ll.ural I} pre CIlI

J.\ .. r.lI1~c \ ra.nge of \alue' I'"

n'rr IIlall\t.' 01 nllmlJI ht-J) lcmp..:-ralUn: hcl.:J.u ...e ll.rt.un l·V f)JJ\ \,,If,-UI11 {altle:' (c.g .• time 01 Ja» Of Jdl\~ III Ie I; . l' eru el mllut."nl:c Ih(' txxl) \ lem~rJ.lUre. In addltum om (Odl\ Ifjual t) pKall) run a filir:ht{\ htr:.hcr or I mtl I:xxl~ temperature thJn the 'llali,II(JJ J.\(:rJge. Therehm: dC'\ latlllO Irom the JH:rage Yo III Ix J.pparenl In'm IOdl\ .dualt,' mdl\ldual a... "ell ,1'0 belv.een mea...ure

9

Men Imal Cycle

In\':~.l cd ICH:-h ul proge... temnc Juring o\'ulJtion cau e bt.xJ) lempcralure to ri ... 1:- 0.5 to 0.9 F (().~, to U.5 CL Th", ... lIght cll..'\<1llOn I ... maintamco until Ju ... t pnor to tht: tnllJalion 01 mcn...truatlun. at \\hKh time It return to normal

Ic\t.+...

I1WTt.'

cleo twm

J. ... m~l("

...ubJeu undc:r \:If)mg clfcum...lam:e...

Tune ofDa}

The lerm circadian rh)'thm d(7)cribe~ a ~-t-hour qcle of nonnal ,mallon.. In bod) tc:mperature. Certain predit:table and regular I.:hange~ in temperature occur on a daily b;:l'\i~. Bod) temperature tend to Ix" lo\\e t het\\een -1- and 6 AM. and highe ...t bet\\,een -1- and S P\1 The ...e regular chang!.: .. In bod) temrer31ur~ are influenced :-.ignificanll~ by both dlg.e~li\"e proce:-....e ... and the k\el of skeletal musclt: activity. For IIldlvidual ... \\ho \\ork al night. thi~ pattern I ... usually m"erted.l.n'i

Age Compared with adulh, infant~ demonstrate a higher nOt mal temperature 0\\ ing to the immaturity of the thermoregulatory ",yslCrn (see Table 4.\). Infants are partieu larly susceptible to cnvlfonmental temperuture chaJ\gr ... and their body temperature \\ ill fluctuate J.ccoroJlllgl} Young children al\;o averagt: higher normal temperatul ...... becau.!.e of the heat pmdudion a:-.sociated v. lh 1i1U~i.I'l,.j metabolic rate and high rhysl ... J.1 actl"lt) ltvels fJd,.;rly populations tend to demonstrate lower L~an average bc:xJ) temperatures, 0\\ ing to a \ a.;~IV of faclOr:-., including 10\\ lor metabolic rates, decrea ...eJ ~ub\"uIJ.neou~ ti ...sue ma... s (\\hich nonnall) m...ul..lte tht" b
Pregnane} Becau...e ot IOcrea...ed metabolic activity, body temperature remain'" ekvated by approximately 0.9 F (0.5 C). Temperature returns to normal after parturition.

EXlernal En,ironment

..

Generally \\arm ""eather tend~ to Increase body tempera· ture, and cold ""eather decrea ...es bod) temperature. EnvlTonmental conditions mfluence the body's abilit) to maintain constant temperatures. For example, in hot, humid environments the effectiveness of evaporative cooling IS ...e\erel) diminished because the air is already heavil) mo""ture laden. Other fonns of heat dl.!.sipation are also dependent on environmental factors such as movement of air current... (convection). Clothing also can be an Important e\ternal cOlhideration because it can function both to conserve and to facilitate release of body heat. The amount J.nd type of clothing I~ Important. To di~sipate heat, ab ...orbent loose-filling, light-colored clothing is most etfecti\e To conserve heat, scv~ral layers of lightweight c!oth;ng to t"'~IP dlr and to 101,U 1at..: the body are recommt~ndctl.

M"""uremenl S:te B.•d) tcmrt~ralule<; vaT) :m10ng boJy part~. RCL:tal ilnu t. npilTIlt l~afl n:(:;ni:'>rane it':np~r titHe .... Ire from 0.5 to ~ F (0.3' 1'1 O.5 C) highe, tnan unI t...·mpl:fi.lture.....\xill,T} tt::fTlperatu1'l:~ .ut" appn uT1
,"1

Emotions! Slress Stimulation of th~ }mpath~tlc nenou'" system cau.1: increa...ed production of epinephrine and norcpinephnnt.: \\ ith a ~ub ...equent mcrease in metabt..)!ic rate.

Exercise The effect of exerL'l ...e on bod) temptratun: are an lrnpor· tant con~ideration for ph) sical therJpi~ts. Strenuou~ e;..erci~e ~ignificantl) mt·re'.ht:~ bod} temperature becJu e of mcrea...ed metabolic rate Acti\e muscle contraUJOn Jre an Imponant and potent. oun.:e of heat produl:tion. During exercl~e. body tempt'rature m<.:rea~es are proportional to the relalJ\e mtensit) at the \\oTkload. Vigorou~ exen":l ...e can mcrea...e the metabolic rate b) as much a~ 20 to 25 t1me~ that of the ba~al level. 1i

Inge

100

f '\ann or Cold Foods

ra!Ure5 villoe atfe-,,:ted h) orallllt~e. tndudmg !o.Tnokmg Pdtle'1b. sht uld refr.utl from smoking or eating for at k.l t 15 min'Jtc preferabl})O n}mute ~ prior to an oral tcm~raturt: readmg.

Ol'al t"'nJ

Types ofThennomelers Glass Mercury Thennometers Traditionall), t~mpaature ha\ c been t.lken \ la i.l gla thermometer. \\ hll:h con ... i...b ot a gla~ ... tubl.· \\ Ilh i.l bulbUl! tip filled \\ ith merulr) Once the buill 1'" in \,,'ontad \\ ith hod) he.H , the mereuT)' cxpaJ1J~ and ri ... t: ... 111 thl: gl~",\ 1.:01umn to regl"ter boo) temperature. Retlux of I11rrl..·ur) do\\, 11

Ph" .eaI RehabiJitation

9()

the

tu~

I

prc\ent~d h~

a n.lrrll\\ me of

Ih~

ha c The

de\ II.. mu I be h.1~('n" 19nrnu I~ 10 return the men.. uf) II' the hulh "'ctnn:: the n t u...e Tilda). the: u 01 gla nR"r· thc:nnnmcta m pallcntl:.trc seltlng hal., been largd) r~pl.h.. cJ h) clCLlflHlK thermometer I fO\... c\'~r. thc)" remain In u...e In thc home Glre \ctllng GI3. thamnmett."r arc l:Jlihratctl In centlgrauC' eel 1U lCH al Fahrcnh Il I FI scale ,,, bo'h. The range I Ir '"1 .1ppro lmatcl) l)~ ((l 10 F· ll..t to 4~ ~ C), \\Ith It.ht \ilfl3tJOn among: Jilt rcnt m.mUIJelUrer The: wllhrallOn are 10 tk,gree 'lnd h.:nth ... 01 3 lkgrec. A ul:h, cal,,;h long 1me repr nt a lull Jc~ree .lOd each hort Ime mdll..,llc () I 1m th'" umtlgraoe thcnnomCh.:r ilnd 0.1 on th I ilhrl"nht:lt th nnorneler \\ hen recording t("mpera ture 11 I (l'lmmOn pradl e 10 r(lund the tra"tH n I
I

A

Oral

37

-= B

b

)

986

Rectal

3'5

e:::

t

FIgure 4.4 len [he {'In

'he'"TlOm< I

r unJ hi.lPC R

U t

)

fkm

,

nln""n'....~' ...

u e nd

III

hlunl

Chapter 4 Vilal Signs

1°F

'"

®

!OC ® v

Figure 4.6 Hand-held eleclr(lOic orallhcnnomclcr. (Coune.. y orOO1ron. Inc. Vernon IIdl.... IL 60061.)

91

Nexlemp

Figure 4.8 Dl"'po!table . . ingle.u<.,e thermometer in Fah~enhcit (rop) and Centigrade (holtom) 'icale'i. (Coune~y of MedIcal IndlCalOr\. Inc. PennmglOn. NJ 0853-t.)

inch« in lenglh \\ ilh a lapered dc;ign (Fig. 4.6). One end of the de\ice 1\ narrow and ~el"\ es as the probe. The oPPO~ite end 1\ broad and hou'}e~ the battery. The\e thermomelers also provide a nashed. dlg.tal display of body temperature. Many models allow u~e with di~posable cover\ and some have memory capabilities. Another type of electronic thermometer is the tympanic (infrared) thennometer. TIlese thermometers measure body temperature through a sensor probe placed in the e... r that detects infrared radiation from the tympanic membrane.2:l-:~(\ This locatIon pro\'ide~ an impol1ant reneclIon of core temperature because the tympani.. ITiLmhrane receives ill, blood supply from a tributary 01 the internal carotid al1er} that supplies the hypoth3lamu~ (temperature-regulating center). These hand-held p(lr~~ble thamometers include an ear probe (with dispo"iablc cOvcr~' and provide a digital di,play or body temper,ture ,vi thin several seconds (Fig. 4.7). They are p'\rticuh:rlv u~efu! with infants older than 2 months and children who may have difficulty remaining \till \I.:hile usmg orhCl type ... of

mOnitoring and in emergency situations where rapid temperature value!' are reqUlred. 2-l A tympanic thenn~meter should never be used 111 the presence of a draining or infected ear. 25 Other variations of electronic thennometers include earlobe clips and finger sleeve or clip sensors. Digital nipple·shaped pacifier designs are also available for monitoring oral temperatures of infants.

Disposable Single-Use Thennometers Thc.,e JeVICt;~ are u~ed in 3 similar fashion to the glass merCllf\l thennometer becau.3.c [hey are pbced under the tongue. Thcy cop.si...t of a thin plaslk' strip with a series of ra!scd cd!ibratcd UNs impregr,ated With a temperature-sen,itIVC: chemica! (Fig. 4.8j. The dots changL color to indi('at(: th.. . temperature. Aftel !he thermometcr is removed from ~he mouth. the do:s are examined for color changes to de:er:lliJ1C li'e' tcmper~lture ~c:J.ding (Fig 4.9). They are a\d!Jable ip bot!) Fahrenhen ;!nd Celsius ~cale.s and are dl~­ posed of 'lftei usc. Alrhm'gh illOSI common I) used for oral temperaturt:s. diliposahle thennometcrs (
Temperature-Sensitive Strips Heat-\ensitive strip..- (tape, palches. or disks) provide a general measure of body surface temperature. They also respond [Q body temperature by changing color and arc

Lasr black dor shows 98.6°F

Figure 4.7 A tympanic lhennomeler mcorp()rate~ a !tensor that delects infrared radiation from the I) mpamc membrane (eardrum) and CO/lveJ13 the warmth mto a dlgllaltemperature readmg. (Coune:-.y of Omron. Inc, Vernon Hill'i. IL 60061.)

LaS[ black dor o

shows 38.1 C

Figure 4.9 The chemical dOl" on the di\po.. able single-u\c thennomell~r\ change color from green to blad. to reneci Ihe lemperalUre (Fahrenheit.1t1l and centigrade. riglu). The green dOls tum bl
92

Pln-tical Rt"habiHtation

more frclJlJCl1tl) u<.;ed \\;111 children. nley O1u,1 he ~rrlic:d to dry ... km. The forehead and abdomen aTe common place· ment \ites. The Icmperi.1lUre reading' ilre non peclli( ~tIld are usuaH) confinllcd \\ llh illllore preci')c mca urc If dc\ latIons are noted,

Box 4.3 Hand Washing Procedure l 4ttjpllt~nt I \\ Iml nmnm!! lAalcr 2 SClJf1 lOll'''' fal.-ihll('... rnl\ Ide h(,IUld n.lp ffLml ren~'r .11 the ml)

J

(,11

.\ P.lI 'r Ill" I...

Procedure for Measuring Body Temperature

Prncl.'durc RCllltl\C

For purpo"'C\ of e\tahh... hmg b.." clinc data and detemlinln~ re'pono;e to treatment. phy....cal therapist' gencrall} u\(" oral monitoring. Oral temperature... arc conlr.lindil'atetl for patients \\ Ith d.\.\rmctJ or \\ ho are mouth hr("i1lhcr\. hil\.c had oral ...urger). or ha e a hl ...tor) of epllep... y or are rrom~ to ~izure~. The) al ...o ...hould not be u'cd \\ tlh mfant' or .small children or patienh \\ho are trrational. uncon ...ciou.... or uncooperative. In ~Ituatiom~ in \\.hich oral temperatures rna) be contraindicated and an eleclronic unit \\luh an alternative ~en"'or (e.g.. earlube clip. finger o;leeve) I'" una\'ailable. an axtllary mea...ure may be ~ub"'lituted. Several prelim mary activities appl) universally to any exammatlon of body temperature. These include:

Wash hand,. Hand washing is "one of the most important

~.

3.

measures for preventing transmission of pathogens in health-care facilities." 27 • p 2 The Centers for Disease

Control and Prevention (CDC) recommends vigorous hand washing for at least 15 seconds covering all surfaces of the hand and fingers." See Box 4.3 for hand

4.

washing procedure.:B - 25 •2K

Don plastic gloves. Gloves should be worn if indicated or appropriate (e.g., medical asepsis, infection control).

• Infonn the patient. A thorough explanation of the procedure and rationale should always be provided in Lenns appropriate 10 the patient's understanding. • Ensure the patient's understanding. safety. and comfon.

5. 6.

Measuring Oral Temperature: Electronic Thermometer 7.

A. Assemble equipment. I. An electronic thenllometer with disposable probe covers or sheaths. Note: Some electronic thennomelers are stored in a charging base to ensure readiness and optimal charge for patient use, The unit is removed from the base prior to use. Hand-held elecLronic oral thernlOmetcr") are self-contained with an internal battery: the proxi-

mal end house, ,he digital display and ballery and the distal end serves

a~

Ihe temperature probe.

B. Procedure I. Tum on the power unit.

2. Grasp lhe temperature probe with the 'humb and forefinger and allaeh the disposable cover over lhe probe unlil it snaps or lock, in place (some probes have a

JC df) a mlt.rnt)rC;JJlI<'m~ I.-Jn lll.-I,;umulaic 10

Ih 1000!!ul.lr '-llrl.lI.-C'S. .\ n t all.:h ma~ ~ pll . . hl."d up In Tmdlnr ann It.."wl, \ott' If p..tpcr 10 \ I.. alt' lil pen 'd \'1.1 .1 k\er or of\:ular ..... heel dc\ic.:e. ad • n((' umpk It"'rllnl.': pnur hI W:I hmg hand",. Thi "'111 thmm.t1~ wnlad 1111 Ih\: c.J1 pen"mg me~haJ11"1ll on("e th~ h..md lin.' "a...~ fum ()[l iller ll",m~ faul.-'et. hllli ()r klll.'e red....l (Illuml and adJu ..t the temperature to ",arm ("orne f.lUl.:et... ha\c; Infrared "'en 0('\ thaI tum on In re pon-.e to mot Inn detce lion). Runmng \\ater d..'-SI.. lli Yolth remO\al 01 mu:ruor.t:;llJl"fn.. and" y.ann temperalure remove Ie .. proli.Xll\e Ill" from the ham.!.. than hot ""aler. The forl'e of the "Jll.'r ,-hould nol C311<.;e ~pla~htng mal can promole tht: rr;m~fer of ITIlcroorgani:-.m:-.. Do not le"ln agam", the "Ink. to J\OIJ conlaLt ",llh a potentIally comamlllated Jrea. Wet handli and di,tal foreanns under running y.aler leeping the hands lower th.m Ihe elbow') ')0 "ilter no\lo' toward fingerlip'!. TIll', technique allow, the ":Her to now from lhe leasl contaminated area (oi"lal foreamlsl to the potentially most contamin..ued arca (hand.. ). Apply ..oap to hands. Using timl circular motion':> 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, l<.al

h

,lita.t.on

n

Box 4.3 Hand Washing Pmcedure .. qmpnll:nt I

atJon" a 1

Procedure for Temperature

~1easuring Bod)'

F . purpo.' Iahli hmg ha",li~ dAta and delenmnm_ respon to lr,,"atmen rh~ h.::al lherapi t £eneral1~ usc nraJ monllonnp: Or,i' t rnperature are f.;ontramJlcaled tor patient uh d\ pm a or '" hI) are mouth hreather ha e

had oral urgel).

(If

hale

a hi

IOf)

ot epllcp:"} or are prone

lo ~Izure . The~ aho \hould not be u'f:d "ith lOrant or

mall children or pallem '" ho are irrational. uncon~IOU"'. N uncooper.tll\.c. In Iluallons In ",hlch oral temperature... rna} be contramdlcated and an eleclronic UOil '" ilh an altemau\e r...en\or (e.g.. earlobe clip. finger slee\e, i... unavailable. an 3\illal) mea\ure may be ub:,.tituted Several prChmlO3f) acu",ties appl} univer~all) to an) examination of txxI~ temperature. These include: \\'ash hands. Hand washing IS "one of the most Important mea.-.;ures for preventing tran\mi~sion of pathogens in health-care facilities.":!'· P 2 The Centers for Disease Control and Prevention (CDC) recommends vigorous hand wa,hing for al least 15 seconds covering all 'urfaces of lhe hand and fingers." See Box 4.3 for hand washing procedure. n ..2S.2tl Don pla'lic gloves. Gloves should be worn if indicated or appropriate (e.g.• medical asepsb. infection control). • Infonn the patient. A thorough explanation of the procedure and rationale should always be prO\'ided in term~ appropriate to the patient's understanding. • Ensure the patient'~ understanding. safety, and comfon.

Measuring Oral Temperature: Electronic Thermometer A. AS'emble equipment. I. An electronic thermometer with disposable probe covers or ,>heaths. Note: Some electronic thermometers are Slored in a charglllg ba\C to ensure readiness and optimal charge for patient usc. The unit is removed from the ba~e pnor to usc. Hand-hdd electronic oral thermometer... are self-contained with an internaJ balter); the proXImal end hou,e, the digllal display and batlery and Ihe dl,tal end "tervc~ a.... Ihe temperature probe.

B. Procedure I. Tum on the power unit. 2. Gra~p the temperature probe with the thumb and fore· fingl:r and attach Ihe di",pO''Illble cover over the probe until it "nap" or locb 111 place home probe... hu\'l-: .1

I)roccdun: I Ro e po'

me JIR!Ular

a nucr""'S""""'''

-\ n II.. b rna m )fQITD lneL \ 't It paper 3 le\n I'" h.. lar 'beel &v e aID pnO{ 10 hlOf hand Th ... I ell Ibe dl pensmg mecharu 0 the hand 1 Tum on" ler u ng 3lX.eL f or <snd adJu I the' ternpt"rature ttl 9t3flll t

mlr.ued

rt

n-.oJ' that turn on

In ~pon\C to

t.lUC'tt."?

IllOlIOO del

Runmng ''''alec a: I t\ Vtlth rC'fI)(J\al Qr J'T1JC1'OCofg ,- m 3Dd a "ann lemptTJture fenlt)H k, prv 11\"( oils lrom the hand than hot \\3ter. The force ot the \\Jta rnluld not cau'C plibhmg that an promote the trJ!' ie: ot mlCroorg:mi m. Do nollean agam l the In IO :.I,Ofd contJC( \\ Ith 3 potentiall) C('Intammated are--.L ~ Wet handl.. dnd dj,tal (oreann') under running ~d.ler leepmg the hands lov.er th;U1 the clbo\\. . . "0 \\ ....ter 110\l, t(J\\:ard fingenips. ThIs technique allO\\, Ihe ":ller 10 flov. from the least contaminated area ldi ... lal fore.lOn, to the potentially mo"t contaminated area Ih,mrl.. ' ~. Apply \Oap to hands. IT,,mg finn cin:ular motlOfu and ,uf.. ficiem lalher. \ Igorously rub the palm... and ~um 01 hands. ftngers. and areas ber",een tinge". Interl:h.:c the fin· gcrs and thumb~ of hand.. during \\ amount ot soap. Carefully clean under ;md ;.U"(lUnd fingernail,> r micf'OOf'g".lIlI,m.. A\oid contact ''''ID the .. ide~ of the ,inl dunng \'J.'hmg 5. Rinse forearm:,,> and hand... thoroughl)- leeping the hanJs lo\\cr than the elbows. 6. Or) hand, thoroughly with a paper to\\e! \\Ith tlnfertJl'" POinting do",n.. The hand., ..hould be dned v. Ipmg Imm the finger tip,) to",ard the forearm. Th. lei.:hmque mtm· mize"i the chance of recontamination of the de.mN :ire.&. 7. Tum off the \\31er. If a foot or knee pelJJI control." nul a\lailable. a clean paper IO\\e1 hould be u...ed to (urn otl the fau~el 1100'.

proXimal bunon that relea,e~ the probe (O\l'r JIt~ temperalure reading is complele). If OIlC I' u,m~' .,mall hand-held electronil unll. the JI~t.11 enJ I' (\l\

ered with a pla"ttic ~hcath. patient to open h,,,, or her nlOluh .•Ull.l plJI:l.' I~ covercd probe ..I t Ihe p
:t A.,l

l h 'lp h-'I • Vi ' li l !)ign.. II hold liJ~' plol~.: 1tl.1\

dl'l'l.h l'

111

I'I. I \~'

i'-i

Ih~' \\l'I!!ht 11' I lh.: pro lx'

!"1I". k,,,.'1 th .., 'lIhlll1~I"lll'0"'''''l...'t un ll ! ,Ill ~II Ii,,1 1

pl'lht'

I'll I":~'p

1.. 111.'.HJ .......

111

\\.I , h 11lL' Ihl' nll On't·h.: r 111

tl'PIO

.... \"). IP)

" .. tl"r

.111<.1

rL' l lim II ) Ihe q o r;I!!C l o nl.HIIl'r.

II 1111111 11K ,uhlln~tI,,1

Il lIkt Ilh'

lJ \\ .,, ,Il h.lnd,

\(:r,tI . . l'u\H~I,' I h .., lx'",p mdl ... JII.: ....

1II.I\Ulltlll1ll'I1IIX'I.IIUIC.' h,l 1'1111 .. 1I111111hl.~ rj1h.·n( .... HUl

.1'

Yl

tx'l'lIll'. llht.'d K l'JlU1\l't h l'

ll10ulh

,IIlJ Ihll~'

th ..· lL'l1I f ll,:r,lr~·..tdlll~ "11 1111..' lh~I1.11 dl ... pl,l ~ lnl r'..... orJ II1!-'

\I"a" uring \ ~ il1af) T.,Olpe ralure : (;Ia~~ \Ie rc un I hermome le r \

\ ,wmhk ,,·qu lpment.

) K 1l\\l\C Ihl' jllllix 1.0\,,'1 tl\l·r .1 \\.I ... It.· Il:,,-..·Pl .h.k Illr

dl'pth;1I II .1\.llbhlt.: IHllhr untl u, ..' the r ll11x rl'It.' ;J,t: 1I1,,· .. h.1I11' 11i II .1 1"1;1,111. ,hl.:'.l1h dl\,,'r ,. . \"L'd. lhl' ., lh.m ". q'll h,\\t.?'1 Inl 1\'01\". 11 (nl\t.?'1 , hl'~Lth '\lIh ".Ipl'! 1 ~I\H'1. pl.ll1': th urnh ,111i1 ! nrl'f m ~l'r pro\ ln1<1l1 ) 1111 pfl,lx' 0\l"1 p
ell-an Ihe l,r.11 g l.b . . Illl' f( uf) thL'l mOlll e ' .... r \ (lIe \ " I!I.lr) It' lllper<.llure:' l' ~tn 31 . . 0 lx' mea",urt'd \\ Ilh ,,'j('t: Ir'('1I11t thCmlOlI1~Il' I \ J' well 3.., di'p,,\.lhle . . ing!t:- u't.' Ih~rmomc l t:r'. 2, Cit-an 1 1 ~ 'I1I e: ILl \\' 'Ill' Ihermomclcr J, A lowel to dry i.\\i llar) rcgiol1 (IllQI'IIUre will conulh.:t heat ).

are:~ 1

-I. \\ .lIell lor \\,tll clock )

\\ ..t ... h h..tlll.h .

B Procedurc

\ka,urin!: Or31 r<:Olp<:r:llUre . (. Ia" \I ercu f) fhl' mlunlc(l·r

E\JlU'Ie Ihe axilla .md en " ure area J, dr~ , I fany 1l101!'Olur~ j, prc 'Ient. the area , hl)uld be. gentl) lo\\el dned

-\ -\ " ..'mhk C'4LJ1PI11t:'nI

\\ IIh

B ProlcJurl' the IhennOl11elt'r 110m 'Itn rage 111 d l'.. lOl cC lal11 nlhl' un de r enid \\ ,I tl' r. ~UHJ dry w ith tl 'l~ U t:' u'1I1g .\ fi nn rma ry m o l ion \\ Irlll~ fro m th e: bulb tu\\<.trd the: lin~er'. .:! II, .11.1 t h~ Iht:n11l11l1t: tt:r ht'1\\ ee n Ihe Ihllm b and fo rt' flOgl'r at Ihe end 01 tht! ' l..;om WPP(,I, lI C Ihe blllh i Rl'll1o\l;

'1,)lull nn,

H\,IJlI1g the IhennOI1lt:ler honlUl11a ll y at I.!y t: 1c\t!1 1(1 obta in an i.1l'l'lI I J It.?' fead in g), ro t ~tlt.' u n til

1!'!.:'qUlr~d

Ihl: I.:lllumn 01 men,.:u~ ,.. ,karly \ I.." hh: ' O l ~ the It'\ d III lht: t.:olumn. Th(! rc:aumg ,hould bc- bdo\\ 4:' r" (1:' C 1 heton: plaCing Ihe thermom e tt:r III the patll.'IlI" mOUlh 11 the \.llue '" higher. ...... hak(' l,h mn" Iht: Ihl;!'mlnmctc-r until Ihe I1ll:n:ur: I.., tx l o\\ lJ5 F (;.s ( J. \ \ hlle 11LIlLling Iht! thermO lllder \eclIn: I). u:\e LjU II.. k.. J~l\\n",J rd ,n,lrp11lg nUlIIOI1'- 0 1 Ihe \\ 1'1 '1 1, \d1lLh \~ til dlc.'d l\t'ly I Il\~cr Ihe "'Illum n

pJucnt 10 ll p~n hi. . o r her mOlith , ~1110 pl"":l: [ilL· hulh llf Iht! lht:rTnnl1l~ l er ~II lhl' pn'llel"lOr b ~ht: uf Itt .. 1t11lt!Ut: Itl thl' nghl or lelt 01 lhe Ir..' nu luill In the \'11-,. the

'uhllll~U,\1 p,x.:kel

IlhtruLl lhe: P;I\Ic.-1l110 dU'Ie

Ihe lip,

IIIC'I tlell!/.t!OUluJ Ihl.: Ih~lmOl1h,:It'r III hl, lo 11 III phlu'

... I.e .I\-I.'

!III: ~Ia .. ~ flIer .. ul'~ Ihl:nnullIc:h:r III pl <.tl'e 1111 "' III

Jlllllule

" 1<,·

0..

Itu; the'fJIll)IIII.:'It"1

, { Ill!! ,I dt'.tll li')"U\! v,1j'l' tht: lht:nlll.lJlctl'r .1\\ .. ) Ir IIll Iile IlfcT !o,\<.tIJ Ihl.:. bulill u,Jn~.t 111111 ro l .1r~ nOII~'n,

i

palling IHOllon (\ igorou'l rubbing \\ III

Im: reJ ....c temperature of the :lr~a) .

( k.tn nf.11 ;!I.h' m.: r\:u~ l h~nnnm .... t.:r

... C\t:.ln U....... Uc III \\ ' Pl' lhcnllomt: t\! r ~ \\ .ill h I (If \\ all dod,l

3

~I

fluid llil' Ihl"l1Ij,Hlll.:'kl .I\l''''" lI.:'\el. IUIJIt:' UIlIlII Iu.: ill.:1 I,.UlY [ Lk.trl) \,[,>.hk, ,IIUI h',ld 111(.' hl~'hl:"'l Pljlllt /llliitl "'l.lle I••\hl ... h li1l' I1KI"ur~ h...... "'ICII Illr II:LOllhl lt!

2. Rem ove Ihermometer frum . . torJge in di,mfeclant ..,ulullon, rin ..,e under cl)ld \\d tcr. and dry wilh lJ'isue u. . ing a firm rotary mOli o n. \l,-iplIlg from the bu lb to w ~lrd the finger!', J, Hold Ihe thCnllOlllcter hori7onta ll y i.l1 eye level and rOI ~IIe: until tht;! column of mercury is clearly visib le: IlOle Ihe level of mercur) , I f nece:-...,ary.... hake the thermometer ullllllhe mercury i:\ be lo".. 95°F (]5°C), -L Place tht! bulb of the thermometer in the center of Ihl;!' ~1\'lI a r) reg io n betwet'n the trunk and uppa ann ( Ftg. -I. (0 ). Tile pallen" , upper "lfemll) ,hould b< pl..tced tightl} acro'l\ the che'l to keep the ther· mumeter 10 place (;.t.,king the patient to m o"c th~ hand to\\ ard the 0 PPO ::' I1~ . . ho ulder I') often a u..,etul direc tIOn ), II the palient j~ JI~o riente d or ver) )oung. Ihe IhemlOmel(' r mUM be h~ld In place, 5, LC i.H '1: Ih eml0ll1 cter in plac\.' for 10 minute.:, tmure IUllt! " reqUlret..i lor thl~ m e rc lIr) 10 expand when m ea'l unng ,1\llIar} temperature ),

6 Rt: ll1o\ e Iht.: I/WnllOl1leler. 7, U... ing i.I clcall 11 ~ 'Iue: . wipt: tht' thermo meter :!\VJ) frum Ih ~ Ilng!.'! r'l (t m\<.1rd th e hulb) u..,ing ..t tlrlll 11101[ 1111

rLllar~

~

110kl Ih.: thermn melcr .11 ~) l' It'\ ~ 1. fOt i.tle until the i:\ dt'~lrI ) \ 1.., lhle, ,Ind re.,d th ... hlght''':!1 p,'111I on Ih l' ,,,..tIL" 10 \\ hll" h Iht: n) .:rLu r~ ha, n~en for m e:!'I.:ur~

rt:' ... urJ'Il~ Gl'lh!rJII) .1 t\.· m p l·f.J l u rL' rei.ldmg j, ..i."'Ullll'J

"flft

.10

{) f

,II nh:.t'liIt:' li n Ie.."

...lI hc r\\

j .... c

IlLltt.'J ,

\l IlJf\

,.tl ut: ... .trL' dl.!'''Ign..tl('li hy oJ u rl h: d r\ after lhe tl;!'IH ~'k!r<.tl u rl' o f Ihe lit.''II!!Jl .il ltlll .. \T" lor ., \llIan I~m !,!"I,I/II1't- (e.!!.,

Rf

(II

95 F Al l .

1I11l1<.tr l }. the JI:'~ign "Hl on

(hi! 'tlIlP. IUltllt IOJ ,I

l'lI (\e d R llh('r lh~ \ <.tluc

II ldll.:.I1 t; .... ,. lell
more frequentl} u\cd '\.-llh dllidren. Th'~ Il1U"'l be applied to dr) n. The forehead .1OtI abJomcn art: cnmmnn pIJ(,:~ ment '-lie Th~ t~l11pcri.lIUrc readIng' dre non'r't=l.-llh. Jnd are u'uaJl) (onlmned \\ Ith i.l 1ll0fC preu...e mC.l,un: it ue\ 1.Hion .t.re nOled.

Box 4.3 Hand Washing Procedure h . llJiJlm~nl I \\ann runnw.' fl"' 1. SO.1p (ntOo,;,t f,lllllllco, p.rO\uJc hyUI.J (MP lrom p.:IN~r;lt the Ink)

" PIJ'l':rW d

Procedure for Measuring Body Temperature I"Of pUJPlhC'" of e lahh ... hmg ha elme dJtJ anJ ut,";tennmlne re\~m"'e to treatmcnl. ph)'ILal thcmp"h i=enerally u..e ural monllonng. Oral temperature" are contr31ndll.iltcd for patient-. \o\-Ilh dHpflU} or .... ho are mouth !:In:athel''t. ha\c had oral ... urger) or hJ\C a hi\ton ot epll\:p.. ~ or arc prone to "IlUrc. The} al.. o houJd not he uI"cd \\Ilh ,"fan.... or \01all clllidren or pallenl'l \\ho are IrratIonal. UO'OI1\(;IOU". ('IT Unl,;tlOpcratl\c. lo ,ltuatlon... In whICh or,}1 temper.lIuTe.. rna) be Cnmr.lmdh,:JICd and an clC\.:lmnll; UOIt \\ nh an

ahemall\c...en...orfc.g.. carl(l~chp.tmger .. !t"c\c) l~ un:J\Jllahk. an J\II1Jry me~t ... ure may oc ,ub... lIlUl~d, Sc\craJ preliminary aLII\ llie... appl) uOl\'cP'Jn~ (0 an~ e'ammatlnn of Ixxl) h:mperature The c mciuJe .1

\Va,h hand .... H,tnd ,"a.\tHn~ I' "one of the mo.. t mlpt:m.lJlt me\.lt,urc tor preventing lran,mL"llln 01 JMtho~cn, In heahh..(:arc IJl:lhllc "2"'Y, TIle Center Ic.)r Ol..ea onlwl .md I)rc\ Olmn ICOCI rculmm~nJ, \ 1~()roU' hand \\a\hlng for 31 lea~l 15 -.c ond, C(l\~nn~ all ,ur Idl.:C' ut Ihe hand and flllgcr Sc-c 80 ~ 1 Itlr hand \l, a,hln~ pnxedurc Dlm p1;,J til.: gln\c.. GIO\(: ,hnuld he "'not IllOlildl d (1r appropn..th.. It:.,g .. mcJIl"~1 a'\('p 1"'. 1Il1e-\.llon umtroll.

"J

tnloml Ih pallenl \ thowu h e'plJlhllhm ot ttt.: pre dur ,ukl r.lllooJJe houl J al", J\ .. hi.: pro I ,I Ir\ h:nl

arrropnal\: 10 the r.jll~nt· und r '..tlll,"~ En'urc the p.i.ilh..· nl\ under I.UlJII1~ "ltet) .lod

'e "nnll Oral teml r"l"r

'\ l\llllh)rt.

'I ·tron;.

TIt "nom «('r A. \

,~mhlC' C"lUIP1fH:1It

\n l.o\ofr

In

",I

h 'lnd' )( I

;11

(haplC,4 Vi,., Sign..

lolwld ,hl' Pll11x til pl.ll'C .\ . . thl' "l'l~h l 01 thl' pn'nc m.l~ d l"'rl.lll' II 11l111ll hC ... uhhngu.\1 rkX. hCI. l ...J Ilnld the I'nlt" In Iht.' ... ubIUl!!ttJI P(XJ..l'1 lJllld Jil 3Uth bk hI:~r " 11l'~,rd (o.,('n·I .t! "<:rond, 11 Il l" t,,:l' J"I Illlh C'~lc ", 1l1;.l\InWOl rCl11pC:f,tlUn." ha ... 1X'1'1l rt'.Il.:hcd. R cmn\'t~ the prohl' 11',)111 1hI." p.IIII.'I1 I ·... mnuth and mIll' thl' Il'mpera !Uho' re~ldlll!! nil the dig ll ,lI dl'",pli.l) 1m rc,ordmg. 5. RCI1lI)\C Ihe pmlx' UI\l,;r mn rl \\;, ... tc 11'l..'cpl'li..'Ie fllr dl'rn..,,,1. II ;l'v.lI IJhlc on the unit , u... ~ the probe rcl e'N~ Illl'lh,tI1l ... nl. If .1 pl,"III: ..,hl.!
7 W",h h'l11d ,.

9.1

H. V,:;I\ h th~ thl·rIlH.lIl1Clcr III h,:pld .. oap)' wall'r nnd rctum to thc \ tflfllgt: C(lOlU1I1t.'r. l) \\ ~hh ham.k

'\tea.uring 'hillary Temperalure: Cla,,-, l\1"rcu,) nu:nnomeler A A ......~ n1bl c

cqlllpmt::111.

I. Clean the oral glas ... I11crcur) then110l11Cler NOlI!: Axillar) tcmverulurc s can 31,0 be mea\ured with e lectronic the nnom('ter~ as \\.e ll lli. dbpOl):lble , ingle-lI t:\! themlomelcrs. 2. C lean ti ssue to wipe thenno met er

3. A IO\\C llO dry axillary region (moistu re will conduct ~.

heal). Walc h lor wa ll clockl

B. Procedure Measuring Oral Temperature: Glas. Mercury Thermometer A. A,\em ble cqulpmcnt. C ICJ Il oral g lJ. ~'l m e rc ur ~ thcnnometer 2 Clean tj\::.ue 10 wipe themlol11ctcr 3. Watch (or .....:;111 clod,,)

B

Proceour~

Remove the thennometer fro m 3Wf'..tgC In di5infectant lloo lulion. riT13~ under cold wate r, J.nd or) wi th II s~ ue u).,lI1g a finn rotar) mOtion \\ iping from the bulb toward the fing er.... 2 Hold the thermometer bet\\cen the thumb and forefinger at (he end of the !l. (em (oppos ite the bu lb ). HolulIlg the thennomeler hon zontall y at eye le\ cl (reljulred to obtam an acc urate reading). rotate until the column of mercu ry 1 ~ clearl y vi:-.ible. Note the le\el of the co lumn. The reading ~hou ld be below 45 c F (3SoC ) before pl3cing the themlOll1cte r in the patienl\ mouth. It' the va lue 13 higher, "shake down" r the thennomcter unIlI the mercur) i . . below 95 F (35 Cl. \Vhile holdlllg lhe thermometer \ec urely. U!'le quiL·k. do\\m\ard !'l nappin g motion<.; of the \.\fi~ t , ,~hich \\111 effec th el: lower the column. 3, A,j.. the paIlen t 10 open hi ~ or her mouth. and place the bulb of the lhennometer at th t posterior base of the tongue 10 rhe right or IcC! of the frenulum 111 !.hc ~ubh n g ual pocke t In,truct the patient to c1o~e the lips wot te~ ( h) Jround the thcnllometer 10 hold It In place . ~ Lc!J\t.' the gla ... , me lcury Ihcmlomeler in plul..'e for 3 to

.5 mmute ,. 5.

R C l1lu \;~

6. L '!>In,g a lrom the

the thermometer. dC
motlun 7 Hol<.l the lhennl''1mt.'ter J.t e}t: le\t~ I , rotate until th~ mercur) I'" d~Jrl) \ hi hie Jnd I cad Iht' hlghe ... t P01l1t un lhl:

..,t:Jle to 'Nhh,:h the l11t::rt:ul) hi.!'" n:-.en lor fl.!cl'lrd lllg.

I. Expo..,e the axi ll ~1 and ensure area is dry. Lf any mOIsture is pre . . ent. the area c;; hould be gently towel dried with :l paning motion (v igorous rubbin g will inc rease tempe rature of the area). .., Remove thermometer from storage in dbinfectant solution. rin se under cold water. and dry with ti ss ue using a finn rotary motion , wiping from the bulb toward rh e fingers . 3. Hold the thermometer horizontally at eye leve l and rol3te untll the column of mercury is clearl y vbible: note the level of mercury. If necessary. shake the thennomeler until the mercury is below 95°F (35°e). ~ . Place the bulb of the the.nnometer in the center of the axillary region between the trunk and upper arm (Fig. 4. 10). The patient'!. upper extremity should be placed tightl y a.cross the c hest to keep the thermometer in place (asking the patient to move the hand tow~trd the opposi te shoulder is often il useful direction) . If the patient is disonented or very young. the themlometer must be held In place. 5. Leave themlometer in place for 10 minutes (mor~ time illo required for the mercury to e;..pand when measuring axilla!) temperarure). 6. Rem ove the thermometer. 7. U~ing a clean lIssue, wipe the themlomcter away from the finge rs (toward the bulb) u:-.i ng a finn rotary motion . S. Hold the IhemlOmeter at eye level. rOlale until the men.: ur) is clt:arl~ Vl!)lble. and read the highest point on lhe scale to \\ hich the mcrcuf) h..J!I<J.f\ \alue~ are dc" ignatcd b) d cuded A "Ittc:r Ih~ tem perature or the dC!'llgllillion '·AT'· for u\/llw) rem · /h ' turW'l' (e.g .. 9) ~ F AT) . SlIllilari). th~ deslg natlon RT (rnfal ft'III/U!Wl/Ire) or it clrded R Jfler the 'value mdil':lI es 3. rectal ml:!a,urc {~.g., 99'1= ®l.

94

Physical Rehabi.litation

Figure 4.10 Po.. lllonmg for m{lnl~ loring a.: dIal) tcmperaluTe PlaLlnl:!: Thermometer

9. Wash the thermometer in tepid soapy water and return to the storage container. 10. Wash hands.

Measuring Tympanic Membrane Temperature: Tympanic (Infrared) Thermometer A. Assemble equipment I. Tympanic thennomeLer (many units include a srorage base and protective cap that fits over the probe Lip) 2. Disposable probe covers B. Procedure I. Attach the disposable cover to the probe, holding it with the thumb and forefinger (ensure the finn circular collar of the cover engages with the base by gently pushing it down: do not touch the plastic film of the probe cover). 2. Tum the patient's head to one side. Pulling on the pinna (auricle) may help straighten the ear canal and provide better access. For an adul4 the pinna is pulled up and back: for a child it is pulled down and back.""'" 3. Insert the probe snugly into the ear canal. A firm genlie pressure should be u!>ed: avoid forcing the probe too deeply. The probe should seal the opening of the ear canal. To ensure accurate reading, the probe should be angled anteriorly toward the jawline. as if approaching the patient from behind.1-l 4. Pre~ ... the button that activates the thermometer. The temperature is u\uall) displayed wilhin 2 s~condlj. Some units provide an audible beep or tla,hing lIght when the maximum temperature IS reached. 5. Gently remove the probe from the ear. Eject or remove the probe cover over a W3ljtC receptacle for

lhe patlent"\ arm aero.., Lh~ t hold Ihe thermometer In place ncar the \'ascular 'iupply to the a'illa.

disposal. Manual removal of probe co\er should be done using a clean paper towel or tissue. 6. Return tympanic thennometer to ~torage base. 7. Wash hands.

Monitoring Pulse The pulse is the wave of blood in the artery crealed by contraction of the left ventricle during a cardiac cycle (one complete cycle of cardiac muscle contraction and rela.\ation). With each contraction, blood i~ pumped into an already full aorta. The inherent elasticity of the aOniC \\;all, allows expansion and acceptance of the ne'" .. uppl). The blood is then forced out and surges through the 'l)~temK arteries. It is this wave or surge of blood that IS felt a\ [he pulse. The strength or amplitude of the pube reOec" the amount of blood ejected with each myocardial COnlr.1ctlon (stroke volume). Penpheral pulses are those located in the penphe0 (II the body that can be felt b) palpating an aneT) over J bon~ prominence or other finn surface. Example~ of penpheral pulses include the mdiaL carotid. and popliteal pul",. The apical pulse is a ceniTal pulse located at the apex of tht' heart that i~ typically monitored u~ing a ~lethoscope. Pre~sure changes in the large arteries dunng the cardlJ' cycle are reflected in the normal arterial \\;aVefOml (Fig 4.11 [top I). The lowest point of pre>sure OCCUfl> dUring ventricular diastole. while the hlghe::.t point occur... dunng ventricular Slslol. (peak ejecHon). The nOlch on the descending slope of the pul~ wave represent' closur~ 01 the aonic valve and i& not palpable."\() A heahhy adult he.ut beats an average of 70 time::. per mmute. a rate that provide... continuous circulaLion of appro\lmatel) 5 to 6 lite!'

Chapter 4 Vital Signs

The pulse pressure is about 30-40 mm Hg. The pulse conlour IS smooth and rounded. (The notch on the descendIng slope of the pulse wave is not palpable.)

NORMAL

SMALL, WEAK PULSES

LARGE, BOUNDING PULSES

95

The pulse pressure IS diminished. and the pulse feels weak and small The upstroke may feel slowed. the peak prolonged Causes Include (1) decreased stroke volume, as In heart failure, hypovolemia, and severe aortiC stenosis: and (2) Increased peripheral resistance, as In exposure to cold and severe congestive heart failure.

f\. [\j\. f\"

The pulse pressure is increased and the pulse feels strong and bounding. The rise and fall may feel rapId, the peak brief. Causes include (1) an Increased stroke volume, a decreased penpheral resistance, or both. as in fever, anemia, hyperthyroidIsm, aortic regurgitation, artenovenous fistulas, and patent ductus arteriosus, (2) an Increased stroke volume due to slow heart rates, as In bradycardia and complete heart block; and (3) decreased compliance (Increased stIffness) of the aortic walls, as In aging or atherosclerOSIS.

BISFERIENS PULSE

A bisferiens pulse is an Increased arterial pulse with a double systolic peak Causes include pure aortic regurgitation, combined aortic stenoSIs and regurgitation. and. though less commonly palpable, hypertrophic cardiomyopathy

PULSUS ALTERNANS

The pulse alternates in amplitude from beat to beat even though the rhythm is basically regular (and musl be for you to make this jUdgment). When the difference between stronger and weaker beals is sltghl, It can be detected only by sphygmomanometry. Pulsus alternans Indicates teft ventncular failure and IS usually accompanied by a left-Sided 53.

BIGEMINAL PULSE

ThIS is a disorder of rhythm that may masquerade as pulsus altarnans. A bigeminal pulse IS caused by a normal beat alternating with a premature conlractlon. The stroke volume of Ihe premature beal IS dimmished in relalion to that of the normal beals, and the pulse vanes In amplitude accordingly.

Premature contractions

PARADOXICAL PULSE

A paradoxical pulse may be detected by a palpable decrease In the pulse's amphtude on qUlellnspiratlon. II the sign IS less pronounced. a blood-pressure cuff IS needed. Systolic pressure decreases by more than mm Hg dunng Inspiration, A paradoxical pulse 15 lound In pencardlal tamponade, constrictive pencardltls (though less commonly), and obstructive lung disease.

to

Figure 4.11 Nanna! "up) and abnomlal pul~'l. a" rellcctcd Bale,>. 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<:e. In monitormg the pul,c. 'lpecilk attention i') dlree.:ted tov. ard detcnllllllOg three paramcler,: raft:. r!"thm. and lu/ume.

Rate TIle puhc ra1l' (Of jleql/('lIcr) i3 lhe number oj puhatiom. lpenphcraJ pube "ave,) per InmUlC, Hrad)cardia i\ an 4bnomlalJ~ ... loIA pul~ rate k,... than (,0 lxah per Illlnul~ "Iach)tdrdia I an e ce "'I\-d) high pul,.. . fait". grl'akr thim 10ft beat per llunUie. Pd/plttlTiUII reIer, 10 Ihe "'cJl"i.lIlOIl 01 rapHl 01 Jrn:gular pube nth.: jX'n.:C'lVcd by lhe p.HleOl \~ IIh

J

out ildu.tlly pJ.lpallllg a pcnpherJI ruhe. Multiple lal"ltlf\ \1,111 mllUenl"e till: pul",c lale IIldudlng age gcndl'r, C'1l1O. llon.tl ~Ii.llu......In: !\ and rh~"IL:al J(II\II) 1C'\el. Bod) "'lIe

the artenal wavclomls. (From

ilnd .,lalUn.: ~tlso innuence pul e rale. T~lli. thin indi\idua\r., generally have a ~Iowcr pul e ratt: than [hose who arc obe ...e or have ... Ioul frame ....

Rhythm The pulse rhythm I... thl: pattL~rn of pulsations Jnd Ihe lIller\ al ... between them In a heallhy inJI\ l\.Jui.ll, the rh y I hill " lef!ular and inJII.:.lll~'" the lime 1I11~f\ al... bel\\("I,.'n ptll...~ heJh Me e"enllall)' equal 1rrhrt}uml1 or J\ \,-!In}UlIll1 r("la~ 10 .In lrreguLJf rh) thlll In \\ hlLh puhe ... Jee nOI C\ en I) ... p,lced t\n lrregul;tr rh)lhm 11M} pn.· ...l:nt a, prCITI::J.turl:, tHe' or I11I\ . . t~J pul ...(" beah. or random. trregllL.lr ht'ah in ~J1h('r J prt'dl~labh: 01 llllprcdlL'l"ble p
-l

96

I'h, .. ical R\'habililalion ...thl·nlilill. ,111l,tr.lllf1n \11 IHlrOJ;11 {tllpl ,lnd (Olllmon alter ,Ilion' III .1l1erla! plll~..: \\;W(·lllrm ....

Quality The quoll'\ (al,o lalled ol1ll'll1/Idc III mlllllfr') 1)1 Ihl' rul'I' reier, In thc ,U11nunl 01 I nfl'\..' u('~llC'd h) thl' \..'ICC!l'd blo\ld 3,!!:.tin'tlhc .n1crial \\-all during cad1 \l'lH,illl!:U \..'nnlr,u..llllll In e\;ullInlllg the 4u.\ht) 01 the puhl', lhl' Ihl'rapi" "dl'll'r milling the led 01 lhl' hlond ali; II 11<1'..e' through" \l'''''t'1 The quan!lt) (\ (llume, 01 hll~od \\ Ilhm lhe H'..,cl pnKlu\.c .. the ron.:c of the pul,c. Normally. Ihc: plll,e volul11c (1Il'.ILh heat 1\ the o;;al11c. fhe fore\.' of tlw pul'l' I ' greater \\ 1111 ;1 hIgher blotxl \'olume. and \\\..'aker \\lIh'l lu\\cr bloud volume. The volume I'" n:llllllled h~ ho\\ C:.tli;lly Ihe pul,c L-an he obliterated. A normal pul,c l"l dc nihcll :1 ... full or \lrong can be pal paled u... lIlg. moderate pre urc 01 the ringer... mcr a oon) landm::uk. \VIlh lu\\cr \(llume'. the pul ...e '" .HI/oll. I'" ea~Jly obliterated, and lermed \Hak or thrcmly. With an increa"eo volume the pul"e ;\ lorge'. difficult 10 obliterate, and i~ lenneo a bounding (or jllll) pube; a fceling of high tension i~ nOlcd. A numeric,,1 "calc i... offen lI\cd to document the yualJt) (~trenglh) of the pul~c (Table 4.5). In addilion 10 rale. rhythm. and quality, the feci of the aJ1eriai wall under the examiner\ lingcrlip\ ~hould be determined. Normally, a ves~cl will feel ~ll1ooth. cla,')tic. soft. flexible. and relatively ~traighl. With advancing age. ve')!)cls may dcmon~trate \c1erolic change .... These change, frequently cause the vessels to feci twi~ted. hard. or cord· like, with decreased claqieily and ~moolhne\'·,. Several other imporlant terms are u"ed 10 de ...cribe Vi.tn· ations in pulse. The term bigeminal i.. . u~ed to de~crihe an abnormality in pube rhythm where two bC;Jh occur in rapid \ucces~ion (double ,')ystolic peak). I)ulsus alterans (alternating pulse, is marked by a Ouctuation in amplitude between ocab (weak and a ~lrong), with minimal change in overall rhythm. A nomlal puhc beal i~ followed by a premature beat of diminished amplitude. A paradox. ical pulse (pulsus paradox us) i~ a decreased amplitude of the pressure wave delCClCd during quiel in~piration wilh a return to full amplitude on expiration: it is oft~n aS~Ol:ialed with obstructive lung disea~e. Figure 4.11 provide", a

Table 4.5 Numerical Scale for Grading Pulse Quality (Strength) Absent

No perceptible pulse even with maximum pressure

1+

Thready

Barely perceplible; easily obliterated with slight pressure; fades in and oul

2+

Weak

Diit,cuit to palpate; slighlly stronger than thready. can be obliterated with lIght pressure

3+

Normal

Easy to palpate; reqUires moderate pressure to obliterate

4+

Bounding Very strong: hyperactive: is not obliterated with moderate pressure

----- ._-_. -------

--~

--

Factors Influencing Pulse I·.~ ...enlhilly. ~1Il) IJ\..lm

Ih,lI ,IlIa... thl.: 1Ill'laholH.: r'l1<> \l,11I ,,1<-,0 Illllul'llLC 11K c.;cvt.:rilll,lLlnr.. Ml.' III panKul"r Impor tanle ,"vhCll \.on'Il.lcnnJ:!. plll"t, rale

Age Felal pul\c rail''' i.l\erage 120 to IhO OC,ll ... ~r rmnulc_ "'he pul,e r,It..: ... lor a nc\\ hom range between 70 ,md I r)O. \l;lIh 'Ill ,-,"crage 01 120 ocah rer Inlllult.:. Pul"l.: rale t!radu
Gender Men and boys lyplc~tlly have ... Iightly lower pul\c rate... than women and girl....

Emotions/Stress Re ... pon:-es to a vi.lricly of emotion" (e.g .. grief. fear. anger. excitement. anxiety. or pain) activate the "iympalhcllc ncrvou~ ~)~telll. with a re ... ultal1l increase in pul .....: rale. TIle \tress inducing clfec.... of moderate to ..cverc pain \\ ill aho

elcvatc puhe rate.

Exercise Oxygen demJmb of 5k.cletaJ mu... c1c' arc ~Ignilit-anll~ incrca ..cd during phy'oical aell\ ity. At rc"it. onl) 20 10 }'1 PI' pereenl of the available Illu"lclc capillanc ... ot' a~ a fUIlt.:iion of Ihe inlcn'olty llf tilt.' ~lCtiviIY. A linc.u rdtltion ... hip exi~l:- bclween pul,c rale and lIlh.'n"'ll) of \\or~" IO~l(1. To u~c the pul ... c r.lle cflcoivcly, bOlh Ihl.' pallt.'lll'; rc~ting and prcdidcd llliD.im;,lI IIR~ ow ..., ~ t.It·tenTIlrR,\1. Maximum f-IR v.due ... C3n ht' delemllilcd by a llIa\lllIaJ graded l.'xcrl.'l'oe le ... I, whenever po~")lbk, or h) u"'lI'Ig .1 fllr1ll111". Ag.I;.adjll ... tcd HR (ma-';IOlllll1 HR tHRill) cqu,ll, 220 tlllnUS age) or Ihe Karvonen Fonnula an: t·xJlllpk'. Generally, pul~e ral~':-' during:J 15- to JO-millutl.' Iha,l~li' tit' cxerCl'C prugrUln for a h..:althy Individual ..hl)uld not (:\{'ced o(J 10 90 pern:nt of pn:dlt.:tctl HR,"~, Lo'Ac:1

l'\NI".I"l: Inll'n"IIIC" .t!"l' Indll,l1l'd Itll Illdl\ IclUJI" \\ Ilh Itm fl111l: .... k\ d.. I '-Il'l' ('h,lpll.:'[ I h. I Illl·\,tI1l11111l~ pul..t: r,lh.'. R' .. p<)n .....• Illl'\lTll k\d 01 ,Il'[nhll fitnl'..... ,,1 ..\) I11U,1 lx' lllll"llk'l'ui Hlllh n.·.. IIIl~ •.md ..uh·

III n ..... h.I"'l.·

nl('~ .Ul 1".("I1I1I1WIII\ II l'll III Ih ~ 1rt:',tlnk.'lll

~mglll.t fll:dl'n ....Inh) tllllll,1

"f • /1\ r"":Ih.'n"llln.•Ind Ihe ,K·ut.:

plt.i'\C nl 1ll~'X:,lhl1;d Il1l.trdlO" SnnK l:\llllll1nnl) pr':"Lnhcd

hl.:la hllx.h'r.. II1dlldl' l!lgll.lll", n,lLloln!. ami dll.'lll,I{11. PdllCllh \;Ikillj! l"Il.'I.l bl<X.~l'l" 1\ plc.lll) L·\rlt..'rll'nLl' C'lrl y 1.\ll~Ul' \\ IIIl

ll1;I\II11,d l'\Cln",-, III{" ;Ul' I)PICidh Iimel III tl,lI1\l'(\ mdl\ Itl u;lI ... In fl'''')()!1 ..e 1<' ,Ill Ilk'llIIL.II t,'\t:l'n"t: II1h'll .. ll~ ,1 ...C'dcn·

l''\l'rtl''~,

l,~ I""II:N\I1\ IIR \\ III delllon"lr,th.' j;rl',tll'r ,h.. l.xk·f;lI11ln \\ h~1l

..udl ~'" R.llll1g" ~,t pI.:I\·cl\-ed I \\'111011 (RPl 'I..,\kl... hl)uld be

l'Olllp,lfl'd \\llh ,llr,tlnL'll indi\ll.lual f('yUI~melll

<.IlL' Ih\..'

11111.:

um"ld~rl'd

.Jltl'm;lIl\'; 11ll',I"Uf\..·

to pul'ot: l1lollltonng,

In mOlll1llr .:\~n.'I""" 1l11I:n"lt~.

Ihe I,mt"f IIR

IralllL'J indl\ Idu;lI (luur 1" a fe ... uJr of a more .. lrl)l..c \olul11c ''''Ing to gl\..'alcr C;lfdlJl ..tn:ngth an<.ll.'lliclc:ncy. fhl' Imeat rel.t1ion ..hip bCl\\ccn puhc r~Hl' and v.orl..l('l.td e\I"(\ tor hoth traillt.'d and lI111rainl'd Illth· \ IduJk 1100\l'\ cr. the fall' 01 ri-.c \\ 111 dllkr \\'hcl1 compared \\ nh a -.edl·!H.lr) per"'OIl, thl' trJll1l'd indIvidual \\ ill Jlhle\e a higher \\01'1.. output and gre;ner O\~ gcn cono-.ul1lplion helnrc reachlllg. ,I "pc'C1fied ..ul.'lIlM\ll11al ItR fL'

pon-<

~m ;'h.. tl\ll~

III

'llh(,u~h lhl' 111t'laNllIl

;md ,m

1Il.1

dll~lellllinuc:a~dl

Systemic or Local Heat During pemKh (1f 1c\L'f. IlR \\ III IncrC ..t ..c. The bod) \\-111 al(~l1lpllO dl ...... lrdt~ heal h) \ ;l.. odllallon oj IX'npllL'f"t! \e ...,el-.. IIR \\111 Iml't~~l..e to l'ohulll bloLXI flow to cut.Il1CQU' .m;·;.!.. lor cooling. Lo(al apphC<.IllOn" 01 thermal mCI(.I.t1l1ic\ (",uLh ;I....1 hot p;lCI..) mJ.~ al ..o elchtle HR 111 order 10 pro\ Ide IOLTea...ed Un.:ulJllOn 10 ..:utaneou.. ar~;l .. "econdaf) to Jr1cnolar ;lnd cdrill,ll) dilation.

Medications

n,L' Ilnpm,:t of I1lCdlC:lllon.. on pul"c fall;' I" par1icularl~ IInporlant for palll:l1I... wilh c:mhac di ..ea"c and h~ perten'J.ion. BClahlocker-. .Ire a cllcgO!)' 01 drug lhal blcx~ Ihe: ...) mpalhellc bela re<..·eplOf\ .md decrea...e bolh re"lmg HR and IIR rl''''pl1!l..e

Pulse Sites A penpheral pubc can I:x monitored at a \;triCIY ot sile ... on thl' body. A "uperticml aner) located over a bone or other firm ... urfJ.cc I" ea...ic... t 10 palpate. Table -l.6 Identifies

Table 4.6 Pulse Sites, Locations. and Indications for Use Pulse Site

Location

Indication ..... Use

Temporal

Over temporal bone; superior and lateral to the eye.

When radial pulse inaccessIble; often used with infants; used by anesthesiologrsts for monitoring dunng surgical Interventions

Carotid

On either SIde of the lower neck, below the jaw, fingers over thyroid cartilage between the trachea and medial border of sternocleIdomastoid; pressure should not be applied bilaterally or high on the neck to aVOid stimulation of the carotid srnus and a subsequent reflex drop In pulse rate.

Dunng shock or cardiac arrest. often used wIth tnfants: used to monitor cramal Circulation: eaSily acceSSible If other penpheral pulses difficult or too weak to locate.

Brachial

Distal medial aspect of the humerus, the biceps can be gently pushed laterally dUring palpalion, or medially In the antecubital fossa: elbow should be slightly flexed and supported to aVOid contraction of biceps

DUring cardIac arrest; used routinely to mOnitor blood pressure

Radial

Distal radius at base of the Ihumb, lateral to tendon of the flexor carpI radialiS.

Most common Site for penpheral pulse monltonng: easy to locate and eaSIly acceSSible,

Femoral

Inferior to the IngulIlal ligament. midway between the During cardiac arrest; used 10 monitor lower extremity circulation anterior superior Iliac spllle and the symphySIS pubiS: typically monItored In supine

Popl teal

Infenor aspect of poplIteal fossa papllteal artery IS deep and at times may be dlfflcult to palpate; tYPically monItored In prone 'WIth knee flexed to relax hamstrings and popliteal faSCia can also be accomplished III supine

Used to mOnitor lower extremity CIrculation: weak or absent popliteal pulse may indIcate Impaired flow or blockage in femoral artery

Pedal (dorsalis ped,s)

Dorsal, medIal aspect of fool lateral 10 the tendon of the extensor halhcus longus: ankle should be sllghlly dorslflexed some lOdlvldudls have congenitally nonpalpable pedal pulses

Used to monitor Clrculallon to feet weak or absent pulse may be Indlcattve of artenal disease or occlusion

I

---

I

98

Ph)skal Rchahiliuuion

P'ocedure fo' Monitoring Pulse

Temporal

Pl'nphcral Ill/I ..c .. alc Illt'nllorcd hy palpallon U"'IIl!! lhe lir
External CarotlCl--j'--'

Femoral

Measuring Radial Pulse A. Assemble equipmenl.

I. Watch (or wall clock) with a ..econd hand

B. Wash hands (see Box 4.3).

C. Procedure

Popliteal (behInd the knee)

Dorsalis Pedis

Figure 4.12 Common sites for monitoring peripheral pulses. Site selection will be influenced by p:uienl condition and reasons for monitoring pulse.

common peripheral pulse sites, their locations, and some general indications for lheir use. 22.2ol .NJ2 Pulse sites are illustrated in Figure 4.12. The apical (central) pulse is monitored by auscultation (listening), using a stethoscope directly over the apex of the heart or by placing the hand over the chest to feel Lhe pulsations. In infants. the apical pulse can be felt with the fingertips. Apical pulsclI are used when other siles are inaccessible (e.g .. medical or surgical contraindicalions) or difficult 10 locate and palpate and are generally done by au~­ cultation. The apical pulse is lypically u~d to monitor the effects of cardiac medications dClIigned to alter HR and rI1ylhm."

I. Explain procedure and rationale in lenns appropriate to the palient's understanding. 2. Ensure patient llnder~tanding, safety. and comfort. 3_ The patient's wrist should be in a ncutral po~ition rei· ative to ne~ion and extension and lhe forearm ~up­ ported in pronation. If measuring from supine. the forearm can be supported across the patient's chesl or at his or her side with partial fleXion of the elbo\\. From a sitting position. the forearm can re~t :'K"ro:-s lhe patient's thigh. ~upported by a pillow or the Ihr:r· apist's arm. Thi~ rela.~cd positioning of the upper extremity generally facilitates artery palpal1on. 4. Place the lirst three finger~ squarely and firmly O\t'T the radial puJ",e; use only enough pres-.ure to fed Ih~ pulse accurately. If the pressure i~ too great, It \\ill occlude the artery. 5. Once the ~trongest pulsation is located. note thl" f'H.Ntion of the second hand on the walch or clock.. Th( first pulsation ~hould be coullled a" lao to .1\OIJ over~stimating.21 Detennine the rat/' (numl'lt=r l)! pul· sations per minute) by counting the pubc for 30 'l'(":' ontls and multiplying by 2: if any iITegulafJllc\ an" noted. a full 6O-M.~cond count !-.hould hi.; tak.cn to improve accuracy. Note the rhythm (lime lnh..'rval, bel ween puls~ bc'H~) and the q/laJu\' (foKe) 01 Iht' pulse.

6. Wash hands.

Measuring Apical Pulse A. A-.scmble

c4uipm~nt.

I. Walch (or wall

2. Stethoscope

doc,",-)

wilh a ,,~cl)fld Iwml

Chapter 4 Vital Signs

3. Antl ...eptlC

wipes for cleaning earpieces stethoscope before and after usc

and

diaphr~lgm of

B Wa"ih hand... (...ce 80\ -t J). C Procedure I. E\plam the procedure and rationale in lcnm appropnate to the pallent \ under.,tandmg. Indicate there "ill be 3 re4ue~t to remain quiet during monitoring to e~~af) to dean the earplec.:e...: the dli:lphragm ~hould alwi.l)s Ix deaned

.\leasuring Apical-Radial Pulse ~lonJlnrlng the apical radial pube tn\'ol\'es I\\-O CXUl11l1ler... slmu!lan....ou\l) mea\Urlng the pulse al IwO 'lcparatc locatil)1l II) thl: aplt.::al pube ill the apex of the hean: .tnd (2) the H'tJliJl pull.: at the "n'll Tht' \alues from the tlAO dlt· h:rt'nt :\Ite... ;lIe tht:n c.:omp;tred. Typll.. ally. the apH.:al Jnd r;ldlLtl rube \alue... an.: the \aOle. lIov"e\er. III some' ~J1Ui.l­ tlllr e g. \aflatlul1S Il1 \truh \vlume or \J'l<.:ular (x:du 1'>0, hlHuJ pumped lrum the ht.:arl rna) nul be.: readllng the 11\,1i,i! ~llc LaU'llllg il v..-e,I'" 01 Impen.:cpubk mdl.d pul ...e, l--or l.- ample II thl: hean umtral"!'" premi.llurl."ly Ih~ \ enlri clt ha~1,: m ulflucntllfllL' to t-.II rc~uhlllg III a dlllllllbhcd Ih' I." olunll and LTc:all.llg an ImpcrLcpllble pu]..,e In the

99

radial anery.16 On the olher hand. Mroke volume may be normal with a weak or imperceptible radi:.!1 pul~e. suggesting a more penpheral problem such as Impaired flow or blockage Within a ve~.,el. In either ~ituation. there l!
Electronic Heart Rate Monitoring In recent years. considerable advances have been made in the design, features. accuracy. computer iJ1lerface capabilities. and infomlation storage capacity of heart rate monitors (HRMs). In addilion to monitoring HR. some HRMs provide data on HR variability (calculation of the time between pulses). reaJ lime display of percentage of maximum HR. and estimates of maximal oxygen uptake (Va,_mu ).3' HRMs with computer interface capabilities allow data to be downloaded to a computer for analysis and storage using HR software programs. This provides a permanent record and sequential data on exercise perfomlance. Most models allo\\ progranlmjng of a pre~cribed exercise HR range with an audible and visible warning when the HR is outside of the predetermined range. Some models include a talking feature that "speaks" HR information through headphones. Memol) capabilities allo\\ storage of exercise infonnatioll over a variable number of exercbe sessions. HRMs. also referred to as pulse momtors and pulse meters. consist of two basic elements: (1) a o;;ensor that transmits data: and (2) a monitor that incorporates a receiver. microprocessor. and displa).'\J One style of HRM integrates sensors into a che.,t strap that pro\'id~~ ~~ lreles~ transmission of signal'.; to a monitor worn as a "nst\\ atch (Fig. 4.13A). Another ,tyle of HRM replace> tbe chest strap "uh a fingenip sensor directly on a wrist (Fig. -t.I3B) or a "om around-the-neck. monitor (Fig -t.I3Cl. HR data are recorded \\-hen a fingertip 1\ placed In COntat·t with the sensor. Still other HRM\ IIlcorporate a lead \\ ire with a dl~tal sen<;;or housed in an earlobe clip. fingertjp cover. or finger slee\e (Fig. -t.13 D. E. and F), Some HRM~ are equipped \\ Ith more than one [)'~ of ~en ...or Thl~ tealUre allO\~ '\ ~election of a ... en~or appropriate: to the activlly. For e\ample. an earlobe clip or che.. . l \trap \\oulJ be preferable to ,\ tinger ~Ieew for monltonng an aLi" Il~ that JIlvolved upper e\t~mtl) mmemelll HRM'l hme g<11.lled c;\pillldc-d U\C' ill prc'H.:nbeJ c\crri . . e and tfi.\IIHng progr.lm'\ ht·cau ... e the~ prm Ide a practll.."al. accurate method of \,'onlll1u31 pui'le mnmll\nng a'l \~dl ih hel.llg hghmcight. C'omhmable and 1.";1'\) tv u..e 4- In relenl year'l. Illdll} type .. of e\erl.."l\c trill!llng de\ il.:e'l (e.g .. treadmill .... ~tJIJ.:Ilmber .... hlcycl~:\l II1lorporatc IIRM., dlfl?L1ly IIlIn tilt' unit Je.,lgn u~ing a melJI hLind-gnp ~en­ :--ur Jl:\ Il:e

c

I

o

F

E

Figure 4.13 Heart rale monitors. (A) Wrbt monitor .... ith che...' ~Irap tran"miuer worn diredl) on the slin and ~illoned al heart le\el. (Coune'» of Sport.. Beat Inc Deer Park. l\ Y 11729.1 (BI E",ample of \\Inst mOIll{ors with IwO fingertip ~n501"'l abo... e and below LCD: the inde, ,lnd mIddle linger are placed on contact point.. to obtain HR. (Coune,,)' of Spor1, Beat. Inc. Deer ParI... NY I 1729.) (e) Monllor wl1h ned. 'trap and fingertip ~nc;or. (Courte') of Tamla Corpormton of \menIo;3. Arlington Height\;, IL 60005.) (D) TIm HRM Incorporate... a bell-clip t!e'lgn. mcludc.. a um\e"~ll mounting strap allo\\ing altachmcnt to cxcrci"e equIpment. a lead wire ~Illd earlobe clip <,cn"or. (Courte~) of Source Dlstnbulor-;. Inc. Oall;!...,. TX 75229.) (El Wri..t monitor"" llh lead win: and fmgenlp ~nwr. (Coune.. . ) of Marl of Filnc\s. Inc. hre" "bur). :...;J 07702.1 (FI Hcart rJle 1ll0nih)f ",om on dOf\um of hand "lIh fingef ~Iee\c M:n"Of. (Coune,,)' of ~bfk 01 Fllllt.:'>\. Inc. Shrt.·",bllf). NJ 07702.)

Other HR 1 features arc avaIlable and differ with the model and manufaclUrer. Among the more common fcaturc~ are multifunction wri"t monitor... (limc. "top\\atch. alarm clock. lap IImer. and calendar), illuminated anu brge-num. ber LCD display" bOlllc \\ ith a 10011\ fcatlirt.: that uouble... the Size of IIlfoml:11ion Oil the ~recn). bar grJph mem0f) dl,pla)" of prcVIOU" lralllmg -,c\"'IOIl'), and c"tlln.tt~.!> of l\l.lo· rie... bumed .mu cnerg) e),pcnd~u uunng exerci ..c. IlRM, can mtert
Tdemerry i... the ...Llenee of n:l11ol..: Oll';},urCl11CIll IhJI lIl<.:lude... bolh galht'fll1g d~l1J. frolll a UI"I;UlI 'OUfl"t..' .\IlL! tr.ul'· mllllnoo the data c1eetronil:all\. Tl'ICl11ctnl.: HR\h an: 11\)1 Ill''''' ,1I1U ha..c be~n .lhulJhk "'I1I.:1' It/Xl SUll.:C Ih,llllllll', (,.,)(1til1u~u re~l' ..tf(:h hJ\ leu 10 !!.rcah:r ,mJ more .tlh,1I11.:cd ,tPI'II· Cell/I III \/f/lllt" III~ \\\/(nI lhat lll\ohc... h;I.... llIg Ihc pdtl..:nl 1,:0l1tlllU.III:-- \v('ar ,I 'lIl,tll lran...mltlcr IllJI L1l'1l\cr" \ \lal "'l1m'" U,tI.1 h) ;l lcnlr;ll 1,11;,111\)\1 \\ here mulllplt: r.UICl1h l";01 tx- 11l0I1lhlf\.·J "'ll1lu!tjl1\'ou .. h

-

.

Chapter 4 Vital ~iKn~

A

101

B

Figure 4.14 (A) Schematic depictIon of 'Wirele...s transnm"ion of data from ~rist monitor to computer \Ia IOfrarc:d ...ignal,. (Councs) of Polar Electro. Inc. Like Succe ....... NY IIO..n.) (8) Hean rate mOllllOr in (omputer Interface unit. (Coune... y of Spans Beal. Inc. Deer Park. NY 11729.)

Gand..,af" el al applIed telemetric technology to examine the efficacy ot u'ling a low-em.t approach to transmitting \'ital "ignf" data trom an aircraft to a ground medical facilJl). Enactmg an m-tlJght "'IlTIulated medical emergency. \'ital "'Ign data ",ere collected v. ith a mOllltoring device and tran\ml1led uf"mg a lap lOp computer. an airline ..,eat-back telephone. Jnd the Intemet. All d.lla \~ere received" ithout corruption" lIh a maximum delay of I second. The author'l \ugge\t that dUring an nuual m-tlight emergenC). pallent data could potentlally be dell\ercd 10 an assigned medIcal facility. a.., v. ell a\ to the ph)'lictan'~ de~ktop computer an) where III the v. orld irrc'lpecll\'c of the geographical kK.Jllon 01 the .urcraft. ~ Another area 01 re~can..h lIl\ol\'c ... de\eloping uniform tdlldJrd\ of commUllIcallon tor tmfl'lrm .... illn of tlata from \ ttal ..,tgn... monitoring equipment dlredl) to dmlLal lIlfOm1o.IIIOn ~) ..,tem'l currentl> 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\<111011' III 11l{~t c\ol e \c/) rJJlIJI) 1l.lla ph:: L·nll.:d lu/.I gl\l;lIl1WIlJtOrlilg JO:\lll .tl d !XUlIL pOInt til tlllll" L<.U1l1ul h..: j!t:lla.IIIlL'J Itl IHur r~lt::111 mudd j1fOJulni h) tilt ,.unl" IIlJnUlaLIUtl.:r

Related Measures Doppler Ultrasound Doppler u!tra<.;ound (DUS) is a noninvJsi\e in\trument u~cd to examine pulse~ thai are c'\tremel) weak or faint. obillcrated by even ... Iight pre~ ... urt:. or "hen arterial flow i'l 'leverely cOll1pronll~ed. DUS l'l ba'ied on the princIple that high-frequency uhra~ound v..aves directed Jt a movIng Interface (I.e .. blood flowing through a \"e:>~el) "Ill C~lU':Ie a change III the \,-aVe frequenc)' rellecttve of the\'elont) uf the mo\'ing tntcrface (called the Doppler £'./!"ertl. In e~':Ience. [he DUS mea"'ure~ ho\\ ~ountl \~ a... e-, are reflected off mO\'lng blood eel", The re:>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
p"!lce mlcrO\\<J\e tr
audible '(lllnd rerrc"cnt<., the dllkrclll:C'

111

Irequt'nq

bellAcen the W;,lye, dm::l:tcd at the \'(',,,('1 and Ihn,c

retlclted haL .... h, motIon oj bh)(xJ celk the frequent') " proportIonal to \e1o(ll~ 01 the mOVIng red hhxxl eelI-.. The ah,cncC' [If an aUlhble S(lund 1I1dH.:atc" no dctC'l.tJOn of mO\'emcTll and .... uO"cqucntl). no pertu'lon, ll"'1I1g il lompUler Inlerface. lhe no,\< nlca"ure ... Lan be graphically di... ~ played and ... lOred It .,hould be noted that \\ hde the <'J>Cclfic eharacten... ucs of the refler..:led ,ollilds are not diagno"'llc. they can 3"... i'l m identifying abnormal t1ow.~".N

the

PuJse Oximelr) Pulse oximetry providell a measure of arterial blood oxygenation th:1I IS updated wllh each pul"le \\a\'c.~HOxygen I... carried m the blood m IWO fonns: (I) dissolved III arlenal pla~ma; and (2) comblllcd with hemoglobm. 1'i Arterial plasma transports only about 3 percent of the o:\ygen in blood and I~ measured as PaO:! (panial pressure of oxy~ gen).The greater amount of oxygen (- 97e:t:) is carried by hemoglobin and measured a!l SijO:! (arterial hcmoglobin oxygen salUration). Pulse oximetry mea... ures arterial blood oxygen saturalion a~ a noninva!>iye inlervenllon. O\ygen salUration via pulse oximctry is reported a~ SpO/I-~' and can be measured at any adequately perfused peripheral

pulse. Nonnal o>.ygen saturation leveb are between 96 percent and 100 percent. In general, saturation levels below 90 percent are considered significant and warrant additional testing beyond the data provided by pulse oximetr) (e.g.. anerial blood gas analysis). as well as mark the potential

A

Ill'cd for ..ulnlll1l"-trallO!l oj 'llppll'ment.t1 o\ygen 11\/,(1\( r1/UI I'" a term 1I 'd til de lnbc def1\.Il'flt lJ Yd-cna· tum (11th\; hlnod Ih/1(11/o I"" dlm1l11 hed <'upply nl 0 \ 1!cn J\ilJldhk tll hody II ... tll· ..... md iii/OWl" thl l.lImpll.'tt· H.: .... of o'\)gcn. it lonuillofl th.11 ',1Il ho'" '-u IJllk'{! for unh i.l \ CIl bncf penod AlleratlOn... In ht~i1rt funUton fl:.!! i.lrrhjlhrnl.h decn.::a"lcd HR I t) pll'all! rl'dm.:c l.trdli.ll output tnt! t <.llTIOllnl 01 (l'l()!!cn <..k'iherct.l 10 11"ue,_ F \ample (II olh('r condition... th.lt l111pJct oxygcn "laluratton k\ch lI1duJ~ unpaired ahlill) of Ihe lung' to 0\) genillc blond anemia (redul.'lIon In hcmoglohlll l11oJer..·UIt:::... avallahle 10 cam ()'I(ygcn). h y povcntllatlO11 (c.g .. brOIll:hltl<". emphy,crnal. and dlffu'loll Impi.Umlent... thai lnlpaU hl(x:xl-ga ... e,(,;hJn~t.: (e.g.. alveolar fibro~l". IIlter...litlJI Iluidl."l The pube OXllneter proVides data on the percent of m.)gen that I'" r..:ombmed \\Jth hcmoglohin ISpOJ The del> tronlC umt" are rel.Hively ...mall (Fig. -t 1.)..-\ Jlld 81. CJ\) In u~e and (Ti1n.,port. and providt: the therapl ... 1 \\ Ith lmmedl
I..

B

Figure 4.15 Pul~ 0'(UI1C(Cr... pro\>lde d,Jl,J on .tfh.'nal hlood o'\)gl.'n ...alur..llnn .. , \\.:11 ..." puhc raPut~. \A)BSlandardl puhc o'(unt"11) Untl fBI Pon..thlt· handhdd pul"c ()'I(llll('l~r (('nurlC...) 01 "l'Ilt'lr ntan em~tl, Ill, Plea",llllon. CA Q45S8.,

B

A

Figure 4.16 Irdll,,'l'lantl~1

O'\lmt'l~ ...en,m, I. \) The tlngcnlp llran,ml')'lon) ...ensor and (BI forehead ..en'(\f (Cnune... ~ III 'c1kor Puntall Bennell. Inc.. Plea,anton. CA 9-J588.)

The fJllO of the ,1I11ounl ot e;lch Ilghl ab~orbed dUring sy~­ lole anJ dlJ'lole allov. ... quanlltlci.tlion of an oxygen . . nlUTa· IIOIl

mea... uremcnl

(SpO~),~"~~

Perhap.. the mo<,,\ importall1 u,e of puhe oximetry in patll'llI management i... thai H a"'~l . . h with (1) early idcllli· liCdlJOll oj h)po\emia: (2) l1lolllloring patienllOlerJllCe to aCli\lt~. and (31 e\aluJling pallenl re"pon:-.e to treatment.

light sources

Monitoring Respiration

vascular bed I

photodetector

===~'::"':-1 Sp02 - - -....~197%

FIgure 4.17 (1I1....H.t;lll')J\al iJriJ~ lilt! 01 " tlngallp m.llllell) I, (diu ltalllle the dualllcht SOUl ... ..:.... pholndo.:lnlor II ,.IIL l

OIH::dll,n I

Pulse oximetry measures may be done continuously, intermittently 10 generate a series of values over lime, or as a single measure at a given poinl in time (e,g., as an initial screening tool or for low-risk patienls), The measuremenl pattel11 will be delcI111jned within the context of the patient history and examination findings. Telemetry oximetry monitonng allows continuous communication of SpO~ data from remOle localion~:B ..

II lI11l'kr ..lIld h) rOIlI~lllal U\}!!~11 '..IIU

(I ,llllca urcmcnl tlUlPUI lilt In the flll.!!l'mp Ilran,ml' Ion) lht' light ~IUlll: 0:11"" pc'~lIlnncd uppO"Ih.: Ihe pholtkk'ICl ror III 1" l"rt'hl;Jd Htll~lt.lIll I Ii or _thl· IIl!hl 'l)Olle, .tIIl! ptlOludel 1<)1 are II(I~1I1011 J un lin" ~Ilk III 111.:-...~n"Hr I Court.:" Jt -III l~urll.J.n H 1lI1l:" In\,. 1'll.I,lnlon C'.\ I}-aj~h I .

The primary funclton of respiralion (movement of air LIllo and OUI of Ihe lung,,) is to ~upply Ihe body \\ Ith oxygen for metabolic aCli\ It) and 10 remove carbon dio.xide, The respirawr} syslem consists of a 'ieries ot bntnching tubes and bring,> allllO'ipheric o.xygen into conl.tCI \\ illl the ga~ e;\change membrane of the lungs ill the ahcoli. Oxygen l~ then tran'poned throughout the body via Ihe cardiova~cu· Jar S),t~l11. E\fernlll re~plrLJ{i(lfJ is the e\change of oxygen and carbon thO.Xldc between the al\eoli of the lungs and tht: blood. Jmenwl ,.OpiroflOll j" Ihe exchange of O,\.ygl~n and carhon thoxidc hc{\veell Ihe l·lrl.'ulalmg blood and bod) ti"'''Ul'''

The Respiratory System The enure p,Uh\\,;l) th;lt lralhports air lrom the en\ lfonmenl (',{elld, tromlhc moulh Jnd nO'>l' do\\ n to Ihe- alveolar sal''' Figure -l I ~ dhl\lmh~"" an o\cn le\\ 01 the reSplratof)

Conchae

----=====~~;3~i1~\

EPI9IOtl~S~~~~::::=====~=~~~~tJ:~~======~

Glottis Larynx. Vocal cords

Pharynx Esophagus

Trachea --------~<:::----~=2

Pulmonary artefles ..:..-

I-

~~~~

Pulmonary veins --:..---l-----\_..Jl.~,_

Alveoli

-1-

~

s)stcm. The upper respiratory airways include the Ilo~e. mouth. pharynx. and larynx. Air enter.! the body by wa}" of the no:-.e and mouth and IS then moved to lhe pharynx. where it is wamled. filtered. and humidified. The pharynx serves as a common pathway for both air and food. Inspired air IS then moved 10 the larynx, which conlains the epiglottis. vocal cord .... and cartilaginou\ structures. The analOmicaJ arrangemem of the larynx and phar) ngeal muscles provides the critical function of protecting the lungs from entry of foreign panicle~. a~ well as assi~t~ v. ilh phonation (production of \ocal sound~) and coughing. which IS the primary physiological mechanism for clearing the airways. The laryllgopharynx i~ lhe area where solid and liquid food inta~e is separated from inspired air. II is also the site of bifurcation imo lhe larynx and esophagus. The pharyngeal muscles close the glotli~ during :-.wallowing lO protect the lungs from a"viration. If a foreign body pa'iSCs the glollis and enters the tracheobronchial tree. the cough reflex IS inllialed to c1c~lr the air passage. Immediately below the thyroid cartilage of the lar)nx ("Adam':) apple", I:) the site for emergenc) opening to the tr~lchcal air patlwiay.l-l ~'.'(Ln The trachea is approxlnlatcly 4 10 5 inches (II 10 13 crn) long and conlinue~ from the ca.nllaglllou"l "LnIcturcl, of the nec~ InIO the thorax. At the I~\d of the carina (Fig. 4.19), Ihe trach~a divides Illto two main:-.tcm bronchi. The canna cOlltains lhe majont) of cough recepton. and i.. located appro,"natcly bel 'Ween the sternum and manubTlum :11 the ~ccond illlercoMal ~p;;lce. Tht' Tight and left malll\lem bronchI arc as) mmetTlcal III ""LC and \hape and continue IIltl) the lov.er re'pli.uory tract IUrlher ~ubd,. \ ,ding II1to lhe re"pmuory hronchiole, where ga~ c,change

Figure 4.18 The rc'plral0'1 palhv.a),_ (From Gu)-ton. AC and Hall. JE.I.l r \11. \\ IIh pemu""l()ll.

begim. However. gas exchange primarily occur... m lhe alveolar duelS and the large 'iurface area pro\ ideeJ b) the alveolI. The bronchioles. alveolar dUCb. and ah·eoh (ah-eolar :-.acs) comprise the functional zone" of the respirato~ Hyoid bone

1\ ~~-

EplgJo",s

ThyrOid

ThyrOid

cartilage

cartilage

VJL-- Cncold cartilage Trachea ---1:~:J

Malnstem bronchus

Incomplete cartllagenous cartJlage Postenor wall

Lobar bronchI

Segmental bronctll

Figure 419 Struclurc of c.trtIlJj;lIlour" .aINJ.) '. II1duJIll~ Ihl' IrJchc;1 and major bronchI. thom HenJt'l'\on. BS.' r '\\Ilh pcrnu~r"lo1\.)

Chaph.'r" "ital ~jgl)"

J05

LO rc(,oll OCl:Uf'o bcl:~tul"e ollhl' mllerelll ela"ttic propenle 01 the lunt.'..... omlal e'plratlon la"b :2 to 3 \econd .


CONDUCTIVE ZONE

Regulatory Mechanisms Primary bronchus

Alveolar duel

sac RESPIRATORY ZONE

Figure 4.20 SI..!lt.:m<.lllc 1l1u'>lra1l1l11 01 tilt: functlOn;ll /Ollt>.. . 01 thl' fl' rlrato~ Iral t Tht: lOp area trum 11ll' tr3Lhea 10 the It::nninal oronl,.·hio!e, j.. l:
Ifan... plIn If;undu\,.1) anhaled air tn Jno IfIlllllhl re'pir.tlm:- lone. The: i'lt'ttum ared III the lllu'>tratil'n fern.: en'" tht' .lfe.h \\ here .Hr c\Lh.tn~e lal...e pl.K.o.: nlo..' .m t:\.Lh..t.ll~C' IX·lU..... In rm~n.::'.. I"d) 1Il... n.:
loc

"re

ptfJ\fIr)

Il'n". II-film Ht:nde

trall 1m
tln,

(hg 4.201.

RS.

.....illl I'k"mll..... lon.I

Th~ alrv. it) ..

do nOI COI1trihul~ 10 air C\dlang(' Clnd I.:ompn!-.(' tht: analUminll dead ...p'H.'e

Inspiration

r Ir

In

1I1itl. led h~

1)1 tht" dl.tphr.wm and , the dl.lphr~gJll ll101\l,;~ Jm\lH\.ud ,md Iht" mh:ruhl.tl !1ft til fin ;lnu It mum up and lluI\\.Jld Till: thur.II.:U: 1:.\\ lt~ t lhu JnClc.t"l.·d III lIt '-Iud ~lht\\ . . Jl1r lung ~\p.IJl"IOl1 Int

... (

1011 I

tal II1U

k

ullllr.H.:lltln

[)ufln~ 1.1InlJ.tdllm 1.)1 the '-' mu ..dl.'

Regulation of re",plraIOr) funclion mvolves mulliplc componenl'.> 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\plr are ..en .. UI\e onl) 10 PaG... le\"eb in pla ..ma and not 10 the tmal o\)gen III blood.tl'lhRe"'plration .tI.. o I .... IIlflucll('ed by il proleClt\c ..trell.'h mel:hafll\Jll c.tlled the Haillt:-BreufT refle,\. Plilmon.lf) ..tretch receptor, Ihroughout the \~ all.. of the lungs detccl the amount of :\lreLch Imro..ed b) enlering ~1If~'j \Vhen o\er"ln:lched. tht: ... e rcceptor~ ... clltl lI11pllbes 10 th~ rc ... plralOr~ ernler to 11l111hll IUl1her ll1"'plratlOll and lIKrea..c the dur.lli(ln of expirJlion, Implll,-t'....top ,It lhe end 01 e\ptr..Itlon ..0 lhal
l'llIlalllhpil;J\lulI 1<.1"1-. I 10 I " ..eullld ...

Factors InOuencing Respiration

Expiration [hJlln e rl j"

pJ

"1\1;:

f.l

r

t:

tUTU

0111.. t

II

fl'"

l:

l:1lI1.t1I~"

pa") tilt rl.:",plr.tltll ~ IfIU I. Ie .. TI.I.I' thl. thu till po lUll/I. ,lilt! the Iun:;? Tn IlL 1111

d hI >ttillng" 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". <",Ialure, excn':l\c. and body pO"'ltHlI1. ~'\ge

The RR of a ne".bom I'" bet\\een ~5 and 50 breath.. per mmute. The ratc gradually "low" until adulthood. \\ hen It range~ bet\\cen J:! and ~O hreatho;; per mmute. In elderly mdl\ Idual... the RR increa..e" O\\lI1g to decreased e1asIlCIt) ot the lung... and decreas.ed effiCIency of gas exchange. Other facwr\ a\...ocI3ted \\ nh nomlal ageing that Impact resplrJtory lunctlOn lI1c1ude weakening of respiratory muo;;e1e.... detenoration of alveolar \\aIl5. decreased thoracic J11obillfy. and del~rea\ed lung volumes. flI

Body Size and Stature Men genera II) ha\·e a larger vital capacity than women. adults larger than adolescenls and children. Tall. thin indi\'iduab generally have a larger vital capacity than stout or obese IIldivlduals. \Vith larger lung capacity there is also a lo\\er RR.

Exercise RR and depth will increa~e with exercise as a result of increased oxygen demand and carbon dioxide produclion.

Body Position The recumbet1l position can significaJ1lly affect respiration and predio;;pose the patient to stasis of fluids. Among the innuential factors that limil nomlal lung expansion when lying down are compression of the chest against the !'upporting surface ~Ind pressure from abdominaJ organs against the diaphragm. Both of these factors cause increased resistance 10 bremhing. Difficull recumbent breathing is common during the late stages of pregnancy as the fetus shift~ the diaphragm upward. 1J as \\ell as in pauents With congestive hean failure (CHF).

En\'ironlnent Exposure to pol!utallls such as ga!' and particle emission'). asbeSIOS. chell1lcal waste products, or coal dust can dimin. ish the ability 10 lrano;;pon o~}gen. Olher common offending pollutanh mdude high ozone concentrations, sulfur dioxide, and ("arbon mono\idc.l produclion. High altitudes abo Imp~lcl the reo;;plr~i1ory ,y"tem ow ing to reduced air mass (I.e.. Ihe panlal prc'sure of o.\}gen In in,-"plred air IS low). TIli... mean, Ihere I" Ic,,, o\)gen molecules per iller 01 air. cau')lIlg a reducllon In ~trlcrial blood oxygen levels. Thl' typlcall) rc,ulh 111 "hOrine,,, of brealh and reduced toler. ance to acu\'llY· Ilypcrventllation. tachycardia. and pul. mon
... olotlon, "tfe"", Sln.~"... a ... ,.. ell J" em(llion.. Cdn ft.: "lJII

In ,Ill lI1ut,:;hcd rak depth 01 re"'plratlon, 0\-\ IIlg til ...1l1l1UI.lllflll /lIthe \om. pathellt: Ilcn:nu... 'y"te1l1

,lOd

Phannacological \gent, Es\enuall) any drug that depre" e" ct:ntcd n·.'r\()U }ste:m (CNS) lunclJon will re"iult III re"plf;Jl0f) rkpre Inn. arLOtll agent... lc.g.. l1lorphme. mependml' h}drochlon1le ![kml'rfllj \\ III decrease the rate and depth of re"plralJon Other calt: gonc'i of CNS depre....,ant agents in<.:lude h.lrhnllfJIt> le,2. phenobarhllol INembutaJJ. '\Ccobarhll~tJ IS~conJIj I. hen71K!1. azeplOes (e.g.. AtI\'an. DlaJepam). neumlepllt·, 'e.g Thorazine. halopcndol. clozapmcI opiate". mu'cle rel.I'(am . tncychc antidepres"iams. and antll"onvuhant.... Comt'f"eh. bronchodllators decre3~ 31f\\.ay re"I.,lance and re\ldual \oiume wuh a resultant increa~ III \Ital capac It) and JJrtloy. Common bronchodilator medicallons II1clude Albuterol (VemoJin. Proventil), melaprotereno! (Alupenll. Icrbutahne (Brethine, Brethaire) and buolterol (TomaJate).1\J

Parameters of Respiration In examining respiration. four parameter, are con'ldered: rate, deprh. rhythm, and sOll.nd. The rate i, the number of breaths per minute. Eilher in~pirat1on.'l or explrallon.. are counted, but not both. The normal adult RR " 12 to 20 per

minute. The rate should be counted for 30 .'lecond'l and multiplied by 2. If any irregularities are noted. a full 6()second count is indicated. The depth of respiration refers to the amount (\OlllIllC) 01 air exchanged with each breath. Nommlly, the depth of re,· piratiol1s is consistent. producing a relatively e\en. umfonn movement of [he che,l. The nonnal adult Iidal volume h approximalely SOO mL of air. The depth of re"'plratlon I~ detennined by obsef\'alion of che..t mo\-eme11l... and I" u"ually dc:scribed as deep or sl/(/I/ol\'. depcndtng on \\-hether ,he amount of air exchanged is greater or Ic.'l!o. than nomlJI Wilh deep breaths. a large \olume of air i~ e\changed; \~ lIh "hallow resplrationo;;, a small amou11l of air i, e\t.:han!.!ed. t)plcaJly with minuTIaJ lung expan"ion or che...t \\all n;o\.t~lllell[ The rhythm refer" to the regulanty of lI1",plr..ltlOn" JnJ explrallOn.'l. omlally. Ihere I~ an ~\cn 1l1ll~ Illlcf\JI belween respiration,. The re~plrator) rh) Ihm I'" de"l"TI~>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<; \\ Ilh CI-IF.

Slridor

I'

J

NORMAL

.07

Si~h

i.. a deep ml.,plratlon lollowcd by 3 prolonged. audible C\pirallOn 0<.:c3')lOn31 ... ighl., arc nonnal and function to cxpand alveoli: frequcnl :-'Igh... are abnonnal and rna) he IIldicative of emotional stre'i~. Stertor is a snoring I.,ound 0\\ ing 10 p;'lrtial ob"lruclion (e.g .. <;ecrctlons) in the upper airway fe.g .. trachea. large bronchi 1_

Patterns of Respiration Examlilalion of the rate. rh}!hm. and depth allows the therapist to detemline the pattern of respiration. NOI all patients will pl"e~enl with a distinct pattern of rc..;piralion. However, ...c\craJ pattern... occur with .!tufficienl frequency that unifonn tenninolog) hal, developed methods for their identitication. Common respir.ltory patterns are presented in Figure -t.21.

RAPID SHALLOW BREATHING (Tachypnea)

RAPID DEEP BREATHING (Hyperpnea. Hyperventilation)

SLOW BREATHING (Bradypnea)

Rapid shallow breathtng has a number of causes, Including restrictive lung disease. pleuritiC chest pain. and an elevated diaphragm.

Rapid deep breathing also has a number of causes, including exercise, anxiety, and metabolic aCidosis. In the comatose patient, InfarC!lon, hYPOXia. or hypoglycemia affecting the midbrain or pons should be conSidered. Kussmaul breathmg IS deep breathing associated With metabolic aCidosIS. It may be fast. normal In rate, or slow.

Slow breathing may be secondary to such causes as diabetic coma. druginduced respiratory depression, and increased intracranial pressure.

Volume 0' a'

The respiratory rate IS about 12-20 per mm in normal adults and up to 50 per min m Infants

CHEYNE·STOKES BREATHING

Hyperpnea

ATAXIC BREATHING (Biol's Breathmg)

SIGHING RESPIRATION

~ Air ltapplng

Apnea

Resplrallon waxes and wanes cyclically so thai periods of deep breathIng alternate wIth periods of apnea lno breathIng) Children and agIng people normally may ShOw In S pottE::rn In sleep Other cau::oe-s> 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

<.Ibnurm.ll re ..pll,HOf) p<.llll:rII". Wht:IlI.'\JIIIllling rl' ..piralul;' p,lllt'flh. l·OI1 .. ldc-r

L.1I' dl)lllrll. ;J..lIJ dCPlh lit Ihl' palll'llI!1i hrl'dlhlll:! rk"C1i~ \\.h.111 ,~~n In the")c h,'ml", 'Ole Ihall,x>l,)\\ "ach Je"'nplor f 1'llumlJl hh:.1lhlfli!: p..tlh.rH <.Irc 1I1Uh: If.JJlllnlldl knm 'Udl,l") I.Jdl~pnl·.1. h) (XrpnC:J. Jnl! h)lXl"\enlllJ.t1on.1t I... lITlr< IIUll

ant l under (<.Iud ",h..tl Ih~ e If<.lI.!IIl\IIl<.llt<:flll m ....,J.ll tllm . . \o,;r. lor purpthe.. of J("I..;um~mJllon. "Impler de....·nl).. h..t ·r..tI'IJ li..ttl\lW br .;tUUJlC ,..th."'l:l\.lIlnh:nJ..:J \ -.\.J.lPh:J hl'lll 8,111: .. , H P ~ "Jth ~mlh... lon.)

Eupnea I~ Ih(' I eI'm lhet.! In de,('nhc ;, nnm).,1 hrcalhln,l! p ... ttcm 01 L! to.:!() time' pt.:r ITIIIlUh 111.111 .tdult ,"ee TJhl1.' -I I fN age nppropn.ue \Ur1alllm'" I-I ~ pl'nf!ntiialiull '''' ,111 ablH'mlallj ra"t rate .lI1d depth 01 re"pll'iHHl1l l'tll~n it~"n(1 ilted \\!th In\IC 1~ . Cnltlllon ,1 1 "'In:.·'~. ,Ind r'\llll.. lh,nrdt..'r'''i, \ C01l1mon re"(l0l1sc to all ,l(ulc l'p'''llde '''' In hit\,\, the pJtll'n! rchre~lIhL' I11tO a raper hag. \\ hll'h rc pL.h:C" ,omt..' p i thl' lil\! carbon Jio\idc (flY/lol'{//llIIa). Prolpogeu h~ pen entil,,! Inn 1l1JY be cuu\ed h} eNS or pulnH'Inal~ dhorJer\. 1-I."pO\CnliIO:ltion Ii- a reduction In th c r~lt\:' and depth nfrespiratlon\. Tim, decrei.l!-l' in the ~tl11nu nt 01 air enh.;f111g th e lunge; CI USC\ an Increase 111 aneri::tl carbon L1io\ lde level\, Difficult or lah{)/'ed brea th ing is caJ lcd dY,\I'II(''' , Patient!'> \\ ith dy\pnea reqUIre II1crea ~e d . Ilmiceab lt! elfort to breathe. and Orl1! Jl 3ppe~1I as if Mru gg llng to ge t ,Hr illlo the IUl1g~ . In an t.!ffort tn mcrease e ffecllve n es~ o f re~ pira­ tjon , accessory muscle\ "'Udl a~ the interco!'tal s and abdomill31s arc oflen HCt.i\C . The inl erco"tab as:-.i··;t in raising the nb:-. to expand the Iho radc cavity; the abdom inal s as ... i~ t function of the diaphragm. Additional 111u"cle:-. that mn} provide accessory runcti ons in rc.\piration are the sternocleidomastoid. pectonll b major and minor. sc al e n e~. and the subclav ius. Use or acces\ory mu ~c l es to breathe i'i referred to as cos t ~ll or thoracic breathing, Dyspnea is sometimes accompanied by pain and nasal naring ( 10 bring in Illore oxygen). Acute episodes may be brought on by blockage of an air passage. illfecti on of Ihe rc!)pirmory tract. or trauma to the thorax. Lon g-standing dyspnea i ~ a hallmark of the chronic obsTructive pulmonary di seases (COPD) such as 3sthma Or bronchiti s. 111erapi s{s often ins truct patients with CO PO in a breathin g technique called pursed-lip breathing to help preve nt small airway collapse, Air is inhaled slowly through the no~e and s lowly exhaled through pursed lips. Orthopnea is difficult or labored brea thing (dyspnea) when the patient is lying down that is relieved by moving to a si tting or slanding posi tion . The change in positioning causes gravity to lower abdominal org3 ns, a ll ow in g increased room for c heM expansion. Orthopnea is a characteristic symptom of Iwan fai lure and also may be seen wi th asthma. advan ced emphysema. and pulmonary edema. Tachypn ea is an abnormall y fast RR . usuaJl y greater that 24 breaths per minu te. Thi s pattem is see n wit h respiratory insufficiency and fever as the body attempts to rid itself of excess heat. During fever, RR may increase a~ much as 4 per minu te with each I F (0.6 C) illcrea::,e in temperat ure.:!l Bra dypnea is an abnomully s low RR . U:jl1 all y 10 breath!) or fewer per minutc . Bradypnea is as~oc l ­ aled wi th impairment or the respimtory control cen ter a ~ may occur with jncrea~ed inlr.lcraOial prcssure (tllI110r). d ru g intake (narcotics) or metabo lic dl!:>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 pul<"e ~ lI e anti place the paltt'lll'\ tim) JCro\IO, Ih~ dlC\1. Thi \ \\ ;11 all O\\ limlled palpation v.ll hout drawmg COIl \C,: IOU \ in put from the pati ent. Chapter I) provide~ a mo re thorough disLu\\ion of the re\p lrator} examimulOn.

Procedure for Monitoring Respiration A. A..:;semb le equipment I. \Vatch (or \\1.1. 11 c lock) \\.i th a ,econd hand

B. Wa, h hand , (see Box -l.3)

C. Procedure EIl~ure palient safety and comfort. R e~ piration ~ are typicall y monitored with the patient e ither supine or si ttin g. NOfl.': The patient should be in a quiet re~ting posil1on for a t leas t 5 minutes prior to monitoring res piratJons. 2. Expose che::,1 area: if area can nO! be e'(posed and re!l" pirmiol1!::< are nOi read il y ob.\ervable, plnce patient 'S ann acros~ chest and k(:ep finge r~ positioned a\ if continuin g to monitor the r3d ial pu lse. 3. A s the patient breathes. ob~erve the ri:-;e and fall of the chest: note the amount of effort required or audl' ble ~o ullds produced during breathing (nomlall ),. re~· piration is effortl e!)s and ~ il e nt) . -L Us ing the "el'ond hand o f a watch or clock. dt:temune the rate by counting re!)pirations (e ither i l1spirallon~ or ex pirmiol1s. but not both ) for 30 seconds and ITIultl,

1.

ply b) 2. S. Id e ntify the rh ythm (regularit) of inspir:.J tion.'t and

expirations); nOte devi"[lon~ from nom1,,1 Ullintt:r· fupted . even spacing. if any irregul aritic\ are !lOIrd. COllnt for a full 60 'cconds to 3ccolTImod:.JH" the nu~· tuation ~ and ~ n ~ lIre an accurate count. 6. Ob!:>ervc the depth or respiration; de termine if;1. . 1ll all. large. or ~tp proxi1l1ate l y 110mlal volume of jir I~ in ~pircd. Ob~ervt" involve ment or (lcl:e ... "ory Illu"ck, which ~ uggt!~ t s \'veakness in th e primru)1 1llu:::ck~ (l! breathing (d iaphr3gm and external intt:fco.. taJ O1U'· cles): if diffi cult to o h:-.erve, palpation of rhe..,t ~jJl excursion ca n be used to identify dt.!pth of re~pir~ttiOi1 Reco rd a" ~ hallo\\. de\! p, or nonnaL Note: C hes t wa ll c"'l.:u r~ion ca n al,o he detenltint!J ~\ circu mferelllial cheM measures u ... illl! a tap-: m-:a!!Ur\'

-

Chapter 4 Vital Signs at specific bony landmarks. Three cOl11mon landmarb. for circumferential che~l measures are: (1) the ~ternal

angle of Luis: 0) the xiphoid process: and (3)

midw
Monitoring Arterial Blood Pressure Blood pressure (BPJ refers to the force the blood exerts again'" J \'c.., . . el \\-all. It is measured in J11illimeter~ of merCU~ tmm Hg) and recorded in the form of a fraction (e.g..

119n9). The lOp number indiclon and recoil in respon~e to the changing \olumc of circulating blood during the cardiac cycle. The mathemallcal dllfcrencc between the ...ystolic and diastolic pre.,\ure,> i... called the pulse pressure. For exampk. a systolic prt'",,>ure of 119 mm Hg and:.l dia.. . tolJc pre<"sure of 79 mm Hg rewlt 111 a pul,>e 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 <.lnd cardi3c output (CO, and peripheral rt'~I~IJ.lllt' (R I J'I expres\ed III the e4uatJOn: BP = CO X R. Additional lactors that contribute to thi!'. relatloll'>hip lJll'lude tht' diameter and eht>:>tit'lly ul ve~<.,eI \\3Ib. blood \ulurnt: ~tnd blood \ ISl:O,>1I}.2 1,

109

rial pressure required to maintain blood flow to body tissue and organs. This occurs because of its close connection to the cardiac controlling center in the medulla (because change~ in cardiac output will influence BP). In addition, the vasomotor and cardiac controlling centers require input from afferent receptors. Afferent input regarding BP is provided primarily by IJarorecep/ors and chemoreceptors. The baroreceptors (prcssoreceptors) are stimulated by stretch of the vessel wall from alterations in pressure. These receptors have a high concentration in the walls of the internal carotid arteries above the carotid bifurcation and in the walls of the arch of the aorta. Baroreceptors located in the carotid sinuses of the carotid arteries monitor BP to the brain. Baroreceptors in Ihe aor/ic sill uses of the aortic arch are responsible for monitoring BP throughout the body. In response 10 an increase in BP. the baroreceptor input to the vasomotor center results in an inhibition of the vasoconstriclor center of the medulla and excitation of the vagal cenler. l .! This resuhs in a decreased HR. decreased force of cardiac contraction. and vasodilation, with a subsequent drop in BP. The baroreceptor input during a lowering of BP would produce the opposite effects. The chemoreceptors are stimulated by reduced arterial oxygen concentrations. increases in carbon dioxide tension. and increased hydrogen ion concentrations. These receptors I ie close 10 the baroreceptors. Those located in the carotid artery are called caro/id bodies. and on the aortic arch they are tenned aOrTic hodies. Impulses from these receptors travel 10 the brain (cardioregulator)' and vasomotor centers) via afferent pathways in the vagus and glossopharyngeal nerves. Efferent impulses from these centers. in response to alterations in Br. will alter HR. srrength of ~ardiac contractions. and size of blood vessels. 16 .65

Factors Influencing Blood Pressure Many factors influence pressurt". As \~ ith alJ vital signs, repr~<"ented by a range of nomlal values and will yield the most u..eful data \.~ hen monitored mer a period 01 lime. Several Import,Ult factor!'. tllat should he considered when e.\amining BP include blood \olume, diameter and ela"licity ot' .Irteri~s. cardiac OurpuL age. exercise. and arm Po'>ltlon.

BP i:o,

Blood Volume Blood Pressure Regulation The \~O('fIIf//()r I nlfl'/" J.... 10000~lted bl1:ttt:r.dly III Iht' 100\t'r pOIJ~ c", through ~lJlp.t1hdll lIer\'t' ... tll ;tll \t'<.,,>e1,> 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<.,ocofl',lnllOI Ilt'nt' Ilber~ It .':> 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~<'<'lIr~ III drop, and C,1n re..,lIlt III h) pO\'olemic shOt~k 11'0111 inadequall' tl~"ue perlu"lOrJ. Comer!C tht" pre",,>ure 10 I i.. c. RcJuce:d tluid \olume, a..o;; mil) Ott'UI \\-lIh dJJrrht:a or Inade'1uate unlJ IIllake (ddl)drallillll. wdl aho IO\H'r BP; exce~::. l1uld. a.. occurs \\ ith coogl'~ll\l' he.lrt I,ulure, IAlll lIh.~rca'>t: pres::.ur~ ..:!.j E~sel1tially. JllY \lluatlo[J (,.'i.lu.\lIlg ..t "lUll \ll1crea<"c or decn:use) in

t 10

Ph}sical RC'hahilit:.ltion

body fluid ... (intravJ"cular. 1llIl'r~lltiaJ. or Intrtlcclluli.lf) will aller BP. '-\ Bladder dlql'n~ion m
Diameter or Elasticity of Arterie, The Silt" (diall1ct~r) of Ihe \c",el lumen \\ III pnn Ilk ('lIher increased peripheral resi ... Wllce (va\ocolll~tricti()n) or decrea\ed Il?SI"\tancc (vasodilation) 10 cardiac output. The ela:>l1clty of the vc\\el wall al-.;o 11l11uences re~i\tancc, NOnllall). the (;"11<.1.I1'1011 and recoil properties of the arterial walb provide a continuou~. ~mooth !low of blood illto the capilL.tries and \cin ... bet\\cen hcartbeats. With age, these properties are dimini'5hcd, Thus. there is a higher resist.lm:e 10 blood flow with resultant II/crease III \y"tolic pressure, Becau~e the flexibility and recoil properties are diminished, there IS a loll'l'r diaslOljc pres,;;ure. A charac· teristic feature of arteriosclerosis is reduced vessel wall compliance in response to fluctuations in pressure,

Cardiac Output When increased amounts of blood are pumped into the arteries, the walls of the vessels distend, resulting in a higher BP. With lower cardiac output, less blood is pushed into the vessel, and there is a subsequent drop in pressure.

Age BP varies with age (see Table 4,1). It nonnally rises gradu· aJly after birth and reaches a peak during puberty. By late adolescence (18 to 19 years), adult BP is reached. For many years. the n0n11al adult BP was considered 120/80 mm Hg. tn 2003. new BP guidelines were presented in the Seventh Report of the Joint National Commirtee on Prevention. Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report (Table 4.7).66 The new recOI11mendations recognize the high prevalence of hypertension that affects about 50 million individuals in the United States and I billion people worldwide. Hypertension is a primary risk factor for myocardial infarct. hean failure. stroke, and kidney disease. The earlier n0l111al adult BP value of 120/80 mm Hg now falls into the new category of prehypertension (systolic pressure: 120 to 139; diastolic pressure: 80 to 89). A BP value of 119n9 111m Hg or below is the new adult

-.;t;lIld:.ml. nll' JNC 7 Report relommend", lInplem~ntatJon of npanslvc and effellJ\t' mCJ<.,ure\ to prcvent lurthcr IJ1Lre,I,C''i III 11ll' prevalence of hypcrtcn\!on I,f, Fnl older adults. the rl'lt' 1Il hlood prcs<"urc value'i ,\ pnllIanly tx'l"<-IU'tt' ollhe dcgcner
Exercise Physical activity will increase cardiac output. "",nh a consequent linear increase in BP. Grcater increa')cs are noted in syc;,{olic pres\"ur~ owing to proportional changes in pre~­ sure gradient of peripheral ve"iseh. Thi<.; means that although cardiac output during exercise is high. vasodilation reduces peripheral resistance to maintain a relatively low diastolic pressure. BP increases are proportional to the intensity of Ihe workload.

Valsalva Maneuver The Valsalva maneuver is an attempt to exhale forcibly with the glottis. nose. and mouth closed. It causes an increase In intrathoracic pressure with an accompanying collapse of the veins of the chest wall. There is a subsequent decrease in blood flow to the heart. a decreased venous return. and a drop in arterial BP. This maneuver serves to internally stabilize the abdominal and chest wall during periods of rapid and ma..ximum exertion such as lifting a heavy object. When the breath is released. the intrathoracic pressure decreases, and venous return is suddenly reestablished as an "over~hoot" mechanism 10 compensate for the drop in BP. In tum. there is a marked increa~e in HR and arterial BP. This rapid rise in arterial pres~ure causes vagal slowing of the HR (bradycardia), Although the Valsalva maneuver can temporarily enhance muscle function via {he internal stabilization. it ha~ an indirect undesirable effect by increa.:-.ing BP and ..hould be avoided by individuals with cardiac imraimlCnl.15,1~ CLINIC'AI. NOrt:· ,\ commOIl nil 'COIUTPUl1l1 COl/( tTl/we rhe \al.wl\·(1 mW/C'/(I'{'f /, rhor 11 dlu'dt\, 1111 "ClIII" I/R und BP. A \ dncnhed a11l!\"C It IS rhe nih"" \ r,'t Ol't't.\ nlt'cha-

Table 4_7 Classification of Blood Pressure for Adults Ages 18 Years and Older

n;sm orslIddl'fl'" incrc(I,\JII,<

n'l/Ow rrflfl'Il

IllLlt

({t/{\C'\

rltl,\

munlse. Til{ H/h\l'!fl/clIl drul' III HP dllt rll Ihe \£1I\IJllll mal/Cliler "1lI\ 1"(''1111111 \('1'111:;

Normal Pre hypertension

-----

<120 120-139

Hypertension

Stage 1 Stage 2 From Chobaman, AV, et

140-159 "'160

---

at66 With permiSSIon

111'-: 1~{dl:=lJ1t'S.\ Iltal

<80 80-89

----90-99 '"100

1I/g

1 J

a

!It'tlq'

ofr{,11

"111(/1'/\

dOl\" alld

fll"

(J((()IIl/)(JII/t'S '11'<11f1111~ \\'//llt

I,d, lip·

ol1;t'/ f

Postural (Orthoslalic) Hypotension A".<.;ocialed with prolonged immobility and periods uf !xd rc ... t, JUHfwol (oullOsfaflc) ItYf10{(,II.\/tI1i i... a 'luddL'1l drop III BP that OCl.'ur\ \\ h~n 0I0v~mcnt to upright posture::.. hilling or standing) t'i illiti.ucd. The {x)-';ltional thang..., ca~" .1

(h;lpcer 4 \ ital I)igw, ~I,I\lt,t1I(lIl~11

hkllW.1

1~\I,ll11g III the

lo\\cr l'\{I"CIllII) \ ",'liP;;. \l'IWU" rl'lllnl ,tnd r~l1\h,1C OlllpUI ,.lrC T\.'lIur.:l'd \\ Ilh a Il'\ull.lIlt lTll'hl,l1 h~ fXll~rtll"lon 1 hI' tng~c:r.. ,1I) c:pI"I,)(1c 01 hghlhl..tdellnl' .. or l'\ ell II,.,.. 01 l:OIl'l'lou.. nC..... In rc"pnn ..c.' to \\t,.,ltIPll;,1 L:h,lIl~C:" unda nOrllhl1 Url:Unht~llll"t>, BP I.. 11l~1l1l­ taillcd h, r('l1l'\ \a ..(>l:oll\lnl.'IIOn (barorel:Cplor.. l. \\hlch l1llrc.I"l~" 11K ·\It~r J r'lt,'nod 01 IOJC.:(I\ II). pc.l..turJI 11) poll'n· "Ion ..htluld lx' ,lOlIup.Hec.l and require.. a gr;Jdual acclllll::ttlOIl 10 the urn~11l pc.)\llIOIl unlll nOnllJl rene\ conlrol r('[um.. , Olher prcdl.. pn"'l1g I"H.. lor.. for po..tural h) poten\ion HKludl' l'\erl'l..e. drug....ul:h :1\ ~lIlllhypertelhi\e.. ,md \ J-.(xldJlc.lr'<, redudlOn III hamreceplor re'pon-.e \\ HIl agmg. lllL' \ Jklh ~l In.meu\ er. ;1Jld h~ PO\ olemia (abnonllall) 10\\ \olul11c 01 cin:ulatmg hlood).t>~,t>~ A .. a u.. .eful precaution. an) pallen! re..lril1ed [0 a rccumbenl po~ition for even \hort period.... hould oc con.. . lucred at n.. J.. for po:-.tuml hypolen\ion. The~ c\ cn.... CJ.!l be miOlmi7cd by u:-.e of c\temal pre,!o,:-.ure \Urron .. \uch J'" abdominal bmders or full-Ienglh ela"'lic ...loeJ..ing ... (ela~llc bandage\ c.:an abo be u.. . t:d effeclivelyl and .1 \er;. gradual .\Ccllmallon 10 upright po\tures. Should PO\lural h) poten\lon fXl:ur dUring IrealJncnL Ihe patienl "hould he redillcd from upnghl and Ihe leg\ cle\Jled.

Arm Position BP md~ \af) 41\ much .1\ :20 mm Hg b) ahering ann po~i­ 11On, For l:on\i\lenC~ of mea\ures. the palient \hould be ... ntlng \\ nh the ann in a horizonwL liiupported po~ition al

A

hcart Ic\cl It patlcnt I:OndlllOn or the lypc of aCllvlly preclude ... Ihc\e pO\lIlon.....dlcraIIOn\ should be carefully documcnlcd. A.. \\ IIh other \ 11.11 \Ign\. faClofll liiurh a51 fcar. dn-":ICl). or emollonal \lre" 411\0 \\ III cau-.e an increa,e In BP.

Other Ri,k Factors ~"gh

BP 1\ al\o d.,..OClate-d \\ IIh high ...odium intake. obe· -'Ity and belllg o\erwelghL a o;,edenlary IifeSl}le. hea\ y alcohol con\ul1lplion. pregnancy. gender. and age (until age )5 men have ..I grt:Hler risk for high BP than women, hetwcen 55 and 75 year\ of age the relalive rbks are comparable. afler age 75 women are at greater ri'iik). race (African American.s are at greater risk as compared Caucasian;l. and heredity (parental history of high BP place\ the individual al grealer risk). In addition. some medicalion~ can eilher increase BP or interfere with anti· hyperten~ive drugs. These drugs include Meroids. nonsteroidal ami-inflammalory agenls, diet pills, cyclosporine. erythropoietin. tricyclic antidepressants. monoamine oxidase inhibitor:-.. and some oral contraceptives. 69

Equipment Requirements A noninva... ive or indirect measure of BP is used by physical therapi~ls. In critical care ,!o,enings, invasive or direct mea'iures of BP are oblained by placing a thin catheter directly inlo an artery. The equipmenl required for taking

8

Figure 4.22 Sph)gmomiillomdcn,. f -\ I Merl'Uf) gauge m,tnUfllelcr\ ha\ t' a \ 1:'111\.',11 glav" IUhc (ntiitnlOg liqUid mcrluf) \\lIb J ~O(J mm Hg .,l,;.dc marJ..ed In ~·mm lIll,;remCllI'l (B) AncHIllJ rn.m\\meterlO eon .. l ..t 01 i.l Cln.;UIJI gIJ'., ll)\t'rl-J lOO 1111ll Hg gaug.e In ~-mm lllcrt'mclH .. \\nll needle lllJ.r~t'r tCoune ~ 01 Ol1lroo, IIll \·Crn~ln HlIh.1I 60061.1

111

112

Ph}ljical Rehabilitation

blood pre" . . urc u'ling the more common 11011111\'a'lIV(' au'I· cultatory (li\lCl1mgl method Im:lude... a s,,!Irgmonul!1(101CfL'1 and a ,\fN!lmcopr. TIle \phygmomanomcter (lrequentl~ referred to a, a MOrici (1n'5\III'(' ("IIIJ) con""I' of a flat. itlr· tight. lllflatable. IatC\ bladder, The bladder I... co\cred \\ Ith a colton or 11) 1011 ... Iceve that extends beyond the lenglh of Ihe bladder. There are t,... o tube ... Ih::!! e\.tend from the cuff. One I~ 3lt3ched 10 a rubocr bulb thai ha.. a \31\e U\CU to

A

B

IlWllltalll or to relea"ie air from the cutl rhe ,cl:omJ lube 1\ attached 10 a pre ...., urc manometer I portion of ,ph} gmn. manometer that rcglen into fork->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<., high-fn:quenc) sound ... to be heard. Electronic (bJnery~po\\ered) slelho!o.copes (Fig. ..J.26A) prO' ide higher levels of amplificalion v. ilh volume control. and dual-frequency sound liltenng: ...omc are available with mt~fl:hangcable rel11O\Jble head\. A design varialion for preho'pllal Emergenc) Medical Sen ice (EMS) pef\onnel pro\Ide~ higher "l.Inphfi<':allon le\el~ b) replacing the earpiece 'I lAlth a heatht:1 (Fig.. 4,268), The headset i~ de"'lgn~d 10 bloc,", out noi'>\.' 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"'<:0pl: l:alled Korulkofl"o, ~ounds The l~1I \Idc

of the stethoscope is used for auscultation because Korolkofrs ';cunds are low· frequency. Initially when pres\ure is applied through the cuff around the patienl's arm. the blood now is occluded and no sound is heard through the stelhoscope. As the pressure is gradually released, a serie":. of five pha~es of sounds can be identified. The therapiM should be alen for Ihe presence of an auscuHalor,'" gap especially in patienls with BP above normal values (hypertelbion). An auscultatory gap is the tcmporar) dl~appcarance of sound nom1ally heard over the brachial arter)' between phase I and 2. and may cover a range of as much as ..to mm l-Ig. Not Identifying thi~ gap may can lead to an underestimation of systolic pressure and overcMimation of diastolic pressure.

Phase I: The fir\1 clear. faint. rhythmic lupping sound Ihat gradually increa\c~ in inten~ilY I~ heard. The period \~ hen blood inilially tlows through Ihe artery is recorded a.. . .H \tolit, flrcullu. Thl~ represent ... the highc~t pre ... ~ure III Ihe anerial ...ystem during \entru.:ular contraclion. Bl' alert for

gap Phase II: A murmur or swbhing sound i:-. heard a~ artery \\ idens Jnd more blood 110\\ s through aner). Pha~e III: Sound~ become cnsp. more il1len~. and louder: blood IS nm\o 1l00\ing rdari\el) unobstructed. Phase I \': Sound IS di~l1ncr. abrupt Illuffling; son blowIng qual it). "In lhildren k'l~ thJn 1J yeur'l old. pregnant WI tIIIJell/r%rr

(

I)

F

Standard ,KOU',(IC "tclho"cope \\ Itll
_'I' r of

II

II

I

1

Combination design :...tethosco!X' head with one

J1

~ide

bcll-"h;lped (hit) to auscultate low-frequenc} sounds and Ihe oppo-

"ile "Ide a tlal di"k diaphragm

(righT) rOf

high-frequency sound':>.

(n~hll.

other a nat Ji:..J... The bcll-..,hapc i.llnplJfie.., 100\~frequenc) ,>aund.., ..,uL'h J .... tho.. .e producc-d III blood \"c ......eb and are gcnLT~lIy recommended for determining I3P. The llal dl'>~ dIaphragm IS more u...eful lor high-frequency ,>oun(b ..,uch a" heart ound,. AnOlher I) pe or . . cnsor IIlcorpofate' bUlh hlgh- and lOlA-frequency capabilitie'> of the (\\ the need to turn the head over. To hear l(m ~frequcnc) '>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 COpl'" art' ~tlso d\<.ulable 101 u"e III ItI~11 II ~ I 1(1 rt).! " \~ht'lt' 1ll1ll1111J/JIlg fhe n ... h. 01 no... ,,· lIlk'_IIIJn I" e"'.. t:ntial

Korotko/f's Sounds When 1lIl.:a",uIIJl~ HP. d )l:r1t;:" ot "OUl1lf.., I:... hei.lrd through tlk ,klhll"Ulpl Lallt'll KurotklJft"~ ~lJUlHb Till; hdl :"'I(.k

of the :...telho... cope i~ used for auscultation because KorotkolT's soul1d~ art low-frequency. Inilially when pres"ure i" applied through the cuff around the patienl's aml. the blood now is occluded and no sound i . . hcard through the :...telho'>copc. As the prc:s~ure i<:, gradually released, a "'erie'> of five pha.':lcs ~oLJJ1ds can be identified. The lherJpi,>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 <., range of a'> much a~ ·W Illlll Hg. Not identifying thl" gap 11l,ty can lead 10 an underesttmatlon 01" s)'iloIIC pressure [lnd o\'ere~l1milllon ot Jia"lOlic pres<:,ure.

or

Pha"e I: The fir"'f clear, faint. rhythmic lapping ,ount! thai gradual I} Int:rca~l'S in \Illcn-,:ilY i... hc.lrd. The period \~hCIl hlood lnltl~ltl) nm\ . . rhrough the drtery I ... recorded it ... ,\'\Itoflc prc\,url'. 1'111', represent~ the highesl pressure JIl the arterial . . y<.,tcm during \enlflcular ('untr~h.:tioll. Be

alt'} I lin- 1.111 Pha~c

1l1l.\C/lifllfOf\

~/iP

II: A murmur or ... \\ I~hlng ..,,)umllS heard ~b ,lIler)

\\Idens anL! more hlood 110\,,') through
Pha... t' Ill: Sound.. . beL\)IIl~ cnsp, mort'

IJ1ICn ....L· ,

and

louder, blllOL! I"> no\\ rlOH ing rdi.1l1vcl) unob.',(fUCfl·d

Ph.he 1\: ~ollnd i.. . di"IJI1t:t, dbrupt lIHltfllIlg.: ......l lt blo\\109 qualJl) "In chlldrt~11 Il~~"" Ih,1ll 13 )L'Jr... uld. pregnant

114

PhHicat R£'habilill.Hion

A

Figure 4.26 ElectronK ... lelho'-l,;0pc" Siandard electrol1lC ..,1l::lho..,(;ope and lSI electrol1lc slctho..,cope \\ Ith hcad,-cI to blod, oUl emlronmental noi~ dl:... Il.!IlCd for U"'l' tl\ EmenzcnC) rvledical Scn-Kc <£:.\.IS) per"onnel (Coune<;y of CardlOl1Ic". Ill~, \\ch"tcr. TX 77598.)

(A)

B

Yo omen.

and patient'i with high cardiac output or peripheral vasodilatation. sounds are often heard at levcl\ far beloy. those at which muffling occur~. sometimes 10 le\e(o,'1 approaching 0 mm Hg. In these situation.... for practical purpo~s. muffling should be used to indIcate diastolic pre'il)urc, but both muffling (phase IV) and dbappearance (phal)e V) should be recorded." 71 I. J10 • Pha~e V: La..t sound I~ heard; is recorded a... dwsfO!ic pre,\Sllre in adult\. The American Hcan AS"iociatJon recommend, U\C 01 the fifth pha~ a... the mOl)t accurate index of diastolic pre ...sure in adult populallon~.7o A BP reading with a ~y"tolil: prcvwre of I 17 and a ~ccond dia'llolic readmg of76 \\ould be recorded :i\ I 17n6. In ~pecific instance, (,h noted above) where both pha'>e IV and V are recorded a\ dia..toile prc\'ure\, three number... arc documcnted. For exam-

pIe. a .;;yc,lolic pres~ure of 117. a pha ...e IV readmg of -Os

and a pha,e V value of 76 "ould be recorded a, 117f7J6. A primar) con ...ideralion III delermlllll1g BP ''I thJI II ...hould be done m a minimal amount of time. The BP cuft act'-. as a toumjquel. A<; ":luch. \enou... poolll1g and con.. ukrable di'Comfon to the patient will occur If th\.' cuff I" lett 10 phlcc 100 long. The brachial artery i.. the mo",t coml110n "Iff' for BP monllonng and Yo ill be de..cnbed III oe'all;\ de.....:nption for monitonng lower extremity BP ,.. al ...o pre..~nlt:d.

Procedure for Measuring Brachial Blood Pressure A. A.....emble equipment

I. A ... Ietho..cope. A bell-\haped heau ,... prc!crreJ. hu\\' ever, a tllaphragm can abo be ul)ct! ctfel:llVd)'.

Chapler 4 Vital S;gns

:! A ...ph) gmomanomclcr \I. ith a blood pre.. . "urc cuff (.. . izc oj cuff . . hould be appropriale for sile of c:\tremIt) ,. In adul". the \\ idlh of Ihe bladder ,hould be 40 pcrCl'll1 of the aml circumference (measurement can he made u.. . lIlg 3 Jape mea~ure mid\\ tty bet\\ een the Jcmmion and olecranon procc'i"ie~) and should be long enough 10 encIrcle at least 80 percent of the ann, In children. the bladder ,hould be long enough \0 cOll1plelel~ encircle the entire ann."'" ~u .1 Anti"epllc WIpeS for cleaning earpleces and head of stetho~cope before and after U'ie. B Ilash hand,

(,0<

115

Stethoscope

Blood pressure culf Brachial artery

BO\ 4.3)

C Procedure E:\plam procedure and rationale in temlS appropriale to (he patlent'~ understanding. Indicate there will be a reque~t to remain quiet during moniloring to a\old lIlterference \\ nh auscultation. '\ Ole: A ... \\ ith other \ Ital sign meu·mre.... BP is monitored after (he palient has been In a relaxed quiet ...clling for a period of time a... acti\ ity or physical c\t'rtion \\111 cause an eleyation in mea~uremenh. J. A"'''lst the pallenl to the de~lred position (the silting po... Jtion IS recommended), If a supine Jlosition is u.. .ed. the ann 'lhould be al the patient's ~ide and slightly elc\ated to the middle of the trunk. If mca.·..uring BP in ...tanding le.g.. monitoring pO~ILJral hypotension) en'lurc Ihe ann i~ ,""upported al heart le\'e!. 3. En'lure palient under~landing. safel). and comfort. ~, lJ~e anti"epllc \\ ipe to cleull the earpleces and head 01 \lelhoscope. ~, Expo-.e the palient\ aml: the midpoint of the uml . . hould be at heart le\el \\l1h the elbo\\ 'llighll) flexed. With the pallent 111 a "eatetl rO~illon, the upper e\tremlly . . hould be )upported on a Ireatment (;,thle or other appropnate ... urlace o. \\rap the deflJted t'ull ... nuggl), and e\enl)' arountl the patient\' bare anll appro\imJlely I II1ch (2.5 1.'111) 3~I\e thl' JnlecubilJI fo~ ...a: lhe ecnta of cull should be mime \\\th the.: bradllal arter) (Fig. ~ ..27)..'\'\old rolling up a gannent 'lleeve a~ Ihl" v. 111 create a InUnllyUd die" .. En ure the anerOId gauge j" t:'a'lll~ \ l"'lble~ j men.:ur) IIhm\lmder mu t be on a Incl "'U ri an: <.11 eye le\el eh d .. thai Ihe ph)gmolllanolTIdt:r regl'ltcr.. . Eeru \ Ire TIlt' tir t lillie BP I II1ca . . ureJ on .1 p.llient. ;,tn t: llnl.tlu.JO 01 thl.: ) qUilL pfe' :,>Ufl,.· . . hould he> Illjde TIll . . \\ 111 ell'lurl,.· Ihal dUring the <.1C1ual ml.:<.1'lur~ J.11 olHkyualt· k d 01 (uB lIlt1allllll '" u .... ed The pnk.I,.~dult: I .J Il)IIII\\ 1.11 Inl:alt: .Jnd pJlpjtC' the radial i.lrter) on Ihe JI tal hllcall1l lit lhl' l·ulll.:d upp~r c.: IreTllll) lhl Llo t' Ihl' \ . the n! the.: UP uilt ((urn h~h.\\I,t: h.1 \\hlk ulIltmulIl!! h. mllfllhlr Ihe pul t: r.lpltlJ~ Inll.. h: lhl.: BP lUIt tll _,0111111 Hg .lbO\c thl.' k\t:I .t1 \\hlllJ Ihl 1<.1LII
Figure 4,27 Placement of blood pre~sure cuff and for mOOltoring brachial anery blood pre,,~ure.

8.

9.

10

II

<;tetho~cope

Cd) 110te the pressure value on the gauge; this is the e:..timale of maximum pre!:lsure required 10 measure "y.. . tolic pre~"ure for [he indiVidual patiem: and (el allow air 10 release quickl}. Place the earpieces of the !:ltetho~cope (tilting ...Iightl) forward) inlO ear,,; Ihe tube~ of the stctho"cope 'lhould nOI be ('fo~sed and should hang freely: u"'e the IO\,,-frequency bell sitle of ~Ielho'll:ope head. Locate and palpale the brachial artery slightl) above and medi.ll to the antecubital fo~sa, Place the head of the ~telho~cope firmly over the Jrtel) at Ihe lo\\cr border of the BP cuff (,"" Fig. 4.c7J. Suflieient pr<'"lure 'lhoulJ be u.. .ed 10 a\'oid g<.lpplllg bel\\een ClfLumle-ren<:e ot . . tetho... cope head and . . klll "!(I/(': In ... ltui.ltiolh l\ here thl.' pul"lt' I... C'\lremel) \\cal.. Jnd uIH.Jelt't·(,c Ihl..· \ .i1\oe of thl: BP L"utl (llIm c!exJ.. \\ het anJ II1tbll' the t'utl tl) Ilw e.. . tunall:d le\el pre\'lou"l) dt:lI..·nnmcu or UllItI Ihl' mJnOOll;'ter re£hter... "ppro\.lmalel} ~() hI ,0 mill H~ .Jtxl\e thl,.~ dntu.:lratl..~d ,,) . . 1\lIlL rlt" . . Ufl: Rek..1 C th(' \i.Ih~ I...lrdully. 3110\\ mg. air Uul ...10\\1), ..Ilr . . hnuld tx- rdc,t...eu Jf a rate llf 2 10 J 111m Hg per hC
12 \ .Jtl.h Iht.' lI1J.Jltllllcle.:r do\el\ and Ilt)(C the putnt al \\ ll1l.'11 (he tlr.. . l "'JunJ I:'> heJ.ru (i.1 rnC:flUr) manorneI('r nUl'll hc \II"'\l,,cJ ..II e)e It:'\cll: thl~ I' Ihe 1'01111

16

Ph"

1 R haluhtatron

\,hc:rc hlc'W,.xllIP.. t Oc.,!;Il1'" In 11m, Ihrou~h Il1l" JrtlT~ Jlld rerrC"'Cnh lht' "'~ "'tolll pre...... urc 11'11.1"'(, I) Ddlclllon", til tht: l!l;l! l'r ""lumll of II1t"n.:ur~ "iii l1.aminer i"i u'ling Ihe SlClho"icope agam. it I~ not ncce\~ar) to clean the earpiece~. Ho\\ cver. lhe head of Ihe
Procedure for Measuring Popliteal (Thigh) Blood Pressure MC<.l~uremcnt

of poplllcaJ BP i~ indicated in situations \\ here compari<.,on\ between the upper and lower extremity i\ wJrramed. :-,uch <.1\ peripheral va . . cular di"i:ca!'>c. The) abo arc u~ed when upper c),.lremJl) prc<.,...urc') are contralm.!Icated. ,uch as follo\\ 109 Ir3uma or "iurger). E"i''icnllally. Ihe procedure i\ the "lame
the "iuplne pasllion may be used. TIle knce 1'" placed in \Iight flexion to facilitate plat.·cmcni of ~tetho~cope in popliteal "ipace. III compan ...on lo Ihe brachial arlery. the popl"eo' oner) ","oil) ) ,old, higher ,y'lolic pre<-

"iure O\"ing to u...e of the larger bladder; dia.,tolic \'alue" are approximately thl" ... ame or "ilightl) lower .., Expo\(: the thigh area u\ing appropriate draplIlg procedures. 3 L(x.:ale the pophte~11 artery b) palp~lIion (JXhlenor knec). -L \\rap the ddlatcd ,;:1111' "inuggl) Jlld nenl) .mmllli the patient'... ~nldllllgh (a \\ ide l:uf! i'l u...cd: lI<"C gtlldcllnt.'''i jor culf ~I/C dc\cribcd for bral'!llal BP). The f.:Clllt:r of tl~(' bladucr ... hould be dm:cll) O\cr thc JX)plllc~tl artery. No/( A, de"'cnbc:d tor hra 'hml BP. a pJlpatol) (""lil. mate 01 ma\lIntllll pre'l'lure requJrt.'d to mea",ult' "'}"'_ lolu.. pn......... urc l'JIl he mJdc U...lllg the pupil I!..'J I or dCl~ah\ peuI.., ilrtt"l). :ri. Proceed \\ Ilh au...cultJtmg the pre",.,ure J ... lor th!..' brachlol Mlel')

Rc

ordin~

Re..ult..

I·or pUlp"C'" 01 ph~"lallht"rap\ dCllUllk'nt,lllon. m,lIl) ther· apl'l'" mdudc \ It.ll "'11Pl\ d.II,1 (IIrcul\ \\.Ithlll tht.: narrJI1\e ltlrmat of thell nnle L ... mg lht" SO.\P (SuhJccIl\e. OhJcUlvc. A ......c"'.. ment. PIJIl) IOrIllJI. \It.d "'I,t!n d..UJ l' 111<.:luded III the (I"/£'('f/I (' '('{IIOII In the P"tlclll/Cllcnt ~lanagcl1lent Model dc",cflhed 111 Ihe GUide 10 PhY'lCal Thcrapio"t Practil.:t.'l the.. .e dJIJ are Inc.:ludcd 111 (n/\ WId \fCClSlIl"t'S. Thc mo\t IInportant clement m Telordmg lhh mfonnalion I'" that II JIIO\\\ ea\) compari ...on lrom one em!) to Ihe nc\!. The dalc. lime 01 d~.). patient po... ltJon. examiner'... name. amI equIpment u\cd ...hould all tx: de•• rl) mdic::ued. For e\.'lmple. a...\ume a \ Ital "Ign... c\.lInmalJon pm\Ided the follo\\-mg data: Temperature: 9X.9 F. lal-.en orall). a pube of 80i bcah per mmulc (bpm). wllh tlllcluation.. between weal-. anti "rong bear...: a rc ... piratory r<.ttc of 16 per minute. \\ ilh a regular rhylhm anti unlaborcd quality: and J. BP readlllg of Ill/Hoi mill Hg in "'Itling and Il0/~6 mm Hg qanding. A ...ample fOmlJt tor lIlciuding these dala a... J com, lXlnent of n~UTJIl\'e documcntJtion I~ pre\Cnted in Bo\-ll The nur~mg 'lection of the medIcal record i" an Importanl ~ource of \lIal ,igns dJta. Here. data '''' typH.:all} pro\ ided III graph form \\!th lime represented on thc honzontal ~Lxil:l and the mca"iurcd value~ 011 the "ertlcal a\I~. The vl~ual record allm\s ea~} Identification of dat.l trend, rcn~ctivc of nomlal variation~ or a rcspoll\C to dl\ea:s~ or therapeutic in(crvention.~.l For the Iherapi"it prJl'liclIlg In facllilic"i wher~ ... uch fOnll'l are u...cd. famlllJflt} \.\lIh the specllic recording "iyslem l"i Import,U11. Several Illl=rhtll.h are u"icd to d.fterenllate \J1al "'I!!n ... entn: thc\ ccneralh. melude 'lome \amltlon of opcn anu c1o'teu cm:lc"l. elln· nCllmg Iinc'l. color code.... or other 'l) mbol'l 10 dlflerenlJate among lempcralUre. HR. RR. and BP d~Ha ~lodlllt:JlI(ln' of thiS I)p<: of form 31"'0 m~ty he u"eful for UOClIJIlenling: re"ponse to ph)~II,;al lherap) Irt·atll1enl.

...

~

Box 4.4 Elements of Documentation for Vital Signs Data Patient '\ame: Oate: rime:

_____ Therapi~l: ld.uc of c';unll1atl~Hll (tUIlC of ~ta)' C'(dllltn..I(IOn

Po~ition:

[cluipmenl:

pc'rf(lml~h

("lung I (electront\.." IhcnnoOlctcr;

men.:ur) I1lJnOmclcr) Temp: IIIl :

qg,l)

~

loral)

X4/mlll;

~Iltcrn.ltlllp.

quuilly

(WC.I~

"rong) 16/mm: regulJr. del... p. ulllJllt.m:d

I 22/X4 120 0

1111ll

Hf!. hlllJll~)

llllll fI~ hl~U\("hn~ I

ill II jUIJ'l!llr-nl Ill!, luJc.. Idc:nllh....lllUl\ l1umhc.''''' 111Io.11I.lo;d In 1I.-.:lJl1ll·nt.llll>fl

IW I ('mp

~111(",J ,. 1Wc: ..ure. l<:nJjl\: hlluo:

IIR

h_ 'n rail' ,...-..

RR

!tll'\

hl'Ul,j t'C

r~plr.lh'f'

1;1 I

Chapter 4 Vital Signs

117

the mosl useful data are obtained when measures are taken

Summary

al periodic intervals rather than as single measure in time.

Value~ obtained from monitoring vital signs provide the physical therapist wilh important infon11Jtion about the patjent'~ physiological slalUS. Results from these measures a~si<,,( in cMablishillg and maintaining a database of values for an indi\ iduaJ patient. They also assist in fannulating clinical judgments for dClcllllining the diagnosis and prognosis. dc:-.igning the plan of care, and establishing and evaluating effectiveness of selected treatment i.lllcrvenlions. The procedure for measuring each vital sign has been presented. Because multiple faclOrs influence vital signs.

Sequential measures allow changes in patient status or response to treatmenl to be monitored over time, as well as indicate an acute change in slatus at a specific point in time. For purposes of physical therapy documentation. vital signs data are typically included within the narrative format of the note. Use of a graph to record this infonnation may prove a useful adjunct to the physical therapy record. Regardless of the system of documentation selected, of critical importance is that it allows easy comparison of serial entries over time.

Questions

for

Review

1. Together \\ ilh other examination data. vital sign

2.

3.

4.

5. 6. 7

8.

measures help guide clinical judgments about what elements of the patient/client management model? Prior to a vitaJ signs examination. what preliminary data can be obtained by a careful systematic observation of the patient? Explain why vital sign values are more useful when monitored as a serial process as compared to meas~ uremenr at a single point in time? Describe lhe primary mechanisms by which the body conserves and produces heat; differentiate the four primary heat loss mechanisms: radiation, conduction. convection. and evaporation. Describe the procedure for determining both oral and axillary temperatures. Define pulse rate, rhythm, and volume. What factors influence Ihe pulse? Describe the procedure for monitoring the radial pulse.

Case

9. What is a pulse deficit? What infonnation does it provide?

10. What parameters are addressed when monitoring respiration? Define each.

11. What factors influence respiration? 12. Describe the Valsalva maneuver. Identify its influence on I-IR and BP during and after the maneuver. Describe the procedure for monitoring respiration. What factors influence BP? What are the tive phases of KOTOtkoff's sounds? When monitoring brachial SP. what guidelines are used to detemline the appropriate cuff size? How does a cuff that is too narrow or too wide effect BP measures? 17. Describe the procedure for determining blood pressure u~ing a stethoscope and sphygmomanometer.

13. 14. 15. 16.

Study

EMERGENCY ROOM ADMISSION A 2~-year-old man \\ as. separated from his skiing group due to an ulh::xpected and violent snowstoml. The situation was l.:ompl1caled by his being in an unfamiliar area wlIhout electronic communication. A 2-day hl'iicopter search located him after approximately 4R hours of expo.,ur!.' 10 temperatures thai ranged bct\\cen 10° and 20°F. The emergenc) learn JOltiated intravenous flUId replacement (to help re:-.lOre flUid and electrolyte balance) cnroute 10 the hospital

HISTORY As reponed by hl.s parent':>. 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-f
-t.

E\trclllc" III CI1\lfOl1mcnt.li tcmper:llufe h.I\('.1 J.IH!t' 1l1lpall on

'c\aminallon ..Utl.! tre.HI1\C'nt:'

GUIDING QUESTIONS I. Descnbe the hod) ")"'CI11 re~rOJ1"C:-' to h) pOlhcnllli.t presented by the clinical fcalllfc ... of the case.

p.ltlenl '''' unrc pnJ1 1\(' .mtl (\,ll1nlll,;

tx' Iht.: I1\Il t lprrnpn,ttc {lui

Plo\Hk;( hnl"l r.ltlon.lk IOf \OUf.m \\"f

PHYSICAL THERAPY rhe pallent 1:-. I1m\

(Pil ldl'flll~ 1111

the hod) ....

ilhl!lt~ In mallllam

C(ln

tam

temperalure,"" \Vh.H t~ pc of c1othm.!.! em he ... 1 .1 111

a ...

protel.'tll1g IhC' hod) Irom 10\\ em mmment,ll

(elll pera t u re ...·J

References

2

3.

4

5. 6 7. 8. 9

10. II. 11.

p IJ. 15.

10. 17.

I~

19 20. 11

.\mencan Ph~ "'Icll Therap) A"!lOCI3110n GUIde 10 ph) \Kal IherapI\1 praclice. Ph) ... Ther81.1.1001. Grabbe. LL. Ph)"lcal a......e . . ~menl sl..ilk In Morton. PG (cd): Health A~sc,~menl. eel 1. FA Davl .... Philadelphia. 1995, p 16. Lc\\I .... PS: Cardiova::.cular a!l..e,sment. In Ruppert. SO. el al (cds): Dolan'" Cntl\;al Care ~uf",ing: Chnical ~ur"ing Through the 1\ul"'oing Proce...... ed 2. FA OJ\ I". Philadelphia. 1991. pi) l. Tnpp-Relm~r. T. Johnson. R. and Sorofman. B: Cull ural dimemlon . . m gcronlOloglcal nUNng. In Sian Ie). M. and Beare. PG: Geronlologleal "lur;;ing. ed 2. FA DOl\ I.... Philadelphia. 1m. p 21 Melzgar. ED: The heahh hl ...lor). In ~10non. PG (ed): Heallh As...e::,sffient. cd 2. FA Davi'i. Philadelphia. 1995. p 3. Speclor. RE: Cullural Dlvcn.it) in Health and Illnes.;. cd 6. Pear...on Education. Upper Saddle Ri\t·r. NJ. 2()().l. Filzgerald. MA: Nur::.ing Health A.,seSSomenl: ConccpL" and AClivilles. FA Davis. Philadelphia. 1995. Purnell. LO. and P'aulanka. 8J (eel...): Transcullural Health Care: A Cullura.lI) Compelent Appro:ll..h. ed 2. FA Da\ 1'<. PhIladelphia. 2003 L)nch. EW, and Ham,on. MJ led~): De\cloplng Cro~..-Cullura.1 Compelence: A GUide for Worl..ing \\ nh Young Children and Thelr Families. cd 1. Brooke.... Bahlmore. 1998. Galanli. G: Canng for P:uienh from Dlffererll Cullure.... ed J. Uni\ersHY of Pennsylvania Pre...... Pliliadclphia. 2003. Luck.man, J. and Noble~. ST: Transcultural COllllllUlllclillon 1I1 Health Care. Delmar Thom . . on Learning. Albany. NY. :WOO. Huff. R.M. and Klinc. MV: PromOlmg HCJllh in J\lulw.:ulluraJ PopulatIon'>. A Handbook for Pratlltloner... SAGE Pubh,,:allons. Thou~and Oal...... CA. 1m. IIdn~n. M Palhophy'iiolog) Foundallon... of DI~ase and IInical InlenenlJon, \VB Saunde". Philadelphia. 1998 GU)lon. AC. and Hall. JE: Human Phy\iolog) Jnd t\h:h.rnI\In<, 01 DI.. ca~. ed 6. WB Saundc"". Philadelphia. 19'J7. McArdle. WD. Katch, Fl. and Katch. VL. tXerCl'>C Ph) ",ology: Fncrg). "lulfllion. and tlulllan Performance. cd 5. Llpplncoll WIlliam .. & \\<111..10'>. Phlladelphra. 2001 GU)lon. AC, and Hall. J~' TC\lhool.. 01 ~h'du..al PhY'iOlog). ed 10. WB S.lUndc~. Phlla.delph"l. 200C1 umon... DE. RIC~del. G. and ~ney. JA 'nlcnnoregulallon and the ttleLh uf themlOlllodahl ....... In GonzalcL. EG. \l)er,. SJ. &khlt"lIt. JE. Llt"beml.ln. JS. and Do",ne~. JA [),J",ney & Darlln{... Phy"'lologll".I1 8a...", of Rchat:lllltJllon Medu.:U1e. ed .l BulteNonh Ikmclllann. BO'lon. 2t(ll. p '\07 ~kArdlt'. WD. K.t1Lh. H. Jnd Katl:h. VL. E'l

ce.

Impllc:uion50 lor the Ph~\llal Therapl<'1. ed:! \\-B Saundcl"' . Philadelphia, :!003. p 194. ,.., KOller. B. 1.'1 ,II. Fumlal1lenl,ll, or Nur.. ing: Concepl", Proce..... JI'Id Pr'h.tl(·\:.". ed 6. Prenlll:e H.IIII-Ic'lllh. UpJXr Saddh.' Rl\cr. NJ 211(10 1.'\. Taylor, C Lilli,. C. and Le~lone. P: Fundamenta.l, of ~Ul"'II1!!· ~ An and Science lIt" Nur<,lng Clre. ed J LlpplOl:on \\ IIIlJm, &: Win.. lIb. .:!OOI :!~. Cra\en. RF. and Hlmle. CJ led\): Fundamental of "'-uNn£: Human Health and Funl'uon. ed l. LipplIlcolt \\ tlham & Will..m... \C\lo ,~

2000. 15. Smith. SF. Oudl. OJ. and \l.min. BC: C1l11u;,11 NUf'o.lng SI..III .. Ba..ic 10 Advanced Sl..rll<,. ed 5. Prentice Hall Heallh. Up~r SJddleRivcr. NJ. 2000. 26. Perry. AG. and Potier. PA: Climcal NUf">arl... \ Y. .:!004. P 545. )0. Bale.... B A Gu\(k 10 Ph~ ...ical E",unmanon Jnd HI"'IClf) T.tltn!!, l."ti 5. LlpplllCOII. Philadelphia. 1991 ~ I. Sle\"cn.... J. and ~lac:\uley. 0: Older e,erl:l~ p.trll...·lpanl... In ....1'11. GS. Jnd Sn)dcr-Ma..:I..lcr. L lcd... ): Ph) .. il:.tt Ther-Jple' In SfII.,rt allJ E\l·n·I"'t·. Chun:hrll LI\ IIlg... lt1ne. Phll..idelphIJ . .200.1. p ~ln .11 t\'loore. KL. and O.llle). \1·: CIIIlll:ally Oncll1cd An.llumy (~'ll ~J Llppllll'OIl Wilharn, &: Will..lll". Philddclphhl. 19l)l) ~3 A....hlell. J.•1I1d Jcul..cndrup. AI:=.: Hc.ln rate l1lt1llllt1rll1g: \rphtdllillt.. ,mol IHllllallolh Spor" "Icd H17I:'\17.100.' l~ Houdl'l. G. anJ ChJU1l10li"'i.. \ Ability ot nt'\\ Iit·.lft rate 1Il1l!l1!l'r.. hI meJ'Ufl' nonn.11 and a.Onomul hea.l ralc. J Spt1rt... \led NJ~ ... hIRe ' ~I

<;4(1. :!OOI

"5 LlUll,lI1en R~lT. JIld \lfl.1I}t'n, Pt..... He,)r1 rale mlll1ltt1"" Slat~'lll Ihe arl. J Sp..t 01 CUn:1 \kd \0: Sporh h.en: )h(ttl.141.1.':!(l()4

Chapter 4 Vital Sign. and nll\l\::rte. i\1 Heart mIl' momt('ll"'- \.lhd'l~. ,1.lhLlll). JlIlllunllll:103hl). Ph)"Il,;IJn ~r
rn.'IC'

c-

~"'I::!-tl.10(l:!

... ' ~1adarlane. OJ, Fogart), S,"" and Hopkm... \\C' The Ju:ural.:) Jnd \anJblhl\ nll:ommercull) 3\alldhk he,lrt rJIl" mOnlto..... N leal J Sr"m \kd 171 ... )51. 1l)~9 44 S«::3\\ ani. BL. 1,'1 al 111e pn.'t:I ..,on and 3l'CUnlC) 01 a ponable heart TJle momlor Blomed In..lrum Technol :!411 )::'7. 1~90 -t~ Tre,~r.1 :\. e'.l1 Validation ot;, hC..ln ratt' mOllllor \~lIh children In laboralory and licld ..eltlllg". Mcd SCI Sporh Exerc 21(3):338. 1989. -10 P:tllcr-,on. GK V;l~clliar e\,;)lu;llIon In Sll....man. C. and Bate.., kn..cn. Br..l (cd,): Wound Cure. A ColiOiborallvc Pr::aClice M:mual for Ph)"I(al Therapi"h and Nur,e,. A"llell Publi.,her<;. G::llthcr~hurg.

'-10.

~OOI.

P 177.

47. \1ohr. JP. and Young. \'- L: Anatomy ....nd physiology of the ~:)'«::ular "urph tll the hrain In Gonzalel. EG, ~l)er,. 5J. Edel~lcin. JE, LlchcnnJn. JS. and Do~nl:'). JA Do\\ney & Darling"" Phy"lologllal 8N" of Reh.abilitallon \1cdicllle. cd 3. Buttemonh Hemelll'mn. BO' Ill31:191. 200:!. 51 Courell GP CardiopulmollM) Amlomy olnd Physiology for Rt:,plrJMry Care PraLiltlOner... FA Oa\ I". Phlladdphhl, ~OOI "i:!. BerT). BE. md Pmard. AE: A ..'e....mg. Ti.. ~ue O,
Supplementnl

119

Pulmonary Ph)'ICal I hcrapy: An EVldente· B.l..cd Approach ~kGra~~"ill. New Yorl-... 200-t. p 7l 57. IlcndeT\on. BS AnattlOl) and ph)\IOrogy ollhe re\plralory "Y"'em In Ruppcn. SO. et dlled~l: Dolan'.. CnlK"al Care f'oUf\lng: Cllmcal \lanagcOlent Through lhe \luP-ing Procc..... cd 2. Ft\ Davi... PhlladelplllJ. 19%. P ;U\7. 58. Goodn\..ln. The rc..plT3lory sptem, In Goodman. 901<;..onn::1U1I. WG. and Fuller. KS (ed,,: Pathology Implicallon.. fllr the Ph)'''lcal Thcrapl'l. ed 2. WB SaundeT\. Philadelphia. 2003. p

ce·

ce,

553. 59. Schdegle. ES. Jnd Green. JF: An overvic'" of the analomy and phY\IOlo};y of ..lowly adapting pulmon3f)' \lreh.:h receplors. Re~plr Ph)<;loI125:17,2ool. 60. Ha<;,an, A, el ill: Volume act!\'alion of the Hermg Breuer infhltlon reflex mthe newborn IOlant. J Appl Phy...ol 90:763. 2001. 61. CC110. C: Cardiopulmonary Rehabilila1l0n of lhe Geriatric Pallent and Chent. In Lewi ... CB: Aging: Th(' Health-Care Challenge. cd 4. FA f)avi~. Philadelphia. 2002. p 141. 62. Roberg... RA. and Keleyian. SJ: Fundamentab of E'<ercise Phyc;iology for Fitnc<,s. Performance, and Heallh, McGraw-HIll, Ne...... Yor~. 2003. 63. Amhcim. DO. and PrentKe. WE: Pnnciple, of Athletic Training. ed 9. McGra\\,lhll. \lew York. 1997. 64. Woo. T\t. Drug!> Affcctlllg Ihe Respiratory Sy~tem. In Wynne. AL. Woo. T~1. and MIII:ud, M: Phannacolherapeutics for urc;e Pr.lClltloner Pre..cnbef"i. FA Davi!o. PhiladelphIa. 200~. p 311. 65. Gilman, S. and '1ewman. SW: ManIer and Gat7'!\ E!'scmials of CIIIlIlal NeuroanalOIl1) and Neurophysiology. cd. 10. FA Da\ls. Philadelphia. 2003 66 Chobanian. AV. el al Se\\~nlh repon otlhe Joml Nalional Commillee Of! Preventloll. DelectlOn. Evaluallon, and TrcalJ1lenl of ~hgh Blood Pre'",ure: The JNC 7 report. JAMA 289(19):2560,

20m 67. Goodman. CC: The cardiovascular ,y\lem. In Goodman. Cc. BOI.. .,onnault. WG. and Fuller. KS (ed~): Palhology: ImplicatIons for the Phpical Ther:lpi"'. cd 2. WB Saundcr-., Pililadelphla. 2003, p

367 68. Gllull!. BE: Pathophy.. iology for the Health Related Profes,ions. WB S::llll1der,. Philadelphia. 1997. Stro~e Facls. American Hean A ....ocialion. DaIIOi!o. TX. 199~-2()O:t RelTie\ed Seplember 2~. 2()(J-t. from Imp:II\\ ww.3mencanhean,org. 70. PeTIoli O. t:I al lIuman Blood Pre~!>ure IXtennmallon by Sphygrnom;lnomet~, \rnerican Heart A"ouallOll. Dalla!>. TX. 2001. Relrie\(~d Seplember 16. ~()()..I. fll'lll hHp:II~\~~,american­ hean.org

69. American Heart A,..ocialion. Heart and

Readin~~

-\lIlen"Lll HC..ln-\,...x:i;lllvn' HlS IBa.. 1i.: I.lk Supponl tor lIe;lhtK.lrc PiU\ldt'T. Amenlan He..ln "\"1""1311011. Dall..l.-'" r\ .:!UOI AUlll. M cl;ll An eJu,-'atll,)l1al pft,; IIllilldlllU111l duolu h~· ..n lOillurc (he"'l IIK( I, "iJ .:!(M.lO (OHm I 1';ll'dld" ..lI,d l ~\lurrnu. \' l'lkd III C\a;:flhl' IlIdd Oillli h ..lilli, Ir ut'll') on h,·.ut ral alld hl... kl pn- .. ure .UUhl!l" dur· mgd ll...llll't:\t'ru IIIlJSpoln J\,1cd~U:!\! l'i'N (roc r ")[ Alhngt.l ( nJ H..l II. UI< .... '-'-uta'-y"l polar ~-1 In h..:an murutor II, c IllllJlc cU('I~)' l' I "I r"l;fll"" t.:d S, I .... p.'n r ~f 1-11 ~u·"" La I¥. ;,d Pk. HIllman DR Jml rUlU,-..lu.: 1\.1.:. In'l'lfal"r~ llIu.... k rc:1 runnauo: 'II rnolurdnt: athlel and .lemJI) uh)l· 1 R\' 1'1l,,1~} I:) 11 '1.11 ldl Jhd IV 1;11 11,(' fdlahlhl) )1 \11;11 i n m~·.I .. ur.-lllo.:lll \lIn f-.nlt'It; tcd II ~UIJ!

E\an... D ~h)(lgkll1'<1lll. B. anl! BelT). J: \ II.!l 'I~n .. III hll'cuIl'l I AI' I Kl I ~ uh III i-1U ulllI'll\ filCI~UI) ph\:!lll.lllll.lfllUI\('kr III a p".&l:Jlalrie J"'-11'ul.i ll\lll BI""c1I'1 \ldlUl 4{ I, W '{JO·j

no

Ph, 1,.1 R.....hilit.Mn

'In It

om

CHAPTER

5 LEARNING

OBJECTIVES

1. Understand the purpo"e(s) of performing a

sen!\ory examination. 2. Understand the relationship between preliminary mental status screeniJlg tests and tests for sensory integrity. .\. Describe the classification and function of the receptor mechanisms involved in the perception of sensation. 4. ldentify the spinal pathways that mediate sensation. 5. Understand the guidelines for administering an examination of sensory function. 6. Describe the testing protocol for cach sensory modal it)'. 7. Using the case study example. apply clinical decision-making skills 10 application of sensory examination data.

Examination of Sensory Function Thomas J. Schmitz,

PT, PhD

OUTLINE Sensory Integration 121

Sensation and Movement 122

Dorsal Column-Medial Lemniscal Pathway 136

Sensory Integrity 122

$olllato"emol)' Corte,

Cllllil,:al Indil:ation" 122 Pallem (DiSiribution) of Sensory Impairment 123 Spinal Cord Tracts J 26 Age-Related Sen"iory Change... 126 Prelilninary Consideration" 127 Arousal. AUention. Orientation, and Cognition 127 MernaI)'. Hearing, and Visual Acuity 132 CJa~ . . ill.t:ation

of lhe Sen~of") Sy"lem 133 Sensory Receptors 133 Spinal Pathways 133

Type<, of SCll<,ory Ret:eph1r" lJ~ Cutaneous Receptors 134 Deep Sensa!)' Receplors 136 Muscle Receptors 136 Joint Receptors 136 Palll\\.ay'" tor Tmmrnis... ion of Somali!.' Scn...ory Sig.nals 1_~6 Anterolateral Spinothalamic Pathway 136

Sensory Integration If all oj r!u si't/.wry srimuli which t'/lIe,. rhe cellrml netTU/I\ .\ysrem were lllloll'ed TO homlJLml fill' higher (ema.\ o{lhe In(//I/, fhe /lultl'ldual would be n'lIdert'l1 urrcrh IIU'ht.'dire. Ii IS rhl' hrain's rwA roft/la, urg(JIl~ I:C lJfld II1U's.:r(//t! a /1/(0.\ (~{st'll.\On' II/fOrJIwtiOIi Hi IJilll If l (/11 h(' IHt'J fur flit' del'l>lopmellr 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\
tCnllrd a II,cor('f/( til ( ",,\fnll -f (a l:C llll cpt that fl rre l'n! ,111 I/l/OIHcll'oNe C\'ent). \\t' GIIHlot dfln rh oh...{'r\t: ( \is pro. L"l~ .... sing. IIltcgriltlon 01 <;cn<;ory mfonnatHHl or the mll!nr planning pmcc...... Hm'e\"c.'r. our currcnt "'1111\' kOI!t: III C S funltlon and ll1()((Jr hcha\Hlr pn''vlde... ( I(knee [hit thc ...e unoh eni.lhle e\ent<; dn ouur \Ve (,11/ nhwr llnp,llmlcnl In motor heha\lor. hut lJn onl} h l'Ofht·w that Ihl') truly rc... ult from faulty ...cn ...ory IIllt:gr"lllln Il1CChanl ...Il1 .... ~

The GI/idc ro P"vs/cal T"aap,H Prattle (' define ... 'l'n"ory illlegnty a ... "the intattne...s 01 conICal ...cn ...ory proces... ing. llKluding propriocepllon. pallc... the"'I,1 lereognn'Is. and IOpogno... I...... ! r fyll(l Sen..ory lIltegrit) 1<; II1cluded among the li ..t of 24 catcgone ... of te ...t... and mea ... ure... that may be used by phy~ical therapIst>, dUring patIent examl nation and i" included in all practice paltern" (I.e.. mu\(ulo"kelctal. neuromuscular. cardio\a"lular/pulmonJry. and mtegumenlary). Bo\ .5.1 present\ example.. . of pathologIC". Impitlrmenh functional limitatioll"l. di"abllities, ri'i\... factor.... and health. wel1ne~s. and (jtne ...... needs ali...ociated with change ... In "t:nsory integrity. Thi~ chapter focu~es primarily on examinatlon 01 ,omatosen-;ory integrity of the trun'" and C').lfCJ111lie . . a" well as screening for cranial nerve integrlt): tClilmg approaches for examining ('ranial ne,,·e I",egruy Jnd 1'£'flex resllug arc addressed in Chapter 8. As the C~S analyzes and uses all sensory input 10 identify movemenl errors and initiate corrcltive respon\e<;. examination 01 sensory function typically precede!' examination of motor function. This sequence a\~i~t~ the phY~lcal Iherapl ...1 In differentiating the lI11pact of ...en~ory Illlpainnen.... on mowr funclion.

Clinical Indications lndic:uiolls for examination of ... ~n\or) luncl10n Jre based on the hi~lory and ... y~lenb ITVle\\ (inl'luJmg J H'I/SO,.,\' sacel/llIg dc:-.cribed later tn thi ... chap[C'r). Thl' includ~~ "informalion provided b) the p..lIl.:nt!cllt'lll. family, ~ignificanl olher. or c~lreglver: "'~ mplOll1' described by the p:lllcnt/cl1ent: "Ign . . ob...erH·d ,1IlJ Jt"umentcd during the ") ...1t.:1l1... rt:\ le\,: ,1l1J IlllonllJlllln derived frol11 o(h~r ...ource" and recon"'''''' p"~ TIH>(' J.IlJ 111 a) indic<.1IC [he c\i..,tencc of pathology (llf n ... ~ \11 pathology) rc ... ultlng 1I1 ..,eJl\ory ChJng.L· ... th~l( 111.1) unpIN' Ilnpaiflllcnl .... luncllonal IlIlllt<1[lOn .... or <.1t ... atlll1t~ 1'1'(,.'

Bo, 5.1 l. St:n ...ory dy ... tuncllon 1ll,1) be ..l......lx:i ..lll'd "tlh ,Ul~ p.uholog) or IllJury dllectlng L'ltht.:r tht: pcnphcr,1I n~r"HlU' . . )'iIcm (PNS) or eNS. or \\ I[h a L'omblned ltlH1IH·1llt.'n[ \11 bOlh "y<;tclI1". DdiL'lh ma) Ol'Cur at ..lily POIIII \\ llhm tlw "'y"'I(,111 llll'ludmg lilt' "cn"or) n:n~·pl()r.... pcnphL'r.t1llt'rH" ",plll:d ncne .... "'pm..ll cord nudel ,1l1J lral:h, hr,11I1,1\.'1I1.

Chapter 5 Examination of Sensory Function

123

Box 5.1 Examples of Pathologies, Impainnenls, Functional Limitations, Disabilities, Risk Factors and Health, Well ness, and Fitness Needs Associated with Changes in Sensory Integrity Pathology/pathophysiology (discn:.e. di~order. or condition) in the following system,;: • Cardiovascular (c.g: .. cerebral va..cular accident. peripheral va:-;cular di..,cu.'\e) • Endocnne/mctaboliL (c.g .. diabetes. rheumatological dl~casc) • IntegumentaI) (e.g.. bum. frostbite. lymphedema) • Multiple System\ (e.g.. AIDS. Gul1lain-Barre \)'ndrome. trJ.uma) • \lu.,culo,keletaJ (e.g .. derangement of joint: dl\ordef\ of bursa. <;yno\lia. and tendon) • Neuromuscular (e.g., cerebral palsy. developmental delay. spinal cord inJury) • Pulmonary (e.g., respirator) failure. ventllatory pump failure)

11 ImpalOllCl1lS in the followmg categories: • Circulation (e.g .• numb feel) • Imegumentary integnty (e.g.. redness under ol1hotic) • Muscle perfoml30ce (e.g.. decrea; of feeling in foot) • Home management (c.g., difficulty with sorting change becau:-;e of numbness) • Work Uob/school/pI3Y) (e.g .• inability as a day care provider 10 change child's diaper because of loss of finger <;ensation. inabiliry 10 operate cash re£i<;tcr because of clumsiness) • Communlly/lei..ure (e.g.. inability 10 drive car because of los'S of spatial awareness, inability to play guitar because of hyperel;mesia)

IV. Di'tablllt). that i~. the lOabilit) or re.::.tricted ability to perfom1 actions. mdl\lduars sociocultural context. in the following categories: • Self-care • Home managemenl • Wor~ (job/schooVplay) • Communil)'/Ieiwre y

task~.

or actiVities of required roles within the

Ric;~ tactors for Impaired senSOl) mtegrity: • bck ot ...afet) awareness in all emironments • RiSk-prone behaviof:) (e.g .. workmg ..... ithout protective glo\'es) • Smokmg histor} • Substance abuse

VI Health, wellnes .... and fitne~s needs: • Fltne<;s, mcluding physical perfonnance (e.g.. inadequah: balance 10 compete in dancmg competitIon. limited perception of ann" and leg ... in "pace dunng ballroom dancing) • Heahh and wellness (e.g .. madequate under-.tanding of role of propnoceptlon in balance)

thalanlu\ J.nd semor} l:oncx. 1I E>.amplc\ of l:Ondltlon, that ~cllt:IturbaIKc" (tlIJJX'te\. h) poth. rOll,lI III .tkuholl\1ll ,; inlel:1I01l\ (L) me dt ...ea..,e. It:pro ~ humo.tll Ilnlllunodetlut:IK) \ Iru..,1 HIV)L Impingement or Ullllpre\~llln (o.tnhnll\. l:i.Irpal tunnel \) ndmme): bum, to\ln .. flc<.td. l11l.:rl:UI). themotherap) I: MJllo.tkJ "-Ith lIlJlIr) 10 nerv .... roob or "'PIll..ilu)fu. u:n."bra I \o.t ulJ.r dll:IUUll «('\'..\1. tran\lent I lhcnllL o.tllad

(TIA), tllmor~. l1lultiple sclero.\i\. and bn.ull injury or dl\ea..,c. Thc,>l' 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 <;ome element of ,en"or}

detil'lt.

Pattern (Distribution) of Sensory Impairnlent b.i1l1lllldIIOn 01 ..,en,or) fUlldlOll nmlnbute, l:ritil'i.lI int'ormiltlllll to c\ti.lhlJ,llIng o.t ph)\IL.\1 therap) lllagno,)I" and progno'I\, uklllll~ Ing J.ntinpateJ goal-. .lull e\JlC"dcJ

oulcome<>. and developing a POC. A 'lemmal leature 01 the el:amination lO'"o!\'ec; delenninll1g the patter" I <>penfic boundarie<;) of ~en<;or) in'"ol'cmenl. Pallem idc:nllficatlon is accomplished uSlIlg "'no\\ led,ge of ... kin ~cgment lI1ner+ vat ion by the dorsal rOOts and penpheral nerve., (Fig .... 5.1 and 5.2). The term dermatome (or ski" sc,':"lellf) refer" to the skin area ~upplicd by one dorsal rooL 9 (/I Ie \I

'''II

I.

\ I

II

Dunng the reVlc"- of '>)",lc01.... a"''''lI1g Ihe pallent to c<\rcfully de,cribc the pmtern or di,tnbution of ') mptnm... (c.g.. tingling. nlJl1lbne ... ~. dimini<;hcd. or ab,em ... ~n-.allonl provide~ the lherapi,' with preliminary InformatIon to help guide the el(amin3tion and to a,>,iq in iden!lf~ 109 the

II

I I

11/

, /1(/1"'"

......... / Ophthalmic nerve } ./'\ . Maxillary nerve

Tngemlnal nerve

_'IV" / Mandibular nerve ~r"y" Great auricular nerve

cervical nerve ......... XTranverse Supraclavicular nerves /

.r

--::~h2T1 _ T2

~

T3

Intercostal nerves Anterior cutaneous rami Lateral cutaneous rami

r----:::L T4

Axillary nerve

T5 C6

_+-;--- Medial brachial cutaneous

1l....-~*T6

and intercostobrachial nerves Inferiorer lateral brachial cutaneous nerve --,<-:'--Medial antebrachial cutaneous nerve Lateral antebrachial cutaneous nerve

T7 n---.::r_ _::::.-T8 T9 ~~

-.-no T11 T12

~-:\- Ulnar nerve

Median nerve

~

Ilioinguinal nerve Iliohypogastric nerve Lateral femoral cutaneous nerve

Anterior femoral cutaneous nerve

Lateral sural cutaneous nerve

r ~~ .

Saphenous nerve

Figure 5.1 Anterior vk\\ uf

Superticial peroneal nerve Sural ne"e Deep peroneal nerve

~kin .,cgmcnt inllcr\'~tlon b)

Fibular

dor-.~I rOOb (hit) Jnl! pt'npIH:ral ne"e'i (ng/"t (From Gilman. S. and N~\\man. SW." r~' \\Ith !X'rTllb.,lon.)

Chapter 5 Examination of Sensory Function

125

Grealer occipital nerve Lesser occipital nerve Great auricular nerve Tranverse cervical nerve ....... / '

~.

Supraclavicular nerves Posterior cutaneous rami of thoracic spinal nerves Axillary nerve Lateral cutaneous rami of thoracic spinal nerves Posterior brachial cutaneous nerve Medial brachial cutaneous and intercostobrachial nerves Lower lateral brachial cutaneous nerve Lateral antebrachial ~ cutaneous nerve \ Posterior antebrachial cutaneous nerve '\~"'-',---Medialantebrachial cutaneous nerve Median nerve Ulnar nerve Iliohypogastric nerve Cluneal nerves

L5

Perforating cutaneous nerve Lateral femoral cutaneous nerve

L2

Obturator nerve

81

5

Posterior femoral cutaneous nerve L4

Medial femoral cutaneous nerve Lateral sural cutaneous nerve

Medial sural cutaneous nerve

5'

Saphenous nerve Sural nerve Calcaneal nerves r""'
r

L5 1l..'-""-L4

Lateral plantar nerve Medial plantar nerve

Figure 5.2 Po!:>terior \ i("" of .,I-Hl !:>egmenl innerv:ltion 0) dorsal roOb licIt) and peripheral nerves (n~JI/I. I From Gilman. S. and Ne"man. SW.'ol. p~~ wilh perml~~ion.)

deml,tIUmch) .md ner\e(~J Imohed. Penpheral nerve IOJUflt~ gener.lIl) pre~enl "t:n~ory lmp;ilrmenl~ thai pural· leI the di~tribulJon ollhe imolved nerve and cOn'cspond 10 I" piJllem olll1nenalloll. For e>.umple. II a patient pre!'>cnl~ "11h l"OmpL.ullh 01 numbnt:')') on the uln.u hall of the rmg flngcr the lillie linger. and Ihe ulnar side 01 Ihe hand. the

therapist ,",ould be alertcd to carefully

addre~~

ulnar nerve

(C8 and TI) lntegnty during the sensory ex.amination.

Complaints or sensory disturbances on the palmar surface of Ihe thumb and the p.llmar and dislal dorsal aspecls of the tilde),. middle. and the radial half of the ring fmger ,",ould be Illdlt.:all'C' ot median nene (C6---8 and Tl) in\olvement.

Other p,lUt'm, 01 "'cn'l")rj 1o... , llli.l~ hl' Ll"Pllatt'd \\ nh ... pel..'ltlC ra1hol'-'g~ Fl\r c'~lInpk. \\ IIh pcnpher.ll IlI.'lI rop.nh) (e.g .. lh=lbt.-te,l. ,en'ol~ 10" " {llll'lI .111 carl~ ... ~ Illptolll and pr~,cn" 111 J ··glm e and ,IPlJ..lI1g"· lh"nhlltit)1l (rekrnn~ Illihe I~ ru:allll\lll\cllll..'nt l\I Ihe hand, ,1Ild I(-cil. In I..'onlra ..... lll11lllpk 'lknl"'I' Irequentl~ pre ...ell" \\ ith :lll unprclllCl.lble or 'l·allered pallnn oj 'Cfl'iJr~ 1m (\ IVt·lllcnl. SpinJI cord illJury (SCI' oftcn pre ...t'llI' \\ IIh ~l 111mI..' diffu'e p,lUcm of 'cn',-,r~ ill\ol\CIllCnl hehl\\ Ihe lC'lllll k"c1 Ihat \, t) piGJll) bil.lleral. ~Ilthl..lugh 11('11 necc"anl~ '~1Il­ melTlcal E,aml11,uilln of ,en,or) lundioll 10110\\ IIlg SCI pro\ "k... aitlcal d~lIa 111<11 reflect Ihe degree 01 neurological llnpalmlenl. Together wllh oll1l'r Ic'h .Ind t1lca'llTC'. 'cl1"'or) d..HJ cnnlribule to delcnnming the rel.lll\t' completenes, of the IIlJur). the e,i ... lence of :01/('\ (d'/)Ort/ol prcsanu/oll (area ... di:-'Ial to a COt1lpk~le Ie, ion Ihal retain pal1ial innenation). ,ymmetry or a,ymmelr) nftht' lc,ion. and the presence of .. acral ~ensation bdow lhe n~urologi­ cal level of lesion {a defining fe~lIure of an incomplC'te lesion}.

Spinal Cord Tracts E\J.mination of ~en::-.or) function abo pro\ ide~ data Ihat reflect the integrit) of the ~pinal cord tract~ lh~11 carr) ~omatosensory and special sense (e.g .. 'ighl. hearing) information. For example, contri.ll~iler"l lo~~ or impairment of pain and temperature perception is suggestive of lesions in the anterohHeraltracts. Deticit~ in discriminalive sen~a­ tion~ such as vibration and two-point discrimination sugge~1 le::-.ions of the dor~al column. Evidence of both ~ensory and mOl or los~ b usually indicative of nerve root involvemenl (recall that the dor~al and ventral rools converge to fonllihe spinal nerve...). C 'S lesions (e.g.. eVA. brain injury) may produce ~ignificant sensory impainnenls characterized by a diffuse p,lItern or involvement (e.g .. head, trunk. and limb~) and can re~ult in significant Illotor dysfunction (sensory i.ltaxia) and impairment of fine mOlor control and motor learning. as well i.lS present a significant threat of injury to anesthetic limbs {e.g.. an inability to detennine the temperature of bath walcr}.

Age-Related Sensory Changes Altcralions in sensory function occur with normal aging and should be clearly differentiated from those associated with specific illness. disease. or pathology. In recent years there has been a gradual expan~ion of interest in and information aboul the causes and con,equence::-. of age-related sensory changes. This has been evident Ihrough lh~ expanding body of literature devoted to the neuro~ciel1l:(" of aging and ils impact on funclion ,md 4ualily of life of

Illlki •• dull ... _" 1(" 111/,,1/,.11 lhl..· Ipurll:ll 01 th, \fH~ fl :tn \1l1.ll'l\ III \gln~' h,I' tk\(ll('l! ,111 nlJn.: I 'dlc;: 101 \"1I1~ ,Illd Iht· Sell l· ... l\pl \ \ \11 !\in I Srnn~ 1141 I Ih III IIll' 11,.-'" addrt..·"l·d.lft.. pt 1111,. q,!l 'l·I.III..'\I I.h Ill" \ 1"'1\111 h.... i.llln~. lind the ... tHll.llt"l·n'tlr~ "'\'Itlll If Hill! nt, pre\~d('nt·l·, j·-~o Agc-rt'latl'd change... III lllorpholng) .ltld d("crea.~ed l:ol1ccntratioll:-- llf Pacilliall l~llrpll"'l..·k... , l"e,pOllsivt' to rapid ti",uc mOVCllll'nt (l'.g .. vibration). ha\t' :tho

,.1

b~en repnrted.~'

De!!.ener'lIi\t" dl'Ill!.!":~ inlll)din ha\t' bCl..'n dOt·lI11h::ntl."d .... ".Jl.lA' 111 both the cenlral and pcTlphl..'ral llt."f\ OU"l ...) ,11..·1ll'." In a rt"\ iew or the literalure on thl· eflt"I.."" 01 Illlnll:11 "ging on Ill}din and ner\co fiber.... Peler,-lll ... uggl.·'" that ....

Chapter 5 Examination of Sensory Function (I) age·a",,:,,oclatcd t'ogniti\e decline i<, Illore likel) due to \\ id~ ...pre

11 Age-related reduced ellicienc~ In motor planning has abo been documented. hi The ... e change ... frequentl~ appear in the pre~ence of agerebled \ I\ual or heaTIng lo'l\c<, that impair compen ... ator) rapabllltlc .... In addition. 'lomc medications may further lIlfluence the dl ... tnnion oj emor~ input. Thi:. combination 01 "en...ory ch:.l1lge ... may po e a \ariety of functional limitation ... lor the elderl) indi\ iuual ~uch a . . po~tural lfhtabillly. ~\ag,ger,tted hod~ ... \\a~. halalH.:e problem<,. \\ide-h"hed gall. dllllilll ... hed line Illowr COOrdlll:lllon. tendency 10 drop Item ... held In Ihe hand. <.ll1d dllfil'uhy in rt'cogni/ing bod) rO\illLln 111 "'''.llt' b Id~llt'e Summary Bo\ 5.~ provide ... .tn (l\cf\ It'\\ 01 re"t',tn.:h dat.l t'\r1onng agc-r~lated "en... or~ haJl~t:"'>

l

(II I' 11 I

(1/ I 111

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"

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II/

ddt/if/"'I

I"

dtl"1

IIlt/\

i1t I Idl,ltl

It

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,('

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l/l:t'-n: lOll tl

/It

t H/I

lu\on

t/h
tllll IUI/1 0' Iltt Ilt/m·

lI't/s,nhl

lit/fIll 1/,.\\

Preliminar)' Considerations llUri.tl 01 ,1.11 .. Ir'lill t:\,llHIII;t1h)11 ,II "''':11-.\11\ Illlll(ltlil II 'II Illl p.IIll/1i ..Illlltl\ (I) It' (lHllJ hi .lrplll,lIlon 01 multq Il llll.ito C'1l PI\ ... llInuh I ...c nl l'\ l-l.tI l:,l lh Jllllllllllr I prdtllllll..tl Il' h \\111 rltl\idc "'UIJI~Il'llI d,t1~1 10 Jd~ tlllllll till jl.tlll·lll .thllll\ til lllllll'lIll.ltl: ~lll ;llId r" ponJ [11 (III,; h..tlh.:I\ \11 Wlhlln h· ... t lklll-. lilt' t\\11 "lll If..il ~ ,jl~ \If Il lIt 1'1 d 1111 11I.1I ~ [c· ...h ll11hllk l!tl' p;Jlll·IlI· ... \ II tHili .. III \d ,-,!ll:lllJiill "'1'1.111 OIIUIl,lllOIl ~IJld l'U~lIl1l\lll' .llId e21 lllt:lIll1l\ h~·.lllll)! dlid \ l"'lI,tI ;llUH~ Illl· ...l:·jlldlllll

I

..

.

127

nal)' tests are typically considered with sensory involvement
Arousal, Attention, Orientation, and Cognition A necessary first o;;tep is to determine the patient"'i arousal le\el for participation in the test protocol. Arousal is the ph) ... iological readiness of the human system for activity.i It is described by using traditionally accepted key terms and definitions to identify the patient'~ level of consciousness. These terms include alert. lethargic. obltmded. stupor. and como and represent a continuum of physiological readiness for activity: they are defined as follo\\s6~:

• Alert. The palicn[ is awake and attentive to nonnal levels of stimulation. lnteraclions with the therapist are nonnal and appropriate. • Lelhargic. The palient appears drowsy and may fall asleep if not stimulated in some way. Interactions with the thcrapiq may get diverted. Patient may ha\ e difficult)' in focusing: or maintaining attention on a 4uestion or task. • Ohfllflded. Thc palient is difticuh 10 arouse from a somnolent !'tate and is frequently confused when awake. Repeated stimulation is required to maintain consciousne!)s. lllleractions with Ihe therapi:-.I may be largely unproduclive":. • SII/POI" (semicoma). The patient re~pond~ only to ~trong. generally noxiou~ stimuli and returns 10 the unconscious :--lale \\ hen 'llimulation i:-. ~toppeJ. When arou'\ed. the patient I'" unable 10 interact with the therapl"'t. COf1/U (Jeep l'oma). The patient canl1Q1 be aroused by aJl~ 1~ pI? of timulation. Rene\ motor re"'pon ...es ma) or ma) not be e~n . Rl~habk infomlattoll about lh~ Intt'gnt) of the ...0111;jto... ~n'lor) ~~ ...tem can be obtalllcd trom pallenh \\ ho ,lrC' alL'rl. Rt'lii.lhilil) i:-. proportion<.ll1~ reJuceJ III paucnh \\ ilh leth ..trgy and nonn! ...tent In pJtlenh \\ ho l.lr~ obtunJed. ... lUporoU .... or eomato...e. \l1UI1/01/ I elccll\~ .marcnc...... ot thl' t"11\ Ironment or rl;""pOlhl\ c'ne 10 .\ ... lll1Iulu ... or l~hJ... \\ II110UI Ixmc lh~Ir,tdl:J h) nlht'r ... tlmuh. 'h~ \t1~lltlllnl.·Jn tlC' e\.imll;l,.'J b\ ,1... klt1g lhe r.lIl('11I III rere;1I Hem'\ 011 .t pr\'Ig-rt· ...... I\ C'I~ ll1or~ \.hJIIl'n~lt1g 1t... 1 The ...e rt"p('lltlon l.h1-.. l'an ~glll \\ uh {\\O or lhrl'l' 111.'111'" ..lJltl gr.ujuall~ progrt· t(l Il\nger li ... h. Fur t·\.lInpk. Ihe rallL'111 1I11ght be ,bkl:J III rL'I'll'.1I .l "'l~rie'\ ~\t numh..:r... kiln.... or \\orck\l1other dPPhli.ll·h 10 c\.lJl1ll1lng ,Jlll'llilOll I... TO ;I ... J.. IhL' p.Ult"nl hi "'1)('11 \\lJrJ:-. h~l\.·J...\\.Ird,> 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
Wiles, et al.22 1991

Purpose

-- --

IT.,an age of 805 years The original sublects partJapaled rn an exerCIse program conSISting 01 endurance and balance tra1OIng The current study had the tol"""ng compooents ques"onnalre (addressmg health habits, VISion and heanng. medical hiStory, and activity level): statIC balance tests (Romberg lests one Jegged slance). walking leslS l»m rormaJ ilf'jj heeI-lo-toe): ard ltjnamc posIurography (sensory "'9'fIl'l1ton tesl(SOTj ilf'jj movemenl COOfdr1aIton lest [MGT])

Conclusions/Co.men..

ChapteT 5 Examination of Sensory Function

131

Evidence Summary Box 5.2 Evidence Sununary: Research Exploring Age-Related Changes in Sensory Function (continued) Reference

Purpose

Subjects/Design

Results

Conclusions/Comments

Bouche, el ai," 1993

To study Ihe effecls of age on the peripheral nervous system and determine nsk factors (RF) thai may adversely affect nerve fibers.

59 phy~cally active subjecls over 60 years of age and 23 healthy young sUbjects. All subjects underwent a neurological examination consisting of a sensory examination and a tendon reflex examination, EMG readings using a concentric needle electrode of the tibialis anterior (TA), first dorsal interosseous (FOI), and extensor carpi radialis (EGR). Median and common peroneal nerves were investigaled using surtace electrodes in order to determine nerve conduction velocities. A laboratory investigation of the elderly subjects consisted of screening for potential causes of peripheral neuropathy of various origins.

The subjects were divided inlo 5 groups (I, young subjects; 2, younger than 80, wilhout RF; 3, older than 80, withoul RF; 4, younger than 80, with RF; and 4 older Ihan 80, wilh RF). 29 eldeny sUbjects were considered to have risk factors. Proprioception impairment, absence of ankle reflexes, and reported sensory systern changes dearty increased wi1h age. EMG amplitude decrease was shown in patients over 80. Decrease in nerve conduction velocity was found with increased age, especially after the age of 80. Group number too small to allow statistical analysis of RF.

Age-dependent sensory changes are a result of atterations of the peripheral sensory receptors, muscle and tendon structural changes, and changes in the peripheral nerves. Age-relaled changes in muscles are known to be caused by myopalhic and neurogenic processes; relatively small sample size.

Bohnannon, et al,59 1984

To establish a relationship between timed balance perfermance and age both wilh EO and EG (Increased reliance on proprioceptive Inpull

184 SUbjects aged 20 10 79, with 30 or more members in each age decade. Subjects had no vestibular deficits or dysfunction of the trunk and lower extremities. SUbjects perlormed Ihe following balance activities: 1) balancing on two legs, feel 8 mches apart, then together, with EO and Ihen EG and 2) balancing on each leg, eyes open and then eyes closed. Trials were allowed a maximum time of 30 seconds.

All subjecls, Ihough some elderly required more than one trial, balanced for 30 seconds in all two-legged stance trials (both EO and EG). For one-legged stance, the mean balance time diminished with age. All subjecls under 45 balanced on one leg for 30 seconds with EO. No subjecl older than 70 could balance more than 13 seconds.

The duration that individuals can sland on one leg is highly relaled 10 age. Inabilily 10 mainlain balance for 30 seconds lEO or EG) while feet are together can be considered abnormal in patients aged 20 10 79. The limiled num· ber of subjects prevents use of these results as true normative values for balance. Expectations for balance test results should be age specific.

KenshaJo, Sr 1986'

To examine several _ 27 young (ages 19 to 31) and modes of somata21 elderty (ages 55 10 84) subsensory acUity and jects. Absolute Ihresholds were determme location measured lor six modes of where losses can cutaneous sensation (tactile, be demonstrated through single ramp-and-hold and whether these skin indentation, vibration al losses are site 40 and 250 Hz, temperature specific Increase and decrease, and noxIous heat). Tests were performed at the Ihenar emmence and plantar surface of foot

Elderty persons were signif· icantly less sensilive than young individuals to mechanical stimuli at both sites. No significant differ· ences were found for thermal stimuh, except thai eldeny feel were less sensItive 10 warmlh lhan young feet.

There was no Increase in defICits found With increasing age; relatively small sample size.

Kenshalo, Sr, DR Somesthellc sensItivity In young and elderly humans. J Geraniol 41 (6):732, 1986. EVidence Summary Box 52 prepared by Stephen A Caronia.

1.\2

Ph}'sicoJ RehabiJitation

Box 5.3 Sample Questions for Examining Orientation A series of simple que<;;tion, i'i posed to the pal lent. The questions arc del1,igned to detemlinc Ihe patienl's understanding of recognilion of who he or she j~. location including the present facility (the !lame of hospiHlI or clinic). Ihe present lime. and the passage of lime.

Person • What is your name? • Do you have a middle name? • How old are you? • When were you born?

Place • Do you know where you are right now? • What kind of a place is thjs? • Do you know what city and state we are in? • What city or town do you live in? • What is your address at home?

TIme • What is today's date? • Whal day of the week is it? • What time is it? • (s it morning or afternoon? • What season is it? • What year is it? • How long have you been here? From Nolan, MF.'·! P 21) with

permi,,~ion.

results of this mental status screening are often abbreviated "oriented X 3," referring to the three parameters of time. person, and place. If a patient is not fully oriented to one or more domains. the notation v.ould read "oriented X 2 (time)" or "oriented X I (time. place):' \\lith partial orientation entries. it is cuslomary to Include the domains of disorientation within parentheses. Box 5.3 prcscnt~ ~amplc questions for examining oriel1tation.9.fi~.f').1 Cognition i~ defined a~ the proce~s of I...nowing and includes both a\l.arene~s and judgment. 11 Nolan b ! ~uggesb three area" for testing cognitiondependent function"l: (I) fund of I...nov.ledgeo (2) l'alculation ability. and (3) proverb inlerprdation, Fund of kno\\ ledge i~ defined as the ~um total of ,10 indi\ idual', lc<Jming and experience in life. \\ hich \\ III be hlghl) \ari~lblC' ~md different for c<Jch patient. Det~lIlcd 1Il1onn:lliOn ahoul premorbid knowledge bJ'le i.. oftcn not avad<Jhk, 1l0\\t:\l'T, a number of gcncr~ll ro.tlcgorie'l of lI1fOrm:lllon Can bl..' u'\t'll to te'll Ihi, cognitive fUllclion. SampJ~ yuc'llinn.. might includc 6 :: \Vho became pre..idt:nt alter Kennt'd~ \\3" ,hot" Who i, tht: lUm.:1l1 \ icc prt:... denl of Ihe l Illtl'd StJIt"! \Vhlch i'l more-a gall\," or .I 11ll.:'-' In \\ hat countr) I.. . Ihe Gre~H p) r~H11ld.' \Vhal ~oulJ ) (lU ,ldlt to ) our 10nJ 10 malt.' II '\h°t.'la"

In v.hat 'lli.lte \"ould you find the til} ot lio'lt!!n' From \\-here do Ihe "'pau: ... hullk... talc otl' \Vhat arc the rlcmcnl'i Ihi.ll m,ll...c up \\ ater ,mil .lIt' C~m you name a car made hy General lotm, I Who is Charle~ Dicken... ·! Calculation ahilit.v C\'dmlllC'" foundJllOnil1 ll1;tthemilll cal abilitie ....":'''' Two a...... oclatcd term<.; . Ire acakulia (inability to calculate) and d)';talculia fddlil..u!t\ In accompli\hing calculation'l).('~ ThIS cognltl\c <';l..rct:nlO:! can be admini"ltered either yerhally or III \\. nllen lorm
10+22= __: 6 X 6

:46x8=

:J:\x7= __ :4"3~

= __: and '0 forth).

Pro\"erh interpretation examine~ the patient .... ahilil~ to interpret use of \\ords oUhide of their u,ual l'Onlcxl or meaning. This is a sophistici.lted cognitive 11Illclion. Dunn~ the screening, the patient .;;hould be asked to d~ t:n~ the meaning of the proverb. Se\cral "ample prO' erb i.lre"- t : People who live in gla'is house, ')hollldn't thrc)\\ ...rone, A rolling stone gathers no rna"',. A stitch in time saYe~ nine, The early bird catche\ the worm. The dog that trots about linds the bone. The empty \\agon make, the 1110\1 nUI ...t.'. Every cloud ha'l a siher lining. Gra~s doe,>n't grm\- on a bu...) slr~et.

Memory, Hearing, and Visual Acuity AJ,o related to the ability to rc ... pond dUTlng. ,(.·n,or~ 1t',\ing is the 'llatus of the patit.:nt\ memory
Memory Both long- ,tIld ,hort-tcnll 1ll1.'l11m) ,hould lx- l'\,Il11llltoJ Imp<Jlrmcllh 01 ,hort-Ierm menwry \\ III Ix' tht.' Ilhhl til ..· rupti\l.' 10 colkctmg 'I."n'lIr~ II1lonn~1l1011 0\\ In~ to r,lllt'nl dlfficultlc ... 111 rCI11t.'mhcnng .Iud 10110\\ Il1g dIlC((lllll' Long·tcTIll (rCIllOh.:) Illemur) can he l'\i.llllllll'd 11\ rl..'lIut',1 lI1g infortlhlll\ll1 nn date .llld r1i.lll." ot hlrth IlUlll!.x'.. ill '111ling" datl.' n! m:lrn:tgl', ... (11001 ... \.lHl.:IH.h.:d. hl',lpTll',d t.lll' and so fUrih. Short~lc.:rnl lllt.'tlHW) can h,,- ,llklrl"'l'd hy \t'r h.IIJ) pft)\ ldlll'::' the p.ltlt.'llt \\ 1111 :t ,"'rtC' 01 \\l\rd, or IlUIli her,. For t.'\i.unpk, d 'I."nl', 01 \\ort.... lllll!hl llldudl.' '\.11 ht~ll, ,,:up"; U't.' {ll nUllll~r, ululd Illlllh.k .1 ":\l'n~dl;:11 lI,t; a ,hurt ,,:nIClll·C could ... 1'0 ht.' lI'l.:t1 10 tl"1 ,hnrt It'rnl memo'). Thl.." 'cqUCIl{(, ... hnuld ht: rt'I"lt.'.Ill'J 11Il1lll.'dli.II~I~ tl\ thl' p.ltil.'nt to 1..·"'lIn: Untkr,I.lIltllnl! tll the 1,1'\0.. IlId" tJII.d .. \\Ith norm.tll1ll'llltlfy IUl1l..I1I111 ... hltuld tx' ""'It.' HI rl'l,lllllw

132

Pby~icat

Rehabilitation

Box 5.3 Sample Questions fa< Examining Orientation A series of simple questions is JX)scd to the patient. fhc questions are designed 10 deternline the patjent'~ understanding of recognition of who he or ... he is. location including Lhe present facility (the namt: of hospital or clinic). the prescm time, and the passage of time.

Person • What is your name? • Do you have a middle name? • How old are you? • When were you born?

Place • Do you know where you are right now? • What kind of a place is Ihis? • Do you know what city and stale we arc in? • What city or lown do you live in? • What is your address at home?

Time • What is loday's date'? • What day of the week is it? • What time is it? • Is it morning or afternoon? • \Vhat season is it? • Whar year is it? • How long have you been here? From Nolan. MF.~1, p Z6 with permis~ion.

results of this mental status screening are often abbreviated "oriented X 3:' referring to the three parameters of lime, person, and place. If a patient is not fully oriented to one or more domains. the notation would read "oriented X 2 (timer' or "oriented X I (time, place):' With partial orientation entries, it is customary to include the domain.'! uf disorientation within parentheses. Box 5.3 presents sample questions for examining orientation.9.61.63 Co~nilion is defined as the process of knowing and includes both awareness and judgment. 6 Nolan62 suggests three areas for testing cognilioltdependent functions: (I) fund of knowledge. (2) calculation ability, and (3) proverb interpretation. Fund of knowl· edge is defined as the sum total of an individual's learning and experience in life, which will be highly variable and different for each palient. Detailed inforn13tion about premorbid knowledge base is often not available. HO\tever. a number of general categories of infornl.ttiol1 c<.In be used to teSI this cognitive funclion. Sample question . . mighl include62 : Who became president after Kennedy wa~ ~hot? Who is the current vice pre~idC'nt of the Unilcd States'? Which is more-a gallon or a liter'! In what country i~ the Greal Pyramid'! Whal would you add 10 your food to ma~e it ","~cler'?

In "h~lt ...talc \\tluIJ y011 find th\.' ut\ 01 Rn... lon'l Frulll \\herc uo tht' "'PiK~ ... hl/lllt" t,-l~e nIl') \Vhal are the clement' thai milkc lip \\ ilh,'r .lIlt! .111' Can you name alar nl.lde hy (jcneral \lolnr... ' Who is ChMk, DiLken,,:

Calculalion abilit) c'{;t111ine, fnundatltHl,11 tll;ttht'l11,l1lcal abilifies.I>' (,\ Two a'"ocl:lIeu ternl''' ;'1'(' <'H:alculia (inahility 10 cah.:llialc) amI d,vscalflliia (diIlILlIl1, In accoJllpli . . hing c~l1culalion"J.I'~ Thi" L'(lgnII i......: "'<:rt:t'lllng can be admini"lered eitha \crball) or In \\TJlh:n fOrm,lt The patient IS a'lked 10 menially perform J. <>ene: ... 01 t..lku~ lation" when provided \\ ith I11dlhcmalical prnhkm.... Th~ leSI :-.hould be initiated \\ith ... implc problem ... i.lI1d prugre"... 10 the more difficult. Adding and ;: People who live in glas<; hou')e... ~houldn', lhro\\ "tone". A rolling stone gathers no mos~. A slitch in time saves nine. The early bird catches the worm. The dog that lrots about tlnd" thl.' bonc. • The empty wagon makes the mo~t noi~e. Every cloud has a ~il\'er lining. Grass doesn't grow on a bu.. . y "treet.

Memory, Hearing, and Visual Acuity Also related 10 the ability 10 re... pond during "'I.'I1 ... (\r~ It'''ting is the status of the patient':, memory and heaflng. tUllCtion as well as visual acuity.

Memory Both long- and :...hort-Icnn ll1ell1or) ~holiid lx' c\.anlll1l'd Impainncnll) of ~horHt:rm mcmory \\ ill be Ih~ 1110"" lll,,ruplive to collecting ...ensor~ inlon11ation 0\\ II1g tll p,'lit'nt difliculties in remembering and follO\\ Ing dm:ello n .... Long-ten11 (remOle) Inemory can he eX:lmint:d b~ r~lllll-",l­ ing information on date and plac(' of birth. nllll1lx'r 01 ... ILlling .... date of marri:.tgl..·. school" atle-nd~u. hi'ltOf1l'al f.h.'[". .lI1d so forth. Short-term ll1\.'mnry can be addrc:... ...l'd b) \t'rbally providing the palient with a ... t'ri~ ... 01" \\ord ... or JllJ1Jlhers. For example, a ~erie ... of word ... might illL'llId~ "car. book. cup"; lI:...C (If n1l11llxr~ eould indude a "'t'\I.'n-l..lIg 11 list: a ...hort ~ent~nce could al . . o ht: u...e-d to te... t "IHlI1-ft'rTll memory. The ",cljue-nee ...hould he repeatcd 11ll1l1t.'dl.tld~ b~ the palienl to en ... ure under...tal1lltng l)f the la ..."'. InUl\ IdU,II" "ith nomlal 1l1~n1l1r) function ... hould hi: ablt: to fl:'l'~t11 tht'

Chapter 5 Examination of Sen."ory Function li..,t :' minllte~Q bter and at lea::.1 two of the items from the li..,t afler 30 lllinllte~.foJ

Hearing A grosl\ c'X3mination of hearing can be made by ob::.erving the patient\ rc"'ponse to conversation. Note should be made of how alteration::. in voice volume and tone influence patient re:-ponse.

Visual Acuity A gross vi::.ual examination can he made by use of a St<-Uldard Snellen chart mounted on the wall or visual acuity card;; for lI~e al bed::.ide. If the patient uses corrective lenses. they ~hould be worn during tesling. Visual acuity is typically recorded ~lt 20 feet (6 m) from the Snellen ChaJ1 (standard eye chart). nlis distance (20 feet l6 111]) is then placed over the ~izc of the type the indi\'idual is able to read comfol1ably. For example. on a continuum of visual acuity 20/20 is considered e'Xcellent and 20/200 is considered poor acuity.9 Peripheral field vision can be examined by silting directl) in front of the patient with outstretched amlS. The index finger::. :-.hould be extended and gradually brought toward the midline of the patient's face. The patient is asked to identify when the therapist's approaching finger is fir~{ ~een. Difference::. between right and left visual field should be noted carefully. Depth perceplion may be grossly checked by holding two pencils or fingers (one behind the other) directly in front of the patient. The palient is asked 10 identify the foreground object. Becau;;e te~IS of ::.ensory integrity require a verbal re,>pon~e to the stimulus. patients with arousal. attention. orientation. cognitive. or :::.hort-teml memory impainnents generaJly cannot be accurately tesled. However. impairment:::. in \ ision. hearing. or speech will nOI adversely affect test re::-'lllt:::. if appropriate adaptations are made in providing 1Jlstruction~ and indicating respon;;es (e.g.. signaling with either one or two fingers during tests for two-point di::.crimInation. poil1ling 10 an area of stimulu::. contact. mimicking Joilll po!o.ition ~ense or i.t\\ arene::.s of movement with the contralateral extremily. or objeci identification by selecting trom a group of items during tests for stereognosis).

Classification of the Sensory System

133

they give ri::.e to perception of a specific sensation. Sensory receptors are highly sensitive 10 the lype of stimulus for which lhey were designed (tcnned receptor specificiry). This .l,peciticity of nerve fiber sensilivity to a single modal· ity of sensation is called fhe labeled line principle. 64 This means that individualtaclile sensations are perceived when specific types of receptors are stimuJatcd. For example. in response 10 touch. selective activation of Merkel discs and Ruffini endings generate the sensalion of steady pressure in the cutaneous area above the active receptors. 65 It should be nOled thaI the teml modalit)' has a specific meaning within the context of sensation. Modalil)' "defines a general class of stimulus. determined by the type of energy transmilled by the stimulus and the receptors specialized to sense that energy."65. p"'U Each type of sensation perceived (e.g.. vision. hearing. laste. lauch. smell, pain. temperature. proprioception) is referred to as a modality of sensatjon. The three divisions of sensory receptors include those that mediate the (I) superficial. (2) deep. and (3) combined (cortical) sensations. 9

Superficial Sensation Exteroceptors are responsible for the superficial sensations. 66 They receive stimuli from the external environment via the skin and subcutaneous tissue. Exteroceptors are responsible for the perception of pain. temperature. light touch. and pressure. 9.66 Deep Sensation Proprioceptors are responsible for the deep sensations. These receptors receive stimuli from muscles. tendons. ligaments. joints. and fascia. 6J and are responsible for posi· tion sense 67 and awareness of joints at rest, movement awareness (kinesthesia). and vibration. Combined Cortical Sensations The combinmion of both the superticial and deep sensory mechanisms makes up rhe third category of combined sensations. These sensations require infom13tion from both the exteroceptive ~Hld proprioceptive receptors. as well as intacr function of cortical sensory association areas. The cortical combined sensations include stereognosis, two-point discrimination, barognosis. graphesthesiil. tactile localization. recognition of texture. and double simliltan~ous stimuhllion.

Spinal Pathways

St\eral different "l'hel1le~ have been propo~ed for categofl71ng lhe '('11"01) "y,tem. Among the more common is da'l\J!ic'Ition b) Ihe t) pc (or location) of I"eceprurs and IllL' \/ll/wJ /I(j(hllll\ mediuIll1g Information Iu higher center\.

Sell'lation:- also hme heen cbssitied according to the . . y~tem by which lhey are mediateLl to higher cemers. Sen~ations are mecliatt:'d by either lhl.~ t1l1ler%rau! .\pillur/w/wille :).\'-,,£,11/ or lhe dorsa! ('olt/11/'Hnedia//enlllis~ Cll! H·srelll.('I(>-7u

Sensory Receptors Sen ... ory receplor" (,elbOr) nerve the

<.1 .... 1:11 t'/H.I

end,ng~) are located al

Man Jlfercm nerve liher. Once )o,llll1ulatcd.

Amerolateral Spinothalamic Thl~. :-.y.. . t~m initIates . . cl f-protectivt' real:tinn . . anLl r(">.:ponds to "lI11ull that lire potentially harmful in nature. 11 cOlllains

Pbult.·al RchahH,tAflOn

134

~lo\\<(lndudlO£ ti~r... tlf

are

unm\~llI1ated

-

'01<111 \ha.tnt"It:r.

"'4.mll·

llle ,\- ...tem ,... 1..·(ml..-l"f1l\.'J \\ Hh

t\t

hl h

Box 5.4 Clalii"ific-afHln \1t'chant)f('1:ep1nn

ratn. tl'mpc.rature. (,;rudcl~ IOC3hlCd IOllL:h. lKl..k.

,

lid\.

.Inti

(ulIlWOU

'Cl1l.,all(\O'

Do....1 Column-'vtcdial I "Inni'cal

("n
tr.lIl OH"·

..:j(ln t'fthennal and nr"(II..C-pll\C lI1fr'ml:llll l ll anti mcdllh.· ...

,c\ual

of

\ \ J

~"teIn

11le dUI'al (,;olumo "the '~,lem lO\ohcd \\lIh rt:'ptllhl 10 more dl"cnmlnallH~ ...cn... alIt.m .... 11 C(\111311h f.t~t-t(·ndul..l lag fiber-. of large d'aJllt"tcr \\-Jlh gre<.Hcr 1l1~C\lI1,ll\{lll TIll... ~~ stem llled,a'c~ lhe scn'allon... 01 dl\\..riflllllall\ C 10lh.. h ,tnO pre'I\UfC' 'en'3110n..:. \ Ihratlon. 1110\ elllcllt. !'l(l... lllfln '('fl'C'. and a"arenc,~ of J(\IOI' at n.""'t. The l\to ,~,It:Ill,,lft: HIler dependcnt and mtegrated '-0 a, to functlun t0f'clher.

Types of Sensory Receptors

.C;

fl 7

II. (Jeep

Cutaneous Receptors Cutaneous sensory receptors are located at the temlinal portion of the afferent fiber. These include free nerve endings, hair follicle endings, Merkel's discs, Ruffini endings. Krause's end-bulbs, Meissner's corpuscles. and Pacinian corpuscles. The density of these sensory receptors varies for different areas of the body. For example. there are many more tactile receptors in the fingertips than in the back. These areas of higher reccptor density correspondingly display a higher conical representation in somatic sensol)' area 1. Receptor density is a particularly imponant consideration in intcrpreting the results of a sensory examination for

r \.('I'I"T'

~nliiuQ Ret"ep'or~

\ \1u\t I rc\.cptor J \1u-.ck "pmdlc :! Gol)!1 rcndon l'rl.!.lO'

o

3. f-r\'c nc ..... c cn\hn~h PJunaan l..'orpu'l..'k .. JOint n:ccptor... ~

I

Thc St:nsof') receptors fre4uentl~ are dn Ided accordIng to their "ilructural de~ign and the 1) pe of ~tlmulu, to \\ Im:h they preferentially respond. Thcliie di\i~lon~ IIlciuJe (I) mecJwnoreCl'!Jwrs. \~ hieh respond to mechanical defomation of the receptor or surrounding area; (2) ,hermor('l"cp· rors. which respond to changes In temperature; (3) llodceptors. "hich respond to no"iou~ ~timuli and result 10 the perception of pain: (4) (hemoreceprors. \\hlch re~pond to chemical substances and are re~ponsible for taSte. smell. oxygen levels in arterial blood. carbon dioxide. COnCelllrJ~ tion. and osmolality (concentrJtion gradienl) of body fluids: and (5) photic (elecrronw.QllericJ 1'l'ceprors. v"hich respond 10 light within the visible spectrum.)l·Q·66,6971 The perception of pain is not limited to stimuli received from nociceptors. because other Iypes of receptor~ and nerve fibers contribute to this sensation. High intensities of stimuli to any type of receptor may be perceived as pain (c.g.. extreme heat or cold and high-intensity mechanical defonnation). The general classification of sensory receptors i~ presented in Box 5.4.63.64.72.n ote that this list also includes the receptors responsible for electromagnetic {vi:-.ual} and chemical stimuli.

"(·n..~l"

I f(' nt:rvl ('ndln H;tlr hllhd,,· flo hi \krlC'1 til ...... Rutfll\l cndmc Kr,m . cnd NJlh \kl .... ncr .. (l'rplJ .. dc PJUnl;1n ltlrpu .. \.!l' ..

Gol~I-()pt: I..'ndln~

2 Free ner\e- emhul.! "' Ruffini cmlmp 4 PaclmJorm e:ndlOg" Ill. ThermortceplOrs A. Cold I Cold receptor... B Wannth

I. Wannlh rCl:epIO""

----

IV. Sociceplors A. Pain I. Free nerve endmg... 2. EXlremes of stimuli'" V. EI("('tromagnetic R("('ep1ors A. Vi~ion I. Rod' 2. Cones VI. Chemoreceplors A. Taste I. Receptors of taste bud.. B. Smell I. Receptor; of olfactof) ncn e, In olf.tClOl! epithelium C. Arterial oxygen I. R~ceptors of aortic and carotid bodie-' D. Osmolality I. Probably neurons of ~upraop(ic nuclei

E. Blood CO, I. Receptors in or on surface of medull....lnd in aortic and carotid bodie~ F. Blood gluc:o~c. amino acid ... fatly acid.. I. Receptors in hypothaJamu, ·EJ.:trcme!> 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:.
\It:rl..t'r... Ui'\l'''l Thl',t lqu.. h 10.: o.:plllr ..In.: 100.tteJ helm\ Iht' epu.lenlll'" III hJlrk llhl\llh 1;.!I..Ihn)u I ... klll \\llh.t high dt'lhll~ lIlthe tin~(", IIp Ihl"~ .til.: 't:n .11\ ... 10 IU\\-tnlclhlt) wurh. J'" .. dl.t to Ihl 1.'1, J1~ til hlUlh ,lIld re ... pond It.> lOlhl.tnl IIlJem.lllol\ (llthl ,1111 11ll'~ PW\ Ide tor Ihe: J.bIlJl~ to 1'<1lCI\t'llllltU.UOU .. oill.1.. 1 1)1 Ilhlt'LI ;Jg.tln... t the ... l..1Il ;lIld .1re ht-h,..\e1Iu pl.l.\ .ln lJUptln.tlll ,,)Ie 10 bolh rwu~pt)ull 1I1"'IlmllliJllllfj .llld II aliUllun 01 Il)Ulh.'~·/'I ~

Ruflini tndJng~ LOlJftd III Iht' ~ko.:p(.', IJ\t:'I'" (II Ihe lkrllll"', the:)t' t'ncJ.p~lI· 1~1t'd t'lldm!,! .lIt: lII\oho.:lI '-' 1111 lhe perrepllon Olll)uch anll

pres~ure. They are slowly adapting and particularly important in signaling continuous skin defonnatioll such as ren::.ioll or streich: they are also found in joint capsules and ..t'll,i... t with joint position sense.().<

Krause's End·8ulb The ...e loVo -Ihreshold mechanical receptors are located in Ihe derl11i~. The) are believed to ha\'e a conrributing role in Ihe perceplion of touch and pre:-.... lIre.~-.t \tei'i~ner's

Corpuscles

LC)(.:aled tn the denni~. Ihese encap"ulaled nene endtng~ Ll)Ilt;1I11 nMn~ br;.lIlehtng nene filamenh \\ ilhtn lhe cap...ule. fill') Jre rapldl) ad.lpting and tn high conl~elltriJlion III tht' fingemp ... , lip.. . , .Illd loe.... ared'" Ihal reqUire high le\ ~ eh l)1 JI"'"Tll11lnallon. The~ ret'eptor" plJ~ .1Il Imponam rok III OI ...LrlllllnaIIH· lOuch (e.g .• rt'cogllllion of te,ture) .tnd J1)ll\emellt 01 obJecl~ mer :)km. fWfI '

Pa('inian

('urpusde~

Th~''''c r~l,;~ptl)r~ are localt'J in the ~ubcutJnc:ou~ ti~:,>ue

I..t) l?r 01 the ~lll1 and III deep tb~ue... of tht' bod) lindudmg tendon~ .tnd ..ott 1I~~ue~ dround Joint~\. The) are ...lil11ulateJ h~ rJpld 1l10\t'I11t"nl of 1I:)'iue and are quickly adaplUlg. fhe) plJ\ .I '\Ignitlcdllt role III the percep!iun of deep touch "mll \ IhrJ.llon ,~

Deep Sensory Receptors The deql \i,e-n ... or~ r('l-cphlP. are Ipt.ned III nHl"'~ k .. lC'ndlln .... and IOlnl ""'-I"~ and Il1llude fl.tllh TnU,(.!e 10<1 JOlnl reCCrlllr... , Tht.·~ Jrt" n"ln... ernC'd rrtl1l.lnh "lth 1"'1' IUfe. fl<'''lll\lll 'cn"c pn"'r"l''(.:plu.m. mu,dl' Innt'.. \Ill! "reed ..lOd dm."lIIClIl of (llt)\CHll'nl I h.... dc\.·p ..\:n"or~ r('ceplC'f'" 1m ludc the mU"l.:k 'rllldic. (Inh.!1 t ndllll ('\rgan'. fr("( nerve ending .... PaUl1Iall \:PfI'U"lk", .Jilt..! 101nt recerlor..

Muscle Receptors '1uscle pindletr; The mu'<..lc ",plOdk linel' IlnlrJfu .. Jl tiht:,,) he III J. p,lrallei :lJTilngrmt."nl to the' 111u~k fihc~ (c\lralu-.JI fiber... l. Thc~ mOnllor <:hange . . III mu..clc length (IJ and fI ,pmolt: afferent endmg" .1\ "ell a, \f'IOCH) (la endlllg) l1t lhe'<." change ..... The mUl;,dc ~p,"dle p13y~ 3 \ Ital role 111 JXhltlnn and mOl cment 'CIlo;;C and to motor fcaming.

Goigi Tendon Organs The::.c receptor" are located in 'ierie... at botl1 the pro\l· mal and distal tendinous In .... enion') of the mu~c1e. 1 he Goigi tcndon organli functlon to monitor tenSIOn \l, ithin the mU'i.t·le. They aho provide a pr()tecti\'~ meCh'1111 . . m by prevenling ~truc1Ural damage to the Illu ...cle in ... itua, tion!! of e\lreme ten,ion. Thb is accompli::.hed by lnhl· bitlOn of the cOnlracting mUlicle and facilitalloll of th(' amagonist.

Free Nen'e Endings These receptors are within the fascia of the Jllu~c1e. They are believed LO respond to pain and pressure.

Pacinian Corpuscles Located within the fascia of the muscle. these receptors respond to vibratory ~timuli and deep pressure.

Joint Receptors Golgi- T~ pe Endings These receplOrs are located in the ligaments. and function to detect the rate of joint movement.

Free Nerve Endings Found in the joint capsule and ligaments. these receptorli are believed to respond to pain and crude awareness of joint motion. Ruffini Endings Located in the joint capsule and ligaments. Ruffini endings are responsible for the direction and velocily of joint movement.

Pacinirorm Endings These receptors are found in the joint capsule and prima· rily monitor rapid joint movements.

Pathwavs for Tran~mi'i..ion of Somatic Sen'ion Si~nal..

.

'-'1101.1111... "'l'n'Pf) Infprm.lIlpll 'nlt:r Ih ~ Ihfl\lI~h Ill\.' l!(lf',ll ({'(lh_ \Clhl\r 1~1l..t1 ...1I I(l hl~hcr ll.·lller" \.ltl
Jt1,

Anterolateral Spinolhalamic Path"a"

nu' "'pll1olhal.t01IL tr,Kt' ..lrc dllfu,l.· r·111n J ... t \\ Ilh nond"lnnllll..ltl\C . . cn'.llinn .. 'Ul h .1' r lin r OJ fa lUre. IKkle. Itch. Jnd \e\ll..ll ,,,,n'JllIlO' rhl" I III I.. The Ihree major [rarb of (he ~ptno{h.llJmll.,; "'~'Iem include the (I) Unlawr (n'lIIralJ \11IIliJflwlcmlll m;d which carrie~ fhe sensation", of crudL'l) !OCJhled lout.:h ..lnJ pressure: (2) the !taeral spillmJwlanllC." fru("{. \\ hll"h l.,lITIe, pain and temperature: and (3) the \pllIOreflndllr (fad. \\ hich i<; involved wilh diffuse pain ~ensdtlOn,.f\'

Dorsal Column-Medial Lemniscal Pathway This system is re",ponsible for the tran.<,mi ...slon 01 J,,criminative sensations receiH'd trol11 ,pe('i..llllt'J me{'hanoreceptofs. SensoT) modalillc", that rl'qulre fine gradations of illlensity and preci~e localiz3t1on on Ihe body surface are mediated by thi~ system. Sen~:lIion, transmitted by the dorsal column-medial lell1ni~cal pathway include discriminative touch, stereognosis. tartik pressure. barognosis. graphesfhesia, recognition of [ex, ture. kinesthesia. two-point discrimination. propri(x:ep· lion. and vibration. This system is composed of large. myelinated. rapidly conducting fibers. After entering the dorsal column the

Chapter 5 Examination of Sensory Function

137

Primary sensory cortex

VPL nucleus

Medial lemniscus

"-''C''<------ Sensory

Lateral spinothalamic tract

decussation

I--\---Gracile and cuneate nuclei

d . ) - - - - - Posterior column Pain and temperature receptors

Discriminative sensory receptors Dor~al

Figure 5.4 AntcrolOileri.lll
Figure 5.5

lltkp" il\ct:lld to the Ill~dulla ,md ") nap~c with the dorsal WIUllll1 nudei (nucki granll ... and CUlll.:illU<.,). From here Ihl:) I.:ro,>'1 10 Ihe 01'1'0:">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\,.

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-

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_-:>.----<:---_

139

Postcentral sulcus

An imporwnt component of physical therapy inlerven~ion i~ to aCt'urately and efficiently meet individual patlenl needs. Together with infOlmation from the history and review of systems, screenings assist the therapist in proficiently identifying the needed tests and measures and setting priorities within the examination process. Screenings consist of a series of brief tests that provide the therapist an "overview" of the system of interest (e.g.. sensation. muscle strength). Within this context, screenings are conducted t0 7.77 :

• Determine the need for funher or more detailed examination • Determine in a timely manner if referral to another health care practitioner is warranted • Focus the search for the origin of symptoms to a specific location or body part Identify system-related impairments that contribute to functional limitations or disability

A

CLINICAL NOTE: The term screening is also used ill another COnteXI. It addilionally refers 10 idemificatioll of indil'iduals or groups who ar(' lIot currently receiving physical therapy Sl'ITices but may be at risk for a health prohlem." Examples mi1:ht indude identification of risk factors for low hack injury, diahetes, obesity. or/ails in the elderly. Physical therapy imen'emiolls associatell with this {ypc of screening ,ypically im'olve prel'fntion strategies. jim('s.\" promotioll, and heallh promotioll and weI/ness pro~rams7_'i designed to meet the needs of all i"di\'itlual cliem or tar;.:et population. B

Lateral

Medial

(A) The ~olllatosensory conex has three main divi· pnmary (5-1) and 'iecondary (5-11) area.... and the posterior parictallobe. (8) TIle sen...ory homunculus. Areas or the body u...ed lor tactile discrimination are represented by large area, or conical thsue. such as the lips. tongue. and fingers. Areas .... ilh redur:ed conical representation. such as the trunk, are renee-tive of body pan,; with lesser roles in sensory perception. (From Kandel. ER. and Je...sell. TM: Touch. In Kandel. ER. Schwanz. JH and Je"\el. TM: Principles of Neural Science. cd 3. Appleton and Lange. Norwalk. cr. 1991 with pennission. pp 3681Aj and 372IBJj.

Figure 5.6 ~lon ...: The

There are ~en'ral remolH Illl> 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·\

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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

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tl'·'''ue.

-t \ r"rafioll TUllll1g for'" ;tIld earphone.. (if ~Ivailable. (0

Figure 5.7 SUl~1e u..c prOll:lle-d ne-uruloglcil pin The- tlll.lgt' 1)11 rill' h'lr .,hll\\'1 lhe pin pll\lr III U'IC \\ Ilh Ihl.: pn1h:lll\1' Lip lllli.h:llalllwugh ~dl('n1dIH':..lII) pre ...enlC'd III ..lllu\\ \ l"'u..lIiL'ilioll ..I pill IOt.llllllll On Ihe lIs:hl IIll.: pnnnll\c I.ap i... rl'uh)\eJ ,Illd Ihe PuI C\I~hcd On Ihl.: "ppO"Jh' cnd 01 lhe pill J'" i..l .. moulh roumkd ... urtall u..ed 10 r~Hldllllil) Inll'r'llx:r~e ,lpplil;lllOll 01.1 dull .. tllnulu AlIl'l U"'c. Iht' POlOt l... lit'~It\I)ctl b) U)mprl'~"'lll,g II i..lgauhl .1 Il.trd urli..ll.',," ;jlld dhfl(l'Icd 01 III it hloh.ui..lrd rCI.·epl
r~dul'l' .lUditory l'Iu\:''i). TunIng tor"' .. are made of steel or magne.... ulll hapeJ prong... (tin~s). 5. \/t'1'l·(J~II(J,\I.\ (vhil'd '-t·nl~JlIlIl'n). -\ \.lricl) of small lUlllmlllll) U"'L't! .Irlille.., ... lIdl .1:'1 a l'omb. I"orl... paper dIp "'1:). (Oill, pencil, <.tnd 'lO furth.

Chapfer 5 Examination of Sensory Function

141

7. R('(ogl/lfll!lI of In/llrt'. SamplC'~

of f"hric~ of variou'i tcxlUrc .. "'llCh a.'" COli on. wool. or .. ilk (approximately -l- X 4 il1chc, [I () X 10 cmj).

Patient Preparation purpo~e of lhe le:...ting 'ihould be provided. The patient abo ... hould be informed thai cooperalion i.. . ne('e..,~ary to obtain accurate tesl result~. It is of con~iderabtc importance thaI lhe palient be requested /lot ro glll'.\,\ if uncertain of lhe COITect response. During the examination. lhe patient should be in a comfortable. relaxed position. Preferably. lhe tesl.<; should be performed when lhe patient is well rested. Considering the high level or concentration required, it is not surprising thai fatigue has been noted to affect results of some sensory tesh adversely.79 Nole: A "trial run" or demom.lralion of each test should be performed just prior to actual administration. This will orient the patient to Ihe sensalion being tested. what to anticipate. and what type of response is required. The importance of thi~ initial trial should not be underestimated. If a practice trial is inadequately or not performed. whal appears to be a sensory impairment may in reality only be a rctleclion of the patient's lack of understanding of the testing protocol or how 10 respond 10 a stimulus. Some method of occluding the patient's vision during lhe lesting should be used (vision should not be occluded during the explanation and demonstration). Visual input is prevented because it may allow for compensa!ion of a sensory deficit and thus decrease the accuracy of test results. The traditional methods of occluding vision are by use of a fabric blindfold (such as those worn by travelers to sleep on an airplane). a small folded towel, or by asking the patient to keep the eyes closed. These methods are practical in most instances. However. in situations of eNS dysfunction, a patienl may become anxious or disoriented if vision is occluded for a long period of time. In these situations. a small screen or folder may be preferable as a visual barrier. Whatever method is used, it should be removed between the tests \vhile directions and demonstrations are provided.

A full explanation of lhe

Figure 5.9 ,.... hJIHI·hcld a~,lhl''''IOl1ll'lCr pHl\'idn ~l qu,l1ltil,lll\l' 111l';I'UrC (111\\\1 POllll-POIllI dl~Lril11lll:ltlun. The t\\O-POllll thrc ... hold I ' dl'll'mllll(:d h) ~radu;lll~ brin!:,JI)~ the Illcwcahle lip' chN:r hl\.!l:lha ,1'" II I'" 'l:qul'nti,llly :lpplicd to lh", p~l1icn(s ,kin. 111t: ...cale l ' :';lllhralcd tulhe 11(':lrc'l 0.1 cm and mea'lm.:... up to 14 on. 6.

1'11/1-1'01111

(h,HTI/l/illaflo/l. Se\'t~ral lIl",trurncnb are avail-

;lh]e III n1t'a~ure

I\\o-point di . . criminaliotl. A two-point di ...crilllin3lion ,leqhc",iometer (Fig. 5.9) i", a small handheld ill ...lrumenl de",igned to measure the :>hortest di:>lance lhal 1\\0 points of contaCt on Ihe skin can be (li"lingui",hed. II con ... i..." of a small ruler with lwO moveahk (\Iidlng) lip~ coaled \\ ith vinyl. The vinyl coverings hl."lp 10 minimize Ihe impact of lemperalure on perceplion 01 conl;I('1. Some Ill,truments abo have a third tip aIIO\\'JIlg ea"e of alternaling from IwO poinb to a single P01ll1 of contaci during lesTing. If used on all uneven bod) "urlacc. care ~h()llid be laken nol to allow the "ruleT" portion of The in"'rumenl to make contact with tIll' ",kin. Nore: The tenn (/('.u!lC-lio/l/crcr i~ nOI specific 10 thi, ill~lrumcnl: il i'i u~ed to de~(Tibe any number of ltl'ilrUrncnh de"igned 10 examine louch perception. For finer gradaliotl~ in mea~urcment (e.g .. fingertips), ,>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 fOunJ<:d lip'" rlJlo:d ,It ..,1.lIllhHd 1<:\!1l11! llllLn:th. (C'Hlll..: ... , 01 "'-tWlh (\1•• ,1 I\lcdlL.J! Ill<. ~lorl!;1I1 H~II C\ Y"iO'7,) . l'lllul.lr 1\\(\ r011l1

\.<)11'1"'1- 01 1\1l) IOIlIL'U

(Ii..,",

The . . upcrfil·1il1 tnh.:rOi.:eptive)

sen~;jtion~

are u~uaJly of more primitive

c\alllilled fir ... t, ina~mlil"h a~ lhL') ~on.sist n:"pon ...e .... followed by Ihl' del'p tproprioceptive), and then

142

Ph~ ..ical

Rehabililalion

the cOl1lhlnl'd l"0I11Cal ..en<;atl(m,. II a le~t indU:~le, Impairmenl 01 Ihl' .. upcrlirial re"I">\")IN~'" ..oml' Imp~llmlCnl of the more di ..cnmlllall\l· (deep and ('Ol1lblllCd) ..cn"i.lllon, al ..o "Ill he Jloted <.lnd 111.1\ be :t l~olltr.llndK·:ttlon 10 lurlher te ... t~ Il1g (e.~ .. lad.. of tnll~h srn,:llion \\ould be a c.:ol1lrmndicalIon for Ir,tmc .. tcrt;'o~nOSl'). Thai I". Ihe primary modality of ~en ..a(ion (touch) ~llll<;t be ~uniciently inlau to permit meaning/ul le!lling ol cortical ... cn~or) funclion (abilily 10 identify obJech pl~,ced in the hand). For each ..cn..ory te:.l. the follo\\ ing dala will be gener;1Ied:

The modalil~ teqed The quantil~ of lIl\ohcment or lxxi~ .. urface area:-. affecled fpallcm identificallOnj The degree or <;e\erily 01 ll1\olvement (e.g .. ab..ent. impaired. or deb)ed re.,pon"e.,) Localization 01 lhe exacl boundane<, of lhe :-.ensory il1lpainllCnl The palienl'" ~ubjecti\ e feeling') aboul chang:c:-. in sensa~ lion The potential impaci of ~en~ory loss on lunclion (i.e.. functionallullilatlon. di~abilllY) Kno\\ ledge of skin ..egment (dennalOme) II1neT\ation the dorsal rool<, and peripheral neT\·e innenalion (~ee FI,g~. 5.1 and 5.:!1 I~ required tor making '\ound. accurate dlagno~lic and progno'-'Iic judgmenl\. They '\er\"C as criti~ cal reference~ during te'\ting a.. well 3S prO' ide a frame· work for documentmg re~ulh. Sem.ory (e:-.t') are typically pcrl·onned in a di",tallO proxIInal direction. Thi~ progTc....ion \\ III COll')cnt" lime. p:U1icularl) \\hen dealing with localized le,ion'\ Ill\ohing i.1 .. ingle eXlremit~. \\ here delicll:-' lend 10 he more ~e\'ere di\tall). It i., generall) not nece~:-.ar) to le,1 e\e~ '>egmcm of each dermalome: Ic,llllg general hod) JreJ,> i.. ,uHiClcnl. HO\\c\er. once..t deliclt arlCa I, nOled. te,llI1g I11U~1 become more di~crete ,1Ild the e"JCI boundJ.ne' 01 Ihe lI11pamnem ,hould be iuenulied. A ')"'in pencil may be lll,dul 10 marl... lhe bound~lne., 01 ,en"or~ change (IIrcelly. Thl" II1l0nn:l!Ion .. hould I'll;" trarhlerred later to ;l ..elhor~ e"al1ll11atJOn lorl11. graphl{:all~ pre"l'lltrd on :1 denllatiHnc chart. and peripheral !lent' 1ll\(lh~llll;"n[ ldt'lltltied. TIll .. form will lhen be cnlcrt:d 1Il tht' medical rt'cord. Fi~lJrt' 5.11 pft'..enh i.l ",lmpk Sel1"or~ I-.\~jmlll.lll()n Funll ~10 .. 1l"IIIlICI.U1" lind II Lh...llh.·nglllg t!lCrl"ale'.1 1Il~1c dOlUlllel1lalHlll hmn .tpplJc.thle to th~ \,lfl!..:'t. 01 p.UII;"Il1" "I;"en III a ~"en pr.lltlL·t' .. dlLn~ l .... llh thL· t: hl'ptlllll 1.1 (1<:LI.IIILed cl·nll'r I." clllllC"1 H, '\h."\ cr, 11Il: loUm.. Ill~ are ullllll10n dt'"nll.:l1h tIl ..en .. \)I") t" .tllllll..tII"11 111m... (I J dl..:flll.llol1ll; chart to gr.. lphiL.III~ c1J:-.pl..t~ llnJlng I~J "I II nt· \.tfhlllllll 01 . I glddlll~ ~l.lk (L g l-lI11 . 1cl 2----Jl:'crL,I,t'd and "0 1I)I·,hl III "c'I}fl' pallt:"111 j"lt:" 1"<. l'pl II II I III 1Ildl\ldu:ll Ilhltl..t'llh..t dllkrl.·Jll "l..:lhOI\ 11lll(JJJlI\ 1 thl: COhH" U..nllo pillt t..tcll "l'n alliin ..tre thl."n b~

coded b) th~ c\Jminer dlrecll)' on Ihe ~onn (se~ Fig. 5.11) . ' " nee, h'tlch m~rks of varYlllg denslly are used . . , I II nWll) 10'\ . 1 ' "r'ld"IIOn~ in ..en\ory ImpaIrment (J.e .• the to rcprc . . en I e ' .. . .. . c1o,cr tQ!!:clher. lhe greater the ..en..ory lmpal~e.nl). With Ihl' method. a complelely colored-Ill area mdlcates no rc,pono:;e to a gi\cn . . en<,ation. Wilh varied or "spotty" Sen..or) 10:''' It i.. llol uncommon Ihat more .than one dermulome chart b required to completely depict <'111 test lindirH!.s. With u...e of several dermatome charts. the ~ensa­ tiol1«,) represented ')hould appear in bold print at the lOp of eat.::h page. . Figure 5.1 I prO\ ide') the foundallonal eleme~lS ~f doc~ umenl3tioll typicall) included for sen~ory exammatlons. It . . hould be modified or expanded to meel lhe needs of a 2iven populmion or facility. It is abo nOI uncommon for ;herapisls 10 induded sensory lesting dala within the body of a narrative or progrcs~ report. During tesling. Ihe application of slimuli should be applied in a random, unpredictable manner wilh variation in timing. This will improve accuracy of the test results by avoiding a consio:;[cnt paltem of applicalion. \\ hich mighl provide the patient \\ ilh '"'clues" 10 the correct response. During applicalion of slimuli. cOl1'>lderation must be given aho to skin condition. Scar lis~ue or callused areas are generally Ic~~ \en\l1i\e and will demon~trate a diminished rc~pon~e to ..en"Of)' <,timuli. Recall that a trial tesl is performed to in,>truci the patienl in \\ hat 10 e"peci and ho\\ to re')pond to application of the :-.pecitic stimuli: and thal patient vi\ion i, occluded during Ic')ling. The following ,cction:-. pre,enl the indi\ idual sensory le .. h. The tC~l':i :.Irc ... ubdivided for :-.uperlicial. deep, and combined cortic,t1 ...en'lalions. T:.Iblc 5.::! pre..en[, temlinolog~ u'>cd to de~cnbe common ,en..,or~ Impaimlel1t!!. (L/\I( --\L \Orf

IIdlll" \I!"fll. ,tlili/\\

to tlnd .lIlt I Il/f/('nt «(mt,l<:

11/,' \I

I/ltjl/lrfllll/

IlcUIt"":t'lI\

nf\t

11/

/lit ,I\/tIt \

Itt·"lth-(

,1/(

Ittllld

hi

IItHltt'c/ jlritw

1111\11/11:: t,\ "'lilt

!' 'I lIn I c. /<1. lilllt \

(lr tilt'

"1IIt: //"(01.\1111\ \ion

- TIlt Cnlft'n

I)"

/tll"

,(In '-1{·ummeJld\ \'II!I" \1·' Ill/d." ('(1\ ('Illig till !talld ,/lid 1111<":( I \ .\n Chd/,tt.,-..J (80,\.JJ I

lit C011f11l1 111/,1 f1,"t"'I'/If/, 'I

tl/"l'l/\ 111111./11,1.\//1111,' /('I".1f 1('tl\1

1111 !{we,1

I( 1/

!tl/lld

lit' ,,,, 1\

./I!ti Ill,' I II, I. I dw ,

Superficial Sensations Pain Perception I It... tnt ....11"11 1e'k'rrL"d h.l ..t" II/,ll I} dlill tI, '('rimillt/flO" Jlld llll.hc.llt:.. lundlun of PI'OIt'ltl\e "'l~lh.lIh,.ln To te . . 1 pam ,t\\,lfI:lll'''' Ihl: ,h . lrp Jnl! dull l"nd ul J l..trl!~-h~,lded or "
This form pro~'ldes a record ollhe type, seventy. and local Ion 01 sensory ImpaIrments It should be used In conjunction .....Ilh addItional dermatome !U't?'et5 1 n~ to graphIcally outhne the exacl boundanes 01 the Impairment The desIgnaTIons P and 0 may be added to Ihe grading key to IndICate el t\.;>r 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. temper
nncllig ht to uch awarene:-.s ca n be obta in ed by d ivid ing the number of {'orreN r('sp(JJlse.\' by the IIIIII/her a/stim1111 appl ied (Ilonnal res ponse wou ld bit 100 percen l).~2 A I.. o. inabil it y 10 verba ll y communicate does nOI necessary preclude o btai ning accu rate da ta. Fo r ex amp le, havin g th e patient hold up o ne or two fin ge rs mi ght be u:,ed for dichot01110U,> rc'>ponse::. (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 <.Igree on l e rlll ~ 10 desc ribe the dll"i.:ctlun 01 mo\ emCJ1( "', R~"'PtJn . . ~

TIle' p..tllt'11I t'> u"l keu III de ':>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<.d '>!le''>'" ,mlllt' Ill\\ b:.h.k. Dunng t e~ llng , 1l1l) \e mt'11I ul l...tr~er joun ... '" u ... u.dl ) dl ,> 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<;e indieuing if the stimulll .'> b vibraring or nonvi bra lin g each rim e the fork make!>. cont act.

Combined Cortical Sensations ~Iercognosis

Percep t ion

Thl . . le..,t Jt:terl11ine>; tac lti" objec t recognition. A variety of :-.1l1i.1ll. t:~I~t1) ob tainable. and l' Uhllrally familiar o bjects of

J46

Physica l Rehabililaljon . ' ay be open during the re sponse component patlen! s eye!". 111 , ',' . .' The diSlallCC between the applicati on of the 0 1 Ihl S t e~ t. . be . I dIlle ,') ite indicated by the pallent can measSltlllll U ~ an . . . variOUS ured and rcc·orded . Acc uracy o f locallzall on over . 1 !11 'ly be compared to determine the rel aparI:-. 0 f t Ile b0 d) ' li ve ~e n ~ ilivi t y of different areas.

Two-Point Discrimination This test determines the abi li ty to pe rceive two points applied to the skin simultaneo us!y. It. is a t~eas~re of the smallest di stan ce betwee n two stliTIUlJ (applIed simultaneo u~ l y and with equal press ur~ ) Ih~1 C <~11 ~ti ll .be perceived as twO di stinct stimu li . Two- po lOt dl sc rlmmatlOn values vary for different indi viduals and body parts. As thi s se nsory functi on is most refined in the di stal uppe r ex tremities. thi s is th e typical site for tes ting. It is be li eved to contribute to precision gri p movements and instrume nt al activities of dail y li vin g (IADL)."

Figure 5.12 A ~en so ~' testing shi eld can be used fo r examining ste reognosis in the pre sence o f speec h or lan guage impairmenu•. In thi ~ ')i muiati on, the subject manipu lates the object without the use of visual input. Fo ll owing manipulation , the ), ubject points to the matching object pi ctured on the ledge of the te"ting <;hield . (Courtesy of North Coast Med ica l. Inc,

Morgan Hill. CA 95037. )

differing size and shape are required (e.g. , keys. coins, combs, safety pi ns, pencils, and so fo rth). A single object is placed in the hand, the patient manipu lates the object. and then identifies th e item ve rball y. The patient should be allowed to handle severa l samp le test it e m ~ during the ex planation and demonstrati on of th e procedure. Response The pati ent i'-l asked to name the object ve rbal ly. For pauenb with speec h im pairme nts, sen::,ory res tin g shields can be mcd (Fig. 5. 12). Alternately, th e item manipulated can be identilied from i1 group of image!'> presented after each te::.!.

Tactile Localization Tilt ... t e~ t addre~ ...e~ the ttbili ty to localize touch ~e l1 sati o n on th e ::,!...in . jt exa mines th e abi li ty to identify th e specific pOtnt 01 ~I pph cati o n of a to uc h ... Iimulu::. (e.g. , tip of rin g finger. lateral Illalleu.... and ~o forth) and nOI :..i mpl y the perceptIon ot touch. Tau ll e localiza tI on i" typica ll y not te:-, led III i ... olat ion 3nd freq uentl) e>...u11 11le.d In co mbination .... 1I1l " m1J1ar l e~ 1\ :.. uch a~ pre ...~ u rl' percepti on or touch dW'lre ne.:o)!). U:-' JJl g a (olt on :-.war or linge rtip. lht' lherap t... t loudles d llkren l '> 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 v<.tlid ity of the te~ l , II is app ropriate to alternate lhe app lication of t\\O .., timuli \\ ith the random applica ti on 01 onl y i.I ..,ingle s limulu~. \Vith c:ach successive applic grad ually bro ught closer logel her until th e :,timuli are pt.'rcei\ed as one . The smalle!)t d i ~ [a.nc e between the ~ til1luli that is still perceived as two Ul..,[tIlCTpoi l1l::, j<.., mca.., ured. l{ es ponse Th e patient

I:,

a-; !.. cd to tUt'llIitv the perct'ption of "one" or

" t\\ O" ,)liI1luli

-

Double Simultaneous Stimulation Doubl ~ "" Illult::tnt!o us :-'lilllu lattim (DSS) examines the abil~

1I \ to ptT('el\e ~

'

I

.1 \ lnlU t an ~ lIlt ::.

. touch ')timu lus on opposite

ChapteT 5 Examination of Sensory Function

147

"'Ide' 01 Ihe hud~: pnnimall) and distally on a ... inglc ('\In:l1lll~: or pnnlJ1lall) ;lIld di~IJlly on one ~idc of the

hlXh TIll' thcrapi ... t ""llultallcou"ly (and \\ ilh c4ual pre~· . . llrt'·llOlll'hl;·...: (ll IOC'l11iGll locatiom. on oppO:..ill' "ide~ of thl' b(~\. t2l pro\lmall) and di'lillly 011 orpu~ile "idc~ of Ihe- bod~. ~ll1d (Jl p1"O\111131 and dl... lallocalion~ onlhe :..allle ... H.1e of ;he Nxl). The ICnl1l'\/iI1UiOI1 phc1/omena ue~cribt''' ~I ",wallon 111 \\ hlch olll~ Ihe pro\imal ,timulu!'- i, per ct'I\l'd. \\ IIIl "e\llllctwn" of Ihe di ... t:ll. 4

Re,pon,e The P;111C11I \ t'rb~llI) ... lalc ... \\ hen he or she perceives a touch <"lJlllulu" and the Ilumber of \limuli felt. Se\('r~t1 addllional le"'~ for Ihe combined (cortical) sen"ali(ln'" IIldude gr..tphe",thc"'li.l (Iraced finger idenlification), reCO~IlJll0n of IC\llIrc. and barogno~i~ (recognition of \\el£-hl). Ho\\t'\"l~r, the...e (e~h are u,ually nOI perfomled if . . ll·r;ogno"'l<" and t\\O~poml di~crimimHioll are found to be 1I1IJI;'!.

Graphesthesia (Traced Figure Identification) The JbJ1l1~ 10 rt'cO~Il1/C leiter,. l1ulllber~, or designs (raced on lhe ~l..In l' examined u\lng a fingenip or lhe era~er end 01 a pencil. A 'lcnc~ of leller'l. numbers. or design~ i'l traced on lhe palm of the patient's hand. During the pracI1Ct' Inal. agreemelll ... hould be reached about the orientatIon 01 the tr:ll'lng'>. (For example. the boltom of Ihc traced figure,> \~dl :11\\(1):-' be oriclHcd low3rd the bi.lse of the p3tiel1l\ hand 1\\I"i~tl.) BCI\\I;'en each ,epa rate drawing the palm ,>hould be gentl) wiped \\ ith a :-oof! cloth to dearly indIcate a change in Iigurc<., to the patient. Thi<" test i~ also a u"elul . . ub'>tI!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 \
fhe p.Hlelli I
Barogno", (Rccognilioll of Weight) nl \\l'l!!ht ;t '1.:1 ull!l"l.Tlllllnallun \~t.'lghb til ... 111.111 ohle... ", ul Ihl;' "dll1l' :">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<"or~ and motor defiClh. Three ...('n,or) le~ts \\crt' aLlIllIllI,h:red ;lnu then repealed by Ihe ... ame t:"\allllller \\llhlll I 10 7 d.I) .... Rc~uh~ re\caled a high rdl.lbtIJt) for htHh "krl;'ognl1"'" (r = 0.97) .mel pO~1l10n ...en\t" (r = 0.90). -\ h)\\l~r rcilabllll~ \~J' reported lor 1\\O-poUlt lh..;cnllllll~l­ tl(lI\, \\ IIh l;om:l.lIiol1 cocfficienh ri.ll1gmg from 0.59 to (J,~~. dl.'jx-nJlIlg 011 the h(lJ~ areu (e'lted. Although llllllll;'d jlllbli...heu dJtJ Me ,t\.lIlable related 10 rehJhllll) Inl;·a"'lIn:"~....e\c'ral appro;h.:he~ Gtll bt:" U~t'd 10 lI11pr\,.I\l;' Ihl:>. :.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-<"h h) tl'i\illl;~d. :..lJllful e\al\liller~: and (J) ~lIbse411enl

148

PIl\,ical Rehabilitation

retcsl~

performed by Ihe same individual. " abo should be noted that Ihe reliability of sensory lests will be further inllucnccd by the palient's under...tanding of the tes1 procedure and the patient's ability 10 communicale results. \Vith developing advance~ in lechnology allowing quantitative approaches 10 collecting sensory lesting data. greater emphasis on reliability will follow. Additional re~earch relaled to standardization of testing protocols and identification of normalive d
Quantitative Sensory Testing and Specialized Testing Instruments Wilh Ihe expanding availability of specialized testing systems and instrumenls, quanlilative sensory testing (QST) ha~ gained con~iderable clinical and research interest. This is clearly evident from the expanding body of literature on this IOpic. 91 - 106 QST allows quantification of the level of stimuli required for perceplion of a sensory modality. Although sufficie11l data are not available 10 predict the ultimale integration of QST instrumentation into clinical practice, preliminary infonnation suggesls irs potential usefulness. This section provides a brief overview of selected QST devices and is certainly nOI all-inclusive. The Inlernel provides a rich source of informal ion on this developing technology and instrumentation

TSA-I1 Thermal Sensory Analyzer + VSA 3000 (Medoc, Ltd, Durham, NC) Thl'i computer-controlled s)~lem (Fig. 5.14) i~ capable of generating and recording a respon~e to repeatable vibratOf) and them1al stimuli (i.e.. warmth, cold. heat- or coldinduced pain). For testing thermal ~en~ation. a ··thcnnode" capable of healing or cooling is placed on the patielll·~ skin (Fig. 5.15). The pallent i~
Figure 5.14 TSA-II Thennal Sensory Analyzer + VSA 3CXXl This system provides quantitative measures of both thermal and vibratory stimuli using a variety of palient interfaces, Note the small hand-held vibratory unit on the far left. (Courtesy of Medoc, LId. Durham. NC 27707.)

measuring touch-evoked potentials (Fig. 5.18). They

are

designed to detect very small changes in touch threshold. The filaments are available as sets. in various sizes (i.e.. thicknesses), with each mounted on a handle. The force required to bend the monofilament increases from 0.026 g for the first handle 10 100 g for the last (pressure range of between 5 g1mm 2 and 178 glmm:!). The filaments are applied individually to the patient's skin until it bends: each filament providing a specific amount of force (thicker filaments are used if the thinner are not perceived). With vision occluded. the patient responds "yes" when a stimu· Ius is felt. The filaments are held perpendicular to the skin

von Frey Aeslhesiomeler (Somedic Sales AB, Hiirby, Sweden) MonofilalllCllh art;; nol 111::\\ 10 examinallon 01 ... en~or) tunLllon and ale alluall) (;on~ldcred a dJ~ ... ic tool lor

F.gure515Th't: nHlXI>l': p I·. . percepal.:ed III hand lor measunng IlOll ut tht'rmJI \limuh. (Coune,,) ot ~tedoc Ltd Durham NC 2770) • .. ,

Chaplt'l " I ,amin"lloll of ~'n"'Hn .-u.... tion

Figure 5.18 Figure 516 I t~ll ",urr01'1 \ Ihr.Llnr~ \klll ...... 1 hI. Durham '< ~7;01 I

"1111l11lalpr I{"ounl'''')

nl

.Inti .tppll\.',lllnn ,... u",u.llI~ r~J1t:'lled Ihree lime....11 ci.lf.:h 1('...1-

m\.'

"'Ill.'

\lnlll,I"iIJJ1lCnh ..m:

fr1.'4uenll~

u... ed

In

h.mJ rcha-

~dll.llllHl dlfllt.~ ....

otlll'r ('\ample ... of dlOlt.:al .tpplll:i.ltton... IIldUlk n~ump;tthle... I('.g. that'll'tIC) Jlld r('nphcri.tl nene mlune...

Touch-Test Sensory Evaluator (North Coa't J\ledical. Inc,l\lorgan Hill, CAl lndl\ Idual lllonofilamenh art' al...o av,lIlable in illCrel1lCnt~ rangmg lrom O,OOX to 300 gram~ (Fig. 5.19,. Thc')e in ... truIllt:nt ... .trt' COll\cnlenl i.IIlJ Call be (,-lrried in a pocl.. et. The hand It: Op('l1'> 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

'Sr.......

.:.ow

Wan"

Ld' ..et lHI'ul Rillhl f ..1ot

,-.

Po.

~I..: . , . "

Ho,

Po.

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

8

8

6

.-

4

j ~

6

----.

4

_2

2

I-~

I-~

----' <-

Figure 5.22 Bio-Thesiometer ro~ measu.ring perception of vibratory stimulus. (Courtesy of 81O·MedlcaJ Instrument Co. Newbury. OH. 44065.)

Figure 5.20 Schematic illustration of the Rydel-Seiffer luning fork. (Courlesy of US Neurological .... Kirkland. WA. 98033.)

applied using a hand-held device applied to the skin. Intensity of stimulation can be preset or gradually increased until the threshold is reached (or gradually lowered until not longer felt).

Bio-Thesiometer (BiD-Medical Instrument Co, Newbury, OH)

Cranial Nerve Screening

This instrument is designed to l11ea~ure threshold percep~ lion of a vibratory !)timulus (Fig. 5.22). The stimulus is

Screening te~ts for the cranial nen'es provide infonnation about location of dysfunction within the brainstem as well as identification of cranial nenes thar require more detailed examination. Data generaled may include function of muscles innervaled by the cranial nen e~; visual. audi· tor). senwry, and gag rellex integrity: perception of taste; swallO\\ ing characleristic~; eye movement~; and constriction and dihHion pi.lltern~ of the pupils. Table 5.3 provides a ..,umm;:u) of the functional components of the cranial nerve..,. Box 5.5 pre~enrs screening tesl~ for e
-... -

.----.:.•.•••.•.•..• ......

.. ...... ..... - "-

\

--

--

----- -----'"''

Sensory Integrity Within the Context of Treatment 'h'l• \ lor I" d(,'ren dent on the pallent::, . . 'lbdH) to lil"'!;, 111 "en . . of) U1fOrJllJ.tlnn tWill rhe boo) and till' t'm Ironment I ' I . . . . tn"or) Illta",e), proCl'~'" II (~~lbOl) IIltel!l';.t!h)n I illld u\e t t l . I . IOp.1n .Int org"UlIZt' bt'hil\lor (outpUI), \\ ht'n patlt'nh _t'\I)'n "-, . . ... c'" I.:t: IlllpJlflncll! III processlIlg ..en"Ol"\ Inl;ll..t' dell· t I . II • . Ll \ )- pIL"1 ) oel'ur til plannlllg and organ1/1Il/; hdlJ\ ll)r Th- p l ' ....' ...... . I" rOt Ule\ l~h,l\ lor~ IhJt lIl'l} tIllertt'rc \\ ith \Ul>l:t'" .... lullll t I

Leal1linlle- •-I IllOt",·

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.lIlIl
L

.

'

h

vt:

.

.

0 l\l t'Mlllflg

and

1l10kw fUI1l:tlon.

,

Chapter 5 Examination of Sensory Function

151

Table 5 3 Functional Components of the Cranial Nerves , ,F .V>rr",,- - ".,,":'~_"-".f_v..:t., '~""~":''''''''''~ ~ .. , . ~~-':' ___ ,_~~~~!e."(V~f"U'~ ~ -, , _

-

I II III

Olfactory

Afferent

011action (smell)

Optic

Afferent

Vision

Oculomotor

Efferent Somatic Visceral

IV

Trochlear

Efferent (somalic)

V

Trigeminal

Mixed Afferent

Efferent

VI VII

Abducens

Efferenl (somatic)

Facial

Mixed Afferent Efferent (somatic) Efferent (visceral)

VIII

Vestibulocochlear

Afferent

IX

Glossopharyngeal

Mixed Afferent

Efferent

X

I

Vagus

Mixed Afferent Efferent

Elevates eyelid Turns eye up, down, in Constricts pupil Accommodates lens Turns the adducted eye down and causes intorsion (inward rotation) of eye Sensation from face Sensation from cornea Sensation from anterior tongue Muscles of mastication Dampens sound (Iensor tympani) Turns eye out. Taste from anterior tongue Muscles of facial expression Dampens sound (stapedius) Tearing (lacrimal gland) Salivation (submandibular and sublingual glands) Balance (semicircular canals, utricle, saccule) Hearing (organ of Corti) Taste from posterior tongue Sensation from posterior tongue Sensation from oropharynx Salivation (parotid gland) Thoracic and abdominal viscera Muscles of larynx and pharynx Decreases heart rate Increases GI motility

XI

Spinal accessory

Efferent

Head movements (sternocleidomastoid and trapezius)

XII

Hypoglossal

Efferent

Tongue movements and shape

hom

I\IIldn.

'1r-:

p44 ""llh J)<.'rml\~IOIl

Gt. gJ\lmilllt:\II!l:Jt.

The POC de~igncd lor a pal lent "illt impaired \en~alion i~ I}pll'ally gUided b) one of 1"0 approache'). lhe St'mOl:" JIl1Q~/wlOn AppruOtn and Ihe Canlpe/Ualon Appmach. The '>elt: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<;; (l~ss of ocular alignment): ability of eyes to follow a movmg target without head movement: presence of plOsis of qelid, .. , Cranial nerve V: Sensory tesb of face (sharp/dull dlscnml· nation, light touch): open and close jaw against resistance: jaw jerk reflex. Cranial nerve Vl1: Examine any asymmetry of face at rest and during voluntary contraction. Cranial nerve VIlI: Test auditory acuity using a vibrating tuning fork (Weber test) placed on vertex of skull or forehead, patient indicales on which side the tone is louder: rub fingers together at a distance and gradually bring toward patient, note distance when first heard: alter volume of conversation: Rinne test (air bone conduction) vibrating tuning fork placed on mastoid process. then near external ear canal, note hearing acuity. Cranial nerve IX: Examine taste on posterior one-third of tongue; examine gas reflex. Cranial nerve X: Examine swallowing; observe uvula and soft palate for any asymmetry (tongue depressor). Cranial nerve XI: Examine strength of the sternocleidomastoid and trapezius muscles. Cranial nerve XlI: With tongue protruded, examine ability to move tongue rapidly from side to side.

The Compensatory Approach is a more traditional intervention that focuses on patient education 10 accom· modale to the limitations imposed by the sensory deficit. The therapist's role is to assist the patient in achieving optimum functional capacity, minimizing functional limitations, protecting anesthetic limbs, and creating appropriate environmental adaptations to enhance safety and function. Guided by this approach. the therapist instructs the patient in practical ~trategie~ such as testing bath water with a thermometer or body pari with intact sensation before entering; not going barefoot: regularly checking inl)en~itive skin area~ for cuts or bruises (partit:ularly Important for patients wilh diabete~); adaptation~ ('"compensation,>" for the '}en~or) lo~s) that can include !>ub~lI­ tuting \1\ion for absent lacule cue~ when carr) ing object:>: weaflng heat-re~I~lant glove:-, when working in the kitchen; u~lng a rolling tart in kitchen or olher work space to tran.,· pan item~ trom one area to another; and arranging kitchen ~upplies 10 elimll1ate need tor aeee\... to "torage area~ directly over the- ,}lOve.

EvalualtOn. DiagnoSIs. and PrognosIs

l Plan of Care (Goals and Outcomes)

l Specific, Direct Interventions (Intake)

\

Sensory Integration

Sensory Intake

\

1

Planning and Organizing Behavior

Feedback (KR)

\

Adaptive Behavior and Learning (Output)

/

Feedback (KP)

Figure 5.23 Elemenls of patient management for sensory impairment. KP refers 10 knowledge of perfonnance (feedback about the quality of mo\emenl produced) and KR refers to knowledge of result (feedback about the end result or outcome of the movement). (Adapted from Bund). AC. and Murray. EA.~ps)

Summary Examinalion of ~em..ory function prO\·ides important information about the integrity of the somatosensory system. Findings from the examination assist in making clinical judgments about diagnosis, prognosis, identifying goals and outcomes. and establishing the POC. Periodic reex.amination prO\ ides critical data on changes in patient starus and In delemlining progre~~ to\\ard anticipated goals and e\pecled outcOl11e~. IndiVidual test~ for each sensory modality have been pre~ented. Reliability of these test procedllre~ can be improved by careful adherence to consistent guideline\. admini')tration of tes.ts by trained individuaJs. and subsequent rete~ls. perfonned by the same examiner.

DOCUmenlallOn of te" re,uil, .hould address Ihe IYpe(S) of

Chapter 5 Examination of Sensory Function sensation affected, the quantity and degree of involvement and locali7,Jtion of the exact boundaries of the sensory deficit:-.. Finally. it should be emphasized that additional research related to :o:cnsory testing is warranted. Further

Questions

for

Rev

4.

5. 6. 7,

8.

would \\arrant (or indicate the need for) an examination of sensory function. Describe the preliminary screening tests used to detCn11ine mental status for each of the following: areas: arou."al. :lltention. orientation. and cognition. Identif~ the se\·en types of cutalleous receptors. their location. 3.nd types of stimuli to which they respond. Identify the four types of muscle receptors. thcir location. and t~ pe~ of ~timuli to which they respond. Identify the four types ofjoilll receptors. their location, and types of stimuli to \-\"hich they respond. Identify the sen . . ations mediated by fhe (A) anterolateral "pinothalamic s) stem and the (8) dorsal columnmedial lemni~cal system, De~cribe the type of data generated from examination of . . en~ory function ~t11d how it is used by the physical therapist.

Case

developmcnt of QST techniques. standardized prolOcols, reliability measures, and additional normative data will significantly improve the clinical applications of data obtaincd fromlhc examination of sensory function.

ew

1. Define sen:-.ory illlegrity. 2. Identify si'{ impaimlcilts or functional limitations Ih3.t

3.

153

9. Describe Ihe equipment required to administer a sensory examination, 10. What is meaJ1l by a screening? Explain how and why you might perfonn a screening for sensory integrity, 11. Explain why impaired sensation is a contraindication or precaution for use of some physical agents. 12. Identify the information you would provide the patient prior 10 administration of sensory tests. 13. For each of the three groups of sensations (superficiaL deep. and combined cortical) describe each sensory test, providing both the test protocol and directions for patient response. 14. Describe the methodes) you would use to record the results of sensory testing.

Study

A 61-) ear-old \\'onun presents for outpatient physical therap). She arri\es in a renled wheeJchilir accompanied b~ her . . on. On inlt!ill meeting. Ihe patient greets you with a verbal "hello" and a hand:-.hake. The ~on ~peaks for his mOlher and reCOUJ1l~ that she ha~ been compl;,lining of a burning feeling in her feCI and difticuhy ambulaling. The ~on indil'alt'') that hi." mother took an early retirement four ) ear~ ago from her po:-.itioll a~ an elementary ~rhool Icacher. Tlw, \~ a') a po~ili(ln she had held and enjoyed lor ~5 )ears. Her children encouraged the retirement. TheIr mother had Ir("queml) complained about difficult) ~eepjng up \~ Jlh the teaching re.-,pon"ibilitic:-. and thai thl' wor~ had become ·'ju"t too Illllch" for her. She ha~ luur other grown childrell \\ ho all livc in the "amt:' .. uhurhan i.·ollllllunJl~. The pallent In e~ aJ()nt~ in a t\\o-bedroom apartmenl In a buildIng \\'llh an dC"l'd lor ."hopplng and Dlher outdoor Ira\ 1.:'1 il~ ..he h"d "tlll1lhlt'd ;..tIKi lJlkn l\vice \\htlt' \\,.d . "lng on ~t le\d "IJe\htl" Yuu thelll" the "un lor the lnlonnarinn anu 1110\ e till' P,-\tICru Into ,I tredtmelll room to ~gitl your o ..ll11in,lllllll.

G IIUI I' ".I, 'l TlOW 1 Alier explaining lilt' rea"on:-. lor conuu\,.ll1lg i.l Ihl1rough c\amll1,t1101l yuu :-'I~lrt \\ IIh
1.

3.

--t.

S.

ination. Describe how you would examine: anemioll. fillld of knowledge, and memory. Your preliminary screening tesls indicate that cognitive function is grossly intact and that there are no abnormal cranial nerve lindings. You plan (Q continue your examination with the following: manual muscle lest. gait analysb and detennination of coordination, sensation. and functional status. Identify which tests or measures you would complete first and provide a rationale to substantiate your choice. The first portion of your sensory examinatjon includes perception of pain and t~ll1perature. Describe the test prolOcol for e:.Ich and identify the ascending path\\ay that medlale\ pain and temperalure. Your finJing~ for pain ~ll1d temperature indicate both are intact. You now pro£re~" 10 tt"SI proprioceptiun and vibrUfion. D~~C"ribe the test protocol fur each. The te"t finJinp indiratt' ~everc lo~s of proprioception and Vibration in the lower e>..trt'lIlities (distal more than proximal). \Vh~lt rec~plOrs are responsible for Ihe"e ~en:-.ory modalities'! \Vilere are the receptors Il)l',Hed? Idcntif) the a~cending pathway that mediates pmpnoccption and vibration. What are tht': fUI1c;:tional illipilri:lIIOlh uf the finding:-.'!

154

Phytlical Rehabilitation

References A\er,. JA Sen"or" Intcgr;llrun and Learmng. Dl",ll'o,lrlll,'" We"lcm P~,~hologll;\1 SenlC'e". Lo"An~ele". 1l}7~. ., R\ I. N Mulll>.ell'OI)' l'onlrol III upp<:r e\lrcmll} fUll(lI(>!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 Na<;hner. LM: Aging and pc"'ture control' Chang.e!> III .')cn"ol) organi7alion and mu"cu!:lr coordinalion. Int 1 Aging. Hum Dev 23(2):97. 1986. 12. Tr.m. DB. el al: Age-rel3ttd delenorallon of mOlion perception and detection. Gl'3cfe, Arch Chn E~p Ophthalmol 236(4):269. 199!l. 13 BenJu}3.~. Meller. I, and Kapl3Jhkl. J: Agmg-Illduced ..hiff:<> from a reliance on ..en"Ol) lllput to muscle COCOniraellon during balanced siandlllg. J GeronloI59A(2):I66. 200·t 14. Fu~unaga. A. Uematsu. H. and SuglmoLO. K: Influence... of aglllg on tu"e percept ron and oral somalic "enl>alion. 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:la<'lncht agmg. "Iud}. J Am Genalr Soc 53(31:374. 1005. 19. Welh. C. et .11 RegIOnal \ana!l()n and change\ with agemg III \ rbrolaude '>ethllr\ 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<:lional pcr'lomlalKe. and d .....lbihty m Ihe elder" Anh Ph>" Med Rehabll 77(61:567. 1996. 21 Menhul. MP. and Tole.I.i". SC' Agmg and 4ualllllall\,C -.en"0l) Ihre~hl)ld... rlcl.:lromyogr Clm f'l."urophy"lol 30:29:\. 1990 .... Wile", PG. t'l at Vibration perl.:epllOll lhre'hulll: Influenle of agl.:. helghl. ;,e>.. ,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<: dle...t 01 .J!.!lI1g HlIlllitlITll..ttlUll'J'fO\.""'" 1Il~ lhanneh III til!.' "t:ll"t: n!lOulh I Ab"olule ,,("n"lllvlty SOlll.tlll'cn" Mol Re" 11'4". 1tJ44 :!5. Pnnll. AC Inrl,I" Juni'lr. PO .md Harcla. JA Ph>:'K;11 illlt\-ll) .tnd po"lUr.J1 'llfluolmlhc cJdctl} C'OUplulg bt't"el'll \ I"!lal inl\lr IOJII'IO and b()d~ ," (iu"tal,tIOAS. 0:1 aI' Ch.1ll~e III b.Jj.1llle p..·lltllntan'l· III ph"I~,III\ adl,e elderl, I'k:opk
'I' 1,'lucm:e of aglllg on penpheral nerve funclIon ..:{ VcrJu E:. cl .1, r 91 2000 .' .,., J pr:r1phcr Ncrv S)'~t 5(4): I . . and regcner.llion S M hod 1 f "'e11313 A and Gib"on. J: el ooglc aClorll 2q I-Iehne. RD. j ' .' ' . 1 ' h h 1 ", te to ,'anallon<; In ex, penmenla pam I res 0 d ",hl~ h conlnl,,1 2004 ,~ple Ncuro"cl LcIl361.1·]:I44. . rcjX)flC(IIor Id e ,..._.. ' Q d f "v Rcc~.. J 3nd Ne" ham. DJ: ua flcep" uncllOn. prolO Hur 1C}. I". h ' e tty and funCllonal perfoml:IIlCe In eahhy young priocepuvc a u , . 27( '5 ' middle-agcd and elderly :.ubJCCI'" .Age AgclIlg. I). 5. 19?8. Ulrhlll.. B. Bergman. E. and Fundln BT: Impalnne.nl of penpheral 31. sen'>Ol) innervation in ~cnescencc. Auton Neur~'ici 96( I ):43.2002. .n. Hofcr. SM. Berg. S. and Em. P: E'd'alu3 "n g Ihe '~Ierdbacpe,ndence of :1 Ing-relatcd (hange" III ,i<;uaJ an au d llOry acuity. anee. and C~gllllr ... e funcllOning. P!>ychol Aglllg ~2):285. 2~3. 3:\. Takduma. K. cl al: Age and gender differences III skin sensol)' Ihrc~hold a~"c,,<;cd by current perception in community-dwelling Japanc<;e. J Epldemiol I()( 1 Suppl):S33. 2000.. 34. Wool/aeoll. M. and Shum\l,ay-Cook. A: Allentlon and the cOnlrol of JXblure and gail: A re... ie\l, of an emerging area of research. Gail POSLUre 16( I ): I. 2000. 35. U.S. Dcpanment of Heallh and Human Services. Healthy People 2010: UndcNtlmding and Improving Heallh. 2nd cd. Washinglon. DC: US Govcrnment Prinling Office. November 2000. 36. Jael.!>on-Wyall. 0: Brain function. aging. and dementia. In Umphrcd. OA (ed): I eurological Rehabilitation. ed 4. CV Mosb), St. Loui". 2001. P 790. 37. Hopper. CR: Sensol) and -.ensor) 10legralive de,elopmenl.ln Bonder. BR. and Wagner. MB (cd,,): Functional Pcrfonnanee in Older Adulh. ed 2. FA Davis. Pllllmklphia. 2001. p 121. 3~. Hill". GA: The changing realm of lhe \enses. In Lewis. CB (cd): Aging: The Heilllh Care Challenge. ed 4. FA Duvi<;. Philadelphia. 2002. p 83. ]9. Gallman. RL. and Elfc(\ ig. LS: The aglllg ~nsory syslem. In Sian Ie). M. and Gauntleu Beare. P (cd!»: Gerontological Nursing. cd 2. FA Davis. Philadelphia. 1999. p 93. 40. Pete~. A: TIll' elfeel:. of nonnal aglllg on myelin and nerve fibers: A review. J Neurocylol 31 :581, 2002. 41. Adam". RD. and VieLOr. 1\1: Principle:. of Neurology. ed 6. r>.IcGr3"-HIII. Ne'" Yorl.. 1996. 42. Gould. B: PUlhoph}<;iology for lhe Health Related Professions. td 2. WB Sauooe...... Philadelphia. 2001. 43. Pm:~', DL: AglOg ollhe br3111 and delllenlla of lhe Allheimer t}pe:. In Kandel. ER. SCh\\ilnl.1H. ,Illd Jes<;e11. TM: Principles of Neural Science, ed. 4. t...kGraw-HIIJ. New York. :WOO, p 1149. 44. Cr:lI~. RL: Sen\orimotor change, and adapl.llion in the older aduh In GuccIOne. AA (ed): Geri.ltrir.: Phy"lca! The"'dp}. CV Mosb). PhIladelphIa. 1993. p 71 45. Dortm.ln. U. and Bo!>le). T~!' Age-relaled r.:hange:. III peripheral dnd cemral nl."ll'e r.:ondUlilon in man. 'Jeurology 2Q( I U8. 1979. 46. BOl.lclle. P. et al: ClrnJla) lUlU deuroph} "Iological "lUdy offhe penph('ral ne(\'ou.') 'y"lern 11l Ihe dderly. J Neurol 240(5);26.1. 1991

°

47. Ta}lor. PK' I\onllneal ellel:b ol.lge l\l1 nene l·onJul,:llon III adulb. 11\euml Su 66::!2.\. 1l)~4 48 D<mllle. A\\ .•ml! r>.('\H,"II. DJ. Sell"-'!)' nene l'ondU('lion In P.Jtll,·lJ[<., \\ llh dlat"oete" rndlllu" .lJld ~'untf(lk Neurolo..' "'876 1%1 ~ . , 49. Bulton. CF 1."1 ,II: A qU,lIltltatr\e "Iud) 01 r>.k.":'lIt"r\ Cllrpmck" in m.m Neuroll,lg} I (J 1. I Q06 'ill Mahuol.d. S. et al· QU.JIlIIWI1\e .Uld 4UahlJll,e "ludie'> of \11;'1" Ih:r\ l,llrnu"de human "...' tn. "1m "I'l!,"('ial rdereoce 10 '1' .. III alter,III!"I" lau-.ed h) .tglllg. J Dcnn.uol Ill( l):205. lilKl :'i I \..:rnllo. R I -\"0: rei I d 'h . e . t e l .mgt·" III lhe "en"I\I' II) 10 \ lbralion (Jemnlul]'; IK'i. 191:<:0 ~:!. I..t,~dk" " RG ,md TI l,lrnd". ' p' • '" l h.lnL'l:''' due 10 age in Ullcmodal kngth lllille Ulal lll'(\' I . J :!940. 196b t U man. ~euwl. ,'uro"urg P"}l,'hialJ)

5\ L

C~~l. ~'B .lnll Botllllllin J\I (jt'n.Jln~ Ph' ..lr.:.tl llk'mp) .\ JnK.1 '\PPhl.h.h Appktoll &: I .1Il!-,~·l'~ lib. CT !9l)4 \\ '14 lIu.l\l,arJI\Llh"1 I· '. " I. ' t 1'1:, .111\11" lip I:It"ml:::ell "lin l:omph;mee. olge. g~lltU, ,lilli t.lltrlr: dl" S tflllllllallVe lhle"huld, III hum.uI" . Ulll.ltuwn" f\hll Re" Ill~ 11'0.\. 1')\)\.

Chapter 5 Examination of Sensory Function ~5

Thomi1ul1 . 1M. and MI \lrt na. eM ' Tactile !:>en~ill\ ity a... a functl OIl of :Ige. J Gerl)nlOl lfi:;\4. 19R 1 :;(1 MUIJ\cr. II' Thc Influence of "pallal contr.l<,t on the freque ncydepend!!nt Ilrtwrc a t vli1ralion ~ns ill v it ). Percepl P ~yc h oph ys 4815)431. 199{). 57. G e lh ~. /1.1. and Pool. R: Two-pOint dl:.trlnllntllion dl.'olances in lhe normal hand Ilnd toreaml. PIa ... t RcconSlr Surg 59:57. 1977. 5S Skinner HB , Barrac\.. . RL. :md Coo\.. . SO: Age-related decline In propriocepllon_Cl lllie Orthopaed icl.> Related Res 184:208. 19~4 . 5q Bohannon . RW. ct al : Decrease In timed balance test scores with agmg. Ph y~ Ther M (7): 1067. 1984. 60 Baloh , RW. et al: Com pari ...on of sl. Ph iladelphia, 2000. 6R. Lund)-Ekman. L: Neuroscience: Fundamentals for Rehabilitation. ed 2. WB Saunders. Philadel phia. 2002. 69. Afifi. AK .•tnd Bergman. RA : FunctIOnal Neuroanatomy: Text and At las. ed 2. Lange Medical BooksIMcGraw-Hill. New York. 2005. 70. Jacobs. SE. and Lo.... e. DL: Sommic senses I: The anterolateral ~ )l.>te m . In Cohen. H (ed ): Neuroscience for Rehabilitation. ed 2. Lippmcoll WiJljams & Wilkin!>. Philadephia, 1999. p 77 . 71. Gardnc::r. EP. Manin. JH . and Je!\sel, TM: The bodily senses. In Kandel. ER, Schwartz. JH . and JesselJ . TM : Principle~ of Neural Science, ed. 4. McGraw- Hill. New York. 2000. p 430. 72. Fitzgerald. MJT: Neuroanatomy: Blli>ic and Clinical. ed 3. WB Saunde r~. Philadelphia. 1996. 73. Fredend s. CM: BaSIC ;;e n~ory mechani sm and the somatosensory ~)st em. In Frederick.s. CM . and Salad in . LK (ed!»: Pmhoph)siolog)" of the Motor System;,: Principles and Clinical Presemations. FA Davis. Philadelphia. 1996. p 78. 74. Pen). NJ: Pnnclple!> 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 "!: Elt',,!>ment 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\'). Belhe<;da. MD. 1003. 84 Nolan. MF: Limils of two-point discrimination ability in the lower limb 1Il young adult Olen and women. Phys Ther 63: 1424. 1983. 85. Nolan . MF: QuantiLative me,L'\ure of cutaneous sensation: Twopaim diSCriminlition value<; for the face IUld trunk . Phys Ther 65:181. 19R5 . 86. Nolan. MF: Two-point di scrimi nation assessment III the upper limb in young adulf men and women . Phys Ther 62 :965. 1982. 87. Desrosiers. J. et al: Hand sensibi lit y of healthy older people. J Am Geriatr Soc 44(8):974. 1996. 88. Shlmokata. H, and Kuzuya . F: Two-point discrimination test of the skin as an index of sensory aging. Gerontology 41 (5):267, 1995. 89. Hennann. RP. Novak, CB. and Mackinnon. SE: Establishing normal values of moving two-point discrimination in children and adolescents. Dev Med Child NeuroI38(3):255. 1996. 90. Richards. PM. Persi nger, MA . and Michel. RN: Ontogeny of twopoint discrimination (or fingers anti toes in children (ages 7 through 15 years). Percept Mot Skills 86(3 Pt 2): 1259. 1998. 91. Ken! . BE: Sensory-motor testing: The upper limb of adu lt patients wi th hem iplegia. J Am Phys Ther Assoc 45 :550, 1965. 92. Soivie, J: CenLral pain and the role of quantitative sensory testing (QST) in research and diagno~i s. Eur J Pain 7(4):339. 2003. 93. Cheng. WY. et al : Quantitative sensory testing and ri)'k factors of diabetic sensory neuropathy. J Neurol 246(5):394.1999. 94. Chong. PS . and Cros, DP: Technology literature review : Quantitative sensory testing. Muscle Nerve 29(5):734, 2004. 95. Gibbons, C, and Freeman , R: The evaluation of sma ll fiber function-au tonomic and quantitative sensory testing. Neu ral Clin 22(3):683. 2004. 96. Granot . M. Sprecher. E. and Yamilsky. D: Psychophysics of phasic and tonic heat pain stimuli by quantitative sensory testi ng in healthy subjects. Eur J Pain 7(2): 139. 2003. 97. Greem.pan. JD, et al : Allodynia in patients with pol.>t-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 <,~on . L. and Lundin. A: Thennal quantitative ...em..ory le~t­ IIlg in lumbar dis£" hemkllion . Eur SPIllC J I 1(1):71. ~OO2. 105 Shy. ME. et (II ' Thernpcutic), and Technolog.) A"~~'~~menl Subcomminc=e 01 the American AcadclIl) 0f Neurology: Quunutatl\'c !.ensory te,tlllg : Report of the Thernpt"lItie\ un<.l Tedlilology A...:.e ... ~ mcnt Subtommmct" of Ihl;! Amcnl.'an Academy 0 1 Ncurology. Neurology 60(6) : 89~ . .10OJ. \06. Zlt'g lt"r. D ~ Ct ul: Validation 01 a Ilt\\el !'.crecning tkvke (NcurnQuld.) tor lluantll,\llvt: d ~~sme nt of !sma.1I nef\'C tiber d . . sfunction -.1..-' an earl) feature of dldbctlc polyneuropathy. Diabete~ CiU'e ::!~(5 ): 1161) . ~On'5 . 107. PeMfonk. A. et al: Sl'n~of) ex am .... Ith Gljuanlll3ti ... e tunUlg fork: Rapid ~C'nsltlVe ami pr~dil"ll\\! 01 SNAP amplitude. Neurolog) 61:(3):461.2{)(J.)

tUK A)t"r:., JA: TUl lJie IUllruons: TIh;:ir rc-lJ.tlon to hypemcthC' and perCt!JllU :tI motor bt.>ha\lor. Am J Oecup Ther 18:83. 19M.

156

Ph, ..,cal Rehabililalion

"yer.. JA ImelTdall(lll' amo'llj! pt'R:Cplual-nlOlor .ll'uhIlC' I'll ,1 group 01 normal l'hlldrl'n Am J OI..lUp Ther :!O::'IlR. 11.)60 110 Aycr.. J" Imprmm(! IICadernK 'l'ore, through -.(""'0.... mtcgr.tlloll J Lcanl Dl'abll,~ ~J~. 197:!. I(lQ

Supplemental

C1u'lcr anal)'I~ of mca...ure.. of ~cnWl) mlegralJon_ Am III A)C"" JA . J (kcupllil~'r ~1:16:'. 1977. n II:! A,cr.. JA: Scn~ol) 1r1legr.aIlO and the Child. Weslem P,)eholog lc:11 ServILc". Lo~ Angele,. 1979.

Readings

-\11(''11. GL. l'l al' Agm~ and p;uh Illle1!r.:lIlOn ,1..111 Kml"~lhellc and \c'llholar lOlllnhouon" 10 "a) finding. I}crccpl P,,)choph)" 66 111:170. :'l(~ On!. \, and I)crl..m". BA Compan-.on 01 "hr.llion percepllon Ihre,h(lld, obtailled "'>llh lhe f\curOlhe'lomeler lind Ilk' CASE IV and relation· ,hlp to Ile.... e l'onduetlon 'tudle~ Dlabel \led 19(8):661. 2002. Gilman. S JIlml po'llIon ,cn,c :lnd \ Ibl"3tnln ,cn ..e: Anatonlle,,! orlplll,allon lind a....c'..rncnt. J Ncurol Neuro:>urg P'ychliltf) 73:47.\ 2002. Ingram. HA. Cl 31: The role 01 propnoceptlon and allentlOn III OJ vi ..uomOlOr ad:rptatlon ta..k Elp BraIn Re" I 32( I): ll-J. 2000. Kamel. f\. et al: Elh,'Cll\ene", of Semme..-\\emqem monofilament e\anllnalln'll for dlabellC penpheral neuropathy -.creenmg. J Dlabcl Compl 19(1)A7. ~OO5, !\a,tenrouer, T, elal: ~ \alue oflhe R}del-Selffer lunmg fork a~ a predlltor of dIabetiC pol~ neuropath~ compared .... nh ,I lll:urOlhe'>Iornett'", Dlabet \ led ~ II 6 1:56,l. 1()()4

Llu. W. CI .II: NOI;;e-enhanl'cd \lbrot3ctlle \Cn:>ill\lllY In older adult" and rJtlenl~ \\ Itll stro~e and patIents wllh dldbetlC neuropalh). Arch Ph}~ led Rt'habll J: 71. 2002. Nardone. A. el al: L.o>;, of large-dl:lmcler "pmdle afferent fibres is I10l dt'lrlmClllalto Ihe conlrol of bod) ,way during upright stance: E\ldcnce trom ncuropathy. E'\p Brdlll Res 135(2):155, :WOO. P;mlc\. AN. et al: A eompan ..on of the Neuropen Agam!>1 siandard qu~mlIHltl\ C:.en ..of) -thre:.hold rnc,... ure~ for a~\cS\lng peripheral IIcm; function, Dlilbet Mt'd 19(:'i):400. 2002. Speer... RA. Kuo. AD. :Hld Horak. FB: Contribution~ of altered sensation and feedbacI.. re..pon.. c~ to change\ in coordination of poslural control due to agmg. Galt Po"'ure 16( I ):10. 2002. Vj" .... an3than. V. et al: Earl) recogmllon of diabetic neuropathy: E\aluallOO of a ~lmpk outpallenl procedure u..tng thermal perce-plion. Po\tgrad Med J 78:5-J I. 1002.

Appendix A: Two-point Discrimination Values for Healthy Subjects 20-24 Years of Age Two-Point Discrimination Values for the Upper Extremi,;es of Healthy Subjects 20 to 24 Years of Age (.\' = 43)

Two-Point Discrimination Values For the Face and Trunk of Healthy Subjccts 20 to 24 Years of Age (N= 43)

K-.J

• '·1

Upper-lateral arm

42.4

14.0

Over eyebrow

14.9

4.2

Lower-lateral arm

37.8

13.1

Cheek

11.9

3.2

Mid-medial arm

45.4

15.5

Over lateral mandible

10.4

2.2

Mid-posterior arm

39.8

12.3

Lateral neck

35.2

9.8

Mid-lateral forearm

35.9

11.6

Medial to acromion process

51.1

14.0

MId-medial forearm

31.5

8.9

Lateral to nipple

45.7

12.7oi

Mld-postenor forearm

30.7

8.2

Lateral to umbilicus

36.4

7.3'

Over first dorsal Interosseous muscle

21.0

5.6

Over iliac crest

44.9

10.1 c

Lateral to C7 spine

55.4

20.0'

phalanx,

2.6

0.6

Over inferior angle of scapula

52.2

12.6'

Palmar surface-distal phalanx,

2.6

0.7

Lateral to L3 spine

49.9

12.7'

2.5

0.7

.

~

Palmar thumb

surfac~istal

long finger Palmar surface-dlstal phalanx,

-n = 26 b n = 42 en = 33

little finger

Two·Point Discrimination Values fol'" the Lower Extremi,;es of Healthy Subjects 20 to 24 Years of Age (,\. = 43)

SIUa

X

PrOXimal-anterior thigh

40.1

14.7

Distal-anterior thigh

23.2

9.3

Mld-lateral thl9h

42.5

15.9

Mld-medlal thigh

38.5

12.4

MId--postenor thigh

42.2

159

Proxlmal-lateral leg

37.7

13.0

Dtstal-laleralleg

41.6

130

43.6

13.5

6.6

18

239

63

222

86

B

Medial leg Tip of great toe

-

---Over 1-2 melatarsallnterspace - - -Over 5th metatarsal

J

"n -

41

From Nolan, MF.&4-86 with permission of the American Physical Therapy Association.

/tl/'/I/(

6 I f ' I . . . IIIJIC1IWlI

", ,n

Musculo keletal Examination 1>• .Ill.' l"e \\ hile. OUlllNI

.

1'1 II ,

----

\lllhh'f'<'IIIl"ln.. ('!l,Jla..l..-n II.... 10'" )(.tll .....1

I.

I :u'n-

I·~III.

x,

tllkH

I''''

hi 1.11 \~hl \t," \ 1I"t ~l II' Ih Ol>-
Till.:

11Iu,..'uh, Lckl.s1 "

l~m lIIduUl:'> hl,IIlC"'. mu,lil·"I

'" llh llH.:lI rd.lh.."d It:ndpll' .anJ ,~lttl\ 1... 1 ,hl'.llh..; bur .L .lIlt! JOllll ...lnKluln ... u ... h

.lnt! 1J~;IlIlt.·nl\,

d.,rupl the

.t,

l.II1I1'Il..'l.". mCI11'l;I,

l;Jp'ulc ....

·\,:ute Illlunl· ... or t.hrollH. 1.0ndltlOlh lh.. t!

.tn,Jltml~

or

ph~ ">Iolo~~

()j

mu ... \,.;ul()... ~elcl.11 11'-

".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-

"Ul."

"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

\1.tn~

t-
Both dm':L1 and IIldlred mu-.<.:ulo...ldelal Imp:umlenh llllHnhUit" 10 lUnlllOnJI IImll..tllon and dl ....lbllil\ thai ,lttCl"l a P<.Itlt"1l1 ... <1hllll) 10 perforllllenalll 1iJ'>""" and' role~

l.1f1

I',"

f\

11

po. ..:lll,n tt,"1

)'all',Illl.n l/o~

\l.,IlI'11

J.. IIII \hltltlll I"h \lu Ie I'crf\X1l\..&no.c 1'7 \pc.. loJl rr,,1 IIW \ Jd.II"nJI rc h .inJ \tC.t....UIl"\ Ixlj \,..

h.

f

m II

I tan

l

I \ 11

,illo>ll

r lfklllh'

II(~

'1

In •...(X:l~l~

B) con'ldcrtll!! the few e\ample\ 01 dI3gno.. .e~ IhJII.:<.IU'C' dlred Jnd IOdlrct:t mU,",t.;uh.l\helc:taJ lmpalmlenh PIU\ Hied III Iht: preceding Inl, une: l'an apprct.·talc ho\l. OltC:1l ph~ "IL..t1 Iherupil:,t'- and other hetihh profe"sionab cnlounta tllmcal prohlclll'> ot lhe musculol:,lelclaJ \} 'llem. dmJnI\tt"nng mU,",l:ulo(,hclctJI le\h and mea~urc:'J, j, .tllllo~t JI\I.")s a major component 01 an initial pallen! C\amlnaiion Thl'> Ch:lpICT di ...l.:u,se" the purpo~e" of. and prm Ide~ ;} gCl1cr.:t1 trall1e\~or" for, conducting a rnu\culoskeletiJ.l e\3mination. The principle.;, and component.') of 3 museulo..leklal c\amlOatlOn. together", ith ho\\ to organize and integrJtt" the data \\ nh those of other body .)y'tem.... are empha"lzed Olher re,ource, Jre available that prm ide dCIJilcd mu~culo,"elel
hody regi()n .... I-~

Purpose of the Musculoskeletal Examination Evaluation of data from the musculo,keletal exalllina· lion conlribute\ to e,tabli"hing a diagno~i,", and progno. "oj,. ~etllllg goal ... and oUicomel:,. and dc\eloping and Implemenllng a pl,JIl of care. A musculo~leletal c).amlnallon 1'\ aho an tml>onant component ot e\'aluatlllg Irealmenl outcome ... bOlh penodically during Ihe (reallIlCIll prot.:c'\l>
l'uq"',t· ... II' pl"I"ll11lll~ Ilh. hhk the lnlh." Ill~ In

,ktt'lJl1l1ll"

llw

' I lllll'tlll",hl'kl.d

PIC,Clh.. l.' ,11

III11t t h 111•• 1I till 11.111\ Ill" .•Ind

h,'.h· .... ,llld Il'l.IIl'd 111'111 "l

11\ Hll"IlIlh Ill"UIIIl":

I~\

lhl" 'r":lIl

"h,ell,',: til

tll"';lhd II \

Ill\ llh

l:\.lrllln,llltlll

Imp.unlll'Il\'..

1ll~

nHl't- k

....

Irth..lun:, 11 ...... Ot....

-l

lh.ll .Ife l;Hl ... lll~/l·llll-

Ihl' Imp.Urlnt'lll. IUlld'tlll.tl lllllll.llhm. or

hltkh:llllllll' h .."dllle 'Ialll'

It\ Ill'll' !llnnul.llc .lpprtlpn.lll." ;'1l1h.. tp,llnl th.:rJ~lIlll

l!tl.tl,.

l·'IX'tll..'d 111lIlOIllC" ;llld I'l.lllll',l'.trl· ~ 1,1 C\.du.lll" lilt' 1..'lh:l..ll\l'llt· ...... 01 reh.ltllIlIJtlon. rnedIL.t1. 11I'tlICll.t1I1l.111.Il.'t'1ll1'1l1

h

"In Id~nI11~

II ..."

\\\)r"'L'nln~ 01

lallor...

(0 pr("\('111

the

llnp.llrmt.:nl .... llllllllflnal

i..!cH:lopmt:nl or

IlInll.IIHIO.... or

J'".ihd,tH.'''

- ro tlelt'rmlill' l)rlhOilt ..lnL! adaplI\ ~ e4u1plnent ncce,,"ar) It'lr lLuh.III'ln.ll perform.mct' of .ltlnn;11 .1(11\ I1lt~". X Tn nWIl\.lle Iht' p;III("nl

111'1111\ IImll

()n·up.lllon~11

.lnd reere-

Examination Procedures Palienl Hislory and Inlerview Pnor In begl11ning the phY~lcal examination it i" Important ,\;alll the examin,:uion to an area and ,>~,>telll of tile bod), Infor1lUlioll on SYlllptoll1~ and tUI1I..'lional dbill'y \\ ill help 10 e~tabli"h a ba~eline again':>t \\hich Ireatmenl cjlccti\enl,""~ can be judged. It \\ill al"o enable the C).:llllll1allOn and trealmelll 01 Ihe palient 10 be

10

conuul"tcd ,afd~. T~ pIC;llly. 1l10~t of Ihi, infonnation i...

obl~lIl1ed

b) inter\It'\\lng the patIent. HO\\t'\cr. lltiliLing olher inlonmHion ,>oun.:c" Gill tx \er) effincnt and pro"ide objcctl\it)' and del;IJI ... 10 ,uppkmelll an mien le\\. If Ihe pallent " ho,>pilailzed III JIl ,l('Ule l·.lrl~ or rehabilltallOn ,>elllllg. the medical rel'ord" IIllludlllg admi,,,ion r('pon .... progre", nOh~ ..., medlI..i.tllt'l/l ...hl'ch. ,urglcal ,Unlmilnt". bod) Inl3!!lIlg reporll;, and I:IbHral0f) le,1 re'uli". ,hould be a\ 'llIable anJ ,ouglll (lUI RdcrrJI "Unlmanl~" trom pre\ iou, medical Glre \eltlll~ ... IhJt ret le\\ prior tre..ttmem 1 \)1 UHll

•

,

.

.", I 1I1l11l11! 01 111l' pallcnt ~ medical lllluL ". ~ " . I 31 lor ... d~CI](l1l :Jlld ,.tll; appllc~llon of " h.ll",'roulllI l"ln 11.. • C .1 1''"'llme.:nl pr(lCl~durc .... For c'\:al11pl~. a h,,. C\..tnllll.lllon .lIlu c. . ""111111 trcllnn \\ould call'\.: lhe Iherapisl 10 ltlf\ 0 I .1 lll~ Ol"" U • • . lor" ('Ichell nloniwr the patient Junng muscle , I _ . I Illllt ,IIlL n.... · I'll" A hi"t(lf\ of dlabcte~ melhlUs would JX'rI orm;II11't' I C"~' -" • . GIU~t: the- IhL'rapi"t to ~ll pe(;t anJ tc,t .lor pOlenllally compromi...('d penpher~d \ a cular and penph~r..d nervous ~~s1C1ll". Jnd to pos~ibl) avoid the lI~e 01 heat modalitIes durin!! treatllleni. E\en if a palient complclc~ a medical h."tor~\ loml. 11 i, imporlant for Ihe therapi"il to review and c1arif~ the infomlalion "ith the patient. Sometimes imporI~ult ~lCLhGd bacl...ground data io;; inad\crtently forgotten as the patient focu\e" on current problems. Verbally reviewIng Ihe infonnation with the patient may jog the patien(s memory. Afler ret ie\\ ing the information gained from medical records. olher heallh care provider.... and lhe patientcompleted medical hi~lOry forlll. the therapist is ready to begin the patient interview, Ideally, the patieOl interview ..hould be conducted in a quiet. well-lit room that offers a I11ca"ure of privacy. To encourage good communication, the therapiq and palient should be at a similar eye level. facing each other. with a comfortable space belween them-about 3 feet apan is cu"tomary in the United States, The patient should have the therapist's undivided attention: telephone calb and other interruption~ -;hould be avoided, The thcrapi,t lllay wi-;h to have p,lper and pen available to ri:cord particular dales and information that i,:> easily forgOllen. but the inter\ ie\\ ~hotlld flo\\' an active com'er... ation. not a dictation <.;e:-.sion. Repeated practice greatly improve ... the: Iherapi:-.t'<; abilit) 10 liMen, direct the inlerview. Jnd e<:.tabllsh a po",ili\-e \\orking relallonship with the patient. O\er Ihe I.·our~e 01 Ihe inten ie\\ Ihe thC:fapi~t gains lllfonmuion about the p'llle.:nt\ l'urrent complaints inductIllg on,el. locallon. I) pe and lx'hd\ ior ll!" "'ymptoms, current mel.hl·alion~. pre\ loth trcalmt"nh. "'t"I.·ondM\ medical problem". and meJlc.11 hl,>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. OCCUp
I

lhnrllll~ 1

l I I'

lid It)

r

In

ul,,~L.dd..,1

I

111111.tt100

Ihl

ng

cart

,,'COld DATE

CH 1I DA E OF NEXT MD VISIT

[f [I

Mf Dle'TIC: S P

I 8t1 medJCal

eur'f>r

betng td~ n along ""H' 'tle dosage jl kno......n and frequency

I

4

5 6

J

SURGERY Please IIsl aflsurg rles and approximate date

DATE

2

DATE

3

DATE

4

DATE

_

_

_

DIAGNOSTIC TESTS Please check lests for current problem only

X-rays

CTSean

_

EMG

Blood Test

_

MRI

Bone Scan;

Myelogram

_

Others

_

_

OCCUPATION

1I FE STYLE

Non Smoker"

Smoke _ _iday

No Alcohol

Alcohol__ Idayor

No ExerCise

Exerclse

__/week

"day or _ _/week

FAMILY HISTORY Mother Father, SIblings Alive and healthy: _ f deceased cause of death.

_

(contmued)

DQYOU HAVE. OR HAVE YOU 'fAD ANY OF THE FOllOWING

Ploase cheek All that apply

Hot or cold Intolerance DiabeteS - Low blood sugar ThyroId problems

HIgh Olood prflssurc Hcan prOhl('mc; Hean palpllahons. murmur Chest pam Shortness of breath CoughIng Dltllcutty sleeping lyIng Ilal Lung problems Asthma Allergies

-

=

Rashes Scars Changes In hair or nails

Ulcers Recent weight gam or loss Nausea, vomitIng Bowel Of bladder changes Loss of appetite

-

Wear eye glasses, contacts Changes In viSion Blurred or double vision

=

DiffIculty swallowing Ear pain Vocal changes Ringing in ears

=

Sexual dysfunction Abnormal or paInful menstruation PelvIc Inflammatory disease Currently pregnant Date of tasl mammogram _ _

Dentures -- Major dental work Difficulty ealtng

=

Blood In urine Incontinence

-

Tumors Cancer Bleeding or bruIsing DialysIs Blood transfusion

Varicose veins Muscle cramps JOint or muscle pain

Seizures Head trauma ParalysIs Loss of conSCiousness Headaches

_

=

Numbness or lIngllng DIzziness Balance problems Arthritis

Psychiatric or psychological care

_

Fractures (broken bones)

_ _

Whe re?' -~""----"---"--"-:-C-:-: Problem requiring orthopedic shoes Hlp or ankle problem Unusual Illness as child

Please check If you have ever been In a motor vehicle accident Figure 6.1 (on!lI1ued 4ue~1l0n .....hould u~e

conversatIOnal language rather than

medll:al lermlnology ~o tht: 4ue ... (ion~ are ea<.,il} under~ ...Iood 11) the patient. The therapi"l ~hould
at a lime and be ~ure 10 ohti.llll a n.~"'pon . . e bdore proct'edIng to other que . . llon ... , Foll{m -up Inquine... milY be neeth:d to clarity InilJJI an",\ en,. It l'l lInponanl I'm the (her'II)I~1 to "-eer an open mind dunng the lI11en ie\\ and not ru .. h 10 (Onc!u"lon" abollt the patient \ '» I11plOrn'l and tlJagIlO'li ..... The folio\'. rng ,>e4uem: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<.kn (e.g .. cau.,ed hy trauma such as a fall. blow. or ski-

or automobile accldclll). Specific infomlation about til:' pal lent', bod~ po.. itlon al the time of trauma and the lllcl'll;ll11"m of inJur~ "III help to identify the \tnlclUres lll\olled. IIlhe on,ct "a\ more gradual or in~idious. a systemll. conditIon or chronic blomechanical problem may be more Il"el~. A congenital on:-.et is also a possibility.

S1

S2

LS

IlH!

'"

J. L2 ' L3

S1 S1

L3

C7

Location of the Symploms "Where i" )our pam'! Can you point to the location?" A bod) chan (Fig. 6.2) can be u\ed 10 help identify and document the specific location of ~) mptoms. The patient (or therap]':!l \\ ith the palient'" direction) can darken the imoh'ed area on the body chan u>;ing a pen or pencil. Often the location of the "ymptoms coincides with the location of (he le:-.ion. Thi .. i~ more likely if the lesion is in . . upcrficial and di,tal ti:-.sue~. For example. a lesion in a .,uperlicial tendon near the ankle will usually cause pain o\er the tendon ,ite. Le"ions in deeper. more proximal

LS LS

L4

S1 S1 S2

ANTERIOR

LS S2

POSTERIOR

Figure 6.3 Sclerotomes. (From Henling. 0 and Kessler. RfI:I.I.I'~: \\ ith pemli.. sion.)

I

tissues often refer pain dislally following sclerotome (Fig. 6.3) or dermatome paltems (see Chapter 5). Referred pain rna) be percei\ed a~ originating from any or all tissue~ innervated by the same segmental spinal level in which the le~ion is located. For example. pain due 10 osteoaIlhrili~ of the hip i~ often felt in the anterior gram and thigh along the sclerolOme~ or dermatomes for L2 and L3. Con~iderable individual variation has been noted in dermatome and sclerolome pallerns.~ "Ha~ the pain changed in local ion? Spread [Q other area.:;? B~coll1e l11urt focusedT' Pain thai is spreading u..,uall) lI1dlcatC':-. a \\or::.ening condillon. \"hile more f(X'used 'i) IllptolllS IIldll"ale nnpro'Yelllenl. Change.. in s)- mplOm.., til relatlol1"hlp to \arYlllg bod) pO\ltlon~. aCII\ itiC'~.•lnd treatmelH.., :-;hould be noted.

\

) Figure 6 2 Jhl' hot.l~ lh •.m l j n .\Uppklll~ntlht' p..tllem .. \ern,I' npllnll III Ilk 1~K. .... IIOll 01 (he: Pjlll. t From One/.. 01\ I... , p ~

do..:

" It II Pt:nlll

lUll.

-

Quality of the S) mptoms "Ho" ,e\ere h the pain'! b Ihe pam ,harp·! Dull'! Throbbll1g Y A "'Imple )et effeclt\ e "J) to documem pain

16~

Ph, ... ic.ll Rt.'h.lhilit,lllUll

Circle the number below which best represents the Intensity of your pain today.

o

2

3

4

5

6

7

8

MInimal

10

9 Severe

Moderate

Circle the number below which best represents the intensity of your pain today.

o

2

3

4

5

6

7

8

9

'0

No

Worst Pain

Pam

Imaginable

. .t'\'crity i... 10 :l,k the patient to rate hi~ or her pain from 0 (no pain) to 10 (most ..,e\erc pain imaginable) ~L" illu"trated In the numeriGI' pilin r.,lling . . calc pre"ented in Figure 6.-L A \ I ... ual analog "cale (Fig. 6.5) or thermometer pain ~calc (Fig. 6.6) can al~o be u~cJ if rrcferrcd. A checklist of adjective,; like Ihal found in the McGill-J\lelzatk Pain Que~tionnaire <; can darif) ~}mploms further (Fig. 6.7). The adJecli\e~ used 10 de\<:ribe pain may have di"gnoslie implication". Dull, aching pain may indicate Illu"de or joint k~ion~. NUlllbne~,. lingling. :.hooting pain. or burning ...ensalion:-. may indicale nenous syslem lIl\'olvemenl. Deep. throbbing pain. or coolnes~ in a body region may IIldir<\tc vascular problems. Weakness. c1ul1lsiness. or incoordination lllJ.y suggesl mu~c1e and pos~ibly peripheral or central nenou:-. ~yslem dysfullclion.

Beha,c;or of the Symptoms "What make~ your sYJ1lPIOJ1l~ lncreao:;e? Decrease?'" S} mplOlll'i from musculoskeletal conditions typical!} vary in re,pon,e 10 re..,t. activity. and body po,itions thar either increase or decrea~e mechanical stress placed on the in\'oh ed lis~ue. The behavior of the ~ymplonh helps to e~labli~h a diagno... i, and detennine \\ hich trealment technIque.., are more IIkel) to be etTecti\c. For c:\ample. pain from overu~e ,yndrome~ ~lIch a~ tendonitis will decrease \~ilh re~1. \\hercJ\ joint ..,tiflne... ~ ('~lll~cd by o~leo;mhri{i.., otlen mcreJ\e.., follO\~ IIlg re..,!. II a patielll repon~ thai the sinmg po~itlon redU(,:e.., b.ld paill. Ihen the thempl\! will

On the line provided below please mark wbere the intensity of your pain is today.

Figure 6.4 Two Iype,", of numerical pain ra!· ing ",cale').

probably have more succe~s in relieving the pain using back ne~ion rather Ihan extension exercises. SymplOms that do nOI vary with a change in activity or body position are rarely due 10 musculoskeletal lesions, and in fact arc a "red nag" for more serious condilions ,uch as space·occupying lumors and pathologies inVOlving internal organs. Often pallent~ will repon Ihat "nothing helps Ihe pain." This slatemelll should be fully explored with follow-up questioll~ such as "Is your pain better or ~...or::.c in the morning when you wake up from sleeping? Does your pain vary if you sleep on your back versus on your ~10111achT Pain Rating Scale

Instruchons' Below IS a thermometer WIth varIOUS grades 01 pain on It from "No Pain at altto -The pain IS almost unbearable" Put a )( by the words that deSCribe your pain lJest. Mark how bad your paIn IS AT THIS MOMENT IN TIME The paIn IS almost unbearable _ _

Very bad paIn _ _

CUite bad pain _ _

MOCIerate pain _ _

No pain at aU _

1\0 pain

1\1 OSl severe Pain imaginable

~igure 65 \'iw,,1 ~lll..llo~ p;JIIl rillllig ">1...tIL.: I h... lUll.:' '" u... u.lll) ..'J III I III lllH III kllglh Ilu.: p",ul..·1lI .. 11l.lrl.. I nll..·~""U1('J trolll 11k" klllll ll p•• lnll..·ntl 01 [Ill" ">1...t1l: .lill..! h rt."I.. ••rJcJ IIl1..1..'11IU1I1..1I..'1 ..

Chnpler 6 ~1u!i("ulo .. keletnl I·.-.amination l~ (."tullV.1 lhe I....entv 9'ouP> 01 ....ortll It .nV ....0'(1 m .nV q. mu'l chao'" Ih, moll )11,,.111... word ,n 11>;01 g'ouP In 9'OUII' Th'l d
G'''''''''

I fhclrl"'jl 0.""",,"9 Put.'''11 n"otlbong BUI I"9 Povnd l"9

G_' Tu99''''1 P"u.ng Y,-enc:h''''iI

GtO<.CI "

r","9 hhowsllng

Group l

Croup 3

Group 4

Group 5

Jump,,"iI

P'lCl'''9 BOfI"ll O"llIng Slltll>."9 l'f>Cln.,,"9

Sh"O G..1I1"9 lKf"r.ng

P'f>Ch."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
Unbe~lble

,.,..,

Group 19

Numb O...... t"9 Squeellng le,rlng

C~d

Group 18

Coo' frl"tZlng

Group 70 Nagg,ng

Nausea(lng Agonlz.ng OteMl!ul To
Figure 6.7 The i\h.'Glll Mdnad. Pam Questionnaire. Patlenl~ a<.ked 10 urdc only Iho"e \~ord\ lhal beSI describe their p~l.In: 10 lcJ\c- out :1l1~ C
:ITt'

Behavior of Symptoms During the Last 48 Hour. It i\ Important to understand the behavior of the symptoms during the pa~t fe\\ day~. not just at the current moment. Sometime~ "') mptom~ ~uddenly worsen or disappe'lr at the lime of the phy\tcal examination. A more accurate picture of the I,ltuatiol1 I) told if Ihe time frame spans 48 hour~. ·Are tht" ... ymplom~ gening better. \\orse. or :'Itaying the ~ame'?·· The am\\er to thi~ question will help the therapist Judge the effecllvene~\ of future treatment. If the patient's pam ha, been "'tcaddy ",or~enlllg over the la<.;t -1-8 huur~ and treatment 'IJbI111e, the palO. then the treatment may be deemed helpful. HO\\c\er, if the patient repons that the pam h:,h been ... tc<.ldlly lI11prm ing mer the la~1 -1-8 hours and IrCJlment 'tJblllle\ the pdin_ then the treatment may be deemed d' uc:lrimcnlal.

Pre\ iou\ (are .\\ hat prc\ iuu~ LJre ha, been "ought for the problem? Who ehe Ct'.~, phy,>lclan, Ihempl"t. chiropfi.lctor) ha, tft.:dtt'U lht: prohlt:m' Whal le,l\ and treatmel1l~ did they IXrfonn I \\'h<.ll h<.l\c you done to rclic\c the problem?"" From lht.:"t' and ~lIll1lal 4ue':>lIon~, all pre\ IOUS e\crci~~s. ph) IL.I! mod •.dII les, lllallual treatment .... medic<.Itlolb. lIlJl:llJllll' onhotK·', and ,urgical procedure~ "houhJ be dc-JlllCJled Ihe ,111 . . " .... r\ to Ihe ...e qlle~liulh help lht" lheraPhI deCide II IUI1!lt:r Inedical reterrab
165

II..X"u" on thl: mo.. . t l'fk~ti\c Ircatmel1ttor lill' (;011<.1111('0. For CX;llllpll~.. 1 P,IIICIH \dl\) fell J day ... ago I.. . e\pcricm:ing ""l'~erc anl..le p.lln and ",,\,,'clling. The patH:nl oorruwl'd a

Ineml' . . crutche.. and ha . . been ,df-treating. the anl..1c with Ice and de\:llion. The ther~lpl\t would flx:oll1l1lcnd Ih31 the patIent be e\amillcd b) a phyl;,iclan and have radiogr.tph, tal..cn 10 rule oul a fracture pnor to phY\lcal tht'rapy inter\cmion. A~ another . . cenano. it a pallent ha:-. been treatcd prc\ iou . . ly by two ph) ~ical therapl~t~ with ullra\ound and had no improvement. then other treatment'- should be con:-.iden:d.

Specific Medical History "Ha, this problem occurred before? How wao; it treated? How \\ a:-. it res-olved?·· Many musculoskeletal problems tend 10 recur with cOnlinued occupational. recreational. and daily activities if underlying biomechanical abnormal· ities. weaknesses, joint laxity. or lightness persist. Information about previous successful and unsuccessful trealment~ for similar past problems can help in treatment planning for the current problem.

General Medical History A brief hislory should be obtained concerning medical problems and prior surgeries involving olher body regions and sy~tems. Conditions involving the cardiac. respiratory, neurological. vascular, metabolic. endocrine. gastrointestinal. genital urinary, visual. and dermatological systems should be noted. Having a patient complete a medical hjstory fann prior 10 the examination is an efficient means of obtaining this information, but the information should also be verified during (he interview. Therapists also need to be aware of other conditions that mimic signs and symptoms often anributable 10 the musculoskeletal system. For example. inllammation of the gallbladder (cholecystitis) may re~lllt in right shoulder pain. However. shoulder pain related to cholecystitis typically will not increase with ~houlder movements or resisted isometric testing of shoulder musculature. as would occur in the presence of musculoskeletal condition~. Patients with cholecystitis \\ould likely have additional 'iymptoms such as upper abdominal discomfort. bloaling. belching. nausea, and intolerance of fried food~. Knowledge of systemic human pathology allo\\ s the Iherapi~l to recognize condition:-. requiring
Medication. The Iype, frc4uenC), do~e. and effect of medications the p~l\lenl i~ lakll1g ~houJd be noted. The u~e of analgesic or JllIi-inflall11l1atory medicatioll~ may reduce Ih~ intensity of ~)mptoms at the time of the examination. Changes in the ll"e of the~c l1lelhcation~ may make it difticuh to detemline thl' dkch of phy ... ical therapy treatment. The secondary

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htlll.lnhill I \ul-h r III III '01 tl1UI 'Ill' "nti 101111 "dllll J hI 11I11'1In! .'1 lor·... lI'iC't.I In (\1'111'0{ lod m.IIlIl.lllhl'I.11'11 n\.l\ IlI..' ('J ", ~ h:dul-l'l!

'>ocial IIi ton And Occup tiona\. Rt..~r

91;00.1, and I-unct;onal

~tatu"",

(JUI' IHUh HI 1111 "rC'a IlHeht mdudc .\\ h..ll I~ I~ III "tIl do \OU til.l III .md nUhlJc.: 01 Ih.: hl)rne' If(," h", du, 1"00· knl .llkl-h:d _ nur ,lhllll\ hi p.:rll'ffil nUl loll I (,m" tI'l \nur ~ htlJlcn) PI", ~l\lr.' Un:..... I H.t1h(' ,. J.nJ 'Il Innll (I'n.un Ill"UI'.Jlltll1.11 ,JnJ rl',..rI·Jllnn..JJ ;,tdl\tl,e... m,l~ t.:on lnnutl' 10 Iht'" phlhlclll or tlUl,tint: "l1h rel\)\':~. hl;ur~ l1 P~"'(.'lI(o. 4ut:,tlon ... Ilul L.IO ht: u~J w 4U.lJllll~ Ihe Clled.. olthl' prnbkm on lUllllllln \Ir.lIt=l!.I..... Il' g JOtOl pn.·o,eT\,J· lion 1C'(.hnI4w:... 1 ,lOll U"'l' 01 .1,... I'II\t' Ol.'\h.:e, m:.l) need Itl he l"\ln ...ldcn."ll to ,1111.,,\ perlonnanlc 01 ncee ...... lf) I....", ... ~kdll'<.tl m"'UI\II1((' l·omp.1nle.. OIICIl m,lJ."c treatment rClIn, bur...cmcnt oC(."I'>Ion, I:l.l,cd on ,J p.ltlcnt'.. fUnl'IlOnal ...I.llu'l :.I, rt"!...lled 10 Ille medlGII problem. "Do ~ou h;t\c 10 dnnh ...talr, 10 ~et inw ) our hou,c? To re;.ldl the tx:drool1l'! B,tthroom"!" Characlai ... ttn. uf Ihe ht)me t:ll\ lronmenl Illj) dt:termine \\ hether a pallenl dCI:w:ndcllI on <:til ambul~Hol) a'.......ll\c dc\ ict': need... m,truc· 11011 III ..lair at·tl\ 111('.. pnor (0 rClumlng home. The l"Ondl~ lIon 01 1100r....... lIe of hal" and dool\\a)~. placement of fur· nllure. ,Jnd halhrool1l h.lLiltlle ... \\ III need 10 be con ... idered lor a pallenl u... lIlg a whet"lch:m. A more detmled dl ...cu ...... on 01 e~amlll:H'on of the COl Ironment ,"eluding Ihe home. workplace, Jnd cOlllmunll~ CJn be found m Chapkr 11 .... Do )OU It\e alone?" It i.., helpful to under:)land Ihe p,:.lIlcnt\ 11\ IIlg .. I1UJI'On 10 dClemline If other~ are a\atlablc to 01""',1 \\ nh exerl·l\e program~. ambulatlon. and

If,H" I ,'1

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"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·

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J ..... ,'Il.I.lfcd

Ilor" h\r loul1'c:ltng.

\nticipated Goals, Expecled Outcomes, and lime hame of Recmery "\\
When do )OU anuclp3h:: relUnlmg homc? To work? To pla~ 1Ilg. l'ootbaIP" and ,:>0 forth as appropriatc. The~e l{ues11011'0 l'nahk the lherapi",t and p311cnl to dil.,cul.,~ and det.:rmlll~ 1ll1llUilll} agreed upon anticlpaled goal~ and expected lJUll'om... ~, The Iher;jpi~1 ,hould not prC'!)ume what issues i.lrc IInp0rl.tl1t lu the p;,uicl1l. An~\"er~ 10 these questions help thl' therapi"t to detcnnine whether the palicni ha~ rt:',t1, ...IIC expt:ttatlOlb or v. illl1ced further pmient education COill.·crnlllg hI'" UI her condition and typical recovery. For c\amplc. an elderly patient who ~ulTcred a fractured hip )e ...terda) and i:. currentl~ hospitalized may expect to remi.lin llllhe ~Icu(e care hospital for 2 weeks until he or she can independently ambulate and be independent in selfcare. More reali'ltic goal<., given current heallh insurance prJclil.'e~ ma~ need 10 be di ..cu:):)cd, \uch as db.charge from the hmpltal III 3 or ~ days 10 a reh3bilit:lllOn or extended care fanlit) for funher nursing care, physical and occupa· tlonallherJp~, or dl~charge home with home health aides. \ I':>lllllg nUr.,cI;o, dnd home care phy~ical and occupational lherap"h.

What percentage of your normal work activities are you able to perlorm?

What percentage of your normal home activities are you able to perlorm?

What percentage of your normal recreational activities are you able to perlorm?

Figure 6.8 Queqion.. ll,ed (0 rale a patienfs funellon. The p~ltlenl Circle,) the percenl of alll"ll)' Ih;)( he or ... he I') able 10 J)l:rfonn.

Chapler 6 ~111~culo~kd{'(al J<:'(aminacion

Concluding Quc.. ion \\ hen 11ll' thnap'\l hd' fini ... hrtl ohlalllln~ the nbo\c 1I1tor1ll.llIon. one 1111,11 Iype oj (l~Il-cndL"d ljue\1101l need .. to he a"''''l~d

.. " then:

.1Il~lhlng

d ...c you "i .. h 10 (ell me?" or ..,..

theR' ,1ll~lhlllg l'I...c )Oll lhlllk. I ,hould k.no\\ l'OIlCcnllng ~nur ...onJlIltm

tl1.Ill h~I\C mil a.. "'ed ahoulT ~1cht m.el)' the p;Ulent ",III rc,ponu by ... ay lIlg lh~ll he or ,he ha_, no fUriher

IlllomMlIon fll nffer ;md helleh·... .You ul1llt:.~r\land the prohlem ck..trl). Sometime". though. a p;ull'nl may lake LIII" opportunity 10 d.tnl) a pre, IOU'" point or ,hare a concern thai I' .ldlhng ...trc ...... (0 hl\ or her life. Without lhi~ I)'pe of que\IIOn .11 the conclu"lon ollhe inlen le\\. important in formallon Ih"l1 may Illlpacllre=l1l11CnI and rccO\cf) may be lost. Till' InfonnJIIOn clicHed v.lth the qucqions li~led above m3~ he ,upplt'l1lcnh~d \\ Ith additional questions based on th~ ~pcClfic rt.'glon of the bod) being examjned and ~u~­ pecled ellologlt~· ... The ph)~lcal theraplst's kno\\ledge of anaIOl1l). h.Jnc"'lolog). pathokinesiology. physiology. and palhoph~ ~I{llogy. a, well as Ihe ph) ')Ical presentalion and progre...'JOn of l1lu'iculo:->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 p<.ltient may benefit from an evaluation b) a neurologl\t. neuropsychologist. speech-language pathologl\l. and/or occupational therapi~t.

Vital Signs If a patient \ medical record or mterview suggests a comproml...ed cardlo\aM:ular ~y~tem. he:lJ1. rate. blood prc!-.sure. and re'plfatol) rale ~hould be detennined prior 10 beginning other ph)')l(;al examll1Jtioll procedures bee Chapter 4). Patlem... !!eltlllg out of bed for the firslllrne folio.... ing recent ,,-urgel) or prolonged bed reM \hould roulinely have \ Ital ~lgn"'l..u..en 10 e\tablish b
Observation/Inspection Oh...enide In Ihe ca~e of ho!-.pil
167

pallent,,-. or III the wallin~ Hltlm for Qutp,wenl\. The patienl' ... general po<;lurl' and ahllil) 10 IX'rfonn functlon:l) t3\10. ...- to remove their shirt and females to wear only a bra or loose hospital gown that can be draped to expose the upper extremity and back. To observe the lower extremities, patients should undress from the waist down. wearing only undergarments or shorts. Once the patient is in the privacy of an examining room and appropriately disrobed. the therapist begins a careful inspection of the body region implicated in the inlerview as well as biomechanically related areas. The lower extremities and lumbar region, being intricately involved in weightbearing activilies. should be inspected as a functional unit. Likewise. conditions involving the shoulder require the examination of the cervical and thoracic regions. and vice versa. Visual inspection should focus on bone. soft tissue struclUres, skin, and nails. The therapist should view Ihe body region anteriorly, posteriorly. and laterally. Often palpalion, which is discussed in the next section. is combined wilh observation. Bone shafts and joints are judged againsl nonnative models for symmetry, comparing one side of the body to Ihe other. Contour and alignment should be considered. Common causes of changes in bone con lOur include acute fraclures. callus foonalion or bone angulation owing to healed fractures. congenital variations. or bone hyperplasia at tendon insertions. and arthrilis. Alignment differences can be due to the above conditions as well as muscle and soft li~~ue tightnes~. muscle weakness. muscle and ligamelll la),it), and joinl dislocation. Orten a gros:o. screening examinalion is perionned to assisl in delemlining postural alignment From an alller;or vie\\ both eye~. shoulders (acromion proces~es). iliac cre!-.ts. anterior ~uperior iliac spines. greater lIochal1lers of the femur. patellae. and ankJe mallt=oli should be horizontally level. Wai~t angle~ should be symmetrical. Patellae

168

Physical Rehabilitation

une of

or blood hemoglobin-for example~ in siluarions. such as . hera I \ '3soconstriction . shock. mtemal bleed.mg.. and penp . E 'rl,nnro . 3 localized rednel\s, usually .mdlcates anemia. n ~ . ,"creased b'lood now and inflammation. Generalized . redness can sugge'it fever, sunburn. or car~n mono~.Jde poisoning. Yellow 'ikin !One may be d~e to Jn~reased carote.ne intake. or liver disease. Bm" n. highly pigmented.. hairy area~ somelime, o\erla~ bony deferh such 3') spina blfida. Open wounds <,hould he mea ured and diagrammed in pallent ret.:ord .... '.'co\\,- "car, "III he red. and older ~ar will be "hlle In color kin lIl\<,uc Ihlck~01n!! ...... uch 3" (·al/tHeJ can indica Ie chronll'" 0\ erlo.llhng and <,Ire;;;.... Thm. gloss)' ... ~tn \\ Ith decrea,ed ela"'Il\.II) .1Ild hair 1o,,, I often found

gravity

\1.

ilh pertpher:11 n~rn~ le.,lon ... ()r ncurm·a<,culdr dl'Orderlj.

Palpation II

I' ,ugge"'h.'J lh..tl r~llr.uJl"," IInmcdl.1lel)

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Ch.lpter 6 MU'iculoskeletal Examination

ttod) area.... but localized tendcmes, oflen helps 10 impli~ cate particul..tr qrllcture~. Localized ... kin temperature ... hould be noted: cool temperatures ... uggest reduced circublion. wherea ... \\ aml1h indicate~ increa<"cd circulation and OftCIl inflammauon. Skin and soft tissue densily and cxlen~ibility :-.hould be cOIl~idered. Often ll1u!'cle spasms and ~Idhe,iom. Jl1 s~in and connecli\ e li%ue can be found with palpation. The quality (amplitude) of peripheral pulses will prO' Ide £Oro ...... II1formation on arlerial blood supply. Bilateral edema In the ankles and leg... Ihal fonns pilS with lactlle pre:.. ...ure (lenned pl11illg edema) can indicate cardiac failure. Ii\er. or renal condilions. Unilateral pining edema i<; typicall) a:-.sociated \\ ilh ob:-.truction of retul11ing cireublion.

Anthropometric Characteristics Ahnonnalltie~ nOled

during observation and palpation may

be further documented \\ ilh anthropometric measure· ments. C... I1l£o a cloth or flexible pl~t')lic lape measure. limb lenglh ... are mca.. . ured from one bony landmark 10 anolher and compared bilaterall). For example. true leg length is commonly mea... ured from the anterior ...uperior iliac spine 10 lhe medial malleolus. Circumferential measurements help ~ub.stantiale joint eftu ... ion. edema. and mu,>c1e h) pertrophy and atroph). TYPlCall). the'lc meawremenb are ta~en al specified distance~ (tnche~ or centimeters) above or belo\\ a bOll) landmar~ ...o the) CJn be reliably reproduced during sub~cqllent mea... uremenl .... For example. circumference mea'luremcnls of Ihe upper ann .'>hould be tal..en at noted distance:o. di<;tal to the aCrOl11l01l proce~, of the .'>eapula or pro;\lmal 10 the olecranon prO<.:e...' 01 the ulna_ If mea... urement~ are needed of the hand... or leet. \ olumetric mea.sllr~ment... can be taken b) ,ubmerf!lI1~ (he dl'-lal c'(lrcmity in a COnlall1t'r of \\ aler and 1l00mg the ,",olume of \\ater that I... dl'lplaced.

Range of Motion JOl1lh ilnd tht'lr relaled ,lrUt.:!llre.....tre e\ammel1 b) per-

!"omllng dltl\e and pa"I\C: JOint motlon,_ j0ll11 mutlon I' a llc:u:"al) I..ompollt'nt 01 mo... t junctional t.l'k.s. \umerou .. ...Iudlc') ha\t' Idl'll11iied [he RO\1 needed to \\al~ on le\d ..urfi.il.e _J Jt''''Lt'nd 'talr.... ~~ ~ ri ...e IrOIll a chair. 'l\ 1 t'al .... lIh a poon. . and per11lnll man) uppeT e\ln:nlll) ,IUi\lIlt''' ~ ( drdul l'\aJl1lllatloll of JOlnl lllotH)n 101 rallgL'. t'lIU-It.:t'1 dkd on ~) lllpl0m'l. ilnd paut'l"ll 01 r~ ...lflltIOIl hclp Idl.'lltll) alld 4U.tlltlt') unp.Unlll·llh tau,mg lunltlllilal 11IllJ1.1111'11 and dl'kmllne \\hILh 'lfuLtun:... nt't'd rn.:J.lmt.:1l1 +

t

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t.

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'lhL l' UUIIll.tII'HI lit .1111111 Il\tllhm hcgllh b) tt.:!-.tlng i.l((i\t' rang... ul mUllun, \H.Or\11 -\1".'11\1:' lllllllllit I'" thl' UII.t... 'I ... led \e>!UIll..tr) 1Il0\L"J11L'lll 01 "ltlllll rhL' pallent I'" ~hl..~d III 1l10\t: .1 he'lh p.tfl 111l1lLlt!h IIll· o ... klll..lllI.:Ill.tlll mOllon....It till t11\I,ht:d anu Ilthl:l bIUlllL"Lh.ulILi1II) Id.tll:J J\llllh

169

Osleokinemalics refer to the gro~s angular motions of Ihe shafts of bones. The e mOlion~ are described as occurring in the three cardinal planes of the body: flexion and exten<;ion in thc sagittal plane, abduction and adduction in the frontal plane. and medial and lateral rotation in the transverse planc. For example. in an examination of the hip the palienl would be asked to move the hip into flexion. extension. abduction. adduction. and medial and lateral rotalion. Oftcn flexion and eXlen~ion of the knee. as well as flexion. extension. rotation. and lateral flexion of the lumbar spine are tested. as knee and spine motions can impact hip function. Some therapists prefer to have the patient move in functional. combined motions rather than straight plane motions. For example. a paticnl would be asked to reach a hand behind the head 10 test shoulder abduction and medial rotalion simultaneously rather than perform isolated. individual mol ions. Active motion is a good screening procedure 10 further focus the physical examination. The amount. quality. and panern of motion. as well as lhe occurrence of pain and crepitlls should be nOled. Often aClive ROM is visually estimated, but if more objective and accurate measure· ments are needed. a goniometer should be used. Nomlal ROM va ric') among: individuals and is influenced by fac· IOrs such a... age, t6--JI gender.-·t;!-1f, and measurement methO from ...ouree ... ,uch a.. Ihe American Acadelll) of OrthopediC Surgeon~~\.~J and the American ~kdical AS:-:'l)cl~l1lon.~~ If the patient can complete active ROf\1 ~a . . il). \\ ithout pre~t'nting pain or other ~~ mpwms. lllt'n further pa ... sive te"ing of lhal motion I~ lIsual!) unneces ...al). It. howc\er. the .llnuunt 01 .ll·tl\e motion I'" le~~ Ihan nUlmal thc lheraplst \\ ill nul oc abk" to l"Ol.tl~ the l'au~e \\ IthoUI further le:-.llng CJ.lhule. Ilg'Ulll·nl. mu~L1e clnl.l 'oft ll ... ~ue tlghllll· ....~. jomt :..urtact~ .lbnomlalltie.... itI1d mu,>c1e \\t'al..nes ... MC all Gtp.lble ll! l';lU ... IlIg. IJlnuauon .. m aCII\e ROt\1. Pam dUIlI1g ill'll\..:' ROi\l Ill;l) be due lo Ihe COI1Ir.tCllllg.... ll"l'tl'lling. 01 pinChing llf i,.'ol1tractlk tl"ue, ,ui.'h .1" 1Il1l ... l·k,. lendon'.•tlIJ Ihelr clllcll-hmc:nh tl,l bone, or due III lht.'" ..trddllllg Of pmLhlll~ ot nllllL'l~lllr;}dllc tl ...... ue~ .. Udl .1.. hg;II11C:llh. Will( L.lp,ule ... and bur,.l."'t' \.lflcltwn .. III the yUalJl) .tOJ p.Jlll~rn \11 .tdl\e 111\,.lllllO ,,:.111 re ..ult lrom l'elllraJ anJ fk:'npht""r,tl 11('l"\\IU, ... \,>{em JhurLlel ... cllld lllctJ.boht: l(1l1lhlh)lh. III .tddIIU~11 III \,.h,,)rdt.'"l .. Ill\lll\tng IllU:-:.":U11)... l..l'Id.tl ... llltLtull· .... ~ll, .llthllUgh ,il(I\(" lllOlhJll 1:, ..til elh:LlJ\l' 'Ill~"'J1IlIg. prol'l~dllre. plI... lt1\t: fIndIng .. require..t \.lfll't) 01 JJullloJlJlll' ...b to IJ\:'llllly lhe unJt'rl)lIlg ctlOlog) .\Ill.! thu .. I:n..lbk clkdl\(' IrcJ.llllcnl

170

Ph, .. ical Rchahlhlalion

Pa"j,,, Ranlt" of \101ion P.t""l\l' lllO!lOn ilrl,,' lIUl\l,,'llll'llh performcd h) Ihl' thcr.lpl ...1 \\ lthout Ih~ a I... t.tnC'l· 01 Ihl' patient Th~ IeI'm pas... i\c rnn~e uf mtJliun (PRO\11 t~pIGIII) reler... to Ihe amount 01 o ... ll·(l~lIlem,t1IL 1ll!)1101l ,1\ .ubble \~ hell Ihe p.ltlenl .... joilll .... mo\cu \\1IhOUI Ihe p,ltl('nt\ ""'I ... I,UKe. Noonall}. pJ~. 'I\C RO\1 I'" ,ltghll~ grcalcr Ih'l1l Jltlve RO~1 hecau\e 10m", ha\ c ,I "'mall amounl of motion at the end of the r.mgc lhal I ' nol under \OIUnl,lr) control. TllI'~ addllional range help ... III proterl JOint ,truclure ... by allowlIlg the jOlllt III ah,orh cXlrin'll force .... P.I ..... IW ROM i~ examined nOl 0111\ for .unounl 01m0110n. hut al ...o for the mollon', effeci on ~) mplom.... the t~pe of I",ue re., ....lance felt by the Iherap"l at Ihe end 01 Ihe 111011011 (end-feeIJ. and pattern of IlInll:lllon Pa...... I\'e range of o ...teo"-lIlematic mOl ions depends all the IJllt'gnt) of joint surfaces and Ihe ex(emibility of the Joint cap\ule. ligaments. l11u ..cle... tendon,. and soft tissue. LlmltJtion... 111 pa<;;'I\e RO 1 may be due 10 bone or joint abnOnnJltlle~or Ilghtnes\ of ~oft li~sue ~Iruclures. Because the therapi,>t 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<:ce~SOr} jOlllt motion le~t', and ligament ,>trt::-.:-. tesl ... \\ III help to ....olilte Ihe lIl\ohed structun.-::-.. The ...e addlliomil h~ ... h are di ...cu<.,:-.ed later in thi~ c1wpter II ho\\.ever, Pil'>\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 rslon.)

Chapler 6 Musculoskeletal Examination

171

bct\\.CCIl Illca,>urement ... made on the ...ame subjcct~ by diflert:nt tc ...ler... 10 be 4.2" for upper e\lrcmily motions itnd 5.10 for 10wcrcxlrcIllilY 1l1otion~. The ...c diffen;nce~ in reli~ abilllY ha\e been allributcd 10 dlfficultic... in me
End-Feel

-....:...-

B

Figure 6.12 \kJ,uremcm 01 the hcgmmng. CAl and end (B) of ~houlJl'r 11c\.lun RO~ I The ulll\er...al g.oniometer .\ mo\. ing trom 0 !o\\;lrd 180 dunng the Illotion. (From Norkin. Cc. and \\'hlll' . DJ: \\ illl pemli... ~lon.l

ro~1I1011 al 0 and rrogre~~ lo\\ard 180. For example. a mouon that beg11l\ at OC and end\ at 135° would be ret:orded .1... 0 to 135".. A ROl\ 1 thai doe... nOI ,Iart with 0° or end 'I premature!) indicate ... Joint h~ pomobilit~. Joint h~ pl'rl1lobilil~ at the beginning of the range i... noted by the lOrlu,ion of a zero (the nonllal ,tartmg posillon) het\.\ ceo the ,t.lrtll1g and endmg mca,uremcnh. For e>.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<.tlkd dc:,cnptlolh of goniomelrlc mea,uremellt pllxedure,. ROM l'h.:a,un.'rncnh laken \\ IIh a lI11l\cr,al goniolllt"la 01 Ihc c"lrcmll~ 101111-. generall) h•.l\e good to l:\l'ellelll rt"lIahlill~ l{ellabllH) doc, \~1I") dl'pt'ndlllg on the: JOIIII and 1I11l11011 tx-JIl~ ml·~I'UrI.'U KehI.:cn h'unti III he,: IIhlre rellahle tlun lllt"a'Ult:lllc:llh III the limel t'\IIt:nlll~· .t1lU "pllll'."< In an olll'n ljUOll'd ,>Iuth BIHIIlt: l't .11' IllllIHJ the: i.l\l'lagc: ,>l ..lnu.lru Ul'\t<.ltH;n

The end of each mOl ion at each joint is limited from further movement by particular anatomical struc{Ures. The lype of structure that limils a joint motion has a characteri~tic feel. that may be detected by the therapist performing the passive ROM. This feeling. which is experienced by the therapi~1 as reSi'5lance. or a barrier to further motion. is 1J called the end-feel. Cyriax and Cyriax.56 Kaltenbom. and Paris-.'\ have described a variety of nomml (physiological) and abn0n11al (pathological) end-feels. A summary of the I) pes of end-feels ha" been adapted from the work of these authors. Nomlal end-feels are generally described as soft. firm. or hard (Table 6.1), A soft end-feel has a gradual innease in resistance as muscle. skin. and subcutaneous li:io~ues are compressed between body parts. 7t1 A finn endfeel hJ~ a more abrupl increase in resistance as compared to a soft end~feel. Fiml end-feels include varying amounts of creep. or give. depending on whether the barrier 10 the end of Ihe mOl ion is the stretching of muscle. cap~ule. or ligament tissue. The finn end-feel with the most creep would be the rubbery resistance offered by the stretch of mU"icie tissue. and the le~st amount of creep would be provided by the stretch of ligament ti ... sue. The fiml end-feel crettled by the ~tr~tch of a joint capsule usually has a mod~rate amount of creep. A hard end-feel is abrupt: there IS an immediate ~IOP to movement as \\ hen bone contacb bone. End-fee'" are con"iidered to bt' abnonnal when they occur ,ooner or later III the RO~'1 than i... I) pica!. or If the) are not the Iype 01 end-feel that i... llonnally found tor that joinl motion, Abnomlal end-fee1'l have been as~ociat~d \llth mor~ pain than nomlJ.1 end-keb.~1 Man) abnomlal. palhologJe.l.1 end-feeb hi1\e been ucsl:fibed. but mo~r can be l'..ltegonzed a, vanation", 01 'lolt. lirrn. and hard endlee'" (Table 6,2l. An ..lbnoml.11 end-feellh,1t C.UlnOI be- Ci.ttl'gl)rizeu i.b ,')011. finn. or hard. i,') an t'l/Ipry ('ml-It't'!. Thl" lerm d~"'L·ribl.', Ihl' Inablllt) of lhe Iheri.lpJ,>t to dele'-'t ..tn) 'JI1,lIomt,-.d harrier hI the end of Ihe RO~t. Rather. lhe p 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
Capsular PaUerns of ReMricled Motion C)ria>.. 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.'
175

Table 6.1 Nom131 End-Feels E eel SCrw:twe Soft

Soft tissue apprOXImation

Table 6.2 Abnonnal End.Fee;"',;,s".,..........,,,...."""

~~~-

pie

Knee flexIon (contact between soh tissue of postenor teg and postenor thIgh)

Soft tIssue edema SynovItis

Occurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or hard end·feel

Increased muscular tonus Capsular, museu· lar, ligamentous shortening

Hard

Occurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or firm end·feel. A bony grating or bony block is felt.

Chondromalacia Osteoarthritis Loose bodies in joint Myositis ossifi· cans Fracture

Empty

No real end-feel because pain pre· vents reaching end ot ROM. No resist· ance is felt except for patient's protective muscle splinting or muscle spasm.

-

FIrm

Hard

From Norkln

Muscular stretch

Hip flexion with the knee straight (passive elastic tensIon of hamstnng muscles

Capsular stretch

Extension of metacarpophalangeal JOints ot fingers (tensIon in the anterior capsule)

Ligamentous stretch

Forearm SUpination (lensIon in the palmar radIoulnar ligament of the Infenor radioulnar Joint, interosseous membrane, oblique cord)

Bone contactmg bone

Elbow extension (contact between the olecranon process of the ulna and the olecranon fossa of the humerus)

ce. and White. OJ.s", P8 With permissIon. From Norkin,

general ~Ituation",: (I) jOint effu~ion or synovial inOammaIton or 12 J re-Iall\ e capsular fibro~is. Joint effusion or synO\ial Inflammalion results in a capsular pattem of limitalion b) dl'ltending the entire joint capsule. causing the joint to mamtain a posillon that allows the greatest intra-articular \olume. Pain lrigger~d by stretching the capsule. and muscle spa... m ... th..tl prutect the capsule from further stretch. Inhlhll nlu\ emclll and cause a cap...ular pattem of re~lricted motion. The other general !)ilUalion that cam.es capsular paltem ... i.. re-Iati\e capsular libro'll!). seen in Ihe resolution of acute cJp-.ular ll111ammation. chronic 10\\ -grade capsular mtlamm,uion. and immobilization of a joint. These conditIon'! caU'le d decrease in the c.\lensibilit) of the entlrt" cap,>ule lrom an mcrea..e in collagen conlem of the cap~ult: relatl\t: to the Illucopolysaccharide content. or fmm IIlkm ..d t:hanges 111 the l'ollagen ti..,..ue. To plan d:Jlltle~. l:ompre\ . . lon. ele\ J.llon. JOInt Ill l loJlll.tllun u Illg grJdl' I "u~lallled and grade I Jnd 2 o.. Llll..tIJtln" gt:ntk ROM e\er('i:-.~. and allil-Illflammatur)

-1

Occurs sooner or laler In the ROM than is usual, or In a joint that normally has a firm or hard end·feel; Feels boggy.

Solt

ee. and White. DJ,S2

Acute joint inflammation Bursitis Abscess Fracture Psychogenic disorder

p9 with permIssion.

medications. Capsular fibrosis. a more chronic condition. can be treated with heat modalities. joint mobilization using grade 3 sustained stretch and grade 3 and ~ oscillations. passive stretching procedures. and more vigorous ROM exercises. Patient history. observation. palpation. and careful detennination of end-feels will help establish the cause of the capsular pattern.

Noncapsular Patlems of Restricted Motion Restricted passive ROM thai is not proportioned similarly to a capsular pattem is called a noncapsular pattern of reslrlcted motion.I-"'6 Noncapsular patterns u~uall)' involve only one or two motions of a joint. in contrast to capsular patterns. which il1\olve all or most motions of a joint. Noncapsular patlem~ are cau ...ed b) conditions lI1\olving ,\truClUres other than the enlire joint capsule. lnternal joint derangement. adhesion of a pan of a joint cap:-.ule. and cxtracap!)ular le..ions such a~ ligament shortne~s. musde ",lrJIIl. and muscle shortne ...!) are examples of conditions that can re~ult III noncap~ular panem:-.. For Instance. shon. nt!),> 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(
nLil' l \) II till' l()lnl 'UI !.ILl.' lit Ihc 1ll0\ In!! bonl' I' (011\('\.

~hJm!C I~ ,n

Iht' i'>I~nl

tilL' \\rl)l.I~IlC lhrnllllll (11

Ihc

.1l1~Uhlr 1110\ ("mcnl 1)1

~urL.ll\.' til Ihe IlHl\ mg N IIlC '" l'OIl\,. ,.1\ e. ~hlhnc I III thl' .unl' dtn:llllll1 .1" Ihe ;.I1l!!ULlf mll\CmCni (lIthe

hunl" ~t1

I BI

II

Ihl: JI \11ll

rtllll!\.l"nL'r. (

.md C~lll'\).1 \

r

"-lIh pcnni"'''IOJl.)

more "pt'... Ir... ~t1I) IOC~lh~

..Ind tre.:.t the .,ouree of imp:lired Ih(l'(l~LnL'IllJtll: mOlIOlh. Al'ce,,,Or) motion ... <..:annOI be perhlmled ;.Ill 1\ el) b) thl' pJ.llcnt beGlu"e lhe",e moL ion... arl' not ulllh:r \olumar) C0l11101. Rather, the) arL' tested pa..,'I\e!) h) the thC'rapht The accev..ory motion", mo~t com1110nl) 1c"ted an.~ tralblator) motion,,: glide~ that are paralklto the jomt ..urface.... and dLHrmllOJlS and (,()!IJpres,fiiol/s th..lt ..Ire perpendICular to the jOlOt .,urface.,. Kaltenborn,"'l.j Ki"ner ~md Colb).'" :'lI1d Hertling and Ke~ ... lerl de",cribe '~llfil le,tmg and IreJ.tm~nt tC'thni4Ue\ that focu~ on Jcce",.or) mOllon,~u\u"llI) under the tOpiC ofjoinl mobi· lizatiun Careful ~Iuention 111UQ be gi\'en 10 general patient pO"JllOning. "j)el'ific joint po,>ilioning., relaxalion of ~ur­ rounding mu~de .... 'ltabdintion of one jOlllt ... urface. and mohilil
(j Jnd h: JOlnl mobill/atJOI1 1"1 nOI indicated. ~urgeJ) ...hould he con"ldcrcd • (,rad\: I .mJ": JOIllI moblllZJllOn to Im,:rcJ"'C' Ihl' l'\tt'l1-

Jhllt':. III jOlIl! "ItruclUre'l 1"1 Il1dltated. Heal Illodaltlle.!:. pflor llllllohtli/allon ,mel ROM c)"eru.,e", alief mobllllJ.tlon 'hould be (,olhl<.ler.:<.I. • GI.II..1e 1: Jllllltlllobilll..ltlOn l~ nOll1eeded, .1" Ill1ulI1g., are nom)J.1

Grade"l 4 and 5: Joint mobilizalloo to increase joint exten...ibllit) I ... not Indicated, Taping. bracing. strengthellll1g exerci~e ..., "od education regarding posrure and po~ition ... to b..: <.t\oided ~hould be con~idered. The tC'lting of accessory motions puts stress on spe· cilic anatomical :-.lrucLUre\. A change in symptoms during the performance of an accc')ftory motion helps to implicate particular fttruclure~, Distraction stres!>e!> the entire joint cap"ule and numerous ligaments surrounding and ~upporting Ihe joint. Glides stress a ~pecific part of the joil1l cap.. ulc ancl particular ligaments. depending on the direction of the glide and join!. Compression applies force to imracapsular structures such as rneni!
Muscle Perfonnance Ml/sele performunce b the ability of a muscle 10 do \\'or~."1~ Line~r \\ork I~ defined a~ force l11ulliplied by distance. \\ hile rotational \\ ork is ddined a~ torque (force multiplied b) perpendicular di~tance from the axis of rotation) multiplied by arc of mm emem. .!:.uall) dunng a mu~cu­ lo"kektiil c\3nHni.lllon. a component of mu,c1e perfonn· i.lncc-mu...cle ~trcng[h-i", le~ted. Muscle !llrengrh, a~ dt:"cflbed in 'he GII/cle 10 Physical Therapisl Pra(,lI('e.b~ i~ the furce I:>.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 1<)L'aled deep to the 111u...culotendllhlu", I i",,,,ue \\ ill al\\l hl' Lornprc"''''t'd. AJth{)u~h bur"ae are not ullhldercd 10 be Cllnnc:111\e tl':-'lle p;lln v.11111t It:lt dunng the l ....o111l'tric l'01ltl<1\.[lon 11 a bUf,>J 1\ IntlallJl::J Fonunilh:~I~. (fe:ltmell[ It)! bur'lIl'" I", . . lI11ilaf [0 treatmenl lor 1ll1l\l'ulotemIIllOlh ,tf;lIl1:-. dnti Illna1l1Inall()11 In adJlIlOl) tll detl'f11l111lllg the ah\t'Ill'l' or pre",ence 01 pain JUIlng thl' r..: . . i... tcd i~Olnl'll1l le",llIlg, till' tht'IJpl'l

--

... J~ -;,. ',-

.

should also note the strength of the muscle contraction. If weakness is found. more extensive testing of muscle strength should be performed using manual muscle testing or dynamomeler",. Muscle weakness may be due to many causes, including pa{hologie~ i11volving upper molOr neurons, peripheralncrves. neuromuscular junctions, muscles, and tendon~. Pain, fatigue, and disuse atrophy can also cause weakness. The pattern of muscle weakness will help to identify the Sill' of the pathology and direct treatment. The patient hi,,>tory and the resul!>; of sensory, coordina[ion. mOlOr control. cardiopulmonary. and electromyography te~ting will help clarify findings as well. Cyriax and Cyriax 56 ~~~ ~

Manual MlI,c1e Te'ting Manual Illllsde t{'.... ling (1\'1\1'1') \\a, de\eloped by \\ nuhl!'" . nd I_O\l;'tl ." tkglllJlII\~ III IlJl2 i.!'} a Illeans 0 I' ~ .1 It",tJll!;, ,1llJ gradIng nHhlle slrel~gth b~b('d on gra\ ity and lllilllU.dJ) dppllt'd I"t"'I'lal1((. O\Cf the }car.. . uthers havt: dt":--I.:nbt:d \,lnou", t\1J\11 lllt"lhl1tk bUI Ihe two methods llhhl Ilcljlll..'ntly u...cJ In the Unlll'd S[ate~ .lrt" those prop\)~l'd by l)<'lIlieh ,llld \Vllllhll1l.!h~lm."I'~ and Kendall and

Chapter 6 Musculoskeletal Examioalion

Figure 6.15 \bnual mu\cle le'iling of the lefl hip abduclOrs mediu\ and JnmllllU") for grade.. gn:aler than Fair. The hmb ha" mmed agalll~1 gr:1\ II) mlO hlp abduction. and is now holding Ihe p
\£Iuh~u\

1949 work entitled Muscles: Recent textbooks describing these method:-. ha\ e been authored by Hislop and Momgomery92 and Kendall e( al.'1\ Both method~. based on the work by Wrighl and LO\etL u~e arc of motion. gravity. and manuall~ applied re~istance by the therapist to test and determme mu<>c1e grade~. Generally. lhe patient i~ positioned so thaI lhe Illu..de or Illu~cle group being tested has to hold or move again'll the resiqance of gravity. If this i.\ well tolerated. the therapist applie\ manual re~i!)t:lnce gradually to the di~tal end of the bod) part in \\ hich the mu~c1e inserts. and III a direction oppo~ile to the torque produced by the mu~c1e("'J belllg leSlcd (Fig. 6.15). In rerelll eduion<:.. both method,> recommend applying manual re~I"ance in the form of a break test in which the patient hold,> 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<:.tlllg (v.o-joint mu~c1e .... In the ca"e of "fakt"r mu,<:h:" Ihat ('annol hold or mO\e Vvell again~t ~ra\ II). lilt" pallem I~ rep<.....ilioned ~nd allempt... to mme lhe bod) p;Jrt Ihrough a gra"ily-mlnimized (hoflzolllal) plant" 01 mollon During all te"ting. qabllil.i.ltion of the bod) part on v. hith Ihe mu~ch: origlllal~ ... and G.lrelul J\OHJam.:e oJ ... ub~tltullon b) olher lllu ...c1e group~ are emphJ !led Rt ... ult-. \,.;an ~ noted In .t narrall\e repon or on lanJ..m.Jllnl recording lonn... (hg 0.161. .-\hhnugh tllaC' art" lllan) ...lIntlanlle.... there are ...ome Jlllerelll:C\ hcl\\c'C'lI Ihe...c t\\O p~)pul
cla~:-.ic

T{'~lill~ amI Film/ion.

179

empha'oi\ on gra"lty-minimi/ed positioning for wC<.Iker I11U'iclc group'i. Daniels and Worthingham recommend lhat the patient move through the arc of mOl ion when testing both against gravity or wilh gravity minimized. Kcndall and associate!'> have the patient move through an arc of motion only when te'iting with gravity minimized; Olherwi~e the palient i'i positioned against gravity at the middle or end of the ROM and a;ked to hold the position. Both method~ use a grading system based on the work of Lovell \\ ith categories of Normal. Good, Fair. Poor. Trace. and Zero. However. Kendall and associates suggest a 0 to 100 percent or a 0 to 10 scale; Daniels and Wonhingham suggest a 0 to 5 scale (Table 6.6). If numerical scoring is used. it is important to clarify which scale is being used by noting the score followed by a slash indicating Ihe maximal value of the scale. For example. a grade of Fair strength should be noted as 3/5 if using a 0 10 5 scale. or 5/1 0 if using a 0 to 10 scale. 11 is important to note that these numerical scales indicate ordinal data, as the intervals between the numbers do not represent equal units of measure. The MMT grades of Good and Norma/typically encompass a large range of a muscle's strength. while the grades of Fair. Poor, and Trace include a much narrower range. Sharrard.CJ.J counting alpha motor neurons in spinal cords of individuals with poliomyelitis al the time of autopsy. found that muscles previously receiving a grade of Good had 50 percent of their innervated mOlor neurons, while muscles graded as Fair had only 15 percent of their motor neurons. Beasley 95 noted that patients with poliomyelitis were graded as having Good, Fair. and Poor knee extension when they had on average only 43. 9. and 3 percent of the knee extension force of nonnal subjects. respectively. Andres and associates,96 in a study of four mu~cle group~ in patients with amyotrophic lateral sclero· sis. found that the muscles were oflen graded as Normal until up to 50 percent of strength was lost. The concurrent validily of MMT with muscle strength measured by hand·held dynamometers (described til the following o;;eclion) and strain gauges has been supported by man) re~earch sludies. Schwanz and co-\\orkersQ7 Mudied 2..t l11u!)c!e group" in 122 patients with spinal cord II1jury and noted correlalion coeffiCients ranging from 59 to .9~ Octween strength mea,ured with MMT grades and handheld dYIli.ITllOll1elry. Qlher inve\tig'ltor~ have reported sim· dar finding:o- 96.<JIS.W Ho\\'cH'r. several researchers have noted a \\ Hle range of strength \ alue~ within a MMT grade and dn o\crlap III ... trength \alue~ between adjacent MMT grade.... e... peclall) III the grade~ of GOO(! and \ornwl'l;,~IlK' M~1T ha ... been !)ho\\n to be less 'it=n~Jli"e in ddedlllg \[rength deficll... 111 ~tronger mu~cle~ than in \\t:a~L'r mu~c1e .... Although more co~tly and lime consumIng lhan MMT. hand-hdd d) n~lJllOmetry <':~iIl be u<.,ed to lI11prmc ubJt~clj"ll) and !)l:n~III"ilY a<., net=ded. When musde ... dre ...trong t=nough to 1110\ e agaill~t gravity and the dynal1lolll~ler\ le\cr aml, I~olllletic d) namOmelr) rna) <.11 ...0 I,)It u...ed

DOCUMENTATION OF MUSCLE EXAMINATION 2

3

NECK CApltoll ellleniio n

Combined a.tension (capital plu. caNl(81)

CervIcal lIadon Combined lIelllon (capital plus C81"11eal)

Combined He.lon and rotation (SternoCleidomastoid)

COl"llcal rolallon TRUNK

Extension

Lumbar

Extension

Thoracic

Pelvic aloll,tlon

Fllllcion Rotation Diaphragm strength Mallimal inspiration less lull ellpl,alion (indlrecl Inlercostal lest) (Inches) Cough (indirect forced expiration) (F, WF, NF, 0)

UPPER EXTREMITY Scapular abduction and upward rolallan

Scapular olevallon SCapular adduction Scapular adduction and down· ward (otatlon Shoulder 118Jllon

Shoulder extension Shoulder scapHan Shoulder abduction Shoulder horizontal abduction Shoulder horizontal adduction Shoulder external rotation Shoulder Internal rotation Elbow !lelion Elbow extension Forearm suplnatlon Forearm pronation Wrist flexion Wrist extension Finger metacarpophalangeal 'Iellion Finger proximal Interphalangealllelion Finger distal Interphalangeal flexion Finger metacarpophalangeal elltenslon Finger abduction Finger adducUon

Thumb metJicarpopha'angeiolllellon Thumb InlerphalangeallleJllon

Figure 6.16 An t"Aampk 01 - . I Montuomer\J J 'J~ f,7 ',1 .a m~nua mu~de Ic~ling recording form. (From Hj';lop , IIJ ,and eo.

),.

RIGHT

2

LEFT

""1 1

pelllll~~I()n.)

3

Chapler 6 Musculoskclelal Examinalion

181

Table 6.6 Manual Muscle Testing Grades C....

Grade AWae.·..· ••

Normal

N

5

10

Full available ROM, against gravity, strong manual resistance

Good Plus

G+

4+

9

Full available ROM, against gravity, nearly strong manual resistance

Good

G

4

8

Full available ROM, against gravity, moderate manual resistance

Good Minus

G-

4-

7

Full available ROM, against gravity, nearly moderate manual resistance

Fair Plus

h

3+

6

Full available ROM, against gravity, slight manual resistance

Fair

F

3

5

Full available ROM, against gravity, no resistance

Fair Minus

F-

3-

4

At least 50% of ROM, against gravity, no resistance

Poor Plus

p~

2+

3

Full available ROM, gravity minimized, slight manual resistance

Poor

P

2

2

Full available ROM, gravity minimized, no resistance

Poor Minus

p-

2-

At least 50% of ROM, gravity minimized. no resistance

Trace Plus

T+

1+

Minimal observable motion (less than 50% ROM), gravity minimized, no resistance

I Trace

T

Zero

0

0-5 Sale ...8

0

Generall). intrale~ter reliability of MMT has been found to ~ good among trained Iherapists using e!o>labll~hed method!'>, "]Ih correlation coefficiellls ranging from .63 to .98. 1(01 Ill' The results of r"tudies on illlenester reliabJlJt~ 01 MMT \ ill) more" Idel). but findings can be summarized. Se\eral In\eMigalor~111l-107 repon complete agreemem bet" een le\lt:r~ "ho examined Ihe ~ame patient 10 be the lo"e,t. ranglllg from 28 10 75 percelll. Using a 0-5 'lale. ..tgreemcnl btll\\ eC'n tcr"lt:rr" "Ithin a half grade (plu\ or rnmu\J "3' beller. ranging from 50 to 97 percenL U~lOg a O-JO 'c.:alc. agreement ~I"een teslers "Ithlll plu~ or minu\on~ full !,!rade "0.1\ high. ranging from 8910 100 perl'em Correl..tllon coeffiClent~ for inlertester reliabillt) ran~ed Inml II to 94'1·1 ho.l htl'i Traming to \Iandardlze Ie t1ng po::.ltlfln . \tabllll..tlion. ,md gradmg cnteriJ re,ulted In lli~her a~reell1elll ..tnd l.:Orrdallon coeffiuent\ ~1\\C'en It'~h:r Global 'trength 'l:orC~ Iha! a\erage Mt\tT result, from mull1ple mU\l.:k group, aho re,ulled m higher rellaI bllm Tn lI11prmc rt'lli..lbllll~ grade dclinltlon~ modified from Kcnd..tIll'I..I.I" J-lt,h,p and MOlllgonll::ry.'i-· and Hine,II'" Me

T

No observable motion. palpable muscle contraction, no resistance

0

No observable or palpable muscle contraction

presented with specific criteria in Table 6.6. Ahhough grades Zero through Fair are based on objective crileria. grade Fair+ through Normal depend on the therapist's subjective opinion of whal is minimal. moderate. and ma,\· imal re~istance. A Normal grade is typically equated I), ith the nomlal strenglh for that muscle given the patient's age, gender. and bod) size. 11 should be noted that lhere IS considerable \'ariabllit) in the amount of resistance that normal mu~c1es can hold against: for e,'(ample. large mu~cles III Ihe lo\\er extremity \\ill normally hold against considerabl) more torce [han small mu~c1es of the hand. The applll.:J.llon 01 re~ISlance throughout Ihe arc of motion (make lesl or acti\e resi~tance lesl) in addllion to reslstJ.nce al on I) one pomt m the arc of mOllon (break test) rna} help III Judgmg a rnuscle'~ :-.rrength.

Hand-held D) namomet'1' Hand-held d) namomelers (HHD) are portable de\ IC~', plJ.ced bel\\el'llihe Iher..tpl\t·~ hand and the patlent's body. thai Illea'ure mel'hJnlcal force III Ihe POInI of application Ihg.6171

I·J rl·l·rc ...... IOll cQu.ltlon' 10 lale mlo h'l\e ,&l...,' 111.. I11\1.: ~ II' "hl -mJ ht.'lc.hl. \lll... 1 nOnnnll\e Il-lllUIlI tt<" I \\I.:I~., . , h . ~nnrtt'd rl,"lIlh III Ufllh of force u(h .1'\ ...1ll.lIl·...

.1\\

f(1'

nor lillwr,lm·lon:t'. I-tO\\c.:\l·r. thc~ foTr'('

!"'Ollll...I ". Il~\\ It \11..... '

~

~ ,1('OI·ntllnl.: on the knglh l'el\\ecn lhe

\.1h)(" ... "I II '.lJ} ,-. . I"" I ... ·.1IUln tll1lhc p.1111,'nt .... .

bod) to .the a.x.l~ of ,... or Inn " tx'lIer l11ethod oll..·ompaw.on acr()'i.~ . moth11l.l1r Il\l.:· . , ,~

lI ' n;lm\lnll: ..

·1 he to u...e torque. II. 1-- To delCrl11l1lC lorque, IlI.:0P Ic "I'll 1U . . the llH.'a... urrd jNI'I~ i.. 11111I11pllt~t.l b) lhe.: dl .. tancc between the til, nallllllllltr·... locatIon .111(\ the jOint a \1 .... Example'\ of unil...-01 lorlllle arc foot-pound,. Nc\\ IOn-mela.... or kgf-

Older.... Fl1r ltJCnh \\ Ilh untlJtcral condillon'. it ma) be he.lp. ful 10 Lump.trt' r("ult ... to Ih.1I of lhe uninvolved extrerntt). Andre"'" el .11 • found no ... I~tli ...ticall)' ... igntficant differem:e In force ocI\\een lhe domlllant and nondominanl 10,,1.'1' ntrcmitlc\ U... lIlg.1 hand-held dynamomeler. but did find <.I dlflerence oct\...e'cn the dominanl and nondominant upper t.'\lr(,l1lllic~. In g(,lIcr~11. differenccl\ were between 0 and -L5 POlll1Lh or between 0 and 11.2 pcrceJ1l of the aver· age forces genemtcd. Phillips and assOCiJle~l17 found sra· li~ticall) "ignlficant diff('rcnce~ in fOrl'e between sides in a \ariet~ of upper and 1Q\\cr e\tremilY muscle groups ranging from 0.2 to .0 percent. Sapegal~' has recommended thar .1 d,ffen:nce in mu~c1e force bet\\cen sides of greater than 20 percent probably IOdic31es abnonnalilY. while a difference of 10 10 10 percent possibly indicales abnormalit) . MLlsck forces mea~ured with HHD have been compared to forces measured with isokinetic dynamomelers 10 evaluate concurrent validity. Most siudies have found good 10 excellent ,alidity \\ ith correlation coefficienrs ranging from .78 to .98. 1.:'+-1.:'0 Se\ eral investigalors have reported Ihat HHD underestimates Mrenglh in large muscle groups ...uch a~ Ihe lnee e\len'iOrs".:'7.1~!tor when forces are grealer than 196 to 250 Ne\\tons"~~·I~ Depending on the stud). hand-held dynamomelers have demonstT<.lted good to excellent intratester reliability. and poor to excellent intene"ter rei iabil ilY. l!1.~5_113.12g.I»-I]6 Several re\'ie\\!) of such reliability siudies are available."~,l\7,1\~ Reliability seems 10 be better when lesling the upper extremities than "hen testing the lower exttemi· lies and trun".llI.B\ in panjcular, Ihe mea~urements of ankle dorsitle'\ion Jnd hip abduc(ion"P.lHiJ~Il,.';\' Agre et alYo found Ihe ...lanuard de\'lallon of Ihe repeated mea~urernenlS expre~\Cd a~ a pt'rcenlage of the mean force measuremen~ (coefficlem 01 \'ariation of replication) to be 5.1 to 8.3 percent for Ihe upper t'\Iremit) mUl'lcle groups. and 11.3 to 17.8 perCt~llt for the 100\er e\lremit)' muscle croups. Wang alld a~ ...ocbtes 1 q reporled coefficient of vari;lion of repli· cation ranging from 4.~ to 7.4 perct'nt for Ihree lower t'''tremit) l11u:'lde group.... Re"earcher~ belie\'e '\Orne of the error in u~ing hund-held dyn:'lIllometer.., b due 10 otT-center load.il~g 01 the d) 1l:'1I110I11et~r. difficultie ... in po~itioning and I,t:lblilz<.ltlon.and IlIllllaltOlb in the MrcmH.h and experience 01 the thc:rapht... -

r.

Figure 617 M('J,... un:lHcnl ul lh~' "'lrcn~(h 01 tho: Idl Illp .Ito-fudllr... \\llh;1 h.llll,l hellllhn.lllltlIOCler, The' hJ.JlJ·held d\llillll\IIIll"ICI mc.I'IUrl· ... II\l ... ~ .11Ihl" llollilli

tIl

.tpplll.tlion. \\hllh

\hlluld I'oe nlll\l"nc,f 10 I(lIIlUl".

P.tIICl1t ....Ire l)picJl1) .I ... lcd to pu ... h ag.lln"llhe Ihcrapl ...t m.l\lm.1l l"'OIllI..·tnr ronlJ~l<.:tion (m:u..~ Ie ... !). or hold J ptl... ltlOn until the tht'r.lrl~1 o,crpo\\er", the 11111:'lclc produl'Ill!!. JJl e~\.·enlnc conlr~lLllOn lh~al h: ... II. The force mca...• ured b) th(' d) namollleter \\111 \ ~U) dependmg on Ihe mel hod 01 aprl) lI1g the- re...I...I:tlln' (malt' or breJlle"I). the p.tllem'" hc.xl) po..,ltlon III J\"13110n~hlp 10 grm II). JOlllt angle. d) nJlllomettr pl.I(,;emcni on the pallt.·m (1e\ er am)). ...t3bllllallon 10 pr~\t'llt mu ... dc ~ubstilution. and the thera· pi"'·... "'Ircnglh.lltl-Il~ Allhough force \allle .. detennined wilh male and brca" tc ..h ;Ire highly corrt.'laled. break le~h u~uall) re ... ullll1 grealt'f force \alue .. than m:t"e te~b.IP,II~ ~o the) :.hould not be u...ed interchange<.lbl). To a,oid the effect of Ihe "eight of the 1110\ ing bod) l'legmenl on force mea'\.uremenh. it I... ret'ommended thai mu ...c1e group'" be le~ted m gra\ It) -mmlllliled po.<.ition'\.. For c>.ample. to te ...1 the ~trenglh of Ihe Illp abduclors lhe patient \\ould be po.<.illoned ",upllle ~o thai the nUh(;k aClion \\ould pull in a honzonlal plane relJlI\e 10 the ground (Fig. 6.17). Soderberg.lI~ provide ... detailed informJllOn on recommended pO"'Hion~ :lIld proL'edlJre~ for HHD. The joint ~hould abo be po ... ilioned <.It <.In e3'lil~ reproducible angle ,,0 th"ll l11u~cle lenglh remalll.., COlhlanL The dynamometer IS applted perpendicular to the bod) !legmem al an e~lablt .. hed loc~ltlon on the patielH\ bod). When muscle~ <.:onlrdCt (he~ produce lurque \\ hH..'h create'\. angular j01ll1 mol ion. The therapl):,t mu ...t be ~trong enough to re ... ist the pdtlent' ... torque to emure an I ... ometnc (male te~I). or If de"lred an etTentric cuntral'llon (brea" te ...t). If Ihe ther<.lPI'\.1 I... unable to prO' Ide Jdcquale Tt." ... islan(·e. the d)Il.lmomela l';,m be allached to a fi\ed ...urlacell or Jil l .. o"lIleIIL· d) 1l.l11101llCler can be u..ed wjlh the ~peed ..et 111 :l

10 ()

j ... l,X

NOnll<.1tl\e torce \ <.Ilue ... lor p.lfticul.t.r mu ...de group... b) palll:lll age .tno gender hJ\e been reponed: l ' I~I butlher. .1pl"'''' Inu ...t Ix caretul It} replll'Jte lhe normaU\e "tud,\ melhod ... II) en.. ure appropn.ltc Cl)(np~ln'\.oll'\.. Some auth~r..,

Chaptcr 6 MlL'OcuJoskelclal Examinarion

...okinetic 1-\11

O,-namOl1tetr")

/\O/..lI/l'I/1 drllaf110mCft"

I.. a ,talionar). deurol11txhan-

"'....11 lil'\ In' Ihat nlnlrol thL' .. do<.·lly of a 1110\ Il1g h<xly "'C'g. ment h~ rC ... I ... llng ~lI1d me,a .. unng the p~lIlf'n(.. enon \0 Ihat the hod~ -.cgnwnt cannot ~l(celcrate beyond Iht· prc,ct al1gutlr \eIOUI~ (hg. 0.\, ). For c\Jmple. the \eIOCII) of a BIrM..le\ S) .. tl'l11 .' Pro l'O"'IIlL'11l' d~n:.lI1lOmeler Il1 t·oncen· mlxk em Pc ..ct from 0 10 500 /... cc and the re .......I:mcc. 1llL'~NlrL'd III lor4ue. CJn be monJlored from 0 to 500 fl-lb'l or O-hl'o:O '\c\\ ton-metcr.... ll
I

Figure €I 18 III 11l..1Il('11 tJ~Il •• 111"llh,:h:r I tx·"l~ U"l·J hi n l'l nul p'1.:rt"lIll.mu:=· dl.lt.lddl Ilv\ III IIIl n~ht 1.111,:(' 'It' r qU.IJllttp I I){",.I l"'I"llll; I III 1111.' I Irl'4Uliuh IWI,,".! dw.r.u I I I

tl

183

mo\t oftcn notcd arc pc;:lk (maXlln;:11) torque. OInd Ie ...... fre· 4ucntly pea'" IOrqllc!body weight ( m/lg). and average torque. Wor~ measuremenls can be derived from the angular di~placel11ent and torque value.... Power.. which is work per unit lime. al.!.o can be detennined. Endurance (mu\cle fatigue) call aho be measured. One common method of mea,uring endurance i\ to note the time required for peak torque to decrea"e by 50 pcrccnl.l~U4() Peak torque ratio.!. of reciprocal (agoni,t·al1lagonist) mu",c1e groups such as the hamstring\/ quadricep~ and external/internal rotators of the shoulder have been noted. However. careful corrections for the weight of the limb (gravity effects) are necessary to arrive at an accurate relationship. loll t.w If gravity correc· tions are not ufilized. the muscles assi~tcd by gravity will exhibit erroneously high torque values. whereas the muscles that resisl gr:lVily will exhibit erroneou\ly low torque value.!.. It has been suggested that submaximal patient effort can be detected by the increased variability of repeated measures of peak lorque. average torque. and slope to peak torque in isometric and concentric contractions.!JS-IJ'" Ho\\ever. research in this area has produced connicting findings and demon~trated large errors in classifying effort into max.imal and submaximal categories.IJl.IJlI-l50 Many factors such as patient pain. fear. or faligue. and damp settings. preload forces. mechanical artifaci. and acceleration and deceleration ram pings can affeci the variability of torque measurements. The use of isokinctic dynamometer record~ to form clinical opinions of patient effort is not advised until further research is conducted. To en~ure the validity of isokinetic d) namometry measurements, calibration of the equipment is necess~lfY and ~hould be perfonned each day of testing. iltlhe same speed and damp setting to be used during resling. IJ1 Proper alignment of joint 'l\i:,> 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.."0ntr<.l1.."11011.... ht h:r \e1rn."Il) selllllg dunng l:ollct'n1ril' nmtr~\LlIOlh \\ III rc ult III IO\\-~r (orque tlue ... than slO\\er \cltX:ll) ...etllng ... \11 Ollhe:~c faclor... mu l be kl'pl con ...tam III order to dll.·..-!I\d) lI\C rt:pedr lI.· ... ung d3tJ to judge pJIIt'111 progre"l). Keating ;,md f\l,H)a.... I~1. Roch ...tein.j.,J· D.l\ h;· ... cot nted IIII11mldlll\n to unprme the .. aIlJit} .llld rell.lbillt) of hoki1ll:IIL tC ... lln~. P,,'a'" lUrque ~uld \\ork mea ... uremenb III a

flt hl 11111\ ,IIhl 1'.11111\1 J""lrU!;stlllll h.I\(' ..h11\1, n r... "l hi \ll"lkm rd."h,I,I\ Itli uln.. l·nlrll l,mU.llIum'. ,I lid 1)4~" III ,i.'He"t ft:h.lhdll\ lor ('1..11~nHll \ l ' OIr.l\.. hl1lh ' Re.' 'Iplt ,llt,ll'lIll1'l ,11I1.1~llnl'"1.. 1Ul' h.I\l' ,h",-"" k" rdhlhllll\ Ih.lll re:.I~ Il'h.JUI 11l1",I"UI(lllt·nl" ' \,(U('I\

"'ilrlll.lll\(, d,ll,l lin ,ldult,I'1

pi'" Hk

il

;1IIt!

thlldn.:ll

j

'L,1ll

fd~'lt-ll\(, hI[ t·,;dll,ll1l1~ .IllJ lllll'rprl"llll~' p,i1IClll

IInv.C\l'1 U.lIllp.lr ... lm...... 1111 puhll .. hcd d.ll •• ,HC ,lpl'f(lrn.llt' Ilnl~ \\hell Illt-lllll,11 rn"olcdUl(.''' .ITt' u,cd .I11l1 Il... 1Cd ptlrul.t1Ullh ,In: 'InlIIJI 11;I1ICI1I ,tgt', pender. "elghl. hCI~tll, ,md .Jlhlt-lIl. ramllpJlltlll lJIl <.lfft'u rc:cunkd \.1.1 un Out (II I1t·n:..... I\. the In.. ohcd (.'\Irenllt\ I ... (lllen l:\)m· r'l.lrt"d II) 1hI..' tOllllJblefJI e\tn:ll1lt). G('ncT,lll~" "'lUdll~" h,l\C lound I1n "1,,"... 11l~tll) ... gn,llt~lnt dltfl..'renu' bemcl"11 dOlllln.11lI ,lIld nondnnllnanl 'Ide.. HI wrquc mC.I.. urcmcnh 11 lor mu,dr .... urroundlllg thc "'-nee JOII1I. I .•' 1 ';11<1>-1 _ clhov..! I"'j ;lI1d 'lhouldcr li~ Allernall\el) ...tllne ~lUdte\ h:l\c lound dllkrence .. due 10 .... de dominalKl' for certain motIon .. :11 Ihe r1ho\, JIlJ .. houldcr e",pc('l~llly 111 highly "~llled m:tlc ,lIhktc..,.I~<jl"I!1W A dllferen e 01 al lea 'it 10 pcn.:cnt m IOn.~UI: \aJue" bcl"CCIl opp Other... h'l\ e noted Il1lhalance ... uf more Ihan 10 pen.:enl hel\\cen \Ide'\ 01 Ihe body III healthy popula11011.... 11<-11<'" I--urthcr rc ...earch I.., needed toc ..t..tbll..,h fhe mag" nltude of dlfh~rclll'c betl... een 0pposlle 11Inb.., Ihat \.. ould tl1e.!Ic3te 1111p'llnllel1l,l~1 At the present lime it \eem~ appropnatc 10 u'>e the guidelinc~ provided by Sapega.l~J ~lIg­ gC'lting Ihal a difference in Il1U~cle force between ~ides of gre31er than 20 percellt probably indicates abnornlJlilY. "hlle a difference of 10 to 20 percent possibly indicales <.Ibnomlality. tl.tt,l

Special Tests After complellng the patienl inrervie\\. ob::.ervation. palpa· lion. and eX3mtnation of ROM. acces~ory motions, and mu"de perfonnanct:, (he Iherapi~t may ~uspect the nature of the pathology. Special tests, designed 10 focus on specific condition\ in a partil:ular region of Ihe body. may be helpful III l'ontinl1l1lg the diagnosis, A therapist would ordmarily c:hoo\e lO perfonn only Ihose tests indicated by prevlOu~ findll1g~ Ihat are relevam 10 lhe area of the body being e"amllled. False-positl\e and false·negative resuhs are poSSIble. Ho\\e,cr. a po\itive le~1 findlllg III conjunction \\ nh other aspect'\ 01 the examlllalion \\ould be highly ,ugge\llve 01 pathology. There are many '\pecial le~ts pre~emed III the work of Call1icl,lMll Hoppenfeld.'; Magee,2 Rlchard\on and InglJr~h.1 and Tomberlin and Saunders.5 One c.lIegory of ~pcc:ial te..,t\ i.. lIsed to determine Ihe Integrity oj ilgdmenb in '..upporting a join!. The.se ligamentous instabilit." tesls, 011 ..0 called ligament 'ltre..,.. IC~IS, are perfomled b) Ihe tht:r;.tp.M on a relal..cd, pa~sl\'e patlt:n1 nle~ lllaneU\er.. are often :-'llllll;lr 10 le~b 01 ..ut: .....ory or JOint plel) mOllon". II po..... lble. re.. ulh should bt:: compared \\Itil lllO.se I rom the UIlIl1\olvt:d, c:onlralateral

Table 6.7 Gnodinl( of LiltamenlOus Instabilit) Tes(~

-'-il'I'. \- ..

. ' "PW"-~ :\.." l ' ,.., _ _ _ ,... __ ...s...... '.',_

o-Smm II III

IV

6-10 mm

11-15 mm ·15 mm

JOint. The amount 01 la\lt}' ." u\ually graded from I to IV (TJhle 6.7) '" Although Ihc ...c IC .. b foeu .. on ligament integrity. capsular IIltegrtl) .l~ ,.. ell a.., dynamic mU'icle support may influence the rc ... ulh. Example.::. of ligamcnlOus instability teslS include the Lachman te .. t, which examines injury 10 the anterior cruciate ligament: the drawer lest. which examines anterior and po'iterior knee instability: and varus and va]. gu ... \tre", IC ..IS at the knee. In addition to ligament insta· bllll) lests. lhere are more general teslS that examine joint \ubluxallon and dislocation. These tests are often called apprehension tests becau'ie the parient is placed in a vulnerable joint posilion while being monitored for apprehension. For example. to lesl for a history of an anterior sub· luxation or dislocation of Ihe glenohumeral joint, the shoulder is positioned in 90 0 of abduction and moved toward eXlernal rotation. The length of muscles that cross and act at one joint can u~ually be examined in the process of testing passive ROM. However. some muscles cross and act at two or more joims. Some special les(s examine Ihe length of these muscles. The Thomas tes1. S2 .93 which examines the length of one and two joint hip flexors; the Ober tesl.!i2.93 which focuses on the length of Ihe tensor fascia lata; and the Bunnel-Lillier lesl, 'A which detennines the role of the lum· brides, intero~sei. extensor digitorum, and joint capsule in I imiled flex ion of the proximal imerphalangeal joints of the hand, are examples of special muscle length tests. Numerous special tests address common conditions affecling Ihe integrity of muscle and rendon structures. These lests I) pically stretch or contract the innamed or injured slruclUre. resulting in pain if the tests are positive. For example. the Finkelstein tesr is used 10 examine inflammation of the tendons of the abductor pollicis longus and eXlensor pollici" brevis by srretching Ihese 'llructuTes. The tennis elbow tesr has the patient isometrically Contract the extensor carpi radialis muscles againsl i " will have prevIOusly . manual resisl'lnce . ' . 01'len th e t leraplsl . d ' . RO M nOled pam ' limitat'lon ,an pOSSibly wealness dunng and muscle "~rfor ). . . . ...II tlnce . ..,penal tesls are lIsed to c1anfy these earlier tindings. Another (;~ttegor' f lo.pecla . I leSls reproduces the sympJ 0 lom~ caw,cd b\ comp '. . . J res~lOn 01 penpheral nerves or dlmm· "hed blood flo \\. For e;o.ample, Ihe te~1 for carpal lunnel

Chapter 6 MlLlOculo~keletaJ EKaminalion wndromc places the WrlS,t in full Oc\ion for 60 to 90 seconds t~ reproduce the nUl11bne~~ and tingling cau:..ed by compresllIR . . ion of the median nerve b) the tran5.ver~e carpallig::uncnt. Homan\' ,>Ign 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

,.,. :<::

......

~

.

.

~Sl1

C5

Shoulder abduction

Deltoid

C5.C6

Elbow flexion

Biceps

Additional Tests and Measures

C?

Elbow extension

Triceps

Dependll1g on examination findings. other procedures may be indicated. Many of the'\e additional examination proce· dure~ arc discus~ed in detail in other chapters of this book. For c\ample. patient complaints, of pareMhesia or difficulty in muscle perfonnance often indicate neurological involve· ment thai call5. for testing of superficial and proprioceptive sen~ations (~ee Chapter 5). renexcs and motor tone (see Chapter 8). coordination (see Chapter 7). or nerve conduc· lion \'elocit~ (see Chapter 9). These tests. in conjunction "ilh muscle performance results. help to identify conditions affecting peripheral nerves, spinal nerve roots. and the central nervous 5.)'stem. Therapists must distinguish penpheral nene \crsus nen'c root patterns of sensory and motor innenation. References on manual muscles testing. lIuch a5. those b) Kendall et a1.9~ and Hislop and Montgomery92 provide extensive infonnation on innervation panern5.. Figure 6.19 presents muscle testing record109 form~ that are helpful in recognizing impaired innervation patterns. Myotomes and deep tendon reflexes thai are often included a~ pari of a musculoskeletal examination are !lho\\n in Tables 6.8 and 6.9. Upper motor neuron lesion~ usually result in hyperrenexia. whereas lower motor neuron lesions involving the spinal nerve root or peripheral nef\es usually cause hyporeflexia of deep tendon reflexes. Impalmlems in ROM. accessory joint motions. and motor perfonnance may impact activities of daily living. and occupational and reerearional activities. In such case~ the examination of gail (see Chapter 10). functional abilitie":. (..,ee Chapter 11). and environmemal surroundings (see Chapter 12) i... oflen appropriate. Sometimes findings indicate the need for additional testing by other health profe~­ sionab ~uch as phy~ician specialists. psychologists. ...peech-Ianguage pathologists. and occupational therapist~.

C8

Ulnar deviation

Flexor carpi ulnaris Extensor carpi ulnaris

T1

Digit abduction/ adduction

Interossei

......

/.

.

AI tht: condu"'lon of the mus,culo~l..eletal examlllation. all penmen! h',>luneal. subJective. and phy~ical findll1g~ are t:\aIUJkd 10 e"'lablt~h a diagno5.l~ upon which Ireter of "'Igo ... and ~) mplOm'>. S) ndromes. or l'alegorie:-..~~ Thl: .. pel'ific tis~ucs cau'>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

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SPIN-Al NERVE AND MUSCLE CHART

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BICEPS BRACH1AU:' TRICEPS

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7 7 7 7 ,'/ 7 7 7 7 7 7 7 7 7 7 7

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Figure 6,19 \ lll.trlU.tl rnu dt' kung rt'I,.{JfJmg loml 11lJ.I.ud.. In Jt'lc-nnmln!! llll' "lit' l)f 11::\l..'1 .1 flt'n t Iltll (I-nml "-t'nJdll, f·P \1l..(rt'J.f).I-K . .lnJ Prm.J.llu' P
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,eo, 437 1904

c..u.- OoIlfQI_ 01 ~ --_Iooo'nGt.,-1

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Chapter 6 Musculoskeletal Examination lu\culo\l..cleli.lI Pracllce Pattern\ li~led in the Guide 10 PhnlCuf rhcrap, ...f p,.acficl''''~ can a:-.~i~t In categorizing dl.. ~gno ...e.. illln comlllon cluqcrs. and provide infon11aLion on progno\is. anticipated goah and expected outcol11e~. and II1ter,entlOI1\ (~ce Appendix A in Chapter I). Somellme.. (he nalualion proce~~ docs not yield an Idenufiable diagno"is: not all patients pre ..ent with Ic\tbool..·rcrfect s.) mptoms. In ~uch ca~e~. a provi'5ional dlagno\i . . ~ll1d the alleviation of symptoms and impairmelll'" become Ihe ba~i~ for treatment. In other instances. the evalUallOn rna) indicate the presence of two or more conditions. The therapist ~hould then prioritize and focus initially on the condition causing the most serious impairmenb. functional limitations. and disability. The evaluation ,>hould 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 upra:-.pinatu!'> 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 <':Ju ... ~d h) a \,ell-defined e\el1l than tor a congenital l:Undlllon or one ""Ith an 1Il"ldu)u... gradual on..el. The mode and mC<.'hani ...m 01' Oll\et al ...o pro\'lde due ... to help dt:'e1op "'Irateglt.::" lor prl."\entHlIl 01 reou:uTTlng epl"iode~ oj the lIlJur~ or rundlllon FIn..tIl) an anal) ..." ot tht: ~'l(JJ111nJIiOn tlllding ......hould e~t..tbh h tilt ~Iag~ 01 the p~llent'~ l'ondiuon The ~tage.

187

whclhcr acute. subacute. or chronic. can IIldicate how well the patient will tolerate mechanical loads such itS thoo;c imposed by daily activitie . . or by a therapist during Ire3tment.IQ(1 The anile sfoge i... usually defined as occurring up to the first 48 to 72 hours after onset The .Hlhacute stage may continue up to 2 weeks to severaJ months after onset. Typically. conditions are considered in the chronic sfage after 3 to 6 months. Another way of defining the stages. which is probably more relevant to treatment planning. focuses on tissue inflammation and the repair process. 1 Conditions in an acute inflammation stage will show signs and symptoms of inflammation associated with hyperemia, increased capillary permeability with protein and plasma leakage, and an influx of granulocytes and other defensive cells. These signs and symptoms include swelling. elevated skin temperature at the lesion site, and pain at rest that worsens with ROM and resisted isometric contractions that even minimally stress the involved tissues. The chronic inflammation stage produces signs and symptoms associated with attempts at tissue repair. including an increase in the number of fibrocytes and the presence of granulation tissue; the patient will now have minimal or no swelling and elevated temperature at the lesion site. Pain tends to occur only at the extremes of ROM when the end-feel is reached. or wilh a moderate to maximal amount of isometric resistance. Tissues in an acute stage will often not tolerate mechanical loading from daily, recreational, occupational, or therapeutic activities. The force, frequency, and duration of treatment procedures must be monitored closely so as not to increase inflammation and worsen the condition. In contrast. tissues in the chronic stage will usually tolerate and require treatment procedures involving more mechanical loading. frequency, and duration to effect positive changes in the tissues. The stage of the condition also adds prognostic information. Typically. an acute condition will show more spontaneous improvement over a shorter period of time than a chronic condition. A chronic condition usually requires a longer period of treatment to promote a smaller improvement in ~tatus.

Summary The mU'5culo~l...eletal examination provides important inform<.ltion concerning the slatus of bones. articular carlilage. joint capsules, hgamcnt~. and mu~c1e~. The e\amination proce\~ beglO~ ",lIh a revIew of the patient'~ medIcal records
conclusion of thi:-- process. all f;nding~ must be evaluated to delemline the diilgnosis. baselinc status. etiologic~ll f:lclOrs. mode of om.ct. and slage (acute, subacute. or

Questions

for

3. 4.

5.

nation. Describe the appropriate sequence of per· fonning these procedures. Provide a rationale for your response. What infomlation should be obtained during a patient interview? Why is this infonnation important? \Vhat are the Ihree types of nonna] end-feels? \Vhal Iypes of lissue contribute lO Ihese end-feels? Provide an example of a capsular and a noncapsular pattern of restriction at a joint of your choice. \Vhat would cause these two different pallems? Compare and contrast osteokinemalic and arthrokine· matic motions. Give three examples of each type of mOlion. How do arthrokincmatic motions combine to produce oSleokinemalic motion in a typical synovial joint in which the moving joint surface is concave? convex?

Cas e

Stud

can be developed.

Review

1. Identify the components of a musculoskeletal exami·

2.

chronic) of the condition. Al this point the prognosis, anticipatcd goals, expected outcomes. and plan of care

6. Distinguish between muscle perfonnance. strength. endurance. work. and power.

7. Discus~ the implications of a finding of pain versus

8.

9.

10.

no pain. and strength versus weakness during the perfonnance of resisted isometric testing. Describe the criteria for the manual muscle testing grades of Zero. Poor. Fair. Good. and Normal. Compare and contrasl the criteria for the grades of Poor minus. Poor, and Poor plus. What are the advantages and disadvantages of using manual muscle testing, hand-held dynamometers. and isokinetic dynamometers to determine muscle strength? What sumlllary infonllalion should be determined from evaluation of the musculoskeletal examination findings to develop a clinical problem lis!. goals. outcomes. prognosis, and plan of care?

es

CASE STUDY 1

2. What additional infonnation

~hould be gathered during

the interview? A 45-year-old man enters the outpatient physical Iherapy

department wilh a complaint of right shoulder pain of I wee.k·s duration. The pain began Monday morning folJowmg a v.eekend of scraping and paiming hi!o. house. The patient describes hi~ pain a~ aching and trouble~ome: hiS pain i~ a 6 on a pam scalc of 010 10. He reports Ihat he is mamed. and ha\ ing difficult) in home maintenance acti\ Itles such a... lav. n 1110\\ mg. He i~ able 10 pafoml onl) 30 percent of hl~ nornlal home and recreational acti\ ilies. The Iherapi ... t decide... to conduci a l11u...culo~kelelal C),.~Ulllnallon.

While palpatlll!! the ... houlder region. incre"lsed tender. ne ...... and S"-1Il tel11peTiiturt.~ 111 the region 01 the bicipital grome ot the TIght alllenor shoulda IS noted. At. t1\ t.' ROM 01 the right ...houldl:r rc\cah lncr-:a.. .ed p.lln and some 11l11ll.. uons dunn!! ')houlder OC\lon. alxludlOll and e\len !\m; all olher auhe 111011011:-, ~Ire p~iln lret" and V.Ulllll J10nnal ROM III11Us, Pas... l\e '::lhouldc:r lllO!It.lIh ,trt~ p;.un If(:~_ \\ IIh 1101111;11 ROM. t.'.\Lept lur shoulder c\lt;'n"'IUIl. v. hll.. h h limited Jnd l·JUS("~ ;111 Il1l·rt'.....t: 111 pall1 towi.trJ tht: c:nd oj llh,ltlOIl

J!I

t

IF

11

\\'h~t Jrt: Ih~ purpo...t: ... ul J IlIU'L"ulo... k.eh:t.d C:\Jllllll,1 !lon'

..

3. What is a capsular pattern of limitation? Does thi~ patient have a cap~ular pattern of limitation for the glenohumeral joil1l? ~. ~he therapi ..., ,uspect, [he pre,enn: of bicipital tendimlis. Do Iht' fil1ding~ during le.,ling 01 aCllve and pas~i\'e ROM ... upport thl~ dlagno'j..."! E\plalll. 5. \~'hal additional ie,,, ... hould be perft.mned 10 ~elec­ 1I\e1) e\,lmllle .cOnlral'till" li ... ~ue ;.md help to ... upport or repudlJte the diagnOSis (\1' binpn,ll lendlllill ... ·! Pro\-ide .. ratlonah.' lor) our ...del'lIon.

( \Sl- STLDY 2

Chapter 6 Musculoskeletal Examination

be ohlert;\c1) Illca ... ured and documented? Why might the pallenI', left kg he thinner than the righl'! :!. Pa'... I\'f' ROM lor left l..nee tlC\lon i~ 10 to 70~. The end· fecI for left knee tlc\ion jr.,; finn. What i!\ an endfed! What are the three general t) PC'" of nomlal end· feel .. ~ Whal li .....uc, could be causing a fiml end-feci for l..ncc flexion in thi::. patienl? J. Whal arccs..ory joint Illotion :-.hould be examined COll~idcring lht;': limitatioll in pas~ivc knee tlexion ROM? Apply the roncave--convcx rule~ for determining the direction of the glide given the shape: of the joint surfJce~. The accc ......or) joint Illotion \\a~ found to be very

189

hypomobile. What grade should the accessory joint motion be given? 4. The therapist conducts a manual mU!o.cle test of the len lower extremity. \Vhat three faclors are important in determining manual muscle testing grades? What would be the criteria for a manual muscle testing grade of Fair? 5. In addition to observing. palpating. and testing active ROM. passive ROM, accessory joint motions, Hnd muscle perfonn;:mce. what other testing procedures would be important to include in the examination of Ihis patient?

References Ht'nlmg. D. ;lnd Ke....kr. RM: Management of Common \1uwulo'lo..del,ll Dl ..0rdl'h: Phy",ical Therapy Pnnciple.. and ~lclho,k ed .l Lippinnlll. PhlladelplH:1. 1996. ~,MJfec. DJ: OrthopedIc Ph~"lcal A,~t:.. ,mcn1, cd 4. WB Saunder~. PhJl.tdclphla. ~O(l~ , Rllh.Hd,on. JK. and IglolT'oh. ZA' Chnilal Onhopaedic Ph) .. ical ThcrJp~ \\ B S'lUnder,. Philaddphl.l. 199.s -I Hi."'llpenleld. S Ph~ '1(011 E"am1l1atlon of the Spme and E~trenlliles. Prenll..:e·H.l11. Englev.ood Cliff... NJ. 1976 ~ Tombt:rhn. JP .md SaUl' of man. Anat Ret' 102:430. l1J4H. ~. J\1el/dll... R: The I\kGll1 pain que'tlOnnaire: Major propcnic, and '>l(lrin~ methods P::lIn 1:277. 1l.J75. II) Bl)I\<.,(lIln,lUlt. WG Ell.am1ll3UOn in Ph}'ll".I1 Therapy PractIU:~: Sueenmg for Medllal DI'>Cd,e. Churlhill LI\Ulg,lOne. Ne\\, Yml... IWI II GuoJmJn. CC .mJ Sn~dt'r. TK' Dlff€.'renlial DI;lgrlO!>l~ III Ph~"H;al lner"r\ c:-d ~ \\ B Saundef\. Phll.loclphI3. 1995 l~ Slemendd C\\. cl al L'(lI1~-lenn bone 1o,.. III men: EBen.. of gerJrlil and en\mmmental fadop." Ann Inteml\led 117:2K6. 19<;2. Il Hopper. JL dIld Set:l11all. E The bone delNt~ of female 1\\ Ill.. dl"· H.rd.tnllnr lob.tlll' u,< N Engl J Mcd :nO:l87. IW~ 1-1 H.III1t'. \1L et .II "'ll1l'~Illg: .1110 lumbar Il1tcT\el1ebral dl\(.· degenerJllWl A.nl\1RI "ud~ olldenllC~II\\Hl'. Spill!: 16:1016. Jl)l}1. 1;;.l:kyo RA, "nd Ih"". JF- Ldc"tyk .tlld IU\I-h.t.. l.. P;III1: Tilt' mOu· ("n\.t· or ,m{)~.lI1g .1IId Ohc\ily-, Spmc 1--1'\01 I ".lX9. In He!").a"rT'> fur dl'ot'J"oC 1I1 lh~ IIC I .tn.1 1)t..uIJcr .IIt:J Ol.lup·lll\lrun Med 51:262. 1l.J9--' It,! hrJg. S ;,nJ B.J<.·rkdoll T 1\1u..... ulu,"dl"l.t1 ",.un.tnd ~l11ol..lng III "r.... .t J Frl,klllll..1 CHrnmUI1lI~ Ik.lhh 'ill 1M 19')n ~o 1 (""illClt: I'.... .Ind .... "rl..lll. C{' JUlllt ~tmtolun .. .InJ Funlllvn. A { .mprchell 1\, A.1l,,1\ I t:d -I FA DoI\ I PhllaJelphld,20115 ~I ".lun". MP ('JIl.l'·oI '"loIll'alh:n1uIIllO\lIl,ellt Am J Phy- .. I\kd -II, ~'~ I 1'H,

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25. LlvlllgslOn. LA. Cl Oil: Stairclimbing kinematics on stairs of differ· ing dimension,. Arch Phys Med Rehabil 72:398. 1991. 26. Johnson. RC. and Smidl. GL: Hip motion mcasuremenL<; for <;elected activities of daily living. Clin Onhop 72:205, 1970. 27. Laubenthal. KN. Smidl. GL, and Kcuelkamp. DB: A quantitative analyMs of l...nce mOlion during activities of daily living. Phys Ther 52:34. 1972. 28. Rodo,ky, MW. Andriacchl. TP_ and Andersson. GB: The mfluence of chaIT height 011 !o\\,-cr limb me<"halllcs dunng rising. J Onhop Res 7:266. 1989. 29. Ikeda. ER. et 011: Influence of age on dynamics of nsing from a chair. PhY~ 1ber 71 :473. 1991. .10. J:m<;'cn. GI\'1. Bussmann, II 8J, and Slam. HJ: Detenninams of Ihe sit-IO·Sland movement: A review. Phys Ther 82:866. 2002. 31. Safee-Rad. R. et al: Nonnal functional range of mOlion of upper limb joints durin~ perfonn,lI1ce of lhree feeding activities. Arch Phy' Med Rehabil 71 :505, 1990. 32. Packer. TL. et al: E.~arnining lhe elbow during functional activitie<;. Occup TIler J Re, 10:323, 1990. 33. /\Ioney. BE CI al: A biomechanical study of normal functional elbo\\' motion. J Bone Jomt Surg Am 63:872. 1981. 34. Ryu. J. el al: Funcllonal ranges of mOllon of tht: wriSI joint. J Hand Surg 16A:.J09. 1991. 35. Matsen, FA: et al: Practical E\'3luatlOO and Managemenl of the Shoulder. \VB Saundet"i. Phil.tdelphi.l. 199.s. '6. Boone. OC. and Alcn, SP: Nonnal range of mOlion of JOllIU III male "UbJcCh. J Bone Joml Surg Am 61:756. 1979. '!o7, Bell. RD. and Ho,hlzakl. TB: Relatlonship of age and \e,{ With range of motion: Sevenleen jOlllt achon\' in humans. Can J App1 Sci 6:202.1981. '!oH Roach, KE, and Mil"" TP: Nomlal hip and knl'e aCli"e range of mOllon: TIlt' rdatiolhhip 10 ;Ig~. Phys Ther 71:656. IY91. lY. Si.·h\\,:Iuc. OJ. and Denton. JR' Normal value, of neonat.tllullb..: An e'aluallon of 1000 nt'onatc.'>. J Re, rediatr Onhop 13:758, 1991 40. Moll. JMH, and Wnght,V' N(lnn,11 rangc of ..pmal mobllll). Ann Rheum DIS 30:3KI. 1971 41 Youda~. J\V, et al Nonn;t1 rang.e of motion ot the Ct:T'\ leal "pille An rmllal gOl'llUIlll.'ITIl· ~Iudy Ph~ .. Thcr 770. 199~. --'1, Allandt:r, E. et al 'uml.lI mng~ of JOIllI mo\en~nl III shoulder, hlp, \\,n..1 and IhulIlh \\,-1111 'peu.tl relerenl'e 10 Mde A comp,I!l-.on hclwccn I\\,O pOpUI.lIIOll' 1m J Epidenllol .1253. 197--' 4l Bt:I1!hlOll. P. CI al: AI1I\ul.11' mobllll) III 1111 Afnl.,m populall7b.

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,Irt'nglh uqng manualmu-.cle le,>lJ Orlhop Spon Ph~ .. Tha 26:192.191)7. 112 Sc"krlwrg. GL: Handheld DYIl:lmOmCll) for r.lu\ck Te<'(lIlg. In Rt·..· ,t'. NB \Iu,.. k and St'n'ol) Tt.:..llllg. WB Saundcr,. PhllJ.dclphl'1. 1m. p II.l BI,h;lnnnn. R\\ f\b~,,· Ie"'" and br..·:l!.. le,I" of elbo" nco.;or mu~c1e ,lrenl.'lh Ph" Ther 6\: 19.1, I%S. 11-1 SlrJ.,illrd P\\. ;lnd Bal..ur. BE: A comp:lmon of Ill,,!..e and break Ie'" u'lIlg a hJ,nd-hdd d~ nalllomelt.:r and the Kill-Com J Onhop Spon.. Ph}, 111er 19:2l\. 199~ ll:i Ford-Smllh, CD. t'l al: Rcllahlht} of ..tallonar)' d} namomelcr lllU:'rk ,(renglh l",,"ng III cOJn1l1ul1lly-dltdhng older adul". Arch Phy:. Mcd Rdl.thill\2:111X. 2001. 116. 'Jad1cr. SF. el;11: Pon,lbk d}namoml'ler all('horing ,laUon for nwa,unng 'lrenglh of the hlp exlen'Or, and abduclnr... Arch Phys \kJ Rchabil hI 1072.200(1 11'1 PIHUlp'. BA. el .1.1 ~Iu~t"k force nwa..ured U"lllg "brca"" te,>ting "'''lh a h'llld-hcld m~omeler III nonnal wbJecl" aged 20 10 69 ~ear... Arch Ph~, \led Rehabll 81 :653. ~()()(). 111\ \ndr<:'" ... A\\ ,I al: ;'I.omUlltC ,alUt:"ltll homelric lllu'>Cle force meawre1llenh obl;)lI1ed .... Ilh hand-hdd d) namomelCl'!>. Ph}, Ther 76:24X.I'Nfl. 119. Boh.tllnlln. RW: Uppa eXln.:rnilY :'lrength and <;trel1g1h relalion,hip~ .tln\lng young "omen. J On hop Sporl Phy~ Thcr R:12fL 1%6. 120 8;J.. J...m,Hl. E....t .II: homelric mu..c1e force and anthropomclnc \'alue, III nomlJ,1 t'hlldren ;Jged bel"lYn :\.5 and 15 year.. SC:lnd J RdlJ,bil \led 21'105, I<)S9 121 \'an dcr Ph)('g, RJO. el al. Hand-hdd nl}omell): Reference ,alue... J 'eurol r'\ieuro..urg P,~dllall) 54:244. 1991 122 \lJgnu',oll. PS Chlll..-al ..lrc:nglh le.,llI1g. Rchab f\IJ.nag ..'melll Dt."(.'J.m:3IL 1991 113 SJpt';!.l A.A. r-..lu,de pertonnal1\:e e\;llualloll 111 onhopaedlC praclltt', j B,)])e JOllll Surg nAII(J):156~. 1<)90. 1~4 \I"cr J el.lI· Compan~(Jn nfma.\imJI \olunlary I,omclrie conIr;J,II~'Il.LrId h..Lnd-hdd d~nanlOm"'lr) III lll":.I,urmg Illu'{!t' ~lrellglh of pJll...nh \'1lh pmgre....ltc lIm ... r mOlor neuron ..}ndrome. '\eur.lmu~ul DhurJ 13:'44 2003 12", Bnnl.mann JR: Comp.tr1'\)ll of a h.md-hdd ,md fi\ed d~ndmome­ ler In 1I)C;J..unl1),.' 'lrt'nglh 01 pallenh .... llll neummu..(:uIJr dl..e3\('. J ()nh"fl Spon.. Ph~~ lllt'l' II): IOU. 11)94 12h B"hJnllt,n. R\\ H.1ml-ht'ld compMcd "nil l'O"lnell" d}Il,lInOlm:lr) I"r lllt'J'urcllll'rll III ..Iallt "nee e\ICI1,IOn lor4ue lp.lralld rt'llabjlil~ (,f d~nal1l(lInela'J. Cll1l Ph~~ Phy"lol r-..k.. ~ 11:217. 11.)90. 127 kt"lll~lllg, ~1f., t'l al A,~t:.,.,mt'r1I ul qUildrit·cp' lllu:.ck pcrlonn:l.llct' h~ h.uuJ·hcld. I"lrnl"lrit .l.nd l"o~IllClit, dyn"HllUmclry In p;lllt'n, .. '\ 1111 1.1l,-": d~ ,Iundlllll, J Onhnp Sport Ph) ~ -I her 24: 154. 1996. 12k 1-.lll1I~'r DO t·t.ll /-I;1nd-hdd d)nJmnmctl) rdl.lblhl} III pcr,on.. v,llh n, ur"fl.l1hll. .... {'..... Il<.: \rtll Ph) ~ 1\lt:d Rt.:h;lbll 71( 11M 1I1g.

.ns

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I.?'J (k.1 "'1 d .11 lomparh'lO ul nMl(lllMI \\IIUOI,tl) hOlllClnt· ton11.11.11"'" ;1m! DI
I ((J A!;r.., j( ..·I..LI \IIClIglh !cling \\ Ilh..L pUfI
191

1:l2 Rukllc. DL. el al: Inlra~'''loll and lnler.es.,lon rch:.blhl} of handheld dyn.tlllomclC'r nl('a"urelllcllb l.l~cn lin br.llll-d...magcd pilllcnh Ph~ .. 69: IlC. I \)l-;9 1.13. Morel,IIlt!. J. el ,II: Inl.:rr.lt;;:r rehablIJI} 01 ,io.; le.. '~ ollrun" mu.'lC1c 11IIlcllon .lIlJ cndur,Hlce J Orthop Sp(11l Phy' Ther .26:200. 1997. 134. Wallg. CY. Ohon. SL. and I'ml:'''. FJ: lhl·rcte..t ..lrength rc!l3bil1Iy: Halld-held dyll,H1l0lllclry in conHllunlly-d\~elling elderly faller~ Mell Phy' \tkd Rehahd 1(1:X 11. 2002. 135. Ollo.:nhacher. KJ. Cl al The rehabilllY of uppcr- and lower'C":lrell1II) .. lrcnglh 1<.:.. ling III .1 commUIllI} ..urvey of older adults. Arch Phy~ 1\tcd ~eh ..blllO: 1423.2002. 136. H;I}e,. K. el al: Rellatollll}' of 3 melho(h for a"sessmg ..houldcr ..lreng.lh Shoulder Elbcm Surg II :3~. 2002 . 1'37. Boh.mnon. RW: Inlene"'er rellablllly of hand-held dyn:lmOmclry:A {'onci..c <,ummary of publi..hed research. Percepl MOl Skilb 88(3 PI 1):899.1999. 1'38. Sloan. C: ReVIew of the reli;lbilily and v31idily of myomctry with children. Phy.. Occup Ther Pedialr 22:N. 2002. 139. Sy,lem 3: Biodeo.; Medical Syslern".lnc. Shirley, NY. 11967. Relrie"ed June 22. 2()().t from hllp://www.biodex.com. 1.tO. Cyocl( 6000 Te...llng. and Rehabllll.llion Syslem U-.ers Guide (Rcvi..ion-D). C} bc'(. Inc. Ronkonkoma. NY_ 1991. 141. KeallOg. JL. and Malya", TA: 'IClhod-reI3led variations in eslimale" of gr3\ ity correction value.. uc:mg electromechanical dynamometry: A !..nee eXlension sludy. J Onhop Spons Phys Ther 24:1~2. 1996. 142. Kdli". E. :Illd Ballzopoulos. V: Gravi1alional momenl correction in iso"inClic dynamomcll)' using anlhropomelric data. Med Sci Sports E.'(erc 28:900, 1996. 143. Roth~lell1. JM. el al: Clinical uses of ic:okinelic measurements: enlical I.. ~ues. Ph)'!' Ther 67: 1840. 1987_ 1....... Winh:r. DA. el al: ErTO.... in the u~ of isokmelic dynamometers, Eur J Appl PhY~lo146:397. 1981. 145. Lin. PC,..:I al: [)eH."Cllon of !'ubmao.;imal effort in Isometric and isokinellC' ~nee eXlen~lon It'SL~. J Orthop Spans PhY'> Ther 24: 19.

n'cr

1996. 146. Bohannon, RW: Differentialion ofl1laximal from ~ubma.\imal Sialic elbow tlc'(or effon... by measuremenl variabililY. Am J Ph)'s Med RchabiI66:113,1987. 1-17. Ki..hino, ND. et at: Quanlificalion of lumbar fUllcllon. Spine 10:921. 1985. 148. Robll1 ..01l, ME. C:I al: VariabJIil} of i"omelric and isotonic leg e'(er· ci~: Ulillty for delecllon of subma:\lmal effon5. J Occup Rehabd 4:161.11194. 149. f\lurrdY, 1\IP. el al: Maxl1llUm i!>omelric knee I1cxor and c'\tenc:or t"onlra('llom: Nonnal p3Ul"m... of torque ...ersus lllnc, Ph}:. Ther 57:637. 1977. 150. H:LZ:lrd. RG. el a]; Lifting C:l.pacilY: Indices of !>ubjcci effort. Spille 17: 1065, 1992. 151. John...on, J. and Sieg.el. 0: ReliabililY of an iso~in~Iic movt:ment of the "nee eo.;len~or~. Re.. Q ~9:880. 1978. 152. 1\1J,\\d!>le}. RH. ;lnd Knapik. JJ: Companson of l...ok.incllc mea,urelnenl' t~ ilh lesl' rept'tlllun,. Ph} .. Ther 61: 169. 1982. 153. Keallll~. JL. and !\Iatya... TA: The Influence 01 'lubjl."Cl:md teSI de'lgn on dy namolllctnc ml"a,uremenh of eo.;lrt'mll~ muscle.... Ph~s Ther 7(),R66, 19%. 154. Da\ I,,',. GJ. ('I :II: A"e.. ,m~n1 of ..lrength. In Malont'. TR. cl .II (cd<,j; Orthllpedlt.: .llld Spon~ Phyw.:al Therap~. cd J. CV r.lo,by. Sl. 10\11,. 1':)97. PI' 215. 155. Gain..·... JM. and 'falhOI. LA: l...o"llIellc ...lrelH!.lh lc,ling ll\ re!>earch ,lIld pr.tdlt.:e. BIoi Rc:.. Nur, 1:57. 11)99. ~ ~ l:ih. ttlolll.Jr. GE. t'l all{eh.lblltl) 01 ~Uallltlatl'e "Irenglh mea.-,urel11en!'> III dlrldrt'n. Ar"h Ph)s \leJ Rehabil60:~IR. 1(,179. 1.'17. Trt:Jlllnlt!.., TJ_ .mJ Duncan, P\\. Rehabitll) of llle.L.,uremenb of ("(lIKellln.. and et·..coulL 1....o!..I11('-11( It)aJlllg. Ph),... Tiler 6S:656. 199~ 15S f\lom ..-Ch.llla R, el al~ IW"lI1ellt 1t",llIlg of J.n!..k ",rcnglh III old..· r adul,,· A,.....' ,..lII,,·ll1 ot lI11er-I'~llcr rdl.lbdll) and ~tablht} of qrenglh O\t'r ... 1\ Ifllllllh, \r..-l\ Ph~ l\led Rt:hallil 75:121.1.1994. I 'il). Emery. Ci\. ,\I.ulland. 1\IE, and M<:euI~ l"l',WH Tt.::.I-rele... 1 reh.)bill!} 01 "ll~IIl ... II'" hlp addu..·I(lj" and Ik.\Of mu... <:k ~lrength. Oin J Sp.... rl.. Mt'd <): 79. 19\)1} IoU \)'lloll 0\1 et .II. Rdtablltl) UII!>ol..lI1elie -;Iren!:lh m':;lSUI\'"llIenb uf lht: ~r1"t,' III t1l1ldrcl\ \\ Ilh ll:rebral p.ih) Dc\ to.h:d Child Neurol .12 19~. 2000

192

Ph, ,ical Rehabililation

1('11 !"nhl P\ cl,ll Rc!lII l-l Noll. ~jll"l(1 I()~ H,u. Al l,mg.I'1 .U1J J.l11 \lH 1,"t-n'lc'r reh...!ldll\ III 1\0"10('11, 010\1.1\- 'trcocth 01 Ihl' 11l\\Cf C\lrt'millc' III p,lll,·nl .. \\. Ilh ,Iro"l' \Rh Ph" ~kd RchJhl1 h \ II 'II ~lIfl2 1(1' QUIlIJn. \1 cl,ll ho"mclK 'tfellglh l,"'tmg In p,lliCllh \\.llh dlmlll... hl'a'1 t.ulure a n:1i:'!lll1t, 'lud~ Inl J Spon, .\kd ~:!-10, 2001 IN \,111 \kctrrcn. J. R'-lI:br\~I... \11 ,md Sf,lIn. IIJ -1r,Hd\"l relIJb!lIl\ III ''''!..lnelll mu"\ it' 'lrenglh 1lll',I\uremcnh 01 the 'houldCT J Rrh.lhil ~1cd '-141, ~()02 lh'i Plprllll..ol1. NA. ,lilt] i\1.Jllnl\l"e, IJI l',;,t-rete,r rch~hillt) ot glcnl)humcral 1Ill\:m,11 ,mJ ntenl,ll nll,l10r "rcngth Clm J '1pun\ Med 12:107,2002 160 Kramer, JI .1IlJ \I~. LR. ~t"lll amI d~n,umc 'Irell!:!lh 01 the ,houlder rnlalllf'. III hl'alth~. -1~ Il\ 75 )car-old men ...nd \~(lrnen J Onh(lp S!X'n, Ph~, Ther 2-1 II. 19'1ti !fl: CahJI"n, ro. el JI: Quantltall\l' ffiCa,>uremcnh III hlp ,>uength In (hfterent agl" ~rour" Chn Onhop ~-1td36. 1989 IllS ~IUITd~, ~IP. el dl: Strength 01 I.,ometnc and 1l0"lIlelu.: conlrJCllll.h Knec mU>,C!t·, 01 men a~eJ :W to R6 Ph}, Ther bOA 12. 1%0 16<) Smith. SS. Cl .11 QuanllfiL ...llOn of lumbar funcllon, Pan L J<,ometrlL: ;mJ mulll,peed t\O~lIIetlc lrunl.. ~lrcngth mcawre,> In '.1g.lu.1l,lIId a\i:d p1.me\ In nonnal \UbJecK Spmc 10:757. 1985. 170. NeJ.:r. JA. <.'1 ;II: Reference IIJluc' tor concentric knee i~ol..mctic ,rrellgth "nJ power 111 nonathktl(' men and women from 20 to 80 }t'ar' old J Onhop Spon, Ph}\ Ther ~9: 116. 1999 PI GaJdo'll... R, \ander LlIlden. D\\'. ,md Wilhdlm. AK. Concentric l,ol..metiL torque chdf':lcten,tK' 01 the t:all mu<,<;le) of Jctlle' \~om('n aged ,2010 M } ear<., J Onhop Spon~ Ph} <,. Ther 29: lSI. 1999. I ~~ Hulen... \1. 1'1 ... 1. A'..e~\ment of I\o"Hletic mu-.cle )tren2lh in \\ornen \\ho;d"(' obe,<':, J Onhop Spom Phy,> Ther l2:3-:i7. 2002 \-:1 :"m3n"\I'". A. el.Jl: \lu'>Ck fUlll:llon In '5-year·old men and \\omen A 10ngiludlll.Jl \Iud~, Scand J Rehatllll\led SuppI9:92. 1983. 1""-1 Holme,. JR, and Alh:nn~. GJ. 1,0~lIIetlt: ..Irenglh characlenstlcs of lht: quaJnt:cp, lemon' and h,un'tnng lTlu,c1e~ in hIgh '>chool qUdenl\. Ph}\ Ther6-l:91-1. 14~-1 175 Weltm,U1. A. c' al: Mea,urem<':nt of I\ol..mellc 'lrcngth 10 prepubertal mall". J Onhup Spon, Ph)', Th....r 9:3-15. !988.

l1n Ilcmlcf'.on. RC_ cl JI- Knee flc'((lr-c\tcn~or ~lrcnglh In chIldren. J Onhop Sl",n~ Ph), Ther IX:5W, IlI'J:\. l , ...1 \lu<,<;le ,tn.:nl!th ...nd hormonallc\eh In adob," R I ,lnlO'. - c .led 1"5' Len.... Gendl'" rebled d,lferent:c' Inl J Sporh I~ .,. _6. 19911 17h Kelll'. ':i ct .II PredltllOn 01 lnee c\len~or and flc>;or I\okrneill.: 'trength III y(lung m...1e 'OCL:er pla)e'" J Dnhop Spon\ Ph)'s ThC'r '0(-,9', ~O(lO 17Y Ellcnhcdc:r TS. and Roeten, EP l'o"lIlctic profile of elbow ne.>;· Ion .IIlJ e"<.'INOI1 'trenglh 111 elite JUIl10f lennI'> player... J Onhop spon\ Phy' Ther ~.':79. 2011'. . 180 Gralc. TG. Cl o!..m{'l1C te"ling of the ~nce. J Onhop Sport\ Phy' Ther 10.59. 19S1oI , LU(l'a, JA. and Kline. KK. Effect\ of upper and lower 11mb preferenle on IOr4ue produdion III the lnee flexors and eXlensors. J Orthop Spon~ PhY" Ther 11.202. 1989. un Aqu1l10 Mlle. A. el al: hokllleirc 3.'>se~<;menl of ~nee fle:(Qr/exten'or mU'oCul...r 'trength rn elderly \\.omen. RC\i Ho..-p elln Fac Med Sao Paulo 57: 131. 2002. 18-1 Hmton. RY' hokrnetic e\alu,Uion of ..houlder rOlatronal strength 111 high-<;chool b:l'eball pIlcher... Am J Sport~ ~lcd 16:274. 1988. 185. PeITIll. DH. et
GIIAPTER

7 llARNINS

OBJECTIVES

I. Under:.tand the

purpo~e,

of performing a co-

ordmation C\:lIlllnation. 2. U,t the- t) pc(" of data !!en~r':lIed frolll the-

examination. .l. De...cribe the common coordination impairmenlS as"lo<:iated "ilh lesions of the cerebellum. basal ganglia. and dorsal column-medial lemni~cal pathway. 4. Explain the primary age-associated changes Ihal impact coordination. 5. Discuss the purpose of screenings within the context of the coordination examination of malar function.

6. Provide a rationale for the preliminary patient observation prior 10 perfanning a coordination examination. 7. Identify the mOlar [ask reqUirements and

movement capabilities addrcs~ed during a coordination examination. S. Differentiate between tests used to examine nonequilibrium and Ihose used 10 address equilibrium coordination. 9. Ex.plain the le~ting protocol for perfonning a coordination examination. 10. Using the case study example. :.Ipply clinical decision making skills to applicalion of coordination e'(amulation data.

Examination of Coordination Thomas J. Schmitz,

PT. PhD

OUTLINE Oven iew or the MOlor Sy'lem J 9~ The Molor Cortex 195 Descending Molor Pathways 195 Cerebellum 196 Basal Ganglia 197 Dorsal Column-~1edial Lemniscal Pathway 197 Feature~

Noncquilibrium and Equilibrium (Balance) Te~ls 209 MOlor Task Requirements 209 Movement Capabilities 209 Prepar.tlion for Admimslering lhe Coordination E;uminalion 210 Tesling Environment 210 Patient Preparation 210 Preliminary Observation 210

of Coordin:Jlion ImpaimlCnl'i 198 Cerebellar Palholog) 198 Basal Ganglia Pathology 199 Dorsal Colunm-M~dial Lemni...cal Pathology 200

The Coordinmion Examinalion 211 Recording Test Results 213

Age-Reluteli Changes Lmpacting Coordinated \I1o\'ement ~OO

Quantitalive Coordinarion Te~ting and Specialized Testing Instruments 218

Screemng 207 Examples of Screenings 208 Range of 10llOn 208 Strenglh

~OX

Sen~atlon

otor control b "the abilil} of the centml nervous ~yslem to conuol or direct the neuromotor system in purposeful mmemelll and po'\lur:.l1 adJU!o.tmcnI by selecti\e a1locatjon of mu\Cle len\IOn acrosS appropriate joint ~gments."l. p 688 Component... 01 motor control include normal muscle lOne i.Uld po"tural re"'pon~e mechanisms. !<>electi\e movement. and l.:oordJnatJOIl.· Coordination l~ the abilit} to execute ~rnoolh, culJr len ...ion In Jddltlon. Ihe) 111\ 01\ e appropflitle s) nergi~lJ(' lntluem:e,> lmu ...dc reLrulllnenU, ea ...) rt'\('r~JI hel\\l:en oppo~ing

CATSYS System 218 Postural Sway Analyzer 218 Choice Reaction TIme Analyzer 218 D)namic Post urography 218 Standardized Instrument,: Upper Extrcnllt) Coordinallon 219

208

FealUrc, of Coorliination TC:-:.13 20Y

M

Gross and Fine Mocor Movements 209

Summary 221

muscle groups (:.Ippropriate sequencing of contraction and relaxation), and proximal fixation to allow distal ffiOljon or maintenance of a posture."' Schmidt and Lee define coordination as the "behavior of t\\O or more degrees of freedom in relation 10 each other to produce skilled acrivily."5. p.4>-' CoordllllltiOIl impairments are characterized by a\\ kward. eXlr.1I1COUS, uneven. or inaccurate movements. Two terms often associ~veral general type:) of coordination. IlI1rahmh coordination refers to movements occurring within a &ingle lilllb7 ItJ (e.g.. altemalely tle'\.ing or extending the elbow; u>e of one upper eXlremil)' rUE] 10 brush Ihe hair;

194

Physical Rehabilitation

or motor pcrfonnance of a single lower extremity (LEI dur ing a gait cycle). Intcrlimh coordimuion refers to the integratcd perfonmmce of two or more limbs working together1.11-1~ (e.g.. altemately flcxing one elbow while extending the other; bilateral UE tasks as required during sliding transfers or dres~illg activities: or between limb movements of the LEs and/or UEs during walking). ViSllol1l101Or coordination'b--IR refers to the ability to inlegrare both visual and motor abilities with the environmental context to accomplish a goal (e.g., tracing over a zigzag line, writing a letter. riding a bicycle, or driving an automobile). A subcategory of visual motor coordination with important implications for ADL is eye-hand coordination ' 9--21 such as required for using eating utensils. personal hygiene, or reaching for a visual targel (e.g., a book from a shelf). Eye-hand coordination is perhaps more aptly termed ey('-hand-liead coordination because movement of the head is typically required for the eyes to fixate on a target or object. Physical therapists are frequently involved in management of patients with coordination impaimlents. Data from the examination of coordination infoml the therapist about existing impairments. These impainllents are often associared with functional limitations that are related to. and indicarive of. the type, extent. and location of central nervous system (CNS) pathologyY Some eNS lesions present very classic and stereotypical impaimlents. but others are much less pre dictable. Several examples of diagnoses that typically demonstrate coordination impairments include traumatic brain injury, Parkinson's disease. multiple sclerosis. Huntington's disease. cerebral palsy. Sydenham's chorea. cerebellar rumors. vestibular pathology, and some leaming disabilities. The Guide to PI1Jsicai Therapist Practice I includes coordination (togelher wilh dexterity and agilily) as a subcategory of Motor Function (Motor Control and Motor Learning) among the list of 24 categories of te~IS and measures that may be used by physical Iherapish during patient examinalion. In addition. the Guide 10 Physical Thl'l'apisT Pr(lcticc l includes coordination among the le!'-ts and measurelllelll~ identified for: all Musculoskeletal Praclice Paltem~, Neuromuscular PraClice Paltem~ A-H. and Cardiova~cular/pulmonary Practice Pallern D. The purpo!ooel'> 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<1tion is conveyed not only frotlllhe motor conl",\ to the .')pinal cord but also directly from premotor area::. at" \\cll. Although the cerebellum and basal ,ganglion are lIl\ohed in 1l10Vel~lent. they have no dire<:( output to the '1pinal l'ord. Ln'ltead. their effect 00 movement i'l prO\ ided via connectionl'> Iu the motor conex.!4 The cri"'.:al role 01 n~of) II1pllt on the motor system cannOI be ovtrt.'l11pha ilt'J. The intl;.'~ratioll of sensory input providc\ all illlcmal repre:..clllation of the environfl)t.·nllhnl infoTlll... and glliJ....... motor r~sponses.~ These sell· ...or) n:pre...entatlolb prO\ Ide the tOlllld:lIion on which motor prugr~nh for pllrpo~eful mO\ l'lllellb are planned. l'vorJ1Il3IeJ l1d implemelllc:d.' Scn'lor) IIlputto the rnOlor ' ) \11;.'111 guldt.· -.elel'lll.:m ~Uld adJpl~1I10n of motor responses ~h \\(.'11 .\... '1hi.lpe~ motor prugranh I"llf I..'orrn·tive action. For l'xUlllplc:. Ih.... ::-Oll1,th).')(;'lhOr) s}\tem pro\'ide~ the needed llltonnauon to adju:..t \l, al"lIlg when moving from a .'lll1ooth "urian: !(I ... n Llllt'Vcn Ic:rn.un; (0 maintuin standing balance on .... 1110\ 1l1~ bus: or 10 1ll.1J...t.' the n:quired adjustmenb 4

4

4

Chapter 7 Examination of Coordination

Precentral gyrus

Postcentral gyrus

Central sulcus

>-:....,;;::::;;~~~~POSTERIOR

Figure 7.1 Prima!)' areas of mQlOr conex involved in coordinated rno\ cment.

'" hen thro\\ iog a ball from a stable sitting surface (chair) \'ersm. an unstable one (Iherapy ball). To rule out sensory impairmenls as a contributing factor to coordination impainlll'nh. sensory tesling (see Chapter 5) should al",3ys precede the coordination examination.

The Motor Cortex The principal brain area involved in mQ(or function is the motorconex. which comprises cortical (Brodmann's) areas 4 and 6 located in a demarcated area of the frontal lobe called the precenrraJ gyrus (Fig. 7.1). However. planning coordinated mO\'cment to accomplish a task involves many areas of the neocortex as it requires knowledge of the body's position in space. the location of the intended target. seleclion of an optimum movement strategy (i.e.. which joints. muscles, or bod) ~gmenb will be used), memory storage until time of e~ecution. :lfld spe:cilic instructions to implement the movement Mrategy selected (where to move or what to do).lJ.25 Brodmann's area 4 is designated the prima!)' molOr rorte.\ (PMC) a~ II i~ the most ~pecific cortical motor area containing the largeM concentration of corticospinal neuTonsY' It Ile~ anterior to the central ~ulcus on Ihe precentral gyrus and controls contralateral voluntary movements. Brodmann's area 6 Iies just anterior to area 4 and is subdi\ided lOlO th~ superiorl) placed supph'memary motor area (SMA) Jnd the Interiorly positioned premOlD,. area (PMA) ~- Tht: SMA give~ rise to axon~ that directly inner· vate motor unil~ II1volved in initiation of movement. simullaneou~ hllaleral gra~ping movemenl~, sequemial tasks, and unenlillloll of the eye~ and head. Th~ PMA provide... lOpUI 10 th~ relJculo~pinal n~urons innervating motor unlt~ Ihall()J1Irollrun~ and proximal limb mO\emenb and can· Inbute~ 10 anlll'ipalory pmtural Chi.U1ge~.~'·2K,29 Slimulation of <JrC
195

6) evokes more intricate coordinated movements involving . multiple joints,2-5 The somatotopic organization of the motor cortex IS very similar to the sensory cortex. The motor homunculus schematically illustrates the amount of cortical area devoted 10 motor control of 3 given body pan or region (Fig. 7.2). Beginning on the lateral aspect of the homunculus, the mouth and face areas are represented: moving upward are areas devoted to the hands. trunk, LEs, and feet. Note that areas requiring finer gradations of control such as the fingers. hand. and face (including muscles of speech) occupy a disproportionately larger representation (approximately half) in the motor conex. The SMA and PMA are similarly somatotopicallyorganized. The motor cortex receives information from three primary sources: the somatosens01Y corlex (peripheral receptive fields), the cerebellum. and the basal ganglia. Somatosensory input is relayed directly to the primary mOWr cortex. from the thalamus (e.g., cutaneous tactile sensations. joint and muscle receptors). The thalamus also relays information to the motor areas from the cerebellum and the basal ganglia. These connections allow for integration of motor control functions of the motor cortex, cerebellum, and basal ganglia (i.e., to carry out the appropriate course of motor action).30

Descending Motor Pathways The most important descending pathway of the motor system is Ihe corticospinal (pyramidal) tract which transmits signals from the motor cortex directJy to the spinal cord. h is among the longest and largest CNS tracts. It originates primarily in areas 4 and 6 and passes through the internal capsule and the brainstem. The majority of fibers then cross to the opposite side in the medulla and descend through the lateral corticospinal tracts of the spinaJ cord. The fibers that do not cross at the medulla fonn the ventral corticospinal tTacts, but the majority of these eventually cross to the opposite side in the cervical or upper thoracic regions. All fibers of the corticospinal tract tenninate on the intemeurons of the cord gray malter. The corticospinal tract is concerned with skilled, fine motor control, especially of the dist'll limbs. 30,J' The other major descending motor pathways used to control neurons innervating muscle include: Corticobulbartracl: Some fibers projec( directly to mOlOr cranial nerve (CN) nuclei (e.g.. trigeminal, facial. hypoglossal), and others to the reticular fomlation before reaching cranial nerve nuclei. Tectospinal tract: This relatively small tract projects to mOlor neurons in Ihe cervical cord; fibers intluence neurons innervating nec~ muscles as well as the spinal accessory nucleus (CN XI); important in guiding head movemellt~ during visual motor lasks. Rellculospillal Iract (medial Jnd lateral): Projects to the anterior hom of the spinal cord; important intluence on muscle tone and retle>.. activily via influence on muscle

1%

rt" flou.1 Itf h.h.l,t.a.t.,n

•

4>s J w

~, lateral

S'fI.'b'

~

,.1

Figure 7.2 The motor homunculu, indicJlelllhe

..,omatl)lrophll: organization of lhe motor cone" The rcJjll\c .,IZ.... of hod) p~ln"l rcl1ect~ the proporlion of the motor cone" de\Oled to controlling that Jrca. ",plllltle actl\ It) (I!lcrca'llllg or Jec..'rea,ing 'lensitl\ it) ): Ihe JXlntln~ (mcdIJI) relKlIlo~plllal (ral"t facilitate ... c\ten'IO!l of Ihe LE~ «('\cIlJtlon 01 e\len ...or motoneuron,) aug· m\.'nllng antigr'l\ Jl~ rdkxe') of the ... pinal cord: lInport~lOt mlluence on po'lrure and g:UI. The medullary (lateral) rellculo'lpll1JI Ir:I(.'1 ha... the re,er...e cfftci (c'\(:ilJ,tion 01 lll'\or mOIOnl"uron,). Ve"tlhulo pmal tr
Cerebellum Tht' pnm:u) IUl1l'1I0!l of the cerebellum I~ regul<slloll 01 mmemelll, pO"lural control. and lllu ...c1e lonc. Although all

01 the me(;h~ml~lTI:-'

of cerebellar function arc not clearly

under,t()od, le,iol1"l h:t\'e been noted to produce typical pJuem" of impaired motor function and balance, and decre:l'oed mu..t1e lOne (!o.ee section titled Cerebellar Pathofog.\ ).

Se\ craltheorie:-. of function of the cerebellum in molor acm il~ ha\e been established. Among the more widely held I... that the cerebellum funclion ... as a comparator and ermr-( orreul1lg mnhal1i:wl. 15 ,'1 The cerebellum compare., the commands for the imellded movement transmitted from the motor corte" wilh the ilulial motor perform· ;lnce of the bod} segment. Thi" occur:-. by a comparison of infonnation received from the corfex with that oblained from peripheral feedback mechanl\ms (termed feedforIl an/ nJnlro/). The motor cone\. and brain~tem motor structures prmide thc cOll1lmtnd~ for the intended mOlor re:-.pon~e (internal feedback) . .l~ Peripheral feedback duro Illg the motor re"'pon:-.e i... prm'Jded by muscle spindles, Goigi tendon organ .... jOIJ1t and cutaneous receplors. the ve ...tibular apparatu:-., and Ih~ eyes :md ears (external feed· bad,). Thi ... feed bad, prO\ide~ conllnual input regarding pO~lure and balance, as \~elJ:l\ po\ilion. rate, rhythm. and force of ... Iow mOVCOlclll'" of peripheral body segments. If the Illput from Ihe feedbac~ "y!',tcm:-. doe1lo not compare

Chapter- 7 Examination or CoonJination

appropn:l\cly (i.e .. movcments deviate from the intended command). the <:crebcllum supplic.. 3 corrective influ· cncc. Thl~ etTecl .... achic\cd by corrective sIgnals ~enl to the cone.\. \\ tllch. via motor pathways. modifies or correel'. the ongoing movemcnt (c.g.. increasing or decreasing the level of aClIvit)' of specific mU'ic1es). The cerebellum al ..o functions lO modify cOrlical commands for subsequent movemenl ... l~,ll Thi~ eNS analy~i .. of movement infom13tion. delennination of Ie"el of accuracy. and provision for error correction i.. referred 10 a~ a closed-loop system. Schmidt and Lee define thi .. model as. "a control system employing feedback. a reference for COITcctness. a computation of error. and subsequent correction in order 10 mainlain a desired stale:·\· p-462 " should be noted thai nO( all movements are controlled by thi~ system. Stereotypical movements (e.g.. gail activities) and mpid. !'>hort-duration movements. which do not allow sufficient time for feedback to occur. are believed to be controlled by an open-loop s~'slem defined as "a control system with preprogranlmed instructions to an effector that does not use feedback infonnalion and error-delection processes:·s. p-466 In thi~ system. control originates centrally from a motor program. ,\ hich is a memory or pre programmed pattern of infonnation for coordinated movemenl. The motor syslem then fol1ow:-. the established paltem largely independent of feedback. or error-detection mechanisms. Motor programs can be called up in their entirety. modified. or reassembled m a nev. order. They provide the important function of freeing higher executive levels from attending to all aspecls of a motor re:.ponse.

Basal Ganglia The basal ganglia are a group of nuclei localed at the base of rhe cerebral cOrlex. The three main nuclei of the basal ganglia IIltiude the caudate tlucleus. Ihe pll1ametl. and rhe glohl/\ pallidus. The:.e nuclei have c1o~e analomical and functional connection!' with two other subcortical nuclei that are al\o frequellll) cOIl:.idered as part of rhe basal ganglia' the suhthalamic nllc/ells and the .wJHtalllio 111;':'0 -- :>~

Although the Illfiuence:-. of the ba:-..tl gangli<.l on movement are nOI under')tood a... clearl) a!, those of the cerebellum. there ,.. e\ Idence that the b~al ganglia pIa) an imponanl role In ..,e\ eral n)mple... a~pecb of movement and po:.tural control 111t''>e IIKludt: the lnlllation and regulation of gros!o> IntentlonaJ mmemenh. plannmg and execution of complex mutur re"'j>lm:-.e... fdt'lillatioll of dC\lred motor re:.pon~~ \\hllt' ..dnl1h:l) IIlIHbltmg other:.. d.nd lhe abllil)' to :lccompll"h JUhlrnatic Illo\'emcnb and po"tural adJu:-.lments..,lI.,+-..ll, In addition. the ba.. aJ ganglia plJ) all IInportanf role in mamtJ.uung nonnal bad-grounJ mu...clc lone. Thl~ h 3C<:01llph~hcd h) Iht' mhlbltoT) eNeel of the ba:-.al ganglia on both tilt: mOUlr t,:l)f1e", d.nd 10\\ er bn.Llll:.tclll. The ba:'J.1 gangli<.l al ..o ..tre belll'\t"d to mt1uenl't~ \omc ..:-.pt:(I~ ofbolh pen.:eptur,l1 and I..ogIIHl\t:' lUll\,. 11011'>. ~

197

Supplementary motor area Motor cortex Somatosensory / cortex ,./ Superior parietallobure

Ventral lateral nucleus

Subthalamic nucleus ,

/ Substantia nigra: Compacta Reticulala

Putamen

Figure 7.3 The mOlor circuit of the basal ganglia provides a subconical feedback loop from the motor and somatosensory areas of the cortex. through portions of the basal ganglia and thalamus. and back to the cortical molor areas (premOlar cortex. supplementary mOlar area. and mOlar cortex). (From Ghez. C. and Gordon. J.-17. p ~8 with permission.)

The mOlor portion ofthe basal ganglia assumes a somatotopic organization. The analomical positioning of the basal ganglia provides insight into its contribution to mOl or performance. The areas of the brain associaled with movemelll (primary mOlor cortex. supplementary motor area. premOlor area. and the somatosensory cortex) fonn dense projections to the motor portion of the putamen. Output of Ihi:-. pathway fomls the motor circuit of the basal ganglia. "hich is directed back to the supplementary motor area and the premotor area. These two areas and the primary motor cortex are all inlerconnected. and each has descending projections to Ihe brainstem motor centers and spinal cord. This anatomical arrangement indicates that Ihe influence of the ba~al gangli~t on motor function is indirect and mediated by descending projections from the cortical mOl or area:..~-4·'5.17 Figure 7.3 schemalically illustnlles the motor circuit of Ihe basal ganglion.

Dorsal Column-Medial Lemniscal Pathway Rt'gulatlon of mO\emenl IS dependent on sensor) afferent Inform~uloll. Peripheral somalo:.ensory receptors and path\\ a)''S provide infonll
198

Ph~"iicaJ

Rehabilitation

encoded and cOIl\c)cd to \ariou'\ parc5. of the eNS. The data are prcx:..: ..:--ed ba,cd on peripheral feedbad. and mcmory. which lead:-- to ..election (or modification) of a 1l10\cmcni strah::gy appropriate 10 the ta~J... deJ11and~ and ..:nvironmcntal condition~. The dors;.11 column-mcdi:.J1 lemniscal pathway is particularly important 10 coordinated movement a~ it is respon,ible for the afferent transmi~sion of discriminalive senSJ* tion~. Sen..ory modalities thai require tine gradations of intcnsit) and precise localization on the body sulface arc mediated by thIs system. Sensations transmillcd by lhe don.al column-medial lemniscal pathwa) include discriminative lauch. stereognosis. tactile pressure. barognosis. graphesthesia. recognition of texture. kinesthesia. (wopoint di~criJ11inalion. proprioception. and vibration. This system is composed of large, myelinated, rapidly conducting fibers. After entering the dorsal column the fibers ascend to the medulla and synapse with fhe dorsal column nuclei (nuclei gracilis and cuncatus). From here they cross to the opposite side and pass up to the thalamus through bilateral pathways called the malial lemnisci. Each medial lemniscus terminates in the ventral posterolateral thalamus. From the thalamus. third-order neurons project to thc somatic sensory cortex.

Features of Coordination Impainnents As the cerebellum. basal ganglia, and dor~al columnmediaJ lemniscal pathway provide input to. and act together with. the conex in the production of coordinated movement. lesions in an) of these areas impact higher level processing and execution of coordinated motor responses. Although it is incorrect to as~ign all problems of incoordination to one of Ihese siles. lesions in these arei.l~ arc responsible for many characteristic motor deficits seen in adult populations. The following ~ections pre~enf un overview of common clinical features as~oci
Cerebellar Pathology A number 01 ... peclfic motor Impamnel1ls that imp<Jct coordin~lIed

mO\cmem are as~oClated with cerebellar palholo-

ID. '~--44 Man) of the~e impainnent'\ either directly or indi. n:ctl) influence the patiel1l\ ability 10 execute accurate. ..momh. controlled 1ll0\emenh. The mOlor dclicih idclllllied empha!ooi/e the crUCial Influence of the ccrt:bellul11 un cljudibrium. pO:o,turc, mu~dt: lone, and initiation and force 01 movement. Ataxia i~ perhap:-. the mo .. t COlllmun term u~ed to de::.crilx mOl or Impalnnenh of l:crebdlar Ofll!ln. Cerebellar at:V.Jd I~ a t!cncral. u)mprehClhl\e term u~ed 10 de::.cnbe lo... ~ 01 Jl)u~de coordlll.la Illay alleet galt. pt>'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 llwgul
Chapter 7 Examination of Coordination irTe~ular. and ...13ggcring. with dcviations from an intended

linc of progre~~ion (vcering to one side; swaying or pilchlllg in different direclions). H) pUlOnia j" a dcne;:l~e in muscle lone. It b believed In be related to Ihe di'ruption of afferent input from siretch rC:Cl'plOr, and/or lad. of the cerebellum \. facililatory efferenl mlluen<.'c onthc [u ... imotor "'Y'ilem. A diminished re",istance 10 pa,... i\c mO\CJ11ent \\ ill be noted. and muscles may fed abnonnally ,oft and llaccid. Diminished deep tendon rellc\e, abo may be noted. '': [01\\ ard

CI J.\IC \1 \Orr

\{f(T tntl/!.!!, ,!Ie patellar lelldo1/ jerk a 1101"11101 ,\II/~icCf. "ll' /"I/(}t.' '."I,i(011.\ rdllm,\ JI/IIIJl'duucl\' '0 !hl' (C"tlllg s,art.'. IVi,h cere/ld"l1 f,(/!h(llrJ~,\. the /...11('(' /ll1I\' lI.\ullott' siJ (() eight 1;11/('S "I·fi./"(' l"t',urllifl~ to re,'! I~' ll'ilh {I

rcf7n

1/(I1I/111{'/" III

N)sfagmus is a rhythmic. quick. o~cillalory. back-andforth mo\emcnl of Ihe e)e~. 11 i... Iypically apparent as Ihe e)e~ mo\/? m\a) from midline 10 fix on an object in either the medial or lateral field (Le.. extremes of temporal or na.-.al \i"on).-U> The patient ha~ difficulty holding the gaze on Ihe obJcct 111 the peripheral field. An involuntary drift bad. 10 Jl1ldlllle \\ ith il1lm~diate relUm to Ihe object may be oh..ened_ 4 - N) ... tagmu~ cause ... difficuhy with accurate fixatlon and ,i... lon and i!o. believed linked to the cerebellum's inlluencC' on '1j nerg) and tone of the extraocular muscles. Rebound phenomt:non. originally described by Holmes, I~ Ihe 1o..... of the check retlex:~.'i or check factor. which function.. 10 halt lorceful active rno\emcnt, when resiswncc is elll111naled. \Jon11allj. \\ hen applic<.Ition of rc~islance to an bomctnt,· lontraclion i'l ~uddenly removed. the limb will renmll1 In approxllnalCI) the ..ame po~ilion by aClion of Ihe OprKNng Illu...lleb). For C'\amplc, in appl) ing re~i~l~lI1ce to an I ...Ol11l:tn( l·unlractlon III Ihe middle range of elbow nexion and then rdeJ"lIlg II \\!thout \\~trning. Ihe intact subject \-\ill "cheI.J,: or 'lOp the mOlion 4UICU) Ihrough aCli\:.ilion of the 0pJX""n!! In... er'" ~I'" \\ ell .1'" Ieedbad.. regardmg Joint po~Jlion and lorIo-to: rc4ulred 10 pre\ent further 111011011. With cerebellar m\Ohl:l11Cnl Ihe p~tllent '" unable 10 IUp the motion. and the Illllh \\ III 11 ,>uddenl) \\ 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......<)(,'lateJ \\1111 cl,'rt'lx'lJar 1I:""ol1.,:\n illt~ntiun" or t..int'tit,. Irt:'ltlor occur.., dunng volUJlltlr~ rlltllll,n of J limh
ii''''·

II) 1I/IIh.ltl'JIll\I'II.'-III~ rdt'l-' hi rh~lhnllll)'>LIiI
hl:dtll 1,ll·(' .... llk lor\\..tIJ .tUO h.I\.I..\\.uJ orlht') Ill.l) h..th'

199

a rolary componenl); however, the lerm is also less frequently used to refer 10 axial involvement of the trunk. In addition Lo these characteristic clinical features of cerebellar involvement. a greater length of time may also be required to iniliate voluntary movements (delayed reaction lime). Difficulty may also be observed in stopping or changing Ihe force, speed, or direction of movement. 24 Motor learning will also be affected. Recall that the cerebellum compares Ihe intended movement (internal feedback) with the actual movement (external feedback). For subsequent movements, the cerebellum generates corrective signals to reduce the errors (feed-forward control). Lack of this feed· forward control is responsible for deficits in mOlor learning and coordinalion.

Basal Ganglia Pathology Patients with lesions of the basal ganglia typically demonstrate several characteristic motor deficits. These include (I) poverty and slowness of movemenl: (2) involuntary, extraneous movement; and (3) aherations in posture and muscle tone. 28.-lj Thus, patients with basal ganglia involvement present on a continuum of motor behavior from severely diminished as seen in advanced Parkinson's disease to excessive extraneous movements apparent with Huntington's disease. J5 The following motor impairments are manifestations of basal ganglia pathology:~8--.56 Akinesia is an inabiJity to initiale movement and is seen in the late siages of Parkinson's disease. This deficit is associated wilh assumption and mainlenance of fixed postures (freezing episodes). A tremendous amounl of mental conccmfalion and effort is required to perform even the sim· plest mOlor activily. Athetosis i~ characterized by slow. involuntary, writhing, twisling. "wormlike" movements. Frequently, greater involvement in the distal UEs is noted'1; this may include tluctuation'i belween hyperextension of the wrist and fingers and a return 10 a fle\.ed position. combil1~d with rotary mo,"emenb of the eXlremities. Many other areas of the body ma) be involved, including the neck, face. tongue, and Inllll. The phenomena are also referred to as atheloid mO\"emenl.!!. Pure athetosi\) i;') relatively uncommon and most often presel1\~ in combinalion \\ ith spaslicity. Ionic spasm.!!, or chorca. Alh~losi~ ran be 3. c1inir<.tJ fealure of some fornls of r~II.;bral paby. Bradykille~i:l i~ il decreased amplilude and velocity of Hlluntary movt'ment. It Illay be demOJ1~lraled in a variety or \\ a) s, SUdl 3."- a decrea~c:d aml ;')wlIlg; .. 10\\, shuffling gait: dillicull) Illltl .• llng or changing direction of mo\ emem: lack l)t facial c: . . pre ...... ion: or (illliru!ly ~IOpplllg a nlO\-ement once bt.:'gun: dlaf'.ll,lcn...uc uf Parl.m~n·'S di..e~. ChOrl"'3 I... 1,.-h.traClellzed b) lfl\'olunlaJ), rapid. irregular, ..tnd jerl..) 1110\ C:It1('1I1'> 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 coordm<.ition IInpalnnenh a\\ocialed wilh patholog) 01 the cerebellum and basal ganglia.

Dorsal Column-Medial Lemniscal Pathology Coon.llnJtlon lmp•. unnenh a..,...OCI <:I1.lr· <.lCh:fl\11l liMn Iho... t: producc:d h) ellha It'r~bell.if or hih.tl ganglia palhulog) Lt ... ion 01 llll: OCr..IL I) pll<.lll) re ...ulllll <.:oorJlIlilllnn and tquilJl1fium IlIlpaml1tnt ... related 10 the pallent :-, lad. 01 Jolnl pO... lllon . .en\1:' .ll1d ;llAarenc...... of 11100'C. men!. ..lI1d Impam:d IOLallLcLi tOUl.h ...en ..,lllllll RClali (hJI

this a'icending pathway carries the peripheral (external) feedback required for feedforward control. It mediates sen~ations critical to coordinated movement such as proprio-ceplion. kinesthesia. and discriminative to~ch. . DislLlrbancc.!l of gait are a common findmg wnh DCML pathology. The gail pattern is usually wide.~ased and "waying, with uneven step lengths and excessive lateral displacement The advancing leg may be lifted too high and then dropped abruplly with an audible impact Watching the feel during ambulation is typical and is indicative of a proprioceptive loss. Another common deficit seen with DCML pathology is dysmetria. As mentioned. this is an impaired ability to judge the required distance or range of movement and may be noted in both the upper and lower extremities. It is manifested by the inability to place an extremity accurately or to reach a target object. For example. in atlempting to lock a wheelchair brake, the patient may inaccurately judge (overestimate or underestimate) the required movement needed to reach the brake handle. Fine motor skills may also be impaired owing to alterations in discriminative tactile and object recognition abilities. Because vision can assist in guiding movements, maintaining balance. as well as improve accuracy of discrimina· live (asks. visual feedback can be an effective mechanism to compensate partially for DCML pathology. Thus. coordi· nation and/or balance problems will be exaggerated when vision is occluded or when the palient's eyes are closed. The inability 10 maintain standing balance with the feet together when the eyes are closed is tenned a positive Romberg sign and is usually indicative of proprioceptive loss. Visual guidance will also reduce the manifestations of d)smetria and diminished tactile perception. However. some noticeable slowing of movemenls may be observed as visually guided motions are generally more accurate when speed of movemenl is reduced.

Age-Related Changes Impacting Coordinated Movement Ahernrion III Iht.' abtlil) 10 e\ecure smooth. accurate. con· trolled mOlor r"'\pon~e\ {)(·lur... \\ ith nonnal aging. The 1Il1pol1anct: 01 under~tanJing Ihe ba~is of these changes is rcn~cled in Iht t:~pandino b<xlv of literature devoted to . . l:'. eXalllllllllg \ilnuu~ a",pcl'h. ot molor perfonnance in older 1ll1 adulh. ~1 Thl\., "'l'l:lion prt.'\enb an mer. lew of the mo:.l ,.tllent age-J.....\...k.IJh:Li l·h.mge, Impactmg coordinaled mo\e· melll E\ Idellet' SUnllllJ.f) 80\ 7.1 prC'\e~lb ~pecific fmdings trom ...Ill(!ln t'\plonng the ImpJ.l'l of aJ\ Jlll'jng age on ('oor· dlll..lh:d IllO\ en1enl For J. more ('omprehen~i\e pe~pecti\'e 011 ,h(" phY.'>lologlcal. nt:ur~)logl\.'aL .1Ild musculobkeletal dHulg~ ... a%on ..iled with aglllg. the reader b referred 10 Ihe \\or'" 01 BOllomk'y and Le\\I,:>.~1i Splfduso et al.~ and LI."\\I~.~"

Chapter 7 Examination of Coordination

201

Table 7.1 Common Coordination Impainnents Associated with Pathology of the Cerebellum and Basal Ganglia

Cerebellar

Paidlh~G:i':l'CY;;":::-;;;;;;;=~~~I!!!!!III!~~~~~~~

Asthenia

Generalized muscle weakness

AsynergIa

Loss of ability to associate muscles together for complex movements

Delayed reaction lime

Increased tIme required to Initiate voluntary movement

Dysarthria

Disorder of the motor component of speech articulation

Dysdiadochokinesia

-

Impaired ability to perform rapid alternating movements

- - ---'-----'---'----'-----=-----------

Dysmetria

Inability 10 jUdge the distance or range of a movement

Dyssynergia

Movement performed in a sequence of component parts rather than as a single, smooth activIty; decomposition

----Galt disorders

Ataxic pattern; broad base of support; postural instability; high-guard position of UEs

Hypotonia

Decrease in muscle tone

Hypermetria

Overestimation of distance or range needed to accomplish a movement

Nystagmus

Rhythmic, quick, oscillatory, back-and-forth movement of the eyes

Rebound phenomenon

Inability to halt forceful movements after resistive stimulus removed; patient unable to stop sudden limb motion

Tremor

Involuntary oscillatory movement resulting from alternate contractions of opposing muscle groups Oscillatory movement during voluntary motion; increases as the limb nears target; diminished or absent at rest Exaggerated oscillatory movement of the body in standing posture or of a limb held against gravity

- - - - - -Underestimation ------=------'-------of distance or range needed to accomplish a movement Hypomelna

• Intention (kinellc) • Poslural (slatic) Titubation

Rhythmic oscillations of the head; axial involvement of the trunk

Akmesla AthetOSIS

Inability to initiate movement; associated with fixed postures

------c:::-

Slow, involuntary, writhing, twisting, "wormlike" movements; frequently greater involvement in distal UEs

Bradykmesla

Decreased amplitude and velocity of voluntary movement

Chorea

Involuntary, rapid. irregular, jerky movements involving multiple joints; most apparent In UEs

Choreoathetosis

Movement disorder with features of both chorea and athetosis

Dystonia (dystOniC movements)

Sustained involuntary contractions of agonist and antagonist muscles

Hemiballismus

Large-amplitude sudden, violent, flailing motions of the arm and leg of one side of the body

HyperkIneSIS

Abnormally Increased muscle actIvity or movement

HypokineSIS

Decreased motor response especially to a specifiC stlmulus

Rigidity

Increase In muscle tone causmg greater resistance to passive movement; greater in flexor muscles UnIform, constant resistance as 11mb 1$ moved Series of brief relaxations or "catches" as 11mb IS passively moved

• leadplpe Cogwheel Tremor (restlng)

----------------------

----,,------,------,---------

-- - ------------

Involuntary, rhythmiC, oscillatory movement observed at rest

202

Physical Rehabilitation

Evidence Summary Box 7.1 Research Exploring Age-Related Changes in Motor Coordination Reference

Purpose

Subjects/Design

Results

Conclusions/('ommt>nt..

Capranica, l,62 2004

To examine varialions in homolateral interlimb coordination across the lifespan; To determine whether in-phase (pairing wrist extension with ankle dor· siflexion; and wrist flexion wjth toot plantartlexion) and antiphase (pairing wrist flexion with ankle dorsiflexion; and wrist extension with ankle plantarflexion) coordination and frequency influence performance differently in young/old populalIOns.

n subjects divided into 4 age

Age showed a significant effect on lime of correct execution, except for insignificant changes from young/old to old. Most older aduns shifled to in-phase mode within 10 seconds when performing antiphase mode regardless of trequency. Older subjects displayed increased tnal-to· lrial variability.

Age, mode of coordination, and movement frequency should be considered dunng examination 01 coordination; authors suggest additional research is warranted to determine if interlimb coonination can be more successtuNy maintained in older adults; moderate sample size.

Desrosiers, J, et al.63 1995

To develop normatrve data for the TEMPA (a UE performance test for the elderly); To assist chOlcians uSing thiS test to differentiate between normal and pathological UE performance. To correlate UE performance with personal vanables lOcludlng age

360 subJects, 60 years and older, stratified for age by decade. The TEMPA administered together with a battery of tests measuring gross and manual dextenty. The TEMPA consists of 13 Items deSigned to test multiple aspects of UE pertorrnance. Each task is measured based on length of execution, functIonal rating. and task analysis. Functional rating is based on a 4·level scale accordlOg 10 Hldependence; task analySIS quantIfies difficultIes according to five dImenSions related to UE skJlI An mtervlew was used to determme vanables potentially related 10 UE pertormance.

All subjects obtained per· fect scores in the functional rating and task anaJySls sectIOns of the TEMPA. The length of most tasks increased significantly WIth age exponenbalty. Vanobillty within length of execution increased with age as well. Age, sen·perceived health, and current actiVIty level were the best predIctors of UE performance. Women pertomned tasks related 10 dextenty faster than men, while men performed tasks related to gnp strength faster than women There were some correlations between the senslbtllty tests and pertormance on the TEMPA

In subjects who are active, ~ is diff",ult to tell whether their UE pertorrnance is better because they are active, or they are active because at better UE performance. Endurance is not related to the TEMPA because the tasks are generalty short and not repeated. ThiS study may noI be representative of all healthy elderty people, and is certainly nol representative of the eIdetly who have pathology affec1ing the UE large sample SIZe.

Harney. AA'" 2001

To explore the poSSibIlity of an agerelated reduction In !he ability to generate and execute 2 Similar motor programs

22 younger adults (mean 19 years) and 22 older adults (mean 76 2 years). Self·report 01 health status adminIstered together With a lest for spatial acuity. Several tramlng trials conducted CoIor·juclgmenr

Task 2 reactron hmes Increased for aU SUbjects as stimulus onsel bme decreased, more so for older adults than for younger adults when both tasks required a manual

The authors note that findlngs can be Interpreted several ways.. Increases In task 2 reactIOn In'lII With shon sbmulus onset _ may occur oWing to factofS slemmlng tram Task 1that atlecl processing poor to response

groups: children (25, mean 10 years); adults (16, mean 22.9 years); young/old (21, mean 67.6 years); old (IS, mean 78.9 years). SUbjects were seated on a table with the elbow and knee flexed to 90°. SUbjects performed flexion and extension movements around the wrist and ankle at a 1:1 ratio for 60 seconds (homolateral). Movement was tested in-phase (iso-direclional) and antiphase (nonise-directional). Each test was performed at3 metronome paced trequencies: 80, 120, 180 bpm. Total time of correct movement was recorded by one observer.

Chapter 7 Examination of Coordination

203

Evidence Summary Box 7.1 Research Exploring Age-Related Changes in Motor Coordination Reference

McGibbon, CA, and Krebs, DE."

2000

Se,I,,"' . Dollnn RD el al

1998

Purpose

(CQlllintu.."
Subjects/Design

Results

Conclusions/Comments

task-letter Xpresented on a computer screen in white, after 500 msec color changed to yellow or blue. SUbjects identitied the change by pressing a key, stimulus remained until key was pressed or after 1500 msec. Tone-judgment laskprocedure identical except that stimulus was a 200-msec tone. LeNer-alone task-similar to color judgment task, except that X changes to the lener B or D. Identification was either signified by a manual response (key press) or oral response (saying the name ot the leller). Dual task lesling-task 1: tone/color discrimination; task 2: manuaVoral response to letter-identification task; stimulus onset time varied (50. 150, 500, or 1000 msec) aller color changed or tone sounded.

response. ReactIon times increased more when task 1 was color discrimination (both tasks required visual input).

selection in Task 2 can begin. There may be a lim~ed capacity for generating sim~ar motor responses, a capacity that is reduced in older adults. While reaction times increased when both stimuli were visual, this was not due to aging. Relatively small sample used tor data collection.

To explore If aging in healthy adults affects the kll"l€matlc coordlnation 01 the lower trunk during ga', and examine dthese changes are modulated by age-relatoo changes In ~nemalJc ga" parameters (wallung speed, range 01 roovement) To exarrune d alterabons In sagittal plane lower trunk coordlnatlOn with agong is a resub 01 flexor/extensor muscle ooor<>naboo

93 healthy subjects divided into two groups. 49 age <50, 44 age ~ 50. SUbjects performed several level-surface walking trials at self-selected speed, lor 10m, bareloot. Force plates detected GRF; 11 body segments tracked u~ng LEOs. segment 3-D movements were recorded, and segmenl mass. COM, and mass movemenl-of-lnertaa were computed Angular velocrty and phase shift angles were observed In the sag,tlal plane

Young subjects walked faster per unit height than did older subjects. Low back flexion ROM was high in young subjec~ Ga, speed Hlcreased moderately with age overall Phase shift s~ nlflCantly increased WIth age (elderly subjects lead pelvIC mollOn WIth their lrunks). Galt speed and loW back ROM do not ~gn
Data suggest a reversal in phase relationship of the trunk occurs with aging, wh~ indicates a reversal in muscle lengthenIng and shortening sequence In the low back musculature. The trunk leading strategy employed by the elderly resulted in an increase In mechanical energy demands of the low back mUSCIJlalure; rmderate sample size

To determIne whether elderlt persons exhibit ,ooprocal phaSing of muscle act!vlty and scale EMG burst amplJtude In the same manner as young peeple

7 subjects (mean age 72 3 years) 7 subfects Imean age 243 years) SUbjects grasped a lever WIth the elbow alief a pIvot POII'll rotations produced by elbow flexIOn and extenslOO displayed on a computer Home posItIOn was 50· from tull elbow ell.lenSlon target poSItIon 3(} of elbow fleXIOn Visual Input

Elderly rtllssed required bme w.mw mo<e Irequently a' each load level Too fast too slow lime fatlO was sImIlar tor both groups elderly lA:ere slightly more prone 10 being 100 slow No dIfference In the average lInle of counted tnals Stgnlhcant age dlffe,ence

Elderly group proved to be less accurate oyerall In attaIning movement goal Elderly group showed decreased ab
---

(continued)

204

Ph}'sical Rehabilitation

Evidence Summary Box 7.1 Research Exploring Age-Related Changes in Motor Coordination (~n,;",.ed) Rl.·fl.,rt."nce

Semen. OJ, et al,73

2000

Shkuratova N el al 7. 2004

PurpOSl.'

To investigate agerelated modifications in in-phase and antiphase coordinalive movements and determine their relative stability. To determine if differences in performance between homologous/nonhomologous limbs eXist in older adults.

. . Subjects/Design

Rcsu I ts

removed by placing a cover over arm and lever. Movement paced by a melronome (800 msec target time for each phase). 3 blocks o( 50 lrials; each trial block had a dlfferenl load applied to arm (no load. .75 kg. 1.5 kg). EMG electrodes placed at the biceps brachii and medial head 01 lhe triceps. 650 msec-980 msec was the reqUired time window for the trial to be counted.

lor acceleration! deceleration phase ratio (elderly achieved peak velocity later in motion than did the younger group). Agonist contraction was prolonged In the elderly, elderly were more likely to co-contract.

6 younger (mean age 24 years) and 6 older (mean age 75 years) part~lpants in good health, involved in daily activities and hobbies. SUbjects seated in a chair; limbs attached to levers that allow sagittal plane movement. SUbjects asked to perlorm cyclical flexion and elctension movements for two limbs at the elbow and knee at a pace provided by a metronome. Six performance conditions included: homologous (uppernower extremities), homolateral (righll1eff side). and heterolateral (righl UEneff t.E. left UEiright t.E). In·phase and antiphase movements were included. lntertimb coordmatlon determmed by Jomt angle between the two movmg limbs DeVIation Irom lhe Intended angle and Ihe peak of lIexlOfl!extenslOn was measured (accuracy), and WIthIn lnal vanabihty was measured (stability). Cycle duratlOll and amp!ltude were measured

Accuracy and slability did not differ between young and older adults lor homologous conditions; they deteriorated for the older adults during homolateral and heterolateral condition, more strongly for antiphase movement. Quality of performance was similar for young adults on nondominant side, decreased for older adults. Older adulls produced slower cycles Ihan young adults. Young adults increased amplitUde during antiphase, while it remained the same lor older adults. Temporal and spallal vanability were Increased for older adUlts. 250 0 of trIals by older adults displayed a transItion to inphase movement when anllphase was 100!tally required

20 healthy older adults (mean 71 5 years) and 20 young aduffs (mean 253 years) Performance compared between groups In the loIlowIng tasks 11) straight hne walking al preferred speed (2) stralghl hne walking al laSI speed (3) figure-ol-etght ~alklng at preferred speed; and 1411lQule-ol-elght wal~ng while performmg a secondary molor

Young adults II1Creased their wallong speed and stnde length to a greater exlent than did older adults when chaflQlng hom plOlerred speed to 'ast speed All subJects SIgnIficantly decreased theu walking speed slode length. and cadence When changing Irom stralghl line walking to walking and lum-

-:----:-:

To determine If older people adapl steppIng behavK>r drfferently than young people In response 10 vanous balance perturba· tlons dUring locomotion. To examme whether changes In gall parameters are

Conclusions/{'olTllTll·lIl ..

Older adults displayed decreases in perlormance depending on limb combination and coordination mode. These modifications can be a result 01 (1) deficils in afferent information processing for steering coordinated behavior and (2) declines in cognibve regulation, emerging from a deterioration of inhibitory mechanisms and reduced attentional monitoring of sensory leedback. Movement slowing may be an adaptive strategy to cope more successfully with more demanding task requirements, Of related to the lacl Ihat older adults rely more on VIsual cues, adding temporal constraints to adJustment processes; smatI sample size.

-----

Reduced speed and stnde Ienglh and Increased double support bme In okier adults are usualy Interpreted as age related adaptatIOnS to prodtJce gall that ~ saler and less destablhZlng QIder adults are usually more caubOUS and opllor grealer stability· smaI sample sIze

(hapter 7 Fxaminacion of Coordinalion

205

Evidence Summary Box 7.1 Research Exploring Age-Related Changes in Motor Coordination t<~';nu
Suhjects/De~ign

Result~

task specific and vary accordmg 10 types ot penurba· 1J0ns encountered.

task (Iranslemng COIns from one podIet to another). Stnde length, cadence, speed, and double support time were measured uSing Ihe CliOical Stride Analyzer. Walkways were mali<ed with strips of blue lape 150 mm apart. SUbjects were Instructed to stay within the hnes in order to appropriately ohal· lenge balance.

Ing. Both groups SlQIl!flCantly decreased stride length and increased cadence when changing 10 dual·task wal~ng. Older adulls showed higher cadence rates and reduced stride lenglh compared 10 young adults. Both groups Irans· ferred a SImilar number 01 coins. Older adults, to general, had a higher double support lime In all condibons than young adults.

Sparrow, WA, et al,~ 2005

To determine whether older indio viduals have more absolute error and greater metabolIC and cognitive cost when performing the same task as younger adults. To determine whether aging would affecl the capacity to learn Interlimb coordlnaMn tasks With extended practice.

8 healthy older men (mean 73.1 years) and 8 heallhy young men (mean 23.3 years) participated. Two arm-andhand ergonometers were positioned side-by-slde allowing the inside handle to be moved independently. Two metronome-paced conditions were measured: antiphase movement (1800 difference, in opposite direcllOns) and relalive 90" phase (one hand follows the other by a quarter cycle). A reaction time task was given by asking subjects 10 press a button after hearing a sound, done alone and dunng the cycling task. Oxygen consumption and carbon dioXide production were measured can· linuously. A retentlon test was done 1 week after the trials.

In the relative phase cond. OOn, the older adults were

ShJnohara M. et a~

To exarmne If changes In IndICeS of hnger interaction dunng maxlfnal force production

12 young (mean 289 years) and 12 eldeJ1y (mean 82.1 years) subjects par1JClpated, all subjects were healthy and nghl'handed An apparalus Wllh

Reference

2004

consistently farther Irom the target coordmalJon and as practice progressed they shifted even further from the desired phase. Young adults were consistently accurate in the antiphase movements, while older adults were inaccurate but improVed with practice. Older adulls had grealer dlfficuity producing the relative phase pattern, and had greater errors in perforrnance than young adults. Variability was greater for older adulls and did not improve with practJce. There was no age effect on oxygen consumptton, but older adults had Significantly higher heart rates. The younger group displayed a greater decrease in oxygen consumption and heart rate from acquisition tnals to retention tnals. Older adults displayed a sigOificanlly greater reaction tune while cycling tor both condibons. Peak maXImal force producllon was higher at the PP than allhe DP lor all subJecls Elderty sUbjects produced less force Ihan

Conclusions/Comment",

Cognitive declines a'ld the dynamIC slability 01 anbphase movement (demanding less cognitive and melabclic energy) caused the older group 10 be attracted to antiphase coordinalion. The older adulls displayed less capacity 10 modify relalive liming from cycle·lo-cycle. Older adulls pertormed Ihe tasks eco· nomicaliy in terms of oxygen con· sumption, however may avoid novel molor tasks due to negabve feelings associated with elevated heart rate. Motor pertormance was more attentten demanding for the older adults, inhibibng their ability 10 dlvide attention across multiple tasks. To minimize the metaboltc and cognibve cost of learning new molor skills, older adulfs may fall into preferred stable, low energy movement patterns; small sample size.

Age is associated with both a larger klss 01 muscle force by the mlnnslC hand muscles and a dimInished ability to stabilize Important pertormance vanat:»es

tCf)(JMuedl

206

Ph,-sicaJ Rehabilitation

Evidence Summary Box 7.1 Research Exploring Age-Related Changes in Motor Coordination (~n';nu"") Reference

Purpose (MVC) associaled with aging are accompanied by changed coordination of fingers in multifinger accurate, submaximal, force production tasks.

" " Subjects/Design

R

I esu Is

loops attached 10 sensors was used to detect finger force production at the distal and proximal phalanges. First, the subjects produced a bne!, maximal fOfCe 1finger at a time and with all 4 fingers together. Then. SUbjects were required to press w~h one finger such thaI the force signal shown on a computer screen followed a ramp line from 0 to the peak force shown in the firsllest. Finally, subjects used all 4 fingers to trace an on-screen ramp fine. Each test was conducted with force applied at Ihe distal phalanx and proximal phalanx.

young subjects. Reduction in maximal force was more prominent at the PP compared 10 the DP. Normalized error Indices for ramped output measures were twice as large for older subjects than for younger SUbjects. Variance for individual fingers and 4-finger measures was higher in elderly adults as compared to younger subjects at both sites.

Conclusions/Comment.. during accurate force production; small sample size.

EVIdence Summary Box 7.1 prepared by Stephen A. Caronia. "Shinohara, M, et al: Finger interaction during accurate multi-finger force production tasks in young and elderly persons. Exp Brain Res 156:282, 2004. COM = Center of mass; DP = distal phalanx: GRF = ground reaction force: LED = light-emitting diode: MVC = maximum voluntary contracllon: PP = proximal phalanx: UE = upper extremIty

Decreased strength. Dimini~hed strength i!'. a welldocumented finding in older adult".KI-l'~ Several factors are believed 10 contribule 10 loss of strength. reduced mU'icie 11l~~ (decreased cro~s-seclional area). and decrea~ed function. These include a loss of alpha molor neurons (decreased number of functional motor unitli), loss or ulroph) of fast (V, itch fiber!> (mO\1 notabl) t)'pe lib), reduced number and diameter of muscle fiber~.1I6 diminished oxidative capaci!)' of exercising mu~de. and a !'>ub"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<.:y: ...peed \\ ill dccreu__e 10 en ... urc gre~ucor aCLUraC) l..,peed-acLural) tri.lde-olfJ.~ In general. the tllllt" mtcnal bel\\cl.:'n apphlullon of d ... Illllulu'l and IllIllallon 01 mO\clllenl I... Intrt"it...ed. II'1 Thi.., findlllg 1'1 <.11'>0 11I1hed 10 degt"Ilt:f<.i1IVe dl..ll1gC'" 111 the mOlOr Will. 111 addllion. 1'1"1'1/1(1101" 1II11l' (lIme mter\ ..tl OCI\\(".:n 011-..:1 01 a ...lIm ulu... and lI11llalion of it rco\pon,>e) and l1I(1\lWIt'/lf lI111t· tllme llltcf\"al b.:;l\h:en the 1I111li.llil)ll 01 mO\el11elll .1Ilt..! the lOI11pldlOIl ot Illl)\t"ll1('lHJ arlO knglhened \\ It II nor111,11 .Iging.'/I,I Somt:' t:'\ Idt'nle ...uggc')h that rt:'.KllOIl (l111\:' arc ,lmH'r 111

sedentary vs active elderly per~oJ1s.9l and that delayed reaction times are more often seen in fine motor vs gross motor activjties.~! Decreased ROM. The majority of investigators examining subject-. from variolls age groups have found a reduced ROf\l in older adults. 9 \-Q5 Decre~e~ in ROM with advancing age ha\ e been found for \\ ri,1 flexion and extension, Q hip and ~houlder rotation. \ small decreases (5° or less) were found in mean active hip and knee motions,Q~ and Jame ... and Par~er'}~ found comistem dedllle's in lx>th acthe and pa.liSI\C ROf\l for 10 LE joint-. in a population of 80 health) adult-. older lhun 70 )ear... of age. Increased joinl ti,ghtne"s lends to be 11I0.-.t e\ idt!l1t Iml,.ard the end ROM and llla} 11lllXlCltlw O\t"fall ..."'illin coordlllated movement. Deul"a...e RO~l ha.. ~en 11Il~ed 10 biologic aoin2 _ e _ of joint .. urface ..."'\ lkgcner.ltl\t' changes 111 collagen fibers. dietar) detiut:'llcit." ... Jlld ..edelllI. a!It.'rl:d lorJolil: l:un e (l"lther tlallt"ned or e'(sggcr..ucdJ. anJ a ... ll.gh{ tllen:.t","" III hlp and "nee fleXion. Tlh..' (la,(" 01 ... uppon m"l) al ...o bt: \\ llkned. DillllllisheJ \Iren.glh .md ROf\l a... \... ell a,> mal'lI\ il~ Jnd prolonged sil-

1111

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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\

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.ltllllll~ II h pi "..tr.llnn lulltlll ,.1 ,IIHI\I..'ml..'nl 1",I
til h.d.trlll.·

\ \Jlll·t~ 01 l.t,k·dl'pl'nJCl1I toorJmall'd 11100l.:nlC'nt (h.lIl!.!l·' h.I\\..' ;11,n Ilt:'clllm"-l'o 10 .lthJl1tlllg age. 1I1clutilng. . . 11", ;ng 01 l')e-hanJ (lOflllll.lllon. llIJ ellx,\\ (1C\IOI1,"I'. ;tuJ ;1111l11l!! IlltHemen"f", rx:r1onn;lllle regre"\lon III coor· lIm.lIcd 1I11l'r1l1nh. - dU •.lI-I •• ,,,-,hJ'· and homobteral hand 71 ;tnd 1t'll)1 1110\Cmenhl ,-. ch.:m~l''' 111 multl'"egmcntaI. - tI hl..',ld trun~,I' and Itml'r (run"- l·oordlllJ.tioll"~: ~.nd 1I1..'rl',j,eJ tlmt: requm~menh for ,KII\ 111t:'J of dJ.ll) li\ 109 tADL.'I,'

Changl" TIl ,killed IllOIOI palormancc are a prt:lhctJble J'J"let'l 01 Ilonnal agmg, I-Io\\l,>\cr. Ihl' mfom13110n "hould nOI nt:g.t1.. . or undenllinc Ihe Import~mce of (rcalment .,IT.Mgll·... 10 Il1lprmC' functional pcrfomlancc and qu~t1il) 01 hie All 1Il1poriant con'lidcr;lllon in trcatment planning b 1113t thc aglllg nl:uromu\cular 'lY~ICnl mainlains ils phy..,ioIOf:lc ;ldaptl\e re~pOlhe to !raining ~timuli.I()1l PhYbical th.. . rapy 1I11erveniion is highl) effective in promoting and ",u':It:.l1ning a more succe..,,,! ul approach to aging. 107~114 This .... a partlLul.lrI) important concern a.., Ihe population ages. £':IIII11;lt(;'1 trol11 the U.S, Cenli,u'l Bureau indicate thai b) ~Olll .lppro\lmatel) 13 pen::enl of the population", ill be 65 or oldt:r and b) :W:W the number ",ill increase 10 16.3 perl·cnt. II';; (11\lt

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\l'fCelllllg, arc .I "",ne... t'f hnt'l tC':Ih that rrm IJC the thcrJp, ...t .m "0"'" 1('\1...' 01 11ll" .m.~a of mlerc'll (e.g.. \(.'lhJ.IIOfl, RO~1. ':Ilrenglhl, Rocl..lIl Ihal 'l"rcenmg" .Ire lhCd 10: (I) dctt'nninc the need lor funha or more detailed cxamin,l\l(m: (1) rule oul or dllfcrenllah: 'l1ecllic '1YSIClll Involvement: (3) deter· mille il referral to another health care pnK'lilioner IS warrantt:d: (-t) fOLlI'l thc 'ie;lrch for the origin of ...) mptom~ to a specific location or bod} part: and (5) Identify "'ystem-relatcd Impalnnenl' Ihal comribute to functIonal limnmion~ or di<;ablllt).llP In combmJtion \\ ith the mfonnation from the his101) and re\ ie.... of s}'items. ')Creenings as~ist the therapist in proficient I) Identifying the needed lests and measures and a,:-.i~t 10
'I.

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"it

For example, ROM. strength. and le\el of function of Ihe sensory syslem have direct implications for successful execulion of coordinated movement... 11 may be likely that formal examination of these areas has already been accomplished prior to a coordination examination. If not, however. screening of the~e area:.. is indicated, ( IJ.\I(, \l.

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208

Ph, ..ical Rdu,bil'lalion

Box 7.2

Slralcgic~

Imp"o,'c Communication with Elders 10

"len~otYI)C.

Do not a.... ulllc:
ll'ltllwl fum;llllll t)r Cllnhhltlil.

touch. 4 Idenlify yourself when greeling an cider. .Iii Rcquc"t infonnatJOll from each cider Oil how bc~t to

cOllllllunicare, e.g .. "Should I speak louder?" or

"Would you like your glas"e..?" fl. A'ik each individual what fonn of :lddres'i i\ preferred. Do not use generic or pel name!> ... 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
fOrlll. Usinl.! careful observation and knowledge of normative ROM v;lues. the therapist makes a gross determination of whether lhe ROM is withill lIorma/limits (WNL); if functionallllovements arc u<.;ed. the designation is withinfimctiOlw/limits (WFL). If complete. active, painless ROM is available. addilional testing is likely not necessary. If aClive ROM is incomplete or painful. a more detailed examination is needed to delemline the cause and extent of lhe screening fjndings.ll~

Strength Typically the ROM screening will precede rhe strength screening so some information about strength wil! already be gathered. If the patient performed active ROM movements againsl the resistance of gravity. a logical assumption is that gross strength is at least a fair grade (ability 10 move through the ROM against the resistance of gravity). The screening will then be directed IOward further refining this esrimate using application of manual resistance. Although standard manual muscle testing positionsl1 9,120 are not used for screening, adherence to foundational principles is indicated. Segments proximal to those being screened should be stabilized; resistance is applied at the dislal end of the moving seg~ ment and al a 90° angle (perpendicular) to the primary axis of movement. From the ~itting pO... ilion. Ihe patiell! might be asked to raise the knee toward the ceiling to test hip flexion with application of resistance on the distal femur; to extend fhe knee [0 test knee e>.lension 'frength with resistance on the di'llal leg; 10 bring the hand tm\ ard th~ shoulder 10 test elbow flexion \trength \\ ith resistance applied on Ihe distal forearm: and '>0 forth.

Sensation To perf01111 a . .en .. ory '.;neenlng. scvt'fal ea!'lily tested (i.e., requiring Imle or llO ",pcl'ialilcd equipment) modalities of . . l.:lhatIOI1 an: "elected. Modalult'\ from each of the general categont:, 01 "elhalJolh should be ~dt·cted. For example. the Ihcrapl\t might '.;tlet't P~IIJ] and light touch (supel1'icial),

l hllllll'r 7 I '\amin::lliull lIf loordindliull ~d'II..... lhl·"",I,llld

\ ltlr.1I101lIdCI.:pl, .1Ild 1\\ll-POllli dl ... c..nIllIllJtltlll III ... 1\'rl·I,~n\'",,'" ll'lllllhlllcdl. I'lll" IllnJ.IIII,\,,,, 'udl .h r: l1ll ,lIld IldlllPudl. Ih\' "'L'n"l~ "'\T\'l'lllng '''' perlnnned b~ ll"'ltl~ I he \l'!\'\ led ll1\lI..l,d It 1\..... tl' \l..l'l·\,11 I .llld(lllli ~ O\l.:.·r \OIl1('1\1l.11 LlI~\' \1II1.I\C :l1"\,d'"

I~or (,\:lmpll: .... t'\cr~lI appll(':'1I10n~

"'llmull" rnl~hl I'll' til . . tnhulc
lIt

(':.Id)

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 mC
Motor Task Requirements Fcature~

of Coordination Tests

Gross and Fine Motor Movements Cil\)fdll1,IIIOn te\"

gt'llerJII~

can be dl\ "ted 1Il10 t\\O main and lim' mowr mo\"el1lel/f~. Gro:-." mOlor Ie " IIlllude bod) po'llIn:. balance. and extremil) I11ll\I:.'I11\'n" 111\'oh mg large mu:-.rlc group~. Example" of gro," nllll0r ;Kti\ it It" . . lI1cluck (T
l"'lle~onc

'.;'1"0.\.\ 1110101

Nonequilibrium and Equilibrium (Balance) Te!>ts (oordmallon tt',t-. c III ~l"'lltlng pO,1I101l. The... ~ tC\" IIlvolve hOlh gro.... and fine molOr arli\'itle",. Eqllllihri/llllle~h con"ldl~r bllth ..tJlK .lIld d) namll' componenl" of po... lUre and h"lanct' \~ hl'l) llll' patlenl 1\ III .111 upfl!:!hl .. tandlllg po..,ilion. Thc~ lIl'\nhc pflmJ.nl~ grm" mOlor attl\ lIie.. and require nh...endtlun 01 the lxxh 111 holh 't..UIC btallonar\') anJ d~ni1mll." lho~~ 111 1ll0110;11 p'hlllre..," ., ~U1llhnull1 or hal..tncl' lp<).."ural ..,tabll.I)) (·oordmalioll 1\'''1' IUt:l1Ilt\ impairment... a",ou;lIcd \\ Ith the 1\\0 primary goal, 01 Ilk l'lil"tural (ormol "') ..,tem. \/(Ihiluy and jlll/('fW/1 B"l t", 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). move; Jnd movemenb that are lIlcon~istenl. requIre increa~ed effort, Jnd Iac~ appropn.lle direclion and timing. In addition, ~~il1 illlpalflnent~ impose limilalior,.., on pn:ci . . e cuntrol of movement, maintenancc of 1ll0\emcnt for e\lended period~. and tht'
Movement Capabilities rhe cO\lrtlln..tllOn t'\
billtlt~ .. III

(I) ,\llal/(al' Llr Jet"ip/oCtl! lI/olioll. \\hil'h i, lhe abllily 10 re\er",' l1lo\emt'nt bcl\\~cn OppO"'lllg mlbde ~roup~:

121 \lfn I

II/OIT 1"1111"1\/11('"

01

111l1\l'llll'111 ",~lnlnll ,h..hll·\l'd

... ~

Ill·r!!~. \\ tll",h 111\ "he... h~ IllIl'l h: ;.!ltllIP'" .ltlln.c

1l1~~·thl·l.

lht.' .lhlllt\ 10 ~,llJ!-,1' ~lr llhh:\,.' dl,l.llln· ,lIltl '1"lI.'l..'d III \llIUIlI.ll"' Illll\t'!lll'1l1 loll Il~"r/ll/l '" IImh ",,!dlll\! .lddrl'''\,.·... lhl· ,lhl1ll~ In htlld Ih~' po llulllill .Ill lIuh\ 1l.IU,llllll1h ~ll III11h ,e.em",'1l1. ,lIld I:', II/JllllhUlllfI (1,,1\1/11",,1 \/ohllu\ I. \\ 11Il·h " thl' ,Ihlll!) 10 1ll.IIIlI,tlll h,tl.llln~ III rl"~lll'(, 10 .l!lefo.l!lOIl' III l'cntl'r 01 f

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11~

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Till' r1ogrl'".. w!1 tll Jlllll~uh~ 01 (ll{lrUUl;.lIIOn 1('''''' f!.!radllalllllrl'~I'I" II1lhalkn.cc 10 Ihe p.t1ll'nlll~ plGIII) ull·

';7("

Ihe lolhl\\l11~ 'l'ljUL'n(L' ('I ullll
,..i,

11 Ilr.. lI1tl a 1l1..l1 or trt.:;llllll"ru wble. A nil 1\\1\ .. t.11ll IJ r\ I ' • • III', ...cl{lnd h;llld 'lhould tX' r1\.lIlable for ' \\.llt h orl'lK.P,,\\ • I '11 ,II Iht.· C\.ll1lln;lll(ln a.. \"l"11 ..... a mClho.J of III1lCI I Ll l l11l){lI1l:1 .. IIlL'\IX'/l'I\l" hlllldlnld U'l:'d for ,Ieepm~u Ixl III 11l~ \ I'" 1,),,(III • \~

I I

\\111'1.. ...

\\\.'111.

Patient Preparation rhe l·otlrt..lln.Hion L·\.~lmlOi.t1lOn ,hould ~ i.ldmini\lt:red "hen Ihl" r;llll'lll I'" \\ell rc ... Il'd .-\ full C\plan
d;..

Preliminary Observation Ob.. en alion i... nn es...cnlial ~I..ill in clinical decision mak-

Preparation for Administering the Coordination Examination Prior to mitiating the Loordin:Jtioll t·xaminalion. the tc.. . ling eJl\ ironment ~hOlild be Identillcd and prepan.:d, Il('eded equipment gatherl'd, ,:l1ld cOIl"ideralion given to p<.ttit>n1 prepar~ltioll (i.e .. "hat information and in~truction "ill be provided),

Testing Environment The coordinalion e\amination ...hould be admini'ltered III a qUlel. \\ell-lighted trealment area ~urficientl~ large to accommod.lle \\'all...ing acti\ itie\ included in the equtlibriulll ponlon of the Ie...". Ideally. Ihe room \hould be equipped

illl!. A<.."cur:.uc ;.tnd careful patienf observ::uion provides a ri~h .,ource of preliminary informal ion prior 10 perfonning a coordinalion examination. Ina~much as treatment intervention \\ ill be directed. at Ica~t in part. toward improving functional performance and activity levels. initial observa, tiOlh ~hould logically foeu'> 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 <"'an be obtained that will a~'li~t in localizing specific area... of ill1pairm~·nl. Thi" infonni.llion \\-ill include:

Table 7.2 Motor Task Requirements and Movement Capabilities Addressed During the Examination of Coordination

Motor Task Requirements

Movement Capabilities

• Mobility. InItial movement WithIn a functional pattern

• Alternate or reciprocal motion: reverslllg movement between opposing muscle groups

• Stability' statIc postural control: abIlity to malntam a steady pOSItIon m a welghtbeanng. antigravIty posture

-==

-

-

--

'---------

-

--

• Movement composition (synergy)' movement control _aChieved by muscle groups actIng together

----

• Controlled mobIlity. dynamiC postural control ability to alter a POSitIon or change posillons whIle maintaining stabIlity' static dynamiC control (vanatlon of controlled mObility): weight shIfting onto one 11mb to free OpposIte 11mb for non-welghtbeanng dynamiC activilles

• Movement accuracy gauging or judging distance and speed of voluntary movement • FIxation (111llb holding) holdlOg POSitIon of Individual 11mb or 11mb segment

• Skill 11tghly coordinated movement that allows Inter· actIon With the envllonment (€ g., galt)

• EqUIlibrium (postural slablilly) maintaining balance in response to alterations in center of graVity and/or base afsupport

Chapler 7 EA4lmination of Coordination • ('l'llcrOlI k\t'l ~ll "'~Ill IIlC,ll'1! .tl'ti\ll~ (,tI11011nt \ll ........ 1... • 1:llln' or .1 ...... I...lt\C tll'\ In· ... rcqutrl.'d, • I Ill' lX ... UtTl~Ill.(' of c\trJncou ... I11lJ\l·mt:nt.... o ... llilalllm.... ... \\.I~ Ing. or un ... I('.ldll1c"" • '1IIlltx'r

01 (',In.-mille ... Imohctl tUllIbleral and/or bl1,lt-

l'! ,III • DI... ITlbUIIOn oll1lotor IIllP;UTlllt.'nl· pro\1I11al and/or dl\tal I1lU"'l-U I,Hurl' · SlIU;lIlon... or OCCUtTt'IKL· ... lhat all!.:r (incrca...e or dccrca-,c) 111l11;1l TIne I1t ... • '\1l1111l1l1 01 tlllle rcqlll!\~d to perfonn an activit) • Ll'\cltll ...;\fl'ty

Fro1l1 thl ... inillal 0h.. crvatlon. the Ihcrapit>t will be guided

til ...electlng

Ihe appropriate te... , ... for the general area" of l1llP,Unllt·nt not ('d. Tabk 7.3 ;jlld Bo). 7.3 pre<;ent sample Il.'''''' arrropriale tor c\:.Jlllllllng noncquilibrium and equilIhTlum l'oOTthni.ltion. rc ... pecti\el). It 'ihould be noted that a . . mgit' le ...1 1\ otten appropriate to c),amine :-.c"eml different 1ll0\emL·nt ("dpJbilill('~ ... imultaneou... l) to cont>crve time. The IC"oh prc-.ented (Table 7.3 and Box 7.3) are intended a~ ...ample ... and are not all-lI1c1u\I\'e'. Olher acti\ itieli may be de\elopcd lhal are cl{uall) effective in examining a particular IInp;umlem and ma) be more appropriale for an indi· \ Idual pallenl A\ noted above. perfomlance in any variety of lum:t1onal .,kill ... (e.g.....elf-care roulinet>. wheelchair propuhlon. tram,fer"o. dre"'limg. and so fOrlh) is al~o an etTectl\e meal,... of examinmg many aspects of movement rapabill\ie... (e.g.. alternate or reciprocal motion, movement compo\llion. movement accuracy. and :-.0 forth). The 1\\0 .... ubdi\ i..,ion ... of coordination teslS presented here IllonequJlihrium and equilibrium) have traditionally been u...ed lor providing qructure and organizalion 10 admll1l\trallon of the t~~t~. However. it should be nOled Ihat the "nonequilibrium" di\ I\ion is. some"" hat of a misnomer 111 that elemenh of poslure and balance (equilibriumbJ"oedJ are required during the~e tesb (i.e.. maintaining an upnght ')ltllng po~lure). In addilion, el{uilibrium demand~ t:an be heightened U"olI1g un ... upported sitting po~lUres. Althou~h each \ubdivI"Jion place~ parlicular emphasis on t:enall1ll1o\Cll1ent capabilitie-,. Ihere \\ ill clearly be o\erlap bemeen finding.. from the 1\\0 ... ubdivi~ions. Table 7A llldudl.''> ...elelled impaIrment ... and sugge"'led teslli appropnatt' lor the clinical problem. In addlll0n to the ~pecifi<.: teo.,lo., presented in Table 7.3 and Box 73. gall analy ... i... ll1ea"ures also add important t \\lth Ihe dlagllosl:-' of movement impair· nlclll h) Idellut) lflg • ('h'lrdt.lCfl\lll'~ 01 IllltlallOn and control of mo\'cmem -\hnunHal itlC"l In mu ...L1e- IOn~ • Intlul.'n(..t~ 01 abnom1J.1 ...) nergl\(K pallem" and l1onmlegrat~J rclle)",c\ • Cuntrol Itl ...c-4uentlal 1IIllIng 01 mu"cular i.lcli, II) • (lIl1lrol 01 bod~ mmcmcnl"l d"l a "hole and 01 body ...eg· ml·nl-. III rclJIlOn to L'adl olha

21 J

rxl..

Dcvlalion-, lrom nomlal turC Jnd motIon k.g .. leanmg. lurch mg. or e>,c.::C"'''I\'C or dmlllli"ohcd mOl ion al a "'pe. clfic JOin!) QUi.lllty of mm ement temlllldllon Imp~lcl of environmental con<.,(falnh Characteri... llc, of dual la'~ perfomlancc (e.g.. wal~ing \\ hile bounc.::ing " ball) Standardl7ed gall m~truJ11cnts and functional balancc measure... arc panicularl} useful (I) in identifying coord ina{~d movcmcl1I impainnents associalcd with a skill-level motor 1i.I~k (i.e., highly coordinatcd movemenl allowing interaction with cnvironmcl1I); (2) making decisions aboul the differences between Ihe patient's pcrfonnance and the parameter.. or Ilonnal gait: and (3) providing data to infonn deci~ion:-. aboul the underlying mechanisms responsible for producing the movement impairments. Although not all· inclusive. the following list of gail instruments are among Ihose morc commonly used in clinical settings: the Get Up

and Go Test (GUG),'" the Timed Up and Go Test (TUG).'" the Functional Independence Measure (RM).12J-1!5 The Sickness Impact Profile. I :!6.117 the Physical Performance and Mobility Examinalion (PPME).'2)l the Perfonnance-

Oriel1led Mobility Assessment (POMA),'''wO the Gait Assessment Rating Scale (GARS).I'1 the Dynamic Gait Index,s9 the Walky-TaJkie Tesl,13l the Berg Balance Scale (BBS). UQJ5 and a limed walking tesL I36 These gait instruments are described elsewhere in the text. More detailed information can be found in Chapters

8. 10. and II.

The Coordination Examination Guided by information from the preliminal)' observation of functional aClivities. tests should be selected (see Table 7.3 and Box 7.3) to address the required movement capabilities of inlerest for Ihe individual patient. Generally. nonequilibriul11 lests are completed first. followed by Ihe equilibrium lests. Atlenlion should be directed to carefully guarding the patiem during testing: use of a safety bell may be warranted. During testing. Ihe following questions can be used to help direct the therapi~I's observations. The findings should be included in the comment section of Ihe coordinalion examination form. Are movCmeJllS direct, precise. and easily reversed? Do movements occur wilhin a reasonable or normal amounl of time'! Does increa::.ed ::.peed of perfomlance affect quality of molOr aCli\ it)? Can cominuou::. and appropriate mal or adju~tmel1u be made if ~peetl and direclion are changed? Ci.ln a pot>llIon or posture of the bod) or specific exlrem· il) be m;:nntained without "waying. ot>cillalions. or eXlraneou\ movemenl:..'?

Tabl 7 3 'on("quiJibnum <. oo...d'naeiun I..."""

~ 10 br"'lllhe lip 01 ... n I I HU1Jog pas.. IOn to

1f'10n..

,on 2."

'I

''''''''Pb''

It

I"

3

F~

'" t

to-h

ext ndOd The pallenl IS 8 ked 10 brlOg both rs from opposl1lQ hands

t

1 thO ,nOel. h

~ hd Of hel nose and the tIp of tho therapst s hnger UleraplSt 5 t r y be a rOO dunng testing to OOsetYe

T

4 An r t 10 flng ,

and toree of movement

The pall nt louc:hoS I gradually Iocr ased

5 Finger OPPOSItion Mass

lIP 01 the thumb to

e lip of each floger In sequence Speed may be

An altematJOn IS made between opening and C'OStng list (from hflger t1eXJOfl to tull elctenSJOn)

gra~

Speed may be graduar

7 PronatJoni suptnalton

Increased

With elbows "axed to 90 and hekl close 10 body the patlent alternately turnS the palms up and dOwn, ThIs test also may be perlormed With shoulders flexed 10 90 and elbows extended Speed may be gradually Il'lcreased The ability to reverse movements between OPPOSing muscle groups can be examined al many JOints. Examples Include active alternation between fleXion and extension of the knee, ankle. elbow. hngers and so forth

8 Rebound test

The pal lent IS positioned wllh the elbow flexed The therapist applies suffiCient manual resistance to produce an IsometriC contraction ot biceps ReSistance IS suddenly released. Normally, the opposIng muscle group (lrlceps) Wilt contract and "check" movement of the 11mb. Many other muscle groups can be tested for thiS phenomenon, such as the shoulder abductors or ftexors, elbow extensors, and so forth

9, Tapping (hand)

With the elbow flexed and the forearm pronated, the patient IS asked to "tap" the hand on the knee.

--- -------

, 0 Tapping (fOOl)

The patient IS asked 10 lap" the ball of one foot on the floor without raiSing the knee; heel maintains contact With floor.

11. POinting and pasl pOinting

The patient and therapist are oPpoSlle each other, either sitting or standing. Both patient and therapist bring shoulders to a hOrizontal position of 90° of fleXion with elbows extended. Index fingers are touching or the pattent's linger may rest lightly on the therapist's. The patient is asked to fully flex the shoulder (fingers Will be pointing toward celhng) and then relum to the horizontal position such that Index fingers Will again approximate. Both arms should be lested, either separately or simultaneously A normal response consists of an accurate retum to the starting position. In an abnormal response, there IS typically a "past pointing," or movement beyond the target. Several va natIOns to thiS test Include movements In other directions such as toward 90 of shoulder abduction or toward 0 of shoulder fleXion (hnger Will point toward floor) Following each movement, the patient IS asked to return to the Initial hOrizontal starting posrtion.

12. Alternate heelto-knee, heel-la-toe

From a supine poSition, the patient IS asked to touch the knee and big toe alternately with the heel of the opposite extremity.

13. Toe to examiner's finger 14 Heel on

~==-=-====::.-::=-=-=-=~~~-----From a supine position, the patient IS instructed to touch the great toe to the examiner's finger. The POSition of finger may be altered dunng testing to observe abihty to change distance, direction, and force of movement.

sh::,n:-----;:F:;ro::m=-a::-::s:-:u::p::
n::e~po=S::,I;:io::n::.-:I:;:h=e-:h::e::e::l-=o::'-=o::n=e-:f=oo-=-1 ::'S--S::I::ld--u-p--a-n--d--d--o-w-n--lh-e-S-h-,n-o-f-l-h-e-o-p-po-S-j-Ie-L-E-.- - -

15 DraWing a Circle

The patient draws an ImagInary circle In the air with either UE or LE (a table or the floor also may be used). This also may be done uSing a figure-eight pattern. ThiS lest may be performed In the supine POSItion for the LE.

16 Fixation or posItIOn holdIng

UE: The patient holds arms hOrizontally In front (slhlng or standing). LE. The pallent is asked to hold the knee In an extended poSition (sitting).

-Tests should be performed first With eyes open and then WlIh eyes closed Abnormal responses 'Incl d did ' f !he "h I " d! h · u e a gra ua eVlatlon rom ad ith tho o ding posrhon an or a dlmlOlS ed quality 01 response Wllh vIsion occluded Unless otherwlse Indic ted t pallenl In a slnln9 posItion a ,ests are perform w LE Lower extremIty UE "" upper extremity.

212

Chapler 7 E.xamination of Coordination

Box 7.3 Equilibrium Coordination Tests Standing. comfortable posture with nolmal base of suppo" (BOS ). 2 Standing, feellogelher (narrow BOS). ~ Standing in tandem position. with one fool directly in f ronl of the other (toe of one fOOIlouching hee l of

opposite fool). -.1 Standing on ont: fool. ~ Arm position may be altered in

each of the above

postures (i.e .. ann$ at side, over head. hands on waist. and so fOflh ). t1 . Perturbations: displace balance unexpectedly (while

carefull y guarding patient), 7 Sl.:tnding. fu ncti onal reach: forward trunk fl exion with UE reach. ~

Stand ing. laterally flex trunk to each side.

Y. Standing; eyes open (EO) to eyes closed (EC); inability to maintain an upright posture without visual

input is referred to as a positive Romberg sign. 10 Standing in tandem position eyes open (EO) to eyes closed (Ee) (Sharpened Romberg). II Tandem walking . placing the heel of one foot directly in front of the toe of the oppos ite foo l. I:. Walking along a straight line drawn or taped to [he

floor. or place feet on noor markers whi le walking. 13. Walk sideways. backward . or cross-stepping. 1·.1. March in pl ace. 15. Alter speed of ambu latory acri vities: observe patient walking at normal speed, as fast as possible, and as slow as poss ible. In. Stop and Slart abruptl y on command whi le wa lking. 17. Walk and pivot on command (!Urn 90, 180. or 360°). I K Walk in a circle, alternate directions. 19 Walk on heels or toes. 20. Walk with horizontal and vertical head turns on command. 21 Step over or around obstacles. """ Stairclimbing with and without u:-; ing hand rai l: one slep :.u-a-ume, slep-over-!.tep. ::' l Jumping jacks 24 Sluing on a therapy ball : alternate fl ex ing and ex tend in g the \.-nee~ {coordinated movement with upri ght balamel.

• Ar~ plac lIl g move me nt S of both uppe r and lowe r e xtrelll I lI e~ t'>. 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
21-1

Ph}sical Rehabilitation

Table 7.4 Sample Tests for Selected Coordination Impairments Finger-to-nose Alternate nose-to-finger Pronation/supination Knee flexion/extension Walking, alter speed or direction Dysmetria

POinting and past pointing Drawing a circle or figure eight Heelan shin Placing feet on floor markers; sitting, standing

Dyssynergia

Finger-to-nose Finger-to-therapist's finger Alternate heel-to·knee Toe-to-examiner's finger

Hypotonia

Passive movement Deep tendon reflexes

Tremor (Intention)

Observation during functional activities (tremor will typically increase as target is approached or movement speed increased) Alternate nose-to-finger Finger-to-finger Finger-to-therapist's finger Toe-to-examiner's finger

Tremor (resting)

Observation of patient at rest; limb or jaw movements Observation during functional activities (tremor will diminish significantly or disappear with movement)

Tremor (postural)

Observation of steadiness of normal posture; sitting, standing

Asthenia

Fixation or position holding (upper and lower extremity) Application of manual resistance to determine ability to hold

Rigidity

Passive movement Observation during functional activities Observation of resting posture(s)

Bradykinesia

Walking, observation of arm swing and trunk motions Walking, aller speed and direction Request that a movement or gait activity be stopped abruptly Observation of functional aCtiVities: tImed tests

Disturbances of posture

FI,xation or position holding (upper and lower extremity) Displace balance unexpectedly In sitting or standing (perturbalion) Standing, alter base of support (e,g., one foot directly In front of the other; standing on one toot)

Disturbances 01 gall

Walk along a straIght line Walk SIdeways, backward March In place Aller speed and directIon of ambulatory activlttes Walk In a circle

._---

Table 7.5 Coordination Examination Form

Patient Name:

~~~~~~~~~~~~_Examiner: _~~~~~~~~~~~_Date:

PART l: NONEQUILIB.UUM COORDINATION TESTS ~

,

-

Key to Grading 5 Normal Pertormance 4 Minimal ImpaIrment Able to accomplish: slightly less than normal speed; reqUires supervision/minimal contact guarding 3 Moderate Impairment. Able to accomplish activity; movements are slow, awkward. and unsteady: requires moderate contact guarding 2 Severe ImpaIrment: Able only to initiate activity without completion: reqUIres maximal contact guarding 1 ActiVity Impossible

I <>-Ie: Left

,

,

Grade: Right

e-ntiIwioo Test

Notations should be made under comments section if: • Lack of visual input renders activity ImpossIble or alters quality of pertormance • Verbal cuing is required to accomplish activity • Alterations In speed affect quality of periormance • Excessive amount of tune required to complete activity • Changes in arm position allers sitting balance • Extraneous movements. unsteadiness. or oscillations noted [n head, neck. or trunk • Fatigue alters consistency of response • Periormance impacts patient safety

---

Comm'aD

-,

;

,-.:

Fmger-to-nose

I

I

f[nger-to-therapisrs finger -

-

Finger-to-finger Alternate nose-to-finger ---~-

Fmger opposition

---

Mass grasp

-

-

---~---~

Pronation/supina tion Rebound phenomenon

; I

Tapping (hand)

I

Tapping (foot)

I

Pointing and past-pointing

II

Alternate

heel~to-knee:

----

-

heeHo-toe

--

Toe-to-examiner's finger

I

Heel-an-shin

I

I

II

,

[

,

Drawing a circle (hand)

,

DraWing a CIrcle (foot)

I

Fixalion/position holding (UE)

I

Fixation/position holding (LE)

--

--~-

(continued)

Table 7.5 Coordination Examination "'orm

(conlinuCfI)

Patient Name:

Examiner:

Date:

_

PART II: EQUlUBRJUM COORDINATION TESTS

---======= Notations should be made under comments section if:

Key to Grading

• • • • • • • •

5 Normal Performance 4 MInimal Impairment: Able to accomplish actIvIty: slightly less than normal speed. reqUIres supervIsIon/minimal contact guarding 3 Moderate Impairment. Able to accomplish actiVity: movements are slow, awkward. and unsteady: requires moderate contact guarding 2 Severe Impairment: Able only to initiate actlvlty with difflculty: unable to complete; salety concerns: requires maxImal contact guarding 1 ActIVIty Impossible

-

I <>-Ie

Lack of VIsual Input renders actIVIty ImpoSSIble or alters quality of performance Verbal cUing IS requIred to accomplish aClIvlty Alterations In speed affect quality of performance ExceSSive amount of tIme reqUired to complete actll/lty Changes In arm posItion alters standmg balance'postural sta Illty Extraneous movements. unsteadiness, or OSCillatIOns noted In head neck. or trun Fatigue alters consIstency of response Performance Impacts patIent safety

-

-

,.

Coordinldioa T_

-

I

Standmg in a normal comfortable posture

--

Standing. feet together (narrow base of support) -----4

I

Standmg on one foot

-

-

---- f--

---

-

Standing. with one foot directly in front of the other in tandem position (toe of one foot touching

heel of opposite foot)

-

Standing. forward trunk flexion and return to neutral

I I I

-

-

..

Standing, laterally flex trunk to each side

---

Standing: eyes open (EO) to eyes closed (EC) (Romberg Test)

-

Walk at normal speed

Walk as fast as possible

-

--

-

---

--

-

Walk as slow as possible Walk: stop and start abruptly Walk and pivot (turn 90. 180, or 360°) Walking. placing the heel of one foot directly in tront of the toe ot the opposite foot (tandem walking)

-

-

Standing in tandem position: EO to EC (Sharpened Romberg Test)

•

1

-

Walking along a straIght line drawn or taped to the floor Walkmg. placing feet on floor markers +-

+-

Walk. sldew"."s

Walk: backwards --i-. Walk: cross-stepping

-

I

I I

-_._-

--_._-+-.-.

I Waik : In a c· Cle-a-I-te'-r-n-at-e-d-j-re-c-tions " Walk: on heels

-

-

---

Walk: on toes

L.

----

------ - - .,.

~

March in place

- 1--

----

-

Walk with horizontal and vertical head turns

,

I

,I

Step over or around obstacles

! Stairclimbing with handrail

- --

I

Stairclimbing without handrail

I

Stairclimbing: one step at·a-time

I

--

- 1'I

Stairclimbing: step·over·step

---

-------

11\ In .1 re.l,nIMhlc .\l11I l Unl 01 l11ne ,.. ..I "'lIl11fX 1llt:111 III rc.:rlllr~l.lIlu· lhl' 1c.>l1flh III lIllle' rt'l{uln'd 10 In,:olllpll,h "l'n.lln .1l11\111l""" rl'\,orJl:t1 h~ u..,,· 01.1 ,lflP\\·lh.h l .. 1I1!! .HI .Idl\

tlllil' .1' J llle.l"urt· nl pt'rl0I111.II1I.c..' lu.. Illl!""'lnanl IInpIlL..I· lion .. lor "oth lUllllHll1 .Inl! ,.llt·l\ for c\..Il1Ipk .•I....lun'" 6.1

Ith mulrlpk '" It:rll I.. \\ ho U',,', ,I \" hl'cllh.ur 1'1.111" 10 Il'wm 10 ""hool hUI It'qum~' 2.~ hnuf'. 10 L'ompkle lhl..... 'n~ i-lltl\IIIt.:... Il1l' 11111(' elcllll"111 herl" \\\lull! 110l be

I'Jlll'lIl

\1,

L"On.. Hkrl.d lunl.'llnn,tl. l· ..pt:"tlilll) 11 allcmpllllg. III 1ll.1}..('

JJl

d ....... 'on"llkr ,il,"\ an ambul.llOr) pallt.:111 \1, Ilh an .11;\\11.. gall unahle to un~ .. a .. treel 111 the .Illulll:d tllllt.: prO'lded 11) the 11;lftll: .. ,gna!. Thi\ lime re4ulremt.:nl plt:-..cnh .1 lon"lderabk palient ,afct) i....uc and. a.. "\It'll.

t',ld) monllllg

\\(HJld al,o 1101 he cOIl\ldcrcd luncliollal.

SOIlll' .. I~tndardlll.'d l11ea . . urel11t:J1t [oob h.l\e bcl."n de\el· (lpeo b~l~cd on tll11t.. d JCll\ llit: ... (e.g.. Timed Up and Go tC.. tl~:1. HOlle'\er, lLlncd perfonnanec l11e~l ..ure.., may he IlKurporaled Into an) vanet) of mOlOr or funclIon.1I ta..}.. .... Penodic \ I(jeolaping 01 p~ttient perlonnance h;.L'" been u..c:d dlelll\e1) to documcnt COOrOIllJIIOn lmpalmlcnh as \\ell:.... monitor progr.:..... over tune. For some patient,> the) CJn prO' Ide the ba:-'I... tor :-.ugge~lI01~ aboul allenng mo\e· ment \tratcgie ... to impro\c function and direct atlentlon 10 ..alet) precaution... Vie\\ed III ..cquence o\er time. video· tJpc'" can also impaci palicnl mOli\3tion 10 att::lln further gain,. Videotape.., have aha been u~ed to determine the impact of medic:aliom on coordinaled movement via pre~lnd po:-.t·intervention recordings (e.g .. p:Hient ... wilh Par"-in ... un\ di ... ea~e). ( L/\I( \L'\Orl

/1 i~ 01\0 lInt III/('Ol1lmOIl /tll Illl'rapt.\f.\

Ii(/{ wnc.'/tl dalo 'I"om lilt' ulan/maa/lflll ('\tlf}/lntlflOlI dUt t III u iI/lin ,lit !JO('-\ 11/ /I 1I0rralll'(· 110ft· (II" 111111111 Illf oh/t·' lilt \i'llioll (~/" ~O·\P IIolt 10

Quantitative Coordination Testing and Specialized Testing Instruments CATSYS System The CATSYS S).\tl'l11 (Dani~h Product Development. LId, Denmark) i:-. a Windo\\ ...@·ba"edtestingsyslem that allow~ quantification of ..e\e-ra] type.. of coordination impair. . a computer via a ment.., I \~ 1.:11 Th e ~) ..Iem 1I11erface~ with ..null dala logger bO>., (~l.:'nal cable). The data logger records lllionnallon Irom lour ..en..or~ II1cluding a: • Tremor Penn,l tor d<xumeming lremor II1len~H) and lrequenl'y • Reallion tllne hand·hdd ~\\ Heh aell\ated b) the Ihumb • Touch recording plate for mea':lunng prollalion/\Upllla. lIon Jnd finger-li.tpplllg • Forc~ platlorm for mea'>unng po~tural w. a)

.IOJ the ,) ..Icm. allo" \ com(,It,1 1 ,Ir\.:·1\JII.lhlt: • . J IIltrJp.ltlcnt d31;1 over lime. ThiS 'i)'~r lfl.."lll tll IIlkr· .m . "., 'J to dfXumcnl mo\cment dy~runcllon tt'lll hJ" Io\'l"ll u.. t,: curod('l!cneral1\c p:llholog) a~ well .1 ....tllhllC J V"I ,h n ~ . ,'J v.lth ncurOIOXIC c\.po\ure (e.g.. mercury thp,,,' ......tK 1.1 t '\lfIll.III\C

ll
,. -

Postural Sway Analyzer The Pmlllro/ .SU'll\' AI/a/\':l'r (Ncuro-Tcst Inc. Pasadena. CA 911 17) mca ... u~c .. po... lllmi ..,way (a componenl of equilihnum coordination) ll~ing a computerized head-tracking monitor. A . . ound-generaling \tylus i.s embedded in a lightweight hcad ...et placed on the patient's head. Two microphonc~ moulllcd 14.2 inche.. (36 em) apart on thc extended ann of a Ifipod arc placed 13.7 inches (35 em) from the patient\ head. The microphonc~ record the horizontal path and mo\cmcnl speed of the \ionic (sound) source. The . recordd mean ~pecd 0 f 's\\ay I,S e a~ em;.I'J.."'AI s. arge :-'\\3) path \\ould be indicative of poMural instability.

Choice Reaction TIme Analyzer The Clwin' Reaclion Time Alla/y:er (Neuro-Test Inc, Pa\adena. CA 91117) is a computerized instrument that allow") moniloring of both simple reaction time (SRT) and choice reaction time (CRT). Reaction times are measured from the time a stimulus appears on the screen to the lime a response in recorded by pressing one of two small key pads labeled ··A·· and "5·· (pressing a keypad SlOpS the timed measure). For example. in measuring SRT. the patien' may be asked 10 pres; keypad ··A·· as quickly as pQ:o~..,ible each time the color blue appears (nole that the color blue here is an arbitrary example. as any number of letters. color!). objec~. and so forth can serve as the target stimulus; items can also be presented at various angle orientations [i.e.. sideways. up-side-down, and so forth!). For CRT. the subject responds differcmially by pressing either th~ "A" or the "S" key in response to two separate target sllmuh. For example. Ihe patient may be instrucled to press keypad "A" as quickly as po~sible each time an inverted number "1"' appears and keypad "B" each lime the number "2" appears in its normal orientation.I.:l6---148

Dynamic Posturography Multiple . hy ~ystems are commerclal. . dynamOIe. pasIurograp c 'oph·· "vallabk Thi I . . . . . ') S ISllCate( ll1strumentatton mcludes a

I)

d) n3mlC ~Ialform (both linear and angular movement), a movlllg \'I\ual . , SIIITO unu.• \Creen. and a computer interface. The d) namlC pl'ltl·on]] . d lI11po.se~ po... tura] penurbattons an ' the '\urround ~Creen (s, f . . \ 3) re erenced) presents Visual contller. BOlh Ihe "Iatlon . d 11 itn ~urround screen are patient referenced \ ia h) dra r h· . u Ie mec anl~m~. POMurography provides 4 ua mUJtlve data on b· I' ~ .. a ant:c control and postural slablhty (dlfeLtion and amplitude 01· po'.,. , t ura I :-.way ) .

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In.lh· l\.lmp;tn"'lI1' \~llh puhll'hCd I1t,"1h 1l1\.tlid -Ill\,' ,lilt 01 Ih~ e,.Ullml'r I'" .tnt\thlT 100p'\n.lnt nUl 'ldCrJIIOll Illt· h· ...h ,ht1uld tx- ..Idmlnl ... tcn:u 1') .m II"KII\ IUu.II "-110\\ 1c.·i.h~C'Jhk Jht'ul 1l·... llI1g ~Uld('hnt>' ..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,

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IJtltln i.:.lP;IPIIIlIt'... a1l0\\1l1g lllea,urClllcm 01 \enlcaJ lorce, lht' rXltll.'nt'... !eCl. °lne pJlienl ,Iantl ... on the force pl.lle .IIlJ I'" ... um1unJr.:J t'l: a \ i.. uall·Jl\ lI"Oml1tni. A "';lfel) harrk: ...... I' \\um h) the p~llIell1 Ihal all.lche, 10 a "ulIonaf) har. 111t' ": ...klll .... de .... gnt"d lor oolh pallem exalll1l1alion a~ "ell J.... 111r lXIlJ.m.:c Irallling u... lIlg \ 1'1I:.!1 biolcedbad·... Tht' paralllcle", ":.111 Ix J.llt."ft'd "u(,:h Ihat both Lhr.: ,uppon ,urlacc and the \ hUid em !fi.>rlJlll'nl can be either \Iable or dynamic. TIle d~narllll "uppon ,urfa,:e i\ intenJed 10 "illllllaic the chaJ+ lcnge\ 1lllfXhed b) d.til: aui\llie." (nonnal cOl1dilioJ1~ Ihal chang~ propnocepll\f' mpul). See Ch3pter 8 for additional Inlomldllon on po~turograph).

"'\l:n~J h:

Prl""!l111 Rul~ ;In. Bolingbrook II 60·WOJ C".J.mmc ... hand ..Inti fin¥cr cooflllnatlOn u... ing ,e\en ... uble'l" of function:.!1 "kll". \\-nllng: Lml turning: plcklllg up "nail object .. : "imul ..IIl.·J It.'l.."i.lIng. ,1..Id.lIlg: plCllllg up largt:. lightweight 00)t"1.1\: .tnd pll.:kll1g up large. hea\) obJecl, (Fig_ 7.5). TI1(~ le,1 l' ca", 10 con,lrucl. atlmini\ler. (Ulel 'lcore (commer1I.dh .l\
The J/lIIllcwra Manual Derterity Test (Lafayelle In:-.lrlll1lenl Co. L.lfa)elLc. IN -HlJ03) was de~igned to ,eleci per...onnel for \emi:-.killed operations requiring coordlJ1:.Hed ann/hand/finger movements a~ well as eye-hand coordlJ1atlon 'luch a.. required for handling smaJI tools or a,,,embly n13terials that do nOI require differentiating size or ,hape (Fig. 7.6). The test includes placing and turning la~k!o. and requires use of a board with wells and round di!o.k!o.. Nonnative data are available. An expanded variation of (hi!! le~l i-; the Minnesota Rate of Manipulation TesL \\ hieh include!! five operations: placing, turning. displac-

Standardized Instruments: Upper Extremity Coordination 'x-\ cr:.t'l!l(brdl/t:<.llc,l, are a\ ailable 10 e~amllle ann-h~uld "nd c~r.: htlnd u)(,>rJmJtlon a." \\eIl3~ fin~ motor dexlerity of th(' linger... throu,gh U~ 01 lunclIol1-~d \klll~ or acti\'illes. \l,in) llj Ihe:...e 16h \\en~ origm.dly dt:...igned 10 predict

t:mplo) men!

lor Job" rClJlIlrmg Ilwnipulali011 of ..,mall p.1n" "uch ..t"'ll1l£hl be rC4uir~t.1 for J~'l;ll1bl)·llIle \\()rk. The \J'I nl..tJont: 01 Ie: b.tf~ ..lured ba\cd both on lime re4ulreJ lor LOlllplt"tllJrl ..Ind 4U.t111) (Jt.(.'lIr.ll"} J of re~ulh. "UL:ln,

Figure 7,5 The Jcb"en-Ta) lor I-land Function Test include!) a ,ub~el 01 "even fllllclion:tllas~s allowing c\i.Unmation of a hroad rang!.: of ~l.ilb re4ulring coordinated mo\ement of the hand and fingeh. Common lIem::. are u'oed such 3::. spoons. p..lpcr clip::.. cans. pcnC'ih.. and ~o forth. {Coune~} of Sammons Prc-,Ioll Ral}an. B(}llnghroo~. Il. 6O-MO-3593.)

· ··· ··

··

Figure 7.6 f\!lnnt"OfJ. ~1J.nu~1 Dexterity Teq COll<;I')1'> of 1\\0 opt'r:lllon ...: "Iu( ill!! .:md fIInllll~ Follo\\ iog J. practICe trial. "'I.'on~.., J.ft.' ha<;ed on Ihe lime ft'quired to complete each of four Inal, IOf each operallon.

iog. one-hand turning and placing. and two-hand turning and

placing..I~l l~~

The P//rdlf(> pfghoard (Lafa) eIte !m..trumenl Co. IN -l-7903) le')t addrcs')cs both gross coordinalion of the armI11J.nd/fingt'rs as well as fine coordination tdexlerit)) of the finger,;; by placement of pins. collar'). and or \\ashes on <.I pegboard (Fig. 7.7)Y>'·I~oThere are l\cvel"al ,')ubtest:-.. including righI-hand prehension. left-hand prehelhion. prehen~ion lest with both hand~. and a~:-embl\. The te')t ha~ been u.. ed to ~elect personnel for indu')tri:11 jobs th31 require manipulali,e ~kill .... N0n11ative value:- are a\ailable. and bOlh unilateral and bil:lleral coordinated mo\ emel1l can be e\amined. Thi, te ... t require ... u~e of a L3f::J~elte.

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Figure 7.8 The O'Connor T\\eezer (left) and Finger Dexterily (right) Te~h examine fine motor coordination. Each board is II X 5.5 inche~ (18 cm X I-l- COl) \\ith 100 holes and shallow welb 10 hold the pins. The blad. cover') '\Iide through grooved channell; to keep pin!> in place during 'itorage. te~ting board. pins. collars. and washers. The Purdue Pegboard wa:> found to high ICSI-relest reliability in per~on ... with multiple ...clerosis. W The emlljeml Small Part~ Dexterity Test (Harcourt Al:i es~ment. San Antonio, TX 78270) uses the manipulation of mall toob to examine mOl or perfonllance. The lest uses pin:-. collars. and screws a~ well as a board into which these small objects fit. Use of tweezer::. is required both to place the pin:- in holes and (Q place a collar over the pin. nle screws musl be placed wilh the fingers and ')creweu in with a screwdriver. Thi::. te::.1 ha... been lIsed in pre\locmional lestim!. NOnllati\e data arc available. This te~1 is scored by timeY~ The()"CoIl110r Tllce:a Tc'\t (Fig. 7.S. Ie/i) a'nd Finger ~{'_\t('n0·.Tcst (Fig. 7.8. right) e\amine lhe ability to rapIcll) manlpulale 'imall object' (Lafayene In~lrumenl Co.

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11k' IIl1l1d 7o(/! Dn(u-uy TCSf (Fig. 7.9) ulili/t:\., ordlll on one upnght u...ing the dpproprii.lIC 1001... and f(.'a... -.emblmg. them on the 0ppo~lle urnghL1 he \e ... 1 i... limed and noml:.11I\t: d<.lUl art: J\i.lilablc. Tht' Ron/('/" \1mlljmlcuil"l' Apllflul£' I e5f 'Fig. 7.10) mc-a.. urt: .....tnn-handlingcr l:oordin:.1tuJn (indudlng Ihru ... tInf' Jnd t\\ I 11Il~ J a.. \\ ell a... eye-hand coordll1allon. The tc... t mJten ..tl ... U)II"'I ... t 01 a hlgh-den"'lly r1a... lH.: board wJlh four \\ell, lor \\J her.... rod cap.... and nUh: a T-bar lor placeIl1rll\ 01 \\a her nul ,j ·,t:l11bIH.~..: and 1'0"';" 01 ~ockel' for In ... l.tllIn.\! Ilub. The le..t protocol IIKlude.. four IlIlled opel'-

tU\.)1'I 1t1

Que,tions

for

Review

\\ h.llt)PL'hl of data <.Irc gt.·ncr;t1rd Irom the coord,· 0.lll0n e\intltnation'/

2 \\ h.lI roll: du the Lcrcbellul11. ha... al ganglia. anu lhe

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the common L:OOrdlll.l110n 11l1p.Jtmlclll' <.I ...... oli"tcd \\Itll pathology (II the c~r~­ hdlullI ha'al gilnglta ,lnJ lht: JL)r~al column-melbal

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An C\3111111.lllon ull·oorthn.lllon pro\ ide . . the phY"lcal ther.lpI... I \\ lth 1111ponlIlgl~ 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 <.:an be reduced by the u..e 01 well-defined rating :scale"i. admini'llTatlOn 01 te'll\., b) sl..llIed examiners. and ...ubsc4uent rcte.. . ting pcrfomled bi' the ~ame therapist. A vanClj of Iradltional ob~r\'al1onal coordinalion leSI~ have been identified. Although Ihe lest~ have been pre"entcd individually for clarity. most can be lI'\ed to examine more th~11 one r) pc ot movement capabililY. Documemation ...hould include the t)pe. se\eril)'. and location of the Impair· ments a~ \\ ell as faltof\ Ihal aherthe quality of performance. Empha~i~ has been placed on the \ariety of influences that c1e £one.

4. Whi.t! predictable a"'pect~ of nomlal aging impact coordinaled movement'! 5. As:-.ume you arc about 10 Initiate a coordinallon e"all1ll1alion. What ~cre~nll1g' \~uulu be appropnale and \'"h)'; and tn \\har on.kr \\ould )OU perform Ihe ~cr~l;':nll1g"~

6, IdenlJf). dtlfcrenlJ<.tle••ll1d de .. cribc thc 1110(0,. (as/... /"£'4J11/'('f!lI.'1/fS and 1IJ0\'{'f/1('1/{ capahilltles addres~ed \\ tthin i.I COOrd1l1ation e>.>lminatiol1.

222

Ph}'sical Rehabilitation

. 0 f a I11isnomer as a subdivision of coordi')omelhlllg nation te~ts? . 9. What dala can a systematic gait analyMs add to the . . ? examin:uion of coordlll3U0I1. 10. Whot questions related 10 patienlperfonnance should be considered during a coordinatIon examlOatlOn to help direct Ihe therapi!>l's observations?

of a preliminary ob.. ~r"a~ion of lhe patient prior 10 the coordination examinatIOn. What types of activities !'lhould be observed? What infonnalion I,hould be galhered'! 8. Differentiate between lhe Iypes of aClivities included in equilibrium \ier~us nonequilibrium coordinalion tesls. Why is the tenll "nonequilibrium" con')idered

7. Explain the

Cas e

purpo~e

Stu d y

The patient is a 61-year-old man wilh a 5-year history of Park.in~on·~ disea~e. Since Ihe time of the diagnosis. he repons a progressi\e decline in funclional activity level. Wilh encouragement from his \\ife and children. he look 3n earl) rellrement 3 years ago from hio;,; career a, a commercial airline pilot. He lives with hi,(" wife or 38 years in a one-level suburban home. Hi~ four adult children all Ii, e in neighboring communities. Initial examination reveals the follo\\ ing: Mo\ ements are decreased and "lowed. A unifonn. conSlant resistance is felt a~ lhe extremities are mmed pa~si\'ely: patient report~ an merall feeling of ":stiffness:' Imolunl3.0. rhYlhmlc. o'tcillatoT) mo\emenh of the dIstal upper e~tremltte . . are noled af re~1. Regular incidence of falh (two to three times per week) IS reponed: ~landll1g balance I~ ea'til) dl'tplaced \\ IIh lendency 10 fall stim): patielll has difficult) changll1g direction of mm,emelll or '!oPPll1g a movement Patient ha~ dlfficuhy ahem
References

The palient's medical ion is aboul to be changed from

L-dopa alone to a combination of L-dopa wilh carbidopa (Sinemet). The phy~ical lherapy referral is for examination prior 10 Ihe change in medication to document baseline function. Following the medication change, the examination will be repe,Hed and treatment initialed.

GUIDING QUESTIONS I. Identify the tenns u,ed to describe the foJlo"ing feature . . of ba~al ganglia disorder~: (3) decreased and ..,Io\\ed mOVemenl: (b) a unifonn con!o.olant re!>istance to pas..,ive mmemenl: and (c) 1l1\olullt3ry. rh)thmic. o~cillator) movemenl\ of the dhtal upper extremities at re ... r.

:!. \Vh.lt gener.1i mO\l:mcnt impalmlenh would be evident in the pre"ience of bradyl..lIle",i.I·~ .lldenllf) the nonequllibrium coordinatIOn le... t, appropn~lte tor e\J.l1lllling the p.i1ient .... mo\emenl capabdilIe... III rx-rlOrnltng Jlternaling dl,t . t1 L E mOH'mt'nh. 4. IdeIHlt,) the equIlJhnulll l·oordllli.lllOn te,,,,, appropnate for C\Jl11l1llllg tht' p.llh:nt\ ...ltl"rt"J J'lll"'lur.ll re.ll.:lJOfb ;md halance. ".

D(''''LTI~ a pl...n hlr Ul'll..Ul11el1t1ng tindlllg' frllm tht' l.'\JmlnJllllll

Chapter 7 Examination of Coordination It). -.Ie Jl1l1g . BM. el . Philadelphia. 2002. 29. '·ldnm. JH . Ncuroan:l1ol11 }: Texi and A lla ~. ed J. McGrlJ\\ H ill, Ne\\ )'orl... 2{)fl.'. JO. GU~1(111. AC :md Hall. J E: 1i:>. tbool.. of Medll':11 Ph ~si(, log y. ed 10 . WB Saund.:r~. Phll:ldelphl3. 2000. ;II. Afifi. A K . .md Bergman. RA : Funclional Neuroamllo11lY: Tex t and .1..tIJ .... ed.:' L..I.l1ge ~kdK;l1 Bou""f~IcGra\1 -Hil I. New York. 200S. 32 Gha. (' dnd Tluch. WT' The ~creheltum. tn Kandel. ER . Sl·h\\anr. JII . ctnd J~"t"11. TM (cd, ): Principle" 01 Nell !':! 1 SClenC(·_ ed. 4. /l,kGrClv.-[-i111. F\cw Yorh. 2(100. p 1'1.'2. -'-' ~1t"11l1C" . ".1E .•md Oreml:lOd. B' \ IO\eillellt d\"tunl'tlun a,,\x· •. Ht'd v.llh u:n:bdl;tr probk·m~. In Umphred. DA led,: Nt'u ro!u£lc;,1 J{dlJ"1111:Hllll1, cd. -t C\ M o,b~. 51 LOub. 2no I. p 7 17. '.t . t-.h:lnld.. ME . Ba.,.t) g,l1lgj i.J Jl,orrler, ~k t :Jho I K. hcn.'lIl1,tr~.. J nd gt'l1dlt dl'Ordt'I' III JJulh In Umphn!ll. OA ted ): Nc urolug'~'lIl Reh.tbl!tl.tlHll! eJ 4 l'\' MI"b) 51. LoU1'. 2001. pMI _ ':15 lkL,ng . ~lR . lhe o.t!>.tl !,!lJngll,1 In Kandt'L ER. Sdll\unl.. JH . ..l1ld Jt','>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
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100·4, I 12. RlIllhbotlolll. R. el al: The effect of 6 m onths train ing on leg power. balance. and func tional mob il ity of independe ntl y living adults over 70 year;;; old . J Aging Phys Act 11(4):497, 2004. 113. Rubens tein. LZ. et al: Effects of a group exerc ise program on ~ Irt:ng l h. mobilily. and fall s :lnlOng fa ll -prone e lde rl y me n. J Gerontol A Bioi Sci Med Sc i 55(6):M3 17, 2000. I I·t Toraman. NF. Erman. A. and Agyar. E: Effects of mu lticomponent trai ning on function:1 1 fitne ~s in older ad ults. J Agi ng Phys Act 12{-l):5J8. 200-l. liS. United States (US) Cen:. u ~ Bureau : US Inte rim Projectio ns by Age. Sex. Race. and H i~panic Origin (Table 23), 2004. Retrieved July 14. 2005 from hn p:llw ww.ce nsus.govlipc/ www/usinte rimproj/. I !6. Odv1ont. ME. and Peatman. NL: Com munication . va lues. and lhe quality o f life. In Guccione. AA (ed): Geriatric Physical Therapy. M o~ by- Year Book. St. Lou is. 1993. P 21. 117. Janos. Sc. and Boissonnault. WO: Upper quarter screening examination . [n Boissonnault . WG (ed) : Primary Care fo r the Phys ical Ther ... pi ... t: E'\amination and Triage. \VB Saunders. Philade lphia. 1005, p 138. 118. Norki n. CC. and White. OJ : Meawremem of Joint Motio n: A Guide to Goniometry. cd 3. FA Oav i ~. Phi ladelph ia . 2003. 119. HI"")p. HJ. and Monl gofn(~ry. J : Danie l:-. and Worthingham's MUI(cie Te ~ ting. cd 7. WB Saunder:.. Philade lphia. 2002 , 120. Kendall. FP. el al: Musclelo Teqing and Funclion with Posture and Pain. ed S. LippincoH Wi1liam~ & Wilkins. Ph iladelp hia. 1005. I ~ I. Mathl;}~. S. et al: Balance in elderly patients: T he ··get-up and go" t.: ~ 1. A rch Med Rc!t:lbil 67:387, 1986. 122. PO~'tad lo . .D. and Rkhardson. S: TIle tIfllcd " up and go": A lest of baSil: functJunalmobility for fnul elderly persons. J A m Geriatr 50cJ9: 142 . 1991. 113 . Granger. CV. el ;tl : FUllclional a:.St'''!.rnem ~cales: A ~lUdy of per. M)n~ WIth muilipil' ~d.:rOS I ~. Arch P h y~ t>. led Rehabi I 7 1:870, 1990. 11-1. Granl>e:r CV• I::'I al'• Ad,·,\nee In ,"Ullclionai a"selosme nt tor .mediC ' aI ~ " • reh,:lbllll,ulon . Top Gerialr Rehabil 1:59. 1986. 115. Kt'IIh . ,RA . el :tI : 1lle lunl~tionill illdt:pcmlence measure. Adv Clin Rch:lbd 1:6 . 1C)!!7.

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Pel.£. j

C>

pn.

~fltl~.

\\ 1t''CnJangel. 1\1 .1Il" ~crnen, ()J .... cuwlngll..tl probkm!ol :lfte~'IJI1g h.Jnd dnlt'nl) Br.un Rc:, Br,lIll R~" ReI ~61~ 3):161. 2001

CIIAI'TER

8 LEARNING

Examination of Motor Function: Motor Control and Motor Learning

OBJECllVES

1, IdentIfy the purposes and components of the

examination of mO!or fUllCiion: motor control and motor learning. 2. De~cribe the e~amination process and 'Ipecific mea.-,ures of motor function. ~'. Describe common deficits associated with dis-

Susan B. O'Sullivan,

orders of motor function.

4, Discuss factors lhal influence the complexity of the mOlor examination and evaluation process. 5. Discu<;s factors that influence detcnnination of the phySical therapy diagno'lis. 'l, Using the case study example, apply clinical decision making skills in evaluating motor funcllon data.

PT. EdD

OUlllNE Muscle Perfonnance 239 Voluntary Movement Patterns 245 Functional Task Analysis 245 Poslural Control and Balance 249

O\crvie.... of \1olm Function 227

b . arninJIIOrl

I)f

rl.lotor FUTluioll ~2~

Patient HisIO!)' 228 Systems Review 228 Tests and Measures 229

MOInr Learning 15<} Pl:rfonnance Changes 259 Practice Observalions 259 Retcl\llon Test;) 261 Transfer Te~ts 161 Learning Slyies 262

Elem~nh

01 the \ 100ur Fundlon E\.
Overview of Motor Function MtHOr control evohe.. from <.l complex \et of neural, phy\+ lcal. and bdla\ ior.1! pWL:e''''l:s that gO\ern pO~lUre and 11l0\emt:nl Some movement" have a genetic ba~i ... and elllt:ri'(' through prOt:e~:-.e ... 01 norm... l growth and dc\doplllC11l Example ... 01 [he ...e lIl11ude the reOe" pattem'l thJt ptnilllTIlll,.lIe during nJUdl of early life. Olha mo\'cmenh, h:fl,;t.;J mOlur 'lokill... ~trI: learned through Illteraction and l'xpll!llllOll 01 tht: ell\ Ironment Practice <.lOd Itc:Ob'-llk .u e lllJ/ \lrliJllt \
11)

ddllllllg

mOl or ki.lJTtlng "nJ motor

.kdllk;\,·!oplneltl St:Il.. (1) InlorlllatlOIl .tboul rno\t'lllcnt '" li ~J 10 t,'uld.: .md ... hap.: the de\t:!upl1lC:llt of lhe mol OJ promlJtor pro~ram J~ defined ..I.... '~1Il alhtft I' -tN> A mntor phHI

t:r,llH, \.

....:11[..1111111 tli..t!. 'I

I,

purpu:-.dul 01 ... t:\t"Ial UlfllPOIlL:l\1 motul

1111e'\ 11/ "", fl1fll!Ji.w/J I .. .tll IdC;l 01

11111\ 'lIll:Jlt

Ihal

I...

m,lde

up

plan

101

Jlll!J;fdlll ... MotuI' 1TI1'1Il(,r} Ipnl(nillflil rJU·IIW/\') lI\\\)I\e~

th..: rt.:t.;;l!l ,I

[lld!ln IJJllgrdllh

or "'UbrolitHh.~' ,tnd llldudt:~

F\alualloll 202 Diagnosis 262 SUll1lnar~

~62

information on (I) initial movement conditions; (2) how lhe movement felt. lookeJ. and sounded (~en"ory con ... equence~); (3) specific lllovement parameters; and (-0 OUtcome of the movement (h.nowledge of result~), Th\: term neuroplasticit)' refer~ 10 the c
the efftuellC) or ... trellgth of ... )Il<tptic coonce· lion!. to long tam qrul'[urJI changes III the organization .1Ild numberc;, 01 connel'liom among neuroll~."!· [l 'I! A:-. leMIlJllg progrt"... ~t:'l there 1\ J ~hitt !rom shOft-lenn to !('Ingtenn melllory pnX'e\~e... t\h.·IllLlfY allO\\ ... for eOOlinued ..lL\C ...... ollhi~ lnloflllarton for ft'!:>e..U pCrfOffi"lanre or flIodIIJcJ.t1nn of e\l ... tlng pattt'ITl'i of lllO\l~mCIlI MOlor ... l.l!h are acqUIred and modlflcd b) :Iction... of Ihe central nCr\ OU'l s~ ... Iem \C!'\S) through prO{'c~.. e~ of motor

learning proc(" .....e~

rel . lll\t"ly

~lo(Qr k,llIlLll!!, I'

defined JS ·'a 'let 01 Internal \\ nh Pf~lUI\.·(' Of eXlXricnl'e le,ldtng to IXnn.tIwnt l:hang\.:':-. III the {'JpJblhty ll.lf ... l.ilted


hcthl\

!l)r:' J

\ ...... t

amount")

I

.)1\1,

()!

fht: Cl\ S orgJIlI lL".... ..tnJ 1l1Icgr;lIe... '>t:n\ory

Inlolnl.H10n

Fecdbact... i ...

12

Pb~ ..leal

Rf'habtlitalion

r~ ...pon"C'rrndU(,.'-=llll1l(mll;ltlon n.~ccIHd dllnnp. ~\r aller thl:

mm.emcnl Jnel I... ll-.cJ to mmHh)f output tor lNreLIl\C the .....:ndlllp. III ",gn~ll ... III a(h;mc..: 01 nW\c.."mcnt tn rc.tdy lhe 'lol'lhonJnnlOr ...y\tcIllS. aIlO\\~ for :.ll1tU:IP:U0r) adju ... tlllcnl" in pO\lural al'li\ ify. Procc ...... ing of JIlfonn.llIon h the CNS 1'" hoth o;,cn.l! ami parallel. le:lding 1<' the production of c()()rdin.lI~d JnO\;cmcnL ('oordinatiun 1'1 lhe ahllll)' to ('\eCUle ~ll1o()th. accurate. ;Jnd comrollc:d mOWf rC~I)On"'l·\. Coordinalhe s1ruc1urcs (\yncrgi... tic UI1II\) fire lhe "funcllonally !otpccific unil\ of 1ll11 ...cle... and JOIl1I\ Ihat arc con~lramed by !.he ner\'ou... !crall\c1> 10 producc an :Iction."'· p.&16 Differenl 111010r control theoric~ have been propo"Cd 10 C\plalll the cooperative actions of the eNS Ihat allow acc..·o111I11O<.lation of mO\lement to the ~~cific dCnli.U1ds of Ihe la~k :lIld the em lronmelll. T\\o of the major ones are dyn3mlL'al ")'~leI11S theory and hierarchical lheory. Dynamical systnl/.\ cOlltrol theory is based on a dislributed model of 111010r control. A basic concept of thi!:. theory is thai units of Ihe eNS are organized around ~pecific task demands (tenned tas/.. S)'!tems). 11-.e entire CNS may be necessary for COI11plex ta~k.&. whereas only small portions may be needed for simple tasks. Command levels vary depending on the specific ta...k executed. Thus. the highest level of command may not be required in lhe execution of some simple movemenl.s.~ Hierarchical ("omrol theory is based on organization of the eNS imo higher, middle. and lower levels with topdown control. The highesl level components include Ihe a~sociation cortex and portions of the basal ganglia \\ hich function to organize sensorimotor infonnation and are responsible for decision making. Middle level components include the sensorimotor cortex. cerebellum. basal ganglia. and brain~lem. These areas shape and define the specific motor programs and initiate commands. The lowest level component is the spinal cord, which executes the commands. translating them imo the final muscle aClions. In hierarchical theory, initial deci!>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

t POC) ~:ln then ht: clfcc.:llvl'iy developed.

.1dlc.m'l ....ct"dfHr"~ud.

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 >'\Il
(b4lpf"-

='' ' 1O",hk hi 1('\11..11 (pfWlIIl1IlIlltU·n ((I~"'!lIl'

dc .... um III ttll" III Ih\" nlcuu.J,1 r('\.\·hl 1111 pHHnt I"n, dill iii

Hlt'll

l1t III 1/\

Iltl p.uo1meh:f') 01 d''''H\f1If\)I",hlluIJ No (,.1I'\"'t"1) \.·\~un

II'l
thl\luvh ll'n"'lI1Jd. lOrlh."nl. Jnd \..rllcnnn·t'lJ-.ed \;Ihdtt~ '\.'lO\.UrTrlll. pn.'dldl\.C'. and p't"",u'rU\~I. fill" r 1Iuhtllt\ <,I .m In"'lrUII1l:n1 ... n:tlc"h:d 111 1hl.' l.OIl.!ooI'ih:nl~ ot re .. ulh (Ihl.JI1lc."d h~ J "'In~k ~\aml~r 1)\('1 n'rc=tltnJI, Itntr3rater r('lt.lbl!u\ lor .Jllltln~' Illultlrll" l'\Jflltncr... Illllcrr.J1e-r rdlahlltl\ .~. n.tlll\ ," refer", to the propunlOn of ttnlC\ that J lllt'thtl(J llt In.lI~ "'11" l.orTt'lIl) Idenlltic, an 3.bnonnalll) ;l bell1~ plT..enl f 1I1J pO... HI\ e I. \pn ,(if "-," refe~ to the propllnUlI1l'\! time'" thJI a mcthlxt 01 aluJ} ...... conelll) Idenufie\ .In .Jl\lhmn,llll) ~I hclng ah~ent (lfU~ negalt\e). Therapl ...h '1lltluld cleu ... landardlled methoch and m...truIncnt ... "lth e .. tabh hcd validll) JmJ reltabilll). (On"lI'itCnt '" lth lhe Al1u:nUtl1 1'11)\1('31 Thcrap) AIi'lOCI;ulon .... goal of e\ Idem:l' b.hCd pwttlte (ERP). An e\amlllalmn 01 mOlor funl-tion I::. a multifaceted pl(~e.... lh.1I rl~,-!ulre'l :J number of dillelcnt I>lXcifil IC~h rtnd mea'Jurc'l. Lrhlflunenl .. c;.ln he qualitulJte. utilizing ob::.ena11011\ of C"Omplc\ l.l'lI"X::I.:b of pcrt·0n11;'lnce. In"'lghh and undt:r!llundHl~ 01 p'luem.. of mmemcnt or poslure~ are de\'eloped Hom IlldUI:I1\'1.' reU'Julllllg lIonnuhum,g

...peclfll ob.<.en.llIon.. j,

grneraliz.;uions from

'n,c expenenced therapi~t or e':\pen

rltmclan I...

1.0" more ellkicllI in reaching

4U,dll.1\J\ t'

rcrlormanc~ (han

de(:i~lon.'l

aboul

the novict: therapi~t.(l7 lIl'Jlrumenh u,e objecti\ e mea:o.urement a~ a

QU.tllllt:.lIl\ l' \\J) of r\J,I1lUlUlg per1llmlJ,JlCe. Documentation const..unb

the h~dJth care ...) ::.tem and thjrd-party payers InCre:L\lll!!l~ C'mpIM::'I2'C obje(,ll\e lO::.trumcm~ a... proof of Ihe need for ~n IlC", and the eflec1J\ ene,s of ~n ice~. Howe\ er,

IInpo\C'J.

Ele~~n~ of the Molar fun~tion E amination Mental Status

Tests and Mealoures "

.... aOlUialinfl 0' \1otot' lUIlCIHln

h~

man) .1~pel.l ... 01 motor Junction ari' nOI casll) mea... ured For e\.ample. motor learnmg h nO( direct!) m~asurJble but ralher l~ mlerred Irom mea"lures of perfomlance. retention. generdllz.abllll~ . .JOO Jd<.lptJblllt~ Thu... the~ con'lrucb. :Ire u~d to mft:r l:h~lOge' 1Il the C S that occur \\ ah learning. TIle therapl,1 InU,t he \l'lhlll\t.:' 10 the n;.uure of the \anableo;;; being l'\JmI~d .md IIJelltlf) appropnate me~ure !hat prO' Ide a lJlt'anmgtul .tnal)'1\ ul pal1em functlon. It 1"1 nOI hkel~ Ih;)t .Ul~ OUt mt"J un: "III pm\ ide all of the data needed for the t' ......J.mmatlnn 01 mOlor lunClJon. Rt:C:\.J.lnlOallOlh iJ.re p.pectcd outcomes I~ an lOdlcatwo lor dl~hi1fge and relerrJ.1 for lollo\\-up Of addllional )e" IU', Kt:e\Jlllinatlon I ..11 ... 0 an Imponant quaJlIY a~sur~ •.met: rnl·i.hUre.

An e\,tlI11n.tllOn uf mClltJI .. lalU ... 11K lu\h.. , (1) Ic:\.'e1 01 coo-

"',-Iou"'nc",". j~) Orl("l1l..ttlon: \.) ,11I.:OIlon.

(.:l)

mCml'l"). and

l"il ,e("UlI\.: or tllghn {ogmtt\c funuIOfh (e.g.. l"lleulal109 J,hll,llc... .lh... tral1 thlOil1lg. con\trlH.:tlon,11 abillt) 1. '-1cmaJ ,IJtt" ~11e(h tilt' mOCK! .md thoughl of 3Jl mdt'Vldu,ll Abo(lnnJlule, l',m Ol-cur \\ uh nt.'ur(\logl ~,I dl~a ...e Ie!! . tronttll lohc dl~a.\.C, IrJUlTIatu: bram IOJur) or p"')l,.h,31nl" llIne'ls Ie g .. p:mic .H1J.lk . dcpre..... lOn follo\\lIlg

'Mole I. CognUf\t ddi mCmOf\ d~ficll~

11\

can range rom

(lncnt~lIon

and

roor judgment. di,trJctlblht~: a.nd dlffiLullle~ In lI1f(lm131l01l prO(;e""ing . ab...lr3Cl re3\Ontng, and leanllng. 10 n:tme Ju~t a fev.. Patient.) \\ith defi Ib aero..., man) ()r all area... of cogmti"c function dcmon~.tratr diffuse or mulufocal pathology te.g._ AILhclmcr's dl\ta5c. chronic br3111 ...) ndromc). Pallenb v. I1h deficlt~ in only one or 3 few area, of te"ulg t) picJIl) Jemon~trate focal deficn... (e.g., "'lrolej. The ph) sic..allherapl:o.1 may be one of the rlr~l prof~~"'lonJ.h to Interact with the p3ti.:nt and should be able to "Icreen for cognill\·e deficit::. and initiate appropriate referral~. A deul.lled examination by a neurops)'('hoiogisl, occupational thcrapi~t. and/or speech-language pathoiogisl i!t u~u;'llly nccc\ ...ary to ohtain a ('omplclc and accurJle pic.lUrt: of lhc~ deficit,. See ChJplcr 21) for a more complete di\cu:'I'Iion. Lack of <.Jltcntion 10 the p3lient's menial ~lalU, by (he phy.. ical Iherapi ... t can render the. re::.ull~ of other motor lunction lestfol in a paticnI with brain damage invalid and unreliable. l(\

Consciousnes~ EAamm3uon of con..ciousnes'i and arousal is imponant in dctcnnining the degree to \\hich an individual b able to respond. The Offending rellcu/ar acti\'alim: syuem f ARAS) IIlcJudc'S core neuron'i in the brainMern lemlinating m the locus cocruleus and raphe nuclei cells. It functlon~ 10 arouse and awaken Ihe brain and control ::-.kep-wal..e t:ycles. Le'Jions in (he brainstem are a",socirued \\ ith 'Jleep and coma. wherefu. high level of activit) are as~ocialed \\ tth extreme excitement (high arousaJ). The desl·endi"g refit ular Ol'fi\Oling systrm (DRASI i'i composed of the pomine retjculospinaJ tracl. which assisb In ... pmal cord antigravity refle"e'io (extensor tone1 and the medullaJ) reticulo~pinal pa!hways. \\ hich have the oppo~ite effect of dene
F1\ e difiereOl level~ of con~lousncss have bee-n ldenlltiet!. Full consciousness is a Slate of alenne~s or aWarenel\~ and Implie:-. onem.ttion 10 person . place, and time. An alert pallelll b c1l:arly a\\-ake and re::.ponds fully and appropn31el) \\ hen ,polen to or to varymg ~Iimuh, There is a\\arene~ ... of ~elf and Ihe em Ironment. Lelharg)' refers 10 a general ::.10" ing of motor prOCC.'iose~. including ::.pee-ch and

:uo

Pby iaoI Reh.bili,.';on

1000eOlcni. The It'lhargic patient appear" urov.,y but when qU~'lioncd can open the C) c') anu rc:-.pond bnefly. The p;lticnt C3'11) f~lI ... i.I... lccp If not continually ~tirnlilated and doc, nOI lully appn..'ciate the CllVlronmcnl. AHemp" to communi ale \\ nil the palie-nl are difficult 0\\ ing 10 d~ficih in mainlallling fOC'u~. The Ihcrapi'l ,hould ,peal.. in n loud "OICC while calling the p:ltient"~ name. Quc,tion~ 'lhould be ,implc and directed loy,Jrd the indi\ idual (('.g.. How are >nu feehng'!). Obtundaliun r
tion of the le,ion(,) within the CNS.' Clinically the patient can progress from one level of con· sciousness to another. For example, with an intracranial bleed. the swelling and mass efIecI compress the brain. resulting in decreasing levels of consciousness. The patient progresses from consciousness. to lethargy. to stupor, and finally to coma. If medical interventions are successful, recovery is evidenced by a reverse progression. True coma is generaJly time limited. Patienls emerge into a \'egera(il'e sUite, characterized by rerum of irregular sleep/wake cycles and nonnalization of Ihe so-called vegetative functionsrespiration. digestion. and blood pressure control. Curren I effort~ are focused on using the tcnn minimall\' conscious state to refer to this state. The patiem may be ~oused. but remains unaware of his or her environment There is no pur· poscful attentIon or cognitive responsiveness. The ternl per· sistelll \'egetari\"e state is used to describe individuah. who remain in a vegetalive state I year or longer after trdumatic brJ.in. iJljUry and 3 months or more for anoxic brain injury. This L\ aused by severe brain mjul).

The Clas~IJ'" Coma Scale (CCS) is tbe gold ;landard u~d to documenl level of consciousnes~. Three areas of

fWlctlon are ex:amined: eye opening. besl motor re~pon~e,

and \ erbal respon;e (Chapter 22. Table 22.41. Total GCS ~ore~ range from a low of 310 a high of 15. A tOlal 'l:ore of 8 or le~s IS IOdicallve of severe brain injury and coma, tI ~core betYveen 9 and 12 is. indicatiH' of moderate brJin injury, \.\ hereas ;:1 ~core from 13 to J 5 i\ indicative 01 mild brain InJury.IO

::' ""llion of Ihe pupillary .. i/c and rcacti n CHn aho l .\,11111 , rc\cal lI11portanl information aboul Ihe ul1~on~d~us p;.lllcni. Pupil' Ih;)t arc hihlt~rallY ,m:.lll may be Indicative 01 damJge 10 the.: ~) mpathetlc path\\t:.l)' 111 Ihe hypothala· mu'" or mctrtbolH..· encephalopathy. Pinpoint pupils are sug· ,..:o;.tin' of a hemorrhagic pontine Ic\ion or narcotic overdose ~e,g., morphine, heroin). Pupil, thJt are fixed in mid· po~ilion ~lI1d slightly dilJl~d arc !'uggeslivc of midbrain

dam".e \\ hile large bllalerally tixed and dilated pupils ~ugge:1 ~evere anoxia or drug toxicity (e.g.. tricyclic anridepre"an,s). If onl) one pupil is fixed and dilated. temporal lobe hcmiJlion \\ ith compre~sion of the oculomotor ncn'c and midbrain is likely.oJ

Orientation Oriental ion is examined with respect to (l) time (What

day/month/season!year is it? What is the time of day?): (2) place (Where are you? What cily/state arc we in? What is the name of this place?) and (3) persoll (What is your name? How old are you'! \Vhere were you born? What is

the name of your wife/husband''). The therapist records tbe accuracy of the patient's responses. Findings are docu· mented in the medical record as: Patient is alert and ori·

emed times 3 (time. person. place) or times 2 (person, place) depending on the domains correctly identified. An additional domain that can be examined is circumstance (What happened to you? What kind of a place is this? Why do people come here?). To answer these last questions correctly, the individual must be able to take in. store, and recall new information. This may be severely disrupted in the palient with traumatic brain injury. Disorientation is also common with in the patient with delirium or advanced dementia.

Attention Attenlion is the capacity of the brain to process infomlalion from the environment or from long-teon memory. An individual wilh intact seleetire llttemioll is able to screen and process relevant sensor} infomlation about both the ~ask and. the environment while screening out irrelevant mfoml~tlon. The compleXity and familiarity of the task dete~llInes the degree of attention rC4uired. If new or complex mformalion i~ presented, concentration and effort are increased, Patient~ who are inattentive will have difficultv c?ncentra~ing. Allemion deficits are Iypically seen in indi. vld~al"'''!lh delirium, brain injuT). dementia. mental retar· daHon. or perfomlance anxiet\. Scl~ctl\e attemion can ~ examined b) asking the :a~lenl to attend t~ a panicul.lT la~~. For e\ample, the Iher· arl~1 .l~h Ihe pJllt:"m to repeat a ,hurt li..t of numbers for· wards or bad. \\ ard~ (dig;r spall re:;r I. The therapist docun~enh lhe number of dlgib Ihe p,Hleml'> i~ able to rerall. Normally IndiVidual , C.ln . rel....tll ~evc:n forward . and five IXH.:kward numb!;;!" F .. . '. .... or pallenh \\ Ilh commul1Icatlon Impalrlllcnt . . the th T • ' I;; .Ipbt ran reat! a h~1 of ilems while the patten I 1" a~keJ [0 Id~ ·t· . 1;;1111 Y or 'Ignal each time a particular

('h",ptt'r '4 t-: ;amiruttloo of \1010r hlflchon ,Il'rn I' 1Ilt:lIllt1nr:d\IJ\1J1I1l/tI clfttl/lum \Ilr \1~lIanl'c) I'"

h\ lkll'I1I111IIl'~ hI'" long lhl' PdllC'nl , ... ;,lll(' Itl on J r,lnh.:ul.tr W ..." (lIllIC on IJ\~ I '''It'ffllltlllr ourmllJIII,ill(,n1l0n tk\lhllll~ I'''' l·\.illll111t:cl h~ n:\fu(,' .. lIl1f th~ IMlIl'1l1 tu ,them,IIt.' h.lll.. ,tnd fonh "-'I\\t'ell 1\\lldllll'r""nl t,t... ~\ lr.!! ,.ldd the Ilr'II\\OpJlr",,'1 nurnl'Cr.... locn .. uhlr,td lilt' Ill'\1 1\\0 p,m... oj Ilumoc,,,,. Kequt: ... t111f llw p.JlIl'1I1 III p...·r111nn t\\I"l t,I'~'" '"11uItJnCllU'lI) I ' u..cd h1 dl'lenmnt: do Iclr·d aUf f1fum h,r n:Jmplc, lht: pJllCnl lal~\ \\ll1lc ",tJ~lI1g d\a/~/i la/All /e'\lI. or ,\311.... \\hll.: IOC,IIIO~ ;1I11.IhJ"'>1.1 pl.u.ed III thl' ... uk (\II11Uliltt:d grocery \hop~ rlll~l I)lKUrm:nl:ltl\)ll ... holild IIlcllletC lht;' \pcl'ilic compo· 1l1'Ilt tlf ;lllCllllUli l"xamincd, .111) \Im, nc..,.. or hC"litalion 111 IIll' re"p
C\Jn1l1h.·d

ltl.ltlllJIIl ,111(.'1111011

+

~1emo')

"'emur.' I .. the proce!1\ 01 rcgl\tratlull. rctcnllon, and r('call llf pa..t experience. \...nowledge, and idea,. Dcdarali\(' memor~ e'en.... le\phcit memoT)') im'ohc.. the con ..ciou.. recollcdion of f.tcl>, and e\ent~. Mutor mrmor.' mformation (procedural or implicit memory) lll\olw, rel:all of ll1o\'emem~ or mOlOr infonnatioll and ,Il'rage of 1110tor program~, ~ubroutine ... or schema. The len~[h of lime required from Initial acquisition il1lO memOf) abo dl-.lingui\hes t)'pe~ of memory. Immediate memur.' \immediate recall) refcr~ to the immediate regisIratlon ;llld recall of informJlion arta an interval of a few \~xond" (c.g .. repeal after me). Shorl-term memory, ST~l (recent memory) refer"i to the capability 10 remem· ber cum.:nt, day-IO-da) e,elll.., (e.g., whal wa~ eaten for brt"Jl..la':tl. d•.IIel. learn !lew malerial, and retrieve m:,uerial oJ.fler an IIltcnal of minutes. hour~. or days. Long·term memor.'. LT~1 (remote memory) refers to the recall of fact~ or e'en!, that occurred years before (e.g., binhdays. annl\er..ar). hi .. lOric [ach). II include~ items an indi\ idunl \\ould be expected to ""no\\. A Illmple test for memory Involves pre~nting the pattenl wnh a ..hon list of \...ordo;; of unrelated objects (e.g.. pon). coin, pencil) and a~king the patient to repeal tho~e . . . oro . . lI11mcdialdy after prc':tcmalion (immediate recall) and again 5 I11lflutes after pre:-.c.:ntation (STM). LTM can be detenl1lflcd by ha\ ing Ihe p3tiem rec311 event ... or person\ 11'0111 hl'l or her past (Where "-ere you born'! Where dId ~ou go to !'chool? Where do/did you work'!). The pJtICIlI'\ lund of general ~no\... ledge can abo be examined (\\'ho I!\ the pre..ident? Who \\a .. pre!1ldenl during \Vorld \\ar II"' I. 1 he 4ue,tlon.. !'deued 'lhould represent sc.:n'ii11\ 11) to the {;ultural and educ31lonal background of the patient. It I') Importalll to con~ider thaI memory may be mfluenced by attention, motivation, rehearsaL fatigue, and olher factor.. '- The MIn;·Mel1lui SWillS £xamlflllllOJl (:\1."'5£ I prOVides a valid dnd reItable qUlcl screen of cog~ nlll\c functIOn.

P;tI1~nt, \\-lIh amnc4iiia t)fllcJlIy cJenwll'trotte pm nounl't:d mcmm'\ dcfkih Anlcruf,:r.;uh' 11mnetilia {p/ht· "dllma/'I omnn;a P7Al rele, .. 10 the In;,hlllt} w IC:lm I1t'\\ mJlt>rlJI .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!<. l:x.'t\\.t'en object'" (e.g.. an orange and an apple, a hon.e and a donke) . ..,kln and troUM:I'\). Impaired perfomlance can be IlldlCJIlVe 01 lrolllal lobe or diffu"oC encephalopalh) or p'y_ ,hIJ,lfK dIne'.... ".111l'111

Con... tnKllonal abiluy i" the abilil) to copy figure~. lntlllg .... tYPll·ally done b) the ()(.'cupatlOnalther'jpi~1 v.ho ilia) u ...e ~ "ene... 01 paper-and-pencl! ll/e... or to dra"" Ihe fac~ 01 i.t clod... fmp,llfmenh III (.:on"'lructional abilily are ~een III putielH' \I. IIh p.lnetal lobe damage and demenlla.

Arousal Balanced inleraction of the autonomic and somatic sys· terns allows for reactive yet !)table responses of an individual. Sympathetic nervous system (SNS. the alarm system) activilY allows actions to be initiated (0 protect the individual under varying circumstances. Stimulation of the SNS results in (I) hyperalenness: (2) increased hean rate (HR): (3) increased blood pressure (BP); (4) increased respiratory rate (RR): (5) increased blood now to muscles: (6) depressed digestive functions; and (7) mobilized glucose re~erves. Mowr systems become engaged in carrying OUI defensive commands. producing fight or flight responses (e.g.. the aroused patient with traumatic brain injury may hit or bite). Dilated pupils and increased sweating may also be evident. depending upon the degree of arousal. Stimulation of the parasympathetic nervous system pr& duces the opposite responses: slowing of HR. BP, RR. and so fonh' Whereas a certain level of arousal is necessary for optimal motor performance, very low or high levels cause deterioration in motor perfonnance. This is referred to as the inverted-U theory (Yerkes-Dodson law)." Excess levels of arousal can also yield unexpected responses. Patients at either end of an arousal continuum (either very high or very low) may not respond at all or may respond in an unpredictable manner. This phenomenon may explain the reactions ofpatiems who are labile and lack homeostatic controls for nomlal function. Examination of baseline homeostatic levels should, therefore. precede other elements in the palient suspected of autonomic instability (e.g., lhe patient wilh brain injury).15.16 CriticaJ components for baseline examination include (I) a representative sampling of ANS responses. including HR, BP. RR. pupil dilation. and sweating; (2) a detenninalion of patient reactivity, including the degree and rate of re~ponse to sensory stjmulatlon; and (3) a determination of compensatol) mechanisms in response (0 physiological stress~rs..CarefuJ mOnitoring during a motor perfonnance examlnallon as~isls in defining homeostatic slabililY. Specific guidelines for the examination of vilal functions can be found in Chapter 4.

Sensory Integrity and Integration Sens~ry information is a critical component of motor

fun~t1on .. ~I prm ide~ the nece~.sar)' feedback for delerminallOn 0.' IOUIaI position before a movemenr, error deteCtion dunng. . the n10\ 'emelll. an d mO\ ement outcomes nee· e~sary to shape funher learning, I A closed-loop system of ,:,",otor control is definl'd a~ "a ('ontral system employinj: feedback , a refere' . of error, nee 0 f correctnes~. computation and . . ub~e(IUenl co rrcellOn In order to maintain . a' desired ~Lale "I pf62 A ' : vanet)' of fe~db:H.:k sources are used &0 mOllltOr movement In!.;-I u d"mg visual. vestibular, . . . . propnolepllve. and lactile inputs. The tenn somaloseosatkHI (or

(. ha plcr 8 "~"aminalion of \lotor !-um' tion 'i,"lah)'l'n,(lr~ Inpnh) I' ,Ol1lcl lnln u, ~ d 10 refer 10 "l'll·

'N\ ml linnal ll lil f\.'t'l' l\cd tnHll lhc ,k.Jn and llllhlU h)!'! k...: h:·· t.d ',)'I(' n1\. 1 he- eNS :l11:1I)/l':' nil :1\,~I1 I :d:)k mO\C I11 l' nt Illl\mn.llhm. i.ktcrll1 lllc, ernlr, ,md IIl ... l ll ul e:- appropria te (.urrcdhl' , 1 ~ ll nn' :.I ' J1l.!cc:-,ary. Tlw" a thoro ugh ,em,ory ('\:1lllrn:uioll uf l'Jch nf thC'l' ') 'Il'nl' i, all ill1purW lll ti r..:t ,Iq) 111 IIll: l"\.lIn rl1all111l 0 1 lll Oll'r fU Ill'ti nn . Sec Chapt c? r .5 f\lr ,I l'Olllpil' tc lil'l.·U';;"'IOII of Ihi ... topic. T he primary ro lC' \\tll o . . cd-Inop ,),11.::01 ... in m olt'll cun trol ap pear::-. to be th e Illolll!(lring tlll' on~I,IJlI \ l:\ tl''i 'iuch as poslUre and ha1<.tn ce. ,lIld till' contwl 0 1 '1 low mOVCIl1~Jl l S, nr Ih o~c req uiri ng a high lk grl'(' of precl'loll or :lcc ur3C). FceJ back infonlla11011 I' aho c'l\c ntial dunng learn mg or nc\\ mo tor skill '!'. P:111t.'llI " willi h:l\e defi cit.. in ~Ul) Illmc l11 cnHllonit orin g 't'11~0r:- ..,yq cm may be ab le 10 compcn'iate wi th OI her sc n\lJr~ "'~"t:I1l!". For c\~ lllpl c. t h~ patie nt wit h major propriClCt'p tiH' l o\..,t'~ (,~1Il u-.e vision a . . an error-correctin g s)s· lem to rn:l1l1! ;J1Il ~ \ !J hle p O~ l ure . When vbion is al so tmp;J ired. hO\.I,c\t:1". po ~ tural lIl~t:.1bi l iIY become ~ readil y Jpparl!nt Significant ~e n sory lo ~~ e ~ and inadeq uat e comPl'Il!-.:u00 \ h irt~ to mh er I,cn:-ory :.ys tem~ may reSult in ~c\ercl.\ di'lordercd move ment rc~ponse,. Th e pa ti ent v.llh propn oceptlve lo ~ ... cs. ,lJld severe ViSll :.1 1 d i s lUr ba.n ce~ ,uch ~ ... Jlpl o pl ~1 (com monl y ~e en in the pa tie nt ' . . ith mul tipl e ~clero\ I :') m:.ty be unabk 10 maiI1lain ;J :Hable p O~ lUre nt all. Al.Jl accurate e \amina tion. therefore. requ ire!) th at the lhaapl ... I 110\ onl y look. 3t each individua l s en~ory sys tem but :tho ~t t the- me rall . . cn:-.ory iJll erac tion and integ ration ilnd tht: adequacy of compcm.atory adjw.tment s. Postural t:.l~l.,.'\. bdlance . . 10\... (ramp) movements. trackin g ta..;;b. or ne\\ fTlotO! l:.t.:-.b prO\ Ide the ideal chal lenge in whi ch to test feedbal. k control medlilni.stm. and closed- loop proce!ooses. An opel/·loop sYHem of moto r con trol i .. a "contro l system v.lIh pre-prog rammed in ~ lruction :. to an effector Iha! doe ... nOI lJ...,t," fcedbJck illfonna tion and error-detecti on proce!oo\e'l."l r .>n<. M ove l1l e nt~ emerge from learned 1110lO r prog ram.') (}r ...,chema thai contain "a rule. concepl , o r rela· tloll'ihip fomlt."d un the b:bi .. of eAperience.") 1' -167 Rapid and ,hilled Illu\c mcnt seyucnces or we ll -k-arncd movemenb can thu.., be L'omplctcd \\ ir holH the benefi l of .')e nsory fCl!dbad... Ab ..enl·c 01 . . en\alion degrades movement qua lIt ~. al., Cqdt!l1ted Irom ..,em.,ory dealTe rcntJlJ on swd ies. A more Ilkel) Iheor) I'Of l:veryday mo[OI" fun ctio n i.') a hybrid mOlor l.:ontrul '\)~ t t:m 111 \\ hich the eNS ulili f.,e~ both L"ln\cd·
Joint Integrity, Postural Align ment, and Mobility JlJun ran,gc 01 IlhJtion (ROM) anJ Ml f\ \l\ \ ue Ilexibi lity art!

ImpOrtdnll..'kllll·nh oj 1110101 JUIlLIlOn . Limllatiom rc.') trict the norJlJal LOllldlnall:d acttOI1 of mu:-.cle~ ' III con tracture , a h).l:d re~I~I"nll;:: r~'wl!JIlg Il"Olll fibr~)!li~ of liss ul.: '>

2J3

<., urrouild ing a join!. 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


hypertonic mOtor disorda chll racta ized by

ve l oc i t y~depc ndl.! nl re~ i s tance

to passive stre tch. Thl!:' rhe hU'ger and quicker the ~t ret ch . the stronger the resis tance. of the spastic nlu:-.de. During mpid mOVe melll , iOiti al hig h resi.')tance (~pa\ tic c;Jt~h ) may be fo ll owe Li b) a ... udden inhi bition or lett ing go 01 the limb (relaxatio n) in rt~:,ponse to a ~Ire tc h stimulu ,. termed clas p-knife res l)onse. ChroniL" ..,pa"tici ty j, a.s~oc i at ed wit h cont racture, abnurmal PO\tur~ ing and deform ity, fun ctiona l limi ta tion:" and dis.abiliry. Sp{lstic iry an :..e:-,. from Injur) to cOl1iL"ospi ndl path ~J.Y~ (pyl'
234

Ph)sical Rehabilitation

motor neuron" n~sults in disordered spinal se~m~n.lal rcllc\c,\). including increased alpha motoneuron exc~tab~l~ty. " oed spindle (lit) and flexor reflex afferent excitabIlity, mcrea~ . 'nh'b' altered ~) naptie activity. decreased presynaptic la 1 I Ilion. and so forth.l~ The signs and symptoms of,UMN syn· drome include hyperactive stretch reflexes. Involuntary flexor and exlen,or spasm,. clonus. Babinski's sign. exa~­ i!craled cutaneous rellexes. and loss of precise autonomiC ~onlrol. D\s~)nergic movement patterns also occur. including coacti~'3Iion of agonist and antag~nist musc~e g~~up~~

abnonTIal timing. paresis. loss of dextenty. and .fallgablIH~.

Clonus is characterized by C) c1ieal. spasmodic alternation of muscular contraction and relaxation in response to sustame.d stretch of a spastic muscle. Clonus is common in the plantar Oexors. but may also occur in .00he.T :uea~ of th.e body 'Ouch a~ the jav. or wrist. The Babmskl Sign IS dorslfle:xion of the great toe with fanning of the other toes on stimulation of the lateral :-oole of the foot.:'O Rigidit)'

"

Rigidit~ i... a hypertonic slate characterized by Increased

uniform re"i ...t3nce Ihal persists throughout the whole ROM and i" mdependent of Ihe velocity of movement t1eadpipe rigidit~,). It is associated with le~ions of t~e ba:-.al ganglia "'yslem (extrapyramidal syndromes) and IS ~een In Parkinson's disease. Rigidity is the result of ei\ce:o.si\e :-.uprasplllal driye (upper motor neuron facilitation) acting on alpha motor neurons; spinal reOex mechanisms are nonnal. 21 Patients demonstrate stiffness. inflexibility. and significanl functional limitation. Cog" heel rigidil~ refers 10 a hypertonic Siale with ~upenmpo... cd rachellike jerkiness and is commonly seen in upper Ci\tremll) movemenlS (e.g.. \\ rist or elbow OexJOn and extel1'lion) m patients with Parkinson's disease. It ma~ repre\em Ihe pre:-.ence of tremor superimposed on ngldlt~ Tremor. brad) \...lOe,>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<..' atrophy. Mild d~cred~' III Inn\,.' allmg "1Ih J,lht'llIa can abo be '>Cell 1I1 l:er~beIlM It: U'!l', 'I enl[)t)fJI") ,>ti.th::~ ot fl3.nldll) or h) potonlJ. lemlcd 'plllal \ho( ~ or ( aehwJ .\llVd depem,hng 011 the locauon ot the k ... ioll.I.:..lJl he :-'Ct:n \I,)th UMN leslOn~ (e.g.• hemlpl gJ
H,po{lIt1ttl

det.:rea~ed

" "cally followed by lhe development of or weeks. It IS typl . "" and classic UNM sIgns" spasuctty Dystonia " d h ." h rkinetic movement dlsor er c aracter" I DystOnia 's a ype "lzed by d,sor " dered tone and involuntary movements mvo " " yof the body. The movements are slfiular . . II1g large portIOns .' _ . . to athelol"d mements o v , with typical tWlsttng . or wnthmg " D)'St01 ,,"e pOSllIring refers to sustamed abnonnal motions. poSlures caused by co-contraction of muscles that .may last results " les hours . or pennanently. DystOnia for severa I mmu. . ganglta) and can f rom a C S lesion (commonly in the basal " "d"th be inherited (primary idiopathic dystoOl~). assoclat~ WI. enerative disorders (Wilson's disease. Parkmson s neurodeg hor d" disease on excessive L-dopa therapy), or meta IC Jsor· del> (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 <.lrriving al a dctcrlTIll1allon 01 lOne. Repeal IC'lling and a consistent approach 10 examln ..111011 I~ nece'i"ary to Improve the accuracy ~\l1d relJabJiJl) 01 te ...t re"ult~.

!mriul OIHt'fmrioll 01 the patienl can reveal abnormal tht IJIllb~ 01 bod). Careful in~peclion "hould be made' reganJlllg the pm,lIlOn or the Ilmhs, trunl..., and head. With . . . pa ... IKlt), po..,lUrtng in fixed, ..tnllgravil) positiom is commoll' lor exarnpll.', the lIppel eAtremit) i.. . ht'ltl fiAed po~turing of

agi.lill~t the body in flexion, adduction. and ~uplllaljon with

elbow :md wrist/finger flexion. In the supine position, the lower extremIties arc held in extension, adducl10n with plalltarflexion. and inver~ioll (Table 8.1), Limb~ that appear llopry and lifele~s (e.g.. a lower extremity rolled out (0 th~ ..,ide in e.\tcrnal rolation) may indicate hypotOllicity. Palporion of the mll~de belly Illay yield additional mformatlon ahOutlhe reqing stale of Illll:-.ck. Consislenc). finnne..,,,, and turgor .should all be ex.amined. Hypotonic l11u . . cle.., \\ ill feel "oft and flabby, \\ hereas hypertoni<.' mllS~ ("Ie') wi II feel taut and harder than Honnal.

re\ C'JI ... 1Il10nll..ltJOIl ,Ihout the: re~poll~l\enc..,:,> of Illu:-.dc... 10 ,trelch. Bccau..,c the'e re"'pon..,e, ..,hould be e\amllled III the 30:,>elll''': of ... oluntar) COlltrol. the pallent I'" 1ll... lrul'tcd In rel:l\, leltlllg Ihe ther'l· PI:'>I support and 1ll0\(' tht~ lunh. During a pa..,... I\1: Illotion te ... 1. the Ihcr;.lpl~1 ~hould llli.ll1ltain lirm and <.'l)ll~I:.llll manu:\! contact. Ilhwing the limb in all motion ..... \Vhcn tone is nonnal. the 11mb 11l0Ve~ ca,ilv antllhe thcrapi..,t io;; able to '1ller direcllOll and 'peed" ithoul feeling abnormal rcsio;;tancc. The 11mb I'" reo;;pon ...lve and feels light. Hypertonic limb~ gcnerall) feel 'Iiff am.! re'ii~I'UlI 10 mo\ emellt. \\ hile Oaccid limbs feel heav~ and unrc..,pon~i\'c. Older adults rna) find il ditlicult to relax: their stiffne.,... ~hould nol be mistaken for hypertonicity. V3rying Ihe ~pced of movement is an important detennina.nt of "paslicity. Faster movements will intensify the re~istance to pa"sive motion. Clonus, a phasic stretch re"ponse. is examined using a quick ~trclch :'Iimulu~ that i~ then maintained. For exam· pIc. ankle clonll~ is tC')led by ~udden dorsiflexion of Ihe foot and maintainlllg the foot in dor')iflexion. The presence of :1 cla~p-knife re~pon"ie should al\o be nOled. All limb~ and bod) segment~ are e.\amined. with particular attention gl\en to tho~e idenlified a.., problematic in the mitial observation. Compari\ons "hould be made bet\\een upper and IO\l,er limb... and righl and left extremities. Documentation ~hould include a determination of whether the tonal abnormatitie~ are bymmetrical or asymmetrical. Asymmetrical tonal abnormalities are alw:lY~ indicative of neurological dy"function. Q Comparison 10 the unaffected side in palients wilh stroke ~hould be perfonned. It is also Important 10 remember Ihat measuremelll of tone in one position doe~ not ensure that mea"urement \\ ill be the same in other po~itioml or during functional acti"ities. A change in po~illon such a" ,:>itllng up or !)landing up substantially alter., the reyuiremenb for pO~lUral ~upport (postural tone). A qualilat ive determination of the degree of tune should be made. Thcrapl~l'l neetl to be familiar with the wide range of nonnal and abnormal lonal respon..,c.., to devdop an appropnatl' frame of rderence to grade lone. Tone i~ graded on a 0 10 4+ 'tcak: Pa'''1 t' mOl/(111 tnfllll.!

o 1\'0 re"'pon... t Cll.tL·CldJly) I...,.. Decred'led re"pon')('
2... Kormal re.,pon"ie 3...,.. Ex.aggcrakJ n:"'pOlhe (mild lu moderate hyperlonia) 4+ SU~lalneJ rC\pOlhe (...c\ ere h) pcrlonia) Spa..,uc h) 1)(; 11 0111 a c;:m ht' grJded u"Jng Ihe Mudi/ied A .. Il\\onh Stith:. a ~uhJedl\e, 5-poil1l onJJlIal ~('ale.:!·'.2,1 nih "Lalc rt:Ill<.JIll\ the "gold \landard" hy "llIch otht:r 11:"1\ ;ire \ aIiJ,t1ed. .tn<.l h
IOlr.:t.fater relldOIIIl) 1O.l'l41 iJnd good Inlt.'ITJIl'r rdi
mdude I I , Jni.ihllll) 10 dele":t ...nl.tll Lhange... ,md (:!) limlled apphcalion· C~Ul ~ u~t:d lnr t:)"IIt'rJllt) te,llIlg onl).

Table 8.2 Modified Ashworth Scale for Grading Spasticity

ar.Ie

D

It.b.

o

1+

Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM.

2

More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved.

3

Considerable increase in muscle tone, passive movement difficult.

I 4

Affected part(s) rigid in flexion or extension.

From Bohannon, A and Smith, M.24 11201 with permiSSion.

Special tests lhat can also be used to examine spasticity include the pendllium test.:!5 \Vith the patient seated or I) ing

\\ ith knees nexed o\'er the end of a table. the patient's !-nee is fully extended and allowed to drop and swing like ~ pendulum. A nonnal and hypotonic limb will

swing freel) for several oscillations. Hypertonic limbs are re"istant to the ~winging motion and \"'ill quickly return to the mitial depcndenr starting position. The pendulum test has been quantified using an isok.inetic dynamometer for lower extremity testing with high lest-retest reliability. Relmive angle of re\ier~al can be de[ennined.~6 EMG re~ponse to \tretch can al\o be documellled for various velocnie... of ... tretch. The detalle:d and lengthy . . etup limits thi ... melhod to hugel) the rc::search environment. A tIlyotmlOfJl('(l..r IS a handheld cOInputerized eleclfonic dl,;'\ ice dC\l~lo~d by Leonard and Co-\\ orker~:!"!.1lt that can be u~cd (0 mea"'ure IlllhLlc tone. It provides quantitative Illt?a~urement.., of forct.'
Chap'....r 8 ....xaminalion of Moeor "undion

(lb,(:n ;.Ihk mo\,cmenl ntlhc IOIllI (hn,J.. or ... tmng n:"'p!.lIl'C\).

Reflex Integrity Oeep Tendon Rene~e, \)Jl

WC.lJ.. re"'r)l:m\c... m'l~ l:lI.: l"\ Idenl only \\ Ilh p,lipallon (... lIght re..,pt.ln.. . ~ ... \\ nh litlle or no JOInI mO\~lII~I1l'. I he 4u..llIl) .00d magnlludc nl rc'pon\<.·... \hould ~ (.·arclully lhx.:ull1cnh:d. Rellnc.., arc gr:ld~d nn a 0 1O..l+ ...('ail::

or ... IUggl ...h

\ n:nt'\ ,I" ,m lOH.lhull.H) pl~(hll;jhll'. and ... pcufic re...pon...e III J "ulllulu... dq"l'I1JCIlI

an Inl,1l1 reflex 31\' ("'I:n",ol)'

n;n"l'tor.... lk~llllll:lIrlmh'. elkrcnl 1lC'IlI\lIlhl.•ll1d re'IXlnd-

Illg 11l1J,\.le( . . ) or gbnd). The decp tl'lldon rell\:\ (DTR) l'C,ulh lrnl1l 'I1111Ul<.III0I1 of the ~lrcllh-",cl1"'HI\e IA

.JIYcn.'. lll"i

01 tht' IK'uroll1u\Cubr ..plllUIe pnxlul'lllg lllu,de l'ontr;JcllOll \13 a 1l10no.. ~n'lpll"; r'-lIll\~;l). It I" te,teu h) lapping . . harply U\er the l1lu~tlc tendon \\ Ilh a ~l.tlll..l.tfd retkx hammer or "llh the lip' 01 the thcrapi'\(~ finger._ To cn.. . urc adequJte re...pon-.e. the nlu",-k .... IXNlioned III midrange and the pallent " lIl~lrudCt.J h) relru.. SlJmulallOIl can re~uh in

() No rc-'pon\t.: 1+ Prt.:",cl1( hut dcpn:s...cd. low Ilonll ..d :! -I A\ erage. normal :\ + Incn."a\cd. bri . . l...cr Ihan average: pm"ibly hut nOI nee.:· e"...arily abnormal -$ + Very bn ... k.. hy peraclI\'e. \\0 ilh donu~; abnomlal

T3blc ~.3 pre..,enh an o\iervic\\ of the examinalion of DTR retle\eo;:.

Table 8.3 Examination of Deep Tendon Renexes • ..... ~!'J!!

I

2.17

Jaw (CN V)

Patient is sitting, with jaw relaxed and slightly open. Place finger on top of chm; tap downward on top of finger m a direction which causes the Jaw to open.

Jaw rebounds and closes

Biceps Musculocutaneous nerve (C5, C6)

Patient IS sitting With arm flexed and supported. Place thumb over the biceps tendon In the cubital fossa, stretchmg It slightly. Tap thumb or directly on tendon.

Slight contraction of elbow flexors.

Brachioradialls (suplnalor) Radial nerve (C5, C6)

Patient is sitting with arm flexed onto the abdomen. Place linger on the radial tuberoSity and tap finger with hammer.

Slight contraction of elbow flexors, slight wrist extension or radial deviation

Tnceps Radial nerve (C6 C7)

Patient IS sitting with arm supported In abduction, elbow flexed. Palpate triceps lendon Just above olecranon. Tap directly on tendon.

Slight contraction of elbow extensors

Finger flexors Median nerve (C6-T1)

Hold hand in neutral position. Place finger across palmar surface of distal phalanges of four fingers and tap.

Slight contraction of finger flexors

Hamstnngs tibial branch, SCiatiC nerve (L5, 51. 52)

Patient IS prone with knee semlflexed and supported. Palpate tendon at the knee Tap on finger or directly on tendon

Slight contraclLon of knee flexors

Quadnceps (patellar knee Jerk) Femoral r,erve /L2. L3, L4)

Patient IS sitting With knee flexed, foot unsupported Tap tendon of quadriceps muscle between the patella and tibial tuberOSity

Slight COnlraCtlon of knee extensors

AChilles {ankle Jerk, Tibial (51-52)

Patient IS prone With foot over the end of the plinth or sitting With knee flexed and loot held In slight dorSiflexion. Tap tendon Just above ItS Insertion on the calcaneus Malntatomg slight tension on the gastrocnemius-soleus group Improves the response

SlighI contraction of planlarflexors

II

I) I R ...

,Ill'

dlliH lilt

10

elH II

fl· ... r~llhl·

(.111 hI,.'

l'lIh.Ulll'd h\ "')l'ulll Il'lllloru'llll'lll llI;lIll·U\\.'r III Iht: "Nlh/I\I//.. m,Jllt 11,1 Ith' p"lll'lll h(l~\l ... h'Ft..:1ha 11ll' Illl~l'I'" nllt1l' h.l1Id .lud ..lllllH'l\ pull ... lhclIl ,.pall \\ 11Ik Ihl' pfe ... \,01\· , ... 1ll,1I1l1.111h:d. Il'\\l'! l·'tll'll\Il\ ,dll"l'''' .lIl' h:...t.:d \1,11lt'Il\l'''' Ih;tl \..tll hc.' u ...cd In fl'llllofll' Il·... ''\(lll .. I,.· ... HI ,hl' "PI'X'I C\lIl'lllllll'" Ililludl "~11(,~ Illl!! Ihl' 1..11(.'('''' h1g('llk·r. dl'ndull!! Ihl Il'l'lh, \If 1Il..Il..lIW .1 11...1 \\ nh Ihl' lllllll;tl.lh:,al 1.'\lIl·lIlll\ Ih\.' II"'\.' 01 .J1l~ n:lnlon.lll~ 111.lIll'U\l·r... In ,,'Ilul fl· .. I'llm . . t.· ... III 1',lIll·I1l-." llh 11\ 11(\11."11\.'\.1.1 ..tlOulJ he: ".rduJJ~ d\~lIl11cnlt.:d

D I R.. ;tft.' Inlll';I"'l'd 1lI l, 1'\ ... ~ ndl"llll' Ct.' .!! .. "'lml..l' I and "nTl'';1 l'd III L\l'\ ~ndnllnc (c.g .. JX'ripheral lll'Umpalh). nen\,.· mol lOmprl' ,olIl. u~rd'lC'll.lr ... ~ndrom('. and nlll..dc lft ...t';1 ... e. Rdll" "'pr\.'ad nhr.: 1',ICIl'lon 01 Ihe re"pon...c hc~ ond Ihe lllu"l'1c normal I) 1: 'fl':lll'd to contr.lll) I' I nJIl'<1 II\C 01 L \P\ ... )ndrol1lC' Bl:lau..."" l'ach DTR an,t:'... Imm "PCllfil.' '1pm;ll "'c:gml.'nh. an Jh,ent renc:\ l:all ht: u..eJ 10 IJ~nlll) thl' k\d 1)1 ;,j ... pm ...1 k,lt)ll (~.g .. ro.ltJil"ulopJlh)). 'I

Superficial Culaneou, ReAexe. Sup("rfit:lal l:ul:llleuu-. 1t:llt,e\ .Ire ehcllc:tJ \, Ilh a light 'llrol..e- applied 10 lhl' .. 1..111 The C:,\pcl.'led re~pon ... c I... bnd (llnlr;IC!lOn of tlHI\(,.. le .. 111l1l.'f\ dlt'd b) Ihe ....Ime "plllal ...egmenl'l rt:'cclvlng lilt' i.dfcrl·llt Input .. Irom rhe cutaneous receplor.... A <.,Iltllulu .. lhal i" strong may produce irradiJlion 01 CUI:tllL'OU" "'lgnals Wllh aCllvalion protecti\c \\ ithJrawal retlc\(:"'1, Cut:.meous rdle\c'I include

or

IIll' pbnl;l!' Idk,. l'(lnhnl1ln~ wC: ... I!!n... (Chaddoc!l.l, and .lhdolllll1.d rdk\l.''' Ihl' p!Ollla/ rt/1n ,.. ll· ..h:d by apply'IlC ,I ,1f()~111~ ... lIlllUlu.., on thl' .. ole oflhc: foot along the hll(1:,1 l'ktHk'r .101i up .!Crt."'... lhc: ball 01 the fool. A nonnaJ Il....')(,III..c: (;"(111'11"'1'0 ~ll f1l'\Inn 01 11ll' hlg!t.'lC'; ... omelimes the Hlher Ill!.." \\111 dCtlllln,tralc .1 d\)\\l1p)ln~ rc"'pon!o>c. or no 1"c:"'pOll... 1' Jt ,III \n .lhnllmlal rc"'pol1 ...e (pu.. iti',c Babinski ...'gn) um...... I.. 01 dor"'llle'lt.lI1 (urgoll1gJ of the hlg toc, wuh 1~lIInlllg of Ihe IJti:f.1I four I(lc.... It IS lIldicallvc of a corti((hplll.1I (l \1') k\ioll. The C'/lId(/m'~ 'iI,!!" i... elicited by \Irokull! ;,lfOunJ the lateral ;,ml..lc Jnd up the lateral dorsal .1"p.:L·t ;,l Iht:' loot It :11\0 produce\ dOf'Jiflcxion of the bIg loc and I' lon"'H.kred a confinnator} we \lgn. The am/omlUa! refll" I ... dicited ".,ith bnc;k, lighl ~trol..~s ovcr the skin of Ihe: .llxtCllllinal l1lu~de~. A localized contraction under lht:' "'Illnulu'l h prlxJuccd. with a re~ult:lnt deviation of the umhlllCu, toward Ihe ar~a ...timulated. Each quadrant ...hould be IC,>Il:J In a diagon:lI direction. Umbilical deviation In a '1uperior/lateral directIOn indicates integrity of "'plll,1I '1egmenl'l T8 to 1'9. Umbilical deviation in an inferior/latera/ direcltOIl lIldicales intcgril) of spinal segment~ TIO 10 T 1:2, Lm,~ of respon~e i.., abnormal and indicati\le of pi.llhology (e.g.. Ihoracic spinal cord injury). Asymmetry Irol11 ~idc to 'Jide i'l highly ~ignificant with respect to neurological di\ea~e. Abdominal reflexes may be absent with in palient, with obe5ily. or abdominal surgeries. 9 Table 8.4 pn:"..cl1l\ an overview of the e'\~lIl1inalion of superficial cutaneous reflexe ... ,

Table 8.4 Examinalion of Superficial Culancous RcOcxcs 5 • c IlUal Reftexes Stimulus Plantar (S' S2)

With blunt object (kev or wooden end of applicator Slick) stroke the lateral aspect of the sale. movlog from the heel to the ball of the fOOl. curving medially across the ball at the toot.

Normal response is flexion (planlarflexion) of the great toe, and somellmes the other toes (negative Babinski sign). Abnormal response, termed a positive Babinski sign, IS extension (dorsiflexion) of the great toe with fanning of the four other toes (indicates UMN leSions).

Alternate sllmull for plantar (for sensilive feet)·

Same as for plantar.

• Chaddock stroke lateral ankle and lateral aspect of fool • OppenheIm, stroke down tIbial crest Abdomina reflex&s above umbiliCUS

below umbilicus

T8-Tl0 Tl0-T12

POSitIon patient In supine, relaxed Make bnsk, light stroke Over each quadrant of the abdomlnals from the penphery to the umbIlICUS

Localized contraction under the stImulus, causIng the umbilicus to mO\le toward the sllmulus Masked by obeSity

::J

Can be absent In both UMN and LMN disorders

-

.

- ---

th"'ptt>r H I "\ ami natio n (,f \.to' o r Fu n t.1ion

f'rimi liH.' and Ionic Rl'n~,c .. 1'1'I"1I11t(~

,mil '.111/1 ,,17<10 ,,,.... norl11JII) pr~ 'l~ nt dunn!! m! al!l \ ,JIlt! t ",,·~ I!llh.' II1ll·~r..lIl·d ,,~ thl' e NS at .m ~a rl ) a g~. ()n(,\' IIItt·~T.lh:d tlll· ...i..· refl~\(,;'\ arc npt g~llc r~dl ) f l'l:{'g ill/ · .Illk HI ,IJulh III Iht:1I pur~ 10rll1 I h~') Ill;!) llll1l1nu t:. hnv. l'H'" .t~ ddJPll\l' II,I,!!ltll.'"llt ... "II~hJ\ Il)r, un<.krl .\ Ill!! n(lnnal nllltlll (l)lltl(lI~\du1T I MI'!';llh \ \lIlt hr :ull IIlJUI) (c.g., ... tr{1~,x Ir.lUnla tlc bra,n !!llltr)) 111;1) n hrhlt pnmlllH-: and t(lllll

,l'Ik·\t.·. .

p' , ... tU I ~ pn''l·1lI

,Itl ett ln!! \011 1111,11 )

1ll0vc.: n1t' 11I cOlllrol mlll

l';lIlcnl... "lltl ("X hlhlt Ihe:"lC rt'nexe:~ l~pli.:all) II III! C\ h: Il .... t \t· hl.lin t/;1fllagt.: ,tIld olher UMN . . t g n~.

()bllt:Jh,r~ Jnd ' U ... tllIIlCd re "' rH)/l!o.t.':-' Ill:!! dumina te motor !"ll'h;l\ Il'f In: .iI\\ LI ~ \ cOlh .tlered pathological III tht.: adult . RI:t1L'\L''\ 1I1Iporta ni It) c\.arnlllt' in the: palu: nl ... u~pe c t ed ('"II ~lhn(Jrrn;tl rdk\ allJ\ it) IIldti l k Ilexnr withd mwa l. tr:..lc!Il.n grJ. ... I'. to/l1C ned.. IOnic lub)rmthlllC". pO"i ill\c ~uppo n. and ;1 ...... llliJtcJ n·anlon .... flew,. lI'u/ulrClIt 'ol /'" ej7l'.\ is ge nl'rdll) Ihl~ . . ltllpkq 10 obr"crv(' and i . . judged by appearance of an mCr! 1ll1'\l'/llCnI rc'pon't.~ . {ollie ned. rej7nl',\ . on the olilel hand. hla.., {hI..: ll1u ..,cu laturc and may not be vis ibl e throu~h 0\ l'n llllnCl11l'llI res poll!-ll's. In fac!. 1110\ t!l1len t b f:.lrel) pn)(luccd but rather po\ wre I ~ typi<:all y inlluenced through 1011 .11 adju . . flnen l ~. Thu s Ihe term ··tuning rencxes·· h :Ill ,Ipproprltltl:! de ... c-ription of their fun cti on. Abnormal !)(b'url· . . !-I houl d be examined for their rt! ne.\. dependence !c.,!! . the pal lent \\ IIh br~lin injur) exhihil.s e.xcc!)sivc ex len :-001" t01l1' Tn ... upin..: hut nOl in "ide IYlIlg ). To obtain an acc ur.ltl· e:,arn inn llull, thl' Ih e rapi ~ t must be co nccmed with sCH'rJI factors. The patiem mU 3t be posi tioned ~Ippropri­ atdy to allo\\ ror the expected re~ponse. An adequat e h!St ... tmllllu, j.., e,»cntial. induding. bOlh all adequale m~\gni­ lude and duration of Mimulalion. Keen Ob~efV nOI readil y appJrent 10 Ihe eyc. Objective ~cori ng of re!'.ponscs i~ essential. A ren~\ . . t..:oring key Irom Caputc el a11,u5 is:

0+ Absent [+ Tone change: sllght. tl'all!)lent wi th no movement of the e.\ tTtmilie ... 1+ V i!'.lble mmement o r ex tre mitie~ 3+ E\.3,ggcrated. tull Illm emc:11I of ex tfelllj li e~ 4-r OhlIg.llury ,mel "u ~ta lllcd lIlovem en!. la~ ting for more than _,0 ",~col1lh Ti:lbk k5 rre\c.!nt\ an oven iew of the exa min ation or pnmilJ\1' Jnd IOllll re ll exc,.

Cranial Nerve Integrity 1here UIC 12 PJlr~ 01 Lr~trJl
I.ht: head <1m.! ned.. with th t' eXl·e ption 0 1 eN x (vugus). '" hllh I'> dl'·.trtbute.d tu the ,honJ'" and abdomen. C'N" I, II , and" [II ar~ purely ~cll~or) i.lluj ( "Irr) the bP..::cial . . en:-.ts nl ... mdt. VJ!'.HJI1, heJnng, and c4 uilihri ul11 . Crani"l ner\'e ... III IV. aud VI ,lit: purely motor and cu tltrol puplilur) 10

2.\9

l'nn,t ll"lI0n and OJ c movelllent<. C"lIl1al nave, X I and XII :m:: al"'(1 purel) motor, innerva tin!! th e "'h':nloclciLlo1ll.I ... tord . Ir;lpcllu .... und 1\)IlgUt' mu ... cks . C'r:mial Il,,'r\.-c ... V. VII . IX. dnd '\ [Hl' 1l1l:\etl. Lo nt.lIlllllg hoth mowr and . . cn:-our) 11m:!'".... i\ !nIOr fl.llH.:II\IIl :-r ini..'lud~ chew nlg (V), facbl c\.prc ...... ion (V II ). ,>w:tllowing ( IX. x). and vocal ... ound~ tX" SCIl ... ali on... arC" ca rried from the f.I<.'c and hClld ( V. VII. I '). ,,11I11l'nt ..\I)' tr~l (; t. heart, \t.... ~eI..... and 11In g~ (IX. X). and tongut!. Illouth. uno palat.e (V II , IX. X). P:\ra~ympathctic ... cc rC:lOllll)tl1( tiber" (ANS) are ca rried in eN III for control of , mooth mu~clc)) in the eyebalL VII for control of saJivary and lacrimal glands, IX to the parotid "iOl li vary gland, and X 10 the heurt. lungs. and mo ~ t of the dige sti ve sy"tel11. An examination of cranial nerve function should be performed with wspected lesions of the brain. brain stem. and

cervical spine. Deficit" in olfactory function (CN I) should bt.: ~ u :-. pcc ted with lesions of the na ~a l cavi ty, and an terior/inferior cerebrum . Les ions of the optic pathways (o ptic nerve leN IIJ, op ti c chias ma. optic tract. lateral geniculate body. superior colliculus) and vis ual cortc.x may produce visual delicits. Midbrain (mesencephalic) lesions may re:-oult in defici ts of CNs ILl and IV (oc ulom otor. trQ{·hlear). Pontine lesions may involve sever al CNs, inc luding V (op hth a lmic. maxillary. and mandibular branches) and VI (abducen s). Nuc lei of eNs VII ( fa c ial ) and VIII (vesti bular and cochl ear branches ) are located m the junction of the pons and medulla. Lesions affectillg the medulla Illay involve IX (glosso pharyngeal), X (vagus). XI (s pinal accessory). and X II (hypoglossa l). The spi na l root of X I is found in the upper five cervical segments.~ The eNs. their function , clinical tcsb. and poss ibl e abnormal findings arc presented in Table 8.6.

Muscle Perfonnance Strength and Power Muscle performance is ··the c~lpacity of a muscle or a group of IllU~cles LO genera te forces.." ;· P 68s Muscle strength i" ··th e meas urabl e force e ... erted by a mu sc le Or group of mu:-.cle s 10 ove rcome a re~is t(1nce ill one maximal eITon.'·5. r 6~~ botoni c contrac tions involve active shon ening o f mu scles. an d eccentric contraction,; involve active I~n g th e ning of l1lu ... c1es. Isometric contr~ctions produce high leve ls of tension for holding l:ontnll:tjons without O V~ rI t~l ~ve ment. Muscle power is ··work produced per 111111 01 time or th e product of st rength and "peed:''i. p t'o!HI Mu ~c h:: pe rl omlance depend s on a numher of intt':lTelated factor') including kng(h-t e n ~iol1 characteristics, viscoela~­ tit:i.' y. ve lo..: iIY, and mCHIbolic adequacy (fue l storage a~d delivery) . or eljll~tl imponam.:e arc Ihe integra ted actions of the eNS (neuromu!o.cu lar control faclOr~) incluLling (I) the num~ I.· and type. ~f motor Unit b recruited, (2) firing rat e. (3) IlIlllng}scquenclI1g. and (. .0 po:-.tural Mabllizalion. Patient!-l with nel1roi ogical dysfuncllon and impairments I~ I110lor conlrol po'}c unique chall enge3 for the examinali on of IllU~l:k performance. Wcakn es3 (pareSis) or

240

Phjsical Reh.bilita';on

Table 8 5 Examination of Primitive and Tonic ReOexes

Noxious stimulus (pinprick) to sole of foot. Tested in supine or sitting position.

Flexor withdrawal

Toes extend, foot dorsiflexes, entire LE flexes uncontrollably. Onset: 28 weeks gestation. Integrated: 1-2 months.

Crossed extension

Noxious stimulus to ball of foot of LE fixed in extension; tested in supine position.

Opposite LE flexes, then adducts and extends. Onset: 28 weeks gestation. Integrated:1-2 months.

Traction

Grasp forearm and pull up from supine into sitting position.

Grasp and total flexion of the U E. Onset: 28 weeks gestation. Integrated: 2-5 months.

Moro

Sudden change in position of head in relation to trunk; drop patient backward from sitting position.

Extension, abduction of UEs, hand opening, and crying followed by flexion, adduction of arms across chest. Onset: 28 weeks gestation. Integrated: 5-6 months.

Startle

Sudden loud or harsh noise.

Sudden extension or abduction of UEs, crying. Onset: birth. Integrated: persists.

Grasp

Maintained pressure to palm of hand (palmar grasp) or to ball of foot under toes (plantar grasp).

Maintained flexion of fingers or toes. Onset: palmar, birth; plantar, 28 weeks gestation. Integrated: palmer, 4-6 months; plantar, 9 months.

Asymmetrical tonic neck (ATNR)

Rotation of the head to one side.

FleXion ot skull limbs, extension of the jaw limbs, "bow and arrow" or "fencing" posture. Onset: birth. Integrated: 4-<3 months.

Symmetrical tonic neck (STNR)

Flexion or extension of the head.

Symmetrical tonic labYrinthine (TLR or STLR)

Prone or supine position.

PositIve supporting

Contact to the ball of the foot In upright standing position

ASSOCiated reactions

ReSIsted voluntary movement in any part ot the body.

With head flexion: fleXion of UEs, extension of LEs; with head extension' extension of UEs, fleXion of LEs. Onset: 4-6 months. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _'n_t_egrated: 8-12 months. With prone position Increased flexor tonelflexion of , all lImbs; with supine Increased extensor tone/extension of all hmbs Onset: birth. Integrated: 6 months Rigid extension (co-contraction) of the LEs. Onset. birth. Integrated 6 months

LE

=k>....er extremity

UE

=.

upper extremity.

InVOlunt~ry movement in a r~;g extremity.

Onset: blrth-3 months Integrated 8-9 years

!j

Chapter 8 Exami.nation of Motor Fundion

241

Examination of Cranial Nerve Integrity

IOllactory

Smell

Test sense of smell on each side (close off olher noslril): use common, nonirritating odors.

Anosmia (inability 10 detect smells), seen with frontal lobe lesions

II Oplic

Vision

Test visual acuity. Central: Snellen eye chart; test each eye separalely (covering olher eye); lest at dislance of 20 ft.

Blindness, myopia (impaired far vision), presbyopia (impaired near vision)

Test peripheral vision (visual fields) by conlrontalion.

Field defecls: homonymous hemianopsia

Tesl pupillary reactions (constriclion) by shining light in eye lighl; if abnormal, lest near reaction.

Absence of pupillary constriction

Examine pupillary size/shape.

Anisocoria (unequal pupils) Horner's syndrome, CN III paralysis

1I,II10plic and oculomotor

Pupillary reflexes

III, IV, VI Oculomotor, trochlear, and abducens

Extraocular movements

Tesl saccadic (palienl is asked to look in each direclion) and pursuit eye movements (patient follows moving finger).

Strabismus (eye deviates from normal conjugate position) Impaired eye movements Double vision

III

Medial, superior and inferior rectus: inferior oblique: turns eye up, down, in.

Observe position of eye.

Sirabismus: eye pulled outward by CN VI Eye cannot look upward, downward, inward movements.

Test eye movements.

Elevates eyelid.

May see ptosis, pupillary dilation,

IV

Superior oblique: turns eye down when adducted.

Test eye movements.

Eye cannot look down when eye is adducled.

VI

Lateral rectus: turns eye out.

Observe position of eye. Test eye movements.

Esotropia (eye pUlled inward) Eye cannol look oul.

V Tngemmal

Sensory: face

OphthalmiC, maxillary, mandibular diVisions

Test pain, light touch sensations: forehead, cheeks, jaw (eyes closed). Test corneal reflex: touch lightly with wisp of colton.

Loss of facial sensations, numbness wilh CN V lesion Trigger area with trigeminal neuralgia Loss of corneal reflex ipsilaterally (blinking in response to corneal touch)

Sensory: cornea Malar: muscles of mastication

Palpate temporal and masseler muscles. Observe spontaneous movements. Have patient clench leeth, hold against resistance.

Weakness. wasting of muscles When opened. deviation of jaw to Ipsilateral side

Facial expression

TeSI motor functIon faCial muscles. Raise eyebrows, frown. Show teelh, smile. Close eyes tightly. Puff out bolh cheeks

Paralysis: Inability 10 close eye, Drooping corner of mouth, Difficulty wilh speech articulation

VII FaCial

Unilaleral LMN' Bell's palsy (PNI) Bilateral LMN' GUillaln-Barre Unllaleral UMN: stroke

loonIJt1
Chapter 8 E.xamination of Motor Function

241

Table 8.6 Examination of Cranial Nerve Integrity

I Olfactory

Smell

Test sense of smell on each side (close oN other nostril): use common, nonirritating odors.

Anosmia (inability to detect smells), seen with frontal lobe lesions

II Optic

Vision

Test visual acuity. Cenfral: Snellen eye chart; test each eye separately (covering other eye); test at distance of 20 h.

Blindness. myopia (impaired far vision). presbyopia (impaired near vision)

Test peripheral vision (visual fields) by confrontation.

Field defecfs: homonymous hemianopsia

Test pupillary reactions (constriction) by shining light in eye light; if abnormal, test near reaction.

Absence at pupillary constriction

Examine pupillary size/shape.

Anisocoria (unequal pupils) Horner's syndrome, CN III paralysis

II. III Optic and oculomotor

Pupillary reflexes

III, IV. VI Oculomotor, trochlear, and abducens

Extraocular movements

Test saccadic (patient is asked to look in each direction) and pursuit eye movements (patient follows moving finger).

Strabismus (eye deviates from normal conjugate position) Impaired eye movements Double vision

III

Medial, superior and inferior rectus: Inferior oblique; turns eye up, down, in.

Observe position of eye.

Strabismus: eye pulled outward by CN VI Eye cannot look upward, downward, inward movements.

Test eye movements.

Elevates eyelid.

May see ptosis. pupillary dilation.

IV

Superior oblique: turns eye down when adducted.

Test eye movements.

Eye cannot look down when eye is adducted.

VI

Lateral rectus: turns eye out.

Observe position of eye. Test eye movements.

Esotropia (eye pulled inward) Eye cannot look out.

V Trigemmal

Sensory: face

Test pain, light touch sensations: forehead. cheeks, jaw (eyes closed). Test corneal reflex: touch lightly with wisp of colton.

Loss of facial sensations, numbness with CN V lesion Trigger area with trigeminal neuralgia Loss of corneal reflex ipsilaterally (blinking in response to corneal touch)

Motor: muscles of mastication

Palpate temporal and masseter muscles. Observe spontaneous movements. Have patient clench teeth, hold against resIstance.

Weakness, wasting of muscles When opened, deviation of jaw to ipsilateral side

FaCial expression

Test motor function faCial muscles. Raise eyebrows, frown Show teeth, smile. Close eyes tighfly. PuN out both cheeks.

Ophthalmic. I maXillary, mandibular divISions

VII FaCial

Sensory: cornea

-----------Paralysis: Inability to close eye, Drooping comer of mouth, DIHiculty with speech articulation Unilateral LMN: Bell's palsy (PNI) Bilateral LMN: Guillain-Barre UOilateral UMN: stroke

242

Physical Rehabilitation

Table 8.6

Examination of Cranial Nerve Integrity

VIII Vestibulococh· lear (acoustic)

Taste to anterior two thirds of tongue

Apply saline solution and sugar solution using a cotton swab.

Vestibular function

Test balance: vestibulospinal function (VSR). Test eye-head coordination: vestibular ocular reflex (VOR).

Cochlear function

Vertigo, dysequilibrium Gaze instability with head rotations, nystagmus (constant, involuntary cyclical movement of the eyebalf)

Test auditory acuity.

Deafness, impaired hearing, tinnitus

Test for lateralization (Weber test): place vibrating tuning fork on top of head, midposition; check if sound heard in one ear, or equally in both.

Unilateral conductive loss: sound laterahzed to impaired ear Sensorineural loss: sound heard in good ear

Compare air and bone conduction (Rinne test): place vibrating tuning fork on mastoid bone, then close to ear canal; sound heard longer through air than bone.

Conductive loss: sound heard through bone is equal to or longer than air Sensonneural loss; sound heard longer through air

IX Glossopharyngeal

Sensory to postenor one third of tongue, pharynx, middle ear

Apply saline solution and sugar solution Not typicalfy tested

Incorrectly identJties solutIOn.

IX, X Glossopharyngeal and vagus

Phonation Swallowing

Listen to vOice quality.

DysphoRia: hoarseness denotes vocal cord weakness: nasal quahty denotes palatal weakness.

Examine for difficulty in swallowing glass of waler.

Dysphagl8

XI Spinal accessory

Palatal. pharynx control

Have pattent say ~ah~- observe molion of soft palate (elevates) and position of UVula (remaIns midline).

Gag reflex

Stimulate back of throa. lightly on each stde

pasSI IV

Examine bo'k. strength

LM

Motor function TrapezIus muscle Slernoc:leldomaSIOtd

ParafyslS palale fa'ls to elevate (Iesoon of CN Xl aSyrPmetncaJ elevahon WIth unIlateral para IS

Absent refl , I SIOR 01 CN IX.

eN

al'opny I,soc,,,..hons. Ipsi_ _

wea houlders upward Shrug bol against reSistance Turn head to aen s

agaInst

~eSI&tanc..e

rug IpSIlateral shoulder.

Inab"Il) 0 s s

(r~

yS

tnab II 0 t\.orn d 10 te stdI lJMI ... 1'" Os 1 p lateraf

,to'" and COOlfala.....

Ira XII Hypoglossal

Tongue mOvements

."tn

EXamine I Sflng pas \.-on of tongu Exam nb toogue mov ohk patte ,t to pr tf\.. longoe roo", s de to':»1

Oy nnn I n leSions 01 CN X '" C I XII al,o Vtll 'a>ciCoJa'

",

I

01 tongue

c.:nh

• .de ,on lunyue deviates away tr\)f'.;,l

co

~

-----_.........

1ieSiOf)

Chaplcr 8 Examination of Motor Function .lh'-t..'llrc {'I mu ...dc ... trcnglh (plcp.w J I'" ,cen III patient-. \\ ilh 1''\1' \l1drllmC ;lIong wllh 'p.I"Ilicil). h)pCracll\C renne ',md ...0 fonh. Pallcnh 111i..IY prc"Icnt \\ ith hl',mp/t'~;fl (l)nl~-'lldcd pamly"I'" l, p.lr:lplcgla (10\\ cr c\ln:mily r;UJI)'I"') or It'trapl('f~1O t1Quadripleglal paral)~i~ of all lour IlI1Ibq. WCJlnc"" of mu'clc... III palienh UMN lesion ... I' .1 pnm:try or lhrt::cl lI11pamllCIlt \\ ilh force produclion llnp'llred III Ihe agllnl,1 rnu . . c1e. Ahcred recruillllcnt and dCl·rca...cd mOlor unil finng rate"l ha\c been idcntificd.\f>..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">'<.tll1lJ1e IllOlor lunctlon In patlelll'l \\ ilh polio (a LM'\ di"'l'a-.eJ. Their u...elulnc\"1 III the dlllical examlnallOn of P.illt:nt '" IUl L'l\lN le'::llon... hd~ been quc"lIJOllcd:H J~ ')tn:nl).th t~'ltlllg U'IlIlg !O)landardllt~d protocol!-. ma) be apprupn.l!t.' lor 'I)m\,' p:ltlenh "ilh UMN ~)'ndrome. bUl not for ot&n.. Apprupn..uc ,mend .m: lheretarc l'llllcal III ddcnnlfl~g \\h..:ther thl.: 'll<.indard, of \ahdlt} and rehabllll) land<.lfllll.ccJ lMT prOl:cdure, and l"IollllCllL pro-

243

tocols. ma) nol be IXlsslble in the presence of UMN lesion \\ ith ...tercolypic ,Ibnonnal movement panem~. abnormal coactivillion. spa....ticil)'. and abnonnal posturing. These barrieN 10 nomlal movement have been tenned acril'f' restraiflf. The prescribed leo;;;l po\iliol1s may also be precluded by the presence of abnonnal reflex activity (e.g..... upine testing influenced by presence of the IOnic labyrinthine reflex). Muscle and soft ti"suc changes in viscoelasticity (e.g .. contracture) offer a fonn of plI\'.sire restraim and may also preclude the use of standardiled testing. In these insrances, the decision should be made Ilot to use standardized MMTs. An e.stjma~ tion of strength can be made from observations of active movements during perfonnance of functional tasks. For example. shallow knee bends or sit-lO-stfUld transfers can be used 10 examine the strength of hip extensors and knee extensors. Standing heel·rises or toe-rises can be used to examine the strength of fool-ankJe mu~les (dorsi flexors, planlarllexors). Documentation should clearly indicale that UMN involvemenl precluded use of standardized MMT procedures and thai estimates of strength are based on observations during perfomlance of funclional tasks. Movements can be graded using the following ordinal scale:

o Zero (0) I Trace (T)

2 Poor (P) 3 Fair (F) 4 Good (G)

5 Nom,.1 ( I

No evidence of contraction by vision or palpation Slight contraction. no motion Movement through complele ROM in gravity-minimized position Movement through complete ROM against gravity Movement through complete ROM against gravity; able to hold against modcraie resistance; can be broken (break tC!o.t) al end range Mo\'emelll through complete ROM against gravity; able to hold against maximum re... i~tance: cannot be brol...en at end range

If MMT 1"1 ta be u~ed. therapists should luilize ~tan­ dardilcd pt..... ~J1ion~. If a modified position is required (e.g .. the paticnt laclo,; full ROM or adequate slabilizallon). II should be C:lTCflllly dtx'um~llIed. Sl/h.\fitl/tiollJ (mu,>cle aClion~ thai compcl13ate for ~pecific muscle w~alncss) ~hoL1ld be ielent ilied, t:J illlin~ued "hellever possible. ami carefully documented. For example. the p~Hlel1l \Vllh ~pini.ll (:ord injury t) plc311) pre,l,CIllS \\ ilh t:OmOlon muscle suhqjtution ... (e.g .. \\ fl'll e:\len~or ... Jrc u'led 10 r1o~c the ting('r~ lhlllg te-node'I'" gnhp). Knowledge of COmmon ~ubstltu­ lions i... \ery helplul "hell \\orlll1g \\,llh Ihl~ p<.ttlenl group. Rehahdll) 01 M~lT III lhe dimedl ..,etllllg h.ls bt-en 10\\0. In one !o)lud). Ihe Ill\c..,lIgalOr~ found Ihe peff'elll.lge or thera~I::'h. obtdllling Ihl' ...;lIne ll1u.')l·le grdde. onl) ranged from )0 to 60 pl"'rl'ent. fa('tors that intluelll'c Ihe reproducibilil\ of tht.' rc::.ulh lududt:: dlftil'U!l)" \\ nil delcTlllllllng the nMg"nJludc of rCShllh~ lorL't" hubJecti'vll)' of good a.nu nonnal

244

l:ttl, ..ical Rehabilitation

L!.r.lllc .. ). (hllrrcnc" .. In IC,llIlg I1H'lhod. I..hflcrcl1l'c\ in force ;lppllralum (POllll. Iille of lorec. ",X'I.:I..I). dtlr~llioll of lhe (·uIIII:1I.. 11(.111, p,lllC'1ll fa lor:
Endurance 'lu~l'Ie tnduranct: I~ "tht: ability to ~u .. lalll t'orce~ repeal. cdl) or 10 generate: tORt." o\er a penod of lime"'~' r(J,"ll( An t:'\i.Ill1lnallun 01 mu\de endurance I~ important in deler. mllllJlg lunUI()lIal l:rJpacll). Faligue h...\ been defined a\ "the t..lilurt.' to generate: Iht: required or e.xpedcd t'or(.c durm!,! .,u"I"llned 01 lepealcJ l'Ontractlon~. '\4 P .jIll Although IJ!lgue I~ prote(:ll\c <1I1e1 ~ne:'l a u~dtJltuncllon in guardII1g "'gam.. . t o\erv.or~ and II1JUry. 1I1~ a ~enou., problem tOf "ome mdl'vl(Juah, For e\ample. pallenI'. \\ ilh PO:'ltpolto ~) nllmme or lhrOlll1' 1,IIJgue ~ynuromt' lila) c.\penenl:e

'r. ·.... ,r'clions III their fUTlctional activities and 'lgl1ll l l'anr r c . . . , . . , " ull of debilitaling 'allgue, Olher groups of wurl'\. a~ a rt:~ . . . exnl'''.rience IImltalions as. a result ,1Il(I'IVI'd ua I~ w ho m'IY . ""Iso '1'-. those wilh multiple scleroSIS. amy' , 'nclude o f f allgll~ I otrophic I.ueral sdcrosis. Duchenne mu:-.cular dystrophy,

,

d

~.s-\<J

and Guillain-Barre syn rome.An examination of fmiguC' begins with routine queslion' 19 . n dUring_ the initial interview. and is followed up with more specific fUll{'tionalteSI~as indicated. Self-assessments usmg a questionnaire are the preferre? fonnat ~ather than .per. fonnance.based tests. which are hkely to fatigue the patient. The patient should be asked questions pertaining to the frequency and severity of fatigue episodes. and the circumstances surrounding the onset and cessation of fatigue. Precipitating activities should be identified within the context of habitual daily activity. h is important to document the !m(r:.ue threshold. defined as "that level of exercise mar cannol be sustained indefmilcly:"60· p 691 In most cases, the onset of fatigue is gradual. not abrupt. and dependent on the intensity and duration of the activity attempted. Additional faclors that can influence fatigue include health status. envi· ronmental comext (e.g.. stressful environment). and temperature (e.g.. heat stress in the patient with multiple sclerosis). The therapist should carefully document the patient's level of performance. including independence, modified independence. or level of assistance required (minimal, model'· ate. or maximal). Perceived level of fatigue can be documented using a visual analog scale or the Borg Scale for Ratings of Percei\led Exertion. tll The Modified Fatigue Impact Stalt, (MFIS) is a useful instrument initiaJly developed to assess quality-of-Iife problems related to fatigue in patients with multiple sclerosis. It includes questions on the cognitive and social domains. as well as physical perform~ ance (see Chapter 19, Appendix B)," Exhaustion is defined as th~ limit of endurance, beyond v. hith no further perfonnance is possible. Most patients can report with great accuracy the point at which exhaustion is reached. Of concern wilh some pallems is overwork weaka ness (injury). defined as "a prolonged decrease in absolute \trength and endurance due ro excessive activity of partially denervated mu~c1e.'"63. P ~~ For c>.ample. patient~ with post· polio ~y~d.rome ma) experience weakness following suen. uou~ JCII\'~ty thai is not recovered \\ Ilh ordll1ary rest. They

re~n ha v ll1g to "pend the cmjre neXf da) or two in bed fol10\\ lIlg an exhau~lj\'e exen.;i\e M"ssioll. h is therefore imporlam to dlXument the type. length. .tnd clTectiveness of rest anemph. Dela~cd onSeT mll.)de 5Jurt'ness (OOMS) is com. mon 111_ palit:nb \\ IIh o\,("n.\,·ork \\ ealness. peaking between I anJ :'> da)~ po:-.t-actl\ it). Examinallon of mu~clt· f:tugue ~an Include both voli1I0nal and cit: ..'Irica'" J e I (ClIeJ fallCliC (e~t~ uSl11g " an look.l· ' netic lJ) namomeler Th' . ~ . . I~ equipment permits quantiflcauon of torque OlltPlIlS.. Patients acc a~ked to perform repetjrive. ~ubma>'lmal l\ol..lJlctic Contractions. A drop.off of peak lorque by SO I'\i"n..:enl' be ~ .' 1-l:an u~t.'d :l~ an index of fatigue. Ell"clm ally lI1duced fatigue te:-.b cali J.lso be used (0 examine

Chapler 8 Eumination of Molor Function pcrfonnance and may provide a more reliable measure In indlviduab wi!.h IO\~ mOlivation or \~ ho havc a disorder of cenlraJ dnve (e.g.. :c.troke). TIle muscle i.. stimulated with group~ of electrical pulses (pulse trains) and percentage of dt.'Cline in force production is lllcasured.64-()(' Timed perfonnanre on functional tasls (e.g.. timed self-care tasks: lime 10 \\ al" a pallicular distance. 6-minute waJl... tcst) also pro\ ide obJccli"e and reproducible measure~ of endurance. I1llhClC'

Voluntary Movement Patterns Voluntary movement pallCI1lS utilize functionally linked l1lu:-cles or synergies that are constrained by the CNS to act cooperatively to produce an action. The CNS is able to reduce !.he degrees of freedom. defined as the number of M"paratc independent dimensions of movement that must be controlled by engaging Ihese cooperative units of muscle action. I Synergistic movements are defmed by precise spatial and temporal organization. Coordination involves control of speed. di~lance. direction. rhythm. and levels of muscle lens ion. In individuals wilh normal mOlOr comrol. the patlern~ of coordinalion are numerous and variable. mcluding pallems of single limb and multiple limb coordination. bilateral (bimanual) coordination. symmetrical, as)mmetrical. or reciprocal limb patterns coordinated with appropriate proximal stabllizalion and postural support. Mo\'ements are also appropriately timed wilh event~ in the environment (coillcidellt timing J. (See Chapler 7.)

Abnonnal Synergistic Patterns Synergistic organizalion of movement may be dbturbed in case~ of CMr\ S) ndrome. Abnormal mass s~'nergies are defined as obligatory. highly stereOlyped mass pallems of mO\'ement. Selective Inmement control (isolated joinl movemems) becomes severely di!)ordered or disappears completely. For example, patients with stroke may demonstrate oblig~ ator)' flexion ~ynergie~ and extension synergies (~e Chapter 18. Table 18.6) Abnormal ,)nergies are highly predictable and characterl'"uc of middle "tages of stroke recovcry..I~.H The examu1
245

movement control are evidence of sequential recovery in patienls with stroke. The Fugl-Meyer Post-Stroke AS.\e.fsme1l1 of Physical Pe,forma"ce provides an objective and quantifiable measure of synergistic dominance and recovery after stroke" (see Chapter 18, Appendix A). Table 8.7 presents a summary of the differential diagnosis comparing upper motor neuron and lower motor neuron syndromes. Table 8.8 presents a summary of the differential diagnosis comparing the major types of motor comrol disorders.

Functional Task Analysis Examination at the functional level focuses on observation and classification of functional abilities and the identification of functional limitations. Performance-based measures yield important information about motor function. umefOus instruments are available with quantitative scoring systems (e.g.. the Functional Independence Measure [FIM]). See Chapter I I for a thorough discussion. Qualitative analysis of functional tasks provides important information about the complex nature of these skills and the patient's level of motor control. Performance is observed through careful task analysis. The therapist interprets the observed behaviors by comparing them to a reference of nom1ative behaviors. [nterpretations are made about the nature of the motor performance and the possible links between documented impairments and performance difficuhies. For example. the patient with acure stroke typically sits up from supine using primarily the sound side. The affecled extremities lag behind. not well integraled into the movement pattern. The final sitting position is often asymmetrical with most of the weight borne on the sound ~ide and the affected upper extremity held in an abnormally flexed and adducted position. It is important to documcnt these qualitative findings as they provide important data necessary for developing an effective plan of care (POC) to improve Illotor function. The \Vorksheet presented Box 8.1 provides a series of questions thai can be used to facilitate functional task analysis. Funcfto"al mohilir)' sJ..ills (FMS) important 10 analyze include (I) bed mobility (e.g.. rolling from side to side, bridging and scooting. moving from supine 10 sit and Sll to "upine); (2) siBing ~kill\ (e.g.. moving in the posture. reaching); (3) transfer s"ill ... (e.g.. moving from sit-Io-:)tand and \tand-to- ... itl, transfer... from one ~urface to another (e.e.. bed to \\heelchair, \~heelchair 10 car Jnd so forth); (4) standing ~l..ills (e.g., ma..ll1tenance of ~ture. movlllg in the poSture, reaching. stepping); (5) walking; and (6) ~tair cbmblllg. Comrol can also be c>.amined In other poslures including pronc-on-elhow~. quadruped (hand~ and k.n~e~), kneeling, halt-"ncl'iing. and ...tanding up from the floor. It is impor(ant to nOll: lhat Ihl:fc i.!t considerable variability in motor performance of FMS acro~s the hfe.!tpan.()h n Changes are ul1luenccd by ~ul'h fal'tors ~ changing body uimension~. age. health, level ot ph}~ical activity, dOd ~o fonh. Thu~, the

. . C ompanso . n 0 f Upper Motor curon (UMN) Table 8.7 Differential DIagnoSIs: and Lo\\er Motor Neuron (L iN) Syndromes -

Central nervous system cortex, bralnstem, cortIcospinal tracts. spinal cord

Polio, Gui1laln·Barre, Penpheral nerve injury, Peripheral neuropathy, Radiculopathy

Stroke. traumatic bram inJury, spinal cord injury

Decreased or absent:

Increased: hypertonia Velocity dependent

......'

From O'Sulhvan S. and Siegelman

Cranial nerve nuclei/nerves Spinal cord: anterior horn cell, spmal roots Peripheral nerve

hypotonia, flaccidity Not velocity dependent

Increased: hyperreflexia, clonus Exaggerated cutaneous and autonomiC reflexes. +8abinskl

Decreased or absent: hyporeflexia

Muscle spasms: flexor or extensor

With denervation: fasciculations

Weakness or paralysis: Ipsilateral (stroke) or bilateral (SCI) Corticospinal: contralateral If above decussation In medulla; ipSIlateral if below Distribution: never focal

Ipsilateral weakness or paralysis

Disuse atrophy: variable, widespread distribution, especially of antigravity muscles

Neurogenic atrophy: rapid, focal distribution, severe wasting

Impaired or absent: dyssynergic patterns, obligatory mass synergies

Weak or absent if nerve interrupted

R, 133

Cutaneous reflexes decreased or absent

Limited distribution: segmental or focal pattern. root·lnnervated pattern

P94 With permiSSIon.

actlvitie~ of rollmg over and ~itti.ng up may vary con~ider­ ably betv.een tv.o adult", of different \ize. age. or health.

Conlfol ob..cf\ed during functional ",lill., cu.n be documented according 10 lhe nalUre of the task: (I) mobility. (21 statIc po~tural cOlltrol. (31 d)'namil: po~tural conlro!. and (4) ,kill (,eo Table 1:\.2. Caiegone; of MolOr Skills). Mobilil~ is the 3bilit) to move from one posilion (0 another IIldepcndellll) and \Jlel).~ Common t:haracleri<.,lic", of normal mobility include the abdlly 10 move the bod) while mamtammg po.. lural l:Olllrol. Deli.. .· Jh in Ulllwl mohilily range from failure to InJlwte or \u"tain movements 10 poor!) controlled movement. Al lh~ \el") lowesll\:\eL the unpaired pallellt ''I only able 10 roll partially over to "'Ille I) mg anti c:xhlbu.!> poorl) ,u...li.lll1ed and (.;olltrolleo mO\emenl~. AI lh~ hlght\{ end. Ih~ pJti~nr .... a ,,,"e-d to "ti.lnd up and \\ alk J.Lro-,,~ Ihe HII.)m. The Imp"J1red pdllenr ~)o;.hlbih lhtllcuh) ~t ..mJlI1g up 10101) rt:qulfl~ ..e\l'ral aHt:mph) hut onle up I'" ahle tn \\all.. v. Ilh onl~ a fev. abnormal gall t.:haraderhllt.:\, Ke)- dt:menl~ lh..: Ihcrapl I \hould oh~f\C' and dl.l,:umcllt IOdude (I j the lliltiduon and luntml of O)mcO)cnt..; (2) the '\\.'n~)I). motor and c.:ognUI\C ~lr;lIegh::'l rt:4ulfcd and O\crall l'l>ordlllallun.

()) 1110\ ement lemlinalion: and (4) envirorunental con...tramh Ihal must be con~idered. Stalic postural conlrol (.'"taIK equilib,-ium. stan'c bal· alice. or r;ruhillfy) i.!> the ability to maintain postural stability and orientation with lhe center of ma....... (COM) over the base of ,uppon (BaS I and the body ai rest. For example, the patient delllon~tratts "'labillty in .. inlJ1g Of standing if he or ~he i\ able 10 malOwin the po:-,ture with minimum sway, no 10\'101 balance, and no handhold. Key elements Ihe therapist

:-,hould oh...cf\'e and documenlllldude (1) the base.of.suppoJt (BaS): (2) Ihe po,i'ion and "ahllil} of the cenler-of-mass (COM) ""hln lhe BaS: (}) lh< degree of postural sway; (·H Uk degree of
O~ namic postural control (dHlUmic equilibrIUm, halance. 0'- (cmrn,Ut'd m~jblJir,,) i~ the ability to I11Jll1lalO po~turiil ~I.lblht)- J,nJ orll.:ntarion wllh the COM OV~T tht' BO~ \\hile pi.tn~ ot thl.: hody are in molion. Thus

t!\f1(JIJl/t'

an Intil\ Idual" ..tble- 10 \\clght .. hifl or rock back and

forth

Chapter 8 Examination of Motor Function

247

Table 8.8 Differential Diagnosis: Comparison of Major Types of Central Nen'ou... System Disorders

Trauma, tumor, vascular insult: complete, incomplete SCI Impaired or absent: depends on lesion location; contralateral sensory loss

Not affected

Not affected

Impaired or absent below the level of lesion

Hypertonia/spasticity velocity-dependent; c1asp·knife Initial flaccidity: cerebral shock

Leadpipe rigidity: increased, uniform resistance Cogwheel rigidity: increased, rachetlike resistance

Normal or may be decreased

Hypertonia/ spasticity below the level of the lesion Initial flaccidity: spinal shock

Hyperreflexia

Normal or may be decreased

Normal or may be decreased

Hyperreflexia

Contralateral weakness or paralysis: hemiplegia or hemiparesis Disuse weakness in chronic stage

Disuse weakness in chronic stage

Normal or weak: asthenia

Impaired or absent below the level of the lesion: paraplegia or paraparesis; tetraplegia or tetraparesis

Normal during acute stage; disuse atrophy in chronic stage

Normal or disuse atrophy

Normal

Disuse atrophy

Spasms

Resting tremor

None

Spasms

Dyssynergic: abnormal timing, co-activation, fatigability

Bradykinesia: slowness of movement Akinesia: absence of movement

Ataxia: intention tremor dysdiadochokinesia dysmetria dyssynergia nystagmus

Above level of lesion: intact (normal) Below level of lesion: impaired or absent

Impaired or absent, depends on lesion location Impaired balance

Impaired: stooped (flexed) Impaired balance

Impaired: truncal ataxia Impaired balance

Impaired below level of lesion Impaired balance

Impaired: gait deficits due to abnormal weakness, synergies, spasticity, timing deficits

Impaired: shuffling, festinating gait

Impaired: ataxic gait deficits, widebased, unsteady

Impaired or absent: depends on level of lesion

---.......1-

From O'Sullivan S, and Siegelman A,':>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
Skill is the ability to consistently perform coordinated movement sequence5. for the purposes of investigation and interaction with the physical and social environment. Proximal segments stabilize v, hi Ie distal segments are free for ,killed function (e.g.. manipulation or transpon). Skills are learned. and are lhe direct result of practice and experience. Key element~ the therapl~l ~hould observe and docu· menl include (I) re~po~ onem~\tion and direction of movements (correct mO\,ement response): (2) precision, coorml, and con~l...tency of mo\emenb (cominuous and appropriate motOr adjusrments. '!)tead1Jless)~ (3) control of movement

...peed and liming including rcdclIon tune. movement time; and (4) oronom) of e/fon. MOlol' ,lilb can be discrele. conlU1UOlh. or ~nal KK~ng J ball is an example of a discrete ...kill, \I.lll1 .t recoglllzable hegll1l1lllg and end. Walking is a COl1tlllUOUS ~klll (no recognizable beginning and c:nd), and playing a piano represents d seriJ.1 ~"'--iH (a series of discrete 1.ICl!on\ pUI together). A !okil1e<.l individual is able to adapt mo\ements ea~i1y 10 the spec i lie environments in which they

(,h.tplt.' r R I '30linarion of Mofor FunC:lion

,\(..,;IU !lUI .... u)ntlol of \\ ,1110. IIlg I~ ~"ltknt III the dilll~ ;h \\el l ,l'" In the hUIne (,l1\ lrolll1l~llt. A rnu\l:l11clH ... \..ill perf0n11CJ In ,I ",I.lhle. ll('InLilJJI!.!lI1g e n\ lronlllent "c,t1lcd a clo...cd mo tor ,~ilL \\ hIit':) nn}\l' ll1l'nl ,~all pcrfonncd III a \ :.lflable.rhang· 1I1~ r n\ lI1'mnclll I'" l· ~tll('d an 0 1) (>11 motor fiikill . A \\..lIled mJ/\ 10u.11 I' ,11'0 Jolc 10 perfonll ' "11ulirulcou, mo\ Cl11cnt t;/ \ \..... rdll,lll./\' «(lIImlli. I'or l'\J.l1Iplc. the mdlvldual I ~ at'lie 10 , tand ur '\
Postural Control and Balance Po'.! tul'
249

.he COM or mo\ Illg .he BOS (c.g .. rnovl'ahle pla.forrn . th..:rap) b{llJ). Fecdb.ld. ~) ... Ie m " provide tht· '\c n'ol) I!lput~ rL'qulred 10 IlIlIiatc corrCl:llve re"'pOn.,efii. "'''''llui,'" (an/Hi· pafon) 1'(1Mllnll ("ofllrol occur.., '" anticipat ion of Internally ge nerated. dC"-lahlllJ'ing forces impo~ed on the body', own movcmCIll\ (e .g .. cu tchin£. a \\e lgh lcd bal1 ):~ An individU:1I', prior e\~ncncc ... allow lhe variou~ e lclnents of Ihe pO~lUral control ~y'ilel11 to be prctull..:d or readied for upcoming moveme nts using fcedforward l11echani s m ~. Po ... tural requirements vary depe nding on th e c h aracteri~· tic!!. of the HI,k and the envi ron ment. Adapri\'e poslillal C01l1rnl allows the individual to appropriate ly "modify ... en· sor)' and motor sy",e m ~ in response to chang ing task and environmental demands.":!:· P 1 Balance emerges from a complex int erac ti on of (J) sensory (afferent) sy~ t e m s respon sible for the detection of body position and mOl ion, ('2) motor (effec tor) systems responsible for the execu tion of mOlOr responses. and (3) eNS integration processes. An exami nation of balance must therefore focu s on each of these three areas.

Postural Alignment and Weight Distribution Nonnal postural aJignment in standing can be examined by observing ske letal alignment using a plumb or we ighted line. More sophisticated ana lysis can be ac hieved using motion analysi') systems with light emitting signals. phoM tography, and electromyography. In standi ng, the COM occu r~ al a point about two thirds of the body height above the BOS . Static posture in standing is exam ined by posi· tioning the patient with the feet apan _ nomlal ~tance width. When vie\.ved from the side (sagittal plane alignment) the plumb line b positioned just in front of the lateral malleolu,. The ve ni cal Iille of grGl·irv (LOG) is eXp"c.ed '0 fall cJo!!.e 10 most joint axes: slightl y anterior to the ankle and knee jomts. at or slightly posterior to the hip joint. through midline of the trunk. JUSt anterior to the shoulder jOint, and throu gh the external auditory mealUs.'tI Natural spinill Lurve., are pre.')ent but flattened in upright "ance depending on the leve l of pO~lUraJ tone. lumbar and cervic . tI lordo~l s. and thoracic or dorsal kypho~ l s. The pelvis is held ill neutral po~Jtlon . with no an terior or po!)tcrior tilt. \l.'hen viewed from the fronl or back (frontal plane anaIY~I'). the fcct are posittoned eqtlld/ ') wJ1I from the plumb line. Th~ examiner look!'l for equ31 weight ui~lributiOIl bet" cen feCI i.lnd ':-) mIllelr) and of the Irun\.. and ex trel1litic ~. Nonnal alignment minimize!!. the need tor active mu..,c!t: t:ont rauion Juring ~1.1I1ding . MU'..cle~ thJt are tonically aCli, Cat lu" Ic\'el ... dllr. ing lIlIiet stance ulCluue tibl,lli!.i anterior a.nd gJ:,trol'nemiu!'l,oleu\; lClhor 1,I..,cl3 latae. g lu(eu~ ll1ediu~. and lliop~oa ... : and atxJumulal ~ and erector ~p Il1ae. 7. In ~ itlllU!' \\ hell \ Icwcd from tht: Silk. head and trunJ... arc \crtiLal. ....Nmurul ~pln
250

Physical Rehabilitation

y Limitli of stabilit)' (LOS) are defined as the maximum distance an individual is able or willing to lean ;n any direction without loss of balance or changing the BOS. Thus in standing an individual can shift fOlvlard and back\\ ard or ~idc to side without losing balance or laking a step. In normal individuals. Ihe anteroposterior (AP) LOS in standing is approximately 12 degrees while Ihe medial-

lateral (ML) LOS is approximately 16° from side to side (nonnal stance widlh. 4 inches). LOS is intluenced by individual characteristics ~uch as height and foot length for

AP LOS and distance between the feet and height for ML LOS." The midpoint of LOS is tenned the COM ali!!"mem, Steadl1lfSf refers to the ability to maintain a given

x ~-----'J~

posture with minimum movemenl (sway).i9 During standine. an individual normally exhibits small range posturJl shifts (postllral s\1'ay). cycling intermiuently from side·toside and from heel-to-loe. Sway em'elope refers LO the path of the bod) 's movement during standing. During walking. there are minimal COM movemenlS up and down and side· lO.side. resuhing in a smooth sinusoidal curve. In .;itting.

the BOS is larger and COM lower (just above the support base). resulting in greater LOS. Postural ~"av can be examined using \isual inspection with lhe patien; standing against a po;tural grid.t<·H More ~ophis1Jcated in\lrumentation. post urography. utilizes for· ceplate to mea<;ure ground reaction forces. either c~nler of force (COF) measures or cenler of pre~~ure (COP) mea,,ures. COF is calculated u~ing only venical furces. ;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) m<.J) pre ...ent \~ Ilh Ihe CUP po"lIIoned J\\ 4.1\ lrom mliJllne r·or t'\1Il!! rK,,,tur.11 "'\\J\ mea"ure'>. A I.lrgl: '\\J) palh I.., ~\idenCt.· l)! po... turJI un't~'lI.1Jnt' .... FOI c\.amph:. th~ pallt:'1lI \\Ith JtJ 1.1 !"pl"all) dl.:nhlll"lralc.. h) p...:nnt'lrt" re"I"lOn ...c ... , \\ Ilh t:\~c ... 1\ c ,,\\ 1.1\ unuxudlll.lk·J mo\cmelll'" ,md limned p,hturJI ~t Jdlll'" . I hl: rMllenl \\ IIh PJrl...llI... nn ... ,,11,::>1,..'' ' '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 .,1<.Ile... {I: ~ lIlu"dt. \\C'.JI...llC .......... kd~tJI Jdtmllll) IIlll

Figure 8.1 PO~luml ~ .... a). Recordmg 01 the movement of the c("lller (If pre'isure for 60 'iel.:ond" m a 'lIbJecl .,landing on a balance pl.ltfoml. V:t1ue...: mean amplitude of "W3)' path m inches = .13 x 15 Y: lenglh of pJlh = l1.2; \clool} = .45 in/sec (From Smllh. L. el al: Brulllblr(ln1·!i. ClImcal KmC"iIOlogy. ed 5. FA 0,1\ I", Philadelphia. 19%. p -l06. \10 Ilh penm"sion.) lonal abnonnalille,,). RC(."\3minJIIOn lollo\lling training u~jng fl1rc~ platform biofeedback hu" been used 10 dCI11\)I1 ... lr;.\IC Ih~ efft:('tiH"ne"... of li.lIning u:-.ing such dt:\ ice~,"N)..\Il'

Sen.ory Organization Thl.' ..,cn"'l~r) ... ).,(cm" (\I'IOn, .,olll
rh~ \hu.1I ..." tt."1l) ')t"f\,t' .. JIl Imr'Mxt~ln( "'-'un.:e of tnit)f'IlI.1llun lur our ..l!"ltIH) to flol,:rl,.C" \ ' "UI 010 cOlenls and llde\.! ,Ill.' I latl\\.' l)llcOlallllll \1 Ihl' ~~) p.Uh and ontol.IIItll\ (\1 the- b..oJ) III ...p..tl-C nil'> ..Jhlln\ h.l. been l~rmed \I,ual prupriunplluQ 1\\\1 "~IJ.ut:' lun ·1101 I Vi uaI ~\ .. [,,·m 11.1\1;' bt:t.'n 1l.i.·nti1'l: I all\lU, Jlth'r~llt n4J)~" ha.. e bel,. n " . . .:1:1 I I II . \" n "d'~nHI l: ('r '(pill-II \ blOO) Ill! ~ .m lit III ,,\,( 71 I ,,"-,n ('II ml.~11I1 o( Impliclr \ I)ion). t ol.ll \ l"'h,n pia}" a JIi.ljl r wI... ill 1'»I..all,mg kalure III the ',1\ Ihln'flull ..tIhJ III \IUI !,;\'n I\.IU~ (':;'\l·lIolI to \1:\u.U c\enb. 111l11IlU .1'1. ;,Ullt'tlcm \ l'l\lil llllllt~:\ thl: entire \ bual fte.ld lO 1'"'\ I
Chapter 8 Examination of Motor Function nonconscious 3\1. areness.\ Thus each visual system has unique functional ~ig:nificance. For example. the patient

with brain injury who has a condition called optic ataxia can recognize an object (focal vision) bUI cannot use visual infom13tion to accurately guide his or her hand to the object (impaired ambient vi:-.ion). The opposite occurs in a patient with visual agnosia. The patient cannot recognize common object~. but can use the ambient visual system 10 reach and grab an object. Vision abo contributes to right-

ing r('actions of the head. trunk. and limbs (optical righting reaction~).

\Isual acuity (focal \ Isicn) can be examined using a Snellen ele chan. A diion 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<\Vlgarc 'lafcly.!ocal. lze feJlure .. 10 the em Ironment. and anllnpate change, ne-ct'\'aJ) 10 d\Old ob'ltacle... Jnd ut·(;e.. . ",full~ feat'h lhe tar~ gel an:a an: t1etemllllcd Pallen " nh .. (roJ...e v..hu e>.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 00<.1\ In rdJlJllH tu Ihl "uppOI1 surl..H.. l:. Cut~Hlt·UU" .. t:n'dllon (Inom.'h iJlld pre lUl; ,)1 lht: 1t:c1/4nJ...k~ ... 4JlJ pr\)rnl.... l·pllOIl III thl.' let'l ~JlU .ll1d hlp" . .In: panl\.ul.ul) Import.1Il1 111 m,untJ.lIl II\~ UpI' gilt 1.; lIdl/lg oal..IOl..,-" Sl:n 'If) e\.ffilillillu)n 01 lhe 1;"\ lil'flIl\Il .1:hl IrunJ... i.. lh..:rdllfc: l:"''lcl1llal h:: .Jll1Ill.tIH)(l tt:(,-r,nlljUl ~lIl dl .. rll ...... t::d luth Inehal'll'l )1. Ihl l!lldl<.. ul.t1 llJnJh.. (~C( "I 01 th.: \ e,ubul,lr .,\ . . tt·1ll dO:ltd ,I I! Uj..tf .llldlf,llhllJ ..tnJ dl·~l'klalh. lIl Ihl\.t:' ~dlng nn Ill~ hto1J ~dl ... h..h Iht; olllltlh org..tll:'" dl"l~ll hne.if .ll'I.e!. e ~Hh n T, nt'llt..tlilln \)f lht; ht'.iJ \\ tlh rd:..~rt'I1L'C H.I gr.t\. II) Til

Ihe-

II

I

.. I

'>eJhlll\l In

1•.1'\1 tpha.'II.)

f1I0\t:'m~nt, 01

thl' Illnlllh ... lnpollJ 10 ,Ill\\ hl'Jtllll\)\ClIlcfll, .Llld PO .. I\!t'1I I II..: \t:' ... lJbuldJ 'y . . 1l'1ll lundlol\') 10 ,lanlil/t' !!JI< dunn:- Ill". IlIU\l'lIll'lIh (\ 1..1 lht' \l' .. lIoullH,ulal ,
ollltJ

25J

tone and postural muscle activation. Tests for vestibular function include positional and movement testing. The patient is observed for symptoms of vestibular dysfunction (e.g.. dizziness, vertigo, nyslagmus)." See Chapler 24 for a complete discussion of this topic.

eNS Integration Sensory integration by the CNS is Oexible; although all inputs arc important. the eNS weights Ihe various inputs. During quiet stance. defined as a stable support surface and surroundings. all inputs contribute to the maintenance of posture. For illlacI adulls under these conditions. lhe C S places greater weight on somatosensory inputs. Somalosensory inputs assume a major role when platfoml perturbations are introduced, If somatosensory inputs. are impaired (e.g.. the p3lient with peripheral neurop31hy) or if somatosensory conflicting infonnation is introduced (e.g., standing on dense foam). vis.ion 3..-<;;sumes a greater role. If both somatosensory and visual inputs are impaired or di~· torted. ve~libular inputs. which are referenced to gravity, are critical 10 resolve sensory contlict. 7s Balance responses arc therefore task and contexl dependent and are triggered by avaibbilily and accuracy of ~pecitic sensory inputs. Because these inpul~ are redundant, ,table balance can be maintained with vi .. ual impainnent. on ulbtable surface~. or in ~n,or) conflict ~ituations. Howc\er. if more than one "en,ory S) 'Item i~ deficient. substantial deficiencies in balancr contl'ol \\oill be evident. x9 In addition. the cognilive ')ystcm play~ an important role in interpreting the infomla. lion .JIld planning J.n eff~ctive n:llpon!)Cs. P;.uicllls "ith Illlpairmenl'i 111 cognition or atlenlJOI1 demonstrate IIlcrea~d tall ri'lJ.... The CIIllIe u/ Tel\{ for Sl'1l\ory InterllUlOfl ", Ba/am t' (CTSI8) I~ b;'l\cd on the \~t)rJ... f Na.."hnerYiI,QI and can be u...ed to det('nninc the elfccti\cnCS5 of J.JI indi\ idui.tllO ulIlilt dltlercnt \enwf) Inpuh. If e\anHne~ btxI} ~v.a) during qUIf:1 '11.mdmg under S.f'" dlfterclll -.en'tOI)' ll'')t COndJlIOlh I t..:lg, \ ..:!)_ I)) namlt,: IXhluIOgraphy equJpmt.'IU pro\ ide... a 1110\ IIlg pl..l.llonu Ilut IIHrodw.:e'l III \.'halucal penurballom. hlli..h ng ur llillng 1ll1.,l\Cmt'l1h), A moving \ I,u~ll ... urround ''IT('cn II" '\-\.1) 11.'tC'frlll..'ed amI inlrodut'c~ \'ISU.)! rontlitt. HOlh the \urrolmd Jud IOfl.'C pl.1£t' iU"e ref(,I\"IKcd to the r~ltJt:m h) llle~Ul\ of h~drJulH. IlJt't'hJ.OI,m,. Tl~'l c:ondlllon I pro\ IU~'l ..l.ccurale . . . .llll.i!O n...u!). \ I,)Udl, .1I1J \e~lIbula.r Inlt)l1ll.tlion .mJ I... bJ."t."IUle refen'O(.:e F.tc:h 01 rhe other li\l' l..'Olltlillon, ')Sh:l1l~lI~~II) \,U"I~s '\t:lhOI) input~, ml..'r("a~~ IlIg the Il'\el III ~Ihllr)o t'unllll'l J.ud ['It..h lunJJ diltiluh),

me

CondliJUn I L)e~ Open, SI~lbl.: urfdte {EOSSt CI\ndllioll 2.' l-~I? ... CI",c:-d 'itJbl~ Surt.llC (FCSSl Clln,lllll~l' \hual COllflkl ~\lth 1\1mmg SUrrol.Ul,)

Stahl. Surfa,'< 1\ CSS I (unJllton~: Ii\<, Open. ~Io\ong SurfaLe ([OMS) ('~lndltJOI\ 5 E)(,· .. CI"'1l>d, \1o\'lIlg Sudan.- ([eMS, ( uUOlliOIl 0 \ I'\lIdl Clllltlll't with \10\ Ing SUrf\.lUIIU, "11 ll,. Ing Plaltorm t \"('\1S I

15..,

1"Jln ...ical R..hahilil.al'on

1 Normal

VISIon

fixed support

4. Normal vISion, Sway-referenced support

2 Absent

VISIon,

fixed support

5. Absent VISion. Sway-referenced support

3 Sway-referenced vision, fixed support

6. Sway-referenced VISIon and support

Figure 8.2 The sensory organization test.

Conditions I ~landing

on a

10

3 are all performed \\ ith the patient

~table ~upport

surface.

pro~iding ac~~rate

somatosensory mputs. Vi~ual inputs are vaned. condition 1 uses EO. condition 2 u~e~ EC. and condition 3 use~ a mov~ ina vi!>ual surround (screen) referenced to body sway. thus pr~viding inaccurate visual mformallon. ~ondition... 4 throu"h 6 repeat the \'j-,ual condition" bUI \\'lIh an ahered e . . support ",uTface (moving platfoml) (hal provIdes macCl.lrate \ornatosensory Informatlon. In conditions 5 and 6 mamle-.

nance of po~lure depends on availabilll) and accuracy of \cslibular mput . Thu .... paliclllS ",ilh v{,~lIbul3r dy<;;funclion \\ II! demon~·.trate ma\lmum lI1\tabIiH} in condlllOn\ 5

and 6.

Pallent~ \\ho ~tfe \-J<.,lIally depcndelH for poMural

COJltrol will demon::.tf~lle lIl~tability ,n conditions 2. 3, S. ;md 6. Pauenls who are ~urb.ce depe:ndcllI will demon"ilr
I 1\11111111al ... way 2 Mtld ... wa)

3 Moderale ::.way 4 Fall Post urography equipment provides a printe~ bar graph indicaung how well the palient perfonned dunng each of the ~i'( c~nditions in t~nns of po~tural sway. Ratios comparing one condition to another can provide information regarding reliance on one sen~ory sy<;;tem over anolher. Addillonal analy:-.es at mowr coordination using EMG can prm iLlc mformatlon about Ihe relative level of individual mu~c1e actl\ity a.s well ao;, overall mu:..c1e recruitment

pattern,.

In the ab')ence 01 ,,>ophl,tlcalcd po~tllrography equip* melli. an alternate ver.~.. IQn of the CTSlB (Sensor)' Organildllon l'e,1) can be lI\ecllll c1inicaJ or home setlings 10 ideJ1111) if tht: U\i;' 01 't"nsory infoml:ltion I~ nonnal or JbnonnaL The t......t reqUIres •.10 IIldl\ Idu~1! ~tand quietly in t: .. lch 01 th\,.' ~I\ dtlterenl ,en~ory t~~t conditions. Dcn::.t: foam i... u...cd Ilblcad of lhe 1110\ ing plalfoml to proVide Ihl.' llMccurate ",orn.ttost.'n... or} informal ion. A dome head plt:t't." h u~t:d ilhtead ot a 010\ II1g 'urround screen l~ provide lnilI.."Curdh:.' \-'hual II1formalJon rCtJ:lIITed in condl* 110m, 3 and 6"· A \lIllphtied \er-.lun, the M*CTSIB, usmg only lour COtl(!ItH.m:-. (I. ~, 4, and 5) has been recoml1leOt!l:tI for nlt.lei. coml1lunlt) dwellIng tldult~, omining the

dome: head ptece. The :-..une pO.l,lllre ~hould be adopted in

(h... ptc.~r

the n:mlhIUJn I.C .. fl~el \houl<.Jer·\\'u.hh apart :md lold{"d .u.:rfl" he\l. lllllC III halal1l.:e (10 \l'l:omh c;t\,:h In,ll. I ~O . . cl.:omh lOl;\1 11111(') ,tnd II1l,:reJ ...~d '\\;ly or 10...... lJ! hJI.tIlcc Jrc re-corded. Subjettl\ c compl:llnh of the pallenl (e.~ .. n:lU,ca. dll/lIle,,) and po'lUr:t1 ~Ir.llegie, u>.ed arc." .... 1-.0 dlxumenll'u The le\1 I, ,topped If (he paln:nt aller.. Ihe pt)'lUn: f" IJen\, or 1I1t.)\e~ feet. open, c)e,. unlold, Jnn,) or lo\,e, h,llancc. requiring manual a''''I\· tann'. Threl' In.ll, Jrc gl\l'n and the u\cragc lime in bal· :lIlC(' j, docuJ1lcntcd.4.I

eJth

ol

Mlll'

\1010r • lralcgics In OO\('",\;1tlOn",1 ludic . . of Infan" and young childrC'1l and le'iloncd animal\ fdecerebrwion expcrimcnl~). nghllng and equlllbnum reaclion~ cOl11pri~e the postural reflex mecha· ml,l1l. AutomallC nghting reactiom (RR) orient the head in 'pace (op,ieal RR. labyrinthine RR. body-on-head RR) and the bod) In relation 10 the head and support 'iurface (ne ~-on·body RR. body -on-body RR). Equilibrium reacuon... IIlc.:ludc tilting reacliom•. and parachille or prolecti\e reaction".. In normal adult .... however. postural adju:-.tments are far more complc~ and demon~lrate a high degree of adaplabJlit) In response to both task and environmental conle\t demanth. Po...lUral adJu,unents \ary from the simple stretch re~pon~e~ to the activation of specific motor strategies h:nergistic patterns of movement). Muscles closest 10 the BOS are particularl) imponant 10 the maintenance of bal· ance. A~ the LOS ;s reached w;lh a COM disturbance, the magnitude- of the postural re~ponse is increased. In standmg. the allkle \lrateg.\' invoh es shifting the COM forward and bad. b: ffiO\ ing the body a~ a relatively fixed pendulum about Ihe ankle joints. Muscle~ are activated in a distal·to-pro"imal ...equence. With forward sway. gaslrocnemiu" b activated first. followed by hamstrings, then para~plOal mu~t1e:-.. V"ith backward ~way, the anterior tib· iali::'l\ aUI\31ed fir...t. followed by quadriceps. Ihen abdom· mal\. The anlde ::.trategy is a commonly used ~tralegy \\hen ul"lurbance5. are ::.mall and "ell within Ihe LOS. The /up .wale,!\' Ilwol\'e~ \hifts in the COM by flexing or extending al Ihe hlp5.. It ha::. a proximal pallcrn of muscle aCll\alJOn. WIth forward sway abdominals are activated fir,,!. fr,llowed b) quadricep~. With backward sway, para"'pll1al mU'lclc\
253

or bad.\\ard 'olep'. In m,t.tI1CCS of IJICral dcc;lJblhl3110l1, the Indl\ Idual u}.e\ J 'Idi" 'ler or a (nh~ .. ler 10 tmng lhe BOS bad. under 'he (,OM n,C "Cpptng "ra,eg'" are t)pically recrtllll'd Hl rc,pon,e 10 fa,1, largl' pO~H1ral perIUrballon~ (Fig. 8.3). Chan!!e·ln-,upport movtmenh of the upper IlInh <.::m ;:11 ....0 3... ~ ....1 III siabdiling lhe COM over Ihe BaS. and ,cnc a protecti\,e funl'lion In ab,orblllg impaci and protectmg the head 111 a fall ('vent. Grasplllg movemcnh as,iq in eXlcndlllg Ihe BaS and 5.lablli/lng. po:-.ture. These rC;.K·tion, were found 10 be pre\ alent In dc~t:lbllizalion \iIU31ions. occurnng in 85 percent of tnal'\. Stepping ...lrategic\ werc also frequent. leading re~carcher~ to 'luggest that change-IIl-~upport ~Irategie~ 5.hould nOI be vie\\ed a., slnuegie5. of last reson. They are often mitialed \\ell before the COM nears or e,ceeds lhe LOS, contrary 10 Ihe traditional view.% While these strategies have been investigated individually as dislinct rnovernenl patterns. research ha'i also ~hown thai during nonnal baJance combinations of strategies are u~ed.q'l In sitting. the BOS is comprised of the 'highs and butlocks and the feet if in contact with the suppon surface. Postural strategies to maintain balance include movement of the trunk about the hips. Backward sway elicits primary response~ in hip nexors along with activiry of the abdominals and neck nexors. In forward sway. extensor muscles of the hips are activated along with the eXlensors of the

(

.

I

1

23 23 21·

, I

( ,~

I

I

, , I

I

I

I

ChtlflJ
ment, of the 10\1, er or upper limb~ to make a new contaci \\!th the ')uppt>rl ...urfacc:17 The !Jtl'f'ping strategy realign ... lhe HOs undcr Ihe COM by u~ing rapid !'.tcps or hop!'» in th~ dlfl.TllOn of lhe u''lplacing force. for example, forward

I ~amin~lion of \.1otor "unction

Ankle slrategy

Hip strategy

Stepping strategy

Figure 8.3 Slrateglf:S for correcling balance perturbations.

254

Ph)'sical Rehabilitation

neck and trunk. If the feet are in contact. tibialis anterior is recruited during forward reaching movements of the ann and the gaslrocnemius is recruited to brake forward movements and return the body to ereCI sitling.91l Somatosensory inputs from backward rotation of the pelvis may have an importam role in triggering the postural strategies in sit~ ting. 99 In frontal plane movements, activity of the hip abductors and adductors along with the quadratus lumboTUm is important. An examination of motor strategies should first begin with the musculoskeletal elements (ROM. postural tone. and strength). \Veakness and limited ROM in the ankles will affect successful use of an ankle strategy. whereas weakness and limited ROM about the hips will inOuence the hi.p strategy. Limitations of neck ROM can be expected in patients "ith prima.ry vestibular disorders. Available motor Mrategies in response to destabilizations (anteroposlerior, medial-lateral) should be dCiennined. Dynamic poslurography pro\'ide~ the ideal way to study malar ~trategies, The Mm'emellt CoordInaTion TnT (MeT) developed by Nashner and co-worker~% provides infonnation about postural responses to comrol the COM when the platfornl move~. including symmetry of weight-bearing and forces generated. latency of postural re\pon~es. amplitude of respon~e 111 relation to the stimulus size. and strateg) utilized (ankle or hipl. EMG monitoring can reveal specific muscle acti\'auon patterns and latencies. The main disadvantage I~ that lhe equipment is e\.pen~lve and not portable. Correlalion with performance dUTlng functional la~ks (\\alk.mgl I ... also lack mg. The therapl')t needs to detenmne and l!<x:umcnl II th~ ~otor l)tratcgie') are (II pre~nt and nomml. (2 J pre"cnl but l~mlled or delayed. (.') prc~nt but mappropnale tor lhe par. lIcular context or . . lluJ.LJon. (-t) 'ibnonnaJ. or (5, dh-.enl.'11 Ditlerence~ III re"ron-.e" (\U1 lx: "-el'n h~ ~~ '1ICmJlICalh \ .lr\mg o;en...ol) mput... and th~ ''lI/t'' Jnd t) pe of penurbJ.tl(~" Both reaclive and antiClpJt(1) pU'ILUrJI '1lnuegie" \hould be e-'anlmed For e\..lInple the pJlIent (~IO be a...k.ed 10 rai Iht.' J11Th o\'ertk:ad Of hlt J \\cl~h(t.'d ball. The de:-.labllil1ng

Table 8.9 Normal

Good

Fair

Poor

effects of voluntary movement and strategies used to mam.. lain position should be documenled. Finally. the ability to adapi posluml stralegies should be examined. For example, the palient can be asked to stand first with normal stance width. then with a narrowed BOS. The ability to improve performance with repeal praclice trials should be documented

Functional Balance Tests Functional tests of balance focus on the maintenance of poslure (static balance), balance during weighl shifting or voluntary movement (dynamic balance). balance responses to manual perturbations. and funclional mob~ity (gail) (Table 8.9). Examples of Sialic balance lasks in standing include double limb Slance, single limb stance (SLS). Iandem slance (heel-toe position). and the Romberg test. Dynamic balance tasks include sit-Io-sland (STS) and sit down (SIT): reaching movemenl>: turning. and slep-ups. Walking ta~ks include timed walking. walking with Commands to lum direction (18lf or 360° turns), lum the head (side 10 side or up and down). or SlOp and start. Scoring can vary from a simple ~ubjcctive scale (impaired or intact) to a scale \\ ilh speCific criterion de~ription~ for successful perfonnance. Table 8.10 presenl' an example of scale of func1I0nai balance grade\ with dc"'Cripwrs thai can be used to define conrrol in both ,iltmg and standing. The objeclivity of mea'luremenlS can be lrlcreased b) u"ing timed performance. For example. a ~top\.. atch can be u'led to document time in balance dunng a 30-"-U'ontl tnal of a .,ingle limb stanee.,oo.IOI Standardl7cd le~h of balanre arc available thUl examine functional perfonllan~e. It i\ im(>Ortant 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<..tlCe'J trials for

ave

~ 5COfi:

S'mple, easy to adrTl1rtlster, quick (3 min)

~

ReqUIrements: indepellllenf ambulation, klr mod. to hIQI> 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 1 u.,e... a le\ el ~Jrd':lIlLl mOUlllt.:-t! on the \\all and po.. . llloned 3t the height 01 the pJUl'n1\ acrollllOn The p.lIient ~land .......ide\\3rd... 1lc:>..1 to the \~all (\\. IIhuUI lOuchll1g). leet normal ... tance WIdth and \~":lghl equall) dl"tnbutcd 011 bolh f..:cl. The "houlder l ... llf')"ed 10 110 and elhm\ e.\tendcd wilh the hane! fi'llt'd An InltlJI 1ll1'.I.. . urcment i . . made of Ihe po,ition of the _'rd mct;llarp.ti along the yard.,ud... For furward reach. the patIent " I"'truc.:t~d to le;lll a... far ron.\ ~ud .1.. . po:-.... ible Ydthoul 1l>"'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 uo<::ulllcnled (1.1..: •• ;.II1lk or hip ... tr,:,tcg). Irunk. rolal1on ..... tapular prOM Ir~ll'tlonl. Sl'C T.Jble ~ .11 hlr J1t. rmati\l' value,,- of ~lDRT.

-

The Her!! Balance Scale Thl' 1lt'1''.{ 8alall/ t' .Sl--ale {8BS' dt:\'dopcd by Berg and ("0\'OI"ker\w" 'Ill i... an objective Illca~lIrc of ... talic and d)n3ll1ic balance :lhilitll.:s. The SC~lle c(ln"ii~Pi of I~ functional lash commonly perfollllcd in l:vcr)d:l) life. The item... range Jrom ... itling or \tandll1g un<;;uppoflcd. to mo\'emenl transi-

lion.... hit-lo- . . t.. nd. ...rand-to- ... itl, \ :lnalion:-. in "tanding pO"!litlon (EO/EC ,. feel togelher. forward reach. retneving an objeci from the floor. lurlllng. ~lal1dll1g on one fOOl) to placing Ihe foot on a . . tool. Scoring usc" a five-point ordinal scale. \1, ith .,cores ranging from 0 to 4. Descriplive criIcria are provided for licoring c.::ach level: a score of 4 is usee! 10 indicate Ihal the patient pel!onllJ indep(Jlulell/l.\ ami me('H lime lind distance crupria. and a ...core of 0 i~ u5.cd for IInahle to pClform (~ee Appendi.ll A). A maximum :-.core 01 56 poinl\ i . . po\... lble. The BBS \\a~ originally dC\t:loped for u"'e \\lith elderly patients wilh stroke in Ihe acute rehabilitJtion ~ctllng ~lI1d has been ~hown to be a sensitive lllca~urc of recovery. Balance scale ~core~ have al~o b~en ~ho\\'n to be useful in predicting falls 111 the elderly III II! :.tnd evalu31ing change~ in palients undergoing phySical therapy. II \ A ~core!) of 45 or below i:-. a\!)ocimed \\ ilh a high fall ri:.k and each one-poil1l drop in scores rang.mg from 54 to 36 i:"l :ls...ociated \~ uh a 6 10 8 percent increa!o.l'" in fall ri~k..lllThe BBS i... a '\ensitive Il1ca:-.ure for lo\.'. -fllnclionlng. older adult~.l' l-Il~ The lip>t 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

<5.6

Backward

4 6 ± 3.1

>7.6

<1.6

Right laleral

62 ± 3.0

>94

<3.8

Len lateral

6.6

2.8

>94

<3.8

From I-Jewlon A

'uti

±

2 J.fl'lOn'llkrrd IOnIC

.uhao(cd

t'l.lIJlll.C I•• ,k,.

Ill("

"1Ii{bfit:(~

. II ( 1/ JW(,) I r".. lud~ ... the l1.t'IC h;tl.lIlCl /lulam I' ,"1111 l1l'm ... Jnd ullll/e, only the .u..lv;ml('t! h;llJI1..:e lll'nh (lIe01' t'I to l·lI rhl.: 1I1~ 'WlllllI\ 'COTe II I I h(' ~1 tlB~ I' 1h It (all t th·"... tnhllll" Llf hlg.hcr·IUl1dIOlll ll g. hi' U"C' I·UI 10 I' l'" ••

11,., ~

j

ll,mlUUI1I1' .Jv.clllllg lIlJ.\ ,dual...

-

- ,

IJ

P~rformanc.:('.()rieflled \tobilil~ \"('''t~nl{'nl t I'()\IA) rhr pc".!rwm,U1l I' 01/( IHe,d ~fdhJ1If\' . \ \ \t'\ \",('111 (P~)'~1A. ~ dl'\l'loped hy Tille-ill l~ lifo prm HJc'. il lmcf. ,md >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<.lthla~ el all~I1I" .1 qUick mca..... ure 01 d) nJmlC balance and mobll11) The palle-nt IS ,eated comlonably in J finn chair \\ ilh :UIllS and back resting again'll the chair. The patient j<., then lIl')(ructl.'d 10 ri~e, "land momelllaril), and then "alk 3 III \10 it) lOv.an.J a \\;111 at noml;t! wall...lIlg "'peed. turn \\ith·

out toudllng the \\all. return 10 Ihe' chaIr. tum. and ~it dO\\1ll. Tape I') u...eo 10 marl... the ".lIkmg dl .. IJnCe and tummg pomt Penoml;lnce on Ihe origmal GUG le~1 i~ ~cored u... lng a li\e-pollll on.llnal ~cale ranging from I. ollllal (no n,k of falh) 10 2. \"ay Slightly Abnormal: 3. Mildly Abnormal (lllcre';l... ed t1!o.k of falb): 4. Moderately AbnomlJ!; and 5. Se\t:rely Abnomlal thigh ri ...k of falls I. If :m a...... I~I1\e de\ Ice I... rClJUlred, Ihl' t)iX l~ rccorded. EfforI!.,IMI rll.)')ItIOn 111 Ihe lh..alr Re...earch mdlc'H~ ... Lhal mml adult... an complete the le ...t In k .... than 10 -.ecund",. S,,:ltn:,,> ul 11 to 20 ..eL:ond, ,Ire: con"ol"red \\ ithin nonlli.J1 hmlt.. fOI lIall doer!) or tndlvH.luah \\lIh a dl\abililY: 'lore:... o\er 10 \e'lond ... ar~ mUltilll\e 01 lmp,urcd lunl'IlonJI n1t.hJlll) The lUlled L p ,Illd Go 1l'\1 prO\lde~ tI reli,Ihle; 4UHJ ...t:le~nlll~ nlt:J\ure <.tbnt}rmal \~ort'\ \~ illTam JJdUu)Jl;.lllOmprl"hc:n,I\t't'\;.ll11lniJt!on

'r'Imt' d \\'olkin o~ Trst

. 'portanI pan of the examlOatioo ~ • A IU1II~d\l'df{1fIg I b·lily W The patient is I and fUl1CllOna 1110 1 . of po,wr'JI conlro I cr preferred spet,d over a set dis",ked 10 \V:II~ at hI' or' h' ·noor (e.g., 10,01 walk lesl oJ

. 'I'" I

I I"" 'm 111 Ii'\ . ' .

mar~ed Oil t C

.

tJIle< , L~ ) . , I' t II 'i mil. The palient IS then asked 11111 or ,0·11 \\.1' Ie' . . I li 1. - ' . m 'l/Jefd 'I~ fa.. t ~ posslb c. (me to wall-... al!aUl at ma\lnlll, .' d. -d • :l ,IOP\\3ICh. The re~ults are repone 10 l'i mCI,urc ul::lI1c. I . , - d or feet/second) or less common y In 'lpeed (mcler'/~c(," be IOfullJlll~ luken (second...). Comparisons arc made t~~n . I G· peed ha') been shown to be a senSlllve the IWI) tna~. all s . . f nctl·onal perfonnancc. There IS a Wide range IllC
,

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:\-1otor I.earning l..x,lrnUl~ I' ,I

nmlrle\ pr()o.x·" LI1;It rcqum~ . . ,palial. Icmpohtl'riJrLhll:;tlllrgani/atlon \\ IIhlO the (' S. Change~ III Ihl' ("5 ,lit: nOi dm:l'lly ob,er\":.lblc, bUI rillht:r arc Inkrn:d hom IIllI'Ill\CITICnt tn 1"It:'ItonnJnce as a re,ull of pr.ldILl: I)r l."\1.. . .·n~nl·e lOll 1\ idual JllJerenct.', in leJmll1g are l'\pe-dl~d ,1nJ lIltluent:~ both lhe rme Jnd degree of learning J'l.h'lbk \lutor Il::.lmin!! ahihlle... Jmong mdl\ iduJb vary Jlf('" Ihree JllalO lound:HIl.)nal calcgone, of abilltlc ...: cog1U1l\ e Jhlhlll."_ perl.l:plU31 ...peed Jbllll~ . .;md psychomotor Jhllll~ DllleII'IKl.'''' ~l(.;cur a"l ~ rl'''Iult of bOlh g.enelic"! and e\llL'fll'rlLt'. lh..: Ihcrapl ... t ..hould be ,en'tlJ\'e 10 '1uch faclOr... a....lknne~\, .1Il\iCI). l11emor~. ~reed 01 proce,smg ml'onna\Jon. 'f"l:dl and ;K'Lur,Ky of mo\ement\, uniquene,,'l of Ihe ,clung. and ... 0 fOl111 In ~Iddillon. pdllenls mJ) vary In their 1~.llTtln~' rOlenllJI .IlTorJing 10 Ihe pathology pre..,enl. the number U"ll~ --\\ hl'e:lln" bl'l'au,e 01 Ihe dllfkulty of Lhe la'll... their ft'"Jual ... hllllll..", .1IlJ gcnerJI health ",taw;;. I,d.

,lllJ

Performance Changes Il~J urt: o! motor learnll1g I" IInprO\ crnenh III perIf'PTiJJI(c IIMI re-~'iU11 trom pnu.. IIl't' or e~peTlence. PCI1.. ml.tllLt:' lTllell,l .Jr~ e... fahli ... h~d and u'led lor Lompar1'1111 10 lc.-'cnnlfl Ihl' 'UU:C'I' of le~lmlne outcome, The III r;')'l I rnu,' l:h:l.I apprup"dl~ re... pun~,<: oulcome Jnd

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thc:rJpl"''' 10..,111 rl.'pon Iht' nUIlIhc.:r .Iud I~pc.: ot l'mtr, '(PH 'I ,till. \,mahkl rh.ll n ....' LUI v.uhm a gt\..:-n pr.ll.lJlC' ....·"Ion Jnd J\.ro..., pr,tllill.' ,e"lon". A Jl·lr1.·.I'l' 10 till' ITnluc:nq \.)1 error, I' n.m~l,rClll \\ tlh nnph)\L'Il11.·n" .n k.Jflllng On(' 1.:011111100 I1lC.I""Url.'menl pmhlcm In ,"-.111 k number ot error.....hould be ('OIhlcler~d along'" IIh \pel'd 01 pcrfonnanc..c. For ta,l..~ thJt rt:qulre ..peed. Ihe number 01 crror, dod IlIne 10 complclc the tOJ'\" C,ln he 3dded . (hen dl\.-lded b) 1\\010 al:hlC'\c J\""t't!· ell (Ural \ _\l orr Redlil.-ed elton ilnd LOIlCl.'nlr;tllon Me mdlCilll\ e 01 leamulg and <;hould he docum~ntcd. \\'herea\ a high degree of ('(lgnlll\e monllonng l'> nec:e"',lr) in earl) learning (t:ognltlve \wge). performance in the a"OClall\c and aulonomou' "age, l)[ molor learning 1\ char::H':lcnzcd by reduced cognJll\C monilOring. ;:md incrca"lng aulOm311clt~.112 A~ It:Jmll1g progre ... "e",. perfOnllJIKC I' lI1(.rcas~ Ingl} characlenzed by per-.I':IICnl:C Jnd con""'lenl:y. Inu\ Ihe acquired <;"-.111, are ob~ned for more than olle per.. fomlance mal and Inal-to-lrial \.lIiabilny uc-uea'e"

.tnu

Practice Observations The number of praclice (nab or praCIIl:C [line reyuired to achieve l>kill ma~lery CJn be documenlt;d. Prac..;tice ob...crv3lioll\ can be mi,leadlng in Ihat performam:e I~ nOl

ai"':l) !I an 3ccurale rel1ectlOn ofleamll1g. It I:' po"",ble to practice enough to lemporarily lmpro\e perfomlance but nOl retain Ihe learnll1g. Converse I), factor, such a, fallgue. anxlelY. poor motl\31l0n, boredom. or drug~ can l".lU-.e perfonnance to deterlorale \\ htle kaming rna: '1tlll OClUr. Thu~ Ihe pallent \\ ho il> fatigued or .;.rre"ed perlunn, H'I) poorl) during ~cheJuled Ircatmenl bUI return, alter the \\eel..t:nd re~led and calm, and i... able 10 perfonn Ihe td~l.. ""ilh ea'e. Pe,j'ormallre p/meaw, dl'ilncd a,:I 1~'\c.:I1I1g otT of performance after a penod of ~lcad) 1I11pn)\Cl1lt:nt. characteriLe normal pral:lll.'e and tan be c\pecled to occur During plaleau,. leamll1g may ,till be going on T) plcall) Ihese are temporary \I(,ddy \I.lle\ ,md perfOnnJnl'e \\ III beg1l1 to .. ho\\ ImprO\emeOl agJIO. PI~lte<1u, ('an aho be the re... uh of ceilmr: eht't H. " high le\el of pertonn' t~ are a 10\\ level

260

Pb)'sical Rehabilitation

Table 8.12 Response Outcome and Response Production Measures of Molor SkiD Performance 1. Aesponse outcome measures

Time to complete a movement (MT) in seconds. m,nutes, or hours

Amount of time to walk a set distance (e.g., the 6-Meter or 10-Meter Walk Test) Total t,me to complete a functIonal task (eg., dressing or bathing)

Time to Initiate a response (AT) In seconds or minutes

Amount of time reqUIred to Initiate Sit-fe-stand transfers

Distance

D,stance completed (e g.. 6-M,nute Walk Test or 3-Mlnute WaJk Test)

Change In score of performance Instrument

FIM score changes (e g . from 3JMod Ass,st to SINo Helper aHer 4 weeks of galt training)

Type of error ,n per10rmlng cntenon task

Error In overall program selectlon (eg patient with stroke Incorrectly transfers 10 the sound s'de when asked to Iransfer to the aHecled S'de) Error In program execution le.g . pallent wUh TBI gets dIstracted and lost In the middle of a Iransfer)

Amount of error In performing cnterlon movement

Constant error tCEl he average error of a set of SCOfes from a target value Ie g pat'ent exh'Ms a Funct'onal Aeac of 6 Inches; mean for age 172 ,ears "omen] 13 8 Inches)

Vanable error ( E I fhe standard eVla Ion of a set of SCOres tram an average 'e rr':'(I:;,ules conSistency of responses

Number

Of

successfiJ

altempl~

TIn'It:.

on oH target

9 roup of patIents ext) t.1 FunC:'l."nal Reach SO of S nc "5 a ,erage SD '5 3 J IOCres

.;m

1

at

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\ 9 S,l-To·Stind lr3nsfv r Percenug t"Ss.1

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r Sc btai1led

entwcto -

Rt'')pOn t:'

prOdJClol ~t"

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rUS,pon>e

Chap1~r 8 Examination of Motor function

16 t

Table 8.12 Response Outcome and Response Production Measures of Motor Skill Performance (conlinued)

~Go~

Warning Signal

Termination of the response

Initiation of

signal

the response

Foreperiod

Time---~

A

v Aeaction lime (AT)

v Movement lime (MT)

80S '" base 01 sUPIX>r1; COM "'" center of mass; FIM = Functional Independence Measure; SO = standard deviabon; T81 = traumatic brain injury. ReactIon lime (An =- the Interval between the iMlal presentation of a stimulus/command to move and the InItIation of a movement response. Movement time (MT) :. the Interval between the initiation of movement and the completion of movement. Adapted from MagIll, R: Motor learning Concepts and Applications, ad 4. WCP Brown & Benchmark. Madison, WI, 1993, P 17, WIth permission.

of perfonnance in which further decreases cannot be delected by limitalions in the perfomlance measure. They can affect a detennination of negative learning. I The paljent who is able to engage in active introspection and self-evaJuation of perfonnaJlce and reach decisions independently about how to improve perfonnance demonstrates an impon.ant element of learning. Some physical therapists over-emphaslze guided movements and errorless practice. Although this may be important for safety reasons, lack of exposure to perfomlance errors may preclude the patient from developing capabilities for self.. .evaluation. In an era of fiscal responsibiliry and limitations on the amount of physi.. . cal therapy ses,ions allowed, many patients are able to learn onl) the very ba~ic skills while in active rehabilitation. Much of the necessary learning of functional skills occurs after dis~ charge and dunng' outpatient episodes of care. The therapist cannot possibl) ~tructure practice sessions to meet all of the functional challenge:-. the patient may face. The acquisilion of independent prohlem solving/decision making skills ensures that the final goa.! of rehabilitation-independent functioncan be achie\;ed. TIle therapist needs to evaluate this very imponam funclJon

Retention Tests More reliable inferences about learning can be made through the use of retention te~IS and transfer tests. Relention refers 10 perMstence of a mol or skill, an acquired capabl1l1) for perfomlance (habit), and i'i. a funcrioll of motor memory. A JelenflOf/ le,H, defined as "a pcrfonnance le.')1 admll1l')tered afLer a retemion interval for the purposes of as~s!-.lI1g learning,"I. p-tn7 provides an import311l measure of leaming. The learner is asked 10 demonstrate the skill

after a period of no practice (retellt;oll illtenal). Retention intervals can be of varying lengths. For example. a palient who is seen only once a week in an outpatient clinic is asked to demonstrale a skill practiced the previous week. Performance after the retention interval is compared to perfonnance on the initiaJ practice session. A difference score can be detennined, that is. Ihe difference in performance scores from the end of the original acquisition phase and the begimling of the retention phase. Performance typically shows a slight initial decrease but should return to original perfonnance levels within relatively few practice trials if learning has occurred (termed warm-up decrement). It is important not to provide any verbal cueing or knowledge of results during the retention trial. This same patienl may have been given a home exercise program (HEP) that includes daily practice of the desired skill. If upon relum to the clinic some weeks later, performance of the desired skill has not been maintained or has deteriorated. the therapist might reasonably conclude thai the patient has not been diligent with rhe HEP and learning has not been retained.

Transfer Tests Transfer is defined as "the gain (or loss) in rhe capability for perfomlance in one task as a result of practice or experience 011 some other task."!. P ~36 Learning obtained from the criterion ta~k enhances (jJositi\'e transfer) Or detracls from (negati\'e transfer) learning on other lasks. For example. the parient with stroke practices feeding skills using the nonaffected upper extremity. Perfolmance on the feeding task using the affected upper extremity is then evaluated. The therapist makes a detemlinatioll as 10 ule effectiveness of the prior pf
262

Physical Rehabilitation

lime, effort) on pcrfOnllanCe lIsing the afTected eXlremity. Tran~fer of learning i, greatesl when tas\...s are ,imilar. lhal is. have !'lmiJar ~tirnuli and similar rc~pon..,e~. Generali7.3bilil)' i~ defined a~ thc "extent 10 which prac· lice on one lask contributeli to the pcrfonllance of other. related s\...ills:·" p\IO Thu~ the individual I~ able 10 apply a learned "kill 10 the learning of olher ~irnilar lasks. Individuab who Icam 10 transfer from wheelchair (0 plat· fonn mal can apply that learning to olher variations of trans· fep.!
Learning Styles Individuals

\3f)

in their leOnUl1f!. j1\"le. defined

::IS

theIr

characten~tic mode 01 gainmg. pr~e~\mg. and ... tonng mfOmlJlIon. Learnlllg ~t) Ic~ ddfer accordlllg 10 a numbc=r of f;:lclor includlllg per...onallly charactcri"tH.'.... r~a~onmg ~l:le (lilductJ\c " deduui,c), mitiau\e (a<.:t1\e \ ... pa~~I\e). and ... o forth Some IIldl'.ldual ... utiliLe.1Il ~Ulahl ical/ohJectlve learnIng ...t) Ie. They pro<.:e'" mtormatJCln'lll a \tep·h)'-slc-p ord~r and learn be\l \\ IIh l..Jewal mformi.l tlon dnd ... Irueturc Olher Indl\-Idual... are mOH.' Intultl\c/glohal learner ... rhC'; {t'nd to pw<.:e ...... II1l'urma liOn all i.ll OIlL't'. and karn hC~t '" hen inf(\rm tJutHJl-'h oJ I.t .. \",. Indl\ulll.i1 <.har'll."tlrl"'lll~ .Illl! pldt'n.. o<.:c, Ml.· he!'! d~lerll1lf1cd h) 1,tll.llll! \\ nil thc plillelll ~IOJ I,UBI!) U~IIlP CJh:lul h ... tt'lIl1l~ .lnd Olhll\i.I 11<..IIl UII Tht: llIutll..t1 fnord lila) ,J.1,0 1'/11\ Ilk Intllr Hlalldn Uml.l:rnlll~ 1t'lc\.lnr prcIII\)rhHI hl"'lOr) {t',g t"du\.aIIOrl;.l! ll'\l'l (lll'UpJlhlll Inll-fe'I ... , .\ IhtJr\!u~h u"~J,,,:r:-.I.llIdlll~ 01 c,lt..h til Ih.. (' 1..1 '!III-. 1110\\ ~ Ilk I" ·;oJ

piSI to appropriately structure the learning environment and thcmpist-patienl imcraclions.

Evaluation Evalualion refers to the clinical judgments therapists make based on lhe data galhered from the examination.' Numerous ractor~ inl1uence lhe judgments therapists make when working with patient~ with impairments of motor function. including complexity and understanding of the nervous system. clinical findings. psychosocial considerations, and overall physical function and health. Therapists evaluate data in temlS of severity of problems (impairmenl~. functional limiwtions. disability), and level of chronicilY. Therapists mu~t also consider the consequences of failure 10 intervene appropriarely when Ihe patient is at risk for additional problem~. Potential discharge placement and resources also influence evaluation of the data and dcvelopment of lhe plan of care. There is a clear need for the therapist to focus on tho"oe problems that direclly impact on function and Can be ... ucccssfully remediafed.

Diagnosis The physicallhcrapy diagllo~i~ j\:; delcrmined from evaluation of examination nnding~ and is based on a cluster of ~ign~. 'iymptom~. or catei!oric\. The Guide to Pln'sical Therapis1 Prarrice.~ a con~cnsus documelll develo~d by expen phy"ical therapy clinIcians. identifies diagno~tic c3tegorie') and prdcrred prJctice palternl) that delineale appropnate mtcnentlOn\ t ,ee Chapter I. Appendix A). For example. lmp~ured MOlOr Function and Sensory Integrity A:-'\OCI3ted \\ Ilh AClJuired onpr,-lgre\... l\e Disorders oflhe Central l'\ervou ... S) ... tt:m IIldudc\ pJtients With traumaLic brain injury. cerebro\ ~1"'l'lIJar at·eidem. tumor. and so forth -~. JI 'I),~ The reader i... referred 10 this dex:ument for compari::.on and rdine-menl 01 hi ... t)r her 0\\ n practice. f\0\ ILt' th\.'rapl"'h can gam undt.'f't.lnJmg and in..,ighls into Ih~ compkx practIce ""'ue.. t'.lung ther.lpl~t~ who "ork \o,.llh p.Hlcnh \\ Ilh 111lp..tinncJ1t... In lIlOlor funclloll.

Summary

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~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",
SiulIlg: can

~it

to TIght.

References R .I.IlJ I.n: T M,}lur ( \lIltrul J.lIJ lX..Irl\lOf" t'd': 1\.lr,('III.: • ChJ.Olpi'Il,'O lL. 2()11"1 SIIll/lI\1.1\ -( \""~ •.\ ..Illd \\"oll..lPll J\I \{,)hll ClllLllIll llkl.r ,UlJ f'J""th..11 Appilldlhlll", ",.12 Llpyllc""ll \\IIIIJ.nl\ &. \\llil~~Jlh

S

Illilldt,

H,IIIl..l1

~

'l,

l'IiII<.lJclplll.1 ~(II'I "'l.l~lll K \1utL>1 1.\..1ll\II1~· -{ Wh,,·pl· an.. l Apph... Ilnulh cd-l \\it H I:h.,v, II ~ H... n... hnlJ.rb. 1't1•• dhuli. V. t I'N ~

Sianding: able to stand in parallel bars with minimal assistance I for up to 2 mmutes. Has to be remmded Io place weioht on RLE. Tends to lose. her balance eas· e ill' if she moves quickly; associated wtlh brief episodes of dizziness and vertlgo.

Functional ~Iobility Skills Rolling: requires supervision and occasional minimal assistance with rolling to the right: she requires max...imal assist when rolling 10 the left. Supine-to-sit: able 10 come 10 sitting by rolling 10 the L side and pushing up with her LUE: requires minimal assistance. Transfers: able to perform stand pivot transfers with minimal assistance of 1. Gait: does not initiate arnbulalion on her own. Can ambulate Ihe lenglh of the parallel bars (2 m or 6 ft) with maximal assistance of 2 persons. Requires posterior splint to stabilize R knee. Propels wheelchair by using the LUE and bOlh feet for pushing; requires supervision for safety. ~Iot()r

Leaming

Demonslrates profound deficits in short-term memory; unable to remember new information presented during therapy. Her memory for events and learning prior to the MVA is good.

GUIDING QUESTIONS Based on your evaluation of the dat3 presented in the case history and lhe physical therapy examination. answer the following questions:

I. Categorize the patient's I~vel of consciousness upon admission to the long-term care facility using the Glasgow Coma Scale (Table 22.-1). 1. Categorile the patient's problems in terms of: (a) direci impairments (b) lI1dlrec[ impainnenh tel fUI1l'tional !ImJtatlon~ 3 Prioritl7e [he problelll~. e.. t.!hlish anticipated goals and expected outcomes. -to Det~rmll1e the' ph~ Meal Iherapy diagno~ls using the pretem~d pr.ll.'li\.'c: patlern~ identtfied b, the GUIde ((I Phu/( al Therapl H Pr.J. {l'~ (Charl~r 1, Appendl\ A I.

Chapter 8 Examination of Motor Function Jensen. G. et al: E\peJ1J"C:

In Phye;ical1llerapy Practict. Buner",orth HculCmann. Bo!;ton. 1999. S Bear. fl.1. Connors. B. and P'dradiso. M: eUro
2001.

Q

10.

II

12 13.

14.

BICKJr). L. and SZilagyI. P: Bates' GUIde 10 Physical Examination and Hiqory TaJ..lng. ed 8. Lippincott William!> & Wilkins. Philadelphia. 2003. Jennett. B. and Bond. M: Asse!>!>menl of OUlcome after se'rere head mjury: A prwical scale. Lancet 1:480. 1975. Zo1l3n. B: Vision. Perception. and Cognition: A Manual for the Evaluation and Treatment of the Neurologically Impaired Adult. ed 3. Slack. Thorofar¢. NJ. 1986. Stnlb. R. and Blad,. F. Tht Mental Status Examination in 1Ioleurolog). ed 4. FA Da\ ie;. Philadelphia. 2000. Foistem. M: Mim-mental state: A practical method for grading the C'ogmll\e state of pallenls for the clinician. J Psychiatr Res 12: 189. 1975 Yerl~. R. and Dodson J: The relation of strength of stimulus to rarldll~ of habil-fonnatlon. J Comp eurol Psychol 18:459.

1908. 15. Wilder. J: BasulletTic approach (law of initial value) to biological rhythms. Ann NY Acad Sci 98:1211. 1961. 10. Stockmeyer. S: Chnical decision making based on homeostatic concept~. In Wolf. S (ed): Clinical Deci<;ion Making in Physical Thempy. FA Da\'I~. Philadelphia. 1985. p 79. 17. Katz. R. and R)mer. Z: Spastic hypeJ1onia: Mechanisms and me3Suremem. Arch Ph)':> Moo Rehabil 70:144.1989. 18. Burke. 0: SP3.'>tIClt) as an adaptation to pyramidal tract injury. In \\a~man. S (edt: Ad\'3llCeS 10 Neurolog). Vol. 47: Functional Reco're~ 10 Neurological Disease. Ra\en Press. New York.

1988. 19 Dobl..in. B: Kl,'urologlc Reh3bihtation. FA

03\

is. Philadelphia.

1996 20. Fuller. G: Neurological ExamlOatloo Made Easy. ed 3. Churchill LI\ mg...tone. l\C\l, Yori... 1(X)4. 21. Janlo\lc. J: Pa(hoph)~iology and chmeal as:.essmem of motor symplom~ III Parl","~on\ dl~ease. In Koller. W (ed): Handbook of Park,"~on\ DI~a:'-l? Marcel Dekler. Ne\\ York. 1987. p 99. 22. Janko'ric. J. and Fahn. S. D)s{onll.: syndromes. In Jankovic. J. and Tolo:.a. E (ed,): Parkll\"on's Oise3l>t' and MO\emem OiSQrders. Urban & Schwarzenburg. Baltimore. 1988. p 283. 2l Ash....orth_ B: Pn-11I1ll1l30 tnal of camoprodol in multiple sclero· ~I!>

Prxtillooer 192:,;.w. 1964

24 Bohannon. R. and Smllh. M: Interr.ncr reliabilit) of a modified Ash\l,onh '>Cale 01 mu-.cle <;pa.'>uCll). Ph).'> lber 67:::!06. 1987. 25. Bajd T. and VodO\nik. L: Pendulum le,"ng of spasticity. J BIOllle(-h

En!!.

26 Bohannon.

and rellllblht) of the pendulum te:-t for u....ng a C)-bex II hOL.lOctlC Dynamomeler. Ph)'!> Ther 67:659. 1987 Leonard. C. Stcphen,. J. and Stroppcl. S: A~~"'SLOg Ihl' ~pastle Condition of IOd!\'idu.ll, \\ Itll upper motoneoron involvement: \alldll) of the /'.l)otonomett:r. Arth Ph), Med Rehi:lbil 82: 1416. 2001. Leonard. C. ci 31 M~otonomcter 1Il1r. Arch Ph~, Mel! ll()fl. T On dlt: nonual U'oC' of refle\e~ Am So 60.591. 1972. Hellt:brandt F. et a~ Method~ uf e\ollllg the lomc ~d. rene\es III IlOIlIlJ.I hum.m ~lJhJ':d Am J Ph)~ Med 15: 144, 1956 Hdldx.mJI F ..,Il! Wakrldnd. J. ExparhlOCl of motor p:memlllg IIndel e\C:f\.I~ '-Ire, Am J Ph~, Med 41:56, 1%1 BrunlL·..trom. S MO\t:lllt:nllherdp~ III HemIplegia. Harper & R~. C~ 'rart.. 1~70 Bvoath. B Abl\~lrmal Po,lurJ.1 Rdlt:\ Alll\ II} Cau!led b} Hralll Le~l()n". HeJncm,,1I1j London, 1%5. Ctpure. A 1;'1.11' PrtlHIII\¢ Rene\ Prufilc Univer"lly ParI" Prt·v•. l3altullore. 1979 Caplllt:. A d ~l hlmlll\t: rdlt:>. 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

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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....

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\,~"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 .

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\\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
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40 SahnJl.,lnn. S. :lnd 1'11111011. 13 T he rctat loll,hlP or '>ol Unfary movement 10 'p.i~lIC11) III Ihe upP': r mOlQr ncumn sy ndrome. Ann Neurol 1' 460, 1\) 77. 41 . B\" ul'bu,\ " al ~. D. Jnd Vanden ~o\t!n . S. Wc:tlo..ne ...s In pallcnl'> With hC1I1 Ip:lre!>I!>. :\111 J Occup Thl'r 43 :3 1 ~ . 19~9. .. 2. \\<,11 10.. 10'>. M, t:1 al ' l\ok incu<: 't',> lmg in pa u ent ~ \~Ilh hemipJlrc"I.I.. Ph", T hcrM:11.:4. 1984. 43 . RO-lit!-.Iein . J, clal: Commcnl::tr\. 1\ lhe men~lLre tnCnl of mu"c1(' , Ircnglh :lppmpflJlt 111 pallt'l\l~ With br.li n Ic,jclJl:'? Ph),,, The r

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Ihe I11 c a~ure111.: nl or mus.cle ~I re n g lh appropriat(' 111 patient.. \\' llh hrain le" loo..,.' Ph),,, Ther 69:225. 1989. 45. Frc~. E. CI a1: Cl ulI('1l1 rrliability of 1TI a nu al lTl11 ~c k lesllllg: MIddle Ir'lpcl.iu, and gluleus m t! d iu~ rnl1'oclc ... Phy' Thc r 67 : I 072. 1<.lf.;7. ~6. Ridd le. D. CI al: I n l r:l~e-'NO II lind intcrse"' JOII rellabll ilY of hand held dynamometer me;l.'i urcmc nls tllkt'll on brJin-damaged panent ". Phy, Thcr 69: 182, 19M9 . 47. Soh:mJlun. R: T..:St- rCIC.,1 reliabi ltly of hand-held dynamometry durin~ :1 " lOgic /)eS~ lo n of strength ass-c . . smcnt. Phy~ Ther 66:206.

1%6. 4X. Bohannon , R. and Andrcw:>. A: lll lerraler relJabi lilY of handheld dyn,.unometry. Phys Ther 67 :93 1. 1987. J9. Agre. J. el al : Strenglh tes1tng WLlh a pon able dynamomete r: Relldbtllt) for uppcr and lower extremilie ~. Art.:h Phys Med Ri.'habll 68:454. 1987. 50. Kloos. A: ~ka!) lI remen l of tnu"cle lone of isokinellc measurcmt!nts. Ph ),s Thcr67: 1840.1987. 52. Griffin, J . el "I. Sequ!!nllal i::.olo. inet ic and manual musc le tesling in patient!.> With neun)mu$cuiar di"ease: A pi lOl :;Iudy. Ph y~ TIter 66 :3 2. I Y86. 53. Kozlow\ki. B: Reliabil H) of isoki nelic torque genermJOn in chron ic hcmiplegit: ~ u bjeC'h . Phys Ther M :7 14 . 1984. 54. Edwards. R: Physiological anal ~ sis of j.l...ele tal muscle weakness Jnd falli!.Uc. Clin SCI Mol Med 54:46.1. 1971:1 . 55. CUrli~. C. and Weir. J : Overview of cxcrci!.e re~pon ~es III health) and impaired stale .... e urology Reporl 20: 13, 1996. 5(, Wade, C. and Forstch. J ; Excrc io;;c and Duchennc muscu lar dyslrophy. Neurology R('p<)n 20:20. 1996. 57. Co..,tcllo. E. t: 1 al : Exerc ise pre~cnplion for ind ividuah. with multiple , .:- 1<::1'0' 1$. Nt:u ro log.y Report 24:13.1996. 58. Bas" k. 0 : GUll1alfl-B:mc ,yndrome :md e,\;ercise g u idd nl~. N!!uro1l).!D Rcpon 2-U I. 191J6 . 5'-J Ml"DoI1J ld. 1\1. EXr:rci'l! and I)(hlpoilo :.y nd rome. Neurology Rt:pOrI ::'~ : 37. 1996. 60. Big l.lI1d-R Il,;hlt.: . B. anJ Wood". J: Changes III mu:.cle l·ontrac;tilc propenit:. and neural control dUring human mu!>Cul.ir f:ltigue Mu,t:le Nene 7;691. }<)84. 6 1. BlIrg. G: P.. )choph)~ic;al b.iM~:' of per('elved e- xl'n ion. Med SCI SPOJ1" E>;..:rc l-kJ77, 198 2. 62. FbI... J . el aL The impact of fJllgu~ on pat it'llb with muhlplc :.cleTO,i:.. J Can Sci N('uml 21:9, IY9~ . 6.1. Remlt·H. R. and KlIov. hun. G: OWT\\orlo.. v.e:ll.nc~:. in partially dt!ncrvatet.l ~ k C [el.LI mu:.de. Chn Onhup I ~ : :!~ . 1958. h4 RJ..f1h?~. S' hul..Hletic: IJtlgue tunt':. al (hiferenl cOlllracll le velOCJt!(',. Arc h Phy~ tIo lcd Rdl.ibI1 6:!:b6. 1981. 115 Rmdcr-Madt'OO. S . .in~1 S),ndl!r Muc: \...lt'r. L: Mu:.,l'ic fatigue.: CIUIK',LI tl nphc LIIOII" fl)r 1,IIH!Ul' It,>,e~\ mll nt and neurOl1\u<,cut3.r eICdn l':I[ ~ lllnuIJtlon . Ph) :. rher 7 .l:902 . 19<)1. 6ll MtD~'Jlne ll. />.,\. l't at Et('~Int: Jll} dklli:!J f:uigue Ic!>1 of Ihe ttu lldnc..: p~ km{lrl<' rnll~~ It- Ph ...... Tht"r 67:94[ . 19R7 67 J--.ugl-Mc)er. A. 11,(, pUM."trol..~ henllpl('gu: patiem. I A method loJ' t'\,-IIU,ltl(\11 ot ph}''''::l! pertomlall>.:r: Scant.l J Rt!habll Med 7; 11. 1975 6x VanS,ult . A LIf..: :.pan de\ clopmCIII L11 fwl...tlon.ll lu:.l...o.. Ph)'~ Ther 7()·78S. II)I)IJ

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Ph, ..;('al Rchabililalion Slwnkm:lIl. \1. el III Wh\llc-hody mov("nlt:nh dunng r"lng 10 'lanJln~ lrom '11l11lf: Ph), Iller 70:6:l~. 19YO \ .. nS;Il\I. A RI,mg from:l "'Uplllt= IJO... l1lOn 10 ('r..:cl ""JIKC: [)c ....:r1pll(l1l ot adult 1ll0\1'I1lCnt :l.Od a drvclopmcntal h)'pothe~..... l·h),11Icr(~·IS5, 19X5. (jr('ell. L ;In{/ \\1111:1111'. K. DIITcr('I1~'t', in de\elOpmClIlal nl(1\C' Ill.:nl p:lltcm... u....:d h) ..cll\\.' \ ... ...edenl.11) rmddlc·agcd "dull.. (ommg Imm a ,UrUl\: 1X"lllIln 10 erN'1 "lance. Ph) .. Ther 71:560. 1992. RKhlcr, R. el Jl o.:"Uipll(111 01 aduh roiling Olmcm.:nl, and h)JX)lhe", 01 de\elopnk'1l1al -.equence, Ph)!!; Ther 69:63. 19S9. G.:nllk.,), Sl..llI 3<:4uI"IIIOO. A{·tJOn. movement and ncuromolor prO\.c.....c... In Carr J. CI al lahl Mo\'cmem Science: Foundatloo~ h.r Ph)'i\:al11lcrJp) m Rehablhlalloo. A'pen. Rockville. MD. 11.)87. P q, Pml... "I High ,peed \ Idco applicatIon'> III phy..icallherapy. elln ~lall.lge 5.1-1.1985 Le\to ..... <\ Dol'umcnla1l0n of 1ll0\emenl paUcm,> used in lhe perlonnanl..c of funclionalla~I..... Ncurolo~D Repon 16:13. 1992. .... orl..lll. C. and Le\angle. P: Joml Structure and Funcllon: A Comprehen"l\e Anal)\.... cd 1. FA DaVIS. Philadelphia. 2002. Smith, L. cl.d Brunn"lrom·.. Clrnlcal Kmc..iology. ed 5. FA Da\i... Philadelphia. 1996. N:bhner. L SCII.'iOI). ncuromu<;cular. and blOmechanical conlribuIlOn\ 10 humJn balance In Duncan. P (cd}: Balance. American PhY~lcal ThCr:lP) AssociJtlon. Ale\andn:l. VA. 1990. P 5. I\lchol.... D: Bal•.mcc relr311l1llg aflcr ~Iroke u:.ing force pl:ufonn blOfcl'dbacl.. Phy., Ther 77:553. 1997. Hor.I~. F: C1mlcal mea:.uremenl of postural controlm :Iduhs. Phys Ther67.18SJ. 1987. GI)ldIC. P. t:1 al. Forct' pl:ufonn mea-..ures for evaluallng postural l'Olllrol RehJbllll) lind \ahdll}'. Arch Phy:. Moo RehabI170;510.

19<9. R:!. LI'lon. R. and Arouv.er. B: Rdiabdil} and validity of m('asure.. f,blamed frOIll "LJo~e pallenb u,ll1g lhe Balance Ma:'ler. Arch Phys Med Rehabil 77:425. 1996. n Horak, F. el lIl: PO'lUral pt=nurblllion:.: New in<;lghls for \remment of blliance dl'order!>. Phvs Tlwr 77:517. 1997. 8'. Dellman. M. el al: Rclal·loll.'>hip.. among walkmg perfonnance. po..lur.ll ~labdllY. and funcllonal as..e.....ments of the hemiplegic pallenl. Am J Phy., Mcd 66:77. 19~7. 85 Dicl.,'elll. R. cl "I. root·ground pre.'>sure pallem of .'>landing hermple-glC pallenl.'): fl.1;tJor I..hllracleri~IIC"" and p altell p'-,,>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'lllnO(ia!("d \to lin ,>llmJlo..cn,ol'\ . .md \C"llrular IIh, bp BrJJn Re.. 1)1: IfJ7. Il)()(l lKl "' ..,hllcr L "-J... pll\C rcflc\n cOIumlhng hum.sI1 pthlure E\p Br,lJn Rc :!t. 'i'l Ill7h ''',.JIllCI I "od "1L< OIlUfll (j'lht' orl!"'I1lLilIlOil 01 human PO'" lural m.h~·lIlelll l\ •• rmal t-o...."l and ell,pcnmcntJI !Io\'mhc!lo.... Bt'hil\ Br",m 'N.' Y J It,o",~ • OJ:! ShUlrhl"y_( "II.. .\. lI nn !'>..I"n... c ~u<:, I,/x,.. }'lo leI t,ll

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'13 ( 'Jll:lI H c'ta! A~tud} {.J (I~HS PII)~ Ih~1 -~ J-Ih. I91H k",..e- IJ· I "II Plu,,1 A Cl>mpll.'hl.'lhl\<': B
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99.

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10 f\clIrfl1ott).

Appendix A: Berg Balance Scale ft. Sianding un\upporU'd \\ilh {')('s do~ed

f. ~ilfin~ til .. ll1ndill),l, In.. . llulilim

PI,'IJ\( H
lid

ltl /1\(

\0111

hl\lImIIO/l ... P/('O\(' l/mt' .\(/W' c.\{'~ lind <>fand

to

ft,md\ I. 'I "I!'/l""

\.'I/'lId\

I I Ill'l·d.. mlnllll.11 .lId 10 ... I.ind /lr 'IJhJll/c

,,/anJ In 'IcconJ 'atd) ,'amJ 10 ...ccond \\ ith !olupcrvi\ion 1 2 .lhle 10 ,tanJ J . . ccond... ~ I ul1:.thk 10 }..e~p eye, dlheu for 3 ~cconds but ,rand.......lkl)

I II Iwed ... nh~kr;lIL' or lIh1XIIll.11 .1"1\1 In ... IJlld

,(J Ill'Nt"

I ~ .Ihk In .. I.md

"llhlllil U"UH! h.llh..I-. .1IId .. I;,hlll/l'"

IndL'I>I..·nlk'llll,

• , .Ihit' , ~ •• hlt-

2.

~1'HldinJ!

ttl ... 1.Hld lI11kpelhJl"llIl~ 1I"'1I1~ (0 "'1,11111 1l!'1I1!!

haud ... lund, alia ...\'\er;d Ifle,

un",uJlpurlt'd

In"nh.lloll'

Plt'tl\C 1101/d 101 l mill/un

\I

U/icllli

I -l .lhk·

I(l

I 1 Jhk'

10

( I ~

In "'1;IIlJ

on floor or on a ... luol IlhtrUCtlon,: Ph'a \(' .\if

1\

/fit

01111.\

~uppnrled

10ftit'd jm

.J. Standing to ...il In')trunion ... : P!t'C/H'
( J ~ 'II'> ....Ifch \, IIh Illlllinul me of h.md ... ( I::; cOillrob de"'l"t'n( b., u"'lllg h..lll(I... { I 2 u'e~ l,-I,ICh. 01 leg!' .igailhl chaIr 10 control dC"'l"enl ( I I ~Ih lIldCIll:l1Jcntl). bUI hi.!" uncollirolled dc......enl ( ) () need, a""'I . . t.mlC 10 .,11

5. Tran..,t't:r... In"'lruCllCnl;,. \rrullgt. llum \ lor 1I pi \'Of tramfer A.\,(

111m

10 /I"OII\}(I" II/Ie 110\

(OIl'al"d a .\I'af

tmnlrtl (/\('clf

11.'(' fll't) ,!JOIn 01 {/

)luh

( ) ~ able 10 pl,ce reel logelher independently but unable 10 hold ror 30 >ewnds ( J I Ill.:cd" help 10 :l~~Ul11e the po!:!.ilion bUI can stand for J 5 second.... feel wgethcr ( ) 0 need ... help 10 assullle the position and unable to

II

illunl!

( ) -t t:Jn reach forwdfll c.:onfidenrly 20--30 em ( I (I lIlebe» ( ) 3 can reach f.. .lf\\;.:.rd ~afely 12 el11 (5 inches) f ) ~ c.m reach fOf\\ard :>afely 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<.llling

\13nd ~<.lfely I minulc

-'0 ...I..'u)nth

unabl\?

10

11110/11 holdlflg

1\

I -l ahk 10 ,t,!flO ..all'l) 2 IllIIlU!l..· ... I 1 Jbk III q,md :! mlllu!..: ... \\ Ilh .. ur~n '''IL'1l • ,2 ,1hk Iu ~Iand ~fJ ""'uHlI,.l, llll"'upporlni ) I 11"l"d.. 'l" l'I"JI tnt" III ..land un'uprt-meJ , (J

help

7. Slanding unsllpporled wilh reel together In\lrUCtlon...: Ph/( e YOllrfet'! loge/her alld stllnd

ht'ldml.;

( ( f ( I

still/Df

up.... r\ I .. e

10

tx· . . ~k

pOMllon

PIC/... 1/1' II/(' S1We .\!Ipper ' . which is placed of Hlur ji'('1 ( I ~ able lu pid 1 I . up t le ... Ipper 'larch and easily ( 1.1"'l .1l>le to pi I" ~ uP (I " . k .... Ipper bUI needs ~lIpervision l I - undhle 10 I' e~ h I lip t e "'''pper. bUI fC'ache~ 2-5 em II -~ Ilh.:he- ... ) IrOlll (11:: I' ... IIppef and kl"ep~ balance IllcJt'pcndellll, {n ... ,ruc(ion:>·

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 In<;lfUCllon,,: Tum

100Hm/ Iht' Itjt

(/1/(/

~"(Jllld('f.

R('/l{'(((

I I 3 100"" behmd ('ne ':iide only. other ~Ide sho\\" less \\ eIght "hlft I :! tum" . . idc\\;l~ ... onJ~ bUI maintain ... balance I I I need . . do...e ... upcn. i... lon or \erbal cuing { I tl need" a...si"lancc \\ hile turning II. Tu rn 360'

In\lrLlClion,,,: TI/I"II (ompletely amund in a f/lll or( Ie. f'dllt( Iht'll turn u./idl em It' In Ille otller din..'ctlOll, f l-l dble 10 (urn 360 "afC'l~ 111 -l ,econd, Of k 'l 13 ahlc fO tum ~(lO- "'afel). one "'Ide only. .t econd ... or Ie,... 1 ~ able to tum 1.60 'latel:. but 'l10\\ Iy I I I need" lh",c <"upen.'i",on Of \erbal cuing j ,U need.;, a"'I"tJnCe \\ hill' lurnJllg 12. Place itlternalt' fOOl on step or ';tool \\ hilc standing unsupPoried ln~tfuclion~: Plan' nlCh foot alternarl!1y on Ihe ,Hl'fJ !,lo,,1

(O/.tlfllh

//J1lI1

('LIt

h filvt Itu,\ wuched tllc\I('!l

/flO/ ...J tmlt

(0 ,,1 ..lIlt.! inJependentl~ and "..tft"l~ and \"'omplcl :" ')h:p.., 111 ::'0 ...eumd... l I ~ d\'l!e tu land II1dependelllh and \"'·ompll'te k ,1C:p

,-l ..Iblt'

:11

t'

lnJ

( ) 2 ahle 10 complete 4 SICP<; \o\ ~ ,Iep" n~cd'i minimal a~iiiislancc

10 needs a,sislance to keep from falling/unable to try

IOiiilllg l:laJ~lnce/f~lling

10. Turning to luok hchind o\er iiihouiders while iiilanding

269

13. Sianding unsupported one fOOf in front In:-.truclion ...: Dl'I//()!l\trule to JlIhjl'c'f. Place olle JOOf Jirnlly ill frollr of rile miter, If YO/f fefl rhal YO/l cal/no' place YOl/l'jlJOf direi'lly il/frolJ!. 'ry alld step/ar l'nOlH~h allead t"at tlte heel of your forward fout ;\ alleud of the toe.\ uJYOllr otller foOl. To score {llree pOlIlfJ, tlte lenglll oj {he step ::,"ould exceed the length oj the otller foOl and the width of the J!(J"ce should approximate the slIl>ject' \ 110rmal Hallce u idth. e I 4 able to place foot tandem independently and hold 30 ,econds ( ) 3 able place foot ahead of the olher independently and hold 30 'econd~ ( ) 2 able to take a small slep independently and hold 30 seconds ( , I needs help 10 step but can hold 15 seconds ( ) 0 lo\e, balance \\ hile stepplllg Of standing

'0

I~. Standing on one leg

In,tructions: Stand Oil one lef?

Q\

I(JII~

as you can

1\ ilIum, holdil/'t ( ) ~ able 10 hftleg Independenlly and hold >10 ,econds ( ) 3 able (0 lift leg independentl) and hold 5-10

iiiecond'l J .2 able 10 lIn leg IIldependently and hold> 2 'l'comh ) I tries h' i11( leg 1I1l..tblc to hold 3 ... t"cond~ but

rcmalll'o ... t
Appendix B: Perfonnance-Oriented Assessment of Mobility I-POMA I (Tinetti) --------_-...:= ';OI11C "laggcring. ~waying. moves arms, or moves

BALANCE

fOOl

In'lrucllon,: SubJ~LI i~ "'C:~HcJ JIl hard annie ...... chaIr. The follO\\ 1I1f:!. m3neu\'cr~ are le~led.

balance o = lean~ or lihdcs in chalf I = leans 10 ch;:lIr slIghtly or from butlock ...

(0

~Iighl

o

increa"ied di.,13ncc

back of chair

= .. lead). :-afe. upright

1

1. Arising

10. Bending Oler (place 5-pound weighl on noor and ask subjocltu pick it up) o = unable or is un~leady

o.:;:;:

unable WilhoUl help or losc\ balance J = llh/r bUI u')e~ ann 10 help or requires more lhan (wo al1empt~ or c\.cessi\c forward flc\ion ~ == aMi' wi thou I U':'C 01 arms in one attempt

I = able and is sleady lOa. Time required

3. Immediate standing balan('e (first 5 seconds)

o=

unsafe (mi~judged diMance: falls into chair) I = lI"CS 3mlS or nOI a smooth motion .2 = safe. \l11oolh motion

--

~. Side-by-side standing balance = ul1',lead)

o J

:!

= Uf1',lead). bUI =

\\Ide !o.lance (medial heel~ more

Ih:m 4 inche:-:. ap.m, or use.\ cme. \\alJ...cr or olher suppon nMTO\\ ~lallt:c \\ ilholll 'lUpport

at \\ rist'

I 2:

~glll~ to fall

= 'l"gger,. gr"b\. but (.;.uche\ \elf =:

113. Timed ri'iing Time r~quired to rise from chair three times

'erond...

5. Pull test (subjrct at ll1a~imul1l positiun a", abme e'\aminer ,rands behind and e~erl\ mild pull ba~k

o=

rotal Balallce Sl/bfl'_\1

G.\lT In_'>lrUClioll~: 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

..-uh

..

~rfrtrfi~i1

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<;trumcntalion ~) <;le", u~d to

record the c1cClrOI1l)ographic (EMGI 'iignaJ for c1ulleal and I..lOe... io!t..lgical u<;c...

2. Dc'>Cnbe lhe general methodology used to pcrfoml an E\1G and nerve conduction velocity (~CV) e),.amin:.Ilion.

3. Dc~nbc the characlcriqics of nomlal and abnormal E~1G potentiah-. -I. Describe the EMG signal and NCV findings typll::all) ~een \~Ith neuromuscular disorder... 5. DI\(;u~~ the Impilc:HlOllS of climcal EMG findmc.,:> for ,!:oal ':>t'ning and lTC'atment pl:lnlllng. 6. D~...cus'l the relationship between the EMG signal and force Yo iih dlfferent types of nlu<;c1e cOlltr.1l.tion<;.

i. DISCUS~ procedural. technical. and phY'M]ogical cOlwckratiom. for interpreting clinical and kineslologKa! E\1G data. S. De!locnbe lhe Usc,!, of kinc..JOlogical EMG dala for e\ulualion of movement. 9, U.,inc. Ihe case <;Iud" examples. :tppl) clinical dec,<;~on lll:tl..lng skill<; in e\ aluating EMG data.

Electromyography and Nerve Conduction Velocity Tests Leslie G. Portney, OPT, PhO. FAPTA Serge H. Roy, IYI'. s,·o John L. Echternach, PT. EdO. ECS. FA PTA OUTLINf CtlIKt'P"

tIl

Elt:nrom)ogr:lph)

(E\l(i\ :::74 In::>lrumenlalion and Signal Characleri.. tics 274 Other Sources 281 Amplif) ing the EMG Signal 281 Dl<;pla) ing the EMG Signal 2~2

r\;en..: ("on
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
l1lu~de~

I.: ltl I m':.11 111,111111.::-.1<.111011:') 01

\oluntar~ rnU'l'le l"()lltr~h:tIOll

In man lJulht.'nnl lllilde ('()n'lllcldhk .tt..!\JIlt.cllle-llh In lhe lelhnll,~u~ ..t)l)fl thl.:rl,'..lllt:l. IHllle-ll'r, Illn" 01 the d(,\i,~lop­ 1l11:nh I,~t:h: uhn.:g... rdetl unlll the t",1l1~ pMl Ollhc t\\Cllllelh ll:l1lur..... 111.'11 lfl":.lruIllcnt,uiull \\<..1:') dc.:\clupeJ 10 m.lle rt:cordmg li,uLh "Ktl\ it) rdl<..lbh: alld \<..IlId TOday. dmll.ll

Rl",ull~

Disorders of the Peripheral Nerve 296 Motor Neuron Disorders 297 M)opathies 297 Myotonia

298

Myasthenia Gravis 298 Ra
ClilllcJ1 P\ 1(; 2~.' The EMG baminauon lIB Smglc-Fiber El\'IG 287

In::>trumeniallOn

CllnlCll Imph... allon.. of EMG Te ..t!\ 296

Surface and Fine- Wire Recording 299 Localing Electrode Siles 299 Signal Processing 300 Timing of Muscle Activil) 302 Nonnalization 302 The RelatIonship Bel\~ ecn the EMG Signal and Force 303 EMG and Exercise 306 Neuromu.')cular Dysfum:lioll .'07 Pain-Re13led Muscle ImpalrmcllI:-. 307 Sunl1n.I~'O~

01 thl' Cltrlll,11

lalllHlal,toll

:::"4

clectrOlll) ograph~ (EMG)

t~ u~ctud) mu~cle funclion. A.. an e\;ltllln:.tllon procedure, dimcal EMG tmohes Ihe detection and recording of dectri;.;al pUI~lltials from .. ldeti.l1111U\l'k fiber.... Nern condufliun \elocit) (Ne") Iclot-. detennllle the 'pt:ed \\ Ith \\ hlch a penphc
durl'\

Gin

pro\ Il.ie Illforllldilon dbout the e\tent of nerve

1l111~l.."k dl.!lt:3":.C. The~c twu (orlm. 01 le~(ing. reterred 10 •• "\ e1eclroneUrOffi)ograph) (£f\M(;). c~n l:onlnbule v
InJur) and/or

"\Olllt'lIll1elo

2H

Ph, .. ical R,'hahilitalion

.1 dwgno'I' :lnt-! progntl,l, a~ \\ ell
...---i---cHr--- Anterior hom cell

Axon

Muscle fibers

Figure 9.1 The molor unit

Concepts of Electromyography

IS

composed of one anterior hom

cd!. one a"on. il" neuromu~cular junction and all the muscle fiber... mnervaled hy that axon.

(EMG) EMG 10;, [he recording of the electrical aClivllY of Illuo"dc and In c\,ence. Ihe .;;tudy of motor unil activily. MOlor units are cOll1po~ed of one anterior horn cell. one axon. it .. neuromuI,cular junctions. and all the mll~cle fjbt'r~ innl.':rvated by thai axon (Fig. 9.1). The single axon condUCIS an Impube 10 all ils mu::.cle fibcr~. causing [hem [0 depolarize

al relatively the ~~une lime. This depolarization produce~ eleclrical activlt~ [hal 1'\ Illalllll:~[ed a~ a 1/11)101" IIl1it (1(11011 potemwl rMUAPJ and recorded and disphl)ed graphlcall~ a.. the EMG signal. In... trumenl
the ~mall eleclrical . . ignal i~ amplified: and an OUlput pha~e. in which the eleclrical signal is converted to visual and/or audible signals so that the data can be displayed and <Jnaly7ed (Fig. 9.2).

Instrumentation and Signal Characteristics Detecting the EMG Signal: Electrodes An electrode i, a tran~dllcer:
Storage

OSCIlloscope RecordIng electrodes Amplifier

Dlsplaymg

Recordmg

L~:~~;'~---1OSCIlloscope ............~_.a.p.p.a.ra.".u.s_ .. Ground

Figure 9.2 Iht' I.. r\ lG n.>..:ordulg ,,>} 'h:rH. \ \11.lpl(·u

1.

lrom Ednc:mach.

P;" Hh ~lC"lIl11')">lon.1

Cha pte r- 9 Eleclromyo ......,.aphy and Nen 'c Conduct;on Velocity Test8

275

"('I1l~ 1-.1I11: . . ioiog ical IrlvC':.. ti g;:nion ... . Th L'Y nre gL'-nera ll y

l·on ... idcrl'o adcqu::Jlc for l11on ilOring large .':I upcrlicial m us· cle . . or Illll'ld t! gmup ..... Surfm.:c e-lcc l rndc~ cannOt be u ~ecl tor cllIlical EMG e\~lI1linali{)n .... They :Irc not con ... idc red ~l'k:C li vc COllUg h tn reco rd ~I c livil y 3lTunllely from
EMG. In i.lddilion to :.1 re('ordlllt.: ('/('uwde (e i ther surface or nCl.!ol c) . :.1 ,emilI/£! ele('tmde I11U.-. t be appli ed 10 prov ide a meCh ~1Il1 1i 111 for cance ling ou l the int erfe rence effec t of c>.l erni.t1 elec trica l noi se . . uch a ~ that c a u ~ed by fluorescent Ilghb. broadciJ'Iting facil i tie.'1. elev:Jtor:-.. and other electri cal apparntu ..,. The ground elec trode is a .,urface elec trode Ihat is :.Ht:.1ched to the :-.kin near the recordi ng elec trodes. but u'l uall} nOI over 11lU..,c! t.! . The "' lInples t .:; urfacc EMG el eclrod e is confi gured as a . . mallmetal di "c. commonl y made of sil ver/..:; il vc- r chl oride. which i'.l typically 3 to 5 millim eters (m m ) in diame ter COI1 wined within a ca... ing thai can be affi>.ed to Ihe surface of the "kin \.\ llh adhe'iive cullar:.. or Jape. Elec trode gel is applied hi:neath the ... e elec trode ... to facili tate th e cond uclion of elec tri ca l poten tia l". Olher surface electrod es are '1e1f- aoh('"i\'t' uno pre-g elled (Fi g. 9.3). Two o f these elecIrode~ iJre i:tpplied 10 the .. kin ove rl y in g the appropriate l11u~dL' . 10 a('h l ~vL' bipolar recording. where Ihey are typi cally arranged 111 :.1 lon giwdl11al direcli on para ll el to the mU'Ivle riner.. I Fi g. 9.4 1. Oft en. "0 me :-. kin p re par~llion i . :; neu''1 ... Jry to reduce ... kin re':l I ~ lan Ct!. \\'hi ch C~tn int erfere \\llh lh~' qualt!) of rCI.:o rdll1g . 11 Thi 'l 11lay mcl ude w;'l 'l hing. rubhln ~ IJ>lth ilkohol. ;md ahradin!! the ", upaficial .. I-..in la)t'r til remo\r.: dt:.ld. dr) ... I-..in cdb, Imprnvl:mr.:nl . . In "'llrfact' electrode Ic\.: llnolLlgy ha ve rl''1ultcd In Iltl.: aUI\(' dl'('Troile whidl ;lchicvl..'s bipohtr rCl'ordmg hom a ..,lI1gl(' "l'mor co nlaillin g prL'a mpli fic r"

FigurE- 9 3 SU ri 'IU: t:I\\"lrnJl'~ .Ll~ .1\.lti.lhle \\ 111t;.1. ')<:11 ;ulilL'rJlJ/.' urt.tu.: lit .., !lUll Ph\lu.II\~ IXld,ltIi! \/,/r, haddllg III jll.il1o:t I~ H~IHU\,:d plH.r Iv l"'~ (11\:111 b.ld.H1!.! h.::1l11.l\ eLl) Noll' tlt l · ... lILl.illllfLUI,1I \1,\;11 tl/ ~JlIll'\Hll
Fig ure 9.4 Two surface el eclrodes appl ied to the skin overlying a Ill u'icle 10 achi eve a bipo lar reading.

and signal conditi oners at the detec ti on si te. A ctive electrodes are typ icall y confi gured w ith ;j fi xed interelec trode separati on o f I or 2 em (Fig, 9.5 ) and att ached to the slcin using a double-s ided adh esi ve interface ( Fig. 9.6). Ac tive elec trodes helVe the ad vamage o f not requ iring ski n preparati on. and they minimi ze sign al arti facts th at can res ult from movement o f lhe leads. Their ti xed interelectrode d istance also minimi zes modifi cati ons in signal amp litude and spectra l cont ent w hi ch can occ ur wh en thi s d istance is all owed to vary, as fo r in stance wh en silver/s il ve r chloride di sc elet· trodc!o. move w ith respect to each other during lim b movement and stretchin g of the sk.in .6 . 11 Finc· w irc indwe llin g electrodes we re introd uced in the ea rl y 1960.., for k ines io loginll stud y o f small and dee p

ck'clruJc 'l tle}l ) are t.'onlig,urt:d wu h a li ... ed Of' :! t' 1II. r\ ;:'lIIal l doubleo,!oKk:d aJhl'\"C ~ lnp \\ 1[11 dCl lrllJ e ll pcnlll g3l ll ~"t) I ~ u3cd for .1\I..tdllm:nl 10 .. l<..il1 '>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: \It Ihe " lh: ;lIlJ h'HI~'" .ue ne<1ted 11. hn:p lhe .... ,re... lml'lcddnJ .... hdl;" Ilk

Io"'cdl.:

I remO\!;'J Iro!l\

Ihe

1l1t1

A needle clcorode is required for clinical EMG. so that 'iingle mOlOr unit potentials can be recorded from different pal1s of a muscle. The first studies of motor unit activity \\ ere done in 1929 by Adrian Jnd Bronk,I.J who used a conce/llr;c (COlLrIOI) needle electrode. This type of electrode con'iists of a st3in!e!)s steel cannula. similar to a hypodermic needle" through which a single or double wire of platinum or silver is threaded (Fig. 9.8). The cannula shaft and wire are insulated from each other. and only their tips are exposed. The wire and the needle cannula act as elecIrodes. and the differenc~ in pOlemial between them is recorded. The bare tip of the platinum wire is considered to be Ihe active electrode and the cannula acts as the referellce electrode. Another cOJlllllonly u~~d approach fOf clinical EMG Involves the u~e of a lIlonopolar needle electrode. which is compo~ed 01 a single fine needle, insulated except at the tip (Fig. 9.9). A second surface electrode placed on the skin near the site of in...ertion ,erve~ a!) the reference electrode. Thelie electrodes are Ic~\ painful tll.an conc~ntric electrodes becau~e they Jrc :-.mallcr In diameter. Because monopolar configuratiulls record mu('h larger potentials than biJXJlar, the type of el('ctnxJ~ ,hould be specltied to avoid misinter· pret"ltlon 01 dald retJtlVC [() the ,ize of pOk"ntials and the

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Ilkl

Figul e 9 . 9 111·I; ITIlmopo IJ,l Il\.'edle ek"l'lrode I., a ~lIlglc fine I) I.t" "ltl~ I J C\n:pl t~)r the O.S-111m tip. t: ... lll'>U .. k

,hJnlt."ned '1

( hap'cr 9 Ek"Clrom}'ogr-aph) and Ncn t~ Conduction Velocity l~u

277

afC'.lol rcconhng. Clllllcal EMG can al~o be u"tcd to record Ir,lOl \lIlglc mu\de fiocr'l.I< Sinf!,li'-fihu I/('t!tl/l' e/('('tmdf.'i ,Ire Ctlll(~nln(". but ha\c 'Wlre'l 25 l1licrometer~ (t-Lrn) In 0I3I11('ler (a\ ,,'Olllparctl 10 0.1 111111 lor \I:mdan..! concentric elcClnxte \\ J r~\ l. ,,,'cdle ekclrodc ... arC' not u\cful for k.lIlc~lOlogical qUUIl.... hC'cau\c 01 Ihe di,comfOr1 cau\..:d by th~ needle rel1l~lin· 1I1g mlhe muscle Junng conlr3Cllon. Fine-wire cleclrode~ arlO lIlappropn3tc for U\C In clinical EMG bccau~e the C\:.Irtllllt·1 ha, neither good conlrol over placement of the dCl"lrodc. nor the abilil)' to move the electrode within the lllu..,c1e Ollce II i~ placed. Ullrasound imaging has rccenll)' ht.~cn u::.cd \\ ilh great success in helping to guide the place· menl of fine-v, ire eleclrodes in deeply ~ilUated muscles. such a.., the Jliopso:l.s,'li Guidelines for insertion of elec· trode.. h3\e been published 17 · I11 and anatomical references ,hould al\\3)' be consulted 10 en~ure accurate and ~afe piacemcni \\ hen u~ing needles. Because they pierce the ,!...m. all needle and fine-wire eleclrodes must be sterilized. Cllmcal ,lUdic,> are done almost exclusively with com merciall) 3vailable ~terile dl~posable needle electrode~.

The \hoelectric Signal Thl~

. . et:tion contallls foundational information about

EMG that penallb to both kinesiological and clinical use bUI I~ not ~pecific to culler use. Later s.ections on each of the"c aprli("allon~ addre~s more specific considermions, EMG electrode~ conven the bioelectric signal resulting from mUl,ck~ or nerve depolarization into an electrical potential capable of being proces~ed by an amplifier. It is (he difference in electrical potential between the two recording eleclrooes that is proces~ed. The unit of measurement for difference of potential i~ the mft (VI. The amplitude. or height. of potentials is usuall) mC<1'lured 111 microvolt" (J t-L V = IO- tt V) or in mill i-

\ 01" 11 m V ; 10 V). The greaterlhe difference in potenuaJ recorded by the electrode,;,. the greater the amplitude. or voltage. of the electncal potential. The amplitude of a MLJAP I~ u:-,udll) mt:a~ured frol11 peak to peak (i.e.. from the h,ghe~t to Ihe lo\\est point). The duration of the potential,.., a mea ure of lime frol11 OI1\ellO ce~sation of the eleclntal pOle:ltlal. Typical peak·to·peak range~ for MUAP amplitude art: 5 J.lV to 5 mY; duration varies from 2 10 14 nll,ec. 4

n"

'''lor Ulllt I\ction Potential (MUAPj

It ,I, IInportalll 10 under.. land the proce~~ by which a \1L!AP t' tli.tIhnllHed to all amplifier in order to underl,t3nd

hoy, !)Ul:h potentlah ';In be Iflterpreted. Becau~e of (he dl~­ pa'ion of thl." fiber... in it \Ingle motor un ii, the mus.cle lther~ from ...t.'\l:r.tl motor unit~ l11ay be Jntcr~per\cd v,lIh tlllc anotht:r !Flg. 9.101. Therdolc. \\hen one 1110101' unit UJlllr<1l( Ihe llepolarillllg tlber~ .Ire not ne..:e~~afll) c1o...e togclha Ctln'(;4Uently. J needle. \\-Ire. or ~urface elecllode (Jnnut ~ SltUJtco prcl'i\ely \... ltilln or over anyone motor

unll

Figure 9.10 Cross-seclional view of muscle belly with needle electrode inserted, Differenlly shaded fibers represent different motor units, Alllhe fibers of a single motor unit contract almost synchronously. and the electrical potentials arising from them travel through body Ouids as a result of the excellent can· ducting properties of the electrolytes surrounding the fibers. This process is called \'o/ume conduction. The elec· trical activity will flow through the conducting medium. the ,"oflime conductor. in all directions, not JUSt in the direction of Ihe inserted needle. wire, or the surface elec· trodes on the skin. Fibrous tissue. fat, and blood vessels act as insulation against the flow. Therefore. the actual pattern of the flow of electrical activity within the volume conductor is not predictable. The signals that do reach the electrode are lransmilted to the amplifier. All others are simply not recorded, although they are present. The activities produced by all the individual fibers contracting at anyone time are summated. because they reach the electrode almost simultaneously, Electrodes only record potentials they pick up. without differenliating their origin. Therefore, if two Inotor units ,,:olllract at the same time. from the ~.une or adjacent muscles. the activilY from fibers of both unlh will be summated and recorded a~ one litrge potcnual when u~ing surface eleclrodes. Myoeleclric ~ignal~ recorded from a multieleclrode array a~ a function of time (Fig. 9.11) is 3 Yoa)' to demon· Slrale that the EMG ~ignal IS generated from the point of 1Ill1ervallon of (he mu~de and propagate~ in opposing dlreclion", ullti..! II dies ..II the tendinous Lones of the muscle fiber~. Figure 9.11 denwnstrates how this technique Can be

278

Ph\.sica) Rehabilitation

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= = =

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= = =

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x:

18 fU/dl",

Y:

1 U/dl",

Figure 9.11 lI]uslrallon of recording from a multielcctrode array demol1qr~ling I.he propaga~~on of the motor unit action potenlJal during a voluntary i-;ometric contraction at the blc~~s brachll 'iu'ltained at con:!ltant force. The drawing on the left illustr.lte:!l how the array wa'i .poSltlonc~ un the 'iurface mer the mU'lcie. E:lch EMG channcl (numbered YO to Y 14) I~ a dlfferenllal recordmg from IWO con'iccutl\le parallel detcClIon "bar,"' or electrodes. The EMG data indicate the preo;ence of an inncr'\'atlon lone at channel Y8 and tendinou"i lanes al appro\imatel) YI (pro~llnal) and YI3 (distal). The lime delay bet\\-ecn :!lucccssi\c EMG waveform... reprC'ienlS the conduction "elocil)' of the E\1G "iignal.

used as a means of e~til11ating muscle fiber conduction veloclly, locating the innervation and tendinous luncs. and noninvaslvel)' tdentifYlllg individual MUAP:...q·IO.I".~U A recent Illerature rev ie\\ :..ummarizes the b::hlc principle'! of operalion of linear electrode arrays as well a, CUtTenl kine· ~iologlc31 and c1mical applicallon~.!l

Variables thai Affect the MUAP What \'ari,tblc\. then, innuencc hO\\ much elcctrical aCll\'~ ity i~ recorded h) [h~ electrodes. and cOI1 ... ~qllel1ll) the amplitude and 'lh;lpe 01 the recorded potenlial? Fir",t. fh..: proAlmHy 01 the eleclfOck:.. to the fiber:.. thaI are liring \\ III dltect th~ ,tmplltude and durallon of lhe ret'ordell potenllal FJber~ thai arc lunher !Or lltlll \\ III ploduct' mure :.Kllvlly. Thlftl the t.h~lanl'l~ bt."tween lhe IIbt'l \ v. III ,dkLl the uUtput. 11l.:cau'lC dill\,' fibcI'l are \t:I) 'lj)l"Lild OUI, k~ .. 01 lhclr lOla! 'IUI\'II)' I" IIj..dy tu n:<.H.:h Ihe C!t-C'lllKlc,> I he 'lile 01 the dedtOJe, nla) ,,1\0 b~ a l"tlll. u..lefatioJl II lhe re(urdlllg .. urIJ~e I~ brgt"1 lh~ t:h::t.:lJode'! \\ III pll.h. up lrom J IJlgt:r :Jlt:ii. nhl"-lIlg the \ue of tile re~ordt:d "'gnJI grcater Therdore, 10 rCl'ord 'rom "IllJlkr IllU .. llt: OJ 'lmallt:r eleltrode ..htJuld ht' u'lt'd

The di'ilance bet\Veen tht: electrodes is another major factor affecting. the size of the recorded potential. Greater electrode \pacing \\ iJi innea:-.e the surface, widlh, and depth of the recording arca. Because voltage is dependent on Ihe difference III potential belween the electrodes. the greater the dl'iancc. the greater the \'ohage, or amplitude, There 1\. of cour~e. ~I cfltical limit to thiS distance above which the electrode') "III not be able to record a valid sign.1L Lynn cl al~~ have Ihcor~lic.llly ~hO\... n thtH any active fiber Jt a depth of approxllnatt::ly half of Ihe interelectrode "pacing \1;111 00111111 ..11(' lhe surface EMG signal. Furthermofl.\ the recording Ir(l111 libel'S at a depth of more Ihan I 5 IIllW'l tht" Il1I~rell:Cll()de :..pacing \\ III be obliterated b~ madel.juatc "'lgnal·lO-nni,e ratiO. Some: surface electrode a~\clTlblte~... uch a'" Jl'ti\e EMG electrodes. have hcCIi lh,~, dflpt:J HI \\ ludl tlt.:- t\\o electrodes are fixed \\ Ithlll .\ (,.":.hlll e. ,",v that 1IlIcrele..·trOllc dl"I..lm,·e b slandard· Ized. COl\tclIlnc nel"dk l'k't.:tr\"H..Je'l h:l\c a ti,\cd distance be{v.eell the \\ Irt''l .ilh_! the lll;;\'dk \h<.tft: U\lS dl~li.lIlce never l:hnllgc\. t'\"':ll \\lten Iht' dellroJe I~ IIlmcd. Fine·wire l11dwdling l'kt.:lf(Xjt..·~ ,Irl' thl~ 1t.'i..tSl reliable in this aspe(:t, bl'(':ilLh~ there 1\ !title t.:ontlol mer (he imerwire distance \\Ithm tilt: tllu,cle 'lhl' \\-lle ... Me oft~n prone ro changf pUSJllon \\ Hilin the mu\de ..titer re(fl:at~d contractions, lI; -"'t1l1dhon th." ma) COlllpnlJlll ...e the \ dhdHy of the signals. rhe ... hJ~ ')tle, Jnd uUrJllon ot the recorded motor rtJkntl",ll .. .1\ tuall) iJ grJphll rt:pre:..entation of the elecuical

urnt

Chapter 9 Electromyography and Nerve Conduction Velocity Tests

-"""ll~

Recent innovations using a three·bar electrode can eliminate the presence of cross-talk through a process referred to as double-dijferellliariofl (DD).2S As shown in

. ...- - - - -

.

~W""_P..

... _--",--.._ _....IliII ..

-4--+ ....-...+~---. ---~"""""'".

....

Figure 9.13A, the EMG is recorded in two ways: first. using the bipolar signal from bars I and 3 (single differentiation [SDIl. and second. by subtracting the SD signal from electrode bars I and 2 from the SD signal from electrode bars 2 and 3. Figure 9.138 shows that there is a difference belween the SO and 00 signals when recording from wrist flexors during wrist extension. The fact that the DO signal is near baseline indicates that the SD recording is cross-talk from wrist extensors. During wrist flexion, shown in Figure 9.13C. no cross-talk is present. as the SD and DO signals are similar in magnitude.

Telemetry When EMG recordings are considered for environments in which it is not practical to have the subject tethered. telemetry of the EMG signal via radio frequency transmitter and receiver is an option.2: Typically, a small banerypowered transmitler combines the EMG signal with an FM radio signal. This combined signal is then broadcaliit at the

Figure 912 SIngle motor unit pOIcntials as seen on an o)ci Iloscope. A

acti\1ty bemg picked up by the electrodes, relative to the structure of the motor unit and the electrode placement (Fig" 9.12," Therefore. wilh a given electrcxle placement. each mOlor umt potential" Jlliook distinctly different. The irnpli· catIons of thl~ proce~s for repeated EMG tesling should be e\ Ident 11 I~ Impo~\lble to recognia a motor unit potential a~ the ~ame one If electrode ... h<s\ e been reinserted or 1110\ cd. bel:au.:.e the "'pJlIa! .1Od temporal relationshlp~ bel\\Cen the ele~.-trodn.lfld the mu.~.dc tiber\ cannot be validl) duplicated. Thl':> hold.. true: lor ...urfJce electrode" as \\clL 3lthough reapplll..Jtiun of .. urtaLe electrooe~ ha.\ been ~hO\\ n to be more rellahle II,an relO~nlon of \\ Ire electrode~.!J ~ro

279

1..11,

Anomer Imp..>J1a.lll l:un ... lderatlon 11) the abilit} of elei;trode~ to n:u>rd aLlI\ II) !'.l'kltl\el} trom J "U1gle 111u~de Becau":>e 01 \nlumt:" i;\lllIJuL(lon. ele.l,.trILal aCtl\lI) from nearb) I..'ontrI} There 1\ lltl \\;J~ II) Ji.,tlllc;.ul...h th", dctl\lI) b) looking ..11 the OUl· pUt :'.1~n;J1 ( ~h:tul deltn.xk placemtnt and "pacing and ChOKe;" ut ~I/C ,mJ t) ~ 0' elei;"lnxie \\ III hdp control :"luch (/o\\'la/~ or c1el·u iL
--20

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Figure 9 13 1IIU\lr.iIIOn 01 the douhle differential (echntque 10 l'IlIlllnale the rfe'e'n~(' of cro\\-lall (-\) Surt.tce EMG i~ re-.:urdc-J from t1l'.\or carpi utnan .. muscle u,mg bOlh ">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, <. lOPS \\.il.h penni.....ion.)

I

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('r Ih( I (IHf, to rum ltml tul ( Ilk I \1 I '0.11 h~ IC'Hl\C' the I 1<. IJlfpml.l li('~n 11~ ptJ\lol·r l'.\Jt!"tJlIII ,hI" Ir.m mille.:[ oifll,llhc' n.'I/uf.. tit It fl'\.('I\('1 d 'lCOIlml" ttl<." ran'~ til rhe: t~ 1t"1O(11"\ Itfl)., CI

;\lthOl1llh tfdO"'llltl I f.1ll C' .... I1lltrt" th.m ..Jt"4u 11C' Illf IllcKI IIPp!llo...lliOn I"\(1 In III mill "' .J 1M fllltfl"' "rhlU" 11m IIIIlF lJ.lll"'- "tht' (1ITt.dh)fl.1l1t, III tht· tI.m"T1l1l1lJl~ .mh."nn.1 \1ultlp' .100l·IUlJ,', e\f omnh,f!"'t,'t10n,;1l .U1tt"nn.1\' J,Tl' u'>(.-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." [t
o\rtifa<"h 'I~nal IotxlUlJ lx: ::I lrue nj"l'~m.atllW1 ot mo{('" Ily tJn:lIrnnl? 10 the olU"-l'le ot mlcre I llnfonun.nel). man~ e\l..~'" 'l):o.lh. Of ar1inll'l~ can tle T'L't-urdoo otnd prOl..'"e'....ed 'ImultaJlt."fH.,hI) \\Ith the F\lG "'Ig: nal An Jrtif.\C1 II, ..til] ull\\..ulIl·d eICi,.1.rK..IJ .lI,;lI\ 11 1 th..lt .lfI"<' oUblde of Ihe th"'U("... l.lelll~ t\allllned. 1lll''>t: JrtJlJu", tan be of ..uiliclent \,olt.tgc to dl'olon the OUlput ...'gllal I11Jrlcdl). Ele<:u-olll) obrrapher. '" tl.l u..u,tlly ob\CT\c th~ output '\lgn,Ll on an o""illo,,'ope m l.'Ol11pUICr ':oC.Tt."en to monllClr .u1Ifa':l\. <)omc nc"ef commercial dc\ Ic.:el: ha\c: bUlIHn anllJu !\Up* rrt.'~3i(ln cirl"uitl). pr produce an audible 'llgnal .mdjM LED di~pl;J] 10 mdicale the pre-.ence of an anlfact "uLh a.... 60c)de Ifllcrft:ren<..'e 111 near real-lime A re~ent re\ 1(''' ..ununJn7e.. rnelhoch tOf reducmg nOI-.e. an.lfact. and LIllerfereoce In recorded EMG "'lgnJI\.~to Recommendation ... 10 the re\ le\\ emph.13lze the ne-ed 10 ti"t reduce anlfact and IOterterem:e at the 'oOUfCe. through appropriate ... k..m preparJ.tlon J.nd lO~lru­ mentation. \'anou, 'Ignal PfOC(,~'1IO£ Il.'chni4ue'i are de~"be'd for not...e reduction lh:1.t t.::ln be Jpplied aftef\.\.ard. II1dudmg band pa.", filtering, adapme nOI.-,e-eJnl..·e1lallon rlllen. . .JJ1d w'l\'elet lr".tll\fonn filtef\.

1llc: [\1G linll

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\lo,ement Artifact All electrodes aTe lompll..cd of a metallic deteclIng ... urIdce thai 1'1 in conl.lct wilh un eleClrol) tc. Thi . . electrolyte ma) be the oils. and mOI\tun: on the sl..ln. the conducti\l,~ elet.'lrodc: gel plJ"ed bet .... een a ,urface electrode and Ihe ""'Ill. or 11 rna} tle thl" t....'ut' !lulds ,urroundlng an ln~ened ncc:dk or fine*" Ire de<:lrode An JOIl t)"chdnge eKCUr.. <11 the InterlaCe ber",cen the ekclrode and electrol)lc. Jnd thl'" I" r("Lorded oi ... J bJ(.JelecITlc e\eOl "hen a difference 01 p'Ht'llIlal e\i ... l.~ hety,een Ihe 1"0 electrode!!., If no mu"de Jl 11\ II} 1\ pre~nt Iheretore and the I0017JIIOn Ihat e\l-.{' al e:'.ll"h ckumde--elcctrol)te Inlel1o.1ce I' ,1.lbk, Ihen no lhlten.:nce of potl.'llual e.\l~h. rC'lultlOg 111 eleuric,tl ..lIellce

II h\l\\t"\t"f ....,mc.· \tl .. tUrt'l.lIKc.· 4,1{lUI' .11 l'ne or both IHll\t" 1I11\.'''...\.( 0 a.. 10 l\ft'W.Iu\.'e:l dlfl("f. t I C. Ih I • ,.'Ke II r-tl\.·nIIJl Ip~ Irt"tlu("nlo~ ... 11=0.11 ~III he: rt(:('fOed lh.1t ti....· not roprc-.c:nll \t<). 11\1'1 rh." 'lgnall caJIfd mm.p'.tfll l'lIf.l,· II 01.1 re,ult frllm mO\cnlC"nl of the 1.10 t'<'lk.lth oJ "url.l\.(' ek-dl\"lk prc .... urr on or mo\ormrtll III the c.·lcdnxk of mm('nll~nl ul a nl.."Cdle or fine·v.m c1nlHkk \\.llhln oJ

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h,lIn"uHl~ mu'oc..1t" .Idl" It\ I' llelO' monll r'fd dunn~ an ,I\.II\ 11\ 10 Ihe ,lItlnp. r~.hltlOn. pr~ ....... urc 011 the e1nlrode\ lIl1 th,,: pe.\'>IC'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 ele
mO\i..:ment Po~{'r Line Interference Th~ human bod] act:') a, .m dnlenna. attracting electrornag-

nelll energy from the Ilurroundlllg em Ironment. This energ) I~ mo",t lommonl) lIra\\ n from power lines and electrical c4 U1 pment o~ratlng undcr an alternatlOg current at 60 cycle... pel ...c:cond (60 Hz) In the United States. and possi· bl~ at othef frequencle ... Internationallv. An artifaci caused b) thts Illtc,i'erence Currelll rc ...emble,~:a sine wa\'e and can ~3U.,e a ("On~lant hum In the rt'lorded 31gnal if il is 001 elllntnJtcd through appropri:.l1C amplific~llion technique~. A 60-Hz 'lgnall..Jn OCcur If elec..:lrode attachments become loo~e. or It eleurode~ are broken Of fra)ed. Electrode v..i~ often hreaJ.. benealh the protec.:l1\ e tubmg thai cOllnecls Ihe e1Cl'truJ~ lbelf to the I~ad \\ Ife If ra" data are not monitored. Iht~ cundHion ma) not be nOllted. Other equipmenl In Ihe area JI ...o may be the ,0url:C of elcctricallnlerl"ertnct. L>IJthl:ml) equlpm~nt. eleClnLal "'lImulamTS. cell phoneS, tlul)I'C'lCOI light.... r<.tdlO,\, and \ Ibriltors are examples of

Chapter 9 Electromyography and Nerve Conduction Velocity Tests devices that generate electrical noise. Sometimes. using isol:lted power lines will help with this situ3tion. A 1/01ch jifter can be used to remove 60-Hz signals. although this will also eliminate some of the EMG signal within that frequency range.

Electrocardiogram A lhird type of artifacl. from the electrocardiogram. or ECG can occur when electrodes are placed on the trunk. upper aJm. or upper thigh. If the EMG is being analyzed for frequency characterislics. this signal will provide significant interference. Correct application of the ground electrode and use of an amplifier with appropriate characteristics should help reduce these potentials. but may nol be able to eliminate them. Their amplitude will vary depending on placement of electrodes. Electrocardiogram artifacts are generally regular. however. and their effect may be succes~flll1y allenuated. One such effective high pass filtering technique was described recently for removal of ECG artifact from EMG signals recorded from trunk muscles.~8

Other Sources In addition to the main sources of artifact and noise described earlier. other sources are present that result predominantly from the inherent limitations of the electronic hardware used to acquire and process the EMG signal. Electronic amplifiers used to amplify and condition the EMG ~ignal are a ",ouree of broad bam!. low-level noise (i.e .. less than 1.5 1-1 V RMS in a well-designed amplifier when bipolal electrodes are shofted to ground). This noise level i~ nOI typically problematic during moderate or highlevel conlraction~ ""here it \\ould typically comprise only I to 2 percent of the EMG amplitude. and therefore maintain a relatIvely high ignal-10-nobe ratio. For very low force level contraction noise due 10 the instrumentation and electrode ·~km IIlterface ma)' be a concern, and fihermg technique ... de"cflbed above may be v,arranted. 26

Amplil)'ing the EMG Signal Differential '\mplifier Bef<Jrt' the m\)lOr unll potential cun be \'I"ualii.ed. jt is neeto amplily the Inht'rently ~Illall EMG ~ignal. An amplifier convert \ the ekuflcal potential recorded by eleetrode~ to a \ultage Signal large enough 10 be di~pli.lyt:J. 'nll" eleL:triLal pOlt'!lual 1\ compo\I.'d ul the EMG ')ignal lrom lllu ...c1e LonLractioll and unv.antcd IJ(JIH' from Slaw: eleclflLIIY 1Il lht' air and po.... er lme". To (Ol1trol for the unwaOltd pan 01 the 'lIgnaI.-.. lhe recordIng elecllodes each tr,UlSllllt eleurlLJI pOlCnll,tb to 1\\ () ~ldt':-. 01 a dlht'rel/fwl wliplIJu!1 eadl t'k~drodt' ~uppl) Ing IIIput to one :-'Ide. The ddfen.:nct' III pottnll
e~~ary

281

the amplifier. [f the two electrodes receive equal signals. no activity is recorded. Noise is transmitted to both ends of the amplifier as a common mode signal, The noise. being equal at both ends of the amplifier. is cancelled out when the difference of pOlential between the two sides is recorded, The signals that are common to both inputs are generally the unwanted signals from interference.

Common Mode Rejection Ratio In reality. however, the noise is not eliminated completely in a differential amplifier, Some of the recorded voltage will include noise, The commoll mode rejection ratio (CMRR) is a measure of how much the desired signal voltage is amplified relative to the unwanted signal. A CMRR of 1000: I indicates that the wanted signal is amplified

1000 times more than the noise. The CMRR may also be expressed in decibels (dB) (1000: I = 60 dB). The higher this value. the belter. A good differential amplitier should

have a CMRR exceeding 100.000: L

Signal-to-Noise Ratio Noise also can be internally generated by the electronic components of an amplifier. including resistors. transistors, and integrated circuits. This noise is often manifested as a hissing sound on a speaker and shows on a screen (oscilloscope) as a "fattened" baseline. The factor that reflects the ability of the amplifier to limit this noise relative to the amplified signal is the signaf-to-noise ratio. or the ratio of the wanted signal to the unwanted signal.

Gain This characteristic refers to the amplifier's ability to amplify signals. The gain refers to the ratio of the output ~ignal level to the input level. A higher gain will make a smaller signal appear larger on the display. The gain is often larger for clinical EMG where individual motor units must be distinctly visible and their amplitude measured.

Input Impedance Impedance is a resistive property. opposing current flow, such a'\ that occlming in altcmcHing current circuils (such as an amplifier). It i~ analogolls to re~istance. which is exhibited by direct circui1s. Electrodes provide one sour\:"e of impedance and are aff~cted by such vari3hles as elec1rode material, electrode size, length of the leads. and the c:leclrolytc. If the electrode lI11pe<.lance is too great. the signal will be alt~n­ ualcd. Electrode impedance can ~ reduced by using largt'r electroclcs of good (.'onductivily with shoner leads. Finewire and needle declrodes generally have much grei.tter impedance thun ~urfurface areo. fiody ti~~ue~. including wJipo~c tissue, blood. and skin, aho provide a \ource of re~i~tancc to the electrical field. Rcsi~t.. trKe and JlnpeJance are med')llfcd in unib called ohm ... (0). S~1Il ill1ped~tJH.:e Can be mea~ured wilh an ohmml~(er ,tilL! Ib \';)Iu~ rcdut.:ed hy proper preparariun. Mosl

282

1""''''01 Rt.'hahililati(m

rr"ll'arlhcr, hall' Iq"ll.lIlcd .llccpt,ll'k .. I..,n IIIlIll'(I.Ull'C unda 20,000 H. ,1[llh)U~h \\lth prOpl'! 1'lCp,ll;lllOII ami ~ood cll'"·trndc,, n:,,,I,H1u' \.:olll u,u,lll~ ~, ll'lhh.\'d 10 1'l('I\\Cl.:ll loon .l1ld 5UOO n ~tllllC !'th.1l1 ..t n'.!'. ,ulh ,I' lIH',,"c l\llh d.ll"'a plgl1lCllh or Ihll"lC th,ll .m' morl' e~\I"'lhed, 1=l'n crall, h,l\l' hlghcl IllIped,llH,('. Skin llllpcd.lI1ll' oh\ l\)u .. 1\ I' .1 Ct.mccm ol1l~ ,lIth 'urlali' c1C4.,trodl.''' IlIIpcd'.Il1lC I' .II",,} pIC ..('1\l ,II the Input e)1 ,UI ,lI11phrll'r rhe mu ..ck ,ldlOli 1)L)tl'llllotll' I'OCllI\'c1) dl\ Idl:J 11\10 \'011ag.c dl,ln~c, .11 Ihe clcurlXk JJld Jmphficr inpUI terminal .. BCI.-Ju...e oj Ihe dlrl"ct reLJtlon"hlp tx:l\\c'('n \ollage .md Imped.lnl'l~ Ib~"cd on Ohl11\ l:.lwJ. Iltlll' Imrx-d::tnLC .Hthe dmpllficr I.., grealcr th.Ul lhe IInpcdJ.IK'C ..ttlhe t'lcl.-tnxk, the \ohagl" drop" III be grealer althe amplifier ,lOd the rc+.:ordcd polcnllal \\ III more Jccur;,llcl) reprc,enl the true "gn..tl \oll;tgc::. II the clectrode Impedance i~ too greal, Ihc \oll..tge "ill drop al thc ...ouree 01 Ihe ... ignal and k ...... 01 Ihc electri31 energy 1,1.111 be Iran,mlltcd 10 the .unphlie-r. Thcrelorc, the alllphftl'r IIlpUI Il1lpedanci.: \hould he "lIb'I,lllti~tlly grealer (at Iea~l 1000 tlllle..,) than the IInpcd~lncc recorded at Ihe ekctrodc'). An lllpUI Ifnpcdance 01 I megaohm (I in ': Ion!!) b acceptahle for sUl1acl" electrode... but should ~ greater wilh finc-\\ ire ,lI1d necdk electrodes, ACI1\C' electrodes u..e amplificr:-. with high IIlpUI impedance (>100 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) (<.,ound). If wc '>iT) the nOlCl\, the chord \\ III M>ulld different. Similarly. the shape and arnplirude of an aClion polcmial are, in part, a function of the frequencies that compose Ihe \\':tvefoml. .;.\mphfier~ usuaHy have variable filter, lhat can be adJu"ted 10 l"mt the range of frequenCIes Ihe) \\ III proce~~. The main reason lor u"IOg fillers IS to reduce nOI~e. The freqlU'my handl\ ldl!l delmeale~ Ihe hlgh~ .. t Jnd lowe ..l frequenc.:) I:olllponents. lhat wJJI be proce~ ..,ed. or the uppc:r and lower ('ulotf IrequenCH~l->. It Ihe tull range') of Irequenue" that make up the major portion 01 a ",a\cfOml are not pnk:es~d. the potential \\111 be JI"toned. Ampldicr:, "hould Ix' i.ible to re,pond to "lgnat... hel\\l'cn 10 and 10.000 HI 10 al:l:ur,IICI) reLorJ nerve and 1n1l,c1e potentia'" tor dJnIl:J.1 LML I'or I..lnt:... JOlogILi.i1 purpo')t'~. howcI.er, \\here "lpel'ltic: v. ,I\'durfll t.:h..trJ.lh:n..,ttn are nul of m,ljor "Here... !. lm"er hJ.lHh\ tdth.. ;,Irl' u'.)cJ The frequL'nt') lOnll:'1lI 01 an U\IG ,,!wJI ,.. Invc .... dy pmporllonal ((l lhl' Illlen:ICl.lrodt: ,ep .u.llion tll\IJllt.:e. COIhc4uently. the frequenc) \p~l'Irum

l'\tl'nd .. Ir\1111 10 to ."()() III fur Illthl ,urluct: eleclrode\, ,wd Irom 1010 1000 III f(ll fllll'-y.lrc clcctrode~. I lIn1lln~ .. Ign.lh 10 thl."c Ircqllt:llt.:y r:lIlgc\ hy :' filler 1\ hl'lplull<'l rl'dllullg 11ll' l,fh.'\ l\ llf 10\"· and hlgh.lrcquency

.I11,I,tI.'"

Displaying the EMG Signal I hl' :lmplllll'd "Ignal mu .. t he Ji"lpla)ed in a u,cful fa~hion. TI1l.' fOOlI 01 OUlput u')cd I' dependent on the type of informJtlOll lk'lr~d .md Ill .. trumenlallon J\ailablc. Computer') ..,;Jmplc :lnd "'lore EMG dala for display Jnd anal) 'I'. D~lta ma} be ,torc=d in alll/log (i.e., as a lOlltlllUOU" \ ;,Ir) mg ,'gnal) or in d,gual form (i.e., lhe l'OntlllllOU~ "Ign:ll i ... con\crtcd mto a ~erie~ of numbers, c;,Il'h of \\hich reprc .. cnI\ the amplitude of Ihe signal al a p~lrllcular in"llanl in lime). The conversion process ili referred to;)') analog-tO-digltal (A-to-D) conversion, and the de\ Ice that perform, Ihi .. las". b called an A·to-D converler. The procC''i''l involves ..,::tmpllng the signal at a Irequcncy of at Iea~t I KHz, and converting it into nUI111'rical form", IIh a lU- or 12-bit A-Io-D convener. or higher. A IO-bil converter divide\ thc signal into 2 10 (or 1(28) discrete Icveb. and a 1:2-bit converter divides Ihe l\ignal into 21~ (or -W96) cli~crcte levels. When working with A-to-D converter.... il is ncce5:,ary 10 specify Ihe ,ampling rate for EMG data acquisition. An important rule, referred to as the Nyquist :wmpiillg rate, is 10 select a .\nmp[ing r')IJtIOIl\ and lhgllal pTlX:n,or~. pen ,tnJ ch~m recorder:s are not \.omnwlIl) u..ed IHlLl\'.

Unlll..~ gr.tphic.: r~~"rder" m~H,. hlne-inlerpr~l3ble n::lllrdt:r..,. "'lll'"h :.I, Ff\l m3gnl'll":- I<tpt: rel'ordep.> 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.

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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

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",hen repo,lIl('ln('J S(lm~ Julht.r h.I\!;" rl'pCln~lt Ihal cnJ~

pl:ttc p"tt"nIlJI .. rna, bI: ~onnal ~1olor

C\L'e''''I\~ In Ikm:'f\.1It"J

f111hdc.

Unit .'\{·(ion POlenllo.ll,

Alh:r (lh"'C'I"\ll1l:! the I1UI"I,..!l: at n: .. t. tht: r,lllt"nt ,....t .. ~cd li.l cumfJlIlht: mU'-i.;k nllnlll1;tll~ II i~. 915). \~\~;tl.. \1I1un·

nll'_

tJT)

cHon ..l1oulLl (JU'-t'

mdl\ IdualmolClr UI\lf'.,

10 tirt'

Illt"W

Il1I)h)r unit P',tcnll.. l.. 3fe C'\alTIlIlCti "Ilh R~ ...pt."'t:1 10 .lJlIrll. lude:, t1urdllon...h.lpe. \l')Und. ,UlJ t~UL"nl'~ cFu! 4 10J. 11l<-...e 11\ ... p.ll:unele" .Ire: the c... -.t'nl1 ... J <.hJrJ.l..h"n .. l1ll, IhJl

Il\t~

II "Jlh pt'(lTll ......lltll I

JI'llneUI\h l"..I<.h nonn.ll .Im! .lhnonnal rot~nrllJl. FmaJJy. the p.Jtl~~1 J" tl .. ~c:d 10 1lk:R'...t'\C k\C'I\ of l.:omraclJon progres-

"'I\d) 10 a .. lfl)n~ ...'flon. allrw,lng tklt=nnm:..I1lon of recnJII· ment pJlll-m.. \ mOlur lIllll poll'nll,ll I' ilL tllall) the ,umma{Jon of elec!nGt! POlt=I1lIJh. lrom 311 the fihl.'r... of ,hal unil close enough w the ckuH.xle.. 10 he rClvrded. The .1mpJilUde (vohage) i!l .lfl~ded h) the num~r of fiber.. In\ol\ed or by the motor 1II11l h:mttlf'. Inc Jur...tlton and '1h<J,"IC are functions of the dl'll
1 , --'-_

L

Figure 9 16 llh.l... lr.uwrl III J. ".I\efOml (normJ.1 motur unlbl, <. ll.Jra~h:n\tll'" III nnmul mutU! umt... Uldudt" j(~I~\ IU4-t10010""U)~\ t-lI'15v.\J 1)1.11<111 n ! 1(1 17 mo<... mI.l t..\re- 1'l h) 1~ m.....l I\.} 41, \luno· 1.1 h\ur'rl\J"c. mo't .lrt" hI' vr Inph,,\"'lc 1"1\le Ih.lIl luur t.. p")I)ph.J... tl.. ,'t 'Jlj( I \ I h\ Oo'\Cl. hl~ht) \ .m.Jhle dClk"nJtn!! on IIldl\ iJual IlllJ ...\k~ ~(,tlfl,j (It;.lf . . h.lrp. Lhump. Ot plunl.. Dur.tllPn and pl\..l\lmll\ Illlk,'dlt: dl;,lrlkJc' Jelcnltlnt.: h..\rpnt: ul '-\JunJ . \ Ira

I'.I"lf/;!I..rt,

'f/'

d rom h hknl..k.1t J

• ~!Ih p..:mu ""Hn ,

Thl; 11,1I.tl duration, meac;;ured from inilial baseliM ddleclIon 10 r('tUIll to ba\l'line, ""Ill !lonnall) rJ.nge from 2 10 17 m,ec. 'WIth the large..,t number being: 8 to 12 m~. Duration 1\ J function 01 Ihl" ~ynchron} with which indj\ It!lJ3Imu\1.'Ie fiben. fire \\.uhlO i.l mOlr unil. This charac~ len\,tJl I .. alh:ded h) the condui.tlon \elocil} of the axon termlOaJ.. ,tJ1J O} the lenglh of mu,cJe fibers. Duration can bt.' ~nelrcd \lgnlfiloiOlI) b~ deL·trical acti\ ity originating III lIht..-:r~ dl'ilunt to the dcurodc. The r, \e lime of the polentla!. Illl.. I".ured fron) the mill'll po"'ili\t~ pea~ to the follo\'lmg negau\1.' peal\. proVide') .m IOdlcatjon of th~ dhtance Ixl \I, cell the electrode dnd the l'OlllrJeong motor unit. A !lonnal unit l'!o..t' to Ih~ electrode ... hould h.."e a rise time ~t" n:n J 00
elellrodc.

plun~) Iht:

The num~r 01

do\er th.lI "lAllP

1'1,

~o

the

recordjn~

h P ..t'-C' 10 a nomutl molor unit can be !Tom one lU four pha.. e.. The- I) plt'al \hape of an MUAP is

Chapter 9 Elect..-omyography and Nerve Conduction Velocity Tests diphasic or triphasic. with a phase represeming a section of a potential above or below the baseline. It is 110t abnonnal to ohserve smaJI numbers of fJolyphasic potentials, having five or more phases, in normal muscle. However, when polyphasic potentials represent morc than J 0 percent of a muscle's output, it may be an abnormal finding. The nonnal motor unit will fire up to 15 times per second with strong contraction. The identifying sound is a clear, distinct thump. GraduaUy increasing the force of contraction will allow the electromyographer to observe the pattern of recruitment in the muscle. With greater effort, increasing numbers of motor units fire at higher frequencies, until the individual potentials are summated and can no longer be recognized. and an intel!erence pattern is seen (see Fig. 9,15). This is the nonnal finding with a strong contraction. Highest amplitudes for interference patterns typically vary between 2 and 5 m V. One of the disadvantages of conventional testing methods is that examination of single motor unit potentials can be made only during weak voluntary effor!. essentially restricting the analysis to low-threshold type I motor units. An interesting aJternative involves the use of olltomaric qlfQlltiratil'e assessmenl. which further analyzes the interference pattern by determining the number of directional changes of the waveform that do not necessarily cross the baseline. ~1 ..12 These data are processed by a computer to display the number of reversals and the intervals between reversals within a given time period. Such ratios can vary between normal and pathological conditions. allowing for greater diagnostic precision in the differentiation of primary muscle disease and neuro· genic lesions.~3.~.j This approach allows the electromyog· rapher 10 observe lhe behavior of motor units even during maximal dfart. when individual potentials cannot be delineated. An electromyographer. therefore, examines insertion aClivity. as well as activity with the mu~c1e at rest and in slate~ of l11Jnimal. moderate, and maximal contraction. The needle electrode i" moved to differel1l areas and depths of each JnU\clt to sample differem muscle fibers and motor uni"'. Thi~ is necc:;,sary because of the small area from which a nt'edle electrode will pick up electrical activity. and because the effects of pathology may vary within a single ll1u~de. lip to 15 dtffert.::JlI poinls within a l11uscle may be examined by moving and n:inserting the needle electrode

Abnomlal Potential. Spontaneuus ArtivilV Becau~e a l1onn~1 mu'scle al re~t cxhiblh elel'trical silence, an) aC!I\'lty ~el.:n dunng the rdaxed state can be conSidered abnormaL Such aUlvily i~ t~rmed ~poJ1taneou~ bel'au~c il is not pruduced b) voluntary ll111~cle cOlllrar.:tion. Four types 01 ~p0nlJneou" potentlab have been Idcnlifjcd: jillJ iI/mum /wtell1tal.\, pO.H/I I'e ~harr It OW'S, !tun"tulattOll pOff'tlfial:,.

:ind

rl'!1dilll'jJ dl:-,(IUl".~l'_\.

285

Fibrillation Potentials. Fibrillation potentials are believed to arise from spontaneous depolarization of a single muscle fiber. This theory is supported by the small amplitude and duration of the potentials. They are not visible through the skin. FibriJlalion potentials are classically indicative of lower motor neuron disorders, such as peripheral nerve lesions. anterior hom cell disease. radiculopathies, and polyneuropathies with axonal degeneration. They are also found to a lesser extent in myopathic diseases such as muscular dystrophy, dennatomyositis, polymyositis, and myasthenia gravis. Fibrillation potentials are biphasic spikes with the initial phase being in the positive direction and their spikes may vary in amplitude from 10 to 300 fLY (can be larger, up to 600 !J.V) with an average duration of 2 msec (Fig. 9.17). Their sound is a high-pitched click, which has been likened to rain falling on a roof or wrinkling tissue paper. Fibrillation potentials have been recorded at frequencies of up to 30 per second.

Positive Sharp Waves, Positive sharp waves have been observed in denervated muscle at rest, usually accompanied by fibrillation potentials. However, they are also reported in primary muscle disease, especially muscular dystrophy and polymyositis. The waves are typically biphasic, with a sharp initial positive deflection (below baseline) followed by a slow negative phase (see Fig, 9.17). The negative phase is of much lower amplitude than the positive phase. and of much longer duration, sometimes up to 100 msec. The peak-to-peak amplitude may be variable, with voltages from 50 !J. V up 102m V. The discharge frequency may range from 2 to 100 per second with to per second being common. The sound has been described as a dull thud. Positive

- ...

A ""-~'1J,.-.\

-t/i'

~

1.''..

f1-

~\r-

~v 50ms B

~"

!Jq.·1fl .... M

~.

II"

~ t""" '"

~ . TY't.."" T

n

~'.

lQ:..5 mV 50ms

{'--

-_-

---(\.-r------{\.. .... ----{\[Q_s mV 10 ms

Figure 9.17

c .....

~

,

--r-..--..t~~ . ~smv 10 rns

udivily of (he :mterior tibialis in a 68ilh amyvlwph.ic lateral "c1ero~i~. Posilive sharp a COIl~ISlent configuration with a sharp positive deflect~on rolll)~:t:d. by ~ long-duralion. low-amplitude negative deflect.loll (11). hbnUdllon pmcmials
)car~old .... llinan .... wave~ (A. B) have

286

l'hytUcaI Rebab;J;lation

sharp waves are recorded when the rip of the recording electrode is in contaci with the depolarized muscle

,..

Evidence indicates thai fibrillation potentials and positive sharp waves may also be present with upper molor

J.,J..-

neuron lesions. creating a need for alternative explanations

Fasciculations.

of ll1u~c1e libtr... or a \Iohole motor unn. Although the-Ir onglO llii not c1eMI) ~no\lo n, there 1\ t'''ldence th.u the \poI1tJ ncou~ dl.~char~e onginal~~ 111 the ... pmJJ l'ord or all) \10 here along the puth 01 the IlI:ripl1cli.l1 nenl' l'.Ill... lng 1,:Ol1lnat.1l0n 01 the lI1u ...c1e llbt'T\ ~ I ra~(;JculaIlOll:' Me "mell \-I'ilhle through the l.1l1. ~t'n .1'\ J ,milll (\\ Ilt.:h Tne) W~ nOI hy Ihcm'CI\~, .. delllll1l\t' "hn\)1 mal findlllg. hO\lot"\el. hel..dU't: thC') arc al",} """~II III I'k)nll.l! II1dl\ Idu..lh...... 1)Jf11I..ularl) III calt IIlU Ie e~n hand, <1Jd In-!' \\1k~1l ~ 'n ""Illl otht-r dhuonn;t! 1.1 It»,. "uLh J tihnl 1.1I10n, .llId IX)~I1I\ l' ... h.UT' \\<1\ (',. la~ Iluli.ll1t lib Jo l 01111 INlI~' mtonn<.iIJlIll tnd". ..llllll! Ilalholng) Illt.''-C pOlenll.J, h.J\o~ Ix-ell luond III .JJll)(Itwphll.. l.:u4.:ral ... d~TU~1 Jntl pr()~n.·""'I\~: , ptn..t1 lllul,c.ulJI '1IfUph) Iuwlug... lit IJ h.ulJtlun IlI.)ll..lllhth 101 tl~\C CimUUllill.. ~hould he \\I~k ...prtad JJ1U lliund III "l'lal

B

ij

4J.

I

~

I.L

lQ..s mV

U-lQ..s

10 ms

10ms

mV

Figure 9.18 Fasciculation polenlials in two patienls with polyneuropathy. Recordings were obtained from the tibialis anterior in both palienls, showing a very polyphasic potential of long dur31ion (A) and a double-peaked, complex discharJ,e (8). Fasciculation polentials are not always abnormal in wave.. fonn, as ..hown here. and are usually indistinguishable in shape from volulllarily activated molor unil potentialS. (From Kimura. J..lll. p 2(10 with permission.)

locations and more th~m one extremity. Rosenfeld has poimaI out thal in amyotrophic laleral sclerosis thai fibriJIation polentials should also be found before a diagnosis can be made.... The amplitude and duration of these polentials!Ny be similartoa motor unil potential (Fig. 9.18). They may also be polyphasic. Their flring rate is usually irregular, up to .50 per second. 'I1leir sound has been described as a low-pitched thump.

Myotonic and Complex Repetitiye Dischargrs. Compla repetitive discharge~. previously calle-d bizarre higb~ frequency dl.~charge.... may be ~n with lesions of the arKrior hom cell and peripheral nerves, and with myopadUrs. IS chamcterized by an extended rrain of po(entiaJ~ of \'tith the ~me or nearly the 'WIle waveform (Fig. 9.IQA). The feature Lh..al dl\llllgUl~hes these dischJqn from othef spolllant'oul.; polcnlial.. l~ their regular and repel_ itivt' Wet' ffonn, The frtXjue-ncy u\ually range~ from.s to 100 Impul~~ per "ieCond. The: dIllphtudc l'an vaT) from.so .... V to

The discharge

Fasciculation\ are sponHUlcou" pOientmb

seen" ith irnl.uion or degeneration of the anterior hom (;'(11. chromc penpheral ncr'! t le~JOn'J" nCf\~ root comprt'.....wn. and mu-.cle 'ip.bnh or cr.tnlp\. nlc)' .tn: beh~\ocd ((l rerre. ~ellt thc Ul\'OIUnI:IT)' ,h) nc:hrollou, CtlntnKlloll of a bundle

y

I ..I.

membrane. :\5

for their occurrence. '6 Researchers have observed both types of potentials in patients with spinal cord lesions and attributed their occurrence to the lack of some trophic factor from higher centers to the anterior hom cell. The occurrence of the denervation activity with central involvement suppons the assumption of a transsynaptic degeneration of aJpha-moloneurons. Bennan suggests that spinal cord trauma can cause loss of molor axons in regions several segments caudal to the site of injury,37 This interpretation may have implications for the design of rehabilitation strategies. Speilholz18 postulated that these findings may also explain the observation of fibrillations and positive sharp waves with myopathies. and that the presence of these potentials indicates that muscle disease also affects the neuron. A similar hypothesis wa.i1i formulated to explain the finding of spontaneous potentials in patients who had sustained a cerebral vascular accident. 39...0 Investigators have also demonstrated sponulneous potentials in nonnal muscles of healthy subjects. primarily in muscles of the fee!.'" I They have suggested thaI pathological changes involving axonal loss. segmental demyelination. and collateraJ sproUling may be associated with aging or mechanical trauma to the feet. DimitnJ h3~ recently question the rate of occurrence and the Iypes of ~lbnormal pofenlials seen in norma.l individua.b: however, he also Mres~s Ihe importance of care in the interpretation the elcctroln) 0graphk tindings. 42 lbese findings have important c1inkal implications becau~ interpretation ot EMG sIgnal paltem... is nec~~ary for accurate patiem evaluallon.

I

A

A.

Chapter 9 Electromyography and Nerve Conduction Velocity Tests lillY. and duration may be up 10 100 msec. Myolonic rcpetIu\,e dischargC':"\ that increa,c and decrease in '-lmplilUde in a wa~ing and w;ming fa~hion arc found in myotonic disord~r~ such as myotonic dy~trophy as well as other myopathies (Fig.. 9.19B). The ~ound is highly characteristic and sounds m.e a ·'dive~bol1lbcr." High-frequency discharges arc probably triggered by movement or the needle electrode within unstable muscle fiber:-. or by volitional activity. Abnormal Voluntary Potentials Polyphasic pOTentials are generally considered abnonnal. and are elicited on voluntary contTaction, not at rest. By definition. polyphasic potentials are motor unit potentials wilh live or marc phases. They are typical of myopathies. peripheral nerve involvement and nerve root compression. In primary muscle disease (myopathies). these potentials are generally of smaller amplitude than nonnal motor units. and of shorter duration and have been described by some as myopathic potentials. These multiphasic changes occur because of the decrease in the number of active muscle fibers within the lndividual motor units due to pathology. Although the entire unit will tire during voluntary contrac~ tion. fewer fibers are available in each unit to contribute to the total voltage and the duration of the potential. The polyphasic configuration may be a result of slight asynchrony of firing of muscle fibers within a motor unit. This phenomenon is probably due to the difference in the length of the temlinal branches of the axon extending to each individual fiber. The effects of this are nomlally not seen because the time differences are so slight. When some fibers are no longer contracting. or a delay in conduction is found in the ternlinal branches. these differences become more apparent. resulting in a fragmentation of the motor unil potential (Fig. 9.20). Polyphasic potentials may also be seen during degeneration and after regeneration of a peripheralncrve. As some muscle fibers become reinnervated, they will generate action potenllab with volumary contraction, However. there are significantly fe\~er fibers aCling than were pre:-,ent in (he original unit. and these fibers will clearly reflect asynchronous depolarization. These polyphasic potential~ are aho much <,maller in amplitude and duration (han normal unih, and they have been tenned nascent mOTOr IInits. Although polyph chronic penpheral nerve le:'!ion~, penpheral neuropathie~, and ante~ nor hom cell dl<,e':he. v. ill result in a change in motor unit tern tory of an inlaCI motor unn by collalcral sprouting of axon<; to libel'S 01 denervated motor unih. forming "gianT" mOTor IIIJ/ts 'v1any electromyographcr~ 110 longer u:-,e thi:'! termlllology. preferring to c.1l1 the...e pOlcnliab ~Imply larger (han normal mOlar unil potential!>. In rhe early :'llage~ of thi:'l proce\~ these ~prout:-, arc of small diameter and have

287

A

LJ 10 msec

B

LJ 10 msec

c

--..,4,..'- - - ] LJ

200

~V

10 msec

Figure 9.20 Motor unit action potentials. (A) Nonnal potential. (8) Long-duf3lion polyphasic potential (shown twice). (C) Short-duration. low-amplitude. polyphasic potential. (From Aminoff. MJ: Electromyography in Clinical Practice, ed 3. Churchill Livingstone IElsevier]. New York. 1997, p 74, with pennission.)

slow conduction velocities. resulting in a dispersion in the recorded potential. which increases the amplitude and duration and results in a polyphasic shape. These potentials may be seen in post~polio syndrome.47-49 If this situation is sufficiently prevalent, the interference pattern may be incomplete. The amplitude of these potentials is greater than 5 mY in small muscles such as the intrinsic muscles of the hands and feet. In other muscles. amplitudes of 3 or more millivolts could be considered as larger than normal. Duration of these motor units is 4 to 5 msec up to 25 to 30 msec. Other characteristjcs are simi.lar to nonnal motor units.

Single-Fiber EMG Some properties of muscle can be examined using extracellular recordings from individual muscle fibers within the same motor unit using a technique called siJlNle fiber elcctromyoRraphy (SFEMG). This procedure was developed 10 study neuromuscular transmission in the end-plale region in palients with myaslheni;} gravis. and has proven to be a useful adjunct to the EMG examination in patients with Illyopathie~. myasthenic syndromes. and motor neuron disease.~o SFEMG reljuirL's the use of a small electrode (25 f.Lm in diameter), which i~ inserted via a steel canula. During a slight voluntary contraction. recordings are taken from a ~ingle ~ite. Because cono;;ccutive discharges from a single fiber have reproducible properties. timed measurements

'288

Physical Rehabilitation

3rc able to :lccur:ltcly record the potentials. To dctcm1inc nellromu~cul:lr tran~l11ission. the electrode i~ positioned to record frum two liber~ in the molar unit. A trigger i~ u~ed to comrol the Ir3cing~ of these potentials. allowing the measurement of latency between the t\\O discharges. This latency. called jitter. repre~cnts the variable conduction time acro~ ... the neuromuscular junction. For normal muscle contraction. mean values for jitter fall between 5 and 60 j.Lsec. In a patient with mya\}thenia gravi:o.. nonnal and II1crea.-.ed values for jitter have been recorded. Impulse blOCking can occur as \\ell. \\·ilh intem1iuent failure of some a.xon .... 'itl This ba~ically experimental technique has been used in studie~ of myasthenia gravis. for example. 10 evaluate the effcctiveness of drug therapy looking for change~ in the jitter measuremeOi. If a drug is effective. the mean jitter value changes to\\ ard normal or lower values. 51 SFEMG has also been used 10 delermine changes in muscle morphology as a function of fiber de'lsity. by counting the number of spikes in a single muscle fiber potential. With conditions causing changes in the organi· zation of mOlOr units. such as myopathies or reinnervation. fiber density will appear higher than nom1al.

Macro EMG Another specialized techniquc. called macro EMC, is used to detem1ine the overall status of the motor uni!. Using a

modification of the SFEMG electrode. recordings are made from as many fibers from one motor unit as possible. Two channels of EMG signals are recorded. one from the needle cannula. and the other as a difference of potential between !.he needle tip and the cannula. Using timed recordings and averaging techniques. the peak-ro~peak amplitude and area of the macro EMG !i.ignal will reflect the number and size of !.he muscle fiber:o. within the entire motor unit. With normal muscle. the macro EMG motor unil pot~n· tiab will differ in shape from one mOlOr unit to another. 52 With myopathy. the macro EMG potential is decreased.

Stud icc; of patients with post-polio syndrome have identified dramatic increases in mowr unit size. often more than 20 times nomMI. 411 •.'i-'

Nerve Conduction Tests Hodes et al" first developed the technique for calculating the conduction velocity of the ulnar nerve in 1948. Dawson and Scouss further refined the procedure a year later. recording nerve potentials from the ulnar and median nerves through the skin at the wrist. This EMG technique has since become a valuable tool for identifying abnonnalities and lesions of peripheral nerves. as well a~ localizing the site of involvement. NCV tests involvc direct stimulation to initiate an impulse in motor or sensory nerves. The conduction time is measured by recording the naked potential either from the muscle innervated b) the motor nerve or from the sensory nerve itself. NCY can be tested on any peripheral nerve thaI is superficial enough to be stimulated through the skin at two different points. The most commonly tested motor nerves are the ulnar. median. f,bular (peroneal). tibial. radial. femoral. and sciatic nerves. Commonly tested sensory nerves include the median. ulnar. radial. sural. and superficial fibular nerves. Complete guidelines for pedonning NCY tests are available in comprehensive references.56.~7

Instrumentation \VhtTeaS EMG tcchniquc& record the spontaneous or volitional potentials of motor units. nerve conduction measure· mellt~ involve evoked potentials. produced by direct electrical ~rimulation of peripheral nerves. The instrumentation. there· fore. include... a stimulator in addition 10 allihe componenLS of the HIG 'y"em alreJdy de'Cnbed (Fig. 9.21).

St!mutatlng electrodes Shmulator

Sweep Ingger

Storage OSCilloscope

RecordIng electrodes

Ampllher

DisplaYIng OSCilloscope I----ioj

RecordIng apparatus

Ground Amplifier

Figure 9 21 In:o.trumentallon r('lIuin..·d f~lr llCf\c conduction sludi~s 1lI\ luti\,,> ,I 'llllllUlalOr III addItion to all Ihe u . Jlnponclll'l of Ihe EMG ,,> 'Iem .llrcJdy de"cribed. (From h:luem;llh, J.'I6·114 With perm.ission.~

A

MP, 10"'1 --('''--'::=;o:Abduc1<>< pol""" "';;::'-""''"'~~'" br_ m

Branch at

GroonO .....Alde (etofsal surface)

medlQn nerve

FtgUf'e 9 22

'('rHo c('t1ldUl.:lll~11 ~'elodl)

blf"OlIt.r ')\lfIlulatmg

Otstal-'~~7~~ wnsl

c1co:.lnkk

crease

'I

The .\flm"lallllll, dnlrodr Iypll,,;all} ..t Iv,u-prongoo elt'droOe WIlh Ult.'" c.uhodc ( ) and the :..Lnot:Ic (+)

~Irolar

~\lendlll£ l[llm ~l pl.t"luC (~;"ing (hg. (22). A needle electrode l,ln al"'-l he ll'\Cd to "llllllulate the nerve. Tht:- "Illnulu"l I" Pl\1\ ldell h~ a . . '-Iuarl'·\\.\\l· gt'ocr:.llt)r v,lIh pul.~' I)pica.ll)

Sttmulatlng electrodes

B

ddl\crtd J.I J. dur.:Ulon 01 0.1 111-.0,: ~lnJ :l frequcllC) of I pul')(' pt."r "4:cond (hg.. Q.2JA and B). Inc inttn'\lI) of the ~llmlllu"l needed 10 effect" c1) "ltlmulalc the nc.r'\l· v, III \.at) \\ Ith lhe ner. e ~trld lhe nxli\ lllu~1 patient. 10<;1 ~lIInUlaIOr-. \, ill deliwr a !lIJll1Ulll~ up to 300 V. or 5 lind 40 mA. ," These mten'lllll'\ are l..·on"lldered ",lfc for 1110 1 p;'llient!). Wllh:l cardlJC pJlemaker. h(I\\e\t~r. groundmg hould be \.·hed.ed :lI1d . . llIl1Ubllvn "lhuuld be a ...utficlcnl dl tance from the pacemaL.er.• \\ lth Ind\\dhng can.llJ.l· l'ametCf"t or central \ cnou.. . pre.......uft line... nene conduction . . Iudlc .. ;}re contrilmdicated, becau-,(" Ihe- I.'1ci.·trJcal CUrTellt rna) dlrecll) rerlch th~ l'ardiac U!>,ue. A tngger meChalll"lm I ... IIlcorporated inlO the ret'ording !'I~·~lem. "'0 Ihallhc !\"cep '>Ceo on lhe -.creeo is Inggered b) the ~tlmublor. The- w,eep begm .. v,hen the ..tlmulus IS dcll\t''fcd. prodUCIll~ a \limulus anlfu(t on Ihe- o;;crccn "ilh each .. uc...·e"... II."e· "lilmulus. 'nll'~ a!lo\\o;; the mea'iurement of lime from \llmulu~ onset to "lUbSCljut:nl motor or :-.ensol)' re",poIN~. Tht: :-.\\ eep makes une comple-Ie excur"lion acros" the l)("rcen lor cadi rube put out b) the ~Iimulalor.

Motor en'e Conduction Velocity Testing Stimulation and Recording Reconhng. pOlenuals directly from 3 peripheral nerve make", munllonng of purel) ~en:-.or) or mOlor fibers impo".. lble. Therefore. 10 I.",olate Ihe potentials conducted b) motor d\On"l of a mixed nene, lhe e\oked potential is recorded trom J di ..tal mu!o>c1e 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

h.

\1 hJl' rl1llm\.·1

"t,:!.:,

'I Ihl" ...lInllllu,

I'

pn"'ltlll.cd. lhe 1t1ml,lu..l

.• 1 " 11K' kll 1'\1 Iht.' ",'rt:'t:'n fhe trigger m«fl.. I I ' '1.,1 • 11 Ihl'\ "od II \\ III. Ihl."rcll,re. ,ll"a}, Jppt'M In

.till '111 \.01\

t'

.

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..\\.... ('<1 1"It.)1(,IlIl.11 I' dc-arty ~rvtd. IlKn.· .l"l·J u n,,1 t Jl \\ hc.'U th\.· 'lIInul.ltllll: l'll.."cnxk I" rmp.:rly pl3l..---eJ over ~ lk:t'e, JIIII1\J"- k, lIUk:(\,ttl.'\.! d,"I.11 It) thalyolllt ~~ III contract ..toll 11K' r.tllt.·nt \lIli ~.~ .mJ !l'cllm hand Jump. The Inltt\'11\ l\ lht.:n IIlUl:.l",,-·J ulltll tlK: r\ok('d n"I)()nse no longtr ll1~rc.I"l·' III 'lit.' '\1 Ih,II linK:, the mtcll.. lI) " intTe3...cd furIht'l It' I" '1l11.' Ill,it Ihe '1IJl1lllu' j, HIf'raml1.umal. Because thl." mlen"'ll\ llW,,1 Ix' 'Utfi.:.:ll:nt !L) rea('h 11K" Ihrc... hold of aU !ntltnf 1Il--.:·f' In the nCI'\C. " 'lupram:l\llTlal silmulus IS Il'4 um: J It I' ..11..,(1 e... \cllU;11 Ih.l.l lhe c::llhode be properly pl.ll..cJ Il\Cr lhe Ill'f\l' tnmk ..., Ih,lt lhe ~t1n1ulu ... rc:ac~ aU

3rd Sllmulatlon 5,oe

2nd sllmLllallon sIte

RecordIng electrodes Recording

Reterence Ground

RecordIng muscle Abductor POUICIS brevIs Figure 9.24 Slle, of .,llOlUl.:tlllll1 lor motor ncne l.Oll\tUlJI\1O

,Iud) Ollhc fnedl.:tJl

n~c

lFrom

b.hl~m:ll.:h.J

~~\\Jlh

penlll~ItJO.1

..kill m;J) bt? cleaned \\Ith alcohol h) r~JllL~ .. ~m rt>'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. ektlfv
Ju... 1 lb"I:t1 to Ihe l1Jl.:'I.lli.lrpophJl..lllgl';i1 Jnlllt. The elcdrout' I... pLtl'\.'d I)\c'f lhl.' meJI3Jl nef\\.' .u

'lImuI::Hm~

u,uJII) .11 ~cm from the: rcolllr,hnf eIt:Uf\xte:l. JU,,>I 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,'<..h .... thl.: 'tnl1ul.JlIng dev trlllk u\udll_\ hl.1.:1-.1 .lnd Ih\.' tJflh/t I'" the IIl.lLIl\c l'lt-l.'. Iwde iu'\u;tll} 1t.'t11 It I, llnporto.u11 111:11 thl' l..tI!Hx!L' be dlft.'\,·leJ to";1J d the rel'llflhng t:k'l'ln.K,!l:') I\.l ...1II1lU];IIC dqXlbrJl.ltlllll 1l''-'.tnJ Ill\.· lllu,,>de IPrthll(frolllll' lonJulilolll

tht' Wn'll..lt i.llI1l.:'a,ureJ

Ih,' nluh",r .not"". \" III the f-,~1<..i '1f!-031. lhe polt'ntl.d....cen on the screen rcprc'(,111 Iht' l.,lt.:l:lflcJI :Kll\ It) dl·lc<.'ted by the recordmg l.'kt.:lnxle rill: 'lgn,tl \\111 r\."pr~!o.enl the difference in cite· Inl-.d pOlcntl:11 bct\\('cn Ihe rCl.'ordlOg. and reference clecIfl..xk~ ... \\h~1I Ihe \upr.lIll;\\II11J.1 ~Hmlllu\ il'> applied to the melll.tIl 11t"f\C :H the \HI'!. all Ihe aXOll~ in the nerve will depol.trlll' Jnl! hegin l:onJutlJng an impul...c. transmilting Iht: 'lgn~i1 .H.. fth .. lhe molor coJ plate. Jnlu3ting depolari~a­ lion 01 Ih,' fl1u ...... 1t: fiber",. During Ihe:-.e events. the t.... o rel'(mjm~ d{'t.If~llie .. J(I not fl;'corll ..1 dlflercnce in potential OCClll"'C nu ,l('II\'II~ I~ Idl..lJl~ pbce bcncalh the electrodes, When thl.: 1l111\dc fibt:r, l"lI:glll 10 Jerol~lfl/c. the clcctril'al rOl~n1ljJ'" .Ire If3.n .. mltlCu to the electrod('~ through Ihe voJ· um~ \.'onuudOf and a def1~cuon I" ~een on the CKCillo"'lOpe. Thl'" the e\Oh.t:J rott'ntlal \lohlch is called theM 11,1\1 The .\1 \\J\(' I" al",\} rt'lc-rreJ 10 a... the MAP (mOlar J.dll)O POtl'lIll.;j 1 M C!'.1AP ll.:ompound mOlor action poten· Ihal I. Th~ \1 .....1... 1.: rt'pre'~nt' the ... ummaled activity of all nhltOf unit'! In Ihe mU\Lle Ih.11 f('\ponded III stimulation of IhL nl'(Ve Irunk The arnplnudc 01 Ihl~ pOlential is. thereIllfe . .I lunctlon 01' th\.· total \lhage produced b) the conIr.:tCtlO~ IlhHor unih. The millal dellecllon of the M .... a~·(' I' the nC::!<.Ill\c portion nt thl.\rJ.\e. aoo\c Ihe b
JI't,ln~1;'

CalculaLion of \1o Lor :".en c Conduction \'elocih Thl" pUlIlt .11 l\hll..h the \1 \la\e 1l"~'t\"c'Jo Ihl.: baseline indJ· \':~IIl"'" th~ lime elap-.eJ from lhe mitt,ll propagation of the JtI.~r\c Illlpul,~ 1\1 thl.' L1eJ1lllanz:J!Jon 01 the muscle fibers o:n~illh fhe dt"uroot''>. "1111'" IS called the n:'ipol1...e lau'nl')'. 1 ht' bll"n~y 1\ Jlle~hur('l!1ll lHIU .... econd ... from !he Silmulus

Chapter 9 Eledrom)'ography and Nerye Conduction Velocity Te'its anlfact 10 the onset of the M wave. This time alone is not a valid nlea~urcment of nerve conduclion because it incorporates olher eventS besides pure nerve c~ndu.ction­ namely. Iransmission across the myoneural JunctIOn and generation of the muscle action potelltiaL There is also evidence that the distal segments and temlinal branches of a),oll:'l to individual muscle fibers conduct al slower rates than the main axon. W Therefore. these extraneous factors must be eliminated from the calculation of the motor NeV. ~o that the mea~uremenl reflects only the speed of conduction within the nerve trunk. To account for these distal variables. the nerve is stimuI':lled at a second, more proximal point. This will produce a response similar to that seen wim distal stimulation. The lltimulus anifaci will appear in the same spot on the screen. bUI the M Wa\ e will originate in a different place because the time for the Impulses to reach the muscle would. obviously. be longer. SubtTJction of the distal latency from the pro.limallatency will delemline the conduction time for the nerve trunk segment between the IWO points of stimulation. Conduction velocity (CV) is detennined by dividing the distance belween the two points of cathodal slimulalion (measured along the surface) by the difference bel ween the mo latencie~ (velocity = distance/time). CV = Conduclion distance/(Proximal latency

- Di>tal lalene)') Conduction velocity is always expressed in meters per (m/sec), although distance is usually measured in centimeters and latencies in milliseconds. These units must be convened during calculation. To compute the motor NCV for the test illustrated in Figure 9.1~. the prm.imal and distal latencies are deler· mmed b) mea~unng the lime from the stimulus anifact 10 the initial M wave deflection. according 10 the calibration scale. or ~v.eep (jpeed. -nle conduclion time is calculaled by taking the difference between these latt"ncies. Conduction diSTal/a b lht>n determined by mea!>uring the length of the nene betv.een lhe 1\\0 points of stimulation. For example: ~econd

Proximal latcn",'): 7 m~c DI~tal laleon 2 m~c Conducllon dl\lance 300 mm or 30 cm tV:: 30 un /17 m.. .ec - 2 mscc) = 30 cmlS m~ec = 60 m«,ec lmerpretatlon oj Ihe lIlotor NCY i~ made in relation to normal \aloe\. which are u~uall) expres!)ed as mean value~, \land.1fd deVh1110Ib. and rJnges. NOnlKtl values have been dctemlllled h) Indfl) 111\ e:!-ugaton. in different laboralOrie50. ben ':>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'.), Onhodromi<.: slimulJtion of fingertip... ..lppe~r . . to be more ullcomfortJble than \ttmulatlon of Ihe nene tnlO~ Also t!le amplitud\" of the rt"\pon ...e t... muth k\rller \\ hen antidromIC reC'OIdlllg i... done. ~ Selhory ro1entlah for the medluJl ~tnd ulnar ne!\C'Il..'i..In Ix l't'Corded antidrullltC
H Reflex The H rene\ (named for Hoffmannbl ) is a useful diagnostic measure for radiculopathy and peripheral ncuro;athy. It.. mo~t common applicatIOn i~ in te ...lmg the integrity of the sen",of) and mOlOr mDno'\~ napllc pathways of S I nerve roOl .... and to a le...')cr c'\lent 31 C6 and C7 .t>~ A ~ubmaximal :-.t1mulu.. I~ applied to the tit"lI.11 ncr. c ..tt the popliteal f~sa. and a motor re... pon . . e I ... re~urdcd fwm the medial portion I the ":-O!Clh mu:-.cle. The :1l'lion pOlcnlial ... travel along the IA atfcr~llt llt.'urOIlS to\\ ard rhe "plnall·l)rd. ~ynapsing onto .llpha ll111toneuron .. \\ uhlll lht.' ;lIlh::T1or hom. The con;;equenr Jell\ allon Llf [he nWli,lr neuron kJd::. to an impulse r,J,\t.:Ill1: f'\~nph~rJl1~ tu lhe rl·... Plm... C' mu ...d~, resulting In .1 lllu",c1~ clllllr;.h:tll1n Ul'... Ju ...c th(' ... tJlllulll~ call . . e~ impulses 10 lr~\t'! bl)lh dl .. t.lll~ .mJ pr~I\1I11.l!h v. ithlll a lTIi~t:d motOr and "'Clblll.' Ilt-'lJn1tl. thl..· LIlt:'Il... ~ nf rhl' r~ ... pun~ IS a messlift' 01 Ihl' Illkgm, 01 both "I,:'n ...ol"\ antI motor fibers. H~-'l lIJ~' Iht.' 111111.': phJ ...... ~lt th~ H renl~'\ 1'\ the afferent Ml' ,Ib1ng 1-\ 11'-x".... lh rc p"ll1.....: 1... lllllt.'d III tht' pn:.-,eDl:eof lllU. ...-I;,.; "'rln.j!~ ... \lu"'l..·h: \\ Illl ,Ill\\' 1\\ l1(h tibeT' con(.un .m .lhu/l,I.llh.t.· pllllU d<.' "'pllld1l..·, ,lIlt! .irt" abl~ to demon. . lrall· tilt' II rdl L" .l1l\hl ,. , I . i.l'n"hIL'l\th I ht'rdorL',thl' so~us 1I111 ... L!l'

"IJllI~h('d

plnll1llllll..lIHI\

t\f .. lu\\-t\\!tl,.'h

fibef".lS

I ..: I.../). I t II ,uh1 i-..h.ilil· . j hJ\e Jl ...o Jemon-tr..ltnllh...• II ("11· I t: ... \ In; k Ik\\\r LJrpl radhlJI~ muscle to

nlU'" 1l111;'11 U •

l~ ,,,,1\,

II I Ih...· Hh: 11,Ill Ild\l

(&lllllialioll uf ~(;II,on C(~llc..1uHlun \dol"ln

~nl~

I.lklilin hl ... ll)rll..jJlI~ ,Ul' U.. UilJl~

ulu
('t'dk

lll~·J"lll\.:d tWill l"l ""tlll ulllll' ..:\ol-.t'd pOkllll..l1 rath
. "'pon ..\,; I ~1t:'11I..-" I' ,t lundlon of age and k,t: kll~lh ,Illllrdtllg 10 lh~' ~ qu.u1un' Ihl,.'l1rl"!k'\I' ~

It rdl...· \ 1..lll·I\\ \

O.4h I k~ length l~mJ) (I I I \ge 1,,)1

+ 9.14

Chapter 9 Electrom}'ography and Nerve Conduction Velocity Tests

ouVI

I

I

293

m.

!

-----i-I=!-, --I-~A~m2E.!.1=.=_.~2~90!u':!.V----!.A~m~2~=_+!:1!!:5~U~V~!!dA~m~p==----~44~UV~

519°'''7 I

1

iji__.jIC-:j\_;

lat1=

2.5 ms

lat2=

3.1 ms

dlat=

0.6 ms

l. Median SNC

Ch. 1

_-+__+__1Recording Site: Wrist

I

1 Amp uV

Dist mm

C.V.

m. 2.1

44.7

120

56.2

2. Index

2.5

44.7

140

56.7

3. 3rd di9·

2.5

36.7

140

56.0

4. Ring

2.8

19.3

140

51.2

Lat

Stimulus 1-I--+_~,-l

o

Site

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L ---+--+----+-+--1

!

V,

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1-lI---1----/;--.-I1I"'\:--+---+---y~;;;:;::::::b'C:,;*'~""--_j

mi.

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Enter number to copy waveform to assigned

trace area, or press STAAT/STOP to acquire another sweep.

- 1""-'-

480mA

STIMULATOR 05102/16 12.38:35

FIgure 9.26 Sensory

le~l

of median nef\C done antJdromicalJy on a Imillull eldt"rly

A norma.! r6pun':>e (alb, \\ 1\111H ± 5.5 111\CC' of lhi\ cakulateJ lmcnc). An ,t\criJ.,ge respon-.e I.., 29.H ill"ec (± :!.7-t m~c).t..\ A ..lov.ed bt':IK') J\ ItldH:a\J\,e ot .lbnormal dor1'>JI root fun...:lion. often lrom d hCllllilled <.II"" or Jmplilgelll~nl ~yndr01lle. B("(.iilht.' 01 thl.., ..: cmral lIl\OhCIllCIlI. Ihe pcnpher:tl motor and ..,cn..,nrj "\('\' .... ould nOI be- ,IHeuel!. 1'hl'> latt~nc) may alsl1 idt'llllh lu:r.\,.' rOOI c(J1llpn.·....,JOll pnoE to Oh\ lOth EMG ch;}ng.l'~. The H-rt:l1e\ L.ltenl.~ i .. l"1H:i,ed u.. lng. fi~l:J ~11mll+ lu~ p..lfallll.'\cr.. n.: ..ulllnr III J ~wble rc .. pon~ trom fni.d 10 tn:.tl.l,ah:l, .. ,In he "llt'lIC\..\ 11) 1,11.:111(,1101') ~Il1J IllhthllOl) h:l.·hIllYU6 1t"'lkctmg the \:\.l'tfJhllit) of (h~ motor lieU/on pool.

hl.l\\(::\'I.·I.

lht.:

dur= 0' ms, smgle

l"l"J'k"ln ..e

\\111 be.: l11\)re \;lllahk.l~

sutJje~l.

thought to rc\'emcmll':

The .. \\:l\e \1.;1 ... flr.. t \.h·~l.nbcd b)

\1.tf!l,ldt~l) .md <\1cDoUfiJ.111l 1'1"\0 Ii I... dlllh:d b~ the ~llpr.und\lmJI ""tllulu\, 01 J lX'ripllaul 111.'1"\'t:' al ,-I lltq,d ""H~ kJdUl~ 10 hoth onhodrolllll ,tud ~Intldrolrlli.: Impube.. While.' Ih..: l)rthnIl\ thl! dl'}l.t! IHll::;d..:. Iht ,tllIlJronw.. Ira\d .. III the ,lnlcrl("r hlll1l o.;dl. I hi.. llnpul-...; I..

dl\lmii. Irnpul"L: u:J\d.. 1('~I)(Jlhe

Ih~

axon hilhx:l... i"l depolJ.r\\ hi..: h in turn

Dr dendnle.,.

dept")lari7e~ the i1\on hlUod.. OJlC~ agaUl. !!cJlt'rJ[ing all onho-

dromlc \ olley bad. It.> the tnt1"c1e. 0 ...yn.:lp'>C' 1~ inv\)hed, ..o [he F \\ :1\'e 1"1 not ('on~ldcn."d J rd1C'\. but only J. measure of motor neuron conduction. The F \'''''\It:' 1<" J. mdul \upplemt=nt lO I1CP.t" o.;undlKtlot\ ,tJhj F~<\1G mC;t .. ur,'.., and I" ml).. t helpful in the Jiagno.. is of \·OJ)...htlOlb \\ hal.' lhe mOl'll pro\.inhtl pl..rttOIl of lilt" "\.l'n i., .1 .. Guilldill-Rurrc "l)nJrolllc. thoItlC1C' outlet "} nJrolll~ bradlla] p!t:\u") IIlluric:-, dnd rJdh:uJopathlC''' \\ Itll IIlprt: Ih,m ont' !ll'f\ e mol 10\ 01\ cd. '>to 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

ph..tnmh:olog1l'al

•.1"> iJ m~J .. url' IJf Jlph..l

".otUOlC"

vt

"'paStl~lt),

1ll\lIl)r Ill.'UIU{\ C'\\.-IlJblll!y.'t7.oll

-I ht' 1:I\~nq ollht" f \\a\(." ,.. norm.lll) apprt)"irn,nd) 30 1I) tht." UPfll'f 11mb and k'., .. th<11l btl \('...' und... in the lll\'~'f InHh_ I hb tolallJOIe ll1duJ~~ lIw M \\a\l.' eltcited.1:pari ot Ih~ Blowe i\C\ Onl) ,1 ..,111;111 percent of mornr ntuHlJ\:o- .ll... I\IJII) fMnil'lp.lle III the F r("pon",,,~.l'l') BetauSf It IS <.Ill 1I1~\m'}l:\knl fl."ptlf1\~. il mu ..l tx: calculated on the bash vI i.H It....- bl 10 "ul"l."l.'~..,ht' IHilb. "~(OIJ(t..

294

Ph)'sical Rehabilitation A

(J

Effects of Age and Temperature Age and temperature are the two mosl influential faclors lhal can cause variatjons in conduction velociry. Nerve conduc~ tion is slowed considerably in infants and young children. and Ie....s so in elderly individuals. At binh, the motor CV is approximately one half of nOnTIal adult values. gradually increasing unlil reaching adult rates around 5 yean. of ,agc. 70 Motor and sensory conduction velocities have been shov.'n to decrease slightly after age 35. with larger. significant differ~ ences noted after age 70.11.7:2 Lower temperature can also decrease motor and sensory conduction velocities significantly.7.1 Decrements of 1.8°F (1°C) in intramuscular temperature have been correlated with changes of 2 to 2.4 mlsec in conduction velocity. It is advisable to wann a cool limb before examination to stabilize the Iimb's temperature. The exanlination room should be a wann envirorIDlem and if the patient's limbs feel cool then skin temperatures should be measured. If the temperature is less than 35°C in the upper extremity or 32°C in the lower extremity then the extremity should be wanned or an appropriate correction fonnula for cool limbs should be used.

ELECTAOM'l'OGIIAPHT UPPER EXTREMITY I )tAlI l J AlgIn

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Reporting the Results of the Clinical EMG Examination

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The perfonnance of reliable and valid EMG examinations requires extensive experience and expertise with biomedical instrumentation. as well as a thorough understanding of neu· romuscular anatomy and pathology. The material presented here. however brief. is intended Lo provide sufficient back~ ground for the reader to intelligently ulilize infoffi1ation from an EMG repon and to apply the~ dJtillo other aspeu\ of paliel1l care specifically relaled 10 progno~i'\. goal ~lling, and lreatmel1l planmng. ~'iLh this in mlJ1d. it ...eern, 3PPr0~ pnate to re\ iey, ho," uch repon.... are prc;)ented. The EMG repun i t)'plI..'ally found in a pat/em \ chan or medical record. The e')~nual data mclude (I} the \peCllk mu~le or l11u..,de~ tt:'sled. Indudlng <:.ide of the bod) and the IOnenalion of tht~ mu~les: (2) the re')pon~ ~n dunng eleurode lI1:-.enion; (3) the re .. pon~ at resl hpont,U1t:'t)lh liLLJ\JlY, "'~1..l1)1f1g t}pt= of potentlah 01 eh.:uril',11 .. deIKe'); ~d (4J re"'lxJn\t'~ y, llh \olumal") n1nlrd\:lion tmotor 111111 po:~enthtl .. i.Ullt rClnlltmcnll (Fig Y'27,. The di.ILd pro\lth:l! hould rdale 10 thc fl\c p.trdme,e~ of ell"crriLJI POLl'ntl.lh J.l1lplltude. dUT,uioo. 'hapt:. '<..lund,

1rt;4U~nl).

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ul 1.lten9 ,till! dl'LilllL':t: llt:l\\een recording and

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FIgure 9.27 Sample repon [\.lml lor EMG. Thi.. pictorial form the rd:ul\e p'-,.. ltlon .md penphcraJ nerve and root IIlnef\'UIIOn .)[ the commonl~ te'led upper e'\lremilY and 10000er

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Ph\-. Thcro3':!1-t I(N.1. \'lth permt"..lon)

f\)lltm th~ d.llc.l. <.;latll1g the' Impre'!ooliJn or Implications of IIIKJlfIg..

hl't>.lrelocl} Impurt'll1llO ..,rre,;) hen: that diagnoses art mal!.: ,nld} 011 rh<: bJ'I:» of l:.~IG dara EMG fiDdmgs .u·c l:un'ld~n.'d ILlgl'tha \\ nh ,,1.\1..1 flOm other appropriaat l'\~llllln;lll\lI1 prlXeJurc.. Il) pro\ IJe d compl ce PICture of nOI

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I

NERVE CONDUCTION STUDY

A

UPPER EXTAEMlT '(

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NERVE CONDUCTION STUDY

LOWER EXTREMITY

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pretdtlon form) tor upper and ICJ.... er extrernu) sho..... relationship of anatom) 10 nene condu\.'llon ddld
~ellXl1)

~Iudies.

296

Ph~ ... icaJ

Rehabilitation

Clinical Implications of EMG Tests Typical findings wilh neurogenic or Inyogenic disorders can be described. The following discussion focuses on selecled disorders ,hal typify EMG and NCV re,ul". and Iheir implications for evaluation and treatment planning.

Disorders of the Peripheral Nerve Electrophysiological findings usually correlate with clinical signs in patients with neuropathic involvement. Some differences exist between types of neuropathies in lenns of relative onsel of sensory and motor symptoms and nerve conduction changes. EMG findings are usually significant only if axonal damage is a faclor. Often, eleclrophysiological changes in sensory conduction are seen before clinical manifestations such as definable sensory changes or motor weakness. In many neuropathic conditions sensory nerves are affected before motor nerves and EMG findings are unremarkable. The sensory NCV [esl may [hen provide [he most helpful infomlation. Clinicians may tind such information useful in following progression or remission of an exisljng condition.

Peripheral Ne.... e Lesions Lesions of the peripheral nerve fall into three categories: neurapraxia. axonotmesis. and neurotmesis or class I. class 2. or class 3 nerve injW). These lesions may be due 10 traumatic injury or entrapment. Such disorders lypically cause weakness and atrophy of all muscles irmervated distal to the lesion. Selbory findings rna) occur first. but may not be as definitive as motor deficits in localizmg the site of the lesion. EMG data can asSiSI in the idelllificmion. diagnosis, and prognosl~ of such ca\es.

Neurapraxia A Ilt'/lrapraxw {cl~~ I, il1\ohes \Orne fonn of local com. pression or blockage. \\-hich ~top~ or "Ilows conduction across that poinr III the nerve. Conduction above 'iC'J Mca. but 110nlldl eondueWill \doc.:u)- aho"c and bclo\l. In ltl ~Ign Th.l' Illtenerenl.f' pi.Hh~rn 111'-1) be dCl.lcJ.,ed or ah.....:nt Illlll.:'re 1\ "It"\er.. . blol...l-..dgc.

Axonotmesis With lIXollotmeS;s (class 2) Ihe neural lube is intact, but axonal damage has occurred. with Wallerian degeneration distal to the lesion. This may be a progressive condition as a result of long-standing neurapraxia. or it may occur from a traumatic lesion. The deficit in NCV will depend panly on the number ofaxons affected. If the larger diameter fiber.; remain intact. the conduction velocity may be normal. However. M-wave ampli[ude will be decreased because fewer motor unjts are contracting, Fibrillation potentials and positive sharp waves are typically seen on EMG 2 10 3 weeks after denerva[ion. depending on the distance of the axon from the cell body.

Neurotmesis Neurotmesis (class 3) involves tot31los5 of axonal function, wilh disruption of Ihe neural lube. Conduction ceases below the lesion. A conduction velocity test cannot be per_ formed because no evoked response can be elicited. Recovery is dependent on proper orientation ofaxons as [hey regenem[e. Spontaneous potentials will appear with the muscle al rest, and no activity is produced with attempted voluntary contraction. Regeneration of peripheral nerves will be signaled by [he presence of small polyphasic polenlials (nuscenl units) with voluntary contraction. These may be seen before clinical recovery is evident through the results of other examination procedures, such as the manual muscle test. After clinical recover} is established. poly phasic potentials may persist. often as larger than nomlal (giant) poleOliaJs. a, a result of collaleral sprouting. Rehabilitation goals for patients with peripheral nerve injuries can be influenced by re,ults of ,erial EMG findings. E\ tdenee of regeneratioo will suggesl thaI molor function I~ improving and trealment plans should addres~ minimal exercise for the weak and easily fatigued mu ...cles. Positive signs of regeneration will al'o ~ h ei p 'III "Ietllng reall~ll(:: outcomes for functional recovery.

Pol) neuropathi.. Polyneuropa'h·,·s I' .. II I· . < .... ) piC .... Y re ...u I 10 ~ensory changes. diSI'd \\eaJ..nes d h . .. '\, an yporetl~\ld ~~uropalhies can be related [Q Ileneral med·· I . . e n.:a t,;Oll d·lllon~, su..:h as. dIabetes. alrohoit...m. ' .renal d ,e' . ' . , I .Ise, or mullgnant'le...; thev may resuJI from II1lecllon<7, "'Ul:·h·...... Iepro'i\ or CUlHam-Barre . : . syndrume; and they m..I) be,· . • . a~ ... o\-rJ(ed \\ lIh metabohc abnornuhlle'> '. ')Ulh <'1'~ 11..1 1 .I nutrllion or the (o\ic effects of drug) or dlernllab eun1p.tthll ('und 1I 1011"1 m.l) be 11l.llllfes[ed as pnman'1 Y dxonul d"II11J.lle 0 ~

I

,_"

r pnrnJ.n y delllyelll1.:1l1on of a.\on5 *N ' . 1I\tUCt- of ~Jlh "' IIh one or th~ other belJ1& Pfl:domlllJIlI \\ th I . I d\On...t.l le'lulh, recruiuneru will be: st:\;ere) affected \ . pJrllaJ tOtertcfl"n<.'e pauem may be u h t'r\t:"t.l \\-lIh In I I . \lmJ eU\-)rt, or 'Ingle molOc unn pocco-Ila I~ In.t) ~tlll he d ' . t

generall)

d

n

Chapler 9 Electromyography and Nerve Conduction Velocity Tests

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A

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Figure 9.29 Large amplitude. long duration 1l1~IOr unit, potemiaJs

frollllhe tirst dor'\31 jnterO"::.ell~ (A) compared with relatIvely nomlal mo!Or unit pOlcntials from orbicularis oculi (8) in a patient \>',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<:lerosl"I. progres\ive muscular atrophy, and progrc-"sl\t: bulbar paby. Spinal muscular atrophies are another clas~lficallOn of motor neuron di~ease_ The reader is referred to comprehenr"l\e texts to rc\ iev., clinical fealUres of these di~ase~. Dise3'lc'" 01 the anterior hom cell are classically indicated by fibrillation potential" and po~itlve ",harp waves (see Fig. 9.17). and b~ reJu(.:ed rc(:rtJItmenl \... l1h volunta!)' cOlllracliOn. due to 10',> 01 motor neurons. \Vhen single M UAPs can be seen '.\ nh ma:"'llllaJ effol1 by the p::nient the resulting aClJ\ tty is c
t1\e dl~a~es

neuron disease. due primarily to collateral sprouting and reinnervation. This is a typical finding in post-polio syndrome and amyotrophic laleral sclerosis, where enlarged motor units are found in partially denervated muscle. 11l .19 Macro EMG has shown signs of reinnervation in these groupS ..~8jJ although denervation often continues and has been found in affected and supposedly unaffected limbs.'" Individuals with post-polio syndrome often exhibit functional decline many years after their acute episode. These individuals experience new muscle weakness and atrophy in extremities, bulbar and respiratory muscles. and excessive fatigue. This syndrome appears to manifest when the reinnervation process crosses a critical threshold. whereby remaining neurons cannot support all their muscle fibers. so

Myopathies In primary muscle diseases, such as muscular dystrophy and limb girdle myopathies. the mOlor unit remains intact. but degeneration of muscle fibers is evident. Therefore, the number of fibers innervaled by one axon is diminished. Motor nerve conduction is typically nonnal, although the amplitude of the M wave will be decreased because fewer muscle fibers per mOlQr unil are responding to stimulation, Sensory nerve potentials and neuromuscular transmission are normal. In the early stages. the EMG examination shows prolonged inserlion activity. perhaps due to the instability of Ihe muscle membrane of degenerating muscle fibers. Fibrillations and positive sharp waves are also seen. sometimes with repelitive discharges. Voluntary contraction typically elicits shan-duration. low-amplitude potentials, some of which maybe polyphasic reflecting random loss of muscle fibers. Less than maximal effort will require early recruitment. and an interference pattern is evoked because more motor unils are needed 10 creale the necessary lension within the muscle (Fig. 9.30). The IOtal amplitude of the imerference pattern. however. will be diminished, Use of single-fiber EMG, macro EMG. and molor unit eSlimation have been used 10 identify Ihe course of myopathic disea~e.l~

_______ 8 A

dl~a')('~ 4 .1>

AI-Shd,hlec anJ Katirji"l1 have ft"ported on a small li.t\C:-' 01 Wc:S( l\lie \lfU') Il1feClioll v.ho pre:-,cnh:d \l,lth J.i,.Ule pJ..IJI) (I<: polJomyellll'>. Their report rocu~ed 011 {hI: usdulnc"I' \If Et\1(J and CV tC'lIng in the,e pallen" rc\ei:i!Jn£ both llK-al pre..td chi.lnge~ a',>('ll,:mled \I, IIh (heir \\1:'>( Nllt: Viru, Infel:llOll, Dcpenolllg olllhe lim. lng 01 Ihe f::.MG eX..tll1JI1.tllun !-.Ol1lC patlclJl~ ~howed \vlde "'prt"aJ fibrillatIOn POI~llIldl ... Polyphal.,h. 1Tl(,tor unli pOlenlJ.tl"l ollnclea",cd ampillude and d ur.tlloll Me ()!ten I.,Clo:n l..tler In the (:our~e of motor

\tne\ ul

297

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Figure 9.30 Luw ::unphludi? ~hort-duralioll mOlor unir pol~n­ ljab lclordNI dunng 1Il11111ll.11 \ olumary cUlllra("(ioll from Iht' hicep~ brachll (A) and llbiali~ unterior (8) III a 7-yt':J.r~old 00) \\ Ilh Ouchcnne'~ d) ...(mph) A high number of discharging motor umbo dUring illllllln:ll COilln.l\..'tlon reflecb early recruitmenl {}-mlll Kllnur..l.J.>u.I·~bIl\\llh pernu.'tslon.)

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po:mll ......hlll.l

po... IlI\C ... h~lrp \\~l\C\. and fn ...ciculation... are lyp· "':l'n (..ce Fig. 9.17). WI[h dcrnyl'11nl/illioll. ner\'t.' conduclion mC:l.. urements \\111 often provide Ihe IllI)"\ u:-,eful dala. Sensory tiber... may be arkued hclorc motor tiber.... and ~ignilicanl s.lowing of '-'\.·n..0l'} condul'llon \docll) may be ...een. The evoked potcnWII '-'llll)picall) he n,.-duccd in amplilUde.

pOlrnua! .. ,

297

neuron di~casc. due primarily 10 collaleraJ sprouting and fCmncrvnrion. Thjs i:-. a typical finding in po~l-polio syndrome and amyotrophic laleral "cIcro~is. where enlarged mol or units are found in partially denervated muscle.' .79 Macro EMG ha~ shown ~igns of reinnervalion in Ihese groupS:ill... ~ although de nervation oflen continues and has been found in affected and supposedly unaffected limbs. so Individuals wilh post-polio syndrome often exhibit functional decline many years afler their acule episode. The~e individuals experience new muscle weakness and atrophy in eXlremitie~. bulbar and respiratory muscles. and excessive fatigue:. This syndrome appears to manifest when the reinnervation process (:rosses a critical threshold. whereby remaining neurons cannot support all their muscle fiber!'l.80

Myopathies

irall)

Motor

euron Disorders

MOIor neuron dlwrucr... moM commonly mvolvc degellcradl~~l.<..e., of the anterior hom cell.... 111e~c indude pollOrnydltl.... ;mJ dt . .ca..e... Ihal arc ch:lraclerizcd by dcgl:."ner..lllon 01 bOlh upper and lo\\'cr mOlOr neuron.... ~uch :IS :lmyotrophtr lateral ..dcro... t~, progre:-.:-.ivc 11111~cular atrophy. and progyc I\(' bulhar pal ..). SplIlalmu..cular :tlrophil:."!>. ilrc anOlher \.·hl lliGIl ton 01 mnlor neuron dl,ea:i.c. The re:Jder is referred lo,,·olllprehC:Il-.I\t· te"h 10 reVIC\\ c1illlcalll:alure\ of

Il\C

Itk'S(' Jl'-'C~S

DlseJ~" 01 tllc ;ultenur hom l"t~1I are d.l....,icall) incllcated b) libnll.llion poll-·lIllal... and POSltl\,{' ..harp \\an:~ (st.~ Fig. (,1.171. i.llld b) rl·Jul..'t'd rC\.TuiLrllCIlI \\ Ilh \OhmlrU) contrac· tiOIl. due 10 10.... tIl 1l10lnr neuron .. , When >'lIlgle MUAP~ can be '-'t:'t:n ~\ lth ma\.lIlhtl elfon b) the patient the n:~llltll1g aUI\ II~ I.. calkJ :J ..,tngle motor unit p:tllern. Mulor NCV m:t) tx- ..,IOV,l'd. l.krellJttl~ 011 thc dl~tnhlllil.JlI or degctlcntllull ;unon~ mu\(Jr lilx'f'h hut ..cn..,ory c\'o~cd potclltHtb are unallellnl. Nt:V,t:1 h~dUli4UC'l lor C.. IIll1.t1lllll of the number nl mnll)r unlb III :t tllu'l.'lt· Il;tl,-c allo\\~d L:kc.:lnllll) ogr~lphcr .. III n.Ullllll.: tht' phl,gr..... IVl' nalurc of nMIl) lllU!01 neuron dl'-'t.t\l'''.... AI-\hc~hkL' ;md K.lltlJI ' h:l\L" reponed nn .1 .. mall Sl.:lIe"ull...I"" III \\nt 'Ill" vlru ... IIlkClll)1l \\ho prL'~t.·nled .... 1111 ~\.ute r II ,iI\ Ill· POIIlH1I) dlll'l ""I..'lr rl..'jXlrl Itk:U'le:d un till" u..t1ullh: ..... 1.11 L~1(1 .llld NCv h: ...llIlg III the,e: PilllL'llb ft:\t:o.llin~· hUlh Ilk. '-II alld \\ IJI..·...plL'.ld Lh,l11g.e.. :1 ...... OI..·I~Hc'd \\Jlll [hell We: .., 1\0 lit: VlIu .. IfllcClllIll lkpl'nJlllg 011 tile: Itllltill! nl lht: I 1\1< J e:\,II1III1<1[lon ...OlllL' pHlll'llh .. hOWL'd \\ Ilk ~prc.h,ltlhnll.Jlhlll 1l4I[CllIl'-ll .. Poh plhhi.. 11l1liur UlIlI POle:llll... l.. 01 lIlnca'led alllpillude .lull ourallun .11\' \llkn 1..'1.'11 lilk·. HI lhL' I.:t)lll ..c- t>l ll1llllll

In primary musde dbe
A

B

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•

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.....'..'........;Iy~

ij

.~

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"IV 10 Ill::!

Figure 9.30 low

.UllplllLUJI.' ... horHJUI'itIIOIl1\lotor UlIlI pOII.'Il-

Jl1nllg 1111111111.. 1 \OIUrllal) L'Ulllr.u:lu)U tmm ,h~ bllt'p.. bl;t.·hil (A) ,llId lit'lI.III...lllll..·rior lRl III II 7-)t'ar·old bo\ \\!th l)udlCIHlt··., d) .. II "ph) A lugh l1umllt'r of lIbd13rg IOtt 111\llul UIlII., dunng 1\l1l1l1ll..J 1..001l<1111Ull retlel·l" 1.'$1\ rt'l.-·nll{• 1l\t:'llt. II flllll .... lmUf.l. J III I' hI' \\llh peml'.... IOIl.) • Ila1:-.

fCl'llr(kd

298

Phy.~icaJ

Rehabilitation

'rrP

In advanced sl:lges of muscular dystrophy. when con· tractile tissue is repbced by fibrous and other tissues. no electrical potential\; may be seen at all. On insertio~. t~e needle will meel some resistance as it enters the fibrotic ussue. Motor nerve conduction measurements will also be impossible under such conditions because no evoked polential can be elicited. Because most myopathies are progressive. clinicians will find EMG and molor NCV findings helpful in documenting the extent of deterioration over time. EM~ ~il1 help delineate lhe distribution of the involvement. asslstmg the therapist in focusing treatment and planning adaptations for functional activities.

3'aiffA .~~

2m.

Myotonia Myotonia is a disorder characterized by delayed relax· at ion of previously contracted muscle. It results in pathological muscle stiffness. Myotonia dystTophica e~hib~IS EMG changes typical of myopathy as well. MyotoniC dtsorders do not have a known etiology. although research suggests that a defect in the sarcolemmal membrane causes after.-depolarizalion following activation of the muscle membrane. sl As a pan of the generalized membrane abnormality. myotonia may resuh in mildly slowed motor NeV, and a marked reduction in motor unit activity and strength. 82 .IB The typical EMG response in myotonia, however. is the persistence of high·frequency repetitive discharges with alternately increasing and decreasing amplitude (see Fig. 9.198). This "waxing and waning" is a distinctive fea· ture, producing the classic "dive-bomber" sound. These Lr'dins of potenlials can discharge at frequencies up to 150 pulses per second. The myotonic discharge follows vol un· tary contraction or may be provoked by needle insertion or movement Myotonic SYnlpIOIl1~ can be abolished or less· ened pharmacologicaJly. The finding of myotonic potentials I~ not specifically dlagnOs.lic since these potenlials can be found In !o>ubjectllo Y. ho do nOI have myomnia.

Myasthenia Gravis Myallothenla gra\ i') .md nl)3Slhenic !o»ndrome are di50rdel' of neuromu~(:ular tranSlnI\i:')lon characterized by 'Weaknc ... 'i lollo~mg n:peuti\e conlral:Uons. and recovery followmg n: .. t or adnllm ..lratlon of an antlcholmeslerd,e M)asthenia gra\ I .. I" thought to be an JUlOlmmune disorder, ohen .c,!o>o I.·(;.lled \\ nh othl:r Immunological di... e~e . III II I') ch,lTlAltC'(· ued b) y.cakne')!'> and 1:\...:e'.>~I\-e fatigablllt) and frc:qut'nll) manll~ ltd by \l,ea"'-nc...s .lJ1d faugabllll) of the ocular mus· cit:., 01 p.tldt.tl illld phar) ngeal mus\:le~ M)a thelllt ...) ndrume often 1\ as!)(lcmtcd Vollh ..mall "nat' \:dl CJrt.:lIlO111a olthc: brunchll~. and I~ more pre\ialent m Illdk') V\rca"'-ne..... dnd latlgdbilu) Pllllldfll) affeu the IOVoel t)".n,::nUllc3. punlCularly Ihl: pel\ Ie glrJle ..uu..l tlllgh mu...dc

Figure 9.31 Decreme~tal evo~ed m~tor resJX)~ses before ~ after voluntary exercise m a patient With generahzed myaslherua gravis. The median nerve was stimulaled at the rale of three shocks per second for seven shocks in each train. The M wave was recorded from lhe thenar muscles. Comparing the amplilUde of the last resJX)nse with the ampljtude of the first, the decrement .. ) was 25 percent al rest (From Kimura. 1.1O.191·h P Wit penmsslon.

Myasthenic disorders demonstrate nonnal EMG charac· teristics al rest. although fibrillation potentials and positive sharp waves may be present in severely affected muscles. indicating loss of innervation. Motor unit potentiaJs will appear nonnal at first and Ihen progressively decrease in amplitude with continued efron. Repetitive stimulation during. a motor nerve conduction lest will cause progressive decreases in the amplitude of the M wave (Fig. 9.31). PharmacologicaJ intervention often will normalize the response. Specific protocols are available when using repetitive stimulation to evaluate the~e prOblems.

Radiculopathy erve root uwolvement. or mdi('ulopalhy, is not an uncom· mon conchtion at aU spinal le\ els.. E 1G can often assist In Identifying lhls condHion. detenninmg the eliology for radiatlllg pain. pel'l~tent Vo eakne.:>\. h} poretlexia. and fasdculanon~, Sensof\ symploms lJ,:c\lltlpan> mowr signs. and may i.lnge trom Inild p.lfesthe:-.la.... to complete luss of ~nsation. The tund3..:lle-mal fc."3turl.: III the dctennUlarion of mocor nerve ftlot Illvohl,;mem 1\ thl.:' ckhnea[ion of Ihe distnbution ot abnonnal fin..tmg') \\ ithin mu~de:-. receiving their penpltc:ra! mncnJt:OIl from I.h(> \.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
Kinesiological EMG In addition to being a litandard method for neuromuscular ex.amination. surface EMG can abo be u~ed as a kinesiological tool to examine muscle function during specific. purpo~flll tasb or therapeutic regimens. For this purpo~e. the therapl!:ll loo~,> .H pattem\ of mu~c1e response, onset. and cessation of activity. muscle fatigue. and the level of muscle rClipome In relatIOn (0 etlon. Iype of mu~c1e con. tf"dCtlOn. and posaion \Vith the growlIlg need for evidencebased practl(.':c. klllC'lologlc EMG pre~nt'\ an objectIVe meam for documeming the c:ffect of treatment on mu:-.c1e Imp,umlenh. lne ther
Surface and Fine-Wire Recording A\ deM:nbed •

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t·J,ee •an d fiIIlC-WII'e . IIld\\t':lIl1lg dectrotles

art ll~d III lmeslologlt.:all'lIUd). although ~urfa<.:e dectrooe...

299

are used more. Once a muscle is selected for study. its size and location must be considered in choosing and applying or inserting electrodes. Based on previous rnscussions of volume conduclion and the factors affecting the motor unit potential. the foUowing determinatjons must be made: (I) electrode size, (2) interelectrode distance, (3) location of electrode sites (including the ground), and (4) slein preparation (for some surface electrodes). There is currently no agreement on the preferred configuration and dimensions of a surface EMG electrode, although researchers have attempted to promote standardization. 25 .87 ..88 Smaller muscles obviously require the use of smaller electrodes. with a small interelectrcxle distance. if electrodes arc too far apart. even on larger muscles. activity from nearby muscles may be recorded. This cross·talk would confound interpretation of the output by making activity look greater than it actuaUy was. The ground electrode should be located reasonably close to the recording electrodes, preferably on the same side of the body. Slein should be prepared to reduce impedance. although newer amplifiers may have sufficient input impedance to make this unnecessary.

Locating Electrode Sites Criteria for location of electrode sites are not universally accepted. Fine-wire electrodes should be inserted into the muscle belly using guidelines similar to those used for clinical EMG. For surface electrodes, Basmajian and DeLuca4 and DeLuca 2j recommend placing the electrodes in the region halfway between the center of the innervation zone and the funhest tendon. Many investigators and clinicians have found it efficient to use palpation for locating surface electrode sites over the muscle belly. if the subject can voluntarily contract the muscle to facilitate this process. However. if repeated measurements are allempted. requiring reapplication of surface electrodes. this method may be unreliable. When electrodes are not oriellled 10 the muscle in the same way with repeated te~t­ 109, the output Will look difierem. even ""ith identical levels of contraction. Some lIlve~ligators have used electrical slimulalion of motor polllh to locale optimal electrode sites. Some have m~lrled the slin with indelible solutions to ~ able to relocal~ electrodes. Slill others have used body landmarks and mea~ured ~pecific distances to standardize application ..ltc.. (.Fig. 9..H). Ba~majian and Blumenslcini'l provide gUldelllles for placemcm of surface decLrodes for use with blofecdbJ.d.. that can be u...eful for kinesiological sludy as "ell. but do nOI adju... t locations for variation in body par.llnch:r~ and mu~c1c bulk.. Verification of surface electrode pldcemelll IS u~ually auempted using manual muscle testing I~rocedll:e~ 10 ~ee If (he EMG ~ignal responds when .tppropnalc rC~lstdl1C'e b applied. The lechnique is only pJl1IaIl) cfTe(·II\'c. hO\\cvcr. because muscle~ cannOI effeclI\el) ~ bohned.

300

PhYi!i"ical Rehabilil9tion

Signal Processing

Anterior lold of axilla

\~

JI/2 distance

A'q~

$' c,
B ..

,,

,

Cubital fossa

Technology h:,\ advanced sufficicndy lCxlay th~t microcom· pUlcr~ are now readily applied to. the proc~S!ltng of conditioned \ignak mcluding integrallo~ anc~ dlspl.ay. Personal ('omputers ('an be casily adaptcd to Interlace wtth EMGs or all types. The EMG signal can be stored, averaged. and sam· pled in a variety of ways to penml del~Jled and complete analysis. Digilal techniques are becommg more common than analog technique!:> but they require A-to-D conversion. All analog proce"ing scheme, can be replaced by a digital equivalent.

Quantification

Figure 9.32 E\ample of sland~dlZed electrode placemcn! for the biccp~ brachii. A line is dra~n frolllihe anterior a>.illary fold 10 Ihe center of the lubilal fo ....a. and a poilll marked at the center of this line. Eleclrodct:> are then placed I em above and

below this point along this line. The di~tance bct.... een electrodes must also be standardized so lhat repeated EMG analY~ls is valid. The be~l way to achieve this is 10 use electrodes lhat ha\e their bipolar detection surtaces fixed as a ~ingle unit. If interelectrode ~paration is altered from session to session, the :-.ame level of contraction may produce higher or lower amplitude readings. or different frequency content. DeLuca:!.'! recommended thaI the surface EMG electrode be standardized such that the delcclion surfaces are arranged as two paral~ lei "bars" 1 cm apart. I em long, and I 102 mm wide. 15 Glhers. panicularl) among the European community. ret'ommend similar arrangemenl~ where separation between the detection ~urf<Jces is 20 mm.1) When using surf<Jce electrode~, the therapist muM also com-ider problem.:; rt:!med 10 the displacement of skin overlying muscle dUling l1lQ\em~nl. The spatial relalionship berween the electrode~ and the muscle can change greatly as a muscle conl.facts through it~ range. This will. of cour~. affect the EMG "Ignal. The electrode ~ite ... should be detenlllOcd ..... nh this in mmd. Such problems :lre often seen \I, hen monitOnng the blcep~ brachJi. sternoclcidomao;;wid. or scapula l1lu~c1e~, for in:'l:.tnce. Electrodes should be applied to the ~kl1l with the limb or body part positioneJ a~ il IA 111 be during the procedure. When plactmcnI uiteria nrc ...pecified. re:-.earchcr:, ha\e 'lh(l\\ n laIr!) gOt)(j test-rete~t rellablht) for :-.urfacc elcctrod~ ..._ ..il although "lubmu\llllal contraction., h;l\c lIclllon:-.trLlted better reproJucibihl) than 1ll3\lmal comracllolhYI ReuppliGHlon ul Indwelling electrode.. 1\ k ....., rdiabh: than th.u of ~llrJace clc:<.Irodes bt'cau'Je 01 [he dilli(."uhy ill con~ Si'itclllly placmg:1 needle ..... ithlll IllLhcle ti-;Mte on reJl1,~r­ lion 'l.~. Reapplil'afJon 01 .,url;Kt: EMC ekctroot".. 011 dll~ krent Ja):.. or lc!:>t .,t:",~ion" I!:> . 11.,0 les"l lc:ilJble than \\ hen rellablilt) I!:> 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 a<.:cumulared aCli\'lt)' can be detemlined lor a :-.ertc\ ot COnlr;jl'!Iun~ or a !:>in1!le contraction. 1l1e :-.Iopt.' of thL' l·llf\C. or ramp. is a di;~('t function of the amount of e1t'\,,'lncdl ~ncrgy ~illg proce.!:>sed. Ahern..IIl\t:!). Iht' conllcnfooer I:<.tll be set to discharge at preJell.':nninl:d IOlenJ.l, b~bed on tim~ or \'ohage amplitude TUlle lntcf\ aJo; can LX' !:>et ~o that the capacilor resdS

<'hllpt('t" 9 FIe<"tromY'OfC'aphr .,Id Nene Conduction Velocity Tnh

301

A,.EMG 810AMP ~-'--'---

T

t_...LA3-_....Lt/\,~....Lb\--'--~6----'--"J:::., V

...1'

T

1mV-sec Integrate

Figure 9.33

01 Ihe

cr.\lmclhod.. of ~lgnal procc ...... lOg. The raw E\tG V.a~ full+\\d\c reC"lltli:d r.J"

EMG itmJ

IllU'ilrJUOIl "'1,'\

and et;pre....~ed 3" a hnear en\ e· lope and lOu:grdled d3la. (From Wmter. DA Olol1lcchanle'J: of Human Mo\emerll. John Wl1cy & Son~. New York. 1979. p 140.

"lth

peml'''~lOn)

.r

i.

.-/

"

over conh

T

Integlate 50msec

5O"V-sec

i..

then reset.

Integrate to preset voltage then fesel

zero on J regular basis. \\ Jlhin periods as small as 200 m~ or a~ long as 10 seconds. The height of each peak. or ramp. Ihen repre...ents the accumulated activity over that time interval. Integration can also be based on a preset \'ohage le\ el. When the condenser reaches this voltage. it rese{.\, 10 zero. \... ithout regard to time. If the EMG signal is \ery "eak. the condenser rna} contInue to collect electrical energ: for indefmite periods until ils discharge thre:.hold IS finall) rcached. The frequency with which the con· denser re~e'" is an indicalion of the level of EMG activity. Each ramp can also be depicted as a pulse. and the frequency of pulsel> can be counted to determine Ihe level of activit) ~~e Fig. ~.33,.

10

A,erage EMG Closel) related to the IEMG is the average EMG. which is the lime integral of the full-wave-rectified signal divided by the imegr.ttion ~no(L Thi~ parameter provides. a single number \\ilh v.hich to repon the genemllevel of activity of an) gi\cn mu~de O\er a predetennined time. such a:. a penod of ffiO\emenl. For example. KeJljl>'iS studied the effect of fatigue on agonil,l and antagonis.t EMG paltems al the knee dunng ~() of dynamic knee extension. He averaged the EMU \\Iilllln arcs. of 10 to 3SO. 36to 55°. and 5610 ~O':. 10 c:haraclenlr differences in EMG at shonened, middle. dOd lengthened range~. C)Lle-IO-<:Ylle J.\'c:ra~e." of EMG profilcl>. !o,uch as during lAaU..,mg, runnmg. or l:}dlllg. can be obwlIlcd through en-.emble averaging TIle full-\~dve-rel,:lified and linear envelope EMG ~lgnals ale uH:raged fur ~ach cydc. where each

Each oulse

= 38 ",V· sec

cycle is nonnalized to 100 percent. To illustrale lhis. Macintyre and Robin.son 96 sludied patterns of the quadriceps muscles in female runners diagnosed with patellofemoral pain syndrome. Linear envelope EMG signals from vastus mediaJis, vaSius lateralis, and rectus femoris were recorded as each subject ran on a treadmill at 80 JXICent of their normal running pace. Each stride period was nonnalized 10 100 percent. Ihen the linear envelopes for 10 trials were ensemble averaged to achieve a mean ensemble for each muscle from each subjecl.

Root-Mean-Square The rool-mean-square (RMS). an electronic average. represents the square root of the average of Ihe squares of Ihe current or voltage over the whole cycle. The RMS provides a nearly instanlaneous OUlput of the power of Ihe EMG signal. 29 This EMG paramet.er is considered by some researchers to be the preferred eSlimale of muscle lension. 2

Frequency Parameters A method of signal processing common.ly used 10 interpret changes in the EMG ~ignal resulting from faligue or abnor· lllaJilics in the neuromuscular system is (0 analy.lc Ihefref/Ul'f1()' spectrwlJ of the: signal by Fourier analysis. Because any continuous sign.1I can be represemed as a summation of ~ine and cosine v.avefonns of different frequencies. an interference paltem can be decomposed inlo its different frequency componeJlI~. With locaJized fatigue (i.e.. fatigue from within the muscle, rather than centraJ).lhere is a reduc. tion III the high-frequency componel1l.s of the spectrum, and

302

Physical Rehabilitalion '. have been successful in measuring sprc· wuvelct ana Iy"ls . d 'h I aJ' . of the signal assocl
Muscle

Tuning of Muscle Activity A number of different compute:-b~sedanal~sis procedu~ . . . and amph. have been desc ribed for quantlfymg lalenCles

""noUE

Muscle Fatigue Index

f_~

.......

.'-

CONTRo\CTlQN mE

Figure 9.34 Diagrammatic explanation of the change to the EMG :.ignaJ and its frequency spectrum Ihm occuril a" a res,ult of localized fatigue, The upper panel represent:- the EMG sIgnal sampled at the beginning. middle. and end of a sustained contraction. Each sample "window" of data is analyzed to calculate rhe frequency spectrum. as illustrated by the POWER ver:-u<; FREQUENCY plot in the cemer panel. The median frequem:y. or midpoint of the spectrum. is indicated ail a vertical line and SUII' in each of the three figures, These three median frequency data poinlS are plolted as a function of contraction lime lrl rhe lower panel. llle Muscle Fatigue Inde;.. 1~ rt:presenl~d b) the decay in EMG median frequency. (From DeLuc~1. CJ.I:,r II' with pemlission,)

the low-frequenc: component~ (fig. 9.3-H. This frequency shift mol) be monitored by tracking a . . I.lli,>tical parameter. such ~ the median frequenc). The median frequency IS defined as the frequenc) that di\'ide~ Ihe fre· quency ~peClrum into 1\1.0 parts. of equal area . .I., tl1u~tralcd In Figure 9.3-l. The I1Jllsde fatil!,lle If1de\ l~ represented h) the deca) 111 the median or mean freyuen<:y dUring a ~us­ loslned <.:olllraction. Caution mU~1 Ix ohseTwd In calculatlllg thl~ mde;.. for acli\'iue~ that are nonl~om('tric or nOI1I,>otul1ll Thlil 1-. because da"''>ILallel.hnique~ for compullng ml'dl~lII and mean frequent). such as FOUrier J,nalysl'. rt:4111rt: Ihal the ,>Ignal I') II1JthelllilllCaU) .\lilliOllan Changes 111 mu ...de length mu"d~ fon.:e. dnd electrode IXNllon dunng 110111"0· 111t:'lrK or nonl~OIOl1il l:OlllraL'IIOI1\ L'all produl'e .1 nun'>talIonary"lgnJI lllereture. U) !lalllh.. contra<.:tIOO,> Me nOli) p. Ilall) alllen ..ble 10 localized e>..amlllJlioll 01 1.lIlgue on the hJ'>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 1<" nel:essary (0 valIdate the~ lOmpans(lO\. Thl::- j<., usually done by firsI r~('or(hng. the EMG of a mu ...c1e durine. a maximal volUIIlar~ '\ometflc COl1traCllun (\1\ Ie). some lmo~n subma\imalle\'el of contr'll"llon.•U1U then expressing aU 0Ibcr EMG \ aJuc" as a pen..ent'H!.~ of thl~ contraction. This (()IfImf \'llltlt' '>ent'"... a'> a "ldndard ..l0amst which aLi c~ i"on., lan be tnade. e\en It tl~'>t \ . .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 \cr<:us FREQUENCY plot in the ccnter panel. The median frequency. or midpoint of the ::.pectrum. is indicated as a yerticalllne and star in each of the three figures, The~e three median frequency data point!l are ploued as a fum:tion of contracllon tIme III fhe lo~er panel. llle Muscle Fatigue Index i... repre~enled by fhe dc,ay in EMG medIan frc4uenC). (From DeLUI.::a. CJ.I~.r 11< \\lIh

permission.)

an incre~ 10 the 10\\ ~fre4uenC) components (Fig. 4J.-lJ. This frequenC) shift rna) ~ momtored by lrad.lOe. a stall ...• tical parameter. ~ul:h a" the medl3Il frequency. Th~ m~dl;,tn frequ~nC) l~ defin~d a.:, the frequenc) thaI divide:,> the fre4uency ~pectrum miD t"o parts of e4UJ] area. as 1IIu')lrall!J 10 Figure loJ.:W The mll'idl' fil1igm' mdt!\ I' repre ..enteJ h) the de<"3) 10 the median or mean fr~qu~ncy dunng a ..u..tained COnlr3ClIOn Caution must be observed In Ci.11~ul.UlI\g th"" IIldex lor acll"Hle~ that are nOOl~meln<. or nOlll!'.otOl\ll Thl~ I.. be<.:au-..e c1a......Kaltechniquc.c... for compullng llll'lhan and m~dn frequ~nq .,U( h :1\ founer dnal) ~i"). requlfI.~ Ihal lilt" 'lgnJI I... lll.uhemJllCall} ,\llIIlOndn Chang~... 111 mu\(:le kngth, lllu'-l:lc.c fUfl.":. and ekdroJe po:o.ltlon dunn!.! nOI1l"onlclrh. or n0l11s010nIC c.:ontr..teliol\') <':.In pl\)(jUf.:~ ; nun,{.l lIonar~ ~lgnal 1 hcrdore. dynalllICl.:Ol1lrJUlun... aft' 11\)( t\ P I\"'all) amenable tu kx.allao c\.dJ11lOJtlOn of Ltllguc Oil the bd\l~ ul lllcdJj,11I or mean fr~4UenL') pafjJJnt't~r .... R~~~ntl) dc\odoped tethlll4ue., u~mg tlme-he4U~IlL) i.Ulal)"'I~ and

A number of different computer-based analysis procedUl'tS have been described for quantifying latencies and amplitude of EMG signals during purposeful activities. The tim· ing of a muscle's response is often of interest lO detennine th~ latency of responses between different muscles. or reI· ative to some other parameter (e.g.. the command to tnO'VC) or specific task components. Measurement of EMG onset to detennine muscle activation time requires knowledge of the 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 ignal activation for a slowly increasing isometric contrae· tion.~~ The top trace represents the raw EMG signal and the 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 ± :1 standard deviations of the meiln value, thus capturing approximately 95 percent of the amplilUde of the noise signal. The raw signal is not suf· licient to mark a clear differentiation between noise and EMG, Using the RMS value. however. lhe specific time at which the EMG signal exceed~ this noise level for a mini· mally defined amount of time (c.g.. at least 20 msec) cao be detcnnined. ThiS can be considered the "on" time of tht muscle, indicated as 10 in Figure 9.35. 2'\This differeoliatioo i... essential (Q an accurJte appr:.lI~al of EMG activity.

Nonnalization For m:tn)" studie!ol. the yuanutil' I [!\to signal is used to l'ompare attivil) bet\\cen '(.'..!'.lOn.... mu,c1~o;;. or subJCCU~el·a.use of the \ anJbllit~ Inherent III the E~1G ~ignal. lAd 1Illenndlviouai dilTerence" In ,matom) and mo\l:(IlICtlL ho\\ever. It I ' . !'. no rea~onable tot \.'\.)mpare the EMG 3L"'UV" of one. IllU c1e 10 anothl.:T. \.)r from OI1~ person to anocfMI. Therefore •. omI;:~ ,.omI 0 t' nomlJhzaHOn t~ ne(.'C~~ 10 .-' .... Ill.lIt' Ihc')(' COllI pan')on.... 1hI ... I' u... uaHy done by .... QIrecordlll"~ the HIG t mlhl'J~ ~iunl1l..!. J m,L\imal -~ .... .i loa ~ Iill) bOmelrl(" l:ontraulun (M\ 1('). ome lnown ~1~1\G~Hal le\ el of l·ontral'tlon. anJ (hen e\prt.·... ~lI1g. all (J/t6 \.llue~ J ... a Ilr'r' I h· . .",,;..,'l"- cell Jgl~ 01 I l"i t:onlr.:u:UOO. " - , I/o I lit/lit '>er\ ~ c'" J ....t ... t<Jlltl.lfll Joallht ,\
0; . .

303

Ch.apter 9 Ele
Figure 9.35 E,amplc of b:ld.g;ound 1l0l..e before mitiation of EMG 'ilgnal 3Ctl\atJOfl (( ) from the eredor "'pinae ' 1\0-muscle.. dunng .. 10\1> I) . Increasmg mclnC e\lenSlon of the trunk.. 1be r,t\l> EMG <;;ignal Ilt pre:.cnted In the upper truce. The shaded area in the lower trace rerrc<;;tllh 2 ~landard dev13tioll'i from the l1\Crage RMS before initIation at Tfl' Mu~le lnltiation b identlfied a~ the time \\hen the RMS "lgOal e\ceed~ a threshold of:! standard deviations of the background "ignal. (Adapted from DeLuca.

"

(J,!:! p il~

10 B

pnori

8 6

wnh penlllssion.)

elimin':l.1e some of the problems related to reapplication of electrode!. as well. Other method:-- of normalization have included using a :,eries of submaximal contractions. 9lS contractions during defmed reference tasks. 99 or one of the tasks being tested. 1oo AJthough no standard method has been developed for this normalization, most investigators use MMT positions. resisting iwmeuic contractions either manually or against some fixed re~istance. In a comparison of various normalization methoc:b. Knutson et al W! found that an MVIC pro\Ided the greate~t reproducibility. When using d) narnie movements, this issue becomes cloudier. Becau~ the changing muscle length through a movemem alter,> 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 <..ludlcd 'lOce 1952.ull.ll~ It is generaJl) accepted that a dlft:t:t relationship eAi~h between the EMG Mgnal and mUSLularetloTt. but thi!!. reJallol1~hip mUM be diScussed In leroh of mu~dc length and lype of contraction,

I

..!f...:.f-L-!~---

20

Time(s)

Isometric Contractions Several early studies have demonstrated that when muscles contract whiJe maintaining a constant length. EMG signal amplitude varies directly with muscle tension. Many investie-mors have documented a linear relationship between m....u scle tension and LEMG.I04-llXl Others have reported curvilinear relationships.I06-I08 The linear slope or the degree of nonlinearity seems to vary with the muscle tested, the joint position or muscle length, the electrode placements, and the method of measurement of force.l()6·I07.I09 DeLuca 2S adds that when the detection volume of the electrode is much smaller than the cross-sectional area of the active muscle (e.g., in large muscles), newly recruited motor units located close to the muscle will contribute proportion ally greater increases to the EMG signal than to the muscle force. ll1is effect will therefore result in a curvilinear relationship between EMG amplitude and force. Conversely. when the detection area of the electrode is closer to the active cross-sectional area of the muscle, an approximate one-to-one relationship between the EMG amplitude and force will result. thereby producing a linear relationship. Although methods vary among studies. they all suppan the general conclusion that an increase in EMG output is observed wilh increasing muscle tension. as long as the muscle length does not change (i.e" during an isometdc comraction). When muscle lenglh b varied. however, this relationship bel\\een EMG amplitude and tension does not hold. Generally. less EMG amplitude i~ 5teen with greater tension as a muscle i~ lengthened and. conversel}. greater EMG amplitude is seen wilh decreased tcn::.ion as a mu~­ cle is &honened (Fig. 9.36).~8 TheoreticaJly. therefore, we can assume that tewer mOWr unU~ are needed to produce the same level of tension in the lengthened position. If it IS Impossible for the Investigator to constmin the test contractions to isometric conditions, EMG signal processing M

304

Physical Rehabilitation

Short

Anterior tibial muscle

Intermediate

Long Integrated EMG

Direct EMG

A Direct EMG

Integrated

EMG 0.1 sec I(

B

JI

Short

IntermedIate

Long

Figure 9.36 (A) f\1a;\lnlal \ oluma!) t ...omelnc mntraction of the anterior llblalis of ~l noon:lI subject with the Oluscle at differellt lenglh~. Note the me in EMG 3CII\ it) as the n.lU...c1e IS pro~res· ~I\el) shortened The uuegrated EMG l'" really a linear em dope. (8 I EMG a(tI\ It)' of the triceps brachii of a cinepl~tlC amputJlIon. Illustrating the ...ame dfclo:t. (From Inman. \1. et al. lN p IQ}

"1m penm~sion.)

for e'limallon of mUM'le force ~hould be limited to ponion"!

of the actl\ II) Ihat are near I,ometnc Furthennore, If the amSOmelnl actl\ It) is. c)c1icaJ. sUl:h a' durmg g;1I1 01 cychng. tht'll a ft>.ed epcx:h in the period of lhe contracrion should be choscn lor anal)Sb. and ..til cQmpari...vn~ \hould be made for till' epoch..,

Isotonic Contraclions The

relaflon~hip bel\",~en

E\1G \lgn.lb and fon.'e i" funher hh.. h ar~ defined t.:omral.:tWJl!'l proJtlnng ~\eragt: (,:,1n..,lanl lor(l: ".r

Lonfounued dunng a~

I~OIOOlI..' I..lln1r.llIIOn"l. \\

\Vhen mu\de knglh l..(lnlmu~ll~ dunge") ltunn~ nlll\e-menl, ... ev~r,ll ral·lor.., lllu~t lw I..'i.lll'ldered 1 h~ lon.:t:-len~!lh rduaon-.hlp (11 the rnu..,de \ anc ... l)UOUdh')Ul ttl\,; .. ,ll1lrallh.m. Ihert:h) (on'l.Jml~ .thcring th\.' OIl'I"1I unit aLlI\Jf) In proporllon tu kn,,,m Th( d),I"l of I\U.lll(\11 I.I'lht:'

h.m.lut

IOHll \.hangl'''' a\ the IlInh I1Hl\c.') Ihruu~h II-. I.lllg~ ...\.l .1'" tll

lllUll1('111 JJlll .md IC'Ul!lll1! IOfll;' ':omp..ln.. · nh. 1h mO\clllcnt llt Ilw.., 111 met lhe Illlh...Je;- ,md Ihe \;U1.1 tlll In ...hdpc: 01 lhl' l1lu"'I.'k J II l'on(I.11.. I-. \\ III .it II J.tkd lhe "II
lh.illgt: till'

dlfferen( mu~cle 1t.'llglh~. It IS difficult. dxrefort"'. to \ JIIJI) quantJf~ mu.. ...:te aeli\ it) \\hen mo\emenl is t'ICl'urnng.

rel'urckd

al

TIle EMG-fon.:c.." relalioll,hip has also been examined in l~nn ... of el:centnl..· and nmcel\lric l'ontr:tction~, Eccentric, CK' lengthenmg. conrTactlolJl" Utllllt: ela..,IK elements and mettbohr pnl\.·~~...e:'\ more dfl(l,'ml) than concemnc contraCtion,. nlcrdore. for Ih...: ....une amount of musck tensKJn.lH'l e':':l'ntril' l·OlHr.ll1lull \\ III requIre fev. er mOlar units (i.e.,

It.'" 0\\.'1.111 E:'\IG a,,:t1\ ll~ Ilh.m.\ ~on('emric contraetion. 11k' rouco t mu~k ..,honl'nm~ I'" J.Holher COI~ Dunn~ 1..'1;,,:cllUl\.' l,:onlr.k.'t1on:> the k\e1 of EMG artI'tll)' n..'l1liiUt...

l'lln..,l.lI1t rOt

J gl\en k~ld. lnd~pem.knt of

the vckJcil)

(.\1 Ilk: 1..·"mnl.:!lon I I r tllll\."l!rri... E\lG .k.'U\ il), on lhr other h.lnJ I k're.uU I\\r.t l=-1\~1. t 'IW .l:lo \t'loclI) I' mcreased. aod p Ib..tbl~ rent: to..l rk."t..-d ft"")l'" ~J.ler r\,."nnunenl to ~ ...I..ll\' illr .1 IJ:-.l,'c l.Onrr';h:H~lO (une I-h,1\\cver, only "hen I . ' 110: · \'~ Il"-Il\ b "'~rll.llQ'UJlt h the I:.MG pmportional to tet:lSlOlL lh.'refllf(, \\ lth

"l)(('If1I\,.

mO\':Itl\:n1 .u

uncontrolled ~lOaI)'.

IhI.: F ttl ~1g.n.11 11I1ll.ll be .J dUC\.-1 n:-tln:-uun of muscle"'" 'hliL flu... h
Ph)"s'ical Rehabilitalion

AnterIor

tibial muscle

Short

Intermediate long Integrated EMG

Direct EMG A

Direcl EMG

Inlegrated EMG

0.1 sec '(

~

TensIon

B

Short

Intermediate

long

Figure 9.36 (A) Maximal voluntary i<;ometnc cO~lra~lJon of the ,ar~tcrior tIbialis of ~ Ilomlal o;:ubject 'Aith the muscle at Jiffcrel1llcngth~ Ole the ,n<;,e m El\IG actl\ll~:l1, Ih~ n,lu,cie h pro~r:~­ sively o;:horlcned. The Illlq'!ratcd EMG 1\ really a linear em'elope, (8) E~1G a('llvII: of the (m;t:p., brachii of a cinepla~tic amputation. ilJu.,tr3ung the ~ame effect (From Inman. VT. et al.'N, p IQI "Ith penni<;.,lOn.)

for estimation of muo;;cle force .,;;hould be liJ1lltt:d 10 portion" of Ihe aClivny that are near i"omelflc Furthennole, if lhe anisometric acti\en for anJI)~I", and all tompari'\om 'lhould be made for Ihl<; epoch. ~~

Isotonic Contractions The relationship bel\.\-een E\1G 'lgllJb amJ forL~ 1\ further confounded dunng ,:-.olOnic ..:'Ontr,lCUon" \\ hit h ..In.> defint:'d a\ cOlHrJclions pmr..!ul.lIlg a\ rrage COlblanl fl)rce Of IOn·lu~ !'l When mu\,,:le length LOlllll1U,III) change~ dunng mmemenr. ~e\eral fa<.:tor~ lfiu')! be C(,lhldLfed fhl" IOIl.:c length relaliofl\hlp 01 lhe IllU\ch: \~tr1t:' ... Ihfoughout the l:Omraclion. th~rcb) LOI1\I,ln'l\ ahenng the motul Ullll ~l.Il'dt) III proporllon 1\) h:lhlOll Thl.: ;1\1\ of ful,illOn ollhe jOlllt l'!lange., J.,,> Iht" 1t11lb 1ll00'l·.. through Jh f,Ulg~, "0 ..1'> 10 l".h..lll;!t" Ihe 11l0111l;fll .inn \.\111,,1.,11 alkll thL' :-.pJtlulldaIIOn.,hlp bel'Al'\:1l tht" elcllfntlL'\ ,Illd mU~lk> ritx-r, anti \.hJl1ge the JIllOUnt nl dt:l'lfll'..ll
rCl'orded at different lllu~c1e lengths. It is difficult, therefore, to validly quantify musde activily \\ hen movement is ex'currine-.

The EMG-force rel~lfion.. hip hJ, :tho been examined in tenll,,> of eccelllnl' and concentric l·c1ntr-.tclions. Ecc~Olric, or lengthening, COntf.:t~lions utlliu l'Ii.l'>tlC elemenu. and metabohc proc~~se., mort: t'tllci~nrl) IhJ.n <.'onr..'entnc contrae. liom. Therd"nre. fur Ihe "ame ,HiltJunl of muscle tension. an Cl.:Centnl' co/ural'non wtll r~ljum.~ fC\\t:r motor units (Le., Ie,,, o\'~rall EMG .1(:11\<11) 1 liMn " con~cntric COnlraCUOfl, nl.... r.UI.' of Illu:.de \hoJ1el11ng i\ ,molher considerduoo. Dlmng l'L('eJUm' ('~lmr.\Ulon:., the level of EMG aetivil) r~OIa/ll~ LUlht~UH lor
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 pre<;ence of constant EMG amplitude suggests that the maximal number of motor units is still contracting. Eventually. ho",evt'r. as [he contraction continues. lhe contractile elements \\ ithin the muscle wiU fail and EMG activity will o;;imultaneousl) stan to decrease. EMG indications of fatigue can occur very quickly. within Ihe tirst several seconds of both submaximal and ma.ximal contractions. Re~archers have ob~rved both linearl05.107 and nonlinear lOll .1l1 EMG-force relalionshlps during fatiguing con· tractions. Tht' slope of this relationship varies with the degree of fatigue. Studies have al,o demonstrated a rela· 1J0n~hip between predominance of fiber type within a mU3Cle and lIS EMG fatigue characteristics. lClb Muscles composed of pnmarily type I (slow-twItch) fibers fatigue at a slower rdte and demonstrate only small incre:lses in EMG ~ignal amplitude.

Frequene, \nah sis EMG e\'idenct: 01 localized mu..c1e fatigue ma) also be quantified b) frequenq analysis of the EMG ~ignal during con~tant-fon:e I~ometric contractions. It has been proposed that spectral mdlce, of fallgue are a more din:~ct represcnt4110n of localized fatigue than amplilude parameter'\. ~.II~ The ~Jkl·trt:mxh ot Illlle. Rt:~caRhen. hi.I'vc been ..tbk 10 dm'\II11Cnt 1ll1l~(:le I.ltlClll' dunng "peL:lllL: ta.. !.. ... U~JlIg thl>" lC'chlll~UC.11 \ 111 Bv Jl)e~a~ unnot- Irc4ll t:'n L\ - ~ 1-' 11 h 111 Ihe ch:uncal (lOtt'l1IlJ.b• of all lI11pJlred rllU\C Ie (Ullllg I lrl:a[l1lcnl J ther
305

being generated. rather than the involved muscle. If a decrease in rhe frequency is seen at first. and the frequency then abruptly levels off without a decrease in output force, the involved muscle may have stopped participating, and other muscles may have taken over to generate the force. Such a technique could be helpful in discriminating which muscles are truly contributing the force output that is measured over a joint. Of course. appropriate instrumentation for recording and analysis must be available. These types of data will not be analyzed with conventional EMG units or biofeedback devices. More and more commercially available EMG systems. however. include spectral analysis as a component of their analysis software.

The EMG Signal and Muscle Strength The above factors are of great significance for interpreting EMG amplitude during activities that require muscles to operate at different lengths or speeds, or that utilize different types of contractions. Those who use EMG signals to study muscle function during activities are· often tempted to make statements regarding the muscle's ··strength." Although this tenn is used clinically. it must be used with caution. Strength is a construct that must be defined as torque or force produced under a specific sct of conditions. Clinicians must be very careful. therefore, about concluding that a muscle is "working harder" or that a muscle is ·'stronger·' just because the EMG activity is greater. \Vithin a single session. when electrode positions remain constant. the position of the limb. the type of contraction. and the speed of movement will affect the level of EMG activity recordell. The significance of these faclors becomes apparent \\ hen comparisons are made between isometric exercises performed at different joint angles. The recorded EMG activity from a single muscle po~itioned at different points in the range may have varied amplitudes. but may in fact repre"ent COlllraCtiOns of simibr tension levels Therefore the EMG signal. which is a recording of molO~ unit activ~ it}. rnu~t be distinglli~hed from muscle tension, which is a lunction of contractile proce'ses. Therapist.. often use the tl'rm "optimal" to de~cribe a biomechanical advalllageous pm.lIlOl1 for a mU="I.:le; ho\\ever, Ef\lG signals could be lo\\er al thi:!!! Opllllli.tl po..ition because fe\\-er motor units 3n: required to Cfe-,lIt: a gi\cn Je\el of torce. Greater E~;lG actl\ll~ 1113) actllured across a joint l1~ay reprl.'Senl 11ll,.' rc~ull.1Jl1 interaction ot agonbt'i. ,1I1tagoIII ... t .... and ~ylll..·rgi ...ls. Adjacent ll1u...cl~~ make differential ~untributlolh 10 the ~lrengfh, ~t;jbllit), and coordination of i.ll·ontr.l..:t1on. The E~tG ~ignah from the agoni')ts m~} no( IICle-."')dlll) be a \alld repreo;;elll.ltion of aCII\'H} around a JUlJlI I herefort. E~IG d,na ..:3nnot be expected to provide dlrC'llllltomlJ.lIun JbOlil an II1di\ IJuall1lu~c1e\ ··~trenglh."

.lO6

Physical Rehabilitation

Muscle Tone Therapisb ll1u..,t aiM) reM..,f the templatlon to ll1.1kt" infl'rencc, about musdc lOne ba..;cd 011 EMG activity. NOllnal lTlu:-cle "tonu~" refers to resling Icn:-.ion within a lllu",c1c due fo the da:-.tic and vilK'oela."lic propcrtic~ (If nllh(:le fihc..... Tone al ...o reflects Ihe level of ~amm:l input to the mu~le :-pindle. or readllle$~ of a mu....c1c 10 C()l1tr.1CI. SsentlallO:l definition of tone j, the f3ct thai even though a relaxed muscle ..,ho\\'~ no clectri~al activity on EMCI, it "Iillmaintain... a pa~sivc state of lone. Therefore. lonc i.. not a function of motor unit :Ictivity. and <:annollx' Ineasured by the EMG . . ignal. Thi" mean!) thal when the tenn "paslicity is used 10 indicate a stale of h} perIonia. it
Movement Patlerrn Kinesiological EMG helps u:") illierpret the role of mu~clc'~ in variou'\ movement';. spcl:ifically related to ;.lInplitudt'. liming, and change!". in lh~ power spectrum. When lIsed in combination with biol11cchanical measures (e.g .. force or torque IIlstrumcmmion. thr~c-dill1en:-.ional motion analysi~ ~ystems, foot Sl,\ itches. electrogoniomclcrs. video). Ihe~ Mudies proVide a rich under"ltanding of muscle function. With an apprecimion for the concepls of recording and of the limit3lions of il1lerprelalion previou:-.ly di~cu~ ...cd, the Iherapisl wilt find EMG a valuable clinical 1001 10 help val· idate imervention. It is impos~ible to provide a comprehem,ive review of these applicarions: ho\\ever, II is useful to con... ider ...ome examples to illustrate the utility and limil:ltion.. of EMG melhodology.

EMG and Exercise Motor Learning EMG has been u~d 10 document change\ in motor unit recruitmenl paltem" With skill acqui... ition and cOOrdlllJllon. Smdie1'. in molor learning have looked at EMG aClivily over time to detcll1line how l1lu...ck a('t,vity ch.lI1ge~ as s"ill IInprovc!). Re-..ean:hcf"l have ,hown dlangC\ in pre movement eleclncal mu'>Cle!). and other 11l}0temporal vilrJi.ltiun-.; \\ Jlh mOlor teaming, I~I 121 BernardI el .t1 1V. exammcd thl' mcdian lrcl.!ucncy po\\ cr ~pel'­ lrum r~(ordcd from hH.:er>~ and Iriccp'i as sllhj~CI'" Icamed fo c:onln)llcvel" of force during elhc.lw Oexlon Tiley found that Je-r)C;'lhxJ funuional u':>\: ollhe Illu,de I('... ulted In ... lower. prolonged nxnlltnlt'llt tlf mutor un!l\ III the agoOl"ll l11u~I{'. i.llll)\'. mg J. mort' rlt:.t.:I~ and iKl:ur.Ue l.:ontrol 01 lOll"" IOCR-. menb.lnc the Ium:llonal d"tnuIIJ... IIHIXJ...ed on Ihe mu ...de. J1 \

Principles of Exercise

... pr,'ncip,", . ' arc ba:>cd . .on anatomical and . billMany c,tring muscles during an unloaded ..::qual in healthy individu~lls. measuring EMG signals during 300 arcs through the range. They found min· im:ll hamstring acrivity (4 10 12 percent MVIC) as compared 10 quadriceps activity (22 to 68 percent MVlC). They :-.uggeslcd Ihat Ihe low hamstring activity reflected low demand placed on the hamslrings to counteract anterior ~hear forces acting on the proximal tibia. So is this cocontraction? How much activity must be present in a group of muscles around a joint for "co-contraction" to be pres· ent? Must all the l11u~clc~ be equally aClive? Other imporW.nt considerations for thi ... question include the difficuJry in inlerpreting EMG when Ihe force of the antagonist is not measurable. velocity of movement is variable. position changes. and cross-talk may be evident. 127 Consideration of concept~ of muscle function must include a di\cu~fiion about the roles of agonist and antagonist. Is a 1l1u~c1e an anlagonist by virtue of being anached on Ihe opposite side of tI joint. or is it defined by its action? Can a muscle normally considered <.Ill antagonist be a syn~ ergi ...l? The~e qucstion~ cau~e us to consider aspects of motor cOlllrolthat are nOI clearly understood. For instance. in a :-.rud} of lncep~ brachii act ivai ion during elbow flex· 1011 and extension, Garland el all1~ showed 'hat rhe same motor units were activated wht:ther the muscle was funclioning as an agonis,t or ~.lIHdgoni,,1. controlling both accel· eration and deceleration of th~ movement. ... The c1o.. ed-chain e\('rl'ise i, another concept thai has been. u--ed to reinforce the appllc.ltion of increased weigbl beating and fatllitation 01 to-•.:ontraclion around a joint. In IQ')1• • LUllel ·,I'Nd· . . ch' • l:Jllon"rf
•

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Chapter 9 Electromyography and Nerve Conduction Velocity Tests

was greatest in the closed-chain activity when the knee was near. .full flexion, and in the open-ch(lin activity when the knee was near full extension. TIle open-chai n movement produced more rectus femoris activity, whereas the closed chain produced more va~ti muscle actjvity. The authors sugg.est Ihal an understanding of these results can help in choosing appropriate exercises for rehabilitation and trai ning. 1n a study of patients with patelJofemoral dysfunction. improvements in peak torq ue were observed in patients who had perfonned either open- or closed-chain exercises, but only the closed-chrun group showed sign ificant improvement in functional slatus.I~1 An important contrast to these findin!!s was demonstrated in a study of upper extremity tasks. where nO djfference in EMG signals was found between open- and closed-chain activiries, suggesting thaI. load was more of all i~s u e III dClemlining muscle activity than the boundary of the task Y! This type of conflict illustrates the need to consider ~pe cifi c measurement methods and activitic", before generalizations are drawn. Pro \imal stabilit y is a l ~o 3n iss ue that lends itself readil ) to EMG investigation. For instance, researchers have examined synergistic ~ hould er ac ti vity elicited during maximal hand grip. Sporrong et alP' examined fo ur shoulder muscle.!.-I he ~ upraspinatu s . infraspinalUs. the middle p0l1ion of the deltoid. and the descend ing part of the Lrapeziu!o.-\\ iih EMG in adducted and flexed arm positions in healthy subjects. They demonstrated that shoulder acti\it) v.a . . greatest with the ann elevat ed during grip, suggc')ting Ihal the stabi lizlng fun ction of th e shoulder was 3n importam co n~i deratiOtl during manllal tasks. In another examp le. Krebs et al 11J examined EMG activity during gait with and without a calle in an 85-year-Old man with a lefLinstrumented femoral head prosthesis. They found highest acetabular contact pre ~s ure<; at the po~ tero ~ uperior acetahulum.just pnor to peak EMG amplilUde, during late stance phase. Their data identi fi ed a ~mall area of high acetabular and femor",1 he(ld 'ilresS du nng gait. and ~ tlggcst ed that mu~c1e aC II\'lTy. rather (h.m ~o l cly body weight. drives hip loading. Therefore. therupe uti c goa ls 10 limit hip loads ~hould include reduction 10 both hip Illu,>cle co ntraction and \l.eightbt!
Neuromuscular Dysfunction EMG ha..., ahll bct!n a u...t::1'ul adjunc t for investigatin g d~ ­ m~nh of 1i10111r c:untrol 111 patient ,> 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
Summary EMG provides a powerful tool for documenring the role ?f m~scle in physical ani\ ity_ and for detemlining the IIltegnty of the neuromuscular system. Despite its common use In movement research, ho\\c\cr. Iherapi~b mU~1 u~ EMG mea~uremenlS wisely. recogmzing it~ limitalions

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Review

1. What are lhe ba~lc component . . of i.l recordmg ")Mem

ror EMG and NCV t"'b? 2. Whal .1fC the !'13£~S III a chOlcal EMG ex.uTIln:uion'> 3. Oe"tflbe hOIA motor and 'lCn")ory nene: l'onduUlolI . vcloutles arc calLulated, 4, Whal dre the I) pica I E~IG and NC\ lim.ling., \\ IIh penpheral n~r\'e lc~iun\, l1l~opJ.th>. Jnd mOlvr nel/lUn Jt'lCil~e"

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as a measurement 1001. Interpretation of the EMG signal must account for the effect of velocity and acceleration, type of musch: contraction. inslrumentat~on. and a hosl of anatomical. physiological. and neurogenic factors thai can innucnce the output signal. ll EMG can show thai a muscle is working. but nol why it is working. and it can only be interpreted as a measure of motor unit activity. EMG cannot delenninc that a treatment is "effective" in the sense of achieving expected outcomes. EMG by itself cannot provide infonnation as to whether a muscle has golten stronger or weaker, or if it is hypertonic or hypotonic. Under most circumstances, with repeated testing over shon time periods. small changes will be difficult to identify. These must be determined through clinical examinalion. But the EMG signal can provide information that may increase efficacy during treatment. It is a form of feedback for the therapist that can be invaluable in situations where overt movement or muscle contraction is not observable. Kinesiological literature abounds with studies concerning the use of EMG signals to examine muscle function under different conditions.~ Therapists should be familiar wilh this body of literature in order to interpret and utilize EMG data, One must be critical of EMG studies, however. because many of them demonstrate methodological faults that can invalidate findings. In addition, the results of EMG studies may not always be generalized to a specifIC patient. and should not be considered the "correct" responses in all cases. Obviously, the therapist's clinical judgment must pre\ ail when observing responses of individual patients. The clinician is encouraged to explore the uses of EMG signals in any situalion where response of superficial mu~cles IS of interest. As long as the limitations of interpretation of EMG signals ore kept in mind, this tool can ~ a maj~r adjunct to patient e.;aminalion and therapeutic mtcrventlOll.

8. What I} pe~ of chal1i!e-" arc 'Ct.'n In the EMG signal "hen a mu~c1e la1Jgue~.' 9. A~~uml' }'\1U ilr~ In'I" E'tG . muscle l Ul Ill!! 1\ to monHor re~poll~e as <.t l'om ) I I oneill 0 ..I lreatment program. What con\IJ~ratJ t 1n ~ .tlt.:• 1I11portanr for ~lling up your prO<.edurl' 111 lem\,> of. ChOKl' .tnJ

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Chapte. 9 Electromyography and Ne...e Conduction Velocity Tests

Case Study

309

1

11 is widely recogni7..ed thai muscle dysfunction can result from direct neuromuscular injury. p..1in. or disuse. ~ome uscles may compensate for this deficit. resulting In a rela:'e alteration in their EMG activity during sustained tasks thai cause localized fatigue. A case repon is described to provide an example of how surface EMG signal ~eas~re. ments were used to detennine par~pinal muscle unparrment in a patient \\ ilh low back pain (LBP).

PATIENT DESCRIPTION The patient. a 36-year-old man with subacute. nonspecific IO'o\CT hack pain (LBP). was inilialJy examined by his general praclitioncr and \\ as treated with rest for several days. a home progrdm of stretching exercise, cold packs as needed. and a prescription for a nonsteroidal antiinflammaTOT) drug (NSAID). The patient was in olherv.ise good health wilh no history of neurological disorders or serious rnu~culoskelelal injuries. The onsel of his back pain s) rnptoms occurred 6 weeks before the EMG testing. The patient did nOI associate this episode of LBP v. ilh a specific tnggering event. but indicated that he has had LBP olT and n for more than 8 years. Previous examinations u~ing radiographic imaging procedures ha\e been unremarkable. At the time of his EMG. which was conducted as part of a clinical research study. the pattent reponed pain symptom!'. biJalcrally in the lower lumbar region and upper butlocj.. area which was most severe on ari~illg In the morning or while ~tanding. At the time of the EMG. the pJl1ent completed a self-repon of pam inlem)ll) (6/10 using the Visual Analog Scale) and pain-related function OR percent using the Oswestry Disabilit~ Scalel~ll.

MEASUREMENT PROCEDURE A surface EMG-ba~d (h namometer. referred to as the Bad. Anal) 'I'" S)"'I~m (BASI. Yoa,:> 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 ':.lrnlllt been dc!>cribed 111 reren! re\leYo Jrticl~ ... 1< I~ .lnd 10 specific rc!>earch publlcalion,:>. ThC' BAS lAa,:> u...t:d 10 monitor Ireatmcnt progre.... \100 10 pJlient:::. IAllh suhal.:ut~ and l"hronic LBP underl!(}In!! \l,orJ..-haftjC'nlll~ r~hJbllltJ(IOIl"l" 111 pallents \l,-ilh l'hrOflil LBP Yo/lilt.: 111 rt.;ml':>~IIJn"ol1\ and 10 compelilive rO\l,tr~ """h \ubJ.c.:ute and Lhn.lI1H.: LBP.I H The BAS JC\ILr:. depltlcd 111 Figure 9.37. mcludes the follo\l,mg I..e) l.:Ompont:nl\, (I} illl adJu':>table 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

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SIGNIFICANCE In thi~ Ulst:mcc. the lack of a gradual. order!) fatigue rc~ponse in the p~lIient with LBP n~ay represent a characteristic los~ of the ability of paraspll131 muscles to produce g.re31cr force~ as needed'" hen e\tema.l loads or torque is lIlcre~. Based on large-!lCale clinical trials. it has been propo~d that the~e differences in EMG measur~l11en.L~ reflect a characleri'itlc signature of pain+related ImpairmenlS that I~ likel) the result of muscle inhibition and avoidance behavior. The hypothesis for this model of llnpalmlent i:-. that in the presence of pain, muscles respond b~ reducing their level of activit) and thereby accommodate a le"!-er share of the mechanical loads displaced across the JOInts they suppon.l~:'i As a result. nomlal patterns of mu~le aetivllY among synergistic muscles become recognizabh altered. the so-called favoring of muscle use. Th~ exammation and treatment of LBP-related impairments have al .... a)"5 assumed a common role among physical therapists. Treatment approache~ to LBP disorders are based for the mO~1 part on reversing and preventing recurrence of the mu ... culo~keletal components to LBP. with the expectation that such change will lead to improved function and reduced disability, Back pain specialists have traditionall~ relied on a variety of qualitative and quantnati\e method~ to characterize the musculoskeletal integrity of the spinal complex and identify related impalmlents. Paru:.pmal muscle impainnents have been quantilatiyely detemlined by the use of dynamometers in

Case

Study

ene Conduction \elodl)' TestS

311

;In attempt to supplement standard clinical examination procedures and provide greater objectivity. The measurements are based entirely on mechanical output, such a~ torque. velocity. or di~placement of the trunk.. . Consequently. they share a common flaw: The kinematic and force variables can be cognitively perceived by the subject and purposefully altered in a manner that compromise validity. Therefore maximal phy<:ical perfonnance c;lpability cannot be completely isolated from factors related to motivation and secondary gain. The developers of the BAS propose that muscle performance objectivity is enhanced by specifying that the test be limited to the performance of submaximal, constant-force. isometric contractions in which the duration of the contraction is predetemlined. 148 Furthermore. the useful infonnation from the EMG signals is not derived from a single muscle group or a single parameter. but rather is the result of the concurrent behavior or mapping of many coactive muscle groups. 11 is assumed that the subject is likely to be unaware of. and cannot volitionally control, parameters derived from such a measurement scheme.

GUIDING QUESTIONS I. What do you consider to be the minimal requirements for an examination procedure to be meaningful? 2. How well does the EMG procedure described in the case satisfy these requirements'? 3. Specifically. how would the information derived from the results of the EMG be used to guide therapeutic inten'ention'? 4. How else might this EMG tesling technique be used to describe other kinds of muscle impairnlents associated with LBP?

2

PATIE]'I,T OfSCRIPTIO The patient l~ 3 64·)ear-old woman who fell and fractured her elbo\l, ten month~ ago. The fracture.'> 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· oj lInplo\-lJ1g lunctlon ,md gainll1g range 01 mOllon (ROM ), The pauen! L:onllnued to COI11pli.llll 01 Iglllfil. ...m dtx)\l, JOint dl'>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.

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! 17 Otlds"VlL II <.:1 al D..:\clopmenl of Ilt:\\ prol()(ul" and lInalY'h prUl;<:dure~ hlr th ... 1l~'oC"~1lI~"1 of LOP b) ~ urfl1\·C FMG tc:l'II1l14ue:. J Kchdbd Rc~ Oe\ ~4.415. 1lJ97 11):1 Ro}. SH .md ()dd!o<.01l. II CI.I . . \i ll..:auon III par!l~pUl~1 mu~c1c ~~:nnt:nt' P\ ,urfa,e t:ler.:lfomyogrJph) Ph)". Thcr 7~UBI(

II~ Shun:tzu H I 1R d 0111.1.1 . c J 11:\1 IL) !.Ind ~M' \.\ IIh rckrcn(.c !\\:ur\ll 6: IU 1%1

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~JXl~tl~ 11)" 111 m..n· E.1t!t.trilmyoglUphic me ruk uj the ~ I obu~ p"lhdu~. Arch

315

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Ph~'sica'

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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<;hlP:> bet.... een myoeleclnc 3Cll\.1I). strenglh. and MRI of lumbar e\:len<;or muscle..~ In bad pain p:uient<; and nonnal <;ubJ«'ls. J Spinal Dl.'>ord 1O:3..J8. 1997. })O. Arendt-Nielsen. L, et al: The innucnce of 10\\ hack pain on muscle IICli\ it)' and cOOfchnaw;m dunng gait: A cllmcal and experimenIal 'Iudy. Pam ()4·VI. 1996.

f back mu"c1c,. Mu:.c1e Nerve J 6:210. (lalron 0 b k 1993. .. . 153, Roy. SH. el 31. Fallgue. recovery. and low ac pam m vaNlIy

m....ef<>. Med ScI Spon~ Exere 22:463. 1990. Sociel) of ACluanes and A,sociatlon of LIfe Insurance ~edical DlreclOr<; 01 America' BUild Stud}, 1979 MelTOpOlnan Life Insurance COlllp:11l}. c:.... Vorl. 198.1 '. 155 R:uJt\llle. J. et 31: Ahenng bchef5 abouT ram and lmpamneTllm I funcllonally orrt:ntt:d trc:lImcnl program for chroniC low back pam. Clio J Pam 9:196.1993. 15~,

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CHAPTER

10 LEARNING OBJECTIVES 1. Define the terms used to describe normal gail. 2. Define reliability, val idi ty. sens itiv ity. and specificity in relation to gait analys is. 3. Describe the variables that are examined in each of the following types of gait ana lyses: kinematic qualitative analysis, kinematic quantitative analysis. and lUnetic analysis. 4. Describe and provide examples of some of the most commonly used types of gait profiles. 5. Compare and contrast the advantages and disadvantages of kinematic qualitative and kinematic quantitative gait analyses. 6. Using the case study example, apply cl ini cal decision making skills in evaluati ng gail analysis data.

Examination of Gait Cynthia C. Norkin,

PT, EdD

With contributions by Sandra J. Olney, BSc (P&Ol) MEd, PhD OUTliNE Purposes of Gait Analysis 3 17 Selection of Approach to Gait Analysis 3 18 Reli ability 3 18 Sensitivity and Specificity 3 18 Validity 3 19 Gait Tenninology 319 The Gait Cycle 3 19 Phases of Gail 320 Types of Gait Anal yses 320 Kinematic Qualitative Gail Analysis 320 Kinematic Q uantitative Gall Analysis 338

ne of the major purposes of the rehabili tative proces~ is to help pat ie nts achi eve as hi g h a leve l of func tional independence as poss ib le within the lim its of their partic ular impai nne nt s. Hum an ambulatio n, or ga it . is one o f th e bas ic com po ne nt s of independ ent fu nct ion common ly affec ted by e ithe r di sease p roc e s~es o r inj ury. Con~e qu e ntl y, the de sired o utco me of mo st ph ys ica l therapj Interve nt ion s is to ei th er re<;tore o r improve a palient 's ambu latory stat us. A lthoug h there are many specific rea~o n s for perform ing a g ait analys is, a ll o f them requ ire ho me info rm ation abo ut th e ga it perfo rm ance of ei ther an indi v idu<.l l o r a gro up o f peo pl e with a panicular dj~tl bilit y. T hl ... infom l<.lt ion is needed 10 serve one o r more of the- 1'0110\\ ing p urpo:;,es that are applicable to eJlher ind iVidu al pe rsons. or 10 a d isabilit y g roup: (I, to gai n an unde rstanding o f the gai t characteris ti cs o f a particul(1r d i ~o rder ; (2) to a ... s ist moveme nt d iag no sis; OJ to Inform tre alm ent ~e l ec li o n : and (4 ) to eva lu ate the t.-ffe,.;tJ\ene::.~ of tre atme nt. Be c a u ~e the re are mu lt ip le ap proache!', to gall ana lys i::., ranging from ve ry sim p le to tx tfcmely complex. the the rap b t mu ::. t carefu ll y cons ider hov. mfo rma tio n o bl t:lln ed fr o m a gait ana ly::. is. i::. to he u~ctJ Gener<.J 1 a:-, we ll a,') ~ pt'c ifi c t: link al Indi c a t ion ~ for I:ond uttmg a ga it an aly~ l ~ ma y be fo und in the Guide ( O PhYSlcul f hrrup/\{ Pun fi n ' . :.ome of wh ich are included beJo\V. 1

O

Methods of Gai t Analysis for Kinematic and Kinetic Variables 342 Gait Pattern Classification 348 Kinetic Gait Analysis 352 Plantar Pressure Measurement Systems 354 Physiological Energy Cost Measures 355 Mechanical Energy Cost Determination 355 Heart Rate Data 355 Summary 359

Purposes of G ait Analysis I . To assist with understanding the gait characteristics of a particular di sorder. This includes: • O btaining acc urate descriptions of gait patterns and ga it vari ables typical of different conditions • Identify ing and describing gail dev iations present. or typ icaJ ly present in specific d isorders • Determ ining balance. endurance. energy ex penditure. and safety • Detennin ing the fun ctional ambulation capabi lities of the patjent in relation to functional amhuJation demands of the home. com mu nity, and work environments • C lass ifying the seve rity of d isability • Pred icting a patient 's fu ture statu s 2. To ass ist wi th movement d iagnosis by : • Identifying and describing gait dev iati ons and describing the di ffe rences between a patient 's perfonnance and the parameters of norma l gait • Analyz ing gait dev iations and ide lll ifying the mechani sm.'> re~ po n s ibl e for producing them • Exam in ing balance. endurance. energy expendi ture. ~t nd I'oafety and de termin ing the ir impact on gait 3. To infonn selectio n of ini ervelllion(s) by guidi ng the t h e rapi ~ t in:

318

Physical Rehabilitation

• Proposing appropnate trea men of impainnents that may improve gait perfonnance . . . .

t

t

• Delennining the need for adapti~e, assl~tlve, ortha'.lc, prosthetic. protective. or supportive deVIces or eq Uip-

ment

s a basis for desc ribing present status that can be used a . . rformance limitations and strengths),planntng and Imple(pe. . ntions evaluating effectIveness and progress mentlllg mtefVe, . ' . luating outcomes, and In some mstances, for over time, eva predicting future status.

.

4. To evaluate the effecti veness of treatment and gUIde the

therapist in :

.

• Detennining how intervent ions such as therape ~tl.c exercise. endurance activities, deve lopmental act,lv lties, strengthening or stretching , e lectrical stimu.lat l? ". balance training. su rgical procedures. and medicatIOn

will affect gait . ' • Detennining the effectiveness and fil of devices or eqUipment selected in providing joint protection and support,

correcting deviations and dysfuncti ons. reducing energy expenditure. and promoting safe locomotive func tion. Many examples illustrating these purposes are found in the literature: descriptions of the differences between a patient's perfonnance and the ~arameters.of nonnal ga~t.2-:~ identification of the mechan isms causmg dysfunctiOn, detennination of either the need for or the effectiveness of a prosthetic deviceY comparison of the effects of different types of assistive devices,lJ detennination of either the need . a. . deVlce, . 14- 19 det ennln for or the effectiveness of an ort hOtiC rion of the effects of treaU11ent interventions,ID.21 detennination . 13 an d pre d"Ictl on 0 f fut ure stat us" of energy expenditure. .--.2]

Selection of Approach to Gait Analysis The type of gait analys is that is selected depends not only on the purpo~e of the analysis, but also on the type of equipment available and the experience. know ledge. and skills of the thentpist. The rype of equipment necessary for perfonning a specific type of gait analy..,is, in tum, depends on the purpose of the analy~ i s, equ ipment availabi lity. and the amoun t of lime the lherapl~L can e>.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 <., 1 be a\~ arc of the typc~ 0 1 anal~'>t \ available and be able to detenlline \\hich 11lt'lho(l\ an: rell ... ble and va lid . Much 01 the !IllunTHlIion about gait <: har...cteri:-.lib of parti~ular dlM)rder'.:>. a:-. we ll a'lo Ihe ll1e. . ' hanl:-.m . . re..,pon'\lblc for producing them, ha:"> been achic\ed III Llmu.:al rC'loea rch \etting :-. u\ing compi e. . 1Il"'lrUlllentalion often nOI ,1\ adahle fo r ge ner..tI patient lI,e }-1m, c\ er, If a therapl'.:>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 <.Indl)'1 I<" method:"> (' an be- Idenlilied Ihat Ilia) ~ e\e n lIlore lI~clld In adurcs,\lng '.:>peutiL purp
Reliability Reliabilit y_ as applied to gait anal ysis, refers to the level of consistency of ei ther a measurmg m st~ment (e.g., footswitches, force plates. moti on an~ l ys L s systems, lectrogoniometers) or a method of analYS IS (e.g., observa~ional gait ana lysis chec kli sts, ambulation profiles, and formulas for measuring stride length). To detenmne If a measuring instrument is reliable. the m ea~urements obtained from successive and repeated use of the mstrument must be consistent. For example. if an electrogoniometric measurement of a known angle of 60° consistently measures 60° on every Monday morning for 2 months. the instrument is said to be reliabl e. However. if the measurement obtained were 60' on the first Monday morning, 30' on the second and 40° on the third. the instrument would have very low reliability. Two types of reliability may be refe rred to: relati ve (association) or absolute (concordance). Relative reU· abi lity uses statisti cal techniques that are correlationaf27; they detect the ex istence of a relationship between sets of data. The statistical techniques used by absolute reliability can detect Ihe magnitude of differences between measures. Unl ike more tightly controlled scientific conditions, the measu res used in gai t for determining reliability reflect al1 of the variability present in the meas urement process. This includes trial-to-tria l or day-to-day performance variation of the ~ u bjec l , as we ll as differences in the way the tester carries out the test. To make the best possible detennination of the re liability of an instrument, one mllst rule out factors olher than the instmmem that ('ou ld influence the mea:-.urement (e.g .. that a subjeci h a~ not injured a knee betwee n succel>sive mea~ uremenh or that the p13cement of the in.., trument had not changed), To detennine \\ hether an J.l1al)':-'I:-' meth<x1 has both relati ve and ab,olute re liability. t\\O (hfft'l'cnt foml:-' of rt'liability nl:ed 10 be detennined : IIllr(l{t?Slt'r and llIlerreller retiahi/It.,. The intr~Jte!'>tcr re llabilit, of an an~tI ~ 'IS method ran be' detel11l1llt!d b) e\i.\ll1Ining tt~e conl.,l..,te~L')- of the rel>ullS obtained \\ hen one indi\ Idual 1I~t' ... a p~utlcutar method repealedl) . For c\alllpk a Iht·rapi..,t u:-.e ... a partlt'utar method 10 e\;'1I1lJne a ... tuJent ph) " ••."0.1 1 ther-Ipl ... ,'.., gail. The tht:'rapl~t re~.t" Ihe C\dlll1J1aItOIl Jt 2-\\eek Inlervab fnr ~ "eel,).lfIJ obl::lin . . the ..,J.ille re..,ul" e~ll'h tllne In Ihl ... ul:-.t::Ull'e. the melhnli \\ould Ix I;on . . luen:d J.... h.n IIlg high Illtntlt:':'Iler rehJbil U) beL.W,C Ihe re ~ lIh~ Ohl.ltllcd hy {he '.11l1C pel"':oon are l'On~J..,tcnt l~\.,;or time I tl)\,e\l.'l . Ih..., e\i.unpk I' ,trictl) h)ptr thl't1l"al ;." laLh.I!':o olher than the lherapi..,t', ... l..lll, ..,u~'h J!'t lallgue, IUlll' 1..11 d.l) and other \.u-i ~lbll.!~. ilia' aifel'l iX r· tonll.lnl~ .tIlJ Illu'\t he \,.·\)JIu....)l1ed III .Ul\ J.i1al\ ":1.,. IllIcrtl',ler Il'Il.lhtlit) I.., Lll' ll'nlllll('~1 h) ~\.lmlllil1g Iht' \,,·UII"'I ... tt.·nl'! lit Ihe li.Jta uhlJIIll'd tmlll r""lx'.lled anal)"""

Chapter 10 Examination of Gait

3t9

perfonlled by a number of different per.;.ons. If the re,u\t", obtained by numerous e\aminer, are in ag.reement ooth relatlvel\ and abs.oIUiely. and no '\ignificant difference ", in the re,,~h ~ e\i:-.t among te,ter" . the method has high

Gait Tenninology

nllcne STcr reliabilit).

The largc~t unit used to d esc ribe gait is call ed a gair cycle, w hi ch has both spatial (d istance) and temporal (time) parame te rs. In normal wa lking. a gail cycle begi n s w hen the hee l of the reference ext re mity contac t!) the s upporting su rface and end s w hen the heel of the same extremi ty contacts the g round again. In some abnorma l gaits. the heel may not be the fir~1 part of the foot to contac t the ,ground. so the gait cycle may be cons ide red to begin w hen some other p<mion of the reference ex tremity contacts the ground . The cycle ends when thai same po rtion o f the ex tremity contacts the ground again . The gait cycle is divided into two phases. STlIfICe and S\\ ·;l1g . and t\\-"o periods of double support. In normal gait the stance pilau. w hic h con s titute s 60 percent o f the gait cycle. is defined as the interval in which the foot of the reference extrem it y is in contac t with the ground. For example. if th e ri g ht lower ex tremity (LE) is the reference extrem it y. the left LE will be in the sw ing phase w hen the right LE b in il>; stance phase. A single gait cycle contajns right and left stance phases. The swing phase. which constitute ~ -to percent of the gai t cycle, is that portion in which the refere nce extremi ty doe~ not contact the ground. Therefore. a single gait cycle includes both right and left swing phases. llle term dOllble support time refers to the two interval s in a gai t cycle in \\ hic:h body weight is tran sferred from one foot 10 the ot he r and both righl and left feet are in contact \\ ith the ground at the same time (Fig. 10.1), Each of these \ ariable, may be mea~u red in time. for e\ample. stance time {right and le fn .fll 'illg time ( ri ght and left). double suppOrt lime , and (yde 1"'11£'. T\\o ' Iep ~ . a right step and a left step. compri se a stride. and a ,I Tide I' ~4u .-:1I to a gail c~cle. Step and stride rna) be tlt·tined 111 1\\0 dll11ensiom : di ... tance ,1Ild time. Step length ' " the di'iT.lIll:e from the POJl1! of heel stri!....e of one e:x.lrem il~ to the poinl oj hee l ~trihe o f thl' oppo",i te t".xtrem it). \\ he reJ '> .\fndt' It'"gll! i... the distance frol11 the point of heel ... Irih e M o ne e \tre l1lit~ to the POIll( ot heel srrike of the ... ame t'\ (re l11J1 ). _' rr ide WIl (' and stl'fl fIIlle refer to the le ngth 0 1 lime re4ulred 10 l'ompkle a ... tep ,md a ",tIlde. re", pc l li \(' I ~ t Fig. IO.:? )

Sensitivity and Specificity Sen"io\ It) and 'pecilicit) are 111lponant cOll':)idcl.ltion, \\ hen ...ele-ctin!! a method of ~U1al\ , i,. Sen .. ili\it) . as it relate.., 10 ,galt :mal\ S l ~. refer... 10 th e pr~porl1on of time ~ thai a method o f anal~ "'1 1; corret'll~ ident ifi e ... a gait abno mlalit) or cond ition \\he;, that abnomlali£: or cond llJon is actu all y pre ...ent. Specificit~ re fe r; to the proronion o f time>. that a method of anal y~i , ,:orrecll ~ idemlfle, the abn0n11ality as being ab,;;cJ1I ,\ hen II trul~ .' absent.='" AddulonaJ infonnation aboul these par.ulleter-- \ \1 11 be a\ 'ailable a .. more ..,ophiqicated stati stical rreatment of gall findmg ~ become" commo n pr.lctice.

Validity \ 'ali dit ~ refe r . . 10 the de gree that a mea sureme nt retleC:b "h:n III, ... uppo~ed to mea ... ure. The re are se\ e ral types of \'Jhdll~ The~ mcl ude:

\uIiJi0 --deten m ned through logi cal ar,gumentaBon ba...ed on theoretical re-.earch e\ ident'e (the abilil) o f an m...trument {(l mea,ure an 3.b~ tr.Jc t concept or COIl\ tnlct ). [ lfI/nU wlidn.,--de tenmned h) prO\ iding e\ idence that the mea ... urmg m"trument (ontain ... a ll relevant e lemenl'. of a C0n ... tru("t and no e\ traneou, e leme nb . In Ihi ~ ilhtance . the le ...t de\(' lopt'r might Ju ... tify the le ... 1 b~ demon ... trating. lhJI all Item, m Ihe te,1 \\ ere co rrel ~lI ed \\ ith each other. [rut 1"11'11·/1(/\( J \al/(hn~"' I :l t"ll l,hed b) compari,o m, o f either t)ne m . . trument " n h another o r \\ ith data obta med lrom other torm . . of le,llng ({II (urn IH \·uflJit.\-the m fe re nl.:e I'" Ju, lIfi ed b) ("ompari ... on ... bet\\een Ih l' rc,u lt , o f ... ... peci li c le . . \ Ig.ai l J.n..u~ '!'" j ;lf1d another Ie ... ! /t unclIon;..1I Ie ", I tahen .It J.rrrm.ml..ltel~ the "';Ullt' tlllle. P" It tnt ahdU\-\alid!t~" Je lermmed b) the lJp ..."II, I\~ ut the 1I1,lrumcnt hl predld future C\c nt .... ,ul..·h .1'" 1.11 "-

(. IIl.\!nt,1

liltlll..UIt tv 'mOl~mt' J. metilll(} 0 1 1Ot'J. ... un ng or an a· 1... llLJl lnha.:ntl) \Ollld lor galt lhe ll H,,)w(,\t:'r g..1It I nut ... !o.lIlfle l·Olh lrut.! bUt"1 I..lll1lplc\ ProLl· ...... th ai nUn" tht' l Irnplt')'Il~ of hum,11l pl"riorm a lll"l' l , mg ;\ I.uri 1I11f'h: ..tppnl.H.h. onc 1..1n
h

I~lln!; ~J.1I1hOlt

fhm

I II!

rdl.thllLh

.J./ld \,ilILiJl)

I II ;..In Il hlrlltllL: 1J 1 lIr

II lI!\lll III .ilI.d~ .... lia., lxl'JJ l· ... I,lhlJ ... hel1 IIt l1l' IlhlJ Uil1l"1ll ur 1n;lhod 1I..t not ixl'li kql'J thl"" l
llpor;.th:

lOot

I

l..t

IIII:th·,J ... Mill! re" t:ardJ lu\t~

.1'> 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\.'
IIl llh.'\II\.g

..tJld h.' mllll.1I .... \\lng) . ~·\( ·

Chapter 10 Examination of Gait perfomled by a nu mbe r of d iffere nt pen.ons. If the re..;uit s obtai ned by num erou s examiners are in ag reeme nt bot h relatively and absolute ly. and no signifi cant di ffe re nce s in the resuils ex ist amon g teste rs. the m cthod has hi g h intert ester re liabil ity.

Sensitivity and Specificity Sen»iti" it)' and speci ficit y are important con sideralion~ when selecling a method of analysis. Sensilivity . as it re lates to gait anal ys is. refers to th e proportion o f tim es that a m eth od of analysis correctl ) ide ntifi es a gail abno nna lity o r cond ition when that abnonnaLity or cond ition is actua ll y present. Specifici l~' refers to the proportio n of times thai a me thod o f analvsis correctly identifies the abllollllali ty as being absent \\'he~ it truly is absent. zx Additional infonn alio n about these parameters will be available ~L'" mo re sophisticated statistical treatment of gai t fi nding:-. becomes common practice.

Validity Valid it y refers to the degree that a meas ure me nt re fl ects what it i'l supposed to me asure. The re are severa l types of validi t). They incl ude: • COlIStl'Uct \'Glidily~et e nnined through logical arg umen-

tat ion btbCd on theoretical research evidence (the abi lity of an instru ment to meas ure an abstract concept or construct ). • COlllell1 m/idity---detemlined by providing ev ide nce th at the meao;uring instrument co ntai n ~ all re levant e leme nt s o f a construct and no ex traneo u ~ e lement s. In thi s instance. the t e~t develope r mi ght justify the test by d e m o n ~ trat in g that all item 'I in the test were corre lated with eac h OI her. • Criterioll-ba5ed \'Glidily-e~ t ab li s h e d by com pari :-.ons of ei ther o ne in'llrume m ""ilh anothe r o r with data obtained from ot her forms of testi ng. • Concurre", ralidi'y-th e infere nce is jll ~ tifi ed by compari'lon'l between the re:-.ulh of a ~ peci fi c te'l t (ga it anaIY~I:-') and another te"t (functional t e~1) take n at apprm,imately the 'lame time . • Prediul\e mhdu.\-\·uli dlly i\ detem l incd by the capa bi lIt) of the in ~ trument to predict lutu re I!\e nt~. '1 l1ch <1\ fa ll s. It 1'1 dIffic ult to IlTI agi nt: a met hod of mea .. urin g or a na· lyzlI1g galilhat 1\ not lIlheren lly valid for ga il il...elf. Ho\\e\"cr. gait i~ not a :-.ingle COI1'ltruct. bu t a comp lex prol:e ... ~ Ihat mirror ... the co mple >. lty of hum,lIl pe rl o rm a nce. U\ lIlg a talrl~ Ml1lple approadl, ant' G.1Il a):,~ if a pa rti c ul ar Ilh;.'a .. ure 1\ "alid luI' the ",)eu li c purpo~e Iden tified. EX;lJlll nlllg Ihe to(.)l ... de~<.:ribed below. one Illay retlec.: t o n tht: purpns,e .. 0 1 gdJt anal) 'Ii .. idc lilified earh.:r. and ",," II the tool bt- lIlg con'1ide n:d Vvould be valid lo r I h al pu rpo'l~ . B) e),. h 1lli.1)' "hh to Jnl:orpur,tlc me thod 'l '1 ul h a ... repeated t':~lIng ,\ ill1 ll1 the 1.."0n h.: \\ 01 a n!'1l'i.lfl.."h '1 lud) 10 l'(m linll lellabili ty..

319

Gait Tenninology The Gait Cycle Th e largest unit use d to desc ri be gai l is calle d a gait cycle . which has both spati al (di stance) and temporal (time) param e te rs. In nonn a l walkin g, a ga it cycle beg ins w he n the heel of the refere nce e xtre m ity c o ntacts the suppo rt ing surface and ends w hen th e hee l of the same ex tre mity contacts the ground agai n . In so me a bno rm a l gait s, the hee l may no t be the fi rst part o f the fOOl 10 contac t the g round , so the ga it cycle m ay be considered to beg in whe n some o ther po rtion of the re fe rence ex tremi ty contac ts the g round . The cyc le e nd s w hen th at same porti o n o f the ex tre mity contac ts the g round again . The gai t cyc le is div ided into two phases. stance and swing. and two peri ods of double support. In no rm a l gai t the slanee phase . which constitute s 60 pe rce nt o f the gait cycle. is de fin ed as the inte rval in which the foot of the re fere nce ex trem ity is in contact with the g ro und . For exam ple, if the ri g ht lower extremity (LE) is the reference ex tremit y, the le ft LE w ill be in the swing ph ase whe n the right LE is in its stance phase. A single gait cycle conta ins rig ht and le ft stance phases. The swing phase. which constitutes 40 percent of the gait cycle, is that portion in which the re feren ce extremi ty does no t contact the ground . Therefo re . a single gai t cycle includes bOlh rig ht and le ft swing phases. T he te rm dUl/ble support lime re fe rs to the two inte rvals in a ga it cycl e in whi ch bod y weight is transferred fro m o ne foot 10 the o the r and both right and le ft feet are in contact w it h the g rou nd at the same tim e (Fig. 10. 1). Each of these varia bles may be measured in time. for example. SIGnce time (ri g ht a nd le ft) swing lime ( rig ht and le ft ), double support time . and cycle lime. Two step:-.. a right slep a nd a le ft ste p. com prise a stride. and a stride is equa l to a ga it cycl e. Step and stride may be de fin ed in two di mension s: d istance and ti me . Step lenglh is the d istance from the po int o f hee l strike of o ne ex tremity 10 the point o f hee l strike o f the opposite ex tre mity. whe rc a'i Mride l£'l1glh i:-. the di stance from lhe point of heel ~ tr i k e of o ne ex tremit y to the poin t of hee l strike of the 'lame ex tre mi ty. SrriJl' lim(' and step lime re fer 10 the leng th o f lime required to comp le te a step and a stride . respec ti ve ly (Fig. 10.2).

Phases of Gait T rad iIl Ona ll ). eac h pha ... ~ 01 ga it (:-. t.lnce and ~w ing ) ha s bC~ 1l di\l(.ied in to the fo ll owi ng units: '\lanl'C' (heel strike , footlb t, mi(h lallce. hl·e l-o ff. and loe-off) und sw ing (accel eratl un. mi d"wing. ~ lIl d deL'c ie ral ion). The Los Amigos R~"c.lfch ,tn(\ Ed ul'
320

Physical Rehabilitation

Doub!e

Double

support

support

Figure 10.1 Double support is defined as the period in whi ch sOl~l e portion of, the feet of both extremiti es are in contact with the supporting surface at the same li me . Two penads of double support occ ur within the single gail cycle. One period occurs early. in the stance phrase ~f the reference extremit y and the other occurs lale in the slance phase of the reference extremity. (From Levangie. P. and Norki n, c :~· p·n9 with penn ission. )

The similarities and difference s between the two tenni nologie s are presented in Table 10.1 . Angular rotati o ns at the joints in each portio n of both

sw ing and stance phases. as well as muscle activity and function. are presented in Tabl es 10.2 to 10.7. Famili arity with ranges and pattem s of motion associated with normal gait provides the therapi st a bas is of comparison to identify dev iati ons from these norm ati ve standard s. Familiarity with the mu scle activ it y and fun ction associated with nomlal gai t all ows the th erapist to anal yze causes of the deviations.

Types of Gait Analyses The types of analyses in use today can be class ifi ed under two broad categori es: kinematic and kinetic. Kinematic gai t analys is is used to descri be move ment pattem s with out regard for the forces involved in produc in g th e movement. A kinematic ga it analys is consists of a description of movement of the body as a who le and/or body segments in relation to each OIher du rin g ga it. Kinemat ic gait anal ysis can be either ({uali/atil'e or qllallfilatil'e. Kineti c gait anal yleft stride

.••.

--

left step right step

.1

right stride

Figure 10,2 A n glll ... triO e and:t le ft ,>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<:' I,the led I hl' Idt '> Iridl' Ul1lLlln'> .. nght :-.11:11 anJ a kit ~ t l' Jl , -I ll': n~ I JI ;" 1l'P k: ngt h I'>huv. II In tho;;: mIddle u l Ih t: dl;tg r;Ull) I'> lilt" (li q;.lllll' nd\\t'l'll lhl' Ildl lwd lUlltdlllo Ihe pO lilt 0 1 till' rlghl hl:<.'I l'Olll;tll. I t.:l t '> It::p kllglh 1\ Iht' dl'>t.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 r ... ho\\ 11 III Fi ~ure 10.3. Practit.'t' ga il 111m. ~lnp~ lJ~elul fl)r de\ eloping an: 1 impmv ing o ne'S oh, t::nallunal ~ J... i ll~ a ... \\e ll a\ fo r kanllflg how 10 lise Iht' r~('o rdlllg lorm ... m,l) be obtained by w l~l i ng to LA REI.

-

Chapter 10 Examination of Gait

Table 10.1 Gait Te nninology ~ RandaoLos Stance Heel strike: Th e beginning of the stance phase when the heel contacts the ground. Th e same as initial

Phase Initial contact: The beginning of the stance phase when the heel or another part of the foot contacts the

.. "1.

a

.

'~ .. ~ ....-r'

.

~.,.,

Swing Acce leration : The portion of beginning swing from the moment the toe of th e referenee extremity leaves the ground to th e point when the reference extre mity is directly under the body.

321

, ,

Phase Initial swing: The portion of swing from the point when the reference extremity leaves the ground to maximum knee flexion of the same extremity.

contact.

ground.

Foot flat: Occurs immedi-

Loading response: The portion of the first double support period of the stance phase from initial contact until the co ntralateral extremity leaves the ground.

Midswing: Portion of the swing ph ase when the reference extremity passes directly below the body. Midswing extends from the end of acceleration to the beginning of decelerati on.

Midswing: Portion of the swing phase from maximum knee flexion of the reference extremity to a vertical tibial position.

Midstance: The portion of the single limb support stance phase that begins when the contral ateral extremity leaves the gro und and ends when the body is directly over the supporting limb.

Deceleration: The swing portion of th e swing phase when the reference extremity is decelerating in preparation for heel strike.

Terminal swing: The portion of the swing phase from a vertical position of the tibia of the reference extremity to just prior to initial contact.

ately following heel strike. when the sole of the foot contacts the floor. T his event occurs during load in g

response . Midstance: The point at

which the body passes directl y over the reference extremity.

Heel off : The point fo llowing midstance at which time the heel of the reference extrem ity lea ves the ground . Heel off occu rs prior to termin al stance .

Toe off: The pOi nt fo llowing

heel off when only the toe of the reference extrem ity is In contact with the ground.

Terminal stance: The last port ion of the single limb support stance phase that begins with heel rise and continues until contralateral extrem ity co ntacts the ground . Preswing: The portion of stance that begin s the second double support period from the initial contact of the contralateral extremity to lift off of the reference extremity.

Rancho Lo~ Amjgo~ Nat ional Rehabili tat ion Celll er. 7601 Ea>1 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 du<.:urTIc llt abn unn ... hli c . . :-. uch a ~ hall ux va lgu. . und hammer lOe ~ . The dynami C YlIa lila ll vt' compo nent of the aJlal y~ I'" U'>e ... ,I :-.honh anLi ~y,>te m lor record in o Iht' det'll l-. ul thc ()CiA Th e ih. ronym U II O RT (gil it. horn~ncll ­ lu .... Ob!o,tT\ e d . h." lation.iI , ,lIld l..thula n 1:-' lhe d h I ........ i ... 1 in n.::o.:ord . I n~ Inlorl11d tl( lI1 g.lIht" fed t rolll the o b..,e r vatio lli.1I

analysi .... (Fi g . 10.5). An exam ple o rlhe recording method is shown in Figure 10.6. Foll owi ng co mpl eti on o f (he dynamic pOffion. the rater 's q ualitati ve impress ions of the patient 's, ga it arc compared with the results of the static anal y~ i ~ to ve riI') the acc uracy o f the find ings and detenni na tion of the C;:lu ~e:-, of a bnonll aJ function. T he autho r states that aft e r the lir ... r fi\ e anill y se~.
322

Physical Rehabilitation

Table 10.2 Ankle and

Fool: Stance Phase, Sagittal Plane Arlal,,.i,

Heel strike to foot flat

0-t5 degrees plantartlexion

Plantartlexion

Pretibial group acts eccentrically to oppose plantarflexion moment and thereby to prevent foot slap by controlling plantartlexion.

Lack of ability to oppose the plantarflexion moment causes the foot to slap the floor.

To avoid foot slap and to eliminate the plantarflexion moment. the foot may be placed flat on the floor or placed with the toes first at initial contact.

Foot flat through midstance

15 degrees plantarflexion to 10 degrees dorsiflexion

Plantartlexion to dorsiflexion

Gastrocnemius and soleus act eccentrically to oppose the dorsiflexion moment and to control tibial advance.

Excessive dorsiflexion and uncontrolled tibial

To avoid excessive dorsiflexion, the ankle may be maintained in plantartlexion.

Midstance to heel off

10-15 degrees dorsiflexion

Dorsiflexion

Gastrocnemius and soleus contract eccentrically to oppose the dorsiflexion moment and control tibial advance.

Excessive dorsiflexion and uncontrolled forward motion of tibia.

The ankle may be maintained in plantartlexion. If the foot is flat on the floor, the dorsiflexion moment is eliminated and a step-to gait is produced.

Heel off to toe off

15 degrees dorsiflexion to 20 degrees plantarflexion

Dorsiflexion

Gastrocnemius, soleus, peroneus brevis, peroneus longus. flexor hallicus longus contract to plantartlex the foot.

No roll off.

Whole foot is lifted off the ground.

Table 10.3 Ankle and

advance.

Decreased contralateral step.

FOOl: Swing Phase,

Acceleration to midswing

Dorsiflexion to neutral

Mldswmg to deceleration

Neutral

None

Dorsiflexors con· tract to bring the ankle into neutral and to prevent the toes from dragging on the floor.

Foot drop and/or toe dragging.

Hip and knee flexion may be increased to prevent toe drag, or the hip may be hiked or circumducted. Sometimes vaulting on th e contralateral limb may Occur.

Dorsiflexion

Foot drop and/or toe dragging.

Hip and knee flexion may be increased to prevent toe drag. The swing leg may be circumducted, or vaulting may occur on the contralateral side.

Chapter 10 Examination of Gait

323

Table 10.4 Knee: Stance Phase, Sagittal Plane AnalV'iis

Heel strike to foot flat

Flexion 0-150

Flexion

Quadriceps con· tracts initially to hold the knee in exten· sion and then eccentrically to oppose the flexion moment and control the amount of fl exion.

Excessive knee flexion because the quadriceps cannot oppose the flexion moment.

Excessive knee flexion initially.

Exten sion 15-50

Flexion to extension

Qu adriceps contracts in early part, and then no activity is required.

Mldstance to heel off

5° of fle xi on to 00 (neutral)

Flexion to extension

No activity required .

Heel off to toe off

0-400 flexion

Exte nsion to flexion

Quadriceps requ ired to control amount of knee flexion.

Foot flat through mid-

stance

Plantartlexion at ankle so that foot flat instead of heel strike occurs. Plantartlexion elim i· nates the flexion moment. Trunk lean forward eliminates the flexion moment at knee and therefore may be used to compensate for quadriceps weakness. Same as above in early part of midstance. No compensation required in later part of phase. None required .

are that the obse rvati onal meth od. being depe nde nt on both

I f ther api sts deci de to use an OGA method , Ihey

the therapist '!!, training and observationaJ skills. is subjec-

sho ul d ser io usly conside r usi ng a cam corder that has the

ti\e.

h a~

onl y low to mode rate reli ability. and validi ty has

not been de monstrated.~ 2 Diffi culties involved in observing and makmg acc urate judgme nts about motio ns occ urring <"imultaneou~l) at numerous body segments. and inadequate train mg in OGA Inethods are th o ught to cOl1lribute (0 (he 10\1. re liabi lit) . Also, Ihe ra p i ~t s di ffe r in thei r observatIonal ~k. il b . A drawback to usin g the Rancho Los Amigo, OGA techniq ue i, th at reliability and va l idity of the method h",e nOt been publi shed.

capability of sl owing or stoppi ng m otion. A vi sual record is especially i m portant w hen using the Rancho L os

A mi gos fonna t because of the time involved in examining a large number of variables at six different body part s. M ost patients cannot walk continuou sly for the length of time required 10 complete a detailed. full -body observa-

ti onal an alysis. Furthermore, the observers cannot rate or score a large num ber o f variables whi le a subject is waJking. Video tape records of a patie nt's initial perfo rmance

Table 10.5 Knee : Swing Phase, Sagittal Plane Analysis

.....

New" M,don

Accleratlon to mldswlng

40-60 flexion

None

60-30 extension

None

30-0

None

r.... n of

Of::Ce lefallon

extensIon

Li ttle or no activity in quadriceps. Biceps femons (short head), graCilis. and sartori US contract concentrically

Inadequate knee flexion.

Quadrice ps contracts concentrically to stabilI ze knee In extenSIon, In preparation for heel slnke

Inadequate knee exten-

Sion.

Increased hip flexion , circum duction , or hiking.

324

Physical Rehabilitation

Heel strike to foot flat

30° flexion

Flexion

Erector spinae, gluteus maxim us, hamstrings.

Excessive hip flexion and anterior pelvis tilt owing to inability to counteract flexion moment.

Trunk leans backward to prevent excessive hip flexion and to eliminate the hip flexion moment.

Foot flat through midstance

30° flexion to 5· (neutral)

Flexion to extension

Gluteus maximus at beginning of period to oppose flexion moment, then activity ceases as moment changes from flexion to extension.

At the beginning of the period, excessive hip flexion and anterior pelvic tilt owing to inability to counteract flexion moment.

At beginning of the period, subject may lean trunk backward to prevent excessive hip flexion ; however, once the flexion moment changes to an extension moment, the subject no longer needs to incline the trunk backward.

Extension

No activity.

None.

None required .

Extension

IIliopsoas, adductor, magnus, and adductor longus.

Undetermined.

Undetermined.

Midstance to heel-off Heel-off to toe-off

10° of hyperextension to neutral

that can be replayed in slow motion allow therapi sts the time needed to make judgments about gait events. Although the use of videotape may provide an opponunity for th e observers to determine the reliabilit y of their scorin g. reliability will probabl y remain in the low to moderate range unless therapists are knowledgeable about nomlal gait paramel.ers and var iables. and are adequately trained to use the measuring instrument. Ru~~ell et aP' found that \\, hen observers were trained in the scoring of a Gross Motor Function Measure (GMFM), a ~ig­ nificant improve-me Ol occurred following training COI11pared with the ob~e r\ er~' pretraining scoring of the \ ideotJpe . On the other hand, Ea~tlack el a11-1 found only 10" to moderate iOlerraler reliabi lit y among 5-' practicing phy~ical therap'~I~ who rated 10 gait variable ~ \\'-h ,le ob~ervi n g the videotaped gait of three patlent\. The~e

....

therapist s had reported they were comfortable perfonnin g observational gait analyses. The lack of agreement among raters found in thi s ~tudy, as well as the rater's lack of know ledge of nonnal g"it parameters and terminology, has se ri ous implications for patient treatments based o n the results of ob~ervation a l gait analyses. J4 Krebs l~ argues th at OGA is impossible to pe rform in a clinical setting. However. in a re('ent ~ (Ud> using OGA, phy~ i cal therapi st') \"ere ab le to make accurate and reli· able judgments of scored push-off power in the \ Ideotaped gait of subject, follO\\ ing :o..lrole. Thi!cd in conjunction "ilh 4uantiHlli\'e mea..,ure~ . Videl1tape or film call prO\·,de a permanelll record of the patH:nt\ g<.u t. ViLleograph} ma)' also

Table 10,7 Hip: Swing Phase. Sagittal Plane Analysis

Now I',. Eh

,

None

Hlp flexor actiVity to Initiate sWing IllIopsoas, rectus femons , graCiliS sa rtorius tensor faSCia tata

Diminished hip fleXion ca using an Inability to Initiate the normal tor. ward movement of the extremity and to raise the foot off the floor

None

Hamstnngs

A lack 01 con trol of the sWinging leg InabIlity to place 11mb In peSI tlon for heel stll"e

NIl, If d •

HI

Acceleration to mldswlng

20-30 fleXion

Mldswlng to deceleration

30 fleXion to neutral

~1

.,

Nee, a

011 aI

,

CllCllmduction and/or hip h'klng may be used to bring the leg forward and to raise the foot high enough to clear the lloor.

Chapte r 10 Examination of Gait

325

GAIT ANALYSIS: FULL BODY RANCHO LOS AMIGOS NATIONAL REH AB ILITATION CENTER PHYSICAL THERAPY DEPARTMENT

Reference Limb:

LO RO Major Deviation

Major Problems:

Minor Deviation

Trunk (WA)

Latera l Lean : R/L Rotates: a l F

Weigh t Acceptan ce

Lacks Forward Rotation Lacks Backward Rotation Excess Forward Rotation Excess Badward Ro tation Ipsilateral Drop Contralateral Drop

Hip

(SLS)

Single Limb Support

Flexion: Limited

Past Retract Rota ti on: IRiER AD/ABduction: AD/ AS

Knee

Flexion: Lirnil.,d Excess Wobbles Hyperextends Extension Thrust Varus/Valgus: Vr/VI Excess Con tralateral Flex

(SLA)

Swing Limb Advancement

Forefoot Contact Foot Flat Co ntact Fool Slap Excess Plan tar Fl exion Exce s~ Dorsinexion Inv('fslon/E\,crs ion: /v/Ev Heel Off No Heel O ff

Excessive UE Weight Bearing

0

Name

Contrala teral

IIp Inddf>quat A Extem ion CICiwed/Hammered Clitia

Patient

to .!u(Jl LARI:.I R.. nf ho Lo!> A IIJlgu," Nltllonal RllhabillllitlOll Ct.-nler. OOWIlf'\ CA 90HZ

Diagnosis

#

Figure 10,3 I uil ljo~h Galt A ll ••I\ ... I... r·vrm I From Ol1 ...enaIHln.Li c..llt Anill) ...... Ittlldtxlo~ ,-\(' "lIh flt'rnll~~ I Ull I

-

.

bt: u ... t:d III t:1r,.trll ln~ )01[1\ ROM .11 tht: hlr, 1..nt!t'. dnd an1..le ,

h~ I..l~ Inl;

gOJl IOllk tfll Illci.l ... urt'11ll'nl" titreul) 11 0m the~rt:t:n )tulkr!-, ct ,t! InunJ Ill) \ 1t!IHl1r,lnt (1IIkrt'llu" bt.:tv..t:t'n g(jnllll11t'1 11~ !llca"Ufclllent ... 1..11..('11 lrolll \Ideo IJJ)t'd gilll and 11l1.: ..hurClllcllh Idhen f rorn lliul Inl 10 ( hll -

dltn .... 11h lC ldll al p.tI,)
I)

Jlollll.!1 dllldn:n '-' <.Jmpk ...

o j Ihe lw0l'e ...... 111\ nh cd III an DGA \\ ill be

prC'~cnted in

the

l ollu\\ Ill!,! ,edlUIl

Exalnination of VariabJe& I ht: ptlrpO"'l~ 01 thl '" ...el'tllHl i ... 10 introduce the pnx'('ss III all OUA Tht: fiN ~\!..'p In the proce'i~ invohe:-.

I moln~d

326

Physical Rehabilitation Bjomecbgnjcgl Gait Evglugtioo

I. Open Kinetic Chain

Righi

-. •

Heighl:_

®

ISupine}

leH

I1_ _ _ _ __

HIP Ext.

- .•

Dote: / / Usual Shoe Size: _ _

Inl.

KNEE Valgus

Usual Shoe Style·

Varus

Weight _ _

Recurvotum

•

-l• leH

_

MAUEOLAR TORSION lsi Roy

•

®

-.•

Hamstrings AJDF IKnee Ext. }

•

IProne} Righi AJDF IKnee FI"".} _ . STJ

o

lov.

Evr.

CD

- t-

•

0

Patient Name

•

_ .

_"Va I } Nevi. ICokuloted}_"Vo I } · In_O& .

FF/RF

II. Closed Kinetic Choin

_Vol } Tiblol Position _Vol } NCSP _Vol} RCSP

"'10._ ' & .

_ ' Vo l _ Vol _ Vol ?ha,hc

Angle of Go,I

Sublalor JoIDI

ObseNQloons

ob)Cryohoos

Contact

Pron - - Supn HS

R_l_

IlO P)

Fo<eIoof Slop Equ,nu,IUncomp } Steppage Go,ll R fe~.tItlOr\on

110.. of Go"

R _ _l

Toe Heel Go,1

Hl

M.dslonce

Exten_ Su!w

han

Abductoty T""", E~Hee

ScI)lOn GoI!

AIoA", Go' Tr b.,'9 Go"\

!.eng'" A S I S toMM ,m

____ em s.

Pr"""""", Hl

_ _ _ cm s

1 0 _-"-_---.J ---!_ r'YUf 10 .. HI he I.md {l

U

I

~

utlh", 1·ln In

I

U 1(1

auld

kJ

,( UDU: Ii

Chapte r 10 Examination of Gail G ait

which prevents use o f increased knee flexion to raise the pl antam e,ed foot above the floor' The therapist must be aware that patient s may use a vari ety of methods to com pensate for joint or muscle de fi cits.

H omunculus O bserved R elational T abulator A method of qualitatively representing observable abnormalities in gait ba sed o n / obvious deviations from accepted visua l norms. Basic G.H.O.R.T. template

Figure 10.5 G HO RT. (From Su therland . ec. H . p 1 ~9 wi th per· nll''l!'>ioll. )

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<.,ect If (he patient ha~ ei ther a stiff knee or extensor thrust. Recorded Points of Evaluation on GHORT -Head lilt

J--.-

---- Shoulder drop Arm length and SWing Back mldhne - - - H I p drop

o

- -- - Relative

~O~

327

angle

- -- - Patellar positioning

<- - - - Tibial variation - - - - STJ EAOM STJ neutral poSitIOn Aeartoot pOSItion Forefoot poSillon Example The GHORT to the right demonstrates a leh shoulder drop due to 11mb length discrepancy with longe, leg on .AT 0... lett and compensatory scoliosIS The,e ~ ~ IS Dtlateral compensated ST J vafUS with EAOM compensation on fight due to lorefoot varus . Top-Io·bottom, front ·to ·rea, sequence on GHOAT

Figure 106 Record mg pomu. of E\aiuat lon on GHORf (FOJlll Sutherland. C( ,J! p 11;>.1 wuh pern\lS~loOl

Review of Kinematic and Kinetic Parameters of Normal Gait Tables 10.2 to 10.7 prov ide a review o f the normal sag ittal plane joi nt di splacements, mo ments o f force, and muscle acti v il Y and fu nc tion. as well as the results of isolated muscle weaknesses and poss ible compensations. Tables to.8 to 10. 14 present so me o f the comm on deviations obse rved in a sag iltal pl ane analysis and probable causes for the dev iations. Tables 10. 15 and 10. 16 provide sample gait analys is recordin g forms. If the reade r dec ides to use the gait anal ys is recording fo rm s presented in th is text, reli abil ity tests should be condu cted because these forms are presented onl y as g uides and have not been evaluated. In Tables 10.2 to 10.7, the phase o f gait, the norm al joint d isplacement s. moments o f fo rce, and muscle activity are presented in th e Hrst four co lumns. and the effects of muscle weakness and poss ible compensati ons are presented in the last two co lumns (lhe reader should be aware that only the e ffec ts o f isolated muscle weaknesses and associated com pensations are presented). The purpose of the tables is to ident ify component s o f nonnal gait that must be considered when observin g gait and to prov ide an example of how to proceed with an analysis of the causes of an arypical gait pattern or particul ar deviation. Tables 10.8 to 10. 14 present some of the common gait deviations, as well as possible causes and analyses. Notice that the sample recording fo nn presented in Table 10. 16 is fomla lted in the same manner as Tables 10.8 to 10. 14. T he refore, the cl inician can use the sample analyses presented in the tables as g uides.

Directions fo r Performing an OGA Directions for ped 'orming an OGA for the sagi ttal and coronal planes are presented below. 1. Se lec t the area in which the parienl \"'ill walk and meas-

ure Ihe di stance tha t you want the patient to cover. 2. Posi lion YOllr~elf to a ll ow an unoDstructed vie\\ of the ,ubjecl. I f ti illling , the came ras should be positioned 10 view the pa l ie ll l '~ LEs and feel as we ll as the head and trunk.. from both the ~agitfai and coronal per~peclives. 3. Select the joint or ~c:glnenl 10 be obsened fir1>1 te.g., anllt: and foot). and mentally re \ lew (he nonnal displaccmem pallern ~ and muscle fu nctitllls. 4. Select ei ther it ~ ag lltal plane observa tion (view from the \ ide) o r a coronal pl.me ob-;ervution (view from the fro nt and/or back). 5. Ob"ervc the se lected segment duri.ng the initial pan of the ~w nce phase and make a decision about the position of the segment. Note any deviations from the nonnal panem. 6. Ob~erve either the ~ame segme nt duri ng the next pan o f the ~tance phase oj' anoth( r seg mem Dt the initi al part of

.\28

Physical Re habilitation

Table 10.8 Common Deviations, Ank.le and Foot: Stance Phase, Sa,gilttal

Inltlat contact

Mldstance

Push -off Iheel-off 10 toe-off)

Fool slap

At heel strike, forefoot slaps the ground.

Flaccid or weak dorsi· flexors or reciprocal Inhibition of dorsiflexors; atrophy of dorsiflexors.

Look for low muscle tone at ankle. Look for steppage gait (excessive hip and knee flexion) in swing phase.

Toes first

Toes contact ground Inslead of heel. The l iptoe posture may be maintained th roughout the phase. or the heel may conla ct the ground.

Leg length discrepancy; contracted heel cord: plantarflexion contrac· tion ; spasticity of plantarflexors : flaccidity of dorsiflexors; painful heel.

Com pare leg lengths and look for hip andior knee flexion contractu res. Analyze muscle tone and timing of activi ty in plantartlexors. Check for pain in heel.

Fool flal

Entire fool contacts the ground at heel strike .

Excessive fixed dorsiflexion: flaccid or weak dorsi flexors : neonatal/proprioceptive walking .

Check range of motion at ankle. Check for hyperexlension at the knee and persistence of immature gait pattern .

Excessive posittonal plantarflexion

Tibia does not advance to neutral from 10 degrees plantarflexion.

No eccentric contraction of plantarflexors: could be due 10 flaccidity! weakness in plantarflexors: surgical overrelease, rupture, or contracture of Achilles tendon .

Check for spastic or weak quadriceps; hyperextension at the knee; hip hyperextensian; backward- or forward· leaning trunk . Check for weakness in plantarllexors or rupture of Achilles tendon.

Heel lift in mldstance

Heel does not co nlact ground in midstance .

Spasticity of plantarflexors.

Check for spasticity in plantartlexors, quadriceps, hip flexors , and adductors.

Excessi ve positio nal dorsiflexion

Ti bia advances 100 rap· idly ove r the foot, creal· in g a greater than normal amounl of dorsiflexion.

Inability of plantartlexors to control tib ial advance. Kn ee flexion or hip flexion contractu re s.

Look at ankle muscles, knee and hip flexors, range of motion, and position of trunk' j

Toe claWing

Toes flex and "grab" floor.

Cou ld be due to a plan tar grasp reflex that is only partially Inlegrated; could be due to pOSitive supportmg reflex: spastic toe flexors .

C heck plantar grasp reflex, positive supporting reflexes, and ra nge of motion of toes.

No roll -off

Insufficient transfer of weight from laleral heel to medial forefoot.

Mechanica l fixatIon of ankle and foot. Flaccidity or Inhibition of planlarflexors, inverters. and toe flexors Rigidity ' coCont raclion of plan· tarfle;.;ors and dorslflexors. Pain in forefoot

Check range of motion al ankle and foot . Check muscle function and tone al ankle. Look at dissociation bel ween posterior foot and lorefoot.

-

--

lilt' hlfK~ ph a..,c. Pro!! re~ ... throu gh lht: . . "m~ pnll.:t!" . . .., ,t~ tn Ilumhcr 5.

7 Re peal tht' pll k. C "'~ dC'>t'nbeJ 1Jl nUIllI'x:, 0 unlll \ OU h ,l\l' twnph:lt'd ,in Oh"t'"r" JII,}o nt .tli ...egllle ll" ill lh~ ~al..! IIt,ll

and l.;f)IOIlJ.1 pl.lne..,. R~IlIt: m tx'r Iv

l,.'Ol1t:c n [I.II(' 1.111

()I ll~ ....l.t'

<

,I

Int.-nl .11 d II mt: III ont' lUll of the g JiI l.') c1e. Do nOl jump t n )1ll Oil\:' ....("'In - If I I .~ 1.: 1 l~ .lnvllel or fro m one pha. . e 10 W\Ofnu ,

!"I '-\ h"il \ ~ n.,', fonn -

1' '-

h

. h ,._.

0 \ t'"f\ ..tll\\I1\ on bolh SIdes ( ng l anu

Id l J. \I though 0111> Olll' ~IJt'" ITI .. \ be tlwolved patholog' It.,Ii). the \u h"'"' I' ... I'ut " n I' I h .· . d I..' rn.K.I) may be atlecle .

Chapter 10 Examination of Gai'

329

Table 10.9 Common Deviations, Ankle and Foot: Swing Phase, Sagittal Plane Analysis

Swing

Toe drag

Insufficient dorsiflexion (and toe extension) so that forefoot and toes do not clea r floor.

Flaccidity or weakness of dorsiflexors and toe extensors. Spasticity of plantarflexors. Inadequate knee or hip flexion .

Check for ankle, hip, and knee range of motion. Check for strength and muscle tone at hip, knee, and ankle.

Varus

The foot is excessively inverted .

Spasticity of the invertors. Flaccidity or weakness of dorsiflexors and evertors. Extensor pattern.

Check for muscle tone invertors and plantarflexors. Check strength of dorsiflexors and evertors. Check for extensor pattern of the lower extremity.

Table 10.10 Common Deviations, Knee: Stance Phase, Sagittal Plane Analysis Ponionof Phase 0 11 'lifer

! Initial contact

Excessive knee flexion

Knee flexes or "buckles" rather than extends as foot contacts ground.

Painful knee; spasticity of knee flexors or weak or flaccid quadriceps. Short leg on contralateral side.

Check for pain at knee; tone of knee flexors; strength of knee extensors; leg lengths; anterior pelvic tilt.

Foot flat

Knee hyperextension (genu recurvatum)

A greater than normal extension at the knee .

Flaccid/weak quadriceps and soleus compensated for by pull of gluteus maximus. Spasticity of quadriceps. Accommodation to a fixed ankle plantarflexion deformity.

Check for strength and muscle tone of knee and ankle flexors, and range of motion at ankle.

Mldstance

Knee hyperextension (genu recurvatum)

During single limb sup· port, tibia remains in back of ankle mortice as body weight moves over foot. Ankle is plantarflexed.

Same as above.

Same as above.

Push-off (heel-off to toe-off)

Excessive knee flexi on

Knee flexes to more than 40' during push-off.

Center of gravity is unusually far fOlWard of pelvis . Could be due to rigid trunk , knee/hip flexIon co ntractu res ; flexionwithdrawal reflex ; domi· nance of flexion synergy in middle recovery from CVA.

Look at trunk posture, knee and hip range of motion, and flexor synergy.

Limited kn ee flexion

The normal amount of knee fleXion (40 ) does not occ ur.

Spastic/overactive Look at tone in hip, knee, quadnceps andlor plan· and ankle muscles. tarflexors _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(heel strike)

eVA

cerebrovascular accident

J

.\30

Phv\;('al Rehabil;t.,'ltion

Table 10.11 C ommon Deviations, Knee: POd'

aL _===:-~ ---~~

Phase ,

Plane Analysis

_:-_.~===~~~~~~~~===~~~~~~~ DI. .10. ____~--, _=-'d4~a~ I~s~~~

Acceleration to mldswing

Excessive knee flexion

Knee flexes more than 650

Diminished preswing knee flexion, flexor-withdrawal reflex , dysmetria.

Look at muscle tone in hip. knee , and ankle. Test for reflexes and dysmetria.

Lim ited knee fleXion

Knee does not flex to 650

Pain in knee , diminished range of knee motion, extensor spasticity. Circumduction at the hip.

Assess for pain in knee and knee range of motion. Test muscle tone at knee and hip.

A n addill onal (bl an k ) sample recordi ng fonn for OGA is prese !1led III Appendi x A. Another (compl eted) samp le record mg f01111 for OGA is presented in Appe ndix B with therapist e ntri es as they mi ght appear following completion of the gall an al) ~ j s.

OGA in Neuromuscula r Disord ers The gait pauems of ind ivid uals wi th neuromusc ular deficilS are influenced pri m arily by abnonnalities in muscle lone and synergi sti c organ i zat ion. influences of nonintegrated earl y reflexes. and a decrease in influence of righting and

Table 10.12 Common Deviations, Hip: Stance Phase, Sagittal Pla ne Analysis Ponion of

Phase Heel stnke to fool flat

Heel strike to fool flat

Deviation ExceSSive flexion

Limited hip fleXion

Deoc:ription Flexion exceeding 300

HIp fleXion does not attam 30

Hip and/or knee flexion contractu res . Knee flex ~ Ion ca used by weak soleus and quadriceps. Hypertonicity of hip fle xo rs.

--- - -

Weakness of hip flexors. limited range of hiD tiexion Gluteus maxlmus

Chec k hip and knee range of motion and strength of soleus and quadriceps. Check tone of hip flexors.

- - - - -- Check strength of hip flexors a nd extensors . Analyze range of hip motion.

wea",.,ess Fool flat to mldstance

Limited hip extension

The hip does not attain a neu tral position

HIp flexion contracture, spastlciiy III hlp flexors

Check hip range of molton and tone o f hip muscles.

Internal rota tion

An Internally rotated POSition of the extremlt'y

Spa ~tlClty of Inte rnal rotators Weakness,Jf external rotatms ExceSSive forv.ard rota· tlon of OPPosite pelv,s

Chec k tone of Internal rota· lors and strength of external rotators Measure range of motion at both hip 10Lnts.

External rotation

An ext ernall y rol(;l ted POSition of th e extremity

ExceSSive backward rotation of oPPosi te pelVIS.

Assess range at motion at both hip JOints

Abduction

An abducted position of the extremity

Contracture of the gluteus medIUS Trunk lateral lean ovel the Ipsilateral hip

Check for abduction pattern.

AdductIon

A n adducted posItion 01 the lower eXh emlty

Spasticity of hlp flexors dod adduCfor~ such di) ~een In spas tic dlplegld elvLc dmp to Cont raIdh~rQI Side

Atisess tone of hip fleJ(o(S anJ adductors Test muscle .t, ngth of hip abductors

:

I t .

330

Physical Rehabilitation

Table 10.11 Common Deviations, Knee: Swing Phase, Salvttol ... 1 •• ., 0;' t :

......

Acceleration to midswing

Excessive knee flexion

Knee flexes more than 65°

Diminished preswing knee flexion, flexor·withdrawal reflex . dysmetria.

Look at muscle tone in hip. knee. and ankle. Test for reflexes and dysmetria.

Limited knee flexion

Knee does not flex to 65°

Pain in knee , diminished range of knee motion, extensor spasticity. Circumduction at the hip.

Assess for pain in knee and knee range of motion. Test muscle tone at knee and hip.

An addilion,,1 (blank) sample record in g fonn for OGA is presented in Appendix A. Another (compleled) sample

recording foml for OGA is presented in Appendix B with therapist enlries as they might appear following compleLion of the gail analysis.

OGA in Neuromuscular Disorders The gait patterns of individuals with neuromuscular deficits are influenced primarily by abnonnali ties in muscle tone and synergistic organization. influences of nonintegrated early reflexes. and a decrease in influence of righting and

Table 10.12 Common Deviations, Hip: Stance Phase, Sagittal Plane Analysis Pomon of w'j.; . Phase D .' .. , . Pc AkCr II "

Heel strike to foot flal

Excessive flexion

Flexion exceeding 30°

Hip and/or knee flexion contractu res . Knee flex· ion caused by weak soleus and quadriceps. Hypertonicity of hip flexor5 .

Check hip and knee range of motion and strength of soleus and quadriceps. Check tone of hip flexors.

Heel stnke to foot flat

Limited hip flexion

Hip flexion does not attain 30°

Weakness of hip flexors. Limited range of hip flex· ion. Gluteus maxim us weakness .

Check strength of hip flexors and extensors. Analyze range of hip motion.

Foot flat to midstance

limited hip extension

The hip does not attain a neutral position.

Hip flex-:i-on - c-o-nt-ra - c-,-u-re-.- -C- h-e-C-k- h-i-p-r-a n - g- e- O-f -m-o-tio-n-

Internal rotation

An internally rotated position 01 the extremity.

External rotation

An externally rotated position of the extremity.

Abduction

An abducted position of the extremity.

Adduction

An adducted POSItion of the lower extremity

spasticity in hip flexors.

and tone of hip muscles.

Spa
Check tone of internal rota· tors and strength of external rotators . Measure range 01 motion at both hip joints.

Excessive backward rotation of opposite pelVIS.

Assess range of motion at both hip jOints.

Contracture of the gluteus medills Trunk lateral lean over the ipsilateral hip. SpastiCity of hip flexors and adductors Such as seen In spastIc diplegia. PelVIC drop to contra. lateral Side

Check for abduction paUem.

Assess tone of hip flexors and adductors. Test muscle strength of hip abductors.

--

_.----"

I

I

i

Table 10.13 Common De \'ia lions, H ip: Swing Phase, Sa ;gi,'a l

SWing

l

Circumduction

A lateral cI rcular movement of the entire tower extremity consisting of abduction , external rota tion. adduction. and Internal rotation

A com pensallon for weak hip flexors or a compensation for Ihe Inability to shorten tile leg so Ihat It can clear Ihe floor.

Check strength of hip flexors , knee flexors , and ankle dorsi· flexors. Check range of mollon in hlp flexion. knee flexion. and ankle dorsiflexion. Check for extensor paHern.

Hip hiking

Shortening of the sWing leg by action of the quadratus lumborum.

A compensation for lack of knee flexion and/or ankle dorsiflexion. Also may be a compensation for extensor spasticity of sWing leg.

Check strength and range of motion at knee. hiP, and ankle. Also check muscle tone at knee and ankle.

Excessive hip flexion

Flexion greater than 20-30 degrees

Attempt to shorten extremity in presence of foot drop. Flexor pattern.

Check strength and range of motion at ankle and foot. Check for flexor pattern.

~al.lIlc{, n':-~IC1I()n .... di:-.soc ialloll alllong

body p.. n ~. :lnd incoordllutU)Il . II pro\.imal ~ Iahllll) (co-colllraciion of tht' P()~ ­ turJI mU'Il.:k' ... llf the trunk) i~ Ihrralcncd h) atypicall y !lm . lu!:!h, or Iluclu,-lling. l1lu~dc lont.'. controll ed mobilit y i!o los!. In gall ..\ 10...... of rontrol over the :,equenlwlliming of muscular ;.Jcti\tt) may re,lIlt 111 :I,) mmctrical .., tcp and ~ trid e length . . In add itIOn . dev iation:, from 110nnal po ~ ture and

Illolion may occlir ~ uch as f(1rWurd or bad.wnrd trunk lenning. cXCl!ssi\C' fle:\ion or ex tension al the h ip and knee in the ~tan(~e phase. ;Ind dimini~hcd dor,;:ifle:\ion or cxccs~ive plamarflc xion . In th e prc ~c n ce of J1l ull ip lc musc le invo lve ment or neurologica l dcficil s Ihat affect balance, coordination. and rI1u!'>c le lone. the de v iat i on~ obse rved and the ruullysis of

Common Devia.ions, Trunk: Stance, Sagittal Plane Anal ysis

r

I Stance

I

---Lateral trunk lean

A lean of the trunk over the stance extremity (gluleus medius gaiV Trendelenburg gait).

A weak or paralyzed gluteus mediUS on the stance side cannot prevent a drop of pelvis on the swing Side. so a trunk lean over the stance leg helps compensate for the weak muscle. A lateral trunk lean over the affected hip also may be used to reduce force on hip if a pati ent has a painful hip.

Check strength of gluteus medius and assess for pain in the hip.

Backward trunk lean

A backward leaning of the trunk, resulting In hyperextension at Ihe hlp (gluteus maximus gall)

Weakness or paralysis of Ihe gluteus maximus on the stance leg. Anlenorly rotated palvis.

Check for strength of hip extensors. Check pelVIC pOSition.

Forward trunk lean

A forwal d leaning of Ihe trunk, resulting In hip fleXIon.

Compensation for quadriceps weakness. The forward lean eliminates the fleXion moment al the knee . Hip and knee flexion contractu res .

Check for strength of quadriceps.

A lorward Ilexion of the upper trunk

Posteriorly rotated pelvis.

Check pelvic poSition.

I

I

L_

---

--

-

332

Physical Rehabilitation

r~~a~b~le~1~o~.~1~5~G~~ai:'~An~a~I~YS~i~S~R~e~c~o~r~di~n~g~F~o!rrn~::;;~~

l

::::::::~~~~ Tothe

Head Trunk Pelvis

1

leh

Backward To the leh Backward To the leh Poste rior On the leh

Hlp

On the leh On the left

On the leh On the left

Knee

On the leh On the left On the leh On the left Anklelfoot

On the leh On the left On the leh On the left On the leh On the left

Iht''>c l.1n lallOlh \\.111 be mure (om plc \ Ihdn IIldKal cd

lhe labln. [,..dlllpk ... of gou t p;Jlh:rn, Oh~l·r.cd ilfJ/1 V. Jlh \pa"'llcil~ anti .... llh hYPulunu , 10 110 ....

til

In " .....OC"hi-

An lI11hviduJI \\ IIh "p~hlh: lI ) (e.g. JII Inth 'ldu.11 ,I, Jlh dlrk~il (';cn:hIJI pal..,y) nl,l~ 11<1\'1.: .t po ... h:: norl ~ tdt..::d T"",.'hI S I Uf\1,.a.nJ Ikxllln 01 Ih" liPpU I rlln~ . pwlral.:kd "'Li.lrdl~H:

.Inri

..,t lln\:\\ hill

eXl'l-,'i/\t

II t'l)..

(· ... It·n ,ilill

1 ~·t'!I"'I\e hip tk"uJII '\llh illkhKlill1l ;.tllll mklll.d 1(l1 ~II JIIU ht' ob"l.'I\I..'d lh lllll ~ .. I a nn' ,HId lI1 i l) Ix:

I'u ... ,orlfl~j m,,~

d\:I"OlilpalllcJ b~ t'lIhl"( c\.t't' ..... i\c I-nn' Iln.luil or h)IX'fC\!trhlon

II eX~t""I\t: h rltT

tle>.HIIl U{:~Ul' dUllllg " 1.1IKl'

d"''''IIlc.II;.lllJl iJl Ihl: .1I1Io..k· 1I1..a~

h•.~ l·\Jl!:.'l'IJlt'd UW 1Il~ I.Ul

... I,t 1Ildpl \:;,Wlllg III ,llhJIII.:~ tin: li h .... (1\('1 till' .tnt- tc .UI~I

('h.-,if 11ll' lOt·., .lIId foretool hOIl1 tht: ground after push..off ~hl'd nil I.) tot" dlfl

In (1IIIC( mill" Iliu,lI ... \\ Ith h~ ~nllnia. h)-perc,\telbIOO ~11I:l' (X\'m ... In ... Iilfh.:e and Imt) be 3l compamed il\ pLllllarlll'\il1n ,mil ltl\t.'f... IOIl ,II Ih(> 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<." gastrvcnemltb,oku ... lIlu ,d~ gn\up... rhl' h;llIhtnng .... l;. tureal. IUld dor.;1 tI\·'OI mu,,\'h' glOUp, Ill.!\ ~ tCL:ipnx:ull) IIItllbued. I II IlIdJ\lJU;II" \\II,Ii Ill\~ lllu'I,:k tOUt' lh)potllCli",) UlI~ tfunh. prll \IIII,tl"I<10,11I, ( h) ni(' C\ h," hl()(1 Jnd l'o-l'UOlmdJ(lll III <1' 1..11 fllU"lk·.,) I... J';llItll"hl'd ['he lk'l\l~ may ~ Wllt'n\)11., lilted "'0 'Ii..&' IIh' UI'I"II.tf lJ1lIl).. I, !l lighlly t:xtcudc."tt. The: .11 Iht.'

Chapter 10 F..xaminatioo of Gait

Table 10.16 Recording Fonn for Observational Gail Analysis Age

Patient's name Diagnosis Footwear Date

WeIght _ _

Height

Sex

Assistive devices Therapist

DIRECTIONS: Place a check In the space opposite the d eviation if the deviation is observed .

Ankle and loot

None

Observations

Foot flat

In the 5agi"al plane

Foot slap

A

L

A

L

R

L

R

L

A

L

R

L

A

L

R

L

Heel off No heel off Excessive plantarflexion Excessive dorSiflexion Toe drag Toe clawing Contralateral vaulting Observattons In the frontal plane

Varus

Valgus Knee

None

Observations In the 5a9,"al plane

Excessive flexion

Limited flexion No flexion Hyperextension

I

Genu recurvatum Diminished extenSion Observations in the frontal plane

Varum

------

Valgum

--

~ --Observattons

In the sagittal plane

-

None

I-

ExceSSive fleXion

-(con Nnued)

Physical Rehabilitation

334

~' Limited flexion

,~

No flexion

Diminished extenSion

ObservallOns

Abduction

tn the Ironlal plane

AdducllOn External rota lion Internal rotation

,

Circumduction Hiking

Pelllis

None

ObservaltOns In sagittal plane

Antenor tilt

Postenor till Increased backward rotation

Increased forward rotation •

,

LImited backward rotation

I

Limited forward

+

I

l-t

rolallon

Drops on contralateral

-- ~

None

Obser/atlons In frontal plane

Backward

I -----

I

! rOlallon

+-

-r.:Forward

1

--

i __ ,

,

Late f dllean

~

-

ACC

i

-r --

--

Backward lean

I

Forward lean

~

accelefailon, DEC

-

-

t---, ...L

..1

deceleration FF mldstance , MSW "" mldswlng , TO loe off

"-

[

fool flat , HO

I

--

-

--

rotation

--

i

f--

Trunk

- f--

-

-L

heel off, HS

,

"-

-1

-

heel stnke; MST

Chapter 10 Examinatjon of Gait scapul ae may be retracted and the head may be forward . Durin2 stance, the hip may be flexed and the knee may be hyper~xte nded, accompanied by pl antarnexi on at the ankl e. TIle foot may be pronated with the majority of bod y weight bome on the medial border. Frequentl y, these indi vidual s lihow dimin ished longi tudinal trunk rotati on and slu ggish trunk balance reactions. TIley lend to rely on protecti ve exten,ion reactions of the limbs to maim ain balance . The qaggering or ~Ie p ping reactions of the lower ex tremities may be pronounced. stli de length and step length may be un~ven. and gait may be \.I, ide based and unstcady. AJthough the gait patterns in neurol og ical gait may be comple\ and an analysis of thc ca uses may be difficult. a detai led OGA can provide valu able data. Generally. to analyze gait patterns in persons v,'ho have sustained neurologi cal damage. the follo\\ ing prelimi nary questi ons must be asked : \. What i., the influence of abnom1 31 tone (hypertonicity and hypotonicity) on posi tion and movement ? ') Ho\\ does the posi tion of the head influence musc le tone. position. and move ment? 3. Ho\\, does weightbearing influe nce mu sc le Lone, posilion, and mO\ement? .,L Wh al i~ the influence of abnorm al (obligatory) synergio:;tic aCTIvity on position an d movement? 5. What IS the influence of weakness (pares is) on positi on and mO\ement ? 6. What is the influence of coordi nation defi cits on posi\Jon and move ment? 7. What i'> the mfluence of impaired balance reacti ons o n position and movement?

Ambulation Profiles a nd/or Scales Profilc~ and ratmg scales constitute types of gait analyses that often include both qualitative (observational) and quantJtalJve (" patla) and tem poral) measures. Profil es and scales are u<.,ed for if \'ariet) of reasons. for examp le, ex am inati on 01 amhulatifHl ~kllls, 1<1 determination of the patient 's need for a.··,-.i-.lalH.:e. identifi cation of a !.:hange in a pat ient 's statU\. ,>ucenmg fo r Identi fi cation of the patient's need for phY"'lcdl thc rapy ..of' and identification of elderl y indi viduals .... ho are a\ n..,~ for fallmgY Gai t analyses of one type or another ma~ be eIther the sole focus of a profi le, or the gait andl )si-. mil)' conslIIute onl) a . . mall porti on o f a broad examlf\;,i!lon profile that IIlciudes balance ..,kills as we ll as other ftuKtiollal a(;l i v IlJ e~. One pal1icul ar ad vantage of ~ome 01 t ht:~..: profiles I~ that !>ubordinate gai t ski ll s such as 'ltandUlg balance may be examliled in individ uals who may not ht >JG!c to \.I,alk una . . ..,i..,red Si nce mallY o f the~e pro fil es were develuped for u':>e \V llh ~pec lf"j c populat JOIh, com parau'vC' datd TlIay Ix: 3\i!Ildblf! to the Iherapi "i. Th~ !olluv.ing prolde~ ha ve bCl!Jl se lected fo r review In Ihl,) c.:hupler be('au~e (hey are III current Ul:.t: and have hccn txanllned for reliabilit y andlor va lidi ty rhe FUlle· 1l0lldl Amhu lation Prolik (FAP) ,''1 Iht' Emory Functional AnibuL.ll lOn Prolilc (E J-A P) and Ihe Modl/ied Emory

335

Functional Ambu lation Profile (mEFAP)." the Iowa Level of Ass istance S core :~ 2 the Functional Independence Measure (FIM )," the Functional Independence Measure (FIM) plus the Functional Assessment Measure (FAM) or the (FlM + FAM).'" the Functional Independence Measure for Children (WeeFlM)," the Gait Abnormality Raling Scale (GARS)" and the Modified GARS (GARS-M)," the Dynamic Gait Index. Berg Balance Scale,23 and the Fast Evaluation of Mobility. Balance. and Fear (FEMBAF)." Functional Ambulation Profile and Modifications The Fllnclional Amhillation Profile (FAP). developed by Arthur J. Nelson PT. PhD, FAPTA, is designed to exam ine gait skills on a cominuum from standing balance in the parallel bars to independent ambulation. J9 A stopwatch is used to measure the amount of time required either 10 maintain a position or penorm a task. The test consists of three phases. In the first phase, the patient is asked to perform the foUowing three tasks in the parallel bars: biJateraJ stance, uninvolved leg stance, and involved leg stance. In the second phase. the patient is asked to transfer weight from one extremity to another as rapidly as possible. In the third phase. the patient is asked to walk 20 ft (6 m) in the parallel bars. with an assistive device, and, if possible, independently. A more recent version of the FAP developed at Emory University is called the Emory Functional Ambulatioll Pro}ile (EFAP). This profile differs from the original FAP in that five environmental chalJenges have been added which the individual may negotiate with or without the use of o rthotics or assislive device. The modified Emory Functional Ambulation Profile (mEFAP) incorporates manual ass istance into the EFAP. Subtasks include 16.4-ft (5 m ) walh on a hard floor and on a carpeted floor, ri sing from a chair and completing a 9.8-fl (3 m) walk and sitting back down (timed get up and go test) , negotiating through a standardi zed obstacle course and ascending and descendin g fi ve stairs. Iowa Level of Assistance Scale The Iowa Le\'e/ of Assistance Scale examines four functional lasks (one o f which involves gait): getting out of bed. standing from bed. ambulatin g 15 ft (4.57 m). and walkin g up and down three steps. The patient's perfomlance on the tasks is rated according to the following seven leve ls: ( I ) not tested for safe ty reasons; (2) activity attempted but not completed; (3) maximum ass istance (therapi st applies three or more points of contact); (4) moderate assistance (therapi st appli es two points of contact): (5) minimal a.,slstance (therap iq provides one point of contact); (6) ~ t a nctby assistance (no therapist contact but therapist not comfonable leav ing palient); and (7) independence (therapist comfortable leavin g room). Functiunal I ndependence Measure The Fw/( tiof1al l ndl'pel1defl ct' Measure (FIM ) is (h~ result of a projC'ct funded by The National mstitute of Handicapped Rl!sca r(' h. whi ch Wih conducled in order to deve lop a

J36

Phy~ical

Rehabilitation

Table 10.17 The Functional Independence Measure (FlM"') Instrument Seven-Point Scoring System for Locomotion-Version 5.1 . . t d'ng position or if using a wheelchair once in a LOCOMOTION: WALKIWHEELCHAIR: Includes walking . once In a s an I de ~I locomotion (Walk or Wheeicha' seated position . on a level surface. Performs safely. Indicate the most frequent rna If). If both are used about equally, code : "80th."

NO HELPER 7 Complete Independence-Subject walks a minimum of 150 ft (50 m) without assistive devices. Does not use a wheelchai r. Performs safely.

6 Modified Independence-Subject walks a minimum of 150 ft (50 m) but uses a brace (o~hosis) or prosthesis on leg, speci al adaptive shoes, cane , crutches , or walkerelte ; takes more than reasonable lime or there are safety co nsiderations. If not walking, subject operates manual or motorized wheelch air independently for a minimum of 150 ft (SO m); turns around; maneuvers the chai r to a table , bed , toilet; negotiates at least a 3% grade; maneuvers on rugs and over door sills.

5 Exception (Household Ambulation )-Subject wal ks only short distances (a minimum 0150 It or 17 m) Independently with or without a device. Takes more than reasonable time , or there are safety considerations, or operates a manual or motOrized wheelchair independently only short distances (a minimum of 50 ft or 17 m). HELPER

5 SuperviSion If walking, subject requires standby supervision, cueing, or coaxing to go a minImum of 150 ft (50 m). If not walking , requires standby supervision , cueing , or coaxing to go a minimum of 150 ft (50 m) in wheelchair.

4 Minimal Contact AssIstance-Subject performs 75% or more of locomotion effort to go a minimum of 150 ft (SO m). 3 Moderate Assistance-Subject performs 50% to 74 % of locomotion effort to go a minimum of 150 ft (50 m).

2 Maxim al Assistance-Subject performs 25% to 49% of locomotion effort to go a minimum of 50 ft (17 m). Requires aSSistance of one person onl y. Total Assi stance-Subject performs tess than 25% of effort, or requires assistance of two people, or does not walk or wheel a minimum of 50 tt (17 m).

Comment: If the su bject requ ires an assistive device for locom oti on: wheelcha ir, prosthesis, walker, cane , AFO, adapted shoe, etc., the Wal klWheelchair score can neve r be higher than level 6. The mode of locomotion (Walk or Wheelchair) must be the same on admiSSion and dlschafge. If th e su bject changes mode of locomotion from admiSSion to discharge (usuall y wheelchair to walking), record the admission mode and scores based on the more frequent mode of locomotion a t discharge . Frcm Tne Untform Data System for Medical RehabihlahOn, a diVISion of UB FoundatIOn ActiVitieS Inc UOS'~I ~I GUIde for the Untfonn Data Sel for Medical Rehabilitation (Including the FIMTM I:'lSlrument). VerSion 51. Buffalo' UOSMA. 1997, With permission

GUide- for a L IliionTl D.l1..l St: tl or ~h.~dlcal Rell;l bl1 i t J II Ol1.~" I hl fl\11~ (.Ic~I).!.rH.::d 10 e\.lllllnc a P..l l lt'llt\; pJ'(lg le,>~ 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<.JhdJtJIIOn 'I ht Fl :\ l 1:-.110\\0

propncl.JI). J.nd Ill ..: f-IMI ~1 1,... the f J,ldelTldf"- o j Ihe U i llfl )fm D .II.1 .)~~tl:1I1 flu I'I.h :dl(,JJ Rt1i.l. hdHJ.lioll , ..I d'Vhl( ln (1f til" l.IJ!\~r"'") 01 Butt.Ito I--OUlHJiilltHl Ann IIln. 11K lh e H f\. 1 i.o( \11111111011 ~.I JJ../\\hedthJir GUide '\ Ihe: P Ullhlll (l l lh~ (1I1Ilk fll( the LIlJ tonn !Jolla ~d fllllludlll~ tilt. 11 1'1. 11\1 lmtrulOcnt 11t'I.IIl'J III gJ.iI (Table 10. /7, A ,""ud) de\Jl!lIld In l'\JluJh:' the ul.:I..U1
FUI1(· litlnal.\ \~t'~\nu~ nt .\ l ew. urt> Thl' 12 JtUIi F'I II/t"ll(lll.ll 4 Ht'\.\l1tt!/t ,\l l'({lU/'t! (FAM l "as (I~"l'hll~'d h~ .1 lI1uhIJI ... (,'iphn ~lr) g roup of dil1lctans at Sdnt.1 ( I.u ..t \ ,tlie} \it!JIl'<11 CC ntt'f, ~an Jose . CA,.w to pro\ Ide d OIt'.I\Ul\' IJf lhc;.lPllm I h a l rl'llccled the- comm unicathIn p')lhll\O<.ldl atillJ!'>l llI('nt. J.nJ ,,:ognlll\l> functions of Ih .... pI.lpU lal hlll'> oJ uu!tvitiuJI ... \\ ho .)lhlajnt"d traumatic hl.UII IIqUI\ ( 181l a llJ \tro ~1;·. rl· ... ,)c-'<.II\·~I) . T ht: FAM u~s .1 "'l·\~n·pt)tnl r,lllflg ,,,:all' ITILXldcd atlcr the- FIM to eum· Ilk' llil· Jl ld lnJu.ll\ Ie\e l or degreJ: of indt:pendeflL"~· J.nhllUIl 0 1 J", . . tan •.:\,.· fl'lluir..:d , u . .c ot dOJPu\'e or a'> 1~l1ve

C hapler 10 Examination ofCait

Table 10.18 The Functional Assessment Measure (FAM) Items - - - -7-. -E-m - otional Status 1. Swallowing

.- -

-=l

2. Car Transfer

8. Adjustment to Limitations

3. Community Access

9 . Employabi lity

4. Reading

----1-0-.-0-ri-'-e-nt-'-a-ti-o_n-_-'-_-_~-]-

5. Writing

11 . Attention

6. Speech Intelligibility

12. Safety J udgment

The 12 items of the FAM are not de signed to stand alone bulla be added to the ' 8 Items of the FIM to produce the FIM + FAM. COurtesy of Santa Clara VaHey Medical Center (1998) . The FunctIonal Assessment Measure. The Center for Outcome Measurement 10 Brain InJury. Retrieved August 23, 2004 fro m http://tb,ms org/combi/FAM .

de\ Iceli. and percc l1I age of tasks com pleted successfull y (T,ble 10. 18). The 12 ite ms of the FAM have been added to th e 18Item FIM to produce the FlM + FA M with the illient of prmldi ng more detail ed data for TB I and stroke pop Ul ati on

group,. The FIM and FIM + FAM 10lal scales are psychome trically si m ila r me a sures of globa l di sa bilit y \\herea~ the 8 1. FIM . and FIM + FAM motor scales are similar measure.., of ph y~ i c al di sability.5o Howeve r. in a

<..Iud)" of 376 stroke patie nts in Canadian inpati ent re habil Hallon unit ....... ho were concurrentl y given the FIM and the FAM. the re..,u!t\ of a Rasch ana l)s is shov. cd that in the

motor dOITIJin only the FAM commun ity acces~ item was more difficult than the FIM i t e m ~. In the cognit ive domain. the onl) FAM Ilt:rn that extended the range of the FfM was the ont.: ,b",c'I..,ing employabilit y. In light of the rc ... uit s. the author from the !liversit )' o f Buffal o concl uded that addmg t'le" FAM Hem ') to the FIM red uced test e ffi c iency and prO'ldl:d only min im al protec ti o n aga inst ceiling

chew. ,,1 the

F I M. ~'

Fun ction al (nde pende nce M ea sure fo r C hildre n The ongmal \'er~ lon 01 the FUI/('110lwl II/dependence ~1(,1J\lJt{' [or CIllldren nreeFIM) con..,i..,ted of 18 items

IIlVolvtng the 10l luIWjng 6 ., ub!.ca l e~: ( I ) ..,e lt -care. (2) s ph i nc~ ler runtl\)!. (3/ tntn~ fc r~. (-l) locomotion, (5) co mlllllJli c a ~ llon. Jnd (6; )'ociai cog.n ition. Tht! Wee FIMI? i!. dt:!. igned to mea\urc: the need fo r :.t">"I<,tancc and the \cve nt ) of (ll sa b i l ~ II) In I..hTldren between the agc~ of 6 month!. and 7 ) ear!.. fhe WI...t:FI\1 II ' '.\ \y~tt:m j., an onli ne pedi:.llnc nu ll.:olllt:~ management S) ')tem, which document-. fu nctional pcrl-o rnl. diKe III dlildrell ilnc! ..tdo l c~e nl" wi lh e ither aC4uircd or I.;on· gl;l1l1al di..,ahlllllt:S 111 all t ype~ 01 ')elllll g)' (inp"lll t~ nt , oUlpa· Utnl. and commun il yl Data frol11 u..,e r" of the FIi\ 1 anJ \\.ed 1M ha\'\.; been rc::poned fo r a num be r uf ) CJ r') 10 Ihe rllll J\idtlonal Rt'habd ll3lion Repul1l1lg SY!.iC I11 at lhe LIlI','cr.., l1> 01 BuH"lo, Foundatio n ACII \ lites 1J1C.4 ~

337

Gait Ab normalit y Rating Scale and Modifications The Gait Ahllormaliry Rarillg Scale (GARSI was designed to identify patients li ving in nursing hom es who were at ri sk for falling. Time, space. and resources are often very limited in nursing homes, and the only expenses invo lved in admini stering the GARS included purchase of a camcorder and videotapes and the therapist's time to film , review, and rate the videotapes. The test deve lopers selected 16 features of the gait cycle and a scoring system, in whic h the features are scored on a 0 to 3 rating scale (0 = normal. I = mildl y impaired, 2 = moderalel y impaired. and 3 = severely impaired). Because the GARS scores correlated we ll with walking speed, stride length, and with ri sk of failing, the instrument appears to be a valid predictor of the hi story of falling when used with nursing home res idents. Ann·swing amplitude, upper and LE synchrony, and guardedness best distingui shed fall ers from other subjects. However, the GARS does not provide infoffi1ati on regarding the type of fall s (trips, slips, losing balance) sustained by this population .52 Therefore. it is not he lpful in detemlining the cause of the fall s. The Modified GARS (GARS·MI. which is a modified seve n~ite m version of the GARS. contains the following variables: (I ) variability, (2) guardedness. (3) staggering. (4) foo t contact. (5) hip ROM. (6) shoulder extension. and (7) arm- heel strike synchrony. These variables were selected fo r inclusion because they were found to be the 1110st reliable in the ori ginal GARS , Scoring is the sum of the seven items: the (otaJ score represents a rank ordering fo r risk of falJin g based on the number of gait abnormalities recogni zed and the severity of any abnormality idemi· fied. A hi gher score is associated with a more abnormal gail. The GARS-M has been dee med a good prediclor for pe rsons at ri sk for falls.22 Shum way-Cook et al ~3 examined the following four instruments in an attempt to develop a model for predicting the like lihood of fa lls among community·dwe lling elderl y (65 years of age and older): ( I) Balallce Self Per('{'ptiolls Test. (2) Berg Balance Scale, (3) mobility (timed walk ing at self-paced preferred speed and at fast , peed fo r 50 feel 11 5.2 mI). and (4) Ihe Dynamic Gait hIder. The Balance Self Percepti ons Test is a self· rating of the degree LO which balance and pe rceived risk for falls imerfere with dai ly activ it ies, The Berg Balance Scale is a perfom1ance-b::t!.ed measure of bal ance and mobility, in whic h subjecls are rated on a 0 to 4 scale (0 .::::: cannot per· form tl.1 ~ = n0l111ai pc:rfonnance) on 14 dlfferent tasks (,eo Chapler R. Appendix A). The 50-[001 Will/.. rest for mohi lil y is IlIlled, and mean ~ peed i.. calcuJ:ued for both \c lf-p"ced and fa ~ te st speed. The Dynamic Gait Index is desig ned to exami ne the ability to adapt gait LO changes in til..,!..
338

Physical Rehabilitation

pivot turn ~ and ~;tep~, Although the DynJlll,ic Gait Ind ex. wa!:l Included 3\ one of the fJl.:tor:-. that predICted J n , k 0 1 falling. the linal modcl included on ly the Berg Bal ~lI1ce Sc31e and hi:-torv of fJlling. \\ ilh the Berg Balnncc Scale being tht' hn t si'ng lc predictor of fall ~t alU:-. . Patient s who have'" hich ~core:-. on the Berg Balance Scale havc a rela tively lall ri,J.. . wh ile patients wi th a ~c,o re or Ic:-.s \Iotal pu:-. . . lble ,C{l rc IS 56) ha ve a hi g l~ n,k lor 13~1~' and would appear to he candidate!' for phY'lcal thcrapy.-

I;w

?f4?

Fast E" ;tluation of Mobility BahHlce and Fear The FOSI £\'O/IlClIIOII oI M (Jhili ty Balal/ ce lIlId Fear (FE/lfBAF J i'l another IIl~ t rU11le llt dc:-.igned 10 idcnl if): ri ... k laclor'. functional pl: rfofmn nce, and factor~ that hlllder 1l1obdit\, It con:-.i :-. h of a 22-item ri sk fac tor questionna ire and an ~ IR-Itelll performance com ponent. whic h include:-.. amon!! othcr me;:l:,urc,>, qair cl im bi ng and descendi ng. 'teppl~lg over an ob:-.wdc. and one- legged :-. tanding.

Kinematic Quantitative Gait Analysis Kinematic quantlwtivc g~\ it anal y:-.is i:-. u:-.ed to obta in informall on on 'pallal and temporal gai t \'ariables. rut \.\cll 3S motion palt~m" . 111~ data obtained through thc~e analyses are ljuantiflahle .md Ihclefore provide the therapist \\ ilh ha<.,elmc data thai call be u:-.ed 10 plan treatment program ... and e\'a lual e progre~ . . to\\ard goab or goa l anainment. The lact that the d::lla arc qU~H1tiliahlc is important because thirdpan) payer. . arc demanding that therapists u:-.c mea:-.urable paramete r . . \\ hen c\ami ning pa tient fun ct ion, cSlabli,hing treatment q ral e£le,>. and documenting the oulcolllc:-, of a plan of care. HowC\cr. data derived rrom qua lita(i\c obser\ allons ma;.- be Ilcces ..... lry 10 deten11lne degree s of Illotor ImpaimK'nl. and tt) cht:(:k the va lid it) of the quantitatlw \ iUlahlc ... mca:-.urcd. For example, c\am inarion of . . p~\lIal ;md temporal \'a n able~ i\ Ilcce . . '>ary for the Inlcrpret, 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.. ~hllp III tht: local . . upcnnarl-..cl. 1 h~IJPJ <" h nu:d to wrvcy the l'OIl1I1I1I1l II) 10 tit'tC'IllHllt' the d"lanc\.' \ ,lnd time It'ljulh,' mt!nh IIlr aLCI:"IIl!! . , lIm: . . J.nd pUh"L hulldlllg\ pnl)1 to 1ll,J...lng. Jludgmull ai>t)Ut J P<.ltlt:J1I \ IUIlLllllll.d a ... lhul .. uOII ... t,lllJ . . RohlllCIi ,Ind Von 1)T<.1J1 " fllund Ih ,11 Ia r .'I,'t ~('JI:o. on a ....11 11 pit' " I gilll ;11I,tI ),., 101m . . \\l're Im\ UlIll p.Hl:d tll dJ,I LlIll t: and \~hK.Hy leqlllrL'III!:llh ill. l: f(J ...... II1 ~ 11ll' "'lIl,:~II() lIlld 111 ..1 UillIIllUIlity "'W\l:) W~II , h l'l al'l~ !\IUIH.l 111:11 IIIUI\ uJUJb .11 1 )l'-;0 1l\:r~C'1I 1 01 thL' nonll~d \\.IIJ..lllg "IX'l:d, 01 thell ;Jgl! ,lIld g\.'l1dl: 1 matlhl:l1 ltIUIlIl:fl'.lfl" lio"'C\lt:1 tOI o~ !)\!H':C III ot till' klll~ik s .IIIJ ~'i perll'l\l 01 Ill\: IIlilk, llll IIflnlHtl "',I I"!!) !,! :-'Pl'\:tl .ltI.llf1l·d y,oulJ nut be ldllllcn t hi UO,\ i.t \ \lu.: t Illh: IW(,..JItH) ,..tk ly

Spatial and Temporal Variabl e s

..

.

. bl e'. 111ca.-.;,urcd III a quan tit ati ve ga lt analYSIS Thc vana . art '1 ~ 1 t: d '.11lu' (Ie
~~ w ,'cndc r,I>("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 <.\!'.scss sy mm etry. for ex ample. right swing time d ivided by left sw ing time and sw ing lime divided by stance time. Suth erl and ci aW' list the ratio of pe lvic span to ank le spread a~ o ne of the dete mlinants of mature gait , "

U d~.

in chi ldren.

Measurement of Variables The tcc hnique:-. and equipment required for measurement of sp;lIial and temporal vari ables range from simple to complex, The time re4uire men l~ also vary, and the therapist mu~t be familiar wilh different mClhods of ex.amining these vari able!'. in order to se lect the melhod most appropri ate to each ~ itllalion. Prior to sckc ting a method of measurement, the therapist mllst lInder'> tand Ihe variable in question and how th at variahle is related to Ihe patient's gait. Sil11 l>lc ;\1et hods of Mea suring Spatial and Tempora l Variab les Determining of thc distance comp le tcd witmn a set time frame i!'. one 01 the . . lJnp l ('~t mcthods used to measure spalIal variable . . An exmllplc of thi ... ,i mpl e method is the 6-Millllfe BalA Test. In thi::-. te~t. the disulflce covered by Wbjl'l' ''' wa l ~1I1g at a comfortable pace for 6 minutes is determined. Schenkmi.ln el al u:o.~d the 6-m inute walk test to c,\ i.unine th~ ph) ,1(, .11 p..:-rfonnancc of patiems with Pi.Ukllhon \ di:-.ea'eY' Thl'> ... imple les!. lI.;;ed ill combin3lion \l,l lh nllll: r p h~ ~ 1C1.I1 pafomlance J nd impaimlenl I1l cawre . . (I c., R()~t and l1lu::-..cit! f\)rc{' ). l'oulJ be used 10 t' lI hel mon nor (k'\. IIIll: llr t'\ .II u.llt: i mpro\ emcnt associated '" Ith Irl';III111'1H mll'f\.{;n lllln~ . Mo.."tx:rg fllund tht' 6-rninUie \\ .tlJ.. t(,'1 ,\ rl'h.1hk IIIl';l,>url;'llIl'nt llf funcllo nal ambuJalion (dl\ tanl.:l' \\ .\H,t.~J I ill p.I(Il"llh \\ IIh acq um:d bnun IOJuI'Y·~ I:or llllil\ Idll~i1, \\ Ith linllled l.·ndur;'HlI.~e, a J- Minule Wall k . . . t lIlil) tll.' lI . . \!d III pLil'C 0 1 th~ 6-lIllilulc IC:-.t.t-9 i\ k" ' lIl l' IIlt'IH III ' p.lh," \ JTlank" such a ... degr(c of fOOl :I 1I!!1t: , \\ Illt h 01 b.he ill '>lljlpurt, "k'p kng[h, and ~Iridt' kllglh .11'>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

~

(
D~p~ i~~·~__~~==~==____~~~-===~~~~~

fBilaleral slance l ime (lor the FAP)

The length of time up to 30 seconds that a person ca n stand upright in th e parallel bars bearing weight on both lowe r extremities. ----

-----

-----

Uninvolved stan ce time (for the FAP)

The length of time up to 30 seconds that an indivi dual can stand in the par allel bars while bearing weight on the uninvo lved lower extremity (involved extre mIty IS ra ised off the supporting surtace).

Involved stance t im e (for the FAP)

The length of time up to 30 seconds that an individual can stand in the para llel bars on the involved lower extremity (uninvolved lower extremity is raised off the supporting surface).

Dynamic w eight transfer The rate at which an individual standing in the parallel bars can transfer weight from one

--...:....---=------

rale (for the FAP)

extremity to another. Measured in seconds from the first lift-off to the last lift-off.

Parallel bar ambulal ion

Length of time required for an individual to walk the length of the parallel bars as rapidly as

(for the FAP)

possible. Two trials are averaged to obtain this measurement. Measurement is in seconds.

FAP

~

Functional Ambulation Profile.

step length . st ride le ng th. step w id th , and foo t a ng le m ay be obtained. Ano ther way of Obtai ning ste p le ng th a nd stri de le ng th data i~ b) pl aci ng a grid P3 tt CIll on the n oor.70 A stri p o f ma,klng tape a bo ut J ft (30 CI11 ) wid e and 32 ft ( 10 m ) lo ng IS laid dov. n in a ')traight line. T he tape is ma rked o ff in 1-1Il. (3 cm) lncreme nt s fo r its enti re le ng th . and the segments are numbe red consec uti ve ly so thaI the pa ti e nt 's heel strikes can be ide ntifi ed. The the rapi st the n c a ll s au{ the heel ~t rike locations fro m the num be rs o n th e g rid pat lern 11110 J tape recorde r. For most methods of dcte nninin g stride and step length~. temporal variables ~ uch as cade nce . ve loc it y. a nd ,[ride [ime~ may be calcu lated if the e la psed time fo r the ~ubjecI to \~alk a measured d istance (d) is o bt ained u~ in g a ~lOpv..atch . ~3 den ce fe) c:m be dete rmi ned by d ivi d ing the number 01 .. tep, ( II) taken du rin g the wa lk ing Iri.11 by the elap';"t;d lime (til j between the firs t and last heel slflkt:s tJ ~ !;1g [he follOWing lormuJa (' = Il/ln . Ve lod ty (I' ) can be caklJla1t:'d by laklllg the lo tal di"tance rd) betwee n the first and Ja~1 heel ':> trikes and dnidlng it by the t'lap~ed ti me (rd) to r the dl",lallce (I' d rd J. To obtain a normal wa lk ing ~peed. the pall~ nt ... hould be iJ ll owed 10 lake a few ~te p ~ prIOr to the begln n mg of am mc-a~ureJllent s

Todd dnd t:o~ v.orkl'r, t~'led K.t non nai children (.t I gil-I, and -l3~ boy!.! dge ~ U month') 10 12 yea rs, and dnaI)7Cfi data tmOl m ~lIe than 1(X} other c hildre n ages I J mun~hs 10 It) ye ar,. A , \\o-lllrn~mllmo..t l g~1It graph 'W~I 'i fle~e ,.opcd u' llIg Ihe dalil that prmidc, ~I vi,u<.tl lccord of a l'hild , 'haH"ng perlonn.,tnl:t" Whde [he gail gmph I~ ",ulli lJJ III ap)A:<.tfanct' to grapth u\c:d lur height ~lIld weight. 11 .,ho\.\. ~ HlInn, lor gJlt lilmen'''JIl' 01 utd~nl'c
lll ,;" trumell h for E,-a llllllln ~ \ anablt:.~

:~U'leI'IJIIW/f'rs. rhe Sl~p W.tteh AUI'II), rvlonllor ]HI ~AMJ J\ <-I. u)mmeft[JiJy J"allabh: UhtrUII1(,1lI Ihill rl!t:orJ, the 11I.Jn1b.:, 0' Slflt.iC' t<.iJ...~n In 1- Il1I1IUIL: Intefhlb (junng

dail y activities for up to 15 consec utive days (CYMA Corp. Seattl e. WA 98 1 f 5). The SAM includes a sensor (cus",," acce lerometer) that measures 7.5 X 50 X 20 mm and weig hs appro ximalely 1.3 oun ces (Fi g, 10 ,8). The banery

provides up to 4 to 5 years of continual use.11 The case is

CADENC E, steps/min.

,w

-

60

70 I

80

90

100 110 120 130

"" '" '50

I

'"

,

I

"" I "" I

'" 8 100 :

,

rr-

UJ

" '"

II:

"

"wz ~

Q

r-

f!

'"


""

HEIGH " ·em .

I

.u X

,.

'.,

GAIT DIMENSIONS:

GIRLS

0

'0

"

"

.,

!Xl

~ ' J I~ /'oJ

100

_1~p.cQl FIt£[

11 0

120

s,.-

WAt KING SPEED. meterslmlfl

Figure 10 I nil: 'nhJ I I ... , II I.: 0 11 t 11;" !,! J.1i graph repr~.')enr~ nonl w · P
p"-11tl""'>llIll.,

,

,

w•

Chapter 10 Examination of Gait

34 1

Evidence Summary Box 10.1 Studies using the Step Watch Activity Monitor 3"1 (SAM) as a Component of Data Collection References

Subjects

Design

Results

Comme nts

Malul, KS and Mueller. MJI" 2003

30 subjects: 10 subjects with· out diabetes; 10 subjects with diabetes and peripheral neu· ropathy (OMPN); and 10 sub· jects with OMPN plus plantar ulcers (OMPN + U)

Cross·sectional with matched groups

Validity: mean absolute error of 1.07 (SO 3.07%) for healthy obese sub· jects and 1.75 for diabetic subjects; reliability for daily strides measured during 2 consecutive 7-day periods (ICC = 0.97); subjects with diabetes were less active than control subjects; cumulative stress was lower in subjects with a history of recurrent ulcers compared to subjects with or without OMPN who had never developed a plantar ulcer.

Need for a larger number of subjects to further explore the rela· tionship between stress and planlar uicer formation.

Hartsell. H, el a1132 2002

10 healthy adults (24-68 years) wearing an athletic shoe for a distance of 530 m over flat ground and up and down stairs; same subjects walked and climbed stairs weanng a fiberglass total contact cast (lCG) with a rubberized rockerbotlom sole

Repeated measures used to determine accuracy of SAM under varying

The mean percent error for the SAM for flat surtace walking was 0.136% for the athletic shoe and 0.206% for the TCC; the SAM undercounted the number of steps taken by the subject during stair climbing while wearing either type of foot wear but percent error considered small and not clinically important.

Although using only healthy subjects was a limitation of the study, the subjects' gaa with a cast was similar to the gaa of patients when casted.

Overall step counting accuracy of 96% for SAM.

Subjects reported that SAM was comfortable to wear and researchers reported that it was easy to use, valid, and was a reliable measure of activity in older adults.

ReSnick, B et al 130 2001

30 subJects with a mean age of 86 (SO = 6.1); 4 subjects wore the SAM for extended penods and kept diaries of actMtles which supported the SAM data

conditions

Repeated measures 60 one-minute walks while 20bseIVers counted steps

contoured to fit just above the lateral malleolus and is attached by an elastic strap. A personat computer is used to set up the SAM for monitoring, and also for down loading data to a computer file . Box IO. l presents a summary of ~tudi e~ using the Step \~/atch 3 tep Activiry Monitor (SA M) as a component of data coll ection . Tria,\ial accelerometers have been attached to (he trunk in order 10 me.l\ure mean acceleration. cadences. step. and ... moe length ..... 7l n Acc!erolllcter.., h,n e also been all ached to the head and pelvi ~ to detemlin~ acceleration paHem~ of Ih~ head Jnd pelv i\ \\- hile ~lIbJt'c .... walked on differL'nt

\ urface .... :-1 GVro)'C(JIJeS are another ry pe of in!ltrumenr that ma y l:k:: used for the e . . lll11.ttion o f sr.uial and temporal g all pantIllL'ler... The gy ro ....cope mea~ure~ the Coriolt~ au.:.: ler;.ttion 01 J \ tbratlng lriangular pm.lll. The signal from

Cyro.\'cope,\ ,

Figure 108 In..., Sh:p WalLh AU I\II) Monllur l (SA\1) 1\ .1 Pd~t'l IL.I;J In (rumen! "om alltll' anl..l..: lUI l ong lum 1Il0nlil)r !n~ "I ~i..111 I Ull~ lilln (Cou rt t .. ) II/ CYf\ l A (orr. Mountlal-. .... Itlla. c. \\A lJ~o.n.J

the prt . . m ''I proportional to the angular velocity. The in:slrulight. 1ll.1nable. ami relilli\ely mcxpen!:>ive . A Stn~It' uniaX ial g)ro'lcopc anl:lched llll (h~ ~kin . . urt'ace of the

Ilh! llh .1rt'

,142

Ph,. "ical Rc ha biJilation

lo\\cr leg C~H\ prov ide dala for calc ul ating cadence . number Ill' ..,Ie p", and c"'lilll:lling "'nde lengl h and wal king ..,rced . Tong and Granat !\uggc..,lt:d Ihal u~agc of gyro .. copc'\ cou ld be a \ lable :.t ltcmati\c 10 fOOl !-cno;;or" for de l ~rmtJ1i ng temporal and \p:lII;l1 !!all param c lcr~ becau .. e gy ro sc ope~ can t:aptun: IIlfonllal ion dunn g <., \~ ing il.... well u!) \)tan ce. i~ Instrul11 c nt ed S.\ ",'c ms fur Determining Spatial .1Ild TcmporHI Gait l)arwlIctcrs E\;1Il1p!t! \ of IIh trUlll CnlCd ... y~ lem~ for measuring " p~lIia l and IClllpor;ll \ariahl es include two t ype~ of walkways : The GAITMAT II'" and The GA ITRite.'" and two Iype; of 1"00\-.\I.'lh:11 .. ) <.; k'm..,: the K ru .. en Limb Monit or and the Strid e AIl,ti) 7<:r. (Manufacture r contacL infonllation for m ol lon analy"i.., equipm ent i'l presented in Appendix C.) lI a lh·ays. GrlITMAT II"'( EQ. lnc. Chalfont. PA 189 14) i,

a cOllllllcn.'lall) .1\:lilable \\a lb\ay wi Lh embedded pres~ ure­ "clhlti,l.' ... witche'l that open and close in re~pon s e to contact "llh the patu: m'", feet. The time of ope nings and closures of the :--\\ Itt' h e~ are relorded h) a computer that provideo;; mformation on indi\ idual roolpriI1l ~. :-- tep and .Io.tride leng th , base of ",u ppOI1 . and ... tcp. ~ \\ ing, ... lance . si ngle ~ uPPOI1 and douhie- .,UPPOI1 time .. lor each e\tremit y. The main advantage of Ihl.., \~ :--tem I'" Ih"l1 tht: paticnt i ~ unencumbered by equipment attached to t:i ther the fecI or body. Bowen and colleague:-- found that th e GA ITM AT Jl rM \~ 3'1 abl e 10 de tc ct dcc r\!a:--es in velocity and increases in Iht" perce ntage of doublt:. suppon in dual -task compared to ",lIlglc-la" k condlll on'l in II pat i e nt ~ with stroke. Uf In anolhe r "IUd ) . variation ... in scoring increased among raters a ..... ubjec t\· v.al !...ing patlerns became more abnormal. ?? rhe GA I/R II'" (C IR S)>lems. [nc .. Clifton. NJ 07012) h Jnolhel commerc iall y 3\ailable walb, ay ~ys(e m . The ' ... -f/Jul ponable \\Jlk.way in this system contai ns 16.12R !>ov. II I he . . embedded be t\\'ce n IWO sheets of vinyl. Spat ial and temporal parameter... ca n be measured, as \\ ell <.I S ?yn:il1lll pre:--..,ure nuppi ng: or foo tprint \) during wa lking. fhe pr~..,\urt' PJr:lmelc r~ rnca)ured include peak pre ... surc. pre .. wn: tllne and '1cctiol1:.t1 Integrated pre, ~ ure overtime The v.alk.wu) .. ystc m ca n be used wi lh or without shoe .. : onh{J~t.." 01 w al" ing aids, and the GA ITRite .. oft".. are b c.lp.lhll! ot calculating "pall ,d and ICl1lpoml parameters and d l ,>pl~t)lI1g Ihl.!l11 111 !!raph.., and t.1bl e~. Fuu/\'witcilt:'.'i and FouH witch System s. FOOl '}wilches arc pn::--suh:- ... e~"Jlive "'''Itches placed I! lIher on the palient \ kt't or t ~L" II1'1H.lc 0 1 ollhlJe 01 the ,hot:s. The sw itchc, do not 1l:4u1re a v... U.. ~J), hut th~ pati ent u ... ual l} ha ~ to l'arry a dald t:olleclloll dt'vlt:t" roul 'W lll hl!~ con:-.i.. l of tra nsd ucer, ..tnd a se nll<:onduclur .inc! art: u..,eu 10 signal ,Ul:h ew nh a'l het.:! SInh On\.' type 01 tool :..\~ Ilch devll·c lh("d to C\<.lrnll1c both temporal Jnd IOi.ldinc_ va rnbl e~ " the 1"\1 " .11\1'11 I .lIU}I • /.(lw/ MOil/tot. . Thh dt:vlCe COI1 "'I'1I<~ 01 a ·~ "re-"'C lhlll\ l' , p' l:..~., tOH:C pl i.tl C Ih ,1 1 CUll be worn in a pa flent \ '1 hoc. It ('ilil he uHlncLit'd to a ."Ilnp f.: halt recorder I" ) lel,I , . ~ I){:! II1JIlCIiI rcx·ord of IClllpora l lind dH'Ilancc g dll varlable..,.'~ .~.

n,e Stride Alia/Fer (6 & L Engineeri ng, Tustin. CA 92780) is a fOOl,w itch syste m with special insoles containiDg four-pressure sensitive switches placed under the heel. at !he head, of the first and fifth metatarsals. and at the great toe. The parame ters meas ured by thi s system include stride length. ,elocit y. cadence. cycle time. single and double limb ~ uPPOI1 time, "wing time. and stance time. These measure. ment s arc recorded automaticall y and the infonnation is transmitted to a computer th at analyzes the data. The computer can also provide graphi c displays of foot- floor contact pattern s. Times are presented in seconds. and as a percentage of the gai t cycle. The computer analysis also includes a perce ntage of nonnal u,in g a built-in dat abase (Appendix D). The advan tages of th e Stride Ana[yzer system are that meas urements fro m both fee t are available. the system is easy to move from place to place. a nd . because it has been used by a large number of physical therapi sts with diffe",nl popUla ti ons, data comparisons a re possible. 13,19.4Q,79-Sl.89 Several of Ihe rece nt studies in w hich the Stride Analyzer was used are included in Tab[e 10.20.90-92 The sample stud· ies appear to indicate that the Stride Anal yzer is suitable for use with various age groups as we ll as for patients with neurologica l or orthopedic proble ms. Electrogolliometers. loint di splacement can be measured re lativel y simply by us ing an e lectrogoni ometer. The electrogoniomcter is composed of two rigid links connected by a pote ntiometer that converts movement into an electrical signal that is proportional to the degree of movement. The rigid links or am1S of the electrogo ni ometer are attached to the pro,imal and di stal limb seg ments. According to Perry." e iectrogoniomclcrs, wh ic h cost approxi mately $3000. are the most conven ient and least costly m eans of measuring knee and anklt· motion dunng walking.

Metl ~ds ~f Gait Analysis for Kinematic and Kinetic Variables Motion Analysis S ystem s Im agll1~-based ~yMe ll1 s. are the most sophisticated and c>.penslvc methods o f determining joi m displacement and patlans ot Illotion . In computeri zed motion analysis sysl ell1 \, ll1ar~ ers placed On body -.egmcnls Stic h as the knee. a~lkl e. and hip are tracked by au toma ted sys tems. (H:nerJlly 1w . . " " ., ' () mel lor tyres o t motion anal ysis sys tems are ,t\.tll"hle .· ... _. Y", t t"ll1'. .th t . l u~(" ac ti' ve marl...ers and sy~ t ems Ihat U"'l' p.I\:--. i, C. Illirke ' e marJ...ers are generally Jig . ht· ~ .r... A <:(1\ ell/IIIII/~ ellOt/l" (LEDs ) that nash at givc:n frequencies. PJ<":-' I \ I:' n nrJ...t..T~ re .. . . • qUill:! an e \lemal so urce of illumlOaUlm th.u mi.l\ bl.: provid l'-u I)} l',\ le m.t1 light . P .., , :-.ourc~s (e.g.. ea.o. Sy .. tl'lll) or a ' 1 . .A fln~ 0 IIllrared cmi uing diodes local cu
Chap.er 10 Eumina.;on of Gait

343

Table 10_20 Studies Using the Stride Analyzer

To obtain intersession estimates of error for time and distance parameters of gait.

Stride Analyzer

Velocity, cadence. stride len gth, gait cycle duration, single support time , and double limb support time

Thirty-one patients with stroke who were four months post-stroke and involved in inpatient rehabilitation

Patients would have to increase gait velocity by more than 6.B mlmin. or decrease velocity more than 6.B mlmin. before it could be assumed with 95% confidence that genuine change beyond limits of error had occurred. Alternative strategies such as serial measurements may be required for measuring changes in velocity.

Hara da, N, et al'" 1995

To identify persons for referral for physical therapyevaluation.

Stride Analyzer, Berg Balance Scale, linetti Performance Oriented Mobility Assessment and the linetti Fall Efficiency Scale

Velocity

Fifty-three patients with stroke living in two residential faci lities

A combination of the Berg Balance Scale results and gait velocity yielded the highest sensitivity level of 91 % and therefore might be the best combination for screening. The sensitivity of gait velocity was 80% and the spedficity was 89%.

Powers, CM. et al" 1996

To establish the relationship between isometric muscle force and temporal/spatial gait characteristics for individuals with below knee amputations.

Stride Analyzer

Velocity, cadence. and stride length

Fifteen males and seven females with below knee amputations

Mean walking speed was limited to 59% of normal. Hip extensor torque of the residual limb was the only predictor for both free speed and fast gait. Cadence was equal to 83% of normal. Hip abductor torque of the sound limb was the only predictor of cadence for free and fast speed. Stride length was 69% of normal.

Powe rs , CM, et ale, 1997

To compare stride characte ri stics and jOint motion in subjects with patellofemoral pain With and witnout patellar taping.

Stride Analyzer

Velocity, stride length and cadence

Vicon Motion Analyze r System

Sagitta l plane joint motion of the pelvis, hip, knee and ankle

Fifteen female subjects with the diagnosis of patellofemoral pain

No significant differences we re found in gait velocity or cadence between the taped and untaped trials. Patellar taping resulted in a small but significant increase in knee flexion loading response. The increase in knee flexion coutd help with shock absorption at heel stri ke .

To determi ne the influence of pain and muscle weakness on galt variables in subjects with patellofemoral pain.

Stride Analyzer

Velocity, stride length and cadence Sagittal plane joint motion of the hip, knee and ankle Isometric knee extensor torque Knee pain

Nineteen female subjects with a diagnosis of palellofemoral pain and 19 female subjects without patellofemoral pain

The primary compensation in the patellofemoral pain group was a decrease in wa lking speed wh ich was a fu nction of decreased stride length and cadence. Knee extensor torque was the only predictor of galt function with increased torque correlating with improved stride characteristics.

Evans , MD, Goldie, PA. and Hill, KD" t 997

---

I

Powers, CM , et al62 1997

Vicon Motion An alysis System Lido Dynamometer Visual Analog Pain Scale

(continued)

344

Physical Rehabilitation

Table 10.20 Studies Using the Stride Analvzer

Von Schroeder, HP, et al'

1995

To compare gait parameters and patterns In patients with stroke and controls.

Functional Assessment Questionnaire

PateUofemoral joint symptoms

3-D Motion Analysis

Joint motion at ankle, knee, hip and pelvis

Suriace EMG Stride Anal yzer

Muscle timing Velocity, cadence, stride length, gait cycle lime. double support time, si ngle limb support and swing phase time

When the system~ were first deve loped. vis ua li zati o n o f marke rs was problemati c. but now markers are automatically tracked and thousands of compu tati o ns are performed by computer. However. pass ive m arke r sys t e m ~ require many cameras. are expemive. and require (ra inin g to operate the hardware and soft ware.2.~ The t\I,.O mo~t imponanl problems that st ill ex ist with bolh active and pa !o.~ ive marker system s conce rn sk in movement ove r the c;ke lelOn and the need to improve accurac) of denvation of joi nt ce nters. In the futu re . m agnet ic resonance imagi ng (MRI) shou ld prove va luab le in locating (he exact jOint center1'l. At the present time. L ED:, fo r the J C!J\ e ~) , tem~ are expens i\·e. and S utherl and suggests that in the fUlUre 11 may be poss ib le to use fadiofreq uency aLu\'e emmer ... to rcpbce LEOs. ~5 'ine follo\l,;mg IWO commercially available c;ystems use 3 (' ti v ~ md.fker~ : Optotrak. (Northern DigitaJ , Inc . Waterloo. Onwno. Canada i':2V IC5) and the SeI'pot System (Sclcom, In ;,;. Southfic:Jd, MI 4R(75). Sy~[em\ that u')e p
Peal. Motu. ' \\hen u..,cd \.\llh the 3~ D G:UI An,-d}~I'" \1oJulc, prOV ides mfonn31lon o n JI'Ipli.lCelllenl IOf neht ,UJd IpIt hlp. knt:e and anldt: jOin! Ctnh:r- of 1\ lt.ll lOl1 ao, \\~ell a.... JUlnt a.nglt.!~ for hlp, knee , :.tnl...!~ J.nJ pt"lviL m O\J OIh 1111 ::. !. ) .. t~m I, i..ble 10 measure ~1I1t'"li(,; \ari.lhle .....h \.\e ll a ... ,p:slJ.tI and lcm portll \'Mi;ibk~. flgurt JO.lJ pro\ Ide::. an e)'.•tml'lt: of pi.l~)"J\e milrke l phu..:t!IlH:nt on d ' Uhll!l'I, ii' \H'II

Forty-nine ambulatory patients with stroke and 24 age-matched controls

Patients walked significantly slower than control subjects. The patie nts had decreased cadence, increased cycle time , and increased double support time. The unaffected limb had signfficantly more time spent in stance and single limb support.

as a g raph of linear ve locities o f the sho ulder. hip, and knee, and ang ular ve loc ities o f the shou lder, e lbow, and knee. In Figure 10. 10. the degrees of motion for the ankle and knee are plo tted aga inst time. In Figure 10. 11 , stic k fig ures are shown w ith accompanyi ng knee ang les. Peak Motus~ systems are able to sy nc hro nize anaJog data, suc h as signals from force pl atfonns and EMG electrodes with k inematic mot io n data .

Ariel Performance System A The Ar iel PcrfonTIance A nal ysi s Sys tem ® (A PA S). when used w ith the APAS/ Gall mod ul e. is able to perform kinemat ic ana lysic; , as we ll as use input fro m force plates for inve rse dynami c analyse~, Obstruc t ion of marke rs by bod y segment s. ski n/soft tiss ue m o t ion , marker vibration. and Improper p!Jce mc:: nt of marke rs in re la tio n to the joint center ot m orion Can introd uce potentiaJ errors. 0" ing tc the use of p.lss ive marke rs. these video-based system .; : are (')" p ~c iall ) su~ceplib l e to e rrors ca used by mark.er Oh:-.trucllOll when marker~ are in c lose proxi mity to one a no ther

Vicon Motion Anah \ j \ S~stem'

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

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Chapte r 10 Examination of Gaie

.145

Sagittal Galt Example Report

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three types of walk ing patte rns are easi ly seen in the graphs, The deviations from nonnaJ ROM at the knee are also easy to identify. A careful obse rvation o f the fi g ures in the ex te ns ion thrust patte rn shows an ex te ns ion thru st of the knee ilmnediat ely after initial contact and excessive plant a rllex ion at the a nk le bo th at hee l strike and througho ut the gai t cycl e. Refer to C hapter 9 ror a more de tailed di sc ussion of EMG,

frame .../..,(.'c and ~y~te l1l accur;.!cy 112800 of the fi eld view. U...ed "11h (JA n EL aC4UJ"' lIiOIl i.llld procc:-,s ing ~ofhva re. clinical!), rdevan! ~ lOe l1lat ic and kin e ti c varia hl e.., ('. tIl be cakulatC'u a.nd report., pro du ced a utomaticall y. MOlJon ..tllaly~ l ~ ~y~ l em'i are continuall y evolving v. ilh

Ihe IIlLorporallon o f flew l ea ture~ and opl i ()Il ~. including \lmult;tnt:iJU", d("'4ui'lllion and proce",~ in g of force plat e and EMG dill" f:.MG 1'10 w..ed 10 Idenllt y the: partic ular POI1 11111 of lht: g.ul ,..)d.: 111 whi ch the mU'id e actl \ il } Ott u"." A n example: of ho ..... EMG I ~ u ~cd 111 {'Om b lnal lon \ .... lIh a mOllon JIl
New Dc,'elopmenIS in MOlion Anal)sis Two

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,uul a IlHtgnctil' system, Hu ile ma and co lleaguesl'i:\ describe an ultr~ho"i(' motion a nalys is system ('apuble o f measuring "' pallal and temporal ga it paraml! tas . Thl! S}Mem l'OnSiSb ot a , mal l ultra~on l c receive r atl ached to txuh slH.'lCS of 3 walklllg i-o ubJcc t. a nd a s t.tlion~t ry 1fi.IIl ... mtlter placed on the nom ('ol11p.ui.,on dala ohtai ned from ! \.)() ( cunla('( ~y,. itc hes on lour healt h) , ubJec" wal l ing o n the floor sho\\ lo!d that by appl) IIlg I\H) tdati\C' thn.~ ... holds to the sPl~d graph of thc loot. heel , trike iUld toe -otT could be rehabl) ge ne rated by Ihe ultnt...onu.: .;;y sl l:." m .lI!i

346

Physical Rehabilitation

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347

~

I" [.. I 0..1 1' I ~I" I J: t~l ' J.t3lI .::J ~ ~ It:11 .1 .1 ~I .. I )

DI~ I IiiII .:tJ ~ lii!1~1"'1

...,

knee Angle

..

m ~

, .,"

~

~ ~

~

10

...

- - ---

~-

/

"

--

"

..

"

lrom Figure 10.11 AnOl her fonnal for prese ntation of the dal~l from a motion-analysi~ sy!)lem is (ompu{er-generJled Slid.. figure rqm~senlations of one comp lete gait cycle. In Ihis p:U1icu lar ca~e. the pJllem uf lnee motion IS graplllcall y pre"ented belon the ~tick figures. (COUllCSY of Peak PeriomlanCt Technologic .... Inc. eCOle-nm 3!. CO 80 1 11.)

height. .1f!c. gender. "eight. le\cJ of maturation. and di:-:,Jbilll~ Tt:IIlporal and di .. tance dClemlin:mts should be used ,l~ :.m II1kg:ral part of. or In conj unction ,\ ilh. bOlh obser\ JIIOI~,11 and \....metic ani.1ly~e:-. to prm· ide a complete picture of g.ail -\ . . ample recording fonn for time and di ~tance varIJol ..." 1:-' prC' ... t'nled In Table 10.13. Ther~pt..,t!- mll~l be e\ln~'l1lcl) ctlltiou~ \\ hen .,electing a nonn ur "tand~rd b) \\ hH:h to me3~ure patient pro g re ~s. Stgndl<,:JIil agl' gender. \\elght. ami activit) level related dtfft'ren,:e~ hJse been found 111 both temporal and dbtance ffie.tr;,ull to the )ounge r p: roup. Age \\;1 ... a . . igntfic
rotation. grea ter knee valgus. and smaller ank le joint moment complIhjects w.. ing one ,tandard deViation lSD) for boundJrie~ . Sutherl.U1d .1IlL! co-\\orl..er,'1 ' sugg~ .. t Ihal motion panem~ l.'a nnOI bt~ full} ~In;tl) lc-d \\ IIholit con::.id.:nHion of all pOint' .thmg till" ('ur",!, The) propo:-.e the U~ of prediction

,H~

Ph, .. ical Rehabilitation

Slow gait velocity Knee flexIon so

60

,"r

40

10

,

'0 !s

,

!,

!

1U

I

)

Quadriceps Hamstrings

o

Knee flexIon 8U 60

-. "

, ,

; ":til

()

T 11-

Stance

SWing

Stance

Swing

Stance

SWIng

Hi H T1 F

-----I--

s

()I

40

,00

Cycle

;0

H

10

rh

i

r

,

H, ..0;' "F,

0

'T

')

s

i L~

o

Ii

Quadriceps

, o

'1. Gal! Cyde

'OU

F'gure 10.12 Graph' and EMG data for motion or Ihe knee in the sagittal plane ror one g~l !t cycle of the three mOlion panerns. Each patient repre'ients only one of the three motion patterns (extension thrust. stiff knee and budding knee) assoc iated with a slav. ga it veloci ty. The solid dark red l i n~ ind icate ... the motion pattern and the lighter red linc rcpre'icnt s Ihe nomlal. HFS . foot !>rrike (iniual contact) on the hemiplegic !>. ide; OTO. toe-off on the contralateral (u naffected ) ~ id e: OFS. foot strike (initial contaCI) on the contralateral (unafft:'cled) ... ide : )-ITO. loe-off o n the hemipleg ic )ide. (From De Qucrv'lin. IA K. e t al. b with po:nllly.,iOIl. )

Knee flexIon SO 60

40 10

o+ - - - - + - Quadnceps Hamstnngs U

IOU

reglOll,) (multiple ... 01 tht! SD abo\le dnd be JOIA the mean cUr\e of d<.l.ta tor eat.:h pOlllt III the gai l cycle ) (Fig. 10. 13). \\'Jlhlll '" predll:IIUn regloll If ~Iny point along t he curve 01 1<'101 mOllon tall ... uu .... ,dc 01 Ihe dcl1ned reg ion, the pJllem \ g;'l.It I... L'on:-'Idelcd 10 be abnorma l.

limir... of normal \
'>Oll s \\ Ilh

Gait Pattent C lassification Idt:lltlliLdt lon 01 g~tJf paramdth Iha l dt!V ldlt' wide I) Irllm ~ norm i\ iPJCJIlIlOIl region . . ' itnlHil the mt:,tn "'U(\l' luI' he,dth) con linl "'Uhjt!Lh III OId!.:1 ttl t,.;::, IJbh .. h Ih....

{h.lt i.lC"curately de..;{"riocs u'!cd to place s.ubjecb ill grnup .. , or .:IlI ... tt.· ...... h;I'i":t.1 o n "11t:citi ed input

!;!Jil "m aI Y:-'I'" 10 a Sc i of k.lturl''!

g:m palil' nl'i.

CIIIS1!'I' ,lIIcJhH\ '\

hOOtOg...·'h:OUS p..tr.IIHclt.·r ....

'\01 Illal", (

1(lt~

Ptlnctpal Ulfllpl"lL·t\r.. JIl .t!\ """ \\a" USt~J 10 dt."\dop :t ."VIIlllld/n II/dl' , (,\I J. \\'It'~'h \\<\ ... ,,'-'Ie to qualltif) tht' .1I11\lunt oj de\ Ii\! Illn III J "'U~JeL· t · ... ga ll compared \lllht" ~LIlt unllllr ..t\[\;·d PC I :-'011. 1hl.' NI ha" Ixcn found to hI.: "~Il\ lt l \\;' ...·Iluug h 10 dr-. tlllgu i .. h ununpaireJ ~ ubjrch 110m Idlnp .. Hhi~ ' Ill(: \\,II I., ..::r ... Jnd lu dis ting ui sh bef\H~ell plq;tl ;tnd UlIlIl\olved Jllno.., (I I he miplt!g lc WbJ~('b .h.I\H "I.' 1 fhl.' g..ttl p.l lh"lll~D ...)1' nOllllldependenl w:t.lkers

01 .III <\\ l.:r;lt!e

A

Table 10.21 Studjc~ j\dd rcssillg Specific Disorders a nd 1\1o,emcn. Diagnosis Using Motion Analysis System s

AIodoon Kim .

eM. and Eng. JJA6

2004

Neptune. RR. Zajac. FE. Kautz SAs;

2004

Schwartz. MH. Novacheck, TF, Trost, Jfl8

-

!\lotio n ~ysis

PDrpooe

Method

Variables

Subjeda

ReIeftm ~~. ~1~ h~ . _ _ __

To understand whether the magnitude or pattern of 3D kinematic and kmetic profiles relate to galt performance

OptoTrak 1 force platform

Joint angles, moments and powers

20 individuals With chroniC stroke

Many highly related variables : sagittal 1 plane parettc side hip power generation , nonparellc side ankle power generation, frontal plane paretic side hip power generation, nonparellc side ankle power generation.

To understand the contribution of indlVldual muscles to suppo rt and forward progresSion of the body

Optoelectronic system2 force platform ; SIMM3

-

--

----

---- ------

Simulated muscle forces, jOint angles, moments and powers

5 healthy males

Uniarticular knee and hip extensor muscles are Critical to body support In early stance ; redistribution of segmental power by muscles IS critical to forward progression of trunk and legs.

-- ---------'----------------'Vicon 370 motion analysis syslem 4

2000

To objectively diagnose clinical change in hip function

Joint angles, moments, powers

6 children With cerebral palsy: 23 normal control subjects

A hip function diagnostic index was developed uSing prinCipal component analysis. Variables included maximum pelviC lilt, a hip moment timing vanable, max hip extension, H3 (pull-off) power.

Maurer, BT, et al 89 1993

To diagnose ankle equinus deformity

Custom-built Podiatric Telefactor Motion Analysis Systeme 5 : force platform

Ankle angle. moment, distance of ankle 10 center of pressure in transverse plane. ankle angle

22 persons with varied equinus disorders aged 5-34 years: 9 ablebodied. aged 23--28 years

Preliminary data showed protocol to be useful in diagnosing nature of equinus and evaluating treatment effectiveness.

l____

Chapter 10 Examination ofCait

351

Table 10 23 Gait Analysis Recording Fonn ' Temporal and Spatial Measures r

Age _ _ _ _ _

____________________

Patient's name

Height

Sex _ _ __ Weight _ _ __

DiagnoSIS - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - No _ __ Ambulatory aids: Yes - - Cane(s): R _ _ __ Walker: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ TyW Crutch(es) - - - - - - - -

L _ _ __ Other: Dale TherapIst's initlals. _ _ __ _ _ _ __ _ __

t--_--+__+_--+__+_-1__+__ f--_+__t--_-t-_-i

Distance walked (distance from first to last heel sirike ) Elapsed time (time from first to last heel strike) Walking velOCity (distance walked divided by elapsed time) Lett stride length (distance between two consecutive left heel stnkes) -~----+-_+-+--+-+__r-r_~-r_~-r-__+ Right stride length (distance between two consecutIVe right heel strikes) Lett step length (distance between a right heel strike and the next consecutive leh heel stnke) Right step length (distance between a left heel stnke and the next consecutive right heel stn ke)

--------41--+---+--r-~-r_~~~~~-4-~ Step length difference (difference between light and leh step lengths)

-------4---- ~ -+_-+_-~-_t--+-~-.4--+--+_~

Cadence (total number of steps taken diVided by the elapsed tim e)

-

-- -

- -I--- - - j - -+-,- -t. - --t---+.. I'

Width of walking base (perpendicular distance

-t

~n right and lett heel stnke~ _ Left fool angle :angle formed between bisecting the left foot and the line of progression)

a line

Righi foot angle (angle formed between a line blsechng the nght foot and the line of p!ogresSlon) Right stnde lenglh to nght lower extremIty length (fight stnde length drv'ided by right lower extremity length)

I

---r

~ I

--

I t

-j

+-I

t

Left stnde length to lett lower extremIty length lIeft stride length diVided by left lower Extrerrll tylength) Tne thH

I

I

- -I---

d.Plst md~ Obtain Clv€:ldges for stnde and step lengti ls. Width u l vhtlklng Od::;A, dnd foot anytes

f

I--- -

I

t

-

-

I

r II , I

t -~l , - - - --.j

I +~ L

l

I

___ ..J

352

Physical Rehabilitation Knee A

m :s'"

B

80j 60 40 20 0

c

', ....

m

100

50

0

0

~

.,

Ankle C

m

c 0

•

g .,

0

DOr$4 fte x 40n

1

..,.

.

'"

100

E 0

D

m

'"

30

"

c

CJ

Do r SI

30

~

a::

~

o ........_......-

o .30

Plantar fle 1( ion

i

PfanllH flex :ol"'

30

0~--r-r-r-5~0~------~100

o

/\';OflTla

~o

motr\jn

- - Pat en1S'

\\.1" 1lt.1\

mo~,o"

m~IIH, \ ,1rI.li:lk~ tnl~nt

fhl

l1lL:tll. he

FIgure 10.13 Ptedu.:uon [('P(IO .. t \utherl.md. DH. el al....

Pa hems' mot. on

\\ Ilh pcm11 ..... IOIl .1

"\l~1

-hh... J

ah'il).! \\ Ith

~ 1Il~ ~

tH.. Jptul

rllll~lp.11 \1)oll""HlL:flh

.1 .... ", nln~

\.m~bk ..

!.I\.. t~·f·

nll,th,JtI \!t:n \ ::-d thl' '\1 1Tl\

p.,

h

rlilp\lrIll

tn

p.tl til

{fll: .11 htU Jt III \ ... n.1li 1( (\

Ithilu.1 th \ ,h.. h ·'..til rn J.'Ufl..· In i p(lJ'uL II"'II. Hd\\\\C;! .. ml.. th ... d.tI.II..I'rll1.: Jnurilttn dr .•il\"l" ,,\"IC'ln thl\ .tr "lJI'I~'dllithl "rill.. u,h J .. It lJ .... Ul.: l'l.t Id ....tl It !Il..tfi- .. r

tiIUIHp.tlrt:

I h'rY'

1~ t

'J

"IL \ Ill,lll\

1.lINI .11 t dl 14U ...

h 1\ .. (I,t!\

h.l~

o f cy cle

Predlct'on region

~ .. I \~le~()n/l'J The ..tuth\)r.. 'U\!f!C'''Il''d th~t ~~r

h.1P" th ... uklu"hm lit

100

50

' of c de

IhL

~

50

0

c:

...

0

;;

-

:s'"

CJ

80 60 40 20 0

0

!llr...~

pt.'\\ \'f

'U~"\pllrt

n1tl m~n" .

j \,rl.t' .•tnJ mlnll'l\" 1t "'1(

'-'tlrl. JOWl rel(llOn !though

Pf(,>'UIl" ITJhk 10.2-H

In th pJ, 1 k.me ll\" ~~II ..tJ1 .1I~ ... ~ .. h_n< Oct.'o u......ed prunarif) 101 (0,;: ('.i.n. h puf'l". ' ....· .. , .1t [hI;' pn"'''l,'m mn(.' the) an: btlng u'o(.1 .. llIlIui\-. "'-1."11 rh m .. trUlnen!JI ,\H .rc'IUlrt·J h ) C\lmlOC' k.lnelk.~ \;&11. .thl\ ~1).I\r!~ \ md 1,'--"f'c: lh l\C ~\..lU-.e fkrt\.1t1l1l'l of k lfl(ll~ rl", If" lr ,~kurt' til ..t B " I mt" lvn. e, 00 the. pan l't Ihe ~'II;h .ut il} I\:~i \;, • dK: h)4,', t )C thi- thight. TIlt I'U I U ll.llh .. t In \\ Ith th~ h -(u: " ~lO!! JWheJ to the I h ~ h i · n, . ;\' f h\ J h .( ... ~ pl..I f': (mbtJUed m ·t f f I \." t: PL'! , " ~ '..1111 h'.",t lr.m....Ju
II

I " ...

~ ,Ht

1111",,, iunll

I'Lld "

l~pK.J.II) , ihelortt

I_

art...tt'1r.., .il tilt-- .mlk l'e\Iu.u "j' Ih, flIVC m.1.''I. ,1.nJ k,l-

t n~

1"'1'1 .,1 UI"J.(~t .uu.hrvpOflk:'tf). ! UIt'l .. , d ,,- r<.llhlO or tnc (",,\1 IJ ....

J ..· ~u...ltl\lil ..

\..IIl

tx

",,1

U{I

llk.1 In''fH(" £\h\ .... \.l.lrrUl~ Jttne

1\.1I1<'IIC

Cail .. n.ll),l.

r

t

If I 11I1;.!" III \n-tier lor U'k: h" p~HI ~ ll l.u Ji,.\.d~rjJlt)th. \\hctJ . . ...n.! 11 I ' "HI.·nt' ,II tf'h: k t .. )

\.uwt. (.. ..

hi Ihe .11.J!,Jt..<11f pt'l1\lro.U Ii

Il· .. , !

1I

'I

""" I!

a.,w,""

hK

c: ... h It\)IJftI

I 1l
l)

W

HH': pt ImJ.t11... :\1.'1' H tbt t w , l;.ml I1l tilth." I" t\lu}lIpheJ ~ t" H~I.·""· H In..: ..Ill Ie .aJl&l ~ t~ ..... et

C h a pte r

Vertical, anterior-posterior, and medial-lateral forces created as a re sult of fool conlact with the supporting surface. These forces are equal in magnitude and opposite in direction to the force applied by the foot to the ground . Ground reaction fo rces are measured with force platforms in newtons (N) or pound force .

Examjruu ion

or Gait

353

Vrt GRF ( R = It ~ ~~_ __ _ _--,

Table 10.24 Gail Variables: Kinetic Gail Analysis Ground reaction forces

to

120

r

100

E

80

\1'

~

60

"if.

40

!

v

----------------

Pressure

Pressure = farce per unit area . In gait analysis the pressure parame ter that is usually measured is the pressure distribution under the foot.

Center of

The poinl of application of the resu lta nt force. Movement of the COP as a function of time is used as a measure of stability of a subject who is either standing or walking on a force plate.

Pressure (COP)

Torque (moment The turning or rotational effect produced by the application of a of force) force. The greater the perpendicular distance from the point of application of a force from the axis of rotation . the greater the turning effect, or torq ue, produced . Torque is calcu lated by multiplying the force by the perpendicular distance from the pOint of application of the force and the axis of rotation.

Torq ue = force x perpendi cular distance or moment arm

20

Time (5)

Figure 10.14 T he compu ter-ge nerated graph of Ihe vert ical componenl of the ground-reaction force wa.\ obta ined using a force plate. (Collrtesy of Dr. David Krebs. Motion Analysis Laboratory. MG H Institute of Health Professions. Boston, MA 02 129.)

weight, show cons iste nt pa tte rns across normal subjects fo r load ing rate, peak fo rce. ave rage force. and unl oad ing rate . T he anterio r- posteri or fo rce has a cha racteri sti c negative ph ase fo ll owed by a pos iti ve phase. The negati ve ph ase re presents decelerat ion. and th e positi ve phase represents de celera ti on o f the body ma ss. The ve rtical force wave form shows a characte risti c dou bl e hump ( Fig. 10. 14). The medial- late ral force wave fornl s are var iab le even in norma l indi viduals.

Instrume n ts for Me asuring Kinetic Variables Force Pl ate Technology

leg. the rt~u lt is knowledge of the net power being prodUl'ed b~ th~ muscles acro<;s the ank le. Conce ntric cantrattlom add powe r to the limb (power generat io n). and eccentfJe l'ol1l racti ons redu ce the power (power absorptlon). The mO.;,l important pe riod s of powe r gene rati on of the v.ork of \\. al kmg occ ur th rough conce ntric cOnl rac tion of the dnkle plant ar11 exof:o, at pu ~h -o ff. Ihe hip fl exors d urmg pu..,h-ulf and the ..,hort pe riod immed iate ly fo ll ow in g. and the hlp t:).len~or~ III the earl y ..,ta nce p h a ~ e . Vari ati ons III Ihe~ I.:xp'-'l:tl!d patte m ~ are parti cula rl y u.;,eful in exammmg dt:huent.:le~ and in oetem1ini ng treat me nt goab. lhc gn~u nd (fl oor ) r eaction furce {G R F ) i ~ defi ned a . . the net \crtil.:al and "hear or ho ri /,olHal forces acti ng bet\\l'en Iht' Inul and the ,) upporting ,> 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..r 11.,11 thai ..t1l0\1, . . till dlnll.'I.l11 hi

o

398

796

11 93 1591 1989 2387 2784 3182 3580 3978 4375 4n3 ~

Figure 10,15 Magnitude and locati on of peak pressure during one complete Jeft foot 'itrike. The highest pressure'; are shown on the hee l. ti rst me l al ar~a l head and great toe. (Courtesy of Tekscan. Inc. South Boston, MA 02 129.)

identify barefoot pre~~ ure s, rvlueller et al 103 used the F·Scan Bipedal I I1 ~S llOe Plantar Pressure/Force Me(lsilremtnt System in the manage ment of patienL<; wi th neuropathic ulcer:-. or m etatar~ ,\lg i a. Ann strong et aP04 found that patient :-. fo und to have hi gh planta r pressu res and wounds greater th:.tn 3. 1~ in . n~ ( m ) took significantly longer to heal th an other p:lli c1H<." \Ve rh( h ct ap°'l described a port3ble II1 solt! phUl tar pre'lsure me ..l ~ urc ment s} ... tem that ab o cooJd be u...c-d 10 stud) cane cadence and rel.,idual limb pressures of bdov. - l-..ll~e pro ... th..:')is. E H £D PeduI" INo,<1 Electro nic,. Inc. 51 Paul. M~ 55 J 0), 1Il-~hoc pla nt er pfl? \w re lllC:hurement system is another t\J1t' 01 prt:~"'lIre mc:.t . . uremenl . . y . . tem. insoles plaLeJ het\\t't: n the ..,hl'le and ... oc ~ are com prised of a mat rtX ,)f 99 rar:K It ~\JlI.·C :-.cn ... or.... \ValTcn and co-worlers U"'l~J Ih, ... t) pt: llf "'t'll.')llr ... ) ... t'-'Ill, combined \\lI h EMG. to J ....... L·IJ'-"'e th\' ll~mpol~tl r.ltt\..' m ~ of rLtntar pressure~ lnd 100~~r I~g mU"ll~ i.lUI\ 11 1(" l)\c r .1 \\ Ide rangt! of treadmill v.a l ~llJ!! "IX'\..'I..J... In normal "lIhJI.·Chyltl SlIllpit: h,tnd hdd d) n~lI l1llme t c r ... and I..okillelic \yl" tern.., ~ .In ht· u...c-d 10 ,)hum ... t ~ t l l' and d) n:tOl!(.' peak: lorqUCS !,rtllr til tlhl'III1H\i! ktllpOl.tl ,tol! tll ... tance mta~ures. ("IU\l' l!\ dlld V..IIHk'nool t Il\Und lhat d{'('feJ~~ to ISt"lJlII,.'ln\,. ,II"! d\ ndlllk qU,IJfllI..-P'" ... In: ng th It'd 10 \lgnjfij.'3!l1 dl..'l'tl',I"''''' UI t.bi pau:d .1Ilt! .. d l ... ckut:d ... pt't"d.

Method. tor ~1ea..uriJlg f..n e rgy (0-" During G .. it '\ d~III".it lllfhl'U11 ... I. . .·~. J 1....\ l \dll..' JI .u..: lj\-It) lhatreqwrt.) Ih.: hod\ 1<.1 ,IJJ l"lh:r.l'\ h\ 11\':,111 \ o f \.·oncenlnc ~onlt"'· 1I0lh

1I0lh

.1I1t! 1\:1l10\l' t.· I K' I ~\

h) m e..lll ... o f el1.'ClllnC conUSC·

I h.:..,~ l'lI~1 ~\ It J.lhkl'" ~Uld I.' \lhangt') :uc cli:\eri)

Chapter 10 Exam ination of Gail dt':-ie.ned 10 make wa lking effidenl. Generally. cond itions that ~affeci cuher the motor control of gait and po~ture or fondilion~ Ih31 affect jOlllt and muscle structure and funclirm \\ ill incfC:t!o.C' the energy Cmlt of ga ll ,I07. 11 1The type of fOOI\\t:ar. II~ lI ~e of assisti ve devices, and speed of gait affect {"Ilcrg) ex pendilUfe ~lS well Y Energy expendi ture is an IInponanl cOlhlderalion in ga it analy~e ~. particularly in n~ urolog.ical COI1(lIl ion, in \\ohich mu:--cular resources are 10\\, Th!?rc .. Ire Ihree ge nera l approaches in detennini ng {"Here.\ CO:o,I" ph",::i%g i('ol J11('(l SUrelll('f1I, nlt('/ulI/ical fm'r;~ Illlo/r\"" and hea,., rate data . The selection of a particular appn'l:.lch ,hould be has.ed on Ihe purpose of taking Iht' mca,urc and the relalive im pol1ance of te sl charac teri sIK' outltned at the beg inni ng of thi s chapler,

Physiological Energy Cost Measures Ph~"'lol11g\Cal ro.., tlllea~url?~

e ...timate the hea t (energy) pro..,uhject at rest and during exe rcise by indirect ('alorimet~. ~a,cd on the as"umplion thai all energy- using reaction.., of Ihe hod) depend on oxygen uptake, The most ('ommon method of rneal., uring oxygen uptake during walkmg. I~ open-loop . . plromcll) In which exhaled air is sampled and analyzed Io.x 115 o')ge n contenl. clas"iicall y using the Douglal., bag method, ten More recently, ~Iationary or mo\,mg metabolIC (;in.., or Iiglm'veig hl pol1able devices perform breath-by-breath o\)gen and carbon dioxide analysi s. Two parameter. . III pnmt: interc!)t are oxygen cost and o.\),l-!en r ,l1t One mJY N- mtereC)led in the oxyge n cost or energy t!xpenditu n.; rer umt of di stance walked (in mL/J....g/m). V,hH,:h Tt"Jat~ . . t('\ the phy . . lological v.ork invol ved in the task JnJ retlech !!.-UI dliclc nc). Altema1J"r1y the oxygen rate, or energy e'JkIll,htuTt' per unit of time (in ml..J'J....g/min), reflects the 1"K)\\cr oj ... alklllg and I' JIltc rpreted u:-.i ng Knowl edge of "JIlln,£ ~~('J II PhY"'loil)[IL..l1 u.N anal) . . I'> method, :'U'c most useful in L'(lmpann~ til\..' ~'nc:rgy l'o ... t of \\al J....mg \\ ith n0n11al values or an mdl\ldual ... £lI;\\1Il1Um l'.lP:Kl ty, and lor dctcnnlll11lg the eltel'h on Cillo' ~'\ (1.1"1'> u j mle rycntlon~ ... ueh a'\ the lI:,e uf llnllO..e, Ph\ .lu1,!H..aJ L\)\t .lIl
duced b)

J

Mechanical Energy Cost Determination Iht:re are lv.\/ mL'lhl"-.h 01 obti.llllln~ me(.; h.ul ic.ll l.' ncrg) In Ih t,r'" llIl'thod. k Jllt lll ,lIll d:lI~ alonc .~ re tr'lUired U 11\' c: 111ll ... 1t:, 01 fl1a.., .. c: . . 01 lxx.l\ 11.I.11 ~ and 01 I . t".I!lun.., 01 lilt, Lt'ult'l\ i1lll1a..,\ of Ihl'~t: p'lfh. By elllpluy" m~ .1 "'p.t!I.J.1 1Il0l\oll .iI1 ...d~ ,i.., \) .. 11.'111 \l,. lt l1 b..... IL \.'4 11. llI on .... lIt nl~llll'H alld ,d,IhrLlponlc:1I1L lO!l..,I.tIl I\ ttlr rl1 ...... 'e.., 01 tlllli) p.trt the.: '11t.:l ll htll'I1I' I ~) ..Ifld IJJlhli.lIIOIl,ll,tnd rllid 1''11,,,1 ~,IIlO:11 (11 I,"' le\d.., 1)1 edclt hod) part L·.1Il ~. c;.I1 ul,lkd lht: lidll'll'nlt.~ lX:I\'t-L'L'1l \Jl uC':-- llot,lIncJ ,iI \:. ILh

lu\1

IImL' III l I lIlJt' /\I I 111\ flail Clh.'I~) ioU""

\

"111I 1U..., \!YUi.llliln.., ilre

355

used 10 combi ne the costs acros s body pans to yie ld the total body cost. The large head-amls-and -trunk segment shows exce ll ent energy exchanges between J....inetic and potential types. providing the body with energy efficiency, When the bod y is at its highest position (mid-\tanceJ. it is al so moving most slowly, but as the head-arm s-and-trunk "roll down the hill" into initial contact of the fool. Ihi o;; potential energy is changed into kineti c energy, and the head-anns-and -lrunk pi cks up speed , In thi s way. a greal dea1 of energy is saved and the movement is efficient. However, if the person walk s ve ry slowly or very quickJy. or has a stiff knee and has 10 lift one side of the body excess ivel y to clear the floor. th e ene rgi es are no longe r complemen tal)' in size and/or shape; less energy exchange call take place. IIJ These modes of wa lking are le o;;s efficient than normal wa lking. The second method of obtaining mechrulical energy COSIS uses a kinetic approach. Brielly stated, the ene rgy changes in a body part between subsequent instants in time are calculated (I) from the products of the forces on each end of the joint and the ve locity of the point of application ::md (2) from the muscle powers, which are the products of each muscle momenl and the angular ve locity of the body part. In some cases, the muscle is adding energ) 10 the part (generati on). and, in other cases, il is absorbing energy. There are a number of different methods of handling the calculati ons of mechani ca l energy. exchanges, and transfers but a sound approach is described by McG ibbon and co lieaguc s,ll~

Heart Rate Data A third general approach to determining the relauve energy cost of gail is by measuring the he~U1 ratc (HR ) during ambuJalion. Relative energy consumption h'ls been found to be hi ghly corrclalCd \\, ilh HR and ab~olute le\cl of en('rgy consumplion h ~ been found to be hi ghl) correlated with HR and ma'\imum walking speed. The 1ll 0~t accur-lle' \Va) to detemline HR i ~ 10 lhe a telemetry ~y~tel1l thaI produce:-be~u - b)' - lxal IIlfOnnat lon a, \\ell a. . electr<x:arJiographJC' aCli\ ity. f..'hlll) lIle'IJen-. ivc heart ..Ill' IlllJnilor.., art' al')u :1\ .ulable and ~ome ar\.' de. . lglll·d 10 downto;ld . . Iored lIlfOlmatioll 10;) COlllpul('r (see Chapk'r -l). HR rcC)POIN:'~ 10 ambu lilrion can ~11"'0 bt> delennined h) p:.tlp.lth)1\ (II tht" raJI.!! or L' ~\muJ ..ulen,:..,. Ihough 'llm e\\ hat more ermr lIl.l) bt' pre'>eIlL IIR me ..hure\ h,J\t' ~ell ..,howl1 10 Ix adequ<.Ih: l) ~t: n"l ­ (I\ e fllr ,omc appl!\'Jl1on,> ''"or c \ ,II11plc-. ~ll1lpl e fllCJ;o,ure, 0 1 HR ami 1l};l:\II11UIll dlllhulJlory \cir...· II) ,llIn\\~d .1",'C li rail' predll· tl on V O~l») llf I'lll'rg) l'OINlmptllJn in _~S l h Lid ren \\ IIh m yt:lolll ..' lIlHgoce 11.' , ' I \ ~kl\\t'\ Cl'. 1-1('1 ix-Il ,tTlLJ L'olkagul,..,hl .ml! tho.,c; \\ 1111 IIltJd lo\\'~ r \',tll'lllil IC'" l'\C:1l thuugh l'ntTg) lun,ulllptJOn \\ .1.., 15 perl'cnl hlght'r In thl' ~' h d d rl'n \\ Il h ~lInpUIJ II Olb Pc rh.lp.., tx'l,llhl' tlw ~lllllillllllh \h' ft" mUle dl'par.ltl', \\J1t'r' .mel 1.0' "vrl...('r~ JOl/nd Iha t III IMIlCllh \\ Ith lup dfl h fOdt',)I~

Phy~ical

356

Re habilitation

. Examuung . . " . Methods of Gait Analysis Table 1 0.25 Salient Features of StudIes .anous

"t

(8)

~~~~~-=~~~~~~~~~

AuIyoi8 ofGaic Stu&cI SabjecUI~ Mecbocl

Nelson. AJ39 t 974

FAP

31 patients with neurological deficits

High interrater and intrarater reliability.

Titlanova . EB, et aP 26 2003

FAP

Comparison between individuals who were approximately 6 months post· stroke and healthy individuals

FAP scores relate well to the patient's galt va riations and variations in functional outcome . but only at an unhurried gait speed.

High interrater reliability, construct, and concurrent vali dity.

----------------------

- - - - - - - - - - ._--I

Woll. SL, Catlin, PA, Gage , K 41 1999

EFAP

28 patients who had sustained a stroke

Baer, HR, and Wolf, SL'27 2001

MEFAP

26 patients who were between

Shields, RK, et ai " 1995

Iowa Level of Assistance Scale

Patients following total hip or knee replacements

Highly reliable , valid, and responsive.

Hawley. CA. et aP28 1999

FIM

Psychometric analysis of 2268 FIM + FAM examinations of 965 patIents from 11 braIn injUry centers

Use of untransformed ratings should be adequate for most cli nical and research purposes In comparable samples of patients With head injury.

Donaghy. S. and Wass , PJ 119 1998

FIM + FAM

53 severely involved survIvors of traumatIc brain Injury (40 men, 13 women )

Motor items In the FIM + FAM have better reliability than the cognitive Items. ICCs In the good to excellent range for 29 of the 30 items and for aU subseales except psychosocial adlustment.

Otlenbacher. KJ, et al 4r 1997

Functional Independence Measure for Children (WeeFIM )

205 Children (1 1 to 87 months of age) diagnosed With cerebra! palsy developmental disabilities, mental re ta rdatIon , Down syndrome , and othe r cognitive ImpaIrments

Agreement and stability of the WeeFIM was fou nd to be excellent across tramed ralers and time .

Van Sweanngen. JM.

GARS·M

52 communny-awelhng elder!y residents

Reliable and valid and could be used to predict persons at risk for falls.

Shumway·Cook . A et at='" 1997

Berg Balance Scale

Community d\.'Jelllng elderly persons

Sensitivity at 91 0 '0 (20 of the 22 fallers COl rerlly classlf,ed) and a speCifiCIty of 82° < ( 18 01 the 22 nonfailers correctly classifIed)

0, FabiO RP and Seay R"

FEMBAF

35 communu\t-d'lllelllng eluef s (4 men 31 ...... umenl mad .gd 79 9 years

Valid and reliable measurement of nsk tactors_ '\inChon I periormance, and factors !niH hinder mObIlity

SAM

CompallsUns b~t ...\een tne percentage 01 lu(.omotloll loonrtOlod by the OyndPOit actlvlty of dally h\ In9 mOIlltcH

et

. - - - - - - -- - --

16 and 66 days post'stroke

~

FAM

at~L

-----

1996

1997 Bra ndes. Mana Rosenbaum 0 ~ , 2004

High interrater reliability and tesHetest reliability for the timed portion of the profile. The mE FAP provided clear and speCIfic functional information and was I sensitive to changes in the amount of time taken to complete ambulation tasks. '

.-

--

.----,

High concurrent validity (r =- 0.95).

.:HId Itl flumbel 01 ~teJ..l::.

determmtu by tnc SAM

I (con,..,odl

Chapte r 10 Examinat.ion of Gait

.,GIII 'I

Table 10.25 Salie nt Features of Studies Examining Various Methods of Gait Analysis 'f III ' 1

Coleman. KL, et al"

•

I 1998 I

Henriksen, M, et aj13

2004

Tong. K, and Granat, MH 75

45 subjects with diabetic neuropathy

Average deviation of the SAM count from 2 observers using the hand·held tally counters was 0.54% for the first trial and 0.65% for the second trial.

Triaxial accelerometer

19 healthy students

High absolute test-retest repeatability for 2-feet standing ; relative reliability low owing to restricted range of values (ICC > .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<:tsyl Despite I'OI1~cwh.al q.u ~~tjo~able variabilit y and sen~itivifY in persons with dl sabllitlcs. It has bee n used successfull y to d i ~tin g ui sh betwee n the COI'! of walking versus wheelchair leg-wheel in g and aml -wheeling l22 in person s wi th molOr l im it~lIions , to demonstrate the positive e ffects of a slider shoc in a single case study of a persoll with stroke ,123 and to ~h ow that increas ing the lateral rig idity of a mechani cal orthosis for achieving reci proca1 walking in patie nt s with high level paraplegic produces a very positive effect on the energetic~, name ly a 30 percent reducti on in PCI . 124 Recently a Towl Hearl Beat Inde\' has been developed which shows promise of greater reprod uc ibi lity than the PCI, and readers <;hould "atch for reports examining its reliability and sensiti\ ity. ':~ Table 10.2 5 presents an overview of the salient features of srudies examini ng van o us methods of gait analysis.

Questions

for

Summary An overview of some method s for kinematic and k.inetic gail analy se s has been presented in this chapter. Many of the common variable s examined in gait analyse s have been defined and described , and examp les of studies us ing gait analyse s have been presented. Observational gait anal ys is and time and di stance variable s have been emphasize d. becau se they appear to be the most common ty pes o f analyses used in th e clini c al se tting . A brief ove rview of some o f fhe motion anal ys is system s has bee n provided . Readers are encouraged to inve sti g ate the capabiliti es of individual moti o n anal ysis system s. and to con sul! the gail literature for reliability and validity studies rega rdin g the se systems . The ability to perfoml a gait anal ys is that accurately describe s a patient's gait will provide importa nt quantifiable information necessary for optimal treatment planning.

Review

t Describe each o f the three diffe rent types of gait anal y~es

OJ ne matic q ualitative, kinematic quantitative, and kinetic). . Li st the \"anab l e~ exami ned in eac h o f th e three types of gait anal) 'e .... • Select one variabl e from each type o f analysis and describe a me thod of ana lys is fo r each vari abl e se lected. 2. bplam illl rate~ ter and interteste r re li abilit y and how the) relate [ 0 gaIt anal ys is. 3. Compare the advantages and di sadvant age s of a kinemati c q ualitJtJve ga it anal ys is with the ad vantage s and dj ~ad\amage:-. 01 a kinematic qua ntit ati ve ana lysi s. 4, U~in g: the model presented in Tabl es 10. 1 to 10.11 , perf0 1111 an OGA rhat inc ludes both identifi cati on o f

Case

359

5.

6. 7.

8.

observed d eviations and an analysis to determine the cau ses of the deviations. Which type of gait analysis would be appropriate for examining ve locity and c adence ? Stride 1ength? Peak plantar pressures? Ground reacti on force s? Describe the anal ys is system you se lected and justify your reason fo r se lec ting that partic ular system or me thod of anal ys is. How quickly mu st one walk [Q cross a stree t befo re th e typi cal traffi c li ght change s? Explain validit y and how it relates to gait a nalys is. Gi ve an example of e ac h o f the differe nt types of va li d it y. How coul d a ga it a na lys is o f lemporal parame ters be used to de m o nstrate J patie nt's prog ress o r lad.. of p rog re ss?

S tudy

HISTORY :ni~ 65-year-old WOlll an 1\ 5 d ays po~t rlg hl lotal hip

anhropla\t) · , 1h e ~Ulgery w a ~ pe rf.ormed fo ll ow .lIl g a femoral nec l" I r.ldure .. .IIlCli lTt: d dUring . 11 fall on lite ICC III . hontofh· h S . . . ,er (JOlt., Itt: ha .. had da tl y bed \ Jdc p h )' ~ I L' al

the rap)' lor thl! p;'l~t 3 Jay~ a nd now t :-. inde pende n t in t r"rh. rer~ . Ii Oy.e\'cr ~ h e need..,. to be Illdependent III wa llo.. -

Ing beftJre .,ht: goo ho me.

S h~ ha" .1 P
tKipate in an y reg ular e.\ e rl i. . e prng ram and ~ pt: nd , a g reat deal ot Ill1\e ,itling dUfing her wor\.. ilS ~1 "eam~ t n;-::." Sh l.;! IS a lf' rt anJ o fl cn t~J to time' a nd pl.l1.:e and h a~ a pka.';;a nt demeanor Shl! " ."i fee l , Illc he~ ra il , am.! \\c il!hs 100 pound, . -

360

Ph)'sical Rehabilitation

Sensory Examination

Passive Rom Examination

AliI

MdW"-,If. RFoot

(Il0M), La.,.. Eaa. 'tiel

Knee

At

. L " .. ,

,

Sharp/dull

5

5

Light touch

5

5

Temperature

5

5

Propioceptive sensation

4

4

Riaht

Flexion Extension Abduction Adduction Medial Rotation Latera l Rotat ion

WFL WFL WFL WFL WFL WFL

0-40 0-1 0 0-20 0- 10 0-20

Scn..,atioll Scale

Flexion

WFL

0- 120

WFL WFL WFL WFL

0-15 0- 45 0-5 0-20

I. Intact: norma l, accu rate 2. Decreased : delayed response 3. Exaggerated: in creased sens iti vity 4. Inaccurate: inapprop riate perception of stimuli 5. Absent: no reo;; ponse 6. I llcol/sis/ent or ambiguous

Not tested

WFL "'" with in functional limits; upper extrem ities: aU ROM measurements are WFL.

-----

Manual Muscle Test (MMT)

Low.". Ex_ities Left

G GGG G G - - -G G-

Right

INSPECTION Patie nt has an ulcer o n the medial aspec t o f the ri ght plantar surface whi ch is 0.7 X 6.0 em in di ameter and Jj mm deep.

FUNCTIONAL ASSESSMENT

Flexion ExtenSion Abduction Adductton Lateral Rotation Medical Rotation

Knee

Flexion ExtenSion

GG

Dre"ing: FIM

Ankle

DorSiflexion Plantartlexlon InverSion Eversion

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,

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Left

Ankle Dorsiflex ion Plantartlexlon Invers ion Eversion

Hlp

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Flexion ExtenSion

G GG G G G

F

p p

Tran ... fers FIM leve l

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GG-

Eati ng: FIM = 7 Bathing : FIM = 7

I. Dc\elop it phy"ical therapy proble m lis t. ::! COlllplt!h! tht' sam pl e OGA fOnll based on the informalion pre'>c•.'llted tSt;:(' Append i\ A). J. Pn..':-"I:!nt Jour recoITIJllt'nJ:1110ns for ph}!ljcal fherapy

G F F;

G-

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SFSATION Hj ~ht 1.11\"-: ,. L\tlllIl Jl\ .t 'i. pt:ll

ot n,gltl

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=7

GUIDING QUESTIONS

p

MMT Upper Extremit,es' all muscle grades are w,th,n the G to Grange

D... h Lil. noted pllm.uJi} ;.thin!! ItK' Illl'dl.d

=7

Chapter 10 Examination of Gait

361

-R c f e r e nee s e\ml'n ..-:ln Ph~ "ical

TherJpy Assoc iation: Guide

10

physical thera-

. i~1 pta(II(C. Phy~ Ther S I: I . 2~1 . . . . . ~Iuellt'r, \ \J, el JI : Difference:. III gall characlen:'llCs:,f pal1ent.~ \\ l1h Jlabele~ and pt'npheral neurop:l.Ihy compare d \\ nh agc-

maKhed l·Clntr(ll~ . Ph~<; Ther 74:~99. 199-t

\ 'On SchrC'eder. HP. ~I al: Gait parameters follo\\ iog woke: A pm,tK:U :I~~"~mt'nl. J Re h:tbil Re<: [Xv ~2 : 25. 1995. \\'al ~er. SC ct aJ - G:lll pallem :tilct1ltion b) j unctional :.cnsory sub.utuuon in heahh~ and in diabetic 'iubject:o. \\ ith peripheral neu fllp31h~ -\.rch Phy... ;"Icd Reh~bil ?~:~~3 .. 19~7 . .

He"..e. S. el ai ' .-\.')1l1men~ 01 gaLl Imtlatlo n III hemlparetlc stroke

t>

o

III

11

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! 1,

l.ut-toKt., Arch Ph~' ~1ed Reh:lbil 78:7 19. 1997. Dr Quenam. IAt..: , et 31: G:lit p:mem in !.he early recovery period aft<.'r ~Imk<.'. J Bone Joml Surg: 78A : 10: 1506. 1996. R~'I. S l, . et al: G:l!1 miliatlon of persons wI th below-knee ampu1J[icon' Th~ rhlTactt"nl.1110n and compari')on of foret' profiles. J Rehabll Re" ,~ I ~ O . 19')5. Roth. EJ. el .11' Hem iplegic gal1 : Rel3llonships between walking 'ret"tlc dip1cg1C cerebral palsy. Yon.~ei Med J

,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~ pre<.enocd on hoses demonl>trate 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

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-

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<: nl>~ 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,- II<'ml' )~ 1~~ . 'f.!.' ~"Jt p~dmt:tt' r ~ J 0 nhop'" 1)0,1 , I'}h~:. 'nwr :' ~. IJ<-J I

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~1J1I,t;rt.J.nd Dl-I Ilic \':\1II UIl')f1 .)1 d lnJe.!1 1,',,/1 .tn.lInl.'.. P,m I I ,-u'ocrnolU,\ (.;H! P"'iUft" i(ll''i'j, 2U02. . (fitll. RL .1&1 Utl,_ fA <;,ut J.~~C~"'H1{:nl ln the Lhnic h~ue... do..i olPPf()"d'", _ J11 "'lIt U Ihloclt\.,. J \1 (cd): f\\ c.J..l> UreOWnl 111 Ph)l>Kal Th~nl)) (I I . Jur, Ill! t l\H'g~tlJnc. london llig'i p \09

27. Dumholdt. E: Phy~ i c al Therapy Research, ed 2. WB Saunders. Phi ladelphia. 2000 . 28. Strube. MJ. and DeLillO. A: Re liability and measurement theory. In Craik. R. and Oat is . C (eds): Gait Analysis : Theory and Application. Mosby-Yearbook. St. Louis . 1995 . P 88. 29. Perry. J : Gait Analysis: Normal and Pathological Function . Slack. Thorofare. NJ. 1992. 30, Pathokmesiology Service and PhysicaJ Therapy Dcpanment: Observational Gait Analysi,) Handbook . Lo" Amigos Resea rch and Education Institute. Inc. Downey. CA. 2001. 3 1. So utherland . CC: Gait evaluation. In Valma ssy. RL (ed): Clinical Biomechanics of the Lower E xtremities. Mosby- Yearbook. SI. Loui~. 1996, p 1~9. 32. Bernhardt. J. et al: Accuracy o f o b:=;ervational kinematic as!>essmenl 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.

RP .md St'J). R th e of the "F"" E,aluatiwl of

\k\btlll) . Bat.uKc." Jild Feat" 111 cider!) wmmunit)" dVielter..: \ 'ulJdlt) and r('h,l blIJ\~ Ph)~ Thel 77:90.1. l!:ilJ7 . 4:'1 r>. lonon. r: UfIlh)rm liala ')'tem I\'r It'hab begin~: Fil"t 1001 1Uefu.-

UH'l> Jt"pc:n"~n .. c: 10::\\."1 Prugre.l>_~ Rc·pon . AOieri'.ln Ph\l>ILU ,\!c\Jndn.l. \A . 19!16. 49. \\01(..011 • .-\ \1. i)oflOr. J"<. J.nd Burn.', (,Op. Clil1J~~'11 JuJ.:;menb of fun.:tu:mal outC()Hl~": Ho\.\ 1:>1.1\ .tnd jX'rc,,,.:J. a~'Curll\.)- .ulei.·t rat· mg AT\.h !>tn, fl-kd R.. h.lt-iI81 : 15o"T. XOO 5C1 lIuron J(' ... t31 E\'i Jt: n~·t'-b,l.')ed me.I'urement. \\o hu.;h di"''l~li1J) "la le for n",ul~llugl~ fffub lhuillOn? l\euruloc\ 57'63'11, 2001. ,,! LuuI. RT. d al' 1),,1(', the Fun~hL'ni!.1 A ...'ot"""I~~l\t M e ,IMift' (F \,\ Ii c\h:nd the Func lloll~d InJt'penJen... e ~l ea)lITe 1FI~tnl) In"lrumem'.' ,--\ k",\' h ,tlMI}',,",, ul '1Tu~e mp.dlclll:). J OUICflll\e .\ It"d'Ult" 1:JJ~, TIl":r.tP) t\ ' ,\ l\.1 ..11l01l.

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362

Ph),sical Rehabilitation

'i3. Robmt'lt. (,S. und \\In Omn . ~1 A' Functl('Onaiambul:IIIOfl velocllY and dislrull~ rcqlllremeTll<, In nlrdl and urban cornmumllc:-; A c hm \.al f'Cp'-,n rhy, The!" 63TH \, 19S~ Sol Wahh. M . ('I al' Phy .. tcal Il1lp,Unuenh and l unctHln ~ 1 ilmll.ll jCln,: A tornpan ...on 01 mdl\'lduats ) )l'ur aher 10la1 I-nce arthropla...,) .... lIh control ,ubll."C't .. Ph}~ Ther 18
and heal th, ("ld('rI~ Ph) .. 111l."t 10 ·UO. I QO(l 5t."1 Rlanl.l", OJ. tlnd Ha,gcm.lIl. PA C(lm ran <;on or ~all 01 young men lUlU t" ldcrl~ Illen PI1\"" 111..:r hq 14J , Iq~9

5- Ikohanm'lo. R~ l'! al. WaH,tn£ "pe\.·d Reference \alue .. and corr{,4 la l~" h'lf (llder adul1 .. J Onhop Srttrh Ph) ... 1ller 71 1'10. 19% 51... O"'tn......l,.\. J\1. et .tl- A .. omran ..on 01 !!:tll char'.k:lcn .. UC\ In young and 01d ... ut'l"...·('\ .. Ph) ... lner - J h.H. I~" ~9 Todd. f'. ('I al \ari..!I\"tns ITllht' gall of nllrmall-hlldrt"n A graph applKabk w thl." ti.:x.ument.t1lon 01 ,lhnwm3htlt"~ J Bone JOIOI Sur~"'I<\ 1%,19~4

tl(l Murra:_ ~t. t'l al \\ all-mg ratlt"m~ III noml \\omt'll J (>nh"p Spn"' Ph~ , flh·r :t, t.t.O. 10<11 N'o SUthc!IJnd. DB e1;t1 'nlC' .k\e\c'P"K:TlI.,f tnalt.m.; ,.1lI J B(,ne Jlllm Surr hi" ,~) lO\,ll ,.,'" \dlclu..m.ilJl \I C'1 at Rdl ......lh" "IIOlI'almlt.nl .tnJ rh~"Il:,,1 ~t hmu"flu mco1 ....... 'C~ I"r ('Cf'tI.m IoI.llh Polrtm"(KI', d'''l'.I'>C! Ph\"'> rht-r -... 1') l'l'r h)\ \1o-. .. ht.·r~ hA Rth.thllu~ 1'1 .. IHTlt'd \. "I ~ "' .. 1 In !'O\:hllf,., "Jlh ioi.4l1lf(·.j ~J 111111 un ~m J Ph~, \kd Rt"h.tbll ~~ .:-:~, ~fJn~ ~ )hum"",·( ~)1- A oI.ltd \\o()113~'\1

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Mcd Rehabil 67 :~2 . 1986. 1 1~ \lrG,hroo . CA. Kreth, DE. and Pulllell~, ~ S- ,Mechamcal c~e r~y anal}", ,dentllie-, compcn',lIllry :. lrah.'gtC'~ In dl!-.ablcd ciders gall. J Bltlf11Cch .\4 ~s I. :'00 I . 11~ MarCirq!l'f . J' The OhJl''':l l\e M..::t"uren~ent of Ph~'~ i ca l Pcrfo.mlancc Yolth l..one-Trml Arnt-ulatol) PhY'lo loglcal SUr\cllJancc Equipment (LA PSEI~ PfllI: ;rJ Int S~ mp em All1hu l:lI ory Mannoring. London.

!9-W. 1979 II'. BOld. It el al HIgh- or 10" - Iec hno l og~ me a~uremenh of energy c\Pcndllul\' III chnn:a' gall a nal~ "I ~? Dcv Med Ch ild Neuro l -41t>~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:'J<:'Urc for the as.-.es<:.menl of ene!"'.,!y expc.ndnurt dunn!! "all mg. -\rch Ph }~ Med Rehabil 83: 1777. 2002. 1~1 '1roe. AV' Ph~<;:iologlt'.:1.1 co~t index of walking in ablc-bodied ado· lr~en" and adult". Chn RehabI 17:3 19. 1993. C~. Slem. RB . et al: Improlcd efficieney wi th a wheelchai r propelled b~

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lhr leg, u,mg \olunt:11') aCli\l t ~ or e lectric .!olJmui:lllon . Arch Ph}' ~kd Rc>ha blt ~2: 1198. :!OOI. Cro,~. J. and T)-.on, SF: The clTcet of a slider , hoc on henllplegic gall ('1111 Rehabll I 7:~ 17. 200J. Stallard. J. and MaJN. RE::: -Ille mnucnce of onh()<;i, ~ tiITnc ".!o on paraplc>glC ambulall('>n and II' Implications for functIonal e lectrical !illmulall(ln ,FES) \\all..rn~ 'y,>ten1i>. Pro~ thet Onl1011m 19: 108, 1(0)

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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, '~:<)71. 2001

363

128. Hawley. CA. cl al : Use: of functional as!>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 ull<;: Reliability and vi,lid;IY of the Stcp Activity Monitor. J Nun. Mea., 9:275 . 200 1. 131. Brandes. M. and Rosenbaum . 0 : Corrc lations between the Step Activit y Monitor and Ihe DynaPon ADFL-Moni tor. C lin Biomech 19:9 1. 2004 . 132. Hanse ll. H. c t al: Al:curacy of a c u ~ tom -des i g ned activity monito r: Imphc3t iolh for d laoclic foot ulcer healing. J Rehabil Res Dcv 39 :395.2002 . LB. Maluf. KS . and Mue ller. MJ : Compari"On o f physical actI vity and cumulative plantar ti ssue s lre ~.\ among ~ ubjccts with and without diabetes mcltilU<;: and 3 hi of gai l measured by an ambu latory system uSlIlg milllaturc gryo scopes. J Biomech

35,689. 2002 . 135. Bliney. B. Monis. M. and Webster. K: Concurrent validity orlhe GAITRite walkway s y~tem for quantification of [he spatial and tempor.iI parameters of gail. Gait Posture 17:68, 2003 . 136. McDonough. AL. e t al: The validity and reliability of the GAITRite System's measurements: A preliminary eva luation. Arch Phys Med Rehabil 82:419. 2001. 137. Titianova. AEB. and Tarka. 1M : Asymmetry in walking perfonnance and po~ tural sway in patients with chronic unilateral cere bral mf::UClion. J Rehabil Res 32:236. 1995. 138. Nelson. AJ . et 31 : Thc validity or the GaitRile and Func tional Ambulation Pcrfonnancc scoring system in the analysis of Parkinson gait. NeuroRehabil 17:255 . 2002. 139. Van Uden. CJT. and Besser. MP: TesHete~t reliability of temporal and spatial gait c haracteristics measured with an instrumellled wal!.. way system (GAITRlIc ll ) . BMC Mu.sculoskel Dis 5:13. 200·" 140. Menz. HB . et :II : Re liability of the GAITRite wal!..way sysfem for q uantification of te mporo-spalial parameters o f gait in young and older people. Gait Posture 20: 2~.2(X)4. 141 . Besser. M . Anton. N. and Quade . S: Cri terion validity of lhe Arie l Perfo n nancc Analysis Sy ... tem (APAS) for the calculatio n of Joint :mglcs u~ing A PAS 1Uld Gall Lab software. Proceedlllg~ of the 20th Annual Mecting l'If the American Soc iety of Biomechan ic~, Atlanta. Georgia . 1996. Retrieved Nmember 30. 2()()..J. from hnp :IIa.~ b-b l omec h . orglonlineab"'ab"trdct s96/bc~r. hlllll.

142. Wibon. DJ . et al: Accuracy of reconstrucled angular eSllmales o btained with the Ariel Performance Analys is Sy ~lem . Phys Thcr 77:17" 1. 1997.

Appendix A: Blank Sample Recording Form for Observational Gait Analysis , Age

Pallent's name DiagnosIs I Footwear

Sex

Height

Weight

I

Assistive devices Therapist

Date

DIRECTIONS: Place a chee" In the space opposite the deviation jf the deviation IS observed.

.' ) a:,. <~ iW£,~ ' (~!~~<.i.~.> 6~Si'''~;;~'i",'':f~ ••~, ~.i~(":~,~,." " ,:,-~;;;" . , C< teJ".:c''Pl" '; , ~ '" ' IIIIC;':-,,! 5 _

Ankle and fool

I

R

None

R

L

Observations In the FOOl flal saginal plane Foot slap Heel off

-

No heel off 1 ExcessIve plantarllexlon

I ExcessIve dorsiflexion

-+

. Toe drag

I Toe clawing j

Ob;ervations In thel frontal plane

,

Contralateral vaultIng

Varus

I

Valgus --4-I

Knee

None ---~

Observahons In the

- --

I Excessive flexion

sagittal plane

I

\

limited flexion No flexion

Hyperextensoo GernJ o..-Mliehed _kteneion

I

I

L

R

L

R

L

R

L

R

L

R

L

R

L

,,

Vaig"'"

"- ,

fJ( Y""

Jr,

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p ..

I I

•

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•

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tr 11,(

; I

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t

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i

I

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-------

I ;

I

I

L

(continued)

Appendix A: Blank Sample Recording Form for Observational Gait Analysis (continued) -

s.........

--s..--d

()p,; iatiOn

Tru'1k

None

ObservatIOns In the Irontal plane

-

HS

j

Backward rotation

--~

Latelallean

1 ~

- --

--t

I

1

t~+ -~

-

-

-

Forward lean

1-

--L

I

Backward lean

-

i-

t ~

I I

II 1

+- j

~

FOMard rotatlOn

Swm,

HO

MST

H

~

1 _

r

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+

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+

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t I

+~

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t tL I -+ I

OF£ ., _ _ I

",

.,- -I

I -,

1L

MSW

ACC

t

-~

PoooIbleC._

AaeIyoio

Appendix B: Cotnpleted Saulple Recording FoTIU for

Observational Gait Analysis Age P..9_S1 lof.!i H:p A Ihro p l
Diagnosis

Footwear

Sh~L_

.PU!OratJ1y

, ~,,-S

__

~3

H f' .gh !

_

W"ght

_ '~·h

D:ajx}tef.

__ _ _ __ ___ ASSls llv e deVice s N_QNE _ _ _ . ___ Therapist J<J9rkm _ _ _ __

Da le _5~6/98

DIRECTIONS : Place a check m the space opposIte the deVIation II the devta llon IS observed

!:....:..,. ' .!j--!!! '!I.'. ..

;,.....:: ,·~ili ,~

;I'1..,; . . . .. . .

! Ankle and 1001 , . I Observations In 1

I

1 None -+ Foot Ual

-

thel'

sagittal plane

. I

A L -. ~ ......

-.----

Fool slap

-+

L 1R

I

l

-

A

i

L

1 ... . R

'*~:;= ~!L.!!DI!IC !!!.;-:'i' ;;~";!""\~ ! '';: ...~'!!L: '~ L+ R

I

L

+- -+.

i

---; E)(cesslVe - - -plantarlle)(lon --+-

-t

=J

-I

i

+_+--+_+--+__+--+,_+--+_+ "- +-+ "-:---i

9 _ _ _ _ _ __ Toe d'_a.:: j Toe clawmg

------I -

-J-+--+--+--·--ft-+-+--l-J- -.-

-

+--, ._, ,

-

-

Valgus

-

I

---+

-+-

Varus

--;-,

---.., -- ..----

Weakness dorslt!C)lors

-i-

______+1 Co~ra_l.a. le.,a.l.v.a.u.:II' _n~g_-+_-+_-+_-+_+_+_+-_f--l_-+_-+_+_+ __ Observations In the frontal plane

+ Weakness dorSltielCors

~-+---,-~ -

______-+1 E)(CeSsiv.e_d_o.". '.lle. x.'o.n_+_+--_+--_-l_-+_+-_. -'+--~I---+-+-l

----

I i

-

--.-~

dorSlf~exors

I

!

t

HeelaN

Weakness

L

l R -.

A

-----+--l- -+---+--+--1- -

I No heel off

-

R

tiI . ,--

;

-----+---=-----++-I-I--+-+--+-+----+--l-l-+-+-+.--!----'None ~=~~~+-~-+~+-~~+-~~~--~~-+---Observallons in the ExceSSive Ilexion ! Knee

-+---

sagittal plane

r

Limited flexion

______4 No on-----+-+-+--+-+--+-+--+-+--+-+--+--+--+--!----I.I-..;. 11. ..

HypereKlenslon

~

---+--+~-r_+_~_+~-}-+_~-+_I-+-~-+.

'r

------T.G~ :==~--+-r~~-+~~-+~~~~+-+·enu recUivatum - - - - - F ·-..:.

L_________.LD_'m_'_nished extenSion

I (continued)

Appendix B: Completed Sample Recording Fonn for Observational Gait Analysis (continued) '-'. 0::~_Y';,;/;:::- ..z;:f';::1.£:"'·· . . ~-"W '.:

,

:?:"',

Observations In the fronlal plane

Varum

Observahons In the

Excessive flexIon

.:.

"

. ~~

.•

:,.

, ~,./-~~ ';:-

_ ., ...,'\ . c" 2..r;;,:~~':~.:{:

----Valgum - - - ---+-- - -H Ip None -- --- .-

sagittal plane

--- --- --- - ---

,

~

Obse'Va hon~ In

frontal plane

---"

--

-

PelvIs

--

No flexion

-

----

-

I

I I

-

-~-

Adduction

-

Extemal rolallon

-

~

.

-

Hiking

-

..... --,

-

- --

.A nt~ rior

ObservatIOns In tht!

----

I ",

Drop of pelvis

I

-~

- -

-

,

-

.

,

,-

---

-- -

~

I ~

I

till

-

"

r--

:

-

-

sagll1al plane

I I

!

None

-

,

--

-

Internal rolahon

--

-

I

Abducllon

Circumduction

-

I

-

extenSion L DiminIshed ________

,- -

--'-

limIted flexIon

lhe

--

--

_._---

Postenor tlit -

-

- -r- -

-

Increased backward

--------

rotallQrl

-

-

---

Increased forward

~tIO~_ \ Umlted backward I

ralatlon

i I

-

'H

',

.

,

..

('

D 4$ · ' _~ ,

.

-'"

.

,

rol(11fCHl

• Drop:, (,n ('Olltra!,lterai side

...

Trunl>.

.

..

;

.

-

-

fV

I 1· .... 1·..

"..Backwa--rd rotation

lIU'I'

I

,

TO THE LEFT

None

.

Observations tn the frontal plane

- -_ ..

.

P!:

,

I

Llmrlf'd IOrViard

...

T I

t

YO

I

1 •

..

-

-

..

..

-

.'.:

;1.

ACe

, V

I V

f ..

'1'0.

-

.-

,

"" ~ -- ~'~~ --

-

Weakness Right hlp abductors .

I

f-- .-- f--

.---.,..

._+ -_. _Lalerallean

I

,

,

I ----

~---

Forward rolatlon

Backward lean Forward lean

V

V

v

Weakness

Compensation to counteract

Hip extensors

FleXion moment

Appendix C: Manufacturer Contact Infonnaticl·• for Motion Analysis Equipmeafl --------------------~-----

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Chapter 10 Examination of Gait Step Wa lch t\Clivi ly Mo nil or 31"\1 (SAM)

Vicon Molion A na lys is Sysle m

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Vicon Mot ion Systems. fne

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WeeFIM'" Unifonn Data Syste m fo r M ed ical Re ha bili tation. a Di v isio n o f UB Foundation Ac tivities. Inc Amhe rsl. NY 14228

371

Appendix D: Simple Tabulated Output from the Stride Analyzer System YOUR DEPARTMENT'S NAME YOUR INSTITUTION'S NAME STRIDE ANALYZER REPORT- WALKING NAME:

JOHN SMITH 1234 OSI 13193 29 M Sprained Righi Ankle

1.0. NUMBER: DATE : AGE : SEX: DIAGNOSIS:

I

STRIDE CHARACTERISTICS VELOCITY (MIMIN): CADENCE (STEPI MIN): STRIDE LENGTH (M): GAIT CYCLE (SEC): SINGLE LIMB SUPPORT (SEC): (%NORMAL): (%GC): SWING (OWC): STANCE (%GC): DOUBLE SUPPORT INITIAL (~o G C)' TERMINAL (OW C): TOTAL (%GC):

ACTUAL 60.3 100.4 1.201 1.20

RUN: STRIDES: DISTANCE (M): TEST CONDITIONS: WALK

%NORMAL 74.0 92.7 79 .8 106.8

-R0.429 86.4 3S.9

0.418 84.2 3S .0

33.S 66.S

34. S 6S.S

lS 2 l S.4 30.6

lS.4 l S.2 30.6

-L-

LEFT FOOT (sta nce = 6S S'o GC) H EEL

- Normal Contact al 0 .0°0 GC (0.0 0 0 Stance )

STH METATAR SAL 1ST METATARSAL TOE

Delayed cessatfon at 50.60 0 GC (772°0 Stance) - Premature contact at 3.8% GC (5.7°'0 Stance) Delayed cessatIon at 633°~ GC (96 6~·o Stance) Normal contact at 224°..., GC (3.J 2°/0 Stance) Delayed cessatIon at 63.9°0 GC (975°'0 Stance) Normal Contact at 33 7°0 GC (5 1.4°'0 Stance) Delayed cessation at 65.5 0 0 GC ( 100 0 0 0' Slance)

RIGHT FOOT (stance HEEL

66 SOo GC) Normal Contact at 00"0 GC (000 0 Stance) Delayed cessation dl 50.8°0 GC (764~o StdnCe) Premature comact at 4 0"'" GC (60"'0 Stance) Delayed ce~Satlon at 64 8°'0 GC (975"" Stance) Normal contact d! 196°'0 GC (294\)'o Stance) Delayed cesSdlrun Dr 63 8"c GC (96 OU Stance) o Normal Contact dt 381°'1> GC (57.300 StdnCe) Delayed Cessd\lon dl6S.2v o GC (DS 1°~, Stance)

STH METATARSAL 1ST ME1ATARSAL TOE

From Ctdlk Rl dnd

li2

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C HA PT E R

11 LEARNING OBJECTIVES J. Di scuss the concepts of health statu s. impairment. fu nctional limitation . and disa bility. 2. Define fu nctional activity. and discuss the purposes and compone nts of a fu ncti onal

examinati on. 3. Select act iv ities and roles appropriate 10 an individual's particular c haracteristics and condilion to guide examination of fun ctional status and activity leve l. 4. Compare and contrast characteristics of variou s formal tests of fun ction. including phys ical fu nction te'iI.s and m uh idimensional fun ctional

assessment Instruments. 5. Identify fa ctors 10 be considered in the selection offo~al instruments fo r testin g function . 6. Compare and contrast various scoring methods used in functional instruments. 7. Disc u s~ the issues of reliability and validity as they reial e to functional in struments. 8. Usmg the ca.-,e study exampl e. apply clinical decision making skill s in e\ al u31ing data from the exammatlon of fu nctional statu !I.

Examination of Functional Status and Activity Level Andrew A. Guccione, OPT, PhD, FAPTA David A. Scalzitti, PT. MS, OCS OUTLINE A Co nce ptu:11 Framcv.. ork

:\7 ~

Eu min.ltlon of Function 377 Purpose of Examinatio n of Functional Status 377 Ge neral Considerations 377 Testing Pcr-.. pcctivcs 377 Types of Instruments 378 In!llrument Parameters and Fom1ats 379 Re. . p Oll ....c Format" 3XO Nom inal Mea<;ures 380 Ordinal Measures 381 11lIerprct ln g Tl...... t Rl.... Ult .. 38 1 Dctcnnining the Quality of In ~ trumen1 S 383 Conll ideratlons in Se lection of Instrumen ts 38~

T

he uitmlJ.!e objectl\e of any rehabilitation program is 10 return the IOdi\ Idual to a life:'l) Ie Ihal is a:, close to lhe premorbid It~\el of fune'lion <1!1 po:-. .. tble or. alternative ly, \0 ma >.. tm lLe th~ r um:n! potential for function and ma tnt ain it. For an otherv. t..e heaJLhy patient \\ ith a fractured ann. th l::' m~ ) be J rea ..onabl) .. 1I11ple proce ~': Improving r~ng e 0 1 mOllon .md "lreng th v.. III ree!llab li"h :-.kli b in dre~~ il1 g and leedmg. H(,:m C'\a, l'l)lbluenng (he p<.iuent \\ tlh 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 ddC 1.1.'1-. ... J.lIi\ 1111..''1, dnd ruin Ih<.ll IlkIlU I ) .1 IlCl ,t)1I '-" "n IIldc:pl..:m,h.'nl ddu l! or " ..

Selected Inslmment:-. Assess ing PhY!lical Function 385 Barthel lndex. 385 Katz Index of Activities of Dail y Li vi ng 385 Summary of Physical Function Tests 385 Muitldlmcnllional FundlonaJ A::,lIe",ment In"trument" 385 The Functional lndependence Measure 387 The Sickness Impact Profile 388 The Outcome and Assessment Information S~I 389

The SF·36 389 Summary of Multidimensiona l Functional Instruments 393 Summar) 396

a child progressing toward adult independence. These activities requi re the integration of both cognitive and affective abilities with motor skills. Functional activity is a patientreferenced conce pt and i.s dependem on \I, hat the individual self-ident ifies as. essential to suppon ph}sical and psychcr log.ical well-being ~ well as to create a personal sense of meaningful living. Function is nOI tota.1ly individualistic, however; Ihere are certain !.:ategories of activities lha.l are common to c\ cf)olle. Eating, .. leeping. elimination. and h) giene art" majur t'omponenb of ~u r\'iva l and protection commun 10 all 311l1llab. Particular to bLUnans are the evolu tioll.lf) ad, dnl:~lIlenl'l of bipedaJ locomotion and com plex h..Uld dl' tJ\ 11tt"!I. \\ hlth pennI! independence 10 the- personal ell\ Ironmen t. \Vor1-. a.nd recre.ltion are fLUu,: ttonal aeli\ ities in 4

" s.Ol IJI (.'OIlIC\t.

Thl .. ch..lpler pre..,tnh a conceptual fr::une \l, ork for t!,amInlng flUKllo nal '1t.HU ~ and mtrOltuces the reada to tenninolog) lI~ed III the field It pre ..(~nb an O\oervie\l, of the pur 4

P{ht' ~ ~ If

luncttondl ...,1.llU .. e:\ am tlltllion ami the range and n ~o r 01 lonnJI h:~llIbtrumcnb turrentl) d\:.11labk (0 diniL1 ~1Il " .Ull! rc")eMlhl'r..., Con~tder.uu)O" III teM !telecuon and pnnuplc.., 01 adll1l1l1 .. ,ratiOn Me aho prl':l;Cnh.· d.

374

Ph, 'sica l Rehabilitatio n

A Conceptual Framework Chronicallv ill and di~~tb l C'd persons represent a large seg-

Illent 01 th; popul<1tion in the United Slate.;;. Approx imately 3-' million indi \' idual, \ uffer from ph y~ ic al or mcnta l impatnllCnh Ihat IIl11ittheir capacity to perfonn some dail y fu nctional ac ti, jl) .~ Traclitionally. th e~e indi vi duab havc be(,1l cat e~ori7Cd or c1.,,\i fied accordi ng 10 their medical dl,ea,es or ('onditiol1". Medi cal procedures ~uc h as. physical e\alllill~lI i on and I \ uch a~ we ll · being. healthrel ated 4u a l i l~ of life . and fu nct ional statu\ are often used 1IlIerc hang c<.I bl) 10 des.cribe health slaWs. The most global defin ition 01 htalth ha::. been provided b) the World Hea lth Ort! anl lJllon (WHO ). which detined healrh a,,> "a ,l, tat e of (om pl<::lt' ph ~ "leal. mental. <.I nd ..,ocial \. . . ell-be ing. and nOt me rel~ Ihe ab"ence of di "ea \es and infinnity." ', p ~ ~'.I Alt houg h ,uch global definition , > <.Ire useful :.I' philo~ophi 1.: a I ... tah!menh. the) lad. the prec i. . ion Jlece~sar) for a cliIll(, J
Disease

~

!Pathology)

Impairments •• If---

(Organic dysfunc tion)

this c hapt er to capture th e concept of health status and the processes by whi ch an indi v ~dllal becomes disabled, begins wi th Ihe pathology or dI sease process that mobilizes Ihe bod y's defenses and response mechanisms. Phys ical signs and symptoms set the ~nd!vidual's clinical pre!!lcntation apart as abnormal an~ rndlcate the bodY's attempts to cope with thi s attack on Its normal functioning. Physica l signs are the direct ly obse rvable or measurable chan ges in an indi vidual's organs or systems. Symptoms are the more subjec ti ve reactions to the c hanges experi_ e nced by the indi vidual. Thus the individual demonstrates an elcvated blood press ure (a physical sign) and repons fee ling dizzy (a sy mptom ). Many medical condi tions are, in fact. not label s for a sing le patholog ical entity, but clusters of signs and sy mptoms th at des ignate a syndrome, Two common examples of "d iseases" that are really syndromes are congest ive heart fai lu re (CHF) and acquired immune deficiency syndrome (A IDS ). Alt ho ugh the definition of d isease presented above implies an active condition. many of the physica l signs and sy mptoms that are important to physical therapy examination and treatment are not assoc iated wi th active or ongoing medical condi. tions. For examp le. a resolved myocardial infarction is a fixed lesion with great imporlance fo r physical therapists. but i ~ not an active disease process in itself (Fig. 11.1 ), Impairmen ts. as described within Nagi's model. evolve as Ihe natural consequence of pathology or disease and are defined as any alteration or dev iat ion from nonnal in anatomical, phys iological. or psyc hological structures or functioll s.&---S TIle partial or comp lete loss of a limb or an organ, or any di sturbance in body pan. organ. or system fwlcrion are examples of impaimlents. Physical therapists are concerned primarily wi th impaimlents of the musculoskeletaL neuromusc ul ar. cardiopulmonar) . and integumentary s)'~ teIl1 S: for ex'Ullple. loss of range of motion. strength, end urance. or scar fonnmion. Im painnents may be temporary or penllanenl and repre"ent an ov('n manifestation of me di\ca~e or p~Hhological Slale. Some imp:.Jinnellls are them~c.I 'e::. . . equelae of other inlpai nneilis. For example. a patient v.ll h a "'\011(,11 and ,riff joilll may evcllluall) develop weak· ~le~ . . . In Ihe muscle ... ..;urrouncling the juint. Therefore, Impaired mu ...c1t' . . trenglh \\ould be all indirect (secondar~') irnp.tirmcnt re~ulljng from impaired joi nt mobi lity. rather than i.I ~pcCJlic di !!l('a. . e or palholt}gical proce:-.s,<'!'JU

-I.... Functional limitations .. (Altered abihly In an .... If----I~ ~ Disability actIon. tas~ Or ac tivity)

PhYSical signs and symptoms Musculoskeletal Neuromuscu lar Cardlovasculal ' Puhnonary

Integumentary

PhYSical

Psychological SOCia l

(Inability 10 perform

or meel expectations of a role)

Chapte..- 11 Examination of FuncCional Status and Activity Level

A functionallimilation is lhe inabi lit y of all indi vidua l to perfonn an action or acti vi ty in the way it is done by most people. lI~lIally ' IS the result of a ll ill1pa imlent.(·...s Accurate judgment about the re ialionship between impailllle nt s and fUllctionallimitations j.:; at the heart of all phys ica l therapi st e;\amination. eva lua tion. and interventi on. 15 Th ree mai n C:.IIe!!orieo;; of fUllC lioll have bee n delineated: ph ys ica l function. p~)'chol ogical funclion. and ~ocia l fun ct ion. Physic:'11 function refer:-. 10 r11O~e sensory-molor ~ k;l1 s necessary for lhe perfonllance of u:-.ual daily aCli viti es. Gctlin g ou t of bed. walking. and climb ing :-.tairs are exampl es of ph ys ica l fun ctional acti\ itics. Phys ical thc rap i ~t s are traditionall y most involved wi th th i~ category of functio nal statu s examination and intervcnt ion. These sensory-motor skill s underli e the ta~ ~ .::; of daily se lf-care such as feedin g. dressin g. hygiene. and physica l mobility that are known as bask activities of dail~' liv ing (BADL). Advanced sk.ill s thai are considered vilal to an indiv idual's independent li ving in the community are ttnned instrumental acti"ities of daily livin g (lADL). Thc~c include a wide range of high-level tasks and activities such as managing pe rsonal affairs. cooking and shopping, home chore" and dri vi ng. The ab ilit y 10 work. including the '''. . ork·· a~soc ia t ed with nonnal childhood deve lopment, may be in\'e ~liga t ed as an aspect of physicall'unction. Part icipati on in community and recreational ac ti v;lies are no less im portant than work 10 main tain qu alit y of life and al so fa ll under the examination of physical function. Exami nation of recreational acti\ i tie~. however. i~ not limi ted to sports. A n UI11 ber of phy'ica ll y demanding ac ti vities, suc h as dancing a nd gardenlllg. require a re latively high degree of balance. fle x· lbility. and "'Ire nglh . Even sedentary ac tivi ties. suc h as stamp collectmg or playing chess. require a ce rtain degree of ph ysical abilit y 111 the h,md and upper ex trem ity and the refore may be meaningful meas u re~ of fu nction and ac ti vi ty leve ls for ~ orne patient .... PS)'chological fun ction has two components: menIal and affective. Mental function refers to the intellectua l or cogIlltl\C abditie ... of an indl\ idual. FaclOrs such as initiative. attenti on. conce11lratioTl. memory. problem solv ing. or judgment are lInponant componenh of n onn~1 mental fUllclion . Affecth t> 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 trocial funflion rele r~ 10 an indi \"Jdual'l pertorman\:t" of ..ocia l rulc'l a nd oblIgation ... CatcgOl"ll" 01 rolc'l i.lIld ac t" itJ e~ relevan t to J elt:fl11ini ng an lodl \ lI..lu;II ·... \(Kia l IUllctlon IIKiude ~CK: I" I .ll"t 1\ it) . IIl..:i udIJlg. panlUpi.ltlon 111 relTt:'alJonal ac tl\ jtie ~ 'Ind (:Iub .. ~ "}( lalmh:l OLl.11 l"ll le'l (eg.,

3 75

worke r, stude nt. spouse). thi s person may be regarded as di sab led as conce ptuali zed within the Nagi model. tHi Disability is charac terized by di scordance between the ac tual pe rformance o f an indi vidu al in a particular role and the ex pectations of the community rega rding what is Hnor_ mar' for an adull. Tim ..;. di sabilit y is a te nn that takes it s meaning from the com munity in w hich the individual lives and the c riteria for " normal" w ithin that social group. Many fac tors can innue nce the connections among di sease. impairme nt. and fun cti on, not the least of which will be the indi vidual's pe rsonal response. Patients w ith the same disease and the same impairments may not always have the same fun ctiona l limitations. Furthe rmore. although an indi vidual may perfoml fun ctional acti vities differentl y than is " no rmal ," thi s perso n may succe ss full y accomplish ex pected soc ial rol es and escape the label of being " disabl ed ." Phys ica l the rapists most often think of " nonnal" adulthood in term s o f independence in self-ca re activities, competen ce and aut onom y in deci s ion making. and productivity. In some cu ltural subgroups. social expec tations may be quite different. parti cularly if the individual has certain impainnents or functional limitations. Physical thera· pists shou ld account for the effects of cu lture and soc ial expectation s in dete nllining what is " nonnal" func tion for an individual. especially when the therapi st and the patient do not share the same social or cultural backgrounds.

In 1976 'he WHO ini,iall y adop'ed 'he [n,emalion.1 Classification of Impainn ents. Disability. and Handicaps (I C IDH )4 with the goal of promoting the use of consistent terminology and 10 provide a framework for discourse among hea lth professional s by standard izing four key term s: di sease. impainnenl. di sability, and handicap. The ori gi nal IC IDH fram ework had a simil ar intent to the Nagi mode l to desc ribe the conseq ue nces of disease. I I The IC IDH unde rwe nt ex te nsive rev ision. beg inning in 1993. Draft revisions of the ICIDH·2. as it was know n a t the time, Ihal were circulated for review internationally in 1997 and 1999 continued using the teml '· impainnenl." but aband oned Ihe te nns di sability and handicap in fa vor of the IcmlS actil'it)' limitation and participation restriction. respct.·tivelyY These proposed c h,ul ges in [CIDH ternlino logy, if they had been adop ted as orig inall y presented whe n the revision began. \\ ould have put lhe rev i ~ed IC IDH dose r to the notion.: ; of functi onal lim itat ion and di~abili l y usee! in Ihe Nagi model and greatly reduced the overal l difkren ce~ bel\\ee n the IWO sets of concepts. The conceprual orien wli on of the IC IDH abo was changed during the revj,ion process. In:o.tead of orie nt ing to\\ art! Ihl! (.:on..,equl.'llces of di s~·'be. thl? unde rl) ing frame \\ or~ \\,a .. d ll\x ted towa rd de .. c ribing Ihe compo nent~ of hea lth . II T hl ... fI:.-.d lrection in L'ol1l"eptual foclls al te red the opl' rationali/a ti oll 01 Ihi,;! te nll ~ activi ty and partk ipation \\ hell the r('\ i..,ion. 110\\ ~n o\\ n a:-. the Illlernational Chl"i ticalillll of Functioning. Health and Disab ilit y (but ahh l\~ via ll; d u~ the ICF). was adopted in 200 I. As in the f\dg l l1lod~l. the ICF refognizl::o. that ac tivit y limitations

376

Physical Rehabilitation

(the ICF analog to functional limitat ions in the Nagi model ) occur when an individual experiences difficulties in perfonn in g act ions. tasks. or activities. Similarly, an individual ex periences participation restrictions in specific life situat ions. nOI unlike the Nag i conceptuali zation of disability in which a person experiences limitations in a panicular socioc ultural context Thus. within the Nagi model. a functiona l limitatio n contribu tes to di sability if that particular tusk or ac tivity is a component of the role expectation.6 The lCF takes a completely different approach to understanding activity limitations and restricted panici~ pat ion because of its concern s to be a classification system for coding as well as a conceptual model of health and functio nin g. The lCF operationalized acti vity and participation with the same lists of acti ons, tasks, and activities, but di stinguished between the two concepts by appealing to the differences betwee n a person's capacity in a standardized environment with and without human or mechanical assistance and a person's perfonnance in th at individual's ac tual environment with or without assistance. The ICF approach to distinguishing be tween activ ity and panicipation has mel with mixed enthusiasm, and further refi nement in the years ahead appears like ly. Much of the success of thi s conceptual approach will depe nd on the strength of its ulil iry as a classification sys tem for clinical practice and research. The c lass ificati on sc heme fo r cod ing

may be particularly intrig uing for physical therapislS ill ill delineation of acti ons, tasks, and activities in an implicir hierarchy of functioning, Within this hierarchy. actiGII (e,g,. rollin g. bending, si tting, standing. lifting and rtaching) are constituents of tasks and activities (e.g .• bathiag. dressing. and groomin g), Tests and measures of actions are partic ularl y relevant to physical therapist practice as they capture the complex integ rati on of systems that permils .. individual to maintain a posture, transition to other pus. tures, o r sustain safe and efficient movement. Nagi's model never had a term to cover the concept of handicap, a term which is rarely used nowadays owing to its negative connotations. Handicap was a term that described the social disadvantage of disability as a function of. s0ciety's response to needs of people with different abilities.' In some instances, even a person who is functiOning independently could still be handicapped by the social stigma of some impainnents or the environmental barriers confromed when using an assistive dev ice such as a wheelchair. Within this context, the concept of handicap is more geoeraUy expressed in less negative terminology by recognizing environmental factors that may be physical or social, The ICF, and further refinements of the Nagi model such as the Institute of Medicine's enabling-disabling process (Fig, 11 ,2),13 emphasize the interaction between the penoo and the environment as critical to understanding functioning

THE "PERSON·· (with potentially disabling conditions) Physical Environment

I DISABILITY

ENVIRONMENT

/

Amount 01 disability is proportional to amount of displacement in the mat .

The strength/resilience of the flexible mat (environment) is a function of social support, culture, physical barriers, assistive technology, etc. PhYSical Environment

Social EnVironment

---

--- --- ---

DISABILITY

Figure 11 .2 The In ~titute of Medi cine model of the enabli 1 '-d' . b . . functi on of Ihe interaction belween the person '~'ld tl,e e . I g Isa lmg process. Dlsabiliry is a ... nV lronment The a f ' repre~ent t. the amount of di ~ability that is experienced by Ih . d' 'd ' mount 0 displacement

. , e til IVI ual Di spl ' ' f unc.:tlOn 01 the strength of the physical and soc ial en\.',ro h · acement IS a " . I1lllents t at suppon ' d " 1he magmtude 01 the potentiall y di ~abling condition (Fro B d an m IVldual and Enabling Ameri ca: A~sessing the Role of Rehabilita;ion Sm. ran I, EN, Jr. an? Pope AM (eds) : Academy Pres~. Wa~hingl on DC 1997 P 9 w"ll, . .clence and Engmeenng. NationaJ

•

.

,

permission .)

Chapter 11 Examination of Functional Status and Activity Level and disabili ty. Phys ical therapi sts can help change discri mi natory social attitudes and environmental restric tion s such as architectural barriers that stigmatize indi vidual s and restrict part icipation in all aspect s of soc iety. AlthoUQh defi c it s in be havioral or motor skill s o r limi tations in function may typicall y exist in cert ai n di sease categories, the exac t em pirical relation ship between a particular set of impaimlents and a specifi c fun c tional disab il ity is not ye t known .14 The ca use-and-effec t re lationship between an impailmcnt and a fun cti o nal limitat ion is most often inferred in the c lini c from empiri ca l ev idence. Fo r example. ph ysical therapists may assum e that the reason a paticllI cannot tran sfer independentl y is causa ll y linked to the fact th at the individual has lost eno ugh lower extremi ty range of motion at the hip (e.g .. hip fle xion contractures) to prevent balancing in a full y upright posture . The re turn of function following remediation of the impairme nt of joint mobility is then considered clini cal ev idence of a cau sal relati o nship between the impairment and the f unc ti onallimitation. For data to be clinically useful , functional assessment mu st be linked to th e other tests and measures which are used by a physical therap ist to examine a patient.

Examination of Function Purpose of Examination of Functional Status Analy sis of fun cti on foc use s on the identifi cation of peni nem functional activities a nd measure ment of a n indiv idual 's abili t) to succe ssful ly engage in them. In e sse nce, fun ctional te~ t i n g mea~ures how of inte n,.e ntion : (2) ind ic ato rs of a patie nt 's ini tial abdll ie~ and prog res~ ion toward more co mplex fun ctional h~\eh: (1) crite na fo r placemem dec is io ns, for e" ample. the need fo r inpati ent re habi litatio n, ex tended care. or CUIll I11 Un Jl ) ~e r v i c~~: P ) manifeMali ons of an indi vidual \ le\d of ,,>a fety in pelfo nning a parti c ular ta~ k and the ri..,J... l)j InJul) \.\ ith <:ontinued performance: and ( 5) evi de nce oj tht etfec lj\ent::!-,,,> of a ~peC .tIC Illttcrvcntion (medIcaL :>.urgu:al, ur re ha bilitati ve, l)l1 fun c tion .

General Considerations Ph}~it:,,1 Iht'la pl<.,l,,> PO\,,>css 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 me
378

Physical Rehabilitation

di ~tract ion ~. I n ~truc tions should be precise and un :.lI11bigu· ous. Te~ t i ng may be bin-.ed by fatigue . If a patient pe rfo rm ~ be ~ t in the mornin g but tires by afternoon, ;111 acc urate dete rm inati on of functiona l abilit y must consider the vari· ation in the palient \ performance, Therapists ~holi id be ;)ware of paticnt ~ whose ene rgy fluclUa les durin g the day, and inlerpret the data accordin gly. In gene ral. informalion from fllllt:1i onal test:. ~ hould always be interpreted in the context provided by oth er da ta ge nerat ed during th e initia l examination (e.g .. te~ t ~ and me3:-.ures of joi nI in tegrit y and 1ll0hililV, moto r function, J11u ~cle perfonnance, and ~e n­ ~ory in;egriIY ). R et c~t in g should occur at reg ular intervals durill~ trealmel1l to doc um ent progre ~'i and at disc harge from the episode of care.

Types of Instruments Performance-Based Tests A performance· based test may be administered by a th er· i.lpi~t who observes the patiem durin g the perfonnance of

an activ it y. Ge nerall y speak ing, the therap ist who c hooses i.I perfon11ance·based test is ~earching for an indi cation of v. hnt a patient ca n do under a specific set of ci rcumstances, v. hich mayor Illay not be similar to th e natural environ· mel1l in wh ich the patient function s. If a perfonnance· based test b chose n wi th the intention of makin g inference~ about how the patient wi ll perform at home. then th e cond itions and setting shoul d be as similar as possible to the actual e nvironment in which the patient usuall y performs the la!'.h and activities, A performance-based approac h may be used either to describe the patient 's cu rrent level of function or 10 identify the maxim um level of func tion po%ible. During the adm in i~tr ation of the teSL each task is pre~en ted and the palient is asked to perform it. For exa mple, to exami ne cu rrent le ve l of function in wheelchair mobil . ity, a patient wo uld receive this instructi on, '·Pu~ h your wheelchair over 10 that red c hair and :-, top:' To de te nnine the patient'" maximum level of fu ncti on in this ac ti vi ty. th e in '> truclion might spec ify a particular mann er of pe rform. an<.;e : '·Pu..,h your v. heelchair ove r to that red c ha ir flS quitUy as you can and MO p." Understanding the difference between the~e I WO co mmand ~, even thoug h both are olht:rvation· based perfOll11anCe of wheelchair mobi lit y, is es~enllal to ~o und clinical dec i ~ion making, Data from Ihe fir!'. t exa mple idelllil y on ly whal the patient ca rl do under '> pe<:ific c ircu m ~[an ce~, but doe~ 1101 ':I Upport the infert:nc~ that the palle nt v. ill be able 10 wheel :.tt ro':l~ a bli~)' in ter. "'I.:::<: tl on 111 the ~hort lirne spml allotted to a typ ic
ate safety precaution as 'I ~ nec decl is' e"iven, Appropri . . S Id be take n dur ing the sess,o n so th at the pat,ent does I S lOU , II y d angerous. "O ko'-' tl1',11 are pote ntia 110t attenlpt t.;:> , • , Thc re arc a numbe r of tests of Im palfTnents that are referred 10 as func ti onal performance ' leo;:> "( Iso ~O l11 e t III , ;11casures, includ ing the 6-Minute Wa lk Test, 15 the PhYSical Perfonllance and Mobilit y Exami nat ion, I6 the Functional Reach Tes!. "'" the Get Up and Go Test.'· the Ti med Up and Go Test,'" and the Phys ica l Performance Battery," A performance instrume nt .of th i ~ sor,t typicall y measures ei ther a comp lex in tegration of IInpalfTne nts, the performance of actions, or a combi natio n a both by d irect observa_ tion . Overa ll. the tests do provide some insight into the indi vidual's capabi lities to maintai n a posture, trans ition to other postures, or susta in safe and effi cien t movement. The data frolll such a tes t. gat he red un de r cont rolled conditions. characte ri ze a pe rson 's performance limitati ons as a result of impainne nts, and may purpo rt to predict the Sue, cess or fai lu re of an individua l in performing goal-directed tasks or ac tiv iti es under natural condi tio ns, using a SCore Ihat sum mates Ihe com bined impac ts of impainnenfS througho ut and acrosS sys te ms on movement dysfunction, Each of these tests can contribute to an unde rstanding of a pe rso n's func tion, but they do not examine a functional limitat ion in a part icular BADL or IAD L Although these tests employ the me thod of d irect obse rvation of perfonn, allce, they most often do not measure the task or activity as it might be accomplished in the " real" world of the patient, whi ch is also influenced by moti vation and habit.

Self-Reports COntrast 10 the method of direct observation, useful data on how a perso n functions may also be gathered by self report, in whi ch the patient is asked directl y either by the the rapist or a trained interviewe r (intc/Tiewer report) or th roug h the use of a self-adminisTered report instrument. The crit ical iss ue in the abilit y of a se lf-re port to capture function cO'Tectl y and complete ly lies in providing dearly worded questi ons witho ut lang uage bias, concise directions on com pleting the ques tions, and a fonna t that encour· age~ acc urale reportin g of an:-.wers to all questions. Self· report i ~ a va lid me thou of delennin ing function. and may be preferable to perfonnance. based methods in some cir· c.um ~tances. 2~ Se lf. rcport s ~ ho uld be des igned so that ques· tl Olh art; a~ked in a ~t a !1 dard for mal and answers are recorded a li ."' pecilied by tht' predete rmined c hoices. Long papL'r·and - penl.:ille~ ", Illay be (hfll c ult for those with uppt'r ex trt:mity dl..,abilil) . ' ' .Cl inica l p~r",o'l,"1 I.: W I10 \\ I' II act ,.1'\ 1I11erVIeWers 01 us't'" Iramed 10 •'ldllllll 1':11.: ' t ,· . .. 11 n"" 1 .1 ql1t'~1I0nn:Hre and shOll t prJc un til Ihl.:::)' h'lve ,·~ '· I 1(.'( I a Illg ' h deg rl'c of agreement ",,'til < t'dl: .. In

expe rt e>'i.tnl ll1 er~ or the ~a ll1c ca~e~ . Periodic retraining Illa) be !leecs..,.· , .11) It "l!lten ,It'"'c rs do not have frequ ,ot practl(:e admlil lsk nn g th e inst rulllC'1l1. The interview ,holllJ be " ' hod u IetI \"-' 'It I1 thl' patient in advanc t ' and ('o IH.lu (,kcl III . . I" .tIl ~ n \, lronmclll co ndw.:ive 10 comp r

Chapter t t Examination of Functional Status and Activity Level

Inten il..'\\' Jllay be co nduclcd by phonc or 111 pc r.. on . hu t Ihl..' 1ll0dl' of adl1li n i ~ t ra tio n ~h ou l d be \..e pt corl',i.. tenl if compmi :-.orh of the d:l1a afe to be m ~de. Ad lib prompltn g b~ the inl cn iewer or careg iver.;; for answcrf.. i... dl .. couragcd tx' G IU'C thc,c intJ'lJ, i o n ~ inl o the pati ent ', ...e lf r.:por1 tend to bia' rc:-. ul l:'.. Irt he patient ha:-. h
("on C(, I1I 1':1I 100 .

Instrument Parameters and Fonnats Perfomlance-ba.,ed and se lf-report in ~ tru me llt s grade pcrfoml,IIKt" on a nu mbe r of d ifferent crite ri a in a va riety o f lomMt.... Therc i... no one parameter or fo rmat th at is perfec t lor e\e r~ t~ pe 01 cli ni ca l enc ouiller or research need, It is parllcularl y lI11portant th at documenl ation of a pati ent 's progre .... not b.... blunted by j7oo,." or ('('i lill!: effects of varIOU, de ...cnplor,. For example . if a thempi!'. 1 \\ i s h e~ 10 mea,> ure chang e,> 1Jl func ti on among ge nera ll y we ll e lderl y p
Dt~cripli\e Paralnelen. l ht'raphl' . . hould u,t' dt: ...l nptJ\l' h: 1l11... that are \\t: 11 delrnt:d ard I un.UII b IgUOlJ' M c ulllllg ' 0 1 Jt"ln pIJ .. e h~ 11l 1' ..,hould bl.:' llt:ar to <111 IHl1t' l ... u.. lIIg Ihe llletiJc
il

IIn:d lUI hU l11dll lIJ llll,;'lhdrlli..'.tl

379

a"si:-.tance 10 accompli '> h a i(l"k, but ~om e scorin g :-,ystcms com.ider reli ance on dev ice:-. and aid ... [IS a mod ified fonn of independence when u.. cd without the he lp of another pcr~on . TI1C u!'.c of equipment du ri ng the performance of a functi onal task :-.hou ld be explicitly noted: for ex amp le. independent in ambul ation with axill ary c rutc h e ~ or independent in dressing with adapled clothin g and a long-handled shoe hom . Difficulty i, a hybrid tem, that sugge sts an acti vity poses an ex tra burden for Ihe patient. regardl ess o f dependence Icve l. It is unclear whether it is a measure of overall pert.:e ptual -mot or skill. coordination. endurance, effi ciency, o r a combinatio n o f measures. Difficult y can be meas ured in two ways. One approach assumes that diffi cult y is likel y to be present and quantiti es the degree o f d ifficult y that the indi vidual ex peri ences whil e pc rfomling the acti vity (e.g .. " How much difficulty do you have whil e doin g hou seho ld chores? None. '>orne, 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 "'
ab~o lut e.

but rather as one dimens ion of perfo nnancc. A llhough th e abi lit y 10 comple te a partinllar acti v it y in a ~JXci fi ed peri od of time doe~ provide one ki nd or im por-

lam data on a palient \ ove rall ab ilit y. ilma y Il ot .'Ilowed down . tht: mO\~I1l t: nb ma) become more l 'oo rdllll1l t:d . with a more; ~a ti ... fac tory fun ctlonaIOUll'Omc . eve n though Ihe tim\:! l aJ.. en 10 do the t;.I\" JOcrea:-.t~ . Sl lll tiarl y,

l:ert .pe nd llure may require Ihal the patient prope rl ) p ..KC a functt ona l at.:tlvi t) 10 compl ete" il li u ccc:-.~ fll ll }. Thu ....

lime ~c()re~ al one do n OI ah\a)'~ yield the complete func" tiona l pi cture. Wh en interp re ted in light of ot her aspects of the pa li e nl '" clmica l pre~e lll ali on . they do provide an added dimen sion to the eval uati on o f data collected during a funct ional exa mtn
Response Formats Nomina l Measures ~..lf the ... implt'~l fonnal ... in fUllcriolla.l tests uses a Donlinal 1('\ cl of mt'i.IMlrement by pl"e.'lenung a cht"'Cklist of variouS IUIll: tIOIKti ta ... b On \\ hieh the patielll i~ simply scored tb able

O nt'

38 1

Chapte r t 1 Examination of Functional Status and Activity Level

do/not able to do, independent/dependent. completed/ . lplete or the Ilk-e. TIle results ilre not part Icularly UKon . t've 'of the exact nature of an individ ual's li m itations .. . ' . descnp I _ _ A l;.ually require further eX il111l natlon pnor to Interpretation .

10

;t1ru

u~

No symplomsipain

Io I I I I I I I I I I 2

Ordinal Measures A few tests use descriptive scales that desc ribe a range of perfoml ance or the degree to which a person can perfonn the ta sk. Most common ly. th e sca les are ordinal or r a nkord er sca les (e.g .. " no diffic ult y." "some d iffic ulty," or "unable 10 do": or "always." "sometim es," " ra re ly," o r "never"). Scale::. may be graded in ascending or desce nding, order. The primary drawback in using such a syste m to ~c~re function i ~ that these grades do no t defi ne categories that arc separated by eq ual intervals. For example. it is no t possible to tell whether the patient who went from m ax imal a~si stance to moderate assistance changed as m uc h as 3 patient who al so we nt one leve l between moderate ass istance and minimal ass istance.

Summary or Additive Measures Su mm ar\' or additive m eas ures g rade a specific series of ~kill s, a,,:ard po int s for part or fu ll perfonnance, and sum the subscores a~ :] proportion of the total possible points. such as 60/100 or 6/24 and so forth. One exam ple, whi ch is \\ell known to physical therapi sts, is the Barthel Index {Table 11 .1)y. Some fonna l. standardized instrument s for testi ng fu nction summari ze detailed infonnat ion about a complex area of function into an overa ll index score. Use of these instrument s facilita t e~ the interpretation of comp lex data and enables the cl ini cian to perfonn cross-d isease, cross-program, and cros::, -popu lation comparisons of function. Caution mu st be exercised in conside ring on ly summated scores. howeve r, because potentiall y important indi \idual differences in func tio na l abi lity can be masked. u A patient who is limited in only a few of the many tasks covered on a fun ctional test will most ILke ly score well , de spite \l,hat could be substanti al limitations in di screte functio nal a('\1\ itie~ that are peninc nt to the ph ysica l the rapi st's anti c ipated goab of treatment . Simil arl y, two patie nts with the same numeric score migh t be q uite different in their functIonal deficits, havin g gai ned (or lost) their point s on different activities. Alth ough these measure::, yie ld a " hard number." \l, hlch is regarded stati sticall y a::, an interval leve l of measurement , the degree 10 whic h "poi nts" are trul y eq ua l Inter"als apan sho uld be carefu ll y ~c rutini zed.

Visual Analog Scales

\" l!'I ual Or lint:a r analog scales attempt 10 repre~e nl l1lea~urement 4uantll ie~ in term s or a straIght line placed hori ZOntall y or \e n lt all y o n paper (Fig. 11.3 ). The e ndpo inb

the line are labeled with de~cripti ve or numeri c temlS 10 anl hor the ex tre me~ o f the !-oca le and provide a fr;,i me of rderenc:c lor an)' point In the continuu m be tv. een them. Some ~ ... Ie~ "" iii abo u~e de~(: ripton) or Ilume n c inte rvab

01

Most severe symptoms/pain

3

4

5

6

7

8

9

10

Figure 11 ,3 A visual analog scale for measurin¥ pai n or oth.e r symptoms. The patient is inslructed to mark Ihe Ime at the pomt thai correspond s 10 the degree of pai n or severity of symptoms thai are experienced.

between the e ndpoints to assist the indiv id ual in g radin g responses. Co mmo nl y the e ntire visua l an alog line is 10 ce ntimete rs (cm ) lo ng, but di stances of 15 and 20 c m a re a lso used . The pati e nt is asked to bi sect the line at a po int re present ing se lf- re po rted posi ti o n o n the scaJe. T he patie nt' s score is the n o bt a ined by m easurin g fro m the zero m ark to the m ark bi secting the scale,

Video Recordings With ever-inc reasin g applicati o n of techno logy to clin ical data co llec ti o n, new tools are avail able to c linic ians and researc he rs for record in g changes in f unctio n . Al thoug h more costl y tha n trad iti o na l m e thods, videotaping o r film ing can be a val uable adj unct to fun c ti o na l testin g, Vi sua l recordin gs are ap propriate m ethods fo r examin ing a nd validating the effectiveness of new intervent ions o r treatme nt approac he s. They are a lso useful to pa tients in d isplaying the q ua lit y of the ir m ovem ent patterns and in depicting the true exte nt of the ir limitati o n. Video recordings are valu able tools for trai ning staff to score tasks reliably by reac hing agreement o n obse rved perfonn ance.

Interpreting Test Results C learly. the sing le most important consideration in examining fu nctional status is using the test res ults correct ly to establ ish and revi se the ant ic ipated goal s and expected outcomes of intervent ion and the plan of care. The the rapi st shou ld carefully delineate the contributing factors that result in the fu nctional deficit. \Vhen d iminished ability is ev ide nt , the therapist must attempt to ascertain the cause of the pro blem . Some impona nt questions to ask incl ude : I. What are the nonnal move ment s necessary to perform the task? 2. Whic h impairmt: nts inhibit perfol1llance or completi on o f the task? For example, do factors such as poor motor planning and exec liti o n, decreased strength . decreased r;,ing~ of mo ti o n, or altered joint integri ty impede Functi o n? Doe::. fatigue hamper functional ability? 3. A re th e p:ltielll \ fUll c llona l defici ts t he resu lt of impaired comm unicati on , perception, vision, hearing. or cogni tion ?

382

Physic-a I Re h a bilita ti o n n e x" . Barth" lid Tabe 111

-

Date Initial

I Pallent's Name

I- - - -

FEEDING 10 ~ Independent. Able to apply any necessary device. Feeds in reasonable time. Needs help (e.g . for cultlng ). 5

,

I

BATHING Independent 5 PERSONAL TOILET 5 == Independently washes face , combs hair. brushes teeth. shaves (manages plug If electric) . DRESSING 10 = Independent. Ties shoes. fastens fasteners . applies braces . 5 Needs help. but does at least half of work in reasonable time. BOWELS 10 = No accidents. Able to use enema or suppository, if needed. Occasional acciden ts or needs help wit h enema or suppository. 5 BLADDER 10 = No accidents. Able to care for collecting device if used. 5 - Occasional accidents or needs help with device. TOILET TRANSFE RS 10 ~ Independent with toilet or bedpan. Handles clothes, wipes, flushes , or cleans pan. 5 ~ Needs help for balance, handling clothes or toilet paper. TRANSFERS-C HAIR AND BED 15 = Independent, including locking of wheelchair, lifting footrests . 10 = Minimum assistance or supervision. 5 = Able to sit. but needs maximum assistance to transfer.

I AMBULATION 15

= Independent for 50 yards. May use assistive devices , except

for rolling walker. 10 ~ With help, 50 yards. 5 = Independent with wheelchair for 50 yards if unable to walk.

I

STAIR CLIMBING 10 = Independent. May use assistive devices. 5 = Needs help or supervision.

I
Totals In

an y cat egory

From Mahoney F, and Barthel. 0 ,23

ptl

62-M

In

which the patient does not achieve the stated

with permi ssion.

Chapter 11 Examination of Functional Status and Activity Level

E\:lIll pl es of Ihe "i n d ~ o f q u cs t io n ~ a therapist mll ~ t pose to n-: .. r:-:-- function and integrate fi ndings into (t comprc hen~i\'e treatlllen t prog ram arc fo und in the case vignett es that f(1l1o\\ :

Case A

Case B

)6-year-old male cOIl.;;,ructioll \\orker

72-yea r-old fcmale homemaker

d\ : traumati(' right tr~m .. 'ibial amputation: po~ t frar lllre left femur

dx : eVA wit h rig ht hemipl eg ia w ith g lobal :lph:l~ i a

Partial Examination Findings Motor Control and Muscle Performan ce Dl~crt'al,ed in all e\ tremiti e!} Flaccid para lysis right ex tre m it ies 1(\110\\ ing prolonged HlllllObilizJlion Functional Limitations L nahle 10 tramfer from bed 10

whe-ekhair

Unable to transfer fro ll) bed to wheelc ha ir

Alth ou gh the fun cti onal disab ility in each case is in fac t Idenllcal. the contnbuting factor<;. goals and o utcomes. and the Intcne lllion ... \\Q uld be markedl y d iffere nt. In case A. the patient"... mabllitj to tran sfer can reasonably be att ributed to decrca ... cd .. trength. When ame liora ted. it i ~ li ke ly that the patiem wi ll go on 10 achieve an outcome of independent ambulat ion \\ Ith a pro<;thesi~. The pat ient in case B ha" fiJctor" fhall:ann()I be addfe~~ed solely through physllalthc rap~. In addition . il ma) be difficult to determine \\ hether II i.., th~ paral) ... i') or the apha:--ia Iha l comp rom ises elton') to a......c . . . . and imprmc fUll ction. Alt hough'l .. imi lar goal 01 mdependenlt~· III \~ heelchair mobilil y and tfan ... te r'> ma~ Ix propo ...ed. n:c\JJI11111 (~I .ltlIJ1(! up .•HIJ ('i) h;tianl ill cu .tllhl· ~dt'l> 0 1 IIll' hell A <

383

functional loss o f inde pendent bed mo bility may res ult from an in abili ty to pe rfo ml an y or all o f th ese subro utines . These are not onl y chec kpo int s fo r ex am ini ng patient s, bu t th ey also later represe nt the anti cipated goa ls o f vari o us interventi ons. The more invo lved the pati ent . the slower the lea rn er. or comp lex the task. the more the fun cti o na l ta!:>k may need to be bro ken dow n int o subo rdinate part s.

Detennining the Quality of Instruments Within the rehabilit at io n se lling, many too ls have been develo ped prim arily for in -ho use use and may have spread from racility to fac ility as staff members have moved . In most instances. the instrum ents underwent many modifications and the ori g inal sources have bee n los t. Othe r tests have been designed more rig id ly and tested in cl ini ca l trials. examin ing the instru ment 's psyc hometric propeni es and prov iding doc umentati on of its r elia bility and va lidity in the lit erature. If the re li abi lity and va lid ity of an instru ment are not established , little faith can be put in the res ults obtained or in the concl usions drawn from the result s. A poorly constructed instrument can produce data that are qu esti onab le. if not worth less. In li ght of the fact th at the viabi lity o f phys ical therapy as a reimbursable serv ice rests on the demonstrat io n o f fun ctio nal outcomes. the importance of these concepts lO fun ctional testing becomes clear. Some o f the mo re rece ntl y deve loped instruments have undergone ex t e n ~ive tes tin g of their meas urement properties. In accordan ce wilh the Ameri can Phys ica l Therapy Assoc iat ion's Standards of Measureme nt. ph ysical therapist!) ~ h o uld use o nly those in!tlru me nt s whose re liabil ity and val id ity are know n .~5 Although no instrument \\ ill have perfec t rel iab il ity or va li d ity. therapi:o, ts m ust be able to gauge Ihe ce rt aint y of the ir data and the appropri ate scope or infere nces draw n fro m the dala.

Reliability A reliable i ll ~ t rumen t meas ures 3 phenomeno n dependably. lillle afler lime. accurately. pred ictably, ~Uld without var iati on. Ir a functiu nal le . . t i ~ no t rcliah l ~. the pat ient \. inI tial ha:--e line ... tatu:-o or the true effect of trl:'atmelll call be (,OJ)l·ealed. An ilhlrumcnt \\ ith al·,,:eptable /t'S I-rl'fc.\1 rt'li(lhllIly I" .. table and \\ II I not inJil";lIe ch~tnge \"hen none has OCCUlTl"J. Tt''''~ perforllll:'d by Ihe ",\lne therapi ... t of tht" .. aIl1l.: pl..' ri"ormance :-. hould he highl) corrdatt'd (U/(raraler ,.e!lcIhiliryJ. III .. trulnent ...... hould al ... o ha\e strong iwata/a ,diah,hn. or agreement among Illuillple ob~t~nt"r.. of the :-'<.1011.' C\CIlI. II it p.lrlll"ular p.111ent , .. (' \..lInineJ b) \t:\ er,\1 11·ll'r;tp I .. h III Ih\;' L·l)Ur .. c ulln:,ttl1l~~nt. t)r rec\ i.ullint:"d mer tulW [0 de te-rnlllk' Illll g- tt' rm l.·hangl'. the rt'li
.184

Physical Reha bilitation

eath din ic,,1 Silu,:Hion: .md (3) a ll the rap i s t ~ in " facility I1l U ~ t be re tr;!i n l~ d period icall y in the use of the instru ment to en'\ure ~ill1i l ar it y.

Validity Val idit y i ~ a l1l u1t if~lCe t ed concept and c!:I tablished in many different way~. Qu es t ion ~ rcgardi ng an ilb trumenl's va li di ty atte mpt to detCn11ine ( I ) whether an instrument designed to l1l e:1~ u re functi on truly doe ~ just thaI: (2) whal the appropri:,lte applicati on, of the in ~ lrull1 e nt are: and (3) how the data ~ ho ul d be interpreted. Fir~ 1. the va lid in!)lrUm ent should , on lht' face of it. appear to mea, ure what it purports 10 meas ure (joce \'(JfidiTY).~o Anoth er clil ical dimension is whether the a~~e~" lll e ni in!:l trument measures all the im pon ant or specified dimension, of func tion (comen! mlidity). If there we re a gold slanda rd (an unimpeac hable measure of a phenomenon. such Cl.') a labora tory test with nonnat ive values). then a new instrument coul d be tested against the results of this ~ tand ard (criterion-relaTed ralidity). Such a go ld standard does not exbt fo r functional instruments. New functional measurement tool'\ can. however. be compared to ex isting ones th at are accepted measures of the same functi onal acti\ itie ~. The degree to wh ich the IwO instru mel1ls agree helps to e!)tab lish CVI/Clirrenr ralidity . Concurrent validity can abo be demonstrated by showing: that an instrument corre!)pond~ appropriately to meas ures of other phenomena. This method is particularl y re levant for self-repon instruments. TIle concurrent validity of some self- report instruments has been detenn ined by compari son with cl inician ratings and other cli nical findi ngs: fo r exam ple, a person's level of func tion as indicated by an instrument correlates directly wit h cl inician's rat ings of improveme nt and inve rse ly wi th the pat ient 's repons of pai n. There is also the predicTil·e mlidi,)' of a test or mea:,ure. whi ch indicates the likelihood of a subsequent phenome non or eve nt (e.g., relUn~ to work ) on the basis of a prior phenome non (e.g .. a baseline me<.l~ ure of fu nction). Finally. the deoree to wh ich , e an lI~ s.trul11 e nl measu res abstract concept!) such as phys ical mobIlity or !)ocial interac ti on can be established over ti me (cOl.l.'iT!·IICf mlidiry). Construct va lidation. using a vari ety of !)tallsllcaJ procedure~. is a never-endi ng proce:,s as Our understanding of the construct is funher refined as instru ment ~ are deve loped to measure it.

Other Factors In addition to reliabil it y and \alid it y. a meas ure of functional :,talUs "hould be ( I) ... ufficient ly sensitive to reilec t meaninglul (:hange~ in pallent ", tatu ~ and (2) concise enough to be clinIcall y u~eful.

Consid e ration s in Selection of Instrume n ts A large numb~r 01 in:,trumeJlt s IUI\·e been d~\ e loped to a"'~e~'" and to cIJ~!) lt y functIonal ablltty. Gi\e n I h~ plethora of tn!)t rUll1ent 1) th at CLJ ITtn tl y ex i ~ t , J[ i~ quit e re" . . onablt! tl)

ask how these instruments compare with one another. It is important to remember that no instrument is perfect for all pa ti enls or all sit uati ons. No instrume nt can measure all the items potenti all y releva nt to a partic ular individual and provide the perfec t composite picture. For example, one instrum ent may provide an ex tensive measure of activities of dai ly li ving (A DL), but not deal with psycho logical Or social dimensions of fun cti on. An other instrument may in vesti gate social fun cti onin g while omitting some ADL tasks. Many items ove rl ap fro m instrume nt to instrument. For ex am ple, a qu esti on on the ability to ambulate is a co mm on item found in most phys ical function instruments. Although instrum ents may cover the same kind of activity, the quest ions posed about the perfonnance of the same ac ti vi ty may be quite di fferent. For example, one instru_ ment may investi gate the degree of diffi culty and of human assistance requ ired to ··dress yo urself, including handling of closures . buttons. zippers, snaps." Another may ask, " How much help do you need in gett ing dressed?" As discussed, differences also may ex ist in the time frames sampled in the vari ous instruments. Critical questi ons to ask, therefore, in selecting an instrument include: I . What are th e domains or categories that the assessment

instrument foc uses on? 2. How adequ ately does the instrument measure the domain or domai ns bei ng sam pled? 3. What areas of phys ical fun cti on are included? Does the instrumem meas ure ADL? IADL? Functional mobility skills? 4. Wh at aspect of fun ction is being measured? Is the level of depende nce-i ndepe ndence considered? What is the length of time required to complete the functional task? Degree of di ffi culty? Influence of pain? 5. Wh at is the ti me fram e sampled ill the instrument? 6. What is the mode of ad min istrati on? 7. What type of scori ng system is used? 8. Are multi ple instruments necessary to provide a more complete picfUre of functional status? Extrapo lating items from a varie ty of instruments may provide the kind of data desired but should be considered w i.L~ ext reme caUl ion inasmuch as this process changes reJiabtluy or vo"t S a\ <.II'Iable for a~se~sing " func tional st3tll~ ':tOme of whle h . . . ... , ale qUlIe cOllllllon ly used by cllnKlaIlS a~ \\ ell as rt'~earehers .

Chapte r 11 Examination of Functional Status a nd Activity Level

-se lected Instruments Assessing . Physical Function Barthel Index The Barlliel lndl'x was deve loped by a physica l th e rapi st )'ear". anD not as commonl y used e ·: -' AlthOUgh ~ . tod a\ .,1~' ~' oln e- othe- r in strume nt s. thi S a sse ss me nt too l. reprt'sen'" ~ one of til e earlie st co ntributi .o ns to the .functIOnal , q;l1U~ liter~nure- and ide ntifies phyS ICa l therap ists long~tandin~ inclusion of fun cti o nal mobilit y and ADL m easurement wit hin th e ir scope of prac ti ce . The Barthe l Index spt'cifically meas ures th e de ~ ree o~ ~ss i st an ce requ ired by 'm indi,·idual on 10 item s ot mobilit y and self-care ADL ;~et' Tab le II. J ). Leve ls of measurem e nt are lim ite d to eitha comple te ind epe nde nce or need ing ass istance. Each perfomlance ite-J11 is "cored o n an ordinal scale w ith a s ~ec­ ified number of poinb assigned to each leve l or ranking. \'ariJble weig ht ing s we re e stabli shed by the developers of the Barthel lnde'X for eac h it em based o n clinical judgment or other Impl ici t cri teri a. An indi vidual who uses human :!s, islance in eati ng. fo r ex ample. wo uld receive 5 points; mdependence in eating would recei ve a sc o re of JO poi nt s. .4. ~ tn £ le !!lob31 score. ran ging from 0 to 100. is ca lc ul ated from ~he ; um of all \\eight ed indi vidua l item score s. so that J 0 equ:lI s complete dependence for all JO act ivitie s. and 100 eq uab complete in de pe nde nce in all 10 activitie s. The Bmhel Inde .\ h a ~ been used w idel y to monitor fun c ti onal change" in individua ls receiv ing inpatie nt rehabilitation. PJni ru! arl ~ in predicting th e func ti onal o utcome s associated v. ith stIOke . ~·:~ .A.lrhoug h its psychometric properties ha\e ne\er been fulh e >. J.mi ned. the Barthe l Index ha s de mon strat ed stro ng inte rrat e r re liabilit y (0.95) and le~l-re t e~t re llabilit~ (0.89 ) J.s we ll a s high c orrela tion s 10.74 100.80) wi th other measure s of ph ys ical di sab ilit y.29

" , ,0 ;wou -tv

Katz Index of Activities of Daily Living The Kar: I I/de.\ (1 ADL foc uses o n pati e nt pe rformance and tht degree of a,,~i '>lallce required in ~ i x ca tego ri e s o f ba:-. ic ADL: bath ing. d re ~ " lIlg . toil e ti ng. Iran ~ fe rri llg. cont ine nce , .md kedmg (Lble I ! .2) .'u lj U ~ jng bo th direc t o bse rva ti o n ,md patIent "elf-report ove r J 2-week period . Ihe exa mine r ~core~ ! point fo r e ach ac ti vity tha t i:-. pe rfo nned with o ut humJIl htl p. A ,,(' o re of 0 i ~ g i\ e n it Ihe ac tivit y i ~ pertormcd \\ lth hUlllan a')') i-.. tance or i ~ not perfo rmed . '\ CII \ J! ;' ~corc: ~ <.Ire LumblllCd to lo rm a c umu lall,e ~ca l e in lelltr grJdn ( A through G) in orde r o f inc rea:-. in g. de pe ndt.'nl"~ An l/ldl\ idu<.d ·~ glo ba l ie lLer :>,core i ndica tt? ~ an e:\ac t P:illt.'rn 01 rnpnn \c.., Il: the lI '> 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
385

de ficit s in the Katz Index reflects a particular theoretical o ri e ntation. The developers o f the Katz lndex assumed a deve lopmental a nd hi e rarc hi cal o rgani zation of function in construc tin o the ir instrument. Thi s organizational mode l is based o n th~ empiri ca ll y no te d integration o f neurological and locomotor response s seen in c hildren . One version of th e sca le de m o nstrated agreem e nt ratios of 0.68 and 0.98 be tween diffe rent professiona l raters. Test- rete st re liabiJity of respo ndent se lf-report s produced intracl ass corre lation coefficient s ranging from 0.61 to 0.78. 32 The Katz Index, originall y deve loped for use with institutio nali zed patients . has been adapted for use in communitybased populationsY A major disadvantage of using the Katz Index in rehabilitation se ttings is its failure to include an item on ambulation. The predictive validity of the instrument for lo ng-tenn survival also has been reported.3 !

Summary of Physical Function Tests Neither of the single phys ical functional assessment instruments presented in the preceding paragraph s covers all areas of ph ysical function (Table 11.3). Even item s that appear to measure the same function may, depending on how the item is worded. be concerned w ith a different aspec t of perfonnance. 34 There fore. one of these in struments may be c hosen to match the speci fi c needs of the clini c ian for a brief. unidime ns ional functional m eas ure , but only if the likel y functional limitation s of the c linical population served are described by the items on the in strument.

Multidimensional Functional Assessment Instruments The prev io us d isc uss ion of functional in strum ents that de scribe o n ly one dimen s ion of health status highlight s a cl ini c ian' s need to unde rstand a patient's health statu s in a ll it s domain s. Further in strument de ve lopment in th e la st 20 years has re sulted in the emergence of multidimen s ional he alth statu s in strument s to meas ure the spec trum of he alth statu s do mains m o re c omprehens ive ly. M o:-. t c on cent rat e o n two or three dimensio ns o f a pati e nt's fun c ti o n , and record little abOtH a person 's dise ase or im painll e nh . T he re fo re , to ! ona1 mca nl ngrul nl.:~~ to the ind i\ idual. the go ld sHUldarJ q ua lJ1 y 0 1 life. ~ lh.: h te n n in o log) Ill ay o ve rs tate the val ue LI t' I h~~t' in:-.t n lln e nt , . Ho\\ eve r. ul)ed in C"onjulll'tion with Ir.td ll wn.1\ I.·hn ie-al m e th od ... of ex. an"lining signs and

386

Physical Rehabilitation

Table 11.2 The Katz Index of ADL Name

Day of examination - - - - - - - - - - - - - - - - - - - - - - -- - -

For each area of functioning listed below, check description that applies. (Th e word "assistance" means supervision. direction, or personal assistance.) Bathing-either sponge bath, tub bath, or shower.

D Receives no assistance (gets in and out of tub by self if tub is usual means of bathing) .

D Receives assistance in bathing only one part of the body (such as back or a leg).

D Receives assistance in bathing more than one part of the body (or not bathed).

Dressing-gets clothes from closets and drawers-including underclothes, outer garments and using fasteners (inchJd. ing braces if worn) .

D Gets clothes and gets completely dressed without assistance.

D Gets clothes and gets dressed without assistance except for assistance in tying shoes.

D Receives assistance in getting clothes or in getting dressed, or stays partly or completely undressed.

Toileti ng-going to the "toilet room" for bowel and urine elimination , cleaning self after elimination , and arranging clothes.

D Goes to "toilet room ," cleans self, and arranges clothes without assistance (may use object for support such as cane, walke r. or wheelcha ir and may manage night bedpan or commode, emptying same in morning).

D

D Receives assistance in going to "toilet room " or in cleansing self or in arranging clothes after elimination or in use 01 night bedpan or commode.

Doesn't go to room te rmed "toiler for the elimination process.

Tran sfer

D Moves in and out of bed as well as in and out of chair without assistance (may be using object for support such as cane or wal ker).

D Moves in and out of bed or chair with assistance.

D Doesn't get out of bed.

Continence

iJ Controls unnatlon and bowel movement comple tely by self.

D Has occasional "accidents."

- - - -- --

Feed ing Feeds self without assistance.

D SuperviSi on helps keep urine or bowe l control; catheter is used, or is inco ntinent

~

iJ

F d f ee s sel excepl lor genlng Receives assistance In feeding or IS assistance In cunlng meat or led partly or completely by USing buttering bread - - _ tubes or Intravenous flUids The Index of Independence In Acllvltles of Dally LIving IS based on - ---~---dependence of pa tients In bathing, dressIOg, gOing to 101let tranSfer~,~ evaluation of the functional Independence or funCtiOnal Independence and dependence appear below Ihe Index g continence and feeding Specific deflnttlons 01 A-Independent In feeding. continence transfernng gOing to tOllel dressln B- Independent In all but one of these functions g and bathing C-Independentln all but bathing and one add,t,ollal function D-Independenl In all but bathing dressing and one additional funcllon E- Independent In all but bathing , dressing gOing to tOilet. and F,-Independent In aU but bathing , dressing gOing to 1011et, Ir dnb~~~II~ddltlO"al function G- Dependent In all 5.1)( funcHons 9 and one additional function Other - Dependent In al least two functions , but not classifiable a~ C D, E Independence mean~ without supervision , dlrecllon 01 dClrve P I ' or F ThiS IS based on actual StdlU5. and nOl on ability A patient h el,sona aSsistance except as specifically no led beJow. form In9 th e f unction . even though he IS deemed dble wore u.es to pertain1 d Iunction IS conSidered as not per-

Icon""..,.1J

I

C h a pte r 11 Examin a ti o n o f Function a l Sta tus a nd Acti' il) 1A!'c1

Table 11.2 Th e Katz Index of ADL

(,o n(in ued)

B".thing (sponge. shower. or tub) . Independent: assi stance only In bathing a sIngle part (as back or disabled extremity) or bathes se lf completel y Dependent· assistance in bathing more than one part o f body: assIstance in getting in or out of tub or does not bathe sell Dressing Independent: gets clothes from closets and drawers; puts on clo lhes. outer garments. braces ; manages fasteners ; act of tytng shoes IS e xcluded Dependent· does not dress self or remains partly undressed

mu ltid ime nsional fun ctional status in stru menh can add an Import ant compre hen sive view of a pallent".. fun ction to the ove rall hea lth sta tu s . In thi s re\pec t the) Jdd CI cruc ia l. and previou sly mi ss in g, com ponent III C\ alu
The Functional Independence M easure The FUIIUIUlJul l ll{hpl'Iulellc(' MeaslIre (FIM ) 35.36 is an 18Item mea\ure of ph )-'Ical. p ~ y c h o l og i c ;l 1. and soc ia l funclion that I') part of the Uni fonn Data S y~ t e m for Medical Rehabllit:ll lon (LJDS\IIl:)' \"1 T he UDS MR coll ec ts data from

Table 11 .3 Items Covered in Selected Ph ysical Function Inlttrum e n ts

Barthel Mobility T

+

+

+

ADl Bathing

Conti nence Independent: urination and defecation entirely self-controlled Dependent: partial or total incontinence in urination or defecation ; partial or lotal control by enemas , catheters, or regulated use of urinals and/o r bedpans

with permission.

\~ ll1ptOJm .

Transfers Ambulatlon Inclines/stai rs

Dependent: assistance in movi ng in or ou t of bed and/o r chair; does not perform one or m ore transfers

Dependent: assistance in act of feeding (see above); does not eat at all or parente ral feeding

Dependent: uses bedpan or commode or receives assIstance in getting to and using toilel D20

Transfer Indepe ndent: moves in and out of bed independently and moves in and ou t of chair independently (mayor may not be using mechanical supports)

Feeding Independent: gets food from plate or its equivalent into mouth (precutting of meat and preparation of food , as buttering bread , are excluded from evaluation)

Going to to ilet Independent· gets to toilet: get s on and off toilet; arranges clothes: cleans organs of excretion (may manage own bedpan used al night on ly and mayor may not be using mechanical supports)

From Katz. S. et al. 31

387

+

Grooming DreSSing FeEding

+

TOiletlng

+

+

participating re habi litatio n fac il ities and issues summary report s of the records that have been entered in to the UDSr.'IR database. T he FIM uses the leve l of ass istance an indi vidual needs to grade funct ional starus from total independence to total assistance (Fig. 11 .4). A pe rson may be regarded as independe nt if a device is used . bUI thi s is recorded separate ly from ;'comple te" indepe ndence. The instrument li sts six se lf-care activit ies : feedi ng. grooming . bathing, uppe r body dress ing, lower body dressing, and toiJ eting. Bowe l and bladder control. aspects of which some may cons ider as im pa inne nts rather th an func tion. are categori zed separate ly. Functi onal mObility is tested thro ugh three ite ms on tran sfe rs . Under the category of locomori on. walking a nd using a wheelchair are listed equivale nt ly. while stai rs are considered separate ly. The FIM also inc ludes two ite ms on comm uni cation and three on soc ial cogni ti on. The FfM measures what t h~ indi\ idual does. not \\ hat that person cou ld do unde r ce rtain c irc um stance .;; . The int errater re l i ~lbilil y of the FI1\l has bee n ~s t abli s hed at an acceptable level of p ~yl' h 0 1ll e t ri c perfomlance (intraciass corre lation co<: ffi c ie nb ran ging from 0.86 to 0.88). I/) The fa ce ilnJ 120ntl,:' Il t va lidi t), of the FIM as \\ell a:: . It " <:lbi lity 10 ca pture c ha nge III a p.tt ie nt 's leve l of fu nl.:tion hm e a lso tx-e n delermineJ . Any ci l11ic;:d wor!..er can admi nister the FIM aft er a p pro priat l~ training III u\ ing the response ~et for e ach Itc m. For pe r... om. \\ IIh ~t rok.e. Ihe motor :::.cale of the FI ~ t ha:::. bee n .., 110\\ n [0 havt" hi gh t:onl'U1Tc nt vahdl t)' with the Barthel Imln ( ICC ~ O.i.:3> 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

11 .4 Thl·'·unltHIIl.lllnut'lltlllknll'

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LflIh'/lIIIJ..tr.l S),ll'nl tor Mnhl.11 Rdl.lbdll;UIOJl .•1 UI\hhlliul l I:S I Ullililatiltn .\lll\ lilt.' Inl Il fJ\\I~ "'1. (iulut' Itlr Itl\"

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5. I act nervous or restless 6. I keep rubbltlg or holding areas of my body thai hurt or are uncomfortable 7 I act Irritable and Impatient w1 th

myself; for example, lalk badly about myself, swear at myself, blame myself for Ihlngs that happen 8 I talk about H1e future In a hopeless way

9 I get sudden frights CHECK HERE WHEN YOU HAVE READ ALL STATEM NTS ON THIS PAGE

Rt!p(jnt~,j

Ly

pefITlj'::'~lon

ot Mdfl lyn Bergner. PhD..J

Chapler t 1 Examinalion of Functional Status and Activity Level 20 to 30 minut es. S IP score s are pe rcentage rat ings based on the rati o of the summ ed sca le sco res to th e summed val ues of a ll S IP it em s. Hig her :-.c ore~ indi cate g reate r dysfunction . The SIP t e ~t-re l est rel ia bilit y coe ffi c ie nt s range from 0.7510 0.92 fo r the o ve rall sco re and from 0.45 to 0 .60 fo r item s check ed .44 Va lidit y has bee n dcte mlin ed usin g subjec tive se lf-report . c lini c ia n m ea ~ ure lll e nt. and subj ec ts ' ~c orC' s on o the r inqru me nt:-. . Corre la ti o ns re le vant to establi ~h i llg m ullip le fo m ls of vali d it ) range fro m a low of 0.35 10 a high o f O.R4 .4 \ T he S IP has bee n used as a me asure of functi on in man y st ud ie s inc ludin g describing the ph ys ical and psychosoc ial fu nc tions of ind ividual s in an o utpati e nt se lling in relat ion to the d urati on of di sease JII a nd the e fli cac~ of usin g transc utaneou!\ e lec trical ne rve stimulation (TE NS , \\ i1h low bac k pain pa ti e nts:' 9The re a re, howe ve r. some concern s regarding its usc and suit abilit y in ce rtain kindC) of ~ nldi e:.. In e xa m ining d isability, SIP foc use s onl y on whether a pcr~o n se lecb state me nt s tha t a re very broad about the in ab il ity 10 perf0 n11 activitie s: fo r e xample. " I do not mainta in ba la nce": " I knee l. stoo p. o r be nd down o nl y b~ holding on 10 someth ing": ,, ' am very cl umsy in body mo\·ement s." It neglects the range of perfo rm ance in between. with some potenti al loss of prec ision. The SIP also cOlllb i ne ~ J11 an~ fun ctio nal acti vities into a single item. whic h ma) al~o reduce its di sc ri minato!)' abili ty, such as " I have difficull) doinf! handwork: for ex ampl e. tuming faucets, using kitchen gadgets. sew ing, carpe ntry.'· A fe \v investi gator\ ha\·c noted th at the S IP may be more sensiti ve to detec ting deterioration of ~ta tu s than to improvement . whic h may dlmJI11~h II .. ,\uilab ilit y as an in ~ lrume nt for mo nito ring the progre ~ ... of re habili talio n for i ndi v idu a l ~ over t il11 e.~o

The Outcome and Assessment Infonnation Set The OIl1("ollle and A 5~es "n('1/1 Illformarioll Set (OA SIS) v-. a" deC)lg ncd to ellC)Llre the co ll ec ti o n o f perti nent data o n t h~ adult pJuem 111 the ho me care ~e njng that \, o uld allow home health agt:lh: le.., to a~~e o;!\ the q ual it) o f care by mea ..,unng lht' ou tLome ... 01 (are.~I~~ Dunng the } ea r. . 0 1 II ~ ini Hal dt"\dopl1lt:1l1. u ~e o t the OAS IS by ho me hc.:a lth age n(Ie .. had hec n \·olun tary. Ho ..... eve r. a.'> 0 1 January I. 1999, home IJeahh >'lllle.'> v.ere mandated to u . . e the OAS IS ,:l!\ J (fit/lilt/fill ()f Pm fiL IP(JfiOIl III llil' Ml' d/( ore pmgmlll b) tht' Ht"i.tlth CJ. ft' FlIlanu ng Adllllll ' ') tfa tio n. Dt'\'doped O\er fI IO-~t:.t' pc.:nod Iht' ru rrt'1lI \t:r~lon 0 1 OAS IS 1.. 110\\11 a ... (JASI~·B It)nt''UIl~ 7lJ rUIt' lte-m\ l:o\e n ng ... t>lHxitnlog lJrl ll~ l·harJ.dt: n ~IILc). t'!l \ ironme nt a! L.lr IOr ..... '>Ol' I:11 ~ LJ p­ pun h\:~lhh ~t.ttU \ .•1I1d tUlll.l io n a! "latu .... OAS IS IC) nut dt"'>JglH;~J 10 hI.: J l·umpn:ht:lh l\t: c.\aflllllatHH) 01 .1 p..tIJ~llt , tlr all add-on lllt'd')urelllellI ()A~ I S I t t:lIl~ .lIt' Illc.:dnl hI be InttgrJkd 11111) Iht: dlllildl ret urJ III 11IghhJ;hl \Jnuu ... ""'!Xli'-, 01 a p..tlh:nt \ C) IJ IU" 111.11 Ilknu l) pa ftlud .. r Ilcnt.... (UJ Ldlc' upo n

adlnl ~~ion

IU li lt' hOlll C

hc<.tllh ~e f\ Itt:

.11

389

fo llow- up eve ry 60 days. and at di scharge . Th e OASIS was intended to be a di sc ipline- ne utral record , admini stered by a ny health profe~s ional incl uding ph ys ic al therapi sts. C reatcd as part of a re se arch prog ram to deve lo p o utcom e s me asures a pplic a ble to ho me he alth , the OAS IS has bee n fie ld -te sted through demon stration projec ts and re fined by a pane l of cx pe rt s . Re liabilit y te sting is on going. Ea se o f admini stration inc reases w ith famili arity with the instrume nt. Unl ike most o the r instrume nts . the re spon se set s that accompany each item are spec ificall y m atched to the ite m . Som e re sponse sets have o nl y two poss ible descripti o ns of behavio r, where as o the rs have as many as nine possibl e descripti o ns o f behavio r. The re fore, the use r must be familiar with the poss ibl e response se t to eac h item . and antic ipate tha t comfort leve l in us ing thi s instrume nt w ill increase ove r a learnin g curve. The ADL/ IADL section is composed of 14 diffe re nt ite m s (Tabl e J J .5 ) inc lud ing grooming, dress in g the uppe r body, dress ing the lowe r bod y. bathing, toi le tin g. transfe rs. ambul a tion/l ocom o ti o n. feeding. meal pre paration, transportatio n. la und ry, ho use keeping. shopping. a nd the abilit y to use the tel epho ne . The format of the instrume nt in thi s section all ows recording o f bo th pri o r and c urrent functi o nal statu s on e ach of the items.

T he SF-36 T he SF-J6 co nta in s 36 ite m s based o n que stions used in the R A ND Health Ins uran ce Study. These 36 ite m s we re

cull ed from the 113 questi ons used by RAND in the Med ica l Outco mes Stud y (MOS) to ex plore the relalionship between physic ia n prac tice styles and patie nt o utcomes . 5~ Th us, it was named the SF-36, beca use it was a

sho rt fo rm o f th e MOS in stnIme nt with on ly 36 q uestio ns. T he MOS pro vide d impo rt ant d ata o n the fu nc tio naJ status o f ad ult s w it h ~ pec i ti c (' hronk cond iti o ns 54 :lI1d the we ll Ixin g o f patie nt s experie nc in g depress io n compared to ~u bj ecb w it h a c hroni c medi c a l cond i ti on .~~ T he SF-36 de monstr:lIc d hig h re li a bilit y and v~lIid i t ) (t'orre lati o n coeffi c ie nts ranging from 0 .8 1 to 0 .88 ), ~o-.~I} NOn111.ltive dala for the "e ~t:lr- report ite lll " h.t\·e been (·o llected .~l All bU I o ne v f the J 6 que ... t i on~ of the S F-.~6 are used to fo rm e ig ht dilltt re nt ,>c,l le ... : ph ) -i ICJ I fun l' li u ll , , oeJ al f uncti u n, ro le fun cll o n, Il1 t l1t:ti hea lth , energ) /fut ig uc, pam , and ge ne ral he.dlh pCrCepI JOIl C). rh(.' la st que ~ tl o n considers ...t' II -pC' ra l\,cti l·hangt' in hc:a lth J uring Ihl..' p:t~t ) ('ar. Items a rt' "t.:o r('t! o n Ill)ll1 in.ll (ycC)/ no) o r u rJin,tl s l' " lc ~ . E ~H.: h po ~_ .., Ihle re"pon~e to ,HI He m o n a Wille' I'" ~t ... C)i c.n ed J. number 0 1 poi n",. Tilt' IOtdl pOt l1 h ror .til itt" Ill : o \\ ithin a ...c ale are thc.:n addc.:d .Hh l trJ. n, t(ll"lllcJ tl l a th l.! mati t·a ll~ h) Yie ld a perl'l.' ll lage \nH·I.' , \\ II h 1OU p~ r t.:l.! nt rt' pre"'l.'ll ting o pti mal hea lt h Sample Ite n"l''Io on ph) "11.'. al Junc tlun and ro le- fUIll: !Inn .Irl' PJC... ~ntl' J In I ~l l)k 11.0 1'h(' SF-J6 h.I " ht-en u~ed In d Il llllltx-r 01 '> 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
.l92

Ph y~ica l

Rehabilitation

Table 11 .5 Outcome and Assessment Infonnation Se t (Oasis): ADL/ lADLs

(continued )

.

.

,. laxi or public transportation (bus, Iraln, Subway), (M0730) Transportation : Physical and mental ability to safely use a car, ' Prior

Current

0

0

0

0

0 0

0

G-Able to independently drive a regular or adapted car; OR uses a regular or handicapaccessible public bus. . 1-Able to ride in a car only when driven by another person, OR able to use a bus or handicap va n only when assisted or accompanied. by another pe~son . 2-Unabfe to ride in a car, taxi , bus, or van, and requires transpo rtation by ambulance. UK-Unknown

(M0740) Laundry: Ability to do own laundry-to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand. Prior

Current

::i

o

o

o

c

o

O-(a) Able 10 independenlly lake care of all laundry tasks; OR (b) Physically, cognilively, and mentally able 10 do laundry and access facilities, but has not routinely pertormed laundry tasks in the past (i.e., prior to th is home care admission). 1-Able to do only light laundry, such as minor hand wash or light washer loads. Due to physical, cognitive , or mental limi tations, needs assistance with heavy laundry such as carrying large loads of laundry. 2-UnabJe to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation. UK-Unknown

(M0750) Housekeeping : Ability to safely and effectively pertorm light housekeeping and heavier cleaning tasks. Prior

Current

o

o

o

o

o

o

o

o

c

o

O-(a) Able to independently pertorm all housekeeping tasks; OR (b) Physically, cognitively, and mentally able to pertorm a/l housekeeping tasks but has not routinely partiCipated in housekeeping tasks in th e past (I. e., prior to this home care admission ). l-Able to pertorm only light housekeeping (e,g. , dusting, wiping kitchen counters) tasks independently. 2-Able to perform housekeeping tasks with intermittent assistance or supervision from another person. 3-Unable to consisten tly perform any housekeeping tasks unless assisted by another person throughout the process. 4-Unable to effectively participate in any housekeeping tasks. UK-Unknown

(M0760) Shopping: Ability to plan for, se lect. and purchase items in a store and to carry them home or arrange delivery. Prior

o

Current

0

o

o

o

o

[J

o

O-(a) Able 10 plan for shopping needs and independenlly pertorm shopping tasks. Includmg carrymg packages: OR (b) Physically, cognitively, and menially able 10 lake care of shopping, bul has not done shoppln~ In the past (Le., pri or to this home care admission). l - Able to go ~hopplng, but needs some assistan ce: (a) By self IS able 10 do on ly IIghl shopping and carry small packages bul needs someone to do occasional major shopping' OR ' (b) Unable 10 go shopping al b ' 2 U one, ut can go with someone to assist -h nabledto go shopping, but is able to Identify Items needed place ord~rs and arrange ~~~

"

3-Needs someone to do all ShOpping and errands UK-Unknown

ICO(IIinUOdI

Chapter 1 J Examination of Functional St,;dus and Activity Leve l

393

Table 11.5 Outcome a nd Assessm e n t Infonnatio n Set (O as is): ADL/ lADLs (continued) (M0770) Ability to Use Telephone: Ability 10 answer Ihe phone, dial numbers, and effectively use Ihe telephone to communicate. Prior

Current

0 0

0 0

0

0

0

0

0 C 0 0

0 0

0

G-Able to dial numbers and answer calls appropriately and as desired. I-Able 10 use a specially ada pled lelephone (i.e., large numbers on Ihe dial, telelype phone for the deaf) and ca ll essential numbers. 2-Able to answer the telephone and carry on a normal conversation but has difficulty wilh placing calls. 3-Able to answer the telephone only some of the time or is able to carry on only a limited conversation. 4-Unable to answer the telephone at all but can listen if assisted with equipment. 5-Tolally unable 10 use the telephone. NA-Patient does not have a telephone. UK-Unknown

From OASIS-B , Center for Health Services and Policy Resea rch , Denver, CO, t997, with

permission.

Rece ntl y, a shortened version has bee n developed that uses a subset of items from the SF-36. 67 This vers ion, known as SF-12 . includes items from each of the eight concepts repre se nt ed in the SF-36 and allow s for th e calcu lat ion of physical and mental subscale scores. An advanwge to using fewe r question s is less time is required to complete the survey. This. however, may be at the ex pense of having a less precise score that may not be as sensiti ve to change for an indi vidual paliel11. 68 The development of the SF-36 ~ tal1d s as the premier example of a complete and publi shed exploration of the psychometric properties of an

instrument as an essential part of its deve lopme nt. and a testament to the responsibili ty of its creators in verifying the qual ity of the SF-36 as a sc ientific tool (see Evidence Summary Box 11.2).

Summary of Multidimensional Functional Instruments For the purposes of illustration, four multidimensional instrumel1ls have been presented. C hoice of a multidime nsiona l instrum ent carrie s the same caveats mentioned for

Table 11.6 The SF-36: Physical and Role Function

I I I

The following questions are about activities you might do during a typical day. Does your health limit you in these activities? If so, how much? (Mark one box on each line.) a. Vigorous activities , such as running , fifting heavy objects, participating in strenuous sports b. Moderate actiVities , such as moving a table , pushing a vacu um cleaner, bowling. or playing golf c lifting or ca rrying grocerie s d. Climbing several flights of stairs e Climbing one flight of stairs f. Bending, kneeling , or stooping g Walking more than a mile h Walking several blocks I. Walking one block Bathing or dreSSing you rself

-

--

DUring the past 4 weeks , have you had any of the following problems with your work or OIher regular dally actiVities as a result of your physical health? (Mark one box on each line) a Cut down the amount of time you spent on work or other activities b Accomplished less than you would like C Were limited In the kmd of work or other activities d Had difficulty performing th~ work or other actiVi ties (for example, II took extra effort) Frorn Ware , J, et a!

1:> 7

-

Yes, limited alai

Yes limited a little

No, not limited at all

10

20

30

10

20

30

10 10 10 10 10 10 10 10

20 20 20 20 20 20 20 20

30 30 30 30 30 30 30 30

--- --Yes

No

10 10 10 10

20 20 20 20

394

Physical Rehabi litation

Evidence Summary Box 11.2 Reliability and Validity of the SF-36 S tu d y

· S tu d y DeSlgn

Samp Ic

Selling

Reliability

Validity

("omm,'"''

Stewart, AL, et ai," 1989

Cross-sectional

9,385 persons 18 years and older who had visited a physician

Ambulatory care

Internal consisleney of scale scores .67 to .88

Not addressed

Used MOS Sf.aI

Stewart, AL, et ai," 1988

Cross-sectional

11 ,186 English· speaking persons 18 years and older who had visned a physician

Ambulatory care in three large cities

Inlernal consistency of scale scores .81 to .88

Used internal consistency as a validity measure; also compared good and poor health samples to diSCriminate; also correlated to sociodemographic factors.

Used MOS SF-aJ

McHomey. CA, et al,59 t994

Cross-sectional and longitudinal

3,445 English· speaking persons 18 years and older with chronic medical and psy· chiatric conditions

Ambulatory care in three large cities

Ware, J, et al,67 1996

Longitudinal

n 2,333, including adults with chronic canditions

Participants in the National Survey of Functional Health Status and the Medical Outcomes Study

Riddle, DL, et ai," 2001

Longitudinal

101 consecutive patients with low back pain

Three physical Not addressed therapy clinics in the Richmond, VA area

King, JT, et ai," 2002

Cross-sectional

88 persons with cervical spondylotic myelopathy

OUtpatient neurasurgery clinic

Internal consistency reliability of scale scores. 78 to .93

Item discriminant SF·36 validity from .09-.58 to .2
2·week Discriminant valid- Article on CII> test-retest .89 for ity of SF·12 simi' struction of Sf.12 physical compo· lar to SF·36 in nent score and groups of patients .76 for mental known to differ in component score, physical and men· in the general US tal conditions. population

Internal conslsteney reliability (Cronbach's alpha) of scale scores .79 to .92

SF·36 completed before initial examination and at time of dis· charge. SF·12 items extracted from SF·36. No ~gnificant differ· ences were found for the comparison of change scores between the phys. ical component score of the SF·36 and SF·12. Construct validity was demonstrated usrng myelopathy scales constructed by Nurick, Cooper, and Harsh as well as a Western modification of the scale developed by the Japanese Orthopedic

Assoc"'tion.

C h apter 11 Examination of Functional Status a nd Acti vity Level

395

Evidence Summary Box 11.2 Reliability and Validity of the SF-36 Study

Study Design

(Conti nued)

Sample

Setting

Reliability

Validity

Kosinski, M. et al,7° Cross-sectional 1999,

1,01 6 persons with osteoarthritis or rheumatoid arthritis

Outpatient or inpatient setting

Internal consistency reliability of baseline scale scores .75 to .91

Not addressed

Kosinski, M, et al ,70 longitudinal 1999b

1,016 persons with osteoarthritis or rheumatoid arthritis

Outpatient or inpatient setting

Not addressed

SF-36 administered before treatment and 2 weeks after treatment. Discriminant validity was demonstrated in groups of patients with clinical measures of arthntis seventy and across patients who improved with treatment.

Hagen, S, et al ,71 2002

Prospective, observational

153 persons recruited within 1 month of a recent stroke. SF-36 administered at 1, 3 and 6 months

24 general practices in Scotland

Internal consistency of scale scores > .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 mea<"ure .. all potent iall y releyant item..,. Table 11.7 prese nt, J ( olllpa n \on of Ih;· m .., em,e red . In Ihe phy . . i<:a l fU llction afea. que..,uon \ on Ihe abi lity 10 amhulme are the onl) Hem.., Ihc\c IIh rrume nt.., have in COlll mon. A"' pec ls of ph )..,i(al tunuion nOI (0\ c: red in ~lIly of th e . . e Ilhtnl/ne nt .., ini.:lude bed l1lobilll) and de\ te ri l). The FIM .I nd Ihe OAS IS IIK l w ...k mo re BA DL it e m ... than ei th er the S IP o r Ihe SF-3o, T he SIP :lIl d Ihe

SF- ~6 I ll\ e~ lI g;:u e

\\01''' pt: r-

IHrm~Ull:e. \\ herC:;J ... lhe FI\1 <-lilt! lhe OAS IS til) n OL rhi 'l I ... nl./I .., urpri . , lng. gl\cn Ihal Ihe H M \\ d ~ on ~ lIl a ll ) tle\d-

it 1001 lor Ihl" IIlpa llt: 1l1 re hahilll .1I101l ... t: llm g ~\Ild OASI) \-\a.., e~prl:\~I) dt· . . lgnt.'d lor home ht:'llth agelllit' .... bOlh gene r.dl) ..,e l \ IIlg " Itlt' / ra th: nh . In l·()lltra~ l . Ihe Jt:\ dupmC:ni 01 fill'S IP ;.a nu SF-36 \', a\ fOi..·u..,ed 0 11 ) otillger .tdult POPU Ll llOlb III <.tmhu ldtol") l dl"e, A nxll' l) dnJ tkpr6"'lon .Ire adult' ... ..,eu .1.., i.lreJ.~ 01 P... )cho log IL.tll uIlL II OIlIIl Ihe SIP Iht· \ r -16. Jnd Ihe OA~ I S hu t 1101 In Ihl' HO\' r ht, (JA", ' S dflt-'> Ilell nplU/e M IL'I ..tI f ll llt· thll l , \\ hl lt- IhL' Olht'l" Illrc!: lIl ... tntrHl:llh uo. h llalJ) . on l) Iht S f 16 h.·Lonh gel!

orx:d a.., Ihl:

c l d l heJlllljkru:,pl ll)!h .

omml'nt,

Limited discriminant validity in this sample of persons with stroke due to floor and ceiling eHects. Assumptions for generating 5 of the 8 scales and for the 2 summary scores not satisfied.

Summary Thi s chapler ha ... pre~ented a conce plUal framework for unde r"' l.1nding healr h ::' Iatu s and e\amindti o n of functional " Iatu .... Th e tf
It)! t'. 1lll/\1 t'lt" \ 11.;'\\t'd ,b.1 hroad . J1lu h l(llIllen~ ionaJ process. Thrl'C' Illdlll l',I[ c'gn n l" 01 tUlllt lon h d \t.' bee n dt'linc:atedph) ... IL.II . P")l..ht)l ng ll.,1. .Ind ",ol.l~lL In strument3UOn h d .. bl~e n p re\t"ll tt" u Ih al ad tl n. . ... ..,t., the p h) sical dimen-

'>IOn

\11 lunclJ oll . Iht'

thl"r"lpl ~h

i1rt.~;1

o f \: \ .... n1l I1<.1110 n that ph)SICal

<1i C' tr
-

C hapt er 11 Examinati on of Fun ctio nal Status and Activity Level

397

Table 11.7 Ite ms Covered in Selected Multidim e nsional Functional Asse ssm e nt Instrume n ts

Symptoms Phys ical function Transfers Ambula tion

+ +

ADL Bathing Grooming Dressing Feeding Toileting

+ + + + +

IADl Indoor home chores Outdoor home chores/shoppi ng Community travell drive car Work/school Affective function Communication Cognition Anxiety Depression

+ +

Social function Interaction Activity/leisure

+

for

that the re suh :-, ca n be u ~ed \\ jth confidence in both Irealme nl planning and re. . ecu ... .., Iht' u">(: :-.. dd \ advantage:-. of [krtormanc:(: -ba ...cd lIl " trumenh, IIltaVI(: \\ er reporh , ~nd ... dl-adm mi ... lert'd repolh, 5, hp1411l hm\ en\ Iron ment, f<.lll guc , and other relatl'd 1...... Ut: ~ '-Iht::ll fllc<.I':I ure mcllt of tUIK tl o n , Suggc">t \\ a) ~ II) l(mtrollht' ~e td l ll)r... II) the din l ~, 6 . Idtlltll ) tht m ajor

::00

I) I'D

+

+

+

+ +

+

+ +

+ + + + +

+ +

+ +

+ +

+

+

+

+

+

+ + + +

+ +

+ +

+ +

+ + + +

Re v iew

1. Hov. do fu nc ti on al ~ 1.1lu :-. and lllea:-.urement of funclion relate 10 healt h s tatu ~7 2. Your rehabtlit atlon fa l: ilit y u ~e ... the FIM . HO\\ C'1Il reilabllJl) he t:n\u red

+

+

General health pe rceptions

Q uestions

+

0 1 ,,>u)rin ~

"> ~ : -:. 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
398

Physical Rehabilitation

Case

Study

A 78-year-old woman wirh a diagnosis of oSleoa rthriti s \\as admitled for a ri ght lolal hip rep lace ment. Th e palienl reported a long-standing hislory of di ~co mfOI1 . She described the hip pain a~ radiati ng pO~ l e ri o rl y 10 Ihe buttock and low back and exacerba led by wcigh lbearing and slair c.' limbing. Over the pasl 12 J11 o nth ~ she has c).pe ri enced n \'cry mar"-ed increase in pa in and ~ Iiffness. Rndiographic finding s demonslrated degenerati ve changel., of hoth Ihe
SOCIAL HISTORY The palie n! i ~ a retired ma nager of a small accou ntin!Z finn that she and her husband establi shed. Her hu s ba~d i"l decensed. She has three grown chil dren who all live in neighboring communiti es. Prior 10 the funclional liJ1lilation~ imposed by the hip pain . th e patient had been independent in all A DL and IADL. Shc also vo lunteered her i.tcco~nling services I day per wee k to a loca l charity that prO\ Ides meals 10 homebound indi viduals. She was a regu lar panicipant in family outings. enjoyed going 10 Ih e thea ler. COllcens. and ~peciaJ mu~eum eve nt s. and was an aC li\e member of the communilY hi storical preservation ~ociet).. Recenrl). these activilies had 10 be cunailed owing ro I.h~ Ulcrea~ed hip discomfort. She essentially had no actl\lllc::, outSide the home for 3 month s prior to admi ss ion an~ u::,ed a \\ alker to minimize we ight bearing and red uce pam. She aho required the assi~lance of a home care aide ~ hour... ada) t\\O limes per \\eek (primarily for ~ hoppjng. eTTand ~ .•md some househo ld managemell! l a~!..s). She expre"l~ed considerable d i ~tres~ at being unable 10 ta!"e a bath and h;1\ IIlg to rely. O~l. the ;h~i~tance of another per~on f.or .<-,ome ba~H': care aC II ... IlIe~ . She had bee· .. n mmg a~plfln for Ih amtlge . . lc and allli-innamnuuory effecb. However the pam experienced III rece ll! 1l101llh . . wa . . not all ev iated' b) the .te'hl\ e medIcal Ill..,u runce cove rage and i.. . . . "houl fm:JJ1C,aJ cOnCt rlh.

POSTSURGICAL RIGHT HIP PRECAUTIONS No Ilip fleXIon be)ond 90 A\OJd lTO""llllg one leg or an "-k O\er the olher ..\\01<1 IflIernal rOlatuHl 01 righl lowt]' C\ trenll l)

REVIEW OF SYSTEMS Cu mmunicalion Aft ,t C· .. Full ' , . t t : , ogn tflOn, Learning S" Ie: ) Lomlllun ICU II\l: dnd Oriented )( l C· . ..

OOperall\t'

and mOli vated . Hearing intact. Wears corrective lens; ex peri ences " ni ght blindness:' which she describes as see ing poorly in dim light and her eyes take several seconds longer than nonnal to adjus t from brightness 10 dimness. Cardiopu lmonary: HR = 84; BP = 130n8; RR = 16; No apprec iable in creases with activity. Integumentary: Surgica l wo und healing we ll ; staples removed. Strengt h: Upper extremit y gross ROM is WNL. Gross stre ng th ge nerally good to normal , except hands. Left hip. knee. and ank le at leas t good on break test. Panial we ightbearing on right lowe r ex tremity. Joint Int egrity and Mobility: Patient reports some sporadi c epi sode~ o f wrist and finger stiffness upon awak_ ening in Ihe morning and after periods of immobility. Crepitus noted in right knee. Heberden 's nodes noted at the DIP and PIP joint s o f the le ft index finger. Range of Motion: Right knee and ankle within functio nal limits: right hip not tested. Muscle Performance: Grip streng th is reduced bilaterall y (4- 15). Pai.n: Patie nl d~nies pa in in wrist or fingers. or right hip. Galt. LocomotIOn , and Balance: The patient is ambulating o n level :, urfaces wirh s upervision using bilatera.1 standa~d aluminum axi ll ary crutches with partial w~lg h.l beanng o n the right lower extremity. Stair c llmbm g also req uires minimal ass istance. Ir is anticipated the patient will be independe nt with ambulali on 011 le\el ,> 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 Am<'n~'. World Hcalth Ort!.IIlIZJtion. Gel1e\:I. 1980. GU:'
r 3U9

~

II!

11

I~

I.~

l-l

l(j

II') 17 IK IIJ

~I)

'\.1£1. S: Ol"abtlll) .md Rehabilitatio n. Ohio Slate UllIve r"it y Pre<;s. Colurnhu". 1969. \:lgl. 5. Somc concl'ptua l i s 'u ~~ In di~abtill y and rehabilitation. In Su~"man. 1\'1' SOI.lolog} and Rehablillallon. Ohio 51ale U ni \cr~lly Pre",. Columhu". 19M. p 100. S(henJ..mm. ~1. and Butler. RB : A modd for llluItIS)"elll evalu Ther ft9:432. I<JX9 \\orlJ He"lth OrganlzJtlon (WHO): International Cla<;!>ificatIQn or FunctlOnmg. O"ahtlll} and Health. World Hc::alth Org:lIIiz3Iion. Gcllt!\,e~"l\g Ilk: RolC' of Rthabllllallon Science and Eng lllec::nng. N,llIonal AladclllY PrC',,". \\.i,hlllgion. DC'. 1997. J~II<'. -\\1. ,lIld Ke),or. JJ : D",.. btlIlY model~ : Implication, for J.rthnll' ~H'R"e J.lld ph}'lc.11 alllvlt} Illtenentiom. Arthn l Rheum 4lJ.!I·t 101n. Gu~"tl. GH. o:t a! The 6-mlllllle .... alk . A 110: .... mea"urc of ~xcrc i"e ( oIp.irll~ III p.. lltll'" .... "h chrollic hcan l[l t!ure. Can J'\'led Assoc J J.~2:<J2~, 19X:, WlllogrJ.d. C'H c'.l1 Lk\dopm~m o! .. ph)~I[ .. 1 perform,mcc and nmnlhl\ e),atrltnallOIl JAm Gt..'n .. tr SOl; 41 :743. 1994. [)Ulll.lIl. P\\ e••1i FUIllLl()Ilal ft'ath A ne .... dlllie.1i me .. ~ur~ o j ht uf h
21 (jUloIl'll l J"1 cl "I A ~h')rl ph}SllJ.I PCdollll..tllle b.tltt:l) ""C'~ lIIg 1"v.cl l.'.\lrcIlIII~ IUn~II(l1l A"Od.iI,On "I,h '>t' lf rtporll'd ,1",tbJIII) "nd rr~dldl()l1 .,1 IIIl)rt.iIJt~ .ind nur,lll!,! home .idmJ'~ion J Gcron1l>1 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<;tlring de\dopmell1al .:md fUIll'liollal !>t.ltus in children wi th dJ.),,,bJli t i~~. Dc\ i\ted Child Nt:uroI4 1: 18b. 1999. -12 Gil,,,n. B. ct al: The S idnc" Impact Pro lile : Dc\elopmenl u l ..Il oU lcome nt ~a"Jrl' 1)1 health t·"re. I\m J Publ ic- Health 65 : 13()...j, 1~ 7S

-11. B\.'rglle r. r-.l . 1:1 .1 1. The Sldne<'l> Impa~' 1 Profile: Vahdatlon of a he'lith ' L.t t u~ Ilk·,\Sure. r-.kd CaTe 1--l:57. 1976 -1-1 . Po llarJ. W. 1.'1 al : The Sl(']..nt's~ Proti le: Reliability of a health ",alus Illl·a~Ur1..'. r-.kd C.ifl' 14: 1-11'1. 1970. -I 'i Can\.'i', W, ~I 11.516. 1976. 40 Berg,nC'r, M . el ..rl . 1 he Sll]..nt'1>S Imp':l!.:t Profile : De\'t'Jopmem .l1ld tin.il r("''' Jon of a he.J lth \ t.. tu:. me"su~ , Med Care 19:71ol7. 198 1. 47 Dc}o, R. ci al : r-.Ie..t~unng fUllc tlonal outcomes 111 a chronic dl!>ea~e: A {'Ulllp.lrisoll 01 tnuJlllo.)nal ~(' ulc, anJ Ii ,elf-administered health , t.ttu ~ qut:.\tJo.)lllwlre 111 patlcnts \\ IIh rh~ulllaloid anhritis. Med Care 2 1 11\0. 1983.

400

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48. De\o. R. et al: Phy~ical and ps),c ho.;oc ial function in rheumatoid ul'1hrlli~ . Cllnic;11 u,e of a ~e lf-admini " te-red health ~ !at u~ in.-.tnunenl. Arch Intem f..-led 141:870. 1982. 49. Ot"\o. R. et al : A controlled tnal of tram.cutanCQU' electrical ~Iimu­ I,L,;on (TENS) and e.~crci,c fro r chronic low back pain . N Eng.1 J Me-d 32:!: 162 7. 1990. 50. l\IacKenzk. C. et .. I: C..n the Sid,ne''; Imp;Lel Profile mea'lurc change: An example of scale a.. , e" ment. J Chron Di ~ 39:429 . 1986. 51 . Kn,1er. KS. l'I :11 : OASIS Ba,i c~: Beg inning 10 U,c the OUlcome and A,'e" menl lnfonnati ron Sel. Cenler for Health Service:. and Polic~ Re,earch. Demer. 1997. 51 . Shau!!hnc"\. PW. and Cri~ler. KS : Outcome-ba'cd Quality I mrr~\'emel~t. A Manual for !-lome Cure Agcncie:. on How 10 Use OUTcome'. NaTIonal A"ocialion for Home Care, Wa,hington. DC.

1995.

5.~. Tarim. AR. l't al : The ~kdical Outcomes Study: An applicalTon of nll'th(l(h for momwnng Ihe re,ull' 01 medical care. JArviA 262:925. 1 9~9.

5.1. Ste\\3!1. AL. et al. Functional statu~ and well·being o f palien" w ith l·hronlc condlllOn,: Re~ult, from the Medical Outcome.; Study. J.l,~ I A 2('11:907. 1989. "5 \\ell ... KB. t"1 al : Tht' func llOn ing and well-being of deprt'~<;cd pal Lent' : Rc.. ul" from lhe Medical OUlcomes Sludy. JAMA 162:91·;' 191:N. 56. Sle\\an. AL el al : The I\IOS ~ hon geneml health :.urvey: Re liabilit) ,lIld \ahd lt ~ m a pallenl popul:Ilion. ~1t:d Care 26 :724. 198R. 5i . \\ are. JE. ;md Sherbourne. CD: The MOS 36-item ~hon foml health 'Uf\e~ (SF-:-6): I. Conceplual framework and ilem ~cIcCl ion . Med Care ~0:47J. 1991. 5S Me Home}. CA. el al : The t-.IOS 36·item :.hol'1 fonn health ~uf\' ey LSF-3M: I[ P'ychomem c and clinical tesh of \alidit) in mt"a:.uring rh ~ .. ical and menial health comtruclS. Med Care 3 1:247.1993. 59 \l c H on\(:'~. CA. ('I ,il: The MOS YH lem ~hon fonn health ,"Uf\ey IS F- .~t'.\I: [11. Teo"I" of dala quality. "'('al ing a.. wmption,. and reliabilIt~ acro" dl\e~e p3tlenl groups. Med Care )2AO. 199~. 6(j. Ware. lE. t'l al: SF·36 He:ll (h Survey: Manual and Intepretatlon G uide B O~ lon. The Health In ~ l itute , Ne'" England r-.h:dical Cenler. 1 ~3.

61 I\\(l~,t>e rg. KA. and MeFarl:md. C: Inilial healt h ~ tatu' OfpJ l ie lll ~ at OUlp..tIICnI ph~~i~' .tllht" ra p) clini c~. Phy~ Ther 75:1043.1995 .

su

l e m e ntal

62. Jette. DU. and Downing . J : Health stat us of individuals.entering a cardiac rehabi litation program as meas ured by the MedIcal Outcomes Study 36-ilem short (orm surve y (S F-36). Phys Ther . , . 74:521. 1994. 63 . Jettt':. DU. and Downing. J : The relat Ionship of cardIOvascular and psychologica l impairments to Ihe health status o f patients enrolled in cardiac rehabilitation programs. Phys Ther 76: 130. 1996. 64. Jene. OU, and Jene. AM : Physical lherapy and health outcomes in pa'ienl ~ wilh ,P"I:! 1 impairments. Phys Ther 76:930. 1996. 65. Jelle. DU. and Jette. AM : Physical therapy and health outcomes in palien" wilh knee nn~airment<;. Phys The.r 76: 1.178. I~. 66. jette, DU . et al: The d isablement proces'i 1Il patIents W ith pulmonary di"ea<;e. Ph y~ The r 77:31:15.1997. 67 . Ware, J. K o~i nsl.i. M. and Kelle r. SO: A 12- lte m Shon -Form ikaltb Survey : conslructi on of ~ca l es and preliminary leSls of reliability and \·alidity. Med Carc 34:220. 1996. 68. Riddle. OL. Lec. KT. and Stratford. PW: Use of SF-36 and SF·12 health ,talUS measures: a quanti tat ive comparison for groups versus individual palienh. Med Care 39:867. 2001. 69. King. JT, and Roben ... MS: Validity and reliabi lity o f the Short Form-J6 in cervical :.pondy lolic m yelopath y. Spine 97: 180. 2002. 70. K os in ~k i . M. et al : The SF-36 heal th ... urvcy as a generic outcome mea'ure in chnical Irials of patient.; wilh osteoarthritls and rheuma· toid arthriti~: te,l:. of data quatit y. 1>ca ling assumptions and score reliabi lity. fl-kd Care 37:MSIO. 1999. 7 1. Hagan. S. et al : P., }chometric propenie:. of the SF-36 in the early pos l -~troke pha ..e. J Adv Nurs 44(5):461. 2003. 72. Findler. t-.1. et al: The re liabili lY and validity of the SF·36 health "une), questionnaire (or u..e w ith indi\iduals with tra umatic brain injury. Brain In 15(8):715.2001. 73. Yip. lY, ('I al: Compari..on of o lder adult subjI!Ct and proxy re"pome'" on Ihe SF-.~6 health-relaled quality o( life instrument. t\ ging Ment I-kalth ) (2): 1 .~6. 2001. 7 ~ . Andre ... en. Et.1. el 31: Llm itat Lon, o f the SF-36 in a sample ofruming ho me re ~ide n b. Age Ag mg : 28:562. 1999. 75 . Hohart . Jc. et .. 1: Quality o f life mt"3s ureme nt after srroke: uses and abu-.c' of SF-36. Slro ke 33: 1 3~S. 2001. 76. Guccione. AA. Jnd Jellc, AM: t>.lultldLmensional assessment of iunct iOll31limilallOlh in patu:I1I' .... ith arthritis. Arthril Care Res 3: ~ . 1990.

Readin~s

Dittmar. S. ..tnt.! Bn: .. h..tm . G: FunCllon:t1 A s:.c:~' men l llnd OUlcome

I\lea,ure, lor the RehabllJtat lon Hcalth Prolc :'~ L onal . A'pen. G Jlrh.:r~t'o urg . MD. l'ilJ7 . FIIl~h E. el al Ph ~,i' aJ Reh,LnllnalLon OUI':OI11C: ~le.l,ur(", · A GUIde 10 EnhJntcJ Chml.la ... mg. ed:! Llpplll(oll Wi lha,m & \\ tlhHh. B,\lumor.:. 200~ H.J1UJJ. HP cr:.1 Dc\dopmc:nl and \..tILd..tlloll 01 a per1orm.uK,,·-ba,,:d mC:J'Url' III Uppt'l ~·\lrel1ll\~ iunctlonal hmtluTlflg He..t lth A GUld ..· 10 R,.IIIng S.. "ln and QUl"'lIvlln..tlrc:,>. 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\
Exterior Ac c e s ~i bilil y 409 General Considerations: Interior Accessibility 411 Specific Considerations: Interior Acce ssibility 414

he physical em'ironmenr in which an individual functi ons consi. . ts of a varie[)1of both built and natural objects. Built objects refer to bu i l di n g ~ and ::,Imctures created by humans: natural objech incl ude other humans as we ll as geographical objecb ~ uch as vegetation. mountains. ri ve rs, uneven te lTain, and "0 forth. 1 The e nvironment e n co mpa~ses a substanti;'ll range of componenb that impact human fUIl(;ti on and in cl ude~ the individual":-. home, neighborhood , community. and method(s) uf 1f<.I.Il:-.portaLi on. in additi on to the indi viduaJ ' ~ educational . ..... orkpl ace. en len ai nmell1 . commercial. and natural se ttings.l Em·ironm ental barrier s are defin ed 3 :-. physical impedim ent ~ thai preve nt indi viduuh from functioni ng optima ll y in thel f ~ urro un Ji n g~ . ;.lIld if1(: lud l~ ~ ak l Y hazard:..,
T

Ass isti \'c Technology ~ 21 Examination of the Workplace .t26 Infonnation Gathering 426 On-Site Visit 430 Community Acces~ 43 3 Transportation 434 Access to Communi ty Facilities 435 Documentation 436 Fundin g fo r En\'ironmelHal Modificalions 436 Leg islation 436 Summary 43 7

Ame rican National Standards Institute (Accessible and Usable Buildings and Fac ilities. ICC/ANS I A I 17. 1- 1998).' the Fair Housing Amendments Act of 1988. and the Unifoml Federal Accessibilit)' Standards (UFAS). Requirements for public and commercial bu ild ings are regulated by Lhe accessibility gu ide lines of the Americans with Disabilities Act (ADA).' Unive rsal d esign (al so called !ife-spall desig n) refers to ""the design of products and environments to be usable by aU people, to the greatest extelll possib le. without the need for ad~ptali on or !o>pec ialized design: 'b· p I This design concept emphasizes soc ial inclusion by cre;;lting environments Lhat are useable by a wide range o f individuals of different ages. stature. sizes, ,-md abi lities as we ll as addresses Lhe c hanging needs of human beings ac ros~ the life span. Alt hough unive rsal design is both access ible and free of barriers. it is not tht' ~allle as bringing exi sting buildi ngs or structures into compliance with the ADA Standards for Accessib le DesignS or otht: r building codes or laws. Applying such standards to c). isti ng ~ lrUl: t U I'l..·s often re ~ult s in important but selective

402

Physical Rehabilitation

:H.:cc~<; i bi li tv, In cont ra~t. uni versa l des ign is appl ied from the illl'l" Ui';1I of a building plan, Of;troff1 arg ues there is COI1 fll~ ion abollt the im portance of incorporating u n i ve r~al d~ .. ign pri nciples in to archit ectural plans verMIS crea ting nc\\ structures and the n approaching the lask of elim inating of c!lvironmental b'lrri er.. : " We ~ee the pOOT de~ig n and the problem, crealed by thi , confu sion. especially in thoughl Ie's ne\\ de:-.ig n:-. thm end up look ing like retrofit s. Ramps added in new COIl :-.ITuc lion are a good example. where nOlle would have bee n needed if the architecls had considered the need, of all u:-ers <\') fundam enta l in the earli est :o. wges o f the prog ramming pr()('e~,. rather than a techni cal requ irement to be added at the end of the design process."7.1' 1,5 Incorpori.llcd into initial planning. uni ve rsa l des ign pri nci pl e:, are e~:-.e ntially "i nvis ibl e" as compared to adaptatioll' made to ex i:-. ti ng structures. Th ey appl y to a ll feature~ and space:-. of a dwelli ng. Seve ral exa mples of uni wn-.al de,ign elemenh incl ude stepless entrances. wide hallwa), and door\\ays. leve l tran sitions between room s (BO doorway thresholds). li se of non slip floors, lever door handle,. rrn:j..er light ,\Vitches. single-handle sink fauce ts. and no-,tep .. ho\\ er access. Reinforced wall s ca pab le of ') upponing handrai l., or grab bars and large closets ali gned from noor 10 floo r sui table for housing a re sidential elevalOr are example:-- of universal des ign eleme nt s intended to meet the future needs of resi dents. fl. - Ill The .;;e\en Princi pl es of Universal Design deve loped at The Center for Uni ve rsa l Des ign (Nonh Carolina State Un j ve r~ity) are pre~en t e d in Appendi x A. Although uni ve rsal de:,ig n ori ginated in response to the need for environme nt al access for indi vidual s \Vit h fun ctional limit ations and d l"abJli t). many of its des ign e lement ~ proved use ful and han:' bee n embraced by the ge nera l public. Ril eyl\ pro\ Ide . . a filllllg e}..am ple of th is trend. 'Think for a moment of the automalJC garJge door. which orig inated out of nece"' Jl ~ lo r a cl ient whose di sability prevented him from liftmg a heavy dooT, Nm\ a ')tapl e of li ving fo r nearl y all of u" ,o-cJlled "abl e- bodied" people a~ we ll a~ th o:-.e with di ,,a bllll1e~. it " bUI one ot mall) exampl es of how Un iversal DC' lgn ha s ral st:d the bar for home design o f all j..ind."x p XII Refk l' l1 \e 01 the Il11pon ance o f envi ronmental :.l('ct'ssi. bilit~ . an 111ternallona lly recogllized 11'''l'(' /dUlir I\'II/hol identltli,"" build ing s tH.:c e ... sihl e 10 indi viduah wi lh 'a di,,dbdJl ). rhe Reh;tbil italJOIl Act of 1973 (Section... 501 ..111<..1 SO-l J reyuJrt' :o. [h ... t all o rganizati on ... rc(:e ivin g relier... ] fundIn g pro\ Idt'! ~u:c..:l:' s" i bk progr:.UlIS and ual dJ ..,pb, . \ uluJl1l' L'l mlrolll'<.1 Il' kpholle'> . •I\ i.llli.ih dl\ ) lit ".gll bngtld gl' Intl"T-

prClal ion. and so fOrlh. The 12 Disabilily Access Symbols are pre~ented in Fi gu re 12. I. These symbo ls are promincnll y displayed 10 idenlify and make public Ihe availabil_ it y o f access ible serv ices (Fi g. 12.2).

Purpose A primary outcome of rehabilitation intervention is for the pati ent 10 be ful ly functional in a fOTlne r env ironmenr and lifesty le. To achi eve thi s o utcome, conti nuity of accessibil. it y 1l1U ~t ex ist within the indi vidual's environmental contex t. With ful l access ibilit y as a goal , examination of the environment mu st address the patient-environment relali onship relali ve 10 access ibil it y, safety, usability, and functi on. The purposes of an enviro nmental examination are multipl e and serve to: I . Detennine the degree o f pat ient safe ty and level offunclion in the ph ys ical env iro nment. 2. Identify design barriers that may impact usability or comprom ise perfoml ance of customary tasks or activities. 3. Make reali stic recommendat ions regarding environmenral accessibility and accommodations to the patient, support network (famil y. friends_caregivers, sign ificant others, coworkers. profess ional colleagues. ne ighbors). employer. govemment agencies or other potential funding sources, and third-pany payers. 4. Determ in e the need for adaptive equipment or assistive tec hno logy to support and promote fun ction. 5. Ass ist in preparing the paticI1I and support network for the patient 's return to a (omler e nviron ment and to help detenninc \\ hether furth er se rv ices may be required ( i.e .. o utpat ient treatment. home care services, and so

fOrlh ).

Examination Strategies Ph Y'Il'~d [hera pi" " li'e i.I \ ari t" lv o f [e:>h and measures to l'\a minc ph)'ical Impedi1l1t'~t~ (e .g .. :>af~[y hazards. ~1I..'e~,s prob lem:--, de.-.Ign barrier... ) JJllpacting the palientellVII'Oll rllt!nt ]'c- Iati on:-. hip. Th e data ge nera ted a.re used to ' ll ggl.::-- t tllndifi,:a li<'lrh to Iht' em ironJl1~nt , guide reeamIllt'ndal lolh lilr ad.tpll\e eq uipment , i.I ~,... i"' II \,1! technolog~. and/or prnpo,c allt"Tnd ti \l~ J.ppro ..ll' he ... to perfonning a task 01 iILII\ II) lc.g. lI11prO\(' ,akt), co n ~e T\e ene rgy) to promol..: l)JlIJ1ll um lunuion. Tht" Gllldt' to Phr.llCal Thl'I'£1p'SI P I OllI e ( . ! In",' lude, C\,ll11 l1l dtl on of e m If\,m mental. home. ~J\d . \\or"- tloh/,,,,hool/pl.l)) ban-je rs i.t fllong the list of _-t l .tlL'gl)l·le, 01 h." h .tnd lllea,:> 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 '")
.,,<

Sign Language Interpretation

Tne synoo

"'deates thal SIgn language Interpretallon IS prOVIded fOf

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<

accOMmodatIons ana servICes suCh as "LARGE PRINT" materials, alJdto cassene recofdlflgs 0( mal&r.aiS Of

ll"l~t'l.-o

Closed Cap1 10ning (CC)

cc

~ 10(. -lola dlt d.

".' a ~ tt to- .... ''!e'Itlf:fr Of not 10 d'spl"'t c.apltOOS IOf 3 lEi aVISton program or vlOdotape TV sets lhall\ave a bui '" 01 a d'o: flQwop&d 10 0 'Pidf dlalOguo;t lor progl,)l'ns !nil! are capl>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<'" r.(J ,v 10 '''dO 1110 IrIII~ttg ~,)oj ~.,,'fo 10 .I r>'I'nlffl .... 11 of' Il'lu,...um~ ana rest
~'JI)1I(11 ~

dOClI

Braille Svmbol

••

I ) II).*" .... o;tlt' I-"Wut.l:tO D, Ilot> {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!INC v,,~1'\

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
Self-Report and Perfonnance-Based Measures of Function a~k in g th e pati ent to provide informa tion aboUi the ability 10 pe rfo rm certain tasks and acti vities in speCific cmironmcllI s. Admini stratio n can be e ither in a papehUld-pencil fomlat o r by way of an inte rview con ducted by the therapi'lt. An inhe rent sho rtcoming of se lfrepon Jn ~ trull1ent :, is that an indi vidual may overestimate perfomlanc:e c:.Ipabilities o r unde res timate the impact o f en\lronmental barrier~ . Acc uracy o f repo rtin g can be nnpro\ed by requc~lmg th e pati e nt ( 1) foc us the pe rfo ml anee ln lormallon on a rece nt time intcna l (e.g .. I\'ilhin the pre\iou ~ v,cd" and ('2) dis lln gui~ h be tween 't:lU lion ullhe t3!o. " . PCljumwllu'-hl.1 .wJ meWllrl!.\ add rt'~ .. c la~~ j ficati on o f tunctlonal ..tbill1l e~ and identi lic..tllOll 0 1 fu nctiona l limit a110m•. r he) are .Idmlll j ~ t erl:!d b) th e lh en.t pi ~ t who o b~e rves patient IXflofm.Jnce 0 1 the al.: lI \' it) . A \ari et) o f in "lrllnlenh drt" a\allable that IIlciude q uan tllJtl\e ~co r i n g ~y.!o.­ ' em~. l:.>.ample ... lIlc lude tht: Flll/uIDl/ol Reac/t Tl'JI.'~ Gt'l I 'p tll/d (.lI/h.".1 Ihe ."111,,1"1 PhYSical Pl' rlumwl/l 'e Bal/l'n IS PPB ).14 tht' 1,lllulOlwl I IIJepl'Ildl' IICl' A1t'I.1.wl'l' IFJM I,I ~ tllned v,ilH..I ng II! ~ t ~.II' 21 and tht' lJ erf!, 8 ululHl' T('M.n~1 Tht tht'rapl:,t IIlh::rpreh Iht' data b) cOlll pari.!ooon 10 nurmalive p.:rlDrmante The mea~u re~ ) ie ld Illl pOl1.1ll1 inlu rmalion ab"Ullht' IIllpa(:( of lI11 ra ll'Jllen l ~ on jUllCl io n and help prt:dlu pall..:nl pt:rltmn.lOu: v, uh ln hi.. or her n:.I1u ra l em 1ronlJlt'nl Tht' rl',tdc l 1:0. refe rred to C'huplt'1" f J fo r Jddi -

Self·reporrs ;11\ olve

405

ti o nal info nnalion on bot h self- report s and pe rformancebased m easures.

Measures of Environmental Impact on Function The e nvironme nt directl y impac ts the ability 10 pe rfo rm tasks and acti vities that suppo rt physica l. socia l, and psycho logi cal we ll -being. Environmenta l factors can e ithe r cOllstrain or PIVI1IOt(> 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<.t.. and prefe renct:s can be mel within the home. T he UIMH inclu (k ~ ,1 per~oJlal. cnvlrorun.:ntal, and aC II\ Il y I.:ompo lll:nt .

1I00omg c lilIhierY ~'i Thi ~ in ~ l.rum t! 1l1 j", auminislc:red

u", lIlg a co mhlllati o n o f imen ie \\ and observation and is

406

Phys ical Re habilitation

d c ... ioncd to exam ine h o me acce~~ ibilit y. It inc lud e s e three ,, (Cps: ( I ) det e rminati o n of fun c tiona l limilJlion s (13 ile111s) and dependence on mobilit y dev ices (2 ite ms): (2) exa mination o f e nv iro nme ntal b:1rri ers ( 188 it e m s) indud inl.! indoor and ou tdo or acccss ibilit ). e n trance s . :lnd com~lUnicati o n fe~Hllre<;: a nd (,)) c alculation of an acce.;;s ibilit v score (h ig he r score s re il ec i greater access i· bility problem.... ). El1l'imnlllclllal Analysis of Mnhiliry Qll es riollnaire (EA \IQ J.~L\: T he EA MQ i" a se lf. repo rt in s trume nt Ih al e ,,, m ine:-. the impact o f the e nv ironm e nt on co m Jl1Unil~ 111o bility. It includes 24 c harac te ri s t ic s of the erl' ironment grouped into 8 dim e n:-, ions, Each charac teri ... ti c inc lude s both an e ncou nt er qu es ti on (" How ofte n do vo u?") and an avoida nce q uest ion (" How often d o ~~u :l\oidT). A fi ve- it e m o rd ina l sca le is used 10 docume nt freq ue nc), o f e nco unte r a nd avo id a nce . s. 0 f ten, a I ways ) ,""pW..) re"'pon ...eo; lnever. rare I y. somet1l11e -, . Encounter and avo idance scores are ave raged 10 generat e a ,'\lIl1/lllary (' 1/1';1'011111(1110/ score and a SUII//1wry (Il 'oid · once score . • Crmg Handicap A SSl'~.\'IlIel/l alld Reponing Techniqlle (CHAR T J. n Thi s in\lrumC!ll was d eve loped to doc ume nt an indi\ idual' s f un c tio ning wit hin hi s o r he r soc ieta l con tc:'i. It exa min es leve l o f invo lve ment w ithin s ix domain s o f functi o n: phys ica l independe nce. cogniti ve IIldepende nce. mo bilit y. occ upat ion. soc ia l integra tio n. a nd economic se lf- s ufficie ncy, Eac h area is sco red based o n 100 point s (600 poims max imum ) w it h greater level ... of parti cipa ti o n rece iv ing hi g he r score s. Th e C HA RT·S F '" is a 20· ite m short e ned vers ion of th e CHART. Omit Hospital I IIl"l'IlIory of Elll'irollm emal Facwrs (CH1£F J.~~36 Th i':-! inve ntory rat es frequ ency and impact of 15 env ironmenta l barri e rs de fined as an y impedim ents that prevent function ing \\ il hi n the ho me and communit y. In add it ion to ph ys ical and arch itectu ral barri ers. the in ~t rument Include!> ~o(:ii.ll. atti tud ina l. and policy barri o er.,: re~pon<;e itenh carr) numeric va lll e~, The C HIEF (...ee Appendi x C) gathers informatio n about the frequency 01 encounter., \\ ith eac h barrie r (dai ly = 4. wee kJ y = 3. mOl1lhl) = 2. k~~.., than month ly = I. never = 0) and the mJ~nHude o t the problem ( bi~ probl em = 2 or littl e problem = I ,. Scu re~ are (:;jJc ul ated by mult ipl y ing the freyuenc) 01 occ urrt~ nce b) the magnit ude of the prob· krn to pfo\ ide an ill/pau SCOff' . High\,;r ~co res indi l:
The abi lit y to perform each acti v ity is scored using a three- poin t scale: illdl' pl' lIdellce, parl fy de~endent, and d el'l'lIricllr . De pe nde n c~ m ean s th at, aSSistance from anoth e r pe rsoll is reLJlllred , The ratings can then be di c ho tomi zed int o independence or dependence . and a rranged in to o ne conditional o rd e red scale of ADL·

steps 0 to 9/1 O. A DL-s tep 0 mean s independent in all acti v it ies, and ADL- ste p 9/10 dependent III all activi· ti cs, Whe n co ntin e nce is include d there are 10 steps and w he n it is ex cluded the re are 9 s te ps. The responses from the A DL-S laircase have an o rde red structure w hi c h me ans th at slat is ti c a l me th od s for ordinal data s hould be used in a nal ys is a s we ll as in reliability studies (U ll a So nn. pe rso nal co mmuni ca tion. October 11 , 2005), The reliab ility and validit y o f the instrument have been eswbli s hed Y....J2 • EIII'irollmelltal FIII/uiol/al Independence Measure (EIIl'iro· FIM' M).")J Thi s in strument is derived from the w ide ly used 18·i te m Functional Inde pe ndence Measure (FIM T") that addresses aspects of ph ysical. psychologica l. and soc ia l fun c ti on·j.. ) (see Chapter II ). "The principal di s tinc ti o n between the two meas ures is that the EnviroFIMTM in strument ex pand s the FLM'TM instrument's 7· poinl rating scale to a n II-point scale . This change gives the Enviro- F1M™ in strument sen siti vity to the physical env iro nme nt 's ro le in the di sable ment process by adding fou r additional leve ls o f func tion and organizing the resulting e leven le ve Jrs l o f function sco res into four cate· gories ....)\· p2 (see Appe ndi x E). The scores range from OlD 10, A score of 10 indica tes independence, scores of 6 to 9 de no te modified independence w ith each score representing a s pecific qualify ing parameter of perfonnance (e.g.. a score of 6 indi cates personal safety is compromised: a score o f 8 ide ntifies the need for an assistive device), scores of 3 to 5 indi cate modified dependence (e .g .. super· v i:.. ion o r ph y~ical assistance is required), and 0 to 2 des· ig nate d('pelldeIlCl' (e.g .. maximal ass is tance or unable to compl ete ac ti vi ty). Enviro-FIM™ func tion scores are guided by starting at the top o f a decis ion tree and work.· ing dow n throu gh the vario us question branches (see

Appendix F). Flil/ uiol/o/ Pet/anI/alice Measure ( FPMTM)Y' This inMflIl11e nt i.;; cOl11pri '\ed of two ~ca l es: Level of Effort Scal e ( LES I'M) and Level of Ass is tance Scale (LASTN). The FPM {'\1 is used to ide ntify nee ded e nvironmentaJ adaptation s requi red to improve pert'omlallce. The design uf Ihe in ~ trulllC Ill ~e par.lle s patient e.Dc)J'( from the amounl of tOsi.HtUU'l' re quired from careg ivers. The LESTN indude ~ eigh t leve l.., 0 1 etTo n expended during aClivity pt"rtorlllllncc: none. blocked. decli ned, impossible. m
Chapter 12 Examination of the Environment

"orl-.ing through a dcci-;ion tree (sec Appendix H ). The LAS T\\ aho includes eig ht categories used for codin!! the leve-J of :t~, i !' w, n ce required during task perfomlallce ("iee Appcndi\ I ) and a decision tree to guide score dctenlli · n~lIion (,e-e Ap pendi x J ). Sco re~ are influenced by \\hether a"I~la n ce prov ided is only incident al to pe r· tonnance. tnt"rel) facilitates performance. or con'litutes dmxt perfonll::mce of the ra o;; k, • [lI\lfOllfllclllaf Lrifily M{' lIslIrc ( EUMT\l j"f.> 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'<; rating ) as "ell a" the (1cU'prahiliry of pe rforming within a "elected em lronme ntal rontexl. After perform ance of an acm 1I~. the DRST\1 i ~ admi ni stered in a two -s tep proce . . ;,,: til foil 0\\ ing com ple ti on of an acti vit y. the pallent lJllliall) characterize~ performance as: difficult. muderate. or cal." u'iing a simplified version of the "cale: t ~ \ the patient is the n asked to p o~i ti o n th e initial charactenz:J.t1on on the rele\ant su bsection of the 7-point ;"cale fAppendl\ K ). The ARSTM examines the percei l'ed ICl-e l (?f u('('Cptahiliry of the ph ysical environm ent for acti\ 1I~ perfonnance within the contex t of indi vid ual !unc\lonal limitatiollo;; or di sab iliry. Admi ni slrati oll al so u,e ~ J two-qep proces~: ( I ) following completi on of an actl\ it~, the patient ini tial!) c harac t e ri ze~ th e environment ;1"_ IllIaCfeptahle . fJ/odl'rate, or acceptahfe: (2) the pallent then r~fine ... perceptions b) charac terizi ng the enYlronmt:nt on the appropnate s ub ~ection of the 7- point ~cale fAppt"ndL\ L).

Visual Depictions and Dimensions of Physical Space Tht" Iherapl ~t ma) fel.{ue't ')uppon net\\orl-. mel11be r~ pro\Ide \],ual dCpH:lIOlh (e.g,. pholOg raplh, video tape'), dlagrilm . llo(Jr plan.,) and ph) , in ll dllllen:-,ion\ h tructural ~pe(';l ji lat IUJh ubt.Jlncd v.Hh a tape I1lca')ure ) l)! the env ironment In \dlllil tht' pat ll:"nl I' e~ pectc d 10 func ti on, I I \1",Uill, J.le una\allahle. an 1J1t:'x pen.., j\e di spu,,,hk I..''-!mera \'.ud

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P.ttlt:llI el]\ IIOlllllclll Sudl cll\Ifunmc11lai In'unlld tl oll .... ill illlo\iy thl" Iht"rapl \ t to ,llllul.tle '1"I">t:li"> 01 the paw:nt'" ~urnJulldlllg I pllor tu dl..,l..h.Jfgcn lor practlUIl!! td"k" \\ hdt· dlrn tHlg ,tttl:1ltlflll 10 11l~),tnllllng. ,,;.Jle l \ and IUIK tlOIl I hi.., .... ill "1\,, a '.1,1 thl: thcr'lJw.,tlu de ter11l1l;t! the nt"ed lor uddp tl\(;: I.:i.jUlpO h.:ll l

407

On-Site Visit On-site visib require that rehabilitation team members IOgether with the patient trave l to the ph ys ical location where the patient will be required 10 function. A major ad vanwge of the on·site visit is that it allows observation of perfonnance in the actual environment in which the activi· ti es must be accomplished. On-site visits are often useful in reducing patient . suppon network. and/or employer apprehe n ~ i o n conccming the patient 's ability to func ti on within the environment. The on-site visit al so provides an important opportunity for the therapi st to identify safe ty hazards and make recommendations regarding altering, coping with . or adapting specific environmental barriers. During the visit, patient acti vit y should be interspersed with adequate rest intervals to ensure fatigue is not a mitigating facto r. Whicheve r examination strategy or combination of strategies are applied, the scope and breadth of the infonnation gathe red will be enhanced by invol vement of members of the patient 's support network. Because it is usually not feas ible for the therapist to examine all aspects of the patient 's Iota I environment. involvement of other individuals can be instmmental in ensuring thaI the goal of maxi mum accessi bility is met. This is particularly important for determination of general community access. The therapist can direc t and guide an investigation of access to community recreational. edu cational. and commercial facilities as well as ava il abi lit y of public transportation, The therapist can ,il so provide guidance in the essential role of ex ploring funding sources for needed environmental moditications (poten· tial funding sources are addressed laler in this chapter).

Home Visit Prior to an on-sile visit

10

the patient's home, ocl.: upalionaJ

and p h y~ i ca l thempy treat ment ses~iom. ~ h o uld be sc hed-

uled that \\ ill include panic ipation from ~ upport group m e lllber~ . These v i ~i t s se rve several functions. The~ pro\ ide an opport uni ty 10 become fam iliar with tht" pO-lien!\ ca pabi lities and funclional lim itati ons. The) gi\e the !Jup· POl1 nel\\ork m e mber ~ time to learn s~lfe metho(h (e.2 .. proper bod y mec hani cs, guarding techniqLle~) for a~~ iqi~2 \\ ith
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408

Physical Re habilita tion

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Precedin2 the oll -.. ite \ j" il. infonllation sho uld be gath e red ~boul ..,:\c ral impOrlan t ~rea' Ihal will influence both Ihe pre paralion for and Ihe type:-. of sugge stio n!) made durIIlg Iht' \ ; ... il. Th;, in follllati on inc ludes: Detailed in l onll~Hion about pre..,ent level of function lC.2 .. cOlllmu ni cation :-.k ill ~. bed mob ili ty. tran!) fer~. gail. and '('I fonh): dala shou ld be gnthe red from all invo lved di:-.ciplinc~ (OC"Clipational th e rapi st. phy ~ i ca l therap ist. . . peech-Ianguage pathologbl. a nd ... 0 fo nh ) . • Kno\\ ledl!c of ph) s ic a l :I'~~is lance or ve rbal c ueing req uired for activi ty perfOnll<:U1ce. ~ Characteri';( ic~ a nd dimen:-:.ions of adapt ive dev ices (e.g. .. raised to ile t . . eat. e nvironm e ntal controb) and ass istive devices (e.~ .. c anes. c rut Che5. long-hand led reac he rs). ~ In fonnatio~ about predictcd leve l of optimum fu nc tion or imprm'cmen t (anticipatcd outco mes). • ;\alure of the func tio nal limitations or di sabilit y (i.e .. , tall( or progressive). In sur. hip of the home can impac t or preclude the type of modifications the palie nt may require. Ho\\evc r. it ~holild be noted that the Fair HOll')ing Act req uires lan d l ord~ to allow indi \' iduah w ith di~abi liti c\ 10 make rea..,onable acce~:>. l1l odifi c ation ~ 10 both per..,onalli\ ing ~ pa ce as we ll as common \ pm:e ~ u ch a.., entr) \YJy .... Inlorm<.Jllon about the re la ti ve permanenl"C of th e dwelling: if Ihe patie nt plan ... to move in Ihe near future. It "J1 1Intlul..!l1re the Iype 0 1 mod ifi ca ti o n,) recommended (e.g. II1 ... t;1I11I1& pc nnancn l ra mp ~ v~ rcrnovubl e o nes, o r pa\ lI1g a grave l dri\ewa)) . Thl'> 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 I.' Ihlllg de\ Ill'''' ~ (3) "1Il/UIII .. ,1 a/lt'rllliOIlJ. which inehMII \\ Ilkning door.... 1I1'1
.1Il

h.l e\ aluale the need for . . iX'cific

Chapler 12 Examination of the Em ironment doorway Ihre~hold : (4 ) modijicaliml o r offered /oemioll of (,1/\';mll/ll£'1110/ oh,l'CIS ~uch a:-. di ~a bli ng a ')tcwe. pl ~lci ng lock ... on door:-.. lI"C of cx tcnOiio n lcvcr:-. o n door hantl lc:-.. rcmO\ in1! Ihrow rug .... or 1ll0v IIlg fu m llu re: and (5) illS/.. lIIodificari(lll~ ... uc h a~ u"c of vis ua l. audilOry. or o ther se n\ory cUing. "or!... ;,; implificat ,on. and c nerg) con~e f\ a l ion or joint pre~ervat i on technique:-..

409

A

.

The follo\\-ing ,ect ions offer sugge~ ti o n ::. for eX~lInma­ tion and modifica tion of the hom e and workplace e nv ironmen!. The infonn~lIi on p re:-.e nted i~ ne ithe r ex haust ive nor inciu ... i\'c of the need s of eve ry pal ien!. The e nv ironmental cOll'liderJtion::. arc intended to d irect all en ti on to "om e of the more comlllon acces .... usabili ty. and .;; afcty concem ....

Exterior Accessib ility Route of Ent.., I. II there i.:.. more than o ne entry to the d well ing. the 111 0st acce""ible ~hou l d be !)elected (c losest 10 d ri veway. most leye l \\al!...ing surface. fewe st stairs , avai labl e handrai ls. Jnd so forth).

2. Id eall ~. the drheway !
~hou l d be level. we ll-li ght ed . and prov ide adequa te cmer from adve rse weathe r cond it ion s. PaLkage .;;helves near the entrance are use ful for free in g hand~ to unloc !... and/or open door:>. 4. The height. number. and cond ition of "ta irs ... ho ul d be noted. Ideall ). ~tep!-... et:lIOlht l Jlill1lt' ter hj I.llcu l oH handra il ':> should he Ottwt:en a IIlLllll11Um 01 1 25 III

3. The en trance

:q

Figure 12.3 (A) Wood beve ls pl aced unde r nosings minimi ze the danger of "toe-catching" during transition to the ne'(t step. (8) Abra:-. ive strips improve traction and depth pe rception.

(32 mm ) and a m ax imum o f 2 in . (5 1 mm ). If m ounted adjace nt 10 a wa ll . cl earance bet ween the hand rai l and wall sho uld be a minimum of 1.50 in . (38 Illm ).~ 6. In s ta ll ati on of a ramp re qu ires ad equ ate s p ac~. Large ramp!:> arc typi call y co ns tru cted of wood o r conc re te: sm a ll er ra mps ca n be m ad e fro m a lum in um o r fi be rg lass. T he mi n imum ramp grade ( incli ne or s lo pe) fo r a w heelc hai r ramp IS Ih at fo r every inc h of th re ... hold height there i ~ a co rrc:-.po nd in g 12 in. (305 111m ) of ra m p le ngt h (a ru nnlllg ... lope of I: I :2). ~ O ut door ram p :> e\ poscd 10 inc leme nt \vcil lhcr !:> lI c h as ~no\\' or ice fo rm JlJon re4u lrc a Illore gradua l fu n ning slop!;: of appro\imalely I : ~O . Ramp:-. !) hou lJ be a m inlllluill of J6 in . (41 i mm) \\ l
or

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410

Physical Rehabilitation

OJ I

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, <;ioll. )

7. \ erflCoJ "Iatform "ff.\ and slairl1'ay inclined lifTS are comm erciall y availab le and may be a cons ide ratio n \\ hen in adequate space i ~ ma ilab le for a ramp . Vertical plalfonll lift .., trave l a pproximate ly 8 feel (243.84 C I11 ) straig ht up and down. Both ope n and e nclosed mode ls are available. Platfonll lift :o:. are oflc n in stalled adjacenl to ... tairs w ith an upper land in g. The liff (a pproxi lllal ely 30 X ~O in. [76 X 102 em]) brings the wheelc hair use r from the ground leve l 10 the la nding leve l to access th e entran ce to the home (t hese lifts can be used indoo rs as well,. Stairway inc lined lifts are in stall ed directly ont o e\ i ~ ting ~tairway ~ and are typica ll y used ind oors. The . , t3i[\\3Y liff ~ are mounted 0 11 runners that trave r..,e th e le ngth of the "' lair5 and sli ght ly beyond. Many mode ls a llow the platform to fold up aga in st a n adjace nt wa ll 10 allo", free ... tai r acces<; for othe r members of the hom e. Re~idential e l e\ator~ are a nother more COSil y opti o n: rhey req ui re cOlhlru cli on of an e nclosed sha ft.

, hoold be directed toward ensoring that the locking mec hani sm o n the door IS suffi Cie nt ly Iliu m mated. 3. The door handle sho uld be turned eas il y by the patient. Rubber doorknob covers (that stre tc h ove r a round doorknob wi ll provide a textured gr ip) o r lever-type handle~ (Fi g. 12.5 ) arc often eas ie r to lise fo r pat ients w ith lim ited grip ~ treng t h (screw fastened, sli P-on leve rs arc also availabl e that convert a rou nd doorknOb to lever- type handle). 4. The door sho uld open and close in a d irection that is func tional fo r th e pati e nt. A lo ng canva s " door strap" may be attached to th e o ut side of Ihe door (or around door hand le) to he lp an indi vidua l using a w hee lchair c lose th e door w he n leav in g. 5. Remo te control automatic door o pe ne rs are ava il able that attach to exi sting doors that can open, close. and loc k the door: some are eq u ipped wit h Customi zed "Slay-open" fe a tures to accommodate the lime req uired to e nte r or ex it. These dev ices can be activated by a ha nd -held remote contro l or a touc h pad. 6. Install ation o f an ime rcom syste m all ows the patient (0 see and/or hear who is at the door. Some allow remOle control opening of a door from any location in the home. 7. If the re is a raised thresho ld in the doorway, it should be re moved. If re mova l is nol poss ible, the threshold should be lowered to no greater than 1/2 in. (13 mm) in h~ i ghl. with beve led edges. 4 If needed , weathe r-slri pplllg Ihe door will help preve nt draft s. 8. The doorway width shou ld be meas ured. Generally, 32 to 34 In. (8 15 to 865 mm ) is an acceptable doorway width to accommodate most w heelc hairs. 9. If the doo r is we ig hled ( 0 aid in closi ng. the pressure shoul d not exceed 8 pounds to be fun c tional for the patient.

Entrance I. For indi \'id ua b u ~ ing a whee lchair, the e ntrance ..,hould hme a platform large enough to allow th e pa ll e~lI to r~\1 and to prepa re tor e ntr). Thi ... p la tform area .1.., panlcularl) important whe n a ramp i:-. in lI ~e . It prO\ Ide~ tor :-.afe 1ram.it rro rn the inclined 'i urface to the leve l ~ u rj;.lce. If an individ ual u:-.ing a whee lch~l ir b required 10 ope n a door th at sw ing ') ou t. thi ... area , hould be at Iea't 5 )( 5 fee t (153 X 153 elll). If [h e door \W lIli!: aw<.I) from the pat ie nt. a "' pace 1.1 1 le;,t:>.t J leel (9 1.) e m } deep and 5 fee t ( 153 till) \\ ide i ... rC4u1rcd.

~ The door locb ... hould be acce . . ~ ihl e to the pati e n!. fh e hClgll( 0 1 the locb ..,hou ld be de te rmined ,h \\c ll the, amOun t 0 1 !ori,;c reqUired 10 turn Iht:' I..e) AltcrnalJ\ clod ') . . tem.., te ,g .. \ o ice- or card -actl\ ated: remote cu ntrul Iud, .... h..:ypad e/etlrunic ...ec lifIl ) "')\ tem ...... nd pu \ h-bullon padlexbJ ma) I~ an I 1ll1)Q I'ta;l I COlhllie rdtloll lur ~OJ1lt' l)ali l:l1l':. . I"ar t·· I.. l U I ..II alh!1l 110n
FIgure 12.5 Lt'\f,:r-\t I d dc-\ Ign t" lenPIH) _) e _nor h,IOJII:' l" frI!411~nllIl1i\'e~al lied gnp \ 11~ng ll~ ~t~l';~I ICUI~lrl ) u ~dullllr Ullin Iduab \\ilh limft'.\;!., 1I \ lc(\ 11 111 t 'I t') l.iIl be- JUI\JIl"J \\I Lh o ther body parts , ~ . lifl'ann. etho\\).

Chapter 12 Examination of the Environ ment 10. A kick plate (meta l guard ) may be added 10 doors frequentl y enlered by indi vidual s u ~in g a wheelchair o r ambulalOry <.i!'>s isti ve de vices. The kick plat e sho uld mea\ure 12 in. (305 mm ) in he igh t from the boltom of the door.

General Considerations: Interior Accessibility Furniture Arrangement and Features I. Sufficie nt room sho uld be made available for maneu vering a wheelchai r or ambul atin g with an ass i:-.tive dev ice. An initial step is 10 move a~ much furniture as poss ibl e again\tlhe \\a lls to increase clearance and stability ( i.e .. pre\ent sli ding of furn iture during movement tran siliom ). Funher stabili ty can be achieved by plac in g rubber .;;uction cup:.. under the legs of sofas and chairs. Acce \ -, 10 furniture should no t be obst ru cted by item s such as coffee table~. foot stool s. or te lephone o r electrical wires. 2. Clear pa s~ age mu st be allowed from one room to the ne\!. 3. T) picall y. overstuffed sofas and chairs do not prov ide lhe needed ~ uppon for movement transitions (e.g .. sil -IOstand ). Althoug h ge ncmll y no t the casco livi ng room chain. should have double ann rests. a finn ~e alin g surface. and an upright bac k. Sometime!'> 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).

I

I I

I I I

•

A

Figure 12.6 Ek c:tru. "t .,W ilc: hc\

B {A }

Ihx ~er ~ \\ 11th (UV'II I.lhk \'. uh l i~ ltlcd ~urt
"\'\'I! l'h \.\Jth Il glll ~C I I!>() ' Ih:lllurn " on o r off upon cntcn ng Of kd\ing thl.! f\'l(l ill (e ) G round la ul! l lrluLl lIllerrUph:: r {(' F-CI } lor u ...c III v, t'! IOCatlolh to pr~\ l.! nt d ellrLl'.ti \ ht.x: ~

c

.. 12

Ph, sical Re habilitation

3. For ~ome p;ltielll~, vi:.ioll may be enhanced hy use of hi(1her \\:l H~\j!e bulbs. tlu ore-:cent lig ht ing, fu ll -specm!!ll bl~b:.. or higll-illlensity halogen lamps. Use of long- life lil1:ht bulb:. reduces the frequency of required hul b changes. -L h;ex pen:-ive. programmablc electri cal timcrs can be used to regularl y tLlrn lights on and off throughout the day and night. ). Innpen,i vc ni ght- lights with Illolio n se nsors can be ptKed in :.t ratcgic loca tion . . 10 provide addi lional ill umination . 6. Touch pad dim mer s\\ i((.-he:-. can be lIsed to activate lamp' \\ IIh :--l1lall co ntrol "-nobs. The dimmer module i ~ plugged in to a wall outlet and the Jamp allac hed 10 tile modul e. The lamp can be IUrn "on" or "off' or level of brightne:. ... changed b) tou ching the pad . Voice acti vated dimmer, Me abo av'li labll". 7. lnexpen-.ive remote con trol unit s can be used in any room of the hOllle to control lights or small appliances. The ~i 11lpl c:-. 1 des i g n ~ of th e~e remote control units se nd ,ir:nab throur:h existin !.! \\ ire~ (rece ive r mod ules are plugged illlo e\istin g outlcts and app lia nces are plugged illlo the receiHT and cOlll rolled by a hand-he ld remote): other:- are \\ ireles:-. and utili ze radio signab. Receive r module ... can al"o be wired direc tly into the e lectrical ... y . . tem of the d\\e lling. Remote control units are avai lable" ilh large-print buttons and numbe rs.

-

-

-

Floors I. Floor~ ... hould be nonslip and level. All noor cove rin gs ~ hould be glued or tacked to the Iloor. Thi ~ will prevent bunlhmg. or rippling under wheelc hai r u~e . \Vhen carpctll1g 1'1 u~ed, a den~e, low pile. low- level loo p ge nerally prm ide, for ea~ i e' t movement of a whee lchair or ambulator) J~ ... i ~ ti\,t" de\ iL't' . lndu<.; lrial-,tyle or "i n-door out-door"' carpeting I) plc;'llIy meet th c'Ie requirement.... ~ Floor . . ~ hould be exam ined lor une\f'n or unlevel area .... Thl'- ma) hI.! particu larl) prob l ~ lllatic with older \\ooden !loor':!. Optirn3l1y, thc . . c ,\rea'" should be repaired or rt"pbced. II fcslOratiol1 I ... not pos~ihlt: .... everal ot her \OIU IlOlh Inlghl be recol11mended: ( I ) eSl,lbli . . h a path 01 1ll00eJ11cnt for the pallen t that e lllnlll~lh: ... u'le of the pn)bklllatil area: (2) pLIt't: a pie(.c of furn it ure over the ol1endlllg <.Ilea; or (3) pl,lCe hri ghtl ) <..'olo red tape a lon!.!. the bonkr, 01 the area 10 <..'oil linuall) rl.!Jlllnd Iht' palier;t lu .t\old till ... ;J,J'~a oj Ihe pot('nlHl I dungn. SC<.lller lUg' , huuld hI..' rt: ll1o\t:d: largel ~1J't:a ru!!, ca n hI.:' "'t.'lurl.'d \\ IIh a goud 4U~IJI ) l-'i.l rpel tdPt:. t he 01 non ... hld v.;n. e ... ... houlll ~ ellu..lul.tgt:d .t If Ilooflllg I ~ to lk' n:pl.tled . Jll~Hll.' 11111 ... ht" ... 'I hou ld be rt.'lollllllt:olicd to rl.'Ju\,;l.' !! I.m: Pallt:nh \\ L1h \ , ... u.ll llllPJ.lnllCllb \-\ iii ht:lldli II OIiI.llontri.hllng loloJ'co hOI Jt"r dlung the pt:fIIllctl.'l 01 Ihe room 10 help lIl..trh til l' hound.tne:-- of Ihe ~ PJn~ \\ IUl.-co lored Idpl.:' L~1I1 abo hI..' u:'>t:o d 1t:1I 1\ 1:1).

Figure 12.7 Com mon mat erials used for th reshold ramps are wood (s how n) and :ilUlllillllnl with a lacq uered non·slip surface. They (all be lI <;cd be tween room s if the fl oo r surface height c h a n ge~ slightl y. (Courtesy of Gu ldman n. Inc. Tampa. FL 33634.)

Doors I. Rai sed Ihres holds should be re moved

provide a flush. leve l surface. [f structural elements prevent removal, threshold ramps {"transition wedges"} can be easily insta ll ed (Fig. 12.7). 2. Doorways may need to be widened (if less than 32 in. [815 mml wide) to allow clearance for a wheelc hair or a~si ~li ve dev ice. Door::-. may have: to be removed. reversed (e.g .. (0 ope n ou!\\O.ud fo r easie r ex it. especially in the c.:l.~e o f an emerge ncy). or replaced ..vith fold ing doors, or .:I. door 01 lighter \\ eig ht. Severa l otht:r op(ions are availab le to increa~e door c lea rance. The ...e options include: (0

• In ~ (al1i.1t i on of POC]...,e:1 door,. which slide into the adjacen t wall w hen nOI in use: som e ~Iiding doors allolA in~ta llati l)n on tht" out side of the door frame and wall to minimize :--Iructural chan gt's . • R~nllwal 01 the \\otxl ... tri p ... on the Inside of a door fml1lt: \\1 11 add appro\111lJle l) 3H lO I in. {l9to :!5Anun) of ch:::a r i.lIl cl-~. • l !...t' 01 0/1.\('( hingl.! . . (abo ca ll ed .\,\I'llig-dear hinges), \\ ilr( h ,\\ ing tht.· open door dear of the frame provide JPpr\)\IIH~IICI) 2. ;\ddllionaim. lSI 111In) of ~pace. • Refill), ,II l,lf thl' dum "lIh 1Il~lall.lI10n of a curtain t 1Ot'\pt'lhl\ e 'PIIIH!-\t,),lth:d curt ,tln rcx)... and a fabril.: or pl.I ... 11C ... h l)\\ l'f I..Ur;iUIl Lan lx' U'It'd).

-

t '\ '" JIlL'llIH)Iled In Ihl' hlllll t' U)\Cl"

u\

h.:gard flll'\tt' l'I l. . r d(l4.) r ... . handles inside ... hould al ... o h\.' L·\~tmllwd. Rubber doorknob

!t-\CHYpC

h;Ull lk . . mu) lx' 1J1lpormnt consid-

~Ilurkd trouglll.'lled) '1urfal'e door handle,:, ,11(' lI'I-'tI (Ill lJ1knm ... III hu ilJlI1gs .tnd l.Iwel hngs when

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tll'qUI.:'Ilh.:d h\ pl.:·l ... tln\

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IIh \ I,ual Illlp.linnt:nts. The)t

C ha pt er 12 E xaminati on o f the E n vil"onme nt J brJ~ivc. knu rl ed , u rface ... prov id e lacti le clu e~ th at the

doo r lead :-. 10 a hazardou ~ area a nd ale rt " the ind iv idua l to dange r. (Nute : Bri g htl y co lored ro ug hened area l; are a l<;o u ... ed o n n oor ing to indi cat e po ten tial da nger: fo r (' ,ampl e . Ih e ed ge o f a train o r :-. ubuay p lat form .)

Win dows I. To rt' du cc g lare. \\'indo \\, fi lm :-. can be in s ta ll ed: fro>; ted film ... are effec ti, e at d iflu , ing lig ht " ith o ul a pprec ia bl y red tl(,:i ng ambie nt ligh!. ~. H (,;ing a \\ hee lc hair or fo r pat ie nt s w ilh lim lied uppe r "' Iremi l) func tion . Ca seme nt windows o pe n u'lng a cran J... -~ tyl e hand le and can be loc ked w ith a s in gle le\-er loc ki ng l11 ec han i~ J11 loca ted ne ar the botto m o f the \~ mdo\\', AU I0111atic o pe ners c an be im lalJ ed o n the ..e \\ indo\\. ...

413

e nd o f the sta irwe ll is ne ar. They can a lso be used o n e ac h ~l ep to ide ntify it s ed ge . C ircu la r bands o f tape al so ca n be p la ced at th e top a nd bott o m o f the handrail for the ~a me pu rpo se. Tac ti le warning strip~ p laced o n the fl oor c an a lso be u')ed 10 s ig nal a c han ge in level o f the wa lkin g s urface or e ntran ce to anot he r area o r room o f the dwe ll ing , 4, Ma ny pati e nt s w ith v is ual impairme nt w ill be ne fit al so from bri g ht. co ntras ting co lo r tape o n the borde r o f e ac h stair. Wa rm co lo r . . (red s, o ran ge s. and ye ll ows) are gen e rall y e as ie r 10 sec than coo l co lo rs ( blu es . g reen s, a nd v iolets) . 5. Fo r patien l.'l unabl e to negotiate s tair~ w ho require access to the second fl oor of a dwe ll ing_ a mo tori zed s tairl ift may be an opt ion ( Fi g . 12.8). These batte ry·powered un its are ava ilable w ith a vari ety o f options s uch as s w ing-away a m1 ~ for w hee lcha ir transfers. adj ustabl e seat w idth (22.5

to 25.5 in. 1572

mOl

to 648 mm ]), and wireless ca ll/send

cOlllra ls, Outdoor model s are a lso availab le as we ll as un its to accommodate curves or tum s in the stairwe ll. Altho ugh a more costl y altc mati ve , res idential elevators are also commerc ially avai lab le. If poss ib le. these e levato rs are Iy picall y insta lled in stacked cl o se t s pace to minimi ze construction to the dwe lling.

Stairs

Heating Units

.-\11 mdoor ~l;( (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 <.lutullldl1C.:all y IUrn o n \\ hen the pati e nt approaches the ... ta lr ... (01 othe r a re a of th e home , can al . . o be an Important .. akt) l'on . . lde ration. 2 Stair ... ,houlJ be fret" 01 c luller. R
t. A ll radiato rs . he ating ve nts . and hot \\.ate r

pipe ~ s hou ld be appropriatel y sc reened o ff o r in s ulated w ith pipe cove rs 10 preve nt bum:,. especi ally fo r patie nts w ho have se nso ry impainn e nt s, Ada pt a ti o n s may be required 10

Figure 12.8 Bo..IlIl'''- po\\ l:red ..,t.lld lrt \ l'llunt'I,\ lIt Bru1I0 1I 1lkpl:lu!l.:nl 1 1\1Il!! \I l h. !til. O l \lnU1Il11\,\ .x·, \\ 1 51006.1

414

Physical Rchabililulion

allow p:ll i.:nl acce ss 10 heal controls (c. g .. re mote con ' · I c h c r~. or en larged . • • 0 1- rc. tml 1hernlll . . tal I.:OTllro I. usc cx te mkd . or adapt cd h:md lcs on heat con lrol : al vCS). :! . The hC:llin g source ~ hou l d be cle ar of combu sllhl ~ material and c lul!('f. Usc of ~pace hC
I-r

.--

aged .

3. S Ill O~l' a larm ... and c arbon Illono:\ide dC lcclOr~ s ho u ld be in Ih(' homc and chec ked regularl y by pre!\.s ing Ihe tc~ t OUll on. Some n(' wc.r model s allow te stin g the unitll 'i ing

a

7'

r

.- Ir

E

"E "S "!"

N N

na ~ hli g hl.

eg C;;;;;;;;

Shelves

C.

~

0

Specific Con sid erations: Interior Accessibility Bedroom Area I . T he bed ... llOUld be ~lationary and pos ition ed 10 provide

amp k "' ral'l~ lor Inlll ~ fcrs . Slabil it y Illay be improved by p lac mg th(' bed :Igain ... t :1 wall or in the corner of the mom Il'\(,.' ept when the palient p l an ~ 10 make the bed). Add iti ona l ... tabilil ), may be achieved by plac in g rllbocr "'lI~tio n (" ups under (,~I c h leg. :!. Tht' heig ht of Ihe ~ lc c pin g ::-urface mu ~ 1 be con s ide red to lal'l llt:ll c tra n ... fcr ac ti v iti e~, The he ight of the bed can be r,u"'cd h) u...e 0 1 \,", ooden blocks wi th rout ed d e pres~ i o n ~ 10 ho ld each leg ( bl<x: k ~ Illa y be used to r;Ji ~e the hei g ht oj I.· hair"l. ;1"1 \\c: II ). The use of an e x tr~Hhick mattress or ho\ ~p ri n g L'a n abo provide addit iona l heigh t to the bcd , The bed he ight cun be lowered by u ~ in g cOlllm c rci ..dl y a\ ai lahl e reduced -he ig ht box s prings. 3, T hl' m aitre,,),) ~ h o uld be c arefu ll y ~ xal1lin e d . It should pnn Ide a fi rm . com fortabl e !'! urfacc, I f the l1lattrc s~ i... in rdali\C.: I) good L'olldition. a finn bed bo ard in!'!crted octv. ecn Ihl' matt rc~~ and box ~ prin g Illay ~ ulTi cc to Im prove the ... Jeeping s urface adequJlel y. I f the mallre s~ I ... b.. td ly wom. a nc\\ o ne ~ h o u l d be suggcMl'(J. .t , A l'led"' lde t~l h l t' ur cabinet ... hould be availab le; it l'an he U"Il'd w hold a lamp. tel e pho ne (pre fe rabl y c ordle~"1 with <.l memor) (hal lo r lrequ entl y u..;,ed number') o r c l1lc rg.":Ill ) phone: lllunlx:r ... I, n('Cc~"'~lf) m t:di c'llio ns. and ca ll

h.:11 II

:1 ')" ... Wncc

i ... needed from a ca reg ive r.

S, The l."Io ...Ct dothc~ bar may rt!quirc lowe ring to provide \dlL'ek h :,lII' atTc"!-o lblill y. The bar ~ h ould be lo w(Tcd 10 52 111 . (I .~:! 1."111) Iw m the: 1100r, Wall hook. ... abo lila ) be a u ... dul mldll u)Il to Ihe d o ... \.·t an::" ,lIld ~ h()uld be p la('cd Ixt\\ cell -'0 in. ( I(J I ,6 n n ) and 56 in , ( 142,2 (, Ill ) from the !lour ~he l vl! '" al ... o call ht: jn ~ l a ll ed al \ari oll ~ I ('\, d ~ ill the L III~C ' {1' lg , I :! .iJ), 'I hl' Ill ghe~t ... ht.: lf ~holiid tlOl l'X l:l·t·t! 4 "i III ~ liS ." lI li J. C lo th ill g and gm o nllng oII"tl l' k ~ Irt' ~ 4UCIlII ) u ... ed h) llll' pil llt:1l! ::- hu uld be p lal:cd III th..: Illlh t l:a ... tI ) ..u.. n·, .... hle bun:.l u dnt\\{' r. ITc.e-.... tamling mod ul ar

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Ull ih
,,' d lll ll.. lh

... 1...:1\\.·... , ,llIti df.. \\t· r~ Ihat ('all lx' ,1I..tJu ... tcd 10 me(· t thl' IICt·\" I,f IhL' u ...c r h gUl l.' 12. 10 Illu ... tl"tC'" tilt' h..... I(..· l'OIll pont' n",
c.

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" Figure 12.9 C lo.;;ct rnodific al ~ on .;; to provide ac~es~ib ility for an indi vidual tI ~ i n g a whee lchair. Valucs denoled In Inches and l'c nlimeICr!'i . ( From Cotl er. SR . and DeGraff. AH: Architectural A ccc~s i bil it y for the Di ~ab l ed o f College Campuse~. New York Stale UnivcOl ily Con"'lrucli on Fund. Albany. 1976. p 57, with pemli .;;~ ion .)

Bathroom I. I f the doorframe prohibi ts passage of a wheelchair. !he p~Hient may tran sfer at the door to a c hair with casters attac hed, As me nti oned above, seve ral o ther so lutions are available 10 addre% the problt::111 of narrow door frames (see Int e ri o r Access ibility : Ge ne ral Considerations. Doo",).

2. An el evated toilet seat can be used to fac ilitate transfers. Some mode ls allow the height to be c ustOm adjusted while olhers provide a fi\ed height l'it' vation . They art al so a\3i lable with grab b"r~ . Po"er-lift toilet sealS w ith g rab b
J . Grao har ... ~t'clirl' l y fa s tened 10 a rC lIlforeed wall will

,,,,,\1in both wik' l and lub lran~reN . Grub bars shoUld Il.Iw ..1 ci rt'ltl ,lr em ...... \l'clinn diaml.!ler of I.:!S in. (32 nun) l5 1 111111 ) InU\.lIlHU11 and be k.nurtcd.

1Illllllllllll1 :. lIlJ 2 lU .

IOtlet tr
u... e

In

h l,)rl/ \)I1IIIII) 'U III

24 .ultl ~6 10 , th l O .lIh191 5 ml1l~ on the b~u,'~ wall {fil· 12 II ) . Id~,tll y. t\\U g rab h:.u·... urI.' ... el'ured hon;woWt)'1O tht: hi.ld. \\ .111 lor U'l' Ul tuh tfalhil!r" One is pl8C\1d 13 to ~n III (X40 lu91 5 mm ) Imlll the tloor of (he tub_

Chapter 12 Examination of the Environment

Nightstand

Bureau

415

Computer workstation

E

Bed

0

.~ c

E

" 0
.

Closet

.... --- - --- - ------------60 in minimum

19 Door opening

Ideal height of bed will vary, depending on individual patient's need

Nightstand to hold lamp, telephone, call bell , medications, etc.

Large U-shaped handles on drawers

... ... "'" ...

,.,., "'"

....

Bed

Computer workstation

Bureau Nonskid rubber suction cups

Low wall provides easier side access

Figure 12.10 S.1mple dm1C.·nsion.., and fl,'::.Ilurt·" of an at.:l'(:s ~ible bedroom ,

the "I:lond l) I II ( ~30 mill ) abme the r im of Ih e b~i1htub. Grdb ba r~ IllJ ) ilho bt- moun ted hOI'l l.OI1I:.:1I1 ) al [he fool end ""J. II (If Iht" haThtu b (reL'ommended lcnglh i,; ~ 4 in . loin mm! v. lIh plal'cmeTlI al Ihe frulll t-dge nf the balh and .1t tht" head-I.: ud w~lll o f th e bathtub ( recoml1lelllJI.'J It:nglh ]\ 12 in ! 105 111m ) Vv ilh pl ,li.:e lHe nl al thl.! trunt edge lIt Iht' bJlh l ub, (F] g , I ~. I : ). Kllurkd "urfan:" to impf(}\'t' ~ r3"' p .tnd

lun,

pH:\crll .. lippin g.

~

A tub tr.lt h k] bent:h t t ub "'ea t ) Ill .! y he rc~onllnclld('d tOi htllh m!!. t\1.111) I } Pt'", 01 co m lllt' rll.tll ) ProdUlt'd ht' nc he~
3dju ~t1l1 e nt ). a bad. rl·... !. and illl apprupnate seating surfaCt' 10 b n ti t "Tl' [ramfa" in and (lui of the fUt'! (Fig.

12.13A Jnd B). Tuh tran .-. fer ocni.:ht-" \\Ith reIJme!) 10llg .'> c.lting ... urfal o afe ty pit'all ) po.-.itioned \\ ith [.... 0 k g:-. in the tuh alld t \ \ { \ kg " ~In the 1100r aOj1.:1' "t.d ! el re.I ... . ;.1 ~o ll ;tp ... ibk ...('<11 ma} be penHanl· ntl .\' lIlI adll'\! ItI the \\ att ( h~, I ~ 14 ), When Il{ll in u ..e il Jok!... tl ill <.I f ,IIIl " ! thl' \\ alt . :IU O\\ Lng I.;: 'h} sho\\er aL'l'(,,,,, Irlllll ;\ "Ldtldmg pO\ll!o n ,h \\dl. 6 NO lh l-l ll aJht',,\ c " II tp . , 1lI.1} 0.: plaL'ed l In Ihe nlh)r 0 1 tlw tub ()r ... lh1\\t' f .11 1..':1

7 ·\ ddi l ltl ll.li h.tthlO4.l111 cOH ... . d,,:nillum 111.1) tndude a hand, pr;!) .1l1.lt hLllI.: IlI to th,,' bath tuh or ... ho\\L'r r~ucet

41 6

J>hysica l Re habilita tion 36 min·

54 min 1370

12 max 305

915

,,",

- r-

~

24 min 610

42 min

1£

1065

C C::: :: :: :C: I[ :::::::::j:1=

.g;

,

;j)

21

,-transfer side

\

{

L-f'-t-1-W

·36 inches (915 mm) I

min imum when wall space permits

I

Figure 12.11 Locat ion and dimen:>. 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.)

JJ

( ~t'e

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 f
CLINICAL NOTE: To PI"l'I '('lIt iI/jury ill fhe presence of sensory iml'uirlll(Jll fJ, patiCl1f, family, {Ind caregiver education should iI/elI/de usillg a Ihermomerer to {('Sf water temperaII/re prior to hmhill):.

8. Idea ll y. ~ i nk s ~hould prov ide clear knee space below and any ex posed hot wate r pipes should be insulated to prevent burns (Fig. 12,15) . In new construction. shallow sinks may be in stall ed to innease knee clearance with fau ce ts placed on the s ide fo r eas ie r access. Storage !-opace lost from be nemh the sink can be partially compen ~aled fo r by an unde r-the-s ink roil -ou l cabinet that can be ca~ il y moved fo r wheelchair access. An enlarged Illmor o ver [h e sink w ith the top tilted away from the wa ll fac ilitate~ lI ~e from a <.; ining position (Fig. 12.16). Fo rward lilt ing mirror., are a lso avai lable with adju')table h i ngl"~ fo r alte mming phlcernent against and awn)' from the wall. Hinged-wall. goose nec k, or accordio n ,fol ~l- up mirror:.. (\\ ith one s id; mugnified) are also ht.;' lpful tor cl o,",e work , Fi g ure I:!. 17 tlJu ' tralt.'s Iht: minimum space requirtmel1l~ o f a \\ hee kh(J ir-..H.'CI!~' ihle bathroom.

Kitche n Fi g ure 12.12 B. lIhlU h V. 1111g),1 1l bar~ ~Cl u n.:d end , ;JnJ hc••d-I;'nd \\ .. 11,. ·1hI;' h'\lhhpra.} laU(:cl

\(1

(luune\) ul I he: SV. ..ul CorpOI:Jllon, SI.

M O (l} lUl ,

bad " tool -

J ilac hlllc lll la,,; ll lid II,; .. lUllIflll .OI " ~ I~ f 11uv. J l r~c I I O O 11 0m ,I \ IHII I~ p()~ H lO n U )Uh.

I , The hl" lghl 01 L"Ollnt cnop <.; (work Spi.l('e) should be apprnpnat e lo r the IIld ividuaL When using a wheeli..' h;JII", the .:m nre!\l,", ') ho uld be ab le to til under the wOltIn g ~ 11I1 .\(,:e . The idco.tl he ig ht of counter surfaces s.boWd

C ha pler 12 1- \:a m ina lion of Ihl" Ern'ironment

417

Figure 12.13 T\"o wb tran\(cr be nch dco.; igns eac h p ro\' idill ~ a wide base of '> uppor! , a :.ccure ..tnd..t long ,eating .. urf~ ce to fac ilitat e tran ~ (c r \. (Coun esy of Lumex, Inc .. Bay Shore,

b:K ~ rt!~t.

\)' 11""00.1

: IQure 12.14

~hov.t"r ,t~dl \~ Ilh ~·()II.tp' lhlc: ~ h\mt' r 't'
..tr~. <.Lilli h<.l L)t.l ~ p ,.t )
be no g reater than 3 1 in . (794 mm ) from the floor with a knee d .:aran ce o f 27.5 to 30 in. (705 10 769 mm ). Co unt er ~ p
4t 8

Physical Rehabilitation

Figure 12.15 Acces~ibl e baulroom with knee clear:lIlce tx:l~w sink ,and in~u l ated pip;~g . The ,hower entrance includes a ~ mall ramp to accommodat e :1 difference In floor surface he lghls. NOle th:1llhe ,hower handspray i ... held by :J venic::al : :. Iide-har (10 l'hange height ) all o'A.' ing: for a sealed . . hO\~ er. Ahematel y. the h:md"'pr:JYc.m be- hand -he ld 10 dircc:: t water flo\\ to "'pel' ltk are a~ . (Coune<;~ of The Swan Corporation, SI. LOlli .... MO 6310 1.)

153 m Ol ) deep 'Aill Improve knee cJ ea r:lI1 ce be Io\\'. Pro\ Idlng s inl.. acl'c''''~ 10 an indi\ idual u:: . ing a 'A he-e ll' halr rnJ.) re4u lre remma l of unde r-the-':lo inl.. ca bi neh. A, In th e hat hroo m , hot water pipes under th t" I.. IH: hen ~ Inl.. ..,hou ld be IIh ul ated 10 pre\ e nt burn". M otori zed ..tdJu : :. lab le : :. 1111...., ( Fig . 12. 11.} ) art" de"' lgned I l ) be mo ullied dgJ. llh l a \\a ll bet\\ een t\\ O ..,tall o nJ.r) l ,lblllel'! \\ ilh tree :::. pa~ e be ne:l1h . B ~ I.tl' tl\ iltin g th e U HlIrul ... v. ltlh , Ih e ... i nk he ig ht ca n be adj u ... ted tor 11lL' Indl \ ldu,.d U"'c'1 \\ ht: ther ~e al e d in a "hct' lchair o r :o.L.lIld III g , A .., rn ..dl LJ.n "' Ith I.." a . . lel.. . ma) be ht'lplul to IInprmt' C'~I "'I.· of IllU\ t lllc lll 01 art i rle ~ from n: fri gt'r.t(or to l Ull nter J nJ tither ~ u L h .11.1 1\" J1 It' :-.. ~ 1 ht· hei ght \ ) 1 t.th l e~ ,11...0 ~ h ould lx- l' h(,l: ked ,lilt! Iht: I db h: ~ 111 01) h ,.I\(' 10 be rJl:::.eJ or IO'At'rt'd . ) L4 U1PIll t' 1l1 and lood . . wrage Jft',b "tmul d he . . d ell t:'d "-llh llPl1111UJlJ I: l h.:' l ~n L"on ...ef\J.lllIn in I1lllld All Ire · 4Ut"nll ~ u, l.·d J.rtl l lL' ~ ... hllul d ~ \\ II hl l1 t·a . . ) re ClLh . •llId ufIllL·Le ... . , .... J ) Hem., . . tlUu ld ~ dln ll l1J.tL'J A dd llJ O lh l \ ., tufJ,gt.' "'p,ll \: nlJ.) Ot' JL hlC\ed b) 1Il':l l i.l ll ,.i l nm u t OJk' ll . . lId ' lng o r u...e u l pegboarJ \ Illr POh ,md p.UI ., . It hc h In!,! I ... dtiJed ..tdJu':lolahle !-ohe h r ... J f e prc- k rabk ,lIld

,hould be placed 16 in. (-110 m m ) above 'he counlerlOp ..~'" Electronicall y powered storage cabinets are also a\ ailable thai automatically JO\\er fo r counter-top acee':::. (Fig, 12 , ~m . 6. EJel' lri c <,,{ o\ es are generjll y prc:ferable to open-flame ga\ burners. Fo r optimum ..,afety. controls should be located on the fro nt or ~ide borde r of the stove to d llninatt' the need fo r rC'3chlllg across the burnersBurnc' r... th at arC' phH:ed lx- ~ Ide each o ther provide: a "':.Ifer ~lrr~lIl ge mC' nt than thost' plul'ed o ne ~hind (he Olher. A ht'J t- rC'!l I", w.nt burn -proof counter surface
7 hH P,I1 h..'llh "' lIh \ ,,,,u31 Irnp.unlicllh, large- print label· m<J~lIl g dc, h. ~ ... J nd I.. rg~ - pnnl ..,lenL',1 overla)s c.. 1Ie l'nLtrgc J,pphanl'C l'onLIl)1 IndkalOrs and

w'!oni

h)

h:·.g

olliOll

( If

tl' lllpe l dturt" IIlLiiC3101b on

cbab

lhenJaOilllS-

Cha l)( Cr 12 Exa mination of the En\'ironmc n l

4 19

hearing impainnent :-.. the smoke dctc(' tor can be attached to a ~ i gnalin g sy,tclll that acti vat es bOlh an tludibl e and :-.trohe li ght re:-.pon:-.e to visu:lll y warn o r dan ge r. These ioI ignaling :-,y:-,telTI li <11 \0 can be u:-.e<.l to Jcti vate Ilashing li ght\ in re""pon,e 10 a doorlxlL knock on the door. telephone rin g.. or burg lar alann. Fi gure 12.22 preiolc nt s "i.IIllpl e feature.;; o r a kit c he n cle s ign ~ d for an indi vidu;\l lI " in g a wheclc hair.

I

_I Fold·up seal

1'6 " (455)-2'3" (685)

;;;

~

~

"~ ~

Figure 12.16 O\er-~!n ~ m irror \\ilh lOp lilted aW
~

M

" "il

A

mICro\\U\e,. "o\e~,

and o ve ns). Timers. wall clock s.

and telephone, \\ ilh large- print number." are also aV:lilable.~ '1

)/;. \\',Ill-mounted ()\('n:-. (:-,eparate fr om the stove ) should

be placed 30 to 34 in. (76 to 102 CIll ) frolll the noor "'lIh a \Ioe-opening door. Th e~e <:ooking unit s are gen erally more ea\il) accC" .. "iblc Ihan a singl e, low-level lomhllleo o\'(;n and bu rner un it. Ove n unit s ~ hould be \el l-cleaning. 9 For !ll,tn~ lIlulv lduaJ... ~I coun tel1o p mi c rowave oven is t;\.,~ ntlal for lood prepara tio n. If) DI\h\l,(\\hcl ...... houlu be d evaled 6 in. ( 152 mill ), be

ContrOl position

fr()n1-!C/;ltllng. with pull-ou t \ hel ve\ and front -mounted

(6m 1152 1111ll !) side- by-:-. ide cl o thes \\,l,>her\ and uJ)er~ ~h l)uld abo be front -load ing wilh

LOllirol ... EIe\aleU

Irlllll-mounted lon lrol \.

the retrigerator \I, ill b e en hanced by use of a ~Jdt-h) -"IUe (rtl ngcralor-I ree7er) mode l. 12 A \ \.mdlhle . pon ablt: lire ex tin gui:-.hers ·.hl)u IJ Ill: a\ ..tl1ahlt.: It )'., gcntrall ) recommen ded Ibal Jilt' e\llngul\ht.'r\ he mounted in Opl.:ll \ 1('\\ near an eX I! and ..tv...t~ lrolll ltHJkHlg. applJiHlcc:-,. I--or pallen" \\ IIh

II AlL!.:\'> 10

8

Figure 1 2.17 M inimum \ pace r~ quirt." m t'nt ~ o f a res identiJI hathroom \\ it h (A) a ~ huwer ~t:.t ll and (8 ) :l bathtub. T hl' dOlled lint' In dl ~a t c" knglh-.. 01 wa ll tha t require rt' mforcc mcntlO reu'ive gLJb bar.., O!" ..,upporh . ( From N i.xon. V: Spinal Cord Injur) : A Ciuu.h: 10 hln~' l j onill OU lo.:umt\ ill P hy~ I C JI T ht:rapy Man agc llw l1 1. A~IX'11 ~~ ~Ie m") ('orpur
420

Physical Rehabilitation hOIll(,": haf/tmOlll, ~i,("I/ell. hclirool11J. ellff)' to home. din1f/~ ;//1"illgf(ll1l1ly room, ollfdoor spar es, ('0I1111IOn rooms, .~'(IIr.\. lI/ic/ tIle area .f/mu .wreN to hOllse. The areas where ~lIhiel"fs l'IICOflllfen'd r/Il' gl'cat('\f c m 'l ro lllllCllfa l difficultil'.\ 11'('1"(" harltroomJ aU? per("{'JI{), kilchens ( 76 perr;entJ, hl'droOlIl.\ (6/ perc(,l1rJ. and £,lIll'yllOys (5X percent).

o

Adaptive Equipment

Figure 12.18 Glide·oul under cabinel shelves improve access 10 "'lOrage area').

CU\I/( \L YOrE. Alrlwllo,.:1i Il11pOrtlllll jor meillY ,JOw'IIT'. l'.\.\(,Jlfiol ftJ/"lr!da lI<1ulr., wah "I'<'ntlc arco.\ {!f"rht' hOIll(, /)I"( '\/,lllIlIg '..:1({lf('1 1/(/:01"£1., (1/(/11 o(/I('n Girlill alld (n-II·(lr~(.,..\ 'Ii (Idtlre \.H't/lhl · fY/l('\ of" ditficlI/IIl'.' olda mlll/h ('\/)t'fit'lln' 11/ rhl /f I!OIJ/t· /)ofa Ir("/"t' cuJ/n (t'd jiwN }I)fl I'o/"{;oPIlIl1., (11/("1 11/ 1/';<' "'3 ~ ...J\t'on J 11\ iI/ t: i /IIen-iell.\. ,t'l/~n "I'(lrts. ( /i". (111 ( \(/fllllltJriofi (~f" rltt' hOI11(, {,lIlinJIIIIIl'J/f IS (Itfl'lI

I~ til ,/.\\('\\ 111(111. c1IIt/,lil"('("l oh.\l'/Torioll ollht' h011/(' ('1/1/_ I 11/11/111/

lIlt

/t'\/

III! lu'l".\ IOr"/H('d

(III

1111/(

clU'O .\

uf" rll<

A large variety of adapti ve equipment is commercially available to increase independence. speed. skill , and efficiency in perform ing activ ities of dai ly livi ng (ADL). Adaptive equipment is avail able to ass ist perfonnance in such areas as bathi ng. personal care. dress ing. meal preparation. and general household tasks. Typically. adaptive equipment is a component of a compensOfOl}' training approach that focuses on achieving the highest level of function possible by using remaining abilities. This approach involves considering alternate ways to accomplish a task. u ~ of intact segments to compensate f(J' those lost. use of energy conservation and joint preservatioo techniques. and adapting the env ironment to optimize perfomlance. Tab le 12 .2 presents sugge sti ons for adaptive equipment to improve function in seve ral areas of ADL The table is organized around adaptive equipment recommendations and co mpens(lrory strategies for fou r impai rments including ( I ) one upper ex tremit y or body side involvement. (2) red uced upper ex tremity range of motion and strength, (3) incoordinati o n of upper extre mities. and (4) mobility limi· lati on ~ wilhou l upper extremilY invo lvement. The rabIc also idel1lilie", co mmon medical diagnoses associated with each impainllenl loge ther with [he rationale for the sugge,red compensJtor) s lrJtegies .~1

c

po

Chapter 12 Examination of the Environ ment

A

421

B

Figure 12.20 Motori7cd ~lO rage cabinets that can be lowered from the resting posit ion to allow rounler-lOp :.\Cce~..,_ Height-adju stment control, HA1 high and lB]low) are located on the right anlcnor panel of the cabinet. (Co urt e~y of AD-AS. Boise . ID S3709.)

Assistive Technology

Figure 12.2 1 { '()uI..H!p v.ub trunHI1t1Unh:d lO ll!w h .JIld \ tlll lolh ,url;".:l,: lhal ..I l lm\ \ ... IIJIIl" ( r"lhe r II1.U1 1111111 ") tn llll

b

_ e/;' urn o..: r lu hl

lclllllullnkrhlp KIIl;'o.'ll!:.lr.t!lU: 1),,' 11<.:.1111 I" '-'''- lC 'l.'tI h ~ iuldllll,' door .. ( f tJune,) 0 1 (jenl:laJ ~: kLl II L. Lurlic kl (

r tJh-l 'I

I

In the Technology-Related A ss istance for Indi vidua ls with Di.'labi lili e ... Ac t o f 1988. ass is ri ve tec hno logy is defined a s " any item, piece of equi pme nt . or product system. w hethe r acquired commercia ll y off th e she lf. mod ifi ed. or c usto mi zed. that is used to in c rc<~se. m ain tain. or improve functional ca pabilitic", of individuals wi th di s abilitie s."5~ A s~ i s ti ve tec hnotog ie", call be ~ill1ple mechanical or mobility d ev ice .. bLH the te rm Ll s u ~lll } de no tes some ty pe of electro ni c. co mplllCr (e.g .. hardware. so ft wan.:, peripherab), or rn icro proce ... ",or- ba ...ed (pros the ti c knee (:onlrol) de vi n~', A,.-,i ... ti\ t' techlloillg ies tATs) enabk individuals \\/i th disabililil'''' 10 IJl:rfonn dait) ac ti ... itie ~ by compensat ing for \0:-.[ or impairt'" d functioll. The) prOlllllte g reater independence and t) pii.: all~ improve qua li!) of life b} ass isting in such .lrea .....l ' cOlnmUlli c:llion. education, cilvirolunenial ac'Cessibtl it )'. and \\'01'10.. or n..'L:rl' atioll act!\ itil", Three lI11pommt l'OIl... ilkr,tlioth In lkh: nnining the need for ATs include ( 1) the indi\ idual "'" :\vadable funcli on. C!) the nalllr..: of the las"-... or ,K II \ IlIe ... that \\ til Ix pe rfonned, .Uld t3) rh~ env ironmtntal l'OllLt'\ t til \\ IIII h It \\ i II lx- IN~d, Al l ('lllHmnu, vant't)' of 1\ r.....Irc cl)nlme rc iall y avai lablt'. Ide:dl). till' l'\i.t!uatinn ~I nd prescriptiun for ,pt:citic iti:'lll~ i.-, al·L'olll plt ... hed b) ~tIl iIlICrdhL' ipli ll<1f) team thai indude . . the

....

.... .... EIN: If.e OV*"l dnd Qr.1I wllll ba'\(> ~".

nC>IIO ..... ~1 th..-n m,n 1400mml 01' Ill" Ikll'H Smailiond dra ... ( IS and 'lI,Ien >~IVf>'" IOf ~mall ,ars I!UP poSl"nn"(f lur An".t/.:I(' rlanpl;fred f'ao,yi'lc. ,," aboYf> .f'(ju .('$ Ih" nef!od \0 or"f'n ..... moey. A,(:. <>!>' In Ionl; I. m

•

SI,·raQ' """a or 11M c,1 fPiI,-h'"

!;mall

'm.'

land

CiI" "Sf!{ "

r

Wall A

Vft

L

Wall B

)

•

1

I

(J

@

c

~

U

-

(;Jaw

-s!.

C.... urlf'fl,)f)m •. 010\", )wen ,..\\" ().sh.IClfKII ..~.

~

ElectriC burners," line

R... '''''''0 c ~~ sn.- _•. , II' flt' .. !!) m\o I"'" c >m,..

to .... ard leaf 01 WOI ... I~'I

Cordless ba tt erv ""hlsk IOf lighter rnl~lures

L _ _ _ _ Putr«ll work lop .... 'lh bo w l hOldt'f.

Long .... fls led oven mHts are saler Ihan polholders

a sl

<;hll..,

If'\({''1 h~n.:1:tooJ IltfTl( •

COl'\! Ilftd hoi anoj

cotd

I.lt'~

elliptic hole 10 grip

a m,,,tng 00.... '

9·" IOf "',I/,l)e""'3

If!

.... Ith t~ bolseOn a ,",QI

long.handled dustpan w!lh longhandted bl uSh

Reachel lo r access 10 long·lerm stOlage area

Storage unIt s 1I.!lh pull o ut trays and dra....t!fS

F fOll! ~dlOQ d,o;t ""dlShe' .... ,Ih pu'1--Ou111 ,'I '0\' ... 1 5141 ( 11 ,"'0

Figure 12.22 Sampl e fealurcs 01 a I..llc hl!ll .lrC
0~.

,

C haple l'" 12 Exa min a tio n o f th e E nvi..-onmenl

423

Table 12.2 Ad'l>li"e Equipment and Compensatory Strategies for Selected Areas of ADL

[Impairment

One upper extremity or body side Involvement.

Common Medicaf Diagnoses Associated with fmpairmen t

Hemiplegia (cerebrovascular aCCident [eVA] or brain injury), unilateral trauma or amputation, temporary conditions such as burns and pertpheral neuropathy.

I RatIOnale for Usmg Compensatory Strategies I

To allow for safe, one-handed performance: to stabilize objects for task completion; with hemiplegia, to compensate for loss of balance and mobility.

l ADLArea

•

Meal preparation and cleanup

To stabilize objects, consider use of: • Adapted cutting board with stainless steel or aluminum nails for cutting or peeling. Ra ised corners on the board can stabilize bread to spread ingredients or make a sandwich. • Suction devices to stabilize bowls or dishes during food preparation. • Pot stabilizer. To allow for safe, one-handed performance: • Adapted jar openers. • Electric appliances such as food processor and hand mixer save time and energy. Note: patient safety and judgment need to be considered when electrical appliances are recom mended. • Rocker knife . • Battery-operated whisk to mix food .

If balance is affected, it is recommended that the task be done in a seated pOSition. • Pots and pans can be slid across counters, rather than lifted. • To open a jar, place it in a drawer, then lean against it to stabilize it before opening. o Scissors can be used to open plastic bags. • Milk cartons can be opened by using a fork. • An egg can be cracked by holding it in the palm of the hand, hitting the egg against the edge of the bowl, and separating the egg shell with the index and middle fingers. For clean-up: • Soak and air-dry dishes for easier Clean-up.

To compensate for decreased standing tolerance and mobility, consider use of: • Utility cart to transport objects. • If coo king is done at wheelchair level or seated, use angled mirror over the stove to watch food on the stove. For clea nup, consider use of: • Hand-held spray for rinsing dishes. • Rubber mat at bottom of sink to reduce breakage. • Suction-type brush to clean glassware.

Clothln~agement (laUndry Ironing, clothing repair) Housecleaning

Laundry can be transported to and from washer and dryer using a wheeled cart. o Long-reach duster. • Long~hand l ed dustpan and brush. • Self· wringing mop o

• Incorporate energy conservation by making bed completely at each corner before progressing to the next corner • No-wax floors are easier to care for. • If balance problems are present, some floor care can be managed from a seated pOSition. (continued)

424

Ph ysical Re habi litation

Table 12.2 Adaptive Equipment and Compensatory Strategies for Selected Areas of ADL

(conlinut.-d)

Impairment Reduced upper-extremity range of motion and strength. Common Medical Diagnoses Associated with Impairment . . Spinal cord injury. burns. arthritis. upper-extremity amputation , multiple sclerosis, amyotrophIc lateral sclerosIs, orthopedic and oth er traumatic injuries. Rationale for Using Compensatory Strategies To compensate for lack of reach or hand grip: to compensate for lack of strength or tolerance for prolonged activity; to allow gravity to assist: to compensate for decreased ba lance.

Meal preparation and cleanup

Consider the use of: • Adapted jar opener. • Built-up handles on utensils. o Universal cuff to hold utensils to compensate for reduced grip. o Long-handled reacher to obtain lightweight objects from overhead or low places. • Wheeled cart to transport objects. o Adapted cutting board. • Loop handles can be added to utensils to substitute for reduced grasp. • If using a walker, a walker basket can help transport objects. For market ing: • Marketing by phone or computer is recommended (objects may be out of reach in store) .

Joint protective measures (rheumatoid arthritis) . o Position electrical appliances within easy reach to conserve energy. • Also to conserve energy, work in a seated position. • Consider convenience foods to minimize food preparation. • Ten odesis action (wrist extension and finger flexion; wrist flexion and finger extension) can be used to pick up tightweight objects. o Use a fork to open milk cartons. • Use lightweight pots, pans, and utensils. o

Housecleaning

Long -handled reacher allows objects to be picked up from the floor. • Long·handled sponge to clean bath lub. o Self·wringing mop. • Use lightweight tools such as sponge mops and brooms for fl oo r ca re .

Use aerosol cleaners to dissolve dirt before cleaning surfaces. • When making the bed, do not tuck sheets in.

Laundry

• If patient is ambulatory. the preference is for a top- loadIng washer to avoid the need to bend. • Push-button controls on the washer and dryer are easier 10 use than knobs. II knobs are present, they may need to be adapted. • If patient chooses to Iron, set Iron at a low temperatu re setting . An asbestos pad can be placed at the end of the iron 109 board to eliminate the need to stand Iron up after each IronIng stroke.

• Use premeasured packages of soap or bleach to avoid handling large containers. It may be more economtcal to buy larger contamers and have someone else measure soap or bleach Into slOg Ie packets. • Place hangers near dryer to hang permanent press Items as they come out of the dryer. Remain seated to dO IronIng.

o

o

I~

I

I

Chapter 12 Examination of the Environment

425

Table 12.2 Adaptive Equipment and Compensatory Strategies for Selected Areas of ADL

(
Impairment ! Incoo rd ination of upper extre mities. Common Medica! Diagnoses Associa ted with Impairment

Brain injury, cereb ral palsy, e VA, multiple sclerosis, tumors, other neurological conditions. Rationale for Using Compensatory S trategies

To stabilize proximal portion of limbs; to reduce movements distally by using weight; to stabilize objects for task comple· lion: to provide an environment in which patient is safe and proficient; to avoid breakage or accidents with sharp utensils or hot food or equipment.

-

.; ".,d

ADLArea

Adaptive Equipmenl

Adaptive '&elm' I

Meal preparation and cleanup

• Use pots and casseroles with double handles to provide greater stability. • Weighted wrist cuffs may reduce tremors. • Use adapted cutting board to stabilize food while cutting. • A serrated knife is less likely to slip than a straight-edged knife. • Free·standing appliances, electric skillet, microwave oven, and countertop mixer are safer than transferring objects out of oven or using handheld mixer. • Use a milk carton holder with handles to pour milk. • A stove with front controls is prefe rred to eliminate reaching over hot pots to the back of the stove. • A wheeled cart that is weighted for transporting food . • Place a rubber mat or sponge cloth at the bottom of the sink to cushion fall of dishes.

• During food preparation such as cutting and peeling, stabilize arms proximally to reduce tremors. • Start the stove after the food has been placed on the burner. • Sliding food and dishes over a counter is preferable to lifting. • To avoid breakage. soak dishes. rinse with hand sprayer and drip dry; minimize dish handling.

Housecleaning

• Heavier work tools are useful. A dust mitt is easier to handle than gripping a duster. • Fitted sheets on a bed are recommended.

• Eliminate or store excess household decorations to reduce dusting.

II

(continued )

426

Physical Re habilitation

Table 12.2 Adaptive Equipment and Compe nsatory Strategies for Selected Areas of ADL Impairment . . Mobility limitations wi thou t upper extremity Involvement. Common Medical Diagnoses Associate~ with Jmp~irment and kn ee fractures. Paraplegia. osteoarthritis . lower-extremity am putation. burns, leg Rationale for Using Compensatory Strat~gies . 'bility includes consideration of wo rk heights, maneuver. Mobil ity may be provided by a wheelchair. W heelc h~lr accessl ability. and access to storage, equipment, and supplies. . . rance Other types of mobility devices (walker. crutches) may require Increased endu .

Meal preparation and cleanup

Laundry Housekeeping

Adapted from Culler.Sl

p371

Transpo rt items usi ng a wheelchai r laptray. The laptray can be used as a work su rface to protect lap from hot pans. • Stove controls should be in the front. o Use an angled mirror to see the contents of pots. • Use front-loading washer and dryer. • Use sell· propelled lightweighl vacu ums.

o

o

Place frequently used items on easyto-reach shelves, above and below counter-top level.

with permission.

patient. fam ily member( s) and/or careg iver(s). phys ical and occ upational therapi st:,. speec h-lan guage pathol og ist. and a rehabi litat ion engi neer. Depending on the needs of the patient other c o ntri bu lO r~ may include a spec ial educati on leneller. seat ing spec ialist. rehabilitnt ion technology suppileI. augmentative comm un ication spec ialist. and med ica l ~ocial worker or fundin g . . pec i a l i ~ t. Box 12. 1 provides an 0\('1"\ le\\ of the generaJ categories of ATs. E mi ron ml'nhll cont rol units (ECUs) are an important exampl e of how AT ~ can enhance fun ction and improve independence:. ECU ~ are e lectron ic interfaces that all ow the use r to control a \anety of appliances and d ev i ce~ (e.g .. telephone..,. he.d contro"". variou'l components of an e nlen.ainme:nI Uillt. room temperature and lighting. open and close (:unam~. open door~) . Th e~ de, ice . , combine operation of all appliance:.., mto a centnJ.1 control pane l, prov iding i ncrea~ed Illdepe ndence lor mdi viduah with ~evere d i ~a b i l i t y. The three mai n componCllh of an ECU irl(: lude ( I ) the IIlpUI de\ ic~. (2) I h~ control uni t, ..md (3) the appl iance. rhe: II/put dt'I"/{(' ('ontroh the ECU u ~i n g .... halt.:ver vo lun tM) m U\e m ent tht: ,ndr\ id ual ha . . ma il able (~.g .. JOYM ld ., ll)ll lrol panel. I-.. c) pad . kc) board IEeU computer ..,o ll ware prograJll~ are a\ adable I. d ...erie ... of ~ \, i l l.: he~. touch pad~ ;.inti ..,net:n~. lig ht pen. optu.. al pO Lll ter!o.. and VOll·C. mou th ~ lI lk. and e)l' I.:vntrol). rhe ulll trvl Wlif 1\ the ce nt ra l prolt: .. ..,or Ihat [ r an!--.late~ tht.: input l<. lglml to an output l'lignal 10 r~~uhtle (h~ large t app lia nct:. T lrt:" 1II'plllJlU '(' I.:all bt> \ trlu.ill ) an ) de\ 1... t.: lhut ('an he I.:olllrn il ed d~tt ro n il-a ll ) .

Examination of the Workplace An investi gati on o f (h e wo rkplace is an important compo ne n! of a compre he nsive examinat io n o f the environme nt. It is used to ex plo re the lI"orker -job-environ,",,,, relationship a nd 10 dete rmine the fea sibil ity of returning 10 a fo rm e r j ob o r if re aso nabl e accommodations wiJl prov id e Ihe needed support to res ume work . The tests and meil!) ures used by ph ysic a l therap ists to examine the workplJcc fall into two broad c ategories: (1) ergonomicS. wh ic h is (he ap pli cation of scien tific and engineering princ ip le:, to (he wo rke r- job-enviro nmenr relationship to improve sa fe ty_ e ffi c ie nt). a nd qual ity of movement:) and C~) hody IIIt'ellUl/in, w hi c h is the inte raction 01 l11u 'lc le . . and j o in b in r6 po n .. e 10 forces placed 00 01 ge nerated by th e body.' Within the c ontext of tbc$e (wo ~\~Im i na li oll catego r i e~, Table 1:2 .3 presents the tesh a nd me aS ll re~ u!--.ed by ph ys ic a l therapist s loge... ..... tth the tuoh for ga the ring d a ta. and the Iypes of dill ge nera ted.

Infonnation Gathering Job Analy.is Interview An 1I111 ia i compone nt of rhe c '{ammation is a pre~ job lIIwlni \ illf(,n"l t' u ·. T hl' purpost' of the interView .. lit gath~ r IIl fon nation about ( I) the fu nc tional ~

Chapter 12 Examination of the Environment

427

Box 12.1 Calegories of Assislive Technology Aids for Daily Living: Aids or device~ thaI enhance perform . !loce of ADL and level of independence in suc h activit ies a~ eat mg. meal preparation. dressing. personal hygiene. bathin2. or hou\Chold management. £wlllples: Grab bars. ramps~stair lif1 s.lo\~ered counter~. bathtub seats. adapted doorlnobs. and alternative doorbells. Augment3lh'e Com munica tion : Devices used to enJwnce personal expres!'ive and receptive commu ni cation. £'\fllllp!eJ: Augmenl
tfonic). booJ..holder!>. communication boards. electric page turners. head wand .... mouthstich. tight pointers, reading machines. personal voice amplification. signal systems. and telephone adaptations. ComputeT Applications: Hardware. soflware. and dev ices to enhance compute r access. Examples : Modified , chording, npanded or alternate I..eyboards; voice recognition syslem ~: alternate work stations (elecLricaJly powered height and til t adju~tme nt s); Braille trans lation software (conver~ io n from prim and Braille): Braille printers: access aids (head-control sticks. light pointers, eye gaze input): alternative s\I,'ilches (minimal pressure, vo ice activated) and cursor (mou'Oe) control: voice synthesizers, large prinl software that allows user to alter background and text colors: magnification sc reens. touch screens , on-screen keyboard. screen reader: keyguards , foreann support s; texllo-speech software: optical c haracter recognition (OCR) syMem that scans written text to a computer and read by a speech synthesis/screen review system: and robotic wheelchair mounting to support a laptop computer. [m'ironmental Conlrol Systems: Electronic systems that enhance') ability to control various devices. Examples: Electronic contTol of appliances. lighls. doors, and security ~)'s tem s in the home.

of the Job based on a revie\\ of dutie s a nd respons ibi lities and C:!) the characteriMics of the ph ys ical space in w hi c h the IOdiv ldual i", requi red to work (job a na lys is wi ll continue during the on-!) it e vis it ). Interv iew question s are deve loped b~ed 0 11 the type of emp loy me nt (e.g., assembly \l,orl... food !)ervice tasks. motor vehide ope ra tion, manual material handling. factory work). During the inte r\ICV., lhe patlem/client .. ho uld be encouraged to provide detailed Il1l onnallon ahou t respon s i b iliti e~ and ta~ks perfanned whde on du t) (e.g .. dural ion of perfo rmance. weight and di!)led and ')0 forth). A !)ample of s ugge~ted job
funClJon ')tatemcllI that IdenlJfie~ the overall purpo:\c as V.tllasade f Sl: npiion 0 {J J the e .. ~t:: ntlal tunc ll on" of ,I Job itOU relall \ e I . line ')pem on each; (2) Ihe phy\lcal em'ironment III v..hlcl, Ihe C\')entla ' Ifuncllons ' . ,tTl; performed (e.g.,

Hearing Technology: Devices designed to enhance receptive comm un ication (assistive listening devices). Examples: Closed captioning. FM am plification syste ms (isolate and ampli fy a sound source), hearing aids. infrared amplification systems. personal amplification syste ms. TDDs/TTYs. te lev ision amp lifiers. telephone adaptations. and visual and tactile a lert ing syste ms Mobility Technology: Dev ices designed to provide an a lte rna tive means for walk ing or mov ing within the envi ronme nt. Examples: Manual or powered wheelc hairs; powered scooters; vehicl e modification (driving adapt ations, hand control s . wheelchair lifts): stair lifts; bus lift s; kneeling buses; and ambulatory assistive dev ices. Sealing and Positioning: Wheelchair (or othe r seating system) interventions to improve postural alignment, stability. head control and red uce skin pressure . Examples: Custommolded seating surface, control blocks, pressure-relieving seal cushion s. head and neck supports, adductor cushions, abductor pommel. lumbar suppons, torso supports, and pelvic and foot positioners. Vision Technology: Devices designed to enhance interaction with the environment for individuals with visual impairment s. Examples: Talking devices (clocks, watches. calculators. the rmomete rs. scales . hand-held spell checkers. dictionaries, and thesauruses), magnifiers, speech output devices, large-print screens, mini pocket tape recorders, voice-activated dai Iy planners, large-bunon phone, large prinl books. magazines. and newspapers. closed circuit television to magnify documents, audio books, and books on disc (can be loaded onto a computer and read to user with a voice synthesizer).

indoors, o utdoors, tempe rature flu c tuatio ns, noise leve ls); (3) the p hys ica l re quireme nts (e .g .. lifti ng, push/pull activities. bend ing . reachi ng); (4) the sk ill s needed (cogni tive processes, lang uage, w riting . or compu ter skill s); a nd (5) the soc ial con text of the job (level of s uperv is ion, indepe nde nt , contac t w ith the public). J o b ana lyses provide a d escription of the jo b ( nol the pote nti a l e mployee) . Ge nerall y. Ihe a nalys is is prefonne d when i.I job is crea le d to g uide h iring of individuals wi th di~abili t ies. (A sa mp le job analys is fo ml is prese nle d in Append ix N.) The physical therapi ~ t may also be ca lle d o n lO a na lyze a patient/clienl'~ c urrent job following the onset of di,ability to make recommendalions for ;ea~ollable accolll lllodat ions.

Functional Capacity Evaluation (FCE) T) ~ ica ll y. the 11l0~t effective ll1ean~ of ex amining the p~tlt::nt/cllent-\\orJ. . e nvironment interface i~ an on-~ ile visit. Ilo\\t!ver, a varie ty of s tandardi zed fUIK"tional capac ity evallIalion (FCE) ilNru me llIs a rc cOl1unt! rciaJ ly avaiJabJc that

428

Physical Rehabilitation

. d M h . . To IS and Measures. Tools Table 12.3 Ergo nom Ics and So y ec a m cs. es Used fo r

Data. a nd Da ta Generated .

. .. . k h t ' done' the actions, tasks, or activities inherent in that Ergonomics IS the relationship among the w~rker,. the wor t a ,IS ' Il ia) is erformed. Ergonomics uses scientif' work (job/school/play): and the environment In which the work (job/schoo :":'nt i~volved in work (job/ school/play). IC and engineenng principles to Improve safety. effiCiency. ~n~ quality of ma. t . d'us! posture in response to forces mechanics are the interrelationships of the muscles and JOints as they main am or a J . . .

placed on or generated by the body. The physical therapist uses these te~ts and measures In e.~aml n lng b?t~ t.h e worker and the work Gob/school/play) envi ron me nt and in determining the potential for trauma or re.p~tltlve stress InJunes f~om Inappropriate workplace design. These tests and meas ures may be conducted after ~ work Injury o r a.s. a ~reventatlve step . The physical therapist may conduct tests and measures as part o f work hardening o r work conditioning programs

=_

and may use the results of tests and measures to develo p such programs . _ _

Tools Uled for GadJering Data Data

and Measures Tests and measures may include those that characterize or quantify:

Tools for gathering data include:

Data are used in providing documentat ion and may include:

Ergonomics • Dexterity and coordination during

• Accelerometers

Ergonom ics • Characterizations of e fficiency and effectiveness of use of tools, devices, and workstatio ns • Characterizations of environmental

• Cameras and photographs • Checklists for exposure stan-

work (job/school/play) (e.g .. hand function tests, impairment rating scales , manipulative ability tests) • Functional capacity and performance dUring work actions, tasks , or activities (e.g., accelerometry, dynamometry, electroneuromyography, endurance tests , force platform tests, goniometry, interviews, observations , photographic assessments, physical capacity tests , postural loading analyses, technologyassisted assessments, videographic assessments. work analyses) • Safety in work environments (e.g., hazard identification checklists , job seventy indexes, lifting standards, risk assessment scales , standards for exposure limits) • SpecIfic work conditions or activities

(e.g .. handling checkl ist s. job Simulations. lifting models, preemployment screenings. task analysis checklists , workstation checklists) • Tools , deVices, eqUipment , and workstations related to work actions tasks , or activities (e.g. , observation~ , tool analysIs checklists, Vibra tion assessments)

dards. hazards, lifting standards • • • • • • • • • • •

Dynamometers Electroneuromyographs Environmental tests Force platforms Functional capacity evaluations Goniometers Hand function tests Indexes Interviews Muscle tests Observations

• Physical capacity and endurance tests Postural loading tests Questionnaires Scales Screenings Technology-assisted analysis systems • Video came ras and videotapes • Work analyses • • • • •

Body mechaniCS • Body mechanics dUring sell-care, home management , work, community, or leisure actions . tasks, o r acti vities (eg., actiVities of dally living [ADL] and Instrumental actIVIties of dally liVing [IAOL) scales, observations photographic assessments , technologyassisted assessmen ts. v ldeographlC assessments) From American PhYSical Therapy ASSOCiation

.

~. "'u·~1

WI

'-h

permission

hazards. health risks. and safety risks • Descriptions o f tools , devices, equipment , and workstations • Descriptions and quantification of: - abnormal move m e nt patterns associated with work actions, tasks, or activities - dexterity and coordination - functional capacity - repetition and work/rest cycle in work actions, tasks o r activities - work actions , tasks , o r activities • Presence or absence of actual , potential, or repetitive trauma in the work envi ronment

Body Mechanics • Characterizations of abnormal or unsafe body mechanics • Descriptions and quantifications of limitations in self·care, home management. work. community. and leisure actions, tasks , or activities

Chapler 12 Examination of the Environment

429

Table 12.4 Suggested Interview Questions Appmpriate for a Clerical Position. Inten'iew Questions Are Used to Gather General Data About Functional Requirements of the Job and the Physical Space In Which the Indil'i_ du _al_is_R _eq~u=-i=r-.:. e.:. d=-t:.:o=--:W =-o ::.:.. rk :.:.=--:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _- ,

I

1. Y N 2 YN

3 YN

4. Y N 5. Y N 6 YN

00 you frequently 1111 more than 35 pounds? Are you reqUIred to lift objects from below knee level or above shoulder level on an occasional or frequent basis? When you 11ft. do you reach across other objects or at arms' length in order to accomplish the 11ft? Do you frequently reach for objects above shoulder level dUri ng the day? Do you Sit for more than 4 hours per day? Does your Job require you to mai ntain one position or posture for 30 to 60 minu tes or longer at one time? If yes , what posture IS 1t?

7.

YN

8. YN

9. Y N

11 .

YN YN YN YN

12.

YN

10.

Are repetitive exe rtions required on a reg ular basis (e.g .. typing)? Does you r Job require freq uent motio ns of the fingers, Wrists, elbows, or shoulders? (If yes. ci r· cle all tha t apply.) Do you feel that your desk height is at a comfort· able level? a) Is your chair comfortable for you? b) Do you fee l that it fits you properly? c) Do you know how to adjust your chair? Is there ample space for your to perform your job? Does your job involve frequent bending , twisting . or jerk in g movements?

From Hunter,60 1>68 w1th perm1sslon.

can be u..,cd to gather preli mina!), data prior to an on-si te vlsi!. Depend in£ on the Job task requirement s. the FCE may be all thJI 1\ needed to de tennine ab ilit y to return to a previ ou.., Job or to a".. umc al ternat ive job pl acement. The FeE pro\ Ide~ a ~e r ies of objec tive tests and measures designed to identif~ both \\ork· related ca pabilit ies as we ll as functional limitati om. Mea surement parameters typi call y include endurance. ROM (nexibi lity). strength . force generati on, pmture. coordlllat ion. manual dex terity, and consistency of perfonnallce. ~ !"'~6 The FeE j 'i u ~ed to measure perfo nnance in speci fi c com ponent!:! of \\o rk-re lated tas ks. The spec ific it y o f the j ob will dictate the functi onal movements required . FeE in<;trumelll capab i lit i e~ are then selected based on these requi rements in order to examine the spec ific group of skill s that compri se the employ ment task s (e.g., liftin g. stooping. trunk rotatio n. reac hin g). A n exa mpl e o f a FeE inqrumen t i~ the ER FUl1criol1ol Testing System fB ahlmore Therapeutic Equ ipmen t fBTEl Co., Hanover, MO 21076-3105). Thi 'i comp uter-i ntegrated system (Fig. 12.23) allow" replication of phys ical tas k demand s using ~Ither ~tandardjzcd tes ting prol ocob or customi zed physIcal tew•. A va ricty of t a~k s can be :-. imulaTed including, but not limned to : lifl ing ( Fig. 12.24). croUChin g. siltin g, stoop-to·~ t and. and kneeli ng tolerance. ove rhead reac h. i~g . pu~hing (Fig. 12 .25). carry ing ca paci ty, and pull ing (Fig. 12 .26) . Other ex amples of physica l work ca pac ity in':Mument3 include the Joule FUllrtiol1al Cap(Jcilv E ra/llUlIOIl Sy~t('m (Va lpar International Corpo ratioll' Th . c30n , AZ S5703-5767). the Phy:-.ical Work PelfomulIICl' £\a~lIar/lJl1 (P" PE ) (Ergo Science, Inc, Binningh::un , AL 352_3,. and the h emJw!:(' 11 Work SY.\Iems FUlluiolla l Caput II.\' El'Uluut/()1I (WorkWeli SY~lf'"m3 Inc. A liw CA 92656) ' .

Figure 12.23 Funcli onal Capac ily Evalualion Sys tem. (Coune...,y of BTE TechnOlogies. Hanover, MD 2 1076. )

Soft ware programs allow compari son of FCE data w ith nomll.ltive va lues such as strength and ROM. Data can also ~ compared aga inst the demand milliml(m jilllctiollal capacIties (DMFC) contai ned in the Dictionary of OccliparionaJ Titles (DOf)H which is a US government publication that define!' phy~ ical demands of j obs in the United States.-"8 Data from the FCE assi st the physical therapi st with: • Pr~d lcti ng the indi vidua l 's \\ ork capaci ty and ability to ~a tel) retu rn 10 work

430

Ph)'sical Rehabilitation requirements. Elements programs. a re based o n speci fi c job. . of the program m ay inc lude ( 1) inte rve nti o ns t~ develop . .ll1t tn . I eg ri ty and mobi lity. im prove moto r function, musJO cle pe rfo nn ance ( i.e .. s tre ng th . powe r, endur~nce), ROM, ·· trd iovasc ul ar/ pulmo nary s tatus; (2) gUided practice and c. . .. (3 and instruc ti on in s imul a ted work ~C~lV It] eS; ) ~ducatjon and (e .g.. bod y mec hani cs. safety and injury .prevenllon); 59 (4) romot ion of self-manageme nt s trateg ies.

~ork hardeni ng prod ucls (Fig. 12.27) are commercially

challenge a. vail able that all ow the the rapi s t to p rogressively . .. the patie nt us in g s imul ated work activ ities s uch .as lifting

!asks using objecls of di fferenl shapes and weight (Fig. 12.28A) 10 an d from different heights, assembly tasks (Fig. 12.288). so rt ing tasks. shove ling, pushing and pulling activo ities. use of table top- .U1d wa ll -m o unted work stations, and so forth.

On-Site Visit Int erve nti on in th e work p lace is a n ex panding area of interest w ithin phys ica l therapy. 60-73 The on- s ite visit to the

work place typicall y includes ( I) further refinement of the

Figure 12.24 Dynamic lifting task . (Courtesy of BTE Technologies. Hanover. MD 21076.)

Identify ing parame ters of the ph ys ical env ironme nt needed to optimize functio n and prevelll fu rther injury (reasonabl e accommodation s ). • Ide ntifying ex tent of functional limi tali o ns (e.g .. compen sation process). • Matching abili ties to appropriate job placement. • Projecling IXllemi al benefits of a work hardening program.

Work Hardening The le nn \\or/.. Iwrdc nmg refer:-. to trea tment imerve ntion ~ ai med a1 imprm ing \-\ork.e r c apabiljtie~ and funt·tion. " ~-\-()r~ h{ml('llil/~ 1\ H highl y Mrul: turcd . goa l-ori t!l1tt!d . indi \ Jdualilt:d int erve ntion program dc~ igned to rctulll the pat lelll/cl ie nt 10 \-\or"-. Work hardening progralll ~, whi ch an." l11u h. d l ~c iplillar) III mlture, u ~e real o r !o. imulated \'vork ..lUI\ Ill e~ de~igned to re~ tore ph y~ l ca l. bc hav ior:.ll , and \Ol.:.lII Ona l IUm.:IIOlh . Work. harde ning addre:-'!o.e~ the- i !:-~ ues of producllvi t). '>a fct) . phY\ H.:a l tokra n Cl~'1, and \\ork.e r beh.t\ 10 r... :·.o;'1 p- Work. hardenmg progr.un ., lypll:.e rc i ~t! progralll~ e.,t <.lbli~hed frc,m an an .... l )":-.j~ o f v.ork.-related acti vlli l!1., v. ilh carl.:"ful a llCfl lio n to e rgonomi c and bod) mec hanic pnnc l ple~ . The allllcipaled go.... b and expct h!d OUlcome:-. of \I, o rk hardening

job analysb by o bservatio n of the patient/client performing work tasks wit hin the e nvironm en t in w hi ch they must be accom p li shed a nd (2) applicatio n o f e rgonomic principles to identi fy the im medi a te o r predicted ris ks of musculoske leta l inju ry fo r an indiv idua l w orker. Data from lhe o n-s ite v is it w ill a ll ow the therapi st to es tablish a plan/or risk redllction that prov ides recommendations 10 eliminate th e potential fo r inj ury. and a plan to optimize Junction that may incl ude s ugges t io ns fo r fi tt ing the job to the patie nt/client's anatom ica l and p hys io logical characterisli es in a way tha t e nhances e ffi c ie ncy and perfonnance wit h in the work e nv ironme nl. 6 1.6! W hen exami n ing leve l of functio n during an o n-site visit to the work environme nt. the p ri nc iples o f e nergy conservation. ergonomi cs, body mec hanics. and anthropometries are of prime importance in p reve nt ion o f inj ury and maximizing the worker's efficiency and comfort. Capabilities should be \Neighed agai ns t (he phy~ i ca l demands of rhe work environment. and the the rapist. lI~jng knO\\ ledge o f adaptive eq~ me n( and app lied biomec hanics. m ay suggest changes appropriate to the si tuation . Many of the area~ exami ned. recom me ndations. and adi.lp t iv~ ~1n.lIeg i es e mployee! in the home w ill be used in the worl.. em ironme nt a~ we ll. Several cons iderations sptc ilk to the \\ork. ~e lling are described be low.

External AcceSSibility

.

A park.1I1g s pace should be avai lab le wi th ill a shOJt diStance o f the bui lding if the patient/clienl plWls to drive to and Irom v.-orl. For wheelchair use rs. parting sJJICC" ... hould be
(hapter t 2 .. ,-amina1ion of the E.m ironment

B

A

Figure 12.25 Compan"on of (A) :Klual and (/1) "lllwlalCd 1 t:lhnologle .... l-blHl\ t'r. 1\1 D 21076.)

pll ~h in g

aCli, It y. (Courtc,,>y of BTE

A Figure 12 26 (IulIp.tn"l)IJ 01 ( "') ,H,; l ual ..tnt! e/J I \IIIlLJlloIled pulling
It:lhIlUil)gJt:, 11..,llmcr "'If) 21(76)

B

-1.1 t

432

Physical Rehabilitation

~ ~ ~ ~ ~ ~ ~

Figure 12.27 Worl.. hardening equipme nt all ow<; dcve lopment 01 progre"'~I\ e Ih t' r~l pe U (ic exe rci:,e (conditioning) program.s .. b,,'ed on <;1I11u lallon of a varicl) of tasks a nd assembly ac tl vilies using ,ollnd ergonomic and body mechanic principles. (Cou n e,» of B.:ule) ]\!fg Co. Lod i. 0 1-1 44254 .)

External acce!'.!)ib ility of the bui lding should be addressed u ... ing guide lines :,imil ar 10 those presented for home ex teriors.

Internal Accessibility InlliJIl~. the componenl requirements of the work task are

identllied. T he complex ity of some ta~ks or the needed interface" IIh the \'ork em ironme nt Ill ay render Ihe ;,tJlal ys i.. of ,", uch ta ... b pri or 10 Ihe on-!'.i le visit inappropriate. Thi s will Include delemlinalion of mob ility requirements (move me nt \\ tthm and oUhlde the primar) work area). as we ll as de lerI11J1ldlion of del11and~ or sk ill requi red in each of the fo llo\\ -

................... ·........ ........."n . .'··................. . ........ . .. ~······················n· ·........ ........ ................... ...... .... ·.......... ........ ·........ .......... ~...... ·......... ·...... ........ ···············n .... ............. · ........ ~··........ ..........U '

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2440

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Figure 12.29 Ve hicle park ing spaces should be a minimum of 96 in. (2-1-40 mill ) \\ ide . with an adjace nt access aisle 60 in. ( 1525 mm ) wide. Values denoted in inc hes and milJ imeters. (From Ameri can National Standards Instirute. Inc.4 • p ]J with pc m' i ,~jo n .)

ing area:,; muscle perfomlance incl ud ing strength. power. and e nd urance (trunk. upper vs lower ex tremities). ROM, po ... tu re. manual dex te rity. eye-hand coordination. vision, heari ng . and communi cati on.

C haple r 12 Examinalion of the Environment

433

Figure 12.31 Unobstructed high forward reach is a max i m u~ of 48 in. ( 1220 m Ol ) from the Ooor and the low forward reach IS a minim um of 15 in . (380 mm) from the fl oor. Values denoted in inches and mill imeters. (From American Nati onal Standards Institute. Inc,4. p II with penn iss ion.)

,J, ~ Figure 12.30 Overview of po~ i tion i n g recommendations for comput er work:,lalions: ( I) moni tor screen top sli ghtly below eye

le,ei:

(2)

bod; cente red in fro m of the monitor and keyboard: (3)

foreanns level or lilled -up slightl y: (4 ) lower back supported by chair: (5) w n ~lS free while typing: (6 ) th ig hs hori zoma l: and (7 ) feel restiml nat on the floor. (From Workplace Ergonomics Reference-Gu ide.-~ r ~ with pemlissio n.)

The immediate work area sho uld be carefull y examined . Th is includes lighting ; te mperalU re; sealing sutface (if othe r than a whee lc ha ir) ; the height and size of the

v. ork5lation

(~om e

patients may benefit from a vari able

height or tilting work surface); and exposure to noise. vibrati on. or fumes. Access to supp lies, materials, or equipment l\hould be cons idered with respect to the pat ient 's ve rtical and horizontal reachi ng capabil ities. Access to public tel ephones. drinking fou nt ai ns. a nd bathrooms shou ld also

be

addre~sed.

0 .... iog to the prevalence of com pute r workstati ons in man ~ empl oy mcm settings, the rapists may be ca ll ed on to make recommendations to optim ize effic ie ncy and reduce the potential fo r trauma or repetitive stress inju ry from poorly de ~ igned work areas. A lthough ind ividua l pati ent parameters may requ ire variations, the foundationa l principl e!:. lor po!>itioning al a comp ute r work station inc lude ~cree n slightly below eye level, body cente red di rec tl y in front of monllor and keyboard, foreann~ level or tilted sligh tl y upward, wrists free whil e typin g, lowe r back we ll SUppOited, thi gh~ horizontal on seati ng surface, and fee t restmg nal on the noor (Fig. 12.30).74 Dunng examination of workstations fo r indiv iduals Using a whedchair. fun ctiona l ~i lling reach is an important

considerati on. From a n upright wheelchair sitt ing position, the unobstruc ted hi gh fo rward reac h is a max imum of 48 in. ( 1220 m m ) fro m the fl oor and the low forward reach is a m in imum of 15 in . (380 m m ) from the floor (Fig . 12 .3 1). Whe n the high forward reac h is ove r a work surface of not greate r than 20 in. (510 m m), the max imum reach distance is 4 8 in. ( 1220 mm ) from the floor (Fig. 12 .32A). Progress ive ly deepe r work surfaces will a lte r the forward reach according ly. For example, a work surface depth between 20 a nd 25 in . allows a max im um forward reach of not gre ater th an 44 in. ( I 120 m m ) from the fl oor (Fig. 12.32 8 ).' For individuals with good trunk control , reaching capac ity wi ll be increased. A variety of building survey forms have been deve loped to fac ilitate the on-site examination of the workplace. These fOnTI S ass ist w ith ane nding to a ll necessary details during the visit. A sampl e of such a foml is provided in Appendix O.

Community Access To atta in the goaJ o f rull accessi bility, the via bility of communit y resources, servi ces, and fac ilities must be investigated. As me nti oned , whe n di rect invo lvement by the the rapist is not poss ible, thi s may best be accompli shed by providin g the support network members with guide lines ror ex pl oring access to loca l rac ilities. Another important cons ide r~:lIi on is to refer the patient, famil y, and/or careg ivers to commwlity organizations such as the A l1hritis Foundation, National Easte r Se al Society, Mult iple Scle ros is SOCiety, the Mayor's Oftlce. Chamber of Com me rce , or the Veterans Adminisrration. These groups can prov ide infoml ation on serv ices avai lable [0 individuals

434

Physical Rehabilitation

x

CO 0

E NN "'~ ....

A Figure 12.33 A kneel ing bu ... lowe rs the ste~s to w ~thin 3 to 6 in. of ,he curb. Bu ...es desig ned to k neel typI call y display a "igll ( Knee ling i Bus) ei ther on or nex t to the door.

~

E .... ....

0

~

~

B

20-25 635

J

Figure 12.32 (\) High tom ani reac h over a 20-in. (510 mm) dee r 'Aorl.. . . urface i ... a ma ximum of 48 in. ( 1220 mm) frolll the !lom (H f A .... orl.. ... urlan: depTh of 20 to 25 Ill. (510 to 635 mm) <.11 10........ iJ ma>.I011Lnl lom,lrd reac h of not greater Than 44 Ill . I II::!O Illlll ) from the Ooor. Value ... denoted in i n c h e~ and mil li meter.,. (1-r()11l Amt!ri<:an t\ational Standard., In<,ti tute. fnc." r II ""1111

Ihe elllran ce 10 curb leve l fo r e as ie r board ing ( Fig. 12.33). Man y buses are nov.' des igned w it h hyd ra uli c lifts to allow direct e ntry by an indi vid ua l using a wheelchair (Fig. 12.34) . Not all public transportati on systems in the United States allow use by indi viduals who are nonambularory or by those with limited ambulatory ca pac ity. However. many urban transit systems are gradua ll y making accommodations for indi viduals with mobilit y impainnents (e.g .. installation of e l evator~. altern ati ves to turn stile e lllrances. identified space for wheelc hair riders). In many areas where public transport at ion is un ava ilable_ door-to·door access ible van transpol1alion is provided to residenrs with di sabi lities. Again, availabil ily of ~uch ~e r vice~ may be limited in some rura1 l oca li o n ~.

perml. . . . IOI1.)

wnh a dl"abil ll Y \\ ho fe~ ide In the comm un it),. Individ uab v. ho art! retu rnltlg to \chool <., hould be encouraged to conlaCI th l' l dmpu ... "tudent ...ervice!'. olfice. which addre ~ ... e~ the Ilel.:<'t... 01 ~lUdenh Vv lt h di ~abilitie~. Informalion will be olkrt'd on hou "' IIl~ . .,pee l... 1 ~e fv ice ". and general c ampu ... rt:~o un.:~:-,.

Transportation (urrclltl) IIit: d\." adahlilly nj a{"ce"~lblc publi c t nlll "' p0rla 111)11 \a fl l.:~ corhH.it:r:.tbly ... mong gt'{)g r~lphll"al afl·a .,. A, !o. uLh. l·J.rduln plllr.llloll b y Iht" patl ~ nt. 1;:lIn ll }. O-l.;iJ lI l- d kllnl lll!! hu...c, t"lj llJPlkd \\ Ilh ~ hyJri.luliL Ulllllhat Il)\\~'"

FIgure 12.34 Bu I I ... . ., I I . . cUl ,lhlt' 10 aC~lm\lllOd3 h! wheelchairs .tIll! IIh)(UII Ll'l! n 11' 1"1 I le 111It.'maIHlIl.1I y"hlte khair symbo IIJr dl...\':I:" ~It"tdli\. . 4. "u.... I II . . . \ Pll .1 } dl.,pl' I )~·i.ll Ui thl! doors of [he bus.

C hapte r 12 Examination of the Environment

435

For patients w hose capac ity fo r long-di stance amb~la­ lion is limit ed and/or w hose e ndurance is low, commutlltygo ing e lectric "scooters" (Fig. 12 .36) may be a practica l alternative for travel within a reasonable proximity of the home .

Access to Community Facilities

Figure 12.35 A ... I ~cring \\ heel-mounted control pad can be lI"ed to comn..)1 Tl1Ulllple \ehick con froh ~ u c h as \'vi nd<; hield \\ lpcr~. lum mdlcator.... and hi gh/lo'\ beam~. (Courtesy of A.cce ..... lnhnuted. Btngh~mlun. 1\" 13903.)

Some rallenh "til \\ant to ma:-.ler drivin g an ada pted aUlOllloblle or 'an. Thi .... of cour')c. wi ll improve op port uni tie... for l'OmtnUnlt) Ir~l\el "ignificam ly. Motor vehicl e adaplallOl"., are ...e lec ted ha<;;ed on the ph ys ical capabilitie s of the mdl' ldual . Common adapti\ e equipment inc ludes hand comrol... to o perate the brake~ and the acce le rator: steering \\heel allJchmenh. ~lIch ~... knob . . or uniHTsal cuff:-.. for tndl\tdual ........ nh limJled grip stre ngth (Fig. 12 .35); lifting Unit... 10 a!l . . "t \\ IIh p1a(emCI1I of the v. heelc hair illl o the \-ehtdl": and. lor patlent~ ""i th tetrapl eg ia or htgh- Ie\cl parapit'g .......ell-contal necl lil li ng pl:Jlfonn ) for e ntry 10 a van "hlle remJlIllllg -.eated In a \\ heclc h'llT. Driver trainmg proE-'Tam ... are otkrC'd b) !.ome reh ..tb1illi.llion L'c me r!).

Severa l considermion s incorporated into exami nation of the workplace warrant atle ntion for gene ral community access, as we ll. Brie fl y stated, area faciljlies used by the patient should be explored for the avai lability of appropriate parking areas: beveled c urbs: ex te rnal and internal siructural accessibi lity of bui ldin gs : and availability o f accessible public telephones. drinking fountains. bathrooms, and restaurants . Theaters. aud itoriums. ,U1e1 lec ture hall s must be considered with respect to accessible seating areas. Many such public presentat ion spaces arc now designed with an accessible isle leading to open !loor space interspersed withjn a row of standard seats to accommodate a w hee lchair. This all ows the individual usi ng a wheelcha ir the option of either sitting nex t to a person who is ambu latory or someone using a w heel chai r. Locations of emergency exit.'> shou ld also be noted for all faci lities . tn addition to these general considerations, stores and ~ hopping areas shouJd aJsa be inspected for access 10 merc handi se (especially for individuals using a whee lc hair). appropriate aisle widths, and adequate space at checkout counters. Another u~eful so urce of information on community access iii the guidebook offered by many la rger cities (funded:l!l a communit y serv ice by local busine!'.~es) . These books provide information on accessibilit) of local c ullUraL civir, ~lt1d re li giou :-. in :-. tituti o ns; govern me nt office~; (heater:,; hOlel s: reSHturanl s : 'Shoppi ng areas: transportalio n: and ... ocia l and renealio nal raci liti e~. These publication .. usuall y can be oblained from the ci ry's chambe r of commeH.-e. the O1ayor\ office. o r Ihe otlice o f lounsm. Combined U5.C! of "lIch g uide!) and phon ing ahead for details

FIgure 12.36 h ..mlpk!o. l) t lIl t llOn lcd "'l:~lUIl:r ... ",utl"l:lk 1111 Iluh.hlOr IrJ\d Muhllll~ I'nllluu (Ol p. h.dl'r Po\ Ibh.P .j

436

Physical Rehabilitation

of accessibility will faci litate travel both with in and outside the local communit y.

Documentation Once exam inati on of the environmen l is complete. a fi nal coll aborati ve report is prepared that incl udes infonnati on from each participating team member. Th is report consists of in fonnati on obtained from the home and , if appli cable. the workp lat'e or ~c hool setti ng. InfOlmati on shou ld also be incl uded about the meas ures taken to exp lore general communit y accessibilit y. Documentation of the on·site visit shoul d incorporate a completed home or building survey form . Add itional informa ti on Ih at should be provided includes ( I ) a de scription of the methods used to assist the patient in ambu lal ion or functional activities, (2) identifica tion of th e type and quantity of adapt ive equipment required (including source and cost). (3) AT recommendations, and ( ~ ) suggested environmental modifications with prec ise specification s. Doc umentation related to community access shou ld include verificati on of the patient's knowledge of avail· able community resources. The sources of thi s informa· ti on. as well as whether the therapi st was directl y or indi· rectl y involved in the community investigation. should be reported. Th e completed report is then included as part of the patient 's medical record. Copies of the report are typica ll y submitted to the patient's support network. the ph ysician, third·part y payer(s) or other potential fundi ng sources. and any community· based health care or soc ial service age ncies that will be providing care.

Funding for Environmental Modifications The patient and suppon network may re4ui re as~i stance in locat ing appropriate financial resources to achieve environ. mental access ibility. Typically, the social worker within the patient care facilit y wi ll provide direction in thi s n, "_, .....1. lnfomlJtion on n:~urce organizations can also be obtained from the National Council on Disabilit ies. Potent ial SOllrcC~ of fun~i ng include pnvate medical insurance comp,mie~. home t: : qUJI). ~r. other type~ of bank loans. Veter.uh Admin iMTat ion. lhl:' DI\ 1:)lon of Vocat ional Rehabilitation (DVR). Lhe Wor\..er \ Comlkn\alion Commjs~ion, and local chapten.. of national group~ (e.g., KI .... an l!) IntematJonai. Veterans of Foreign Wars. t'I~ 3.M>nV~ hnncf:) ~.ges. and Lions lmemationai) or diagno. M~·spe(;Jllc organtZatlolb (e.g., National Strole A s~iation .

National Multiple Sclerosis Society, National

Pamnoon

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

tu'"

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 I1<.Hlent . famil ). tlnd/or caregive rs will ensure :1Il Op.tlI11 UIll and hig hly indi viliualiled palicm-environment IIlt L' rfi.ICc.

438

Physical Rehabililation

Questions

or

Rev

ew

1, Identify the rok :-. and responsibilities of the phys ica l Ihe rJpi ~t in eXJ mination of the physical e nvironnl ellt. 2, Di~(u,,~ exam pl es of the tes ts ~lI1d measures: too ls used for gathering data: and data ge nerated durin~ exaJl1i na~ [ion of env ironment al. home. and work bam ers. 3, In lie u or an on -~ ile v i ~ it [ 0 a patie nt's home. di scuss alternative approac hes 10 gathe ring info ml a[i o n "bout [he pali e n( ~ environme nt. 4. Deve lop a li\t of information you woul d need to aCtlllirc prior to an ac[ual on-site vis it 10 a pat ient's home environmen t. 5. Provide exam pl e." of how Ih e princ ipl es of uni versa l des ii!n can be incorporated into new construction. 6. Wh;[ ,peei/ic aSI)C(' ts of the exterior of a pati eJ1l '~ home ~ hou l d be examined d uri ng a n on-sile visit ?

Yo ur respo nse sho uld address the route to the en t ran ce ',nd ( (ac tua l e ntrance to th e home. 7 . What spec ific as pec ts of the ;/~/erior of a ,pati~n.t's hum e sho uld be ex amined dUring an on-Site VISII? Your respon se should address furniture a rrangement. n oor surfaces. doors, stairs, a nd cons iderations specific 10 the bedroom , bathroom, and kitchen areas of the dwe lling .

8. Di sc uss how a jo b ana lys is ca n promote accommodating indiv iduals with di s(l bililies w ithin the work e nvironm e nt. 9. What civ il right s of ind ividua ls w ith di sabilities are

protected by the 1990 Americans with Disabilities Act?

10. Describe the infonnation that sho uld be included in documentati on of an o n-s ite envi.ronmental examination.

----------------------------------------------~ ~

Case

Stud

A 78-yea r-o ld \\oman wi th a diagnosis of osteoa rthri ti s \\a5 admined for a right total hip rep lacement. The patient re po n ed a long-standing hi story of di scomfol1. She de,cribed the hip pain as rad iatin g pos te riorl y to the bUllock and lov. . back and was ex acerbated by \veightbearing and ~tair climbing. Ove r the past 12 month s she has expe ri enced :.l very marked increase in pa in and stiffne~~. Radiograp hi c findi ng:-. demon strat ed dege ne rative c hange ~ of bOlh the acetabulum and fem o ral head con s i ~. te nt \\ il h o~teoarth rjti ~. The ~ urg i ca l int ervention replaced Ihe fight femora l head and ned. with a metallic pro~ the~ i s and the ace tabulum \\a~ re\urfaced wilh a plastic cup, Pa,1 medical h i~tor) i, unre markable,

SOCIAL HISTORY The pJllenl i~ a retired m>tn:.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 <:an: .udt: 4 hour!):.l 0.1) 1\\0 tune~ 1)(.' [ Vrt.:tk (prllllun l) 101 ~h()PPlflg. l'rr..UI\,h, dJ1U ~Olll\.! hou \t: hold

manage me nt tasks). She expressed co ns iderable distress at being unabl e to take a bath and having to rely on the ass istance of anot he r person for som e basic care activi· tie s. She had been usi ng aspirin for its a na lgesic and antiinflammatory effects, Hm\'ever. the pain experienced in recent mo nth s was not a ll ev iated by the aspirin and other conservative measures she has bee n instructed to use (e.g .. loca l app lic ation s of heat. periodic rest intervals. and gentl e ROM exercises). The patient has medicaJ in surance cme rage and is wi tho ut financ ial concerns.

REVIEW OF SYSTEMS Cognit i\'e funttion: Intac t. Vision : \Vear~ correc ti ve len:,: experien('es night blindne ... ~, \\ hich ~he de~c ribe s a~ see ing poorly in dim light and her t')'e~ take ,everal ~econds longer than normal to adJu ~ t fro m brightne!)\ to d imne ss.

Hearing: 1111<1('1. Str('n~th:

Cpl'er

l'l/n'Ilillit"

Gt'n~m ll) \\ ithlll IUIKtlllnal lilllll \: p~rti~llt report~ some \ poralill" epl\odt' ... of \HI\t :lnd tinL!.cr !o. liffness on :1\\ .J ~ ~· nillg 111 th e morlllng and att;r periods of immo~Iltt) Onl' ... lrl.'Jlg th i ~ r~dut:ed hrL.uerall) (MMT of Ilngl'l Ile\llr\ ( j ) HI.'"~n.len \ node~ noted 31 the DIP alld PIP Join[, of th~ lett Illdex tinger, PaLienl de-nll,!\ p.1I1l III \\ 1'1'11 or finger,.

l (lilt"

C'lt/tli/lIIt"

Lett. IJ.lIhm fun ctio nal IJlnil~ . Rlgln withln tUIlClillClJI limits ( hip 1lI0tlOns not tea.1ied O\\lJIg 10 . . urgH..'a l illlen.eJ1llOn); crep itu!, noted io riP' \..nl~t' ,

Chapter 12 Examination of the Environment

Weightbearing status on right lower extremity: pania l weight bearin g Ran ge of Motion : Within fu nctional limits (wi th the excepti on of the ri ght hip. which was not tested) postsurgical Right Hip Preca uti ons: No hip nexion beyond 90°. Avoid crossing one leg or ank le over the other. Avoid internal rotati on of right lower extremity. Coordin ation: \Vithin nomlal li mits. Sensation : lntact. Gait: The patient is ambulating on level surfaces with supervision using bilateral standard aluminum ax illary crutches \\ ith panial weight beari ng on Ihe right lower ex tremity. Stair climbing also require s minima l assistance. It is anticipated the pati~nt will be indepe nde nt with household ambu lat ion on level surfaces at lime of discharge from the hospital.

PATIENT GOALS The patient is extre mely motivated to be independent in her personal care and hou sehold management. The prosthetic replacement has successfu ll y relieved much of Ihe pain experie nced in the hi p prior to surgery (most of her current discomfon is described as " minor" and associated with the surg ical incision ). She would also like to retu rn to her fami ly. voluntee r. social. and leisure acti vities. She is \'ef) determined 10 discontinue the horne ca re assislance 3':lo ~oo n as possible.

H OME ENVIRONMENT The palient Ii\es alone in a fifth tloor apanmem in a building with an elevator. The li vi ng s pace is a o ne-

439

bedroom apartm ent on a sin gle level. At your reques t, o ne of th e pati ent 's children has prov ided dim ensions of door frames and he ight of slee ping and seating surface s toge th er w ith several photog raphs of e ach room of the pati ent 's home. The ph ysica l dime nsions and photographs indicate the fo ll ow in g: Bedroom: two small area rugs, a ni ghtstand w ith an alarm clock, a bureau. a wooden platfonn bed w ith a slee ping surface I 1/2 fee t from the fl oor. and a ceiling lamp fi xture cont rolled by a switch adj acent to the door. Bathroom: an area rug, standard toilet and si nk , bathtub does not include a shower, a doorway entrance 30 in . wide . Kitchen: polished linoleum 1100rs, adequate counter space, and a dinin g tab le in the center of the room . Li vin g room: overstuffed upholstered furn iture w ith low seating surfaces, a large carpe t that appears to rippl e in several areas, a centered coffee table, a te lephone with an ex tra- long ex tensio n wire placed on the coffee table. a manual cont rol te lev isio n. two end tables and a bookcase. Hall way (between rooms): poorl y lit with a long. narrow area rug.

GUIDING QUESTIONS With general knowledge of the patiem 's li ving space. what environment al modificatio ns. adaptive equipment. or additi onal instructio n would you suggest or provide to o ptimize safety and function in eac h of the foll owing areas of the home? I . Bedroom

2. 3. 4. 5.

Bathroom Kit chen Liv ing room Hallway

R e fer e n c es I. Corcvran. M . and Gllhn. L: The role of th~ phY:'lCal en\ lron mclll In O\:<:up..tll(ln:ll perlumlaJlce. In Chrh!13n~ ell. CH. and Baulll , CM h:d!»: Ocl.UpJtlull.11 ·nn:rap} i:.nahlmg FunClion and Well - Bclng. ed :!: 'ilild,. Thorofare , NJ. 1<)97. P n6. :!:. La .... "m, MP. el al A..'>C':.\lIIg em ITOllmen\!, lor older PCllplc .... ith lhr,10ll lllnl::.\, J M..:nl Health Aglng~ ·83. 1997 . ~ Amc(JL,In Ph}~Il.al ·nlt;rilp) A!>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\d<1fd ALL..:\:.,hk and U~able Buddlllg ~ "od Fallhlie~ (IC('fA~SI A 11 7. 1- J <)9S). IlIlcrniJllonal Code ('oulln!, 1I1L . Fall:. (hurLh VA, 11191':1 5 ADA StJJlddrJ.. h)f At'(:e~~lblc De-~ign 12K C .... R Pm ~6). liS r.~PartIIlCIiI or JU :.I I L~. Re\l...:d . JuJ} I It)l)4 Rdnc\cJ Srplcmhn 15. ~(J05 Irum hup:II" " \t. u:.dl'j.gt)\ I<:rt/adol/:.ld~pdt.hlln (} Male. R. Abvu\ U III \l!r~oll J)e"l~n \\ hil' h l 'nin"I"!,. ... 1 tk~lgn 'J NC S'ille LIlI\er!>uy 'n,c ('~ll1n l or U n l\e J ~ .. II.k-!)lgn. all IlIltuill \'C of tht College oj DLI,lgn . J<)97, p 1 Rl!lnc\t'd Scplcml'lt:J 1'i. 2005 hUHl hnp:/I""Yo (k~lgn III ~u cUu/L'ud/i ndc>. 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.

7

New t)

Yor~ ,

)\}IN

r-.hcc. RL · Lhll\l' r~al d~"lgn III hvu'>lIlg A·,... Tedlnol 10( t ):2 I.

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 cfl Il l' dl\l(Rt Sl"Ilnd J Rdl.lb Mc:d 2 I (-I): 171 jI.JlSlJ '

38. Sonn. U. and A sberg. KH : A ssessmen t o.f aGcti v,hitiesb of d8.l·)Y living: A stud y of a popuhltion 0 f 76 -year-o 1d s 111 0 en urg, S wedtn. Scand J Re hab Med 23(4 ): 193 . 199 1. 39. Ka! z. S. et al : Studies of illness. of the aged. The l~dex of ADL: A qandardized measure of biolog ical and psyc hOSOCial function. JAMA (Sept 2 1) 185: 914 . 1963. . .. 40 Sonn, U, Gri m by. G . and Svan borg , A : ActIvitIes of daily Iivin, studied long itudinall y between 70 and 76 years of age. Disabil RchabiI18(2):9 1. 1996. 41 . Sonn. U: Longitudinal stud ie s of dependence in daily life activities among e lderl y persons. Scand J Rehab ~ ed. 3.4 : I (Suppl 34), 1996. 4 2. Sonn. U. and Svensson. E: Measu res of mdlvtdual and group changes in orde.red categorical da ta: A pp lication to the AOl Staircase . Scand J Re habil Med 29(4):233. 1997. 43. Danfo rd. GS. and Steinfeld. E: Uscr 's Guide for the Environ.mentaJ Function 100-407 and I OJ.-218~ Retrit;'v!?d (A·tober 7. 2005 from hnp:/Iwww.resoa.org/taprojecfJ Iihrary/la ws/techac t9-1. h tm. 53. Hart. DL , h emh;tgen. SJ . and l\htheson . LN: Guidelines for fuRc· tionai cap;tclty c\',ll uatio[1 of people with medical conditio&&. j Orlhop Sp{)rt~ Ph ) ~ Tht"r 18(6):681, 1993. 54 . G ' b~o.n . L. llnd Slrong. J: A l'OIWepfuaJ fmme work of functioall ~':I p-ln ' ) eva!U-I!IOll for oc("up:uional IherJPY in work. rehabililBlKa Au\t ra l Occ up Ther J 50C):64 . 2003. )5. Klhg. 1'1\1 . TUl' ]..\\ ell . N. ami Burrett. TE: A eri ticul rev iewal,... tl.onal ,apac iIY n;llu a.tlOn... Ph)' Thc;.>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 <;9. Allll'n,,~ul Ph) _~ Il'I.-,,;,·jallol1 Bow of Duccwn:: ~,,:\.uPdl lon.t1 Health Ph) \Ital Therapy Guideluli's.: Wort t I.ILldlt l i .nlll g .illd Wor].. HarJt:l1Jl1g Pr\\g ranb BoO 03-01-1 7." (P1·.og~'Ul\ 3~.). Rctnc\<..:d Oc tutx>r 8.1005 from http://*~ At\1/1 finler fl·lllpl .. tc l fm·.ISo:,· tlon "'- Ho me& CONTEN'TlDI )O~X& n:~lPl A fT -"'/Ct\V('Onlt'"llIDhplaycfm.

Chapter 12 Examination of the Envi..-onment 00. Hunh:r. S U'lng CQlto Improv(' \\ orl-c r\ heallh. PT MagazlOe o f Ph},lc:l1 Therapy .\{1 11:64 . 1995 O~en' , TR. Hoflman . GL. :lnd Kum:lr. S: An ergonom ic pcr,peCII\e (In accomm,")(]:ulOll m acce"lbilllY for JX'optc \\ Ith dl ~ abiht y. OI';lbd Rehahll l R(~): 402. 1996. . ' 62 . Alpert. J: The ph)'lcaltherapi,t\ role 10 jot> 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.os<1.mi l/cap) 75. The American , wi th Disabili ties Act of 1990 (As Amended): Public Law 101 -330. 76. Connolly. JB : Undc:r, tanding the ADA. Clinkal Management 12(2): 40. 1992. 77. Architectural Barrier.. Act. Public Law 90-480. I ()MI. 78. Publi c Buildin g~ Act. 98th Congre\s. I ~ I \es\ ion. 1(}8 3.

Readings

Agree. EM . Freedman . VA. and Sengupta. M : Factor:. influencing the u'e of mobllll~ technolog) in communit y- based long-term care. J Agmg Health 16(2):267. 2()()..l . Agree . EM. and Fr~dman. VA : A compari ..on of assisti ve technology and per<.Onal care In allevialmg di\:.tbillty and unmet need. Gerontologist ·n(3):335.2oo3. Cool. . A M. and Hu '~\'. SM : A"I .. uve Technologies: Princip le ~ and Practice. ed 2. Mo~b~. SI. Loui\. 2002 . Fangc. A. and 1\\ ar .. ,on. S: A cce~,ib ilit)' and u ~ abililY in housing : Construct \ulldity and implication, for research and practice. Di ..abl! Rehabl! 15(23 ): 1316, 2003 . Gulln. LN Conducllng re ..earch on home e n v lronme-nl~: Lessons leamed and ne\\ dirc:( tiom . Geronto l ogJ~t43(5):628. 2003. Gitlm. LN. et al. Effect-. of the home em Ironmental skill·building progrdm on the t:uregl\'e r-care reCIpIent dyad: 6-month outcomes from the Pfuhtdelphia REACH imtlatlVe. Gerontolog Ist 43(4 ):532. 2003 . l lAar..~on. S: A long·tenn per,pect,,·c on person-en\' iron ment fit and AOL dependence among older Swed l ~ h aduIL~. Gero/llo l ogi~t. 4SnJ:~27.

441

2005.

I \\ar~,on. S. and Stllhl. A' Acce~~ lbiIIl Y. u..... blilty. and univer,al de~lgn- Po'III01l1ng and defi mtion of concept.. dc\{'nbing per-on.

el1lHOnment relatiomhlps. DI .. abiJ Rehabil25(2):57. 2003. 1en'cn. G, l\\aT:.\on. S. and S I ~ hl. A: TIleoretlctll under .. tanding and m~thodologlcal ch allenj;:e~ in acce ~ ... ibilit y as\es<;mC/II\. l oc u ~ l1l g th~ em Iftmrncnlal component : All example from tra,·cI c hain ~ 111 urb;aJl public bus Irampon . DI ~abii Rehabi I 24(51:231. 2002 . Kn~ht. B ACle~"lbjh t) regu latiOn.<. and a unl\'~"al dnign philusoph) lIl'plrc thc deMgn proce~~. Archlt Ret I 14 5,2004 M.mn we. ('I al' Eftecll\cne" 0 1 d,.,I:.II\·e technntogy and en\'lronmcn. lalllllef\entlOlh III maliltalllJn!,\ mdept:ndence tlnd fl:duc ing home Cdn' lO~h for Iht" fraIl elderly: A randOll1lll'd controlled tri:.tl. Arl'h Fam Med Kf3r21O. 1999, M~Cl,' 11l L Shopping center wheelchaIr a(x'e~~ ibllity, Ongoin); ad\()tdl) to un pkmenl the Amenc
Preiser. W. and O., troff. E (cds): Universal Design Hand book. McGrawHill. New York . 2oo!. Newman. S: The Ii"ing conditions of elderly Americtlns. Gerontologist 43( I )099. 2()()3. Sandler. LA. and Blanck. P: The quest to make accessibiljty a corporate article of faith at Microsoft : Case study of corpomle cuhure and human re~ource dimens ions. Behav Sci Law 23( I ):39. 2005, Sanford. JA. and BUllerfield, T: Using remote assessment to provide home modification serv ices to underserved e lders. Gerontologist 45(3):389.2005. Schur. L. Kruse. D. and Blanck, P: Corporate culture and the employment of per..on, w ith disabilities. Beha v Sci Law 23( I ):3.2005. Shumway-Cook. A. et al: Environmental demand~ associated with com. munit), mobili ty in older adults wilh and w ithout mobility disability. Ph y~ Ther 82(7):670. 2002 , Sonn. U: Longi tudinal Sludie:. of dependence in daily li fe activities among elderly persOIl..,: Methodological dcvdopment, use of assistive devices and rdation to impainnents and functional limitations. Scand J Rehabil Med (Suppl) H: I. 1996. Spataro. SE: DiH!rsi ty III context: How organizational culture shapes reac tiom to worker~ wi th disabilities and o th c r~ who are demographicall y differ~nI . Behav Sci Law 23( I ):2 1, 2005. Steinfeld. E, and Danford. GS (ed:'l): Enabling Environment ... Measuring the Impact of Environment on Di:.tlbilit~ and Re habilitation. KlulAer Academic Plenum , New York, 1999. Thtlpar. N. et al : A pilot study of functional accc\s to publiC buildlllg~ and f3cililie .. for per<;()n:. with impaimlenl'>. Disabi! Rehabil 26(5):2RO,2004 . Ward . AC. and Bal-l'r. PM : Slffilt'"gie:. for \\orl-pl:tce Inlegratlo n. Behd\ 5\."1 La" 23( I) : 143. 2005. Woolen. LP, and l ame ... EH : C hallenge~ of or~aniz.lIlOnalleJ.mi ng : Perpetuat ion of dl\crimlnatiOIl again~1 emplo) ee .. \\ im di\"billtie.. , Bch:.t\ Sci Lil\\ 2 1( I): I"23. 2005.

Appendix A THE PRINCIPLES OF UNIVERSAL DESIGN 1. EQUITABLE USE

2. FLEXIBILITY IN USE

The design is useful and marketable 10 people with diverse abilities.

The design accommodates a wi d ~ .r~nge of individual preferences and abIlities.

GUIDELINES 1a . Prov,de th e same means 01 use for all users ,denl.eal whenever possIble equlvalerll when nol.

GUIDELINES 2a. Provide ehoree In methods 01 use

1 b . AvOId S@gregalongof Slfgmal121r1g any users

2b. Accommodate fight· (It left handed access aod use

l e . Make provISIOns lor prIvacy secunty. and safely equally ava~~bIe 10 all users

2d. PIOYIde adaptaDtlity 10 the user S pace

ld . Ma~ e lhe deSIgn appeal ing 10 all users

EXAMPLES

2e. FaeMale the user-s accuracy and pf9CISlon. EXAMPLES

SClsso,s deSIgned 10f nghl' or left· handed users.

Po .... er doors w,th sensors al entrances Ihal afe convenient

An automated lellef machIne (ATM llhat has VISual, tael,le. and audobJe feedback. a tapered card Opening al'ld a palm rf!~1

f()l all users

Integrated dIspersed. and adapl<Jble seallrlQ ,n assembly

areas such as sports arenas and lheaters

3. SIMPLE AND INTUITIVE USE Use of the design is easy to understand regardless of the user 5 expenence , knowledge. langu age skills. or current concentration level.

4. PERCEPTIBLE INFORMATION The design communicates necessary mformatlOn effectively to the user, regardless of ambient conditions or the users sensory abilities .

•j ,

I'

, I GUIDELINES 3a £1 m.nale uf\J)tH.e!oSri1r tompI". dy

U>I'I~I. 1"!l1 w·ft, US,,! .... poc\.J"on~ <11"10 ,"1("1.)(1

3b

Bfe

3c

A(~ (I" .dng., ot hl~."(~ dl1d IdngUag& ~"1l11

3d

Alf41lg6 m\(;rrr, .. I,,,,,

l(m"~I"'fll "',Ih II

GUIDELINES 4a.

4b MJ. ",lZa IffiJ bolly 01

If!lpOllalW;1O

4c

3e f'rc..o(Jo. ,,""" t,,,., prvrnj.JII'1\I
I) fl.

velbal t~hl~)!Of et;~hall(1tor"'abOll

h~"/II,..IIf'tIOr,nat.uf't

'''10'.1 ... IWay" Ih-lt car' be doitSC:lload

Iidiu

1:1 tn..,. .. Ita.hl 10 g. ... '~I'U.·IIO"5 0< dolecl101'1$l 4d Pro • ..", W(nJ).ll tI 111\ .....i'1 a ~ .. ,tII}r 01 1«t11l0Q09b IJo(

13 I "nlpl""""

EX AMPLES

U~" (j;Ir"ff'fll rt,,>dt:s 'po...tor,al 'tKIi. '10 '''1 pte5ij'IlJIII)n G't

Amo"'ltg5000:0"'.oI1 <.or .. ""dI«l...., "I a puDlo(';'p.;;...e

0.. ..."" U'.iU\j

EXAMPLES

r·,~l"~ ~

c;; -l

O~ ~ .... 'tn::i-lJOSOry ~moUbOns

U.:lJ .lr'IIJ .1"d,l:Jj\j CU"I.lnd

u,wlftOitv

h'>
1fl~IIll(;bOtlS

~".mg 110 9 ~""-101 ~on\(]lUrllC""Oflli ilnd

'''J''''\I''11fl i\.·1iOr1&. !f<,,1l bt..hOtUl MlU

~u.bw\ta~ cars.

Chapter 12 Examination of the Environment

443

THE PRINCIPLES OF UNIVERSAL DESIGN 5.TOLERANCE FOR ERROR

6. LOW PHYSICAL EFFORT

The design minimizes hazards and the adverse consequences of accidental or intended actions.

The design can be used efficiently and comfortably and with a minimum o11atigue.

GUI DELI NES Sa. Arrange elements to m>nlmlze hazardS and errors

GUID ELINES 6a . Allow user

most used elemenls. most accessl bj e. ha za rdous elements eliminated , Isolaled . or shielded

5b, Provide warn>ngs of hazards and erfors.

6e,

MInimiZe repehtlve aclions.

5c.

6d .

M,nimize sustained physICal effor1

PrOVide lall sale leatures

EXAMPLES

5d , Di scou rage unconSCIOus aCllon In tasks thai requ ll e vigilance

EXAMPL ES

10 mamlaln a neutral body poSItion.

6b, Use reason able operaling forces .

Lever or loop handles on doors and fi:!ucet s lOuct1 lamps operat ed without a SWilCh

A dou tlle -<:ul ca r key ea sily Insefted '1'110 a recessed

keyhole In elthe l of two ways An ·undo· leature In co mputer sottware !hal allows the U&el to correct mistake s without pena lty

7. SIZE AND SPACE FOR APPROACH AND USE Appropriate size and space is provided for approach. reach, manipulation, and use regardless of user's body size, posture, or mobility.

THE PRINCIPLES WERE COMPLIED BY ADVOCATES OF UNIVERSAL DESIGN, IN ALPHABETICAL ORDER : Bettye Rose Connell , Mike Jones, Ron Mace. Jim Mueller. Abir Mullick. Elaine Ostroff. Jon Sanford , Ed Steinfeld, Molly S tor~ and Gregg Vanderheiden .

GUIDELINES 78 PruVidt a cledr I,ne vI sight 10 "nporIJm elemenl" lor sedled

vI

itll'(

~t ..ndlng 1.1"£,,

7b Malo.e l"aUlto all compollenl~ cvm lmlabl€ lOr any Mlal"d 01 stdndlll9 use,

7e Auvn,"lOOdle ~a!l,jtlV l\ s In h"nd .. no glOp Sil..

7d PI""'OO dde'llJale llf.'d~a

' PI tn ..

u~e 01 a5SI ~I'~e d,'h
pel~,"",dl dS5,~t;:mce

EXAMPLES

Conhvb ....n tf,e lro,,1d,oO<.I t "r tlou. slJacu .. round ..ppl' ''IIL~. d umpste(~ ...nd oll ,c, t;ltlm"nl~ W,d" 9011/:15
NOTE :

The Pnnclples 01 Universal DeSign are not Intended to constitute all en tarla lor good deSign only universally usable deSign Certalnl~ other factors ale Imporlant such as aastheucs, cos t safety. gender and cultural appropriateness and these aspects mllst also be taken Into ConSideration when deSigning

Appendix B: Usability in My Home-A Self-Report Instrument Di rect io ns: The quc'ai o llnaire consisls o f Iwo pa rt s. w ith a number of qu e ~ l ion s about the des ign of the physical hO// si n ~ cf/I' i r OlllJll>fII in which you live. You are a~ k ed 10 an,,> wc; the questi on:, by assess ing how you feel that the desig n and Co nn of the physical housing env ironme nt s uit s YOll , YOUT need s. and your wis hes. By physical ho usin g environment is mean t here your home . the car park . garage. o r park ing s pace thai you use if you ha ve a car, your own lCll crbox. the du stbi n/re fu se

I. In re lation to how you no rm a ll y ma nage your persona l hyg iene. dress ing. v is iting the toil et, or how you eat: to what ex te nt is the hous in g e nv ironment suil. abl y des ig ned? (If you do II Ot manage any of these at

~ I o ra g e

place. the storage space. and the shared la undry.

2. In relatio n to ho w you no rma ll y m anage your cooking/

if there

i~

one. Th;:, includes all the roules

along w hi ch

move on the site to and from these places. It also inc lude~ ~I balcony. pat io. and garde n w he re appl icable.

)OU

The questi ons a re ve ry ge neral. and the aim is to cap· lure your immediate percepti on of how the physica l hous· in g e nv ironment suits you. Fo r eac h q ue sti on the re are seve n respo nse a lte rn atives m the fo rm of the numbe rs I to 7. Th e numbe r I ~ tand ~ for w hat is the worst a nd lowe st alt e rnati ve fo r )O U. ,", hi le 7 s tand &fo r th e bes t and hi g hes t a lt ern ati ve . The J1umber~ 2 10 6 de sc ribe th e pos ition :-. that lie betwee n th e be~ t and th e worst alte rnat ives. The numbe r 4 i~ the ne utral poi lll on the :-.ca le. ne ithe r good no r bad . Put a c irc le ro und the a lt ern ative th ai ag rees be st w ilh ) o ur pe rce pt io n. £.wmple: If )OU a re so d iss ati sfi ed wi th your p hys ica l ho w., in g e m ironme nt Iha l it could no l. in you r opinio n. be \\ o rse fo r yo u. then c ircle the nu mber I . If you a re so sat is fi ed with the de ~ i g n of y ou r ph ysica l housing e nv iro nme nt th at it coul d no l. in ) ou r o pin io n. be bette r. the n Circle the n um be r 7. You use th e n um . ber... 110 7 10 d e~c ribe hO\\ close to the be s t o r wo rsl alterna lJ ve yo u fin d th e feat ure s of yo ur hou s in g em lron me lll . There no,", fo lio,", a number of q uesti om aboul how ,",e ll )uu fee ll hal the de ... i!;!n of you r ph ys ica l ho u ... in g e ll\ lronme nl sUII :-. your need s a nd wi~ h e~ . So me LJu t'st iom. conce rn . . ec: uri t). ~oC Ja I in teract ion . etc .. w hile ot he r.., conce rn hu,", th e dc.;, ign of Ihe ho using en viron me nt Ill alt'~ II ea\y or diffic ul t 10 do the eve ryday ta ... h ) Oll '"' Is h and need 10 perfo rm . Dr~l v. ~ c ird t' round the number tha t you thj nl... ag re e ... be!'t v. IIh )0U/ ov. n perceprio n ,h,'m I .Illgt'. A 11tl(l~l, t '~,1hlhl ) III

M} HOOll" M.UlU,11 ,lIld

all, cross out the whole question.)

3

2

5

Not at a ll s uit abl e

6

7 Very suitable

he alin g of food or preparat io n of s nacks: to what exte nt is the housing env iron ment s uitabl y designed? (If YO II do 110 t manage any of these at all, cross out

the whole question.)

2

3

4

5

Not at all s u itable

6 7 Very sui lable

3. In re lario n to how you nonnall y m anage your washing up . cl eaning. care of fl owers: to what extent is lhe hous· ing environment suitably desig ned ? (1/ .'1011 do not man· age any o/thl'se at all. cross out the whole question.)

2

3

4

Not at a ll s uit able

5

6

7

Very suitable

4. In re lati o n to ho" you no nnally manage your wash· ing . ironing. o r re pa ir o f clothes: to what extent is rbe ho us ing e nv ironme nt s uitabl y d es igned? (1/),011 do I/ot "wI/age any (I//l'srioll . )

0/ rhese tit all. eroSJ out the whole

2

3

No t a t a ll s ui lah lc

4

7 6 Very suilllblo

5 . H. ow "iCC lII'e do you fee l i ll your hous ing e nvi ronment?

2

6 Complelely secure

NOt at a ll ~ec ll n.·

6. To \\ hat ex te nt t..Ioe~ th~ de-. ig n o f the hou~ing envp 1lll' lIt a Bu" ) o u to be by }-our..,(' lf whe n you so wisb~

I n'>t ruJH~' nt

I llnn f)J\"lUII .)1 (A'lUll.llltlH,11 I hcrtlp),. Lund tlll \,.. ' '> II ). S .... ~JC H I( .A.gm:til 1 .1II~c, 1(11)1, .... llh pt: n lll~l,m)

4

3 Not ~H a ll

7 6 5 A; much as I w... III

Chapte r 12 Examination of the Environment 13. What proble ms do you find in the design of the entrance to your home (e.g. heavy doors, narrow stairs. ramps, cramped lift, poor li gh ting. etc.)?

7. To what ex ten t doe s the design of the hous ing environment all ow yo u to sociali ze with th e friend s and acquaintances you want to m ee t? 2

3

4

5

7

6

As much as I want to

Not at all

8. To \\ hat ex tent does the des ign of the housing environment all o\\' you to do hobbies/leisure pursuits and relax?

2

3

4

5

6

3

4

5

6

There nov. fo llow a number of question s about how usable yo u feel th at yo ur hOllsing env ironment is. First you make an ove rall assessment (question 10). This is fo ll owed by a number of more detailed questions about usabili ty in different pans of the hou si ng environment. State the proble ms yo u percei ve and make an assessment of ho" acce ss ible eac h pan of the hou sing environment is. wilh regard 10 the problems you have stated (questions II to 22 1. If you do not feel that there are any special problem'), please say so. Do not forget 10 assess each part of the ph)'~ ical hou si ng env ironme nt , even if you have not Slated an} speCific problem.

10. Ho" usable do yo u feel that yo ur housing environi~

Not

al

3

4

5

all u),able

6 Fully usable

16. In view of the above problems in question 15, how usable do you feel that the secondary spaces in your home are?

2

3

4

5

Not at a ll usable

6

7

Fully usable

17. What problems do you have in reading and understand ing markings and signs outside the building or at the entrance? (For example, are lift buttons fully v isi ble and easy to use? Are the signs at the waste sorting station c lear and easy to understand? Are the markings in staircases easy to see?) (The queSTions should only he answered by people til'illg in apartmems. If you til'e ill your oU'n house. omit this question and

18. In view of the above problems in questi o n 17. to what exten t would you say that the markings and s igns o utside the building and at the e ntrance cn n be read and unde rstood?

2

omit (1IleMioI110.)

all u\ able

7

3

4

5

6

5

6

7

Perfectly easi ly

19 . What probh:m ~ do you lind in the de,ign of your balcony, palin, o r garden? Ufyol/ do 110t hm'e un\' halcOlly. patio , or ~a,.dell. please .m\' .w . You m(l~' then

12. In vie .... ol lhe above prob le ms in que'\ti on II . how u~abl t do you fee l that the environment ollt:-'Ide your home i ... ?

dt

6

Fully usable

Not at all usable

Not at all

Not

5

7

11. What problem~ do }Oll perceive in the ph ys ical environment JU\t oUb lde you r home (e.g., paths and pavemem .... car park/garage/carport, the design of the refu se ~tora gc: place. lhe plac ing of your letterbox, elc.)?

2

4

questioll 18. )

in general ?

2

3

7

As much as I need to

Not at all

2

15 . What problems do you find in the de s ign of the secondary spaces in your home (e.g., store room s, attic/ basement. refu se storage place. laundry [if any], and the routes you have to follow indoors to reach these p laces)?

9. If you r healt h should change. to what extenl wo uld il be possible for you to make simple changes to your housing em ironment (e.g .. to use a different parking place. to u~e a diffe rent toiler. to rearrange the furniture. to use a different room as a bedroom. etc.)?

2

14. In view of th e above prob lems in question 13, how usab le do you feel that the entrance to your home is?

7

As much as I want to

Not at all

ment

445

7

Full y u"ble

•

To rondude. !here 1'1 a ge neral 4 11C !\Iion w hich allows you to C\pr(· . . 'l your \\' I, he... and need".

20 In \ Ii,'\\ ollhe ,lhmL' pm hlcm ... III quc'lilon 1<), ho\\ 1I,.th k do ~ ou kl'l 1h~11 thl' halcony , p.l1lll. or g.. 11 <.1\.'11 .Ife -I

1

';

"

7

hili) u'
.

21 \\ h.1I prohlem ... <.11) \ ~lU find nor 01 ) our hornl' ,

.

111 the dC'11.!1l

01 thL'

Il1le ·

.,., In \ Il'\\ olllw ~lhO\L' problem' Jfl qUl',uon 2 1. 110\\ u,.thk do ~ou kl'llh;lllhe Interior 01 )ou r hOIll\' I ' -~

.1

7

5 Ful ly u'lahlc

23 . If yOll \\crc able 10 \\ .... h tor any thmg at ali concern . Ing your home and your hou"'l ng env ironment. Whal \\ou ld you \\ I ... h 10(.'

Appendix C Craig Hospital Inventory of Environmental Factors From Craig Hospital, Research Department. 3425 S. Clarkson Street. Englewood , CO. 80110 , with permission .

© ller information contact chamson·lehx@cralghospltaLorg or dmelllcl<@craighosplta!.org) Being an active. productive member of society includes partlci pati.n~ in s~~~ thi,ngs as workin~ , going to school , taking car~ of your home, a~d being Involved with family and friends in social, recreational and CIVIC actiVities In the community. Many factors can help or Improve a person 5 partiCipation In these activities while other faclors can act as barriers and limit p articipation. First of all. do you think you have had the same opportunities as other people to partIcipate In and take advantage 01 :

Employment

_ _ yes _ _ yes

Recreation /leisu re

_ _ yes

Education

no no no

First. please tell me how often each of the following has been a barrier to your own participation in the activities that matter to you . Think about the past year. and tell me whether each item on the list below has been a p roblem daily, w eekly, monthly, le ss than monthly, or never. If the Item occurs. then answer the question as to how big a problem the Item is with regard to your participation in the activities that matter to you. (Note If a question asks specifically about schoo l or work and you neither work nor attend school. check not applicable)

In the past' 2 months. how often has the availability of transportation been a problem for you?

0

0

0

0

0

When thiS problem occurs has It been a big problem or a liMle problem? 2. ln the past 12 months. how often has the design and layout of your home made It difficult to do what you want or need to do?

0

0

0

0

0

0

0

0

0

When thiS problem occurs has It been a big problem or a little problem? 4 In the past ' 2 months. how often has the design and layout of buildings and places you use In your commumty made It difficult to do what you want or need to do?

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

When thiS problem occurs has It been a big problem or a lillIe problem ? 9

Ir~he past

a

12 months how ohen ha~ the availability oi heallh Care servICes medical care been a problem lor you?

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

When thiS problem occurs has It been a big problem or a laUe problem? 8 In the past' 2 months, how often has the aV8llablhty 01 the educaflOn and training you needed been a problem for you?

0

0

0

When Ihls problem occurs has It been a big problem or a little problem? 7. In the past 12 months. how ohen has the Iniormahon you wanted or needed not been available In a forma t you can use or understand?

0

0

When thiS problem occurs has It been a big problem or a lill ie problem? 61n the past 12 months, how ohen have other aspects 01 your surrounding s _ hghtlng, noise. crowds, etc.· made It dlfflcullto do what you want or need 10 do?

0

0

When thiS problem occurs has 11 been a big problem or a hnle problem? 5 In the past 12 months. how ohen has the natural enVIronment - temperature terrain , climate - made It dllflcult to do what you want or need to do? '

0

0

When thiS problem occurs has It been a big problem or a httle problem? 3 In the past 12 months. how often has the design and layout of buildings and places you use at school or work made it di lflcult to do what you want or need to do?

0

0 0

When Ihls probl6m occurs has II been a big proolem or a hnle problem? lO in the past 12 months, how often has the lack 01 personal eqUIpment or ~peclal adapted deVices been a prOblem for you ? Examples mighl Include earrng aids eyeglasses o r wheelchairS When Ihls problem OCCurs has It been a big problem or a little problem?

0

0

0

0

0

448

Physical Rehabilitation

11 In the past 12 months, how often has the lack of computer technology

been a problem lor you? When this problem occurs has it been a big problem or a lillie problem?

0

12, In the past 12 months, how olten did you need someone else's help in your home and could nol gel II easily? When this problem occurs has it been a big problem or a titUe problem?

0

13. In the past 12 months , how often did you need someone else's help at

0

school or work and could nOI get it easily?

0 0 0

0 0 0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0 0

0

0

0

When this problem occurs has it been a big problem or a little problem?

14. In the past 12 months, how often did you need someone else's help in your community and could not get it easily?

0

0

0

0

0

When this problem occurs has il been a big problem or a little problem?

15. In the past 12 months, how often have other people's allitudes toward you been a problem al home?

0

0

0

0

0

When this problem occurs has it been a big problem or a little problem? 16,In the past 12 months, how often have other people's altitudes toward you been a problem at school or work?

0

0

0

0

0

0

When this problem occurs has it been a big problem or a little problem?

17 In the past' 2 months, how often have other people's attitudes toward you been a problem In the community?

0

0

0

0

0

When this problem occurs has it been a big problem or a little problem? 18, In the past 12 months, how often has a lack of support and encouragemenl from others in your home been a problem?

0

0

0

0

0

When this problem occurs has it been a big problem or a little problem?

19. In the past 12 months, how often has a lack of support and encourage _ menl from others at school or work been a problem ?

0

0

0

0

0

0

When this problem occurs has it been a big problem or a little problem ?

20 In the past 12 months, how otten has a lack of support and encouragement from others in your community been a problem?

0

0

0

0

0

When this problem occurs has it been a big problem or a little problem? 21 , In the past 12 months , how often did you experience prejudice or dlscnmmalton ?

0

0

0

0

0

When this problem occurs has It been a big problem or a little problem?

22. In the past 12 months, how often has the lack of programs and services in the commuOily been a problem?

0

0

0

0

0

When this problem OCCurs has it been a big problem or a little problem?

23 In the past' 2 months, how often did the poliCies and rules of bUSinesses and orgamzatlons make problems for you?

0 0

0

0

0

0

When this problem Occurs has It been a big problem or a little problem?

24 In the p~~t 12 months, how often did education and employment programs and poliCIes make It difficult to do what you want or need to do?

0 0

0

0

0

0

When this problem occurs has it been a big problem or a little problem ?

25 In the past 12 months how often did government programs and poliCies make It difficult to do what you want or need 10 do? When

t~

problem OCCUI S has 1\ been a big problem or a httle problem?

---

0

0

0 0

0

0

0

0

0

0

Appendix D THE ADL-STAIRCASE © Sonn, U, Huller Asberg, K. 1990, with permission Note: In this instrument, the term personal activities 01 daily living (P· AOl) is synonymous with basic activities of dally living (BADL).

DEFINITIONS Cleaning: performs house cleaning, vacuum cleaning, washing floors Independent: Pertorms the activity when necessary. . PIIrtly dependent Gets assistance in taking the carpets outdoors or assistance very ~e.ldom. Dependent: Does not perform the activity or gets assistance with some part of the actIVIty regularly.

Shopping : gets to the store, manages stairs and other obstacles, takes out groceries, pays for them and carries them home Independent: Performs the activity when necessary. Partly dependent: Performs the activity but together with another person. Dependent: Does not perform the activity or needs assistance with some part of the activity.

Transportation: gets to the stop for public transportation, get on and goes by bus, tram, or'raln Independent: Performs the activity when needed. Parity dependent: Performs the activity but together with another person. Oependent: Does not perform the activity.

Cooking : gets to the kitchen, prepares the food, manage the stove Independent: Performs the activity when needed. Parlly dependent : Does not prepare dinner-food or only heating up prepared food . Dependent : Does not perform the activity.

Bathing: means sponge bath, tub bath, or shower Independent: Receives no assistance (gets in and out of tub by self il tub is usual means of bathing). Panty dependent: Receives assistance in bathing only one part of the body (such as back or leg). Dependent: Receives assistance in bathing more than one part of the body (or does not bathe self).

Dressing : means getting all needed clothing from closets and drawers and getting dressed, includes using fasteners. and putting on brace if worn Independent: Gets clothes and gets completely dressed without assistance. Partly dependent: Gets clothes and gets dressed without assistance except for help with tying shoes. Dependent: Receives assistance in getting clothes or in getting dressed, or stays partly or incompletely dressed.

To ileting: means going to the "toilet room " for bowel and urine elimination, cleaning self after sllm/nsUon, and stnlnglng clothes Independent: Goes to the "toilet room: clean self and arrange clothes without assistance. (May use support object such as cane, walker, or wheelchair, and may manage a night bedpan or commode, emptying it in the morning.) Parity dependent: Receives assistance in going to the "1oilet room ~ or in cleaning self or in arranging clothes after elimination, night bedpan or commode. Dependent: Does not go to the "toilet room~ for elimination. Transfer : means moving in and out of bed and in and out of chair Independent: Moves in and out of bed and out 01 chair without assistance. (May use support objecl such as cane or walker.) Partly dependent: Moves in and out of bed or chair with assistance. Dependent: Does nol get out of bed .

Continence: means function of controlling elimination from the bladder and bo wel Independent: Controls urination and bowel movement completely by sell. Partly dependent: Has occasional ~accJdents.~ Dependent: SuperviSion helps keep urine or bowel control, or catheter is used, or IS incontinent

Feeding : mesns the basic process of getting load from plate or equivalent Into the mouth Independent: Feeds self without assistance. PartlV dependent: Feeds self except for getting assistance in cutting meal or bunering bread . Dependent: Receives assistance in feeding or is fed partly or completely through tubes or with intravenous fluids.

or using the

450

Physical Rehabilitation

THE ADL-STAIRCASE © Sonn. U. Hulter Asberg. K, 1990. with permission Definitions of personal (P _) and instrumental (I -) ADL according 10 a cumulative scale of conditional ADL-steps (the ADL Staircase)

ADL-Steps in I and P-ADL Step 0

Independent in all activities

Step 1

Dependent on one activity

Step 2

Dependent on cleaning and one more activity

Step 3

Dependent on cleaning. shopping. and one more activity

Step 4

Dependent on cleaning . shopping. transportation. and one more activity

Step 5

Dependent in all I-ADLs and one P-ADL

Step 6

Dependent in a/l I-ADLs. bathing. and one more P-ADL

Step 7

Dependent in all I-ADLs. bathing. dressing. and one more P-ADL

Step 8

Dependent In aU I-ADLs. bathing, dressing. going to the toilet. and one more P-AOL

Step 9

Dependent in all activities

" Others "

Dependent in two or more activities but not classifiable as above

If the item continence is included. the definitions of the last two steps will be as follows: Step 9

Dependent in all I-ADLs, bathing. dressing, going to the toilet, transfer, and one more P-AOL

Step 10

Dependent in all activities ADL-step 0

ADL-step 1 Cleaning ADL-step 2 Shopping ADL-step 3 Transportation ADL-step 4 Cooking ADL -step 5 Bathing ADL-step 6 Dressing ADL-step 7 Toileting ADL-step 8 Tr ansfer ADL -step 9 Continence ADL -step 10 Feeding

Appendix E: The Enviro-FIWM Instrument's Eleven Levels of Function and Their Associated Scores inappropriate am ount of time. mayor may not use a n ass isti ve dev ice(s) or aid(s) and mayor m ay not c hange (or ca use some o ne e lse 10 c hange) th e e nv ironm e nta l contex t.

Independent The per~on receives no he lp wi th a ny of the behavioral

components involved in the ac tivity. 10 No Assista nce-The person completes the acti vi ty wi th out tak ing an inap propria te amount of ti me. without usin g an as~is l ive device (s) o r aid(s). wi th out changing (or causi ng so meone else to change) the environmental contexi. and withou t ri sking personal ~a fet y or we ll -bei ng.

Modified Independent The per':lon receives no he lp with any of the be hav ioral componen ts invoh'ed in the activity. T he person com-

pletes the activi ty independentl y but either takes an inapproprialc amount of lime . uses an assistive device(s) or aJd (s). changes tor cause s some one else to change) the environmental context or ri sks persona l safe ty or well -

bemg. 9 Additional time-The person completes the ac tiv it y independently and safe ly but takes an inappropriate amount of time. At least one of the followi ng is true : (he person hesitate s. make~ re pe ated anempts, takes a t least one period of re ~ t or s impl y take s at least double the amount of time nonnall), required to comp le te the actJ\Il). 8 Assisti\'e device-The pe rson completes the ac tivit y IIldependen tl) and safe ly by using an ass istive dev ice(s) or aldh). The per~o n mayor may not take an inappropnJt~ amount 01 lime. 7 Modified em ironment- The person completes the Jell\ II) independentl y and ~afe l y after l' hang ing (or cau..,mg '>ulnt' 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~ <:ompletcd ~LJccess fu l l)' only aft er eI,e rerfoml~ the task on the person's behalf. Len'I 3-\ l aximum: AI least one of the fo llow ing is true: the per-0Il rll'rfomh the ta~k s ucce~~ fully only after more than ('lOt' anelllpl: ~ucce",';;fu l task perfonnance takes much more than the amount o f time (i.e., :lIiea<.;' double) thJI \\ au ld he typIcal for a member of lhe general popula. tlon tunctioning under .. imtlar circu m ... tances: the person ~omeone

o ffers frequent o r lengthy complaint (verba l or nonverba l) a~ an expre~s i o n o f frustratio n. inconvenience o r an xiety d uring ta~ k perf0n11 ance: o r there is frequent o r lengthy intemlpti oll in the cOlltinuity o f task perfon1lallce. Level 2- Modc ra le: At least o ne o f the fo ll ow ing is tru e; successful task pe rforman ce takes o nly a littl e mo re than the amo ullI o f time (i.e., less than d o ubl e) th at would be typic,d fo r a me mber o f the gene ral po pu lation fun c tioning under simi la r ci rc umsta nce .. : the pe r~o n o ffe rs o nl y infrequ ent o r brie f compl a int (verbal o r nonve rba l) as an express io n o f fru strati o n. agg ravation. inconve ni e nce o r anxiet y durin g tas k pe r· fo nn a n c~ : o r the re is o nl y infreque nt o r bri e f interrup· ri on in th e continuity o f task pe rfo rm a nce. Level I-Minimu m : All o f the fo ll ow ing are true: s u cce~sful tas k perfo nnance takes no m ore time than wo uld be ty pica l for a membe r o f the ge neral po pu la· lion fu nctio ning under similar c irc um stances: the per· son offe rs no complaint as an ex press io n o f fru stratio n, aggravati o n, inconve nie nce or a nx iety du rin g tas k pe r~ fo nn ance: and the re is no in terrupt io n in the continu ity o f task pcrfo nnance.

Appendix H: The Functional Perfonnance Measure's LES™ Decision Tree Yes Is performance of the task unobservable? ------.:.:::'----~•• UNKNOWN

"j "j

Is task performance not required

lor completion of the activity?

_____ __

Yes

---'::.:c__•• NONEI NOT APPLICABLE

'''·~r··~

Yes

"~""""1 ~ ,~,~,

Yes

-

• NONE! NOT APPLICABLE

• BLOCKED

Is the opportunity to perform the task declined? _____---' \<=es~_---+

• DECLINED

.j

..'·-:1

Is the task not completed without someone

~ ~'""'""~"

Yes

Does successful task performance lak h one attem I e more t an h p or much more than the typiCal amounl 01 time or ave either more than one or length . I

·-""":r,'", , ~"-,

Yes

or. while performing the task does theY In errupllons: _ _ _ _.:::~_~•• 81th , person offer

Does task performan I k than the tYPical amo~en,aOle Only a IIltle rnOre 1101e b lime or have only fief interruption or while perf one

-'"".-~T ""=:.:::,::;, • MINIMUM

\o'lr l l l ""lIJU _I,IU)

• • •

IMPOSSIBLE

MA XI MUM

Yes

MODERATE

Appendix I: The Functional Perfonnance Measure's LASTM Eight Levels of Assistance and Their Defining Characteristics Lc\'el X- Unknown : A s~ i ~ lan ce with ta!:lk perform ance is nOI ob:-c rva hl e. Le\'el O--None: No a ss i ~ wll cc is provided becau se task perfonnance is nOI required for completion of the activi ty in the ob!:lerved situa tion. becau !:I c the task is se lf-perfonn ing. or because th e person perfonnin g the task req ui res no ass istance. Le\ eI 6---Blocked : The abil ity to prov ide ass istan ce is Ih \, al1ed either bec3 u!:Ic c h arac l e ri s li c~ of the observed situ ati on make ass isting th e las k pe rfo nn ance fu tile or beca use the activ it ), was abo rted before ass istance with lask perfonlli1 nce co uld be att e mpH~d . Le,'cIS-Declin ed : The opportun ity to provide ass istallel" is refused. (From D:tnford and

Slei n fc l d.~ ~

r 1.1 wi th

penn i,,~ i on l

Level 4--I mposs ib le: The task is not comp leted s u cce ss~ full y eve n though assistance is prov ided that involves an allelll pt to perform th e task o n the person 's be half. Level 3-Max im u m: The ass istance provided e ffecti ve ly constitu tes d irect pe rfo rmance of the task on behalf of the person performing the activi ty. Le \'cl 2- Mod er a te: The ass istance provided mere ly faci litates perform ance of the task by the person per~ form in g th e activit y. Leve l I-Minim u m : The assistance prov ided is only incide nt al to perfo rm ance of the task by the pe rson perfonni ng the acti vity.

Appendix J: The Functional Performance Measure's LAS™ Decision Tree Ves

Is assistance with the task performance unobservable?

'" j Is 5uccessfullask performance nol required for completion of the activity?

'" j ,,,.,~ l~'-'"" Is assistance with task performance nol

---~.:....--+.

Ves

UNKNONN

• • •

•

NONE! NOT APPLICABLE

Ves

•

NONE! NOT APPLICABLE

Ves

-~--'"r"-"""

•

NONE! NOT APPLICABLE

Ves

Is the ability to provide assistance thwarted ? -----~~-.....

•

BLOCKED

Nol

"·-"""1. _. ··'

Ves

•

Is ~omplelion of task nol possible even

• ,' , - , .

•

DECLINED

•

~~• •,,~-, ------.:~~e"-s-~·~IMPOSSIBLE

Does the assistance provided effectively constitute direct performance of the task _ _ _ _ _-.:~~ e"-s_ _~ on the person's behalf? ~

Noj

•

MAXtMUM

Doe~ .the assistance provided merely

lac"IIate

F ( rom D:mford and

pert:~rce 01 the lask? ------..~:~e~s--••MO!

•

MINIMUM S h; lIIfdd ,,~,11

•

. h ....11

pemll ~SIOIl )

ATE

Appendix K: The Environmental Utility Measure's Difficulty Rating Scale (DRSTM)

\\>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

<25%

0 0 0

0 0

0 0

0

0

0 0

0 0

0 0

0

0

0

0

NIA

<25%

0 0 0

0 0 0

0 0 0

0

0

0 0

0

0 0

0 0

0 0

0 0

0

0 0

0 0

0 0

0 0

0 0

N/A 0

<25%

0

0

0

0

0 0 0 0 0

"Frequently : activity or cond itio ns ex ist from 113 to 213 of the time

PH YSICAL REQUIREMENTS : Indicate the percent of time the following are per/armed. The following activities cannot be performed concurrently, so the total should equal 100%. To bend legs at the knee, come to rest on knees

KNEEL CROUCH

l o bend the body down and forward , bending the legs and spine

CRAWL

Move on the hands. knees and feet

CLIMB

Ascend/descend ladders , stairs, ramps

SIT

For up to two hours at a time

STAND

For up to two hours at a time

WALK

Move about on foo t

The following can be performed concurrently , so the amounts need not be totaled.

25-49% 50-74% >75%

0

0

25-49% 5()"74% >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

<25%

25-49% 50-74% >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

<25%

0 0

0

0 0

0 0

VERY HEAVY Exert 100 Ibs of force occasionally' and/or 50 Ibs. of force frequently" 'Occasionally : activity or conditions exist up to 113 of the ti me " Frequently : activ ity or conditions exist from 1 3 to 2 '3 of the ti me P HYSICA~REaUI R EM E IiTS :

Indicate the percent of time the following are performed. The following activities cannot be performed concurrently, so the total should equal 100%.

25·49% 5()..74% >75%

KNEEL

To bend legs at the knee. come to rest on knees

CROUCH

To bend the body down and forward. bend ing the legs and spine

0 0

CRAWL

Move on the hands. knees and feet

0

0

0

0

0

CLIMB

Ascend/descend ladders. stairs. ramps

0

For up to two hours at a time

0

0 0

0

SIT

0 0

0 0

STAND

For up to two hours at a time Move about on foot

0 0

0 0

0 0

0

WALK

~

0

0 0

0 0

N/A

<25%

LIFT

To raise or lower an object >10 Ibs. from one level to another

0

0

0

0

LIFT

Toralse or lower an object >25Ibs . from one level to another

0

0

0

0

0

CARRY

To transport an object

0

0

0

0

0

The following

be performed concurrently, so the amounts need not be totaled.

25-49% 5C)..74% >75%

0

PUSH

To press With steady force, thrust objects forward. downward, outward

0

0

0

0

0

PULL

Todrag or tug objecls

0

0

0

0

0

BE ND

To bend downward and forward by bending the spine at the waist

0

0

0

0

0

BALANCE

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

Pinch , type. actiVity with tingers

0

0

0

0

REP MOT '

0

RepetitiouS movements of arms, hands. wrists, etc.

0

0

0

0

0

TALK

Express or eXChange ideas verbally

0

0

HEAR

0

0

0

Perceiving sound by ear

SEE -"

0

0

0

'J

0

Obtam impreSSions through the eye

0

0

0

0

0

·· ·Check alt that apply :

,----

AepelJ\I~e motJon

o vision clarity grealer than 20 inches o vision clarity less than 20 inches o ability to distinguish color

466

Physical Rehabilitation JOB FUNCTION ANALYSIS ......

EQUIPMENT. TOOLS. ELECTRONIC AND COMMUNICATION DEVIC ES. A

NO SOFTWARE' .

Llsllhe items the employee will use to perform the essentiaVprimary functions. 4. 1.

5. 2.

6. 3.

PHYSICAL SURROUNDINGS AND HAZARDS; Indicate which statements are applicable. Spends approximately 80% or more of time indoors.

'.J

'J J

Spends apprC»:lmalety 80% or more of lime outdoors.

':l :l

1emperatures may be below 32 degrees for more than one hour at a lime .

;:J

NOise is sufficient to cause the employee to shout in order to be heard .

-:l J

Exposure to vibrating movements to the eX1remities or enti re body Risk of bodily injury due to proximity to moving mechanical parts, electrical current. animals, etc.

:I

Cond itions that affect the respiratory system or the skin, i.e., fumes, odors. air particles.

Activities occur inside or outside in approximately equal amounts.

l:!mperatures may be above 100 degrees tor more than one hour at a lime.

GENERAL INFORMATION; Comments: _ __ Must a vehicle be driven 10 perform the essential/primary functions?

0 Y ES

0

NO

LocatJon(s) where work is performed: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ __ _ Day/Hour schedule: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __ __ Na me/phone of Supervisor to whom this position reports: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ __ __ Title of SuperVisor: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __ Name of person completing form: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Oole _ _ _ _ __ _ _ _ __ Signature of incumbent - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Oate _ _ _ _ __ _ _ _ _ __ _ · Slgnature of perso n currently In position . If " vacant" or " new," leave blank. If you are requesting the establishment of a new Merit position or reel if . Compensation and Classification, 121 . 11 USB . ass Icatlon of eXisting Merit position, submH th. . . . . tD:

All. merit requisitions must have an EFMA on file In the hiring departm enI b ef ore the requisition . . will be It

IS

pro'"

d

recommended all P & S requisitions have an EFMA on file in the hi rong ' d epartmenl al Ihe lime 0 1 _ ......

Comments :

Appendix 0: Building Survey Form Nam~

of bu ilding: ___________________

Location : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _

Yes Parking Area I. Are ~lC l'f' "s ibk parl.. ing sp 3c e~ \\ ilh adjacent 3 CC (, ~S a isle \0 accommodate a \\ heek hair J\ailabk'! 2. Are cu rb culoul, availab le and :lpprOprialely labeled? J. Are parl...ing :o.p:l('C'~ ('asily J cce~s i ­ hie 10 \\ alh\:I) \\ ilholll requiring negotiating behind parked cars? Entrances to Build ing I. I.. aJ lea~t one major enlranee available for use b) an indi\'idual using a \\ heelc hair? 2. Doe~ the entrance prov ide access 10 a leH'1 \\ here ele\alOrS are 3\ ail able? Ele\ ators

I. b

3 pa~,enge r

elevator available?

~ . Does, the elevator reach all leve ls

of the build ing ? 3. Are control bUllons (both inside Jnd OUl.~ idt' of the ele\3tor) no more than .:1.8 in \ 122 cm) from the floor? ..t. Are (·ontrol bunoH" raised and ea!>~ 10 pu . . h·) 5. I. . an emergenc~ telephone a~,:e~"'lble?

Public Telephones 1 Are an appropn3te number of phone . . 3\ aJlahle Jnd acce ...s lble 10

mJ" Iduab. uo.,mg ,) "heelch::u r'.l ~ Are the~ duJ or pu~hbu ll on·? 3 J., the height of the d ial me-chao m'lll no more Ihan -W 111 ( I 12 Clll) I film the HOOT'-) ..l h J. reLt'I\er \o]ume cOfllrol J\JiI.J.ble·'

Dale of survey: ____ _ _ _ _ _ _ _ _ __

Surveyor: ________________

No

Yes

Floor Surfaces I. Are surfaces non slip? 2. If carpeting is prese nt. is it ti ghtl y wove n and sec urely glued 10 floor (to preve nt rippling under wheelc hair)?

ReSI Rooms I. Is there an adequate number of accessible rest rooms available? 2. Is the re alleast 48 in ( 122 em) between inside wall and parti lions enclos ing toi let ? 3. Is e ntrance to cubic le at least 48 in ( 122 em) w ide? -L Are grab bars present and sec ure ly mounted? 5. Is height of seat not more than 17.5 in (4-1.5 em )? 6. Is toilet paper holder wi thin easy reach? 7. Is adequate turning space (6 fl X 6 ft [183 el11 X 183 em)) avai lable in main area of rest room? 8. Is there adequate space fo r cle arance of knees under si nk? 9. Are drain and hOI-water pipes covered or shielded to avoid bum~ ?

10. Are fau ce t handl es !;trge (bl:.tde- type) and accessible?

\ Vafer Fountains I. Is [he founlain height appropnate for U.':'le b) ~Ol11eon e 111 3 \\ hee khair'! 2. Are control .. pu:-.hhulton or bladt:· I) JX:." J. 10., il fl)()!l·OOlrol .\\ ..ul at.le? .1-. h adequ ..tte !'Ipal'e \a t Il'J't J fl [92 l III J) prm idl'd IIC\lr fOllnt311l 10 permi t \\ hl"l'kh.1If mobJlily?

No

SECTION

Intervention Strategies for Rehabilitation

THREE

C HAPTER

13 UAiNINC

OBJECTIVEI

Strategies to Improve Motor Function

I. Describe a model for c1lO lcal decl su)n mak ing. that mcorporJh~ S component" of nomlal mOlor control and motor learn ing. 2. Identify factors critical 10 motor control and ~ribe inlervention strategi c" designed to opllmize the acqui sition of motor contro l. J. ldentit) I..e) fart on, in reco\ el) of lu n(,:llOn and de'tCribe mler. cnllon strat c gie ~ d e~ l gn i.'d 10 opumize rccovcl) . 4. ldentif} factCIr~ critical to mot or learOlng. and describe Illtenelllion ...tralcgies deSigned 10 optmuze leanun g. 5. Di fferenuate among the foll ow ing : fun cti ona l traimng. ncurofacilJt3t ion lr3nung. and compen satol) lfJtn,"£ 6.. Anal}l.~ and inte rpret pallen I data . formulate" anticipated goab and e\ pec tt"d ouH:omC!i. a nd develop a plan of care that prC"!>CllI s an integrated appr("lach 10 rreatment \\ hen presented \10 Ilh a cllOl cal cJ. ~e \ tud)

Susan B. O'Sullivan,

PT. EdD

OUTLINE \1010f Cuntrol "",71 Th("one . . ot MOlor Comrol "", 72

Functional Tmmmg 484 '1euromotor [)c\e lopment Traming "",89

"1otor Prog rammin g Theory 473 \1 utor Leanllng. -'74

Compcn ...atory Tn:u nmg 491 Integra tmg Approaches 491

Theone., 01 ~ I 01or LcJ.rnmg 47-'

Intt'f\t'ntlon Slr... tt'},!I!'''' 10 Imprn\ c

Stage ... 01 \1 01or Lcanung -175 Strategic!' to Enhance Motor

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472

Physical Rehabilitation a coordinated movement sequence,"], p 466 The structuring of motor programs includes attention to specific parame_ ters such as synergistic component parts, force, direction, timing, duration , and ex tent of m?vement. :arametric specification is based ~n the constramts Of. the mdividual, the task. and the environment. [nfonnatlOn processing during thi s stage is sensitive to the complexity of the de sired movement and duration. Thus, complex and lengthier movement sequences increase the duration of processing during thi s stage . Programming can also be affected by response-response compatibility. This is the compatibi lit y for dual movement tasks that either OCcur simultaneously (e.g ., bounc ing a ball while walking) or whe n choices are required (e .g., one paired movement re sponse mu st occur before another). During response execution (movement output) , mu scles are selected again st an appropriate background of postural COntrol. Feedforward , the sending of signals in advance of mOvement to re ady the system, allows for anticipatory adjust· ments in postural activity. Feedback, response-produced infonnation received during or after the movement, is used to monitor output for corrective actions. Although this simplified model gives the appearance that the information flow is linear, actual processing by the CNS is both serial and parallel. Thus . both single and multiple pathways are engaged to process information.] Figure 13.2 provides a sche matic depiction of the major direction s of information flow within the CNS during voluntary movement.

WIIIII. til. CfIS Stimul~ Idtntfficltion

Response Satection

senling percaiving memory conblct

inblrll'attng planning

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Figure 13.1 Model of infoml ati on-processing stages of movement control.

length of limb. di stance to goal. and so forth) is a critical characteristic of motor behavior. In the response selection stage the plan for movement is developed. A motor plan is defined as an idea or plan for purposeful movement that is made up of component motor program s. A general rather than detailed response is selected: that is. a prototype of the final movement. Decision making during thi s stage is sensitive to the number of differenl movement alternatives possible and the overall compatibility bet ween the stimulu s and response. The more natural the association berween stimulus and re sponse. the easier th e deci sion making. For exampl e. in a well- learn ed movement like crossing at a street li ght , an ind iv id ual easily responds to the green li ght by moving forn'ard. If a crossing guard signal s the individual to move forward even though the li ght is red , the indi vidual is likely to be more he sitant in responding. The final stage is term ed response programming. Ne ura l control centers translate and change the idea for movement into musc ular actions defined by a motor program. A mot or program is de fined as "an abstrac t rep re ~ se malion thaI. when initi ated. result s in the produ ction of

SENSING

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GANGLIA PUTAMEN

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BASAL FOREBRAIN

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A theory is the o rderly explanation of observations. Different Iheori es of motor comrol have been developed over time. and reflect currenl unde rstanding and interpretation of nervOUS system func ti on. Because theories provide an important framework for clinical practice, a brief overview is war' ran!~d . The reade r is aJ so re ferred lO the excellent works of Schmid" and Shum way-Cook and WooUacon' for funher review and study.

PROGRAMMING

BASAL AU IE

SENSORY CORTE X

Theories of Motor Control

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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<.: ific task. Both internal f.lelOr:.. (Jomt stiffness, inertia. mm ement -dependent forces) and ex ternal factors (g ravit) must be taken into con ... idera ti on in the planning of movement~. It as!'Iumes a ~hifting locu, of neural COntrol. referred 10 a~ a tii,wriJmted model of cOIllrul. Thus, large areas of the eNS may be eng
47,}

man y degrees of freedo m at one time. Coordillati\'e structures are used 10 simplify co ntrol , and to initiate coordi nated patte rn s or sy nergies to produce moveme nts. The use of synergies for the cont ro l of locomotion (central pattern generators) and posture (poslUra l sy nergi es) is well doc ume nted. 7

Motor Programming Theory Motor programs allow for movements to occur in the absence of se nsation (deaffere nt ation) o r in situations in which limi tations in speed of processing feedback negate control (rap id movements). Motor programs al so free the nervou s system from consc ious dec isions about movement, reducing the problem of mu ltiple degrees of freedom. Motor programs can be run off virtually wi tho ut the influence of peripheral feedback or e rror detect ion processes, temled an open-loop control system (Fig. 13.3). Thi s is in contrast to a closed-loop control system (Fig. 13.4), which employs feedback and a reference for correctness to COOlpute error and ini tiate subsequent corrections. Feedback and closed-loop processes playa criti ca l role in the learning of new motor ski lls (response selection) and in the shaping and correction of ongoing movements (response execution). Feedback is also essential for the ongoing maintenance of body posture and balance. The complexity of human movement negates any si mplisti c model of movement control. An inlermillent COIl trol hypothesis described by Schmidt ' proposes a blending of both open-loop and closed-loop processes, in

Envi ronment (Senso ry input)

~ Perception (St imulus ident ification)

~ Execu t ive (Decision mec hanisms)

+

Motor program

I

Muscles/ Movement

Figure 13.3 Orell-loop collirol .!o).!olem.

I

474

Physical Re habilitalion Feedback Elfor

Motor program

Environment

Figure 13.4 Clo\ed~loop con[rol system. KP = knowledge of pelfonnance. KR = knowledge of results.

whic h both o peral e in conce n as pan of th e larger sys te m . Motor prog rams prov ide th e genera li zed code for m otor cve nt:-. (schema). while feedba(' k is u:-.cd to re fin e and pertecl movement s. Eith er m ay a ss um e a domin;:m t role . depending o n Ih e task at hand. Both Illay operat e wi thin a g]\cn moveme nt but at different times and w ith differ~ ent funclion s. Gene rali zed motor program s inc lude bOlh invarian l c haracterist ics and paramete rs. 1"\'{Irian' charaCTeristic!; are thc uniqu e features of the sto red code: rel dlive force. re lative timing. and o rder of co mponents. Paramerers are th e c hangeable feature s that e nsure ll exibil ity of motor program s and variation s in movem e nt s frolll o ne perfo rmance to th e flex !. These inc lude ove rall fo rce and overa ll durat ion o f the move ment. For exa mple. walking perfo rmance can be changed by speeding up or :-. lowi ng down (c hange :-. in overa ll duration ) whil e Ihe ba:-.ic orde r of stepping cyc le and relative tim ing of the <.:ompone nt s (invar ian t characte ri sti cs) arc maintained.8 Pallent :-. with defic it:-. in motor fu ncti on Illay de mo nstrat e il1lpairment~ III vo lunt ary movemenb ( impaired mo tor planning or prog ra mming) o r the corrective acti o ns (feedbad. adju:-.lmen ts) needed to init ially learn and ('oordinate movement').

Il() { (Ire . ''lbl e but ra th e r a re inferred from I · ,·,,I y (, i)scrv c h;Hl ges in molOr behavi o r. Im prove m ent s in perform. anfe'- re~ llit fr o m pra cti ce or ex pe rience and are a fre . qu e lltl y lI sed mea ... urc ~ f lea rnin g. For example. with prac ti ce an individua l IS ab le to deve l o ~ ap.propriate :-' l'4 uc ll<.:inf. uf move me nt ~oll1po n e nts wit h Improved limi ng a nd re du ced e tforl a nd co nce ntrat ion. Pe rforman ce. how ever. i:-. not a lway s an acc urate reflec_ ti o n o f learnin g. II is po~s ibl e to practi ce e noug h to tern. po rari ly improve pe rfo rman ce .but not r~ tain the learn ing. Conversely. factors s uc h as fat ig ue. an xie ty. poor motiva. tio n. or Ill'edication s ma y c a use performance to deteriorate wh ile learning may still oc c ur. Bec ause performance can be affected by a numbe r of fac to rs. it can be reason· abl y d efi ned as a .. te mporary c hange in motor behavior :.ee n durin g prac ti ce ~ess i o n s."2. p 24 Retention provides a be tte r measure of le arning . Re tention refers to the ability of th e le arn e r 10 demon st rate th e skill over lime and after a pe ri od o f no prac ti ce ( retention interval). Performance after a re ten ti on inte rva l ma y decrease slightly. but should return to original pe rfo rman ce leve ls within rela· t ive ly few prac tice trial s. For example , riding a bike is a we ll -lea rn ed skill that is ge ne rally re tained even though an indi vi dual may no t have ridden for years. The ability to apply a lea rne d skill to the learning of other similar tasks. terme d generalizability, is another imponant meas ure of lea rning. Indi v idual s who learn to transfer from wheelc hair to plarform mat can apply that learning (0 o th er type s of tran sfer s (e.g .. wheelchair to car, wheelc ha ir to tub ). The tim e a nd effort req uired to organize and lea rn these new ty pes o f tran s fer s is reduced. Finally. learni ng can be meas ured by resistance to contextual c hange . Thi s is the adaptabilit y req uired to perform a mo to r lask in altered environmental s ituations. Thus. an indi v idua l who ha s learned a s kill (e .g. , walking with a ca ne o n indoor level s urface s) should be able [0 apply th at learnin g to ne w and variab le situations (e.g. , walking outdoors. wal king on a bu sy sidewalk ). Motor leaming is th e direc t re sult of prac tice and is hi g hl y dependent on se nso ry inform ati o n a nd feedback proces ses. The relative im ponance o f the differe nt type s of se nso ry information vari es accordi ng 10 {ask and to Ih e phase of learning. Indi vidual d iffe rences ex i.'!. t ( motor fapacity) and rna) intluen ce both th e rale ;.lIld degree of learning possible. Im pai rm e nt s in learning are co mm o n for the patient with eNS uy:-.fu ll c li on.

Motor Learning Theories of Motor Learning Mutur It arnin g ha ... bCt' ll defined as "a se t of int erna l proc nse~ a\~o('ia t ed with practi<.:e or experie nce leading 10 relatively permClnenl chClllge ... in the capabi lll y for :-. kliled heha\ [or. I p .jnh Learning a motor ... I-.. ill [... a complex proce .. :-. lhal reLju[re .. ~ p a lj al , temporal , and hiera rchical o rgClniza l ion 01 the CNS. Change:-. in the eNS are

Ad am:-.'J deve luped a (heor) of mOlOr Je:aming based on L' l o~ed~loop l'untrol (L'iosL'c!- loop theory) . He poslulated that se n!)ury feedback from o llgoing m ovement is compared \'o';l h sto red Tllt: ll1o r), or the inte nded movement (perceprual Ir~lL'e) tu provilk tht' eNS w;lh a reference of cor~ ,tnd e lTllr detec ti un . f\,lle mory traces are then used 10 product

Chapter 13 Strategies to Improve Motor Function an appropriate action and to eva luate outcomes. The stronger the perceptual trace devel oped through prac ti ce. the 2reater the capabilit y of the learner to use closed-loop processes for learning movements. Adams concenlrated on f'\aminin!! slow. linear-positi oning responses. TIlis theory does not ~adequatel y explain learning under conditio ns of rapid movements (open-loop control processes). It also does not explain learning that can occ ur in the abse nce o f sensory

feedbac l-. (deaffere ntation studies). Schema theory. proposed b) Schmidt. JO is based on the concepts thai ~IO\\ movement s are feedback-based while rapi d movement s are program-based. He proposed thai schema \\ ere u~ed for storage in to memory. Schema is defined a~ "a nile. conce pt. or re lationship fo rmed o n the basis of e\perience.··1. r~6- Schema can in cl ude such things tb initial condition~ (bod) pos ition. we igh t of objects. and ~o forth ), relation ships between parame ters of moveme nt. environme ntal outcom e~. and se nsory conseq uences of mo\'ement. Recall schema are used to s~ l ec l and define the initial mo\'ement conditions while recognition schema are u~d to c\ alu:ne mm'ement responses based o n expected sen~or~ consequcnce~. Clinicall y. thi s theory supports the concept that practicing a variety of movement outcomes would ImprO\c learning through the development of expanded rule ~ or schema. It also provides a plaus ibl e explanatIOn for the learning of novel an d open sk ills perfomled 111 a variable and changing enviro nm ent .

475

Associative Stage During the midd le or a ssociative stage of learning. refinement of the mOlor strategy is achieved through continued practi ce . Spatial and tempora l aspects become organized as the movement deve lo ps into a coordinated pattern. As performance improves. there is greater consistency and fewer errors and ex traneous movements. The learner is now concentrating on " how to do" the move me nt rather than on what to do . Proprioceptive cues become incre~ ingl y important. while dependence on vis ual cues decreases. The learning process take s vary ing leng th s o f time depending o n a number of factors. The nature o f the task. prior experience and moti vation of the leam e r. ava ilable feed back, and o rganizati on o f practice can all influence acqui siti on of learn ing.

Autonomous Stage The final or a ul o nomo us stage o f learning is character ized by moto r perfomlance that after co nsiderabl e practi ce is large ly automatic. There is o nl y a minimal leve l of cognitive monilOrin g. with motor prog ram s so re fined they can almost .... run themse lves." The spatial and temporal component s of move me nt are becoming hi ghly organized. and the learner is capable of coord inated motor patte rn s. The lea mer is now free 10 conce ntrate on other aspects. such as "how ( 0 succeed" al a competitive sport. Move ments are large ly e rror-free with little interfe re nce from environme n-

tal distractions. Thus the learner can perfonn equall y well in
Stages of Motor Learning

(tenned open motor skills ).

Tht' proces!> 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
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Php.ical Re habi li tation

Table 13.1 Characteristics of Motor Learning The learner develops an understanding of task ; cognitive mapping assesses abilitIes, task demands; identifies stimu li. co ntacts memory ; se lects respon se ; perform s initial approxi mations of task ; structu res motor program ; modifies initial res ponses ~ What

to do" decision

and

Strategies

Highlight purpose of task in functionally relevant ,terms . I performance of task to establish a reference of Demon strate ·d t ea

correctness. . Have patient verbalize task components and requirements . Point out similarities to other learned tasks . Direct attention to critical task elements. Select appropriate feedback. . . . • Emphasize intact sensory systems: In.trln.slc. feedback systems . Carefully pair extrinsic feedback With IntrinSIC feedback. High dependence on vision : have patient watch movement. Knowledge of Performance (KP) : focus on errors as they become consistent; do not cue on large number of random errors. Knowledge of Results (KR): focus on success of movement outcome. Ask learner to evaluate petiormance , outcomes; identify problems, solutions. Use reinforcements (praise) for correct performance, continuing motivation. Organize feedback schedule. • Feedback after every trial improves petiormance during ea rly learning. Variable feedback (summed , fading, bandwidth designs) increases depth of cogn itive processing , improves retention; may decrease performance initially. Organize initial practice . Stress controlled movement to minimize errors. Provide adequate rest periods (distributed practice) if task is complex , long, or energy costly or if learner fatigues easily, has short attention, or poor concentration . Use manual guidance to assist as approp riate . Break complex tasks down into component parts, teach both parts and integrated who le. Utilize bilateral transfer as appropriate. Use blocked (repeated) practice of same task to improve periormance. Use variable practice (serial or random practice order) of related skills to increase depth of cognitive processing and retention; may decrease petiormance initially. Use mental practice to improve periormance and learning, reduce anxiety. Asse ss, modify arou sal levels as appropriate . • High or low arousal impairs petio rmance and learning. • Avoid stresso rs, mental fatigue . Stru cture enviro nment. Reduce extraneous en vironmental stimu li, distractors to ensure attenti on, concentration. Emphasize closed skills initiall y gradually progressing to open skills.

Associated S~e Characteristics

Trai!ling Strat~es

The learner practices moveme nts, refines motor progra m: spatial and temporal organization ; dec reases errors, extraneous movements

Select appropria te feedback.

Dependence on visual feed back decreases, increases for use of proprioceptive feedback; cognitive monitoring decreases

"How to do" decision

Continue to provide KP; in tervene whe n errors become consistent Emphasize proprioceptive feedback , "feel of movemenf to assist in esta~ li shing an internal reference of correctness . Contin ue to provide K R; stress relevance of functional outcomes. Ass!~t I ~arner to improve self-eva luation, deciSion making skills. Fa~lhtatl ~n techniques , guided movements may be counterproductiVe dUring thi S stage of learni ng.

Chapter 13 Sirategies

10

Improve Motor Function

477

Table 13.1 Characteristics of Motor Learning Stages and Training Strategies

(C'Onlinued)

Organize feedback schedule. ... . • Continue to provide feedback for continuing motivation; encourage patient to self-assess achievements. Avoid excessive augmented feedback. Focus on use of variable feedback (summed, fading, bandwidth) designs to improve retention. Organize practice. Encourage consistency of performance. . Focus on variable practice orde r (seria l or random) of related skills to improve retention. Structure environment. Progress toward open , changing environment. • Prepare the learner for home, community, work environments.

, ..'

~-">,,,,,~

.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!) .!
Feedback

The vast body of m o tor learn ing and t~erapeutic. literalUrt s(rcsse s the criti ca l role of feedback . . .In .pro motmg motor . Feedback c an be e ither IntrlOslc . , occurring as a Iearnm g. natural result of the movement , ? r provlde.d by. e"lrinsit, a ug m ented se nsory c ues no~ tYPica ll y receIVed In th~ task. Pro ri ocepti ve. visua l. veStibular. and cutaneous Signals are of types of intrin sic feedback.. visual, auditory. or tac ti le c ues are form s of extnnslc feedback (e .g., ve rbal c ues. manual c. ues, biofeedback devicesEMG. pressure-sensin g devlces-forcep lates, foot pad). Dur ing the rapy. both intrinsic and extrin~ic feedback can be manipulated to e nhance motor leammg. Concurrent feedhack is give n durin g task perfo rmance while lermirwl feedb ack is given at the end of task perfonnane•. Au gme nted feedback about the end result or overaU outcome of the movement is te rmed knowledge of resutb (KR ). Augmented feedback about the nature or qual ity of the movement pattern produced is termed knowledge of per fo rm a nce (KP).1. P 465 The relative importance of KP and KR varies accordin g to the skill being learned and the avai labi lit y of fe edbac k from intrinsic so urces.'6-20 For example. tracking tasks are hi ghly dependent on intrinsic visual and kinesthe tic feedback (KP) while KR has less influence o n the accuracy of the movements. In other tasks (e.g .. transfers) KR provides the key infonnation about how to shape the ove rall movem e nt s for the next anempt whil e KP may not be as use ful. Perfonnance cues (KP) should foc us o n key task elements that lead to a successful final ou tcome. Clinical dec isions about feedback include:

~xamples

~hiJe

• What type of feedback shou ld be employed (mode)? How mu ch feedback sho uld be used (i ntensity)? • When shou ld feedback be given (scheduling)? Choices about type of feedback involve the selection cI. which intrimic se nsory systems to highlight, whal lype ci augmented feedbal:k to use . and how to pair extrinsic feed. bad. to intri n. . ic feedback . The selec tion of sensory syS1e1115 depend~ o n speciti~ e~amination ftndings of sensory lnIegriIy. The sensory s,",tems selected must provide- accuraIC IIIi u,able info mla;ion . If an intrinsic ~nsory system is impIiRd and provldt':' di.,torted or tncomple(e infonnation (e.,g.. impaired proprioception with diabetic neuropathy) then.01 altelllatc ...en.;;ory '1)::.tem::. (vision ) ~hou ld be ernphIsiacd. Supplementll augmented feedback can be used w ~ ICJml1l,!;. De('i"'l(ln~ are also based on ~tage of leamina· e..:ty III Jeamin~. \ lSUa} teedback i ... t:~lly brought ro aHemion and tht'refl)re: i~ IITiponanl. Le!'\.~ consdousJy If:CO' "'Ihll~ ..,t.:n'lol") Int~\ml.l(iun 'Iuch
ctJIIK-

slowS'"

Chapter 13 Strategies to Improve Motor Function retention tes1. 21- 25 Thi s is most likely due to the increased depth of cognitive processing that accompanies the variab le presentation of feedback. Varied feedback schedules include (I) swnmedfeedback. feedback given after a set number of trial s (e.g .. after every othe r trial or every third trial): (2) faded feedback. feedback give n at first after every rrial and then less freq uentl y (e.g .. after every second trial. progress· ing 10 every tiflh trial): and (3) hand.,.id,h feedhack, feedback given on ly when perfonnance is outside a given e rror range. DeJayedfet'dlmck, feedback given after a bri ef time delay (e.g .. a 3-second delay). can also be benetic ial in allowing the learner a brief time for introspection and se lfassessmenl. 1b In contrast. the the rapist who bombards the patient immediately after task comple tion wi th excessive augmented verbal feed back may preclude acti ve infom13tion processing by the learner. The patient's own deci sion making skills are minimized. whi le the therapi st's verbal skills dominate. Winstei n 21 points out th at thi s may well explain why many studies on the effectiveness of therapeu· lic approaches cite minimal carryove r and limited retenti on of newl y acquired motor skills. A feedback delay interval that is prolonged or filled with practice of other movements results in interference that may decrease learning. Finally. the withdrawal of augmented feedback should be gradual and carefully paired with the patient's efforts to correctly utilize imrinsic feedback systems.

Practice The second major influence on motor learning is practice. In general. the more the practice, the greater the learning. The therapi st's role is to ensure thai the patient practices the desired mm ements. Practice of incorrect moveme nt patterns can lead to a negative learn ing situation in whic h " faulty habits and postures" must be unlearned before the correct mO\ements can be mastered. The organization of practice will depend on several fac tors. including the patient's moti. vation, anention span, concentration, endurance, and the type of task. An additional fac tor is the freque ncy of allow. able therapy session~. which is often dependent on hos pital sc hedul ing and availabi lity of serv ices and payment. For outpatients, practice al home i5. highly dependent on motivation. farml ), suppon. and suitable env ironment. Clinica l decision ...
• H ~" ... hould pracllce periods and rest periods be spaced (dlstnbution of pro1c ti ce)?

W~~t ta!>k!, and La!>!... v,tria tion~ should be pra(.:ti ced (va ri ability 01 practicc)? • How should the tasl.. ... be :-.equcnced (practice ordc rJ'! • Ho", . . hould rhe environme nt be .., trUl.:lured (do~ed \ ... open),! •

Massed \ersus Distribut~d Practice Massed praclice refcn, to it ~eque m;e of PrJt:t tcc and re~t I~me.. In Wh lLh the re!)t IIml! I~ l11ul.:h leo;;, than Ihe praclil:e lime . I. p4M F"· a I g' uc. dC('re~1!d" per orJl1UI1Cc, and l'I .':!k of Injury arc Idcton. thai mu .':!t tx· cOt1~idcred wlll.!l1 lISlJ1g

479

massed practice. Distributed practice refers to spaced practice intervals in which the prac tice time is equal to or less than the rest time. I . P 463 Although learning occurs with both, di stributed practice results in the most leami ng per training lime ruthough the total training time is increased.] 11 is the prefe rred mode for many patient s undergoing active rehabilitation who demonstrate limited perfonnance capabilities and e ndurance. With adequate rest periods, performance can be improved wi thout the interfe ring effects of fatigue or increasing safety iss ues. Distributed practice is also of benefi t if motivati on is low or jf the learner has a short attention span, poor concentration, or motor planning defi cits (e.g .. dyspraxia). Distributed practice should also be considered if the task itse lf is complex. long. or has a high e nergy cost. Massed prac tice can be conside red when motivation and skill leve ls are high and when the pati ent has adeq uate endurance. attention. and concentration. For example, the patie nt with spinal cord injury in the final stages of rehabi litati on may spend long practice sess ions acquiring the wheelchair skills needed for community access.

Blocked versus Random P ractice 81m'ked practice refers to a practice sequence organized around one task perfonned repeatedly, uninterrupted by practice of any other task. I. p 462 Random practice refers to a practice sequence in which a variety of tasks are ordered randomly across trial s. I . p.166 Whil e both allow for motor skill acquisition. random practice has been shown to have superior long·tenn effects in tenns of retention. ~8-30 For example. a variety of different transfers (e.g .. bed to wheelchair. wheelchair to toilet, wheelchair to tub transfer seat) can be practiced aJi within the same training session. Ahhough skilled perfonnance of individual tasks may be initialJy delayed. improved rete ntion of transfer skills can be expected. The constant cha lle nge of varyi ng the task demands provides high cOlllextlla/ illfeiferellce and increases the depth of cog. niti ve process ing through retrieval practice from memory stores. The acquired sk ills can then be applied more easi ly to other task variations or e nvironments. Con~lant practice will resull in superior initial perfonnance because of low contextual interference and may be required in certa in situauons (e.g .. the patient with traum:.lIic brain who requires !l hig h degree of strut..:ture and consistency for learning). Practice Order ~ctice orde r refers to tht.' licquencc in whic h tasks are practiced. 810('1.('d order refer.':! to the repeated practice of 8 tdSk or group of ta~k l\ in order (three tria ls of task I, three lrIaJs of t~l,k 2. three tria ls of ta,l.. 3: 111 22233]), Seriul order re i\:: r~ to it prcd]ctftblc and repeating order (pr'..Ictice of multiple la . . . ks in the folio" Lllg orol!r: LB 123123). Rant/vm urr/I.' r refers 10 a nonrcpt'l.ltmg and nonpredlc tablc order t 123321312), Although . ; 1..111 acquhition c:m be achieved \~ tlh aJi IIm~e. djn~rel1ce~ ha\'c bt:CIl found. Blocked order pr~luce!lo .lll1pl\l\cd earl) al'quisitJ()n of ,:., klii s tpcrfonllance ) \I, hll~ :lenal l Uld randOlll Ol'licr pnxillc(" better retenLion and gentraItL.!bi lit) of s... J1b. Thi!
480

Physical Rehabilitation

.. processmg: . 11 .32 interference and .IIlcreasedd epth 0 f cogmllve The key element here is the degree to which the learne r is act ively involved in memory retrieval. For exampl e. a treatme nt session can be organi zed to include practice of a num ber of different tasks (e.g., forward-. backward- and sidestepping and stairc limbing). Random ordering of the tasks may initiaJly delay acquisi ti on of the desired steppi ng movements but over the long teml will result in improved retention and gencra li zabil ity. Menial Practice Mental practice is a practi ce strategy in which perfonnance of the motor task is imagined or visualized without overt physical practice. I, p 46~ Beneficial effects result from the cognitive rehearsal of la~k elements. It is theorized that underl ying mOlOr programs for moveme nt are activated but with subthreshold motor activity. I Brain mappin g techniques have al so revealed activation of sim ilar brain areas during imagined mo\'em e nt ~ as those activated during actual movement. n \.J Mental practice has consistentl y been found to facil itate the acquisition of motor sk ills.35- 31! It should be conside red for patienL" who fatigue easil y and are unable to sustain physical practice. Mental practice is also effective in alleviating anxiety associated with initial practice by pre"ie\" ing the upcoming movement experi ence. Me ntal practi ce when combined with physical practice has been shown to increase the accuracy and efficiency of movements at sign.ifi cantly faster rales than physical practice aJonc. 39 When us ing mental practice. it is important to make sure the patient unde rstands the task and is acti vely rehearsing the correct movement s. This can be ensured by having the pat ien t verbalize aloud the steps being rehearsed. It is ge nerally contraindicated in patie nts with profound cognitive. communi cation. and/or perceptual deficits. Part \'e r sus \Vhole Practice Compl ex motor skill s can be broken down in to component part~ fo r prac tice. The component parts are practiced before prac ti ce of the who le t~k is attempted . For example. du nn g in itia l whee lch air transfer training the transfer -,tep'" arc practiced in i.'.olation before practi cing the who le Iran"fer (e.g .. lod_lIlg the brake ~. lifting the foot peda l ~. moving torw<.I rd in the ch<.lir. ~tanding up . pivOIing. and ~il ­ I lI1g down ). It I ~ imperlam 10 ide ntify the key -, te ps Ihrough UL:L uriJ le ta.,).. a naly",b a nd to ~e4u e n c e them in the reyuired ordc r. II I )' a b o impo rt ant 10 practice the integrated who le III t:OllJu llt: li on with [h I: partt, pnlL:tice ' 0 Ihal the IC<.il11er dc:\'clup-, the """ ho le Idea for the reljulreJ I;] ~ h. (u:" l'ogni tJ\ot: mapJ_ 1)c..' lay mg praclit..:c of the: Inl ~g rat l.!d VI hole Can Il1Ierkre \\ it h tr a n ~ft'T e ft ec~ and lea m lng. ' Pan- VI ho le pral! lu' i~ Ill
Transfer of Learning Transfer of learning refers to the gai n (or loss) in the capa bility of task performance as a result of practice or p436 Le . can be pro. expen.ence on some 0 1her t as k . l. ammg moted through practice us ing contralateral extremities te rmed bilateral transfer . For example, a patient wi~ stroke first practices the desired movement pattern uSing the mo re no rmal (un affected ) extremity. This initial prac. ti ce enhances formation o r recall of the necessary IJlOtor program, which can the n be applied to the OPPOSite, involved ex tremity. This method cannot, however, substitute for lack of movement potential of the affected extrem. ities (e.g .. a naccid limb on the hemiplegic side). Transfer e ffects are optimal with similarity of the tasks (e.g., identical components and actions) and environments.40 For exa mple. optimal tran sfer can be expected with practice of an uppe r extre mity flexion patte rn first on one side, then wi th an ide ntical pattern on the other side. Practice of lead-up activities is commonl y used in physical the rapy. Lead-ups are s impler task versions of a requi red complex task. The subtasks are practiced, typically in easier postures with s ignificantly reduced degrees of freedom . Anxiety is also reduced and safety is ensured. Thus in itial upright postural control can be practiced in kneeling, half-kneeling. o r plantigrade before standing. The patient develops the required hip extension/abduction stabili zati on control req uired for upright stance but without the demand s of the standing pos ition or fear of falling. The more closely the lead-ups (subskills) resemble the final task. the better the transfer. Closed ve rsu s Open Environments Alte ring the e nvi ronme ntal context is an imponant consideration in structuring practice sessions . Early learning beDetits from practice in a stable or predictable, dosed tnvi· ronment. As learning progresses the environmenl should be varied. and incorporate more variable features c0nsiste nt with real world. open em'ironments. Practicing waiting on l) within the ph)sica l therapy clinic might lead 10 !'.u cce~~ful perfonnance in thm se tting (contell-specific learning ) bu t doe s little to prepare the patient for aroI>uIation at horne or in the communi ty. The therapisl sIaouId begin to gradually modify the e nv ironment as soon as per. fonll:.tIlce becomes ~ons istent. It is important to remcmbet that :)O Il1 C patients (e.g .. " patient with traumatic brIiI IIlJur) and IlIllilt'd rc..-I.:overyl may never be able to (uocCioI In :.lI1ythJl1g but a highly stru ctu red environment

Functional Skills The dc\doprncnt of functiona l 5>"'LlI~ is a ccel 'r evoh II1g proce~') thai proceeds throughout die ...... FOlilltiJtional ~l..llb are Ical1K!d III mflUlCY and -.I h rl " II the cme rgen~e of :o.pe(,lfic manen. of de\: ' £

.fa

Chapter 13 Strategies to Improve Motor Function l1laturnt i on .~I--W These skill s are often referred to as del'f/-

opmental motor skills although they remain essellfial jUl/ctiollO! skills throughout the lifespan. Examples include rolling. supine-to-sit or sit-to-stand. maintaining stability or moving in progressively more challenging anti gravit y postures (i .e .. sitting. knee ling. standing). upper ex tremity manipulation. and locomotion. Essential functional skill s can be grouped into four broad categories of motor skill s: mobility. static postural control (stabilit y). dynamic postural

control (controlled mobility) . and skill. See Table 13.2 for a description of these categories together with e x ampl e~ of activiti es/postures and impainnent s. These acti vities and posrurcs are a focus of functional training during rehabilitation . Careful attention to the demands of the postures can effectively address the degrees of freedom problem in controlling body segments. For example. the prone-on-elbows posture focuses on devel opment of shoulder. upper trunk. and head control while eliminating all demands for movement control in the lower bod y. Because the center of mass (COM) is low

and the base of suppon (BOS) wide it is inherently safe. Kneeling and half -knee ling postures can be used to improve trunk and hip control wilhout the demands for control of the knee and ankle. A s with prone -on-elbows posture, the low

CO M and wide BOS reduce the likelihood of fall s and injury. Table 13.3 presents a li st of developmental postures and possible treatment benefits. It is clear that con siderabl e variabi l it~ eXiSL
motor skill s in both children and adults and a specific sequence for acqui sition of skill s cannol be appljed. Age-related factors result in modification and adaptation of functional skill s in adults:' ~-4!1 All stages of information processing are affected by aging.49 Sensory losses (decline in recept or sen siti vity. recognition , and sensory encoding) affect stimulus identification. Respon se selection and programming are al so affected by eNS changes.5o An age-related slowin g of movements is well documented with increases noted in both reaction and movement times. 51 Coordinati on changes result from changes in motor unit size with defi cits partic ularl y noticeable in fine motor control. Older adult s are al so more sen sitive to compl exit y of movem enl. S2.5J The principle of speed- accuracy tradeoff typicall y applies as adult s age. that is. the accuracy of a movement is decreased as it" speed is increased. To accommodate for thi s change , older adults typically move slower. especially when accuracy is required. Decreasing level s of cardiovascu lar fitness and strength and increased weight commonly associated w ith a sedentary lifestyle can also affect the perfonnance o f motor skill s.54 Finally. older adults often experience multiple disease pathologies that affect their ability to move and learn .:'i5 For example. an older adult may alter the method used to roll over and sit up secondary to an increase in body weight. a decrease in overall strength and fitness. or an emerging pathology such as Parkinson 's disease.

Table 13.2 Motor Skills Mobility

Ability to move from one pOSition to another

Rolling ; supine-to·sit; sit-tostand: transfers

Failure to initiate or sustain movements through the range : poorly controlled movements

Static postural control (stabIlity, static eqUilibrium, or static balance)

Ability to maintain postural stabi lity and orientation WIth the COM over the BOS with the body not in motion

Holding in antigravity postures: prone-on-elbows, quadruped, sitting , kneeling, half-kneeling , planti· grade, or standing

Failure to maintam a steady body position; excessi ve postural sway; wide BOS; high guard position or handhold; loss of balance

DynamiC postural control (controlled mObility, dynamiC eqUi librium , or dynamiC balance)

Ability to maintain postural stability and orientation with the COM over the BOS while parts of the body are In motion

Weight shifting and reachIn9 In any of the above postures

Failure to control posture dUring weight shifting or reaching tasks; loss of balance

Skill

AbIlity to consistently per· form coordinated move ment sequences for the purposes of investiga tion and Interaction With the phYSical and SOCial environment

Upper ex tremity reach and manipulation

Poorly coordinated move ments; lack of preciSion, conlrol, consistency, and economy of effort

BOS

base of support, COM

center 01 mass

481

Bipedal ambulatlon

482

Physical Rehabilitation

Neurodevelopment Postures and Pote ntial Treatment Benefits Improve upper trunk. UE. and neck/head control Weightbearing through shoulders. elbows flexed Increase extensor ROM at hip extensors Improve head/neck and shoulder stabilizers strength Wide BOS. low COG Improve upper trunk. lower trunk. LE. UE. and neck/head

2. Ouadnuped

control Weightbearing through hips and shoulders and extended UEs Improve hip, shoulder, and elbow stabilizers strength Decrease extensor tone at knees by prolonged weightbearing Decrease flexor tone at elbows, wrists , and hands by pnr longed weightbearing Increase extensor ROM at elbows, wrists and fingers Wide BOS. low COG

3. Bndging

Improve lower trunk and LE control Increase hip stabilizers strength Weightbearing through feet and ankles Lead-up activity for bed mobility, sit-Io-stand Wide BOS . low height of COM

4 . Sitting

Improve upper trunk , lower trunk , LE, and head/neck control Weightbearing in upright, antigravity position; can include weightbearing through extended UEs Functional posture, important for reaching and AOL skills Improve balance reactions Medium BOS. medium height of COM Improve head/neck, upper trunk, lower trunk, and l E control Weight bearing through hips in upright. antigravity position Decrease extensor tone at knees by prolonged weightbearing Increase hip and trunk stabilizers strength Improve balance reactions Welghtbeanng through ankle in half-kneeling Narrow BOS. intermediate height of COM (kneeling) Wide BOS. Intermediate height of COM ( ha~· kneelingJ

\ 5. Kneeling and half-kneeling

6 Mochlled plantigrade

Improve head/neck. upper trunk. lower trunk, and UE and LE control Welghtbeanng through extended UEs and LEs. upnght antigravity pOSition Improve balance reactions Functional posture, lead-up for standing. stepping and reaching Decrease tone In elbow. wnst , and linger flexors by pr0longed weightbeanng Increase extensor ROM al Wrists and fingers Wide BOS high COM

7 Standing

Improve head /neck Upper trunk , lower trunk. and lE contrOl Welghtoeanng through extended LEs futl upnght. antigr8"iIY POSition Improve balance reacttons FunClional postUie IlTlportant for ADL Skills, lead-up Natrow BOS high COM

tor'"

BOS bCl::.b 01 !>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<.Ji r i[ ... t'l f."~" r j ,~ Mec hanl"llb of nc?urop l a~ ticit y includl:! neuroa nd.lom ic al. neu rochemical. and neurorecep t iv~ change .... AnalOmic

483

se nsiti vit y are improved (sYflaptic p lastic iIY)· Changes in synapti c strength, Irmg-term potentiation (LTP). finn up neuronal connecti ons and se rve as a basis for all memory and learning. It is important to remember that these neuroplastic c hanges m ay be adapti ve (functional) or maladapti ve (non fun cti onal). Neural regeneratio n, repair, and reorganization is a topic of intense ongoi ng researc h. For exce lle nt reviews. the reader is referred to the work o f S tei n, Brailowsky, and n, Will 56 and Pl oughrnan . Recovery can be c at egorized into two main types: ( I ) sponlol/eotlS r ecol"fl"Y res ulting from repair processes occurring immediatel y after the in sult and (2) functioninduced recover.v. the neura l reorganization that occurs as a res ult of increased use of invo lved body segme nts in be haviorally re levant tasks. Initi a l spon taneous recovery is innuenced by th e return to function of und amaged part s of th e brain with th e resolut ion of te mporary blocking factors (i.e .. shoc k. edema. d ecreased blood fl ow. decreased g lucose utilization). Thi s process has been te rmed diaschisis and takes place over a relati vely sho rt tim e fra:ne, typicall y 3 to 4 weeks. For ex ample . th e pati e nt w ith ce rebral edema following stroke is likel y to demon stral e ear ly worsening of clini cal sig ns as edema develops fo llowed by spontaneo us improve ment wilhin a few week s as the edema reso lves.

Function-Induced Recovery Functi on-i nduced recovery (use-dependent cortical reorgCJlli::otioll) refers to the ab ility of the nervous system to modify itse lf in respon se EO changes in activi ty and the environmen!. It is important to re me mbe r that rhe brain is organized w ith parall el and di stribu ted c ircuits Ihal prov ide rnuhipie inputs to m any areas and overlapping func tion. Different and underurili zed areas of the brain (e.g., cortical suppleme ntary and association areas) can lake over the functions of damaged ti ssue . a process that has been called \·icariance. Another possibi li ty is Ihat rhe eNS has backup or fail- ... afe system s (para li c I cortical maps) that become operat ional when the primw'y system breaks do\\ n. nl~ unmasking of new. redundant neUfl)1l p;'ll hway s penllil~ corti cal map reorgani zati on and maintenallL'c of func tio n. Whole ditTerent areas of th~ brain are also l.:apahle of ~coming reprog rammed , a process rerllled sllhstirll/ian. An example of sub::. tiwt ion is the incrca::.ed sensi tivil), of th\,.' ha.nd~ <1;:. a sen.'!ory infollll ~ttion sys tem for the per~on who be.comes blind. tn Ihi ~ ex ample, the t:hanges III ~e n~ory ::.rr:.uegy lead to structural reorgan izati on \\ ithin the brain. Newa tt'chni411e.'! in brain ma pping ha\ e teu (0 ncHe-r lImk·r~l'Ulding of me51;" procc.'!.'.e.'!. The,e includt' (I) (XIsl tn..II1 ~lllI ..,s i on lomogmph) (pET) ..,canning lI~e d to rnea')ure regional ce rebraJ blOl."Xi Ih)\\ (rC.'Br). (2) tex.·aJ tr::ub<:r,mial Illdg netic ~ Iirnulalion (TMS ) used 10 me;.t"ur~ n..":-.ponst:~ in 1110101' c\.lliicat regions l u focal magllc?lic lidt.l .'! tllnulalioll. and (3) fUlll.:tinnal magnCli c rc~on~Ulce IInaglllg. lfi\tR 1J lI~d [0 mca~ure ~ma!l c hall gt'~ 1\1 hlond flow dunng brllin lil"tiv~tllon .n .~'j Recovery

484

Physical Rehabilitation

is a compl ex and dynamic process. and likely involves all of the above processes, There is an accumul ating body of research on constraint· induced mo\'ement th era p~' (CI therapy or forced- lise Therapy) in patients following stroke th at has demonstrated significant and large improvements of upper ex tremity (UE) funclion,62-71 Treatment-induced corti cal reorganization has been demonstrated in studi es using TMS 64 and fMRI. M Box 13. 1 presents a summary of evidence from selected researc h in this area. Two factors are criti cal to the successful outcomes ach ieved in these studies. The first is the conce ntrated and repe titi ve practice of the involved UE. Train ing was intensive (averag ing 6 hours/day) and focused on practice of common functional tasks. All subjects staned wi th some voluntary movement (wri st and fin ger ex tension) in their affected limb. Second. move ment was restricted in the sound UE through the use of mitis or splints and slings for up to 90 percent of waking hours. Behavioral shaping techniques (ope rant conditioning) were used in whic h the pat ients were rewarded for improvement \\ ith verbaJ re inforce ment but not blamed (punished) for failure . The tasks we re selected and tailored to address the specific motor de fi cits of the patient and ordered to allow for improv ing movemelll control and appropriate rest intervals. Locomotor training using partiaJ body we ight support (BWS ). a treadmill (TM ). and manuall y assisted limb movements has also been shown to promote functioninduced recovery.7 2-i5 As in CI therapy. pract ice is intense and task-specific. The lim bs are max imall y loaded to tolerance whi le movements are coordinated to stimulate actual walking. Compensatory strategies are minimized or eliminated . Training is progressed by decreasing the amount of loading (body weig ht suppon ) and ass istance and moving toward overground and communit y ambulalion. See di ~cuss ion in Chapter 14 and Evidence Summary Boxe~ in Chapters 18 and 23.

Effect of the Environ ment o n Recovery of Function BenefiCial effects on brain function (i ncreased cortic:tI de~th . bralll weight . dendritic branching. and enzyme aCf1 \' lt ) ) have been demonslJ'ated in rodt:nts ex po~ed 10 e nTJc h~d en\' irol1lncnts.76 N The enriched e m ironment s

con!.l..,ted o f manipulati ve toy~ for pia) . and structure5J for d Jlnbing. runnmg. or sWingin g. In ('ontra\!. II1lac( rodents ral::.ed JI1 Impoveri::.hed or ::.m all cage environments did 1101 demom lrate the ~ame level of bmin development. When k :-" IOlh \'oc rc induced in rodcnb , exposure 10 CI\ f](,.: hed envlronme nt ~ and aCfl 'v ll y pnor to ~urgic
Rats housed in social gro ups in e nriched environmeDb dem onstrated superior recovery over isolated rats.1S Animal stud ies have also revealed that there may exist an optimal time period for such exposure, When rats with brain lesions less tha~ days were given intensive trainin& additional neuronal injury was demonstrated. These findings suggest that during the earl y post- lesion period. the damaged brain may be vulnerable to the stress imposed by intense training with additional injury.86 In humans, an unfamiliar and unpredictable hospital or rehabilitation environment may contribute to depression disorientat ion. and decline of functi on. Thjs same envi~ ronm ent may be overly structu red and protective to the point that it contributes to learned helplessness and disuse.8' Carr and Shepherd arg ue that poor recovery after stroke may be partially explained by the impoverished and non challe ngin g environments that many individuals recovering from stroke are ex posed to.88-S9 Whi le there are fe w environmenta l studi es, there is evidence that patients recove rin g from stroke who were treated on an acute stroke unit demonstrated better recovery and functionaJ outcomes th an patie nts who received a comparable amount of ph ys ical therapy while on a general medi
?

Framework for Intervention Different nt!urorehabilitation approaches and theraptUlic techniques have evolved for patients with disorders of ~not or function . Historically many practical treaIJIdI Ideas have evolved from empirical knowledge and cJ.injcal practice. Theory ha~ bee n applied to e;
Functional Training E\ Idenl:t" from rC~J.rch on function-ind uced recowrY ... ~cd IO f~lu.·tiona.lJtas k ~orientcd traininM;.61. 75 CcnnllO~

appro.~(h l 'i Ihe Ilk~a Ih.1I sl'Cc lfil: t:.l..\k-oriented trainiDa'" C.\h:n.-..lve l,ra'·'" .e ' . to feaL.·qwnna .' -i.~u..-.l "" e~~enll:.t1 3iaIIII f 11'.\1 nllllUlMltj

(M,.,.-

Chapter 13 Strategie fii to Impro,'e Motor Function

485

Evidence Summary Box 13.1 Constraint-Induced Movement Therapy Designl Reference

Subjects

levy, CE, et al" 200t

Nonrandornized cohort 2 patients. post· stroke (3-4 months); design;

post·rehab, With moderate motor defrcrt;

Intervention

CI training of aHected UE With restrictlve mitt worn on nonaHected hand:

Duration

Results

Comments

6 hours/day. 5 days/week for 2 weeks

Significant and large improvement in motor function and performance trme.

Findings support use of CI to reverse deficits and prevent leaming nonuse:

fMRI : i motor cortex activity near lesion site; i bilateral hemisphere activation

convenience sample. behavioral shaping techniques; IC: 20'. voluntary wnst ext. and 10" linger ext

Pre- and posttreatment testing using:

Small N, no conlrols:

fMRI is a useful 1001 to monitor recovery and treatment eHects.

WMFT MAL fMRI LJepert. J et al" 2000

13 palienls, post· stroke (>6 months): post·rehab, WITh moderate motor defrcit; convenrence sample'

IC: 20", voluntary wnst ext. and 100 frnger ext; no balance or cogmtlve problems

DromencK, A. Edwards D. and Hahn. Moc

2000

---

20 patients. post·

stroke within 14 days of rschemlC stroke. With moderate motor deficit and In active rehab; screening tools for mcluslon·

NIHSS MAS

Nonrandomized cohort design;

6 hours/day. 4 days/week for 2 weeks CI training of aHected UE with restrictive hand splint and sling worn on nonaHected UE during 90""" of waking hours;

Significanl and large Small N, no conlrols: improvement in motor Supports Cllherapy as functions; a powertul treatment for Significant enlargeimproving UE function ment of cortical motor post·stroke: oupul area in the significant brain changes affected hemisphere; seen with short time

behavioral shaping techniques;

Treatment gains maintained up to 6 monlhs post· treatment .

Pre- and posttreatment testing using:

MAL TMS Single randomiZed clinical Inal;

2 hours/day. 5 days/week for

Trealmen! group· CI tramlng of affecled UE With restrrctlve hand mitt worn on nonaHected UE alleast 6 hours/day;

2 weeks

Controt group: traditional OT treatment;

behavioral shaping acute stroke, pre- techniques served eagnni've func- Pre- and posttreatment lIOn. Plesence of UE testing usrng protective response ARA

Ie

course.

Mean total ARA score was signlftcanUy higher rn treatment group (r = 0.66):

Supports Cllherapy as a powerful lreatmenl for improving UE runcbon post-stroke;

No difference in disability measure (BI).

Lower treatment intens/lies than other stUdies:

Small N. with controls;

81 not a sensitive measure of UE changes. Average age of control group was 10 years greater lhan treatment group;

No Iong·lerm follow·up. (continued)

486

Ph}"ical Re habilitation

Evidence Summary Box 13.1 Constraint-Induced Moveme nt Therapy D

Reference

Subjects

Blanlon, S. and Woll. S" 1999

Single patient 4 months post-stroke; post-rehab, with moderate motor deficit; Screening tools lor inclusion:

MAL

Miltner. W, et ar:'8

. Duration

6 hours/day 5 dayslweek for 2 CI training of affected UE weeks with restrictive mitten worn on nonaffected UE during waking hours: Single case report design;

behavioral shaping techniques;

MMSE

Pre- and posttreatment ,

IC: 10'. voluntary wnst ext. and finger ext; no balance or cognitive problems

3 months follow·up test·

15 patients, post· stroke. post-rehab. with moderate motor deficit (mean time = 5.1 years);

1999

. / eSlgn . Intervention

I~n ';n u,"')

Kunkel A. et al~9

1999

-

conventence sample Screentng tools for Inclusion

MAl Cognitive battery IC' 20 , VOluntary wnst e.(f , 10 finger ext , no cognitive problems

Significant improvement of motor abilities and timed abilities on WMFT;

Small N, no controls;

i self·report use of UE on MAS; Treatment gains maintained 3 months posttreatment.

Supports Cllherapy as a powenul trealment for improving UE function post·stroke; May reverse effects 01 learned non-use.

ing using:

MAL Nonrandomized cohort design;

7 hours/day, 4 days/week for Cllraining of affeeted UE 12 days

Significanl and very Small N, no controls; large improvement on Supports CI therapy as a motor tests (MAL, powenul treatment for WMFT); imprOving UE function Gains maintained post-stroke; 6 monlhs post· Mean chronici1y 01 5.1 treatment years discounts effects rJ spontaneous recovery or prior lherapy.

WMFT MAL

--- ---

5 patients, poststroke, post-rehab with moderate motor defiCit (time post-stroke = 3-15 yrs) ;

Comme nts

WMFT

with restrictive hand splint and sling worn on Convenience sample; nonaffeeted UE during 90o~ of waking hours; Screening tools for IncluSion: behavioral shaping techniques: EMG, EEG, MAl, TMS. Cognllive Pre and post-treatment battery testing using:

IC: 20', voluntary WrJst ext. 10° tinger ext; no balance or cognitive problems

Results

--

Nonrandomized cohort design;

6 hours/day 5 days/week for

CI training of affected UE with restrictive hand splint and sling worn on nonaHected UE durtng 90% of waking hours;

2 weeks

behaVioral shaping techntques , Pre- and posttreatment testlOg uSing

WMFT MAL AMAT AAUT

Significant and large Small N, no conlro1s; improvement in Supports CI therapy as a perfonnance tImes powenul treatment for (AMAT. WMFT); imprOVing UE functia1 quality of movement post·stroke; (AMAT WMFT. MAL); More than 100% H1 and use of UE In real actJve use of UE. WOl1d (AAUT); Gains mamtamed 3

mo. post-treatment

Chapter 13 Strategies to Improve Motor Function

487

Evidence Summary Box 13.1 Constraint-Induced Movement Therapy Reference

Subjects

Van der Lee, J. at aVo

66 pallents, poststroke (median time = 3 years) wl1l1 moderate motor

1999

defic~ ;

Screening lools for inclusion: ARA IC: at least 1 year post·stroke; 200 voluntary wrist ext, log finger ext; no cognitive or balance problems

Designl Jnlenention Single randomized clinical trial; Treatment group: CI training of affected UE with restrictive splint/sling worn on nonaffecled UE:

(~nl;nucd)

Duration

Results

Comments

6 hours/day, 5 days/week for 2 weeks

Small and significant improvement in motor pertormance (dexterity measured by ARA) and use of UE (MAL);

Larger N than other studies; Supports CI therapy as a treatment for improving UE function post-stroke;

Gains in ARA maintained 1 yr. posttreatment

Control group: traditional PT treatment according to NOT method (bimanual training); behavioral shaping techniques; Pre- and posttreatment testing using:

Benefits found in those patients with sensory disorders;

60111 RAP and FMA failed to reveal any differences suggesting inadequate responsiveness of instruments to chronic stroke.

ARA RAP FMA (UE motor subtest) MAL Taub E, et aI" 1993

9 patients, poststroke with mooerate motor deficit (median post-stroke time = 4.1 years);

Single randomized clinical trial

Screening tools for inclUSion:

Treatment group: CI training of affected UE with restrictive splinVsling worn on nonaffected UE 90% of waking hours

Cogmtlve tests

Control group:

IC: at least t year post-stroke: 20" voluntary wnst ext, 10 finger ed; no cognrttve or balance problems

Received training strategies to focus attention on using affected UE; traditional PT (PROM)

7 hours/day, S dayslweek for 2 weeks

Significant and large improvement in motor pertormance (performance time, quality of movement on WMFT) and use of UE (MAT); Gains maintained dunng 2-year follow-up.

behavioral shaping techniques Pre- and posttreatment tesltng uSing: WMFT MAT

1 .,.- 1n~rea-.ed AAl'T Anu;!1 Amuunl of U~t: rt.>,,[ ! 11K ludl:'\ ~ I [[ell1\ 01 ~II -ft'pon (II ann U!>l'); AMAr Arm 1\11I1\ I ~ lompk, 1.! .. I.. !> I; ARA -= .-\UIOIJ R\"I',ll\.h Ann TI:'/Il ! lIIdudt'~ II} lIem 1.1 LE \IU:IlJ;.lh. dl:\lcnt >. 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<': ~ mdu'h"'" rIIl' n.!. r..·IAL "" Motur Attn Ity ..o~ I Mrucl Uh.d 11111:'1"\ Jt'1I> Ihill Idelllllic\ pert onn.!r1u· 011 '\0 d.' I I} U\l I\ 1111:'),1. MAS MOIm A'>'>C-'''rnell\ S'·.llc l"llot.c"pn.h~ Ilhlllitllenl); MM~ I ' - Mllll M,nl .. l \1 ... le I .'dlll ( Fllbtt' 1I1): N IIllIllt'>t:rll! ~ u bJ('~h, 1\o0T \l;.un•.odo;\d,lpflI..:m.JJ Trt:.JlJlklll; "'lI i SS N.. llunalllbllluIO:~ o lllt>all h !'llh}" 1! ~(.ak I\lr\.l"~·~ps.'(lfi~· m'tru . mttlt; 01 Oo.lUp.!\tlllld.J lherap} RAP l101( 1"";:1..1 Inknlt .... th..t ia!>~)~, dl'dl1llltl~~ and h.JJldl .. .. p~ .tllll lvll'ol)h \)1 :! I 11t.>111» II I 'i JUln.!I 'b), Rt"h.a11 l,hab,Ju.t \I'lft. 1 M~ I C>I..allrLln~r.tl1lul Hl.J~llctj( ,lIInuL.•lwll , \\o-MI- I \\vil MnlHl 'ulldh)U k~l . "Il l l;. fUndlolMI le,>llllallflt.Judo.: \4 wncd .., U\'1I1~ ' ilnd ~ ' Irength k'h

Small N; Supports CI therapy as a treatment for improving UE function post-stroke; Long follow-up penod Attention training of control group reduces likelihood improvement due to attention/placebo factors.

488

Physical Re habilitation TASK

;...---l."

...

Components Attributes • Mobility • Stability • Controlled Mobility • Skill Amplitude Velocity

INDIVIDUAL Cognition Attention/Motivation Sensory/Perceptual Integrity Muscle StrengthlMotor Function Endurance Chronicity/Stability of Condition Co_morbidities/Complications Overall Health Stalus

ENVIRONMENT

Physical features • Regulatory • Nonregulatory Socioeconomic Factors Social Support/Resources

1 MOTOR FUNCTION

t

INTERVENTION STRATEGIES

COM PE NSATORY

TRAINING STRATEGIES

NEUROMOTOR STRATEGIESI THERAPEUTIC EXERCISE

FUNCTIONAL TRAINING STRATEGIES

MOTOR LEARNING STRATEGIES

Feedback: KP , KR Task·Specific Training Practice: Type. Sequence. Order Behavioral Shaping Neuromotor Training Transfer Training Environment Enrichment Developmental Activities Problem Solving Balance. Coordination. Postural Training Gait/Locomotor Training Strength, Power. Endurance Relaxation Training Figure 13.5 Motor function emerges from interaction among the task. the individual. and the environment. Defi cits in motor function can be improved using Neuromofor, FllIICfiOl/ol/Task OJ';el/ted. M OTOr LeoJ'll illg. and/or Compensatory intervention strategies.

Substitution Adaptation Assislive/supportive devices

enhanc ing recovery. Theoretically. the interacting systems of the e NS are viewed as organi7.ed around essential functional l t". !:> tanding, and walking) are e mpha~ i zed. Invo k ed i-eg mcnl!:> are targeled for training (i.e .. con::.traint · mduced movement thentp)). Level of diffk ult y i.., varic:d and IOll ial t a.sl.. ~ are ~e l ec l ed to en.'> 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 c
m,IY increase the vulnerability of the bruin 10 ~ P.ttients who are not able to panicipate on enled tmllling include (hose who lack volunUll)'

dalll;.\ gt;': .~~

in"'· ~

or t:og.nl.ti ve fUllc tion. For exmnple, a patient wilh ~ br~lln Injury who I ~ 111 Ihe early ret'overy slages haS lIIIII-

Chapter t3 Strategies to Impro\'e Motor Function

489

Box 13.2 Task·Oriented Training Strategics to Promote Function-Induced Recovery Focus on carly training as soon as poss ibl e aft er brain damage to utjl i1.e specifiC' windows of opportun ity and avoid learned nonusc, Consider the individual's P;lst hi story. health status. age. and experi~nce in designing appropriate. inlcrestin g and stimu latin g acti vities. Involve the patient in goa l-selling and decision making. thereby enhanc ing motivation and promoting ..ctive commitment to recovery. Strucrure prJclice util iling task-related training acti vit ies. • Select tac;ks im portant for independent fu nction: incl ude tasks that are important to the patienl. • Identify the IXlIicn!':. abilities/:.trengths and level of reeovcry/lcarning: choose tasks that have potcnlial for patient success. • Target active movements involving the affected ex tremi ries: constrain or limit compensatory strategies. • Utilize repetition and ex tensive (nHlssed) practice. • Include both superv ised and unsupervised practice using an activi ty log.

potential 10 succeed w ith thi s Iype of intensive training . Similarl) . patients w ith stroke who ex perience profound upper extremity paralysis would not be eligible for constraint induced (C I) UE tra inin g. One o f the con sistent exclus ion cri teria for C I therapy has been inabilit y to perfo nn vo luntary wri st and fi nger extens io n o f the invo lved hand . Thus thre ~h old abili ties to perfoml the bas ic compone nts of the task need to be ident ifi ed. Care ful analys is of underl y ing impairment!) w ith a foc us on int erventi on (e.g., stren gth . ROM ) comp leme nts task-o ri ented tra ini ng. For exampl e, duri ng locom otor tra ining us in g BWS and a TM system . pallems are guided in thei r :.tepping and pel vic moti o ns int o an effi cie nt moto r pattern . Patient s need to demo nstrate essential pre req uis ites of bas ic head and trunk stability during upn ght positioning in o rder to be cons idered appro pri ate candidate"! fo r th is type of train in g.

Neuromotor Development Training Neuromotor deHlopmenl training incl udes deve lopmental acti vitie ... tra in ing. mo to r tra in in g, move ment pat tern training . and neurom u:.c ul ar education o r rCt!ducalion. Neu ro mu ~c u lar/:.e n ~o ry :. timul ation tec hn iq ues and thera peutic exe n':: I 'ie~ are used to alte r se n ~ o rim o t o r impa inn c nt :. and promote fun r.:tio na l mu ve ment s. The affected body segmenb an: tiirgeted for trai nin g while cornpc n:'cd 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 o n the u ~ of both feedbad.. and leedfo~ard mechani sms to suppon poslUral l'onLroi PO~LUral control I" viewed as the fo undation for all ~ki ll learmng. Nonl1~11 deve lopmen t in child ren and no nnaJ move ment pattc:rn.., in all patien t.') are stre.')sed. T he pat ient lea.rn, 10 control pO.'lture and movement thro ugh a .':>eq uence of pro~ grc.'I.'Ilvel) more cha ll eng ing I){)::.iures and aCl ivil ie't. NDT u"e~ ph) to.ica l hanJII1/1: (el'lmiljue.\ and key f}O/J/I.\ of ('olllrol fe. g., '.Ihou lder't, peJv l~, hand!>, 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 <.I moveme nt re~ po n se Ihrough altrred :-.yna plic potenti al. The sy naptic th rc~ h old is rJ i.:;cd. mahillg it more di ffic ult for the neuron to fire and produce 1110\('I11Cnt. The combination of spinal in puts and 5-upra:-.pina l input ~ acting on the J, lpha motor neuron (fi nal comJllon path\\ ay) will dc tenn ine wheth er a muscle respon:-.e i:-. facilitated. activ3led. or in hibited. Se\'eral general guidclille:-. are imponanl. First. fac il itative technique:-. can be addi ti\'e. That is, seve ra l inpu ts applied ,iJ1lultant'ou~ly. :-.uch as quick streI ch. resistance. and verbal com l1land~ commonl) combined in PNF panems. prod uce Ihl' de"iircd motor respoll'>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<, a single ~ t imul u s does not. Thus. stretch is u,ed repealed I) to CIl'iure that the patient with a weak muscle I." able to mo\'e from the lengthcncd to the shortened range. The re..,pon~e to stimu lation or inh ibition is unique to each patient ,md dependen l on a number of diffe rent factors, including Ic\el 01 intac tne~s of the eNS. arousal, and the speCific lewl of acti\'it) of the motone urons in questi on. For e\ample. a p~lIiel1l \\ ho i ~ de pres sed and hypoacti ve may require large Jlllounts of ~ til11 u \a ti ol1 to achieve the des ired re)pon..,e. SIlIllUla(ion i." generall y contraind icated for the patient \\ Ith h) peracti \'it ) \\ hile inhibition/relaxation techIllquc<., arc of benefi t. TIle intensi ty. duration. and frequency of !:> llllul:'l\lon need (Q be adju"ited to mcc t indiv idual patient need",. L1npredl cted re::,pon~e~ can re~ ll lt from inappropriate apphcatlon 01 t e-c hniqlle~. For example. "tretch appl ied to a .. pa~ti c mu ~d c 111a ~ inc rea~e ,pasticit y and negatively impact \olunt31) mm ement. Facilitation techniq ues are not appropnate lor pallenb \\ ho demon::,trate adequate vo luntary comrol: the) ."hould he \lev.cd primarily as a bridge to voluntary mO\cment control. Appendi x C pre~e nt ~ an overview 01 neurolllu ."c ular/~en",ol") ... timu lat ion techniq ue!':..

Compensatory Training The loc u. . 01

(O Ii//)(! II\lI f (ln' frainllig

i ~ ea rl ) re~ump ti on o f

tunu lonal . . 1..11 1... u.., lng the unin\'ohed or It: ~~ Ill vo lved \egOlcnh lor lunuH.)fl For t:'>" lInple. the pa ti ent" Ilh hellllplt: gla I.., tau ght to dre~!':. u' JIl g Ihe l e ~, - ~fk(" t ed upper t''' tremII ) I ht' pall l' llI ", Itll parapkgl;t regain", functional mobility Jnd \.\ ht'e k h. ur Int.lqx: ndenlt' U ... lllg th e upper t'>.t rt'llli lte .... Cellt rdi tu Ihl' ;tp pru~t(.: h \. . the conr t" pl ot loo ub,tilUtioll . l ht Pdt )(: nt 1\ made a\\ Jfl! ot movemenl defi ciell( h~~ (cogIl lll \'e d\\ ,tr(" ll e..,,,, I ... dt'\c lopt.:d l. C h angc ~ are IhL:n Illade til the patlclH ' me rall approadl lu f unLll onitll~l \b . AIh: nUIlC 'Aa) ~ Ie, ..tu,.:omplt ... h Ihe 1<1' 1.. art! ~ uggc.:-.led , \ 1I11PIIlICd , an..! adopted I he !lil lH:llt pr.ILlIL e, .:.tlld rdCilfll "l Ihe w. . 1-. lI'> lng the nc\\ p.H h:: m I he p.:.tl! t·nt thL' n pracw.·I." \ Ihe Ilt! " pallern 111 the Cn \ II UlI llk' llI III \ \l111.:h the IUil CIlOIl h C.\ IX'ClcJ to (k.:tur b h: l g) l on . . n v.t110n tcc.: hJllljue." are IIlL·orpor.ltcu to t' n ~ u rt' the pdtll.! nt Lan ' lI cL e~~ l u n ) LUltl pl L'te . til u.ul),

491

tasks. A ...econd central tenet of thi s approach is modificalion of th e task and environment (ad a pta tion) to faciJilale relearn ing of skill s. ease of moveme nt. and optimal performance. For example. the patient with unilateral neglect is assisted in dres!':. ing by color codin g of the shoes (red tape 0 11 th e left shoe. ye ll ow tape on the ri ght shoe). The wheelchair brake toggle is ex tended and color coded to allow the easy identi fica tion by th e palient. One of the major criti cisms of thi s app roach is the foc us on un involved segments may suppress recove ry for cen ain pat ients and cont ribute to lea rned nonuse of impaired segment s. 102 For examp le. the pa tient with stroke fails to learn to use the involved ex tremities. Compensatory training can also Icad to deve lopment of spliflfer skills, whi ch are skills acquired in a manner inconsiste nt with skills the indi vidual alread y possesses. Spl inter skill s ca nn ot be easi ly ge neralized to other task variations or to other environm ents. A compensatory train ing approach may be the only real isti c approach possi ble when recovery is limited or the patient presents with signifi cant impainnents and functional limitations with little or no expectation for additional recovery. Examples incl ude the patient with complete spinal cord inj ury or the patient recovering from stroke with seve re se nsorimotor de ficits and ex tensive co· morbidities (e.g .. severe cardiac and respi ratory compromise or memory defi cits assoc iated wi th Al zheimer's disease). The latter is severely limjted in the abilit y 10 act ive ly partici pate in rehabilitati on and to relearn motor skill s.

Integrating Approaches An unde rstandin g of how the brain reg ul ates move ment is esse nti al to makin g sound clinical dec isions in selecting intervelllions. Therap ists must be cau tious not to deve lop a "di sciple-like" adherence to one approac h. Therap ists who become ce rtifi ed in. and a propone nt of. a particular approac h must be partit' ul arl y ca utious abou t ove rreli<:tnce on a single grou p of treatmelll intcIVcllI ions. The divcrs ity of problems ex perienced by pa ti ents wi lh disorde red motor functi on negate~ the idea th at anyone approa('h could be ::, u cl'e~~ ful for a ll pa tients. A~ patients recover. their abi lit i e~ and nceds change. Therapish must be att ullcd to lhe patient ' ~ chang ing s t a lU ~ and recognize anticipated goals and o.perted outco mes may change. A varic t) of interve ntiol1!-1 i:-. lihcly 10 be the mos t cfferti\e approuch in meeti ng the thvt.' r:-.l" n ~ed, of p~Hielll s. A common b"loot" for a ll in tcr\l!lltioJ) i\ train ing 10 Improve fUll ctlOllal sl-. ills and motor learnlllg . IIlICrVCl'lt lolh also need 10 promote ada pl:lbi lity of . , l-.tl l, for function III real-world enviro nme nts. In selecting 1IlI e r\' e nti on~ . th ~ therapl ' t must l'olbider tho:-..e th ai h.n e the grea l e~ t eh.uKe..' of 'lH.:cC':-.. Tht.' I.:hoice of IllIer\ t'n llom IIlU'1 al ... o tak~ into l'on",ideration other fl.ll"lor::,. lIlduding ~lbdil y III deliver ca re, cosl-cffe l,: ti"encss in terms of Icngth 01 :-. tay dllli number 01 .lliolteci phY;:" I('al the rapy \ 1 ~ lh. :lg~ of the PdllCIlI ,md Illlllltx'r of (Oo-morbldities. ~(x: ial . . upport . ,Uld porcl1Ilal diSCharge placc mc nl. Exampl es of

492

Physical Rehabilitation

r.

Box 13.3 Examples of General Go~ls and Outcomes or

Patients with

Disorders of Motor Functio n Impact of pathology/pathophysiology is red uced. • Risk of recurrence of condition is reduced. • Risk of secondary impai mlent is reduced. • Intensi ty of care is decreased. Impact on impainnents is reduced. . • Alertne..
• Level of supervision for task ~~o~a~ce is deere 111 • ~, 0 Ierance of positions and activItieS. IS mcreased. ' . • Flex.ibility for varied tasks and environments lS II1IpIVvM. • Molor learn ing skill s are improved. • Decision making is improved .

• Safety of patjent/c1 ient, family, and caregivers is improved.

. .

.

Di sability associated with acute or chromc Illness IS reduced. • Ability to assume/resume self-care, home managemeat. work (job/school/play), community, and leisure roles ia

improved . Health statu s is improved. • Sense of well-being is increased . • Insight. self-confidence. and self-image are imphNed. • Health. wellness. and fitn ess are improved. Satisfaction, access. availability, and services are accept'" til

patienl/cHent. Patient/client. famil y. and caregiver knowledge and a.ww____ of the diagnosis. prognosis, anticipated goa l s/e~pected (Nt.. comes. and interventions are increased.

Adapted from Gllidr to Physifa/ Thrropisl Practicr lO1

genera l goals and out comes for improvi ng motor function ada pted from the Guide to Physical Therapist Praclice l03 are presented in Box 13.3. These can serve as a basis for deve lop ing speci fi c antic ipated goa ls and ex pected outcomes for an individual patie nt.

Intervention Strategies to Improve Motor Control Strength, Power, and Endurance Training Muscle perfo r mance is defined a~ "the capaci ty of a mu,,ele or group of mu~c1 e~ to ge nerate forces:'IO.l.p6I1h M uscle strength is the "m u ~cJe forc e exe n ed by a mu scl e or a group of muscles to overcome a re~i stance under a spec ific i>t: 1 of circu m ~lances:'Wl pl>1I11 Muscle power is " the work produced per unit of lime or the product of strength and ' 1"'"d " Ie en d urance .IS ··h ·· to ~ u ~ lalll . . . .'· Jf) ~.P bl>If M usc I e ability force~ repeatedl) or to generate force~ ove r a pt:n od of " IU ~ p bKIs M I IIIne. · usc e pt: rt'onnance .I ~ reg ul ated by a num ber of f'lclOr!) , incl udlllg mOlOr unit retTUitmenl , mOioneu ron finng patlern~, mu ~c le leng th and t en~ion , mu scle fiber compo~lIi on , fuel storage and delivery. ~peed and type of cOlllraclion. and movemc m ann .l()..j Techt11que~ Ihal optiInlle Ihe~e fatlo rs \\ hile addre~~ing the '} pecilk demand~ of Ihe ta!:l k and environment yie ld maJl.illlllJJl functional

,,,,1\

outcomes. Im proved sense of we ll-being and confidence are also impo rt ant o utcomes. Pati ents unde rgoi ng neuroreh abilitation commonly present with di sruption of mo(oneurons from central pathways. the d irect result o f upper motor neuron lesions. Weakness o r paralys is can affect o ne side of the body (hem iparesis, hem ip leg ia). both lowe r limbs (paraparesis. paraplegia), all fo ur limbs (tetraparesis, tetraplegia). or a sing le limb or segme nts of a li mb. As recovery progresses. the stat us of mu sc le strength and perfo rmance may change (e.g .. the patient recovering fro m incomplete spinal cord injury). In addi tion. prolonged periods o f disuse and immobi lity res ult in dimin ished neural ac tivity. atrophy. and" eaknes>. Older ad ults typica lly demonstrate a preferent mlloss of type 1I fll:>ers. It b also impon anllO recognlz.e lhal the patie nt Inay have beC:-1l inac tive prior to insult (J" injury re\ ult ing in pree>..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 <:l Isa improved. The effec tiveness o f a strengthen ing program is dependent on achieving an adequate tra ining stimulu s. For stre ngth and power trainin g. an exercise prescriptioll sho uld in clude the followin g e leme nt s: mode of exercise (type of muscle contraction. appli cation of res istance. arc of l11ovcmenl). imensiry (exercise load or level of res istance). freql/ellcy (num ber of repeti ti ons a nd set~: number of exercises pe r set). rest illfen'ol (recuperati o n time bet\\een ~ts and exe rcise sessions). and duraliOlI (total time of resblance tra inin g). Additional detemlinants include use of COITl'l'f aliglll11l'1If and srabifi:ariol1 and consideratio n of rep lication of /llIlerjollal demands. tO~ Basic principles of effec ti ve strengtheni ng prog ram s incl ude overload. spec iticity. cross training. and reversibi li t y.!I~ nle loads placed on muscle mu st be greater than those nonnall y incurred (o\'e rload principle). Appl icat ion o f a progressive resistance sequence that achieves 80 perce nt maximum voluntary strength is a gene rall y accept ed crite ri a for effective strengthe ning. Free we ight s, pu ll ey syste m s. elastic re:-.istance bands, mechanical resistance machines, isokinetic dynamometers. and manual res istance all provide sources of extemal load on mu scle. Training effects are specific to the mode of exe rcise stre ss imposed on the exercising mu sc Je ~ (s pecificit~· principle). Thu s. the training effec~ from an isometric protoco l are spec ifi c to the exercising muscle and the point in the range that the muscle is holding. Effects do not carryover to improved dynami c perfonnance (concen tri c or eccentric contrac ti ons). Nor w ill exerci~e training of the uppe r ex trem it ies transfe r to improved 10\1. er ex trem ity pe rforma nce. C ross training refers to a training program that includes a variety of training elements (e.g .. i ~ol11etric. conce ntric , ecce ntric. and endurance). Cross training is u:-.ed to place broadest poss ible demand s on the neuromuscular ~ystem and ove rcome the effects of ~pec ilicit) . Reversibilit y principle refers to thc failure 10 sustain the benefits of . . tre ngth training if musc les are not regular!) used in a maintenance program o f re:-.istance or functiona l exer(' i~e ~. Detraining e ffect:-. incl ude a reduction in mu~c1e performance. decrea ... ed neural recruitmemo and mu ...ck liber atro phy.1fJ7 Stn:ngth trawing method :-. hm e been \l.c ll de~cribed ..tnd documenLcd Y'~ !")o, Selec li on 01 a parlil:ular training ~4ut'Il<.;1: muSI be ba')cd on Ihe specific need~ of the pat ie nt and the pottmial bt! n~fils 01 lJ paniculJr me thod . For example. l~ume tn L: tr..llnlng \\ III re!o.uit 111 gain~ in sta lK' ~ tn: n gth \I. nhoul .. tdded Jumt motion . Thi s nnly be lI11po rtant dUTlng earl} rehabi litation v,ht:Jl paUl i ... a I"Ktor or When poslUral"'labdll~ t ~ the locus oilrl::.t tllll!l1t. O) nant/(: e>i.cfl':l:-.e fc..:Ollcc ntlK and ecce nlru. j .1110\'...... II)f JOll1ll11o\,,:"rnt:1lI and exc ursion 0 1 it bod} sCglDC IlI and ! ... e",st.: nItJI to develop th~ ..,I re rtgth . pO\\cr, dlld cndUrdlll:e r('4ulred lor tlJl1clJ()J1ul mohdlly .., klll ..... Pallem ... with defir..: lh 111111010r lu m:ll oll l11i.1} del11on ... trate ~efic il \ 111 llluM:k atllv<J\ lul1. Ear l) InUIl!ng . . hould io(:u~ l)ll I\OJl1l:trt c and e(:centm.: (,.on lr<.lr..: ll on . . btcau ...e mu :-.de te ll:-'IUIl

493

is be tt er maintained than w ith conce ntric contracti ons. Thi s is due primaril y to the improved periphem l refl ex s upport of contraction as opposed to the spindle unl oad ing that occurs as the mu scle moves into the shortened range of a conce ntri c contrac ti o n. The pati e nt is initiall y asked to ac tive ly hold at midrange w he re the g reatest te ns io n can be generated. The pa tient is then asked to s low ly lower the lim b (an eccentri c contract ion ) and ho ld (an isometric contraction). Once control is ac hi eved in both of these types o f co ntracti ons. conce ntric contracti o ns can be a tte mpted . For isotoni c contrac tion s prestre tc hin g the muscle by s tart ing the contract ion in th e lengthe ned range o ptimi zes tens ion de velopment through in c reased use of viscoe lasti c forces (le ngth-tension relationship) a nd peripheral reflex suppo rt. Wea k musc les can be initiall y li ghtl y res isted (tracking r esistollce) to facili ta te contraction through propri oceptive loading of the musc le spind le. Control of velocity is al so important to e nsure effi cie ncy o f initial moveme nt a tte mpts. During conce nt ric contrac ti ons, total ten sion decreases as ve loc ity inc reases. Thus. pat ie nts may be able to generate a contraction a t slow speeds but not at hi gh speeds. For examp le, the patie nt w ith stroke who de monstrates limi ted contro l sho uld be instructed to begin w ith slow and controlled move me nts. As move me nt s become more effi cie nt. they call be prog ressed to faster speeds. Open-chain exercises in volve the di stal segme nt of the limb movin g in space without simult an eo us motions at adjacen t joints. Musc le ac ti vat io n occ urs predominatel y in the prime move r(s} cross ing the moving joint. Res istance is applied to the di sta l movi ng seg me nt. typi ca ll y in nonweight beari ng pos itions. Closed-chain exercises involve mo tions in w hic h the di stal part is ti xed (foot or hand) whil e the prox im al segme nt s are mov ing (e.g .. weight shiftin g in stand ing, bilateral short-arc sq ua ts). They are perfOnllCd in weig ht bearing postures and involve si multaneo us acti o ns of syne rg istic musc les a t multipl e joints. The added joint approx imilti on and sti mulation of joint and muscle proprioceplor~ enhances ne uromuscular conlfol and joint stabilization (co-con trac ti on). A limitation of closed chain exercise i:-. the sub~ titlltion of othe r agonist muscles for :,pecific mu scle \Veakne~s. In compari son , open-cha in e\efl:i ...es ca n be u:-.ed to i ... olatc ('onlf"dc tion of a lllu::,cle Or rnll ~ck group and I.!n h ~U1Ce ~pec ific t raining .!O~ Pylomelric frainill.!: jmolvc ... quid. pm\erful mowments wi th pre~t rl.' t l' h ing of the mu ... de for impn)\cd ne uromuscular r(":-,p()!1,C~ (uo;ing ~ tret ch-:-. horle nin£ principles). For exam ple. \\ he n performing a vertic;,tl jump, s lig htl y lowe ling the bod) 111 a partial sq uat fir~t pl\wide~ incl'c.bt.::d ", trell:h on the quadn cl"' p:-, clnd heekord:-. .lI1d t"n ham:e~ the pu::, h-otf. PI ) OllleItK e~en..' ''l! dnlls .Irl;.' u~ed during the advanced ') Iagl;." o f rehabilitati on 10 prl!part" indi vidu:ll~ for ex.p losi,'e 1Il\}\'clllenh n!qUlfed for l ·l;.'rt.un sporl:". IU ' (;,1111 ", III ... trength C.III he obl.llned through progressive 1'':'"''111''' c.,ef\.: i ~e:-. (PRE ) u~illg free \\eigh ts or fi xed lHedulIlIca l re"" sti.llH:e llli.ll' llines. A 1l1.ljor disadvanlage o f PRE 1'1 thai the \\c l!!ht sell"i.' led I~ d e ll'fllllm.·J by rhl.:' amounl

494

Physical Rehabilitation

that can be lifted by the muscle al the weakest po int of the

range. Isokinelic training dev ices offer the advantage of providing accommodating resistance t.hr~ughoul the range. Muscle perfomlance is therefore 110t hmlted to the weakest part of the range. The amount of force generated is recorded. providing an important objective measure ~f perfom1
can be predelcnnined. This is an important considerati on for trainin g the pali e nl who demon strates neuromuscular impainnent s in liming and velocity control. For exam ple. the patient recoveri ng from stroke may be unabl e to gen,erate the acce leration and deceleration forces needed dunng

the differem phases of gait. This results in delayed sequencino of muscle components and a general slowing of gait. l s~kinetic training that focuses on the timing of these various components can improve gail function. Carryover to improved fu nctional perfonnance with any of these resistance training methods is not ass ured YJ9 Additional functional train i;g is necessary to ensure effective transference of strength and timing parameters to functional skills (spec ificity principle). Manually resisted patterns of movement (PNF patlems) offer the advantage of functionally based, synergistic movements. Paltems of motion are spiral and diagonal in nature as opposed to straigh t planes of motion. The therapist can accommodate 10 the patient's specific level of weakness by providing repetitive graded resistance throughout the ran ge and by adding add itional facilitati on as needed to improve or maintain pe rformance. Effecti ve verbal commands improve the magnirude of muscle contraction. Stretc h is applied in the lengthened range to assist in the initiation of contraction and throughout the range as needed to sustai n contraction. Approximat ion is applied to ass ist ex tensor panerns "'hi le traction i~ applied to assist fl exor patterns. Specific PNF teChniques (e.g .. slow reversal. repealed contractions. and so fort h) are de scribed in Appendix B. Elasti c re~l~lance bands or pulley we ights can also be used to pro, Ide re~ l s tance in PNF paHenb. Strength giiin,> can be achieved through functional training Ihat u')C\ ta.'>~-related practice. I10.1 II Resi.'>tance is pro';ded by gravity and body weight and ;s applied !)imultaneou ~l) to multiple moving. segments. It can be supplemented . . . illl manual re~i :-.tance of the therapi .'> L weight ~, elastic resi<;umce band.'>, or resblance of water during pool therapy. ActivtlJe~ can be .,elec ted that focu~ on specific body !o.egmenl!J and progre .'>~d to invo lve increa!>ingiy large r seg mcnto;; of the body. Thl'\ .'>c rves to increa~ the le\lel of ditlicult y and the degree.., 01 freedom that I1lU~t be controlled during the movement. Benefit'\ of functional train mg include improved coordmatlon of ll1u!>Cle.'> . imprO\ed postural control and balance. and tmprmcd mu~ le extensibiLit) and flcx ibillty. Functional lTammg help~ the p.tltCnl develop l'omrol of '» nerglMic mu.'>cil! group:-. at.ling Ul multip le a.xes and plitnc~ of mme menh II al~) I{}~ tcr.'> the control ot '~U) IIlg t) I)c;!" und combtnatlon!'> til ll1u.'>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<; ing a di scontinuous protoco l that carefull y balances exerc ise with rest, IIS.II!.! Energy conservation. acti vity pacing. stress management. and lifestyle modific:uion are esse ntial components of the educational prog ram.

Flexibility E xercises Joim range of motion (ROM ) and mu scle flexibi lity mll st be adequale to allow fo r nonnal functional excu rs ions of muscle and biomechanical alignment. Prolonged periods of di~u~e and immobility can lead to c hanges in muscle and Joint fun c tion . postural alignme nt. and a hosl of in direCI impairments (e.g .. muscle tightness. atrophy. fibros is. conrraclUre. joint ank ylosis. postural defomlity). O lder adults demonstrale age-related c hanges affecting joint flex ibil1 l). The ~e inc lude increased viscosity of synovial flu id. stitTening of the joint capsule and ligame nt s. and cakdicatl on of artku lar canilage .I~O Early inte rvenlion is cnl lcal in maimaining joint motion. ti ss ue ex te nsibilil y. ph)"' lcal abi lity. and function. Additional benefit ~ include imprm ed circulati on and ti ssue nutriti on to th e limbs and pain 11lhJbi[lon. Technique~ Include ROM exerci ~e s. mu scular stre tc hmg. and JO int mobili z3lion. The use of a preliminary Ihe rapeUlu.: heat modalit y (e.g .. hot pack or ultrasound ) increases mU'-,{'le tempt:rarure and e lasl1 city. and collagen ex tcn sibil l!y.I!I.I~~ A \\arm -up period of exerCise can abo be used. rOf e.>..ample. cali ,thenic~ or low - re~istance cydi ng will graduall~ I1lcrea.,e 1I ~~ ue temperature~ and e la~ ti c it) , there b) enhanc l1lg Ihe ... afet) of stretching . Co ld moda illie~ can be u':>Cd to <:001mu~cle~ and dc(.'rea~e muscle ... pa ... m and ph) ~ lolog lcal ~pll nllng .l;; Patlenl~ wJlh :-. pa"ti c it y mJY benefit from preliminary pro longed Icing and re la xati on h!chm 4ue~ (e.g .. rhythmic rOlation. cognitive rela'Xation). Icing tan 011<..0 be added lollov.lng ">Lre tching , If neces~al)'. to reduce lJ ...~ue InO:unmallon

ROM E..erci.e. Kange (If mUlion b " the arc Ihrou gh \\ hich n1mclllcnt al a j(ll111 01 U ~ene~ of JOI1H,"IIH /,(>',111 ROM C.1J1 be /.Ir 11\'( (A I
Ol-.:ur~

495

the rap ist or caregive r). The Guide to Physical Therapist Practice cl ass ifies the fi rst two as the rapeuti c exercise whil e passive RO M is classifi ed as manu al the ra py.103 PROM is typ ica ll y used w hen acti ve move me nt is not possible (e.g .. du e to pa in . pa ra lysis, or unrespons ive ness). AROM and AA ROM have add itional be nefits of improvin g circulation , dec reasi ng atrop hy. and improvi ng motor fun c tio n. Prog ress ion sho ul d be to A RO M exercises w henever possib le as they are a n impo rta nt compone nt of the home exercise program (HEP). ROM exe rcises a re performed th rough the pat ient's full avai lable range. The lim b shou ld be well supported with stab le pos iti onin g o f the pat ient to preve nt joinl traum a. The move me nts sho uld be slow a nd rh ythm ic and w ithin the patient 's tolerance. Excess force and pa in are contra indicated. Thi s is espec ia ll y impon a nl whe n worki ng w ith the patient at risk fo r osteoporosis and heterotopic ossi ficati ons. Exte rn al fo rce during PROM or AA ROM can also be applied mechanicall y (e.g .. continu ous pass ive motion machine, pu lleys). RO M exe rcises can be admini ste red in an arorn ic planes of motion or in diagona l patte rns of motion (PNF pattern s). T he latter may be more effi cie nt as ROM can be ad ministered th roughout a limb. combin ing motions at mo re than one joint. ROM can a lso be ac hieved d urin g fun c tiona l traini ng acti vi ti es (e.g .. shoulder RO M is ac hieved during weight shi fting in quadru ped or plam igrade pos itions). An added be nefi t may be the patie nt's lac k of attention to joint motion during the acti vit y with less protective spl in ti ng. Funct iona l activi ty tra in ing should fo llow RO M exerc ises. The adage " use it o r lose it" holds true for maim aining the benefits of both streng then ing and ROM exercises.

Stretching Techniques Stretc hing involves (he appli cati on of manual or mechanica l force to elo ngate (lengthe n) structures that have adaptive ly shortened and are h ypomob i le .IQ~ The ternl slatic .\I,.erchill~ refers to a method of stretching in which the muscle is slowly elongmed to to le rance and the end position (greatest to lerated length) is he ld at least 20 to 30 seconds or longer depending upon the palienl 's to lerance. T he u~e of slow. pro longed stretch minimizes muscle spindle aCll vation and rene'{ tontr3ction of th~ muscle being ... trt tched. Ma imaining the posi tion at maximal end range re~ ult ~ in thl! firin g o f Ihe Golgi tendon organs (GTOs) with rebulting inhibition of the mu",c\e being stretched throu gh mechan i... nh of autogenic inhibi tion. The combined ncuroph)l)iologlc aJ dfec\:!. re~ult III improved musd~ elongJllon. ddilional bendill) of static ;;;tretching u\ ing 10\\ load ~ l/Idude Ie", ... dJ.llger of 1)0[( ti~s ue tearing. I c",~ l1lu ~dc SOrl'IH~':-., and i.lec rca",ed e ne rgy reyuire---. m(' nt~ 11J 1;7 L{m -load. lung duration mcc hanit.';ll strelchIIl g ,,:
496

PhysicaJ Re habilitation

Ballistic stretching involves the use of a hi gh -I o~d . short -duration . intemliltent stretch. For example. bouncing movements of the body during silting toe touch can be used to increase range in youn g. hea lth y indi vidua ls as part of a conditioning program. Th ey ca n be appropriate as part of:.m advanced training program for hi gh- veloci ty sport s, particularly when used in conju ncti on wi th stati c srretch ing. l30 Ballistic stretching is generally contrai ndi cated for the elde rly. the chronica lly ill. or for patients unde rgoing active rehabilitation wi th neuromu scul ar impainne nts. It involves hi gh- ve loc it y. high-inten sity movements that are not eas il y controll ed. In add iti on. activati on of muscle stretch receptors (mu scle spindle Ia e ndings) result s in reflex contraction and limits muscle elongati on. Al so in chronic contractures. connective tiss ue is more britt le and tears eas il y. Thus it is assoc iated with hi gh rates of microtraum a and injury. 105 Facilirared stretching refers to the use of ne urom uscular inhibition techn iques to relax (inhibit ) and elongate muscles when used in conjunction with stretching. PNF facilitated stretc hi ng tec hn iques include Hold -Relax (HR). Contract-Relax (C R). and Active Contract ion (AC)IOO (see Append ix B). The limb is activel y moved 10 the lengthened. range-l im ited pos it ion. The patient is the n in structed to perform a maximal isometric contraction of the ti ght muscles in the antagon ist pattern. The prestretch contrac tion result s in mu scle inhibition from activation of the GTO (a utogenic inhibition ). Thjs is followed by vo luntary relaxation. The limb can then be pass ively moved into the elongated position (HR ) or can be actively moved into the elongated pos iti on (Hold -Relax with Ac ti ve Contrac tion . HRAC). The CR techniq ue utilize s strong. small range isotonic contracti on of the restricting muscles (antagoni sts) wi th emphasis on the rotators followed by an isometric hold. Movement into the new ly gained ran ge of the agonist pattern is active. nOI pass ive (CR with Act ive Contrac ti on. CRAC)' AC produces addi ti onal reciproca l inhibi ti on effectl:> (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
mi zed duri ng earl y tra in ing a s they m ay re inforce (he ig hte n) lo ne and acti va te abno nnal assoc ia te d reacl io ns. Impo rtan t fun cti o nal s kill s a re targeted fo r tra in ing . For ex a m ple. thc pa ti e nt prac tices reciprocal reac hing . s it-tostand movc me nts. ste pp ing. or wa lki.ng, Iso kine lic exe rc ises are e ffective in improving fun c tion in pati e nt s w ith ~ pas t i c i t y. 1J8~14 1 Streng th tra ini ng c all be used and is he lpful in impro vi ng mo to r func ti on in patie nts wi th s pa s t i c i t y.I-I 2~ 1 4S Aerob ic conditioning ca n be im pleme nt ed and is bene fi c ia l in im pro vin g m o tor f un cti o n in pati ent s w ith spastic ity.I-It>- 148

po:, luon

Exeru')c t!'<.l IJl lng i.., kty to l a~ ti ng improveme nt in to ne and motor func: tion. Th e fo ll o \~ ing g u j de l in e~ can be m ed : PnmciJ) lo(' u ~ ~ho ul d Ix un 11 1\1 activat ing cont rac tiun 0 1 J.ntJgonl~t Jllu~d(:!' (m u..,lI e .. o ppo ..,j tc the .-. pa:'li c m u ~­ de\) to prm Ide mh lbl tlon and lengt he n :,pa.-. ti c mu "d e~. • A~\i""anc.:e (RRo. actl\C a"'~ I ~II \c: o r guided movt" llle nl ') laJi bt.' u,ed IIl1 tia ll} a\ needed but wllhd nl\l, n a\ ~oon .1'" dC!I\t: 1l10\Cmenh l III \ ma ll r.mgt.' ... hhon an.!>} 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<.t (fbt(' idit)) can Include quick ... tre lch. tapring . r~"'I~tance. Jppru)'lmatlon. and po"'ltloning l.,ee Appendix C) , Pallen'" typ ically abo demon strate- weaknc.':>.':> 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<.hJl1un" t .,ee 1'0110\\ mg "'('<..Ilon Ull IXI'[ural ... tjbilll ) traullngl . SUPPOI1I\1.' and pnUeL!l\c dl:\-u.c!) ma) be 111.:"(.;t" ... .,,11) to pre.H· nIIl1Jur) to IlI l1h" an<.l pt.1' _ tur:.d a ... ) Illlllt'tnc~ (e.g., d ~\\~dl')h l..nt:c i.Llgc ('an he u.,ed lu pll:"\t:nt h)pt:n:\ lcIl"l IOnj . t-.~l L~ l'an al~o lx: u~'d Ii) ji..ll\dit' hY!XJtnnl ... fllu ... ~k.,. 1Il"lpro\L' ... trl:ngth . and gent' hill' Illm,,' men! III plfJI)lt:J hmh., \dHk prt:\l.'ntlllg th.,u-,c "Iroph) II I.... 1Il1pOn;m1 III !oc·u., thl: pall enl . . dllclllJOll on the th~"Jn.·d IIIU\I,.·me lll JIH.! \erh~tll) l:UC thl.' Pdllclll :-. 1ll00t'Illl"n! alklllph .11 \'Ulillon<.tl umtrttLllon \\ Ithuu! MKh Cllt'llIg d.ntllllll\tll\\.'111 atkmph, I:JJT)U\l:r III \OlltlllllJI 1.'t1ll1lOI I., not po., ... lbk

, I I' nulalion should ideall y be coupled with . •

Elec tnc:l S 11 , I " ng activities liona trallll

(0

rune.

optimize outcomes.

postural Control Training ral control (ba lance) is the ability to maintain the bod ' " . d in eq uilibrium o r to control the y s poSitIOn m space bo Y I' " for stability and o rientation . Postura o~len~hon IS theability to maintain nonnal ali gnment re latio nships between the vario u:;. body segment s and between the body and environ_ ment. Postu r a l stabi lity contro l (stati c equilibrium. static balance. or stabilit y) is the ability to maintain stability and oriematio n w ith the cente r o f mass (COM) over the base of support (BOS) wit h the body at r est (no motion), Dynami<

1 PoSU

postural control (dynamic eq ~I~lbnum . d,yna.mlc ~~, or controlled mobi lity) is the abllllY to mallltalll stability and orie ntatio n with the C OM over the BOS while parts of the bod y are in mo ti on (see Table 13.2).2 An intervention pr0gram to improve postural control must be based on an accunue evaluatio n of data obtained during examination of defici ts (see C hapter 8). Training activities can be used 10: Improve static pos tural control. bio mechanical align. ment. and symme tric al we ight dis tribution. Improve d ynam ic postural control including musculoske le tal respon ses necessary for movement and baJance. Improve adaptation of balance skills for varying task and environmental condi ti ons. Improve senso ry function including sensory integration and sensory co mpe n sation . Im prove safet y awa re ness a nd compensatory strJtegies for e ffec ti ve fall prc\cnti on,

Strategies to Improve Static Postural Control Patle nl.':> 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<.:e. The ther"PI" ... hollid I.'n",un.: pJIICllll' onfu..tc n cl.! by providing ac~ l:\pl.lIl.ll1t l ll 01 \\ h.J1 I~ gUlIlg to hJPpen, and what &i C\ lx'ued ollhl' p.llltlll IIlt~ I11I " that are ea,')y to un
Chapter 13 Strategies to Improve Motor Function all ow focus on acti ve control. Th e thempi st varies th e leve l of acti v itie~. se lec tin g ilctivities that bot h provide success as "ell as appropria te ly c htan~e 01 the band:.. Thi~ :-.cicl:lI\eI) IOdd":. and taL-lillate:. (;OlllraClIon of the Illp :-, tablllzer\ IJbduL tor.,>. CJ\.tc'hOr~). improVing \ tubdil) ~on trul at tht. hJP~ hJ\C tilt' put lent ... t ~lbJlIL.e v. hil e '> Htlllg O!l <.tlhellipy hall (abo knu\.l.ll a:o. S\\I\:' or \ tabdll)' h..dl ). (Jemie bounung provide:. Joil1l dppru)...IH1i111011 through til e 'cllch,al JOlnh, liH.: duatlng t:,tell\Oh and all uprigh t PO!'ltUrt. t-ur Pdllt:'llh re4lllnng Illorl.' ..1\ .... I... talltX" :.lItlllg L'Olll lol tilll jlr~1 he pri.tUILcd ( Ill a (';olll pllant ... urla(e ~f\)dnl. \~ob­ hie no.lrd. (Ir D)l1adl":.c IM j placcd on a pluLJonn nwi Ill' ~j l ung 011 a ball \\l lh J hall iwldt:l IJllderne.lt h till' tht.'r.tp)

rile Ihcr<.tpI,>1

(,111

499

ball. Task diffi cult y can be increased by reducing the BaS (feet apart to feet toge ther to sing le limb support ). Aquat ic therapy can also be used 10 e nhance propriocepti ve loading. The wa te r provides a degree of unwe ig hting a nd res istance to m ove me nt. Thi s can be quite effective in reduc in g hype rkinet ic movem ent s and enhanci ng postural sta bi lit y. For exa mpl e. a pati ent recovering from tra umati c brain injury who demon st ra tes s ig nific ant ataxia may be ab le to s it or sta nd in the poo l with minimal ass istance whil e these sa me ac tiv iti es o ut side the pool a re not poss ibl e. To improve standing cont ro l, th e pa ti ent is directed to practi ce neuromuscu lar jixed-support strategies th at occur at the ank le and hip jo int s. Feedback is provide d to ass ist the patie nt in rec ruiting the correc t pa ttern. To recruit ankle strategies. the pati e nt practi ces small -range. s low-veloc ity shifts. Attenti o n is direc ted to the action of ank le mu scles

to move the body (CO M) ove r the fixed feet (BaS). Standing on a wobbl e board o r foam rolle r w ith the flat s ide down progress ing to fl at side up are e ffective ac tivit ies to recrui t ankle strateg ies. The patient is a lso directed to prac ti ce tasks that no mlall y recruit hip srrOlegies. These are rec ruited wi lh large r shifts in the COM. that approac h

the limits of stability (LOS ). and/or faster body sway m o tions and are c harac te rized by earl y ac ti vation o f prox ima l hip and trunk mu scles. Hi p flexion and extension re s pon ~es are gene rated during an te rior- poste rio r (AP) di splacement s and lat eral hip motions are generated during late ra l dis placemen ts. Patie nt s can be instructed to mo ve the ir uppe r body forward and backward while stand ing o n a foam rolle r. Tande m standing o r tande m standing on a foam roJler can be used to recruit late ral hip strategies. Anticipatory postural adjustments should also be practi ced, because predictive control mUSt be operational for fun ctional balance. The patie nt is provided w ith advance information about the upco ming demands of the tas k. For example. "'I want you to catch thi s 5-pound weigh ted ball whi le maintaining your silt ing posi tion. The prior know ledge :.erves as an important so urce of infonllati o n in initi atin g the correc t po~ tural pattern. To promote genera li zabi lt). practice should OC,'ur in a varie t) of em ironments. For exampl e, training can progress from a closed or fixed environmen t to a more variable e nvironment ~uc h as thl! phy~I(.: altherilpy g) Ill . Balance Iraining Il1U~1 ultimate ly be l·unte.\ t ,> pec ifi c tu fl'al -Itfc se tting s of home or communi ty to en')u rt: fun L'Tlunal ca rryover.

Strategies to Improve Dynamic Postural Control Pati enh \\ ho dCllloH" tratt' illlpaimh;'nh in d} namk fk.")sturalcolllrol are ulI.thle to control po!o. tu r~11 Mabillt) and oril' nl<.lllon \~ hile 1110\ IIlg \egmenb 01 the tx:M.ly. A number of ImpalfllJl.'II1"- Illa) 1'It: l.:omnbUli llg laclor~. IIlcludmg tonal IIllb.li,uIL6 ( ... pa . . titit). rigidity. h}poIOII I:l). ROM re~tric­ tlOn~ . Imp~urC"d \olu ntar} conlrol ami h)'lx-nnobility (uta xl:'l, dtht.'to"'l\I . uHpJirco rCl' iproca l a(;ItUil .... of the antagoni sts

~O()

1'11\ .. " ,.1 H.t' halHI it.11 ion

(cc rchdlal dy\ funclion ). or unpaI red prox IIll:.1 ~t J b ll .IZi.l ' lIon. Clllllla lh . Ihe pal ient tic lllon<;; tnl lc!- difficu lt y we Ight , hlitrn <(' from ' "ldC-lo" ,de. lor\\ ard- bad. . \\ art! . or diago· na lh . Dilliulille' arc ;thu appa rcnl in moving onc or more IIInh .. \\ hll e malllwrnl ng a pO\ lure ('mmeli mc~ refe rred 10 a' \wrlt'ch ,lO /we nmrro/). For example. one limh j<; freed for rno\emclll (re:H..' hing or , leppmg) while Ihe pali ent 1llJIIl I ~"n , the <; llI lng or , land ing poo;; lure. O r from lhe ljuadrupt'd pO ' li ion Ihe pa l lent i, a!-.ked 10 lif! one ann or leg or 10 1111 the oppo\ ite arm and leg. The!-.e added movemcnt.. Ill crea'c the dema nd fo r ~ I ab i liza tj o n co ntro l hecau ,e Ihe O\ eral l BOS is reduced and Ihc COM rnu ~ 1 .. hili o\ er the rema in ing "uppor! :-,egmc n[ ~ before th e dyn:ull1l' IlIllh 11l0\ C1l1cnt can be ~ u cce s~ful. The therapI .. t call ..c icc I an y of J number of we ightbcarIll g (lInll gra\ ll y) po ~ t u re . . to de velop dynam ic postu ra l rO luro!. Pracllce beg in .. with move ment s emphasizing ~moolh dIrecti onal c h an ge~ Ih:lI engage anla gon i ~1 actions «('.g .. \\cig hl ., hift" . A ~ control improves. the m ove m e n l.~) arc gradU dll ) ex panded through an increasing ra nge (lncrc men!'. of range). D) nami c movement s ca n be facil itated u'ling qUIck :o.tretch. lapp ing. light track ing res istance. manu al COI1(;Jch , and d) namic verbal commands (~ee Appe nd!:, C). Alt hough acti ve movement is the goal. ass islance may be requi red durin g initia l movement attempts 101 bOl h the dynam ic movement s. a~ we ll as the stab ili zing hod} "eglllent... Spec ific ta ~ k - ori e n l ed trai nin g (e .g .. reac h· IIlg .... tepplllg) are morc mo tiva ting. especia ll y if the task is illlpon alll 10 Ihe pat ienl. PNF eX trl!1llIt)' piJ ll t: rn s can be used to in crease the level of diffi c:ul t). For example. in :o. itt ing th e patient is asked \0 mO\e th e dynami c limbs in a chop/reverse chop pa ttern \\ htl c m.JlllIaining a ~ Iabl e poslure. The patient's fu ll allenlion I~ foc u,ed on pe rfomlin g the pattern and not on the :-.tabtlizmg po., lural components. Th is abi li ly to redi rect c:ognlllvc att entI on i ~ an import ani Ill ea ~ ure of developing po\tural con trol a, 1I11ac l postural contro l fun c: t ion ~ largel y on an autQll1J.\] (· and un co n sc i o u ~ leve l. Specifi c PNF techniques appropriate fo r a~:-,i.., t m g patienls incl ude Dynamic Re\er\.th (S imI" Rc\e r... ab). Repeated COlll racti ons, Rh} thill i,,: Inlli allon. and Combinat ion of I sotoni c~ !AgoOl \t Rc\c r..,al.. ) hee Appe ndIX B). For ex ample, in bnd~1I1g Ihe p :..tlle nl -... movt.: lllenl:-. are re.:. isted 111 as~ uming the brr dge po ... tu rc (I"OLOOI C con traction .:.) and during tnu\c tnt' rll irom Ihe bridge po:-. it ion LO hook lying (tcccmnc tOrllraC lwn.. , u.., lng the Co mbI nati on of bl! t o rll c~ h:'l:hIlt(.jue TIll'. itCII\ II ) I. . ;.t n Important lead -up for lJ lh~ r Jun c. 110n;.\1 ~tlll\i tle . . IhJt rt:tjulre ~ Im ll ar cf)m bmallon ... in l lud. lllg .. 11 -1O·..,I•.trld LritnsHIOlh, 1110\ rn g Irom knedm g. 10 het' l ., Itung ~In d d't..c ndlng -- arc clfeCl I\C in dc\ t:!0pln g U} Ildlllil "'la hll l!} lummi h )r exampl e, Ilw p~II It: llt ~ I I " on .I bdll (allern..tle leg or
Progrco;;sion i<; from unilatera l to bil ater.a l and finally to rec iprocal lim b movements (e.g .. ~ ex lcan . hat dance). Vol unlar) trunk motions can be practi ced while Sitting on the ball (e.g .. head and tru nk rotati ons or forwardlbackward lean o;;). 1"1 R e~ i stance can be in troduced by using elastic resist:mce bands or we ight cuffs on the ank les or wrists. Di ffic ulty can also be increased by add ing a second task (d /1lI1 fask rra i l/il/g ) such as catchin g and throwing a weig htcd ball. ball oon vo ll ey ball. or ki cking a ball. Group acti vitic!) can be introd uced when pati en ts can safely per_ fonn e~tc h of the activiti es indi vid uall y. 181 To improve .stand ing con tro l, the pati ent is directed to pmclice neurom uscu lar sfepping strategies. The traditional view hold s that stepping strateg ies occ ur when the COM exceeds the LOSY·l-185 Perturbation is used to provide the COM displacement. Stepping movements are accompanied by earl y ac tivation of hip abductors and ankle co-contraction for medial- lateral stability during single-limb Support. 11I! Maki and Mci lroy l R1 investigated the role of limb move. ments in maintaining upright stance. specifically compensatory steppi ng and grasping movements of the upper limbs, which they termed change-ill-support strategies (as opposed to the fi xed-support strategies at the ankJe and hip). These i nve~ t ig ators fo und that both stepping and ann movemenlS were very common reacti ons to loss of balance. Moreover they we re init iated well before the COM reached the LOS, contradi cting the trad itional view that they are strategies of Ja ~ t reSQrt . They also fo und that stepping may actuaJ ly be a prefe rred strategy to using a hi p strategy. The direction and mag nitude of change-in -s upport strateg ies were found to vary accordin g to the magnit ude and di rection of the pertUrbat ion. For example. stepping may occur fo rward or back· ward in re~ ponse to anterior or posterior displacements. Lateral d isplacements typ icaUy resulted in cross-stepping pallem (seen in 87 pe rcent of lateral stepping responses) as opposed to stra ight side-stepping. Lateral destabilization \\ ith its increased demands for lateral weight transfer is partic ularl y probl ~ m ati c for a large pon ion of older adults who experience falls. Ann reacti ons in response to whole-body in, tabiJi ty wefe al ~o found ro be prevalent with activation of' shou lder 1ll u~c1es occurring in 85 percent of destabilizing tfi ;'ll o;;. Increased understand ing of the range and variability of po~ tu ral ~ traleg ic!> fo r balance negates any simplistic view of balance b,h ed on a deve lopmental pe rspective of reflex control ( i.(' .. righting and equilibrium reactions). Overall. Ihe org(mi z<.l liu n of balance ~ traleg ie$ Illust be viewed as flex Ib it'. rHlt ri gid . invol\ ing multiple body segments. in thai <.: nnh: xt, pa [[~rn :-. \\·ill var} according [ 0 a number of different t.lr lon. I1lci u
Chapte r 13 Strategies to Improve Moto r Function

postural Awareness Training Fault y postures such as forward head. kyphos is, lordosis. excessive hip and knee fl exio n. or pelvi c asymme tries can resuh in decreased postural stability. inaccurate kinestheti c awareness of true verti cal, and pain . Alth ough mild defici ts may not affect ba lan ce contro l. de fi c it s that s ignificanli y a lter the COM pos ition can impair baiance,I89 Patients are typica ll y unable to se lf-correct faull y postures. Physical therapy intervenlions should focus first on improving spec ific mu sculoske le tal impaimle nts (e.g., lim ited ROM. weakness). For exampl e. active exercises to improve standi ng bal ance can include standin g heel-cord stretches. hee l-rises. loe -offs. partial wall squat s, chairrises. side- kicks. back-ki cks. and marc hing in place using lauch-down support of lhe hands as needed (sometimes referred to as the " kitchen sink exe rc ises" ). Pos lural reeducation begi ns with demonstration of the correct posture. Verbal cues should foc us on control o f essenlial postural elements. that is. stable (neut ral ) pel vis, axial exten sion (e.g .. sit or stand tall ). and normal a lignment (e.g., head erect, shoul ders bac k, weight evenl y distributed under both hips Isitt ing] or feet [standing]). Patients c an bene fit from tacti le cues durin g initia l pract ice (manual or surface-re lated ). For example. pati ent s can stand with the back positioned against a waIl or patie nt s w ith a lateral lean (e.g .. post-stroke patients with pu sher syndrome) c an sit with thei r side pos itioned again st the seated therapi st or a \l,all . Corner standing or standing between two plinths can be effec tive fo r pat ients with signifi cant COM di storlion. Mirrors prov ide importa nt visual c ues regarding vertical position but are ge nerall y contra indi cated for the patient wit h visuospalial perceptual defi c its. Applic ati on of correct postures to real -life functional s ituations is imponant to ensure carryove r and lastin g c hange . Center-of-Mass Control Training The therapi st should focus on obta inin g symmetric al , balanced weighlbeari ng. Pati ents may present with spec ific directional in'ilabilit ies, such as weight bearing more on one side than the other. For example, aft er a stroke the patient typicall y keeps we ight cente red toward the so und side. Practice shou ld focus on redirec ti ng the patient into a ~emered position by mov ing toward the affected side, both 10 sitti ng and standing pos itions . Lim its of stability (LOS) should be explored. For example, in si tting or standin g, the p~tlent i!lo instructed to .., lowly sway forward- backward and SIde-to-side. The ou ter point at which the CO M is still maintained within the BOS is teoned the LOS. Loss of balance OCCurs when the LOS have been exceeded, for example, when the COM extends beyond the 8 0S. Practice of volitional body sway is important to ass ist the patient in ~eve loping aCCu rate pe rceptual awareness of sta bility li mIts, an lmponant component of an ove rall eNS inte mal model of postural conlrol. Because LOS change with different tasks, a variety of func tional activ il ie!lo should be practiced 111 different environmental sett ings.

501

Posturography Feedback Balance training using augmented visual feedback has become increasingly popular in treating the elderly and other patients al ri sk for falls. Research reports substantiate its effectiveness in improving baJance. I90- I96 Force-platfonn devices are used to measure forces and provide center of

pressure (COP) biofeedback or pos/urography feedback. COP di splacement is associated with movement of the COM or postural sway. While COP excurs ion always exceeds COM sway, thi s relationship is close during ankle motions (ankle strategies) when the body moves like a pendulum over the feet. However, when a hip strategy is used (upper body

motion focused at the hips) the COP:COM relationship becomes d.i storted and does not accurately reflect sway. 197.198 A computer analyzes the data and provides relevant biofeedback concerning sway path and COP position on a visual monitor. Some units aJ so provide auditory feedback. Posturography training can be used to shape sway movements to enhance symmetry and steadiness. The patient can be instructed to inc rease or decrease sway movements or move the COP cursor on the computer screen to achie ve a designated range or to match a designated target. It is an effective training mode for patients who demonstrate problems in force generation. For example, the patient with decreased force generation (hypometria) as typically demonstrate d by individuals with Parkinson's di sease is directed toward achieving larger and faster sway movements during posturography training . The patient w ith too muc h force (hyperme[ria), as typically demonstrated by the individual with cerebellar ataxia. is directed toward decreasing sway movements progressing to holding a stable, centered posture. 194,195 It is important 10 remember that balance retraining using post urography biofeedbac k does not automatically transfer to functional skills like gait. Winste in 191),200 found that a reduction in standing balance asymmetry did not result in a concomitant reduction in asymmetrical limb movement patterns associated with hemiparetic locomotion. Given the specificit y of training principle. thi s is not a surprising finding. Finally, a sel of bathroom scaJes or limb load monitors can provide a low tec h, low cost form of biofeedbac k weight information to ass ist patients in ac hieving symmetrical we ightbearing.201.20~

Strategies to Improve Safety Prevention of falls for the palie nl with baJance deficiency is an impona nt goa l of the rapy. Lifesty le counseling is important to he lp recognize potentiaJl y d;.mgerous situations Wld reduce the like lihood of fa1I~. For example , high -risk activ ities like ly 10 result in fall s include turning. sit-to-stand tramfe rs, reaching and bend ing over, and stair climbing. Patients shou ld al so be d iscouraged from clearly hazardous i.tctivilies li u{' h as climbing on step stools, ladders, and chairs, or walking on slippery or icy surfaces . The educal ~on plan sh~uld stress the harmful effects of a sedentary li fes tyle. Pati ent s should be encouraged to maintain an

502

Physical Rehabilitation

active lifestyle. includ ing a program of regu lar exercise and walkinc.. Medications shou ld be reviewed and those med ica· lions li~lked to increased risk of fal ls (e.g .. medications that result in POSIUraJ hypotension) shou ld be addressed . A consult with the phys iciml for medication review may be indicated. Compe nsatory training strategies sho ul d be utili zed. T he patic nt should be in st.ructed in how 10 mainta in an adequa te BOS at all times. For example. the pa tient sho uld widen BOS when turning or sittin g down. If a force is expected. the pati ent shou ld be instructed to widen the BOS in the d irec· lion o f the expected force (e.g., leaning into the wind). If greater stabili ty is nceded. instruction sho uld be provided in how to lower the COM (e.g .. crouchin g down to red uce the like lihood of a fall). Greater stabilit y can al so be achieved if friction i ~ increased between the body and the support sur face. TIle patient should the refore be instructed to wear shoe~ \\ ith low hee ls and rubber-soles fo r better gripping (e.g .. athletic shoes). Assistive devices shoul d be used ass ist to balance \\ hen necessary. Consideration should always be given to using the least restrictive dev ice (LR D) wh ile at the same time ensuring safety. Light touch-down support using a vertical or slam cane (used by individuals who are blind ) ha, been shown to improve balance.203 A fa ll prevent ion program must also address environmental fac to rs that contribute to falls. See Box 13.4 fo r recommendations fo r reducing falls in the ho me environmenl (see also Chapter 12). M

Sensory Training Several genera l concepts are impo rtant to an unde rstandi ng of the role of sensation in moveme nt. Sensat ion all ows o ne to illleraci with the environment, gu iding the se lection of moveme nt responses. Sensory inputs are used to modify movemenl!! and shape mOlOr program s throug h fe edback for corrective act io ns. Variability and adaptabi lity of movement!! to environmental Change are made possible by the IIlformation process ing of sensory inputs. Finall y. sensory

inputs are used to preve nt or minimi ze inj ury. lnteractionor sensory and motor system s occurs througho ut the CNS. Muc h of the se nsory informa ti on received is not eon.. sciously perceived . Spi na l-level inte ractions are largel reOex ive in na ture. whe reas supraspina l centers modul~ more complex leve ls of sensorimo to r behavior. Conscious pe rceptio n and inte rpre tation o f se nsory information occurs at lhe highest leve l, the cortex. The vario us types of sensory receplOrs demonstratedif_ ferential sensitiv it y. Each recepto r is hi ghly sensitive to a preferentia l sti mulus whil e be ing re lati ve ly insensitive to ot he r st imu li at nonn al inte nsities. Use o f appropriate inte nsities o f sensory stimulati o n is important to ensure that the des ired recepto rs are stimulated. Excess s(imula. tion call acti vate un wanted se nsory receptors and produce undes ired respo nses, including gene ra li zed arousal and sy m pathetic fig ht-or- fli g ht reacti o ns. Another special char. acteristic of se nsory receptors is the ir adaptation to stimuli over time. Ge ne rall y, they can be divided into two cate. gories. s low- and fas t·ad apting recepto rs. In t.reatmenl, fast-adapti ng. phasic rece pto rs suc h as to uch receptors are gene ra ll y more effec ti ve in initi ating d ynamic movements, whereas slow-adapt ing. Io nic receptors such as joint recepTors. Golgi tendon organs, and mu scle spindles are used more in monitorin g and regulating postural responses. Ve locity of m ovement is a lso a consideration . At slow ve loc it ie s, affere nt sti muli can contribute to movement responses. whi le at high ve locities there is insuffident time 10 a llow for afferent info rmati on to effect motor cOllb'Oi: (open ski lls). Ce rtain body segments such as the face. palms o f the hands , and soles o f the feet de monstrate boch hi g h conce ntrations of tactile recepto rs and increased repre~e ntation in the se nsory cortex. These areas are highly respons ive 10 stim ul ation and are closely linked to bolh protective and exploratory func tions. Damage to the CNS can produce impairments in seasory function. Alterat io ns in tact ile. p roprioceptive. visual.

Box 13.4 Fall Prevention Strategies: Modifying the Home Environment • Adequate lighting is essenti al. Both low li ght and glare call be hazard ou ~. panicul arly for rhe e lderly. Glare can be reduced with lIanltlucent shades or curtains. • Light switches should be pos ltiuned 31 the e ntrance to a room and full y acces'tible. Timers can ensure that l i g hl~ come on routine ly at dusk Clapper devices can be used to enable llle patient to tum on li ght:. from across the room . Nig htlight s typically u')ed in bathrooms or hallways do nOi provide eno ugh light to e n ~ ure adequate ba lance. • Carpeh with loose edge!l should be tack.ed down . Scaner or throw rugs lthould be re moved. • r urniture that ob:..truclS ...... Ib.ways ~holiid be removed or rt!pos ltloned • Chairlo should be of adcljuate height and finnness to asW.1 10 'ill-to·!!tand IrJ.n .. fe~. Chai.... With armrests and eleyateJ 5("at

W"':1

hc i g ht~ may be required . Motorized chairs .......... pmiellt into "ilanding may be hazardous for ( n .... ... ~ ho are unable to initiale active balance i e~ Ilme ly mlUlner during Initial standing and (2) do. 'III....

l\Ii1.!!

Imp,tlred LE strength unable to maintain firm with the floor as the chair rises.

focu• •

• Stuirs ure the site of many fal ls. Ensure ~i.:~:: COrllmst tape usmg bright ..... arm colors (red. )ello . . . ) l'Wl be uloed IU hi~hJighl sleps. H ertzajll ~ant fo r safe ty on Slam, and, if n()I pre!ient• . . , m'i.tulled. • Grub bars or 1'".1Ib J\."duce the incidenc.:e of filII r(I{)I11. Nons"id mollS or stnps in lhe bedIIub or loho ..... cr ~al call al~o imp'me safety. '1biIII e lev uted to fllf.: llital~ independent use.

I.,

Chapter 13 Strategies to Improve Motor Function or vt'stibular syste m s can affect a patient's a bilit y to move and ie,U11 new ac tivi ties. Deafferentation in animal s and in hum ans is associated wit h nonuse o f a limb, altho ugh g ross movements are possible unde r forced s ituations. Learnin g of new move ments throu gh corrective actions is impaired . The the rapi st mu st focus a ll forced trai nin g of sensorydeficie nt limbs even thou gh the pati e nt may have little interest in movi ng the limb. Th e moveme nts obtained shou ld not be expected to be nomlal. however, because significant defici ts have been noted in fine motor con tro l in deafferentated limbs. Following damage to the eNS, sensory inputs may be reduced or d istorted. Percepti ons are therefore impa ired . Sensory tra inin g strat eg ies can be used 10 sharpen and heig hte n pe rcepti ons and ass ist in reorganizing the eNS .

Training Strategies for Sensory Loss Sensory stimu/mioll refers

(Q the stru ctured present ati o n o f stimuli to improve ( I ) a le nness. anent ion. and arousal: (2) sensory discrimi nati on: or (3) in iti a tio n o f musc le activity and impro\ement of move ment control. Effects are immediate and specific {Q the current state of the nervous system . See Appendi.x C fo r a compl ete di scussio n of these techn iq ues. The tec hniques a re important e lements of th e neurofacil iwtion approaches. 98- loo Behaviors are modified usi ng: tec hniques to increase or decrease attention and arousal. Move ments are e li cited and moditied through the use of spe.cific slimui i (e.g .. s!relchin g, tapping). The effects do not carryove r to s ubsequen t movement a ttempts. Be ca u ~e the move me nt s re ly on augmented iJlputs, their gTeatest u::,e i~ to ass ist the patient with abse nt or severe ly di:;ordered \oluntary contro l (e.g .. a patit!llt who ::, ustain ed a stroke and who i" unable to cons istentl y initiate mu scle co ntra(' t lon~). Once a des ired motor respo nse is obtained, focus shou ld ~hlft to active 1l100 e ments th at utili ze natu rail) oct urrlng in trin SIC se nsory information . Thu~ , se nsory slim ulatJon tec hniques nHl) be a n e lfec ti ve hridxe to aSSist earl) ..tllt:mpts at movement but should be \\ ithdrawn as ~n lb Plh~ l b l e. Repeated u::,e o f se n~ory sti mulation lo ng after It I... neet \s:.!.l) can result 111 mO\ emcnts that become sttmulu, dependent , and tan funher limit {he patie nt \ abilit y to regain \ oluntar) control. Sefll,ory Ifuegrlll/O/l !ra illlll,~ refers to "the ui-Ie of enhanl ed contro lled st: n~lIry ':> 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 <;, upport a nd propu b ion in the inte nded dir~c. lion, {3J d) namlc pOM ural <.:ont roL and (4 J abilit y to adapt to chang ing t as~ and environme nt al demand:-..~IU Multiple

mu scle groups a re active in alternating synerg istic patterns Stabilizing musc les con tribute to stabi lity of the sta~ limb and trunk d uring weight acceptance and single limb support . Other mu scles contribute to limb advancement of the dynamic limb during the sw ing phase. The pattern is then reversed as the gait cycle progresses. As the Speed of wa lk ing inc reases, the requirements for timing and control increase. Olde r adults can be expected to have reduced walking speed, shorter strides, shorter steps. increased time in double support , and decreased time in swing phase than young adults. 53 Interventions mu st first be direc ted at improving func. ti on of indi vidual gait components. For example, attention is direc ted first at improving ROM and strength of weak muscles such as hip abd uctors or knee ex tensors. Emphasis can then shift to improving synerg istic control of muscles and Oex ibilit y through functional training activities. Important lead·up or preambulalion activities that improve strength. range, and control necessary for gait include bridging, sit-to-stand tran sfers, and static and dynamic postural control ac tivities in kneeling, half·kneeling, mod. ified plantigrade, and standing. Finally, stepping r"'t in modified plantigrade and then in standing are imponant lead-up acti vities. See Chapter 14 for a detailed discussion on locomotor training.

Task-Specific Training Walking is typically practiced first under supportive condi· ti ons using parallel bars or ass isti ve devices (e.g .. walker. cane, crutches). The goal is early mobilization of tlte patient out·of· bed or o ut-of·c hair is to prevent furtherindi· rect impai nnents (e.g .. weakness, decreased endw-ance, loss of mobility, and so forth). Gait is typically slow and delibe rate with a great dea l of consc ious effort. Therapists often ass ist required gai t e leme nt s. including the weight shi ft , stabili zation of the stance limb, or advancement of the dynamic limb. These compensatory srrategies are effecti ve in promoting earl y ambulation but do little to pr0mote the balance a nd dynamic control needed for inde· pende nt gait. Once o ut of the parallel bars close stand-by guarding may be nece:-.s ary. In general. a hands.off approach is rec· omme nded a:-. soon as poss ib le. In itially. the patient can use li ght touc h-clown (ti ngenjp) suppo rt walking next to a treatme nt tab le or wall to maintain balance. Progression is then to walking away from the wall with no touch-doWD ~ uppOrt . The therapi :-. t can ve rbally cue the patient to maintain the pace ancl sy mme try of gait. A \ a rie t) of \\ alking patt;ms should be pracl)ced. I/lc ludi ng fo r \\'ard~, back.ward s , and sidewards. S~ Me pp ing a nd lTo:-':loeci-ste pping can be practiced finI ho ldmg on to the Outs ide o f the pani ll el bars or 10 an ovaJ ~a r prog re~~ ing to no support. T he PNF activifY of br~ H.I.': IS a :-. k.ill -Ieve l gail ac tivity that involves alleroaUnS :,lde· . . te ps with Cro:-.~-SI('pS. One limb steps out 10 die

Chapter 13 Strategies

side while the other li mb alt ern ates bet wee n steppin g up and across in front of the other leg (i n a 0 I fl ex ion pattern ) or back and around the other leg (in a D2 extension panem ). Alternat ing the patterns res ults in improved pe lvic{lower tru nk rot~t ion and LE cont~ol. Locom~ti on can also be re sisted uSin g th e PNF tec hmq ue of Re sisted Progression (RP). Manual contacts placed on the pe lvis first lightly stre tch and the n res ist mot ion. Im proved timing and control of pe lvic rotation is the goal. Res istance can al so be provided using e la stic res istance band s wrapped around the pe lvi s. Th e therapist wa lks near the patieOl . holding the ends of the res is tance bands. Speed element s can be controlled using a metronome or bri sk marchin g mu sic. T his is an im portant considerat ion for the patient with Parkin son 's di sease who responds well to rhythm ic auditory c ues (see Evidence Summ ary Box in Chapter 2 1). Walk ing should be practiced on varying surfaces, from smooth surfaces to uneven terrain outside. Varying the BOS can challenge walking. The pat ient is instructed to walk fi rst using a normal BOS to narrow BOS to fm all y semitandem or tandem walking. Hav ing the patient walk with eyes open progressing to eyes closed can vary visual inputs. Having the patient walk whi le movi ng the head right and left or up and down can vary vestibul ar in puts. Walking with directional changes and abrupt starts and stops should be practiced . For example. the patient is asked to make an abrupt start and stop on command and to tum on command. lnitially turns are wide progress ing to more narrow rums: partial turn s (900 turns) are progressed to full turns (1800 rurn s). Anention can be varied by hav ing the patient practice walking with while perform ing a second task (dual-task train ing). For ex ample, the patient walks and carries an object or bounces a ball . Talkin g to the patient while walking can al so divert attention (Wa lkieTalkie Test ). Walking through an obstacl e course around and over objects can also be used to chal lenge control. Patients can be asked to stop and perform a task (march in place on a foam cushion) be fore proceedi ng on to the nex t obs tacle . l g~

Climbing stair.!:. is an important fu nctional ski ll. For many patients, it may mean the diffe re nce between going home or going to an altern ati ve living e nvi ronment. Important lead-up activ ities for stair climbing incl ude s itlo-stand transfers. standing we ight shifting and stepping activities. Step-up and step-dow n exe rc ises can be practiced usi ng. varying step heights from low (4 in . 11 0 em)) to high (8 in. 120.3 e m)). The patient initiall y is instructed to slep- up and ste p-down in the same direction and progressed to ~ tep p ing up and down in differe nt directions (up and over the step). Practice can begin in the parali e l bars or nex t to a treaune nt ttlble or wall fo r li ght touch· down !'uppon . Stair cl imbi ng j ~ then prac ti ced, first with limited stairs and progres~ in g to a full ni ght of stain,. Considtration is given to the numbe r of sta irs requ ired in

10

Improve Motor Function

505

the pati ent 's home . In itia l upper extremi ty support on handra il s may be used to compe nsate for any in sta bility the pati ent may experi ence. Howeve r. puiling forward with the hand durin g a scent or pushing during desce nt masks active control of trunk and lower extre mity muscles. As soon as possible stair cl imbin g shou ld be practiced without uppe r ex tremity support. Prac tice on ramps may also be necessary for some patients. For pa tients with knee exte nsion in stabil ity, ramps pose an increased challe nge duri ng descent while knee stabil izati on is e nhanced duri ng ascent.

Locomotor Training Using Body Weight Support Treadmill Training (BWSTT) Locomotor traini ng using part ial BWS , a TM . and manua ll y assisted limb movement s has a lready bee n di scussed in a prev ious section in this chapter as well as in Chapters 14, 18, and 23. There is no unde restimatin g the im portance thi s type of training has had in influenci ng recovery of gait. Ev idence supports its e ffi cacy as a training strategy for diverse groups of patients with defi c its in motor fun ction. Stud ies comparing tradit ional phys ical therapy approaches to gait w ith BWSTT have show n significam improvements in ga it speed for the BWSTI group. Once treatme nt is stopped, the differences between the two groups become less apparent .72.211.2 12

Summary T his chapter outl ined a conceptual framework for rehabil itati on of the patient with defi cits in motor func tion based on norm al processes of motor control, motor learni ng. and recovery. Clinical decision making is based on a thorough exam in ation of the pat ie nt 's defi c its in terms of im pairment s, functional limitati ons. and disability. The un ique problems of eac h patient require th at the therap ist also recog nize a number of interrelated facto rs . including individual needs. motivation , goals. concerns, and pote ntia l for independe nt func ti on. Given the tremendous variability of patients wi th defi c its in mot or func tion, it is unrea listic to expec t that anyone interventi on can be successful with all patie nts. Interve nti ons must be carefu lly chose n to improve fun ction and to minimize injury. fu ture impairme nts. or di sabili ty. The effective use of motor learning strategies can dramatica lly improve treatment outcomes. Care full y pl anned and structured education empowers the patient. Pati ent ski ll s in se lf-evaluation. problem solvi ng, and dec ision mak ing are promoted to foster indepe ndence . If patient indepe ndence is not possib le because of the complex it y of de fic its and lim itatjons in recove ry. education of famil y, fri e nd s. and {" areg iv e r~ assumes paramount importance.

506

Physical Rehabilitation

Questions

for

Review

1. Differentiate be t\\leen the te nns motur cOllfml and m010r learning. How can impa irmenls in motor con· Iro l be dist in guished from those of mol or learni ng? 2. Describe how information is processed wi thi n the CNS to arrive nt an appropriate plan for movement. What is the difference between a motor program and a mo tor plan? 3. Differentiate between the three stages of motor learn ing. How should training strategies differ during eac h stage? 4. Discuss motor learning training strateg ies designed 10 improve retenti on and genera li zabilit y. How do they differ from strategi es that optimize pe rfomlance?

Case

PART I: PHYSICAL THERAPY EXAMINATION FINDINGS (INITIAL ADMISSION TO REHAB, 4 WEEKS POST-INJURy) ~ogn ition: Th~ patient i . . semicomatose and unre~pon­ s ,ve. He meons.Melllly respond .;; to a cOlllmand to " Iook at mc" with eye open in g and to "Iif! up your leg" with movcmcm o f the right leg on ly. Otherwi3e the re i:, no re ~ pon~e to dudllory or vio;; ual Mimulation. Language-Communication: Umtble to exmlline. Social : Married wi lh no c hildren . Wife h a regi~tered nur~e and very ~upponi ve of her hu sband .

Vita l Sign~: Hearl fate 60 bpm : bl ood pfC\')ure 122nO

mm Hg; respiratory nHe 14 brealh ~ per minute: 0 ) ~a t

92.

a.

intervention s of eac h. Defi ne compe nsatory tra ining. Ide ntify three interven. tion s that can be conside red compen satory training strategi es.

Sensation: Loca li zes to pinprick with withdrawal.

TIle patient is a 36·year· old man who susta ined a traumati c brain injury following a moto rcycle accident. On admis· sion to a loca l hospi tal. the patient was found to have a le ft frontal laceration with an underlying linear skull frac ture. CT scan revea led edema. a right basal gang lia contusio n. and a left fromal contusi on. The patient was comatose o n admission. Hi s acute hospi tal cou rse was comp licated by increased intracranial pressure and seve re spasti c ity whic h requi red casts and spli nts. A gastric tube was inserted. The patient 's neurolog ical statu s did 110t s ubstantially improve at the acute hospital. He was transfe rred (0 a reha. bili tation hospital 4 weeks post·injury for intensive re ha. bilitation . He had a brief readmis sion to the acute hospital during his sixth wee k post inju ry for stabiii zal ion of acute hypotherm ia and hypothyro idism. He was then returned to the rehabilitation facility for continued intensive rehabili. lalion. Hi s medical ion s consisted of Tegreloi (200 mg po qid), mul tivitamins. and Colace.

I :'

PNF. How do they differ from each othe r? From compen satory training strategies? Give three examples of

Stud

HISTORY

le\e l

5 . Define neuroplas ti city. Wh at are the different theOries proposed to ex plain recover: o f f~n~ tion? 6. Define functional/task-s pec ifi c tra m mg. Give three exa mples of interventi o ns based on this approach. 7. Define the neurofacilitation approaches of NOT and

-

Passive Range of Motion: • RUE is limited in elbow ROM (0 to 70°); LUE elbow ROM is( IOto 100°). • 80th lower extremi ti es (8LEs) are within normal limits except for ankle dorsiflexion 0 to 5° o n Rand 0 to 10° o n L.

Motor function Tone: (Modified Ashworth Scale grades [M-ASJ) Severe fl exor tone and s pasms of the trunk that res uh in the pati ent movi ng in bed from a supine to a left sidelying.

curled-up (fetal) position_ M-AS = 4 • Right upper extremity (RUE) ex tensor tone, M M AS = 3 • Right lower extremity (RLE) extensor tone, M-AS :: 3

=3 • LLE extensor to ne . M -AS = 2 • LUE tlexor fone_ M-AS

Renexes: • Frequent asym metric al tonic neck reflex posturing with head TOHlted to the right • Flexor withd rawa l reflexes bilaterally in response to pain (dt"Jayed 0 11 the left with decreased intensity of response) • Positive s uppOrt rcl1ex on the left • Hyperac tive deep tendon reflexes throughout

• At time .. the patient di .. plays deconkate posturing with mas~ pattcming. The lower extremities scissor at times. e'peciall y w hen upper body fle\or tone increases

Voluntary 1\'10\ emenls: • ~he patient i.s agita ted wit h restk-.s:-. movements and is Irc4Uellt ly d l.lphoreti(". • No head or trun!... con trol. dependent silling

• Moveme nt of RUE is Spontaneou ~. purposefwll u.nea. and out ·or.~ync rg) .

Chapter 13 Strategies to Improve Motor Function • Movcment o f the RLE i ~ :-.pontallcous. nonpurpose fu L and out-of-~y ll e rgy.

507

• LLE: Impaired se nsation. d ec reased proprioception .

• R UE a nd RL E: InWCI

• LUE no ac tive movcm ent • LLE movement is spontaneolls. nonpurposcfu!. w ith ahnonnal ob li gatory synergy. Coordinalion : Una ble 10 a~"es:-.: unres pon s ive. Skin: Mult iple healed lacerationo; o n the knees and (:al ves and prC'~~urC' sores bilale rall y on the lat era l mall eo li and calcanei from biva lve po~ i tioning s plint s. Bladder and Buwel: Incontinent o f bowel and bladder. and ha ~ external cat heter in pl ace. Functional AClh'ities: De pendent in all activities

PART I (OUESTIONS 1-3) I . Identify and prioritize the clinical problems presented in tim. c;.lst" 1Il lenn s o f di rect and indirect impaimlems. and funclionaiiimilat io11'> ba ~ed o n initial adm ission data. ., Identify the goai'i and ou tcomes o f ph ys ica l therapy 1Illervcntion fo r thi ... patient at thi s po int in hi s recovery (i nit ial adm iss ion). 3. Identif) treat ment in t e rve nti on~ appropriate fo r this patient at thi ... point in hi s recove ry (initial admi ss ion).

PART II: REEXAMINATION 6 MONTHS POST-INJURY Cognilion: • Orientation: The pati enl is al ert . o ri ented X 3. • Me mor~ : Memof) is impaired: .s how ~ limited carryover for re leamed ta~k s ':I lIch :t...... ~elf-care: pao;t mel1lorie ~ s how more dcpth and dcuul than ~ hort - te nl1 mcmory. • AUt-o tion: Att ention "pan is reduced ; he requires re pe tilion and ~truclUre 10 complete ac li v ilie .... • Insight : He demon ~ tr::tle~ littl e insight into di sability or ...afel) aware llc~~. Behaviur:

He I~ lunc llOlllllg at Ran c ho Leveb of Cog niti ve Functiomng (RLOCF) Level V I Confu ~cd-A ppropriate. He ... ho,",'1 ~ol1le limn ed goa l -d irec t~d be ha vior but is dependell! on ex ternal dlrecl ion. He ... howl't ",ollle carryo\er lor IlC\\ learning but at a o; i!,!llilicantl y dl:!("fcast:d rate. B~(()me~ l!a ... lI) fru ... trated and rl.'~ pon(b \\ illl d isi nhlb iled behavlor~ (ndme ('alling and ..,wearing ). Lungu4.lgc-Communil:alion: The p;'lllent i~ d y~a nh ric: "'JX:cLh I ... lI ... ually intelligible but diffi cult 10 lInde r~wnd and ddayed in on ...et. Aud il or) Lomprehcmion I ~ good . Vital Sign,; WNL ~kin : L,lu.:ratjun~ are hcakd

~cn ...ation:

• \ i~ion 4.lnd hearing are \.\ it h ln normal Ilmi l'> • 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(.'livitie<;: • Bed mubilit)': Rl)lI ... 10 nght and leI! "lth super\ ll'tiCln lS) • S upin~ · to. !toil : ~lod dqxmlcnn.:, I\:quirc:. Mill A to l'Io...t! S

• Tralhfel'1'I : ~111d A X I In ... tand-pi \OI trall~ fer:-.

508

Physical Rehabilitation

• \Vheelrhair Locomotion: Maneuvers power wheelchair wilh close S for sa fe lY • Gait: Unabl e

5. Identi fy the goals and outcomes of physical therapy inte rvent ion for th is pa tient al thi s point in his recovery (6 months post- injury) .

PART II (OUESTIONS 4-<;)

6. Ide ntify treatm ent interve ntions appropriate for this patie nt at thi s po inl in hi s recove ry (6 months post-

4. Identi fy and priorili ze thi s pa tie nl 's prob lems in terms of direct and ind irect im painll enl s, and fUllc ti onal limi tal ions (6 months post-injury).

injury).

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1983.

:n.

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~()

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<7.

\\ .)OII,I(;OIt. " I .lIlJ ~hUIll"a)-Cll(ll... A Ch:mgo:s III ~IUJTcOO­ Irol INI.U.IO,~ the: hk 'PJ.II A "- 'lcll b Jpe"o,leh. Ph)") Ther 10;"]99,

Phy, Th('r(l'J ItI.'i . 19/'i/'i

"X ~l)

~\'OOIl~'OIi . M. amI ShulH \\tI) ,Cook. A l.'ds): [k~t lopllicnl of

.l,b IUr~' .lilt..! (1,111 AHO'~ the Lite , pJn UIllWI~lt' of Soulh • ( .lrolm,1 Pr(!\-,. (olumblJ 1')8IJ I. h K· ,. I~ I, InformJlh)1l Vl o...·e;»;O' lIlg lOr I1IOh11' pt'rfomlance m .... .ldult, Ph), nll'r7U: H2 1. 1990

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lemeatal

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
Readlu

Carr J 4ud !thcphard R ~eUI(lI\l)!I.al Keh:.lbl!Jt"!I(iU OpltUllltn~ "I, .. ~)[

Pt'1"f,l(TI)
511

\~hnudt R llnJ LA-c.

t \101." (\lIllrnt .mJ Lc-arrulli. (U 4 .~ K"wtll' (·h".mp.ugn. n 2(XJ5 ~U"nJv..t) CI)IIl... -\. M\I.J "Ot}ll;.a~ ..:.. t M M\)f\"!f ('mMfQI1"bcory .tnd i-*t,KlJ(al :\pph\.;uI.... J~ e4:: llppu}.;Ott W1UiAfm &. \\ il!m.;., Plllla4:lphl-l-.

~OOI

Appendix A: Neurodevelopmental Treatment Approach (NDT)98,99 ne uromusc ul ar faci lilati on, inhibition, or frequently a combination of the [WO o Manu al contaclS are used to:

I. NDT Basic Principles • NDT i:- based on an ongoing analysi s of sensorimotor fun ctio n and care full y planne d int e rve nti o ns

de'igned to improve functi on.

Pr in c i pl e~

of motor

('o ntrol. motor iea ming . an d mo tor deve lopment g ui de the pla nning p roce'~.

• Therap)

foc u ~e~

on th e cliem's strengths and com pe-

lencie:-. \\ hi Ie at the ... ame time add ress in g impa ir-

ment ... , functi onal limitat ions. and disabilities. Negmiw sign.;; (wcak nc.':t!). impaired postu ra l control. and p :.lu c it~ of rn o\ ement) are equall y import ant to

:.tddress in

lre ~llm e ni

as positi ve

~ i gns

(spasti city.

hype-rac ti\ e re fl exe s ).

• The POC i~ developed in partne rship with the patient. fami ly. and inte rdi\c iplinary learn . • Treatment focuses a ll the relationship be twee n sen:-or) input and motor output. • Therapeu tic hand li ng is the primary NDT intervention ~tratC'g~ . Faci litator)' a nd/o r inhi bitory inpu ts are pro\" ided to influence the qual itj of motor res pon~es. • Trainmg i ~ foc u':oed on !o.peci fic t3~k 20ab and fU llc1I0nal ... kill s. The ta"k and/or environm en t is mod ified a... needed 10 cnhance fu nction . • Al ti\t' paJ1iCtp3l! on b) rhl;' p3ti e nl i ~ a goa l and an ('\ pect~t\ i oll of tn..'alm c nt. . -\ m ajo r rok of the therap l... t i... a...... i.,ltfH! in all :lCCUr.tte an,d ) \ 1, o f mOlor problem, ~IIl<.l de~ dop mcnI of ettet:ll\e ...(llutl on....

• ~1 01 M karn tll ~ pnnl lpl e ... .Ire ad hered to tn the therapeu ti c ...~l1 l ng, Inc ludlllg \c rb,11 rl' lIll on.'ement, re petltlOll, L,llllil;Il Hln ul l' no r ••\~an: n e ...... final
eng.JgJn~

J I1 L'1l\

Iron ment l.o nd uu\ l' to Icami nl!

the pallcntki le lll/ talllll) and

t' lhUf1ng~'

Il1 Uil\.i!I On

•

J)lrt'tl l t'.Jlh ll J~ 0 1 the r..tl ll.'nt/d ll:ll til d lll i l ) /t ;Jrq .! I\('r t:lhu re C ilrr~ O\ tT oj tu nllional ~h,.Il\ li lt' ... In Ih ~ hOll'l .Jntll"Ul1lfnU lll t ~ "'l· lt lll~ I...
II)

llllnrHl lh:nt

• ·'Direct. regulate. and organi ze tactile, proprioceptive and vestibul ar in put. • Direc t the clienl 's iniliation of movement more effi. cien tl y and with more effecti ve muscle synergies, • Support or change ali gnme nt of the body in relation 10 the BOS and wi th respec t to the force of gravity prior to and duri ng movement sequences, • Decrease the amoun t of force the client uses to stabi. lize body segments, • Guide or redirect the directi on. force. speed. and timing of muscle activati on fo r successful task completion, • Either constrain or increase the n exibility in the deg rees of freedom needed to stabili ze or move body segmenrs in a functi onal activi ty, • Dense the response of the client 10 sensory input and the move ment outcome and provide nonverbal feedback fo r reference of correcti on. • Recog ni ze when the client ca n become independent of the therap i ::. t·~ a~s i s tance and take over conrrol of post ure and move me nt. and • Direct the cltenl \ att enti on to meaningful aspects of the moto r t a:::. k :~ r ::'iq K") Points of Co ntrol : Ke) point> are parts of the body the Iherap t, 1 choo~(' .. a~ optimal to control (inhibit or f.. c i lll ~il t:') po-, ture" Jnd movement. Proximal key points lIlL"iudt:' the ..,ho ulder .....111'-' pe h hand ..Irt' used to IntlU l' IIl'l' prox imal ... egmt' lHs and tru nk. Disrul key P Oflll\ upper .md ltmt'r e\ l rt'rnll le~ t t) picaJl) the h:mds an u I t'l.'t ).

Ke~ p l llll h 01 cont rol Me ,II '0 u... t'd In pro\ ide- inhibition uf ahnnnn.1I ItHlt' .tnJ po ... ture"\ . F\ample-, incl ude: • I kad .Ind IIUIl"'- 111:\1l)11 d(."'l're~l-.e, ~houJJe r retra~:rion, tnlll '" ,mil li mb c: \ t ~· II ... lOn ( Io..t') PO lllb 0f ~ontrOl : head

and trunk, d t·tlt',I"'t'-'

II.

DT In tervention Stra tegies and

1 e~hniqu e.

'I ht"nlpt" lJl il l-t a llcll i n ~ : 1

III.?'\ IPII h Ill\? l . t

PlIJt il ~ l ll\ lIl1h )1 h UrI1L-lu", 1. • lh u l li h ,1";'/ Ul lI \111 Jnd

h VJ. tP\.' UlIl"

h"lIdllll ~ ,... U"'l';'/

I I Hl l hlt·nlt til, 4U:..IIII"\ nl Iht" II hlh~1 Il· ... I ~l l h.: ..tJlJ h l.lIl·hd l~ Ul.It.."huJ lu li lt" p.1l 1t" III ·, .dlllJlI C'o III U..,.

clI!<.lIr)

90 dl!gr~;) tht' up~r c:x trelll il) (kt')

• '·h ll lll· r,t!l'\ It"rn,1l rl'I•.I(IOI1 ..lIld I1l' \1 0 /1 to

1111 11111 •• 1111111 .. lid ~\(.J d jll 11 1\ l\ l"/l I\."II "

It Il1l ludt"

t' \kn'I~ln \\ ilh lore-arm

tWd l" ~lll\rol. the thumb). • f t: ll hIIJ l l'\ I I..' IIM IIOldhllll Jnd JbJ Ul"1I 0 1l decreases ~\k ll"'t)! i .ldd ll\ "lOI h1lh.' ul Ihl.:" Il~\~ l' r c\lremit) (key 'UplIl.ll!l)1l d l·\."fl"."l" tk \ !\)t) tont: 01 the \\ n Sl

IIn ~l' l '"

( 10.. 1.:') I)(IUII II I

polit I 1.11 l unl h)1 IlIp l

Chapter 13 Strategies to Improve Motor Function

F'acili t.ltion : Components of posture and movement that are

('~se nli a l

for success ful fun ct ional task perfOnll -

lIllce are facililat ed th roug h therapeuti c handlin g and

key poim:... Inhibition : Componen ts of pos ture and movemen t that are Mypical and preve nt deve lopme nt of desired malar

patterns are inhibited. While originally thi s term referred

~ Iri c tl y 10

the reduction of 10ilC and abnomlal

retlex('s. in currellt NDT practice it refe rs to reduction of any underlying impairmelll that interferes wit h func tional performance. It can b(' used to:

513

• " Prevent or redirect those components of a movement thaI are unn ece~sary and interfere w ith intenLi ona!. coordinated movement.

• Const ra in Ihe degrees of freedom . 10 decrease the amou lll of force the clien t uses to stabilize pos ture. • Bal ance antagoni sti c mu sc le groups. or • Reduce ~ pa s ti city or excessive musc le stiffness that interferes with moving specific segments of the body:"")' p 2f!1

Appendix B: Proprioceptive Neuromuscular Facilitation (PNF)lOO.lOl I. PNF Basic Procedures for Facilitation Patlerns of Motion: Nom,,,1 motor activit y occ urs in synergiMic and func ti ona l patterns of movement. PNF patle~ s are "spiral and diagonal" in character and combine mOlion in all three planes (nexion/extension, abd ucti on! adduction, and tran sverse rotation). They c lose ly re~e T1lbk patterns used in normal fun cti onal acti vity and spon s. Extremil ) patlems are named for the act ion occurri ng at the proximal joint or by the d iagonal (antagoni st pairs of pallcrns make up the diagonal ). L'pper £xrremi/.\ (UE ) Diagonal I = Flexion. Adducti on. Ex ternal Rotation (01 Fl exion) and Extension. Abduction. Inlernal Rotation (01 Exte nsion) U£ D iof?onal 2 = Fl ex ion. Abd ucti on, External Rotation (02 Flexion) and Ex tension. Adduc ti on. [nternal Rotation (02 Exte nsion) Lower Exrremit), (LE) Diagonal I = Flex ion. Add uction. External Rotation ( 01 Flexion) and Extension. Adduction. Internal Rotation (0 I Extension) LE DioROllol ] = Fl ex ion. Abd uction. Int ernal Rotation (02 Fl ex ion) and Ex tens iun. Adduc ti on. External Rotation (02 EXlen"ion)

Pattern s are varied by changing the action of the inter~ mediate joint (i.e .. elbow or knee) or by changing the po.,uion of the palient (i.e .. supine. silting. ~ta ndLng ). Pallem!) can be uni lateral or bilateral (i.e .. symmclri· cal. a.,Ynlmetrical. or rec iproca l). Trun~ pattern, include chop and lifl pallern~. bilateral \o",er euremll) ( LE ) pane rn~. !)capula and pe l vl~ pal ~ tern .,. and head/nec~ pall enh. Timing: Nonlla lll rlllng en ~u re s :-.moOlh , coordimued movement. In PNF pauern, normalltming i ~ from dl !)~ lalto prn\llllal 01 '> 1:.11 ..,cglllenh (hand/ '" ri..,1 or foo tl anl-.l e) mme fi r"l followed clo . . el) by more pro\lmal lornponent f.. Rotallon Ol"cur!) throughout thl! pall~rn . Irorn begl/llltng 10 end . 'I iming fur Emp ha liiis (fEJ; Ma.\ rrnum rl!~i . . t.trl('e I ... u"'l!tI 10 elll'lI a ... tron g lOnlraLtron anti aJlo\\ o\erflO\\ to O\.("ur Iroln ')Iron g to \\~a l-. l'ornponen t\ \\ Ilhln ;t \) lI e r~ !1l')tl(. patlern: the ~ lron £ nUI\<..!e5 arc re~l'>lt:d l'>onW tfl lall) j""loll..lIlg 111 "1 "' hlle IIll)II On h ullowed In the V\t'a~t"r mu~dt"~

/lIdll u/llnl.\ \\\:.1l-.n\;'"" .lnd/or IIl~OorJrnalion Ht ... i';;lanu·: kt"-.r .. ldJKl· fdl'llil,tll' ~ Illu ~cle n)ll lral.. lr UIi and mOlor LOl1lrol Both IllIrillu "JI dlH.ll"\lli.lfu .... .l1 nHhde

fi bers contract. resul ting in rec ru itm ent of motor units and improved stren gt h of contraction . Resistance is applied manually and functionally through the use of grav it y to all types of contractions (isolonic-<:oncentric and ecce ntri c: isometric). • Tr acki ng or Light Resistance applied to weak muscles is facilitatory and is usuall y applied in combina. tion with li ght stretch. • Maximal Resistance (the greates t amount of resist. ance to lerated by the patient) is used to generate maximal effort and adjusted to ensure smooth. cOOf~ dinaled movement: maxi mal res istance varies according to the individual pati ent. Indicatiolls: Faci litate weak mu sc les to contract; enhance kinesthetic awareness of motion: increase strength : increase motor control and motor learning. Overnow or Irradiation : Refers to the spread of muscle response from stronger muscles in a synergistic pattern to weaker muscles: maximal resistance is the main mechani sm fo r securing overfl ow or irradiation, Stronger patte ill S can also be used to reinforce weaker patterns through mechanisms of overflow or irradiation from one extremi ty to the Olhe r. or ex tremity (0 trunk. Indicariolls: Enhance synergistic ac ti ons of muscles. i n crea~e strength. Manual Contacis (M e): Precise manua l contacts (grip) are used to provide pressure to tactile and pressure receptors ove rl yi ng muscles 10 facilitate contraction and gUide di recti on of movements: pressure is applied OppO~1I1:! to the direction of the desired motion. IlIdinlluJIIS: Enhance (.'onrraction and synergistic pallem ~.

Pusi tiuning: ~ll1.,cle positJOning at optimal range of fun cti on a ll m ..... for opum,11 re~pon ~es of muscles lIt'lIl?flt-It'll\iulI Il' lufioll.\JIlP). The greatest muscle tenwm i., gC lll..'raled In nlld ~ ranges " llh \\ cak contrJctilt forrc (a clin' /I/lIIt]iClt't/{.' ) Ql:,.:ulTlng in the shonened IJ.ngt'.., rhl~ Itngthl' rll'd rangt" pro\ ide,> opllm,11 ~al\:tch for muscle "' plnJIt..: . . upport \11 Cllrll r~ll·tion while the .. horteoed r.1ng(' \\ rth Inll'>c le . . pllldk unhMJing prm ide~ the 1("351 i.Illlount 01 lIIu",lk .. pmJIc 'UNk)ft for cuntraction. Indli ·tlfWI/I f-inh.m ... (' \\1..'.11. l'ontriJdlon . Thl'rapi,t Pu,jtiun and MOth Ml'(.' hanic~ : T herapist is pU . . JlH1IIl·d dlll·\."II) 111/111(' ~Ith the dt:'!lirt.'d motion (laung Ih~ dlft.'lilun 01 the 1ll0\l!fIll'lUl Ul order to llptr muc thl ' dlrl'l!IOn o j r('~I~'anl"l' th~H IS applied.

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

Improve Motor Function

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:
contractio n is resisted fo llowed by voluntary relaxation and pass ive movement into the lengthened range. The patient is then in structed to move back into the end position ; strctc h and res istance are applied to facilitate thc iso tonic contractio n. For each re petition , increasing RO M is des ired . I ndications; Marked weakness; in ability to Sustain a contraction in the sho rtened range Resisted Progressio n ( RP): S tretch, approx imation. and tmcking res istance is applied man ually to facilitate pelvic motion and progressio n during locomotion; the level of res istance is li ght 50 as to not disrupt the pati ent's momen rum. coord inatio n. and velocity. RP can also be applied us ing elasti c band resistance. I ndications: Impa ired tim ing and control of lower tru nk/ pelvic segme nts d uring locomo ti on, impaired endurance Rhythmi c Ro tation (RRo): Re laxatio n is achieved with slow. repeated rotation of a limb at a point. where limi. tation is noti ced . As mu scl es re lax the limb is slowly and gent ly moved into the range. As a new tension is fe h , RRo is re peated. The pati ent can use active move. ments (vo luntary effort) fo r RRo o r the therapist can perform RRo passively. Voluntary re laxation when poss ib le is important. I ndicatiolls: Relaxati o n o f excess tension in muscles (hypenonia) combined with PROM o f the range-limiting m uscl es

Appendix C : Neuromuscular/ Sensory Stimulation Techniques The lenn neuromuscular technique re fers 10 the fa ci lila· lion or inhibition of musc le co ntraction or moto r responses. The h.' nn sensory stimulation re fers to the struclUred pres-

entat ion of stimuli

10

improve (I ) alertness. ;.lItent ion. i.Uld

arou ~ al : (2) se n ~ ory discrim inat ion: or (3) initiation of IllU S-

cle activity and im proveme nt of movem ent contro l. Effec ts are immed iate and specific ( 0 the curre nt state o f the nervous !),slcm. Addi tional practice using re levant inputs and feedback is necessary for meaningful and lasting functio nal change 10 occ ur. Variable perceptions ex ist among indiv idu als: may see decreased sensi tivity in some o lder adults and wi th "ome ne urological condit ions.

I. Proprioceptive Facilitation Techniques 1. Quick Stretch Stimulu s: Brief stretch a pplied to a m uscle. Actll'Gres musc le spind les (faci litate s la e nd ings): se ns i-

tive to "eioc ity and length changes. Has both segmental (spinal cord ) and suprasegmental (eNS highe r ce nters ) eftects.

Response : Streich refl ex: fac ilitates or enhances agonist m uscle contractio n: phasic . AddJlionai pe riphera l refle x e ffects: inh ibits antagonist'), faci litates S) n e rg i ~ t s (rec iproca l innen '(lfio l/ ejJ{'((.q. Infl uences perceptio n o f e ffo rt. Tec hn iques: Q u ick srre tch: mo re effective when app lied In

the leng thened range (e. g .. PNF pan erns): tapping

o'e r mu ... c1e be ll ) o r te ndon

Comments: A lov.-thre .. hold respon~e. relative ly ~hon ­ h\'ed.

Lito

add re sistance to maintai n contracti on .

Adve rse Etfcct~: May increa!ooe spa stic ity when app lied 10 ') pa ~ t \C,; m U\LIr.:I,.

1. I'roI Cl n~(.·d ~tn..'tl'h Stimu lu!): Siov.. main t..ilned ~t re ldl. appl ied al maX Ullum availahle le nglhentLl range 4.UiIIlILl llIu!ooc it: ~ p i ndlc s (hi gher thre~ hold res. poll 'lc. pnIllM!!) lI ~j. GlJlgl tendon org;.llb (I ll end i n g~) : 'Ie n "'l ~ II\\.: 10 length ( hange'l: ha':l both ~l!g men l J I (~ pllla l cord ) .tnd \ upr~egmen l .u (eNS hLgher center') ) tl fCl.:' h . Ht'!ipun,-,e: I nhibJh o r d..lmpcn ... mu ... d..: ct)l1tr,II,'tll)Ll JnLl lone d ui.'" 1..LJgd) lu p(: npherJI re fl ex l'Ih!l: t ~ (.\ltt!ll/J , /Jloleu/Ull 1/ '(1e .\).

'I t=chn ique!!o : PU.., l IJOIlLn!!: Hlh Lbitor) 'IpIJntLng.l.-..i ... IL ng :

I»Cl..h,Ulic.:allov. ·Ioad v.elghh u ~ mg Lraclum

C omments: Hi ghe r thresho ld respo nse : m ay be m o re e ffec ti ve in ex tenso r muscles lhan fl exors due to the added e ff ects of " inh ibiti o n. To ma inta in inhibito ry effec ts. fo llow w ith activati o n o f antagonist mu scl es

(reciprocal inhibition effects),

J. Hesistancc Stimu lus: A force exerted to muscl e ACliwlfes muscle s pindles (l a and II e ndings ) and golg i tendon organ s (Ib e ndin gs); se nsiti ve to veloc ity and length changes. Has both seg me ntal (s pinal cord) and s uprasegmenlal (eNS hig her ce nte rs) e ffects. Response: Facilitates or enhances muscle contraction due to: ( 1) peripheral reflex effect s: muscle spindle e ffecLIO via reci procal innervation (facilitates agonist, inhibits antagoni sts, faciJitates synergists); Golgi tendon e ffects via autogenic inhibition: dampens or smooths o ut the force o f contraction and (2) suprasegm ental e tTects: recruits both alpha and gamma mOlone urons. add itional motor units. Hype rtrophi es ex trafu sal muscl e fi bers: enhances k inesthetic aware ness, Techniques: Manu al res is tance , carefull y g raded for opt i· m al muscl e fun ction. Use of body we ig ht and gravity lI sing upright pos itions. Mechan ical re sistance : use of we ights. cuffs or ves ts . Isok inetic res istance: res i!)tance is applied to a m uscle co ntrac tin g at a constant rate. C omments: Trackillg (light malll/aJJ resi~tal/ce is used to fa c ili l p indle u nl o~td i ll g ) . M a x i m ~l l res is hmce may produce o\ l it li tion . M l.L) pos:, ibl) 1rl1.: rl..' :J ,>~ ~ 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 <.:e ntt'J3 } eft~<.: t~ . k b l,u1be: FJc iI1l31l"'I po,tur,d e.\(l..'lt" Of'l :rnd ~ Iab lli l ing n.'..,po n ...t'l> (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
C hapter J3 Strategies to Improve Motor Function

Potential for interaction with autonomic nervous system, parasympathetics Response: Calming effecl. generalized inh.i~ition, . decreased fight/night responses: desensItI zes skin. Tec hniq ues: Finn manual contacts Finn pressure (0 midline abdomen. back, lips, palms, and/or soles of feet Fiml rubb ing midline back Comments: Useful for patients with agitation and high arousa l (e.g .. th e patient with traumati c brain injury) Usefu l for patients with hype rse nsitivity (e.g .. th e patient wi th peripheral nerve injury and paresthesias or the patient with tactile defensiveness). Can be used in combination with other maintained stimuli and sensory discrimination training. Brief touch stimuli should be avoided.

4. Slo w St roking Stimulus: Slow srrok in g, applied to paravertebral spinal ~oo

.

Act;\·ates tactile receptors. Has both segmental (splllal

cord) and suprasegmental (CNS higher centers) effects. Potential for interaction with autonomic nervous system, parasympatheti cs Response: Calming effect, generalized inhibition, decreased fi ght-or-fli ght responses Techniques: The patient is placed in a support.ed position such as prone. or sitting head and ann s supported and resting forward on a table top. A nat hand is used to apply finn , alternating strokes in a downward direction over the paravertebraJ region for approximately 3 to 5 minutes. Comments: Useful with patients who demonstrate high arousal. increased sympathetic (fight-or-flight) responses. Can combine with other relaxation techniques (e.g .. deep breathing exerc ises, quiet environment ). Patients with large amounts of body hair may be less responsive to calm ing effects: hair follicle stimulation may be irritating.

5. :\clItral Wanmh Stimulus: Retention of body heat AClI\'alfs tactile and thennoreceptors. Has both segmental (~pinal cord) and suprasegmental (CNS hi gher centers) effecb. Potential for interaction with autonomic nervous sys· tern. primarily parasympathet ics Response: GeneraJized inhibition of tone; wann ing produces a cal ming effect. relaxation, and reduction of pain Techniques: Wrapping txxly or body pans: ace wraps. lo\Ye! wraps Applicalion of snug filling clothing (gloves. socks, lights) AIr splinb Tepid baths Duration variable depending on palient re~poll~e

519

Comments: Usefu l for patients with high arousa l. or increased sympathetic activit y; spasticit y. Ad verse Effects: Overheating shou ld be avoided, may produce rebound effects (increased arousal or tone).

6. Prolo n ged Icin~ Stimulus: Cold applications ACTivaTes thennoreceptors. Has both segmenta l (spinal cord) and suprasegmental (eNS higher centers) effects. Potential for interaction with autonomic nervou s system. sy mpathetics Response: Decreases neural and muscle spindle firing. Prov ides inh ibi tion of muscle tone and pai nfu l muscle spasm. Decreases metaboli c rate of tissues. Tec hniqu es: Immersion in cold water, ice chips. Ice towel wraps or ice packs Ice massage Cooling sui t Duration variable depending on patient response Comments: Monitor effects carefull y. Ad verse Effect s: Can produce sympathetic nervous system arousal , protective withdrawal responses, fight-orflight responses. Contraindicated in patients with sensory deficits, generalized arousal. autonomic instabil ity, and vascular problems.

III. Vestibular Stimulation Techniques 1. S low Yesti b ul a r Stim u la t io n Stimulus: Low· intensity, slow and rhythm ic vestibular stimu lation ActivaTes primarily otolith organs (tonic receptors); lesser effects on semicirc ular canals (phasic receptors) with inputs via eN V III (vestibulocochlear) to eNS higher centers and spinal cord; pote ntial for interaction with autonom ic nervous system, primari ly parasympathetics Res ponse: Generalized relaxation: inhibition or dampening of tone and motor output (vestibulospinal reflexes); dec reased arousal, fight/ flight responses Tec hniques: Passive, manuaUy assisted or active motions: slow. repetitive rolling or rocking movements. e.g., sidelying rolling. sitting roc.king. Mec hani cal: use of a rocking chair or bed, therapy ball or bolster. equilibrium board. hammock. swing; wheelchair ride Com ments: Useful with patients who are hypenonic. hyperactive. or who demonstrate high arousal, or tactil e defensiveness (e.g., the patient with tr.lUmatic brain injury who is combative) Can be combined wit h olher relaxation techniques (e.g., deep breathing. cog nitive/image ry techniques. quiet environment).

2 . Ve s tihular Srilllulutio ll Slimulus: Vestibular sti mulation via head and body movements

520

Physical Rehabilitation

Arrimres semi circ ular cana ls (ph asic rece pto rs th at detect ro tatio na l acce leratio n and dece lerati on), oto lith organs (toni c receptors that detec t head positi on with respeci to grav it) and linear acce le rati o n} with inpu(s via C N VIII ( vestibulocochlear) to CNS hig he r cente rs (vestibul ar nuc le us, spi nal cord , retic ul ar fo ml ati on , superi or collic ulus, cerebel lum). Vestibu lospinal and vestibu looc ul ar re fl exes Potent ial for interaction with autonom ic nervo us system Respo ns(>: Postura l and to nal adj ustments HeJd and eye moveme nt s Improve ment of re tinal image stab ili ty (vesti bu looc ula r re fl ex). decreased pos t-rotato ry nystag mus Imp rovement of mo tor coordi natio n Ge ne rali zed aro usal and consc io usness Techniq ues: Change of pos it ion o r movement Fast spinnin g and linear move me nts wi th accele ration and deceleration com po nents he ightens alertness and motor responses (e.g .. !>pi nn ing in a c ha iJ, mesh net or hamm od.: prone o n a scooter board). Eq ui pme nt: eq uil ibri um board s, wobbl e boards. the rapy ball. dynamic pos tUfography Co mments: Useful wilh : Hypotonic patient s (e.g., an indi vid ua l wit h Dow n syndrome) Pati ents with sensory integ rati ve d ys fu nction (e.g .. a child ", ilh hyperac tivity) Patien ts \\ ith coord inat io n problems (e.g., stroke, cerebral palsy) Helpfu l in overcom ing the e ffec ts of akinesia o r bradyki nesia (e.g., a pati ent wi th Parkinso n 's disease) Ad " er se EtTerls : Prolonged e ffects may incl ude behavioral changes, se izu res. and sleep d istu rbances. Comraindicated for patie nt s with recurrent se izures o r who are intolerant 10 sensory stimu lat ion.

IV. Augmented Visual Stimulation Techniques Stimul i: Vj !:.ual object ~ : pen ligl1l, bri ght ly colo red bloc"-" fa miliar objecls. photo card ~j ~ ual background ,,: checkerboard bac kgro und , 1110\II1g ,> urround ...creen Vide-otapes Visual bioteedback ACI/I'CJ(e.s

phot~receptor'l (rod!> and cone!» wilh i n pu I~

VIa eN IJ (Opt iC). 10 eNS higher ce l11 er!> (l ate ral ge niculate nu(,: leu ~ .. prmlilry \ i!>ual Cortex in the occ ipi tal lobe, a~!>O<:Jallon art::as) R e~pon~e: Vi suaJ di~cflminau on : con..,cioll~ a\\arenc\!> and recognilion of objec t!>: \ I"ual t ra~' k lllg Al ertlllg , orie nting re",polhe~ : "'an Ie re.l. po n!>(' 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~db
Res ponse: Auditory dl!>cn 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): .

521

Comments: Conside r patient's premorbid interests and likes as we ll as odors in the ex tern al environment and scents you Jll ay be wearing. Adverse Effec.s: Avoid sensory ove rl oad: irritating stim uli that ca use ag itation. Ad ve rse fi ght/flight or emoti onal responses can occ ur. Conrrailldical ed in pati ents wi th hyperse nsiti vit y.

VII. Gustatory Stimulation Techniques Stimuli: Taste stimuli A Cl i\'OleS taste receptors on posteri or longue to e N IX (g lossopharyngeal ): anterior and sides of tongue to e N x (vagus) and e N VJI (facial ) to hi gher centers (temporal lobe) Response: Recogniti on of tastes: fast adapting Techniques : Structured applicati on of stimuli : presentati on of va rying tastes. Feeding is a multisensory experience including taste, smell. pressure, texture, and temperature. Comments: Various foods evoke emotional contexts. Adverse Effects: Dysphagia management requires careful cont rol of food inputs (e.g .. taste, tex ture, size).

VIII. Sensory Integration Training Stimuli: Multimodal: varied sensory stimuli are prese nted in the context of meaningful activities (tactile, vestibular-proprioceptive, and visual). A CTivates sensory receptors and higher brain centers: engages ce ntral processing areas of sensory informati on. Response: Improved sensory discrimination: identifica· ti on of specific stimuli (e.g., shapes. weights. tex ture. num bers written on skin ). intensities, and improved ability 10 locaLi ze stimuli Improve perception: selec tion. attenti on, and response 10 sensory inputs with appropriate use of information 10 ge nerate specific motor responses Techniques: Multimodal . presentation of various di fferent stimuli is combined with functi onal task training. Tactil e: deep touch-pressure activities (e.g .. stroking or rubbing the skin. use of a vibrator. manipulation and identification of objects. drawi ng leiters on skin. learning to read Braille); one- handed and two-handed (bimanual ) ac ti vities Ves ti bul ar- propriocepti ve: activities designed to stimu late a variety of movemen t expe rie nces (e.g .. linear and acce lerated move ments, resisted move ments, gasping and moving objects. throwing objects. therapy ball or wobble board activi ti es) Em phasis is on functional task . . , illleri imb cont ro l. Vbual: visual cues. tracki ng tasks Foc us is on postu ra l trai ning ac tivities with progression to more di flicult adapti ve motor res ponses. Comments: Sensory organi zation training is an important component of balance training: act.iv ities focus on

522

Pln .. ica l Ih·h .. biJilalion

'em.ory input s (e.g .. the hype racti ve c hild with t're.

"OI:"l1l11g, , upprc"i ng. and ('(llllhin lll!! d ifferent JflpU I~ under \
quell!

L" l~d lor pallt'll l, ,\ Ilh ,cn'ory Integrat ive d) ", fu nction \\ho 11:1\(' a poor ahili ty 10 d i'l:ri mi nale 100Il' h. lllo vc-

Mai ntain optimal concc nlr<.llioll and .mention: Provide frequent res ts and change o f tas k.

Illt' n!. lorl:c. pr in l onnal ll)/l ahoullht' lr hod IC1-. 1'\ '1<1)'

umkrllc di",ordc r, 01 hila teral II1 legra liol1. ,equenn ng. :lIld dy'pra;\/;I, SOI11C p:ll lc nh prl· ...clll \\ IIh Jl'crca'cd ci i,c ri m lOali on :Ihdlltc\ ,lnd

IIl lcn'c crav in g fo r rc n <.l in type' of

O llt bu r~ ( s)

Reduce environme nta l d istracto rs: combine with relat;. alion tec hniq ues, Ad ,'crse Effecls : Sem o?, o~e rl.oad may produce prolonged a ft{' r-e ffccl ~ (e.g .. pup" dilation. changes in respiratory ratc. fl ushi ng or pallor. na usea. sleep disturbance).

C H APTE R

14 LEA.NINC OBJECTIVES J. Discuss the major elements of physical therapy intervention for patients with gail impair· menls.

2. FonnuJate general goals of an exercise program designed to prepare a patient fo r locomotor traini ng. 3. Describe the characteristic fealUres and foc us of control of each posture included in the

preparatory exercise program. 4. Contrast and compare the ad var'll ages and lim itations of using parallel hars for locomotor

training. S. Explain the rationale fo r each compone nt of the indoor overground sequence.

6. Describe the rationale for locomotor (mining using body weight support and a motori zed tread mill . 7. Describe the guidelines for selection and measurement of canes. crutches. and walkers. 8. Identify the common gait patterns and guarding technique used with assistive devices. 9. Describe strategies for varying task and environment.a1 demands during locomOior training . 10. USing the case study example, apply clinical decision-making skills wi thin the context of locomotor training.

Locomotor Training Thomas J. Schmitz, OUTLINE Preparatory Exercises for Locomotor Training 524 Bridgi ng, Pelvic Elevation 525 Quadruped Posture 526 Sitti ng 527 SiHo-$ land 527 Kneeling and Half-Knee ling 528 Modified Plantigmde 529 Stand ing 530 Locomotor Training Strateg ies 53 1 Parallel Bar Progression 532

alking is the final and highest le vel of mOtor control b ~al1, . It represent s a foundational compone nl o f independent hu man function that s upport~ and e nhances effective interaction With the environme nt. It is also a fun ction al skill commonly nnpaired b) pathology o r injury. Independent ambul ation is an expected o utcome for many patie nts who ~ "- ph YSical therapy interve ntion. The major rt!q uireme nb for , uccl:ss ful wa l"-in g incl ude:

W

Suppo rt of body m;t,., by the lowe r eX lre mitie~ (LE!o» Prod u( 1I0n of locomo to r rh )' thm D) namic ba lance con trol 0 1 the muv ing body Propublon of tht: bod ) in th~ inte nded d irt:l' lJo n • Adapl.JhII Jl )' of locomutor re ~ po n ...~s 10 c ha ng lll g la, "and e nvironmenta l d e ma nd !I

• • • •

The cKami na tion of gai t pre~e nl ed in C ha pl e r 10 1(it:nllfil JI IOIl III gail dc, iatto n... thut Illlpdi r o r pre lI enl wnbulatlon ..IS "('II a s t ht' 1I po,>slble C;;tu')c,. Eva lua tio n of gat! anal YSIS data a llo ..... s tht! lhc rapl ... 1 to develop an appropriate pl.an o j ca rt: (POC) to Jdd n.' s') h.X:Oll1()llll unp,1lrmClll s and I) pil all y IIldud,.:s a program o t prepilf'dtor)

mtludc~

PT, PhD

Indoor Overground Progress ion 534 Outdoor Overground Progression 534 Locomotor Training Using Body Weight Suppon and a Motorized Treadmi ll 535 Ovcrground Locomotor Training Using Body We ight Support 540 Locomotor Tmining Using Assislive Devices 553 Adjunct T
exerc ises and locomotor tra ining . The general goal of intervention is to prov ide the patie nt wi th a me thod of locomotio n that all ows maximum independence and safety at a reasonable e nergy cos t. Lnterve mion s for impaimlenls that restrict or prevent a mbulatio n ace applicabl e to a broad specfrum of pati~ntsl cli e ntI'> ",ee n by phys ical Ihccapi sls. The: Guide tv Ph vslc lIl Tllerapi.H Practice I indudt!!i. elemenb of gait tOld locomutor tra ining a~ an inlervemion catcgof) \\ ith ill each of the four prefe m: d prac tice p:Hlems. Tht' c ontinuum o f procedura l Ink rve nt ion, for this category incl ude dc\elopmental acllv Hie, tntinlllg ; gail Ifuming: imple ment and device training; ~ t : and '\ hcd chatr Iraining . 1 l 'A'heekhair trainmg i!\ ,l d d rt':\~d in Chaplt":f 33.) Th " dlJ plt'f pre~ell l ' J general d l '",u ~s l o n of prepara ttl ry exen.:I,el!! and I(x'o m o tor tnun ing :, trall!gles th.u can be J)lo{t1ficd to mc:ct the n ced ~ o f an InJi"HJua l patient til uetenlllnmg tht: t'xlc nt .lIId type of (nunlng 'Ktivlties fl!quired 10 u(.'hit've the dC' IfI:d ("' I">ectt!d ou t l'o nw~ The,e raclOn; II1clude the

Sc" crJI fadOf' \\ III ~ 0 1 nujor influence

524

Ph ysical Rehabilitation

.,

Box 14.1 Locomotor Tra.mll~g:

. I M ' Elements of PhyS'C3 aJor

The rapy Inte rvention

A. Preparation for Locomotur Training InstrucLion and training in: • Bridging • Quadru ped • Silting • Sit-to-stand • Kneeling and half-kneeling • Modi fi ed plantigrade • Standing

B. Parallel Bar I'rogression In struction and trai ning in: • Moving from sining to standing an~ .reverse .. • Standing balance and limits of stabilIty (LOS) (rammg . • Stepping. side-stepping. cross-stepping • Use of appropriate gait pattern . forward progress Ion. and turning . . . • Moving fro m sitt ing to standing. and reverse. with asslstlVe . . device" • Standing balance and weight shifting activiti es with ass lsUve device • Use of assistive dev ice (with appropriate gait pattern) for forward progression and turning" Q

C, Indoor O"e'1lround ProgressioLl Instruction and training in: • Walking forward and backward • Resisted progression • Side-stepping and cross-stepping • Braiding • Stair climbing • Fall ing techniques (generally included for individuals who are active ambu lators; particul arly important for individuals who requ ire long-term use of an assistive dev ice)

O.OLltd oor

round Progression o,'c .... ." ,

lnstruclion and training 10: , d passing through thresholds that Iead_ • Openmg doors an doors , ' and I ped ••'""-.. , b'ng' negotiatlOg ramps, stairs. . s 0 --.a . Curb CIlm I • ' n even and uneven surfaces • WaIklOg o . ( , , ' h' 'mposed ti ming requ irements e.g., CI'OIaIC • Walkmg wll 111 I at a stoplight) , 'd • __ unity envlfonments: outsl e uuun _ • Use 0 f open comm thresholds . • Entcring/c]l.iting transportation vehIcles • Use of elevators. revolving doors

E Locomotor Training Using Body Weight S~PP()rt and a Motorized Treadmill instruction and training in: • Walking on treadmi ll using body weight support (BWS) , . gressing to no BWS . • Production of locomotor rhythm : slow speed ~. faster speeds • Forward propu lsion of the body • Dynamic balance contro l of the ~oving body . • Reciprocal stepping patterns: asSisted movements (pelvis" LE) to unassisted • Strategies 10 improve speed. symmetry, and enduraacc

F. Indoor Ove'1lround Progression t;s~ Bodr Wei/lht Support Instruction and training in: • Indoor walking on level surfaces with body weighl . . . . (BWS) progress ing to no BWS • Use of assistive dev ice (if indicated) for ambulatioa ...... surfaces • Elevation activities: step- ups • Opening doors and passing thro ugh doorways

"0.... mg to limIted ~pace, u~(' o f Iht! paralle l bar~ may flot be po!> ~ i blc. I-~ owe \'e ~. wht::n adj u ~ta~ l e-widt h bars :m' avai lable. they provide added ~c urity for prehminary u,e of the IbSI:.lI VC d C\' lce. An alternatIVe approach "ould be to begin u...e of the de\ ice outside and ne ... t 10 ~Ianda rd paralle l bars or o\.tI-shaJ>l!d paralle l bar;.

patiel1l '~ goals for ambu lation ; info rmation obta ined from Ihe gait analys is and s ub~eq u e nt eva lu ati o n of these da ta ; and the diagnos i!). progno!) is. and we ig htbea rin g !) t a t u ~. For exampl e. the progress ion of locomotor tra ining aClivitie'\ mdicated for an othe rw i::.e hea lth y ind iv id ua l w it h a no nweight bearing tibial fracture wuu ld be very d iffe re n t from thmc developed for a pati ent with paraplegia o r strol-.e. The major c lement s o f phys ica l themp) int ervention that compri se locomotor tmining a re outli ned in Box 14 . 1. It should be noted tha t the e ntire ~e qu e n ce of intervention \.I. ill not be indicated fo r eac h patie nt . Depe nd ing on lJ\dividua l patient need. Imlltip le seg m ~ nt s may be accom plished conc urre nt ly, a more rapid progre\sion may be u::.ed , o r po ni o nl'! may be co mpkte ly om itted.

Preparatory Exercises for Locomotor Training Prepara tory exe rc i;;;e.;; re ady a patie nt for asswninl . , upri g ht po;i tion and typicall) in vo lve a large componoalol

mat \\ ork.. Man) of these preparato ry activities are ~ o n a developmental fra mework and pro gress from ini1iIl .u.: ti\ Jtit: ~ wit h a large bru,e of s upporl ( BOS) and , _ ce nter o r Illa" (COM) through la te r activities thai , n"t lk .. BOS ,,,, d h igh COM , The technique.

u.e I

UIiIIJId

within t:ac h po~lure of the preparato ry exercises . . ~equt:nced and progres'!' fro m (I) mobility, which iDcOQII" ratel'! in ltiallon of lllo\'e melH techniques.

inciudiDa auiII-

525

Chapter 14 Locomotor Training

positiofl in which th e therapist manua.lI.y assists the .palient to achieve a given posture: 10 (2) stahlla)'. chara~ten zed by the ability to mai nt ain a posture against grav ity: to (3)

dYnamic stability. which is the ability to maintain postural c~n rrol during weight shift ing and moveme nt; and final.ly to (.t) skill. which is the highest level. characterized bY. ~ls­

crete olOtor contro l superimposed on proximal stablhty. The tC'chnique~ used withi n each posture typically progress from assisted or guided movement 10 active move men t to resisted movement to ind ependent movement. These preparatory mal exercises or lead-up activ it ies (the lern, lead·up implies thallhe act ivities are preparatory for or " lead up" to ambuiar ion) have important functional carT\,O\'cr 10 other daily activities as we ll. suc h as relieving pres~sure . dressing, and bed mobility. Many fonn s of exercise provide important components of an overall program of preparatory exercises (e.g .. progressive resistive exercises. endurance and cardiovasc ular training. and mobility. flexibility. and coordinat ion exercises). Depe~ding on level of patienl involvement, the development of specific anticipated goals for a preparatory exercise program. b based on the following gene ral goals: l. Impro\e- strength, power. and endurance. 2. Increase or maintain range of motion (ROM ). 3. Impro\ e motor functio n (motor control and mOlor leam ing). 4. Enhance ...e nsor) integration . S. Instruct the patient in handling and moving the affected extremity or extrcmitics. 6. Oevelop postural ~Labi lil y in s itting and standing . 7. De\elop dynamic ~ Iabilily as evidcnce.d by the ability to move \l.'llhm and be lween postures. 8. Impro\oc trunk and pelvic COOlro!. 9. Oe\ elop tUllcl10nal balance respon:-es .

A general outline 01 sugge ... ted preparnlOl)' mat e:\ercbe~ follows . TIle aCt!\ il1e ... ~houltl be ordered from en!)iest 10 mO~1 diffi cult . Total mn~(ef) of one ij('ll\ Ity i~ nOI nece~"'aJ) belort" rno\ 109 10 the next higher !t'\el. Sequence~ m;,,) bepl3.nned III ... uc h tI wa) thai multiple po:-ture~ rna} lx- overlapped and u~ In an t'>.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<111) . 'J 1,uu..ll1lg .

patient IS III a hookJying position (supi ne with hips and knees fl exed a nd feet flat on the mat ) and elevates the pelvis off the mat (Fig. 14.1). The BOS is tbus reduced and the COM is raised. This activ it y is panicularly useful for facilitating pelvic motions and strengthening the low back a nd hip extensors in preparation for the stance phnse of gait. In addition. bridging has several important func tional implications. including bed 1l1Obility. use of a bedpan. pressure relief. LE dres.sing. movement from ~it~ l (}-stJnd. and sta ir climbing. Specific pelvic Illations (e.g .. pelvic forwa.rd motion, rotation. and latcm l shift) required dunng gait also can be initiated and practiced in this position. Se\eml suggestions that can be used as a progre':'':'lon withm thi~ po~lure folio\\, . I. Initial 3ctlvitit::'''i \\ ill Ill\ohe a., .. i\ted a ..... umption and a",sl'lted mamlen.lIlce of the poltlllOn , Manual onllle,s (MC~) 10 a~""I ... 1 10 po'litwn are at the ~I\'i"i . A.!
"t.·

i.lnJ h ... ro,~cd f"hHhln)

.t

tet'hl1l'-lu~ ~\t t..IynilJln~ rt'\e~",I, b!tl\\, f"t'\cf'.ll ..md ... h," h:'\ er'W. l-huIJ I (JO be u~'d to fJulltJt~ ~1\l1.' rot .. tH. \J1 J.J}.,I t•.iteraJ ,hllllllg 1 he

'ul,.. n~·lh.... nlll~ ..·,Jjl Ix- .1t.\.-ompl,,~d Junng hndgUlg b\ Jppil\. Jllvtl tlt rC"I . . t.ml,,~ "uh MC, of the.... dJU.t.~nur rupc.

Bridging, Pelvic Ele\3lion Bnd~JOg Jl1n"" '" "" elght~.mng lhrou~h lhl' teC't
Figure 14.1 Bridging. pe lvis elevation. Manual contacts al the pelvis can be used to assji\( or 10 res ist pelviL' elevation.

I1UI IhJ\.' "'pule illi

unportafll prc\-ur~m IU dS\Unllng Ihl' l..nt.'dUlg ro"IIH'1l dnd In de\dUJllllg MHO ' MJnd I.ontwl For (hi' ~h.ll\ II) tht."

Ili.lJh \ ~r

Rt."\I"'LJ.llI,;t~ Jhu .,·;,tn

J.1.,.r emphJ'1

(.It

t"r! upph d ..hago.

r\!'\I . . t.tJ\\,·t" 10 OIl<

t J~ IhIJh.' l '1\ 1(, nW.lIIHU Jfk.Vor to 1Ot:r1.!.1.,'4!

md)

t\Jl

.,m.. ..,1Jc.

"'Ide)

ROM

to

lec~

526

Physical Rehabilitation

6. Bridgi ng C~\Il be used to fa c ilitate hip abduc ti on and ~dduct ion . Thi s can be accompli s hed ei ther sym metri call y (res istance appli ed agai nst the sam e mo tion in each ex tremit y) or asymm etricall y (res is tance app lied aga inst oppos ing motions) by use of a lternat ing isometrics wi th manual contac ts at the knees. Theraband® tubin g can be placed around the patie nt's di stal thig hs 10 increase contraction of the hi p abd uc to r mu sc les (g lu teus mediu s) Jnd to inc rease propriocepti ve loading . 7. Resisted (e.g .. us in g agonist reversa l) and unassisted moveme nt int o and o ut of the posture . S. Severa l modifi cation s to bridg in g can be made to make the activi ty mo re demanding by altering the BOS. The lie modifications includ e (a) perfonni ng the activi ty with ... uppo rt from on ly o nc LE in pre parati on for \\eight ~ccept:1nce du ring the s tance ph ase of ga it : (b) dec reas ing the ang le of hip and knee fl exion (i.e .. moving the fee l di stall y) : and (c) perfonni ng the ac ti vi ty \\ ith the upper trunk s uppo rted o n a thera py ba ll (wa lk out posilion).

Quadruped Posture Thi s a ll-four~ (hands and knees) posture furthe r decreases the BOS and rai ~es the COM w ith we ightbeari ng lhrough m ultiple joi ms. The quadruped pos ition a ll ows weight bearing through the hips and is parti cularly use fu l for promoting conlrol of the lower trunk and hips. For patiem s \\ ith ... pastici t),. Ihi s pos tu re can be used to provide inhibitory pre ... su re to the quadriceps and long fin ger fl exors (us ing an open hand position ) to d imini sh lone. A ...s umption of the quadruped positi on can be achieved from t\\O po~ition,. If the patien t is able to s it. the patient ma) be guided into side-sitting by ro talin g the trunk to all O\\ \\c lghtbearing on the hand ~ w ilh the e lbow~ ex tended . The Ihcf(lrah:d illlo the lju"d .. u~d plhHlon 111110\\ 1111110.11 au 1\ 1lie ... lJl\ol\ e .I ....~ .... tcli .. ~ .. ulllption ,tild a ........... Il'ti 01 till' pU"'llIllll It Iht· ..<.: act 1\ tlle\ Me dllll_ lull. .I ,llh:lilP) ba ll CU ll ti .... l 1>1: U'\t:O to \ IIPPlIrI the IMlIl' llt:-,. tlunk liunng the: 1I10\L'IlICIll tl.tJl\lIIOn jr~un ' ' It.I\:'!lIIIJIl~ iI) th~ 4uadrupc-d pv ... ,tlun and thc:n Jurin . 1l1 ..llnlenanll· ollh e [Xl .... lllilll rhe bJIl Can be p lill'cd \.'l'n~ m:lIll1l.:'nillil('

u:..

!rally under the trunk or moved toward the upper or depending on the area of Impaired strength. Additional ann support for the patient with stroke can be achieved with the use of an airsplint.

2. Stabi li z ing reversa ls (alternat ing isometrics) will facili. tate co-contrac tion of s ho ulder, hip, and trunk muSCUla_ ture. Manua l appli cation of approximation force can be used 10 fac ilitate co-contrac tio n of shoulder and/or hip s tabili zing mu scles.

3. We ig ht s hifting can be used in a forward , backWard, and s ide- to-s ide directi o n to increase weightbearing over two ext remities s imu ltaneous ly to improve dynamic stability. 4. Roc kin g through incremen ts o f range (forward , backward , s ide -to-s ide, and diagonally) will faciJitate balance and proprioceptive respon ses as well as increase ROM at the prox imal weight bearing j o ints. 5. S ta ti c-dy nam ic activities, s uc h as freeing one or more ex tre miti es fro m a we ig ht bearing pos ition , may be used in the quadruped pos ition . A progress ion is freq ue ntl y made from unwei ghtin g one UE to unweighting o ne LE to un we ighting oppos ite upper and LE.s s imultaneous ly. Thi s activity wi ll provide grearer joim a pprox im ation force s o n the su pporting extremities and increa se dy nami c ho lding o f postural muscl~

(Fig. 14 .2). 6. Unass is ted moveme nt illio and out of the quadruped po')t ure can be practiced. 7. Moveme nt w ithin the quadruped position (creeping) bas ... everal important implications for ambulation, This
Chapter 14 Locomotor Training

Sitting Sitting can be ll sed effec tively to promote slatic and dynami c postural control. reac ti ve and anti cipatory balance cont rol. \ crticalmi dline orient ation and postura l ali gnme nt. as well as \\ei(> htbeari ng through Ihe UEs. In add ition. im proved slabi li ,;' of the head and neck can be achieved in th is pos ilion. Two type:') of sitt ing are often incorporated inlO a mat program: • Shor1 siuillg. In th i~ positi on the pati ent's hips a nd knees are ne~cd wilh Lh~ fee l fl at on the tloor (sma ll BOS and inlCmlCdiale COM). • LOllfo: siftill r;:. In thi s position the hi ps are flexed and the kne~s are ~xlended on the supponing surface . The long ~itting posi ti on prov ides a large BOS.

eLi \ I(

-iL \OTl

~ , (/{' lor l1i(/( u wnlll' S COI/.\ idl' rarioll "I

\ clc( lil)1I (~1 (1 ,\ /ll/ng IJclsrun' is ,Iu' ROM requin'd to 1i\ .\/lI1lt · rh e ,.,u\lfJ(JlI Tht long ,i1flllg ,.,ositioll will he difJi, ult jiwo;, 'Ille p(Il/( ·III.\ o\l'il11( to IIIIIIfeJ RO.W 11/ flie loU' hu( ~ Lllld (I/" '1tJ /II.H ml ~s. Hul1lstrlllg (i ~ "IIl('S.' III 111(' long ." m ll~ {',I.\;r;ol1 1\ ,II rnuir;11 a/teral/om in peine !1m/fioll . u lll .H lI g l i lt· f,atu' fit 10 .\ ;1 had. 011 tIll' I .\tllia (rliel"l"l'c.I (0 {IS StU relf \1f{1II.!: j

The BOS In siHing may be altered by chang ing the positions of UE and LE >upport. UE support may be placed posterior to the peJvi~ (large BaS), lateral to the pe lvis (small BOS). or anterior 10 the pelvis (i IllCn11ed i"uc BOS). LE suppon ('an \ ::U} from bOlh feet down to legs crossed and one fOOl dm' n. Se\ er-Ji suggestions that can be incorporJled into a progTe~c;lOn of aC liv i lie ~ used in ~ i l llng follow. J. Initial aclt\'i tie'l include 3s~i~ted a~'1 u mp l ion (supinc-IO-sit tramlllon~j and a~si~ted mai ntenance of the position. Focu~ j" placed on holding (static po.,tural control) \,ith LeE \Veightbeanng. on the mat : lig.ht apprO\im3lion force ma~ be ~pphed al lhe !:> hou lJer 10 facili tate aCI!\ it} of :-.t3blllzmg ~ho ulder 11111!->cle .... The head, pel\ i!:>, anti trunk '1hou ld be In 3 venit-al midline po~Jlion. A miJTor may be u~d 10 Improve ~I\\arene~!:> of '1)mmelTi cal"iuing ro~tur'e. h)r patient"> \\ IIh ~pa ... ticlt}, !:>ltI mg .... lth e>;h:nded ann '1 Upport .... 'Ih Ihe hdfld opt' n and nat 011 the mal \\ iii prm Ide mh,blloJ) IIlput to the long lillger t1e\or~ 10 dampen tunc. I \\ 'elght "hi lling. Illay he pral.: tll.~d in all d lret rlon... tior· \i..trd. hal..l\\ard, '1 ,de-to·\Jdt>. 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<"t Thl..' tht·r..trt~1 m.t~ lIu lI J.lI) .h~ht h~ supPOr1 Ill!; thl' nlm tn g 11mb .... lIh ' 1(\ . 11 the I~el/ank le (long 'l Iltin g) {Ir d .... l,d thi gh (:.hl..)1"( 'tHing).

Sil-lo-Stand ~h)\\~ llh:n t t rdn~III\'lh from ~IHo-~toJ.nd ~h\)ulll cmpha~lLe . . \mllk·lnca! 1,I,t'lghtbc ..mng a~ \l,dl ~ n.)orumJlIOn ilnd tLlIHng 1..1 1 m~it or rl',rW:Ubl..' , Intliall,L th p..1hCm t-hl tl ~ ""tight

528

Physical Rehabilitation

forward by using momcntum and activel y tlexing the tnmk forward (ma ss flexion patl ern). The feet are place.d bac.k partiall y under th e supporting s urfact:: to engag.e the dorsltlc xors ill forwa rd rotation . I. Fo rward weight ~hift s can be promoted by ins tructing the pati c nt to foc us on a v i ~ ual ta rget at eye I,eve l directl y in front and u ~c of appropriate verba l cucs t rom the therapist ("rock yo ur shou lders forwa rd. continue rot'king, and come to standing" ). ., The paticlll'S UEs can be used effectively to fac i l ~ t ~lte the wei 2l1l tran ::. fer required of thi s movement transit Ion by w,in~g a forward reac hing movement or clasped togethe r in :l pra ye r position and swung fo rward (momentum ). With the therap i~1 positioned di rectly in fron l of the patient. acti ve-assisti ve transition s can be accompli s hed by pl aci ng the patient's UEs (shoulders fl exed, el bows e>. tended , and hand s c lasped together) on o ne of the therapi:;;t 's shoulde rs. Alternately, the patient' s UEs can be ex tended again st the therapist's side s (lower trunk). T he therapi st u; e s MCs on the pat ient's upper tru nk to pro· mote forward weight shift. Active·ass istive tran sitions can also be practiced with a low table placed in front of the patient. With hand s placed on the table, the patie nt practices panial stand-ups with the hands weightbearing on the table (s it-to-plantigrade ). A large therapy ball can al so be used to promote weight transfer. W ith the ba ll directly in front of the patient, hi s or her hands are placed on the ball being stabili zed by the therapi st. T he thera pi st coordinates forward movement of the ball with the forward we ight shift. 3. The he ig ht of the sitting s urface can al so be var ied. Thi s may be particularly important for pati en ts with hip and knee ex ten sor weakn ess that limit s vertical moveme nt in to the upright position. Th e required ex ten sor forc e can be dec reased by raising the se at height. A gradual prog ress ion is then made to lower se at height s. 4. Agoni::. t reversals ca n be incorporated to streng then hip and knee ex te nso rs bo th during the sTanding III' and siftillg d011'11 pha se~ of the move me nt. Modified wa ll squa ts ca n a l ~o be used to strengt he n th ese mu ~­ c le group .... 5. Once the patient i~ upri ght , lowe r trunk rotation can be promoted by ac tive late ral sh in" o r the pe lvis to o ne ~ide and then ~ itl ing down nex t to Ihe o li ginal start positi o n. The position or the feet is th en adju ~ t ed. 6 . Se lf-Initiated functional balance la~ k s ,> 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<* " bilil) in thi s (X1sili on. MCs arc at the pelvis. shouJderS.(J bot h shoulders and 1X'lvis. Light approximation fon:e ~ be app lied at Iht" hips to facilitate ~tabilizing activity oI~ musc les, UE weight~
Chapte r 14 Locomotor Training

the hip::. arc moved into increments of Ilexion with a retum to exte nsion. The excursion of movement is graduall y increased. This technique also im proves abilit y to move from hee l-silting to the knee ling or side-sitting to kneeling position. 4. Transfer of weight from onc knee 10 the ot her will promote stability on the supporting limb. 5. Balancing activities ma y be practiced. prog re ssing from support \\ ilh one UE to balancing wi th ou t UE suppOl1 . The patient':-- balance also may be challenged in thi s position by kn ee ling on di sc~ or foam roll e rs. Throwing and c.Hching a ball from vari ous directions also can be u"ed a:-. a component of these balance ac ti vities . 6. Una..,si:-- Icd as::. umpli on of the posture can be facilitated by u.. e of reve r ~e chop or lift trunk patt erns. 7. Hip hiling and forward progression. or " kneel wa lking," "hi le the UE!:o are supported on the therapist's shoulders call be incl uded in thi s positi on . A resisted progression can be u!:oed to facilitate forward movement. A progression j" then made 10 a resisted progression with the UEs un!:lupponed. In half-k neeling (Fig. 14.3) the COM is the same as in kneeling: howeve r. the BOS is wide ned. Greater demands are now placed on the posteri or weight bearing limb in preparation for weight acceptance during the stance phase of gait. Weight on the forwa rd limb is nm\' borne through the fool. Thi!) posit ion allows facilitation of hip exte nsion. la1eral pelvic con trol, and ank le move ments as well as increasing proprioceptive input th rough th e fool. The fol10\\ ing tec hniques and activi ties are appropriate for usc in the half-!..neeling po!:o ition.

ti ons of manual contacts may be used: shoulder and pel vis, shoulder and anterior knee. and pelvis and anterior knee. 3. Anterior- posterior diagonal weight shifting in thi s position will fi:l cilitatc ROM of the hip. knee. and is particularl y effecti ve in mobili zing foot and ankl e musculature (see Fig. 14. 3). 4. Resistance may be introduced with manual contacts at the pelvi s during we ight shiftin g (e.g .. slow reversal or slow reversal -hold ) 5. Practi ce in assuming the posture (mov ing from kneeling to half-kneeling) is an important prerequi site to accomplishing movement tran sitions from the floor to upright standing (e.g .. afte r a fall ).

Modified Plantigrade Modified plantigrade (Fig. 14.4) is an early we ightbearing posture that can be used in preparation for erect standing and walk in g. In thi s position there is a large BOS and high COM. This posture inherently promoles stability because weight bearing demands are placed on all four extremities and the forward position of the COM creates an ex ten sion moment , enhancing knee extension. Modified plantigrade is an important precursor to walking inasmuch as it superimposes close to full weig ht bearing 011 an advanced LE pattern. This pattern, required during gait, combines hip fl ex ion with knee extens ion and ankle dorsiflexion.

1. Initial activi ties will inc lude ass isted assu mpti on and aS~ls t ed

maintenance of th e posture. ~tabiILzalion or ahemating isometrics may be used in this po!:;ition to improve !:I tabi lity. Several combina-

2. Rhythnllc

Figure 14.3 H al l . ~nec l!ng . Anl erior 'l>.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>
111 cree l stand ing the BOS is s mall with a high COM requ iri ng max imu m ba lance contro l. Standing actiVit' ' can be in itiated in the pa rall e l bars (described in the nelt! secti on ). For many patie nts these activi ties can be ~ e ffec t ively ini tiated o utside but nex t to s tandard parallel bars. next (Q an ova l parall e l bar, appropri ate height treat. men t table or ot her s upporti ng surface such as a wall. CLINICAL NOTE: Sume p(lfients may demonstrate suffi. ciel/t stahility to lIIo/lIlain (J stalldinx postllre prior to bein _- - I d g ah/e IV as.HOII(' Ill' 1 {Jus/lion /11( epl'l1 emly. It sho uld be noted that achieving a specific level o(motor control with in an indiv idual posture of the preparatory exercise sequence does nar guaramee ,ralls/ation of gaim to .Handillg . Subcomponents (e. g .. hip stabi lity in quadruped) do not tran slate in lO stand ing fu nction without context. specific practice. Motor leaming re lies on sensory information and feedback provided by practice and experience to shape spec ific fu nctions. Compone nts of the lead· up activities must be incorporated in upright standing to ensure tram. fer of subcomponents into a functional who le. The amoum of practice req uired and the rate of learning vary amoog patients. The fo ll owi ng activ ities and techniques can be used in the standing positio n. I. Initial activities invo lve ass is ted assumption (see earlier sir-to-srand section ) and assisted maintenance of the position. Wi th the fee t pos itio ned paralJel and equal we igh t di stributed on both LEs, hold ing the posture is practiced. The ability to maintain the posture can be pr0moted by stabi lit y tec hniques such as stabilizing re'r'efsal s (a lterna ting isome rrics) with m anual contacts al tbf pelvis, scapula, or both scapula and pelvis. With the LEs in a sy mmetrical slance position. Theraband® tubing can be placed around the thighs (0 increase proprioceptive l~ad.ing and pelvic stabi lizati on by the hip abducton. 2. LUllIts of s tabil ity (LOS ) training involves determining how far the patient's COM can be displaced while bal· ance is mailllai ned. Witho ut a ltering the 8 0s. early ex pl omtion o f LOS can be accompli shed usmg guidedanteri or-posterior weig ht shifts fo rward and Nckward: and lateral weight shifting from side-to-s ide: Mes on lbe pelvis. Add itional support mily be provided by placeft]eftl tt,le patient 's h~Ulds on the, support surface or the thenPIS! s ~houldcrs (bilateral s upport progressing w ~ hand. Mlppon): as stabi li ty improvt:s , UE support stPtId be elIminated. A platfonll biofeedback device can be used 10 enhance limih of stability trajlling as well as ceoaeccd q:Ul(' e with weighl bome t:qua Uy on both LEs. 3. ~yn,nni~: stability activitie.') o f the trunk. can be practiClltf III stalJdmg w-.,ing weigh t ~hifting with the feet s)'~ ('a l o r in "trioe . Anterior-po.!>terior, lateral, and ~ movemen ts of thl.:' trunk can Ix e mphasized. A ~ b l(~ll:'edbad. d~vice can be used to enhance weighl .... lTaJlllllg (e .g .• the patient wilh ~trok.e is enc~. ~h llt wt'" i,'co lll to 'W..tIC-I Ihe more affected sick).

0:

Chapte r 14 Locomotor Training

53 1

Table 14.1 Focus of Contro l: Pre par a tory Ac tivities fo r Locom o to r T ra in in g

I

Bridging Hips/pelVIS Lower extremIties Quadruped

Trunk Proximal and intermediate upper extremities Proximal lower extremities

Sitting

Upper trunk Pelvis Proximal an d intermediate upper extremities

Kneeling/half·kneeling

Tru nk Pelvis Proximal and distal lower extremities (knee and ankle) Reciprocal control of lower extrem ities

Figure 14.5 Ste pPing (.. t~l i c· d) n ~ mi c :lcti \ it) wi ll promot e \\ elg hl
.t. Stepping will promote weig ht acceptance by :.tdvanc ing

the d) mU llIc limb fo rward and mov in g bod y we ig h I ove r the ad\"i.lIlced lim b. MCs at the pe lv is during stepp ing are particularl) effective in promoting. forward rolatio n and lataal,hift 01 the re lv i.., ( Fig. l·tS ). The patient step:-. for\', ard \,·Jl h ont leg. ,hi ft .., we ight an t~ ri o rl ). and retum s to the ..,tartingl:>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.
Chapter 14 Locomotor Training wheelchair wi th verba l cue ing fro m the therap ist (" rock 'our shou lders forward. cont inue roc kin g. push dow n o n ;he armrests. and come 10 stand ing" ). Th e palient sho uld nol be allowed 10 Sland by pulling up o n Ihe parall e l bars as this approach has lillie functi ona l carry-over. As the patien t nears an erect posture. the hands sho uld be re leased from the armrests one al a time and p laced on the paralle l baT'. The palienl 's COM shoul d be g uided over the BOS 10 promote a stable stand ing posture .

Training Activities During init ial parallel bar activitIes, the therapist usuall y stands inside the bars facin g the patient or outside the bars on the patient 's weaker side. In guarding the patient from ins ide Ihe bars. one hand should grasp the guarding be l! anteriorl y. and the opposi te hand should be in front of. but nol touching . the palienl 's shoulder. From outside the bars one hand sho uld grasp the bel! posteriorl y with the oppos ite hand in fronl o f. but not touching. the patient's shoulder. This method of guarding provides effective hand placement for an immediate response should the patient lose his or her balance. It also eliminates the patienl 's feeling of being "held back" or "pushed forward." which may occur with manual contacts at the shoulders. The following in itial activities in the parallel bars can be modi fied relative to the patient's we ightbearing status and the specific requ irements (e.g., use of a prosthesis or or1hos i ~). Guard ing techniques are maintained by the therapist during these ac tiviti es.

1. Sianding. ho lding. acclimation to upri ght positi on; feet in symmetrical stance pos ition, eq ual we ight on both LE,; hands supported o n para llel bars. 1. LOS trai ning (weig ht shift s: alteration in hand placement on parallel bars). a. Lateral weight shi ft from side-Io-side without altering the BOS; hand placement on the paral lel bars is not altered. b. Amerior-posle rior we ight shift ing forw ard and back",ard v~ ithou t altering the BaS ; hand placement on the parallel bar:o. i~ not altered . c. Antenor- postenor hand pl acement and wei ght shift : patient 1ll00 e" haJld~ fo rward on bars and shi fts weight anten orl y; alterna ted with po~ t e ri o r hand placement . and \\ eight i:-. ~ hifJed bac kward . d Single-hand :-..uppOJ1; patient balances with suppon fro m only one hand on the parallel balb; hand~ are alternated . A prog. re~:-'Jon of thi s acti vit y involves gradual change.') m po.'lltlnn of the Ire~J hand and UE. For e.\ampk , muvIl1g lht: freed hand ~veral ill(:he~ abO\e the bar and gwduall) prugn.:~~ to altemalc po.'l itiol1.'l ~ uch u.') .'!ohuuldcr ne~ i()ll . abdut:lIon. cros .. mg the Ill id line. and ')0 forth . A progres!>lon l' an be Indde to baidllC IIl l! with lx>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!l!)ted progTt!s~ion ) wllh MCs allhe pe l VIS and thigh. 4 B rald ll1~ . TllI~ activ it y IIlvolves a cros..,ed and t'l ide. blep progre::,~ , on w ith one li mb ad va nci ng alternate ly ame n -

o rl y and po ste rio rl y across the othe r while the seCOnd lim b s idesteps. It in corpo rate s lowe r trunk rotation as we ll as c ross in g the midline . Thi s is a challenging ac tiv it y and may require s uppo rt from the therapist s tanding in fro nt of the patie nt ( foreanns supinated, pa tie nt 's han ds li ghtl y t~uching th.e~a pi st"s hands) or by use o f a modi fi ed pl a nll g rade pos Iti o n WIth UEs lightly s upported o n trea tme nt table . A res is ted progression may be incorpo rated wi th M C s o n the lateral pe lvis for s idewa rd move me nt , the ante ri o r pel v is elu ring forWard lim b c ros:-. in g. and the po ste rior pe lv is during backward limb c ro ss ing .

S. S.ep-ups. To prac.ice Slepping up, a portable Slep can be pl aced direc tl y in fro nt of th e patie nt. The patient weight shifts late rall y toward the s upport limb and places the dynamic limb o n the step. The limb is then returned to the ori g in al slance pos ition . Verbal c ues and manual guidance is prov ided as needed . The he ight of the step can be vari ed to increase or decrease the diffic ulty of the activity, For example. a 4-in. (1 0 cm) Slep can be used initi.ally w ith a gradual progress ion to a s tandard 7-in. (I7.5-cm) step. A progress ion is made to a s tep-over-step pattern on stairs. Early acti vities w ill require s upport from a railing. An erec t trunk pos ture s hould be maintained and "' pull ing" o n the railing s hould be avoided. Additio na l indoor ove rground practice activi ties may be incl uded: • Wa lki ng w ith head turn s o n verbal command such as look rixht, look left. look lip . or look down Increas ing speed and rhy thm of gait by us ing pacing cues to vary speed s uc h as walk slo w and walk f ast Use of a metronome o r marc hing mus ic to increase speed and im p rove rh ythm Progress to lo nge r di stances w ith d ecreased number of rest interval s to im prove durmio n o f walking • Prac tice dua l-task wa lking (e.g .• walk and talk: walk and

ca.ch!.hrow a ball ) Practice walk ing o n varied indoor surfaces such wood !loori ng, and carpe ting

as tile.

Box l·t '2 presents s trateg ies fo r varying task demands d uring locomotor tra illlng. It provides practice activities for enh ..tnci ng spc(' ific (missing) components o f gait that can be incorporated intu the indoo r o ve rground progression.

Outdoor Overground Progression Al' ti v i lJe~ 011 o utJoor surfaces are amo ng the final compon~nt \ o f locomo tor lra ining. They must be specificaUy (!xam ined to de- Iennine the ir appropriate ness for an tDdiVidual palient.

I . C.urb!). A use ful lead· up ac tivity to c urb climbin, is",

v l~ed by a series of interlocking pon able step' irrIIJIIII In I nc reme nt~ of he- igh l. For add itional security tbl)'dI be p laced nex t to a treatme nt table. waH or other suppod

Chapter 14 Locomotor Training

535

Box 14.2 Strategies for Varying Task De mands During Locomotor Training l'prigh t Postural A1illmnent • Practice walking upri ght. • Long poles can be used [0 increase upri ght alignment and reduce forward head and trunk lean (common with use of an

assisli\'e dev ice such as a walker).

Foot Placementffoe Clearance • Practice heel· toe fl oor contact; tactile cues can be prov ided to dorsal fool by tapping over pret ibial muscles.

• Practice high step marching in place (high steppage). • Practice foot placeme nt during walking using fool markers

on floor or noor grid for promoting even sleps, or increasing step length or step width. • Practice walking with altered base of support (BOS): progressing from wide (8 to 12 in. apart) to narrow (2 in . apart) [0 tandem (heel-Io-toe).

• Practice walking on a 3-io. wide line taped to floor; halffoam roller. Sill~le

and Double Limb Support

• Practice controlled lateral and diagonal weight shifts . • Combine diagonal weight shifts with pelvic rotation move~ ments and stepping forward and bac.kward .

surface. A progression can be made from a 3- or 4-in . (7.62-cm or 1O.16-cm ) increment 10 a 7-ln. ( 17.78-c m) ('urb he ight. 2. Ramp:-. and slopes. Ramps and other slopping surfaces can be negotiated in seve ral way~. If the incline is very gradual. It rna) be suffi cient simpl y (0 instruct the palienl to u\t smaller steps. For sleeper incli nes the patient should be !n!,tructed to use smaller s.leps and 10 lraven.e the ramp ( u ~ a diagonal. 7igz.ag pattern) for both a~endlllg and dc!'cending. Prac ti ce ~ hould include mcllllc., of \aryi ng heig ht. Walkin g up an incli ned !-Iurlace I~ a~~oc lat ed with decrea!tCd ~peed, cadence. and :.tep length. 3. Terram \3n3t101l'. Outdoor walJ..ing pre!>ent ~ a varie ty of lerr.1In:. thai rcqulre adaptat ion of iocomOlOr "J.. llk Pral·tlu: , hou ld IIldude unC\t!n !'IurfJ.CC:~ 'S uch ~h side.... :.IIJ..,. gra!\,.,y "urla\..e~. parJ..lng IOh . •Old .,0 forth ~ TIn1ln!! n:4ulrement~. St;\~n:tl outdoor wtliling !)(; ltllt g~ Imp\'<,c prel' , ...e tllne IcslriCi ioll.l. (co inl:ldenl tinullg) Oil mO\emcnl \\'IIJ..lOg !>hould he prall Iced ...oIlhlll t he~ time lon!>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 tJ.:-OJ.. and envirulIment "'pcn tk, .... ulJ..lIlg "hould be PfJ.ctll·ed Ol JII ell\!fOlllllt!nh nonn.lll) u..cd b) tht Pdlll:lH

Fonvard ProllNssio l1 and Pusb·Off • Practice push-ups (toe ri ses) in stance; progress to toe-walking. • Practice heel-ri ses in stance; progress to hee l-walking. • Practice forceful push-off on command during walking. • Prdctice walk.ing agaiost resistance using resisted progres sion; walking against Theraband® positioned around pelvis.

Trunk Coun terrota tio n and Arm Swing • Practice walking with exaggerated arm swings. • Practice walking with long poles; therapist is behind and holds one end of poles; patient is in front and holds other end of poles.

Stepping • Practice stepping onto and otl varied surfaces (e,g .. foam pad , half foam roUer, Oyna Disc®).

Stoppinll and Startinll • Practice abru pt stops and starts on command. • Practice tums on command progressing from a quarter tum to half tum to full tum. • Practice forward, backward. sidewards. and crossed steps. • Practice step-ups and step-downs forward and sideways; vary step height , progressing from low (4-in.) to high {8-in .l.

Additional outdoor overground practice activities inc lude:

Exit and entrance through outside doors and thresholds • Outdoor stair climbing (e.g. , cement stairs ) Entering and exiti ng publi c or private transportation • Variations in visual conditions (e.g .• full to reduced lighting)

Locomotor Training Using Body Weight Support and a Motorized Treadmill Considcrab le recent attention has been focu1'lcd on the impact of paniaJly supponing body " eight during locomotor tr'.li ning. \,.11 Locomotor [ruming u5.ing BWS and a motorILl'd tf\!admill (T MI involves having the patient don a trunk harnc1'I!> with adjustable stmp!> thm ilttach 10 an O\e rhe.ad 1'IU$pcn~ l o n ~)" te l1l . The hame~s (Htu ", atl a(' hmem~ ~lIppon the de .... red amou nt 01 \\eight requi red for the mdividual patient. The \\ ht'e kd ba.\(' . . . ith locl.ing ca.\lers b positioned over a tre-adnl1l1 (Fig. l ~ 7). 1111.! lift fUllclion brings the pauent (0 upright ~ t anding ture . The ,y,rcm l:aJl .IIM) .tC"'\'IlUnOO.ltl' iUl1lt ~d lAeighlbe'U"lng requirement.!) on a llolngk LE kg .. p.lrtial \\eighthean ng). The I.on,,'('pt of body v.- ~ Ighl !iUpport l BWS ) locomOfor lrJ.ullllg In hUllldlb \\ .t~ fiN uHr<'I..IlK.ocd b) Finch arn.J Barbcdu,lt> -I he mlloodie for liS u~ h 1'IupporteJ b) o.ll1unaJ ,rudie, of 1..11, '" Ilh th,>rJtll.' !'oplIlal ('(\fd ieMQlh th.ll reg..umd tnnJ lilllh !>.tcppmg jhll1COb wh~n \Uppork' , ugg~ 'lt the ~pinal l'onl " Cd l~hk \)t rl'\.·lpn;ll,;JI k-.'oU\Olor (Xlucms prudUl'oo by

536

Ph)'sical Rehabilitation int ensive task-specific training (whole····k t of x the con te ' W0 , ) With bod y we ight supported, , the TM speed "'" practice, t"U" 'd rhytlunic input. Manuall .VI es a . . y g Uided movements ' -~ used 10 enhance the r~ yth~'l1ClIY o f the .g~1t pa.ttem. This continues until the patient IS abl e to participate m generating the rec iprocal stepping patterns befo re a progression is introd uccd ,'4 Thus. training can occur well before develop. menl of the prerequi site skill s required of more traditional

Figure 14.7 Locomotor train ing using partial bod) we ight .,upport and J motonzcd treadmill provide~ a safe palient envj. ronmenl. promote., an uprigh l posture. and allow, the Iherapi'l 10 rnanual1~ gUlJe 11mb mO\ C' ment~. (Coune,), of Mohilil)' Re.,earch, Tempe. AZ R528 1.) centr.11 pattem generato r~ tCPG~) at the !)pinal corJ level in the ab::.ence of ~upra!>pinal inpul. l~ CPGs are also in fluenced by !>I!lhOI') tnpUI allo" ing. motor output modification txc,ed on em ironmentai demand.." HI A k.e~ eleme nt of locomotor trainmg u!>ing BWS and .1 TM I .... f:lulltJIIOn of automatic \~;:tI )..jng mo\" e mell t ~ within

ga it tminin g strateg ies . . . Conventi onal gait tramln g approaches are often delaYed by Ihe tim e requ ired to practi ce.co~pone nt .elements such as balance. we ight.shiftin g. coordin atIOn. or sit-la-stand transiti ons (parts· to-w hole practi ce), Early use of parallel bars and ass iSli ve devi ces can promote compensatory patterns (e.g., forward di spl ace ment o f uppe r body, compensatory asym. metry. dependence o n UE support to substitute for impaired LE functi on ) that are undesirable and difficult to change as interventi on progresses.' In addi tion. these activities can pl ace such ove rwhelming dem ands o n the patient and thera· pis! to ensure adequ ate static/dynam ic balance control that only limited locomotor train ing can actual1y occur (prevent· ing optimum use o f treatment time for sk.illed intervention by the therapist)' Sufficient ev idence has acc umulated to suggest llw locomotor train ing using BWS and a TM may become a mai nstay interve nti o n fo r some patient groups . 1lle efficacy ha.-',. large ly bee n exam ined with patients having neuro log ical invo lvement . most no tabl y patients with stroke and s pin al cord inju ry (SCI ), Many o f these srudies com· pare more co nve ntional gai t tra inin g approaches to locomotor train ing strategic,; us ing BWS and a TM; improvemen t\) ure t) pica ll y no ted in the later group. although dtis b nOI exc lu. . ivc l} the case (EV ide nce S ummary Box 14.3). For pmienh \1, ith slroke . increa~d stance time has been l1ocumelllc(f' ~I \) \\cll a . . imprO\emelH~ in gail synunetrY l~ , te n ('ontllU4~J (ilt pagt}lOl

Figure 14.8 BuJ) "~I"''''''

r"m .., .,lem httlllS: J ~ '" upn~llt In pll:p.lf'olUon for

toto-

tlm",)r Iralnlng (('oun~y 01 '1~li:llll1) )(\!.,e.ll'Ch. fempe. AZ ~,~S I )

Chapter 14 Locomotor Training

5.17

Evidence Summary Box 14.3 Locomotor Training Subjects/ Design

Reference

Purpose

Results

Brown, TH, el ai' 2005

To delermine whether locomotor Iraining using body weighl support and a motorized treadmill (BWSTT) is more effective Ihan conventional overground gait training (COOT) in Ihe chronic traumatic brain injury (TBI) population.

Randomized controllrial. Twenty participanls (14 men, 6 women) in posl-acule phase of rehabililalion for TBI, randomly placed in 2 groups (BWSTT or COGT). Pre-Iesling/posl-testing con· sisted 01 the TUG lesl, Ihe FAC, Ihe FR, and colleclion of gail paramelers. All subjecls walked a lotal of 15 minutes during a 3O-minute session, resting when needed and received 30 minutes of therapeutic exercise. COGT group: walking on level surfaces with assislance/device deemed appropriate. BWSTT: Ireadmill walking wilh 30% unweighting, decreasing by 10% when subjects were able to achieve 10 consecutive heel slrikes. Speed was increased as tolerated.

Bolh groups significanlly narrowed slep widlh. BWSTT group showed an increase in slep lenglh asymmelry, while COGT group showed a decrease. No significant improvemenl in FR, FAC, or TUG lesl for either group, nor was there a difference between groups. While lIlese results were not statistically significant, the results showed a Irend toward improvement.

Field-Fole, EC' 2001

To examine the effect of an intervention combining body weighl support (BWS), funclional electrical stimulation (FE S), and treadmill training, on overground wal~ng speed (OOWS), treadmill walking speed (lWS), dISlance. and lower extremity motor scores (LEMS) In patients with chronic Incomplete SCI.

Pre-lesVposHesl comparison. 19 subjecls (13 men, 6 women, mean age 31.7). All subjecls had ASIA class C injuries. Test measures included: OOWS wilhout BWS or FES (2-minule timed walk on an 80-ft oblong track) with needed devices at lIleir chosen oomfortable pace, Ireadmill walking willl BWS (up to 30',;,) and FES lor optimal gait, and strength examination In the LE uSing the LEMS Inlervention Included: 36-sesslon program of BWS and FESassisted (common peroneal nerve In the weaker 11mb) treadmill walking Sub,ects were allotted a t 5-hour block of time and choose their walk/rest penods Time and distance were recorded No attempts were made to decrease BWS or FES

6 subjecls needed manual assistance to advance weaker leg inilially, only 2 subjecls posl-inlervention. Mean OGWS and lWS increased significanlly. All but 2 subjects significanlly increased their treadmill distance per session. LEMS scores signiflCantty increased over the Course of traming. A moderate corre la~ bon was found between pretraining OOWS and LEMS scores. Four partICipants were available for follow-up al 2 monlhs to 1 year. 3 subjects demonstrated lIlat OOWS was as good as or better than lIlell final evaluaIron The olher IndiVidual had undergone surgery, and had a prolonged perIOd Without ambulalron,

Conclusions/ COinments Since these subjects sustained their injuries between 7 and 23 years prior, improvemenl could be attributed 10 Ihe Irealment provided during Ihe sludy. Significant decrease in step width can be seen as an improvement in balance. These results do not support the hypolllesis Ihal BWSTT would lead to greater improvements in gait than COGT. Two limiting faclors: nol a long enough time frame, trunk control was not practiced while trying 10 maintain maximal comfortable speed.

All subjects had a SCI of at leasl 1 years duration, lIlus improvements can be anributed 10 the training in lIle sludy. There is little evidence in this study's results 10 suggest that a change in OOWS correlates with a change in lWS. That LEMS scores correlate With improved funclion IS debatable. None of Ihe subjects approached normal values for OOWS. The lack of a coolroVcomparison group in thIS study allows for the possibility thai other interventions may have given the same results. Overa~ this study suggests that BWSlFES treadm~1 lralnlng may have a posmve effect on functronal measures In pallents with chrortlc Incomplete SCI,

(coollllUBd )

538

Physica l Rehabilitation

Evidence Summary Box 14.3 Locomotor Training

1=0"0""",)

· I I S u b le e s

( 'onclusion ...

'. D c Slgn

R e sults

('omments

To determine: (1) the muscular activity and cardiovascular response of a normal population during locomotor training using body weight support and a motorlzed treadmill (BWSn ); (2) if tower extremity (LE) mus· cular activity changes with BWS; and (3) ~ muscle activation can be preserved while decreasing loads on healing tissues, conserving energy, and reducing pain.

10 healthy recreational ath· letes, mean age 28.9 years. Electrodes were placed over the following muscle groups on the dominant side: vastus lateralis, vastus medialis obliquus, rectus femoris, biceps femoris, semimembrinosus and semitendinosus, and the medial gastrocnemus. Subjects walked on a treadmill at t.34 mls. 0, consumption and HR were recorded during the last minute of as-minute exercise period. BWS was changed from 0% (FWB) to 20%to 40%.

Average EMG activity did not change sign~icantly for any muscle groups when FWB was compared to 20% BWS ambulalion. Average EMG activity decreased sl9nilicantly in 40% BWS when compared to FWB in the quadriceps, but not in the hamstrings and gastrocnemius. 0 2consumption decreased sign~icantly from FWB to 20% BWS and from FWB to 40% ambulation. HR did not change significantly for any conditions.

Findings suggest It1at _ cle activation can be P
To determine: (t) the feasibility and patient tolerance for using a BWS system for overground ambulation; and (2) to meas· ure the function of patients with chronic stroke prior to and following BWSn and BWS overground training.

Pretesl posttest comparison. Two participants: one 87-year-old woman 10 years pest'stroke (Participant A), one 93-year-old woman 14 years post-stroke (Participant B). Prior to and after training, participants were given the following tests: Berg Balance Scale, 10·m limed walk test, and the gait section of the Tinetti Test of Batance and Mobility. Templates of footprints were taken, step length was measured, and gait observalion was noled. BWS training occurred 2-3 limes per week over a 6 10 7-week pened. Each session included 4 bouts 01 ambu!atlCn (first 3 on treadmill, the last being overground) sepa. rated by a 5-minute rest interval. Each bout was limited by pallentlolerance. BWS started at 40% ane progressed to 20% and 000; treadmill speed progressed from 0.5 mph to 0 75 mph to 1.0 mph. Speed of over· ground training was determined by patient comfort

Participant A - Showed improvements in Berg Balance Scale scores (26156-40/56), Tinelli Gait and Balance Assessment, and 10·m walk speed (0.35 mls-O.65 mls). Her right and left step lengths improved by 35% and 4t %. Gait symmetry improved as indicated by observation, however bilateral trunk sway during single-leg stance remained, Self-reports and family reperts of her gail illustrated positive changes.

While participant B sIIOIId less improvement than participant A, both showed ptIIitive signs alter rec:eMng BWS treatment. P8IticipM B had occasional days 01 agitation and confu8ian III may have conl!illut8d III "-

Refer-e nce

Pur-pose

Colby, SM, et ai' 1999

Miller, EW, et a~ 2002

Participant B-Minimaf improvements in gall and balance were evident. The greatest improvement was a 22°0 Increase m her 10-m walk time, Her step length for each LE improved by 35°0 and 25%

limiledi~

Participant A displajld_ motivation to ~ ... did Participant B. Participllll B had bilaterat foot dafamities that may have COlItributed as well. For boll subjects, BWS amI>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 resp
\tl(.hdl "

Resulb Single-leg stance lime of affected limb increased with increased BWS and was longer tor TM wal~ng than ground walking. Subjects walked more symmetrically on TM than on the noor. GRF decreased more prominantly on the affected limb with increased BWS. Mean activity levels of the gastrocnemius and vastus lateralis were less dunng TM walking. There was decreased clonus

activity in the gastrocnemius betore and after initial oontact and decreased co-contraction wffh antagonistic muscles at the lower leg with treadmill walktng. Mean velocity and cadence were sign~icantly increased for ground walking, however stride length did not

Conclusions/ Comments Training of stance on the affected limb is considered highly relevant for restoring gait. Increasing stance time may promote balance. weightbeanng, and strength in paretic limbs. Decreases in co-contraction may lead to more efficient movement pattems. BWS training should not be used in excess or for a prolonged penod of time due to the significant decrease in the actio vation of weightbearing muscles (gastrocnemius and V8StuS taferalis).

change. Walking speed, endurance, and energy expenditure unproved signrf~ntly for all subjects after 12 weeks 01 training. All subjects improved or maintained their ambulatJOn status and use of asslstJve device; however these changes were not statistically slgn~~nt Muscle strength tended to increase, but these changes also were not sign,fi· cant. Subjects 2 and 3 displayed a distribuuon of motor oontrolln the lE that shifted toward values seen In healthy subjects

l..,.-vUt.o

~I ~mtrh,.ul \pUhlJ IUJ\lr} A,'~"'-I.lhH" I A,< IWldl,,.J,.&! .... lIhu.l .. I\,,.,,l ,04Ic.I:\"" • R IUJlo,.lw.u! 'CA:.I, I Ii lulJ~,J .... , ... ht (IH I rh~.u .. lr\· .... hllilun.: ttN !.• ...nr.l({" \( I ·'ll1naJ~, ...JllIJUI) I M II .aJ:li111 II (. I IInnll I I .mJ (,II

Subjects walked faster, tarther, and WIth more efficiency after training. The measures for assistive device usage, ortllotic device usage, and muscle strength test were nol sensitive enough to detect small changes. Small group sIZe limits conclusiveness of study.

540

Ph) si(.'al Rehabilitation

spced .J~·2(f.lJ e ndurance. 'J and di stance 20J1 para mcte rs. S imilar C li nd'mgs 'me1ud"mg lin p rove me n t s 11' 1 speCdII.IR.IQ.21 • and e ndurancel!.!9 have bee n doc um ent ed fo r p
18 and 23. Evidence sugges b that ~e n sory input s uch as a pprop riatelv ti med manuall y a~~ i !<. t e d limb moveme nt s can promo;e function-i nduced recovery. l~.!1! Wi th in a task -spec ific and I;.afe patie nt cnviron me nl. locomoto r trai ni ng lI si n£! BWS and a T M 3IJ O\\ 5 th e the rapi ~ t access 10 h ip s. pch is. and LE5 to nlanuall) ass ist. g uide. o r adju st locomotor rhythm. li m b p laceme nl. we ig ht shift~, and sym metry. Mov~l1lenb are coordinated to s im ulate no rm al g ait : upright po sture and balance is ma inta ined. and s peed o f watk1l12 is controlled . Kosak and Redi nglOemph as ize the role of se nsory input du ring locomotor train ing us ing 8WS and a TM by stal in g. "S tride and cad cnce vary w ith tread mill ~ peed. ind icating local se nsory feedb ack to a lumbosacral gai l patte rn- ge ne rator. Th e int ens it y and tim 109 o f sCIll;.ory feedback from press ure receptors in t.he sale of th e foot and joi nt proprioce ptors fro m the ankl e. knee. and hip are thought to prov ide faci li tory and inhibitory e ffect~ on flexor-ex te nsor motor neuro n pools In the s pinal cord at appropriate time d uri ng the gait cycle tp 14 1," Description s by Shephe rd and Carr9 and Seif-Naraghi and Hennan l 4 provide an apt s ummary of the advantages of locomotor training us ing BWS and a T M as fu ll owl;.: tnter- and intralimb timing can be practiced before li m bs are capable of full) .. upponlllg bod) \\eighl.q Gall IraLlllllg can lk ini tiated earlier within an ep i ~ode of care _! ';' Specific clt-melll ... of the gajt I.:)cle II!.g .. mid ~ tance 11 mb loadmg. '\\ lIl g pha~e un \\e ightlOg and ... te pping) can be trained \\ uhin a dynamiC la~k-~peclfic ... tnut.'g).IJ Li mb loadlngl.:an be ':tn ed ba,ed on abliit )' to ~ lI ppon \\elght Gall de\ latlon~ ma) ~ uddre ...... ed ea rl) u ... lng g rt'al er BWS dnd 10\\ I'M \e ICX llie'l. I..t O ..... mg lO l oru: d , tl; pping ll)On: menh. " h~i.mJ(~ d lliln u... c'" nla~ be preH' l1I ed b) f<xu'IlIlg ..tllcll110n on hOlh Ill\tlhcd .U1d unltwoh t!d lunb ... y • Orpunullll), 10 rri.K tiu~ \\al~ lIlg " pn. )\ llll"d \\ llh\HII undue kilr 01 lalllllg .... D)niil1lll balallu" tr.lIllln!! tan LX' cnh,uH;I.'c1 b) d l!l: fea~­ Ing U\VS iind Inu~a ... iJlg rtvl ... p~~d I" Cl>lllpcn.,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 <1L1I\dUOn I "

Co n.I;. tan t s peed of the T M provides rh ythm ic input that re info rces a coord inated reci procal ga it pattern .14 I Hip ex te ns ion is fa c ilita ted . "

As rec iprocal patterns em erge and improve, training is prog ressed . T h is is accomp lished by increas ing TM speed. and dec reas ing the amo/lnt 0/ BWS. and manual guidance. For examp le . trainin g may be in itiated at very low speeds (e.g .. 0.25 m ph ) w ith minimal o r no we ightbearing and constan t man ual g u id ance. and progressed umil Walking speed s of app roxi m ate ly l.0 mph are achieved with 100% . 14 we ight bearing and no manu a 1 1I1pUt. Inte nsi ty o f treatme nt is required to attain a training effect. Recomm end ati o ns are be tween 30 and 60 minutes (d iv ided into two o r three bout s wi th inte rvening rest interva ls). five time s pe r wee k. However. w ith severe involve_ me nt. train ing sess io ns m ay be as s hort as 3 minutes with 5-minute rest interva l ~.J4

Overground Locomotor Training Using Body Weight Support The tas k-orie lllcd approach to locomo tor training using BWS is continued by prog ress ing to o ve rgro und walking. Unl oc k ing the caste rs and mov ing the BW S system away from the treadmill c reates a mo bile. safe. and eiflClem environme nt fo r cont in uin g the c onrro lled reduction In body weig h t s up po rt to ove rgrou nd surfaces.

Chapter 14 Locomotor Training

Figure 14.10 Body v.eight suppon overground locomotor tralnlll,!! u\ing a v.al~er. (Counes) or Mobilit y Research. Tempe. AZ 85~81 )

Durin g initial ove rgro und training. verbal c ueing and manual guidance is co ntinued a~ needed. Gait speed s wi ll t}picall~ be :-lowcr on ove rground surfaces wi th e lim inati on of the rhythmic steady-s ta te in p ut provided by the TM . Ambulatory a~:-.istive device s s uch as a ca ne (Fig . 14 .9, or a walker (Fig. 14.10) ca n be inco rpo Ttive deVice or h;'lI1d~-free reciproca l arm move me nt s

IFlgI4.11). Some BWS device~ are de~jgned :-.pecifically for overground u\e (Fig. 14. 12). The~e unit s are re lati ve ly li ght ..... elght em Ib\ ). have :-.wivcl ing wheeb to a ll ow turning in 'imaU area\. (.:an lit o\cr a w heelchair or to il e!. provide adJu:-.table \ uppon and arc available in wide and heavy du ty tle ~ig n f" Thc.') :-.uppon body weigh t during standing and Walking :1\ ""ell a~ ~IHo-Mand Irans ItJOn~. As the~e devicc~ ha\c. a rea\onably ~maJllurning radiu~ of 20 in. (50.K cm), they art .l,ul(J.ble for the home ~elljng for patient s requinng long·term U\e . DI'~adva nlage:-. of the~e unil ~ are that the amount 01 body ""eight ~u pported cannot be prc(;i:-.cl y dClcrnlined and the JI::'lgn of the :, idchiln, prcvc llt \ llll~Up­ poned rct'lprocal arm ~ wlllg.

541

Figure 14.11 Body weight support overground locomotor I(".lining withoul an assistive device . Hand placements allow the patient to move and stee r the unit during forward progress ion. (Courtesy o f Mobility Research. Tempe. AZ 8528 1.)

Assistive Devices There are three major categories of ambulatory ass isti ve devices: canes, cm{ches. and walkers. Each has several mod ifica ti ons to the basic design, many of which were deve loped to meet the needs of a spec ific patient problem o r diagnostic group . A ss istive devices are prescribed fo r a variety of reasons. including problems o f balance. pai n. fatigue. weakness. joint instabilit y. excessive s ke l e l ~li loading . and cosmesis. Another primary function of assislive devices is to e liminale weightbearing fu lly o r partially from a LE. This unloading occurs by tr-dmmi ssion of force from the UEs to the fl oor by downward pressure o n the assi slive dev ice.

Canes Mos t ca ne'i used in c urrent c lin ical practice are cons truc ted of li ghtweig ht a lum inum. The function of a cane is 10 widell lite BOS and improv{' halallce." Canes are no t in tended fo r lise with restric ted wcightbearing ga its (:-.u..: h a!) non - o r partial-weighlbearingl. Pat ients are typka ll y in s tnKted to hold a ca ne in the hand opposite thr off(!( 'led ertremity. Thi s posi tioning of the cane most c lo!>cly appro ,x illiates a nOffili.1l reciproca l ga it pattern

542

Physical Rehabilitation

A

B

Figure 14.13 Shown here are (A) standard wooden cane, (8) SIandard adjustable a luminum cane. and (C) adjustable offset cane. Figu re 14.12 Body weight support system designed specifically fOf overground usc . The patient depicted is practic ing sit!O-~ I:tnd tfan ~ ition s and standing using a mirror for postural alignment feedback.

ith the opposite a rm a nd leg moving togeth er. II also \\ idem. the BOS wilh less latera l shiftin g of the COM than \\ he n the ca ne is he ld o n th e ipsil ate ral s ide. Contralateral positioning. of the cane is particularly impol1ant in reducing fo rces created by the abductof muscle\ ac ting at th e hip .~4 During nonnal gai t. the hip abduclor~ of the stance extremity contrac t to co unteract the gravitational momeJ1l at the pe lv io;; on the contral ateral side during: sw ing. Thi .. pr\!vents tiltin g of the pelv i.l. on the contralateral I", ide but fC~UIt~ in a co mpfes.~ i ve fo rce actin g at the ~ tan ce hlp. Use of a cane in the UE oppmite Ihe atJected hip will reduce the se fOfce:-.. The floor (ground) reaction force creJlcd by the downward pre~~ure of bod v "eight un the c,:me coun terhalances Ihe gravl1~l1ion~1 movement at Ihe utlec led hip. l~ Thu:-., the need for tension In thl' abductor rnu:-.cl e ... i ... reduced . with a ... ub,equt.'"111 dCI:re""e in joil1l (,. ompre~ ... ive to rl't':-o. Seh'ral COIll IX)Jlc:n1", 01 Ooor reau i()11 fMel'S that create Jom! cOlllpres~ion at the hl p can be redun:d h} u~c lit a n llle Ely ,uld Smidt ",) f(lund Ihat cOTllralJtenti u'>e of a ~a ne delfea ...ed Ihe vcl1ll"at and pu':.tcrior componenl'> 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 11<1 ... a hall' c lrelt:' (""c rook ") handle. 1'be di ... ,al rubber lip is at l~a':ool I In. in diameter or large'1.

-\,/wlI~rage), . Thi ... can~ IS, lIlexpellSl\ e and fits easily 00 ... Iall·... llr other slJr fal"c~ \\ here space is lirnilc!d. OIJmh Wlf(l~,,\". Th~ ,>Ianllard cane I~ not adjust»bleaod 1Il1l'>t . tw elil 10 fil tht.' patient Its point of s upport is anle n nr EO the: hunt!. not dire\.·tly hcneuth it.

Chapte r 14 Locomotor Training

Standard Adjustable Aluminum Cane TIlis assislivc device (Fi p.. 14.138) has the same ba-;il" design ;t\ the regular or standard cane. It is made of aluminum IUbin!! and has a half-circle h;mdle with il molded plastic coverin~. The telescoping design of this cane enables the height 10 hc~ adjusted using a push-hutton mechani sm. Variations in available height range differ slightl y with manufacturers. However. they are generally adjuSl;Jble within the mnge of approximately 27 to 38.5 in. (6R to 98 e lll). 111c di~lal IlJbber tip i:- allc'l.~t I in. in diameter or larger. (NOfe: Most adjust
cane is quickly adjustable. facilitating of detemlining appropriate heighL Ii is light weight and fit.':. easi ly on stairs. Dlsad,'allf'J.ces. The point of support is anterior to the hand. not direc tl ) beneath it. n,i s calle i:-. more cosily than a standard cane. eJ~e

Adjustable Aluminum OfTset Cane ThE' proximal com ponent of the body (shaft) of thi s cane is offset anleriorl y creatin g a sTraighT (or offset) handle. It is made of alumin um tubing with a plastic or rubber molded grip-shaped handle (Fig. 14. 13C). The telescoping design allow ') the height to be adj usted from approximately 27 to 38.5 In . (6S to 98 em ) by a push-button mechanism. The diameter of the distal rubber tip is at least 1 in.

The design of thi s calle allow s pressure to be borne over the cente r of the cane for greater stability. This calle also is quickly adjusted. lightweight. and fits eas il y on stairs. DisadI'{JlITages. This cane is more costly than standard or adju stabl e aluminum canes.

AdmllfclRes.

Quad (Quadruped or Four-Prong Cane) Thi s assistive device is co nstructed of aluminum and aluminum tubing and is avai lable in a variety of designs depending on the manufacturer. Both large-based quad canes (LBQC) and small -ba sed quad canes (SBQC) are commerciall y avai lable (Figs. 14.14 and 14. 15). The characterist ic feature of these canes is that they provide a broad base with four points of floor contact. Each point (leg) is covered with a rubber tip. The legs closest to the patient's body are gene rall y shorter and may be ang led to allow fOOl clearance. On many designs the proximaJ portion of the cane is offset anteriorly. The handpiece is usually one of a vari ety of co nt ou red plastic grips. A tele~ scop ing de sign allows for height adju stments. Quad canes are gene rally adjustable from approximately 28 10 38 in. (7 1 (091 em). This ca ne provides a broad-based support. Bases are avai labl e in several dilrerent s izes. This cane is also easiJy adjustable.

AdvalUag£>s.

Fig u re 14.15 A \ .!.nett

FIgure 14.14 ~hO"VIll llLr(' !in: a \jJoely 01 'Juadrur.il.:d t.:J.nc.,

J.... rge

ha . . !;'
543

~ll

,ruull-bascJ ljuJdruped l·ancs.

544

Physical Rehabilitation

Disadwllllages. De pending on th e specifi c de sign of the cane. th e press ure exe rted by the pati ent' s hand may not be cente red over the canc and may re sult in patient complaint s of in sl3bilit y. As a result of the broad BOS. some quad can es ma y not be practical for use on stairs. Another di sadvantage of broad -based canes is thaI thev warrant use of a slower gait pattern. If a faster f~r\Vard progress ion is used. the can e ofte n "rocks" from rear legs to front legs. whi ch decreases elfec tivcness of the cane. Patients should be in structed to place all four legs of the cane on the floor simultaneously to obtain maximulll stabilit y.

Walk Cane Th e walk cane also is constructed of aluminum and alu minum IUbing (Fi g. 14 . 16). It provides a vcry broad base wi th fo ur POl11lS of flour contac t. Each point (l eg) is cov ered with a rubber tip . The legs fan her from the patient's bod~ are angled to ma i11la in tl oor contact and to improve slab ility. The hand grip ;s molded plastic around th e upper1ll0'it seg men t of alumi num tubing . Walk Canes fold flat and are adj ustabl e in he ight from approx imately 29 10 37 in. (73 10 9-+ e m). Adl·antageJ . Walk canes provide very broad -based . . upport and are more stable than a quad cane . These cane . . 31"0 fold fl at for trave l or storage. Disadl'(lIIlagcs. As \\l ith the quad canes. the spec ifi c de..,ign of a wal k cane or handgrip placement may not

Figure 14.16 \\.111..

1.:..11\..:

allow pressure to be centered ove r the cane. Walk canes cannot be used on most sta irs. They require Use of a slow forward progress ion and a re generall y more costly than quad canes.

Rolling Cane Conslruc ted of aluminum and alumi num tubing (Fig. 14. 17). (hi s cane provides a w i?e whe~ l ed base allowing unint errupted forward progress IOn. It Includes COntOUred handhold s. easy height adju stm ent from 28 to 37 in. (7 1 to 94 em), and a press ure-sensitive brake built into the handle engaged using pressure from th e base of the band. Ad nlllrages. Th e whee led base allow s weight to be conlinu ous ly appli ed as the need (0 lift and place the cane forward is eliminated . Thi s also provides for a faster forward progress ion . The second and third handles placed be tween the upright s can ass ist in ri sing to standing (brake engaged). Disadwllllages. Thi s cane is more costly than standard quadruped canes. and requires sufficient UE and grip stre ngth to en gage the braking mechanism. This cane is not suitabl e for patients di splaying a propulsive gait patte rn (e.g: .. Parkinson 's disease ).

Hand Grips A ge neral cons ide rati on relevant to aU canes is the nature of th e ha nd grip . The re are a variety of styles and sizes

C hapte r 14 Locomotor Training available . Th e type o f handg rip sho uld be judged <.Ind selected pri maril y o n the basis o f patie nt comfo rt and 011 the g. r ip · ~ ability 10 prov ide adequ ate surface arc<.l 10 all ow effective tran sfe r of weig ht from the UE to the tloor. The more common types of handg rips are ( I ) the cmo/.. handl e. (:!) the STraighT (or uffset) hand le, (3) the sIlOl'('/ handle . and (-1- ) the pistol hand le. whi ch COnf0 ll11 S to the pati e l1l 's hand. It i'\ u~efu l 10 have severa l hand g rip styles available for e'\ 3minatio n and trial with indi vidu a l pati enl s.

545

(4) Cycle is repeated .

t

o

(3) The uninvolved extremity is advanced.

Measuring Canes

o

In meJ~ lIn n g. cane he ig h!. the cane (or center of a bro ad ba sed cane) i~ placed approx imate ly 6 in. from the Inl eral border of the toe~ . Two land marks ty pi call y are used durin!! mea~ urcmcl1l : the grearer Troc/wllla and the (Ingle 01 Til;' clhol\' The top of the cane sho uld come to approx im al el ~ the leve l o f the g reater trochante r. and the e lbo w , hould be Oexed to about 20 to 30¢. Beca use o f individual \'ariatio n::- In bod) proponi o n and limb leng th s. the degree of fl e'\ lon at the ~ l bO\\ is generall y considered the more important Ind icator o f co rrect calle he ig ht . Th i" e lbo\\ tle xi o n ~e rve s 1V,:o im portant function s. It allows th e aml to shorten o r to lengthen durin g differe nt pha~e ~ of gait. and it provides a shoc k· absorpt ion mec ha· n i~ m . Fi n all ~. a~ \.., ilh all a!->sisti ve dev ice s. the he ig ht of the cane shou ld be co n~ i de red with reg ard 10 patie nt comfon and the ca ne ' ~ effec t iveness in accom plishing it s intended p u rpo ~e .

t ot

(2) The cane and involved extremity are moved forward

simultaneously.

'CJ

(1)

o

..

Starting position. In this example , the left lower extremity is the involved limb.

Figure 14. 18 Gait pall em for usc of cane.

Gait Pattern for Use of Canes A'\ d i~c u .. .,ed. the cane should be he ld in the UE opposite the affected limb. Fo r ambul atio n on leve l surfaces . th e cane and the in\ olved e" tremi t)' are ad vanced simultane · ousl)' fFlg J ..t 18). T he cane ~ hou l d rema in re lati ve ly cl ose to the bod y
5. I ~ there a d,ft c lclKe III gnp .'\ Ire ng lh l-,e m l'c n ha nd
Conside ration of the se questions will generally provide surfIc ie nt info rmation 10 detennine the most effective cane placement and use when bilate ral invol vement exists. Crutches C rutc hes are uscd most frequentl y to improve balance and to e ither re li eve we ightbearing full y o r pa rtially on aLE. They are typi call y used bilate rall y, and fun ction to increase the BOS. to improve late ral stabilit y, and 10 aHow the UEs to transfe r body we ight to lhe Ooor. Thi s transfer of weight th rough the UEs pCIl11its fun ctional ambulation while maintaining a restric tcd we ightbearing status. There are two ba ~ ic de sig ns o f c rutc hes in freque nt clinical u ~e : axil .. lary and 101'('(11'111 c rutches.

Axillary Crutches as ~ i , t i\'c

dev ice:-. a.\ 'Io arc rderred 10 <1:-. reguJar or stan(Fi g. 14. 19A ). They are made of lightweight wood 0 1 alumi num. Tht:ir desig n includes :m axillary bar, a hand piecl·. and double lI prig hl ~ lomcd di 'l lall y by a sing le leg covt!red with a rubber ~ tu.; ti o nl i p (which -;hould have a diameter 01 1.5 1O 1 Ill .). TIle 'i ing lr leg allows for hdght \'arialiolh. He ight adju"'IJlll: ll h for \\ooden crult'hes are 8CCOIllplt ~ ll("d b) allenng Iht! pl.Kt!mclll of SCI~ W!'o and wing bolts in pred rillt d ho l(: .... The llt:s ign of lIlust aluminum crutches

T he'>l: 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 crut<:he .. i ~ adju.. ted h~ pla.::ement of '-Crew .. mid \\ 109 bo lb Ul prednlled ho l t!~. 111C handgnp height on <'()me a.l um inulll crutchc!'.> 1\ adJ u,<,ted u.. lI1g .J pu ...h-buIIOIl lllechanJ"m \\ ith n re in rorl'in g cl ip-locI... {Fig. 1-' 201. Both the u\crall hl.! lght of Iht" cru( L'h a~ we ll as Iht" ht'lghl of Ih~> handgnp t)'PIGllIy adj u, t in I-i n Ulcrl'Illenh A\llIJJ'~ (full.-, he~ an: gL' l1craIJ) adJlh l.tble III ad ull "'11t" ... llUm ;lppro)'II11.uely .:t ' to flO in ( 12:! 10 151 L:1Il). \\ Ilh chddrl!n\;md t'\ln, long "I/e\ ,l\.uldbk A llwdifiullllil fo th, ... h.I..,'c d(,"lgn I", the or1 ho l'rU tdl t f-t~

I~ IqH ). fhl ...

1'\1"'" 01 ~1'\l1l.l r)

uU I L h I,

111.1It...· \) 1 .tlll

milium It ... oe'>lgn 1111 lutle..,.1 ... lIlg le upnght .In :J\il IM) h.lr L' )\t' red '" nh ' r\ltl~ L" ruhber paJdlOg ,1Ilt!;j h.mtig ' lp l'm c:rc:J v.llh mLlhkd pl~l'.. tIL Tht: l:rUh.-h dJW ... h l"kllh P'O\' 11lall~ jill allel elhlv" .1Il~1\: \ dnd lh .. t.dl) \to
'IJllllUlll',

lip .'\\III.1.f)

I,.rutlhe~

IInpn.\\· haLml..t· ,md l.tl~r.aI

,>I.-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 \\ <.l ll...as. Their fu nction is to allow fnl n ... k r 01 hlXl) \\t' ightlhrough the fo reann to the assistive dc\ ICIt A platlorl1l dlHtciune lll , ... u\ ell whe n y, e ighlbearing I ... L'Olilralll(l! c,ued throug. h the \\ r i ... t J,nd hand (e.g .. anhn-

arm ror>: 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

f
I hl..·'l· .h"'I,I!\l· dc.\

( ,1II,/lIIl lll l' fUldlt"

.

usmc

C h.apter 14 Locomotor Training

54 7

handpi ece shou ld be adjusted to provide 20 10 30· of e lbow flexion . Supine . From thi s position the measurement is taken from the anterior axillary fold to a surface point (mat or treatment table) 6 to 8 in. (5 to 7.5 em) from the lateral border of the heel.

Forearm Crutches Standing is the positi on of cho ice for measuring forearm crutc hes. From a supported standing posit ion. the distal end of the crutch shou ld be pos itioned at a point 2 in . late ral and 6 in . anterior to th e fool. With the shoulders relaxed the height should then be adjusted to prov ide 20 to 30° of elbow flexion. The forearm cuff is adju sted separate ly. Cuff placement shou ld be 011 the proximal third of the forearm. approx imately I to 1.5 in. (2.5 to 3.8 em) below the elbow. Figure 14.21 Plalfonll an:lchment to ax illary crutch.

Gait Patterns for Use of Crutches

di!)lal end of the cnllc h is cove red with a rubber suction tip. The foreaml c uff.., are ava ilable with either a medial or :inferior open ing. The cu ffs are made of metal and can be obtained \\ ilh a p l ~bl i c cOal ing.

Gait patterns are se lected on the basis of the patient's balance. coord inati on. muscle function, and weightbearing sta tus. The gai t paHerns differ significantly in their energy requirements. 80S. and the speed with which they can be execu ted . Prior to initiating instruction in gait patterns, several important points shou ld be emphasized to the pat ie'll:

Adranrages. The foreann cuff allows use of hands with out the (Tutche~ becom ing di sengaged. They are easily adju~ted and allm' func ti onal stair dim bing activities. M an) p,nienh fee l they are more cosmetic and they fit more ea:-.ily in to an automobi le owing to the overall d~crea<.ed height. They are al so the most fun ctional t~ pe of crutch for stair cl imbing activi tie s for indi viduah \'earing bilate ral knee-ankl e· fool orthoses I K AFOs).

DHadl(ulf(l.~el. Foreaml crutches provide less lateral sup· port o\.. mg 10 the ab~e n ce of an axillary bar. The c uffs Illa) be dlffic uh to remove.

Measuring Crutch es Axillar) C rutches Se\eral method!) arc avai lable for mea suring axillary cru((he~. The mO~1 common u...e a ~l.mding or a ~ upine PO:-'Illon. Meas ureme nt from ... t'Uldin g is most accu rate and 1:-. the preferred approJ.ch.

SfalJtfllJ~ From a ... upported standing po.\. ition. crut c he~

,Mould be Ill~a!>un: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\
5-1S

I'h) ",i ca l Re habilitation

Four- Point Ga it

(5) Cycle is repeated.

o

o

.

Thi s pattern prov ides a slow, sta~l e g.a l t as three points of fi oor cont act are maintained. Weight IS bo rne on both LEs and Iypica ll y is used with bil ate ral invo l ve m ent due to poor ba lance , incoordin ation, or muscle weakness. In this gail pallcrn one crutch is advanced and then the opposite LE is adva nced . For exam ple. the l eft crutc h is m oved forward,

t"

the n the right LE. followed by the ri ght crutc h and then the left LE (Fi g. 14.24).

Two-Point Gait

(4) Bot h cr utches are advanced.

Thi s gait pattern is similar to the fou r-point gail. However,

t

it is less stable because onl y two points of floor Comact are m ai ntained. Thu s, usc of thi s gait requires bette r balance. Th e two-point pattern more c losel y simul ates normal gait. inasmuch as th e opposi te lower and UE m ove together

"

(Fig. 14.25). Two additional. less commonl y used crutch

o

o

(3) Weight is shifted through the upper extremities onto the

crutches, and the uninvolved limb advances beyond the cru tches . If th is presents difficulty, the unaffected limb may initially be brought to the crutches and later progress beyond.

o

o

(4) Cycle is repeated .

t•

o

(2) Weig ht is shifted onto the uninvolved right lower extremity,

and the crutches are ad vanced.

o

(1)

t

gaits are the

swing-to and sw in g-through paltems. These gait1i are often used when there is bilateraJ LE invol vement. such as in SO. The sw ing-to gai l involve s forward movement of both cru tches simultaneous ly , and the LEs "swing to" the

t Q

o

'V

o

(3)

Weigh t is sh ifted onlO the crutches and partially to the affec ted ex trem ity. and the IJnalfected limbadvancss.

o

o

Startmg positIon. In this example, the Jell lower ex tremity is non.weightbearing.

Figure 1422 1 hrce- ptltnl g all pallern.

horne p,tJ1tJJI ~ on hoth nutc.he, ,tntl IlFl tht: aJ lel.:tct.i t' ,\lrl'Jlltl \ ' h g l..t .]'h Dunng Ilh l ru(.' lJon in thL' IXH11~ 1 \\L' i ghtt\t,lJtn ~ gill!. t'rn ph.t' I\ , hould he plart:d un U\L' o j a !lonn .1I ht'\:: 1 Il~ p rug ln"l IOIl \Ill Ilk .tth:u ~d t'''' lrClllll) Ojh,~ n Ihl~ Il'rn1 pJr h\ thl' p alh.:nt ,I, 1lI~' i.lllln~ I h~lll1l1l) the h lt" \ 11 hJ II ullhe l out , hould n llll.td til l' I1cl\\I h.t: 01 th l\ P0'-lI luIH ng \)\(;r a 1"Il'f1od o f Ib ) ~ or .... ....\.' ... , \\ II I k.uj I II hed llllJ I I ~ hUle,\. I IIllh h \.,d mOlJlh lh .tI e IlltUl .\ u~tul .,dI UIK IIU parll,ll .... elgill tx'.t lltl~ !!i.IIII1 .,IIIiJi lo! .Uld .lI l tll:"Lnl...... d IJl t'r III Ill .... dl
hllrn~ 1111 ,m l'\lI l' fJHI )

~

t

(2) Welghlls shIfted onto Ihe uninvolved limb. The clutches ancl the affec ted ext remity are advanced sim ultaneousf'; as Shown or can be bro"-en Into two components: (a) advance crut ches, (b) advance aUec ted extfemi~

o

Ot 'V

o

.,

( I ) Starting pOSlllon In Ihls example, the left lower extremllf' IS parttal,w9lghtbeanng bY1,1 1423 P.trli;tl \\ t: li.!httx-.Inn~ &.111. lIIoJlficatiutl tl ll~\' ~'I\,IIIH ~.lll r'II\~' m

or.

Chapter 14 Locomotor Training (4) Cycle is repea ted .

(6) Cycle is repeated .

t o

o

o

t.,

(5) The left lower extremity is advanced .

o

t

!

o

(4) The right crutch is advanced.

t•

t

t

o

It ., .

o

(1) Starting position. Weigh t is borne on both tower

extremities and both c rutches.

Figure 14.25 Two-point gait pattern.

o c rut c he ~.

(3) The rignt lower extremity is advanced.

o

In the swing-through gai L the c ru tches are moved forward togethe r. but the LEs are swung beyond the crutc hes . 80th thes.e crutc h patterns are di scussed in greater detail in Ch3pler 23.

Walkers

tt

o

tt . .,

o

(2) The le ft crut ch is advanced .

o

t•

(2) Th e left cr utch and right lower extremity are advanced together.

t., o

t

o

(3) The right c rutc h and left lower ex tremity are advanced logether.

o

o

549

(1J Starting position Weight IS borne on both lower extremit1es and both c rutches. Figure 14 24 I-ou r-polln

gi.l l1

p•• ltem

Walkers are used (Q im prove balance a nd relieve we ight bea ring. ei the r rull y or partially on a LE. Of the three cate gori es of ambulatory ass isti ve device~, wa lkers afford the greate:-.I stabilit). They prm ide a wide 80S. i J11prov~ anterior and lateral stabilit y, and alJow thC' UE~ (Q tran~fcr body weight to the floor. Walke rs are typi call} made of tublJlar alumi num with molde d vi ny l hundgrip s and rubb~r tip ... They are :.H.lju ~w.hk' in adull ~i.lf's from .lpproximale l) 12 to 37 in. (S I to 92 em), \\ilh c hildren's, yo uth , anu t.111 sius ava il ablt- . Seve ral de .. ign vanation ... and Tllodilil'alion:-, to fh e ~ tandard dC 'dgn art aV:lllahle and are dt"scnbed bell)\\'.

(;Iide ... GliLle ... :'11\ ' ' m:III , pla"lic attachment-. p lal'cd on Ihe poste n or leg ~ 01 walJ...a.. I) piL'aJl) in combination \\ ith \~ heel .. on the frlmt leg .. (Fig 14.10). The) prol1lol~ a :-. l1Iooth for\I" u'd prog n:~':>illil \\ IthOlll ha vi ng to 11ft and pbKe till' \\ alJ...er \\ Ilh cill'h "'h.' p, I hl') ;l rt: I) pit'all y Il1.JLle 01 hlgh-d..:n'lt) pl,I.. lI l 111 .111 111 \ .... ned I ml ::.hf{Jom-~I1<\pt" O ther common

550

Ph ysical Re ha bilitation

A

B

Figure 14.26 Walker in (A) open. and (8) fo lded po~ition. This walker has several unique feature!. Illcluding: pla"tic posterior glides. a buill-in seat with a molded back bar to support the user during re"t Illtervais (the seal n ips up for folding). large front whee ls (6 in.) to improve ease of use ol1lllultiple terrain ~. a second set of hand les set at approximately the seat level to assist si t-to-stand tran ~ lIl on s III the ab!.ence of chair armrests or for movement on and off a toilet. and a removable walker pouch for storing personal items. Height of handles adj ust using a collar and pin mechani,01 that eli minates having to tum the walker ove r to change the height. (Courtesy of Full Life Produ c t ~. LLC. Moorestown. NJ 08057.)

glide de!'igm. include a I -i n. diameter "disk" " ith a ce ntral stem thai ,I ide~ illlo Ihe tubu lar leg and is tightened into place ""th a ~ re" dri\'cr; and a fined cap that is placed directly onlo the" alker leg (in the !'lame manner the rubber lip IS :mac: hed). Another slyle of g lide incorporales a lenni l, ball \\ !thln it fixed hous lOg. (Fig. 14.27). Folding Mtchani!oolll

Folding "al ker!. are part icularly u!'lefu\ for pa!ient~ w ho tra\cl. The~e ",alker ... can be ca<;i ly collap!'cd 10 til in an automobile or ot her ~Iorage space bee Fig. 14 .26A). Handgrip~ ( H~ndl es)

Enlarged and molded handgrips are availab le. and may be u!'cful for ~ome patl ellt ~ with arthriti .... Some l,.\..tJker::. om.'r a ~et:vnd ... el t)f handl e~ to a:,.::.i... t with s it -IO -\wnd tran"l lIun :-, hee Fi g 14 :!5A). Platform Attach ments

1 '11~ ddapt.ltlon

I'"

u..,ed

\I.

hen v.elghlbearing I ~ I..omral ndi -

l Jtcd through the " fI !'l t and hi.Uld ( de~flbed in lTutlh !'leUlun) .

\\ heel Auachmenl s n 1ll" adaptallon 10 \\-dll..cr:-, (oltcn caBed rollillm~ vr IOIIIII I.!, ",dl "'~ r" Indudc~ Ih~ addition of \\heeh. (either to II;e

1\1.1) Ironl wheeb onl)

l)f

to all four " heel",. The addulon

Figure 14,27 rh\' d~ .... gn olth('~e ",al l er gltdes Im:OfPCI"-" h! llIl .... h.11I \\ Ithlll J fh\!d hou:,ing . a ~pnng-IO"1,kd brak.e for IlHenlll tll."1lI bral.ing dunng \\.:tllllig .•md bral.~ lock.-OU1 cbpl U't:tIIU de.ll:il\.:tle [he brJllllg feature lor umnterru~ fOfWll'd mll~lon Tllc tentu ... hall can b..! IlltUlUully rolated 10 WlVtOlD'" III lOlllrh;l e l~ ICIHO\eJ to ",nap-ill" a replacement. (COI,lI'Iefi)' rJ Im .II.MC Corp. ' · I)fl4. 011 +l036.)

C ha pter 14 Locomotor Training

551

in 3·, 5·. a nd 6 · in . d iamete rs. Eight· inc h diamete r wheel s are also ava il able a nd can be used to add height for tall users. Braking Mechanism A braki ng syste m is an essential feature of walke rs designed with wheels. Walkers with four wheels freque ntl y include handbrakes that lock the rear whee ls (see Fi g. 14.28). Posterior pressure brakes are effective when wheels are placed only on the front walker legs. Tripod Rollators Three-w heel ro ll ators incorporate a tripod des ign (F ig 14.30). A major ad vitnt age o f thi s dev ice is ease o f mane uve ra bilit y and tumin g . Heig ht adj ustme nts a re made a t th e ha ndl es: the unit folds for storage a nd trave l.

Figure 14.28 The fron l whee ls of Ihi ~ ~a lke r swive l freely in all directIon". Handbrakes allew, lockin g Ihe rear whee ls. 'Co urtes~

of Imacare Corp . E I ~r; a. O H 44036.)

treq uentl~ all o" s fun ctio nal ambu lat io n fo r \\ho art:' unab le 10 lift a nd to move J conventio nal v.alb.er (e.g .. fra il elde rl y). Swil'ell1'hl'cls TU m freely in a comp lete circle (Fig. 14 .28). Fixed lI'heels rolate arou nd acenlral J\I~ (Fig . 14.29). Whee ls a re ge nerall y ava il ab le

of .... heel s pallem ~

Storage Attachments The ability to transport items is an im portant consideratio n for many patients and is o ften essenti al fo r those need ing frequent access to medicati ons. a cordl ess or ce llul ar pho ne. remote control devices. or a ppo intme nt books. A varie ty of sizes and styles o f attachable baskets and pouches are ava il· a ble (Fi g. 14.3 1: also see Fig 14.25 A). Seating Surface A variety of walker seal designs are available that fold out of the way whe n not in use (see Fig. 14.25A and 14 .298 ). The structural design of many walkers also incl udes a contoured back support . Seats are an im portant cons iderati on for indi· viduals with limited endurance (i.e .. post-polio syndrome) as well as for comm un ity ambul ators w ho requ ire periodic rest imen'als. Walke r seal S should be carefu lly exam ined for

A Figure 14.29 \\Jlt..t'l ~.It 1.\) IXI"llltlllcd IlII1"e. Jnd 111 1 n l p~d ·up lurambu l"llon lhc 5·m. ln~'d hom "hcd" ul tl\l'. ",!l l..tr lutollc: olll'umi <4 " lllglt' "\l~ h"olIUlt':" ,11 thi-. .....d~c:r tndude rear '!'pnng 100adeJ brabe~. a Ik'lbll! b.Jd.. rt:"1 tOI )I IIUlg . " dual -p.JdJJe l olLill1g n~ .. h.IJ'II'.. m. and adJU'Il&blc: :'Cdl tu· t1oor h~l~h l ,Coune)) of lI "<4tMe Cmp Li)no.l . Ott 4-10.\('1 )

B

552

Ph) ... ica l Rc habilita ljon

,labi lity and ~afel Y with respect to individual patient netds. Palien t praclice in u~e the wa lker scat should be provided.

Reciprocal \¥alkers Thc ...e " 'aiken. arc designed to allow unilateral fOf'llotard rrogre<;~ iol1 of one si?c o.f the wa lker ~ Fig. 14.32). A disadvanlagc of Ihi ~ des ign IS th:H some mherent stability of the w~llker is lost. However, they are use ful for patients incapable of li fting the wa lker wi th both hands and mov. ing it forw;lfd (in ~ituali on s in whi ch a rolling Walker might be contraindicated). Ar/\'{lJ/fOges. Convent ional walkers provide four points of

floor contact with a wicle BaS. They provide a high level of stabilit y. They also provide a sense of securilY for patients fearful of ambulat ion . They are relatively lightweight and eas il y adjusted. IJisO(/\'{Jl/wgeJ . Walkers lend 10 be c umbersome, are awk. ward in confined areas, and are difficuh to maneuver through doorways and into cars. They eliminate nor· mal aml swing and cannot be used safely on stairs.

Figure 14.30 Th ree·\\ hee l ro llalor \\ il h handbrakc<; and r()l~ urCl h:tne lire, 10 ;mproH' perfommncc on a variety of ICTT'Ll n ,. ICounl!') of Invacare Corp. EI ) ria . OH +4036.)

Measuring Walkers The height of a wa lker is measured in the same way as that of a cane. The handgrip or handle of the walker should come to approximately the greater trochanter and allow for 20 1030° of elbow flexion. Gait Patterns: Conventional Walkers Prior to initiating instruction in gait patterns using a con· ve nti onal wa lker (4 points of floor contact without wheel

Figure 14.31 \\'<.I I\..cr ba.,kt:1 1/('fll .U1d ".lI\.. l.: f JXllldl I.ongilluil i. (() M050) ,

(1'1 ,III)

~

.

(C

'.

oune~) o f Sunn ~~ Medical

-

Chapter 14 Locomotor Traini.ng

553

Partial Weig ht bc;:tri ng Gait

I. The wa lker is picked up and moved forward about an arm's le ngt h. . . 2. The involved LE is moved forward, and body weight IS transferred partially onto thi s limb and partially through the liEs to the walke r. 3. The uninvo lved LE is moved forward past the involved limb. 4. The cycle is repeated. Non-Weightbearing Gait

1. The wa lker is picked up and moved forward about an am, 's le ngth . 2. We ight is then tran sferred through the liEs to the walker. The involved limb is held anterior to the patient's body but does not make contact w ith the floor. 3. The uninvolved limb is moved forward. 4. The cyc le is repeated.

Figure 14.32 Reciprocal walkers allow unilateral movement of one ~ide of the walker while the opposi te side remains stationary.

Nore: Rolling wa lkers generally aJlow use of a reciprocal gait pattern as the walker can be rolled forward while walking. As the need (0 lift the walker forward fo ll owing each step is e liminated, a smoothe r forward progression can be achieved .

Locomotor Training Using Assistive Devices Level Surfaces anachmcllIs ). several point s related 10 use of the walker should be emphasized with the patient:

• The walker ~hould be picked up and placed down on a ll four legs si multaneously 10 achieve maximum stability. Rocking from the bac k to front legs should be avoided because It dec rease~ the effectiveness and safety of the assistivc de\ • The patient should be encouraged to hold the head up and 10 m ai ntall1 good poslUrai alignment: forward flex~ Jon of the trunk , neck. and head should be avoided. • The patient shou ld be cautioned nol to step too close to the front crossbar. This will decrease the overaH 8 0S and may result In a fa ll.

:ceo

There are three types of gai t patte rns used with co n. ventional walker~. The~e are the full , partial , and non.....eightbcaring gai t ~ (rollin g devices are nOI recommended for patlent ~ with allered weig hlbearing s latu ~). The ~eque n ce for each pall ern follow s. Full Welghtbearing Galt 1. The wa lker is pl cled up and moved forward about all arm 's length . 2. lhe fir"t LE i ... moved forward. 3. The second LE I ~ moved forward pa::.t the firs!. 4. The {:yclc i" repealed.

Several important preparalOry act ivities should precede 10comoIOr training on level surfaces with the assistive device. These activ ities may be comple ted in the parallel bars for added sec urity. However, if the width of the bars is not adjustable, the BOS of the assistive device may make movement within the bars difficult and un safe. An alternati ve is to move the patient o utside but next to the parallel bars (or oval bar) or near a trealment table or wall. These preparatory activities include :

I. Instruction in assuming the stand ing and seated posilions with use of the assis ti ve device. These techniques are ou tl ined in Box 14.4 for each category of assislive device.

2. Standing balance activities wi th the assislive device (simibr to those using the paraJlel bars, described earlier), 3. Instruction in use of assisti ve device (w ith se lected gai t pattc:rn) for forward progress ion a nd turning . As mc:nti oned , demonstrating these ac tivities by assuming the role of the patient during verbal c.xp lanati ons is an e fTc(.'live teac hing approach. FolJowing the denwnslralion. munuai COlllact~ . verbal cui ng, and explan ations can be u:-.ed again 10 guide perfonnance of the activity. Menia l practice (menl,,1 rehearsa l of a t a~k) is another impoMant MTatc:gy to a~~ist III the learning and pcrfomlance of mOlor ta ... h . )7-4(, The literature ~uggests that mental practice

554

Physical Rehabilitation

Box 14.4 Assuming Standing and Sealed Posilions with Assislive Del'ices I. Cane A. Coming to stalld j" R • Patient moves forward in chair. o Cane is positi oned on uninvolved side ( broad~based cane) or leaned against annre!.1 (standard cane). • Pat ient leans forward and pushes down wilh both h and ~ on annreSb , comes to a standing position, and then grasps cane. With use of a standard cane . the cane may be grasped loosely Wilh fingers prior to standing and the base of the hand used for pushing down on a mlres l ~.

B. Reful'll 10 Jiuing • As the patient approaches the chai r. the pat ient turns in a small circle toward the uninvolved side. • The patient backs up until the chair can be fe lt against the patient 's legs. • The patient then reaches for the anureSI with the free hand. releases the cane (broad-based), and reaches fo r the opposite armrest. A standard cane is leaned against the chair as the patient grasps the armrest.

II, C rut ches A. Coming 10 sta"ding • The pat ient moves forward in the chair, o Crutches are placed together in a vertical position on the affcctcd side. • One hand is placed on the handpieces of the crutches; one on the armrest of the chair. • The paTiem leans fo rward and pushes to a standing position. • Once balance is gained. one crutch is cautiously placed under the axilla on the unaffected side.

facili tates acqui siti on of a motor skill as we ll as improves retention . The physio log ical ba~ i s for me ntal practice remains in que!.tion. Howeve r, it has been suggeMed that mental re heaThal may be fu nctionally similar 10 m olor preparation .J7 Kohl and Roen ker~' propose that imagined moveme nts and actuaJ perl"onnance are clo~e l y re lated and may pa niall y share a common physiological substra te. Me ntal practice is ge ne rally com. idered most effective w he n combined w ith physical practice. Followmg the~ pre lim inary instruc tions. gail train ing u ~ ing the a~~ i ~ ti ve device can be begun on leve l surfaces. The following guardi ng techniq ue (Fi g. 14 .33) sho uld bt! used. 1. The therapiM ~ I ands po~terio r and lale ral to the p a t ie nt '~ ",caker !.idc .

2. A "' Ide BOS ')hou ld be ma llli ai ned "i th the Ihera pi s[ '~

u::

leadin g rollowing the a ~~ i !. li ve dev ic:e . T he [h e ru ~ pi ,:> t \ oppo!.i le LE ~hould he ex te rna ll y TOta ted •.Hld 1'01. Jov.. the patlenl '~ wea ke r LE . 3. One of the thcJ'api ~l \ hand ... i ~ p laced po~ lt'Tiorly o n the guardmg belt a nd the other anterior 10, but I/O' (Oluhlll,~ , Ihe patie nt ' ... .,houlder un the v.caJ...er ~ idc ,

• The second crutch is then carefully placed under~ axi lla on the affec ted side. • A tri pod stance is assumed .

B. Refil m 10 ,~itti"g • As the patient approaches the chair, the patienI .... .. a small circle toward the uninvol ved side. • The patient backs up until the chair can be feb: ..... the patie nt 's legs. o Both crutches are placed in a vertical positioo (OIl from under ax illa) on the affected side. o One hand is placed on the handpieces of the CI'Uk:iIeI; one on the ann rest of the c hair. o The palie nt lowers to the chair in a controlled manner. Nofe: See Chapter 23 for alternative methods using bi'-atI knee ankle orthoses,

IH. Walker A. Coming ( 0 standing o The patient moves forward in the chair. • The walker is positioned directl y in front of die c:IIIiL • The patient leans forward and pushes down to come to standing. • Once in a standing position, the patient reachet fm . . walker, one hand at a time.

011_

B. Return

(0

sitti ng

• As the patient approaches the chair, the patieDt . . it a small circ le toward the stronger side. o The patie nt backs up until the chair can be felt ..... the patient's legs. • The patie nt then reac hes for one armrest II ..... • The patie nt lowers to the chair in a conttoIIed ~

Should the patient 's balance be lost during training, the hand g uarding at the s ho ulder shou ld make conta:t. Freq uentl y, the s upport prov ided by the therapist's hands II

the shoulder and on the guarding belt will be enough ., allow the palie m (0 regain balance. If the balance loss is severe. the therapis t sho uld move in toward the patient SO lha t the body and g uarding hands can be used to provideScabilizat ion . The palie nt should be allowed to regain balanCt w hile " leaning" aga insllhe the rapist If balance is noIl'eOO"· ered and ;t is apparent Ihe patient must be moved to die tl oor, fUI1h e r allCmpts sho uld 110t be made to hold the paticDI up becau se thi s is likely 10 result in injury 10 the patieBI and/or the Iht.' rapist . tn th is s ituation, the therapist sboIIId l'olllllue 10 bm(.'e Ihe pa tie nt against the body (0 break die fa ll a nd to pro ll'ct the head and move wi th the patient all ~i ning po~ ltion on the floor. It is also importanllo talk 10"

patien t ("" Help me lower you to the floor") so that the pa&iaII doe.!. l10t continu~ to stmgg le to regain baJance. Gai t lru m ing ac ti vit ies o n le ve l s urfaces should i,ndiItI i n~lrul' lI on a nd practice in passage through ~a)·s." va lon.. a nd over thresho lds. When using crulCboi. dolW" way!. arc IlIOM ea . . i1y appro ac hed from a diagonal, A bifid

C ha pler 14 Locomolo r Traj ning

Figure 14.33 Anlenor (left) and JXhlenor (fIl.:hn v ic\~., of !!uarchng I\!chnique for leve l .., urfact". delllon..,trJlcd 'A Ilh use of crutch",. The .,ame po.,illolll ng b u\ed \\ Ilh cane " and \~ alker"

be freed 10 ope n the door and one cmtch mu st be placed III a po,;., itioll 10 hold it open, The patient then gradually proceed'l through the doo rway. us ing the crut ch to open the door", Ider if necessary. Becuu"c man ) patienb u ~ing a walker or cane may ha\ e balance problem ~ . ca reful examin ation will determUle Ihe '1 ufe'll method ~ fo r pa s ~age throu gh doo rways. A pJllcnt u.,i ng a co mc n l i o n ~1I walke r wi lh suffic ient balance ma~ be able 10 u\e a lechniq ue ~i m i lar to that desc ri bed abO\ e, mu~t

Stair Climbing Se\eral !!cneral guideline\ 'lhoul d be re layed to the patient dunng IIh truclion in 'lla lr cl imh in g. First. if a rai ling is 3\allablc II ., hou ld al'Aa) \ be u')ed . T hi s is true eve n if it requlre\ pl aclIlg an a . . ~ I .... ti\'e dev ice tn fhe hand in which it J~ 1101 nonnal1 ) u,;.,ed. Fo r ~ l air climb in g with a,'( illary crutchc'::l U''>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 gU'!lce nd ing Stairs 1Fi g. I.t]... ) I The therupI .. t 1\ PO" ltlOlled po\ ten or and lah::ml un the aftected " Ide be hll1d the pUlIent.

Figure 14.34 Guard ing techmque for ascending stairs.

555

556

Physical Re habilitati o n

Box 14.5

Stair· Climbing Techniques" crutches and partiall y o n the affected lower extremirJ while the unaffected lower extremity leads up. 3. The invol ved lower extremity and crurches are then brought up together.

l. Cane A, Ascending J. The. un~ffect cd lower extremity leads up . 2. The ca ne and affected lower ex tremit y fo ll ow. B. Descendillg I . The affected lower extremity and canc lead down . 2. The unaffected lowe r extremit y foll ows.

B. Descending I. The patient stands close to the edge of the stair SO dill the toes protrude slightl y over top of the stair. 2. Both crutches are moved down together to the /roN half o f the next ste p. The affected lower eXlremity is

II. Crutches: Threc-Point Gail (non-weight-bearin g gait) A. Ascending

.

1. The pati ent is positioned close 10 the foot of the stairs.

The involved lowe r ex tremit y is held back to prevent "catching" on the lip of the stairs. 2. The patient pushes down timlly on both hand pi eces of the crutches and leads up with the unaffected lower extremity. 3. The crutches are bro ught up to the stair that the unaffec ted lower extremity is now on.

B. Desal/dillg I. The patient stand s close to the edge of the stair so that the loes protrude slightly ovcr the top. TIle involved lower extremity is held forward over the lower stair. 2. Both crutches are moved down together to the from half of the next ste p. 3. The patient pushes down tinnl y on both handpicces and lowers the unaffected lower ex tremity to the ste p that the crutches are now on.

Ill. CruH:hes: Partial Weight-Bearing Gait A. Ascendillg I. The patient is pos itioned cl ose to the foot of the stairs. 2. The pati ent pushes down on both hand pieces of the crutches and dis tributes we ight parti ally on the

then lowered (de pending on patient skill. these may be combined). Note : When crutches are not in floor c0ntact, greater we ight mu st be shifted to the uninvolved lower extremity to maintain a partial weight-beuing status.

3. The uninvol ved lower extremity is lowered to the 5Iep the crutches are now on. IV. Crutches: Two- And Four-Point Gait A. Ascend ing I. The patient is pos iti oned close to the foot of the stairs. 2 . The right lower extremity is moved up and then the left lower extremity. 3. The right crutch is moved up and then tbe left CJ1dc:b is moved up (patients with adequate balance may find it easier to move the crutches up together).

B. Descending I . The pati ent stands close to the edge of the stair. 2. The ri ght crutch is moved down and then the left (1M)' be combined). 3. The right lower extremity is moved down and thea Ibe left.

oJ The sequence.:; pre<>enled here de<;eribe ... tair·climbing. tec hn iques without the use of a rail ing. When a \elUre railing i ~ a\3tlable, the pallent shou ld be inslrucled 10 u~t= it al"3) ....

') A '" ide BOS :-.hou ld be maintai ned with eac h foot on a different stai r. 3. A step sh ou ld be taken on ly w he n the pati en t is not movIng . .t. One hand is placed posteriorly on the g uardi ng belt and one is anterior 10, bUI not touching. Ihe s ho u lde r o n the

'" eaker

~ide.

Descendi ng Sta irs (Fig. 14.35) . The therapist i~ po ~jt ioned ante rior and la tera l on the affec ted :-. ide in front of the patient. 1 A '" ide BOS ~ h{Juld ~ mailllained with each fOO L on a different Mair. 3 A .. tep s hould be tal...en only'" hen the palient b not movmg .

the the rapist sho uld move toward the patient to help brace tb: patient (the patie nt should ne ve r be pulled toward the therapist on stairs) or leaned toward the wall of the stairwell (~ Final ly, if needed. the the rapist can move with the palient to sit the palien! down on lhe stairs. Remember 10

a\ ailabJe).

infonn lhe patient o f your in te ntio ns (" 'I'm going to sil)OI.I down·").

NOTe: As desc ribed under Ihe sect jon o n Outdoor O\'crgrowtd Pmgrl'ssioll , locom o tor trai n ing us ing ass islive deviceS ~houl d a lso inc lude o utdoo r tra ining and practice wim c urbs, ramps. and s lopes ; uneven te rrains: timed activities (e.g .. cro::.sing at a stoplig ht): and negotiating open cOlD" mUIlII) env ironmen l::. as we ll as o uts ide doors and thfeIIto ld .. , and publi c or private transportation .

.t. One hand i., placed J.J1Ieriorly o n the guarding. be lt and one IS anLeriOl to, but nOI tOllc h ing. the ., hou lder on Ihe

weaker

~i d e.

Should the patient\. b.tlalll.:e be lo<;{ during :-'1 ~lir climbing, the follOWing procedure ~hou ld be tolhmt!d. Flf<;l, I:Oot
Adjunct Training Devices Limb Load Mon itor. A Innb load moni lor b a foml of b io feedback. usedClinicIIIY as an adj unCl lnterwnlion during ea il training. The limb)old . ~« monitor IIlcorporates a srrai n ga uge attached to the ...-

Chaptel" 14 Locomotol" Training

557

hee l of the "hoc . \Vhen a force or prcs~ure is app lied. the strain gauge is defon11ed and an auditory signal provides feedba ck 10 the wearer. As prc~~ urc inc:rease~. the signal becomes loude r or more rapid. Thi ~ feedback provides infomlation about the amount of v.'cightbearing on a limb. Limb load monitor, can abo be u ~ed to re inforce the correctnes~ or timin g of a move ment. For exampl e. an audible noi se or bu zzer !o>ounding 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 pi<.lccment as well as pressure applied 10 the c,mc.

Summary

Figure 14.35 Guarding technique for desce nding stairs.

Questions

for

Recovery of independent locomot ion is an important goal for many patients seeki ng physica l therapy inte rve ntion . It is a functional sk ill that directly impac ts perfonnance of expecled roles w ilhin Ihe palieJ1l 's soc ial, cultural, and physical environment. A general fram ework of preparatory exe rcises and locomotor training strategies has been presented that can be modified to meet the needs of an indi v idual patient. Through a process of carefu l examination and communication wi th the patient, family. and/or care· give rs. th e appropriate preparatory activities and spec ific training strategies can be identifi ed.

Review

1. What fac lors infl uence the ex tent and type of loco· motor training acti vities required to achieve des ired outcomes for an indi\ idual patien t? 2. Whal are the major e l ement ~ of physica l therapy intef\;emion for patients with gait impaimlc nl s? 3. Li st the genera l goab of a program of the rapeuti c exercise de.., igned to prepare a patient for locomotor Iramlllg. 4. What are the characleri,tic fealUre~ and focu~ of con· lrol of each po~tu re (bridg ing, sitting. knee li ng, half· luleelmg. modified plant ig rade. and ~tanding) included In the preparalOry l'xerc i ~e rrogram kading up 10 loco· motur lrai nlll g? 5. COlli raM and com pare the advan lage~ and li mi tation :-. 01 u~ing paralle l bar~ ror locomotor training . 6. Explalll the rationale 1'01' e ac h compone nt 0 1 the mdoor ove rgruu nd loc omotor train ing ~eq ll (' n cc. 7. De . . t.; ribe the nuionale and procedure for locolll otor tfJmmg usin g body \'\t:lg h l ... upport and a motoril.cu treadm ill .

8. Contrast and compare the advantage s and disadvantages of eac h calegory of ambulatory assisr ive device: canes, crutc hes. and wa lkers. 9. Describe the guidelines for selection and measuremen! of canes. cru lc hes. and waJkers. 10. Describe the seque nce for instructing a patient 10 rise from and re turn to a s ilting position with a cane. c rutches, and a walker. 11. D e~cribe Iherapist po~ilioning and hand placement for guarding the patient on level surfaces and ~ I air, .

12. Describe the seque nce for the following crutch gai ls : four-po int . two-po int. three-point. and partial weight· bearing. 13. Iclt!l1 lify the common gait patte rns and guard ing t~ch­ nique lI!\~d with canc, and wal kers. 14. Describe stralegie:-. for varying task and environ menlal dcmand~ during 10comolOr Iraining.

558

Physical Rehabilitation

Case

Stud

The patien t is a 26-year-old male who was invo lved in a 1ll0IOrcycie accide nt 3 days ago . He sus ta ined c losed tran!)verse fraclure~ of the left tibia and fib ul a secondary to angul:l tory forces acting on the limb du ring the accident. Di srup tion of the per iosteum a nd su rrou nd ing soft ti ss ue wa!) evident. The m id- s hafl frac tu res we re reduced and a long leg cas t ap pli ed with th e knee nexed 10 30° (to he lp contro l rotation at the fraclU rc si te). The cas! i!) 10 remain in place for 4 weeks wi th progres:-.ion to a be low-k nee p,lIeliar te ndon we igh tbearing cas t. A Colle:. fracture of the right wrist was also susta ined a-, the patielll attempted to break his fall landi ng o n an open hand with the forc-ann pronared. The ma in trans\cr<.;e fracture line I!) al the nared out di s ta l metaphysis of the radius with avulsion of the ulnar sty lo id. The fracture was reduced and a cast applied 10 the wri st and foreann. The thumb and finge rs were left free. A seri es of repeal radiographs are pla nned at 2-week in tervals to ensure !)atisfaclOry alignment is main tained. The plan is to progress 10 func t ional frac ture bracing of the righ t \~rist within 4 weeks. Pasl Medica l Hi sto r y: Unremarkab le. Socia l Hi sto r y: The patient lives with h is mother, stepfather. and two younger siblings. He has a bac helors degree in engineering. is employed by a large automotive manufacturer. and is working part-time toward Ll ma!)ters degree . He plans 10 be married in 6 monlhs. The patient is an avid sports man with partie. ular interests in sailing , arche ry. and sk iing .

REVIEW OF SYSTEMS Vis ion: Rtspiration: Hearing: Coordination: Blood p ressure : Sensation: Pu lse: Cognit ion:

tmact 14/ minu le Intact Intact 124/80 Inlacl 6O/millute Intact

\\leig ht bea~i ng statu.!!: Non- v" eigh tbearing left LE; no \\ elghl IS to be home on Ihe right wrh l. ROM oa rn ination : The left lE and right wri" and fin ?er!) not tesled oWlIlg to tracture ... ROM for all other JOIllH~ I!) wllhm n Om 1:1 1 limH~ (WN L} .

Manual muscle testing: The left LE and right wrist iIIld finge rs no t tested owing to fractures. All other stre ng th val ues are wi thi n norma l limi ts (WNL). Plan : The pat ient is to rema in hospi ta li zed for another 48 hours fo r observati o n and p hysica l therapy interven_ tion. He will then be fo llowed as a n o ut-patiem th roug h the ort hoped ic clinic. The patie nt has been referred for ga it tra ining ac ti v iti es. Assume you ha"'e se lected ax ill ary crutc hes as the ass is ti ve device for this pati ent.

GUIDING OUEST IONS I. Wh at advant ages woul d selectio n o f the ax illary crutches have for this pa tie nt? 2. Would you recom mend any spec ia l attachments to the axi ll ary c rutches? If yes . g ive the ra ti onale for your selection.

3. What type of ga it patte rn would you select for this patien t? Prov ide a rati ona le for your selection. 4. As you plan the parall el bar progression for this patient . you dec ide to p rov ide a verbal deSCription of the ga it pattern wh ile you concurrently demo nstrate proper use o f the c rutc hes. Identify how you wou ld ,'erbally describe the sequencing of crutches and foot placeme nt fo r the gait pattern selected. 5. Prior to ini ti ating instruc tion in use of the axillary cru tches. what general g uide lines fo r the ir use would you emphasize with the patie nt? 6. Are there any s pec ial considerations o r mooiflcarions you wou ld need to make to the parallel bar progres_ sion for this pat ient? Describe an appropriale sequence and progression of paralle l bar aCli vities. 7. Describe the appropriate therap i.) r positioning and hand placements for guarding the patienr during gail: training on level surfaces. 8. De~cri~ the seq ue nce of crutc h and foot placement for a::.cending and descending sta irs using both crutches (fur this response. as~ume a railing is una\'ail ~lble).

9. De!)(Tibe the appropriate therapist pos itioning and hand p~acel'llent~ for guarding the patient while a!)~l!ndlllg and de,crnding "'fairs. 10. ~Vha t b:blC outdoor activities would vou include cU'mg gai l WHning for thi ~ patient? .

Chapter 14 Locomotor Training

559

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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 '> plIlCul ar aC( lde lll ~

Ph) $ 1111:, nil 1PH I. 1992.

~I udfdnel. M8. et a l P.utllli bod)' 'helghll1ouppo n ~ ith treadmi ll IUO':fJlUull"llitllmpW\e gal t ufte r In(ompittt ~plllal torJ inj ury A IIL,le ~llbltl,.l t'\perimcllta l dellign. Ph )~ The r 71$( 4 ):36 1, l'J9K 2l S.. hIOJI M k c t ;il Tre ..dmilitramlllg .... lIh pamal bod) v.c lght Uppor1 Ln nonamhu1 atol) patlenb "V.- Ilh I;ere bral(uh) Aflh Ph ,~ Mc-d k l:hahill!hl'~(II. 2uo O. '.! M,lLer. E\\ Boo, ~cIgh! I>uppont: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

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•

CHAPTER

15 lEIRNING

OBJECTIVES

1. Define the disease processes (i ncluding de fini tion. eliology. patho phys io logy. cl inical presenmti on. and cli ni cal course) of chronic obstmclive pulmonary disease. asthma , cysti c fibrosis. and restri ctive lu ng di sease. 2. Descri be examinat ion procedures (including patient interview. vit al signs, observation . inspection. palpation. au scultation. and laboratory tesls) for a patient wi th pulmonary di sease. 3. Identif) the anticipated goals and expected outcomes of pulmonary rehabilitati on. ... Describe the re habilitative management of a patient with chronic pulmonary d ysfunction. S. Value the therapi st's role in the management of a patient with chro ni c pulmo nary dysfun ction. 6. Analyze and inte rpret pati ent data. formulate real istic goal s and outcomes. and develop a plan of care when presented with a dinical case study.

P

Chronic Pulmonary Dysfunction Julie Ann Starr,

PT. MS. CCS

OUTliNE Respiratory Physiolog) 561 Chronic Lung Di <:ea<,e .. 563 Chronic Obgtructive Pulmonary Disease 563 Asthma 566 Cystic Fibrosis 567 Restr;cl;vc Lung D; sease 568 Medica l Management 568 Smoking Cessati on 569 Phamlaco logical Manage ment 569 Surgical Management 571

ulmonary re.habiLitat ion is a multidi sciplinary program of care fo r patients with c hroni c respiratory impainne m that is individually tai lo red and designed to o ptimi ze phy sical and ~ocia J pe rforma nce and auto no m y.1 Years ago. patien~ \\ Ilh chronic p ulm onary di sease we re g iven a standard prescription for rest and avo idance o f exercise.'! The stre~ s imposed by exerc ise wa~ considere,d de leteri o us to people with pulmonary d i sord e r~. A pi votal study b y Pie rce et al. ( 19(4) provided the i m pe tu ~ to cha nge di recti o n in the treatment of pulmonary dysfuncti o n. ~ Exe rc ise trainin g effecb of decreased heart rate. respiratory rate. minute venti lation. oxygen consumpt ion. and carbon d iox ide producti o n at I:o>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
562

Physical Rehabilitation

Figure 15.1 Anatomy of the distal conducting airway. me temlinal ~ronc h i o l e and the respiratory unil. the respiratory bronchIole. al veolar ducts. 3veolar sacs. and alveoli . (From Brannon, FJ. el 31: Cardiopulmonary Rehabil itation: Basic Theory and Applicat ion. ed 2. FA Davis. Philade lphia. 1993 . p 43. with pemll "sion.)

lung volumes are teml ed capaciti es. Figure 15.2 illustrat es the relationship of lung volumes and capacities. The amount of air tnspired and expired during nonnal resting ventilation is tenned tidal \'oll/me rn f). As this tida) volume of air enters the respiratory system, ittI
male. The amount ~f inspired air l~at actuaUy reaches the distal respiratory unJl and takes part In g~s. exchange is ~ 350 mL of the 500 mL totaL The remammg 150 ml of !he inhaled tidal breath remains m the cond ucting airways ald does not take part in gas exchange. When onl y a tidal breath occupies the lungs, there is "room" for additional air that can be further inhaled. Thj s volume in excess of that used in tidal breathin g is the inspiratory reserve volume (fRV). Apt! named. it is the volume of air thai can be inspired w~ nceded, bUI is usua ll y kept in reserve. There is a quantity of air that can potentiall y be exhaled beyond the end of a tidal ex halation. Although it is kept in reserve, the volume of air that can be exhaled in excess of tidal breathing is caUed tit: expiralOl)' reserl'e \'olume (ERV). The lungs are flO( com. pletely emptied of air even after maximally eXhaling the ex piratory reserve volume. The volume of air remaining within the lungs when ERV has been exhaled is called !he residua/ volume (RV) . The sum of two or more volumes is referred to as a capacity. Tidal volume plus the inspiratory reserve volUJnc is known as the inspiraTory capaciTy (I e ). This refe" to !he vo lume of air that can be inspired beginning from a tidal exhalation. The combination of residual volume and expi. . rawry reserve volu me is the fimcriollai residual capacity (FRC). Functional residual capacity is the volume of air that remains in the lung s at the end of a tidal exhalaboo. The sum of inspiratory reserve volume, tidal volwne. ad ex piratory reserve volume is called the vital capacity (vCJ. It is rhe total volume of air wilhin the lungs thai is under vo litional control . The common method of measuring VC is to achieve ma ximal inspiration, then forcibly exhale all of the air into a measuring device as hard and as fasa as possible until ERV has been exhausted. Because this i5 a forced expiratory maneuve r. il is termed the forced viJaI capac it y (FVC) . As stated earlie r. all vo lumes togetllcr equal total lung capacity: TV + IRV + ERV + RV

r--J:

Aa )(Imallnhalation

-------

--1--1

j -------------- ------T__ ~ ___________ :-~:::h_a~.~~___ _ Irc

L__

TV

. --Etv-

--

-

TjLC

= TLC.

Flow rate measu res the vo lume of gas moved is • period of ti me. Expiratory fl ow rales. therefore, are measu reme l1l ~ of exh31ed gas vo lume divided by the aIJI()UItI cI tIIne required for the \'olu m~ to be exha led. Aow rIIti reflex t the ea ~e \, ith whic h the lunes can be ventilaaed and rela ted to the e l 4.1~ t icily of th; lung parelx:hyma. ~ Important airtl ow mea.':oure mCO:: nI is the volume of air dill l::'111 be forcefu li ) e \ha led duri ng the first sccoad 01. Inn.:cd v Hal capdcit) maneuver, This i;. called the jtxttJ npillll(Jn I'Olwne ill I ,e-cond (FE\, ). Th.h. flow _ i6 thoug ht .to rdleci the ~Iatll') of Ihe air~ay!) of lhe I...... heJ.lth) mUI\ tdu.tb , FE \, j, 70 perce nt or more of _ _ I've (FEV / FVC " 70<:C\.b l",plTatory now ratesCl8 .... be: dete nn llwd b) II1ca~ lI n ng (he amount of wr inipired'" th t> alllOu nt of timc n~c~s::,"ry tor the inha,lauon. Mt1HmW~l 111.\ / )0 (110 /) p r C'.l ,\w·t ' (PI..., ) re(kcll . . gfl!.tlt'!'o, t , l all C Ilhpll'all)r) e ffort lh.lt can be gene""'rn ll..illai \ olul1lc. It l~ m~a\urtd as a pre~ure in miw . .

:tn!

Chapter 15 Cbronic Pulmonary Dysfunction of mercury or cubi c centimeters of water and reneels the strength of [he muscles of inspiration. Maximal sWi1ained inspiratory pressure (SIPmil) is a lest of inspiratory muscle endurance. The palient is initially chall enged wi th - 6 e m H ~O pressure resistance. Gradually the re sistance is increased - 2 em H,O every 2 minutes until the patient can no longer achieve ·adequate ventil at ion flow levels.1 The maximal pressure is defined as the hi ghest level Ihat the patient could tolerate during the testing procedure. Lung volumes. capacities. flow rates. and mechanics depend on the size and configuration of the thorax. There· fore. height. gender. and race influence static a nd dynamic lung measurement s. Any ah eration in the properti es of the lungs or chest wall due to the aging process or a disease process will change the lung volumes . capacities, flow rates. or mec hanics. Respiration is a tenn used to desc ribe the gas exchange within the body. This should not be confu sed with ventila· tion. which describes only the movement of air. External respiration is the exchange of gas that occurs at the alveo· 1ar capillary membrane between atmospheric air and the pulmonary capillaries. Internal respiration takes place at the tissue capillary level between the tissues and the surround· ing capillaries. The following discussion traces the course of gas exchange. specifically that of oxygen and carbon diox ide. during both external iUld internal respiration. For external respiration to take place. there must first be an inhalation of air from the environment. through the con· duetin g airways. and into the respi ratory bronchioles and al veoli . Ox ygen diffu ses through the wall s of the respira· tory unit, through the interstitial space, and through the

pulmonary capillary wall. Most of the oxygen (98.5 percent) then travels through the blood plasma into red blood cells where it occ upies one of the gas·carryi ng sites of hemoglobin. A small portion of dissolved oxygen (1.5 per· cent ) is carried in the plasma. The oxygenated blood returns to the left side of the hean via the pulmonary veins; from there it travels through ~he aorta. and the n through a network of connecting arterIes, arterioles. and capillaries. until it s destination , the tis· !! ue. is reached. IllIemal respiration begins when the arte· nal blood reachel!! the li ssue level. Ox ygen diffuses from the gas-carrying sitel!! of hemoglobin , out of the red blood cell, OUI of the ca pillary. through the cell membranes , and lOto the mi tochondria of the working cells. Again . thi s p rOCe:~s occur::, through diffu sion. Carbon d iox ide (C0 2 ), which is produced at the ti ~sue level as a by·prod uc t of metaboli ~m , diffuse!! oul of the 'Worklll g ce lh and into the capillaries. Carbon dioxide is tr~n~ported through the venOUl!! sys te m int o the fight side 01 the hean . Once the carbon dioxide makes it s way to the pulmonary capillary, it diffuse51 out through the capillary membrane, throu gh the: Jmer~titial ~pace, and into the al ve. oil , '" here JI is fin all ) ex haled IIllO the atmo!)phe rc. When the cycle of ex te mal and inte rn.d respirallon hal!! OCcurred. oxyge n ha~ been ex trac ted from the cnvlronme lll

563

and provided to the body ti ssues meanwhile. carbon dioxide has been removed from the body and re leased into the ex te rnal env ironment. Of cou rse, this system is dependent upon an intact cardiovascular system to pump the blood through the lungs. deliver it to the working cells , and then return it back to the lungs. all in a time ly fashion.

Chronic Lung Diseases Chronic Obstructive Pulmonary Disease C hronic obstructive pulmonary di sease (CO PD) is the most common c hronic pulmonary disorder. afflicting 14 million adults in the United States and is a leading cause of

morbidity' It is the fourth leading ca use of death worldwide wi th a mortality rate that continues to rise .6

The 200 I Global Initiative for Chronic Obstructive Lung Disease (GOLD) was a collaborative work of the United States Heart, Lung, and Blood Institute and the World Hea lth Organization (W HO) that set out to increase world· wide awareness .of COPD and decrease morbidity and m.ortality from th e disease. 6 According t.o GOLD, COPD is defined as a "disease state characterized by air· flow limitation that is not fully reversible. The airfl.ow Iimitation is usually both progressive and associated with an abnonnal inflammatory response of the lungs to nox· ious panicles or gases."6. p 6 Disease severity is based .on both clinical sympt.oms and measurements.of airfl.ow lim· itation. See Table 15 . 1 for the c1assificati.on of severity of

COPD.

Risk Factors Risk factors for the deve lopment of COPD contain both host factors and environ mental factors . Host fact.ors that w.ou ld make a person more suscept ible t.o the development

of COPD would include hyperreaclivity of the airways, overall lun g growth , and genetics. One welllcn.own genetic cause of COPD is an a lpha· ) antitrypsin deticiency.9 Recent stud ies have al so investigated inflammatory mediated ge nes that may influence the development of the di o;ease . 1o Environmental factors th at contribute to the developme nt of COPD include primary and sec.ondar y tobacco smoke a~ well as occupational exposures , and indoor and outdoor pollutants.o Cigareue !)moking is the major envi· ronme ntal causal agent in the development of COPD.6 The re is ,I relationship between the Ulll.ount and duration of (: igarell c 1>ll1oking and the severit), of the lung disease. although significa nt individual variation does exisl.!i It is perpleA lIlg that nOt all ~Illoker~ de\'cJop airway inflammalion and that not all persons with ::-airway inflammation go o n to dt: \l!l op clini cally !'a glllficam OPD. It would appear th.'" the development of COPD rc~ults from a combi nation ot host and environmental factors.

564

Vhy... ical Rehabilitation

Table 15.1 The GOLD Classification System for Severity of Chronic Obstructive

0: AI Risk

I: Mild COPD

Disease

• Normal spirometry

,

• Chronic symploms (cough, spulum produclton) • FEV,IFVC < 70% • FEV 1 ~ 80% predicted

,

__________________~.~VV~ilh~o~r~w~il~h~O~UI~c~h~r~o~ nl~·c~s~y~m~p~l~om ~s~(~co~u~g~h2'~s~p~u~lu~m~p~r=od=u=C=I~10~n~)___________________ 1 II : Moderale COPD

• FEV,IFVC < 70%

.

• 50% :::; FEV 1 < 80% predicted

,

____________________~.~VV~il~h~o~r~w~i~lh~O~U~I~c~h~ro~n~ic~ sy~m~pt~o:m~s~(c:o:u~g~h~,~SP=u=t=u~m~pr_o_d_u_c_tlo_n~)~_________________ III : Severe CO PO

I

• FEV,IFVC < 70% • 30%

!5

FE V1 < 50% predicted

.

• VVith or without chronic symptoms (cough, sputum production) IV: Very Severe COPD

• FEV ,IFVC < 70% . . . • FEV, < 30% predicted or FEV, < 50% pred icted plus chronic respiratory failure

Classification based on postbronchodilator FEV l ' FEV 1 = forced expiratory volume in 1 second ; FVC = forced vit.al capa,city; respi r~tory f~i1ure = arterial partial pressure of oxygen (Pao 2) < B.O kPa (60 mm Hg) with or without artenal partial pressure of CO2 (Paco2 ) > 6.7 kPa (50 mm Hg) while breathing air at sea level. Repnnted with permission, NILBIIWHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary.6 .

Pathophysiology COPD is a combination of airway narrowing, parenchymal destruction, and pu lmonary vasc ular th icken in g, These changes are related to chron ic airway inflammat ion and are most pronounced in the peripheral airways. In addition. there are imbalances of proteinases/antiprOleinases and oxida nts/an tioxidants in patients with COPD.6 Chronic inllammation. characteri zed by an increase in neutrophils, macrophages. and T Iymphocyles, damage s the endolhelial linin g of the airways. Airway damage re sult s in airway repair. leading to airway remodelin g. These a irway changes appear to be most pronounced in the smaller pe ripheral airways· The glands and goblet cells within the bronchial wa ll s hype rtrophy produc ing excessive secreti ons, which ei ther partiall y or completely obst ru ct the airy, ays. Decreases in cil iary functio n and alterations in physioc hemical c har<:tcter i[)t ics of bronchial ~ec re ti ons al so impa ir airway c learance and contribut e to airway obstruction. Damaged and inflamed mu cosa show s an in creased ~en ') itiv it y of irritant receptors within [he bronchial walls, which in turn cause bronc hial hyp erreaCli\'ily. During in~pifati on, the lun gs and the airwa y~ are pu lled open, jJ1cr~as ing the diameter of the lumen. During ex halallon, a ~ the thorax retum~ 10 ils resting position, the airway~ dec rease in siL.e. In COPD, the airways are pulled open wide by rhoracic ex pan:-,ioll . allowing air 10 enter. During exhalation, the airway narrowin g from inflammation , remodeling and exce:-,sive &ecretion ~ , cau~es premature airway c1o~ure , trappin g air in the diMal airway~ and 'ilr~pace~ . Thi ~ ai r trapp ing i~ call ed hyperinflatiun, which

is defined as an abnormal increase in the amount of air within the lung tissue. The most common parenchymal changes found in COPD are di latation and de struction of the respiralory bronchioles. which is Ihought 10 be due to an imbalance of proleinases and antiproteinases in the lung.6 This change in pulmonary ti ss ue results in loss of the nonnal elastic recoil prope rt ies of the lungs. The pulmonary vasculature is also altered early in Ihe development of CO PO, There ate endothelial changes Ihal resu lt in thickening of Ihe vessel wall. In advanced stages of the disease, there is destruction of the pulmonary capillary bed' Ventilation in the alveoli and pertl/sion in the capillary membrane are no longer malched, This results in hy(JOl· emia, a cond ition in which a decreased amount of oxygen is carried by Ihe blood 10 Ihe tissues. As the disease pr0gresses and more areas of [he lung become involved, hypoxemi .. will worsen and hypercapllea, a condition in which the re is an increased amount of carbon dioxide within th e arter ial blood, will develop. Increased puI. monary vascular resistance secondary to capillary "'~ damage and des tru ction and reflex vasoconstriction ID the pre~ence of hypoxe mia and hypercapnea resul15 ill righl ventric ular hypertrophy. lemled ('or plt/mo",,/t, Polt cythemia, 3n increase in the amount of circulating red blood cells, is another complicalion of advanced COpO.

Clinical Presentation I'alien" with COPD will present wilh symplOlllS at chroni c cough , expectoration. and exen-ionaJ dyspacL ".

Chapter 15 Chronic Pulmonary Dysfunction

565

~~~~~3C:<0C-- Barrel-chested thorax

Pressure

~'+--+- Flaltened diaphragm

Protruding abdomen

Figure 15.4 A lteration in alignment of fibers of the diaphragm due to hype rinflati on. (From Levangie, P, and Norkin , C: Joint Structure and Func tion . ed 4 . 2005 . P 204. with permi ssion .)

clubbing may all be present in the advanced stages of COPO. ( See the secti on o n Examination for clarification

of tenn s.)

Figure 15.3 Changes in lhe configuration o f Ihe thorax with ChrOD1l ob<;trucll\'e

pulmonary di::.ease.

Significant and progressive airway limitatio n is reflected in altered pulmonary function tests. Lung volumes and capacities, espec iall y residual volume and functional residual capacity. 3re increased from the normal value due to air (rappi ng. Fi gure 15 .5 shows the chan ges in lung volumes and capacities th at occ ur in obstructive pulmonary disease.

inten~HY

of each !!.ymplOm varic!'I from patient to patient. Cough and expeclOration appear slowly and insidious ly. D~ spnea IS first e'ddenced during exe rtion. As the disease

Normal

progresse.!., :-.ymptoms \\'or~ n . Dy~pnea occ urs at progres~i\'el) lo\,.,er activi ty leveb. Severe ly involved pauems may

IRV

appear d) ::.pnclc even a1 rest.

On ph~ ~ILal examination. the tho rax a ppear::. enlarged oVdn£ 10 lo.!.s 01 lung ela~lic recoil. The anten or- poste ri or (API diameter of tht: che... , in crease') and a dor::.al kyphosb IS noted. The::.e analOnlical change~ g ive the plill e nt ;} barrd--che::.t appearance (Fig. 15 .3). The restlog po.. llion of the thorax b in :t more inl-opir..uory mude. there I!! J decrca ...ed 3\atlable range of Illotio n, I.e., deuea~d (hOl"tlCH; e>.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

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'EAV Expiratory reserve volume I RV ' InspIratory leserve volume RV ReSidual volume TV Tidal,",olums

Figure 15.5 Lung \\lIUIIll" uf a Iwalth} puhnol'Uu) llt)stem lomp.ll cd \\ Ilh the lung volume, tou nd 111 l)b~ Iru\.'tl'wr: db~ase . {Ad"PIl'llll o nl KOlh' ICIIl. J. Ri). 'i. ami \\'011. S: The Reha~il i · Idllun S rk:lHt1I~I \ Handbu{lL . FA D"VI:' , Phtluddphld, 2005, P 41K \.\ till pcrnll~),J on )

566

Physical Rehabilitation

Expiratory flow rates, especia lly FEV I' are dec reased. The ratio of FEY to FYC is also decreased « 70 percent). . These change~ in pulmonary fun crion do not show a major reversibili ty in response to phannacological agenls. . . Arte rial blood gas analyses may refl ec t hypoxe mi a J11 the earl y stages of CO PD. Hype rca pnea appea rs as the di se ase progresses. Wit h disease progress ion. c hest rad i· o{! raph l:i show severa l characte ri sti c fi ndi ngs. T hese include d~ pressed and flane ned diaphragm ; al le rati on in pulmonar.y vasc ular mark ings : hyperin Oa tio n of th e th ora x, eV Idenced by a n inc reased A P d iameter of the chest: and an inc rea!':!c in the size of the retrosle rn a l airspace. hype rlu cency. elongation of th e heart. a nd ri ght ve ntri c ul a r

,

hypertroph y.

Course a nd Prognosis The clini ca l course of COPD has an insidious onset with a disease progression that can run fo r many yea rs. Early identifi cation of those indi viduals at risk for the developme nt of COPD has been elusive. Whil e smoki ng is the most preva lent risk fac tor fo r the developme nt of disease. on ly a percentage of smoke rs develop cli nical ly signi ficant lung disease. T he refore, a smoki ng history in and of itse lf is not predictive for the deve lopment of COP D. Ce rta in pu lmon:l ry function tests. for example, mid-max im al expi ralOry fl ow rate, once thought to be ind icative of potenti al disease. also lack predi ctive val ue. Stage 0 COPD of the GOLD guidelines (clinical comp laints of cough and sputum produ ction withou t pulmonary fun ction test ab no rmality) is c urrentl y proposed as a wa y to ide nti fy the population at risk for the deve lopment of COPD .6 Some patient~ m3) demonstrate these cl inical findi ngs for many )ears before deve loping si gn s and sy mptoms o f airway limi tation. However. recen t research has not prove n stage 10 be a predictor of future di sease. II . II Once COPD is e"lablbhed. e>..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 <.Ilkred ~e c r~ tlon .." fc" ullln g III airway obs.Jrut:l ion and hypcnnfltlli on E:\agge r~tc.:d and ... u... I
567

~ I veolar units. Ventilation and perfusion within the lungs

are uneven. Fibrotic chan ges are ultim ately found in the lung parenchyma .

Diagnosis The diagnosis of CF may be suspec ted in patients who present wilh a positive famil y history o f th e di sease, with recurrent res piratory infections from Staphylococcus aureus and Pseudomonas aem[;inosQ, or with a diagnosis of malnutrition and/o r failure to thri ve. A chl oride concentration of 60 mEq/L found in th e sweat of children is a positi ve tes t for th e diagnosis of CF. Genotyping for the most common CFfR mutations can also be done.

Clinical Presentation The clin ical prese ntation of C F can be re lated to any number of invo lved syste ms. Failure to thri ve due to gastrointestin al dy sfun ction, diabetes du e to pancreat ic dysfunction or frequent re spiratory infections are all poss ible prese ntati ons of the di sease. The severity of the di sease, wh ile quite varia ble, has bee n linked to the classification of th e CFfR mutation.22 With pulmonary invo lvement, a patient presents with thi ck bronchial sec retions that may be difficult to clear. With advanc ing di sease. the chest wa ll will become "barreled" with an increased AP diameter and an increased dorsal kyp hosis. Hype rinflation causes a decrease in thorac ic exc ursion. Breath sounds may be decreased with adventiti ous sounds of crackles and wheezes. Hypertroph y of accessory muscles of ve ntilat ion, pursed-lip breathing. cyanosis. and digital clubbing may all be presenL Pulmonary function studies show obstructi ve impainnents including decreased FEV I' decreased FVC. increased residual volume, and increased FRC. The abnomlal ve ntilationperfusion relationship within the lungs res ults in hypoxemia and hypercapnia, as shown by arte rial blood gas analysis. As the di sease prog resses. destruction of the alveolar capi llary network ca uses pulmonary hype n ension and cor pulmonale. In advanced di sease, chest radiographs show diffuse hyperinflati on. increa .. ed lung marking. and atelectasis.

Course and Prognosis Although ~ornt: pmicills die in infanc) and early l'hildhood, the 1l'Hljority of palienh currently s un ive mto adu lthood. Life e.xpecta ncy continues 10 increa....e o\~ ing to ~d\'a nces in e arl y diagno'i s and improved Illedicc huoi agc .~1 Re.,piratoT) failure IS the 1110 ... , frequ ellt c.tu.,e of death in palie nb wit h CF. Theretore. tr(':\lm Cllt (11 [he pulmonary U):-.fUIlC lioll induding removal of tht: ahnOnllill ~e nL' t i(ln :-. and prompt Irf":ltment ot pulmonary infcl:tions. l~ le y to Ihe management of CF. G .. ~ tf(Jilllcqll1al dy :. . hllKlioll frorll C'F ('an be aided by plOpcr dIet. Vltullllll ~ upplen1('llh. ;.Ind rcpldl..'l."'l11clU uf

p

568

Physical Rehabilitation

with 8-year survival Y Nutritional stat us 25 prcdi clOT of prognosis.

IS

Normal

Restrictive

correlate " fiItness .IS ~ strong pancreatic e nzymes . Aerob Ie ~

r

a lso a powerfu l i!:-

IRV

0

Restrictive Lung Disease

""" '"0 -'i" """

~

ERV

0

j-

-'i"

AV

Pathophysiology The particular change s occ urring within the lun g ti ssue (parenchyma) and pl e ura depend on the e ti olog ical factors of restrictive di sease. Parenchymal c han ges often begin wi lh chroni c inflammati on and a thickening of the alveoli and int erstitium . As the di sease progresses. di stal airspaces become fibrosed , makin g the m more resistant to expansion (i.e .. less distensible). Consequently. lung vo lumes are reduced. A reduced pulmonary vascular bed eventuall y leads to hypoxemia and cor pulmonale. Asbestosis (asbe~tos- induced pulmonary fibrosis) is a type of restri ctive lung di sease that shows both pare nc hymal fibrosis and pleura invo lve ment in the form of pleural plaqu es. These c hanges may be due to injury or inflammatory reac tion~ that ultimatel y lead to pare nc hymal and pleural fibro s i ~.

Cljnical Presentation Dy spnea h:, the c1as~ i c sy mptom of re ... tril' tive lun g di sea~t:~, A nonproductive cough is often encountered : weak.nes!' and early fatigue are abo commun. Sign~ of reMnc ~ ll vt: lun g di1\ea ...e mclude rapid , shallow bre.tlhing: limited ch!!.:.! expansIOn; crac kles , e!)pI!cia Uy over Ihe lower luno lie ld~; digital clubbing; and cyanosi.... 2b co In the t!a rl y ~ t ages of parem:hymal reMril'li\e di.!.e a~e , the e he!!. t radiograph reveals line interMllial marJ...ing ~ defined a.... a grou nd gla~~ appearance , honeYI'{Imblilg. , isIble IIltralobuldr bronchiole~ , and fibroll c con~ohdJli()n ~. Reduction III lun g volumes ('an be 1\ccn t:oenally on e he')l

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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

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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 cess
Smoking Cessation Smoking i:-. the major caus;!! agent in the developmen t of CO PD. a~ well ;]:-. a contributin g C;]U!)C 10 many ot her di sease procc~~cs . Smoking cessation is the most imporlant intcr.enlion for improv in g the outcomes of pal icnt :o. with CO PO .~· Sl11o~ing

increa:-.c" th e annual ral e of dt'cli ne of lung function a:-. mca:-, ufcd by FEV 1 fro lll - 25 ml/year in a non-slllol-.er to - ·W ml/ye ar in a s.moker. }!! SmoJ..ing cessa-

tion ... how:-, an initial ::,mall recovery (2 percenl) in FEV"

hut more imporlalllly. the an nual fa tc of dec line of lun g fu nction w:.t<.; approxima tely ha lf th e rat e of continuing :-nwJ..e r:-..~~ Therefore. spec ial foc us o n the be nefit s of bemg a nOIl!'!11loJ..er and in terventi on for sliccessful smokIng ce ... "a11011 :-.houl d be incl ud ed in th e medi cal manage·

Phannacological Management Pharmacologica l agent s provide relief from the symptoms of chronic lung disease and improve ment in the health and functiona l statu s of indi vidua ls wi th lung dise ase. Each different pulmonary diagnosis and the severity o f that dis· case w ill require a tailored plan of care . Table 15.2 shows the recommended treatment s according to the severity of COPD as described by the GOLD standards· It is not unusual for patients to be on a combination of drugs for the management of their pu lmonary di sease. Th ese drugs can affect exercise perfomlance. heart rate. and blood pressure, both at rest and with exercise. Thi s

ment of patienl~ wit h pu lmonary dise ase. There are man~ t ype~ of smokin g cessation program s. such 3 :'1 eduC~Hion. behavior modification , "cold IUrkey:' d]\'Cr~ion therapy. aversion therapy. nicot ine gum. or nico· tine patch . Ad"lce from a cl Jni c i ~Jn. coun se ling. and be hav· lOr therapies can increase the sm.-cess of a pati ent's intent to qUlI "moking. Nicotine repb ce mcni th erapy either by patch . gum. or spra) ma y improve cessa ti on rate s even further. ~ In th e Lung Health Stud y. a comprehen sive treatment approach including physician recommendation ,

Table 15.2 Suggeste d Pharmacological Manage ment Based on the GOLD Classification of Severity of Lung Disease.

~d

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Characteristics

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• Chronic symptoms • Exposure to risk factors • Normal spirometry

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.: Mild

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. . .... ,:'.

t ~•

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• FEV,IFVC <

• FEV,tFVC <

• FEV,/FVC <

70% • 50% ::5 FEV 1 < 80% • With or with· out symptoms

70% · 30% :s; FE V 1 < 50% • With or without symptoms

70% • FEV 1 < 30% or FEV 1 < 50% predicted plus chronic respira· tory failure

I

--

569

Avo idance of ri sk factor(s) ; influenza vacci nation

-.-

- t---

Add short-acting bronchodilator when needed f------ - - T Add regular treatment with one or more long-acting bronchodilalors

-

,

T t

-

- t- ---- -

L I I

,

-

-

+_Add rehabilitation --

-

-

--

Add 1I1haled glucocorticosteroids if repeated exacerbations

-- --- - - -

I

,

I

J

I

,

I

-

" Reprinted With permIsSIon . NILBt/WHO Global Initiative for ChroniC Obstructive Lung Disease (GOLD) workShOp summary II

- --

--

Add long-term oxygen if chronic respiratory failure Consider surgical treatments

--

-. -~

570

Phvsical Rehabilitation

Table 15.3 Common DTUgS Used in the M e d·lea I M a nagement of Patients with Chronic Pulmonary Disease

Maintenance

Bronchodilatio n

Alrave n!

Anticholinergic

Throat irritation Drying of tracheal secretions Tachycardia Palpitations

L o ng ~ a c tjng

Serevent

Bronchodilation

Tachycardia Palpitations GI distress Nervousness Tremor Headache Dizziness

Flave n! Prednisone

Reduces th e infl ammato ry

Increase BP Sodium retention (edema)

Beta;.> agonist

Steroid s

response

Muscle wasting

Osteoporosis GI irritation Atherosclerosis Hypercholesterolemia Increased

susceptibility to in1ection Intal

Cromolyn sodiu m

Prevents the inflammatory

response Leukotriene receptor antagonist

Blocks allergic

Singulair

reaction

(bl ocki ng leukotri enes)

Throat irritation

Cough Bronchospasm GI distress Sore throat Upper respiratory tract infection Dizziness Headache

Nasal congestion Rescue

Short-acting Beta .. agonist

Al buterol

Bronchodilation

Ven tolin

Tachycardia Palpitations GI distress Nervousness Tremor

I

Headache

L

- - - - --- ------ --- ----

d l ...CU ... SlOn will provide inform.ttion on bOlh maillh::narK'1' drug~ ~lIld n:~cut' drug ... u.:..td JIl th e ca re 01 p:tticnl~ \.\ illl pu lmnn;Jry cll"e
Maintenance Drug,,riw·,

L·,.h::gt JI) o f drug~ j,> u ... ed to . t:-dUl'C or rnll1lmi/ ...• pul

monar)

'»

mpH.rrL... throughout th l! d,.),. 'I he ......• liru!! s 1(,l1d In

be- talL'll IHl J Il:g ular ...liu·duk A ntl chulllh:'lgJl:'. Ion!!

i.tL IIIl g.

HJ

i.. 1.!1..' p

':»

lupt onl , at b,.),

lx-tLl.! agOlll ... ' .... ' h."rold:., l;l lJ-

Dizziness -

In nlY ll ,lldIUITI. and l e u~Olfiene a nt agoni sts are coom~Y pll:"cnt,...'J drug..; for P:IIICllb \\ ilh ch roniL' pulmonary disea\t:!. Tht'oph) IlIlh.: . \.vhlk an ~frel· ti ve drug for the m al1I11:: nt of l' hronlL pU lmonarv dist'Jses. i. . le . . s fn: quendy pre-

'>cn br..: d "..., lh ert' .tr. .' "aft:~ Illrdications avai lable for the J11 ~liilll'nanl'4;; of ~ hronil.· pu l monary dis(ase. RouLCS, of i.1Jmilll')tldlio li l lf Il1,HIlI~nall\.'~ J rug~ are usually jnhal~ or JIl gc, tu.m, \VI1l'n tn h.t ldllOIl is (:'ff~(: t ive, it is the. adv'"

ahle f(\1J1t" 01 ~ldmlnl'lnttilln u ...

t' II Cd ... ul lh"'~"'t·

drug:-.

It

limirs systemi.c "Side

Chapter 15 Chronic Pulmonary Dysfunction Inhaled anticholine rgics are a commonly prescribed drug classification for patie nts with COPD.32 Their action is to promote airway smooth mu scle relaxation. thus promoting bronchodilat ion. Inhaled long-acting beta agoni sts are also used to bl ock smooth muscle constriction in patients with chr~mic pulm.ona~ di se~e, thereby prom~t­ ing bronchodiJallon. Ster~ ld s. either mhaled .or systeml~. are the mainstay of medical management of the chromc eosinophilic inflammation of asthma. 16 Steroids do not appear to have the sa me pote nt affect in the management of COPO. Therefore. inhaled steroids are used as a com plement to bronchod ilalors. lnhaled cromolyn sodium is used to prevent the inflammatory response by stabilizing the mast ce ll within the alveolar units . Used prior to exposure of a know n tri gger for bronchoconstJiction, eromo lyn sodium can prevent airway narrowing before it can begin. 11 is therefore helpful in pati ent s with predictable bronchoconstriction. such as exercise induced bronchospasm. Leukotriene antagonists a re systemic drugs that reduce airway inflammat ion and relax airway smooth muscle. Again. all of these mai nte na nce drugs are used for the long-tenn manageme nt of chronic lung disease. They are tailored to the severi ty of disease, the patient 's symptoms, and response to the medication.

571

bacteria. The action of these drugs is either bacteriostatic or bactericidal. There are many categories of antibiotics (e .g .. penicillins. cephalosporins, tetracyc ijnes) that are effective on different organisms. It is important to identify the infecting organism in order to prescribe the appropriate antibiotic. The Alliance for the Prudent Use of Antibiotics

(APUA ) encourages the use of antibiotics for only diagnosed bacterial infections to reduce antibiotic resistant strains of bactcria.14

Supplemental Oxygen The use of supplemental oxygen has been shown to prolong the survival of patients with COPD whose resting Pa02 is lower than 60 mOl Hg.]5 An absolute indication for use of long-tenn oxygen therapy is an arterial partial pressure of

oxygen (Pao,) of 55 mm Hg or less. which correlates with an Sa02 of 88 percent or less.36 If a patient is limited in the ability to exercise due to dyspnea. then supplementa1 oxygen may be warranted Y Patients with nonhypoxemic COPD may be able to more rapidly increase their exercise capacity using supplemental oxygen. lll The amount of oxygen used should be titrated individually to maintain an 5a02 of at least 90 percent. if possible.]9 There are various delivery methods available: continuous flow. pulsed flow, and reservoir are among the most common.

Rescue Drugs Rescue drugs are used fo r a mo re immediate relief of break· through symptoms. Inh aled shon -acting beta 2 agonists are used for thi~ purpo-,e. Patie nts are advi sed to use their prescribed inhaled ~h on actin g beta., agonist on an as needed basis. rather than a ~hed ule. I(a patie nt repons the frc quem use of a rescue dru 2. it is ind icat.ive o f a flaw in the malOtenance regimen or a change in the patie nt 's pul moo3T) status. Shon acting beta.., agonists can be used prior to the onset of 3tllvny lO enhan~e exerc ise perfo nnance. l 1 AJthough the mechanism of action of each bronchod ilator IS differen1. there may ~ an increase in resting hean rate and blood pTt:~sure with the ir use. Employing the Karvonen formula for e).ercl~ In tensity acknowledges the elevated reslmg hean rate and an appropnate target hean ra te can be (:aicuilued. Other common Side effec l ~ o f bronchod il a· tors m<:ludt:: nef\.ou\nt'~s. tremor. an'( iely. and nausea. T he ~I(ie eHeels of ~) Memic ste rOids. including oSleopoT0:' IIl, m)opathle~ . and muscle wasting. may TelJuire mod ificauon~ 10 an exerCIse: progrum "Iuch as mu~ le strengthening and lOlA ~ Impacl herl:IM!".

Antibiotics PUlmunaJ) mte(;tlol})) ate frt:que m in pat ienl~ Yo !ttl chronic pull1'k>n4l") dl~a<.,t. TIle) can be de"'~lafUlg 10 the pallem <md C411-.e major lloetbac L III pu lmonary re hab ilu3110n effon~. nle earl} \Ign of an IOte4:hOtl ar~ oflen noted b) son chilnge ml1te paucnt'llo ba.!.eltne !>lutuS (I.e., a change II'l kn.L'ot:: dblht) . d)~po .. , color or amount of putUIIl. or an mcrc:a~ III Ihe u c of re~ue i nhaler~}. Anubioti(";) are Ulotd 10 Imerter "lIh the grov..l h and prolde- Id.1I 0n of

Surgical Management The re are few ))urgical options for the patient with pul-

monary disease. Lung volume reduction surgery (LVRS) is a surgical technique that removes nonfunctional , overdistended lung tissue , in order to restore the norma] biomec hanics of the thorax . Patients with heterogeneous e mphysema have areas of the ir lungs that are relatively no nfunctional along with functional lung tissue. The

surgical procedure removes approximately 20 to 35 percent o f the most di seased lung tissue , relieving the more nonnal lI ssue of its burden. The purpose of the swgical procedure is to decrease residual volume and functional r.sidu. I capac it y (i.e .. decrease hyperirulation). This a ll ow ~ fo r a more no nnal resling posltion of the d ia phra gm \I, ith a po~s ible inc rea.!'>e 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<.:lfiL antic ipated goal-, and e\peclc-d outcome ... fo r the IIHJI\Id uaJ pati ent with pulmonal") Impairmen t i, ba!-oted l)1l tht:' JollnwlOg general goal~ : • lncre;J ~eJ under... landlllg of pallent and famil y of di ...ea,e procc . . ..,. t:'\ pc{.t.1t l o n ~. goaI-" and Oult·OIllt: .... Inc:rea . . ed L..lrdlo\3 ...l:ula r l!nt.iuTance, I nul.:i.I 'lt:J ... m.:nglh . !JO\." er• •JIlt! enduJ.IIlI,.·C' 01 pcnphc r.tJ mU"'Ll e~.

IllIpru\·ed pal onnance of ph )~ I c.:i.t 1 ta , k.... both ha'll( o j dad) li\lllg and lIl ... l l ulHl'nlal a(.'tl\III~ _'" i.lt

i.I t: lI\I!le ,

dull) 11\ 111 14.

InclcJ ...cd .. trcngth . pm... cr .tnt! clldu rJIl(.;e 01 \cl11ll.,h.lr) !llu .. ,,: le... .

ImpnJ\t"d InUI'IX' ndcllu; III ;:l lr\\,!) (1t:~lrt! I)t: Lfea ..cd

No Breathlessness

Figure 15.7 The visual analogue <;calc iii an empty \o'enical line with end caps labekd "GreatC$1 Breathlessnelis" and "No Brcathles,nes!-ot." The patient IS a<;ked to mark the point on the l ine Ihal reflects hi s le\eI of breathlc !-ot~ ness, (From Mahkr. 0, CI

al..Jq p 2 15. wi th penni s~ion.)

Examination The examin alion of a patie nt 's pulmonary status has stY. eral p u rpo~e::.: ( I ) to evaluate the appropriateness of die: pa ti ent' s parti cipati on in a pulmo nary rehabilitation pr0gram : (2) to de lermine the therapeutic measures mosr approp ria te for the part icipant 's treatment program: (3)10 moni tor the pa rti cipant'~ phySIOlogical response (0 em· CI.,C; and (-l) to app rop ri ate ly p rog fe ~s the partkipllllr's Irt,'all11ent program O\,e r ti mt: .

Pa tielll History

A patie nt imen i. . \~ ... hou ltl beglJ1 \, ith the chief complailL

the ralil"nl '~ jX'n..:C' ptil)Jl of\\h) pu lmonary rehabilJ~8i bei ng ... oug ht. COll1rnonl~. tht' ,:hief complaint ls • ... h1.m nc ...... of brc,uh and/or 10"" of function, QuantifyiRI d) .,pnca <11 thl' ht.' l!lJ1lllllit and the ~nd of a rehabil..ilallDa progrJIll .tnL! dUring peruxh l ) f c \ a'-.7t:rtxuion can be ace.pl .... hcd Ihrilu~h J \ i ... u,\1 .tIIJ lug ... calc- (Fig, 15.7) or ..

-

U lHt'/IIIt' O}\/Jlh',' IflJl'1

-

(Tuol\! 1 5 .4 ):~u.'O Quality 01. tifr

IIW.t,\url"!\ . . m·h a . . tht' ,\ f3 () o r the Chrnmc Rt,\'p4'fOIIJI'1 ()lIt '\1I01IlWfl t 11\<1) ,tl"'\1 he h""' l' ful in detemuninl dle !'.ull·m " h""dml' h\.',tlth -ICJa lcd quall l) o f Hfc,R'2 ,,,-_ il,-Il hhlOJ) l'unt ;um [h:' rUncnl pu lnw n.uy !oo),mpl0m5" '- lIlr 10 thai p.III(,11I I.'Dugh. \ putum prO\.l U('II01\. w~ anti . . htlrlllc 'l'" 01 h rC'~tlh (A-('up.ulona1. ..ociaL rncd" aM 1I11d 1.111111) hl!-othlfle ...... holiid ..tho Ix rc;:cord~d,

\("" a nd !\1"a..u .." , Ilul "'gn .. h: 1l1 1k l',1I111C ,lilt! I'C"' IiI1~ oh.xxi pr«!\~lIre . ht'an .... -I I:\IIII.II\JJ) ,"He !\huuld tx,. uetl'n1l1l1cJ Ilnd rec:orcMd ....

Table 15.4

I

,

Biias~e~'~i~n C~'i~~~~'n~d~C~'X~~~~~~!~~~~~:;~~~~ii!~[!

_G_r_a_d_e_4: ---':;0 l;;'pa~t.Abi;to carry out usual actIVIties and occupation Without shorlness of breath.

Grade 4'

Extraordmary. Becomes short of breath only With the greatest Imaginable effort. No shortness of breath With ordinary effort

Grade 3

Slight ImpaIrment. Distinct Impairment in at least one activity but no activities completely abandoned. Reduction in activity at work or In usual activities that seems slight or not clearly ca used by shortness of breath.

Grade 3

Major Becomes short of breath With effort dlslinctly subma)(lmat. Tasks performed Without pause unless the task reqUires extraordinary effort that may be performed With pauses

_ __ Grade 2'

Moderate ImpaIrment. Patient has changed jobs and/or has abandoned at least one usual activity due to shortness of breath.

Grade 2.

Moderate. Becomes short of breath With moderate effort Tasks performed With occaSional pauses and requIre more lime to complete than the average person .

_ _ _ Grade 1:

Severe Impairment. Patient unable to work or has given up most or all customary activities due to shortness 01 breath .

Grade 1:

LIght. Becomes short of breath With little effort Tasks performed With little effort or more difficult tasks With frequent pauses and reqUlnng 50-100% longer to complete than the average person might require

I - - - Grade 0:

Very Severe Impairment. Unable to work and has given up most or all customary activities due to shortness of breath . Amount Uncertain. Patient is impaired owi ng to shortness of breath, but amount cannot be specified . Detail s are not sufficient to allow impairment to be categorized. Unknown. Information unavailable regarding impairment. Impaired for Reasons Other than Shortness of Breath. For example. musculoskeletal problem or chest pain .

Grade 0:

No Effort. Becomes short of breath at rest, while SItting. or lying down. Amount Uncertain. Patient has hmlted exertlonal capaCity due to shortness 01 breath. but amount cannot be specified Detads are not suffIcient to allow Impairment to be categorized Unknown. Informatton unavailable regardIng limitation of effort Impaired for Reasons Other than Shortness of Breath. For example. musculoskeletal problem or chest pain

W:

x

y.

Grade 4:

Extraordinary. Becomes short of breath only with extraordinary activity, such as carrying very heavy loads on the level. lighter loads uphill, or running. No shortness of breath with ordinary tasks.

Grade 3:

MaJOr. Becomes short of breath only with such major activities as walking up a steep hill, clim bing more than three flights of stai rs, or carrying a moderate load on the level.

Grade 2:

Moderate. Becomes short of breath with moderate or average tasks, such as walking up a gradual hill, climbing less than three flights of stairs, or carrying a light load on the level.

Grade 1:

Light. Becomes short of breath with light activities, such as walking on the level, washing , standing , or shopping .

Grade 0:

No Task. Becomes short of breath at rest, while sitting , or lying down. Amount Uncertain. Patient has limited exertional capacity due to shortness of breath, but amount cannot be specified. Details are not sufficient to allow impairment to be categorized. Unknown. Information unavailable regarding limitation of magnitude of task . Impaired for Reasons Other than Shortness of Breath. For example , musculoskeletal problem or chest pain .

W:

X'

y:

From Mahler, D. et al.. 49 p 399, With permission .

W:

X: y.

-------

I

574

Physical Rehabilitation

Chapt er 4 ). An indi vidual's hcight should be measured as there is a direct relati onship between height and lung vo lume Weie.ht shou ld be measured on a stand ard scale and each' Sub~;qllentmeasure should be performed on the sam e scale.

Observation. Inspection, and Palpation By obse rvi ng the nec k and shou lde rs of a patient with pul monary di sease. th e use of accessory mu.sc lcs of ventilati on can be observed. A nomlal confi guration of th e thorax reveab a ratio of AP to lateral diam eter of 2: I . Destruction of the lung parench ym:l resulls in an increase in th e AP diameter and a reducti on o f th is ratio (up to I : I ). During inhalation and ex halati on both sides of the thorax should move sy mm et ri cally. era/lOsis i~ a bluish di scoloration of thc skin that can be obsc;'ved periorall y. periorbital ly. and in nail beds: it indicates acute hypoxe mi a. An indicator of more chroni c hypoxemia is digital clubbing of the fingers and toes. 1.11 ctubhing , there is an increa~e in the ,mgle created by the distal phalanx and the point where the nail exits from the digit. The tip of the di stal phalanx becomes bul bous (Fig 15.8). Auscultation of the Lungs Al/scIIlrmion involves li steni ng over the chest wa ll as gas ente r~ and exits the lungs. To perf0n11 ausc ultation of the lungs. a steth oscope is placed ti nnl y on the patient's thora x anteriorly. laterall y. and posteriorly. The patient is asked ro in spire fu ll y through an ope n moulh , then to exhale quietly. Inhalation and th e beginning of exhalation nonnally prod uce a soft ru stling sound. The end of exhalation is n0n11ally si lent. This characteri sti c of a normal breath so und is teml ed ,·esiclllar. When a louder, more hollow and echoing sound occ upies a larger portion of the venr ilatory cycle, the breat h sounds are referred 10 as hrol1chial. When the breat h so unds are very quiet and barely audible, th ey are termed decreased. These three terms-vesicular, bronc hial, and dec reased-allow the lis· tener to describe the intensity of the breath sound .53 [n addition to the nonnal and abnonnal intensi ty of the breath sound. there may be additional sou nds and vibralions heard during ausc ultatio n. These are called adrellfifioll s breath soullds. These sou nds are superimposed on the previously de sc ribed inten::.i ty of the brea th sound. According to the American College of Chest Physic ians and the Ameri can Thoracic Society. there are two types of ad venIllious sounds: crackle s and wheezes. 54 Crackles, historically termed rale~ , so und like the rustlin g of ce llophane. Whee:e s are more Illusical in nature . A decrease in the size of the lumen of the airway will create a wheezing so und, much as ",t retching the neck of an inllaled balloon narrow~ the pa!)sageway through which uir mu~( esca pe and produces a whj stling sound. Measurement of Strengt h Patient s WIth pulmonary disease may !>how periphe ral and/or ve ntila tory muscle weakness due to decondilio nin g,

c Figure 15.8 Digital clubbing is a sign of chronic tissue hypoxia. (From Effgen. S: Pediatric Ph ys ical Therapy, FA Davis. Philadelphia. 2004. p 307. with permiss ion.)

malnutrition , chronic hypoxe mia, and hypercapnea or steroid use. 55 Peripheral and ve ntilatory muscle weakness can contribute to exercise limitations and an inability to perform activ ities of daily li vi ng.56 Therefore, measure· ment of peripheral muscle st.rength and maximal inspiratory pressure should be assessed to determine the need for strength training during rehabilitation.

Laboratory Tests Various laboratory studi es may be performed to examine patients with pulmonary di sease. These include radiology. pulmonary functi on tests (PFTs), graded exercise tests (GXT), aneria l blood gas (A BO) analysis, oxygen saturation measurements (Sao:!), and electocardiograms.

Exercise Testing in Patients with Pulmonary Disease A detennination of functional capacity is part oflhe e;(am· inati on of a patient with pulmonary disease. A graded exercise fe st (G XT. exe rcise tole rance test) can provide the objecti ve infon11ation to ( I ) docume nt a patient's symptomatology and physical impa im1ent : (2) prescribe safe exer· cise: (3) documenl changes in oxyge nation during exercise and detem1ine the need for supple mental oxygen; and (4) identify any chan ges in pulmonary function during exercise interve nti on. There are a numbe r of testing methods available to determine the max imal oxyge n consumption and fuot> 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<: r~per~e d Yvllh rc~t period~,b·nu

EXt"rci:,e Inl('nsit) a ... a Pen:cn t of He:lrl Ra te Reserve Whl\t> u ... ing a perL:c.' nl agc o f \1° 2 rna) be the Ino~1 accunHI' Illl.!lhod of pre~c.Trbrng e"erc l ~e frolll a g r'.H.II'Li ~xe n: r ...e le ... l, JI doc" not gi\t~ tht' cil nruan a mealh hl munitor ..:xe rllsc Hlten!) rl ) during the perlo nllance of Ih ~ eXe rCI,e st!~~ ioll .

" he •'trt rate is a .commo nl y used parameter tor ExercIsmg . presc rr' b'I'S r exercise in tenSIt. y. r. he target heart " rat, rallOt 0) THR R) de fin es safety g Uidel ines fo r ex.e rc lse mtensity

~uring the treatment session, The ta rget heart rate (1HR) for a specific patient defin es the m ost appropn ate heart rate within the prescribed target he art rate range to enslUt

endura nce training . A comm on met hod 10 dete rmi ne the THRR and the T H R for pal ie nl popula tions is the he art rate restl'Vt method or Kan·Ollen·s!ornw la .64 The heart rate reserve is the diffe re nce be tween the restin g heart rate (HR reSl ) in the seated posit io n and the m axi m al heart rate (HR",,~)

achieved on a GXT. To calculate the THRR, percentages of the heart rate reserve a re added to the resting hean rate. T he eq uation for determi ning the THRR is:

Fo r examp le, on a GXT a patie nt achi eved a maximal

hea rt rate of 165 beats pe r minute (b/min), Resting hean rate was 85 beats/mi n. The heart rate rese rve is calculated to be 165 - 85 = 80 beats/min: 40 perce nt of 80 beatsl min;\2 + resting heart rate 85 = 117 beat s/min: 85 percent of 80 beats/min" + restin g heart rate" = 153 beatslmin, Thus. for this patient . a THRR of 117 to 153 beats/min has been calculated. Determ in ing the appropri ate THR (i.e. , where in this

wide range of 117 to 153 beats/min to exercise) reqWltS carefu l consideration of ind ividuaJ abilities and func:riooal limitations. Corre lating the THR w ith a percent of VOz. fro m the exercise test w ill he lp de term ine the most appr0priate exercise intensity. Patie nts with m ild to moderate pulmonary disease do not usually have a pulmonary Ilmitatioo to exercise, the refore , a maximal cardiovascular exercise ~ is like ly to have been perfOlmed. Fo r these patients. theTHR is often ca lc ul ated using a m inimum o f 50 percent and a maximum of 60 10 70 percent of the he art rJte reserve. In Ibc

above example, a THR of 120 to 136 beats/min would ensure cardi ovasc ular training. Patien ts w ith severe pulmonary impainnent will like ly approac h their ventilattXY maxi mum before their c ardiova.scu lar max imum is reached Ihill i ~, the ir maximal exercise heart rate may be lower drift the ir cardiova sc ular heart rate maxim um owing to pur. m Omlf) t'onstraint s. For these- patients, exercise inte(lSilies thaI approach the ir ma)"imul1l ve ntilatory limits or the upper end of the THRR . 70 It) 85 p~ rcent of heart rate reserve. CIP be uscLi .1r In Ihe e xample, thi~ would be a THR of 1:36.10 14 ~ beat"'/IllI IllHt' . II "I hould be emphasized that exercISC l nt("n~ lI) .... hould be pre~('nbed \\ ith an uppe r and lower-mtt:' limll, 110 1 a ... inglc numhcr. E , ercise In tensit y by Ra ting Pt'rceiv~ ExertiuD U\ ing heart rate parumeter~ for the l'rescriptioa. 01-CI ...1' IIll e rh it) rJOC"l nof directly add re~~ the cause ieJ.1 Irtllitali(ln 11\ p.lllt'nb with low velllilatory ~ R.lllng of pcrl'c lVc d c\crtlon (I.e., th!: Borg RPE ~ prov itt(' IIllJlonUIlI IIlformatJon abo ut ho w the pa&icIII ' "

of""'-

Chaptel" J5 Chronic Pulmonary Dy~function or perce ive s the int e nsity of exercise, i.e .. how he avy or strenuo us th e exe rc ise fee ls to the patient. The pe rce pti o ns are based o n the strain and fatigue of exe rcising mu scles (peripheral factor~) and fee lin gs o f breathlc-" s n c~s o r aches in the chest (ce ntra l faclO r ... ). 71 The Borg C R 10 sca le uses scores that range from 0 (no thin g at all) to 10 (ex tremel y stron g, maximulll pe rce pti on) (Tabl e 15 .6). RPE is ::I va li d and re li ab le ind ica tor of an individ ual's e\ercise tol erance and is highl y corre lated with HR and VO ~. Perce ived shonness of breath (d ys pnea) ha s bee n e>.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. Thc freq ucncy o f t!x.ercise i~ often depc:nd('nt on tht! in ten,u) Ih at c.m be .1Chleved and the duration that I.: .m be mall1t~lI n eJ . It 2010 30 mlllUle~ 01 con tIlHH.I U ~ dl..'fobi(.' e\e rci ...c Can he ~ll'lomp l i::-. h l.' d \\ itlllH lht' TI-IR . the-n thrt.'c to five ('v~n l) ~pal'l'd \\ or]..,Ouh 1'II;'r III t'C'].., .Ire rCl.:ommcw.led. M ore tre4u~nt e\er~IO;;C' "l~~'IOIl'l df\:" rccol11l11endeu for patit'm~ \\ IIh hm(, 1 IUlh. lI l\11.I1 .1bdII It'.':o. One to 1\1,0 d,uly :-.e''1iOll' ilJ\.' :Ilh l')ablc lor IMtlcnt ... \\ IIh \cr) it)\\ IUIl\,.·lionJI \.\ork

9

r.lp.II,:I IIC.!).

25 3

Moderate -

4

5

Strong

Heavy

6 7

to

Very strong

Extremely strong

"Max p '

Pulmonary RehabHitation

tt

•

Absolute maxImum

HIghest possible

For corr6C1 usag& oltha sc;ale th& e.o;act design and In::.lfuc· heo/IS gwen In Borg I:> 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~n<.~h.

rhe

l'h~C'l- ln

tll t,I]"'C \11,,1 ~lglll", Inl'ludJl1!! r~~(ing hcan r.Hc . rl.." pLf"I\II) rJI~, ,IlIJ hl()&.d pn.'.!),.'lIn:; .Iu~ultalton of tbe

578

Ph),sica l Re ha bili tation

lung. . , ;lIld weight. II i'i al~o the lime 10 discu . . ~ \\ ith palients thei r IllcdiC~lI ion sc hcdul r.:. any proble ll1 ~ Ihey have encounIcrl'd. and any change ... Ihal need to be nOled and addressed by " member of Ihe pulmonary rehabili lalioll teaJ1l. If Ihe p:tl ienl was found 10 have a decrease in FEY 1 of 10 percelll or more on the GXT. a prescri bed inhaler :-holi id be used al thi!'! time. If a palien! W~I'" fo und 10 have a signifi canl dec rease in (lx ygenalio n wi th exercise. the supp lemental oxyge n , holl id he readied at th i... time. Prior 10 Ihe aerobic pe riod of cxcrci~e. the parti cipalll pl'rrOnll ~ slrclching exerc ises 10 help prevc rll 11111 :-c ulosk~ le­ tal injurie..... Stre!c hing cxe n: ises should be pe rfonncd dunn g cx haL:ttion 10 prevt. nt a Valsalva maneuve r. which wo uld wur... en a pal1i cipa nt' s pulmonary capabilitie..,. Patients often U:-'l' acce . . :-.ory muscle . . of ventila!ion during the exerc ise prog ram: Iherefore. the neck and upper eXlremi lies should be incorporatcd il1 lO the ~.tretchi ng program. The wanTI -up (.'omponcl11 i . . a time 10 , lowly inc rease the HR and BP 10 ready the cardiova~c u lar ~y~t em for aerobic exercise. Th is is u'luall ) acc 0 mp l i~ h ed by performing the sa me mode of exerci... e thai will be lI ~cd in the aerob ic portion of the proI! ram but at a lower intens it y. with an emphasis on contro lled breathing. For example. cyc li ng wilh no resistance could be u<..ed as a waml- Up acti vit y for a patient with a biking program . The \'ann -u p portion of the program la~ l s between 5 and 15 minute~. The aerobic porti on of Ihe exe rcise ses~ i o ll consists of a mod e or modes of aerobic activit y at the appropri ate inten~ ity 10 mai nt ain th e THR of the exercise presc ription for the advised duration. This portion of the prog ram lasts for at l ea~ t 20 mi nu tes. The part icipan t can be monit ored by u!'! ing a rat ing of pe rceived shortness of breath . perceived exertion. heart rate va lues. respiralOry rate. and ox imetry. The aerobiC training peri od ~ h o u l d be followed immedi alely by a cool-do\' n period. This consisis of 5 to 15 minute~ 01 low-level aerobic activities that ~ l ow l y re lUrn the cardiova..,c ular s)''item 10 near pre-exerc ise leve ls. Aga in . there i~ ;111 cmp ha'l l:-' on co ntro lled breath ing. Finall y, :-.trelch ing cxerci~e!'! are repealed to maintain joint and mu ... cle integrilY and to help preve nt injur) .

Strength Training St rength of both uppe r and lo\','er extremities will i ncrea~e lib WJlIl appropriate Iraining. ' Strength !ra ining L:UI1 use similar m ode~ of eXerCI'ie 3!> the. endurann! Iraining \~ ith a change 10 higher re~I~lancc and lower repell t i on~ (i.e .. incrca...,c the grade of treadmill. lIl(.fea~t! re!>I~lancc on , li.llionary cyde or .JfJll ergollldcrJ. or we ig ht traini ng of Ihl: imolved lIlu .... cle g lf>Up~ can he pre'lt:nbed. Panicipanh '\hould be CIll"l)Uraged to reir<JHl f rom u\ lng the Yili'lal ... a m.lI1eU\l:r dunn g lr<JJIllng a~ thl '\ IllU ) Impair ve nt ilator) exdl;tngc and e rtel· t cxe rcbt pcrt oml'-lJKc. i'..xercis.e Progreho!'l>ion

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 <.I) 'II UIl~llon nft~n hav..: re:-.pintlor) ~efba\.' ks from exaccrlJl" tU)II ..., 01 the ll ( lI ~eibc. Contlll ueJ L"ontac l and eneOW'. . . . . III Ihe lonll oj" pemxhl' evaluat ion arc cssenliaJ 10 QlIinIIiiI

Chapter 15 Chronic Pulmonary Dysfunction the new level of physical activity. However. reimbursement for such care can be difficult to obtain. Patients are encouraged to join community-based groups that fac ilitate compli ance wi th their medical and exercise reg imens.

Multispecialty Team A diversit y of health professionals is essential to meet the medical. phys ical. social. and psycholog ical needs of the patient with pulmonary disease. The team may include a nurse. physician. physical therap ist. occupatio nal therapi st, nutritionist. pharmacist. respiratory care practitioner. exercise physiologist. psychologist, and most importantly, the patient and the patient's famil y and caregivers. Although aerobic exercise training is integral to pulmonary rehabili tat ion, patients require additional services and infomlati on to optimize their exerc ise capabi lity and to improve quality of life. The following section addresses other element s o f a pulmonary rehabilitation program : patient education. secretion removal techniques, ventil atory muscle training. and pacing. Smoking cessation shou ld also be considered as a component of pulmonary rehabi litation. Please see section on sm oki ng cessation in the medical management section of this chapter.

Patient Education The concept of self-management is promoted in the educational sessions of a pulmonary rehabilitation program. By using both indiv idual and group sessions for education, the benefits of both types of interaction can be attained. Partici pants are given individ ual , one-on-one time to identify their own needs and address issues that are partic ular to themse lves. Benefi ts from group di sc ussions include suppon from peers regarding the patient's fee lings or needs. learning from ot hers' e xperiences and qu estion s. and the ~cx..ialization only a group can provide. Key components of a patient education program are presented in Box 15.2. Education makes it poss ible for patients to assume the responsi bility for their own well ness. A patient wi ll carry out the req uired activiti es to produce the desired outcome onl y if the patient knows what to do. how to do it, and also Wants to do it. This theory of self-efficacy for the patient \I, ith pulmonary disease begins with a daily routine that IOcl ude~ se l f- a!>~essment . adherence to a med ication ~chcd ul (", pe rfo rmance o f airway clearance techniques. act iv llle~ of da ily liVin g with pacing. and a home exercise program . Se l f-~s~s!\ment is used to recognize the first sign of an exace rbati on o f the di sease (increased dy~pnea , dec reased exercise tolerance, change in sputum color or consiste ncy. pedal edema, or any other signilic3111 change from baseline). An exace rbation protoco l is devised for each patient thaI includes a se t o f standard in~truction s co ns istent with the panlcipant 'it di :<>ease and abilities. These behaviors may

579

Box 15.2 Education Topics Anatomy and physiology of respiratory disease Airway clearance techn iques

Nutritional guidelines Energy·saving technjques Stress management and relaxation Benefits of being smoke free Impact of environmental factors on COPD Pharmacology/use of MDls Oxygen delivery systems Psychosocial aspects of COPD Diagnostic techniques Management of COPD Community resources Exercise: Effects, contraindications. adherence COPO = chronic obstructive pulmonary disease: MDls = metered dose inhalers.

include the use of airway clearance techniques. pacing techniques, a change in the exercise prescription, as well as a call to the primary care phys ician for a review of symptoms and pharmacological management. Individuals can be taught to manage their lung disease through an educational program that addresses the needs of individuals with pulmonary disorders. Compared to educatjon alone, education as part of a comprehensive p ulmonary rehabilitation program produced significantly improved exercise abilities, decreased dyspnea, and greater self-efficacy." Once the patient has progressed through pulmonary rehabilitation, access to new infonnation and continued support is possible through community support groups (e.g .. the Better Breathing Club, sponsored by the American Lung A ssociation).

Secre tion Removal Techniques Secretion retention can interfere with venti1ation and the diffusion o f oxygen and carbon dioxide in some patients with pulmonary disease. Patients with secretion retenlion may improve their performance on an exercise regimen if proper sec retion removal techniques have been perfonned prior to the exe rcise session. TIle preferred practice pattern from the Guide 10 Physical Therapisl Practice for these individuals would be 6C-l: Impaired ventilation, respiration and aerobic capacity associated with airway clearance dysfunction ." An individualized program of secretion removal techniques directed to the areas of involvement can optimize ve ntil ation and therefore gas exchange capabilities. Sec retion removal techniques include dependent programs that rely on a careg iver (postural drainage, percussion, wld .haking) or independent programs such as the AClIl'e Cycle of Breathing Tcchniqut (ACBT), airway o. ci llation devices, Or Posili... £rpiralory Pressure (PEP) devices.

C h a pte r 15 C hronic Pulmonary Dysfunction the new le"eI of phy~ical activ it y. However. rei mburse ment for ~u c h care call be diffi cult 10 obtain . Patient,; are encou raged 10 join cOJ11 nllJ~l ity- ba.sed gr~u ps th ~1 facilitate compli :tm:c with their me(il ca l and exe rc ise regimens.

Multispecialty Team A diversit y of hC:J lth professional s is es senti a l to meet the medical. phy~ i c al. l<>oc ial. and psyc ho log ica l need s o f the patient with pulm ona~y di sea~e .. The team .m ay i nc lud~ a nurst.'. ph )~ic i an. physlc altherap lsl. occupa ll onal thcrapl st. nutri ti oni st. phamlrtc isl. respiratory ca re practiti oner, exercbe ph ysiolog i:..1. psyc hologist, and most import aml y. the pati ent and the pati ent 's fam il y and c areg ive rs. Althom!h aerobi c exerc ise training is int egra l to pulmonaf) re~habi lit al ion , patients require addi tional services and info mlati on to opti mize the ir exerci se capabi lit y and to improve qualit y of life. The foll owing secti on addre sses OIher e leme nt s of a pulmonary rehabilitation program: patient educati on. secre tion removal techniques, ve milatory mu ~ l e training, and pac ing. Smoki ng cessation should also be considered as a component of pulmonary re habilitation. Please see sec tion on smoking cessation in the med ical management sec ti on of this chapter.

Patient Education The concept of self-management is promoted in the educational ses!)ions of a pu lm onary rehabilitation program. By using both indi vidual and group sessions for education, the benefits of both types of interacti on can be attained. Panicipams are given individual, one-on-one time 1.0 identify thei r own needs and address issues that are panic ular to th e m se l ve~. Benefit s from gro up di scussions include suppon frolll peers regarding the pat ie nt 's feelings or needs. learn ing from others' experiences and questions, and the :..ociali zation onl y a group can provide. Key component s of it patie nt educ ation program are presented in Box 15.2. Education makes il possibl e for patients to assume the responsibility fo r thei r own wellne ss. A patient will carry out the required acti vities to produce the desired outcome only If the pallem know~ what to do, how to do it. and a lso \\a lll ~ to do il. Th is theory of self-e ffi cacy for the patient with pulmonary di:-.ease begins with a da il y rou tine th at includes se lf-a:..:..ess l11c m. ~dheren ce 10 a medication &.chedu1e, pe rform ance of airway cleara nce techniq ues , aClivilie!lo of dall y livi ng with pac ing. and a home e xe rc ise program. Self-a~se<j~men l i!> u ~d to recogni ze lhe first sign of an exacerbation of the disease (i nc reased dyspnea, dec reased exer(.;i\e tolerance, c hange in sputum color or consb lcncy, pedal edema, or any mhe r :-'Ignl fica nt change from baseIme). An exace rbation protocol i ~ deV Ised for e ach palle nt that mcl ude!) a !
579

Box 15.2 Education Topics Anatomy and physiology of respiratory di sease Airway clearance techniques Nutritional guidelines Energy-sav ing techniques Stress management and relaxation Benefits of being smoke free Impact of environmental factors on COPD Pharmacology/use of MOls Oxygen delivery syste ms Psychosocial aspects of COPO Diagnostic techniques Management of COPO Community resources Exercise: Effects. contraindications. adherence COPD = chronic obstruclive pulmonary disease: MDIs = metered dose in halers.

include the use of airway clearance techniques. paci ng techniques, a change in the exercise prescription. as well as a call to the primary care physician for a review of symptom s and pharmacological management. Individuals can be taughl to manage their lung disease through an educational program lhat addresses the needs of individuals with pulmonary di sorders. Compared to education alone, education as part of a comprehensive pulmonary rehabilitation program produced significantly improved exerc ise abilities, decreased dys pnea. and greater self-efficacy.74 Once the patie nt has progressed through pulmonary rehabilitation. access to new information and continued support is possible through community support groups (e.g., the Better Breathing Club, spo nsored by the American Lung Association ).

Secre tion Removal Techniques Secretion retention can interfere w ith ventilatjon and the diffusion of oxygen and carbon dioxide in some patie nts with pulmonary di sease, Patients with secretion retention may improve their performance o n an exerc ise regimen if proper secretion removal teChniques have reen performed prior to the exe rci se session. The preferred practice pattern from the Guide to Physical Therapist Practice for these individuals would be 6C- I: Impaired ventilation, res piration and aerobic capacity assoc iated w ith airway clearance dy sfunc tion.-4I:1 An individualized program of sec retion re moval tec hniques directed to the areas of involvement c an optim ize ventilation and the refore gas exchange capabi liti es. Sec re ti on removal techniques include dependent programs th at re ly on a caregiver (postural drainage, perc uss ion. and );o haJ.. ing) or independent programs such as the ACI/\'i' Cycle of Breathing Technique (ACBT), airway osc illation de\'ic~s. or Posim'e Expiratory Pressure (PEP) dev ice:,.

580

Physical Rehabilitation

UpPER LOBES AnI."ior

Bed or droinage

Bed or dfafnage \able fIal.

8tod Of dra'nagll table nal Pal,.nl It!an~ back II\OI'aPlSI

on pillow II 30" angI" it!JiI"lIOl

PilllefllllllaflS we' IoIded pillow al

Tlwfapst stands l>eflrnd It
on bot/! SIdeS.

RIGHT MIDOLE LOSE

LEFT UpPER LOBE Ungula, Seamet'llS

bed &ieval&d 16 ,nches Pel,~Jlt I,es I16Ad dOwn on leI! SIde lind roIo'Ites 't_ tum WQ:ward P""" may bt pIac8d behind lrom

Plltien1lies helld down 00 rigM side and rotates

FOOl 01 ..tile

0<

ahoukler 10 hlp KnEK15 $hoI.I1d be llaxed.

'I.

lum DaCIoward. Pillow may be pllICed behind ffom shouldtf to hlp. Kne9s should De fkillwd.

ThefapiSl claps with modefately cupped haocl OYer lelt rIIppIc aroa. In Il.lmalos wltl'l bfcast dOYCloPtnen! 01" Wldttme$$, 1.1,., wpped ...... nd wi\tl ' - ' 01 hand ~

Theroplst d8QS

betweefl clavicle and

ruppIe on eactl SlOe.

Fod 01 table Of bed ttIIwaMlct 20 1I"IChes.

Foot oil" Of bed ttleval&d 16 inches.

JWW4liI and fingers ~ bward bInealh

!he DfeUt.

I4tJIe 1Iat.

P8I1ooI11es 00 baGk whI1 pillow under luww.

30" angkl ,

TheraIJISI daps wIIt1 markedly eupped nard 0l'OI' 3fOO i>tIWOOI'I eiavde IIntllOp 01 acapuHl on flltCh!Mdf!

Stqmen!s

Patient lies on lJIde, helle! doWn. pillow under ~ TI\ef~ eIap9 wrttI sIIghIIy aJQP8d I'Iand 0\0If Wer !tis. (PositIOn $hOwn i$ tor drl!llfl.llge oI_..-nor basal &egmenl. To dtwlhe ''!fit iV1WiOr bMII segmenl, pelient should ie on !he left $Ida in ~ _~l

~

~;;j LOWER LOBES 5,,2"101 Stgmantt: FOOl 01 ~ 01" 08d e!evlJted 20 ,nches

Fool oIlabitt 01" bIId elevated 20 inches.

Bed Of table Ita!

PalItInI liM on abdomen . /wilt(! 00w1'l . 1I\ef> 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 ~

...

~

Thef~~ clapt; OWl" upP9frflClSl PQrtion 0I1owef rC&.

,a

undoIr"

Thentplst do!Ips eMIr md:Ie 01 bec:*.1ip 01...,.,.. 0" either 8Ide oi Sj)II'I(I.

IPoIIIion chown i$ for drlllt'lagl 01 rig/lIlllI.IRll basal seomenI. To dram the left late<1I1 basal Mgment. ~1ienI $I\Oukj ~I! Ofl Ihe rlghl Ide

.1'1 the

5llIne

_~l

Figure 15.9 Posi lions used for poslUral drainage. (From Rothslein. J. Roy, S. and Wolf. $ : The Rehabililalion Spec iali st"; Handbook. ed 3. FA Davis. Philadelphia. 2005 , p 444. with pennission.)

Postural Drainage Positioning a patien! so that the bronchus of (he invo lved lung M:gment is perpendicular to the ground is the basi!, for poslural drainage. U~ing gravi ry. these positions assist the mucociliary transport sY!!olem in remov ing excessive secre. lion~ from the tracheobronchial trec. Standard pos(ural dralllage po!litioll!l are prcs.emed in Fi gure 15.9. Although these postural drainage pos ili on!l are optimal for grav ity draina~e 01 ::.pe.clfic lung ~gment~. they may not be realistic for 500me palienr r., Modification of these standard po~ilion~ may pre\cnt any untoward dlecl!l )et ~lil1 en hance :.ecretion relnoval , Box 15.3 list!'. precautions thaL ~ holiid be considered pnor to instituting po!ltu ra l dramagt: with pallents enrolled in an outpalicllI pulmonary rehabilitation program. Tht:se arc not ab!lolute conlraindicjJtion~, but relati ve precaution~. The

Box 15.3 Precautions for Postural Do

1

•

PreC3utjons for the use of the T"~f1deltnburl"""'" Circulalory: congestive hew failure. h)ptt .. Pulmonary: pulmonary edema, shortness of ..... made y,.orse with Trendelenberg po.i'ian,(Io. .t"~'~fh bed lower than fOOl) Abdominal: ObeSlIY, abdominal dilitenrioa.liIIlIllII!I nausea. reeeni food COO!lutnplion Precaultons for the u~e of the side-Iyina posidOa Vascular: axillofemor.tl bypass graft

rec~;,n:':ri:b~=~:;

Musculosll.elctnl: anhrilis.any burltiu\, or Icndonius, make appropriate postural dralnqe uncomronable

C hapter 15 C hro n ic Pulmonary Dysfunction lisl is nol mean I 10 be inclusive: however. it docs provide the reJder with a range of dysfunction that s hould be considered prior to instituting postural drainage .

Pe rcussio n Percussion is a force rhythmically applied \\.'it h the theracupped hands to the paticnI's che~t wall. The percu,, sion technique is applied 10 a specific area on the thorax lh.al correspond, to an underlying involved lung ~eg l1l cn 1. The techntque is ty pically administered for 3 to 5 minutes o\er c;lch invol ved lung ~egmel1l . Percu~ s i on is thought to release the pulmonaf) secretions from the wall of the air\\:.ty~ and JIlIO the lumen of Ihe airway. By coupling percuss ion \\ ilh the appropria te pO ~ lural drainage pos ition for a "pec ifi e lung segment. the probab ilit y of secretion remova l IS e nhanced . Becau se percuss ion is a force directed to the thorax. there arc precau tions that need to be con ~ l d~re d prior to its use . The~e precautions are o utl ined in Bo\ 15.4. The li ... t i... again by no means inclusive. il does pro\ Ide ')ome gene ral guidelines that deserve considera !lon \\ hen percussion is pan of the th erape utic regi men . It !Ihoul d he noted al so thai ~o me modification o f this technique can be made to enhance patient tolerance. pi s (~

Shaking Follov. 109 3 deep inhalation. a bounci ng maneuver is applied to the nb cage throughou t the eXpirJlOry phase of breathing. Thl~ shaking i ~ applied to a .':opecific area o n the thorax that corre" pond ~ 10 the underl) ing involved lung segment. Five to .,even tnals of s hak.ing are appropriate 10 hasten the removal of secret ion... \ ia the mucociliary tram,port system . Shaking i~ commonl) u-.ed fo llo\\ ing perc u ~ ... ioJ1 in the appropriate f.lO'\tural draInage position. Bccau~ thb leehni4ue cOll s i~ t !) of a torce applied to the thorax. the ... ame co n ~ ideralion ., are needed 3') m the applicati on of percussion .

Airwa~ Clearance Once tht . .ecrclJ on s have bct:n mobilized with po:-:.tura l dramagt: pt:rcu "'~lon. and ~haklOg or vibr..ttion. the ta ... k of !"e!llU\ In!; lht: -.ecrellOJh from the airways 1<; undenaken u'iing an .urv.JY CkarJJ1lt' It:cllflll.jue CIJII ~ Jll ng i... the mo~ t COIll mon and ea .. It'\1 nl t!JJ1'l I) i c1eJnn£ the :11f\\
Box 15.4 P.ecau.ion. fo. Ihe Use of Percussion and Shaking (Ir\.ul ..1o)1) hemop1) ~h , coagulation db(Jrden. Itlll..·,e'hcd pan lUI thromoopia<;(lIllinle. \ I'1T1 or pTothromblll!Unl'

wn. pl.llelel eltunt below S(j .(~)(I)

Mu~ulll<J..t:lct.. 1 fratlur..:..j ribz-, frail cl~~t . deg"'I)t~r,Jt,\e l)tmc dl."~~""C

581

/-luffin g b another method of airway clearance that is useful for patient ... with COPD. A huff uses many of the same s teps of coughing. w ithout creat in g the hi g h intrathoracic pressures. The patient is asked to take a deep breath and rapidl y contTact the abdomina l muscles and forcefully saying " HA HA HA ." Thi.'l allows a forced ex piration throug h a Slabilized open aif\vay and make ... sec retion removaJ morc effective. 75

Acti ve Cycle of Breathing Techniques Acril'e Cycle of Brror/,ing Techniques fACBT) is an independent breathing exerci'ic program that includes a breathing control phase, thoracic ex pan sion exercises. and the forced ex piratory teChnique to c lear secretions from the air"'iays. ACBT begins wi th a few minutes of the breathing control phase. defined a ~ relaxed. diaphragmatic. tidal vo lum e breathi ng . Th ree 10 four thoracic expan s ion exerci ses, defined as deep inhalations with a 3-<;ceond hold fo llowed by a passive ex halation are performed next. A return to the breathing control phase follows. Depending on the patient's necds. this breathing control phase can last for seconds to minutes. If the patient fee ls that there are secret ions ready to be moved upw'.lfd. then the forced exp inttory technique comp letes the cycle. If secre ti on~ are not ready to be moved. the patient returns to thoracic exp~Uls ion exerc ises followed by another period of breathing control for re~t and evaluatio n of ~ tatu s . The fon::ed expi ratory techniq ue. defined as one o r IWO huffs from tidal volume down to low lung vol umes. is used to expe l sec retions from the airw:1y~ ralher than a cough. The forced cxpinllory technique is foll owed by a rest period of breathing control. Usi ng ACBT. secretions are milked from !o.maller to larger airway:-:.. Once Ihe secretions have mO\ rd into the larger aif\,-"3ys. hutr~ or coughs from m id or hi gh IUllg vo lume:-:. remove the secretions. This independent teehni qut: has be~n demonstrated to be :\..'\ eifecrive as po~turaJ drainage. percussion , and shaklllg.-f'

Oral Airway Oscillation Devices Ai rwa) osc ilJ ~tlion devices. for examp le . the flutter or the .. capella (Fig . 15. 10). alter the exhaled airno\\ throughout the air\\d) ' . Thl: p.t1ien l II1hale~ <.t brl\lth, appro'dmately V~ of his or her \ iHiI (" Ipacil). <mu hold:o. u for t\\O or three :o.econd s. During :Icti\ e exha lation through Ihl..' de\ iL"e. the e>..haled air l':llhC'" an illlenniltent b.ld.,\\ard air pre~:.-.ure that Jar') tht: air\\ .1) .... The u .. ual pr ('\hal('d volume"i Ihrnugh the lit'\ icc anJ fi n.tll y :1 hutT or (; IHI ~h It) (: Iear mo hillzed :-ecreIlOlh . 1 hi ... rout ine is n:re,tll';.j unt il ;\11 ..t:'\: r~tl lHh are c:ll~i.\n.·U lrom the lung.... An ~111"\\ a) Ih~ Jl hiIl O Il dt" \ll'C ha ... been ... htmn In help in the rt' lOl)\ ,U 1I1 ... t.'" n C: I Il.ln ... fwm Jif\\.I) .... - "

PU.!titiH." E pindOr) Pressurt' Th ...• p0., ltl \t.: (' \plr.ltol\ pre ..... ull:: (PE P ) lhl~"" a mask Of nwulhpll: ...·;.· \\ Ilh .\ \;.11\(' I..., regul,tle t~\rlrJtory fl, ... i ... lallCe t il.)!. 15. 11 L IlIh ,ilJIJ VII Ihrou~h th",' 111:1 ...... or lIloulhpiel't: ;.II IILiJ.1 \OIUIIIl' I'" u lln.· .. I~lt>tI 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

<

50% predicted

FEV,/FVC < 70%

Riera, HS, et al"

2001

20 patients with severe CO PO FEV, < 50%

Melhod.

Duration

Results

Comments

Pretest. posttest , ran-

Cycle: Intensity of 50% of peak work rate on

Significant increase in MIP with IMT postt raming

GXT, 20 min/day, 5

No change In MEP post training

4 people dropped out of the study, from the CET + IMT group, because of dif, ficulty with training. Addition of IMT did not enhance training effect

domly assigned to 3 treatment, + 1 control groups

days/week. 4 month s

Treatment 1: lMT

Significant increases in peak

Treatment 2: Cycle training Treatment 3: Cycle and IMT Control : education

work rate and peak oxgen uptake in the cycle and

IMT alone did not reduce exercise induced dyspnea

IMT: 5 days a week 30 min/day at 30% of MIP

cycle + IMT group post training Significant decreased perception of dyspnea with CET and CET with IMT post training

Pretest, posttest, ran· domly assigned to 3 treatment + 1 control groups SIMT group: high load IMT and low load EMT SEMT group: High load EMT and low load IMT SEMT and SIMT group: high load IMT and EMT Control group: low load IMT and EMT

1 hour/day (1/2 hour of IMT and 'h hour of EMT), 6 days/week for 3 months, High load was ramped up to 60% of max by the end of first month , Low load was 7 cm H,o pres, sure.

Groups that trained inspiratory muscles showed a signIficant increase in Pima.. Groups that trained expiratory muscles showed a significant increase in PE ma~ Significant increase in 6 min walk test in treatment groups Significa nt change in dyspnea scores in only the SIMT and SEMT + SIMT group Significant change in perception of dyspnea in only the SIMT and SEMT + SIMT group

Small sample size of only 8 participants per group Increases in 6-min walk test were statistically significant but the SEMT and the SEMT + SIMT did not reach clinical significance for improvemen t in thai test (> 54 m)

Pretest, posttest, randomly assigned to 2 groups Treatment group: IMT at 60% of SIP..., Control group: zero resistance th rough flowmeter

Treatment and control groups: 15 minutes of training on device, 2 x Iday, 6 days/week for 6 months

Significant increase in SIP mall and Pima.. post training Significant increase in SWT distance post training Significant decrease in dyspnea post tra ining Significant improvement in CRO scores (quality of life) No significant change in Vo2mall , VE mall , or W mall No significant change in Borg Scores

Home based program Training was at 60% of Sustatined Inspiratory pressure that is approxi· mately 30% of Pima.. " Device controlled inhalation and exhalation time via visual feedback

Home-based program

(continued )

Evidence Summary Box 15.5 Ventilatory Muscle Testing

(e",,,;.,,. d)

D ..

SuIIj""

Dejong, W. et al" 2001

16 pallents with CF. FEV 1 = 70% predicted

Comment. Pretest, posltest, assigned to two groups

Threshold tra iner 20 min/day,S days/week for 6 weeks % Pl mall was ramped from 20% to 40% by week 3

Significant change in inspira· tory muscle endurance post·

Mean In spiratory pressure in each group was 100% predicted Mean inspirato ry muscle endurance was 50% of PlmtU.

training No significant change in Plma~ inspiratory muscle strength Control: minimal prespost training sure load of 10% Pima. No significant changes in exercise capacity post training No significant change in sub· jective findings of fatigue or dyspnea ----------------------------------------------------~~----------------------------Pretest, posltest, Significant increase in respi· Training apparatus was Twice daily, 15 minutes Scherer, TA et al"" 30 patients with COPD FEV, <. 70% not a threshold nor resistRandomly assigned to per session, 5 days per ralery muscle endurance post 2000 FEV ,1FVC < 70% two groups ance trainer, but a device week for 8 weeks. training < 15% improvement in that used a fixed TV and Treatment: respiratory Training apparatus was Significant increases in FE V, with bronchomuscle endurance set at frequency of 60% frequency rather than PE ....., 6 min walk test, VO, dilation training MW and tidal volume peak and physical comporesistance to provide the Control : Use of incenendurance training. of 51H30% VC nents of SFt 2 post training tive spirometry No change in Pl max or mental component of the SF12 post training No change in dyspnea index nor treadmill endurance post training Treatment: IMT at 40%

EMT "" Expiratory muscle training; GXT = Graded Exercise Test; IMT "" inspiratory muscle training: MIP "" maximal Inspiratory pressure; MVV = maximal voluntary ventilation; PE = maximal expiratory pressure; PIIfIU = maximal inspiratory pressure; SIP max = maximal sustained"inspiratory pressure .

Chapter 15 Chronic Pulmonary Dysfunct ion mild to mode rat e di sease. training did not s ignifica ntl y improve mu scle fun c ti on. A lso. in patients w ith mild and moderate lu ng di se a ~e . improve ments in dyspn ea we re doc um en ted whil e patients w ith severe di sease did no t show an ah e rat ion in their pe rce ption of dyspnea w ith training. Fina ll y. there is a sugges tio n th at the use of ve nti latory mu sc le tra ining ma y in crease hype rinfl at ion in patients with ~eve rc pulmonary di se ase. making thi s treatme nt potentiall y harmflll. ~1 Use of thi s inte rven tion should be made indiv id ua ll y. based on the type of di sea':le. the severi ty of di se ase. moti vation of th e parti c ipant and the progre ss made wi th the ve ntilat ory mu sc le train ing prog ram . C urrent researc h on thi s intervention is presented in the Evide nce Summary Box (Box 15.5).

Pursed-Lip Breathing and Pacing Pursed-lip breathing. when used by patie nts with CO PD. has been shov. n to decrease resp iratory rate a nd increase tidal \olume.!)tI Pursed- lip breathing may delay or prevent airway coll apse . allowing for better gas exchange. Most patienb demonstrate this behav ior during periods of d ys pnea and rarel y need to be taugh t the technique . Activity pacing re fers to the performance of an activity within the lim its or boundaries of thai patient's breathing capac ity. Often. thi s mea ns tha t an activity that usuall y causes dyspnea needs to be broken down into component parts such that eac h component can be pe rfonlled at a rate thaI does not exceed breathing abilities. By breaking activities down into component parts and interspersing rest peri ods between each component . the lOlal activity can be com-

Qu es tions

for

585

pl cted wi tho ut dyspnea or undo fat ig ue. Pac ing can and shou ld be part of every activity that would otherwi se cause dyspnea. Pac ing should be used when performing activities of d;'lily li ving. ambulation. stair climbing. and other dail y tasks. Paci ng is not a technique to be used during the aerobi c portion of a pulmonary re habilitati on program. During exerci se. some short ness of breath should and w ill occ ur.

Summary Pulmomuy rehabilitation program s a re a we ll es tabli shed treatment for pati e nt s with c hroni c pulmonary di se ase. Compone nt s o f these prog ra ms ty pi ca ll y include exe rc ise tes ting and training. sec ret ion removal in stru ction. edu ca ti o n, a nd psychosoc ia l s uppo rt. In c reases in exe rc ise to le ra nce have bee n documented a nd maintaine d in fo ll ow- up studi es. Pulmon a ry re ha bilit a ti o n re sult s in an in c rease in aerobic capac ity. an increase in skel e tal mu scl e stre ng th , an improve me nt in the symptom of dys pn ea both durin g exe rcise and activitie s of daily li vi ng and an increase in the perce ption of health re lat ed q uali ty of life . Gain s mad e in pulmonary rehabilitation programs ca n make the difference betwee n a lifesty le o f de pende nce and one of inde pe nde nce. Ph ys ical the rapi sts have the important role of evaluating patients. de te rminin g the ir potential, and through exerc ise prescription and exerci se programs, ensuring that rehabilitat.ion goals are realized .

Review

1. How doe!'. the cli ni cal pre!o.ent ation of obstructive dis-

7 . How do you know when to progress a pa tient 's exer-

ease differ from the clinical presentation of restric tive disease'"' 2. Explain hov. altered airway structure leads to airflow Ilmn 3110n. 3. What v. ould be the expected breath sounds of a patlent v. Ilh CO PD? With ast hm a during an ex ace rbation ? (Re member to describe inte nsity as we ll a!o. adventltlou~ ,\-ound'i. ) 4. Idem i!) lhe te!,t'i and meas ure~ req uired tu de te rmine the exten t of pu lmonary dj~ea~e. 5. What are the pulmonary end po int ~ to a sy mplom limlled graded e.\en..' i~e te~l "! 6. HoI,\. dOt' ~ cxen: l ~e pl e~uiptjon d iffer for a pati e nt with mild pulmonary di')ea~e and the palient with ~ve J e pulmonar) di sea~c'?

cise program? What is the nature of that progression? Whe n is another exe rcise test warranted? 8. How would you explai n sta.ir climbing that utilizes the princ ipl es of activity pacing to a patient with pulmonary di sease? How wou ld you combat the patie nt 's assumption that it would take longer to c limb stairs w ith pac in g than wi thout? 9 . Des ign a sec retion remova l trealment plan fo r a pa ti e nt w ith CF th at c an be carried o ut independe ntl y prior to coming to pulm onary rehabilitation. 10. What t!v id(' nce is presented in the c urre nt lite rature rl!g'lrding th t.! bcnctits o f pu lmonary rehabilitation'?

Case

Study:

Patient

w

A 67-)eal-old IW hJle female lA'd,:, admmed to the ho'>pn •.11 v.nh a dl
th

COPD

,

anti bNncillxtllatof''I , After the acute rare ho,:,pilal ,:,IIlY of 7 da) .... the patient y, as tran~terred to a rehabllitatjon radlity for 7 da),:, . She I') nov. referre-d 10 outpaueOl physical thernpy.

586

Physical Rehabililation

PAST MEDICAL HISTORY CO PO. pneum oni a 4 tim es over the past 2 years. sIp lumpectomy of ri ght breast 8 years ago. smoking hi story of 45 pack/years. quit on day of admj ssion to hospital fo r ac ute bacteri al pneu moni a.

MEDICATIONS 2 WOlin of pulsed oxygen. Atrovent 4 puffs qid, albuterol PRN. prednisone 5 mg/day.

OCCUPATION Sec retary. works 32 hours/week. Presentl y on medical leave.

SOCIAL AND ENVIRONMENTAL Lives with hu sband in own home. Ramp to front door, six stairs within the home.

OBJECTIVE FINDINGS Inten'jew Mental Status: awake. alert, talks in three- to fo ur-word sentences. Adequate hi storian. Chi ef complai nt: shortness of breath limiting funct ion . Patient is able to walk 150 ft before needing to rest to catch her breath. No complaints of increased secretions. Baseline dyspnea index: functional impairment, grade I : magnitude of task, grade I ; magnitude of effort . grade 1. Patient's desired fun ctional outcome is to be oxyge n free and able to care for grandchildren without shortness of breath.

\ 'ital Signs HR 72. BP %(74 , Sao, alrest 86% on RA, 98% on 2 L/min pubed 0 , on I pulse/breath. RR 34, Temp 98.5' F.

Ob'cITation. Inspection. Palpa tion Thin. frail-lookin g fe male wearing nasal cannula. Kyphosis noted. Pat ient uses posture of forward sitti ng with arms supported to enhance ventilat ory accessory muscle use. Increased AP diameter of thorax. accessory muscle use at rest. Labored, symmetrical breath ing pattern. No venous distenlion, no edema. no cyanosis. minimal cl ubbing evident.

,\u"'L' uitation Decreased breath , ound, throughout both lung fie lds, especiall y at base ~. End ex pi ratory w heeze~ al left lateral base.

Strength Bilateral lower ex tremit y manual muscle testing: hip flex. ion 4/5, Ienee extension 3/5, plantar flex ion 4/5, dorsiflex_ ion. 4/5. Bil ateral uppe r extremity elevation, abducti tltl elbow fl ex ion, wrist flex ion and extension, 4/5. Pat~ unable to lie fl at or prone for further testing. Tested in alter. nate positions. other muscle gro ups able to mOve against grav ity with near maxi mal resistance. Maximal inspiratory effort (Plm.. ): 52 mm Hg. SIP m.. 26 mm Hg.

Fun ctional Independence ~[easurements ( FI~I scores) Ambulat ion: 6 (modified inde pendence-slow gait with pacing necessary). Stai rs: 6 (mod ified independence: requires pacing and rail ing). RPE of 6 (The Borg CR-IO Scale) wi th one fli ght of sta irs. Patient is dependent in shopping, house cleaning, and laundry.

Exerci se Test Data Patient perfo rmed a 7- min, staged (3 min/stage) exercise test using a mod ified protocol. Treadmill speed was hdd constant at 2 mph , grade increased from 0% (stage I) to 2% (stage 2) to 3% (stage 3). ECG was within normal limits. HR~" was 84 beats/min , HR ~ 121 beats/min. On 2L pulsed 0 " Sao, resting 98%, 93% at max exmise, 90%during the first minute of cool down, returned to'-line with in 4 min of recovery. Rate of perceived sbortnesI of breath at max exercise was 7 ( 1- 10 scale) . Exen:ise . . term inated due to patient request. There was no change ill pulmonary fun ction tests pos t-exercise. 6-Minute Walt Test: 200 m on pulsed 0 ,

Laboratory Test Data Pulmonary

FEV 1

Function Tests:

FVC FEV / FVC

1.107 LIsee (45% predicted) J. 78 L (64% ",edictodI 62%

GUIDING QUESTIONS I. What are the patient 's impairments and fun<:lional lim itations? 2. Ide nt ify antic ipated treatment goals. 3. Identify antic ipated functjo nal ou tcomes of pIIysitaI therapy. 4. Fom, ul. te a phys ical therapy plan of care for week l. Patient will be ,een 3 times/week fo r this filsl week fl therapy.

R e f e r e nce s I Amen..;an Thorauc Society PulmonM)' Rehablllt... uoo- l999 Am J k e.,plrCril Care Med 154' 1606, 19W. :! Il ughelo. R_and Da'>' I!oon, R' LlmH
" Fmlt:r. S, and n lOma .. H' PulmoolJ) rehabUn.aQon ..... .....

Ol~f than chrotll(.' o~lructl\ e poln'lOfW)' JISiCUC. .... ..., ......

01) 141 bO l. 19<>0 5 Morgan, 1\.10 . iUld Bntton. JR. O llomC obslr\M..'U~ p r' .ease /:1 - Nou-phann,tCologlCaJ mana,e:menl Qf ~ 5~: 4~\ 2003 .

corn

Chapter 15 Chronic Pulmonary Dysfunction () Pau\\d,. R. er al: (; 1"to,ll , rr.Hcg) for the dl :l gno~I~ . m:lIl\ 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<;t hm ... Che,1 II i 15S.1000 Q L;uudl. CB . Jnd En~"on. S: The cil!ctw phorcllC alpha - I g lllhu hn pJt1enl of \..:rum In alph:'l - I ani It!) p'ln dcfl c lenC') . Scaml J Cli n Lab 1!1\ l',t IS . IJ~, 1 9h~ 10 Chen. y . Gcnel1c' and pulmonary mcdlcmc. 10: GenetK cpid": l1liol('1;\ III pulm{lnary fun ctIon. 11lOra )' 5 ..U OR. 1999. II \'c~lho. J. and Lange. P: Can GOLD \ Iage 0 prO' Ide- IOfo mlal10 n of prognn'uc \aluc III Chrome Ob,tmCl IH' Pulmo nary I)I\("I'C'" Am J Re\pl r ('rtl C:lfe ~ kd 166:31Q. 100~ 12. Kohler. D. el ,11 · l ,efulne" of GOLD da,si li l:tory of a') thma. J Ped"m 142:515. 1003. 10. Panhu~ ~en. C I. et al: Adult patlcnt-. Ola} o utgrow the Ir asthma. AmJRe'plrCmCu e Med 155: 1267. 1997. ~J. C)~tK Flbm~I' Foundatron Patient Reg!"ry 2002. Annual Report. B et.he~d a , MD. 200:2. 22 ' kKone. EF. et al : Effect of genotype on phenotype :md monalit}, in Cy~l ll fibrosi\: A retro~rccti\e cohon ~ tud y. Lancet 361: 167 1. 2003 . 23 R;uJen F. and [)clftng, G: C),tic libra:.!,. Lancet 361 :68 1. 2003. 2~ Kerem. E. tt al: Predl(.:tlon of mon;lht ~ III pallenI.'. With (')\tIC fjhrO~1\ '\ Engl J Med ,\26: I 187. 1992. 25 DUrie I'R. and Pencha rL PB : Cy\Ul' frbro~l~ nutrition . Br Mcet Bull -411:823, 1991. 26 Sh,IOTI;l. 0 : Edttori,,1 revle .... : Idlupmh it pulmonary fibrO~ I ' . Cu rr Opm Puhn \ied :2: 341. 1996. 27. Sm. DD. el ill' Contemporary m: bu ~. fi2ull" and 1;;.Ilallc, Tho rJ'( 52:820. 1997. 2y. SCi.ullon~ PO (;1 al' Srnoklllg n:,~atloll ,md lung lun('u on rn nuld to Inodcnue o,;hronlo,; I)O,truUj\ f pulmonary c.l1'-t'\N~" 111l" Lung I kalth St ud ~ Am J Rnpn ent Carl Med 161 :3S I. 2000 .,£j O H"rd. P cI at. [)c"gn and re ... ult~ of Ihc JllItlal intl:r\'cntloll pm· ,.-rdJTI lor tht: Lung H..:alth Stud y Thc Lu ng /-it:alth Stud y Rc\{'arch Group, PrC\cnl l\C MedllUle: :.:!10):1()4 1993. 31 Amhunlo,cn. Nk , et ill r· n ech "I \ moklllg tntcl"\e:nru m and the: u ~e lit "n mh;lkd anlh, hulj( lcrgit brondu){lilat(lr on the f:.llt' (/1 (/l'lllr1C III I LV r The LUllg Ik.llth Study JAM A 172: 1497. Itjtj4 12 Iitp. B Dlo,cC AIH J K~ ~ pll (III Carl' Med I S]:467. liNn 14 Al hJuu: Illf Ihr Prudenl [!\l! (lll\l1l!hIOtl l~ (A PlJA): Wh.:11 .1I1d Il o.... to IJ~t' I\llt lhlum ,. Rl."trk \rJ I dlfUJt y 2. 20lifi Ir.m l hl!P!I\\. .... ~.t ul l~ ..:du/med/"pua/P,lt Icnh/I Ie,,, 1 r... k..: htllli )~ '\'>I,;tufndl (jA }1O.; n '111.;1 JP) I n JI GWUjl CUllIltlUOth or nt"- lUI rw l to~H'l'n tl,l'f"'PY III h)J)UA<.:tnK lhnllU ..' Ob.. trulll\c Iun~ dl \<.:.I>1.·' A (hr.'laltnal Ann Intern Mcd Y ~n): wI II)hll "l{) M,m SI t r ..II (!)ntelllpural) 1I1,IIlJl.!ttllel11 o f IJU(J1l1t nlh lfUllr\t' l>uitm!lJaJ} dl'(:;I'>C: ('llfil .. ,11 ,1])\1111.. ;11 1'111\, JAM A 2 ~1). 2"\ I "\,)( 11' "\

58 7

J7 Garrod R . et af. S upplc menl:ll oxygen during pulmonary rehabililatrnll tn paticn" w lllt COPD with c:<erc i!o.C hypoxaemia. Thorax

55SN. 2000 . JX. Fl1Ilner. M: Bene ]i"

19. 40. -I I,

-1 2

4].

-14.

45.

Ill' ,upplemcntal oxygen in cxerci,c training in nonh y poxc mic t hront c Oh<Muctivc pulmonary d l<;ea\c pati cnt'>. Am JRe'plr Cnt ('arc Med 168: Im4. 200:1 . Bnll, h Tho rac ic SociCIY: Standard <; of care ~ ubcommlll ce on pulmonary rl'habllltalron . Thora x 56 ( 11):827. 200 1. Bendel!. J. and Albert. R: Surgica l npllon ~ for paticnh wi th ac.l v:l1lced C J1lph y~c ll1" . ClIO Che\! Med 18:577, 1997 . Crmer. GJ. et al : Pro~ pc c ti ve randomized Irial comparrng bilate ral lung volume redll("tio n ~ urge ry to pulmonary rehabiliwtl on in <;evere chronil' oh<;truU lv(' pulmonary di .. c a ~, Am J Re\pir Cm Care M cd 160:201!S. 1999. NatIonal Emph}'<.Cma Treatmenl Trial Re-.e3 rch Group: Pallents at hIgh mk 01 de;rth arle r IUllg volume reduc lio n surge ry. N Engl J r>.1t!d 3-15 : 1075 .2001. Nali onal Emph}'cIllOl Tre:ltmenl Trial R e~arc h Group: A Randomized trail comparing lung-volume reduction surgery wi th medical therapy ror severe emphy"C ma. N Engl J Med 3-18:2059. 2003. Szekcly. LA. et al: Prcopcrati \e predlc(Or.. of operatIve mo rbidity and m on a lit ), in COPD patient <; unde rgoing bilatcral lung volume reduction !>urgcry. Che\! I I 1(3):550. 1997. Americ an Tho racic Society: Intern:Hional guidelines for Ihe ~elec­ tion of lung tr;rn'plant candidates . Am J Res pir Crit Ca re I\ 'led

, ,,,335. 1998. 46. Ke'te-n. S: Pulmonary rehablittOllion and surgery for cnd stage lung di selli>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 and American Tho rac ic Soci':Iy: ACCP-ATS Joint commiuee 0 11 pulmonary nomendature : Pulmo nary teIT11' and ~y mbols: A reporl of 'hl' ACCP-ATS joilll committee on pulmonary nomenclature. Chest 67:583. 1975 . 55 . C:l\aoori , R: Sk.:lct:r l mu....cle func tion III COPD. Ch...s t 11 7:167S.

2000. 56. A mcri ..'an ThorJdc Soc le ty!European RcsplralOry Socl.:ty: Skeletal rnu,dc d y)ofuncll on in chronic o bstructi\ e pu lrnon.lfY dl ~ea't!. Am J Rc .. pir erit C lre Mcd 159:S I. 1\)99. 57. Anlerican Thor:rnc Sol'icly/Amcril'an Collcg\' of ('h..... t Ph)'\icians: ATS/ ACCP ~ t.th: m('nt on c ardiopulm\lll:try eXt:rc j ~e tt:::>tlllg . Am J Re'pl r Cnl C;Jf": t\1t:J 167 :2 1 I . :.:!OO3 'is, Sleele. B: TLOlcJ \~,Il~tn.g tt:~ t 0 1 \'~Crt.I~\' CJpan ly in ( hrolllc C.lrdlOpulmOll.lf} ItJlll·~" J C ilrdll) puItU(lIl,lr) Rt"ha bll 16:25 .. 1990. 51) Rcv tll , SM . ..:t ,II. I hI;! cndllrancl' .. hutt k w:11~ : A ne\\ field 1.:,1 (or !he ,h ~C~~l1W nt (0\ \'lldllf:>lntc ti\'~' pul mllllar) dJ ~('!"e _ TIrOl;t \ 5-L~ 1"\. 199<) 60 Jon.:" N' E\clu \C I<.',ung III pullIIOnal) C\..t11l,1I10n- Rilll('lnale. md h(){I\ .md lh\' 110 111\:1 1 rf~pl r~c~,­ men I 01 IU lldlt)fldl ,1t' rUOt.. Illlp.llntlcnt LH t: J.rdlu\a",~· uJJJ· lIhC:U\e . Alii !Je.tn J lo("l'i-lfl. 1971. h ,l N,tugith 'n, J , c t "I M(Oi.lllted .... "I ~ ~,Ip:"-' It ) ~ tudll" III IIH..hvidu.lIS v. LIlt .tnl.! \\I thuut \11WtlJ ry MI ~' I ) dl'l::iI'>e. J Spo rt\ t-.kd -L~08. I 'If) I

h4 U .II~ l'. B . ... n,1 \\ ilI'l, K An c \pi.'llm.:nt .• 1 ~ tud ) III ph }'\I~- at filnc,~ of' ,W f"ftt:' lk:r'I HlLwl If:-. Annl'd hll"\'n t\1t:d J 10:675, 11)59

588

Physical Rehabilitation

65 . American ThorJcic Soc iety: E\ alualion of im painnenl ~('~'ondal)' 10 re"plralOI) disea-.e. Am Re\ Re~ pl r Oi~ 126: 9~ 5 . 1982. . 66. American College o f Spon' MedicH1t': G mddHlC's for. Excrc l-.e Testmg and Pre~a;pl ion. ed 5. Lea & FcblgCT. Phlla.dcJph~a .. 1995. 67. Lake. F. ct al: Upper hmb and lo" cr limb e~c rc l se lramlng In patient.. \\ nh chronic airOo" ob~truct ion . Chc~t 9 7: 1077. 1990 . . 68. Nonnandm. EA . 1."1 :II: An c\"luation of two approaches 10 excrcl.'O e cOfldmonmf H1 pulmona!,) re habi lliation. Ole, t 12 1: 1085. 2?O.: t . f,9 . Maltai:.. F. t't al: Slelctal mu~c k adaptation to endu rance traln mg to paue nl ~ \\ ilh chrOnic Ob'ITUCII\e pulmonal) d l ~a ,e. Am J Re"ptr e n l Care Mcd 1 5~ : -l4~ . 1996 . 70. ~bl t :lIl>. F. el ;I I: [men,il), of traming and ph}'~i ologi c adapllu ion. in patlenb "11h l' hronic o bstructl\-!: pulmonar) di l>C a ~. A m J Rellplr COl Can' Mc-d 155 :555. 1997 . 7 1. PunzaL P. et al ' ~1a >;i mum H1IC IN I~ excrCll>C tr::u nmg in pallcnb \\ nh chronic ob"trucli\ c pulmonary di sea~e . Chesl 100:6 18. 199 1. 72 . Borg . G: Borg's Pcrce r\cd E'I(en lOll and Pain Scales. Hu man Kinet· b. Cham paign. [ t. 1998. . ' . ~ 3 . Horov. llz. MB. el ,II: D~ "pnea ratmgs for prescnbtng e xercl ~ mte n'11\ m patien!' " 11h CO PO. Che~ 1 109: 1169. 1996. 7-l . RI~'. A. el al: Effecb of pulmonary re habilitation of ph~ 'Iologic and psychosocial outcomes in paucnb with chronic obstructh'c pulmona!) dl..case. Ann Intem Mcd 12:1 :823 . 1995. 75 . HIetpas. B. et al: Huff coughmg and airv.ay palenC) . Resplr Care 2·U IO. 1979. 76 \\ ll£Of1, G E. e1 :II: A rompan ~on of traditional chest physiotherapy " lIh the acti \c c} cle of breathing in patients " jlh chronic suppura\ 1\'C lung dl l>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
689. 1994.

.

.

78. Gondor. M. et 31: Companso n ~f n utler.
trainiIc.

a.:

1 20 :7~8 ,

2001.

85. de Jong. W. et al: Inspiratory muscle tra ining in patients witb CJllic fibrosis. R e ~ pi r Med 95:3 1. 200 1. 86. Scht· rer. TA. et a l: Respira tory muscle endurance lTaining in daIit obstructi ve pulmonary disease: Impact on exercise capacity, ~ and q uality of life. Am J Respir Crit Care Med 162.: 1709, 2(Qt. 87. American Thoracic Society: ATS Statement : Guidelines for 6 minute walk test. Am J Re"pir e rit Care Med 166: 111,2002.

s

Amen can Colleg~ of Che ~ t Physicians/American Association of Cardio\a)('ular and Puhnonary Rehabil itation: E\'idence Based Gu idelines. Cheq 112:1363. 1997. Amencan Collc£e of Spons Medicine. Guidelines for Exercise Testing and Pre~ription . ed 6. Lippincoll. William!> & Wilk ins. Philade lphia. 2IXXJ. Amen can Thoracic SOCiety/American College of Chest Physicians: AT S/ACCP Stalement 00 CardiopUlmonary Exercise Testing: Am J Re~p jr ent Care ~l ed 167:::! II. 1003.

Goodman. C. Bo issonnauh . W. and Fu ller, K : Patho logy: ~ for the Physical Therapist. ed 2 . WB Saunders. Philadelphia._, Pauwels. R. et al: Global strategy for the diagnosis. managemcat,'" preve ntion o f chronic obstructive pulmonary disease. NHLBJIWII) global initiative for chron ic obstructive lung disease (GOLD) MIl- . sho p summary. A m J Rell-pir C nt Care Med 163: 1256. 2001. Man. S F. et al: Contempomry manageme nt of chronic ob5cnIctfte", mona!)' d iseaite: C linical appl ications. JA MA 290:23 13.2003. Ratjen, F. and Doring. G : Cystic fibrosis. Lancet 361:681 , 2003.

C H APTE R

16 LEA •• INI ,.JECTIVEI 1 Describe the etiology. pathophysiology, symp~

. tomaiology. and sequelae of coronary heart disease. 2. Describe the etiology. pathophysiolo.SY. symp-

Heart Disease Kate Grimes,

DPT, MS, CCS

tomatology. and ~equ el ae of congestive heart

OUTLINE

failure. 3 Identify and describe the exami nation procc• durts used 10 evaluate patients with heart disease and establish a diagnosis and plan of

care.

. .

4. Describe the role of the physical therapIst In . assisting the patient in recovery from heart dis-

ease in tenns of interventions. p3lienH-eiated instruction. coordination. communication, and documentation. 5. Identify and describe strategies of intervention during various phases of cardiac rehabilitation. 6. Analy ze and interpret patiellt data. fo nnulate

realistic anticipated goals and expected out-

comes, and develop a plan of care when presented \\ ilh a clinical case study.

Epidemiology 589 Cardiovascular Di!tease S90 Cardiac AnalOmy and Physiology 590 Surface Anatomy S90 Muscle and Connect ive Tissue Structures 59 1 Coronary Arteries 591 Cardiac Cycle 592 Hemodynamics 592 Neurohormonal InOuenccs 593 Blood Pressure 59-t Cardiac Output 595 Myocardial Oxygen Supply and Demand 595 Contractility 596 Electrical Conduction 597 Exerci!).t.! Re<;ponse 598 NOnl,al Exe rcise Response 598 inappropriate Exercise Response 598 Cardiovascular E,amination 600 Medica.l Record Review 600 Patient Interv iew 600 Vital

Si g n ~

Te. . t~ and

T

he term heart dlagno~e"\ ,

di ~ease include s

a variety of clinical

including m yocardia l in fa rc tion ( MI) o r

heart attar!.... angina. heart failure. a rrh y thm ia~. s udden death. and vah ulaf dy~function .1 The most prevalent type of heart dbe;J~e I:" disease o f the coronary arl e rie~. also !...no\l,n a~ coronarJ artery disease (C AD) , coro nary hean dl.'tCa~e (C HD ), or i~chemic hearl di ~ease. The World Health Organizatio n I dentifie~ coronary heart disease a... elther . m acute or chront c card iac di sability re:-,u lt log from a redUl"Iton (or a rrest) o f blood ~ uppl ) 10 the m)ocardium "jth a~socia led coronar)- arterial disea~e .2

Epidemiology In the Unlled Stal~:". he<.lr1 di~a......e i ~ the It:ading ca u,e 01 death for maJe~, female~ , wh il~~, black:-,. Abians, American

60 I

~ 1 ea~ure . . 60~

Electrocardiogram (EKG. ECG) 602 Left Heart Catheteri zation/Coronary Angiogram 604 Echocardiogram 604 Invasive Monitors 605 Exercise Tolerance Tests 605 PathophY'l>iology and Physical Therapy Intervention 608 Coronary Artery Disease 609 Physical Therapy Intervention for Patients with Coronary Artery Disease 612 !-lean Failure 622 Physical Therapy Intervention for Patients with CHF 626 Conduction Abnormalities 629 Physical Thenlpy Intervention for Patien ts with Arrhythmias 630 Special Exercise Considerations 632 Education for Patients with Heart Disease 632 Primary Pre\ention of Coronary Artel') Disc3"f 635

Summary 636

Indians, and Hispani cs:' Since 1900. cardiovascular disease has been the number one cause of mortality e very ) ear except 1918 (innuenla pandemic)] An estimated 13.7 million pe0ple have CHD in the United States; in 2004. the estimated inc idence of new coronary events in the United States was 700,000, and for recurrent aaack.s, 500.000.·' Atherosderosis i\ the mO ~ 1 common CJU'ie of CHD; besides ils fatty deposits within the coronary ancri~s. atherosclerosis also affects Illooemte und large ..,IU: artenes such 3.\ carotid and femoral ;.trtene~. Therefore . if heart and blood vessel dise<.l~e we re loo !.. ed at loge lhe r. an eMimaled 70 million Ame ri ca ns would hm e one or more f<'rm5; of cardiO\Qscu Iilr (i.e .• heart or 1;11000 \ ~~sel) di~ea~e .l Cardiova'\c ular dbeasc is the leading l'all~e of death in the United States loony. " dCCOUfl['I for nCJIly I Illtllion dt:ath!, each year, or appro"l(.imatt:iy 43 IJe rcl'lll of nil tlealh:-,.

590

Physical Rehabilitation

Cardiovascular Disease The pa th oph y~ i ol og ica l condi tions that underli e card iovas· cul ar dise ase are atherosc lerosis. alt ered myocardi al mu s· c1e mechanics. va lvul ar dysfun ction. arrh ythmi as. and hypertens ion. Atheroscleros is is a di sease in whi ch lipid· lade n plaque (les ions) is formed with in the intim al layer o f the blood vesse l wall of mod erate and large size arteries: over time th e pl aque may ex tend into the lum en ca us in g a dec reased lumenal diameter. Atheroscleros is is also a primary con tribu tor to ce rebrovasc ular di sease (stroke) and peripheral vasc ul ar disease (PV O). Altera ti on in myocard ial mu scl e mec hani cs invo lving thc ~ysto l ic and/or di as tolic properti es of the myocardium rc:-.u lls in an impaimlent of left ventri cular (LV) fun ction· ing . Heart fai lure is a clini ca l di agnos is that resu lts fro m impaired LV fu nct ioni ng and is referred to as congesti ve heart fa ilu re (C H F) \\ hen it is accompanied by s igns and symptom s of edema (i.e .. congestion). There are man y causes of heart fai lure. including myocardial scarrin g and remodeling as a result of an MI. cardi omyopa thy from var· iou ~ ca u ~es. or im pai rment in valvular fun ctio n. espec ially the mitral and aonic valves. Arrhythmi as are caused by a di sturbance in the electri cal activity of the hean, resulting in impaired electrical impulse fomlation or cond ucti on. Arrh ythmias may present as be nign or malignant (i.e., life threatening). Examples of malignant arrhythmias are sustained ventricular tachycardi a (v-tach) and ventricu lar fi brill ation (v-fib ). An example of a common benign arrhythmia in the elderly popu lation would be atrial fibrillmion (a·f1b) wi th a controlled ventricular response. H ype rten ~ ion is "the most prevalent card iovascu lar d is· ease in the United States and one of the most powerful contribulOr:-. to card io\'
Table 16.1

Stages of H yperte n sio n as De fin ed byjNC VU '

HypertenSion IS defined by either systolic or diastolic elevation. A BP of 110/90 is Stage 1 diastolic hype rte nsion; a BP of 160/60 IS Stage 3 systolic hype rte nSion.

Pre hypertension 120-130 _.,--Stage 1 130-140

80-89

Stage 2

100-110

-

140-160

Stage 3 Normal 119179 or below

90-100

T he clinica l presen tations o f cardiovascular disease_ d iverse and depend on the so urce o f the impainnent: JleIfg. sion o f coronary arteri es. contractility of LV myocardi.... or alteration o f e l e~tn cal aC(J ~ lty. Common SIgns and sYlhptoms associated wlIh heart d lse~se .are chesl pressure, dys.. pnea. fati gue, syncope. and pa lpitatIOns. However. altboup these clini cal man ifestations are strong ly associated with heart disease. they are not exclusive fo r hean disease. Therefore. taki ng a tho ro ug h pati ent hi story and porfonnin g an appropri ate exa m ination and evaluation are crucial to estab lishing the phys ical therapy di agnosis, goals. outcomes, and pl an o f care. I! is also important to consider that there is no direct objecti ve measurement o f fun ctio na l limitations based solely upon the cardi ac diagnos is and pathology. Individuab with seem ing ly simi lar cardi ac patho logy may exJlO1'ienct d ifferent fu nctional limitati ons. Functional limitations experienced by the patient who has a di agnosis of CAD or heart fail ure may vary wi dely and are influenced by many factor.< other than the amount of intact. perfused myocardiwn. or the fu ncti oning o f the LV (LV function). In response toardiac im painnents, neurohonno nal and cardiovascular ct'IIItpensatory mechanisms are activated that allow cardiac functioning to continue for a while before the patient becancs symptomatic or there is a sign ificant change in fimctioa. Functional li mi tations are therefo re influenced by the amount of com pensation as we ll as the pharmacological management. The clini cal signi.fi cance o f heart disease is determined by the impact of the d isease o n cardiac o utput (CO). The majo rity of d iseases prim aril y affect the LV (i.e .• ischemia, in fa rction. card iom yopathy. heart failure). When the rigll! ve ntricle (RV ) is involved. it w ill be documented wiIbiI the medical record based o n fi ndings from diagnostic te1ling. such as the EKG. ec hocard iogram . or cardiac catheterization. Patie nts wi th CA D. includ ing MI. isc hemia. and rev»cularizati on procedures (e .g _. coronary artery bypass graft [CABG] and ang ioplasty). as we ll as patients willi ca rd iomyop ath y. arrh ythmias. and hypertension, an: all inc luded under Practi ce Pattern 60 in the Guide to Physica l Th era pist Practi ce. 6 T his pattern is entided. " Impaired Aerobi c Capac ity/End urance Associaled willi Ca rd iovasc ul a r Pump Dys fu nctio n o r Failure." 11Je re,lder is refe rred to thi s so urce for ge neral guidanCe " planni ng exa min atio n and inte rve ntion strategies . thi :-. pop ulation.

Cardiac Anatomy and PhysioiotY

-

Surface Anatomy The he ar t lies within the left tho racic cav ilY. TIII - th e heart is located s uperiorly. approximalOly .......

t ha pll""r l 6 Il cart Oi -.ellll ..c the ~t"c(lnd anti third fib : the ape:.. i . . ICK:.Ited i lll c r~l:rI ), arpnlxll1l:Hd y ilt th l! le"eI of th e 51h rib. In Ihl . - ra y (Cx R ). th e RV OCClIp IC'" ~r ~ I g­ ru ItC:tt11 portion o r till' fro nlal plane. The fI!!ht atrium (RA J I ... gl'ncra ll y located in th e area o f th e !'.ecoll d intcrc:oqal "pate ... ;"1(ll hc til/ g /(' of LfJ/ / I\ . Wh l! n o ne palpat e ... the ., tcrnum , th l' ang le 01 LOlli ... I!'. th e "bump" that J c marl' ~lIe ... the manuhrium from th l! hod) of til e ... te rnum . Th e ... c:cond Interco ... t:tI "pac!.:'i are laler,1I and ... ltg lllh hc hl\\ Ille angle of Loui .... Th t' ... eco nd intc rcosttll ... p;:CI.' .... JI"I.': an illlporlJll1 ,tU ... c u!t::l!or y lam.lm ark: the ri g ht ~pacL' I ... kllo\\n a ... th e anrll c area. Ihe left :t!'. the pul mOlli e :1I"I.:a . The :Ipex of th e normal ht:: art is in th e fifth inICrCU .,t:t1 :-. pace :11 th e mid -c lavic ular line. In a hea lth y hean . thi ... :.trea. known
Muscle and Connective Tissue Structures The majo r ti ~s u e s tru c lure~ of the he art are composed o f mu ~cJe, connec tive ti s~ ue, blood vesse ls, and nerves. The wall o f the LV co n ~ isl5 of mu sc le (the my oca rdium ) t>;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 c<.l1lt allowing th e two ~ urfacc~ to ~lj de pa st une an oth e r. The !, talu ') 01 Ihe peri cardi ulll primarily intlu e nce ... th e dia stoli c behav ior of th e heart , spe c ifi ca ll y cOlll plialKc. A dec rca!:lc In compliall ce:: of lhe peri cardium may lim it ventn elii al filling . Co nnec ti ve ti~!:Iu e is al so fo und within the wa ll ~ 01 bloud ve t.se l..... It is importanl to note that any d, t.ea'lc that aJt ects the co nn ec live ti .., . . ue in o lh er area.'. o f th e hody may aho affe-ct any of the Connec ti ve ti 'is ue .., truc lurc:::s I01.3 ted wi th in th e "';:l rdio v'l\c u lar :,ys tC'lll , endo(:ardiulTI , eplcardium , valve.'. , pertcard lum , Hnd blood vesse l ~.

.59 1

Coronary Arteries Thl.' cl)ron~lr) .trh:ril' 'l or igtn.tl l.' in the ... 1I1lI .... 0 1 Vabalva I ()C~H l'd In th l' \\al l o f th l' :iOrW Ile nr the ;tonic va lve. Thl' ri!! ht corollary o ri gi nute ... lrom the a rea nc ar IhI.' rig ht aorti C Icafld. th c.. ' Id t cMon:lry fr(,'Iln the area 11 (: •.11" the left au rli <.' k:=It1 c t. Wh~1I Ihe .Ionic va lVt.' r... o pe n dunn g $y~­ lo le, th e ori gi n ... of Ihe co ronary .rrt .,;rie s ure located he hin d the ;:to rti c k'al1 c h wit hin the \~all : w he n Ihe aortic v:ll ve i... clo sl?d during d ia :-. lol ('", the o p c nin g~ of Ih e coronari e ... are c lea rl y ex po~cd. allowing th e m to be ea,il y perfu ... cd. Th e coro nary : lrt c rie~ th e re fo re receive the m:lj ()r it y of th.,; ir blood fl ow during cl ins to lc . unlike the other arrcrie ..; o f the body tha t ~Hl~ pe rfused duri ng ~ys· tol e , Th e left c oro nary artery b eg i n ~ a ... th c le ft ma in ( LM ) and the n bran e h c~ in to the left anlerior de sce nding (LA D) and th e c irc umfl ex (eX), Th e LAD Illay ha ve fur· Ih e r di v i!:. ion s. known a ... dia go nal branche s, th a i co me o ff of the p rima ry LAD . T he LA D und it s diagona l bram: he:-. primaril y s uppl y the
Figure 16 .1 Coron,u"), circulation. (A) left main (LM); (B) left anterior dC'CI.!nding (LA D); ((') left circumOtx (eX) (D) right cQronary (RCA); (E) posterior de~~:c nding lPDA). The branc hes of the LAD arc kno\\ll as diagona ls; the branches of the eire are known a~ tlHlrgina l.. ,

592

Physical Rehabilitation

Whe n the PDA comes fro m the RCA. th e anatomy is es re ferred to as being ri ght dominant : if th e PDA con: from the c ircumfl ex. the anatom y is referre~ to as ~e.m g left dom in ant. For phys ical therapists. there IS no c1. IIlIC~ 1 importance to whether th e anatomy of th e m yocardium IS e ith er left or rig ht dominan t. . The inner d iameter (i.e .. the opening) of the arteri es th rough \\l hich the blood flo ws is the lume n. The size of th e lum e; is critica l for adequate blood flow. A significant. narrow in g of the lumen. such as that which occurs with a fi xed . .atheroscleroti c les io n of CA D. will decrease the available blood supp ly 10 the myocard ium . Lumen size may also be altered by the smoo th mu scle within th e walls of the arteri es. as smooth mu scle regul ates vasomotor tone of the coronary arteries. Vasodi lation wi ll increase lumen d iameter as a res ull of relaxat ion of smooth muscle, and vasoconstricti on will dec rease lume nal d iameter as a result of smooth muscle contrac tion. The responsiveness of arteri al smooth mu sc le is also in fl uenced by the integrity of th e endothelium. the lini ng of the coronary artery that is in direct contact with the lu men. The endothe lium has a num ber of nonnal funct ions and "plays the ce ntral role in co ntro ll ing the biology of the vessel wal l.'·7. p 1265 Some of {he~e important fun ctions are an ti -i nflammatory actions, growth inhibit ion. anti -thrombOlic activity. as we ll as its infl uence on vasodil atio n. Endothe li al ce ll s re lease endOThelial deril'ed relaxing [acror (£DRF). which fac ilitates vascul ar smooth mu scle relaxation. Ni tric ox ide (NO) i~ the most preva lent EDRF. An injury to endothelium can result in impaired NO release and a decrease in vasodHatation.1i NO release is in fl uenced by many fac tors includi ng acelylcho line. norepi nep hrine. semlo nin. AD P. bradykinin. and hi stam ine.s The etiology of the cl in ical conditio n known as coronary spasm , in whic h smooth muscle contracti on within the walls of the artery resu lts in narrowi ng of the coronary artery_ is not clearl y unders tood. Coronary spasm occ urs in anerie~ that have endotheli al injury (e.g .. atherosc leros is). as v.e ll a::o. in tho~ arteries that appear to be nonn al but ex hibi t hyperreactiv ity to a variety of vasoconstri ctor stimuli ..... uch a~ serotonin and ergonov ine, and loss of endotheliulll depe ndent relaxing fattor.1} The role of the an erioles of the coronary arteri es is to regulate blood fl ow through the capill ary beds to provide adequate oxygen for at:roblc me tabolism. Arteriolar to ne is Illfluenced by a variety of factor~ . such as s) mpathetic nen.ou::. ~) Mem n e uro.lran ~mi lle r::. . h o mlO ne~. and auto regulallon TIle greatest Ill fluence on coronary artery arteri Olar IOnL" I ~ autoregulallon. Autoregulation prov i de~ a mechanl::.nl for a quick and d,rect re~pon ~e to a change in local mt=taboll~~_ or blood flow alterations and can lherc: by be more .'.I Pt:.CIf.1C and ta~l er re~pondlllg thiil1 s) lnpu lheti..: neu rot ran~ m l ss l on or bl ood · born~ catcchu l nl1line ~. In the nOrmal health) hea rt, autoregul~lJon pro\'ide~ an ~t1mu~ t IInmed latc res pon~e of Ihe aftenole~ to vd~odi l uk III re),pon~e to local metabo li c c hange~ s. u(:h a~ a dec rea~~ in

an increase in carbo n dioxide, or an increase I't! oxyge n. . . . hydroge n ions. In th IS way, the heart tS able to qUIckly and adequate ly provide for Its aerobic energy needs. In diseased arteri es, au toregul ati o n will respon~ to a decrease in erfusion pressure due to dec re ased artenal blood flow by ~asodilating th e arte ri o les. Autoregulatton provide, a mec hanism to maintain adequate capillary bed filling of the di seased arte ri es by influenc ing local arteriolar vasodi_ lati on. In this case. it is important to remember that autoregul ati on is a local no t syste mk effect it influences the arteri oles of th e d iseased vesse ls only.

Cardiac Cycle The cardiac cycle consists of two interrelated phases: sys. tole. the contrac ti on phase. and diastole, the filling pIwe. (Nore : systole and diasto le occur within both the right and left ventricles; becau se the esse ntial functioning of tilt heart is primaril y dependent upon LV function, only tilt LV will be referenced). During diastole, the LV is filled with blood from th e LA via an open mitral valve. The tint two thi rds of the fillin g is passive ; during the last one third the atri a contract and push the blood into the LV. This COlItracti on is known as the atrial kick. After the atrial kid. d iastole ends and the mitral val ve closes. Systole begim wi th both the mitral and aortic valves closed. An initial isovolumetric contracti on, similar to an isometric contraCti o n of stri ated muscle, in creases the pressure within the LV, and th e aortic valve opens. The LV then undergoes a concentric contraction, causi ng the stroke volume (SV) to be ejected. After the SV is ejected, the aortic valve eloses and systole is over. The cardiac cycle is defined by !be presence of normal heart sou nd s, S , and S,. Heart soundI are associated w ith vaJv ul ar closings: S , is associated willi mitral va lve closure , and 52 is assoc iated with aortic vaIw closure. Sys tole occurs between S , and S,. and diastole occ urs be tween S, and S , (Fig. 16.2).

Hemodynamics Blood enters the heart v ia the superi or and inferior cava into the RA . Blood moves fo rward from the RA

Diastole

Systole Diastole 5, ....... 52 S3 S. 5,

Systole OCCurs between SI and 82 (in the shaded area) Diastole OCCurs between S2 and 8, Normal heart sounds

S, =mitral (and tncuspld) valve clOSing S2 -::. aortic (and pulmOniC) va lve clOSing Abnormal heart SOunds 8 3 heard In early diastole assOCIated wrth CHF 8. heard In tate diastole associated with an MI or hyPiCbJ_

Figure 16.2 He.tn \ound:,

0 1 the

cardiac cycle.

p Chapter 16 Heart Disease

593

through the tricuspid vJ lve to the RV, through the pul-

through the right heart. Common measurements taken w ith

monic valve

a right heart catheterization are RA pressure, PA pressure, and pulmonary capillary wedge pressure (peWP). The pewp is an indirect measure of the left venl1';eular end dia,wolil' prc.uure (LVEDP ), one of the most sensitive measures of LV function. An advantage of i.I right heart catheter-

10

th e pulmonary aJ1ery (PA) and pulmonary

capillaries. The capi llari es perfuse the alveoli. and the

alveo lru" capillary membrane is the si te or gas exchange. Newly oxygenJted blood within the pulmonary vei ns (PV) traycb 10 the LA. and pa sses through the mitral valve into the LV Blood wi thin the LV trave ls down to the apex, where il is squeezed in a wringing motion during systo le :Uld moved from th e apex 10 the LV o ulnow tract and finall~ out through the Jonie valve 10 the aorta. Blood vol ume in an y c ham ber or vessel generates a prt!~ s ure ; the no nnal pre ssure recording s for the card iovascular ~y~ tem are pre s~ n1 e d in Table 16.2 . Becau se of the n:laliollship of blood v olume~ and pres~ure s . direct determinati on of bl ooo volumes \vithin the heart may be done \:!) invasive monitoring of the intra vasc ular or chambe r press ure:;. In a riglll helln (,alherer i:atioll, a catheter with pre :~~ ure- sens iti v e recording ab ility is insel1ed into the internal Jugular or subclJ\'ian vein and progressed antegrade

Table 16.2 Hemodynamic Variables Rip! Heart c.dtecerization Nonu.l Ranges

Neurohonnonal Influences

~--~

Centra! venous pressure (CVP)

Q-8 mm Hg

Right atrial (mean) 0--8 mm Hg ------------~---Pulmonary artery (PA) SystOliC 20--25 mm Hg Diastolic 6-12 mm Hg Mean 9-19 mm Hg Pulmonary capill ary wedge Pressu re (PCWP)

I

6-12 mm Hg

----I

Left Heart Catheterization Left ventncular end

5- 12mm Hg

diastoliC pressure

Th e autonomic ne rvous system (ANS) influences the heart and blood vessels Lh rough direct neural and indirect neurohormonal mechanisms. The heart has dual direct innerva lion from the sympathetic ancl parasympathetic nervous systcms . 10 The sympatheti c receptors of the heart are prj· marily beta-adrenergic receptors I I and are locat.ed on the ~inus node and w ithin the m yocard ium. Stimulaljon of the recepto rs by the neurotran sminer norepinephrine (noradre naline) increases the overall act ivit y of the heart bv inc reas ing the hean rate (cllrollo/rop.v) ruld force of con"traclion (jllorropy). and al so resuh s in coronary aner) di latation. I:: Symp~lIhe tic s lil11ulat ion of the alpha-adrener. gic recept or~ 0 11 peripheral blood vessels will res ult in v
Left vemncular peak systOlic pressure

90-140 mm Hg

Systemic artenal pressure

SystOlic 11 0--120 mm Hg Dias tolic 70--80 mm Hg Mean 82- 102 mm Hg

Cardiac output (CO)

4-5 Llmln

Cardiac IIldex (CO body surface area)

25-35 Limln

Stfok vol ume

55-100 mllbeat

Syslemlc vascular ReSistance

800-· 1200 dyn es/seC/cnl

t.

H ~ClaPled from Braunwald, E, Zlpa~ , 0, and ltDby R (ads) ean Dl&ease A Textbook of Cardiovcu!
.m 6

~Unde(s Phllade!p"la 1997 p 188
ization is the ability to monitor filling pressures nol only on the right side, bUI al so. by est imation, of left heart pressures wi lhoUl the need for the more difficult and risky LV cathete ri zation . Illvasive monitoring can also be done by a left heart cathete ri zat ion by placing a catheter into the femoral or radial a rtery and advancing it retrograde to the !low of blood through the aorta, across the aortic valve. and into the LV where LVEDP can be clirectJy monitored. The LV catheter lies within a high- press ure system (the left heart and aorta). and therefore can stay in place for only a short period of time (e.g .. an hour) because of the difticulties associated with cannulating a high -press ure system . In contrast, the right heal1 catheter, w hich lies within a relatively low-press ure syste m (the right he(1). provides continuous monitoring of pressures and can be kept in place for days.

Be DocKel

Inc, 1987, p 36

The "ympalhctlc Ilcrvou" ~ystcm may :.tlso stimulate the ~l~rt'nal CO l1ex to t-ccrt'H." the ca tl'c holamine epinephrine. rill , blood- bome honnolle will han" sy mpathetic dfect-. thai JI. time, lila) e\'e n be more long I:l~ting Jnd p(!lent than direc t ~.\ lnp~ulll'll t' ac ti,·ation, Epillc-phrin~ is relf'..lScd ,I" p.i!"! lit the nOflHal e\(' rCI.'ie rc::-.ponse, ('spec iallv when C\l! n.: I '~ i . . conWllll'u bt') ond a te\\' 11l1l1lIle ... , The i;lcreu~e In IIR .Iflll l'OIllTadilll) nOleo \\ ilh e\('f('I.')t' is in P,lrt due (0 th" hUrnWfl:ll lllflut' n ce. Mdll) l'~mlil)\'asculJr dru~..; ei ther c nhil n~e or ... upprt: .. " ,ymp;lIht rit fUIl(;llL'lllllg. -n~) . . c. thaI 1I!l Il IH: lhe aC llo n 01 the- "j mpatht' tic nen OU~ ~ystem m'e i.. UO\\ II ~\ ... .\ Impalholflfnlt'lh ,\. tho"ie th ut ~u ppre.ss ~ympa ­ tht.'!Jc IU lk'lH'nlng ..m,~ klh)\~ II ~h \ HUJ'atlwlYll( .\ , Frequently u'>Cu .') m palhttlllII IH:'Ill's .m: dopMl line. e-pilh!pllrlne. and J th)IH Ilt'. \\ IlIlh die l' Oll llll t'lIly u~t>d IIll fltlcal care t-e nings, .D OfMI III IIC •.UlJ l~plnephnill' ilH..' rea,e CO. \\hlle atropine IIh: I..:'.lsn Hk III the p...~~ ni,:t.' uf \:rilinl l hradycarJia

594

Physical Rehabilitation

Factors that influence CO incJu~e venous preSSUre. HI. and LV contracti lity. Factors that lI1t1uence peripheqJ ... cular resistance include arteriolar tone, vasoconstrictiaa. and to a lesser extent, blood viscosity. The central system (CNS) regulatory site for BP control is !he_ motor center primaril y located within the meduUa. 1'ht vasomotor center mediates sympathetic and vagal iap-. and is influenced by neural impulses arising in the banJrt.. ceplors. chemoreceptors. hypothalamus, cerebral cOI1Q, and skin. ( 1.1 ) The baroreceptor reflex is activated by_ pressure or stretch receptors located within the internal carotid (carotid sinus) and aortic arch. They are . . res ponsive to constantly changing pressure than to SQs.. tained constant press ure. Therefore, they playa key role it the short -term adjustment of BP that was altered abrupdy and not in long-lenn BP control. 12 These receptors respond to an increase in arterial pressure by facilitating a compeo. salOry decrease in CO and PYR. Activation of !he boreR. ceptor refle x by an increase in arterial pressure results ina decrease in sympathetic activation of the heart, arterioIca. and veins, and an increase in parasympathetic actMrion. Conversely, a decrease in arterial pressure will deaea fi ring of the arterial baroreceptors. resulting in an inma in sympathetic activation of the heart. veins, and anaioIes. and a decrease in parasympatheric activity of the heart 1k increase in sympathetic and decrease in parasyn:apilllldk activ it y will res uJt in an increase in CO and PVR. ~ increasing systemic BP (Fig. 16.3). Patients at riot '" hypotension include those who have lost blood ..... wi th a subsequent decrease in CO and those who an alte ration in peripheral nerve responsiveness (e.g....... betic neuropath y, spinal cord injury),

Frequently used sy mpatholytics are the category of drugs known as bew-blockers (beta-adrenergic antagonists) that suppress beta-ad renergic ac tivity. They are common ly used as pan of an anti-ischemic drug regimen and for the medical manage ment of hype rtension. The nonnal parasympathetic influence via the vagus nerve has a primary impact on the resting hean, influencing rest im~ HR substantially morc than the sym pathetic nervous SystCI;l. Parasymp:uhetic stimulation results in a depression of HR. dec reased force of atriaJ contracti on. and decreased speed of conduction through the A-V node. Vagal fiber innervation of venrricular myocardium is relative ly small ; therefore the effect on LV function is minimal. 11 During exe rcise. the effects of the sympatheti c nervous system and catecholam ine rel ease significantly override any effect from the parasympathetic system. The impact of direct parasympathetic influence on peripheral blood vessels is limited to a vasodilatory effect on the bowel. bladder, and gen itals. The catecholamine role in myocardial functioning during exe rcise is especially crucial for the patient who has lost direct sympathetic activation to the heart. For a patielll '" ho has undergone a heart tran splant. the heart is essentia ll y denervated: the sympathetic and parasympal helic fi ber" to the heart are excised. Sympathetic influence on the denervated heart is therefore solely dependent on catecholamine stimulation of the be t a~adrene rgic myocardial rece ptors 10 increase HR and contract ility.

nerve..

may_

Blood Pressure S) Slemie arterial blood press ure (B P) is a product of CO and PVR. TIle influences on BP are multifactoria.l 13 (Fig. 16. 3),

Jf Cardiac Output Jf , Heart Rate

NerlJOus SympathetiC

r HR

Blood Pressure

x

Peripheral Vascular

Jf

Stroke \btume

1 ContractIlity i

\Ie nous return

Arteriolar Tone

Resistance

,

Blood

Viscosity

i Va soconstncllon (alpha adrenergIC receptors)

t

Hormonal EpInephrine

,

i HA

Figure 16.3 Foclor'S dial ..... blood pressure. Some of . . . . . mfluences on blood ~ ...... homlolle~. ner'o·CS. le:spia nl'· _

Epinephnne

Va sopresslIl AngiOtensin II Inspiration

Skeletal Muscle Pumping

Hematocrit

~----- Btood IA:>tume

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 c&ed in mete" ,uc h that C I = COl llSA . l\ol1Hal CO range il) 410 5 L/mlll, norm al (' I range III 2.5 10 3.5 I.•/lmn/m·. C I provides a more compl ete detcrmHialiun 01 the adequacy o f an IIldl v Idua.! \ CO than CO
595

individual eac h with a CO of 3 Llmin , the 5-rt tal l person will have a higher CI and therefore better tissue perfusion because the re is less body s urfi:tce area req uiring the 3 L of CO. Determination of BSA and CI is often done usi ng nomograms based upo n the Geigy sc ientific tables. I!!

Myocardial Oxygen Supply and Demand M yocardial oxygen supply and myocardial oxygen demand mu st be in balance. M.vocardial oXYf.:en supply depends o n the delivery of oxygenated blood through the coronary arteries, the oxygen carrying capac ity of anerial blood. and the ab ility of the myocardia l ce ll s to ex tract oxygen from th e a rterial blood. Myocardial oxygen demwul (MVo 2), the energy cost to the myocardium,. is dependent upon many factors. 19 Clinically, however, MVo 2 is calcu lated by the product of HR and systoli c blood pressure (S SP). known as the rate pressure prodUCT (RPP) or doubl e product.2° Any activity that inc reases HR and/or BP will increase MVOr Therefore, any increase in systemic oxygen demand (e.g., exercise) will increase the energy cost of th e heart and MYol . The myoca rdium is routinely very efficient at extrac ting oxygen from its blood supply. Therefore. during times of increased energy demand. very litt le increase in extraction can occur. The primary mechani sm for increasing myocar· dial oxygen suppl y during times of increased demand is by an increase in coronmy blood flow (eBF ).11 In general there is a linear relat ionship between CBF and M-Vo.,. During exercise, CBF may increase five times above resiing leve l in response to the increased demand. Unlike ske letal musc le, which has the capability of both aerobic and anaerobic metaboli sm, the hean mu scle (myocardium) is esse ntiall y dependent on aerobic metabolism and has ve ry limited anaerobic capacity.

Pathophysiology The prime reason for a decrease in myocardial oxygen sup· ply is the presence of atherosclerosi s. Atherosclerosis is a progressive inflammatory disease of primarily large and medium s ized aneries. whose le~ions will become more complex if (he inflammatory process is nOI ab<.ued. The etio logy of atherm,c lerosis is hypothes ized as an inflammatory reaction in response 10 an injury 21 th;.u caused endothelial dys function ur eve n perhaps denuclation. 21 The les ion initially 1'0 flll'.. \\ ithin the intima and contains element~ of the innammatory response such a~ mucrophages. Iympho. cytes. and phllelet~ us \Veil a~ fibroproliferative response cdb . . uch as libroblr.c.t::., foam cr lls. l'onnective tissue. cal{·ium. and lipl(b. In response to the injury, ~mooth muscle cc ll '\ migr:.He f10lll the media into the ilUima of the arterial wall. In an advanced. comp lica ted lesion , it may comain necrotic tb::.ul' covered by a fibrous ('ap. The causes of endothelial J ) .... functiun art! vllried and again not clearly 1II1J(on,IO(K1. Prol>ost'd po\.sible cau~e~ include elevmed and Illodillcd low-dcll~lty lipoproteill (LDL) leve- Is, elevated

596

Ph ysical Re habili tati on

Myocardial Oxygen Demand

Myocardial Oxygen

Supply

Figure 16.4 Myocardial oxygen sUpply and demand (MVo2) relationship.

Myocardial oxygen supply and demand art

innuenced by many Factors; demand is strongly influenced by contractility, bean rale and wa ll tension; supply is primarily influenced by coronary blood flow.

(Adapted from Ellestad M: Stress Testing ECG abnormality

LV dysfunction

plasma homocysteine. and lhe presence of free radical s in response to hypenension. c igarette smoking. diabetes mellitus, geneli c abnormalities. and infectious mi croorganisms such as herpes viruses or Chfamydia pneunioniaY· Passive exposure to ci garette smo king is also associated with loss of endothe lium-dependent vasodiialion. As compared to premenopausal wome n. postmenopausal women ex hibit impaired endothella1 vasomotor fu nclion .23 The presence of atherosc lerosis itself appears to result in a dysfunction of the endothel ium , re sult ing in. among other things , decreased vasodilation capaci ty. The cause of thi s is nO[ completely understood, but may be attributed to the producli on of oxygen-free radical s. Alexander noted "exces~ i \'e producti on of oxygen radical s may be a gene ral metabolic femure of atherosclerotic arterie s that may exp lain , in pan . the abnonnal vasomotor control and tendency toward vasospasm,-·7. p 1265 A potent endolheli al vasodilator is

vasoactive substrates

Principles and Practice. ed 2. FA Davis.

Ph iladelphia, 1980. p 24, with permission.)

ve ntricul ar chamber size increases) the ability of the myocardium [Q develop force is increased, up to a point Beyond a certain length, however, force development is impaired owing to the inadequate alignment of actin and myosi n (Fig. 16.5).

Pathophysiology Contractility occurs during systole; a decrease in cOOllllCtility results in systolic dysfunctjon. Common reasons for systolic dysfunction are loss of myocardial contractile proI
EDR F. a fonn of whi ch is nitric oxide (NO). NO facililates vasc ul ar smooth mu scle relaxation : atherosclerosis. how. e\<er. miiy interfe re with the availabilit y of NO and therefo re re~u lt in a decreased vasod ilatory capacity of the coronary arteries. When a patic m 's oxyge n suppl y is inadequate to meet the oxygen demand. a cond ition know n as ischem ia occ urs (Fig. 16.4). Clin ical d iagnoses of isc he m ia or myucardial in larction (MI , are due to an imbalance bel ween myocar-

Left Ventricular Function Curves

c A

Stroke Volume

B

dia l oxygen su pply and demand.

Contractility T.hroughoul the card iac cycle . di a~ t o l c and ~Yl'!t ol e place dllfer.e nt demand:, o n the ventricle~. During d iasto le, the \it::ntncle~ m u~t be com pliant , able to \ lretch to accommod.ne the blood e ~lte rin g the ve ntri cleI'! (pre load J. DUring ~y~ l ol(;: . the ve nlndes must be abl e to contrac i aJ equat tly 10 eJ\!cl the Sv. T he prlllc ipl e of S t a rlin g'~ l e n glh-te n ~ i on reld.tlon:,hip IS appl icable 10 the myocardium and tht:: reJ::ll io n s~ip bt:: lwee n the prope rti t'~ of d ia~to l c Hnd sys !Ole. Ounn g d ias to le a~ mu ~c1 e le nglh Increa~c.\ (c.g., [he

LV End Diastole Volume

F'

... Igure 16.5. Left ve ntncular (LV) function curves. (.4)."... nonnal LV luncti on. a~ Ihe Icft ventricu lar volume ~ Mrokl! vo lume will al so inlTease. (8) With LV funcrioo iJIfIir' melli , IIlI! Curvc will ~ hift 10 the nghl. and for any Si". . . . . 'tIfO~c \'o lum~ is derre:l\ed compared 10 normal (point .... ~ece
Will shIH to the left and SV wi ll increase (note that poiIleil greml'r than point aa ).

Chapter 16 Heart Disease

Sinuatrial (SA) node

597

Left atrium

Right atrium

Atrioventricular (AV) bundle (Bundle of His)

Atrioventricular (AV) node .II ........

aAS

0.2

st _

0..

0.6

0.8

\1\l--r-- Purkinje

-~~;:::::J~-1;

fibers

Right ventricle ---f~*-

-11"\,\0'11-- Left ventricle

ElectrocardiographIc tracIng of a normal heart

\.::::;q

~~

' Left bundle branch

Right bundle branch

Figure 16.6 Schematic representation of the heart ~d ~ omlal cardiac ~lec.lricaJ activity. The EKG i~ the bod) surfac.e manifestmion of the depolanzatlon and repolanzauon waves of.the. heart . The P \I, 3\'e i~ e.eneraled by atrial depolarization. the QRS by ventricular muscle depo lanzatIon, and the T wave~ by ventricular repolarizalion. The PR interva l is a measure of conduction tj m~ from atrium to \entricJe. and the QRS duration ind icates the time required for all of the ve ntncul ar cells to be actlv3ted . The QT in terval reflects the duration of the ventricul ar acti on potenti al. (Adapted from Taber 's Cyclopedic Medical Dictionary. ed 18. FA Davis. Ph iladelphi a. PA. 1997. P 852. v.irh penmssion. )

response to a variety of stimuli. such as myocardial inj ury from a large Ml ; alcoholic. bacterial. or vi ra l cardiomy. opath) ; valvular heart disease; or certa in types of chemotherapy. If the dia'lOlic prope rti es of the ventricle are impa ired , myocardial function will also be impaired . Decrea~ed LV fillmg OCcur~ whene\ter the LV IS limited in its abili ty to stretch adt'quatel), to acco mmodate preload. Examples of impaired diastolic function include intlamed pericardIUm (e.g .. pericard it i~) , thi ckening and stiffening: of m)ocardium due 10 hype n en ~io n , pericardial effusions. ~car H~sue , and connective tiss ue c hange ~ associated y.uh dlabele ~.

ti on through AV node; QRS complex. ventricular depolar-

ization: ST segment, initiati on of ventric ular repolarizati on; and T wave. completion of ventricular repolari zatjo n. 1S .26 Each EKG complex re presents one cardiac cycle. one

heanbeat. In a se ries of EKG complexes representing sin us rhythm , each Q RS complex should be preceded by a P wave and the QR S complexes should be equall y spaced apart , indicati ng a reg ular rhythm.

Pa thophysiology

COlllr3ctlon depend\ on an iniac! ek ctri ci.IJ conduction ~y~_ tern thai re ... u\tl, In depolarizat ion of the myocardium and IJmel~ fc:polan z3IJon. In normal li"us rhYlhm (NSR ) the tropube bt.:g.IIl~ in tht ,inu ~ node , travels through the atria, the :\- \ node, bundle of I-h .. , Pur"'inje jlber~ , Se pIUJIl , and

A HR greater than 100 bpm is known as tachycardia : a HR les.s th an 60 bpm is known as bradycardia. Exercise commonly result s in a tachycardia as part of the !lonnal response to the increased syste mic oxyge n demand (Va.,). Volume lo:,.s, ~uc.:h as that wilh surgery or deh)dralion. may re~u lt In i:I cumpensatory tachycardia to maintain CO in the pr«ence of a reduced SV (remember CO = HR X SV ). Bradycardia at re~ 1 i...... commonly ~een in people with good aerobiC capacitic!'l a~ a resuh of regu lar endurance exercise; however, thei r I-I R will appropriately increase in response to the increast:d Vo :! of exerci~e-. Paue'ms may have brad) -

Elo..lfllai couduclton C.. (Fig. 16.6). Each compoueTll oj the complex rcOedS a calain phase of CUE1lhJCIH..m: P Wave. )tnus 1l(1C:i!: tind atrial depo ldriL311on; PR ~egmt!JlI. conduc.

cardia beC3U~ of impaired conduction, Ii sic k. sin us node , or ce rtalll me dl cati on~ (e.g., beta-blocker'i). If HR does nor II1Crea.')C' appropn.uely when Vo~ is increased. CO wi ll dc(' rt:a~e . Jnade-q UJh: CO llIay produc~ a varie ty of clinical ~lgn ... and ~) 11lp10Il~ 113 a result of in adeq uate tissue or

Electrical Conduc tion

\emndt: ~

598

Physical Rehabilitation

organ perfusion slich as light headed ness. a lterati?n in mental status. and an gina. Insufficie nt HR response III the prese nce of inc reased Vo~ is known as chronotropic

incompetence. A rhythm is e ither regular or irregul ar. A regular rhythm indi cates a consistent re lationship between eac h QRS complex as measured by the R-to-R illle rval between EKG comp lexes. An irreg ular rhythm indicates an incons istent relationship between each QRS com plex. There are many d iffere nt types alThythmias and conduction delays. The most comlllon are the atrial arrhythmi as of atrial fib rill ati on (a-fib), paroxysmal atrial tac hycard ia (PAT),s upraventri cular tachycard ia (S YT). and the ve ntric ul ar arrhythmias of bigeminy. trigemi ny. v-tach . and ventric ul ar fib rill ati on (v-fib ). nle seve rity of any arrhythmia is de te nnined by it s i mp~lct on CO. Because the ventricular arrh ythmias are more like ly to cause a decrease in CO. part icu larly if prolonged. they usuall y have a more detrime ntal effect on cardiac fun ctioning than aLrial arrhythmias.

Exercise Response Normal Exercise Response

vO

An increase in J occurs with an increase in ex ternal workl oad (i.e .. mph. kpm,). T here is a direct, almost lin ear relation ship between HR and extern al work load (Fig. 16.7). Therefore. if the physica l therapy intervent ion requires an inc rease in systemic oxygen consumption expressed as e ither an inc rease in MET leve ls, kcal , L/O.,. or ml O2 per kg of body ,..'eight per minute. then HR should abo increase. Allhough some cardiac medi cation s, particularly the beta-blockers, which suppre ss the sympathetic nervous !)yste m 's effect on the heart. w ill lim it the actual amount of incre ase. HR should ri se nonethe less. Fail ure of the HR to inc rease wi th increas ing workl oads (chronotrop ic incompete nce) should be of conce rn for the ph) !)ical therapi st. O ther ph ysiological parameters should be quid.. ly exa mined, suc h as BP, respiratory rate, skin co lor, and tem perature as we ll as the pati ent 's leve l of cog nit ion and pe rce ived exe.ni on. An adverse re spon se in any ~~ the!le parameters is an indi cation of th e pa tient 's mabllily to hemodynamic all y respond to the given amount of", ork .

BP should be taken before and immedi ate ly afte r exercbe wi lh tl?e patient in the sam e positi on (i.e., supine, sil tlllg , ~tandmgJ and from the same ann each time. Ideall y, BP should be taken during exerc i ~e to dete rmine the actual htmodynamic respon-.e to the increa~ed workload. However depe nding on the type of exerc ise modalit y. thi~ is Ofl(;~ technically difficult. If I-IR and BP a re both to be Lilk follo.wing exerc ise, HR should be taken first. Whenev:~ poSSible, a more accurate examination of BP and I-lR response to exe-rc i ~e is obtained if these mea~ u re m e lll S c an

be taken during exerc ise. As w ith HR , a linear increase ' systoli c pressure is expected w ith inc reasi ng levels of w~ (Fig. 16 .7). Helierstein e t al" reporte d that for each 10 per. ce nl inc reme nt of maX Im a l HR, systolI C BP Increased 1210 15 mm Hg. Naughton and Ha ide r" inte rpreted an increase in systo lic BP in excess of 12 mm Hg/MET as a hyPenen. sive exe rcise res ponse and a n increase below 5 mm Hg as a hypotensive exerc ise response. D iastolic pressure exhibits lim ited changes with exercise: it may not change , or either increase o r decrease by 10 mm H g. As syste mi c oxyge n require me nts inc rease, the depth and rate of respira ti ons w ill norm ally incre ase from rest (i.e., tida l vo lume).

Inappropriate Exercise Response The Ame ri can Co li ege of Sports Me d ic ine has identified signs and sym ptoms o f excess ive e ffort (Box 16.1). Obviously, if a patie nt experie nces any of these symptoms , the acti vity should be sto pped and the patient stabi· lized. It is also impo rtant to infonn patients that some responses may be delayed for as long as several houn after exercise. Observati o n of the patient throughout me ph ysical the rapy in terve ntion provides a mechanism for ongo ing examination . By pay ing attention to any subtle c hanges in the patient 's fac ia l expression. skin color, tone of voice, or thought process ing that may indicate activity intole rance, the phys ical the rapist may quickly respond a nd modify the intervention a fte r c ritically evaluating the patien t status. Beside s the patient's subjective compla int of fatigue CI' discomfort. there are othe r responses that should term_ an exercise session. These a bnorma l responses include ( I) fai lure of the systolic pressure to rise as exercist

Box 16.1 Signs and Symptoms of Excessive Effort • Persistent dyspnea • Dizziness or confusion • Pain • Severe leg claud ication • Excessive fatigue • Pallor. cold sweat • AtaA.ia • Pulmon;:t(y rales Resp o n ses that 11111)' be delayed for .. .... as several hours include: .

• Prolonged fatigue • insomnia • Sudden weight gain owing to nuid re~ Fro.m Amencan Colleg.e~ of SPOr1S Medicmc: GWdeI- for E),;~rcII>C. T~sllOg and Training. ed 4. Lea & Febiger. fIIih'h'fH' 199 t. ~lth pennis:-. ion.

C hapte r 16 Heart Disease

t600 mlJmin.

Oxygen Consumption fV~) V~ = HA x SV xa -\l02

Yo,

BOOmlJmin. DmlJmin. lSmm.HII

Cardiac Output fHR x SV)

co

lDmm.HII Smm.HII· 180 belts/min. 140 beats/min.

HR

Heart Rate 100 belts/min. 60 belts/min

Stroke Volume

------

151101%

a-v02 Difference Art'erial Oxygen Content minus Venous Oxygen Content

-

SV

IIOml. l00ml. !IOml.

101101 % 51101 % Oval % 180mm.HII.

Arterial Blood Pressure BP=TPRxCO

140 mm.Hg. l00mm.Hg. 6Omm.Hg . .014 mm.HgJmIJmin.

Total Peripheral Resistance fTPR)

TPA .010 mm.HgJmIJmin. .006 mm.HgJmIJmin.

Minute Ventilation Ve=TVxRR

100 lImin. 6lJmin.

V.

~

TV

7<:

~

Tidal Volume lTV) Respiratory Rate fRR) 0

~: Resting

Minimum

AA

Moderlte

Maximum

Int.n5ity of work

Figure 16.7. Card iopulmonary response 10 acule ;Icrobic e"(ercise. (A dapted fro m Berne. RM and Levy. MN: Cardiovascul ar Ph ysiology, ed 5. CV Mosby, St. Louis, 1986, p 237: Zadai . CC : Clinic!. in Physical Therapy, Pulmonary ManagemcllI in Phys ical Therapy, Churchill Li vingsto lle. New York. 1992 , p 27 ; and McA rdle WD el al: ES\jcnlia l~ or Exerc ise Phys io logy, Lea & Feblger. Phil adelphia . 1994 . p 230.)

599

600

Physica l Re habilitation

. Iu d·mg a sys. es' (2 ) a hyperten sive BP respon se, mc . contmu . d! r a diastoli c IOli c pressure of greater than 200 mm Hg an 0 . . f II pressure greater than I to mm H g; or (3) a prog.r~ss lve .a, in systolic pressure of 10 to 15 mm H g.~ In ~dd ' tlOn . ~ Sl ;~ nificant change in cardiac rhythm detected. el t~er by palp tion or by EKG monitoring warrants tenmnatJon.

Cardiovascular Examination The ph ys ical therapi st mu st determin~ h~w cardiac impairment ha s impacted cardiac functIOn .In or~e r t.o plan safe and appropriat e exercise inter.ventlons. V0 2 IS direc tl y relat ed to CO: an increa se in Vo 2. such as th at wilh exerc ise. will res ult in an increase demand for CO. Therefore , anythin g that limits CO will limit the amount of sys te mic e nerg y that the patient has ava il able . Depend ing on the practice site of physica l therapy. the ava il abi lit y of pati ent information will be varied. Before planning an inte rvention for a ny cardiac patient. in a~di­ ti on to ques tions concerning medical hi story, medications. and rev iew of systems. the following questi ons need to be an swe red: • Wh at is the pat ienl"s cardiac d iagnosis and hi story (e.g., ischemi a. noncomplicated Ml. compl icated MI. CHF)? • Does the pali ent presently have ischemia? If so, how does the angina present? • What is the result of the latest exercise tolerance test (ETI) in order to identify the ischemic RPP? • What is the pati enl"s base line rhythm and rate? (Identify any eclOpy and the EKG interpretation of the rhythm .) • What is the BP? Is it the same in both ann s? What is it sitting and standing? • If the patient has been revasc ul arized. what vessels we re involved and what is the starus of the other vesse ls? • Does the patient continue to have ischemia afte r the revascualari zation? The patient h i ~lOry is criti cal in directing the appropri ate questions.

Medical Record Review Rev iew of the medi ca l record b helpful in understandin g the patj e n1 '~ slatu !. and in pl ann ing ph y~ical the rtttl ng (e.g.. inpatie nt. outpatie nt . acUlc, rehabil itation ), the specific contt: nb of the medical record may val) Tht! acute inp,Ulcm record I ~ gene rall y the m OM thorough regardmg medlcal/burgical 1I11crve ntIOIl 'i. Item') Importalll to note IIlci ude (he fo llowing :

I. Med ica l problems. past me di ca l hi story, physician's exami nati on 2. Medicati ons including type. dosage, and schedule 3. Laboratory test s . . • Blood tests for specIfi c cardIac enzym~s.that may indicate an MI has occ urred, such as a posItive CK-MS or

troponin leve l. " • Elec trolytes. especially potaSSI um (K), If ventricular arrh ythm ias are prese nt. and albumm IfCHF IS pre$ent • Comp lete blood co unt (CBC), which may indicate the presence of anem ia via the he~oglobm ~d hematocrit val ues and also the status of k idney and 1tver function. • Presence of CA 0 risk factors. suc h as elevated lipid va lu es (e .g., tota l c holesterol , low-density lipoprotein s [LDLl . triglyceride ), a nd elevated blood sugars (g lucose) . • Arterial blood gases (ABGs) 4. Results of any diagnostic studi es or interventions: CxR, EKG s. EIT, cardiac catheterization, surgical reports, hemodynamic monitors (e.g .. pressure readings from central line and! or arterial line) 5. Nursing and othe r health care provider notes

The medical record contains information regarding what has happened to the pat ie nt , as well as the StaIUS of the patient within the last 24 hours or since the last healdI care provider intervention. It ofte n is not sufficiently up-todate 10 give the immediate status. The use of flow charts, which record vit al signs, temperature, oxygenation requirements, and vol ume status, provide more up-to-date patieat data and may therefore provide invaluable information f(l' the phys ical therapist, especially when working willi the more medi call y challenged patient.

Patient Interview The formal patient interview shou ld follow the medicoI record review. A detennination of overall cognirioo (e.,.. orie nt ati on. me mory, learning needs , compreheosiOl) should be made . Information regarding the pori••f. lifestyle, prev ious level of functioning, recreational inaeMS, \lv ork requireme nts. and goals is important in e~ li shing the inte rve ntio n. Data should also be obtainedaboUl the pati ent 's res ponse to health and illness, coping staIUIt suppo rt systems. and knowledge of heart disease. It Import ant to note that nol all the infonnation from die inter\- iew need~ to be obtained on the tirst session. [)uriI:W ~ u b'ieq llc nt seS ~ l on~, the pa ti ent may begi n to feel ~ and less 3n.'\ IOU' and may the re fore be able 10 c~· cate mOle easily. Patient education can otten be ,,",oven'" the IIlterv it:\\ proce~ , . e llh~r SUbtl y or ove rtly. The pIIiIII ~ hou ld (h:~cn be , III his Or he r own words. the quality ~ location 01 the ~ym p(om for which medical artr;Otkllo bci~lg , ought. It is l'ommon for physical therapistS 10 Ilk a paUellt
mse-. -

ChapleT 16 Heart Disea!$e

is pain. f\'1any patients will not lise pain as their qlla lifi~r. but instead describe their symptoms as pre ... ~ure. hcnv mess, shortness of breath (dyspnea), aching. heartburn. or general malaise. to identify a few. Knowing the symptom presentalion tor each individual will make patient ed ucation and activity progre~sion easier. II i~ also important to identify any rOIl!)istenl precipitating factors and alleviators as well as duration and frequency of symptom ~. The interview also helps to establi sh rapport and tru st between therapist and patient. creatin g an env iroll me nt for mUlUa l gO~l l sell ing and facil itating easier compliance with the o\'erall rehabilitation program. PatieOls who are recovering from an Ml or from surgery need to have an underqandi ng of time frames for healing and co nva lescencc. Education for family members and significant others is also cru cial for patient compliance and understanding.

Vital Signs The physical therapist will take and monitor vital signs (see Chapter -1. ) at rest and with activity. auscultate the heart (and lungs). as well as perfonll a general inspection of the patient. An overview of the pertinent compone nt~ is presented.

HR and Rlwthm In taking an initial HR. either by palpation or auscultation. it is Important 10 count for a full minute. When examining the patient \. response to an activity and no arrhythmia is present. an immediate post-exe rcise HR can be taken for 10 ~cond ~ . Alway!) note if the rhythm is regular or irregular and report it as such. Unless there is EKG monitoring. it I~ impossible to identify a specific rhythm by palpation or auscultati on alone. Note lhm Ihere is a normal respiratory vari ati on in HR : inspiration results in an increase in HR. ex1lalation III a slowing dow n of HR. Obviously, since the patient i!'. go ing 10 be both inhaling and exhaling throughout the counting. do not identify the rhythm as meg ul ar. R'''l'irator~ Rate, Rhythm, and Shortness

of Breath .1\., \I. IIh the hea rt . both rat e and rh ythm of rt!!'. pir:lIion!)

should he nOlcd . a\ wdl as Ihe breathing pattern and u ~e of acce\')of) m u,>d ~,>. Patient... Wllh cardia c imp;'l1fm~nb !requently co mpl ain of shortne", of breath ( 11\' \ /111('(1 ) and report that it I'> tlll>' let) provoking The patient need ... to Ioed, Im mediate medical care If d) ' pnea O\.'c.: ur~ at re~ 1. r' r(oquentl) d) "pned. I.!. m,.,o(,; l. ttcd wi th acti vit y ;.Ind b 1-.110\1.0 h d.. .5PI1(' U (IflneniU II (1)OE). It i~ impOrto1nt 1'01 the ph Y~ lcal Ihcrapi ")t 10 doullne nl .tnd ullder~ t:lnd the J mOUnl dnd t) pel) 01 aCll v it ) thai pro\'Ok ~ DOE. Patie nts may aho desc ribe a type of d) ", pllt>a 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.~ \\<.I~ an ol1ho"talir respon~ . ('ven il BP I ') onl) minimall) uCI.' rc<.I:-eu . Pati~nt ... at ris~ for tJl1ho:-. t,l1i c change":'! arc lho-.c \I. ho h.i\ e been on prolonged bed re.. " ,\Ill.) ma) be \sion 11"0111 ... tlpml: hI "'11 , gradually elc\ming the hcaJ \)f the bed III allow ph) '} lologIC.ti adapll:Il lOn to oc('ur, When sJlling on the !) id~ ot thl' l~d . Iht: fed .. h{)uld be ~upponed and the

602

Physical Rehabilitation

pati ent encouraged to take deep bre at hs and perfonn ank le pumps. all of whi ch fac ilitate venous return . Usc of sup· pori stoc king!' or ace wraps to increa se venou s return may also be indic::tted for some patients.

Obse rvation, Inspection, and Palpation The pati enl'~ skin color should be in spected . Cyanosis. f.I blu ish co lor of the sk in . nail bed s. and poss ibl y lips and tongue. Tlla y be prese nt when 811erial oxygen saturati on is 85 p erce ll! ' or less.'2 Pal/or. the absence of a pink. rosy co lor. may indicate a dec rease in CO. Diaphoresis (cxce~s s\~ ea ti lH!. cool c lamm y skin ) should also be noted becau se it ma y ~ldi ca t e excess ive e ffort or inadequate cardiova sc ular response. Co ld fingertips may be due to compen satory vasocon str iction in re sponse to a decreased CO o r from the suppressed beta·sympathetic respon se of some bela-bloc kers. Palpation includes monitoring the fe moral. dorsali s pedis. and posteri or tibia li s pul se s. which are compared bilaterally and doc umented as bounding (4 +). nonnal (3 +). weak (2 +). thready ( I +), or absent (0). A diminIshed pu lse may be d ue to a decre ase in CO or a local arte· rial occ lu sion. The extremi ties are in spected for the presence of ede ma; pat ients w ith LV failure may have an increase in peripheral ede ma owing to the inc rease in hydrostatic intravascu lar pressure associat ed w ith increased pressure from the LV transmitted retrograde th rough the hean to venou s system. Edema i!' exami ned for it s leve l of pitting (indentation ) when mode rate pre~s ure is applied. Bilateral pe riphe ral edema may be a result of C HF. Edema of one leg. howeve r, is usually assoc iated wi th local facto rs w ithin the same leg ~uch as. \ aricose ve ins. lymphedema, or thrombophlebiti s. 32 The patient with chronic CHF who has a weight gain ow in g to 5.odium and wate r retention may notice edema o f the ankJes and lower leg s du ring the day (due to an increase in hydros1311c pre ~sure) that diminishe .. during the night.

Auscultation Invaluable informa ti on as 10 the status of the heart i ~ obta ined from ollscllfration (listeni ng) of the he an so und:-. . Nonnal heart :,ounds a re ide nt ified as SI (l ub), whi c h occur!! a l the tI1ne of the clo~ ure of th e mitral (and tricus. pld) valve and marks the beginning of systol e and S, (dub) , which occ ur~ at the time of ;.tonic (and pullllonic~) \,<11,,(' cJo:,ure and marh the e nd o f s)~to l e (see Fig. 16.2).

Other abnomlal sounds are 53 and S4' SJ' also known a \'fll l";(' lIlar gallup. occurs after S2 and is clinically ~ c iated with LV fai lur~ . 54.' ~I so known ~s an a~rial gallop, occ urs before S I and IS c ilmca ll y aSSOCiated WIth an M10r chronic hypertension. The abnonnal hean sounds art the refore "booke nding" the normal hean sounds such tbat they would be orde red as: 5,. S,. 5" 5,. Another type of auscu ltatory finding is the pericardia/ / ri('lio ll rub. These friction sounds are high pitched with a lea the ry and sc ratchy quality, although they may vary in int ensity from hour-to-hour or day·to·day, or may even tran. sie ntl y di sappear." The pericardial rub has been described as similar to the squeaking sound of rubbed leather, 3S This rub res ults from an inflammation of the pe ricardial sac either w ith or wi thout excess ive fluid. Pericardial dise~ may res ult from many causes such as trauma. infections. tum ors. collagen di seases. anticoagulants. and MI. POSt. MI pericarditis is known as Dressler's syndrome.Y, An e xample o f docume ntation for heart sounds would be: Cor: RRR (2)111. g, r, wh ich wou ld be interpreted as Hearr: regu. Jar rate and rhythm without murmurs. gallops, or rubs, Au sc ultating the lungs is an important component of the cardiac ph ys ic al exam ination. Patients who have LV fa ilure o ft e n have the adventitious sounds of crackles, Crack les may a lso appear as a result of atelectasis; in tiI3! case. deep breathjng wi th an in spiratory hold and coughing may correc t this impairment. A patient with decreased breath sounds or conso lidations may have a decrease in me oxygen content of his or he r blood; a decrease in oxygenati on may res ult in an increase in myocardial work aM aggravate a preex isting cardiac impairment. Ausc ulta tion is used 10 determine the presence of an abno nnal sound known as a hl'lli" which is associated with a narrowing within an artery. It is heard most commonly in the carotid and fe moral arteries and indicates the probablt presence o f atherosclerotic di sease. Auscultation the hean borders is al so done to examine size. The location Ii the apex and po int of max imal impul se (PMl) is noted; if the LV has inc reased in s ize. as frequently occurs with patients in LV failure. the PMI will be djsplaced laterally towa rd the axi ll a. Addi ti onal e'(a minati o n detail s may be found in many medic",1 and llur~ illg texts fo r phys ical assessments. 31-:W

or

Tests and Measures Abnormal Heart Sound. Munnur:, are abnormal heal1 ~ou nd:, l:ommonl) the res ult of val vular di'lorder:, due to the thange~ in blood tlO\\ around ;ll1d through the altered v'ilve. q A \ ,,;+.(ollc I1/1Umw will prl!~cnt tJ\ J udlblc IUrbu1e ncf: bel\\cen· S, and S . (lnJ a dlUHo/t1 nllIIlIllir a ~ t ~rhu lcn(:e betv.an S,! and ~S l' A How ll t valve has unpaired open lilg. and J. regurgit ..Ull valve ha'l Impam!d c1o\ lng . A v<.the may be: both 'I lenntll' and regurgitant

A number or cliniral tests and measures are used 10 eu'" me m)-ocardial tunction . A fe\\ of the more c()OVl1ORlY u'It:d an: u('~r n~d be lo\',.

Electrocardiogram (EKe, ECC) -I he EKG (ul>" re le rred to "' ECG) i. used 10 e...... HR . rh)-Ihm, "':onciul' tll)1l delays , and coronary ~

60J

Chapter 16 Heart Disease

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I A ·i Figure 16.8 Nonna l 12 lead EKG from 50-year-old woman ; slight ST elevation is insignificant. T.... e!ve leads are presented: al the bottom of the page is a rhythm strip from Lead 11. Heart rate from the rhythm strip is approximately 52 (there are 5.8 large boxes between complex 3 and 4: therefore 300/5.8 = 52).

Two of the most common types of EKG are the single lead and the 12-lead (Fig . 16.8). In the single lead, only one area of the heart (e.g. , anterior. lateral, inferior) may be viewed al a lime. Thi s area may be changed. however, by altering the location of the electrodes. In the J 2-lead , 12 areas may be viewed a lmost simultaneousl y. The single lead IS sen ~ ilive 10 rale and rhythm changes and is com monl y u!;ed for monitoring patients during ambulation and activity. MonilOring is accomplished either via telemetI) (radio lrammi ssion). allowing the patient freedom to move around when wearing lhh portable device. or by hard'Wire . where the patient is attached 10 the mo nitor by a cable approximately 15 ft long. therefore limiting mobilit ). A variation o f the ~ ing l e lead is the 3-lead. which IS usuall y hardwire and i ~ used for monitoring in an inpatient ~e lllnl! . It can be wom continuou sly throu ghout an enti re lreatm ent ~etlos ion o r throughout the en tire hospitalization The 12-1ead EKG i\ !;ensni ve to chan gc~ in pe rfu siun as we ll d~ rate . rhythm. and co nduc ti on. Each coronary artery i ~ repre ~ent.ed by a cJu~ter of leads that , although not absolutely corrcl:u,ed wi lh each indi vidual '" imatomy. glY e~ a gene ral ~c hema for myocardial pe rfu ~ion . For example. choln gt!~ in Ihe perfu ~ ion of the RCA affects the Infeno r pan of the heart and are genentlly di"'played in le"d~ II . III. AVF: le lt coronary perfusion uf the antenor. anterior- Iat~ral . "nd aJltenOr-~p laJ pan,> of the hean are dl !'o pb.yed by \'an ou s combinations of the other lead s ITahle 16.3). Unlike the ~ illgle- Iead ~y5tem . the 12-It:ad

does not provide continuous monitoring (except during an exercise tolerance test [ETTD. Two common uses fo r the 12-1ead are the resting EKG taken with the patient quietly supine and the EIT. Twelve-lead EKGs are invaluable in identifying perfusion impaimlents in the coronary arteries and in ass isting with arrhythmia detection . During the EIT, the EKG is conti nuously monitored to determine the presence of ischemia or arrhythmias with each increase in workload. EKG interpretation is an important component of the eva luation process. For a mo re thorough understanding of EKGs and for guided practice. there are several excelle nt le xlS avai lable on EKG interpretation .-IO--&2

Table 16.3 E lectrocardiographic Lead Change. Associated with Anterior, Lateral, Inferior, and Posterior Transmural Infarctions

a or as in V1 10 V4 2 . Lateral infarction : a or as In lead I, aVL -----3. Inferior infarction: a or as in leads II, III , aVF 1. Antenor Infarction:

4. Posterior Infarction:

Large R waves in V1-V3 ST depression V1 . V2, or V3

' Standard 12·lead eleclrocardiogram' leads I to III, aVR, aVL. and aVF are 11mb leads , Vl 10 V6 are chest leads

604

Physica l Rehabilitation

Figure 169 Cakuht ion of a heart rate fro m a rhyt hm strip. Begin with the fi ft h com~l ex (whic h . . to Iheng ' ht 0 f ~ h'· omplex In the order falh on a large blad., line) and count each large black hne IS c. of 300. ISO. 100.75. 60.50. TIle six th complex fa ll s betwee n 11,','0 large hnes (I.c .• 50 and 60). There are five small lines be tween each large line. Between 50 and 60 there are 10 beats. therefore e:lch slllalll ine in thi s case wou ld be two beats. The ~leart rate would .be,60 - 4 ~ 56. A ~oalt.ernale method wou ld be to count the number of complexes In a 6-second stfl P .md mul tiply by .

Rate The EKG graph paper cons ists of a series of sllKt ll boxes (represented by lig ht black li nes) and large boxes (represented by heavy black lines). Each large box is made up of five sma ll boxes. The horizontal axis represe nt s tim e; when the EKG paper is movi ng at the usual speed of 25 mm/sec . five large boxes constitu tes one second. Know ing that time is on the x-ax is, there are many ways to calculate a HR from the EKG graph pa per. An easy way to calculate a minute rate is to co unt the number of com plexes in 6 seconds (i.e .. 30 large boxes) and mult iply by 10. Ofte n the EKG paper wi ll have 3-second interval s premarked. An altern ative approach is to identify an R wave from one EKG complex that is close to or on a heavy black line (i.e .. a large box), and then assign each of the following heavy black lines (large boxes) a numbe r in the fo llowing order: 300. 150, 100.75 , 60, 50, 40. The heavy line closest to the next R wave wi ll provide an approx imation of HR (Fig. 16.9). Fina ll y, dividing 300 by the number of large boxes between two R waves w ill also ind icate the HR . If the rate is reg ul ar. any of the precedi ng strategies will work. If the rale is irregu lar, however. the complexes wi ll need to be counted ove r a long time fra me, a minimum of a 6-second strip should be used.

ST Segment The clinical usefulness of the ST segmen t is to identify the prc5.e nce of impaired corona ry perfusion , ei ther isc hemia o r injury. The J point. the point where th e S wave turn~ into the ST ~eg m ent. i ~ the point of reference for in terpreting the ST ,egment. On the EKG paper, if the ST segment is dcpre~~d (one or two small boxc!\) at two ,,111<,11 boxe~ beyond the J point , then bchemia b like ly presen t. Ischt:mia i ~ tran sil! l1I . and when myocardial supply and demand are reba lanced, the ST segment will return to ba!-'eline. Unlike the ST depression of i'\chemia, a tram.mural myocardial injury (i .e .• infarcti on) pre~e lll s as ST !l.eglllcnt elevation (Fig. 16. 10). A nontran~l11ural myocardIal IIljury. however, pre:..ent:.. as S1' deprcs, ion and I~ U\U-

ally accompanied by labo ratory values (e .g., CK-MB, troponi n) that indicate infarcti o n has occurred.

Left Heart Catheterization! Coronary Angiogram Left heart cardiac catheterization or cath. as it is common ly refe rred to, invo lves insertion of a catheter into a major artery (ofte n the femo ral or radial anery) aud advanci ng it retrog rade thro ugh the aorta until it reaches the LV. Th e cathete r may the n proceed into the LV and is used to measure hemod ynamic pressures during systole and d iasto le and to ex.amine LV function. The ejection fraction (EF) is a clinicall y useful measure of systolic LV fun ction . T he EF is the relationship between the SV aud the LVE DV (EF = SV/LVEDV ). Normal EF is 55 to 15 pe rcent . meaning th at w ith each contraction 55 to 15 pa. cent of the volume of blood that was in the LV at the ODd of d iasto le has bee n ejec ted into the aorta during sy5lOle. [n sys to lic dys fun cti on, a general rule of thumb is tbat Ihe lower th e EF, the mo re impaired the LV functiOll. The angiogram com ponent invo lves injecting a radiopaque dye into the osti um of each coronary anery. obseniII blood flow through eac h of the arteries to determine" presence of les ions or blood flow o bstructions. DepeodiIt8 on the infomlation desired. the patient 's status. and the planned in terven tio ns, a ca rdiac cath procedure may 1IIt rrolll I to 3 hours.

Echocardiogram With ultrasound techno logy. the echocardiogram is ...... examine wall Illation tntegrity. vaJvular statUS. WIU .... nes~, chamber size. and LV function. The I:alcu lated lIsing the data obtai ned from the echoC.... £ r An ec hocardiogram may a<.~company a streSS . . . . II: known a~ a stress ('cho . The purpose of a suess comp;:Ire LV function and walJ motion between leju"'''~/(j c i"e when ' U1 int.:reased V02 results in an d l"IIr'~'~~

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•

Chapter 16 Heart Disease

605

R Figure 16.10 EKG following an MI. IA) Zone oj inJan lio ll: when infarrtion occurs th rough the full lhid..ne ~s of the myocardiu m

(transmural ) :111 abnOn1l31 0 wave usuall) appe3.r~ . (B) Zone of mjllry: ST e l e\,~lti()n occurs In the area ofinJUf),. (C) uJlle of Ischcmw: ST deprc:-.sion and/or T \\3\'e inversion occ ur~ in an area of

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positive stress echo indicates a worsening of LV funclion as activity increa<;;es: a negative stress echo indicates that the LV

has adequatel y adapted to the increase in energy demand.

Invasive Monitors When is it not feasible to perform a left heart catheleriza· tion to examine LV function. or if continuous monitoring of myocardial fum:tion is desired. a catheter may be inserted through the vesseb. entering the right side of the heart to record the following pressures: central venous pressure (CVP). PA pressure , and pu lmonary capillary wedge pressures (PC\\rp). This catheter is refcrred 10 as a cemralline. A common type of cen tra l line for hemodynamic monitoring is the S\\< an-Ganz cat heter. Because the cardiovascular system is a c1o!o.ed loop and the LV depends on the integrit y of the RV to function appropriately. recording right-sided pre!)!)ures gi\ e\ an Ind irect indication of the status of the LV. By com parm g the actual readi ngs from the patient to the expected noml. a fai ling LV may be identified by elevated pres::.ure.... whI le lowered pre s ~ure~ may identify
Exercise Tolerance Tests To exami ne Ihe abtlJl) of the cardiovascular sy... h: m to aC(;Qmmod ule 10 im; I 1:;I <; mg \10;:. an exe rcise IO leram;e le~1

~Ty-

(Err, stress test or graded exercise test) is useful. The patient exercises through stages of increasing workloads, expressed in units of oxygen . Oxygen cost may be ex pressed in L/min. m l 0 ,1 kg Imin , kcal, or m eta bo lic equi valents (M ET s); a MET represe nts the basic systemic oxygen requirement at rest. roughly 3.5 m l 0,lkg/min. The clinical usefulness of METs is that an activity can be expressed in comparison to resting energy cost. For example. the first stage of the Bruce protocol requires roughly 5 METs of energy (i.e., it requires five limes the energy expended at rest). The most common modalities used in exercise testing of patiems with cardiac impainnents are the treadrrtill , bicycle. and ann ergometer (Fig. 16. 11 ). In the earlier years of exercise testing for examination of CAD, the step test was routinel y used: however, it has for the most part been replaced by the other modalities. The step test is useful for fimess screening in the re latively hea lth y population and in exercise training for both the cardiac and noncardiac populations. Knowledge of systemic energy req uire ments is important in prescribing exercise and act ivit y guidelines. as well as in exercising testing for patients wit h cardiac impairments. Many charts arc ava ilable that express systemic energy req uirements usi ng a variety of oxygen equivaJenrs (Table 16 . ~ ) . The two major goals of e\.e rcising testing are (Q detect the pres-.: nce of i~chemia and to Jelermine the functional aerobic capa..:i ty of the individual. The prttient is monitored \\ ith a 12-lead EKG throughout the test and recovery; mfOmlalioll regardi ng perru~lon. rhythm. or l·onduction Ch;;1I1gC:o. 1\ therefore im meJiatdy avai lable. In addition to the EKG . OI her diagnostic tools m~ty be used. most common l) the tc hocard iognun and nudear imaging . The stress Unt , ()lIlmu('s

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Chapter 16 Heart D isease

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Too low in energy level

Desk work , driving auto. electric calculating machine operation, light housework. polishing furniture , washing clothes

Standing, strolling (1 mph), flying, motorcycling. playing cards, sewing, kn itting

Too low in energy level unless capacity is very low

Auto repair, radio and television repair, janitorial work , bartending, riding lawn mower, light wood-working

Level walking (2 mph) , level bicycling (5 mph) , billiards, bowling, skeet shooting.shuffleboard, powerboat driving , golfing with power cart, canoeing , horseback riding at a walk

Yes. if continuous and if target heart rate is reached

Brick laying. plastering , wheelbarrow (1 OO-Ib load), machine assembly, welding (mode rate load) , cleaning windows , mopping floors, vacuuming , pushing light power mower

Walking (3 mph) , bicycling (6 mph), horseshoe pitching, volleyball (6-person, non-competitive) , golfing (pulling bag cart), archery, sailing (handling small boat), fly fishing (sta nding in waders), Horseback riding (trotting), badminton (social doubles)

I

Recreational activities promote endurance; occupational activities must be continuous, lasting longer than 2 min

Painting, masonry, paperhanging , light carpentry, scrubbing floors, raking leaves , hoeing

Walking (3'h mph), bicycling (8 mph) , table tennis, golfing (carrying clubs), dancing (foxtrot), badminton (singles), tennis (doubles), many calisthenics, ballet

15-6 METs 18-21 mU

Yes

Digging garden, shoveling light earth

Walking (4 mph), bicycling (10 mph), canoeing (4 mph), horseback riding (posting to trotting), stream fishing (walking in tight current in waders) , ice or roller skating (9 mph)

Yes

Shoveling 10 times/min (4 'h kg or 10 Ib), splitting wood , snow shoveling, hand lawn mowing

Walking (5 mph), bicycling (11 mph), competitive badminton, tennis (singles) , folk and square dancing, light downhill skiing, ski touring (2 % mph), water skiing, swimming (20 yards/min)

Yes

Digging ditches, carrying 36 kg or 80 Ib, sawing hardwood

Jogging (5 mph), bicycling (12 mph), horseback riding (gallop), vigorous downhill skiing, basketball, mountain climbing, ice hockey, canoeing (5 mph), touch football , paddleball

1 1','2-2 METs 4-7 mUkg/mln

2-2 1J2 kcallmin I

2-3 METs

7- 11 mUkg/min I 2'h-4 kcal/min

I

_._--

--

3-4 METs 11-14 mU : kg/min 4-5 kcal/min

I, 4-5 METs 14-18 mU kg/min

kg/min 1

,,

8-7 METs

21-25 mU kg/mm 7-8 kcal/min

--. 7-8 METs

-

25-28 mU kg/mm 8- 10 kcallmin .

-

.

-

8-9 METs ' 28-32 mU i ,

I

- - ---

---

Yes

Shoveling 10 times/min (5'1, kg or 141b)

kg/min 10-11 kcallmtn

._10+ METs 32, mlJkglmln 11 + kcal/mtn

-

-

yes

---

-

-

-

-

-

Shoveling 10 times/min (7 % kg or 161b)

-

--

, L

---

-

-

--

.

-

-

-

Running (5'h mph) , bicycling (13 mph), ski louring (4 mph), squash (social), handball (social), fencing, basketball (vigorous) , swimming (30 yards! min), rope skipping

-

---

Running (6 mph ~ 10 METs, 7 mph ~ 11 'n METs , 8 mph = 13 % METs, 9 mph ~ 15 METs, 10 mph ~ 17 METs), ski touring (5 + mph), handball (co mpetitive). squash (competitive), swimming (greater than 40 yardS/min)

-

-

------ -Flom Fox Ca d SM , et al. PhYSical activity and cardiovascu lar health 3 The exerCise prescnpllon' Frequency and type 01 act,vlly Mod Con r IOvase DIS 41 '26, 1972, with permission

-

.

608

Phys ical Re h abilitation

t'c ho examine!) \\allmOlion ahnorl1lalilie~ IhJt mayor ma y not be pre~ent al rest. but may becomc more prono un.ced d N lIC Icar · II. n 'll!in(l c· Ihailium wllh inc rc a"" .l1lg \\or"' Ioa.... ,~ e (e 'e"

:-.c!)tamibi) compare" co ro nar) perfusion betwe~n ~cst and cxerc i... c. If the re i . . no dC(' rl"a~c in pe rfu s ion w1th IIlc reasillg work I Qad~. the l e~ t is nega tive : if there i... a decrease. the [e:-. I i.;; considered po..,i li "c. Sl rc:-.~ Icst ~ are int e rpreted a~ e ilha po~itive ( + ) or negall\ e ( - ). A pos;t;\"(' fIT indicat es thai there is a po int at \\ hic h the 111 ) ocard i ~1I o\ygen :-.uppl y i ... in'ldcquatc 10 meet the 111\ oc ardiai OX) gCIl demand. and the Ic'l i!o. therefore po . . ili;.e for Isc hemia . A lIl'gar;l·c Err illd.ica tes thaI al ne r\ le:-Icd phy:-. io log ica l work load Ihere I.'> a balanced o\\~cn :-.up pl ) and demand . P:Hi e nts are oflen confu sed re~a~rdin!.! Ihi ~ g:rading s)!) tcm: it is helpful to reass ure them th~lI in tl;i::-. ca~e. a negativc te:-.t i ~ in faci good. Strc')s lests arc nOI unliJ...c other diagno ... tic lOob: however. th ey ~Ire nol 100 percent spt'cllic and 5>c ns itive in idem ifying the presence of i-.c hemia. A fa/\('-"l'gmit·c ETT is one that b interpreled ao;; Ilegali\c but the patient in fact ha!o. i ~che mia . Comer...cl). a/lll.1c-l)()jlfi,·c fIT i:-. one th at i:-. interpre ted a ... po ... iti\·e but the patient does nol have ischemia. Althoueh relative ly safe fo r a vast majority of pati e nt s. there a;e certa in contrai ndl cJtions to exerci se testing that ,hould be noted (Box 16.2). Whe n a patient is unab le to perform an exerci~e te st because of limitations ... uch a" musculo~keletal or ne urological impai nl1 ent~ . a pharmaco logical stre ss le st s uch as a persalltillc rJ/OJ/illm test is often re co mm e nded. Persan tine. when gi\ e n intrJvenously. d ec rca ~e~ corona ry \a;;cular resi!)tance by ca u!)ing arterioles 10 v a ~odilat e. and therefore increase~ the b lood fl ow through the capi ll a ry bed'). If an arter) i~ atherosc lerotic. it~ arterio le may have graduall~ dilated mer time in an a ttempt 10 increase capi llar~ blood flow by means of pressure autoreguhuion. Thereforc. \\ hen persantine is give n. th e di~ea sed arteries rna) h,ne a l1 milalion in the amount of fu rthe r arteriolar dilation that can occu r. In com pari!)on to the tlondi sc:.t ... ed arlene .... liler\.: will be :.t relative decrea~ e in b lood flow through the (,;aplilar) bed') 01 the dbea!)ed arte ric!o.. Imagi ng !)tudll'~ V.llllhu') deleCi a re lalh e decre a:-.e in b lood flow 10 tht: area ollhe Ill) ocard iulll Ihat i... pcrfu ...e d b) the di ... ea~ed arter~ compared to th..!1 pcrfu ...ed b y ~t nondl \l' a ...ed artery. Adt;no,lnc . .... h lLh I'" a c.:oronary and peripheral v" ... odi lator 1.1\ v.ell :\!o. an anWlrrh) lhmi c.:l. ha ...... imJiar crfecb a ... pe r."lIl1lt1C anu Ill;}\ be u.,eu in"'It':ld: B

Pathophysiology and Physical Therapy Interventio n Sllllpl) ')tdh:!d . Ihe he"lfI 1\ a IJlU~culdr pUIllP ,,110"'1: primar) IUtH. llon 1\ tll plm IUl' adt.:4U,tte t'il rdlilC uut pUI lor Ihe bod) ., lIlelabolll nt:etb The pathoph) .,u.J log) ul tilt." h('afl . lor the 11"10:-.1 p'1I1. l-..In be \ lev. ed a .. a failure ut" an) ul rhc

Box 16.2 Contraindications to Exercise Testing

Absolute contraindication. • A recent significant change in the resting ECG ........ ing infarcljon or other acute ~ar~iac ev~nl • Recent comp licated myocardial mfarctlon (unless . . . . io,; stable and pain free) • Unstable ang ina • Uncon lrolled ventricular arrhythmia • Uncontrolled atrial arrhythmi a thai compromises cardiIc fun ction • Third -degree AV heart block witho ut pacemaker • Acute conges tive heart failure • Severe aorti c stenosis • Suspected or known d issecting aneurysm • Ac ti ve or suspected myocard itis or pericarditis • Thromboph lebiti s or intracardiac thrombi • Recent systemic or pu lmonary embolus • Acu te infections • Sign ificant emotional di stress (psychosis)

Relative contraindications • Rest ing: dias rol ic blood pressure > 115 nun Hg or resriIc syslO lic blood press ure > 200 mm Hg • Moderate valvular heart disease • Known electrolyte abnormalities (hypokalemia. hypomagnesemia) • Fi xed-rale pacemake r (rarely used) • Frequen l or complex ventricular ectopy • Ventricular aneurysm • Uncontrolled metabolic disease (e.g., diabetes. ~ eosis . or myxedema) • Chron ic infectious disea.o,;c (e.g. , mononucleosis. b ....I~. . AIDS) • 'euromuscu lar. muscu loskeletal, or rheumatoid 'i- :lac that are e'<.acerbated by exercise • Advanced or compli cated pregnancy Frum tht" American College of Spons Medic ine. Guide lines for TI.''''llIlg and Prescnplion. ed 5 Williams & Wilkins.

E\erCN~

B.I!tlmor~,

1995. p ..J2. \.\. ilh ~nni':.ion.

three imerre la led factors thai influence pump functioning: (I) the o.\)ge n :-. uppJ y 10 the hean. (2) the contractility of lhe \cmrkk.,. or (3) the e lec trical impulse initiation or conducl ion. C lini cally. an Imbalam:c of myocardial OAYgetl ... upp ly anu de mand is the ha ll mark o f C AD, inadclI ua tt.' Ill)oci.lrdial oxyge n "upply to meet the metabolic \)\ygen dt.'tll:tnd!) a t the l11)ol'ardium. A decrease in In) lKMdl,1 1 ('ontracrilll) impair:o. thl: S) stoliL' functjoning of tht.' Ill) l~';.lrd llltn : it cietTe'<.1sc in the compliancy of me Ill) OL'<.If(jl lltn Itnp.ltf~ the dia~tolic fWlC lio ning of die tllY('h:i.lHhutn . I-It.'drl la tlurc tn.lY result from either ~. melll in !o.\-:, toli c or dla,>lo ll c functioning . A n alteration lIS t"l thl~ 1 th(' IIllltatl()n of the e!cc rril:al unpulse or in irs COO" t.!lH:tlon palhw:..t) '} 1:-. the- ba-.,i:, for many arrhyttunilSBt'L·au-.,c tht' \\'()r~ uf the LV i ~ rea lly the powcrhouSC of" el\ lIre he.1Tt. ~nd Il ~ ('Tlt:rgy require ments are si&nifw;IIIdJ

5 C hapter 16 Heart Disease

grc;;II Cf than lhe cllcrg.y requir~ men~ s of the RY. mos t clinical problems result 1To111 an IInpallment of II~c LV ~c.g., inadequate LV perfusion v ia the coronary m1enes. or mad-

equate LV contracti lit y). Im paired R~ fUl1c,tion,ing c~n

occur in combination wi th LV dysfunctlOll. as lIl /nrellfnl'I/ltll'!aill//,e. Impaired RV function seen scp:uatcly. i s see n

in t: ither cor pu lmonal e. whic h is right-sided fai lure owing pulmonary 3bnonnalities. or ri g ht-s ided va lv ular d~ sor­ ders (tricuspid. pulmonic). Clinically. however. LV failure is much more common than RV failure. to

Coronary Artery Disease The primary impaimlent in CAD is an imbalance of myocardial oxygen supp ly to meet the MVo~. The decrease in s upply i ~ due to a narrow ing of the lumen of Ihe coronary anery. usually due to a lixed atherosclerotic IC!lion. The lesion result s from an initial endothelia l injury that causes changes within the intima of th e blood vessel and progress~s to lumenal narrowing. The cause of the ini tial inj ury i~ not \\cll understood. but ri sk factors have been identified that are associated wit h an increased risk for the fomlation of an at he rosclerOlic les ion. The earl iest identified ri!.k factors by epidem iol ogica l studie s such as The Framingham Hea n Study included smoking. hjgh cholesterol. hypenension , diabetes. emotional stress. and famil y histof).~ In recent years. obe~ it y. sede ntary lifestyle . and elevated blood homocysteine and fibrinogen levels have abo been identified as possib le conlributors.~7 Premenopausal women appear to have added protection from atherosclerosis. Initial clinical manifestation of coronary disease is delayed an average of 10 years for woman compared to men: the incidence of M Is presems as much as IWO decades later.~1<, Staning at age 75. the prevalence of cardiovascular dl~ease among women is greater tlUUl Ihat for men .~ The u,')e of honnone replaceme nt Iher..apy (HRT) in po~tmenopau sa l \It omen has been a wpic of much di~cus­ sion. In 1997. Hennekens reviewed 31 observat iona l ~ tudi es and e~limaled thai there was a 44 percent reduction in coronat) hean disease among poslmenopau~al women receiving estrof!en replacement.~':1 However. pubLi&hed studie,') in 1998 and 1002 rt!suitco In suppressing Ihe routine use of HRT due to the n s/... 01 hornlone senS itive <':
Clinic al \1.uu'e\tatton, Patients ma) ha\ e ocll u" lon~ WJlhl1l their coron.try arteTlc ~ dod nOt havt' ~ylllptom ~; 111 general, ~ym pl onh 01 CAD
609

occluded. The re are. therefore, many patients w ho are unaware of the ir subac ute occlusio ns. It is imperat ive that an individual's risk factors are known and interventions and mo nitoring adj usted according ly. The clinical condition s resulting from CAD are due to inadequate myoca rdi a l oxygen s upply 1O mee t the Mvo r The most coml11on clini ca l presentations of CAD a re ischemia. infarction. or arrhythmias. It has bee n estimated, however. that as many as 50 pe rcent of patients with CAD present with sudden death (ca rdiac arrest) as the ir first sy mptom . Ventricu lar fibrillation is the arrhythmia most commonly associated with sudden death. 56 Ischemia Ischemia is a temporary deficie ncy in oxygenated blood now 10 ti ssues. and is due to arterial disease. Ischemia is a te mpo rary condition: when the balance of myocardiaJ oxyge n supply and demand is reestablished , ischemia will be reve rsed. Reca ll that the factors that in1lue nce myocardial de mand are HR and systolic BP (the RPP). When ischemia is present , reducing the RPP by stopping the aggravating activ it y and decreasing rhe v 0 2 may correct the myocardial oxygen imbal ance because as sys temic 0 2 demand decreases so too wi ll HR and SBP. A blockage of 70 percent or more of the coronary artery reduces blood fl ow e nough to cause ischemia. Thi s blockage is most commonly due to the prese nce of an atherosc leroti c lesion. A less common cause of coronary narrowing is spasm of the smooth mu scle within the wall s of the vessels. As a result o f myocardial isc hemia. the patient will feel the sy mptom of angina . The c lass ical presentation of angina is substernal chest pressure accompanied by the Ledl/e sign (the patie nt clenching hi s or her fi st over the ste rnum) . The Lev ine sign has a high diagnostic accuracy for i sche mia .~7 For some patie nts. ang ina does not presen t in the c lass ic way but rather may present as a pain or heaviness in the shoulde r. jaw, an11. e lbow, or upper back between sca pulae. Angina may radiate from the c hes t to the am, or up to th e throal. or it may prese nt as indigestion o r even s h ortn e~~ of breath . The patient is often asked to rank his or her di ...comfort 0 11 a scale of I to 10, \\ ith 10 being the mo~t pain/discomfol1 ever e,\ pcrienced. The ternl stahle £Ingil/a b lIsed when angina occ ur') at :1 predic tab le RPP and is alkviat.ed by decreasing (he RPP. commonly by stopping the i.lcti\ it) :mel rt!sting and the possible u')c of nitroglyccrln (NTG; TNG). In s table i.Ul1!ina, the patll!11I often de')l'nbts the 'ien'
610

Physical Rehabilitation

necessaril y respond 10 a dec rease in RPP, U nst ~ bl e an gina usuall y warrants immediate medi cal inl erve~tl o,n . as the patient is at im pendin g ri sk for further complicatIOns such os a MI or a leth al arrh ythmi a (v-tach. v-fi b). Ischemi c myocardium demonstral es both systolic and diastolic dysfUllctions, During the time of i sc h~l11i a . Ihe~e is a marked depression in cont ractility and an Increase In myoca rdial sti ffness (dec reased comp,lia nce). in , the affected area, Reversal of these myoca rdI al dys lunctlOns will occur if the myocardi al oxygen supply is reestablished after a short interruption, The longer the isc hemic period. the longer it will take for norm al contractilit y and relaxation 10 occ ur: ~" the patient is th en at ris k ror irreversible damage such as M I (heart allack). Infarction Individual myocard ial cells may di ffer in their tolerance for ischemia: howe\'er. irreversible changes start to appear 20 minU le~ to 2 hours fro m the onset of myocardi al ischemia58 The aelUal process of an infarction evolves ove r a period of hou rs. Angi na commonl y precedes an MI , but the intensit y of Ihe symptoms is dramaticall y increased. Patients frequentl y descri be lhei.r di scomfort as a 10 out of 10 on the pain scal e, Ln farcti on is irreversible. Whereas ischemia is due to a partial blockage of the coronary artery. an infarc tion resuhs from complete occlusion of the vessel. This occlusion commonly results from a rupture of a vulnerable plaque with resultant fonnal ion of a thrombus. The type of plaque, more so than the size, will influe nce the ri sk of rupture. Lipid rich and soft plaques are more vul nerable to ru pture than collagen- rich and hard plaq ue. Angiog raphicall y large plaque lesions are not necessarily more susceptible to rupture than smaller lesions. Because at herosclerosis begins within the waLb of the artery, many vulnerable plaques are invisi ble via angiogramS'I or appear smaller than their actua l size. Although not as com mon as plaq ue rupture. coronary occl u... ion can occ ur a~ a result of coronary spasm. coronary emboli . congenital anomalies. and a wide variety of inllam matory disea!,c .... w The actu al cause of plaque rupture i ~ not clearly under~l ood: howeve r. as iJ result of the ru pture, a thrombu.. i ~ fo mled. There may be several mec hanisms for thrombosis forma tion. "iuch as mechan ical obstruction of the lumen. release of ti s~ue th rombopl astin and the initiation of the dOlling c3!)cade. and platelet plug fOnlla ti on from the contact of plmeleh and expo~ed collagen.()() Onl y les i on ~ thaI occlude the lu men b) 70 JX!rcent or more cio n ~ doe~ not dClermlilc whether or not an MJ can occ ur; a ..,mall plaque l e~lon of 30 percen t a!) we ll a~ d larger lc,ion 01 81) pt:rcent may rupture and ~u b ...eq uenll ) fonll a Ihrolllblh that occl udes the n:ll1alllder I)f tht: lumen. The majo nt), uf M('" Occur on the vt: ntridc a, a result o j the infarc ti on often ex tend btyond Ihe ,Ieule inlarl'lion ~

period; these long-tenn effects occur primarily in ventricles that have sustained a moderate to largc MI. As the ventricle heals, a process of rem~(lelillg occurs as a resul,l o~ the presence of the infarcted ttssue and subsequent drlallon. Over time. th is reengineering process produces an alteration in ventri cular size, shape. and functi on. Thus, the resultant ventricle often ope rates at an increased myocardial energy cost due to its ineffi cie nt muscle mechanics. Often pictured as three conce ntri c c ircles (although not absolutely histologicall y correct), the area of infarction would be at the ce nter o f th e circle surrounded first by an area of inj ury and then an outside area of ischemia (see Fig. 16.8). Mis are identified by EKG findings, such as Q WQV, .. 1I01l-Q WGl 'e . whether or not the ST segment was elevated or not at the time of intervention, the Mllocation (anterior, inferi or. lateral , septal or posterior), and the reSUlting EF. A Q wave Ml is identified by the presence of an abnormal Q on the EKG . A Q wave Ml was formerly known as a fra",IlllIral MI beca use it was believed to involve the full thickness of the ventri cular wall . A non-Q wave MI was fonnerIy known as a Ilollfrallsmural or subelldocardial MI because it involved the endocardium. However. it is possible thai • Q wave may be absent from a transmural MI, SO the newercl$sitication was chosen. Anatomical classifications for MIs are based upon the surfaces of the LV, not the anatomic heart; an anterior MI involves the anterior su.rface of the LV, an inferi or MI invo lves the inferi or surface of the LV (the diaphngmatic reg ion). a lateral MI involves the lateral swface of dtt LV (also may be referred to the free wall of the LV for dtt lateml wall is not adjacent to another structure), a sepIaI MI involves the septum. and a posterior MI involves the LV posterior wall. If the Ml involves the RV. it will be referred 1015 a RV infarct: because the RV and the inferior wall of the LV are commonly perfused by the RCA. it is possible to have an inferior MI wi th RV invo lvement. An EF of less than 35 percent is considered " large Ml with significant systolic dysfunction and wi th the potent ial for LV failure (recall that a nonnal EF i. approxi mately 55 to 75 percent). An MI that init iall y prt!.'}e n t~ with ,-Ul elevared ST segment on the EKG (STEMI : ST elevati on MI) Illay be an ind ication forernergeRI thrombolyttc therapy or revasc ul arization.62 Alt hough Illos t M Is heal ini tially without incident. COlD" pJicali ons ma y occ ur, The major complications foUowm, an MI are rcrurrt' ncc of ischemia. LV failure. and ventricul ar t MI pefl (xi. h cht'lllia post Ml is iruportaDl to dOl:lllllent bcC
w."

Chapter 16 Heart Disease illfrfl.aort;c halloon pump (IABP) .6 l The IABP facilitates CO. decreases MVo,. and increases coronary artery pe rfu . ; ion. The IA BP is ~l balloon catheter placed within the aorta th at infl ate s during diasto le thereby increasin g coronary arte ry perfusion ~U1d de nate s during systo le thereby d ccrea~ in g afterload . The IABP may be used in other condirion~ besides post-MI ca rdi oge ni c in stabilit y. for exam· pie. pat ie nh with hemodynamic decompen sation who are awaiting heart tran splantation, patients with un st,able angina and malignant arrhythmias (such as v-tach and v-fib). or post-card iac surg ical patients with severe he mod~ n:ll1l1e instability.!>] 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.
611

If the pati en t presents to the emergency room with the sy mpto m of angina that is supported by EKG (e.g., ST depress ion). the ph ysiological goal is to decrease MVo2 and/or in crease myoca rdial oxygen suppl y. The patient is given suppl emental oxygen by nasal cannula and admini ste red the medication nitrog lycerin (NTG). Nitroglycerin is a potent vasodilator of arteries and veins: it will ( I ) decrea~ myocardial work (i.e .. e nergy req uirements of the hea rt ) by decreasing BP (afterload ) a nd ve no us return (pre load) and (2) increase coronary blood supply by dilating coronary arteries. The impac t of coronary arte ry dilation is minimal compared to the othe r effects. Pati ent s not respo ns ive to the se and ot he r int e rvention s arc at ri sk for a MI. They may, the re fore. be candidates for an e me rge nt cardiac catheterizatio n to locate and identify the criti cal les ion and be considered for a revascu lari zati on procedure to decrease the atherosclerotic les ion, such as p ercutaneolts {ralls /wninal coro nary angiop/asty (PTCA) with stent , rotati ona l arlierec'lomy of the les ion , laser surgery, o r CABG. If the pati e nt's EKG is consistent with a pattern of injury, ST elevation, a thrombolytic agent such as streptokinase or ti ssue plasminoge n activase (TPA) may be given. The effect of the thrombolytic s is to lyse the new active thrombus being formed within the coronary artery. This red uct ion in thrombus size w ill help to restore at least partial blood now to the myocardium and either avert an MJ or red uce its potential size. Two of the most common me thod s fo r determ ining whether a patient has had an MI are EKG finding s and blood work: specifi c to the latter is the presence of e levated leve ls of CK·MB. an isoenzyme released with intrace llular myocardial damage. Unlike in an Ml, (here are no definitive b lood tes ts that indi ca te the prese nce of ische mia or injury. Other marke rs that may be used to diagnose an acute MI are the proteins Trop anin /, Traponin T. a nd myoglobin. Alexander and co lleagues64 note that total CK-MB, troponin I. and troponin T have a high sensiti vity for th e di ag nosis of an MI. CK-MB and myog lobin may be the most sensitive biomarkers for patients presenting for eme rge nt medical intervention wi thin 6 lO 10 hou rs of the o nset of an Ml.64 For patients presenting after 10 hours. troponin biomarkers are preferred over C K-MB because of their in c reased ;;;ensit ivi ly.t>4 C K is found in many ti ss ues besides the myocardium, especially striated mu sc le. brain , a nd li ver. Injury to these areas will e levate total C K. To differe ntiate the type of tissue injured . lIse of C K-MB wi ll iso la te the source to the myocardium . Tropo nin le ve ls should not be e levated in the se lling o f stri ated mu scle trauma. Once the diagnosis of an M I has been reached (i.e .. the patient i:-. " rul ed in" for an Ml), the goa l of medical man ~ age me nt b to kee p the palie nt he modynamically stable and op timi ze the wound healing of the myocardium . Usually aftl! r an uneventful 24 hours of lx!d rest. the patient lHay gradu a ll y beg in to il1c rea~ hi s or he r ac ti vity, ideaJly under the :-. upervis lon of a phy!)ical the rapist.

6 12

Physical Re ha bilil.alinn

Revascu lari zation rTCA usc:" a balloon on th e lip of a ca theter th at is inscI1 cd into cither thc femoral or radia l artery and ad vanced relro· grade .. 1011~ the aorta 10 the ope nings of the coronary ;Irtcr· ies. lllC C:llhelcr is inst· rtcd int o the corona ry artery and al the sitl~ of tht' les ion the balloon is in Oat cd 10 compress the plaque aga in '" the wa ll of the coronary artery. tlll'reby i llcrea~ i n g the lume nal art'i.I. A wi re like cage (stent) is pl:.lCed ove r the compressed arca to help it sla y in place. The cage is commonl y coa ted with a drug (e.g .. Ihe dru g e luting stcnt) \(l prevent endothelia l ce ll proliferation . whi ch ma y occur in rl~sponse to e nd othelial trauma :tnd the presence of a foreign object placed within thc coronary artery. CABG u se~ a donor vesse l to bypa ~s the invo lved les ion and e~t ah li sh an aherna t~ blood suppl y. The donor vesse l may be the radia l art er) of the nondomi nant hand . the s:.lphenous ve in. or the internal mammary artery. The pat ie nt's harvested sa ph enous ve in or radi ;,11 artery mu st be comple tely detached fro m both its proxima l and distal insertion:-: the graph i..... ulured proximall y int o the aorta and di sta ll y into the involved artery beyond the occlusion. The inl cmal mam mary artery maintai ns its native prox imal allachm('ot wh ile the di:-.l al segment is reattached be low the area of occlu sion . Bypa.. s surgery tec hniques are con· ~tantly changing: tradi ti onall y. the fu ll slemum wa ~ cut and retracted. but newer mi nimally invas ive techniques have emerged that involve less ste rnal c ultin~ and some lechnique~ il1\ olve no sternal culting at all. bl:t access the hean via the in tercostal sp.Ke . Most CA BG proced ures iovo".'e placi ng the patient on an artilicial heart- lun g mach~nc (bypass pUlllp ). which ma int ain!\ the oxyge nati on and CIf(: ul3llon of the blood while the heart i, stopped durIIlg the wrgica l proced ure. As a re sult o f the bypass pUlllp. pal lC'l1h nw) have additi onal tluid weight gain foll ow inc. '-.urge.ry. ma~' fee l fa tig ued. and some pa tient s ma y hav~ Iralhlelll alnal ti brillalion and cog nitive changes.

Ph a mlacolo gical Ma nagement Cardiova:-nliar pharmacological agent s are ni tical in the. me~lcal n.lanagemcnl of pa lienl s with ('A D. There an: ;l ":lfJt:I Y drug~ dt'~lgned 10 ret:~ t;'l h li s h the balance of m~Ol a rdw. 1 "'upr ly and demand. with new drll" ~ I::x:in o added all ihe tlllle:. :-ht: majur ant i-isc hcmi r ca{eg~ries ar~ hcta-hlockcr~ . c:.lh:lllm channel hlod,l·P... and n itf't t .. IJ e/(f- lJIu( J.l'I".\' dt:crea ...c bl~ta ... ynlpathell c acti vit y on< t~ ;~ 1ll'~~1. re . . ultlllg 111 a dec rt'~, ...e. in H R and con trac tilit y and thclt'I(lrt: el1l'rgy lkmand (MY,):.- ). C'lIlllll1l1ll/(/!/IH'1 hlOI ·J.en reJu (c hlow prl'\~ Ure dlld therdl)!'e d~neasc thc \Vorl-. oftlw hc<.trt . Calci u]]) Lhanncl blocJ...!.:!':- .If\: ~tbo :- ilml'wh~lt un lqut" 111 prt'VCl1UIi!!' l'fJlonary !-.lIlUlllh lIlu ~c k ... pa ~ 1ll and Ihefl: hy tllay 1Il1'le;t"C In yot' ardi,d biulld ~ upplv . Ni l w/{',\' t)]!t~ 1,1 the ol<-lt':...1 l'llcgurit:~ 01 dru g . . , arc POll:I~t ,a~Odila~ hlr.... tha i dc(rc C th;}1 .lftcLl 111l'

(:f

renLn - an)!lllll·n .'~,]n - illdu ~lI:ro ne

... y ~ t l'1ll

... lI t h


A( 'I::

ill hihiwrs (angiotensin convertin g enzyme inhibitor) and ARB.,' (ollg iOf(J llSin re('epf(~r blocker) are : requently used to counter:H.:1 th e adverse elfec ts of ventncular remodel' Ihal occ urs foll ow ing Mis (see C HF sect ion). )) mg There arc many exce ll ent reso urces for further study of ph arnlU Kupersmlth ,61 and Grimes and Cohen.!>); Therap ists workin g with patients who have CAD must be famil iar wi th these medications and their side effects. es pecia ll y the ir e ffect on exercise response. The effec t of some of the more wide ly used cardiac drugs on HR , BP, and EKG finding s are presented in Table 16.5,

Physical Therapy Intervention for Patients with Coronary Artery Disease Accordin g to thc APTA Guide to Physical Therapist Practice'. the preferred prac ti ce pattern for management of patie nt s with cardi ovasc ul ar disease is Pattern 6-0. The deve lopment of specifi c ant ici pated goals and expected outcomes for the indiv idual with CAD is based on the rol· low in g ge neral goal s o f phys ical therapy intervention,6 I . Ae robic capacity is increased. 2, Abilit y to perform phys ical tasks related to self.c"" home manageme nt , community and work integration ~ re int egra ti on. and leisure activities is increased. 3. Ph y~ io l og ica l response to inc reased oxygen demand is improved. 4 Strength . power. and endurance are increased. 5. Symptoms assoc iated with increased oxygen demand are decreased. 6. Abil ity to recog ni ze a rec urrence is increased. and interve ntion is so ught in a tim ely manner. 7. Ri sk of recurrence is redu ced. 8. Be hav io rs that foster healthy habits. wellness. and prev ..... nti on are acq uired. 9. Dec ision mak ing is enh::mced regarding health of parieol ~ nd .the use of health C<.lre resources by patienr/c1ient. lam li y. signifil'ant oth ers. and caregivers.

Ph y~ici.1l therapists Irea! not on ly patients who have a ~ mary (lt ngnosis o f heart di:-.e'L'ic. but also. and perhapS nw;R commonly. patients with multip le medical diagnoses. rdy one or \~' ~l it'h is cardi ~K·. Phys ic.:alrherapy intervention uq the ~r'ldIlLon~d acute c~1nliac rehabUitation phase involveSfoI· low Lllg the patient \\ hik rl:L'ovcring from his or her C!vellt. ~u(:h a~ an MI, prOV id ing he~lOdynamic moniKWiRld ~r~gn,~ ... \\V{· acti, ity. disc harge guidelines. education. ... lfI lnn n;.Hlon rcgartlmg olltpalie l1l refelTJ.1. It may i,ncludeIXIII.t· 11! .rn:tna~c! lllent k i II1· g '. _ 0 ..... ' 1 1#" LlIJUI). tt' llIIis elbow intervention. pN '

C.-

..

Chapter 16 Heart Disease

613

Table 16 5 Effects of Medications on Heart Rate, Blood Pressure, ECG, and Exercise Capacity

I. Beta blockers (including labetalol) II. Nitrates

. ' (A and E)

• (A and E)

• HA' (A) • ischemia' (E)

t (A) t or <-----+ (E)

.l (A) .I or <-----> (E)

t HA (A) tor <-----+ HA (E) .I ischemia' (E)

IlL Calcium channel blockers Felodipine } Isradipine Nicardipine Nifedipine

i

Bepridil Diltiazem Verapamil

.I (A

}

tV. Digitalis

or <-----+ (A and E)

VII. Nicotine

tor <-----+ HA (A and E) • ischemia (E) • HA (A and E) • ischemia' (E)

t in patients with angina; -+----+ in patients without angina

May produce nonspecific ST-T wave changes (A) May produce ST segment depression (E)

Improved only in patients with atrial fibrillation or in patients with CHF

+-----> (A)

-+----+ except possibly in patients with CHF

and E)

J. in patients w/atrial

V. Diuretics

Alpha·adrenergic blockers

t in patients with angina; in patients without angina; or -+----+ in patients with congestive heart failure (CHF)

+---t

• (A and E)

fibrillation and possibly CHF Not significantly altered in patients w/sinus rhythm

VI. Vasodilators, nonadrenergic AC E inhibitors

t in patients with angina; • or
<-----+

t or +--+ (A and E) <----->

<---> ior ~

od

(A and E)

May cause PVCs and "false possitive" test results if hypokalemia occurs. May cause PVCs if hypomagnesemia occurs (E)

• (A and E)

t or +-----> HA (A and E)

.I (A

and E)

+----->

• (A and E) t (A and E)

(A and E)

-+----+ except i or +--+ in patients with CHF ~ except i or ~ in patients with CHF

t

or <-----> H A May provoke ischemia, arrhythmias (A and E)

-+---7 except J. or -+---7 in patients with angina

Adapted trom American College 01 Sports Medicine: Guidelines lor ExerCise Testing and Prescnption , ed 5. Williams & Wilkins, Baltimore, 1995, pp 246, 247 , 25 1, with permission . Key: i '" increase ; ~ no effect; t = decrease. 'Seta·blockers with ISA lower resting HR only slightly. tMay prevent or delay myocardial ischemia . A ""- rest; E = exercise. ;0

ambulalion training, or intervention follOWing a cerebrovascular accident (eVA). I f the physical thcrapi . . t underl:o tand :o, the pathophy. . iology of rhe cardiac condition , and the energy demands that are being placed 0 11 the patient , then the therapist wilJ be able to adjust the phm of care accordi ngly.

1t

is important to rem embt>r lhat a patient with known

CAD may not have :-.ymptomatic ischemia, either because the le:-.ions are not of significant size to interfe re with blood flow, or the ant i-ische mic med ications are able to kee p the patiem's physiologica l response to activity below

614

PhysicaJ Rehabilitation

his or her ischemic threshold. Following a noncomplicaled Ml. ischemia should n OI occ ur in the area perfu sed by the involved artel)' beca use infarc ted tiss ue cannol become isc hemic. However. if there is di sease in othe r arteri es. then isc hem ia ca n occur in any non infarcted tissue Ihat has a compromised blood suppl y. A physica ll herapisl working with paficnts wit h sig nifi cant CA D must be aware that their basic cardiac impairment is an imbalance of myoca rdial oxyge n suppl y and demand. and any increase in systemi c oxygen consum plion will increase myoca rdial oxygen cons um ption. A past medical history of CAD does nol mean that the di sease occ urred in lhe past and is no longer present : once a person has been diagnosed wi th CAD th ey ha ve the pOlemial for ath erosclerosi~ progression al any later point in time. Even in pa ti en ts with lesions that are less thi.ln 70 percent there is the possibilit y of plaque rupture. Although the precipitating factor:, for plaque rupture are not clearly understood. th e plaque wit h increased levels of oxidized LDLs is thou ght to be unstabl e with a greater potenti al for rupture.69 [( is important to note that plaque rupture Illay occur with lesion~ of any size. nol just those that are grea ter than 70 percen!. 61.~O Therefore. it is pruden! for the phys ical therapist 10 kno\\' the status of al l the coronary arteries. not just those that were revasc ulari zed or have a greate r than 70 percen! lesion. The degree of a patient's ri sk for increased morbidi ty and mortality is based on a number of factors. The American Assoc iation of Ca rdiovascular and Pulmonary Rehabilitation (AACVPR) and the American College of Ph~ sic ians provide a fTamework for ~t ralifying cardi ac patIents (Table 16.6).

Exercise Prescription The Clinical Pracllce Guideline~ for Cardiac Rehabilitation

'" cre e')tabli ~ hed afte r ex tensi\ e and criti cal review of publl ~ he~ ~cientific literatu re.?1 The~e guideli nes suppon the

benelJcmi effect of excrci .. e trai ning 011 exercise to lerance for patlent~ '" ith hean dl~a:,e . The rno~t con~iMent be nefit appeared to occur Yvi th exerCl~e training at lea~ llhree limes pc.!r w~eJ... for I::! or more wceb' durmion . Thl! duration of aerobiC cxen:l:,e (raming :,e:'~ JOns varit'd from 1:0 10 40 minute~ dl an inten'iit y approx imating 70 to 85 pen.:elll 01 r~le b~I~c:hne maxllnal exercI'C:: IC~ I HR . Exerl' i~e pre~l'rip 110m are ba ..ed 011 tn.:qucncy. II1It~n) ll y. tim e (duratIOIl ). Jnd I)pe (mode) , Ihe FITT t:4ua llon . Activity .. hould he grdduall ) plOgfc~~l\e In a luglcal :,Iep\\ J::.t: ta~hiun 01 lO<.:re".'1lOg l'nerg) <':O~ I :, (Ie MET:" j.. ih.x·.t!onc') I \\ IIh approprlJle HR and BP monl[Oflll1!. Althuugh e . . . Cfu:-.t· 1110 hlghly . . .;e!,.;ulllmenlkd Illr the P<JIIt.:1lI '" IIh he..tfl dl'll:d,>e. (here' arc londillum in \\-hl(.;h eXCrt·I">t' '" unwI'>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
t_--

'I,

E\t'rdse FJ'l'iIU e nr"

L:.\~ILh.~ 1\ rnrnmn;lly prc~(.:nbcu three to five .... .. \Ie,·. 1 he pJII cnl ' · . --_ .... ...... '" h oui d nO( l':\penem'e Inc~--

Chapter 16 Heart Disease

615

Table 16.6 Risk Stratification Criteria for Cardi~c ~atients by ~he American College of Ph ysicians (AC P). and Ame rican AssociatIOn of CardlOva..cular and Pulmonary Rehabilitation (AACVPR)

Uncomplicated MI or CABG

Uncomplicated MI , CABG, angioplasty, or atherectomy

Functional capacity 2::: 8 METs 3 weeks after cli nical event

Functional capacity .2: 6 METs 3 or more weeks after clinical event

No Ischemia , left ventricular dysfunction or complex arrhythmias

No resting or exercise-induced myocardial ischemia manifested as angina and/or 5T segment displacement No resting or exercise-induced complex arrhythmias

Asymptomatic at rest with exercise capacity adequate for most vocational and recreational activities

No significant left ventricular dysfunction (EF

Functional capacity < 8 METs 3 weeks after clinical event

Functional capacity < 5-6 METs 3 or more weeks after clinical event

Shock or CHF during recent MI «6 months)

Mild to moderately depressed left ventricu lar function (EF 31--49%)

Failure to comply with exercise prescription Inability to self-monitor heart rate

Failure to comply with exercise prescription

Exercise-induced 5T-segment depression < 2mm

Exercise-induced 5T-segment depression of 1-2 mm or reversible ischemic defects (echocardiography or nuclear radiography)

Severely depressed LV function (EF < 30%)

Severely depressed LV function (EF "'30%)

Resting complex ventricular arrhythmias (lOW grade IV or V)

Complex ventricular arrythmias at rest or appearing or increasing with exercise

~

50%)

PVCs appearing or increasing with exercise Exertional hypotenSion (~ 15 mm Hg decrease systolic pressure during exercise)

Decrease in systolic blood pressure of > 15 mm Hg during exercise or failure to rise consistent with exercise workloads

Recent MI «6 months) complicated by serious ventricular arrhythmias

MI complicated by CHF, cardiogenic shock, and/or complex-ventricular arrhythmias

I In

ExerCIse-I nduced 5T-segment depression I :> 2 mm

Patients with severe CAD and marked (> 2 mm) exercise-induced 5T-segment depression

I Survivor of cardiac arrest

5urvivor of cardiac arrest

'---

From American College Sports MediCIne: GUIdelines For Exercise Testing , ed 5. Williams & WIlkms. Baltimore , 1995, pp 20, 21 , wJlh permissIon. CABG =0 coronary artery bypass grah; MET = metabOlic equivalent; EF = election fraction, CHF "" congestIVe heart failure , LV "" leh ventricular, PVC premature ventricular contractIon. 0;:;

01$ ii re ... uh of c>.erci!:.e. If farigue doe~ occur, then the frequen(.·y and/or intensity of exercl!)e t.hould be decrea ...ed. Pat/enb who c hoo~e to exerc i ~e dail y must watch for signs and symptoms of fatigue and overexerti on, recognizing lhal fatigue may not Just OCc ur dun ng the activit y, but be delayed umil later in the day or Ihe next day.

Exercise Duration (Time) 10 -10 minutes or aerobic exercise with an adduional 5 to 10 minutes of warmup and an adequate cool-down is appropriate. Lf this aJnounr of activity is uncomfortable for the patient , whatever amOlin! he or she can do comfortably without adverse symptoms is appropriate. The g03 1 of 30

616

Physica l Rehabilitation

Table 16,7 Rating of Perceived Exertion : The Bor g RPE Scale

6 No exertion at all 7

8 Extremely light 9 Very light

to 11 Light 12 13 Somewhat hard

14

15 Hard (heavy) , 16 17 Very hard

18 I 19 Extremely hard I

20 Maximal exertion

' Copyrlght Gunnar Borg Reproduced with permission . For correct usage of the scale(s) the exact design and instructions gIVen In Borg's folders must be followed. See Borg , G.. 1998, Borg's Perceived Exertion and Pain Scales. Champaign , IL' Human Kinetics , 1998, or www.borgproducts.com

Patient ~

'" ho are decondilloned may require interval work , bnef ft',b ~\ ery 5 minute') du ring their earl ) training. Adequate "amlup I~ crucill for all paticnt~ but e~peciaJly f or p:i UC nl ~ "nh CA D. B~ graduall~ mcrea!'l in g the M Vo ~ ar,d dJJU\~ 109 thr coronar~ anenc!l. l ime 10 \'asodib l~. a bal: am'ed l1l)o\. ardial ~ urpl ) and demand ma ~ be po!'l')ihlc \\ nh !'l uh,e4Ul:m .tCII\' it) .

'1ode of' E.\trci~(· ( T~ pcl The \ arlt'! ) ull'\ e ru~ C4uiplllt: nt ha~ o,p.:mded tn the 13",1 :!o ~t";H" -Ille good ne\~ .. I, Ihatlht' pallen I hoi., the opporl un ll~ In e'lx:nt:nct" a \ ..1fI e l ~ of "4 u1pnwnt lIh: ludllll! Ift'adml ll" ..,I.u r l' lullht-r:- , h l l~ dt' ~ . row('(.., . LJ'O'!)~l Ou rll f\ ') l.. 1 \. lmu laI IH" rn Iln int' hl l,} lI t" . .. It'pp~:,f'I , drill t' rguJlI;. .tOJ (llht.' r~ P.J.lJ t fl h Irc4l1t'Of I) a')~ \\hl l'h '" 01(" 1x'!'>1

it-f\.,

cqulpm c flI .

\",11

U,l'

Iht"

Olll'

Ih;.tl tht' ~

l,.' llJ U) •.tncl

I" h~ IJr tilt' ht-q lI)f tht lll.

Ih\:'

(till'

Lhal

Iht.'\

'

II d P
facility. help should be sought imm.ediately to etIIUIt II1II faci lity guide lines are qUickly initiated. Such ~ may inc lude supplemental oxygen, a 12-lead EKG, IIIIrniQ. isrration of NTG, and o[~er antl ~lschemlc medicatioaa. If the patient is in an outpat ient setting and has his orherowa NTG (which the patient should be carrying at all timeo~ the patient should take it and fo ll ow the prescribed guide. lines. NTG should produ ce a tingling or burning sensatioa if it is effec ti ve: failure .of the NTG to produce these 1lII)' indicate thai the NTG IS o utdated. Patients are gatcr3lly inSlructed to take one NTG s ubhngually (under tile long ue). although some patients use an NTG spray. Wait 5 minul es and repeat administration if the symptoms are not compl ete ly gone. A third NTG may also be taken alta waiti ng another 5 minutes. Patients are frequently IOid that if th e symptoms have not resolved completely alta three doses of NTG they sho uld come to the ema....., room for further management. If the patient is in a OIlpatienl settin g without hi s o r her own NTG and has.symp. toms that do nor reso lve after a few minutes of rest. . . the facilit y g uide lines to activate advanced care for dae patient should begi n quickly. If the patient's s~ escalate, even after the first NTG. emergency cae __ 10 be initiated immediately. If the patient is cIindiat stai rs. the patient should stop, take a few euy iIIqI breaths. and then descend when the symptoms ... abated and walk slow ly to the first available SUfIIOII. However. if the patient 's symptoms are quickly ICCdonI. ing despite Slop ping the activi ty and taking deep . . . . the patienl should be assisted to a position of funher medical assis tance sought immediately. The .... pisl should present a crum demeanor. reas ....... patient thai this s ituation can be handled efficXlllly . . eas il y (which il can). Ph y~ical Iherapists must be sensitized to the fact . . nOI "II Chl'..,( pain is necessari ly cardiac in origin;. ..... many differenli.tI diagnoses including visceral (Pia. J6.Ut and mus,,'ulo ... l..elctal (hat may mimic cardiK. pIi& 1'II:J mu ~: therefore be able to differenliale mUlCull t 'n' l rom cardi il c pain, whic h (i t times may be diIIa& Li~lc:ning It) (hI;,' patie nt 's ~ ubj«tive repon of . . . . . ' } llIptOllh , Ilk nt ify ing pertinent risk facrors.lDd,.... trig "'Cfcenmg 1(;." 1" to c1e.u the musculoskeletal~. ,III indil ~rt:d Gcnaally, cardiac pam is a.ssoci. . . . . ' IHl'J c a 'i(: 1Il m) tX'.trdlal demand. (hat is. an ~ . . and UP. tintl Ihcrefun: i:-. often associated widt ..... Whl.'n the Illlen'\U) of the aC li\ U)" (kcreabU, die L,Q • ,hould rnohc::. til ueclc;"",,c, Breathing patlet'Dl......,~ l ion'!.. 01' rang .... l )t !lIo tion generally do nOl. aIfecI .. ..., \',lfJIJ.~ unglll Inl' 'lbsl)l ult' measure of ill,! I- " G: Ill,' S'I "'~11). nt '\ill depr"ss or the T ..1Jl\t'1l lAuh I~' hl'nlia and remam as ~ . . . . . I !'>lhelru~ I, I.k\.. urnn~

comIiJrt_

is<;,._

C .. relia.. Rehabiliiation: Myoc:arcIiII. ~:=

Although II b l 'OIlIlHOU today (0 liAke cardUw: .. lur gJ..uH~d , II !'t' d I) W.u nOI (hal Ion,.., ...._

Chapter 16

PAIN REFERRED FROM VISCERA Anterior View LO'

Rlgh l - - - (Uphragm (cenlUI' porllOflj

Pleurll

Heart"

----1LJ--

./-.....,n

Ga/ltlIlIOdeI and _ _ _

"

.-oom

1'-- Pleura

_.----/---I'

SoG~_

(ulcer)

Fig ure 16. 12 Pain n:fcrred from vi~cera. The pain of coronary m ~ u fficie n cy can involve any a~ peci of the antenor chest: int er-

scapular. retro~ tema1.

') hou ld e r~ ,

anm , and

e pi g~t ri c

area.

Another .. it ~ for myocardial i<;chemia i:-. jaw discomfon . AI ~o

nme the " ari el1 e~ of different ial diagno..,is 1hal may present in the locatio ns a .. myocard ial ischemjc pai n. (From Rot hstein . J

~ame

el al: The Rehablillation SpecIali st 's Handbook. cd 2. FA Davis. PhiladelphIa. 1998, p 484. \\ ilh pe rmi ~.':> lon) .

for pati ents v. ilh M I included wee h of prolonged bed rest. In the pl vowl 1952 ')w dy by Levine and Lown ? ' chair rest and I(m -level activity wa ~ found to be more bc neficialthan the traditional K \l{ee l-.. ~ of bed rc:sl. Today. the patient with a noncomplicated MI ma y be hospilalil.cd for a ~ few as 3 to 5 da) ,. Cardwc re habilitation (cardiac rehab) i ~ Il)uhidisc iplinaf) dnd Old y IIlciude the ph ys ician. nurse, physical and occu pational lh t' ra pi !) t ~, exercise ph y' lulogi ~ 1. nutritioni!)t, and ,>oc ial &ervict ca ~ew or!...er. Cardiac rehab begin... in tht' hospnal dnd t"x tend ... IIldefinllcly IlltO Ihe lllalnt~n [lIl ce phast. Tht: inpaucl1I u lill pone nt i') rcf\!rrcd to a ... Phu \t' I OUlpullent pha'>C.':I 1Il(.:iude PJw.\{' IJ . the exe r~ I "'C Ir~tLnll1 g pefl od. and Plime '" . Iht: nl,unt enJIKe pen od. The AACV PR dt' ~t ribe ... Ph
H~art

Disease

617

intervention s. 7~ Aerobic and strength train ing may begin based upon th e results of the ETT, whi ch is u~u~lI y done ~1 approximately 4 weeks. In Phase III . the, pH.llent has stabili zed and requires EKG monilOring onl y If Signs and sy~p­ toms ncccs.-.. itatc; endurance training and ri sk faclOr modtlication cOnlinue. Ideally. Phase 1\ is initiated within 2 weeks of hospital di sc harge. It is important to note t~a~ .these phases are not absolutes and th e time lines and actl vl tJt:S of the~e phases may vary according to managed care models. contracts with re imburse ment plans. and treatment protocol designs. Owing to insurance coverage. some patients do not ente; into a formal ca rdiac rehab program until after their sy mptom-limited maximum ETf at 4 to 6 wee ks post-M1. Inpatien t/Phase I The length of hospital stay for a patient with an MI has changed dramati call y in the last decade and is commonl y 3 to 5 day s for an IIlIcomplicared MI (no post-M'I angina. mali gnant arrh ythmias. or hea rt fajlure) . compared to at least three to four times thai duration in the early 19805. Inpatient cardiac rehab uses a team approach based on acti vit y progression. patient ed ucation, and hemodynamic and EKG monitoring. together wit h medical and pharmacological management. The ro le of the physical therapist is to monitor activity tolerance. pre pare for di sc harge. educate the patient to recognize adverse symptoms with activity, support ri sk factor modification techniq ues. provide emotional support . and collaborate wi th other team members. Vital sign monitoring occurs before and after and. if possible. during activity. The intensity of the activity is considered to be low level , perceived exenion for the patient should be comparabl e Lo the " fairly light range" of the Borg RPE Scale (see Table 16.7). For an increase of one to two METs. a HR increase of 10 to 20 bpm is appropriate. if beta-blockers or ot her HR sllppressers are not used: however, the absence of beta blockade in Phase 1 is uncommon. If a beta-blocke r is used. there is no standardizati on as !O the deg ree of HR suppression; subjective ratings of perceived exertion and objecti ve observation of patient effort become increasingly important. A patient on beta-blockers who has a HR inc rease of 20 bpm during low-level inpati ent activi t) would be considered inadequatdy medi cated , unless tht: activity leve l was considerably hi gher th an appropriate . A dec rease in HR or BP uuring activity for any patient , rega rdless of medications. :-.hou ld be evaluated for the presenc!! of an arrhythmia. Following the ph y:-. iGtl therapy intencntion. the patient 's tokrance or aC livit y and hemoo) namil' stability should be docume nt ed . There are a ,ariet) of inpal ielll cardiac rehab program s. Irt:quentl y p rog r~~ .':I i \'e based upon levels of incr('a~ in g c: ncrg) r o ... b \e. ~ .. r..1ET level~). Each facility \~ ill establish the ir OWII Icve l-. and Cri teria for aell\ ity prog res~ i(lll and cdul'allon; an t: \ump\e of an inpatlCnl program is ~hown in Tabk 16 . ~ Flllimving are o;;ome ge neral com ments and recununenuuti on . . about thl' variou~ levels. Lt is important to n O ll! lhal J. C\lVII Y proglt'.':Ision OCt.: Uf1'l along i:t continuum

6 18

Physical Re habilitation

Table 16.8 Inpatie nt Cardiac Re habilitation Prc)gram

level 1 1-1 .5 METs Evaluation and patient education

Arms supported for meals and ADLs d ('f CPK have peaked and patient has no complications) Bed exercises and dangle with feet supporte I s Education . Introduction to inpatie nt cardiac rehab and role of physical therapy Education Monitored progression of activity . . Home exercise/activity guidelines/outpatient cardiac rehab

""

~"""'f1"J..,,~"

..... . . ' __

~_L.

,.. ~

...,... :w: '~

~

rr:;..

-

'

Level 2 1.5-2 METs Sitting 15-30 min, 2-4 times/day Leg exercises Commode privileges Reclining upright chair Lim ited ADL Electric razor Limited supervised room ambulation for small uncomplicated MI Education Identification of CAD risk factors Concept of "healin g interval" and need to pace activities ~ ... ~--""

.~~~!"' •• -

_.

t" . . . :, -:--r"I.: :.

~"'~

.-..•

Level 3 2-2.5 METs Room or hall ambulation up to 5 min as tolerated 3-4 times/day Standing leg exercises optional" Sit on side of bed or in bathroom to wash (per discration nurse/PT) Manual shave Bathroom privileges Independent or assisted ambulation in room or hall as advised by PT Education Size of infarct and how it relates to the need for gradual resumption of activities Impact of exercise on reducing the patient's risk factors Teach use of Borg's Scale for Rating of Perceived Exertion and appropriate parameters with activity

Level 4 2.5-3 METs Hall ambulation S-7 min as tolerated 3-4 times/day Standing trunk exercises optional" Independent or assisted ambulation in hall as advised by PT Education Teach pulse taking and appropriate parameters with activity Reinforce benefits of outpatient cardiac rehabilitation

I

LevelS 3-4 METs Hall ambulation 8- 10 min as tolerated Arm exerCises optlona'" Standing showe r Independent hall ambulation as advised by PT Education Written home exercise/activity gUIdelines reviewed Patient given written information on outpatie nt cardiac rehab

p

Chapter 16 Heart Oisea....e

Table 16.8 Inpatie nt Cardiac Reha bilitation Program

619

(~ ..';nued)

Level 6 4-5 METs . Progressive hall ambulation as tolerated Full flight of stairs (or as required at home) up and down one step at a Ilmeb Education Answer patient's questions Check for understanding of activity guidelines

No systolic drop in BP > 10 mm Hg or increase > 30 mm Hg No HR increase > 12 if beta blocked, or no HR increase > 20 if not beta blocked No complaints of dizziness, lightheadedness. or angina Perceived exertion < 13/20

Levell HA and BP before and after supine bed exercises Orthostatic signs supine and dangling at bedside Level 2 Orthostatic signs (supine, sit, and stand) before exercises and transfer HR and BP after leg exercises/transfer to chair HR and BP affer retum to bed Levels 3-6 HR and BP in sitting and standing prior to activity HR and BP immediately following activity HA and BP 5 min aher activity From Rehabihtation Services Department, Newton Wellesley Hospital, Newton, MA, with permission. aOpttonal exercises are al the discretion of the physical therapist (PT) and may be used to establish the patient's CV response in the room, prior to moving on 10 more challenging hallway ambulalion; or in Ihose patients who require general strengthening exercises. bStaJr climbing activities should take place after the En if the scheduling of the ETT permits. Otherwise patients may, at the discretion and supervision of the PT, climb stairs on the day prior to the ETT.

and is not done i n a rigid fomlat. Although a patient mu st demon~l rate the abil ity to sit at the bedside with appropriate hemodynamic response before ambulating in the hall\\3Y, the

patient'~

individual response and medical hi story

will diJ.:late how quickly he or she is able to progress. A patient may progrel;.~ through more lh an one leve l within an~

treatment sess ion.

Le~rell. The

patient i l;. in the intensive care unit (leU) and

i~ stable; generall y phys ical therapy intervention does not begin untjl aftef thc fifst 24 hours ffom admi ss ion or until

the pallclll has been stabl e fo r 24 hours. Ph ysica l therapy mtcrvenr iull ...hould begin alier the blood wor!... ha ~ indi cated Ihe MI J ~ comple ted . CK and troponin (both I and T ) le\'el\ art' monitored. For both C K and Troponin kvel!'l. fe li · able dlagnosllc .l;.en\ lt ivlly (grcmer than 90 pefce nt) I!)

reached

",1111111

12 10 J 6

h()ur~ 0 1 the onse t

of \) mplom~.11'1

CK peak. lev.:b occur bc:t'Wee n 14 and 36 houf~. wi th a return 10 normal levd uft':f 4g to T!. ho urs; troponin pea " ~ al 24 to 36 hour... \'dlh a return to normalle\ e!\ ", jlhlll 10 10 12 day\ .16 Common I" three M!ts 01 CPK level ~ collec ted 8 hour. . apart are cnll eued. B c~ au ')e C K I .... rdca . . ed vc r)

quickl y into the bloodstream with cellular damage. it is typica l fOf the first and second CK levels to show a progressive increase and the third set 10 be less than the second (i.e .. the CK peak has occurred, and the values are now (rending dO\lmwafd) . Because CK may be released with cellu lar damage to areas other than to the myocardium. specific myocardial isoenzymes known as CK -MB are monitored. Approptiate activity for the patient in the leu during the first 24 hours is to move comfol1i.lbly within Ihe bed, perfOffi1 ank le pumps, deep hreathing exerc.ises. commode use (if hemody namically stable). and perfonn lim it~d personal care.

Level 2. Once the patient has been hemodynamically stable for::!-l hour~ he or ~ he may progress OOB (out of bed). The therapi st ~hl)uld also be i..Ilert [0 ~igns of orthostatic hy potcn\ lon when the patient {"hanges poSition from supine to ~illlllg on the ~ idc 01 th(' bcd. The patient '!, feet should be !, upPo l1ed on a ~t ool Iv assist venous retum If they are nOI able to touch the lloor. The patient walh to a bed!)ide chair. 'I he pallent .l;. ltS 11\ an upnght chair for up 10 30 minut~s n fCIA lill1~~ a day There IS a real temptation for many health c~n~ prm Id~rs 10 ha\c Ihe patient ··do'· something while

620

Ph,,,i c;,tl R e-habilit3Lion

~e at ed. :- uch ~l~ wa:- hin g. eati ng. or visiti ng with famil Y', lt is

pro habl y \vi:-e 10 j u ~1 leI the pat ient s it for th e firs,' 1 .".l 1~. wi tho ut being encumbered \\- ith o the r t3~h . The Ihe rdpl s,ll S . I ' :-, r's c-pon"(' I pallen Ihll ' be llc r able 10 evalua te 11C " to hems q upng hl. If the patic nt ha, had a large M I Of rc U.lrc.: ~I .S I ~W pro!lrc..;, ion 10 upright po:-.wre. then the u...e of .t . l ~ dllll11g chair I ~ a \\ LE e \c r(' i :-.c~ ... ucl~ a... ~nk l e rU 1llp~ .. }.,,~ec cx \cn:-ion:-.. Of marching in phH:e. Vll al signs arc 1l1 0 lHI OI Cd

for hemod ynam ic :,wb il il ) and appropriate act i v i~ y . r~spon ...e. The impm1 ancc o f he~lIi ng tim e. paci ng J CIlVl!l e:-i, and

~ reat i ng a hea lth fu l e ll' iromm"nl arc com ponents of i.I pn::: h c n ~i\'e

COI11 -

p3ticlll educatiun program .

Ll' l'el 3. P<Jtien t:o. arc i ll~ t l1lctcd to graduall y increase their :.Imhuiat ioll. One approach is 10 ed ucat e patients 10 judge thei r ambulation in tcml ~ oftim c ;n.:;tcad of distance. Ti me is ;I more re' producible mea. . urelllenl. while distance may be dilli\.·ul t to judge (e.g.. " 1 "ant ~ou to walk for 2 minutes" vs "'I \\ an t )O~ to walk 2(X) ft "'). It ~li . . o allows for an easier traJ1~ Itlon to the ho m c e).erci"c program . " hit h is c0l111110nly b~N'd on l e n ~th of time. For doc umentation purposes. it is 1110 . . t ellecti\"; to docume nt the di..-.tance cove red in the time pe riod \\ hene\ er pO!'l~ ible (e.g .. Patient ambulated 500 ft in 6 111111UIC\ \\;Ih a RPE of 10/ 20 ). Infom1ation regarding CAD ri ,>'" factor,> allo\\ "> palient:) 10 begin to lake responsibil11 \ for their (;hoice~ <.IboUI activ it y and lifestyle. However. for '>~l11e patienh this 1113) be tOO carl y in their recovery. and the\ are unable 10 focl" on what i ~ being said. Giving pat'ien h \\rin ell 111forl11atl 011 is a good way to provide educati on and ) et ghc patie nt ~ the choice when to read it. U::.e 01 the Borg RPE ,cale a ... ~ i st s the pati ent ;n monitoring of act]\ II) Intcn\ II ). i ncr~a. . e the frcand time of their wal"'s al a comfort:.tble and lei,>urt'ly pact'. The goal 1.... to progre"s \\a lJ.. . " from 1: minute .... 10 5 mi nutes, to 10 minute, \\ il h appropriate hcmod ynam/( re . . pon"t'. StaIr. . rn a) be di mbed foot m er fOOl \~i l h a p l.m!!~d r~ ... t hall \\ a) or . . 0. o r one f OOl al a time. de pc:ndIll!,! on the SIJtU . . o l lhc p ..IIICIlL Palient... are oft en he ... i t~1Il 1 to Ilhl\t'. C .... jXll.l lI) 111 ... Ifl'tehing Ihelr ann, o\l'rhead: thcrelorl' jXrlolllllng .t \ ;J nl:l) o! tru nk ,11111 , Jnd ~ 1 i.lIl dln g leg. t'\l;"rll'l"' lor a Ic ..... h: Pt'll lI lHh eal h 1J1h::11 .tlhIY' Ihe 11.' ..11" and help . . tlw pJtll'1l! kt'IIll(Jrc conJl 0J1ahk: film ing. P 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')

IJlIII.11

..lull 111I,:ntJI

.tnJ thl' u) . . 1 pi not

IU.,t

ph) "h•.• tI hut

I.: ll h\

Jl 11\ Ittt:" J ... lJl\dlu.lhk. ( ') r ll jl .tnll~ t:1I\'r!:!~

~ I, ,I It) JII(IIIt·) II .... ~

11t:lp Il le p..llllill 1(1 P
\llIl I ifill'

I \Lr)

IUllL th(.;"~ rn t

1\ I

1I ~t: g\)III~

tOlh.,: -\ 1 I

for a quick refill. In this way. patients become knOwledge_ ab le about the expendabi lity of energy and ye t are given the responsibilit y 10 spend (and save) as they choose.

Documentation There are nlany ways to document physical therapy exam. inat ion and intervention. In th is patient popul ation, appropriate documentation wou ld include: I . Objective activit y data, includi ng time period and distance ambulated, type of sittin g and stand ing exercises. and stair

clim bing (num ber of steps): num ber and duration of rests

2. Pat ient 's vil al sign res ponse to each acti vity incl uding a statement th at addresses pati ent performance with respect to vital signs (e.g .. Pati ent ambu lated 6 minutes cover in g 500 ft and c lim bed 10 steps fOOl over fOOl

using handrail wi th adaptive VS response wi thout signs or ~ympt om s of hemodynamic compromise). 3. Education provided and response of patient, family. and careg ivers.

Home Exercise Program (HEP) Two of the more import ant concepts for a patient to understand al the time of d ischarge are symptom recognition and appropriate acti vity gui de lines. It is crucial that the patient be aware of. and recogni ze. cardiac sy mptoms and under· stand the! action to take if they occ ur. Ph ys ical therapists establish activity guidelines during the fi r::.t 4 10 6 weeks post-Ml while the myocardium is bealing. During thi s healing phase. physical ac.tivity involves a gradua l increase in ambulation time. with a goal of 20 to 30 mi nutes of ambu lat ion one to t \~·o times per day at 4 10 6 \\ee ...... po~I - M I. Pat it: nt~ arc encouraged (Q walk: comfort· ably, dress appropri ately. and to try to e,xercise in ambient tempe rature at indoor ma lb if weather is not appropriaR (I.e .. belo\\ -W' F including \\ ind chill fac tor. over 8ooF, or excc,>"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

I'or

Ih.: p.IIIl"lli ,ukll1\"' !..l' .... ' ......ll l H.. .... It ' 'I;!.t' .... tJ011~. ,tS wdl as pIO'Ii

.11I1' 11\

~-

..._..... uI

[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~t
It is im portant 10 rev iew the s urg ica l and cathe te ri zatio n reports to detenni ne w hich vessels were revascul arized . and wh ic h vesse ls have less than 70 perce nt les ions and were the re fore nOI revascul arized . Jus t because a vesse l is not a candidate for revasc ul arizati on does not mean that it cannot be probl ematic at a later d ate. e ithe r by rupturing o r cont inuing 10 demo nstrate progress ive athe roscle ros is. II would be sho n s ighted for a cl in ic ian to believe that a patie m who has had a revascul ari zati on proced ure canno t become ische m ic .

Percutaneous Translum inal Corona ry Angioplasty (PTCA) There are at present no stri ct guide lines fo r w he n a patient may res ume ae ro bic tra in ing fo ll ow ing an angiopl asty. Conventi onal wisdom, however. favors waiting approxim ate ly 2 wee ks to all ow the infl amm ato ry p rocess re s ulting fro m the interve nti on an appropriate time to s ubside . The new exercise prescripti o n sho uld be based o n the res ults of

the post-ang iopl"sry EIT. not the pre-ang iopl asty EIT, '\lhich was mOfe than like ly pos iti ve. Patie nts may continue 10 ambul ate at a low intens ity and comfo n able pace during the first I 102: week s fo llow ing the PTC A . but sho uld avo id the mode rate to hi g her inte ns iti es assoc iated w ith aerobi c traini ng, Coronar~ Arleq' Bypass Graf'l For p<:rtie ms w ho have had bypas ~ s urgery (c.g .. CA BO ). recovery is some what ... lowe r than th at fo r ow in g 10 Ihe complexi ty o f the ~ lI rg i ca l procedu re and the inci, i ~nal hea ling. Th~ nu m ber and loca tio n of inc is ions depe nd o n the , urgeon "" h::c hniqu ..., (i.e .. e it he r a full s icmal c uI. part ial ... t(' rn al CuI. (If mlN CQSlal approac h). T he do nor gi.1ph s ite 111 3) n!4uire addi tional Iflc l '\ ion ~: a leg inci~ ion if ~ aphc IlOU ~ ve ill I;'; u'cd , a nondominanl arm ltlcis ion if rad ia l a l1l'ry j!oo 1I \t:J , o r no IH.ldi tlOll.ll illc i!) ion If gntfted \\< lI h Ihi' IIllc rn aI IllJIllIll i.lI) aft e l) Ph)!)lca l therapy IIlt CT\c nU on !) ho uld ;.td d fC'~ all) ... o ft ti ,~ul' IInpai n nellh that 111:1) he alTl.."c t('d h) tht' illci' lo n 10 Ill .l.i main appropria te J1 cx lh li it ) and po, ture,. \\llIh .tIl :l\\arC lles~ thnt pat ient:-. ollell InJ II.:ilte ,()re rlt:"'" Ulld/i)r dl,eollljort aro und the dono r "" II ~ I f d ... lernJI \\ ou nd i, pfe~~lIt . appropnare po"ture. 'l.lpu l.t n! lr'K th)ll . and hllln ionJI ... ho ulder mO\e l1lem~ ,hilU lti ~ t.: n(u u r.l g~lI Propn\)t,.'cpIlW e uromut-c ul ar I '~L'lI II "'IU ilI I PN P ) u ppe r t' \lI~ l11l1 y ( LIE ) diagona l pnltt! m s OII t:11 \\t lll '''cli, a~ do Ihe traull io na l ('arLii nal plane RO M

rrCA

622

Physical Rehabilitation

exe rcises. Patit~ nt s shoul d be reminded that onl y a few repetit ions at a time throu ghout the day are better tolera ted than more int en"ive reps (5 to 10) I to 2 timcs pe r day; the latter regimen often results in incisional sore~ess. SO~l1e ~ urgeons choose to lim it UE fl ex ibilit y exe rcl ~es dUTl Il.g the 4 to 6 wee ks follow ing surge ry whi le the stcmum IS heal ing: however. it is unclear as to the rationale for the limitation. A professional collegial relati onship with the surgical tcam to disc uss ~ u rg i cJ I tec hniques and mobi lit y cOl1cems will cn ~ ur(' the bes t outcomc for the patient. To avo id sternal discomfort . all pati ents will benefit from splinti ng the incision with a hand or pi ll ow when lau ghin g. coughing, or sneezing. Patients shou ld be instructed 10 avoid lift ing, pushing. and pulli ng objects un til 4 to 6 weeks pos t-s urge ry when th e sternum is well healed. Pat ien ts wi ll also apprec iate infollllalion regarding e nergy con~e rva ti on and rest peri ods. Even though the functioning of the heart i-; perhaps the best it has been in quite some ti me. the effec ts of major surgery on energy level and mobilit y muSI be emphasized. The impact of fati gue on the palienl's sense of we ll being may be profound. and it is impon anl that pa ti enls understand the need for rest as we ll ~ ambul ation. Earl y ambu lation and mobilit y beginning the first day post surgery will assist in the patienl's ph ys ical and emotional recovery. During the ini tia l weeks followin g cardi ac surge ry. the early in-hospital limi tati ons following cardiac surgery have perh aps more to do with the surgical procedure and altered mobi lity and less to do with the heart itself, whi ch i~ th eoreticall y health ie r than it was before surge ry. PoslOperat ive fatigue may be due to a combination of factor~ . including anesthesia, blood loss, ini tial weight gain due to cardiopulmonary bypass machine. common arrhythmia~ such a~ atrial tibrillalion, and the energy cost o f healing. A\ "ith the post-M I recove ry period, whe n the surgi~al patient returns home it is a good idea to break the day Into ma~). ~ ubuni ( s including rest, l e i ~ urt! acti vi ty, and pe rhap~ vI~ llIng with frie nd s by phone or in person. De\eloping a ,chedu le but keeping it fl ex ible helps the patient exe rt ~o me control ove r the day and ene rgy level. . The pat ient i~ encou raged to gradua ll y inc rease wa H,mg, wit h a goal of ~O mi nutes of all1bu lati on I to 2 ti mes ~er ~ay at 4 to 6 \\eeks post-surgery. If the palicill is wa lkIng In the nei ghborhood , ~lIggest that the ini tial wa lh be brld. i.tnd forth in lront of the how:,e rat her th an around the blucl<... In th l~ " :.J y. if the pallent ove re~Hj m al es hi~ or her tnergy level. the dU'ie proximlly of home will provide a welcomed re~ t and preve nl merexenion . Many pat ie nts ilmhlllOu~ly beg"l their walk only to find them~e l \'C\ ~1It1dent). fati gued and further from home than tile) \\ou ld !J~e . ~OI1lIllUI~g c.\er~ l \e)) lor pOMure. E anti tnlll!... mobilll) , and ~Ierna l protection arc abo Important cOIllI)Ont:lll. I the home eXfli:h.e prognull. :, t)

~I:('e a P<1t lt::.nt '~ im.:i" IOlh have ht:alcd (approximately 6 'oI.ccks). and hi!'. or her blood COUnt~ 111c1uding Iwmalo<..'nt and hemoglobin are in acceptable range:" cardiac rehabi h-

,"tion may begin . The patie nt may have a maximal Ell and begin ae robic and stre ngth training according to the

general guidelines.

Heart Failure With the marked improvement in anti -ischemic medica. tions. inc reased knowledge and management of CAD risk factor~ , avai labi lit y o f sophisti cated monitoring, and revlScui ari zalion techniques. more patients are living longer with co ronary di sease than similar patie nts 20 or 30 years ago. Ne w tec hn ology and medicati ons continually improve the understand ing and manageme nt of CAD; however, an undes ired effect of lo ng- term CAD may be the increased preva lence of heart failure, also known as congestive hearl failure (CHF). For the year 2004, Ihe estimated d irec t and indirect cost of C HF in the Uniled Stales was projected 10 be $28.8 billion.' Coronary disease may well be the most common etio logy of C HF. 82 According to the Heart Disease and Stroke Stalislics-2004 Update, lite prevalence of C HF in Ihe Uniled States in 200 1 was 5 mil· lion Am erican s. 2.5 million males and 2.5 million females.' Although disease prevalence is similar belween males and females, female m ortality e«eeded thai of males within the same lime period, 33.0 thousand venus 19.8 thou sand; fe ma le deaths accounled for 62'" percent of a ll death s due to CHF, ma le dealhs 37'" percent' Hcan failure has s urpassed Ml as the leading cause of cardiac death s in the Uniled Slates. Heart fai lure is also the IIlOSI frequent cardiac diagnosis for hospital admissions and readmissio ns.' In 1998. il was reported that once signs of oven fa ilure appear, approximately 50 percent of patienIs would di e wi thin 5 years, despite medical management.' As understanding of the di sease process improves along wi th new drug combinations. these statistics may improve.

Types of Heart Failure Although th e tenn he an failure mOSI commonl y refers 10 LV fa ilure. heart fai lure may include both right and left ve ntr ic les or be limited to the RV alone. As a result or LV

fa il ure. increased pressure gradicllls may occ ur not oolyil the LV but may continu e in a retrograde fashion to include the RV as we ll. Whe n le ft and ri ght heart fai lure coexis~ Inl'('lIIrint/ar f~ i lu re is prese nt. Ri ght heart failure tillY Oc,·ur indepe nde ntly of le ft he art failure wilh pultnOlllltY d",e~~e ~ lIc h as chroni(' obstru(: tive pulmonary disoaSt (COPD), in which c hro ni call y e levated PA ptessr~ 'i l1lt In RV hulun:: lhi" is refe rred 10 as cor pulrnooaAe ( rable 10.9). L\, rajlurt' i!\ aho Identi fi ed . t:o. primarily a sysuiliC 01 lila\hlllC tI) ,t· .. d t:~ndlll g upo n whether the :-if. , unl.:l1on, u...-Illl-.nt I' 1)f1111art· ly on", a I· \ e ntrl(' . UIar contractility .. (syaw-"' dy~tllnllionl or Vcntncul ar re ia;\ ation and/or fLllinI tliite. d) ' ~ f lI11C'lIon . ). " The d inical presc!l1lation of sy,.,...,. --"" dy, lunctlOn relates to inadequ ate CO with resulWlI ~ and symptom S II f h ypo pe rfuston · (e .g., fatigue. I'ell M

t-

-

Chapter 16 Heart Disease

Table 16.9

E xample of Hemodynamic Pressures

Associated with Heart Failure An increase in PA and/or pewp pressures is associated with LV failure; an increase in CVP is associated with RV failure : and an increase in CVP, PA. and pewp pressures IS associated with biventricular failure .

6mm Hg

CVP

12 mm Hg

12 mm Hg

(il-S mm Hg)

PA (9-19) mm Hg

22 mm Hg 16 mm Hg 22 mm Hg

PCWP (6-12) mmHg

18 mm Hg 10 mm Hg 18 mm Hg

and reduced e\crcl,e tolerance) ,~~ Dla"lolic dy..,funclion rre""nl~ \\ilh clc\31cd filling pre~..,ure!'! and decrea~ed \cntrlcular capa(,II~. )'lOhc d)sfuncllon has chara teri slics

of Lk('rea~d COnlI3t:llhl) and re ... uhant dC!crca\e in EF. Ol:t,(olic d~ .,fun(.'tton has characte ri stics of de,,:reased

compl,Jnl't" and a nannal Or increas-cd EF. There are thre-e common da,siflcalion~ of carduwlY'puthld. dJlalt"d. h)penrophic. and rC! dl~t ... tt)lit d~ '!ofun('lI on '" lin all JOuea..ed \l"Olncular m;1"; lhrofll(' h~pertcn'lOn Jnd aorth, ,tent.'I' at C">.amr!e_. . nl h~ pt:rtwphlc caJ\.lIom~ t)pa th ~. Rt.\tnt 11\ r • drJII./Il\,·p.ui!\· al~ pn:..ent, ,I.., JIJ..,h,,11C d) .. f UI1(IIOI1 due1(1 the- rTl" ...~nn: (,I t::X('C .. '1' el) ngid \entnrllL.1f ".dl .. , r\.:~ullll1!! 10 J JI."~r~i.l't: In

l.:ompl, . U1L:t:

...... .

The

lUn nCUI\ 1?

LhJ.utt ... IIf the he.m I.h'l-lM..'ldted '" Ifh dlaheh:, :ue JIl e\oImpk III Ii ~'ln~tI\(" l·'lrdlolll~op.Hh~ Thl' LF ot pJlu:m, '" Ith ""helm\. or dll.ueJ 4.:aJdlt.lm~()r:Jlhle, , . . ), Will ti~,lulldll'nll:o.. dI."LTC.:.I-.cd II()m fi(lnnal. u .. u.ill~ h) 01 lit' HIJJI 711 Jk.~l\.:t:111 pJlJenl, ~,Ih h)perUl'phll lI( lnlrlCln'c: \. dhlOl\ "r;lIIHt"~ Idl.1~hlla\ d\ ,tundaHl!') m.1~ hOi\(' 4 11~lrn .. .l Of t"\t'CI .tbtJ\t Ilurnl.il (J ' B l'l" U~ 01 lhl' !.lCl ftl. 1 \ ,,1)\ lll,,'h·il, J) ,1\JIh.-lWI1 m... , pr" ....:nf With 01"(1\)1111;1\,11 ( il \\' i l J f)\)lnlh,~I...t-.t: hll"V.('\I!I.

lh')Ut

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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, ..

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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

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"'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 <.,s ification I)y~te m . Class I. II, II , IV, for henrt fnilure has been ",lablished by Ihe New York Heart As'\ocialion ba...cd upon the palicni'!' subjective report of funclional activit y limitalions based upon their "ordinary physical activity,"1!6 Grading using this classification is based on the individual phy..,ictan 's Jud gment from listening to the pat ient. " is not pre.')cnlly ba"cd upon any formal objective meas urements (Table 16.10).

Pathophysiology of Congestive Heart Failure Heart failure result:.- from a com plex M:rics of events IOvolving neurohomlonal and mechanical faclors. In re:,pon~ 10 un initial myocardial injury. When Ihe myocardium ha.<;; reccI\'cd sig nificant injury (c.g .. a~ a re... ult of a large MI or multiple Ml ... ). compensato ry mechani sms are acti\,t(oo \\ ith the goal of maullaining Jdcqumc CO. The compensatory mec hanism.;: IIlclude: ( I ) ,"crea~d ... ympathcw.~ tone (Increa,...ed HR . myoc,mJial conlr!lcliiity, . tnd penphcral \3,cuiar \ asocon,tri clIOn): (2) ventricular n:moJelmg (m)ocardial dil.II0n and h)'f'Crtroph) l: (3) oc",,"on of

the rcrlln anglolclhin ') Slem ( incf(,J'1Cd sodiu m and ""Jlef reahsorpllon by l"tcLion of aldosterone and penphernl V3$()L'on~triclton

by ac llon or an~IOtl'lhi.n Il l: and H) redlstrib...

of blood flo,", (m a~ trom perip~f) 1(1\1, ard l'cntrnl (' Irl ul.tllon '\UlOn ~ ,)f lhe tht"M" nll?'ChJ.nh01\ re,uh m an IIltrl!a....c 10 CO from . . )01I).tthcllc to'eel'" on HR ,lJld cooIr.H:· tlht~. an aitl'r:Hit\O of the kngth- ten')lon rdJlIon~hip due: 10 Ihl~ e nl.jrg~,J l \ ' from "~ntrlcular rem\x1dmg ri:Io.uIt IIIg 10 311I11t'rc4I-i." in pl..l,ma \01 um~, IncrCJ\lnlo! I \. FDV, trom til< .tIJO!oolen.)flc: dle ...-" For:.\ \l.hile C0t11pt'U,Jh.)" fllC't.haJll'llh .Ire aole to pro\ Ick- ade4UJte l...1nh,k tUfll.llOllllll; and Ihe paltl!'llf n:r1\.ttJb a.:)~mp· tOlnali~ ( r ig. 10. t 1. 1l1l' txM.i) \ Jfl ll1aml:Hn the cuml ·o.")..tfOI"\- fTh:~h.lnbl'lh vnh tor of, IlIlllted Inut' the- ent'f'g\ (u.. { l")f tlk C1llUpcn...aUtiO"

4

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Il1c.. hJnl".. m "III

t,\llmUl'h tor~

1I11p.tllhi \Cntndl' rtK- p~u('1lI '-'III bc.'l:llme -..\11Iph.tflUtU",I h .. UKI~,I'< fl\ 1 \ F()\ l ,lmnblllt:' 10 a r~ IJl L\ pre" \\lfI:

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'"\J('ilUI .......

Ift'lll the pu m~..".il\ \\"U1..' OIltd ~..tfliU..u ttk polnwu"u) 411.tt}, fight ht:MI . .:1ild

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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
L ln~ l o ll'!b lll ~~ ~ 1 t: 1\l

\ OIUIllt', LJIl" renin· ~hJllUh1l10il MId :.I\.' li, rtlj (..ln of ah.h)stc:mne l"d

11I •.u.!cquale

rt:~ lIlb It1 n'h'lItlon u t

wit and walt' l". In realil), hvwt"\'~r. nO!ll,,-,I Hlk bli..lO,J \\tIUIHI.", but ratht'l";m mappropri· lilt· ,.d hl.: .Hhl(1 ul , ol ulIlc l \\ ithin Ih ~ h e ..ll1 llr \'t'"IlOUS ~) .. . 1(;: 11 11 . rl'!>liltl1l~ III d d ~\.· rea;)\· in ..t11<."n .l t tth,"IOd I1U\\ , Sodllun •IIIJ \\ .11\:' 1 r~ I(' 1l1l01l (\)11 l n"uh.'~ It\ Iht' fllnmtti(\fl vI' pul-

t!wn'

I'

m')Il.l r~ t'tkma (~\ild Ih ;h.':'lX· I.llt·J s llOrtlh'~S UI bll"'.uh ) and lX:1,pht'ral eJ t'IlI.\' A l ..tl\ .I l\rln \It' rt" IU1\-aJl~lOll."lbiu , t"spt:·

(,jall y owi ng to the conrribution of angiotensin. also causes peripheral vasoconstriction. Vasoconstriction redistributes blooJ to the central circulation and. by increased PVR. may conlri hute to an increase in BP and. therefore. periphera l perfusion pressure.

Clinical Manifestations of Congestive Heart Failure The clinical presenl;llion of the patient wilh eMF depcalb Il\H on ly on the amllunt of LV failure. bul also on the status of I.'olllpensalory mechan isms and drug therapy. OYer tilm', the (m~rgy cost of thi." compensatory

mechanisms

pro\ ~s to OC t04J Inw,'h for the impaire.d myocardium.. "I'M pat ient pt"t":'l.t"nts \\ itll CHF signs and symptoms.. and now !Il(nes frlllH bc."ing asymplomal"k~ to sympaomaaic· Although the- lenninulvgy nuty bt:' some .... hat coofus;ina. it is iml'onam t\) appre;.:iatt th:u \\ hen a patie:Ol is. rcR:ned to ;.,~ being in ('omp IIS(Ut"(J hfUrI fcliltlr~, the parieafs aJIlg('sth'e symptoms ran ~ rellevlt'd by medicallboflpy.u A palll'nt who is nuncomp:.nsUIN is sbowina ,s ips . . SYIIlPIl,)JHS of t"ongt"sHLlO and requ.ire-s medical ....... 1n.:lL'oll1gk re.l\lju.sullcm.

625

Chapter 16 Heart Disease Myocardial Infarction

~

Initial Injury

i

Figure 16.13 [)("\CIOpmell.1{~t:

COIU!f',U\C heal1 failure. An Initial mJlI~ 10 the LV cau,e~ aCll~ation of l'OnlJX'n,ator~

mcchall1"llls 10

ordt~r

--l.~

Cardiomyopathy

mamtam adequate LV function. \Vhen the patiell[ is adequately compen\ated

mrm~ and peripheral congestion).

Asymptomatic period I ---l.~

Compensatory mechanisms

I

Symptomatic

pulmonary

I

peripheral

~demy

!

i sympathetiC

t

r"

T renin

Congestion

angiotensin system

activity

(0

thert' are no 'yrnplOlll' of ('ongestioll II.e .. edema) The f.lilure of Ihe com~ pen~lO~ tnc(hanl,m<; result, in ,ign<: ami s\mptom, of conge'llon te.g .. pul-

I

ventricular remodeling LV dilation LV hypertrophy

t

Failure of compensatory mechanisms

TIME

Common <:igns and symp loms of CHF include fatigue. d~spne:t.

edema (pulmonaJ) and peripheral}. nuid weight gain. presence of an S: heart sound. and renal dysfunction. Pulmonary edema ma) be evidel1l by chest X-ray tilm. and au'cuitation of ad\elllitious sound s (e.g .. crac kle s). Peripheral edema ma) be evident in grav it y dependent lo\\er e\lremitie:-. b) the pre.:-ence of indentations in the (1;kin when pres~ure is applied, i.e., pitting edema. Pitting edema due 10 CHF is usually bilateral and ma y extend from the foot 10 the prelibial area.R!'I.IN Documentation should Include nOI onl) the amount of pilling. but al5.o the

area co\ered. The u,ual abnonnal he-an sound a~~ociated \\ilh CHF i ~ the pre~enCe of an St probabl) rc!>ulring from aJtered LV compli •.lI1cc Hean munnur!>. 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.<.' 0 1 the po\\ ':-rlul IX,'lIpht>f;JI \ a.'-UI..( 111 . . lrKtof:-. illlgHt1t!n'l n II alld '..1!',opn..: '>'11 1. (JIll' ul till' l(\lIllHon tOnlplUllll ' t)II'.ltlC'IH' \\Ith C ill Uldl
cle fatigue. The cause of their mu scle fatigue may be multifaclOrial , including a decrease in peripheral blood flow, c han ges within the peripheral vascular beds. peripheral vasoconstriction. atrophy of mu scle fibers, or inc reased utili zation of anaerobic metaboli sm. 90QI The contribution of intracellular mechanisms to muscle fatigue has been studied. Examples of the se intrace llular mechanisms include an alteralion in the co ntrol o f calcium rel ease and reuptaJ...elJ~ and myocyte apoptosis. 9 ' In addition to peripheral musc le functioning in patients with heart failure. exc rcbe !O tudies have also inveslig:ucd V3f1ous o th er factors. including oxygen uplaJ...e J...ineti cs, ncurohormon
not Ju:o.t a dl"'C,hC of Ih~ ht>.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<.i "nd heIJ -hlo4.:l{!r,.

CE th •.: ,)mpIOm, of \olume

I1lI11bllor,.
!1(I\Ul\j '

UlUlroJU'\: (hI!

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626

Physical Rehabilitation

are oft en on a sliding scal e dosage of diureti cs depending o n the amo unt o f flui d we ight gain : th ey arc instru cted to we igh themse lves dai ly and adj ust d iuretics accord ingly. A ft crl o ad redu ce rs. particul arl y those th at bl oc k th e effec ts o f th e rc nin-a n g i o l e n ~ in syste m (e .g .. AC E inhibit o rs. know n as ACE inhi bit ors or angio tensin rece pto r blocke rs known as ARB s) . arc ofte n a criti ca l componen t of dru g man agement in th is populati on. By bl oc kin g salt an d wa ler rete nti on th ro ug h aldos tc ro ne s uppressio n. pre load is dec reased . by bloc kin g vasoco ns tric ti o n throu gh ang iote nsin II suppressio n. afte rl oad is redu ced . The i n c rea~c in sympathe tic ac ti vit y th at acco mpani es heart fai lure C~l u ses an inc rease in MVo z (from betarece pto r .'l lim ulat io n). peri phe ral v3soconstricti o n. and resultant reducti o n in pe riph era l blood n o w (from alph arece ptor stimul ati on). Dru gs th at combine both betareceptor bl oc kade and alph a-recepto r bl oc kade minimi ze these affects: be ta-blockade wi ll res ull in a dec rease in MVo . . and alph a-blockade will result in dec reased afterload d ue to s uppress io n of th e vasoco nstri c tion assoc iated with alpha activati o n. A re lati vel y new approach to CHF ma n32.ement is the use of a pote nt vasodil ato r. sildenafil ( tr
bloc k on th e EKG ). Thi s pacer coordinates the contr~ction . ht and left ventri c les and III domg so provIdes a o f t he ri g , d CO 102 more e ffective LV contraction and inc rease .

Physical T he ra py Intervention for Patie nts with C H F

'0

Accordin g to the APTA Guide Physical Therapi" Practice. the manage ment of CHF is included under the category of Impaired Aerobic Capac ity and Endurance Assoc iated with Cardiovasc ular Pump DysfunctIOn or Failure , Pattern 6- D. Th e development of specific anticipated goal s and expected outcomes for the patient with C HF is based o n the fo llowing general goals: I . Physiological response to inc reased oxygen demand is improved . 2. Se lf-man agement of sy mptom s is improved. 3. Ability to perform phys ical tasks is increased. 4 . Behaviors that foster healthy habits, well ness, and prevention are acquired . 5. Disability assoc iated w ith acute or chronic illness is reduced. 6. Ri sk of secondary impairmen ts is reduced. 7. Awaren ess and use of community resources is improved. 8. Pe rfonnance of and independence in ADL is increased.

Mechanical and Surgical Support For th e sy m plOmatic patie nt in Class II 1{1 V, the re are dramati c surgica l o pti ons th at may improve fun c ti o n, such as hea rt tra nsplant , left ve ntricul ar devi ces (LVAD) and myop lasty. It is beyond th e scope of thi s chapte r to di scuss in deta il the complexity of each of the se procedures. He art tra ns pla nt ati on in vo lve s re placing th e pati e nt 's heart w ith a donor heart. Th e do nor heart w ill be denervate d: the refore. it wi ll not have an y direc t ~) mpathe ti c o r para sy m pa theti c conn ec ti on and w ill be dependent o n the intri nsic pacemaker of Ihe SA node and hormona l stimu lat lon to increase HR . Th e pati e nt wi th a heart tran splant requi res care ful pharmaco log ical manage ment. Immu ne s uppre~~ i n g d rugs are used (Q prevtl1l the bod y fro m rejecting the orga n, as we ll as fo r ca re ful control of infec tio n. T he LVAD is a tempo rary pump lh at i ~ i n ~e rte d inl o the patient (Q pe rfo rm Ihe \\or~ of th e L V o r 10 au g me nt Ihe fu nction of the fa ilin g heart. The pati e nt is connec ted to a n ex tern a l e ne rgy ~ource but abo ha ~ the o pti on of weari ng a ba tte ry pac k that allow!>. 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-<3

home~based

Intensity: 70--80% of peak HR Modality: cycle and calisthenics (Canadian Air Force XBX for Women) Frequency: 4-5 days week Duration: 20 min

16 weeks (6-16) Majority at 8 weeks

Dubach, D, et aP06 1997

Plepoh, M 109 1998

Coats. AJS, et al 110 1992

...~

Characteristics: Class II-III; prevIous MI but no previous dx of CHF Age: 56 :!. 5 EF: 31 .5 ::!: 67

N = 19 Characteristics:

Class II-Iff ; Ischemic cardiomyopathy Age: 61 .8 :!: 1.5 years EF: 19.6 + 2.3%; Va, peak: 12.5-13.3 mllminlkg

separated by 5 min

Intensity: 80% of HRmax Modality: Cycfe Frequency: 5 x lweek Duration: 20 min

Exe rcise time

i

24%

trained group, NSD In control ; 10% 1" V02 max; 1 anaerobic threshold: tOOL; no training related adverse effects

of rest

Controlled crossover trial Location: home-based with activity restriction

Comments

In

Duration: 3 10-min endurance sessions

and clinic

Results

t CO t A-V 0 ,

t pcwp i Va, by 29%

16 weeks

a weeks

training, 8 weeks restricted activity

t 13%

\/02

max

t 17% exercise t

BP with peak exercise; J. noradrenaline, aldosterone, renn in, ANP, and adrenaline Cycle plus calisthernics had > benefits than cycling alone home + clinic (vs. home alone) had > benefits

Improved submax Exercise response with training delayed anaerobic threshold during exercise, occurring at a higher \/° 2 : improved autonomic function

Short duration interval training shown to be safe and effective In men

High-frequency and intensity training improved exercise capacity without worsening myocardial function Improvement In both M and F; ischemic pts showed less improvement than nonischemic in \/°2 max: greater gains in pts who participated for 16 weeks than 6 weeks; 6~week training duration may be too short Neuroendocrine function demonstrated an i in parasympathetic activity and t sympathetic

(continued )

~

Evidence Summary Box 16.3 Studies Investigating the Effect of Exercise on Patients with eHF

(Con.;""ed)

Reference

Su~jec(s

Design

Inten'cnlion

Duration

Results

Comments

GlannUZZI.

N = 80 (76 M, 4 F) ; Post-MI; EF: 34.4-0 :!: 4 5

Multicenter, RCT; Location, home + clinic

Intensity: 80% HAmal( Modality: cycle, walk Frequency: 3x/week Duration : 30-min cycle; > 30-min walk

6 months 2 months supervised then FlU at home with q 2 clinic visit and exercise prescription changed as needed

-+ LV volume and dilation in exercise group however signif t in control; t in exercise group but not in control; tOOL in exercise group

Improve global and regional (LV) function over time in patients with .j, EF following MI

N = 54 Characteristics' Male and female Age ' < 75 years; EF: 36% :!: 11 .5

RCT Location: outpatient clinic

Intensity: 80% of '110, max Modality: cycle Frequency: 2-3 xlweek Duration : interval training; 90-$ exercise, 30-s rest Increase in duration from 15 min 2 xlweek to 45 min 3x/week from week 7-16

4 months

t Max exercise capacity t Va, max in M ischemic etiology; not in F t OOL ----+ submax performance

Men and women differ in their response to exereise training Included ischemic CHF and nonischemic patients

Intensity: HR 6G-70% of HR ma,

12 months

t 6MWT performance at 3 and 12 months for both ex and control group and 12 months ex and control; t va, by 10% post 3 months; NSD 12 months t strg at 3 months, none at 12 months

PG, et a1 111 1997

W.llenhelmer, R. et al 11 2

1998

N = 181 80% M; 20% F Characteristics: Class I-III; Age: 66.1 t 99 ex group EF- 27.7°/0 T .9 in ex group '110,. 14 mVkg

McKelVie, RS, et aJl1' 2002

----

--

- - --

CHF - ,Congesbve heart tfH\ure~ co

=,. PCWP AM ,0.1..

Resistance training: 40%

1RM increasing to 60% Modality: cycle, TM, arm ergometer Frequency: 3 x lWeek: clinic 2 XlWeek, home 1 XlWeek Duration: 30 min aerobic Resistance: 3 sets per ex session; arm curls, knee ext, leg press

cardiac output; EF = ejection fraction; F = female ; HR = maW.; MI myocardial Infarction; 6MWT = 6-Minute Walk Test; pLd"-lary capIllary wedoe praaaure, OOL ..... quality of hte: RCT randomr..._l.a1"O(M mllU:ln'.....'" . '\1 0. oJl.ygen consumptIon per ... nlt hma

~ ...... LV - ,..,,~; M ~

RCT, single blind comparing 3 months of supervised training followed by 9 months of home based

-+COL LV function

-+

Adherence to exercise decreased with home-based exercise Patients required close supervision programs to ensure compliance with exercise training

629

Chapter 16 Heart Disease desaturate if their CO is inadequate or if pulmonary .gas exchange is decreased owing to pulmonary c~ng~stlOn . At limes pulse oxi metry may be difficult to obtam vl.a ~n­ er probe due to the effect of peripheral vasoconstnctlon ;s a result of blood flow redi stributi on dire~ted a:v ay from the periphery toward th e cenlra l c lrc ulall o n. Regardless of the reason, it is. p.rudent to stop and re~x ­ amine the intensity of the aClivlty as well as det~rm~ne the need for supplemental oxygen. Patient exammatlon shou ld incl ude vi tal sign monitoring, auscultation. observati on. and recording of RPE . A recommendati on for an exerci se prescription is to keep intensity low and duration grad uall y i~cre~s jng .as the patient LOlenttes. Beca use of the ,dec~ease I~ dlastoh~ filling time and the potential alterauon 10 cardiaC functIOn ~t hi gher HRs, keeping the exercise HR below 115 bpm IS prudent. However, as a resu lt of drug managemen,t with bela-blockade, many patients may find that their HR increases only approx imately 10 to 20 bpm above resting for an adequate work out intensity. RPE is a valuable tool within this population and should be kept to a ratin g of fairly light. In the nonnal heart, an increase in HR is accompanied by an increase in inotropy. In the failing heart, an increase in HR may actua1ly result in a decrease 87 in force~ this is known as the negative treppe effect. Duration of exercise depends on the physiologi cal response of the patient. A compensated Class III patient may be able to complete 20 continuous minutes of lowlevel sustained activity such as treadmill walking or recumbent cycle ergometry. Another patient may req uire an intenninent schedule with planned rests after every minute of exercise. Light calisthenics in the s itting positi on are often a good initial exercise for the most compromised of patients. Besides low intensity and long duration, the exercise prescription should include a prolonged warmup and cool-down period and avoidance of isometrics,II9 lnclusion of light resistance work has shown to be safe in this populatjon. l20 Modalities for res istance training may include elastic bands for mild upper and lower extremity resistance work or light weights. A patient 's hemodynamic status may change quickJy with activity; therefore, it is prudent to be prepared for sig ns/symptom s of exertional hypotension, chronotropic incompetence, and significant dysrhYlhmias. 119 FunCTional exami nation of this population may be done with the 6-minute wa lk test (6 MlVTJ , Patients are asked to walk as far as they can in 6 minutes, taking as many rests as needed during this lime. 119,121. 122 One study reported that 1.0 patients with heart failure, the oxygen consumption (\'02) measured al the end of a standardized 6MWT was On ave.rage only 15 percent less than the peak \102 attained On an EIT.H3 Quality of life question naires ~ uch as the Minnesota Living with H.eart Fai lure Questionnaire are valuable for tracking patients' responses over lime. The reader is referred to the following Web site for additional infonnation on this questionn aire: hup://www.mlhfq.org ,

Conduction Abnonnalities Ectopic Beats

.

.

A beal that originates rrom a sIte o ther than the .smus node is known as an ectopic beat. The common ectopIc beats. are atrial (premature atrial contraL'tions [PACsj) and ventncular (premature ventricular contractions IPVCsj). PVCs may occur either by them selves or in groups such as c?u~ plets (two PVCs) or triplets (three PVCs), or altematmg with sinus beaLS such as bigeminy (every other beat a PVC) or trigeminy (every third beat a PVC). There may also be a premature junctional beat from the A-V node, but at times thi s is difficult to differentiate from the atnal beat, so they are commo nly referred to as ectopic supraventrj~ular beats, occurrin g above the ventricles in either the atna or A-V node. The presence of ectopi c beats results in an irregu lar rhythm. Usually, ectopic beats are transient, and their severity depends on their impact on CO. It is certainly commo n to have a few PVCs even in a normal heart. Many people may have ectopic beats during times of stress or with stimulant s such as nicotine and caffeine. Even though thi s may be a common response in a normal heart, it is important to educate patients with m yocardial impairments who may have ectopic beats or irregu lar rhythms to avoid these aggravators. An increase in ectopy is undesired. It is unwi se for any patient with cardiac disease to engage in exercise follow ing recent c igarene smoking. Although the specific time frame that a patient may be at ri sk for increased ectopy is not clearly known, a good rule of thumb may be abstinence of smoking for at last 2 hours e ither before or after exercise.

Conduction Changes in the length of the PR interval, the width of the QRS complex, and the length of the QT interval are some of the EKG measurements indicative of conduction abnormalities. Conduction delays throu gh the A- V node are classified as first-, second-, or third-degree A- V block. First-degree heart block occurs when the conduction time through the A-V node is prolonged; therefore, the EKG will have an increased length of the PR interval. There are two categories of second-degree heart block: Mobitz type I and Mobitz type II; eac h is hallmarked by the presence of dropped beats. Mobitz I, also known as Wenckebac:h. presents with a grad ual increase in PR length in the preceding beats and then an eventual dropped beat; Mobit. II has non11al PR intervals in all the beats preceding the dropped beat. In third-degree heart block, a mismatch of atrial and ventricular cond uction exists, so there is no consistency between the atrial contrac tion and the ventricular contraCtion (i.e_, no relationship between P waves and QRS complex on the EKG). Cond ucti on delay. through the bundle of His lie known as ei ther right bundle branch block (RBBB) or left bundle branch block (LBBB), Bundle branch blocb lie

630

Physical Re habilitation

not true arrhythmias beca use there is no chan ge in the actual rhythm. just in th e timin g of conducti on through th e bundle of His. The heart i, still depolarized from the same pacemaker: on ly th e rout e of ac tivation is c.hang~d . Bundle branch blocks present on th e EKG as a di stortIOn of the QRS compl ex wi th an increa se duration (Le .. widening), The presence of :t LBBB 0 11 the EKG is, ~s u­ all y pem1anenl and ind icates a pathological conditi on. RBBB may occur fro m a varie ty of reasons; it may be a pe nnanelll chan ge due to underlying di sease. or it may be be nign. RBBB can also occ ur transientl y. LBBB usually indicates the presence of more sig nificant disease than RBBB . Physical Therapy Intervention for Patients with Arrhythmias Atrial Fibrillation (Fig. 16.14A) A-fib is the classic irregular rh ythm , characterized by a varied number of non si nus originatin g P waves (known as flutter waves) fo r eac h Q RS complex.. Patients may exhibit thi s rh)-1hm contin uously as their baseline rhythm. Physical therapy intervent ion may be appropriate for patients in a-fib who have a good ventricular response at rest. with appropria te hemodynamic and HR increase with exercise. A I!ood rule of thumb is to avoid physical therapy interven ~ons and seek medical consultation if the patient 's resting HR is greate r than 115 bpm, if the pat ient appears uncom fortable. or if there is an inadequate he mody nami c response, Because this rh ythm is irregular, it is important to monitor the HR for a full minute. Premature Atrial Contrac tion (PAC) (Fig. 16.14B) A PAC is an ectopic beat that origi nates in the atria and may present as an irregular rhythm. Usuall y. PACs wi ll not compromise- CO. and physical therapy intervention may be appropnate if accompanied by adequale hemodynamic and an appropriate ventricular response. A run of PACs occurring at a fas t rate ( 100 to 200 bpm) is known as paro.l),s, mal atrial rachycardia (PAT). A com mon ca use of PAT is digoxin toX icity. It may be difficult to distinguish a PAC from a premature junctionaJ contraction (PJC), an ectopic beat that originates in the A- V node. A run of eit her PACs or PJC~ at a rate of 150 to 250 bpm is known as slIpraventneular tachycardia (SVT) (Fig. 16. 14C). In some cases, it may be difficult to di'tinguish PAT fro m SVT; SVT usually re~ponds to a carotid massage whereas PAT does not. No physical therapist should ever initiall y in!itruct a patient to the use of a carotid J11a ~sage or perform u carotid massage be('ause adverse rhythm changes may ()('(' ur with its use; a phYMcian rnu!,t first carefull y ~creen pHtiems during EKG monitoring. No physical therapy interventi on sho uld occur dUring an episode of SVT or PAT. These rhythms usually la~t for a short time (minutes, not hours), and activity rna)' u,ually be resumed after the patient has been

examined. the patient is comfortable, and the etiology detennincd and correc ted . if possible. Premature Ventricular Contraction

(pvq

(Fig. 16.14D) . .' . PVC is an ec topi c beat that ongm.tes til the venlncl. and may present as an irregular rhythm. Usually, single PVC, will not compromise CO if less than 7 per minuIe. Therefore, physical therapy intervention may be appropri. ate if accompanied by an adequate hemodynamic response. If PVCs increase with activity, the activity should be stopped and the patient examined for possible myocardial isc hemia. PVCs that come from different ectopic sites within the ventricle are known as multi focal PVCs. They are more seri ous than unifocal PVCs, and, therefore, the patient should be medically evaluated before beginning or continuing an activity. Ventricular Bigeminy (Fig. 16.14EJ and Ventricular Trigeminy (Fig. 16.14FJ In ve ntricular bigeminy, every other beat is a PVC; in trigeminy. every th ird beat is a PVc. These rhythms occur transientl y or episodically, and many patients have fre· quent bursts of these rhythms. Altered LV function and ischemia are two of the more common causes; therefore, medical management is directed toward improved LV function and perfusion whenever possible. as well as arrhythmia control. Physical therapy intervention is COIIserva ti ve at best and depends on the hemodynamic stabil· ity of the patient. If ectopy increases with activity. then activity should be immediately stopped . Ventricular Couplets (Fig. 16.14G) and Ventricular Triplets When two PVCs occur together, it is known as a couplet; when three PVCs occur together, it is known as a triplet. Co uplets and triplets are important in that they suggesta hi gher level of ventric ular irritability than bigeminy or trigeminy. In general. ac tivity should be stopped for anyo ne who has a couplet or triplet. and the patient should be examined for myocardial ischemia. Activity shoul d not conti nue until th e patienl has received medical clearance. Ventricular Tach ycardia (l
'S

Cha pter 16 Heart Diwase

A

B

c

D

E

F

G

H

6Jl

Figure 16.14 Example') of ectOpy ~Uld arrhythmias. (A ) A tria l fibril lation. (8 ) Atrial prematu re beat, aJso known :t~ pro! ll1<1lUre arrial contraction (PAC) (note third complex). (e) SlIpr.:lVentrkular tarh),cardia (SVTI tD, Pre mature venlrir ular r ontraction (PVC) (note thi rd complex ). (E ) Bigeminy (note ~econd , fOU11h . and :-.I>.lh ~omplexe~ arc r ves !. (F ) Tligeminy {note ..econd. fifth. ,mel eighth COIllplexe~ art' PVC". (G) Couplets (note fo unh i:lnd fifth complexes an: r VCs). (1-1 ) V(~llIri l: Lllar tachycardia (Hach). U) VClllribu lar fibrillation (v- fib ) (v- tach deteriorates into v-fib ). (From Brown . K. imd Jacob1.un. S' Ma ..te ring Dysrh ythm iil s: A Proble m-Solving Guide, FA Dav i<;, Philadel phia. 1988. p 30. With pemlJ .,~ jo Jl )

cardiac li fe bUPI>o rt IAC LS ) system . V-lac h may detl!fi orate quic Kly into ve nt ric ul ar fibri ll a ti o n . NOIl!)u:-:. l altlt;d V-Tach OCc urs e ithe r in groups of three to livt: PVC!) knuwll a!) .\ull os . o r iJ. rU Il o f si x or mo re PVC~ lastin g ror up to 30 ~cconds.. Ilot NOJh U!)lained v-tach i s ':Oll sJdered a high-risk ind icato r fo r pote llli 311 y le tha l arrhy th mias. Becau~e the rhYlhm i ~ non~ u staincd . the de c rease in CO may not bt: suflil"icnl 10 cause ~ymplom!). However.

untit the e ti o logy of the arrhylhmi~t is idenl ified and the rhythm controlled, physical the rapy intervemion is gene rall y inappropri.ue.

Ventricular Fibrillation (Fig. 16.141) Whl.:' l1 the ve ntric les do not contract but insll!ad tibriUate. there is ineffet tive CO , The patient will expire if this rhylhm is no t altered immediate ly: the treatment of choice ,

632

Physical Rehabilitation

is activation of ACLS . including e lectrica l defibri ll ation and medication .

Conduction Abnonnalities Patient s with third -degree A -V bloc k are candidat es for pacemakers. Unlike tirst-degree block. which has no limi tatio ns to exerc ise. paticnt 5 sho uld nOI exe rci5e whil e th ey are in third -degree A-V bloc k. Wh ether o r not exe rcise is penni lied with second -deg ree A-V bloc k depend s on the eti o logy and s ubsequ elll hemod ynam ic response; the 3nendin g physic ian should clear thi s pat ie nt po pulati o n before begi nning any exe rci se. The presence of 3 new bund le branch block sho uld be medicall y cvalualcd before begi nnin g o r progress in g an exe rci se prog ram. After lhe medica l eva lu ati on, there is usually no contraindication to exerc ise in ei the r the RBBB or LBBB population , Beca use of the al te rati on o f the QRS complex and as a re sult th e ST segment. the sens iti vit y of the EK G in detec ting isc hemia via ST depression is los t in the patient with LBBB ,

Special Exercise Considerations For a brief overview of areas fo r cons ideration when designing an exercise prescription for patients following a CABG, \ alvu lar su rge ry, PTCA. pacemaker, automatic imp/amab/e cardiOlwter defibrillator (A /CD). o r heart tran splant, 125-130 and for those patients with a diagnosi s of silent ischemia or seve re LV dysfu ncti on, refe r to Table 16,1

I.".

Heart Transplant Patients who ha\ e undergone a heart tran splant m ay preswith the following : ( I ) calf cramps (occurrinQ in approx imately 15 percent of patie nt s) ow ing to ~ the tmmu nos uppres5 ive drug cyc losporine; (2) decreased lower e>..tre mit) .,trength ; (3) obesity owing to lono- lenn , cOrticosteroid u~e: (4) in creased ri sk of fracture owing to osteo porosis aS50c iaied with lo ng-term. hi gh-dose cort i~o5teroid~: a~d .(5) an increa5ed probabi lity of develop in g atheroscleroS IS III the coronary arteries of the donor heart after the fir!)t year post su rgery. 127 Because the hea rt is denervated, HR alone pro vides J limited measure of exe rcise IIlLen,\uy, Therefore. BP and perce ive d exerti on 5hou ld be Included in the routine dat3 collccuo n. ent

,

.

Automatic Implan table CardioverterDefibrillato r (AJ C D) A ICD (JeD) are placed In p:.Hlcnb who havt:' life-th reatenmg \cllIriLuiar arrh)t hml~5 (v- Iach, v- fib) . Th e A ICD is

plOgri.1mmed to deliver an elec tri c ~ h ock If it dClecb a HR higher than li S programmed HR IlIlll!. There lorc . il i ~ ImpO rtanl for th e ph)'~ l ca l therapJ !>1 to know (hJ ~ limit and
th e patient with a pacemaker. the re are o ther considera_ ti o ns. ST seg ment c han ges on the EKG may be common and are not speci fi c for ischemia: the refo re. other diagnos_ ti c slU dies mus t be do ne. In add iti on. UE aerobic Or stren gthening exerc ises sho uld be avo ided initially after placement o f the pace r 10 avoid inadvert entl y di slodging the dev ice o r th e lead w ires. 118 Check in g with the physic ian when Ih ese exerc ises may be included is prudent. The re may be 3 danger for patie nts wi th AICDs or pacemake rs from electromagnet ic s igna ls suc h as anti-theft dev ices, e ith er ca us ing th e AICD to di sc harge or causing pacers to slow down or s peed up , It may be no problem for patie nts to wa lk through these dev ice s but lingeri ng within a fe w fee t co uld be dangerous, 12'

Pacemaker Pacemak ers have become extremely sophisticated in their capabilities and are no lo nger used just for the patient with bradycardi a. Other indications for pacemaker use include the fo ll ow ing; ( I) symptomati c second- or third - degree A- V condu cti o n bloc k. e ith er acq uired or as a complicati o n post MJ ; (2) bifasic ular or trifas icular second-degree A- V bloc k: (3) si nus node dysfu nctio n; and (4) rec urrent sy ncope due to hype rsensitive carotid s inus reflex or neurocardiac sy ndrome , /36 Pace makers have rate and rhythm sensitivity as we ll as the ab ility to override certain arrhyth. mias, Pace m ake rs may also be combined with AICD capabilities. Pace makers are coded by e ith er a three- or fi vecategory system according to which chamber (atria at venlricle) is sensed , w hat chamber is paced (atria or ventricle) , and whet her the elec trical sti mulus will trigger a respon se or be inhibited ."o (Table 16. 12) Becau se pacemakers may fai l to work properly, w henever VS response and HR appear abnonnal during rest or activity. EKG monitoring is helpful to determine jf the pacer is working properly_ As stated p revious ly. patients with Class IJI CHF and left bundl e branch block may be candidate s for a specialIzed pacemaker known as a biventricular pacemaker. the p~rpose of whi ch is to synchronize LV contractility to proVide a more e ff"eC!lve C 0, The biventricular pacer does nol intluence HR or rhythm .

Education for Patients with Heart Disease Fo~ patiel1l S wi th he a rt dil>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<.ilTI ·I ' b' I' ' . I ) ~ a I uy to understand the informatIOn
the

Chapter] 6 Heart Disease

Table 16.11 Special Con side ratio ns fo r Earl y Re habilita tio n •

0 . ,

I

0

•

-.-

0

-'

'.

_~

•

~

,(,

0

o. r~f.x.:.. o.

~'j.• ~,~ • .I.:::' -

'.

,

_

_ • ; .... :"

.... '"

CABG or valvular surgery

• Incisional discomfort • Infectious processes • Anemia

• RPE of 11-14 • Range of motion for trunk and upper extremities • Muscular strength and endurance for upper extremities

PTCA (or similar procedure). MI . or angina

• Intravascular inflammation post procedure • Signs or symptoms of continued ischemia • Anxiety • Symptom denial • New ischemia (signs or symptoms) • Resting (unstable) angina

• HR criteria if below ECG signs of ischemia • limited by symptoms • RPE

Silent ischemia

• Associated signs (e.g ., shortness-ot-breath , nausea, general malaise) • Sudden decrease in exe rcise capacity • Sudden changes in overall condition or "sense ot well-being" (prodromal symptoms)

• RPE preferred for monitoring

Severe LV dysfunction and CHF

• Significant weight gain (> 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
Nutrition 1),lIIe nl ':) tI~ujjl

co ml11 onl ) meet with a nutriti o n l!') t \0

di ~ (,tI !'Is

their

d, clary hJb ih and 10 mak e recommc nd~lt ion s wht"n

Chapter 16 Heart Disease reported two studies in 200J in w hic h R9 me n we re followed preope rati vely a nd lip to 2 years fo ll owi ng !o. urgery.! 'l.I ': They fo und that pre ~ urg ical dep ression was an independe nt predi cto r of postope rati ve pro longed surg ica l pain and fai lure 10 retum to prev io us ac tiv ity. In the stud y by Blumenthal c t Jl , 8 17 pati e nt s werc st u di ~ d preope rative ly. up 10 a mCJn of 5.2 years posto perat ive ly. They reported that the patients with moderatc 10 severe depre ss ion at basel ine (preopera ti ve ly) that persisted postope ratively had 3n inc re ased dea th rate compared 10 the nond epressed. lJ .\ Ai et al re ported that th e presence of preoperative CO-Illorb iditie s !o. lrollgly intluenced whethe r depressio n existcd. l:4 Mc Khann e t a1. in th e ir st ud y of 124 pati e nt s. concluded that th e maj o rit y of pat ie nt s depressed after surgery were in faci depressed prior 10 surgery.U.'i Pirrag lia e t al reported on 237 patients and noted that 43 percelll we re classified as depressed preoperJ.t ive ly and onl y 23 percent poswper:ltively. Fac tors that infl ue nced post s urg ical scores were length of ICU stay and the amoun t of reported soc ial s upport.I ~(' Th e dec rease in postoperative depress ion compared to preope ratively was supported by Lindqui st et al in 2003 : they stu died more than 650 men and women and found less anxiety and depress ion following surgery than preoperative ly. u7 Of in tere st. they a lso no ted that wome n's repon of QOL was lower th an men 's up to one year follow ing surge ry. Wes tin et al a lso re ported a gender difference in CABG outcomes in regard to depress ion and QOL measure s. In their study of m ore than 300 pati e l1l s. women scored lower on the QOL and higher on de press io n scale than men at I month and I year fo ll owing CA BG . compared 10 men. 131\ Phillips et al repo rted women to be at grealer ri!o.k for both cog nitive difficulties and anxiety tha n men 31 I-year postop CABO than me n. !]11 The physical therapi st needs 10 be aware that depre ss ion may exist fo llowing ~ urgery and. as a mem ber of the hea lth care team. assist in d irec ting appropriate care an d support for th e palient.

H e art Failure E ducation As \J>ted in Box 16.4 , the US Depan ll1ent of Health & Human Serv ice.., Clini cal Practice Gu ideline ~ for Pati e nt s wnh CHFI-UJ ~uggests addi tional topics for pat ient and fam il y educallon fo r patient!o. with LV dysfun ction.

Primary Prevention of Coronary Arttery Disease :dtien:s who ~o not have docum e nttd CA D hut who hH ve J~e lllJfl dble n~ k i(J.cto r::. !o.hou ld be encouraged [u adopt hfc::.tyle beha\ lor::. lhat cHn llIodify tltel r ri !'. h. fa c tOl'\. Healt h edu c ati o n and pflmary preve ntIOn pi og ralll ~ throug h tn div lduali/,ed educ;lLJon and ex.erc ise gUIdeline, atlempl It) nlodll y an indl vidu:.tl "" ri .. 1-. tll tor:-, and (he r\? by preve nt CA D.

635

Box 16.4 Suggested Topics for Patient, Family, and C a re giver Education and Counseling General counseling Ex planation of heart fa ilure and the reason for symptoms Cause or probable cause of heart failure Expected symptoms Symptoms of worsening heart failure What to do if sy mptoms worsen Se lf-mon itoring with dail y we ights Ex pl anation of treatment/care plan Clarifi cati on of patienl 's responsibiliti es Importance of cessation of tobacco use Role of family members or other caregivers in the treatment/c are plan Availabili ty and val ue of qualified local support group importance of obtain ing vacc inations against influenza and pne um ococcal di sease

Prognosis Life expectancy Advance directi ves Ad vice for famil y members in the event of sudden death

Activity reconunendations Recreation, leisure. and work activity Exercise Sex, sexual difficulties. and coping strategies

Dietary recommendations Sodium restri cti on Avoidance of excessive flu id intake Fluid restriction (i f required) Alcohol restriction

Medications Effects of medications on quality of life and survival. Dos ing Likely side effects and what to do if they occur Coping mec hanisms fo r complicated medical regimens Availability of lower cost medicat ions or financial assistance

Inlportance of co mpliance with the treatment care plan From Clinic al Pra('lh.:e Gu ideline .. . Number (I. Helin Failure; Evalulti on and c.m: of Patlerll:-. Wuh L(' !I -Vt·ntn..;ular Sy stolic [) y~ fun(, llon , A II C PR Publicalr(.11l No. Q-l-(}(l\:! . P -1'1 . \\ IIh jX'llni:-.sion.

. Patient s an: instructed in ap propriate d ietary g uidelines IIldud!ng Itw. fat . :Idcquale fibt·r. mincr~l l s and \'i tamin~ and decreased ~a ll. particularly if (h(~ palil! nt has hjgh BP: Be::. idn 10\\ ering tolal dietary fa t, jllllie nts are in s lru~ted (0 uec rea~e I h~ ir pe rcentage of s~lIurat ed fat s anJ avoid tra ns fatt y aCId s, F lcva ted It vel:-; of rhe amillo ac id homoc ysteine ;~pl.':ar to In c rt!~I ..e the ri sk of artaial e ndo(helial disease. t:o lic acid . {t 13 Vllall1ltl . lowers humocys leint' le ve l::. . If V.t:I~ I~1 lo~ ~ is neede d , pdtic nts arc e ncouraged lO see s nUlnllonl..,t to de ~ Jgn a sc n., ible t."JIIlIg plan. Pa tients are

636

PhYliiical Rehabilitation

encouraged to gradua ll y increase their e ndurance activity. slich as walking toward a goa l of 30 to 40 minutes (not including wannup and cool*down) fOllr times a week. The American Coll ege of Sports Medicine and the American Heart Assoc iation recommend that anyone over the age of 40 wi th two or more ri sk fa ctors should have an Err before beginning an (terob ic or strengthen ing exercise program . The purpose of the En is to ident ify the presence of any I~ltelll isc hemi a. If no ischemia is present. a typica l aerobic exercise presc ripti on might be: Int ensity: 70 to 85 perce nl of HRma.o; as the aerobic tra in* ing lOne DUriltion: 30 to 40 mi nutes in the aerob ic training zone: appropriate wannup of 5 to 10 minUie s. and coo l*down Frequency: three to four times pe r week. ~'laximum HR may be estim ated by subtracti ng the pe rson 's age from 220: this. howeve r. is not an exact sc ience for any indi\'idual and cannot be accurate if the person is on any card iac medications. such as beta-blockers, that may decrease the max imu m HR . S upplement al res istance \\ork is also encouraged at modera te il1len sitie s. wit h in itialmonitoring of HR and SP. Modification of the Dlher CAD risk factors is a lso key to the success of any primary prevention intervention. Patients are encouraged to idemify risk factors and to seek re sources to ass ist in modifying them . The re are Illany community-based smoking cessati on programs or med* ically supervised programs that a patient might explore. Stress management programs are also vaned and can be adapted 10 the individual's needs. Proper and consiste m use of any medication s that might be used in con trolling risk factors. such as anti hypertens ives, antihypercholesterolemias. blood glucose lo\\cring agents (hypog lyce mics). and anti*anxiety or antidepressants. is cruc ial to the success of an) program. Hyperten sion. as the mo~t prevalent cardiovascula r disease in the United State!!>, is o ne of the IllOSI powerful contributors 10 cardiova~cu l ar morbidity and mortality:' The JOll1t National Comminee on Detec tion , Evaluat ion and Tre
Summary Physical activity is imponant. fo~ ~J individuals and is ezpe.. cia ll y bene fi cial for those indIViduals already di.gDOsed wi th CAD.7 1.11 are at ri sk for the development of CAD,I42C. who are d iagnosed with CHF.'" lndividuals with hean tisease should understand that a consistent exercise program is part o~ the m~na~emenHt fo~ thehir dised~se and is as t'¥'t csa) as the ir medlcallons. av mg eart lsease means that the person needs to understand the parameters in whicb he or she may safe ly parti cipate in activity either recreationally (I' as a prescribed exe rc ise. The role of the physical therapUr is to provide a safe exerc ise prescription for all patienlS. During the time o f illness. the e ffects of decreased activo ity can be devastating (Box 16.5). A parddox exists, how. ever, in that the less activity that is done . the less activity an be done as a resu lt of a decreased work capacity. Therefore. the relative e nergy cost of all activity increases, and the bean actua ll y works harder for any g iven task. Not encouraging the patient to resume act ivity whe n he or she is medically stable is a disservice. As physical therapists. our role is

clear: to understand the pathophysiology of the dise&!< process, to accurately examine the patient. and to establish I safe plan of care. The ultimate goal is to improve die palient"s physio logical response to activity and, in doing so. decrease the work of the cardiovascular system.

Box 16.5

Deconditioning Effects of Prolonged Bedrest

A decrease in physlcaJ work capacity An increase in the heart rale response to effort A dec.rease in adaptabi lity to change in poshU'C...... " manifested prim:lliJy as onhostalic by". 38 A decrease in the circulalion blood volume (widt.-volume de-creasing to a greater e"tenf IbM red ~ m a~ ), )

A d~crc~e

III lung volume and vilal capecily A d('creasc in liif'rum protein concenh'ation A negali\c nilrogen and caJcium baJance A deCfe;lSe in the conl ractile stren,gth of the ..,.

mu ~c ul a lure

Fwm \\ en!!i."r.. ~ . Cor(lIl.ll'\ Can': Reh:d'l.tilatioll .diu II.I)ocJrdi.. llni ..m:tt\U\ meric..m HeM A>~iauou. New Ycd:. 1f.)7 .~. "Hil ~mu~"'Ll.m

636

Physical Re ha bilitatio n

encour'Jged 10 gradually inc rease Ihe ir endurance activi ty. such as waJking IOward a goa l of 30 to 40 minu les (not induding wannup and cool-down) four ti mes a week . The American Co llege of Sport:; Medic ine and the American Hean A ssociation recommend thai anyone over the age of 40 with two or more risk factors should have an ETT before beg inning an aerobic o r strengthening e xerci se progra m. The purpose o f the ElT is to identify the prese nce o f an y lalent isc hemia. If no isc hemia is pre se nt. a typi cal aerobi c exercise prescription mighl be: • Intens ity: 70 to 85 percent of HRnld" as the aerobic trai ning lone Duration: 30 to 40 minutes in the ae rob ic trai n ing lone; a ppropri~He wamlUp of 5 to 10 minute s. and cool-down Frequency: three 10 four ti mes pe r week. Max imum HR may be estimated by subrracting the person 's age from 220: thi s, however. is no t an exact science for any indi vidual and cannOI be acc urate if lhe person is o n any cardiac medications. s uch as beta-b lockers. that may decrease the maximum HR . Supplemental res istance work is al so e ncouraged at moderate inten silies, with in iti al mon itori ng of HR and SP. Modification of the o ther CAD ri sk factors is also key to the success of any primary prevent ion intervention. Patients are e ncouraged to identify ri sk fa ctors and to seek resources to assist in modifyi ng them. There are many com munity-based smoking cessarion programs or medically superv ised program s that :.l pat ient might ex p lo re . Stress management programs are also varied and can be adapted to the individua l's needs. Proper and consislent use of any medication s thai might be used in contro ll ing risk factors. such as antihypertens ives, antihypercholeslerolemia"i. blood glucose lowering agents (hypoglycemics). and anti -anx iety or antidepressants. is crucia l 10 the success of any program. Hyperte nsion. as the mOst prevalent ca rdiovascu lar disease in the Uniled State ~. is one of the mos t powerful contribulors to cardiovascu lar mo rbidit y and mortality." The Joint Nalio nal Commillee 011 Detection . Eva luat io n and Treatment of High Blood Pre~stJ re recommends a multifa clorial approach and ~ uggCS ( S Iha tl ife::.ry le modiiicmion"i including "eight reducliull. pby ~jcal activity and moderalion of diela l) ...odlUm are recommended :t~ ei ther dcfini Iivl.! or adj unctive Ihe rapy for h yperten~ion . 141

Summary Phys ical activity is important. fa: ~II ind ividuals and is ~ ciail y benefi cial for those indiV id uals already diagDo!ed wit h CAD.11.72 are at ri sk for the develo pment ofCAD.I.2 CW 4 who are diagnosed w ith CHF.1 3 lndi viduals with heart disease should understand that a cons iste nt exercise progr.n i& pan of the m~na~ement fo~ thei r di se~ and is as necessary as their med ical Ions. Hav lIlg heart disease means thallbe perso n needs to understand the parameters in which be.
Box 16.5 Deconditioning Effects of Prolonged Bedrest A decrease in physical work capacity An increase in the hean rate response to etlan A decrease in adaptability to change in posbife. wIIidI iI mani fes ted primari ly as orthostatic h)JXACi" A decrease in the circulati on blood volwnc (wid!:,--. volume decreasing to a gre3ter extenl than dd Gl ma.ss) A decrease in lung volume and vital cap«ity A deere,be in serum prolein concenualion A ne£ativc nitrogen and calcium baJ:m.--c A decrease jn the Cootl"
From \\I:uger. N Corollal) Care-: Rehabililatioo amr

r.ly{)(·ard lat loran·lion. American Heart Association. Nl"w Yori. I"JB, \O,uh pernHs....OIl.

Chapter 16 Heart Disease

Questions

for

Review

1. DisclI;;s tht' role of the endothelium in alhe-rosc le rosi ~. 2. Describe the evolutio nary procc~ s of an M I. addressing plaque fonn::Hion. plaque rupture. throl11bu~ fo rmali0n. and the role o f TPA . 3. Compare pertinent finding!!. in the medica l record: ECG , ph)' ~ical examination. heart sounds, lung 501lnd~ . peripheral pulses, blood work. presentin g clinical !'ympIOI11S, and so f0l1h, between ischemia. infarction, and CHF. 4. Di sc u s~ the ph y~jc 31 therapy management if a patient has angina during a treatment sess ion . 5 . Desig n :J HEP for a patient who ha ~ a positive ETf. 6. Di sc u s~ the compen~ator)' lll C'chanisms associated with LV fa ilure

7.

DJ ~c u ~~

637

the difference bet\\ ce n compensated and

8. Des ig n a HEP for a palie nl wilh Class II C HF. 9. Identify the various potential p re~e ntalion s of angina.

Discuss how you would in ~ truct your patient in sy mptom recognitio n. 10. What is the usual clinical course fo llowing a ooncomplicated MJ? What i ~ a co mplicated MI? 11. Di!!.cuss the HEP for a patient being disc harged from Ihc hospilal 5 da ys post CABG .

12. Idcnlify and di scuss Ihe components o f CO. fa) How docs a patient respond to an increase in \fO ,? (b) Wh at sy mptoms/signs may you r patient prese nt .:vhen there is a decrease in CO? 13. Discuss factors reg ulating BP. Di ~c u "c; what acti ons you may take and why if yo ur pat ien t becomes hypotensive.

noncompc nsa led CHF.

C a se

S tudy

A 5 -)ear-old man present s to the local emergency room ""h chie f complainl of SOB and difficull)' s leeping laS( night: patient had to sit up all night to make sym ptoms e\ en a little be ll e r. Pati e n t came to ER because he was unable to gel ready for work owing to inc reased SOB. Patient repons that he ha s felt SOB o ff and on for a cou-

Lung sounds: Crack les 1/3 way Rhylh m/ra le : Irreg ular. 140 bpm Blood pressure: 100/60 mOl Hg Re spiratory rat e: 26 breath s/minute Sao,: 90%

ple of month!'.. usually assochtted with physical activi ty; symptoms, howeve r. u ~ua lJ y resolved with rest. Today's epi'iode wa~ the fir~t rel<.lted to sleeping: .

JVD: 5 em Echocardiogram: Akineti c apex. aklll t.·tk d l::-.tal -;eptulll and ant eri o r wa ll : d ilated atria and LV. Che ... , X-ray : Unavai labl e.

PAST MEDICAL HISTORY

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GUIDING QUESTIONS J. What is a reas?nab le p:esenting diagnos i~? Identify

PHYSICAL THERAPY INTERVENTION Exe rc ise tolerance via low level exerc ises sitting and standing, as well as 5-minute walk.

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Silli,," (reSl): HR 90 bpm: BP 110/60 mOl Hg Silting t!xerci ses: HR 108 bpm : BP 110/60 mOl Hg Standin g (rcst): HR 110 bpm: BP 108/60 mm Hg Standi ng exercise: HR 11 6 bpm: BP 110/60 O1m Hg 5 ~mi"ute walk: 1000 ft: HR 120 bpm: BP 116/60 mOl Hg

HOME INSTRUCTIONS Meetings planned with patient and hi s fam ily to d iscuss discharge guidelines over the next 4 10 8 weeks.

FOLWW-UP Palient returns to hi s pcp 3 months after di scharge. Echocardiogram is unchanged with EF 30%, Patient Slales that he has been following d ischarge guidelines.

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eac h piece of mfo rmatJ0hn (da ~d ho~' you Interpreled it) that you used to make I IS lagnos ls. 2 Exp la in the patho phys io logy o f the patient 's present' . sy mptoms. Di sc uss the significance o f hi li HR and 109 rhythm in re latio n to hi s s ymptoms 3. If the patie nt 's sy mptom ~ and signs worsened. and he was admitted to the CCU. a. What do you think h is Swan-Ganz reading could reasonabl y look like? b. What would you expect these signs/ symptoms would be that would bring the patient to the ceU? c. What mi ght be a reasonab le cause o f his signs/symp(Oms worsening? d , Wh at o the r drugs/ interve nti o ns migh t be given in the CCU ? 4. Whitt rhythm do you th ink the patient is in and why? What do you think might be a re ason Ih al he is in thh rhythm ? 5. What do you think the CxR would look like and ~bl' 6. What is your interpretation of the pat ient 's vital sign response to PT interventi on? W hat is you r plan for your ne "l( ( sess io n':' 7. \Vhat exercise prescription ~ o uld you recommend for the patient at home (modality. inten sit y. du rat ion. frequenc y)?

References I. Adanu.. PF. and Mar,mo. MA : Curren! estimate, from the t\. allonal Health SUf"\ C'). United SUle!> 199..l. 'v"ital and Hc:thh Slau.)ollcs. Vol. DHHS puh no (PH S) 96- 152 I . US Gl,\emmCm Pnnllng OlTtce, Washmglon . DC. 1995. 1. World Health Org anJl3110 n (WHO ): I\I O f\,""I CA ~la ntlU I rt': \I.~d ed lllon, Cilfdlo\a!oCul3f DI....ebes Unit. WHO MO l\ICA PrOjrtl Gent:\ s. S ~ltzerl and. 1Q90. 3 Amcnun Bean A'.)O("I:tUOfl IABA I Hl':l.n DJ ~a~ and ~tr(lk e SYII'.IICS :!OO5 Upd,lle AHA , Da llal. TX Rct ru:H!ll Dccem be.1 17. :!(X15 ' rum \.\ .... W alllcn n mht'ltn.llrg 4 TI\OfTl. TJ . c t al h"" ldeocc, prc\ alcncc and mun.a lll) 01 t .srd lO\ a,. cular d l ~a'>t In the Unlled Sla h."'\ In I ;u ~ter. V A lc\.tnJer RW. and O ROlIrle. R u:d..' I. lIur~(s The Ht!:t n . cd 10 ~tL Gr;t .... · I·h ll. ' e~ Yori.. :!I)) I. P 3. 5 U. Ocp.lIl ffit'nt o lllc:.Ihh and Human SCI"\ Kt). "nil: S<,vcnth R.:pon 01 the J(lm! " allonal COIIUll11IC\;, ()111~.:' ..: nllon . Deleliloo h aJU ..lluli. and 1 reatJllt!1I1 of H I~ h Blond Pr... ~ ... UlC" 1h(all(.Hl 2U·,.' ,,"0 ()t . ~ :! 1l () Anll'fl~ .. JI PhY' I~ .. 11))("l1I py AS'>CIl. laUOII G \l1de 10 Ph) ~I~ .. I n lcr"p' " Pract ICe t·d 1. Pby~ nle( IS I \ I ' ~ 7 1 lOOl 7 o\\t"\aJ\der KW; Cvr( 'fI " r~ j;';"h\'m u. b) nJl"lIlC~. Rd ..l lt \lhh tp til Ill<· hllllo~) "f .l,heft>~ler~l~ In 'k hlo.1ul RC ,, !( , .tll\k"r R\' ,Iod 1 '''I<""1 , . tcd~1 Il Ul't"~ !lIe" lIeM1 nt \) i\k Gra\.\ , U IIi

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C HAPTER

17 l EARNING

OBJECTIVES

I. Understand the an:uomy. physiology. and pathOphysiology of the vasc ular. lymphatic. and in tegumentary system s. 2. Describe wound physio logy as it relates to normal and abnormal wound hea ting. 3. Recogni ze the characteristics and ri sk factors of common di sorders of the vascular. lymphatic. and integume ntary !o.yslems. ... Identify the compone nts of a compre hens ive examination of a pat ient w ith a di sorder related to the vascular, lymphatic. and/or int egumentary

systems. 5. Anal yze and integrat e wound examinat ion data 10 compl ete the ph ysical the rapy e valuation.

6. Describe the rationale for skin and wound care treatment w ith partic ular attent ion to moi st wound healing. arteria l wound hydration. venous wound com pression. lym phedema treatment. pressure ulce r prevention. and foot care for the patie nt with diabetes. 7. Design an appro priate plan of care for an individual with a vascular. lymphatic. and/or integumentary di sorde r. 8. Collaborate with other disc iplines to determine a realistic and compre he nsive pl an of care.

Vascular, Lymphatic, and Integumentary Disorders Deborah Graffis Kelly,

PT. MSEd

OUT L INE AnJlomy :lIld Phy'IOlog) o f the Va..,c ular. Lymph'JlLc. and Integu me ntary S~'i t l' lm 6-L' Vascular 644 Lymphatic 644 Integumenlary 644

Arterial Insufficie ncy and Ulceration 65 1 Venous Insuffi ciency and Ulceralion 652 Lymphedema 653 Pressure Ulcers 655 Neuropathy 656

\Vound Ph ~ "Io log) 045 Normal Wound Healing 645 Abnomlal Wound Healing and the Chronic Wound 649

PatIent M ,l n ~ge m e nt 658 Examination 658 Evaluation. Diagnos is. Prognosis 664 Intervent ion 664

Va,(:u!ar. L) m phatlc ...II1d Integumentary

Summ;u) 6X6

Db-order, 6S I

atients and clients with disorders of the vascular. lymphatic . and integ um entary sys te ms have complex need!',. Intere:-.t in the function of these essential systems has grown as opti ons for improved inte rve nti o n have expa nded significantly. This chapter provides founda ti onal material on whi ch to bu il d sound cl in ical decisions. While interrelated. the system s d iscussed have unique charac teristic:-. and fun cti on ~. This chapter facililates understanding of the ~e pa rale !>y:-.l e l11~ and then illustrates how the system:-. are intric<.Ilely and essentially re lated. C hapter 27 in thi s tex t coven. bum wo und :-. and is comp leme ntary and suppl ement al 10 the information in thi s chapler.

P

Anatomy a nd Physiology of the Vascular, Lymphatic, and Integumentary Syste m s In th t: ITIlCro'l:OP tC \\o rld 0 1 c irc ulal ion . blood
and nutrients while remov ing carbo n d iox ide and wastes. No t all vesse ls invo lved are th e " large tubes" so often assoc iated with the circ ulato ry system . Capi ll aries are wove n througho ut most of the ti ss ues of (he body, around muscle fi bers. through connective tissues. and be low the baseme nt me m brane of th e ep ithe li um . I A rt eries a nd vei ns are too large an d too th ick to all ow diffusion be tween the bloods tream and surrounding (issues. Thus. a delicate netwo rk of blood and lymph capillaries controls a ll chemical and gaseous exch<.lnge between blood. interstit ial fl ui d. and lymph. ' In Ihe normal sys tem, homeostatic mec hani sms adju st blood flow across th e cap il la ry wall s (0 meet the needs of periphera l ti ss ues. Every year. new information is uncovered that further e lucidates the ('omplex it ies of the circulatory sys tem and how if interacts wi th the other sys tems of the body. It is important to have a c lear und e rstanding o f the de licate vesse ls thaI ca rry blood to th e pe riphe ral ti ss ue s and the normal prm.·t!sses that occ ur there to ga in insighl into the disorders di scussed hiler in the chapler.

644

Ph, .. ical Rehabililalion

Vascular Arterial Arteries c:ITT)' ri ch. OX) genaled blood away from the heart. branchin g ofT into secti ons with smaller diameter.. called ~'rlerioles . lead ing ultimately 10 capill ari e~ . Arteric .. ha ve thrcc· layc rcd walls that give them :-tre ngth and cla'l ti cit y. The wa ll ., of arl eri cs are ge nera ll y thi cke r th an tho~e of ve in:- because they have to bear strong blood now prc~wre~ ge nerated by the heart . Arteri es arc slrong and durabl e. abl e 10 keep their cylindrical .. h3pc when stretched. The move· menl of blood through 3r1cri es is dependent on heart func· ti on. Art eries have the 3bility to change in diameter when the vo lume of blood passing through them changes. They ca n abo change in di ameler when the sympatheti c division of the autonomi c nervous system (ANS) is triggered. either contrac tin c (I'llsvrol/srrictioll). or relaxi ng (I'll.wdilatioll ). Bec:1Use they have contractil e abilities. arteries do not need va lve!) to effect blood now. These tenns will be im portant when the chapter di sc ussion turns to peripheral vascul ar di sease and ('apillary blood now.

Venous Ve ins return oxygen depleted blood from tissues and organs to the hean. At the begi nning of the venous !)ystem. superfi· cial blood capillaries empty into l'eflu les that carry blood toward medium·sized ve ins (about the size of mu sc ular aneries). Superficial veins run above the fascia of the mus· cles. Dee p ve ins run below the fascia. Perforating veins run betwee n the supe rlicial and the deep, penetrating the fascia to connect the superficiaJ and deep vesse ls. Veins also have three·layered walls but they do not need to be as musc ul ar or elaslic as arteries because the blood pressure in ve ins is lower than in arteries. Venous walls are so thin that they do nOl hold thei r shape weU under stress. collapsing or tearing when stretched. As blood moves throug h the out enn ost regions of the body (the peripheral vascular system) from the meries to the ve ins, blood pressu res decrease. 1l1e blood pressure in the med ium· sized ve ins is w low that it cannot oppose the force of gravi ty without structural assistance. J In the limbs, med ium·o;; ized ve ins contain wAvl's that projec t from the inner walls of the veins, pointing in the directi on of blood flow. Under norJllal cond itions. the val ves allow blood to Ilow in one direc ti on , preve nting bac kfl ow of bl ood. When the valves are working nonnall y, any movement th ai compresses or pulls on a ve in will push blood toward the heaJ1 . Skeletal musde contraction wi ll squeeze blood toward the hean. \Vhen the wa lls of ve ins weaken. or are enlarged, the valves cannot functio n prope rl y and blood poob in the \' ein\. E\emually the ve i n ~ beco me di\lended, leading ( 0 wnC{Jse r el1ls. Jf a val\ e or val ves do nOI clo ~c prope rl ). thiS lead ~ to a condition known il.') "('nullS reflll.\.

Lymphatic Although purallel , and lAorJ.. ing III concer! v..lth Ihe venou \ ~y\ l e m . the Iy mphatu.: '\) ~ ltll1 i ~ s epMal ~ and uniqu e.

Becau se of its many roles and diffuse locations throughout the body. anatom bt~ place di scU!~!) i on of the lymphatic sys. tem with the immune system. the circulutory system. and the integumenta ry sy!)tem. The two primary functions of the lymphati c :-.ystcm are to protect the body from infection and disease via the immune response and to facilitate movement of Ouid bac k and forth betwee n the bloodstream and the inter!>.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
C hap' l"r l7 Vascular. l r mphatic. a nd Inlegumenlar)' Disorders SplCnl

is depende nt on the nonnal fun lions of the arterial.

\'cnou!'> . 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 !:lsip<.lI ion. Melanocyte .., detcml ine skin color and prov ide protecti on from ul trav iolet radiation. The e pidenni s re ge nc r~H e" rap idl y. The dermis i!:l 20 to 30 times thicker than epidenlli s. II contains blood vessels and Iymph.:lf ic!:I: hair foll icles: ~we at glands, and se baceous glands: nc r. C~ and nerve endings; and co ll age n. elastin, and ground suh!:llJllce th at prov ide structu re. stre ngth . fl ex ibil ity. and el ~ II C II) . The nai l, are located in demlis but project through the epldenni s to the su rface of the skin. The hypodermis (also re ferred 10 ~ lhe subcutaneous layer) is nOt part of the integ.ument bu t i . . impol1ant in sta bil izing skin over skeletal muscles and orga n:-.. It consi.s ts of loose connecti ve tissue and fal cell s and prov ides insulation and protecti on to underlying MntCtureS. CLINICAL NO TE. Subcutaneous fat and faSCia (firm and adherent) should not be confused with yellow slough (soft and stnngy) In a deep wound.

As a re ~ ult of inju ry. some or all o f the components of the int eg um ent are impa ired. re sultin g in sequ elae such as edema. decreased lubricatio n, and loss of elastici ty and tensile strength.

Wound Physiology Normal Wound Healing In the hum an body. a n e legant seque nce of eve nts takes place to ensure that when injury occurs , wounds will heal. Withi n Ihe endogeno us flu ids of the body, every cell and chemical mediator is programmed and ready to act when needed. When cond it ions are nonnal, the body is eq uipped to heal i ~lf.

Phases of Hea ling !he d as'\ ic mode l of overl app in g phases of wound healI~g de . . cribes a procesli thaI is continuous. its phases nOI ~ISli nct. The model is used in thi s chapter to draw alle nlion to the nomlai process and to prov ide guide lines for ....·hat can be t: xpected in nomlal healing . The numbe r of day~ to complete each phase will vary owing 10 factors sut h as age. !:I ize of wo un d. comorbiditi es, continued ~ ra u ma . nutriti o n. blood fl ow. med icat io ns, stress. a nd mfectl on The proce~5I of repair i ~ Ihe ~ame for all wound ~ but the se4uence will be much qui cke r in more shall ow .... Ound S \.\ "111I Ies . . 1I.~~ u e loss. In all ~ tages o f hea ling,

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wounded Lissues arc :-. trivi ng to ac hieve ho meostas is. hali ciled wo rd_", be low stress im portunt concepts. • /Ilj7l1mmariOIl (Phase I) The lIormal immune system rC:lcti on to injury The ccn lr:l l acti vi ty in wound hea ling Tc m po rary rc pair in itia ted by coagulati o n (d Olling factors. plate lets) a nd shOrT ferm dt'creased bl ood fl ow Nec rosis occ ur:-. afte r ce ll s ha ve be e n injured o r de ~ l royed .

The spread of path oge n ~ is slowed : de bris and bac te ri a are attac ked by :t host of cell s. If the wound is acute. ~ o m e peri wound ede ma. erythema. and drain age can be cxpected. Q If fluid acc umul ates at the inj ury site it is called pus. O xyge n is de live red v ia i"creased bl ood flow to keep the phagocyti c ce ll s ali ve and fun cti oning. Pe nn ane nl re pai r is facilitated by creating a c lean wound . setting the stage for the nex t phase of healing: s ignals are gene rated that re-epithelialization can begin. Time fra me: day of injury to approx imatel y day 10. RlIfe of inn a mmatory process is affected by bl ood suppl y. ava il abl e nut rie nts, and th e ex trin s ic e nvironm e nt. o If thi s ph ase is inte rrupted or delayed, chronic i"flammatioll call result. lasting from months to years (see Abnomla l Wound Healing and the Chronic Wound) • ProlijerOlioll (Ph ase n ) o N eil' risSlt e fill s in the wo und as fibroblasts sec ret e co ll agen. o Skin int egrity is restored by re-e pithelialization and/or contraction (see d isc ussion below). o A ngioge nesis occ urs: new blood vessel growlh fro m e ndothelial ce ll s, fragile capillary buds grow into the wo und bed ; new reddi sh , slig htl y bumpy ti ss ue is ca ll ed granul ation ti ss ue. o Epitheli al ce ll s differentiate into type I collage n. Collag(' 11 synthesis OCCurs but the resulting new scar tiss u.e is frag il e a nd mus t be protected ; traum a during thi S phase may re turn the wound to the infl amma to ry process. , Time frame: day 3 of inj ury to approxim ately day 20. Rate of pro li fe rat io n is affec ted by bl ood s upply, av::u lable nU Lrie nts. a nd the extrin sic e nvironme nt. o If thi s ph ase is inte rrupted or de layed, the result may be a chronic wound .

• Mmuratiolllremotieling (Ph ase III) M a~ uration ~gin s whi le granul at ion tiss ue is fo nning dunng the pn or (pro liferat ive) phase . Epi the lial ce ll s con tin ue to d iffe re miate int o type I co ll agen. New ski n has Tensi le .Hre"~l:rJ, th at is 15 pe rce nt of no rma l. Scar t i~~ ue i:-. re buil di ng bu t at best reaches 80 pe rce nt of original tensile stre ngth . Unde rly ing granul ation tissue is repl aced by less \'osclllm· ti ss ue.

c 646 o

Physical Rehabililalion In dee p wo urHJ ~. dermal ap pe ndage .. arc ra re ly repai red (hair folli cle,',. sc b~l cco u ~ and swe at g land s. nerves) but instead a rc replaced by jihrolls ri.lsUl' . Over time Ihe !\car li :-.\ue malure". changing fro m red 10 pin~ to white and fro m rai "ed and ri g id 10 flat and Il cxib lc. Tim e fram e: approx imatel y day 9 o r injury up to :1 year!\. I?are i~ affected by blood supp ly. avai lab le nutrieJ1l ::.. and the ex trinsic e nvironment.

The Role of Oxygen in Wound Healing O xyge n reHc h e~ Ihe wound bed th rough blood fl ow to the a rea. The need for oxyge n to sustain life is ap pare nt. not onl y at the -.yslcmi c level. but also al the cellu lar level of human phys io logy. Most ce ll s in Ihe wound e nviron me nl IHiVe a n enzy me that conve rl s oxyge n to a form that all ows Ih e ce ll to support wound hea lin g. IV Wound co n· Iracti on. coll agen deposition. angiogenes is. and granula· lio n are eX i.lmpl es of wou nd heali ng ste ps supported by oxygen. Oxyge n eve n has an a ntibi o ti c e ffec t allowing tissues to res ist pa thogen s.' I Wound ti ss ue oxygenation is a se ns iti ve indi cator for th e ri sk of postope rative infec· tion. l:!.I~ Wound pe rfu sion may be lim ited for a vari ety of rea so n ~. The prese nce of ede ma and necrotic ti ss ue makes il more diffi c ult for oxyge n to reac h the wo und . Since co mpress io n can reduce edema a nd de brid eme nt ca n reduce th e pre~e n ce of necroti c ti ss ue, these procedural in terve nti ons are impo rtant com po ne nt s of mo st wo und care. Un less contrai ndicated owing to arterial di sease. compressio n a nd debridemen t will dec rease the obstructi o n 10 woun d oxyge nation . Pe ripheral vasocon· st riction ca n also limit wound pe rfu sion. Problems with vasocons tri ctio n ca nnot al ways be improved readil y. Interventions that wi ll ilH.:rea!-.e wou nd pe rfus ion a nd are appropria te for all individ uab include keeping the wound area wa rm . avo idin g 5. lllokin g, hydrating the indiv idual. and con trollin g pain a nd a nxie ty. Seve ral clinical studie s ha ve -. hown that keeping pati ents warm and gi vin g th em suppleme ntal oxygen decrease::. the rate o r infect ion a nd shorte n5. hosp ita l !'. lay. lJ.I~ Improve me11l of oxyge n leveb in ,",ou nd t i~s u e alone may tri gge r wo und healing. Adequa te oxygen leve ls \~ ill abo e nh ance the e ffec ti ve· lle~'I of grow th fac t o r~ ~nd . o f the individua l a ~ di ~c u .,~e d be low, wi ll abo have an impact on ox)ge nation <., int:c hemoglobin. iron, vi tamin B 12. and foli c a Ci d are needed to e nah le red blood (:e lb 10 (:arry UX)f!t:J1to hc:a ling ti ~.., ut: !).

The Role of Moisture in Woun d H ealin g In th e ra ... !. (h e goal 0 1 wound <.:a rc wa.., to cre dt e al1d maintaIn ..I dry wo und . pi.ld. . ed with dry drc ~~ in g ... , dri ed hy ht;J t lal1lP ~. and expo ... ed tu tht: air. Mod ern \\Oll IH.l

mana ge men t is based o n the concept o f crea tin g and maintainin g a moi s t wound e nviro nm en t (0 facilitate wo und he:.l ling . More than 50 years :.Igo. research confirm ed that a dry wo und creates an environment that is h o~ ti lc to wound healing . A dry wound all ows the forma. ti on o f wou nd scab
Chapler 17 Vasc:ular, Lymphatic, and Inle gume ntory Disorders pati ent's sympto ms. c lin ic ians may be able to ut ili ze occl usive or mo istu re-retentive dress ings over many types of wounds th at are in fec ted. 2s Th e use of thi s dress ing technique may broade n if the ev ide nce cont inues to build in strength. Desp ite half a century of research to support the concepts of moist wou nd healing, there are still practitioners who ignore the ev idence and util ize outdated meth ods of wound management. C li nic ians mu st stri ve to ed uca te patient s. fami lies. and a ll me mbers of the woun d care team about appropriate wound care concepts.

The Role of Nutrition in Wound Healing It is well established that nutritional status can have a significant impact on wound healin g. Literature abo unds with infomlalion about import ant nutrit ional issues such as the ro le of specifi c nu tri ents in wound healin g, how poor nutri tional statu s can del ay wound healing, the use of special pharmaco logica l interve nt ions. and appro priate rou tes for nutritio nal s uppo rt (enteral versus parenieral).26-34 In response to this infonn ation. nutrition and metabolic sUpJX>11 of acute ly and chronica1l y ill patients is emerging as an important branch of medici ne. Nutri ents that mu st be present for a wound 10 heal incl ude iron, vitamin B I2 and folic acid (essential so that red blood cells can deHver oxygen to tissues), vitam in C and zi nc (essenti al for ti ss ue repair). vitam in A (essential to stimulate collagen cross-linking). and arginine (enh ances hea lin g and immune fun ction). 35.36 Hi gh prOiein intake prov ides the amino aci ds required to build new ti ssue. Protein and calorie needs will vary depending on me size of the wound and me medical condition of the patient. As a part of the wound care team, a physical therapist will make contributions to the plans fo r nutritional support of the patient. Clin icians will co llect data th rough chart rev iew. observa tion, hi story tak in g, and the use of dietary examination method s.J7

Wound Characteristics The charac teri sti cs of wounds may be de fined as dry. Wet. or granulatin g. Wounds can also be defined by thei r eti ology such as diabetic, vascu lar. or traumatic. Wound characteristi cs de~cribe the physica l appearance of th e wound but often prov ide the clues 10 the etiology, phase of healing. and like lihood of closu re. Wound characteristics can provide va luab le information needed to make Sound clinical judgment s about treatment. For examp le. the IOl'ation of the wound ma y prompt the clinicia n to se lect a partic ul ar dre ss ing. cha nge parie nt positioning, Or presc ribe orth otic footwe ar. Wh en wound characteri.!.tics are described in documentation . they can indicate ~rogre ss (or failure to progress ) toward closure and heal ing. Wound characteristics should be ide ntified during the initial examina tion and then monitored at least weekly during the wound bealing phase. Depending on

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the etio logy and chronicity of the wo und , some characteri sti cs may not be ev ident upon initial examination but co uld appear at a late r date as co mplication s of the wound hea lin g process. The fo ll owing are characteri stics th at sho uld be tracked and doc umented througho ut the phases of wound healing:

• Location: where on the body • Size: depth , width, and length • Shape: irregul ar versus di stinct • Edges: conditi on and shape of wound edges, ev idence of pre mature healing • TWlll eling. underm ining. sinus tracts: presence and depth • Base: characteristics of the wo und base compared to sides and edges o Necrosis, esc har, slough : am o unt , col or, tex ture, adherence to wound bed o Exudate: am ount, color, odor o G ranul ati o n ti ss ue: presence o r absen ce, am o unt . location o Epithe liali zati on: presence or absence , pre mature o r on schedul e o Exposed structures: color and condition of bone, tendon, li gament • Per;wOlmd area: edema. induration, maceration • Pain : although not a visible charac teristic. it is measurable and significant to the intervention Quamity of bacteria: amount present in a wound. This is referred to as the bio-burdell. The quantitative biopsy is the gold standard for obtaining a wound culture but it is not used universa11 y owing to cost, lack of lab facilities, and potential pain for the patienl. lo A swab culture is often used as an alternative but it is limited 10 detecting surface contamination. not tissue infection. Some lite rature supports swab culture , whe n used appropriately. as an adjunct in the management of chron ic wounds. 38 Clin ical intuition is also import ant in deternlining if infection is probable. The examinati on will include data abo ut the characteristi cs that have been gathered using meth ods s uch as observat io n. palpatio n. meas uremen t. pholOgraphy. and traci ng. A cl inician who is new to the wound care team shou ld remember th at these are ski lls that take practice.

Wound Closure Primary lntention Hea ling by primary in ten ti o n occ urs when a surgeon closes a wound by bringi ng the edges together. Approx imating the edges can occur through the use of sutures, staples, gl ue. ski n grafl's, or ski n flaps. (See skin grafting in Chapter 27.) Wounds closed by primary intention still pass throug h th e phases of wound hea li ng but o n a smal ler sca le. A wou nd closed by primary intenti on that lacer opens up agai n owi ng to macerati o n or infec ti on has opened by the process of dehiscellce (Fig. 17. I). Following

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Physical Rehabilitation

•

Figure 17.1 Wound dehi scence following appendectomy.

dehi scence. a wou nd is almos t 31ways all owed to close by secondary int enti o n. Se{'onda r y In ten tio n Heal ing by ~eco ndary intelllion occurs when a wound is lell to hea l on il~ O\l..'n. \Vo un d hea lin g by seco ndary illlention will close by contractio n. re-epitheliali zatio n, or ~t comb in:lIion of both. Deepe r \\ounds heal by replac ing lIlJurcd ti ssue with scar ti ssue as co ll agen fill s the wo und bed. Dunng the proce~, of contrac ti on, ex istin g ti ss ue rlll gra t ~'" pullrng the \,ound edges toward the ce nt er of the \\oUlld . No l1e" ti,~ue is fonned by th is process. New lI~ . . ue ma y be forming in the \\ oUll d s im ultaneo us ly but not \ IJ l'ontr~tction . GTO" th faclor~ trigger myotibroblas ts Il) pull th e "ounJ edge!o. ill\\ari..l . M )o fibro b la ~l s cu n be mtluel1l'ed pO!o. iu \e l) or negati\e'I} h} ph}~iol og ica l r
often intervene by applyi ng special types of preSSure to the ti ss ues to s low the deform ing fo rces o f contraction. (See the sec ti on on scar m anage me nt under Intervention.) As no ted in the phase s o f no rm a l wound healing, chemi ca l med iato rs se nd Sig nals fo r ree plthelialization to beg in in Phase I o r th e infl am matory phase. Actual repair beg ins in Phase II whe n ti ss ue is fo rmed to cover the wo un d. Grow th fac tors sti m ul ate speciali zed epithelial ce lls. keratinocytes, to begin to m igrate from the edges of the wo un d toward the ce nter. In part ial-thickness wounds in which the derm al appen dages have not been destroyed, the ce ll s w ill a lso m igrate fro m the hair fo ll icles, seba. ceo us g lands, and sweat g land s. In sm all er, more shallow wounds th is process may be triggered to beg in as early as 12 ho urs after wo un di ng. In large r wo unds. it may be 10 day s o r lo nger befo re th e cells beg in to mi grate. In a chroni c wound th ere are m any reasons why this process is no t triggered o r is interrupted. (See disc ussion under Abnonn al Wou nd Healing and the C hronic Wound .) Re. epi theli a lizati o n stops by contact inhibition. W hen epithe lial cells meet at the center of the wound, migrati on ends and ce lls will stop dividing. This is referred to as contact inhibition. At the time of contact inhibition and/or fu ll re-epithe lialization. wound closure has occurred, Wound healing. however. may continue for several years. A s ignificant amo unt of treatmem intervemi on is still required to s up port the wou nd s uccessfull y from "c1osed" to "healed" status. Fac tors affec tin g c los ure by secondary intention include:

• Wound shape: linear wo unds (s urgica l) contract most rapidly, c ircular wounds (pressure ulcers) contract most slow ly.J9 WOllnd depth: all things equ al , the more s hallow the wound , the qui cker the c1osure.W--I2 o SlIpetjiciai ( loss o f the epide rmi s): closes by reo epitheliali zi.\tio n. ParTial-thickness (loss of the epidermis and dermis): c loses primaril y by re-epithelialization with minimal comrac tion. .. FIIII·,hickness (loss of all layers o f the epidemti s, der· mi s. and deepe r structures) : closes by contraction and scar fo rmati o n: howl:\ er. epi the lial ce lls witl migrate from the wound edges 10 ass is t in wound closure if the environment is h omeos t ~ll i c. HC")ul1d location: areas wi th least pressure. most perfu· sion (face) \\ ill r1{)~e morc rap id l) than areas \\ ith most pres'Imc. lea::-' I perfu!o.ion (sacrum, heel). U'OIwd t'I;olo:~y : leas l trauma ti C' (s urge ry) will clost' more rap idl ) than mO!o. t traumatic (pressure ulce r, bum)· A!o. dec' pe r \\ o unJ s hea l. the wound is fi lled but the repa ir proces!o. dOt~!o. nOI replace los 1 mu scle. fat or dennis \\i lh tho!o.e !'!ame t~pe!o. of ti ss ue . T he wound is tilled with granub.llio n or ~car tis'> ue made lip primarily of collagen. BC\,.',Hhe Iht" ong ma l ti~s ue IS nOi repiacf"'d \\ ilh more of

Chapter 17 Vascular. Lymphatic. and Integumen tary Disorders the same. a wound that is closed , a nd finally healed, does not rerum to its prewounded stat e. This concept becomes parti cu larl y import ant when understa nding th e pos iti on on reverse staging of pressure ulcers as described in the section on Tests and Measureme nts. It is also important to unde rstand thi s conce pt when planning. protection. positioning, patie nt education , foot wear, and exerc ise programs for individua ls wi th all types of wound s whet her they are ac ut e . closed. healed. o r c hronic wounds.

Tertiary Intention Also ca lled delayed prill/at }·, this occurs when a wound is allowed to heal by secondary inte ntion and then is closed by primary intention as the final tTeatment. The delay in primary closure is usually owing to the presence of infection . or waiting for granulation tissue to form.

Abnonnal Wound Healing and the Chronic Wound When the sequence of even ts that leads to normal wound healing doe s not occ ur, a c hro ni c wo und res ult s. The characteri sti cs and causes of chronic wounds vary ow ing to th e di ve rse nature of the indiv idual s wi th wou nd s, their medical hi storie s. and the eti ology of the wound . Even if th e chro nic wo und moves through the class ic phases of wound healing. it does so in an abnoffila l manner. Vit al acti o ns and reaction s necessary for wo und healin g are inte rrupt ed . stunted. or abse nt in the chroni c wound. Wh ile the characteristics of abnormal wound healin g may be \aried. concepts can be used to illustrate the failure of a wound to pass through phases of wound hea ling in a timely manner. The following discu ss ion focuses on the results of IIlterruption to the classic phases of wound healing: • Infl amma tion: if th e re is inadeq uate blood flow and o x~ge n suppl y to ~ uppon ce llular life and activity. cell s may nol in itiate the repair sequence. Debris and bacteria bu ild up . pathoge ns spread more rapidly. Bio-burde n i')' mea!.ured ~ greater than 105 organ i sm~/g of tis~ ue, the clas~ i( defi OitlOn of infection. CIU1 i~al ~ign~ : increa!.e 111 amount o f drainage. Change In t olor or od or, linge rin g swe llin g. eSI.: har/necros is from the j,che mic condi ti on!'> , Jknwound mace ration . chroni<.,: mn..tllllnalio n. tunneling, und ennining. and mkcllon ma) de \e lop If (he ho,t's immune ~) ' te m i\ unable to re, l,t the impact of the buctcrial load . o P, olll erat lun ' If co ll age n ~) Ilth e ~b I,!, delaye d . , kin Integru y .... III be poo r If an.g i oge ne~ I ')' l !'l dclayed , lIl ~ofJbrobla\ t,), .... III be too Ie .... to mit la te ..... ound COlllr:.ll·lIon. The n« d tor ()X~gl'1I and nutncll b \\ ill be ver) hi gh .md YvliliOUI them _..1 \ J !I ..Ih l~ t elh .... ill he un ,lble 10 re produce rapldl) rc ... uitillt! III dda) ed ep ithelmhz.atll)J1.

649

Clinical signs: keratinocytes do not migrate because the wound bed is nol moist, healthy, clean, and granulating. Epithelial cells may attempt to migrate from the wound edges bul without a wound bed Ihal is ready, tbey wiU build up at the wound edge and may migrate over the edge. fonning a lip that curls under. Granulation tissue is either absent, pale, or delayed; new tissue is weak and breaks down or bleeds easily; tunneling. eschar, and peri wound maceration may be evident. Necrosis, if it has not been removed. will delay angiogenesis. Changes in drainage color, amount, odor. or lingering swelling, may signal a return to the innammation stage. • Remodeling: if the synthesis and lysis of coUagen is out o f balance, weake ned ti ssue will break down too easily or hypertrophic scarring will build up too rapidly. o C lini cal signs: newly form ed skin breaks down with little provocation, scar tissue builds up within the o utline of the original wound (hype rtrophic), or beyond the margins of the original wound (keloid) .

Infection in Wound Healing Wound infecti on is a significant problem for any individual. Bio- burden has a greater impact on wound healing th a n most unde rl ying medi ca l conditions. 9.43 Infec ti on may tum life-threate ning if the patient is elderly or critically ill. Regard less of the conditi o n of the individual. wo und in fection is detrimental to wo und clos ure and healing time. Effec ts of infection Inefficient ce llular activity. decreased col lagen metabolism. chemical mediators absent or dHute, cell s absent or confu sed by lack of instructions from chemical mediators and presence of other cell s. When the bioburden is greater than lOS organ isms/g of tissue. epithelialization may not occur.J8 Decreased oxygen in the wound bed, need to supply e noug h oxygen to support the regeneidtion of tissue and to assjst in the preven tion of infection Increased idte of cell necrosis () OveraJi decline of body systems contributes to strain on the specia lized ce lls Risk of wound sepsis. osteomyeli tis. gangrene Signs of pote nt ia l infection Change in wound dra inage: amount , color, odor Swelling Peri wo und redn~ss or warmth (less obviou~ with darke r &lin ) IIll'Tease in pain or tenderness Change In the ljuali ty of granulation [issue or failure to prod uce good qualllY tis~ue (may be pale, soft, ~IlS­ II ~ ltrolen do .... n ) No me
650

Physical Re habilitation

Clinicians shou ld use a structured approach to ide ntify clinical infection. Careful identifi cation of infection m ay help to avoid the ri sk of overuse of antibiotics. 44

Factors Contributing to Abnormal Wound Healing The factors or trigge rs that may contribute to abnonnal wound healing are varied but can be placed into broad categories for better understanding . Most abnormal wound hea lin g w ill be influenced by factors from all th e categories. Trea tment interve ntion that addresses factors from one category and not others will be incomplete.

Intrinsic Factors Intrins ic or internal factors are cond itions within the body th at may contribute to abnormal hea lin g. These factors re late primarily to th e wo und and peri wound areas , and include hypoxe mia owing to inadequate blood flow and oxyge n supply and aging skin. Decreased moisture conte nt. brinle quality. delayed re newal time affects the stratum corne um . Rete pegs. undulation s be tween con tact layers of the e pide nni s and denni s, become less functional with increased ri sk of sheering. C hanges in the dennis include a decrease in elasticity, collage n. and mast ce ll production , a long w ith a decrease in the vascu la rity and number of pain receptors. Available fal in lhe subc utaneo us layer begins to resorb after age 70, leading to a decrease in protec tion again st pressure and sheering . Finally. underlying disease will impact acute and chron ic wound hea lin g. The more common condition s known to impac t healing are diabetes. cancer. circ ulatory insufficie nc ies . human immunodeficiency virus infection, and connecti ve ti ssue di seases.

Extrinsic Factors E>. trinsic o r e nviron me nt al fae wrs are those influences that come fr om o ut s id e the bod y. Th e medi ca l profes :-.io nab ca ri ng fo r the pe rson \\ ith a wound ma y be able to moderate the impact of ex trin sic factors on the wo und em ironment. The~e mcl ude th e e ffech o f radiatio n the rap)- or chemot he ra p); Inco nt ine nce: med ic ati o n , smo kIng. reneallonal d rugs. and alco hol (all slo .... o r e limi nale cellu lar reac ti o ns needed for hea lin g); de hydrati o n and md.lnutriuon lboth \ 10 .... the de ll\ery o f oxyge n to .... ound li~~Ue\l : blo-burdenlinfettion (hea lin g IS s lowed h) pathogen." ne~rotlt tJ~~ue, granu l oma~); and f, tr e~1j tnegdll\e etiC'l'b of ~tre,,~ can lead 10 IInpalred hea llI1g J." .. ~ . ~I '

la lrogt=nk

Fa c tur~

J11ne~~ that oc(:u r~ d') the rc,uit of medll.4t1 care TheoreIlLall) . the...e Item .. are under the contwl uf the med lUtl rrok~\I0nab \\ ho (<.Ire lor the p31lent ,md are therdore . ~)fe\cnto.1ble Pour \\ounJ man agement (Ju:ur ... IAHh Irequent lh .. rupllon at v.ound through mappWpTld.IC' dCdfhmg. u-.e 01 lfldppropnatt." dre~:>lllg~ dJld de nl! It:l-hIllLjUe... Cj tOto\l\. tvplL'o.1l Jgem'\l that kJJ hJ

Itilrof!,t'll1l

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 rt: . de<.rea. . . l!'u tJua lll} o f lit t: perception.'), depre''!. lon in tt!l tion. ma ln ulfltlO Il and 'We ight l o,~, prolein dep le(Jon, 1I \..,ur: n b ru"'I~ . lu ..... ot 11 mb, and deal h. E,ery )ear O\a :) millIOn AmCfll"an, are tn:a led to r chronu.: v, ound .. at a l.:O\ 1 uf billIOn .. 01 uollo.1r ... , Itldklllg rhl li t)JX of \\Qund onG 01 Lht!' mo\ t (o\t l) lhal lt.:ngc:> 111 heahh CdlC." A l:hf()nl~ lAound 10.111.., to heal bc\.au~c of J.1l underi),'lO g Pdt ho l ~)~D ,.lOci \\-111 nUl ht ..t l un ll l the ca u!.e 1', corrected or IInpro\~d Ole dmH..l..tn IOU\( dett'rTIulle the t.sctor!l con· tnnutmg to dbOOmlJI \\ound hca lll1g and then dewlop an apprupn<.llt" plan vI t:dfe (IJ(X J tu O\'C l l'i)fn~ or addre, s the ob ... tJ.LIt: ...

650

Physical Rehabilitation

Cl inicians sho uld use a structured approach to identify clinical infection. Careful identification of infection may help 10 avoid the risk of ove ru se of antibiotics. 44

Factors Contributing to Abnonnal Wound Healing The factors or triggers that may contribut e to abnonnal wound heal ing are varied but can be placed into broad catego ri es for better understandin g. Most abnonnal wound healing will be influenced by factors from all the categories. Treatment intervention that addresses factors from one ca tegory and not others wi ll be incomplete.

Intrinsic Factors Intrinsic or intern al factors are conditions within the bod y that may con tribute to abnonnal healing. These factors relate primarily to the wound and peri wound areas. and include hypoxemia owing to inadequate blood flow and oxygen supply and aging skin. Decreased moi sture content, bri ttl e quality. delayed renewal time affects the stratum corneum. Rele pegs. undulations between contact layers of the epidennis and denni s, become less func ti onal wi th increased ri sk of shee rin g. Changes in the denni s include a decrease in elasticity. collagen. and mast cell production, along wi th a decrease in the vasc ularit y and num ber of pain rece ptors. Avail able fat in the subcutaneous laye r begins to re sorb after age 70. leading to a decrease in protec tion against press ure and shee rin g. Finall y. underlying di sease will impact acu te and chron ic wound healing. The more common conditions known to impact healing are diabetes. cancer. ci rculat ory insufficiencies. human immunodeficiency virus infection. and conn ecti ve ti ss ue di seases. Extrinsic Factors E>..t rin sic o r environmental factors are those influences that come from o ut side th e bod y. The med ical professional s caring for the per:-.on wi th a wou nd may be able to mode rate the impact of ext rinsic factors o n the wound environment. These in cl ude the effects of radiati o n therapy or chemotherapy: inconti nence; medicatio n. smokmg . recreational drug:-.. and al cohol (all slow or e liminate cell ular reaction ... needed for healing ): de hydration and malnutrition (both ~ low the de live ry of oxyge n to \.I,.ound li:-.">ues): bio-burden/infecti o n (heal ing is slowed b) palhoge n ~. necrotic ti ~~ue , granul o mas): and stress (neg atl lve effect:.. of stre:-.s c an lead to impaired heal. mg I ·nJ~ ~!I latrugenic faC:lOrs IcJfrugelll( reltr!)

10 any mjury or illne ... :-. th at occ ur ... ali the re ... ult of medical care . -nlr:ort'llcally. the~ items are under the t.:untrol 01 the mcthcal profe:-. ... lOnats INho care for Ihe p..tuenl and art' therefore, pre\entabte. Poor \\ound managemt'nt occur,,> \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:'lIJUfl I ~ \lglIJliLdntl} IOlAer than that for VellllU) dl~­ ea)e .1I1d ulcer<.llilln hO .... t:\t:'I. al"lenal wound ') mon: lit.: queml) ICJd III lu~"1 ul lunb <.Inti dC.IIl!.

Clinical Pre~e-ntalioll • MO\I flc4uenth ItK:Jlt.'d un tht.' LI::.':> : 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, f
Tests and Measurements One of the 1l10~ t important te~I S {(l lkrfom1 or ha\,t: pertonned for indivldua l ~ with ant!rial dj~euse i~ the AnkleBrac hial Index \A BI) . The Ali i I> a leSI designed 10 l'\al11lllt: the \,~hl' ular ~) \l tC' lll. Re~uhs proVide useful informa llon abou t Ih~ potential lo~s of ~11'u.\i on in th e LE. Rei er to Arlen..!1 PC'rfu"Iion in Ih~ :o.ection un Test..; and MCi:l..,urclllcllb under Pal lent Managelllt:'nt.

In len e ntion " ..Ill u\(- . :r;IIIUI\ I~ pre~cnl, tr~·.tlm c nt ~hould C'nhance . ,:hCIIH~.. 1I ;'Ino ga\L"ou"I hOIll('O~t:.ISI~ til the ~ound b~d. l'h.lllI;.lk' ", ur"k.~ rfi\.'ldl bkxk.1 nu\\ to larget 1I.\~ue~. and euu \,;,11 1.' ".lth." lIt !>. JboUI the Illlpon.tnt'c of fa~' illtJt,"g blood

652

Physical Rehabilitation

Figure 17.4 Venous insufficiency with leg ulcer.

Figure 17.3 Clin ical presentation of artenal insufficiency. fl ow to the ex tremities. Treatment will include appropriate wound care as well as important adjuncts to wound care (see Intervention under Patient Manageme nt). Result s of the ABl wi ll g uide the therapi st and refe rring practitioner in the appropriate use of compress ion . In a diagnosis of mi xed arterial and veno us disease the condition that is mo re severe sho uld be treated flrst If the arterial conditi on is wo rse. compression ma y be inap propri a te even when edema is present. A non hea ling wound o n an ischemic limb can lead to gangre ne . amputation. further amputatio n and/or loss of life (Fig. 17.3). In th e mo st severe cases. condition s are inhos pitabl e to wound closure . Necrotic tissue shou ld not be debrided. si nce the ti ssue will not be replaced. Skin grafts do not adhere 10 the virtually life less wound bed. Antibioti cs cannot reach the wound ~)~ lel11i ca lJy and topical age nt s are 100 superficial to stop infection. AI thi s point. vascular surgery may be an opuon fo r some individua ls. A bypass g raft is used to re;;tore arterial circ ulation to the ischemic ti ssue. For ot hen., living .... it h a chronic no nhea ling wound o r coming to tenn s with amputation are the o nl y opti ons. Most experts agree that the s ingle most important inte rve llli o n in peripheral va:,cular di:,ease i:, prevention of :,moking . The second mo:,t important interve ntion i:. e;'\e rc ise for we ight con trol. impro\ ement o f co llate ral c irc ulation and lipid profi les. and managemelll o f hyperten sion . A phy sica l t herapi~ t pla y:, a c ru c ial ro le in wou nd ca re for arterial .... ounds and should address patient education and exerci:,e 10 the lnten e nll on plan .

Venous Insufficiency and Ulceration Venou:, IIl 'l ufficien c) refers 10 In~td e qua l e dra ln agl! o t' venou:, blood from a bod) p~lfI , u:,ually H!:' UltlOg In ede ma

and/or skin ab norma lities and ulcerations. Chronic venous insufficiency (C VI) refers to venous insufficiency that persists over a long period of time. The majority of individual s with periphera l vascu lar disease are diagnosed with CVI. CVI is the most common cause of leg ulcers. 34 In current literature. venous insufficiency is synonymous with ve nou s hy perten sion. defining the beginning of a cha in of pathophy siological events that often end in ulceration . Some authors still use the tenn \'enOllS stasis ulcer a lthoug h it has been shown that blood stasis (blood pool· ing) is 110 t the cause of these wounds. 55 While it is clear that ulcerations are the result of inadequate venous circulation, the mechani sm by which thi s happens is not clear. Attention is currently foc used on the contribution to skin breakdow n made by dysfunction of circu lating white blood ce ll s (WBes ). endothe li al cell dysfunction , fibrin deposit ion, edema, and lymphatic congestion. 56.57 Th e in c idence o f ve nou s ul ceration is much higher than that of arte rial ulce ra tion ( Fi g. 17.4). In fact. 80 perce nt of all leg ulcers are caused by ve nous disease53 The hi ghe r in cide nce is not c learly unde rstood even th o ug h years of c lini ca l and laboratory research have been d evoted to understanding venous disease. The path from CV I to ulceration can take many turns. Aging. lack of exercise. obesity. pregnancy. long ho urs of standing or s itting. a nd hered it y wi ll predispose an individual to venous hy pert ension and subseq uen t CV l. Predictors for ulceration includ e the facto rs just li sted as well as: hi story of deep vein thro mbosis (DVT ). num be r of pregnanc ies for women. fami ly his tory of ulcerati o n. and history of vigo ro u ~ activit) in th e presence of other risk fac to rs. \:1

Clinical Pre!itentation • S\\elltng of unilatera l or bilate ral LEs relieved in the ea rl y :,(ages b) e le\ a(ion • Complainb of il c hing , fatigue, achi ng . heavines s in il1\ o h ed hmb(!) S\"in ciMnges including he mosiderin staining and lipodennato~clero!. i:,

Chapter 17 Vascular, Lymphatic. and Integumentary Disorders • FibJVsis o f the demli s • Increase in skin te mperature of lower legs

• Wounds o Most frequ entl y loca te d o n th e LEs: prox imal to medi al mall eolu s altho ugh can occ ur anywhere (arterial wound s Illay al so occur at thi s locatio n) Not significantl y pain ful : usuall y complaint s o f minor du \J1eg pai n are re li eved with e levatio n. o Gra nulat io n tiss ue is usuall y prese nt in th e wound bed. ~ Ti :-.sue is II'ct fro m a ty pi ca ll y large am ount o f drain(I

ing c.wtial(,. • Sig ns and sy mptoms of ly mphe de m a ma y be pre se nt (chronic in tlamm alion and fluid o ve rl oad can trigger the onset of lymphedema). History Becau se the inc idence of C VI in cre ases with age . clinicians should be susp icious ofth e d isease in older patient s. The ",low development of venou s di sease and ulceration usuall y impli es a hi story of li ngering swelling. slow healing. repeated infect ion. and freque nt rec urre nc e of skin breakdown. O nce ulce rat io n occ urs, venou s wo unds can c"i sl for years. This progression o f sy mptoms frequ entl y leads to a mechanica l overload of the lymphatic system and sub::.equenl deve lopmc nt o f lymphedema . If the individual is older than age 50. it is like ly there are com orbiditi es such as d iabete s. h ype rte nsion . congesti ve he art failu re . o r hi sto ry o f DVT. O win g to th e long lat e ncy peri od bet ween injury 10 the ve no us c irc ulati o n and clinical manifestation s. hea lth care prov id ers. pati e nt s. familie s. and caregi \ en, mu st j o in forces usin g the 100l s of educati on. prevent ion. and vigil ance. Tests and Mea su rements One of the mo::. t importanr tasks during the exam inati on process is to rul e o ut an arteria l com pone nt 10 th e ve nous pathology. If there is arte ria l insuffIc iency. healin g w ill be impaired and co mpre ss ion ma y be co ntra indi cat ed .~3.s1.i-1,i,1 Skin te mpe ratu re of the lo wer leg may be el evated. Thi s ... ig n can impl y a v. o rsening or impe ndi ng complicatio n of CV I. 61 E x i ~ t i n g e d e m a m ay d ec re a se wi th elevatIOn u n k~s n occ urs in the ad vanced ", Iage s of di sease or III L:omb Jnati o n \~ ith ly mph e de m a . Wi th venou::. dJ:-t e a .s ~ , pil li ng e d e ma m ay o cc ur in Iht: pe ri wound ar~a . the foo t and Irong dl ..,ta l pubes and a normal AB!.

E ve n though e dema is a natural characteri stic of the first ph ase o f wo und he aling . exce ss ive edema can delay wound hea lin g b y s lo win g perfu s ion of tis s ues and fa c ilitatin g th e growth of bacteria. 16 Along with compre ss ion and appropriate wo und care, treatment will includ e exe rc ise to in creasc mobility. and pos itioning to support and e nhan ce venou s blood flow. 54 Compress ion the rapy is essential for timel y he aling if arterial disease has bee n rul ed o ut. As mentioned e arlier. in a diagnosi s of mi xed art e rial and venou s di sease , the more severe patholo g y is tre ated fir st. Significant arterial di sease w ill most likely preclude the use of compre ss ion. For the individual wilh a diagnos is of venou s di sease or mix ed (mild) arterial/venou s di sease. a c ombination of therapeutic mea sure s will a ccelerate results. 62 The se include compress ion bandaging and garments , gait training , manual/:rmphatic drainage (MLD ), and exerci se including range of motion ( ROM) . Wound c are should a void whirlpool use owing to the ri sk s of dependent po sitioning , cros s-contamination. cytotoxic additive s. and unnecessary costs. In some cases. surgica l correction of venous abnonnaliti cs is indi cated.

Lymphedema Lymphedema is a chronic di sorder characterized by an abnormal accumulation of lymph fluid in the tissues of one or more body regions.2.63 The accumulation of fluid can be caused by a number of events but is most often owing to a mec hani cal in sufficiency of the ly mphatic system. Some ly mphati c component s are not fun ctioning sufficientl y to manage th e ly mph fluid present in the body region . Ly mphedema can be c lass ifi ed as primary or secolldary lym phede ma. Primary lymphedema (Fig . 17.5) is caused by a conditi o n th at is conge nital or he reditary. With primary ly mphed ema , ly mph node or lymph vessel form ation is abno mml. The most common abnomlalily is h,'p op/asia. a

Intenention The mO~l Jn1PUIldIH thcra pe-u tll' m CiI ::. lIrt' tor pn:\'c llt ion and IreJ.lmellt

01

\CI10U~ kg lI k:t:I~

I)

('(llIIfJ/ ~

l\liJl/ (lie/(/}H'

653

Figure 17 _5 Prlll1.lr" I) mphei.l(; II1 •• of bibterul LEs .

654

Physical Rehabilitation

filariasis. In fil ariasis, n~matode worm .I arv~e li ve a full life cycle in the Iymphauc vessels. causmg mflammation and blocked lymphatic vessels.

Clinical Presentation Swelling distal to or adjacent to the area where lymph system function has been impaired Swe lling usuall y not relieved by elevation Pitt ing edema in the earl y stages of disease. nonpitting edema in later stages. as fibrotic changes occur Feelings of fatigue, heaviness. pressure. or tightness in the affected regi on Numbness and tingling Discomfort varyi ng from mi ld to inte nse Fibrotic changes of the de nni s De nn al abnormalities such as cysts, fist ulas, lymphor-

rhea. papillomas. hyperkerorosis Increased suscept ibility to infec ti o n. at first local to the

affected region but often becoming systemic Loss of mobility and ROM

Im paired wo und healing Fig ure 1 7.6 SeC'ondal")

l~

mphedema of unil:l1eral UE.

cundltlOn in wh Ich there are fewer lymphatic vessels and the) 3re smaller than nonnal. One of the more common fonns of primary lymphedema appears in Milroy's disease. S('cnndar_\ lymphedema {Fig . 17.6) i~ cau"ed by injury to

one or more cOlllponent~ of the lymp hatic system: some pomon of rhe I) mphatic sy~tem has been bl od.ed. dis...ected. fibro-.ed or othef\\ i~ damaged or ahered. S~I..'ondar) l~ mphedema i.., more prevalent than pri01;10 In de\ elo~d cOllntrie", the mo~t common cau,>e 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

III

rf..·.;IlIJlJ.1 I~

mph Ih...1" .. 1'0110\.\ mg lipc.l-

"1J .. tLtlll. r~:I\h. Ir.htUit.'

lIiI('f\cntll,n"

h;.:ml.J rCpdlf. JJ1J (uher .. ur~h.
k",. [,j ~- (\·lIc411011 \11 J.!IJ llO lil... IIh.lJ('nc.C" !,)t Ik)fl.. ,n ... l,.'J r~ ;tltoJ ,~" 11 . .1. ;. l)fllrh~d . . . mJ I" IImncJ tn (fit: I.a..::). I 'Ix·..th..... Ju;..1[ llfl rdah.':u l ) I~mpht'..tc-Il\..t .tlHl..:n~ h... .Jth .. an: pn>tt: .... l d , J ' ~1.1 h) J !,J ....... 01 .. tllll;'.!! ,u"'r'ni1\h1u.1 ,.\Im .. h:,>ll)f t.lf .II d .. ubrr 'P" JI f('" ~'lJrb t.1( th~ I, ..kma. II .. , fh n • ..I ......l:J b.

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 <.I~;' ur.J!e JJJlmO,,,, In mv...t .J..."-i! ... L n~u~ findings 1l11fhl 1I"k.luJ~ ."l/t "I/ ' /t"' \ I.:,ff ,lin lc\lurc lhoingc='), .,j,.Ul luIJ,. Uf:\rt."I" Hk.n. . ,j....t If) l=lrth flUI'U/c' \ I~mrh le a~, ,J..nJ (" t,!tuNl.1 \e\ r nr. b \kknnlik.-d b) a \.vltc=4.:uoo ot

.Lt..t

:(k:LJJtni r"C'X"O;.c HI

tiIJrotl ...

U,.ut'

\.h.1.n e.>

!bra~l1~

\\'l.~h .1nJ I..lf k~t'U~I, oum ~o r lIt "Pl ~ of c.:eUuhla• .. noJillfltl .. r Uk-- ..u ·rn..l..tllflh:~ umcm u1 the f}mphedr:.Jl'\,:S" ll'U' ti.l'llb (J apolc" k ...~.; tun~Wt \ 110tb ~ £¥hr. (It". ...... m.tcrC'L"" or \olufT•.; uillcr r", .. bt=1"ecn lI1\ohcJ .and u.nu1~1) ocJ I III :) ~tJ '-i ~hl~ vi 1.1C: h"~' ,,~, moht-l1[\ ok 1h

t \!'l

" ..Luh

Ih til'; 1 DL.. re: fk.Jfhtulb)..

Chapter 17 Vascular, Lymphatic, and Integumentary Disorders

Intervention A physical therapi st should be ca utious about the appli ca tion of pressure to an ede matous or lymphede mato us bod y part. Altho ug h co mpress ion is an essen tia l in te rvent ion. press ures that arc 100 hi gh wi ll o cclude superficia l lymph capillaries and preve nt the initia l ste p of fi ui d absorption needed to control edema and ly mp hedem 3. 4 Curre nt interve nt ion for the pati e nt /c li e nt w ith ly m phedema requi res att e nt ion to detail and a leve l of ex pe rt ise not ofte n prov ided in e ntry-leve l professio nal ed ucational program s. Practi tione rs are best se rved by gai ning addi tional edu cJli o n to bener prepare the m to trea t these palien ts. The c urre nt rec o mme nd ed co urse of ca re is a two-phase p rog ra m o f Complete Decollgesrh 'e The rapy (CDTl. Ph:be 1 (inte nsive) incl ude s skin care . M LD. ly mphedema bandag ing . ex e rci se. and co mpress io n g am lent aT the end of Phi.l se I. Phase Ll (self- management) include s skin carc. compression gam le nt durin g the day. exe rc ise , lymphedema bandagin g at ni g ht. MLD as needed. Appe ndix A prov ide!:! Web slles fo r tfi.l inin g programs or othe r in fomlation on COT. tra ined therap ists. and patient edu canon related 10 th e treatm ent of lym phedem a. A:-. \\ ith many prog. ress ive . c hronic di so rders, the e frecti\'eness o f treatme nt i!o. sign ifican tl y improved by earl y imene nt ion. Accu rate a nd e arly d iagnosis o cc urs whe n health care profe~"io n ab are se n ~ it i zed to the sig ns and symptom, and carefully eval uate the examination data. In the POc. the number and frequency o f treatme nts shou ld not be detemlined by lymph ede ma staging o r by c irc um ferential dlftere nce" bel\\ ce n hmbs (al tho ug h the se ve rity of the condition I;;; not de te rm ined b) Ihe!:!c data al one) . Some IIldi\ IduaJ.., wil h I~ mphede m a m ay presell{ with more lIl\"olved 'I£n~ and ~) Illpt om'l than Ihe me a su re-

merm

ITllpl~

Pressure Ulcers A pll.I.\/lI( afru I ... a "'Quod f..3u'It,>d h) unre lie\ ed prc~" ure to the dt'mll" and unde rl ) IIl g \u'Il"ult!"Li l'
655

Press ure ulce rs occ ur m ost freq ue ntl y a m o ng indi vid· ua ls w ho a re im m obi li z e d fo r lo ng pe ri o d s o f time . W hil e pressure ulce rs can o cc ur a t a ny age d uring prolon ge d pe riod s o f imm ob ilit y, th ey are m o re li ke ly to occ u r on indiv id ua ls w ho a re hos pit a li zed , e ld e rl y. in co nti ne nt. and/or un d e rwe ig ht a nd am o ng indi v id uals of a ll ages fo ll ow in g spin a l cord injury (SCI) ..... ·67-69 Up to 25 perce nt o f hosp ita l-acqu ired p re ssure ulce rs may o rigina te du ring surgery.70 Accordin g to Reed e t ai , the prese nce o f low a lbu m in leve ls, c o nfu s io n, and a Do Not ResusciTate (DNR ) orde r are a lso pre ss ure ulce r ri sk factors. 7t P r~ ssure ulcers inc rea se the ri sk o f death fo r e lde rly indi v id ual s whe th er a t home o r in a hospit a l o r lo ngte rm ca re se tti ng .72 Th e inc ide nce o f c h ron ic wou nd s . in cl ud in g p re ssu re ulce rs. is in creasing as the pop ulation ages.

Clinical Presentation The severity o f p re ss ure ulceration can be estim ated b y obse rving c linica l s ig ns. A p rogress ion from le ast t iss ue damage to most seve re d am age is presented. The first clinical sign of press ure ulceration is blanchable erythema alo ng w ith inc reased skin tempera ture . If pressure is re lieved , tiss ues m ay recover in 24 hours. If press ure is unre lieved, no nblanch able e ry thema occ urs. Progression to superficial abrasion . bli ster. o r a shallow crater indi cates invo lveme nt o f the derm is. Whe n full -thi c kness skin loss is appare n t. the ulce r appears as a deep c rater. Bleed ing is minimal. and ti ssues are indllrated and warm . Eschar fomlati o n marks the full -th ic kne ss skin loss . Tunne lin oo o r unde nnin inae is o ft e n pre se nt (see stag in g syste m de scribed in Ta ble 17.2 ). T he majo ri ty o f all pressure ulce rs d eve lo p ove r six prim ary hony areas ( Fi g . 17. 7): sacrum ( Fi g. 17.8), coccyx. g rea te r troL:hante r, isc hi a l tuberosi ty. ca lca ne us (hee l). and Ia lera l mall eo lus. H i st or~

If an Illdi vidua l has a histo ry o f a period of immobil ity fo ll o\\e d h ) th e d bco\t'r) o f a \\arm . red , s po t o ve r ~ bon~ prom in e nce. n pr~~:. ur~ ulce r can usuall) be con iil1l1eli. It the ' POI i~ unni.tlu fiJ.lI ~ soft to the lo uc h, sometillie, rdl! lTed 10 .1' " bo~gy ." ! hi ~ I' e no ug h e vide nce to 'U'IpeC! lh.1I damage i, deepcr Ih:.ln the e pid~ rml"' . Tt"sb .Hld M ca ... ur t l1l ~ nt ...

Dunng

I:Ul1I ln,1I1 01l, ,ll nng '"

Jlh ge ner~" \\ ound c har~lc ­

tefl,til~' , pre'..,lIle ukt'r~ Me l'I:1'~ l fied P) g radin g o r ~ lngJl1g ~ ..

""L"rn, (hdt dC'scribe the dcg rt!1? o f ti~ue dam . It 1'1 Ull pOfl~Hlt to also U'e an c.\aminJ lion ll)o l 10 Illl?dSU rl' .111 Inon IJui.ll 's n ... k o f dcve- Io ptng a ph.·~ ... ure uk~r t'le llirc a pl'e~!' u n~' ulce r C'xi st&, T he se mc a'UH~~ tarl Jhu bt: u..,ct! 10 pr~h> nt re(' urrt'nl'O afte r

.Jgl· 0b,)lT\l~J

\~~llilld

11I.:allflg.

656

Physical Reh.bilitation

/~.:o..

_ _ Occiput

Acromion process

."...-- Scapula

Thoracic vertebrae

~~

Figure 17.8 Sacral pressure ulcer. (From Kloth. LC. and McCulloch. JM ,IJ1 Plate 31, with pennission.)

Lumbar vertebrae

'--fi-;----t~--:_-r-. Sacrum'Coccyx -+--+"-7-~ ·Greater Trochanter ---\+,.../

, 'I:~~+J~. lschial tuberosity·

positioning/turnillg schedules. and education of the patient , family and ca regivers. Other factors that Con· tribute lO ulcerat ion or ri sk of ulceration such as shear. friction , mobility. sensation , moisture, nutrition. age, and underlying medical condition should also be addressed. With appropriate wound care, control of pressure, and attention to risk factors. a wound should progress through the phases of wound healing. showing signs of jmprovement in a matter of weeks. Partial-thickness wounds typi~ cally take I to 2 weeks, while clean full-thickness wounds can take 2 to 4 weeks. 40·73-76

Neuropathy Neuropathy can be defined as any disease of nerves and can include peripheral nerves. cranial nerves. and/or autoMedial malleolus (inner ankle) 'Lateral malleolus --#~, -iI-' (outer ankle)

~

i

Metatarsals

toe.)

•_~.;.:O,,-,~_ Calcaneus' (heet)

, Most common sites of pressure ulcers

Figure 17.7

Pre~~ure polnl~

of bony

prominence~ .

Intervention A phy~ical therapl ~t treal') integumen tary diso rder:; th at involve Ihe epidelmis. the denni:;, hypodermis or be lO\\ into expm,ed bone, tendon, mu~le. and organs. For heal ~ 109 10 occur. lIlter\'cnlion for di sorders of the integument must facilitate local and regional hOl1leo!) l ,bl~ of the \'d~­ cular and I) mph<.illc ~y!>h! nh. 1n additIOn to appropriatl.! ~ound carl!. 1\ i\ Il11perallv~ that the under!) Ins ca u ~e of pre~surc bi.: dddre ,~e d . Wounds Yo III not heal and lemain tlO~cd un Ie.,.., Iht redul:lIon of plc~~urc and prevcntion of future brt'Jkdov.n arc lOp prionlle!) In the intervelllioll plan . Prc!o:o..,u re man.tgt::mcnt i~ auumpll\hcd Yo uh the U~I! uf PJ{D .... pre.\llllt IIl1.1P/JU1t: 10 d~h:nlline prc~~lJre Ina(h .

nomi c nerves. Neuropathy exists in many disease processes: however, the most common disease process seen with neuropathy is diabetes. For most chronic diseases. including diabetes, the eflects of neuropathy are peripheral. The etiology of diabetic neuropathy is not well understood but thought to be relatod to high levels of gl ucose in the blood over a long period of time. Diabetic neuropathy is a generic term for any diabetes mellitus~rela(ed disorder of the peripheral or Ju tonornic nervous systems or (he cranial ner"e~. The majority of syrnpwms from djabelk neuropathy W ill he located in the LE with foot insensitivity and ~ub..,eq llenl ulceration being the most common (Fig. 17.9). Bet\\. ('en 5 and 12 perce nt of LE leg ulceratjons are ('au~ed by the complications of diabetes. 53 10 addition. man) Indivldua.l ~ "ilh dla~tes have coexiSling ar1e.ria1 dbease her3u,\c the conditions are not l11utuaHy exclusive, While lht ~ percent is 100I,er than "enoUS Illld arterial "Dund.., III general. the underlying dlalxtic condition cre~ ate~ J dlflkult em Ironment in which 10 clru,e a \\ound The mClclrnce ut ncurop.l1hic LE \qHtnd~ is. likely to grow as the popul.tllOn ag~:o. and the mChJence of diabetes continueS to e"'Ci.dalC'. r'\~'col'dll1g In the U.S. Depanmenl of Health and HUIIl<111 Sen Ice .. ( HilS), someone in America is diacnO"-l!d \\-uh lhabc:lc" ever), 25 :;e(;ood~.n AJmosl half of aU

Chapter 17 Vas<:uIar, Lymphatic:, and In.egumentary DUonle..

657

o Ischem ia o Impaired healing time (also present ow ing (0 diabele~) c Impai red transpo rt o f ox yge n. antibio ti cs, and nutne nLS needed for healin g

History A history of diabetes is sufficient to warrant investigati o n of d iabetic ne uropathy. U the individual has had di abetes for a num be r of years o r has had trouble regulating insulin levels even fo r a few ye ars. the presence of d iabetic ne uropathy is ve ry like ly. Whe n an ulceratio n is vi sible. t~e histo ry will incl ude specific de ta il s about the wound In addjtio n to infonnation about othe r sympto ms .

Tests and Measurements Figure 17.9 Chronic wound as a result of diabetic neuropathy.

adults now are at ri sk for the di sease.7I! Based on infonn a· tion from the Cemers for Disease Con trol and Preven tio n (CDC) diabeles affeclS more rnan 18 mi ll ion peop le of all age~ in the Uni ted States. Thi s fi gure represents 6.3 percenl of the popu lat ion. About 60 to 70 percenl of people with diabetes have mi ld to severe foons of neuropathy and mo re than 60 percenl of the nonlraumatic lo we r· limb amputali on ~ that are perfOimed in the United Stales occur among people wi lh diabe tcs. 79 At least ha lf of the amputations were pr~ceded by a fOOl ulcer. m,m), of which could have been prevented by appropriate learn management. if current trends prevail, the impact of diabetic neuro pathy o n futu re wound care need, \\ ill cont inue to expand.

Clinical Presentation • Ulceration u\ually located o n the we ig htbea rin g SUffaces of the foot • Usually anesthetic. rou nd. over bony promin ences bu t can be located anywhere • Sen ~ ry neuropathy. if prese nt : . Patient unable to .;;ense pa in and pressure : Rls\... of ~ki ll breakdown withou t patie nt aware ness Mech;.mlcaL repe titive ~I r esses a fC most co mm o n cau~a l i\e factors of wo unds . • Motor neuropat h}, if pre~ent: ~ Lo~!'I of intrinsic mu~c1e~ o Ham mer·wc, daw-toe defo fmiti e .. adding to ri sk of breakdov.n owing to poor weight distribu tion and ru bbmg FOOl dfop • AutonomH': neu ropathy. If pn:se nt : Decrea~cd or ab ...e nt ~v.l! ;j t and oil producllon leading 10 dry. ineiu'>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 1<0 A rt" il'\~ (\1 rh L" tesl an d IllC ...I'.,urern\,;nt La lcgufln Ihems('hcs . . hou lJ ~t:nl! a~ il ICII11 11der 01 Ihe re.., polIslbllll) 01 Ihe t.~ .\ anll n lng t hcr..tpl"" 10 dOluml~nl [h"f()ugh l) h u' pUljX1\CS ul Sp~I Cl". only thl" mO:.1 e ......l' llll.iI ~~th:~on("s h.tH' bt-en "ddl('s')cd .I"\ n ,U1IW [,Jled \t.'r. . lol1ol . . l·kt.h.:J tc ... '" ,lI1d /l]c~hlllell1t'llh h.t.., been ItILiUlkd hi d ........ l .. t

thl'

Ih..:

l(,.ti..kr 10 ~11'.ller ulldt: I ... t .lIU.lIJI~ 01

1C" .... h ..tIIlJ Ih~ lPlitillltllh unJl'r t'l"dl1lllJ.JIllln

Figure 17.10 Volumetric examination for edema.

Aerobic Capacity/Endurance Aerobic ca pacit y durin g functiona l aCtiVIties will be important to meas ure since activity will be encouraged as part of long-tenn management of the majority of the disorders in this c hapter. In addition to infonnation obtained during the systems review (i.e .. blood pressure. respiratory rat e, heart rate). the gathe ring of additional data will depend on the individual patient. This might include the use of angina. claudication and dys pnea scales, pulmonary function tests. and ECG. A detennination of heart rhythm sounds. and breath and voice sounds may also be required. Anthropometric C haracteristics Height alld Weight. Data on height and weight are neces· sary to address and track: normal weight values especially for the patie nt with a di sorder th at resu lts in abnormal fluid re ten ti on sli ch as diabetes. edema, lymphedema. venous disease. or underlying cardiopulmonary disease. Volumetric Aleasurement. Volumetrics are performed utili zing special containers that hold water. and a graduated cylinder for water collection (Fig. 17,10). This method is accurate for measuring changes in body dimensions: ~­ ever. it is time l'onsuming. awkward and may be inappropriate for open\'\' ound" 0\\ ing to cross·contamination risks. Girth Aleasllrement. Glnh i... recorded using a tape measur~ 10 de rel/n ine l'i rn llnferential body dimensions (Fig. 17, 11 1. ldeall). ,I Id~ 1l1('i.l\llfe ..,peclally designed to 01('3.\lire !!Inh .'I houl d he u'ed. WIllie tX>I1)' landmarks are <;()fTlel i lllt' .... u'lCd ,I.., re jerenl'''' point!> 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 . . lun<, SJX..~;al In(usunng board' (.tll ~ tlhl.II1/l:'t! lor fIl~4hunng th l' lE or a "-ell-pl3C'N lllphu.lrd l,III ~ UlIlllt"d ro er., lithlt .; h (he beginning I1\CJSUlt'nh~1II (imh llIl'a .... url:' lHl." lI (:, , hould nol be utilized "loot

Chapter 17 Vascular. Lymphatic, and Integumentary Disorders

659

• Stage I, reve rs ibl e lymphede ma: accumulatjon of protein -ric h fluid, e le vation reduces swelling; pits on pressure.

• Stage II , spontaneously irreversible lymphedema: prote in s stimul ate fibroblast fonnalio n, connective and scar ti ssues proliferate; minimal pitting even with moderate swe lling .

• Stage Ill, Iymphostatic elephantiasis: hardening of dermal ti ssues. papill omas of the skin, appearance of skin

is elephant-like.

Palpation/Pitting Scale. Palpati on of soft tiss ues must be

Figure 17.11 Tape measure ex amination for girth measurement.

to delenn ine seve rity. frequency of vi sits. or du rat io n of the epi sode of c are . Advanced fibroti c changes can occur to the dermi !) and un de rl y in g connect ive tiss ue wi th oul signifi cant increase in gi rth of a limb.u ,s

-

-

Additional Tools. Data o n an thropo me tric measurem ents may be collected using TOnometry or bioelectrical impedalice. Altho ug h not a standardi zed procedure, soft-tissue tonometry uses a de vice th at meas ure s ti ss ue te nsion at the surface of the ski n. T he grea ter the te nsio n reading , the l es~ pl iable th e skin. impl ying the presence of fluid and/or tiss ue fi brosis . Dat a from tono metry can be useful for subc linical ev ide nce of e de m a. lymphed em a, a nd fi brotic ch:.m ges before they are visibl e o r pa lpab le. Bioelectrical impedance anal ysis provides acc urate measurern ent ~ to he lp pre di c t t he on~et of lymphe de ma . o ft e n many m onth ~ be fo re a clmi cal diagnosis is poss ible. The techn iq ue m\"o l \'e~ pa ss ing a very ~ m a H a mo un t o f AC current th roug h the limb to be tested and me asuring the jmpedance 10 its fl o w at vario us freq uenc ies. Th is tec hnique l ::!o mUl.. h mo re ~en s iti ve than I im b volume mea!) uremen l.', in detec ting c hange s in the ex trace llular fluid vo lume. In .',ludIC!:! lilU!:! far the fa b e- negative ra te has bee n

leroY

l'l

Slilg;llg 0,. Grading of Lymphedema. In an e ffo n to ('.tl Cgorize le\'e l~ of ~e\ eri ty, ~Ol1le profes!) ionah U~ ... tag ing or gradmg . . ) ... ICIl1~ for edema and lymphedema in add ition to one 0 1 more of the measure ment tt!chniq uc\ above. 1 G rad ing or ...lag ing of ~dl'ma and l ymphede l1l ~ i~ no t UllI ve~
a reg ular pa rt of vascular, lymphatic, and integumentary ex aminati ons. The re is no universal pitting scale c urrentl y used by health care profess io nal s. So m e scales are based on how deep an indent atio n is left after apply in g fin gertip pressure. Other scales are based on ho w severe the exam ine r believes the pitting to be. The follow ing scale, m ost comm o nl y used by ph ys ical thera pi sts and phys icians, g ives a nume rical grade to the pilling based on how lo ng it re ma ins after fin gertip pressure is applied : I+

2+ 3+ 4+

Inde nt ation is barely de tectabl e Sli ght inde ntatio n visible when skin is depressed. return s to nOffilal in 15 seco nds Deeper inde ntatio n occ urs whe n pressed and return s to nOffil al wi thin 30 seconds Indent ation lasts fo r m o re than 30 seconds

If using a pitti ng scale during an examination. it is wise to document an explanati on of the grades o r scoring system uti lized . Pedal edema may be atuibuted to c hronic wounds. in flam m ation, infect ion, ce ll uli tis, diabetes, liver disease,

renal di sease. CY I, lymphedema, ph lebo-lymphedema. congestive hean fa il ure (C HF), or trauma.

Arousal, Attention, a nd Cognition After recordi ng sc reeni ng re sult s dur ing the hi story and syste ms re view. the physical the rapist will decide whethe r there is a clinica l indicatio n fo r tests and meao;urements in this category. It is important for the the rapi st to unde rstand the patie nt 's level of moriva tion, orientation . attenti o n. and abi lit y to process insrruc tion s. Man y of the di sorde rs in th is c hapte r. s uc h as d iabetic ne uropathy. c hron ic veno us im~ ufticien cy and lymphedema. req ui re li fe -lo ng adhere nce 10 Ihe t>e 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
A rterial Perjll!) ;oll . The tilc rapi:»1 collect s dat a to de lr rm ine whether ad ~qual e blood n (l\\ I .... r~a c hi ng dl ~ t i.tI ti !'l" ul' !'I. If blood nO\\ I!'I adt lj uate. the t)xygen -; uppl) \\ ill be adt'q uatc. Som!! nOll 111\ :'hl\ e te.,h and lll ~ il 't Ul\:'menh are de ... ig ned to lkt e nm n ~ Mood 1/0 11' ,IIlU .\/..;11 Pl'r/U \//II/ . \\ h ll e oth er!) "d d l e~ . . orY,!"'1 It'l d\ III the II . . "UC&. Pul . . e ... "h\)uld ~ p.l l· pat ~d Hl ill all) 10 p rm Ide 1I1 101111a tlo n abou t pO.... "l hle 'J ....UIl;if . . )"It.'1ll lIl\o h e lll e nt f hl.: I.:\Jllli nal Wn \hnuld IIll lu. .le palpallon III Ih ~ 10111,", I n~ '.1fI t'I'I('\. hradw.d dlld r.llt ...iI . kmor;J1 puplneal dUI't,tll ... I'k Lih, .lI1d IX J\ tt.' ftI..'r tt hhlll \ I III..' lulhlV,lng 'tLilll'. lOlllllh)l) l) u'>\.'d b) rh)'tH..:a lthn.lpl . . h ami rll)"ll-ian~. gl\l.: ... J nUIIll.'IRa l gr,u.k 10 th~ pul . . t.· .... ljualll) (J

I

"II JiIll.H H ,'Uk pul"-t: dllth.lIlt

10

p.. lpd tt'

2 + = Palpable but not normal. diminislted 3 + == Normal, easy to palpate 4 + = Bounding. very strong. may imply the possibility of an aneurysm or other pathological condition. Auscuhation by stethoscope of major pulse points may identify a bruit. If turbul e nt blood Il ow is heard. the patient may have partial b loc kage of the artery. Barriers to effecti ve pulse taking include scar ti ss ue. edema, fibrosis. and ti ss ue induration. Doppler ultrasound is considered an essential component of th e vascular examination . :'i~ ·55.R5.86 The examiner uses a hand- held probe to di rect a sound wave inlo the vesse l to be tested. The sound wave is rellected by red blood ce lls moving in th e vessel. The sound wave signal is changed inlo audible sound that is tran smiued from a small. hand-held unit. The ABI is the most frequentl y perfonned test using Doppler ultraso und . A bl ood press ure cuff is inllated to occlude blood tl ow temporaril y then denared as the exam iner li sten s fo r the re turn o f now. This is perfomled on the uppe r extrem ity (U E ) at the brachial anery and on the LE at the poste rio r tibial and the dorsalis pedis artenes (Fig. 17. (3 ). The AB I i, a ratio of the LE pressure d Ivided by the UE pres~ ure . Table: 17. 1 presents the ranges of AS I value:, :and potenti al \·a~c lliar IIldications. Obtaining

Table 17.1 Ankle- Brachial Indices with Corresponding Indications

AB1 RaDle. 1.2

PouibIe fed!c.1= Falsely elevated , arterial disease. diabetes

t 19--{) 95

Norma l

o 94-{) 75

MIld a rtenal disease , claudication

074 050

Moderate arterial dIsease,

050

"1.

Severe arterial disease

Intermittent

+ rest paIn

Chapler 17 Vascular. Lymphalie. and lnlegumenlary Disorden

n AB I will provide useful infomlalion about the arterial a stem since the ABI is an indicator of loss of petfusion ~; the LE. Res ult s will guide the therapist in decisions aboUI the use of compress ion and debrideme nt. and will heip to predict the likelihood of wound closure. When the examiner cannot occlude blood flow wi th the blood pres-

sure cuff. calculations may show a fal sely elevated ABL Ar1eriosclerosis or ca lcified vesse ls (from diabet.es) can make it difficult for the cuff to compress enough to get an accurate AS!. The large t arteries would be documented as lIollco mpre:Jsible \'esse/s. Test opti o ns when th e vesse ls

are noncompressi ble include taking loe pressures with a special cuff. proceeding with transcutaneous oxygen testIng (see below) or recomm endin g referral for vascu lar labora tory workup.

Troplric Changes. Trophic changes occur in the ski n of the LEs when c ircul ation is impaired by poor arterial blood flow. Observation is the most acc urate way to note changes. Trophic changes inc lude dry. shiny skin (pa le in Caucasians). decreased or absent leg hair. and thick toenails. It shou ld be noted that these sig ns are al so a predictable part of aging but not to the same degree as can be seen Vi ith trophic changes. The presence of changes indicales the need for other rests of c irculation.

Pain. When related 10 c irculation. a thorough pain hi story may be all thaI i ~ necessary to suggest the possi bilit y of anerial di sease. Reports of pain indicale the need for further tests and meas ureme nts of the vascular system. Pain as [he re~ult of mtemlitlent claudication (Ie) is described earlier in thi s chapter. Re~t pain thai deve lops at night. awakens the patient. o r requ ires analges ics for relief is cons idered more severe than Ie. Pain can be measured for seventy on a Visual Analog Scale . The degree of impairment from IC I'" ofte n measured in terms of how far an indi\idual can \\alk before ex perienci ng acute leg pain or fatigue. Ie can be dJ.s~Jfied objective ly wilh a rating scale to IJldlcate se\enl v ba~ed on di stance walked before onset of pain. TIle \4ali..'lII S: Impairment Questionnaire (WIQ ) is a di~ea'\'e-specitil q ue~lionnalre commonl y used to examme claudication h doe ~ not . however. measure th e imp,tct of c1dudu:.:atlon on quali t) of life (QOL) .!I1.8K The Ill os t extensi\el) re~earc hed dbeal)c ~pec ifi c QoL questionnaire for Ie IS the ("111£1/(011011 Scale (CLAU_S J.'tI7.",jIi.Y(1

Special Te~lS. There are many other noninvasive and Lnvate,\,ts u!,ed 10 deleo . exam ine. diagno~e , or con linn artenal dl ~ea~e Jnd d)hfunclion. Appendi.\ C prl"~enr~ a bncf de'Hlpti on of special le::.t:; for arteria l and venou ... lunn l(ln IIlcludmg 1<11/)01 vi /JejJl'fldel1c)" Air Pletilysf}wg ruphl IAPG ), T'eJl1H 11/(IIIl'V/l.\ On'xen (T( PO , ) mea ... ureme nl . itnd .54 ,11 !,1f11UJIO Il Pn'J J II;'e (.\'PP) m~a'\' urc rn e nl Although ~omt: uf tilt: le.,h are u~eful for pred icting hea llllg 01 u\cc-r., Mid aml)UldtLon wound~, they mtty not be read tl ) rClmbUfM"d .... hen pcrlormed hy a ph) : -. iL·al tlu:rilpi.,t. The A.PG. Tt PO . Ul(} ~ pp .In.' u~J pnmanly for re~arcll purPO'\(\ bccJ.u\c Iht:~
SI\e

661

Venous Patency. Venous disease and dysfunction can be detected with a wide range of teses and measurements. The amount of time avai lable for eX31uination as well as reimbursement issues may impact decisions about which lesls 10 utili ze. Refer 10 Appendix C for a brief description of Venous Filling Time. Percussion Test, and the Trendelellburg Test. Owing to inconsistencies in interpretation and administration. the Homans ' Te st. or Homans' sign (pa in in Ihe calf when Ihe foot is passively dorsitlexed) should not be relied upon to detect a deep vein thrombosis (DVT). A physician should be contocled and a Doppler srudy ulilized if an individual exhibils two of the following signs: change in s kin temperature. change in skin co lor (darker). pain in Ihe calf (experienced by approximalely half of patienls). or swelling.

1-ymph Vessel Integrity. Palienl hislory and clinical fmdings are utili zed most often to make a diagnosis of lymphedema Most invasive tests have lost popularity because of the risk of triggering the onset of lymphedema or an exacerbation of existing lymphedema owing to the irritation caused by dye and/or needle puncture. When invasive tests are indicated, the most common test procedure is lymphoscimigraphy. This test, us ing dye and a special camera and computer, can visualize many lymphatic system functions. 2.91

Gait, Locomotion, and Balance The importance of movement to impact blood and lymphatic flow, and (Q facilitate the overall rerum to function for most individuals, will validate the use of lests and measurements (Q document patient abilities in this area. During the initial examination, gathering data through observation. gai t analys is. and posrural control tests is usually adequate. The examination results may indicate the need for additional tests such as inventories, or batteries of tests to further documenl safely (fall risk) or equipmenl needs. Integumentary Integ rity Collection of data about skin and subcutaneous tissues is interrelated with the tests and measurements for circulation and cutaneous se nsation.

Obserl'alion and Palpalion. Characteristics of the skin are no ted almost entirel y by observation 8Jld palpation. A compari son berween invol ved and nonnal integumenl is made wilh careful attention 10 color. mo isture. texture. firmn ess. temperature. eiaslici lY. sym metry. and shape. In Ihl.! pr~ se n ce of ..I wound. the ",ound tissue. the ptlriwound area. and the wound exud"lIes shou ld all be! ob~en ed and uata recorded regard ing the observations. The location of ;1 '" ou nd , pfe~ence of edema and I} mphedcma can be documented using a body (/lUgram. Trophk C hangt!S. Becuuse lh~) are an imponam part 01 muny dl~ordcn~ invo lving tht' intt·gument. trophic change!' J.re mentioned again under lhi::-. sec lion. As in the "ieCllon on cirl' uhttion , obsen alion is an important approulh to 1l00ing L·hange-s. C haraClcnSllL'S to consider IfH lude the predlu J.blc ... igns of uging.

662

Physical Reha bilitation

Fibrosis, Palpation is the best way to detect fibroti c changes of the skin. Tissues will feel thickened. firm . and unyie lding or immobile. Testin g for the presence or absence of the Stemmer's sigll is an o bjecti ve measureme nt that can be added to the exam ination for lymphedema. When the dorsa l skin fold s of the toes or lingers are resistant to lifting or cannot be lifted 31 all. the Stemmer's sign is said 10 be " present." The clinician must be cautious, however, as a negarive or "absent " skin fold test does not rule out lymphcdcma.

Coloration_ Skin co lor will vary based on the underlying di sease. Observation is the best way to note comparisons between nom,al tissues and those under exam ination . The 1110s1 abnormal color cha nges incllJde red, purple, and brown. Color c hanges may indi cate a chron ic conditi on such as hemosiderin stain ing or an acute situati on such as redness associated with DVT. If color changes are intermittent they may signal a di sease such as Raynaud's.

Temperature. Tempe rature is most often exa min ed by palpation but data can be objectivel y collecled and quantified using a radiom e ter or a therm istor. A dec rea se in superfi cial skin tempe rature change s may indi cate poor arterial perfusion. An increase may indicate infection or active disease processes such a s Charcot joint disease. Maintenance of normal skin temperat ures is essenti al for good wound healing. Wound Size and Depth. There are a number of tool s as we ll as sca les available for gathering data about wounds. edema, lymphedema. and other aspec ls of integumentary integrity. Wounds not classified with staging or grading can

be described ba sed 011 th e depth of tissue damage . The descriptions used for depth of burn injury, superficial, partia/ , anclfllll thickness, can also be used 10 describe wound de pth in other types of wound s. Objective measures included in doc ume ntation are vital for communicatjon about lhe patient. A calibrated grid, photographs, tracings, graphs, and spec ifi cally des igned forms are most commonl y used 10 documenl wound size and depth.

Staging. Pre ss ure ulcers are typic ally classified using a staging or grading syste m that g ives information about the seve rit y of the wou nd base d on depth of tissue destruct ion . Both the Nat iona l Press ure Ulcer Advisory Panel (NPUAP) and the Agency for Health Care Research and Qualit y (A HRQ ) support the use of the universal four-s tage class ifi c ation system described in Tabl~ 17 .2.92 .93 Despite some standardization and acceptance by some government agencies, staging of pressure ulcers is controve rsia l among wound management experts because il is often mi sused and even more often mi sleading. The mi s use most ofle n occ urs because the staging sys tem de sc ribes o nl y the depth of ti ss ue de struc tion and not other characteristi cs of the wound that need to be conside red. Treatm e nt plans should not be based solely on the staging sys tem . Staging can be mi sleading in that tissue damage may be dee per than what appears on the surface, wou nd s can not be staged when necrotic tiss ue is present and darker skin does not always show the reddened alteration s indicating sta ge I. The staging descriptions are intended for use wi th press ure ulcers but are often used inaccurate ly 10 describe Ihe severity of othe r wound types.

Table 17.2 Pressure Ulcer Staging Criteria Stage I

Stage II

An observable pressure-related alteration of intact skin whose indicators as comp~ red with the adjacent or opposite area on the body, may inClud~ changes In ?ne or mor,e of the following : skin temperature (wa rmth or ~oo! ness) , tissue consistency (firm or boggy feel) . andlor sensation (pain , t~chmg) .. The ulcer a~pears as a defined area of persistent redness in lightly Pl9,mented. skm , whereas, in darker ski n tones , the ulcer may appear with persistent red , blue , or purple hues.

Partial-thickne.s~ ski n loss involvin-g--'-e-p-'id- e- r-m-,-s--'o-'r- d- e- -rm-,s-,-o-r-b-o-t-h-. -T-h-e-

--

ulcer IS superllclal and presents clinically as an abrasion, blister or shallow crater. '

Stage III

Full-Ihickn,ess skin loss

I~~M~~ dama~e or necrosis of subcutaneous

tissue, whIch ma.y .extend down to but not through underlying fascia. The ulcer present s clinIcally as a deep crater wIth or wIth t d . f adjacent IIssue. , ou un ermlnlng 0

Stage tV

'

Full-thickness skin loss with ~~t~~slv-e deslruct~nt i s- - - dama t t b ' sue necrosIs, or gl e) 0 musc e one or supponing structures (such as tendon j' olnt ~_e

The NPUAP position on staging Staging Should not be used In r ~-~ - - - - -- ---' staging or down -slaglng) The staging system IS not a measure of hellers€! order {also called backa stage IV If II IS healed , II would be leiellsd 10 as a heal d I vsahng A slage IV lileer IS always T e sage I not a stage 0 he NPUAP has developed and validated the Pressure UI S cer cafe for Healing 1001 ThiS 1001 documents plessure ulcer healing

(PUSH IOOI)~~

,

Cha pter 17 Vascular, Lymphatic, and Integumentary OiBorden

Wound Healing Tools. A varie ty of wound hea ling tools can be uti lized to doc ument wo und sta tu s and wound healing:12 Since the re is no sin gle wound c haracte ri sti c that can be used alone to moni tor hea ling o r predict ou tcomes. it is best to use a tool that incl udes multi ple c haracteristiCS as meas ures of wound hea ling. The th ree tools \,-jlh the mO!o.t we ll -e~ lab l is h ed reliabi lity a nd val idi ty are the Sussman H'(J/md Heafillg Tool (SWH T) ,J2 the Pressure Ulcer Scale for H ealing ( P USH }42,9J and the Pres.fill re Sore STatus Tool (PSST).42 The P US H 1001 is pre se nted in Appendix D. Th e !Vagller Ulcer Grade Classific(I{iofl S\slem is a tool des igned for exam ination of the d iabeti c f~t v. hen ne uropalh y and isc hemia are pre sent. 95

Risk faclor Assessment. Alt hough a ll indi vid ua ls can be ~ ubjectf'd to the same intensi ties of pre ss ure for similar amounts of time. th ey all will not develop press ure ulcer, . As a result. fa ctors re lated to individ ual risk. susceplibiiLt) or tolerance capaci ty shou ld be de tennined. Data can be very he lpful in plan ni ng cost e ffec ti ve in te rve nt ion qra t egie~ . As di sc usse d earlie r in th e chapte r. there are man) factor~ that put some peop le more at risk for de\e loping pres~ ure ulcers suc h as poo r per ipheral ci rculation. diabete s. nutritio na l stat us . mob ilit y. and conti nence io; <; ue o; 10 name a few. To objec tify and s t an ~ dardi ze risk a s ~es ~ ment, a number of re Ji,lble too ls have been \alidaled b) re~ea rch: • \'ortoll Risk Assessme1i1 Scale: original risk assessment

imlrumem sco re, ind ividuals o n phys ica l condit ion. mental condition. activity. mobili ty. and incontinence.96 • GoslJell Scale-Pressure Sore Risk Ass('SSmelll: refi nement of Nonon's ~cale includes changes to the fo llowIng ,conn g c ategories: nutrition , menta l co ndi tio n, acti\ ll~ . mob ility. conti nence. skin appearance. medicatIon. dI et. and fluid balance. 97 • Bradt'lI Scale jor Predinillg Pressure Son' Risk: the six ~CO T1llg catego ne ~ of th is instrument include se nsory pe rcept ion. moi,ture. a<:tiv it ). mobili ty. nutri tion . and fncl1on/.,hear.'h '\l u~cl e Performanclt ~l u')de

..,trengt h \Crecnlflg. during the syste ms review and 'lktlfk manual mu.,de te\ting i~ oft en included during t'\aJ l1m:lIIOn uj the II1dl\ Idual with a di sorder of the vascu1l· 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 (( Ign, , uc.. h a ...

Intervention Phys ical therap ist interve nt ion for disorders of the vascula r. Iympha ti<: . and/o r in teg um e nt ary syslems should include a var iety of tec hniques to address the problems ide nt ifie d du ring th e ex ami nat ion. It is comm on for p at ie n[ ~ with di sord ers in these sys te ms to present v..ith mu ltiple fac t o r~ contributing to the primary diagnosis. The int e rve ntion pla n "i hould re fl ect a ho li sti c vi ew of the pati ent. For exam ple. an indiv idual wi th signs and symptOI11:-. of ve n o u ~ disease ma) also present \\ ilh poor ankle ROM . a LE wound. and Iymphr de ma. The \\ound must be Ck31b Cd ~lIld d re~ , e d but the lim b should ab o receive compre:-'", Ion for o p t imu m heu ling . Ankl e R O ~·l must be im proved , ince ambubti on \\ ill e nh ance calf pu mp fUll(' liOll. AnOlhC'r C:\ ~' Cl\.) rlh ­ n.lted to .Ilkin:" .1rIt'n,d health. lil,\ bC'tc~ lll,lnJgC'lllent . ,mJ

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Chapter 17 Vasc:ula r, Lymphatic, and Integumentary Disorders and a stronger wo rkin g relationship with referring practitioners. The use of photographs . special form s for data collec ti o n. and bod y graph s are very effective tool s to enhance communication and documentation . Appendix E provides an ex ampl e of an exam ination form that might be utili zed to docume nt data coll ected for a patient with a wound.

Patient/Client-Related Instruction Disorders of the vascul ar. lymph ati c. and integumentary systems re pre sent majo r he alth event s for patie nt s and their fami lies and require life-lo ng management strate gies. Pati en ts and families often react with anger. de~pai r. or at least confu sion when learning about a condi tion that may be permanent. The value of patient and fa mily edu catio n c annot be underestimated . Patient ed ucati o n will be th e key to preparing individual s to manal!e their sympto m s. prevent recurrence , and remain vi gil;n t abo ut th e ir co ndition . Information should be provided tha t is app ro pri ate to the pati ent/family/care e.i\'er's ed ucational leve l with provi sions for follOW-Up ;nd repetiti o n. Motiva ti on strat eg ies are important to en sure ad herence to se lf- manageme nt. For many chronic di sord e r ~. hi gh-qua lity patie nt education has been shown to res ult in pos iti ve changes in health behaviors , QoL perce pt io n ~. and adhe re nce 10 home program s. Instruct; on fo r the pati ent sho uld include resources, education material s. and a ho me program. • Resources Community serv ices and support groups related to the patient 's diagnosis Coun seling services. as needed . especiall y for ass istance v. nh QoL Issues Internet siles (refer to Appendix F for Internet Resource.;,) Family member part ic ipati on in care • Education materials ln~ Lructional materials, muJtim edia tool s Self-manageme nt sirategies A\allable re';'Qurce s incl ude Wound Care by Sussman UJI ) or Lin".': Well wilh Lymphedema by Ehrlich.lol • Home program Sk in and/o r v.o und c are; preve nt io n practi ces; sc ar managelllent COlllpre~~lon garment or bandage wear and care Exen.: I ~

Edema con trul P re~ ... ure rd lt:\ IIlg de\ I ce~ . FOot carl" for palle nt!. wit h d iabetes ( re fer to AppendIX B lor.t toot cafe £ ulde I. OUlpalJenl or h OIllt: tht:T Ih\: tX:'l1 .... :.t) \0 l.tcllJlate ad hcn::nce 10 Ihe . home pru~r.tm .1I)(j to pre \l'n t recurre nce or e xacerba ti o n of ~}'ll1pl\lIn'l

665

Procedural Interventions This section has been organized in the order in wh.ich a physical therapist would provide patient care. Within each section, infonnation has been organized from most invasive/ lea st selective to least invasive/ most selective_ [n developing the POCo a physical therapist should select interventions that are least invasive/most selective. always trying to create an environment that is conducive to healing. The ultimate goal should be to optimize the body's opportunity to heal. Despite tremendous gains in the management of vascular, lymphatic. and integumentary disorders, there are still an alanning number of practitioners using outdated and often hannful methods to treat these disorders. Overused agents such as povidone-iodine. wetto-dry dressings. whirlpool, and compress ion pumps have been replaced for at least a decade with more advanced. biocompalible. and cost-effective methods of treatment. The use of inappropriate agents can delay healing and may cause harm. Supporting literature abounds for the clinlcian seeking evidence-based practice. Elements of skin and wound care that are often overlooked or underesti mated for their impact include pressure relieving devices (PROs), positioning, exercise. patient education. compression, and orthotics.

C leansing Wound cleansing is differentiated from wound debridement that follows in the next section. The wound cleansing method should be selected based on its ability to support or return a wound bed to homeostasis. Chemical and mechanical trauma should be minimized even in the presence of infection. A decision to cleanse should be made carefull y, as many wound s do not need to be cl.eansed at eve ry dressing change.

Whirlpool Since whirlpool can be classified as a means of cleansing and mechanical debridement, it is disc ussed in both categories of int ervention. Despite at least a decade of investigation , with lillie evidence 10 support its use, whirlpool is still used for both no nselective mechanical debride men! and fo r wound cleunsing. However. many clinicians invo lve d in wound c are have decre ase d th~ir use of whirlpool sig nificantly with the evolution of wound care and subseque nt publi cnti on of the Age ncy for He alth Care Researc h a nd Qualit y (AHRQ) guide lin~ s . Stand a rd~ have c hanged with the inc reased knowledge of the microe nvironment in the wound bed and a g reater understanding of tht: c he mica l mediators necessary for homeostas is. The hi~lOl'ic al ratio nale for w,e of whirlpool was based 0 11 it ~ u ~e in deodon l.Hion. skin ancl wo und c leansing. nlec hanlcal nonselective debridement. \\oound decontamina tion iHld IO fec tio n control . and soft ening adhe re nt necrotic tissue in pre l>ararion for debridement . There i!t lilII..! evidence to support whirlpOOl as Ihe optimal method

666

Physical Rehabililation

fo r achi evin g the se . If usi ng whirlpool for an in fec ted wo und , the AHRQ reco mmend s thai whirlpoo l be di scontinued when the ulcer is clean. First iss ued in 1994. the g uidelines are cons idered to still be cUITent. 91 It includes m o re th an 300 re fe rences: bi bl iog ra phic so urces and updates that can be eas il y oblained . 102 Ev id e nce-based rati o na le fo r change s in the use of whirl pool is based o n a num ber of factors ..~·1O'-105 T here is ri sk of contamin ati on from waterbo rne pathogens to clea n wo unds and o f patient cross-contamin ati on. T he depe nd ent pos iti o n can init iate o r increase venous congesti on and extremity edema. There is lo ss of endogeno us flu id s from the wound bed and heat loss affectin g core body temperature and/o r th e loca l wound area. Even mild changes in core body temperatu re (hypothennia) have negati ve effects on ce lls impo n ant to wou nd hea ling. Mechani cal disruption of granul ati on ti ~ s u e , epitheli a l cell s. and new sk in grafts occurs, primaril y from the use of ag itation. Whirlpoo l satu rates wound ti ssue and surrounding skin creatin g the potent ial for mace ra ti o n a nd s kin breu kdow n a nd te m porarily in acti vates no nnal skin defe nses thro ugh immersion. Thus there is the potenti al 10 pro long inn ammati o n a nd de lay wound he<.l ling. Whirlpoo l c an a lso in crease hean and re ~ pira t ory rates. Finall y. the use o f whirlpoo l is labor in ten sive and costl y in temlS of use o f water, utili ties. linen. and staff. Based on current standard s of care and g uidance from the litera ture c ited earl ier. it may be poss ib le to j ustify the use o f whi rlpool in the fo ll owing s it uations. \Vo und s thaI need intens ive c lea ns ing th at c ann OI be accomp lis hed wit h other methods m ig ht benefit fro m whirl pool. Min imal ag it at ion o f wale r is recom mended with on ly sma ll bod y a rea~ tre ated for s ho rt amo un t!) of ti me (5 to 10 minu t e~) 10 lim it the negative effec ts of tempera tu re and p rc~s ure c h a n ge~. U n l e~~ infec ti on is co nfi nn cd wit h tis:>,ue c ultu re . cy to tox ic age nt s in th e wute r s ho uld be avo id ed (c.g., pov ido ne- iodin!.:!, chl o rin e). Wo und s Ih ut need ~o ft en lll g o f loose ly adh ere nt tiss ue be fore ~ harp. en?) ma tic o r auto lytic debri demcJ1l m ig ht belle Ii t from ",llIr lpoo l when o lhe r li ~slle ~o ft e nln g I1l c th od~ a re nOI appropna tl'. (Nol e: there i ~ little to n o re llllbur ~e l11 c nt for the u'\e 0 1 whi rlpool to ~ofte n u '\we be fore debri de me nt). Wou n d~ that woul d hene fit Irorn Mim ulalion o f periphera l c ircu lat ion might lkne fit fro m \\ hiJipool. Ne UlrJ I "armth ur nonnothermi;l (normal txxI) h.~ n)pe ra tu re 98 .6<: F t3rC p 1'1 reconll11t:nded. P u l'-lali le

req u ire s Ie " c lea n up lim e . PLWS can be perf beds id e a nd in Ih e ho me. (Nole : family or visit 0htI0tI no l all owed in the roo m durin g the procedure ow~­ aeroso li za ti o n of m ic roorgani sms.)'08 II COllects .. " ex uda les a nd de bri s effi c ie nlly and delivers .::: a ~ti b i ot i c s , anti se ptics, an~ antibacte.rial solutions 4 c le nl ly. PLWS speed s heahng by rapid removal 0( t:.lm inants ~nd treat ~ tunn e ling w? unds and undt~ wo und s us m g s pec ia l ca nnula tipS. Ri sk of peri'A'Oled mace rati o n arid cross-contamination is eliminated . . use of di sposa bl e equipme nt. While the ad vant ages are cl ear, there are disadvantaces to using PLWS . These include ri sk of overuse especially with clean, g ranul a tm g wounds and ri sk of trauma to new ly fo rm ed li ss ue from pl asli c lips, pulsed irrigonl and/or suct io n. Trea tment may be painful to the patient. ' PLWS use sho ul d be limiled lo experienced Iherapists who are well versed in anatomy especially when irrigating trac ts, undemlining . ex posed bone. tendon. blood vessels cav it y linings. grafts. o r naps. All staff invol ved in lreat~ ment mu st wear di sposable personal protective equipment (PPE). Compared to othe r irrigatio n opti ons, di sposable, sin. g le- use equipment contributes to landfill burden. There is increased cost (labor, PPE, equipment).

L a\a ~t'

\\i th Suction (PL U S, .tI ... o re Je n ed 10 ..1'" Illn l'/ulllllgIlfWII) 1'1 ... 1llt.'lhod 01 \\ nunLl IITig.ul on LOIll b llh.:d ,, 1111 '1 ul li o n ( Fi g 17 I)) I!~ Pubed Irngatliln and "' Ililultam:uu'> ~ Ul'lIon remm e ... th L' Irn ga tmll Ilu id . \\(lund C\lHjat ~'1. <1111.1 loo ... e debn ... III U'Il' 1010\ 1:1 I\\ e llt) ) (" .Ir'l, thl'" \\" und l k.llhl n g ~Ind dd'llllit.'nh.' 111 m e thod 11.1 \ ~l' \ t.' 1.d alhJ lll.1 gC:') U\I: I \\hlripOlll l:k dl h lllg HI' II U'I ..· ... k ...... \~alcl k ......... 1.11 1 '1 uppnrt. Ie ...... tl c
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Chapter l7 Vascular, Lymphatic, and Integumentary Disorders

Figure 17 .16

W(~un d

d c.msing with nonforceful irrigalion.

\"onforceful I rrigat ion A, ,oon .1' po ...... ible . wo und clean \ ing shou ld be accomplJ'hed \\ II h minim a l pre~ sure or fo rce on the wound bed b\. no nl or~e t ul irn 231J0 1l . This can be aC('ompli shed by pounng a . . OI UIiO Il over a \\ ound . or using a bulb syringe. or Otht' r de\ ice d (,,~ lgn e d to deliver an irrigant 10 the ," ound (Fig. 17. 16 1. Th e re are ~ everal products that pack age" ~:l.Jm(''' ~ret' l fI(311 ) f or wo und c leansi ng: Blairex ill Wound \\ a,h S.lilne maJ1ufaclUrl.:'d by Blairex Laboratone~. Int. Colull1nu.'). 11\ 4 7201 and Saljet _ single-dose ' tenle ... allne mJnuf~u: ture d b) \VlIlc hesler Laboratorie~.

-

LLC. SI. (harb . IL 60 174. Se"ral manufaclUrer> 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

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Figure 17.17 Wound cleansing wilh a spray cleanser.

of debridement. clinicians must consider not only the wound statu s but also the physiological. emotional. and financial staLU S of the patient. Modem \vound management experts avoid debride men I techniques that ca use the wound 10 bleed owing to the highly damaging effects to the wound tissues . Nonse lective Deb ride me nt

We/ow-D ry Dressif/gs. A wet -to-dry (WTD ) dre ss ing co n ~is l s

of wet gauze applied to the \\ ound bed ,md allowed to dry on the \\ OUild. Removal of the dry dres~ing deb rides th e \\ ound. pulling ;.I\vay ;lilY cellular male rial that has adhered to the gauze. This meth0l1 of debridement removes necroli c tissue ;.t~ \\ell a~ rich endogenous tluids. fibrin , ilnd other celb critical to 'Wound healing. II is also frequently uncomfortable for the patient, often caus ing bleeding. and tr.luma 10 Ule \\ountl bed. \\'ound manage ment expert::, agrl!t" \\ Ilh :l lllultldl.')ClplinaJ) panel: "One of the mo ... t roulindy and inupproprin td) u~eu ronll~ of non ~dec lI\e lllec h:lIli ca l debridemenl IS the \\ct-to-dl) dre~~­ ing : ' ~~' jl ~II OIl<.:C helit:\ed Iv tx: I C' ~ I\ l 'O!)II) thun olher drcs~ ­ Ing option..." II Im& l~l"'n shown Ih .lt WrD J.r\!~~ll1g~ arc uClunll) mOl e l.' tl~ ll) tn :tIl rlcl\.Uh.'t:d Ul"l'\\m£", R esear~h a ddre ~"'lI\g Ih e nl'gult\ ~ illlr;ll"t l)1 \\-''1'0 dre ... sing~ on \\owll.b I ~ ,unIOl,lfllI:d In E\ Idcnt:~ SUI1Ullar) Bo~ 17. 1 As \,'-1D drl.' ... ,ulg ... l;lIl l:'tc cld.')"' lti~u a~ J toul lor mechaJlh......tl d~bnu~ment and/or it pnmal) \\l..lund drn ... ing. thl'Y h.1\e bC;'~n dl ~' u" "'~'d 111 bUlh ~,Hl"g0nf.:.'''' ,

~dl'l: lI\l' IIll·lh'~l.h

Surgical Sur£ll:al dd')nd~> nl~fl( prt.\ ick" rapid rt' ... ult~ v, tK!n (reatms life Ihr(,JIt:'nll l ~ oc-LJu ... i,. l.trp· v,l)UnJ, . tUllJ~hng ~ound",

.Irhl gu ll k to Ihl' \\OlU10 llcd htll 1,ll th: , l l l\\ I) \\ Iwn l'il t )(.) ... lng" IIll,;'lth~t

Jnd net fOlK nr lI1h-l'(cd hUllC' . \\ IJI! C\.l:hlOfl. rl!movin~ \ l.lbll! liJ\J nom 1~lblc h~::,uc . 1\ U'U.1Ii) Llollc 10 the Of"'!rutulg

lil u ;.J l dlll l ll tl n .llIll: lliod

11 1t ' 1\: llll l, I.III ,III I1:

11 ,,,, 11.· 1i1l 1 \ ~ II'> 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<.' nh

Ovmgton. LG Inc: 2001

N/A

Systematic review

NlA

WTD dressings have been standard procedure for wound care although research indicates gauze dressings are nol opUmallor the patienl. !he clinician, or the health care system.

Gauze dressings do not SIJIlIlOI\ optimal hea~ng and are more labor intensive tf1an advanced dressings. This article provides cliniclilns with the rationale and evidence to collaborale with physicians in choosing cosl·effective products to achieve posi1ive patient outoomes.

Lawrence. JC Lilly. HA and Kfdson . A'!I 1994

Simulated wounds: 7 subjects 14 dressing changes Ie: colOnized bum wounds

Experimental

Two dressing changes per wound

Removing dry or damp gauze from a wound released significant num· bers of organisms into the air. Significanlly fewer organisms were released when removing an occlusive dressing. Significant numbers of bacteria were still in the air as long as 30 minutes alter removal of gauze dressings.

Wounds are often undressed in open areas, sometimes with other patients nearby. Some health care practitioners do not wear masks when undressing a wound. There is an appreciable cross-contamination hazard from removing dry or damp gauze dressings without protection to aU individuals in the room.

Experimental

16 days

12 days after wounding 0% 01 dlY. 20% 01 moist and 86% of wet treated wounds were reepithelialized.

The basic mechanisms of skin wound repair: granulation tissue lonmation. r!HPilheliaJiza· tion, and contraction were influenced by moisture level. Ory wounds heal more slowly.

10 subjects with 10 wounds and 10 control areas IC' fuU-Ihid
Experimental

6 hours, with fluid assay every 30 minutes

Wilh evaporation allowed by gauze dressings. test fluids became hyper· Ionic.

Evaporation and saturation are difficutt to control with gauze dressings. Fluids undef a dressing remain isotonic until the gauze becomes completely saturated (which occurs prematurely in a heavily exudating wound) or until the gauze dries out as is often allowed on purpose. To remain is0tonic. gauze dressings must be changed frequently.

9 sP8Clafists Ie: mullidisciphne, inde· pendent Clinical experts in ge"at(1C care, familiar with 4dObndernentmodels

Nonexperimental: computer modeling and decision anafysisltherapy with each of 4 dObridemer1t methods

1 month

The likelihood of achieving a clean wound bed was 70% with 00I1agenase. 57% for f"rinoysln. 50% for autofysis, arid 30% for WTD dress· ings. Cost for treatment was highest with WTD and towes1 with

WTD dressings are often used as a d8bridement technique. They are not as effective 06 o!her options, their use leads more often to infection and they are cosily to the heaJtI>. COAl system.

SvensjO. 1 et al'1 1997

lsm. JK. et aI"· 1999

----- ------

3 porcine animals With a total of 70 wounds IC Female. Yor\<sh"e pigs. 3 monlhs 30-40 kg

- --

Mosher. SA. et aI''' 1999

collagenase.

Rodeheaver, G, et a l)l 1~

Roundtable of 7

Ie 10

mul~-drsclplfne ,

expel1s

000-_

Report of expert communrty

N/A

A multidisciplinary panel of experts WID i. one of the moot roulil1ely bullnapconvened to discuss wound care with propnalely used larms of a special emphasis on 4 types of mechanical debridement. The disadvandebridemenl: mechanical (WID), tages are numerous: bleedfng, pain, surgical, chemical, and enzymatic. removal of granulatkln tissue, desiccation (drying) and cost.

woond care

Kohr R"4 2001

1 (Gase Study) IC: wound lhat had failed to heal

Moist wound environment applied to wound that had failed to heal wilh WID for 21 days.

10 days

Switch from WID 10 moist-woundhealing (MWH):10 days to signmcanl wound healing.

Thelemperature in the wound was optimized. autofytic debridement promoted. Cost companson issues between WID and MWH also wen illuslrated in the article.

EriI<sson. E. et aI" 1996

1 (case Study) Ie : chronic wound, failure 10 heal

Moist wound environment applied to infecled wound thaI had failed 10 heal with WID for 7 years.

10 weeks. Followup al24 months.

Significant changes in 2 weeks. Wound closed at 10 weeks. Remained closed at 24 months.

The wound was bathed in endogenous (its own) fluids continuously, eliminaling the discomfort. wound bed disruption, dessIcaJion, and nsk of infection associated with frequenl WID dressing changes.

Colwell. JC, Fomman. MD, and Traber, JP11S 1993

70 patients With 97 pressure uk:ers IC: noninfected stage II or stage 1\1 pressure ulcers

Prospective, randomized, conIrOiIed sludy

15 months

22% of ulcers receiving hydrocotloid therapy healed as compared 10 2% receiving moist gauze therapy .

There is an overwhelming difference in healing between gauze and adVanced dressings. The per diem COS! of the moist gauze dressing w.. 512.26; the per diem COSI of the hydrocOlloid dressing was 53.55.

Capasso VA. and

50 adult patients with WOI.rlds, IC; 25-WIDdressings, 25-amorphous hydrogel

Nonexperimental, relrospeclive chert review

4 '"-kIy data collection points

The overall cosl of wound care was signmcanliy higller for patients in the normal salina group, with a high.. number and cost 01home nursing

DemorlSlratil1g the value and COS! eIIadiveness of hydrogel dressings sI10Uid anhance 1herapeuIIc decision making and guida treatment dacisions.

Munro, SH uf 2003

dreosiIlgS -see also Lawrence,ITO 1992. Ie =- indus Ion criteria; WTO "" wet to dry.

visits.

670

Physical Rehabilitalion

room with anesthesia. Laser debridement. another form of surgical debridement. may be appropriate when an individua l is not a candidate for operating room procedures. Surgical debridement is not within the scope of practi ce of a physicaJ therapisL

Pulsa til e La vage with Suction PLWS w ill provide non se lec tive debrid cmenl while c leansing a wound. Refer 10 the detailed di sc uss ion of PLWS in the previous section on Cleansing. W hirlpool Whirlpool ca n be utilized for mcc ha nic al de brid ement throu gh its feature of waler agitation. It can also be used to soften necroti c ti ssue in preparation for sharp, enzymatic. or aut olyti c debrid eme nt. Th ere are, howeve r. often better methods of preparing tissue for debri dement than whirlpool. See discussion in the previous secti on on Cleansing.

Selecti\'e Debrid ement S h arp. Sharp dehridemellf is defined as the remova l of dead or necrotic tissue or foreign material from and around a wound using sterile instruments sllch as a scalpe l. scissors. and/or forceps (Fig. 17.18). Considered the gold standard of methods for removal of necroti c ti ss ue. sharp debridement is a minor. tissue sparing procedure that is perfomled bedside or in a procedure room. In the vast majority of states in thc United Stales, it is with in the scope of practice fo r a physical therapist to perfonn sharp debridement. It is incumbent on the therapi st 10 be aware of hi s or her ow n practice act regarding regulations. In the June 2000 American Physical Therapy Association position statement. sharp debridement should be perfonned excl usivel y by physical therapi sts. not other per~onneJ. Additional infon113tion c~U1 be found in the GUIde to Physical Therapist PracfiCl, .80 A physi cal therapi st shou ld not debride except in the presence of necrolic ti ssue. E"en th ollgh "harp debridement is effec tiv e for all t) p~s of necroti c Il s~ u e. th ere are situ ation:.. \\ here thi ~ foml of dehri deme nt i~ not appropri ate. It i ~ cOlllrai ndi . caled for \':.t:,cular '"'ound . . v. ith limit ed hlood fl ow and

Figure 17.19 Maggol therapy for a cavity wound. (Counesyof the Biosurgical Research Unit. Surgical Materials Testing laboratory. Bridgend. UK.)

eschar servi ng as a cap for a chronic open wound. Without adequate perfu sion, there is lillie hope of wound closure. It is not appropriate for wound s with tunne ling (the wound bed ca nnot be see n) or areas affected by dry gangrene. Patie nt s wi th low p late let cou nt s, on anticoagulant s. or with other condi tions that inhib it clotting are not suit ab le candidates. It is also contraindicated for pressure ulcers on the hee ls cove red wi th dry eschar (Note: Some experts maintain that in thi s sce nario, eschar provides protec li on as long as th ere is no infec tion prese nt; others maintain that esc har mu st be removed because it inhibi ts ep it heli al cell growth .)

Chemical or Enzymatic. This type of selective debride· ment includes the appl ication o f a topical agent containing enzyme s that act by disso lvi ng nec rotic ti ss ue. A referral fur treatment and a prescri pti on for the enzyme ag~nl from a re ferring practitioner are curren tl y req uired in most r~gion s of North Amer ica. There are several types and bmncb of enz) matic agent~. e~lch designed to affect a cer· tain Iy pe of necrotic ti s!) ue . Advant~lges for this type of treatment ..Ire th at d ~ bridem e nt i:\ ~e l ect i ve, patient discom· fo rt i\ mi nimal. and appli cation procedures arc simple. Dis· ,Id \,antagc<, IIld ude the potential development of dennalitiS of the intaLl pc:n wollnd , k.IIl . fre'- Iuent dressing changes diS' rupting: tht: \\nund !xli. and e~char whil:h ma) have to bt' cfO,>,- 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
'L 1)1 '>I.. ....

Jp~.:1

..u\(1 hUll'jh hl/.h~I'p lid)! ,dum'ol

,I'>

IIlI..·th ll· ill lll- n:'I , t,lIlI Sf
\Il'nk. 11,--' \\ I} hakhl.'d JdJ'\ ,:It. aft' placf'd on Chr(Mlk' \H)llIltb .tJld hdd III pl.let· \\ Ilh drl· ... s lng ... h)r ~ 10 5 dayS l:Iefort'

Chapte. 11 Vascul ••, Lymphatic, and Integumenta
removal. Biosurgery has been shown to remove devitalized tissue. decrease the risk of infection and im prove wound healing wi thout side effects in a wide variety of wound types. Biosurgery is recommended for osteomyelitis and deep wound infections that remai n unresponsive to morc convenlional ant ibiotic and surgical therapy. Although moist wound healing is compatible with biosurgery. a very wet wound environment has an adverse effect on larval surv ival. Certain 1)'f.lCS of moi sture-fCtentive wound dress ings arc more com-

patible with larval survival than others. II7- 124 Autolytic. Allfu/ylir debridement uses the endogenous enzymes on (he wou nd bed to digest dev itali zed ti ssue and promote gra nulati on tiss ue fo rm ation. In prac ti ce, th e body's naturJ I fluid s are held in contact with the wo und base with a moisture retent ive dressing for 3 to 7 days. By increasing the moisture content of slough and necroti c ti ssue with the body's own enzyme- ri c h flui ds , au tolyti c activity is faci litated. While this me th od is the least invasi\e/ most selective as we ll as inexpensive. painless, and biocompatible, each pa tient is examin ed to determine if this type of debridemen t is best for the ex istin g wo und . The type of moi:.,lure retentive dressi ng selected to promote autolyti c debrideme nt will be based on the health of the peri\\ound tbsues and the leve l of fun gal or bacterial loads. A:., de~cribed and referenced in the disc ussion on moist ",ound healing. the presence of infec tion does not rule OUI the u!o,e of occl usive dressings.

Topical Age nts Curren t standards for chronic wou nd care have decreased the use of top ical agents even in the presence of infecti on. In the li terature the:.,c age nts may be refe rred to as antiseptiCS, duinjeu(1l11s. and /or antimicrobials. Oth e r topical agent calegone ... incl ude amihiurics and analgesics. When di sc u s~ ing the u"e of topica l age nt s with a ph ys ician. alwa)~ e\'aluate cytotoxicity. biocompatibil ity. safety. and efficacy. Even unde r Di rect Access, in most !o,tates phys ical therapi:.,h are nOl penll ilted to prescribe medications, even o\er-the-counter product'>. for wo und care. G uidelines re\'eal that almo!o.t <.III ma.n-made produc.: ts are cytotoxic.: 10 "hUe blootl u: lJ... even when dilutedY' Many agenls once thought to tx: ~
I'fH'idu" e-l (Jdwe. The comhllliuion of iodine plu:-. a pol) -

mer prcn Idn haltcnudal effccb. One c:oJllllwnly known

6 71

product nalllc is Betudine (Purdue Frederick Co. Stamford , CT 0690 1). Used indiscriminately for many years on acute and chronic wounds, it is now recommended mainly for wo und s infcc ted with Staphylococcus oureus. The AHRQ guidelines published in 1994 state: " Do not clean ul cer wo und s with skin cleansers or antiseptic agents (e.g .. pov ido ne- iodin e. iodophor. sodium hypochlorite so lution I Da kin 's solution". hydroge n perox ide. acetic ac id)."93. p 1.5 Although th e guidelines address press ure ulcers, the wound healing evidence is appli cable to all wo und treatments. This ev idence implies that the use of povidone-iodine as well as other antiseptics is inconsistent with prac ti ce standard s. In rare instances whe n such agents are recomm ended by a ph ysician and are indeed appropriate, clinicians should document sound reasoning behind the use of these prod ucts becau se they will be held acco unt able to these published and respected guidelines. The literature does not support c linicall y or legall y adequat e reasons to use pov idone-i odi ne for manag ing wound s. 125 In addition, the Food and Drug Administration (FDA ) has not approved the use of povidone-iodine soluti on or pov idone- iodine surgical scrub solution for wounds. 126 Its use is contraindicated for the noninfected wound. 93 Hypochlorite Solutions: Dakin 's (Bleach and Boric Acid), Sodium Hypochlorite (HousehoW Bleach). Sodium hypochl orite is cytotox ic even at very dilute concentrati ons. It damages fibroblasts and e ndothe lial cell s and causes cellular damage to granulation tissue. It is irritating to the skin and can initiate severe reacti ons in some individuals. It is used in the ma nagement of wo unds with purulent ex ud ates. Treatment should be di scontinued when the wo und is clean. Its use is contraind icated for the nonin fec ted wound YJ Acetic Acid Solution. Aceti c aci d is trad itionall y used to inhibit bacterial infections however, the solution has been fo un d to be more damagi ng to fibrob lasts th an to bacte ri a. 127 A comm on form of aceti c aci d is fou nd in vinegar. It is corrosive and cytotox.ic at any dilut ion. Most recentl y. it has bee n utilized 10 manage contamination by PSt' lIdOnl()1I0S al''''I,~;lIm;a. its use is contraindicated for th e noninfected wound.9' Oxidiu ng Agents: lIydrogen Peroxide Solution. When th is ~o lu t i o n comes in conlac t wit h tissue. there is a rc lea ...e of oxygen and temporary antimicrobial activity. liS bubbling ac tion is u!\e d fo r nonselec tive debridement to loo~en ~mall dehris. It is l'ytotoxic un l e~s di luted to a very weak c.:onc(! nLnltion. It is contraindil'ated in wou nd~ that arc noninfected. tunneling, or granulati ng.'I l Antibacterials This sectioll includes u sample of com monly utili zed topil'a J antimicrobial'). antit'liotic:." and :tntib::tc terials. These tnpicalugenb are cal'h (,tlcctivc agaj n~t a vi\ri~ty of bac te~ 1"1.1 ilnd arc ~clecled by th~ phy~icial1 based on the species

672

Physical Rehabilitalion

cultured for ~Ul indi vidual patient. All o f them share risk of simil ar side effcc t~'i sllch as bUJ1ling. itching, co nta ct dermatitis. and/or all ergic sensitivit y. There is little evidence in the iiler
Growth Faclors

gre;]test incidence

En dogenou s growth fac tors normally abound in the Ouido of a wound . In so~ne chromc wounds where the 00rrnaI tim elable ror hea llllg has been de layed or stopped, and growth factors in the wo und bed are decreased or absent, they ca n be added topica ll y. Increas ing Slrength of evi. dence support s the practi ce o f adding growlh facton 10. wo und to faci litate hea lin g . The application of e.oseno.., grow th fac to rs in conjun ction with good wound tare

Sii vadcnt'h, ilvcr s ulf~ldia z inc: primari l y fo r th ermal

increases wo und healing outcomes. 13I - 13tJ Growth facton, can be isolated from an indi vid ual's ow n tissue, added 10 a

Bacitracin/ B,l c i gllcn l : :t, soc iat ed with allergi c reac -

ti ons. Nco~porin/neom yci Jl

sulfate :

cau se ~

of allergic reacti on::. . injuries, sil ve r is !\clcClivc ly toxi c 10 bacleria bu t ma y lnacti\ ate topi cal protl'olytic cnzYl11e s . I~)( Furacin/n ilrofurazone : cytotox ic in animal stud i e s .I ~') Sulfamy lo n/lllafl:nide ace lale: diffu se::.. easil y through eschar. pri maril y for tlkTlTIal injuries. Bactrohml/l1111pirocin ointment: currently e ffective again st all species of !\taphylococc us. G e nta1l1i c in/G c r~lIn y cin : current ly e ffe c ti ve agai nst all :, pec i e~ of :-. Iaph y lococ c u ~ ~l1ld streptococcus.

0\\ in g 10 th e paucit y of infonllation on cytotox ici ty. th e r i~k o f side c ffe cb and th e growi ng incide nce of anlibi Ol ic- re.-..i stant bacteri a. use of these products for chro ni C \\Io und ~ , hould be consid e red ca refu ll y and is ll "uall) co ntraindi cated for the noninfected wound. Crea m s alld Oil11m ellls (Orer-ih e-Colllller). Some anti bacterial ointmenb and cream s ~lIch as are Bacitracin and Neosporin can be pun:ha:-.ed \~ ithout a prescription. These arc minimall ) bacteriostati c owing to th eir dilution. Once they lo"t." th eir ant ibacterial stren gth. the ointm ent s may [rap hJcteria and encourage bacterial growth from surface co m3m ination . If oill!mclll s or c ream;.. an: used . th e lA oun d ~ h ould be clea nsed regularl y to remove pote ntIal co nl aminal1 on. hov.e \' e r. freq uen t c l ea n ~ in g may di ... rllpt tilt' he:1ling rroCl.~"' \ ' The"'t'" preparatio n::. provide.' mo islLlre \,i l ~it e\ pelhi"cj to a d ry \\o un(\ but th e) m~l ) crea te a gre.·J. . . ) ,\ou nd bed. mal.. lng earl ) e pithelial cell migr
T he: u'-.c 01 IOpiL.l1 .Inl' ... t h ~ ti c . . to control ,... ound paI n I ~ Lon l rmer"'htl 111 th~ I lteraturc. Cunllid ing rl: po rt ~ Hnd th t: I..iLI... (It \Ub ... I .l 1l1 1~j l rC~(:iln h h ~l \c led Ii ) \.:OIl L"l.Tlh Clb0ut th l'"

lin r;'H.. I 01 u.1ll'..., lheliL· ... on lhe v,oulIll I~d. Thi... I \ .... U C I ~ !urther Lt)lIlpitL
ilion

th~lr t"tl{)I ()~ I ~'" ;111<.1

,I~t'nh

01

lit Illl\lUfL' ~II

L'olllLlrhlllll le... 1 he Illnrc com · tl'..ed ttlpll.tl l) art' IIdlkcllllt' and Ff't. 1L A 1t.· lI iL'L"-

lidtl;...tlllt'

l'ih!l"

IIlL •.1i dJlnl h l' l lc.-..j LTL'..ttll, \\ hldl 1...,.1

Jl lI,turc

.lnJ prilOL..tinc \A . . IU/t·II.:I..~1. \\,illll ll1 g h.lII, D[

'\nlltnpl)llllt·. a trh:)Lh~' ,UJlllk'prt· ...... ,llll 1M" illLdl

J.n~ ... tll~tll

prnjlertle .....tnl! ha . . ...,110\\ II plnllll"'l,' .1. . all (IP I I~)1l \·,! ,und !' ..un I'" \"'lIk t((pll.ll .IIW..., l hL· l lt· .... /lId)

1111 IlL',I1I11~

hI.. UIHkl "'LIUllJI) hll tllL'11 t'lIL'lh \;htlLt1IbtnLtI(lll Ilud,ll,

;\ fil.J.I'"

tht:n:

III p.tr

I'" d Ih:n.1 hll IlhlrL' Ill\C"'II1,!.
1..... UL·I"1 1111,,1 jl,III~'II"

\'-lllt \\uund

liqui d formula and reapp li ed to th e wound. An e.ampleo/

an autol ogous growth factor product with a name familiar to man y clinicians is Procuren (Cu rati ve Health Services Hauppauge, NY 11 788). Recomb inant DNA technolog;

has res ult ed in oth er produ c ts such as becaplermin gel, trade name Regra nex® Gel (Ortho-McNeil Pharmaceutical In c. Raritan. NJ 08869 ). Re imbursement for application of

growt h fac tors vari es a nd should be checked before use. For exa mple. bccaple rmin ge l is FDA approved for the treatment o f LE diabetic neuropathic ulcers that extend int o the subcutan eous tissue or beyond but currently not approved for th e trea tm ent of press ure. venous, or other nondiabet ic-related wounds. Topical Agents and Acute Wounds

The Lise of antj sept ics and antibiotics to reduce bacterial leve ls in acute. traumati c wounds follows a different rationale from that of chronic wounds. For wounds resulting from trauma or themlal injury. the risk for contamina· tion b hig h. It is accepted practice to utilize cytotoxic products ..;uch as povidone-iodine or Silvadene in the early m.lI1agement of acute traumatic wounds. The goal is to dis . continue use of cytotoxic agents as soon as the wounds are clean and able to produce and support endogenous fluids.

Mechanical Modalities Proced ure s l or u:-.e of mocblities vary based on unique

patient t haracleri stics and individual patielll response. A u . . eful place to beg in i::. with protocols recommended in L·o tl lprcilen-.ive wo und management tex ts such as Wound II l'a h ll ~' A frl'rll t lfll n in Ma na oemem bv Kloth and \ 1c Cullol' h l17 and W (l /{ I/d Care b~' Suss m;n and Bates· Jelben Il~ 0\\ in i:'u to Ihl' eve.~ r-c hanoiIFJ ;:, eo rules of reimburse . m e lll . It I'" prucknt to chl!r l.. c urrent reimbursemenl and JOlument dll tlll gllH.kli nt'::' '' hen billi ng for these servlCe~. lllra ~u llnd

ll r;t-'\)l.lnd II JS, .11'plic31 iO~l for wound. m.3Illg; Ilk'nl tllth' r", tro m I\-. li::.t.'" a!\ a lllocbl lt) to rreut pain. U ...,IIIHUl.th;' ... Lt~11 .l1..1I\·i l) . •h.:cl;.' k raling processes ::.uch. ; Illfl.llnn1,HllIll ( )nL'e thou!.! hl \(l large! only the slugg \'\Pllnd in the.' Inll a l ll mcl lO ~) ~ I age , c\. idence noW d~= ... lr.Ht: ... Ih.u tht' t'l lt·c l-.. l'.Ul bt- :-.een throughout all ~. ht·.J lt ng phd...l· ..... l3a!\tL' . . l· Il' I1 L·C ~\ idence and c1inicaJ re:,taldl Ita\\:' L" ... ld blt ... lt.:-d tlt.1I \1...111 rt'p~Hr ~lJld \\ound ('onb"'dClionr3ll ~t' .1l"L~.'kr;l!Ld, u)II.lgen ' ecrellon can ne s~iOlulate-d~ ll.hlill prnp ...: n! \.· ..... 11 it'l"fni tll ... trl·lIglht.~n scar USSUl!· Siru l 'herdl"k.'l.IIIL· u

C h apter 17 Vascular,

L, mphatic.; and Integumentary Disorders

673

Figure 17.20 Application of lll(ra ~o und 10 \vound :tnd peri wound fI ~, u e\ \\ I\h h) droge l sheet coupling. (From Kl oth. LC. and McCu[[och. JM .1\1 Pl ate 15. with perm iss ion.)

Figure 17.21 Electrica l stimul;;Hion direct [one electrode ( +) on wound I electrode placement method. (From Kloth . LC. and McCulloch, JM , ln Plate 48. with permiss ion.)

procedu re for the trcalmen! is 10 cover the wound wilh a , heel of hydroge l. or an applicatio n of amorpho us hydrogel. US is th e n de livered w ith a ha nd - he ld appli c ato r ( Fi g. 17.10). AnOlher opt io n for tre atme n! is to appl y US tran smi ~s ion ge l to the periwound area and treat from thi s reg io n in additi on to or i n~l ead of the wound bed. 1)9-14-1

li ze radio waves to prov ide the nnal and nonthennal e ffect s respectively. All tran smit radiation from an applicalor head 10 the target ti ss ues. PSWD heats superficial and deep ti s~ s ues. CSWD heats deep muscle and joint tissues. PRFS can influ ence ti ssue at the cellular level. Wound sites treated with diathenny have demonstrated inc reased fibroblas t prolife ration . collagen fo mlation, ti ssue perfusion . and metabol ic rale. While the number of clinical studies is smaller than that of othe r modalilics. the evidence is mounting for the role diathe rmy plays in wo und healing. The clinical use o f these modalities has increased since the publicalion of a numbe r of s tudie s regarding the nonthermal e ffect s of pul sed diathe rm y and the production of smaJJe r trearment units for cl inical use . 156-158 Equipment needed fo r treatment inc ludes a diathermy unil/el ec tronic con sole. and one or two applicator heads. Treatme nt is us uall y delivered w ith ~ o ut touching the skin . Wo unds should be carefull y prepared before treatme nt according 10 guidelines. With newe r units s uch as the Provant lInit pictured in Fig ure 17.22. the pad c an be placed ove r wound dre ss ings, co mpre ~s i o n gar-

Electrica l S timulation The uo.,e of e lectrical stimul atio n (ES) to treat chro nic . and morc recentl ) . ac ute wound s is well d ocumented. ES is rccommended to e liminate bac te rial load. promote granul alion. decrease innamm ati o n. reduce edem a, reduce wound rela ted pam. and aug me nt b lo od fl ow. Human s kin , \l,ound,>. 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 <.I{; li v it i e ~ by ~ upp o nin g. alte ring. or pro\ id lllg el et:lrical c..: urrents to accelerate wound he aling. A clear undtT'>td.ndi ng of med ica l e lectric it y will a::.s ist lhe cli nician 1fl a ppl y ing an ap propriate ES treatme nt. The ava il able literature IS dive rse and i n~l ructive.z ~ I S_\ The re are a \ariet) 01 \) pli ono., fo r trealme n t setu p d epe nd in g on th e goals of treat me nt. the type of wou nd . and the conditi o n o f the pallt:nt Standard equ ipme nt fo r the direct me l hod o f "'pp!tl:aIlOn wi ll Incl ude an ES unit , trcallne nl and no nlre at ment elcurode,. and J ~ ub s t an c e !o. uc h as saline soake d gaule or J hydrogel d re~~ ing applied to the wound bed o r ta\ It~ to cnhiJnu~ c leurica l conduc ll vity u nde r the treal ment electrode (ri g. 17.2 I ). For the indirect meth od. e l cc~ trod~, ... tf;Jdr!lc Ihl: wound and in te rface with the periwound "'~m U..,lIlg gel clCllrode~. C linical dec i ~ ion~ re lated 10 volt J.~e. elturoJe pl~l(.:t: lIlent, do ...age. Jlld o ther variable ... lllu ... 1 he n1.ld. . on .1 l:.In d ~ Hnlhc rmal Uiathcrl1lJ "uJ'>l'd .hon ;'I \l.' dZi.l lht:nny CCJnIlIlU()U ~ !ohm! \1,<1\1.: dldtlJellll) j( '\ WDJ and pu bed radlOfrcquency ~11111 ulc o f 'AIIUIIJ I" .dl ll}! III Illl' nn\ I hl'...e d ml h t: lIll ) trc;J llllcnl '" ulI -

,pswn,.

Figure 17 .22 Pru\ 'JIlI >' Wound Clo... ure SYlI lcm {CQurle~y of Reg .... lll· ... ' \' BlOm..:(l!t aJ 11K ., St\lu \dak . AL X:'i:!37. )

674

Physical Rehabilitation the ir e ffec ts on human skin are UVA , UVB. and UVC. UV has c utaneous and bacteric idal e ffects that include increased blood fl ow. enhanced g ra nulatio n ti ssue formation, destruc_ tio n of bac te ria, stimulation of vitamin D production. and thic kening of the stratum corne um . The effects of UV radi_ ati o n o n antibi otic- re sistant bac te ria make it a useful tool in wound carey..o-l(>l UVC in partic ular has been found effective in the treatment of methi c illin -resistant Sraphylococclls aI/ reus (MRSA )Y>-I The treatme nt is typicall y delivered to a cl ean wound w ith dress in gs re moved. using a UYB Or UV C lamp (Fi g. 17.25 ). Treatme nt di stance and dosage . frequ e ncy. a nd sub sequ e nt c li ni c al outcome s will vary based o n the goa ls of the treatme nt and the statu s of the wound. The vari ed ph ys iol og ic al e ffects make this treat. me nt appropriat e fo r a vari ety of skin di seases as well as ac ute a nd chronic wounds,cW,165. 166

Figure 17.23 Wound be ing treated with Pro\';.mt® radiofrequency stimulus. (Courtesy of Regcnesis® Biometli ca l Inc, Scottsdale, AZ 85257 .)

me nts. and casts. Because the effects of heal may continue after the treatment. pati eIH s should be observed care full y and protocol g uide lines sho uld be followed cl ose ly. Fi g ure 17.23 pre sents a wound cUlTe ntl y under treatment with the Prova nt unit; Fi g ure 17 .24 de pi cts the Provant treatme nt pad in place over a leg wo und .

Ultraviolet Radiation Ultraviolet rad iati o n (UV ) ene rgy is a fo ml of rad ia tion be twee n X- ray and vis ible li g ht o n the e lec tro m ag ne tic spectru m. 159 UV wave le ng th s have been d ivided into wave length s and band s. The three bands most use ful fo r

Fi g ure 17 24 Ltg \\nU !ld l.()\t:teJ \\ Illt Pl(n,'ll l 1I\:atl Ilell I p,ld ({ ·oun t: ... ) u l !{cg..:tlt: ... t... BlillH..:dl l.1i 11 1\. Slu lh t\ ,lk \"/ K52:'i7)

Hyperbaric Oxygen Therapy Hyperbaric oxygen therapy (HBO) delivers 100 percent oxy_ ge n to an individual resting ins ide a sealed chamber. The oxygen is delivered al a pressure greater than the atmosphere. Thi s system ic treatment increase s the amount of oxygen available for ce ll metaboli sm , improving oxygen delivery to hypox ic tiss ue. Systemic HBO is. however, associated with ri sks rehlled to oxygen to xic ity. The literature demonstrates positi ve responses 1O thi s treatment when used as an adjunct to o ther forms of wound care but few controUed, randomized trials have been comple ted . 13':1.1 67-17 1 Chambers to deuver top· ical oxyge n have been avajlable for at least a decade. Discus· sia n amo ng investigators comparing the effects of systemic ve rsus topi cal oxygen is o ngoing. In some studies, topical o xyge n is al so re re rred to as topical hyperbaric oxygen (THBO ), and O ~ lherapyYl.171.17-1 Instead of the full body c ham ber u~ed fo r HB O , THEO is de livered in a localized

Figure 17 25 \pp hnulLIlI olullr.l\ w ier hdl 1 lft :.u ment u!!ing. Dt:rm.m.lIlJI t.t ICOUrJc '-, \ 01 Nd[lllIlal BiuI7J!!-ICUt Corpor.!.lioll . 1\~ 'tl ... bu l g. Of t -l--lIIS7 j

Ch apter 17 Vascular. Lymphatic. and Integumentary Disorders limb chamber. Using THBD. oxygen is de livered directly to me surface of a wound throug h a portabl e unit large enough \0 enclose a limb o r the sac ml a rea . 12 · m THBO has bee n combined w ith elec trical stimulati o n and a lso with cold laser for the trea tme nt of pressure ulce rs a nd ne uropalhic foot wound~. I"n.17J l o pical O~ the rapy has enhanced the effects of (!rowth faclors in investi gatio ns within the last few yearsyl Renewed inleresl by investi gators ha'\ lead to more refined protocols ;.md improved strength of evidence in the fi e ld . If investigation!) con tinue to prov ide pos itive result s. the usc of topical 0 , in \\ound care could result in lllorC cost·effectivc and eflid-ent care. fewe r risk s and appl icabilit y to a wider population 3'1 compared 10 sy~ t em i c Or

Therm otherapy (Rltdiant Heat ) Thr proce ...... (If \\·nnni ng wound !) 10 promo te healin g is an IlllpOnani part of wound care inte rvention . Owing to the ir local ion . the I) pc of trealme nt used and/or the l o~s of s kin prol e(llon . 111 0 ... 1 \\ ou nds are hypOf I,crmh· ( be low core hOO) temperature). II i ~ not ~ urpri s in g thaI wound s heal more effi c ic:nll y if Ihey are normothermic (norma l bod y temperalUrC'). "II I-" \\ hile reac hi ng n o rmothe mli a c an be ac<:ompl1 11 hed In a numbe r of ways. the Wann - Up Wound Therap~ Sy\tcm™
Figu rtl 17 26 AllhUI! h i

'.l lIll

I 1 II

I

I ' I ,I U I

I" M 1.lihJ IlI hc J I HI C uml

-\1

II ... \..l~ I

1("~lliI1 L"') vI

675

Figure 17.27 A stage IV sacral prcc;."ure ulce r with reticulated fOllm dress ing. tubing, and polyurcth:mc shcet covering the entire wound to mainta in the vac uum during treatment with vacuum ass isted closure. (From Kloth . LC'. and McCul loch. JM ,131 Plale 14. wilh permiss ion.)

as se miocclu s ive dress ings a re used fo r mo ist wo und healing and c an be le ft in place for up to 72 ho urs o r unt il Ihe absorbent ed ge of the c o ve r becomes sa lU ra l e d .IW. 1 7 ~ 17';1 Althou g h ro rm e rl y m a rke ted in North A me r ica and s till being used here. avai labilit y is now limited . These dev ices. however. are ~ u ccess full y utili zed a nd l11 a r~ c l e d in Europe. Nega ti ve Pressure Wound Therap)' Negati ve pressure wound the rapy (N PWT ) is used as an adjunct to wound he aling to fac ilitate wound clos ure in ac ute s urg ical wound s as we ll a ppl ied throug h the foam 10 Ih~ enti re wound bed . Ty pi ca ll y. fo r the fir·.;L ft:.\\ dny~ ( --l ~ huur~) the negat ive prc:,-; u re i~ a pp lied l'o nt inu ous ly viu Ihe pt.)1'I..Jb lc pump ... )stcm . Afler a ' Ig nifil'ant amount 01 c,ce~!'I \\ound n uid h ~l~ bee n w llh dr.I\\dl. th ~ p UIllP I'" progrJmtll~d to .. tpp ly prc ... ..,urt: int ermitt ent ly. T il t: foam drl! ...... l ng h (' hanged evcry 12 hour ... (intcch:d "ound'll to ~~ hOill·... ur longcr (Ck'.111 \\ o und ... ). The \ I rl' n ~th of C\ Idt'IKl· 1"1 mount ing ~" hU'I It' It.·"carc h t'\.p lon· ... tht' d l ee l \ uf thl'" n . . atllleni. N PWT ha'l lx-cn 'S huwtl . III ';01111.,: '1 lU liic'l. 10 ~ tllu n t~· granu l.llton li~\ul' fonlHHllln prolllnlt.· "QUill! edge ,lppn...... un.1 tum, n.: movc ~dt:"nhl /rtlm v.ollll(l.... and Im pl'll'VC ~n)g.t.·n leve l... III Ihe "ollnd. llill 1>0. 4 0111..' LI
676

Ptn-sical Rehabilitation

rccommend':l.Iion by the th erapi st. In differen t el~viro n ­ ment .... administration of the tcchnique may be perlonned by ther.apisl~ . Ilur'cs. or othe r clinical staff.

Cold Laser Therapy Cold laser is a l ~o rderred to in the li terature a.. low - l cv~1 co ld laser. low-level infrared laser. or monochromatI c infrared photo energy (MIRE) . Low-energ y I~~er treat ment usc ~ lioht in th e infrJrcd spec trum . ThiS therapy ~ . Ill-~ d has been promoted for augl11t:"llling wou nd heallllg al~ reversing th e :-. y mplom ~ of peripheral neuropath y 111 individual s with diabcles, ll'.h.IK7 It is thought that th e effects of 13ser increase circ ul :Jtion and reduce pain by increasing the rele
Dressings Th e t) pc of wo und dre~s ing s ~e l ec t e d for a wound may have a profound effec t on he
Figure 17.29 Appli cation of infrared photo energy to the fOOl using an Anod yne® Therapy toot pad . (Courtesy of Anodyne Therapy. LLC. Tampa. FL 33626.)

necessary 10 make clinical deci sions about dressings: the characteri sti cs of the dress ing categories and the effects of the dress in gs on the wound bed, Refer to Appendix H for a listin g of dressings categorized by treatment goal (purpose) or type of wound (indica ti on ). Choosing appropr iat e dr~ ss ings should be directed by the characte ri sti cs of the wound and peri wound tissues. not by what is availabl e in the suppl y close t. A product th at presc rve~ wound hydration and limits fluid loss is u!-I uall y iden l. In add ition to foll ow ing the principles of mOi!)1 wo und healing in mo!)t dre,s ing 'ielections. the follOW ing \\ ounu chaf
remov\' Granu la llon ti.'sue : pres...·I1t or ah~e nt : proted. facilitate or ~ l nv. ulIw n fo rma ti on Ep itlll'il .illl:tl io n: pre-,(" nt or a b. . e llt : facilitate- or slo\\' d{"~' n fOfJnat lon Pcnv.ou nd ;u('a; IllI act, at I'I "!., or macer.ned; prote..·lor trl'at llll'Olll lll~nl'l' : r r(".'('n t o r .Ibsent: prott't·t or moniwr Cd' 1I1~:-, ;tnt! tunnl' lI ng: rre . . cnt or .Ib~l~ nl : fill or pre\ent h 11..11011 , prl"c l1l. ~OOll' 1 j, J.,. . slg rllticant ri,k: CU))IUOIl. pi \ltCl' t 01 prt"\ t'llI

Odi..lr' 11lllllllhll llr nced It"d lll: ll o n: rl'dUl llIg Jlt' ... slng ...

F ,JurE> 17?8 ·\nnd~ Ill' "~~I\"I!I ilIum I 1111 \\ lIh "~\I p,LlI. (('uun," ~ ot \1\11\1\11\ Itll"l.I(I\ I t { l.,mp.l, II \ 'h~t. I

Ig nLU'I:

or add Ollor

I hl: JiI..'''ill1g that h 'lpp lieJ lhrel. tI) 10 the \\ound I ' 1~'kn~'J Itl .1 ... Ihl' jlllllllln drc'''' II1p.. The drcs!<>ing th.U 1) ...p plll'tl ll\~'1 th\.' plllll..tr\ url' ...... IIll!. I') Il' fc lT~d lO :b the-S I',·· Ill/cJ(//\ dl t· ...... lllg "HI/II..: JL!\,Ull':d t.l r.... ~s ing!) M~f\( It\ Ihe

Chapter 17 Vascular, Lymphatic, and Integumentary Disorders

677

Figure 17.30 Samp les of gau ze dressings.

Figure 17.31 Application of a film dressing. primary and secondary. incl udi ng ad he sive and absorptive quali ti es in the same dress ing.

Ga uze/Fiber Gauze dress in gs ( Fi g. 17. 30) a re co ns id ered by many wound management ex perts to be o uts ide the descri pti on

of modem wo und dress ings. Used and mi sused for decildes. there are morc reasons not to use gauze than there are mdications fo r use. As a primary dressing. gauze le aves cOIuaminalin g fibe rs in the wound, contributes to desiccation. is permeab le to bacter ia. can be adhe re nt to the wound. releases excessive am o unts of bacte ria into the air upon removal. and causes pain upon re moval if it adheres to the ~o und surface . O nce tho ug ht to be cost e ffective, it has been shown in mo rc than onc study. to be mo re costly than other dressing choices. (See Ev idence Summary Box 17.!.) G uppo rt a cavity wound but shoul d no t be u~d 10 aggre~!) ivel y pack any shape of wound . It was once thought that c avit y wo unds sho ul d be pac ked very full bu t it has since been established that g ranulati on ti ssue and epll hel ia\ ce ll s do no t survive we ll wit h a gg ress ive gauze padi ng . Th e addi tio nal pre ss ure from a ti ghtl y packed wound will Impede the flo w of oxygen and nutri ents to the gran ulati ng wound bed. Gauze can be an effecItve ~cond ary drt:\"i lllg. espec ia ll y if the dressings wi ll be changed frequentl y o r if e xudate h. heavy. Gauze 4 X 4s and a roll of gau / e are Iypica ll y u!:oed to c reate a WT D dreS~ tng . Becau ... t.: WTD d res~ lIl gs ca n be classified as a tool for me<- han ica l de br idement or as a primary wound dre~~ing. the) arc di\.C u\::.ed in both categories. Impregn ated Ga u1.e ~"Igntd 10 Ix: It:~ .. adherent , t hi ~ category includes prodUct.., mad!; 0 1 llgl.t ly melo. hed ~ y nlh e ti c fibe rs or woven prOd uch ..,ut h OJ.., ll!lIulo ... e ace tat e . Fibe r mate ria ls arc lmprcgndlt:d .... nh OJ petroleum emul ~ i on such as Vaseli ne*, Intended 10 prC\CllI the gauze from ~li cJ...ing to Ihe wound 'urfate . L 'ted ~l', ,I prima ry dn.!lo.)'i ng thi !. choice is mini mall} dh,orpti\ t:. prm Ide~ Il1 HlI l1la l I)roteciiOIl , does no t

e nh a nce a mo ist environme nt , and may create a g reasy wound bed. Tr a nspa re nt Fil ms Films are made of a transparent membrane with an acry lic

adh es ive laye r (Fig. 17.3 1). Transparem film s do not allow bacteria or moisture into the wo und . Currently, few film s have a bsorpti ve qualities and c annot be used o n hig hl y ex uding wo und s. They fa c ilitate a moi st wo und envi ro nme nt , tra pping e ndoge no us fluid s in the wound bed to ass ist w ith auto lyti c de bride me nt , wo und bed homeostasis, and angiogenesis. Films ass ist in protecting skin fro m the e ffec ts of shearing, fri cti on. and the contam inating e ffects of in co ntinence. Re mo val. ho weve r. can cause skin tears espec iall y w ith frail o r aging skin . Foam Foams are hig hly absorbent pads, sheets. o r packing of polyurethane avail able in many sizes with many features (Fig. 17.32). They are ava ilable with o r witho ut adhes ive bac kin g so tha t they can be used as a primary and/o r a secondary dressing. They are hi ghly absorptive but a lso he lp to create an occlusive env iro nment fo r moist wound

Figure 17.32

S;l lll p l ~3

of foam drelos ings.

678

Physical Rehahilitation

Figure 17.35 Sampl es of hydroco lloid dressings.

Figure 17.33 Sample of a hydroge l sheci dressing.

healing. They shou ld not be used alone on a dry wound but could serve a's a seco nd ary dre ss ing if the primary dressi ng was a gel product. Hydrogels Hyd rogel s are categori zed as amorphous, referrin g to a liquid-like gel or as sheets, co nsisting of a thin . flexible sheet of polymer contain ing at least 90 percent water (Fig. 17.33), Both types are used to increase moi sture in a dry wound bed. soften necrotic ti ssue and support autoly tic debridement. Both have some absorpt ive qu alities and will swell slightl y until they are saturated . The amorphous gel (Fig. 17.34) mu st be contained in the wound with a secondary dressing. The tl ex ible sheets usually require a secondary dressing but are ava il ab le through so me vendors with tape attached 10 the borders. Patient re sponse is usually very positive 10 the sooth ing se nsation of the hydroge l application. Hydrocoll oids Considered the most occlusive of the moisture-retentive dre ss ings. hydrocolloids are also avai lable in less occlusive or semipermeable sty les as well. As with foams, these

Figure 17.34 App li t:
dress ings come in a variety of styles and shape s including pastes. granu les. powder, and sheets. They typicaJJ y consist of an absorbent co lloidal material combined with a film or foam backing ( Fig . 17. 35). They work best on mild 10 moderate exudat in g wounds. When wound exudates combine with the collo idal pol ymer, a soft , ge latinou s, o ft en ye ll ow. and malodorou s mass is formed. Patients, families, ca reg ive rs, and other health care providers must be info nned about this harmless reaction so that infection is not assu med, Hydrocolloids have been used s uccessfu ll y as occl us ive dressings over infected wou nds wi tho ut fulmination of existing bacteria. Alginates This dre ssing category is al so known as calcium alginate because the dress ings are manufactured usi ng the calcium salts of alg inic acid derived from marine algae and kelp (seaweed). The raw material is wove n and then converted into nat sheets. ropes. o r ribbon shapes (Fig. 17.36). Alginates abso rb 20 to 30 times their ow n weight. are gentle to appl y and remove, and biocompatible wi th the wound bed. A chem ical reaction betwee n the dressing and wound

Figure 17.36 S,lInplr ... ot algin:ut! dre:-,sing"',

Chapter 17 Vascular. Lympha tic. a nd Integumentary Disorders

679

Table 17.3 Examples of Skin Substitutes ~ IF.:.

>.

.....-F.'·· ', .. .,,,' : ..

~,

:..,.~'t.{,.~c.... ;!'ii'':'.:-.-_ ," ".

__

~_

.

~,-J;.

''':~

'-.•

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

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Figu re 17 39 llllu .. ~ .... )r .tpph ...·J.tlol\

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'r('\\(I/£'. "hich means thai they cont inue to con'tnct \\hen the \\earer i, re~ ting . Owi ng to their ex te ns i· blilt~ or .... n;·lchlne"i'l. the) do nOI prov ide s ig nifi can t '\'(Id Ul~ [>rfl_\/ I rc the ahil il) 10 rc"isl muscle contraction

Figure 17.41 Sample of short :o-.tretch bandage.

during acti v it y. Long stretch bandages are readily availab le and require lillI e training to apply. Short-stretch bandag.es such as Compri lan® and Rosida J.I provide fow re'sring pressure and high u'orking pressure (Fig. 17.4 1). The y are le ss eX le n :-.i ble or s trelchy. providing a more rigid s he ll when applied to a limb. Thi s feature make s s h o rt s treich bandages more appropria te for treating ed e m a and lymphede ma . H ighe r \\orking pressures inc rease the effic iency of the muscle pump during activit) while lower resting press ures make Ihe bandag.es m o re to lerabl e to we ..\f. Short-stretch bi.ll1dages require special training to apply. The number of b ye rs or bandage, Ihe age and condition of the banda ges. th e tension on the bandage \"hen it i ~ applied. and the ~ kill of the clinician \\ III all influence the amount o f \\orling and res tin g pres'jure delive r~d to the limb.

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L) mphedenm Bandaging Thi.., high!) ' ''pi'c.:ialilcd foml of bandJglllg lItili7es mult ipk Ia) e r~ 01 lItlil(ue paJdmg matl'riab and :o. hon s tre ich band agl''I to ere.lle a ... uppmlive ... !nll·lure for elk'matoll :o-. ~Uld I) mphedem:ll om blK.l) :o-.eg ment.!o. Lympheden1.l bandaging prm I {k~ \Urron lor 11 ~-.;lIel> th ~1I h,l\{' lo.;;t t.'Iasticit). J 'k· llJt.II~ '" a m ild Inl..' r~a'\e 111 IInllt' pre.ll:o-.ure. assisti ng 1)l11ph \ c ... .lIeb In O:l\1pt), prt"\ enb re filling of (he imeNII ~ lIum bel\\ ce ll t-.tLO tre.llmenl\. Iltlpro\l!'\ Ihl" c.."fficie-Ilc) of Ihe llIu..,d e PUll1l) dunng al'll\ it) ilnd pro\ ide:o-. localiud prc-';"'U1t! \\ herl' Indi~'~lIl!d h ) ...o ft en til"orotlc ,i ":o-.ue . B;tIlJ.i~lIlg p n..lIO\:o l:oo. IIKlude t e~ hniqlll!" fl.lr applying I.lImprt.':o-.'jloll to Ih l! h('.I(J :'1Ild Ill." :k. , tinge r.ll. and hands

682

Physical Rehabilitation

Figure 17.42 Applicalion of lymphedema bandaging 10 fingers and hand. (Courlesy of Klose Training & Consuhing. LLC. Red Bank. NJ 07701.)

(Fi g. 17.42). UE (Fi g. 17.43), and LE (Fig. 17.44). The che~t. abd ome n. genital area. and back can al so receive . , peciali zcd support from compress ion products. As with MLD. the benefits of thi s treatmcnt are nol limited to the population with lymphedema. When compress ion is indicared, ~ tandard or modifi ed lymphedema bandaging can be bene fi cial to the population with ede ma (e.g., postope rative. CV I. ve n oll~ uJcer~, orthopedi c injury ).1'J~ 196. 100-10~

I

I

Figure 1743 I

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{.111.U[11 11;-

,",.llld.l)Cm~ lu lh... L I I ( \1 11(1\: .. , (II II ( KI.:~I B.l ll~ '\ J 1177\)1 I .

Figure 17.44 Lymphede ma bandagi ng to the LE. (Counesyof Kl ose Training & Consulting. LLC. Red Bank. NJ 07701.)

Compression Garments Compress ion garrnents are utili zed by many patient/client populations (Fig. 17.45) . Originally designed to assist venous blood flow in the LEs. they are now specifically designed (0 manage bum and surgicaJ scars. provide suppon to venous circ ulation , a nd to prevent reaccumulation of fluid in the lymph-edematous limb. There a re a varie ty of design style s and fabric s, c ustom and off-the·she lf. garments to meel Ihe unique needs of differcm populations. When appropriately se lec ted and fitted by a trained professional and worn correctly by a prepared patient. [he gannems serve an e!\!\enlial role in managing c hronic life-long conditions ~uc h as CV I and lymph ede ma (Fig. 17.46).105 Gumle-nls should not be used as a treatmclll to remove e'(cess fluids

Chapter 17 Vascular. Lymphatic, and rntegumentary Disorders

683

deci sion making. the following is a summary of gene ra l guidelines for compress ion bandaging and gannents for edema and lymphedema:

Figure 17.46 Pilllen! .... r.::mng cu .. torn filled compres'i io n garment
from an e\trcm l1 ~ Applied 10 all c\tremi ty that has not been ;lde4u"lcl~ e\ 'KUaled. the gamlenl s will be ullcom ton able and 1l1 .J) "o r~e n the patient 's sy mpt ol1ls.S-l · !t Ib- ~ C urr("'n{l~ JI , anul.lllure r~ are panicipating in clinical re!>eaTlh \UPPI)J1 lOg Ihe u\e 01 »Iher 111 compress ion garme-nl'.. JU/II )Iher I1U70 . C'u)ahoga Falls. OH ..t4223) oJdd" JX'nniln~lll l ) honded .. liver 10 the text il e fiber of LE gannl'/l! hi mhlhlt h<.lt tc nal grl)"' lh and reduce odor. Another )pHon tnr ' Olllt: IIldl\ Idual!> j, a 4uilted garmt'n! th.11 l·.111 pn'\ Ide" compn;..,\h)!l .md ea..,y donning and dolf lll~' II If li ..t7 ,. 'I Ill'. optU)/l rna) be tI'.etul lor a per~on .... hI) 1:0. llllilhk In ..I ppl ) a Illore titled ),uppon garmenl lIIdel)(:ndt'Ilt!~ Of V. IHhC ., !..1I1 I ~ cOin pro ml "ed 01" Iragde. 1 he~t' PI I.dllt·d 1-' .lrIl1Cl1h can oc made 10 ~ uppon "t: nl )lJ~ lIH. ul..lI IOIl 01 I) mph.ttlt. dra lll<:lgc. by aite"n ng Iht: .. I~ It .mJ llll' '"Il-b lng t h.. llnl'l 'l. For Jdded comprc~~ll)n t I ht:~ l
Arte rial wound s: No compress ion or very light compress ion with close involvement of the referring practi tione r. Long-stretch bandaging or off-the-she lf low compress io n ganne nl ( J 2 to 25 mm Hg) can be used. Ede ma will nOI be g rea t and will evacuate quic kl y. • Ve no us wounds: Compression is an essentia l component o f treatm en t for wound healing and s upport of the venous sys tem . Short-stretch bandaging with high working pressure and low re sting press ure will facilitate the effec ts of ca lf pump during activit y. Hig h press ure of 40 mm Hg at the ankle has been suggested .20J • Neuropathic wo unds: Compression is co ntin ge nt o n blood fl ow. Fiftee n perce nt of these patient s also have an arteria l compone nt to their di sease and must have ABI checked before compression is applied . If no arterial involvement. compress with short -stretch wrap. Lymphedema: Short-streIch compression wrap until limb reduction goal reac hed the n moderate to high compress ion garments at 20 to 30 mm Hg to 30 to 40 mm Hg depending o n locatio n and severity of swe lling as well as abi lity of the patient 10 don and doff garment s. Edema: Case studies and reports from the field establish tha i Ih e co mpression treatment for lymph ede ma also works well for edema.204 Short-stretch compressio n bandage is worn 23 hours/day. graduating to daytime o nl y. decreasin g as edema resolves. Re lati ve contraindications for compress io n should be evalu ated including hi slOry of deep vein thrombos is. acute local infection. congesti ve hearl fa ilure. cor pulmonale, and ~cute dermatiti s.

\\ -\ IIMH_ (olnpr"

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IOn Ih:;!illll'1I1 ... ho ul d

{!J'IJ,I<..h.:rl II"..

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684

Phyoical Rehabilitation posilion or reposi tion .independentl y. The standard rime · I rvals used for turning sc hedul es (I.e .• every 2 hours) III e often 100 long for individuals who are frail . have liag. are . hdl ile skin or ex isling wounds. A turntng sc e u e could be as frequenl as every 30 minutes in some cases. Suws. . . , progra lions for patient positIOning ms'me I ude21 6.217 ..

Figure 17.48 tnlemUtlenl pneumatic compression pump.

Pneumatic Pump Until the 1990s. internlittent pneumatic compression (lPC) was one of the few clinical interventions utilized to treat swelling (Fig. 17.48). Since then. new infomlation aboul the physiology of edema and lymphedema as well as lymphatic system fun cti on. has limited its value in treat ing some edema and most lymphedema. lntennillen! compression pumps can facilitate venous return and may be an imponalll adjunct to o ther form s of compression for the individmd with a venous disorder.3.209 A review of the evidence provided only modest support for the use of ICP for th e treatment of venou s leg uJcers. 210 Man y individuals with long-standin g venous insufficiency al so have lymphedema. Th ere is even less ev ide nce and more co ntro' Iymp Ile d ema.-'11-'1< ver~y related to th e u ~e 0 l· IC P tor Each client should be carefull y examine by an experi enced health care professional before pneum atic compression is applied. Blood pres ~ urt: re ad i n g ~ shoul d be lake n before each treatment. In cre a ~ in g lOla I periphera l rc ~ i~tance with pneum ati c c ompre~' lO n wi ll increase the work of the heart . inc rea ~ in g blood pre~~ ure. Indi vid uals v.. ith h y pc rte n ~ i o n or a blood pre~ , u rt: readi ng greater than 140/90 ~ h o u ld not recci\ e pnell111alic compres ,> io n (realmenl . Olhe r C'ontra ind i-

cul lOm. 10 illlcrm illeni l'omprc,> , ion inc lude acute intl am m atlon ur Irauma. local IIlfel·tion. pre , encc of th rombll ~. cardiac or kidn",) d)t'll ullcllon. oh..,rructed I) tll phal ic channel ,>. imp fUllctl on.

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• The patient's heels should be protected and elevated off Ihe surface of the bed. • The head of bed should not be elevated past 30" unless medically necessary. • An individualized turning schedule cycling from 3010 120 minutes should be provided. PROs should be used in conjunction with a turning sc hed ule. Posilioning with weightbearing directly over the greater trochanler should be avoided. Positioning with full weig htbearing over an existing wound should be avoided. Donut-shaped devices for seating Solulions should not be used. Pillows and wedges should be used to separate bony prominences from bed and other body parts.

Pressure-Relieving Devices Pressure has a direct influence on perfusion or vascularity of a wound sile. PRDs should be utilized to prevent skin breakdown. during the wound healing phase. and during the self-management phase. for life-long protection and preven· lion (Fig. 17.49). Along with positioning. patients must be educaled aboul pressure relief and prevention of pressure· related trauma. Advances in pressure reducing support surfaces have made them more sophisticated and effective (Fig. 17.50). Expe rts in positioning systems are rcadil) ava ilable to advise and instruct clinicians working with special populations. Groups such as The Consortium for Spinal Cord Med ic ine and Ihe U.S . Department of Health and HUITI:l1l Services h ave made recommendations and aJgo-rit hms for posit ionin g a1ld press ure relieving devices mal ' . .61191.m.2IQ See ('a n bL' Uti'1'I z e d" f Or 1Illerve nt .IO n p Ianmng .. , . ppt: ndi x F for infonnar ion on Web sites tor these agencieS.

Chapter 17 Vascular, Lymphatic, and Integumentary DisordeTS

685

ta ken to protec i aging or fra g il e sk in from breakdown whe n se mi · rigid th erm op lasti c material s are use d for splinting. The lI SC o j" splinting to man age bum scar is cov· ered in C hapler 27. Positioning and splinting pointers found there can also be app li ed to patien ts with other types o r wounds.

Figure

17.50 Se/cu Alr MAX. a

for pre, .. urc reliel. lCourtc ,) IL 6:!n I.l

low air

l o~<; <;upport <;),stem

orThe ROtiO Group. Belleville.

Exercise Too ofll'll . e .\e rc i ~e i'l neg lec ted in the intervention plan for md]\ Idual, \\ IIh \'asc uJar. lymphatic. and in tegumen. tar) dl.,order.-,. es pecially those with wounds or ede ma. The phY<"lcal therapi . . t !
Orth otit. , \phll ling P.llleill ,\h" ,\1,,' IllIfllOhTlt: lila) helle hl Irom re~ lIn g 'pl ull III I 1;111'1 01 d ~ 1I<.IIllIL ... phnh to fl'g3 111 , lunt:llOllul kr)\1 I.,pllllltll).! l,tl l .1bu prn c lll ... k.1Il brcJ k.duy.1l by JI'I
Total Contact Casting O ne meth od for red uction of weightbearing stresses on the fool. is the app licati on of a Iota/ COJltacl ca.\! cr CC). This method ca n be usefu l for the individual with a neuro· pathic ulcer on the plant ar surface of the fool. After infec· tion and swe lling ha ve been contro lled. a pl aster cast is appli ed fro m th e toes to below th e knee. A spec iall y trai ned indi vidu al lI ses plaster. padding tec hniq ues. and the placement of a rubber insert on the weight bcaring part of the cas t to com pie Ie the application. A tOlal contact cast is usuall y worn for 7 to 10 days al a time. removed for :.k in ca re. and then reapplied. According to Salsich et al. TCC j:, effective al hea ling ulce rs initiall y but the ratc of reulceration once the cnst is removed is high .220 Neuropat hi c \Valker A rcmov'lb le. ankle foot ort hosis (AFD) can be custom fab·

ri cated or ordered prefabricated to provide weight di stribu· Lion and CUShion ing for the indi vid ual with an insensa te foot. a chroni c foot ulcer. or Charcol joint (Fig. 17.5 1). This option is ve rsatile in fit and all ows skin checks. dress ing changes. and pressure alterations as needed.

Cast Shoes Cast shoes or postop shoes can be uti li zed as an inex pen· sive. temporary alternati ve for wound off. loading . Th e~e shoes do not provide any means of co ntrolling fOOl Illoti on and littl e cu~hio ning protect ion for the ch ronic wound . This option shou ld be conside red temporary. Patients wea ring caS I shoes for press ure di stribution shou ld be monitored clo . . cly for signs o f complications.

Figure 17.51 An i.i.Ill..lr f'~l onho-, .... !I.~ltit.:all>, deSigned 10 .,1.11\1\\ I..h -.lnookd \\e l ~h lt)(.1nng lor 111d.\.jdultl~ "'
686

Physical Rehabilitation

Figure 17.52 EXlra*deplh ~ h oe.

Figure 17.54 Application of elastomer pUlly 10 scar ti ssue duro ing the maturation phase of wound healing.

Extra-Depth Shoes Extra*deplh shoes have feat ures such as a roomy toe box and a deep sole to provide shock absorption and cushion . The shoes shou ld redirect fool pressure away from bony prominences and wound . . (Fi g. 17.52). 221 Ava il able in many styles. they can be purchased from un Orthotist or at a specinlty shoe store. Individua ls with in . . ensate fee l. wi th or without wounds. ~hou l d strongly conside r wea ring thi s type of protective shoe to SUpPOl1 the health of their feet.

help. there is room for furt her investi gati on into how to have optimal cont rol of scar fommtion . Most scar tissue is managed by a physical therapi st using compression garments. stretching exerc ises. orthotics. positioning. specific types of massage, and the use of topical adjuncts such as silico ne ge l sheets (Fig. 17.53) and elastomer putt y (Fig. 17.54). Topical creams. oi ls. and o intments have some positi ve effects on scar but it is nOI known if the massaging aC lions used to app ly the agents or the agents themselves prov ide the therapeuti c effects. Early and adequate mter* vem ion can prevent most of the com plications of scarring. Since the process of scar fonnalion usually continues for 6 to 24 months, follow· up care should be part of the interven* tion plan. When conservative meas ures of scar management have not controlled scarri ng. surgical intervention may be indicated. Followi ng surgery, the individual will have a new wound ..md subseq uent new scar to manage.

Scar Management As de scribed ea rli er in Ihis chapter. scar formation is a component of wound heal ing. After the wou nd is filled with collagen. the tis ~ ue must be remodeled. and shaped into the fine ly ;;tructured end product. Cont raction of scar tissue can lead to di sfi guremen t and loss of function especially if the scar ti ~s ue is loca ted over a joint surface. Iss ues of dislig· urcment and dysfunction are great est fo ll owing thenna l injury and are di sc ussed In Chapter 27. Curren tly. th e mechani ... mo:; by which . .c;u can be controllt:d are not COI11rl e te l ~ und e r~ t ood. Whi le 'iome intervC'ntion:-- do seem to

Figure 17.53 A pplt";,UI ( ltL 01;J \111,,011 gl'l . . 11I.:l"Ilu dunfl g Ih \.' 1I I...IIUlilil UO ph.I...!; 01 .... uuld hc:u llll g

..,1.:.11 II ... ~ U{,

Summary These an: t,'xciting ti mes for clinician~ interested in matte" conce rnin g the va scular. lympha tic. and integ umentary "'y"tcm.... Sk in <.Ind wound L'are practices have changed signilil..:3ml y owr the 13 ~ t dl!c ad~ . Nc\\o infonmHion about the mI croc irculation of blood and lymph hao:; chang.:d treat* m enl !o! l rategie ... Th~ rol l' of Ihl' ~kin <1:-- an organ has gainct! ne\\ r~ ... pi..'l..·t. It i... nol ~u rpri 'S ing thaI Ihe re il' an cxplo~ion of n.~"C dl'c h . li terature. ;.I nd prodUl' b to ...t;:rvc Iht' needs of tnd lVldu ,tI ... wllh tll"on.kr" afr('clitlg the"l' ,,)Sfems. Current and fu ture ge nl;' r.lllon" are facing Ih.!Jlthcare challcngc3 of a tll itgrnlutlc 11(' \'l' r be fot't' "t'e n ttl l..lur 'iucic ty including ail IIlcrl! .t ~c It) the tlulll ht- r of Inl h\ Iduub with diabetl!s. ohc"' 11) . \.Iw ul .tr :Ino lymph.lIi r.: dl se a ~e , an tibiotIC- resistant ll.l thogCI1 ... , " grI1\\ llig IJI. )pul.tliotl or older individuals. health l d r e.: 1\ .' lmbu r "'l' Hlt:11I l'haJlt-ngc:--, and the £ 1'('1 \\ ing number of 1..' lh lC
Chapter 17 Vascular, Lymphatic. and Intcgumeo lary Disorders parti c ular impo rtan ce in c lud e curre nt strategies for \\ ou nd mana ge me nt. th e impo rtan c e of adequate and appropria te patie nt educ ati o n. primary ulce r pre venti o n. ulce r prC'ca uli o n ~. ad vance d foot c are fo r indi vidual s \\it h diabe tic ne uro path y. o ptimal c ompress io n for 1\,l11phedema. th e esse nti a l role of mo isture in wound healing. and lhe im port a nce o f e xe rci se a s part of the

poc. Ongoing and futu re re!"carch will establi sh the level of of ev ide nce for a variel y of topic s suc h a s the

~ t re n g t h

Questions

for

687

impact of bio· burden on the wound infection continuum, the preparation of the wound bed. the mic robio logy of pressure ulcers. the use of exoge nous oxygen applications. noncontact US . nonth e rmal radiofrequency stimu lation . c o ld laser. biosurgery. bioengineered rissue. exogenous growth fac tors. and topicul sil ver preparations. Wise clini· c ian s mu st kee p abreast of new informati on and curre nt standard s of c are. approaching new entries to the field wi th a strong sense of clinical intuition as well as a firm grasp of the scient ific evidence.

Review

1. Ol',c us .. the di ffe re nce s. simila rities. and relationships bet\\ een the arte rial. venous. and lymphatic systems . Compare annt0111 Y. method of fluid movemcnt. and functi on. 2. Outl ine some of the un iqu e characteri stics Lhal can be ident ified cl ini call y fo r d isorders of the vascu lar, Iym· phatic. and in tegume ntary syst.em s. 3. Creale a .. imple diagram to illustrat e the normal pro· g re~<; i oll of v.ound hea ling using the three phases of wound healin g as a guide. 4. L i ~ 1 factor, that contri but e 10 abnonna l wound healIng. Oi\ ide the list into fac tors that may be influenced b~ a ph) sica I therap ist and fa ctors that may not be mfl uenced b) a phys ical the rapi st. Discu ss why and ho\\ the faclo r~ in e ach li st may or may not be inflll· enced b) a phys ical therapi st. 5. Re\ iev. the annotated tests and measurements mcl uded III thi S chapte r th at should be used during a p h )~ i ca llh e ra p ) exam ination. Identify lests and mea<,urelllt' llt <, rout ine ly perfonned for patients with \ a')cular. I~ mphmic. or integumentary di sorders.

6. Design a checklist, decision tree, or flow chart for

7.

8. 9.

10.

examining a patient wi th a di sorder of the vascular, lymphati c. and/or integumentary systems. Create a general outline of the primary components of a POC fOf a patient wi th a wound . Illustrate the interrelatedness of the vascular, Iym· phatic. and integu me ntary systems by di scussing how one system can impact another. Discuss how a physical therapi st should respond to the knowledge that many vascular. lymphatic, and integumentary disorders have a long latency period and req uire a heightened level of vigilance and proac· tivity in order to identify symptoms and begin treatment as early as poss ible. Identify the rationale for each of the following treat· me nts in skin and wound care: moist wound healing , arterial wound hydration, venous wound compression. lymphedema treatment, pressure ulcer preven· tion , and foo t care for the diabetic.

Case St udy REFERRAL A 7!<.·)t:ar·old \\oman ',I, lIh a primary diagnosis of Al7htlOlcr\ dl \l.'d"t: h:.h bee n living in a res idential fadl · II) lor 10 month •. ~he I .... rtlerred to a phys ic al therapi st b~ the ph) . . LlI.1Il
P>\ST Mf J)(CAL HI STORY Lme rn.1I1Jbll.' until OI1 <'l"t 0 1 . . ympwfll );. of AJ zhe ime r' s ~ ~e
CU RRI- NT M r: D1CAL HISTORY Ant:Tl{.l~l k ro~ I "".

LLHld h) pcrte m.ion controlled by medica· In.:att:UI 'JI plc~~u rt: Ulc&:f fo r 4 v.eeks (30 days) with hid h) drogt'n IK:ru:>..ide tlll~ht:!lo foUowed by dry gau1..e 4 X 4~

11011

covered with Kerlix and adhesive tape. No changes in wound for 4 weeks. No other imervenlion in place.

SOCIAL Hu sband al so resident of same facility. lives in smlle rool11. Husband is frajl bUI mobiJe and contributes to care for wife. No children. Patient enjoys music and trips by wheelchair to ac tivity celller in fac ility.

COGNITIVE Patie nt di soriented to place and rime. Becomes agitated during wound care . Unable to follow weight shift and turning schedules independently. Follows some instruc· lions whe n supervised by husbmld or staff. HR: 70 BP: 145t90 Resp: 15 Temp: 99°F Weight 1181bs

688

PhY5icai Rehabilitation

PHYSICAL THERAPY EXAMINATION DATA Wound Stage UJ pressure ul cer o ver right ischi al tube rosity. The wound bed is 50% necrotic yellow tissue and 50% red granulation tissue. The patient has a rec~nt hi s.tory of positive culture fo r Pseudomonas aerugUlosa .1O,the ulcer. The wound is currently contaminated bu t not Inf ected. Drainage is moderate_ ye llow-brow n and th in. The periwound skin is intact.

Strength and ROM Patient un able to fo Uow com mands consistentl y but appears to have functional strength and ROM of UEs . bilaterally. Gross LE strength is impaired perhaps ow mg to decl ining activit y levels. Active ROM appears fun ctional in UEs. Bilateral hip flexion contractures of 20° can be reduced to 10° with passive RO M. ~Iobility

Pati ent is either in wheelchair or bed 24 hours/day. Patient is unable to roll independently but can often assist using

UEs when instructed . Requires maximum assist of two to pivot transfer. Unable to ambul ate at this time.

GUIDING QUESTIONS I . What are the contributing factors that have most likely led to the chronic ity o f thi s wound? 2. What combination of interventions to clean and debride would all ow removal of necroti c ti ss ue while protecting granulati on ti ss ue? 3. Wh at electro modalities mi ght be appropriate for treatment of thi s wound? 4. O ther than local wound care, what type of intervention wi ll be esse nti al for wound closure? 5. O nce progress has been m ade in wound healing, if the wound were to becom e dry, wh at dressing types could be used to create a mo ist wound environment? 6. If using an occlusive dress ing, thi s patient should be closely mo nitored fo r what potential occurrence? 7. Assuming this pati ent 's wounds will close, what are your expectations for the condition o f her skin over the wound site?

£C

References 1. Martini , FH: Fundamental s of Anatomy and Physiology. ed 4. Prentice-Hail. Upper Saddle River. NJ . 1998. 2. Kell y. DG : A Primer o n Lymphedema. Prent ice-Hull. Upper Saddle Ri ver. NJ, 2002 . 3. McCulloch. H.,I ; Therapeutic modalities stimulate wound managemenl. Biomechanics April: 67, 2004. 4. Eliska. O. and Eliskova_ M: Are peripheral lymphalics damaged by high pressure manual massage? Lymphology 28:21 . 1995. 5. Casley-Smith. JR : Varying lotal tissue pressures and the concentration of initiaiiymphatic lymph. Microvasc Res 25:369. 1983. 6. Mo rtImer. PS. el a1: The measurement of skin lymph flow by isotope clearance-reliability. reproducibi lity, injection dynamics and the effect o f massage. J Invest Dennato l 95 (6):677. 1990. 7. Obzev. ski . WL, and Engeset. A: Intri nsic contracti lity of prenodal lymph vessels and lymph flow in human leg. Am J Physiol 239{6), H775. )98U. 8. Smith. A: LymphatiC dramage In pallents after replantation of extremities. Plast ReconSLr Surg 79: 163.1987. 9. CampIon-Johnson. S and Wilson, J: Infected wou nd management : Advanced techno logies, moiqure-relellli\e dresslllg), and die-hard method!>. Cli! Care Nurs Q 24(2): 64 . 200 1. 10. Sen, C K: TIle generdl case 01 redox control of wound repair. Wound Repair Regen 11 (6):431 .2003. I I. KIl.tghlon. DR , et al· Oxygen a~ an amibiotic : The effect of in)pired oxygen on infecllon . Arch Surg 11~:199. 1984. 12. Gordillo. GM . and Sen. CK: Re\ .\.tmg the e!o:,ential role of o"ygen III ..... ound healing. nle Am J Surg I KO·259. 20m 13. Hopf, H. Hunt. T. and West. J: Wound tJ )~ue o"n:;en tensIOn pr~­ d'l·h tl~ n!>k 01 ~ound infect ion Ifl\urg ical pall~nb . Arch Surg 112:947, 1997 14. Grit,>f. R. c:t al· SupplementJ.1 pt"rtopcr.l.U\C= oxygen 10 reduce the Incidence of!>utgl<..al .... vund mlCCIIOIl t\ Eng J Mcd 3·[!: 161 . :WOO 15 KUrJ. A. Se!o~lt:r. D , and Lcnh.. rdt . R· Penopcratl\t,> 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 ,",oon<.l healing. Adv Skin Wound Care Ib(o):292. ~(){)o3. l:! Wllhan)) . J.nd 84(001. Nutnuotl ilnd \IoOllnd hellltng.. SIUi C lin N(lftn Am 83:571. 1<X13 1l Zulhm!>kl, K,
n.

Chapter 17 Vascular. Lyml)hatk. and Integumentary Disorders ~.t

Rodehea\cr. G. et al: Wou nd he aling and wound management : Foeu,> on De bridelllC'nI . Adv Wound Care 7( I ):22. 1994. ~" Kid.... 51. et al : Arginine stimu lates wound healing and immune ." function melderl) hum.U1 beings. Surgcf)'. 114: 155. 1993. .'6. Barhul. A. ct al: Arginine cnhall ce~ wound hea ling and lymphocyte UllmUlle rcspon!>C' in humam;. Su rgery 108:33 1. 1990. 37. Canwright. A: Nutritional a\~e,~ m cnt as pan of wound manage· men!. Nur~ TiI1l~'" 98(44 ):62. 2002. 38. Bill. T1. et al: Qurmlltative ~wab culture versus tissue biop~y: A com1>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<;. ed 2. A~pen. Gaithersburg. MD. 2001. P 26. 4"' Bate~-kn"en . SM. and Su:.sman. C: Toob to mca~ urc wound heal· me . In SUS\lllan. C and BJles. BM (eds): Wound Care: A Colt aboratl\": Practice !>.hnual for Phy:.i(·JI1l1erapi sts and Nur<;es. ed 2. A'pcn. G ~lIthl!r~burg. MD. 2001. P 142. 43 Weed. T. Ratliff C. and Drake DB : Q uanti fying bacterial bioburdcll during negatl\l' pre:.:.ure wound therapy. Alln Plast Surg 52(3):276. ~OOI

44 Lmdholm. C: Pre"ur..: ulcers and infeclion·Understandi ng clinical feJ ture,. O~tOIll) Wound Manage . 49(5A):4. 2003. 45. Beltz. 1/1.1. ::md Goldberg. E: The li ved experience of having:l ('hromc wound: a phenomenologic sludy. Medsurg Nurs 14( I ):5 1. 1005. 46. Gb~pt'r. ER. and De\'rie~, AC: Social ..,tructure innuences effects of PJlr·hou~mg on \\ound he aling. Brain Beh:)\' Immun 19( ]):61 . 1005. 47 . Detlilion. CEo el al: SOCial facilltalion of wound healing. Psychoneuroendocnllolog) 29(8): I ()().l. 2005. 48. Ebrccht. \ 1, ct al: Perce ived :.tre~ ~ and co ni :.o l 1eve1.~ predict speed of wound hepo..")n Si'~. pressure ulcer deve lopmcnt and adaplatlon. Br J ~ur, I ~j II Suppl ):S 17, 2003. 51. World" Ide Wound Management 2002-2012: Products, Tedmo lo· gle~ &. MJ.Ikel Opponunllies. Repon S200. February 2003 . MedMarket Diligence , LLC 52 Hlall . \\ k MutTicicllCY and venou \ leg uiterallOll J Am Atad Demlatol 44(3): .lUI . 2UO I. 54 KUIIUlU.to . B. el :I!' Be\1 pnlctice, for lht' prevention and trcatml'nl u! 'enou" 1o:g ukl·r,. O~lom) Wound M<1nagt' 4712):34.200 I. 55. Sel)!g:rccll \1Y..,md KIIJl\!. RA. Va~cular ulcer,. In B ara n o~ kl. S, and A}ello. I:A (cd.'>): 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 \ I L'11 a ,lI\lt~ AnglOk.!!) 511 6)647 , 2(j(12 . 'it) SUldrup. j d .11' lllt.· ... "lcllI.:e 01 \)h~trudl\e Mh:n,d d"e,hc and ~hro!l1 ( ' t ll"ll.') ,1.1'1' 111 kg uke. p,tl lcnb. Clm l;:"p j)~' rnMh)1 1~ ..j III IIJ:-\1 fJ() 11I)11""a, (,,\ ()UI SK. jll~ulfl l lelK, J \\, lund (J'\{'llI; Conllll.:llte r-.,JUI~ .'(lI J 1 17. 2001. II! ~t IV ""lfl'hthe, kll .... l'1 ill ( ,u ldclI .. c, 101 Iht ,lpp llUlllUIl ,If ".HUII U1 IOf plIlIlJI") ,llld wLoud:lI ) 1)lilph..:d':lI1a and ulh~1

6 3.

M.

65 . 66.

67. 68.

69. 70. 71.

72.

689

selected patho logies. In Foldi. M, Fo ldi . E, and Kubik. S (eds): Textbook of Lymphology for Physicians and Lymphedema Therapi sts, ed 5. Elsev ier GmbH. Munich. Gennany. 2003. p 590. Fo ldi , E. ct al: Lymphoslatic diseases. In Foldi. M. Foldi. E. and Kubik . S (eds): Textbook of Lympho logy for Physicians and Lymphedema nlc ra pi fol~. ed 5. El sev ier G mbH . Munich. Gennany. 2003. p 232. Gaber. Y: Secondary lymphoedema of the lower leg as an unusual side·effect o f a liquid silicone injcc tion in the hips and bunocks. De nllatology 208:342 , 2004. Sitzia, J . e t al: C haracteristics o f new refe rrals to twenty-seven lymphoedema treatment units. Eur J Cancer Care 7:255, 1998. Cariati. A, e l
32(){ 13),850. 1989. 73 . Lyder, C. et al: Quality of care for hospitalized medicare patients at risk for pressure ulcers. Arch Intem Med 161: 1549, 2001. 74. Van Rijswijk, L: FulI-thickness pressure ulcers: Patient and wound healing characteristics. Decubitus 6( I): 16, 1993. 75. Van Rijswijk. L. and Polansky, M: Predic to rs of time to healing dee p press ure ulcers. Ostomy Wound Manage 40(8): 40, 1994. 76. Van Rijswij k. L: The question of outcomes. Ostomy Wound Manage. 49(2):6. 2003 . 77. C H A Good Heal th Report. Fall : 7. 2004. Red Spring{r) Communicati ons, Inc. 78. Cowie. CC. et al: Prevalence of diabetes and impaired fasting glucose in adults-United States, 1999-2000. MMWR Morb Mortal Wkly Rep 52(35):833, 2003. 79 . Centers for Di ~ease Contro l and Prevention: National diabetes fact sheet: gene ral information and national esti mates on diabetes in the Un ites Slates. 2003. Atlanta, GA: U.S. Department of Health and Human Serv ices. Centers of Di sease Control and Prevention. 2003. 80. American Physical Therapy Associalion : Guide to Physical Therap i ~t Prac tice. ed 2. Phys Ther 8 1( I ):S49. 2001. 81. Corni sh. BH , el al: Earl y diagnosis o f lymphedema in poslsurgery brea~' cancer patients. An n NY Acad Sci 904:571 , 2000. ttL Mike,. DM . et al : Bioelec trical impedance anal ysis rev isi ted. Lymphology 32: 157, 1999. !D. Corni~h. BH , el a l: Earl) d iagnosi" of lymphedema using multiple freq ucncy btoimpcdance. LymphoJogy 34: 2. 2001. 84. Brenn:tIl . MJ. DePompolo. RW, and Garden. FH: Focu!k'd re"iew: PO\tma'hX tomy Iymphedenl:> se~.') meot in intt'rllI1\ttlll c1auJt~' uIl0n Rc\ II!W, Eur J Endov:l..\c Surg 25:202, 2003 . R~ R..:gt"Il\It!tIltr. JG, et .11: Eqlu:HlOIl 01 walking illlpaimlt'nt by quc ~­ tlOI1U;.Ilre Ul p... tieuh wllh I~nphcral arterial di::.cafoe. J V:c. Med Bl~.1 2: 142 . 1990. XII L~hcn , P: QU<.lllt}-of·lli'e a~~el>~m l~ ltl in c:omparatlVi.' therapeullc tri . .JI ~ aud cau~a l s tru~lUre wJNde r<.l ti on~ in pcriphcr:11 occlusive :m en;,1 dl \C'a~c. Philnlhl('C....·tOt tUIlU(·s 1\)(2): 121 . 200 I. 1)0 r..larqui ~, P. Conll":. S. .,nel Lehen, P: hUcfmlti o lla l Va lidation of the ('I AUS-S Qutilll~l)I - l.th- Q uc... llonnaire for Use ill Patients with Jntt'fIlHIt..·tlI ClaudlCalton Phafll l(tc()el'onomic ~ 19(6):6b7. 2001 .

690

Physical Rehabilitafjon

91 . TIedjcn. KU. el al: Radiolog.ical Diagnostic Procedure!. III Edema of the EXlremiueS. ln Foldl , M. Foldi. E. and Kubj~ . S (cd.. ,: Textbook of Lymphology for Physicians and Lymphedema Therapl.. ts. cd 5. EI...cvier GmbH. Munich, Gcnnany. 2003 . p "'34. 92. National Pre ~su rc= Ulcer Advlwry Panel tNPUAP): Prc,\,!-urc UkCN: Prevakoce , COSI and risk assessment : Consen<;lI" dc" clopment conference statement Decubitus 2:24 . 19M9. 93. Bergstrom . N. ct al : Pre s~ urc Uker Treatment. Clmit-tli "raclice Guideline. Qu ick Reference Guide lor Cliniwtn,. No. IS. Rochille. MD: U.S. DepartmcnT of Heal th and Human Se n 'lcc.,. Public Health Scrvice Agcn,·y. Agency for Health Care Reliearch and Quality. AHRQ Pub. Nu. 9S-06S3. Dcc. 1994. 94. Thomas. DR. CI al: Pressure ulcer scale for healing: I)cnv:lIion and \'alidation of the PUSH tool. Adv Wound Care 10(5). 1997 95. Wagner. FW: The dy~ ...asc uhlr foot: A ~ y" lem for dJ:IgIiOSIS and treatment . Foot Ankle. _~ : M . 19HI. 96. Norton. D. McLaren. R. and EKton-Smith. NA : An Investlgallon of Geriatric NUnling Problems in H o~pitat s . Edinburgh. Scot land : Churchlll-LivingMone: 1962. 97. Gosnell. DJ: l>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 . De<:ubi'i ~ 2:44 . 1989. 100. Sus~man. C: Wound Care : Palient Education Resource Manual. Aspen . Ganhersburg. MD. 1999. 101 . Ehrlich. A. VinJe-HarrewiJn . A . and McMahon . E: L. vlng well ,...lIth lymphedema. Lymph NOles. San Francisco. CA . 200S. 101. Fo lkedahl. BA. and Frantz. R: Treatment of Pres~ ure Ulcers. low;i City. lA: Unl\' e r~ it y of lov. a Gerontological Nun.tng Intervention:;. Research Center. Research Dh~emill::llion Core; Au g u ~ 1. 2002 . 103. McCulloch. 1M . and Boyd, V: The effects of whirlpool anti the dependent pru.itlon on LE \'olume . J Onhop Sports Phys Thcr 16:169. 1991 IO. t Sussman. C: W1Hrlpool. In Su ~\man. C. and Bate~. BM (cd,» : Wound Care: A Collaborative Pracllce Manual for Phy~ical ThcTll p i~ IS and Nurses. cd 2. Aspen. Gaithersburg . MD. 200 1. P 62 1. 105 . Burke . DT. et al : Effect!> of hydrotherapy Oil pre ... , urc ulce r healin!!. Am J Ph )~ Med Rehabil 77(S,:394, I99S. 106. Luedtke-Hoffmann . KA. , and Schafe r, OS: Pulsed lavage In wuund cleansing Ph}'s Ther 80: 291. 2000. 107. Ha }'ne~. U . et aJ : Compari!lon of Pu bavac and ~ Ien l e 'W h irlpool regardmg the promot ion of t i s!. u~ granul al lon (ab.. tract,. Ph}., Ther74 (Suppl S):S4. 1994 lOS. Loehne. HB. et OIiZJ tlon of m icroo rgalll ~ rn .. dunng pul s.atile l a ~ ... ge WIth ~ uc l ion . Pre,enled al Combtned Se( 1I0m; Meettng/Amencan Ph~" cal Therapy A!>'>OClatlon. F~bru3.r.- 2OCJl.l New Orlc:an ~, LA . 109 Ovmgton. LG Hangtn!;! ..... eH o·dl) d re'~ Lllgs oullO dl). Home 19(8 J;477. 10() 1 Health<; IIU Lav. ren~e. Je· Drc:s~ mgs ...nd v. o und mfecuon. Am J Surg 167I P q:2 IS. IY::I4 I I I La .... rence. Jc. Lil ly, HA. •.tnd K.d \Un. A - Wound dre;'\ lIl g~ and omborne d"per, a) of bauc na L.in(.et 339;~07. 11J'-J2 112. LIm _JK . et al :-' onnal <.:lllll!! v.uund dre ....\mg-h II reall" norm"I ' Bt J PI... "t Sur~ 5~ 4 2. 20{JO . 113. Mo...her, SA ct al OulcOfJ'lc' of 4 me!hud~ IIf ddmdement u~mg 01 d ecN(ln andly ... ' m... u-"..d(Jlllj,:~ f<.d\ \I, 'Jund ('.Ire f\l.trLh): 121 2dn It,/<Jt/ 114 K.-.ru R' \ 11) 1\1 HtalUlg \c:r)u, .... ct H) Jr~ ( ... n :-"U f>C: 'J7t II. 17

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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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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
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211 . Augustine. E: i-li<;lOrical review of eJuemal compression for Iym. phedema management . Summary of presentation a1 CSM. Rehabil Oneol 16(2): 17. 1998. 212. Brennan. MJ. and Miller. LT: Overview of treatment options and review of the current role and use of compression gannents. inter_ millent pumps and exercise in the management of lymphedema. Cancer 83:2821. 1998. 213. Lerner. R: What's new in lymphedema therapy in America? Int Angiology. 7: 191. 1998. 214. Ko. D. et al: Effective trealment of lymphedema of the extremiliu. Arch Surg 133:452. 1998. 215. Petrek. JA . Press man. PI. and Smith , RA: Lymphedema: Current issues in research and management . CA·A Ca J Clin 50:292. 2000. 216. Rrienla, DM . Geyer MJ , and Sprigle. S: Seating. positioning. and ~ uppof1 ~ urfa ces. In: Baranoski. S. and Ayello. EA (eds): Wound Care Essentials: Practice Principles. Lippincoll Williams & Wilki n ~. Philadelphia. 2{)()-t. 217. Panel 011 the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adulls: Prediction and Prevention. Clinical Practice Guideline. No.3. AHCPR Publication No. 92-0047. Rochille. MD: Agency for Health Care Policy and Research: May 1992. 218 . Mc innes. E: The use of pressure-re lieving devices (beds. mauru,sn and overlays) for the prevention of pressu re ulcers in primary and secondary care. J Tissue Viability. 14( 1):4.2004. 219. Sti er. L. el al: Reinforcing organizationwide pressure ulcer reduc· tion on high -ri sk geriatric inpatient units. Outcomes Manag 8( I):28. 2004. 220. Salsich. GB, CI 31: Effect of Achilles tendon lengthening on ankle muscle pcrfonnance in people with diabetes mellitus and a neuropathic plantar ulcer. Phys Ther 85( I ):34. 2004. 221. Foto. J. and Birke. J: Eva luation of mulitdensity orthotic materials used in footwear for patients with diabetes. Foot Ankle Int 19:836, 1999.

Readings

Baranoski. S. and Ayello. EA : Wound Care Essential s: Praclice Principle~.Lippincotl Willi:l.lm & WiU.. in~ . PhIladelphia. 2()()4. '\allOnal Diabete:. Data Group. edllors_ Dlaix'tc~ in America. ed 2. \\ashlllgton . DC l'.S. Department of Heahh and Human Scrvke~. National In ~lllules C'f Health. Nallonal inqitUle of Dlabete') and Dlge"u\(: and Kidney DI5ea...es. 1995. NIH PubJiciillon No. 95-1468

Weiss leder. H. and Schuchhardt. C: Lymphedema. Diagnosis and Ther· apy. 2d ed. Kagerer Kommunication. Bonn. Gennany. 1997. Wound Care for Ihe Lymphedema Practitioner. VHS video. Moderator: Fife_ E.\pert Panel. Presented at the 5th Biennial ational Lvmphedema Net~ork Conference. Ch icago. IL August 2002. Can be obtained through the NatiOllal Lymphedema Network. See comact infonn :l.Iion in Appendix A.

Appendix B: Patient Education: Skin Care and Footwear Instructions Inspect Your Skin

yo ur health care provide r about yo ur foot care practices.

I. Look at you r fee l eve ry day. Use a mirror. a magnifying

6. For padding and air circulation. use sma ll bits of lam b's

glass. or the help of a fam il y member to help you see all

woo l between the lacs. Change th e lamb's wool every day. Be sure 10 use new pieces after you wash your feet. Do not use co tton or cott on balls because the fibers may irritate your skin . 7. Put on a c lean pair of white socks after your skin care ro utin e. 8. Do nol wa lk barefool. 9. If you r feel are cold at bedtime. wear cotton socks; do nO{ use a hal water oottle or heating pad to warm your feet.

ove r you r fecI including betwee n your toes and the bOltoms of your feet.

2. Look for the se things o n your feet: blisters. sores. corns. calluses. red spots. swe lling. pain . drainage from 3 sore. broken toenails. cracked skin. odor. Notify your hea lth care provider if you see any of these things on your fee! or if you injure e ithe r of your feel.

Take Care of Your Skin I. Wash your feet gently eve ry day usi ng lukewarm water and mild soap. Test the wate r te mperature wi th your

hand before yo u was h your fecI. If you r hand is not sensitive 10 temperature. use a thermometer. The temperature should be about 85 0 Fahrenhei t. 2. Dry your feet we ll. espec iall y between yo ur lOes.

3. You may want to use a lanolin -based loti on o r petroleum jell y 10 soften dry skin. Do nOI appl y any lotion betwee n your toes. You may use powder or cOnl 'ilarc h bern ce n you r toe!.. 4. Never try to treat corns. call uses. or lOe nail s w ith sharp instrume nt s. home remedies. or store-bought foot c are produCb. These items can all hurt yo ur "kin. 5. Cut toenails !-> 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
um e changes du ring rest. standin g. and light walking. Venous o bstru cti o n and arte ria l infl ow c an be obse rved w ith Ihi s lest. Tr a l1 ~l' utan ('uus u .'\~' ge n

(TePo 2)

A noninvasive ex am inati on too l fo r arl e ri a l ci rc ul ati on . A spec ia l probe ~ nd a healin g e le me nt measure profusio n. Measureme nt of oxyge n at the ski n leve l gives info rmati o n about what i~ ha ppe ning at the ce llu· la r leve l. A lso fo und in the lit erature as trallSCllloneOttS partial p res· sure of oxygen a nd trallsCllloneOIiS oxygen/elision meaSliremel1t. The re sult s arc pred ictive fo r hea lin g of ulce rs and ampu tatio n wounds.

Skin Pt'rfu.,i ull Pres!;ure (Sp p I I1l t'as u re ment

A noni nvasive tesl that meas ure s blood n ow in the skin. To take the l11 e a ~ ure m e nt s . a modifi ed laser Dopp le r probe is scc.: ured in the bladde r o f a s pe ci~li ze d blood pressure c uff. Results are predic tive for he alin g of ul ce r~ and amput ation wou nds.

\tnuu ,", fill mg liOl l'

T he extre m ity is e levat ed and the n lowe red into a depe nde nt positi o n. The time it takes for the ve in s o n top of the fOO l 10 refi ll is recorded . No rm a l fi llin g lime is 15 seco nds. Grealer th an 15 seco nds indi cate s a rte ria l disease whil e less th an 15 in dica tes veno us di sease.

Percu..,..,ion 'l e."

With LE 111 a de pe nde nt po~ iti o n . the g reater sap he no us ve in is palpated di stal to Ihe knee w it h o ne hand while il is tapped 6 in . pro}. ima l to the ].. nee w ith the uthe r hand . If a wave o f n uid il> 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!
PL'S H ToW I Sco re '

Pressu re Ulcer Hea lin g Gra ph

~--.---.-_,--,-_T~~~,~_r~~-_,---r__.--

17 ~

16

,

15 14

L1 11 II

-l.,.

:--r=r:=f +

10 y

H

7 6 5 ~

_1

1

Hl'<.Iil'c1 -; 0 I).itt.

-+

~

--t

i ~

--t-

-

I

~

,Ij t f i ,

=t~~1-1

--- -

-

r-f--' ~ - ---i-t

-+ ._-+-

-

-- --

f-

-t 1

I I

I

1

•

I

+

~1

j

I. t

.

I I

r

t-

+ I

·•

.

\-

:

i

.. t ~ ·

j

t

i

r I

t·

t

•

t

I

1

•

I

+

Pl l"ll '1001 \'c~ l (m \.1) 9/ 15NX

~ ~ 1\ I1VU d P .Uf).!

(ON'ltllllld!

Pn.~~ . . ur~

Uk'C'r Alhhory Pann( 1

Appendix E: Sample WOund Examination Form NAME:

SIP

HR

Resp

Weight

Temp

Orientation to time/place/person? ( l Yes

Date:

( ) No

Arrived : ( ) Ambulatory ( ) Cane ( ) CnJlches ( ) Walker ( ) Wheelchair ( ) Stretcher ( ) N/A

( ) lnitial Examination Reviewed: Changes in medicine, allergies , or health history since last visit? ( ) Yes

( 1 No If yes, indicate

changes on Oowshect.

Wound Number Wound Location Wound Type

Wound Stage

( 1 I ( ) II ( ) III ( ) IV

()I( ) II () III ( ) IV

( ) I ( ) II ( ) IT! ( ) IV

() I()II()IlI()IY

( ) Yes

( 1 No

( ) Yes

( ) No

( ) Yes

( ) No

( )Yes

( ) No

Length Width

Depth Tunnel s!

Undermining Granulation Slough

I

Eschar

(

) Yes ( ) No

( ) Yes

( ) No

( ) Yes

( ) No

( ) Yes

( 1 No

Odor

( ) Yes ( 1 No

( ) Yes

( 1 No

( l Yes

( ) No

( ) Yes

( 1 No

Drainage Amouni

(

) None

( 1 Moderale

Dramage Color

, I

,

I

Expo..e.d ~h.J !l.clcl rt:'ndonJLlg.lmenl

,i !

( I Ye!l. t I

y~ ...

- - - - - - --1-----

I Pcri .... ound I Appe.arJ.lll t'

,

,

, ,

c____ -~

._I_ J::

,

J

I Iru..tel

J f\ ':U(iU ~

-

-----

I , ,

-

~

( ) None ( ) Minimal ( ., Moders.. ( 1 Heavy ( ) Serous ( ) Sera Sanguineous (

) Sanguineous

I

( ) Purulenl

( ) NA

( ) Yellow/Green ( ) NA

(

) WelllA'fincd

(

(

) Poorl} Delined

(

) WeU Defin
(

) Yes

( ) No

( ) Yes

( ) No

I

I

)

No

C'd ll u ~

-

-

( ) No

+-------,

-if

( ) NN ro! l.

) Er) them,\

--

-

( ) Yes

I M..t..:erallun \ I IflI a~~1

,I

i '

) Sangui neous

( ) Purultnt ( ) Yellow/Green

) Well Definrd ) Poorl )' Defint"d

t--

El) lhcm;,

--

,

(

---1.. I ) Y<s _~ ~o____

! M d~ era ll vn l

, I Callu ... \

( ) Serous ( ) Sera Sanguineous

) Sera Sanguineous

, ) Yt:"

( JNo

-

( ) Serous

(

r-

E.\ po:.ed Bone.

--

(

(

W
) None ( ) Mjnimal ) Moderate ( ) Heavy

(

) Sanguineous ( ) Purulent ( J Yellow/Grecn ( ) NA

I' )

, "10

(

(

+--'-

Wuund Margin ( ) 'r'e...

( ) Minimal

( ) Moderate ( ) Heavy

(

, ) NA

I

,

( ) None

I ) Serous ( ) Sera Sanguineous I ) Sanguineous I I Purulelll ( ) Ye llow/Grten

I

I

( ) Minimal ( ) Heavy

) Yes / ) No

-

I(

) M lew..thon I } 11lI 3rl

(

I ErYlhc m..t

---~--

I ( ) ('.lI lu:;

,

-- --

( J !\{'crolic

( ) M aceral j()11 ( ) lnIacI ( (

--

) Callus ( ) Necro
1,--4)

.,

n

I ~ " 111 ..-, 1 ~,

c,

Dull

( ) HllfII lll~

Ilunbt ' 111 ~

R II"I:IIIU ~

\ ) (".IINllnl

I lIlnllulll ' ol

1\"1

( ) PM

!'III:I'I '

Ii "

7

~"b,d" :

1

( ) l}kvlt'r(l'1 of tcl''I't )In\llllI11IWRc..'1 1 ( ) Mt',!lt:III!lm ( ) SUllldhl~lllkll1p. ( ) Olher

tllllll\Cllh :

) 1 AI

) I "" ~:III1 ~'

( INA

) ()Ih~r: (\JIIUllcnl ~ :

[ ...·hlhl,·1111'11I

1,lu"lll,111

l~hn

~l, lf('

I ~Ia}-' (' I I St.!!'\' It I SLI",' 1\

" I-..In Inl.n: 1. Ii ~ hl

!\kiu: 1I()ll hl;lIl1..' hul,l c red

{l1'\:1I:

P:IIII.lItlud'dl\' " 1'o l-..IIlIIJ!\s IlIlIlht~ ' ~ll l'"

... kill h,:-..:ilWllh l'd

II II " " k/l~ Ith'lI, Hili ( ... )

Si lol ll;lllIl't" :

I hi l'I !"illlt..':

d,u''''

l'> ~ill : Wi.lrlll . indul'nled, h:ll'd \'d(,'ma

Appendix F: Selected Wound Care Internet Resources http://www.worldwidewounds.comhttp:/fllledi-smal1.col11 htfp://www.woundcare.org hltp://www.plasticsurgery.orglmedi cal_ professio nal s http://www.woundcarenet.col11w ww. orthopedictechrev iew,com!i ss ues/j un jul99/pg5 I http://www.veillSo111 ine .comhttp://med lib. mcd.utah .edu/k w/denn/pagcs/woge _ 12 hUp:/lwww.smithnephew.com/whal/wD und .jsp http://www.ch ri stianacare.org/pat icl1 t_carc/patient_care_wound .crmWoundcareshop.safeshopper.com hlrp:l/www.vh.orgwww.woundex pen. com http://v.ww.harcourtinlcmational .com/wou ndca re hnp://www.diversified therapy.comwww.in lemuTse.com http://www.healthproductsforyou .ushttp://ccpe.smsu.edu http://www.firsrmark.com http://w .... w.hea lthsystcm.v irginia.edu/ intc rnet/su rg ica lsc/cwcc.dm hnp:l/www.ai iegromedi cai.com http://www.bu .ed u/woundbiolech/woundcare hllp:/Iwww.medicaledu.comwww.cs mc.ed u http://,, ww. wound .comhttp://gort .ucsd.ed u/newjo ur/a/msg03 302 http://www.joumalofwoundcare.comhttp:/lphys icalt herapy.about.com http://''''\\'\\ .lww.com\\ ww.aaw cone. com www.u iuc.ed uwww.apma.org http://,,,\\ w. \\ound.comwww.med lin\!.com http://www.woundcaresociety.orgwww.ea ton hand .com h[[p :l/ww~.in l em urse .com

hit p:/IW\\ \\. vcp. l11ona~h hi Ip:/ld i r.yahoo.com/ Heal t h/Med ieinef\Vound_ Care hlrp://". \\' v. .v..oundcarestrateg ies .C0111 hllp:I/v.. \\ \\ . v.. o llndcaraesourcc!).com hnp:/Iww\\. merel.. .com W,It \\' .cmOf) healthc~lre .org http://\\',\v. .wocn.org

hltp://w v.. w.p' a.org}rc,!cpg!conr3L1 .htm http://'''v. v.. .emedlcine.com/med htt p:/",\\\\.coll\'atec.col11 hnp:!/v.\\ v..\ CL' J<;.cuIJrdomfl in .colll http://,,,\\v. .hh \.gm hit p:/lv. ,\ w .elk .gm IJJ i.l txt{'~/pu b:-./fat I... heet .hUn

Appendix G: Selected Wound Dressing Manufacturer Web Sites Augulill nC Tv1 cdica l Bertek Phamli.lCCUllca l... Carringlon Lah Colopla" ComalCC

D, Ro) 31 Hoallhpoinl Job .. t John . . on & John ~ (ln Kendall Smilh & Nephou Spenco

3M

http://www.Jugu!)tlnemedical .com hllp:/Iwww.benek .com hltp://www.carringtonlabs.com hIIP://www.co loplaSl .com hllp://www.convalec.com hllp://www.deroyal .com hllp://www.heallhpoinl.com htlp://www.jobst·usa.com hllp://www.jnj.com http://www.kendall .com hllp://www.smilh-nephew.com hltp://www.spenco.com www.3m .com/us/heah.hcare/medicalspecialties

Appendix H: Dressings by Treatment Goal (Purpose) and Wound Type (Indication) I. Dressing by Treatment Goal Purpose

Dressing

Space fil ling (cavities. undennining. tunnel s. or sinu ses)

G auze Foam s (some) Hydrogels (am orpho us/sheets) Ai g in ates Impregnated gauze Absorpti ve dress ings (beads. powde rs. a nd pastes) Composi te dressings (some)

Mechanical de brideme nt Exudate absorption

Gauze Gauze Foams Abso rpti ve dress ings (beads. powders. and pastes)

Aigi nates Hydrocolloids Co ll agen Hydration

Hyd rogels (amorphous/shee ts) Saline- mo istened gauze

Autolytic debridement

Tran spare nl film s Hyd rocoll o ids Hyd roge ls (amorpho us/' heelS)

Foams Alg inales Impreg nated gauze Ab ~o rp l ive d rcs:.mg ~ lbe~ds. powder~.

and pa'tes)

Compo):) ile

PrOl C:C IJ On agaJn~ 1 contaminati on

Tran ~ pare l1l H~

fi lms dnx:oIlOld ..,

H y Jro~ e l ~ h eeb /:.JHnd

Cumpo"ite ' . . o llle) Fl>~un . .

H e 1l\n~ I .t ' I ~

,\ome I

r\1~ll1a t l'''' C\ ll la~l' r l ~I IJlhp'l rt'tll Itl nh ft ~ Jrl x \l lh lr lh

lI ) lh tl~~1 "het't-,

hOI II\;

r

f l) ,1111' ( ' illllp,hUl' (I,JU/t'

---- -----1IIIIh - - - - - - - - -- - -I r .Ul ' l i,Ul'll t

I h d llllPllllld., Ih drlftl"l., hn+1 l"tlllh' j

- -- - -

Chapler 17 Vascular. Lym pbatic. and

Purpose

Dressing

In:o-ulllll OI1

Tr:lIl s p~rcnl

Intcgu~ntary

Disorders

film s Hydroco lloids Hydroge ls (amorphous/sheet ) Fo;,ul1 s Composite home)

Gauze Pam reduction

Transparent films Hydrocolloids Hydroge l. (amo rphous/shee t) Foams Alginates Composites

Odor red uct ion

Hydrocolloids Hydrogels (amorpho us/shee ts) (some) Aiginates (some) Foams (charcoal) Absorptive dress ings (beads. powd ers. and pastes) (some)

Cushioning

Hydrocolloids Hydroge l sheets (some) Foams Composite dressi ngs (some) Gauze

AllI iblCleriai s

Silver-based dressings Iodine-based dress ings Silver sulfadiazine

II. ()re" ing, by Wound Type Jnd ical ion

Dressing

InleCied v.ound"

Gauze Alginates Hydrogels Hydrogel sheets Impregnated gauze Foams

Burn\

A iginaies Hyd rocolloids Hydrogels Tran sparent films Impregnated gauze Foam s Biological drells ings Co llagen

Sla~t' I prl!\"l!re u ke r~

Transparent film s Foam~

Stage II prt:,o.,u re uk.e n.

Aiginalt!s Hydroc'o ll oids HydTtlgeh Tran ~ parell1 film:, Impregnated gaUL': Foams

Collagen

703

704

Physical Rehabilitation

Dressing

Indication Stage HI

pres ~ urc

ulcers

Stage IV pressure ulcers

Ai ginates Hydroco ll oid, Hydrogel' Impregnated gauze Foams Co llage n Aiginates Hydroco ll oid, H ydroge ls

Impreg nated gauze Foams Co llagen Venous ulcer.:.

Arterial

uJce r~

Aiginates Hydrocolloid, Hydroge l' Foams Alginalcs Hydrogel s

Foams Diabetic ulcers

Algi narcs Hydroco lloid, Transparent film s Foams

Donor sites

A iginatcs

Hydrocolloid, I-I ydrogcl s

Hydroge ls sheets Trnnsparcm films

Impregnated gauze Collage n

C H A PTER

19

------------------------~~ " , , 1 ' 1 ' IIHCTIYfI - I)eSCribe the: etiology. epidemiology. t. ~)siology. sign!! and symplom!\. ~is. :and course of muhiple SciCroS I'i (MS ). z. 1}e!Cribr eit'l'11enlS of the medical management of pob
""""""IS,

Multiple Sclerosis Susan B. O ' Sullivan, PT, EdD OUTliNE Epidemio logy 777

Framework for Rehabi litation 788 Physical Therapy Examination 789 Tests and Measures 789 Goals and Outcomes 793

E'iology 778 Pathophysiology 778

Clmica l Course 778 Exacerbating Factors 779 Chnical Man ifestations 779 Sensory Changes 779

Pam 7HO Visual Change~ 780 ~Iolor

D) Sful1(.'lion 78 1

Speech and Swallo\\ iog

D) ..,funclion 78:! Cogmll\C and Affective Chang<.."S 782 Autonomic Changc\ 782 Dlsgnosll> 783

Physical Therapy interventions 793 Management of Sensory Deficits and Skin Care 793 Management of Pain 794Excrci~ Train ing 795 Management of Fal'iguc 799 Management of Spasticity 800 Management of Coordination and Balance Deficit.<; 80 I Locomotor Training 802 Functional Traming 804 Management of Speech and

S"311owing 804

Imag:lOg 783

Cogniti\(" Training 805

Cl' rebro"'pinal Fluid 783 E\oJ..t"d POienTlah 7~~

PsychoMIC iaJ Issue., 80S

PtO¥n('I~l~ 78~

Patienl and Famll,y/Caregiver Education 806

\1("dl"'-3.1 Management 785 Agent.. 785

Summ",) 806

DI-.('a ....:- • .\1cKhf) Ill,!;

\1anagcrllc1l1 of Relar'l'\ .md

S)mplOlm

7~"

Epidemiology rh~ on:,('1 01

\I S t~pi'-·J.lI~ lloCcur tx-I"een the IIgt.·~ llf 15 ".IOU _() ~ e'lU.... \\ Ith lhr redk ..II Jgl' JU. The diM'J, ..e IS rare 10 dlJId.1."0 J\ 1\ the OlhCl of !'oylllpionh In .Idulh nlJe.r (han th..• ..tge Ol )0 )1.'".lr... II .tfl(.·~h ,1I'PW,(II1l.Uei) 400.(J(X) intI!· \ n.lu.ih In Ih l nilt."d \1.Ul''), r ht." dhe.t~ i~ more (ommlln If} "0111.111 Itt.tII to Hlt'll h) .1 raW' of 2: I. a Jli terent....(' e:"ipell.tll~ t "' hknt Jl the- ~uuHga dge ... rh~re are "ell repol'tc:d clhlltl d,lIallh.\.", 1.l.IIUlh .

h.d ! Ih\-

\1110.. ,,11\

' I, . ..tk.. h

popu-

\mt:llc,uh ~1I".lO'IlfJh.~ .lppro~ ilf1:u~l)

n,,).. l'l .illjUltlng

HPOfil'J II)

r'nl~l(llln~l ld} ~h ll\.·

"'1.U1' .Uld

Ihe

.111\(,."

dl~~J""·,

1.0"'

rolr~)

G.rc aJ",

Hll'rtl.. Jlb

i pld,,·lOlul\..l!!I\.i1 ,tudl<."' h,Jh~ n:H\,fC',1 a geographJl:af pau"-l11 ;,ll J,\tnbUUl'tl (It \1\ \\ nh .irc... ." (If hf~h. medium,

118

Ph, "ical Rehabilitation

and low frequen cy. High . frequency areas include tI~e tC.m· perate zone ~ of the northem Un ited Slates. Scandmavlan counLrit"$. northern Europe. ~outhcrn Canada . New Zealand . and sou thern Australia. with the incidence reported al rates of 301080 per 100.000 population. Areas o f med ium :re. quellc)' c1ot.;er to the equator include the sou lhem UllIted Slaies and EIJ ro(X' . and the re~ 1 of Australia with a reported incidence o f 101025 per 100.000. Low -freque ncy tropi cal areas (Asia. A fri ca. and South Ameri ca) have reported rates of less thall -" per IOOJ)OO.lJ Mit,'Tation studies indicate the geographica.l ri s" associal C'd with an individual"s birthplace is ret amed if emigration occurs after the age of 15 years. Individu ah mi!!rating befo re this age as~ ume the risk of the ir nev. locallo n ..' There ha\'e been reported epidemics o f MS in the Illerature. one in the Faroe Islands off the coast of Scotland and o ne In Iceland fo llow ing occupation by so ld iers duri ng World \Var 11 These epidemiol ogical studies lend ",uppon to a theory thar e \posure to an unidentified infectiouS agent tra nsmirt ed per,on· to -person , such as a ('10" -Jeong ~ iru s. predi sposed individuals to the develop· menl of M later on. ~_6

stalls altogether. Eventually the ol igodendrocyte, become involved and m ye lin repair canno t occur. One form of MS, primary-progressive MS. appears to be assoc iated exclu·

Etiology The precise ellolog) of MS is unkno wn . The mos t widely aCd~'rted theo~

ulin s (antibodies). In tum , a co~mand ?r trigger prOtein, Ihe antigen. is acti vated. productng autOimmune cytOto~ic e ffec ts within the eNS (this process can be viewed as a fonn o f " fri e nd ly fire" ). The blood- brain barrier faiJs and mye lin-sensi ti zed T-Iymphocytc ce lls enler and attack the myelin sheath that surrounds the nerve. Myelin serves as an insulator. speedi ng up the conduclion along nerve fibers from one node of Ranv icr to another (te nned .taltatory Conduction). It also serves to conserve energy for the nerve because depolarization occurs o nl y at the nodes. Disruption of the m ye lin sheath produces active demyelination, slow. ing neural transmission and causing nerves to fatigue rapidly. With severe di sruption. conduction block OCCurs with resulting di sruption o f function . Local inflammat ion , edema , and infiltrates s urround the acute lesion and can cause a mass effect (abno nnall y hi gh pressures). funher interferin g wilh the cond uc tivity o f the nerve fiber. Conce ivabl y, thi s inflammation (whic h gradually subsides) may. in part, account for the pattern of fluctuations in function that charac terize thi s di sease. During the early stages of MS. oligodendrocyfes (m ye lin -prod uci ng ce lls) survive the initial ins ult and can produce remyelination. This process is often incomple te and as the disease becomes more chronic.

I' thaI it

b

an autoi mmune di sease induced

h~

a \ IraJ or other mfcc ll ou ~ agen!. In panlcular. herpe!:> \ 1I1he\ d. II. and V l) and chl am yd ial pne umo nia are agents 01 greatcq Illlere,! III an mfC'ctJ ou", hypo thes i,. ',1i The pres· m.;e of IIKrea'<:d Immunuglobulln (lgG ) and o ligoc lo nal

band, m the cerebro,pmal OUld ICS F) of 65 to 95 percent of \ 1S pilllffih pro\ Ide, com m Clllg e\ tJence of a pre" ipltating mfectlOn dKlfln!! an JutOl.mlnUf1(" ft:~pon~ "lIh resultjng palholO!!Kal Lhange,.1J Vira l lnfec llo ll hib bee n ~ h (\"n to rrt'npJI.J.le dboU! 3.':\ l"'Ierct:nl 01 relap~~ 10 MS G ",' nellcs a lw pI3~\ a rule Ul the tu;.<-Iul~J!lnn oj ~1 S Appro \. unate l) 15 per.. ('nt 01 patlent'!o h.t\e :i l'V'lme- famil~ hl'l,tol) (fi r' t·degree rdam e, lkh a." a p..trcilt OJ "-Ihllllg "1m MS). 'l1lC n~ l.. I~ 3 hi) ~Rl'm lor.i lratem.d lOI\\ III htn nse-... 10 2h percent for dn wt"ntJlI.ll .. ",H"ln G('nl"Ul "udle, ha\l! rt:\eJ leJ l11ul l1 pit m.ub."p. 10 muluplt'\ l .ullth~\ . defined a... fillllllJt",\ IJI ",tu. h "oC''\t"loU IHt-IlIhc.-r.., lu\c ~ ' S In p.U11l'u IM lI uJor hl ... IOUWllr;,tllOlh l ,\ "-~Irurln i Ul( , pruleln"". t'1K:OlIt:d on lhro· m .....n!ht' fl. noJ\1! i:k;1,."11 Iml-td II) uHI.t,,~) prUdtlt llOtl (d l1~\ I ... lIt1~i·n·", .1liJ \1'-, Ii drpc~ litJt .ulh()U~h IfIdl,"h.tUJ.I~ dn no, truK"111 1114: d.-.c'.l':lt: tlin rtlJ) lnhe-Ill oJ gerk'th; "'U~t'PIl hllih IJ:t ,ITII)IUf}(. '~~ lt'nl dhlun" 11.)(1

sively with disease of the oligodcndrocytcs. 7 Demyelinated areas eventua ll y become fill ed with fibrous astrocytcs and undergo a process called g liosi s. Gliosis refers to the proliferation of neurogliaJ tiss ue wi thin the eNS and re!:>ults in g li a l scars (plaques}. At thi s slage. the- a>.on itse lf becomes interrupted and undergoes re trograde degeneration (dying axonopathy ). Axonal loss vanc ... from 10 to 20 percent in milder fo mb o f the di scaSt' to a... much a!:> 80 percent in severe MS.I: In advanced case .... there are both acute and ch ronic le sions of varying ,ilC' ..,cattered throughout the C 'S (brain. brain stem . cerebellum . and . . pm
"I ~

hlghl~ \,Ifldbk dnd unprc"ltc!.Iblr fro m pt,-..on-ro"11hlll d gl\en IIIdl\ IduJ.1 (l\",£r tl m\' . AI unt' end til the UJI1tIlIUt.!1Il tlklt"):) h('lll 'II " \ ddint",.i .t' L"~,c.t to "ilidt Iht' I'<.allen! reltl..tll1 .. ful/.,. h'lh. ll nll.IJ III.!JI neUfllltJg1.. <11 )"'h.::ru~ I~ " ltl.'l' lln~'1 fklll~1l ~lS .1Ifl'\·I ... k\liCf' Ih ..lll .!fJ pch l"1l! ('I f.:
pC~'h(ln :1nJ

,-.-.tt,

In ~

lit'fiI "lUI '1'-, IItt IIl1l1 htnl n p"fI~ ln~ rei Ute;' ph'" 1. ,'''-11.1 J hillptl'" H ~ Ill'" ,,,,,hotf ,m,llIlIllIutH..,!,I.lb

Chapter t 9 Multiple Scleros;"

..

h within

rel.tively shon lime 'Ifter onsel. RelapsingfC

MS (RRMS) is the 1110S1 commo n C?ursc. a CC~ n~nllrlll g . "I 70 noorcenl of patient!lo wuh MS. .It dIS . proxm13ft: y t'~ 109 ap . d by clearly defined disease relapse,\', peno s charactenze nint! o f nc urologicaJ function. fo ll owed by £k!!H. "

3

. f acute \\ orse o• 1II5S/0 . 11S , de fined as period s without .di<;eased progressIOn I nI . I an sympto m s. d panm or complele abalcOlenl of slims an 0 rcenr of RRMS ca...es go on to develop secAboUI pe . MS (S P'1C) SPMS beeins wilh . a n ' 8 IVr.:r{,SSII'(' /I ~} • e om/a " p ~ 'II' · " " cour ..e followed by prol!ress io n w llh lapSIn!Hl:'Ol I ~ . .... re . " occasional relapses. mmor remiSSIOns. and Of \' HhoUi . . I Proorl'Jsh'e-relapsil1fl MS (PRM5) beg ms wi ll a lateau
. pronressl·on MS (PPA1S) IS a disease ~ . ~ . Primary . pror:.ressl\·e , . rare (oml occurring in aboul 10 percent o.f cases. II IS. c harnearl\ a c ldeb)n;]z e . conrinuous worsenmg of .the .disease . I md lvld ua s from the onset wirhoul di!)linCI relapses. Some . . do ha\'c occasional plaleaus o r lemporary mlllor Improvements. PPMS rypically has a lalcr onse t. us uall y after age JO. Permanent neurological disa bility res ults from re lapse s \nlh incomplete remiSSions. progression of the di sease . or both. Becau~ Ihe course of the disease may a lter. clinicians need 10 be alet1 10 changes in signs or sympto m s in lenn.-. of se\erit\ and frequency.l.l,14 Box 19. J s ummarizes the categorie~ of multiple sclerosis,

779

Exacerbating Factors MS relapses (ex acerbations) arc de fined by new and rec ur. re nt MS symptom s that last at least 24 ho ur)) an d are unrelated to a nother etiology. Several fac to rs have been idenri li ed . Avo id ing these aggravat in g fa c to rs is important in e nsurin g fh e patient 's optimal function . An individual whose overall he alth dete riorates is m ore likely to have a re lapse than one who remains healthy. Viral or bacterial infec tion s (e.g .. co ld . flu. urinary tract infection. s inus infec lion ) and disease s of major organ system s (e.g .• hepatitis . pancreatitis. asthma attack s ) are associated with re lapses of di sea se. The re is al so a m odest link between stress and acute attacks. Both major life stress events (di vorce, death , losing a job. trauma) a nd minor stresses (exhaustion. dehydration . malnutri tion , and s leep deprivation) c an affect the immune system and an a lready compromi sed ne rvous system. ]5 PSfudoex{lcerbatioll re fers to the temporary worsening of MS symptoms. The episode typically comes and goes

quickly. usually within 24 hour s. The overwhelming majority of indiv iduals with MS demonstrate an adverse

reaction to heal. known as UtholT's symptom . Anything that rai ses the body temperature can bring on a pse udoattack . External heat stressors include sun exposure , hot

muggy environmental temperatures. or a hot bath. Internal elevations in temperature can be produced by fever or pro-

longed exercise. The e ffects are usuaJly immediate and dramatic in terms of reduced function and increased

Box 19.1 Definitions and Tenninology Used to Describe Categories of Multiple Sclerosis • Rtlapsing-remilting MS IRRMS ): Chamclerired by ~~ v.ilh euher fu U recm-'ery or some remaining neurological .MgnV~)'mpl.Om~ and residuaJ deficit upon ri!COv~ ~ me penod bel~een rel~s are characteril..ed by lack of dif!ea.-.;e progre ~ion .

· Pri...,.y_prog......... MS (PPMS ): Characlerized by di,ease progre,.\<;.lon IroID on~f . "",lfhoul plateau., or reml ~1KJn~ or V.lth ocl,.,a£lllfl:t1 plale'oiUS and temporary minor

lIIlprt)\emenb.

• s..uo""')oprogressi .. ~1S (SPMS ): Characterized by millal re~ps.lO~ Tt:mllllO~ cour'ioe, foll owed by progres-

won

il

a \4lUble ro1(e thai rna)" ~I!.O mc-Jode ~ca>JonaJ

rtlaps,t and minor remb ..l0Ib.

·l'tovoW, fllT"Jtrc

Iltt

-relapsing "S (PRMS): C1,ar"'lell
cLl>ea~ 'n)Hl 00'<1 hut '" Ithillil df'iU" a(;Ul

rfi~ (hat molY or ma) 1101 hu e '-Oint! ox()"ery or rtml....aon: ~onlfllOnJ) M!n1 m pt"oplt' ~ Ito ~i?lor the: -dj~ . her 40 )'e:.m. 01 ui!t:: loiS t&n • Charactcn1{'d h)" Jtllid dl~ih In '0\, hlf,.;h J* 11 rem..m fu.lly [ulM,'Uourllm aU Ill!unltugh:ut \}!o. . I. I ~)'f" ~ftt:r dl~iI lIthd

fatigue. Most pseudo-attacks resolve within 24 hours of cooling off and/or the end of a fever.

Clinical Manifestations Signs and symploms of MS vary considerably. depending on lhe location of specific lesions. Early symptoms typicall y inc lude minor vb ual dislurbances (e.g .• episodes of double vbion) and parcsthcsiu 'i progressing to numbnes~, weakness. and fa tigability. In more u(l\anced s rag¢s. p<.ttients demon .. trate muhiple 'ymploOlS 'wi th varying im o h e m en t. Common symprom, In MS are presented in

8 0' 19. ~ II.I· Th. on,et 01 ,) mptom, can develop rapidly O\("r a rour',," of lIu nule') or hour)): Ie~s frequenlly. onsel is in\ idiou'\, occuning 0\,1..'( a period of ""eel, or months. An ...·a.rly remi,)'lJOn Ina) lead rhe ul(jh Jduulto pOMpone initial ne urological "or~up lor momh.." or longc!r.

.a.... •

~t ~~ l \tarbuf'&' '",Id P' ~. I

\-u lanO: Char"f.:ltriled tl)< . ~ ... ~ Inn e
Sensory Changes ('omph:lt' 10\\ of an~ 'lIlglt" ~lhJ.lIOfl (aJle~~'ia ) is 11lIe. h :x.'al defu.· .h (.' dtl PHlduce IlInll~d area,.." of diminished 't'n'Jtlon. It ... rl'd bell:,alJOIl\ ~f(' far more conunon and tan Jlh lud~ purt' .)lhpHlO (pUl~ olno needle, sen~..on) or I\UIflrn-I(: ", 01 tJlt! t.h.e~ ~lJ}, or C'lilremUIC& L>UilUfbao..",

Ph~ ~iCJII Rt.. hahilita. ion

780

dl\"l<.,JtlH"

Box 19.2

Common

;'-'1101' ~ha" Ing. or ~Imply tllllc..hlllg,' the Lll:< ' pw, 1~.... r;>". . _ , ll11) ,l CIH,odes. A L-omlllon ~Ign 01 nrl~tcn. , ,nll lfIggrr pOI . . " . , ~", 'CJJj , n"'''C 111 lhe splIl,ll l,;oHI IS Lhcrnllth' .s !,'un ' umn t.1 ... tIl I 'to "hidl tlexllm of the nee"- prodtlce~ nn eleclri~ ,hOCk.likc stns~ltion runnmg d(";wn Ihe ~pme and IOto the I.E pJfO,e;ysmi.tl IlI1Ih pam presents l~ ,abnormal blirnln .Iching p:un <:an allcctmy part or hotly but I'; morc common HI the I. b., II I'S the mmt:orn. mon type of pain in MS .!lod IS wor~ 11t nlghl a~ after cxerdse. It can he aggravated hy temperature elevation.,

Symptom' in \1ulliple

:II\( I

Sclero,i!lo 15, '6 'enwry "") mplum'i Hy:X1CSlhcsl.l, rlumbn..:s l"•..rc"~hcsi.1S OYSCslth.S! 1.",

O~l(IC (IT U '~CJllIO.11 ;lCuntlS

L, "'n:nmffl"S ~.;n (,bronu.: pain \ i .. oal "') mpwlI1'i Blurred or douhle n,,-ton [)lffitnlShed a:"'JII,·k s '1

\'L",lon :-;,:01(11.1

hl.lIgue

(dyse5olhe~ias, ~hal

Inc'/
Cognilhl· ".oo,\mpIOm' Memory fe'_,:;,11 p.-''''km Dc-~'--e.lSt'd

attC'ntion. ::.:.."tralIM Di.'lIJ1I:'~~ .Jhsu..... leas,omn!=;

Dlmmlmed p-ri-:,,::m >Iv ng _.Jdgm:':"'J Dlll1imshed >r
-spati:1

Olbllities

Emotional 'i'mptoms • )cpre.'SIOO

'tc-.:::Jbulbar .0"",

Ircquent In MS than 10 the gcnclal population dud can be Olll:!rainc or tension type Chronic. flf'uropl1rhir PHin I:;an result from demyelinating kSJ(ms 10 ~rlQothalanliC fIacts or in the- sensory roots. It IS more cemmon In patJMt!i with minimum di~ahilily and ie; descnbed a~ a burnmg pam L':!

[)ec-ease:' l~bidt'

'0

Da.::-;:ased v ':gmal lubrica

ilar pain de>cnbed by indIVIduaLS w th d"k herniation. ,\lu>culo,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<.!:!Ily self·hr._lIng \;'I"n gen~-,[ ","hlll 4 to I 2 w~h. DamaGo t~ Ihe "p~ ~'." .. c'Xt light .. Ile>..s. "~rcu, C;unn pupil oft:'~· "'th MS to tndi"tlual, "hl have ~3d ..- c~:.:~ f

I~

( 'is

nec~: 'i

post:.on seme art' aiM) C:-nunon • .:: L[ I impairments of vibratof\' .. "'n

l:!

ilJ'C

IG;;.rer tXlre'lluy

Snimng

[}Ie ~

poun. ""lh r,

pen..c:l

n

:

of paL=n:- ,,·,lh \1';

.'P«

U1l pal~ OC~jrnn2 I~ '-~·ut

P.: J

it bn;~t

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product: rc"ilc" ""~ntract ,en In !"tile.), If t:-e hr.ht i, th<:n .u.io,u.:. ldeni:"'",g !::: ,~-n) .:

Pain A~ -::::~')- 8~

~

'hPCfptlthia, a hYpcPicnsl11 .... lty In InUlf)r sensory stimuli can ou:ur For example. ;1 light touch or lI!,hl pre~:o;ur~ sttmulu't cJi(;its a ~cverc pain n:.KtIOn. IIc;'l/tu:he I~ more

Htaddl'l' '\' IIlr1mn , lnn:lIY orgC'nt y. frequent y 'OI:tUl ;a Inl,;ontincflcC' l nnalY hesitanc" JJ ibbling "'"·,ual S} mrtOJ11' Impoteoc:

","ystag'llUS

\;.-~'

'ttlIHT "') II1"turn" \\e;ll;:I)(S'\ or paJ .11":-'1~ Sj1;.....lil.:,ty

.... in

IIIllcrvatmg the fai,;c c'k , ,l ie tnvCllllII,llnclve C' H~~e

~'

., 'I

1:"".X'

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....I '.. ,."'doItbII ....... _ .....

~N.'iiI·.". .... r n..,~ . . . .\I6'1:1 ............ DLIV....

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'd.

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... 41) malt ami .. '. " 11140111<1"' . . · · .1'.. .' .tlffdi riH'ily. 11Ie et'IecIIof~ .... . . . m..,d _ . . . . IiIoUld be carefIIIIy.oxamlnlld.

IIrd? D)" JII '

.cdoD

.

1.~;-,

V --. --.: --' .1'4 [' ............. -........ " ._1 - _.-~-...... --'-~' ............. IlIJllI .....

'i

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at; ~~~ ...~_(~~.~ !1Y.................. re"""es. mvuouu!aI'Y ""xor h

os, clonus, Babinski's sign. e~ autonomic: control e 19 •• bi... UMN iDvolvemeat (see 0Iapter 8), 's _ slow. stiff. ami weak, Ihe rau1t of loss of .",.., ~ amI...ctuced firing nile IDOCIuIaIiGn of _I (III&. Reduced muscle sImIgth, power. ~ . ' ..... along with iIrIpaired S)'II"IIIi..... lIIIaIionabipI....... 1'IdcIJIs willI c::eodleIIarajqns~ n ail • .,. r...t .-:Ie "pa II along willi . . . . PM' t . . _eapeaic:ax: IDU8CIe '" do: F ""<wh , ID-ialaff.. • Made. • • em .ary from • mild P '1; Gftaa · . 1.fiml.IDIIJbII . .al)'sisoflhe~eil. rI«.. . . .

IT Sf

,

aefIexeS, IIIId loss of ptecise

*

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-...

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iUf' . dr,'. " ' '

MSc-:ilIiarCfiaioll PncIiI:e <1ti"rI_ ·u ......... cl plrysiollllldlor mental energy dIat is JIIIIllIIived

..,. ... iadividuaI or CBqiYer 10;' f a .·"IritIa ....._ . . . aca.iIicL-., I !Wipe is • daily ~ " , (3

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~ ...

'1" '"

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'1t.

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,

(abnormal ~~ \ (MRs), CIOllUI. t'IeltIOIIor.1I1l iT I ,;' de<::!ea¢ed ranae of iIlOIIIIit~.'~ increased fali"'i:.~.tdtan.tli'..~

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'Iy . . . . . . . " . . . . . ... .... ..,. . funrticWaa (79 ' " . .. ' .1Il p1 . ••IX (67 JIM. . tiff 4 :! . I ). . . 5

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fIIIIP,..·_.illtriri. '

.... by7Spa HfIiD9SI*uuor ,..U. h ...... ..... Apprwi '..,. 50 liD 40 J flllJiI"CIf ..... l'IpIIItdlatfilliaue is _of _ _ ,", •

,

With MS, ""'IN• •1Il1ll '.

r

flU""""

~t,,,,,,,:,:'

.'

.

If "alt·", ,,<:'ii;i'rii,'EitRitt', " spaeltcl '" ' . t)" ·11 , .' ~._l'i' _ _",' .' .. ,_:. . . . :. 'la2" ,.',."~:'..,,.,',. •. '" \

c,

fillip bas boM deliaed by die r-t OIl FIIIipo . , _

W,~,;," e

..

Chapter 19 Multiple Sclerosis .,'clcralion and reduuion in blood rrc~sure

,

-aru ll1JL

.

dunn" (,\cn.""Ie. Some IIldividu;:lis with MS nlO ~ h'"e clther allellu
1..., ~sp'-lns..

"

:tl~,'

(add." Dysfunction

~ , kl"lddcr "dY"ItullctlOn occurs In about 80 percent of [nn'l.,l"

783

Sexual dysfunction has u'cmendous functional and psychosol:ial implications for both patient and partner.l.~

Diagnosis

r\

, I' .:. Loss m volitional and synergistic control of the aflen s· '. .... p. nOtion r~11ex is produced by demyelinaLing lesions 01/1. nJ . . afh: 1ing the I;Hcral and posterior spmal tracts unmasking t '''~r;i reflex arc. Types of bladder dysfwlction in MS t ht' s..1.. .. .. " include a small. spastic bladder (a fadure to store ""CI'm) a flaccid or big bladder (a failure to empty Pf{W I.: , problem), or J dyssynergic bladder. The d~ssynergi~ or -,lotlicling bladder represents;) problem wHh coordma~l)n tx"{ween Ihe bladder contraction and sphincter relax:Hlon. I~ C(l0l1l10n symptoms include urinary urgency. urinaf\' frequency, hesitanC) in starting urination. nocturia l~qucn~) at nighl). dribbling. and incontinence. The ~\"eriI) of bladder symptom~ is associated with severity ~)f llth~r neurological s) mptoms, particularly pyramidal [fact Ifl\"ohemenr. Progressi\'e loss of functional mobility ;(",'2., hand Shills. SItting balance and transfer skills. ambubtion) contributes to per-onal hygiene problems. emoUOO:!! distress, and functional IIlconrinence (inability to taiJelormanage dysfunction). Emptying dysfunction with iarge reSIdual urine \'olume increases the risk of recurrent urinary lract infections (UTI) and kidney damage from

frequent lrrL.....~:

Bowel Dysfunction O'Jnstipation IS the mo~1 l:ommon bov,:el complaint in MS and result') from leSIons affeclmg control of the ga~trocolic reflex. lJ 1<, ilSiOC .ated v..'ith thC' prc\ence of spasticity of th~ peh'I"; floor mU!iocles and is also a frequent con ...equence of inactivll)'M:l of flUId mtal..e, poor diet and bO\, 01 habih. deprt£sion, ~d medicJ.tlon side effects. Bowel impaction a litfl:?..:..s ..;omphcation that reyuire"lo Imme.diate attenllon. Dtarrhea.:nd mcontmenct is less of a pre>bJem hut can also 'J] 3:- a l'e5.ulr of los~ vf fl!l:lat control, sphincter abnnr· ;~ or a~ the rt'$ulf of SCi. onrlar) problems (gastruen~ ·It":!lS.

mflamm;tor\' bowel disease)!

s.,"ua1 D\'Uunct . . inn

['js!UOCunu IS Cl.~moo, blfecung .a'~ IU;;UIY as t) I pe!\'Ct;: of rnMl and 11 per;..ent of women. In WOrJle"n.

luu(' . h,,,.; ...ieC!~~~ !Sensatlun,

psms.. pal ,,;

![)i..·m!1ll;

til

self un"

The diagnosiS of MS is made by a neurologist based on history, clinical findings, and supportive clinical tests. including magnetic resonance Imaging (MRI); CSF; and evoked potentials (EP). Diagnostic criteria for MS are outlined in Table 19.1.'4

Imaging MRI is a sensitive tool for confuming disease when used along with other clinical and CSF data. MRl detects both acute and chronic lesions, small and large, with high resolution. Gadolinium is a chemical compound given during MRls (Gd-MRl). These scans are used to help distinguish new lesions with active inflammation that occur during the preceding 6 weeks or so. Lesions are seen as areas of increased signal intensity, "bright spots." T2 scans are used to detect more long-term disease activity (i.e., loss of myelin and axons, gliosis). These lesions are seen as "black holes" on the MRI; the darker the lesion, the more extensive the tis,ue damage. Approximately 95 percent of patients with clinically defined MS have well defined MRI changes. Ex.cessive MRI activity includes three or more enhancements on repeat scans separated by at least quarterly intervals (.fcattered ill time and place). Lesions revealed on~1RI do not always correlate with clinical disability. "Silent attacks" documented by MRJ changes outnumber the attal:ks that cause active symptoms sUl:h as paralysis or VIsion loss by 10:1. ~-1isdiagnosi\ can Ot..\.:ur a.. . 5 percent of individuals wilh confirmed MS do nol e,hlhit l\lRI changes. In additIon, other diseases can cause similar k"il)nS t"vide-nr on ~1RI (e.g., disseminated enl:t'phalumyditb) and some hl'a1th~ individuals can e\.hibit bright spt)ts nn ;\lRI. Current neurology gUIJdmes caii for MRls to lx' lX'rfllfl11c:d :.it pn.~. .k'tint!d Hltcfvab tu dCk.:uml'IH dh~"St.' pwgre.ssiOn and response In dl,~C:<1"'~·J.ltering nlt"dl .... atii.HlS ..l.

Cerebrospinal Fluid PaUe-nt.s with \IS . . hnw eil!'\)'[C'o tOlal irumullog!ohuhn 1I1 ;plffid j1uid ",nd the presencc i,)f \\liglli.:lonaJ 19t1 hands ,seen III 85 lO 90 pen:cot uf patlent.s). Parients Yo uh PPMS ha"e h!~hef i:\.'"vels of immu(loglobulms 10 spinal flUid than p~lIenlS with I{RMS.

woked Potentials I(> 9(, perrent fof lIl
l P

784

Phnical Rf.."b.bilitation

Table 19.1 'lip .. h ....I: "cOonald Oiagno-li.· Criteria for \fultiple Sc!ero,is (MS) What Is an AtIlIck? • Neuro;.,)gicaJ dislubance of the Kind seen In MS

• Sur lec"ive <epo" or objective observoUon 24 rn.ors duration, m;:-;lmulT' E"xciUdeS pscudOanacks, sirgle paroxysmal episodes DetermInIng Time Between Attacks • JI.) 1ays belweer onset of event ' anC! onset of event 2 How is" Abnormality" in Paraclinlcal Tests Determined?

Three out 01 'our • t Gd.cnha"ci~g or 9 T2 rypertense leSions rl "0

MaoretlC resorance imaging (MRi)

Gd.enhanc'ng lesion • , or more I"fratentor'al leSIOns • 1 or rTWre .uxtacortlcal le$10<'5 • 3 or more ponvenlricular !eSlons (I spinal co,d lesion 1 brain lesion) C--e

• Oligoclonal IGG bards In CSF (and not serum) • or elevated IgG imex

1d

• Delayed bUl well-prcseNed wave form

r"',Aed po!en!i8ls

Nhat Provides MRI Evidence of Dissemination In Time?

A.:::f

demOnStrated 1"1 a SC8I' done at IelISt J monthS loIloWing onset 0' C!::"irnf aT'.ack at a

l'4if1Af'l1

or d Gd-G<1hSnCng .csiors lil

3·rc~th

fc.1ow· up scan aner an add,bonal 3 monthS shOWIng

'r2~

Steps In Making a Diagnosis Of MS"

CIinICc! 1!VIdc"l:e ""lIl;Uf':~e (addl .1 rost be .. Jf'SIStenl

~

.

..r.:- M

ev,deJ'"ce

'c

,

• MR:

C' --;:;:-..:...-~-.!:::n MRI or '1 C:,~::.

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and

n t:.~_ ~=: .~-;~~

te;..:~--l.r--''-'-

......~

s.1e

-

~

Chapter 19 Multiple Sderoliili

785

Table 19,1 TIl' Shccl : McDonald Diagnostic Criteria for Multiple Sclerosis (MS) ("on';n."",) - InsidiouS neurological progression suggestive of MS {primary progress,ve MS)"

Positive CSF and Dissemination in space demonstrated by .. MAl eVidence of 9 or more T2 brain lesions • or 2 or more spinal cord lesions • or positive VEP with 4-8 MAl lesions • or positive VEP with - 4 bram lesions pius 1 spinal cord lesion

and Dissemination in lime demonstrated by

, MAl

...

• or continued progression for 1 year

.

-- .-.-

From N
,

'McOorIald et ai' Recommended diagnostic crderia for multiple sclerosis: Guidelines from the International Panel on the Dianosis of Multiple SclerOSIS. Ann Neural 50(1):121 2001 .rThompson e1 al: Diagnostic cntena for primary progressive MA A poSition paper. Ann Neurol

'1832 2000. Bar1dl.:= et aI: COmparison of MR Imaging criteria at first presentation to predict conversion to clini~J define MS, Brain 120:2059. 1997 TII'IIOre et at ISOlated demyelmating syndromes: comparison of different Imaging criteria to predict

conversiOn to cOuca11y del,na MS Am J Radoology 21 ]02, 2000.

:tMon~ o..:n \"lsua1- auditory, "'omalOs.cn~ory. or motor path\\'~\'~ produ(:e siowe-d pr abnonnaI conduction.

JI is important to remember that Ihese remall1 general guideline~ and cannol be used to describe outcomes for

indi .... idual palients.

Prognosis

Medical Management Omy a small pc •.:~"ltage of patienb actually die a\ a con~~uencC' of the disease for mo ... t indinduals, lif~ elpe~"lC)' IS not redulC~ ,,'.:!.h 7.f percem of palienh surI\"~'g ~~ years ~~er O:'!sel (of ~ymptom~. HO\\t:vcr. only a nont" of mdividuals wnh MS are still in the workforce ,-.arHfle'on>c1. AI15 yean, iOpe"'entofpaLents wdl ~~ LL,t use of an assistive dcvil:': 10 \J.;alk. and at 20 years, 50 percent Will require a whee'cha.: 6 Dc-spile Us \'anable I."U~ ~.:rtatn prJg~osuc faile.rs """" be:~ Idc':!i."ed .n ~1S •

~'-;"';;;~'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<.lW down the Immune system f6pOnse b) redUCIng inflanuna lion, sweUmg, and rapid pmhkrJtion of T ""d B cell" mey also block activaloo T cells t10m crossmg the hlood- brJln barrier dIld damagmg Ill) toJin. Oth('f dise.:lSe-mOOihing drugs mdude ,G latiramer aC'Ctatc l.Copa \ ooe) dod ~uvantronc, C,-,pa.\.one IS a.bo zm·JlIll1uoomodulatC>r thaI deb as d deco)'. elo£ging -I cell rCCerl('lT'!.. ,\~I\'.alt:n')ne i.<:. an unmunnliiiup' pf:-ssant ".U1U has d liTnncJ lifellme do~C' to pr~\"cnt heart darll;\L'::'"

li:tble I Y.2 p.-:')ents

An

(i\ief\'tew \" che di~'ol,,'",~

nodr:yiL.£ driJg'i.

For m(l~t pauellh rtXei\o lDp dlscJ.!:e· modl(vlll~ dru~" trealmc-nl 15 :.Illy p.;.rT1.,I'!), cfln.tiv(' In lo.ontfiJllwg rheu dl'ie..,,~ SOlr..:: JJ;!tllnlS ha\'(,~ ~ho~'n rCdlh:('" fC'ialhl"S Ill\! dx·ut \() pe.... ~m w~n 4:umr:JreJ 10 plai.... bu tn'armcnl,. dm.:J ~\o"c'll \" «"f .itT...::d; ft~ e\ itk'-Ill.~d h) a(:~uirrd neUH l'd~ t.kf,clts, frv.;:-o illd smal ter duna,gcd .lfc.as un MKI and .. SIO....''-f : .ire of oJj~-;,:.l~ jlrogrr-"S..'il\)I)

ok)

Conlinued

lk'nt rc'",p:.o ur n.~t"~",f\-e 'UU i...:li . .·f(\, mol} md.l'.dc;: n~o:J to ~'4;lb,;1'1 dru;,: lner.lp'r rn 11I~hcl d05("'\ and more

--

~~~

788

Ph, ~k.1 R.·habilil.. lion

Psychosocial Amciety/depreSSion

JnJ fn.")m calhell'ril~fJ(," prp..:Ctlun:~. AnutllOIl(; therapy I ~

tht" mamsU1~ or (rcatnll'l1l 4 C(mstipalion IS :1 \,.'on1l111'n prflhlcm ~tnd IS typiGIJI) m:maged with di("t.1n .;hangc.." Thc..,I,: melutlc IncrC'a~cd flUId m13~l" and fllX"rln the diet, Jilt! c.Ul abo mdude hUl~­

Detachment Intellectual deficits

Decreased sensory

fonmng supplementS ( ' kt:unUl.:II. hher(\lO. ('11111("('1), or

dine IlktTOIJ. propanlhclil1c IPro-Banthmc))."

Framework for Rehabilitation l11e chronicity of tbis di,e3.~e, along with ih \·ariab~c: und unpredictable course· :nay lead . . orne to \'Ie~' mdl"HJuals 't~ as poor rebabllirallOO candidate" \\blle the dISease cannot"" altered by rehabilitation. there j, a grow 109 bod) of t'\' 'dc-ncr thai mdic.!les significant ~alU'" in reducing

,,,til

L.:;:nt:nllon~ nimed at n:me ~!"~ ~ .:n;:-.~m~ lmpainntrtb. funC'lionaJ limitati(lus. ~ co:!l:;'= - DIlttt rill S .mpaument.< m.} he Ie .. R~'- "0 to lI1tm-entjc:-,. c'P"< lat') In the lat< stages of ~ (; •• -•• Howevtt dur ,n f the e:trly .md middle
itrength . l'"amiQ~ reiu!t\ ..!l inproved I")alance and galt, u'.:dt:-~ ~ lmpru!"IIlaLl~ (' .. ~j b) e\'o!vlng ntui!;'s),litcm dy'J, f;.:?'_ :;~n from m=:;: .\"t\' ~ dlsu~ (rJ~. "' 91) orC(imor ~,.r.:-' also 2.:: ~~~nrtant brus of ,'I"CSloTaI)"e c.:.n- nus

-"- -

·'I"'·~ -'.. _.it:" In

..UJI; '--

the .:'!!~~t':hC when 'Ja\' " h~ f,;u:dJy ..."" re'lutrl: prompi d o".!!!..- .:~~C' Iltat.ements rdJ~ve f ..f '.,.;;~r f.:~~ -,

~t

.:!~v:-:;L=..-

"'hl1c

1'''''''''' ng

"

e~;l! - _.:

\1 ..:!.::

!~

,-" - -.' --,-,.,.. '~··'·-'~l'r

--

of

ICnt 1llh1

t!".t'ar::: '~:' h!~ ':~'I\' In

Decreased contr&c:th

Decreased motor control poor coordinat1on AutonomiC lability

strength

Decreased muSCle endurance Atrophy Digestive Loss 01 appetite Constipation Poor nutrition!

Renal Urinary stasis Increased unnary mlectlons Renal calculi

delayed healing Respiratory

Cardiovascular Decreased phystcal work capacity Increased heart rate Thrombophlebitis Orthostatic hypotension

DecreaSed VItal capacity DecreaSed re$pfratory endurance

Impaired coughing Increased respIratory Infections

t::!r.:-'IDC1~' and promoting functional mobilIty and mde-

pendence can be .due,ed. In addjllon. known compllea!JOIl> 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 <<.lil}, tmlte
=

(ntnpt'IIJ,a(~)r\' iflUn-,."tilUl IS turned .:lI moJitymg the ra:·l Ildwlty l'f CC}'t'If('lUTICIlI tn ,)r:icr to dU""", the p31 to remam fui:\' f..:nctmnaJ \o\';:thm the Ii.. "pt' of e"sUO 'mpalm~nts !.o.'1d I~mttltilms, Goal dmJ lll.Jl(.'()me ~Wh.·fllt.'J\(S :-,,;t1«tl'te of C.)II1I~n,,~..-.-n.- mt\:tvcntlon

;;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<; '3m (lUI the maintenance program, .,. 0..~ cCKlrdinated interdisciplinary team is necessary to o\ersee the comprehensive examination and management n«ded 10 addre,s the patienl" complex and multifaceted problems. The team typically mclude, the physician. nur'e. ph) ,ical therapISt. occupational therapist. speech-language pathologist, nutritionist, and social worker. As with any 1=. the patient 15 the central tigure. "Jth family and caregiver> hemg ~e) member-,. The ideal rehabilitation progranl cooslden. the patient 's dic;ea~e history. course and symptom.". including Impairment.'), functional Iimitarions. and disability. Of equal important'e are the patient's abilities {a}...e.b:·, p.,orities. and re~ourcc~ (e,g., family. home, commumty!. The focus" on long-range planmng with anliclpaled epISOdes of care, mcluding hospital-b""ed. outpatient. and hometcommumty-based <'are Dal Bello-Haa, '. d,,cusses a continuum of care based on di ...ease stage (early, Iilddle. and late) for mdJVldual~ with neurodegenerativc

789

unique status. The severity of problem~. stage of disease (acute, subacute. chrontc), age. phase and setting of rehabilitation. and other factors muM all be taken i.nto account in structuring me examination.

Patient/Client History Data obtained through interview with the patient/family and review of the medical record should include information on general demographiCS. medical/surgical history, social and employment history. family history, living environment, general health Slatus. and social and health habits. The patient '$ current/chief complaints and current functional status, and activity level should be ascertained. Coexisting health problems and medications should also be identified. Data obtained from the history will help focus further indepth examination and systems review (Box 19.3).

Tests and Measures The following are specific areas and relevant tests and measures that can be used to examine function in patients with MS (for more detailed descriptions. see earlier chapters in this text focusing on examination).

Cognition l\1emory function, attention, concentration, conceptual reasoning. problem solving. speed of information process-

ing ,hould be examined as well as the effects of faugue on cogmtive performance. An expert panel convened b} the Consortium of MS Centers in 2001 developed the HininlU/

Ewmmut;on of Cogll;t;re FUller;on ill MS IJHCFlHS,

Ph,.sical Therapv Examination

This comprehensive bauer) include>:> 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'.... n
~sed

'.0

at

~vecltit.'d lI1f(:r

~.I,ulOg1.llsh chan~e Jll tt:ttUS

~ ";eaunent.

It llIav not
ftll1C IItlOJI

as

w~1l ~l":i

po~'tble to dll

-flU .ate clt.ne;,; 111 $tatu~ asSOCiated with rrmi';Slun of n tI"eat::1.... nr out'o~s. f ,ursitiering Ole vari· m;·lnms -:-:f any L~!VlduilJ patient It ,'S (tten

J>!.-r-fOlTI the ~n1t1al t."xam::!atJOn ()\-er a penod ...-.. ·Jb~~n J« \·pr.:-Sl· ltaU"e !Sample: (·f tHls,ehn~ l,g r JL~:le and t"l._lI.trbuting fan on; should he lICC"ount \l. h~ .-Ihed.ullOt! the ell.~lljllal ;(:n,

J Ir

l"";ht~l!ll tlon~··t n.jfT1:m~,.on

pr,\.

tent: ~nea by lhe: patt:r.l

Etnolll)fw! :-.lability ,\houIJ l)t' c\.1T111ned. rht:' pn:·,cnt,.·e of cinollllllal lahlltly t'"uphuria, eIlHltlllll.:\i dY'ft',¥.uIJUon. tkpreSSHH} (symptom.;;, sevt'rit y h."n1;lh. en~ct 1m fune tU:Iflo.ll perforOlJ.I!:(·e); Ie-h't l·f 5t(255 unJ uO\It"l!' copm£, lilfjteglt~s', und prese-nee of slce;, J!solJers sh0Uld ~ d(KUmented. A l..~::fl1l nS1rumeIU is the Bcd., Dt.:presJu'n

inW'nt

SensatIOn Sup("rticu! cind detp ",,'nS.1l10L1~ (toUl'h, pn.·ss\lr~, lemperatl'..:-:' • pair.. pn'l~ri(>4..'::-PI lye I ,In.J cftlTlhlOe-d or \.:\.1ltlCal scnSJ rions hte I .:"ol'nt.>'!Ils. ladlle kl(·.lhzJ.l all), l\\L)·poim d!s,,-'rim lJ~l·,c'n) ,hl"Ui.d ht- C"J.mllled. flIt' prt'sellL"; of ill.~utc, parox l lll'l~ml1ttt'"!5. ~;~n. d\·sl:sthesla.~) 4illJ ..::hTt)m~ P"lU'! mdudH\1t f,;.un h(Tl~\tOrs ,md n,· ..KI)OflS dunng spt'\.'ltk

790

Physical Rehabilitation

Box 19.3 E lem e n ts of the Examination of th e Patient with M ultiple Scierosis 7J Pulmonary ,igns and 'ymptom .. in response lu cxerlise

llalicnt Client Hislor~ • Ag1." ... e\. fKt'kthnil' ity. pnma ry language. CdlK31ion • Sf'II: i;11 hi \ ((lf) ' l' ulltlrJ.t belief" and behaviors, family and c;trcp, j,'. r re"oun.:cs , soc ial supporr systems • O(Cup;triOn/t'Ulployrneut/work. • L.h j!l~ eminmnwnt : home/work barriers • Hand lklOliru[Ke

• General health sla{u.~ : physi.:aL psychological. sot:ial. and rok luncti<m. health h;\oilS • Family history • !\kdic;.Ll/surgicaJ history • CurTenl conJill ons/chld romplamts • Med ICatIOns • MedKa l/laix1ralory test results • Functional stalU S and activ ity leve l: premorbid and current S\"item .. Rc\ie\\ • \i euromu ...cul.1l

• Mu, . .:1Jlo"l..eJetal

Cardio\ a..;,cular/pulmcmary • IntegumlJlb0

Tests and ,\feasures :lmpairmeots • Cognition: mental '> talUS. memof) • Communicatlon • Anthrop<'melric char.icteristics: body mas.s index. girth, kngrh Circuhuion: respon\e to po.~ i tion change/degree of orthostatic hyrxllen... ion • At'TObic capal'l!j and enduran(.:e: during functional activities and ~tandJrd i" l."d exercise protocols. Cardiovascular signs and s.~mptoms In rc-spon..;e 10 exerci':>t' and aetiv ity.

mo\'emenl~ and prm'oking s!imuii should

be documented.

The McGill Puin QuestlOnnaire stJ or the Dallas Paill

QU~ltiorJ11airc. dt.:"veloped to examine the effec ts of chronic ~pinal pam on daily activities, anxiety-depression, and socIal interest. Lan be used. H-

and activity. • Ventilation anJ ~as exchange • Integumentary ullcgrity: sk1ll condil1on , pres!.urc sensitive areas: activitjes, positioning. and posiurcs to relieve pressure • Sen!)ory integrity and integration • Pain: intensity and location • Perceptual function: vi'iuospatial sk.!lls • Joint integrity, alignment. and mohility: range of mOlion (active and passive); muscle length, and soft ti~sue extensi_

bility • posture: alignment and position, symmetry htatic ,md dynamiC, sitting and stanchng); ergonomics, anti body

mechanics • Muscle performance: strength. power. and endurance • Motor function: motor control and motor learning. • PosturaJ control and balance: degree of postural instability, balance strategies: safety • Gait and locomotion: gait pattern and speed, safety • Functional status and activity level : performam.:e-bascd examination of functIOnal skills (FlM level), basic and im.trumental ADL functional mobility skills; home management skills • Psychosocial function: motivation • Assistive or adaptive devices: fit. alignment. function. use: safety • Environment, home. and worK barriers • Work. community, and leisure adivlties: ability to partiCipate in w..:tivities. safety

Muscle Perfonnance Functional strength using manual muscle tes tmg ( ~t\lT) and dynamometers (isoki netic. grasp and pinch dynamome· rers) should be examined: strong spaS[)(,H) rna) l:k;- J. con· train<.l icalion to standard T\. fM T positlUn .....

Visual Acuity

Fatigue

AcuHy.tracking. and aCl.'ommodation should be eX;:lmincd: the- prese-nce of visual deficits (hlun·ed vi:\ion. field defects 1''''''°"'''1, dIplopia) ,hould he documented,

The frc4Uenl.·Y, duralion, and SI.."·tTlly of fatigue :-.hllUIJ bt' examined; prc\.'ipitatjng ra~klr-.;; "Kti,"'it)' Il'vt:'is and ~H1~aC) of rest uHempts should lx' d\.xunwfltt'd nl~ JJ~Jdjjit'd l- ulf8li(' Impud S('ale (/I, IFI.. . . ) wa" d('\'elllp\.~d by F isk lt .:1 Jl :-"',! ,~md 1:-:; inclUtj~d III the NJliot1al I\fultlpil..' Sd('w:,IS

Cranial !\iprve Integrity Motor and ~cHS(,'I)' l:ranial nerve tunttlOn !i.hould he' exam , ined; !~hC' presence,.,f defll"il~ topti(' raill {Ilplic lIt:UIIU,1, oculomotn dvscc ntrol. dy5irha~ja. Impall1:d gag rene-x.

tri~elrunal ""UTatgla) should he documented.

Rang., of Motion (ROM) p,"" •• YROM) and active (AROM) range of "Quon ,uld be exanuned; the presence of '1'''< die ROM u"fic uld be d",uIQented,

SOt.'il.'l) CllIlIl:al Pradlce Citlidelrne..; (\1\ F,tllgut: 8-1 It :~ a MfuclufcJ, self-report 2l-ile-lJ1 lluC\tionnJire addre,>sttl~ 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 , <\ \I( A, was Jc\elopcd to e\amml~ the nature and degree of:noh.irand fundwnallkficJls in palienh with MS. M~ Srasticity can t'Ie examined u.'ing a subjective ratlllg ~31(', "'Oc Ash~· )rlll Spasticity Scafc 86 led to the more \\',j('ly used the ,\1·xJifird Ashworth Sca/t'.Po-: These are .,:~irl!ll ~wes designed to mea.:-.ure tone imensiry: the mod-

died A,h"urth has an additional grade at the lo\\er end aUO\\ing for more dislie-te rating. A detennination should be made- of the differences bet" een lower limbs ven.us upper limbs. right and :iefl ..,ilks: and factors th
---Tbe

.. ..

bc~ ..3I

~erJpist should examme for tht: presence of cere-

inlenllon tremor. nystagmus. ojrsart.hr~J). The effe",:ts of posit,on change (e.g., ~inmg~to­ l:::lClingl ma)· produce dn increa ... e in ata.,ic movement ... ,,'!..'l iIh..reased demands for p(htural stability and should Mgns

(dtax13.

be c.!OCumented. I1le thmpist sht>uld examme for the pre'cnce of ,·tstiblllar dysfunction fdizz:le.Ss. \'cTtigo. n) ~tagmu .... \'. Slon with head and body movements. dnd postural unbalant..~ '

Postur, t

.:nd.l)= postural control m \ moos different post , . ..ru,.;. 5I3nCng, should be The presol .:'::::umaliues and postur.t.1 c-wr should be umen!< .'"" include posture gilds, plum~ ':-~v.;:-~y \\1m lig.ht-enuttm~ diodo

.,""uned.

omotion

and the All/hula/If'" GIllI L \,II1IIIIa(1011

Jlldex 1.\11.'"11

(R~ ·GA)CJ6 wa~

791

The 1(1\'l'I"I1ICl/t! \ ·',fllaf devf'loped III CXtmlOe

gait In patients 'With MS Alignment and fll. <;afety. pnKticality and ease of U'ie of orthotic anti i,tive dcvj(cs ,hould he examined along wah energy conservation and expenditure Wheekh~lir "k.ills mcludmg rum:tional mohihty. man;lgC'mcnt, safety, transfer skilh. and energy con~crv<.ltioll .antl expenditure should be c\amined.

.h.

Aerobic Capacity and Endurance Vital ... ign ... (heart rate. blood pressure. rCSplri.Hory ratc) and hrc;:tthing patterns should be examined ,\t ft!st and dunng exerCise. Exertional ~ymptoms (dY"'pnc
Skin Integrity and Condition SklO mtegrity and condition should be exammeJ. The pre ...ence of areas of lIlsensitivity. bruismg. moisture bUildup. and !)k.in breakdown ~hould be d,x;umented along with level of urinary continence: bed and wheelchair po~Jtioning. effectiveness of pressure relieving compensalory strategies and pressure-relieving device ... (PRD ... ); and cognitive status and safety awareness.

Functional Status An c!\ammation of functional mobility skills (F\·1S'j. bJSlc a,,;II\'ities of daily hnng j BADL) and m ... trumental JCt;v"tiC'i of dailv Imng (I.-\DL) is mdlcmed along with social 'unc tiollmg: community dJ1J work adaplj,,·c sla['s. A ..:orrunonly used Instrument for pati~nb unuergomg Ilcuve reha'oltit! lion is the Fllnt!!'(mallru1epend~ncf l\!rilsur." {FIJI .. ;;

Environment (Home, Commuuir,', and Work) . s.lfety shoulJ ~ e'(d-'"Jl' i.-~d~ iI spec' . ~c I~k Olnalys-:.:;. (patiC:'l pcr~_·'mu"n:c !;>.3.Sed lammarlon in rele\'.lIlt em"LoJnr.enL ('"'OlnC'. "~'rl. m .. he Inc .u,kd ,\C: Chapter 2) Pl]) !.d:'"k..j spOice f: r barr er!)

.11.. .. .:ss.

l.."l1L:: ,uti/,. and d~ nanllc txu..llll.e.

ud. Iten~ry m:~.Jl:i(n. dnd r_1 ~'!~~'rnts me " !~~e (he .. 'y- ann

<--1

G"n(>ral Health General hrahh ~;:.:.:;urrs JfC used t,: ,x.,:.,une out:. ... me :.:rum .:' gk.'ha! CJ' L'!!~' te~ ''!::.JJrh .)1)1

f.:-:VC"yt cf t~.: nd <.ual'· ... .:~:h.

p.a~c;:"n: !l

xr

792

Ph, sit-aJ Rt'habililatiQn

patients. l-,;u111,:lpating 111 mpatlent rehahllit;ltitln with ~ig .. IlIfkanl n(x)r and ('~i1I1,g eff~('f'; in four l)f dght SF-3h dim('n ... ion .... 11,(" \,/tknt:ts Impact Pmfi/e ,'OJ .Iml the Examination L'I

\fOft/1"

and rroceu .\bJl.t (AMPSl

tt14

~Irc

ahl,) general hralth measUn: ....

Disea
..

DI"'c.l"e-:-rx'Clfic meaqlr6 are Jcs,~ned 10 C."\;lmmt'" ~ltlnh­ utL''' ('()011ll0n in a "'rcc"lll~ dist'a ...e entity Items arc JIldmkd to proVj,le infonnatlt'n ap~)ut the disea ... c rnx::c ... ~ Jnd out~ l..'Qme". and Ideall~ document clin1l'aily meanlllgiul change over tllne. 11lU.;, tht.' m... trumcnts ha\·c grc-att'r respon~lvc~ nc~, or sen.o;;lti\' II: 10 changc than general he~llth mca ... urc!->.

hpand
311 d"ablhl) III MS ,;he O".hllity Stalus SC3ic or 05S).'05 TIus ~calC' \\JS ~:t;pJ.nded in 19~J to mcrea... e i .... clInical .~.,:nsi::..vi~ by mduding h3lf-poinl increment .... becommg the EDSS IArpendtx B). "" 1111> ,.:ale has Peen \\ Idel) adopted b)· dmi{ians and has Peen u"d 10 slandardize .\IS ~se:lrd~ Based ",n 3 .~tandard neurologicaJ ex.amination,

patients nrc first grnded ;In pre!'cnting symptom ... in seven spec.fic funcllon.1 system., mcluding pyramidal. cerePeI· lar. bnJnstern. sensory. bowel and bladder. v.,ual, menial. plus ~""r funcllons. Funcllonal system ,coreS (FSS) are ob~ned us.ng dI1 ordinal clinical r3tmg scale- ranging from 01;:"· '016. The fOSS IS based on the grades ob.amed In >In !be FSS and uses a 0 10 10 ordinal scale gr3ded tn hall· pomt mcrements. ""h 0 equal to nonnal neurological f uncti"" and 10.0 equal to death owing to \ 1S For pie, pa1ie~ts c.· ~"fied in EDSS step 2.5 demonstrate min· .mal disalT':ly L~ \We FSS IIwO f'>S grade 2 others (I or I J. The EDSS ('lCuseS ',n ambubtion as Ihe pnmal) ,"dic.lor of dis:.b,hty ..., 1.0 through Ii.' for levels "f ambu lion: p:!L::tt> with sea"" 7.0 N greater are unable to wall.). (rt.:: .5"" ·,f the FOSS mclude tis lad: of sens,II'10 .han8" thol do nnl include function.1 mohllity bul,woo and problems an IOleTTat;.Iion.: Jlluhlple oc :~.'I/ II ~np:ilw"" ~.nat ;onalm)~,c.i~ly.'"\rg/

n,"'"

"'orc,

fh.

• ,I.,IUS finam:ial and economi<.: statu" place of re !l1~. • . ' . . delKe. pcr~onal a:~I~(~~ce. tfan.sport~tI~,.~' co~munity a ...... ls,tanCc, and ",'X: 1al a<.:tlvlty. Solan el al examulCd the validity of the "elt ••ujnllJ1l~lercd version ~f. the MRD lAd 10llnd Ihal delenmnallon 01 amnu)alory ability, ADLskill. anJ fi,ocial actiYltics wa~ both a(;curate and cost-effective.' \\Of'"

'IS Functional Composite C\1SFC) The M5f'C " a 21'llem thai IOcludcs 3 different func. tional ,uhles" IOciudIOg the TImed 25·Foot Walk (123. FW). 9-Hole Peg Te,1 (9HPT), and Ihe Paced AUditory Serial Addillon Test (PASAT). The MSFC Administration and Scoring Manual can be obtalOed from Ihe Nalional 'lulupl< Sclera,,' Society al hllp://www.nationalmSSOCi. ety.org/MUCS_MSFC.asp.

Ie"

\luhiple Sclerosis Quality of Life-54 (MSQOL) The le,t IS a modification of the generic Health Statll.! Qllc.ltiollllaire (SF·36) "ilh the addilion of items relevant to people WIth MS. It om lis one ilem In the SF·36 (graphic representalion of qualily of hfe) and instead uses a <emanlic d,ileronltal sc.le. There are II suhseal..: phYSical health. role Iimilalions due to phy,ieal prohlems (RLPP), tole h.ni· lalions due 10 emolional prohlem s (RLEP), pam. emotional "ell-Peing. energy, health perceplion s, social function, cog. IlItive function. health di"itress. and ~xua1 functiOrL 110 .\IS Qualit) of Life Inventor) (.\ISQU) The MSQLI wa, developed as a comprehen"ve oulcomes examinatil'" package b) Ihe COllsonium of \Iultiple Se k"'" , Cenk". Health Sc.ence Research Suocomnunee: In Include, a ballery of 10 ,'15, induding Ihe Health Sldtus Que,"onnatte I SF· ~hl, the .\ \(xlilied hlligue Impaci Scale ,\IFlSl, lhe \\OS rain Ellects Scale (PES), Sexual Sallsfacul'n S..:tIc .55$·. Bladder Control S,a1e (BLCS" Bowel Control Selic (BWCSI, ImpaCI uf \'isual Imp;urmc:nl Scale ,1\15 Perceived Deliuls Quesllonnarre (PDQ\. \lental Helith Inventory (\1111) WId Ihe MOS \1,x1.Eed SOCial Suprort Survey 1~ISSS) The hallen can hi: Jdnun"lered In approxlm~!ely 45 minutes ~ man o\bbrcnated \·er·

c=,

ions -.)f some of the sc Jle, \.-an rc~~u\o..e the sci to ~ I ne:nt s

requtrlng UPP",xlIlIalely 10 minute' t" admlOt>reT A l Manual can Ix- obtamed f((.m hltp: .~,.. natil'lIalm'S<Xlely.(lrg,'\ll'C <; \ISQll.

se,..

"r

nr

"'" .... 11 b< ~., f;. th: 1..",",'1., lOS

luiliple Sdero Ill<. \1'>IS·:'I

mp'"

I ,,' ~tS.

I mpuCl 'icalc I ISI~,~9) u",; the ph h. ..IJ .wI.! p$Hhllhlg ...·311

l"he

!:it-itt"

\1,.

prJm~ml~'

Ik\(hlf'-..J t

Cbapter 19 Multiple Sdero$is

793

BoX 19.4 Examp les of General Goals and Outcomes for Patients with Progressive Disorders of the Central Nervous System

tmpect of p3thology/pathophY!'iology is reduced. • Palienl/dienl. family. and caregiver knowledge and awareness of the disease. prognosis. and plan of care is en~· • Symptom management is enhan('("d.

• Risk of st"\:ondary illlpainnent j, reduced. • Intensity of care is dC(,:rea.<;ed Impact of impairments i!'. reduced. • Cognitive function i~ improved. • Joint iOlcgrity and Olohility are improved. • SenS(lry ~lwarene~<; and skin integrity are improved. • Pain is decrea~d. • Motor function is Improved. • Mu..cie performance (strength, power. and endurance) is improved. • Postural control and balance are improved. • Gait and IlX'omotion are improved. • Management of fatigue is enhanced. • AerobIC capaciry IS mcreased Ability to perfonn physical a..:'tions. tash, or actL'\ities is impro\·ed. • Independence In aCll\'itic:s of daily ]j·... ing i!' increased. • Tolerance of posltions and activities is increased. .. Activity pacing and energy conservation are enhanced. • Problem-solnng and decision making skills are enhanced

• Safety of patient/client, family. and caregivers is improved. Disahility associated with chronic illness is reduced. • Ability to assume/resume self-care and home managenlent is improved • Ability 10 a ..sume work. (job/school/play). community, and leisure roles is improved. • Patient/client and family knowledge and awareness of personal and environmental factors associated with worsening of the condition is enhanced. • Awarenes", and use of community resources are improved. Health status and quality of life are improved. • Sense of well-being is enhanced. • Stressors are reduced. • Insight. self-confidence, and self-management skills are improved. • Health, wellness, and fitness are improved. Patient/client satisfaction is enhanced. • Access and availability of services are acceptable to patient/client and family. • Quality of rehabllitation services is acceptable to patient/client and family . • Care is coordinated with patient/client. family. caregivers. and other professionals.

Adapted from thl:. Guidi' fil PhysiCllI Tlu:rapi."it Pracrll-e H

commumty-based populations though testing with hospital-hased populations Ipatients admitted for inpatienl rehabilitation, IV cortlCoMeroid treatment for MS relapses, and patients With PP\1S) revealed comistency of psychometric propert,J~s

..

of funclional outcomes include the works of Quinn and Gordon I 15 and Dittmar and Gresham. 116

Physical Therapy Interventions

Goals and Outcomes The general goal!.: and uut;,,'ome~ for patients", Ith

progre~~

f;ivE' disorder$ of the lentral nervous !iy~tcm, adapted from the GUlIk to Phy.sical Thrrap;.\t Pral"fiu.·~~ j axe presented in Box 19.4 These general Soith \\'ill proVide th~ ba~i .. tOi the development 01 SpeCifIC Illltlcipllled goals and expecled )utcOrnes for an Ifdlvldual pallen!

Tne preferred practi\..(" pallem for pallcflls with mU!l!ple l'i from the Guidr (or f'hvs/cuJ Then.'I'i.H Pr,lrrice is 5 E Impau-eJ Motor [UfJl,jOIi and Sen:w n' III/eglll\' A::u", i.nt"d "ri ·.tll ProxrO]/\'f /J/sordefS of tilt' Ct'fIlral In tIllS dclcumenf lhe reader will find fl:"k· tAllenl diagriO~hC das?J;ilu..'J.t.ion: JJ:lm.mahnn components, C-:lll:)idcl J.lion

dwgnos15. nnd prognosis, .md Si.l£ge"itcd Gll.Idt'l :,eT\o'C'b a: it primary r~sourc, .lg0 an appropnJ-te plan ot 1'\Il~es ptf.\, lde-d and out4;.u.lll anr t"ffi:cl1\c. \1o( llmentatinn

Management of Sensory Deficits and Skin Care Stri.ltcgJ~S should be- instituted to increase av. an.'l1t"ss of sensory uefluh. compensate for SL'Il\ory lo.;"s, and promote ... aft~ly. It 1\ important to reme-mher that sensory deficits

may ft!mit, ,,0 ongOing examination I~ i1('I.'\.· . . sary. The succt!ss of \"ompl.'ns'ltory training. Slrak~git'"~ lIt-pends on the 8vaditbility of" llthe'l" ilHad st'lisory !;yo;lt'HlS. For example. vl'jual l'Olllpt:n>;atIOlJ {(·(:hJH4U~S i..~nn he instl£uted when

dennls In propn(lt."c'ptll)(l pro·duce imbalance i.U1d pl~'e the jl'Jtlenl at fisk for falls. If Hlultjple sensory system.'j W"t' l!l\'olved (e.g. nSlonlS .,iho impaired). sen~dl)' c()mfXnsa~ lQry t.ar.ltcgu·s ;.tre nOf likely ttl be ~UI.'l.·essJul. Pl1lt~nr .. \\-nil rlvllfhx"cPII~t! h....<.;sc ... l~monSl.rate Impair ments in nlO\l;mcnt (omroi and motor leltnting. 'I'hey require Ultn"asel.1 usc' of other M.:'nsory systems, t"spcciaUy visioo '"Piling, vcrbal c"emil. and/or bioleedba.:~
794 throufll

' .... "toical R(·hahilit.ation

c:.\er(l~.

JcJ..in 1 n:"I'.,L.mc",. n.~SiSL.IJKe hJ.lld .. lI£:hl IT". g I 11'1\ heighten IC:-dlh1:l1 Jlm

or "C'i~t~. an(lthe U~C 11 .1 pri()!,:epllve fUllctron

and

r-lI.)

I '.

, ... 'ss

HnpHI\'C TllU\'C'ment av>.lIltt: .. tunl

", I I"""s will intcrlc~ "Jlh movement alli po" • \ ISua v,~· 'h ' I )w hfhl "I rontrd H1urrcd \'1~IOn. C'~"llC(.:I;i1ly at Illg t Of 1~1. ( h ~ '. tions' can t'lccnr alh.'T rplsoc:ks (1. optiC ncwllI". It Ii I (; ~c.: ua '. rtlll.O m",rTw.:1 th(! palienl In rn~\lnlalllmg i\( C· fot\~ IInpo I ' , ' I' I 'I ghl) . II ' C (e g w..e (ll a hn~ht It! 11.1 n1

ljualc h~hrlllg jllll lUll" _ .. ' , ' " , \J I' • -ontr:!'.. ! .~I r;'JudO!! duller 10 nnpro\'c 'Jld~.. (Ill!;" 'l.. nV.,) can bct\",~C'n nems in [hL~ rnvlfIlIlll1ent (c.g ..... Ialr 111.IT I Q ....."

b

,

"

'0 1I11pnwe S
importanl stratet;)-' to impn.n c vision. ,5 If low vision pc",i,ts.

me patient should ~ r('kITed 10 a lo"-vi"ion speciali ... t or one of the uarional M'nicc organization ... that provide help to mdiVlduals Wllh viSion nnpamnents (National A,,\ocialion fer \isually Handicapped. :-\311onal Federalion of Ihe Blind. Amercan foundation for the Blind),

PalieTJts with ddicJt~ in !-uperficlal sensations ri ... k damage 10 msensJtJve an.'as uf skin. The development of cleGJbilUS uker~ occomcs a major concern in individuals with chronIC. pmgrcssive di!-ea~e. Changes in skin turgor. 'Stat c 'XtSlunng. and prolonged pressure mer bony prom I nences mcrea')C Ihe..lkclihood of
pnIl\.lp!cs ~f stln. l"are

I he .1,10 Ghuuld be J...:pl clean md dry SOIled., III ,houl
R;...:~ular

r;l"i"iUre relk"" .:i e~scltial Patienb Khould be 111: ;;uctcd Ie - ~~-. rhcJf ~."I{,,~ u:- be ch~"ngcd fTl"4~'llv ." ot:'\'cry .. hourx in be1 :md oC\.;,.-".- ~ 1111nutl'~ wi IdlJlr Wiceld~11r ' ;::~tHII~ c- "=I":)';:~:~)JI ·tlld ~ l
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 frikm redness develops (lasting longer than 30 minute\) patients should be instructed to stay off the area until the rednel!S disappears. Blisters. blue areas, or open liorcs indicate more serious inJury and require immediate attention This may Include systemic antibiotic therapy for infection and wound management tcchniqul.'s (cleansing and debridement. topical antibiotic agent.... and protel:[lve dressmgs).I'i

Management of Pain The management of pain depends on .:10 accurate' de-tennination of Its cau"'es. Musl'ulo ... "-clda.i strain or laint malallgmnent from chroOically weakened mu~C'lcs are important con~iden.ttion ... and art.' responsive 10 physIC.:.! the rap) intervention. Patients may expenC'oC'C relief" !.~ pain with regular strctchlOg or exercise ms;;;;sage. and ultra'iouml Po:-.tural reII,;tinm~ dnJ i.:C'r.'{'ction of fault) movement pattenb alung WIth orthotJC' amLtlr "d::..p(i\"~ seatlllg denl'es t..an reduce 1Il1i1alignment and pam. Stahhmg r.lln from Lh~rmlllo's "gn may toe rehe\'od wuh a sof' cnli.tl' tll Illnil !leck llexi"n, Ill'drorherap) 01 pt>ol ". ,1 therapy uSlOg /ukeU'.Jrm W.alcr rna)- have lJ ~neth.:t.L etiCt:1 on pi.llllful dvsc'\th ..-sla'l. Pr;'~SSJrc stO(klOg!'l vr ~ltI"'es t..\1Il dlso he lIs;d to I"clie\'(' Jlo.l!!l. CfJnv,"rllng the . . eIi S:1t10Jl of p~lIn II) one- of press..;!.: N~ulral \\iJ.lmth may bt' a fi:l\:,;:flr III Ihe t'"t~:!B ""~he~- c~~nenced with sti:.... llOg:" (II gh:"vt'~. llatlcn!) \\" :1 tluC'",,, pain w Jl I;cncfit from r.:t~1 r.!: t'j ;l IOLd m~lnagem('nt i;ii prl.1adl t~'r "hrol1l(; f:ill1. tor I!'\~:npk the 1ll1lirlJJ.\'( '[ili.'lan· pu.n r"'~l~ {sel.' (tup'''' 8, 'itre~s r: :"la~~C'mc.-,t ~C":.hl ,h.lu,:s. 1:la\_lI~oIi tfllm~; t'lOf~·l"d":ld;.. r-cliIl31Iu!:'_ .l:-"d S~) heth ,tIl: llftc:r. hdpful.:' "'~:'!!JuoJ "xl~~ lOXJf:ty J.f":d p~." rhc U'i(' t,f lr..r:nSl"utaJ'l«lli e~f:~"ll~1 ~:-rH' .k:j~uJaliof' ( n " , 'i:t." r. udu,.,;tC' p.Jlil111 'ahem"I w "_,~.• ·,l, 'IS "1 •.-. flL _::,! .. Ur:,flll..llIl': ' " rh ..'c.r.< ri?SUIc;.."1 pa.! J';:"':"'ls CXllCiltnl,lr!..! l-:tpn.\'\''Ill('nt ,I~J st..,mt~ a wnr.' . . Ji:llj'

ur ~.YmrtUJli

•

C'hapter 19 Multiple Sdcro!lOi.1j

Exercise Training

Progn:.""ltHl is generully slower 111<.111 with hl'althy mdi·

\1u..;,,:k "l,'aln~:-;.'i Ilnd ul.'l."h:a:-.ed cnduranl'(' Me common

findlnp III pallcnls \\ ilh MS. In addition. patients with MS (lfl('n '.Ilh)Pl J ... ('Jen!ar! life"'(yle and linllt their ~lhy ... ical ;l(ti\iIY. "lmlt'linK" (111 the mistalen advice of health care prt,fcs,innab \\ ~~o. seek ((1 _l11llli.mize rl"iapses and s)'mp[(\n1' ('If f;1tlgUC •. 1 he bellcllts 01 exerCise have hecn Ilrmly established in ft'mls of producing meaningful rhysiologl~ caJ Jnd p,ychologiL';.1l changes. improving function \v'hlle

lesseOlng di,ai:lility. and enhancing quality of life.!!" I:!~ InJi\lduah wlIh minimJI to moderate impairments (i,e .. EDSS s('orcs hetween I and 6) and stable diseuse demonstrate the best e\ercise tolerance. This speaks to the need IQ mstitul~ e\crcises early in the course of the disl'ase, E\~rclse responses of lhe patient with MS are influenced b, J host of factors (hat rc.:-quire careful attention during e~ercisl", including fatigue. spasticity. incoordination, lmpaired balance. sensory loss and numbness. tremor. and heat intolerance. Depression may affect adherence, Therapl'''Ib therefore need to provide constant reinforcement and a positive em'ironment. Box 19,5 presents a :summary of re"ean:h on Excrci.\"(· and Alult;plc Sclerosis.

Strength and Conditioning \laxiOlal muscle force during sustained isometric or isolunenc exercise is lower for persons with MS secondary to reduced ability to activate muscles (reduced force/unit muscle mass). reduced muscle metabolic responses, and muscle \},,'eakness secondary to muscle fiber atrophy. spastu.:ity. and disu~e.12n Delennining an appropriate exercise prescription to improve ~lrength and endurance is challenging ,:md needs 1O be carefully individualized for each patient. Prescription is ba~ed on four interrelated eit!ments; frequency of exercise, intensity of exercise, type of e).ercise and time or duration (the FlIT equal ion). ThefollOWing gUidelines can be u..,edl~7.J28: ExerCise session, should he scheduled on alternate (non~ endurant:e I day!'; and during optimailime~, suth as In the mommg. whi:1l body rore lempt'raturcl) fend to he lowl'st .and b.-fore faugue Sfts in. t;:! Pi.tlients with great":-I" neUf{)" logit:al Ul'vojvcment rllay require more frequent exerci~l' (e.g daily ext"rC"isl' tlOlt). Suomaxunal CX~T(·IM.' intensities (moderi.lll.! Intt-n"'ltll'S 'il) 1.0 7f) po:n:t'nt MVC) an: lokrah:J, WIW[C;'IS maximal ex.erdse IS gel!t:rally /101 wrtllolClall'd II Re" iHant.:e trammg 'Hod!?,; \.;'111 Illclude wt:'ighl IllildliIH!S. ":,~

0:

I:el!(; n

pullt"y weIght,:. c!aslii· ;ru..tuBe

n:!SI",taIH,:t' billlth, or

iso~1

IrlB~

I!Lellhr>l,d 01 ttl'gllt:

viJuals. fJ'

Prl'('tlUlions :-.i1ouIJ be tJkcn to prevent the Jeleterious dlects or ml'r\\ork. EXl'rcising to the point of fatigue i ... \:onllainui<.:ated and Ciln result in wOfsening. of S) mptOIllS. most notably increa'ico wl'akness. This may hilve additional advl.!rse etlects on thc contlnuJOg motivation of the patient. m

Precaution ... should be taken to monitor the effects of laligue. nl/le~(()~fv!iX/(e varies greatly among in(lJviduals with MS and is not correlated with the level of physicJI impainnem or disability. 12(' Precautionf.i should be taken 10 manage core hooy temperature and prevent overheating. Environmental temperatures should be carefully controlled, Air condirion~ ing is ..I medicui necessity in many climates. Additional cooling can be achieved through the use of ransY'~ V.let neck wraps. and spray bottles for misting the skin with cool water. and immersion in cool water with aquatic exercises. l nU~O.lll.l1Il,I~':i Surface cooling d('vll"cs have emerged as effective tools in managing body temperatures. controlling fatigue. and imprOVing function, These include cooling suits[J().. D~ or vests.L'·l Precautions should be taken \vith certain impairments, Tactile ilnd proprioceptive losses or incoordmation and tremors may make the use of some Ctluipmenl (e.g .. free weights) unsafe, Visual feedback. when int<'lct, should he used to monitor e.,ercise performance, An alternate sug~ gest ion would be to use synchronizeu arm/1eg ergomcten; to control limb movements. 12{\ Precautions shoukl be taken wilh cognitive and memo!") impairmenls, Individuals Illay require written or po:-.r~d exerrise instructions/diagrallls including reminder... or the number of rc::petitions. proper t~lml, anti correl·t Use 01 equipmenl. 12n FunclionaJ training acti\itjes (~.g,. dosc::d chain CXt'r~ cises) can be lIst!d 10 promo!l' <.;(rcngth and run~:lional endurunce. Illl.lividuals with halill11'i.:' rrohkms rl'Ljum: thl~ use of more stahle po~lures (e.g., plallligradl'. LjuaJmpcd. or suppm1l'u sitting)Y" (imup ('x1.;'"fL'ise classes can pr~)\·ilk~ vilILlar.k' lI\Otl\;!fHIII
01 l-'1"I1Up IllL'mhl.'rs h) dl'lt'lI1ll1ll' sp~'l'dil' ,~t\.tls

;'lud l':o.erl.·isl.'s.

Signifil.'.ml

d(,llliln~t\all'd 111 p;1til'llI~

1

J&houtd mvu!ve di'il.l)ulullJOUS W(II1;" (..!Idully

bOllalH.. lng cXC"fCI\{' Ydth a(kqual~' n'~1 l~iI(,d'i

1I11prml,'/lll'llts

with MS

11\11

III

havt' h~'~'il

al·ln(' l'\al'~'I"'

iI'IUlllh, I'~ (JUIl'tlll1l: 1ll~:I."'Ut;,:S ukilldi.:'

(mu-I tramUl1\., In "" !w.:h ifHllItlVt'U w(lIk l'apaetty IS (.U:~"I!'pcd through 'hI! use ,)f V'-,I",III1S dille-fellt M.lIl0H that ~ilteHl;tt\; wort Oel\\'C("ll UpPtl ,lOti lowt'l eXlrl:lllilies d:~ lIihlllC:, tlll.; I, ,.au UInNlf rllU! cle6 .:tnd llIay fl/ (lh" he~1 f·,r n° \uCtnn lile

795

\1,\1 1", l ... nl..il1{'tl~· d\ll;lOh,lllJl'

try, h"-k.I" Cllll1pu:-.llillll, langu\,' 1~1I-l'.;). iUndu)lla! Il· ... IS, Illd quahty nf lile nICa~ur\.·'!O {f1I{(..J1 )

-' . ( ' urnlovas,-·u

. ...

.

ar ( '~on( "((uung

Indl\ .dual" \Iollit ~I' lkfll\llblr\jll~ l"J!l"LIt>cJ 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~<.·

(\Ill .. )

,r,.'t .. 'til/nUl·' I,"'I"',lir' """JS,

7~6

l'h),loi,'al Rehabili(alion

Evidence Summary Box 19.5 Exercise and Multiple Sclerosis Reft."rcncC" White, LJ, et aP11

2004

Surakka J. et aI''' 2()()!

Su~jects 8 sublects with MS, mild-mod disability; EOSS scores between 1 and 5; baseline BMI 27% (overweight calegory)

95 with MS, mlldmod disability: EOSS scores between 1 and 5.5, exercise group ~, 46,

Non~exercise

group

48

Designl luten·eotion Nonrandomized, cohort design Resistance training (RT) progressing from 50% to 70% MVIC;

Duration

Results

Comments

8 weeks, 2>'/week

Significant it in strength of knee ext (7%), plantartlexlon (52%) Slepping performance it (8.7%); fatigue
Lacked control grOllp; RT resulted In 1t slrength and ambulatory funcllon: RT ~ a safe, well tolerated Intervention; small sample sIZe

Supervised exercise c 3 weeks; HEP = 23 weeks

Significant
Long training pened (6 months) may have masked disease progression, espetl8lJy Ul men, Men more ~ke~ to have PPMS then RRMS

4 weeks,S 'X Iweek, 30 ,"10 sessions

MS training 9'oup " aerobIC threshold Improved health per cepticn IVltal,ty .~ 46~~ s,"ial ."lei JCtion t 3N); !'Ctiv. ill' 0 ' levet (i 7'"

Outcome measures: MVIC on isokinetic dynamometer. MRI thigh muscles, body composition, 25-ft Walk Test, MFIS, EOSS

Randomized control trial

5 supervised resistance and 5 aerobic exercise sessions; aerobIc exercises In pool (temp 28'C), 6S-70~, age-predicted HR"", resistance training (RT) CirCUit IralOing UE and LE Ms, 50-60% 1 RM; home exercise program (HEP): RT used elastic bands; aerobic tralOIOg, walking, sublects kept dally diary' Oulcome measures Ms torque (dynamometer!, FatJgue ,FI, FSS, AF':

M.."'SteIt. S, ted Kess£l'::'g, ~ <Xl2

~~

37 subjects with MS 'TlIld"'lOdjisabi::1' ' '1;lt:!'1 rehabifita'.ion, EOSS scores ~n2,5-6_5;

MSExerd$e group • 3; MS.flO rterventlon gr~ ..p • 3; Healthy contit1group 26

RandomIzed control ~Ial AerobiC exercise trainmg, eg cyel, ergometry: Outcome measures' Max GXT lests ofurg function (FVe;; spasticity LE.s (mASJ;

EOSS BaetM Activ") ':luest ~';"V; Sf ·J6 }.je::~ ~.urve't

F"· 'J

t

leodency fOl i1'ss fatigue; M v~_ Md lUIlg " •.-'00 "J! "·t ...... ,.-!ll)

Aerobic

'ral~'0g

s

safe and "'proves aerobIC oapaciJl t'."llplom exacerba· t~:;j"I

fowor than

e'pected fii

comt'",nce of MS 'ral 'og .roup lias lew <',"o), .1lesses nee<:! fe ",olival·""31 setting: MS pltlents leSS ~11"3'" heatthv ,"'~ - .~ iJ'iilb:ad ~,,;

:.

....

----

:--

,."-"~~--

795

Ph}""$kaJ RehAhilitation

Evidence Summary Box 19.5 Exercise and Multiple Sclerosis I~'""""""

poructrtera· MulcJre, J. et sr'· 199'

Non,.ooomized. cohort deSign

10 su!>1ec1' WI!n MS (6 femaleS. 4 rnalesi rniId-mod d:sablhtv: EDSS scores 01 1-4.5; matched to 10 nonMS subjects (age.

Exercise testing with arm ergometry (ARM). leg ergomell)' (LEG) Of com· b>ned LEG/ARMI. discon· tinuouS protocol Outcome measures;

gender. helghL weight, exercise

3 teSts using tile "'"erenl modes. 72 hours apart

training for P2bents wi1h MS; USed recun.

bent cycte erg<Jmete,

HA mIIJ during ARM,

With back support; toe and heel straps lor

LEG. LEG/ARM was 89%, 86"/0, and 91 q,o of predicted HAmal lor MS group: 96~, lor all. non·MS group.

GXT.

Vc, peak

avel. !les1yIe)

Combined LEG/ARM desig11 may be • rno.e effective testing Br<1

Va, peak signiflcanlly higher for non·MS group for ARM and LEGiARM lests but nOllor LEG tests;

legs; separate Iiyoheet for arms;
HRrna.;

AFt Ambutalory Fatigue Index (SOO-m walk test); 8MI - body mass Index; EDSS Kurtzke Expanded Disability Status Scale: FI Fatigue Index: FSS Fallgue Seventy Scale; GXT Graded Exercise Test, HROOL Health·related Quality of lIfe~ LE lower extremity: mAS Modifted Ashworth Scale: MHR maximal heart rate; MFIS Modified Fatigue Impact Scate: Ms musde: MVIC . mIDClmal voluntary isometnc contraction; POMS r.: Profile of Mood Srates, PPMS primary progressive multiple sclerosiS; RAMS Relapsing remitting multiple sclerosis: SIP SICkness Impact Profile; 1-RM.- 1·repetlllon maximum contraction: UE upper extremity; VLDL very-Iow-density lipoprotein; V0 2 max' maximal oxygen uptake,

al! Ulcreasc In a hnear fas-hion in response to IOcrea~tng work-oads, Re~riratory re:-.ponses (respiratory rate IRRJ and minute ventilation I also increase. ;::6 However, HR and BP respons-e~ may he blunted secondary to cardiovascular dysautcnomia. !~.: ,':' Reported incidence of these l:hanges has been as hi,gh as 50 percent of patients \I.'l1h MS. A direct !":Jationship exists between the duration and extent

recommended to control foot placement especially m palients with spa~ticity. tremor. or weaknevs, Perfonnance measures Include: HR. ratings of pcrceJ\eJ exert ion (RPE). BP. and expired gas analysi~ {\"O,I. U~ing the RPE scale. peripheral exertion I~ consistently rated as more ~tressful (higher) than central exertion, A continuous or discontinuou ... protocol (3- to 5·mmut~

of disea.~ and the likelihood of autonomic cardiova ...cular dysfunction. Patients with mild disease typically do not cx1ublt \!lese re~r~;lO"e-S. whereas patients with :-.ig,nificant _ong-1Ullding disea~ are much more likely 10 demonstnlle autonomI\.: Jysfunclionyll Pauents w,th \1S c,an dlsu

... tages) can be u... ed; the di ... l:onlmuous protocol IS int.1t· cated with symptomatic dist"<.Ise. e...pccially fatigue A subma\lmal le ... t should he used . .\lost ;,ndi\riduals With \lS can achieve 70 Il) S5 ~f(:ent of thel: age-predicted

demonstrate respiratory muscle Jysfunl.:tlon (\l.eaknes .... d)'~r--gi:t). contnbuting 10 reduced exeruse h.}lerance I. } E.x.erc!st: tolerance and maximal derobic rxlwer (\.r()~:,",,) art reduced In mdlvidll:!ls wuh reduced cardiore:-.pir':ltory filJle'is \e: .ndary to phYSIC~ mactivity Dec',.:a$eLi physi. c.:! \I,'... rL capaclly. denea'ied vilal capacity mcreaset.J heart ';!!,t I.t rest a~ ,n response tcext'rnse dt'c-:-ea$ed musl'ular rtrlgth, Increase-.1 fatigue IOt're3.\ed lHlJi.iel Y alld LlqHC'S' sic:.:: if(: t,; Immen findings.

Re('ommcndations for Increa\ing w~rkloads for elt:h

Oi:lennmmg tn appropnatt: exen.lse prescnptiC'n to Impro\'t carL!~va~ular condJ(uming IS clJilikIlgtng dnd 'lee~:.. :0 be. JICfully tndi\loldualll.ed fur e~h polliMl. The fol IO'II!.' :ng gUlddirr- for r/inil ,1/ ~Xt'TCI.1t' krtillll L:~n be u':e':

lie ~... ~~d mode i", ~'Iher at: Jpnght or r.:-' ::mtJ('lIlleg cycle"! t~VII -\ r::_Jn~m ~Vll"'" I!.. indu: .... tf'_ I fll ng h

paIred ComhmittJon Ic-g i:Ild

,,-u.!:!It'try

",ell 1I

....

•

If "';~-:-:}(::':\I \'::_nent

'~

--,.,... .i)':'

::-J3)

rO(: cllf"':! ~d b

,;t. _Ok -

7"' _

_ •

\lftn

be neceslhlr) ..... Uh

.....!.....--.

arc

maXimal heart rate ~ HR mu 1.

~Iage an~··

12 to 25 wath for LE wlJrk and S If'!'

for l'ombincd LJE and i.E work. I

l~

watt."

.;:;

'!enmnati\}fl c:nh:na ',ndude ;Jch~e-'\'I!'ment of peak. HR. l;tllgue, slglllfit:Jnl BP ('h.mg;:~ ,_"'HP :> l,OO mm H; 01' DPB 115 mm fig or .1 h.)'~otC'nsl\'e rc"poml"l, cT J decrease in oxygen urtaJ...t~ \\llth m":Tt"3.'itng "I~rl ralec Ptel'ilU lioni ~holild re t'lken U-" morltllr t"etr .,Htenuated UK (II BP responses dunllt -c\t-n:I ';C Prccaullons !-hnuld he lak(,11 W muna.Lte l'ore bodY rem l~r~tUl ~ dnd prevent ovcrhCi.lting. , Prn JUl!nns should be t~IJ...C'1l ~;:, J1h)!'ltor (he dlel,.l''i d faru!U1

Pr:~··Julil IlS shuulo he w~en to revcnt th~ delCfc."fl tl Ll~ ltTcos of l'verWol Ii. Prel'!utic~s \!"'ould be lak(,11 Wlt~ CC:-:"lll1 nledicaU<m"; :1al <;..J1 !affect re'Sult!!l: "\.,lan;J.dL:"'e UCI !:1a\' ienttWr:rnr" r..:·jul."e fall'-'J~; t--dckfen dnd lrlltrlpt\' ".nr;: IIti ~11J\ '':U'h;

_ ____

::'ll.~ 1(' \\i;:aknc:!s~ p:: 11l1:'OOt' ,(6111 ,1:'il'

..

___ _

," U'l' I,.J

·' soo

Ph,-sical Rehabilitation

nluJblc

sug~c~tions

l.~liun. anJ

In

t~':ns of plJnning. w.;rk snnpil t en('rg}'~{'tliu('nt .u.;.' ,v tle~ fur self I

d-evctopil11! 30(.1 h(lmc m3nJ.gcmcntlbe \"lX'3twnal TchablillJlum (;l'un""lor car pro\';dc useful ~~3tcgles for tJehavIClr:,11 m(,J,jr'COltion n~ \'(XJuonal rcttabllit3tion. Team cllons (.:Jl"

with the phYSIL\; lherapl,t ~nd others arc important for ,,:n.~ISle"ll..y and remfoJ"C':11e"l1. \\-I."ck 'y rev,c\\ of 8Cliviliec; ar.J recommended m,)(!ificafoc'S

15

oscrl to c\'aluate

~•. Tho \lFlS should be .dmim.tcred on a regular "'.;lSIS to monllliT onS!,Ulng f..:ugue staws (Appendix A). Tbc OTtpT tC"aITI Shl:,uld complete a din>~t cuvin1nmcI'ltai aaminau0n vf ~:1~ home If'd/,,)r Job . . itc (see Chapter 12" 1\ number of adaptations rna) De co..-,sldcrt'd h,l Impro\'t" elf ci~"y ~ safety. ,ncludin~ alr~l'(lndil·oning. horre C'r wpo;: rr.:.~..Jic:tiC"ls . ..::r ergonomic equlpmnt. The- patu~nt/fam· i;)"fCL'"t'-glV('1'S s...lc.ul~ t-,e educated as 10 the .:mponancc ot rhese ret-~~!:!"ldatioru. for improved function. Periodic tt'\' N - o~ equipment md envlrOllneutal modifications is o I'CC"..;..~..'":"..=:-:::':""~ During %,,-, acute e:ul.rrbauon. the patint wil: fare bel Itt ,f ~ '" she " ,,::nwed 10 =t for ~ (ew days. Allowmg the ::;!....=nt t~ CO""'tinlle the 5.21C' 1e\-eJ of e"(erc ~ ·:·r ambu Ltion j ~;>t hrlpfc! Therapv C"lIl be reinstituted w hec the detcior.u.i;...~ h3.s sut!~ and n< I new symptoms are oppering. !'Ie f,,,,us and pa<e of !hemp) must be readiusted ~-~"""::--2: 10 the I)3I1CnI'S specific ablues .md needs at that time Finall). s..... ss man~ernMt cechlllques;:re impor

l3Dl COO1ponent~ of rym;tmt:· manar,cment

Management of Spa.<>tici~ pst".1y IS func .ooaIl} •.mum~ .:.'1<1 .ontnbut<s t=, the dcvclcpment "f ~ num~ "f '>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'

gie, to assist In gammg range. See Chapter n for 1 !lscmSlon .:" tt-ese techniques. MalOtameJ strctch, hetd f"r ~O minute, l' l hours, .!so DC be u;cd and has been sh""n t~, deer.:...,. srre'ch rene< actiVIty.'''' ~tJ1ntaloed strctch can be .:t:ble\ed Wtth prolonged poSltiomng (e g tlll!3b1e -:: !be ~e.ircd range. r)j:'ic~ly lhe L f:, democ:slrate SUOOgtt ""'" tic .ty th,~, the L Es. especIally tn t muscles. !\hhough spastic::)" v.:.,," grc"'l~ fJ person. muse ~> th~: requ:."':' ('QrLrul:l1 C;7.y, Slretchtn~ ",dude t~e q"-'llr la~ts

,,·.t

tarfk,o~, I

!--or l:Jtients ~'~,.) sr
""'leeL~-,r. slll:te'lil18 ..."ouId .;:

-!.~

hi:'! fk \or;,

( ·h".,H' !" lq l\1ullilth.~ Sd,'.Wii'.. )m~er

"T"l •

~

pro\.imal

dt1rn1i1Jt~. sO

nl. u ... c1es,. E,tetl~()r tOile ,,(,(,In ... 10

_ , o.1(,:t1\1I1(:"

pn.'

that stress LE 11(,\.1011 \\ Ith Ifun"ft1Gllill n are genefall: the. most ('n(,L'II\'t~. For cxalllpll.!. kl\\~r [flInK rolalion (LTR) 111 ,. . lliclyll1g or hnoj..IYlllg L'an he t.,t!t"cli ve in reduL'lIlg l"ll'n~or lOne. Onl' very dkL'tlvl' strate!!' is [0 posililln the pillicnl in hooklying with a therapy b~illinJer the tle\.e<.i legs and gently rock. the 0;\11 bi.lek und forth. 'toying. from ljuadl1lped po!\ilion to "ide-sHIm); I.:l.Il1

;tIso Ix:' effecTive in reducing e,tensor 10lle J1l "OI11C pat iellt!:i a.,; the JCll,-i!) COll1hlllC''' LTR with prolonged II1hihitory pre .. sure on the qU;ldn~eps. 114 A more gCI1C::.lIi/Cd <-,Iecrease III tone may be adllevcd through tCclUl1qUCs allned ..U Jecreasing OWTilll eNS central activity while promoting rdaxaljon (e.g., .... Iow rocking, relaxation lraining). For the patient \vith limited functional mobiluy (EDSS levels of 7.0 or above) positioning out of abnormal, spastic [Xl."rure. . IS an important component of fhe, management pro-

!:ram, In general. prolonged or statlc pO . . ltlOning

JI1

any fixed

~(l1

1lll'llls, Slll"h as hndrill!:'" '11 h)sl;llld. "I;OlltU\g, alill Wi.dl sqU'lh.1 H

rill" pool i ... ;UI I1llpol"l'.III1 thl-'r;q)l'ullI.': 1lll'dll11l1 to I'Lh.lIl'C" ilnd dVIli.\mll puslUl'al ttllHrol III h\\lh <;llIill~' ~lIId stHlldlllg. Waler provitks ~11'a(k'd n: .. ist.lIln· tltat S!(J"'..... dn\\'1\

'I,ltil'

th!,'

paUl'lu\; al:\Xl\.: 1ll0VCllll'nt!o{,

whih.' lill..'

h\l\ly~lt\l')'

,lid ...

Iii

upright baldllcc, Water m:rnhll's h,.\V1.' ht..'I..'n ~lH)wll dkdlw III imprnvinp ~ln,'n!!tIL d('(Tl'''I'llig lI\u~l'111ar ti\li~ilhlilly. .alt- and IUllctional hal~Hlt.:e. Eltl'TIIVl' Ir'linlng sh{)uld 111V\,hT it variety ta~ks Ihut (h;lII\.'llg~ h~II:'IJ!I..:c. A'i trjlllllllg pili grc\se~. tal.,.ks arc mocldkd (c,p: .. whit- bas,,' \0 lIillT\lW 11<1"'1,." to li.1I1l.ll'rn "il
or

and should be avoided, Fur example, the patient who

ccptual contexts (c.g .. eyes open 10 c.:YC'i do .. ..:d. finn ~UI face to Ihic.:h foam surfatc) I hl' InlCfvcntHlII progr;1111 l:al1

;mains in bed all day "'ith the LEs positioned in extension,

also utilize lorce platform tr'll1\ln~l, (c,g., SMART ii.dante

adduction. and plantaIileXfon may be unable to nex enough at the hips and knees 10 sit in J \\·heelchair. Similarly, the feet

Mastci' [NcuroCom Inlcrna!i(,o~ll. 10(;,. Clad:iulla", ()i{ 97015 I), Lim its of stahi Illy tra in1l1~ is al\o IllIporl\1I11 I h\,' patient with ataxia needs 10 11.!i1ff1 how 10 rcdu(;c C;\I.:CSS po'itural sway (frcqucn<.:y ano al11plllUdc) ;!lul 10 l:lIfllrol center of alignment po,>ition. Th(! ,uhk-d bHlfecdh;It;I<.. IrOlIl vi\uttl and/or auditory fccdhat,;J... c.l1s.rl;;tys, 011 lhc:sc:

Posmre can be deleterious to the patient with strong spastic1(\

wm remain fixed in plantarflexion and cannOl be positioned on the footpedals. A pOSItioning ",hedule U'lOg varied positiom (10 bed. chair or wheelchair) will help keep the patient from getting stuck in anyone posture. Mechanical positionmg de\'ices (e.g., rcstlOg "plims, toe spreader, finger spreader. ankle splin.) are helpful in mamtaining pOSl •• on

and preserving joint s.tructure~.

!'.lanagement of Coordination and Balance Deficits Cerc"eUar defICIts are common In \IS and can h<: difticultto m:.na~e lmen'eollOOs du-ected at promoting \,tatj~ postural CJnt:t',1 ShOUld fir~1 f(x;us on static control (holding J in

"eJghtbearing. amip.ra\,lly posture, I~ g , Mllmg, quaJrupeo. kneeling plantJgrh, and n Lirough a of postures " u.oo to gradually mereas:' jXl'>tur': demands ",. \,"'ymg the h~ )f suppon (BOS" r;;,;sfOg !b of ffia>S COM),'::-.,l ~"lCre"'.r.;:: the n~m'>er C'f body rnts .....:;=;.:f flttdom~ rI:rat ::Jusl he )11ed. se tec:-ruqt:!'s thaI....", be use\Igh rro~,,.\louId.:r5

=

"_'fl"

mu(;hincs is especially

u~clullor

patlcnt-; wlIh ~(J1l1alO~n

sory deficits-_ Prolonged !atenllt!fi (nn"I..'t 'It U:"'pUII~C;) ... hould be expected. Fum:tlol11l1 haLIrl(..'c ClJlltH11 "tu)uhl iil'.t. be challenged u\ing reill Ilh! ta .... ks WII.11lfl I)IITIutated mil lite cnVtrnrHnl'11h. For ex.1IIlpk'9 ~If IIItliated movement u,ing reachmg. tummg. 01 I)cndmg C,:in' br pladlLcu lO both ~ltlJl(g and standing . .\-loverne-flt tranSition, ~e g ';It, IO ,tand tran~tcrs) em illso be pr.lLti(!:d, A m(rVc:.tt'lk liur lace can be lI'",d 10 'h"llcng~ t>al,;n<e I'or <\.unplc ~Ithng r

;:LCtl\iltics on a (h('r~py han l.lrc .c;' C\(-eI!Cllt w:.ty h) 1)J vmotc dynam.c holane! eOfllf"1. '. ~I"n~ pallenl', "'Ih MS may benefit from ve~tibular traim!1,g flCT:"I!:''!\ ttl rcduc:c the

,ffect: or c<"'lral ,,-slIbular d··.fu,'cl. I mlt:'~ on the effeC1 ct suc~ balan:e t:,JI[:;m: r:l-'J1!rarn., r,)r p'.1l1en:

.AI-. " . S02

. ..-===---

7··

Ph,'sial Rehabilitation

1J1t~rl('r(' with the dc\ICC dunng .1I11Plllatwll- \\'l.'lghtl'd

u,cd 10 J'('tilh.:C' dt.:l\h. tE 1ll11\'CIllL'n .... that u . . e of an ... pt'lOt1."i

(If

3~';;lstl\'e

fllrks ...:-an lx' ll"'i.'d to enhance eat mg.

fllf

pill1~"nh

with significant tn.'I1111T. the,e JI....'i(:e ... may m\!:m tht: dltter t"nc(" bC'w,'f'cn Jepl.'lHknt and Indt:r\,.'oJent fundlon .

E\lcm:t1

dC\' Kl.~ Ihran::S llf "'rlioh) l."an ~

m,t."'d hl st
313:\11..' limb .. hut Jb(l haH' the unoe ... lrable clTt.'d of adding

wCIght to IImh 1ll0\t.'menh. All ... phnt ... can abo ... lahlliJ"c Iimh 11l('\ cmCllh and ... h(luld Pc I.'onsldcred as they are It.'ss rnC:T;JY co"th A ...oft nl.'d. ("ollar c.m I"x> ust,xl 10 slahili/l" hC:ld and n<."ck Ircnlllr.... All these stralc:glcS. however. .. hould lx:- \lc\\ed ~.... temporary and compcn ... atory. Oncc thr dl.'VI':'-C$ 3rt" rt"'110\cJ. at<.l\il· movements \\--ill return or in some l.~a"eS ma~ Jcluall~ temporarily \\'or"'l'l1. Fn.'nktl' ... ('\.crci ... es \\ al' originall) de\'c1opcd m I ~X9 to treal ~atients \Ii ;Ih tahe ... dor...ali ... and prohlem ... of sen ...ory

10 ...... of pfllprioception, These exerci ...e ... ~\-e ocC'n :lppJied In the I~alment of individuals \\ Ilh MS. TIle exetr~ are performed in ... upine .... ilting.. and standing. Each BC'_-vil)' IS pcrfonncd . . Iowly v.ith the patient u.... ing v';.sjon Ie c.arefull)' gUide corrf'(,.-t mO\·cmenl. The extn:i::.es Teljuire ~ high degree of mental concentnItion and cHon and are. therefore. not appropnate for all patients" ith MS. For lhosc patient:, "1th the prerequisite ahilitie ... , they may be helpful in regaining control of movemelll through cognitive ~"mpen.sat.on lStrategie..'). Patients wuh partial sen ...ation ('-an progress 10 practl'dng exercl ...e ... v.ith eye ... c1o-..cu. Frenkel .... exn:isc, are Fscnted In Box 19.6.

linwanlcd i110Vcmt..°nts arC v.orse under ("onliJtlon .1.1 ' of ... tn:"f-"i, ;m'lcty. and cM.:itt:nlc-nt. lC lOuc:a\cd arou~al. tht rc!o.ull of adrcnahn pumping throughthe sy~lem. mc:reast c:\l ... l1ng tn:"1110r5 while dClTC~I"lTlg t~ncl1on. Stress tnan~ agenlt.."nt tcdlntques arc thcrclorc ..111 IInportant componc:m of the plan of care. In gencral. pat1t;~'I~I~ dn hetkr in Ii ,low. M\lllUlus environment that allow~ full ("onecntration on control of m{lvcm~nts. !hcy henchl from augmented feed_ h:ll"\...: (verhal CUCll1g ot "no~leJge 01 re'iults and knowi. edge of pcrformanl:c: biofeedback) and rcpelilton to improve motor Icammgo The patient with MS is often rc~tncted 111 prall Ice hy neuromu"'l:ular fatigue and ne Uro~ logical deficits that impair scn~ory fecdh'H.:k, attention memory, and concentratton. The, ~ucccssful therapist wiIi need to carefully identify the patient's resources and abili. tiCS and capitalize on them to maximi/c leummg

nt:n13 o"lng h; ,1

Locomotor Training Walking abIlity IS frequently imp;llreu. However, at loa>l65 pc,,·ent of patients with ;\1S are 51111 walking after 20 years's Early gait probkms often mdude poor balmce and he~t\'ine ...... of one or more limo'>. 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'"'

ld

~.1

u&:ll

Chapter 19 Multiple Sclerosio;; .1 Ie the qumirin'ps and Illp abductors. Quadriceps

JIlL 1I(

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.

,1ft.' ,l ·1),·,,(1 /::,,'and

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.~<.:fibt:d for fOOl dwp, P:!i"'I U~e .:.ontro! (~re::Hdly h)Pt'rt;'xten~lOn), minimal to 1l.1(Kier•• lc Spa~bcl1y. and poor Itornato,ensalion. Tht:': Illosf IJmmun • ~>pe used I~ ~ be standard IXllypl'llp", jen~ 1"\ HJ "'In: ti u. I19htwelght u..nd r.:.a~ the add~d Oel"ll'fJl. of COSl1h~. J\n '\FO "'Un an >Ill( .:la[Op. Rt:lative comId.mdl\.'8I1ons 1\) the nplI\,,'1l ~l rhese dM-'ll -i!~ 1Il( ;'!Jc!~ !;{"'\'efl' ~4i.SlicHy. f(}(JI II:.fId Y.'C;ll,Il("}ts ~nonfUtldltln:(1 m.ilLk~ ,---,f Lt. Inus. i-p!"\ia1!} hIll ne~ol" I. Although knee lItHtk' ft.lot K.~fO:;.. t ...'lG pI .\-.de addl!iollal "t~i.bllualioll dy useo ""'-au"" of the t~1erg~ xp:-nulture. required i{od·,tr t.h~ J)-aflJ:-h lociI' hayr lx:n o:ul. .. eOJ'Sful wllh

80.'\

selec.:ted patients with MS in compensating for lost ankle mobIlity. Gail patterns appeared more nomlal, with a significant savings in energy cost (150 percent over amhulation withoLlt rocker ShOCS).I% Canes, forearm cnltches. or a wnlker may be necessary to compensate for deficits in fatigue, strength, sensory loss (numbness), or balance. For many patients acceptance of an assistive device involves full recognltion of their dis· ability. They need to be convim:ed that use of these devices is far safer than "wall-walkmg" or "furniture walking." Devices also provide recognition to the community at I::.trgc that patients are not staggering or losing their balance because they are "drunk," a frequent occurrence with many patients. The devices may be the difference between com· munity participation or remaining homebound because of fear of falling. Patients should be encouraged [0 try different devices out to detem1ine which works best for them. For example, the patient with significant fatigue levels may benefit from a large-wheeled walker with locking hand brakes and a seat that allows for frequent rests. Cosmesis is an important factor in promoting acceptance. There are many innovations in assistive technology that make the choices easier. For example. designer canes now corne in many different colors and styles, including clear Luci[e. ABLEDATA (http://www.abledata.com) is a federally funded project that offers product information, resoun.:es. and links to manufacturers. IS? As the disease progresses, many patients benefit from a wheeled mobility device (powered scooter or wheelchaIr). The course and progression of the disease and presenting symptoms should be taken into consideration when tk~Cld. ing on a device. For patients with ildequat~ trunk stabihty. UE function, and appropriate visual. perceptual. and cog~ nitive ~kills. a scooter proVides needed mobility while ':l)fi~ serving energy. Scooters also do not carry the \mne ncg~l" tive stigma as [hut of a whcelch'lIr. Both [hree- and Ivur,"'heel ,",cooters arc ilvailable. Four·whed "conlers have superior outdoor and uneven terrain performan.:e. hut Ml" not as ei.l~iJ)' lransponcd. Fearures that should he rec.:om· mendl~d include J seat that rot:lle ... for ea."») mounting and dismounllllg. ,.....1S) Jismanllll\g n)r IO;h_hng Intu the- C.1.r. unJ . . tecnng tIlt"challl-"l1h thdt lllinlllHZe thi..'" \'.l)rk of the liEs.. One dlsad\"tHHagc of "il'nolers IS Ih.;H seating: ('atllli.l! ~th".ay . . 1-...: ('uslnmill·d. Tht') ilh' oth:n lIt1t Ik'si!"!lled fl)t pro(\l]lgt'd sittUlg 01 fur p~\lients with mOII~lale in 'il'\"('ft: po ... tuml instahility Some new thll..'c·v.heeled SllR,"t[ers are dcsIgneJ to tllrn In very small area"-' ~hllC' otbers h.m.~ a Wide rum .. w,g radius dIld may nt I( he SUII;tbk lor III .. home use whccL.::h.a.lr ShOUld bt......·('Inside-red when postural

dc-manJs neCCSSl1J.te incrc.t-;ed support. 1\ Maodard whtXl~ (.:juit IS ofu:n not lUUI.il" help jl) PJ.fh¢IlIS wHh MS bn:allsC'· of the \nel~! y eA,~lCnllj'Llr(" ~"\Jld (,;fl\)(di.nit(u)1l l'eQUltCu. for pl'opul 11'111. A power wheek'hall should hi.!' l(Jn~J\.k-red when illlpalr~ me-ncs ptC\"cmt ()f limn manull propulsIOn Power wheel .. cltaJl's aft'" rhom Lostly. more JiflidIlt h,\ repair. and require s.pi;X lalilt."d tr .)Ilspun"IK'lf1 b~ a y..tk.~t"Il,:h.llhlC\.·('s.."itble \:.-&11 or

1"'1\ sica) Rehabilitaiion

804

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.. slid, \1 ~.lSI palk'f1ts \"'IIIIl~I\ 19~1Ic U,LIlf! a JOY . I

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with unlxtired hand 'Irt'ngth Rnd ~n ... alJ(lfl,1 }C' 11.1' \ lJ g t-oc adJusteJ to increase ~('n .. ill' Ity. \Vhceh..-h:nr seal1n . !- l(~U d "nrc pror.....·( dligmnrnl of the pchl .... Hlll1k ~m\l head. an . ~~hs w'hi:c cnhal1nng lunctinn. O,mmtln malahglll ncnh include ['l,stCrit-'f tilting or the- pch"" I~'ral slIllIl£) "uh ~"phOSIS. ')1"1c01Il), Ihe rc$uit 01 'ra,llcity III the h:lI,n~~nng • .1 s This \:311 be imrro\'cd "1m the addition 01 ~ Lw,h·

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"'11h J ...oiitf t'I;t....e of 'urrnrt ( ... nlid

,('3t llr W(l(

msert

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prevent hamm<.xkmg of the" hl'ddKIlf uphnbh:ry. po... tur.iI ulignmenf ••'an Jiso

~

a..........tl'J by the addition oj c(lntoured

seaung ((usfOm built' or J L'(ln({lun~d whcelch:ur cu~hlOn ',,! g. ,,:onttlufC'd cu ... hlon "" ith gel). A solid b;K!... ... urrort and ld,U!'tahlc latcrJI tron!'" supports ma) ~ nl.:'cded to enhance .JOstunl i:dignmcnl and upright ... itting. FO()lre...ts ... Imuld ~.

JX'SillC'~lCt1 to cn ...ure Ih:11 the lhigh~ are parJllcl to the nO(lf, 11

el.-:tcn ...~ spasm.'i uTe stronf!. they (an actually propel the patint out d ':hC' chair. A ,tri'ng lap belt Ihat ,ecure'" finnly around me pc'vis b Tlec~"''''aT)' for ... afety. For patlcnts who present w th !;~ adductor ... pa.... ticlly. a medial knee bloc!. . ?(lI1lITJ('J) 'nl)' be ne-ce~ ... al) HI..'t'1 kx)p~ and ... trJp" may be t'CQwred 10 naintain foot position on the footrest.... Patient" \\~ no longtl'demonstratc adequate trunk and head ... tal1ilit} reqwre in .tltC"TI:.th!: ~ating de"ign. For ...orne patients. the tiltin-spat:: wheelchair wuh headlneck ~upport i~ a better option

than ~ -eclining whcckhair v. ith high back and elevating leg

rests. The frnncr mJintJ.m" the nonnal hip ... illing angle: the latte produces exten ... ion of the hip... and may feed into ... trong ('"'(tense spasticity. Elevating lcg resl~ tend to stretch hamstring muscles and may cau:.t" posterior peh'lC tilting \\ hen spastu.. "ry :; present. TIle reclining wheelchair with ~lt:-vallng hSts also I.. ~:llC) ~:reater em-Ironmcnlal JCI.:C"'S problems, MOIorzed I.. ':f1troi ('If the re::.t back (availJble in cuher lilt-Inspa<.: ."1 re:::rung wheeJchrurs) w,ll allow 'he pallen! to make

(;is'' .ldiustments m position, thus preventing skin hreak-

dow Pat,lents should be 1O.struCedn transfer .md wheel..:hair moblhll/mana£~cnenl ,lulls A transfer board or hydraulic .Jt may be necessary II!.') l F "unctior. deterJoratcs. l\tte'lIiOn ~~ good Sitting po~Jre Jnd pressure ~Iief technique) IS iSeIll1.:.J b mamtam ali;-unr-::n ay,d pre\'~nt skin h'-eak Jl ':,I,·n. t-at~""'b should he. ~L uraged 10 b41ance time jln Ihe wh«lch:..:.:r WIth -tl!e'f' aLt;\I tic, such as wJ.lkinCt (II (XCT ~ ::'IL" ilIld :.hould be extra eli] gem III lilrldlln; mu~de' ,.ual IC"~ to contr"rt as ~ result (tI- rrolo~'ged SHIIII11 - . .. i e ,I h Ir .:nd lnee flexo:-s,. C . '0'· One ~f the c.:onSln.::nts the thnapliit will have: I d -,j .~ th I~ fmar:' 13.1 relmbu .,U C_ (t:.;;I' 'f ~- " "n~ :If'',t fc'r the ch~nglllg nH'blilly ,-. .. ,I;. " P~f'l wJlh ( "!,.....)OIC MS PU'!li' or r" hi . -- .u ....ice (....... <*n'-~---tl~I\S requl!"~ a t!'1lCIH(·nt of ,-d" , .~ nc_ --..-=:: :1\1 fr.- b1"-..•. -t A me ll_ , . ".,' .. - " \ rymptonb ~rc lin Ii. ~lIl' in \~; pIL::"J \i('er--""1:;;: :·r rt:1l1it the th . • -.ar"1 . , < , ; , IPI!~ need~ ':1 pre)1 - d l:onVI~~ mg .:'ncumenUI·on cf Ilt\.-j ,1:: _un and h:.:~etl· MJ.r,' -~'... " .' I t: 'I ' _ ,.1L: - ra: h . - Teln, _J'~ f 'r ne"" ',,-,,~. " _ ..' liun ~ '-... _ \". ... ~.~hal. , r-: :-\Cr,~·~ I ~ - •• -' tim.. tnb:T\'.;d,', Of In ..... "-.. h . -,'''' eSHal:t t: I

fin.ml.: c e,pcll~i\c .;;pt(lahy whcekh~lir~ \lKh ;1'; the tilt-an. ~pa(,:l' chair or a <.;t·conu lightweight chom lor traveling. The thcrapl"t ",ill need to provH.k: c;lreful ~Ioollncntation Of r t.'llo a l auycr~~ lIutl.."omes 111 order to Ju ... tlfy the I,;()st of ot the neW I.:halr r"OT example. a likely deleterious Outc for a paw:nt who is J"nicd rClmbur.semcnt for a h i : 'p'lce 1 he costs 01· n . . c:halr . maV _ be ~km brcoakdm"n _ ,urSin and . . urgu.·al C
Functional Training Functional trainlllg should focus on prohlem !'.oJ\ling and the development of appropnate dcci'iion makmg skills reqUIred to meet the challenges of belOg dis.hled. Skll" should be adapted and practiced to ensure safe perfonn. ance In both the home and community emironrnents. TralOlOg 10 functional mobIlity skills le,g., bed mobtlity. transfers. locomolion) is typically directed hy the physical therapi,t while ADL training (e.g .• dressing. personal hygiene. bathing. toileting. and feeding) is diretted by the oLTupationaJ therapist and trammg in communication skills by the speech-language patholo£"l. Close communication and coordination among team membt'p, IS necessary to ensure that training method ... are con ... i~tently applied and succe,,[ui. Full partlLlpatlOn of the pallent in all phase ... of planning and train1l1g \\ ill in(reao;e personal involvement. \\ hile decrea-.ing dcpl."nd~nl.')' and pa",slvity. The majofll)' of patients with \IS "ill use multiple ldaptive dcvu.:cs. This require, tan.-rul attention to JPpropri:ue pre~cnption of devu:c ... and ('Tl\'1,nmmentJl modifications to ~h ... i ... t the pati(,Tlt in cllTl",("fVing (nerg)" and maintammg IUI1r.:tlon . .r\dapllve' equipment ,an Include bed or hathroom gr~b o'lrs, o\'erhcJo tmpez('. raised seats. transfer board. or hydraulic lift. \\'nsl n:"its h \ fae ;,lJtatC' wnring or typing" and: plates "'Id ('ups With lips to ttllnlllltz. sptlls are ofkn hell'" ful U1 assi>ling with h'lOd fun.:tion. l.onghanJled ,he< horns, r~achers. bunan hooks, St.'lCk Jlds, or Velcro" dosu~s c.m assist in dressmg. l:ffl!cl1\'c c~nllnUIm:ation rna) r"qulre tltlllt, up \I, ntl.!l~ ufc:nS1;'3 0)( _ ufl)v;;rsal cuff f('lf wnl"

Il."n cOlllmullkation cr more SOphl~~,('~lfed computertzrd Jevlr..'Cs. P:lliC'HS w;,th !iCVere sJ'k.·C'ch pr-\otCJ1l;'; m3~ re-qUlJt ,"c,tce cll11vliflcatir'l1 devh"es, dcdnIDl1.. ~h"''i, vr 1.(lmrurer ~5~.::lc=' Jlte~,~ati\'~ cummunii..llion S,,.stl'ITiS. rhc te.Vl1 must 'fCOpl1lle whe: a t:ev,;1,.:C :i lDdiQt~ ur:d ~;Sl;,.t thl.~ patic':tl

In "1,:i..:('Pll!\i..~ "nd

In

Icamm& hl)" to J~ .he deVIi.:~ N :-... n":!k'll fK.·,",~1

IgnJ!~.!nt dcew: n.tlion ~!

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,\Ianagcn.... m of S,)(,'<,('h lind Swallowing (o,aIlG',:;'

piT .!!("l)' pilUl!rns '- cJfit.lhule It sp('C'(.:h ltitlkUI" j

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Lhapter 19 Muhiplc Sder-osi.. -arc ,I..l," p.ltiellts with chronic MS. and .should Ix combined ~ 'ith ;Il.,'II\ltlCS 10 Impro\C' trunk stability. head contIol. ilnd ·'flng hal~Ulce. Re~plrator) pallems can be facilitated :-1 ~ I . )u,'h the usc mantlJ con taCh. reSistance. and incentive 1htL ~ TIle [hemrlsl should focus on diaphragmatic "'leU'. ~pl rl . oJ "epnrutal chest expansion. expiratory training. and ;fil~""ri\t" 1..'('Iughing. A ';lgniticam increase in expiratory fIlu ..lk ... ~ngth was demonstrated following a 3-month s trailling pmgram III patients with f\,-tSY Whell dY"'phagia or difficult) in swallowing is present. h,';lCal therapy effon.. shouJd be clos.ely coordinated with ;h<~:-e of the speech-language pathologist and occupational thcrapl ... r. A detailed exall1lOation is necessary. including qde0-tluomscopy for dj sphagia. The physical therapbt can a.';'~I"t 1fl the management plan by improving sitting posltion. bt~ad ..:-unrrol. :md ornI-motor coordination. An upright post'JI'f' ",ith a ~lightly forward head position and chin parallel k1 tai:'Je or ,ti,ghdy tucked is nece!;_',ary to achieve good swalIowtn!: and aYOld asPU3t:J.Ofl. Oral--rnotor exercises can impro~·e mouth function and include specific exercises for Ep d0';'ure. lOngue rnovemenh. and jaw control, Stretch and !CSl"tanCe ":-3I1 ~ used to strengthen weak muscle actions. 5\\'allo\\iJlg refle\.es can he stimulared b~ using icy be\"~"'e" 5oltctJ. as J s.hale, ~rbet. or fruit s1\l.'ih. Patienb are irO'!>7'.1..-re-d to hegm meah with 'Something cold and to take siDgle smal: SIpS. Dever uyiog con~ecuti\e ~wa1Jowing. R"",-suve ,uclmg through • ,traw can also be helpful. TIucter liqwds, wbJch provide some resIstance and therefc::-e some th.:1litatmn of muscle :Ktion. are generally ea~ier 10 s,...1!!:..... !han th!Illiq!Ilds such as water ~loi" food, 4II ith broIh. ....3Irr or mLk, are easier manage than dry Sennsolid and pureed foods are easier than regular

'0

. Foods tIw rrriUle!he Ih:oat e.g , "megar) and crumor slIm!" loods (e.g. take. (OaLes. poWa chips. celerJ·. = : sbouid be av-..>ided. Patients Jre instructed to focu ""'aru Mo~

~ ,

~

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,

Cocnitive Training

gUS

Referral to a ncuropsychologiq may be indicated to deter· mine the patient's strengths and weaknesses and to as~ist in the adaptive process. Compensatory strategies for memory defiCIts can be helpful. These indudc the use of memory aids, timing devices. and environmental strategies. Memory can be assisted by making liSh of things to do, usmg a memory note hook to log daily events ami

reminders. and li~tening to audiotapes, A pill di.\penscr can assist the patient in maintammg a correct medication schedule. Cueing devices such a'i an alarm clo~k, bell timer. or watch alarm can help patients remember when to do certain tasks (e.g., taking medications, performing pressure reilef). Structuring and labeling the environment is also an effective strategy to assist memory (e.g .. labeled drawers, cabinets). Directions for functional tasks (c.g .•

transfers. self-stretching 'echmques) should be carefully written down for both patients and caregivers. Complex tasks can be broken down with dear written direction5 pro. vided for each step. Direction.:; can be posted 10 different areas of the home (e.g .. steps for toilet or tub transfer posted in the bathroom). Additional cognitive ~tratcgjes

that may be helpful include mental rehearsal. re'luestmg assistance. maximizing alertness. avoidance of difficult situations. and mental exercises. Poor follow-through should be expected among patients with severe cognitive deficits. as. often there i .. very little insight. In this ~ltuation, the

efforts of family and caregivers must be fully maximIZed'·

Psychosocial Issues Individuals with \IS and their f.unihes expcru:ru.e a ~mety of loses such as loss of SOCIal funOJ1;1I relationshIps, employment status, Illdependenee. and fune tiC>Ilal .kilt;. DISabilities <"merge ., the di=se progresses o,'cr time Various Jiffercm psychosoc.al adaplations CiIIl he 5teI1 inc luding anger, denial, depre'''",," and so fonh. The =que fem= of • rei,.,!" ,ng·· reml!lmg dISease L-our->i! F that " reqUires continual rc..djuvtment C\'eJ) I'me 4 new sel of ,ymptoms JJ?PCJ.!" Polien!'; who 4'pe;!l' ",II adjust"'" at c1f1t the i.t;1e.l.~ ~or~;nl, l'be Ufu,:ertamt\o' of

•

an ',\ldual" \Ulh "" ~:;:I d('11 nct tak'" nl('dil' lions to hc'P .. In I lu:tr MS despite mcdic~1 ~Oh" hnes rCH)Ouncndlng I~ modtf• n' drul's. e Th longer they ill nOu rlf.:ec.. h)', .1UUG'1C • thl!" Ics likely the), llrt' 10 seck help. " c=tr. Ix pi ness. I )\\ sd~· tlicJC)'. and 131..'" 01 en,.: Ii" m· mental :;la,tc'" hav(" been id<."nllfi~d as r:13J r f.u.:tOI L;on· tnhuu. 0 dl ssKi! i.1ld fat :::Je "·u.·If.·t: ntl'OC,' i-s the be' t that (1l ndlvldu~ll \\111 be lrk 111 dC'11 with par (;utar ltu.11 ,"S hal m ..n (; t.lln llt.,\cl. unpredictable. and sires' JI c. Is .. t 11cg es that promt.lC '<"-efflcacy lind If.m:.n .nenl rrrrower the patu."Tlt ""ith \1S. The u...e nt r.;

~tre'\ .. rr.... U(;unn I..... hmquc~ (c g lC\;hOlqucs rogtl,' \"C' nugcry

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.... 1141tlllnJ c tn tll-w he help·

ful n prom('lUlB ( .. tl\ -. ,cPUlfi· I on 1 '~tremc'\ ( m.mon ",111.. In some lO(hviG' m.1 tlt~ be pan of the c.:~ pr 'lCess. DIOPrcsslO n lG1 n e )0 correlate 10 the ~ "'nl) of th disea.se F.>r cum!" n .. ,_ m:d can be """.rely '"C3 the person \lo1th rc .lISJbllu'r IS ort

.,

c'",,,,

m:. ' alen to lhe s.gn of dcprcss.('n led ntel" dPJY.0pnare l'taptcr 1 present a co. plcle C ......;:o:,,,n of thl loru.. r

Patient and :Famil} /Caregiv~r Education r r

I

pro

ro cl t dinlLI \..a.n ~ c °c r ... dS m;.' lcaA.her (: ~r .Jl compete,t pr !t:. ilffmn .,. altitude .In • tu and

Prom!" rcfl"rral 10 conullunlly rCS(UfI..:c In 1ud' SLIP!"" rt £fI)uP can pre ... de ;] ncccs~ary ,0_ -bl. zing t ..... ' a p:.t1cnts and their faml C /I,:«':";J!,IVC" . Within th for

Il1cntlO~IV

,

.

m_"on..

de.:!.' ",an gam tCluf.He anJ useful mf

ahout the disease (h:..clIss. cummOn problems " d~''''' . Ineth•.• of ... pmg and share anXIE:t1e" and rc ourees Th .. 'V\l.'t \' des a \'alu=~lc forum to "- 1st In the COnt inual ~,It pre.process. rhc "atlonal \ 1 JII pie SC'c us,m JtL'IIr. ~O< III

(httpFw~w.nationalmsso\"l~ty.rrg provides edu t~t'i eme 1I0nai c;.uppon. lOci it vanety of programs ll\d . 10 mUlvluuals wIL1 r\l S and then families. th rOugh sen-1..-;!1 ,'. 10\;;11 (;haptl!rs. 167 Other orgatUzations 4\n~ W "n:lr rCSlHlrc... s Me proVided in Appendix D. eb-b A ,igntflcant number of palic-B With I~I -S I"iflC 0 every twO pallents) will qUire the as.'ht3nce of.-n:Il;;ut c' person Jt some pOInl 10 the cours<: 01 their place, an extra burden on Ilm.l} mecnbers and f :lanclal re~urcl'"'S of t - patient If oUl Ide (lfef..ve~;be be Utllled. The "'" onty of cd."Cgt\.r penL';"e m ale lC\els of stress a<soc ,",' the.r , art'" IX!:: ••vlOg d:" \; the level dnd durauon of phYSical, re In<: . 'I\en CJr cxpenefK.( a \.lr etv of signs and .. neludmg ph)SI al (e g., f,' 'UC, I-eada.he "an,." ;,peltle, hanges), p \ chOlog.c (e.g an.~

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dcpf(ss.on. fru'lration). soc ~I (e,g, f.mL) confl.1 deereasmg ,,":.11 ~pcncnc or lack of lifol. .md 'n lual changes (e g, hope"" anO meanmgl hre.. , rk l. The Iher lpt.1 ... 11 need 10 be sensl ,. 10 ' c :..n~c and 10 contll IS pr tlcms, and tens.LC .IS 'h.:l d ,e, p. ('n Ilkr,.ble time dnd energy w ! be OItIl L un hng and cduc ", ,lfe'" r ' coord!" home manJ emenr.

111\

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# Chapter 19 Multipll.~ Sdero~i~

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plan of care'. . , 3 Ho\\ is ttl.: dl3!!:nosls of \15 c ...tahhshcd! \\hat h!~h . and me:J$urcs an.' used 10 cnotinn the diagnn\.s'? 4. Identify the JI",ea",('·mnlhf) mg drugs u\cd m the medICal rnanap:cITII.'nt of \15. \Vhat arc thelT imlKa lions and f",llcnlJal ~Id\'crse eflcl"h'? 5. \\"al component'-. ",hould he included In a p~yslCal therar: eXJrnmallun? Oe"'l"nhe three disahillly ~pe1..'fi( mea~u~s dc\C'lnpcd for u ...e with the p
HISTORY The patient b d 27 year 'Id graduate ... tudent who was adnuned t('" an dCute ~e f.d(' .Iity \\ ith a chief complaint of double v.s.on for 2 weeks, She reported that hoth krtler extremJI e~ (LEs) seemed weaker recently. Four months :r'_. she had n('luced rcr ... iSient ljngling of h("r imc-_ ~ ::J the left hand ilnd some" numbnes. ... on the left of or ere ewol -g'1i..4l eX.;Il1mallO sho'Aed a M:Oloma III the ,;pper fl d of the left eve. "e..k~ss of the left medial 't.; muscle h
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MEDICATIONS Preum .. one 20 mg. P(l yid \iaah)\ ",0 cC po qid \-allum 10 mg 41d

SOCIAL HISTORY Patient has heen li\ing on her l)" Tl fur S( et'JI \cars until her recent Illness. She has L\~en 3 IlleOu.;al k.\\I: frC"m "raduate school and had retu~1 home tl' h\c 'Auh her parcnls rheyare htlth surpt'rtl\e.md \\vuld .kt: wm~ J(h ICC as to ho\\ to modify the;r t\\(l-stOT) om The-re ,th a handrail on h4.:th "i.ld~ s rh re IS 8. flrst n()Of i"'-J.tf;fOl·m . md they ,-.1.111' ti ",'Il~ rithe tlrs' I,()l'r !iol;JC~' Iun t ~tln14·m. Il,- t";lTen!~ u ... hoth In th 'If al;, {,usn ',oJ: _31th. nd \:C'ry lnXI\lU, .i!:wul Ihl.: ,r daur.ht '!"!Ii. (;;lpldl~ .. ' terUlII:1 I,.,mdii-um

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• rundlonallimitiHions • DI:-oablht~ 1 Identify IWO outcomes (the remediation of functional ... Ilmili.ltion:\ and disability) nnd t\VO goals (remediation

of imp:lIllnents) foJ' this p:'ltie-nt.

809

3. Fonnulatc four treatment interve ntions that cou ld be used at the :--tart of the rapy to achieve the ... tated out~ comes and goals. Provide a brief rationa le for ear.: h. 4. What ~tra lcg i es t:an be u~cd to develop self-manageme nt skill~ and promote self-efficacy and quabty of life'!

References I [k:lJl. G: The multiple "derf"is pn"lblcm. Sci Am 2n:40. 1970. Andcf";on. D. er al: Revised (':-olllnale of the prevalence of multirle ,def(lsi~ in the l)niled States, .\nn Ncurol JJ ;,:1.13. 1992. Kurl:U1d. LT~ The ('\'oiutil)n of multirle sclerosis epidemiology. Ann r\eul\)136\Suppl 1): S2, 191.}4 4 :\lter. M. ct al: Migration :lnd risk of multiple sclerosis. Neurology ~!': lOX\). II}:R

:. }\.urtzJ,.e . .I. and Hylle<;!ed. K: Multiple sclerosis in the Faroe hjJnd~ i Clinical and epidemiological fealUre:). A1m Neuml 5:6. jlJ;Q.

6 \\-eimheru..er, B: Epidemilliogy ofmuhiple :)clero!)i!!t. Neural Clio 1':.291.1996 Herndon. R: The palholog~ 01 multiple sclero~is and its varianb. In H~·rd~m. R \ed I: Multiple Sclerosis: Immunology, Pathology and rathorhy~iology. Demo~ Medical Publishers, New Yort... 2003. p 1~4.

hlhn..;on. R: The \irology of demyelinating disease. Ann Neural ~6ISurpl):S54. 199.J 9. ("helmJCka~Scfl(\(lr. E, and Amason. B: "ieTVou!> "ystem-immune q .. tem lOteractions and their role in multiple sclerosi~. A1m ~eurol lb..Suppl I):S'::9. 19Y4 SJ.d'lVllick. A. and Eber.. , G: Genetil:" of multiple sclerosis. Seurol .1')

(lit! 13:99. 1l)Q5 Kahana, E. et aI: \1ultiple "r.:!erosis: Genetic \'en;u~ environmental ae[loll'~' Epidemi('llog~ in h,rael updaied. J NeuroI241:~41. 1994. J~ \latthev.s. WB. el al: \kAlpine\ !l.lultiple Sclerosis. Churchill Lj\·ingo;,tooe. Edinburgh. 1(}9J. .l Lassmann. H. Suchanek, G. and Oz.awa. K: Hi~toPalhol0gy and the blood- --(-erebr~mal flUid barrier in multiple s..:leros-is. Ann ;~ kl,Sllpplll: S~~, 1994. 4 tJJ,bllt F and Reingold. S: Derming the clinical COlm'e of Tllultiple sv:fc:'_s; Results of an international suney. "Seurolog~ 46:907

19% 'i ':!1:1p:ro. R: M.m<>.gmg the Symptum~ of \fultipk Sdero~ls., ed-1:>emD!!> MediC31 Publishc-r... N~'w York. ~OO~l lechtenberg, R: Multiple S(kro~ Fact Book. ed 2. fA Da'is. I'Ililadl;lplua, 1995. C;tuihTO R: S)'lIlII:::mlwuge"'l'k:nl in multipk sckrtlSi'i. Ann "'~':30

'194.

II; Pain in Multipk SC!etm.I". Cmu:ai Bulletin. ~..I~:;"'\na1 $.: .~i5 S-ociety, r-.;'cw Yorl~ J 'f'-I4J. 19 K..!J R, .":.."ld Rymer. Z· Spasti.. b)'pc111ni.t: MC(.h!fiism~, ,,nd melS· Ar:.; Pl:tys Med R~:habl. 70: 44. 1989 1'..:.~..:;>m 11., anJ s..''1fl..: :ler. ~): Managnne:::t lIf Llugue in nluhirk '::'-~';= Oink-'_J Bdk"'J.JI). NallLmal ~1ultlPk: SI.:~L"n~i~ !.O::"i;ty

d: fo.!.

'" r-:.~ti~I~'

L_'

~l~h. ·\n.:tI ,,"cw')i 4.'i:43'5.

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2R. Smedman. I Tremor. Multiple Sdcr()sl'" Ba"ic Fa\;l<; Seric:-;. !'Iational Mulliple Sclerosis Society. New York. 20(14 29. Herrera. W: Ve~tibular and other halance di~order .. in multiple "de rosi~. Neurol Clm 5:407, 19(}O. 30. Clinical Education Committee: Gait and Walking Problem", National Multiple Sclerosis Society, ~ew York. 2004. 31 Clinical Education Committl!e: Speech and Swallowing. National Multiple Sclerosis Society. New York. 2004. 32. Schiffer, R: Cognith'e Loss in Multiple Sclerosis, A Clinical Bulletin for Health Professionals. National Multiple Sclero~is Society. New York. 2004. 33. Petersen. R, and Kokmen, E: Cognitive and p~ychiatric abnormali· ties in multiple sclerosis. Mayo Clin Proc 64:657. 1989 34. Franklin, G. et at: Cognitive loss in multiple <;clero.,is. Arch ~eurol

46: 162. 1989. 35. Samuel. L, and Cavallo. P: E motional hsues ()fthe Person .... ith MS, A Clinical Bulletin for Hea lth Profe"'~ionals. National Multiple Sclerosis Society, New York, :!004. 36. Brassington. J, and Marsh. N: Neurop~ychological aspects of mul· tiple sdero~is. NeuropsychoJ Rev 8:4\ 1998. 37. Shnek. Z. et al: He lplessnes". self-efficacy. cogn itive distortions and depression in multiple sclerOsi~ and "ipmal cord injury. -\nn Behav \ Ied 19:287, 1997. 38. Minden, S: Pseudobulbar Atleel, A Clinical Bulletin for Hl:alth Professionals. National Multiple Sclero~is Socict),,\icw York. 2004. 39. Feinstein, A. et al: Prevalence and neurobehaviontl correlates nl pathological laughing and crying In multiple <;clero<;j;,;. Arch ~I!urol 54:1116.1997 . -to. Minden. S, and Schiffer. R: Affetlive di-.;ordel'i in multipk scJerosi ... _Arch Seurol 47:98, [990. -ll Andrews, K. and Hu .. mann. 0: BladJer dy~function and ma/lJ~e· men! in multiple ~clerosi". !\tJ)'o elin Proc 7~: 117h, 19'17. 4~. Kalb. R: trinan' D.. , funcljon ~md \1S: A Guide forPeopk \\lm \1ultiple Sdero~ls. ~ational \lultiple Sckrosi_' So(:iety. \ew Yoft. 2002. 4~. Clinil'al EdU..-ation Committee: Bowel Prnl:'lkm~. '\ational Mllhill:
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- . 01.1.'1111'*"111 Jte.jllcn(~ j,III).!U!'oI·eltl'"CtIH"nl·" or multiple ~dcro'l~ rrtlahilit::llron: A model N('uroio{:.y "I PIt.. IqSI ~!'I Frecm.1tl." tl al The inlJ'lll'l of mp;,I1I'nl rehabilitation l·n pmgrl's.• \'(. mulupl.:- IK.km~is..\nn \,:uf\ll.L:!\.:!):.:!.'\(l. J9Q7. ~9. 1'l't'Cm.aIl, 1. el al: Inr:l1ient 1'l"hahlJllatlon III muhlple ~t'1crO'I' Du the haltlits..,:.any aver ,nlo the ~ommunity , \euf(llo!!)' .ci2( I): 50.

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1JrJe !Clem"1:>: -\ em!trolkd Ina!. Clm Rchllhll In: IQ5. IQ90. (irecnspun. Ii, d &I: \lultir1e SClcrosl' and rehahlillatl(ln (lutcome. \reb P'lV5 'led Rch!1biJ 68:·t34, 198 7 I\ldd. 0: Cl at: lltc benefit or inpatient ncurorehahlhtillion in multiple t.:.1~ls. (lin Rchabil9: IQ/'i, ItN.ci. . . . KoKo. ( l:tlccth-cl'lt$s 01 rehabilitation lor multiple "dero~" (lin Reh;lbil I ~I I I J:;. 1m, KnIt. G K(hll.hllitltion still thc llnly v.a~ to improve fun~lhln in multlple klemm. l..ancC1 :;I.ci.l:20IO. 1m Langdon. D, and ThompS\ln. A: Muillple sdero,,,: A prchmtnary stuch o)f seJe-cted "anabk~ afke.:tmg rehabililation outnlme. Mult

Sder 5:94. 1999, b6 Liu. C. Playford, F~ and Thomr"on. A: 1A)t'~ neurorehahllitation h:!.\'(' a role in rtt:ap!!.lnJ; rcnuttlng multiple M:lero~I
Ned 14 'fO)r 2bO 2002 ~;n

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?~ Krall G. and Scbzlpiro. R (Co·Chain;) '.dlona! \\S .$o(jcty·s \te4i;cal Ad,'1.SOf) Board: Rcbab,iltalioo: Rf'{'OllllllentiJboru; for Pr'WIlS wllh MutlJPIc: ~h,,;rosu.. National Muillple Sd.:ro5l1i $1.1("~;:y, "'k'''' \'or\: "-J(~ • ~ !\me: '.,," 'Ph"'L!t!~ Awoclhli0.n: (rUh.1e to ph"-foIcal ther, :::1::. :)filll\ P'Wf, 1"":=-,' I.S 1 I. 2(1)1 . Muf:.::t·lfl'1"lcr, M, Ie'~ .\lIerruu:' W· Addrt"~ing fl.ln,"~"1fl.11 tru'IOIc

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, _ .• Bed.. R: Scrt't:ninp. dcprcsllCd patlcntli in famil,_ 7'1., f'kd. •.A, .'pld \IIIU· .. '\'" I '''72 ~-. techfllque. po'lgrad l'..kll1'1ftftk' ~....Ift. G S .Int l~t~I:511. 1'~~'), . ., ~, / ~ JD, tt al: The Impact of fatigue on pattenl'l .... lth muiliple ,.. S(~~... t'osiS, Can J Nl!urol SCI 2 Ull ~: I~. ~J. hsk, JD. ci ill: Mc-a!lounng the tunclIIlIM,' .Imp:ll.:t (If fatigue: Initial 'VUhdalion of the latig:ue Impatt M:"Ie. ( hn Infet:t DI<; SuppllS79

X.l NatJ(mal Multiple Sckrn"'ll; SOlie,ly Chnu.:al Practi-.:e Guideline.: filllguls. /"oatlon.ll \lultlplc! Sclefl)l;is Stllicty. New YNk, 20U..l. Wi. De SOUla, L. and A .. hhum, A: Examination of Tnotur fuoclion in people With multiple ,dem"'l$. Physlothcr Rc..-s Inl 1:98. 11J96, R6. Lee, K. el ..11: The Ashworth Sc..!1c: A rellahl..:: and reproducible method of Tnca.~uring ~pa.~ticity. J Ncuro Rchab 3:20:'i, 11)89. 87. B{'Ihannon. R. and Smith. M: fnterratcr rdiahility 01 a modified Ashwonh ~cale of mU'icle spa~tKlty, Phys Ther 67:20fl. 1987. H~ Shumway-CooK. A. and Hor.l.K, F: A~ses!.tng the mfluence of IW:IJ. "NY tnlera(;tion on balance. Phy .. 'Ther M: I 5.l8, 19Rfl. ~Q Nelson, $, ct al: Ve!>tloolar and <>ensol)' tnlc!rat:llon deficil<; a.\SeUed by dynamic platfonn (IO,turography in patients with multiple scltro,i,. Ann Otol Rhinol Lal).-ngol IO-Ui2. 1l)l}5. 90. Jacbon. R. et at Abnllnnahtles in posluropraphy e'itima~ 01 visual .. ertie.:al and horizontal in multiple Sc!eroSII;. Am J 0:01

.uw

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1995.

91 Berg:. K, el al: Mea,uring balance in the t'ld!!rly~ Prehminar) deveI· opment of an instrument. Ph) ~i.lother Can .ll :J()..a, IQS9 q.:!. Berg. K. et al: Mea .. uring halance 10 the elderly: Vi1lidation of an mslrument. Can J Public Hc;\lth SuppI2(Jul·Aug):S1·11. 199~ 93. Tmelli. M: Perfonnanr.:e-oriented c.'l.amtnation of mobility problems tn elderly patienh. J Am Gcriatr SI)C 3.l: IIQ, I!,)XIl Q4 Shumway-Cook, A. and Woollacott. M: ~1olor Control Theory and Practical Application ... cd ::!. Lipptn..-ott William .. & Wllkms. Philadelphia. 2001. Q~. Schwid. S. et al: The mea,uremcnt 01 amhulatOl) lmp3.lrmeot in multiple ..dero.. i~. Neurology -l-Q:l-l-IQ. IQ97 Q6. Lord, SE. ct .1.1: Vi,ual gait anaIY'>ls; The development of J. I,.'Imic"aI cx.amlOJ.tion and S4.:ak. Cltn Rehahil I:!; \07. 1998. 97, Borg, G: PsychophY~lcal ha...es t,j" lX'Tt:ej'·t;d exertion. ~kd Sd Spon, beft' 14:.'17. IQlS:!. qx. Aml'ncan College of Srx.lrt~ \kdicine: (\C'S\I's Gutdeline~ for E,erclst" Te~ling and Prl"l·npllon. ed 6. LIppincott Willblm &: \\'ill..in,. Phlladdphia. 2000. Ql) Guid Ycd at Buffalo. Ruffalo. 1Q%.. 100. Grangt'r, C. el al· Functional rumination SC.1L:s: 1\ stud\' oJf pd" sons WHh multiple sclerosIs, ·\n,-h Ph\iS \tc.."\1 Rehabil 71 S'l'll. l-:NO 101. S!('WJ.rt••\. HJ)'s, R. and \\Me,J: [be \lOS 41urt·ronngeom! health sun.ey. RdiahililY dud \'a1idlly in. F:thenl popul.ltl.m. '101 \tI~

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!oUf\l')' an mullipit' >.clerosts. J :-';eurol bS! 1): I .tii(l. ~\'I(')t). tUJ. (jtlson. B, et aJ· l"he St(kness IITlJ*.'T rrofdl' lJlo:\';:it'Pfl,,-"I\f(!f»l (IU{('Ol1le- tnc.;l~re of Iwalth ,'3ft' o\nl J Pubh;;: .h,~.dth 65:.1 1()4, 113"'~ 104 J)UblC'. '5., c:t al: Fun ..:honal ",ompct...~"C c,f lUlUllunil' -dvo'dtm~ pe''"''-lOS With multiple k'kn.~l" Ulllr.~; the: E' \.unulJtiao of ~t ..."il( and 1'1oxe~ Skills, \n:h Ph";;' \k-d R(I~t-ti .. ~:~:.t. I~ W~. I\urtzle 1 On tbc- ~',jlu;ltlon (If dls.:Lbttil} ,n rnul!irk S\ll'rai~

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',n,

I~

( 'hapter t 9 Multiple ScI("rcui!l) UN. ',\Ian. \, ,'I !.IS. Qu:&11 ,re Res 4: 187.199'<>. : II ('onS\lrrium of ~Iulllplc SdC:ro:'l5 Centers. He,I'llh S..-iefll.;C Rest.m:h Suhcomm.l1cc .\ 1utIIPIc Sdcrosls Qualil} ,Jt Life ImC""'lM)' A l iCr s \lanwl l':alional \fuiliple So,...l·~... i~ SOC •.:'I},

'I:'" Y{J1~ :'" \.r13. ill: elll: \'.31id:1tior. 01 the funcliort:ll 199'"

E~aJmnatiOn 01 ,- MU!lIpi: ~\.-!:n>.iHI "u~lity ,~f life instrumf"flI. 'curol~y $7( I): 129.

1-

1"1' U~. JC c( al:

TflC Mulliple ~Ckf"(lSIS Impoct S.. aJc ~MS1S A flt\\' ;l3.tienl bl~ wt.:ome 'lle:t.",ute Br:Lin 1~4:9tl:'. ].11111 114 R."•.:i.A. c1 ~I: \tu1tit=]e Sdeusls hUp3Ct S.:a1e {~ISIS211): RC'~ubili'y 1M \I.llidlry 1n hospital baSf'd S;tlnpl,~s. J ,""curol

29)

~""<JrosUi~ p.;whi~' nlb):7nl. 200~ I ~ Qul
- W"'tile, ~ J.

eI

aJ Rr-slo;,llini.:C tninin8 impl'f1\'ts strength and (une

tJm3.I capai.:lt)'

:n pe--sons with multiple sc.:1.erosis. Mull Seier

c0"f>6~. ~

A. at ["fct;ts of::"'Oblc mj ilrcngth acrclsc on motor blign..:'~ DIm and w;;;aen wub multiple sclero'Sls: A randomized

Sttrakl. J.

~~ c:;--&J. C:",,: Re."'..::.bll \t= L S, ~ Kc::::~:'-ng

18 7 37. 2,i04.

J: I ffecl'! of a short,-teml c:tel\:i5C train ir..~ .)Il':"'~ ~ IIt:'Obic fi~, utig~, health pcn:epr:ion. and Xliv ly ,-,-,'Cl ~ subJl!-'l!. "'lth "'"T.1Iltiplc sclcrosts ft,1ult xle1l' M: 16i :':~12. Roclr"!.. T L,-";:: Kant. u; Effe::-'''5 of an aquatir.:s exercisc ptoli ram JI'I Quality ~ life neasw_':. f\. indj\lI,1u.a.I~, w,rn progres.",i\'C mulll f:':'-' "J;:-:;:;-J" ~~PT ~Sl2):M, 2(K14 Suthe~2Dd. l.i. ~~. M. ud S"'::.J'Ve, \1: (':m acrohic e"er"~ II"':.=' 'lealth-r,-':atcd qualit)- of life for PC'Jplc with multi, ; Span I x~r ...- PrtycI1012,1: 1;2, 2f()1 ..I: 1mpac-' ...( aerrni.: tnmlng on fitness ,md qUJ.!it)" 01 multipl!: ~:-~Ii. Allo f\Ot:Urol '\9:4,l2 1996 :;, \~:.::!:..L.~ .: eO! al: ('lang;: In aerob~ fitness d patlC"nt'l during. a ~month tr~rung prC:p:1m. C;pon ·~I:j.lwr

M:.::~=-.;

J. ('11..1 M

C'1Ct'I,::::

time

of :ooivldu try (lin

~:

f'::n.:

,~am

V."th

mu::.:r;

Ill!em

81 •

,'l!l Ih-'SoullL' .\ ditfc«.-nt ;1ppm3.1h to phy!>olO'h("'r ... py for multlpk "fernsIS patients. I'11V~iothcfapy 711: '28. 19S4 I ~6. "ncma, J, el ;1' l';,uditJ\','"cular aulonoll1lo.; lutk:liun m multlpk !\dcnw!\, J "'eurul Sci tl»: 129. 1992 1:\1 Stcnn;ln. \.. el III: I)~sernmatcd .Jhnormahlics or, artho\·.:w;:ul.u II,ulonomic funl.1:lvn<; 10 muh,plo.: Klern<;15. Nl:urology \S: 1fl6"i. 19R;\,

tlR. I't'nlland, H. anJ Lwing. \) C.\nhovasc..'ul:u- ~':U'':'

In

multiple

.d..:rtlsi'l, Eur NC'JTllI 2ti: .\11, 19R1

114 hogllo. K, et al: Re$.p1ralrny muse It: luru;tinn amt Clcn:i!tc c,;ap;u;ity III muhlrl~ I.f.:kU)!-.I'J. Eur Rc;.'pir J 7~2). 1¥H 140 {'ilppmlllo:'r, I, ct ,II: "erobi~ t.:1crci"o.: in inultlrle SCk'1'll"i~. Ncurology Kqx.'Jt P);41 199:'\ 141 Kllsch.~. and f\,tly ... lin\lo.i. MI The dle\."t III ;j [wnunat1y JL'sign..:d htness program nn the .lCfnhil.. opadly .mtl lunchnn lor two inJivuJual" with mulltplt! Kkrn~i$, Ph)':' 'lher Ca'-C Kt'p 2:19.1999. H2, r-..kCnrna'i, A. CI al: f'ati!:ue t'lrought on hy ntallllnction of tht! a:n tralllluJ pt.'nphl'ral nervous syst.:m, In Simon. (' cl allcJ..;): Fatigue Pknum Press, '
..

York. 200..t. 1.17 AJlcr. S. Br..'\.:kers. D. "lnd Hu(:Io., ~l Pf'I;f" Spflnger. N",," York. 2003.

LI1

P.-:",;II\,"";, eoJ.2

148. K.u....er. S, Ro..e, l), and Oarl, S H.d.uu:e training for adult\ with multiple ,..dCfOS1S: \lultiplL' C;l<;(' 1;1:udi,,'l;, l'I.ieuroh'lt)' Repel1' rnow

JNl1) :!1d): S. 199Y

1411 lI:.amtlJon. Rfi. d al: -r r>llOm: eHeel" during ~pt.'·~ucd lhl'r:tp) "'C~· Sli .n'J 01 i'1011;11lCe tmining using "'Isual re~dhad.. \n.h Ph'Y~ Mcd Rehabt17:l7·QS. l'N.!, I~(l. tkhrman. ~L. and lI:ui.t:ma. 51: , ,lComOlor tralOlng after hum:m lPlnaJ c,-,rd injury '\ srrits or (l'iC' S"!uJn:~. f'h)'s fher SO:~gS ':f.O.. L51 Nymm. I, e~ 11: Bod, v,("lgIIl ~IJpp"" lrc~Id1:!11I £111 u;uninS!. 1~llhe l.lbat,ltc n:c,_,\·cry ph..-Ul! of In,umpl.;.:te spuul _ord lJllut\ Reh1b 1.!·! .~_ 1995. I >Ii:' V ~!lotntin, \.t. e( ..I; -\ L\C'W Ilrrroach 1.' re~Jtn lhlou;;h bod) w.;;s:h: ,uppon Wld ur,;1JsniJl L

]9: I : '2 199M_ Sulll\";an. !oJ. Knowlton. ('J .nd lk""r

body Vw(:,hl support: [flee! d w..wmiil ..::;.,. ~~ on P'"~;:,no1.e i,~.)mt.lll '. ~,.)V f.j-:"..~,~ 1')1.1; "". MI"-.l I. 'I iAI: T"~.sdmiU teatnlr ..In P-.trlm~,JII'" .11\..1,;-' -~ \!

rn:

•

•

•

Ph~'s;c" Rrh3bililalion

812

rl

.to' Ct'1"\,:'t'ldlrul. I ,1.J: "':":'.11 handit3{l~ (If murripl. ~lero_-,,, an,l '.hc';r rtl.uiOn to

'1Cunllt~); ..I.lIICN;lIam .\r. h I~\~ 'lftl Rcr,ahil

",iii: _:2J. rl)94

163. KhI-'t. C eo: al Olubilily. di.;c's:, dur3tiufI. anJ r=,",3bi!ilJllvT) fie'" ~~ need" rtl mulll~ ~k-oSJ·' Po;l»nl pcN'Je(:li\'C:. Arch l'hvs \fed RchaMl67: 1M. 1'186. boI. Shntk. l. ('I &I: 1-I('lpk~ ~ ,II IPffM.lI.,. W~;ljli\fl dj~·)'1i(1I1'1. Je'prnl.h1t1 In ImJ!lir~e sclcm\i' 1111.1 ,pm.!1 ,'O'"d -;'1j'J1)' Al1n 8dtI\' ,\lcj 19;.:s7. ?9~ (,~. I.• ;~I\ ,Iri. II. ~I .1: I I :mt'n":s elf empt;;:.cnr_'n'I and '1 ~ patients. J NClJfI,l"I,.-. "-JUT' 311: I 0'. 11}Q1I.

Supplemental

"

~';!i;. ~

[hft. ~H,

"'"'X~~

"0<:»

:8:•.

1M\, rrl~';,_ G: T~ challen£c to the f;1mlly. Am J ~urs.1W 1981) 6'J Sludkrf; n \, an·j Roben ... (,: .Ic.atth ptoJTWtlon DractKl".!,' of .....'nen With multiple ~krosls AJ'l:h I'bY" ~kd Rl:hJ.bil 7&Su

1Ii):S·}.

i'Jq~

ppl

Kratl. (iii: Rchabihtalion pnnupl':J 101 p;~ticm' wilh rnultipk sc:len"" J Spinal Cord Med 2112J:117. i99R. \h:t)o'l:Ild, WI. elll: Rec,mun"ndcd dlag~,=,: ~IC ritl"ri., luI' mullipk tlC"i..-:rosis; GuiddlRes from Ihe IntcmatlOn~1 P-.me l on rhe iJiagnor.h of 'lultipl~ 'idCroSIS. ,\nn N'curol "1.0: 1--1 200: \1I11.:r. " Lublin, Elnd Co)le. PI\: Moltirle Sck':"U'iU '.n (lmk.d P'r-dice "'1.if1in DumtL LGldon. }OOJ. "IjorthrOP. DE. and {-')Oper s: Health In! llranee Res.oun:~ ~Unu.t.l: Oplton... for People with Chronic f)~.J3e and DiJabl!Jlv Derno\

\Iedkal Publi~h.in&:, Ne~ Yon. :".,03, Pal\,. OW. and Fbers. GC' leds Multiple SclC':'OSt;;,

F~

Dln1!.

Philadclphi:1. 1')98,

5:h.:.pirc R .\tarubin£ 'm. C;y'nptorns ,:1 Mulliple Sde":ml~. >J.t Demos ~lcdic31 Publj~mi;: ~~. Yort, ~')O'!,

'cu.-\'

r.-i t..:aunnr.. M

161. Jkm. D, and H,)llJnd 1\1: (ummUrHlY RCSOUF\:cs tor Your P '. Wlih \is ,RCliO'Jrct' Bulletin. Jnfornlati.l"Ifllor Hedth alltn !"'rok"filon;,I'i)- Nation.;ll Mulilple Sclel'O"'-i'l Society, New Yon

Rl·:tdill~s

f!:;::.lsttlf1- 'I' "In! "fe -t- \fu:ti~ ~,:!~." An L~1!ial (JUlo.. Inr II~ ~t'....- '.. 0; :;::::-:~d. Marklw an.i ('o. "Ik"" ,"011. 2(102 Burh. JS. an1 Johm~ KP 1C11;.'; M,,:-:;.,I. s ...' ,LTQSIS p.u,!;n<1'U'i, M::!:__al \I~ --..r..:-;; .;..,d r•.:.:h ,b'li:atioo. Denu)S \Iedic JI ~JJ;cn. ' ... Yori.. '"'XJ(). Co ~~n !\ . .I-'"; J i{:t;!._3.. RA \. !.,): MlJlliple "L: 'ro~,. fbcofOipt:"uti .. :;. td 'iart....t l>unjlL L:miOl1. 10(": '. Pt.:. and Halper, Me:;;e: the Cl"...llk I~ of PrG;.-;-~~:;I\ Muhipk ~!.::-•. -~, l)cmm. ~~:.:;: I\I.b·jO(hers. ~ew )"orL, 200 ;:J, "}, Murrn, .. ], and R:':"-...:ot::: ,( Mulliple Sclcn us, A er.::=.., __ :he 1'.,;, .... 'y O::q:n~ C'd'::' ll='-'i \kdical PlJbJi!>hht;

YM..

IMi. neJlo-H;'~~. \', Hene. \1. ,lilt! Mtl.·,umQCoJ 11 I'r'ld 11f life: Cb,llIengo; and stratq;:lc$ lof .he rch .. hlllt31ion prore~lOnal Neumlogy ~ep
L~-tng

:. ();::,;;lS ),f.=:;!...::

v.- lfl Muli::,k- S.'I~ .; -\ Wellness Publicb,'I:: ~e~' ",-11. 'lXJ()

.

Appendix A: Modified Fatigue Scale (MFIS) ___ _-0- Impact __ _ __

-

~_

Rttig ue j .. a fedmg of r~~ 'kal. ftredne,'" an~ hKlo.. of energy th~1 m
fl1th"lwing I' d li:-.t cf "latclllcnC... that descnhe the effects of fatigue Please re~lrt each statemenl c.ncfully. Ihen dn/{ he ,mt' llumh(~' th.at tx;st In(ilr3les llllW often fatigue ha~ affc(tcd you in thiS way during the pust 4 wed-s Of yuu need bc':tp 10 m~rhing ~~)ur respl..)n",~s.I('11 'hi' II11l'r\'ICWcr lhe nlimher of the best response.) Plca,:,.ol1swer ('I'erv qJl~',\tIon. I f ,,00 3f(' n01 :-oW-I." which an:-;Wf..~r to selCd. choo:--e the 0111.' ~lflswer that ('omc~ cJo~esl to descnbmg you. A"ik the Interviewer

;oC\r 1alO an) word., or phra.50c, that you do not under~land. Date: ._ I

_ 1___

'\alIle

Te,t: 1

11)£"_ 8ecJlu"'c of m~

fath:~ul'

during the

2

4

,,~

p3~t ..j wee~~... R a rd~

' e, er 1 h ....·C

"t

o

heen k : -:s alen had difficult~· pa"tn~ ath.--ntion fj "r kng

I

o

Sometimes

Often

ah~' a~' ~

Almost

2 2

J 3

.j

2 2

3 3

4 4

4

~ :x" Jtime ,, ~\'

flink c' ea..1y il.'1d Wl("OC':"..::ll3ted.

o o

ph"·~Jl,:11

bad \I. 1"'!'lCt' Dlyse

1

.j

3

~

~

4

2

3

~

J

2

3

4

o

2

J

~

o

2 2

I)

,

n

r:.'!in: .I,~

_ been Ie L. • .

N

11 ,t i\t3ted 10

do anythIng tit:lt

Mt,,1 cl(h" I~~ 1h,Jtt\'ated ~o parul..ipate to SOCial

y 1:. dl "brntt"'\ :.;tl

~

•

C :::"

J!,"I"

long

c

4 4

u-- -rh.ftn LOut

Ibll11-

,

-r;:.}..

4 4

• c~

~

,l

,.

u

4

"

,-.,-I

I

",h:ll

.,

• L,ot"Ut"UOIl!o

fur ~"",

M.

y

•

~S""'JO .i

.;, ·~lielj .

tC'tal

S14

Ph~·siCllI R(·habiIilarino

Pb, ..scale ical can SubSl",lc ThIs rango lrom 0 1036, It s comp"led by addIng raW scoreS on Ihe follOWIng Iloms' 4 ,'6 .. 7 .. 10 + 13 + 14

17 .. 20 + .:?I

Co~ithc Thls scale carSubscalc range from 0 10 40, It .s compeled by addirg raw sco,es 01" IhO Kllowing liens 1 + 2 .. 3 .. 5 .. 11 .. 12 .. '5 .. 16 + 18 .. 19,

Psychosocial Subsrnle This scale can range lrom 0 to 8 It Is computed by adding raw scores on 11'9

followi~g

lers; 8 ' 9

Total "IFIS Scorecan rarge from 0 10 84 It.s comp"'ed by adding scores on the physical, cogritive. and ps The lolal MFIS scora subSCllles, From: Mt.tftipte Sca&rosis Council Ie." CliniCal Practice Gutdeline9. ,.: ; With permisslOf'l

YChosocIa·

Appendix B: An Expanded Disability Status Scale (EDSS) for Patients with Multiple Sclerosis Functional S,'slems

mild decrease 10 tou(h or pam and/or moderate uecrcitsc 10 all prnprmccPtJve test!) in three or four limns. 4. \.lark(,4J (k'uc;lo;c in lou(."h or pam 41r loss of pmpnocep lioll. alone or comblJled. In one or 1",0 limbs; or modeT

r......midaJ Functions :'\onn Abnonni: S.:~S without~lSJ.bllily ., \fmmu.l jls~bi 'It}'.

ate oC'lTcasc In touch Pf pain and/or severe proprioceptive decrease in more than two limbs. ~. Loss (cssemi<Jlly) of ~ens..1tion in onc ur two limbs. or moderate decrease in It.,)Ueh or pam and/or loss of pro. pnoc.proon for most of Ihe body below the head. 6. ScnsJlion essemially lost below the head, V lnknown.

l Mild. or moderate pau.~ls ;,r ~em"parcsis: severe CIpJl'e~':'

4. M:..'i.ed ~SIS or henllparesis. mo.1crate quadnmmOl!le~, l3..

\

henup!:-EJa, or maned ,padr,:;:-aresis

... n

Cerebellar Function

Bowel and Bladdcrfunctions (re\ised 1982)

o.

I'orma], \11Jd unnary hesitanl..'Y. urgency. or retention. 2 \Iode-ratc hesitancy. ur~enc}'. retention of bowel or hl~l(.1dcr. 01' rare urmar) inclJOtincnce

w,:1001 d,,,-,b':.ty '1IJdcnllt.: "'1..J1~ or J..Im~ ataxia

4

s..-= ataxia, ~!Ilimb-;,

~

pc:

1. I-'requent urm;u)' iDl.'ontinence

--l In aeed cr almost constant I,,'Jrhcteflzatlon. ,5. I o<s of bladder functIOn, (), l"ss "f bowel dnd ~Iaddcr fUDclIon,

c:oordmated m(l\emcnts due tl" IlLlxla

J,:.......0\\T

\. ....'1

r ~ each numbc- when" toakne rr:::-: l.!n pnd:nudah mte.i"eres with Icsllng

" l nlnown .

Br.unstem Function

'isual (ur Optic) Function fl. Nomlal.

,

Ill. tr.J(J(ular \\"ealnt'\~.

01

11\".

"Y

,

Wma "uh visual 20{30.

tKUlty

\\'or\C eve "1(h scot..'m3 w!lh I:l1;t\Jnhlf \'isUJI :-rrc~t.;:J) of

Ii.:

j1.~lU-",

':0; lO to .'O/~t), \V(lr:-~ c:yo: w ,th t:.u~'"C ",-tHOma, Qf modcr,!te deere-a."" ll1 flt'ld:!. but With ffia.l>inal .... ~ll.u a1.'Utly t"'\)necli.,,...h t,f DIm to 2(li'1\t,

4, War"

" funCtiollS (r('n~ccI 1982)

(.'c'rrettedl h,ettrr than

)1' fld;,;~ .mJ m~\lmal 'IJO: I!r~tdl'

m~cr(\\

:\.t('dl k~.\ ., tx'th:r i'\'

\.{)rj ..

lnJ 1.,.-,)

uf \

,

fI f" t

Ph, .. iC'al Rt.~habi'i"'tion

816

"i 0 = Amnulatory \VilhOlll ;.iut Ill' n:~t for Joout 2tW) -' t11ctl'fS; dlsahliity 'cvcrccl~(lligh In IInp.uf lull dally

C"rcbral (or 1\f(>ntal) Functions

wOfk.lltll day \\lIhOlil special pro.. VI<.,lon,,). (l1su~" I-'S eqlll\'ah.:nts ;lre one grade S alone, othcni 0 or I: or (Ornhlllatl(1n~ ()llclOi~r grade:li u. . uaUy e\(;e'clilllg \peclficatHl!l5 fllr ~tcp ·HI) actlvilic'> (e.g"

O. 'llmlal I \1Otxt alll~rall(ln only (doe~ not affect DSS ~core). "\ MtlJ dl..'':fe3'c m mentation ,~ ..~hl(kr.al(' J~I..'rea ...e

in mrntatton.

4. \Iafked dl.."C1"C':l<"C' in mentation; chrorth.:: bram ~yndrnme:

:'.,5

mlxkr3tC'. :\ l"kmcntia

('f

chn:mK brain !'.yndromc' severc or Incom-

V 1 nknllwn.

fl.

6.0

~\11lC'

\.ny ,,-,ther J1t'Un'!O!!lC findings. attribu1ed to

J\15 (specify).

\. Unknown. t';..:panded Di~abilil)'

StalUS Scale (EDSS)

'} . 'ormJJ neurolof1c exam (all grade 0 in functional ,,'stems [FS i. cerebral grade I acceptahlel I..' di~hilit)'. rniniIDaI :r.igns in one FS ('.e .• grade I excluding cerebral gnde I \, I < ' No J,sat>rlit). "'1imma: "gn, In more than one fS m= !haL one f.T3de 1 excluding cerebr:ll grnde I). ., {\ ~b~'n:;o. drs,b,llty in one FS ,'one FS ~rade 2. the:> ( ," I " , M,mmal dj,...hlit), in two FS (twe FS ,;rade 2. olh

,,

ers (1

OJ l),

Moderate ..1tsablilty III one FS (one FS Grade I. CIh, en; () 0; I. or mild dL"t-iIiIY in three or j"ur E~ Ih:;:"jfour 1'5 pde 2 others 0 or 11 though fuU~ arr"ulaton F..lIv arnhci.1lory h>t w.th

~(>deraIC di::~hJ!il) t"

r.,

r-r.lde '1 I ..~ one )f !W{' IiraOC 2' or oade \, If 'i.e fS ~r.!de 2 f )thers () or I). '>Ile

4

4~

Anlhulatory \\ Ithnul ~ud or reM for uhout 11K) mders~ t.hsahility '\(.~\ier(' cnmlgh to prcdudc full

daB) adivltlt' .... (lhual FS ('qlll\j;J!cnN .ire one Kfade .c;; alone. othCf'i 0 or I, or cOl11hil1;}tlf,lIl~ of 1ClSer grade.., u'SUJlly exccedmg those for ~tcp1.0,)

pet('nt.

Orher Functions

ttl

IntermHtcnt or unilateral cnnsli.lnt a')~i"lance {cane. crutch. or nraccJ rCljuin.·d to walk ;lboUI ton mcters with or without rcslinJ;!" (USUJI FS l'4uiva!t'nts are combination~

\\'llh more than two }:S gi..ld~ :t+.1 6.5 -: Constant pilatcral 'l~t;.isl'II1r.C' (Li..II1es. 'rutches. or br'Kc.f)) required to WJ!!.. "nout 211 metc:rs Wlthow. re"tll1g. (Usual FS e4uJ'd.llents. ar combm.allun.\

with more than two fS J;ra~c ~ '" I 7,() l nahk tn walk beyond aboul 5 meters C1Ien v.ith aId, ",cnually rcslrided 10 v.hcekhJlf. wheels ",If in \tandanl-v.hee!chJJr and Ir.lll::l:rs alone; up all\! .,hout in "hcclchail"omc 12 ~()ur, 1I,by l sua! F) eqtllvalcnh JrC t'ornhlllalIOn"l. with r.;ore- than ont FS grade 4 + wry rarely p)fan-Jdal gr.de ~ alone, 7.5 l ~"ble tlll.lk~ more than ~ few Sleps. o·... ul1.1ed 10 wheelchair' may need dId In Iran, fer wued, ,,,,b hut "OInm,1 carryon In ,Iandard wheckhaJr • rJ] <1.1)'. may requIre mOlor',led v.hecl..halr, f.l sua] P; equiv.lknrs me \.-(lmbl:":.J.!iun.\ Wtth m("re than. CIle Pi grJde ! r } lUI 'r.",.-.:.ally rn!TtcteJ to lI' ehalf N ambo :I "hr:,,"=. "ut be >u1 oi ~d e:,' mlli:~

-'' ')I

be"

W,: Jay retams !'::r,\ r::i

~u~';:!Of\' \\'1t..~~....~ c~_.

\elf '£:=rrU... IC'nt. up 2 bC".:;, a day dc.p;:" r(latl't~v g of .me r s J!l'ade 4

ha

., lin

•

Appendix C: MS Daily Activity Diary Instruclions A.i (he 10p of" Ihe ~y"s diar,),. dc:scnoc htlw yeu slert the night berore ., 4.'iSI{!n iI nunber ,'alue from t tH 10 ( heir1£: vel' low und 10 ht:mg VCr\' high) f{w • 'WUf kn~1 of f .. liguc (I, ) • The \"_uc ~'r impt~runlo! cf thL' aLlivlly YJU U"(' tllilOg f \ , 'fhe S4ltisf,action ~' ~ u fet'! wJlh ,,"U1 j-erfonllam'c of the tll'li\'rI) IS) Y:~ czn c:.'mrute U1C " \" liur.

)f.m

JL'i\ ~ ry

the' C(')U-"'Se ('If the da'\" for <
My \.olllr;lfing it to olhC:T

, \dhit~: Fhjn~

iICl1v1tll'\

you \.\-'Huld like to do dunng

lunch \tandinA IS minutes (hoU:

Always des...__;;;:' the- ph)slcal \H'n.. done In the .\cth it~ SCfll(ln (e.g•• sloot.iIO shower 10 mmutes. went up ~O ~talrS ~l:-~ 210 fcct . 4 ':1: the ('::\.1ernal tcmp(·rature- ot t.he environment under ,\ctivlty U~ ~ (omments ll~ "t~ symptoms d:> they appear or worsen Juring the day. ,neludmg ~ogt1ltive problems. VlsLlal aln< ",s, di..!Lncss, dragtng fO<'t. pain. numbness. burning. dnJ 50 forth 6 Make notes every hour. Date:

'Wne:

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Appendix D: Web-Based Resources for Clinicians and Patients/ Families Living with Multiple Sclerosis hft 1':/\\\\ v.,. nat ional ms~OC let)'. ori.~ \atlon!!! .\1ul"'-pk .sdcn)~I'" S(X'lety ~\mCTII.:J.ns "Ith Di,apl11t1~:-. Act' AD!\ home pa~~

",etil(';lrt" ~nfL)mMti{ln

http://w'' w, u,d"J.grw/crt/ada hi Ip:l/cl1ls,hh,. gOY http:"",'ww.ssa.go\'

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,\alJi)O:lIlnslitut(,'

l)f

't,."urolr\gic'll 01:-.nrder.;, and Strnkl'

:'\atieoal Library {,.II \ki ,leior !\rdun~~

(\1'

~curoh)g)'

.'cUfoloiO

(entcr\\a!ch Uml1;al Tna" Listlllf Sen ice \cte'.lI's Aff,,'TC )IS Ceoter< of Ex,elknce CL A~I~ Computer literate Ad\".>C~te for Multiple Sclemn Consorti''''' of Multip;~ So CC""ter. Tl'e HC1Jg' C~nter 'IS Can Dr> progr;r ~!.ul('le 'i(;::"'SI' [memallonal fedr:"lltio" \mgen- -d:-I!J -nanufaclurcr of "\ovantrone

http:!.'"'WW rn.'\,.iL-;' ort;, http://\\'\\\\, hcuga, org

' ' 'OS''

llio::-.-= druc m",'uf;r,.;turer of AvoneA

Berle> dn:Z '1anuf3C'urer of HCIJ';cnn r~,·. "<eu"sc,enccl> .erug c,anufa,lurcl cf ("paxn;;~ $<'''00 (;roup- d'1!J runt:~' ""l.!'!:r or Rebif

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http://www,nim.nih.gov h tlp://archnclIr.ama -il"n ,I'rg bt tp :/lwww.ncurolil£y.flfg 111 I,1 J/www.centetwaleh.cum hltl"I1"" w. va,p-'" hI> hltp://www dams org

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hllp: IIwww .l;:sif,org bllr:;;www .mgen,~o~ I,alp' /{wv.-W,r:cv.mtn:me ('Ill t-.!~? I/www.ms...l~tiv:$Ouxe .(.llm l!::'''):.'lwww.lnog'o:- C<'1ll WWW ;lvone, CJm hLr:J[www.OcrJe, <:'In WWW oclascroo.(cnl h!~p: '/ww w Ie.' ..:tncUIt~~·.(..jcn",C'c~rJ httpJ. ww"lIlsw.::.ch.com http:'\\'ww SC;,lOO,,,-(·m hllp: "w'" ". n:bif c::::-, hop: I .VIi....,. \\' m.'iwcd~.nr.,;,;..:_~r-,Unt\...:.!lt..4"''S.. h..~ hllp: "" ;', r'}~' - { leur "" w ~ ~~;:: cr .>(~

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20 lEAl_INC OeJECT I VEI

Amyotrophic Lateral Sclerosis

-----------I. [);:54:n/'lc (hi: epld('ml('~ory. ctioiof\ p>llho!=.Clll''I:;. diarm'Sfo;, .md ~enc~,11 proglw'"is of anlpltrnphll blel.ll ~t.. If'fL'!.:) S (A.t ~ , 2. Cllmparc ;O\J ,'onrra(t Ih(' [t [:;1 .0u:rllliag. Illl.~til ,-.1 rlena fllr A l. S. , Oifh:rentiatC' ilnwr'lg !mp;1innt!nti rc:1;Jlcd 10 .. 1,;\\IC:1 molpi nturf,n i1:1tltol~ g\.' upper mCllnr n..'trmn r;:th(';(l~. and ')Ulbar Imp.Jlrmenls. ... D::><':i1'i.." th: flY.'di .. l1 mJ health urc manage m.:;'It "f mdi\'lduals w'lh \l <;,

S. ()u.tl:ne

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822

Bulbar r~th(llo~)' ~2.1

Rcsplratory IOJp~lIrnJC:I" K24 Cogmtlve Il11paimlCllIi 8N

Hare

be i'aken

~ ~ ;l!!i:

.ind Balance 833

I'illhology 82,1

i!'i1.o\1<\ ..,,, !i..

Gall 8.13

IrnpalITTlenlS RelaleJ 10

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e

Irnralrmenl~

824

01:'::"" '" ('- ''':J ox;

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S."mptom..ttc kLtn':'g:"llCnl 821

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Functlunal SI.Uu~ 811 r.n'rlrnnmental Harrier'S 81'\ htllgue KJ1

: )i ::~.i!.!:e· Spe(. ' fk md Qu.iJl.rv 0: llle \4f".t:tlft ~ H~ IJiooc;ne.Spcclfic \kasures H33 ()ualtty 01 l ife \1 I!:I:~urt:s H."l4

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(,I' [)OI"" 1.1\,,118 8.18

fli r ·lISC \'Iroph·.! ~-S, (l-;.:n:-;c ,-
\M". J bott

Amyotrophit 4th-,al w:ft..rusis

aim 'mplnnI!01'. JU14

Oc~relJ.\Cd MOf'llilt) ~~,C)

I, ne and K-l ;- ~'i K-: (. 1~lal ~C'T\'I~ !nh _'nfl' 84

fttur ni'urlHl ('\1\'"1») nl ,~- - .. ! -,t l:"hr:r-IM .··(t fiJX-r-~·..:~

tc We.alnc"':'1 '1" ~

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(}i~-:-:!se "'lodlfvin~ ~

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M~~~~!enl ~26

DC""'·~-~

hocllon

{','r... ".::.] Mu~lc \\-·C'atnl.."'\.'i W'-''i DY$anhna and Dy,.pha:;'i;l ~36

Progn .::: " f.:l,Ci i j~

Re~plTOIlory

Inregumcnt

Phy",.\;JI Th~l JPy lnten',~nljon" ~J4

OiJ1t'c:,' 874

I!

SH

fllh-'NlV Aolo£v 8,

lmp
\l I). ~ llure '-=!.atcd II Clcrl.lse

[Jr,.' ".

~ell~aliofl

Po"turill Altgnmrlll, <. 'oolrnJ

PrHJlf'lo~y

wlm ALS Ullce mrervention

;: --.:~_ L'-:'",-",,'orl dJ.r,a~e and

"S::.!r

r.: o

lrr.p1.innelll~ ~dated

"'i\~ ldu.::l

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for rchaNj;Ulil 'TI (n

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Vanina Dal Hello-Haas,

h!..t."'l_\'! '\ lllC" Illn·sil.nmm(ln

'!'I f_~ltll n·ntnr neU!,'1' dJ'''''':-..l:" mlonJ~ .b.lults, '"---~I h· 11'1. . ,!~gcIlCJall' '11 wid (,.Ii.) , 'f I1Ul(Cif I elll.! tJl lin I{;'ln, and hr,lul, n·'i.u!fHl1l 11l ~,: I \t'- ' li,ll-lJI uJ:n', ,Ifht \\.IJlPIIlIIl', 1

rut,."., to I <.m"",· 0\1 \

.. 20

Phuical Rrhahditalion

,..

Table 20.1 :>10'0. :-"'uron Di .... rde rs DegeneratIOn 0' tile corticospt;,al trncts. novons n thO motor cortex and brainstem, sOC! anteriOr hom cells in 'he .:Anal ccr.d

Amyotrop/'iC ",Iera' od<:'OSIS

Degeneratior 01 upper

Pr":"'1ary ;:teral SClerosis

motor neurons Degenera!Jo~

Progressive bulba!

~eurons

palsy

fir. Oijressive atrophy

">f "1Otor

do crarial nerves

X to XI: ",L.SC~lar

Adap!Od - pen "","'

L.:.ss or chen-atolysis of mol", neurons of the sp!r.al cord and brarnstem

RowIan, lP

Epidemiology

Etiology Other 4~1~Hi a "mall percentlge of Cd:":CS, ct;ology for the mosl part 5 ~nlmown. [t i~ hypothesized that no \me ~mgre fT1C't..h:..nism, but rJther multiple mcchani:-oms. may be ..~"pon~ihte for ncuror: dege-xratior: ::1 At c;. ' P'--'~~ I hlc )1alhological mcc~anisms mc1;.adc

I. \'upcn..... idc dismwales \(lVs)ue 8 group ,.,f C11rymes j

Ihat eliminate ox}.:tn free rod ... al" that• .uthuugh ""ld, ucts c:f nomlal cC.il mc-~boli~~ h:.r.ve been ImpJIQlcd In neundcgcntrJIirn,There aG'" three is<.forms of ~OD In hum~: crto.w/jt. CO;:ptT' rm J.'lPt';-;'-H~dc li::.mUJuu

,tlnSOD,. mitn{'ro.mdrwl nwn~·;uu·":t" 5UfM'''',xrJe d,}mutase (lll1~O{),. and t.(lr"~ lfli:.z:..:.r !_'IPt';- nolt dum;.,. lu1C ItCSOlh ~ODI • Il= rn 'hr"",OSOfne :1

I(

~ocodc, ( ~ZnSOD. Oe'lCllc studies (f:ullVidual, .. lIh 11
",4.1 .. may accumulate

c;..lL..."J.U1l! t:b.nuS~

:..

J

!\ks~ rmrta·

_=n:

tions Identified in h\l ~ ,~ mu.k-_t I",c in 1I<.1I\'lty. :O ,ug~~ng t~= I:".utrt <;\)0- , pr:~m ma' h:lvC 10'11.. propen.::i I..;lal ,l;:"::~ motor '1ee.'fl:-', ~;;:, d;: L~ rnechac:o-= of which lias HI tu he ·:::r"",~d,

f!.il

1

"

al:;~)

b«n

Ph~-sical Rt·habilitation

820

Etiology

Table 20.1 AmyotropNc lateral sclerosis

Olher than a ,mall percentage of cases, etiology for the mo~t part is unknown. It I::. hypothcslI.cd .hat no on!' ~mgte mechaTli~m. hut r.lther multiple mechanisms. may be re"p(lflsihle for neun," degener.ltll," In Al.~. I. Possihle

Degeneration of the corticospinal tracts, neurons In the motor cortex and br8lnstem, and antanor horn cells in the spinal cord

pathological mechani~m~ IIKludc'

Degeneration of upper motor neurons

prmary atersl sc.erosis Progressive bUlbar

palsy

t- SUflCro.lit/('

Degeneratton of motor neurons of cranial nerves

IX to XII

Progressive f"'Iuscular

atrophy

Loss or chromatolysis of motor neurons of the spinal cord and bralnstem

I

Adapte
It ,estimated that ,(\000 IndiVlduab .n .he Untted States have' ALS III inV .Jne urnC', and 15 cases of the dlsea~e dre ~iagnosed per Except to a verv few areas, ,uch as

day,

Guam and ~'le KII Penonsula of Japan, InQre recent 'tmhes r;>on the ov~rall incidence of ALS ~o be in the range of ,4 to ~. 4 :..:iSOS pc" 100,000, \\ith the ~,ci<'encc ,~crtJ:ling WIC: eat...l ~ o! I'!e untii -.!t !east the seventh ul!cade. ,"';,. prev..! ~ 'iOs,.,- 'M<'SI stud,es have found that ~'lc -"'-se alla" c.,.~ ,h~htl)' more than women, w,th <;;rc::.!:'= ratio cf I -, I' -, howove- after lhe .~e of ~< t~1S gend::"relaled 1II\.J(lcnce ,ic'o~ pronOUJl\.ed.' In ~ percent t:.: _'J 1'=CIl: d ind:vdual, WJh AL S. the di:'" J:""_~ a\ .iL~ Ill!:: >OIJUl.I donunam tr,d , f":<JlIlal "'-l S (HLS,), - .Ith..,".;~ rare ,."', of Juvenile -,n'''t Al lflhenl~ L' d.D ZlutO$om:s1 rec,:-1Slve .:' ~tlern. 0'- t. ''';' ":1)' At ~ ':l~""'S, a~..:x.:natl". 20 percC'tll are tl r nI'",; than 9:' ntu:.:~{)", n SOD 1 I: • gene that the ~:-?per l ~lC. ~llpC;-;JXlde disnlut~~ ell),:le iu/.Jh,)OD). The vcry lar~- m- pr.:y 0) adul: ,nd"td~_ \1- ') hJV~ :!! i":I~~~}' -:ISlOl)' of the dise~~" (s/JOI"ddI4 ~t. 1. ~ 8 ' - ry cn;;~ tll'TCG.; .':-:", d i:~:,,' ,duab " 'lith rp.~ also Iuw. a mUlL!;'>-." L-

(t;CSOD). SOl) 1, a gene nn chromosome 21. encodcs CuZnSOD. Genetic Mudies of individual';. with adult-on'
of thc,e mdividuab have mutatiOns "n ~O{)L however, the pnm.r), gene defect " unknown, Wilen the SOD enzyme aCliyity I~ uecreasro, as has hecn observed In individuah WIth FALS "Jlh SODI mutahorL_, free radi cab 1113Y a~cumul3te causmg, damage' 1'-1(,1 \lost mula·

Epidemiology

OJ.'

(50Ih) arc d sroup of cnl.yrne<;, fhal chmin.:.ue oxygen free radical*;, Ih~H, illlhough produ(:h of nonnal cell melaooli~m. have been implicated m I1curnucgcncration. There ,are three Isofonns (If SOD 10 human.,; c\'Iosolic ('oppt'r·:illc mpt'fo.\l(/e dl,\nlUtme (CulnSOD)' mitoc/ulluiria/ ntllflguncsf supero).ide dismutas£' (;HI/SOD), and exrrarl'llll{ar rupl'roxide dumll di.ulllltOfl'S

rOD' '

lions Id~ntltied in E\LS show modc'it loss ir ~n2yme alt" ity,'" suggesung the mutant 50D-1 prot",n may hJYl' to\i( propenies that (.;ause motor neUfC'ns tC' die the mechanism of v.hi~h ha..o; yet to he- Jctennined. 3 '"I Glutamale, an ex(:italory n("Ufillr:msmmcr, h~ dl~o been IIllpli('ated 10 n('utoticgt'neT3tion. Ex,,-ess glutamat;:- trig gers a C"~,c3de of e\'ents leading 10 ~ell death, 'lncccase;; le".I, of tlutamate jn th< cerebrospmal flutd l(~F), plasrru. an" In JX',!!;'onem tissue ,tmotl:::- At ~ tl""> WJ' reponed and c:tds support I" the theorv cf (\c:", to:\lC~:y (Jt.:smg ~urodegenerJ.~..;cn. J 1. ~ I. (' lumpmg of neurofilamcnt protet~S ",t" ,;he- )teL 'n the ,.:ell body and froxunal ~\(ln 1~; one ,-,f (he! lttstopamolo!1" iC"!1 ,_h...:.racierli:,{'S of At. <) I t"l_ ~ \\,h:"_"':-cr cr nc,c ",moe nml iK~,umulau('n is 'iccond palh:,I"8' He If r: 1o:'~ntnbut(i. 10 motor n¢uron \~ n,~' :dlon ha'S \'c:1 I!. ~

I"

det,"ni~"d

4 'ievc· ill stut.l •

IJ

,'I'

\: ,i!:.ltltn

l 1<

I

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'" p

.t, ".

::-.

It"

"

(1181)«.. ' 20

;\1...1\ hJ\-e not

heC'1l UlIlc!U'!VC.

For (')..Jmple~ a po~t·

tLlun~ ~~'deJ,ed amounh ot cdl
tnl"'Icm study

:.cre deCreased In the motor cortex, hUI Increased in the

~ !..'olumn of the 'pmal J.:ord. n Y . 1131 I have been .thought to l>on~ 1),00hCt potcntialthconcs uibUtt 10 neurodegcncrallon In ALS, whh.:h have limited ar Indirect eviden\:e, mclude cxogenoU'., or environmental (.1ctors. M apoplosis. programmed cell death.3~ and \"rral infections kI

,I

.

~

•

Am~'olrophic Lait ra1 Sd("rosi~

821

O

•

,.0

~,.

.... -'~~'.

oI

I

~~.'" ......

~

'

,

~ ;.;~-.

\

V

p;rthophysiology ~ph!C

lateral ~derosl'" is characterlled by a progresdegeneration and loss of mnl\."IT neurons in the spinal _-on!. bmnStem. and mOlor
Figure 20.1 Lu:c:ol Fa ... B <,tamed ero..... ..,eetlon of $pinal cord at the high ccrvlr.:allcvcl from a patient with cia'1.<;lCal ALS. Marked pallor...ccondary to degeneration of the lateral anti anterior Olrtl4 co!>opinal trad... can be <;een (large arrow .. ). The ventral mots 'V. !>omall arrOW.,) are atrophied. especially compared to the dor~1 root ... (D. f.mall arrows). [From King. PH. and Mlt... umoto H Neuropatholn8Y of amyotrophic lateral sclerO!>.I<;. In Behh. J\1. and Schiffman. PL (cds): Amyotrophi..:: Lateral Sdero";l'j: Dlagnm.ls and Management for the Clinician. Blai,:k\4clJ Publi ... hmg. Ox.ford. VK. 1996. P 205. with penni ...... ion.j

feature of FALS and ha, been de'Crlbed on sporadic ALS, although it is rare. 44 Posleriorcolumn degeneratIOn is mOTe common m FALS. but rare in sporadic ALS.·7 As motor neuron ... degenerate. they can no longer control the muscle fibers they innervate. Healthy. intact ... urrounding axons can sprout and reinnvervate the partially denervated mus4 cle 48 (Fig. 20.2), in essence assuming the role of the degcn 4 era ted motor neuron and pre~erving ')trcngth and function early in the disease; however, the ""urviving motor units undergo enlargement.·'J·~ Reinnervation can compen~a[e for the progres!-ive degeneration until molor unit loss IS uhout 50 pcrccnt.J.tudies have found evidence of motor unll reinnervation in indio \'iduaJ... with ALS.51.~~ As the disease pro~resses. reinner~ val ion c:,tnnot cOnlpt"n'loale for the rate of degencr.ltion. 51 and a variety of impamn('nts de\o'eiop
Denervatioo

HeatlhV

'_r.

i"'~'!,!" "

A

c

B

F'.gur. 20.2 S')fI~ini" t.") ~Ufntal motOl neur<

B t (}f1l('T\la'

Ilj kC'IIII1C'I\'''lJon

:822

Php.i('al R.·habilitalion

Table 20.2 Common Impainnents A"ociated with Amyotrophic I.ateral Sclero.!Jis Muscle weakness. hyporeflexla. hypotonlcily. atrophy. muscle cramps. ImpairmenlS related to LMN palhology Impairments related to UMN pathology Impairments related to bulbar pathology Respiratory Impairments

fasclculatlons Spastlclly, palhologlcal reflexes. hyperrefleXia. muscle weakness Dysphagia. dysarthria. sialorrhea. pseudobulbar affect Exertional dyspnea. nocturnal respiratory difficulty. orthopnea. hypovenlilalion Dementia, cognitive impairments

Other impairments

Sensory Impairments. bowel and bladder dysfunclion. ocular palsy

Rare impairments Indirect and composite Impairments

Adapted in

LMN

Fatigue. weight loss. cacheXia, decreased range of motion. tendon shortening, jOint contracture, Joint subluxation, adhesive capsulitls, pain, balance and postural control Impairments. galt disturbances. decondltioning, depression. anxiety

part trom Swash, M. Z motor neuron; UMN - upper motor neuron,

Lowe!

locally Within a region Ce.g., tlUlbar. een'leaL thoracic. lumbosacral) ~fore moving to other region~, Caudal-to, rostral !!.pread within the ~pmal cord and ~pread from the cen'i<.:ai to bulbar region appears to occur faster than ro~­ tral, tOo-caudal ~pread within the spinal cord. )'7.s~

Clinical Manifestations Oimcal marufestations 01 ALS vary depending on the locatizaLon and extent of motor neuron lo~~. the dl.!gree and combination of L\l' and L\1r\ lo~~. paltt:rn of onset and progression. hod)' region(s) affected and ~Iagc of thl.! disease. At ,)nset, agns or !iymptom~ are usually a'\ymmetrit.al and fOC .1l and pngression of the disea'\e leads to

Lncreasmg numhers and

~eveflly

of impatnnents,

Impainnents Related to LMN Pathology orne ']lost frequent presenting tmpalnlltnt is toc;t1. ~ylll' ·real weakness ~gHlnlOg In the lowel extrclIllly (I r ) or upper extrcmllv CUE}. or weakness III the- bulhar I1lU'i' des. exxurring in a Im.l)t.lnly of pi.U'lcnts,J.1 MusC'lt:! w(al\.' I~. con:.d.ercd the ca.rdinal fjlgfl of ALS ilnd llIa,Y ~ ,"l.use~ hy LMN or I) M"-I ",ors. '11:1e weakness ass()(;I~1tcd i)e'..5

u,ith lY.N loss C.1U~-='.i more Slgmfh. ant dY:iolullctlO1l th.. n ":he l "MN It :;:: ...vcakne~!' .." 100tL..1 nUM; -c: We~kile'iS usual: y ~- JflIi In Iso~':'lC'd

mUSl..k:;" TIC n often distally and is f01, lowed b)' progrc'islve w':'ikness .lC~ lunc: onal limita, ~<)ns, ~ hxr nan-pie. al (m~et ;':'::1 mdiv fJual may not ce dlfficuhY wiT'l fmc I1lOWr n(Vcmcnts. buc;h JS butlonlll~_ mchm, .)r wflting. r 1l1.:;'Y ":loti\:;: kO(lt "rlapplIIg" \il l~cre-4!>eO frC" ,ul'nq..,f tappmg w'lIJe w.l!luH, Indwldwsl

__________

~= ~a.~

_______

with bulbar on~el may notice changes in their voice. difficulty moving the tongue. decrcalo,eu ability to move the lips. or open or close the mouth. in ALS, cervical extensor weaknelo,~ jl., typi(al. ... individuals may imtially notice neck ~tiffncss, feel"hea\yheaded" after reading or writing. or may have dlfti(ultie~ stabilizing the head with unanticipated movements, surh as in an accelerating car. As weakness progres~l·~. th~ head Illay begin to fall forward. and in more advanced stage~ the neck hccomes completely ilexed "ith the head dwpp
~e\'eral ru.e-[or 1ll1paLl fiStlgO!! cvels n 1-"'jr:,~l1t~ ~Ih AI ':t, As LlUtOf nCUlons ~:I." the remauil1£ n"uf\)n,,)( prouII neu; )IIS lfC' ...:IV, bu; ":;:Ih"~ \\c.,J... muSt.lc't Jll~l W,)rk. al a hl,'!he-r l.crce,rage ("f::leir 111.1,111 .$.1 :iotrc"f.~.h'."" ot'-tor~l th ...· 1.l1I1l" --to:: _\liV fllS h.. :-.te-n'i nn-;.d.: faUg u.:"

ChapIer lO Amyotn>phic l - . J !hl

1

au

II

sive capsulitis. or contracture•. Cramps ond lpaltic:lly _ other sources of pain. as i. increased preuure 01\ \be ItiB, bones. and joints owing to immobility.,....

I

Impairments Related to UMN Pwth. . . . UMN lOllS may also cause muscle wealateos. but ia dell>terized by spasticity. byperflexia. clonus. ond pathoIosicaI reflexes. such as a Babinski or Hoffmann lign. Aa \be disease progresses. UMN signs may decrease.,.... Spasticity can eventually lead to contractures ond defor-

mities. as well as cause dyssynergic movement paReI'nIt abnormal timing. loss of dexterity. and fatigue. all of which impact motor control and function.·'~2 For exunple. difficulties with the swing phase of gait secondary to diaIaI spasticity and decreased balance secondary to generalized spasticity are often seen in individuals with ALS.

Impainnents Related to Bulbar Pwthology figIn 20.3 \larI;OO h
ALS _ 6", developed pro~ssive weakness in both upper _illeS, (From MilSumoto. H. Chad. DA. and Pioro. EK." p 52. "'iIh pennissioo .•

FaIigue may also he related to sleep disturbances. respiraII!!)' impairments. bypoxia. and depression. Sanjak et al. ~

that individuals with ALS bave ahnonnal metabolic responses to single bouts of .....iIe.,. Shanna and colleagues found that in individu• witII ALS. tetlInic and maximal voluntary force during . , illed contraction were decreased compared to con.... No impairment was found in the muscular mem. . . or neuromuscular transmission. suggesting that ...... fatigue in ALS. in pan. is due to impaired con~ical and

Q:tion activation.~

As """"Ie fibers progressively denervate. their volume ... '" resulting in atrophy. FasciculatiOll$ are commoo individual. with ALS. although they are rarely an initial OJ I 'R. The etiology of fasciculations remains unclear . . ., Ibooght to he related to hyperexcitability of mocor

0... LMN iign.

include h)'J1
.... 1dIe_.

-..

,........

_ _ _ far \be _

..... Ia AL5

pial.." ill ,....... ....

_ _ III . ., ....

..,.....

11If) . . . .

As UMNs and LMNs of the bulbar muscles degenerale. spastic bulbar palsy or flaccid bulbar palsy (respectively) develops. In individuals with ALS a mixed peIay. thM includes both flaccid and spastic components is toUdbOII.54 Dysarthria. impaired speech. can occur with either ...... tic or flaccid palsy. owing to weakness of the tonpe and muscles of the lip. jaw. larynx. and pIwynx. Initial symptoms include the inability to project the voice (e.g.• shouting. singing) and problems with enunc:iatioa. In opaIic dysarthria. the voice sounds forced. as more effart II needed to move air through the upper airway; ....._ • flaccid dysanbria. the voice sounds hoIIne IlI'lJraIh)'. WIllI pharyngeal weakness, air in the mouth leaks .... the _ during enunciation. resulting in a nasal tme. Aa \be di f

_

..

progresses. speech becomes more difficult ond llllialleHilible. and eventually the individual becomea., ........",. Dysphagia. impaired chewing or ~ _ also

occur with either ....tic or f\accid peIay. M if I " • food inside \be mouth or IIIIl¥iD& food into tile is difficult, ond .waIIowina is impUJed. WIIb .......... bar pal&y. liquids may regtlIJiIaIe inIo \be _ t I: I fI phuynJeaI wealateos. ond \be CIlIIIIt reftex IIII\Y ...... or aboent ,reatly iJtcreasi.., tile risk ttl Individuala with oputic bulbar palsy will ..... •• '.' • DIlled clolun! of \be daaia tIIsI . . . . )f... ....idII to pua 10 tile , ........ zre-wedwillld) I' Ii ":' riIk for . . . . . . ' ... d 1lIIid . . ,t ...... II ............ _ ... , 1 1Ft '

L'.

,1.1.

~.uo;"

. . :.... wi1IIALI I ........ " I \I '

:"=>:>41 eY:5:tVt

82-1

Php.iclll RchahiHtati"n

Rare Impainncnts

Inillllll~.

the IIhll\'Hluat 111;1) tlCgUI III IHltll'C dltltllmg .It llI~hl\~,g .. thc pdh,l\\' l'j \\1;'1111 Ihe nWllllng); thl~ cH'nwally re~luir~~ rt~pc;lIed u'¢ (11 a li~~u~' to WIpe ;t\\ity lhe s.III\,;\ ')'l'uciuhulh;lr ;"Ilt-d, ~I 1cnll u:.(·d III dl..'!'>(nhc IKH,lr or l p.lIlh 1Il1gi l'ill cmnlullUll l..'llOtfnl,fo " \.'llIllIlWnl} s(,ell 111

inlilndu;l1-; \\ ilh sp.lslic bulbar pab~,"'j.4 Spolllalll..'oU' nying 1..1r laughtcr ,lCcurs in lilt' ,i1hsl.... nn~ 01 cllIollol1altllggl.." 6 t-.r ('mot Hm;" rC~l)(\Jl'I..'" arc 1..',;lggt.·r:Hcd. and (lin (lI.:l'ur III It, l11:lIlY a... _~t1l'efi,,:~'lIt \,1 IIldl\'idual s.6oI

Rc~piratory

Jmpainncnts

RI..",l'lr.tlOfV imr'limll·nl~ in ALS art' rciatt'd 10 loss 01 n::-.· plratPI) lI;u~dc.: Mrl'llflh :Ind i1 dc(rc.:a,(' in vital rilpa~ity (\'eL A \'C n.'du(cd Itl )0 pcn.:cnt of prl..·(itclcd IS oft..:n

3S.,ooalcd with r~rlr:uur) s)mp1(lms.tI~ Early slp.m Jlld symptlJm~ of rc'rmIlOf} l11u~dc we~lknt::-.' may 1IH.:ludc fati~ue" Jyspnl.."a on C'I..~nJ('n, difliculty slct:plll£ in SUPIIlC, ~ frequent aWJkcning at night, n,xurrent slghlllg. C\cCSs.,,-c d3ytlme ':oltcplllc~'_ and Illuming headache:-. duc to hYPoxla,6b.fi7 P~llIent' C\[X'T1t:ndng a gradual inl"ft:a:-.t: in respirator)' 111USCh: w{'aJ..nl.."s:-, will not complain 01 rl.."sr)lra· Illl'y symptom-; b(\.-aus(' they tend to decrca,c their overall IcYr' of physical Jell\lt) owin!!, to mu..,d(' weakness in the cxtremitics. 68 Ahhough the de-dine of rcspmllory musde stn."nglh dlffcr . . umong indiViduals. for thc 1110:-.1 part it ttnds tu progress at 3 linear rate,~ A. . weakness progrc . . scs. truncated "J'Ce("h. orthopnea. dyspnea at resl , panu..!o\it:al bre'llhlllg. ac(.'cssoJ) mu~dc u .. e. and J wl..~ak cough are 1yr"llcally c\'idem, A VC of less thJIl 25 perrenl In -'0 Pl'I~ cent of predicted lndi(,:ates s.ignificant risk of IInpenlting rrspiratory failure or dl·ath.t'~ If an tndi\'idual does not f'C'Ceivt ventilatory fiupport, cventual COl retentlun will Ic-..Id to acidosis. coma, hnd re~plrJ10f)' fJllurc- Nl.

Cognithe

Impainncn~

Although cnce: consit.lered rare out~lde the Wl~stC'rn Pac'll u.: regIOn cogn!:ve Imp~lJrments runglllg hOIll IItlld de' _,elts '0 to fleVcre!rontulf'm/1oral dC/}/f"flll (I In .I,ll have heen reponci. A recent large pro'ptClivt "Iudy 1IIIIIIlllh
SI..'!l'.ory r:llll\,ays arc !>IMI~d" 1'01 the 1I1I"t p:llt, In AI.S, Some IIHllvidll;lb mOl)' (.'ofl1plalll oj vtlgue. III ·deflO('d ftCn... ory ~ymptolllS (II p.,re~the'I;1 or loc.11 1':'1111 11\ the limbs.~ Fxtt:Cllal (l('lIl.Ir musdes art:, u~lIally ~rared III Al.S; and If dt:~cnl'ri.IIIOIl fl4..·\.."urs. It docs Ml \;tte III the ("nurse of the diJ. (' .. I\C .)~ Palll..'nts ,,-hl', havt! hccn mallll;Ilned on venlilaton for long pCri(ld, of tll11C may develop the 1I1;thihty to voluntarily do,e the eyes or 0l'",halmop!c·gtl-l. ulInplrlc OCu-

lar paralysIs." Motor neurons <.:onlrolhng the anal illld vcsicourCthral I\phinctl.."r I1lW,,<:\Cs and Inllsdcs oj' the pelvic flunr &Ire generally spared., ~rinary "ymptonls. slJL:h if') urgency, obstmcllve ml<.:tunllon. or hoth have O..:en reponed, "'ug~ gestlllg thJt suprJlludcur control over sympathetl~ para,ympalht.:tic. and ,ol1latic neurons may he ahnormall~

AI.S.'·

Diagnosis With thc cxcc-ptinn of nnl' gcnctir tl..'st. no d..:ftmllve di:J.gnnstic lest or lliagnnstlc binlogi(,JI mar,,"er eXl:-.h for ALS For Individuals With a c1inu: ... 1 presentatIOn of'\l S laboratory studies. FMG. nervc condul-tion veloclt~ (NCV) ~lUd· les, muscle nnd nerve biopsies. and ncur\)lma~lng Mulil6 arc u'tcu to ..,upport the uli.Ignosis of ALS and to e\dude l'ther diagnoses. rhe dl;:lgnosls orALS relllllrl..·~ till.." Pl"c'.\f,,,,t 01 (I) LM\ signs hy ..:llllil.'al, clel:troph)smingil'JI. llr nturl'pJthologl' I,.:al cxamlilatlOl1; (:!) U\1N sij;n., by climC'." eXilminatiOIt iUld (;\) progression of the dls.ra~ withm it n:glf'll or to nth"r re~ion'i hy dintl..·ul e\an\ll1;lllt_'" or VIJ the medh:a1 hl~l(lry; anu thl.." llb,\t'IlCt' III ( I) clrctrnphysH)loglf.:JI ilnd pathulogKal ('vllk·nl't..' of nthN dl'ica~cs that may ('plJln the lJ~lN and 1 \1"1 "~I". dnd (2) noun:llmagm~ c\ ,de",,' of oth~r dl~'asc pn)('csse'\. thai 111~'Y ~'pl.lin the obs(1"\o'cJ (Iuueal Mid Cll~C1rtlphY&lologil,.'.tJ signs, Bee.lust III tht:' "Idahlht), in clu"iI,.';J1 l~i1tt.ItJ;s in dle e.ldy Milge-S IIf t\IS ~H\d the- lack \.)f ,Ihs,,.,tutt" htologll. .J dlaglhhtll..' rnar~{"rs, the \\'ntltf h.~der(tll\."ln l\f ,scuwl\)J;Y Rl'srHlI..'h Cihllill 01\ ,1\10hU (\;clIrcm l)i ~C'''l~~cs l.~la,",II"hed lhe 1-'/ i"scUlIUI (nUn", in t tNt. anl...l f'C\' Ised thrill m Il)9S n I"t~t': Y.'Ide-ly d~c"C'ple,..1 nller'J M(" .,;onstdcreu o;;t3ndJtu lor the diagnOSIs (f -\1\ 1(", (,_lIut~ Pfih:U\,C thC'rapcuw: Iliais. 11Il.! other '~seO;tr..~h purpo:-c" In tllt' ~bstnrC' ;.. t p.:lliu;)uglcaJ CVilk""H:t" the di:lgnosls of .\1 S II d.,o:slrtul Intll l'Ii""'ullv dr/i:",,,_ dillh (1/[",' pT. 'lhlNr ,. 'w. dlly ,m lb : ~ 'hI~ 'nth h:!Jor:;,1( n' ,Wpp:lrI ..1I1d P:"Hfill,lt \.~It~~,,-lllr!o (fig 20.4 ~ A '~,!.JJn('SIS I:f '211l' .1... J;'Il[f ,I.' (kilned as ~)UPI lI~IN alh'~ I \tN tindm&'" In .tt kJ,1 lhr~ ot r ',ur fCJ(ilms (~tll:" _iU C:f\il'.: ,II Ih('r:\\;II,,-, d .ulI1· I)(,.'._Il..rah llr t. ~1~ illUJ l M~ 1':;,'11:: III the:: hUlh.tr ft"gl\~ alld II ':e !~I 1",o \[linal re"~~H:'"'S, \:11111'::: .II'" .,nlh•ltt!';:, \l'

el,,,,:

('hap ..!'r 20 Am~otrophic l..att."ul Sch.· msi3

82.::;

WHktMl8llAtrophylH~JliaISp.11' cfty

Prog_ aver timo EMG/NCY"..,roIrnogIning/BIopo Ne~

r

I

I

lMN .,gns only >1= 1 regiOn

LMN. UMN 1 region

LMN .. UMN 1 region or UMN >/::: 1 region

POSSIBLE AlS

EMG Acute denervation

UMN SIgns onfy >1:::. .. region

SUSPECTED AlS

LMN. UMN

2 regions

LMN+ UMN 3 regIOns

PROBABLE ALS

DEFINITE ALS

.,.f",,2 I1mbs

I

I

kSentilied DNA Gene

PROBABLE ALS LabOratorv Supported

DEFlNITE Fam~ial

AlS

laboratory Suppo!led

Figure 20.4 El E~orial Criteria for the Diagno<;is of ALS, (from The World Fcdemtion of '<."UmloK\, london. lX. Retne\ed \1arch 23. 20m trom http://w,,,,,,,wfneurology.org. \\ilh peTmir.;~ SIOn. ~. tr lbe Suspc-cted ALS calegory wa., removed when the EI E~corial criteria were revised.)

IS ..:iefmed as U\i\ and L\t"'t :-'Igns in two regions. with ieast ..Jne l-M\, finding rostral to the LMN findings. Clinitdlly p."bable, lab"ratury·,upported ALS i, defined as LMN and LM,' cluucal signs in one region only, or l \t'J signs alone pcc!:,ent m one regIOn and L~l~ ~igm der.ned by [~'G cite:f'Ja present in at lea~t two regions. T'le E.\1C, criteria include signs of active denenJ.tion. such as ":b{]atirn potentaals and poslu\,e sharp W:lVe~: and. tlgns of chronic dt'nervatJOn such as lar~e motor unit potentialS (Increased durJ.tion increased proportion of ;:>o1~'Pha~.it.; puenti.:!:;. increased amputude) and un':itable '1l0b1 unit polentlals. C'.nkally poss.ble ALS IS defined ~ "'iN and LMN tHgns found together in only (ine regiL':l. or l \iN SignS found ~Ione in tWd or more rrp'I!S, or LMN s~.;'lS found .-ostral 10 l \is signs und the uubillty l!. estabb!h a di.1,lDosi'i (,·f climc.llly proba. bl. ' ~"atory.~pported ALS .

a:

9

Di!>easc Course l ') ha~ J prO~sslve cilld dctl"ril .ratingjlS(::ase traj(";"tOl'V j ::he Fr; 'grelsi(on from pathology t. 1nlp~\Jmle-nh 10 t ·.n '..1: "--L.l: .mU.ltiClr:" -. t:- dl" ~bilih,-, I: mcv .table '-tthouJ!h .:our leo: L'noll,g iru11VIdual~" \\uh Ii I"

'3th i,jl()2in~ frum !i:'-\c'--,ll month5:, If\

l!)

years. slUdies have found the average duration of ALS to be between 27 and 43 months. and the median duration to be bet\\een 23 and 52 months. J.s.7.80.Bl Fi\'~~year and h::nyear ,uf\'ival rate!'t range from 9 to ~m percent and 8 to 16 percent. respet:tivdy.7J1Al-R~.8J :\. 50 percent survi\al proba· hility after the tir:-.t 'ymptom of ALS appears JS slightly grcntcr than 3 year~. unie,s rnechailical venlliatlon IS used 10 ~ustain hr~:lthing.6 In mo ... t patient'\, death occurs within

.\ to 5 years after diagnosi ... and u:-.ually r~suJts [rom respi ratory failure' (rig. 20.5).

Prognosis Age Itt time of onset h'i" the ~tfl)ngest rel..1tlollShlP III prog nt)Sls. Studies ha\'e found that VJ.lienb' !cr.;s than l5 tu 4(\ years ot dge ul onset had belt,,!, 5· yc:.u f;,ucn\'al rate" than older imtivldu;tb..' "'II.: K4 .• ~ Indi\' ~duah \\, Ilh hm~ l.n.'iC'1 :\.LS have- d ktter pr.>gnO'ilS chan (hClse \Ioilll bulbaH.;nscl. "'year sur.... lV~t utt.·s \\'('1,' reported tv be r; pt:1'\.~nt and 4.. percellt, comp~red 10 SLlf\i 1\1<1.1 r'll!!'!) of Q peCC'l!llt and I fl perC'~nI r;,r r~~tfie,nts WJth t'tulrur,unsct Al SHI' Le!l ,;CVCH! lO\'\JI~emenl pt the tunc of .,jjaS!l('I'Sls... tnn£er mlcn: .. 1 betY.'~11 tJII$.('t illld dl:lSllu"l'S. 40d "t) symrlom~ of dy~pnc!' .. at "nst"t.ue olher fJlltlfS JS>t1rl.:lat~ \I, Ith d I:'Clh.'( vro:;llll~1

.

t;

PhYIi,ic.a1 R"h:abilitRtion

82b

A ~tudy of ,144 indlvHtu;J.~S "'!th l\lS found th4; tho'\tO: lIHtl\'ldu;l1
0.9 O~

limes J;rcalC'1 In those expencm:.mg psyc:hologl(:al cll~tre ;uld the rcl;'lIlOn~hi.p was i~dc~Jldcnt of u!e., d:;-":Jie sevc-. It)', ~1I,d I:ogth of time from dlagll(~\IS. ftteseindm1;1 wCre conhmu:t.1 111 il later "wdy .that found degree of phy Il'~ll lh<;~lhlllly, disease progrc1~lOn. and !->urvlVJt C_ lid 'X' pn..:du:le"d hy the patient's pSYlhoioglCal status M

0.1

f

0.6 0.5

~ 0." 03

d!

0.2

Management "u

,2

24

36

48 60 72 84 9Ei Mcmhs from FIrst Symptom

'08 '20

Figure 20.5 .... .:plan·\11..!'!' curve dC~4,:ribing suo',,,",1 in ·\1 S T1C :1umhcr ('If patients L..nown alh-e III date of flr.1 sy nptnm and ~ \·::.Jl~ n'en'al~ Illrt'uft~ 8~1. 7~8. ~O·t 102. 170. 103.

(,9, (,"" ~

.',

n

(f~u~ ~O·I from 'Am)"otfTlJ'lhll.': LIter-II

:;,. ArJ'C I• 5mith. l al M(1SiCT and 113\ ecri..amp. from

Ptol-'1lO!...5 of ~wrol",i~ Oi~;;;;!.,-s. cd 2. edited by Rando1r h \\' L \.m~. rl LI, ..":Ji'v ,~,ht I~:! ll)()() f\y thf4 rd l nivcnoity b" r~i'iMon cf Odord 1'-:lIvcrsil)' ~:rr.. Inc)

P~Hll""T1t$ ",ilh .\1 S

may receive care It. a vafety vf hc:!~1 care seiling', SpeClo,hzed centers or dinic... th!t 1)ffi\'I!it a comprehcnslve dnd mullldisl,;.lplinary approach to care cor.~ldercd the mll . . t advantageous conslder-og the pro grcss,vc nature \)1' the c.;ease and c;:-ntinually, ch:.":.;jng p;llIcnl s{3tus (Fig. 20.h). '\ reCCQi study \..~mparing a cohort pf pJllt:nts ltte-nding 1 mutdisclplin:uy dinie ,,;:r· SU'i thesl..~ lttcl1ding B ~enc:-.11 ~f'u:-ology practlC fLund ! I11cdill1 sur\'ival of the \1.S climc cohon \\..!5 '.5 month longer th~n fur pallents 1.1 ~"c genc-JI ncurolcogv co/:" ~

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1....·SIpUOUI E 01 Z JIIj IWAlAIIIS ....... oq 01 ~1!lI JO ~:IIp!U Da. II I .staU!ZZ!p JIUII .~ ~ -UOOIlP Ial!nbaJ 1f.'!IIA\) ,u!"!l<0I ~I apnl~ ..... afII pR '.e., ., SQIIl!$ """ 1"IQWI 8w OS ..., S! OJO'!IIJ!:Ua, •• ;; pDpInlS ~ 'S'JV JO _ : l i p JIIj ·1Ol!'1!1P. - ....,

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Phy!tiC'al Rt'hah.lilation ox : ALS

+

M.:lMor body weight Dysphagia exarr.'.r.attOn ....-.... C ';nic visits every 3 nont~s

- ... trums;-;:I

Nlo:rltJ~"'liS.l

or "pee...-"; language patt'<.' JgOS. referral

Mol"lltor

FVCorVC

.~y

...

+

1ySphagia detected

+

Nutrili;:-31 eduec:tion Inducting PEG"

+

..-... C;'-ic vjsils every 3 months

+

I

Symptom prtlQ'ess,on<'

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FvC·,5V'

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High risJ<

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828

Ph~·sicat R(,habiliLtc.ion Ox; ALS

~

Monitor body weight Dysphagia examination .-... Clinic yt$lts every 3 months irSlfumenf8

-+ Early dysphagia delecled Nutritionist or speech, I language patholog!st ....-.. .. reterral Nutritional education including PEGtl

+

Monitor

...... Clinic visits every 3 months

FVC or VC'

+

Symptom progress.o nc

t

FVC' >50%

FVC ' 30-50%

FVC'<30%

+

-+

+

+"

I

Low risk for PEG

I. .

t

Moderate risk

. · -1

".

t PEG accepled I +-

I

High risk

. ...... ~ .. .. . ..... ... . .

.... ....... ....

-

. ... . .... .

--

-.-:.---'~

Experienced gastroenterologist

I

~

•

+

Ora ,ntake as '.oleraled

I

:

Oral intake Palliative IV hydration as toterated Palliative NG feedln9

Enteral nutntlon via

PEG as needed

Figure 20.8 Algi nthm for nutrition management. 1" 'or exampk. Coillr3li<.l DysphaglJ DI'Qbllily .:J'o'f'nt(1) bulbar questions in the A1-'i f -unctional Kating Scale, nr (,ther tnstrument. bRole ouf contramdic31ions, Prolonged meal1ime .:nding m~al prematurely be\.;a.u<;c (,f fatizuc .•\ccderated \\elgt.; II ~ due to ~1 caloric inta1;e, family ~OIK!!7l abou, feeding dlfiil:uiLics, II rorced \' Jal ,,-~r\' U. .\,C·) L"1 \I ... tal C3p"dtit)' ·ve) 1;...10 ~ UW VC may be- mllfe al.- ... :JrJ.te in patients with buloor dvifUOl"JOn OJ\. diagn()sl~; PEt. pe~cuUneous endoicopll- gastr-0'jt(lm~ {From 'hiler, RC" d al. ;; p I ~ c 6. w.th pern1L\SIOn )

:"Jrg wit...~ po!'ilive pn:- s.m: dfld a~s~_"' ( ..:..Jugh with net;'lllv pressure thr )U;;'" the flip "f d sWlte!.. A PCSl~ I'Ve pr:-ssure ath of lilt: W . r. H.O ovu U I 103 : econd period \'Ia

an o;-a)· nasal mask or Ir.>Cheal

wrw~y

s provldod. Ibe .,r· ~tL\' nc- ~ .... re L th~ n:v~ned !~ruptly t~ ;'010 '\0 ~m r.-alflta.med f-'f 2 to \ £i'Cond~;i_ A pea~ exptratory :lUgjl- "1~v. W .lhm nO!1l,aJ 11:-"£ WIt-

range

I:'

alh:;:-\'ed, thereby

~utfitlOn status

ha..,. been Ilten(~f,ed tls.J j"'rof'rlOstir: t :j1;!(}f' ftlr sllI'vlval dIld llis{"~ c..-nmrlkw.Utl'ns. ,., A '\1"Jd)' '-'f IbOO hO$pJ1.llucd pattents. w~!h,..\1 ') fc>u:!d n~ most \"vm monCOO\.lll'(:::1 J!~[.'1OS"i was deh:o.\lt~ukn unJ mJlnutrlt(tH1. r rcstnt If! '6 pcr\,..:m ..)f patJenr':, I Ill!", findin1! ':fl--;pha.'iJ!';!,'\ the need fOf

\" _ul!ful dtenLon to nut'lticn.J.1 an..~ h\,1r.\lIon ~lJtU d:'rr-~ ted IOW.mJ t I

;J ilUlJ

t!--e .. Ie-uran".;'. of boCc:-;: ~ ~r'~

pauen!

u . . h cht"Vo ,! l

!'tu

lIn.rm)J1

Chap.er 20 Amyotrophic Latew Sc:1erooIo

829

I 0IuAL8!

+

Respiratory symptoms or FVCa < SOOIo

+ 1----..\ l

t

t SymplOmaticcare

~I

Counsel aboullermtnal phaae Hospice referral

+

IPailiatNe care

Invasive ventilation accepted

+

~ir..ttory

~1. -kJrc(';i '"ltal ".Ip3Cil), IJY('l Of ,1l.1! ...-~.r\ (\,C) com be used. YC may more 1l'..,:";Jrat.:: in p3tienl~ with Nilbar d)"

flm;::lion. ' Aptt'me11t needed

DiSCUSS withdrawal condftionsb

+

conditions cf .·lthdrawal poor 10 or conc-urrtnl "'1m InstrtU1ln'- mvasJ"'C n:ntIJation (c g .• locl..ed 1 ~ C~i:".!l, ell' ). Ox

fOf

Institute invasiVe ventilabon

+

diaPlosls. ([-rom

L _ _ _ _ _ _ _ _ _ _ _ _ _ Invasive ventilatiOn withdrawn

UiUef. RO, eI al,·~ p I H" with ~nm~'lon.\

the5e wing dlfficu'iliC'S to ...-ause an lu.:~.:l?k:rat('d WC'ight In these cIrcumstance . . 8 pcrcutancou . . t'ndu'l'opic ~1Slr=} .PEG) nu\" be recommended. A PEG I) re omy luhe on ...ned na endos.:C'pic surgery thai ['I('nnanenl ('Ipem~ mto the stomach for (he Introf'lOd. For opllm.1 safelY and efftcacy !he PEG pt\l<%dun: ohould be r>ffcrcd I" the panenl and compleled tal '.lI"3<"1) I VC) faUs belo" 50 h3\"e found PFG InseniC'n PEG were found .f

IS.

..,m

_A. k.., _. ../" b(~ •

InvaSive DtecuM::;alll.a ,! . . vanlllallOn . . (a.g.. dechned and .. ,..... ~

+

Ftgure 20.9 AI,onmm for

t

III Ii\'(' I to .. months longer than those individuals who refu>ed PEG or were deemed ineligible for Ihe procedure. Survival was greatest for patients with a VC greater than 50 J'I'f,'enl predicled al Ihe lime of the procedure ... ·.,. It is importanl 10 Dole Ihal a PEG does nol prevenl !he risk of aspirJtion.1OO,IOI

Management of Respiratory Impairments R<sp".lory· Impairment< place !he palienl .1 nsk for resptratOl,)" tr".lrt infC\:tions. Imponant management con...iderali<>05 include, (I) pneumococcal and yearly Influenza vaccil13tionsM~ (2) prevention of aspmtti{ln~ and (3) effective oral and pulmonary """retion managemenl. Supplemental ygen mU'it t't' u~d \\ilh caution het:au."ie it can 5uppress resplratOI)' drive. ~'J,-'('rbatl! hypoventilation. and Wti· malel) lead 10 hYI":n:arbi. and resptrarory arrest. Jypically. upplementa1 o'ygen IS recommended ooly for ilIdividua15 \\' llh ("Ol\f..llirutanl pulmonar) di)C'iPC or as a comfort meufor p.tttmt~ '" ho dcdine \'Mlilaror,.- support \\ hen VC de.;",-. w 50 PC""'" at pmIicI
no

k_ "" toienIod or iI

d«lsioa I1UbI be nYde beI.deD IIh tnc ............y VIA ~ ... , ..t.n.. I
·'l1li. . . .- •....-: _ _

c

_

.. _ ~

830

Ph,~caI

Rehabilitation

()\\ ing It' the ~mulitlll;,I. """.'lal. and fmallcial ,",unlcn of IV, paue-nts HnrJ f.;mlllicos InO~l lX' (.'arefull) inlnnllcd lll" ,hI.' mUlliple coSh md !"lenerll'- of the intervention. (ontiillllll' fClr w thdrJwal (\f ,'cntllatior. iilfC dl ... ~u ...... ed pmlr 10. or at thC" Ilm~ ('If. m\filllting IV nee-au",,, thl.- patient mil) tx'l.·omc: unable (0 c(lmI1lUnlC.3h.' hi~ llf her \\ i"h(' ... J!o> Iht.' dl'\C~l!i.C

pr:.'gn;s'cs flK.

Management of Dysarthria J»)'arfhria lmpaimll"nh are managl.'d primanly hy a spt."t\.b- bngu:tg~' JXllhologl"'t. Initial . . pcet.::h l'h;:mge... are l/'.U~ ally managed WIth IIllelligihilit) ... tralegle ........ ur..:h as having the mdi\"ldual C'\a~er;U(" articulatIOn or der..:n:asc thl..' rate of spl'ech: and. ern inlnmCnial m(xJifiI.'3tion ....... ueh a ... dc,,:rl'asmg bad.ground noi~. As the se\'cnI) of d)~arthria pm· p-e'is=s.. managcmeQt w.II ftleu ... on decrea"mg tht: pallent"... depodt"th.'e o:'l speech as the pr mM) mt:til(xt of t:ommunic:tiC!. Interventions fir ... t mc2:Jde "Iow-tcch" d('vicC!S. such

using a wnting board or pad and pen for patll!nts With adequ:uc hand functlOll or uSlPg an a1phahet hoard, A pm-grt"S!.IOD is Chen made [0 more ~'high-ted::" de\'h':CS.... uch us ,--::;::puters "ith \·oict synthesizers or single-switch. sl..'J.nrlIl~ t.-~-PUk'rized CO::;-v7unic3tJon "ystem .... I~i .. palatal Wt prostlll!,,", may b< pre,aibcd for indivld· dais WI!''! good articulation but who have a nreathy VOh.:C quali:y or decreased oullness D:i,;3Use of e.'Xcessive air 1(1"':\ t:-.:.)U.;~ t~ nos< The device a dental .ppl anee "esigne,1 to attaC'l ~o the ex. ":ting teeth and to e'.'c\':lIc the- soft palate:; I,.:u;;~m·,nudc by a rrosthodontist It allow'i (h~ ",oft ~:.te to ,-~(""ie ar_)Ur.~ I:""!! surtJundmg stru.;:.tures suctJ. as lhe ph:J:\.;-~ - 'uai.mg verbal communJC'3t1OIl more undc-"'tandable by red"'-Irlg ," e' nun.tmt hype""".1 'pec.h. "owe:-s the hard pz:.::e whit:h reduces lowing spe... ~ to be less !"allgllJr.;.; ,. )Spect,,·e "Iudy of 2~ p,ti
,tuscle Cramps, SpaSlicit) , und Pain ~

phcnywln ... 1),I01nl1l1 n"'''ribed

PiuiClll'i \\ ilh hn~k. widc~pn:au f;ht.:iculatlon c; arc ' gene,. all~ In,uucted to avoi{1 or mll1lmilC caffeme and nlCOli.

LOrillcpam (Auvan) may he prc5.cnbcd to dC{rcase .. , mten'lt} of Ihe fa"~ILulatHln'i.'S4 Dependmg nn the e1IQIo~ 01 pam.
Management of Anxiety and Depression An,\icty and depreSSIOn can greatly Impact a pillient'!.:o1 hi, or her family'~ quality of life CL~ well a~ the ability cope With and adapt to the progres~lve chang~ and tOSSts of the dl... ~asc. Thus, phamla'lltherapy and psychologtc.iJ counseling arc important managemenf strategies lor addressing: the! an.xit:ty and Jcpre",slon that can develop IndiVIdual> wllh d<press",,, may be prescribed an SSRI such as !luD,etme (ProlJC) or sertralmc (7AJJort). illS itnpo. tant 10 not~ that antidepressant effects may 1101 t;;cur for sc\'eral \\('ck, after initiation of the rredicdtions, and !:'I cffcl'l'i may IOciude agitation and insc-mnla. I: the patieD pre"l.!nt'5 \\ ith dcopre.,sinn and IIlscmma or agitation. a II ('ydle antidcprcs-"ant. 'll!c.:h as anl1tript) line F,lVl!~ or imipram ine (Tofranil) I' prcf~"l.·d.~ flt:1l10dia/cplOcs, SlKh as chiortiiazepo'ide (L itrun( ~'I()ralcpate LiiJ1Cpam. and tlurazepam (Dalmanc' ma'i be prt.~ri~d fur anxiety ,Jr for patients Wltl" der-eS\lon an mscmni.J.. For patients whose resoir.uory status Ij, afla:toj, .. Qonhenzodi3Zepme anxioJy:..c '~rh ~ buspmlll< (BuS Co preferred. '.

Framework for Rehabilitation 1"1< ClUNe d "1-'; ""nnCl IJe .It~r
li~"'_1~;:": ~

r

":'!!;'..Hol

cf - 'AI Ih::.: j:-h} .~:;.. ! pI':"

,. .J

1l~~

k'

.~,~-

~

.,Lf

\ 1,· \

8.12

I'hl§h. .. Rehabi'ication

n:t',,,mlllC monitor. ~mcl evaluate changes.

Allo/tJJ,:JU' it'i

some

met!

il~l' dC'l.:::ion¥tnaklDg may be based ('11 the rhyslcal Iher•• pl-'-I"'" [nding~. ror~\olmrlC'. the pal lent s pcn."ent predicted VC!lnd the timing "f PI:G plal-'ernenl flle patient ~ 1~:J!lls ald individual rSythoWC1:11 factors ratc "f .;!!~"e.:..."'~ progrc~slon. C'i.tent and are.. of invotvrnlcnt stage of the dis--:l">e, r('~piratory and hul:-;tr invol\'cmenl that n3Y Impact on the pallent !\ ability to pattlC.pate all need (0 ~ takcn lOtI' at:count when strUl.:turing '.he ;,m!;a1 c'(amma· tit.m, The Iy~s (1f da~ c=~r",tcJ from the ~aticnt hiQory and .ntcmow .'" pre« ,ted 10 C1!apter I \\then eoll
n3lTOW the pp between d ;-auen!'. expeC"",Uons and hopes and ... toal "'penenc, throu~h reahstlc and appror nat • interven:-'on~ . For ex..!.~plcc a ~'oung mother With At ') may mfonc the pb~"c.!. theT3p"~ t",. !)nonty IS ..MUll: for her ~.c.!ren rather 'han rr.:.:nt.:.:nmg employ'nem Thus, the mi· mu!latioo would "" structu~ around ab:~:tles and daled to rather than work.

,,=

~). appropnate Wnlponats of d c->mpreher:Slve CL-':l3!lOO for "" IIJd"'.duaJ ,...th ALS. Howe,er. sc:1CC'."on ;;;·JYs '"ased "" specIfic panenl need. The tests and rr.:= f""l~entl) applic~~le to patient, AlS ude exam1!lallon of: ser.surv (unc" ."usde pcnonn· :mati:.:n. m~r f;.:nc·cr.,.. galt. Lme: o~.al status t" kv:' the ,.:nvlronmenl. and ... ogmllve function Chapters 5,6. 7 ~. I!<. 11 ..' and 29). The (-;lIow,ng ;oo.mts areas rat Iyp=) warrant ."'pM,1S dunn~ !he <>an:na!

=

,,,,,·,1

=

Cognition ItSI
me.

If 1. u:: :1".., fc..'!:. c:..--::1O:)'. .wd !be MC-J· M.;~:.:; 'il

$("(1/('

for example. Pam is lIot necessaril

dire,1 imp'Hnncnt of AI I S.' hut rather un indiroci (drr..:r'- "aJ.ed Ya HO'-'1.. adheSive cap~u~JlIs, of a \.om[lOf'ttc impa.irmem u oint ma.lahtnment sec.<>ndary to 'P3'-"CI!y, I· urt'Jef c. , c~.lmin:1I10n "f undcrlyang CJUst''' of pam 1'\ CJ!len required.

Joint Integrity, Range of Motion, and Mu~cle Length FunctIOnal rang!'! of motion i J{( )\1}, dctlve ncl ive~il).~ISted and passtve
Muscle Performance SpecIfic deficIts oj mu",lc strength, power and endur:uu dnd muscle performance during functiorr.u aclivltie, should "" determined Specific deflCus C.J1l be rnea.ured with manual mu ... le tesli~.g (~1\\l). ookmeltc musele Slren~ tesung. or Mnd-held dynamometry In elim",! Inah, ma ~Ie strength IS c.f1<1 exammed as \l3ximur.c Volunwy !some!!'it Contraclioll (M VIC I usong d SIT... n .;aug. L'Tl",omeler sy'terr.' 'This method elimtrulleS mu::..ie ,en~ .lDd veloCIty as factors "n tcslin;; and produces rcli:ililc '''lid, IIltef'dl 1:!!J. 1(>.,1' M\'I( ; c"rnldcred the 11'.<'; dlTeClleChntCjue for::we..,ugJti::i) motor unll k~, and ~ fleen ned exten"vely hr eXll."'imng ':fuse:': mength m Individuals with Al_~ f", the pasl ru \·ean. It, range i11d i:ivily h;r.~ hcen v~lida:=:' bv 5e\·.....aJ r.l!ura' ~jo~" studies: 'J lIowever. MVI(' testi:;:: req":r., spec~:ZC: C;;~lpnk""t and framing in Its U'IC '" recenl .tudy com.-=red t«t n:liablhtv of ~IMT md 1\11C SC<Jrt".unont cn!!CJr:'J) tramed rb) al .",-era! UlSIitulY.JnS Rcproducl!>thty belween 'I\IT 1" 1(' wa.. f:>u:Id to be tql!:n!=-CI Sc::'.~ ~ " to ~ 1\'; ml......:..-Ie r.l "~Ir. I

~nJ!:th th.:::~""~ I~ L~~:'J;"~":":'·

and i4 r.u .. •

Rc~::r,

•

~'i 1

Psn'ho.... cial I'unction

l\'llIlnr Funl:lion

iT•

.\I. [J

10n(, and Rdl ..

.

• ( 'h'--·f(·r 20 Am"'otrophic Lateral St·)ero,.i"

8,1.1

[ranial !'Iiene Integrity

Integument

TftC' ..,,:' "Il' , ".(ol1nHonl:,- alft',"'led lw ALS mdudc' V, \ ~ I'.,. 'X and .\11. Cranial naves ,hould he Ic"tcd to c~:;mllne the ("xI("nt of hulbar Involvemenl. St:n:("nin~ tor nlOwr fum:uon. phonallnn. and ,pt:'cch prOdw.:lJOl1caJl '~"-lpli,hC'd lhrou~h the mten le\\ und oo,cr\,mlOn. he." 8l~-" Rc1erral ill ~ ~pe('dl laf'!!uage patholog],r ., fCCOm

In 'neral C\'cn 10 the latc .. tage of ALS .. kin mtegnty is rarl"Y ~I prohlem. SIo..in m<,pcdioll ~hould be u~cd to ell.:am. mc I.:ontad points bct\.\-CCIl the hody and ; the sleeping wrlacc. Su{'h m .. pcdlon is C.. pt:-dally Important when the p;Hienl s mohdily hccomes lIl.:rca~l1lgly more licpcnlient. If prc~enl. swelling ~hould . tlso tx>- e\dmined and monitored. Swellmg of the di ... tal limh may develop owing to lack of musde pumping action in a we;1h.encd ex.trcmity.

.

,,-J

nlended.

Sensation If ml." patient ... "mplain ... m-:h'ement

SC"\"

3

of ,c"),ory symptnms or If 'l'n~ suspectet..., '('n,or), 1(""'ling ... hould he

"... 11PIe~ed

Postural Alignment, Control, and Balance lat«. L~ dY'1amJ( pc-stural alignment and be"Jy mechan~ ,_, dunng ",If-can: functimai mobiloty sl
.

duals an Iho <:ely or 0.::1) rIddle

Functional Status Fum.:tUlOal mohility ~klll\, safely. and energy c,;penditure are Imr0rl
En,ironmental Barriers

'rne p~uent s home until week

"::\"Ironr;:cnts ~ould be' exM'l

Ired Jl'r \.Urr.:'I.ln~ pt.:t::,rial bJ.!!ll!r".. ru. .. .:ss. and safe(~

Fatigue

Gait

rall( Je 1:\ \'d)' commo~~ i:- ...:11 '.•V:.duJh Wll~ '\ l S ~ll ,,. F.l~\!." ?\l~.~ ( ••111 ,.t"t:;~:~'

"'S

p;:-~:~c ml:"::'u;~'!t \.t sr; the Fal'!,ut' "("'fF'Y S~(.;'!t'",,· ha.\ ~;-;:

used m , Ii;

IUJ t"

Dis(,'as(,' pecific and Quality of I if, it'asure piralof) :F unction Diseaso."Slk·cific M.,asure. and I/>

----:-:-

.. -,.......--------------------------------------------------------------------------..

Ph,.-••cal Rdu:bilitation

of

and ,,-'-~ found to he \'dlld and rcllJblc for lllC'asuring the diX:,nc: in fUI1Clilm Ih~l results from Jpss of must,.-u1JI '\uc:'!Zi:h. J Thl,; Ai Sf R!; R \\d~ c'(~tnikd t~ mdude lddltiun:.l rn,plrJ1ory Hrms •.lf1d was found t!J have Irtcmal .... mSs1:!l1,. \ ~:f';:StruC~ \'.J.hdlty• .ll"'d h~1\'':: rC'l.llncd the pmj)Cnics of i..'ll.. "'T:: inal ~::2c D Other ,jlsca~ SI)c(';'lflL "'..;~, ,"c1udo ~.o 1r,~(1 \l ~ Seal< : til ~"L' the AL~ S4-l',-r.J: ~('ar f 11. \')SJ. l.I i:r.J Ihe "'or";:> Scull'

,C'

Quality of tife .\Ica
\\1t."! g~nem. mC...;:;L~:S. s~ ..:h .lS the 'if "6, I: the ft.c-hl'dult r E ,-d"C":' OJ r.f In::;..,dual Qualm -f l4( Dlrc'-I ,~t.1Qt:J..

DU ,

I~

and

l~e

S.I-b,es,\ Impact

PI .,1:- , ')/f II. S,I(/ $; \.'0;'1[:.::"'1;

- an '\l<;·speccc qualil) of ,,'~ mea,· 4fI1tcm~ L~_! Icpr:se"lt fve J..stinc! ,ueas of

ltem'I, ",-IJ\,I;es of dally IIvang 110 lang 'Item, I, commumcat"," (7 ;rtlon3.1 funcu;"11:~~ ( 0 ,;h:m$.. ~ que l)

l.&~ '-::;.hen:l' c.:c-fldltion dur:":1g the past :

on," five, POirt 1.1J...C:t c.uc heah!-,

~L!:JS

1~

\/.o,IQ

in

~3\.h dom~un

1'1:::,11.11"

c-f Ih.

l1Ioed i.nd r:portcd. ~1. 'lbe rt(rrd t,[, 11 itt"t::1t:.i!d :':.;.0 &Pjle!Lft'

S tasks. HI" aCllvitics may be adapted to stages 0 I· /\1 .• dchieve funCtion As ,the d,-;case progrcs~s. mcrca'ilnS c nvironmentJI adartatumo;; _ . 0 w,lI be ncccssdIY t(l maintain lOci rromote funcllon In Ihe early dnd corly m.ddle srages of ALS. pro._llla• Iht..~ inh:rH'ntion IS dirc<.:tcd townrd nllnlmizin~ POtential impJl1mcnt~ t;,uch as loss of ROM acrublC. ~;,tpacity, or strength. prc",cntin;! pneumom..l or ntelC!l.ta';] '. and rune. lional limilatmns. BegInning an earty prcvcmic..rO program fTI.!1Y _liter Impamuents ,100 malrrtalfl phYMeJJ function tempf'r:tTllv, nnd may .1,(, .mprove wen-heang and Jecf'case fali.£ue .l'j well .l~ the 5e(onJary effects of Immoh.i,IY In Ihe i31C middle dnd J.ltc stag"", the pathology 1\ mor< .dvanced and mob.lity becume, progrc'SlV mll.pte Ihe effe~ts :)1 the p~tholoo;y thaI lead to impairments In •)ther systems. f'or ~tlm.plc. educ.llin~ c..Jre~!lve~ about a rass,,~ RO:'>I ""erei:;c pwgram III prev:"tll adhe'lve ''P" sul.1G '" the shoulder - l In J!eneol. lhe r,,!e of t.'Jc ph)". cal ther,lpISt Indudes, • Pr(lmotl~,~ mdepcnucr:cc llnd m.a!'!lIZlng hmdloo

the 5ta~es "f (he: dl.~asc thnJugh I'i:<::turrure nd ,-ornpensatory Intener:,tlc'n', that .utdres!!o ImpaU'(peN,. funl.w!.mall,!miIJtipn::.. hr.i1 ('t~s.abL;~:,c\. Promol,"!! heallh dnd we;Ll.,,; an It. r. !,dJle ~tlj!,!,S of Ihe di~:.tse tr.r..)U

1'h;f,lUghout

\'C' '~lIor.

l"-O\,HJln;! .. ltCITlcl!~'·\!' mean" of .. ..1.rn,',"'1"] out 'J::'!:.'t..1f

Ph"sical Therapy Intenention

,\'i.:i:",.; ~.:~ adaplhe eqt:.rf fcr pC'rfll.lmir"-'I '"e.L."i und p:lgr t

,1 ;11::: ... --:'!. or irr\-..:ntlfll.:. .. \-i: -l~! ve l-:::-n't' ~ len

] '\1 ,

<4\,'

or

~....:..:: L:'..t

If for c:.;:-:p:"'"" _n: .:: j "ec 1 .:;. ~I'! ~ ,In", 10 ....., J. ':_

r;'..;:~~~.:!

::::::

O ...UW i : ...

lor"") line" \.... ntiun

r:I"":~-

"

-

lL_~

" '!J ,\1 <, v

:::!·v~

~

C

Chapter- 20 Amyotrophic Lateral Sdl"ro.. iCi

R.l5

Eng l•1nd lunl'tit\l1 ... \..'on::-.. sr:. ~o Ph) ... iGll Function scores and f(lT~'rd \Iral l'~p'Klly (l'\'C) compared 10 a matdled .:0.11111\"",1 gnlup wl1\1 r't'rh'TIlll"d 'In.'tdllng ('xercise's only. Patient; dnd thcrapi ... 1S l11u,1 under-land thai any ocndiclal c{fC'I..""tS of an early pTt'\('ntion program v. ill bt! ,hnrt tl'nll and will 1101 h.I\\..,.m impad nn the O\t"rall course of the dl'1.'3 ..t ' \ ludl mOTe rc ...... Hn.:h 1111(1 thc ellecti\·cnc ...... of mtl'r' n:'nlioll' for indl\ Hjual, \\ 1111 ALS I' nel'ded In dl'\I'Ir'pmg a plan of l'"~rc (POCl. III addition to the ratl~"'nt\ J;ll,lk the tht.'rapl't l11u,t aho con"ildcr the rate of di ..ea"c progfl'~'1011. the extent and area of invoi\'t.:l1ll'nt . .. t.1£t' (lfthe dl't"a,c. n.~'''riralOry and bulbar fal"tor, that Illa) Imra(1 pJrtil'lpi.ltlon. timing of thl' intl'rvCnlion. patient :l((l'rrJnc(' .mJ m(ll1\'MlOn, life ... upport choll.:e,. availabil4 II) (,fr .. )I..'htNx:ial .. urrtH1. and rc ... ourer, Some patjent.-. may \'ll'\\ the need to u...e adapti\'l' clJuip~ ment. 111 ambulatory a....... I... ti\"C' dl'\ice or y. heelchair a. . a Jefmit1\'e mml~ for di,e~'e progn.'", .. ion and impending k.ath. Thl" may 1'3US(' tht: patient to 'he he,itant to al'l'Cpt

the rec·,"'!,:-amended aid or de\ke a... a mean~ of maintaining aspe\..1 of ('('ntrol (wer the dl'ea.,e. The phy ... ical therapist w:.l N- required to mamtam a balance between being 't3liS.tk about what C3Il ~ 3thlt.'"\ cd and pro\ lding a ...en",e of hopt:', not helplessne..,s. \\ hen di:-.cu"ing IIlterventton opt1Ons. An O\'C'I"\'IC\\' (If ALS di,... ea,e ... lage .. and general nteJ"\'C'DtiOC" ~tra1egi('~ I, presented in Table 20,.l Common ,r:':~,.jnneDts and fW1ct1cnal limitallons associated with ALS ta.,::: the',r respe\."ti\'C' mten cot Ion ... are de~cribed below, !=omt"

Cenical Muscle Weakness Pr(-gresSI\'C ..:rn-"cal extensor we~l~e~... will eau ... e the he.td fat: forward. =u.ting I~ o\,.:rstretchmg of tho l""tenor :S4.Jbture and soft tissue'). This may C"JU'~ bouts of Ir. '"";'r develop mto chrOOl\. cerv 'c~ syndromes. and '.<11'

~eir JX'sturc duting amlrul'lion. if r:lcj to mcderalt~ C:I"\'llll we.:i.Kncc;~. a scft foam be \'i~!""" dU!"lfi8 spe'.. iflc acti\'!l.if'). Sc,fr col· 'or....l>le and .·,,·· .. II~· we:.l loie1.lted 110we\,er

,

Figure 20.12 Th~ Ht:anma'-oler ('oUal {( ....!Jf1c:w 01 'i\ [X51gni. Salt Spring bland, Be. Can'lda. "~K (Q

wear-iodu\."cd compressihility (cquues lllev l'oe frl'qul'ntly For moderate to "'\."VC1'C \.',c.lkn:ss. "-

r.~

. ':1I1~~.

11:I5'H:

or rigid coll~ i~ pre~cribed, Th~')e arc !.l5U.,1I Co padded rigid plJ"illl: llr !rather and pr'N!d~ v.... r. port. Patient, muy fand the cullars very """;':,!: -"lW' r cnt.'e disc('Imf
mandit'lle .... tcroum, or over cb\' LCiC'i. rna'" k .. • the trachea; and. may feel cOllfmed. <)C\':'J. lars are presented 111 F I~ures 20.12 Jmi :().. 1 !: .md cons rlf indi\'idua! cullar f\'JX'<; c.:'~ Tal>k 2n~ Some patlenls w!lh 1.1 'mbrned c we».:l1es.Iii may ~nef!t 11'<}m 3. ren

.\

) I

i

j

Table 20.3 Amyotrophic Lateral Sclerosis Di.sease Stages and Common Intl'n'ention Stratl'gies: Fmmework for Rehabilitation for Individuals with ALS

-

. sc.p

Co 7:"11 ~ and ~~

Early

Intervetldoat Restorative/Preventative . a142,169170 • Strengthening exercises 17f • Endurance exercises • Active ROM.'" Active-assisted ROM, stretching exercises

Mild to moderate weakness in specific muscle groups Difficulty with ADLs and mobility toward the end of thiS stage

Compens atory • Determine potenlial need for adaptive or asslstive devices • Determine potential need for ergonomic modifications of home/workplace • Energy conservation • Educate the patient about the disease process, energy conservation, and support groups Middle

Compensatory • Support weak muscles (assistlve and supportive devices, adaptive equipment, slings, orthoses) • Modifications to workplace/home (e.g., inslall ramp. move bedroom to first floor) • Wheelchalf prescriplion • Education of caregivers regardIOg functional training

Progressive decrease In mobility throughout stage Wheelchail needed for long distances; rcreased wheelchalf use toward end of stage Severe "'lusele weakness in some groups; mild to moderate weakness In other groups

Preventative • Active 172 actlve-asslstive, and passive ROM, stretcrlng

exercises

Progressive decrease In ADL skills tl'roughout stage

• Strengthening exercises'''''''.' "0 (early middle) • Endurance exercises '7 ' (early middle) • Determine need for pressure-relieving devices le.g .. pressure distnbuling mattress)

Pall'

Late

Wheelchalf dependent or reslncted to

Preventative • Passive ROM • PUlmonary care' • Hospital bed and pressure· relievlO9 devices • Skin care. hygiene'

bed Complete dependence with ADLs

Sev€:e weaKness of UE. LE, neck and tr,nK

~\J~es

Compensator y

~art!"ria, rysphagla

• Caregiver educalion regarding transfers. posrtioring turning, skin care • Mechanical lift

Respiratory compromise

p&:, ~!;'I 1:

bE!

r:-:.::;ratwe.

~7.!:.::: '3C:l~ :iaas. v, . IP ·23, wtth parn

ADL

~~~;ties,~ daily tivrng: ...E

upper

s:.::m

.,}wer extremity: ROM

eX':.::;:~niti

range c: jj."",~~"';

""';:::: "',:~<,!-,lar . 7!InoDilozcr '''OMI). Th

,r-

bUI l~:

me re expen!:.. ""o!'

1 i.-' ..:c~ and

"·~rr:. ,,_::"! • a~f bc.'. ,~,

t\,tf

r'(: J 't!"\'

I'll U:"'O:

~_:-~-:';;:1'

oA-': _ "!!'l~ \.O~. 1:''&, t!

) ~Ilt.

,.

fit

,divl'.!;..::JJ w

I

f"/ •

for p!""o!.mb':-"~' I:

!!'fHwJ,:' p.rcper u )~ I-oe.t( rest \\.-;~:'~l fi'~ a ,~~ lind eii'.(ni~mh.· ",han r l\"crk c~ntC'rs. i! S ~r' Jr.', It n,- 10... lh.-U \\' •• (rum;. We.l.t.ne-:-:, "ft,.. ,.r;!j"""1~'" k W ;L.I~~ .~:', (:"!..)~;:tr n;: fflf h(;.td !,UPI'W'rt ,-,: ..-.'j'lt"

~

th

h.illcn

F_

I)y~u llh ria and D ysphilgill n ph\

.:: :.!,":) • ..,-~.

WI!...:; I..

..

,

lar._~'.:_ I!~

!!}",t;:~£·"". :n' .:1:11' IC·

j!

(~r:.l

Chapter 20 .<\mlotrophic I ..teral Sclerosis

8..,\7

of Semirigid and Rigid Cenical Colla" ...<_~< .. ,." .:.-:" ."...-:.:r

c;ouars W11hOUt

Collars wlth anterior

traCf1eOStomy)

'I'I'~

. :-',. ;1'

,':-,

-''::4

Philadelphia" Collar'

Offers good support

Patient may feel confined May cause pressure on trachea Patient may expenence difficulty breathing or swallOWing Can be uncomfortably warm

Mlaml-~ Collar" Aspen Collar'Malibu Collar'

Padding absorbs and Wicks mOisture away from skin SUitable for individuals With cervical weakness in all 3 planes

Patlent may feel confined May be uncomfortably warm More expensive

Canadian Collar8 Headmaster Collar'

Open design allows for circulation of air lightweight No pressure on trachea Some patients conSider collar more cosmetically appealtng

May put pressure on chin and sternum Some models more expensive Some models require custom cutting Not adequate If rotalion and lateral flexion weakness IS also present

.meliOr neck access

nee« access (for

;,ifarj,'i )(

- ---

Cerv'..:ll Collar Co. 1'>orofar•. NJ 08086.

'Jerome MBdtcaI. Moorestown. NJ 08057-3239 'Aspen Uedtcal Products Inc. CA. 926' 8-5202. '5ea!!Ie Systerrs. PoulSbO. WA 98370. 'Symme,nc: DesIgns Ltd. Satt Spring Island, BC, Canada

.1ysphag.,., by addm;sing the patient', head and trunk ..::lntro! and po!.it;P..r. III sitting In addition, the phY-'Il'al merapl!t ~ar. rC',mforee the use of strategies fl'r eating wanO\l.'inJ! and the use of prescnbed commumCd· WL~ the pat,rnt Because patients are at fISk f'ur aspiratir,c ~Lltion ,:f the patient, family, and care

Imperativ< (see RespuJtt)ry '-1usde \\eakne.

DE MuSC'le Weakne!>s

rhythm ~et.:ol1dary to -;pa-;tit.:ity or \\cakness causmg imh.tlanc-e that may l~aJ to 1I11ptngement; overuse of strong mU"ick'< mu-;de strain: poor resting position; glenohumeral 'Subluxatinll ,el,.'onuary to we:akne~s; or a fall. Dept!mhng on the cause t'f the shoulder pain, mterventlons m3Y mdude nll.1dahlles. RO\t exerCIses. pa~SJve ~trt'"t\"hing. joint mobilizations, and education about proper Jornt suppon and protection. A recent repon de.cnbed. 20 percent IneldaKe of..n..,sive cupsulilis m individuals with ALS, Rei.:ommendation fur managrng the pam and decrea..ed ROM rnduded a protucol of an intra-drticular analgl..---Sic and afltHntlammatory t.:ocktaJl in.}Cdlon, (olklwcd b~ a course uf aggrcsSl\'e RO~1 exen.hCS. 'Some l).ltient~ rept"lOeJ M u,,'ulc rc~llution (If pam, whIle uthe-rs rc(Xlfted Improvements n\"~r ~ to .~ w('t". ~,," _ &01

Relipiratory Muscle Weakn_ Wrist or 'f

",t"\lht.., 10

Shc..'lcIer Pain

10

r'.;t·~l

IT

-

"

,\8

Ph\ll.ical R('habilh.atioR

II' ortimL:c Vl'"ut.LbtH'Il/rcrfllsl('In O141I(IHng may ubo be InCnlr".of..lt{'J although thctr cffectivcnc~s In i\l S Ita" uol

~('n JetamUlcd. \lfW.,IY (kar.lll.,:C h."'l:hnil}llcS Illa)' be ni.~'(,~SJ.r.. when I,.'om.lltlon'i that cJ.mC ...("('rcti~)n J'l'tentHln. sc .. h as pneumOOlJ or ,Jt.::h:ct':ISIS, ;Ifise T;~' l'(Unrc"l5'o.~t(' CdT .I "e.'lK=llCd c('lUgh the patiC'11 ~md c.,JC£', veT n-a~ he mstTUC'led ;n Ihe use of IllJnually assl~l('d coughmg. tcdmlqucs tJT f'lcl'ilaOl('al I.nsuffl.ttlon---e\SUm" '; ,{In. I\t!~'in. lht etl"""tIvenCSS ~Jf thC'se tct.:hmYl1l''\ or (k~\lk'~ '~~ "u..4 ocen ~mnnstrJtcd In ALS, hut c:t'..;e report-- have ,:lcscctx-d ',he bcTlCflt:'. from leglliaT u"t.' of i.l Olt.'dunu.:ai insutllat on Je.\';cc I-~' -16" "cccnt ~tudy oaminillg l'nllgh now~ .mt.' prC'!'surcs JUlin£ l't1ugh auc::m~ntation found manu:.:. assis:...n~c incre'lsed f.l)W II pt.'Tl'Cnt 111 hulbar and I ~ pe',.::..,t on oorbulbar AlS patient ..... and \lI-F In\.·n:a~('d ow :!~ ~ent n hut~ md .2~ pe.rl'f ... t In n~mbulbJr ALS I;Ulcnb. TIle i.:-:'1.::st Imprc,vemenh were In pJtient-- wllh he

\\"';-,1);.::;'1 ... ,)ughs

LE l\1u~de Weakness and Gait lmpainnents ();":.:.""",,:;~:.:;

rel.ommc-ded L,r Impron" func':,on hy to wea1:.:--ed "lu ... de . . ;lnll the Joints ~.hcy :~~d, det. -1SC the !'tress 'n rcmammg functloOlng Jr ... _. ,.~-n:-.3.tory mUSl.ies. con.~ne '~('re:y. or Truntmizt.~ local ~ gencr~ ~!lSL:e fatigue l'ontrotling knet" Impi:nncnts (.lIl o~:en be t.U. ~Iev~ thnu.::h an .mkle orth(l~;:s . .lnu thu'i ankc should be co:-'sldcrcd firsL It IS aIs!) <"",.;\e' the "eight of the onho,,; «, mdi> Id " ....:1'£.-" ~'K.~~~~ture 1S.:-UC'S, and n ;-~ f. ,r t"!~ pat en' t::: amnulJtc with j. 10 anlbuUtc without the unpalmlc ':1 CIi' reason. l Ic-ec .mk Ie f""t cnh<> tr_)' f"C

hut the r,lte 01 lh~ca~e pf()gre ... ~ion should a\';" he consid_ ered hlr all mdi"ldu~'1 with rapidly progressive ALS and who l"i likely to use the orthosis lor limited lime. a pre· m;lIluia"tun:d orthoSIs m~ly . . utflcc _ Sohd Jnk.lc~fOOt llrthoses (ArO,,) Me a good (hoice for patients v.ho have medlo\alcTitI instability o\" lhe anklc with 4uadnceps weak· Ilt..... s. The Ihell anldc position, comhined with the yuadri· ccp ... wC'l\...nc"''' may make it dillit:ult for slt~to-stand trans· fers. dimhillg ~taiT"" and ncg(ltiating inclines. Hmged AI;O~ allow dorsiflexIOn and may he appropriate for the paticnt with adcquate knee extcn"or "trength with mild ankl~ :-.trcngth lo~ ... _ The Iype of ambulatory a"si'jtive device preSl:rihcd i", d~rcmknt on the degree of pro'<.imai musde strength or lO~tahi1ity. function of the LEs. the pattern. extent, Bnd ratc of disea~c progression. acceptance by the patient, 3nu finanl'ial constraints_ Aga1l1, weIght of the lhr-vice IS iln lInport~tOt factor to con"ider 10 dCl:i"ion makmg, while al . . o ta\"'ing into account \Iy'hich deVice will fn~ure optimal function and "afety. \Vheeh:u walkers. which do not rClluire the palient to lift the device. are usually recom~ m~nued. In general. crutLohe ... arc rarely used by indi'lil.duilh with ALS. If usedo LofhtTand t.Cw3dian) crutr.:hes are

0: .: "...:;! WpflI·,rt

,men~

uf31tured ' OC":'SUS ~u:-:l!Jm the palic-t \ resou'

",";t)

prcfcrn:t.l.

Activities of Daily Lhing A large \ariet) of adaptIve eyuipment 1S available to d"slst II1lh\'1duab \\ Ith mu . . de weaknes..; perform evel')Jay t3!-k ". Hov. ever, the ncneflt" and effec!J"encss 01 adaptive equipment for ALS have not been evaluated S)'S' tcrnatiC"Jlly. ~o one t) pe of deVice IS SUltJ.Ne for eo."tn' patient (lr '-or everv -aagt' I.lf the di~ase. RCi.mkusement I~r the equlpmc~t IS vdTiable and ':!hou~h J piet. ,.{ ild3ptme l4ulpment "an help the patIent m:untam inJe pcndenl.e. Hr.ited fin:.l.,l.ial n:sour... .:s may prevent retomr:cending (,T pUl\.h"".:1g the i:::r: (-0' tumple. m tlI<

Table 20.5 Commun T)pe!l of Adapt"" Equilunent Feedl"g end Eating

F-am tub!"1g to .-crease the 6.Z9 o! utc~sll ~aPdles. I..te~lj und r~?8 WI'" modified h.!"
[)yearnSeU.ca,e and BathIng

E'lI\h.-g bet>

-

Other

ana

&eat;

bars;

... ~:-. Vc:'_;J

Dressing WrItlng

mi.~~

~ -:.'~f j',ealt ; \ifi"lb £:: l.P'1 ~J

clIng -~

8J8

f'hYJ;;lcal Rl"habilitation

10 0011r.ii/.e VC11t~l.1ti("'n/pcrfuslon ';natl'hlOg may Zl.lso he "ncori"!:r"r-.Ul'
when (l'n(hlinm.

i.!lal ~.lUSC SC(.~·.cticn

rctcnflon.

c l! ], pncum(lOlJ or ddc(tJsl~. dnsc 10 ".~'-r;qx7'.;;..;te lot a w:a1.:.~J cough. the patient and v., rr.:.:, be :nstl'uclcd ,n the d.'liC of manual I)' a'isislcd

~:"'lng IC~ '1n.c;'Jcc. or

tnt;1.. haru ... .al

ir!siJfflatiC'n <: \su ma-

~-,n A~am. the cffectiv, r:':ess of ~!l()C tcchnu.;ucs or devIL: hJ~ not been ,:1e'1l('ns-J.ltcd In \L~, but C~ rC'p«Jrts have "ltlCd the ocncflts from rt:£;ular usc of a nle~h3mCal n!Ouffialion Qvu.:.: ~ . .a6 ,\ rt'("cnl ~tud)' :,Xammmg (ough !o\'\,-~ lII'.~ ,-.~~.;s.;;~ ..::ur.:..,!! cough augmC'lltatlon found manu:: assl!..tam.: ncrc:.s:i flc'w 1 ! percent In hllihar .1I1d \ ~-:-~cnt lr 'lunbul!:tal At ~ r~ients. and ,\11- F mcrcao;ecJ Cov. 2!l percent in hu:bar and 28 pcrcc:1I in nonbulbat A L , _ ::I.!I1B. r1C ~reatcst L~nprovements were In p~tients with ;:,e w-.:k:st ('ou~~\. ;

lE Muscle Wealmc'~ and Gail lmpainnents omme:,t.:~ to impl.we furn.tkn hy

uppo-t t- w~-:L~,ed muscles lnd the JOints L~cy decrease the strc~~ on rerr:ainin~ func'tlomng or :m1p:n:.at(Y.'\' mUSl·les. cono;eno: energy t"r ;:1l1mmize locJ.l r general mu:~k' fali{!ue. Controlling knee Imp:umlcnts 11 o~·cn be at:hlc\'ed through hn ankle urlht"Sls . .lnll thus :dd! ~ :::':"":1 t~e anUc ~tlUld be considered fihl. II IS d.l~(l ·~r the ,,,.ctg:ht of thC' ."mhos;s as l.ildlVldI ha\"C -lnerg) o..pcndilu;"'C I;;'SUCS, and It u.nl; for "'!le patic;:t to hmbula:c with u :!1 to ambulate \Ioithout the impalmlC'Tlt ! Jr thts rc~:m. a ~r':'- ..:nkle- ft."lOt cnhoIlv ~..Jt r __ ,-mmend('d 'hJ >< ., il ""7el11anufal~:Jred v~.a (..Jstom Iy ckpcn&.:tlf "" the IU..lf.:-nt ~ rnourcc

bur .he rate of (hS.C;1se progression should also he consid· en:d. I-or ilil mdivldual with rapidly pnl£feSSlye ALS and who IS likely to use the ort.hnsi·~ for limited time, a premanut'actlired orthOSIS may liuflicc Solid ankle-foot onhoses (AFO~, Jrc 1.1 good ,:hOlce for patients who have mcdiolatcrallllstabliity of the ankle with quadncep~ weakness. "I he faxed ,mkle posillon. com"'ined with {he quadriceps wedk'lcsS may make 11 difficult fN SJI to--stand tran,fers. clllllbmg stairs. and negotiating tnclines. Hinged AHh allow dorsifleXion and may he appropriate for the r~lllent With adequate kn~c extcnsor strength with mild ankle qrcngth loss. The type of amhulatory aSSI"lIve devh,:e prescribed is dependent on the degree of pro, im'll mUicie Mrength or mqahility, function of the CFs, the p;.lttern. extent. and rJtc of dl ...ease progres"lon, acceptance by the patient. nud rin~U1Clal com.tramts .•\gain. wCl,ght (If the deVice IS an import~lnt factor to conMder In dl!CtSlOn makmg. while oliso taking Into al""':Oum which deVice VilIl ensure optimal fum:tJon ,md ... afety. \\'hecled walkers. which do not re4uirc the patient to lift the uevice. are usually recommended. In gencral. I:futc.;hes arc r..trel~ used by indiVIduals WIth Al S If u""d. Loflstral1ll (Canadl:l!l) crutch", are preferred.

!.!.."T4)und.

Table 20.5

(ommon

Feeding and Eating

T,,,,,, of Adal',iH'

Activities of Daily Lhmg '" larp..: variC't) of J.oaptl\'e equipment J.::,. dv.ul.1ble to Indi\iduals \\ Ith IllU"icit: \\'eakness perform everyday tasks. Ho\\cver. the benefJt'i Lind cflcClIveness of ddapllve cquTpment fN ~\LS have not heen c\'d1uated sys~ ternatll.ally. '\0 one type of devlc,: 1S sUlu~le for e\'cry patlenl ('Ir ivr every s.1Jge of the Jlseasc, Re)mbursement for the eqUipment IS v'lfI.l.Ne and ,"a hough Il. Pli~\;o; of ac!J.rti\,: cqutpment c,m bdp the p:llien~ mJJn!.4n mde JX~n~cncc. : i,mlted fmanclal Tno;..r:::-s rna"" prevent r:commending ur purChaSL'lg the l~cm, f-.'r c,aIrple. In {hi ,lssi~t

Equiplllt"nt

, '>IITT1 tub!"lItlJ Increase t~e lize r I utDr.SII ~.mj!es; u!C!1SilS and cups with modllled t-andles t')r holders, 1Orr; levered jar t..pe:"cl'" plate guard: sent~"j 0; rc ,~ker "",ife" wrist Of.:'n~·~1apt(j cuff lIor holdicg lc·~I~ and 1"1Slrumelts): mobil, ..:m support [)YCerr:""

SeH-care and Bathing

Bathing henche"J., bat!" tU!~ seats; Gt'~ ~-NeJ CC~:l4":!te' handt·e~,) thOwc: head; gr~b bars r t~avc' litrap-'Itted

Dre:;$\ng

m; VJ.

Writing and Reading

A

"es

, nt,i\1ef"S

Other

F

ctdl;1ng C

--,. "z'W·

___ _

( .hapler 20

Am~! ot.rophi4.· Lateral

Sclerosis

839

('arly 'ta!!(.~S \If ~\1 S J l'llI\cf";11 I.."ull '"'-1111 a l'ol.."kL'l 1m \\ritIng nr 1(.'t.'dlllg uh:nSlb 11l~ly (-\1..' llt:nl'rICi~\1. A" Iht.' di~L'a~C' pro~rl'sses .lIld pro\.IIllJI ,Iwuldn ,",-C';I)..ne:ss 'IK-n'!l'l'S, .] n}l)hll~ unn "UI'I'(lrt ma~ ~ IIll'()rJ)nrale:d 10 tht" p.tlil-nt III maimaln IIlliepcndcncc III l'atillg. In

Jill'\\'

the ttle 'u~C' {ll Al5 whl'n the: patient is depC'ndC'1l1 on Ihe c.!f~gl\l.r f\)f eat mg. ~I long "Ira,",- and !'.lrJ" holder m.l} N fl'c,'nutlen(kd II) a."S ..... t thl' (':o\Te:gl\'C'r ~ ilh Ihl.' i..II,:tlVII) E\.;lmrlc:~ of adarlin' equipment lh<.lt may he bCI1C'ficial f~

pt"f'fom1ing

adl\'ltil'~ of

Jail) hYIng arc prescnlC'd III

Tahlc 2(1S

Decreased Mobility POilll' t~ \"th LE wl..'nk.llcs" 1Jla~ have diffi.culty with Sit-to stand or CJr transfel"''', Simple intervention!'. includl..' placing a tim (.'u"hwn 2 10 ~ Inches IhKk. unda the bUlh,X:k.~ III the cil:..Jr or ele\"afng the (halT hy placing: the kgs in prcfabric!ted hl(l('ks .Fig. ~O.14). Self-powered lifting cushion ... are relau\'ely mexpensl\ r: dnd portable. hut the individual ~s Jd~quat~ t:1lnk control and halam.:e in order to U'iC the device safely tF;u' 20. S), Powered scat lift reclinci :'1;:.::-5 may abo t,e recommended, hut are more e\.rcnsivc 1\11 these 1OlC""\'entions ,m.'Tt'a~e the hlOmechanical advan· ~"t 3ll'-1 mM.:! .1 easIer for the patient to nse from a ... itting

posmon. (~vers w_:I need to he educated regarding " ...... i ... Ullg lhc ,::tint with trans~tlonJI movement<.,. Transkr hoard ... may be u-\ed f~ :r trans!""crs once the wdividuJI IS unahle 10 t..::...=d, ellher alonc 'f the pen.on has adtXluate ann ... trength L....j good slning balance. or the carc{!ivcr ~an be lIl"tflH.:tcd .:l bO'w t:J aS~lst the patier'lt. Orner useful dcvir..;e~ tc, assi ... t the patiaJt' '" mobility ~re transrer belts and SWivel ,'u"hinn ... - t:,;.;t .... fransfcr "ellS c.:.se tht' burden of the transfer i"0f the c.an."tiver and a:revent pltenLaJ pulling un the p3lienl'~ l 0 , Swiv~' ....::!..:!wn~· are ,t:tVo'':lghl ~I.lshioned seats that '" -::. L" both direcoru. .md maJ<e gelling on and oul of a ::reaslerffu.!. ~ I 6).

F

·a 20.15

:'-JIZ

j

1;_.1 II It:

i>:;:~-:

It

Figure 20.14 Pn:-fJhril"aICU hinds tCOllrlC""Y III" IIGme(rafl AhllltyOnc Klrkhy-in4A<..hticht. r-\ottinghallll
Once an individual cannot pcrfonn

tral1~fcrs,

even with the a!'.!'.i!'.tance of a caregivCf, a hydr~tUlic or mClhanicJllift is required. Commonly rccomml'mkd lilts de\"il'cs incluJc the LhY PiVO(M Obnd-Scot Int:. Fort Collins. CO X1I52-l). and the Hoyer Lift* (Sunri ...e Mcdil'al. l..4l11£l1llll1t CO X()501). U...t' of an elcctril: hn ... pital hed nwy fai,:tlifJIC hed mobility and Iran~kr~ both lor the: patil.'llt i.lnJ c.tref!lver and, dc:pl..'nding on rCS()lIrl'(>!'.. home ITlOdllkalHms IUld automohile adaptations may also he: ulll<..ldercd Chair pi ides or stairway lifts l'an he suggested for those iIldhidual, v.ho live in O1ulti-Ie:\'el home:" hut who fo.: •.IOnot or ... IHlllIJ not climh stairs {sec Ch3pler lolt These 11ft, nrc mCOl~ured and l"u'\tommade for JlHltvlduJI stam:.l3.:
840

1'1,~'Sical Rchahililation

featurc~ for patients who used pO""'crcd wheelchairs IIldudcd II1dependent mobility. m~lOeuvcrabJIIlY, overall comfort and uIHn-spacc/recline fC:lturcs; undeslrahle featun:s- included low, nonreclinmg hack, hea\'IOcss or large ~Ile. uncomfortahlc seat, nonadjustahle leg rests. and genlJlI eral discomfort. Although power ~cooter~ may he suitahle for a patient wuh adequate U E and trunJ... ~trcngth in the earlier ~tages of ALS, the vehicle becomes limIting as the dl~ease progresses and \hould not be prescribed, If the patient ha.') already been reimbursed for a sc.:oott!r. must insurance companies will not pay for a power whcelc.:hair. because (he scooter is considered a power mobility device. If a scooter is to be recommended at all. the patient should rent or borrow the device for short-term use.

Muscle Cramps and Spasticity Figure 20.16 Swr.. d ..:u~hi"n, (Courtesy of Sammon .. Preston Roh'3I1 Cnnada. _'lissisiauga, Ontario. Canada, L4Y 4C5.)

As,oclation (\10A) chaptc ..... may have lifts that have been rec\'cled.

:1\1 some time point as the disease progresses, the extent

of mu!>c1e wcaknc:-.s or the energy requirements for ambu~llion \\";11 nece:-. ... itate wheelchair use for mobility. In the earl v or earlv-middlc ,tage of ALS, a manual wheelchair, preferahly lightweIght, may be used for traveling long dis-

tances as an energy con~crvatjon technique. This wheelc~alr should be rented on a "hort-lenn basIs or loaned from a '.001 Al.SA or MDA chapter or other source, as most mSllrance companies will reimburse for only onc

wheelchm purchase. As the disea ... e progresse .... a power wheelch:;...r system tailored to the patient'~ curn:nl nccd~ ..md pltentjal future !1eed'i will be necessary. Numerou~ custonllzed wheekhalT features dnd option., are availahlc that can d SSl!::.t the individual in maintaining a maximum level of iodcpe~dt!nce und c.:omfor1 A referral to u \\ heel chair md seatmg clJnj~ lIlay be the he!)( option oWing to th: numerous. :tipec~.1ltted, and evolving needs of the imhVIdual with ALS . Tm:1 .m~ ..:~Aleagues surv"'!yed 42 patients wilh AI.'i and moder.!tc ....lsatllity. d S, joclllTlt'nted 011 the AAJ S. i.lhulil

the w'lr.elc~alr fealure~ they found roO')1 bCJ\efl\.ial ," iiXfy , one percent )f pallenls repc-rted that IhC'lr whecldl
weight frame . fi,malltuollng radIUS, hl£.h rediOlng h;'lf.:K dnu UrpOJ1S r: ~r tl';: h-at~. j",;""Jllk. and CXIJ'!"mlll,es j ... IlUK,l de-Sir rolf'; ur-.::1e:"lToibIC fC:lturc -; uM.. luded low. tiling. nonri!ciirung b-.u.:k oeJnrnt){vllad; Llatil Ilonadju'itable leg '-:~!lls. heavi ~-;.~ tJr ,JIge r,il'.. ) and. 1l0nrem(,v.:able afllll":"ltS. DOHahlc:

Muscle cramps may be alleVIated with massage and a stretchmg program, Cold can temporarily decrease spal,iticity. Physical therapists can perform and iO\truct caregivers in slow prolonged Mretches and passl\:e ROM exercises to address spasticity. In addition, pm.tural and positioning techniques can be incorporated to dec.:rease ~pasticity and splinting may be necessary to prevent contracture,,-. A recently published Cochrane review describes one study that found patients with ALS who engaged in moderate Intensity exercise had decreased ~pa~tici()'. as measured by the Modified Ashworth Scale. ".

Psychosocial Issues A diagnosis of ALS is devaqating for both the patient and family-caregiver unit. Because of the progre"lve nature of the disease, impairments readily lead 10 fun~tional hmnations and disabilities. which may imparl qua.ht~ of life. The emotional respon,es of Iht: per... on e.xpcrienctng the disea~e, family members. and individuals cMing for the patient an:: multifact:ted and may tlUtlll
(.'haptct 20 !\myolrophic Lateral Sdt.."Tosili

..r,.oons.

because left untreated rhcsc psychosocial ....".mnems can adve~ly aft~ct 8n individual"'; ability (0 and panlclpalC In Ihe plan of care 11'00. [)epf'eSsion ma), al!'o lead to suicide. .In addition, an\lcty .... depression rna)' also he prevalent among famIly mcmberS or caregivers, 1~1

....... core.

Exercise and ALS [)espirt the." high im,'idencc of mU!'l'lc wC'al..nC'''is in indlvld· uals with ALS, the cffclots of C':\ercise programs hav(" nol been exten!'ivcly studied. :md thtt.." arc not "cll under, srood Often physical therapy program, inmlvc ROM and ~JChing exercises only_ Despite' the 13rk. of rescarch evidenCe. ~ dlSCOuragc exercise programs because of fear of O\TRlSC' weakness and hcJic\'c that no exercise other !ban t'\'cI)'day actlvities. IS indicaled, Studies of mdinduals with other neuromuscular dis(NMDI such as pohom)ehtis. Duchenne's muscular

_5

dySlroJ'hy. myotonic dystrophy. hereditary motor and sen·

sory neuropathy. spmal muscular .trophy. and limb-girdle. 1Ied<er. and fascioscapulohumeral dystrophy have found dial exen:LSC programs are beneficial and do 001 produce overuse \\'eaknessYl-'6I) 1be rrsearch evidence in these potient populations suggests: OwmIse wealmess does 001 occur in muscles with • Manual Muscle Te.I (MMT) grade of 3 (fair) or greater our of 5 ,normal) • ModeraIe resis~ exerci.IIieS CCU) iocrease strength in JIIU§C\es ..·ith a MMT grade of 3 or 8"'3"'r out of 5. o Strength ~ains are proponional to initial muscle sumpb. o Heovy eccentric exerci"" should be avoided. o bettise may produce fuoc.ional benefits. o Psychological benefi•• have yel.o be
When pre><Tibed apptop"a",ly. exe",i.., may be benefi"",""wly m the oarty "",es of the d.sea>e. Exefci""

-.y ... improve the >trength of mu..:le. already weat· -S by ALS. <m.oinh fI(~ Ilk"" below grade 3. However. ...... 1Cti>'t ROM and s"",dllng of afte..'1e
denervated mu<;dc. 161 -[{,'I whcrcai other ,tudies ha\'c reported no etft."Ct\""'-U:'~' Of that aCli\- it)' loan promote '-prnuting or reinnervation, 16K If/I On th(' othrr hano, a marked reduction in at.:tlvity level sCl:ondary to AL~ can lead 10 t:ardlovascular dc(';ondltioning and disuse weakncs~ oc)'ond the alllount l:;lU<.,CU hy the di"'l'~l"C II .. cll. ThtOrdore. the type and int~n~lly of the exercise program ~hould be cardully rnollllorcJ and adlu_'-Icd h)' the phY~H.:;tl thcrapi"t In ordcr to pre"ent ex.cc~sivc fatiguc. v.hilc at Ihe s~lme tlmc promoting (lptlmal use of intact muscl~ groups, Patlcnts ~hould he ac.I\.-lsed not to cilrry out any a(.'l1vities to thc point of cx.lrCrne fatigue. and should kcl'p track of s.\"mploflH OraU.H', such as. the inability to perform dai ly activities following exercise due to exhaustion or pain. increased fasdculalions or increased muscle c.'ramping. They may also be advised to exercise for cffcd" on sprouting III partially

or

several brief periods throughout the day. with sulfiden. rest in between.

Disuse Atropby Reduced physical activi.y. panicularly if prolonpd. reduces function of the neuromuscular sYslem. in addition to the skeletal and other organ systems. Wid! insufIH:ienI activity. disuse atrophy develops when muscle CCNIb . .1iooIs are less than 20 pen:ent of the tocaI 1ell5i0ll a muscle is capable of producing. A. COIIlrllCtile proeeinl are i0oi. Ibe muscle weakness progresses .. a tale of 3 pen:caI per day.I'" Strength loss through inactivky and cIisuK eM Ii&nificandy debilitale individual. with ALS. mati... Ibem highly susceptible to decoodilioninJ. and muscle and joiaI tightness leading to conttaclUres and pain.

o.ea w e Fatipe The: poIeO.ia1 for inducing O\Ierwort cIr .. ia inIIW.... with ALS through excessive exercise ia • (1M • OR cern. Sanjak ot aI. demonsuated IIuI ....... willi demons",,'. abnonna1 pbysioloJic:a1 and response. 10 M,1e bouts of cxerciIe. OJ.YJIIl c during submuimal curciae .... iDaeMc ~ it willi ALS compIred 10 cCIIIINIs. _ 11' c""""ity were decreuecl. Ie mil metllbolic IIUbIInIeI of . . - _ ~ ..... men.. did II1II in
Vn- ..

wId"M., "_ ...... _1

r.c.L" "" prucnm for •

841

,r

842

Physic-a I Rehabilitation ~i.'·UJI

(human ,... Iudles) and F·vicil:n(.;! 'iurnl11ary Bo\ 202 (ani. mal "tudJt:<::).

(wc1"\\'"rk damarc in JlnpJircd "i. TI:~' r(,J11Jl1i:'~ mNormits w.ll rt.~sPl'nd hi I nil 11;,. Ih:~:~ ll( ,II)r unj:~ Tlllst wpr .... harder to handle J • o~- '\cn::'~ s.;.~;;~..:;," J ThJ,;s. spcl.lal .JttcntHUl ilL)'

)' C.1USC

Patient/Client-Related Instructi~~

he ~'lld to:~·..'t.!oping :tr ex.!"";"; IS(' prp~rJ.m for palle:nt,

\I. 'ii, iUld pnv i( 11 thenl ISi'"J: shr-uld prcsLfihc c'u'r,('l(jc .lle :(' k \V mtl r:siti;:s, __. H, reldted(" e.xerc "'"C III indivlltuals With c _d. \;.) t:.:.r y C l!o.C studies d~mon:'olratl"J pos\1 < : spec c slrcn~lhefllrg ~;lli cnduralll'c cxeTJt..fI~C recenl- Y~le c,fI.:<..ts of e\cn.:isc 111 il1(h ........ \l ~ ha\"~ ~~n evaluated \\ ith larger ... am -"-sc studic; found significantly Ie.""s I..!cl'linl: .~ ~ . .'~rcs ~:1L )thc outcome measures r l r 4 in the

A

I

. Two rc... -nt animal studies found that . J , _ t.~alll ,ng at modC'n.te intcnsll:c ... sJO\\ed .:;:;_C"~ 'to. whcJeas. a IhilJ stuJy round

<

• ,

"

fI-

--,cc ..

\L ~

had dClnmenlal The e\'~d~nce related 10 exer·

~nl,,"

ot Al.S

IS

deva ... tat,ng ror Individual<.; and the

the patient. family. and caregiver In un open and encou: agmg environment may empower pallents III their efflXt" to cope with their di"c'L,,>e. fo'Stcr a sense of purpose and self-efficacy. and cnhanl'e the overall effetliveness of tfk intervention by JOcrcJsing compliance II

(x-·\.i~C' traml~lg

c_ f'r<sentc~ I~

Ui;.lgI10SI'.i

f<.unillcs. They UTC faced with l:ontlnual. multiple \:hang~ and losses, and eventual death. ASSl~llIlg the mdiv ld ; .. I lyan d t'-lrcg,lvcrs to (';ome to term ... With and Ills or he~ f ami the impa(.:t of Ihe th",ca",c IS ,In Ilnport •.tnt role ror the ph , . Y'iral therapist. and prov ltltng p"ychologlc.t1 ~UppHn and opportunities ror ~xpres~lOn of feel lOgS, frustrdtl()ns and com.:erns is imperative. ('ollabor;lting with and educatin

E v dence Summar), Box 20,1

Evidence Summary Box 20.1 Exercise and ALS: The Evide nce from Human Studies Reference

"

,-;

Subject(s)

Methods

Duration

Results

':J..1t-.:r· ... ~1j r' ',ambut:.

Case study lJE lF patterns

75 days

'4 muscle groups zncreased • strergt!' lfOITl 7"io to 96', 4 muscte !J'O!.Il6 I06t strer¢ bv 10-~'

41..' - ,. _ j

Case .!:Idy A:' Dyne bzcycle ergomete'

6 weeks

lsok;-.·.~

Pr~'r," OItrc.'C(j 'm~e b~-,j

(.:!

FIo!.~

L

f 6

,

•

~

r.

16

-.0

Oop."V,ry respo!'ses '0 exer- ,e '1I\l-oved in t:Ie UEs. but <e! d1e lE, mon'~

endurar.ce protoc;. Z;-, or r.;:"~hton treadm;:1 pr0-

le ..-::.::ng BiPliP: exr:;:se.' until Q)p ...."'leTS r;:acJled

.gr,o.~;;--~_ .• thr:!~ ~

,

.,

~

-,

"

>'

~m;,..J~::

~

..

c·/f-

,

"

, ) fiOtlth

•

"

~

M " )-Pa<",Ity.

~(

bt:-::

E r' ,;r':!::1nt1~ !:reate: FIPJ

e"',,' tt>e~ Jf<\'C

;:" .J

"'•.;0

strenqn ancJ ;;31-

'"

AI

l.18,

Chapl('r 20

Am~·o(rophjc ulNa)

Scll"wtis

8.1.3

Evidence Summary Box 20.2 Exercise and ALS: The E vidence from Animal Studies R"fercnCt."

Animals

,'\Ielhods

Duration

Re~uh!i

5 days/week until unable to keep l4) with a speed of 7 m'min

E' overall. SlgniflCanl increase rn lifespan of G93A.

JGrkjneZOS, IG. et all ~

7·week old G93A·SOOI

E. running on a lread'mn

2003

transgeniC mIce

(30 min 8113 m'min II1i!rar!y; speed and duration

.:fecreased stepwise) C: sedentalY

8'Week old lransgenic Iow-ccpy hSOOl mICe and wil
Y'eldlnk. Jr!. el al';(I

2003

E: runnmg on a treadmIll

Until 100 ill to run

SOOI mice tp 00071, significant Increase In male mice lifespan (P 0,02) trend toward increase In female msce lifespan, but not significant lP 0.1 J E: exerCise delayed onset Of disease 10 lemale. but not male hSODl mice; exercise prolonged survtval in female

(45 min at 16nvmin)

C, sedentalY

m'ce ~1ahoney,

OJ, et •

4(Klar-old G93A and v..-:.j·tr;9 ..ttennate ...~'trol rn;ce

2!X)4

c ~ contrc: E

expenmental: min

E: running on a treadmill (20 rrun·'day at 9 m/min lor week t; 25 mirVday for WI1ek 2: 30 min/day for week 3: progressive inCrease in ntenSlty week 2 and 3: 45 rrun/day at 22 mlmin) C: sedentalY

3 days/week for fllst 3 weeks; 5 dayslWeek for remainder

E onset of d",ease nOf affected" female and male mice; exerctse hastened death In male, but nol female mICe fp" 0.00011

minutes.

Patienl and fam:..lY/c"::..!glver education is Inlc£ral tbroUPlouI the Slag.. of the disease The .cope of edue". "in" ,an ~_ ~':!de bul to; r:".J1 limned 10:

• Prmu.hng infonnatlOn on health dnll ",',tibbie. soei:tl ~nJ support servICes. 10

L~lding ·lCCUrate fal.~uallnfoffilation ahQut the disease

The At.S A'i.'ioclalJon and Ihe '\lu~ular Dvsuophy AssociJtion are rhe t\A:() national voluntary organlla{~ons

•

proces..s .:rid (.:meal manif~Luons, and lheir slgnjfjt..;..-::.:tn terms of management. Give only J.S much anfoT. mation ti the -:-3.:"-!'nt, !.!nuh". and C2re'bwers ne\:".:!~ infof. mation LlouJd be ~ded in 'llanner 4fprorrialC 14) then undcr,tandm~.

•

~--:ing pa!:"Cnts,

f2...':lly members, ilnd

cart'~ivcn

mc·ven::::)fij thar c,::'n be carne-': oul r.ndcpcnrl. wch .:: morutlong '':he dfe:-'"s .a.d Side eflClL\ ('If nedL...Jions. u:..e ot ~lU1V~ :t:..:\"lces dIld atJ..1plIV~ equip..

~:''ll, and prevent:;-g fOe..:· md:Jy compi!! II :ons ..... . bout C!::."'t.)th to fT' ~mok (;c":1cnl .I

z..n..: I'..c

eri')'

•>

c~~SC"'n.!.on,

001

'" tec.lnil.;ucs 11!."l"

:he patient t, _"pe .. ,th th ~

f I~~

•p

,

•

Ihat provide many iunction"i and programs fN IndiViduals

WIth AI S Jnu theIr families and C.LtCgl\!CIS, IOciuding lhe proVISIOn of written and video edw.. J.tiomtl maten.1l~, 11JCai education progrMlls., parlelll and l'olfeglver slirror1 groups equipment loan llro,grams, re<;pite progf.J.m\. II ,tnSf' Ina liOn pfCIgrJ.m~ ••1dvilC3CY progr,In!:', ilnd \L S /\w.nl~n("'Ss

Progr..Jrns. Pallenfs "-.In: explore th~sc re.soUl ~~ rhroUfh Ille following contac t Infr\nTU!loll AI11)·l,lnlphic '.aleraJ Sclero51'i \~I ... tron '>'()Ol \gour... Ro..d. SUit!' I ~U ( It.be:" 1I1Ij" l \'11 101 ~1t)4 f~18'!,8t,·9tJf.'I, ·.0(" 'K)·~· .. hup ~. W"'W ;-'1 r~ MU'cui

,(XI I

.<

"I uc,;~.n

"

J!t42Ji4;,JAJJ1"

I>\';,.~rc·phy ,\~~)(, ial ion

Un\-T f5'1,.1:t)S

1';~~:J ~flor.II.)(O(HCj"

"p

..

'i

~f~

....... Jl1

.1.01

I&LU.#}€i@!.C

I':~

I

8""

Phn,icat Rehabilitation

~nd fUIlI..'lIon ftlr as long as posslhle

lateral

!Oclero~ls.

tllr -nest (,{lmmcn and dtv

a~t3ti~~Y f ... t~\l mot{lT ncui-n ~ISCol:;: among adtuts, ... .;luses

a J7. -grcssi\'C mcfCa.nslr-Ic for the disc.:sc- Although the ':: no curt' for \l S and liS coursc (,mnot he altcred, It s.hould he ... :mside"'eti a 'tfi".:na't-lc dis(,;L~" \ 1edn:al man agcncnl IS primanly ~}'mptnmal c. a1d Iteam ilpprt"adl to ... :u: _:; . . .:.'nsldcred ·puO'al. Rehabl:ilation manage men I i'·' 'ocustd on max .mlzing fun\.. on ;ln~ promotmg ,odepend c:nce Il.. ~1C' highest ",,'rl .:oss.ble" lfld en~ur :ng lJpcmal quality of life ~L")U;:."out the ,,:,}ur..;e ot the disc~ dnd ~ "":."ss hL~th

... If:''' s=!: .ng ~ O;:-~\'~J('.:.l thcrap::::: plays an Integral rt"lc In a~lgnin::: ~ unplemt.'lting t....:-apeuti, :nter\'e~ticns for indinduals w!.."! I\LS lhat "'il: 4Lo'A them 10 mamtam mdependence

Q

11 C , I

for

0 II'

R c ,.

Ihe indi"dual's goal'-

rsyc~os(",al

'Jcl... • thai ",an

impact.jCclS lon makmg Slh.h as the individual's 8C ay ilncC of the dnd the cIOti.vldual's s(1cl3l and 'lOan· ... tal re~ources. Beclll~ of '.ue progressive nature ,-I L • h~ J\l S. the ph)slcal thcrapl:..t must not only dddre, S the patient's <.:l1rrcnt prohlems, hut llso plan for the pal·I\~nt ,!I

dlagno~.-'

~CC"pt.

future: nel"th.

_..

.

---

Acknowledgments Spec,.1 Ihanks 10 l.1Z ~cott and I. r'," I'oole lor 'kr eXlraC'rdinaT)' typing. admmi:;lr.ltl"c amJ editonal skl.ls. and to PeVgy Ingels.Allred fJr her thoughlful ~ cntl
DIfferentiate anonp. ,ffiFrOlemS rss('II. . laicd with upp:-"

5. Cunsldaing the "'-lrlet)' of :mpalmlents J3Socl3ted with \1 S. \\ hal rhYStC:lllherd;OY le,ts and m.,-..sure, shoul"

~""cr lIl!~cr IlCUl.", p:::!:,logy and bul: aJ ...,thology W", clC_,,-,tion procedure. !.-, used to 'eip ';:ppon

6. DiJrerenh:Jte ,unorg

fJe IOduded In .J ~omprche"lSi\'c ('XJmmatlOn'"'

of At ~. 3. iden1lh and ~ I!'''::: r- l-':>CO:lal cr·.tcr.a ~\"eJo~ b~' the . . f~dC::::!~"7j 0; .... cu.-ll~£\' Re,,:z._~ GrJup on

"curon D

of .6.L S.

"nat f"lC".ors ~la\-e

•

... t IJ

,I

'-:

:~

rl'~(')J ':::,; w'f! C'c.mo(','Ulll!..TV,

.r........

pm'clfI'\'e inten:enlic-ns. 7. \\ he, Jeslp,r.J an exen:;sc p.Jgrcm fur" pabon! " ,~ At-S. whal factors ",:eed t~ take~ IO~~ ... )fl~.d.:.:":: 8. \\ hal ::lfOlr.::~!.o~ shut;:d he consid,':J ..'ld ."'- 'uded when ~e\"el()pmg " pbr' fer IXttl~nt arn.~ f..:m.:.~' l~"::'::­ lion follow ,ng Ihf! dla~~no:;_l U~ -\L S

~.

I nt,ht-haJlc!!_.( lb-\.:~: .:lL Yo'htlL JI~

I"\~

At 'J

'\l)

Ill') fOR,\,

r MI' \)1(

I.IPH~~:":

!!,",!

\l illS rOR'

p- ·-1 cedi:.: 11 h

~()n\1 III'> lOin -~-:: t.!!'::;"":.:~::;.'J ~- ~_~ll!!~

tin c"--

r

-,.

,"_U' _

u .. ,'.

~

r(>-~ L:"!~ ~! l!.~. b.:en • "·~.r. ;___1 k:; I - - - • __ .,;J. ".'. ~~ 'II! • ('Id :::::1 "':~~ t"':"111~

!,..a,l,···~,n.·.

~

l

C \\

• Jesrn~ the clint
Z

t',

eyer p<..s~'_hIC. is na~ec!' on the st:'lgc dnd pror;resslOn of the JisC3SC and may tc re~toratl\c cnrnpen_sJtory- "'r preven· l':'I1H~ These II1tCrvC~t10Jl' should take Into ccnsldc:rati

Summary Amr~.::-rh.lt..:

rhe selection

,"1('IV,~ltun<. ~roul1,.ed n ev,J~-CChLSCd research when

rJ L.~~ • • k~ t·· .. ,----,

r.' "'~.::~ j

:~ 1 "

HI'

r.,,;!') it

( ' haptcr 20 Am}otr«)phic Lateral Sclero5is He sll'rprd p13)mg }:I.;tslClhall noll haseball ~cau~c he is OlNlTTa5"ed AbOUt the tn'quelll tnrpl1lg. but contmues 10 .,;olf ~n the 'A~d,l"nd 1h.~ US,C8 11 gnU cart hccau~l~ hI! f'I""u~Ne to k('~P up with ~IS I"."ends on the golf Ctlurse."

I")

.

'

He- \\'ould like 10 tx~ more do" tlve

OCCLTATI0:-' H(' 's It m3Il3ger at J romputC'r ~raphK" hO~lI1e~~ and rc~s his vOice bclomcs hoarse c'n Ol.."( ,1Sh.," dtter long p"'t!'CflGltlOn!io, lk repc1ns signlfica.nt fali~u(' If he v. {lrks ~ thC' computer lor long pcrk-ld.~ (1f tim(" {If It he h'l~ tC', s::.nd for long per;.od~ f~'r pi'ese'ltatil..m~ He attrihutcs thIS , 'I!
DIAG:\OSTIC TESTS L~!:!Omy(\graphic stUdies showed: ( I ) low C'omptlUnd :;,;;-.:!Jr ,:l;tion potentials in ~ extremities: (2 \ normal sen~ ~'o:!fVC \..:;nduction~ (3) fibr-.Ilallons and fa-.ch,:ulatlons ..., ~ ,x.tremitl~ and (4) widespread neuTO£cnj( (.hanges c.~! ..--no.; potentials. abnormal R'l'ruitrnent ~ an the d:stal1eg musculature dml mild to tnOtkr· lit (.'::......_.~. n the upper extremities.

PHYSICAL EXAMINATION FI",DI'SGS ~,\;!jo:t: \1arted W,lSlln (..f th~ .nterossCl .e-gions

.,'

~~;J'I'

v

." .

n.~Mla1i:--rs noted

RO\' """1 (er ali OInts ,;xceplwe t'umbs dnd we L anlk I'atieru "'as only 1.b\e 10 oppDSC thumb, to the dun! &~~.,. He lad.:,~· of 1
r~,R

and4+."

1land 'lren~lh: R

12 Ih,: L

845

24 Ihs (h"",J-held

~1)'nall1om~tcr)

Pinch !iotrcngth: R-tflpod :! Ibs; lateral 31hs. L-Irirod .c; Ihs; lateral ~ Ihs {see helow for llormal1v(' data on grip and pmch "lrengthl. (n{'lrdinatwn: purdue Pegboard le~lmg R (, peg holes In ,0 second'i; L ,peg hole, In ~O second'S. Tt)!lc 1 for bt)th UFs and 1 t for bNh LE..... fModif1.Cll

Ashw\lT1h t.pa . . tic-Itv

~cores),

Rctlcxcs; A \.'\onic jaw reflex: hyperreflexia In hoth l.!f..s; hyrorctleli.1
hilatcrally.

Galt: IIldl:pendcnt 01 a~sist ivc d~\'ICCs; po"oitive for L \"oot drop ami hip hiking; IS-ft walk tt!!-.t 3.0 SCl.:OIll!o.; BaialKc ( ... tandtng): unilateral stam.:e/cye~ npen, R 25 !
AppendIX ,\ I. ALSFRS·R ,cores (,ee Appendi, B)

.\LSFRS-R Scores

Speech Salivation Swallowing Handwntlng (pre·ALS dominant hand; Cutting food and handling utensils (patients without gastrostomy) DreSSing and hygiene Tuming i~ bed; adjusting bed clothes Walking Climbing stairs Dyspnea Orthopnea ResPlr~tory InscfficiCrcy

4

3 3 3 3 3 4

3 3 J 4 4

L

1'9.7

240

48

"6

176

R

1129

:;17

4.4

73

1 :)::-:'

l

'SO

36

T1

1'

~8

16

• Z4

'1.~

65

.:,

:12

..

'8

32

f'

hi

36

1 1T

'4

40

FI

•

~

4.J.U

(."~

..

4 ' ,4

,

~

0.', tel 28 AMy.... " 67. Vucca. M. It.a: Bu

.. S "

I

I

2.......

2.

,......widlWS)Cb :" 1997.

......2

,

..,

i..,

7 It,

$

; . . . . . . . , .......

68. KriYn.. L: ~ ......... e 2; &II ........ Mitsumoto. H. aa.s. DA. ... PioIo. £It (edit. .W,A IS' LaImII 5 0 _ F.A. om.. _ ... '991" 3G. fRo Schi........ PL.... 1IeIJh. 1M: ,.. ) _ . ' 2 '111 amyocrophic 11IerII1e1aoli5: It.teof I ita _ a..~ S

199).

mi.,

70. Abc. K. et .1: Copitive fuDc:Iioa iD b ;1' .......... J Neurol Sci 14:9~. 1997. 71. Kew.JJM.etal:T'he,.I•• alDpbelweenel: 1Hnol~ live function .ad cerebral a:d,aIitA. in ••1)011. . . . . . . . . . . . . . sis: A neuI'Op8ychokJaicallDd poIitnxI _ _ _ 2 __ -

-

---"-

study. Bnin 116:1399. 1993.

F"

72. Massman.PJ.etal:PrevalenccandUli'! 01_,» p cal defICits in llllyocrophic l8IenilCBoIia. J NMnI Ph:=_a Psych;,,,>, 61:4~. 1996. 73. WlI_ CM. et aI: Cognitive ........... iD _ _ ALS: A pathological continuum wklei.)iDla makilyllall . . . . . Ne...-oloBY 51:651. 2001. 14. Lomen-lloenh. C. et": Ale IIDyObUpbic: - . . _ . . . eogniIive'y normal? Neurology 60(1):'094. 2003. 15. Neory.D.et ..:F...... J Neurol -....... "'ydUttIr)' 53:23. 1990. 76. StrorI&. MI. et II: A jNoapcx:tiwc IbIdy 01, • me' , . .. ALS. NeutOIoJIy 53: 1665. 1999. 11. AhroIutms. S... II: VaboI n-.:y ... ~c ....... _ , . N_ydtoIasio3J(6):T.l4,:IOOO; 18. A _ S... oI!Relotionobip_~we.., , i Mel PI........... ....,. in Wi)OII ,aRc ...... 1dInIiI. J,...... -....... "'ydUttIr)' 62:461. '997. 19. Broob,BR, .. oI:EI_re'· 1 _ _ ..... ..,....of.)011 ;ltir ...... ICIaoIiLA8I) ... .a....I s.ler ~ _ _ DiMd I(S):l93.lOOO. 80. Jueqeaa. SM.. Ii: AlS iD , 3SO " lisa

Iobe_ ... _ _ _

.i.

..,0'

7

•

:MN63. '988.

8 •.

7

".1.,.sP-.

~.n.MaIYi1oi1,MN._"""R::

odeoooio: ,. - . . - , . Neall CIiII 82. ~ O.... MoJp.d. B: _

........

•

4

F 2

•

' • .,.AclaNeall_,I9I7,

83. Onniai,E, ....: _ _ _ . . . . I· 1IIIy, • •964-,9U." • »31:1. . . ....

14. T>-,OB. -.sa._Aadi.M:F;'P . I • .,.". ....,..., _ _ .11 II .... AcIo _ Sea &J:2III, IS. -.AD:AIa)'"' ;1' _ I • 0iI0I0II~"

I.'.

,~_

. . - - . AId! NealIlSl63II. 1971. 86. T>-, OB, .. 01:

Po. ,. _

IIIenIlIClarolia. NE

£

1 ,

,i

J

... _

,

_ALMIPIb.

-.----o..i,:=: 1

'999.

19. ~. 81. . . .

or_.·.., b'f"-

90. 5

91 GIoop. I . . . . .".

?

,IP:, S .................ALl:4_ ... '!'."~. , • ., (' - I . AD

11."-'-_ •• 14,'• .

••

101...

» 13c21S. ,IN.

17. Md)c=,y 1IIt.. II: . . . . . . . USO-4"-' 1'lIe role at .., •• I .... 8M. I I .... 01:_ •• _

.... « •

.

;&5

Appendix A: Schwab and England Activities of Daily Living Scale J 00%

90c:t ~. :-;0% ~ 7W;j- :;.

flOt;, -"'50ce = ..wit'

=

30r,. = ~O~J

:=

10'.,) ~ (Y,j, ~

Compiet('ly jndependent: able (Q do ;.Iii t:hores without slowness. difficulty, or impaumcnt; ~s"f"ntlally !lonnal: unaware of any difficulty Completely indepcndl!J1t; able to do all chores with some degree of slowness. difficulty, and impairment; may take l\vh.;e as long ill) usuaL beginning to be aware of difficulty Completely Uldependent in most chores; takes twice as long as nonnal; conscious of difficulty and slowness ~Ot completely independent: more difticulty with some chores; takes three to four times as long as normal in 'lome; musl spend a large part of the day with some chores Some dependency; can do most chores. but exceedingly slowly and with considerable effort and errors; some I..:h(lre~ Impo..;.sible \Iore dependent: needs help with half the chores. slower. etc.; difficulty with everything \"~ry dependent; can assist with all chores but does few alone With effort. now and tilen does a rew chores alone or begins alone: much help needed Does nothing alone; can be a slight help with some chores: severe invalid Totall) dependent and helple,,: complete invalid Vegetative functions such as swallowing. bladder and bowels are not functioning; bedridden

From Sd\v.ab R. and England. A. !~O with pcm1ission.

Appendix B: Amyotrophic Lateral Sclerosis Functional Rating Scale-Reviseda 2 Some help needed with closures and fa\tener~. Provides minimal assistance to caregiver. () Unable to perfonn any aspect of task.

SPEECH

4

~om1aJ ~r(,!e-ch rn.x'es...,c~.

7t fk.·I("(tabk~ speech dl~lUrbJnct' " Intelllg1hlt" with repeating.

o. DRESSING & HYGIENE

Spt.'f'ch i,.'(''Imbim.'d with n011vocal communication. 1) LAy, . . of useful o,,;pec,,"'ch.

.\ V1\ A Tf{),\ J \\'rmaJ

\!lght but definite exce ....... of ~ali\'a in mouth: nM) have rjghttime -1roolmg. \1odC'Tate-Iy e"xcesslq:- saliva; may have minima.l

droo!mg \1arl.:~ ~x ... e ... "

of sahva with some drooling. 'larked droolmg: reqUlre~ con:-lant us~ue or hand~er­ \."lud l

'U,o\UOII/I\'G

~

'oma! eat n~ h3bus,

3 [.J.I'fJ e.;,.;t,ng

Diel.ln:"

prob1crns--- .(ll~CaS.iOnal

oon~ ;;1em:~'

4 Normal function. 3 Independent and complete self-care with effort or decreased efticiency. 2 Intermittent assistance or substitute methods. Needs attendant for self. o Total dependence.

- TURNING IN BED AND ADJUSTING BED CLOTHES 4 1\;0n11.1. " Somewhat slow and clumsy. hut no help needed. :2 Can tum alone or adjust sheets; hut with great uifficully. Can initiate, but not tum or adju\t sheets alone.

choking.

o

(!lange'S.

lleJpJess,

. . ,::C, ",ppkmen~ lube !ttdmg 8 IIA1X1SG

'M l,ex ... lusJYcJy rare:m.erai or enter;).i feeding).

4 '-onnal. 3 Early .:tmhuIJ[lon ditliculties. , \\alks with a_~si~13n,,;e.

4 HAVDV. RITING 4 .... \1'.70\'

:q'

'd<, "'" kgIble

sI.)pp)' ..::

.... 0:

''-

",I

n ~,,,,,-:,"=:!

t:_J unab1:

t:, \\'f:.te

PC' <

o

'onambuhlwry functIOn.!1 movement only \0 pllrpo~efulleg movement.

9

ClJ.\lli/~G

Tl\'{, fIY./JJ ~''iD HV';[)llhJG l rt\,jl/. ~ IpatimtJ .'i/htlut gtzs/IWI""'yl

4 'r>rmal

....

, \.l!ld

'\ "i Inw

help need:-d

v Ill1d

but

JlJ

t.ll'~'. St~'Int:

1.:ed

or

fUllgUt

DHP\H

1\

" tk .. u

I •

ur,"tt~diOt·s.s

Need:· tL5-M'tt..t~e() C"nnol ~o

4 "

OR

''[\IRS

0,.

,1\L'lI\C 1.1£' lilianait' seak lur patlf'trts ...tth rQUT(J$tulIf)'

"

n w.ll).mr ,!h

1\(

nwi'1..:

~,t

Iht' fl)th,winl!: elltin n

hreaduni: when ('ilht'r SIU"', to

,~knnil: Ul'iiml

1lb.-..d"wu4.'ai

'.'" i(IJ

S52

Php~ic.-.al lh·habilital;on

12 RESPIRATOR}' INSUr FlC ILNCY II oRTI/Of'M:·\ ~

1'\()ne

3 Silme dlllKUlty !>keping at night due to "hortors" 01 nre;1lh. lk"IC... " 1lI1! roullncly u~c more Ihan two pillows. 2 ~e('d<; c\tra pllI(lws in order to ~ker (more- than 1\\-0). (\In 1'111) ... !err sitting up. n Unable II} "kl'p.

-I None. ~ Intenniuent u...e of BIPAP

.2 Continuous use of BiPAP during the flight I ContlOuOus u>e of . BiPAP during _ the_ night and dav. o Invasive mechamcal ventIlation by intubation or . tracheostomy.

I.rom CeJarl'out11. r . t. CI.ll,Hlw1th pcmlh ... l0n

"Orlgmal AI .SFRS Cl)llsi ... ts of items I through 9 and the original item 10 nelow. 10. IlRf,ITH/.\G

.t

'\lln1UI.

_~ Shllrtnes\ of breath with minimal exertIon (e.g" walk-

mg. talking).

2 Shol1n(''''s of breath at rest 1 intermittent (c_g. nextumal) ventilatory assistance,

o \'enlilator dependent, alPAP

bidtrectional j:IOSlilye auv.ay pre... .-.un=: '\lPO : Ilon per os, nothmg by mouth.

G fl , \ I' T

I~

II

21 II A R N I N , __ 0 B J E C T I , f I I. [)es~;nbe the e1iolc~y. pathcph\ SJology. dinil'nl mamfcstJIII'lm,. and sequelae-

pf

ParklO .. nn's

Parkinson's Disease Susan B. O ' Sullivan,

disea~

:. Idcnti(' · ~d dCSl,;nhe the exalllination procedures used to ('\ J.luate patient .. '" llh Parkinson' .. disease 10 tstabltsh 1 dlaPl0'ils. pro!!nmi .... and plan ol,,;Me .'. Dcscnbe the role ot the phY"I(J.i therapist In a<.;ss5ung d j1.:ltient with Parkinson's disea"e In termS of direct mtervention..:, lI1d patient and f.lmtly.f~·.aret!:l\"er' related inS[]Ui. :!lon to maximile

fune-hen. .1. ~nbc uppropriatc elements cf the e~erci .. e JttS(;np:iXl f''1'p3lients v.-ith Pl1Ikmson'~

PI; Ed[)

OUTLINE F JJ~ 11101og)

8~3

Cognitive Function H61 Ps)'cho<.,ocial FunctIOn ~67

: if·loi.:Y 8"4 Par~in~on·!'.

Sew,ation S67

Di<.,case R54

Secondary Parlon'ioni~m 854 Parkmson-Plu\ Syndromes 855 Palhophv~ij

IOLY 85."

l: ,100eal PrcsenLtion 8$6

~c;:c

~_

/Jrnufy the ocur-opsychological errects and 6JC ial impact cf Parkinson's disease and describe ;1pproprtatc interventions to maximize qualifY of" lite. 6. Analyze .JJld mterpret pallen1 d:ita. fomlUlate !U!lstic to:J~ and outcomes. and de\'elop a p!m t,f Colfe when presented with u clim~1 C..1Se study

Cardinal Feature, 856 \1otor Planmng t-l5X

\1otor Learning 859 Gail 859 Sensation H59 Speech. Voice. and Swallowing 860 CognitIve Function and Bchavi{lr 861 Autonomic !\erv{)u .. System X61 Cardiopulm,mary FUnI.:tion 861

Meak",1 Diagnc,sis 862

Clinicai

MedIC..:1 M.: .nagem.:'1' 86..:. PhannacologH.;al Manage-menl Btl) !'\IJlrilional \1anagement 8M Surgh,u \tm3gt"menl 1\65 (j

r ll.ebbllit..:: or. Stl"

.) . ;t;al fherap} [~-=-'7.mLtion an ....

I

\';ll~-.::a

P

"'.,l1= s di;e.", IPD) _; d chrome, prog",sSlve oilS

""se of the rervous system c'laracterild oy (he cardi '3lure'l of rigidll) , hrad)kinl$ia, tn'mor d.nd po

'., ",lability In .dditlOn, ttce disease m~y ,ause a .r::!~1 of OfM'r lj\lr,plC'I~!S Including mOVe1lent and g.uI

c::

[)ry 'har.~:s . qx:cci., VOICe dll~ sw dnd bchavionl (.hange:;~ auto \'ous t.'jLtcm ~)'sfuncT!"'n; bJ.Sr-otnte - t',;}al M1 crdl~·pulmt_.mar)' chang'..s. OnSC'( is anstdi..:u5s c:J crgnt~ _ ~e

. b

Di:-ruptlon I~:-,

,;-.h;--:-~

dJld

In

pn:: '':':'Ion i -

"'.:ul) fun... \.~mcun

If",

FunctIOn Xh8 Motor Funl.:tlOn 868 Autonomic Function 87() Cardiopulmonary Function 870 Integumentary Integ-my 81', Functiunal Statu.., 871 Global Health and Di~ase.SpnJflc Mea'iUre~ H71 Physlcal Therapy Inlcrv'ntion g-r} Motor Learning Strategies 872 Exercise Training X73

Balance Training !P8 Locomotor Training ~7Q Cardiopulmonary Tralnmg :-;80 Group and Home Ex(.·r\.:ise~ 880 PsYc ho'Soci;J !SSl:;5

COUI se ~6 ..

framcw

~usculoskelctal

~8 :

Pal ::nt. rou!ll ly and (MeJ,'Uve-- EJuc.llion 881 Manai;~enl Com._~·

J,(ion b.... Stage o! Di:;..::-:!: 88~

'\ummarv 883

SfS

Epidemiology PI) 11 b v.:ry c('mmon

neur("\le'g(:lI~ratl\e

dlsea'\c thar

,affects mOl':: IOltn ) percent d"the ptlpulJIH"lf1 okkr .han 65 YCo.I!1 of'dge Avrrugt' .:ige of PO onsct I" J.ppro,\imatcl.,"' ';;0

(r

('L) vej!"'"~.

lr'ueJ'!II1~

fh,e m~ Idem.: IlKre3SC') dramaricJII~ w1Ih llgr rhere Mt Ic!\s than 10 new (J.~es per

;O(\IXX' uildeT age o1Iin ",lllie there are .:It ICdSl 100 ne", \:..t:.e3. per lOO.(X'W) agn "10 to tj4.} )'~:lli alUlll.J,lly\ small peh.:e:lfage (" '0 1(1 rcrcc:m! dc\'ell..lp ,\'OUII(-OllSti PD. wllh.h l'i d"'f,l1e-d by fht, .. ppc:antm:e .A nUlial . . )mpwms

Ph~-~iCRl Rehabilitation

854 hc..'fl.l[l?

the: a~t!

1.)1" .+(),

Men and women w<e afkcted almost

equ~i1I)

syndromes refers to those condition~ that mimic PD .;. some re~pccts, hut the symptoms arc caused by oth 10 rode generative disorders. er ncu-

Parkinson's Disease

Etiology The h:ml parkinsonism is used {O refer to a group of disorders thJI produce ahnomlalilies of basal ganglia (BG) funclion. PD, or idiopathic parkinsonism, is the most common foml. affecting approximately 78 percent of patients, Secondary FarkinsonisflI results from a number of di fferent identifiable causes, induding virus, toxins, drugs, tumors, and so forth (see Box ~1.1). The tenn parkiflsolli,Wn-pl/fs

True PD or paralysis agitans was first described as "the ,halung palsy" by James Parkinson In 1817.' Etiology ·· idiopathic or unknown. T wo d IstLOct clinical subgrou " have been identified. One group includes individuals WhoPS dominant symptoms ,p.ostural and disturbances (l'oslliral IIlslahl/Jty gall dlSlurbed {P/GDJI. Another group Includes indIvIduals WIth tremor as the main feature (tremor predOn/want). Patients who are tremor predominant typically demonstrate few problems with bradykinesia or postural instability.3

in~lude

i~stability

g~

Box 21.1 Classification of Parkinsonism

Secondary Parkinsonism

Idiopathk Par!...in-.on's Di ..case Latc-on,c-: \: ...1-(1 yea!"'-; genera.ll) sporadic) Early ....'Il"et (---:; 40 ~ t>:trs; often familial)

The influenza epidemics of encephalitis lethargica that occurred from 1917 to 1916 affected large numbers of individuals. The onset of parkinsonian symptoms typically occurred after many years. giving rise to the theory that a slow virus was infecting the brain. There has been no recent recurrence of this influenza and the incidence of this type of parkinsonism is slowly decreasing in frequency' Moving case histories of these individuals are portrayed 10 the book Awakenings by Oliver Sacks.' The development of parkinsonism with other encephalitic conditions is rare.

);'un~-{tn'd\~2,i years) Ju\'emle (. 21 yt!ar-)

- ------,-,---cc--

Parkio'Oflni-.m Due to Identifiable Causes Virus ',e.g., encephalitis lelhargica) Toxms (C,g •• carbon mono'\ide. manganest'. meLh ylpheny Itetrahydropyriiline (~IPTPI)

Drug!. (c.~. phenothjazint>s. reserpine. ''butyrophenones, meloc]l)pramide) di"ea-"c (multi-mfarct)

\'a~uJar

Tumors fbasal

Postinfectious Parkinsonism

~U1glia

'ionnJ.J j:?~~ ure hydrocephalus

Toxic Parkinsonism

Hemip<:::kinsoni:m, hcmiarrophy '1C'taboli{.:

Parkinsonian symptoms occur in mdJvlduab exposed to certain industrial poison~ and chemicals (manganese. carbon disulfide, carbon monoxide, cV
\\ ,~s: m ~ disease

:lepatocerebral de-generatiOn Hallef" ,,,jen,SPltz di'Se
P;..rkinsonl\m in ()tht"r '\.t"urodt'generati\ (' Di\ordt."r.. Progrc ~,Ive upranUdt4 i-•.ilsv ( or... .:,.1 ~JSa. 1";1nglionl- degenCTati('lD

nL~urdcrs With (.'P.f"ebeUiifl .mtOtll}mt({pvramidal [l\aJllksl~1 lI)n Multiple \;.y~~ atrophy Stri3l"IJi bTdl degenL'fatF->ll ~hy ')I.~g:!r t'\IlJrome

OlivoPOnI1t::erch-'llar oiIt:rf>pil),

'Aach'.ido .. Jn!-nh lii:,'l!" [)I~>O~ kn; w,th pr('lIlmrnt ,lIld ,ften <1-!:-kmell1w {,.:"-~~:! '::mi( a} l'w)' body ;11~,"·::;·.' All ~ "::;: loth part IO~"' ·nl'm h'1;j n ;:1;-~ -\1') '-umpkx·f Guam P-..11 C'X.tll~ "'-~;-; itl deg''''U''r,jIlOf'''''.lj~iniUbllloll i il1!a"9ilf~lfi~ 'ni:-m ,'.W\",>Uopnv t,', 'Ill~)t~~ j'

h Off' p~ P ('lid "':lm1maJ fC'lLlr~\ )f eMI)' Pan. !".:.;)lJ ' di~~C' In ~I ... - ~ Wfle"' \\' (~.d!): "artmsun'l; rjl'.el'"e- Ltiatn :: ~ IUl.J i1 Mall _'lrn~nJ N.-:w Yc 'i;, l~mo_ M~dKal PUb,;.ithinj. i .xl

.. OIl

,nth per:.~ .~ Ion

Drug·lndueed Parkilhonism Il)fP) A variety of drugs <.:an ProUUl'(" t;\tmPYf;.umdal dy~fun(li(ln that IIlimil'S the signs oj PD. 'lhe",l' dru~ ... ar~ thl.lUgIH (0 llItL'rferc- \\-'flh dopi.lmin~rglc mCLh.HUMIl:-> t"ithC'f pr~~)nJp­ tlcally or fll)SbynaptlLallv. The\' includ .... {J) flt'ltrolf[1f1~

drtlgs !)Ih.:h ;j~ (·hlorpror~mlinc ~ (f'horaLme), haI0JX'nd~'1 (HaldoJ). thiodda.Line (\1eIJ.:.mll, and [hhllhl "«("l1c (~~\ J.n . . ):

(.2) cmtiJi'jlf"('Htllll (IrU~fi su,;:-h as .ullitnplyllll~ (rflJ\l~-, ;.lIth}Xapllle (A:-.t'ndin i, und tral(}Lh.Il1t,~ (nt;'- ~\TC"I,. anJ tUJfi/z 1'('rt('nSln~ drm:s Slith u.s tHeth) Idvp..t (-\ilk,'T}tl) und

e,)

Cl"sC'rpWe" Ihgh dc~~-s (If th~se nedic"tions arc parllculw-iv pi uhlenlatic ill the tided)' \VilthJrnwal of Ule$t" ageJlb USU~

lilly reVt"fse" the S}Il1PLOlil'S wnhm.1 tew weeks . ..llt.h0ughIH sou"e, ~ast.'s IhC'~ (;'ffel"t~ can persi'll 41hJ may N rel-iltelt 10 >;ubcllllll,:al PO

Chapter 21 llarlUoton's

\fetaholk Cans"", Par"'iil"llnJ,:l1 can, ~ (aused in ,rare l'asc:-. by mCL.lh",lk· 'onJili(\n", mdudmg disorders l,ll'aklUm mctahc.lh50m that l j;1I11 in Rei ('aktfi..:atlOn. The'e indude hypothyroidism , ~:perp;lrath) roidJ,m, hypoparath) rOH.Ji . . m. and \Vilsnn"

di'\'a."c

Parkinson-Plus Syndromes .\ group of ncuflxie::l'neratlvc dl,ea,cs CJn affect the subo;tanll:l nigra Jnd produ(C' parkmsonlan symptoms along ~dth lllheT n('urologlCal "'lgn ... These diseases include striatemgr:ll Jegeneration (SNDI. Shy-Drager syndrome. pro!!f(''''''\\{' ,upranuckar pab) (PSPO). Oli vopoIllocerebcllar ;rrophy lOPCAl. and conical---basal ganglionic degenera;OD ICBGD). In addition. parkinsonian symptoms can be exhibited in patien" with multi-infarct va ... cular disease. Alzheimer's dl ...ea"e. dIffuse Le\\")' body disease (DLBD), DOIlna! pre»ure hydrocephalu, ("IPH). Creutzfeldt-Jakoh di«..e tClDI. \\',I,on'> disco" (\\'D). and Juvenile Hunungton'~ di!'ea~~ ,\ 1any of these conditions are rare and affe('t relac\'el) small numbers of individuals. Early in their cour'e. these disea....es may present with rigidity and t~..~)'k.inesia mdlstingUJ ... hahle from PD. However. other .:iiagnostk ... ymptom ... e\entually appear (e.g., cognitive lDlPa~t in Alzheimer' ... disease). Another diagnostic feature IS that Parkinson-pius :-,yndromes typically do not IDaW measurable Improvement from the administration of anti-Parkm,>on medications such as levodopa (L-dopa) lherapy (termed the apomorphme teJt). -;·8

Pathophysiology The basal ganc;! ..:J {BG, are a collection of IOterconncucd gray maner nuclear ma5s....~ deep WIthin the bralO_ It IS C)Lt~

of the caudate and putamen (collectIvely tenned

])i.~

855

the Mnatum) rlu~ the glohm. palhdus, !\ullthalamic nucleus, Jnd the ~uh:-,t'lntla nigra (Fig. 21.1). The main Input MruclUre of the BG 1" the stTlatum. Input is received

from all parts of the cerebral cortex via corti..:ostnate pro. jection. The striatum also receives input from the suhsl41n4 tia nign\ (!-ubstantia mgra pars compal.:la. SNc). Output IS channeled primaI1ly through the globus p .. lhdus 1_£lobu'i p<.lllidus intcmum, GPi) and the f>ubstantia nigra l~ubst
'pinal cord (Fig, 21.2), Neuron, in the BG dl'charge before movement begins.~·IO The BG plays an imponant rok in the planning and pro. gramming of movement by selecting and inhibiting spe~ cific motor synergies. Motor programs are con'i.olidated into efficient goal-directed motor plans. translatmg thought into \",illed movements and regulating le\;'el~ of kinetic activity. mu~c1e tone. and muscle force. 9 The BG aho play a role in some cognitive processe:-,. primarily the caudate nucleus. including awareness of bod) orientation in space, ability to adapt behavior as task requiremenh change. and motivation. II PO IS 3::isociated with degeneration of dopaminergic neu· rons that produce dopamine. They have their cell hodies in the SNpc and send their axons to the qriatum. Clinical signs beglll to emerge with 30 to 60 percent d~gcn('rJl1on of n('u~ rons. Nigra! cell los\ b e~timated at 10 perL'ent per year anJ is more prevalent in the ventral cell 1,.'Toup. Lo!.' ... of the mt:ianin-containing neurons produce ... L·hara(l~ri ... tJc .:hange ... in depigmentation (Fig. 21.3). There are other Jeti(';lcncies in neunltransmltters as well (e.g., serotonm. nl)replll~rhnnel" The effect... of the ...e deplt"tlons are kss well urnkrsrood. Ai

Anterior horn

lateral venlrlcle Caudate nUCleus (heaf1) Lateral Y8f1lricle

Anterior 11mb, Inlernal capsule . ~Pl,Jtamen

FrontallCibe conex

~

f ~~ '.. '.. Caudate nucleus ;::::::r."JC.. , ' . -" . tnternal capsule

.-:it: w Ctaustrum

c"....., . I - lnSUlar

l·

-

~.

cortex

'T emporat lobe cone:.-

Putamen Claustrum

GJoOOs palildus Nucleus 8CC!Jmbena

Thalamus

Uncus

F~. 211 lh'!' CbJO! Un::' (Uf~ ,.1" Ihe

.. "

11 ganpJLi

856

Ph"'-ical RE'habilitatio n

Other BG d"orde" produce hyperkinesias. charactefl/ ed by eX(CSSlve or abnonni:11 movemcnh (e.g .• hCfnlballismus chorea). Thc:-.c are thought to result from undc-raclive mdi: reel pathway'"' while dyskinesia'!. dy~tonia. or uthelosis are thought to rl'sult from an overactive direct pJth\\ ay,'1 Tremor is Viewed as a release phenomena. repre~cntative of loss of inhibitory influences within the BG, Slgnific~lOt changes In striatal dopa~ine .receptors o:cur~. rc\ultmg in decreased bmdmg SItes for dopamme m Ihe BG. This may explain the loss of clinical effectiveness of L-dor' (~ dopamine lOA] substItution treatmen!) during later stages 01

CEREBRAL CORTEX

•

?GW

•

• • GLU STRIATUM

OA ~

. •• •

al,,?

. " ... -

- e

the disease.12· J3

- ... GABA SP SUBSTANTIA • NIGRA PARS COMPACTA

•

,

EXTERNAL PALLIOUM

-t GABA r-------~~I

-

Y GABA. ENK I

i

SUBTHALAMIC

NUCLEUS

.

,

INTERNAL PALLIOUM

:______ ___ ; _~ GLU

I .

THALAMUS

I "'~ABA

Clinical Presentation C ardinal Features

j

-'

Figure 21.2 Schemallc diagram of ..orne connedions of the basal pnglia. showing e\cltatory (+) and inhibitory ( -- ) S)-napses and neurotr.m . . miuen., 'The direct !'.mopallidal projectJ(m is bold shaded and the mdin.--ct projection is da... hed. Cortic.:onigral anC1 conicosubthalamk projection ... which are excitatory. are not shown in the diagram. (hom Kleman. JA: Barr's The Human ~cn'OU~ Sy!'tem: An Anatomical Viewpomt. cd 7. LippincottRI\'en. PhiladeJphia, 199~, P 255. With permission.)

the disease progresses and neuron~ degenerate. they develop dwactenstic cytoplasmic indus ion bodie~. called Lcwy OOdies. Other sHes (If pr~dikctj(ln include the dor,al motor r:Ulleu~ of the vagus. the hypothalamu,. the locus ceruleus. the cerebral CNtex. and the autonomic ganglia. I I Lo,s of dc<pamine results In .:m overactive Ifllilred path'" a)' that IS though to under l , .~ akinesia and ngldity. An underactive direct pathway IS thought to be rc·,pon .. ihle for brad) kineSia

Rigidity Rigidity is one of the climcal hallmarks of PD. PatlenlS frequently complain of "heaviness' and ",tiffness" of lheir limbs, Rigidity is defined as increased re~istance to pa""i\e motion It is felt uniformly in both agonist and antagonisl muscles and in movements in both directions. Spinal stretch reflexes are normaL Rigidity is fairly constant regardless of the lask. amplitude. or speed of movement. T"o types are Identified: cogwheel or leadpipe. Cog"heel rigid it) IS a jerky. ratchetlike resistance to pa,",sive movement a::. muscles altemalely tense and relax. Leadpipe rigid it) is more sustamcd resistance to passive movement. with no flUl.:matlOflS. Rigidity is often asymmetrical. e'pecially in the early stage" of PD. It typically affects proximal muscb lirst. espedall) the shoulders and neck. and it progress~s to involve O1u..cle" of the face and extremities. Rigidity may ulltially affect the left or right side. eventually "preading to imoh'e the whok body. As the di",ease pro~rres:-.es. rigidity become, mort' 'evere. Rigidity uecrease\ the ability to 'nove easily. For e,ampl~. 10"' . . of bed mohility or il)SS of Te'Clpnx'al a11Il

Figure 21.3 The ,uhstJllWi lligra 10 pn The upper lJye'(ZOIU

compa~tal of the !;uNitantiJ

nigr.! numtat:y has 1n:IH) mel~ tt.::ui.ning neunm!'). In :ne (J'3.I\Sve"'Sc st'.:tion through th(' mill

bram (left' me tiut"l~tanl13 mgnt Jf a pall('nl \\ lID PD ,hows J nurk,:d

acplc:(iQn of cu~lolI11Il-\.·ll~:;5mn& ilen-c \."CII:\. ThIS pn:xhk.p a . . :\

:en:_\." p.al1or I. J('Plg"lneI1 t4 t"k;!!. l D(lrtttal " ..... ,ovI. ,nghl), From RO\\l.mJ. LP .lcJI

.. ,":1pareti \\ith

Merrin s "~\.lbt..."l('Ik of ~(':!'!"l'"!:"'-i \

~.J 8. Cop}nghl L.ea &- rce:;,;"1."f·

f'tULsdeI,piuu, 9S') . ., tW. 1:101 ~ 'l\iuldn ,

Chapter 21 Par".n,,,n·. ~~ing during ~all an:- ofl~n related to the degree of trunl:al AdJ\ ' ~ movement. mental concentration. or emu· n·c. . idit'. • tional ,trc~ ... may all II\('TCa,c rigida). Prolonged rigIdity

n.... ult ... in dC'~ren,cd range of motIon (RO\t) and ...eriou ......cr.: ·

ondary lOmph",:atioo\ of contra'-.'lure and po,tural dcfonmty. Rii:ldity :Jj,o has a din:d Impact on tnl'fCaslOg rc ... tmg en~' exp:nditure and fatigue le ... el ....

Bradykinesia Patients \dth PD demonstrate prohlcm:-. with voluntary

nlO\Cl\lcnt Akinesia refer.... to aIJ,ence of movement. .\ lomenl' of freeling may Ol..'cur and are char:h.:tcrilcd by a ... udden break or hlock in Il11WCmcnt. Akillesla repre",cllh

a ddh.:it m the preparalOI') phase of movement control and .:an oc dlTe\.l.l)' influenced hy the degree of rigidity a ... well as ,rage of di.lie3'C and fluctu3l10n, In drug action. Disturbance~ in Auentiun and deprc.., ... ion can abo compound rroblcm~ with akine,ia. H~ po~ine~ia refer-. to reduced amplitude of mo\"et1lrol. Bradykinesia refers to ... Iowness and ditficult) maintainmg mo"ement. Movement.;. are typical1y reduced m ,~. range, and amplitude. Rigidity and depre\sion can alsc' influence- bradykme"'la. Often it h. the mo ... t disabling symptom of PD. with the ,lowne" and prolonged movement times leading to Inf.:rcased dependence In dai Iy

tasl:s

Tremor Tremor IS (he milial symptom of PD in about 70 percent of patients.' It is an Involuntary o~cillalion of a body part (lCcurring at 8 slow frequency of 4 to 6 Hz. Parkinsonian tremor is desl,.'·1ibed as a resting tremor. becau ... e it is typH,.a!"J presen: at rest and disap~ars With voluntary movement . This l!a usually manife~t as 3 pill-rolling tremor ot the hand. although resllng tremors Olay also be seen In the rorearm pronauon· ,upmauon). jaw. or tongue Tremor Ir.: the rowe'" limbs IS most apparent Whllc the patient is supme Tremor of the bead lnd Irunk, po-,tural tremor can be seen when muscles are used to mmntalO an Upf.bht po~iuon agamst gravity. Tremor tends to he Ius iC'\'ere "hen the patlent IS relaxed and unnccupled: It " diminIshed by voluntary effe.n. and dls.!pPClfS com I?letefy dur'ng sleep It IS aggravated hy emollonal stress ,·r fat;cu-: . In the e3J" v 'tages. tremor IS usually urulater .1.1. 4U1te m Jd and ocl.:urs 1'01 only ,hurt periods, whereas in lalrr liuges !.r!:mor can bet..·jme severe Interfering witll da.~l [unc.on. F"uduatlons,n frequency and intens.ity itTt:

l)i~ea:tc

857

IOcr~a'es po...tural instability. Patiem... aJt.;o e.xpencm;e incrc:a... mg difficulty during dynamic dC~lahilillng actlVlllC\ ,ul.'h .,~ ...elf·initiatcd movement..; (e.g .• fundional rc;.\ch. wallo..mg . tUn1mgJ and perform poorly under condnlon'i (If perturbed halancc. U The rc ... pon~ to in"tahllity i~ an ahmlr. , mal path:m 01 c:oactlvatlOn. resulting in a flgid hody and an inability to utili/e normal po<.tural !\yncrgies tn recover halance. I 6.,' Patients also dcmomtratt! difficulty In regulating fccd-forv.ard. anticipatory adJu~lments oj po.. tuml muscles during voluntary movements. 5.19 Comrihutmg factor~ mdudc flgidlt)', decrca,cd muscle torque productIOn. loss of avail
C'lUTIrnnr

Prn;tural Instabihtl P':Lfnts ymh PO ~1cmon'..trate abnonnaJities f'f ~ture and

1hcse

,,-h.m~e\

arc rare m the earl~' yean of PD ftt-r dlagnCriI~ ). A:.. 'Ihe (fls.e~':ie pronfkxlblr. pt"l'Sturat I,'_)pon

'.....~;I·,r are fi«'rl. lI'

NOll n)W~IC

l.lf Ihe has

'mgle-umo StJIlCC I "r ,:mnpet· diVided iUkntiL"111 IIIIJalloT't\)

,1'lWlfe .!.Itd Pi,- The NwJ)' pt"IUrt' or .. pilt~nl vdth PI) l.\' I ,onl \·K'U. ,81 'ilk \1c.'W. I' rum R~~lanJ. lP :.:...1: MClTill" "1('xl~ ,l( N("urolugy. ("J ~. ('op~ n,::hl I.c. & h:hl~\-' Ptul.lJdrtu.:J;, 19~~. p ~.:!Q. ""IIh pemll~s"Jn.)

Figure 21"

•

,.-..::858

- - .. Mn ~ic.al R('hahiliutioo

I'D ~\pcnencing faJls .md D percent falling m()fC than om.~ a wcd.:" The Tate of fall inJuT)' I~ ;.lb
tar), Illo'\'t'ments ~h"oclatcd with long-h:ml u"'c 01 anllparkin,onian medlc3tJon ..z.a Falls, can h:<Jd to "rcar nl failing" with tncn.'Jsmg Icycls of Immohllity and depend·

eoc\" with 3. dc..'lennralmg quality of hf~. Torque production I' deaea...cd at all spcctls_Tc,tllting m functional linlltatlOn, ilnd l11u,cJe wcaknc:-.~. ~·27 It i\

thouchl to ht' c;:tu . . ed bv in~utlicienl neural adival10n 01 Jp.(ln~st Illusclc:-.. Elel"trl~myography (EMG) !>.tudie!>. reveal that nwtor unit r~cruitmelll i~ delayed and that ont.:c l1lili~ ated is char.H..1eriled hy asynchronization: that is. pau\es and an mability to smoothly increase tiring rate as contrac· lion con1inuC's::!."~ The~e difficulties are compounded durmg 1.tH." prodUI."'tIon 'u f compk\ mO\·ements. A... the di\easc pmgTes5es. disu ... c Yo cakncss evolve\, incrcu!>.ing movement difficulties. lO 31 Patients who are in an "off" llatc. churactenzed by rcdut'cd leveb of L-dopa medication and dimlnlshed effcc!l\"eness, typk"'aJly experience increased muscle weaknes..... especially m exten~or muscJes.=5 In patient... with PDJot;gue is among the most common symptom . . reported. The patient has difficulty in sustaining activity and experiences increasing \\eakness and lethargy as the day pro!!re~\es. Repetitive motor act\ may \tart oul strong hut decrease in strength and amplitude a\ thc activIty progrC'3;se~. ~lovemcnts then become arrhythmic with frequent heSitations and aITe\t\. For example. the tlrst few words spoken may he loud and \trong but dimini~h rapidly as speech progresses. Performance decrea\e~ dramaticall) w th great physical efftlrt or mental ... trcs\. Re{,jt or ... Ieep ma~ restore t:Tlobility. \Vhen L-dopa tht:rapy is initialed. the pallent may notlce '1 dramatic improvement initiallv and feci !Sign!.! cantly less fatigued. In long-standing Jis~ase nd drug therapy. fatigue typically reappears. A C\lmmOn

pcn.:epli(li1 :lInong paw:nts IS an II1nell'icd sense of effort aSSO('wteti With movement that IS mamfested b)" difficuh y a(.,tivatlllg and "u~lamlllg rcspun~s. \10\1 pallenb With PD arc elderly :uu] .show the effects of gcneralilcd mus..::ul(l~ke.!etal d~condHlonmg. especially as the disease progresses. ~ on/raellf"('s commonly deyelop in hip and knee flexor .... hlp rotators and adduc tors, plan. tarllexors. dor"al !ipll1C and neck flexors, shoulder addu(.;_ lor~ and internal rotators, and. elbow flexors. Function becomes progressively more limited by these mu.')(u_ loskclctal con~tra1l1ts .. Kyphosis IS the mo<.,t common pos_ tural defonTIlty hec Fig. 21.4). Some patients may develop .\("olios;.'!. the result of unc4ual. dlstnbutlOn of rigidity in the lrunk . Older individuals With reduced al:livit)" leveh and poor diet are likely to develop oJtcnpormis.

Motor Planning Motor planning deficits are present With this disease. Movement preparation (i.e .. the when. where, and how to mitiate movement) is significantly prolonged fa findmg also seen with advanced age). This
Freezing episodes (motor blll"ks) ","'" and can b< triggered by confrontation of ,,:ompeting ~tJmul' F~ example. the patient slo\\'j or stops ",.ailmg when exp..-rsed tn a narrowed \pace or .Hl obstade Thc")c epiSl-...k..; 3rt linked to hradykinc~la .mJ dc~(-rrcased t.:lrcubt:n,g !r\'c!s of

~"t "t 0.. "'" ~ ~,~ lA",*,. ~~ "w'_~ofIw"""', (,4M~~ --1'~

""J-

~-...,

.. .;.

r. . . . ~.


~~;..--I~"

. -;) ..-r~

Figure 21.1i M Icr. Ih.~·r It:::..·.m ·:lb. (,

J!"!!."1uu.omlUl

Jill

Ph

n PD. I~;=~~ ~ilh PI.) ma .illS

J( I. 1"1,1 \\I

HulU Move Si,..

'1,,1 (;an I ~~: ~u I I

n',

4..,..

I:" ~,~blelT

._.-

f'lal'"

I

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.' U'g (jlul" )

; .....

I

2cm

r'U: s;';.Jk uf k ~. 1!!1 .I~·"I

''t" 'q

Chapter 21 Parkinson's Disease

(specifically norepinephrine and scro· . . n ) Freaing episodes are typIcally short-lived and usuWrlll1 . . , "111 be overcome by attentlOnai strategies or "hehav~,. , . ,I tnd ... ·· U':IlIlg c.xtemal cues (e.g .. droppll1g a tissue tnl~,S ' , , ""tepplnll response). tress can exacerbate Ireczmg oJ!!.'" . e oJ~s In ad\'anced PD. freezing episodes can severely epls ". l ",Il..;ll1iUCfS

~uro

t, • ' .

'

\

p

',,"

1111111 funct,on~

rJtient:-. WIth PO demonslrate poverty of movement. ·n'1..·. .d as an o\'eral/ decrease in the total number and LII.. Jl'~\. lpJitude of movemenb. For example, patients with mod;~'lTe or severe PO present with hypomimia. a reduction in the expressiveness of the face. The patient demonstrate~ a 11111SAtdli;cf with infrequent blinking and dimished animanon and e\pres:-;ion. Smiling may be possible only on ~l'mmand or with volitional effort. As task complexity incre3 se:-;, rno\'ement difficulty increases. This provides e\idence of a central deficit in motor plannjng.-~4 Rotation 1110lemenh are reduced, rC!:iulring in movements that are vas"all) umplanar (m one plane of motion). Constantly CO'll bating the etTects of bradykinesia. rigidity. and movement impoveri.-..hment can lead to mental fatigue and loss of motivation

859

abnonnal stooped posture contributes to development of a f('sliJ1atIl1R gUll, characterized by a progressive l1H.:rea~e In speed with a ~hortening of ~tride. Thus, the patient takes multiple shon steps to catch up with his or her center of

mas> (COM) to avoid falling. and may eventually break into a run or trot. Gait can be ullIeroplll.H\"(' (a forward festinating gait) or less commonly relmplIlsi\'e (a backward festinating gait). Some patients are able to stop only when they come in contact with an object or a walL Patients who are toe-walkers owing to plantarOexion contractu res exhibit an additional postural instability from narrowing of their base of support. Turning or

changing direction is particularly difficult and typically accomplished by taking multiple small steps. Problems with controlling posture and balance limit independence. community ambulation. and safely . .l9-41 Patients who are in the "off' state experience a deterioration in gait performance while gait patterns are reproducible when peak medication prevails.-f2 Most patients with gait deficits Can

compensate at least partially using external cues and anentional strategies. 40

Sensatio n Motor Learning ProcednTai learning deficits are common in patiems with

PD .h,1e deelarati"e learning is usually intact. However procedural defict!s are not universaL Deficits in motor skill learnmg have been demonstrated for complex and sequenflal tasb but not for relatively simple movement tasks,3SJti 111U, the processmg requirements of the procedural task are critical tIl determining the degree of expected learning df'ficlt~. Learnmg 15. abo impaired with random presenlailO'lS of ~lImulus condjtion~ (random practice order) while Mocled practICe order reduces learning difficulty. Thus .::mte~ mterferenct! degrades leanling in patienh with PO.H Deficits CJn he expected to be se\'t.'fe if multiple mllor p'l.'grams iU'e feyum::d either $imultaneously or iequeJlIally (1.(" swikhing among different motor pmUdUlS), For example. the patient freezes up when "s,cd to C'Mry out lmuther motor ta.')k while ""·(liking (dual tJskll1g). { }flIP~)Undlllg variahJe~ that degrade learning mdudt: tlK' 'he-! ty of di\ea')e. dementi;.t. and VllSUClJ pen':l"r tllal jttlc,ts,. Dltfercnce~ in leurnll1g c;·~m aho bl! e\peL·ted h>lSt'd JIl mcdK"ation levels, M!',lor lellnllng is de~ralled WitCIl Palit:D.b are "'off" ~late m~dlCJtion.l~

Gail AnOIlmalelv Il tc ~'i percent or p~UCnl- PI:Sf"llI Wllh 41 lnSlabthtv and galt t.lislumancc', :1'1 the'r IlIltdl ~~Or :-yrnptolH illiG co;:""pri~e " p('stunl Installl II)' t_lI:

~-d O'I('D) group. (Jan dIStur111lHC':S dJr" also ~t \:O! 't.lturc ·of l.ut':-\.)flsc"" 0:'" ut_l\'..lnced

'lhe rlt1i('nl PI) dcmonstrJk Ii number of (~~Juf.C...lt"t gi! t ... 1I;lr,.e::.)j I~ ~m Impever:-he·d -llIV mellt (1-\0>., 2! 1), "'II ('1>.1·

Patients with PO do not suffer from primary sensory loss. However, as many as 50 percent experience paresthesias and pain. including sensations of numbness, tingling. coldness. aching pain. and burning. These symptoms are typically intermittent. and vary in intensity and location. The BG is thought to participate in sensorimotor integration. with primarily inhibitory output directed toward the thalamus and neurons that project to corneal arells involved in somatosensory function. Som~ pati~nts report their pllin is linked to the motor Ouc-tuations experienced during L-dopa therapy (c.g., pllin is mort: inten!-e in an "off' state). Pain may also be inneased III patients e\.periencing depression,-fJ In is also imponant to rt:member that some of the discomfort and pain L'an re ... ulT from poslural stress syndrome seconci;.lr) to IJ\,.·!.. of mll\"eml~nt. mllsde rigIdity, faulty posture, or ligamcntllus . . train. For ex.ample, haLk: pain may OCClIr ~l' a f6Ult of a stoOp~J. ".yphtltic postUfl' SOlllt~ patients cxperit'TKl' ak.lthisi.a, a "'c'lht' \It an mnt:r i.llld n~ed to movc. ThiS motor ft'stk-ssfk'''S ilild agitation ,1tl't"("1\ 1:1'1 nw.n) ;,1S 25 p4;.'l"l"l'nt ul p.HIt'HIS and I,,) rdlc\\,:d wllh Illll\l'I1I{'IIl (t.'.g w~i1"'lIlg l'J" nhl\ ing lh(,.~ I 11th') \.. hilt- sei.lt~d). It l'an intl.!rll.'rc With rt'''r~.atlon alld !'th:~ep Al...tithlSI
Hun, 4

PWPli..x·CpIIV("

n.'.;.~lL1atl(ln \)1" \\)ltlnt~IlY

tnnv.::m«:lu lila)

'"T' ~ im;~rcd Pal,cats wllh PI) I'c[{";nm s1c:;nJtI.(\uuly wt.\rse than ~. mtrol 'IuoJet.'ls 011 tests kllle,th..·'SI.I. ,\ ithnut

or

"·I)ua! i!.tIHJ'UILC, 11311t:llh \.f;;'··lltm~tnilr HKn::J.:\I."U dlffl("uh~: 11 4'l;.lt:".lteiV pt'll..'(',\b,g Iht~ e\h~(\r uf llh1v.:rne-111. l:QUSI$

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Phl'5ical Rehabilitation

860

Box 21.2 CardinaJ Features and Clinical Manifc"ttations of Parkinson's Disease Pm turf' (' .. rdinal t't'atuN'S

Kyphosi>; ",jth forv.:aro hl'.1d I. c:lnmg 10 one side with tflnal a~ymTlletnes Increu!'.ed fall mlo..

Rigidil,"

13r.ldyli.ineslJ Trc-mur

··jf'molion Parcslhc!>i3<;

Pmlunlln'St3bilil~

Clinical \lanirl'statinn ... \folor /'cr[fJmlOncr

P~in

Akathj'l.Ja

L)c(:T3scd IM:'qUC rroducti ......

,\pach, ll,ia. and S~'a/lowing Vi~ordf'r,' }I) l)(llo..lnl'[IC dy"arthna

f.(II¢,U~ mlt~'

( , ,n!.!--:t:. Iuru and dd

common

Dp·rh~lgia

Hillor /'Iannlnc ~Ian

Co~"itirm PlIm:lioIJ alld lIeho~'it)r

hC5il.illOn

Ikmcnlla

Frt'C'.7ng: t"PisL.>d p,-,vern' 01 'n(I\'Cnlcnt \1:j;e:J .!:~ \1i ... ro;;"4~::'

Bradyphrcnia visum:patlal d~ficits Dcpres~ I('n

.\Iotor varning Proc.':'dur...J.1 eU'lln7- d=f7'ciis ',or compkx and ,;,cqucnrial ta,;,h

D y~phori(.. mnod

(.1U1

,tulono",i(' ,VermiH SyJtem (:xcessi\'c sweatmg

R:'dtk,:'== st: ';de '.:-~~h; ,ncn:.J'SeJ n('p-to·step v,maNJlry

Abnolw;ll ;;:en\ations of heat and cold

R.;.::!!.~ _-?:"'~ .:oif w.Jkr.;~

S~~'rrh~3

(..dc:nce (::.!eJl;- PC'!' muunc)

Sialorrhea

ad,,.,"~,,

tvpacally mtact: mav be reduced in

C.uIl'inpatiOI1

PO

double limb !.Upp',n f::~:;K .:"r ~ip. kn~ ,md ankJe flexIOn: shuffling step ::ru::~t ~I stnke ..... Ith inLrea.sed forefoot loading R~J~ tnmk 1'Qlati.-11- decreased or absent arm swing r ""S:~.,atir.L galt: antcn..'pulslon r..;llmmon ... ~~ ...~ of galt (FOC:

)ifflcull',)Jfflru!~~1

l'Tinary bladder dy~functlon ---_._._.- -_.-

CardioplIimmwry Funclion

Low re:.ting hlood pres~ur~ ( B1') COmprOl1l1sed c~rdim'~I"l'ular respon se to uefLbt: Imp:uretJ re~ plratory function

";;min~ incrc:l'·::;d st..j'lS rt'!. tum \\lth Ju:J f2.~km2.: s1multaneous motor and/or c, 'gni ,c~

"

;pie It.

~.

en".' lrt)1I1l H"j\~

Cmverumnal Jrugs (e.g., antIcholinergIc drugs) dsc:d In (!.g •• blurred vIsion and photophobia 1he.se ~rugs can "l!.o worsen the nor m:.. \'I:':J~: ..:.~anges a·.~oc.:::d with ag,:lg -prc$hY"pla ( ·'n.ugAte caze and uc.::adl(.. cy:- nt.Neme-nti. may 11:'0 f)e ':npaned fye pursui: mc\'emenls may ha\'e " Jcr.. y, ~,)g. wheeling ~ual.ly. lkcrea;ed bLn~lOg can pI >duc~ ol",>(]. :hOl 1:" :~!.ed ~v:~ that hum ~d itch 4]

PD can cause v sual dislurb:mc~'S.

Sp'.'ech, Vo;('e, and Swallo"ing J)liphagt:a, im~!!"~ .W.i!JOV.I=:: i\ pre t It": d,) man~' as ~ ~m "f Dat~-t!. and 1 the feltull of I:Lt}. -;juced of :\('\' 01 the :,'=~ !hough .. Y-~!i

\!.'

:h PD expentn(:~ (~ToI.l

Ihe

r:

p:"!;.:c . dC).

::~

~

\Ion. delayed swallow response, and p<-';':":::is. Dnphog.I; '~n lead to chclmg or aspiration pncumomJ and.rnpaimJ nutrition with Significant we'ghl loss, Nutr tiollal IIUd: lJuat,,;)' ~d.n "onlTlbute 10 the farigue urd e:\,~'UlUSfl("n t),PIf,:.illy expenenced by pallenf~ with PD. Pauems also fy:'ICJU~ expenence ('.'«:e~~lv~ ,,'n101'ng (.uiJkrrhN.. , as " resull of IIlcrea~('d sahvruy produc :C'O and. de1.'TCJSc:d :
Sr~::'"

IS IIllpatred U1

r"

:0

~tJ pen("nl 0: .....:~~:;:nt'i tr'.J "

fle ~uJI of prunary !!ii',-nlptl"::"'i of r 1) (r~;;ldl(Y b .hJyL. t'fJll-~l~si~. !.~ IIctnl~)" I~!:::nt~ "'Ih PO (\.,X"'!":~' JuC;OTl!2n'1 \'- ~1i..~ is 1.:11.;:.:-;", I::::"'"....::d t-\' ~L't 1c~·JnrpH~ h sJ'l~·h. Irnprcc~ ~

,

t.-:': dP.l ~

-l

breath·, JE~ hil.i~h. I,: •..q

ull'~ntT('IIl."tJ

spt:

,

,

i1

\\,'

Chapter 21 Parkin!ion'~ Disctie

difficulty of yocaJ . onsets and olfsets. Reduced mobility. restrictcd range of movement. and uncontrolled rate of mo. . e-lIlt.ot (If muscle ... cOlltroUing respiration. phonation. ~sonJlion. and articulation is present. Reduced vital capacif' results in reduced air expended during phonation. In ad\ anced cases. the patient may speak in whispers or nol at all. d('mon~traling mutism. Sensory problems may also c(.1otribute to speech difficulties. Patients who are instructed to upscale their speech sounds to produce loud speech <.:onsl."tentJy describe their speech as "too loud:' Speech difficulties contribute to social isolation and impajred activity ' 47 r.lffl_.C1p3110n.

present. Hypomimia, a reduction in facial expressiveness. can give the appearance of depression.-~IJ,.~] Patients C;ln also demonstrate a dy~·thymi(" disorda characterized hy variability to dysphoric mood, or a wide mngc of anxiety disorders, including panic disorder and phobias tha t occ ur at higher than expected rates for an elderly population. Social withdrawal (social phobia) can result from the emharrassment patients ex.perience from PD symptoms. Finally. greater anxiety is experienced with patients who are in the "off" medication stale. 52

Autonomic Nervous System

Cognitive Function and Behavior unpalm1ents m cognitive function can be mild (e.g., mildly Hnpalred memory) or severe. PO dementia occurs in approXimately :0 to 40 percent of the patients. Older pJ-rient~ appear to be at greatest risk fOf dementia, with reponed rJtes 4.4 times higher for individuals 80 years of a1!e or older. 49 Dementia is associated with increased mOft;lity rales. Coexisting Alzheimer's disease or multi-infarct dementia secondary to atherosclerotic disease are also common in the elderly and may be contributory factors in .;orne patients. Dementia associated with PD is characterized by loss of executive functions (planning, reasoning, abstract thinking. judgment. and so forth) and changes In \'J.~uospatlal skills, memory. and verbal fluency. Brad~phrenia. a disorder of intellectual function, can be seen in patlems with PD dementia. It is characterized by a s!ir/tJng of thought and infonnalion proces~ing. Patients typJCaHy demonstrate problems \I. ith selective attention and mshiftmg attention. Cogmti"e performance is degraded in the"off' ~tate.49, W Hallucinations and delusions are f""""~ ~mp1ications

861

owmg 1O l--dopa toxicity,

DeficilS 10 vlSuospatial ski11s are abo pre~ent in this disease Patirnts dMlOnstrate signiticantly more errors than norma1 m VISual perceptlon ta~ks involving ~patial organ~ .nnon. The BC,.n associaton with the frontal lohe, appear to p!J)' ~ Important role in the mtegratiun of f,,<:n~ L:;,ry mfonnaton. DeflC~".s have bee~ reported m vcnlc::l:l 'pa perc'eptJ!m. ;opographl" (mentation, body scheme, ~~,:j relatlOOS_ Mr"tor t~ ..:..,\-,:;1" ":"1g ge'-;tUidi mo"ement~. delayed !.oub!: l!:k-. trackmg, and construc\ie,1U! abll,ty ,..., ::np
."d

I" p~.e
PD l\1ajur , "PproXl,,·atcly 4(. pel

flcan! num!)('r,f "at:nh devcl.··p I .. f m<'tOf symplOr:cs. be '~Iatl>('l to

a.nel nl';f

Autonomic nervous system dysfunction (dysautonom ia) occurs wi th PD. Thennoregulatory dysfunction mcludes excessive sweating and abnonnal or uncomfortable sensations of wannth and coldness. Patients in the "off' state experience impaired peripheral vasodilation with difficulty dissipating body heat. Seborrhea (increased oil secretion of the sebaceous glands of the skin) and seborrheic dennatitis (o ily, chafing, and reddened skin) are common. Patients with PD exhibit abnormally slow pupillary responses to light and pain and reduced overall response to changes in light. Gastrointestinal dysfunction includes poor motility, changes in appetite, sialorrhea. and weight loss. Constipation is a common problem for most patients WIth PD. Urinary bladder dysfunction occurs with common symptoms of unnary frequency, urgency, urge incontinence. and nocturia. Many of these problems occur in the aging populatton in general and in men with benign prostatic hypertrophy. Sexual dy."ifunction is often present, mcluding impotence and reduced rates of sexual activjty.j~

Cardiopulmonary Function Orthostatic hypoten~ion IS common Patients compbm 01 Iight~headeJness and blurred vj .. JOn with position \:han.ge$ ~e.g .. ,>upine-to-sit or :-.It·to-~tantl) or follo\\ mg c'!.ercis.e Oral L-dopa mcJil.:ation em exaggerate s)'mptoUls ot oltho"ratic hypott'osion. Pari~t1ts With ~u.hJnt:ed PD a].;o exhihlt 10"' re...,Unp. blood pn:'isur..:: (UP}.' Can1!(lv;:hl.:tJiJr n:llcxes L:an be comprollll~ed. «Iusmg "hnom1.al \;;j.fl.hJc, responses to exen..-iscc t~or io!\ample. t~u.:hy\" arula in respon.:o>e to e~erclse may tX! suppre::;~ed.~' ' ( ar(Jiae arrhylhmia .. c;.In oCCUI" and IiIre aSStl(.\.JI.:d

With mos.t ilflllp.tIklliSOlUilll

medk~dion.

p.Hiertt'", WlllJ PI) Jemon!>tnne re-spiwlory IrnpJ.lrfneurs. per;:mt of pi.lltcnt.s. AICWJj )t'SJ"i Ilct:ou 1.=. g ,air tr.lppll1g, Iuns to'iuft1atlon} IS the rno\(

cq:::>Jted

!11

as many

,115 10: ...

1_"e~uei:lJ:t :-c-p0rl ...>.1 l'ulmtlUal"

prot'Fkm and h3S be(n 'inled lO tph{M,k'lo .A puifli'1nary 1J11urc I he t'lwlogy unknowH bur fll"lY bs: IlnkeJ to bnllj},k.mcth,: ,,!is-or r';:,!>i'IC<.lton mO"i!nICn~, RI,;~n'illl\'<- liulg d)~­

fUI:~tum J"i Conunc.Jl ml'!.Ci~"'.

and

.~ IlIdr.~d

t(.1

rhe

dc:\r~aM:'d ,,'~t

that {,,:';un, .1.~ a re . . ulr of n~ldJly or the rfunk 1m', ul mu.'-t.·uloskektal f1c':ul'lllny. 4fld k),phoht.:

862

Ph,·.kaJ Rt·hahilitation

ll(l~IUrCc 1>,lIll'nl';' \~ ilh PD dcmon"'tratt: lower I<m'cJ \'ital 1::ar~lclt) I F\'C\ lower fnrceJ cxpirJlOf)i volume (HS ). and IlIgh('1' ft:slduaJ nllume (RV) and .lIrway r('~l'olan(C tRAWl \·.tluc~ "hen ((lmparcd 10 Jgl~-Jl1J",:hcd conlrnk Dally funclwn dnd al'lInty pal1.lcipalion arc n:duL·cd 111 p;llir"nls \\ Ilh rulmnnar) d) ,fUnClicln. ~6.S7 A scdcnlJI)" lift: .... ylt: \\ ith dccrca..,cd adlvit)' Jc\-ds. l'I 1 ntribul6 W l'ardiopulnlllnary dc-condillOning, Lllnited rC',"'an:h .. ugge .. h that palien" wnh mild to IlltxJcrJIC PO do nllt apJX'~lr to demon"tratc signifiL'untl.y different exer· CI'l' C'~paclly (maximal hl.'art rate, maximal oxygen con· ,umption) '"' hen compared 10 agc~matchcd controls. :'18,5<1 Ih)\\C\"CI", Iht:Sl' patients did demonstrate der.:rca ..cd peak p<.mcr, and highcr subma\.imal heart ratc~ and oxygen con.. umptlon ralc . . than controls. "9.60 In lon~-qandll1g disease, thc lower extremities may exhihit l'JrcUlalory change~ owing to VCI10U~ pooling a~ ~ re"tIlt of d('("rca,"~d mobility and prolonged ... itlin!!. Thu .... paoents loan prc ..ent with mild to moderate edema of the feel and ankles. w"liel-t usually subsides during sleep.

Early diagnosl~ at (m"et of PD IS difficult with a~curate~ di3£!OOS" po<',ihle only with continued ob~ervatlon 01 evol\'mg dinir.:al ,ign') and symptom~. There i\ no single definll'~ test Hr group of tests u ..ed to diagno\e the disea~_ The diagno:"l\ I~ made on the ba~is of his(Ol} and cl~rtieal ex.ammatmn. Hand\\·ritll1g ~ample~, speech analysis. interview 4ue'tion~ that foeu';. on developing .. ymptoms., and physical examination are u..,ed in the preclinical stage ~o detect early manifestation ... of the di..,ea ...e. A diag~ ~,j of PO can be made f at le:t~t lwo of the four cardinal features Jre present. [:cluslOn of Parkinson-plus syndromes IS necessary. The presence of eXlrap)Tamidal sl.;ns thaI are bllate.-.J symmctriul and do not re'lxmd to l-dopa and dopanune .gonists (apomorphine te;11 is sugges!Jvc of these s},dromes, not PD.8Imagmg. can be used hl rule Out other pathologies. In vi\',;:. functional lffiagmg (magnetic r;:,:n:mce Imaging. MRI i usmg chemical markers to Identify dopaminerpc dc-ficus In PD and related disordc!'S Idenufles dopamme defic:ency but does not dislfllulIl:ue CilUseS

Minimal or absent; unilateral If present.

II

Minimal bilateral or midline Involvement. Balance not impaired

III

Impaired fighting rellexes. Unsteadiness when turning or riSing from chair. Some activities are restricted, but pallent can live Independently and continue some forms of employment,

tV

All symptoms present and severe, Standing and walking possible only With assistance.

V

Confined to bed or wheelchair

---

From Hoehn

and Yahr,"'" p 433. with permisSion.

to be at least 5 yea,,·' Before I.-dopa therapy, 28 percent

Medical Diagnosis

~v.-een PO and other

Hoehn and Yahr Cla.. ification

of parlmo;oniMJl. PI'.sitron

em:!:'"ion ll:mograJ;lh)' (PFT, and s.ngle·photon emiislon

I~rutc-ized tomi-grJ.phy (SPEC r 8'_ lOS .lrt ~mergmg tedmolo)rics that have been use-~ In human studies but not in --:JUline di~c!.~

CIinicalCourse

of patients became severely disabled I functionally dependent) or died WIthin 5 year... of diagnm.is, 61 percent withm 10 years. and 83 percent within 15 years. Folio" Ing L-dopa therap)_ only 9 percent had become dISabled or had dIed at 5 year,_ 21 percent at 10 yea,,_ and 375 percent at 15 years. Overall the mean survival has lI1ueased hy .. hout 5 years since the Introduction of L-dopa. 6l There is. variJhility of the rate of prohTfession. Patients who have a young agc at onset or who are tremor predominant typically demon ... trate a more benign progressIOn and a relatively good prognosi'l. Patient.;; ,\ ith PO \\ h<) present with pos· tural ,",tability and gal! d"turbanccs tthe PIGD group) tend to have more pronounced dCI~riOf.ltkn With I! .nOTe rapid dlsea..:;c progression. ,\"eurobehavlOral ~Jsturblnct"s and dementia are aho more common in this group. :\1ortality j, u ... ually due to tardiO\'uscular ~;sea.."e or pJlC'U~

monla." (,1 An e . . tirnate of the Mage and severity of the Jjs

ease cun he made u~ing .I stagll1g scale The most w:deh" used " the lIoelm-Yahr CluJsl/icut!tn -,{ DaahillIT \calt , 1:lhle 21.1)6 It pn),id"" & ""ful measure for char!' ng tho t"lr0,gre . . s.lon of the'" disease. Stage J is used ~. Irdic.:t(' nun Imal Lliscilse inh)lv~mC?I1(. whereas "uge \ is InC!'-J.ti\"t ...·f Kev~rc dctencratlOn In \\-hiC'h the pallent IS ,onfined Ie he'd or it \\'~eekh __r

Medical Management 1\1~!\.:J nunagement ;::. ~.• rC'... ::_ dls.~a~-: pr.:.:.;r.: :;:;.:;-.n, .t:d .l!o.Yr._rlt:ma:~

fherc D no CUre f::r H).

\A.·h· p!".;:~n:-:;':-J\""' 't\ith a loop, t.:.:tx.'hm('JI 10d hnthoullfpparrnl chrut;:.d nuni :~ ta.:...on\ •. c:-timated

il l. 'vw~:tg .ef

trt'arm~nt rt m~: tOI fC: •. :~rcs, r:~O~"r 1,.-- m;Ih..;IIH n." ,A non· mo1'r f~alu:-e1. \11::'.:1 anti· p.ar1.:;~~.oni3r mcdi':..:l1('·""l'

864

Ph,.·liOlI Rt'llsh.litation

lluclUJllons. Ad\'C'f'c cIlL·CIS arc ~mlllar 10 those 01 I dopa with OIlh(l~ralil. lighth(':IIJedm:s ... and n;tU~a heing the to mOS( C(\lllIllon. -

AntkhnlintrJ!k ,\f,!cnC ...

Anlll.holmC'rgil: at!~nt'i art.' used 111 c:.lrly untreated PD or 35 ",,11 achulld fnr pal ten" (111 Icv{x.l{lpa. Th~y hltKJ..: cholintrgll: (lIIKllon nnd hah.' Ihl.' I11U"" Ix'nellt motic:rallng Irl.'I1Hlr ~Uld rigidifY they 'l;1\l' huh: or no ('fh,x:t on hradyJ..:1 n~"'iia. Jnd pn,lurill inqahilit) - They may lx.- given in (.'on jUlll.'th1n \\

itll l.-dnpa

til ,mooth

motor tluctllation ....

Tnhc\ypheillJyl {L\rtancl. ~nltropinl' (Cogl'ntJn). etho· rropaline (P~II"td{ll). and procyclidine (Kcmadnn) aTC ,,:omlllonl~ I'l"c'l'nht'd drug ... in ,hi ... group. Anticholinl'rgll' nd\l'r~e ('IIt'I.'IS indude- hlllm:d vl'\ion. dry mouth, diZli~ ness, t'on ... tiratil,n. und urillar~ rt!tcntion. Central lOX it..:" ity is InJt~~a,C'J hv imp~lII"tJ TllI.'m0T), confusion. halluclllations. Jnd delusIOn .... ~

Amantadme (Symmelrel) is an antiViral agent that ha~ 3nl Parl Ilson dlt'l'h It potentiates the action of dop:mllne: in lh~ (''\is Paticllls talmg amantadine: dC'monstrJtl! modest IInpnl\Cmellt in tremor, rigidity, and "rad)J...inl"sia.

Implications for the Physical Therapist The IherJpi,t needs to ht! fully aware of each of the med·

lcations the patient j ... taJ..:ing and potential adverse effcL"ts. It ;:i impoI1.1nt 10 n..'J1lcmtx'r that patients on Icvodopa therapy

Table 21.2

Nutritional Management A high-protein diet can block the etfeclivene" of L-dopa. The dietary amino acids in protein compete with L-dopa ab,orplion. Thi, t' particularly problemalic in pallem, with chronic disease who exhibit nuctuations in motor perronnance_ Thus patients are generally advi ...ed 10 follow a high-calorie, low-protem diet. Generally no more than 15 percent of calories should come from protein. Dietary recommendations may also include ... hifting the intake of dady prott!in to the evening meal "hen patient... are less

of Parkinson's Disease

Anlicholinergics

Trihexyphenldyl Bentropin

Dopamlre replacemert

Dopamine agonlsts

denl(ln . . trate tluctu.llJlln., related to ITlcdk:ation cycle. Opllmal ~rttlml;II1CC ('an he t~XllCl.:ted al reak dosage \\ hen::I'i wnrsenmg perfonnance IS Jss<X:latcd with cnd.of. dose I.:yc!c and medicalion depiction. Thcnlplsls are . . Il1volvcd 111 monitoring, drug. cttecllvencss nn motor pe r· . . fomlancc. function. and adlvlly partiCipatIOn. As the disea~c progresses. patJent~ I~ay develop a (nlcr;mce for a par. tlCular medication. necessltal~ng a (.'~ange 10 prcst..:nptlOn. Otten. it is the thl.!rapl!\t who first notices a Change in fune. oonal .-.tatu~ as the patient's .sy~tcm adapb to either UIC amount or type of drug preSCribed. Accurate observation examination. and reportIng of these changes greatly as\i'a~ the phYSician in modifying a drug prescription. Therapi\ts may also he involved with clinical drug trials as new medications or combinations are developed. Table 21.2 presents an overview of the pharmacology of PD_ Illily

2 mg lid 1 mg bid

Dry mouth. dIZZiness. blurred viSion Tachycardia, dry mouth, nausea. vomiting. confusion

Levodopalcarbidopa

10/1 00 tld/qld

Sinemet S,nemet CR

251100 25/250 25/100 25/200

Dystonia Abnormal, involuntary movemer'lts Nausea. vomiting ConfUSion Dreams, hallUCinations

Pergolide

1 mg lid

lidlqld lid tid bid

Nervousness, dyskinesias. Insomnia

halluclnattOf's. nausea, confUSion. Bromocnptlne

Amantadine MAOI·rj

d

~W1C8 a -usy, ~tf

5 mg bid

tOO mg bid Selig¢ :~ne

i,hree times II!! day; ~..,

'-1AOI-(l.. mon:-amine }xidase lnh4:ii.:o,. ~ 8. F'r;.:i'Tl C;ut:::'l:. or et al p )6, wit'"l oefmlS~lOn

erythromelalgia Nausea heaaacho, dizziness, fatigue. cramps/constipation, contUSion. pulmonary/peritoneal fibroSiS lIghl~eadedness.

livedo reticular!.'

edema f> mg bid

'our times a ddy

Nal..:oa, cre&ms. hallucinatic;ns, confUSio" .jys"-,nesias

(.' haptef' 21 PaTkin.,on's Disease :.I(tiu·, Thcs~

modilicJtions Illlllllnil.e motor tlu(w:Jlions ;lnJ l11~l\imile re~poll"'I\'Cnc ...... to l~dopa therapy. The r~ll1Cnl j.., encouraged to eal a \'ariet)' of fOOl.b '-'nL! Tllay be ad\'l."ed to take dietary supplements to ensure ucicquate inlJ"-e of vitamins and miner~\ls, Patients arc also advised to increase lheir daily intahe of v,Jater and dietaJ)' fiber tu allcnJ{c pfllb1ems of constlpation. os

RigIdity and bradyJ...me ... ia can limit upright posture amI urpt~r ('\tremiry (LIE) feeding movements. Leamcd motor plJrls. for {'\ample. U~U1g a cup or eating uten.sils. may also Pc difficult. Occupational therapy intervention to improve feeding and recommended adaptive eating devices is of consider:lble import,Ulce in helping 10 maintain nutrition and general health status. The speech-language pathologi..,t also has an important role in the evaluation of dysphat!1J. and the recommendation of strategies to aSSist with , ' swallowmg dysfunction. Patient. family and caregiver edu~ calion should focus on the importance of maintaining good nutritional intake.

Surgical Management Surgery b an accepted treatment for patients with ad\-anced PD who re~pond poorly to medication or who e\rerience complications related lO pharmacotherapy. There are three mam surgIcal approaches: ablative surgery. deep brain stimulation (DBS). and neural transplantation.

Ablathe Surgery St~rt!otactic surger~, the surgical iesionjng of the brain. was plOneered in the 1950s. and is in current renewed use ;;wing to the increa;;,ed accuracy of imaging and surgical equlpmem,6"! Pallidotom~ involves producing J deslrucrive lesion III the sen . . orimotor portion of the globus pal~ lidus. mtemu,-> (GPi), The lesion reduces exces'\ivc OPi Inhibitory aL:tivity that results in tonic thalamic hypoactivil'}'·. It IS indicated for L~dopa~induced dyskinesias, . . c\·cre "'on·-otr bti1te fluctuations. rigidity. and tremor \I.,'hil~ bal~ anct', gall dis.turbances, Irer/lIlg" and hypophoOia are less rc:ponslve LEec'::.. are contralateral and ~nt.'fits appear :) be long lastmg ThalamOlOm) mvol\'cs produ(:mg a \1~~trw:tl\'... lL~lOn vdlhm the velltri11 inl..:-rmeJiatc nucleus \'IMJ of" tbe :halaI 1us, II has heen ...hU'A'1l 10 l."tlt.'\.:tivl.'ly fe.:.J.uce tong:landing tremor that il) unrespoll':iiv(' to drug JlJC!:!!.:nenl tUld may )ffe, ~me !ll1pmvrmem of riglliity. II not dfc.ctiv:.,. un s\lmp!c·ms of blJ.d)kmeslJ. or galt 111iJ' tuli-JJP.~·:. BH:.!!er.1.l :UIJII,...J.! le~.nns are llsuillly out J~t.:~ --: ~ because of u hl~,~" raw )f Jlll,lm COmpli!;3tlOns. lall\' f'~r::_l_~ and S\\ :l.lluw;ng di)TiclJlues, Kt:I'oned 1

1i.~t<; of .'ur~;Ll1' Lnclurle Ilt:Ulonhage_ IIlf.lf\.II(lll. 'on. ~!"_zur.;'S, "'..Infu"ion, (kprl!',ssJon JY~'a rthr la, or d('":ilh

Dt't'p Brolin Stim.. Iation De, p

br1Ul

I'r,mulatiun UBS) IDVOh"~,

c:~':lro:1.e ...

Inc

ImplalltaHon

tnt!. the br.:til' when: thc'! bhll.};. ne(w

865

signal<. that c:uusc symptoms. Stimulation of the VIM of the thalamus i<.; commonly tionl;! with severe and uncontrolled UE tremors that are unresponsive to medicatIOn A pacemaher IS implanted in the chest, with a thin wire that goes undcr the skin to the brain electrodes. Hjghfrequency stimulation is provided. The patient can control thc pacemaker's "on-off" switch while the physician determines the amount of stimulation it delivers. tailor~ ing it to the individual's need .... Total suppression of tremor is observed in one-third to one-half of patients. il ThalamIC stimulation is not indicated for other PO &:ymptol11s, 'Its major advantage is its potential to alter tremor without producing an irreversible brain lesion. DBS has also been shown to significantly improve patient performance on instrumental activities of daily living (lAOL), with the greatest improvement noted when control is for tremor in the dominant hand."!2 More recently DBS of the globu, pallidus (GPi) and the subthalamic nucleus (STN) ha; been used to ,uccessfully control other PD symptoms of motor overactivity (i.e .. oo-state dyskinesias. akinesia, rigidity) along with tremor.7J.74 STN simulation has been shown to reduce the medication requirements in PO?5

Neural Transplantation Transplantation of cells capable of surviving and delivering dopamine into the striatum of patients with advanced PD is an experimental treatment and currently under investigation. Studies involve the grafting of embryonic stem cells from umbilical cord blood or fetal cells. Ethical considerations are posed with the use of human embryonic tissue. Sustained clinical improvements have been observed in some patients and not in others. Variability in term:-. of efficacy and outcome ma) be due to cell therapy techniques. Younger patienh in the early stages of the disease appear to show some improvement in motor function. Adverse side effect;;, such as seriou\ u;.. . . kinesias in more than 50 pan'nr of pJ.tients have heen r~ported.70 Patjents u'\uall) undergo immuno· suppression follO\\"ing surger) II) rl.~dllCe the ri~J..." of graft rejection. Curn:ntly under il1\~sligatJOn are tel.'hni4u~", to expand ct:1I pnlduction and USC' f!enclKally engml'er~d cells:' AV~Ii\abjlity or transplantation prol.'C'dure . . i . . very limited

Framework for Rehabilitation RdHlbihL...tfion h::Js an ItlIptHI;mt nIh: Ul redu\..'ing fUIll'Iional JjtrHl.III\HI~ whtll:' prolllOtJIl~ ;I~'UV!I) pJrtil..'ipation and IOdl'PClltll,'"lh:e III ..lddl[I\\!1, kuown cnmpl1L'alion~ uf

PD I..;\i! 111,: r~:-dll,:eJ or pn'\'ent('d wilil" qualll}' of life is pr"'lTloted npl1IHai 1It:U1Jgclllelil 1m olves a cl)()rJinated iJllcnlls(:,phnar)" h"am to ('I\'ersee.1 cl)mpn,'hcns1\'c plan of" "Jfe ulll tuidr~,,_~ lhe piJll ..'nt"s individual ,,:Iink'al prVblc:ms.

,66

Pbnical Rehabilitation difLcult adjustmcilt tc' hVI,ng wlIh a chronic and prugresSlye ,liseasc-

()I'k.,cms..1Ild nc-c\h The learn tyPlc:llly mLludc!S the "~ysl'-lan. nUise' P.ItYSll~ll thC'Tdrist occup~!.'()nallhempl.st. spet'lh.~gt.:3b: patholopst. and SOCI!l1 wor"-:er, R('fcrral ('I (lthe'!' !p.."cJIi"'t.s ma" also t,e ncce~ry for lxamplc. psyc 1)t.:-~('IgISI. nutrltit.:n:st. gastroc'1tcrologlst. Uj" Jlosi~t. nul:n.illologis; and so ror1~ As"'.Ih an~' lear.-'. r'lc pa.tient

Physical Therapy Examination and Evaluation

tht ,,:culral fi£ure with fL111::)' '.lOd c m.'glvers bemg key mC'moc-:' Tht:' Ideal r:a,abilltation pr=gram l"C'nsldc-TS the. pat.rol's ti_,,~~ease 1ISI('l1)', .. ,,)U:-'Se lnd 'iymptC'ms. Illgcthcr with impamncnb. functill":lllimit.!tion~_ and disJolIIIY. Of equ~11 impo:1ancc JfC '''c patient s abllillc";. (ru.scts), prlOflln,:'S, and '-C'stJurcc inc1dlOg fam~ ,)' home d..;,d cCOlmunitv n:~u':-.:.::; Dc":c:irT8Iion ..:f C'on~:: on and mcdil.:ation indul~ ful.. .!3tinns an ''lCrt.::mlancc shc-uld he e,\pet:lcu. 111: o\t:'"'all focus oj ~n lon~·r;lnge plannmg. Wit!: antid· F-IcJ ~pirode!!. c~ c..:..-: :~duding hosplt..!t based, outpa ti0t.

L.,-:;

"'ome,/~::mm un.!)'

basC'd

A comprehensive examznation IS required to dctennine the lev:1 of IInpalmlcnts ,md degree of function, Su""'sequcnt reexumlll3110n at "[lCcificd mtcr\la!:;. IS u!',ed t0 distinguIsh change? 111 ~latus as well a.., elrerts 01' treatnH:nt DOlta are ohti.-IIned from .he patient's history. systems re\'lew. Ilnd rclevalll lc~h and mca~ures (Box 21 1). The seiecfjon of exannnatl(m procedures dnd level of inquiry IS dc:!ennmed by Ihe paliem's uriquc status. The sevenly of problems. Mage ~If disea~c age. phase and setting of rehat;.lhtatlOn. ,,"d other factor~ mll'St all be tJ1.en into ac..:ount In E!rUc~:Jring the eXilIllinauon oL,d cvolh.:''::'Ung dJIJ. During the c'uly and r."lddle ..::JzelJ of PD. mea~ures of tmp3mnent dnd phys,oal perfonnance are ",Iati,.;:-Iy ,table" Dur'"g I,lte stages of the disease ""d Lndcr condi;. 00.< of f'uctuo: 109 symptoms" Ith phannacQloglCal IllStability mea,,"< C,lD be expected to be less stabl, This sccf:on prcscnt~ str.ttc~ic'i ")r cx.IDunation 4.~ w .IS relevanl lesls md measures. A cemplete descriplion of many (f Ihe Icst:; and me3Surcs IJcntif ell lrc pro,-Jd . \.. ~licr l:haprers fo"us.ng on c'\tmirutlon,

c~.::

-'::~~ao;;.e c~e (cz.:I)'.

A ('ontinuum of niddle. late) IS d!'J

~!f~:j\'': W,3\' 10

or1!an:ze ...are lnd IS prc'i~... tcd In 1'lhle 21' Intcr\·~7..::ons .:,:-.: rc$tor;!~:\'oC . aimed at Improvmg ;:.!!rtnC'lts. ~';.:nc:",,:;,,;:,,: L~ltati(lns. dnd dis~~lhIICS,l prc\'en;..::ve J.I .....-ed at minimizing potential complica' l:-'!J mdlfec~ lmpalnncn:..:.I. ane t;ompe:~satflry modtf) .:"g the La~l:. actiVity.. ~r e~v ,ronmtn~ (0

fun,;:<·r.). See l:",""",on .n (,hap,er I II IS crI!· for t~ v.hele team 10 p-rt:\'ide a su;,poniye C'lv~n· .:~: tl.) ,,;::';;::;.1 p3tirnts L'~ !~eir fan11. \' :nembc.rs ,:1 the

;.

Table 21.3 (hen;.".' of ParLin,,, ..', Or Ea(y

r,jrldle

Oi..,a~

.' .I

Fully! May new .ontIateral

AntJcm!:~c~

trem<

protection)

C

Levodopa!carldopa

('remer\

Selig;.:ne (possible neuro-

Sf;~J

PrevL.':tabve exe:-.:.~

:G:..'t
program COfre<;llYf)

~\lrmalion

exere!

(',

p'_lIrar M

r-.

Ie_

M &V'mn!...._"":",~

1IoI("'_~A

t - ,I

Lev;>dc~.c.!~

Dc;.:...

Compen2!: 1Y and

May

!Ia

'"

------.

AI) ~

-.

p-."

Ar::~:~rc~::lS

"c_ riy ,iI"

C)'eQI

•

(hil"tt"r 21 "arkin."ion'fIo Ui:se,,~

867

BoX 21.3 Flelnent..., of the Examination for a Patient with Par kin..,on·s Disease"

'\\!'l\lblC .,;apaCII)' ami

Paltit'nl flit'nt Ui .. !t)I")

Jnd swndaroiJ:rd

;C. ~,. rd~"(''clhl1lc1tv

rilmao lanS:UJgc, NUc.tUon • SOci~( hio;.lOlY '-.ultlll.lI helieh and bchilviors" f,.unily .mct

.md pulmunarv

1..1fi.:[:i\'cr ~(·un;l!s. s(xl.tl fUrrOI1 s)"1'tctm

• (A,,,·up..Iti"n/cmph"l\ -menl!\\" III • LI\ 1fiJ! cn"il ,'\tlm~nl hptnt:' wnl k to;u llcrs

· I hnd ,101111n30t' oUcnr1.1I1IC.1llh sUlu$.; rhyslI.:al. r~y",'holo.f!.il'al . Soona1, alld role fundi,'n, hC';thh habit • hmily hl!'lOT)' • 'kJi\.·aV~urf.h,;.ll history

• Currt"Tll (:onJilion~~hll!' ('omplalnG • \lcdic.ltIon • \!CdIC".al1.lhofJI0f}' lest ~ult... • Fum. til,":!.] statu'> ,:U lJ .l'r.:ti\.lt)' I~\'et: p:i"cmorbid .md currenl ~\-sl('",\ ~('\' il'\'

• ".:u(.mlU!w.:~:.iJ' • ~1u~ulo~l..d

It''SI'' und

\teasun~

Impairl1lt.'nh

• (~-';mtir-.n: TT!'.:::U;.J statu"', mcmory hc-sllatinn, sltlwnc~' of thou;ht (:'r.a.,,-..es .OromNol lunclic'n' commUnication (I1Ul~lu~llh"n .... rc-dw..'elt \.)!ume , s\l.lllo,," ing • 'P~v..:hos.oJ\..Ial fum' tilm nll)f1\'ation. am.lel,·, dep~,)!ioipll • \ntt-~'"1'K''!'Il('lril. t.hMllClt'rISHL'); N.kl~ mass lillie", girth,

k"l:"ll. eden wlion: r~~pom.>-: 1('1 1X

I~

po~iuon

changc. orthostatic

lind symptoms

~Iowness.

UITCSIS of 1\100'C'Olcnts; poveny of mOVClllc.'nt

• PWt:edur~d klnling lor complex and sC4ucnllat usb • Po!-tur~ll ~'(lnlrnl .mt! halaJK~; degrec (If postural Inc;tabtlity. P;tI.U1C~ !-Iralcglcs; Silkl)' • (;JII and IOt:mnlllinn; gall patten) ami S~"Cd,lWfcty • I;Undil)n~1 ,t:UlI' ,Uld 'I(II\-il)" !c,"el: perfonnancc-based ('xamIIlClIll'nt lit' fUIlI,'li(lnal ,kill ... lJ-lM level), basic and in."trument.d Ant.; fllndlonal mohilily ... ~ilk home miUlJt:t"mt"l1t s,l>;iI1s • A'sl"'uVl' 01' ad~lrti\'l' dC"ll:C"; lit. JlignmC'111. fum:uon. uS('; sat\,'I~

• l':n\lhlflllll'ni. hom1!. and work hanlcrs • Wt1r~. ~·onHlHltlil~. and ICI"urc tJ{'tiVllics: ablhty hI parth,,:lpalC In

':"

sl~m

dunn£, fuoulonal activitar prolo(ols inL:luding ..:an.hu\'a~ular

• Vc:ntil3l1on .\Ill! &.Js r~l hanEe" • Integumentary mtc:r,rity: skm l'ondilion. prc",!'urc senSitive llr~:ts: a .. ll.vitil'.... po'iltlPnmg, and posture.. to rellC:\lc rres,ure • AUlllllOI1HL: ncrv{1U~ system inh:grllY Ihemlal re"ronse~. SWl'Htlllg • Sl'll'iory illlcgnt) ~lIld inrcgr:tfltlO • I';un: II1I('n"ll), and Illl'atiPIl • l'rrcfptual lunl,:lll1n: vj,umpalial ,.~ills • Jl11111 1IlIC~nl). alignment, i.lnd mohllity; r~Ulge I)f Inflllt)ll (lftClive lUld pas.... 've J; Iml~\:le length. tUn] S(lft IIssue e'ttensihltit)' • Pllstun:-: allgnmenl ,Ulll (Xl~illon, symmetry 11Ilati.;; and lIYllaTTlIc): Cr~(lIlOmICS, and hotly met:hamcs • t\ tu ... d" P'o!rformaoce: "Ircngth. po\\:er. and ..:ndurancC' • Molor I unL"hon: Illot(lf conlroi lIntt molor le.mung: tone. \'1)1unlary ml1VCIl1~nl ralt(,nl'~ im()llIlltary ffimicmenls; he~lla·

11011,

• (JJ.l,il;\ ',lS4.:illar;\-",-.1lml-naT\'

rnduram;~:

e'(en.:i~

ac..-tinti('" 'afct)'

Cognitiw Function

Sensation

Memory, Oflcn!.!Lon. conceptual reasoning. prohkm soh InO. and 'judgment should be " .. mlll"d. SI'"eu "I' inlon""-

_\ '~·r\."C'ntn~ l·\~\mln'ltlOn Ill' "'I,.'!\\allo!l

pr\:::"isin&. attenlion, ami COn4.'en Lralioll are parlH.:u cMtv ImJX.lr"...:nI lu detemllne ~T hudyphrrilla 15 SlI5.pected

ft('lal and de~p

b indir3tcd (super ... ~n ... atillJl'. <.'t1l11hlllc:d \.'t1rtu:al sensation ... )

""'I1\lll) dl;lI1f.l~'" ('an tx· e\tX'(t("(t \\'uh aging fhlunting 0f toudl sC'I1"i;.tlinns and prtlprhX'('ptil11l \\ Ilh grt'3tcr losses

the Mini Mental Statu.' llam (IIM.
Ill'~('T' l'\lrl'illitll'C; Ih;1II IIppl,."r dltd d, ... tJI more than PI"O\II1\:II). Th~ p;ltl\.'nt slwuhl be as~c:d Jnt..1 ut thr: pres ('tlt:,~ Ilf p ..lIt· ... tth.. St;t ... ~Sl'Il'i.llllHI ... o(numhll('\" l11 tmghng)

I\}cho~f)dal

Spe,,:itl\' .IIC;\S 01 'i.l'lbl11) Ill"S ttl;\) ~ mtil{,8tnC' \If ,-'llnlOf hid p ..\1lh1Ing\, f"r t:\i11l1pl('. stl\lb.C. di:lhr,,'tI,· IIl!urtlpathy

A ;::-Ief iCrecn of cQgnil:\.'c funuion (dn h¢ tlhlalll~d \Isin

Function

sbould AI.ctc'm.me uver).11 levl'l: :y ,md available COptng titrJt('g;c~. II

Pll" theo'-apllil

~!le

patient t.t-oul

;~t'

pr,,:sc:'n\.·c of

ne'Si - apat..:"-:y

P;!:~ll,.. ~t)'

III l.trf'iS

11\

uu.1

11

IS Im ....'or·

,,1~~rn::\MH'I

1,1lt"

ro:'filltl .hat will

them

r:\lIelil

I,r \ 1~lOn

shouhl mdud~ a. dctenmna·

pcnrllC';J.t ""Il'n, tf3l:b.lng. J~ct'mm('t!Jt1i.lI1.

and
a, WCII!hl lo"'~_ 1r..,J!;:~\.'U)- md dcpt"nd('t'lO'. lIlahl!

d 1I1li;:!rf"', merit)')' or t-UI\.-,dal "icudc lilt' (J~TlC~,.i. the, Ht"" Ut,,.'r~lton lm',-"for ~ 1It!:=;C,ts, a'Hliu;:~. "nd dotU

fllflh , C".In)in~llon

fillfi 0f .\.-lIlty

lIlsnOllll:J

tr.!-nenh

SC'

mid h}~s of "",,!or diSf..-wmnali,'n. P-.lli('nt., \\lth

rn

.\lay

rcn~lK: hlufl1l11,; (If VIstNI dnd ,htl'kulr~ n.·:lllin~ 11t;.1I I 1101 Impr,)\.ed t~ ... ,;ITI'1.li\"l' k'II-t\'\ .\' \\I!l] OlS l'r,'~kllh \\ uh )1.:

11'1('

r'Uf'ult ll'O,\\h.:cling),

or .. ,'U1NllId

Sre" In\. ddilits rna,' t'I..- mdi,,:J'

pathl,llll·I('....

lh:u ~uc

\.{llllnlllll 111

,he

SbS

Ph) siclll Rehabilitation

to document muscle endurance and has been suggested f . . I or documentmg tremor. usmg s ow speeds of movement (25 mm/s) and low torques'S

ddcr". ~uch a:-; catarJcts ~clollding of central vision fir~t. th~n .rl'npht"L.lJ). glaucoma (carly loss of pcriphcr~11 \j ... l(lOt ,("nile m.Kular degeneration or diabetic rt..'tinopath~ (C~lrly lo~:-. l)f central \'i'1(11), and cerebrovascular accident (hl)111tlnymoll' hemianop"ia). MedicatlOn" may also rrodUl'C impaired llr fuzzy vision. for example, antidepres-

-

Motor Function Rigidity

~jnb and anlich0linerglCs .

..\11 c\.aminJli()l1 of the pre:-.ence of pain is indicated. \lild :Khing and cramplike sensations are common in patient:-> \\ llh PD and are often poorly locahzed. It is imr0flant \0 eXJmint' fDr po,turai stress syndrome (pain linked to lad... Df movemenl, fault) lllovements or posture, and ligal11enlOU~ strain), Frequent pain or excruciating pain are m"'\t common but may also occur. Useful instruments s include TJI( ,\leGill Pam Questionnaire -' and the l'isul1l a/T(1!{igU(~ _~c.djC' t VAS)

Musculoskeletal Function Flexibility An examination of muscul0skeletal ROM and tlexibllity is important The therapISt can document specific ROM Impatnnents (."'RO~1. pa,,,,e ROM [PROM]) using goniometric measurement. Patients with PD are likely to rre ... cnt with losses in hip and knee extension. dorsitlexion, s.houlder ncx.ion, elho\\- eXlension. dorsal spine and neck extensiOn, and axial rotation. To a lesser extent, many of thzse c.'a.ange" are also experienced b) the elderly in general. It " paJ1lculatly important to examine spinal ROM ability to route fie.\., and extend the ~pin~) bCl..'ausc patJenlS with PD Iutve been ,hown to "shIh" impalfments 111 this area 11" \,11 sezment..; of the ~pille ')hould h~ I!X:lInIt.~, mdudmg ..:enical thoracIc,., and lumhar se~menrs. The mohlily d the. spine
Posture An exammatlon ('Jf re':,ting lJO$tUTe und \:haoges

10

PQstun."

thut QCcur with .n0vement IS IOdJCtlted lhe Ih~rJpi'it I,.an u::..e J-lO'StUil'" Cris:'Jplumh line):. stili pilNOJ] I aphy or \ Jdl:"t)!~pe 10 doc amen! ~h,,"ges. r-.tkms v.,th PI> typlc.ll!y .UTllt 1 tleud, "''''pet! PC""u" (k)Pho,'1S WIth forward adl \O\l~ ~ ~efnl!'--- of m
rfOmlan(."e

n.:

01

Itren~:-

ilnd .:-ndwAJ

f4ut" L I

-t1¥U!.

_,1'0(

d

.

.

RIgidIty IS usually equal 10 both agoOl s l and antagonist muscle groupS. It can be sustamed (lead pIpe) o r intennit_ tent (cogwheel). Distribution of rigidity is often asymmetric especially in the early stages of the disease and can vary during the COUlse of the day and with stress. It is therefore impoJ1ant to detennine which body segments are affected and the severity of involvement. Tone changes in the neck and shoulders are suggestive of early disease. whereas tone changes in the trunk and extremities are typically present \vith more extensive disease. Deficits to functional mobility and postural reactions should be suspected in the presence of SIgnificant trunk rigidity. TIte patient should be examined for facial immobility (hypomimia or masked face); the ability to smile or use the muscles of facial expression should also be examined. A detennination of severity of rigidity can be made ba~ed on criteria of resistance to passive movement and availability of ROM. For example. a detem1ination of ,,,vere rigidity is made if ROM can only be achieved with dIfficulty (see Appendix A). All inspection of voluntary repetitive muYCmCnh should be, perfonned to detennine actIVe limItations imposed by rigidilY.

Brad}kinesia lnitJally mo\emenh are slowed, the1l movements denc-ase in amplitude (hypokine~i;J.), and wiater stages. movement, tx-cnme arrhythmll' \\Ith fre4u('nt ht',itatlons and arrests jakine')ia). A sll)pwatch can he used to qu:.tntif)' dt'tt.'ctabk ,,!two ing of movement (movement time) dod mlwement hesitancy or I'nlUWIl tinu' (e-Ia.psed time between th(" patient's dC~lre to move and th~ al.:tual mo\"cmenr ~P"n.~). 1'he therapl ...t ~ht.!uJd l,.~xanllnc l'\\'(~r,J.j! amphtuJe of ffimte-men(

and change . . In amplHllI.k l'or e\ample. ,tmphtude nt ann swmg dunug "'alking CUi he c\unHn~d A~ tht disea.\t I'rogn:s~es, nwrked slown~s. J-1
t"'"

hbS

Pt,,-siC'.a1 Rt.·hah1litation

elJcrl~. slh.:h as

I.:ollilfach {clouding of central vIsion fir:-.t.

thc;:n pt:npht:raIL glducoma (early los'> of peripheral \ision), sCllIk ma~ulJ.r degeneration or diabelk retInopathy (e~\r1y 10"'", of central vision). and cerebrova:-,cular accldl~nt (hl)Ownymous hemi;mopsia). Medication" may also rn'ldul't" impaIred or fUllY vi.;.ion. ftx e:ampk. anlidepres· ... anl... and anli('hl)lincrglC~ An c:\Jmmalion of the presence of pain is indicated. .\Wd ~\!..~hl\lg and cramplike ~ensallons are common In patienlS \~ uh PO and ,lfe often poorly localized. It IS imponant to e'\amlllC for postural stress syndrome (pain linked to \;.H.:k of movement. faulty movements or posture, and ligamentous stfaint Frequent pain or excruciating pain are Ill)! common but mJY also occur. Useful instruments include 111c .\fcGIII Pain QI/('srim1llairc~} and thc l'isJlul (1nalo~/({' snlle (VAS),

Musculoskeletal Function Hexibilih

J\n examin;tion of mu~culo"keletal RO~1 and tlexibility IS lmportant. The therapIst can document specific ROM impainnenl> (ARO~!, passive RO\! IPROMJ) using gonioI'!1t"tric measurement. Patients \\ ith PD are likely to present v. ith lo~"es an hip and knee extension, dorsifleXIOn. shoulJer jl~xion. elbow c\.tcnsion, dorsal spine and nel.'k exlen-.ton. and axial rotation. To a lesser extent, many of the~e changes dre also e\perienced by the elderly in general. It h panicutlfly important to eXi.unine spinal ROM (ablltty to rotale, flex, and extend the spine) beclUse patient-. \o\'il.h PD ha\'e- been shown to exhibit impailmenh m tti~ aJ~.84 ,\11 "cgments of the "-pme ~hould ~ c\um· med • .ncuding: cervH.:al. thoracic and lumhar !>cgmcnts. 1be mobl,lfY of the ~pme ~houlJ be eXilmllleu ouring a 'Se.!leS of unctlOna1 movements. wl"h as Jxial rotaltun (ookmg t::~L-dl and walkmg, Hamstnng Ie~gth .all be de~~ninc1 u~~::"g a srraIght leg te5.t

Poourc An eummauon (f resting posture and dung:.:s In posture, -hal ct.Cur \\'l1h movement IS iudic:aled, The thelapl"! call a.sc pCi11,lre gJ"H.b/p}umb lines: sull phutography. fIr" ide" t.a.J:>e 10 document °tang«:s PalienlS 'WJII! 1,10 typil..'lily ume a flexed, Mooped rustun! (k.ypll():..i~ Willi furv\-,trd :..1£1) '""'1111 the ~-ntcr )f IlUl'iS f"'Ji
Mu..Je PerfofIlU".oe 1J1!.1j~ted ~;"; thr:r.an!' ' .. iO mc..!::;ure ttrength illmg manual rnusct-

An I,;XlUlllnahf n of trefl;::-- and e,Jur.mce

f

Ui

:(,1 ~"ld l:<{)kL~tit.: .:\nw:omnry 1. ""'n;e {~n.• ur u\.ltpul). P'J~;:'t 1 to IAhJ ....lt iJ.J1i.~:-ll-:--tiO III lh' n And ill n"aX'.lHtlf11 '~orqu~ rrodr.: o'l.n\....~ d:·lwmouic:: . . / tJn ~:':~ t,- ~d

to document muscle endu~'ancc and has been suggested fr do~uJ1lcnlJl1g tremor, u~lI1g slow speeds of m oveme )f (25 millIs) and low tnrqucs.II'i nt

Motor Function Rigidity

Rigidity is usually equal in ~Olh agomst. a~d antagonist muscle groups. It can be sustained ~Icadplpe) or intermi t. tent (cogwheel). Distribution 01" ngldlty IS often asymmet~ ric especially in the early stages of the tlisease and can vary during the COLlrse of the day and with slress, It is therefor~ important to d
Bradykinesia Imtlally lllO\'Cments are .. I()\\oed. then moveref'nh dec-rt';Ise in amplitude (hypokinc-.ia), anJ Hllat~r stq;es. m{l\'em~lS tX:l.:ome arrhythmic \\ ith frequent hc~ilJtion:-. ;lnd arre)b (akinesia). A stopw,lk'h GU\ ~ used to quantJ.(\ detectable -.hl\\ ing of movement In-W\.'fflICllfllmel and C"m'em?'nt h6~ lt~lOC)< or rea( nOll funt' (elapsed timt'" tx·t\\een t~ ratlem ' desire tu T))t\\oL' anJ thl! ih.'mal movement re.spon-.e,~ fhf lher-IIllst :..hould eXJn1l1l<: over.ttl Iil.iuphtudc of rno v...menr

dlld l:hanges Ul amrlitUlk~ Fur e\~'mple. amplitude of "nn SWHlA dt.lfln!;! waH.. lIlg L..tf) ~ cXMumed \, thl.~ Ji;,:i;",1,'1'

progrcssc.'S. rnar"'~d ~I\l\\ llC\j,S. poverty. and ~ltIall -lmptitude 01 movement ~h(!utd tho"'! cxp~ctC11 rimed te~b fllr fJpJd ull.:mating IlU>Vt:"l1Jefll S. ~ itA\, II "OJll he u~j h) dt!tcnnHle" the ('fl~h ot bf~h.hkinc-.st:t.{ h.: ",e il dll~k' r.:;)C.·lIed orpo~WIJll ,~I ttc fOldingcr and hWlIh, 4.ltc:mutJn,g rrornlh)il -'\ul'lnJriOf . .lpemng 40( cklSirg of ~!'d~ .1nu l.lppm.g fir:;er C'1" (p,-'I t:tpPUl!O, 1)('\ler_'y In conple, nwlllr (.1:'(.." (~.( \\1,OJ1f'

urr:ss.ing, sl;:llku .lbJe-.. t maOlpu~,:: l"~) \.~11l be (\pt'"i.. ;:~! to he 1m: .iured and shoe.1.! tx: cx ... nll:"'ul ~ ~, '''',rJu~ IV lJ,'w"d r·~·.). This I;. 'li.i.") t.",~ "..: r lnolol 1;\:.1.:1 in' ,Ivng nultaneot..~ ~~-; "~rnlth nJt'i (:'I~' rnpuJ IH~::,,~U;~;:r prc!!"",,liufr SUpH':....!.LJl! ()f hO:~l a.rm ... '. Mur~ 1i01 h ~,li( .ll":! U\;;;: .J'1"'>lI~ to;.a\'c tc':'_ U'5.:.~ tl shld'

I-Iu\'em:--,,~u I[~ r-.mnts \It-. ~h PJ>. J_::- 'd '" '11 l'le 1'('"«' ll'i.. lw ~ i."ny' l: M(' h..:t'; hecu lI~d Quallt ;;y C e \ IT~'"{l.S l)! riSi tilP

'0',

Chapter 21 Parkinson's Disease 111d hr~ldyj.;inesia on motor perfomlance. Long-latency ' 0 0 E~tG re:-ponse~ (5 to LO msec) have lx:en observed when Olu scles are subjected to sudden stretch. Abnonl1al patterns tlf motN UOlt recruitment have also been observed. R.'i

Tremor The location. persistence. and severity (amplitude) of tremor should be recorded. The therapist should detcnnine if tremor is present at rest (the typical pattern) or present VI lth action and interferes wIth function. nlis Jatter pattern rna\" occur in severe, long-standing disease. UE functional ~kiils such as \\Titing. feeding, and dressing should be close1.y examined for effects of tremor. Tremor in the lower extremities is generally only seen when the patient is :o>upine and usually disappears with walking. As stress increa,es tremor, simultaneou:o. cognitive tasks such as "enalseven subtraction~ (i.e .. counting backward from 100 b\ 71 can be used to te~t for tremor in apparently urun\~l\"ed lunbs. S6

Postural Instability A thorough examination of balance is indicated including an examination of orientation to vertical. The patient's perception of vertical should be ascertained as some patients

wiG ,ays they are full) upright when actually is leaning fO"ward, A plumb line and grid with stili photographs can be u.....ed to document position. Balance control can. be expected to degrade under conditions of naITO\ving base of support. or in response to perturballOn..,\. The patient "hould be asked to maintain steady

srandUlg ",hile varying the b",e of support (e.g., feet apart, feet together. tandem ~tance~ ~tep stance. and single-limb stance) , Penurbation task, that can be u,ed to challenge balanCe ;nclude self-tnniated mO\ements (e.g .. ann rai:o.e. bendreach. Funrtional Rellch Telt iFR ),1,7 or the A1ultidirectional Rca, liTeS! (MDRT)'" and step te-ts), In addition, the r,.>tropu!slOn test wdden sternum push or shoulder pull. can he used, Patients with PD <,!",cially IJ1 the early stages __{ the du.ease may not demon~trale balance impainnents in ruponse 10 steady standing/nomlal BOS or !>elf~initiated m(.'vement;. as along a~, thor auentlOrl f"'t fully diretted to the t!sk at hand. HU\\'ever if competing ;Jlkntional demands are. UJ,St'tuted o.e., dual ""king such as talkmg whIle trJ.Uuh.mg }. m~t\Jlity (Jf1 hi: el<;.pel.:kd Self. H1111:iled ~ w'th a timllig componeni (number of skpS per rrunule) wit also Lkd)' reveal balance impairments u.s ,",ill re-;ponding to unexpected perturhanons. \\'ith cQntmueti dett1lOTaL.OlJ. greater unpatrme.nts ffi. balan\.;t: cuotrol will t)e (h..
869

DynamIC pOJlUrography uses a standardized and reprodudbJc postural perturbation from a moving platform that C<.U1 reveal deficits in placement of the center of mass (COM), increased postural sway, and unstable responses to platform perturbation. 90 Variability of responses in patients with PD has been demonstrated, especially during the '"'on" phase of medication.i)l Available postural strategies and reactions to challenges should be carefully documented (e.g., ankle, hip, and stepping strategies). The patient with PD typically exhibits coactivation patterns (rigid body) with an inability to recover a stable posture. 16 Responses to perturbation typicaJly include delayed respon~es for recovery (start hesitation) Or absence of postural responses

(patient would fall if not caught by examiner or body support hamess). The patient with PD can be expected to exhIbit problems with sensory organization related to difficulty changing sensory conditions. This can be examined using the Clinical Test for Sensory Integration in Balll1H:e reTS/B), Six different sensory conditions are examined, including (I) eyes open, stationary surface (EOSS): (2) eyes closed, stationary surface (ECSS): (3) visual conflIct (moving surround), stationary surface (YCSS): (4) eyes

open, moving surface (EOMS): (5) eyes closed. moving support surface (ECMS), and (6) visual conflict. moving surface (VCMS).,,·93 In [he absence of posturography equipment. the patient can stand on dense foam instead of a moving platform and a visual dome can substituted for the moving visual screen. 94 A Modified Test for Sensory Integration in Balance (m-CTSIB) uses four different

sensory conditions: EOSS. ECSS. EOFS I foam surface), and ECFS and proves a useful quick clinical s('reening measure.',15 There are a number of clinical balance tests that examine functional limitations relatc-d to bahmce. ~1any of the,,~ in~truments have been developed for use with rhe ~Iderl)' and co!Tt~latc well with fn:4uency of falls. The Timt'J Up and Go Test'~6 is a particularly valuable instrument for patients with PO becau . . c it 101.:luJes tasks that are Iypil:ally problrmJli..::. Th~ tn~li\"jdual ri'i6 from a chair," al~s 10 ft. rums, and then r~[Um" h1 the ..:hJ.lr. II U:.C, tUllC' a .. ,m ouh.:ome mC'~I'\.ur~~ S\.'ore.., \\ Ithlll HI ~e\.·~lnJs an: nl.mllJI lor most ..tdulb; ,\.~ore,' llf I I kl :~o ,e"i,,:onJ ... an: \\ ithlO lhulnaJ limlh for frail ..'IJerly \..If dl'iabll~J p':ltit'"nb; lil:orcs gn:·,lh..·r than .:!O &e\.',lnJ, ilrt." ('olblJered :.1bnormal and lItdil:UI~ need fOJ Illrthel e\;1Il11l\~tton ,UlJ intt"n·c-Illit,)it. I tTleni's Pt'r/ormanct!·Olit'lltl'd \/iJPllltv Al.1i'.o;mlFnI tPOM .\(- includes both statk und dynarml,; bJ.lan..:-e Item.j,. organil.rd inw two s.ubtf"sIS of balancC' (milt' Items} and galt ISL\ It~m~; . lt has a llital p'l'isIMle s\..·ore of 2:S: pattents WIll' til'Ore l~ss th~H ill .tre nllhldl.!reJ UI high rbl fur fall.s

willie lho')t.~ \\ ht)

1\.'(lre

tx"lWei..'1l It) aud 2A ~ut" ~t modefate

tllJor. a\" !h\.~ (es.B

n~k tnf talls.lhe g;'IJI ~ubtC':il \~J" tound to ~ a u.seful

Pfl";!7d morr: dj~.rl~matlng 10 H1entifYlng falk I S (t: g., Ian qgk hm~ rlance f Jm:tlf..n1J.l re~h a.nd Ih~

screl'Jllng mSltUHlt'UI in Hk"nllfYlug ~au dy~futH:tion in

,"om.pil.dnf; I:.ilJen With 000

t .

fJ.Jlt::J"·~.

j,l,dkms y.. th PD IhJfIl fteallhy etdetly, hUl wa...; uOt ~nSl fiVe cl\\.lu~h t.o

di'ilmguish

~rtl.mla.ll~e Ih.NSS

t,:oudiu\)!l'i

8ro

I'h}~ical Rrhabili,acion

..:-,r \·.1nI08 IOslnlCllt.nal "'CIS 'walk fa":' "r~lle large !:teps'"

(1.('.

··~wlOg

your

ilnlls:

9fI

(ulit

An C\.!Inmation of galt I" lndicate-d Pnr.lOletcrs J.l1d (har3l.. rCTl,tics of g3il l:hal should he eX4J111ncd dUring straight line ".1IL.. ng it\l..~~dc sj'lCC'd of w.llkm~, stnde IMgth, cadence s~bdit\', \omability. and safl"lj. t\ IO-Ut'fer Hulk T('st '--:tn he used t~ d~tcnnine speed. average ~tridC'. and ca.ic!'nc;' or Jl1('ITe sophisliC31Cd "'nt.'1ic analysIs l.."1In he o~t'l1ncd from. mheddcd force platt:"S. bndy marker"" and ({)mputl'rill!d equlpmrnl lmob(\il an31~·sl'" "'yslcmS typit';llIy ",(,(,11 in the laJxrdtory ,ening~ Patirnl' ¥.1th PD IYrJ(ally dcnlllThlratc difticulty atuming an": SU..,t31lllllg \\alkmg "IX'('d anJ may hay,: diftj,:Ilty \\'.th foot (karancc onlO force plalcs with shuf.1U1~ gait patterns ter.'! in advJnced dbca....c_"; Gait ,houId he c\..:mined for kjocm:uic or qualita[ive clw1g~s. inc'uding reductions Ie hip. knee and ankle motion, that ~uJt IP. ] shon· stepped, shut1ling )!ait pancm "Ilt! reduced trurUr; ~tim and dn1 swmg, Po.,.tural ahnomla1l1ies that (",,::coot<: 10 the 6:velopmenl cf • kSlmating ga'l pattern should.,. dO('WTIl!a1ll1g an ~~stad, cou,",e [n<.rc:ased dif"culty on ".Ik, mg t5 ~so npentIlL-..:d m response tC' "..!Tying sltentional dGi::-"') L~ f;Cts. ~e~ observed durin" dUal task \\,:dk, f. 0,11" lI"::k·, Ta/Ld"I' "JlLng "hue'"_1fTy n~ obJC;'1 ..:tf'I ~.:.r \\~k.mg m rcspOIlSC' to anrntic:!!l ",I; ( • .e, ... mg ,OW" U11lS," 'walk fast,' ~hudd ,~ .!oc-JI'!".ented. 1H r:;;-«zlng illV:.-Ulgmed n ten;'s of f--:-equem'y. dun: ~ 'i.~ Gumuli «audit()~\' ..)f \' ,'~~~.:lI c~, that F--~I ~-,d t!!.;;-;.' .ruti=:on of ,~,'t,~"ement, ~-:err:::~:tl~ .:,f tall h:~~,ry and fat lf~~U:-lt~ i\ In 'nl of ~ t:1.arr:-naUon of I--.:slance lind r. dUfu'

Ofl'

Swallowing and Speech An eX
Autonomic Function The th ..'l;'lpist ~hollkl t!x~lInine h'r problems \\ith ilutonomu; dysfunction, Excessive drooling (sJliv31ion) or sweating. !!rl!"3"y ~kin, and "bnnmlahtlc-~ in thermoregulation should t'IC noted. Exces~ive swe'-ltlllg ~lIltl tlu~hlng during the ··On'· slate is hnkcLl to the presence of dyslinc!-.Ias. Epl!:odes of ortho'otatic hypotension
Cardiopulmonary f'unction Enduranc~ may be reduced as a rc<mlt of impatred ~.lr­ JU1Je .. piratory tundton ar:d long-sunding '.nactj\: II), both l'ommoo problems in chrome PO. An e:\.lmmation of respiratory fUOl'tlOC shouJd jndudc ms.pec~or: of rib cag(: c\ lTllpE,mcC'. chest w;11I mobil It)' and thoraei\; expanslon. \islial m"f'Cdion of nrcathing panems, tlnd an c~&illlmation 01 the 'JIlfluencc of J'l,sture on breathtng Oi\houll..ll be per formeo. VC'ntJ3tion par.unctc;"; IrcsplfatC1)' rat: mmute ventilation. msplfllory lime: should be ~e-~::-::nmed. Changes III breathing p~e!:! \\' ,th aCTIvity ~ho;;!J ~ Ix Qoted. ObJeCtIve Ole:1sun:menb c;.In include l; rcumfertn ~,:..: measurements of the chest l..."1C atxk:men. R::: 1evalll

mon,u), functicn tests include Spll1: f11c!tr:'- tl~' volwnc: lunl; \'Olumc3. and ..urwJ~'- re'i13f.ln\.'C (e g. '. rv.-.. -:;J VI~ ("Jpadl} ;J.VC), forced expIratory V(,lum.: [fT \ I, r.a
WJY "''':Ian('e [RAW',

IDe

Ih:~JP"'!

blllOd P'

nt

,I

)

.:'11

~:'-Jrt

"

,I fllllf'\\

,mid I. m ',. ur '

fJle P[J '~:"'1il'l

"t, 'C In-IS ,f..:t

Pl"

"

•

871

( h.-pter 21 Pnrkinson'lj DuealO<' mlllfC"f dl~l"C mai11k~I.IIHm,. ~K E\crtlona.' ~yllJPlnl1ls

• Ih~n"

· 1.1Ilgue, pa I . or (t'l1I U"'IOIl. cxce"I\"C d'·-..,...·( • ;. and Sll forth) should he (:arc-fully ,hll'umt.'ntcd v' "erer1 \-.dC\l"rtIOIl Loan tx~ rcnlrdcd . U'II1U .... Horf.! '- 's Rari"g "I. ~ 'H,(d Fur/lOll Sca/~ fRPf l'ra/cJ.lO- The patient Pcrn1d lx' ~U(,SllllOC'd n-garding level of btlguc or cxhaus lhLZllh.'~'

"hoU

.. ("\pC'nt.·oC'C'd dunn£: d.uly a.:liVlIY (the fall f1'}.. diary II_n tx. used to d~"'I4.:ument Ihc~C' finding,,). Knowledge and ~. .. ~se llf e'ncrg) ~ons.CT'-:1I10n anu JCtJ\'II) pal:lI1g' ... lratc-gle'S "'I

.

~hould 1150

tx.. dctcnlllncd

Integumentary Integrity The ·, h('raJ?:l ... t .. hllUld c\amlflC the parienll:lo,cl) lor areas )' b!lJl'~mg ~d . . ~m hrcakdown. Patlcnr ... \\ ho arc ,cvcn:ly dis,ablcd rna} ~ ~ . . Irlclcd to ht-d. whl'ck:hair. or hoth, incontjnr'n~'{" rna)' ..xcur during late ~tage dlsea ... ~, The "eel of these prot'tJem:-; on ... lin integnty ,houJd be care~ full) docwncnted. l se
mented.

functional Status An CX31TUnation or functional ~t3tUS is indicatcd. includ~ in~

performance of funclional ·nohility skills, ba ... lc J,cll\ '· ItJe~ ot Jat.y linng (BADI.,. and in:-.trumental ,H:tivitie~ of :!aity IInng .IADL). For paU
rehabIlitat 00, the f UilrllUnaJ Il1dcpl'lltienn' JtcU.wre FlMJ .5 comm("'nly Jdmmiste-red. T04 "'eed tor and appro, p-:ue use of protecuve dod SupportIve devices IS an 1D1pOrt3nt ccmpont'nt cf .~ fJJlclIC'nal ,tat us cx.:tmina~ lion. ao~ -oiJabo!"atlun with the occ.upational therapist IS

..

es> w.th mode-'Ie: to severe PO as eVlden<~ b)' IDCreased .me and increased falls. These changes have ,buled to hypokinesia,_ dCCKased rales of force uctIon, W'k1 ('han&es ~, dlstaJ muscle Iming. ':,,:urlh l he in treaunenr to Imp.Jve siHo-stand fun "'i.": he \'eTy different dependln:~ (n corft~cl idenllfk';J' the ""'rc~ of p"'~hle"l1 I'~! .cnts I'IlIYI""llIy

0&;:', ~

,,,j,

t diflkulty In ::!!"Ise activities ~a\'inlJ 11 MACh tlS I"!. ·Ilt;,g n tunutlr. in :"-)cd or I~ t:.kes to I"lltLate .md 10 (.·~mpk~ !1n

-:a.: comrv-,nrrn

:led.

Bt""_llf.!~ '."~Jh": pa~ ,(l1h C"XP;PI

.....Ith [esultant

nUCIO;l~~C.""'S

II

IT.!"

houl~ "" kep: h

d

lint:..: nment

~J '-_

IIltlll'!lIl'd

lor

Thc patienl S physic;-.l cnvinlOrncnt access and ~afcIY.

1<;

I:'xJmim.""

hi.lrrll'TS,

Global Health and Measures

Disea~e-Specific

he use.1 to determine IOdivlduill ouh.:ofl)(' .... <.Inns!; <.l hroad ~pc(:lrurn, In~trul11entc; Iyp" cally include 1lt"IflS that ex'lIninc ahllity to perform rourine dally al·ti",itic ... and quality of life (c.g .• physical .md so('ial fum:tion, gl'neral health and vitality, emotional well hemg. hodlly pam. and \0 fOrlh). General health mca:-;urc~ have bCl'n lI~cd to study large populations and arl' 1110\t u ...eful in dCh:nnll1ing long-term health oull·omes. Thc)' lad. the ~en­ ... itivity needed to document short·tenn null.:ome ... of treat107 l11('n1. Commonly lI\cd measures of general he!llth status indutlc: Rand 3fi-lfl:11I /lealth Sun'l')' Sf- ,.30: 08 and the .\';('/"'1/(''\'\ Imptlu Profilt>. ; ~ Di,ea ... e-~pecifk measures arc deSigned tu dctermme attrihllte\ unique 10 a s~cific di"ica~e enllt)'. Items are Induded that proVide mfonnation ahout the dlsea~ process and outcomes. and ideally document clinically mcaning:tul change over time, Thus the'\c in~lruments have gIT'atcr rc"'p()l""ivelles~ or sensitivity to change than gcnL'ral hCJ.lth mea..,urcs. Examples of m,truments dcvclupt.'t.I !lpccifil:ally fnr the examination of patients with PD IIldudc the l'mtied Parkinson \ Disea"ie Rating Scah..' and Parkm.'i(m·s Dlsea~c Quc,lionnalfe (PDQ-.19). Glohal health

I11C,I'SUfC'S .. an

rhe UII(ficd Purkln.wn'J [)iJc>ase Rlltif1~ Sra/e (UP[)RS)ll0 \Va ... originally devi ... ed to utlcumc:nt the over

all ctleC:h of the dlsea ...c (Appendix A.). It IS a comp(1slte scale con"'lsting of ... i, SCl:IJOns. Part I I,neludes four item, c'<.ammmg menial !o'tatus, behavwr, and mood. r-Ml II includes J3 iI~m~ that ~,amine dc!i\ ities of '''
nausC":! or \i.Jtllltillg. skep dislurbar,l'es, and orthO.-:t31i" hypotenslrn. Un.'ess 0thel'wlse !oitatcd, Items Ill," (raded on .. sc~lc 01 U to 4 with ,) bt'-ml! nprma} and: '-'eing \'erei) dlle"led Part \ IS d rmx!';";~:J Jlodm :,;1(1 }'"ihr \"~I::·It): Disease st'veruy IS ':,!\'"dC"'J ~I ... er ~ S1~I)!C:' mIll unll:uc!,.ll cr hi .1lera! 'ilgns, h i~ht'f·lum:-'('red ~fa~(".., rep· t pr '~'-~!oi~,l.. ;,ly mere dltrh.:ul~" wif.ti rnt.lt'tllu) and ,alancL~ Pan \ J I: Ihe~: h}\".. l~ Ulhl t'1gJ,lIId k ... ,';,'.(,S 'i /Jwl\' i. .. ."'.~ "tuli.' l:!Ji~,'1IJ.le~ are ~ni,a: m terms .'f f("('nl impar:ment (0 ~rct'nl w;"'(lrh..;- fum.lam (lx:d~lddc~) to .i.eJ( perl"em .. OUlpleteh mdcl',noc-n(! nlC l' PDRS IS lh~mlast c;.omrnonh· u'Scd sr.dc tf' C:X;Ull ne PO lh~e8~e 5c\l(,r-'y dM pr"£l"uil'lo J) ~:II as th pa:...:.::t ~ "!i,l.':{)!15;" ~o ,~fJg the'ap~' Over.-!I the ~t.Jle h

872

Php.ical Rchilbilitation

Box 21 .4 Examples of General Goals and Outcomes for Patients with

Progressive Disorders of the Central Nervous System.' adapted from the Guide to PI.ys;eal TI.cr(tpist Prnctiec 79

Imr:1d o f ralhlll ng~ /r;1th{)ph~·s jology j" redtlccd. • ratjwt/di~'nt. family. ,md caregiver know ledge and awarc or . . " ~'f the disease, prognosis, and plan of cart' j"

cnhancl·d. • Symptom management is enhanced. .. Risk l,f st~c(\l1d~u) I1npairment is reduced. • tnlen.;;it) ()f I.~ are IS dei,.:Tca . . ed. Impad of i1l1pailments is redu ced. • Cognitive ftUK'lioll is improved. .. Jt)illl integrity and mobility are improved, • Sensor) Jwareness and ",kin integrity are improved, • PalO is dt'ue,l.scd . .. \lotor fundicm IS improved. • \lus£:!(" pt'ti'onnance (strength, power. and endurance) is lffipn:ned . • Postural control and balance are improved. • G31t and ID..;omolion are improved. .. \ -1anagement of fatigue i~ enhanced. · Aerobic .:-apar:ity IS increa.,ed. Ah lht)' tlJ pcrfonn ph) ... ieal actions. tasks . or acti\itie~ is ·rnpruvcrl. In dependence in acth'ities of daily living j" increased. • Tolerance of po ~iti nn s and activities is increased. ~ AI.'"tlvit)' pacing and energy conservation skill" are enhanced. Anliclpak.d Eoals and expected outcomes are

~pecific

· Problem-solving and deCision-making skills are enhanced. • Safety of patient/client. family. and caregivers i~ imprO\led. Dtsability a\sociated with chronic illness is reduced. • Abihty to assume/resume 'ielf-care and home managemern is improved. • Ahihty to assume work (job/schoollplay), (,;ommunity. and leisure roles is improved. • Patient/client and family knowledge and aWareness of personal and environmental factors associated with worsening of the condition are enhanced . · Awareness and use of community resources are improved. Health status and quality of life are improved. · Sense of well-being is enhanced, · Stressors are reduced. • lnsight. self-confidence. and self-management skills are improved. • Health, wellness. and fitness are improved. Patient/client satisfaction is enhanced . • Access and availability of services are acceptable to patient/client and family. .. Quality of rehabilitation services is acceptable to patient/client and family. • Care is coordinated with patient/dient. family. caregi . . er.... and other professionals.

to the indi vidual patient.

.ood interrater reliability (r = 0.98) wi th some indi vidual atem~ demonstratmg less reliab ility (l.e .. fac ia l ex presSlon , estimating :;:evcn lY of sensory sympt o m s and brady"meSia) " The Putbnson"s Di... e(}J(' QUt'.uiol1naire (PDQ·39) i:-. a 39-nem que~tionnaJre developed from in-dept h in terviews WIth pattents with PD.1l2 It focuse~ on the subjec· lJ've report of the impact of PD on daily life and add resses eight health-related quality of hfe dime n,iom (mobIlity, AlJL. emot lonal weH-heing, stigma. soc ia l support, (,;ogDItion , cumrnunu.:allon, and bodily discom fo rt). T he ,PDQ" 34 produceli <.l profile 01 scores on the eight in di Vidual dl!1)tIlSiulls . A summary :o.-core !the Pilrkinson's

Discu)e Summary lndexlPDSl1J can also tx- d~tennjn~d, wuh SCOrtS that I JIIl?e" trom {) (perkct heJllh) \n J no went "leallh) II pro\' Ilks a USf'lul If)JI('<.ItlUll of the glob'J.l lmpal..l ot t'l) 011 he;.thh ~Iatus _ Irllt:llliti .tIl..! t::::: rc:te-st reil.lbility were found to be 1l1l)derate to t.ugh

Physical Therapy Intervention A combined approac h of ph y, ical the rapy and pharmacologic al inte rventio n pl ays a key role in the man~lgement of the patie nt w ith PD. Fo r most pa tie nts. phys ic al rherap) b no t prescri bed until the di sease has progres-.;eJ to th~ point ..",hen fun c tion hu:) declined . 1\ vari ety o f IIltt!f\, cntwil..; Jrt used to ac hieve goals a nd ou tcomes, inl:l ud1l1g d ired inlerventions. su pervision of as.s lstive pt..·r'l1 rm~l. pa tlc nt/fanulYI caregiver in::.tnlc ti o n, en\' iwnmenta ! moJ ificatwn . .tnJ supportive <."olln se-ling. EMI)' lII[c n t n l ll)J1 h e mica! in pf"t'~ venting. the devas.tating mu.; . .·lll{lsh'lL'ta l impa ifmt'nt<, tht'se pat ients art' SU prone 10 (.kvelop. In tl..Tvt.'nWJtb .. b ,) f(lcu~ on improvt'U1ent of moror fUrlctwl1. exc-rci.,t l'ap,!,:il}" rUIl~'ttonal pt.'rfolTllanCt\ and ad!,ir: paItil.·ipanolt. [ JU('Jtlllfi o f p"1fil"llb. falnil)' ml'l l lbt'r\, and .:ure~ i\'er~ {\ '"'ntll.al to :ll laimng "pH -:-nalou1\.·lllllc:-, .

wuh !'L'ponl'L1 nmr,r:1J; fculT" 0.68 ~ 0-9(1, C OlJlilTu~t vahd

was examined bv

COlT paring

,lie PlJS I wJlh

(lltll."·!

me8'ures of ht"alth Signulc..:mt and hog'" corre .,tIlOH~ \"! -re 'nlnd between the PDQ· ~9 and the Sf ;· ~h and II::Hoc'ln 1U1d Ya~r I'lag;ng, M.."{)ft; II >" . " df"!~uilnatlon .,f gO!1h and ootn"Oles il) ba~J un 't'hL txam"nal 00 drul evalU..l.tlOn of the- pallent 'tt Ind .dual \h.li: ,C'i, mrnum,ents. t'un~ " onul Ii:'lltatu:'~"' c tillli 'l" nY (fJl,.lI: ~\1.4.

Motor I ,earning Strategie, Patents Y{Uh PD typlI.:al1y ,lelilonS(f.HI!' moi("rr h:ammg deflc Its, Lni..luding IJnpdlfi:1'lellls in learning long d ni! .:-om·

J!le\ mc-vernent sequelH.:~s. slmlll fJr:C'llt.is mOlor:~-l'&I U tJ'i" ~J'ik.s . an~ 111m , ment\ oql('lltknl on tn tC'rn:d ly gt'nC:-1.tle-J "ues \,ersu . . e:'<,ternaJ '"ties, II" II' In 111...- CJ d y sr ages 0 1 II!': ,llst!ase _ rrjl~II"':- ,";ij~ he e\p(~l..-Ied hI IlIl j"' I\WC' lel i!llng ,lIld

pcrh1nt1;UKl' wl~ik III till' mor~' nl~\:anl;.,.'d _Sl
' -!\ ! h.,t.

bl'

k· ...- ,- ...- un.· c ......., ful . '7

lli,IIKI.'t)

llt'cJ ... III qructun.' In.~.\lmt..'lll ...(' ...... IPn ... In

The then!w;t •

op"mi7l'

motor

karnlO!!.

rl)Ulld

"IllIullarh.·Olh

(he ...t·II.... llly Ir.lillllig gnlup.ll l1ll " When u ... t..' of dudrlf)l), ,HId \l1"\lal (.;Ill'') W
111

imhvltlually. file), well nol found 10 olkr "'~nihCiult hl,.·lwlil In illlprovlll,l; gall ovt'r lI'i(.' 01 Pilfl'd In II:-.l' 01 hOIl\ nil'S

e;ll'ill'tll.· aIIHH:.'40

Crilll';li ckmcTlh (If rr;Klict' indudt.> a largl' numh,,:!" 01 rerclltalllS 10 liL'H'h,p pn:x-,cdural ski (Is. I,ong and ((lmpk'\ fll(WCOlcnl ... CqUCIKl· ...

infO ,:t1mp\l/K'nt

\\\."t..'

should he a\'OIded

or

broken

uO\'.'11

r arr . . , RanJom practice order (I.e., pral,.'tll'c

in \\hlCh Ih" p.lllt'nt ,,\\'il('h('s had. and forth hl'!WCl'1l w~b)

should be .:l\'(lided in favor of a hlol.:kcd pr.u.:tilT order. thereh)' T('ducing the effecls or l,'ol1tl'xtuaJ inh:rfci ence. Ta . . ks should he lIlodified to minimize l,'Olllpeling ('ognlli\e demand .... Thus the patient j,;; inMruclcd 10 avoid dual ta ... k.ing in 0rdcr to improve movement pCli"ornwnn:, Thl' em Jrtlilmenl should aJ.. . {l he modified to reduce clulle!" dJ1d competing Mtcntlonal demand;; that may trigger Ir('cl109 erl"rnje,. The Iherapi'l ... hould In~truct U1C patlcnt 10 ddilx-rdlel~ focus his or her full attention on the de"'lred mO\emcnr L ~t: 01 l/TurturrJ instrlfoiullu/ sets ha ... Ocl'1l ~hown to trnprme movcment ... peed and con~istency.'t'l,I:>! For example. ".Jkmg pattems can be impr()\·ed wilh focused instructJons 01 "S\\ ing your arm .. ," "wall<. fa .. I," Of 'taI:e large teps." For !he p,ulem With advanced tlivcave and cognn;ve defictts. repetitive drill-like pracljl:e should be used along \\iUl an IOcreil"icd focu.s on l:aregivcr Ir;.Jin· m~ ,0 ensure safe1Y ~

External "ues have ~n ~ho\\'n effective in. Iri!!gt:llIlg ...~uentJaI mt'vc.'menh and improving movemenl chulJc" tt"-;st.l.:s 1:'1 .. ndJVldual With mild to mOc.kralc Pf) (M~C EHdence SumnaJ) RC'{ 21 5). \ 1,'Wa! ('IIC.~ ,"elUde "'t;1 Mnan floor rrarlurgs e /! _ bnthtly co!ored IUI,"s on Ihe floor placed perpendic~lar 10 the gart POlil and po,cd 3~.U1 one ~ lengt lIPart) and dynamIC. tr~ul'i.p()nJhle c_ oe a "'rught ".me :lVeT1ed and hdd !oil the pullellt '" t hand It A , .. b,ec, n,Dunted lIght de\lCe dev.ce attached t the Lhest that pro,cct two laver II :0 foor on front of th, rolt no I:!a.s .1 0 bc:o. U>ed u f - Y10 tr erst ppmg ';",,,Ii target """'.. h to I PI." :raU
F\lnn:t1 ~ IIt!S ~IPpt:illlO lanillilll' 1II0Vl"II('I11 hy utilizing
anct: of wl.'ll··kamcd,

Il·Pl'IIIIV\..' lll(lveJT)l'lll Sl'q11t.'nccs, 1"1

EXH.'lIwl cues hl'lghll.'n p:tlll'lIl nlll'ntiotl through a COlllillon mode of ilttl(lIl. thaI is. III hypu ... ., 1111.: difllllu...ht'd IfIll'1'l1ill l:L1cing of th~ na<;al g:lI1l-t1ia. rhu\ foi.'Il''; i"i shifted 10 ks, aulOIll'JIl(.' movement using 11 !tI.:Tnat lVI:, IlHlfl.-' (':IIII\(ltllJS

motor control pathways. I'hi" is I'Ilippol'll'd hy 1111: tindll1£ thai whl"Jl putknts were fcqw..'stnllil (itrry (jut n SC(..'IIIIt..ial), t:lsl\ whllc: walkmg (dual.tasklllg). till" tWIll'iil'lilil'fft'l'l!'I of vhual Jnd i.lltcnrillllal cue" Vo.'it" I'l'dut'l'd. 1'11\ S~'ledioll of the type: of (til.! JlJd ... Ul.:u:\,,;lullhc WII! cll'IR'nd 011 till! iJldivld lIal pJtielJt. Dicl/ cI HII'I foulld thai lilt"! pn:dich:d 101lgIl'rm OcI1~fjl of a p~Ir(lcular

Iype

01 (.:lIe Wa-s dl'J)('lIdl:nl 011

its initial 'lICCC:-.S. LXh:mal tllC:-' j.ll'C dt'arl)-' nol l·n,'l·tlve lor jill

wllh PD, For piltknts

wllh

"ulvilJln'd

p;tlll'lIh

{h:-.t
rcdutllol\s III 'oIndc length, l'llcillg ;\ nol t'lICl:f'vc.' ( When

will1li,'ld, perfornl~trI(.:c (\01 he- C.'{IK'l·l('d 10 lkh,'ri orate b)(.;tls('u allcfJlIOfl willi I.'Ul'llIh'. n.'4tllfcS (UII\I;1II1 'fig dtl!lct' jlnd I"" (..'oglllllvt'ly dl'fJlaJ1{jint' lhll L lIC I Ill' '''' rlnl cw.:lng 1\

",ulluhlc tor pali\.'I11..., wilh

dt'Tlll'llIl;l, ( U\.III'

may .11~o U~.I1

he d'tcctlvc ",'hen fHcJI~.:jjlJ1lf1 11I ... 1,lhdIlY .IIlJ cb,.f,;'t~ lIul . (UallOn~ alC presenl ,)6 Howcvc'r, JtJI' /HallY p,;urenrs. U \ oj extclII;t1 \.:l1l."S I. it vallll 'rcatlllt,'nl foIlr;.ltcg), tnt! on lmpr(!v~1 pcrlllrlllaf1Ce 1..,1/1 alit! 'pated 14

E"crci~e

In

WhH,:h

Training

Relaxation J crd,,,s (jt"ntJ

lockmg (.,I.n he use..l

'I)

pn'l(lu\'

11 r 1111 I J 11

utiOrl I)t C'xc IVe- mu d ... f n II HI till to rl f(JlIY J'rllh: or ( hall.:"t wh,'ooted dr,Uft.ltl(.. 1111,,10\0 111 nt '11 (l It, Ttl "11h 1'1) JII!tOWjf. rHJe, III humpy hOI"c 1r.l~1I \ Irn.!· t.' llf I de fit d Ull clIe I aJllw t t)f) )" ,I I¥{) 111 1-<-111 I i!UWHl" .hI:Sf'Jb'Kt\~tJlll Ii co t tnu.:h·d.l \-1!,rHIIIII' 1,:1l.i1l 14, J It Althou h th

"',li

, .L ff

Ph\-·sical Rehabilitation

H74

Evidence Summary Box 21.5 External Cues and Motor Performance in Patients with Parkinson's Disease lehman, D. et al 121

2005

Part 1 5 subjects, no controls Part 2: 11 subjects With early stage PO (Hoehn & Yahr Stage 2-25. UPORS scores 1-2); normal mentation (MMSE) Palients stable, within 1-2 hours on PO meds Training group = 6 Control group = 5

3 training sets/day for 10 days

Significantly increased gait velocIty and step length and reduced cadence, significant eHects noted In both groups but more pronounced in exp. group

Nonexpenmental, cohort study Protocol: 2 condilions of sit-to-stand (STS) (1) self-iniliated: (2) uSing auditory cues (verbal commands) and visual cues (circular light at eye level) Outcome measures: force through feet (force plate); kinematlc analysis of movements (reflective markers, high speed video camera)

2 lest Irials: STS, self-iOitlated STS, cue-Initiated

PO group: STS-self'lnrtiated had slgnlf. dec. In hip fleXion and ankle dorsiflexion torques: dec. horizontal and vertical veloc~ies: prolonged movement lime to complele STS STS~ued slgnlf. Inc. all torque values; lime to peak torque reduced by 23-27%; no Improvement in peak velOCity; S1901f. dec movemenl time

Nonexpenmental. cohort study

6 practrce trials; 6 test

Protocol: 2 condllions of reach109 task (1) self-regulated reach and grasp stalionary ball as fast as poSSible; 12) reach and grasp a 'oiling ball (Visually cued)

tnals

Nonexperimental. cohort study Protocol: Exp. group walked 30 ft using verbal cUing "take long steps" 10 times/session; Control group: walking with no verbal cueing Outcome measures: step length, velocity, and cadence, preferred walking (Gait Rite" electroniC walkway).

----

Ma" M, and Hue-Chan.

ct

2004

IS subjects with PO (Hoehn & Yahr Stage severity score of 2.5) Patients stable, within 1 hour on PO medlcallon 15 healthy controls matched for age, gender. weight, height (no PO)

Ma;sak. M.

6 subjects >'11th PO

el a! !:'98

(Hoehn & Yahr Slage 3) 6 healthy controls (rlQ PD diseasej

Control group: STS-- cued had small but Sl901f inc. knee ext torque

Healthy cc"truis had comparable rM:hlng limes under both

Outcome measures~ 2·dimen~jonal kmematlc analysIS oj reaching movements (video camera ) rellectJlle markers} MClnlosll. (;,

31 SUbjects'Mlh PO

"'l1 (';en', •.

H~hn ~ Y&tll Stages il, III, arv:llV) 21 on m~ Within 1 •

Flanagan _ A

1

112 tr--Jrs of 00""11:

·0 'olr me-<..s (:4 '" )urS after lat.l dose)

1J "ea"h~ C0.11"

NQne,perimelilal, Cohort .tudy Prohcol 4 (o/1d:lions of walklng: (11 seI1'se!ected 1POOd; (2)"lh rtlvttrnJi; auditory tr'wat:" (RASj onaltheo 10 bas!:''18 eaoonc~: (3) RAS 10% f:::!c: 1I1an baot!'IO: (41 W1Jhc..lllA:" RAS

11sl,"",ental 'Tl\JSi: 5C

msec tq~lfe W,f:O

oa••

OuIcorneneas""es: tty ~nc. .Iride length C,)Il\ p.mmzed foot !¥ideh $ISlij'l'\\

PO group: In response to VISually cued target, ·nc. speed and acceleration 01 reaching (comparable to control group) decreased movement time movement accuracy maintained

conuitions

Warm-'ip 2-min walk 20m 4 gall

walK

"uts, each 'lO-tn

F,r;ler RAS prcdu':ed Significant ""'provement tn mean galt velocIty, ""dence. and slnda .ongth 01 all groups. '10 MS. ol'l PO paneOfs shOWed abnormal gall I'lttems:dt" gnJl!J; - [han 't.f' gJ"CIUP Inc In gall '''fIXIty ca
~ ,

Chapter 21 Parkinson's Disease

875

Evidence Summary Box 21.5 E:dental Cues and Motor Performance in Patients with Park lJ1S0n ' S D°Isease (mnl inucd) o

Reference

Subjects

Design/Intervention

Duration

Results

BurlelghJacobs, A, et al 125 1997

6 subjects With PO (Hoehn & Yahr Stages III-IV when off)

Nonexpenmenlal, cohort study

5 practice trials; 1 tesl tnal

When "off," all PO pallents had marked dilliculty walking with freezing episodes compared to "on" and healthy controls.

Tested both 'off' meds (overnight) and 'on" meds (Within 1 hn!Jf at de :. lQ .: : he ~Ith" r.ontr j\::::

Ie

Protocol: 3 test conditions (1) self-generated step; (2) step to cue (pulsed cue to earlobe or hand I; (31 step to perturbation (horizontal backward surface translation)

Both PD and normal subjects inC. force and velOCity of movement in response to cutaneous cueing.

Oule )me IE 1: 'e: grou n n ~(Ii lq In:~ ;t! plc'll: .r '1~! po b dy klnemat tep

f

l(:th 1m .:or,

Step to perturbation: both PO and normal subjects improve speed of postural adjustments; PD subJects did not inC. force of push-

dn~,I'y

011.

9 u ilng

MO'flS M

ral

e:

1'1 rn NaIK~ rr

19~6

,tnde

':"

sel length ):ed

ur'

~.

::::d ,]alt

" I/,

~~;

,

,

,

,A

ler;flf F!f:r::man J

,UbJE'C'"; With PD. )n routl "If: n len <.tlor 11 ,J 1< 1) je-:I.I€

Q

~G

ImpalrmE:n l 12 healthy ontrols

,y~ IE

II

"

,I III

M,

PI,I'

II:~

_r I~ Iten

j 10 I

n)

Nonexpenmental. cohort study

4 tnals: ? each hand

Prl"l\l)cn c mdltl ns , dudltor~ :ue) )1 target tap pmg frequencies over 30-s period: (2) auditory cues ollar gl~1 tapping frequencies flf~\ 10 ,ec mly /30· p€:rlOdl

"III< I ,,1 1'"
Patients who trained With RAS sign If, Improved gatt velocity (25',). stnde length (12'6), and step cadence (10%) more than self-paced subjects

In RAS group, signlf. changes In EMG patterns.

,I<

I I II'

. I" . I . ,lIIl 1'1)

I<

I, 01,

,,, i'll,

Healthy controls were able to duplicate target frequencies and sustam frequencies dunng WIthdrawal of stimulation. PO patients less accurate in duplicatIng target frequencies. especially at lower and higher end of frequencies; Withdrawal of auditory stimulation resulted in marked Impairment of rhythm .

Outcome measure! Frnger lapping \esl (computel analysl::: of frequency): Irem )f I€:C lrdlng!

-1111

Secondary tasks reduced stride length

No-training group dec. velOCity by 7"0.

I

III 1m ml' ~ur(:i. EMC: pdtterl I 'cdo( It'y =adenc ~wltd,

Both visual cues and attentlonal strategies were effective in producing a normal stride length.

11,,',1

,10111,'1

111<'
,lllll,rI,111 'II

11-' III I

l'ha,)tl.-T 21 Pa.. kinson·", Di"!&I§e

87.1)

Evidence Summary Box 21,5 Extemal Cues and Motor Pe rfonnance in Patients

"ith Parkinson's D isease Reference

Suhjt'Cb

l>c~ign / lnlcn(.·nlion

Durntion

Re~mlts

Burtel91>-

6 subjects WIth PO (Hoehn & Yah. Siages III-IV when off'

Nonexpewnental coho~ siudy Pr01OCol: 3 lesl C'JI1dillons 1) soH·generaled slep, (2) slep (a cue (pulsed cue 10 earlobe or hand): '3) slep 10 pe~urIJa lion (horizontal backward surface translation)

5 practice 1]1als: 1 test trial

When 'off,' afl PO patienls haG mar1<ed diffiCUlty walking W1Ih fr~zing epISOdes compared to on" and healfhy controls

JacobS. "

el81 t

(continued I

1997

Tesled bolh 'olr meds (overm9hQ and "on' madS (wllhinl hou: of dosing) 2 ~ealthy malched conlro1led

Moms. M.

54 subjects wI:h PO

8181

response to ~utaneous cueing

Outcome measures: ground reaclton forces (force plate); body klnematlcs-COM post lion, step length (~ion analy. SIS system)

Ncnexpelimental coI1ort study

3 tnaJs. wafklng with use of (I) VISual 'Iocr mar'Kers (21 anentional s~alegles (31 secondary tasks of Inc. lev els of complexity

'996

Both PO and normaf sutljea. inc. [orca and velocity 01movement in Step 10 perturbahon: both POand normal subjects Improve speed of postura! adjusfmenls. PD subJects d~ not Inc force of push, off.

20 min training using repeat 10 m walks, set at conlrol slnde 'ength

Both VISual ClJes and aHenllOnal slralegies were effectiVe In producinq a Mrmaf Siride 1eniJ!f'

Gail patterns monitored every 15 min for 2 hours

Secondary tasks reduced slnde length.

3-week home' based gait Iralnln9 program

Patients "ho ~atned With RAS sign/f iIl1proved ga~ velocity (25~,), stode ieI'gtf' (12',.. , and step cadellee '10',) more tr.an sefilaced su!tjects

Outcome measures: computer Iled stride a""lysis: spatial (distance) and temperal (bmlngl parameters T~M

Exp. group: '5 sub-

Nonexpenmental cohort study

Ell af'

jec's WI'.h PO

2 ~'" groups: "

Exp. group: training WIth rflytl>rruc auditory stimulation (RAS,

Sibjects

W';o: groups: seH·paced

'996

"a:nIng, and no training

No-~a:"ing

RAS inslrum'ntal rntJS'-, O!t.(:-me "","sures: EM" pat·

)n RAS group.

·e:ns. ga,: ,.;~ity cadence.

coh::t c::.,'

Pr;-"DCoI: ~ r:""1I:t:»

(' , auc>1ory CJe> of target !ap-

Ii". freQUooc'e: over ». t

~ ~~.,. ":':"~lots

p;!"xl; (2' auc!tory ~.., c1 \:1'

S>gl~.

cr.ang8s

it' EMG pattems.

stnde .mgth (o,;rnP~''''Zed foot sv.itcf'l sy:m;-::; 'xpe.ro1le:,"~

group deC veooty

by 7',.

4 ~!~. 2 ea,:f1 ....In "!,

tiealthy ,;

!~ we~

abie to

dup,ql!; \:Loge! frequencieS 1nd r:...stLll "~ncli' 5 ,jul1tlQ ~­

c!rawa! of!: 1"";".JlllCl"I

.,

gel ~;:-'J "TeqUM(':e-sIt-; I

c:- ..... ·'jI'3(rS ~ Outc' "" ~

"t::;u,'te1 .1 t ;fTo,."m.

76

PhH:ical Rf."hahilitacion

1',\1- (echmt,UC' (If rhl'thnuc uuria/ivn j N/). In Whli. h nUn-C' menl 1'11)j:Jesse~ frum PJ~sj, e III d~tIH' .lssisIlH'" W lIghlly

rCMSICtt ('Ir ~Ii..:li\'e movrmcnl W4.'" speclll(all \' ilC!l.I!!.lled h" help ~\ercomc the effei."ls of I"lghilly In PI) "I Addillonal strdtegles 10 promote re1.i\,1II0n mclutk ,10 rnlph3.SI~ on di~Ll'hrJgm.ttH. hre~ltlllng lIuJlug C'xercise 1-llr e\~llllrlt:. hil.lIl~r.l1 S~'lllll1etrH.:~il I'\T 1>2 t1l'\WII palll'rn'i ~Ire Important pJIICnl'" thOlI C~1I1 tx~ lIsed to c\p;lIld Ihe rcslril. h!d l.'heM llnd prnnlt)lC' ~hnuldl'r Rl)~1 "he p,tlll'lll 's illlC'llIum (;ill 1X" fnl.'u.;ed 011 dcC'r lIl'plr:l1ltlll dUring 1)21 chrl":Hhe 111 J~('rl) ~'l \\ 11lk Junng Il.:'F r:lllnn"i alll.'lIllOI1 is itx-usC'd on l'\plr:ttinn r'hreall1l' out dc\.'ply·').14I Palll'l11'i may also lx'ncfil from t:0fllltlve inw!!lng or IlIl'dllalloll lo tC'dmlquC's \l
III C"1llf'1l1a1i(l1\ Wllh l(lt,IIH'Il~11 t"\~Il'1

111 prumnle

feln,Hil)U

lrJ\!luon.ll str~l~ IlIlig h'c1tnlqucs \-,HI dt.;O he U\td to el()llg~tl~ mllsl'ir ... Spf.""11 \-(lnsukrJtltm "houlJ he ~i\len In Ihe J,:t'luk "lr('h.:htn,G of l'lho\\" 1l,,·Xl.lfS. Illp .mtl ~n('e tle_ OIS, .111.1 1ITl1.le pIJIII~IrIIt"\llrs, StrctclHU& 1...10 be u'mhined "Ilit luinl mobllll
ate .. trt'ldling CXl'll""":S dud tht,.' JllljltlJ"lilllCL' I1f mi.lllliainlflll IIIL' "tll·tdl Iml'C ItI, al 1e.1,1 ,20 Itl \0 J;('uJllli'!.. hlt,
can ~tilOlilalt.;' pam n!l:Cptufs allli C:IIl'ie Icbuuncl mU'iClc

movement forms, Stress management t~("hOJqu~s are an Important adJlInf.:1 10 relaXdllOn trallllng. A daily ~l'hedule needs 10 he planned to acc"mmodare the re51nctiolls of the dl'\ease und thl! functional need.. of the patient. Lik~tyll" moJific.ltlOIl .. and

contr;tdion. Palll'lIt'i "11h PD \\-hll ..Ire eldeil)' ;md ha\'c hmg ~Mallding dl"iea'«! fIIu"il he cOII~lll¢red fil nll~ tor mIen porO:-'11J and IlIer(!'llIrl~ rnu;;t lx- ~trl'llh(A1 d("'l'c1rdlllgly fhe thrraplit should 111'i0 lI'ie C;.tUIIlHi "htll "",etchang edema-

time management techniques reduce <.Inxlcly asso('Jatcd with movement dlfficuhies and prolonged time!> rl'ljuired 10 complete baSIC functlOna.1 tasks.

l'Jall'd wilh HlIllHlhtlity as rJ<\k 01

flcxibilil), Exercises Both active j}Jld passIve RO~ exercIse's arc used to tmpnlVe l1exibility Ideally RO\I extrClse. empha,,,c :tive mo:~OO5 thai lire performed two to three limes i1 day EXC-... lSCS shc..wd focu~ t..·n strengthening the weak, e10n plc1 ateoer nw.cles. whlle lengthening the shonened. ughl I1rAor muscles, Pa.SSlve RO\l .>erc;-;es work .. ilhin po.U
0"

L'1d

t"lee eU,cn:-U~fl ~~~.l~ be err.t:!:!.::~LCd

tou'-) II%lIC.

i.t

cOllunon 10w('1 C).lfl'llIl1y

IfIJury IS

III~n

IIll'll"ased

In

thi, liilualion 1m P'I ~~ lye po'\ltioning.

n IOJlg tillldlJOn ledllllqut" Iii improve Ilexihility, Cow illso he u:I\C'd 10 ~Irddl light IJIU~ l'll's alld ~t)fI Iissues, P;ttt~nt5 Ifl lall! ·... Iagl~ I'D lire IIltl)' to tk,nomll'atc t,eveIC, tlexJOII C"OIr.Ktures flf the trunk .,od limns, 'I he "phant' Jill ,Iillow" f')O:lIUrC may ,jevt.:!c'p III t.Upmt" lh~t 11, the hC:J.d und rhouldt"n. ,ne !lexcd lS If there w&;s pIllow present J:Jrly on,the patient may hc'nclLt (mm doul)' poSitioning In pronelYlIlg, AI Ihe cJI\t:j".e prowc~ . . ~' .J.od eJt;l1Ifit.:ant posturJl JcformlT)' and (oIl Jiur('\plraltlry Imp;Jjrmenl\ develop, Ihe p;Jtjem may nul ti,it:rJIC' fhl po\lIion. TIle patiC1l1 With ,J (1l!vcloplO.i.1 Iiter.~! ' UI\,,lfurt · c.;1fi t}e poslti(>Jled 10 I"defymg with l _m'dl Pillow (lode" the lateraJ trunk Med"!inKJII,.~' lo.;.!.d ... !'r.'1..l:tltnri.Jl1,Jt f)e ~J\e'J. r '.Jr r:xillTlple. Ihe p~T~-:ljt \\-hlJ '", r"Jrltllicn m:.., f)en('!';~ r,m) wf:..!hb applIed 10

f'

Ie:: cuntractu:;-" rh~. "ppro.,u ~

Ul.! .le

:Ul hIp lInd lure rk· \!..~

r;;hlc:J yuH

,!.")c Irw;:l.tJll tt1 JD .... ltt. :C;Ai IO:Jl~ ~ ' ....... ' ... 1- r

C rl),1 i

..

trct~h

Il(

(R (r""glh ~

ILL) probkm J'i'l(}

h':Ullillg

878

Ph)"~ical

Rehabilitation

and hand" wcighlbeJrtng on il wall can be u~ed 10 promote upper trunk e"tcn~ion (e,g,. qanding \..'all push-ups or cor-

ner pu~h-up'). Patients \\ ith PD typically e"\pcrience a high number of falls and should be laught how to get up after a fall, To that end. sk.ills in quadruped creeping should be practiced \0 the patietH is able to move to a nearby stable chair or couch al home. The patient should also practice transitions moving from quadruped to kneeljng to half-kneeling and finally to standing using UE support. Mobilizing facial muscles is another important component of the C'\ercise program because the patient will have limited social interaction and poor feeding skills in the presence of marked facial rigidity and bradykinesia. These factors can greatly lI1tluence the patienfs overall psychological state, motivation. and social participation, Use of rna~~
mouth and chewing should be combined with neck stabilizauon in a neutral pOSItion. Verbal skills should be practiced in association with breath control.

Adapthe and Supportive Devices Attention should be directed toward needs for adaptive and supportive devices that can improve function. To promote bed mobiJity. the patient can be helped to assume a sitting position by elevating the head of the bed with commer~ ciall" available blocks of approximately 4 in. (10 em). or by ~sing an electronic hospital bed. A simpler solution might include attaching a knotted rope to the end of the

bed to pull on. The bed should be stable and the mallress firm to faciHtate mobility. Satin sheets and pajamas have :-.ometime!o. been helpful to enhance bed mobility. Patients t:;hould be in..,trueted to select finn chairs with annrests and avoid ~oft. low s.eats suc.:h a.') a low sofa. The chair can be ral~d (I,e., 4 in. [10 emj and s.ecured with blod.,s. or liltcd forndrd by elevating only [he back legs about 2 in. 15 eml), Some patients benelit from the use of a rocking c.:hair to facilitate independem 1>it-to-stand transfer!o.. Cham:i that have !o.pnng-Iua.ded "eats that push the patient into standing are heaVIly marketed to the geriatric populatIOn but should be u')Cd with caulion. The palient IS propelled mIt) Manding but may have ditT!cuJty !-;toppmg the mOVcmL'nt and/or gel ting tU'i ur he-r halhould hav(' Il~uthl'1 til haJ(j oC:'mposHion sole. h~dlJse ~hoes \\:Jth "'l'pe 01

ruhbcr ,oles wilJ not shde easily and can re~ult in faUs. A festinating gait can sometime~ be alleviated by the addition

of 1110ditlcd heel or shoe wedges. A flat heel or toe wedge may slow down a propUlsive gait. whcrea~ a raj~t!d heel or heel wedge may diminish a retropulsive gait pattern, The use of assistive devices can be problematit: owing to move~ ment difticulties. A cane or walker can be helpful for patients with mild to moderate disease to a!o.sis{ in balance

or cue stepping (inverted walkmg stick). It is Il11portant that the height of the device not promote increased fleXion of the trunk. Vertical poles can also be helpful dUring walking (i.e., pole striding) to improve upright posture during walking, Patients with more pronounced movement diffi-

culties and poor balance are not likely to benefit from assistive devices. Walkers with wheels are particularly haz~ ardous. and are likely to increase a festinating gatt hand brakes are an essential requirement. Most patients use adaptive devices to assist in ADL. Reachers can be used to provide assistance in dreSSing as well as for other activities, Eating can be facilitated in a

number of ways. The patient should be seated properly. close to the table. with good posture. Specially adapted utensils. plate guards. and enlarged handles can aid the patient's efforts. Because eating time will be prolonged. heated plates or pads may help keep food warm and palatable. Drooling and/or spills should be anticipated and clothing protected. EXira time should be planned. and the patient should not reel rushed.

Balance Training It is important to recalJ that learning is task and context specific. Thus, a balance training program should mclude a variety of activities that alter task demands and expose the patient to varying environmental conditions, \VheneH'r possible the therapist should try to duplicate the ccmditlOn.\ the patient will encounter in everyda) lifc. The levd of challenge is important. A therapist should k..no\\ the limiIations of the patient and the specitic J~mand~ of the t;:15k and environment in order to .,decr a.nd progrc'is ta~ks accordingly and enslIre patient .sall·ty. The rt'ade-r i:-i r~fen"('d to Chapter I 3 for 3 more compklt;' dl,(.·usslon of b..i1ance and gail trnining,

An imporlanr focus of balnn4..'t! lnlllllllg for the r~lfi('nt \\'Jth PO is cenler-of~m<.l's (CO~'1) and limits ()f ~1;lbili[y (LOS) ('olHrol training. Pholiid ahlll!'\pJon: tlll'ir LOS and pr~H:tke \\llrl· lug low.lrd t'xpantling rht'ltl in Ollth 'Ithug iUhi ,l.:1nJing. In "!;,Illdlllg, palient'i \\ ilh PO tYrJ\.. all~ \kmon,tr.lll' r('.ari~'t('ll l.OS wtlh forward displ~ll'elllcm Ilf \"t.'nkr uf tool pre'l'.. lln.~, ";llll'uts ~hl!ulJ tx- 11l\(fUl"ted III ho\\ [\1 JllIp!'!IV/!' p'J,'iIUr.ll ,diglllllell\ alld in W:I)"" III i.iVoid pOMural dl'IUl"b.tJl(t.~~ unJ lalb . I h~ tIKi ..l!'i,,1 em 'I<;!i>ht \\ollh po,tural.lild !iah.·l~ a",ilfl'ul'~;; hy IISlIIg ;.lppn1pl"iilk \nhal, t.I'"til~~ or prllprU,)-

• , , 4

880

Ptnsical Rehahi.lit.;tlion

w;,l~lng willie

manHillJ1Hlg safety .lIlil pr...·V(.'lllillg I.. II~.

ClJn 1pcn<;3t(U) trainlll~ ~Irall'glcs ml~ imliL'all'd. ITt.'Clll1g cpl'(xi("s .1n~ ...·ommon and un: ofll..'n rt:'sl!-tallll(\ drug thl'r"py, The therapist anJ patlcnt !o.hould idcnlily .1Ild rr;lclICc strah:sjes Inr unfreezing gJII For C:\;lInpk. r(lWlional ~lIITl ulaticm or "'ttid.;'" IlHl\('lllents ~ulh as dwpping a ti~'lIt: that the p:Hlenl nm,,' st("P over can be ~U(xcs ... rul In rcduL"lng frl'l'zing. b'\

Cardiopulmonary Training Rc'riratoT)' d~,funl·tion i~ linkL'd to morbidity and mortal· It\ in patient:. with PD. Both ob:.trUl'tlw '.IIld n:~lrKIIV(, \'~"tltdatory dcficlb are pre'ent as Ihe dlsea'c: hcL'on~c~ more ad\·amed.SIl,lM F0r Iht.""e patlt:nts. a comprchc:n ... ,\,c pulmonary rehabilltaticm program shnuld he 1I1 ... UIUll'd, Compoocnts include diaphragmalli.' bn:alhJl1g C\CrCI~C~, llr."hlftlng tcchnlque~. and cxerci:-.~s that rC:l:nul m'd:. shoulder. and trunk mu~de" The pallent ... hould he mstructed In deep bre::uhmg exerci:-.cs to impnw~ chc!;.t wall mobilit)' and vital capatity. Air ... hlfts are prollHltc:d to ICSSCT.VcntUJted areas of the lung. For ex~rnph;.. halial expansion ("an be promoted u,mg manual ",trch.:h and resjstan~

to those segment.... Lipper body rc:sistant'c tralll· mg exercises are mdicated. These can mdude rai~lIlg and lowenng a dowel with light weights ~dded to lO...:fea"C: reslstanee (e,g,. i lb [453.5 gj). \Vt:ight ... ale in('fea~ed ..IS function Improves. As pre\'iously mentioned, dle~1 wall ",obllity can be 'mproved h)' using Pl\ b L E hlla'cral .yrnme1I~cal D2 flexion and e~t(n~inn patll'rn," Light \\t'I!;h .... (wrist cuffs) can tUS!1 be added to the~e exerci'ies. P"III~·nt'i are c'"lCJUraged to ~oonJmate breathing with l' fi llIove .. mcnl lxen:~$ are performed :In umupported !'ltflOg 10 F'OfllOlC trunk stabilizalwn, A tlKus on imprOVing trunk.

e).,tension

tj,

palterns In

cspcciall,v lmpuunt 10 Improving breathmg pa',C11" ..,th pos,ural k) ph""s. Pulmonary

training FOgrantS- have been 'Shown to be safe and efTet'llvl~ '~..z palienb with PI) m Improvmg pulmonary fUI11o.tion I.t , oxygen ",'"Onsumpuon : Y() 1. IIlll1ute venlJlatlilO l V I. r~pu.!!Ory rate. in~pirdtory mu~le strengtb)I" '1'11 and J':r.

ccptlC"U 'f dyrpnc.1 u Indlv .duals with mild to moderate PI> ,j~lI1(Jnslt ate .1 maximal cxerc. w; ...':lraLilV that I" 11n,il.u ' to hCZlllhy ad I ·~·i U1$ They also demun'itrille u pc,,~ tu:rohlc l'~pallty ~..:l ~rs at I ~, ower wor~ level lhan ilea.h hy .-.dultJ, Jtandardllr.d rJade~ exert: l'St lC'Jlm~ (..Ln he \!:;.;:tI t:"' It.Jr:.ly dI ::~nnJnI" 11 t: IJ;.lIMt . . I . I_ _ _ , CH • ,j fitnC'~ _ , PlI( ,r 10 C'~ : 'l11l1u:n C

R-:-:'::-': &.-roj;."""m,~1/ An 10 t~

de"elopcd ba!ed

indIvlduati~("d el{:'-

dl Ihe

I\(',)M

Kill

~:. \' mtc~!" IY, dur;ati~!! • .!.'1d pror,rl

",~J he~!~, Ulan nol"'1Ut: =-~~llng nlcw,iIlC~~ n t'~ ~!) ( .c; IlCfl"Cnl of Illa);unum he-M" r;:~:

,: ox"'gen ulltak ~ '-:~rve)

r:., Ih(' Jlatlent

,!"'et :--: ~eruary ' .f~;,:)'le aud '-\I:±:n: t~!!~ . lIl a Li"i: J~d. ,:{,"~,C' dUfJli: ':~

fr: .::=:!! C~;.-~ ~ -J ~

;::- ri_

~ J 10 UUVro\O

'(·'Ir·~llJl fllllnilOfll1l'r;o I') llldiralCd, Lilt autonomic · ~.. t IIIlCIliiS.

dy~fulldl(ln l'i l:omTlum, I ()ppa r;1JI prodllC'c arrhythmia., .l11d oltho':ltJtK hypoh."llo;.lon u\(\ng "It II dyskmcslas. The thc."'
l11wkranl'l: (C,g., sjgndi~anl dysrn~ac hypotensive respon.~.

scri(lu~ dy,rh)'thlJlla~. lind so forlh). Iralillng modes typi~ t..:allv induoc 1.£', crgol11etry~ l L ctg o J11Clry. oml Walking. Sd~(;ti{ln "III d\:'penu on the ~pccllk ahllilles of the palient; for example. pn~tural In..,tlhdllY •.lIIt! IIlcn.:as('d risk of fall~

may rule ouL u,e of a treadJ11II1IA,lthout an overhead harness. RCl:umtx'nt or sl'alcd LE c:rgolllctry is a sUltahle alternative, For mo... t pall~nh a program of regular \\alkmg 1.(0 rt!~om· Il1l'nded. lhe duration, speed. ;:IIlU tl'rram (overed can be modified. h~scd on mdlvidual anility. i\CI,:("s ... ihility to a ~UfX.'rvlscd walkmg program u"lng all IIldonr w;JI"lIlg mack i~ important for ~()ml~ In ensun" safcty. For olltdoor walken. a ~hopping mall can provill~ an 3ttcptahlc environment In ca ... e of llldcmcnl weather. A "1IpC'f\' Iscd <1('whic pool pr~ gram L~J.n also pro\' Ille an aL:ct'pwble mode for !-o()me patients, The wamllh of the waler may tx.- rcia'Ulg dnd the buoyancy may enhancc movement. The nllnimum re\:omrnendcd exer~ cis" frequency" 3 to 5 d,,), pcr week, D.lily ",.. Ikill!; wilh ~hort OoUl', throughout the (by I') rc[omOlef}ti<:d [or indh'ld· ual ... \o\,lh lower lum:tlOnal capacity. Intt"rrmllcnl exef(l\e with repetitive cxcrci ...c·resl penoJs IS Imhc;'llcd tur those patients who arc eldc:rly and de("(Hlditllllleti . ~,"d who presenl wilh pulmonary dy ... l'undioll, Acrohlc trallllllg progr.un, have hccn ... howl1 to he ~;tlc and Ctll'(' ive for p~lllents with PD III Irnpnl\'mg ac:mhll' ('i1ra~'ly"'H.I~"'h"

Group and Home

F.xerd~es

(,roup e."\crci'ic c.:ht'ises C.III be valuable for patienl.\ with PD, 1\'.IllcnlS Ix~nefit from the ('OSiU\'c suppon. cmta ralleric. 'lna COllll1lunlc.1llOn the gr'JUp sfIuatlOn otl,-n Careful eV~llualion of Clh..:h pal lent pflor ti,.' Jdmli."ilon mlD:l group IS essential. Patients should bl.~ able 10 perform 1M therapeulic core of the c1:I~, 'itic'ting palients with sinu, lar levels of dl~lhilily i" uften ddv!sahlc bCtJuse the sense of competItion can fH"4ut~nll).' tJ\:' a ~y "Jclor m fiI\.luvating gruups. [he ratio of ~tlff 10 patients should he krpl ~It1JI! (;dcally I S or I )(1) • .IOU eXira ~t~ltl shoulJ be .Idlloo il p.ult,.'nIS an,~ unahle 10 we,.l "In th~'r fo\\'41 "\'.1ri(·I) pf ACllvnt.:s "an be used 10 !i.ll; ilu.~tal~ f11(lll\'ltC, ~'JI1"nh

"If'"

('he p.:Ulcnt .. ' .If! hq;m III the Ih.':Ut'O P(\·.ltloI11Inli rrl1grc ...' 10 staruhng. Ut~.ng Ii£ht. t('UC!"Hh.,',.n ~tJPf"..'rt (ll Ihc (1' Ihe hJu, \)f!:lI..h!n;! CleT;"l~,('S t'( (llio:lhcUlC." !n\'\)h'tnl! .,00nt "an b;: used !,", mUJ,lI \\ iUntJp .1(H'IoIt u." Pn\,L:r;" ~:' lon IS 10 ",Ul1binalltm m()\"":fj,;nf ·, folPpt' I an,II(,,,,cr

b.,,"

xtn:lilllit5 With .IUalINnk. rl"tiltiCiU). \\el.I stlltdUre,I,I,"""

unpa.; aewbk ii li.:.-: .,n _lfpwpnat: h!i UJ I~r a ~roup \." r ,~,r r.\aIrph: ril[j('1lts ,.a11 11l;t(",h il., r lili ";"" fir:.f ~n stlltn, Ihen IIllIr:U!'i, ~n~; nt..: .n"upcdl th(f, (,rO:\I;II .. , WJ}k1l1. "'11ft I

lpt~~J~ ""0 L.J.:mg i.1rj;: . tilfh :lH'P:, ~'USh b u~~d II.' lunu: tlh,\Il II. I I !IU\,"\. me-nr .IUd rrll}\.'''1l ltJlt

Pl _'.;; j;,: lI('ce ;;:...Wr

1.lUJpit" r 2 1 1)llfkin ~on ·/I: lliOJleu..",·

IUU

JUc'n;. I-'\('n:'~l~ sOl :on~ (c {:. ~1.JtionJr)' l1h.·~-cl('. milts pulkys, and Stl forth' un also t-,e used. l·xcrclsc-", dUllc by tnC wilDie ~n.1Ur to,l;crhc-r shlluld hll.. us on lr.pt,rt'lIll ('xcr

SUl'l·c!>sfully lle;,1 wllh thr (hMTg'" ass",:iall'd With tile di

"l~l' ~(~ls ~C" 8· IInpmymg RO\1. r.obllil\, dnd so f('nlh}.

f.ItHily

RCCI"C.atWllal 1;."llnlies can I'ol!..)w lLe aerobll poltinn. !'i.J(h ,5 hnc. darn:ing- h:!- Ih,.'tn.:-cs. be..Jltx;~ [tlSS. Ln~ Sl} fOfth The' I.ctln~ cs sdN'lcd sllllUld be Inl('resling. .tnd ,·aricd F ":ally. :I. rela\.:1t101l trammg segment ,hoilid he 1Il~:l'rpo. ratc-..J anl(' e;J(~ dass. ' 1l1e HEP Include') many oft1l~ intervcnlll'n., .llr"cady dl~ ~.U~,~, w~th ('",ernsc, dC'signro 10 imptt \ ~ reli.lX.ltlon. ncx '

Ic-s~ness tllld dC'lx~tl\k:ncy

.btLt)".

strl~ng:[Jl"

and antiopulmonary funl'llnn A "coy t'IL-· Ihe Imponance 01" regular (till) ('\l'rusc and lvOtdanl'C of pmlongcd pcnods of IIlJdivll),. ·1hl' flrl' shOU:": be reaLstic and of nll.xlenlte duration ;md ink'lI~lt\ The patienf should br C""Jutic"ncd ~am:-,t \l\"Crdning dl·lI\iIY. "turn could result In ex:;.eSSlVC fatigue. E.1r1)" Illl'l11l11g warnooUP clJ:sthcni~s .::.~ onen helpful in rl"du(,lIlg the mcrcascd suffne..'iis patiC':ns "::\3.)' cxpcncnce upon an;,lIlg. Strel<.~ing and streng!helllnll exere;",s "'" pcrfonlleu In "c equ'I'''"''''. l-or =ple to reduce the .ffeets of forwJrd head and '}phe",,' ".,...--1fC. !he patirnt can be Ulstroeted 10 hang by the hand, c:.;ng a1 "':I\'erhead b.1! St3IldlOg, come- w-all ~lrch.:hcs can at"" be used t~ proVl(le a m.mlatned streich on thc' uprer tru."'lk '1aors. l·~ of 1 wand or ,,:ane (an he: ctfC"("II\':: in pr 0· rooting ovenead noUons. In standing. a (.'Ollntertl.p Ilf hac~ of B sturdv chair can be used t(' itS-Slst JIl slahiliLliliun dUflllg [=~!."'!~ ~isthenics ..mel balance acuvltle'i. ~. tun el ld I compared the effex;;iveness 01 J self-.uper"",d home exef· CIS. progr.ml With a phys;ca1 'herapi-" '''-pc:''Vlsct cx'rClSC "TOgram ~ £,aUld 'X>!h were equally effective In .tnprovlIljl 11l!--:;! IS .. tr:<>sing

r:tsC'~ others
tinu

eduCJIH'n IS tIle" lC")' ti... nS'iI:-ittn~~ patients .and

.llemhc~ a'iis1lTI1C rcspe'II"'lhlJLty l'crlLngs of (~olltHll

u scnS(" of

IPC's, uno siress

h()pe

p~llicnt dev('1

ov:r

Ill')

manat:C'IHCllI

le( hniqucs.

II

IS

equally

IflIptllL.uH In C"1l~l1fC Ihal P;lhClih lI" rlOt hccomc isolated nnd Ihat :tpprtlplI;th' hCrVI(CS lIrl' ~1V~lIlal\le. 'le.lt11lTlt"'"mhcrs II1ml

he \rgllilnt r\!g,tfUtllg th~1t a"~lIl1lpllllll'i ,1011 l';f.pcCLJ·

IHUl~. ,\ l·Plhh!Sl·I.'llllJllg 01 pt:SSIIlIl ... II~' lIlId hunling ~Iltltudc

l'an 1"X'l"olll~ ;1

sdl 11IIfilling prophl'cy P..tIICIII~ !lnd lamih mCnlhl'Il\ Ill'ed n:iI')<'\II".tll("CS .illIll·Il('(LUf.lgl~rncnl I\n over all C"lllphd ... is 1111 "hal p;tllt'nh CII" do ralhel than \\-·hal thev l·;IIlIIIH dn hclps III CllIpov.er IMIR'nts. Thcf,lp.I\I, need 10 rro\ Hl~ ~l ml'~<,age 01 11,,/14' tf"fIlI'f.·/<'d Kith l"(·tlIi.Wl.

Patient, Family and Caregh'cr Education Ihe il1ll'Idlsl:lplinary temll PfOlfidcs IlIlClnlliltltm dhout d wilh PI>. ·1hi:~e Me rrcsl.'ll1l'd III Bo\ 21.6. InlC"r\"tllllOIl~ C.m take the fOlln of dlfl'ct onC-OIl-one lIl",trudlun, grt.)UP 'iC"i~ton5. printed material ... , ~tlld video Of UHlIplllcr PICs(·III.HiOIl'io Ihe thl!'ra·· PI~t's OVi'fall approach tle'cd, to he IXhllivc and surpllrt.LVCV.lfIt'IY of tOpll'S fl'lalcd 10 IIvIIlg

• Par~imon's

Psychosocial Issues

.Ire feduced lL\ Ihe

or her 0\\11 iI!~ Self-man dgt"fllC""1I1 sk.dl~ Ihal should he prol1loled ine,:iudc Ildv;;UhC.:i planning of l'l-Ilvilies. t,'1f&:lI,vC' lillie management ~trale lipS

Box 21 .6

rm~~~nPD.

fir.'"

'n~(n:(r-:

Uemt' .. h of a Pat;.'nt. Family 11 .. .1 ('arcgi\-er Edunuiun I'ru.::r.II" di~C".J~.c

dinkal rn. 'OCllGllllm ... rnt('rl

[0

"),1111>10111

• '.k114 H1on,: PU!"T'f.:",t" dO'::J{:''''. (Xl:'L<;lblf' m.I\'cr~t' 'hI·

The -:-.~i.-~::j\,~ ~urc d PO neC~S£Jlatc, frc4ucnt per and o.;aal ddJUSlmen:, and .ff",!S.1. aspcc of life " , both •.he pauent dnd fam: y 9isruptlon ~

ci:, y I Jlle :::-, and dL!jVj;';o:.-, arc CltpeLen~~ ..~n(1lc :;( the alL~ wit2 PI> !!""~ W. lally Is.c:-Ialing "lI~-J...t:d ~ ::)hr&y

l...--.. •. '

lQ(;re::t~.cd j

In

l.rHnrdH!-!ib:;: Ii~:

ut;·• ..;:~(;;: Fnpu.:.: ~.. a.nd • '!II be

!-'=t'l' "ir."'"" (·,f· tither (l'·cr· '-'f ..mrk'mw... hcalioll PrC'--1I ~II\,:' Ir:~1"l.tr("111' I'iIUIIUlILI..' Ib,> \Cl,;.)lld.uv ()mpli

arion'", an.:! Jtllpalnnl,.·nt: Impw:t ~-,f PI) nn mmclJ\(nI .lIltJ dInt"':.: ITIJ.H6I~ _ ,11i.)\ _·mclli 1'1, ,hh -In O.""(:-J'f II "'L·fu.·~.md .. p.:..trt!~

n..·.dJ~',... ~nIUll\m·, III '(-Ilulal

,p.. lw,n

I Illt:' J u~ f'(l ...! tl.lll.,tion md lofk,·u

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~l

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Ph~'sical

882

Rt-habilitation

Communil)' sUppLlrI groups are availablC' for pal lent ... and thclr families. nley disseminate infon11ation and offer a Chal1l'l'" to discuss common issues. problems, and l11<1nJ,t!1'1ll1'111 tips_ They abo can proyide a stabilizing influence. a ... sisling palJent' and families to rocu~ on healthy beha\'ior.... coring skills. and effective ...elf-management. FN "orne p.:Hlt'llh 10 the early stages of the disease. particIpalion in a support gn'lup may increase levels of anx iety as 111(''\ op_"en.c mOTe disabled patients. Groups particularly targeted (('I patients with early stage disease and sinlllar ages may be more helpful Educational pamphlets. newsletters. and location of support groups can be obtained through nat ional PD assocIations.

'alional Parkinson Foundation (NPF) 1501 "Jorlhwest Qth Su-eet (Bob Hope Road) \liaml, FL JJ 136-1 ~07 Web . . ite: IlltP:llw\'¥'\\.parkinson.org Ph: (SOO) J~7-45-l5 E~mJil mailbo\@parkinson.org Parkinson's Disease Foundation (PDF) 1359 Broadwa), SUIte 1509 :-'-ew York.:-';Y 100lS Web ~Jle: w\\w.pdf.org Ph: H'OO) ~57-6676

E-maiL mfo@'pdf.org The American Parkinson Disease Association (APDAj 1250 Hylan BouJe,ard Suite 4-B Staten bland, "ew York J 0305 \\'eh site' http://www.apdaparkinson.org Ph: (WO) 223-~712 E-mail: apdil(q: apdaparkinson.org \Veb-hased resources for climcians and patient~/fami~ livmg '":th PI) are presented in App
Ii",

l1letlmngful assistance in understanding the disea~e and it"> ramifications. Early referral to suppurt groups is also helpful·? . During the middle stages of the disease. symptoms are more readily apparent ..md functional limitations emerge. The patient may still be ind~pendent in gait and many ADL. although performance IS slowed and less efficient. Some assistance may be required. Treatment with L-dopa is typIcally delayed untIl the early mIddle stages. although individual differences exist. Once placed on L-dopa patient') may exhibit a dramatiC improvement 111 symptoms, most notably in rIgIdity and bradyk.inesia. The alleviation of these symptoms does not always produce a SImilar level of improvement in function, however~ poor habits and faulty posture may have developed. Exercise training programs have been shown to be effectlve for patients with mild to moderate PD in improving motor perfonnance. 157 ,IS.Io:.17S-118 Perceived quality of life and subjective well-being is also improvedy,g·179 Family and caregiver instruction is mtensitied to assist the patient 10 remaining functionally mobile. Patients with late-stage disease typically demonstrate a number of complications including phamlucoiogical intolerance. increased primary symptoms. fi:\ed musculo . . keletal impainnents. a decline in cognitive functioning, sJeep disturbances. incontinence. malnutrition, signjficant cardiopulmonary compromise. and severe immobility, Patients are dependent in many or most of their daily functional mobility skills and ADL. They may be wheelchair bound or bedridden. Family and community resources are vital in maintaining the patient in the home. Some patients may require placement in a chronic care faL·ility. At rhi:-. stage pf dif,,~ase. patients generally do not respond as w~11 to medkal management and experic:nce decreasing efl~ctivene"s of pharmacological interventions, fluctuations In pt?nomlanl"t~. and adverse "ide effects of long-tenn I.-dopa lllt:'dj,:'J.lion. These changes GUl be a S(llirCe of ~~Jt fms(ration ro the patient and family. Goals and ~'pedatl',"'i Dc-ell to be

rt'stnh.:tured, During late-,"tage dJ.';;l~~tse. thL' therJpl!-1 n('{'J~ Itl fOt:u.., on skIn cart' to aVOid nrl..'itkouwn ~lIlJ pre:-.sllre \\ ount.ls. pulmonary hygiene h) avoid pneunwniJ. ~mJ a~SlstarlLC in pO"!itlomng and tccl!Jng to .Wllll.! lluinutfllh.lO. a}.rlr~Hinn, and pneufHoni;t_ (':l. ..~gl\"rr lr:unHlg ~~(lme$ Hk'rt'a"in~l} lInpt1n ..-tnt. Safel) (Of hoth tth' caregiH'i .mil

Management Considerations by Stage of Disease lr :.*1e earlv .luges oJ lhedl~~se. paUCflt:-> ,He funl,;tiilll,d

tlw p;we!lI het'oll1('s u prill\;JIV C(lnCI.'m th p;.IIIt'OIS !He ;lS~IMed III pi),>JlH"'Ill Cit:HlgC!> l!l bed IIf tiunoi!, tran~kp•.

l;. pr ,v:,de 5 ') wptomatic re ,cf, , refer: -lJ for 11 ih:rd.pV!:i !! '~':'l dchyed ,:it Ihi~ siagt: -llt,h(H"'l~ coul(1 drary "x- b~.!.l!lt::j. DU:-Irg ~ r:le eal'tv :-!tiun~ ;-.~ irdr: J.'~'llhat fo..:>.,:\ .'11 pr~v':lI. r-ver~J 01 r.-u:,c~jl"·· kre~-,!: J.1.1 .. 4rdinr"'''j1fl.

pur "t bed hOle dnU to rnove,h !llltd! ;.h (X''S.~1hk dod 110t dUOW ~erythlflg in be dOfll' ("1..11' them t)if~Jl. fllVin.lllluen· ' _11 utiJptatil'n'i Ii 1:..1)· iIle-·J.1l ihe dilfo.!rcn'~ tletWCCIl total dt"IX'ndcllce,u-:,J ~·JrtJQI independl,,~!h.' nIl: rehatulit;1nOtl ...:IlI ~.holJlu h~' "tJPl~lfl-i-~·(' cf the f";ttiem's «ffllfb nil ou.tb!r how sm~H thL') 1l1ilY lx' P:tth;nt .. ,n i~fe '!ool:i.j!f: PD derunll-.;tLHc cXlremd}- hnuted Sl;IIJ:-: h. 1I1t~1.t(t "11h thtlr "m;"'iil!lf"nt v-lIh m.neas!llg C:(l\IJI I"!(,bhon ..lnd \\utl

~ urJep;::1~.ent. fhey arc typlcally ~n un .m OUlp;.tti~nt h2··1~ MeOJc..:..; then.tpJ.c, may indode the. ddnnOI!l.lra1ion Ie-l!.hnc to lilay Ihe i1~ 'r L lOp... huM other drl.I~" I

mC'!"'I!" gC·ler(l

h::tJ:r-.

pallen: and [,mlllv (in

$.1.".

r'r("\'~d

t\lIlI!Hts ~houhl hI,; erh':\1uLlg,ed ~l1d .uS:~I:\I\~d 10 IH.I\lillln!

d:-iwJ.l r "m.I,,,.,. ..-Iso

x\lt!ir "1 dU1

th,e 11lt.f('"~~WUl uCIllJJl'h

Chaplet- 21 Parkinson''\I Di!Je1l.Se l,f ..~:\fI.', ~uml.)ut ...md

,,(x:ial isolation. Therapists need 10 m:l,\lfllue r"ychoso~lal sllppon and be readily 3vailahlc fl1r l·llnsuh.ltH)IL

-Summary PD , ... a ,,:hmi1lc. progrcs"'l\'e disorder of the ha:-.al ganglia \.'h.'lr-tl1erilcd hy the cardmaJ features of rigiduy. bradykln"~I3,.. lrcmor~ and pustural instability. Additional Illlpair~ menb include the dc\clopment of abnonnaJ fixed po"tures. pl,,,erty of O1(Wement. fatigue. masked face. contractures. a fesunaring ~ail pattern. w,:al1owlI1g and communication dlffi ..-ulties. \'1"u31 and :-.t'nsorimotor disturbances. cogniuve .tnd ~h:wioral dysfunulOn. autonomic dy ... function. 3nd .. .ardiorulmonary changes. Phannaco]ogicai inten-en-

Que

tion"

for

Rey

2. \\nat t:.;~ t!"'e ~ardinzJ features of PD? AdditIOnal ~mpamnents and l..(mlpllcatlOIl':'l·~ 3. \\-:-13-1 l~omronems ,hould he lI1cluded in iJ phYSKUI Jdenllfy: fOUT standardized

.1T

l)istor

d

,\r

r.-;l

7. Identify three interventions. that can be u ... etl to reia"

carJiorespiratOf), fitness? De~lTihe the gait impairment' common in p. ulenb \\ ith PD. What interventio[)~ c:.tn be used to impron~ loc.:ol1lotor function? 10. \\-,h~H type" of interventions are aprwrriat~ for the patient v. ith ad\i.Uh::l."d di\ea\~ who h r~lJ.ti",t;!ly unre'pnn ... ive 10 drug mi.lnagemen(' 11. DifferentialI.:' Ix'twet."n ~I rehahllilatlon pfllgwm with J r("!-lorali\'c ft)t'u ... \-("fSU'" one \\Jlh.1 functIOnal mJ,lIltc r!Hller, fo~tI~_ Con\ider gO~I"'. outcome ... ;Iud overJIl tr~t1Jl1ng approJl:h. 12. \\,h~H an: the major Uln\IJl.:'f,uitln'" In rroviding psy "llostX'IJI ~urpon '? Patlenl, famll) :.tnd l.U'I.·~i\er edu 9.

..neasures that w{.wd be appropriate to u ... e "ith th~ I13llC"1l v. "!l PD 4. D<:=--r.bc the "'rug the-rap" u~ed 10 PD. How might a phycTaI ther.>py I)rogr~n be llfluel1ced hy -dopa c!r J~ lll3l1'geme-1 5. \Vha: c..-:. ,.,~~ r.~or goals Mld oulcome~ 01 phY"I~Jl ::-'l,- mter'\'em ,or.; HO\\ might tht')' \'~u)' Py slage ,f 6. \\ Jlon~ed lllaCU\,lly for the tify thre~ inll'rventtC'ns that call ., unte'1lCl these

d

chosocial support as needed,

the patient and improve flexibility. 8. \\ihat interventions strategies can be u...ed to improve

Ho\\' IS the f"..:n(-:lon cf the ..c ...tructures alrered?

C'l(animlllnn'l

tions have become the main~tay of treatment and provide protective and symptomatic treatment. Efl'ct:t!ve rehahilitatlOn focuses on the patienf~ stage of dise;Jse and symp .. toms. functional limitations. and re~idllal ahilities and a~sct~. InterventIOns arc restorative; that is. rehabilitation i" focused on the Improvement of strength. ROM, fum:tlonal sk.ilIs. endurance, and so forth. Individuals wilh PD also benefit from functional maintl!nulH.:e programs designed to manage the effect~ of progressive dl"icase. Strategies are developed to prevent or redu<:e mdirect impairments, and promote regular exerCI~e, good health. and sclf-1TIwmgement skills. A comprehensive team approat:h including active involvement of patient and family provides optimal benefits. Team members need to he active dunng all ~lages of the disease, as!'.isting the p.nient and family in maintenance of funclion and providing psy-

ew

1. \\"11,,: are ·.he rna'or C\S .. tru(:[ure~ involved in PD'?

thcapy

883

C'Jlion'~

It :'ttU~·IIOl~l.,.t ,,"'ho fout·,J (TIext("f-1re Irerw,.\1 dnd ngldlt~ un H~z left t;';{k He pr:'il.~.~' 4..rtaoc, whl(h Wd'i hdpfuJ for Ii W'lilc I \'':;~llU~~)' the '.~f'!1Hr hl"1,;J.m( WOl~ e ... ~~cu.llv londer 4..0f!! '.liJun':, (.t- f.(r~'S!t ""'h~n ,ht w.~ ",n.Jt"lIt.' 10 1I~ her I l1: '11 dl! \hc.l WJ~ then s.urtt~d '-'11 'i1ltt'm{'1 JmJ Ii

IwnORY

fo~

ill.

ioHIJ.1 (I'I-.;otk

,1f phY"C;:.1lllk·rJPY .u dn '.1n tt· ~'1rl.. .nd ht"r J()I11P

Ik:r

n Ill-: lle.\.': !, W

f flef

10

,,·(.tr-..a.,. ''11.'"{" $)-lilphJf1l'i mi.l

ul "'iJflC'Jll(! \.Ii"'') ...z\t,;ll!a~('1.J.

m'p

rh~·~ical Rehabilitation

884

CURRENT STATUS The pal lent j., CUITt!l1tly tiling Sinemet and Bromocnptinc. Shl' rcport~ tX:"luts of dy~k.inesia about 45 minutes into taking her Sinemct thai involve involuntary writhing move~ l11ents of her ~houId('rs and neck, Her chief complamts are:

I Difticulty walling, especiaUy \"hen she ha~ La go through a narrow doorv,ay, or walk in a crowded place. .2. Episodes of gait blocks: if she t.ries to do something while walking like rake a tissue out of her pocket. she stop~ abruptly in her tracks. The harder she tries to move. the worse It gets. Episodes of freezing have lasted up to 20 minutes. 3. Postural instability: over the past few years she has experienced increasing bouts of uncontrolled or unsteady balance. This is particularly disturbing to her becaw,e if it occurs while she is walking. it causes her to fall. She has fallen seven times in the pa!-it month. with no residual fall injury. Because of her increased rear of falling. she has stopped going out by herself. 4. She is experiencing increased difficulty rolling over in bed, getting out of bed, and standing up from a chair independelllly. Her husband now has to provide assistance 90 percent of the time to accomplish these activ-

itIes. 5. She reports having trouble sleeping at night. She has stopped drinking coffee but this has not helped. She wake~

four to five times a night. and requires assistance from her husband to go to the bathroom at night. She also has hallucinated at night. claiming to see bugs on the wall. During the~e periods she becomes extremely frig.htened. 6 She complains her medication seems to be helping less and les~ . If she plans to go out, she take!> an extra Sinemet. She revisited her neurologist in hopes that he Vt'Quid mcrea...e he~do,age . lnstead he told her the !>ymptom..., 9.ere mo~t hkel,Y the result of exees!) medication, He. Hl~tructed her not to take the extra Sinemet and has 3dJuQed her dosage

EXAMI~ATION

FINDINGS

{Jo~niti()Jl

A.lert. (Inented )( 1; she is displaying mild ItnpamnCllb bh()rt·tenll memory.

JIl

'tsy

~ ',1)SO(·IUI

She is r hflwillg !.1~J1 S of dC'pre:-.swn ; ~h!! 1~ kss 1111.:rt'stt'ti In

g(lillZ out and socialillJ1g . ... he n:ports. ·'11 is J11~t 100

much ellnrl·· Ill!.·

Mud dY'3nhr.a, hyp~,phOtua IIS ·,tit'I1

5lightly de'- ccased pr' ,priuceptilln bllb1t!rally HI 1!t.'I!t d.nklL - 'lhe~wi~'.: .ntact.

T()11C

Rigidity (cogwheel type) moderate in all extremities L > Marked rigidity throughout neck and trunk. R. Masklike face.

RO\! Decreased due to moderate rigidity; limitations noted in: Bilateral elbow extension (10 to 140') Bilateral hip extension (0 to ](t) Bilateral knee extension (10 to 120") Bilateral ankle dorsiflexion (0 to IS' RLE; 0 to 10" LLE), Strcn~th

Generally fair (3/5) to good minus (4-/5), Poor (2/5) dorsiflexor muscle grades noted in both ankles. ~Iotor

Function

Moderate to severe resting tremors, L hand> R hand. Bradykinesia: marked slowness. poverty of movement. Hesitation on initiation of movement; frequent arrests of ongoing movement.

Posture Forward head position; flexed; kyphotic spine. Stands with flexion of hips and knees.

Gait Ambulates independently with a shuffling gait pattern with decreased step length and arm. tnlnk. hip and knee motions; tendency for propulsive gait.

Frequent freezing of gait.

BnJanet.: Decreased limits of stability, Patient'S fonvard alignment lI1l'fcases her tendency to fall fOf\\iard. Sitting static control: good (able to maintam ~alanL·e without handhold). Sitting dynamic controL fair (al·L'epl.... minimal challenge: able to lift both anns). Standing static control: good laole to m~unlain halancc wlthOlIt handhold) Stanulng Jynanuc t·ontroL poor ltmablt~ w aL'I.:t'pt millimi.lI chaJleng(' withom hJndholJ I. She hu"i !)lowed reaL"tiol1"i to lo~ ... lIt hal:uKl'. With dClTea"ed rorational muvt!"IIJ('nls ot Ih':,IlL'~runk ",nJ 1I1dlel'll\t:" use of "tepI1in''t eo .slr,tlL"~ie\ ,. n"u-d t'p & Uo "'L·pr~~ IS ~o 'ic('ulhh. i'uti<..'nt !S feaTful ot falling

h act:·.,,,,1 \/chdil\' neIll-rally Jc~:re
rollin~ in

lx--u. MlpJlletn-SII

lrJIlS[ers. Slt·to--~Ian\l il.msfers

l'u;\hll' to hrld£(, sel'ond.u'\, I\.) hlp Ik\hln contr.I,-'furrs.

P....ti!:HI has ~ood sJ.fety ~t\\·:lIf(h':S."'.

{ 'ital'h'r 21 I)arld .. ~m ·fi ~d(.!

885

GUIDING QUESTIONS

,1""

R'~~IUlrl"" I1lIlHnlal aSSI'!iI~'Ilf.:t' hl sup,,-'r' i:-'Itlil I'm h.'I.'dlllg R~'q\l ::r("" tlltrnOl:ti 10 m(ldl'l~lIt~ a"'~I ... 1 ,I t'lr

\11\- .... itl!~J~;llllln,£

(.dnti(lpulnuHllln' lO,lHl'titlnil1ndl1fHIlI.:I..' ,ha1ll"\ \Url'N rt'plrJtC'f!) hrt'Hlhmg rath.'nl. (it'llcratly dC'CfCl,I ... ('d fUIl ...'lhlUal (;.lp,wlt~ (Cslnmtlcd fUI1l: ;J~ln:ll \H1rl ....Ilp;ll'iIV

f FWe1

i .. 6 nH'tJ;hoh ..- \.·quivaknt...

.\lfT'!'

PoIllCDI f,'lttg\l(.· ... l"."Oa"il) and rt'qu1fcs fr~ljuent re ... t

Idl'lllJfyA;all!goli/l'lhis palit'nt'" prohlcm'i in It.·rtll~ of: ;.I,

I)tn;d ImpalnlWnTS

h. Indirect Imp;.1inllCnb L. Fum:tlOnal Iimltation~ d Al.:llvlly rl't'itrktion,,/(lisabiiny 2. Identify 1WO Olllcome1!i (the remediation f}f flJnctional InnitallOn.;, and dlsahility) Hnd two goal-t fremedlation of "l1p;'lim1('nl~) for thl"; pati~nf. :\. Dele'rmme four treatment interventions that umld be u.;,cd ill the ,tart of theT;JPY 10 ;1chieve the outcomes and

goal ... provided for

pt'n('I,b

\hlJ cdnna

l)i~ca4e

h(llh

4ue~llOn

2, Provide

iI

brief rationale

for each.

ank.te:-.

4. What motor Jcarning
·.;1.:1n

Int3ct. no are:ts of bn:~lkd('I\\n of m.:rea';;f.>d peT..piratiflIl.

3')<"I\jt

5. What strategic.;, would you use to assi . . 1 in the dt'vdopment

t:~nt'ncr . . J.,out~

of self·m~U1agemenl ;.;klils and to promote quality of life....

References M, and RaJPUl A E lldcmJOlog)' of 1'!1l..J""-..:.ooISlTl In F~'"tOC S. and \\'eina. W ( "d5.!: Parlinsou's Oisease- Oiagnrnols and ( Z}Kai Mana,cmcm . ~~ \h-dicaJ Publ~ung, St"W Y1'711.

,

)' on the: ShAking PH],;,}' SIlC'rv.'OCId 'eel.)' &:

W, cl aJ Tht heterogrncty I.:. ·f Pa..1;Jm.~ s dl'ioC.aM' , It."'::;:. ~IlOSl1' impltQltions, 'etlrolo~'

'5, ,,:~

I ~J8:)

4. Miller, \\ ('lD;$sduation Of ~r"'Ul$O.Il.lsm. fa K.)ller, W led!:

Handbook. )f Parlm50."":1l1t. fhSQl;t;. Mart'C1 DekKer,

\~

Y(lrk,

~O.

Bridgev.3ter. K. and Sharpe. M: Trunk mu~le pcrf~""1WlCe in early rarkln,on's dl"t'a,<;e Ph)"s lllCr ,'''l:566, 199ft 21 \1.~hlm.a. S, ct al: \ ·i.'WO~r3U.l1 impalm1C'l'lt il1ld act.IVinU; ~.! JaIl)' h~mg in patieniS ...... Ith Parldnwn·!J. disc~. ·\m J Pflyo; ~kd Rl'hahiJ 76:383. IQQ7 .. ., WIXl
w:

1.2:98. Iql\I;J 2·t tiliil)" P. and Hlldrbnrtd, r;, Fall ri,k tlctorS lit P1fllrt!,-~f$ Ji~~ J 'euru~i ,'\uNing '2:2L!.1Ot(). .2"5. Corcos,. D, tt ill' Strength in PaT"m~ s ru5l.~ Rc:I..ltionship tralC' of tllrC:"1 generatlOfl and dim\,;;! stAtus. '\nn ,'"nol J~ "9. 1996. '26. ~ Sow 00era. B: ~ rum~lh .;1 Par~4".....:n·.• c.~ Quaritit;ltr.-e :neasumn...b. foUo\\"mt;. ..... ,lhdrawaf of mcd.icltion Em ~eumJ '3~' 199J. 2"' Stcl.='"...l!:.". (,- ~ .111: FXl:! ~odlh.;tk1ft c~ :e..-'ll\.~ m

diSC'3,$('

rX,l

BI'3in Res '6: 165. 1 :r.-;?,

Milr,:-, -llrt.·":l.l1.

c_ al: Fk.. tn(\ll pfoptr1~;if mot;

~ .1X'liS.~A!

r( .lflowdup ....·'lh t'ad)

N~urg ~)c!ti.:tfrr ,P-l~.

• k.

~ aJ

Kth"" lor

"'-16'" I9l-X

~.

p-

P1r\-

886

I'h)sical Rehabilitation .'

,

lQ, p,-dcrson S, ~I al (1;,11 an ' . •
"N"ri"

Rdl.1h \unage Atlg;'SCpl:4~,.. ," . . , t ~ I'a biJ't", ,)f gall III P"rl..m'ion 5 dl\C3~ 42, di!ea'iC' 'f,uris. \1. ~t III l\!'ntpC1f3 I,

I'ttys Ther 76: 761 1996 toml> In fac.:h.r S and ""ClOer, \\ If'd ..)'

4.\ 4-'

""IS', R., S~n'>Ol') 5\m& agnosls and Chnu.al ~bn.lg(,lllent Parlmson s DL<..('ase

I

..

.,

fl7

~~~~ \~f.l~~~~~~:~~~~~~~l:: ~:;;I;~~"~ PDL~a~

Rl'port ..a"i,

P.lrl..lINlO

~allonal f'arl..llls~m foundalwn, I\\lanll. I S I J,lt"!.. 1 l ('1.11 SCII~ory pcrcerl10n 1Il Parl.ln~on dl,C.I\e ,\rl 1

. 4"

l"Uwl q:..$SO, 1\jq7 " d' . I . . \, , e ,_,. A nu , .. m'l(ch N-Iween I.mc .. thellC ,," "I .. ua .. , . 7'"'1 ,9'17 · ,. - ,n rarl.lIlwn" di~a~e Ann Neurol ~ I: ,., . jX'r~'f"p Il .. , " d· d" In 47 R IS l t'l al: Sr-'('ch. \oin', and ",wallo\\ Ing ,'(H \;r" · 1-::11.' <'lind \\.;int!r, W (elhl' Parl..m'on·' DI\t'a.. c- , Dla.g:nn~" and Clinic1.l 'hn3femenl. Dcml)S Medical Pu"h~hlng, ;0.;,,", )ork [)~rnlrc,.:

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Supplemental

Readings

( inica.I \t'JOOgIoIph Fi~ Caunts. e-d 2. ~alional Parkin\()n

Foundation.lnc Miami. FL. ZOO·, Retrie\ed June 25. 2005 from

hDpJI.....".partill5OR.OIJ:

StEP (Stale\-o E.dlKauorW Programs~ inttiati\e~ .\1anaging Pllrkm...un', Dbcasc thnp:f/vl'W",.ttepkil.net). ~OVItIU.. , dL"Ve-loped In con~ulbtl\m 'IIr'ith the ~~onal f'l:1.inMK'l Foufllbtion. the Ameril:an ParklOson i hsease- AMOCIIlion and the Part..inson Alliance. MOIil'fJriltg 4fCt"'~s 1M PnJplr w"h Parkinson' ~vldeo divided 111111 three iCClC!s: 'How·.o)jo MOII\'31ing M(wC'$" 45 minl,1ne PX,CYClse

165. \ian V3C'rcnhergh. J, Vr;tlll.en. R, ~tJl~1 Barn. I": T~c IOOul;nce CJt rntahon3l exercises 1m IreeLmg m. arklmon I dl~ase, hm(;1 ,\,jeurol 18: II. :!001 1b6. TlC'lepl~, G, ct aJ: Respiratory muscle dY5funtti0Tl In Pa,l,inson\ dl';C::ne. Am Rev RC!<.pIT 01'" 13M:266. 14il8. 1h7. K01CO,glu. f. ('I "I: 'Tbe effect'i of II pulmonary rdlahilibtion pr0gram on pulmonary lunctlfln tests and exerCISC tolcfafl(e In patn.'n!'i \\llh Parktn ... nn', tll..e.I~, Hillel Neuro! 12:119, If1-J1. IftX Inle'ltlerg. R. et al. In~ptratory mll~lc trillRlng and the pe-rCe-ptIOll III tippnea in Parkmson'$ dl<;e~l'te: Can J "Jeur~'1 Sf.:l '12'2 1,\. 200~ 1(0)4. Bergen, J. et 011: Aerohl": .exen;lse Inlervenllon I,m proves acrobi4 capacity andmovementlntl1311on m Parktn~m s dL'ieasc palienU.

NeuroRehabllllatlon 17: 161 • 2002. 170 American College of Sports Medicine' ACSM's GUidelines for Exeru"e Tc\ting and Prescripllon, ed 6. LlppmclIlI Ylilhams & Wilkin\, Baltimore, 2000. 171 Pedersen, S, et al: Group training in parkm\onl\m: Quantllative measuremenl<" of treatment. Scand J Hehabll Mcd 22;207. IC/lXJ. 172. HurwitJ:, A; The beneftl of a home excn.':liC rC!!lmen tor ambula. tory Parkinson's di'iea<;e patient ... J Neuro~i Nurs 21 l~O. 1989 173. Lun . V, ct al: Compari.-.on ot the efled'l of a 5eJt~upervl~d home exercise program with a phy~i()therapi\t~upcrvl~d e-xcTl..:i~ program on the motor symptom .. of Parli.in ..on·, disease. \11)\' DISOfd 20:971. 2()(15. 174 Abult. $, el a1: Park,in\on's di!>eaK "ymplom ..: Pallent', perception~, J Adv Nur; 25:54. 1997. 175. Comella. C, el al: Phy"icallherapy and Parkimon's dt.
and

Materials

Cla\s 116 minI. and ··Pr.lCllt:ai TIps for Dady livtng"(4 miolJ A~·ailahle from the ParklllSon Dlscu>;e f'JUlldation, ~;::w \crt. 'iY http://www.pdf.org. The PDF E..tf'rt'lH! Program. Available from the Par"m~ lm Foundatlon• .'!ew Yurl, ~y, hup:J/www.pdf.org. Levine, t AI'A.lvS 00 CiLll When Illness Tums Fanulle.-. nto earegivn, ~d .. \·.lIlJ~Pilt Ull!versiry f"'~, ;\ibhviJ!::·j '\, 2<~

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Appendix A: Unified Parkinson's Disease Rating Scale (UPDRS) , Version 3.0: February 1987a I. 'Ientatioo, Beha,iar and Mood \. infclh'{'fI(al impollme11l.\'·

None. 1 -= f\.Hld. ConsiStent forgetfulness with partial rec~ ollecti()11 of events and no other difficulties. 2. ;:: Moderate memory loss. with disorientat ion und moderate ditlicully handling complex problems. Mild but definite impainnent of function at home with need of occasional prompting. 3 ::; Se\'ere memory loss with disorientation for time and often to place. Severe impainnent in handling problems. 4- ::; Severe memory loss with orientation preserved to person only. Unable to make judgments or sohe problems. Requires much help wilh personal care. Cannot be left alone al all. :!. Thoughr disorder (due to dementia or drug intoxica(l;

tIon):

0; None 1 :;:; "Benign" hallucinations with insight retained, 3 = Occa,ionai to frequent hallucinations or delu· sion~; without insight; ('ould interfere with daily 3Cl1\llle~.

Per'ii~tent

hallucinations. delusions, or florid psychosIs. Not ahle to care for self.

1 Dt'prdsum o -: ~ot present. 1 =~

S. J-/andl1'riring: o ; Nomlal. 1 Slightly slow or small. 2 :;; Moderately slow or small; all won.b art.' kgihk. " = Severely affected: nol all \\'01'<.1" ~lr(" legJl:'tle 4 The ITInjorily of v.:ords are not k'gihl~. Nom"l. I - Somewhat slow and dUllbJ', l1ut no help nel..'ded. 2 : Can cut mosl foods, JlthllUgh clum . . , ~lIld :-.I~l\\, some help needl!d J Food must be CUI hy . . omeon~'. hut (.. til :-.Ill! fCl..'d .'ilowly ..). Nl'etL'i 10 ~ fed

I () fJ/"i's.\"t'ng ()

~onnal. r~t~si\'t"

.2

lo 'is III wiliallVt 01 Lij:sintcresl 111 ~'kctivc (noll1

l..,(Y..~ of 11l,IHtIlW' (lr dl')inlcreM in day-ItHl.IY roul:.1I<:)

~'ll\1!1ie

\\'illIl1r..,wn, I.")rnplelc~ I()~ Sill' 11I(llivlitioli II. 4.('lh' llic~ hI Bottll" l.hjn~ ~drh'rmln,' tor ·'un/un") .-, -:';('10 11. f) "'onnal 4

Mildly

Normal SOml'\\ h;J[ slow, PUI no Ill'lp IIl',-'dl..'d

routine) Ul,t,VIt,e',

'1

7, Swallowing: 0; Normal. 1 = Rare choking. '1 = Occasional choking. 3 = Requi res soft food.

(l"

Period~

Le:l>s d:iserll\'C than usual. mort'

2

1 :::: Slight but definite excess of saliva If) mouth: may have nighttime drool ing. 2 ;::: Moderately excessive saliva: may have minimal drooling. 3 ;:;;; :M arked excess of saliva with some drooling. 4 = Marked droojjng. requires constant tisslie or handkerchief.

9 Culling fuod 1I11d handling lIft'mils.

of sadnes:-. 01 guilt greater than nom1ai, nevtr su~tained for days or weeks. :2 =-- Sustajned depres~1011 (1 \\eek or more). j Sustained depression with veget
o

6. Sali"Grion: 0 ; Normal.

-+ :::: Requires nasogl.lstric tube or gastrotomy feeding.

1 ::; Vivid dreaming.

4 -=

2 = Moderately atIectcd. Sometimes asked to repeat sl"ltemcnts. 3 ; Severely affected. Sometimes asked to repeal statements_ 4 :::: Unintelligible most of the time.

tlftf'"

led l\Jo dllllCully h' IIIg u(j~kr'~hu,d

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Ilhlskal R('habilitalion RequaH.'S .il'isi~t~.m\.·c for ""Ishmg. hru,hing tcclh.

l

(nmhlllg hair. going w hathf(l(l~l.

14. fiwiai nprcs\/OI1.

o

. '.

4 Foley c;llhl'ICC or other mechanICal .llds. 12. TurnmR in /Jt.J (md tldjll. .mng hcd cloth('.\ o s,;. ,:\\lrmal. t1 : S\.\Inc" hat ~Iow and dum,,),. but no help ncC'dl.' l~.111 turn alone or adJu ... t ,heeh. nul \\ It11 gn..':lt i.illfil'uit,

1,

Can inll'I;lll" hut not tum or adjust ... heet-. alone

4

Iklrk".

o

~llne

R;ll"e falling. Oo.'a'ionalh falb. Ie ...... than OIlL'e per di.l~ ~ Fal'" on an,'rage of (liKe daily. ~ Falb more than Olll'e daily. 14. frec:.mg wilt''' wtllkwg. () 'one. Rare freellng when "ailing; may have ... tarthc,ttatwTl, .::! (kl'J'lonal treelJllg when walking. 3 - frequcnt freezing_ Occa ... ionally falls from frcaing. 4 .; Frequent falb from freezing. 15. llalkmg ~ :-;onnal I \111d dlfft(:ulty; may not swing arm ... or may tend to drag kg .; ~ \1oderJte difficulty. but require ... little or no

o

3.'isistJ.n~e.

:l. - Se\'ere dl!)turbance of walk mg. requiring assIStance. Cannot walk at all, e,en with assistance. 4 Tremor (, - Absent.

Slighl and mfro4Uenllj pre"'nl. ::! ...: ~1\Klerate; hothersome to patient. l Se\'ere~ mterferes wah many actlVlttes. 4 f\1arled: mterfercs with most acttvilil"s. 17 Stn::on ompJalnts reluted 10 pdr#.:l11sonhm

o

Ilr

nHld

[xcTUClatmg pam.

III. Motor Fumiruuion \pUt"l:. ~orm.::"

, I 4

u_

the

tllne. \1a ... kcd or fixed fal:ie~ with ~cvere or complete los ... of facial expression; lips parted ~ in or more.

7i'('1II0,- al r('st

,:Jk,llOO.

Absenl. I ~ Slight and infreyuenlly presenl. 2 ~ Mild in amplitude and per~istent: or moderate in amplitude. bUI only inlcrmillently presenl. :l ~ Moderale In amplitude and present mosl of lhe time.

4 = Marked in ampillUde and present most of lhe time.

21. Action or postural tremor of h«nels.

o=

Absenl. I = Sligh!: present with aclion. 2 = Moderate in amphlUde. present wilh aClion. 3 = Moderale In amplitude with pOSlurc holding as well as action. 4 = Marked in amplitude; interfcre~ with feeding. 22. Rigidily (judged on passive movement of major joints with patient relaxed in sittmg po ... ition: cogwheeling 10 be ignored): 0= Absenl.

I = Slighl or delectable only when aCllsated by mirror or other movements.

2

= Mild 10 moderale.

3 = \Iarked: bUl full range (If motion eaSIly achieved.

rapid sucl'e,.'~ion with wide,r ampIJtude possible'. each hand scraratdy) (I Normal.

2 . I-requently has numbness. tingling. or a(;hing. not dj'iUessmg. \ frequent pamrill sensdllon~

~hghl Ii ~s or n.;r.ssl(m.

:l

fw.::ial expression. Moderate hypomlmiJ: lips parted some of

-l ~~ Severe; range of motion tlchie"\led \.\' Ith difficulty. ~3. Finger tups (patient tar~ thumb with mdex finger m

~one

OcC..i-')lonally has numoness. lingling, achlng

4

Slight hut defiJ1ltcly ~lhnomlal diminution of

o~

I ')

,6.

.::!

4

20.

l.l FaJlm~ ("",-('/01('(/ 10 ./rt't':l1Ig J

Normal. Minimal hypomllnia. l'ould he- normal "poker f;Kl'.H

':.

-

J

1lIl{"..,'or "....

100mOIl(' ilurred btu undcntandal)le~ moder titel\, ,mpatred M.arled Impairmenl .:Iifik-:J1t 10 under,land lnmlt"U::.,bl,

I .;

'hid ~loy,;lll~ and/or n:uuc.:tlOn 10 amplitude. ~loJ{'rately impaired; defsnlte dnd early filUgujUg"; may h.lVC' lX'caslnoal arresb 111 mo\ement.

St:n.-rely im(XlireJ; frequent h~itati(ln In mitlJI· lug movements or arrests ill ongoing movement 4 C'an rare Iy r~rfoml i..he la..~k 24 /lilnd mO\'Ollt'nI (patient opens, Jnd cloSl.'s hand~ 10 rapid SU\c\!SSWIl With. Widest aIT1pluudt~ Pll"jslbl~. cai. h h:.tnd sep.Jrcl!ch)· (I ";ormal. • 3

, I

..

'hid )1('IWIr..g clIlt.Vor reduI..lit1n

tn

.'Uilrlltud~

l\loderatcl\( ImpaJred; definile MId ~~ tJugu Int,· rna>' haw OCC-i'ilUnaJ .nf(sls III awwmffil Sc\\!reh In'p;,urcd frequent he~lt..alllJn tn 111111.:11' tn~ m(wo.:fTl{"nh '.r arrests U1 ,'n~OIllC nwn.'ntcnr. (,I,f)

bardy Jl('nonn I1le la~L

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!f.':J """ang ..~.". riuctJoo an amplitude "'1~ :~ate , y Impaired~ d..:f lite and ('.oniy f.!!:,~=_:1g , rna)' tu\'e o..:Ca5lOr..:J arrests In movemct Sa-erely impaued: frequent hcsl13.til'n

109 movemc:"its or aJ":'ests 4

Can b:uely

p:-fOnl

~n

~ I B-"'lH rrc.,:",,·nf' ~i w .i~1 11"'_....: .t..~",.;:- J~.; (t.:l'~}llm Ing ;O\,\'IlCSS. he.sIt.lOt\' d('c,,::a..o:.~j dlr.:!S\\ Int!, ~m31l umplituoc_ and pmi:'ttl (If :::h)'cm("nl m S:l'll\"fJI, .\"onl"

e

In Inltl3.t-

\tinim:J ... 1owness. ,g~"mg mv\'''~ncnt

(tOg-omg movement

the ta.,k

ups heel on ground in rapid .;u( ceMlon. plck;ng "P entire leg. amplitude ,hould ht,

mg: may ha,-C' occ.lSlOnal arrests in movement 3 .- Se\'~rely impaIred; frequent he,jlJtion in iniuming mm emcnts or drre ... b

In

ongoing mO\ emcnt

OlMH lh..u l ' I.kfinitC'l)' 3ilnl.lrtnal, ,\It("mati\\!'ly, :-.t)mc redlKN dmpHtude

.3 " ,\loJ~rate- ,lv\\,ltc:-." pc:wi.'n). ('Ir ,mJII ':lmplituu, {)f

A D) ,kin~SIi.h

J.2. nuratioll, n'hat proportion ,)I,ltt' wuA;m,S: ital' aTt~ d\',\I"-'flt"'itl'i pr('St'III,'J (hl\l\..lfh.:nimfnnll:lIll'n)

II = None. I "...., I ~25% of day. :! 26--50l!;' or day~

across cheM)

o ': .'\orrnal. I :"":: Slow, or may need more than one attempt 2 r- Pu\h~s se lf up from arms of seal. J . Tend, to lall back and may have to try more than one tllne. but can get up without help. 4 Lnable to ari,e "uhoUl help.

:8. Posture Normal trett_ :'o'CJl quite erect. ~lightly stooped posture: l'ould be nornal for oldt."r pcf\on. MI:x!erately Mopped po:-.lure. definiteh abnormal: Can he slightly leaning to one sidt."~

2

kypho"'I~; can be

J

Severely stooped posture w ith

4

"lloc:kr3tcly leaning to one ",ide \,1Jrked f7exion with e).tn:me atlOonmtllfy of pouure

J - 51-75<X ofua) 4 ,- 76--100'; of <1.1;. 33. Disability ' lioH" di\dhling eltt' 1111' dY\~l/In;as" tillS torical infonnafion; l11ay bl' 1110thtil"d b) nfl1l,;~ ('\,101 illation) o Not dISabling. I .- Mildly "ISablmg. 2; Mouaatcl) dl .....lhllllg. 3 ~ SeveI'd)' dl...... hllng. .. ~ Completely di .... tbl(·d J.J Painlit! dn~ff1f'\Ja_ }IOII" I'uuifu/ 1:11'1' Ihe d\'JA"" 'i/a.'i?

,

No p.tlnlul dysklllC"I~IS Slight ModrrOlIt.'.

...

M,uked.

o

:9 Gait

o I

1.

S~vl"re.

'IIonnal Walks slowly. may t-huflle with ~hllrl ~I{'r~. hUI no f;-:tinatlOn or propulSion. Walls With difficul1Y but requlr('~ little or no as!il~IarK."'C~ nl.!;Y !'o.3ve iOrne fc'Stin.atioJ1. IihOl1 steps,

l.'i.

/'I'{'H'II("(, (I/I'tidy

SC\'::; dislurbJ.fice of gaH, ~ulr ng d'iSI!"tancl' 4 Cannot ~'1.1L. a.t t.:1. C\'cn \J,-uh a,"sistanc pr -::.:r11 uablbr; (n:~ponse In sUdden posterior :11 -~:l:>::""~1 produ('~1 h,.' pull ,-" dtouldrn ...hiJ\O

nt'_, ""'nh eyes. o~.!.."1d f~-::, ~~:i''':~~)'

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mmlltn,; '/-.'\!f'WU (hl'«((llil,:;I"lIfof

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or P! ""PU!SliU

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mo\ C-OlL"nt.

4 = \t.uled ... I(l\\n~,:-., pt.wC'ny. or sm:l.lI (lmpluud(.' \,f mO\e-mcnt 1\'. Complication~ ofTht'nlp~ lin Ihl' p~I't 'H't'~1

4 . Om barely perfonn the task 17 ArisinR {rom . hair (patient attempts to arise from a straight-backed wood or metal chair with am1S folded I~

ddibcr

P,w"ibl) redu('t'u nmpl:tudc. :? ;;: \ hId dl.'gret.· of sk'wne,s und pu"'cny of mt'\'{"

26. F-?I agilh')" ~ palicm

about ~ ,ncheS) !' "'orm.1 \fJld s.'owing dDt/or reduc.:rion In ampLHude. ., - Moderately impaired: definite .md early fatigu-

II

d!e- ...·harJder. .:C"u!d be nonn:t! for some: p('1'~l'n

,

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ire Uti: -'If pl-r~f",1\ ullpn-J'{ltlhI,' tJju'J'/(lJ( ',mrdi. '11'1 'Il fI

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10

IIhtln~'

Ph'\'.~ical

892

Rehabilitation

3R Do any of Ihe "{~ff" periods come t'.lampft'. (11'lT a 1('H' seconds? ( l ' No

011

Hldden/y.

f(Jr

1 ;::: Ye:-.

39. UhLIr pIWJortion of the waking day is the patieflf "(~ff' 011 ol'cragc"

0= :'-ione. I = 1-250; of day. 2 26-50')f of day. 3 51-75% of day. 4 = 76-100'* of day. C. Other complications. -to, DOf.\ tlie pofi£'111 hare anorexia, nausea, or vomiting? 0= No

=

I

=

Yes

..fl. Dot?"\ the paTient hare any sleep disturbances, for

ch1mplc , insomnia or h.\persomno!enre?

o=

:-';0

I = Yes 42. Does {he pallem hm'c symptonlmic orthoslOsis? 0= No I = Yes Record the patient's blood pressure. pulse. and weight on the scoring form

Y. ~fodified Hoehn and Yahr Staging Stage 0 = No signs of disease. Stage J = Unilateral disease. Stage 1.5 ::: Unilateral plus axial involvement.

Stage 2

= BIlateral disease, without impainnent of bal-

ance. Stage 2.5 = Mild bilateral disease. with recovery on pull test.

From Fahl'1. S, et al

111

ltfJefmition of ~ scale

pp 36-41 with permission.

Stage 3 Stage 4 Stage 5

= Mild to moderate bilateral di,ease; 'orne postural instability: physically independent. = Severe dhability; still able to walk or stand unassisted. = Wheelchair bound or hedridden unless aided.

VI. Schwab and England Activities of Daily Living Scale JOO%-Completely independent. Able to do all chores without slowness. difficulty. or impairment. Essentially normal. Unaware of any difficulty. 90%-Completely independent. Able to do all chores with some degree of slowness. difficulty, and impairment. Might take twice as long. Beginning to be aware of difficulty. 80%--Completeiy independent in most chores. Takes twice as long. Conscious of difficulty and slowness. 70%-Not completely independent. More difficulty with some chores. Three to four times as long in some. Must spend a large part of the day with chores. 60%--Some dependency. Can do most chores. but exceedingly slowly and with much effort. Errors: some impossible. 50%-More dependent. Help with half. slower, and so forth. Difficulty with everything. 40%-Very dependent. Can assist with some chores. but does few alone. 30%-With effort. now and then does a few chores alooe. or begins alone. Much help needed. 20%-Nothiog done alone. Can be a slight help with some chores. Severe invalid. IO%-Totally dependent. helpless. Complete imalid. O%-Vegerative functions. such a ...... wallowing. bl~ldder and bowel functJOns. not functioning. 8euriuuen.

Appe ndix B: Web-Based Resources for Clinicians and Pa tie nts/Families Living with Parkinson's Disease ~:;.!jonal f~lIkin s()n l-oundalllHi 1!\iI'I-)

Par~mson's Discn.\.C Foundation! PDF) :\mcr.c.m l'ari\.In"m I )1~''iC A~SlX'latioli (APDA) World Part.mson Dj),ca,\(' AsSo(""latH11l C\VPDA)

Parl..lOSC'n c;(lI:iety ( lnada Young On~1 l'arkmscn s At;.SOClatlon ·wun~ Parl n~m's Infonn'llion and ;i!nJ Referral CCliter \Iichacl J. f'o'( wUlu13110n frr Park mson 's, Resc.arch The Paltinson A,:lar~

ran: ,rr;.-n -s Action Net \\'orl...

The: Parlmson's Institute People l.Jvmg with Pur~mwn s l ~r-standing Parkonson's '\mer cam, \\I th OisabllitJes Act A DA home p<1gc Mc-1icmnlo:1l131-0n SOCl:,J

N:uior131Inslltutcs cf llealth NatIOnal L br:try of \1echclOc Archive" of "\Ieurolo1!Y

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Infonn:.tion Center

.\!:!::a:y U:c~ 1:1~~:'.: •• 'Je rc,hm I('I~)' "'Bl~.o"'T"'·

hltp://www.ml(hacIJtox..urg hltp://www.parklnsonalliJncc.net hll(1://www.l.arI\AclNct(a. AOLcom http://w",w.parkimonin...ritutc.nrg

hllr://www·rlwr·nrg http://www.undcr~t;lndingpar .. ins(ln·s.com

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C H A PTER

19

~-----------------------~~ 1, . . 111.

IIHCTIYfI

- [)eSCribe the etiology. epid('m io logy. 1. ~)siology. sign!> and symplom!\. djaplSis.:md C(>W'S< of multiple SCieroSl< (MS ). ,, 1)e!C:ribr elements of the medical manage ment of poIi
mtervenlJoos and parienl/client re:lated in.l;1JUctioo {('I makimize fun ction "'" quall!) of life. S. J)r3cribe approrriatC' C'1t"mt:nts of the e :\ercj ~ peocripoon for parim!. "ilh MS. .. Re\-icw cum:nl research flnding ... concerning tIIr rebabilJtJtion of pallent> wilh MS. ' ,16entif) tft<, p>),chosoc,," impact of MS and h.~De

appropnate 1Ot.ef\.'t:nllorh.

Allatyu and 1fl1erpre1 p3rient data. formulaiC' _ ~oab and outrom« , and de\dop a pbo of ~ when presented \\rllh a c linical _


Multiple Sclerosis Susan B. O ' Sullivan, PT, EdD OUTLINE Epidemio logy 777

Framework for Rehabil itation 788 Physical Therapy Examination 789 Tests and Measurc.s 789 Goals and Ou tcomes 793

Eliology 778 Pathophy, iology 778 Clm ica l Course 778 E'laccrbat ing Factors 779

Physical Therapy Interventions 793 Management of Sensory Deficits ilnd Skin Care 793 Management of Pain 794Excrci:,e Training 795 Management of Fatigue 799 Management of Spasticity 800 Management of Coordination and Balance Deficib 80 I Locomotor Training 802 Functional Tratning 804 Management of Speech and S"allowing 804

Chnical Mamfestations 779 Sensory Changes 779 Pam 7RO Vis ual Changes. 780 ~I olor

D) sful1(.'tion 781

Speech and Swallo\\ ing

D) ..,funclion 781 Cogmli\ C ;.lnd AffeCl i\ c Ch.:u1gcs 782

Autonomic

Ch.1nge~

78 2

Dlagnosu, 7 ~~ Imag:lOg ;b'

Cogniti\t~

O.. rt't'lru~ri nJ.J fl uid 783 E\ o1...d

Trainin,g 805

Psycho~ iaJ

POl~ntlah 7K~

Issue..... 805

Patien! and Famtl.)'1Caregiver EducalJon 806

Pr (liOO"' l~ 78~

\ kJ,,""al Management 785 OI-.('a\.C"- <\1odlf) 1Il~ Agent.. 785 \1an:tgcnlcIU of R eIJr'l'~ Jnd

Summary 806

S)l1lptOlm 7Rfl

Epidemiology rhl" om,(.'! til \lS t)p h.:J.ll) lloCcur tx-I"een the ngi''i llf 15 "md 50 ~ l"4U.... . \\ Ilh the' pe.l}.. .11 age.' 30, The diM'".bc IS rare III dlllc..hl.."n ~t, 1\ the Uthel (If !"ympl o m, In adult" nlJer (han tht' .tge 01 )0 )I.'.If... II .In(.·~h ,1I'pw\ll1l.ud) 400'()(x) imh· \iJlloll, 10 Ih l'nilt"J \I.U(.''), The dl,e.l~ b more ('ommlln In Youln.iIlltt .tII to fllt'rl h) .1 raWl of 2: I. a tJiltcrell","'"t" e!l-pet..l.tll~

,,", l~k'OI

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~oung

r dge ...

rh~re

are "ell repollc:d

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II I ..H.ljUlllllg

Irfl")nl'J II) .<\'I.1n' J,nd

i J'ldl.:mll)h"~h. .t1 ..tudl(·' h,J,\C' n:\(~. lft"tl a geograplul.."al patt\.IU ,.r JI\tnbOUl'tl (II '1') \\ uh Jr~ ... 'J nt hf~h. olrdium,

118

Ph, "ical Rehabilitation

and low frequen cy. High . frequency areas include tI~e tC.m· perate zone ~ of the northem Un ited Slates. Scandmavlan counLrit"$. northern Europe. ~outhcrn Canada . New Zealand . and sou thern Australia. with the incidence reported al rates of 301080 per 100.000 population. Areas o f med ium :re. quellc)' c1ot.;er to the equator include the sou lhem UllIted Slaies and EIJ ro(X' . and the re~ 1 of Australia with a reported incidence o f 101025 per 100.000. Low -freque ncy tropi cal areas (Asia. A fri ca. and South Ameri ca) have reported rates of less thall -" per IOOJ)OO.lJ Mit,'Tation studies indicate the geographica.l ri s" associal C'd with an individual"s birthplace is ret amed if emigration occurs after the age of 15 years. Individu ah mi!!rating befo re this age as~ ume the risk of the ir nev. locallo n ..' There ha\'e been reported epidemics o f MS in the Illerature. one in the Faroe Islands off the coast of Scotland and o ne In Iceland fo llow ing occupation by so ld iers duri ng World \Var 11 These epidemiol ogical studies lend ",uppon to a theory thar e \posure to an unidentified infectiouS agent tra nsmirt ed per,on· to -person , such as a ('10" -Jeong ~ iru s. predi sposed individuals to the develop· menl of M later on. ~_6

stalls altogether. Eventually the ol igodendrocyte, become involved and m ye lin repair canno t occur. One form of MS, primary-progressive MS. appears to be assoc iated exclu·

Etiology The precise ellolog) of MS is unkno wn . The mos t widely aCd~'rted theo~

ulin s (antibodies). In tum , a co~mand ?r trigger prOtein, Ihe antigen. is acti vated. productng autOimmune cytOto~ic e ffec ts within the eNS (this process can be viewed as a fonn o f " fri e nd ly fire" ). The blood- brain barrier faiJs and mye lin-sensi ti zed T-Iymphocytc ce lls enler and attack the myelin sheath that surrounds the nerve. Myelin serves as an insulator. speedi ng up the conduclion along nerve fibers from one node of Ranv icr to another (te nned .taltatory Conduction). It also serves to conserve energy for the nerve because depolarization occurs o nl y at the nodes. Disruption of the m ye lin sheath produces active demyelination, slow. ing neural transmission and causing nerves to fatigue rapidly. With severe di sruption. conduction block OCCurs with resulting di sruption o f function . Local inflammat ion , edema , and infiltrates s urround the acute lesion and can cause a mass effect (abno nnall y hi gh pressures). funher interferin g wilh the cond uc tivity o f the nerve fiber. Conce ivabl y, thi s inflammation (whic h gradually subsides) may. in part, account for the pattern of fluctuations in function that charac terize thi s di sease. During the early stages of MS. oligodendrocyfes (m ye lin -prod uci ng ce lls) survive the initial ins ult and can produce remyelination. This process is often incomple te and as the disease becomes more chronic.

I' thaI it

b

an autoi mmune di sease induced

h~

a \ IraJ or other mfcc ll ou ~ agen!. In panlcular. herpe!:> \ 1I1he\ d. II. and V l) and chl am yd ial pne umo nia are agents 01 greatcq Illlere,! III an mfC'ctJ ou", hypo thes i,. ',1i The pres· m.;e of IIKrea'<:d Immunuglobulln (lgG ) and o ligoc lo nal

band, m the cerebro,pmal OUld ICS F) of 65 to 95 percent of \ 1S pilllffih pro\ Ide, com m Clllg e\ tJence of a pre" ipltating mfectlOn dKlfln!! an JutOl.mlnUf1(" ft:~pon~ "lIh resultjng palholO!!Kal Lhange,.1J Vira l lnfec llo ll hib bee n ~ h (\"n to rrt'npJI.J.le dboU! 3.':\ l"'Ierct:nl 01 relap~~ 10 MS G ",' nellcs a lw pI3~\ a rule Ul the tu;.<-Iul~J!lnn oj ~1 S Appro \. unate l) 15 per.. ('nt 01 patlent'!o h.t\e :i l'V'lme- famil~ hl'l,tol) (fi r' t·degree rdam e, lkh a." a p..trcilt OJ "-Ihllllg "1m MS). 'l1lC n~ l.. I~ 3 hi) ~Rl'm lor.i lratem.d lOI\\ III htn nse-... 10 2h percent for dn wt"ntJlI.ll .. ",H"ln G('nl"Ul "udle, ha\l! rt:\eJ leJ l11ul l1 pit m.ub."p. 10 muluplt'\ l .ullth~\ . defined a... fillllllJt",\ IJI ",tu. h "oC''\t"loU IHt-IlIhc.-r.., lu\c ~ ' S In p.U11l'u IM lI uJor hl ... IOUWllr;,tllOlh l ,\ "-~Irurln i Ul( , pruleln"". t'1K:OlIt:d on lhro· m .....n!ht' fl. noJ\1! i:k;1,."11 Iml-td II) uHI.t,,~) prUdtlt llOtl (d l1~\ I ... lIt1~i·n·", .1liJ \1'-, Ii drpc~ litJt .ulh()U~h IfIdl,"h.tUJ.I~ dn no, truK"111 1114: d.-.c'.l':lt: tlin rtlJ) lnhe-Ill oJ gerk'th; "'U~t'PIl hllih IJ:t ,ITII)IUf}(. '~~ lt'nl dhlun" 11.)(1

sively with disease of the oligodcndrocytcs. 7 Demyelinated areas eventua ll y become fill ed with fibrous astrocytcs and undergo a process called g liosi s. Gliosis refers to the proliferation of neurogliaJ tiss ue wi thin the eNS and re!:>ults in g li a l scars (plaques}. At thi s slage. the- a>.on itse lf becomes interrupted and undergoes re trograde degeneration (dying axonopathy ). Axonal loss vanc ... from 10 to 20 percent in milder fo mb o f the di scaSt' to a... much a!:> 80 percent in severe MS.I: In advanced case .... there are both acute and ch ronic le sions of varying ,ilC' ..,cattered throughout the C 'S (brain. brain stem . cerebellum . and . . pm
"I ~

hlghl~ \,Ifldbk dnd unprc"ltc!.Iblr fro m pt,-..on-ro"11hlll d gl\en IIIdl\ IduJ.1 (l\",£r tl m\' . AI unt' end til the UJI1tIlIUt.!1Il tlklt"):) h('lll 'II " \ ddint",.i .t' L"~,c.t to "ilidt Iht' I'<.allen! reltl..tll1 .. ful/.,. h'lh. ll nll.IJ III.!JI neUfllltJg1.. <11 )"'h.::ru~ I~ " ltl.'l' lln~'1 fklll~1l ~lS .1Ifl'\·I ... k\liCf' Ih ..lll .!fJ pch l"1l! ('I f.:
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Chapter t 9 Multiple Scleros;"

..

h within

rel.tively shon lime 'Ifter onsel. RelapsingfC

MS (RRMS) is the 1110S1 commo n C?ursc. a CC~ n~nllrlll g . "I 70 noorcenl of patient!lo wuh MS. .It dIS . proxm13ft: y t'~ 109 ap . d by clearly defined disease relapse,\', peno s charactenze nint! o f nc urologicaJ function. fo ll owed by £k!!H. "

3

. f acute \\ orse o• 1II5S/0 . 11S , de fined as period s without .di<;eased progressIOn I nI . I an sympto m s. d panm or complele abalcOlenl of slims an 0 rcenr of RRMS ca...es go on to develop secAboUI pe . MS (S P'1C) SPMS beeins wilh . a n ' 8 IVr.:r{,SSII'(' /I ~} • e om/a " p ~ 'II' · " " cour ..e followed by prol!ress io n w llh lapSIn!Hl:'Ol I ~ . .... re . " occasional relapses. mmor remiSSIOns. and Of \' HhoUi . . I Proorl'Jsh'e-relapsil1fl MS (PRM5) beg ms wi ll a lateau
. pronressl·on MS (PPA1S) IS a disease ~ . ~ . Primary . pror:.ressl\·e , . rare (oml occurring in aboul 10 percent o.f cases. II IS. c harnearl\ a c ldeb)n;]z e . conrinuous worsenmg of .the .disease . I md lvld ua s from the onset wirhoul di!)linCI relapses. Some . . do ha\'c occasional plaleaus o r lemporary mlllor Improvements. PPMS rypically has a lalcr onse t. us uall y after age JO. Permanent neurological disa bility res ults from re lapse s \nlh incomplete remiSSions. progression of the di sease . or both. Becau~ Ihe course of the disease may a lter. clinicians need 10 be alet1 10 changes in signs or sympto m s in lenn.-. of se\erit\ and frequency.l.l,14 Box 19. J s ummarizes the categorie~ of multiple sclerosis,

779

Exacerbating Factors MS relapses (ex acerbations) arc de fined by new and rec ur. re nt MS symptom s that last at least 24 ho ur)) an d are unrelated to a nother etiology. Several fac to rs have been idenri li ed . Avo id ing these aggravat in g fa c to rs is important in e nsurin g fh e patient 's optimal function . An individual whose overall he alth dete riorates is m ore likely to have a re lapse than one who remains healthy. Viral or bacterial infec tion s (e.g .. co ld . flu. urinary tract infection. s inus infec lion ) and disease s of major organ system s (e.g .• hepatitis . pancreatitis. asthma attack s ) are associated with re lapses of di sea se. The re is al so a m odest link between stress and acute attacks. Both major life stress events (di vorce, death , losing a job. trauma) a nd minor stresses (exhaustion. dehydration . malnutri tion , and s leep deprivation) c an affect the immune system and an a lready compromi sed ne rvous system. ]5 PSfudoex{lcerbatioll re fers to the temporary worsening of MS symptoms. The episode typically comes and goes

quickly. usually within 24 hour s. The overwhelming majority of indiv iduals with MS demonstrate an adverse

reaction to heal. known as UtholT's symptom . Anything that rai ses the body temperature can bring on a pse udoattack . External heat stressors include sun exposure , hot

muggy environmental temperatures. or a hot bath. Internal elevations in temperature can be produced by fever or pro-

longed exercise. The e ffects are usuaJly immediate and dramatic in terms of reduced function and increased

Box 19.1 Definitions and Tenninology Used to Describe Categories of Multiple Sclerosis • Rtlapsing-remilting MS IRRMS ): Chamclerired by ~~ v.ilh euher fu U recm-'ery or some remaining neurological .MgnV~)'mpl.Om~ and residuaJ deficit upon ri!COv~ ~ me penod bel~een rel~s are characteril..ed by lack of dif!ea.-.;e progre ~ion .

· Pri...,.y_prog......... MS (PPMS ): Characlerized by di,ease progre,.\<;.lon IroID on~f . "",lfhoul plateau., or reml ~1KJn~ or V.lth ocl,.,a£lllfl:t1 plale'oiUS and temporary minor

lIIlprt)\emenb.

• s..uo""')oprogressi .. ~1S (SPMS ): Characterized by millal re~ps.lO~ Tt:mllllO~ cour'ioe, foll owed by progres-

won

il

a \4lUble ro1(e thai rna)" ~I!.O mc-Jode ~ca>JonaJ

rtlaps,t and minor remb ..l0Ib.

·l'tovoW, fllT"Jtrc

Iltt

-relapsing "S (PRMS): C1,ar"'lell
cLl>ea~ 'n)Hl 00'<1 hut '" Ithillil df'iU" a(;Ul

rfi~ (hat molY or ma) 1101 hu e '-Oint! ox()"ery or rtml....aon: ~onlfllOnJ) M!n1 m pt"oplt' ~ Ito ~i?lor the: -dj~ . her 40 )'e:.m. 01 ui!t:: loiS t&n • Charactcn1{'d h)" Jtllid dl~ih In '0\, hlf,.;h J* 11 rem..m fu.lly [ulM,'Uourllm aU Ill!unltugh:ut \}!o. . I. I ~)'f" ~ftt:r dl~iI lIthd

fatigue. Most pseudo-attacks resolve within 24 hours of cooling off and/or the end of a fever.

Clinical Manifestations Signs and symploms of MS vary considerably. depending on lhe location of specific lesions. Early symptoms typicall y inc lude minor vb ual dislurbances (e.g .• episodes of double vbion) and parcsthcsiu 'i progressing to numbnes~, weakness. and fa tigability. In more u(l\anced s rag¢s. p<.ttients demon .. trate muhiple 'ymploOlS 'wi th varying im o h e m en t. Common symprom, In MS are presented in

8 0' 19. ~ II.I· Th. on,et 01 ,) mptom, can develop rapidly O\("r a rour',," of lIu nule') or hour)): Ie~s frequenlly. onsel is in\ idiou'\, occuning 0\,1..'( a period of ""eel, or months. An ...·a.rly remi,)'lJOn Ina) lead rhe ul(jh Jduulto pOMpone initial ne urological "or~up lor momh.." or longc!r.

.a.... •

~t ~~ l \tarbuf'&' '",Id P' ~. I

\-u lanO: Char"f.:ltriled tl)< . ~ ... ~ Inn e
Sensory Changes ('omph:lt' 10\\ of an~ 'lIlglt" ~lhJ.lIOfl (aJle~~'ia ) is 11lIe. h :x.'al defu.· .h (.' dtl PHlduce IlInll~d area,.." of diminished 't'n'Jtlon. It ... rl'd bell:,alJOIl\ ~f(' far more conunon and tan Jlh lud~ purt' .)lhpHlO (pUl~ olno needle, sen~..on) or I\UIflrn-I(: ", 01 tJlt! t.h.e~ ~lJ}, or C'lilremUIC& L>UilUfbao..",

780

Ph}'sical Rehabilitation

Box 19.2 Common Symptom s in M ultiple Sclerosis 15, 16 Motor Sy mpto ms Weakness or paral Y!" is fitli gue Spa.;;ticity

Sensor~

Symptoms Hypoe~lhes ia. numbness Paresthesias

lncoordination

Pain Dysc.~thes i as

Optic or trigeminal Lhemline's sign Chronic pain

. neun ll ~

Visual S,'mpCo mS

Blurred or double vision Diminished acuity/lo..s of \ision Scotoma Nystagmus S) mptoms Memory or recall problems Decreased attention. concentration Diminished abstract reasoning Dlmim .. hed problem solving. judgment Diminished speed of information processing Dlmmished visual-spatial abJlities Cognitin~

Emotional Symptoms Depre~ion

P,eudobulbar afrect A1u1
IJUCnTi on tremQr

Impaired balance Gait disturbancC) Bladder Symptoms Urinary urgency. frequency

Nocturia Lncontincncc Uri nary hesitancy, dribbling

SeAual Sym ptoms Impotence Decreased libido Decreased vaginallubrica-

lion Impaired abil ity to ach ieve

orgasm Bowel Symptoms

Constipation

.. '

f the tri gc minal nerve innervutin g the face, ch.._. . I h' ''''
tures, and immobi lity. often the resu lt of wea k mu'iClc . powerfu l spastici ty. and tonic spasms, Anxiety and fearean worsen pain sy mptoms. 1'1

Diarrhea lnconlinence Speech and SwalJowing Dy.anOO. Djm ini~hed verbal fluency

D)'!iphonia

D}sphagia CardiovascuJar d)S8utonomia

Pattern of S) mptoms \ -ary greaLl} from person-lo-perwo \aJ') O\er time In ~ch tndindual affected FlrM s~mptoms us:uall) 1I0tnsieni Earl~ ~) mptomjl are l~ PilaU) ~n"of) and \ isual

lo\oh es lno~ than one funclional component of the C!'tS

m po~ltl0n ~n~ are aho common. a are IO\l.er t."\lr(,,01 II ) I LE , Impalmlem!t of \ IbratUI"\ ~ n -.e,

Visual Changes Visual symptoms are common wi th MS and are found til approx imately 80 percent of pallents, Involvement of Iht optic nerve produces a ltered vi~ual acuJly: bHndne'is I~ rare . Optic neuritis. infiammation of the optic fiene. is a com mon problem. and produces an ice· ptck Ilke pam behind the eye with blurring or graying of, ision. or blind· ne s~ in one eye. A scotoma or dark lipot rna} occur In lbe center of the \ I ~ ual field . ~ eun lJ~ rarely affecls both e~es.. and j, u!>ually ~ If-lirni ting. Vi~Jon generally imprmt'S \\ ilhin 4 to 12 \\cek '). Damage to the optiC nef\e \0\ !I' a1~ affect light refle,e" \l a reus (;unn pupil often de,'e!op> \\irh ~1S III IIldhidu.ll r; \.\ho ha\\! haLl.in epl.,ode ot optt( neuflti \, Shilling a brlg.ht light mlu the heal thy ~e ... 1-11 product:' re fl~\ L:()OIraC'Uon If1 both t."\~., h.on~n~aJ bghl Tt' tle\). It (ti t.' J Ighl i\ then "hon(.~ In the: .d1 ecteJ eye. J par' "doxI(.:dl '" Idelling fJllallllll1 ut bo(h pupfh tX:CI11' E)t.'

Pain

0

d,vl ~ J on

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bt- dl,LUfhcd

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pallcO(') \.\ ilh \1 S and rewlr.; Jml11 le'lIlIn .. alh,'I,:lm th\.' \.. ~rel:x!lJum or C'e'ntrJI ,"",Uvu; ~"" paLh,,".;l~~ 1hh In\\II\C' 1O\I)h.JntM\, lh.lti.:J.J Ino\tJ1)C1Il~ • tit< 01 the (',~h.dl f hOrll(lnl •.d or \ ~l1h.:.II, lh.st Ur:"dop ~bt1'I • tn,·

.'\ \ HII "Iflm 1'10 l·I.,)OlrnUn 1Il

tht: 'lo.oe., ur \c:nll...tlh, I .i!JL~'uxJ~cu • , the P<.I(ll·OI m(I\t'.., Ilk: head !fllfrfWC- 1( . oplllh(lJ,IIPplt'J;ltI j t'O , f"'ll"-'U,~") Ifl,,-omplc:re c~c;" p:. Hun (l..ater.l.1 galt.: p.Jh' 1l.lfI lhl· d..ftt"Lh.'J "'I~.and "~»lp;J~ , ,.. J," l)' the UPptl'lh.' .lhJUdlf1g C:"I.' \.\ Illt .~alc. 10l.me '"'" tJ# p.;.ttu:m 100 ~ II..!

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n..lJ ,,,' h.. u1u ... \ " U ,

Chapter J 9 Multjple Sclerosis , d contro l of eye movements may also be prese nt

":Ill." ,til < ' I brainslem

w V,," or the

•

.

.

lesions affecllIlg em illal ne rve s III. I V. and

, (Oll I bl C VISio " n. occ urs \V h,en lie I fvlLF. Dip/O{JIO, "\:: th 'U control Ihe eyes art' no l well coordllialcd . I

n1u.s('t ~

·

.

.

I di·... urhanc:es Ir('qu elltly re l11l1 and arc ~c l dol1l the " ,U:l . .. 'r f . ' d " , '" C" U"'" of JisahIIH) . rhc cl ecls a IllllxHrc Vl !-l on ~ , " P b I' nee 3nd nUWCl11cn! should be ca rc l ully exmlllil cd. on .1.1 r..

.-

MOlor Dysfunction Weakness \\ ,ill Paoel It ~

,.

C0l1i(,o~P1l131 lesJOn~

.

de monstrate signs and .

srOlplOn1S of upper ,molor neuron {U ~~N ) 1I1vo l vcment. 'are.".,'~~. ."PJ~IIC'il\. . briSk. tend on reflexes. f1wolul1 lary flexor

P :mJ e\ICnsor spa:.Jl1!'-. clonu~. Babin:-ki· ... sign. exaggerated cutaneous reflc\cs. and 10,s of preci,c au tono mi c cOlll rol all characlt'n zt' L!MN imolYcmCnl l'l (!!occ Chapler 8). Mo\emenl!' are s lo\\. "uff. and \\cak. Ihe result of loss of orderh, rec ruitme nt and reduced tinng rale modulation of m(llOneuron~ . Reduced muscle ~Irengt h. powe r. a nd endurance. along \.\ Ith Impaired synergi stic relationships are (,,\'Idem, Palienb \\ jth cerebellar le~ions demonstrate asthe ni a or ~eneral1zed mll~cle \\caJ...ness along with maxia. Pa ti ent s can~ 3.1"0 e,-penenee l11u:)cle weakness secondary 10 inactiv· ir'l Muscle \.\eakne:,s can \ aT) from a m ild paresis. often ~.uNenl at first. to IOlal paralysis of the invo lved extrem ities.

78J

is a strong psychosoc iul predictor of fati gue. Indi viduals with a low ~e n se o f e nvironme ntnl mastery reported signifi can ll y more fati gue and fati gue-re lated distress, 2,~

Spasticity Spastic it y is an ex trcmely common probl em in patients with MS . occ urrin g in RO percent of all cases. Spa<;ticity can range from mild 10 !o.cvcrc. dependin g o n the progress ion of the di sease. a nd occurs most frequently in the mllscles of the upper and lower extremiti es. C linical indi cati ons of spastici ty include impaired voluntary contro l o f move ment (abnonnal co-contraction): increased deep tendo n reflexes (DTRs). clonus , fl ex ion or ex te nsion synergy patterns. and decreased ran ge of moti o n (ROM ). Spasticity a lso results in in crea:,cd fati g ue. impaired functional mo bil ity. and im pa ired ac. ivities of d ail y li ving (ADL). Spastici.y can cause pain . d isabling contractures. abnormal posturing. and problem s in maintainin g skin integri ty. Spasticity flu ctualCS on a daily basis and can be exace rbated by certain fae wTS. slich as fatigue . Slress. ex tre mes of temperature and humidity. infections. or nox io lls stimuli (e.g .. tight clothing).26 Ce rtain antidepressant agents (serownin-rcuptake inhibitors suc h as fluoxetine. sertraJine. a nd paroxe[ine) can exacer· bate spas.ici.y and should be used cau.i ous ly," Spastici.y d oes no t typicall y a bate during spontaneous rembsions. Ln patients with advanced disease. spasti cit y can be quite dis· a bling and difficult to manage.

Fatigue Fall~ue ha~

been deli ned b) the Pa nel o n Fatigue of the MS Council for ClinICal Practice Guideli nes ~I S "a subjec· tJ\e lad. of ph~ ~Ical and/or mental energy that i:, perceived b~ the mdl\ldual or caregl\e r to interfere w ith us ual and de~rred 3('11\ nie~:':'iJ r J Fatigue is a daily evenl. eAperi· enced b) 75 percent to 95 percent of Individuals with the d,,,.,,, "-pproxlm"te!} 50 percent '0 60 pe rce nt of pau('nt~ fepon that fatigue 1\ one of their mO~ 1 troub ling !I)mptom\, P3lielll\ COlhl ... h:nll~ repon lhm fatigue intt!r· jeJe~ "11h ph)~Il:.lJ functioning (79 percent of patients).

metal! mle perfurmJJll..e (67 pen.:ent of patienl~ ). and percel\ed heahh ~1;Hu .... ·l . ' Fatiguf! come" on abrUpll ). ~amlng. i.UllJ rt",emble ... ..lJl oh'ruhclmll1g f1u- lI~e t."h3U~tlon Se\\.·nl) 01 d,...ea<.,c' dOl· ... not !)~em 10 he rcl:.tted ; falJgut' !.I:\t:'rII). thai I..,. IIldJ\ ItJudh mlldl) i.tltl"'4.: led 0) l\e.3~' (JmbutJ.lof) pallent', I ~ r()n JI''),lhllllg lutlgue uphn~. PreLlpll.ltlng t.l(' -

"'lthOUI

""

[lImnhuunt' hi l.tlJi1ue IIh.lude JJh' 'Ic~il e\t"1'1I01l, ~ • prHJre til heal i.llld hUIlHdll) ( rc l~)n ed b) Y2 1k'll'enl oj

\Ill" t~

P-4J~nh)


dl'.OIdl·"~.

to\.\ iool: ll C''' 'l;'clll

dlwldc:r,. m~dll'dl (.'un(.IIIIOlh and -.c . . ond.lT\ . P J;.."llon\ c,j M~ ie g . n:,plr,.h.l) IIHp;UJlnl"nl. Ink,: h·II, ., S.dt: ttf~n oj ml~dlt:"lIon' dl~o IIllr.Kl l .. lIgue . Jlkludm I

41ld mOt'llJ, All I

g ana

404I. U)l(tm

n

t!c\I\,; \,

~u1tl\:{J0\ uhilllb. , ,mtH.h!prt~ ....1Il1~

Int:~, dnllt.)I)cft t· l hl\\~

\jql)r) "genu.

.t.l,wnt"l. !till..! ,u1II tnn,Wl ' 1.11\ lronnlcllil.ll IIl.l-.lt"r), hcn~t' t)J t:Olllr\~1)

Balance and Coordination Demye linatin g lesions in the cerebe llum and cerebellar tract s are commo n in MS . producing ce rebe ll a r symptoms, C lin ical manifestations include ataxia. post ural and inten· lion tremors. hypolOn ia. and truncal weakne ss, Ataxia is a ge ne ra l tcrm lI sed 10 desc ri be un coordinated movements c haracte rized by dysmet r ia. dyss~· n ergia . and dysdiado· {'hokinesia, Progre:-.~ive maxia of the trunk and LEs IS orren appare nt. During :-.i tli.n g or ~tanding. \\ hen .1limb or the bod) must be 5. upported against g ravity. the patient typIC~l lI y presents v.i th pO\'lilral tr('JNor (shak ing. bac k-and· fonh osci llatory 1ll0v~menl''' , I tllf'Jlliot! (ocllon) tremors are imolullIaT). rh)thmic. ,haling llIo\ ~ment ... (hat occ ur \\ ht' n purro!'>e Jul 1l10\clll..:1lI j, aUl'J1lptItJ anJ re~ul ( , from the inability of the ("erebcllul1l 10 d.unpen mowr movellI~nB , Trt~ l1lor, \,try III SeH'TII) irulll ~hg h( . bud) per~ ce pllhk 4ui\Cnng (line Iremor) en \qtil' o ...l'i.ilatiolls (g ross trc:nll'h). Se \ Cft' Ifcmor, illlpu~e )lgOl rkaJll ItmitJtio n:-. III pertOflll.UlCl' III IUlu,'l1l1mll al'U \ tlle, . parLiculJ.rJ) til stich ~I ~a"'.t\ ~..&tl ng. 'IJe.lllng dearl). "ritlng. per'>onal h)giene, tJllti \\ all-dug, I rc:mor 4:,111 be .:~uct."rbatft\1 by ~tf('" • excile ~ !nt·1l1. lind dll\ict) • .ill .tJ(l~n'lllO ~ ritl~a.) lI1g comillions pm-l.il.ICIHg.l h:mporaty arou\t:d "'lllldi tion !)o, Se\cre numbt~s til Iht... h'C't can l 'omnbutl' to dlfticully ~ iln .. unding 001.JllI.: ..." or \\ tJll..lng ('~I1""Of) u(a~u.J.). Ii DIIIIII~~~ 1\ a \,.'01l\010n ~}lnptulll of M and rtsuJts Irom Ic~iol)~ tJtrcdi ll~ the l.~ ~r~ht-Jlum (arl.'hi('~rebdlum) (K' l(:mml "t',,"buIJf palh,*,1)~ Patient-. I)picall} c'(periCIIL:t

782

Ph,.-.-ica l Re habililJl. ion

(hfli culllcs \Vllh halnnce (dy,cquilihnum), vC rl igo, naus.ea. and '0 fonll , Sy!l1ptom \ Me precip lt ;lIcd or nwdc wor~c h,Y moverncllt .. 01 thc head or eye \ . Pati ents ca n
produce cognili ve jnne~ ibility: Significant mental deteriora~ . ( g lob"l !ton .. denlcnt i'l) IS. relativel .y rare and . may be ' - I I In rapid ly progressing disca~ (malignant MS ) ~~ in palients wi lh significant cercbralleslons. ~vcl of c?gnltlve dysfunc. lion i., a major faclOr in detcrmllllllg quality of life. SOcial runctioning. cmployment status, and function in ADL.JJ~'W QC
Ambulalion and Mobility Indl vldmd , \\ jlh MS c.lI. pcriellcc dlrficul ty wa ili ng as a or wcalnc \" latiguc. ~ pa ' ll ci t y. impaired ~en~a ti on . vi, ual pro hl em', ttlld ala XI;!. Approxima te ly hiJlr of

re. . ult

p :HI('Il " .... i'h RR is will rc~u i re ~nmc rorm or ~1 ... , i' lancc dunng ",ail ing \\ lIhll1 15 yeM' of their di ~lg n o ... ' . 11.1 St
Speech and Swallowing Dysfunction SJlC'cch problem ' arc Ihe re, ull o f 111U ~c/ t! weak nc'i". spastl u t ~. In:mo l. or :!IJ\l J a nd affcc l ... , many a .. 40 perce ll l of mdl \ I d ua J~ ,, " h MS. DJ ."arfhria II) characlcri lcd hy .. Iu rred or pood} ari ICulah.·d ~ pecc h with low volume. unn..ttu ral cmph a"" . and , low ra le . O y ~phunia j, c harac · le n /cd h) dli1l1g c, ill voca l

q u~lI i t y

incl uding ha r"i hnc .. s.

hOJr..cnc ..... brcalh lllc .. " or h) pcma \ al "ound s. Poo r COOfdlO.JII OI1 of Ihe longue and oral mu \ck 'i can al !',o re~ lIh in

d." phaj!ia or (hflic.; ull ) 111 'Iow.lliow ing. Sign.., o f ' wallow1Il~ d~\f u nl ll(ln tndudl' difficult y chcw tll g and maintainlilt! .1 li p 'CdJ . tna hil ny 10 /:1 \\:1 /10\1/ (i ngc" food), .ulci ~ pil ­ IInp 01 coughlll~ dunng or al l(; r mca l..,. A' piralion pncu nwn lJ 1\ a \C IJ OU.., complle.lI lo " thaI Gill develop if lood ., 01 114Uld ... arc Inhaled Intn Ihe trat ht:.. . Sign .. or Ih i., include J \\\;.., \ (lIL(' 4 ua lll ~ \\- llh gurg llll g. or \ ound ... o f congL" ti on. Jnd k",c l Tht' IXI'I CIlI I.., al . , ,, "t ri , l for pliOI' l1utrnion ul IIIt,J ~ L ilno dc:h) drdtlon .tnt! Ill" ) L' '' pen enct'' weig ht lu....... fluor luordmauon of hrcdlh i.·olllltli i.l nd po ... lurc- i.'on(f/hutl' 10 "')let'''h ,tJld Il'tJ iIlJ! dII I IU lhl L''' \1

Depression Dcprcs~ i on is comm on in patients with MS, wi th at least 50 percenl of individuals expe ri enc ing a major depressive c pi ~odc. l~ Dcprc50 .. ivc symptoms can inc lude feelings of hopclc<;sncss or despair. diminished inte rest or pleasure in aC l j v itie~. chHnges in appetite and signi ficant wcigh tloss or gain, insom nia or hype rsomn ia, Feelings of lethargy or worthl c:-,snes!o.. Fatigue or loss of e nergy, dec reased concen_ trati on, and recurre nl thoughts of death and suicide.JS II C;U1 occ ur as a direc t re sult of MS lesions. as a side effect or some drugs (e. g .. ~tero id s , adrenocorti cotrophic hormone IACTH I. i,lIerferon medicalions). or as a psycholog_ ical reacti on to the stresses of (hi s far-reachin g and unpre. di c t~b l e di se,lsc,lo An x ie lY. den ia l. ange r. aggression. or dependency ca n also occ ur. Patients with MS face enor. mOllS iss ues related to the ambiguity of their heahh status, Ihe unpredictable co urse o f disease ac tivi ty. unpredictable future statu s. <'lI1d the loss of e ffecti ve funct ioning during

Ihe prime of Iheir lives. Feelings of learned helplessness

and low scif-cHicacy are comillon ~lnd have been linked {O clcprcssion.17 Moreover. many of the :-.ymptoms of MS (Iremor. scanning speec h. incontinence) arc ~oc:ia ll y cmbarra \s ing. call ~ ing additional e mot ional distress.

Affective Changes Affec ti ve db orders OCc ur in appro:XlJnat~ly 10 percent of cu~.: ... and can include changc ~ IIllllood. fcdinll:s. emutional

cx prc ... ~ illll . and control. l~ I")se udobulbar atT~t (emOli(ll/tl l /(J/Ji h ty. (JfIIOfioliU I cl\' \/'(',1: 111m ion .\ \'lIdro m(') IS characterized by Midden 10 ..... of \.' Illolional ('ontrul (1.llIghing or crying or hmh ) On mulliplc lIL'Ca ... IOlh Ilhlt " I) pica II)' ullrelated 10 c\tcll1:.t1 ri rclIII1, I.tIlCl·', dL·rrL~ "' <; J(m . ur underl ) mg mood. " le nd .. 10 Ix ' .... 'lH.: I:lll·d wllh m o rc pmgre-~" I\ t.· di ~:thdiIY and f n· ..lll·r Iitiei teL lU.iI I IIlp;l I rrlwnl 1.., Euphoria ..:on~ '')b of an L'\ag!!l'fitl cd I\'·c ling 01 \\ c' 1I llC.: ing . .t "l.·lhl' \)" OPllllll\nl 1I".:OIt~IlIC II I \ \ Il h Ihl' p J l l l'fl ' \ I IlLdp.llI l .lIlll!! Ji'
I l n~l'd ill dlllll 'tC. P Il'iFl'1l1 II . )., . •

L' llfl lrtllIII

l\

t \

hll"h.; r,t l l l' rl~ hr,11 11l\"hC-ml' lll .1111

l' /l lt ti lilll.tl

I

LO rl l, 'O

tJulh.lr

l.\ pn: ...... !tlil l I..

(t',,)l"(I.lIl)

'

~

1f . 1 ~' f '" lIl\ n hl' U III II,,"

C hapter 19 Multiple Sclerosis

783

enr I nse during

d"oacceJerali on and reduc ti o n in blood prc~s ure . S . d · ·d . cx c rc l ~e . ollle 111 IVI u;:IIs wuh MS can ""PO d b · abo have either attenuate or:t sem s w eatll1g responses.

Sex ual dys fun ction has tremendous functional and psychosoc ial impli cation s foc both patient and partner. l .5

Bladder Dysfunction

Diagnosis

Urinary bladder dy~func i ion occ urs in aboul 80 percent o f palienls:1! Loss in voliti onal and synergisti c cont ro l of the icrurilion reflex is produced by dCl11 ye lin atj ng lesions m d .. afrecling the latern l an pos te.n or ~pll1al trac lS unmaskin g

the s,,1CTal reflex arc. Types 01 bladder dysfuncti o n in MS can incl ude :I s:ma lJ. spastic bladder (3 fa ilure to s lo re prol>lcm). a naccid or bi g bladde r (a fa il ure to cmpty problem), or a dyssynergic bladder. The d ~ss yn erg i ~ or conflicting bl adder represe nt s a probl em with coo rdll1arion bel\\een the bladder contractio n an d sphin cter re lax auon.l ~ Common symptoms in c lude uri nary urge ncy. urinaN frequency, hesi tanc) in slarting urin ati o n. nocturia (fre"q uenC) a l ni ght ). dribb ling. and incontinence . The se,'crit)' of bladder S) mploms is associated with severity of other neurological S) mpto ms. pa rti c ul arly pyramidal traCI invoh emen t. Progress i\'e loss of functi o nal mo bility (c .• .. hand skills. siltin g balance and trans fer s kill s. ambu13110n) contribut es to personal hygie ne probl em s. e motiona l distress. and fu nctional incontin ence (i nabilit y to lOil('t or manage dys fun ctio n). Em pt y ing dys fun c ti o n with large fe'\'idual uri ne \ o lume inc rease s the ris k o f rec urre nt urinaJ) tract infec tions (UTI ) an d k id ney d amage from f"'luent UTI,."

Bowel Dysfunction ConslIp3tion IS the most commo n bowe l co mpl a int in MS and re;-,ull<., from le~ion'\' affec ting contro l of the gas trocoli c reflex. It i a..;socialcd" ilh the prese nce o f spastic it y of the ~h lc floor mu ~cle.~ and i ~ also a frequc llI con~equ ence of m'(11\ It) . l ac~ of nU ld intak e. poor di et and bowc l hab it; . ~pre~lon . and medi alton side etfec t"'. 8Q\.\el im ptlction I a senou~ complication lhat req u i re~ immediate unemion. Diarrhea and LOCOntmence b le~s o f a problem hut a n abo OCcur a!l a re~ul! of lo<.,~ of rectal COnl rol. sphin cter abn o r~a1It.Jes. or a~ the l e,>uit of ~condar), probl em s (ga~lroen­ enu!i. tnflammd.LOr~ txmel (h~a,e) _·H

The diagnos is of MS is made by a neurologist based on hi story. clinical findings , and s upportive clinjcal tests, in cluding magnetic resonance imaging (MRl); CSF; and evoked potentials ( EP). Diagnosti c criteria for MS are outlined in Tabl e 19. 144

Imaging MRI is a sensitive tool for confinning disease when used alo ng with othe r clinical and CSF data. MRl detects both ac ute and chronic les ions. small and large. with high resolution . Gadolinium is a chemjcal compound given during MRls (Gd-MRI). These scans are used to help distinguish new lesions with active inflammation that occur during the preceding 6 weeks o r so. Lesions are secn as areas of increased s ignal intens ity. " bright spots." 1'2 scans are used to detect more long-term disease activity (i.e .• loss of myelin and axons. glios is). These les ions are seen as " black holes" on the MRI: the darker the lesion. the more extens ive the tissue damage . Approximately 95 percent of patients with clinically de tined MS have well defined MRI changes. Excessive MRI activity includes three or more enhanceme nt s on repeat scans separated by at least quarterly interval s (scaffered il11ime Gild place). Lesions revealed on MRl do no t always co rrelate with clinical disability. " Silent attacks ' doc umented by MRI changes outnumber the att ac ks that cau se ac tive symptoms such as paralysis or v is io n loss by 10: I. Misdiagnos is can occur as 5 percent of ind ividua ls with confmned MS do no t exhibit MRI changes. In additi on. o the r diseases can cau se s imilar lesions evidem o n MRI (e .g .• d isseminated encephalom yelitis) and some healthy indi vidu als can exhibit bright s pots on MRI. Current neurology g uidelines call for MRls to be perfo nned ut prede fined interval s to doc umt":nr d i~ase progression and re ~pol1se 10 dl~ase ·alt e ring m edjcat ions.~

Sexual Dysfunction 5<,.U,1 dc'fu J nC1101l 1 ~ lommon . itf1~"' ll!l g .. ", man y d O) 9 1 peri-tom of d men an 72 pt'n.: en t ot ""omen. In "ome n. ~lI11"'.omb CJ;n ' I ·' DeJOC _out: <.hange') In ,en'\J.llon. \ agm.tl Jr) · trouhlt' readung nrga,>m",. dnd I(h') ot libido In men. }tnptnm t an I _I ~ mL ude- IInpotence. lienea ..~d ,C lbJli o ll " Ik:uh • ' \to ' ) or lIlabLht~ to tJ.lcul:Hc-, and lo~ ') (lJ libido. lu41 a(.11\'11 I . \ rn ) b a boO dfttd~d b) the appc:aralll.e of oth
a~ \Pih Ul:If}.

umonuull ablc

')pa",nh , pam .

and t atl~~ , bladder or bo" el Uh..un!Jlle lll'~ ... In 1 • Ps)Chok Ullcllonal mobl llt ) . and d\iIJ)~< to ",If-ullage . ) leal f!:l,non, haH: " large IInpalt o n fu n( tlon t-

Cerebrospinal Fluid Pal lt: nb " ith MS .,how e leva ted (Dial immunog lobulin in

pin.11 nUld .md the presence u f o hgoc lonal IgG bands 5 lO 90 l'lCrl.cn t of pa tients). Patienrs with PP~1S have:' highe r leve l, o f mlInunog lobuHn~ in spinaJ fluid than pallem, with RRM S. (\ecn In

Evoked Potentials Up to 'XJ 1"'C<·CIlI o f indivIduals with MS demonauaae abnormal e,·o\.ed poi
784.

PhysicaJ R4:':habiHtahon

Ta ble 19.1

•

•

f,

Tip Sheet , McDonald Diagnostic Cntena or

Multiple Sclerosi. (MS)

What Is an Attack? • Neurological disturbance of the kind seen tn MS • Subjective report or objective observation • 24 hours duration. minimum

I . Excludes pseudoaltacks. sIOgle paroxysmal episodes I Determining Time Between Attacks • 30 days berween onset of event 1 and onset of event 2 How is " Abnorma lity " In Paraclinlcal Tests Determined? Magnellc resonance imaging (MAl)

Three out of four: • 1 Gd'enhancing or 9 T2 hypertense lesions if no Gd-enhanclng lesion • 1 or more Infratentorial lesions • 1 or more juxta cortical lesions • 3 or more penventricular leSIOns (1 spinal cord lesion : 1 brain lesion)

--- --------~~==~~~~~~~~---• Oligoclonal IGG bands in CSF (and not serum)

Cerebrospmal flUid

• or elevated IgG index Ev

ed pctenllaJs

• Delayed but well-preserved wave form --- -- ._---------'----------- -- - -What Provides MRI Evidence of Dissemination In Time?

A Gd..,nhancong IesJOn demonstrated In a scan done at least 3 months follOWing onset 01 clinicat anack at a site l.-om anack

d~erent

or to absenc 01 Gd-ilOhancIOg feslOns at 3-monlh scan. follow-up scan after an additional 3 months showing or w T2 leSion

Gd...,SIO~

- -----

Step. In Making a Dlagnosl 8 of MS'

• 2 01 ·?

~----.----------------

C'l()(e anac~

or mo'e obt

dtn:cal

· 20< more an • , ob

!~

dlneC8 l le~

· , a ..ttC ~ • :-- Of!llOl

,t~'V

eli

one chO/cal evidence Will suffICe (addltiOtla) evidence desirable SIOIlS

bu1 must be consistent With MS) D,ssemIOalion In space. demonstrated by • MAt ' • Pos,tIVe CSF and 2 or more MAl I ons consrst&nt "',til MS · or Funner clinICal anac different site

---- ----

[),ssemlO !Jon III riffle oomonstrated by • MAl · or second Cion ttack

• , dB I t.

. demon.lrated

•1 • 0< \1\ t'~

t>-,

I .8 C::'F .. no

MS

and

o.s

· I.'

.~

Chapter J 9 Multipl e Sclerosis

785

Table 19.1 lip Sheer: McDonald Diagnostic Criteria for Multiple Sclerosis (MS) (,on,;o."")

i

InSidioUS

Positive CSF and Dissemination in space demonstrated by • MRI evidence of 9 or more T2 brain lesions • or 2 or more spi nal cord lesions • or positive YEP with 4-8 MRllesions • or positive YEP with < 4 brain lesions plus 1 spinal cord lesion and Dissemination in time demonstrated by

neurological pr?gression suggestive

of MS (prima ry progressive MS )b

I

• MAl • or continued progression for 1 year From National Multiple Sc le rOSIS SOCIety. with permisSion . ~ M c Do n a ld

et at Recommended diagnostic cnteria tor multiple sclerosis : Gu ide lines from the

InternatIOnal Panel on the Dlanosls 01 Multiple SclerosIs . A nn Neural 50(1 ):121 . 200 1.

tThOmpsOn el al Olagnosl!C cntena lor pnmary progressive MA: A position paper. Ann Neurol

" '832 2000 ' Bar1o.hOf et al Comparison of MR Imaging cnteria at lirst presentation to predict conversion to clinically dehne MS. Brain 120:2059 1997. -lInlore el al: Isolated demyehnallng syndromes: companson of different imaging criteria to predict conversion to cllmcally define MS Am J Radiology 2 1:702, 2000.

Je~ion'

on \ I,ual. audito ry. ~ o m a lO se n s of}. or motor path wa~ ... produce .:.10\\ cd or abnOnllai conduc ti on.

Prognosis

It i s important to remember that these remain general

guidelines and can not be used to describe outcomes for individual patients.

Medical Management

Onl~ a .;.mall perce ntage o f pa ti e nt ~

actuall y die a s a con.'lequence of the di"?a ... e. For J11 0~ t ind ividuals. life expect3Jl(,~ I' nO! red ut:ed. "ith 7.t perce nt of patient::. s ur\Iviog ~S ~ear"l aha on,e! 0 1 sy mptoms. Ho\\cver. only a mm(\rit~ 01 mdl\ lduab \\ ilh M S are 'itill In the workforce 10 ~e;lr ... aiteron,ct A t I:) year.... )0 pe rce nt of pat ie nts wi ll requIre the U...t' 01 an a""l~li\"e de\ Il·CO to " all.. . and ~tI :20 ~ ear,. 50 pt'fu:nl \\ ill reyul re :.t \\ heelc h31 r. It> De"'plle lb \ .mable- l.-oUl· ...e. l·e nain progno ... lic fa c tor., ha\f' ~en Idenufi~d In ~1 S • S.\mplOml

On"'t't \\ nil on l) one

'»

I1lplOlll I... o ne 01 the

~lIonge<.,(

•

mdh. ,dll.>r ... til a I•• 'vorah le prog no"' l'i COitf\( 11 Jl\('U'1 Bent);n and RRM S arc a<,,>oc laled .... Jlh a mure 1.. \ (lr.th!!..! pn'gnv<.,i ... \\ he f"l; :I ~ PPMS i", gent'r....!!~ ':IJIl'>lderl:d mure omlllou ...

• Art

Young >lgt: at Oll ...~t

, ... mM!..!

• AtUIII/"-.:/(ul /"JJI/le,' UI 1\ \<,11, .1f"c 'me 01 It"Jdlt:i1'''f

"'gil'

\I,

LiLlO! ....... , g. n IJ Il' <1 111 p~

til t:

Ill """

rillTlIll ,li .Il1d

,th m\'(II\l'menl :,, 1 JIlu lllpk .. Ill'''' .,n .) poorer pI IIl!nO\ ' \ J.nd l!Iure

)t:;JJ\ I .. i.l"~l\.Jitlt:J "" IIh J

\ere d'\db,IJI\

'tt/a

[;"I/In t'\_

f- J\Ofdblt pr.lgllu ... IJC tall u, ... Indlll.1!.: 10\\

tl'lldllco,lflll hUlden !tw" dtll\'c Il'''loIOn l o rma lllUl. ;'II Ht n q !

llYlhlt

IIl)o:lm (I r a>.oll hI ......

Advances in phannacotherapy have produced synthetic interferon drugs (interferon bela-I b fBetaseronl . interferon bela I -a IAvonex and RebifJ ) that have substantial immunomodulating propenies. These are close copies of a naturaUy occurring human chemical. interferon beta. Interferons slow down the immune sy stem response b) reducing inflammation. ~ welli n g. and rJpid proliferation o fT and B cells. The) abo bloc k activa ted T ce lb from crossing the blood-brain bamer and damagi ng lTl yel in. O ther dl-.ease-modjfying drugs Incl ude GI ~ttimlller ace late lCopa..\One) and NovalHrone. C'op,L\one I... abo an Il11l1lullomodul.ttor that aclS a~ a decoy, clogging T l"dl l"!..!ct"ptOf'.> . NO\J.ntrone i~ an immu n o~up­ pre" " J.I1! dlld ha~ ..t

fmllr.tok lil.iIl o n "e ! >tIkI" Ill'c II. \l,hlLh I", J.''>f)l.I,t!ed \'.llh.l PPJ\ IC:; lour ...e and IOlrr: .l't'd dl"' J hlilt) Imp.il1aJl\ prllgllo ... IIL

Disease-Modifying Agents

damag\:'''~

luntled Illclll11e do\e to pre,cnt heart p l c ...ents ~1I1 overview of the di~~ ­

l ablc 19. ~

mod l1) m g drug\ For 1ll0\t patl~III "" r~ u"'I\'lJlg Jlsca~t' - modiryil1g drugs. trl· ..t li ll~ JlI I .... u nl } pJ.r(1311 ) e ttecli\e III ..:ontrolling their dh ~.I~t" SOllie p:JlI Cnh h ~t\ 'e ~ hown reduced relapse!. (by ~ h(}u t 1() pe rn~ 11 1 \\ h t' ll C\.tlllll.lfed to pldt'ebo lreaUl1Cnl). n:Juu."d ..,t" \t'TH~ lit dtlad.. as l"\ IJc lI(:CJ by acqUi red neurohtg H:JI d~lk II.,. le\\ t:r ruld ... llldller J.unagl!d art!U!) on MR I, lin{j J ,ll )\\C'r rille.' 0 t J I"'l:'u:-.e pro gres~ion . 40 Cllnflnued, trl'4Ul' llI rel.llh ': .. 1I1 l· '\· t;~ :il\e MRI .h.:tiYIIY may i.ndlcate thl" nCI.:'J 10 !)\\ ill Ii drug tht rapy (0 higher doses and more

Physical Rehabilitation

786

support t he p ati. ent"s . , hope for a positi .. ve outcome inclUding . I·se.lse course and a POSitive effect from drug thera bel1lgn c I. . , ' . of early treatment and the Importance of con. ~ BC~ fil I S . • . .111 Inrul'lgement should be emphaSized. slstcncy '(

Betaseron Interferon beta- 1b Approved 1993,8

Avonex

Every other day 250 mcg 1M injection 30 meg

Copaxone

SC injection

Approved 1996,' Novantrone mitoxantrone

Approved 2000,8 and c

clinician should have a thorough understanding of the medicati ons the patient is taki ng, th e ex pected benefit, and poten ti al adverse reactions. . Cort icoste ro id therapy (e.g., prednI sone, methylpred_ ni so lone) is used to treat acute d isease relapses, shortening Ihe d uration of the epi sode. These drugs exert powerfu l antiintlammatory and immunosuppressive effects. diminishing swe Uing within the eNS and tem porarily repairing the blood- brain banier. They may also prevent ci rculating tox~ ins or immunoactive cells from entering the eNS. These drugs do not modify the disease co urse or degree of recov~ cry. Typicall y corticosteroids are given in high doses (l00J mg/day), admini stered intrave no us ly fo r a brief course (e.g .. 3 to 5 days), fo ll owed by tapered dosage of oral med ication over a pe ri od o f 10 days to 5 to 6 weeks. They are associated with adverse side e ffec ts. whi ch can include agitation, nerv~

Every day 20 mg (20,000 meg) IV infusion in a medical fa cility Lifetime limit: 8- 12 dose s 12 mg/m2 every 3 months

Rebif

SC injection

Interferon beta- 1a

3 times/wee k 44 meg

Approved 2002.'

Prompt m anagement o f fl are-u.ps and symptomatic and supporti ve treatment are esse nti al elements Of. care. The

Once/week

Interteren beta- 1a App roved 1996,a and b

Glatiramer acetate

Mana ge ment of Relapse s and Symptoms

SC injection

Approved by the FDA for treatment of a t:>

= relapsing-remitting MS = single cllmcal episode If MAl features consistent with MS

'=" progressive-relapsing or secondary-progressive MS 1M = Intramuscular injection; IV = intraveno us; SC = subcutaneous injection (Just under the skin).

C

frequent!) administered beta- in terfe rons or comb inati on therapies. However. the~e age nt s ca nn ot reve rse ex isting deficJts.~~ Cl inical t ria l ~ have primarily included ambu l a~ tory patients wi th RR MS as these dru gs are not indicat ed for PPMS. Common ;jdver~e effech of the int erferon dru gs incl ude lIlJecti()n+~ite skin reactions (sorene~s, redness, pa in. bruismg. or ~wel hng ) and flu -like . . ymptoms followi ng injecti on that Ics~n over tIme (f~,er. chill!'.. sweati ng. l1l u~cle ache .... ~Uld ILttlgue). InJeC IJOll '>Jtell 3r~ va ried to red uc e adve rse etl ech. Rarer and morc ~\ere ad\cr,:>e reaction!'. incl ude depre!o.)lOn. aJierg lc re:.lCl10lh, .uld liver reactJOlh. Cop~] xone can produce <" lllllbr injectIOn 'l ite reac tion!'. and an in itial Ilu'lhmg re'II.,:llon imll1l'"dl alcl) aller JI1)CC t HlIl (unxiel)" che..,1 pam, P
ft'O':I\C

"o\tullront" by IV II1IU<.,ItHl

til

Pr(jb l t:Jll~ Vltt h auhl.:rtnLl' u. . 'ng IIlIlIlUnLllIlotlllL.IlIf1~ J~l~nh ..m:' v.t:1I d, ullIt"nlcd Ap l)tll'\lInah~ l ) ,~ pt~r\:('n\ po1liem<., WJ' IlI(RM~ dH.' Ihl\ (In HIIIlIU I10llhXlultlh-'() Ihl!r;lp, HtJhh pr"fe\.., h,l\
t;'

ousness, and insomni a: increased sweat ing, appetite, and susceptibility to infection: and GI d istress incl uding heartbu rn an d d ia rrhea o r constipat io n. ACTH (adrenocorticotropic honnone) can also be used to provide l ong~tenn suppress ion o f the immune system , either alo ne or in comb in ation wil h steroid s (e. g., cyclophos phamide and ACfH). Potential ly serious adverse effects can occ ur with these powerful im-fllu nosupprcssant drugs, incl uding suppression of b lood prod uction by bone marrow, bleed ing di sorders, and increased risk of infeclion, 15

Spasticity Manag~me n! of spast icity and :-.pa~ms inc ludes the use of l11 usdl' re laX,Ul h , O ral bac lofr:n (Liorr:~aJ) is t) picall) me fi rs! drug of inlf'rvcnlion. Do ... 3ge is progre~~rd gradually 10 obtain o pti ma l e ff("('(\. Other oral agent..; u,c>d incl ude tizaIlIdin~ (Za nalle\), d.J ntrolt'ne l D~HHnum ), and lhazepam lV~llium). The- fl'dllL' tlon In 'lIJJ . . licit)' IllU.... 1 be balanced " 'ith the: I)()\\lhilil\, 01 .ILhc::r\L" t'fll'('I<., \\ Ilil ov\:rdo~tng, ind uding ~nldtlon (dn;'\'-' U16<;,1, \\ c.ll...ne ...... , Jnd f:lIil!ue . thefi1pi.;1 Illu <., t be <-tlen In thl' ..e l'h~lIh?t'\ ,ulli l'onll~1un ica(e \\ ilh Iht'

The

ph) . . \CI:Ul to ..h.:llI\:\l:

opti mal dO\lng for rt'h.lbdltarioJl. The

IlIer ..tph l llilhl "1,,,\1 I(',,-,ognilc.' Ih,1( .11 timc:o. "'rdsrit-it) c~ be 1I,\~d 10 enlulI,'\'? IUlKtlOn, ... ub .. rll ll tiog f,'r I,~d, 01 srreng1h, hu' ....... lIl1pk. 1,' \.I\:n .. \). "'p,hliL'ir) 1.' ,10 lX' u~ed II) a.s~ iS[ sr.ult't~ Ing dunng a "'1.IflJ ~PI\,OI [r.ln~fer. ~ll.!nl tidUl[ redUl.'lIOn of ~p,I"'IKj(y H JlIi fll(:dll',1I h)lh lO i!!iu ulIl~ ",t'n t' h) produce Il~5 ~ll tUllLtlll1l C,Uhillll.I/t'PIIIi' ( n~~ rl'lt:ll (\\0 tit' C'ntx'tin~ m Ic dUt III!!, p.m.I\) ... 1I1d.1 {\utldl?'ll , ... h,lrp nn ... t.() ~PJ, ... ms. P-,nl(f1b \\-ho d\1 11\)\ ,ldl·qU.lld~

re'pond

hl

l")ll~f\.U I\t' d n lg (fl'-:U -

nW III \I.~g" IIh1\\' \\ IIi! II1t l ;u..·I,lbk "'11.l_..., t i\.' I1~ OJ ,... pa!>111 lO) II};I~

C hapte r 19 Multip le ScieTosis

from 1I11mthccai admini 1>lnli ion o f baclofcn din::cll )' i'M"'tll . . d.e CSf of Ihe lumbar SplllC \ m a cathe ter. A program10 10 1(' iJ11plan1cd pump ('olllrols the dosage. Signifi canl v

(llBb

reduCI1

in

~n,1~licil) and "p~ISI11~ ha~ ~.

been re ported in the • d tnlnk. \\ ith les!) Improvement n'lx u1ed 111 the UEs.

0 11

. t ..

LEs ~ effect . . incl ude pump fai lure . infec tion. ,md lead Ad\ e . ~1..<1 di..-p!J\."eOlenl. . ..

-Surgical inter\'enllo,ns are 1I1~ I Ca( cd fo r m ore sc~ere s pa~.' The " plcal surg ical cand idate has had s pas tic pil ra lyurI;' nl3Jl\' \ ca~ re~u l ti l1g in a nonfunc ti onal limb and seri SIS lor ., • . OUS com p l icali o n ~ (e.g .. conlr.lclUrr-s and :,klll breakdown). The lC'C hniques im'Jude severi ng tcndon: (tendfn/owfUY)· nt'f'\'es {1Il'urectomy). o r I1C I"'\'C rOOh (r/lI::nlOmy). Phenol 'r block... are also used 10 decrea:-.e severe spastic ity and

effecl1w f('lr up to 6 months. Botulism tox in ( Botox) a parah tic agent thai can cause a te m porary b lockage of. a I~ -e musc le that has a s imilar lim ited time fram e for ~li\,'f'ne$~. Repeat injecllons are the'n g iven. '5 nt'r'\ be

~ <;

and

Pain

Pam is managed accord ing to the pathogenesis. Paroxysmal paln responth be~1 ~o carb.am~epi ne .(Tegretol). ami.triplyline (Elavill. phen)10m (D llanll n ). diaze pa m ( Vali um ). or gabapentin (Neuronrin). Dy~sthes i as are managed with low dose> of ami ui pt) Ime (Elav il ). imipra mi ne (Tofranil) or desipramine (Norpramm). A w ide varie ty of drugs are used to manage chronic pain. The discomfort and paln assoc iated \\Ith "PJsticity and spasms may tx managed with over-theCOUnler or prescription anti -infl amm atory drugs. Pain and numbncs~ can sometimes be successfu lly managed w ith a boef C()UJ3e of COniC05Lero i ~ . Sometimes ant ide pressants such ~ amirriPI) line <Ela\'il} are used . or pain is managed \\rth mild p.linkillers (acetami nophe n or ibuprofen . Narcotic ana.I~ics are problematic and not lypi caJl y prescribed. 18

Fatigue S)mplomauc treatment of fatigue can aho inc lude the use of drug,. Amantadme h)drochloride (Symone trel) is the recommended fi~t~line therapy in the C lini ca l Prac tice GuidellOel> of the MS Council. 2f1 Thi~ is an ant h lral and dopamme agonJ . . t shown to ha\i:~ a ..,ignJfica nt impact on 1"'''flIng faugue Modafinil (Pro, igl l l ha, abo shown efficac). Ahhough !tOmdlllle-... prescribed, pemo line (Cy le n ) is II C!\S sumulalll lh~t hU!!l undc,iwble ,Ide effct·ts (e.g., illlOfexlii. ImtabliJl; . m...omlll3)

Tremor Agent 10 ImprO\e Iremor hd\C been u-.ed \I\!t h \ al) Ing dtgree\ 0 1 \UCceM•. '}ome patlc!nt:-o re~poJld "1,;"11 to a s in gle : : . ~ to combin<1!lons oj drug/). dOd ...orne finJ no ~fil Medlcalion-. u ...ed w decrc:-a trc:IHor Hld ud~ ~C)~)/lrk IAf.U<1.11.. Vn.u1YIl, c10naztpa m i Klo l1op lll j). ~lvl (indcrd.i) bu£tlu wne ( Bu ~pljr), ondan setr\.'U l.J)fJarl). 4fld pri nlldone ( M)'~()llI1e) DIV ine!'>!', .Old \ c rt igo (OUt • 1 InJJlap:ed Wil li antl1l ... u ~eall l d rug). ~ M l! clVllle ~h~enj) or 'A uh S(.upot.1JllIne palch~) Se\ e rt: l .l....e\

787

m3Y require the adm in istrat ion o f;] short course o f conicosteroids. Seve re tremor can 31so be treated w ith ne urosurgery (thalamotomy) or deep brain stimul ation (DBS) thai involves im pl anting e lec trodes int o the tha lamus. DBS was developed for pa li e n t ~ w ith Park.i nson ·s d isease and remains expe rime nt al fo r palie nts w ith MS.2S

C ognitive and Emotional Problems A ge nt s a pproved by th e FDA fo r th e treatme nt o f

Alzheime r's d isease (doncpezil (A ricept D have bee n used to slow cogniti ve dec line in palienls wi th MS . Modest benefi ts in me mory defi cits have been observed .32 Depression can be managed with a ny of a num ber of antide pressant medi cati ons (e.g .. flu oxetine [Prozac[. Pax il. se rtraline LZo loft]) . Some anti depressant s can also decrease fati gue. Sti mu lan t medi c;:ui ons (e.g .. me th ylphe nidate [RitalinJ, pe moline fCy le rtl . dex troamphe tamin e lDexedrineD can also be used but may be habit formin g. Pati ents w ith pseu dobulba r affec t can be e ffectively treated w ith the antidepressa nt med icati on amitriptyline (Elavil ). Profess ional co unseling and participa ti on in suppon groups ofte n he lp the patie nt cope w ith the stresses o f thi s unpredictable di s~ ease. An active life~s t y l e al so helps reduce de pression and a nxie ty ..15

Bladder and Bowel Problems Urinary proble ms require a comple te urody namic work· up ide ntify the spec ific cause of the proble m and to arrive at the appropriate course of treatment. Treatme nt for an overaCli ve. spas lic bladder (sto rage dysfun c tio n) typically involves pharmaco log ica l manageme nt w ith anticholinerg ic med icati ons (propanthe line [Pro- Banth ine]. oxybutynin [Ditropan], imipramine [To frani lJ) to regul ate bladde r e mptying. Adverse effects can incl ude dry mouth . tac hycardia. and accommodati on di stu.rba nces. Die ta')' recommendation s include d rink ing 8 g lasses of fluid per day (wale r) w hi le limiting intake of caffei ne or alcohoL A flaccid bladde r (empty ing dysfunclion ) is ma naged with alternate tec hniq ues ror e mpt ying, incl ud ing instruc tion in the Crede mal/em'a (Ihe app lication of manual dow nward pre~ u re ove r the lower alxlome n) or in te rmitte nt se lf-cathc: terization (lS C). Dietary recom Jnc ndm ion.'\ include limiting intake nf t'it ru ~ ju ites while dri nking c nUlberry j uice da.iLy or rak.ing tTanl"lerry wble b . A dyssy ne rgic bladder (com bined dys ~ junc ti o n ) i& ma nuged with a lphu·adre ne rg lc blocking age rl l~ (e.g .. (e r.tm" in It-I ytrinJ . prazos in IMin lprcssJ. ta m ~ ~ ul os ln rFlo w M ax I) and lllltlSpal"lici t} agent s (e.g .. bac lufen I Linre,a il , lIL.1fl1dUle h}droc hloride [Zan.nex!). O n rar~ Q(.'t·a~ i olh \\ht'li bl.ldde r ,YJllprorns cannOi be f.."011trolled"., IIh m t'dj c~lIion and/or ISC. con lJllUou.$ c3lheteriu ... lion (md \\(: lImg Of Fulc:!y t'alhete r: condom . or Te.x,w, ca lhele r) or 'lurgil'al Uruldl) 1I1\"Cntlot) (supntpubic c8lMtcr ) 1m!) be nece,, ~a:r) For ~ ,\alllp l~ . 1M patie nl wnh advlUK'Cd dl ~d and ,)JgJuticam •.u.aXid of the upper ex tremitift. may he unable 10 mdnud lly pertonn ""If-t'athe.....w..ioo. Urinuy troLl ultecllon') re"\uh from n:lc nliCNl of urine in the bladder [0

788

Physical Rehabilitation

prl."lCcdur~.

:md f"JIll cn lhclcriznli('11

Antibiolic lherapy

4l

(he 1l13U1SlII\ of lreal lll l'1l1. d ' l yp icnJ I)' '. (n prohl em an l .!t • Con,,'ip'lIlon ,\ 3 COIlIl11 ) . d • I TI l e " include 11lcrea,c managed \~ ilh d~clary c HI~g~:o,. d '~~n al'-o include bulk Illnd Ultaj.. ~ and Ilocr In Ihe ,('t. ~II ~.l , • ~n C itrucc l). or fonllllll! surplelllCJ1l ~ tMCt;.Ullllcll. FlberC .. Ie I' J) IIX'! ,,;) fl C nC r~ (dlOC'l y l ... odlUm ~ulfO~ UCC Il1 ~IC o.lce. ~ ~c\lhr or CQIl IIIlU(1US usc of s.lilllulanl laxati ves and e nc · '- • d .1 IncontInence maml gc111cnl mJ~ i:-. nOI fecollunen Cu . "dance of Irnwnl s _I Idt" JieI3J"'\' chancl· ... !oIue I1 :l~ 3\ 01 . 1"( l \ I I) JdJu"i men l of mcdi c311on ~ used 10

h

(l'aftc mc.

:.t

'b '

co 0 .

PsychosocIal " Anxiety/depression Detachment Intellectual deficits

i~

Musculoskeletal Osteoporosis Fibrosis/ankylosis Decreased contractile strength Decreased muscle endurance Atrophy

Neuromuscular Decreased sensory input Decreased motor control poor coordination Autonomic lability

the probl em or

redu~t' "pa'illclt~ \\ hich can conln ule 10 . addit ion of medlC
J1Ilr I DerrolJ. proP;1l11hellllc jPro-Banthmcj).

Framework for Rehabilitation The chrolllctl\ of thl" lh,ca~e. along wi th its variable and

unpredlctJble' cnur-e. 1113: lead ~ome to vie~v indiv~duals \\ lin \1 S:\, poor rehabi lltauon candidates. \Vhll e tJ1C di sease

/.-ann('lt f:\f' Jitt'red b) rehabilitalion. there is a gro\" ing body e\ Ide-nee th;Jt indICate . . 'lgnilicanT gaiJ1S in reducing lmr3mnenl~ and promollng funeoonal mobilit) and indepcndenl'e ('an ~ 3chlC\ cd, In addi tion. kno"n complicat)(lO~ of \ 'lS can be reduced or pre\ented v,hile quality of Ide I' t'nh:mrcd <:--\i.(\\rdll1g Ii.1 the r\afl onal MS Society's Med ll..'al A(h 1"'00 Bl)3Td, reh:.tbllilauon re ferwl ... hould be Initiated \'hcn~\er there I" all "~brupt or gradual \\on,c ning of fune!llIn Ilf an Incre<J"'e tn Imp:unnrnt that ha~ a ... igl1lficaOl Unri..:t on the Uldl\ldual\ mobllit). ~ Jfel), mdepenlien<"-e.

Digestive Loss of appetite Constipation Poor nutrition/ delayed healing

Renal Urinary stasis Increased urinary infections Renal calculi

Respi ratory Decreased vital capacity Decreased respiratory endurance Impaired coughing Increased respiratory Infections

Cardiovascular Decreased phYSical work capacity Increased heart rate Thrombophlebitis Orthostatic hypotension

\'1t

and ,Ir ~uJII1: 01 hfe -:

IndJ\lduah \\lIh

neurlx1~gent.'rJtt\e dl"'t.'a ... e~

\uch as

\1 bt-ndit trllm r~lor.ui\t~ inlenen tion. aimed al reme c.iIOJtltlg or Impn" 109 ImpJtnnenh, fUJlCllOnJI I1f11t1;.ttlom. dJlJ d, ... arllllllt.: ... - Dirt""\.! ( \5 ImpJlrtllt:lll ... 111;1: he Ie" ... rt 1""11)1]'/\1: 10 lllle-f\c-nttOJl. t"~llall) III Ihe lalt' ' l<Jgc ... of the dls("J'c- l"h)\',I.:\CI , dunng lhl.: carl) and middle ... tage ... (·1 Un. d,

t:.I't(.",

f!.:'/llt-dlallng

J f("u, 011

re"'l.dt III nll'.ululglul ImpfO\t.'nll'nt ...

\lnpalrrnenh l.Ul

III

fOlldHln Ie

g",

'lrC"n"~tb lr.uulrt· fe~ull .. 111 unplO\t:J bai.m"e ,IJld !!.tlil 1:1I.1lrt'41 Hltp..tm,,,,."nl"" .. all~tJ h~ l'\\lh\ll~ flll.ith\ ...tl'l11 d\ ... JUf, 11\111 1flilO tn.t..:tI\II\ d.1ll1 JI'U't: I II~" 19 I '"dl" lom~r hll.itllC'l lIt .l1,q an IIlIlhlrt.lnt II)(.u UIIt.·,tol,tll\e l.trl~ I hi, I

C

III

l~t..I ... U)

IIl1r,JJITiIl:nt

1)1 lhl.:

1I1.1} (:\111\C'4U1,,}.,.h

,wL!

U"eulm III

(,11.11

r

1I1!t.:r"l·lltlollllh,:U

10f"".J1!\

'I,t~l"

trUe In lilt' j,dl.""1

"lil\. -1111

dll~1

dhl'.I'c .... 1l1'11

f('"yUlh: pW1lI1'1

... tdll.'nlC"llh rdk..tl\t, ot

tllllt'lUl'dl.lllr1? 1I11pUIIIl!.:'lIh

and It" <.IlfIlll!-; JUH(lll..,,,.1 ilu.llTO\"lh.Jl"n,C "ilile PI:IIHOIIiIL! It I., n ad

IlhUIJ."l'"n'd,l

r

,II

~ t II

drtJ j ' o!.t.tlltl

C"tt \ II'd

L.Upllll.l

1111

II It I IW.A'>I iJl tlf!ll I d

t'.

1111 lit I" itlllll
qua.t h

11

Ie

Iii (nh-.lli

(I

I1\

I' 111\ lJu~

•.111"1 (;111"

,~ ...

.

IIlIpdl

~\""I tliit Ih~ p,t\h'/11

jlllIllHltlJll' ,IU... t·Pl.lltu

Hhl

dl~"hllllll: " .111..1 tnlt"lh.l/ll III Ii tjll.lIlt, I.It lilt'" rh.H HI

Integumentary Skin atrophy Decubiti ChroniC sepsIs

Fig ure 19.1 ClinicaJ

rn:1nife s tation ~

or inactivity"

fact be the moSI meaningful outcome for patknts in the face of chrollic neufodegencrati\-e di ...ease. Prel t!lIftlll\'e illfen'entioll i~ aimed at minimizing polen· tial complications, i mpaiml enl ~. functIOnal limitations. or di.l\abiliue!o> :I ~ lh~ di ... e a~e progre"e" 1111'. tncJude~ pre""en· lion uf J di,~a ...c in a \u~cep{ihlt: or potenllally ,usceptible populalioll" (('mled prill/eli)' pre\·t' nflUlI . Pre\enthe efforts for Ihe pall enl wi th ~IS arC" geared to\\.lfd dt'crea;;;mg (he uuratwn ,mel \c\c-ril) o f ~) mplum .. or delJ) IIlg the emerg{'nl~ 01 <.h~t!a ... ~ \t"'Yllcl.1t" through e..lI l) Jetecuon anJ 1Il1Cf\(,flllon. tl:lllleU \("( .,,,dl/n PUTt'IIIIt'''. Pre\ Cnlloo h al,n :lulled ..I t mtnll1llllHg Ihe dcgrl~('" ~)t dl\abtl l[). [~mteJ I, , IWi \ JlIt'1 t'm/tlll (in.11 .1ml ~ lut,,"l'llIe !)lat~ 1 nen" retlc'(,U\ e Of prc-\('nl:UI\e IIlh:f\CnUtl/1 tr~ lI' t11l pr0tno(ton of heJlth. " l'I111:'I" .....,, 'Ilnt· ... ~. ('dllll't II\O/en\

,Inl I pl~·'t!n,lrli.'n nt IlPllnl,11 /11ft i \ f'lI/hl/l 1\ .IIIllL'J

." , tun\.' uon,

.it II1lk.li t )' /Ilg

the

1.1'~ . Jdl\ 11\ 01 l'tI\ Iftmlllelll III ordl!l to .tllo\\- th~ polttl'nl to Il'tH.1I1l lulh IUlkllon.ll \\ tlhlll thl~ 'l'lI~ of ~\I')lIng UIIP..illllkl\h .mJ IInlllJ(lllfh <.iu..iI .lllti l'Ul\.·,ill1t' . . tJtt.'nl(/lb 11:111..:\ 11\('

ot l"illHll(;'lh.tLIII) Il1h:r t:II(1011 j(X"U .... l'fl rl!g.un· IUIll..I!on

Iflg"lll.lIl11,IUIIII·

fll..l:a . . JOIl J1 \.IUlllJl l'du~,t1I"III,lI, ,lIh l d.Jlllllll'tr.t1lh'" ... el\ll~ d61gnl!J 10 IIlanH,11i1 Ihl:" p.HI,,'fH, ,:lInt'lIl h"'\d nt tunlll'''' ,II II II it \ Ido.1 i, "!th ~ f" \\ t1l I tX'II~11l t Illill n \,Hnh"'nOlI!\. r tl1(r:tp) hpl\.Jlh ill" til ttl~ IJh"' 'l..1~\·' ,'I Ihl' dl'4.:',l'l" (l' J),\S ,t~~ \1411111' Ihll/. cOil I(l/'\ "

d\.'ItHcd ."

.I '\;.'11,,", 0 1

C h ap ter t 9 Multil,l e Sclerosis ) 10 9.5)· Maintenance program s are Iy pi call y nol we ll 7.1 ' h' fllflded b) private 'IIl s ura,l1c e: M,< ,ddlca~. w re h co:,ers Sl' fV . . for the t'ldr rl y all d 'lC d Isa J c: • wil l co ver ll1
(lbiecti' r: s of med Ical m~mag e lll e llt. lInpkmcnt s the plan of and JXriod icall) reeva lu:lIes the pl an as requ ired by

C'~-

the p:1fjenI 's condition. A vari cl Y o f IJlt c rventi ons are used 10 achle"e goal:-. and OlltC(l I11C~, inc luding li mited direct Inler.'rnt loll:-'. patient/client -re lated i n~lruClion , and support]\'e coun ~e h ng , nle primal") foc us is to teach patie nt s. fannh. and caregl\'er.s the management skills necessary to . -41'i .:am (lUi the mamtenance program . coordinated inlcrdiscipl lll ary team is necessary to o\ersee the comprehensi \ e examination and m anagement n~ded to addre"~ thl." patient'!>. compl ex and multifaceted problem ... The team 1) picall: incl ude!>. the phys ician. nurse, ph)sical therapist. occupational therap ist. speech- language pathologl"l. nutritJoni'il. and social wo rker. As with any ream. the patient IS the central fig ure. \\ ith famil y and caregwer.. hemg le: member". T he ideal rehabilitati o n prog ram consldef' the pauent's dj'ease h istory, course and symptoms, mdudmf! Impairments. fu ncti o na l limitations, and dl~bill\: Of equal importance :lIe the pat ient' s abil ities ':i'..e.b.1. rnonllC' . and re~ou rce . (e.g .. famil y, ho me, commUnlt) I. The focu~ l~ on long-ran ge planning " ith anti c iplied ep"odes of care , mcJudin£ ho'pit al- b""cd , outpat iem, and home/commwlil)-b""ed rare, Da' Bell o- Haa., '· di scu~-,e . . a continuum of care ba ... /;,d on dhea~e stage (earl y, mIddle. ;!nd Ltlln for IIldl\ iduab "lIh neurod egene rati ve disease,.

A

Physical Therapy Examina lion

789

unique stalu s. The severity of proble ms, stage of disease subacute. chronic). age, phase and setti ng of rehabiliwtion. and other factors must a ll be take n into account in stru cturing the ex ami nat io n.

( ac lite .

Patie n t/Client History D~,ta obtai ned through imerview with the patient/fam il y and review of the medical record shou ld inc lude infonnation on ge neral demographics. medical/surgi cal hi story, social and emp loyment history, famil y hi story, living environment, general hea lth status , and social and hea lth habi ts. The patient 's current/chief comp laints and c urrent functional statu s. and acti vity level shou ld be ascerta ined. Coe,usting health problems and medications should also be identified , Dala obta ined from the hi story will help focus further indepth examination and systems re view (Box 19.3).

Tests and Measures The fo ll owing are specific areas and relevant tests and mea sures that can be used to examine functi on in patients with MS (for mo re detailed descript io ns, see earlier chapters in thi s text focu sing on examinati on).

Cognition Memory fun ction . attention, concentration. conceptual reasoning. problem solvi ng. speed of information processing shou ld be examined as well as the effects of fatigue on cogni tive performance. An expert panel convened by the Consorti um of MS Ce nters in 200 ' developed the Minimal Lamination of Coglliti,'e FUlictioli ill MS (MACFlMS) , This comprehens ive battery includes se\ en neuropsycholo gi ca l te sts examining processing speed/ working mem· ory. learning and memory. executive function. visualspallal processing, and word retrieval. The MACFlMS talc~ approxima tel y 90 minu tes to admil1lster,n A brief sc ree n o f cognlti\'e fun c ti o n can be achic\ ed us ing the

Mini "'len tal Sla ms E.\UIJ/ ( A1MSE J.7~

dlHercnl ;jrea~ oj th~ C'NS mil) be aff et: led . I.ardul c\aITIlnilt!on ,... perlom1cJ lO determine the t">..t~n1 of lleulOlog lL' ,tl and fUlltthlOa l Imul\.c.'Illt:nt SUb-"l'quL'm ree)".lOlInatlOn at ... peufiet l mt\.'[\4.1 un: u~d to dl-'lInglIJ~h dli.lnge III .... 1.. lUI., .IS \\ ell a-. etfc..:h (II lrC:dtment It 11l"'~ not ..II"" J~ ') I')t' rO~-'lbJ e to d ll Scl.J.u-..c m4Il:

11 hi Imper.tll\t: th~t J

krS!nJl.:sle (' hallge In ... t.JLU~ "' ......(x,I..t I.:d \\ IIh relllb:o.lQIl

• mplflnl' from IrL' atrnL~1lI OUIl.\IIIIt: ... ('('n ' ldenng

(I I

til ... \ ilU I \~mplClOh ot riil) mJI\ H111",1 pal n:'111 , It I ... olh."11 '''''lIef! 1<11 til perf1lnn lhe Innl,,1 i..' XJlIlllldliLin 0\(;1 llll'OI'1) hl' ! I'I) .tnd !I~'ICIII'> h·\ I\·"" , .ml! I ~ I . \-.. m k - ld.fIC ' n,l" .. ~U I L· " I 11, 'oekl'lIon of ['\IUI1 I1 \(.Il1o ll PH) l.eDUlt:\ .rW Ie"t'lul I II~ ll lf\o .lIt· dch; W) lIlcd b Ihe p",IH: m \,

.t). III,

I)

AfTecth e a nd Psychosocial Function ErnolJ onal \l tt biht y should be c .'(.lmined. The" presenct! of emotl o n ... 1 lab ll it)'. ~u ph o na . em o tional d y sr~gulation : dep r ~-' '''I on h)"mph.lIlh. 'ot' \erit: . le nglh , effect on fu nc tional J1CrtonI1Jn~ d; It' \ d ot ..,(rt"!l 'o and anxiety, coping .. Irdh!g lt" .... ,Ind pre-.ent:e 0 1 .. It'ep ll!..,o rJCf\ , ho uld ~ documt'nh:'d A u-'\"fll l 1II", ln1lllellt i ... th!? Bed Depre.rsi(m

III, "111'" \

'I

Sen.alion SUI,-,IIII.. IJI,tnd dt:ep ... t" lhJI1 01l" (Ioudl. pn: s ~ure . t~mpef3-

hire p.un p f\ l prHX~ l' ptl\, c) allJ comhwc.... nhtJ pJ 111 tI ht' rmllt e'~ "'Igll, d sesthcsiasl and chronic I'
790

l'Jh ysical Re h abilitat io n

.

B OX

.

193 Ele m e nts o f che Examma Llon ·

.

S cle r OSIS

of th e Patie nt with Multiple

73

..

Pulmonary sign

hlit:n tlCii('nl His tory . c sc'( race/cdlllicity. pnmary language. ed llcal~ on : ~!i~1 hi~,~ry: cullUral beliefs and behaviors. family and caTc£!.i\ er re<;ourccs. SOCial suppon systems • Oc(:~p3fi()nlemploymenl/work . • l-i\ ing en\ ironment: home/work barners • Hand dominance

. ' I and

• General healrh SWlUS : physical. psychologICal. SOCia •

role fu nction. heallh habit ... • Fami ly hi story • Medi~aJ/~urgicaJ hislory • Curren! condillons/chief complainls • Medications • Medical/laboralory lest result~ . • Functional status and 3ctiv;l)' level: premorbld and currenl

S.\'stems Re\ iew • Neuromuscular

• Mu,culo,l..elctal • Cardlovascular/pulmonary • 100cgumenla')

Tests and Measuresllrnpairments

• CogOillon: meOial Matus. memory • CommWli(:allon • Anlhropometric charactenstics: body mass index. girth. length • Circulation: response to po'iition change/degree of orthostatic hypotension • Aerobic: capaci l) and endurance: during funct ional activities and ,>tandardized e).ercise protocols. Cardiovascular signs and s ~ mplom!l In response to exercise and aClivity.

mo\'ement, and pro\ olmg '\lImul i ~ hou l d be documented . The \1( Cdl Penn QUl'HIOlUUllreSI ) or Ihe Dallus Pain QIU Jllllf/1/U/rr. dc\eloped 10 eX Llmine the effeclS of chronic ... pmal pam on dall~ atll\ Jlie .... an\lely-de prCs\lOl1. and "'oLlal mten: ...t. c'an be U:-,~d."l

s and s)'mploms in response to exercise

and activity.

• Ventilation and gas exchan~e

..

..

ary integrity: SklO condition, pressure SCtUlUve • Integ ulllen ' • . . ... ',·, es positioning. and postures to relieve pressun:

• • areas, aeu VI •• • Sensory integrity and IOtegratlon • P~lin : intensi ty and localion . • Perceptual funcLion: visuospatial s~I!ls . • Joint integrity. alignment. and mObility: range, of mallon (active and passive): muscle length. and soft tissue extensi.

biliry .. , • posture: ali gnment and pOSIItOn, symmetry (static and dynamic, si tting and standing): ergonomics. and body

mechanics • Muscle performance: strength. power, and endurance • Molor fun ction: motor control and motor learning. • Postural control and balance: degree of postural instability. balance strategies ; safety • Gait and locomotion: gait pattern and speed. safety • Functional stalUs and activity level: performance-based examination of functional skills (AM level). basic and instrumental ADL: fun ctj onal mobility skHls; home managemen t ski lls • Psychosocial function : motivation • Assistive o r adaptive devices: fit. aJjgnme nl . function . use; safety • Environment. home. and work barriers • Work, community, and leis ure activities: ability to participate in activities. safety

Muscle Perfonnance Functional ~lrellgth lIsing man ual mll,cl~ tesling ( ~'IMn and dynamome ters (i~ok lnetic. gra~ p and p inch d)namonlt'· rer,, ) ... holi id be examined: ~lrol1 g ~ pa~t1cil) may ~ a con· Iralll<.ii calilln 10 Mandar d l\ lMT pO!lolfion ....

Vis ual I\cuil)

Fatigue

'\LUJl~ trad'lIl~ ....IIld aCl;ulllOlocbl lon ,>ho uld he n amincd : tllt' pre'>l'IKt" oj \ I\U<.II ckfilih (hlu n cl.1 \ I"ion , fit'ld del~Ch j-,LlllomJj. I.1lr1llrl,l) ... hould be JouII11t:nlt.'J .

Tht: fn:qllc nc~, Jurallon, alld "'l'\t'rtl) of lallguc ~ hou ld be l! \i.lJlllllcd: I)fC'l'Jpi lating (;Iclo r" , .lc' ll\ It) I('\cb and efficacy 0 1 1\'.., 1 i.UI t' Il1PI ~ \ hould 11\:' thx: umClllt·,.1. The t./o(Jljied FU flgl l(' Jill/ h i d Scutt' /Mf'S ) \\ ,h deH~lor~Jd by Fbk e t JF'- 'Ii J nt! I ... 1m Imkd Irl Ihl' ~.lIll11l.tI Mult iple Sdl'fosis SO(' I C I\ CItIllL.tI PrJL 1I U~ (iuli.lehne,> o n F41t!gueY It IS !I

(ranial J\ene Integrity MUli)! oIlIJ 't:JJ"lJl) LrOlJlJ i.iI Ilt.:r\t: IUlllIII,Jl "hoult.llk' t"d lll Inc/j IIIl' Ilil',C·!ll..c 01 JcfilJl" {or"c p;J!1I 10PIII.. nCu llIl ... /. fw.·ulonlOhlr J)'\>lj,mrul d.\'pha!!l:.t II1IPt.lllC'J j.!.t~ I t.:ilcA lfJgt:lIIlJli.tllltUlalp,tl ,hould bt· dt.K.UIllc-llkJ

...trullllrl'U ... ~" f(POrt ~ l -ill'lll ljUI' ... lloOOJlrC .lddre~s ln!! lilt· d l i.'Lh i.lt 1i.lIlgUl' UlilOglltl l\(. ph~~ILJI. .wd PS)C h(l:"to(hil hill,- thm U\lIIg ,\ )'PU IIH ( )rJlIl-iI 'l·otl\? \\ lIlt 0 t"qll.tJ to Ih:\l" l nllh" {n i.llnlO .... ~th\i.I\ '" F.ll' h an.'.' h ubsl.J Il"\ ll(lfeJ \ep.u<.lIt' I}. Ihc tut.ll ~ t HS :-'l:ore r.U1ge i) Iwm II hI X..J (~t: -\ppenJI AI rhe ~ I "' I S CJIt be dov. nIO;'I\.. I ~tI III 1'DI tOHn,H h om hItJl ./"~ \\" nJlH.lnJ.l m"Jsl,).·u~IY.

.mu

,,,,,1M! C, I . th f eJ' "'ll g ut:' ..... p . -\11 .Ibbre\ I,tled \crswO ot ~1H" hJ\ rl\c lth" \IF!~.51

""Ill,

C h a pter 19 Multi ple Sclerosis

Temperature Sensith'ity , ,

and Ihe Amimlariull I lldex

.

(AI) . '-1~

791

The i
11le dl'gtee of lempcr.ll ure sen "'l.llv lly and lis e ffect 0 11 fati gue

Gm l £.\'a", ;I/(II ;oll (RVGA )9t· w as deve loped 10 ex amine

anti wcak.ness should be examined. A ty mpani c membrane herTflomeler (car Ihemlo lllelcr) can be used befo re . during.

gait in patie nt s w ith MS. Ali gnme nt and fil. !l.afe ty. practicalit y and case of use of orthotic and ::Issistive dev ices should be examined along with ene rgy conse rva ti on and expenditure . Wheelchair skill s inc lud ing fun cti onal mobility. man age ment. safety, tra nsfer skill ... and e ne rgy conse rvation and e xpenditure !l.hould be examined.

Ind afler l11oderare-i nlensi l), exe rc ise. A delenllinJtion o f the c hange~ and worsening of el),· ... nt-urolog ical symptoms can be 1l1~lde. II ..-Ialion bet ween temper,llure

MOlOr Function

.

The therapist !)hould eX8 1lllllC for Lhc presence of corti cospinal sig ns (pa resis. spas ticity. hype rac ti ve DTRs. positive Babi nski'!) sign . and involunt a ry spasm s IO cxor or e~ten sorJ) . Th e Amended MOlOr Club Examination (AMCA J \\ :1S dc\eJopcd to e xamine' the na ture and deg ree of mOlOr and functi o nal de fi c it!) in pati enh w ith M S.~5 Spasticity can be examined us ing a subjecti ve f Uling ~caJe . The AshworTh Spasl ior), Sealest! led to the more :Ideh used the M()d~fi(}d .4.s111\·orrll Scale ,'i-7 These are ordin~1 scales de Signed to l11e3 ~ ure tone inten sit y: the modIfied A ~ h\\ o nh has an additi onal grade a t the lower e nd allo\\ ing for more discrete rating . A de tennin atio n should be made of the differe n ce~ betwee n lower limbs ve rsus upper li mbs. right and left s ide s: an d facto rs tha t influe nce rone.

The therap ist should ex am ine for the prese nce of ce re bellar ~ig n ~ (a ta~l a. intention tremor. ny stag mu s. d) sanhria t The effe-cls o f position c ha nge (e.g .. s itlin g-to~Iandin g ) may produce an inc rease in atax ic movem e nts vd th increa.·,ed demands fo r postural sta bil ity and sho uld be documented. The therapist sho uld exam ine for th e pre~e n ce o f \ e~ti bu lar d) ... func tion ( dl zzi n es~ . vertigo. n~ stagmu s . bl urred \ ",JOn \' lI h head a nd bod y movement.s . a nd paslur.tl 1mbalance I.

Posture Suu.. and d) nanlle ~tUr.lt control in \ an ous diffe re nt posi litJl'b leg. ,mmg. "'1.;Uldi.ng t ... hould be eX..lfllined . T he prestll\."t: 01 po~lur."a1 JbnOmla1i ue .. and po')lural tn:-mor .,hould ~'umeslled In'UlJlnfnl ~ lJn mclude lXhlUrt" g rid ,. plumb lll~ . .. nJl phol ugraph) \I,!lh lighl-em nung d iodt"'i.

re

Balance, Gail, and Locomotion ~

therilpl')! ... hou1d

t" " ~mllnC' '1~1I1l

dnJ J ) n3Jl1ll

and .s.ntll.lpalur) nmuol. ~e n ~\lr) IntcrJ(. ti OIl ..mu \ nt:J __ I~ljl. ~1r..t1~~.I c, l ,< I uJ lI1 ~ t rumelll'" lIll l uJ~ ltk:St ' ''tl('\

b/lt I.) . Hem 11/

Bu/ufI( t~

i\ \

d~ n"m ll

p''''luru~r;.trh) .~ • 7 f rJliT I

the- lhrg 8.41111l. t ' ~ ,"d', .VI ~ and tht:' Pt. ljtnItHlIt ( t ()' l f ll tt ~1 \.1(, /,, 111\ I HJmlll..lltO/l

Po H I G4JI

mduJ m

~'4J .smch~r~ dlld lh.u.H"len"l tll. ;) ,ht)uld be t" \,lnlUleO ~aJl reed b lll<."III.lIh.."I ,,>lahJlit) '-<Jil l) . dUJ

enJUI ~tk< r , .u11 10UHlllI . lf

p.ltit"lIh \\

he rnh""J"'-t'd rh r (Ju~h (I Mk:t

I.

Vital signs (heart rate. blood pressure. respiratory rale) and breathing patterns should be e xamined at rest and during exe rci se. Exe rtional symptoms (d yspnea. ele vated blood pressure. heart rat e, respiratory rate) and perceived exer ti on during and afte r ac tivity sho uld be documented. Use ful scal es include the Rating 0/ Percei ved Exertion Scale (t he Borg RP£ scale)97 and the Dyspnea Scale.'" v

Skin Integrity and Condition Skin integrity and condition should be examined . The presence of areas of insens itivity. bruis ing . mo isrure buildup. and skin breakdown should be docume nted along with level of urinary continence: bed and whee lchair positioning. effectiveness of pressure relieving compensalOry strategies and pressure-relieving devi ces (PRDs): and cognitive status and safe ty awareness.

Functional Status An e xamination of functional mobility skill s (FMS ). basic acti vities of daily living (BADL) and instrumental activities o f da il y livin g (lADL) is indicated along with social functioning : community and wo rk adapt ive skills. A commonly used instrument for patie nts unde rgoing active rehabili tation is the Fllf1( riOfWI I"depenl /ellce M easure (FIM ).'W,IOO

Environment (Hnme, Community, and Work) Ph) ~ical ~pace fo r b;lrrier~. access . ~afe l ) should be e :(amined : ;} ~ pecific tas l -analys i!' (patie nt perfonnance-based e\am ina tion ) in rde vant enVl ronme llt '\ ( hom~. " o rk ) may be mel uded h ee Chap te r I ~ ).

b.lLmce.

R.'.1(U\~

('''U t uf TI \l Ji ll

Aerobic Capacity and Endurance

Ilh )olgnlf'l.llll oil.l'u ,J

U~ 0 1 \1J cow.pt"d ~~rtHn n l ~ful t\""h uhlllih 11fJ)t·~ \\, .1IL h.-,I .. ( IO-mt" tef "' aU.

General H eaJth ~ ne ra l health Illc: J ') UTe.!t Jre u~J 10 ("(amine outcomes at rn., ... a broad ' pc!.:' trum 0 1 g.lo~a.l or long-tcnn Ilcailh outl,.;OI11~ ... , Ilh lruUl(' llh IOvoht! ~Ifvreport of the patlC'm 's perll.' pllon, 01 ph} 'h: ai 11Il\ltctllon and quahl) of hlr (t'.g .~ ph )!oica l anJ , , -,,, iJ.1 tUIl~Hon . gli."f1(.·m l heallh and Htahty. em<>l', n.u " . II · hclO ~. 11<)(111) p;1 111, and '" fonh l. The /l t ll llh ' wlm QUt'fllOntWIf I F _3h j hH IS \\- Ide l)" ~Imowl­ ~d~t"J 0:1::-, the gold ,Iandard of gcnt"nc mefl~U~s or hi:allb StJ lU~ Tht: phlpt"rtIC!, of tnl:-" IlbUUn'k:nt hd.\e been invetl" ~"'ft:d m pJ.1lc:'llh \Io lth ,tS Fre.trnan C'( !li lt)"; found limiutlion) In ~\ .!lu.J.un • i;han~~ m U\~dk iii) ~ere:t) dbabItd

792

PhysicaJ Rehabiliration

p
Disease-Specific Measures D i !'ea~e--speci fi c measures are designed 10 examine attrib-

utes comll1on in a specific disease entity. Items are included provide infonmuion aboul Ihe disease procc~s and out come~, and ideally documenl clinicall y meaningful change over ti me. llms the in~lrul11ents have greater res pons iveness or *JlsitivilY to change lhan general heallh measures. 10

Expanded Oisabilit)' Status Scale (EOSS) for Patients with Multiple Sclerosis In 1955. Kurtzk de\ eloped a IO- poi m scale for rating overall disabili'l in MS (the Disability Slatus Scale or DSS). to, Thh scaJe \\ as expanded in 1983 to inc rease its clinical ...en;;jlj\ It) b) including half-point increments. becoming the EDSS (Appendi, B).''''' This scale has been wide ly J.dOPfCd b~ cltnJcian~ and has been used to standardize MS rc:-.earch B ~ed on a siandard neurolog icaJ examina ti on. patients are first gradt!d on presenting symptom s in seven speCific func tional sy~tems includ ing pyramidal. ce rebel lar. brain~tem. ~ensol'). bo\\cl and bladder. visual. mental. plu~ other funcuon~. Functional sys le m scores (FSS) are obtamed u~ing an ordmal clinical rating sca le rJnging from (l to 5 or 6. The EDS is based on the grades obtained from the F S and ,",e- a 0 to 10 ordinal scale graded in halfpoi.nt IOcremenb. \.\ IIh 0 equal to normal neurological funcuon and 10.0 equal 10 death owing 10 MS . For e~am­ pie. pauenb cla~,lfied in EDSS step 1.5 demonstrate min IIllal dt 0 or I). The EDSS f()('u..,e~ on arn nu iatlOn ~ "i the prnnary Indi c~H or ot dl'.J.blilt) (-.ee ...core~ :to through 6.5 for le"el~ of ambulallol} pJlIen", "ILh 'K:ore~ 7.0 or grea ter arc unable to \l,Jlk l CntU:I~I1l') of the EDSS int/ ude 11\ lad. of ,en ... itl\. 11) to chJngc).. rhill do 1101 Include functiona l mobtluv lambul..t.lIun t Jnd problem.., 111 100errJler reliJbllll\ \\ lIil pI' Sl'K. lcty I h 'II .t lip \I, \\ \\ naIIOnall11nOCh! I)Orgl 'vI L CS r ~S "'P I h. \1'nirnum Rel~ '~K~It.·IIt:' 111 l(n~S "" fl ' I h '11, IIhlrUlH(,nt lit I It:e 'Uh:'lJ ln the: J D'l':. \\ilh rs'\ I I \fiJ'''1 \ I / " I h III 1.11'''' Ih '\ ( a, (\~I .:.lIlO th" fli lIfOJllfloJlul')!llllh )Iolt' 1 .) ) It I .l.ldt"h ll...c:J nd I' ~ 11 m( UuC ... dO .... ilII.Jllon l,ll.h ... IUJI.. IIOO ~.. (ordll\~' hi \\ ()I IJ Ile,lllh Or' (. n e"llI/.llIon tf'rmlllul ·

'~\ .,.><1 I

HIII)o.Il1l1len. I.h I , ' < I. b.thllll; tI~~ • ..1lhl hl1nJIt..,pt l \\) III · ISS 11Idu,k .. III Iklll II JJ l; 'AI I I I ),11 a\ rn~ hth\.lInoJI dhi.lbllu\ IH -, J II! I ...,~ n c "'. I Iu

fJ~~

Ih', IO"'lrulnt"1l1 .1ddrt'''l' ...

d

• .a lin:, !-o1.'<.ld

perJlJlllhtll\.'l. 1111.Iudlll!-'

work statuS financial .md economic status place of " . ' resi· dence. personal assIstance. transportatIOn. commu . . I .. S I ' '09 n.ty ass istance. and SOCia a~II:lty. 0 an ~l al exam ined the

validity of the self-adm'nlstered version of the MRD found that detennination of ambulalory ability, ADLSk~ and SOCial act iVItieS was both accurate and Cost-effective MS Functional Composite (MSFC) The MSFC is a 21-item tesl thai includes 3 different f tional subtests including the Timed 25-Fool Walk ~: FW). 9- Ho le Peg Test (9 HPT). and the Paced AUditory Serial Addition Test (PASAT). The MSFC Administr.!" ' '00 and Scoring Manual can beb 0 tamed from the Nali I . S · h 00. Multiple SclerosIS oc.ety at ttp://www.nationalmsSOci_ e ty.org/MUCS_MSFC.asp. Multiple Sclerosis Quality of Life-54 (MSQOL) The test is a modification of the generic Health Status Questionnaire (SF-36) with the addition of items relevant I people with MS . II omits one ilem in the SF-36 (graPhic";' resenlation of quality of lire) and instead uses a semantic differential scale. There are II subscales: physical health. role limitations due to physical problems (RLPP). role limitalions due to emolional problems (RLEP). pain. emotional weH-being.ene rgy. health perceplions. soc ial function. cogOItlve function. health distress. and sexual function. llo MS Quality of Life Inventory (MSQLI ) n,e MSQLI was developed as a comprehensive OUICOmes examination package by the Consonium of Multiple Sclerosis Centers. Health Scie nce Re".,arch Subcomrninee.'" In includes a battery of 10 self-report ~cales ( 138 items) that provide infonnalion about health-rela ted qualit), of life in MS . including Ihe Health Slatu;, QuestionnaIre (SF36). the Modified Fatigue Impact Scale (MFlS ). the MOS Pain Effect> Scale (PES l. Se,ual Sali,raclton Scale (55S). Bladder Control Scale ( BLCS ). BO\\el Control Seal' (BWCS ). Imp ••et "r Vi>ual Impa.nnent Scale (l\~SI. Percei, cd Defi e." Que>lionnair. (PDQ ). ~1entJI Health Ime nt ory ( IHI ) "nd Ihe I\IOS I\l odilieJ Soc.al Support Sune) (MSSS) . rhe batter) e,IIl be a<1min"terrJ In appro,, (lInalel) ~ 5 I1lITlUIC:-, III moq cJ'e:-. bbre\ I':H~d \ec· ..,ion, ot "'Oille l)f the' ,,,-',tie ... l.JIl redul-'c Ihe wi 10 81lfeoh re4Ulfing .lpPIO\IIllJICI) .10 mmute~ ro adnllnbter..-\ L . . er\ t\ l,lnual l' dfl ht:' \.,DlJ lned from hllp://"'"" 'l.tllonalnl~"'()l.It"I) . or~ t UCS _ ~ IS0LLI'~p

~:;:;".tional E,uminatiun

or \Iultiplt Sderosis (HMS) J-\ \/ <; " •• 'i9 lIelil ",..I" 01 he,lltll-rc/.lleJ qual", of "I, lllt"d ... UI\" df\cl0pt:'J b) Cdt} t"1 al II' fhel C .ire , '"( .. u~ak'''

1

I nUJbllll) . ') \" .•• • I plunh. c-JOotu.jl1.11 \\ ... JI-t\:'I11!.( l(kprt ..~lv' gt"llcraJ I'OlHl'UIIlI<.'III.

Ihlflllng/l~lllglJc',

.ut,-i

r~llll.ll) /.,o;'iJl

\locll IX·IIl!! ). I Ill' IIlI.ltuilt\ ,uo\o.JIc ~fmnglY corn'I.IIt's ~Ilh

Ihe f. lllll\.c· rDS~ ~Iultipl. ~<' I r

·

-

. I Inpuft ~"al< ( ~lSIS-29) I/l<' M\I, "I . I ·,1 .. I1llJ'Ult:' lhe' ph~'h.aJ .1OU fh)Lhoogi\. linp.tll uf "I" I l' . ~ tot he \l.,k~ \hh rnfH.lnl) dt·\dnJ.-=

. • 0'"

C h a pter 19 M ultipl e Sclerosis

793

BoX 19.4 Examples of General Goals and Outcomes for Patients with Progressive Disorde..-s of th e Ce ntral Nervous System

Impaci of patho logy/palhophysiology is red uced . • Palient/client , fam ily. :md caregiver know ledge and awareness of the disea~e. prognosis. and plan of care i~ enhanced.

• Symptom management is enhanced . ~ Ri sk. of secondary impairment is reduced. • Inrensiry of cafe is decreased. Imp3ct of impainncnbo is reduced. • Cognitive function i~ improved. • Joi nt inlegrity and mobilil)' are improved. • Sensory awarene·s'l and skin in tegrity are improved . • Pain l~ decreased . • Motor function is improved. • Muscle performance (strength. power, i:md end urance) I:' improved. • PosturaJ mn u ol and balance are impro\cd. • Gait and locomotion are improved . • M3J1agement of fatigue is enhanced. • Aerobic capacity IS increased . Ability 10 perfonn physical actions. tasks. o r activ ities

is improved. • Independence in actl\·ities of daily li\'i ng i ~ increased. • Tolerance of poSItions and activities is increased. • Actl\ it)' pacing and energy conservation are enhanced. • Problem-sol" mg and decision making skills arc enhanced. Adapled from tht' Gwd(

I,'

• Sa fety o f patient/cli ent . famil y. and caregivers is improved . Disabilit y associated with chronic illness is reduced . • Abi lit y to assume/resume self-care and home management is improved . • Abil ity to a... sume work (job/school/pl ay). community. and leisure ro les is improved. • Patient/cl ient and family knowledge and awareness of personal and environmental factors associated wi th worse ning of the condit ion is enhanced . • A ware n e~s and use of community resources are improved . Hea lth sial us and quality of life are improved . • Sense of well -being is enhanced. • Stressors are reduced . • lnsigh!. self-confidence, and self-management skills are improved . • Health. wel1.ness, and fitness are improved. Patient/client sati sfaction is enhanced . • Access and availabi lity of services are acceptable 10 patient/client and fami ly. • Quality o f rehabilitation services is acceptable to patient/clienl and famil y. • Care is coord inated with patient/client. famil y. careg ivers. and other profess ionals.

Ph) "'( lll TherapHI P"{/CII( e 1.\

communtt)-ba~ed population~ though testing with hos pj· taJ- ba~ed population~ (patients admitted for inpatient reha-

of functiona l o utco m es inc lude the works of Qu.inn and Gordon I L5 and Dittmar and Gresham . I !6

bilnallon . IV cortlco\teroid treatme nt for MS re lapses. and patJenh \\ Ilh PPMS ) reyealed con~ i s ten cy of p ~yc hOJn e lri c

propertle, .. ,

Physical Therapy Interventions Goals and Outcomes The general goab und oull"ome, for patlenlli

\~ IIh progrc s-

. . h·e dl"order!!o o11he <.-entr(i! nen.ou~ !o,y"tcm . adapted from the Gllide 10 Pln .)lCof Thl'fOPl l T Pru( fict!."l Me presen ted in Box 194 . The,t' gt'nnal gO'-ll, \AlII pruvH.le th e b:.J'>i'> fo r the dc\clopmt!nI 01 :, pet:lflc anlJupi.Hed goah and e)(pected OUltomcs for
!ioC"lenJ..,h IJOm lhe (JlIIdl ' f Of PJl\ ,/ui/ 'J "(' I.IIIHI P n/l TlU' I') ~ L. /mpllllfd M(I{or (Ullt f i liI/ IIlld Sef/\on I lIIe\?ll1\ J '1.,11 PW l! ld .\1\ ~ lJ, lordl' I ,\ 01 lilt' ('Pllfrul Nen'olO ~\\/IJm in liJ" dlll..·ufflt'nt ll.e reader "'til fll)(llt.:ie VaTU u,1urm.tllOn on Pi.lth: nt/tllt:llt dlagmi:-.ll c l l a ,) "IIH:~ltl {)n.

A U f.l( Itlt.

tell 4..( ' \1 \.odt'"\; e\i.Unmdlll"i!) (.(,n.ponent "l: LOlhldenltlo n ')

dl/J~nn"'I ' . lUld r1UgTlO"' I ~ ..tnd ~ u g}!c'l~d Thu ... the ( ,ulde ~n e" a", a pnrnar) n:"OUI"{:c h) help ph\l ... lcal thtrUpl ... h de"lgn. ail '"'J1plopn J. tC'" I'jen \t.e.., pHI' Ldtd and (tlltt'Ollle~ ~c:hll:"\{;.d AddilliJnJI re\uu lu.· ... II II e tk" 11\ C lkK.UIlIe-m..tlton

tUt f"ldluduol, II.teTH0I10fh

Management of Sensory Deficits and Skin Care Str;'lIl.!gic'i should be in~tilUted to inc rease ;)\o\!Jr('ness of ~e n",ol) defic its. compe n:-.3Ic for ~C"n'\ory luss-. and promote .:;ufet)'. It i, important to re member that sensory deficits ma) rcnw ,

')l)

o ngoing exami nallon to) llt.'L'C',\s ar) . T he sue -

Cc'~ of co mpen..;aror) Irailllog ~ Irat(".gie~ depends on the uV or) ')y" te lll s. For examp le. \ I~ual l·on1 1)(~n .. atIll11 lel:hnlllllt" ... '';In he in~Lllutcd w hl!u ddkll~ III pIOpnnl:l~ptlo" product'" imbalance and place thl!'

n . . k for tltl"'- if muhipk :-,.e n"or), y:-,.tem" are Ul\oh·t-·d (c.g., \ I'lon I.., .tho impam:-J ). !"ie n~ory l'ompcns3lory '>11.ttc:~IJ:'" J.l\: nOI !I~cl) to be ... uccc . . sfui.

pal lent

.It

Pali l:l1I \ \\ JIll plopri~.)I.:cptih' lo~~!!o demonMrme Impairil't.Illling. They reyuiro lrH. ri.'d'>l·d u\t" of other \tll-.ory '>Ybte"ms, t'~pcx.· 1U1l) vbiQIl. 'IJpplUg . \crlKII cUt'"IIl~. l..U1d/l.lr bioftX.-dba". ... ('"un ~\ll be effecmCIlI '" 111 nl(l\~'m~ 11I ~vJ1lml and llIoWr

II\~ hmll ... vf augnwllIcd

kecJbad.. Proprioccpu",'e loading

Ph )'s ical Reha bilitation

794

.. rl' ~i~ lance b:llHJS . r hi tracking rc~ I ... lancc. . ' . through C'x('rcl~C. 1£ . I _Y heigh ten r"~ ldu~'1 pro· .

or

.

'

\\ Clg hl ..... tn<

1Iht: u..,C 01 a .

.

roo Ill
prilX'cpti vf' fu nCtion and l~lP J ' II in terfere Vi:-.ual o .. ~

WI, .

.I

oVClllent and pm.lural

will III

. ' '.

.

II al ni -hi or in low li ght .. 11 -

cOlllrol. Blu rred VI,,?n. t:"'~od cl.1 y f orl~c neuri tis. II i:. ther.eoc ' ur 'Iller elm. t's 0 . I

U;1I10II". call l ', I at'ent in l11ainl:.linlllg a( erl 11 to 11l , tfud t 1e p. 1 . h ) fore IIJlpo· .. II . f '\ bright lig ht 411 IlI g I - I . . I all !lIllC" (e g. u..,e 0 • lluale II~ ltlllg a • . ." , ' r-" I Adding contra."" . 1111 ' 1' to Improve ,',.1 t:). and rl' J uem£. e l l , . I ( " ';:",i r l1larking~ ) can in (he r nvlrolll11Cn c ...... · • o

bcl\\CCn Jl e:~l" 'l fcl\1 Double vi..,ion i ...- ,he freq uent res ult of . . I ' I " be con ~ irnp:lIred coordi nation and \\'ea~ eye mu ~C es: ~ c'~n )011anl Irolled h) placlIlf!, a patch ove r Oll~ ~) ~ ;.lIld I~ ~In , }' I viq r'II CUV for improving reading. dm mg. or w.Hchmg Ie ~ >, ' ~i "ever. c\c patchi ng ~hould not be used all the !line ~~Olll\' l~ prC\CIlI 'po~'iblc adaplation ~f the C S. Eye pat~h~. inc al:-.o intcrfcre~ \\ ith dt!plh perce ption . The symptoms of \ .j:lI.J1 "'luITlng and double \ i, ion also fluctuate and can be hCI!::hlcned wi lh falig ue. an increase in temperature. sLress. and~ infection. Management of Lhese ~ymptol11 ~ can an important ~rralcg~ to Impro\c vision .l~ If low viSIOn ~~S l stS . the palicm . . hOll ld he referred 10 a low-vision sp,cclallst or ont' of the national service organizations Ihat proV Ide help 10 mdl\'ldual" wllh v i ~ ion impaimlems (National Association for Vi')ually Handicapped. Nati onal Federati on of the Blind. Affiem:an Foundation for the Blind). Patient~ wllh defi CIts in superficia l sensations ri sk damaoc 10 in"e n ~itive areas of skin. The development of o decubitus. uJccr~ becomes a major concern in individuals \~ith chronic. progre~she di ~e a.:-,e . Clw nges in skin turgor. ,,'JtIC posturing . and prolonged press ure ove r bony prol1li ~ nence.., JI1crea~e Ih(' likelihood of ~k in breakdown . Patients Illa~ nOI feel Ih e di~cOJl1fo fl of prolonged positioning or ma) be unable 10 !)hift po..,ition beC3.U ... C of we akness or "'p
tx:

-e relie\';I1~ del'i{.'es (PRD~) may be nccc,\sary." ~ . ..., vc areas and should be Implemented as protect IIlSC. 'l"iti " . Th c ~e can IIlciude maUres5.CS (water ge l . appropriate. ~ . . . , aIr ~r alt ernaling pre ~~u~c) ~o d l slnbut~ ~y w.c ight and rc{UCC s-hea< r ~'lnd fn ctl on In bcd. Shec p~klll s , aIr Or fn-:._ ....... 11 I cuff>; and/or bool ~ may be nece ... sary to prot c u ~ Ilion.... . ect bod y arcas prone to breakdown (shoulder blades, elbows. ischi al wberos itie5., sacrum . tr~h ant~rs , knees, malleOli, or hcels). Cushions (foam : nUI.d o~ air pressure-relieving cllshions)
dre ss in gs).I ~

Management of Pain The manage me nt of pain depends o n an accurate delemli· nali on of its ca uses. Mu sc ul o~ k e l etal strain or joint malalignmc nt from chroni ca ll y wea kened muscles are important co n side r:.tti on~ and arc res ponsl\f' to physical the rapy inte rve ntion . Patie nb ma y ex paic nce relief of pain with reg ular Il trc tc hin g or exe rc ise. ma~sage. and ultra ~o und . PO~ lural retra ining ami correction of faulty move ment palle rn , alon g w ith o rtho tic and/or adapt ive ~ei.lting J ev ices can red uce l11 a lall~ntllcnt and pain. St3bhlll g pain froll1 Lhcrmith::':-, ~ign n;ay lx' relieved wi th a ... oft I.:u lla r to limtl nec ~ flt'\ion . l-h drOl herap) or pool thc rapy U'll1g IUhf' H'lIrm \\ ~It c r lila)' ha\ l' a beneticilll efi ef.: 1 nn palllfui lh ,C',th l· . . i.t... . PrC'3l1rC ~ t lX~ing3 or glove:-. 1.' •.111 lIho tx- u... ~d In rl"lll!\ C p~lIl1 , con\t'ffil1~ the ~t"n' "'.Ilion 01 p~1I1l 10 one lIf prc'", urr . NI..' tltral \\ann lh t1uy be .I LlI..,tol 111 Iht.: p.1I11 n:IH:t c\pCnenl.:l"ct \\ IIh ,wd.lOg!t or glll\ ..::", P .l1l l' l lI ... \\ nil l.'hronll.' )1,1111 will hl..·Ilt'lit fmm ft't~r. ral It) .1 tolal InJIl.tg..:nlt'llI .Jppn.),ll'h for chronll.· pain. for l'\,tlltpk' , the mU/lleI,,! Ip/IIJIII \. [>4I1n chlll(, ('::'~l' Ch.1plt·r ~){J ~Irl> ,)' IndJlagl'III~lIt tt'l· hniqu(! .... rt'l ,I\ :lIIon tr.Ullln~, hhlll'l'dhad\ rlk·dll,lIll111. ~Ind '0 Inl th .If t" lllten hdpful 1l1 n.:dlJ\.Ill ~ I'l(\th .I11\ll't\ !lnd p.llll. I hl.' lhl~ ollfdn,(UIJIl~(lU~ l: ln tl llJI Ik'l\l~ ') llllltll.tIIUli t I E~r..; ) III nluliul.ltt.' p,lin]ll P,HI\,:lIt, \\111 1 1~\ I .S I1.1" h.ld l ' l)llllh,:tIH" rl"lIll" \\111" I \Iltt' pata' llI ...

t

>

• '(1)C• 11l:lh uig

ul ") IlIpit)IU .... I '

IlIlprO\\.· IIl~1l 1

e o . UlA ,uHI ') \.II1I'-' .t \\I)(:O>l.:ll ..

C h apte r- '9 Multiple Sderosl5

Exercise Training Muscle \\caknc:ss a nd

d l·~n.·a~c d

cndu ranl.."c arc

(, 1l1ll11l01l

tindill~s in p~t li ('n l s with MS . III addi li \..'Il . patll..' nl s wilh MS

oneil ~Idopl a sedclll:uy lifc~ l y l c and lilll it Illl'if' physi c,,! 1I(:li"il)". !'olllt;"limcs (lll Ihe llI i~ la"c n advice of hea lth care rofcs!'iollals \\ho sec.'!.. 10 minimi ze rdap:-..c .. and sy1l1Pp -,- lhc - be n t' l -ll~('1 r exercIse " - ,y loms:offatiguc. ):IVl' lCcllllnn established in 11.:' 1111' ('If pf(l(lm:ing meaningfu l ph ys iologica l ;lnd ps),chologi c:d c ha nges. illlpnwing fUllL'lioli wh il e , " ,l~IIlClllg ' lessening dl:-~lbdIlY, ;Ulljen qua "11) l) t , , 'I,'c. 11 1 p~ . InJiyiduals \\ ilh minil1131 to !110da'l1e impairmen ts ( i .c .. EDSS :O;C(1re~ tx"' , Wl'\,.'1l I :tnd 6) and stahle di sl~ a sc demon -

strate the best l',\cn'+.. t' loleran c(', This :-opcah 10 the need (0 inSlilUll' exerci~(;~ earl) in Ihe ('l)urse of Ihe cli sea~e. E"erci~(' rl'~pt)I1!oOt"':-' of the palielll \\ ith M S are inOucnccd bv a hosl of f::letur:. Ihal require careful atten ti on during e~ercisl". incilld i n~ fJligue. ~PJsti ci ty. iIKoord in~H i on .

impaired bab nce. :.t'Il:-ory 10:-:. and numbness. tremor, and he,H inlOkrance. Deprt's~io n ma y affect adhere nce. Therapl ~b therefon." need to provide con slant reintorce· ment and a po'iiti\"c environment. Box 19.5 present s a summary of re"earch on Excrcisl' and Multiple Scfaosis.

Strength and Conditioning Max imal 11111:.cle for(.~e during suslained isometric or isolinelic c\crcise is lower for per~ons with MS secondary to reduced Jbilil) 10 Jl' ti\'atc mu scles (redu ced force/un it muscle ma . . ~). reduced mu scle metabolic re sponses. and muscle \\eak:m'~~ !-l"condary 10 mu scle fiber atrophy. spasticit). and di suse. 11ft Detem1ining an appropriate exercise prescnption to improve !-trength ;,.II1d e ndurance is challenging. and need ... to be ca refully ind ividua li zed for e ;Jch patient. Pre:-cripl ion i5. ba~ed on four inte rre lated e lements: frequency of exercbe . int e n ~ ity of exe rcise. type of exe rcise. and lime or du rati on (the FI7T equo/ion). The (ollowmg gU ideli ne... can be u ~ d I1"7 1'::11 : E xe rc i ~e I)e,,~j()n.,

. . houkl be :>.cheduled on

a lt c.! fIl31 c.!

(non -

enduram:e l di.l) '1 and during optimal ti m e~. ~ u c h as in tht!

morning. v. hen body core temperature ... tend to be lowesl and before fUlIg.ue ,:>c l ... jn .t':: ~ PattenI'! wi lh gr..:alc r neuro -

logic."l involvement ma)

r~4uirt!

morc Ircqucnt exercise

(e.g ., dall y e>..erc, ...c tllne)

Subm a>'lInai c>.l~ r(.' i:-.c intcn~j[it'.., (I1ltltk r;Jl c inlcn:-'I tl e:-. 50 to 70 pcn.:ent MVe, IJrc IOler-ated . w herea,:> rna >. ima l exerCI'ioC 1'1 gene rall y n{)t v,ell h)k'ra tect . l17 Re~iMan{;c Inllnill~ mode ... lan lIlc lutk weig ht Illadlim: .... free 0 1 pulh:y we lghh. c la ... til' rC\I''I lanl'e hand .... (lr i..o l-.I ntlK Illdl-hlnC\ . I 1"1 /III

C'ir(uit tr.tllling. In WlllL'h imjJlovcd worh. l"apa<: ll y I... dc\-clopcd through th~ U't: of Vi.l flOtl ') dlrkn: nt ..,la!lOlh

lhat aJLt r n~te wurl-. hetween up!'k' r .Uld lowel c~ lrclllitic,. dhlfibUle~ thl: h.Md amnll g IllU ...t k'" and ilia ), pi (lve he . . ' tor rcc\ulIng.lhc Itkelthoull (II 1;t\lguc II I! Sc..,~i()nb ~h~,uld IIl vu lve d l...conl llllwu, work. l'ardu lly blJlaflllng CXtl l.l\.(,· Wit h " dt:~uaH." re"t penud:-..

795

Progn:s:-ion is generally ... Iowe r than wi t.h healthy indi ~ vitl ual .... 1!7 Prcc:llltilll1'i shou ld he taken 10 prevent the deleterious d l ccls of uverwork. Exercisi ng to the point of fatigue is contraindicated and can result in worse ning of symptnm s, most notabl y incre~l scd weakness. This Illay hnve add it ional ad vc rse e ffec ts on the conti nuing motivation of the IXlticnl. 1!1 Preca uti on:-. shuu ld be taken to monitor the cfrccl~ of fati gue. "li"1II(' -to -{aligue vari es grcall y among individuals with MS and is 1/01 correlated w ith the level o f ph ysical impainne nt or di sability.126 Preca uti ons should be laken 10 mann ge core body temperalllre and preve nt overheating . Environmental lempe raturcs should be carefull y controlled. Air conditioning is ..I medi cal necess it y in man y climates. Additional cooling can be achieved through the use of fan s.'~l wet nec k wraps. and spray bottles for misling the skin with cool water. and imme rsion in cool water with aquatic exe rci ses."S.120.111.11!UN Surface cooling de.vices have emerged as effec ti ve tool s in managi ng body temperatures. controiling fati g ue. and improving function. These include coolin g suits lJCl- 1J2 or vests.IJJ Precauti ons should be taken with cenain impainnent s. Tactile and propri oceptive losses or incoordin
COildit.ioning

Indlvi liu:JI "i wllh MS dt' 1l1onMnth! l·x.pc('led physiological n.·... pol1 ...e~ tu ... UblllilX.lIllUI :It,'nlbll' excn.: b.e. thai IS. heun

rmc (lIK ). blnoJ

p1'1.:1'o\1I1"C

(!JP I, W1U

~\A.ygl·n

fl,'"

upt ak" (Vo,J )

, '111/1"'114(1) 1m

I"',e( M )

796

I'hysical Rehabilitalion

Evidence Summary Box 19.5 Exercise and Multiple Sclerosis R('fl·r('n('(.~

Suhi("clS

While, LJ, et al' t7

2004

8 subJecls wilh MS, mild-mod disability; EDSS scores between 1 and 5; baseline 8MI = 27°0 (overweight calegory)

I>,,,ignl Inlent.>nliol1

fluration

Results

('omment ,

Nonrandomlzed, cohort design

8 weeks, 2x /week

Significant it in strength of knee ext (7%), plantartlexion (52%) Slepping performance it (S.7%); fatigue 1i on MFIS (24%); self-report disability (EDSS) 1i from 3.7 > 3.2; no change BME; no MS exacerbations reported

Lacked control QrOl4t, RT resuned in it ' strength and amboAatory function; AT is a safe, well toterated intervention; small sample size

Resislance Iraining (RT) progressing from 50% 10 70% MVIC; Oulceme measures: MVIC on jsokinetic dynamome-

ler, MRllhigh muscles, body composilion, 25-ft Walk Tesl, MFIS, EDSS

Surakka J, et al llfl

2004

95 With MS, mildmod disability; EDSS sceres between 1 and 5.5; exercise group :; 46, Non-exercise group = 48

Randomized central trial 5 supervised resistance and 5 aerobic exercise sessjons; aerobic exercises in pool (temp 2S-C), 65-70% age-predicted HR"",; resistance training (AT) = circuit training UE and LE Ms, 50-60% 1 AM; home exercise program (HEP): AT used elastic bands; aerobic training, walking; subjects kept daily diary;

Supervised exer· cise = 3 weeks; HEP = 23 weeks

Significant 1i in motor fatigue in women (n = 30) but not men (n = 17) after 6 months of aerobic and strength exercise; exercise actiVity of women was 25% more than men.

Long Iraining period (6 months) may have masked disease progression, eSpecially in men, Men more likely to have PPMS then RAMS.

Outcome measures: Ms torque (dynamomeler), Fatigue (FI, FSS, AFIJ Mostert 5 aoo Kesselnng J'" 2002

37 subjects With MS, mdd-mod dlsabrloty, '"patten! rehabllnatlon EDSS scores between 2 5-6 5. MS-Exerclse group = 13. MS-no "'tervent,on group z 13 Healthy con. Hal group 2

Aandomlzed central tllal

4 weeks, S'
AerobiC exercISe training. leg cycle ergometry;

30 min sessions

Oulcome measures Max GXT, tests 01 lung lunctlon (FVC), spaSticity LEs (mAS), EDSS Baec, AClivlty Queshonnalle Sr'36 Health Survey FSS

MS training group it aerobIC Ihreshold, ImprOved health perceptlon (Vitality it 46°0, SOCial Interaclion it 36',), it actrvIty 01 level (17',) lendency lor less tatlgue MVa ar", lung fUl1ClJOIl did nol cnange

AerobIC tramlng IS safe and Improves aerobic capaCIty; symptom exacerbatIOn lower than expeeled (6'.); compliance of MS lrallllng group was low 165',1 Stresses need for molivaltonal setlong MS pallents tess hi than heahhy cootrot. tnOIe d;sabied MS pall"r", lrnPfO'ed mor. Ihan less lied pan.ms,

'"

smJff sample Sl10

-

Chapter 19 Multiple Sclerosi.s

797

EVidence Summary Box 19.5 f..x eCCise and Mu ltiple Scle rosis

31 suotects

,..Itl pri.

I~n.' .. u"")

NooranOOn'uzed. cohort

12 weeks,

mal)' or secondary

des'9"

p'<>greSSNe MS

AquatICS exercise program (waler temp. 83-85 F) Includmg aeroboe. slrenglt1. balance and fle>Jbilrty exerctSes

2x 'Week, '·hour sessooos

SIgOlficant Improvement noted in

Aquatic exercise appears safe in PPMS and SPMS;

domains 01 social functioning (SF·J6, MSSS) and fatigue (MFIS)

lacked _rot group; small sample size. 19

subjOClS compleled Interven1lOn: ,2 indI· viduals withdrew from study; 6 belor. any participalJOn and 6 during partK:lpaflon due 10 multiple rea·

Outcome measures Sf·J6 MSOLI

sons; bamers to exe!t1S9 need to be anllC!paled

---$;JI!le"'",.a

-..'

SIoo>O 1.\ " 2'JC'

G

"""

22 soJbf9CtS w1t!1

liS MIId·'1\Od dis"{ EDSS o! 5 0 01

. IlO-weaa!'

~ ll'0UIl el~

ij'OUIl •

"

&

"

.

RandomIzed control trial

,0 we...

£>e:asa 1"",",,1IOn.

3A week

E.ercise group ft III physICal fl1ness (nol

..ro-based ",'ghl ~"''"9

45 fTII1 sessIOnS

Sl!JllIficanl);

wat aerobecs water /099.ng C>.l1como 1MaSUre5 Subow GlCT. HROOL

FIepor1ed t energy and vigor. mood, bet18< SOCIal alld seJaJal fuoctoOnJng, leSS bodto( paII1 and ta\JgUO

E,ercJse improved psychological heaI1II and quality of life; use of water·based aerobics can be eHecIlV9 10 patients with US who Ita"" spastiaIy and coordI1aIIor\ deficlts, smaI sample SI28.

~~.

~ ccnI!CI

EOSS~

AortlOc UaJIWIg oomboned leg alld arm lIgM18!ry

, ontI ••

Outcome '"

-..,.,.,

-

~- 2

:tal

Sognificant flO "0, mall (22",). WOI1
strengtn. 5'9fldJCan1 • 10 wlfoId& ~ . endeo. VUll . sqlJ\canl • 10 POMS de!>
"!1'fat\! IIlIOOill I!'actaon IffI080niiiII ~

blCIII SIf'

_ _1QIO _

Exetctse 1raInIOg mpIO'Ied fiNos aI1d had a large, posi1I\'e mpact M quaiIy of

.,. -.:

SInaI sample lIZe. 7 palIInls .~ ... 1Oed an exaceroatJOn ckIr· Ing IrWW1g (4 _

.

ase 4 non-e_): cooing Ial9tt_pIIl'<1Oed "'"

EOSS ~

. .,. ,. _0IId bIadUtt

b

stU..

59*>'"

II ~O.

2O'Ao AAt! 5"

<X1IIt1li gr""" ~1

_ .... . . ., Il0l., '" _ -_tn_'II.............. ""'''E_,..,."",

~"."...

..-

Sf"'"

COGI\IIg~"

198

Ph ~"SicaJ Rehabilitatio n

Evidence Summary Box 19.5 . d Multiple Sclerosis ExercIse an

ponidltera· Mulcare, J, et aP24 t99t

to subjects with MS (6 temates, 4 mates), mild-mod disability; EDSS scores of t-4.5; matched

to 10 non·

MS subjects (age, gender, height, weight, exercise tevel. litestyle)

t<. n,;n .....)

Nonrandomized, cohort design

Exercise testing with arm ergomell)' (ARM), leg ergometl)' (LEG) or com· bined LEG/ARM), discontinuous protocol

3 tests using the

different modes, 72 hours apart

V0 peak. significantly 2 higher lor non-MS group lor ARM and LEG/ARM tesls bul not lor LEG lests; HR dunng ARM , LEG, LEG/ARM was ~.

GXT,

89%, 86%, and 91 % of predicted HAmal lor MS group: 96%

V0 2 peak

lor ali, non-MS group.

Outcome measures:

Combined LEG/ARM design may be • """ effective testing and training lor pafienIa with MS; used fOQrn. bent cycle efQOmeler with bacl< support; Ilo and heel straps lor legs; separate IIyohea lor arms; distributes exercise load better.

HR~

bod~ mass ind~x: ED S~ = Kurtzke '. anded Disability Status Sca le; FI =- Fatigue Index; FSS = . Fatigue Seventy Scale, ~fT Graded Exercise Test; HRQOL = Health-related Quality of life: LE ~, lowe r ,extremity, AS =- Modified Ashworth Scale : MHR = maximal heart rale; MFI ~ = Modified Fatlg~e Impact ~Ie: Ms =- muscle ; MVIC = maximal voluntary jsO~elric contraction: PS'MS = .p.roflle of .Mood States: PPMS = primary progressive multiple sclerosIs; R ~.M S "" ~elapslOg re ml~ln? mul~ple sclerosIs: SIP = Sickness Impact Profile; 1-RM ;= l-repetltlon ~axlmum contracllOn. UE - upper extremity; VLDL = very-low-density lipoprotein; VOl max = maximal oxygen uptake . AFI =- Ambulatory Fatigue Index (500-m walk test): 8MI =

""

all increase in a linear fashion in respo nse to inc reas ing workloads. Respiratory responses (res piratory rate rRR] and minute vemiiation) ruso inc reaseY6 Howeve r, HR and BP responses may be blunted secondary to card iovasc ular d) sau tonomia. 1~.1J7 Reported inc idence of these changes has bee n as high as 50 percent of pat ients with MS . A direct relation ship exi sts between the d urati on a nd extent of disease and the likelihood o f autonomi c cardiovasc ular dysfunction . Patients with mild di sease Iypica lly do not exhibi t these respon ses. whereas patients w ith s ignifican t long-standing di sca~e are much more li kel y to de monstrate autonomic dysfuncl!on, nH Pati ents with MS can also demonstrate respiratory mu scle dy sfunc tion (weakness, d: '\~)'n~rgia). contributing 10 reduced exerc ise to lerance . I N b .ercise tolerance and maximal aerobic power (Vo, ) ~re reduced in indi vlduab wilh reduced cardi ores pi ra·t~~y fl\ne~!. secondary to ph ysical inacti vi ty. Decreased ph ysica l "ort.. capaClI ), d e.crea ...ed v ita] cil pac Hy. inc reased heart rate at rest and in re~pon .:;e to exc rcbc , decrea~ed musc ular ~lr(' n gth , I nl.rea~ed fallg ue, incrca..,ed anxlc ty. and dc pres~ I o n arc Common rindjng ~. Det t: mwlIn g an appropriate exC fi: lse pre~Cnpt lOn

l (l

IInpl O\t cardlo\ Li ,>cular condH ltJllin g I ~ t halle ng.ing and

;leed:o.. to lx C~'clul ~} Ind ,v ldualll.cd tur each p;'luent The 1'01ow mg glmiehne!l 1111 l III/wal eTt'I C/) I' I n/ill g t J.Jl be U <.,cJ .I ~~ lllf pre1erred mude 1<" t:! lIhel all UpI Ig ht or fc-l.: uml~1l1 h.: ' c~c l

g

. c ~rgomekr A relum be nt 1.1(;\ Itt.! I!> Intil U.lIl!d II :-' 11 _ tm g bal ante 1\ IIlIPilU t"d ('Olll bltlatioll Itg and arm

lit::- t' rgUllletl ' .) 1I),I, Y t~ II t'I...: ....... "r) \\ Ith II1cr": oJ.'rt.·d I r 1 I • . - II \(J \t' lllt:' nl. I c~c I, lqh dlH.l ll{'d .., t r'lp~ lIi"I..'

ergOlllcl ry or

recomme nded to co n trol foot p lacem e nt especiall y in pat ien ts w ith spastic ity. tre mor. o r wea kness. Pe rfonnance me as ures inc lude: H R. ratings of pe rceived

exe rt ion (RPE). BP. and ex pired gas analysis (VO,). Us ing th e R PE sc ale. pe riphe ra l e xertio n is consistently rated as mo re stressful (hi g he r) than ce ntral exertion. A contin uo us or di scont inuo us p rotoco l (3- [Q 5-minme stages) can be used ; the di scont inuo us protocol is indicated with sympto m ati c di sease. especially fatigue . A subm ax imal test sho uld be used, Most individuals with MS can ac hieve 70 to 85 percent o f their age-predicted maxima l heart rate ( H R " 1:1..( ). Recomme ndations for inc reasing workloads for each stage are: 121025 walls for LE work and 8 10 12 wailS fo r combined UE and LE work . 12;'1 Te rminiltion crit e ria include achievement of peak: HR . fati g.ue. ~ igntfi cal1l BP c hangc~ (S SP > 200 mm Hg or DPB > 11 5 mm Hg or a hy poten-,i\e response). or a dl:':crca~e in o \ yge n upt ake wi th in('l'ea~ing \'ork rate. Precau ti ons ... hould he takt'n to m oni tor fo r JHCnualed HR or BP respnn~e ~ during t..' \eIc i ~c . Pft'Ctttltio n ... ~ h oli id tx- takt'll 10 manage rore body tent[)Cnll u l'e and prl~ wlH overh('..lII1l I!.. PrCCi.lut!olh ... llOuld be (" kell I~ monitO r the effe(ls of lali g ut' . Prl'r Olutioll ...... hOlJlJ be Idlen IO prt'\l'l1I the dek t~riOU.'i t' ITecl'I of in en, or" Prel"~HI\IOlh ... hnu lJ tx: IU ~ CIl \\.-lIh c~ rt'lin medication.s th en ~:an d lf~I..'1 r~!)ull" . Allla nludi l\l.~ He l m~t\' lempNaril) I c duL'C tatt g ut..·; hador~ n ..lIld lllll i lriPl y l il~le- riC l I1Ui) t.'au \ l' mU"l.' lc V.1:l.lklh: ~ "' : pn::'<.lI l1sone l' dll al..,O ('au"t'

ChaV1~r

mllscle \\ {"nl..ne:o.s al o ng \\i lh reilu(:eil :o. \~·e a t in g alld hyperlension. ~,i onl i ng is the o plil11 nlti mc rO T teqing. Ind ividuals \,j lll :- tllble M S appear 10 be good ('andi tmining bt.·(· E\ idence S um mary Box 19.5). Prescri pti on i.. agai n ba~{'d lHl the four inte rre lated elei1l cn t.s of the FlIT equ atio n. R e(·oll1lll(· nd;.lI ion~ fo r C\t'rc i ~e program mi ng 10 improvl;: cardi ova:o.c ul ar ('ol1di (ianing incl ude p~ -'. "" - : d:IICl'o for e.ll' 1r ;s('

19 Mult iple

Sclc ro~ i s

799

ell! Ih at provide" add ll ional Hllportant bc n cfi t~ of re lax ation and hal am:e I rain i n g.'~·' (ion iomc lry is an appropriate o Ul co me measure .

Manageme nt of Fatigue

mon iloring difficult). teSls of lung functi on (FYC). body

Fat ig ue is o nc of the mo~t de bilitat ing "y mptoms o f MS and is cha racterized by overw he lm in g sleepiness. exces, ivc tiredness. and sense of weak ness that comes o n sud. dcnl y and severe ly. Ave rsio n to activ it y for fear o f bring ing o n fa ti g ue is a lso commo n.n The resu ltant lowered act ivity Ie\'c ls have impo rtant imp licati o ns fo r dim inished hea lth stalu s and d econditi oni ng. Therapi s ts are faced with a ba lanc in g act. o n o ne hand prescri bin g exerc ise. wh ile o n th e o the r hand avoi di ng ove rwork a nd the develo pme nt of fati g ue. 14 ! Ae robi c exe rc ise train ing (p rev iou sly discussed) and ell e,.~y eJfecrh'e" es!i srraregies (£SS) are central ia any in terve ntion pl a n to lessen fati gue . 14 ;.\ Pa tients are o fte n inslructed to keep an acrivity diary in w h ich the y record how th ey slept the n ight before , dai ly ac tiv ities by hou r. and how cos tl y those activ ities we re . For e ac h ac tivity. they ca n be asked to rale the ir level o f falig ue (F ). the value o r imparlance of the activ ity (V ). and sal isfac tion perce ived wi th pe rfo nnance o f the activ ity (5) by ass ign ing a num ber between I and 10 with I be ing very lo w and 10 be ing very hi g h. For examp le . the ac tiv ity mi ght be fi x in g lu nc h. Scores reported for th is activity mi g ht be F = 7. V = 3. and S = 2. Aggravati ng factors associated wi th inc rea sin g fatigue (e.g .. heat stress) and MS symptom s th at a ppear o r worse n d uring the day are a lso recorded . An MS Daily Acti\'iry Diary is presen ted in

composition. RPE. fatigue ( Fl . MFIS ). fu nct io na l sta tu s.

Appe ndix Ct43

:md quality of hfe measures (HRQ L).

Based o n th is information. the ra pi sts c an ini tiale training sess io ns. teac h ing e nergy e ffectiv e ness s trategies. E ne r g}' co nservation refers to the adoption of strategies tha t red uce overa ll e ne rgy require me nts o f the task and overa ll leve l o f fa tig ue. These c an include modifying the tas k o r modifyin g the e nv iro n me nt to ens ure successful comple ti o n of dai ly activities. For e xample. a mo torized scoote r o r powered w hee lchair ca n be conside red fo r communit y o r ho me mo bi lit y to he lp conserve energy and m a intai n inde pendence. O the r mo bility equipme nt ~ uch as wa lkers. and c rutc hes , o r onho ti cs ca n a lso be cons ide red . Act i\ itics lhal are di ffi c ult o r have hi g h e ne rgy needs can be b ro ke n down int o ~llmpon e nt pa rts. requiring accurate tu.: tl v it y ana lys is. i\cti\'it y paci ng re fe rs 10 {he ba lanci ng of alli v it y wi th re-.t pe' riocl s 1I1IersPL'r~cd th.rougho ut the da) . For Ihe patien t \A. II h chroni c fa u g ue. ,.t'~/-aL'li\·"y ratios are developed . with p<' n oo lt: rest pe no(b planned in ad vance . 'l ill Ie-Out s \\ Ilh comple te r~r-t ~hould be in~ti llltC'd If an :ll:lJ vi IY becom e.., cx hauli tive . Overall leve ls of e ne rgy G ill tx, Impruved I f palle lll s learn t1l1'ltl priori tie s and limit the ir .lcti\J t ie~ .... a\, 1Ilg thei r e ne rgy fo r those activities thai ,Ire lruly imporHtIlt 10 tht'm (e.g .. u~tlvi l i (!S that are enjoy"ble <.1.11(1 mt":l l1lng lul III t\,.'fIllS of the mdlvidua l's lifestyle). 1 h\: O('l UpottJ (l11 a llhe rapl :.. t addres~t:' ~ BES and can provide

• Recomme nded IT;lini ng frequenc) is Ihrcc sc~:-. i oll s/ \\eel... 0 11 :l ll em~lI e days . D:.Ii ly exe rc ise at 1 00\(~ r leve ls o f intensity is recomme nded fo r individua ls wi th mo rc li mited c;\ercise ca pacities (c.g .. 3 105 me ta bo lic equi va lent

tMETsj). Trainin!! inten ~i t y ... hould be li m ited to 60 10 75 pe rce lll peak or 50 to 65 perce nt peak VOr I~I> · n 'pe of exercise c an incl ude cycling. wa lkin g. :-. wim I~i n g: . or water aerobics. II)!, Ilq_I~4. 140.1 41

HR

· Circuit training Ill ay prove ixs t for opl imi z in g trai n in g. • lndinduab \\ ith balance prob l e111~ o r se nsory l o~ s w ill reqUire non-wclghtbearing act ivities. • Recommended duration is 30 mi n/sessio n o r fo r m o re lIl\,oh'ed indi\ iduab. three J O-m in sess io ns/day. · E"erci se precaution ... : discu ssed in pre vi o us sec ti o n. · Depres sion 013) affect adherence requ iri ng constan t s uppon and planned rei nforccmenl for the pa tienl. · Outcome measure, include g raded exe rcise test in g (Gh'T)' HR (\A. hich may be di ffic u lt to mo nit or w ith d)s:wlOnomia: ~en~ory loss in the fin ge rs m ay make se lf-

PalJem edUl' alJOn i ... panic ularl y important as the overall success of a fi{ne~ s program i ~ in flu enced by the indi \ idual' s level of understandi ng o f the ba.... ic princip les of trammg . mdependence In -.e lf-mo nitoring. and s ).. ill in deci'lon-ma)..mg relalJ\e 10 leve l o f Impairme nt and exe rC)<;e mO(iJfi callon~ required . lifc:o.ty le. and gene ral heahh and 'iafel) com iderltion .... !41

Flellibiliry Exercises FleXlblht> f.'> tre tLhlngJ and ROM exe rCI<;C~ are nece..,s:.try to tn.., ure adequ:ue JOInt ROM and 10 counte rac t the effC'ct~ OJ spasllClTY Sedel1ler ... on'i who a rt' dependent on y.heek:ha lr~ olten de\'e lop tightnt:s ... In hlp fle\or.." adduClOf>, ham..,mng."). and heel cord I:.. LIITIlled o\'erhe.1d ROM i~ \een \A. IIh IIghulC'''' In lht: pel:lOrah ... m::'JOT/mmor. •md bl1"'''lmu~ d(lr ... l and h a,,)~oc lated \I, llh a )Jumped for\.\, ilId po"tlJrc P:.ttl enh ('onfi ncd 10 bed I) Pl cilll~ pre'!loCnl \A. nh ttghlOe", III hlp/ knee l·);. len~Or'li and plJ,n . larIlt,,,, Both PROM ,",d AROM e,erl"," ,hould be per(lIOllcO di.ul) lor ...hun pt'm.ds. Suppondi IlO' llJon" ('>Collcd or I}Ulg ·mn) .Jlollid be u!,ed to dc:(rc.a-..e IJ1<' IInpad oilMI .ilfM,.t problem!>.. More ,K U\.t! rallellt ... may hcnc lil Irllin TIll

800

PhysicaJ Rehabilitation

work ~ impl ifi Hdua~h.' ~U!!gC~tl0Ib In l emu, ('I p ~ nm ng .. . . ' If'" c1opin£! Clll'nn -ctTiClcnt acttvHIC' ; ; fo r se d rl ~311 1 1O. an.. ~ _. b I' . ~':u-e and home rn :lIl agcmt nl. T he YOCallonal. re ha I 1I~t1 on ('llunsclor (',m provide u ...cfuJ ... lr:lIcg ie:-. for be havIOra l modifinll1on and \OC3lionaJ rc h3bi litation. ,Team effort s \\ lth [he ph) >oIc,,1 lh~mpi!lt and others arc m)porta~l. ~or . I "'n~\ and n."mforcemenL Week l y re\ le\' of act ivi ties \,.·l'I1" .... t: l . • . , ' I evalua te "commenlied modlfic:HlOO';; IS U ~Cl 10 :m d r t I rro~IT'!'>:- . The MFIS ,hould be admin istered on , a rcgu aT ba~J5': 10 mOlllwr ongoing faugue ... IaIU ~ (Appcn~l)' A) . The OTJPT leam should l'omplclc a direct clwlTonmental e \Umlnath.10 urlhe home and/or Job o;;ile (sec Chapler 12 ). ~ number 01 adaptallon:-- may be' con~idert'd to improve etlle len('\ and -"<.Ife!). includmg air-cclOdi tloning. home or work modification,. or ergonomic cqUipmenl. TIle patient/famIh IC3fCl!I\eri ,hould be educated as to the 101portanCe of t~ ~('omm('ndJ(,on ... for Improved function. Periodic fe\ I~\\ of eqUipment and em lronmen tal modifications is fl

'

l

Jho recommended. Dunne a.n ac ute c'\3cerb.'u ion. the patient "" ill fare be tler II he ~r ,he i, "Jlowed to rc~1 for a fe\\ day .... Allowing the palien! to conllnue the '.:lme le\cl of exerci~e or ambulallon I" not help1 ul. Therap~ can be reinstituted \\ hen the deterioration h3.;" ~ tabiJiled and no ne" S) mpLOms are appeanng. The focu~ and pJce of therapy must be readjusted a..:.::ordtng 10 the patient's !opccifi c abll iues and needs at thOit lime F maJl~. "'(fe'... management technlque!
Manage ment of Spasticity

to remember ,'- __ inutes or hou rs. II is important lasts for m . . ., ....

"t'.,e'lt' m. p . . . particu larl y those . wi th Intact. sensation• "IQY reac t to the un pleasant sensa tion of cold wllhflg ht or/ligh' (autonomi c nervous sys te m) responses, such as increased heart ratc. respirato ry rate, or n ~lu !'.ea. Cryotherapy may bt contraindicated in these patients. RO M exerei"" begu n earl y in the course of the disease and con tinued da ll y can help patients mai ntai n joint in tegri ty ::Ind mob ili ty. In the face of unremjlting sPasticit stretching tec hni ques are indicated to increa~ ex tensibil{ of Ihe musc le tendon un it and connecti ve tiss ue. lntennin~ "atic stretching held a minimum of 30 to 60 seconds Should be opplied. ideally fo r 5 to 10 repetiti?n,. Combining ~trctching moveme nts \\ nh rhythmlc rot~tlon (gentle rotation of the limb ) or PNF fac il iwted stre tching technique, (hold-re lax ac tive con traction IHR ACJ. contract-rei"" octive contraction ICRACI> are also effective strategies to assist in gaining range. See Chapter 13 for a discussion of these tech niques. Maintained 5tretch. held for 30 minutes 00 3 hours. 31'0 can be used and has been ' hown to decre'l< stretch reflex activity.l~ Maintained "tretch can be achie\ed with prolonged positioning le.g .. tilt table >landing with toe "edges). lo,,·load weight> applied uSIOg
-

"."111

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L 1C'\.tnLJJ ,UmulJlltlfi IJl tIC u...aJ II 1\ L'lu ...·flh th..tl el1..:1 ulrJ~C' l'( unltli'

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h..h . I(Ih:1I ft>,UItL'J 111 "'l_llIft~.mT nnrro\ffilt"nL~ III H\t.' r:.dl II!\d vf rl'~ P 111.;111, ,\ Ilh rr{lhkoh lth a~" Ifnt..tl ' l l \(III((d, l ...n m.l\ ~:n •..'ttl Ih)Ui C"i.'I ...·I ..:~ II," U"lo.~J un IHirlo\ lit:.! lIlot"l i..\.nurlll tumm ('(~( ... I.,,(~! tIC Il)" dd

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(,I"'pte,- 19 Multiple Srlcn.",il'o ·

nl!er pro"irnnl mll sd cs. E'(cI1 1 ." IE ' ' 1 ' s O ;H.'11Vlll t:~ 1 lat s l n~s ... ~ ~ ~'I CX I O~l w ill Irun,..

sm> _ dOOl i l1 :m~.

ration an:: gene mll) the most C O CC II\' C. hw C'x am ple. :\\ cnru nk rol:lIion (LTR) in :-.idelyi ng or hooklYlIlg can he 'ffecli,"e in reducing n lcnsor lo ne. O nt.' vc ry clTecl ivc ... Iral · ;IZY is to positi on the pati ent in hook ly ing w ith ~I Ihcrapy ~ II under the ne"cd legs :lI1d genll y roc k the hall h~l..: k and forth. M oving from qUildlllpcd po... ition 10 :-.i de-:-.i uing can Iso be effecli\'e in red uci ng ex tensor l o nc in :-.ol1le pal icnb the ac tiv it y comhincs LTR w ith pro lo ngcJ inhihitory ressure on the quadri ceps.' \J A more gcncrali / cd dcc rc;l ~c p . .. I in lOne may he 3c1l1t~\'ed th roug h Icc hlllt.JlIC!:- ;lII11e( a t decreasing O\erall eNS ccnl ra l ac ti v ity w h ile prom o ting relax at ion (c.g., slow rocking, re la x~lt io n tr:-tin ing). For the pa ticm wit h limi ted functi onal mobi lit y (E DSS levels of 7.0 or above) positioni ng out of abnornwl. ~paMic posrures is an impo":lJll component of the ma nagemcnt pro· gr'Jm. in general , prolonged or stalic positioning in any ri xed poslure can he deleterious 10 the patient w ith ~ t ro n g spasti c-

:5

i[\ and should be avoided. For exam pl e. the patie nt who ;mains in bed 311 day wi th the LEs pos iti oned in ex te nsio n, adduction, and plant.arllexion may be una ble to fl ex e no ugh at the hips and knees to sit in J w heelchai r. Similarly, the feet ",;ill remain fLXCd in plantarflexion a nd cannot be pos. itioned on the footpedal s. A positioning sched ule using varied positions lID bed, chair or wheelc hair ) w ill hel p kcc p the patiel1l from getting stuck In an) o ne postu re. M echanical pos itio nIng de\'i ce ~ (e.g., rcstlllg splints, toe spreader, fi ngcr

spreader. ankle splin t) are helpful in ma intaining po,ilion and preserving Joi nt stru lures.

manage. Inten en llon~ directed at promoting static postura l

control should fiN loeu, on ; tatic control (hnldlllg) in ~eightbeanng. anugra, ill postur", (eg .. ' ilung . quadruped. Img, pianlIb'r.idc. and .. tandmg). Progre,slo n through a senes at p"'tUfe'. " u..ed to grad uall y inC rea"" postu ra l demand, b~ \Jf)mg the ba", of su ppon tBOS). ra' \l ng the center of m~\ ICO\1J, tJIld mcrea..,lOg the number o f bod) ~gmem~ Ide e') ot freedom, tint mu,t I:x- l:ontrollcd. Specific e\en..i')t kchfllquc) U1Jt LdIl. be u~ [0 p,umote ,t..::t b,lJl. mdude JOint approximati on apphtd lhrvogtl pru\IOlJI }Om . shoulder.., hi hip, I (,f he.aJ Mk.i PI11(", d.nJ rh~ IhfHlt.. stDbdl.l.&Ut..lt1 ( P;\F J. Pall~nh ~ ith "1'nlfi\...t.Ill ",t.t\I..a ~ III Ottl br.:I 4ble 1O hold .. lc~Kh' and. ffid\ lxncfit tn.lln th< tllVlIl\.afi41f1 .,. l. the l«hru~l.K or P J- d\ndlTH"": h ..... C'C.;".,J .. ~h, ... rl!\t.'("'-1.j J (>ru)!re Lflg lhruu~.h dc"'~nK'm ,A r;m .. • D)f\..I.ltlli: 11', •• u tlJr4.lI. nu-ul .. 1 ..:h.1.IkT,ged b.\ If \~H'.tlU~ i:aII..ll\!t ... .... e-~~hl dllmt" Of rt: htne elf) or PlJlf'!t 11 f I UJIIIlhme!> 1 f I

rrtlC'Ul

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j .. nil I1llpol'l ilnl thera pe uti c m ediulll 10 pmt.:ti l'l' :-.Iatil.: alld dyn::llllil' po..; lural cOlltrol III IXllh . . iltiug ami

. . tandi ng. Wa te r provuk ..; 1!r:ldet.! rCS il>l:lIll'C Ih:1I :-; Iow~ dowll the patlcnt '!' at:l>". i..: mllve lllents, w hile Ihc huoyancy aili :-; in lIpri ght hal:lIlcc . Watc r :u.: ruhi cs have lX'c n :-. h,)w n c l'kt' l!Vc in il1lprovi n ~ ~ Irc n g th , deere" . . in!; 111 U ~ tll4IT fnli gllbllit y, uud in c rc ~l :-. in g c ndur:uH.:c in pillicnl s with MS .l ltl.l l l In addition, the li M..: or m o dc filt e o r coo l wutcr tc mpc Tlllurcs ( 11 0 ~ rc lltcr than X~ " F \29"C I) can he lp !n\l(Jcn lte ~ pa ... tiCil y. A n import ant gual of therapy i..; tn promote ~:Irc und fun ctional halancc. Effcc livc lru inln g foIhould invol ve t\ vari e ty o f ta:-.h thut dmllengc h ~d ; lIl cc . ,, ~ training pro. grc\sc'i. t" , ks arc llIodifi ed (c.g .. w ide b.. ,c to n :lrrl~W basc to tandem ~ lan cc . :-.Iablc ~ urla cc to llIoveahl e s urface ) tll promot e adaptnti o n uf ... kill s. Sc n')o ry c l)n (hlj()Il ~ 'Ife al so vari ed 10 promot e adapti ve control in variou ... difTcrcnt per.. ce ptual c ont ex t ~ (e,g .• cyc~ open to cye>; cio..;cd , firm 1-o ur· facc to thid. 1'0<.1111 "' lIrf~tce) , The int e rventi o n prngrrun can

also utilize force plalform Irailling (e.g .• SMART Ralance MasteaA' [NcuroCom Intc rmuional . Inc .• C lack;urHl"I, OR 9701 5 1). Limit, of stabilit y trainmg i. a" o important. The pati ent w ith ata xia n ccd~ 10 len rn how 10 reduce C)l.CC'l'" postural swa y (freque ncy ;tnd amplitude) .lOli to control cent e r o f ali g nm e nt pos iti o n. The added biofeedback fmrn

visual a nd/o r a udito ry reedbac k di' pl ay, 1) 11 th e,. mac hincs i ~ e'tpcciall y u ~c ful fO f paticnt'\ With ~ormH O\e n · sory defi cits. Pro longed late ncic, (o'het I)f rc'pon..e'J shoul d be ex pected . Functi onal balance control , hould ,,1 '>0 be challe nged u,i ng real -life t",k, wi th io , ilTlul,,!ed realu, ing reac hing. turn ing. or be nd,ng Can be practiced ,n

Cerebellar defiCIts are common in MS and can be difficult to

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Management of Coordination and Balance Deficits

F~)f e . anlpte u.

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ooth '.t Itl ing and sta nd ing. Move me nt t ran "' lt iol1 ~ (t.g _, "' H~ to-,tand tran,fc,,) can abo be practrced A movcahle ' Uf-

face can be u",d 10 challcnpc halan, c. f or
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802

Physical Rehabilitatio n

. . lerfere with the

u ..e

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.",lIve device dunng . unbulat1on. C l e . lI~e III .111 a:-.. . . F at Icnts . fork ... can Ix' u ~cd 10 enh;mce eallng. or P . :-.poon:-- (If . 1 th e dltfcr· \I,i lh .. icnific'lJlt m'IllO!". the,e dev1Ce~ may meal . . . between depende nt and indepe nd elll funct.l ~n . c.:11C"e . be d 10 SWb lh/C E\lcm,d drvil'es (hra(e~ or :--pllnls) can 1I~~ " I' ' I"lbl ~ cll e'ct of .Ide Ill!!~ l k ' b"1 olso l1:lvt" t Ile un(Ie~, t; , alaXIC I11ll11~ ., , • T' ~,,:if"'llI 10 limb l1lo\'emenl'l. Air splint~ can abo stahl I ~C .' d d "" they are Ic!\~ limhC I1H.l\CmCnIS and ,houl d be'" conSI ere • . ..

cnen,!\ co~tl". A "oft ned, collar can be used 10 ~lablhzc I '" Ira It: gic... . however. hc.ld_ and. ' ncd. Iretl1()r~ . ,4 II 11t::!'>1::" ... hould I~ \ ie\\ed a.'" tcmporary and compensatory. O n~c thc dc\ Ice ... are remo\eu. ata\;, 1l1ovcme nt ~ wi ll retum or III . . ome ca~e:-. may aCIll;tIl~ tcmp?r:lrily worse n. . '( Frenkel's e,ercises \~crc nnglll:tll) developed In ISR J to treat patient . . \\ nh tabe, dm,ali ... and proble11l ~ of sen~ory J.ta.\la 0\\ ing to :l 10';;'\ of pr0prioception. These excrcl~cs h;l\e heen applied 111 the tr~aI111en1 of individuals \~ ith MS. The c\erCI,e' are perl'onlll!d in ,upine. sitti ng. and standing. Each aCIl\ H~ i!'l pertonncd ,Io\vly \\ illl the palient using \ 1. . 1011 10 carefullv guide corrert movement. The exercises require a 11Igh degre; of l11enlal conce ntration and effo rt and lIe. therefore. nO{ appropnate for all patients 'With MS. For tho'c pallent-. "ith the prereq ui si te abilities. they may be helpful In re~all1mg control of movement through cognithe L:oll1~n ....ltJon strategic::.. Patients \\ ah partial se n-,ation can pfllgre ...... to practicmg c\crci ...es "ith eyes c1o ...ed. Frenh.cl"s c\ern~e, are presemed in Bo, 19,6,

unwanted Illovements are worse. under conditions of , ,'lelY and excitement. The IIlcrcased arOusal. 'k. s tre~'\. a n · . lUe , It of adrenalin pumplIlg throu gh the system. increase rt:S U . f ' S , I ' 10 tre m or~ while decreaslIlg unctIOn . Stress ma CX IS II eo . ' n· agcment tec hniques are th e ref ore ..~n Important component of the plan of CMC. In ge ne ral. patJ el~ t s do better in a low. stimulus environment that lJllows full concentration on control o f move me nts. They benefit from augmented feed. back (verbal cueing of kn owledge of resuJl~ and knowl. edge of performance: biofeedback) and re petition to improve motor le~lfIlin g. The patient with MS is often restri cted in practice by ne uromuscul a r fati gue and neuro. log ica l deficits th at im~air sensory feedbac k, attention, memory. and concentration . The successful therapist will need to carefull y identify th e patient's reso urces and abili. ties and ca pitalize on th em to max imi ze learnin g.

Locomotor Training Walking abil ilY is frequently impaired, However. at least 65 percenl of patients with MS are still walking after 20 years. 15 Early gait proble ms often include poor balance and heavi ness of one or morc limbs. Patien t ~ frequently repon

difficullY lifting Ihe ir legs (hip nexor weak ness), Weak dor· si flexors are also comm on. result ing in foot drop. Problems with foot clearance may re~ ult in a ci rcumducted gait pat· tem. Later problems evolve owing. to c lonus. ~pas ricity. sen· sory lo~::.. and/or ataxia. Weakne,s gc ncmlly c'(tends to

Box 19.6 Frenkel's Exercises Gener-.t' instructions: ~xercl~es can be pcrfonned wilh Ihe pan o;;upponed or umupponed, unilatc:r.tlly or bilaterally. The) should be PTal'1 lced ;b ~mooth. Timed mmemenb. perfonned to:J ,1(v.l. , even tempo by counrjng oul loud. Con,>i\lCOC\ llf ~rfontUOC'"e 1S ~lre~~d and a ~peclfied tarce! can be u~d. 10 d"'l--rm no ' . fXhll10ns .' . . . ~ ...... I range. Four baSIC are uSt"d: Iymg. silllng'. 'landmg and \\all.ing.

The e),cn.:I"ie..

proore... !i. from t:

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IXl\,ures .of 0·... vr.ooale~'I s IabI I11)1 II ymg. ' " ) to 5.lttmg

poshlre~

of grealc ... t chaJlcnge

\MIUldin2,

.\\-3Iking) As

\lol unt.uy tomrollmpro\-c ... • lht' exercise., proores I . d . . • ~ ... U 'ih.ll)pmg an ::.t.lrtltlg on cOnlm.uu.l, incre'L"ing the rani;e and performing tht 'aJne C>'('rtl5(\ 'W Ith e)(,10 d o-.cd. COlll:emTalion and . ' I , . de\tl!--" ,-,,, tl rcpelltlon are lie h.e}~ (I) ... uc('e..,.~. A "lfIlJlar progre ...... ion ot ewT\.'! !:o can be 'I~U ., le Uppel c: \tre mnl e ~ . >

C hapte r 19 Multiple Scleros is

, '1 I ' the lj wtdri n:ps and hip a hJu{:lor.... Quadrice ps . Wi.';lknc~!'o typically n...:... ul1 ~ In h yp~~re~ lens lull of the knee JI ll U\ C

\"Ird lkxion o f thl' Inlllk Wll h II1crcased lumbar l or-

f~) r \ • ,'. HIp atxlu(' (nT W('~ "' II("SS res ults in a Trcndclcnburg dO~ I :- . . , ,'lll Cnl wi th II s lrtm g huera l lea n 10 the weak s ide. ~:1I1 I . . . . . A wc ll -(k :-ig ncd cx(.'rc Is(' prog,mm 0 1 lone redu (: t lO~' . o:. lrclching. and ' Irengl lu: ning t' xc rci:-cs c:tn im prove ga ll. ~ di ng :lnd "alk ing aCl ivi tic ... sho ul d stress safety a nd ~1 :lJl • . . h ' r"' lIl i n ~~ :1 . . table !:lase (If " upport : max imum wC lg t rl1;i11l .> hr3rin~ th roug h the L E~.: and ;l df..~~IU a lc we ight I.r an~ fe r and , "J'(II'l'o1!~ res:-i01l \\ 11 11 tfunk. 11 mb. and pe l v Ic km emat 1M", K~ (OIl,iSlen l wil h 110n1'1a l wal king. Verba l and manu a l ,".cUll! (.':111 :Is:-. i:-.t the r:lli~' nt in the l'o rrect mechani cs o f l!:lil. The pool i:-. '-ill importalll med ium fhal ca n also be ~~d f(I a:.:-.i:-.t [rJinill~ \\ hik rcdur.:ing lo ne a nd fati gue a nd aJl(I

-

controlling for ;l1 ~l\ia . L()CllTllOh)r training u:-.ing. an <werhea cl harness TO suppnrt txxI~ wci,;:ht and a r11l1Iori:red treadm ill has been the focus 01 incr("a~ in~ atten tion in the lit e rature and used nlt'n:-.i\·el) 10 illlpro\ c galt in pati e nts w ith spinal cord InJul) and :-.t roh "",1 1,\. l ~c(" di sc uss io n in C ha pte r 13). t\ppl ll'O.III011 10 other chronic neu ro log ica l conditi o ns is lim ited bu t emag ing .'<..J Thi:-. task -o riented interve nti o n was u:-.rd a.. . pan of a ('oTllprehensivc 12-week prog ra m by Fulk to Impw\ (' ga it ... peed . endurance. a nd ba lance in a patie nt v,lIh VIS (EDSS , core of ::!5) . ' ~ ~ The amo unt o f bod y \\'elght ... uppon \\ a ~ redUl:ed (20 perce nt to 0 percent ) while gall spe<.>d mC~3:-.ed b) 11 pe rcent ( 10 me te r walk test) a nd 2~ . 6 pen:ent (6 minUi c "alk Ie;;;!). Sco res on the Be rg Bal ance Scale (BBS ,. and AC liv iti es-Speci ti c Balance Confidence rABCI ,cale. and the Modified Fa ti gue Impact Sl.:ule- S· L!C'!l1 te"t (MFIS· 5) abo im proved . Pe rhaps most tmportant of all. the' patJel1l repol1ed feel ing !illfer and better :1ble to e ngag.e 111 d~-lIl) :-,oclal activit ies. Thus thi s fo ml of locomotor Irallllllg aprear:-. 10 be a fca!ol ib le and safe Imen ent lQn pwduCII1f!, ' Iglllfic'.lni po ~ i t ive effects a nd descn' m~ llt ~dJlll on~tI r(>.. ean:h. Pauent.. \\ uh MS I) plCalJ ) rt!4uire o n hoti c devices a~ ambubu on , kill .. dec lllit' . An"'I~-fOOI ~Iabi li ty can he achlt\ cJ h) the add lli un ui an i.lllkie - fool ort ho, i:-. (AFO) . Impro\'t'mt: nb 111 ella£.) dfiuc nq and ~ afe l Y a re abo Impon:illl OlJ lt: lInlr, . A H)" aft:' pre:-.c nt)t:d for fOOl drop, poor knee cllno-ol tc'':)pt:l..la ll ) h ~ IX'Tt: xten :-. iotl) . nllnim;,t l to mctder.1lr "P3"11\. 11 ) . and JXN. 1r ~Ol1lal,):-.e n ....llion. The 1 J10~t l{)mmon I)pe u:\cd 1:\ th \.' ~ t :tndarJ po lypJ'up) le nt' Ar-O ""hlCh h l/ghl V.l·l!!. hl and hib Ih e :"'lllkd ht: ndi l lit n ... mc . /~ All AFO y" nh ..Ill an llu l.Ht:d )<11111 l all be pr .. lTlbed 10 PI'O\'ldt' mCn e 11);ld l.\ lntfu llUI till· dil l- It· ",111 the .add it ion ( Jf a pldntarilt:''- Ion "HlP H e ljjll \~ lllnll .tllldll: ","un~ lu the pre~ npIIL'n III Ihe ..e 0('\' 11..(.'''' IIh luJc l'>e \ (,' I\~ ~Pd '! tu:: H) , 1001

~ic,"a. and \\(' ",knn!t>.

( no nfU rlLll o n<.t! !:! r.adn 0 1 LE H\1I:-" l Co, l·\ !kl l•.d' j hl p th . '- III :\) Although k,u'e " nih' Iuol orthh~\ I K A HJ, j l "n pHI \ Idt' ,.lid/IUJu,,1 :-.WlHh,liIiOIl lOntrol of (h~ ~nc,· . tht') ~ Il" rill"l) u. . cd bnJu ltt' 01 tht: IrK:reil\ed {Il - e r~) n pc.:11 J I I UI t: Icqull cd i( od.. t:'r !)hoe .. {rnO(hfl ~d D1I1I1, h df)~\ ) ht\\\· ix:t:' n ,> UllC h ... ful with

8 03

selected pat ie nt s with MS in compe nsatin g for 10SI ankle mobilit y. Gait patte rn s appea red morc no mlal, with a signifi ca nt savin gs in e ne rgy cos t ( 150 percent o ve r ambulali o n w itho UI roc ke r shoeS).I~b Can es. foreann c rutc hes. o r a walke r may be necessary 10 compe nsate for de fic it s in fati g ue, strength. sensory loss (numbness), o r balance. Fo r m any pati e nts acce ptance of an ass isti ve dev ice invo lves full recog nition o f their disabilit y. They need to be co nvin ced that use of these devices is far safe r th a n " wa ll -walking" or " furniture wa lking." Devi ces al so prov ide recogniti o n to th e community at large th a t pa tie nt s a re no t stagge ring or los ing their balance because they are " drunk : ' a freque nt occ urrence with many pati e nt s. The dev ices may be the difference between communit y pa rti c ipation o r re maining home bound because of fear o f fallin g. Patie nt s should be e nco uraged to try differe nt de vices o ut to dele nnine whi c h work s best for the m . For e xampl e, the pati e nt with signifi cant fati g ue levels may benefit from a large- wheel ed wa lke r with locking hand brakes and a sea t that allow s fo r freque nt rests. Cosmesis is an important fac tor in promoting accept a nce . The re are many innovations in ass isti ve techno logy that make the c hoices eas ie r. For example, des igne r canes now come in many different colors and styles, including clear Lucitc. ABLEDATA (hltp://www.a bledat a.com ) is a fede rall y funded proj ec t that o ffe rs product info rmati o n, resources , and li nk s to manufacturers . 151 A s the di sease prog resses, many patie nts benefit from a whee led mobility device (powered scoote r o r wheelchair), The course and progress ion o f the di sease and presenting sympt om s sho uld be ta ken into conside ratio n \!'the n deciding on a device. For patients with adequate trunk: stability, UE fun c ti on , and appro priate visual. perceptua l. and cognitive skill s, a SCOOlcr provides needed mo bilit y while conservi ng e nergy. Scoo te rs a lso do not carry the same nega tive sti g ma as that o f a w hee lc hair. Both three- a nd fOllrwheel scoot ers arc available. Fo ur-whee l scoote rs have superi o r o ut doo r a nd uneVl! n te rrain perfo rma nce, but are nOI as eas il y tra ns po rted . Features th at should be recommended inc lude a seat tha t rota tes for easy mounring and dismuu nt ing, easy d ism a ntling fo r load in g inro the car. and 3tee n ng lIl ec h:tll i" m ~ th a i mi ni llli 7~ the work of the UEs. One d lsad\ J IW.lgl! o f 'l·OOter~ is th:.u 31..' al ing cannol al ways h4: l..· u ~ ( ol1li,cd . T he) an' ufte n Iwt desig neJ fo r prolonged "Ill ing 01 for pi.l t i~ n h wit h mooeratt' 10 st!vere postural II1, tabilit) . SCl1nt" new three- \\ hc.'cled ... ('ooten. a re desi gned 10 hJrn III H"ry ,mail art'i.l~ \', hiit.' otht'rs have a wid«: rurning radiU S and lil a) not be :') uilablt" fo r in-ho me use. A "hl'c khair " hu ul d be conside red when pus tural dt"llUU ld, nt.'I..'t''', lI ak uu.:ren.wd "'UPlx u1 . A standard whedl' h,ur I ~ otte ll 1101 llIuch hd p 10 pati<:llb with ~'1S bti:ause of Lhe l'nt"rgy l~"pend i t ure and l:oordina w)n requlIcd for propuI~ t\ll i . A po .... t:.r \I. Ik."eh.:hail shuuld be ('Otb idered when impa.irn~nb prevt.'1lI Of Ill n it man ual propui:'!ioo. Power wheetl:haJr~ are n l\ ~rC \.'l)stly. tnl)f'C dlnk'uh IQ repiUf, ~ require 3iX!l,lalill.'d tran~POl1ntlUlI b) a whe.:h:ha.ir·a(..'CCwbfe YW1 or

804

Physical Rc ha b ilita tjon

. . _ _,' . 'oyslick. For patients hll~. I\1os1 pa lients wil l navIgate uSlIlg a~ II e J'oystick can . . . ~d I ' d "u-englh and scll . . allo n . 1 '

\vllll 11l1p31re . l.in " . . _, W heelchair scating should V be adjusted 10 Increase sensJtl ll). . k d head and

r

ensure proper a Ignn,lcn limbs while e~han.(,I~g

I

of the .

uun an •. 1111110n maJa li gmnenlS ~~s ("acra l sil ting) with

pelV IS.

fl.ll.lC:l~n.

~:~:;~~i:'::l~::~;I:,::;~gre~~I~ ~f ~"S1ici;y in the h;';'~~~~~ . . I ' Thi" C311 be improved w Ith the ad dI ti on 0 ,

Im] ~ C):;. . 'd ' ood iOIl "~Ih a solid base of support (soh scal 01 W

Insert ) 10

,

revent h:lllllllocJ...ing of Ihe wheelchair UI~I~olstcry. postur.1I PI · 1 C' ll ·,lsll I"'~ :.1 .;:;;;;istcd by the addJl lon of contoured 31!Wmen <1 • • ~,-•• , • h'

S~;lil1l! (c ustom built' or :I contoured ~heelch'lIf cus Ion (e .!! .. ;olllOured cllshion with gel). A solid bac k SUppOl1 and

ad~ll ... l3ble lateral tnlllk supPOl1S may oc needed to enhance 1"';~llIral alignment and upright si tting. Footrests should , be

posilioned to ell"urc I.h:lIlhe thighs are parallel to the fl oor. If extensor sp:lsm~ arc strong. they can actuall y propel the patient oUi of the chair. A strong lap bell that secu:es fi nll ly arollnd the pelvis i:-. necessary for safely. For patIents who present with "trong adductor spasticity, J medial knee block (pommel) may be necessary. Heel loops a~d straps m:l.y be required to mainta in foot position on the footrests. Patl~~ts \\ ho no lonoel" demonstrate adequate trunk and head stablhty require an aJ~emate sea.ting design . For some patients. the tjll in-space \\ heelchair wi th head/neck support is a bener option than a reclining wheelchair with high back and elevating leg re ...1.!.. The fonner maintains the nonnal hip si tting angle: the latter produces extension of the hips and may feed into strong ('\tensor spasticity. Elevating leg rests tend to stretch hamstring muscle~ and ll1
Palients should be inSlnlcted in tram fer and wheelchair mobrlu)/ma.l1ageme nt skilk A trans-fer board or hydrauli c 11ft may be nece",saJ) as UE IUIll:Li on deteriorates. Anention 10 good sillmg p<),ture und pre!l. . . ure relief tec hniques is es\enllal 10 majmaJll alignmem and prevent skin bre:..k do"" n. Patient:-. "houlJ be encouraged to balance lime in the v.heekhair with olh~r iKlivllic'l. wch as walk in ~ or exe r(·["mg. and "hould he eX l r::! dihgent III \ Irelching muscles lhat tL'nd \0 contra<.1 ,I"
hlp aruJ \...nee fle>.or:-. )

...

Onl"" or the ton,trall1h Iht: thtnlpt\t \\ III ha ve 10 dea l v.llh I.., fin<J IKlal fClrnhur'L'llIetll 101 Ihe Lhan gmg 1l11)biht \ (lj (hI! paue-nt ""'J1h Lh ronic MS Prj, ale or )uh h' . m..,uraJll.:e OfWHlI7' I . I l e-,a 1011"\ teyulft' ,I , t ..tLemenl 01 m~dl{'ul ~c'-'':)'" :V for Pi.l)Il1~ 1I1 A \ »)lllptOflh Me 110\ ~ I :"ill III MS I'UI r;;.thtJ lypll'aH) 'X . h . t: .H. t'l ..... tll n~1 rl.:tmbuI"c l UI nt'\\ v.lu.-:l"lc haJ;.., PII''''l:'t':~ \1

need ,

1.\ I(

lin "'pct.IIIl'ti

lin e I

I

111It.'1\ i:1 ..

ur

1I1<1Y

I. . . .

hl' <"I I, lI lI

'

tll

_ sive specialt y wheelchairs such as the tih-i finance ex pen .'... . n. or a second lightweIght chair for travelmg. TL _ space c h:lIr ' f I .. '" . . '11 need to pfov lde care u doc umentation Of therapist WI . ' , . I dversc outcomes 111 order to Justrfy cost of potenll a a . ,the ' the new chair. For examp,le. a 1.lkely de letenous OUtcome for a patie nt w ho is ~el1l ed reIm bu rsement for a tilt· in_ space chair may be skrn bre~kdow n . Thc costs of nurSing and surgical ca rc fo r decub itus ulce r~ can. then be com_ pared to the cos t of th e new w heel ~h a1f, W hl c~ can be justified as a preven tive measure, It IS equ all y Jmportant to antici pate futu re needs as lhey relate to rate of disease progressio n when orderi ng equipme nt.

Functional Training Functional tra ini ng shoul d focus on problem solving and the development of appropriate decision maki ng skills req uired to meet the chall e nges of be in g disabled. Skill, shou ld be adapted and prac ticed to ensu re safe perfonnance in both t.he home and com m uni ty environments. Training in fun ctio nal mo bility ski ll s (e.g .. bed mobility, transfers. locom oti on ) is ty picall y d irected by the physical therap ist whil e ADL training (e.g .. dressin g. personal hyg iene . bathin g. to il eting. and feedin g) is directed by the occ upational therapist and training in com munication skill s by the speec h- lang uage patho logist. Close communi cation and coordination among team members is necessary to ensure that trai ning methods are consistently applied and successful. Full participation of the patient in all phases of plan ning and t.raini ng wi ll increase pe.rsonal invo lvement. whi le decreasing dependency and passivity, Th e majority of patients with MS will use mul tiple adaptive dev ices. This req uires careful attention to appropriate prescription of devices and envi.ronmental moditications 10 assist the patient in co nse rving energy and maintaining function . Adapt ive equipment can include bed or bathroom grab bars. overhead trapeze. raised scats. transfer board. or hydraul ic lift . \Vrist rests to facilitate writing or typing, and plates and cups with lips to minimi ze spills are often helpful in ass isting with hand function . Lon~ - hand led shoe horns. rei.lc ht' r~. bulton hooks , <.,ock <.lids. ~r Velc ro'§! ch}~ urcs ca n as~i"'l in dressing . Etfe("li\'e com munica tion may require huilt -up writlll l! lIttn .... rl, or a lIni\t'r~al cuff for \ \ n(ten comlllunic ation O~f mort" ... oplw;lI\.:at~d compUierizt"d devi ce", P
Ma nage menr o f Speech a nd Swallowing Sh,tlhm rt''''p . , · I 14.1 t l) l ) pducrn, l't lntnhutc- 10

~pee-c h

I·tl-,('ul(,1

ttl') and tC('Ufrt.·llI rL'~rlra l("tr) ltlkcIlOI1 .... 1 hu~ . re~plnllOJ'). nnt \ck It ,Ullnweo- "' .\(1 , f I Ian ot lI11porlanl t.:Otl1 l)()Jll' tli 0 t l ~· P

C h a pte r 19 Muh iplc Scle rosil.

re for patient s \\'ith c hronil' MS . ~lnd should be combined c. h '''' Iivilies 10 improve trunk s tabilit y. head comrol. and " '11 ''' . . .. " tinl! balana. R t'~ plratory pall cm s can be tacliitated ~t l ~ I . . .

uch Iht" usc manna colll.ac!."" reS istance. and IJ1ccn llve h t"' ' . The th era pi.s t Sh ou I d foc us on dIaphragmatIC

~ jr01nt> I~ .

' Pd

;;(CT11cnlai

;~ec~i'~1:'

chest

c~pansion. ex piratory trai nin g. and

I..-oughing. A s ignifi c3n1 increase in ex piratory --k ,,If('n'-·I.h \\ as demonstrated fo ll ow ing a 3 -m o nth

mU:
.

:;:.

.

.

.

;lin ing pwgr:llll 111 pallents with MS.

1~)1.

tr. When dvspha~ia M difficult: in swallowing is present. h,'Sicai ther:lpy etTon" Sh0Uld be close ly coordinated w ith

;~ of Ihe spet"l..·h-langua~{' P3lhologi"'t

and occu pational

therapIst. :\ detailed cX:J.Jll1l1at ion IS necessary. including

\',dt"l."'-fluoruscopy f'of d~ ' phagia. The physical the rap b t can the rn:rnap:-ment plan by improving s ilting pos iti on, uprigh t posrtm' ~ith 3 ~hghrl~ f0rward head po~i tion a nd chi n parallel tl1 tJbl~ ('f sli.:; htly I'U cked j..-: ne('essa~ to achi e\'e good swalIO'inm.: and J\ Old J:-pJr.\tton. Ora.l- fllotor exe rcises can imrro~e Ol<..1uth funcHon and include speci fi c exe rcises fOf IIp d0Sure. tongue movements . and ja\\ con trol. Stretch and restSllIX'e (,JTl bt.' used to strengthen \\ eak muscle actions. S\' :lllo\\!ng re t" \e::. C~ be srim ulated b~ using icy bevITages su.:h as ~ sh:.U...c. sherixt or frui t sl us h. Patie nts are rns01lI.'ted 10 begm meab with something co ld and to take s.mgl::- sm.l11 ~lpS. ne\er 1.0 ing consecuti\c swall ow ing. Re51 1l\e- ,u..:-klng through a Str3" can also be helpful. ThIC' ~r II mill. wruch provide some resistance and the ref.::rre "me f.l.l'lhtation of muscle aCHon. are generally easie r ~~ lliov. than th in hquld::. ~ uch as \\ ater. Moist foods (\I. ith ~oce .... broth. \It,ater. o r mil k , are ea'ie r to manage th an dry ~ SeITH: lilt <.L'lJ pureed foods are easier th:m regular 6 Food .. th.:il tmt.a!e the duoat Ie .g .. \'inegan and crum . ~ or:!lt! :l g~ food.·· Ie g .. c.1ke. coo .... ies. potatO chips. celer: . ..ilet~~ ~,oold he J\ 0 Ided, P.:tuenh are instructed to foeu)' t:il!rr ,=f. on~ on. che\\ tn g fvod thoroughl: 3.nd not attempt to till. o.12"L'1~ ':;li:"rt..; \Ll.lnLJID.ln g.! qUiet and peacetul e n\ 14 lOnrnem ..hlr";;f nk<1l .. t .. im portant E..:t1t?ue can aMect food UlUk.e- \ Xr; tbc p..ttJC!1! "l..!I:.., :.11l\\. mg dO'An dunng OJ. Incal . ~ l.~~ I' ..i1 , UU,.1ed W ')·,l~":J..n b..it'" tl) ,>o mt:thHlg H..) . Latc if} t1k dJ .. . ~Ucnh... JJd , m :o.tlITh.'" lhld\. IIquld'- hdt: \ .1\ . m_ L1'IJ " I 4.,/.j j , t.1( c ~ ~ If\ U-o'C .:iJ.! P~k:nh m;.a.~ ht:oclit rom f"O:!u... l!"t: [~If I..! rnc~., m J e",,[lng mulupk , " \.til r:k'~ . W, -ehou-~ t.rll( '.!.I ~ The ...pcc... h- Ia.fl _U.1dC' p.1th... k.i l'l l.t~~ ... -l_li "'11':; tcd 'fli.>..jun mi..'l w.,hng U\C' pO ...... Cf 3....... ISI

In

ht~ad control. 3I1J ora l-motor coordination. An

4

805

Re ferral to .1ne uropsychologist m ~' y be indicated to detefmine the patienl's sire ngths and weaknesses and to assist in the adapti ve process. Compensatory strategies for mem· ory defi cit s can be helpful. These include the usc of memory aids, liming dev ices. and e nvironmental Mrategics, Memo ry can be a~s i s ted by makin g li sts of things to do, us ing a me mo ry notebook to log daily events and reminde rs, and li Men ing to a udio tapes. A pill di spenser can ass ist the pati en t in maintainin g a correct medication sc hed ul e . Cue in g dev ices such as a n alarm clock. bell time r. or watch alann can help patie nts remem be r when to do ce n ain ta"ks (e.g .. laking medi cations, performing pressure re li ef). Structuring and labelin g the environme nt is also an effe cti ve strategy 10 ass ist memory (e.g., label ed dra wers , cabinet... ). Directiono;; for funcljonal tasks (e.g., lran~ fe rs . se lf- stretching tec hniques) !-Ihould be carefully written down for both patients and careg ive rs. Complex tasks can be broke n down with clear written dire<.:tions provided fo r each step. Directions ca n be posted in different areas of the hom e (e.g .. step" for toilet or tub tnm sfe r posted in the bathroom). Addi ti onal cognitive ~ trategje s that may be helpful inc lude me nial rehea r o;;~lI. req uesting ass istance. maximizing a l e nn e~s. avoidance o f diffic ult sit4 uati ons, a nd menta l exerc ises. Poor follow -throu gh should be expected among patients with 5.CVe re cognitive deficits. as o ft e n the re is very littl e in s ig ht. In th is liii luation . the efforts of famjly and careg ivers mu ~t be full y maximized . ~fj

Psychosocial Issues Indiv iduals'" ith MS and their famjlic ~ experience a \ariety of lo s.c'\ suc h ~ los!t of 'toc ial functioning . 101erpersonal rela t ion ~hip~. employment .,tutus, independence. and runetio ndl ':'I kllh. Di ~bili llC: ~ emerge a.\ (he di~a~ progres~ o'< cr time. VariOU\ diffe rent ~yc ho\ociai adaptatIons can be ~cn Incl udmg JlIger, de lliai. dt7pre')") ion. and w fonh. l1li: unlqu~ ft7~lUn: 0 1 a

rd .J p.,ulg- rcmllung di....ea\C COUriC 1.!oJ that

1 he

reqUI re ... cOJltl11lJai r"C.J.dJu,nnem c\'cr:- ItW.c a I"k:W set of ') mptom . . dPpe.tr P of .\1 <; pruJu\.e~ ' I.OIli"',J.,.'11 l.ogntll \ e .md emollonal ...ue.,,\. P"ucnh u tl .:n h:d ( lUI o f loo lwl dlhl un.,ur~ of Ihe~I\t~:~_ \1 ""hon dOd Unlt,l , fxum C1\.II Ih..&t It'lo IIlg \\otth M. requlres not !"If'-II) m 1lidl d(.. ... cptand.·, hn ah.o ", ITCmef),lj(jf.h f)e\ibtli ty III .xJI ith ( l ~ 1,,4. k. "I ... w..urc ' I I Pallenl,) ..ho o.penelll--.e

?t"'",.X't!'lICf. ~ ·"' ~I'.•. , :: .tl-...... C': J.[i/J ... .... o1.ll. ).i!. ") d. ...J.J:P F (.-6JI II ..!

Iroe .... t.alli u !.t[I\ t: (' H C\.. t~ p f ..maHer. C'-C:f)
L.,-...c".... .

" ...( \.. '..aIr,1 .4 un Il\.Jbllll) tu pcrtl)ffll .<\OL dL-pcndL."tlC')' 00 (Jfh:;", '\o. oJh .illl:dw",I txarrk'!h , .aIlio.1 \() (f"nn ,~. - It\o! Marl) (ae-

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Copune Traini0l ~, .< 'hr:

np...m\C',h, .. :.or" pt'~r.1 nu,}Of dJf, ... l.ittC"\ 1(.>( 11.... a.e f~rl.jbdl14:..on [e~J} In ,tcoer,;lL

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hoY. oUllJ1d,""kfu.t.l t eacb to'",c'4JI dfrt. 01 til<- dJ",..., \Ill daily

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I. Ie h"""Ul illlfl-!!: pr:!'\ UKb Cdpm·' pacc,~ed J-i:'.ffi~ 1..", \, t\ltm HI 'loOI.1.d \Uppon. W1d \flfUuat ~dHJttn... "f'bey ffi..l) e ... pt'TlCr\(·c "'rlth.!(..... , of ,".bl and ~ ... OI' .....nodan& ~

"" <1<"",

Ttu. m. y <,pi",,, ... h) an ••IImak'd 42.-.- til.

806

Physical Reh.bilir.tion

illdl\'ldual,.. \\ ilh M S , 1111 do nol fake med icalions 10 help 1..'01l1n.")1 their M S despi te medica l guideli nes recommending d l ~e~I...c~ Il1()(h f) ing d nlg~. The longer they arc influenced by tht.~ ..(' :1rIj t udc~, the le'l~ li ke ly they are 10 sec k help,ltll l.camL'd helplc.,sn(",,\ , lOlA self-e ffi cil("). and lack o f env iron ~ llIental ma.'-Ic l} haH" Mccn iden tified as major fac tors co nLrihutmg 10 de pre, ~ j on ~md fa rigue.Z'i Self~mcac'y is Ihe he llcf that .tn llldlvidu:!I will be ahlc 10 deo, I wir h panicular "' llll~lllllll" lhat may contam novel. unrredictable . and s t re~,,­ ful d em ents ,lto-t Strategic!' lhal promole ~ I f-e flicacy and "-Clf-mana£!c lllcnt empower the p;Hicnr wi th M S. The use of .. rrc ...:- rr du(.;llol1 lC'chl1Jquc!'! (c.g .. prog rc !-~ivc re laxation Icrhmque.... c(lgn llIH" Imagery. medll;Jlion) can al.;;o be he lpful III promntmg e tlcrlive coping ,

Deprt'''sion i'l e\lre lllc J~ cOlllmon and in some indiv id ual .. rna) 3",0 be pari of Ihe di'lea.sc J1 roc e~ !:I, Dc p re~sjon doc, nOI nccc'll,aI"lly correlate to the 'Ieveril ) o f the di sease . For ('\.ampll." .. pcr..,on " ith mild db.ca<.;c can be severe ly dl'pre .. ~d. '" hereJ~ the pcr"on with severe disabi li l v is not The thempl"l mU'l1 be afen 10 the ~I gn~ of depression and trllerH"ne ~I' appropnate, Cha pter 1 presenr s a comple te JJ')("'lh\',on of [hI' tOpiC.

Patient and Family/ Caregiver Education

Prompt referral to community resources ' , 1~lud '

Ina.

~upport group can proVide a necessary stabili z' . , 'I' J ' mg b><_,_ patients and the ir taml Ics,carcg lVeN . Within th ' ~ ~ , , . ' IS en\" m e nt IIldlvlduals can ga m accurate and useful . ~ '" . In' Onnat' aboul the di sease. diSCUSS common problems d lOa , , an IOel..... o f coping. and share anx.le tles and resources. Th , -""'II

. " 10 t he continual adu'. vldes a V;J Iuab le foru~ I0 aSS ist ' I1_ I"lVO process , The Na ll o na l Mulliple Scleros ' l~ IS Soc' (hllp:// w ww.nali o na lmssocie ly.org) prov ides edu.-..,'"'Y emo ti onal suppo rt . a nd 3 varie lY of programs and -- ......~ 10 indiv iduals wilh MS and Ihe ir families !brOIl ~ local chapters, I., Olhe r o rg ani zations and W. gil Ihoir reso urces arc provided in A ppendi, D, eb-baoecJ

A s igni fica nl num be r o f pali ents wilh MS ( eve ry two patients) w ill require the ass istance Obt or pe rso n at som e poi nr in the COurse o f their disease ~ places an .. Ira burden on famil y members and' llIis fi nanc ial resources o f the pati e nl if outside care ' on dar ,. , gIvers ..... be ull'I'l zed. Th e maJon t~ of careg ivers experience

C;;

ate leve ls of stress associated w i th lhe ir caregivin ~'

A s the leve l a nd du ralio n of phys ical care l'JlC g duties, . reases Cilt g IVers ca n ex pe rie nce a varie ty of signs and . . , I d' , symptoms inC u 109 phySica l (e ,g ,. falig ue . headache. . , appe ille c hanges). psychological (e.g .. an,' de pressw n. frust raIIOn ). socia l (e,g .. fa m ily con~ decreas In!! soc tal e'pe n e nces o r " lack of life") "_" " I h . W ", ,!"n· lu a c angcs (e ,g ,. hope lcs, and meaningless life and work),"" T he Ihe rapist w ill need 10 be sensilive 10 Ihne changes and 10 con ll icl>. problems. and lensions as m.y dC\e lo p, Con>Jderable lime and ene'!!)' will be coun >e'lng and
Summary

C h apter 19 Multiple Sclerosis

Q lle s ti o n s -

fo r

R ev i ew

Wh:H arc the pathophysio logical procc .. ~c~ in vo lved 1. in M5 ? Primary area!' of eNS involve me nt ? . Conlnlon Signs an d S) mptom s".

2 Differentiale among the va ri ou ~ clini ca l coursC:o-. MS

6.

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plan of C:'lre . 3. Ho\\ is Ihe diag no:-i s o f MS c!'> t:1bli shcd? Wha,t ~esl s

7.

8.

and measures are lIsed 10 confinll Ihe dwgnosls. 4. Identi(V the d i:..ease- modifying drllg ~ u~cd in the medical manage ment of MS . \Vha t arc their ind icaIjon:.. and pOlcnlial ad\cnoe effec ls? 5, What Ct1mponent!l , hou ld be included in J ph ys ical therlr~ e \ 3Jllinalion'! De~cribe th ree disabi lil Yspecific meas ures de"eloped for use wi th the patient

\\ith MS .

Case

the compone llt " of an c ffe cli vc exe rcise pre· for the pati ent with MS to improve both ~ tre n g th and aerobic pc rfo mlance. D i~cu ... s the pro bl em of r;:lli g lic in MS . How wil l it influe nce the design o f an exercise prog ram? What arc the clinical effects or prolonged inactiv ity ror th e patient with chroni c. progress ive MS ? Identify three s trateg ie ~ that can be used to cou nterac t thc<;e effect.". Differentiate between restorative . preve ntative. and compensatory interventio ns. Give an example of each. Whal arc the general conside rat io ns in ordering a w heelchair for a person w ith chronic progressive MS? How can psychosocia l adju stment and se lf~e ffi cacy be fa c ililaled in the patie nt with relapsing· remittin g MS?

9.

10. 11 .

St ud y

HISTORY The pallenl I~ a 27-year-old graduale stude nt who was admmed to an acu te care facility \\ ilh a c hi e f complainl of double \i smn for::!: week 'l. She repo n ed thaI bolh lov.er extremilie~ (L Es) <;eemed weaker recently. Four months earlier. she had nOliced persistent tingling of he r fingers on the lefl hand and some numbne"i'l on the left side of her tace. ."'-eurologlcaJ ex.amm:llion '1hov. cd a scotoma in the upper field ofthe left e~ e. "eakne..,~ of Ihe le ft me dial reclu~ mU'IcJe. hOfl70nlal n)'I:tgmW. o n le fl lateral gaze, and mild v.eakne ....... 01 the left ce ntral fac ial mu!)cle). All other mu~de':. had nonnaJ )lrt!llglh . The deep tendon reae\.e~ \\erc noml;'!) on the- rlg.hl and bri~k on the left. and there \\oJ I, a lefl e">.. Len 'lor plJJ1l.JJ' rt"!'opon!'oe . The )c n· M>f) sY!)lem W
. [U ROLOG IST REPORT lJ 4 t1em pn:~nh v.lth u, Ide·ha!ioe.d u ( 3),1I: g.HI . Illinor ~ Iu f· nnr of ~pet:ch. blldlt:I;lIIH~I1lUr In the fin£~r IO- no'l~ te ... l. and dYM:hadoch()l-.mt'~la. ("'" I,('an I ~ "' uhln 110011<11 hmlh . MRJ bean rt:\t.aJ nUITIertlu, 'While drea~ mdH.all\e oj 1c~loni l -umbar puncture ~ho",~ 56 mg o j protein "Ith locrea~d le\eJ of gamma-globulin All o ther CSF findin: nQrmal TrCillmeUI \.\ lugh do:,e~ of Ult(11·

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venous cort icoste roids seemed 10 improve the neurologi· ca l symptom s. Palient was discharged home with a refer· ral for outpatielll rehabilitation. Two mo nt hs later, the pat ient 's sy mptoms worsened and she is now admitted for inten!)ive rehabilitation.

MEDICATIONS Predni sone 20 mg po qid Maalox 30 cc po qid Valium 10 mg qid

SO CIAL HISTORY Patient hi.l ~ been living o n her own for ~everal years until he r recent illness. She ha" taken a med ica l leaH' from crad uate $chool and had returned home to li\ e \\ ilh her ~arcn t l:O. They are borh s uppo rtive and would like "'01111j ad, ice :i!) 10 how 10 modify their t,.. o-
PHYS ICAl. TH E RAPY EXAMINATION F INDl N( ;S 'klllill "I:tll"

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10

Static: Able to maintain standing position in parallel bars with min a~sist X I for up 10 3 minutes; during ManeSiog. patient is unable to maintain centered alignment demonStrale!ot moderate postural tremor; with EC, s" is increased dramatically and patient quickly loses: balance Tends to keep her hips and knees stiff in e:< tension/ hyperextension Dynamic: Unable to weight shift or step without bilateral handho ld .

undcr!
, ob io n Tran"ient double vl ~ ion Gaze-evol..ed ny . . taglllus to bolh left and right Ocular d ) r"metna Uppcr field def(:ct of left eye El) du ra l1 (.~c/F: 1 ti~l1c ~

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e\ LCn'Or ' pasocit} (2. on the modified Ao;;hv.orth Scale, 111 both Jo\\er eXlIemilies (BLEs). left £reater than right CX:ca~lo n JI c\ ten , or \ ra~ m s. \10 hich are a major safet), n . . l.. v. hen the} occur during rransfcr~

"'...·",.Hioll Pare'lhe .. ia 10 BL E~ \\ uh moderate propnocepu"e Im.~ .... anl le JOll1h gre ater than proxlm:t l Jo int '\ Buth uppe-r n lre nlllle,> I RL E!it): mild decrea!!oC' '" light lOuf..h. Idt greater than nght

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assist Locomolion- wheelchair: FIM 5: super\'bion, uses man· ual wheelchair for distances up 10 150 ft : postu", in wheelchair: sacral sitting Rcquire~ a lap belt due to extensor Sp1b1fl5. 'AhlChcan cau..,e her tu lhng out of the chair CumrnunlcJtlon--expres<\ion: FI \t 6~ require!! extra lime. mild u) "nhna Communicatlon--t:omprchen,loo' FL\I 6; complete undcr,ta.ndlllg. requires e xtra lime fo r pl"Ol.'e,\!ilDg Stx.: lal InleraClJo n FlM 7 Problem ...uh IIlg: R.\l 6 ~ rt>4um:., e\tra lime, ~lJghr diffi~

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809

3. FOnllUlatc four trcatme nt int erve ntion s that could be used at the sta rt of the rapy to achieve the stated outcomes and goals. Provide a brief rali onale for each. 4 . What Mrategies can be used to develop self-management ski lls and promote se lf-efficacy and quality of life?

-R e f e r e n ces L [Jean. G: The mullipk "cle ro,i .. pr(lhlclIl . SCI Am 2::'.1:40. 1970 . 1 AnJc~on. D. el al : Rc\ I:>ed (':-llIllMl' o f the pre\ale nt'e of muhipk sclero~i .. In the L'nlled St:lIes. A nn Neurol 31 :.'.1]. 1992. .l Kurl:uld. LT' The t'\olutitlll (,r mult Iple !>c icrthi:- epidemiology. Ann Ncur(lI .16lS uppl I): S2. IQ9-1 . -1. Alter. M. l'l "I : MI£Talion and r; .. k of mulliple sderosi s. N('urol t )~D' 2S : 1089. I ':l7f\. 5. Kun zkl'. 1. and Hy lle<:ted. K: Muillplt' ..clcro~i .. In the Faroe bl :lOd~ : I. ClIllK'al and cpidemiolo!!ical features. Ann NeLlml 5:6. l':l~o.

Ep;demiolog~ of mul tiple ~clero!>i!> . Neurol Clin 1-1 :101. 19%. 7. Herndon. R: The p;llh(\log~ of multIple ,clerO"is and its variaob. In Hcrdl.ln. R led I: Multiple SderQ"w Irmnunology, Pathology and P31hQrh~""lolog~ . [)cmrn. Mcdical Publi-.heTS. Nt'w Yorl.. :!OO3. p

6. WCIn!>heMt'T. B'

I~-I .

8. John,on. R The \ Lrology of demyellnatmg di,<;;case. Ann Ncurol 3btSuppllS5-1. 199... Chelmlr:ka·Sch(\("r. E. and Amason. B: Nenous system-immune S\',lem IOter3ction!> and theIr role in multiple !>clerosis. Aim Neurol 3'6CSuppl Il · S~O. 1994. to. SadO\·nlCl. .-\. and Ere". G : Genetic" of multiple sclerosis. Neurol Chn 13'9Q, 1995. II . Kahana. E. /:1 31: \1ulllple ... clero:-.i .. ~ Genetic versu!> environmental lIeuQlog~ ' EpLdt'miolog~ III )<;rael updatcd. J Neurol 241:341. Q

W6 . el al: /l.kAlpme ·s Multiple Sclerosis. C hurchill

LI\mg'tooe. Edmburgh. 1991. us!>mann. H. Suchanek, G, and Ozawa. K: Histopalhology and the blood_"t:rebro-.pma! flUId barrier in multiple sclerosis. Ann " eurol36tSuppll 1: S-1~ . 1994 . 14 Lublm , F. and Remgold. S' DefinlOg the clinical coon.e of multiple <.e1ef(KIS Re .. u1ts or !lit international "une),. Neurolog} 46:907. I~.

1"""

R: t..bnaglng the S~l1lplOm~ o f ~1ul(ip1e Sclerosis. ~d-1. MedKal Publtshcf5. ,('\\ YorL 2003. 16 Lechlenherp R \lulnpk Sc lem!>L!> F.lC1 Bool... ed '2. FA 03\ is. Phil.tdt-Iphili. 11195 )1 Shllplro. R_S~mplom management lJ\ muhlple scleros is. Ann ' eurol 3tI SI:'O. It)9J ih Ma,loru . H Pl1n III \1 uluplt' ScierChL". ChOicai Bulkllll. NaILonal \1 ulllplt ~kr..n L ~ So.lety. ,,(.~ Yorf.. . 19 Katz. R .tOO R \ 01er. Z Sp.;t... 11t. h) pt"rtollla Mrthln .... m ' :U'\d mc:t!>uremem Ar(.h Ph\ .. \1M Reh.lbll"O 1+-1 19S9. 20 Sd,.lIHrO. R ,100 5..hneldc:-r D \bn:tgcOIcl1t 01 f.ll1 gue 10 multiple ""'k1'0!>1~ .(1tnlt..J BulkUlH , .... alulllal Mulllpk ~ckro!> i .. Socict) . t\ tv. Ynfl . ::!l.(u 21 Krupp , L 1:1 ..1 I .m~ut: 1I11ll1l1uplt' .... k1O~1 \ Arch "\curol-1:~ ' ·n5 , NI)r. 12 m..i J et 3.1 S~mp\.(.Hu311(. lillI[!ut' Iflilitliupic ~d_t.· fOSI" Arch Ph ~lo Meet RdLilb11 b'U1~ Iq\4 ~3 P-.,:l.er T, t't ...1- f-allgw.· -.c:.orn14r) 10 . hr.lIlil 11I1l(',,!> PO'lpl,ilO ~~ndl'omt dlTfJfl ... l.oIlgO(' ~~JlJronlc ,1m! multlr k ""leR)'>h \r\.1l Ph} . Med Rch..hll -'i 11 11 . I~ 2-1.. J ('\' al ~ 100P-.io.t..,( (all~tK' un ~',1I1C'nh .... "h mult lplc ",-t~ r""L, J(.." 'Kl .... curuI21,'i IINJ ?~ SCh .... W1£ C ~t 41 f',~ dl\' -.Ial (. ("Iel.ttt .. of 1.lItJl1e U\ nll..lllplc-.k-Sthb Arion J'h\ , Med Rttw.~l ·n If)' 1tN6 ~b tW..hn.t:J, ~ a.nd f]IUl ldi" ..!> , h. ~1'1t"lldn l('1uu •• 1 Bu.Jklll1 l. N4W1fU1 .'tulupl!':' ~~IC'f\l"H, '> o ... )ct, "\t."¥.. ,'on. 2'Y~ l' ~oIp·r,.lJdlh K c-l . 1 MIIf"'~cnklll til ullj).unnt m . dl-~bIILl~ , 41tJ h..Mk.-.p d t l) lJIulnp1< \(kru,Il>. '1... v Clm Plo... "71 11~4 1'Jl)l

15

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39. Fei nstein . A, et a l: Prevalence and neurobehavioral correlates of pathological laughing and cry ing in multiple sc lerosis. Arch Neural

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;';4

~ 5.

~~i~. J. 1'1 al; A randomi red c(ltItrollerl lI;al cOlllparil.lg rehahil.il alion a~ a m ~1 "'13mlarJ thcmpy In mult iple 'iderosl.s patients r(."{'cWlilt: "'[crold t~allllcni. J NClirol Nl'urOlourg PloYl'hllltry 74 : 1225. 2()O~ f ' . 'th ·- b .... R l' l '11 ' Ilc:!lt h·rcllUt:1.1 quality 0 life for pe rsons WI I) I "r .1 I.·. • • • '1 . PI

plTIgf('~ , i\'c muhiplc locicrom,: Influ ence of re habl Ilation.

l yS

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,n Ul progrc... Jo,I \ c I1lU hlpk ...c!erosl .... t\ n:h I hys Mcd Rehabll 7Q: I ..H . I09S .

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0:

1501(10):

12 1~ .

2003.

67 Palll. F. cl 31 : Effa:LS of a !!oho n o Ulpaliem rehabilitation lrea tmenl on UI:.abIIIlY of m ulti ple ",Ierosis pal ic nL~- A randomized co nuolIcJ tnal. J NeuroI 150(71:86 1. 2003 . M Slade. A. Tennan t. A. and Ch:un berlam. M : A randomi7.ed conIIOI!eJ InallO de h:mlUle the elTf.'C l of 1I11cn~ it y of the ra py upon length of ... cay Hl a neurologK':.1 rehabllilalioTl selling. J Re habil Med 34 (0): ~60.1002 . 61} Solari. A. el al Ph) ~ Ical re hablllt;)tio n h ~ a postli \le efrect o n d is... blllt} 11\ muillpit': It("ll'ro!.lS pallenb. Neurology 52 ;; 7. 1999. iO \\ lie"!!- C. el 3.1 Controlled r.tndoml zed crosso\ er Inal o f the eff« ts 01 ph~~lO'Iht':rap> on !Hoblltt) III tllTonic muillple sc l t': ro~ i s . J "'euroll\etJro~urg P,~cllI atl) 70; 174. 2001 . 71 ~ulherland. G. JnJ A nd('N~ n. M; E\ t': rCll>C and muh iplt:- ~ lcrO.'li~: I h~~IOll)~ll·a l. p'}lhlllvglcal. :Uld yu altt ) of life i...... ut'~ . J Spon~

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I :421. 2001.

7:' Krall. G. and Schaplfo . R il'v-ClIIUI'\) NatIOnal MS Soc le l) '" Medical Ad\ I,Uf) I:\l};Jnj' Reha bllltJtlOIi Ra:Otlllllt'ndallofb 10 f ~fM)Il' .... Ith Multiple SdCflhl... Nallonal Mulu plt! Sclero... is S\l( lely ~t'-'-' 'hUL. 1tJO...1 71 Amem:an PhPIU.I Therolp) A~~ lat lon GU ide [0 f>h).'Iu:al tht'IJ . I'I~I pr.st 1L~·t" l'tl\' Ih :r KI . I. 200 t 74 Motl .... · 1rOlkl' M lUlJ AJ"it'1ll dt',W· . - I-'"" [e~Ulg fu n~'II\liIJI malllte. noUl\. r Pf\--'~Idnt ... III hHnle lalt' Ad\.tllt:r, AU8u ~1 24 l'i'l 8 ." ~~~Ul J Rch.1h.lltall'lfllll Illuhlpk lollcnhl\ lUI ~clJrul \oSllO. "b D...J Iir lil,H ... .s,. " "I I"illl~"' \ >I •,. 10r Id ... htl llall\)11 ~)t U{Uroo..lrsell c:r,ul\r 1.h,< .. ~C '" P1J.lu\Jllt/- LUl' .. nd 1H,,1!;lmIlUl~ <.juaJ u 0 1 lit e . ~ curoloW-) kqJOll (no", J f\ IYI 11{l(hl l '\.l.OO~ ) 11 .cOC"tiln k . 1.'·1 .1.1 MUlUrul llC;urUlh\l.h"I\It,K.JII"\IiIlUl ...lltt(' lIf MS "Ir\ rlilllCJlh A UJI"I'oCJhu\ .. p\il U:lth Chn "'cuh'J)~)dMI If-, t ') 'l~1 '001 It ~ll'm. M ~1JhJ u~IlI"l l>lJ.t\ A pr.lo...lI,,-e lllml'lh.-"Ii.1 f), ' "H' ~ ttl..: U fllJlJ\ 1 t t r-r ..... lIlg e ... " ... ul 1l411CJlh hll" th~ duuuun j P\\duall R" ~ 1~'1

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B k A and Bec k. R: Screen ing depressed patients in family PfIc 79 . li~;: ~dpid technique: pos~gf',Jd M~d 52:~ 1. 191,2 . . 80 . Mcll.ack. R: The M~G III Pa m QuestIOnna ire ; MajO'l" propc"ie~ and scoring method.,. Pam 1;227. 197;. . 8 1. Lawlis. G . el al : The devclo pmcnl o f the Dallas pam questionnlirt. . " Spine 14(5) :5 11. 1 9~9. 82. Fisk. JD. el a l: The Im pac t. o f fRlIg ue on patients w ith multiple sclerosis. Can J Neurol SCI 2 1( 1): 9. 1994 . 1S3 . Fi sk. JD. el a l: Mca~ urin~ the functional ,impact of ~allgue : Initial validation o f Ihe fati gue Impac t scale . Clin Infect DIS Suppl I:S79.

A

1994.

. .

84 . National Multiple S cl e ros i ~ Soc ie ty: C linical Practice Guide-lines' Faligue lind Mult iple Sclero~i s. Natio nal Multiple SclerOSis ' Soc ielY. New York, 2004. . . 85 . De Souza. L. and Ashbum . A : Exammatlon of mOlor funchon in people w ith multiple scle rosis. Ph ys ioth~r Res tnt 1:98. 1996. 86. Lee. K . et al : The Ashwonh Scale : A re h able and re producible me thod o f me as uring spastici ty. J Neuro Re hab 3 :205 . 1989. M7. Bo hannon , R. and Smith . M : inte rraler reli ability o f a modified Ashworth scale of muscle spastici ty, Phys The r 67 :206. 1987. 88. Shumway-Cook. A. and Horak. F: Assessi ng the influence of sensory inte raction o n balance. Phys Ther 66: 1548. 1986 . 89 . Ne lsoo . S. et a l: Vestibular and sensory inte rac tio n deficits asst:ssed by dy namic platfo nn posturograph y in pa tie nts wilh multiple sc l~. rosis. Ann Otol Rhino l Lary ngol 104:62 . 1995. 90. Jackson. R. e t al : Abnonnalitics in posturograph y and estimations of visual ven ical and ho rizonta l in multiple sclerosis. Am J 0101

16:88, 1995. 9 1. Be rg . K . e t a l: Measuring balance in the e lde rl y: Pre liminary deo.eI. opmenl o f an ins trume nt. Physiolhe r Can 41 :304 . 1989. 92. Berg. K . et al : Measuring balance in the e lderly: Validation of an instrument . C an J Public He alth SuppI 2(J ul- A ug):S7- 11. 1992. 93. Tinetti. M : Perfo rmance-orie nled ex aminatio n o f mobility prob-le ms in e lderl y patie nts. J Am Geriatr Soc 34 : 11 9. 1986. 94 . Shumway-Cook . A. and Woollacott . M; Motor COnlTol Theory and Practical Applicatio ns. ed 2. Lip pincott WilJiams & Wilkins. Philade lphia. 200 1. 95 . Schw id. S . et al: The me asu re me nt of ambulatory impainnem in multiple scleros is . Ne uro logy 49 : 141 9 . 1997. 96. Lord. SE. et al: Visual gait a nal ysis: The development of a clirucal examinatio n and scale. Cl in Rehab il 12 : 107. 1998. 97 . Borg. G: Psycho physical bases o f percei\ ed exen ion. Med Sci Spons Exerc 14 :377. 1982. 98. American College of S pons Medicine : ACS~1 's Guidelines for Exercise Testing and Prescriptio n . ed 6. Lippincott \\i lhams &. Wilkin s. Philade lphi::t. 2000. 99. G uide fo r the Unifo ml D ala Sel for Mt'dka} Rehabil itation includ· ing the AM instrume nt . Versio n 5.0. St:lIe Un i\f:rsiIY o f Ne~ )'Oft at BuffaJo . Bu ffa lo . 1996. 100. Grangl.'r. C . et a l: Functional t'um iu,uion ... cales: A study of pel' ~ns ~i th multiple sc le ros is. A rc h Ph)"' ~ I~d Rt' habiI 71:870. 1990 10 1. Stewart, A. Hays, R, and Ware. J: The MOS /lhort·fonn gener.ti he allh surve) . Reliahilit )' :Uld \ uhdll) Ul li p~t lel1t populllllOU. Mel! C are 16( 7):724 . 19S5. 102. Freeman. JA . et aJ : Cl inica l ap pro pn .tlenc)o~: A key factor in OUI· I.'()mc me a ... ure '-Clt'>:"tlon- Tht' .'6 ltel11 lI-ho n ronn heallh SUf'e) U\ multip le- ~ Iero\ .... J 'curoI68t11 1511. 1000. 10J. G ilson. B. l" t al ' n~ Su:·t..nc...s Impau Prufi le. [)e\ e lopmc.·nt of:an out'::onle mea.. un: of health C.lre. Am J Public He-aim 65:1.300'. 19"5. 104 Dubie . S. \· t al. Fun..·u on.tl I.'Ulnll(!ICIK't' 1"1 1' n1 mnmOll) -d\to('lhug pcr~on~ \\, Ilh mu illple ~d('I\ ""I' u ~ l ng Iht' Ex[unu!,IIIOII of MOllY and Pn~ ('~ Sl.. llk AI\' h Ph)lo Met! Reha btl ?:; -43. 1994 IUo;; I\ urtl t..l". J O n the (,\ dlultlt)fl of ~l hJ.blllh 10 ntUl1lr'" )\·h!j"())b• "CIIr\ll..lj;) 11 61;6, 1% 1 10h ,,"unl t..t'. J' R,Jun~ neumlo~I('.ll lntp,lJ nll
C ha pte r 19 Multiple Sc:lerosis 1('19. Soltl.l"l , A. el III :. ~CC~rd c)' of sc lf-cxflmin:J!lcm of the minimal

record of disabillf) III p:lW:nls wllh l1luhipll.' s.,: leru!'i«, ACla Ncuml ScAnd 87:·13. 11)9) , 110. \ 'idrey. SG. el al: A heallh·rc lntcd qua lily of life measure for multiple $derosis. Qual Life Res 4: 187. 1995, III. Consortium of Mull.iplc Sc l e~ I S CCnlers. Hcallh Scicnce Resean:h Suixomnul1ec: Mulliplc SclerosiS QualilY of Life Im'enlor)': A User's M:mual, National Multiple SdCroll i.;. Society. Nt:'" Yorl. 1997, II.!. Cdla. DF. 1.'1 al: Validal,ion of I~ Funclional Examm91ion of ~1uhiplc Sderosl~ quall l)' of lite Itl "lmmClll , Neurology 47( I): 129.

1996.

11.3. Heman. Je. "I al: TIlc Muluple Sclerosis Impaci Scale (MSIS· 29): A nclt' palienl·based OUlcomc me:hure. Brain 124:962. 200 I . 114. Riazi. A. elal: Ml1.ltiplc Sclerosis Impaci Scale (MS IS·29): Rehabilif) and \ahdlt) 10 ho'pllal based ~a mpl es. J Ncurol Neurosurg P,Yl'hiarr:- 7:'(b):701. ~OO2. 115. Qumn. L. and Gordon. J: FunCliollal Outcome" Documenlalion for Rehabiljlation. WB Saunders. PhiladelphiA. 2003. 116. DIttmar. S. and Gre..,ham. G: Functional ExamlOatlon and OulCQllle Mea.;;ures for lhe RehabiiJt3tlon Health PmfC'\Slonal. Aspen. Gaithersburg. MD. 1997. I J7 \\rlute. U . el al: Re'I:-t.a.nce traliling improve..\ strength and fun cnonal capacll~ 10 pen.on~ With multiple scle r~is. Mull Seier 100668.2004. 118. Sural..ka. J. el al : Effcch of aerobiC and strenglh exercise on motor fallgot' 10 roen and women with muluple sclerosis: A randomized ronrrol mal. Cltn Rehabll 18:737.2004. 119, Moslen. S. and Kes.-.elnng. J: Effcc(s of a shon·teml exercise IntinIni! program 00 aerobiC' fitnes~ . fatigue. health perception, and ac(jv. if) len~1 ofsubJOCl<; I.I.lth multiple sc lerosi~. Mult Seier 8:161. 2002. 120 Roehrs. T. and Karst. G: Effccts 01 an aquatics exercise program on quaM) of life nlt:.1~urcs for Individuals with pro8re~s i'..e multi· pie KlerosiS. JNPT 28(2):63.2004. 121. Sutherland. G. Ander')('n. M. and Stoove. M: Can aerobic exercise tnlmmg affect health·rela·led qual it) of life for people with muhiplr ""Ierosl~'t J Spon Exerc Ps),choI23: 122. 2001. III PetaJan. J, el a.I Impact of aerobic traming on fitness and quality of bfe In mull/pie !odero'il\. Ano "'Jeurol 39:432. 1996, }~l POlUcbtera -Muk.~ . J. el al: Change m aerobiC fiLOo.'i of pauems lil.nh mulllpk 'i(:lero<;l,,> dunng a 6-month 1J1l1mng program_SJXlns \1ed Train Reh:tb 7:265 . 1997. C4. POr1J,"htera -~1ulcllf(" . J. ct at Mnlmal aerobic nerclsc of indivldu· als Yollh muJuple ..cle~1..:'l u. . .ml!: thret modes of ergomc.lfy. Clio KlI1es lol 46:12. 199::! 125 Gdtl~ G. el.t1 Etfe<;t, of an aquatic fillle") program 00 lhe ow ular 'itrength and endurance 01 pallent!. y,..ilh muluple ;,c!t=ro-!>.Il!.. Pb}· ... Ther (~65 '. 1c,lR4 126. Mu~ . 1. and PelaJan . J MUluple x lell)\l!t In Amencan C.)lIcge c4 Spon.. \1.edIC IQe ACS\1 'j;, Rc!tOOfi.'O for C'hnKaJ Exen:.l~ Pb) 'ao&ot;.-: ~'u.~:uk~l..e l cl.t1 , "euromu..cul.u. Neoplru.uc. 1tnmuoolo~ . dlid H t: nlalnlof!:l{ Condition... Llppmcott WIIIIIIOl'> A.. WllLJll.\ Phil.6(klphll, 2002 . P :N 111. C.QMe:l1o'JI E. ef a' LkC:":J ~ pre .... C'uml(ot:y Report 20'24 . 11N6. I~ Muk. J MIJJuplc Sdelo-..b III AIllt'Tldlll Colle~~ 01 \por1.,> Mcdk..mt · A( \\1 '" ,b.O'(I'-'" Man"gam-1lI fll( PehQIl .. lfh Orr•.u... DI:.(ObC ~ DI'I4t'r!I/II~ .. Hum.ill KUll.>t11.. Ch;ullp.t.ljln II. 1m p"~ I:!~ "-1l.t\t A I. et;tJ F.t1l;l t ,4 rl!C1nuhfl~ on ph) ,k.,.A pt rf'\fm:6~~ III mt.Jupk lol.i~I(/'" Mult I).. k'l {. ,-'/ 1. ~(I('" 1 r,{J f:.rland C e1 IiII I f1t:~1' "f Ihl M ...11. \Ill pt:fl~Hl,\;d \;"Hhn~ \\ h:m til, lotbJ.c;....-d } IDP'l, .. n~ ,.4 muhlllll! lehl'olt.. "':1.11'01"8) Nrp",ct 19 21 I~ I), ,rilbl)iUl. J a ...1 (. lJI.J1I1! Mill If., rhl.liupk .... kf(n.h IUOl.l" ",wi I1OfH' .... CHlt"ut iii d.td) 11\ lOr' \.: lin J Rd\~I)11 Mtd Q 2H. :'000 f • (J tIbJ I." er.,:t on;,. r In-:· I.;"...,III\.-.:...ull ( . -.(" "",,",I":~ ",' '4.Uf 4.ClUll'li f llhl ua.!l\uw.h '" Ith loolhpJ It'" . . . J:\lh

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135. DcSoula. L: A different approach to physiOtherapy for mulliple sclerosi~ p:lliems. Physiotherapy 70:428. 1984. 136. Anema. J, el .11 : Card iovascular autonomic functioo in multiple sderosi~. J Neurol Sci 104:129. 1992. 137, Stcrm:tn. A. et al: J)i ~semin a tcd abnormalilies of cardiovallCu lar aUlOnomic functions in multiple sclerosis. Neurology 35:1665. 1985. 138, Pentland. B. and Ewing. D: Cardiova.~ ulllf renexes in multiple sc lerosis. Eur NeuroI26:46. 1987. 139. Fog.lio. K . el al : Re...;.pir3l0ry muscle funClion and cxerci!le capacity in multiple sclerosi"!. Eur Resplr J 7:23, 1994. 140. Gappmaicr. E. ct al : Aerobic exercise in multiple sclerosis, Neurology Repor1 19:41. 1995. 141 , Kir!ooch, N. and My!oolinski. MJ : The effect of a personally de"! igned fitnes s program on the aerobic ca pacilY and function for IWO indi viduals wilh multiple sc lerosis. Phys Ther Case Rep 2: 19.1999. 142. McComas. A. ct aJ : Fatigue brought on by malfunction of the cen. tral and peripheral nervous sysll!ms. In Simon. C, et al (cds): Faligue. Plenum Pre<;s. New York. 1995. p 495 . 143. Mul1iple Sclerosis Counc il for Clinical Pr-Jctice Guidcline..\: Fatigue and Multiple Sclero.. i,,.: Evidence·Based Management Strategies for Fatigue in Multiple Sclerosis. Paral yzed Veterans of America. New York. 1998. 144, MeyLhaler. JM (cd): Spastic hypertonia. Ph)ls Med Rehabil Clio N Am. 12 (4): November. 2001. 145. Bmr. S. ct al : Evalualion of treatmenl protocols on minimal to moderate spaslicity in multiple sclerosis, Arch Phys Med Rchabil 72: 186.1991. 146. Kushner. S. and Brandfass. K: Spasticity- A clinical bulletin for health profe~s ionals . National Multiple Sclerosis Socicl)I. New York. 2004. 147. Adler, S, Beckers. D. and Buck. M : PNF in Practice. ed 2. Springer. New York. 2003_ 148. Kasser. S, Ro!ooe. D. :tnd Clark. S: Balance Iminmg for adul~ with multiple sclerosis: Mulliple case studies, Neurology Rcpon (now JNI'T) 23( 1): 5.1999. 149. H:tmmon. RG . el al: Tmining effeclS dunng repemed therJpy se..o;. ~ ions of balance training u.'>ing visual feedback", Arch Phys Med RehabiI73:738. 1992. 150. Behnnan. AL. and Harlo..ema. SJ: Locomotor trwning after human spinal cord injury: A serie~ of case studle~. Phys 11le:r 80:688.

2000. 151. Nymark, J. el at: Body v.elght suppa" treadmill gllit mUIlIn.g in the subacute recO\'cry phase of lIlCOmplelt . . plllal cord UljUry. J l'Ioeuro Rehab 12:119. 11)Q8, 152, Vi~intin. M, el al. A new approach 10 retain g.alt 111 o,troke pauetU.~ through bod) weight \uppon and treadmill o,tlmulalit.lA. trot.: ~~:1122 . 19'18. IS] Sulh\30. I<J. Kno ..... lton. GJ, and O". . .blm. BH . StCf' tr3in!O& Io\llh bod)l weighl ~urport Effect of tre.adnuU ,peed and prJLu~:e para. dlgms on poshlro1.e 100·omvc.or recO\Oef)". A.f\:h Ph)' Med Rehabd 8168.\. 2OC12. J 5~ , MI )al, 1, et oil Tr~ ...dmllllr.llntn8 .... Ith bod) Vltlght uppon: Ib ('fteu on rdfl.Ul'iOU· .. tlJ\ea....c t\reh l>h)\ Mcd R~habd 81:849, 2f1(10

155 rutl. G I.AXOmOhX ll .tlnm~.uKt \1I1Uail('alil)-t\llo¢d baJ.anc~ 1'-,JlOII\@ lilt .1Il trWl\ "'u~J ""'lIh RluhljlH: ....,,;kr'(\w;~ A C~·

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Physic.' Re ha bilila lion « Be II0 - H ..."~'.. V, Bene I".. . M, and MitsumOIO, , H: End ('If life: ' Ch;lflenges :md strateg ies for the re h" b dllalion pro fessional, Neurology RejX)T1 (now J Neurol Ph,Y~ TheT) 26(4): 174 , 2002, 167, Hert z. D. and Hol/:md , N : Communny Re<;OUTecos fo r Your Pati~, w th MS ( Rt', \)u Tct' B ullel i n, Informallnn for Health ~fe,slonal"). Nallonal Multiple Sclel1Ki~ SOCiety, New Yorl.

2004.

IflR. Price. G: The c hallenge 10 Ihc fam ily, Am J Nurs ~O:283. 1980. 1"9. Slu iflx·rgcn. A. and Roben ... G: Hea lth promotion practl(:~ of women with mulliplc sclerosis. Arch Ph y~ Med Rchabil 78(Suppl

.'H:S-J, 1997.

Suppl e ment a l

R e Ading s

\1 ' FIF'\' Year-\I ulllplc SdCI\K" \n E"t'IlII:1J GUldc lor l/l(o ' 1;'\\ h DIJcll{l~.1 . ~1:ul ("l" lmd Co. ~t'v, Yorl . 2002. Bun'. JS. an'd )(lh~.OfI. "p I{'d, I· .\ !ulll pk SdCl\l~I~· Diagnos,... \I ('{hc~r \1aIlJt:C'ment :md Rdl:lIllllt:mon Demo .. ~kJtcal Put-I,.hrr-.. \ l'\\ Y("In. ::'0(10 Cohen. JA. and RuJJd. R \ It'd,,: Mulrlple- Sdt'I1N~ Tllcrapeuflc,. cd . 2 \laJ1ln DUllltl. L,)nJ,)n. ~onJ C(l\I~. PK. and H.tlpt.·r. J . . ' f'("tin!! Ih(' C'h:ll leTl1;t" 01 Progrc~!> l\e ·"'ulnpk Sdel'{h" Demo .. \kdKal Puhh~he,"". r\l'\\ Yorl.. . 2001 Hf'IIJnd. ' J. \l um\. n , and R~,"~old, SC: Multiple Scler(I'I~ : A GUIde tror thl- ' ~\l l~ Otl1gnlN."d.l'd 2. Dcm~ Medical Pubh:-.hmg. ' t''' Yort. 2(102 .... alr R ·ed! \l ulllple SCH:O"''' -\ GUld(' for Frunllll'~. Demo" Moolcal Put>II·Jltn~. ' ('\, h'\fl... r99~ Dr.lh. GH. and Cal.J1lL.trO. "-I L,\ Ing \\ Ith \1ulIJpk $\ leros,,; A \\'t.'IIne... ~ -'rf'm:k.h. ed ~ Dem.~, \!N"'a! Put>II'h,"~. ;'\t'v, Y,wl . .:'«X) BI,Id..~I('In.

Kraft. G H: Rehabi litation pri nCip le", for patjent~ with mu ltiple sc lerosl~ J Spinal Cord Med 21(2):117.1998. . \ 1cDonll ld. WI. er al: Recommended dlllgnostic crileria for muhlple 'iCiI!fO';i,: Guideline" from the Internationa l Pand on the DiagO()fi of MU!' lple Sclcro1
Philadelphia. 19<"18 .

Shapiro. R: Managing the S)mplorm of \1 uh'ple Sclero,i'i, cd .l. Demo" J\'I ~dlca J Pub l l~hing. New York. 2003.

Appendix A: Modified Fatigue Impact Scale (MFIS) Farig. ue is :I feeling of p.h~s ical. tiredness an~ lack of energy th ~t many ~opJ e experience fro m ~irne to tirn~. But people hO h3Y"C' medicall:ondlllOn!) hJ...c MS c'\pcnence stronge r feelings of fatt gue morc often and w ith greater Impact than

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~ for ~rull rneMf'lS

"" Into IAFIS CAA be ggfe<J8tod I1no mr.... 6Ubo>caJe (ph}'SlCal. eogrwlNe and psychosoaaJ) as WIllI as tnIO • eoaI Uh& lI 100000te a \),eatet ompact of fa11QUtl on • pe($OO'. _ .

814

Physical Rehabilitation

Physical Subscale . Items: . TIlls scale can range from 0 to 36. It is computed by adding raw scores on the following 4

~

6 + 7 + 10 + 13 + 14 + 17 + 20 + 21.

Cognitive TIllS scale canSubscale range from 0 to 40. It is computed

by adding raW scores on the following items:

1 _ 2 + 3 + 5 + 11 + 12 + 15 + 16 + 18 + 19.

Psychosocial Subscale This scale can range from 0 to 8. It is computed by adding raw scores on the following items: 8 + 9. Total MFIS Scorecan The total MFIS score subscales.

range from 0 to 84. It is computed by adding scores on the physical . cognitive

From' Multiple SclerosIs Council for Chnical Practice Guidehnes. tt3 With permission .

' and psychoSOcial

Appendix B: An Expanded Disability Status Scale (EDSS) for Patients with Multiple Sclerosis functional Syste m s

mild decrease in louc h or pain and/or mode rate

dec rease in all pro prioceplive tests in three or four

p,nunidaJ Functions

limns.

0... ~tonnal. I. Aboom13151gm wi thout di~Jl;l illl ) . ~.

\1 LOIIJ1aJ d ISa hlli l) .

_~.

"'hid or moderate parapare~is or hcmiparesi'i: severe

~

monopare':.I' \ tarked parapare"'LI... or hemlparc"is: moderale quadri·

pare'I~; or monopleglJ . 5. Paraplegia.. hemlpic£l3, or marked q uadrip3re ~ i ~.

6. QU3dripiegl3 , - lnl nav.n

Bowel and BladderFunctions (revised 1982)

Cerebellar Functions

o. Nom,,!.

o '>onnal

I. 4.bnorma.1 "i~n\ "I \1iJd 313\13

\l

ilhoul di,a b tli l) .

3. ModerJ.le lrum:a.1 or Ilmh

~ t.a \ la

J

Se\crc

Ii

Lnahle to perlOnTI l"()()rdmat~ mo\ c me nl S d uc to 3t3t..ia.

J.I \IJ.

alllimbi\.

\ L nl..JlO\\ n A. I u-..e-d throughoul afler ~al'h number ,*hen "e
' ()rm .11

I Sign ..

nnl~

1 \1WffJlc n~'la!!fIlU~ Of other mild d l\abil ll ). S~\ e're n~""glllu"" Ill.t t:':J e\.lr.1tk..uI4lf \\ eak.ne,'!I, or modcl.tlc: dl'dhlltl\ 01 othl:""r l:r;lnial l h:TH.' 4 t>.brl.t:.d d~ .,.tIlhn.: nr oilier m..trl ed dh(l bl ti t ~. ~. InOJ~!ln " li' ... "'''1\0 .... Of ....peA l n~no\A,1I

~""I") (J

r unction.

(<<'noed J 982)

411(11 1 01 fl);Uft.'· ""

riling !..it"

h.

li.:Y,t.

"...c ollh. I n lint.' or t .... tJ

""\ "'Ihi (I \ Ica '~ Iii l"udl HI paUl Of pU ... llhlO "l'n .. "", ci ntil hJ 1I.~ ... kIo1tt dllhd .. l HI \Ihllltlt.m IH Uill" tlf (\ioU Illllt: 1'1, Ihfoll"r~ l.k~ h '- .. t· dlvm III lhrt't; IIr hlUI

Imill 1

e141r;"

"'IJ..." t:1

U· f"'ol!:le In toJtJ~h ~1I >fflfl..ll) 10..1 \1 \,';£11"0

rum

~Ir

l)(hlllUlt

IIll.Ut' \)r }\.\\I

I. Scotoma \\ Ilh vi 'iuaJ acuil) (c.'orrected) bert!;!f man 20/30. ., v" or, e C}I.' \\lIh , COlOma "ilh 1n3\Il11aJ \i\ual acuiry (corrected I 0 1 20(.lO t" 20159. 1 \\ Of~ f:ylo! 'Wllh IdfgC ,~'otoma, Uf Ill.oJe-Ci.tte dccn:a~ In

"uh IOd\lmal \ l.) u31 d4.'UH) H. orrectt·d ) u f 20/60 to 201'J'i .t \\ 01">(' l~)l'" Yo nh marleu del'f("a..~ uf tit"'ld.") ..and ma~imaJ \I",uJI o.ll.llll) (\.utTr t. h.'d) of 20/ l():) ro ~O/.?UO; gr.tde 3 plu'lo 1Il..t\ ul1al .t.. Ul f) ot lx' u e l I')C of 20/60 or )CS~ . tieilh , btH

u1'IlI ..11 !

I. Mild urinary he sitancy. urgency, o r retention. 2. Moderale hesitancy, urgency, retention of bo\\cl o r bladde r, or rare uri.nary incontinence. 3. Frequent urinary incontinence. .t . In need of almost comaant ca thcterizatjon. 5. Los> of bladder function. 6. Lo" of bo\\e1 and bladder function . V. enknown.

VISual (ur Optic) Functiuns O. Nonna!.

Brainsl..m Funclions (I

4. Marked decrease in louch or pain or los!) of propriocep· lion, alone o r combi ned, in one o r IWO limbs: or moder· ate decrease in touch or pain and/or seve re proprioceptive decrea~e in more than two limbs. 5. Los~ (essc nriall y) of sensati on in one or two limbs: or moderate decrease in touch or pain and/or loss of proprioception fo r most of the body be low the head. 6. Sen ~alion essentiall y lost below the head. Y. Unknown .

"-'Ih~

IlInh ..

\11"

"

\\ nr-.< I.. . )t: " ith HIi.I\lIl1al \ 1),UaJ .\CUIt) {l..:orre~led) le.\.c, th ..m :!lJ.t200, ~r..aJ~ 4 pith nU\lOlal JtUIt)' ot bcn~r e)e

h

GI.tde ~ piu . . tnJ \j tn!U \bl l .... t JI..UU ) 01 hen~r e)'i! uf

01

20/t,l1 or k',

2tl;()('lof k·"t..,

\ l i1 ~ 1I0" n X. h _,,-"led It.l ~rd&.·", 0 to P·1i1(J(

tt t,)T

pfY~n\.'~ \If lemp...-vai

816

Pbysical Rehabilitation

5.0 ~ Ambulatory wilhout aid or rest f or ~bout

Cerebral (or Mental) Functions

o.

Nonnal. ) I. Mocxt a lle-rali('n o nl y {doe~ not affect DSS !)corc .

"\ Mild decrease til mental ion . ~ . Mode ra te decrea$c in mcnl3tiOI1 .

.'

,

~. Mart. . f'd decrease in mentation: chrome bmm :-.yndromc.

modemtc. 5. Dementia or c hronic brain syndrome: severe or Incompetenl. V. l 'nknov.-n.

Other Functions O. l\one.

. I . .\ny other neure>log'c finding< attributed to M S (s!",c.fy ).

\ ' l lnl..nown .

u-panded Disability Status Scale (EDSS) ,

o=

1.0 ~ I.~ ::

e0

~

c,~ =

:;,0 =

,",pnnal neurologic t!\3m (ali grade 0 In fUl1(, lIonal >,stem' [FS) : cerebral grade I acceptable). ":0d'S3bll.t~. minimal sign, in one FS (I.e .. grade I e\cludmg cerebral grade I). \ l' dJ'3blhl~. mmnnal .sIgns In more than one FS troore than one grade I e\c1uding cerebral grade I I. ~1 ml1n"1 d"abiilt) .n o ne FS (one FS grade 2. othe" 0 or I), ~' 11111nal J".hllit) tn t"o FS (t"0 FS grade 2. o th e'" () or I) ~1odCrJle d"3b.!Jt~ 111 one FS (one FS grade 3. oth· er. () I' I J. or mJld dISability In three or four F I thre 10UJ F grade e. othe l' 0 o r I) tho ugh full) d.lntxJldto,)

, <

Full~ )fh:

1\\ ,

J I

J.11100LtIOf) but \\ Jill mooerme d l'!)dhitll~ ITl ~)ne ~rade 3, .tnd one or t\' n f-S grade ~ (lr F~ r-radt' ~.. , \.\r fhe F~ ~rJ.d< ~ tothe'f't (J or I J.

f·

rll,l~ o1nlhtil.lIo~ .... !thout JJd, ,d l -I.,ulllueni. up

:..nd oJ :luI "'l~ 12 h\.\uT"I ;} d;j) Jt:'rlte r~I3I1\t"I) "-('\e-re .jl"lJ.htll(~ ... ,.n" .. ung Of ont r s 1!r.tdt.' 4 jl)tr~ .. I. l\' 1 . of <.omhll1:11lun, uf k',c:r ~radr:~ t.' \.nJJ:I~ limit o j pre\ I"U" fc'p .. "-hle: It) "'.tIl

+.,

f."

Me- l..OmhHhtlll,.\n\. gcnC'rJII~ lrJt.k"'''' Ifl ~...,CraJ. Y'lem, I 1.:'lo«ou.1l1 r -'ItCh. lui I., ht-.j mlKh 01 the' d..t) . hai ,ollle- dtcl.."II\l"" U,~ til ",.tl\: tuu ... tl\~j'" t l u•.d

IAitnou131\j 01 It'" '\)ftK" :'\( '" ml.·lt.'f

h .. 1

of till. J .. ~ t\o.!.\t"

.1,1

·I.'C

r.d .. ..;

u, . . oi.l

'.u c It)

IJ.

.lid,

up ..UlJ ;.tht~1 rlllu. . h

11011"\.

full dol\ 111.." lI(h\~r" I"-C:

t·t tull

..k·U\ 11\

HI

d .... r.a...klll d )\ Itl... 11 (""1\ l,lJ.I) {'l.otl I lir.. If 1., 1\

I I~ ... OII,fn:'MI,,)1 l..1 h c\.\J ,): t 1,lt .. ;,1 'fe\' J\l' kT tuJ of r~ ... r 'r

til 1ud....

~-C;'k:I.JU

Hdple ... , tx'{1

f t.'lI l1ll ,

.(I ' t'fll tllIr

0lJ

"'4. . -

\iJ .... ,g... •1

IUIlUoIlI(l1l

).. W! II.'

l.un .. 1 " ... ,

I ....

..... Jth.. ltlt

dmo1..li.1t'!f

200

mclers: disabil ity seve re enough t ~ IInprur fu ll daily activilies (e.g .. to work full day wllhnul special Pmvision;). (U,ual FS equivale n" are OIlC grade 3 alone. olhe" 0 or I : or combi nati ons of le'o;cr &rades u ua ll y exceeding speC ifications for Mep 4.0 .) 5.5 ~ Ambulatory without aid o r reM for about 100 meters: disability ,evere e nough to preclude fuU daily activities. (Usua l FS equi va lent> are one grade 5 alone. others 0 or I : or combinations of I..... grade, usuall y CKceedll1g lhose for ' Iep 4.0.) 60 = Inte nnitte nl or unilate ra l constant as,iSlance (cane . crul ch . o r brace) required to walk about 100 m.~ with or w ithou t res tin g. (Us ual FS equivalent, 3rt combinati ons with more than IWI) FS grade 3+.; 6.5 = Constant bilateral ">si"ancc (ca ne>. crutches. or braces ) req uired to wal ~ :.ooUI 20 meters without re,ling . ( sual FS eq uivalenl' are comblOatiom w ilh more than two FS g rade 3 7.0 ~ Unable to walk beyond about 5 meters even .. jib aid .• "cntially re'tnc ted to wheelchair: wheel, ,. re 'tflCted 10 wheekhair: mal need a.d 111 tran,fer.... heels sclf but ca nnot ca rryon 111 ,tand.trd ",heelchalt a fuji da) : mal re'llllI'C m<>tortleo ... !todd"",. (usual FS C4ui\ ,tlent , !tre tOmblnJtlOn, "'" 111'1 more than one FS grade -1 +.) ,0 = [',on".II1 ) r.,tm:teo to bed " r th.m ()( ambul.1ttd In "hcdchall'. hut 10.1) be out 0 1 J>,ed 1I\eli much of Ihe tid} . retaHh m •.Ul) \(!II-l J.rl! (unOU)Il", ·.:neraily h,.h dtc~tI\t· U~\ 0 1 ann I l ,u,11 I-S c~UI\Jkru

'J -

1 (.:tU

t

'pdfl ..'n

~JllC',.

r"

)

'd

h:{~Un., "JOInt 'itlt-

'qlH,,JlcHh ,Jre: l.lJInmrw·

In "",-,"\ ..'"r.ll

""'

,l ",u,JI f '\ \"4Uh Jel lh gJ~.u.j !

'k'"1

lIllu

\ ... t m .. )

l..\H lHII ;tllUnt .. Jk" .,t!

~

It.k:N

tal

1Tl'~.tv

n. .t~"'· t,,) \.~"11J'JW111

u.11 f~ 100

JnJ

1..,IIJ1PIIMtlofu.

u",..

Appendix C: MS Daily Activity Diary InstrUctions 1. AI the lOP of the da) .~ diury. describe how you slepl the night before. ") !\ssico a number value from t to 10 ( I being very low and 10 being very hi gh) for:

- ' : "o~r level of falig.uc (F)

. The \'aille or importance of fhe aClivily you are doi ng ( V) (.lIti~facfion you fec-! with your perfomlance of the aCli vi ly (S)

• The

You can compute the '\ alue" of an activity by comparing it to other acti vi ti es you would like to do d uring Ihe course of the day.

For example: I pm : F 7 V 3 S 2 Act;'-ity: Fixing lunc h sta ndi ng 15 minutes (hot); Comment : Blurred vision

=

=

=

3. A]"'3)S describe the ph~sical \\orh. done in the Act ivit~' secti on (c.g .. stood to shower 10 minutes. went up 20 stairs. " -alkod ~OO feel) _ ~.

Note the exlernaltemperature o f the environmenl under Activity. 5. List under Comments 311 MS symptoms a~ lhey appear or worsen durin g the day, including cognit ive problems, visual problem!'!. "eaknes~, dizl.ines!'!. dragging foot, pain. numbness. buming, and so forth .

-

6 Make notes every hour.

Name - _ _ __ _ _ __ _ _ _ _ _ _ _ _ _ Date: _ _ _ _--.:.,'= -___________ Descnbe sleep last night: _ _ __ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ __

F

Tune

s

v

Comment

Activi

6:00AM 7:

8:00

~'---+I- _~Ir-_-_-_-_-_-_ -_ - _-_ - ++_-_-_-_-___ - _-_-_-___ -_-

9:00 10:00 II~Xl

I~:OO

PM

I :W

2:00 • IK I

4'.1 $ -111

ficlj()

7 (~I

",'-'

-=-+--+-----+-------------------~----------------~

r

....

-

--{--------1 --f--------~ I

V'WI linK! I Ill)

1-----

Appendix D: Web-Based Resources for Clinicians and Patients/ Families Living with Multiple Sclerosia National Multiple Sclerosi. Society Americans \, ith DisabllitiC~ Act: ADA home page MedIcare infom131ion

Soc,al Secunl) Online National Ins[ilLllC of Neurological Dt:-.orders and Stroke

N.l1onal Library of Medicine Archive:, 01 Nt'uroJog)

i'\eurolog) CenlerWalch Chmcal Tn.l, L,qing Service verernns Affalf'> M Cenlcr; of E\cc11ence CLAM : Compu,er LlleralC Advocates for \luJliple Sclem," Con,omum of \lulllple Scleros,s Cenle~ The Iieuga Cenlcr- M Can Do program \l uhlple lern'" Inlemalional Federalion o\.mgen--drug manufacturer of No\-antrone B,ogen-drug manufa.:lurer of A\'oncx Bcrlex-dru g manufat1urcr "f l3el3>.erOn rug manufo\.turel of C'op!u,nne

ll~'a ~ eun)-,(·Ie m.e~

Sen)no Gwup -drug tnJnutaclurer of Reh,f

hllp:/www.nalionalmssociely.org hllp://Www.usdoj.gov/crt/ada hl1p:/lcms.hhs.gov hllp:/lwww.ssa.gov hIlP:/lwww.ninds.nih .gov hllp:/lwww.nim.nih .gov hllp:/larch ncur.ama-assn.org hllp:/lwww.neurology.org hllp:/lwww.centerwalch.com hl1p:l!wWw.va.gov / ms hllp:/lwww.clams.org hup:/lww".mscare.org hup:/lww\\ .heugn.org hll p:/I'" W\\ . msi f.org hllp:l!ww\\.nmgcn.com hllp:/Iw\\ W.nOY;lOlrone .com hllp:/lv. \\ W .l1lsacth C'Ollll'e.com hllp:/I\\ w" .hiogen .wllI \\ \\ Wa,one • . om hllp:/'" \\ w.berle\.com ,,\\ v. . bet~ roo. om hl1p:II\\" ....Ie\ancufll-.c'cn e.coOl hltp:/,'' ' .... '' .m \\al.:h.com hllp"/" " .......cron.,. om hl1l':/I"" \\ .reblt .Cl.m hllp:/I"" \\ m,\\orld .vrtUU-< ,,)fll hnr Iii' '''' •IJn "I'm ,I \ , \ nlelll"" r, . ~... ok"tonahl I Jf' lIIp ""\\ 4.UhOI111I'ubl, tpul-It ~Ju _111)0 \ IIUP II '" u '" n l.1!l'- l-,,\ffi

hllp j,,, ,,,, p "OI~ ltllp Jj " "" . b,ll1\hub '~,~t' u h . JblnL 1>.I .'~\I hili' WI< \ , J , ....,u-'LI ,-J<'UIIfl<' ~pHi

",,:l'" ",,'

,

h1111'/ """'" lJ .1· uHI

lip l """

hur t

\Ii.

lilt'.

""lo,i"" 1>1 ~JIll. u ,hI

;.k\..\:

lr." ,,~r

hlh."(\,,ull .\. '

C IJ A P TE R

20 111"11' .IJECTIVEI ()e5Cribe the epidemiolol!). eljology. pa~ho­ J. . '" diagn{lS'S and general progI10~1' o f genesl.. ' . LS) .00000hic later.. 1sdero'ils (A . ~pilre and (..'()llIraSI Ihe EI Esconal di:lg 2. no..g ic cricen3 for AI...:-'i. . Differentiate among IOlpalnnents relaled 10 3. Jower mOfor neuron palholog~. upr:cr motor neuron palholog)'. and bulbar Impamncnt!>. 4. Dlscu\S the medica1 a~d hea lth care management of tndividua.b. Wllh ALS. < Outline a framc",ork for rehabilltallon for •. md>viduals with ALS. .. ()escnbe the components of, tl~e physi~al ther'3p) examinanon for II1dlV1dual~ " 'Ilh ALS. 7. Describe: the role of Ihe ph)'sicallherapi~' in the management of an ind;";jdual with ALS and the factors that innucnce intervention

-

opUon~ .

a. Compart: and contMt overwor~ damag.e and dl!iU~ atrophy as 1t relate 10 ALS . • . Sununariz.e the hterature related to exercl
Amyotrophic Lateral Sclerosis Vanina Dal Bello-Haas,

IlScI'T, PhD

OUTLINE Sensation 833 Poslural Ali gnmcnt. Conlrol.

Epidemiology ~2() Etiology X20

and Balance 833

Gait 833 Respiratory FUIl<.: tion 833 Inlcgument 833

PJlhophy!' iolog.y 821 C li nical M,lIlife ... t.lIiun .. R22 Impainncnl<) Relalcd 10 LMN Pathology 822 Impaimlcnls Relalcd to UMN Pathology 823 JOlpainnc nts Related 10 Bulbar P:lIhology 823

Funclional SLillUS 833 Env ironmenta l Barrier.. 833 Fatigue In) Di!.ea~ · Specific

and Q uality of Li fe Mea!lure'i ~33 Di..ease-Specitic Measures 833 QualilY of Life Me
Rc!>piralory Impairments 824 Cognitive hnpainnenL" lQ4 Rare Impalrmcnt'\ 824

Phy\ic,11Therapy Intervention'} 834

OlOlgnO'il'_ 824 DI'oCa.. . c

COU~

Cervical Mu,c1c Weak.ne,,!1 835 Dy~anhria and Dysphagia 836

l<2:ri

UE MUlIde WcakneslI Shoulder Pain 837

Prugno<"'10 X25

RC!'Jpiratory Mu~lc Weakness 8.' 1 LE Mu<'(; k: We
Man.tgemenl 826

Di....ea ..e-Modifying Agents 827 SymptomatIc Managl' nlclil M27 Fnuncv.nrl. for RchabJlnal101l

Ino

PhY\ lca.1 TIlcmpy E.xamlOdllon X] I

Cognillon Xl2 P.s.),chO,)Ol'I;il Fum;li un X]2

or Dal ly LlvlIlg !:ns

Dccrea....ed Mobilil y 1139 Mu,clc Cramp~ Ulld SI)a"lil'II)'

~4n

E\cru\t' and AU, ~·II DI ~ u!'c Atrophy 8-1 I Overw.t Fallgut" H-II J'IlIlCfll/C'hcnt R{'I.lh,:d In"llth.llon H-J2

Mu IM.:)(o Pcrlorm:t/lcc k '2 M Olor '·ulI\.:lIon X31 H.cncxe ..

Al·tiv ilics

Psycho-.ocilli IS5 UC' ~40

I\un K32 Joint hw:gruy. I~an ge of M,,,iul1, and Mu ..... lc Lcllgth t02

lvllc and

837

,",uJnnl"lrv ~ I

X12

Cr
Mffltlf

nturon di!itoea~~ ( M~U , II\dudc

iJ

Ikh! mgl'ncou,

peuru.fl"ll)f mhenuil dnd t. POfJOu.. / 110 family h'''J !f)(y)

~hn"dl dl~rder

01 ttK: upf'tr 1I10lnr neuron"! t t M f\ .\ J, ~tr molor I\euron~ fI .MN"" or a llJtnbtn,t!lon ot oolh'

rr ..htt 21).1,.

Am)otrophic latt!ral ""'Icn~i~ (A I.S),' com

monty kJloY
IIllhe::

\ptn~ J

(:1.)(1..1, bnun I;. l,-,n, and bn,un. n'~u"jng 111

\-Mlety 01 li MN iUlll1 MN clinical M~n ond \}mpcums. 1

820

Phy'li icaJ Re h abili fafion

Etiology

Table 20.1 Motor Neuron Disorde rs

~

AmyotrophIC latera! sc!eroslS

Degeneration of the corticospinal tracts , neurons In the motor cortex and 1 bralnstem, and anterior horn ceUs In the spinal cord

Othcr than a .. mall percentage of ca'iC'i. etiology ror the InO"! part i .. unknown. It I' hypothes ized that no one single Illccha ni .:., m. but rathe r muhlplc mcchanl.!lms, may be re<;pon,ihle for neuron degeneration in ALS, ll Possible pathological ITIcchnni!-olTI' include:

Pnmary lateral sclerosIs

Degeneration of upper motor neurons

I , Slfpc/fitide dimlllfOses (SODs)

ProgressIVe bulbar palsy

Degeneratton of molar neurons of cranial nerves IX to XII

Progressive muscular atrophy

Loss or ch roma tolysIs of motor neurons of the spinal cord and bramstem

Adaoted

In

I

I

;:lrC IJ

group of enzymes

that ehmlnate oxygen free radicals, that, .tJthough prod~ uel , of norrn.u cell mClaboii.'!.m. have been implicated in neurodcg,encrallon, There are three isororms of SOD in ilumaO) : CYIOJo!lC ((1{Jper.::ill(' luperoxule dismuzau (CuZuSO O) . f11llncitondnol maflganese superoxidt dij· (,'vlnSOD). and erlra rellu/ar superolide d,S!1u". 1we (ECSODI SODI . a ge ne on chromosome 21. encode" CuZnSOD, Genetic stud ic., of individuals with adult ·(ln~CI FALS have determined that uOOut 20 percent 11II1WS(>

pan from Rowland. LP 1

of thc-..c mLilviduab have mutations in 00/: however, the primary ge ne defect ;; un\.nown. When the SOD enzyme act ivit)

Epidemiology It I'" 1' ... IiJn.lled th.11 ~O,(I0U lI1dl\ ,dual ..

(}.f I

~L:-'

In fhe

~.a

~,lll tJ.j,.

at

..

•.14:11\ II).·.. ' \ug~(" .. t1ng lhl: mutJnt

:tn~

Ilh_'IU(·H<..t·.4 hi HllJ"-'"

~er' a ..:a.M,:ldc ('I ("\ ~nt.. k.k.llng

I'll,;! "1(1,0("1

4.ldll l u .. l1 At.). .. ..t.ntxtur .1I.1n~ .1p' It~ J\C'r.igt! .Ii"· I..It In-..e: J:!o tltc rod ttl"I.H!>" "\h " .. \tu,t ... tUJIt.·, hd\ C h~n.l lhJI lite,:

.1J'<'.)"- Affl."\

t, m~n ,I!chlj~ mure dl.1tl "~)Jllt"n, '" Hh

\lIll.th~ r~tld (~t i ~ r.' Ihl' ~~u.kl rtla:.~tJ 11K I

:&-1

"'Pf'l

..."ht I:' II

I

ttt 1'1. hnll

tll!Kllkd..,

fAI

I

~ til'''''' "" l'f •• Il~'J tlu.- .Itt" pi I1\.C b k, ... Pn.'H1)uI'll.{:J I n ",

"" Ilh\1 ... 1tH: JI-..c:"J"'j,.· IIt"tnt U"ll! 'IUljjiJ,:. \/ \

· ,1 ilidll I'i'U.t!

-,'I .lllilN.1I1Ioli .. h,

1\1\.1.11\ I. .Hi 'ln~ H(un\.lq;~~rJh\.~"

,phaoli.h

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Physical Rehabilitation

E tiology

Table 20 1 Moto r Neuron Disorders Amyotrophic lateral sclerosis

Degeneration of the . corticospinal tracts, neurons In the motor cortex and brainstem, and anterior horn cells in the spinal cord

Primary lateral sclerosis

Degeneration of upper motor neurons

p rogressive bulbar

Degenera tion of motor neurons of cranial nerves

palsy

IX to XII

Progressive muscular

atrophy Adapled

In

Loss or chromatolysis of motor neurons of the spi nal cord and brainstem

part from Rowland, LP. l

Epidemiology It ,. . e,timated that 30.000 ind ividu als in the Un it ed Swte~ hine "'LS at an) one lime and I 5 cases of the di sease are diagno ...ed per da) . Except in a very few areas. such as Guam and me K il Pe nin sula of Japan, more recen t studi es report the o\cfall IIlcldence of ALS to be in the range o f 0.4 to.1 ~ ca"e .. per 100.000. wi th the inc idence increas in g \I, ith each decitde of life. unl il at leas t the "even lh decade. The pre"lence of ALS ha, been reported to be hi ghe r th an the Int.-idenee. 4 to 10 ca~~ per IOO,(XXl.:\-1 Although ALS can OCTUI at In) C aitel'ts men ~Iightl~ more than wumen. " ith .tn o.1ppro\Jmate rJ.110 of 1.7'1 ."'; hu"e\t~r. after the age 01 65. £.hI'! gender relo.1ted incidence II. le~~ pronounced ; In 5 pen..:c:nt til JO pt'r(.;~m 01 1111..11\ Idual ... "nil ALS. til(' dl ...eJ ..e I" mhented 0,1 ... ;,in d.uh.l.,lImal d(lnHI1JOI 1• .111 ifmmlwl 4.L) / rAL \/I. ( Jllhnub!h fJ.fI: n.\-.e~ of ju\enJie on~e l ALSt o.1rt' mhentc:d II I un
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Other th an a sma ll pe rcent age of cases, etio logy for the most p:lrt is unknown. It is hy ~othes i 7.ed th~l no one s ingle mechanism, but rather multiple mechanIsms, may be respo nsible for neuron degenerati on in ALS .!] Poss ible patho log ical mec hani sms inc lude:

I. Superoxide disnwtases (SODs ) are a gro up of enzymes that e liminate oxyge n free rad ical s. that . although products of na nnal cell metabo lism, have been implicated in ncurodege nerat io n. There are three isoform s of SOD in humans: cylosolic copper·: inc superoxide dismutase (Cul l/SOD ). mitochondrial manganese superoxide dismutase (MIISO D). and e:rtracellu lar superoxide dismll· tose (£CSOO). 5001 , a gene o n chromosome 21 . encodes C uZnSOD. Genetic studi es o f individua ls with aduit -o nset FA LS have determ ined that about 20 percent o f Ihese ind ivid uals have mutations in SODI : however. the primary gene de fect is unknown. When the SOD enzyme ac tivi ty is decreased , as has bee n observed in indi vid uals with FALS w ith 500 I mutations. free radicals may accum ul ate causing d amage.l1· IIUQ Most muta· tions ident ilied in FALS show modest loss in enzyme activi ty.::!O suggesti ng the mutant 50D-1 prote in may have toxic prope rties that cause mo ior neurons to die, the mec hanism o f which has yet to be determ ined. 13 2. GIl/fan/me. an exc itato ry ne urotrans m itte r. has also been im pl ica ted in neunx lege ner:ujon. Excess g lutamate tri g· ge r, a (.·a~(·ade of eve nts leading: to ce ll death Y Increased leve ls o f g lut amate in the cerebros pinal tluid (CSF). plasma. and in postmonem ti...s ue of indiViduals with ALS has bee n repo rted."" In 1995. a de ri clenc) in EAAT2. a speci fic g lutamate trans porter proteIn. in the mo tor rone"\ and ~ pjna l cord o f po5.tmo rtem ALS ti ssue \\ a ~ re pon ed and lends :,upport to the theor) o f c'(cit£r 10,\1(: 11 )

c ilu ~ ln g

ncuroJegeneralton. ~l;J

3. CllIl npl ng of neuro fil..t menl prull:lIh to to ~rhero ids ID 1~ ~cll tx.xt) and prox lIlla l a \ o n "ont" lIf the ht ... w patholog· I~J I (. h.tr;.u,.:len ... lIn o f ALS I :~ ~I't \Vheth"r o r nm abnorl1\:tl ::K:lUIlIUlau oll IS '>CCOIHJM) III the JXllholog)' or if II Lontnbult: .. h.l motor IlI..·ll hJn dl'gt'lI.:n1t ll.m h"h )t!t 10 !;'Ie dck lilHI1t"d Ii

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C hapter 20 AmyolJ'ophic Lateral Sclerollis LS have nol bee n conclusive. For example. a post· fou nd dec,reased amount s of cil iary neuphir faclor {CNTF) In the ventral hom of the spinal blu not in the mOlor cortex ; nerve growth faclor~ co . deCreased in the molor cortex, but increased in the wert . I \l ..nlumn of the ~ pllla cord . IlreraI ""-' . ()ther potential theones that have been tho ug ht 10 con6. 'bUlt' 10 ncurodegeneralion in ALS . which have limited D1 • I d . or indirect evidence. me u e exoge nou s or e nvlronm enlJIl faciOrs.J..l apoplosis. programmed cell death,35 and

~em study

ror;

. viral infections.

821

o

..

'"

Pathophysiology Amyotrophic lateral sclerosis is characteri zed by a progresdegeneration and lo!)s of motor neurons in the spi nal

Sive

roni. brain;!em. and motor cortex (Fig. 20. 1). UMNs in IDe cortex are affected. as are the corticospinal tracts. Bramstem nuclei for cranial nerves V (trigeminal), VII IfarlalJ. IX (glossopharyngea l). X (vag us ), and X II ihypoglossal ) and anterior hom ce lls in the spinal cord are also imolved.2 Brainstem nucl ei for cranial nerves controlling external ocular muscles (fll : occ ulomoto r. IV: troChlear. and VI : abducens) are usually spared. and if degeneration occurs. it does so late in the course of the dis~ .r; Molor neurons of the OnuJrowicz nucleus (Onu!'s nucleus), located in the ventral margin of the anteri or hom in the second sacral spinal leve l. are also generall y spared; if the} are affected. it is to a very limited extent. 38.3\1 These neurons control striated muscles in the pe lvic floor, includI1lg anal and e.\temal urethral sphincters. 40 The sensor) system and spinocerebellar tracts are also generally spared in ALS . Some studies suggest that se nSO!) neurons may be involved in ALS. but to a much lesser extent than the motor neurons. Morphological studies have fOUnd peripheral ~mj,ory nerves exhibit axonal atrophy. demyelination. and degeneration 4 1 42: dorsal rOOl ganglia cells at autopsy reveal los~ of large ganglion ceJls.43 De.generauon of Clarke'~ neurons and of the spinocerebellar tracts has also been reponed ."4-46 Degeneration of the 'PlIlOCerebellar lracU. j.!, a well -recognized pathO logica l

Figure 20.1 Luxol Fast B stained cross section of spinal cord at the high cervical level from a patient wit h classical ALS. Marked pa llor. secondary 10 dege neration of the latera l and an terior corticospinal tract'). can be seen (large arrows). The ventral roots ( V. small arrows) are atrophied. especially compared to the dorsal roots (D. small arrows). [From King. PH , and M i l~ u moto H: Neuropathology of amyotrophic lateral sclerosis. In Be lsh. JM, and Schi ffman. PL (eds): Amyotrophic Lateral Sclerosis: Diagnosis and Management for the Clinician. Blackwell Publishing. Oxford. UK. 1996. P 205. with pennission.]

fea ture of FA LS and has been described in sporadic ALS, altho ugh it is rare. 44 Posterior co lumn degeneration is more common in FA LS, but rare in sporadic ALS.47 As motor neurons degenerate. they can no longer control the muscle fi bers they innervate. Healthy, intact surrounding axons can sprout and reinnvervate the partiall y denervated muscle 48 (Fig. 20.2). in esse nce ass uming the role of the dege nerated motor neuron and preserv ing strength and fun ction earl y in the disease; however, the survi ving motor units undergo enl arge ment. 49.50 Reinnervation can compe nsate fo r the progressive degeneration until mo tor uni t loss is about 50 percent" ·'" and electromyograph y (EMG) studies have fou nd ev idence of motor un it reinnervation in individuals with ALS.j ,·j2 As the disease progresses. rei nnervat ion ca nnot compensate fo r the rate of degenera tion." and a variety of im painnents deve lop (Tab le 20.2). The progression of ALS is thought to spread in a con· tiguous man ner. with in sp inal cord segments (e.g., cerv ical segments to cervical segments). before deve lopi ng rostral or caudal ~y mpto ms.17 .5] Th us. signs and symptoms spread

Oenervallon

Healthy

Reinnervat10n

.-,.!\ .

B

c

Fagure 20.2 Sproulln&:: (AI Normal motor- neuronJo, (8 ) Dt'lleTvabon ; «(') Rcinnerv:luQn,

822

Physica l Re habilil81ion

.

d

'th Amyotrophic

Table 20.2 Common Impainnents ASSOCIate WI Lateral Sclerosis Impairments related to LMN pathology Impairments relaled 10 UMN pathology Impairments related to bulbar pathology

Spaslici ly, palhologlca r

,

Dysphagia, dysa rt hria, sialorrhea, pseudobulbar affect Exe rtional dyspnea . nocturnal respiratory difficulty, orthopnea ,

Respiratory impairments

hypoventilation

Dementia, cogn itive impairments

Other impairments

Sensory impairments, bowel and bladder dysfunclion, ocular palsy

Rare impairments

Indirect and composite impairments

Adapted in part from Swash, M .2 LMN = Lower motor neuron; UMN

.=:

Fatigue , wei ght loss, cachexia, decreased ,ra nge of ~otion . ten~~n shortening, joint contracture, joint subluxatIo n., a~heslve capsuhtls, pain, balance and postural control impairments, galt disturbances, deconditioning , depression, anxiety

upper motor neuron.

locallv wi th in a reg ion (e.g., bulbar. cervical. thorac ic. lu m~sacral ) before moving to other regions. Caudal-torostral spread within the spinal cord and spread from the cervical 10 bulbar region appears to occur faster th an ros. I cord . 17.. 51 tral·lO-caudal spread W .II h'to t he spma

Clinical Manifestations

w ith bulbar o nset may not ice c han ges in the ir voice, diffi cult y mov ing the to ng ue. dec reased abili ty to move the lips. or ope n or close the mo uth . In A LS, cerv ica l ex tenso r weakne ss is typical. D4 ind ividuals may init ia lly notice nec k stiffness, feel " heavyheaded " after read ing or writ ing , o r m ay have difficulties stabili zing the head with unanti c ipated movements. such as in an acce lerati ng car. As weakness progresses, the head may beg in to fa ll fo rward . and in m ore ad vanced stages the neck become s com pletely n exed w ith the head dropped

Clinical manifestations of ALS vary dependi ng on the localization and ex tent of motor neuron loss, the degree

and combinallon of LM N and UMN loss. patTern of onset and progression. body region(s) affec ted and stage of the di~ase. At onset. ~ i g n s o r sym ptoms are usuall y asy mme trical and focal 2 and prog re~s i on of the di sease leads to IIlcreasing nU1l1ber~ and sevc rity of impairments.

Impairments Related to LMN Pathology The m OM frequtlll pre~e.nli n g imp. t MU ':oc k wea~ ­ ne')!!. I') con\ldered the '-' u,rdlllu l ~ I£n of ALS a nd Tll'-ly be ca u'ed by LMN or UMN 10\\. The "'cll\....ne\.' .. ,st)(;la lcd "Jlh LM!\I l o~\ c au\C ~ more ,igmtiutnt d}':oiuIKlI un thun Ihe UMN lo\!'o weaJ...J1~\~ .~~ Inll ial mu,de weak nc . . .., u", uall y OC(:ur., JIl I..,oldl ed mu,t1t" . mO') 1 olten di !>l.dl y, and..., 101 luwed by prO£fC\,)lve ",ca kne~" :.md t Ulitiion.1I 11I 11 11a Ilon_~.~ y h,r e~ample, .11 <m..,et an IIIdJ\ Idual may IWIII..'(' difficulty ", lIh fine IllOlor m U\,C llle nh , Mll h ii' bUllolllllg. pll1(;hulg , or '-'rHlIlg , or 1llU ) nUlicl! loot · ' ~ I 'IPPIJI g" ill IIl(:rt: d... ~d fre4UelK) 01 InpPlIIg ",hI lt: .... i.lI~, III~ . l t1d lV ldual!>.

forwa rd . caus ing ce rvical pain and impairments in ambo· lati on and feedi ng (Fi g. 20 .3).

Muscl e weakness typ icall y leads to dec reased range of motion (ROM). predi sposing the pati ent to j oint subl"xa· tion (e.g., shou lder ). tendon shortening (e.g .. Achilks ). jo int conlractures (co mmo nl v cla \\ -hand defomlity) and ad hesive capsulitis. \Vea knes"s also resulrs in JmbulutiOfl diflicuhies. deco nditi oning. J nd impaired posllIrai control and balance. Foot drop. secondary to d is[a l \\<eakness, and inMability. secondary to proxi m al \Vcakne~s. are common. T hl! patt ern amJ p rogrcs~ion of LE we.tlness is chartKlerized by grci.Ilc r Josse" of mu"l'I e forl.:e in dbral muscles cOlllpan:'d 10 prox imal lIl u..;(' les. ~"'--~{'\ A rc rrospeclivc ~wJ)' found th aI decre: ..,cs 111 \ , ~I H,iJl1! ap ilil\ from independt'nr \\a n, ing. Il} waU.. in,u in the I..'on;mun il}; wit h ti.:.si"lanci'. to wa l king 0nl y a l home, 10 bC lIl g un;lble 10 walk Wl're pn; C IP H ' Wt)1 k ,II a higher pen.·l!flIage of their ma1( III1 ~11 Slrt'l1gdlll~ pt' rlnr l1l thl.' ".tnw ,1CII Vll y. Thl :') h" ' l en') lI1u ",d c t'al igtJ('·

ALS . A"

Chapter 20 Amyotrophic Lateral Sclerosis

823

sive capl'uliti s. or contractures. Cramps and spasticity are other sources of pain. as is increased pressure on the skin , bones. and joint ~ ow ing to immobi lit y.2.34

Impairme nts Re la ted to UMN Pathology U MN loss ma y a lso cause muscle weakness , but is characte rized by ~pu~ ti c il y. hyperflexia. c lonus. and pathological renexes. ~ u c h as a Babinski or Hoffmann sig n. As the disease pro gressc ~ , UMN ~ igns may d ec rease. 2.~ Spuslic it y can eventuall y lead to contractures and deformities. as well as cau se dyssy nergi c moveme nt patterns. abnonnal timing . loss of dexterity. and fatigue. all of which impact motor control and funct ion. 6l ,62 For example. difficulties with the swing phase of gait secondary to distal spa sticity ,lIld dec reased ba lance seco ndary to generahzed spasticity are often seen in individua ls with ALS .

Impainnents Related to Bulbar Pathology Figure 20.3 'larked head droop ill a 65-year-old man with ALS "ho fiT'1 de\eloped progress i\c \.\cakness in both upper Nremlfle, 1From ~tlt.) umoto. H. Chad. DA . and Pioro. EK .S4 p 52. "llh perml,slOn.)

FatJgue rna) a ls.<> be related to sleep dbturbances. respira ImpaIrments. h) pox ia. and dep ress ion . Sanjak et al. demon~lrated that indi vid ual s w ith ALS have abnormal ph~ sioiogicai lnd metaboilc re sponses to sing le bout s of exerclse.~~ Sharma and coll eagues found that in individuals ",ah ALS. tetanic and maxima l \
As mu!.Cle fibe r~ progress ive ly denervate. [he ir vol um e decrease . . re.,ulung III 3tTOph). Fa!>clCulations a re com mon 10 IOd, \ildual ... v.nh ALS. a lth ough the) are rarel ) an initia l symplom. The euolog)' of la~ucul3tion., remains unc lear and l~ thought 1O be: relalt:-d 10 hype rexc itab ilit y of motor a>.ons.~:

Other LM~" ~'gn:) mclude hypore ll e",ia, decrea:')td or oib!.ent rt'net.e~. delTea~ed Illu&cie lOne o r fh cC llii t), :mcl :!.C.le l rarnplIlg.:! "4 The ellolog), 01 mu'tcie crampi ng " h '.I. ell ,under\l00J and 1\ JI ...o thought 10 be rdatec1 10 )ptrekll1o.thiluy of mOlor :1,;.00'<•• In ,nd,vidual" "" IIh ALS . mU~Ie: Udmp., can occur In UIl\..ummOll "' I te~ ~ u c h a~ th~ lIlngu.e. Jav. . ned... ahdomtn a~ "ell .. ., lfI the UE~, h ""lld~. iIlld ca.lf or thlgh .-

hov.~n-.()f) p~lhy.u)"~ di e ~pUJed for the mo..... pan in ALS; loQflle patIent s JIlay l'om pl ,u l1 \)1 d l-de li'.l{'d pa,.c ~­ Ir pamulthe IImb~ . 1-';lIn Lan Oll..ur. c ... pcc lUJl y whell OJU""le \\.'t=alJlC"'~ imd "p" ... ti ('; lI ) lead to irnmobiht) . adh~ 1.-

tIIIe

e ... er Iii (

As UMNs and LMNs of the bul bar mu scles degenerate. spastic bulbar palsy or J7accid bulbar palsy (respectively) develops. In individuals with ALS a mixed pal sy. that includes both flaccid and spastic components is common. 5J Dysarthria . impaired speech. can occur with either spastic or flaccid palsy, owing to weakness of the tongue and mu scles of the lip. jaw. larynx. and pharynx . Initial symptoms include the inability to project the voice (e. g. , shouting. singing) and problems w ith enu nciation. In spastic dysarthria. the voice sounds forced. as more effort is needed to move air through the upper ainvay; whereas in flaccid dysarthria. the voice sounds hoarse or breathy. \Vith pharyngcul weakness. air in the mouth leaks into the nose during e nunc iation . resulting in a nasal (One. As the di sease progresses. speech becomes more difficult and unintelligibl e, and eventually Ihe individual becomes a n art hri c . :!.5~ Dysphagia. impaired c hew ing or swallowing, cun also occ ur with e ither spastic or flaccid palsy. Manipulating food ins ide the mouth or moving food into Ihe esophagus is difficult . and swall owing is impaired. \Vith flaccid bulbar pal sy. liquid~ may regurgitate into the nose because of pharyngeal we:lb.nc"s. and the cough ret1e~ may be weak or ab!«en! g rc~lIl y im:rcas: ing [h e ri 'i k of aspiration. Indi vid uab w ith ~pas t k' bulbar palsy WIll have unl'oordi n..cc ....... l ve ') al".~ .lnd drooling . beC:IU~ of fill absence of automatic , ... polllaneous .;;"allowing It) clear excessive :-.u li v>I . or b...'"Cau . . c thel lower (~I\: ia.1 mU!tl'le3 are lOU weat lO dos(,' th\.' lip~ lightly 10 pre\fcnt I~.u..agt' . ~.j Individuals With blllbar· on~el \~ ill cxperil'flCl' this sy mptom relanvely early.

824

Ph ~jc,,1 Rchahililatio n

. " II the indi vidual Ill :ly begin to Tl OIL~:C drooling at 111111,1 y. . I ' . · Iwill y . -hi (c. ' ,. the 111llow is wei in the Ill U l1llng) : t liS t:VC II, • Ill!" g . o r •'\ l i s~ uc 10 wI pe away II. It;- s.··,II V"• . r\.'qu .lrl.:s rep!.:.",1't: ,1 u..:c . pS('urlobulhnr .. fT'·l'l, a l erl11 used 10 dcsc n hc pllor II ',Ioginl l emotiollu l ("Ol1lfOI.(>\ is cOllllllonl y see n III paJ'II.. I ,"I ~ \\ I1h . • b II " . I ,~.\4 S I,onl •'l11l'oU~ cry.111 1\ " ' ' ' , ":o. p "', "' II l: 1I 1.U p .l :0. ) . , . : 1 • • •

?f

. , or 1:lU clu cr occurs in Iht: ahsc llc(' 0 1 emotlOll al IIl gl:!c~8

:~I11()I ;O~:ll n.;.\.pon~es an: c \:tggc r:ll cd. h l and can occ ur 111 a~ Illany ;t ~ 50 pacelli of inclividuab,04

Respiratory Impairments Re~p l r:.tlOry i m r~l i nl1en l :-. in ALS arc rc l a l~d I ~ loss or r~s­

pir:uo ry mu scl e streng th and J ctcc rca~c 111 ~ llal ~ apuC l~ Y (Ve), A VC red uced to 50 perce nl 01 pred icted IS Of! \;11 a""ocialed with respiratory sY1ll pl OI1l S ,t>~ Earl y signs and :. \,l1lpIOITl '> of rC'~p l r~110ry lIlusdc weakness lIla y in c l ~ld e f;tll p.ue. d)'s pnr.::1 on c\cn ion, difficull y sleeping i n suplIle,

and freque nt a\\a ~ ~ nin g at nig hl , reCU1Tent ~ ig hin g. cxccslij \,c cbytil1lc '1kcp inc:-~ , and mornin g headac hes due to h YPOX IJ .(,(,·h1 P:ll icnh experi enc ing a gradual increase in n:' piralOf) Illll,c k wcakne:-~ wi ll not complain of respiratory :-.Y111 pt0I111., becau~e they tend 10 dec rease the ir overall le",,\ of phy:-.ical ~lC l i"i t y owing to muscle wea kness in the C\lrcnll t ie~.6!1. Although Ihe decli ne of rc~p i ral ory muscle >;trenglh di ffe r~ among ind ividuals. fo r th e 1110St pnn il tend, ICI prog.re~ .. JI a Iinear rate,t>~ A" weak ness prog ress('s, tru nc3ted :-.pecch. orthopnea. dyspnea at rc!)t. paradox ical breathing. al.'cel'lsory rn u ~cl e use. and a we~lk cough arc IYPI('~ll1 y ev ident. A V of Ie-so.; than 25 pe rcent to 30 pe rcen! of p r edict ed I11d ica l c~ ~ i g nifi c an t ri:-k of im pe ndin g re .. pmuory failure or d c a lh .6~ If all ind ivid ual docs nut rccc:i\c ventila tury wpporl. eve-nlual CO, retention w ill le.ad to 3cidol., l ~. COI11 :.1, and re ... pirato ry fai l~lre.M

Cognitive Impairments Al though onLC con . . idercd rare Ollh ldc th e WC:ottcm P~I C 1 1I c

region . cogn it ive IInp tJ lnnent . . ran ging from m ild d r: 'II ell( 11'1 10 \e\t' r t:. J1ullfof(,nlpoml til' III(' II/1lI (,..rv ).71 have been n;, pon ed A Icte nt I ~' rgc pro" pct: IIVt: .. tud y ("undt hal 15.6 percent of pallcn" v. ilh ALS ~ h owed d ill ie- all y ~ i g­ nlfi ... .tlll COgHII I \ C IITIlx llflllen t, I~ and it 11:1\ IWe ll ~ lI ~gc . . ted

Ihal r l j) flOy., Ilt: Lon' H.iered ;t uUll punent nl Ihe j);Hho logu.:;11 ~pcurull1 01 A L~ 71 ALS .t'~{)"' la h: d 1-" ( 1) lia, l)(;cll LlWrJI..ICI"w: d by (;og nll lvc de:t..I lI1l', l' xc(. ull\(" tun~ II Ol1ln Irnp;nrlllt:'IU \. dllhl.. ul ll C'\ '" tlh pl.1I11l11l1-! . clrg ••I1 .... alulll all~ I

l.. OIlU':Pl

. lb' I I J C [IlHl

( h'II\ IIt:'1 II .4 • C"

II,

Hll d

I II d" I I I I( IIi.! '

pC".H!.illl )

d ll d

hl.. !t ,IV IUI

I A I ") wuhmll I- I I ) , have: 1,1,-111

ht~l'n reporlt:'d 1o 11.1\ ... u \afll'l~ ~) I lll,!:,llI t l\l' II 11 Ihll '-" IL' 1I I. . IndUlilfig dtf lJl UIlI~ '1 ""nh \ ... rh,l lI lIl'II ' I.1 "~ lI"" ~l· lOin h . \ PI C.-' CIl'I('lI IlIl' nlC,ry, uh"ral\ I l',•.., UIl IfI )!. . d lHI ~(' nl' l a l l.ll'd IIIiPoJ lIl lIClIh II. 1IIIl.:IIlltlJul I tllll t lllli I 'I. "' . 1 I f tI . JllI\.IIl' ~ 11I\I.' hUll IlIiil palll' l1h \\- lI b II, hJ\'t 1\' '

(. ~111 1 11.. t

1I1I \t: 1 (11\(':t\4.' ", "

hu lhal

\I II ..,C \ A I

1IIIP,III II II ' II" Ih ••"

S

,.

I , ,,.'

jli l l H' ll h

I' I

IWIIl' ' M ' ) \\ Itll iltl l b

Rare Impairments 'IIhW'IYS arc spi.lrcd. for the mO. . 1 part. in ALs .SC Il ~ ()f y P· . ' ." ' Some individu~t1 s ma y co ml~l a m (~I vag ue: II.I-defined sen. :-.ory symplOlllS of parestheS ia or 10000a l pam .m the limbs.S. Ex te rnal oC ular muscles arc usuall y spared 10 ALS; and if dege ne ralion occ urs, it does ~o late i,l1 th,e course of the discasc ,~" Patients who hav e been mallltamed on ventilators for long pe ri ods of time may devel op the inability to Vol untaril y c lose the eyes or o/lhrhalm oplex ia . complete OCu. 17 lar par:l IYS IS. Motor neurons controlling th e anal and vesicourethral sphincter musc les and musc les o f the pel vic Ooor are generall y spared. Urina ry sympt oms. such as urgency, obstru cti ve mi cturiti on. or both have been reponed. sug. gcstin g that supra nu c lear cont ro l ove r sy mpathetic. parasympatheti c. and som;'ltic ne urOns may be abnonnal in ALS."

Diagnosis With the exception o f one ge ne ti c lest. no definiti ve diagnostic test or di ag nosti c bio log ica l marke r e xists fo r ALS. Fo r individuals with a cl in ical prese ntati on of ALS laboralory stud ies. EM G. nerve conductio n ve locit y (NCV) stud· ies, muscle nnd ne rv e biops ies. a nd ne uroi mag ing studies are uscd 10 suppo r! Ihe d iagno s is o f ALS and 10 e.cl ude ot her diagnoses. The di ag no'is o f ALS requires Ihe presellcf o f ( I) LM N signs hy cl inical. c lectro ph ys io log ica l. or ne uropathologi, cal examinati on: ('2) UMN ~ i gm; by c linical c.x aJll inUl ion: and (3) prog ressioll of Ihe d i:-.ea:-c:: within n rcgi("lll or 10 other regions by c linil:a l t:xa minat ion or vi.1 the I1lf!dical histu ry; and th e uhs t'f/(.'(' o f ( I ) c lcc trop hysiologic;t! and pat hologica l ('vidcllcc of "'her d i"cJ' t.'s Ihat may e'(plain the UMN :tnd LM N ~ ig ll " : a nd (2) II L'UrUlIllagrng t'vlllcnl'c or ot her d i sc
cUh>lo~)

I{ t·'(.';:UT h Group 1111 t\ 10 t Oi t,' lI f l l ll Di 'l'.I"':' ~· 'lUhli, ht·tI fhe U " \('(11101 ("1/ff ' l /(I In 19{) .. ,llId 1'(' \ "l·tI I h~: 1II 1Il 19 1 ):-; -~

I IH' .. r \'Hh' !\ .I~":l" pt l'd l. litl'n,1 111(' l ~)I I ' l lkrt:l1 Iii tallliJrd Ili r Ihc d l.lt: I111 '-lI' 0 1 1\1 S fi ll rh llh:a l r fJI l.' ll l ·C. thl' r;lpeUUl' [lI tl l.... ,\li d olhl'l Il'wardl PIUP"'('" III Iht.' .lh.:-. en":l' nf P:.I\ ltll lu~ll,d l· ... HiL'IICI.·. 11ll' lIlt1gl" .... I ' III Al:'; I' d .I:-'id l~d 111111 , III/II 111/\ dl 'j/nltt' . ,/""t ,,1/\ /JI"Ph.lhll, dUllnll" rmh "hi" II/I/' /,Ihmll'''' \ \/11'/1011, .mil () ( .\\lhh \".lIl"~llfl(' (I I!!.. 20 ·l l. "j J\ dl.I}t ll n,,,, 0 1 dllll' ''''' ,1t'/IIl/U' :\1 I .. dd llwd ,.... hUlh l l f+. 1N .lIld I ~ 1 N nndlng' III JI k ll ,1 ( bulh,lI . l.'l· l \ 11....11 11i() liI":1l', IH IUI " hq~,h· I .II ) \ 11 l IM N ;tIlLJ I M N ' lg II' III Ih~ hulhM 1"t.·8 I\111 .In d ,II k.I" I v.- ~) ' p"I.I I ' qtltlll\ ( .1111 11.'0111 ) jJl\,h.lhI(. ,~ I S I h h.'\,'

1ft II l UI

19! 1l l l h

Chapter 20 Amyotrophic Lateral Sclernsis

W_

825

AlIOpI\ylHyperrelle.ieJSputicity Prog- """' ,.". EMGINCVlNeurolrnaglnlnglBlopoy Ne~

I

r

I

l MN signs only >1= 1 region UMN signs only >1= 1 region

lMN+ UMN 1 region

LMN+ UMN 1 region or UMN >1= 1 region

LMN+UMN 2 regions

LMN + UMN 3 regions

SUSPECTED ALS

POSSIBLE ALS

EMG Acute denervation >1= 2 limbs

PROBABLE ALS

DEFINITE ALS

Identified DNA Gene

PROBABLE ALS Laboratory Supported

DEFINITE Familial ALS Laboratory Supported

Figure 20.4 EI E~coria l Criteria for the Diagnosis of ALS. (From The World Federation of London. UK Retrieved March 23. 2003 from http://www.wfneurology.org. wi th permj s510n.\07e: The Suspected ALS category was removed when the EI Escorial criteri a were rev ised.) ~ eurolol!;\,

IS defined a.') UMN and Uvl N s igns in two reg ion s. with 31 leasl one U!'.l N finding rost ral to the LMN finding s,

Clinically probable. labora to ry-su pported A LS is defined as eM!\' and LMN clinical s ign s in one region only. or U ~1 N signs alone presem in o ne region and LMN s igns defined b) EMG cn teria pre sent in at leas t two region s. The EMG cnte ria IIlc lude ~igns of ac tive de nervat ion. such as fibrillation potentials and pos itive sh arp waves: and . sig ns of c hro niC denerv::Jtion s uch as large motor unit potentials (increased duration , increa.':>ed proportion of pol yphas ic potenllah. increa'ied amplitude) and un stable motor unll potentiab. Clinically po s~i ble ALS i.':> defined a~ UMN and LMl' ':> Igm found togeth e r in only o ne region. or UMN ~ign':> found alone in two or m o re regions. or LMN s Igns lound ro'lrai to UMN ':>ig n s a nd the lIl:l.bdu y 10 c':I.lablish a dlagno':>i~ of dim~ally prob
Disease Course AL~ ha~ a pro~rt!"" I\~ .md ddt'riorating dl\ea.':>t! IraJeL'IOf) , <1M the progres:-' lon fmlll palholog) Iu imp,lIfnk nh to funUUJIlal hmll<:lllOlh to d l.'>ubtli li e, I') In\:\ liable. Although the dl~H'ie C{,ur~ \ants ilmong mdl\ Iduuh. v. uh lime Irom onset 10 dea lh rang 109 1I0ni St;;\cral 11l0ntlL'" 10 20

years, s tud ies have fo un d the ave rage duration of ALS to be between 27 an d 43 months , and the median duration to be be l\veen 23 a n d 52 months. J .5·7,80,1S 1 Five-year and tenyear survival rates ra nge from 9 to 40 percent a nd 8 to 16 percent, respectively. 7.So.8~,8j A 50 percelll s urvival probability after the fir s t symptom of ALS appears is s lightl y greater than J years. un less mechanica l ve nti lation is used to s us tain breath.i ng. 6 In mos t patieill s. death occ urs within 3 to 5 years afte r diagnos is and usually res ults from respiratory fa il ure j (Fig . 20,S ).

Prognosis Age at lime of on:-e t has the s lronge~ 1 rt."lutionshi p [0 prog nos i:,. SlUdic!) have found thaI patit!nt~ le~s than 35 to 40 y~ars of uge at Ofl~el had tlt.!ttl'r 5-ye:lf ~urvivaJ rate~ than o ldt!r indi\lidu.ll!'. ... n)!lJo,.; ~~ Individuills w ith li mb-onsel ALS ha\ e J hc!lc!l' progno .. i') th<.lfl those \~lIh bu l bar-on~t; 5) eal s urvIval ralr.::~ Were reponed to be 37 r~rf'e nl Ilnd JX'rl'l:m . compared 10 "urvival r:III:S of 9 percent and 16 perce ll! for palienb with bu lb:!f onSt't ALS.iW..8" Les" SCVC l e iu\,ul\t':II1CIlI ~tI tht' llllll.! of djl\gno~is. a IOllger

..w

inter\ al ht;1\\ I.!t'n 01).')...'1 and diagnosi" , !\nd no symplom.;: of

d Y"I pnC:J al

Ulhet

pJ'ugnn.'>i~ . 5.b So

are olher f,KlOrs a:-.~ociall!d \\,;£11 a bent"(

I'h)'~ ical Re hab ili tati o n

826

A ~tudy of 144 individuals with ALS found lhat Ih IIldi vidual;; with p~ychological well-being hOld ~i ~ , 1 ' gnlfJ. ca ntl y longer ~ urvlva t1Illt!s co mpared to lho..;e wnh ' I' psy, chological d l: trcss. Mona I~ y r~tes were found to be: 6.8 limes grc~llCr 10 tho"e expen enc lng p'ychological dislr , was 'In dcpcndem 0 f age. di ..;case se . and the rclaliollo;hlP

09 08 ~

07

]i

~f

diagn~si'i.1I1

e"

fi~d;:;

~ 06

ity. and length

0

we re ~on~r,mcd ~n a later stud y .Ihal lound degree of physIcal dl ,abIlJl ), (li'>ea,sC' ~rogresslOn , ~nd survIval COuld be pn.:di clcd by the p~lIlcnt ~ p,yc hologlcai stillUS. KII

a:

05

;;;

,• O· 03 ~

'" Oz o1 °0

lime from

These

Management 1'2

24

36

48

60

72

84

96

108

120

Months !rom Fnsl Symptom

' l l' ll'! \ u' .... e Ik .....:nblllg ... ~'1"\1\.11 JIl A I .S. llll' Ilumtll."' 411 p.HKI1I ... I<..mmn ••In t' ,11 d;1[ e 1)( l ,r<"1 'y mplUlll .md ,1\ \'\'~uh l1lh·r\;\ J... ,hl·re.llIe! ~ .~1. 73~ . 50..1. 30~ , 170, IOJ , f,\.! .l "' -,~I, I"" Il. (ll p lrl.· 1.(l1 \ m)n!n1ph ...· LlIcrai \ , len"" ... · b, \pre l. "nllth. l,u . \ '\('1 ... ll,'r .Uld I I.t\ccrl<..an,p. tmlll

FIgure 20.5 ..... lIpL111

"'ml ..

P" ' r ll l ' ''' ' ''' \.t ' ..· U1tll\'~ ' ..,.tl D, ... nnk' .... cd: n lll r."...i b) Randolph

\\ I \ .In... t"1 .II \. \lp\l l~ hl 1l){J~ _ ~O()(I b) O"IClrJ l I1l\er. . I! ) Ilrl' ...... In\. l ... \' ..1 b\ pt·lIlU ...... H'I l\ (\1 (hlurd l 'IlI\""'!) Pn: ....... l nc}

PatiCnh wi th ALS mil y receive care in a variety of health care ~C' tlin g,. Specialized center" or clinic" that provide a comprch cn~ive and Illultidisclplinary approach to care are cOll,iLiercd the mo __ t ad\ alltagcou, cOTl,idering the progrc\!\I\C' nature of the discJse ..md cOllll11uaH), changing p~lI icn t 'tat us. (Fig. 20.6). A recenl \t udy com paring a coho rt () f pJlicnh att~nding a muhidl "c lpltna~ cliniC" 'ter· "'1I" Ih(hC allcndlng u ge neral I\curolog~ pr.ll'tlce found the median ... ur\i\:.tl o f the ALS clint ~ ~ohoi1 \\:l~ .5 mQ(ubs longer th~ln for patlenh 111 the gener.11 Ill'urolog) cohon.

Occvpallona'

TherapIst PhYSICal

Speech· Language Pa lhOlogJsl

TherapoSI

NutnuonlSI

Novrolog I

\1

Ih '\1 .... I '.

,

\

I ,

,,'"

C h a pt er 20 Am yotrophi c Late ra l Scl e ros is fin dings ind icated Ihat atlend ance at the A LS c lin ic 'TII~ independent covari ate of surviva l. suggesting ac ti ve \~'a!l an

Clinical Complaint: Drooling (sialorrhea)

andThe Amyotrophic L I S c 1e ros .ls A SSOC13110 . . n (A LSA) ~H e ra

Evaluate severity of sialorrhea

,.gcCTfCSsive manage . ment enhances ~ urv i va1. ltq

d the Mu scul ar Dystrophy Associati on (MDA),

+

827

I

n 0 11 -

!\~fit \'olunlary hea lth age nc ies: I~ave d eve loped stand ards PALS clinics and celller!'!. C hlllc:-o and centers th at meet

for . ALS.4."s !'I wndards and pass ~l ngorou s app I"Ic a l lon ;meI ~ It' c .. . re certified as ALSA C ent ers. MDA ce nte rs lha l con \,1 511 .1 duel ALS research and ~ave sw,.ff w i~h ex pertise in d eal in g . h ALS e arn SPCCI ;:l ! des lc.. na l lo ns a s MDA ALS \\'11

Research and Clini cal Ccnler!o..

+ + Usually not treated

Nighttime sialorrhea

Daytime and nighttime

+

I

+

Glycopyrrotate Amitriptyline benztropine (if patient transdermal hyoscine has depression , trihexyphenidyl pseudobulbar affect, hydrochloride atropine sleep disturbance)

Disease-Modifying Agents Currentl y. there is no cure fo r ALS . althou g. h a num be r of clinical drug trial s arc bei ng. conducted . In 1995 . the Food and Drug Adm inistrati on approved Rilu:ole (Rilllfec). a glutama te inhi bitor. for the trealm ent of A LS. The standa rd dose of Rilu zole is one 50 mg ta bl e t two times a day, and side effects incl ude liver to xicity (whi ch requires di scoll Ijnu:nionl. asth en ia . nausea. vomiti ng. a nd d izziness. E\'idence suggests the effec ts of Rilu zole to be modest, extending sun iva i for 1 to 3 mo nths. 90•91

S}mptomatic Management

I

ClinlelJl

I

Re_..?

Ves

No

Follow patient every 3-months

Nonpharmacologic approaches

Yes ~ Figure 20.7 Algorithm for sialorrhea management. (From Miller, RG . ct a l,93 p 13 15 . with pennission.)

Disease-modi fyi ng agent s c urrenll y ava il able are not c ura-

Ih'e and may extend survival for a very short time. Because the pathological process cann ol be reversed and is progressi\e in natu re . the contex t of medical manage me nt fo r mdi\iduals with ALS may be conside red pa lli ati ve . As defined b) the World Health Organizati on. palli ative ca re IS" . the acll\e total care of pati ents whose disease is " ot rt,'Spunl /l'e 10 c/U'oll\'e rreatmelll, Control of pa in. of othe r symptoms. and of psyc ho logical. soc ial, and spirirual pro blems l~ par.slTIount. The goal of pa ll iat ive ca re is ac hi evement of the be" pol.,l)i ble qua lity of life for pati ents and their farmhe ... :>
III 1m

multld lM:' lplln ary l aio.k lorce wal- el.,tahhfl ht d ~e~e I IJP reLommenUall Ol1!'o lo r ll1anage mc ~lt of A LS .'H t .. oJ, tun.:t e).anHned the rc~arch and l.hnll·aJ eVHit:: l\ce ~ fi\-e
a nd prognos is: (2) symptom ma nageme nt of sialorrhea and pseudobulbar affect; (3) nutrition ma nageme nt and PEG deci sions: (4) ma nageme nt of respiratory insuffi ciency a nd ve ntilation decis ions: and (5) advance direc ti ves and palliative care. Medical dec ision-making a lgorithms ( practice patte rn s) deve lo ped by the task force fo r the management o f sialorrhea, nutriti on. and respiratory sy mptom s a re prese nted in Fig ure s 20.7 to 20,9.

Management of Sialorrhea and Pseudobulbar Affect Manageme nt of sialorrhea is d irec ted at I.lll ti cho line rgic medi cations that dec rease sa liva production, suc h as glycopyrro lale (Rob inu l). hcn ztropine (Coge ntin ), tlansderIll ul hyoscine (scopo lamine), atropine. and trihexyphenidyl hydrochloride (A I1 ane), For pati ent s with assoc iated Ihick mut·us prod uction , be [ i.t - bl od..er~ such a!'l propranolo l Ondera l) or melOprolo l (Toprol) are u ~ed , For patient s with p ~l,;'lIdo bulbzl r affec t. tht.' IfIi..'ydlc ant ide pressunt. umitriptylille t Eluvil} o r :,elec tl w seroton in re uptake tnhibitors (SSRh ), Mll: h <1:-. Ou \ oxamine ( Luvo x) ure prescribed , secondary 10 the ir du al aClion,'n Nfmphannal·ologicn l treatment f Qf' !'o iulorrhea includes manua ll) a~!t i ,;t~ J coughing Icchniqucs a.nd use of a suc;tion ur lIIet /ulfIl('al 1I/\/l.DluIWII- t'.uujj1u/ jon (A1I-E) dl" ';c~'H \Fig. 20 . 10). -I he MI -E device i8 de>igned tu mllare the

818

Physical Re babilitalion DIr: ALS Monitor body weight Dysphagia examinatIOn ....... Clinic vlslls every 3 months

instrument· Early dysphagia detected

Nutrruonist or speech - ........

..

language pathologist

referral

Nutritional education including PEGb

Monitor FVC or YC'

.......... Climc visits every 3 months

I

SympIOm

progr-I

i

~

I

FVC'<30%

FYC·30·50%

FVC'>SO%

+ I __ L.

I

! . .................'1"......

Low " sIder PEG

PEG accepted

+

I

"51<

H4gh risk

· ···· · ::::~:·.A

Anestl1eslaev.,ua~·······7~ 1 · ;e::'ned

+- Experienced g.stroen1erologlSt

.

()cal tntake

Enteral nUlnttOn via

Otal .ntaKe

PalIl8live IV hydratoon

as toler.led

PEG as needed

. s !OIeratod

PaJlratllle NG feeding

Ftgure 20.8 Alpttnthm ftll" nutnll(~l l1l.tnd~(,lI~1lI -fur (,:\Il.mplc. Coloradu 0 ,>ph .lglol Dl~blht) 10\('010(\ hUIb.rr que"h"'''' III the; AL~ run\.·II~"'11.t1 R.lImg ~ .. Ic. or l'lher In-'.lntmc-nI Rule OUI l.:untr.IJndll..1ll..'K" or f..lllgue, ili:\.de-ruled ..... t'l~hl 1\", Jut" Il' POt)f 1.",lIon ... lotJ. c 1..I1l1l1~ ll'lf'k:t.'m .ttt.)Ut '("(dlng dIIIKUhl.:') - fun:"d \11.tl .Ip.:... t) (I ' (") (III \ 11~ ~ajUo.. 11:\ 1\ c. \.;&tl b<- U~'J y( m .. ~ tlt' morr ,k..\--urJ1e In palk"nb 'Auh hulb:tr d\ ,tuo.... lI, on l), dl.i!!Oth." Pb( j ,..... f\ UI.U,(':1,."U' C'M')'I."Orh. ,ga'lh"IOIn), ( hom \I iller R( I. ('I III fI I.~ If, ~Ilh pt.:llllh .. ,nn I lun~ "'1111 pt. Il!\t; pIC 'lift" lind oJ ""I" \..uu~h \~lIh ul!'g.ul\t" prt-.."ult: mJolil.'h Iht" lhp \...t ..i '\.\Ilt:h A po ItI\~ · prt", .. ur~ hre .. lh III ,(11 ~J ... Ui H () 0\('1.1 I· to '-!)4:"\..llnJ Jlerllxl \1..1 all ,)f~aJ !I.&~OiJ

n'J.J.. vr !I.k-he ... ! i11~.I~ I,. pro\'llic.:J 1111,' Oill \4,,1'. Ph' ' lOt" " Own ft'\tr....c'd abruptJ) 1t~ 0 \0 _ ~) lin Ii () oInu lI1ol1nto1HkJ J,)f 1 II) .' ..n..ond .. A IX-.J.. t!" plralOr) ""HudJ tlu .It. ,UUIl Jll1nn.d ran~t" J'J, hle\ l'd Ihl'rt"h .\I I~illl' .... utl ttK"' dl·dl.ln.. t of ><~tdll)fl, ""

l\1anallcm\: .. 1 h) " 110111l1(\lII. I ,I, fl' I cfcd dllllll..1f11tl~~:th.J ~Jtl " Jk: ...... h 1..u',Udl! p.1lth1lu } \ 'lj', I P l11rori 1 1 \11o .. Ii.)>o\-dl C"'d.ll1Jqtl\;U' 1'>0. h .. \jli,lc(lfJ\lojt '1"') hlJ\lt:l1ll1lll'lt"n!: k"rn~ctJ,\III""uh: lI' It........ 1,· .... ,11 lfIlJ,.llIlhl'lIl .snJ It. ,1~ .. I,t III .... nm!.tllil " pl .. n t tl 1.:"1( UlnlJuf' l I pro uJt.- ... >lUl hUa! I J 1.1.("1 lila" llil HI lil,.iu lto'u! IJ~ \ JUf I,t tI .1\ .j,

,", ulnllt"Cl 'tLi.llh h~h b«-n Ilknllti~d

'"'-, j./; prt'!1rlf''iU\.· rli.: lvr ..old dt~a-..: \. \)fuph.. ..tl1l1l1. \ ,cud) of 16ft) tk)'>I'I1.tilll'd p.tIk."llh \\1th .-\LS h\un,ilhe 1I10,l ',l(nmoocoo\Ufl\"'llIl ltJ\.'04."l'I\ "<1 . ddndr... tI,'n .Jn~t mJJnutnlton. pre''>Cnt Ifl l6 p.'f(.\.-na ti l 1"..1111.'111 t'J' I hI-. til"IU1~ l·mph.L\I«:t tilt' nted hlr ,Uf\ I\;..tt

tOI ~ fduJ .dtemwn hJ lIuU moodl Afld h UrJW"'f1 ...wtus. hlll1J.1 lh:.llOlcnl ItJ (j),ph.l!!IJ I dln:\.~d h"'l"Jl\l \I)

..h,~toAJ)

fHudltKJlhlfh.

"lht ... t;:Jk.k

lH.h

tOJ t".hl't ..ubI

c-d\.!... ,IIHI1 h.-g;.1rd)ll~ ll!,,:I.u,

.IJ.tpIJll~ tlllxh JlOd Jlu.J Itc."t " .... all('"lnc '~I podttal

6i.'

'II ..U~ 'Ie.. h,..-· nU \ lnun81

•.11..n ... .. JJ I IItJll h:I U-" and rn IIH.lltlin .t~k"\.fu.m" h,JrMIOIL :tiki t 11 ",d.IIII.J1l('lh h. p.(\{lMI,-= ,\-.J!lol4lll" 'l.t\.'n ii ... tU\.t.UtI III~ ~ hili tit)"" dUtHlI "".dl\l'""th~ Of l ·rt,lnn,n~ J dt~ l.U\J·h.it (l:a....h . . \It"lIv.... ~ d~ ph-4glJ ...."',.'l· .......·' Ilk..- IlIIu:" f ..-",um:J h) t..l UJIW .. IIh·.,d r.lJu",lh m ....fC....tl"\(., It\4- In 10 Idll 'U(~ tfk'rc....;OJ Jlt~

f~ ... uh) 'n..; .... UlI d,.II~l

tn:'lUL'"111 d,..LIIJI,l 111 ..

,l\" UJk \'i11 0 .....1f1

828

Physical Rehabilitation

ox: ALS Monitor body weight Dysphagia eX"amination .....-... Clinic visits every 3 months inslrumenta Early dysphagia detected

t

Nutritionist or speech- ............ language pathologist referral Nutritional education including PEGb

Monitor FVC or VC·

....... Clinic visits every 3 months

Symptom progress ionc

I

Low risk for PEG

1

FVC~<30%

FVC·30·50%

FVC'>50%

I

I

Moderate risk

I...

Oral intake as tolerated

High risk

····················1··········· ..... ~~~~~~~~ Anesthesia ..aluation • • . • •.

PEG accepted

1

+-

Expenenced gastroenterologist

7~ 1 · ;: ~ined .

Oral intake Palliative IV hydratiOn as tolerated Palliative NG feeding

Enteral nutrition via PEG as needed

Figure 20.8 Algorithm for nutrition management. M For example. Colorado Dysphagia Disability Imentory, bulbar questions in the ALS Functional Rating Scale. or o ther instrument. bRule out contramdicatlons.
and a~~ist cough wilh negative through the flip of a !J,\\ itch. A positive:.pres~ure

lung v.llh pres~ure

po~ ltive pres~un~

breath 01 30 10 50 em H; Q over jj 1- 10 3-becond period \' io 0111 oraJ -na~al mJ.."'Ik o r tracheal airwa) H. provided. The airwa) pre.,~ure j~ then reVl'T~ed abruptly to - 30 to - 50 e m H.O and maintained for 2 '0 3 ~('cunds. A real ex piratory ··~ough· ·

noy" v.lthm norrnal mnge ilt al.hit\t:'d , thereby

8')bbtlng

with the c:1ear<1llce of ~t:rellon,.'U

Management of D} ph .. gia Earl),. nuld d)bpha~ia h addn;,>~d h) u. nulnllUfl l\t Of re~ hl.ercd dJtllnan together ""Jlh d ~ pe~(h language f)J(holorn~t (SLPJ SLP\ londu'l b\\alluwlng (>XarT\JIUHumS -.ulh U· \-h.1eQ fluuro~op y to dctermmt lhe dCllr~e .and 1\~lun: of the w.. allo~ Ifl~ Jmpdlffilcnt and to ttltW,) 1 In h-'lInul.uUl~ ., plaJl 01 'au: NutfitlOIH,>1 p[m Hie co un,ell11~ lUld diet m"l\dl!cmriit th rnut;lwut the l'()ur~ lIt tht dl...eJ"'~

Nutrition ~taluS has been idenufied as a prognostiC factor for ~urvivn l and disease complications.95 A ",rudy of 1600 ho~pjlulized patient, with ALS found the m();)( commOJ1co&

diagnos i, WHO, dehydration and malnutrition. pred in 36 pe rce nt o f patienl~.% ThiS finding emphasizes £he need lor care ful alle-Hllon to nutritional und hydmtion stams. . Initial treatment ot dy~phitgia b di£~('Ie:d IOWard (~I dietary moJifi ...' ahoO\. buch as adapting foods and ~

ClI lTCll 1

COlhl ~lt"nClc~

for

ea,ie:r and :otafer \\\ul1owlng: (~)

paridIt

tdUl...ulOn rcgdfding diclJ.J) Mralegics fur nltuun~ c<.Ilone'l .efld nutrtent-. "oJ maintJinlng adequJ(t' h}~ and (3) .,U~lphlllons to promore ,\.\ ItO" ulg ~uch as I~~ the \.:hm uown during S'A JlJn\\- Ing or performing a cJtarill

,,:ough afte l ("al.·h

~wallov,.. ."''''

A-. U)''1ph..lgm progre'~e~. the lime- required to l~ a Ilic ....1 gradual!) IJlcrea-.c~ (tWlllg tn fultgue. lIk:~ased n,·u lt\ dlc\qng. ,JIld trc4lh~lIt dlOkult! It b nOI unc~

C hapl e r 20 Am yotrophic Lateral Sclerosis

829

I Ox: ALB I ~

Respi ratory symptoms or FVC a < 50%

Noninvasive ventilation counseling

Noninvasive ventilation

~li_n.~:_or_n_o_t ~ _, ___

r -______

Symptomatic care Counsel about terminal phase Hospice referral

Invasive . . ventilation declined

+

r ________

Discuss treatment optk>ns (e.g.. tracheostomy ventilation) and terminal phase

I

Invasive ventilation accepted

Palliative care

Figure 20.9 \ 1).:\\lllhm 1M re '- l'lr;\ l l tr~ m.m.I!!cnWnl h"'l l~'d ',1.11 ~ .lp.h..· II ~ ( t \ '(' )

Discuss withdrawal conditlons b

\lI,tl.-.lpaUI\ , \ C \ ~.lI l ~, u,-.."d. \'C Ill.! ) f\c." '"(tn' .1\,\'ur,J\(' 11l r ,U l l' n!'- \\ nh t>lllh:lr d ) '- \11

I U11dl\\n

\ 1!1\'~'lHC'I\ I nt'l'dell

ft...r

~t______~

l~\)IH.lll l o n'­

Institute invasive ventilatton

,tl "., Ilhdr,l\\ ,II rnt H It} \11 l', tlh um' lll " 1111

m.tltulllW Ill' J'-IH' 'l'lIl1l.llIn n te ~ .. l oc ~ C'J Til ,1.11<, ~'t\mJ t'1~ I. I h lh.l~mh l '- ( Frmll

'hlk! Rli , t"I.II

Invasive ventilation withdrawn

I' I ,~ 1- , ,\ 'Ih ~X' nnl'-'- I (m .)

h)1 Ill, ... ~ c.ntng dllfil'u hl l'~ It} ..'aU"t' .1Il :tcceleraled weighl 1\",... In [ht"!." lll( lI m ... t ~l l' t· " ;1 percuunellU C) t'ndo'l'opIC ~.htr\hh\ Jl1~ t f' Fli) lIl J\

OC

r("~·omm(' nd~d .

A PEG

I ... a t)

pe

~I f ~.1 .. 1IO' l l111l~ IU~ m"'l' n ~ d \ 1.1 l" nd\h~t)pi~ ~urg. t~ r~ Ih :1I \:IC'''t l t'~ :llwlln.1nl~1l 1 \) ''It'nm~ I nti) th ~ ,tom:lch fpr Iht' irl1ro-

dUdKln \It h\o,xi I l i l l\ ptu ll ~ 1 " ;llc t~ ,mJ ~fIi(Jq 1he PEG ph,,-('\hlrc .. th)uld Ix' tllh"h'~i tl) tht~ r.t1h~ nl .I1\U (, flmple l~d ht'I, \r( tlk m,jl\ Idu,J I', 'lui t'.lPJ l ll ) ( \ (' ) fall ... !:x'h.)\\ 50 pt"r(,'n! \11 pIn-tIded ~ IUJIt.:' ... h.l' e hwnd PFG ll1 ... n lion 01.1\ phllt ll1!-' ... ur\t\,ll

P,1I 1t.:"1l1 ,-

\~l lh

prCi \\t' re iound

10 li\'e I to -l. months longer than those individuals who refu::,ed PEG or were deemed ineligible for the procedure. Sur\'i\31 was greatest for patienb with a VC greater than 50 per('cnl predi cted al rhe time of the procedllre ,q,·~ It is important to not e Ihal a PEG doe s nol prevent the rbk of u... pir:ltion.IO.l. IOI

Management of Respiratory Impainne nts Rl"pir:uot;- impainnC'nts place tht' palienl at ri sk for re~pi­ ra lor;. LraCt infec llon ~ . Imponnnt management con . . idera· lion" tncilU.it': ( I) pn~Ulm.)(:occ31 and ~early IOtluenza \'3C(J1l~H lon~M: (~ ) prt'\enlitln of 3'1pmtlWn: and (3) e.ffec li\C' l)r.U .u,d pulmon.tr) "'t."\;~fion nl41nJgemenl. Supplemental O\~ ~t"n TtlU,1 he u,,('d \\d lh ..·.lui l on be ..~ .l u:-.e II can 3uppreC)!I rt' "plr.Hlll) "'1'1\ t' , e\,l~t"fb,:Ht' h ~ pm cntll.il ion. and uhlm.u t'l~ kJJ Ii) h)rx>rcart'l.l J.JlJ rt·~Plf.lh)J') ~lT1'e' '''t. T)picJ.Jly. ,uppl~m('IlI.l1 o\~~ell 1\ fCl' OlTIrnelh.IeJ cm l~ for 100" .duals \\ Ith n)I\~. l)mH.UH pulmnu:tr) dhe . l~ or.h a comfort measure h\r r~tllC'IlI' "h() u('llme \CIII1JafOf) !lupport .o.. \\ h(' n \ (' t.l':t..£"e.l...c:lo III 50 pt'fCc:' nt or pre(hctN, pt-bIUVe~lI(''1 ... lJft' JU\fllll\ .1')1\1;' H~nttl.u U,lO (!\i\ ) , .. reconunen..1ed.~,"'i "1\ h .. , ~n ,llV\~n hI det.· ft'a~ ")JlIl'h.H ll' I,)f h~po\el1l1 IJlll"'l .,n.) ulI..re.l-< .. Ul"\i\..J IUlk! b~ \C\eraJ month5. 1U: ItlC'i

\\ hc:n ,\1\ I.Jn

~""" an 10 " ~\ h"'i ... ..1 UJ. • .:ttl~II."tI1 •

l4.t

l ',. \-.

f lH

l lh .. ~w.: I .

(' ll,uublh ofl t ' tl I 1 t .l'HNhi~c \t U., 141 ) 1

( Ikd l\ ~.

,,10I1WI\

;I.

11 \

01.)

longer

b-,'

tokrrJh."'li or

It 1."1

no longer

~t(."t;I~I\.)Il I1m,( ~ n1a<.k bt:190"~O Ul\'b'OO 'te.n

I ~ Ilh

h, \"' rl"'~ ,,"..u'l"

4

1roh.heo·,;t;.wny \ III :o.UIgIC.UlOU!'f\<"flfH)U ,)f

hl Jddre:");) I.ltf-!lol.lge- r~~plratoC'} ~)mi\cool

8.l0

PhysicaJ Rehabilitation

0" in!! to the em olioll a L :'.ocial. and financia l burden of IV. patien~s ::md famil ies IllU~ t be care flill y if~ fonned ~f. the multiple costs and benefi ts of the intervent Ion . Cond ItIOn s for withdrawa l of ventilation are di scus:.cd pri(lr to , or at the lime' of. in stituting IV hecause the pat ie nt ma y heco1l1c una('l e 10 cOTnmunicalc his or her wishes a~ tht" di :.e;}~c

rrogresses.ts..Q' >'

Management of Dysa rthria O,.sarthri a impai nll enh are m anag('d prima ril y by a s~ech-13ngunge path ologi~1. Iniri3\ speech cha nges are usually managed with intellig ibil ity str.Heg ies. such as having the mdn'idual exaggerate 3l1icu\3l io ll or decre,lse the rate of speech: and. en\'ironmen tal modifications. ~ uch as dec reasin!! b3ck!!f(lund noise. As the severit y of dysarthria prol'T;S~es. ~anagement wilJ focu~ o n decreasing the patie nt's dependence on ~peech as the plimary methexi of comm uni Glfion . Intencntions first include " low-tec h" devices, such as u ... lIlg a \\ nung board or pad and pen fo r patie nts w ith adequate hand function or usi ng an alphabet board. A progressIOn f:- then made to more ·· high-tech" devices. such as computers \\ ith voice synthesizers or single-sw itch , scannmg comrutenzed communicalion sy"tems. 10t>.101 A paJalo! lift prostllesis may be pre ~c ribed for incl ividuab with good an.iculalion but who have a b reathy vo ice 4ua1ny or decre a~ed loudness IxC:lU ~~ of excessi \ e ilir los.... thrOufb the no~e. The device, a de nta l appliance des igned to .mach to the C'\.i~ti ng teeth and 10 eJe\'a le th e soft palate. IS cu ... lOm-made b) a pro\thodonlisl. II a ll o .... ;;; the ~o ft palate 10 c1o\e around the surrou ndi ng .., tnll'ture.., such 3~ the ph.lf}n\. mal..mg \el"bJI communication m o rc under... umdable b) rc:du cing or eli minating hyperna ..,al spee(' h . The de\ ICe alw lov.er\ the hard palat e \\ hi l'h reduce:lOngue mo\ement 31l0v.Jng speech to bt' Ie')') lari gu ing . IIC fllld lllg:-. 110m u retrthpect!\e ..,lUd ) of 25 pa tient \ \\ ith ALS Ireated \\ Hh ;1 palatal Ifft Inthl t:J1cfi.1f1ll1! :u ICD,I modt:ralel~ lor h nlunth~. 'II' -

\ianagement of MUl>c1e Cramp., Spastidt~ , .... asciculaliun'. and Pain Aml\.oll\ Ul"'aul medll.tlJOn ' Udl " ... pht."n, !\Illl ( D I I..I lltlf1 I .lItd

1,: ...tI'h...tmOJ/tpI IH:

("In.'hll

I t'gn' ,oIIIH'';j tl< pn.:'lo(ri bc:d

tllr mu~k" \.·I...tmp"'. d It It:) .U t; not 1t'"IIt'H'U v.Jlh \1 pHlg l ,Ull

·A nlu,~k ..,t rc tc..1Ilflt: "IlJ adl'lju.llt' h,dralHIJl .InJ nutll

B\ ~th ....j tll~"'l! mt'Jllatflln'll \...tn \.i;t'u ...C' ~;t.,tf\)lnlt"' ... llllitl UI"cl w.t.! I.b-h . ..t.fu.1 l,\rh .ull:l /t' pm t' \.:".IJI ~ ..IU"'I..' ... t'd.iIIOII H· fiJi Kild.ft" I'J lIt' '- ~lh. h ... .., JI<.1./l'l'dn I ( \ "lllIll II. l It IrU/c:p~lI1t O,luUllpllJl . Of It;f.vq'~\"l (AIJ\ ,UII . \.-4.11 OJI"',I Ix- J'IJ.:"-lflh...d .'r f1I\1 ..... h' l r.ullp.. J:.ih.l "' Id, I; Jl!:\:h 111..1\ \u\.lu"k ... \.·J.ill\)jl IJlm

It: .plld~"" ~krfl'''''''''IIJI\ ,tnt! 111...ll·,lwJ \'\\.~~dK"''' IIb>JI.u.t:Plll~ c .. pt."l.f,Jh lh.uq ••tUJ JlI,1\ o:lhll t ... • pI\.:' ~ nt, d fIll _Pol"tl" 11, .dd"'\ll'h b.,," tll'n t I I'J(l· ...;.t! J ..u"j b/"lIui!I!L t / ,l1hI.11L·') .... \ " IIlllfC l""I1I\~ lflh u'>\'d 'iilk t lin t~ fll,I1 IL' b

ht

11l.:.lu ..k

..... I l' lit

liHi!-'tll.

:.n1.,H.JI\ .m\! h'lkAI.·n 11m •

Palie nl ;;; wilh brisk, w i de~ prcild L.I <.,c in datI Oll \ .11\: ~c to avo id Of Oli niOli l..c ca ,oil y "n;;;truClcd . . fl e fl1l." <md Ill"~ ml~cr­ ~ Lo ra7Cpam (A liv;.!n) may he prc o.,c nbcd to dl'U\'d~C ~. in tcnsi l), o f the fa, :.c 'lc li I" li' on.... " D e pcntlI· ng. on th..: L'IIi)lo(He of pain. a varie ty of man~gelllcn~ ~tr.... t.eglc~ m;IYht ut ili l.CgX Mi ld pai n (\r pa i ~ assoc la te~ with J01l1t dl ~(,o11lt nrt f ~ usu~ a ll y ad dressed W.Jl~l anal gc~ lc :-,. slich as acelaminophen or llolhH:roida l a ntI-I nfla m ma tory drug!'. . For more co . . ." vere rcfraclOry pai n. narcot iCS suc h a::. cocie me, hydrocodone , d I ·w met hadone m ay be presc n ~ .. n the te rmlllal stages of ALS, morphi ne ~l'~y be ad m l~l l ste red ~o provide analgesia. sedat ion, a nd re he t fro m re spiratory d l s lrc ss.~4 Ifll\

Management of Anxiety and Depression Anxiety a nd de pression can g reatl y impact a patient 's and hi s o r he r famil y's qu alit y o f li fe, a s we ll as the ability to cope w ith and ad ap t to the prog ressive changes and losses o f the disease. Thus. pharmaco therapy and psycholoe.ical co un se lin g are impo rt a nr managem ent strategi es'" for

add ress ing the anxie ty and de pre ss ion thaI can develop. Indivi d uals w ith de pression m ay be prescribed an SSRI. such as tluoxe tine (P rozac ) o r sertrali ne (Zoloft). It is impor. tant to no te th a t a nt idepressant effects ITIi.ly not occur for seve ra l weeks after initi at ion of the med ications, and ~ide effec ts m ay incl ude agitat ion and in so mnia, If the patient presents w ith d epression a nd in:-.omnia or agitalion . a tricycli c ullI ide pressant. such as amitript~ line (Elavil) or imipramine (Tafran i!) is pre fe rred .~4 Benzod iazep inc,. suc h a s c hlordiazepo~ ide (Librium), c lorazc pate, diaze pam . and Il ura ze pam (Dalmane ) may be prescribc-d for anxi e ty or for pa t i e nt ~ with depres;;ion and insomn ia. For patients whose respiratory statu, I~ affcclt:d.l nonben zodiaze pillc anxiolytic, s uc h a~ buspiron..: (BuSp3II, IS prt'ferred.\..i ·lI~

Framework for Rehabilitation l'our\t: of A LS l' all]l t) 1 he alt~r~d and t:\"(nt ually the !Olin ldu,tl \\ ill lx'come . .Iqx:ndent 111 c ...... t' nlJ,tll) all a~pt"C" 01 Itlllb fl il) ..tnti ... t"'ll l·, trc: 11 ~)\\I.·\t'r, .Irrropri.tte reh.lbiIJlJtWII rrog.rt..im ...... Imuld h..:· d~\lgll<"d Jn d IIllpkJl1e'otrJ to Jllll\\ Iht' IUJI\ It hlJl 11..1 IlMIIIWm hh or her ilhlepcnJeIK( and IUlll"llon 101" .L\ klllg ih P'h"' l bk~, \\ IIhtn Ih~ ('ullte\! (II T hl'

hl <., UI hCI ~tIJt... a nd J~\ ~lun..t.'\, Ihruu,ghuu t Ihe' dl..,e33t' anJ I'th ... hc..~,lJth l'.lrt· "'c'IIII1t!~ R ~>\'·J\I ...e ot dilL' progl"t' . . \I \(" IhHUIt.. III , \I . ') It t .. 1I111"!~·a lil't." Ih~lt the ph> ... t-.:al rherapJSI ntH 0111) .,L1dlt· .......UI IIlJJ\ tdut' Llr).!\.' ht. ... Jy tit <.' \ (dl·fh. t' h I hdp \!.uldl" ph~3-h.'JI t1ttrap) • - J,J[' ,I\.,{ t"'lOll IIMklilg I' ,,·ur l..:ntl) Wl.I\.tILlble \ s IJrntJ11C.' '-, .Il

lit" \1.1/\

I '\ h.i.I'" i.ll'lOglt;' . . ,i\C .u.d \kr~rh)IJIJII!-\ dl~~ Ira.ft'

\~Hh lnn ll.! hlt..· proV(\,........ II~1 to I.h,,,tl1JII). Hu~(\(~

II h.:h· I... g H'.J.1 v.utJhdll' .Ul lOllllt IIldlHtlu:lh _,..,t.lg,in"~ tiL' lllhl nil 1-..

,..

IIIldt/Jc- k.iJ I) lIudd/t' ,.ilI.! I.H\.•. ItJlJJk), III

ttl

'u

f,·

Therapeutic Care Continuum Disease Stage

I

Early siage

Evaiuation

Middle stage

~

few/minlmai impairments

~

noim lnlmalluncltonal

~

limitatIons no dlsabliltles

Findings

Late stage

• increaSing number of Impairments • Increasing severity of Impairments

• numerous Impairments • severly functIOnally limited • numerous disabilit ies

• mlnlmally/moderately functIOnally limited • some dlsablhlleS

j • preventive • restorative • +1- compensatory

Procedural Intervention Stratgeies

I

I

• compensatory • preventative • +1- restorative

• compensatory • preventative • +1- restorative

t Other In tervent ions and Physical Therapy Ro les

+ Patient/family/caregiver education and training + Psychological support +/- Referral to other heallhcare professionals

Figure 20.11 I ran1(.·\\or~ tor Reh:lhrh t.ltion for IndJ \ Id u:ll . . "jlh ALS . (From D,II Bell o- I-Iaa .... \ p II h. \\ nh pCnlu .....·,lon.1

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;Irtt:t ) ot txxI~ regH>O' ~an be- ~ltTe,,:tcJ b) A LS ,tnt! III \ ;UIO U \ l·omblnJlillll ' . lmp.tJmlt'llh lila) tXl ur n....1 dlrt'u n.~' lIl! of Illl' p.lt hu log) lllt reu ''''pwr1111'1111 • •, ... "c'lueb c rn Ihl' p ~ITht~tl)~ ~ (,udm', [mlpturrnt'ItI). or 11 \.1\ Ix" Ihl' 1t.· ... I111 \.If nndupk 1Ilh k rl \ i ll ~ \ trlg llh fnJtn · J \

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Physical Therapy Examination

lind III. 1I:,t ... I1l~I~ Illllrl'

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8.l2

Ph}'SicaJ RehabilitAtion

n'C' xanllllC, mOllll or, and c \ a lu a lc dHl n );.e~, '" ...('tme II1cd ~ , ("allk(.' i ' IOTHlla ~lIlg Ill:l) he h:J'ccI o n thc ph}" lc..d rherapi,, ', fi ndi ng'. forcl{;unpk , rhe jx t!l cr ll \ perce nl pred u.:lcd

C and 11ll' lIllllng of PEG pl ,ln.' IllCIl I. Thc Jh.Itien'· ... goal, and indl\ Idual p~yc h(l ... o<.ta l 13(1or\. r31~ ('If d,-.ea ..e pwgrc"" lon. CX L~nI Jlld arc:, 0 1 IIwolvcmC lll. "' I ~H!C 01 tht' dl,e:,\,c, rc"pl ratnr) :lI1d hulhar lIl\ohcrnCJ11 thai ma; IInpacl on Ihe pallen!'" ahlllly t~' panlC.. ~p:I1.C all net.'~ 10 t'IC laken \I1to account whe n <., truc IUnn!! the tn rwil cX::lInnl<.iIwn Thl" I~ pe ... 01 d~lIa generated Irom the palienl h,.,lor)' .tnd 1I11en IC\\- 3rt" prc'cntcd to Chapler I . When coliecli ng I.hc~ dJta, dctC'nllmmg v. hat I" 11l1~)lJrtan1. n: lev3 nt. and v
e)'J.JTlIn<.1110n for an mdl\ Idual \10 ah ALS. Ho\lo C\ cr, ..election h ah.. J~'" b:;;"ed on "pt"ofic panenl need. The le ') t, and me.t"ll:-C'" fTe.quentl~ apphcJhlc to r;:,IJent\ v.llh ALS I!'h:lude Cl, •.tInm<.1tlon of. ~n"or) Juncllon. mu~c1e pcrtolm· :JJKt . ...·(If'lrdtndIJCln. mOlOr junctIOn . gall. tunctlonal

talU S.

o.InJ Cid;\ H~ le'c\. the en\ mmmenl. :.!nd tognlll \e fun<.:lion Chaple" : . A. 7. . 10. II. I c. and 29 ). The !ollowlfIg '>C(.l,oT} prt!'-C'nl'" ;"aTt:d' thai I~ pu.:..lll~ "arT.Jnt e mph~J" d~nn;! L'1t." C\..1mmdlt"n

Cogni tion ~LS .....:~ '...

" 1I

.~ n;tJ\e le" ttr me" urt· r\h1 .. II Ol'rTlcn .. :.tre u'f'l:1..1cO e •. t'l..ulJ\t,· IUll<.-

01 ~ _fLit \C Imp.j rrOt:nt

'I,rom:- dr;::-u _t' I.. tlllrrchcn'I\"1 mc:rn',r\ . .tnJ ah.. traU f;,j 'n ll~ ,ho:.Jh.l ~ n ..llntrtc-d , hI':' \hnl' \1 t'nI.l! ~t.Jtt. C:\il.m ~ • () f:~ ""'·CL u'.::d In .... 11111'-"'1 til lit:', I<' t"il:rr, d l IlT .. ~ 'f .. ~}'

1...

lC\<.1.!l~.uI')fl n

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he mdtl...J.1 d

P~~ch o~ocia l Fu nction ',' ps. /;

d.

... '

H

Joint Inte grity, Range of Motion, a nd Muscle Length Funcll o naJ ran ge o f motion (ROM ), active. acti vc-a~sjsted an d pa<;~i ve range ROM. muscle length , and 'iOn tjss~ flexi bilit y and cXlen\i bilit y ... ho uld be exam ined UStng stand ard me,hod,.

Muscle Pe rformance Speci ftc deftc i b o f mu ')clc streng th . power and endurance, and muscle perfo rm ance dunng func ti onal actl \l i t ic~ should be determ rned . Spec ific dcficit \ ca n be measured with manual mu<;<; le te., lin g (MMT). l"JoklOeuc m uo,c.le strength testing. o r hand -he ld dy namometf) . In clinical trial.,. mUir cle strength i.., ofte n cxam lOcd a.\ ~l axlmum Voluntary b Olll clri c Contrac. tion (MVIC, U\Jng a \ lr<110 gauge ten... !Omeler sy"te m . IH1 Thi\ m c thcxJ e ll m lOille\ mu\Clc le ngth and veloci ty a\ facto rs in tC\ lIng and proouce\ reliable. \ altd. mlen :.!1 d4Jla. 11-11\1 M V IC 1\ com,dered the m~t direct tec hnique for lIl .... e'llgdtmg motor unll l tnum:tl ph}'Kdt tTh: raphh J( \.C\(;rOJI 1Il .. 1I1ulhm ... R~prodtlllhJIIl) tx't"..c(."n ~1"1T anJ \ 1\ 1(' v..1' h,unu 10 he C'4ul\ .Ikll t \en "'l1l\ I[~ 10 dela'l rr(~ ~

~rc

I\c."

mu",l~ ,t n.:nglh ch.tn!.:1!

,t

11l!1

n

Ittil\l'l j.1\

<.11 "-'It.

1;01

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metJ a

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1I1,J \II!/I

tndl\IJU.t!\

\4lth ALS

II ...

J I

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"U~.I ' I I":""

"

.l,r . . atavt

\1 \ 1.1

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ur

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l o ne a nd H...fl "Ke,

,.

10

JoJ\or("d \ 1\ 1 r H tt~n("r, f, mu:"'k, ... at" l~,t d 1A11h \1\rIC .In...! ~ mU'ot.k \Ioc:n.:. te h:O v.uh \ 1\1 r Ihu , (he t.ilth:reocc: In d~' lCdlOf dli1ngc: \<" ..h I... r\!d) Ji.u)Un l~d for b} Ihe Dtlrtr n.cr \It JT!Uxlt.·\ ~nrkJ ~~ \1 \ 11 hr,u \1\ 1<: .

J h.

Pam

a

ALS, hut rrt lhc r Cln Ind l fCt l (decreased I
MOlor Func lion

d POI1.iJd:tnd ec:1 n Ilu..1 t 'If' f:ll1ber c " ..... "".

.... ...". ~' I

I( {lIe ft Jr ex ample. Pa in 1\ not nc(...c~\arily

" " " I01-: 11£' ,

.. ('1' ,

LUfllrl.I'It

H.tlltJ fuJ"'~

m,·.t'rut'nt

(ha p ...·.. 211

\m)fllmphil. I

:.Ileral ~dt.' ro ... i.,

S.H

cranial Nerve Inte grity

Inte gument

(:~ ,common.l::. al ree led '-") ALS Include. V, \ '11. 1\. X, and XII. ~r:lIl1:t1 1,1(,I'\ C:-' , lh)IJld he Il''-Icd to

e\t.:!1 111 rhe h,l (' ..,t age 01 !\LS , kin Integ rit y I., prohlem . Shin Hl ' P Cl' l l01l .. llOuld be u.,cd to CKa lll IIlC coni act po mt .. l)I;t\\ ce n till: hod y and " ..,.,i.-.tt vc. adap\I\-e. orthotic. protec ti ve. anti " lIpportl v~ device ... mobility device .... .... well '-" th e .;" lce ping surfal:c . Such in . . pccllon i.. c" pccI ... ll y important \\ hcn the patient· .. mobility become ... II1cre~" in g l y morc depcndcn t. If present. .. we lli ng shou ld also he examined and monitored. Swelling of the di lital limb mil )' deve lop owing to lack of mu:-,cle pum ping act ion in
The

\,.· r:lIl1:11 11('0

.,k1t'!1l11l1 t' Iht' t~\l~IlI111 hulbar Il1\ll lvC IllCllt . SlTl'Cn ln ~ Inr 0(;11 illl1wr functIon. phonation. and "'pel'Lh produ ction l.1I1 tx,' aCI..·(ll1lpli~ht'J through the 1111('1'\ ic\\ and oh",cl"va ti lHl. RelefT'J I 10 a . . pecch- Ia ngunge pi.ilh olo!,! i :-.I I' recolll -

Illended.

Sensation If the ral1~nt cLlmpiain, 01 :o.cmor) ") mplolll!'. o r If ~cn­ ~(\~ 1n\llhcl11cnt I' :-.u~peclt'd. ,en ... or) IC !:I lin g :-.hou ld be l'on1rler~d.

Postural Alignme nt, Contro l, and Balance S13tK and d ~ l1aml,,:' rO'lUrai alignment and bod y mechanl':~ dunng '\elf-c~re. functio nal l11obllil) ... kill ~ . funcliona l aell\ Itle~ . .rnd \~ or\.. condlt lOIl'l and at' li\ ltie ~ should be e\lmmed. Por..tural . . tabllll). reactl\,e co ntrol. anticipatory

control. and JdJPII\ e pO!-lUrai control should also be determined . !\o ALS-speclfic bJ.iJnce le~ L o r mea ~urc e\l~t'. A \ariet~ ot balance "alu.., measures are aV~lil:lble ongtn311) de ... lgned for u.,e \~ nh olher palicllI popula-

tion". m..:JudJn!! the TIIll'lfI Pl rformallc l' Oriellll'd \1\.1 /1111(\ -\\ ( _B nUlil ( PO\/4/, l~' the Berg Balall ce Sd1 lr . • th e 7mud Ll' and Go 7l'sl ,t :~ and th e FilII: Ilell Rcv, " Tr l l I_~ Lo\\ IOlal I meIII Balm/{ l' TI' \1 '~\'re, mdlL.tllng Jlnp;,.IIred balance. \\ere found 10 be moder011el~ to 'InlO~l~ related to LE mu.,cic "l~ :.tknt''' '' lind fund ll mo1i dha~llill1:~ In Indl\ldu.tl .. "ilh ALS . I~~ I\. loo,.I.iI ... uggc"lthat tht' Tinelll Bal:uH..: c T~"'I i ... a rell-

"hie ffic.t, ure lor mdl\ Idu~l., ~t"g(" , 01 A LS

In

Ihe t~ ,lrI ) or ea rl) -l11iddlt!

In

gC!l(.' lal.

rare! }

;t

Functional Status Functi onal mobi lit y skill s. safety, and ene rgy expenditure are important considerati ons. Basic and instrumental activities of dai ly li ving and Ihe n~ed for adaptive equipment should be exami ned. The Flll/crio l/al Indepen dence Measure ( FIM I\I)I~Q h
Environmental Barriers The pa ll (,"nI'~ home and \\ork envi ronmenb should be examined for curren! and pmemifd barric'r~ . access. and safety.

Fatigue Gait \. 4.L~ pt:ufl\. ~.11l tc ' t or m~i1'Uh: c'\""_ (.,ttl .. tabilll) . \i11et~ aJ.J t:nduriin~ • .,hou1l..l bs: t:\.uJllnc:d I:n~fg~ C\I':.cIld,t...I~ O1h~flnh:1I1 III pIJl.lil.1i1t} ... Jk l .\- .llId l',l.,e Ollbt" 0 1 1fth",,~ .J.lid <.1"1'-11\ t " dC'\ IU' :-' ... hlluJJ i.lJ..o l~ t"\.unmt'o at r 'Jbr

1111"[\.1.1"

1 -~llI guc I., \t:T~ I.·ommon III mdt\ idlhll .. \\ IIh ALS . No :-\LS' IX'Cltic Jl)Ca.,Ufl·., c\.i"ll; till' Faflf( ut' S£,\,('nty 5, aie l I: ha~ reen U"Ic'J til c.:IlIlllallrlal ....

Oi!>ease-Specific and Quality of Life Measures

Respiralory Funclion (~lt:nlllflo1ll'm

ill

iC''''l'lfii\ttf\

"l..ttu' anJ IUI II.II IIII 1IlI..Iud\!')

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and

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Q~t.lo

PiJlm~.tfl.1f) tnJuldn ... l· 111.1) bl:' k .. lt'J 111

of i\ l~ u~ln)..I.Uld .. f(li/l'U phn ..... ~II ... hi

t"oaJu.:sk o:UW 11)01111111 h ·.,!'un ..l·· t\1 dl:rnfoll I,.IJihJllhmUl!!

Disease-S pecific Measures 1he \/ \

.kal£' f. \L. ·FRSJ 1H aod the LSI K" ·H t" L-\ppendi:-.; R) tlJ(amine the

lUlU Illil ial RUIlIIV

rC\I ..~d \l.'f~I('II ,

t

Iun..:tJol1.aI ... 1.1(U tlt P..IUI.'II'" \\ llh ALS. Tht! pallem is ibied h\ 1 .1t~· hl \ (,r ht'( IUJll..1I0n U~UlS. d .,'-'Jic from ~ (nomUll Ilml"ftOtli tu 0 ~11I\.lbk In JtlCOl(l1 lhe! ta,," ). '~ origlRill .......Ik th<: ,\L\l t<"). ~o(relal It po~ilJ\oejy ~Ilh objet.·'i~e ml'iJ~Uf\!" or uppt:r ,tilt.! hm\.'( x.lr fUll)! mu~le stre.ngth

834

Physical Rehabililation

".I'" found

10 he \ahd and reliable for 1l1c4I .. uring lhe dt"\:line in IllllClioll Ih :-' I re w l" frolll 1(l~,'" o f lllu~C' ular and

"l rcn i.'! lh ,1 t, The ALSFRS- R \"a .. c'\lJ.'u uk d (0 incl ude ,Ideli lI onai f'(" r i ra ((lr~ Il cm ~. and" a.s lound 10 h:1\'l! infernal

C'lm~ I "'It'n('\, l.' o n'l ll.Iel \Jh d ll ), :md 10 ha\'e fe lained (he rn~p<' 111e, ~oj lhe original .. calc .l~l Othcr d l!'Oca ..c "pcc ilic ....... Jk, mclude 1he 4PI'cI Al SU1/,' (A ALS) ,n~ Ihe ALI:) ~\ I'\ 'tTl" Scolr ('\ L~SS),I{~ and Ih(' Nnrn\ .~(1I1l' p ,,-

QualilJ of Life Measures Qualll~ 1,1j ilk III mdt\ luual . . \\. 1111

LS ha . . been e xamined \\ 1111 l!t" ncn ... me~I"'urC\, .. lith a ... the S/--3(J. P" Ihe Sl h,~dJl/t' f/., /1.l/II.We'1I (If !I,Jllldllll / Qualll\ of Lljr- Dir('ct He ~hrlflf! (C;E/(}(II.-D H I. ," and the !>1tJ..nt'H Impa! I P'·Jlil,{~/1' '".. The\L QQ-.Hl ~ JI1 XLS -'penD" 4u.11i1) or lire me"'ure .... \,)n lam'" 40 Item' that repre'l'llt Ihe dl ... llllc t area .. o f hCJllh nll'hlll1~ (10 Ift~m .. ), JCII\lllC',> 01 dJi l) li\ lng ( 10 Jlt'm ... I, c:.HJng and dnnl..mg L~ ih?m ... 1. l.'oml11uni(:all on (7 lIl~m"', anJ C'moll,mal IUllclIoning (10 1I1.,· m .. ), T he qu e .. !I,m' n.:jl~r 10 the rall("n(~ l.'OndtllOn du n nf! the pa.... 1 ~ "cd... .Uld r ...·:'IIXm ... e .. ,irt' ~I\l'n on J fj\e- pt.") II1T LIl.. en .., ~ al e , 111 V ' 4Q J 1 mC.I ... url''o hC.llth ... 1.lIu In (":teh domain U',"!!
'- Iages of A I.-'i. ta,ks . or aClivillc", may be adapted to ~c hi evc lum.:l lon. A s th e d l o f ROM , ae robiC capacity . ' ., ~ 'i trengt h, prcve ntlllg pne um onia or ate leclasis, and func~ lional lill1il ~ li on ~. Beg inning a n ~arl ~ prevention program may altc r Imp3tnne nt '\ and matntum ph ys ical function Ic mporaril ) , and may a h o improve well -being and

a\ we ll a~ lhe seconda ry effects of im.mo.. holil ) . In Ihe laLe-milldle and laLe
Promoting inde pe ndt' nct and 1l1.t\' lnl ll lng function th roughout Ihe 'o t ~l ge ... o f Ih~ dl ... ea ...c . through re ~loratlve and t:ompelh J tor} tnte n cllIion, Ihdl dddre 'i ImpaIr· me nt" fu n l,~ ti ona l Ilrn il..lt ion ... , and d l "~I"'i li lle . . : Promoti ng hC,lllh n Ih ! \\ l' lInt:" .. 111 th.... ea rl\, and earh. Hlldd le .. IU!!e .. 0 1 tht.: d h('41 ~ Ih rough n:·... lOra tl \C' lOu~r,

.

\ t' nl Ion .. ,

Pn)\ Ilh n~ J lti.'r1hl(I\t;.· 111 an ... uf t;.~ .lmmlJ out funuiooaJ - ~ ill' l" l1u: .. \\ I(h ad.cpu \c C'I,IUlplllt"nl Jnd .;.Iitem:ll£' meth,)(.1.., tClr ,wrtf'rnll ng 1.1'l.. ... JnJ Jdi'l. Illc''' .l'" m(' (h..e;l~

-

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Illililil"

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Chaptcl"" 20 Amyotrophic Lateral Sc1cl""Osis

England fune.li on scor~s . Sr:-36 rh y~ i ( al Func tion SC'orcs d fOfx:ed vlt 31 capacit y (f' VC ) ('olllpared 10 a m:.l lchcd :l1lrol group who perfonll~d :<; lrl'1l"hin g. exe rcises onl y.I.P Patients and therapi sts mu st unde rsta nd th:11 an y be ll (' fic i ~lI effects of an early preVt' llti o ll prog ram will be short le rm and will not have an impact on fh e ove rall course of the d isc.1SC. Much more re:-::can:: h int o the ~ rk(" ti \"l' ll c ... ~ of inl cr\'ention ~ for indi vidual s wilh ALS i ~ nl~eded . In de\'cloping a p lan o f carl' (POC). ill additi o n to th e patient's £oal s. 11.ll' the rapi :<.t IllU ~ 1 ab o c'on s id~r Ih e ra te o f disease progress io n. the ex l ent and area of lIlVO IVC lllcnt . stage of the di sease. respira tol) ' and hulhar ra cto r~ tha i may impaci parTi cipati on. tim ing o f Ih e int c rve nli o n. patiellt 3("(:ept:lIlCt' and moti va tion. life ~ uppOrl choi ces. avai labil it\' of psychosoc ia l suppo rt . and re~ourcc s . . Some pal icnl s may view th e need to use adapt ive equipmenL an ambulat ory as sistive device or wheelchair as a df.'fi nitive marker fo r d isease progression and impending de.ath . Thi s may cause the patient to be hesitant to accept the recommended aid or device as a means of maintaining some aspect of con trol ove r the d isease. The physical therapist \\ ill be req ui.red to mailll a in a balance between being realistic about \\,hat can be ac hieved and providing a sense of hope. not help lessness. when di scuss ing intervention options. An overview of ALS disease stages and general intervent ion !'trategies is pre sented in Table 20. 3 . Common impainnems and func ti onal limitations associated with ALS and their respective interventions are de scribed below.

Cervical Muscle Weakness Progressi \'l" cerv ical ex ten sor weakness will cause the head to fall forward. resuJting in overstretching of the posterior muscul ature and soft ti ssues. This may cau se bouts of acute pa in or deve lop into c hroni c cervical syndrome s. and anterior mu-:,c le tighlnc ss. Some patients w ill compensa te for the foru ard head position by increasing lordos is . as the~ ane mpt to maintain their posture during ambu latio n. For mild to mode rate cerv ical weaknes s. a so ft foam collar ma y be worn d uring spec ifi c activiLies. Sofl col .lars are comfon able and u:,> uall y we ll to le ra ted . However.

835

Figure 20.12 The Headmaster Collar. (Coun esy of Symmetric Design s. Salt Spring island. Be. Canada. V8K IC9. )

wear-ind uced compressibiJity requires they be re placed frequent ly. For moderate to severe weakness, a semirig id or rigid collar is prescribed. These are usuall y made of

padded rigid plastic or leather and prov ide very fi rm support. Patients may find the collars very warm: may ex:peri· ence di scomfort at points of body co ntact. suc h as the c hin. mandible. sternum , or over clavicles: may feel press ure on the trachea: and . may fee l confined. Seve ral types of co l ~ lars are presented in Figures 20.12 and 20.1 3, illld the pros and cons of individual coll ar types are summari z.ed in

Table 20.4. Some patients with combined cervical and upper thont:elc weakness muy bene fit from a ccrv ica l-thor.u:ic ol1hosis. or a

. O' and Common Table 20.3 Amyotrophic Late ral SclerosIS il~se~se Stages f, Individuals with ALS

1

Strat gies' Framework for Rehab ItatlOO or

.

RestoratlvelPreventatlve . . a142, 169, 170 Strengthening exercises . 171 • Endurance exercises o Active ROM,172 Active-assisted ROM , stretching exerCises

Mild to moderate weakness in specific muscle groups

Early

o

Difficulty with ADLs and mobility loward the end of this stage

Compensatory ' . . • Determine potential need for adaptive or asslsbve devices o Determine potential need for ergonomic modifications 01 homel workplace o Energy conservation o Educate the patient about the disease process, energy conservation, and support groups Middle

Compensatory o Support weak muscles (assistive and supportive devices, adaptive equipment, Slings, orthoses) o Modifications to workplacelhome (e.g .. install ramp , move bedroom to first floor) o Wheelchair prescription o Education of caregivers regarding functional training

Progressive decrease in mobility throughout stage Wheelchair needed for long distances ; Increased wheelcha" use toward end of stage Severe muscle weakness in some groups; mild to moderate weakness in other groups Progressive decrease in ADL skills throughout stage Pain

Late

Wheelcha" dependent or restncted to

bed

Preventative o Active 172 active-assistive, and passive ROM, stretching exercises • Strengthening exercises " '· I. ' .170 (early middle) o Endurance exercises '71 (early middle) o Determine need for pressure-relieving deVICes (e .g., pressure distributing mattress) Preventative Passive ROM • PUlmonary care' o Hospital bed and pressure-relieving devices • Skin care, hygiene' o

Complete dependence with ADLs Severe weakness of U E, LE, neck and trunk muscles

Compensatory Dysanhna. dysphagia

CaregIVer education regarding transfers , posItioning, turning. skin care • Mechanical litt o

Respiratory compromise Patn May De reSIOfall ....e

From Oa! Sello-Haas V

fI

P 123 wllh perrn l ssK)I1

ADl act· ,IlleS 01 da!ly bYlng LE UE upper e>1IEim1ly

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kt:

dt

Ul~ 1Pllioil

lo~er extremity ROM

range of motlOO:

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pfll\· H.11.' tft".IU' , \-u IJIXln

hUI Uh .' mor e:

t'\ I~ lh l\'t"

hc.. dl!flt lJiI III dun ,iI1~1 Jult I ur "l'\l' l c H" m("".I",hl\- Ikd v.l'~ l nc rdt,rto.1J Itl can orthol, ... l 1(\1 .t ,dl1 ·nl-nhllh dC'\ h \;; IIJ~) lx' IIl."tt ....... u;. fUlJ

t

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!lId!

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fJl IlCllJI

'Ilhl ct.iu ... l llflli •• I;(Iul

rl~~t

0.&1111 \,UPp",1

O y;.arth ria a nd Dyspha gia In lo ll .l t~ II ~I II"" ", (ti, the ')IX '",II IJoguJj:!C' p-,JlhoWgJ"" ~ ph~ ,1".,1 tik'"I _'PI" l.lll I"ld ) J lilli.' til IIl.UliIglll~ d) ~

ChapteT 20 Amyotrophic LateTal ScieTosis

837

Table 20.4 Types of Semirigid and Rigid Cervical Collars .

t'~~,

...,.-

":'" .......

Collars without anterior neck access

Collars with amedor neck access (for , tracheostomy)

,""'"

P hiladelphia ~

. .- •

Collarjl

::::::::::::~EM ~.~7~J~'~b~'~.~r~r~::~;:;::::J

%

Offers good support

Patient may feel confined May cau se pre ssure on trachea Patien t may expenence difficulty breathing or swallowi ng Can be uncomfortably wa rm

Miami-J® CollarD Aspen Co llar' MalIbu Colla r"

Padding absorbs and wicks moisture away from skin SUitable for individuals with cervical weakness in all 3 planes

Patient may feel confined May be uncomfortably warm More expensive

CanadIan Collare Headmaster colla re

Open design allows for circulation of air Lightweight No pressure on trachea Some patients consider collar more cosmetically appealing

May put pressure on chin and sternum Some models more expensive Some models require custom cutting Not adequate if rotation and lateral flexion weakness is also present

'f'hliadelphla® Cervical Collar Co. Thorofare. NJ 08086. lljerome MedIcal Moorestown, NJ 08057-3239 . 'Aspen Medical Products Inc, CA . 92618-5202 . "$eanle Systems. Poulsbo . WA 98370. ~ymmel nc DeSIgns Ltd, Salt Spnng Island. BG. Canada .

andd):,ph ag ta b) address ing the pa tient 's head and trunk control and posi ti o n in silting. In add iti on. the ph ys ical theTap l ~1 can rem force the lise of S!T3tegies for eatin g and s\lt.allowm g and the use of pre~cn bed communicauon de\ ices v. Hh th e pati ent Because pa lient s are at ri sk t ora ~plratl un . educati on of the patient. fa m i ly. and caregl\ er h IInperati \'e (see Respiratory Mu scle \Veakncss helo~ I

UIi. Muscle Weakness Weakne~.,

the l E~ gre~ul) 1I11pact" the pall enl '.., abil iry .Kln iu~!>. of d~1i l ) 11\ 1Il g: . There IS a large vari -

\)f

10 , ar~ UUl

of "dapm e eqll lprnem J\ ;lIl,tb l ~ mat ma) a~~i')l the patltlU pl ljlon p tun..:llOn fo r tI ~ long a~ po~s l ble (~ee Ai'tJ\ Jl it'!
et)'

rh ythm secondary to spasticity or weakness causing imbalance that may lead to impingement: overuse of stron g muscles: muscle strain; poor re sting position; gle nohumeral subluxation secondary to weakness; or a fall. De pending on the cause of the s houlder pain, interventions may include modalities, ROM exerci ses. passive ~ l re l c hing, j o int mo bili zation s, and educati on about proper j oint s uppon and protection. A recent report described a 20 perce nt incidencl! of adhe.;;ive capsuliri s in indi viduals with ALS . Recommendations for m:maging the pain and decreased ROM included a protoco l o f an intra-articular analgesil" and anti -intlarnOlalory cocktail injt-cti on. fo llowed by a course of a ggre ~sive RO M exercbt,s. Some pal ielll') reponed an s,,'ute re w lution o f pa in, wh ile Other-.. re ported impro\·emt;! nt.s ove r :2 to 3

wee k'i . t -l4

Respiratory Muscle Weakness EJUCdilOll b t:x l remel y important. PilOt'lIl'i and caregivc~ IllU~t be t.w ght how to

rated uholJt enl"rg) C'ou ~ rva ( ion techmqut"s. Patients and ~ h ould 4 1 ~o be et1uc al~d about sign~ and symp~ U)nh of ;bptrUll on : po-"lt ionlllg 10 a VOId a.splration. such 3:-. upJX!r c ~n Il..,t Iopirk" tlcX10Il durmg CilUOg ; c au~ I:Uld ' I!JH" 1\( re~ptr<1tory mkc liou : and sO'Utegies f()r manal" mg oral ~L-er(' tl un ... or (' h~tkUl g e pb~lJde5. Souch as the lIeu nlKh miiUlt'u'¥ tl, Bre alh.tJt& eA~rl.'l~S .ukJ p'-liitionin.

caregl\(:,h

SbouJde~ Pain lnili\ldua.t ..... 'Ih AL~ ma~ Pl't1tcm ",th \. ltll1.ul l.ilu-c:d b~ M"\. t' Iu.!

d,.: 'vclop :-.ht)u ldrr ruun and U'"hll' l lOll PbJIl Ina} be.eahul.)nnal ')\.4olpulohuJI)t"ra l

r p.illtITI,) of f;n-I Of !>

babnce activity and nt...t and rdu ·

8J8

Physical Rehabilitation

10 optimi ze \'enti l alionJperfu ~i on nHtlchin~ ma y al so be incorpor:.Hed. alLhough their effectiveness I ~ ALS has not hccn dClemlined. Airway clearance. techOlq ues may be nl~cc~sarv when conditio ns that cause sec reti on retention . :-uch as pneumonia or mclecHI!"is. arise. To (,ol11pens~Hc for a weakened cough. the patient and arel:!iver ma v be instructed in the use o f manuall y ass isted coughing h:!i..·lmiques or mechani ca l in surn~ti on-cx s uf~ a­ lion. Amtin. the effecti veness of these techn iques or deV ice has no; bee n demonstra ted in ALS. but case reports have dc"cribed the ocneli ls from reg ular use o f a mech anical insuffla tion de\' i C'e.l"'\,I~ A recent study examinin g cough nO\\ s and pres~ure~ during coug h :m gmentati on found mJ.nual ,,~sist nnce increased Ilow J I perce nt in bu lbar and I.~ pcrc€'llt in nonbulbar ALS paticills. and MI -E increased flow 26 percent in bu lbar and 28 perce nt in nonbulbar ALS ratic",~. TIle greatest improvement s were in patients wi th the" eru..est coughs. l .n

LE Muscle Weakness and Gait lmpainnents Onhose.. 1113) be- recomme nded to improve function by ot)'enng ..,uppon to Yo eakened m uscles and lhe joints they ,urround. decre:bc the ~rress on remai ning functioning or l\mpen"3lo,) mu~les . conserve ene rgy. or m inim ize local or general mU!o.Cle fatigue. Controll ing knee impainnem s can often be achlc,>ed Ihrough an ankl e orthosis. and thu s aJdre~sing the ankle ,hould be considered fi rst. h is al so important to ('on~ider the" eight of the orthosis a~ individual ... YoILh ALS wilt have energ) expend iture iss u e~. and it m;l.~ he m()r~ fAtiguing for the patien t to am bul ate wi th a hea,~ ortho"l~ than to ambuht.e without the im paimle nt bemg ~on'eCled For thi'S re~on, a knee-ankle-foot o rtho-,1 d{.\.FO ~ b u\uall~ not recommended. Del'ldlOg beru.ec-n a premanutactured 'ersu~ CU!'l tom onhO~I'" 1~ cen. unl) dependcm on the pallent\' resources.

Table 20.5

but the r~ te o f di sease progress ion should also be considered. For an indi vid ual wi th rap idl y progressive ALS and who is li kely to use the orthosis fo r limited time, a pre. manufactu red orth os is may suffi ce. Solid ankle-foot orthoses (AFOs) are a good choi ce for pati ents who ha.e medio lat eral instabi lit y o f the ankle with q uadriceps Weak~ ne~s. The fi xed ankl e posit ion, combined with the quadri~ ceps weakness may make it difficu lt fo r sit-to~stand transfers. climbing stai rs. and negoti ati ng inc lines. Hinged AFOs a llow dorsin ex ion and may be appropriate for the patient with ad eq u ~te knee extensor strength with mild ank le strength loss. T he type of am bul ato ry ass isti ve dev ice prescribed is de pendent o n the deg ree o f p ro x imal m uscle strength or instab ilit y. fu nction of the UEs, the pattern , extent. and rate of d isease progress io n. acceptance by the parient. and fi nanc ial constra ints. Agai n. we ig ht of the dev ice is an important fa ctor to consider in deci sion making. while also tak ing into account wh ich device w ill ensure Optimal funclio n and safely. Whee led walkers. which do nOI requ ire the pati ent to li ft the device, are usually recommended . In general, crutches are rarely used by ind ividua ls w ith ALS . If used. Loftstrand (Canadian) crulches are preferred.

Activities of Daily Living A large variety o f adaptive equipment is available to ass ist individuals with musc.le weakness perform everyday tas ks. However. Ihe benefits and e ffective ness of adapti ve equ ipment for ALS have not been evaluated systematically. No one type o f dev ice is suitable for every patient o r fo r eve ry stage o f the di sease. Reimbursement for the equipmem is var iabl e and although a piece of ad aptive equipment can help the pat ie nt maintam independence. Iimiled fin ancial resou rces may pre veOl reco mmendi ng o r purchas ing the irem . For e.'( ample. in the

Types of Adapt;'·., Equipment -Common - --. -- ----- ----

Feeding and Eati ng

Setf-Care a nd Bathing

Foam tubing to If)Crease the sIze of utensil handles; utenSils and cups With mochfted handles or holders; long·levered Jar opener, plate guard, serrated or rocker knife; wnst spflntadapted cuff (tor holding tools and instruments). mobile arm support; Dycem

Bathing benches balh lub seats shower commode, handheld shower head: grab bars: raised tOlle\ seat. tong handled sponge electriC toothbrush or shaver; stra".fttted hairbrushes

Ore •• ing

-

-

-------

-

Zipper pulls 0< hooks bunon hool<s. long-handled snos horn . Velcro. clolhlng ciostJr8$'

elashc

!:>noe laces

Writing ane! Reading

Foam lubong to Increase the Size of the pen or pencil, ttoangular pencil grop , peIll1oldalS. boo, hOlder. aulomallC page lumer : adJuslable angle lable

Other

Key holders. doorknob aoaplers lamp eX1ensoon sWIlch, person I a arm system, swild>- /' op8fcded environmental COfltrots spea er PhOne wnh automatic; dtahng . l~ holder. use of loleoom,llUOlCauon
-

-

---

818

Pb)'81cal Rehabilitation

10 optimilc

venl ilat ion/pc~us ~on .m~lI c hin~ may al,so

be

incorpora ted . ;.l ltho ug h the ir e ffcc tl vencss I ~ A~S h~S not been detcml int'd . A irway clearance tcch1l1~1Il,:S m,IY. be • e"' " ....., whe n ('-cmdi tions lha t cause secre ti on retenti on . nec ;.~<,, : . . ~u ch 0" pneumonia or ate1cttas l .... anse . . To tompcn_,alc fClr a weakened coug h . the pallent. and c3re~lver lOa) he in,truclcd in th~ us~ of man ~a ll y as~;]"tct.1 C(lugiling. techniy ucl; ('If mechan ical II1 S U m~fl on-cx~~f~ a­ lion. AC;lin. lht" drecti\,cnes ... of thc:-;c tcCh111ques or dl.:.vlce ha' 110; oce n del1lon~lraled in A LS. but case report s h~ ve d('''criIx'J the benelit, from reg ular U'C of a n~echn nl ca l lI1~u fll
LE Muscle Weakness an d Gail lmpainnents ()rtho...c, m.n be fC."Commended to improve func tion by nfl..:n ng. "'lIPI~n I() wea!..encd mu~cle~ and the joints Lhey . . urround . dc{"re~ . . l' the :-tIC~'" on remaining functioning or d lmpcn ... atoT)- Illu:-.\.le .... l'Ollltcr\ e cllerg)_ or minimize local \)r f!.C'nC"ral 111U 'Ie bti£ue. Cont ro ll ing !.. nee impairme nts 1,.:U1 ~llien be- :lchle\ cd throug h an ankle orthosb. and thus addrc,<"lIlg the ankle ,!wuld be con!o lde red firs!. It i~ a lso lInponant to <,on'ldc.:r the \\c l£ht of the onholtb as indiv idu;d" \l.llh ALS \\ II! h ~l\ c encrg) I.."x pendilUre i ~.s u c!!l_ and it 1ll
Fur

lhl~ fl.:!~bon.

11 I..ne-e·-ankle- loot ort ho--

...... (KAFO , I" u ... u~dl} n(lt re4.-·ol11l1lendcd. l..)cudm£. Ix-I\\ ('tn a pre mallu lac:tured vc r ~ u , (·u .. torn 011ho'I" I~ n·n.;llnl~ dcpcndcllI on the palie nt \. re!)ource ...

Feeding and Eating

but the rate of di sease progre ssi ~n should al~ be consid-

ercel. For an ind ividual wi th ra~ldl~ pr~~essl~e ALS and w ho is likely to use the orthOS IS lor li mited time, a pre.. manufact ured o rthos is m ay suffi ce . Sol_id ankle-fOO(

orth oses (AFOs) are a good choice for patie nts who have mcd io latera! instabi lit y of the ank le with quadriceps weak. nes~. 111e fi xed ank le position, combined w ith the quadriceps weakness may m a ke it d ifli c ~1t .for ~ iHc:rstand transfers. c limb ing stairs, and negotlatm g Inchnes. Hinged AFOs allow dorsifl ex ion and may be appropriate for the patie nl w ilh adequ ate knee ex tensor strength wi th mild ankle s tre n gth loss. The type of ambul atory ass istive dev ice presc ribed is de pe nd e nt on the degree o f p roxi m a l muscle strength or instability_ fun c t ion of the UEs, the pattern. extent , and rat e of di sease progress io n. acce pt a nce by the patient. and fi nanci a l constra int s. Again. weight of the device is an import ant facto r to conside r in decision making. while also taking i nto acco un t w hich dev ice w ill e ns ure optimal fun cti on and safety. W hec led walkers, wh ich do not requi re the pati e nt 10 lift the device. are usuaJly recom· me nde d . In ge ne ral. cru tches are rare ly us ed by individual. wi th A LS . If used . Loftstrand (Ca nadian ) c ru tc hes are

pre ferred .

Activities of Daily Living A large va ri ety o f adapt ive equipm ent is avail able to assi st individua ls with mu scle weakness perfo rm every·

day tas ks. However. the be nefits and effectiveness of ad ap (i ve equ ipment fo r ALS have no t bee n evaluated syste mati ca ll y. No o nc type of device is suitable for every pat ient or fo r eve ry stage of the di sease . Re imbu rsemeDf for the eq uipm e lll is va riabl e and a lthough a piece of adapti ve equipm ent Can hdp (he patie nt maimai n independe nce. !im ill"d li nam:ial reso ur...:es may prevent ree· ol1'l ntendi ng or purdl;L"ing the item. For ex.ample. in the

Foam tubing to increase the size 01 utenSil handles; utensils and cups with modified handles or holders; long-levered Jar opener; plate guard; serrated or rocker knife; vmSI splinVadapted cuN (for holding tools and tnstruments ). mobde arm support:

Dycem Self--Care and Bath ing

Bathing benches. bath tub seats. shower commode, hand~eld shower h~ad; grab ralsea tOilet seat. long handled sponge electric toothbrush or shaver; strap. t,tted

ba~

h'urDrushcs

Zipper pulls 01 hooks bunoo hOOkS , el&5l1C shoe laces

Wntlng and Reading O ther

lo~g-~;ndled sh~ hor~'- Velcro" CI~ ;hlng closures;

Foarn tubIng to InClease the size of Iho pen or penCil, (na~gUla ; penCII '~rt~;-~n hokfet'$; bvok holden" automatIC page lumer , adJustaOle angle table

Key holders doorknob adaplers lamp ext~nslon swllCh ' personal alurm 5~St;~;--;;;;:­ COfltrols , Spealo.er phone wnh automatic dialing leJephOM h04~1 use oj It.'! Of'lllnullIcauon Oe\llces for the deaf ~TDD) ,

op6rat&d envuonmentdl

~haptct

20 Amyotrophic Lateral Sclerosis

8]9

ALS a, Uni ve r:o;;d cuff with _a . pock et for ear I)' stages ' . of .

wn·t,·o"~ or feediOg utensil s ma y he

disease progresses and pro x im oll

bt'nell c lal. As lhe

~ h o lild c r

wca km' ss

"rlcreases . ;1 mobi le arm s upport ma y lk' in co rpnrall' d to ~1I0W the pMit'nl to maintain indc pcndeni..'l' in ~atiJlg. In ,he latc slage orALS when Ihl' paticill is dcpl~ nd c nl o n lh e caregiver for l>aling. a lon g. ...,Ira w an d .., Ira w holder Illa y be: reconlmend ed to ass ist th e careg iver w ith th e ;ll'li v il y. E);.unpl es of adaplive cljU i pm Cnl [hat ma y he bcnefi c ia l

for perfom1ing activities o f dail y li vin g

afC

prese nt ed in

Table 20.5.

Decreased Mobility Patients w ith LE weakness Illay have di ffi cu lt y w ith ... i1-10stand or car transfers. Sil11pk~ interventi o n s include p lacin g

a finn cushion:! to 3 inch~ s thick under the buttol'ks in the chair or elevJti ng the chair by placing the legs in prefabri cate-.d hlock s (Fi g. ~O . 14 ). Se lf-powered li fting cushi ons are relative ly inexpens ive and portable . hut the ind ividua l need'! adequate trunk control and balance in o rde r to use the dt'vice safel y (Fig. 20.15). Powe red seat lift rec liner ch air~ may also be recommended. but are. more expensive. All these intervenrions increase the biomechan ical advantage and make it easier for the patie nt to ri se from a sitt ing position. Caregivers will need to be educated regard ing assi sting the patient wi th trans iti onal movements. Transfer boards may be used for t.ransfers once the indi vidual is unab le 10 stand. ei ther alone if the per~on has adequate ann strength and good sitti n!! balance. or the caregiver can be instructed in how to ass ist the patient. Other useful devices 10 ass ist the palient'~ mobility are tran sfer belts and swivel cushions or seal\. Transfer bell'i ease the burden of the tmn sfer for the caregiver and prevent potential pulling on the pat ient 's VEs. Swivel cushion:o. are lightweight . cushioned seat:-. that swivel in both dircclion:o. and make ge tLing in and out of a car easier (Fig. 20.16l.

~'9 1 Ure 20.15 D

R 1M2.)

UpLIft St:al (CUtJf1esy

Figure 20.14 Prc- fabrku lcd blocks. (Courtesy of Homccmft Abi li tyOne. Kirkby-in· Ashfieid. Notlinghmnshirc . Eng land NGI77ET.)

Once an indi vidual c;.mnot pe rform transfers, even with the ass istance o f a caregiver. a hydraul ic or mechani ca l li ft is required. Com mon ly recommended lifts dev ices include the Easy Pi vot'" (R and-Scollnc. Fort Collins. CO 80524). and the Hoye r Lift® (S unri se Med ica l. Lo ngmont. CO 80503). Use of an e lectric hospi tal bed may fac ili tate bed m obi li ty and transfers both for the patient and caregiver and, de pend ing o n resources. home mod ifications and automob ile adaptations may also be considered. C ha ir gli des or stairway lifts can be suggested for those in dividuals who li ve in m ult i-leve l homes. bu t who cannot or shou ld not climb stairs (see Chapter 12). These li fts are meas ured and c ustom-made for indiv idua l stai rcases and are very ex. pe nsive. Insu rance companies usually do not reimburst.! for stairway li fts. bur some medica l supply comp,mi es offer "rent-to-ow n" options. In addi tion. local ALS Assoc iation (ALSA) chapters o r Musc ular Dystrophy

,.f Upllh Tcch llUIQglcloi I n\,; .• J);trlllillum . NS. Canada.

840

Physica l Rehabilitation

features for patients who used powered wheelchairs includ ed independent mobility. maneuverability, overall comfort and tilt -in-space/recline features; undesirable features included low. nonreclining back, heaviness or large s ize. uncomfon abl e seat. nonadju stable leg rests , and general di scol11fort . 1411 Altho ug h power scooters may be suitable for a patient with adequate UE and trunk strength in the earlier stages of ALS. the vehicl e becomes limiting as the disease progresses and sho uld not be prescribed. If the patient has already bee n re imbursed fo r a scooter. most insurance compani es will no l pay for a power wheelchair, because th e scoote r is conside red a power mobility device. If a scooter is to be recommended at all , the patient should rent or borrow the devi ce for shan-term use .

Mu scle Cramps and Spasticity Figure 20.16 Swivel cushion. (Courtesy of Sammons Presio n Rolyan Canada. Mi ss issauga. Ontario. Canada. L4Y 4C5.)

Association (MDM chapters may have lifts that have been recvcl ed. At some ti me point as the di sease progresses, the extent of muscle weakness o r the energy requirements for ambulati on wi ll necessitate whee lchair use for mobility. In the earl y or early-m iddl e stage of ALS. a manual wheel chair, preferab ly light we ight. may be used for traveling lon g di stances as an energy conservati on technique. This whee lchair shoul d be re nted on a sho rt -term basis or loaned fTom a local ALSA o r MDA chapter or other source , as most insurance compani es wi ll reimburse fo r onl y one wheelchair purchase. As the d isease progresses, a po wer wheelchai r system tailored to the patie nt's current needs and potential fu ture need!: ! wi ll be necessary. Numerous customized whee lch air feature:> and optio ns are ava il able that can a"sist the individua l in mai nta in ing a max imum leve l of independence and co mfo rt . A refe rral to a whee lchair and seatm g dini c ma y be the best option ow in g to the numerou s, ~peci ali zed , and evo lvin g needs o f the indi vidua l with ALS . Trail and colleague!) burveyed 42 p31ient s with A LS and moderate d isabilit y, a\ doc umented o n the AA LS . about the wheelch ai r featu re~ they found most be nefic ial. Si xtyone percent of pali ent' n: ported tha i the ir whee lch<.l lr\ allowed them 10 main ta in tht: ir previou1:> activ it y leveh-.. In order o f )mont y, manua l whee lchai r u ~c r!) cit ed a light we ighl lrame . '\malllUnllll g radlu!l, hi gh recli ning buck and buppon \ for the head , trunk . and ex trcmi ti t!\ a ... 1110,t uc. . irable; undc:> irablc featureb included low, :> iJll g. nunrec lin ll1g b-I;JU C. lIonadj ustable leg n:~b: hc;tvi ne,,!!. or large f, 11.C; and . lIonremovab le annreM\ . Dt::> lrablc

Mu scle cramps may be alleviated with massage and a stretching program. Cold can temporarily decrease spasticity. Physical therapists can perform and instruct caregivers in s low prolonged stretches and passive ROM exercises to address spasticity. In addition, postural and positioning techniques can be incorporated to decrease spasticity and splinting may be necessary to prevent contractu res. A recent ly published Cochrane review describes one study that found patients with ALS who engaged in moderate intens ity exercise had decreased spasticity. as measured by the Modified Ashworth Scale.

I"

Psychosocial Issues A diagnos is of ALS is devastating for both the patient and famil y-caregiver unit. Because of the pJogress ive nature of the di sease. impairments readil y lead to fun ctional limitatio ns and di sabilities, which may impact quality of life. The e motio nal res ponses o f the pe rson experiencing the di sease, famil y membe rs. and individuals caring for the pati ent are multifaceted and m ay flu c ruate th.ro ughout the stages o f the di sease. Much is lost when living with a terminal , progress ive di sease: p hys ical health and abilities. body image . work and fam ily ro les. ide ntity. family and soc ial ne twork s. lifesty le. inde pe nde nce. control , hope. mean ing. and the anti c ipated future .ISO. ISI The physical Iherapist mu st be able 10 recogni ze thl! patie nt 's ability to cope tl nd adap t. and hi s o r her psycho log ical reactions. leve l o f
ledicalions. beca use left untrea ted Ihc~c p~y c ho sociul ~ In.'linncnls can t.dwrsel) affect :1n indi\'.dual"~ abilit y 10 111.... I . por dapt. cope. :md partJ c lp~u e III t 1C plan 01 care ( ,,). ~'pres:-ion m!l) !tl~o lead 10 .'uicide . In addition. •1Il\ic t y 1 dr:pre:-.sion mu) al so be pre\alcnt among. falm!) m CIll :ul{ . 1~~ bers or C!lfcg l\'cr:-.. •

Exercise and ALS lXsPItf' lht' high inc idence of Illu"clc \\c:t"nc ... ~ III indl\ Id -

uals ,",'uh ALS. Ihe effe('h of C\erc,..:;c program ... ha\c nOI been e\lensl\ely "",udled. and tllU .... arc not wcl l understood.. Often ph) ,ieaJ U1CriJp) rrogram, 1m Di ve ROM and

stre'tchmg e:\ereJ,e<; o nl ). Despit e' the lack of Te<;carc h cvideOi..~e. ~ome dl,courag,e f'>.erc l ...c progr311l!o. bcC3U"C of fear of O\'eru~e wea"nes~ and belic\c thai no e,crcise other than e\e~day act!' lues IS IIldlcmed. Studies of mdlnduab '" ith other Ilcuromu s<" ular di seases ('\~ID ) :-uch as po hom)e1i ti s. Duchenne'~ muscu lar d ystrOph~. myotonic dystrophy. hcredilar) molor and sen5<'1'} neuropath~ . ..,pmal muscu lar arrophy. and limb-gi rdle, Becker. and fa~cio'-CapulohumeraJ d) slrophy have found that e"ert1~C' programs are beneficial and do nOI produce O\-eru~ ,"eak.ne~s .I~t- ,..., The re~arch evidence in these pauen! populatlon, sug.g e,u,:

• O\'eru~ \\ eak.ne,~ d()C~ nol occur 10 mus.c1es with a Manual Mu.cle Te,1 ( M~IT ) gmde of J (fair) or gr.ercl':tC rna) produce tunc-lIonal benefib • P~~'chologtcJI bene1ih h,l\C )(,110 be: delelmined .J~\-'-lhl\ ~l1t"n

preM:nbcd appn.)pfl:1tel~ . exercl'>e 1ll:l) be' benefiCIa! e:-~f.:lall~ IIllht l"arl) \ tiigC(, of Ihe d"ea,e . ExerChC ma} not Impn.)\c Ihe ...trengt h of mu"'l..'lt, alrcad} y.eal...· ene.d b~ ALS. \.~n.unl~ nm tho~ tx~It)V. gr:tde :l. I hml:\er. ~enerltl . ti.-u"e RO~1 and ~tre t c h.ng of .1 fIc,,:lcd JOlnh. rl',j~ ­ UVt ....lrengthC'"'n~ t"\.en.:I-,e .... 01 ul1 ~tfe ( trd mu ...d c\ "lUI 1o'\l, III mudcralt '" t'lghK aut! ucrnbK i.1 \:11\ Itl tt~. l:> uCh i1~ .~tmmUlg . \I,.1I~HI~ . d.nd Ph.: )dml!. :.il \ubmJ\; lInal ICH!'b. m.) plC"~( nbrd \\ hen
tnc

b.daillt"

tk lv. ten t)\t:ru\t..

l.tllgul

,Old ..h ... u"o<

all '~~ f\Jdt!h\"~ f llnn Ilalieru \I, lih .\Ihl' l llt"un>nlu . . ..:uldJ dJ'-c:j,h(' \UggJ..~h Ihdt IlIgh)) 1t:p..:IiIJ \t" Pf t-.eJ\) ft" ... hldO\.C UtTlbc ",an "oiUI"c rn~loll~cJ lo.. ~ (,11 mw~.. k '1~1I~t.h .u t -.e4U.<:fJtJ derh'f\i:ib:d illu:-.l,;I,,· ;1•. , ~,"ll dflHIl,,1 ':Itudt~1, h..-e '.lUltd (h.d fkUloUlll:'H.. ul.lr <1\.11\ 11) h..... mtHtlllut)

drect ... on "prollting in parti all y de ne rvat ed lnu \(.;(e,Ir-,\ 1M " he re", ' other , tudi e~ ha ve reported no e ffcct IM.l(.7 or that actl\ it y ctltl promute sproutin g or re innervati on.II.1( ,"'.,

On the other hnnd , .1 marked rcd uclion tn aCII" lt y leve l :;.ccond;try to ALS can lcad to cardiov: .....cul ar dccondllion ing and di ~ u :-.c weal-..ncs, hcyond the amount f.: i.tu scd b) the di sc a .. c Iht-: lf. Therefore. the Iy pe and inl cll\lI y of the cxe rc i ~e program . . Imu lct lx' carclull y monitored and adJu\l cd hy thc ph y~ i ca l thera p; ... t In order 10 prc"CIlI l·xf.:e ...... ivc ratig ue. ",hile at th e Ii:tmc 11111C promoting opllmal u,c or intact l1lu :-,cl c g roup..,. PaticJlt ~ ~ h ou ld be advl\cd not to ca rry ou t :1I1 y uctlvttie ... 10 the point 01 eXlreme fat ig ue. and should keep track or ,nmp/Ofll S of (Jl'cru.\ (" , uc h as. Ihe inabilit y to pe rform dui ly acti vities following exe rci"c due to cx hau ... llon or pain. inc reas.ed fas.cicu lations or increased mu scle ('ramping . They may al so be advised to exercise for ~eve ral brier periods throughout the day, with Ijufticient rest in bel ween.

Disuse Atrophy Reduced physical activity, particularly if prolonged. red uces function of the neuromuscular system. in addition to the skeletal and other organ s.ystem s. \Vith ino,;ufficient activi ty. disuse atrophy develops whe n mu scle contraction~

are less than 20 percent of the tOlnl tension a muscle is capable of producing, As contractile proteins arc lost. the musde weakness progresses al a rate of 3 percent per day. liO Strength loss through inactivity and disu:,e can significantly debilitate ind ividuab with ALS. making them highl y susceptible 10 deconditioning.. and muscle and Joint tightnes~ leading to contrac ture~ and pain .

Overuse Fatigue The potentia1 for inducing ove rwork u3m~g{' In indh·iduals "ith ALS through ('xcessive exercise i\ a common COIll·ern. Sanjal-.. et al. demonstrated tbat indi\'idu.Jb. ",jlh ALS dt'mOJI';Ir<.lfe abnomul phY,)lologlcal and meLabolH: rc.)po'hCi'o to »'Ingle buuts of e\erci~e . Ox)gen cOlhumpdon dunng subrn3xim~,1 C'xtn..· is~ ""as tncrea~d in lIldl\iduals '" Ilh ALS compared 10 coot10b • •Uld VO~ ,. and work I.:rtpacuy were- de-crea.,eu. In addition. II \\a~ found tfut !'te\' tru l mClabolu.: ,u)-l~lmte') of pld\ma .Inti mU~' 11," -,:offip.ln· ~jl'

rnt'nI~ diU 1101 II\l.rea~ to lht" !ull1\\! le\'t"1 ;.e, unrralned COll-

(rol .. ubJ~t h . indtc.HU1g Ihal th,( .. \dllahlll1)' uf ..,ubstralt for ~nerg} pmdm.non ,.., .lff nt'u .....' III II1dl\'tliu.,1 \\lfh ALS , the -t..lle ran~e I'M therapeultc e \Cn:h' IhlfltJ"'~. find th~ d.:gree 10 ",hl(.·h (hI.! rwtge Dar.. IlI\\ .. h t.iepellJenl Ull thlt e\h.'tU uf di!tea.>c! lm()h',"'ment and the lall' nfdl"oC'.hC" pwglt:~· ')Iun A "'t'aL OCJ.;.·llefVQletl mu.\i~ de I~ IIlore ... u~.:puble w me-rv.or1. l,.Luu"i:!~ becau:a.¢ II l\ dhc.tdy IUJ"K"fll1llmg (,,'luM,> \t) 1I~ ma.\nnai lUll,b, Acu",(Jt'~ of d.ul) Jt\o mg .d()I~ OIJ) ,-,au. 1I11pUIre\f' I)()I"(DII

842

Physical RehabiJitation

llIu .. cle'i may aCIl13l1y cau~c overwork dam age in impaired Inu:-;c1c~. T h·c remaining motor units will respond to traininc. and Ihc~c motor unil$ must work harde r to handle a i21~Cll amount of c~erci..:;e stress. no Thus. spec ial attention ;nu!ooT be paid TO develop ing an exerc ise program for patients \\ ilh ALS. and physica l therapists should presc ribe exercl:-,e training at Im.xienlle to low int e nsities. The litcrlJlUrc related 10 e,xerc ise in individuals wi th I\LS j, 11l111ted. 1\\'0 eady case studies d emonstrated posline effects of ~pecilic ..,trengt he njn g a nd end urance exe rd'C.:;.FI.I"'=- l\1ore recentl). the effects of exercise in individuaJ:.. wilh ALS hine bee n evaluated with larger sam ple~. 80rh of Ihc:-e st udies found sig nifi ca ntly less decline l In !unctit)!l r.;core~ and other ou tcome meas ures 7:t 174 in the c\crci . . e group. Two recent animal studies found that endurance c\:erci.:;e training at moderate intensities slowed d l~J ...t:' progre ....... ion 11~.l7n: whe reas. a third study found Ihal hIgh endurance- exercise training had detrimenta1 ('tfech on male mice onl). 171 The ev ide nce related to exe r\~I""" ;md ..\LS , . . pre:-,ented in Evidence Summary Box 20. 1

(human slUdies) and Evidence Summary Box 20.2 (l1limal studies).

Patien t/Clien t-Related InstructionA diagnosis of ALS is devastating for individuals and their famlhes. They are faced wuh contmual, multiple chan and losses . and eventual death. Assisting the individ: and hi s or her family and caregivers to come to tenns . . the .Impact 0 f the d'Isease .IS an Important role fo r the wllb h .Ica l t herap,st . , an d provl'd'mg psyc hologlc.1 ' supponP ysopportunities for expression of feelings , frustrations : : co nce rn S IS Imperative. Collaboratll1g with and educaf the patient. family, and caregiver in an open and ene I~ . . 00[· agmg environment may empower patients in their eff; to cope with their disease. foster a sense of purpose : : self-efficacy, and enhance the overall effectiveness of the intervention by increasing compliance. l1o

Evidence Summary Box 20.1 Exercise and ALS: The Evidence from Human Studies Reference

Subject(s)

Methods

Duration

Results

56-year·oId nonambula· tory woman

Case study UE resistive exercises using PNF paHems

75 days

'983

14 muscle groops ina8IIIICI in strength from 7% iJ 96'J. 4 muscle groups lost sIIqII by to-21%

$a0i'" M. Redelan. W.

46·year-old man

Case study Air·Dyne brcycle erg
6 weeks

lsokinetrc strength and CfIo diopulmonaly respordIS II exercise ImproYed .. IW UEs, but not ., the lea

20Ss E 8 Mean age E 62 :!: 14 years C: 64 ;: 16 years

ProspectIve, cootrolled slngle blind; C: no endurance protocol E. Bruce or Naughton treadmill pr<>tocol, While uSlng BIPap. exercise 10 anaerobic threshold unM stop parameters reached

12 months

E: SIgtlificanlly greaIIt All scores IP < 0.(0); - -

SohaOOI'l

RW'71

al"'.o Sroo":s SRI'i '987 PI'.IO. AC ""os M. .'ld N"9I'" fa A "

1m

-:-_:-:-_~_____

DrOOl VE, et ai'" 200'

25 mal -S- E ---- - ---- • s - 14 Randomly assognedlo 2 groups: Mean age C usual dally activities E. 58.0 ! 132 year. E Irmb and trunk exerCIses agaInst C 60 7 ' 16 4 years modest loads

SpIIlal Norris Sco<e .... (p < 0 02); stg!llticlrllonce in the slope d PiC dec,ne IP < 0.(08) - 2 ItmeS/day for t 5 mrnutes 12 moo'" " ..

Ai 3 months, E: ~tIII .~

less decrrne In AlSFRS II < 0.001) and AshWOlil SpastICIty Scale SG1)III (p s 0.005),

no~­

ences 10 INT. FSS. pili.

SF·36 SCOIM, al8"""" len no~diI.. a U

bo!>oeon~

Chapter- 20 Amyotmphic La teral Sclcmsis

843

Evidence Summary Box 20.2 Exercise and ALS: The Evidence from Animal Studies RL'{l'rc O('('

Veldll1k. JH, et ap:"fi

2003

~4ahoney. OJ. el a1'20()4

Animals

l\lcthods

Duration

Results

7·week old G93A·SOOI transgenic mICe

E: running on a treadm!1I (30 min at 13 rrv'mm initially: speed and duration decreased stepwise) C: sedentary

5 days/week until unable to keep up with a speed of 7 mlmin

E: overall. significant increase tn lifespan of G93A5001 mice (p ~ 0 (07): significanl increase in male mice lilespan (p = 0.02); trend toward increase In female mice hfespan, but not signillcanl (p = 0.1)

B·week old transgenic low-copy hSODl mice and wlld·type littermates

E: running on a treadmill (45 min al 16 mlmin) C: sedenlary

Until too ill to run

E: exercise delayed onset of disease in female, but not male hSODl mice; exercise prolonged survival in female mice

4O-day-old G93A and wild-type I;Hermale control mICe

E: running on a treadmill (20 min/day al 9 mlmin lor week 1; 25 min/day lor week 2; 30 min/day lor week 3; progressive increase in intensity week 2 and 3; 45 min/day al22 mlmin) C: sedenlary

3 days/week lor first 3 weeks; 5 days/week lor remainder

E: onset of disease not affected in female and male mice; exercise hastened death in male, but nol female mice (p < 0.0001)

C = control E == experimental: min = minutes.

Patient and famil~/ca regi\'er ~d u c at ion is in teg ra l throughout the stage ... of the disea~e. Th e scope o f educa· tJ.on ran Include. bUI is nOI ltml ted to:

• Pro\idmg 3('(.'urate. faLlualmfonnation aboullhe d bea!\e proce~ .., and c:h Ol cal manifestation!!. and the ir !-. ignifi · ranee In term . . of management Gi\e onl) as mll ch info r· mallon a... the patJenL iamil). and caregi\cr ... need: infor· marion I.,hould be prO\ IdeJ III manner appropn ate: to the ir Under~tandm~

• Instructmg patlem .... lamJi ~ member... , e 0 1 ,j ...... I."II\'C de\ u::e." and adi.tptl \t~ t q ulpIlX'ru. <1nd rre\cl1lmg '>CLundM) lornphl·~I II..)Jl"" -\d\l\mg the P.J!h:1lI abou t mcthod') h) PI OlllulC !!t:nerd l ~d.ltk Ln . .trULtl(l!l 1t't=ardUlg t:nt:rg y cu lher ....llion, bal :'':tn~ r~"',1 .10<.1 .11..11\11) and rd""
b

,uPf11Vfl

~rvllp~

01

p~) dJl)lu~iL<.lI

Provid ing in fo n n ati o n on health and avai lable social and s uppo rt se rv ices. I JO The A L S A ssoc iat ion an d the Muscular 0 YMroph! A ~r-. oc ial i o n are Ihe two nat io na l vo lu ntary orga ni.l
Am)olrophi l' Laleral S(.·lelwlI ... A ~"(>C- I Ml o n n OO] Agoura Road. Su ile 150 Ca lilba .... h H ili .... e \ 91 ;(11 · 5 10..1 IX I XI8SU·lJ\KI7: (k(X1l7~2· ~ 7 4 hllp:/I", \~ w ,iI~'l.o r!!

I h e Mu'><.' ul.u- U) " l l'O ph ) A . . ,",,,c iall\)n 'H UH 1:1\1 Sunn .. C' D m,l," I lil'.un, AI It)7 1M ~ 1 0 H

'5c1l152'1 2rlf ~ l, Ik(lO) '\n- 1717 hllp:!I\\, '" y. mdau .....1 or¥-

S44

Ph ysica l Re habililatioll

for as long a~ possible. The selcction of " . • 'd gro unded 10 eV ldcncc- b.tsc re:,carch when, . . 'blc i\ ba"cd on th e stage and progreSSion of t~_ ever PO~"I " u-';; , , (I m',y he re~ ,or;Jtl ve. compen ~a tory, or preven dl sca.l.,c ,1 1 1 ' , , ~. . ~ , Thc'c intcrventlo n... should take 1I1to consideration lallve. . I f actors thai may I .In div idual'" goals: psychosocHt 11C l.. • d' 'd . . I dcci,ion making such ~t~ tJle In IVI ual's accept. Im p.le . d' ' d I' , anee of th e diag nos is and the 111 IVI ua s. socIal and finan. cia l reso urce'). BeC3u"e o f the progress ive nature of the ALS, fhe ph y... ica l therap i-il mu st no t onJ)' address the p;lt icn " s current problems. but also plan for the patient's futu re needs. .

.

tll1d j unCll o n , " IIlICr vc nI HJn '"

Summary

Acknowledgments Specia l thank" to Li l Scott and Erica Poole for their extraordinary typ ing. adm in ist rative and editorial skiUs. and to Peggy Ingels- Allred for her th oughtful and critical re\ iew.

R e \.

for

Questions

cw

1. Dc-'ln tx' the dU1If"J.! mJlulc'! ~l1lon'" nl ALS [)J!fercnl1 al~

:.md i"..... a

.ullone'

mOilll

5. Con~idaing (he \ariety o f IIrlpairmenb a!''loclated \Io ilh

a, ..f'h.. hll\.'d \\ IIh upper

ImpJ InTIc n( \

nl'uron pJthology ;tnd hult-.ar IML.holog~ .

2. \ 1, hJ I t"\.trnlO.J1 I\ I[l

rro~.edll re,

.tn' u,t"o 10 help '1urpnn

tht: lhapno . . , .. (II AI S' 3 IJl"I11I1~ .mJ Jt'l inl' the 11li..lJor \.i J." lll l,illon .. ul ALS In 11K EI L " .. off JI l- nl ~· n .t d~ , l'io pt:'J h~ Ihl" \l, i lrlJ I t'lkrJII ' Hl 01 ' t.:'l ll nhlg\ Kl· ... t.:' illdl Grnup nil '\1ot'Ir 'lUII'11 DI .....·.t~·'

In ... h..,it'd

4

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DLo\GNOSTI C TESTS EI('Ctrom~ op..trhil· ... lUdic, ... h()\\C'd : (1) 10\' compound moWT 3ctlon JX' lcntl3b 111 311 c\tremllies: (2) nomlal sen· ,{If\ 1lt'I'"\C condu('[Ji.:m .\3\ fibrillrttions and fascicubl1oll~ In ~I c\trernIfIC'I : and (4 ) \-"Idc"-prcjd neurogenic changes U1 motor unll actlon potentJ:lk abnomlal rccrullment rottem . . In the dl'-l3i leg nlu'Iculature and mild to moder•ale change:>. In the upper e\lTemllle~ .

PHYS ICAL EXAM INATION FINDINGS ONI"\JtJOO \1Jr ked \\J.5,1I1l£. of the intl'TO\o;.ci region~ bJlaI('rJjl~

\ 0 at-nomlJhtll" '" noted RO\1 W'L fN JII .101111'\. except the thul11b~ and the L anlk PauC'nt \\:1:>. 1..>111) 3blt: to OPP(ht' Ihumb ~ to the third dip!,,>. HI.:: I.Kb. ... 5 01 L dor"-Ifle-xion. SlTen~th B.iJ,craJ LE >l ren£lh gr"ded a., 515. e,repl for thr p 11<"" ~rnur (R ~ ~ _: L ~ 4.;. 15 , and Ihe L ankle dOl'lt1t'\('Ip.., \ ,-/51 Illluider tnu"-Cie '1treng Lh ~'1:i(kd d. ~- ."\ fR J .mu 4,) IL ): e lbo\\ Olu,clc !lotren~th ~r"ded :b 4·~ ( R I .md ··h 15 I LJ pet"(

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H,nd ' " cnglh : R = 12 Ihs: L = 24 Ib, (hand-held d ynam oll1cter). Pinch stre ngt h: R-Iripod = 2 Ibs; late ra l = 3 Ibs; L-tripod = 5 Ibs: latera l = 3 Ibs (sec below for no nnati ve d::lIa o n grip and pinch stre ngth ). Coordi nation: Purdue Pegboard Testin g. R--6 peg holes in .30 ~cco nd ~.: L--3 peg holes in 30 seconds. Tone : I for bolh UEs , nd I + for bUlh LEs (M odified Ashworth spa stic it y score!). Rcnexe ~: A clonic jaw re fl ex; hyperreflex ia in both UEs: hypore fl cxi a in bOl h LEs: po<; itive Bab in sk i re fl ex bil",erall y. Gait: independent o f assistivc devices: positi ve for L fOOl drop and hip hiking: 15 -fI wa lk le51 = 3.6 seconds Balance (standing) : unil a te ral stance/eyes ope n. R = 25 seconds: L = 6 second s. Respira tory: Forced vi tal capacity a nd ma ximum inspira tory press ure (M I P) are w ithin normal limit s. Functional sta tu s: The pa ti e nt ra ted him self a t 90 percent on Ihe Schwab and England Ralin g Scale (see Appendix A). ALSFRS-R scores (see Appendix B):

ALSFRS-R Scores

Speech Salivation Swallowing Handwriling (pre-ALS dominanl hand) Cutting food and handling utensils (palients without gastrostomy) Dressing and hygiene Tu rning in bed: adjusting bed clolhes Wa lkIng Climbing stairs Dyspnea Orthopnea Respiratory insufficiency

4

3 3 3 3 3 4 3 3 3 4 4

R

1197

240

4.8

76

176

L

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21 7

4.4

73

157

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180

36

73

12

27

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177

38

76

10

24

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261

32

65

21

32

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25

39

77

18

32

R

262

41

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259

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846

PhY5ica i Rehabilitalion

GUIDING QUESTIONS

I . What EI Escori ;1I diagnosli(' c riteria wou ld you al1li l.:i ~ pale docullh.'nt cu in the palicllt' ~ medic;,.1 r~c(lrd? . ::! . Juentify the paticn!'~ probl em s in lenn.~ 01 dm.'r t. mdm":cl. ;,Uld composih:' impaimlc l1l ~. :t What impact do Lhc impainnc nl s have on Ihe p
4 . Whal atJditi\)Oal leNts ~lI1d measurements should bt: conduct ed : w hat consultations should he rccom~ me nded ?

5. AI present. whnl arc the k.c~ ~lrcas of p:.u icni education thai I' ho uld be addresscd Iniliall y? 6 , Ide nlify th c general e1e.mcnts of a ph ysical therapy plan of care ror the pUllent.

References I. R,IVo land . U ): Div.;~r.-l" limn, 01 I1Inl llf m' urn!\ dl'l!a'e, Adv Nl'1I1'1I1 36 : I. 1 l)~2 .

2, S\\ ;I,h , M: Clnlll'al 1callIH" amI di ; l iP ll. ~is o f :l1l1Ylltl'llphll: Ialera l SCIcr(l"h. In 13wwn. R Jr. I\klningl'l'. V. and S\\
~\~;i!"

F. l't 31: Omcl . n;lEUr,11 hl ,tnry :11ld (\lItl"l1ll1l' in idiop.c;1).e . J Nellrol Sci II~ ( 11:41<. 199:1, 4. Pradll!l. J. (' 1 ,II : The n:lll1fallll~ll1 ry of amY"ln>I'Jm' laleral ~clc ru s i s :l1ld thl' U~I' lit 1I:lllJrul h i'lnry ClH1trllls ill lhl'ralx: utk triab. Ncur'II,"'g) -Pt·H:7 51. I9l'1. V. and I\PI'I{'1. SH: Natural h i~IOry (If amyolrophll lalcr:11 .. ck f<)~ i .. In ci'll aha,e populalion: V••lillation of a "l'orin!! ,~, q"n1 :lInJ;I mood for ~ lIrvi v
10l)5 .

7. GlIbb3Y, SS, c-I :11 : AmyotmphK late ral :.c 1ero~ i ,~: A stuciy of iL~ rre_'l'nt,llIon and prognosi,. J Nl'urol ~ 31:29 5. 11l~5. S. Appel. SH. l'l :11 : t\1I1)otmph.c I,nem l M: kros l": 1\ ~"QC iated dinie .. 1 dl!lOrdl'rs and immunologirul evaluations, An.:h Ncul'ol 4 ~:2J -I. 1486 9, Mulder. OW,

10.

II

12

Il

14

15

16

e.

al : Familial adult motor ne uro n di ..easc: Am)otfl1plllc la'l'ra l S(1cro .. i ~. Neurology .1 0:511 , 191<7. Strong , MJ . lI ud-.on, AJ. :lIld Ah·llrd. WG : Famil ial amyotrophic lateral ",,'lero.. .,. I 1<50·1989: I\. ""I I ~ ti ("al ana lyo;j, uf Ihe world li t· era.ure . (';111 J Nl'Urol Sci IR:-I5. 1<)')1. Hamid:.. MB . lind Ht'nta!i. I": Ju vcnik ,11l1),otrol'hil' laleral sclem 'I~ . In Brown , R Jr. Meininger. V, and Swa.~ h . M (cds ): Amyolfllphil' Ll;teral Sdcro~ I '. Manin Dunill Ltd . LOllUOll , 2000. P 59. Ko~:n, DR . cl al. Mulm iun, 111 Cu{Zn supaoxid\.' (h ~ mlll;tse ~t'nc arc a'''I('J,lted .... llb ra nHhul :l1ll}OIrnphic lal c-ral M'1l! ro" i ~. Nalure 31125'). IIJ\H J al.~~un . M. :mJ Roth'lt' lfl , JO: A11l)otrophic l"lc ml !.den."'I~. In Marl'''u!.. I-\Y. HOU Chl)l , i)W \1.'(1'01 . ('cnlral Ncr\'ou.. Sy~ 1l"1Il NCUWPWICl"l\lI1 Srnng.cr. Nt'\\! Yur~ . 201)2 . p 421. )"(1.. ... 10 , M, I;'t al : A nal}M' ufthr\JlIlo~II"' '': 5q l J ~..: nc .. ill am) . o,ruplll~ lal..:I.,1 " kI O'I': I ".mu/ygu u, NA ill dell-uulI III it 101"0 ' ratll( la'ot;' AIIIl Ncuroi 19 '746, I\t')(l, Robbc. Cl..hl , W, el al: 1>,)(1 A IwtcrOlYt, ,,it } in .he SOD I geill' I' a.'l>UlWleJ ..... .Ih 1;lIl11llal and ,IPt l.II I·IIII} Iopt)!ad ic a nl )olnlllilit' lal. eral .. dCIU~I' ]'.~'urnlog) 47. J 11" . 11)')6. C,U f"(i." J I , (':l II" ,u n. WF, illl~t Yaill . MD' 1'1<1~ 1I " ' II C l ;h. l"r, ill nlolt,t fo":U I'Utl c.lt-.ea:.c : .o\ pn"fl\'dt\l' ' Iutl} ul IUII ~"'\, II ) III R......:.

'Ni l Re ....·.If"dl IJfI)!!Il'~~ III Mtlt"l Nl' III,'n D ...... I~· PIII U:III . Loudun 1'11'>4 . II '\4 , 17 H,,,n l. ,, liK ('1 ... 1 flle 11;11U1' I III"I"r~ .. 1 .u lJ) l ,lfI 'pIH \ I.Hl·' ,11 ~\ I t" fI'~" In 'N,lImu" ,l\( · ll'd. M, •• ,.r Neu nlll,' 1>1'.,. ... , .. ( 'llaplIl ," 1 lind 11 ,,11 LUllduli 1'.1'1-1 , I' I:!I IK l-I u~lel lil\ , IIlId Blu wn . HI I { ·"PP" ' /IIIl\. ''' IIIIt.· I O~ I ..k lh'lll ul ... w mUldllllll .. ;lIIl! '1'1:\: radl l .tl (J,jIIIolI:'C III fI'!I~( "l j' I "lJl 1,11,'1,,1 "l kl(' ~ I ' Ad ... Newnl (JKn 41 , I')l)'i 1'1 l{ olh"'CIll JJ) ,'1 til. elUullll 1I1111 hl lll>1I \01 , uP"''''dde dl .. mut..tw prod«t ,-" '1~'pl.'l t~ ,II;,,11i ,,1 ~ pHI.jl neUI"II' I'liot NUll 1\,',.. 1 '>l (

2 1. P1:titaki s. 1\ , and Caro!ooio. JT: Abnnrmal glulamalc metabolism ' am yoIJophi.: late ral st:lc ro"is. t\lln Neurol 22(5):575, 1987 , m 2:!. Roth"lr ill: JD . T ~ai ..G. ~n d Kune l. R~ : Ahnorlllal excitatory a minu ,K id I11c la!loll .. m 111 ;1111yotruph lc luteral sc1ctO'iis. Ann

Neurol 2H: I H, 1990. 2:\, Rlllh .. tcin . 1D. ~'Iartio , LJ , and Kund. RW: Dcc rea.q:1I glutamate transport hy the bra ill and .. pinal cnrd ill amyotrophic lateral Kle. rI)$ i ~, N Engl J Mcd 2J6: 1464. 1992, 24. Rnth sll,l ln . JD , ct al : Sclecti Vl' l os~ of glial glu t;lIll:tte transponer GLT-I in il myolroph ic 100t\:ral sdcrus i ~. I\.nn Neurol 38:73, 199~ , 25. Carpl'lltl!r, S : Proxi mal axo nal e nlarg.em cnt in motor neuron disease. Ne urolog.y 18:84 1. I%X, 26. Hirano. A. ci ill: Fine l'i lruclura l oh"Crvations of ncurnlilamentoui c hanges in amyotrophic lat~' ra l !ooclcros i .~. J Neuropathol Exp Nl'utol 43 :4fll . I ()84 . 27. Wolfgang. F. and Myers. L: Amyotrophic latera l sdcrosis: Effect of serum on anteriM horn ce lls ill ti s.~ ue c ulture, Scienc!! 179:579, 1973. 2X, Troost. D. Van Den Oord. JJ . and Vi;mney Dejong, JMB:

21).

JO,

.1 1.

n. .\3 .

J: lfIl'( 19q .... I\ 1 J . r:\U~l'l1l'U " l1('Ul', 'I\'\ iI1'. III Bru .... n. R Jr, MClIunger. V, :llId :O;w."II , 1\1 !NI,)' Amyutrlll'llIl' Llteml Sd,'fll"" i\f:u1111 DUll i1 1 !.td . Lundo n , .!( ~ X.) . p ~7'1 . ' .'i . B rl'\\II . R. )r: Ap\If1((I~I' HI .1I11) ,)ln ll'llI\· I;ll e l"(l1 sdl'ft)si, : A I"t'V~' III II r"wlI . I{ Jr. M'·Hl l1l !..:,·r, V, .111\1 Swa' it . 1\1 t!!cb l: r\II1),J1fUI,hli. 1.lI ll·r,11 Sdc rl"t'. I\hU'll~1 l)lIllit l Ltd , L"1l4.1i1l1.111C1O, P :103: I anJ

)~, Slrtll1~.

3h

F( '

I ISA')I 4 ' ''''i 1'/'}4 '!,/j

i311!dwh , I H< , , ' ,II : S\J p... rtl\,[h! ((I..,nul ,' ....· I '" nil 111111.1\ 11"" hflJ..~d iHIl)'I 'II Ujll llI 1,,"'1.. 1), I.:I\"" ~ I " ' ~~ \'" ''' ' "1-',"11',1,,1 at'I V,ly 1'11 1\. N ... \I A.ltd S" \ r'>A ')1 X,N l, 1')')-1

1"1,111111 ,,,1

llIltnullohi.') tochClll iea l characterization of the inOammatOl')' infil· trate in amyolrophic 1:l1t:ral ~c lc rns i ~, Neurop:uhol Applied Ncurobiol 16:40 I. I WO. Smith , RB . cl al : SCnl111 alltitxRlies to L-typc calcium ,harmd~ in patients with :mtyotrophil' later;)1 ~c1erosi". N Engl J f!>kd ;\27 : 172 1. 1l)92. I\. ppel, SI·I: A unifying h y po lhe:. i ~ fl.r the C:1I1.,e or amyotrophic lal cral ~c1cros i s, p:trkinsollis ili. 11lld AI/h..: illll'r dl!>t.'ast'. Ann N~ lIlOl 10:-I99. 19NI. LindloIlY. RM : Br..in -dcrvit:d IIl'Urnlrophk f(ltt or: An NGF·reJated n~·u rutruphil1 . In 1.1Iughlin . SE, ;wd Fall un. H I (cd~): NC\lrorropbic F"clors. Aeadellli,' P rl:! )S. San Dieg.o. I~ J. p257 . 11u.)I.'n(.'I1. II . HlI g.hl·~, RA. and Sendlllcr. ~'I : Trorhir !>lIppOO of lllo to lle ll1'OIlS: Physi(llogi,·al. p:tthtlrh ~~i l)i(Jg 1i.' It I , and Itier.llX litlC impl ie;'liull", E\p Nellrui 11-1 :-17, It)t)J . An:1Ild . P. CI al : Rq:innal dmng..:' in l' lIiM)' l1 e llmtrtlphj~' tit.::lof and Jh! l'\'l' gtl lwth fnct,)f kvc l, ill IllI.'o(11I1 ,rtelll ~ pil1al ,'(lrd and ( (!T" hral ,'urll'>; frum pati\'lIh ",ith 111(>[,,1' n'· lIr"lI lh~\·i1~c. N.. t i\kJ

"

l:"

" ..111'41 1111111 '. I I. t ·h.ld . j)}\ , :tlld "hI m , I h jli!lht.'M.'-' lor \ !fa ,)Ih,..- 1r.1I " "II" "I">I,' .1).:\'11" II) iIlH)lIlh.phl\· ,:.lll·r••1 St.·ler'l~l~. hi 1\ li hUlJItI!t. II. Child . IJ:\ , .111,1 Plllrll, E" 11',h): Anl)I,(fopIliC I .111' 1.11 ~\ k l'"'' 1-:1\ 1).1\ I' , l'IIII .IUd ph l.l. I 'NK" IN. " ' 1/111.1111, 1 ,'llI l 1\. 111 "'lft'plll\ 1.1k"r.11 ,ell-f'''''' \\'It h 1'1 'hthll~III'" · ,' -I(fI1I P Iqll.1 .111< 1 1I11 1111 ,), ,, , ,'!1I dq'e ll\'r;ul oll ttl 1',11I \·Ub.1I1 1\\11",

u'"

,,' 1'I':~ PIl ,lhlf'

hi

I "":11... " .\11\1 ' ;1\ 1.11 mlh:I I UI

;\\'1.1 N"l1r\)I',lIh' ll S-I 1 7 ~ . 1'.)<.}1 . 11 11.1I1.l. A "IMI .lltt "llh,' {J.luln..... I'·' 111 lcktl~ III how l,'''u" , Allu K\,tl ru l-l . .!,I ~, 1i)7~ of

l'l

1\ 1,IJUIl' 1I I . \'.

1.1 " !('WI' 111 11\11 ,ll a ,·\· I'I. IIIIIII""IIII'U"',,1(

ifOl,'P

" Ie. !OO.'. 1.11 1,111 1 III lUI1), ••• uphtl· 1,11\'1,.1 ,,~· I ~·n).") 1b \ '1•III \ 'al \lgIll t·.III(,' J N\·III IiI',I.hol t\I' N ~' HI'I I .J 7· h.U . I!)~X ·W. 1.1 .<11 , "" 11 .• 111.1 K 1,· l ll.ItI , J,;\ I'Iw Iltllilan Ni;' l,\lIU ' ~) ~ll'"r;\11 .\11, 11< 11 11 1<' ••1 V I\·"" llll ll l1. (',I

11"'11

I, J /I I IPI'UI~'()1I C", PluIJddplll.1.

fi.

Chapter 20 Amyotrophic Lateral Sclerosis .II B ~lcy. \VG. CI al: Morphometric and buX'hcllllcal !'tudics of . rcri~r.11 nC'm,'~ In 3mY0lrophk lalcml :<;clero:-i.. , Ann Neurol 1~ :267, 198.'. .;1" HraJ'. T, el 31 : Sen:-ory nerve palholog) in amyolroph k latera l ... ~'IcrO~b. ACla N~un)pmhl)l RL lIn. 199 1. 1 ~a\\'aJnuT1l . Y. ct al: Morphometric ("olllpari ~on III Ihe vulner,lbllit y 4.. of periph{'rallTlOlOr ,1Ild s~nsory ll{'umn, III am yotrophic lat{'rul S\.'k n',~ i' . J N{'uror alhl)1 Exp Nl'uro I 4U:~7, 1988. ~ S'o\::bh , M, cl al : Selecli\'e and a:- ynllnetrk vulnerability of cortI' . ~pinal an.\ ~p1l1occre~'"ar tract ~n moto: Il{'uron disease. J N eOrl' Nl'UrlNl1] Psychl;}I!}' 5 1:71S5. JQ R~ , 4~ . A\('rb.1C ~ . P. :!OJ Cnxker. P: Regular imohcmCnI or Clar" l."\ oudcu~ In 'IXlrndlC am) OIrophlc 1:tler.! 1 ~clc rosi". Arc h Neun>1

W:155. 1982.

-*b. Ta"ah3:-\..I , H. et al: <;Iar\..e ·!i column ~n "porndic 3.m~ "t rophi l· 1::11 · eral ¢ l eR»!~ , Act:! Neuropalhol R-I : -I ()~. 19'11. .17. Hudson. ;\J : Am~"'fllphlc latl."r:11 'CJcro~I' :lIld it s a'isociat ion wuh dementta. rar"Ul ~onl "m and Olher nl'urologlCal d l'om crs: A revi(,l\ Bram 1(}.l:1Ii. 1981. .IS. \\'oh lfart. G. Collateral re-gem'mtlon in partialJ~ denervated m u"· ele,. r-.. eurolng~ 8: I i5. 195R .j Q Han!'c!n. S. and Ballantyne, JP: A quantItat Ive e lcctfoph) ~io l ogic al stud) of mmor nt"un:ln d l1>ease. J Neurol "'euro~ur!! Psychl3tl)

.II 17_-:'. 19'1R. ~kComa,. AJ. e l al : Funct ional C'ompcn':tllon 111 part iaJly dener· ~·.lIed nlu'-Cle, J K('urol Neuro~ur£ P, ~c hlatl') 34:453. 1971. ~ 1. 5"a:.lI. M. and Sl-h\\anz. MS : A InngllUd mal study of (' hanges to motor unlh In motOr neuron dl"casc, J Neurol Sci 56: 185. 1982. 5: . S.... ash, M. and $I.,h .... artl. MS: Staging mo tor neurone di sease: Smelt' fi t'lre EMG .. rud Ie'S of a.!>ymmetf). progression and campen · -'I"!lJld Thcrlp) of Am)otmph lc Lateral Sclerosis. LlppmColt ·R.l\en. PhiladelphIa. 1995. p 16), ).I. ~1 1t:.umoto. H. Chad, DA . and PIOTO. EK : Clin ical features: Signs and , ymplom~ In Mitsumoto. H. C had. DA . and Pioro, EK (cds) : Am~otrophic Lateral Sclero~L1> . F.A. Da vi~. Philade lphia. J1J98.

50.

p.n.

55. Brook... BR .l\.atural h l,tory of ALS .

S~mptom~.

strength . pul·

lllOIl4!) fu ncllon. and dl!>.3blht). Neurology 4 7<supplj:S71.

56 Jell(. Dl . et 31 : TIle reiatloo:.hip of IO\l.er- lLmb v,alb.m~ ablll ~

1996.

mu~le

force 10 to pallent.s \l.Llh am)olrOphic laleral :.clerosi:!>. Phys

Ther 791' ~ dl!:!. 1999 5i Oal Bello- Haa,. "el 31: DevelopmC'nt . analysis . refinemenl and uuluy oi

.to

Ulterdl<,uplm:lf) am)otrophic lateral ~ l ero~ l ~ d:lta· Lateral Slier O Lher MOlOr Neuron Disord

h:l')C Am~olmph

2n,:N. 2(KJI ;8 Kilmer. DO The role oll:"c rct~ III neurumu ~ ular dlscase. PhY'lcal '1edKHlt and Reh.!blillallOll Chnlc1> 01 North A merica ~lJ l I5 .1 998

59 SanJ31r... M el ai' Ptl\~ lol flgIC and met,\oohc f!:spon~ to pf(J~re s · IH and prL,longed C''-t'n.l<,c LJl .ml)Nloptuc Idteml sc le ro~l' .... eurul~) '7·1~17. 14~ 7 l(l. Sh&noa KR. t:I ,d . Ph)'-'IQiog) of lalli/lie In am) otrophlc Idte ral :.o.:ltIO"II•. I\,e urolug> 4'\ Tn, 1'J4'i M ::'ahnmmn SA Iliid l\onQfl BJ ' llie rtll1t1nn:-h lp 01 \olullI:try mo"C'lllent III b P~II11t) III till: upper t1h ll)f lLeuron ~y ndrnll1t" . AIIU J'l-tUloI2 :460 JI.J77. £/!. MOI )Cf f\H Chrw.;()pilYl>IOlogll ClIf\CCpl:'lJl .. "a~t l(ll ) ,Uld motor d:-~lun...lInll m adult> ..... Lm an upper nlC"-UlkUr Qll le'lOf].. Mu"'-"Ie ~l'\t I).~I 19':17 63 SJuffer. RB Cs!).h J. itJ'1d Hemduli. RM rre8tn lO:m nl \:motL(IIl.t1 labiht) ",uh 100000-d~£t ulq·dtl :uillckpl\: ~.lIIb, P»)t ho.'>Onmll'::!> ~4 J f J9i1 Hnd ~ vllliol~I\c:1 JP Piltiw'k,g.~ loiughter 4.nd U) m~ III AU; A M'BHn lor Ult'lf '''''Iglll All;') "eurul ~t aJ)d ~O · 114 . 1'/&1). 6" i ll/tal . kJ ~I iii Spll(.omell) LIllirn)(.Lruph K Idler"l M:krO~ II. An.h l\wm) 3614 . 11J1Y 6(1. k.Q:~1 or and E~. ~A A~..e, .. mellt 01 \ t noloilOty IUIKII(111 m p.oeou With nfUJ' lfnUi(.ular d' K~ (."I LII ( lk'l>I M ed 14 .751 . 1'194

847

67. Vllacca. M . ct al : Breathing pattern and re.'opiratory mechanics in paticnb w ith amyotroph ic 1::IIeral sc lerosis. Eur Respir J 10:1614 . 1997 . 68 . Kn vickas. L: Pu lmonary fUI1l.:tion and respiralory fai lure . In Mitsumoto. H. C hild. OA . and Pimo. EK (cds): Amyotrophic Lateml Scleroo;i1>, EA . D av i .~. Ph iladelphia. 1998. p 382. 69 . SchiAman. I'L. and Belsh. J M: Pulmonary fu nction at d iagnosis of amyotrophic latera l sclcrosi1>: Rate o f de terioration. C h e.~ t 103 :508.

1993 . 70. Ar.c. K . ct al : Cngnitivc function in am yotroph ic lateral sc lerosis . J Neurol Sci 14:95. 1997. 7 1. Kew. JJM . CI al : The re lationShip between abnormalities of cogniti ve rune lio n and cerebral aClivalion in 3myotrophic lateral sclemSl": A ncurop~yc ho l ogi cal and positron emission tomogr.tphy stud y. Bralll 116: 1399. 1993. n . Mas .. man. PJ . CLal : Prcv;lle ncc and correlales o f neuro psyc ho logi . cal deficils in amyotrophic lateral sclerosis. J Neuro l Neurosurg Psychi
30,463. 1980. 8 1. Camseio. IT. Mulvihil. MN. and Sterling. R: Amyotrophic later.t1 sclerosis: Its nat ural history. Ne uro l e lin 5 : 108. 1987. 82. Kristensen . O. and Me lgaard . B: Motor neuron di sease: Prognosis and ep idem io logy, Acta Neuro l 56:299. 1977. 83. Gmn ieri . E, et aI : Motor ne uron di sease in the prov ince o f Ferrara. !la ly. in 1964- 19M2. Neurology 38:1604. 1988. 84. Tysnes. O B. Voliset. S E. and Aarli. JA : Epidemiology o f amy· otro phic lateral sclerosis in Hordaland Count y. western Norway. Acta Neu rol Scan 83 :280. 1991. 85. Rosen. AD: A m yotrophic laternl sclerosis: C lin icaJ fealUres and prognosis. Arch Neurol 35 :638, 1978. 8tl. Tysnes. OB. e t al: Prognostic factors and survival in am yOlrophic lateral sclc.ros is. Neuroepide mio logy 13 :225. 1m. ~ 7 . Mc Donald . ER. et al : Survival in amyotTOphic lateral sclerosis; The ro le of ps ychological fac tors. Arch Neuro l 5 1: 17. 1994. RR. Johnston. M. ct a l: MoOO as a pred ic tor of d i1>abiJity and survi val in patients di3gno~ with ALSIMN D. Br J of Health Psych -I : 1 ~2.

1999. KY. Traynor. BJ. el al: EtTecl of a ll1u ltldi1>£'lpi inar) amyotrophic lat&=.rai ~dero:!> i s (A LS) c link' on ALS survhlll: A population ba:-ed srudy.

1'W6-20(X)' N~urol Neurosurg Psych iatry 7J:1258. 2003.

90. BensillLun , G. ulcolllbJez. L. and M dntllg~r. V: A controlle..J trial

41

9::! Yl .

of ri lu.lo le in tim) ntrophic lah.'ml :o.c kl'O:'ls : ALSIRilulOle- Stud y Grl)up. N l--.n~ 1 J M.:d 1)0:585, 1994. U iw mbk.t. L, et al : 1'IIt: Amyoirnpillc Lateral ScIc:rosl.s/ Riluzole Stud) Gwul' II. j)(he· ra.llgill~ stud y or rilu~[lI¢ in arnyOlrophic laleral M'1cro~l~ Lancet ·U 1; 1425. 1996. The World Ikahh O rganizatloo (WHO ) E~i)C n COfllmiure: C.",:et palJl ~ hefund PJ llmmc '·Me. WHO. Gc l~\lt. S\Iolturland, 1990. MIlic I'. RO. C'I aJ (A LS Pr",Ul'C' Par.unc:tc:r.s·t1W; Fnn.:t!): The cart uf the- p.ltlCnt 1-\ Ith IUJI) (I(rHphic i:tttnll ~dtf\)fil" (iln evLdenc-e--bascd n:v lC'\I.). Rl"l)Qf1 of th.: qualify Standards Subcouunitt« of !he Amcru;aJl AladclllY of NtMoloiY Ncuf\llog) 52(1): 13 II . l1 a(;h. J}{ . R~) rL rat\lry OIu.scle wds for ~ pre\ elUlOO of pulmOfl.ar} Illo rb ..:JlIy and lUl>ttaJity. Sttmlll Nl!urot 15:72, tW='o Dcspon. JC. i:'1 III ' Nut,i honal $ 14l.IUti ~ • pcoPk>fI.Uc factor for $Uf\ ivai Ul A.LS pll.htn.ts, NewolOJY .5J{.5) : JO~. 1999.

1m.

Y4 . 9.5

848

Physical Re habilitation

96. LcchlZin . N. el al : l-tospilalilalion in amyotroph ic la~eraJ sc lerosis : Causes. CQst s. and oulcornc~. Neum logy 56{~l:753. _00 1. ' . 97. Hillel. A D. and Mille r, R: Bulbar umyolrophlC laleral sclerosIs.

PaftelTl)o of prof!res:. ion and clinical manage ment. Head Neck 11 :51. 1989. . 98. Mathus- Vl k.~c n , LMH . cl 31: Percutaneo us c ndt)~cop I C ~astr~lS­

lOIn)' in P:llicflIS with :unyo~rophic ,lateral sc lerosIs and lmpalTed

pu lmonary fu nc tion. GastroIllIC.'> ' Endosc 40:-'63. 1994.

qq, MaZ1.mi. L. ct al: Pcrt'ulallCOUS elldo~opic ga~lfo"'lOmy and emeral nuUi lion TIl am yotrophic I::ueral SCleroSIS. N eurology ~42 : 695 . 1995 . . 11'1< ,CI "aI' The effi eae)' and limitat ions of perc utaneous 100. J .amag.TIl,

endOl'{'OpLI.' gm.lrosI01l1Y. Arch Surg 127:261. \992. 101. Kada\..ia. Sc. SuJlivan . 1-10 . and Swm es, E: Perc utaneous c ~do ~ scopic gastro:-.tom y (If jejunostom y and the inc idence of asp lrallon in 79 pa t l e nl ~. Am J Surg 164: 114 . 1992 . 102. PIper. AJ . and Su ll ivan. C E: Effec,t ~ of lo.ng-term n.o clUmal na ~a l vcntilatlon on ~ pont a n cou, breath ing dUfing sleep III ne uro muscular and " he:--! wall disorde rs. Eur Respir J 9 : 15 15. I ~6 . .. 103. Cav:olh . PA . and Oppenhe imer. EA : Home me,c hantcal ventd.lt1on for ant) otrophic Ialrral ~d ... ro~ i ,,: Nasal comp~re~ to tfa. c h ('o~ t o Ill Y. lIl t e nn itt e nt positi ve pressure ventilation . J Neurol SCI JJ 9(~ u rpl) : 12.'. 1996. .' . l().l. Pinto. AC. ('I al: Respiratory a~s i :> lance with a no n-ITlVaSIVe ventllalor t Bipap ) in MN D/ALS patienls: S urviva l rates in controlled trials. J Neurol Sci 1291 :>uppl): 19 . 1995. 105. Abou'!!o~ou3n . LS. el al: Effect of noninvas ive positive-pressure vcnulation on survival in am yotrophic lateral sclerosis. Ann Inte rn Med 127:450. 1997. 106. YorkslOn. K M. et al: Spe...ch deterio ration in am yo tro phic late ral sd ero:-'I:': Im plications for the timing of interve ntion . J Med S~h - Lan g.uag.e Patho l 1:35 . 1993. 10; Adam:>. L. and KaLandjian . M : Managing communication and s\.\a1JQ\.\ ing diffic ulties. In Mitsumoto . M. and Munsal. T (eds): Am~ otroph ic Lateral Sclerosis: A G uide for Patients and Families. cd 2. Demos Medical Publi shing. Inc ., New York . 2001. p 133. 108. E!>posito. S1. MibumolO. H, and Shanks. M : Use o f pal atal lift and palatal augmcmalion prostheses to improve dysanhria in patients \.\ ith amyotrophic lateral sclerosis: A case se ries . 1 Pro slhet Dent 83f I ):90, 2000, 109. Gehna!>. OF. and Miller. RG: A trea table d isease: A guide to the managemcm of am yotrophic lateral sclerosis. In Brown. R Jr, Meminger. V. and Swash . M (eds): A myotrophic Lateral Sclerosis. Martin DUntil Ltd. London , 2000. p 405. 1 10. Da! Bello-Haa:.. V: A frame .... ork for rehabilitation in degene rative d l !>ea..e~ : Plannmg care and ma.:d mizing qu:tlity of life. Neurology Repon Ino ....· JNPT i 26(3.1: 115.200:2 . II I. Fo lstem. MF. Fob1l·in. SE. and Mc Hugh , PR: Mini -mental Slate : A pracllcal nwthod for grddi ng thi" cognitive state of patiems for the C"hOl\'lan J PS}~' h lalr R e~ 11(3): 189 . 1975. I I ~ B.ed.,. AT. Ward. CH. and Mende l<;on. M: An m\'e ntory fo r m~ a:. ­ un ng d~prc~slon . A rch Gt'n P:.\oC h -' :56 1. 1%1 . 11 3 Radloff. LS CES· D !.Cule: A ~I f-rcjl(m depre~sion scak fo r rl~arch 111 Ihe gc:neral populalton. Appl P"ychol M ~ as 1:385, 191''' II . Zigmond. AS. :lnd Sna lth . RP: T he Hospital An.\ld ) an d Depre :-'~ Iun S {~ale Alia P ~ ) dlla lra SCllnd inavlca tt7:36 I. 1983 . 11'1 Spld btorgcr. CS . Gur..udl. RL. ItnJ Lu ~ h c: ne. RE : Manual fo r (he St.:.LIc: Ir aJl An";lc:t)' Im enlOl) Con\ ultlll g P ~)c huh )g l ~ I ... l're s~ . PI;:-.' m l: l1I in am yolm phlC" lliltra! ..... le'fo\ I ~ . \lc llnl].)gy 36 9 .1 1. II)k6 11 7 deRlll'1. A. Buu .. ~~. RJ. ,LIlt! ~ Ic rl" . JC: Kd iabdl l} 01 d} naIlH)IHc:tr) III piluelll \ .... llh n<.' ufOJnu'o(·u\..If d l\"rdcf\. N Engl J Mc:d II thL.). I%:!

118 ~\. ull. OM cl al C}U;i IlIJII~ "'I Il>n of lIl u ~~k tun\IIUIl III dll ld r~- I l A pro<;:pcOJ\'c ~I ud) HI DUdk'llllr Itlu\.l,. ul.1f d) ~ lmph ) . MU!>l h.' NC:IH.' '\ 21;11 tYK2. 1 19 MUll""I , ., L. AnJ a·b.. P• •1IJ.{i I,I.erl) 1.. 'l1l1::filf'l.!ulll.. Inab 1ft <1111\ ~ruphll' t:'I<':I'41 '.': kro ~l ~ Me a~u rem~ lI! ut dlHh. J.1 m il(' l!. 111 R:"\(' . l led l Am ) Ollpl"lU. Late ... 1 SdCHh l.> ()(' filU" Publ lt: .. lloll'. i'.c .... 'ror.. 19'1(1. pM I::!l.J 8n~ ~ . BH ~u lil PI.. and Dd >.:iul K L>c ~ If!n o f d lllll ,l! tht;r"pc u Ul lrloit, Hl lulI ~ Olrvptll .. 1.. lo,' , 'd.! ", Ier ..hh A ..h N.. uwl"li) 'il l I'JlH

12 1. Great Lakes A LS ~tudy Group: (\ comparison o ~ mu~le ~ testing techniques III amyotrophiC lateral sclerOSIS. Nel.lfOlon

6 ,( 1, ), , 503. 2003.

122. Bohanno n. RW. and Smith. MB: lnterrater reHabilily of a rnodified Ashworth scale o f muscle s ~l>li ci ty. Phys Ther 61: 206. 1987. 123. Tinett ;, M E: Perfo,:"ance-ofl e nted. assessment of mobility JII'Ob. lems in e lde rl y pau ents. J Am G en atr Soc 34: 11 9. 1986. 12-' . Be rg . KO. et a l: Mea... uring baJance in the e lderl y: Validarionof .. inslrument . C an J Public Health 83(2 Suppl) :S7. 1992. 125 . Pods iad lo. D . and Ri ~ ~ardson . ~: The timed " Up & Go": A tea 01 basic functional mobility for frail e lde rl y persons. JAGS 9:142. 199 1. 126 . Duncan . PW. e t al: Functional re ach: A new clinical measUlt 0( balance . J Geronlo I 45: MI 92. 1990. 127. Kloos, A. et a l: Validity.of the Tinetti B ~ lance As~ssment in individ uals wi th am yotro phic lateral sclerOSIS. Proceedings of the 9th Inte rnatio nal Sympos ium 0 11 ALS/MND. Munich, Germany. Novem ber 1998 . p 149 , 128 . Klooli. AD. et al: [nte rrater and intrarate r reliability of the Tll'letti Ba lance Te st for Individuals w ith Amyotro ph ic Lateral Sclerosis.

JNPT

2~(I) , ' 2.

2004.

129. Gu ide fo r the Uniform Data Syste m for Medical Rehabilitacion (Adult FlWM). versio n 4 .0 . State University of New Yorle at Buffalo . Buffa lo , N Y, 1993. 130 . Sc hwab. R. and Eng land. A : Projection techn ique for evaluating surgery in Parkinso n 's disease. In G illingham . J. and Donaldson. I: Third Symposium on Parkinson 's Disease. Livi ngstone, Ed inburgh . Scotland. 1969. J3 J. The A LS CNTF Treatment Study (ACTS) Phase 1·11 Srudy Group: The amyotrophic late ra l scleros is functional tating scale: Assessme nt o f activ ities of daily living in patients with amy. o troph ic lateral sclerosis . Arc h Ne uro logy 53 : 141. 1996. J 32. Krupp . LB . et al : The fati gue severit y scale: Application to palients w ith multiple sc lerosis and systemic lupus erythematosus. Arch Neurology 46 : 1121. 1989 . 133 . Cedarbaum, 1M. et al: The ALSFRS-R: A revised ALS functionaJ ra ting scale that incorpora tes assessments of res piratory function. J Neuro l Sci 169: 13. 1999. 134. A ppel. V, et al : A rating scale for amyotro phic lateral sclerosis. Ann Neurol 22:328, 1987. 135 . H ille l. AD. el al: Amyotro ph ic Latera l Sclerosis Severity Scale. Neuroepidemio logy 8: 142 . 19 89 . [36. Norris. F. e t a1: The administration o f g uanidi ne in amyotrophic lateral sc lerosis. Neurology 24 :721. 19 74. 137 . Ware . JE, e t a1: S F-36 Health Survey: M an ual and Interpretation G uide . Health Institute. New Eng land Medical Center. 8 05100, 1993. 138. Hid,ey. A M. el al : A new "ho n form individual quality of hft' measure (S ElQol-DW): Application in ;1 cohort of individua1.5 w ith HI V/AlDS . Br MedJoum al JI3:29 . 1996. 139 . Be rgn er, M . ... I a l: T he Sic kne:.s Impac i Profile: Ot\ elopmt'nl and fi nal re vision of a health Matus me as ur .... Med Cart' 19:7S7. 198 1. 140 . Jcnk in:-.on . C . ... t al: IXvd opmem and ..,aJidation o f a ,h<.-'I1 me~ of health status for mdi\ ld uals w ith am yotrophk lateral sciet'OSl§/ mOlo r nc: uron dbt'ase: The A l SAQ -40. J . Ne uroI 246: 16. 1999. 14 \. JCl1l" in<,('I1 . C. CI a l: E\'idence for [he \'aridity and reiiabilil), ofthc' A LS a:-.:.~~:.me nt "u ~ :. l i ull n:llre : The A LS AQ~4 0. Am yOfroph L.lll·r;l J Sder Olher I\ lu[o r Nc:uron D I ~o rd 1:3:1 . 1999, 142. Je nkll boll . C. and FIILp.llfick. R: Rc:d u c~ d ittm set for the am),ulroph ..... lal c: ta.1 SCk I O~I~ u:.~~ ~m ell l i.j ut':>lWlmtllrl:: De \'cI~llCn[ ItllJ \'a lld,lt l,lJl u r lhe A L SA()-5 . J Nc urol Nli:' u (~ uF!: Ps),chH!U)' 7U1. 1 I: 70 , ~ OO I , J -'3 D.d lidlo- I t .m, . V1'. ~I al : A prd imlllarv , hid ) : TIk' effcocis oft . . """'rriIL , u cllll lht*l1 l11g program 0I1I1lJ\ i mUUl \'ululllary I:>OOlt::(l'IC........ 'th 110 11 , IUlll'll{,":I! ... lll htlt*~. filllgUC and (1IIa lll) of lif~ in pallt"lliS ~I .1I11 ) <J FH lphl ~ lal....raJ ~ kru~b . Am)'olrtlph L.a I ~rJ. 1 s.;1c( OttlV' M llh,)1 Neuron D I.~ord ~ lSlJ . I,I ·I . :!( tOl. . 14-1 tnt l!k PL. " I al' Adhc\I\'c l'OI lh Uh l l ~ : t\ ('(1I1111l0 n O('cUI'K ....."t' In r ·l lI l.'l1l, .... lI h A LS Ant)otroph L.ut"ral Sd... r Od k'r Mol'. Nc:urtJII Hhu(,! 2(S2"')[J. :!OU J l -l~ Lalum:U lu . I t. e l .. ( . l:'plf otIOr)' I llIbl.: lc \'\ I!aln~~ ami a~ l.ough III AlS . A,fII}Ut.ruph 1.•o1I~raJ Sdt.'r Other M....\for ro-l!uf'OO lJlM>l d 4( I ):49. ~00 3

Chapter 20 Amyotrophic Laleral Sclerosis I~

Ibn:mlma. ":' . Yuk:.. I. .Ul\1 Bach. JR ' m)Olrophic latcr:.1 ,..:1l."rt l"I~ ' S~(Tl.· .. ~fullre;UnlellI ofmlK"Ous pluggm~ b) mechanical In!>ufnatioo-<'\;!>uf1lllIIOfI. f\m J Ph~;>o ~1cll Reha bi l 76:338. 1Q97. 1"7, Mll!b.. Nt'urolog) bl (9~: C85. :OOJ. 14S. Trail. M. el 811 : Wheekhair U!iC h) patlcnl.s wllh amyolrophic l:tIer;ll "C\t'rosIS: j\ ... uney of u..er chliffitlcri..,rKs and selection preferen~ . AI\.·h Ph)<:. l\Ied Rehubll S.2(1):9~. ~OO1. 149. A<:.hworth. NL. Sallunam . LE. lind Dcf(lr~c . D: Treatment for ~rm"dt~ In amyotrophi,' lateml ",lero"INmotor neuron di<:'cu!lc (Cochrane R e\il!~). In: The C('IChrnne Llhmry. (bsue ..0 . John \\ lie,' & Son ... Ltd.. Chlchc~ll·r. l ' K . .2('04. ISO. Kt'mp. ~)chOSOCI.JJ ne<'d:-. prohlem ... :md lI1\cncntIOll'; llw IOtti'ldual. In Tennm31Il1ne~': A GU ide 10 'lJII T'olllg Care. cd .2 . L1rPu....'OU. Philadel phia. 1999. p 17. 151. Dot-a. KJ ' Mcoummg ~)cho\OC.·!al lo!l:-. Anticipatory mournmg in Alzheimer·... ALS. and Irre'e ..... I!:>le coma. In Randn. TA !l"d): Chl\lcal Oimcn~ions. of Anticipator} Mournmg : ThcO!) :md Prncric(' in WNkmg WIth th(' Dymg. Hlc ir Lcwed Ones. and Their Carcgl\·e~ . RC"~rch Pr\>" . Chnmraign. 1L. 2000. p~ 77. 15~ 0 31 Bello- Hail.'>. V. DeiBenl". M . and Mlt~umOIO . H : End of hfe: Oollieages anJ 'Imlcpe~ for Ihe rehablli taoon pmfe<:.)oional. :-" eurolo~ Repon Iflffi' JNPT) 2N~): 174 . ~002 . 15.' Kilm&r. DO. el 31' Tht' effect of a high rt'<:'I)otancC exert l!lC pro£l"Um In Iolo~ l~ rrogrcs~iH' ncurom u~' ular d .... ease. Arch Phys Med Reha!:>ll - 5:560. 1'.N. t 15-1 Lindeman. E. et al: Slren!!th tnunmg in pallent.:. wjlh myolonic d)strorh~ and h('redltar) motor and ... e nsol'")' neuropalhy: A rnndOlnll.C'd chmcai mal Arch Ph~ ~ Med Rchabil 76 :612.

c:

JQQ5 155 A ltl..en~. SG. et al; Moder..llt' re"lS!ance c'ere ...." progr.un: lis

156 lSi.

158 159

160,

effect In .. lo~l) prope$!>I'>e neuromu~ular dlscase. A rch Phys Med Reha!:>.1 74;7 11. 1993. ~11Iner-Bro\o\.n. HS . and Mi ller, RG : Musek .men~themng through high re<:'lqam~ \o\.elght training In patient.' \\ith neuromu.;cular di ~ ­ orders. Arch Ph) \ Med RehabI169·J -1. 1<,188. AoreIlCt'. JM. and Hagberg. JM : Effecb of traimng on the exercise m>pon'>t' of neuromu ~ular dl,t'ase pallcn~ . Med Sci Spon~ E). 16(5/400. 19S..\. Vi{!tlo'. PJ. Jr: Ph}slcal model!> of rehabilitation III I)cummu"cular disea-.e , \1u'lCle '\;erve 6(5):3B. 19 ~. Emar!>!lon. G. Mu<.Ck "."ondluoolng 10 laIc pol lomyehtj", Arch 11tI~ s Med Rehab.1 n-II. I'IY I ~kCartne)'. 1\ . et al' The cfleet.!. of strength training 111 pal lent .... "-1m ..e1ec1ed neuromu!.Culrtl dIMJrdt'~ Med Sci Spons EACn~lN4) :3b2. IY~R.

• pplem e ntal

Readjnlts

Afbrm, M loe~.a~ :lo .. lIh Mome -An Old Moill, A Young Man , And Life "Gre..lt~ 1 Le<."-Orl B,llIlam l).)Ubleda) IJdl. Ne .... Yorl.. 19lJ7 Am)«mphK uleral Sdero~b A~\(lC.latl(,.on til mt "" Ith A1..5" 1\1 "'-lu"l, IlIld V~ . htlp:/I"\lI\o\. ..Iw Am)'QlrIJpbK Lale~1 &.Ier"""i,> SOLlel} 01 ('.Ul ..dll A M~nu3.l hx I'eopl .. {.J\ Ihl \.\ Ilh ALS, hup:/;..-....... a1<..~lI D-..t Bdll.l-H.J4~. V Ki{)')s A anJ MII.... UIlI..to Ii l'Il}"'\:dllhcr.lpy lut It&: ita t·~ of .ut1YOllrOj'lhK laR'I'ill ",-lew·,tt. A (. "'-~ H"j)\If! Ph), flIt'f ,.~ 12):1]12 1'191\ Fn!ttoh.ium 0 t~lh JOUIIi<')' .. .... lIh ALS Pcr...on.tl T~lo ul COll' '',~ .nd (''Pi'' v.. ,th I.ll\.1 GehO! I UI)I.;I.w.- 01 RC IJrc 10. VUylrlt.t Uc,'d.lh

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A..u,..Jp M t cJ) (.()nunUII.~iIlhtfl and \\.\ti1j(jVolI\~ ~.Iullolh Iu. Ihe AL~",,1 !1.U romml.llul) Sll~u l.. Pun\! hlll¥ Droop \411i>lq,U. ,Yin.

849

161. Bcnncu . RL. and Knowlwn. GC: Overwork wc .. l..ne~!I in paniaUy deocr'3tcd , kelct:tl mu')('!c Clin Ort hop 12:7 11. 1958. 162. Jo hn'"II. EW, :md Brnddom . R: O "erwork weakne!i' In fll"iOS(:apu~ lohumc rnl muscular dy<:.troph y. Arch Phy" Med Rehabl l 52:333. 197 1. \bJ. T:ml . SL. ct al: Increa"!ed neurom uscu lar activity n:d uces sprouting in parlialty oenl"lVuled lIluM:les. J Ncurusci 2 1(2);654. 2001. 164. G:lrdin('r. PF. Mkhcl. RN . anJ ladeluca , G : Previou~ exercise (raining inf1ucnce~ funcliona l sprouting of ra t hindlimb mrnoneurons in rcspon~c to partial dCllcrva(ion. Nc urO"C1 Leu 45 :123.1984. 165. Rafu!'C. VF. GordOIl , T. :U1d Or07£0. R.: Propon iona l enlargement of motor uilil" :tflcr panlal dcncrvation of cal triceps surae mus. c\c<:.. J Neurophysiol68 : 1261. 1992. 1fi6 Miche l. RN , and Gar<1mcr. PF: Innucnce of overload on recowry 01 ra t plantari" from panial dcnerv:uion. J Appl Physiol 66:732. 1989. \67. Scbum . KL. and Gardincr. PF; Properties of spwllted rat motor units; EffecI~ of period of enlargement and 3l.:tivity level. Muscle Nerve! 19:1100. 1996. 168 . Ribchcstcr. RR: Activity-dcpen
76:2663. 1994. 170. Coble. NO. and Ma loney. FP: Effecb of exerc ise III neuromuscular disease. In Maloney, FP. Burks. JS. and Ringel. SP (eds); Interdisciplinary Re habilitation of Mult iple Sclerosi!; and Neurom usc ular Di sorders. JB Lippincolt . New York. 1985. P 228. 17 1. Bohano n, RW: Results of resislance e~e rcise on n palienl ..... ith amyotrophic latef'JI ~ Icrosis . Phys Ther 63(6):965. 19tH. 172. Sanjak. M. Rcddan . W. and Brooks. BR: Role of mu'!Cular e.'(erci ~ in am)olrophiC' lateml sclermis. Neural C linics 5(2):25 1. 1987. 173. Pinto. AC. Alves, M. and Nogueira. A: Can amyotrophic laleral sc1ero)ois patie nts \\ ;Ih respiratory in!luffictcncy CJl.crcise? J Neurol

S<:i 169:69. 1999. 17-1. Drory. VE. et a l: The value of musclt' excrci~ in patients with amyotrophic ImeTaI sclerosis. J Neurol Sci 191: 133. 2001 .. 175. Klrkinezos. IG. el al : Regular t'xercisc is beneficial to a mouse model of am yotroph ic lateral sclerosis. A nn Neuro l 53 :804, 200,l. 176. Veldink . el 31: Sexual differell(:cS in on~t of diseuse and Teliopon~ to cxcrcise III a transgenic mood of ALS. NeuromusculllT Di~a o;e 13 ~ 737. 2003 . 177. Mahoney, DJ. el al: Effl!Cb of high·inlensllY enis. Mu.\(;le Nerve ::!9: 65b , .2004 .

m.

and

Re

ource

Mlbumoto , M .lInd hlll...al. r I~(h): Am)otnlophll I u,eral Sckrow.: t\ GUltk (or 1):lII\:lIh all.! f.lJluh('", t"J 2, Dcn)(~ M ':lh(.~1 F\ibh-.hing. f'o.ew 'lOr\. . !(W) I Mu'OCul.ar D) ... trol'h y A"''AA.IJlh)f!' AL"i A GUide 10 RdJt('li Moiten<4h (lI1 MDA\ \\dl Site. hllp·/I... " ~ mc.lau~aorg!pubIK,'IIOI\.Val:otlJhlt:.. hu"l N;.III.)nallmllll,1IC , If f'o.eufU l n~l~al Di"~If'lkr.. UIllJ Strole:. N.U,iNlotl 1II.)IItUIC~ . 11 1 1 ~a ltJllj\III ). LJ S. lklW\fllCllt (.( 11I:.lIh and HunUlIi 'it'n.' I~e , \\ r:b !l 1I1! , hili) 1/\0\. ... '" nllll.h_mh 8\1\ " l,rIJ h :defru f1J.. AU.)UII, 2{k..1.a

Appendix A: Schwab and England Activities of Daily Living Scale l00Cf = Compl etely indcpendenl: able to do a ll c hores w ithout s lowness, difficulty, or impairment; essen tiall y Ilo nnal : unaware of any diffi culty 90lk = Complete ly indcpcndt!nt able to do ull chores with some deg ree o f slowness, diffi c ulty. and impairment; may lake twice as long 3~ u ~ual: beginning to be aw:ue o f difficulty = Complelely independen t in most chores; lakes twi ce as long as normal ; conscious of difficulty and slowness 70Ck :;::: Not completely independent: more difficulty with some chores: takes three to four limes as long as normaJ in some: mu st spend a large part of the day wi th some c hores 6()ft = Some dependency: can do most chores. but exceedingly slowly and with cons ide rable effort and errors; some chores im possibl e 5OC'r = More dependent: need s help with ha lf the chores. s lower, etc.: difficulty with eve rything .fOCi .:::: Very dependent; can assist with all c hores but does few alone 30'< = With effort. now and then does a few c hores alone or begins alone; much help needed 20'1- .:::: Does nothing alone; ca n be a s light help w ith some c hores; severe invalid ID°1e = TOI.ally dependent and he lpless: compl ete invalid 09c .:::: Vegetative functions such as swallowing. bladder and bowe ls are not functioning ; bedridden

soer

Fmm Schl,l,ab R. and England . A. l1u

.... ilh

permi ssion.

Appendix B: Amyotrophic Lateral Sclerosis Functional Rating Scale-Reviseda I . SPEECH

2 Some help needed with clos ures and fastene rs.

4 NomHtl speech processes.

o

1 Provides min imal assistance to caregiver.

[)c1e{"13ble speech dl srurbance. ~ Intelligible " ith repeating. t S~h combined \\ Ilh 00lwoc31 communication. ."3

o Lo<s of useful speech. " S,4L/\ :4TIO,\' 4 N OnTIaJ.

light bul detin ue exce~~ of ,ali va in mouth : may have

3

mghtti m' drool mg. 2

~1odera t ely e '( ceS~J\e .... al iva:

may have mini mal

drool mg. 1 M.arl ed e\ees" of . . ali\ a ", ith some drooling. Marked drooling . reqUI res const;1Ot IIssue or h and ~ erdueL

o 3

\\ '\uO\\ 'I\'G

Unabl e to perfonn any aspect of task,

6. DRESSING & HYGIENE

4 Norm al functi on. 3 Independe nt and complete self-care with effort or decreased efficiency. 2 Inte mlitte nt ass istance or substitute method s. I Needs atte ndant for self. Total dependence,

o

7. TURNI NG IN BED AND ADJUSTING BED CLOTHES 4 Nomlal.

3 Somewhat slow and c lumsy. but no help needed. 2 Can tum alone or adjust sheets, but with great difficul ty. I Can initiate. but not tum or adju>! sheets alone. Helpless,

4 ;\onnaJ eatmg hoblts. ) Earl~ eaung problems-occa~ionaJ choking. ~ Dle'tal") con,,'tenc) change. I ' eed, ,upplem,ntal tube fcedi ng,

o

o

' PO

8. WALKING

4

H~\D\\

(e\clu~I\'d)

parenteral Or emeral feeding ).

4 Normal .

Rrrl'-G

) Earl y ambulation diffi culties, ") Walks wi th a.)slstance. I Nonambula tory functional move ment only, No purpo;eful leg moveme nt.

4 ' onn :I 10\\ or ,Ioppy: all "ord, ,tre legI ble. all ","ord ... are legible. I Ahle \0 ~np pt"11 but unable l n.hle 10 ~llP pen

,

. lot

o

o

10 '" nle

9 CUMIJIr.G

u (( TflM, FOOD ""\D IH ,\DU \ G I T I:..'I SIL (palirnt~ ... ·uh oul

gauroMomy.

4 '\ lflmiil

3 SH'~Y.h.ll ... Iu.... .tnJ dUnb). hut no help needed

~ CdJl ul mo ... t lc~o,j., . d..!lhou~h duOl') dfld ~I (I"" ,orne he Ip I",,,dcd I Fffl,td ml.J-.t he \,,"ut h) ~IUlt·uHf but l-,un \lIU (efJ .. hN I) Ii Sr~d · u. ht fod

I)k
~IT"G r O(1/J ~\I) 11.0, , fJ/ I\G I 1t.\\J/ \

IAlIt rnfiU ~1.'(Jl.t-/cJr paut'nb

M

un gUjlr(#~IQIH)')

"mal

4 l~

ItJ

pcrt.,ml

oU II1.iill P UldJIHIll
1O(k

~TAlRS

~

Nurmal. 3 Sluw. ... M ild Ull\teadil1c...... or fatigue.

Nt"eus U')\h l J.l1n:

o

Cannot du

JO. Ol'SP,\

r,~

4 ' one' 1 Q..l,. UI -. v. h..:n \, .ll~lO~ 't (x:... ur\ \\ilh nn~ or nlor~ vI the foll o~ in8. C'8.hol. \l.t1I111 '. I ADL) (l<cu" dt re,t. dltriwlt) Ilreal hlll¥ when either >tuil\& or I) Uts. 1I ~ tgnift....nt ,hlh. wI) . «H"lde m l¥ u,ill~ n1&.""hIitu<.·1II

w" ""g

re:.pu·atuf) . . Uf>1XlO

852

Physical Rehabilitation

12. RESPIRATORY INSUFFICIENCY

II .ORTHOPNI:."A

4 3 2 I

4 None. 3 Some dilTiculry sleeping tit night due to short ness of brc;lth. doe~ not routine ly usc more than twO pillows. 2 Needs ex tra pillows in order to sleep (more than two). I CUll only sleep sitting up.

o

o

Unable 10 sleep.

None. Intennillent use of BiPAP. Conlinuous use of BiPAP during the night. Continuous use of BiPAP during (he night and do Invasive mechanical ventilation by intubation Or y. tracheostomy.

From (C'dilrh:lulll. JM . CI aI, III wrth pcmlb!'ion.

1I0 riginai ALSFRS cO Il ~ i st s of ilems I through 9 and the original item 10 below:

10. BREATHING 4 Nom,"!.

J Shortness of bre:Jth wi th minima l exert ion (e.g .. wa lking. talking). ... ., Shortness of breath at rest. I Intem1 iucill (e.g. nOClUrnal) ven tilatory assistance. o VentilalOr dependent. BrPAP ;: bldiTl."Clronal posil ive ai,..... 3y pressure' NPO = lion P" os .

, no

Ih '

ml;:

b

y mouth.

C II APTE R

21 IIARNING

OIJICTIVES

J. Describe the erio logy. pathoph,Y sio log). cli nica l manifestations . and seque lae of Parl.. inson 's

Susan B. O ' Sullivan,

disea.se. !. Identify and desc ribe the C'xam inatio n procedures used to evaluate patiellts with Pa r kin son '~ disease to establish a diagnosi'l. prognosis. and

plan of care .

3.

. . .

Descri~ !.he role of the ph y~ l('a' therapist III assisting a patient with Parkinson 's disease in tetmS of direct interventions and patient and

famiJy/caregi\ er-related instruction to maxim ize

function . 4. Describe appropriate elements of the exerc ise prescription for patients

v. ilh

Parki nson's

disease. S. Identify the neuropsyc hologica l effects and social impact of Parkinson 's di sease and describe appropriate interven tions to maxim ize quality of li fe.

'- Analyze and interpret patient data. foml ul ate realistic goals and outcomes. and develop a plan of care \\ he n presented with a clinical

case study.

Parkinson's Disease PT. EdD

OUTLINE FP l lklll10[Og~

H53

El loio!;!y 854 Parl.. inson·s Disease 854 Secondary Parkin soni sm 854 Park inson-Plu s Syndromes 855

Palho phy\iology 855 C'lJlllcal Prc~cn l a l i on 856 Cardinal Features 856 MOlOr Planning 85 8 MOlo r Learning 859 Gait 859 Sensation 859 Speech. Voice , and Swallowing 860 Cognilive Function and Behavior 861 AUlonomi c Nervous Syslem 861 Cardiopulmonary Function 861

Cognit ive Function 867 Psychosocial Functi on 867 Se nsatio n 867 Musculoske letal Function 868 Motor Function 868 Autonomic Function 870 Cardiopulmonary Function 870 Integumentary Integrity 871 Functional Status 871 Global Health and Di sease-Specific Measures 87 I

\I1edicul Diagnosis 862

Physical Therapy lntervention 872 Motor Learning Strategies 872 Exercise Training 873 Balance Training 878 Locomotor Training 879 Cardiopulmonary Training 880 Group and Horne Exercises 880

Cllmcal Course 862

Psychosoc ial Issues

'v1ed ll':<11 Management 862 Phamlacolog ical Managemem 863 "'ulmio na l Managc mem 864 Surgical Manage menl 865

Patlcnt. Family and Caregiver Education M81

~8 1

Management Cons iderat ions hy Stage of

Frarnc .... orl.. for Rc habd ll.llion 865

Summary

PhY"lcal The rap) Eli:am lnallOn and

Di~ase

882

8~3

F'~tluallon ~M

p arl.Jn'i.Jn·~ dbea.':Ie (PO) l ~ a chronic. progre!)~i\'e d iSC~e of the nen-ou!) ~)\tt.: 111 charac terized by the: c
Epidemiology

nit! featw·t:'~ 0/ rigidit ~ . bradykint!sia. Iremur . and 1'0'-

PO is a \ ay co mmon

n e Hnxl~g~llaali\'e disease that

tural In li1blhl). In JddlllOIl, the dl.\,ea<.,c ITIJY <.3u-,e J \-arlet) 01 (Ither ") mplOm"l mdudmg muvement and ga il

urfeel, nlO rt: tha n 2 pe rce nt 01 thi:' popuJalion olda than 65

-.en">ol) (h~ge'; .;,pecch, \OH..: e. and !) \\a ! ~ k.J ...... m~ dhordeh: cogn ul\ c ,tnd heha\ lor.i.11 lhange" .I UW-

)e . tr... of tlge. A\('fagr ~ge 01 PD OIl ...t: 1 j, a pproxjmately 50 to bO ) ear... The incld e nci:' in(' rease~ dramatically with

dl !urb.:Ult..c..,·

nOOIll

ner\<(jU~

~) Mtm

di',fundion;

~d"'lro l n t c"'lln<.ll

ch;Ulg~,. IU1d c..:ard lupulmonary change .... Olhe t J ~ tn\h l!OUr.., ~Jlh a ... ll)w ra te cd prog.re\o~lOn DI,rupIHJn In d"lI) lum:tum , lole, ,md
y.

Hh PD

II H.:rei.l\tng dgl~

There a te k Sb than 10 ne w cases per

100.(K)() under age 5U "hik there are at least 300 new ca,e, pel IOO.OOU age, SO to '19 year. annually. A smull !)e h.:cnt age (4 10 10 pen:,-,m) d~\'dop youllg-onset PD, \\ hH h

h

(k.. hncJ by the UPI~JIan('~ of initial symplOn~

854

Physical Rchabililation

ocfore Ihe

~ge of 40. Men ll nd women arc affec led alm os l

equally. I

ers to those conditions that mimiC PO in srndromes re f "so me rcspcc . . . s. ' but th e symptoms arc ca used by other neu. rodegcnerative disorders,

Parkinson's Disease

Etiology The I(:nn park insu nism is u!'e.d. 1O refer I~;:I ~rou~, o~:~; orders Ihal produce abnonnalillc!' o~ bas~ 1 g.mgl l'l - , . 1 PO or idiolJ"llhic parkinsollls m . IS Ihe 1110s1 com1uoc~·· f . mon form. affecling appn"xill1alcly 78 percenl 0 _P~I~~~l I S, SpCOf/elm:" l'adiflsolliJnI resulls. from :J. l~uJl1ber 0 1, d lflt:1 C I~1 idenlifiable ca ll se~. including vI rus. tox ins. d.ru gs' .lum o rs. --' 80"... -, 1 ' ') . The 1('1111 parklflsoll/sm -pllls 3n d !'O f or tl 1 ( :-~.t:

Box 21 .1 Classification of Parkin sonism

True PO Of p
Secondary Parkinsonism Postinfectious Parkinsonism

Idiopat hic Pa rkinson'5 Disease Late-onset (> 40 yean.: generally sporadic) Earl),-onsel «40 ) ears; often familial) Young-ono;;el (> 2J years) Ju\'cllIlc «21 years)

Parkinsonism Due 10 Identifiable Causes Virus (e,g., encephalitis lerhargica) TO).Jns (e,e: .. carbon mono"(ide, manganese, meth)lphenyltetrahydropyridinc [MPfPJ)

Drugs (e.g.• phenolhiazines. reserpine, butyrophenones. me.oclopl1ll1tide) \'ascular disease (multi-infarct) Tumors of basal ganglia Normal pressure hydrocephalus HemlparL:.msonism. hc:mi3trophy \1etabohc Wil~ 's dIsease Hepatoccrebral degeneration Hallervorden-Spall disease Hypoparathyroidl~m

Parkinsonism in Other Neurodegenerath'e Disorders Progre!)!live , " upnmudear pa1.s) Corucal-basuJ ganglionic degeneralion DI~
Sh y~ Drager ",yndrome Ollyopvnllx.erebell:tr atrophy Mru.;hado-Jo!oCph dl..ea\e D!s(mien. \l.llh prommeOi and often early dl'meulla: DltluM: ct)nlC"aJ t...c'A) body dl'>Ca~ Ab.helme, '_ dl~ase wlfh parlinsoni"lm Pl.lritinw-nllsm-
The influenza e pide mics of encephalitis lelharg ic. that occ ulTed from 191 7 to 1926 affected large numbers of individuals. The o nset of parkinsonian symptoms Iypically occu lTed afle r many years. g ivi ng rise 10 the theory thai a s low virus was infecting the brain, There has been no recent rec urrence of thi s influenza a nd the incidence of this Iype of parkinsonism is s lowl y decreasing in frequency.' Mov ing case historie s of these individuals are portrayed in Ihe book Awakenings by Oliver Sacks.' The development of parkinso ni sm wi th o the r encephalitic conditions is rare.

Toxic Parkinsonism Parkinsonian symp toms occ ur in individuals exposed to ce nain industrial poisons and chemicals (manganese. carbon disulfide, carbon monoxide. cyanide. me.hano\). The mo-;t COlll1110n of these lax ins is manganese. which represents a seriou) occupational hazard to many miners. Se\'ere and la~ting da:>sic parkinsonian has bet'n inad \ enently produced in individuab \\ ho injec t~d " s) nthetic huoin tOlllaining the chemical MPTP.tI Drug. lndu ced Parkin ~unisl11 ( [)I PI A varle ly vI' drug ... Ci ll1 produl.'(:' t!xlrapyri.lmidal dY!'Ifunction Ihal III I III Il':> the 1'I ign:o. 01 PD. ~I hC'lt~ drugs .~re thought to Illtl.'rfC: fC' Wil li dOpi.lmine rglc IIlCch.lfl l :o.m ... e ither presynap111': 0111 ), Uf pO"'I :» Ill.lpli call) . The~ indudt' (I) neurult'rth' d,.",\ . . 11\.: 11 .1 ... chll)'llfOlIllll ll1e ( ThOntLilll!) . hulopendol (H'lldol ), Ihlorid,u.mt! (Me-IIJ nl) , and IhlOlhl\ene (Navane): (2 ) WllldlPU ' \\I..If/( ,bug\ !)Udl a:'l .Hnunrl)lint.~ tTna\iJ), dll)l).\apIIlC lA!lcndlll). and trJlOOOlll.' (lxl.,yrcl); and (3) j"lIIh\/lf'l1t'IJ~1I t' d",,,<\ !) ut' h , h meth) Idop.t lA ldomel) and re ... t.'rpln~: ~h~h du,:-..e~ of Ihc-'>e rtll'lhullion30 arc pal"lu:;ularl} pl l.IhklllJ.lh: In the eIJ~rI) . \ ilhdnt\\al of lhi!'i~ age"t~ USUall) re\t>r~t!'i the ~}nlpIOIll'l \\'Ithm u te\\ \\eeh. although III "'UIIW i..· d ... ..:~ Ih~' c:f1t"i..' ("t can per~1\1 ulld Ill:'} be relalt"d 10 w l-x illlll.'td PO 1

C hapter 21 Parkinson's Disease

Metabolic Causes

.

p;lrkillSonisll1 c:IIl, be ~auscd

In

rare cases by metabolic

nditions. incJudlllg di sorders o f c3Jci um metabo li sm that CO;;:ull in BG calci fi cati o n. These include hypoth yroidism .

~;,erparJthyroidisl11.

hypoparathyroidis m. and Wilson 's

disease.

Parkinson-Plus Syndromes A croup of neurodege nerative diseases can affec t the subsla~tia nigra and produ ce parkinsonian symptoms along with other nCLIrol ogicaJ ~igns . These diseases include striaronigra l degeneration (SND). Shy-Drager syndrome. proI!teSSi\C supranuc lear pals) (PSPO). oli voponlocerebe ll ar

;rrophy (OPCA). and cortical- basa l gangli onic degenera tion (eBGD). In addition. parkinsonian sympt01ns can be exhibited in patients with m ult i-infarct vascu lar disease. Alzhe imer's disease. diffuse Lewy body disease (DLBD), nom,aJ pressure h)drocephal us (NPH ). Creutzfeldt -lakob disease (em). Wil son ', disease (WO). and juve nile Huntington"s di sease. Man) of these conditi ons a re rare and affect relative l) small num bers of individual s. Early in their course. these di seases may present with rigidity and bradykinesia indisti ngui shable from PD. However, other diagnostic symplOm~ e\ e nrually appear (e.g .. cognitive impainnent in Alzheimer's disease) . Anothe r diagnostic fearure IS that Parkin so n~plus syndromes typicall y do not show meas urable improvement from the administration of anti-Parkinson medications suc h as levodopa (L-dopa) therap) (lenned the apomorphine Tesr). 7.8

Pathophysiology The basal ganglia (BG) are a co llec tion of inte rconnec ted gra) matter nuclear maS!l.es deep wi thin the brain , It is composed ohhe ca udate and putamen (coll ective ly tenn ed

855

the striatum ) plu s the g lobu s pallidus. subthalamic nucl e us. and the substantia ni gra (Fig . 21.1). The main input structure of the BO is the striatum . Input is received from a ll part s of the cere bral co rte};. via corti costriate pro~ jeclion. The stri atum also receives input from the substan. Ii:. ni gra (s ubstantia ni gra par~ compac ta. SNc). Output is c hanne led primaril y through the globus paJlidus (globus pa llidu s inte rnum . GPi) and the substa ntia ni gra (substantia ni g ra pars rCli c ulata. SN r) to the thalamu s and back to the COr1 ex. compl e ting the loop. The re are both direci and indirect path ways. The direct pathway facilita tes BO out~ put to the thalamus and motor a reas of the cortex while the indirect pathway provides di sinhibition to th e subthalamic nucl e us (STN). a nd in tum suppres sion of some move~ me nl s. Pans of Ihe globus pallidus project 10 the brainstem and in lurn 10 the mOlor ne urons in the brainstem and spinal cord (Fig. 2 1.2). Neuron s in the BG di scharge before moveme nt begins. 9 ,lo The BG pl ays an important role in Ihe planning and programm ing of movement by se lecling and inhibiting spec ific motor syne rg ies. MOlor programs are conso lidated into efficient goal~directed motor plans. translating though( into w illed moveme nts and regulating levels of kinetic activity, muscle tone. and musc le force .9 The BG al so play a role in some cognitive processes, primarily the cauda(e nucleus. including awareness of body orientation in space, ability to adapt behavior as (ask req uirements change. and mOlivation. 11 PO is associated with degeneration of dopaminergic neu· rons that produce dopamine. They have their ceU bodies in the SNpc and send their axons to the striatum . Clinical signs begin 10 emerge with 30 to 60 percent degeneration of neurons. Nigral ce ll loss is estimated at 10 percent per year and is more prevalent in the ventral cell group. Loss of the Jl1elanin~containing neurons produces characteri stic changes in depigmentation (Fig. 2 1.3). There are other deficiencies in ne urorransmitters as well (e.g." serotonin, norepinephrine). The effects of these depletion s are less well understood. As

Anterior horn , lateral ventricle Caudate nucleus (head)

Lateral ventricle

Anterior limb, Internal capsule

Caudate nucleus

Putamen Frontal lobe cortex -.....lk - ..!\- Claustrum ,'I-........J.-- Insular cortex , ·t;-'-Tempo(aIIObe cortex

IntemaJ capsule

~i,t"'",..ij- Putamen Claustrum

~:::"'L.}-.J'u...(i::;?'~"'~~ Nucleus accumbens

Figure 21 ,1 The maJ{Il

'!. lru(;IUr~ !t of Ihe hasa l gung l...

Globus pallJdus Thalamus

Uncus

Pby ica1 Rehabilitation

856

O the r BG d isorde rs prod uce h yperkinesias, c haracterized by exces SI've or a bnonnaJ movements (e.g., hemiballismus • chDrea). These are tho ugh.t tD.result fro~ underactive indi . rect path ways w hile d yskmes tas. d ystoma, or athe!OSis art thought to res ult from an overactIVe dt rect pathway. Tremor is viewed as a release phe no me na, representative of loss of inhibitory influe nces w ithin the BG. Significant changes in stri ata l d Dpamine receptors also occurs, resulting in decreased bind ing s ites for dopamine in the BG. This may ex plai n the loss o f clinical effective ness of L-dopa (a dopamine IDA) substitution treatme nt ) during later stage., of the disease. 12 . IJ

CEREBRAL CORTEX

?GLU

+

+

•

GLU

STR IATUM

DA

-

---:.:

•

-

- : GABA, SP 'f SUBSTANTIA NIGRA, PARS COMPACTA

•

EXT ERNAL PAL LlDUM

- ... GAB A SUBTHALAMIC NUCLEUS . '

•

THALAMUS

- ... GABA, ENK

~----'--'-.,

INTER NAL PALLI DUM

. . . . .. . . . +. . ~.

GLU

GABA

Figure 21.2 Schematic diagram of some.co~.ections of the bJSal ganglia. showing e).cital.ory (+) and mh~bllo~' (-) . . s ynap~,> and neurotran o;; miners. TIle direct stn opalhdal projection io;; bold ~ hdded and the indirect projection is dashed. Coniconigral and cortiCD'iubthalamic projections. which are ex.citatory. are nDt ~hov.'Tl in the diagram . (from Kiernan . JA: Barr's The Human 'er\'ou~ SYMcm: An Anatomical Viewpoint. cd 7. LippincDtt· Ra'en . Phliadelphia. 1998. p 255. with penn ission.)

the dlsea-,e progresses and ne urons degene rate. they develDp characteristic cyt Dp l ~m i c inclusion bodies. called Lewy bo(ite..,. Other ..,i te ~ of predilection include the dorsal motor nucleu s 01 the vag u ~. the hypothalamu s. the locu s ceru leus. the cerebr.il cortex. and the autonomic ganglia. II LDSS .of dDp~mine re:::.ults In an .overacti ve indirect pathway that is though to undcrlte akmc'Sia and rigidity. An underactive dlrel'! pathway i'l thought to be re~ pon')ible for bradykines ia.

Clinical Presentation Cardinal Features Rigidity Ri gidit y is one of the clini cal h allm arks of PD. Patients freque ntl y comp lain o f " heaviness" and "stiffness" of their limbs. Ri g idity is defmed as increased resistance to passive motion. It is fe lt uniformly in both agoni st and antagonist muscles and in moveme nts in both directions . Spinal stretch reflexes are normal . Rig idity is fairl y constant regardless of the task, amplitude, o r speed o f m oveme nt. Two types are identified : cogwheel or leadpi pe. Cogwheel rigidity is a jerky, ratche tlike res istance tD passive moveme nt as muscles alte rnately te nse and relax. Leadp ipe rigidity is more sustained resistance to passive moveme nt . wi th no fl ucruations. Ri g id ity is ofte n asy mmetrical. especially in the early stages of PD. It typicall y affects prox imal muscles first, especially the shoulders and neck. a nd it progresses to invDlve muscles of the face and ex trem it ies. Rigidity may initial ly affect the left o r righ t side , eve ntu all y spreading to involve the whole bod y. A s t he di sease progresses. rigidity becDmes more severe. Rigidi ty decreases the abi lity to mDve eas ily. For examp le. loss of bed mobiliry o r IDSS of reciprocaJ ann

FIgure 21 .3 TIle 5ub:..I31ltia nigra In PD. TIle upper layer . (1.011.1. \:omp..ic la ) of the su b~tan tla llH! ra 1ll1011.1IIv

has

man)

tlld:uun--

C(l~Hall1I1lg oe~m .... (0 the uans\~"t" sc.:thln through the Ulld· . br.lin \/i'ji). the sub:.tanltJ nig!1l ot J p.:lll~1U ~ Hh PD ~ho\\ ~ a fIl..lfl td

depl . . t1l'n 01 lllelamn-ctJIlI.uning Ill,.' r\ l' I.:ellll.. 1111 ~ pWdlH:es a c~· .k.'teH:..II ... Poillor ldeplglnentallOll t.:ll rnpMw \\, Ilh d l)onu :1I "(10[1'01 .

lnghll \Fmm Rov.l.mJ, LP ledl. 1\ 1cfrln ', T"\.tOcAII.. of Nt'urol,)g.\· eJ 8 COP) nghl LeJ & FdH~el. Plul:ttle lphi.l. 1\.)89, p 059. 't\1It! ~nnl:':" hJll .)

Chapte r 2 1 Pa rkinson's Di"ease

swing during gai l art' often rckllcd to the deg ree of lru nl..·nl rigidit y, Active move ment, mell t;'!1 concentration. or emotional stress ma) all if1cre,,~e rigidi ty. Prolonged rigidi ty results in decreased range of mot ion (RO M) and seri ous secondary compl ications of contracture and postural defonni ty. Riii!idity also has a di rect impact on increasing resting en~l1Z.Y e.xpenditure and fa ti gue levels.

Bradykinesia ParientS with PO demonstrate proble ms with voluntary mo\·cment. Ak.inesia refers to absence of move ment. Momenls of freez in g may occur and are characteri zed by a sudde.n break or hlock in movement. Aki nes ia represent s a defi it in the prepar~lIory phase of movement control
Tremor Tremor is the initial symptom of PD in about 70 percent of patients.' It is an involuntary oscillation of a body part occurring at a slow freq uency of 4 to 6 Hz. Parki nsonj an tremor is descnbed as a resting tremor. becau se it is typically present at rest and disappears wi th voluntary movement . This IS usually manife~t as a pill-rolling tremor of the hand. although resting tremors may also be seen in the foreann (pronation-supinat ion). jaw, o r to ng ue. Tremor 10 the lov-er limbs is most apparent whi le the patient IS suplOe . Tremor of the head and trunk , postural tremor. can be seen when muscles are used to mai ntain an upright po'!.ltion agalO~t gravi ty. Tremor tends 10 be less 5e\ere v. hen the pallcnt h relaxed and unocc upied; it is dlmml~hed b) \'olumar) effon, and di~a p pea r~ completely dunng bleep . It I'" aggravated by emotio nal stress or faugue . In the earl y ~Ulg:es . tremor i~ usua ll y unil ateral, quile mtld and oc c ur~ tor only ~h ort pe riods. w h erea~ in later stage~ trt~ mor can become ~evere . interfering wi th dall) 1UOl:llon . Fluctuations in frequency and i nte n ~ it y are common I"

857

i ll c rca,c~ postural instabi lity. Patients al.;;o expe rience increa"ing d ifficult y during dynamic de ~ l ab i l i z in g activ ities 'lic h a~ !-clf· initiatcd movement::. (e.g .. fu ncti onal reac h. w~llk i n g, tum ing) and pe rform poorl y under cond it ions of pe rturbed bala nce." The response 10 instabili ty is an abnormal p
Postural I""lability Patient.!, with PO demoll'Jtralc I1hnonn:llll l ~ of po~ t ure wld bala'lCe These l'hange clre rMe m the earl) ycar~ of PO fI.e ., the fir\l 5 )"e~ after dlligno~bl. A~ the dlsca..e prt)gre~& abnonnhi ,tnd IIlfle)"'lblt: po ..tural rc'pol1-.c, along \\ nh ul1.:.reit~d body ,way are 'loeen. Narro\\ mg of the ba ...e or MJJ)pQn (Landem "UtHee or IIlgk-hmb stance) or com pet~ '"# aHenuonal demand" (dl\' ldc::d all cnt ion :!IoI tulitlon 'lo)

Flgu(t:t 21 .4 l\l.'lolU re and PD. The bod)' po!>lure of a pIltr.enl \¥I lh PI) lA) Front \ iew. \8 ) Si~ \ lew. (from Rov.hmu, LP led) Merrill '~ TC'.\lbool (\f Neurology, etlS. COP),righl l cM&. h ::hl gl,.'l". PtlllaJ d plu3 IQg9. p 529, ~uh pt"mll ~ton.)

858

Physical Re habilitation

li on among pat ients is an increased sense of eff,.. " perce P h · ., db -. ·ated with movement t at IS m aml este y diffV...a... a SSOC I ---~1 acti vating and sustain ing responses. Most patients with PD are e lde rl y and show !be etfeaa of ge nera li zed mu sculoske le ta l deconditioning, eslltcially as the disease progresses. Conlraclllres commonly develop in hip and knee flexors, hip rotato rs and adducto", pbo. tarfl exo rs, dorsal spine and neck flexors, shoulder adductors and intern al rotators. and e lbow fle xors. FuoctioQ becomes progressivel y mo re limited b y these muscu. loskeletal constraint s. Kyphosis is the most common po&tural de fo rmity (see Fig. 2 1.4). Som e patients may develop .
PO experienci ng falls and 13 percent, fallin g more th an . a week 2~.23 The ratc of fall inj ury IS aOOu140 percent, DOle ~ . . I d ah hough most injury is not serious. ~i se~se seven ty me ,0 iog freezi ng. poor gait. and balance Im pamnent s are,c1earl y linked to increased ri sk for fa lls. Other ri~k faclors, mcl ude dementia. depression. postural hypotensIOn. and mvolu~ ­ tary movement s as~oc i ated with long-te ml use . ~f aollparkinsonian medicati on.!.! Fa lls, can I~~d to fear of fall ing" wi lh increasing levels, of Im~lOblht y and dependency wilh a deteriorating qualit y o f li fe . .

Torque producti on is decreased at all speeds 1 re~'J, ultJn.g 5 7 in functional limitations and muscle weakness.· - . It IS thOUi!ht to be caused by insufficient neural activati on of a1'!.onls t muscles. Electromyography (EMG) studies reveal th~t motor uni t recruitment is delayed and th at once inil i·

ated is characteri zed by asynchroni zation: that is, pauses and an inabil ity to smoothl y increase fi ring rale as co ntrac· tion COni inues.::S.19 These diffic ulties are compounded d ur· ing the production of complex movements. As the disease progresses. disuse weakness evolves, increas ing move ment difficulties. X1•31 Patients who are in an "off" stale . characterized by reduced leve ls of L·dopa medi cation and d im inished effectiveness. typicall y experience increased muscle weakness. especiall y in extensor muscles.25 1n patients with PD .forigue is among the most common symptoms re ported. The patient has diffi culty in sustaining activ ity and experi ences in creasing weakness and leth argy as the day progresses. Repetiti ve motor acts may start out strong but decrease in strength and amplitude as the aCli v· ity progresses. Movement s then become arrh ythmi c wi th frequent hes itations and arre sts. Fo r exam ple . the ti rst few words spoken may be lo ud and strong but diminish rapid ly as speec h progresses. Performance decreases dram alicall y with great physical effort or mental stre ss. Rest o r s leep may restore mobil ity. When L·dopa therapy is in iti ated , the patient may not ice a dramatic improvement ini tiall y and fee l ~ ignificaml y less fatigued. In long· standing d isease and drug therapy. fa ligue typica ll y reappears. A common

Motor Planning Motor planning defic its are present with this disease. Movement preparation (i.e .• the whe n. where , and how to initiate moveme nt) is signific antly p rolo nged (a finding also seen with advanced age). This s tart hesitation is especially ev ident as the di sease progresses. Movement times are also prolo nged but not to the same degree." Patients experience difficulty performi ng complex, sequenti al or simultaneous movem ents. These are linked to de fici ts in response programming. For exam ple, the p.atient is slow and hesitant or unable to initiate movement during a trans fer sequence. Overal l contro l is also impaired in roo· line actions representati ve o f ingra ined motor progr.uns. Fo r example, patients wi th PD typ icall y demonstrate m icr ograph ia. an abno rmally sm a ll hand writing that is dif· fic ult to read (Fig. 2 1.5). Freezin g episodes (mo lor bloc ks) occur and can be triggered by confro ntatio n of competing stimuli. For ex am ple . Ihe pat ient slows or sto ps walking when exposed to a narrowed space or an o bstacle. These episodes are linked (0 bradykines ia and dec reased c irc ul ating levels of

~ 'fa' ", 0. "'" :....~,~ ~. ~~

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III

PD. Pa I IC,'lh ""'lIh PI) lila ha\ c r

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.

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Chapte r 21 Parkinson', Disease litters (specificall y norepinephrine and sero~ rolransn . ' oe~ F czing episodes are typ ica ll y short- li ved and usuto flln ). :. overcome by attcnt ional strategies o r " behavIN~ d .... 8 " " k" usi ng ex tem al cues (e. g .. roppmg a tI ssue In! · rJI tn c S b f . 1~ . stepping response). Stress can exacer ale reez mg na~es ,\ In advanced PD. freezing episodes can severe ly es eP,sod . . 13 · if functlOn.hill . ts wi th PO demon strate poverty of movement. Pallen . _ · t.....~ d a!' an overa ll decrease In the total number and n dcsc . ",de of movements. Fo r examp le. pati.ent s W it. h mo d ,o,phlU . . d· · 'cvere PO prese nt w ith hy pomlmla. a re UCtlO11

ef.lIC or s

.

In

. ressive ness of the face. The pattent demonstrate s a {he elxP d fioa with infrt"qu ent blinking and dim ished an imam(lS e . . . · d expression. Sm d lll g may be poss ible o nl y o n p m ... . l'ommand or with vo h~l?n a l eft.o rt . A s tas k .comple~ HY · a<e"-.,. movement diffic ult y Increase s. T his prov ides mere" evidence of a ce ntral defi c it in mo tor plann ing;'4 Rotati on movement s are reduced. resultin g in movements that are basically un ip lanar (in o ne plane of mo tion). Constantl y combating the effec ts of brad ykine sia. rigid ity. and m ovement impoverishment can lead to me nta l fati g ue and loss

859

abnoml al stooped posture contributes to develo pment of a f estillating gait . characteri zed by a progressive increase in speed w ith a s hortening of stride. Thus, the patient takes m ultip le short ste ps to catch up wi th his or her center of mass (COM ) to avo id fa lling. and may eve ntually break into a ru n o r troL Gait can be alJt erop ulsiYe (a forward fes tin ating gait) or less com monl y retropuisive (a backwa rd fe stin ati ng gait), Some pati ents are able to stop only when th ey co me in co nt ac t w ith an o bject or a wall. Pat ie nt s who are toe-wa lke rs ow ing to plantarflexion co ntractu re s exhi bit an additi o nal postural instability fro m narrowing of th e ir base of suppo rt. Turning o r chang ing di rectio n is partic ul arl y difficult and typically accompli s hed by taking multiple small steps. Problems w ith controlling posture and balance limit independence, communit y ambul ati o n. and safet y.J9-41 Patients who are in the " off' state ex perience a deterioration in gait perfo rm ance whil e gait patterns are reproduc ible when peak m edication preva ils." M ost patients with gait deficits can compe nsate at lea st partiall y using external cues and attentio na l strategies. 40

of motivat ion.

Sensation Motor Learning Procedural learning defi cits are common in patients with PO while declarative. learning is usuall y intact. However proceduraJ deficits are not universal. Deficits in mo tor skill learning have been demonstrated fo r complex and sequenlIaI tasks but not for re latively simple movement tasks.35 •36 Thus the processin g requ iremen ts of the procedura l task are critical in dete nnining the degree of expected learning deficits. Learning is also impaired with random presenta tions of stimul us conditi ons (rando m practice o rder) w hil e blocked practi ce order reduces learning d ifficulty. T hu s COntext interference degrades learning in patients with PD." Defici ts can be expected to be seve re if mult ip le motor programs are req uired e ither sim ultaneously o r sequentially (i.e .. sw itc hing amo ng d ifferent motor program~ ). For examp le. the patient freezes up w hen asked to carry Out another motor task while wa lking (dual ta sking). Compounding variables that degrade learning include the ~\':~lty of disea~e , deme nt ia. and vis ual perc ept ua l dehe-Its. Dlfference:-. in learni ng can also be ex pected ba.sed Or, medicat ion levels. Mo tur learni ng is deg raded when PlUtnt-., are " 0 ff' " Slate medICa . tion . . \'"

Gait ~Pl'ro"nnel .e m s pre~ent w Hh flU iI Y 13. to 33 l>er{;clll o f.pali

~1.ufQJ IIhlablllty and ga lt di:--.turbuncc!oo a ~ thei r init ia l

ItI(A(n

'Y

. .

d mptom and compm.e a I>o.!. tura l i n~t a hllit y l'ui l ISturbed I PI(" r C ilion f .' J ») gruup. Gui t diM lI rhdm;c~ an..' also a com · "'llh p~(.Il urc. (It hH e-on!>cl Or ad\;HlCed PD . U T he puriem

I~ .. I . ) dClllflllstnll('''' a numl)(~1 of higlll rk ant galt l:hanges .-U

ling I

. . rum ll:llj>ovenshed mo\'e lH~nI t Bo ", 21,2 L An

Patients with PD do no t suffer from primary sensory loss. H owever, as many as 50 percent experience paresthesias and pa in, including sensations of numbness, tingling, coldness, aching pain, and burning. These symptoms are ty pica lly intermittent, and vary in intensity and location. The BG is thoug ht to participate in sensorimo to r integratio n , with primaril y inhibitory o utput directed toward the tha lamus and ne uro ns that project to c ortic al areas involved in somatosensory functio n . Some patients report their pa in is linked to the mo tor fluctuations ex perienced d uri ng L-do pa therapy (e.g .. pain is more intense in an " off' s tate). Pa in m ay also be increased in patients experie nci ng depression:&] In is al so im portant ro remember tha t some of the di scomfo rt and pain can result from postural stress syndrome secondary to lack of mo vement. m uscle rigid ity, fa ult y posture. or ligamento us strain. Fo r example, bac k pai n may occ ur as a result of a stooped, kyphot ic pos ture . Some patients experient"'C akathisia. a sense of an inner re stless ne ss and need to mov~ . T his motor restlessne ss a nd ag itatio n atfec ts as many as 25 percent o f patie nts, and is re lieved wi th mo veme nt (e.g .• walking o r mov ing the limbs w hile seated). It can inte rfere w ith relaxation and s lee p. Akathisia is associated with advanced PO and is more co mmon ly seen in the "off" stf:t;le IJICdiea... 1I0n ."-I

Propriocepti ve reguhuion o f voluntary .I11iMlQIeIlt!JUIy also be imp"ired . Palients with I'D perform !l.ianificaAl/lf worst.' than cumrol s u.bjccts on tesli of kiJtestbesiB. Without I' ls u. 1 guidance. patie nLS demonstr~te ill\>reased ditfIatIt)o in ilc.'·c lIrate ly pe rcetving Ih¢ rx leor of movematll, ~F1'" tcnlJ y underscuJing. their moveJrumt·,.4}-.47 . ",";;" "",' )'

860

.",,,,,kal Rdtabilitatinn

f Parkinson's Oi. _

.

Box 21.2 Cardinal

feature< and elin.i",,1 Manife.tatJons

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860

Physical Rehabilitation

Box 21.2 Cardinal Features an

,

d

cr .cal Manifestations 0

f Parkinson's Disease

Ul'

po!l."n

K hosis with forward head . YP . side wilh tona] asymmetnes Leantng to one Increased fall risk

Cardinal Features Rigidity Bradyki nesia Tremor postural instability

Sensation

Clinical Manifestations Molor Performance Decreased torque production

Parcslhes ias Pain Akathis ia

Speech, Voice, and S~aUowing Disorders

Fatigue ConlJ3ctures and defonnit)' common

Hypokinelic dysarthna Dysphagia

Molor Plllnn;ng Swn hesi tation Freezing episodes Poverty of movement Masked face Micrograph13

Cognition Function and Behavior Dementia Brad)'phrenia VisuospatiaJ deficits Depression Dysphoric mood

MOior uarning , Procedural learning defi ci ts for complex and sequenti al tasks Gail . bT Reduced suide length ; increased step· lo·slep van a 1 It)'

Reduced speed of walking . Cadence (steps per minute) t)'Plcally intact; may be reduced m 3(h'anced PD

Increased time: double limb support '-nsufficlent hip. knee, and ankle flexion: shuffling steps Insufficient heel strike with increased fo refooi loading Reduced U'U11k rotation: decreased or absent arm swing Festinating gait: anteropu lsion common

Autonomic Nervous Syslem Excessive s weating Abnonnal sensat ions of heat and cold

Seborrhea Sialo rrhea Cons tipation Urinary bladder dysfunction

Cardiopulmonary Function

Low reSling blood pressure (BP) Comprom ised cardiovascular response to exercise Impaired respiratory fun ction

FreezlOg of gall (FOG) Difficult) lurning : increased steps per rum Difficult) with dual laskiog: slmuhaneous motor and/or cogOl· tn·e ta~k..\ Difficulty 'A Im allcnt;onal deln.'tnd~ of complex environments

Comenuona l dru g~ (e.g .. anllcholinergic drugs ) used in PO <.:an <.:ause \,I~ ual d l ~ turh:.tnce, k..g,. blurred vl!)ion and photophobia). The ...e drug~ can a l... o wor~e n th e nor· mal \ ,..,uiil ch.lOge ... a~",o(.:lated y, uh aging (p resbyop ia), COIlJug.ale g01U' and ,an:adil e)e mo\cmen h may abo he ImpaIred E)t: pun.. un mo\'cmcnl\ may h.i\'e II jcri-. )" cog· "-heelmg 4lJallt) [)el;re J ~d bllll l.. mg c .. n produL:(, blood

..,hot. Im tated

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hum lind lu.:h-l l

Speech, Voice, a nd Swallowin g D}.'Jph"gia lI11pi.ured !ilv.J.llov...IOt!. 1-. pn.' ... ~m In 01' nl..lIl~ "I... 4~ pt"llelll 01 patH:rlt ... iind '\ tht rc,uh nl n ~udll) ft:duu:d rnohlht)'. and rC'lolru.lcd IC1lI ill JII \~i1gc Iud" ,du,,1 '" Ith PI) t:~peflt:IH':c pl l,bkm ... III ,\I! iDur phJ-.c=!
tion. de layed "'I \\allow re~pon'!"e. ;lnd periswlsis, Dysphagia ca n l e~Id to choking or a~piralion pneumonia and impaired

nutrition \\ ith siglllfic;.tnt \\ eight lo,!., ... . Nutritional inadequae) c.m contribute to the rOitigut! and e'\haus.rion t),picall) expe ricneed b> patJenh \\ tlh PO, Patient:-. al,o typic:lll~ expcrit: ncc e\(:e ....·~I\~ droolmg (\lt llorrhcaJ tb a resu lt ot il lc:n:awd ... i.lllvUJ) pr()(lut"(i~m and dc,,'re.tsed !oIponraneous w/uJlOWing Drnultng b pi.lfltcul.lrl) prul:llemalk \\-h!l~ , l c~PJllg ur IlItlhlllllg ... pt!~,,' h and in advanc~d c~s Imll"d'~~ thlt ri,~ ot .1:-.plrilllon . E\l't"'>' l\C dn)()hn~ h:b IInpOrtdm nt'g.ttl\"· '>u..:i.tll1npll\:~-Hll)n ... ·... I~ . "'pet'lh I,> nnp.llft'd III

75

10

MlJ

1)(, 1\'l'lII

01 ~1It' nt,!., und. IS

th~ n;- ... uh 01 pnIlldf) '~IlIPIOI11\ 01 PI) (flg ldll~ . brad)'llT~St:L

h Y rll"'tn~"'I .I ••lnll In.!Hlnr),..l P~tlll'nu. v. tlh PD C' \pen\!IlL'C Inrlf,J.. lIIt·fll dnanJuu,. y,hu.:h I~ ~hdr:tl t('rlLC:'d b) dl.'Cre;bC(1 \ OIU: \ ilium"". ttlOnOlnlle-/HlOIiOpillh ~pt.~l· h . impre~I ...-e LV lh"'lon...d ..trtlcul.ttlun, .tnd ul1t:oltlrulll'd ,)f1'"'e-dl n.lte, Vlle:tl

qUoAlrl) I ... dC~fad~d \\-lIh ... pc:' I.'i..h de!>l:nbed .I~ hu,\fSC· oll!~lIh) . ..and hilr-.h III .tddlliun. p.tllcnL" ~\pt: nen~\! tlIlliJ1g

C h apler 2 1 Pa rkin so n 's D isease

861

difficuJly of "ocaJ onsets a nd olfsels. Reduced mobi lit y.

present. Hypo mimia . a redu c ti on in fac ia l ex.press iveness,

slricled range of move ment. and uncolll ro lk:d ra te of

ca n give th e a ppea rance of d e p res s i o n .~/I,~ I Patient s ca n

rc vement of mU!'cies controll ing respirati on. phoTl ation. ~ . Ial1· sonalion. and at1 ICU OI1·IS present. Reduced v .ital c apac ~

also de mo nstra te a d)'slhymic disorder c haracte ri zed by variabilit y in dyspho ric mood . or 3 w id e range o f an xie ty di s ord e r ~. includ ing pani c di sorde r a nd phobias that occur at hi gher th an ex pected rates for an elde rly popul atio n. Social w ith drawa l (soc ia l phobi a) can res ult fro m the e m ba rrassme nt pati e nt s expe rie nce from PD sy mpt oms. Fin a ll y. g reate r an xiety is ex pe ri e nced w ith patie nts who a re in the "off" medi cation s t ate. ~2

~,

results in redu,'ed ai r expended d urin g phona ti on. In p~lIi eJ1l may !-peak in whispe rs or nol al all, dCOl on!'lratil1£ m u tism . Se nsory prob le m s m ay a lso contribu te to !iOpeec h difficullies . Pat ie nt s w ho a rc instruc ted

advanced cases. the

10 upscale their speech so und s to prod uce loud speech (:on-

.· ..tenth' describe their speec h a~ " too lo ud ," Speech di ffi~L . cullies contribute to :-:ocial isolati o n and impaired ac tivit),

. " p.111i ci pallon.

Autonomic Nervous System

Cogniti,'e Function and Be h avio r Jmpaim1ents in cognitive function call be mi ld (e.g .. mi ldly impaired memory ) or ~evcre . PO d e me ntia occurs in percent o f th e pati e nt s. O lde r approximatel y ~ O In patients appear to be at greatest ri sk for de me nt ia. w it h reponed IdteS ~A times higher for individuals 80 years of J£e ('If older.":u Dement ia i ~ associated with inc reased l11 or· t;lit: rates . Coexi~ lin g Al zheimer"s di sease or mult i· infa rc t dement ia secondary to atherosc le roti c d isease are a lso common in the elderly and may be contributory facto rs in some patient~ . Dememia 3ssociated with PO is c harac te r· ired b~ loss of c\ec uti ve fu nctions (planning. reasoni ng. abstract th inki ng . j udgment. and so fo rth ) and c ha nge s in \' isuospaual !'lk lll s. memory. and ve rba l fl ue ncy. Brad~ phrenia. a di~order o f intellectual fu nc tion . can be ~en in patiems \\ ith PD demen tia. It is characterized by a slo~ ing of thought and infonnation proc es~ ing . Patie nts typically demonstrate pro blems \\ ith se lective atten tion and in shifting ane ntio n. Cogni ti ve perfomlance is degraded in the "o1f ' ':!tate ...\'+-~( ' H alluci n 3 ti on ~ and de lus io ns are Common compl icatio ns 0\\ 109 to L-dopa toxicity. Deficits 10 \ I~uo,p~ ti a l ~ k i ll ~ are aha presenl in thi s db.· ease. Pallent:-- de-mOn .,tr3tC ~ i gni ticantly more error~ than norma l nn \ hual pe rcepti on ta:-.k\; involving spa tial organ· izauon. The' BG. 111 a... ~(){ latlUn With the fro mal lobe. appear 10 pb~ an 100f.>\Jrtant role in the Integration o f ~ en­ SOJ) mfOnni1l1on . Ddil..'lb h;n e ixe n reported III vc nic~tl perceplJ on. lOJXl~ri.Jphll onc nt:l.llon. bod ) ~c heme. and ~ pa ­ ual rtlO1uom . !vtOIOI ta.-,k':! lIl\ o h Ing ge~lu ral 11l0veme nh , dela)t:d dOlJble:: t.J.!)~~ , tratll1lg.. !.1no lum trul'lI cJnal abilit) ma~ be: irnp<.t!red .. Dcpre~~u.m I~ lurnmon 111 p;.ttjc-nt~ wnh PI) M ajor dePfC~!'lh..m II., n:porkd to Ol(.'ur III <.tpproX Hl1 01teJ) ~O pt: 1t<;m >.)1 paUellh _\I A ~lgOlijl..anl numht-r ,-, I p,-,tl e nt ') d~ \dup dcprt))"Iton pnC)f \IJ UJ Jl.I~t ...th:r IIn ..d 0 1 OIOWI ') mpHJII1\ . ~uggt: ., lJ ng W} clIdugt:o,)U't l .... U\C thai nm) tx rchtlcd 10 unJtrl)lnl!' Jelk ltil\,.ll:; \ tlf dUpalllll1t: ~t: r(lLOllIn.
..to

~3. ~ (J I t:lit'rg] poor l..(Jn\..~lHrallon. -IUl

hi-nee.,

m "PPCla e :tl1d .. 1C('p SUI{ ,d.l1 tlwughol lIla:y ltj..u be

A ut ono mi c nervous syste m dysfunction (d ysa uton omia ) occ urs w ith PD. T he nn oreg ul ato ry dysfun c ti on includes excessive swea ting a nd abnormal o r uncomfortable se nsa· tions o f warmth and coldness. Patients in the " o ff ' Slate ex pe ri e nce impaired pe riphera l vasod il a ti o n with diffic u lty di ss ipat in g body heat. Seborrhea ( inc reased o il secreti on of the seb aceous glands o f the skin ) a nd se borrhe ic dermat iti s (o il y, c hafin g. and redde ned skin) a re comm on. Patie nt s w ith PO ex hibit a bno nn a ll y slow pupill ary responses to li ght a nd pain and reduced overall respo nse to c ha nges in light. Gastro intestin a l d ysfuncti on incl ude s poor motility, changes in appetite . s ialorrhea, and weight loss. Constipation is a common proble m for most patie ntf) with PD. Urinary bladde r dysfunc tion occ urs with common symptoms of urinary frequency. urge ncy. urge incontine nce , and nocturia M any o f these prob le m s occ ur in the ag in g populati on in gene ra l a nd in me n w ith ben ign prosta tic hypertrophy. Sex ual dysfun c ti on is oft e n prese nt. including im pote nce and reduced ra tes of sex ua l ac ti vit y.-S)

C ardiopulmonary Function Orthostat ic hypote nsion is common . Pati e nts complaj n of Ii g ht· headedne:-.s and b lurred vision w ith pos ition c hanges (e.g .. sup ine·to-s it o r ~i H o· s t a nd) or fo ll owing exercise. Oral L·dopa medicati o n can e ,'(aggerate sympto ms of o rt.ho, tatic hypotension. Pal i e nt~ w ith advanced PD also ex hibit Im\ rt'\ ting blocxl pressure ( BP) .~I Card iovascu lar rdl c.\e~ can he comprom i.ficd, cau"iing abnorm al c,a ruiac re\pon'}c~ to e,crci~ . For e.\ ,unp ll.". tac hycardia in response to l'xerci!olc ma), be "Iuppres"Ied.~J ~ j Card iac a rrhythmias can occ ur and 41re ~",oc I'-' le d with must amj pa rkinson ian med ic.ttl o n. P:llicOl!lo "" ith PD demonMrate respiralory imp'l1imlenls. rClx med In a \ mall)' a., M4 perren! of p.H i~ nls. Airway oh~ lruC:llon Ic.g . <-lir tIflpplllg. lung in-. uftlu lion) is the mosl 1(t4uclll1y reported pli lmonaf) proble m and has ~n IIn~t;;d to e pl"Iode, 0 1 pul monary fail ure. The etiology n: mallh unlno-w(l but 111<1) ~ linked 10 brudykillt'tic w6Qr· gclnllall on of r~",plratur)' movem C'ntll. Re~(ricth'C: JunS dys-

, unuion

I)

common and I~ hnlC'.d

10

the decre~ c hest.

at lhI" tI'UI$ l1[u><:I<,. 10." or n1uM:ulo.
e"pan\I(In that l)(:('Uf':' lb a re~ult of 0 Mldu)'

862

Pbysical Rehabilitation

H oehn and Yahr Classification , 'th PO demonstrate lower forced vital posture Patients W I FEY) , . (FVe ) lower forced expiralOry volume ( I • capac tty · . es iSlance and higher residual volume (RV) and airway r .. (RAW) values whe n com pared t,o . ag~- matc hed control,s. Daily function and acti vity partJ Cl palJ on arc reduced m •

.56.57

alients with pulmonary dysfu ncti on.

. .

P A sedentJ.l), lifestyle with decrease~. a~ltvllY .1e~el s contribu tes 10 card iopulmonary deco~d lll on.mg. ~lmlted research su gge~ls th at pati ents w ith mild to ~lOderal e PD do nol appeal' to demonstra te s i gnifi can~l y di ffe rent exercise capacity (11la\;imaJ heart rale. maX im al oxygen C5~~~ , ) 'hen compared to age -matched controls. sumpllon "' . . d k However. these patie nts d id demonstrate decrease pea power. and higher subm:lx im al hea rt rates and oxygen con-

Minimal or absent; unilateral ~ present.

II

Minimal bilateral or midline involvement. Balance not impaired.

III

Impaired righting reflexes. Unsteadiness when turning or riSing from chair. Some activities are restricted , but patient can live independently and continue some forms of employment.

IV

All symptoms present and severe. Standing and walking possible only with assistance.

V

Confined to bed or wheelchair.

W 60

.. sumption rates th an con trols. . In long-standi ng di sease. the lower cx tremll1 es may exhibit c;culatory changes owin g 10 venous poolin g as a result of decreased mobility and prolonged s iltin g. Thus. patients can present with mi ld to moderate edema of the feet and ankJ es. which usually subs ides d uring sleep.

Medical Diagnosis Early diagnosis at onset of PD is d iffi cult wi th acc urate diag nosis possible onl y with continued observat ion o f evolvim! clinical signs and symptoms. There is no si ng le defm iti ve test or group of tests used to diagnose the di sease. The diagnosis is made on the basis of history and clinical exam ination. Handwriti ng samples. speec h analysis. inte rvie w questions that foc us on developing symptoms. and physical examination are used in the precli nical stage to detect early manifestations of the disease. A d iagnosb of PD can be made if at least two of the fo ur cardi nal fea tu res are present. Excl usion of Parkinson-plus syndromes is necessary. The presence o f extrapyramidal signs that are bilateral symmetri ca l and do not respond to L-dopa and dopamine agoni sts (apomorphi.ne test) is suggestive of these s) ndrome~. not PD.1t Imag ing can be used to rule o ut other patholog ies. In \ i\o fun ctional imaging (magnetic resonance imaging. MRI ) using chemical markers to idenufy dopam lllcrg ic defic ilS In PD and related di sorders identifies dopami ne deficiency but does not di sc riminate betv.een PD and other cau\C~ o f parkin soni sm. Pos itron eml~Slon tomograph) (PET) and Single-photon e mi ~s l on cQmpu ten7..ed tomography (S PECT) M:"ans are emergi ng technologJe~ (hal ha\e been used in hu man ,l udic') but not III rOUlme dlagno,)ls.

From Hoehn and Yahr,62 p 433. with permission.

to be at least 5 years " Before L-dopa therapy, 28 percent of patients became severely disabled (functionally dependent) or died within 5 years of diagnosi s. 61 percent within 10 years, and 83 percent w ithin 15 years. Following L-dopa therapy. only 9 percent had become disabled or had died at 5 years. 21 percent at 10 years. and 37.5 percent at 15 years. O ve rall the mean survival has increased by about 5 years since the introducti o n o f L-do pa .62 There is variability of the rate of progression. Patients who have a young age at o nset o r w ho are tre mor predo minant typically demons trate a more beni gn p rogress ion and a relati vely good prog nosis. Patients w ith PO who present wi th pos· tural instability and gait d isturbance s (the PfGO group) tend to have more pronounced deterioration wi th a more rapid disease p rogression. Neurobe havioral distur bances and deme nti a are also more com mon in th is group. Mortalit y is usua ll y due to cardiovasc ular disease or pneumonia. l61 An estimate of the stage and seve rity of the di sease can be made lIs ing a stag in g sC:ll e. The most widely used is the Hoe)/Il-Yah r ClassificatlOll of Disability Scali (Table 2 1.1 )" It provide> a u" fuf measure for charti ng the progre~s l oll of the d isease. Stage I I~ lIsed to indicate minimal d isease invo l\ e ment. \\ hereas .. tage V IS indicali\e of ~evere deteri orati on in '" hl c h the patie nt b confined to bed or a wheelc ha ir.

Medical Management Clinical Course 1lle dl~ast' I.... lOlA I}- progrcs~ l\ e. v, ith a long o.,ubdllutai penod I v,llhoUI appurcllI chntt,;ill llloJ.n l fe"l ts I IOlh), ~"I ll nulkd

T hae 1'\ no cure lor PD. Med ical Olanageme-nt I~ directed .11 ~ I~m ing o f d l ~t"a~~ progfe '\~ ioll . (Uld "yrnpIOIlHUi...:

trea tm en t of mutor fea lU rc s. motor compiJc al ions. and motur fCoJ.t ure,\. M o!\ t 'HlII - p:lr~ln ..,on l an mC'dj(.·3[iOOS

non

Chllpter '21 Parkinson's Oiseue beCame avai lable in the I 960s and have become tilt' maill -

stay of nmnagement. Ntllrit ional management is ;:,lso an inlpor1anl considenui oll. Some p;ui cnt s benefi t fro m surgi cal interventio n. \Vilh effl' ctive man ageml.! nl. the effects of the di~e" st· and complicat ion s can he min imi zed .

Pbannacological Management Drug manageme nt ca n be di vided into earl y nc uropro tective therapy and sym plOm ... ti c the rapy (sec T~, b l e 2 1.2).

Neuroprotecth"e Therapy Monoamint" Oxidase Inhibitors (MAOs ) Patient s in the earl~ s t ~lges of PD Ill:.!y be g ive n MAOs to improw metabo lism of inl r..h.,-c rC'bral dopamine le.g .. selegil ine ISD- Depreny lJ) . C lini ca lly. se legiline has bee n shown 10 dela) the primary e ndpoint at w hich patie nts need 10 start laking levodopa by abou t 9 month s and may slow the over..III progre ssion of the d isease . Seleg il ine also appears 10 h,l\'e a mil d sympt omatic benefit in early PD, impnw ing pt"Ifonnanct'- on mea!'ures of di sability and motor impainnem. O nce le\'odo pa the rapy is staI1ed , se leg iline in combination pen n its a lowe r dose to be used . The re are fev. ad\'erse effects: 3.fl increase in dy!'kinesias a nd o rthostatic h~-pote nsion may be seen when se leg il ine is combined \\ ith leHx.iopa th erapy.b.l-65

Symptomatic Therapy LeHldopa Levodopa lL-dopa) i~ the mainstay of sym ptomatit' treatment for PD. It was first introd uced in 196 1 as an experimental drug and ca me into widespread clin ical use by 1967, II is a metabolic precursor o f dopamine that is ab le to cross the hlood--brai n barrie r and r-J isc the leve l of striatal do pamlOe in tht! basa l gangliu: thu s. admi ni stration of the drug repre!!ooe nb ::111 attempt to correct the esse nti al ne urochemjcal imbalance. Most of L-d opa (almost 99 perce nt ) is metabolized before reachin g the brain . requ iri ng ad m inlstr:ttion of high dO"ies thaI can p roduce nume rous s ide eft'ect~, Today. l -dopa I~ commonly adlll i ni ~te red wi th car· hidopa. a decarboxyl~ inh Ib Itor th at allows a hi gher perceOlag~ of l -dopa to e nte r the eNS, Thu s, lower do :-.es o f L-dopa can be u~d with fc" C' r ati vc f !'>C' si de c tre{, l ~ . Smemet is the mO~1 <..'ommoll l'itrhidupa/L-do pa ITII.!c..iic.' a· lion. Its primary benefi t l ~ II I alkviatin g hrad)- .... i ne~i a and rigidity with le~~ eOerl o n tremo r, It doc ~ n OI apJ:",: ar to have a direct IInpact 011 po~tu ns.l In sulhihty. The 1Illiia i f uocltonal lInprmement I ~ o ften dral1l atll·. Tht :-. i ~ ...omctiTHe .. referred 10 a\ l he I! lIn t'\mO{)f1 / loPllIkJ , III w hICh Ihere 1!> cleaI~ut drug effen l\ene,:-.. Sine-rne! IS a\·... tI.Jblt.' in Immed la.te ·rch·a':o>C: OR ) lind C: un lru ll ed - re- Ica~e ( 'R ) forQlUlall un~. The IR fonn h a~ a ~hurt 11
TIlc re arc numerous adverse e ffects of l -dopa therapy. Adj u!oa j ng the dosage and admini ste ring the medication in combinati on wi th other d nl gs can manage most symptoms. T he 1110st COl11m on di sturbances are ( I ) gastrointestjnal (tlllorex iil. nau sea. vomitin g. constipation ), (2) cognitive (I,.' onfu sion and htlllucinarions). (3) cardiovascular (hypoten sion and arrhythmi as). (4) ge nit ourinary (dysuria). (5) neu romu scular (motor nuctu ation s and dyskinesias). and (6) s leep d isturba nces ( in somni a. s lee p fra gme ntation) .6J During the initi al dos in g , patie nts may fee l so much better th at they may e ngage in sudde n overactivity. seriously ovc nax in g the ir mu sc uloskeletal and/or cardiovascular system s. The the rapist needs to watch for this and to pace the palie nt accord ing ly. A dete ri orati o n o f the ove rall the rapeutic effectiveness of L-do pa can be ex pected over time with a reported increase motor complications o f 10 percent per year,6-t Fo r many patie nt s the the rapeutic window is 5 to 7 years before o ptimal benefit we·ars o ff. This is thought to result from a progress ive ni grostriatal degeneration, Thus. there is an ongoing debate of whethe r levodopa therapy should be initiated earl y or reserved for indi viduals who are in the late r stages o f Ihe di sease , Wearing-"off' state or end-of. dose deterioration is a worsen ing of symptoms during the expected time- fram e of medication effective ness, Freezing e pisodes. o r sudde n e pisodes of immobility. may appear. Rando m flu c tuation s in motor pe rformance. te rmed "on-ofT" phenomenon, occur in about 50 percent of patients treated for more than 2 yea rs and can be· very disabling , Invo luntary moveme nts. dyskinesias. often emerge in tande m with end-of-dose de te rioration. Initially these may appear as fac ial grimacing with twitching of the lips and to ngue protrusion, With lime the involuntary moveme nt s become more prevalent . vigorous. and more extens ive. invo lving the limbs, trunk , and neck. Patiems may also experie nce di sabling psychiatric tox icity (visual hallucinations, de lusio ns. a nd paranoia). drpress ion, anxiety, abnormal s leep palle-ms. early mo rning akinesia. and pain, These changes a re dose related and ind icate the need for drug mod itication, Depre nyl can be admini stered with L-dopa to control mild w~aring "oft''' phe nomena. Unsupervised reduction or sudden discontinuation of I.-dopa is con~ traindin lted and may produce dl.lngerous. life-threatening adve rse t· ffC\.' IS,b1,o.s J)opamilU! Agonists Dopam ine agollisb (DA) l.lC'C

:t

cl ass o f drugs designed to

a(." directl y un the posl ~y n llrt ic dopamine receptors. They

aft: admini ~l ~n:ct along wi lh l.-dopa, allow ing lower doses 10 hl" adlHi n i~lcrl!'d w ith prolonged etlt:ctiveness (i.e., L.. dora -~paring therapy ), p.uie nl s with 11l0000ra~ to advanced

PO wht) de nwnstl':uc declining w s ponl'C!S (0 L-dopa &he.... ~tP) nH'Y bene fit fr'Olll OA drugs su.ch w.; ~ (P..dodd), ropinirok (Requip), and pnltllipex,* (~). T he ~ reatc>l bene fit 0 1' the"" drugs ,is on RIdoIoiq !iaWII7 and braJy~ i llC,i", they COllI . 1", he used 10 reduI:tt . . .

864

Ph Yliica l Re habilihlCion

Adve rse clTce ls arc :-.i mi lar 10 those o f I.~do pa f1lI c tu :lII o n ~ .. be ' the wilh o rthoSWl ic l ig lllhcadedne~s an d nau sea "lI1 g .

most c0i11111on.M.,.7 Anlichnlin ergic Age nt..

Anticho linerg ic agcnl 1> :lrc u~C'd in ea rl y. untrea ted PD .or as an adjunct for p:llicnb on Icvodopi.1. They bloc k cho l,lOcrg ic fl;nc lioll :lnd have Ihe . most bene fit mod~ raI 1l1.~ tremor an d rig idi ty: they h;wc hllh~ o r no effect ,o n b~ad y kl m:sia. ~lIld postu ra l i ns l ~l b ili ly. They Ill"), be given HI ,COI1 juncl inll \\ ilh l. -tlO p:1 10 smooth . 111010r f1u ~ l lI a fl o n s. Trihcxyphcllidyl (Arlanc), bc n7trop1l1 e (Coge nlJJ1): c lhopropali nc (I'ar:-;dol), and procyc l idine ( KCI~la dn.n ) a~c COllllllo nt) prc:-;cri bed dru gs in Ihi ~ group . An ti c h olH1~ rg l.c

ad\ cr.;,c effec ts include blu rred vision. dry mouth. d I ZZ I · ne~:-. con~ ( ip::ui on. and urinary retcnt ion. Ce ntral toxic it y is indicated b) impaired 1llt:lll ory. confu sion. ha ll uc inat ions. and dc1l1:-ion. . .t>~ AlI1an tadine (SYll1l11et re1) is an ant ivira l agc nt that h ilS ~1I111 . Parkill!-on effec ts. It po te nt iates t he tlc ti o n of dopaminL' in the eNS. P~l l ie n{ s tak ing aman tadi ne dcmon~lrate modest im prove me nt in Irc mo r. rigid it y. and brad) J..1I1t' :.. i ~l.

Implications for the Physical Therapist The th('r;]pi ~ 1 need:.. 10 be full y aware of e ach of the med·

ication . . the patie nt i... taJ.. ing and potential ad ve rse e ffects. II i ~ Important \0 remembe r th at patient s o n lcvodopa therapy

Dopamine replacement

Levodapalcarbidopa

10/100 25/100 25/2 50 25/100 25/200

Pergolide

Amantadine

,?~ , .",AQ

A high-protein diel can block the effectiveness of L-dopa. T he di etary am ino ac ids in pro tein compete wi th L·dopa absorption. T his is parti cularl y problematic in patients w ith chronic di sease who ex hibit fl uctuat io ns in motor per. farmance. T hus patients are generally advised to follow a high-calorie, law-pral ein diet. Generally no more than 15 percent of calori es should come from prolein. Dielary recommendati ons may also include shifting the intake of dail y prote in to the evening mea l w hen patients are less

2 mg tid 1 mg bid

Bromocnptine

MAOI·B'

Nutritional Management

Trihe xyphenidyl Be nt rop in

Smeme t Sine mel CR Dopamme agonlsts

fluctu ati o ns re lated to medi cation cycle . may de m Ollstrate . Opl imal performance can be expected al peak dosage whereas worsenin g perfo nn ance IS assoc iated With end--of~ dose cycle and medicati o n dep l~ t ion . Therapi sts are invo lved i n monit ori ng drug e ffectiveness on motor ~r~ ro mlancc. function. and activity pan ic ipatj on. As the dis. ease progresses. patie nt s ma y deve lop a tolerance for a par. ticular med icati on. necessitatin g a change in prescription. Often. it is the th erapist who first notices a change in func. tio na l statu s as the patient 's syste m ada pts to either the ~lmou nt o r type of d ru g pre scr ibed . Accurate obse rvation, exmn ina tion. and reporting of these changes greatl y assists the ph ysician in modifyin g a d ru g prescripti on. Therapists may al so be invo lved with c linical dru g tri als as new medications or co mbinati o ns are developed . Table 2 1.2 pres. ents an overview of the pharmacology of PD.

tidlqid tidlqid tid tid bid

1 mg lid

5 mg bid

100 mg bid

Dry mouth. dizziness, blurred vision Tachycardia, dry mouth, nausea, vom iting, confusion Dystonia Abnormal , involuntary movements Nausea, vomiting Confusion

Drea ms, ha llUCinations

- -- -

Nervousness, dyskinesias , insomnia, hallucinations. nausea, confusion, erythromelalgia Nausea, headache , dizzi ness, fatigue, cra mps/constipation, confUSion. pulmonary/peri toneal fi brosis Llghtheadedness. livedo retlcularis.

edema Sehglhne

IWlce a ddy lid three limes a day Qld T I·B monoamine o )(l(ja!>e mhlbltof, Iype B From CUlson. 1 01 al f, p 367, WIll) permissIon

5 mg bid I our limes a day

Nausea, dreams, ha ll UCIna tions , confUSIon, dysktneslas

-------

<:ha pt cr 2 1 Parkinson 's D iseAse active. These mod ilic at io ns Ill in im ilc motor lllKlUati on s and m3,X im izl' respo ns ive ness to L~ d op a the r.tpy. Th e patient i ~ CIl(o urOlged to eat" varie ty o f foods and ma y be advised to take d icla ry s u ppkme nt ~ to ensure adeq uate intake of vi ta mins :lIld m ine r:d s. Pati e nt s a re a lso adv ised 10 i ncre~ts(' their dai ly in take of w;.lI er and di e tary fibe r to alleviate proble m!> of con ~ tira t ion .6s Rigidi ty rind bradykinc:-. i:l can limil uprighl pos lUre allli upper extremi ty (LIE) fceding movements. Lea rn ed motor pl ans. for f'X ,lin pk'. lI sinp. n c up or ea ting utensils. Ill ay a lso be difficult. Occupationa l therapy illlervcntion 10 im prove feeding and rec01lll11cnd cJ adaptive e at ing dev ices is of considerable importance in hl..· lping 10 ma int a in nu trit-ion and ~ent'ral health statu s. T he speec h- lang ua ge patho l o~ ~ist ;lso has an imrortJIlI ro le in the eva lu ati on of dyspha~ia and the recommendatIon of strateg ies to ass ist wi th ;wallowing dy~fu ll ct I0n . Pa(it~n t . fami ly and careg iver ed ucalion sh0uld foc u ~ 0 11 the impa rlance of mai ntai n ing good nutriti onal intakl.'! .

Surgical Management Surge r) 1:- an accepted treatme nt fo r pa ti e nts w ith ad\'anced PD \\ ho respond poorl y to medication or who experience com plications rela ted to p ha rm acoth e rapy. There are three ma in surg ical approac hes: a bla tive surgery, deep brai n :-.timulation (DB5 ). a nd neural transpla nt ati on .

Ablative Surgery Stereota cti c surge r., . the surg ica l lesioning of the brai n , Y.'a~ pi oneered in the 1950s. and is in c urre nt re newed use owing: to the

in c rea~e d

accuracy of imag ing and surgical

equipment .(>~ Pallidotom~r involves prod uci ng a destruc-

tive l e~ion in the ~en~orimotor portion of the g lo bu s pa llid us intemu ~ (G PiJ. The l e~ ion reduces exces"iive G Pi mh ibi tor) .lCll\ it) that result , in tonic thalamic hypoactivit}. It is indicated lor L-dopa- ind uced dys kine sias. seve re "on--off' . . t:.itt' nuclUa t ioll ~. np.ldlly. and tremor w hil e bal ance. !,!ait di ~lU rbanct: ~. freezing. and hypophonia a re less responsI ve. Effech ;'tr~ con tra late ral and bcnefit~ a ppear to be long I:hting.· /I T h a la m oto m.\ IIlVo lve:-. prod u(: ing ;J destruct 1, l' l e~ ioll \~ lthl ll t h~ \ Cll1ral interrn ed iiit e nu c l eu ~ (V IM ) (If the th.d~tIlllh II h.,.-. he..:n ... hulA n to dlcdivc ly reducl~ IOIl g.~ti.l lldI11 ~ IremU l Ih at 1'\ unr..: :-. pon"i vl,;' to drug treatment and lIl:.ly oft er ~ome- ImproVl.'llll:.!IH of ri gi dit y. It i~ not effl:.!clivc on ~y rnrl ()l n ... 0 1 br;ld)kine ~I '-1 or ga lt d i ~­ ltifb~_me~ r:H Bli'-ikra \ ,:,> urgKal Ie !> ion :-. ar!;: u:-. u'lll y 11 01 rl'~ ­ VUlmt'nded bcca u ...e III .t hIgh IiI Lc' 0 1 1ll0tOl cOin pl u.:a tHHh. e'peclall) ~pccch ,md " \ aJlo\l.1I1g dillic ultlc :-:,. Rc porkd itdver,c l:tre(" I ~ o j \ Uf gl.'f) Illc ludt' hCI 'lurrha gc. Infi:tl~ l l {)ll . lnfettl(lll . '-t"i /ure ... ".'ontu "' Hlil . dtprc' ~h)l\ . J ) ... .urt hll ~l . or dealh .!'~

O""p Brain Slimulation

Dec

",.tllI

865

s ignab th a I c a u ~c sy mpt oms. Sti mul a tio n o f the VIM of th e th a l.. mu s is co mm o nl y done w ith severe .lIld uncontroll ed UE t remo rs tha t are unrespons ive to me d icati o n . A pace ma ke r is im plant ed in thc c hest. w ith a thin wire Ih al goes unde r the ski n to the bra in e lec trodes. Hi ghfre qu e ncy stimulati o n is prov ided . The pa tie nt can c on lro l the pace maker 's "oll -ofr ' sw itc h w hil e the ph ys ici an de termi nes the a mo unt o f stimul ation it de livers. ta il o ring it to the indi v idu a l' s need s. To ta l suppress io n of trc mor is obse rved in one- third to on e -ha lf o f patient s.?1 T ha lamic stimul ati o n is no t indi c ate d for othe r PO ~y m p t o m s. It s major ad vantage is it s po tenti a l to a lter tre m or wi th o ut produ c ing an irreve rsibl e bra in les ion . DO S has al so bee n shown to signifi c antly improve pa ti e nt pe rfo rman c e on in strume nta l ac tiv itie s of dail y liv in g ( IA DL). w ith the g reates t improve me nt noted whe n co ntro l is for tre mor in th e do m inant hand .n More rece ntl y DBS o f the g lo bus pallidus (GPi ) and Ihe subth a la m ic nucl e us (ST N) has bee n used to success full y co nt rol othe r PD sy mptom s o f m otor overactiv ity (i.e .. o il -sta te d ys kin es ias. a kine si a. ri g idit y) a lo ng w ith tre mo r.B.]'; STN s imulati o n has bee n show n to redu ce the med ica tio n re quire me nts in PD .i5

Neural Transplantation T ransplant ati o n of ce ll s capabl e o f s urviv ing and de liv e rin g d o pamine into the striatum o f p a tient s with a dvance d PO is an e xperimental tre atment and c urrently und e r investi gati o n . Studies involve the grafting of e mbryoni c ste m c ells from umbili c al cord bl ood or fe tal ce ll s. Ethi ca l cons iderations are posed with the use o f hum a n e mbryon ic ti ssue . Sustaine d c linical improve me nt s ha ve bee n o bserved in some patie nt s and not in oth e rs. Variabilit y in te rm s of effic acy an d o utco me may be due to ce ll the rapy techniq ues. Yo unge r pa tie nts in the ea rl y stages o f the di sease appea r to show some i mprov e ~ me n! in mo to r fun c ti on . Ad ve rse s ide e ffec ts suc h a s se ri o us dys kines ias in mo rc tha n 50 pe rcent of pati e nts have bee n repo rt e d . 70 Pa ti e nt s usua ll y unde rgo immuno~ upp r~ssio n fo ll O\vi ng su rge ry 10 re duce the ri sks o f g raft rejec tion . C urre ntl y und er in ves ti g ation a re tec hniques to expa nd l 'CI! produ c t io n and use ge ne ti c all y e ngine ered ce ll s .l1 Availabi lity of t ra nsp la nta tio n proccd ures is ve ry lim ikd.

Framework for Rehabilitation I{ e h:lbiltlatiun h3!) an im porran t ro le in redudng fune 110lla l lim ilat lons whilt' prulll uting ac tivit), participation and Inlkpl.!l1~ t ('m.· e . In addj tion. known (" ornplkations of PD ,:all ~ red u('ed or preventt'il w hile quulity of life is prumvtl'tL Optima l maJlag~lIle nt In.\ ol\'es. a coordina~ IOI('rdiM: iplillary h.~am 10 oversee a comprehensive plan of l".lre (" <111 uddre1'l'\ the p.l1iclU 'l) individua1 clinical ~

866

Pbysical Rehabilitation

roncC'm~. j nd nced ~ . The leam lypic~llIy inc ludes thl' phY!'ic HIIl. nur~e . phy~ic:l 1 therapist. oc(' u p~tiona llherapl 'j.I , ~pef'l'h - Iang u:.tgt' pal h(l lo~i S:l . and <;,ocia l \Vor~cr. Referr;.) I to (lthC'1" sper iali i ; ls may al s:o be nccc:,sary. for c:\ample . p!'ychologi(' l. nUlrifiolli~t. ga'troentero l og i~ t . uro l o~ i ~l . PU ltll0llologi:-1. and so rort h. A ~ \\ ith any t~:lI11. the. pafl l'nt i:. till' ('(,!ltral fi gure " ilh ramil ) :md l' ar('gl \"er~ hClII g key 111('111 be r~ .

TIll' Ilk :'1 1 re ha hiilt:.I1i o n pfllgralll eon:.idc r.-. the palil'nt':, dr " l':I,e hi sh""!rv. cour.-.c and s ymrlom ~ , togethe r wi th i mpai 1111l'n1 ~. (:lIlcti cHla l IJI11 i l :Hi cl!l~ . and di '\abil it y. or equal il11 porwnce :lrl' Iht' pali cl1t '<.; ahlJiti c (' ( ::t:. ~et" L prinri lics. ,md rc,ourc(' '' Includin g family. home. :tnd comm unit y n.'''ource'' . DctcriNat inn ( 'If condition ~tnd mcdicmion inJ ul'ed ll Ull uatlOn, in pc rfOrll1an Cl~ should he expec ted . Tht' (\H~r;'11I ('Jell' I>' on I \)n g- r~mge p l:lnning. wi lh anti c ipaled cpl,oJe , 01 f :lrC includll1 g ho~ pital ~ ba"cd. nutpu lI en1. :tnd home/C"(\m11luni r~-ba "l' d c arc . A ('on l inuum o f ...·are h:l~('d o n ,h"'ca , c ' l:I gc (c arl ) . middl e. laic ) is an d tf"l:lI\ c \\ .i~ I ( l l""!rf! ani7c \,." are and is prc:;cnlcd in Table 2 1..~ ll1 h.~ f\('n l ion .. :trc r(" t 0r~l ti\ e (aim ed at improving Ilnl';ll nncm,. fun ctIOna l Ilnl it atio n.... and di sabilitic:--). prl'\ Cm.HI\C? 1.1IIned :tt 1I111llmi7i ng plltent i:ll cO lllpli\..'atum .. ~ n d ' ndll ~c t lmp:lIrm e nt .. La nd co mpc n, alory l ;mnt'd.11 i11olh l ~ IIlp Ihl.' 1.l ... l . aCl i\' It ~. or environm ent 10 Imrr''' l' fU Il l' lltlll I. "t't' dl'L~ U,,,i~)Il in Ch ~ pl e l I. It is: crit h,::;t! h" tilt' V. hok 1l' 31ll to pflWH.k :t ~ upponi \-c ~ n\ iro n-

tnCO! 1\ \ ;1"1,,1 P:ll ll· nt, :md th e ir b lll ily nll' mht'r{" in the

diffi cult adj ustm en t 10 living with a chron ic and progrel_ sive d i se~l.sc .

Physical Therapy Examination and Evaluation A compre hensive examinat ion is required to determine the IC'vel of im paimlcnt s a nd degree o f fu nction. Subsequent reexami nation at ~ peC" ifi ed interva ls is used to distinguish change in st<:ltus as we ll as effects of treatment. Data are obtained from the pat ienl 's his tory, sy ·tems rev iew, and relevant tc sts and measures (Box 2 1.3). The se lection of e xa mination procedures and leve l of i nquiry is detennined by the pa ti enl 's un iq ue sta tus . The <;eve rity of problems. "age of di sca~c . age. phase and sett ing of rehabi.lilarion. and ot her facto rs must all be taken into account in structuring the examinati on and evaluating data. During the carly and midd le "tage') of P D . measure s of impai rment and ph) si cal pl:rtorm ance are relali\"ely stable.78 During late ~ Iages of the di se a~c and under condition ... of fl uctualing "ymptoms wi lh pharmacological in!o.ta biljt), measures c an be e~pe'"tcd to be le s~ stable. Thi:, section prescnl s strategic ... for exam inaljon as well <.l'" relcv,lIl t t c "' ~ and I1ll~aSu re s . A com pie II.' dC!scription of Illany of thl' lest, and meas ures idenulied are provided in l!arli.:r l 'hap' er" focllsin g on eX3min;u lon .

Table 21.3 O,'e nic w of Parkinson's Disease M:a .nagen.c.lI

Edr1y mlddlf:

FUlly h... nCHonal May ha-.-e Unilateral Hemor ngldlty

A nllcholmerg1cs (tremor) Sehgl iine (poSSible naura Pf o tectlOn )

Preventative exerCise prog ram

S ) nlp1oms ntla lOlal bl a dy

l e vodopa ca roldopa

y I n e~t(j Ilgldlty

Sellglhne

Corrective e).e fClse prograrn

EducatlOl1 _ __

M Ild speeCI ' nnpd fffllen!

0 16 ,"Iadl",

A I ~yp1 pt orn~ w(Jrse bul Il\O£: i~eIVj(;nl

,I t AOl ~

Le \'VdolJct l::-d1tJ tOOpa OO ~ri" lI !lt' dy on, sts

COll) p~ nsa lOrv

dod

Cu! IOCI!Vb e '( erCISt3.

(lIleCIiCa lions ,

!

mobllny)

I

Scltv rl;np

~h -Ia.ng uage th~ ( apy

A'lI l..1eJ)1to t:>.t:>d n b

(A:(.. I..P.:i tJOfld ! rherapy

~C "''''I t!'ly UI ~ ~ l,.'(l IInpcil180j

l C-.'o IJd l.:" tlIO<...Pd

lJ t '~bItOdli ..... llr, ,AlA.

COfl\pcl\~ a( O f) c '-\erL:l:>

()efnel1l1a

Dv~k.Hl hr Ie d U ~ " ~l~

O'~l ri fy ~oncef""

Depr.'""",

S k it I Cdfe

P lll!Hvnary IUr'lC tJ\Jl } ,'!.{

-- - II

Bd li"I(Aj rllvt) it.; l ' .S

H'I 9;elle' '1,.

IJo1 0.... " I' ''' ~IJ ~ "I~

r

.j!U t. H ,(..~' . ..;..:.." V/

i

Cd1eglver Issues

M dt n~ed ml,)O: dSS1~td l .('c

AnthJ \;:'I~r US:>4 11 H:

". I

Support group

depreSSion

sttn net:> t:>

Gatl IfOpalfrnenb b6Q!(\

I

I

Counseling M onItor fOf

A, .al rlgld r1)" S!ooped po!:> hm::~

lnf~rmatJ_o_n _ _ li

_II

M orll /Of" for dementia _

Chapte r 21 Parkinson's Di8eue

867

BoX 21.3 Element-Ii> of .he Exa mination for a Pade n. with Parkinson's Di sease 7'J

...tienllelient History • A$,e. sc~ , race/clhni city. primary Ia.nguage. education • Social hislOry: culluml beli efs :tnd bch:lViors , family and c:tresi\'cr resources . social support systems

• £X:cupation/employmenl/wQrk • Livin~ environment: homel wo rk bani c11i

• Hand dominance • Qc-neral health status: phys ical. psyc hological. soc ial. and role functi on. hcal1h habit s

• Famil y history • Mcdi~8VSllrgi(':d hi story • Current conditions/chief ("omplainls

• Medications • MedicaJJ1aboratory lest result:. • Funcliornt' ~ Ialus anti aclivity leve l: premorbid and current

Systems Review • Neuromuscular • Musculoskeletal

• Cardiovascular/pu lm
length: edema • Circulation: ~ ponse to position change. orthostatic

hypotens.ion

• Aerobic capaci ty and endunUlc~ ; during functional attiviliet and !;Iandardized exercise protocols including cardiovascular and pulmonary signs and symptoms • Vcmilation and gas ex.change • lntegumcillary integrity: sk in condition, pressure sensitive areas: activities. po!;itioning. and postures to relieve pressure • Autonomic nervous system integri ty: lhenna! responses, swenting • Sensory integrity :md integration

• Pain: intensit y and locution • Perceptua l function: visuospatjal skills • Joint integrilY, alignment. and mobi lity: range of motion (active :U1d JXlssive); mu scle length. and soft tissue extensibility • Posture: ali gnment and poSition. symmetry (stalic and dynamic): ergonomics, and body mechanics • Muscle perfonnance: strength, power. and endurance • Motor funcLion: motor control and molor learning: lone! volulltary move ment patterns ; involuntary movements; hesitation, slowness, ~\fTests of movements: poverty of movement!j. • Procedural teaming for complex. and sequential tasks • Postural control and balance: degree of postural instability. balance str3tegies: safety • Gait and locomotion: gail pattern and speed, safety • Functiooal ...tus and activity level: performance·bas
Cognitive Function

Sensation

M emor~ .

A screeni ng examination of se nsat ion b; indicat('d (superfic ial anti dt:l'p se nsat ions. combined cort ical sensations), Se ll sory c hanges call be ex pec ted with aging (blunt ing of

t)n enta llQIl, l'onc\~ p lU a l rl· ao;onin g.. prohlem solvin g, and luJ ~Il1 t' n1 "ll oul d he l·xu minnl. Spel'd of infomlaliun l)rnl'l'''.. lI1 g, all (: ntiUJl, and l'OflfCnlral ioll an: pankularl y nn r n n i.llu 1\ 1 J~ I l' nninl" 11 bradyphn:nia is 1\ u ~ pel: teJ , A bl iel 'I,.' rn'n 01 ( ognlli\'l ' fU!lt' IItUll't11l he oblaint!d lI:\ing thl' M lm -M I' fll u/ .1)/(11/1 \ I , Will I MAtS/: ) :VI

Psychosocial Function Thl" Ihcntpl loJ l .. hould dc- lt'l'Il1illl: lI vl'la ll k\,l' ls of 1\lrn ," and ~tll' I ~ l y, :tli l l o,I\ ullahll' ('Oplll J:! ... tJ';Jl q .! Il' !'I . II 11\ lIupor hUll In u ... l till' Iwtl c ll t ahout the P I I' '''I:'Ill' C uf lkpn: ,,;t, lvc ~)'m phlll1 '" , ulo h .. " ... ad I h' '''''' . apUlII~ . p ..... .. lvll y . III:-'UllI II i:.l , CU1tll C).II.I, IAt:ll} hl 10 ..... . lOal.:lI\'lI) JIIJ d Cp<:'lllh,: n~ y , II whil II} h i CVIll,c l)llatl' .lflU 1IIIPUII Cti 1111'n1ory, or ... uil,.' lda l id":"llnn . l hr lul II1 ... ltlllll~· lIb II H: IIIJl' th e C) " notl'lt /) t'IJI(',\MII II S' I / /{,I'I

1)1

Iht' LJj '/

t

1)1' 11I(' \ .\I 1J1I 11II'1'1/I/JI )'Ii "

rhl" p.III .. "1 ' .. p n.~l\\ol'bld 11I1 ~ h:l'I l ~, UIHlil k s, li nd dull ) nr(il'r IV Ira ll ~ l a k the m Il'Ilo u II C'I1 I11~ 1I1 I)ft)glaltl th:.ll wi ll ~' lI g"ge thc palll:'lIt's full COtll,<,rallon ,

IKII Vlll e, bhlllJld lx ' 1I1\'t' ... lI bl.llt·d II I

touc h se ns<.t tions and proprioception with !!reawr ioss~s in lower l'xtl'e miti es than upper. and dis ('li more than proxil1\j l). The patient s ho uld be as ked about the presc ncL' \)1' pal'\' stht.·~i ~s ~sensntinns ~If numbnes.", or tingling), Spl'cilk areas of st.!nsory loss may ~ indicative of comorbid pal ht)l o~y, 1\)1' e xampk', sirokt:'. diatlt: tit.: neuropathy, uno so forth . An 1!\1tIllinalion uf \'i~i( Hl shnuld inc lude u detennina lion \ ) 1' lh:UII) . pt'I'iphaal vision, tmd.. ing , U{·c"llImodalioll. light IIntl dur~ tld~lplati lm, tlnd lkplh pt'l\'cption, VisuaJ dl;tllgt.:~ ('.111 lx' c \I'I\.'dcd wi th aging such as loss of visual lll' uit y. ill:lhilil )' t\) tt)(.'us loUI Ilrilllct.i wont (presbYOI)la). dC('fl:uscd adupl :Hioll 10 lighl. ~(fll~i t iv ity wlighf and Klo.n\ ItIlJ l o~.., of ro lor di :-tlTimimuiun. Jltuients with PI) may CXI>CIWlIl '(' hturrillg 'Jf visioll ~U\d dink-uh), l'eading thot is 110t ililpro\ e d hy "lII1XK'lhlc I~IISCS us well ~s problem with <"yc pur:-ouit ll'ug \\oh('eiing). Spccitit.' ddidts may be i.ndicative ,)1' l't,nnnrhiJ pulbl)I,)gies U181 ~ l.-omll1Oll in the

868

Pbysical Rehabilitation

'uscle e ndurance and has been suggested for

to docul11ent n • . tin l"J tfe mor, using slow speeds of movement liS d oc ume n co

. . I Idin e of central vision first. eld\!r1 y. :o:uch as ('al .m:IC I ~ tc ot , f cri hera l . h ~ . 1) c hucoma (ea rl y loss 0 P P ~~~;~nr~:~li~:':l1;~Cl:I ~r degcne r::lIion or diabc~ic rc.til1,OP~~ . _\ ' \ . . s 1)1' cen tra l visio n). and ce rebrovasc ul ar acc i th~ (ca l ) o~ · l . ' ) Mr . ( on... may al ~o de lll thomonYl11 ous henll annpslU . ec lea I " .d ~ '_ produce impaired ?f fu zzy vi~i('ln. fo r exa mple. ,\1111 c pres

(25 111m/s) and low torques,

Motor Function Rigidity

.

.

. "th PO and :m: otte n poorl y locali zed . It IS palient:- \\ I I (pai n . t to ~ x :lnli n(" for pO~lUral ~tresS s)'m rome Imr0rtan I: 'I e link\!d In lack of 1110\ emc nl. faully m ovemen ts ~ r ~os U f .• . " ) Fr"'q ucn l pain or exc ruclatm g pam and It~;,U1 1~nwu ~ ~ lr.l1n . I: , ' , 'ire n\~l common but llla~ abo occur, Use- luI Insl run~e nt s ;nclud~ TIl("' .HcGdl Palll QHCsli01/l1aire~l, and the l'lsua/

Ri gidit y is usuaJl y equ al m both agon lSl, and amagonist muscle gro upS. It can be s usta med ( le ad pi pe) o r mtermit· te nt (cogwheel). Di stribu tio n o f n gldtty tS often asymmet· ric es pec iall y in th e earl y s tages 01 the d ISease and can vary d urin g the course of the day and w ith stress, It tS therefore im porl ant 1.0 determine w hich body se gments are affected .lIlei th e severit y of involvement. To ne changes In the neck. and sho ul de rs are suggest ive o f earl y d isease. whereas tone changes in the lrunk and eX lre miti es are typically present

{l/I.J /I).f!/u' scale ( \'I\.S I,

wi th more extens ive d isease. Defic its in functional mobil·

...:mlS and anticholinerg.ll'S.

.

.

.

. d'

.\ 11 examinnlioll of the presence of pam IS III lea

.... d t:: , •

~t i;d aching and crampJikc ~cnsa{ i on s are ,c~m I110n I.n

Musculoskeletal Function Flexibility An e \am i n:~li on of ll1u,culos kelelal ROM and flex ibi lity is Imponant. The ther3pi~t can document specific R
ilPllin 10 rotate. Oe\ , . md extend the ~pi ne) because pJllen;" \.\ ith PO ha\ e been . . ho\\·n to e\hihil impairments III thl . . .trea"- .<\ 11 ~gmenh of the :-opine ~h Ollld ~ exammed, ml.'ludUlg Ct'T\ 11..<11. thoraCIC and lumbar ~cgments. Tht' mvhllJ1~ l,r the .,pme- .., hould be l" x ;lmln~d durin g ~1 ~nt> 01 t Urlt.llllnal m()\ I,,· mcnt . . . . . ud) a ~ ;.l\ia l rotation ll.\t )k.ml:- I:xhlll,i) Jnd \l,J I"'lng H.Jm..,trtng Itnglh can he dt:h:rn1tnt' d u .. lIlt! " .... trJlgh l I ~~ \\:, ... 1.

Po~t.ure \11 t' \<.lJlIIll..1I1O!l 01 Il..... lm~ Ik l ... tu rt:

It-!..! t

fto.: l. UI "" 1111 1l 1\I\l'Il1t:nt h

and I" h,mgt· ...

mdt L:lh: J

I h~

In pthlUrc

Ilia,till .., 1 I..an

U'>t:" pO"' \UIt: ~nd ... lpllJllJ\)

I, flt: . . . . 1111 pJ!oIOVl.Ij'h ) PI \ Ideo lol.['l 11) d')I,.Ulllcnt I..II ..Ulg\" ~. 1\ .tllt'llh \\l lh PI> l ) rJl.. . dl~ .. \t"" 'P\.'t! P,hIUft: I "' ~ ph\"h \\ 1I1t l n n\
..i\ '-U\l11. J.lkH-d

he..td, \4-IIh Iht' .. t.: ll h : t III 111.1.., ..

pl ..!l C'J

tht'

I ntv.,tl d \ \ llhm

ltltul ' til -l u r,lIth

~lu~'~ P~rfurrnanl..e f , ~·)..tJJ llI)Lll!I ' I ' (11

Il l"; l l h: r.lpt:-ol

,I I!

,ll"t' IJl'lll .!l ld

11 1.... 1 ~1If\;

\; .,Ilft? t "'1 \11 ), Il und hdd .11\

l it; u ';C,j 10 YUwlt 1l 1

... 1I1t

I'IJ

\,,' Ih.hu.tlll. l

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ity and post ural reac li ons sho ul d be s us pecled in the presenre of sig nifi cant trunk rigi d ity, TI,e patient should be examined fo r fac ial immo bil ity (hypomimia or masked face); the abi lity to smil e o r use the muscles of facial ex press io n s ho uld al so be examine d . A de terminati on of severit y o f rig idit y can be made based o n c rite ria of resista nce to passive movem e nt and ava il abi li ty of ROM , For example . a determinatio n o f severe ri gid ity is made if ROM can o nl y be achi eved w ith diffic ulty (see Appendix A), An inspecti o n o f voluntary repetiti ve move me nt s should be

perfo rmed to detennine ac tive limitations imposed by rigid it y.

Bradykinesia Initiall y movemen ts art'! sk)\\ ed. then moveme nts decrease in amp litude (hypokinc!'lia), and i.n bIer stage" movements become arrh) thmi c with frequt:'nt hesitatiuns and lJ'T'ests (akHtt:.., ia), A S.lOP\'\~H(h l':m tx u. . ed to quantify d~ tectable ..,10\\ ing of rn(.l\ e m~n t (mo\'lJf}f{'w "'tie I and movement hesit<.tI1l') or (('01"110/1 lilfll' (l·!ap..,ed lime belv.e~n the patit:ot 'S de.., lre to m l)\C and Ih ,,' aelllal 1I1ll\~ mt.'nf re~ pNl:-e). 1lle' Ihcrapi . . 1 ') hould t.'\alHtnt' \)\ \.'fall .un p lJ llIll~ 1) ( movement ~tncJ dhlll~l:'" in 3mpllllllk For t~,\ ~ll11rk .
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tJbysical R('habilitatio n 10

documenl muscle endurance and has been suggested J . . I d or

e lderl y. such as catarac ts (cloud in g of centra) vis ion first. the n peripheral). g la ucoma (ea rl y los s of pe ri phe ra l vision). senile mac ul a r degene mti on or d iabet ic retinopathy (earl V loss of cenlr:.li vis ion). and cere brovasc ul ar accid~nl (ho'monymous hemianopsia). Med icat ions m ay also pr(lduce im pai red or fuzzy vi sion . for example. antide pres-

doctITne ntm g tre m or, uSlIlg sow spee s of movernen&

sant!'\. and a nticholinc rgics . An ex amination of the prc!'\.cnce o f pai n is ind ica ted . Mild ac h.ing ~Uld c wmplike sensati ons are co mm on in patients w ith PO a nd arc ofte n poorl y loca lized . It is im port ant to ('xaminc for postural streSS sy ndrome (pai n linked to b ck (If move me nt. fault y movc me nt s or postu re, and li gamentous str:lin). Freque nt pa in or e xcruciatin g pa in arC' not common bu t may ~\I so occ ur. Usefu l instruments s incl ude Till' McGill Pain Qllcsliomwire , and the \'i:wol

Ri gidity is usuall y equal in both agonisl and antag . muscle groupS. It can be sustained (lead pipe) or in: lenl (cogw heel) . Distribuli on o f ri gidity is oflen asy uric especiall y in Ihe earl y slages of Ihe disease and duri ng th e course of the day and wi lh stress. It is lhemary im portanl 10 delermine whi ch bod y segmenls are affe: and Ihe severil Y of involve. ment. Tone changes in the nee. c L and shoulders are suggesltve of early d isease. whereas lOne changes III the trunk and eXlremities are typicall y present ~l th m ore exte nSive ~t sease . Defic its in fun ctional mobil· Ity and poslural reaCllons sho uld be suspecled in the p . res . .fi ence a f Slglll Icanl Irunk rigidity. The patient should be examined for facial immobilily (hypomimia or masked face ); Ihe abililY 10 sm ile or use the muscles of fae't a! . expresSIOn should also be examined . A delermination of seventy of n gldlty can be made based on crileria of resist· ance 10 passive movement and ava il abi lilY of ROM. For exampl e, a dete nnin atio n o f severe rigidi ty is made if ROM can onl y be achieved wilh d ifficulty (see Appendix A). AD IO spectl o n of volunt ary repe titi ve movem e nts should be perfo rmed 10 determ ine aC live limilalions imposed by n g ld lly.

a/lolng ue scale (VAS !.

Musculoskeletal Function Fle"ibility

An e)"3minati on of mu scul oske le tal ROM a nd fl ex ibilit y is

Impo" an\. The therapist can doc ument specific ROM impainn enl> (ARO M. passive ROM [PRO M]) using goniometric measure ment. Patients w ith P D are like ly to present \\ ith losses in hip and knee e xtens ion. dorsiflex ion. lihoulder fl exion. elbow exten~ i on . do rsal sp ine and neck c \ten,ion. and axial rotat ion . To a lesse r ex te nt. man y of lhe~ ch an ge~ are a \5.o experie nced by the e lde rl y in genera~'. 1t 1 ~ par1lcul arl ) im port ant to examin e spi nal ROM t :lbll1t~ to rotale. flex , and exte nd th e spine) beca use pa.lJCnb v. Ith PD haw bet:n shown to ex hibi t impainnents III thl'!' area."i.4 AJI ~gme n h of the ~pine ~hou l d be. exammeet. indu?i ng cer' ical. thuracic:. and lumba r segme nb . ~e mobJ hl ~ 0: the ..,pine :-.hould be ex amined during ~I ~ne ~ oj functIOna l move me nt... . !) u(" h a ... a.xial rQlalion f lookm.g be ll1nd ) and \\:l lk ing. I-I am, tn ll g le ngth ('a n be

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Bradykinesia Ln itiall y movements a re slowed , then mo vemen ts decrease in alll p litu de ( h ypokine~ i a) . and in later stages. movements

bec~m~

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(aklllesta). A stop walch can be used 10 4uanlil\ delectable ~Iowing of m ovem e nt (mo r emefl( f1 n1e) and mo~ement hesIt a n~y or rell c'lio" tune (e lapsed time- tx'iween the patient 'S de sire . to move and the ac tual mo\t.'mt>nt re ~ponse), The Ih ~ r', I I) I .~ t ~-' 110 1I Id exam .lilt' uve rall am p htude of movement and I.:h ... .... 1.1. n II;.·~ IIlCludc re peJ ted o pPOSllJOR ' Ilw torl· tlnl.!t." . . ' ... r 'til , I..l th un lb. d Ilemu ll' ug pn1nUllOIl-"Uplllar;oo. " r)c lllll ~ u J.nd l"I ~ ) .., Iug 01 I1.IJlJ ... . and lappmg t fiJH!e'r or '.Oof: tappmg) [A' 'i.I ('' r I t ) 11\ l'OI1lP"' X 11Iflior I:, . . b (c= ,g- .. wnnn~. .• drc""I Il!.r-' ' ... J,. III I.:·u j) b I"'J:I rn .ll l1 p" LI{h, n) .::a n be ( \ pel'lt'd to Ill..' IJnp.ured I I tx' (' .\ :11\\ ·111('\ 1 (c.g. p,m lut 1~'1 ... . •t II \,.I , Ih ) lIl HoI.o " I i!\/J rh " I ... .tho true tor motur U\sL.s in\'olvIPi . o,lt.liu!ta n l'l HI .. U ' "'t': o t 1....... 1I1t "'Id ~ ~ le.g . rapid altt.'l'TllttlJ\j p I OlMI H>n MUfI..'

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Chapter 21 ParIUnoon'.

and bradykinesia on motor perfom13nce. Long-latency EMG responses (50 to 120 msec) have been observed w he n muscles are subjected to sudde n stretch. Abn onn al patle rns of motor unit recruitment have also been observed .R-' Tremor The location. persiste nce. and severit y (ampl itude) of tremor should be recorded . The the rap ist should dc lcnnine if tremor is prese nt 31 rest (the typical patte rn ) or prese nt with aClion and interfe res with func tion. This latter pa tte rn may occur in severe. long-standi ng di sease . UE fun cti onal skill s such as wri ti ng. feed in g. and dress in g sho uld be c10sel v exam ined for effe cts of tremor. Tremor in the lowe r extre~ iti es is ge nerall y onl y see n w he n the pati e nt is supine and usually di sappears w ith walkin g . As stress increases tremor. simultaneous cog niti ve tasks such as serial se,'en subtracti ons (i.e .. count ing bac kward from 100 by 7) can be used to test for tre mor in a ppa re ntl y uninv~l\'ed limbs. !it!

Postural Instability A thorough ex amination of balance is indicated including an exam ination of oriemation to vertical. The patie nt's perception of vertical shoul d be asce rtained as some patients will says they are full y upright w he n actually is leaning forward . A plumb line a nd grid with still photographs can be used to document pos it ion. Balance control can be expected to degrade unde r conditions of narrowing. base of support . or in response to perturbations. The patient shou ld be asked to maintain steady ;tanding while varying the base o f support (e .g .. feet apan , feet together. tandem stance. step stance. and single-limb SlanCe). Perturbati on tasks that can be u>Oct to challenge balance incl ude se lf-ini tiated moveme nts (e .g .. ann raise. bendreach. Functional Reach Test (FR )87 or the Multidirectional Reach Tesl (MDRT!,' and Slep tests). In additi on. the retropulsion telf . sudden sternum push or sho ul der pull. can be used. Patie nt with P D especiall y in the early stages of me di&ease may not demonstrate ba lance impairme nt s in re spon ~ to steady standmglnonnal BOS o r self· iniliated movement s a~ alon g a ~ the ir atte ntion is full y directed to the task at hand . However. if co mpeting atte nt ional demand are In, ttWted (i.e .. dual taski ng s uch as talking While balancing). i n~lability c~n be expected. Se lf-init ialed tasks with a um ing compone nt (number o f Mep s per minute) W ill also li.kel y rcveaJ bal a nce im pal nne nb a b will re!>pOnding to un~xpecled penurba l1 on ~. With cont in ued deterioration. greater Impairme nt !» in balan~e cunt/ol will be Iloted. Smithson et al li9 demon~traLed strong tempora l itabil·ity of perfonnance (repe.alabiJity of measuremems ) on balance test'S in a group of 20 plll1e nlS w it h Idiopath ic PO duong the "on" pha:,.e of the med Ica tion cycle. Whe n COfTlpatrtng f1lliers wilh non· fallen . ~ome of the tests proved more dl scrimmallog in Ide nt ifying falle rs (e.K.. tan dem stance. ~ Iog le-- l imb stance , fun~(ional reach, and the ""'opuIMOO tes,).

ow-

""

Dynamic posturography uses a standardized and repr0.ducible postural pe rturbation from a moving plalform IhaI can reveal defi cits in placement of the center of mass (COM). increased postural sway, and unstable responses 10 pla tfonn perturbati on.90 Variability of responses in patients with PD has bee n de monstrated. especially during the "011" phase of medi cati on.91 Available postural strategies and reactions to challe nges should be carefully documented (e.g .. ankle. hip. and ste pping slrategies). The palient with PD typically ex hibits coactivation patterns (rigid body) with a n ina biJity to recover a stable posture.16 Responses to perturbation typically include delayed responses for recovery (start hes itati on) or absence of postural responses (pati ent wou ld fall if not caught by examiner or body sUJr po rt harness). Th e patient with PD can be expected to exhibit problem s with se nso ry organization related to difficulty c hanging sensory conditions. This can be examined using the C linical Test f or Sensory Integration in Balance ICTS/B ). Six diffe rent sensory conditions are examined, including ( I ) eyes open. stationary surface (EOSS); (2) eyes closed. stationary surface (ECSS) ; (3) visual conflict (moving surround). stationary surface (VCSS); (4) eyes open. moving surface (EOMS); (5) eyes closed, moving support surface (ECMS), and (6) visual connict, moving surface (VCMS) ,,·93 In the absence of posturography equipment, the patient can stand on dense foam instead of a moving platform and a visual dome can substituted for the moving visual screen ." A Modified Test f or Sensory / nIegralioli in Balance Im-CTS/BJ uses four different sensory conditions: EOSS , ECSS , EOFS (foam surface), and ECFS and proves a useful quick clinical screening measure. 95 There are a number of clinical balance tests that exam~ ine fun ctional limitations related to balance. Many ofthese instruments have been developed for use with the elderly and correlate well with frequency of falls . The Timed Up alld Go Test" is a particularly valuable instrume nt for patients with PD because it includes tasks that are typically problematic. The individual rises [rom a chair. walks 10 ft , turns, and then returns 10 the chair. II u.... lime as an outcome measure. Scores within 10 seconds are nonnal for mos l adults; scores of 11 to 20 seconds are within nonnal lim its fo r frail elderly or disabled patients; scores greate r than 20 seconds are considered abnormal and indicate need for fun her examinat ion and intervention. Tinetti 's Pnjormallce·Oriemed Mobility As.sts.tllWat I POMA ).7 incl udes both static and dylWllic baWlce i _ · o rganized into twu ~ ublesl s of balance lome ilems) aDd g~ i t (.ix items). It has a total poss ible lI<'ore of 28: paIienU who score less than 19 are considered III high riak fur faIIJ "h ile those who score between 19 and 24 IW II moderaIII ri.k for fall s. T he gait sublest w.. found 10 be a IIM{UI ""r.." jng ins lrum.1ll m identifyina gail dyllillll;lioa -ill patie ots willi PO from healthy elderly, bOIl wu DOl . . . tive e"ougjlt(l distlnguiill perfomu.lII:e ....l'OIIcoollil. . .

810

Physical Rehabilitation

of v3J)' in2 instnlcli onal se.IS (i.e .. "sw in g your amls:' "waH, fast:- ' " rake large st,c ps "j ."

Gail

An examination of gai l is indic~t~d. Parameters and. c har~c­ leri ~lics of g:lit Ih.11 shoul d be examined during straight line wall.. inl! include speed of walk ing.. stride length . cadence. !ystclllS t y~ ica ll y see n in the Ia~ral()r" :-en ing). Patient .;; "" ilh PD Iyplcall y demon~tralC difti cul,,: all:uning and sll stail1ln g wal kin g speed and ma y hj \ C d ij~icuh \' " jIll fexlt d cara ncc onlO force plates with l shuffi U1 f! gai~ panern:- seen in advanced di sease." Ga it ~hould ~ n am ined fllr 1..II1cm3ti c or quali tati ve changes. tnrludl1lg reduction;;. in hip. k. nee. and ankle motions that rr'> ll li m 3 :-.hon· stcpped. ;;;hullling ga it pattern \\ ith red uced lrun l.. rotation and ann
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Swallowing and Spe""h An examin ation of swall owing fun cti on, feeding. and speech is impo rt ant: Referral .to a speech- language pa~hol-. og ist is indicated I f the patient demonstrates functional limitations in any of these areas.

Autonomic Function The therapist should examine for problems with autonomic dysfunction. Excessive drooling (salivation) or sweatins. greasy skin. and abno nnalities in thermoregulation should be noted . Ex.cessive sweatin g and flushing during the "On" slate is linked to the prese nce of dyskinesias. Episodes of orthostati c hypotension should also be carefully document ed. wi th blood pressures taken at rest and after posi. tion change. A chan ge in BP of greater than 15 mm Hg is significant. Ln patients with advanced PD. blood pressures are signifi cantl y lower in the "on" state than in the "off" state. leadin g to frequ ent hypotension and complaints of dizzi ness. l ol

Cardiopulmonary Function Endurance may be reduced as a result of impaired car· diores piratory functi on and long-standi ng inactivity. botb commo n problems in chronic PD. An examination of respiratory fu ncti on should incl ude inspection of rib cage compliance. chest wall mobilit y. and thomcic expansion. Visual inspecti on of breath ing panerns and an examination of the inflIH.' Il(; (, of postu re on breathing should be perfo nll ed. Vl!nt ilation parameters (res piratory ra le. minute vent ilat ioll . inspirato ry time ) should be detennined. C ha ng~~ in brealh ing paucm wi th activ ity ~hould also be nOlt'J . Obj ec tive meas ur~ rn e n(~ (·... n im.:lude circumferenf1 al l11e :hllre lll ~n B of the t.: h~ ... 1 and abdomen. Re levant pulmonary fum.·ti o n tL· .... tS indude splfomc lf) : flow· volume. lung \·olulIlc!'I . tmd airw a,:. rC;; h ttU1CC (t:.g .. fon.:oo Vital C:lp:Ii.·il y I FVC I. ron·cd ~'\p i ratlJry \'o lurn~ I FE Y I. maximal c .\ p l r ato r ) n uV. fMEFJ. m:lx illl.tJ In",p ll':1I0 1) flo", IMlFl. I(\U! IUllg ('..tP:H: Il~

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Chapter 2J Parkinson'. DUeaae ," h milder disease manifes l at ion s.~11 Excrti onal sy mptoms

~It

, f . . f ' dysPn". , . di zzlllCSS or con uSlo n. eXl ' eSS . IVC atl g ue ' pa l· ( and SO f orth ) should be care fu ll y documented . lor. ·v. d exert ion . can be recor(Id ' (J{ c U ~ 'II1 ~C. B oro~ ' s Rafill" Perc<'1 (il'ed Exertioll Scale (RPE scale ).IOJ The pati ent Prrc be qucSl .lOn e d. rcgard, 'Ill £. Ic~' e.I 0 I" !.ll .lg UC o~ ex 1l ~U S should . eXnl' ricnced dunng da dy ~lt'll v ll y (the fa ll ri sk diary lion ' eh 1- d' N' used 10 documcill I esc In lOgS), Knowledge and can . d '" . of energy conse rvati on 3n :lCII Vll y pac lIlg strat eg ies use . d should also be d CICOllIflC . L

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,:;

•

Integumentary Integrity The therapi!'t ~ hould examin e the patient clost:ly for areas of bruising and skin breakdow n. Patic llIs who are severely diS3bkd Olay he res tricted 10 bcJ. wheelchair. or bolh. Incontinence may occ ur during latc stage di sease. The ('fleet (If lhese proble ms on skin integ ri ty shoul d be carefulh documented . Use and effec tiveness of pressureff'li~\'ing strategies and dev ices sho uld also be documented.

Functional Status An examination of fu ncti onal statu s is indicated . including perfonnance of functional mobili ty skills, bas ic ac tiv ities of daily living (BAD L ). and instrum ental acti vities o f daily Ii_ ing (IAOL). For pati ent s undergoi ng inpati en t rehabili tation. the Functional Independ(·nce Measure fflM j b com monl) admin istered . lua Need fo r and appropriate use of protective and supportive devices is an tmponam component of the fu nc tional statu s ex.am ina tion. Close collaboration wi th the occ upational therapist is

essential. During fun cl.lOnal performance te~t s, eac h skill sho uld be ana1 yze.d LO determine the impaci of direct and indirect impairment~ on performance. For examp le. sit -Lo -stand transfer), I ) plcu.lly pre!)cnt a .~ i g n i licanl challenge fo r ~alie nl.S with moderate 10 ~evere PD as ev idefl('ed by mcreased lime and increiJ~d falb . These changes have been attributed to hypoll ne!)ia, del. re~d nlle~ of force prodUCtion. and change~ ill d lMal muscle liming. 105 .1(11) The approach UM"d in Irc;aunent W Improve l:I it-IO-!i>tand funchan . . .·111 be vcry dlffere m dl."lX"nd ing 0 11 ~orrt!.ct identi tica1J.0I1 of the t.>Ource oj problem. Pati ent s wi th PD Iypicall y demon~trate- greule~t dltficult y m tilo&e uctivities hav in g a fOlalional cnrn pn nem. ~UL'h a!) roiling or turn ing In hed or ).lIll.Og up . The lime 11 lake.!) 10 Inillate a.nd to c.:olllpl eLt: an atlJvity ~hou ld be recorded BI.!(,:au..,t' theM: patient l:ll"xperitnl.t inc-rebOO Icnigue with f(, ~lIlta nt fl uctuJ tions in perfOrn.lanct'. t.l.ami natlon !)eSMon~ bhou ld be ke pt brief. Repeal seblloJOn~ bhould be undertaken at the !)anl'; lime o f day fWd ill the Mime, time. tn the medication cyc le. An ~panYlng vldeot~pc can provide lin objective rocord of (W"k'lional perfomuulCe. An examination of functio l\a) PtrtOf"nla.nte in the home (or wo rk: ) en\'ironment IS al so

871

ind icated . The patient 's physical env ironment is examined fo r barriers. access, and safety.

G lobal Health and Disease-Specific Measures G lobal health measures can be used to determine individual ou tcomes across a broad spectrum . In struments typicall y in clude items that exam ine ability to perfonn routine dai ly activ ities and q ua lity o f life (e.g .. physical and soc ial runcti on. general health and vitalit y, emoti onal well-being~ bod il y pain. and so forth). General health measures have bee n usecl to stu dy large populations and are most useful in de ternlin ing long-term health outcomes. They lack the sensitivity needed to document short-term outcomes of treatment. ln 7 Co mm onl y used measures of general health status incl ude: Ralld 36-lte/1l H ealth SlIrvey SF-36'~ and the

Sickness Impact Profile.I09 Disease-specific measures are designed to determine attributes unique to a spec ific disease entity. Items are inc luded that prov ide information about the di sease process and o utcomes, and ideall y doc ument clinically meaning ful change over time. Thus these instruments have greater responsiveness or sensitivity to change than general health measures. Ex amples o f instruments developed specifical ly for the exam inatio n of patients with PO incl ude the Unified Park.inson·s Disease Rating Scale and Parkinson's Disease Questi onnaire (POQ-39). Th e Unif ied Parki nson's Disease Raring Scale (UPDRS)" o was o ri g inall y dev ised to doc ume nt the overall effects o f the di sease (Ap pendi x A). It is a compos ite scale. consisting of six secti ons. Part I includes fo ur item s e xami ning mental statu s. behavior, and mood. Part II incl udes 13 ite ms thal exam ine acti vities of dai ly living as we ll as ratin gs o f d iffi c ult y wa lk ing . tremor, and sensory sy mpt oms. A determin ation of "on/off" perfo rm ance is ind icated . Part Ill. mo to r exa mination. includes 14 items that examine speech. facia l expression. finge r and hand mo veme nts. pos tu re, gait. and the effects o f tre mor. rig idi ty, and bradykinesia. Part IV investiga tes the com pli cat ions of therapy incl udi ng dysk inesias. dy stonia. c linica l tl uc tu ati ons ("on/off ' perfo nnance), nausea or vo mi tin g . s leep distu rbances. and orthosratic hypotensi on. Unl ess Ot herw ise stated. it.e ms are graded O il a sca le o f 0 to 4. with 0 being norma) and 4 be ing severely a ffec ted . Pa rt V is a modified floell" and Yahr Sru!-:illg . DiSlcasc s~ ve rity is divided over 5 s I3gCi inlo unil att:rdJ o r hi lateral signs; higher nu mbered slages repr~senl prog re ssive ly more difficulty w ith mobility and

balance. ParI VI is the Schwab ami England Activitit! of DeJily Lh·j"g Scale. E~ti m ales: are made In tt-nns o f

p~r('ent impairme nr (0 perc~nl = vegelaf"ive runco·ons (bcdriddon ) to 100 pel'cent ~ cQm pl .~l y independenl). The UPO RS is the mosl commonly uoed scale 10 oxam. inc PO dise.se . everilY and proare ••ion iii ....U .. !be p.tient 's re sponse to dnllI lberapy, Overall, !be ICI!IIo 11M

8 72

Physical Re habilitation

Box 21.4 Examples of General Goals and Outcomes for Patients with

Progressive Disorders of the Central Nervous System,' adapted from the Glli,le to Phys ical Therapist Practice"

Impact of pathology/pa.hophysiology is reduced. • Patient/client, famil y. and caregiver know ledge and awareness of the disease. prognosis. and plan of care is enhanced , • Symptom management is enhanced, • Risk of secondary impairment is reduced, • Intensity of care is decreased, Impact of impai rments is reduced, • Cognitive function is improved , • loint integrity and mobi lity are improved, • Sensory awareness and skin integrity are improved. • Pain is decreased. • Motor function is improved . • Muscle performance (strength , power, and end urance) is improved. • Postural conu-ol and balance are improved. • Gait and locomotion are improved. • Management of fatigue is enhanced. • Aerobic capacity is increased. Ability to perform physical actions. tasks. or activities is improved. • Independence in activities of daily living is increased. • Tolerance of positions and activities is increased. • Activity pacing and energy conservation skills are enhanced.

• Problem-solving and decision411aking skills ~~== • Safety of patient/client, family, and caregiYellIa Di sability associated with chronic iIlnesa; is reducId. • Abi lity to assumelresume aelf-caro and home ......,........ is improved. • Ability to assume work (job/schoolJplay), COiUiiiiiiIlty, leisure roles is improved. • Patient/client and fami ly knowledge and awomlelt of sona1 and environmental factors associated with ...,. . . .~I of the condition are enhanced. • Awareness and use of community resources are impau.c4 Health status and quality of life are improved. • Sense of well-being is enhanced. • Stressors are reduced , • Insight, self-confidence , and self-management sIciIIJ . . improved. • Health, wellness, and fitness are improved. Patient/client satisfac tion is enhanced. • Access and availability of services are acceptable to patient/client and family. • Quality of rehabilitation services is accepIable 10 patient/client and family. • Care is coordinated with patient/client, famil y, ~ and other professionals.

-AntiCipated !,oals and e Xpe'cled ou tcomes are specifi c to Ihe individual patient.

=

good inte rra te r reliabilit ), (r 0 .98 ) w i.h so m e indivi du a l items de monstrat ing less reliabi lity ( i.e ., fac ial ex pression . es timating severi ty o f se nso ry sy mpto m s a nd bradyk ines ia) . 11 1 T he Parkin son's Disease Qu eSTionnaire (PDQ ·39) is a 39-ite m questionnahe deve lo ped fro m in -d e pth int e r"ie~ s \\ilh pal ient~ w ith PO. 11l It foc uses a ll the subj ec tive report o f the impac t of PI) o n dail y life and addresses eight health-rel aled 4u a lit y o f life dime ns io n s (m ob ilit y, AD L, emOli onal we ll · lx ing , ~ti gm a , s(){'lal suppo rt . co gnition , comm un ication , and bodil y dbco m forl) . T he PDQ -39 prod uce b a profi le 0 1 ~core s o n the e ig ht indi vid ual dlO)en ~ ion " . A ~ ull1 m a.ry ~core Uhe Parl in ~o n 's D I ~ a ~ Summar j Inde x I PDS I !) can a b o be d e te rmi ned . "ith M..on:::!!. thai range from U ( pe rl e~,: 1 ht'a lt h) to 100 ( WO hl health , It pru\ Idl"~ a u ~tfu l irh.h c3t1 0 n o f th e g lo bal I mpdl.1 o f PD 0 11 ht' alth MalU ., . I n h.~ rn a l .Hld te~ t-re l t"~ t re liabili ty "ere fou nd to be 1Iloonl' Oft: 11 1 II I A d-.:tenn lllUl lon 0 1 gOi1 I ~ .tll enl 'l'o IIIdi \id ual ilblh l le ~, Im paJ rn)t:n t ~ . l unui oJul 1 IIfIl II til i!)n.." tl.lld

du.abihty I Bo~ 2L4 j.

Physical Therapy Interven tion A co mbined approac h o f phys ical the rapy and pharmacological interve nti on p la ys a key role in the management of the pa .ie n . w ith PD. Fo r mos t pa tie nts. phys ical .he rapy is no . prescribed un.i l the d isease has progressed to the point w he n func ti o n has decl ined . A variety o f inte rve ntions are used to ac hieve goals a nd o utcomes. includin g d irec t intervent ion s. superv ision o f as:
Motor Learning S trategies PatH.'n" Wll h PO typica ll y demo nslra tt! motor II!Bntin, ddl,-· tt ~, ind ulli ng impulrmen ts in tea ming long and corn· p l!.!1- m\ )\ CI11cnt bcq uc:nct"s , :!o imu Itane-olls motor/cog 1u1l'o'e

Hi!:
( 'h opte r 2 1 Pa rkin",ou ',s IJtIK!A.e

pcrfomHlIll'C \\ ',l ik In Ih(' I1ll)rl' ul~ val1 ccd ~"' I :lgC !!o :lI~d. in ,he pfCsence of pronnunccd C O g lllll v C lkt!(: lI ~. 1r:1 1l11ng II l ik ~ h hI;' It's:-> \u L'cc ... :-.ful. n.I)(.1111 1.'11 The Ih crapi~1 \\ I

•

Ilt'ed:-. 10 !-lfU C1UI'C' Irc almc nl ~c"'~ l o n , 10 o p lil11i 7(, mOl or

learni ng.

('rilic:li eiCI11Cn l!- of pr3cli ('c Include ~I large Ilumlx' r of fl"pt'l ition s 10 d('\ciop procedural ~kdb . Lon g and \,;omp lcx mon~nlcnl ..,cqllcIlCC';; ,houlJ he avoided or broken clown

into cOInpont: nt pJrI ... , R:muolll pr:lclicc order (1,(, .. pr:lci icc in "hleh the pal lent :-,,,ilch('.., h.lCJ.. ;'Ind rorth hetwee n f3sk, ) should be ,l\ oidcd in fa vor o f a hlod .cd pr:tc licc order. the reb~ reduc ing fh e e flec" o f conl{.· xlu ..11 Interference. Ta",k ...... hould tx: T11l)d ilk d to rninillli Lc competin g rogmtl\'e dema nd ... , T hu ... fhe pJlicnl ' " instrucl cd 10 ~lv()id

dual ta ... kmg In 0rder 10 impn_ ' \ c move ment pc rfunm.tnce. The envi ronmen t . ; hou ld 31. . 0 he mod ified to reduce clultcr and competing ~ltten l lOIMI dc miU1d\ thaI ma y trigger l rcczing epl\ode .... The therapl\! .. houl d In , truct th e patient 10 deJibe rJtel ~ foeu ... hi ... or her full 31lcnli on on the desired mO\ emenL L '\c of ,Ina lured IIIHrllU;onal 'iN S ha ... been sho" n 10 lmpro\e movement 'peed and cOIl''IiMency.'N.J2 1 For example. v. al~,"g pattcnll, can he improlfed wi th focused lO 'truclion~ of "\"' I11 g )our arm .... · " walk fa~I." or "take large qep,_" For the pall ent w it h ad vanced di ...ease and cogll1U\C defic it .... repc tlu \ c d nll -like practice ~ hould t'f: used along with an IIlcrea".!cd foc u ~ on caregiver Ira in-

en\ure ~3fe-l~ U4 External cue .. have been \hO\,n effetti\ c in triggering sequenlJal mo\emenh and Impro\ ing mo \ ement chal'3clfnqtc ... 111 mdlv'lduaJ, y, 1m mild to moderate PO (M:C EHdence Summar) BOA 21.), \ iwul u /es Include ~ Ia ­ ltonaf) floor mar\..lllg ... fc-,g nnghtl) tolored hne\ on thc floor placed perpend icular t" the gall path and ' paced about one ;"te'p lencth aparu .md d) !lilOl K tran ' rx,rwhle cue (t .. a "'nit hi t,;ant 1O,,'('n~d and he ld \ 0 the pallent 'It.e'p\ o\'er th(.' handleJ .1,1 \ A , ubJeLl-mo unted light de\ Jce I~ l.,o;"er ,,k\IU: i:t1U1Ched 10 Ih~ Lhe... t lhat project<. t'll'O 1.1-.ef Ilf1e~ to tn(' Oe,.;)r 111 from of the pOJ llcno ha, ,11 '0 been u>ed .. U\,. ...e ... full) to tngt,'t'r .. h:pplIlg VII,uiJ l t.trgct... h;n.e beer. .. h ;4" to Impru\c- lIltie h:1Il-'th J nd \f:kK';I I) ... hilt ... ..Jt>IKc ..... 01' rd;,l1l\eI~ uO<..hanr\·cf l-re...·/ ll1g cpl ....odc'l mg

10

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ud / .. ,

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873

"C-re found in the 'clI~ury Iminillg group.llS.1l9 When

. . imliltfllll·OIl:- lise of auditory and vl",ual clles W3"l com. p
117 Fo r exam ple , the prcmotor conc~ dirfcrclIl brain nrl!as. i\ activc in the gCll cr;'l Iio!l o f move menI ill rc'\ po"'\e to

vbual or audilOry Mtl11uli . NOtnlall y the ~llpplcrncntary mOlOf area (S MA ) will! inpuls from the BU j, involved in the ini ti;Hiol1 of ~e lr gc ncm tcd movement!'. and lhe pcrfonn. UIll:C of we ll-learned, repet iti vc I!lUVe rnellt scqucncc\ . l l~ Ex te rnal C llC~ heig ht en patic nt attention throu gh ~\ common mode of ac tIOn . Ih,,' is. 10 hy pu!o.~ the dim ini, hcd mtcrni.tl cueing of the ha,al ga ngli a. Thill" focus i... shifted Iu less au tomatic 1110vemen t w'I in g :tltcrnalivc. Illore conScious motor contro l p"llh w
"' ,k while vi~ua l <.t nd

w",

luatlOlh ~re prC'Icl1 t,1V, H owl!vcr. lor I11l1 l1Y pJ tienl'. u":c I)j I\ ;t \,~llld treatment \Ir~t h:gy .ll1d one Impruvcd pcrforrtwncc C:1Il he tlll tiupated 141

external cuc,

111

'Nhl{.h

Exercise Training Relaxation Exerci ..,. Gentle rod .. mg ( all he u"\t'd 10 pmdu... c ~ (,' u('rah/('( 1 rd'l\ .Ilion ti l C,'H l·~' IV I.' Hlu ...d c I ~' II "' IOII till'" to n,L:H.lJt'V, I'ruk."or

(hdr, O' whl' IUJtcd clr."II~III"" IInl'n'\. ~nl~1I1

In pallf:lll' "'Ih PI) J tl ll uwll1~ nth;, III hUlliPY I1Of'(' (11.1""11 l lrrIJ t l·~ . 111,1 de ..c.. lI bc d tlll '" t'lh:I.' t almo t 100 } ~ JI '" ,,~tI III Pull'

I olluWII Il! flll .. nh~'r\ _tl'OJ! to u-.c: ~ Jl h til ' ,,__ llCIII ...

h l" I,:4.IlhtlUdl~d.l 'VlhrdllllJ!;

c:h.AJr

I\lthuu~h Ih~~ C\ .RI n1\:( h'IIII"OI UIJt~ ' '') UI ' II I. ht ) h,l' 11. /1 1...... 1."11 Itknl l fi\'\1 It...- ht.·udto.d efl It\ 01 .Im'\' hJl. k ln~ on l \ I.-.~'t" IVfK' h.tvc till:cn 1k"l1lOtl jl,l h"d • • oJ 1.,11,,\0\ 111' (h,lIlO( \ IetMl. a " h.ttf llill tJll: u'iC"d II) Il·JUlK " ...lI h ft ·dll.. ~ n ll ldlt~ IU14t "'nhdnl II to· t.u,,1 tri,ul\. h :1!t I>W llltt tllt r.tp, ~lol4 ,11\·tJulllf.;. ' IM..tlIlJII..tJ 'hl1~t flWnh p I Ilk: " "" l' HU1!t .uwf trun1. '.\111 n-.- l.(1thl~k(l..'. 1 .....el hot;ld IJft:,(:tk IIlfe 1\ l:'utIHtl\ 1,1<. II It, HI):\1 lr~hJUII~ . " ' }.i j l uJll h OH•• ' ttdlHllllo! • , .)( c..\lJ.lftjlk. hHOLJYIII¥ ".V.C1 I(uuk not ...tlt",l ", tlHkh lH~ ,,,Umg ( I{ uPJl(1' ~.mlltM'CI tn.,tl,

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(.11 ~('''I''''/''( i#' 1",... "76)

874

Physica l Rehabilitation

Evidence Summary Box 21.5 External Cues and Motor Performance in Patients with Parkinson's Disease Reu. r ' n'nce

Su ".~(.~c 1s

. n DcsiU"n ... / l nh.' n L'n'lo

I) lira I Ion '

R ... ,uh,

lehman ,

Part 1: 5 subjects, no controls

Nonexperimentaf, cohon study

3 training sets/day for 10 days

Pan 2: 11 subjects with early stage PO (Hoehn & Yahr Stage 2- 2.5; UPOAS scores 1-2); normal mentation (MMSE)

Protocol: Exp. group: walked 30 ft using veroal cuing ' ake long steps' 10 times/session; Control group; walking with no veroal cueing

Significantly Increased ity and step length and ~ cadence; significant effects rtaItItI in both groups but l110fe pr0nounCed in expogroup

Patients stable, within 1-2 hours on PO meds

Outcome measures: step length, velocity, and cadence, preferred walking (Gait Aiteelectronic walkway).

0 , et 81121

2005

Training group = 6 Control group = 5 Mak. M, and Hue'(:han.

C,'22 2004

15 sublectS with PO (Hoehn & Yahr Stage severity score of 2.5) Patients stable, wi1t1in 1 hour on PO medication 15 healthy controls matelled for age, gender, weight. height (no PO)

MaJsak, M, el aJ'23

1998

6 subjects With PO (Hoehn & Yahr Stage 3) 6 healthy controls (no PO disease)

Mcintosh. G, Flanagan J, and Gen~le, A.t'" 1995

-

31 sull,ects with PO (Hoehn & Yah, Stages II, III, and IV) 2 t on mads WIthin 1 _ 1 1/2 hours Of doSing 10 "off' mads (24 hou,. afie, lasl dose)

10 healthy COntrols

Nonexperimental, cohort study Protocol: 2 conditions of sit·to·stand (STS) (I) self·initiated; (2) using auditory cues (veroal commands) and visual cues (circular light at eye level)

2 test trials: STS, self'initiated STS, cue'initiated

Outcome measures: force through feet (force plate); kine. matic analysis of movements (reflective markers, high speed video camera)

Nonexperimental, cohort study ProtOCOl: 2 conditions of reaching task (I) self·regulated reach and grasp stationary ball as fast as possible; (2) 'each and grasp a rolling ball (VISually cued) Outcome measures. 2-tlons of walking. (I) seW ·selected 'Pged; (2) With

rIlyfhrnJc aUdllOry SUmulatJon (RAS) matched 10 baseline cadence, (31 RAS 10% taster than baseline, (4) Without RAS RAS In'trumental muSIc. 50 msec square wave

0u1c0rne moesur. ,

gao Veloc. Ity, cadence stllde lenglh (ConI, pUtenzed loot swrtch .y,tem)

gaiI-.

PO group: STS·seff·initiated had signif. dec. in hip flexion and ankle dorsiflexion torques; dec. horizontal and vertical velocities; prolonged movement time to compiete STS STHUed signff. inc. aU torque values; time to peak torque reduced by 2~27%; no improvement in peak vetocity; signff. dec movement time. Control group: STS- cued had small but sign if. inc. knee ext torque

6 practice tria ls; 6 test trials

PO group: in response to visuaIy cued target, inc. speed and acceleration of reaelling (COIIlpIrable 10 control group); decreased movement time; movement accuracy maintained Healthy controls had comparable reaching times under both conditrons

- -Warm·up 2'mln walk 20m 4 galt trlats, each 3().m walk

Faster AAS prodUCed srgnificanl Improvement In mean galt ve1oCIty, cadence, and stode IengfII of a/l groups, No RAS aU PO pahents shoWed abnormal galt patterns. "off' group ..,. than "on" group Inc. In 9 II velocity, cadenoe, lid st,,,,,, length parslsted dunng iIII UIlCued walking mal WIfh ody I small decay rate (t- 5"')

~ ,

Chapter 21 Parkinson's Disease

875

Evidence Summary Box 21.5 E:dental Cues and Motor Performance in Patients with Park lJ1S0n ' S D°Isease (mnl inucd) o

Reference

Subjects

Design/Intervention

Duration

Results

BurlelghJacobs, A, et al 125 1997

6 subjects With PO (Hoehn & Yahr Stages III-IV when off)

Nonexpenmenlal, cohort study

5 practice trials; 1 tesl tnal

When "off," all PO pallents had marked dilliculty walking with freezing episodes compared to "on" and healthy controls.

Tested both 'off' meds (overnight) and 'on" meds (Within 1 hn!Jf at de :. lQ .: : he ~Ith" r.ontr j\::::

Ie

Protocol: 3 test conditions (1) self-generated step; (2) step to cue (pulsed cue to earlobe or hand I; (31 step to perturbation (horizontal backward surface translation)

Both PD and normal subjects inC. force and velOCity of movement in response to cutaneous cueing.

Oule )me IE 1: 'e: grou n n ~(Ii lq In:~ ;t! plc'll: .r '1~! po b dy klnemat tep

f

l(:th 1m .:or,

Step to perturbation: both PO and normal subjects improve speed of postural adjustments; PD subJects did not inC. force of push-

dn~,I'y

011.

9 u ilng

MO'flS M

ral

e:

1'1 rn NaIK~ rr

19~6

,tnde

':"

sel length ):ed

ur'

~.

::::d ,]alt

" I/,

~~;

,

,

,

,A

ler;flf F!f:r::man J

,UbJE'C'"; With PD. )n routl "If: n len <.tlor 11 ,J 1< 1) je-:I.I€

Q

~G

ImpalrmE:n l 12 healthy ontrols

,y~ IE

II

"

,I III

M,

PI,I'

II:~

_r I~ Iten

j 10 I

n)

Nonexpenmental. cohort study

4 tnals: ? each hand

Prl"l\l)cn c mdltl ns , dudltor~ :ue) )1 target tap pmg frequencies over 30-s period: (2) auditory cues ollar gl~1 tapping frequencies flf~\ 10 ,ec mly /30· p€:rlOdl

"III< I ,,1 1'"
Patients who trained With RAS sign If, Improved gatt velocity (25',). stnde length (12'6), and step cadence (10%) more than self-paced subjects

In RAS group, signlf. changes In EMG patterns.

,I<

I I II'

. I" . I . ,lIIl 1'1)

I<

I, 01,

,,, i'll,

Healthy controls were able to duplicate target frequencies and sustam frequencies dunng WIthdrawal of stimulation. PO patients less accurate in duplicatIng target frequencies. especially at lower and higher end of frequencies; Withdrawal of auditory stimulation resulted in marked Impairment of rhythm .

Outcome measure! Frnger lapping \esl (computel analysl::: of frequency): Irem )f I€:C lrdlng!

-1111

Secondary tasks reduced stride length

No-training group dec. velOCity by 7"0.

I

III 1m ml' ~ur(:i. EMC: pdtterl I 'cdo( It'y =adenc ~wltd,

Both visual cues and attentlonal strategies were effective in producing a normal stride length.

11,,',1

,10111,'1

111<'
,lllll,rI,111 'II

11-' III I

Cha,)ter 21 Parkinson's Disease

875

Evidence Summary Box 21.5 External Cues and Motor Perfonnance in Patients with Parkinson's Disease « n"tin ued) R(.fel'"cncc

SU~jl·C'ts

l>esign / lntenention

Dum.ion

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6 subjects with PO (Hoehn & Yahr Stages IIl-iV when off)

Nonexperimental, cohort sludy

5 practice trials; 1 test trial

When 'off: aR PO patients had mal1<ed diffiCUlty walking willi freezing episodes compared 10 'on' and healilly controls.

JacobS, A, et al l25 1997

Tesled bolh ' off' meds (overnighl) and ' on' meds (within 1 hour of dosing) 2 healthy matched controlled

54 subJllCts with PO

Morris, M.

Protocol: 3 test conditions (1) self-generated step; (2) step to cue (pulsed cue to earlobe or hand); (3) step to perturbation (horizontal backward surface translation) Outcome measures: ground reaclion forces (force plate); body kinematics-COM position, step length (motion analy' sis system)

Nonexperimental cohort study

et a1"" 1996

Both PO and normal subjects inc. force and velocity of movement in response to cutaneous cueing,

3 trials: walking willl use of (1) visual floor markers (2) attentional strategies (3) secondary tasks of inc. levels of complexity

Step to perturbation: boIIl PO and normal subjects improve speed of postural adjustments; PO subjects did not inc. force of pushoff. 20 min training using repeat 10 m walks, set at controf stnde lenglll

Both visual cues and attentional strategies were effective in producing a normal stride length.

Gait patterns monitored every 15 min for 2 hours

Secondary tasks reduced stride length.

3·week home-based gait training program

Patients who trained willl RAS signif. improved ga~ velocity (25%), stride length (12%), and slep cadence (10%) more than seff-paced subjects.

Outcome measures: computerized stride analysis: spatial (diStance) and lemporal (timing) parameters Nonexperimental, cohort study

Exp. group: 15 subjllCts with PO

ThaU!, M. etal 127 1996

Exp. group: training w~h mythmic auditory stimulation (RAS)

2 controf groups: 11 subjects

Controf groups: seH·paced training, and no training

No-training group dec. velocrty by 7%.

AAS = instrumental musIC

Outcome measures: EMG patterns. gart velocity, cadence. stnde lenglll (ccmputenzed foot switcll system) Freeman. J,

el aI,a 1993

9 subjects WIth PO. on roUIi1le medication. mUd to moderate Impaumern 12 nea. Vcontrols

Nonexperimental, cohort study

In RAS group, SIQfIif. changes in EMG patterns.

4 trials: 2 each hand

Protocof: 2 condi1l00s (1 ) audrtory cues ollargel tapping frequeooes over 3Q.s penod; (2) audrtory cues of target tapp'ng Irequ"""es lirst 10 sec only (3Q.s penod) Outcome measu(es~ F,nge< IappIllg test (computer analysls 0( frequency), tremor recor
ro\., _ o:nlcf(lol m>o COJ> M! 1)F - \1.tru· \1~tal "LIt<. r 1lCNf~

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Healthy controfs were able 10 duplICate target freqtJtlllClBS and sustain Irequencies dunng WIlt>drawal of stimuial1Ol1. PO patients less accurate in duplicabng target IroquenclBS, especially at lowe, and hlgher end of Ireqoe<1Clf!5; ~11Il
1>f1)~;C-.II 1 Re h a biHtnt ion

876

PNF Ifchniqu(" of rhythmic ;llIt;allOl~ (RIl. i.n whil'h 1~Ill\ C­ , e'S;-l " ' .' from I}a,~. i "c 10 :IClI ve.-:l:-.:" y I11c nt plOgr _ I:-IIVl' 10 li ghtl • , ' ,ed or active I1l(Wl'llll'nt \\01:0. ~pt'r 'll c;l ll y cil.!'lgned In n.: :- I ~ Ul help O\crcOIl1I,.' the cf!ccts o f ri gH.IIl )' in _P_~ . ' " _. , Additional !iilr:ltcgle~ 10 prolllOlt' relax:lIl1l1l 1I1( ~udc.: .111 " I.;' n d ',..,"phraj)Ill ~\li c breat hinl.!. dunn. g exc rc l ~c . For• emp h:1:\11,\ ::0' ~ . c:\:lll1ple. bilateral :-'YIl1 I Ilt~trictll PN F 0 2 /l ex lOll I'allcrn~ are important p3l1ern~ that C:II\ be u!'.cd c,'(pand I I ~c rc!'. triClcd c he~ t and promote :.. hOli lder RO~ . rhe !') :Hl cnt :.. attention l'an be fO\.' u ~ed o n deep ilb pirall on dUring 1~2 F (" breathe ill dt'cp ly") whill! durin g D2E P;ltlCnl!'. :lIIc l~"on is foc used I.m ex pi ration ("brei:Hhc oul dee pl y " ).141' Pi.lIle.llts may al"o bcnrli l frolll C'og nili ve imagi ng or IllCdllatHlIl I~ehnique~ (t'.g., th e rcla'(~lIion r('~ p~n sc or Bcn ....on I47) o r con!o>cious recogni ti on and re lease 01 J11l1"cle tCI.l.\o> lon (c ..g .. progre~'i ive rdax~t1ion lechniq uc,~.lll ) . Relaxati on . audiOtapes ('an be lI~ed al hOllle as pan 01 Ih.e home ex~.rc l ~c prog.r~lm (HEP). Genll e yoga and Tai Cil! ca n be c ll cctl v.c .for patienls wilh PD bcc:lllsC o \" Ih~ empha sis ? n comblllm g ~lo'\ . ~ t e3dy stretching with mallll enance oj po~ tllre~ and movement fonns. Stre ~s management techn iqucs arc an irnponanl adjunct 10 relaxation trainillg . A daily ~ c h e dul e needs 10 be planned to acC'ommOd;Jle the re ~ lri c ti o n s of Ih e d isca!o>c and the functional need ... of the palient. Life.st yle modifi cati ons and lime m:magement lec hniq ues reduce anxiety assoc ialed ,qLh movement difficulties and prolonged lim e ~ req uired to complete ba ~ i c fu nctional tas ks.

Il:

Flexibility Exercises Both acti\ c and pass ive ROM ex erc i se~ are u ...ed to ImprO\e fl c\ ib llit y. Ideall y ROM exercises empha ... izc acti,e mouons thaI are pe rformed two to three ti mes a da y. E\crci~c5 !l-hould focu~ on stren gthening the weak , elo ngated exten.sor mu,cles, v. hil e lengthenin g the ... honened , light flexor mU '>L le~. Passi\e ROM eXe rcise"} work w ithin the pallen! \' 3\oailable ROM to nli:J lIlt.a in range. B~(3 U ~ the...e paucnh nave a minimum of energy to ex pend and mult1ple chnll i11 prohl em ~. lht! ~ ma y bcnefif from ROM e\f'n. l ~s In ph )"' l ol ogl(~: al p~tl.Crn ... of mution . For c).:.t. mp lc.::. P~F Jl
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l"I: lil X:1lil1ll . Traditi01lul li lrclching !t'l:hn lqu('l'o l'an ul..,o hl' used to dongillt: 1ll1l!'L"ir q. Sl'ccial l'on'llil'f(Jli(ln ~ hould t)( givelllo the genll r "tretching of e lboW ncxor~ . hlp und kne.e fleA{If!. , and an~lc pl:llllarfl("xl lr,. Slrclchlllg can be cOlllblned wilh joi nl lllobili n uiol1 Icdlniqllc!o> 10 reduce Il g htne.~s of th e j(~i l1t (,H psul t: or of ligitlllc nt s lIrliund a joi nt . By usinl .. ckl'l cd grade.:, (If acc.:cs,nry movement , hOlh improved ROM and dec r~3,cd pain (;.111 he uchi cved .,,,ij StretChing I cc hniqu e~ arc an lI11ponanl ('mnponenl of the HEP. The palienl and cllregiver ~ ho tlld be in ... lrm·led in the appropri Htc !'. trctehin g cxc n.:ise:-. und the imporwnce Ill' malnlninin~ the stretch furec fur at l e a~ 1 20 10 10 :..cconlls. Idl.!ally the , tretches arc repcmcd al ka~ 1 Ihree to fi ve lime", Bollislic slretches (high-inle-nsiI Y hounci ng \ Ire tche ... , ~ hould he avoided bccall ~e Ihey are lin ked 10 incre:a,cd inju ry. Muscle tea rs o r ruptures o f weake ned li:-.:-.ucs fire c~ pec i f1 l1 y prevalent in e lderl y, scd~ nlary individuak Vigorou'l stretching can stimlll::il C p:lin rece ptor" and ca use rebound mu~lt cOnlfaclion. Palient .;.; with PO who arc elderl y and havt! long-s tandin g di .'lea~c mu ~ 1 be l.:onsidc red al ri ... k for osteo. porosis and Ih ere fore mu st be ~ Irc l c h cd according ly. The Ihe rapi st shou ld also use l.:aution w hen , 1f'I.! IChing edema tous ti ss ue. a co mmon lowef I.! xtrl!mil Y (LE) problem a.\'tOeiated with immobi lity a1\ ri sk o f injury i... al...o iucre-ased in thi \ S ilu3Ii on , I ~' P:hs ive po, ilioning. a lo ng duratioll technique f(J improve ncx ihilit y. can .. Iso be u ~ed 10 Mrc tch ti ght mUl,des and ~o ft l i ~'1 ue .., . P;] tie nr "i in hne -\ tage PD ure: Ilkel)' lo demo il lit ratc ~cVl.! re fl ex ion co ntracture !) of the trunk and lim bs. The " phantolll pillow" po!)!urc may dcvd op to "upme; th at is, the hl.!rtd and !ihOulder ... an: flexed 3'1 if there were a pillow prC"ic nl . Ea rl y 011, th e pLl licnlmay hclldl1 from da.il y po"''' ioning in prond Ylllg. A ... th e d"t:3 ...c PfO!!n.':\\e\ and \ l g nlfi c ~111 po\(urtJl dcfo l l/l ll Y and f.." a rdl url.!"'PIr3lOry imp~lrm clll " develop, Ih~ pal/elll 111:;)' no{ tulaalt rhl \ PlJ\ If/on . The PO'.lIIt: 111 'N Jlh a c1evdopHlg JJh: rJI I,.; u(vafure l. an be PO\ IIIIJIlCd ill ~ Hid Y lnt! with a , rn .,Jj P lJiO" und('f th e lattntl trl/II~. Ml.'<. h,IIlII.. :11 low /lJ.l.ci "lr ·ll.. hlllg CJtl ~ I)i) he u\ed FOf CXillIlpk , (ill.! p.H/t.' IJI V. hl' ,.., hcdndtit' ll may henefi, f rom Wt: I1!hh dPpl lt'd IIJ , .... c.IU{ c h lP ,Inti lut'e ileA' C()J1IraUlIrc' I hh ,ippfO;J(. h Ll llh/ t:' ... . 1 W~ I }J hh'd puHc:Y find tr
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Physical Rehabilitation

and h,md s wc igh lbearing on a wall can be used to promote upper trunk ex tension (c.g .. standing wa ll push-ups or co rner push-ups). . . Patients with PD typically expenence a hi gh num ber of f a II ~an d Should be .augh. how ' 0 gel up afler a fall . .To d.ha. so end .s k l·II :;:··1O qu adruped crccpin .e..- should be practice . the patie nt is uble to move to a nearby s.rabl e ch~l~ or co uch at home. The patient should also pracllce In.~n s lllOn s mov . f ron1 qu •·,dru ped to kneeling"- to half-kneelm g and finally 111£ to standing using UE supporr. . Mobili zi ng fac ial musc les is another lmp~rtant ~ompo­ nen t of the exercise prog ram because the pallent wll~ have limit ed social in teraction and poor feedin g skill s 111 Ihe resence of marked facial rigidity and bradykines ia. These ~ac[Ors can grea tl y influence the pati ent 's overa ll psychological slate~ motivation, and social participation. Use of massa ge. streich . manual contacts. and verbal cueing can be used [0 enhance facial movements. The patient can be instructed 10 practice lip pursing. movement s of the lOngue. swallo\\ ing. and facial movements such as smil ing. frowning. and so forth. A mirror can be used to provide visual feedback. In cases where eating is impaired by immobility. the movements o f ope ning and closing the mouth and chewing should be combined with neck stabi lization in a neurraJ positjon. Verbal skill s shou ld be practiced in association wi th breath control.

Adaptil'e and Supportive Devices Attention should be directed toward needs for adapti ve and supportive devices that can improve function. To promote bed mobi lity, the patient can be he lped to assume a s ittin g position by elevaling the head of the bed wi lh comme rcially available blocks of approximalely 4 in. ( 10 em ). or by using an electronic hospital bed. A simple r so luti on might include attaching a knotted rope to the end of the bed lO pull on. The bed should be Slable and the mallress finn to facili tate mobility. Satin sheets and pajamas have sometimes been helpful to enhance bed mobility. Pat ie nt s should be in ~tru cted to select fiml chai rs wi th annrests and 3\oid !'oft. low seat~ such as a low sofa. The chair can be raised (i.e., ~ in. IIO cm) and sec ured with blocks. or tilted forv.ard by elevaling onl y .he back legs aboul 2 in . 15 nn I) . Some patienl ~ benefi t from the u ~c of a rocking chair to facilitate independel11 ~i t-to~~la nd lrall~fen, . C hair!) lhat have ~pring-Ioaded :\eat ~ that push the patient into ... tand ing are heaVily marketed to the ge riatric populat ion but ~hould be u~ with cau ti on. The patient h prope lled int o Manding but may have difficuily &topplIl g the movement and/or ge ltlng IlJ ~ or her balance Within an appropriate lime fram\! when firM rt=adllng th~ ~lallding po~Jtio n . A rai.!.eo toilet ~at and toilet rail ~ are abo e~\enlial deviu;,:!!. to facillwle ea-.e of ~ IHo-~tand lran:,itlon b in the bathroom. Lorn.e-filting c10l hlllg and ~neaker') with Vdcro' do~ure\ can he UfJt:d 10 fac lliHtte ure'\i~lIlg , II the pa t i~nt demOn~trlSles a hhuftllllg gall, ~hoe') ~ h()uld have Il!ltther or hard compoMI10n ~ole\. becau~e ~hoes wllh crept' or

rubber soles will no. s lide easi ly and can result in faUs. A festin ati ng gait can sometimes be alleviated by the addition o f modified hee l or shoe wedges. A flat heel or toe wedge Ill ay slow down a propuls ive gait. wh~reas a. rai sed heel or hee l wedge may dimini sh a retropul s tve galt pattern. The use of ass istive dev ices can be prob lemati c owing to mOVeme nt difticulties. A cane or wa lk er can be helpful for patie nt s with mild to moderate di sease to assist in balance or cue Slepping (inverted wa lking Slick). Il is important th aI the he ig ht of the devi ce no t promote increased flex..ion o f .he !runk . Vert ical poles can al so be he lpful during walking (i.e .. pole Slriding) lO improve upri ght posture during walking. Patients with m ore pronounced movement difficullies and poor balance are not likely to benefil from assisti ve devices. Walkers with wheels are particularly hazardou s. and are likely to increase a festinating gait; hand brakes are an essential require me nt. Most patients use adaptive devices to ass ist in ADL. Reac hers can be used to provide ass istance in dressing as we ll as for other activities. Eating can be faci litated in a number of ways. The palienl should be sealed properly, close lO the lab Ie. with good posture. Specially adapled ulen sils. pi ale guards, and enlarged handles can aid the patient's efforts. Because eating time will be prolonged. healed plates or pads may help keep food wann and palalable. Drooling and/or s pills should be anticipated and clolhing protected. Extra time should be planned. and lbe patient should nol feel ru shed.

Balance Training It is important to recaJi that learning is task and context specific. Thus. a balance training program should include a varie ty of ac ti vities that alter tas k demands and expose the patient to varying environmental conditi ons. Whenever possible the lherapist shou ld lry lO dupli ca.e the condilions the patie nt wi ll encounter in e veryday life. The level of c hallenge is important. A th erapi st sho uld know the limitati ons of th e pat ient and the spec ifi c demands of the task and environment in o rder to se lect and progress tasks accordingly and ensure patient sa fl' ty, The re-ader is referred 10 Chapte r 13 for a mort! complett! dis(;uss ion of balance and ga il training. An important foc u ~ of balance tra ining for the patient with PO i ~ cC lll er-of-rnas-, (COM ) ,mel limits of stability (LOS) c.:o ntrol training. Puciem s shou ld be ins tructed in how COtvl in flut!llces b~lance and how to improve posrure HI !l .Ilting. 1'o tUJ1(I·mg. and <.lun ng dynamic.: 1ll0"emelll las ks ' .Patit' nh "I hou ltl al'io ex plore their LOS and pr3ctice working tOWHrJ expandin g them in bolh silting and s tandi ng. In ..,t ~lIlding, patients with PD typll'ally demonslrare restricted LOS wit h forward displ.ll'cmt!1H of cent t."f of fOOl pressure. P
Cbapter 21 Parkinson'. Diseaoe n: live cut'S t~~ f:ll' ililafc (he des ired responses. For c xam ~ I~ the patient is in1 nffness .lnd fixatio n. Srr.uegies for \:l!)- Ulf t'n\ lmnm t'nt.ll lkm .lJld ~ mclude altering the supf'."\rt ..u..'·f .h.-t" l e ~ .. :-r.UlJ lIlf, on fl."'Ulll \. \ isual inputs (e.g .. R'\lJ"....J h ~ hH .:: , ? ~ ~ ,'I ('! ~eJ L or ch:llk nging the patient 1o\1 L 1 \:trtJ ~ ;.:" l"pt."11 en' U'0f1 l11em le .g .. bus~ clinic setl."k·I{J..lt:' :,m':tf th J.nJ R O ~I ~ im pt) nant components ,l' \A. \:h ..u n-J tht" ,,' hMkng~:, of b3.IJnCt" . The patie nt ,,~ m ...~ ~ l'J l!' .. t.u-.rlU1f ' '\('n.' i ~s to enhant't" OOJ3Th:e. lUi.,; 1t.tJm~ ~'I-n o,(;'" .lJroJ h,.'\t' -o rf'_ panl:ll \\ 3.11 squats 3nd ~twlf n~, . ,;i~ - llr.t- ~unc(' nh SJJt"- l l': S or rod •.· ~

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locom(){or Training L.:..

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879

ve rbal c ues to " walk tall ." Gait training us ing an overhead ham ess also ass ists upright posture. The harness eliminates the need for UE weightbcaring inherent with the use of ass istive devices. a practice that promotes the forward fl exed posture. The harness also protects patients from fall s and all ows faste r speeds than normally achieved. In studies o f palienls with PO that combined use of an overhead harness with wa lking o n a motorized treadmill , both walk in g speed and siride le ngth were improved. 16f ,162 Miyai et al' 62 prov ided support for up to 20 percent of body weight w hile Pohl et a)l 61 used the harness for safety and did nOl , uppon pali ent weight. In a foLiow-op study. Miyai et al 1o) found that gains in walking speed and num~ ber of steps following this type of training were maintained at 4 months. The researche rs state that attentional strateg ies were not used and spec ulate that the enhancement of ga il mi ght be due to activation of central panem generators as is tho ught the case in stroke and SCI studie s. Gait training strategies to normalize step length, velocity. and ann swing excursion include the use of verbal instructional sets (e. g., "walk fast," "take large steps." ··walk while swinging bath ann5·). Behnnan el aJ ,.. found that commands for large step and ann swing were more effective insrructional strategies than the command to walk fas t. As previous ly discussed, vis ual and auditory cues are also effective in improving gait speed and step length. Strategies to improve foot placement can include use of floor grids or foolprints o n the floor. Strategies 10 improve step height include praclice of marching in pl ace progress· ing 10 walking using an exaggerated high stepping pattern. Brisk marching music can be used to enhance pace. SideStepping and crossed-step walking should be practiced. The PNF aClivity of braiding. "hich combines sidestepping with alremate crossed-s tepping. is. an ideal tr.lining act]' jty for the patiem with PD because it emphasizes lower (JUnk roration \,I; ilh Stepping and side-stepping IDO\ emenLS. It can be practiced Yo ith the patient balding on lightl\" 10 , dowel held jointly wilh lherapist or as a free " alking pwern. T"o do"els I held b. the patient and therapist. one in each hand) can be used 10 facilitate reciprocal 3!1Tl s\\ ing during gall. The therapist use h13 or ber ann , .... !fig 10 >hISI tbe pall""'-'. Task peciflC training should .J.J4iO lOC fude prx:uce In cbanglOg dlrecriorb. turns. and Ik"goo.:u. ng 13C re.s.. tr.lli"~ ~ tor \.lr) mg emuonrnemaJ demands. inctudt :llll!nng the "l:pport ~ r f lll.c tc .g _ .. 3lk.mg 00 a tile tJoor 10 .....J.l.in un carp:'~ to .. aJimg OUIOoors 00 a gJ3$.\} &err.uD ' ..'JJ "IJ1f:ooes (e.i!-. f.... '. \ . m;>u".boJu1d be \:uied Ie g . redoced hglu"'f.eyes " .• n., pwcru .bo..1d halJ.eoged .. lib -aIbns in " \ MUb..e ..-.pen ('r.\o lI'OOrl'Ient { t.. g.. cl"tf!MDMlf) vialbocJ. n.. pol""" an p ....."""'" .wt cbmbiJl!. up and doot" ",...t-.. and ramp P.woeou m tbe a6 :ot
880

Physical Re.habilitation

, Iki lll.! while 1l1~li llwini l1 g safclY an d prevent ing fa,lIs. ~~nlpe~t~aIOry tmi ning strat egies arc indic!llcd . FrcCl ll1g

. 00"" are common and arc often resislmll 10 drug therapy. ,--, . . _ . T he thempj ~ 1 and pali ent sho uld Identi fy ;] 1l ~1 prac~ l ce CplS

I Ice"ies for unfreezing ga il. For ex amp le. .rOla l1o. nal sllln sm I ··,r, · ck·· ,novcmcnts such a: o . clro pplllg a t iss ue l1al · uIallon or ' . the pa l ienl Illust :-;tep ove r can IX" successfu l in reduc in g frecling .l"~

Cardiopulmonary Training Respi ratory dysfunction is linked

10

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fi tness. Ca reful moni tori ng is indicated, as autonomic dysfunction is common. L-Dopa can ~roducc .arr~ythmia.. and ortho~tat ic hypotcnsion alo ng with dyskmeslas. The ,herapisl shou ld mon itor ECG changes. hea n rale, blood press ure. RPE, fa tigue leve ls. and symptoms of ex.enional intolera nce (e.g .. signi ficant dyspnea. hypotensive response, se ri ous dy~rhythl11ias. and so f011h). Train ing modes typicall y incl ude LE ergometry. UE ergomctry, and walking. Scleclion will depend on the spec ific ab ili ties of the palient; for example, po~tu ra l in ... tabi lity and increased ri sk of falls may ru le ou l usc of" treadm ill wi thout an overhead harness. Recumbent or se<J1cd LE crgomctry is a suitable alternative. For most patients a progra m of regular walk.ing is recommended. The du rati on. speed. and terrain covered can be modi licd. based on individuul abi lity. Accessibility to a s upervised wa lki ng program using an indoor wa lking track is impo rt an l for some to ensure safety. For outdoor wa lkers, a shopping mall can provide an acceptab le envi ronmenl in case of inclement weather. A superv ised aerobic pool program can also provide an acceptab le mode fo r some patients. The warntlh of the water may be re lax ing and the buoyancy may enhance movement. The mi ni mum recomme nded exerc ise frequency is 3 to 5 days pe r week. Daily wal king with short bouts throughout the day is recom mended fo r individua ls with lowe r functional capacity. Intcnn itten t exercise wit h repeti l ive ex.e rc ise- rest peri ods is indicated for those patients who are elderl y and decond itioned. and who present with pulmona ry dysfunction. Aerobic mdning prognuns have been shown to be safe and effective for patients with PD in improv ing aerobic capacit y..~lI·I ~ ~. IIJ'j

Group and Home Exercises Group exe rci ...e cla~scs ca n Oc va luable: fo r paticll t~ wi th PD. Pati c nt ~ bcndit from the positive suppon. camarade ri e, and cOllllllunicatiull the group ... itutl tion otTers. Careful e Vi.J lui.l1 101l o f cach pa tie nt prior It) alimiO:;f..lOn into II group i ... ~\!'tl: nt ial. Palic: nts .. hou ld be ;lhlc 10 pe rfoml tht IhcrupclIti c cure of till' <.:I" ........ Sl'Ic( tm g palil'nb with !)imilar lev\!J-... I)f UI \:'lbilll y I' ohe n ad\ bahk' Ix .1t.I\C th~ ~n5e of c.:O nll)cIJlitln l:an fn.·qucntl y 1-x: .1 ~ ~)' IHCtur In fII(ltl'/ a ling grollP~ TIll' ratio of ... 1U1I 10 pmil'lIh I
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pulleys. and so (ol1h ) ca n al!'io be u:-t::d. Ex~ rr i st~s done by the '" hole ~roup lll£l~ lh('r ~ h tl uld f',K lI;;;: on IIn pu rt :ml exercise go.1h; (('.g .. im pmv ing ROl\'1. mo bility. and so fo rth ). Recre:tl ional nCll vi lic:-. can fo ll ow the [le mbic po rtio n. s li c h as lint' danci ng. ha ll aC li\' ilie ." l~a ll bag lOSs. ano St) fo rlh . TIle acti\'ities sc k,,:u'd shl'\ul d be illl crcslinf:, :lIld varied. Finally. J rt" la.\:llio n tra ini ng ~t'g IllC11l s hould be illl'orpo rJ led inlO eac h cl a5s. ' 71

The HEP includt".. Illan y of 1he interventi ons already di scussed. wilh excrd ..~ s dcsignt"d 10 improve rl'l ax~lIi on . ncxibililY. strength. and can..tiopuhnonary function. A key c le men; il' strcs:;.ing the il1lpon :ulI:t' of regular daily exercise and a' oidancc of proloJl~l'tl pa iods of inacti vit y. The HEP should be realisTic and of modera te duration ~nd in tensit y. The patient should bc cauti oned agai n ~1 overdo in g ac tivi ty. which coul d re:-uh In cxccs:-.i vc fa ti gue. Early morning w:lJTn-up calisthenic:-. arc ofi cil helpful ill reducing the increased !'tifTne ... s parie n t ~ may experience upon aJi sing. Strelchi ng and streng then ing exe rcisc~ are pe rfonned in supine. :-Inmg. and :-t3ndi ng positions. Home ROM excrci..-.es can oftcn be as:- istcd by use of adaptive eq uipment. For example. to red uce the eO·ec" of forward head and kyphotic JX>Slure. the patient can be in ~ l ru c l ed to hang by the hands using an overhead bar. Standi ng. comer wall stretches call al so be u~ to provide a mai nrallled stretch on rhe upper trunk flexor,. U~e of a \\ and or cane can be effective in promoting overhead m o t i on ~ . In standi ng. a countertop or hack of a li:lUrdy chai r can be used 10 assist in stabi lization during SLlndlllg calislhenic~ and balance aC l iv ities. 17~ Lu n et al17 ' compare.d the e ffec l l\'ent."s~ of a 'ie lf-~ uperv i '5e d home exe rcise program" ilh a ph y!) ical the rapi~l - ~ u pe rv i~d cxt!rtiSl~ program and found both v. ere eq ual ly effecti ve in im prov ing molor ~y mptOrm, In PD.

••

sll ccessfull y dell] with the changes associated with lhe dla· ea«', lit hers are 110 1. Cop ing skills cun be radlil4ted. Pint :lI1d foremost education i s the key 10 Rs~isting patient! and fa mil y membe rs a s ~ u rnc responsibi lity. Feelinglt of hope. ICl'sness :1I1c1 clc pe ndc ncy arc reduced llS the patient devel.. op!' a Sf'nse of coul ro l ove r his or her own life. Setf·nuu1~l gc l1'l e nt ski lls th at should be promoted include oov8nced pllllllling o f ltL.:1 ivitics. efft:ctivC' time management strate-gics. and !'tress management techn iques. II is equally imporHlll1 to en!oi urc thai patients do not become isolated and Ihut appropria te services urc ava ilable . Tenm me mbers must he vi gilant regard ing the ir assumptions and expecta. tions. A cO ll d c~cc ndin g or pessim istic und limiting attitude can become a self· fulr.lling prophecy. Patients and fMlily 1nt:'lll bcrs need reassurances and encoura gement. An overa ll e mph asis o n what patients n Ul do rather th on what they cannot do helps to empower patie nts. Therapists need to provide a message o f hope lempered wilh realism.

Patient, Family a nd Caregiver Education T he inte rdi sc iplinary team prov ides info rm ation about a va rie ty of to pics re lated to li v in g with PD. These are prese nt ed in Box 2 1.6. Inte rve nti ons can ta ke the form o f d irec t o ne~ on -o n e in struc ti on , gro up sessions. printed materia ls. and video or comp ute r presentations. The thera· pist 's ove ra ll approach needs to be pusitiv. and supportive.

Box 21 .6 Elements of. Patient, 1'''''lIy aad Caregiver Education P, ....... • p..u1Unson·, dise-JS<:' clinical pte"""';"",,~ '"

Psychosocial Issues

manage symptoms

The prog re''}.,i\!' nature 01 PI) nc(·e . . !ooitateli: frequen t perMmal and '(I(,~ 1 "dJu,tmcnh. and affec ts all a"l)Cth of life for bolh the patle nt and lu mi ly_ D, ... rupt lon in d~u l y fUllc tlon .... roit.'!oI . and i1L'tI\ IlIc,) arc cXjX! r ll:m.-ed . SI )!))e 0 1 the

t."hange~ a !:."IX:I O.\II~d with rD an: ....(K:lally i...,-o htlin,g \II) ~"k t:d face. progre,::.,,,,ve Hnnu,hdJl y. and uni nte lli gi ble "pcl:ch) ~~li . mhe!' ch;.m£e\I Ult:f..:u-.cLl \alivii tliHi. pcr"'plf:.I1 11111 , ,ea~d M!~ udl tUflulon, ar",' dl ... lfe...\IIJ!' and

G UI

be

wx.lall ~ CmbolfT~l\"lng Tht- pdlu..:nt nUl ) fee l 1I1CTe;t\ lII g l) I~ated and huntl y 1t.-la liCll1 t. h'IJ \ ma) , ufter J)~p,-t.,!!ojtJJl 1\ tXI(t mel y lumJUun -l A f... ulnprd1elh l\,1" (:"\;~ JU (tII()Il I" '.needed w dc:terrntnt eiidl lIIdl \i .duul ... Ul uqu~ ..,Jl UdIJ OIl and

emotional re\'JU((..C\ 1l~ pnnn pal gnCLI

fOI 1e<111I

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patJeJll.a.ad taml l) III UWI! uhde l :!lot allLiJllg of the d l.seol\(.: uno

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• Medica,;on" purpo;e. oo.a,o. poNible " " _ . effects. &igns of either over~ or undrrmedk-.doa • Prevemal i\l(: measure" to minimiu lbe ~onduy ~ c alio,t~ and impuinneniA • Impuc! of PO On nto.." ...t and elfocll'iC SII" e'w 10 lTuUlagc m o vement proble1'nj • Darriers tv e•• rei.. aM dfecilv&lIQIuliollo .., . .

,.11*".-. ",'11>.

eXerCLie pan icipil!ion

, Im"""t or po on l\ulction and oIfOd.... ,nainml.. """'pendent r.....'Iim i4 c

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882

Physical R~habilitalion

'IY
:l~hancc

to di!'cU5S common issues. problcn~s.' ~nd ,manThey al~o can prov ide a Sl3 bl h z lIl g mllu accmcnl lip. . " . h althy e ~ce. assisti ng pati ents and fam ili es to foc us on c. . . op,·n. skill s. and effective self-management behavIOr!'. c ~ . " , " For some pa tients in the earl y stage!' 01 the disease. ~ar1 lc­ . . . a
.:;

cia li ons, ~a lion al Pa rkin son Found a tion (NPF ) 150 1 North ",es' 91h Streel (Bob Hope Road) Miami. FL .13 1.i6· 1-107 Web site : http Jlww"" parkinson.o rg Ph: (800) .1 "7·-15-15 E-mail: mai lbox@ pJrki nson ,org

Pa rk inson ' s Disease Found a ti on (PDF) I:;59 Broad way. Sui Ie 1509 No" York. l\'Y 10(118 Web si le : ww\\ .pd f.org Ph: (800 1-15 7-6676 E· mai l: lIl fo@ pd fo rg The America n Par k inso n Disease Association IAPDA I 1"50 Hyl3J1 Boule\ard Sui le 4 · B Sial en 1
Management Considerations by Stage of Disease In the t: i1fl) .,wgt:., 0 1 the d l ~.t~, pallt ill " art: l u nl.' l ion~11 .:nd IOdtpendenL. n lt» afe Ij p u.: all > ~~ II un .1Il o utpiJ lJ e nt ba'I!)'. \ 1t>d I .... tt I Ihtr"l ph.~o" lila) H1Cl lJJe the: adlllllli o" lralHln hI ~dq!l ltn t' to !>. t :i) Iht' ne..:d l o r I -dop.1 dno o ther dru l!, dt"'dg lJed p ro\ Idc ... ) rn plOm:11ll Il;! iu: f A n: krral ph:.,h. rt l ( hc r",p~ I.., n tll.:n dC' i.1yed il l Ihi .., ~ 1.l g\.' , .j l l h nu ~ h ll'Cllc:lll~ lould t lea r! , IX' o ht" J II~d DUll nV Iht:" e ~I " 14j;c" . InlCf\c::n1 10n, "rc U1u ll.. .lk d IIMI lol..u,> ti ll PI I..'\C' . ; wIn or 1t: \ ('f, o:!l 01 IIlu, ... u l o"' ~ t: i e la l /.I 11l...! ( ltH.l l l u n pII J lC} f ) I m p ttlllfl t' IH ' dHJ iIllp'"\l' n ll." 1I1 11 gc nt'r.lllt t· ,llth '> 1" l u ~ Littl~ t: J Uc..: ~Htlh tor I'o.tt h IH (. •.111 prll\ Itk

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. g ful as,, ,' ,. ' a nce in un dersta ndi ng the di sease ......... meanIn . -~ it s ram ifi cati o ns. Ea rl y refe rra l to s uppo rt groups IS also he lp ful · ' . Du ring the middle stages of the d Isease. symptoms are mo re readi ly appa re nt ~lIld functi o na l limi tati ons emerge. T he pat ie nt ma y still be ind~pendent in gai t and many ADL. a lth ough performan ce IS s lowed a nd less effi cient. Some ass ista nce m a y be requ ired. Treatme nt with L-dopa is Iypicall y de layed unlil the ea rl y m idd le stages, althOUgh indi v idual diffe re nces e xist. O nce pl aced on L-dopa patients may exh ibi t a d ram a ti c improve me nt in symptoms. most nOlably in ri g idi ly a nd b rady k.ines ia. The ali ev iation of th ese sympto m s does no t always prod uce a simil ar level of improveme nt in fun cti on, howeve r: poor habits and faulty postu re may have deve loped, Exercise training programs have bee n show n to be e ffecti ve for patie nts with mild to m ode ra te PO in im provi ng mo tor pe rfo rm a nce., s7,JS8.17s-178 Pe rce ived quali ly of life a nd s ubjec ~ ve we ll-be ing is also improved ,158. 179 Famil y and caregive r instruction is inte nsified to ass ist the patie nt in re m a ining fu ncti onally mobile . Patients with late-stage d isease Iyp icall y de monslrale a number of compli cations inc luding pha rm aco logical intole rance . inc reased p ri mary symptom s , fi xed musculoskeletal impaimlents , a decline in cog nitive functionin g , sleep distu rba nces. in co ntine nce. m a lnutrition , s ignj fic ant cardjopu lm onary com promi se . and seve re immobi lity. Patients are de pendent in m any or most o f the ir dai ly functional mo bi lily sk ills a nd ADL. The y m ay be w hee lc hair bound or bedridden . Fam il y a nd com m un ity resou rces a re vita1 in ma int aini ng the patie nt in the home. Some palients may req uire place me nt in a c hronic ca re fac ility. At this stage of d isease , patie nts ge ne ra lly do no t respond as wdl to medical ma nage me nt i.U1d experie nce dec rca:.; in g effecriwness of phannacolog ical inte rve nti ons, nu ctU' ll ions in perfonnanee . and ad ver"e s ide e ftl:!cts of lo ng -te nn L·dopa medication, These c h a n ge ~ can be J so urce of g.rC::.1t frll slra(ion to Ihe pati ~ ll t a nd famil y. Goals Hnd t',\ pec ta tions need to be restruc ru red . Du rin g laiC· stage d i ~eas~, the therJpisl needs (0 focus 0 11 skin care to H\'old br~akdO\\ n and pressure \\OlHl (h. pu lillo nary hyg ic nl' 10 il voi d pm:,· umonia. and i.t~~ i ... tan ...'c in po..; it iull lll g and feed ing 10 a\,o itlmaln utririoo, ..... pl rati o n. :.1 1111 pncullllm la. Caft'gl\ t' f Irainm g becomes in(' re ..... in g ly imro n ,tllI . Safl.! l\, fnr hoth lht' cart!giver and 11ll' pall e nl ilt"COlTh,::'" 11 pri ma l) c u n('c rn u:') pa tieOlS are a'''' l'. lcd in IXh ll illH Ch..lIl ~e , In bed tlr JU ri ng t r.Ul~fers . P.. It Cllh ~hollid be ~ f1"" llllra1!L'd .tnd J !>"' I!'Io It.' d 10 maxim ize ou t o l -I\t..'d lillie and Itl 1110 \ ; .1' Illudl a, po!'lo !> lb lt: and not <111 1..1\\ l'\l.·I}lhlllg 10 lx' d .. lfl~ to r 1 h~lJl . O ilCU, C Jl\o lron llll'lII
he ' UPPt.lfllh' \ 11 Ihe rMU CHI \ t' ffl"lrt'i no Olal1~ 1 hil"" 'lI1cl ll thl" Y n la) Ix'. l'a lic llr... in l.tll..·- ... tagc p~

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ai,,, 'I li tl er tlo lll Ihl.: IIIt.: rl.'lI~ ing dt·mands

Chapter 21 I'lIrIUIUOD·. 0;...., of cnn.... bumo ut . and social iso lation. Thera pists need to maximize psychosoc ial SUppOr1 and be read il y ava ilab le for consultati on.

Summary PD i~ J chronic. rr{l~n."s~ive diso rder of tht.' ba ... al ga ng li a ch.'lntctt"rizcd h) the cardi na l features of ri g idi ty. b rady ki nesia. tremor. and postural in ... wbi lit y. Add itio nal im pairmenb include the dc\ elOpl1l4..'11 1 of ahnonnal fixed pos lU res. po\'erty of movcmenl. r. lIig ue. nu,l"ked face. colll raClures. a festinating ga il pallem. ~wallo\\'ing and communica tion difficullle .... \'j<,;u31 and sen!'.orimol0r dl stll rbancc:-o. cognitive and behanoral dy~fun4.., tion. autonomic dysfunctio n, and c.:lTdlorlilmonar~ change~ . Phannacological interven -

Que s tion s

for

e

7. Identi fy three interventions that can be used to relax the pati ent and improve flexibil ity. 8 , What interve ntions strategies can be used to improve card iorespiralOry fi tness? 9 . Desc ri be the gait impainnen ls common in patients with PD. What interventions can be used to improve locomotor fu n c tio n '~ 10. What types of intervent ions are appropriate for the patient w ith advanced disease who is relatively unres pons ive to drug manageme nt? 11 . Different iate bel ween a re habilitation program with a resto rative focus versus one wilh a functional maintenance focus , Consider goals. outcomes. and overall lrdining approach, 12. Whal are the major conside rations in providing psy. chosoc ia l support ? Palient. family and caregiver educalio n?

S tud y

1be pau~nl 1\ a 6(1- ) l!df~OJd \010- \ 11111..111 ..... Jlh a 7- ycllr h l:-.IOr) of PO Lutc! ) "he- h,, ~ ~ "p.:I1e ncc:d lfll'rt:a~lnl! '>C\t:rt t y of ..ymptC'lm ~ and l !lo ft"kn . . . d for uUlp,mcHI ph ~ k~1 tht"Htp> imd It hUIH(" t lU' lc.. 1Jo.e program IHI ' PJ

HISTORY

n.e rnlhenl flrohl pl C'~nlt!d

\4 illl IICIi'l(tr of h r left hand "'CJ@I'e:IrI~ It) lUc ludt hll ft lle~~ and 1tw~wardJ'h!") 0 1 htr itTt UL arid LE. fkr Ituml} ph) "IClan reft·,ycd her to

thai

tions have beco me the mainstay of treatment and provide protecti ve and symptomatic treatment. Effective rehabilitaI ion foc uses o n the patient's stage of disease and symp-. lo ms. fu nctio nal limi tations, and residual abiUties and asse ts. Interventions are restorative; that is. rehabilitation is foc used on the im provement of strength, ROM, tuncI ional skill s, cndurance, and so fo rth, Individuals with 'PO a l s~ be ne fit from fun ctio nal m aintenance programs dctil gned to manage the effects of progressive disease. Strategies are deve loped to prevent or reduce indHect impa imlents. and promote regular exercise, good heahh~ and self-management skills. A comprehens ive team approach inc lud ing active involvement of patie nt and family provides o ptima l be nefi ts. Team membe rs need to be active du ring all stages of the d isease. assisting the palieol and fam ily in mai nt enance of funclion and prov iding psy_ cho soc ial support as needed .

ew

1, What M e the major eNS ... I.ructu re~ invo lved in PD? Ho" is the fun ction of the~e struc tures a hered ? 2. " 'hal are the cardinal features of PO" Addili onal impal.rrncllls and complicatiol1.!lo? 3 . Wh31 componen!> ,hou ld be incl uded in a phys ica l {herap~ (,.\amination? Identify fo ur sta ndardi zed me a..'\ ure ~ thai "'ould be appropriate to use wi th the rauent " ith PD. 4. De>cnbe the drug therapy used in PD. How mi ght a ph ~ " cal lh erapy p,ogram be inn uellced by L·dop. drug maniJ gement ? 5 . What are the maJur goal!, and nut Qllle) of phy~ic al therd P~ illl en enll o n? Ho\\ might t hc..~) \ar)' b} stage of d l~ a !.e ·1 6 . Wh.ll are the effect... uf prolong('d lIlacti vi ty fo r the pali~flI \o\lth PO'! Jdc llIif} three II1l e r ve nt io n ~ that loan be u ~d 10 c.OUllle racl Ihe ..,(' ellec..'b .

c.

8IJ

a neurolog l\ t 'A' ho found modenue lfenlOf" and rigidiry 00 Ih,· left .ide. He prescn bed Artalle. which was hd pfu1 fQr a Yo hil t. Eventuall y the tre nwr ba.·C81~ worse. especially unck r condi tion) o j ~uess when she Wtbi unable &0 use bar left UE al all. She "as then Slarted OIl Sinernet ond r< ten..d for.n miliJI e vr S_ine n~1 w~ lncRased.

.y....-...

884

Ph ysical Rehabilitation

CURRENT STATUS The patient is c urrently taking Sinemet and , Brom~ripti~c. She repo~ S bo II ts of dyskinesia . aboul 45 mmutes . . 1I1tO tn ing her Sinemci thai involve involuntary .wnlhmg ~ov~e- . menrs of he r shoulders and neck. He r chief complalllts are. I D' ffi c ult y walkin g. especially whe n she has to go

.

lh~O~gh a narrow dOOf\vay. o r walk. in a crow~ed pla~e,

2 E . odes of gai l bl ocks: if she trieS to do somethmg . w~li~e walkin g like take a ti ss ue out of he r pock~l . she bruptl y in he r tracks The harde r she tnes to SlOpS a ' . h I .ted move . the worse it gets. Episodes offreezmg ave as up to 20 minules. , . . 3. Postu ra l in stabilit y: over the past few years she has experie nced inc reas in g bouts of u~ conl~olled or unsteady balance. This is parti cularly ,dl s t~rbm g to her because if it occ urs while she is walkmg. It causes her to fall. She has fa lle n seven times in the past month. with no resid ual fall inj ury. Because o f her increased rear of fall ing, she has Slopped going out by he rself. . of. She is expe rie ncin g increased diffi c ulty rolling over I,n bed. getting o ut o f bed . and standing up from a chau independe ntl y. He r hu sband now has to provide ass,istance 90 perce nt of the time to accomplish these activities. 5. She repons hav in g troubl e sleeping at night. She has Slopped drinki ng coffee but thi s has not helped . She wake s four to fi ve times a ni ght , and requires assi stance from her hu sband to go to the bathroom at night. She al so has hallucinated at n.ight. claiming to see bugs on the wal l. During these periods she becomes extremel y frigh tened . 6. She complai ns her medicati on seems to be he lping less and less. If she plans to go out , she takes an ex tra Sinemet. She revi sited her ne urol ogist in hopes thai he \I, ould I11crease her dosage . instead he to ld he r the symptoms \\ e re mOSI likely the result of excess medi cati on. He instructed her not to lake the extra Sinemet and has adjusted he r do~age .

EXAM INATION FINDI NG S CI)~ni t i() TJ

Alert .on eilled X 3; ~he is di~pla y in g mi ld impairme nb in shoTt -te rm memory,

I' .. yc h u~( Ida I She i~ ~howi ng , ign ... of de pre~~i on ; she i ~ le!<-, IIHere" led In gOlng out and ~O<.' i a li l l n g: ~ he re pon ~ " 11 is ju ~t too much eff ort "

"iX'l'ch Mild d :r~art hlla, h}pophonia. "c ll ~alion

\ hghtl y de( rta~d pm pnoct' ptlon bil ateral! ) tn IXlth anl..le~. otherw l-.e Int act.

Tonc Rigidity (cogwheel type) moderate in all extremities L:> R. Marked rigidity throughout neck and trunk . Masklike face . RO ~I

Decreased due 10 moderate rigidity; limitations noted in: Bilateral elboW extension (10 to 140") Bilate ral hip extension (0 to 10' ) Bilateral knee extension (10 to 120') Bilateral ankle dorsiflexion (0 to IS' RLE; 0 to 10' LLE). S tJ'c n~tb

Generally fair (3/5) to good minus (4 - /5). Poor (2/5) dorsiflexor muscle grades noted in both ankles. ~ lotor

Function

Moderate to severe resting tremors , L hand > R hand. Bradykinesia: marked slowness. poverty of movement. Hesitation on initiation of movement; frequent arrests of ongoing movement.

Posture Forward head position; flexed; kyphotic spine. Stands with flexion of hips and knees.

Gait Ambulates independently with a Shuffling gait pattern with decreased step length and arm. tmnk , hip and knee motions; tendency for propuls ive gait. Frequent freezing of gait.

Ba lance Dec reased limits of stability. Patient 's forward alignment inc reases he r tendency to faU forw a rd. Silting statk control : good (able to mai ntai n baJance without handho ld ). Sitting dynamic contro l: fair (acce pls minimal challenge; a ble to lift both arms). Sta nding s latic control : good (a bl e to mai ntain balance witho ut handho ld ). Standin g d ynam ic contro l: poor (unable to accept minimal chaJle nge with out handho ld ), She h Ull ~ I owed real..'tions to l os~ of ba lance with decreased rotationa l lllove l11c nl $ of head/trunk and i ne ffecllv~ use of stepp ing s ITafl!gies. Tim i'll Up & Go Score is 36 seconds. Pmi~nt i ~ fearful of fa ll ing.

I' unctiu nnl ~l uhH i t\ Ge ne ra ll} dt:crea ~cJ . ReqU iTeS J1"1odCl1Ui." Jss i"it: roll ing III bed, suplOC'~to-sil I mn~ fcrs, S IHo-~ land tTan... Jt:h. n.lhll· to hnligc l'Jeco ndaf) to hlp Il,!l(,ion contracture' .... P.lt lent hU I) good sutCI) awllrene~ ...

Chapter 2 1 Parkinson', J)geue

Requ irt":- OliulIllai il.s:'\I .... lnnl.;t' h I 1<. tlp{" rvi~i(,t!l for Iceding. ;I!>..s l :-.I f~lr

minimal 10 1l1Odcr:lIe ,in';.. " i n~ /b:lI h i ng .

Rl'qUlI t '!'

h.lll~'"

b. Ind irec t imp~lirl1l e nt s

F IlIh.: tiIHI/ E ndll rt1l1 (! C

( : lln Ji n plllnH 11 1:1 r y

\U f'p<"' r rc . . I'Ir;Hor: ) hreathing patlen}.

Gl'm~rnn~ ciC(rt:'a... l'd fUIKtinnal c:.t p~Kil) (estima ted rune" 110031 "l"'rl... nlp;ll' lI~' I F\VC1I~ () I11claholic eq u ivale nts

IMFT,Il. L1tlfUC" ca:-.d~ .Hld f(·qUil'l· . . f n.'quen t res t IlCnll
~lJn

InlJ(l.

arc:l' of l'fl',lkdo\\ n .

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of mcrca,eJ

GUIDING QUESTIONS I . Idclllify/catcgo ri Lc thi s patient 's problems in terms of: :I . Direct impainnenls

pef'piratinll.

c '-:un c tiona l limitations d . A c ti vi t y restricti ons/di sability 2. Identify IWO outcomes (th e remed iation of func tional limitations and di sability ) <md two goals (remediation of impairments) for this patient. 3. Determi ne four treatment interventions that could be u ~cd at lhe start of therapy to achieve the outcomes and goa l... provided for ques tion 2. Provide a brief rationale fo r cacho 4. What mo tor lea rning strategies wou ld you use to assist in improvi ng her mowr function? 5. What strategies wou ld you use to a"isist in the development of se lf-management skills and to promote quality of life?

References

4

Rawui.

' i. ~1

rSl:1.l11

S and \\ t' U~1" \\ l ed q Parl...m"ou ·, DI"ea~e-l)ia gnosl~

RftJpul -\ rpldCmIL\I\ 'g~ (If Pltr~1n'-Qm'm In

3IlJ C!J :u..:a1 \1Jnsgl'"mrnt Ikm()<. \t(dlcal Pub h~hun£ , 'l'('\\ York. 2(Y'': p ~I ra.rLn",\(I J A.n E.. ,a\ un (he Shat...Ulg PJl .. ~ SheNood !'It'd), & Jone.... L,:I'I1J. 'Tl 1"! 7..("lU~~\ \\ ,'I a.I TIlt hctem::enell) 01 ParLH"I .,(lf\'" I.h-.el)'-t,. ("lm..: .. :..mJ 1'H1~llC>'"u<. Im phCJ1J\llh "eu roh)~) 1 'i21. 1985 . ~,\la:"1 \\ ('I..... ~I1 I(:.UI\)f') (If P .. rk tn.... \L"lhlll. In )(" lIef. W le(H

H.l111..1b.:"\o; ....

tt!

PlIr\..IIl"'"lr\'" DI-.c:It~ \iaKC'1 DdJ.. er. S ("1A YI'r~ .

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s.... .\..,

OA"", Aetltnt;!> IflifperCu llm... !'o c.-\Iro 'tvr\.... li:AO l.-tn!- .;j(lt> J\\ 4!ld B:d1.)1\1 I)' Quool( rarl..m"4)Ilt:-ttl til humam due

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119:55 1. 1996. 127 . Taut. M. e t al : Rh ythmic auditory stimulation in gail training fo r Parkinson's di sease patients. Move Disord 11 : 193, 19%. 1 2~ . Frccmun . J . e t a l: Thl' int1ucnce of external timing cues upon the rh yt hm (If volunt ary movc menTS in Parkinson's d,sease. J Neurol Neurosu rg Psychiatry 56 : 1078. 1993 . 129. Dibble, L. and Nic hol son. D : Scnwry (ueing improves mo tor pcrform :mcc and rt!habilitaTion in persons with Parkinson's disease. Neuro logy Re port (now l NPT) 2 1: 11 7. 1997. 130. Bage ly, S. e l al: TIle dfect of vi<;lml cues on the gai t of independently mobile Parkin son's patients. Phys iothcrapy 77:415, 199t. 131. Dic tt:, M, et al: Evaluation of a modified inverted walking stiek as a lreatment for P:.lrkin~onian freezing t! pi::.odes. Mov Disord 5:243 .

1990. 132. Dunne J. Hankey, G. and &lis. R; Parkinsonism: Uptumed walk.ing stick. as an aid to locomolion. Arc h Phys Med RchabiI68: 380, 1987. 133. Lewis, G, Byblow. W, and Wah, S: Stride length regulation in Parkinson's disease: 'nlt~ usc of extrinsic visual cues. Brain

1n 2077, 2000. 134. Eni, G : Gait improvemenls in parkinsonism : The use of rhythmic mu sic. lnt J Res II :272. 1988. 135 . Enzcnsbcrger. W, and Fischer. P: Metronome in Parkim;on's dis· case·. Lancct 347: 1337 , 1996. D6. Freedland , R. et ill: The effcct" of pulsed auditory stimulatio n on various gait mcasurt': m e nt ~ in persons with Parkinson '.~ disease. Ncuro Rc habil 17:81. 2002. 1:\7. Jahanshahi. M, e t al : Scif-inili:l1Cd versu" ex ternally triggered move ments. I . An investigatio n using measurcment of regional cercbral blood fl ow with PET and mOvcmenHc iated potcnriuls in normal ~nd Parkin~on 's disease subjects. Brain 118:913. 1995. 138. Dam . M , d al : Effcc ts of conventional and scnsory enhanced Imy .. iOlherap)" 0 11 disability of Parkini'oQn ·:- di ~case pa,ient~. Adv Neurot

69:55 1, 1996. 139. Mul ler, V, e t :11 : Shon -term effect:. of beh;lviorul treatment on movement initiation and p!.J!>turai r.:o ntw! in Parkin.,on·s diseas~ ; A controlled clinical trial. Mov Disord 1~ :J06, 1997 . 140. S utecraw:l u ,manon , M, et :11: EfT~cts of vi"lIftl lind auditory clles on ga it in indlvidu:l l.. with Parl.tO ~O Il -": di~ease. J Ncurol Sci 219:61.

2004. 141 . Nie. uwboer, A, CI (,n ~c: of IUc~lia! JXllllomrdull;;ary rcllcul,lr IlCllmll~ dUrlHg rqN;:1II1~c CUlaIlCpU". vc~tlPulut, curllcal ,tIlJ ft·~ tnl ~JHnuhIlJi)n J Ncurophy\ 11J1 \') ' ~04 , IQ7tJ 1-1 :5 \ .. hcul..rnan. M. cl .\1 . M"rlageIJl WIth Pl.IrUllsofl ·.!t tiJ ,C d'< tbllcJIlalt' "nd ('a\c .loIIlJln . l'h}" 111c( 69·9-W . 1\18'). J-I6 VI"'. D, \' 1 :11 i'r1'pnu,.:cpuVt' N~· Ul om u ..e uJar f'oiCihwlI OII, led J. IIMjJe:! ,\;: R'IW, Nt~ Y,)(I- , 1')85 147 Ik ,hol l, It I ll\! k ci:l,ar inll Ke)p<}fl,"-' AVI'", N ....... Yor" 1975. ' -I ~ J.tlObllUn, J-' IJfII!!\rt·," lvc KdaAlIIU" \ lllH\eo.lt y of ('tuClt81J Prta.~, C hll.·a~o). 19'1( 14'1 K"I!\'H buOl . 1-: MotuiJL.lliufl 0 1 the F'Irt'/l,II) J (l1nl~ . EAltlUUlatlotl ..md B ;\~tl I rejjlUl('n l " Cl h.lu-.uc" Olaf No,.lh Hol.handcl, o,IQ.

I~)

NI.f\... ;j v. II/XI, KI ... Jitr, ( ... ("/JIb). I . IllCr;l~tllll EAl!rt lo,c l Wllwhvu" INld

,I'"

J e\.h ' "'IIJ('~,

cd 4.

'An·.. 1.,1111!iI(1e1Jlllla, 20:12. ~

888

PhyaicaI Rehabilitation

th . ' . patients with 1S1 . Glendinning . 0 : A raljonaJe for strenl tnUnlRg~) 21 ' J 32 Parkinson's disease. Neurology Report (now IN . ' 1997.

.,

.

onagenari ·

152 Fialarone. M. et al: High-intensity strength munmg In 1'! . . IllS. Effects 00 skeletal muscle. lAMA 263:3029. 153. Judge. J. el a l: Effects of resistive and bal.anc:e exercises on:;.kl netic strength in older persons. J A~ Gena~ Soc 42 :937, I . ' 154. Tinnetti. M. el al: A multifac~riall~tervenllon to ~duce the n sk of falling among elderly people hving In the commuruty. N Eng\ J

t9?'l' . '_

Med 331:821. 1994. . 155. Wolfson. L. et al: Balance and streng th training In

.

ol~r adults.

Intervention gains and Tai Chi maintenance. J Am Gen atf Soc 44:498. 1996. . f .. . IS 156. Scandalis. T, et al: Resistance training and glut ~nct1On tn patlen with Parkinson's disease. Am J Phys Med Rehabli 80:,38. ~OO 1. . 157. Hirsch. M. et al: The effects of balance training an~ h,g~-tn~ens'ty resistance training on persons with idiopathic Parkinson s disease. ..' Arch Phys Med Rehabil 84:11 09. 2003. 158. Reuter. I, el al : Therapeutic value of exercise trammg In Parkinson·s disease. Med Sci Spon.'~ Exerc 31 : 1544. 1999. 159. Sianley. R, and Proc.as, E: Parkinson 's Disease. In Ame~~an College of Spons Medicine: ACSM's Resource,s f~r C hn.lcal , Exe~ise Physiology. Lippincott Williams & Wllkms. Philadelphia.

2002. p 38. 160. O'Sullivan, S. and Schmitz. T: Physical Rehabilitatio n Laboratory Manual. FA Davis, Philade lphia, 1999, 161. Pohi , M et aJ: Immediate effects of speed-dependent treadmill training on gail parameters in early Parkinson 's disease. Arch Phys Med Rehabil 84: 1760.2000. 162. Miyai . l. et al: Treadmill training with body weight suppon : Its effect on Parkinson's disease. Arch Phys Med Rehabil 8 1: 849, 2000. 163. Miyai . l. et al: Long· tenn effect of body weight-supported treadmill training in Parkinson 's disease: A randomized controlled trial. Arch Phys Med RehabiI 83 : 1370. 2002. 164. Behnnan, A, Teitelbaum, P. and Cauraugh. J: Verbal instructional setS to nonnaJize the temporal and spatial gait variables in Paronson's disease. J Neurol Neuros urg Psychiatry 65 :580. 1998,

Oinical Mooograph: FilnCSS Counts. ed 2. National Parkinson Foundation. Inc. Mifll1li , FL, 2004. Retrieved June 25. 2005 from

http://www.parkinson.arg. SteP ~ Sta1evo Educational Programs) initiative: Managing Parkinson's ~ase (hltp:llwww.slepkit.nel). Novanis, developed in consultalio n w~th the National Parkinson Foundation. the American Parkinson Disease Associlllion and the Parkinson Alliance. Motil'Or~ng MO'o'f!S for P~op/~ with Parkinson' s (video divided into th ~ sectl Qll S; "How to Do Motivating Moves"'45 minl . 'The Exercise

165. Van V....nbeJ1h. I. V,anken, R: """ Buo. ~: The ~'" rotational exercises on freeZing In Parkinson !I dlteae. Pact Neurol 18: II. 2003

•

166. Tzetepis. G. et 11: Res~irat.ory muscle dysfunction in ~rm."I disease. Am R~ Resptr Dis 138:266. 1988. .. 167. J(oseOglu. F. et al: The e~ects of a pulmoruu:Y rehabiJitaitio.,..

gram on pulmonary functIOn tests and excTClSe tolerance to patients with Parkinson 's disease. Funct NeuroI12:319. 1997.' 168. lnzelberg. R . et al. Inspiratory muscle training and the pac f ' 0 of dyspnea in Parkinson's dise.ase: Can J N.e~1 Sci 32:213. 2IDCl5. 169. Bergen, J. et a1 : AerobiC exerci se mtervcnbon Improves MftIbk capacity and movement initiatio n tn Parkinson 's diJeue piIIiaa NeuroRehabilitation 17: 161. 2002. 170. American College of Sports Medicine: ACSM 's Guidelines b Exercise Testing and Prescription. ed 6. Lippincott Willian; Wilkins, Baltimore. 2000. 171 . Pedersen, S, et al : Group training in parkinsonism: Quanti.we measurements of tre atment. Scand J Rehabil Med 22:207, 1990. 172. Hurwitz, A: The benefit of a home exercise regimen for ambadatory Parkinson 's disease patients. J Neurosci Nurs 21 : ISO, 1989. 173. Lun. V. et al : Comparison of the effects of a self--superviled holM exercise program with a physiotherapist-supervised exercise pn> gram on the motor symptoms of Parkinson's disease, Mov Diaad 20:971 .2005. 174. Abuli , S. et al : Parkinson 's disease symptoms: Patient's perceptions. j Adv Nurs 25:54. 1997. 175. Comella, C, et aI : Physical therapy and Parkinson's disease: A c-. trolled clinical trial . Neurology 44:376, 1994. 176. Viliani , T. et al: Effects of physical training on straightening-up processes in patients with Parkinson 's disease. Oisabil RehabiI. 2 1:68. 1999. 177. De Goede. C. 01 al: The effects of physicallherapy in Parkinsoo', disease: A research synthesis. An:h Phys Mod Rehabi182:509. 2001. 178. Sche nlcman. M, et aI: Exercise to improve spinal flexibility and function for people with Parkinson 's disease: A randomized. rootrolled trial. I Am Gerialt Soc 46: 1207. 1998. 179. Baatile. j, et al: Effect of exercise on perceived quality of li(~ of individuals with Parkinson's disease. j Rehabil Res Oev 37:529. 2Ol).

a

Class" [36 min). and " Practical Tips for Daily Living" [4 min]). Available from the Parkinson Disease FOWldation. New York. NY. http://www,pdforg. Th~ PDF £X~rcjst! Program. Available from the Parkinson [)isease ~oundati on. New Yo rk, NY. http://www.pdf.org. Levme. C. Always on Call: When Illness Turns Families into Caregivers, cd 2. Vanderbilt Universicy Press, Nashville. TN. 2004.

Appendix A: Unified Parkinson's Disease Rating Scale (UPDRS), Version 3.0: February 1987a I. Mentation. Behavior and M ood \. Ime/lN'lIIal impairmfllfs:

0 = None. J = Mild. Consistent forge tfu lness w ith part ial recollection of events and no other d iffi culti es. 2: = Moderate memory loss. wit h di sorient ation and moderate difficult y hand li ng complex problems. Mild but definite impainnent of functi on at home with need of occasional prompting. .., :::: Severe memory loss with d isori entatio n fo r time and often to place. Severe impa innent in han dling problems . .:1- = Severe mem ory loss with orientation preserved to person only. Unable to make judgme nts or soh'e problems. Requires mu ch he lp w ith personal care. Cannot be left alo ne at aU. 2. Though' disorder (d ue to dement ia or drug intoxication): 0= None. I = Vivid dreaming. 1 = ·'Benign·· halluc inations with insight retained . 3 = Occasional to freq uent hallu ci nati ons o r de lusions: witho ut i n sig h t~ coul d inte rfe re with dail y activities . 4 = Persistent halluci nati o ns. delusions. or tl orid psychosis. Not able 10 care for self. 3. Depression: o = Not present. 1 = Periods of sadness or gui lt g reater th an noml al. never ~ u s lained for days or weeks. 2 = SU<.,tained depress ion ( I week o r mo re). 3 = Sustained depress ion with vegetative sy mptoms (im~o mnja . anorexia. weight loss. loss of inlercsl). 4 = Su~taincd depression wi th vegetati ve sy mpto ms and suic idal thought ~ or intent. 4. Morillatiolil inifiatil'e I) = Normal.

1 :;;; Less assel1ivc than usua L mnre ra~~ive. 2 ::. Los\;) in initirllivc or di:-.int eresl in elective (nonrou l ill~) activities. 3 ;;: Los!<> of i nltiUljve or di ):ai mcrcM in daY -lll-d.,y (rouline)

ac tl v ilie~ .

4 = Wi lhdfllwn , com plete! lo:-;s of motivat iull . U. Acli vitit=s uf Oaily I.h'ing (d£'1ermine t'or ··on/otT") S. ;,penh :

0 :;: Nomlal I ~ MIld ly affected. No dlfTil:u lty bei ng undcl'~tood.

2 = Mode rately affected. Sometimes asked to repeat statements. 3 = Severe ly affected. So metimes asked to repeat statement s. 4 = Unintelligible most of the time. 6. Sa /il'Gfi oll :

o=

No rma!. I = Sli ght but definite excess of saliva in mouth; may have nighttime drooling . 2 = Moderately excessive saliva; may have minimal droolin g. 3 = Marked excess of saliva with some drooling. 4 = Marked drooling. requires constant ti ssue or handkerchief. 7 . Swallowing: = Norma!. I = Rare choking. 2 = Occasional choking. 3 = Requires soft food. 4 = Requires nasogastric rube or gastrotomy feeding .

o

8. Handwritin g: 0 = Normal . I = Slightly slow or small. 2 = Moderately slow or smull; all words are leg ible. 3 = Severely affected : not all words are legible. 4 = The majorit y of words are not legible. 9. CUffin g food {lnd handling utensils: 0 = Nom,,!. I = Somewhat slow and clumsy, but no help needed. 2 = Can c ut most foods. a lthough clumsy and slow; some he lp needed. 3 :::;:: Food must be (" ut by someone. bUI can slill feed slowly. 4 = Needs to be fed. 10. D res.\' illg ,' o = NO llna!. I ;:" Somew hut slow. but no he lp needed. :2 ;;;;: Ot.:casionai llss istancc with buttoning. or with gelling amlS in slct"ves . .3 = COllsidemhle he lp ~qui~d, hut can do some th ings atollC'. 4 Il elpl css. :;::0

II . HYI::ietli' :

o

Ill:'

I

#'

Norm al. Somewhat slow. but no help needed. 2 ~ Ne
,

890

Physical Rehabilitation . r . sh,'ng bru:,hi nc tee th. J == Requires assistance .or W .l .. ~

combing hair. goi ng to bathroo~l . . 4 == FoleY cat heter or olhe r mecha ni ca l a',ds. 12. Turning ill hed lUulot/justing bed clOlhe~ . 0 = Normal. I == Some\\ hal .. low and clumsy. but no help, needed. o rcal ' 2 = Can turn alone or adJust shee IS. . bul w ith e difti cuhy. 3 == Can initia le . but not lurn o r
~

Helpl ess.

2 == Ocrasional1y falb. less than once pe r day.

o ~ None. I == Rare freezing when \\:llking: may have start he sitation . 1 = Occasional freezing when wa lking. .3 == Frequent fre ezi ng . Occasio na ll y fall s from freezi ng. ~ == Frequent fall s from free zing. 15. Walklllg : o ~ Nom1a!. I == Mild diffk ult y: may nol swing anns or may lend to drag leg. 1 :;:: Moderate difficulty. but req uires little or no

a.. sistance. 3 == SC\t':re di sturbance of walki ng. req uiring assistance. 4 :;:: Cannot walk at alL even with assistance. 16. Tremor: o ~ Absent.

related to pari..insonism :

I :;:: (X{'a"lonall y ha .. nUl11bne'lo~. tingling. or mild aching

:2 :: Frequentl) ha .. nUl1lhne~s, tinl'.l inl!., or aching:

dl'1 trcs.., lng Frequent p~inj ul ..en'lallon.... -l = E\l'ruL!ating pain. lll . ;\ l uLOr E"aminatiull nOi

I~ .

~

~

=.

\lht'l h

o

=.

' nnnal

I

=.

ShgiH In" .. Ot .... \pn.: ' ... lon, lhct lun . amVor 'hlUlllt"

::!

ampl itude, but onl y intermittent ly present .

3

~

4

~

Mode rat e in amplitude and present most of the Marked in amplitude a nd present most of the

time. 2 1. Action or postural tremor of hands:

o ~ A bsent. I ~ Sl ight: present w ith acti o n . 2 = Mode ra te in a mpli tude. present with action.

3

~

Mode rate in amplitude w ith posture ho ld ing as we ll as ac ti on.

4 = Marked in ampljtude; interferes with feeding. 22. Rigidity (j udged o n pass ive moveme nt of major joint s with patient relaxed in sitting pos ition; cogw hee ling to be ignored): Ab se nt. I ~ S li ght o r detec ta b le on ly whe n act ivated by mi r-

o~

ror or ot her move ments.

2 ~ Mild to moderate . 3 ~ Marked: bu t fu ll ra nge of m o tion easily ach ieved.

I :;:: Slight and infrequentl) prese nt. 1. :;:: Moderate: bothersome to patient. 3:;:: Se\ere: interferes \\ith many activities. 4 = Marked: Interferes with most ac tivities.

3

Absent. I = S li ght a nd in freque ntl y prese nt . 2 = Mi ld in amplitude and persistent : or moderate in

tim e.

I ..t Fr('e:ill,f.? whell lI'alking :

o = !'\one.

time. 4 = Masked or fixed fa c ies w ith seve re or complete los!) of facia l expression: lips parted y.. in or more.

o~

J = Fall . . on ,lVcragt; of once dai ly. ..j. = Falls more than once (kti ly.

(01111'101111\

face." 2 ~ Sl ight but defi n ite ly abno m1a1 diminutio n of fac ia l ex press ion. 3 = Mode r" te hypom imi a: li ps parted some of the

20. 1h' lIIor (If l'l'sl :

11 Follillg (1IIIft'fared to ji'f!e:illg): o == NOlle. I == Rare falling .

17. SetlJ(wy

19. Facial e.\'Pressioll : 0 = Nom 1a !. . . I ~ Min inwl hypomlmla. coul d be no rmal "poker

\1 ont>tonC' ... Iurrcd but undt'r,landdblt: ; fIl(l<,i t:r

4

\I... ith mdex finger in rapid succession wi th widest amplitude possible,

each hand se paratel y):

o ~ Nonna!.

i = Mild slow ing a nd/or re-duellon in amplitude, 2 = Modera tel) impaired: definite and e~lrI~ fatiguing; ma) have occa::. io na l alTC"'b in mo\cment. 3 = St;\'cre l) Illlpaired : frequent he " il~Hion ill initiat-

ing.

or tlrre.,,,, IfI ongo Ing movement. b:m:'i ) perfurm the' la.'!o J.. . I/wlll nWl '('nlf'I/l (Patl~nt open.!. and clo",c!) hlnJ, in ri.lpld .. uc\..·c ...... lon \\ IIh \\ Ide.!. t ampli tude poSSible'.

.t

1110\ emen'"

= (':10

c.I\..'h h.lIld ,cparatch ): •

o = Nnnll .. 1. ~

I

~lild .. \I,.mll1g andAl r n:dul.' lIun m.unplilllde. !\1 odt'r~ud)' imp..lIf~d : dc finilt' luld ~.3r1) t.UI£U -

-,

Sc\oerel) Imp.llred ; Ire{lucnt he, It.1I101l

4

lllg 111m cmcm ... or drre;;'b III on!!o1ll~ mOH!nle"OI. C..in hMI.:' I) llert't--'nn lhe m.,k .

"'lel~ IInp.ur~d

3 ::..- M..tr~cd Imp'lInlltnt , olttiluh lu unoer'!oL.trId - l nll1lc1h~lhlt"

= Seve re: range of motion achieved with difficulty.

Fi"ger taps (patient taps thumb

mg, mol) hJ\c OCI.'J.::'lonuJ arre .... h III mO\elllCnl U\ illlll lli '

CIuopc..-ll

.:.s. R~ afl('rna.mn

f'l(}\

('f't~ flU

.f Ikrn..-is I pron;u~.

rDO'\ emettlS of I:wxb ... e.rticaJl~ or horilooWl~. "uh as L1rg~ an amphlOOe 3!0. pos~lblc: . both

~

2

= \l oder3tel~

impaired: definite and (.·arl~

faugumg : rn a) hd \ e occ~lona l a rre ·qs in moyemenL 3 = ~ erel~ ImpaJfed: frequen t hcsita uon in mittatmg mo\'emenb or arre ... ts in ongoin g movement. 4 = Can bare l) perform the task. 26. FOOl Olliff,) I patie nt tap s heel on ground in rapid succeSli lon. pIcking up enure leg : am pl itude should be about 3 inches):

0= Nonna!. I :::. Mild slow ing and/or red uction in am pl itude. 2 == Moderately impai red: defi nite and early fatiguing: may have occas ional arre sts in move me nt. 3 = Severel y impaired : freq ue nt hesitati on in initiating movements or arrests in ongo ing moveme nt . 4 = Can barely perform the task. 27 . Arising from " hair (palie nt attempts to ari se from a slraight· backed wood or metal chair with ann s fo lded acro s~ chest). ~ Norm al. I == Slow: or may need more than one attempt. 2 ~ Pushes se lf up from arms o f seat. 3 ~ Tends to fall back a nd may have to try more than one time, but can get up without help. 4 = Unable to ari se without help.

o

28 . Poswre:

o =- Nomla l erect. 1 = Not q uite e rect. slightly stooped posture; could be nonna l for olde r person. 2 ~ Mode rately stopped posture, de finitely abnormal ; can be slightl y leanin g to o ne side. 3 = Severely stooped posture with kyphosis: can be mode rate ly leani ng to one side. 4 =- Marked flex ion with ex treme abnormality of posture . Q9. Gait: ~ Normal . I = WaU.. s ~ Iowl y. may shuffle with I'> hort s.teps, but no fe stination or prop ulsion . 2 = Walk s with difli cult y. bu t req ui res lilli e or no asSl ~t ance; may have some festination, short steps, or propulsion. 3 = Se\iere dmurbdnce of gail , requi n ng a!)!'.bta nce. 4 =- Cannot walk at all. e\tn v.i lh a, sl, tunce. . Pusrura/l ralJlht) ( re;) pon ~ to .. udden J"'l~l~ rjor dl \ . pl aceme nt produced b) pull on ')llOu lder~ while p~llenl IS eeen "'llh e)'e ~ open and feet ~ I ightl y apart;

o

p.illI.tnt J \

prC:J'lMedr

0= "omlal 1 ;: Retropul .. ion . bu t recoloers una ided .

OIJio ' __

t>sen....: of Jl"SlUraJ ~..,: \Au.lld roll .f _ -.aught h} t xamll'tC.f.

supuwtioo

hand Slmuh.aneou~I) ~: 0= \;ormal. I = ~hld I"" mg and/or reductJoo In ampli tude.

=

~.

3

= \ "'1)

un!ot.dble.

[~ ,

to k\sC' ba1ancf:

~.

neQu~I~ . ~ = Un•• ble to land \\ ithout lISS! t.anc't'. .\ 1. BVliy hmcivkm t'510 !llkl h.' !J'.)t.Jltes,o

NQm",nana

hes l t anc ~.

slowness.

decrt'3Se-d nrms"", mg. $I1\a,U amplitude-. dod {'Ove n )' o fmo\ement in ~e.nena.n:

0= None. 1 = Min imal s lo\\ ness. giving moveme nt a dt.IHxrale C h nr-~lc te r. could be noonn] for some person. Possibly redul't'd amplilUde . 2 = Mild degree of slowness and po'feny of I1\(lVC" me nt that is definitely ~,bn onnaL AltemIulleJy. some reduced amplitude. 3 = Moderate slmlr'Tlcss. poven y. or smull nmplitudt: o f movement. 4 = Marked slowness. poveny. or smull amplitude of movement .

IV. Complications of Thuapy (in the past we«k) A. Dyskinesias

32. Duration: lVI1ll1 proportioll oj Ille waJ;,ill8 day dyskifJesias prese fll ? (historical infonmllion)

ill'l'

o ~ None.

I ~ 1-25% of day. 2 ~ 26-50% of day. 3 = 5 1- 75% of day. 4 = 76- 100% of day.

33. Disability: How disabling are tht' dyskllln;as ? (hi~~ torical infonnation ; may be modified by o ffice exam· inat ion) o ~ Not disabling. I ~ Mildly disabling. 2 ~ Moderately disabling. 3 = Severely disabling. 4 ~ Comp letely disabled. 34. Painful dyskinesia : how p(ljnful {lrt l/tt' dysk.;/UI. .

?

Stas .

o=

No painful dyskincsilts. I = Slight. 2 ~ Mode rate. 3 =- Severe. 4 = Marked . 35. Presence of ('tIdy nllJOljllK llystnlliu (historical inf{)l' mali on): o ~ No

I

~

Ye>

B. Clinicul

flU ClUaIiOl'I \

36. Are lilt)' "off" pe,.,ods " redit"Ulhle a.I tio.VI' of fIlnh callon?

10 tim/II/(

II/ier (J

0 = No I

Ye;

17. Are

l Jf/)

"

off" period, u"pteJiOcJbl". U1 uf Ntn h t illll1lJJ ?

uflf'l' a dOlt'

o I

No ~

YC!tl;

IfJ

iJ",U'R

Physical Rehabilitation

892

38. Do an\' 0 f IIIe

··".Fr·· I" riot!, 'JJ '

(O me " n slIddenly. f or

exampie. 'or a a felt' seconds ?

0 = No I = Yes 39 . What proportion

0.( 'J

Stage 4

Ihe wokin.",., day is Ihe palienl

"ofT ' on Ol'erage? 0 = None. I = 1-25% of day. 2 = 2(>--50% of day. 3 = 5 1- 75% of day. 4 = 76- 100% of day. C. Other complicatio ns. . . 'J 40 . Does the pa rien! ho\'(, O1wrC.no . nausea , 01 \01111 t fll g. I

••

0= No I = Ye, 41 . Does The parien' hare any sleep disturbances , f or example. il1So111l1ia or h.' personmo/ence? 0 = No

I ;:: Yes 42. Does the pariem hare symptomatic orthostasis ? o ;:: No I = Yes Record the patien(s blood pressure. pulse. and weighl on the scoring fOim

Y. Modified Hoehn and Yahr Staging Stage 0 Stage 1

= No signs of di sease.

=

Unilateral disease.

Stage 1.5 = Unilateral plu s axial involvement. Stage 2

= Bilateral di sease.

wit ho ut impainnent of bal-

ance.

Stage 2.5 = Mild bilateral di sease. wi th recovery on pull test.

From Fahn. S, et al·11 o pp 36-41 with pe rmission . ilDeflni110n 01 0-4 scale .

Stage 3

Slage 5

~ Mild to moderate bilateral disease; some pol.:

. d epende nt. . lural instabilily; physicaII y m = Severe disability; still able to walk or . unassisted. = Wheelchair bound or bedridden unless aided.

VI. Schwab and England Activities of Dally Livbla Scale loo%-Complelely independent. Able to do all c~ · withoul slowness, diffic ulty, or impairment. Essentially normal. Unaware of any difficulty. 90%-Completely independent. Able 10 do all chores wirh some degree of slowness. difficulty, and impair.', ment. Might take Iwice as long. Beginning to be aware of difficull y. 80%-Complelely inde pendenl in most chores. Takes twice as long. Conscious of difficulty and slowness. 70%- Nol complelely independent. More difficulty wilh some chores. Three 10 four times as long in some. MuS! spend a large part of the day with chores. 60%-Some dependency. Can do mosl chores, but exceedingly slowly and with much effort. Errors; some imposs ible. 50%- More dependent. Help wilh half. slower. and so forth . Difficully with everything. 40%-Very de pendent . Can assist with some chores. but does few alone. 30%--Wilh effort. now and then does a few chores alone, or begins alone. Much help needed. 20%-Nolhing done alone. Can be a slighl help with some chores. Severe inval id. IO%-Tolally depende nt. helpless. Complele invalid. O%-Vegelalive funclions. such as swallowing. bladder and bowel func lions. nO! funclioning. Bedridden.

Appendix B: Web-Based Resources for Clinicians and Patients/ Families Living with Parkinson's Disease N:uional Parkln .. on Foundation (NPF) Park i n ~un' ~ Dl"C~I "C Foundation (PDF)

Amcrican Parlon ..on Di ')ca .. e A~ ..oc jation (A PDA) World Parl..lI1\on Di :-e~l ..e A ..."ocia llo n fWPDA)

Parkin ...on Soc lelY Canada Young On.;;C't ParJ...ln ..on ' .. A .... oc iallon Youn£ ParJ...lIl <.on\ InfnTlnat lu n and and Referra l Ce nter Michael J. Fox Foun(\Jtlon for ParJ...in .. on .... RC'IciJ rch Th~ Parl..lIl.,on ,'lIwncc

ParKln .. on'!o. ActIon Nelwork The Parion <.on·:. In .. titul e People Li\ 1I1~ '" ILh P~lrkin ..o n'" UnderstandIng Parkln ..on ·", Amencam with Di",ahilttlc\ Act: A DA home page M edicar e IIlfonnatlon SOCIa]

SeCUTll) On l1Oe

Nallonai In ... l1IuI C') of Heallh

Nallonal Library of M edl(;inc Arcluve .. 01 Neu rology Neurolog)

Veler"ns Affa ir... Na110n,11 Fam il y Carcgi\c r~ A ..... ociat ion (NFCA) Parkm ..on\ d i>tea\e Ca regiver Informa ti on Well SJXlu\(> Foundation Amencan Acadclll) t)f Neurology (ANA) Natlomll RehabilitatIOn InfoTlflat loll Cc nt er (NAR IC) Ahlhl) Huh- 1.I"\ I \IIVe ICL hnl1l ogy ABU:.DAl A- a\')I"'lve ledlOology DI"abled Online

h tI p:/Iwww.p':lfkinsoll .org http ://www. pdLorg hltp :/Iwww.apd aparkinson.com hl1p ://www.wpda.org hllp://www.park inson.ca hIlP://www.yopa.org hit p://ww w.youn gparkin so ns.org hit p:/Iwww.mic hae ljfox,org http://www. parkinsonalliance. net hllp:l/www.ParkA cLNe .@ AOLcom 1111 p ://ww w. parki nsoni nslilu l,e.org hllp:/Iwww.pl w p.org hltp://www. unders tanding parkin son .s.com h •• p:l/w ww. usdoj .gov/crt/ada hll p://cms. hh s.gov hltp://ww w.ssa .gov h" p://www.ninds.nih .gov/med lincplus/parkinsonsdisease.HImI hup ://ww w. nim .nih .gov http ://'Jrc hne u r. nma - 3 ssn .o rg hIl P://ww w.ne uro logy.org hllp :/Iwww.va.go v hl1 1':/Iwww. nfeaeares.org htlp :/Iwww.my parkjnso ns. org hllp ://ww w.well spo use.org hltp ://w ww. aan .com (ANA members. profess ionals) htl p:/Iwww.:ulIl .com/ pub lic (pub lic education) htlp :/Iwww.nari c.colll htlp ://www.a bilit y huh.colll IUlp://w ww.a bl cd ata .col11 Ilttp://www.di.iHbl edonline.com

C H APTE R

22

~-----------------------------------~==~ fl~~IN'

D8J ECTlVEI

~nbe the pathophysiology of traumatic I.

[)<5<'

•

rr,un inJul).

...

[k'iCri~ Ih~ intC~~lsc~ p lma.J"?' t~al.n concept ,. 1L-..ed in the- re.ha?1~1[3110n of md lvld uaJ s wi th Ulll3UC braIn inJury.

,

:ntih the different team members involved

3. .

man:uzement of the patjenl with trau~[lC brain i njury and di fferentiate their re:;pet:[lvc! roles. t J.kSi..---nbe I~O c1inicaJ raling scales and their usefulno .... , [)e.:;cribe commonl) seen defici ts that result ,. from [TltJ'l1.3tic brain injury. " J)eSCribe the Tole of the physicaitherapisl in the difttr·"111 episodes of care of the patient 'Aim [faU!l1:· t jc brain injury. [he

7. E.'tplain 1.X'!.';lHivc considerations required dunng pt'o''jl~'31 therapy examination and imen.enTlOr. &. Identify the components of a phys ical therapy aamination for the patient w ith traumatic

tnin mjury. ,. Describt! treatment imervenlio ns availa ble to the physical the rapist in working with the

pariem 'With: traumati c brain injury at the ,-:moos <;.{ages o f rehabilitatio n. It Analyze and interpret paLiem data, formulate realistic goals and o utcom es. and develop a plan of care when presented w ith a clinical

case SIud).

Traumatic Brain Injury George D. Fulk,

PT, PhD

OUTLINE Epidemiology 895 Pathophysiology 896 Focal Injury 896 Diffuse Axonal Injury 896 Hypoxic-Ischemic lnjury 896 Increased intracranial Pressure 896 Diagnosis 897 Sequelae of TBI 897 Neuromuscular lmpainnenls 897 Cognitive Impairments 898 Behavioral Impairments 899 Communication Impairmems 899 Visual-Perceptual Impairments 899 Swallowing lmpairmems 899 Indirect Impairments 899 Clinical Raring Scales 900 Glasgow Coma Scale 9(X) Galveston Orientation and Amnesia

Test 900 Rancho Los Amigos Level of Cognitive Functioning 900 Glasgow QUicome Scale 900 Disability Rating Scale 902

t

traumatic brain injury (TEO population is one of the most challenging that a physical therapist may encounter. Because of the multiple body systems affected by a brain mJUJ) and the strong likelihood of secondary impairments. ' physical therapist must be proficient in a wide variety of t'\3.rnination procedures and intervention techniques. Owing : ~h", ioral diffi culti es encountered during recovery, a )"<31 therapist working with this population must also ~ strong interpersonal skills, be able to react quickly lttneffectively to suddenly changing situations. and have Orkiobservatton skills. These factors and others can make ng With th is population both challenging and exhaustor a,botlt emotionall y and physically. However. the rewards ~\ls.tmg a patient with a severe brain injury to return ~ijlat Or to school vastly outweigh the challenges of reha -

Functional Independence Measure and Functional Assessment Measure 902 Prognosis and Goal Setti ng 902

Medical Management 903 Rehabilitation Perspective 903 InterdiSCiplinary Team 903 Physical Therapy Examination and Treatment 906 Ranchos Los Amigos Levels l. 11. and Ill: Decreased or Low-Level Response Levels of Recovery 906 Ranchos Los Amigos Level TV: lbe Confused-Agitated Level of Recovery 913 Ranchos Los Amigos Levels V and VI: Confused-Inapproprial.e and Confused-Appropriale Levels of Recovery 914 Ranchos Los Aroigos Levels vn and Viti: Appropriate Response wets of Recovery 9 J 8 Summary 922

rehabilitation centers, community reentry programs. outpatient therapy. schools. vocational rehabilitation. and assisted living centers. ' Because of the wide variety of impairments and complications arising from a brain injUI)'. it is vital that a strong team concept be employed when treating this population. A physical therapist is an imponant member of this team in any setting. It is crucial that there be open communication between all team members to ensure safe. timely. and consistent treatment. Regardless of the sening. it is imponant to remember that the patient is the key member of the team.

Epidemiology

IOn.

Cont~ pattent With a brain injury i, treated aero" n \\ ide uum of care. u. hich Include, acute

ho~pit3Iil3uon.

TB I It.; (l common and dc\ OblJtmg <'l'l"um:rk~ 10 ~rican ;OClct) . It I'" lead In!! cau", of tk.th.md dl",t>lltt) m )oong

"'

Pb,1IicaJ Rehabilitation

adult. m ~ t; m\e\l I.ll~. An e I.maled 1.5 10 2 million P"OPIe,.tII .ncur 3 TBI e h )ear' ppro"m3tely 50.000 1IldI'1.nw, ,..11 die ..... h )ear· • re,u\t of a TBI. ",h.le "''eI" 130.!YXl are h..""p.tJ.\ll.N and ,un. IVe. Of Ih~ md.· .0(10 to 90.000 people ""II de\elop inlellectual, bd\3"ooJ. an.IIor ph) .cal d.S3blhues that will prevent rerum to a normal. IIIdependent hfe't)le.' Thi has resulted m betv.~n ~ and 6.' mtlllOn Amencans living with the on:.cqu<:ncr of a TBI.' \ Iotar ,ehicle aCCIdents cause apprOlllmately one half ot all trallJ1UUC brain injunes. wIth falls accounting for 25 pen:ent. "'>-lull> and VIolence for 15 percent. and porlS and recreation for 10 percent." ~1en are injured more often than "'omen. The tJ-lllcal patient is berneen the ages of 15 and ~.t )e= al the time of injury. The economic impact of TBI is substantial. for both the inastating effects of a brain injury or spinal cord injury. The program teaches tudents the basics about ho", the brain and spinal cord worlc. Students are also instructed on pre· ventative measures such as wearing bike helmets and seat bell>. the dangers of driving while intoxicated, and the importance of using proper protective equipmenl during ath· 1ctJcs. Perhaps the most effective 1001 used by the Think Finr program is having brain injury survivors participa[e in the presentallOOS. They are able to tell the students firsthand about the debilItating effects of a brain injury. Seeing and hranng their storie" have a much more profound effect on the stUdenl> than li'tening to a lecture on the dangers of drinking and driv ing.

,iJua".

Pathophysiology A .ancty of pathophy"ologJcal mechanISm, r. ult from a TBI. eac.h a re~ult of externa1 force., acting on br::un ussue. Acceleration. decelerauon. and rotalional forces of the bram relatl"e w the bony o;kull cau')e compre\'sion. straIn, tJJc:aIlng. and dl~pla&.:ement of brain u"sue For ex.ample. d.otnwge U) the prefrontal area of the brain may occur 3.'1 a f'e'.iUlt of a mowr ,,'e;:h,cle a,(;cldenL The moving bod}' and

head ,uddenly \top bul the brain COntmues to the 'kull and 'trike\ the lOner urface of them"". '" Ide cran. Oamage from a penelratmg object, , uch a, a bullel u~ cau~ tiss ue lacerations and contus ion~ InJ" • C4i. . fl t\ c' •. both focal and diffuse. an ""

Focal Injury Focal brain Injury IS localized to the area of the bra' . . '" under the s.te of .mpact on the ,kull. The damage may be .n the form of a hematoma. edema. contusion, or laceratIon combination of the four. A severe blow to the head' or a · ma, resu It In bram damage not only directly under the "Ie ~f impacL but also directly opposite the SIte of Impa!:t. Thu results from the brain "bouncing" and making contact ~Ilh the skull at a si te opposite from the SIte of iM,,1 impact Such an inj ury is referred to as coup·contrecoup injun Common sites of focaJ brain injury are the antenor-tnf~_ rior temporal lobes and prefrontal lobe,.

Diffuse Axonal Injury AcceleraLion. deceleration, and rotational fl}rcG~ C,lJ5e dif· fuse axo nal inj ury (DA I ). which is charactenw! b} w.de· spread shearing and retraction of damaged a.'mr3••l.'l:onai changes eventually lead to their separallon frt:'!!l me SOIlt!. Diffuse axonal injury may be se\-ere enough to: capse COO13 and correlates with less clinical recovery . In add.tion to cortical white malter. it often invol....e') the corpu ...aaOStJD. basal ganglia. brainstem, and cerebellum.

Hypoxic-Ischemic Injury Hypoxic-ischemic inj u!) ( Hill resull> from 13<. of oxygenated blood flo,"" to the brain Itssue. It can be cau,ed by systemic hypotension. anoxia. o r damage to \pecific vascular territories of the brain. H }po:\lc ,..;chl!mlC in)!l!) can lead to global damage and I as\OClated ".th poorer cognitive function and lower expected outcome ...

Increased Intracranial Pressure Because the rigid sleull surrounds the bram. ,,,oiling Of abnormality ofbram fluid dynamics often resull.> to i~1 ICP ma~:coitied ""brol iog 10 their sile (epidu r.d. 5ubd u raJ. or. antracere C! 1cP Normal ICP " 4 to 15 mm Hg. E\en m.ldl) ~ h 3550Clated wnh increa..-,ed morbid~ry in un. j\'0f"\ 5e'o~ increa>ed ICP may result '" herOJauoo of the br.1II1~ 22.1 presents common [ype~ of bram herruarion to) and their effect;. Increased ICP IS also correlated ",.th poo«" expected oute"""'" and tllgher monaJil} rate< uIt 01 • Secondary cell death can aI"., occur .".",.. 1b<>" vanety of cellular event! [hal follO\\- (j<;..,oe danU~ ~ include glutamale neurolo,\Il:II)'. tnflu, Df calcium

Chapter 22 T ",1UIllItk Bnain Injury

ra b1e 22.1

Hentiations of the Brain

Tentonal notch.

Mass leslOO

IllKfbram

lobe or middle lossa

In

temporal

H.ppocampal gyrus and uncus Oculomotor nerve

Cerebral peduncle Midbrain ascending retic-

ular activating system Postenor cerebral artery

Hemlparesis

Coma

Homonymous hemianopia

central

-

Tentonal notch.

j[l'a1\5tentooaJ)

mtdbrrun

Mass lesion .n Irontal. parietal. or occiprtallobe Progression 01 uncal hemiabon

Foramen magnum. medufIa

Mass leSion in posterior lossa Progression 01 uncal or transtentorial herniation

Midbrain and pons

Decerebrate ngodity

Ascending relicular activating system

Coma

Cerebellar tonsils

Neck pain and stiffness

Indirect activation pathways Ascending reticular activating system

Flaccidity

Vasomotor centers

---

Par9S1S of nerve 11/

Coma Alteration of pulse. respiration. blood pressure

.--------------------------------------~----------~

~;r :~_~

oR. et <11; Medical Neurosaences, Ed 2. l.Jtde, Brown. & Co., Boston, 1986. P 368,

~ oe-~ C::.'jf"

..... f·

radical release. and cytokines that can lead to cell

"""'c Diagnosis ~ """'t) of neuroimaging teChniques are available to aid in Ir.e diagnosis and idenuflcation of neuroanatomical struc-

." and ') stem5 damaged as a result of the injury. The available technologies are the computerIUd tomograph} (en .can and the magnetic resonance ;aging ( \IRI) >ean ••\1ore teChnologically advanced, but

PET. SPECf. and fMRI are functional neuroimaging techniques able to detect regional cerebral blood flow, metabolism. cerebral perfusion, or increases in neuronal activity.' These imaging techniques are becoming more widely used in research centers to investigate !he effects of rehabilitation intelVenrions on cerebral function. europsychological testing is often done as well to provide further insight into cognitive and behavioral deficits. These tests can also aid in establishing the prognosis and expected outcomes after TBI.

iilOY COihIiJOtJJ}

.... rtadily available teChniques include positron emission "-<nography (PETI. ' ingie-photon emission computerized lCgrap/J) (SPEer). and functional magnetic resonance Llnayng (NRI,. CY lC. n, are u",ful in identifying hematomas, ven'lCtJlar enlargement. and atrophy. However, compa r,~.., 01 CT and MRI confinn that cr is relatively in .. n..r •• to many of the le,ion, pre .. nt after trauma. MRI ~(hide\ kJperior "'Jft ti \ l)ue di~rimj"aljon compared to 1 (,7 and\1R I finding. correlate moderately wit h r-atht,I,,!y .nd outcomes. Prof."ion.l, and family >e" w ",ld be aware that a lack of ,ign .f,cant ....""
Sequelae of TBI TBI i1)

~sociated

with a wide variety of neuromuscular.

cogni tive, and behavioral impainnents that lead to functional limitations and disability. Table 22.2 identifies some of the prevalent impainnents associated with TBI. Although phy,icalthempis" are primarily concerned w,th .mpnl'lOt! neuromuscular function. the cognitive and beh8\'lOraJ c hange, ..,soci.ted with TBI are u,ually the m"'t dJ",bhng In the long run.

Neuromuscular Impainnents The palLent w.th TBI often pre",nt' ".th al>oormaJ tone. Prumuvc po'lurc, muy mduue lho\e fl! -.QClaled With

PhYAical Relulbilitalion

Table 22.2 Imp. innc .. l~ A.weialed wi lh Tra um al ic B ra in Injury Neuromulculer • Abnormal tone • Sensory Impairmanls • Motor function (motor control and motor learning) Impairments a Impaired balance • Paresis/paralysIs

Cognilive • Altered level of consciousness/alertness

• Memory loss a

Altered orientation

Behaviora l • Dlslnhlbilion • Impulsiveness a Physical and verbal aggresslVene&9

• Apalhy • Lack of concern • Sexual inappropriateness

• Irrilablhly • Egocentricily Communica tio n • Receplive aphasia

• Anenllonal deficils

• ExpreSSive aphasia

• Impaired insight and safety awareness Problem solving/reasoning impairments • Perseveration • Impaired executive function ing

• Dysarthria • Audilory deficits

a

Visual

Perceptual

d ecorticate or d ece rebrate ri gidity. In deconicate rigidity, the upper extremities are in a nexed posture and the lower exrremities are extended. This is indicative of a lesion at or above the upper brainstem (above the superior coll icu lus). With decerebrate rigidity, both the upper and lower extremities are positioned in extension. The lesion is located in the brainstem between the vestibular nucleus and the superior colliculus. 6 Abnonnal lOne may take the fonn of spastic hypertonus. This may range from spasticity that severe ly affects the entire body and greatly inhibits nonnal , functiona1 movement, to lesser levels of lOne that affect individuaJ muscle groups and function. Alterations in sensation are common following TBI and may include impairments in light touch, pain, deep pressure. and temperature. Proprioception and kinesthesia may ruse be impaired and are of particular concern to the physical therapist. Ambulalion and other mobility sk iIts can be secondarily impaired if the individual does not know where his or her body is in space. Impaired proprioception. along with visua1 or vestibular impainnenlS. will affect balance. Motor control impairments can take many forms. They include monopares is. hemiparesis, tetraparesis (q uadriparesis), and/or abnonnal reflexes. indi vid uals with TBI may also exhibit impainnen15 in coordination, timing. and sequencing of movemenl. This is particularly true with damage to the cerebellum. MOlor control deficits and abnormal lone are highly variable. both between patients and With day-to-day fluctuations in individual patients. Chapter 8 provide, an in-depth discussion of motor cOOlrol impairmenl~ and exammalion procedures. Many palien" who experience a TBI will exhlbll balance impaumenb. a~ cerebellar injury i'\ common. 1lles.e deficits may be ,ubde In palient~ with minor brain injuries. Owing 10 the. cognitive ImpainnenL, deSCribed below. neuromuscular

• Impaired reading comprehension • Impaired written expression

• Impaired pragmalics (use of language) Dyspha g ia

impairments may become magnified tracting environment.

In

an open and dl\--

C°wMtive hnprunnen~

Altered level of consciousness occurs con.!ti

k.

ly ""lIh

acceleration-deceleration type injurie~ (OAI ~.:J may occu r with some focal injuries. Con~istenl u-.oe f ttrminology in dealing with alte red co nsciou~ne5. . If: runt According to Jennett and Teasdale. coma is defioc 1 J.! not obeying commands, not uttering ","ords. and 1'0' ~g Ihe eyes' The Glasgow Coma Scal e fGCS ) ",ore c." be used to identify coma, with a score of 8 or Ie, .. &'·inw..; coma. Patients in coma ha\-'e no spontaneous e~e opemn; and do not res pond to vigorous sensor} umuLation. It l~ imponant to note that coma us ual1) lasts only f~ weeks at most. Patients with a decreased It'eJ of d'olo"3!eness with intact eye open ing and sleep--a\\ake qcles tll1 no ability to follow commands or speak are de..aibed;b being in a "'es:etat;\'e slate. Patients in a p~r5ij{rnl uZttath'e state have no meaningful moto r or cogmtI\e tunction and a complete absence of a\loarene - of :;.elf or the: environment.' This is I) picall) defined b greater thaD I year for TBI and greater than 3 mo nilli. for anoXI~ br.UII injury. 11 is imponanl to distinguish patients \\ ho are m J \~­ elative state from those who are In a minimall~ (,()Jb('ioUS stale (MCS). The MCS i< defined as ",,, erel ~ a1tered-~ciousness \\ ith minimal but definite e\ idence of -.til fI environmental 3\\areness.1I Cogniti'c-me11bJr:lV>

Chapter 22 Traumatic Brain Injury o,< ious stimuli. A patient in a MCS will localilc 10 fro fll n . .

u'" .,lil1luil and reach for obJect",. ~,t n .

Conll1l0n1 y u,",cd term ... 10 dCl,cnbc other altered level ... f con.. cioll "l IlCS,,) states arc Jwpor and oh/llnded. Stupor i~

o.~cribed n" an unrc'!'poll':>ive ~lalc rrom which the patient do. be lrou.. ed only briclly with vigorous. repealed sen(an . . .

.,Iimulnllon. The oblunded patient sleeps often and
[ OrienUilion and memory defici ts arc common cognitive impairments. The patient is often di soriented to person, lacc. and lime. M emory deficits can include both relroPrude and/or anterog rade amnesia . Posttraumatic amnesia

fPTAJ describes th e lime between the injury and the time when the pa ti ent is again able to rem ember ongoing events, such a~ what was eaten for breakfast or what happened the pre, ious day. While Ihe patient has PTA, it is as Ihough each moment ex ists in isolation. There is no carryover of inromlalion rrom hour-lo-hour or day-to-day. The implications for functional Lraining are obvious and can be frustrating for the patient and rehabilitation team members. It is difficult to relearn functional skill s without memory. There is a difference between declarative and proce~ dural memory. Declarative memory is the abili ty to recall facts and previous events and is used in explicit learning. Procedurdl memory is related to the knowledge of how to do motor tasks and is used in implicit learning. This refers to learning tasks that can be performed without attention or conscious thought, such as a habit ' Repeated practice of a motor t"sk may lead to procedural memory. Patients with declarative memory deficits may learn (or relearn) motor skills using procedural memory. A patient with PTA is unable to describe memories (declarative memory) or verbalize the steps necessary to complete a task. However, he or she may. at times, show carryover of skills that do not requ ire verbal explanation (procedural memory). For example. wi lh repeated practice a patient may improve the abi lity 10 Iransfer from sit-Io-stand but could nol describe the steps necessary 10 complete the lask. Impaired allention also plays a role in the rehabilitation process. Patien ts may exhibit hyperactivity, impulsiveness, and a decreased attention span. Patients may be easily distractible. The di straction can be externall y mediated, or in SOme cases, internally. This can al so contribute to difficulty 'n reacquiring functional skills. Patients may not be able to focus on a task for a long enough period of time to faci lilale learn ing. Indi viduals with TBI may also lack insight Into their impainnents and demonstrate diminished safety awareness. Thi s can be especially problematic with patients Ihat have fair to good physical skills but slill require some Phhysical assistance. The patient may not realize that he or \ ec annot tran sfer out of bed or ambulate across a street safely w"thout supervIsIon . . or pIlYSICH ' I assi.stance. I Executive function cognitive &kill s refer to four ovcr: Ping capabilities: volition. planning, purposive ac tion, d erfective IX!rformance.IOExecutive funci ion I)kil1~ allow

899

the individual 10 \ ucc",",full y develop and carry om pur_ po,eful goal oriented behavior. An 1l1-<1epth di..:u,,,on of cognitive impairmcnlS a\sociatcd with neurological injurie~ is provided in Chapler 29.

Behavioral Impainnents Research and cI inical experience have e')lablished that behavioral disorders arc the most enduring and M>CiaJly diy abling of any of the impainnents commonly seen afterTBI." Long-Ienn changes in behavior such as sexual disinhibition, emotional disinhibition, apathy, aggressive di~inhibi­ lion, low frustration tolerance, and depression often affect socia l skills and make re-integration back into socicty difficult. Factors to be considered in the evaluation and management of behavioral impainnents are (I) the person's premorbid personality; (2) the physical, cognitive, and em(}lional effects of the injury; and (3) the nature of the social environment. Typicall y, neuropsychologists skilled in lhe evaluation and treatment of behavioral diso;-ders playa leading role in determining behavioral programs. However. to achieve a successful outcome, behavior programs need to be generalized across all treatment settings.

Communication Impainnents Numerous types of communication deficits are noted with patients following brain injury, and these can have a significanL impact on rehabilitation. Expressive or receptive aphasia, reading comprehension and wrirten expression. language skill deficits, and dysanhria may be presenl to varying degrees. See Chapler 30 for a discussion of these impairments.

Visual-Perceptual Impainnents Damage to cranial nerves or the occipital lobes can cause visual impairments. This can include hemianopsia or on rare occasions cortical blindness. Perceptual impairments can include spatial neglect, apraxia, spatial relations syndrome, somatagnosia. and right-left discriminat.ion deficits. See Chapter 29 for a discussion of perceptual deficits.

Swallowing Impainnents Following TBI, many individuals commonly _'periencc dysphagia. Swallowing deficits can be caused b) dam'g' to cranial nerves, motor control impain11ents. apnL\.m~ and poo r postural conlrol. A speech- language P31hologbl IS the primary team member in lrc:lIing lhis illlpnimlcnt l~ec Chapter 30).

Indirect Impainnents Owing to the complex ntllure ofTBI nnu prolo!lgeu 11111110bililY. puticlll\ nrc likel) 10 \uftrr from n \ llfiel) of mdll'ect

Ph~"icAI

900

Box 22.1 • S~lll Uv,u('

•

~m

Rehabilitaliun

lndin...'"Ct Impaimlcnts AssociAted "ilh Traumatic Brain Injury

cntllrm.:lure~

tm:-akd(I\' n. dccubllU\ ulcer

· Dttr ,em Ihrombo.,l.,

• 11elcrocropu: o'.!olfil'llll(lll • [)(\:rea..w bone dcn .. it) • Mu,dc alrophy •

Det'rca.~d

cndurnnce

• Infection • Pneumonia

impninnents as we ll. Box 22. 1 presents thc more coml11 on indirect impainllcnts associated with TBI.

Clinical Rating Scales

Table 22,3 Gla
- -='-e.-.--

Eye Opening Spontaneous To speech To pain No response

4

3 2

Best Motor Response

Follows motor co mman ds Localizes

6

5

W ithdraws Abn ormal flexion

4

Extensor response No response

2

Verbal Response Oriented

3

5

Confused conversation

4

Inappropriate words Incomprehensible sounds

3 2

No response Outcome measures are ex tremely important for the rehabil itation professional. Valid and reliab le outcome measures can be used by phys ical therapi sts to assist in predicting ou tcomes or in making a diagnosis. They are used to evaluate change in the patient over time, which also provides a means for detennin ing the effecti veness of the interventio ns provided. When dala for large groups of patient s are presented in aggregate ronn , the findings can provide infonnation regarding the cost effcctiveness of physicallherapy and other rehabilitation inte rventions. Some of the most commonly used clinica l rating sca les designed for individuals Wilh a TBI are briefly described be low.

Glasgow Coma Scale The GlasgoII' Como Scale (GCS ), developed by Teasdale

and Jennett , is the most widely used clinical scale that measures level of consciousness and helps define and classify the severity of injury.]2 The GCS is comprised of three response scores: motor response, verbal response, and eye opening {Table 22.3). The scores from l he separale responses are summed to provide a Score between 3 and 15. Coma is commonly defined as scores $ 8. Scores :58 are classified as a ~vere brain injury, scores between 9 and 12 are defined as moderate and 1310 15 are class ified as mild brain inj ury. The GCS hru. hig h inter-rater reliabilit y 13 i.md C'1n be used as a prognostic mcasure. 14

From Jennett and Teasdale ,7 p 78, with permiSSion.

and the abilit y to recall eve nts prio r to and after the tnjury. Scores between 100 and 76 are co n~ldered normal and pati ents with scores below are considered to haH' PTA. T he GOAT has hi gh interrate r reliabili t) ."

Rancho Los Arnigos Level of Cognitive Functioning The Rancho Los Amigos Le\·el of CO~Jlith·/' Flln(ti{llllll~ (LOeF) sca le is a descript ive scale u\ed to ~\amin~ cognitive and behav ioral recovery in inuh idual" \\ ith T81 (Box 22.2) as they e merge frol11 comaY' Th i.. "(.lie doe, not address s pecifi c cog nitive de fi c its, hut I' u,eful for co mmunica ting general cogniti ve and/or ht!ha\ iOr.l1 'lJIU~ and for IrCatmcm plannin g. The e ight calegone' dt',cnr.ttypical cog niti ve and beh m ioral progre\" ana i.1 br.lln injury. Client s may plateau at ~\Ily l e \" ~1. The LOCF ~,1' been shown to be a re liable and valid m ei.IMIrl' of (ogl1l1l\( " .' and behl.lvioral function for ind iv iduab. \\ illl hr.lln IIlJUI) . This sca le. together with the GCS. i~ among the I1ll1'l \\llkl~ L1sed in cl inical facilities.

Glasgow Outcome Scale ' t'lll'r.11

Galveston Orientation and Amnesia Test The Gahc.\l(J11 OriellfatiOIl alld Amnesia Test (GOAT) is a mca,ure of pO'ttlraumalic amnesia ( PTA ).I ~ Duration of PTA ha\ been 'thown 10 be a va lid predi ctor or lon g-te rm outcome afler TBl. lf,.17 The GOAT ilO admini stered by U1<,king OJ \C rie\ of Mand::trdi/cd quc~ljon "l relaled to orientati on

The GI(Js ~ oll ' OIlt(,Of1l(, Scah' (GOS ) IS lI "'t:l I :1 ...1 f I t .1 ~ {) rIl' Il \1.....··d ill pl'l)~ o ut comes, measure a I'le r a T BI.'I ~ It~'r . I· · nostl c stue ICS al di sc harge tl nd 6 mOllt I1" H) ' 1 •\l',lr .1 , . , I
Chapter 22 Traumatic Brain Injury

901

Box 22.2 Rancho Los Amigos Levels of Cognitive Functioning (LOCF)" I. No Response Patient appears to be in a deep sleep and is completely unresponsive to any sti muli.

II. Generalized Response Patient reacts inconsisten tly and nonpurposefully to stim ul i in a nonspecific manner. Responses are limited and often the o;ame regardless of st imulus presented. Responses may be physiological changes, gross body movements, and/or vocalization.

rn. Localized

Response Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type of st imulus pre· sented. May follow si mple commands suc h as closing eyes or squeezing hand in an inconsistent, delayed manner.

J\ . Co nfu sed-Agitated Patient is in a heightened state of activity. Behavior is bizarre and nonpurposefuJ relatjve to immediate environment. Does not discriminate among persons or objects; is unable to cooperate directly with treatment efforts. Verbalizations frequentl) are incoherent and/or inappropriate to the environment: confabulat ion may be present Gross anent ion to environment is very brief; selective anention is often nonexistent. Pati ent lacks short- and long-term recall. \ . Confused-Inappropriate Patient is able to respond to si mple commands fairly consistently. However. wi th increased complexity of commands or lack of any external structure. responses are nonpurposeful. random. or fragmented. Demonstrates gross attention to the environment but is highly distractible and lacks ability to ~Conde n sed

form . From

Profe~., ion a l

focus attention on a specific task. With structure. may be able 10 converse on a social automatic level for shan periods of rime. Verbalization is often inappropriate and confabulatory. Memory is severely impaired: often shows inappropriate use of objects; may perfOffil previously learned tasks with structure but is unable to learn new infonnation.

\- t. Confused-Appropriate Patient shows goal-directed behavior but is dependent on external input or direction. Follows si mple directions consistently and shows carryover for relearned tasks such as self-care. Responses may be incorrect due to memory problems. but they are appropriate to the situation. Past memories show more depth and detail than recent memory.

\-I1. Automatic-Appropriate Patient appears appropriate and oriented withi n the hospital and home sett ings; goes through daily routine automatically. but frequently robotlike. Patient shows minimal to no con fusion and has shallow recall of activities. Shows carryover for new learning but at a decreased rate. With structure is able to initiate social or recreational activiti es: judgement remains impaired.

\111. Purposeful.Appropriate Patient is able to recall and integrate past and recent events and is aware of and responsive [Q env ironment. Shows carryove r for new learning and needs no supervi sion once activi ties are learned. May continu e to show a decreased abil it y relalive to premorbid abi lities. abstract reasoning. tolerance for stress. and judgement in emergencies or unusual circums tan ces.

Staff Association. Rancho Los Amigos Hospital. 1M pp 87- 88. with pennission.

Table 22.4 Glasgow Outcome Scale Original Scale

Extended Scale

Dead

Dead

Dead

Vegetative

Vegetative

Dependent

Degree of disability:

5

Severely disabled

4

3

c

2

Moderately disabled

0

Good recovery

Total Categones 8 From Jennett and Teasdale ,7 p 306, with permission.

5

Independent

3

902

Physical Rehabilitation

Table 22.5 Di""bility Ra ting Scale Eye openingl Verbalization 2 Motor response 3 Feeding4 Toileting 4 Grooming4

Arousabllity, awareness and respon sivity

Cognitive ability for self·care

Dependence on others Psychosocial adaptability

Spontaneous To speech To pain None

0 2 3

=======

Oriented Confused Inappropriate Incomprehensive None

Completely independent Independent in special environment Mildly dependent' Moderately dependent" Markedly dependent ' Totally dependent"

a 1

2 3 4 5

0 2 3 4

Obeying Localizing Withdrawing Flexing Extending None

Not restricted Selected jobs Sheltered workshop Not employable

Level of functioning 5 "Employability""

..........

NIf . .e

0

Complex Partial Minimal None

2 3

0 1 2

3

4

5

0

0

2 3

2-3 4-{;

7-11 12-16 17-21 22-24 25-29 30

None Mild Partial Moderate Moderately severe Severe Extremely severe Vegetative state Extreme vegetative state Death

Condensed form . From Rappaport,24 p 119, with permission. aNeeds limited assistance (nonresident helper). bNeeds moderate assistance (person in home). cNeeds assistance with all major activities at all times . d24· hour nursing care required .

Disability Rating Scale Rappaport's Disability Rating Scale (DRS) covers a wide range of functional areas and is used to classify levels of disabilit y ranging from death to no disability (Table 22.5)." 1t can be used to track indiv idu al progress from coma through community in tegration. T he maximum score is a 29, indicati ng extreme vegetat ive state, while the lowest po~sibl e score is a 0 , indicating no disability. The DRS has good reli abil ity as weI1. 19 •24

ab ili ty in individuals undergoing in·pariem rehabilitati~n. and is usefu l for monitoring patient progress and e\·a1uaung outcomes. The Functional Assessmem Measure (FAM ) was developed as an adjunct to the FIMT>I. It includes funetionru areas not addressed in the FIMDI that are important for individurus wi th TBI and stroke. The other ilems include community access, reading. writing. safety. emplo)"abi~it). and adjustment to Iimitations. 2829 The FIJvfTM in com~l~a· tion with the FAM are valid and reliable measures ot diSability after TBI. 30.31

Functional Independence Measure and Functional Assessment Measure

=:-----:-----=--=----=-=-----:-----1 Prognosis and Goal Setting

T he Functional Independent'e Measure (FIMTM)~-21 is a commonly used measure of funcl ional mobilit y and ADL func li on. The FIMTM was designed to meas ure level of di $·

. ' . mot o.rand Ow mg to t Il C WI'dC range 0 r cogllllive. . ' neu·i~ robehavioral impairments that accompany brain JIlJlIr)·

902

Ph~~cal

Rehabilitation

Table 22.5 Disability Ratin, Scale Eye opening 1 Verbalization 2 Motor response l Feeding4 Toileting 4 Grooming4 Level of functioning 5 "Employability""

Arousability, awareness and responsivity

Cognitive ability for self·care

Dependence on others Psychosocial adaptability

Spontaneous To speech To pain None

0 2

3

Oriented Confused Inappropriate Incomprehensive None

0 2

3 4

Obeying Localizing Withdrawing Flexing Extending None

Complex Partial Minimal None

0 1 2

3

0 t 2 3

4

S

Level of Disnhiliry Completely independent Independent in special environment Mildly dependent' Moderately dependent b Markedly dependent ' Totally dependent d

0 1

2 3

Not restricted Selected jobs Sheltered workshop Not employable

0 1

o

2 3

2-3

1 4-6

7-11 12-1 6 17-21 22-24 25-29

4 S

30

None Mild Partial Moderate Moderately severe Severe Extrem ely severe Vegetative state Extreme vegelt'tlve state Death

Condensed form . From Rappaport,2. p 11 9, with permission . -Needs limited assistance (nonresident helper). °Needs moderate assistance (person In home). cNeeds assistance with alt major activities at all times. d24·hour nursing care required.

Rappaporr's f);saMlity Rat;ng Scale (DRS) covers a wide range of functional areas and i'i used 10 c1assiry levels of diliabilily ranging from death 10 no disabi lity (Table 22.5).24 II can be u ~d to track individual progress from coma through community integration. The maxi mulll score is it 29, indicating extreme vegetati ve !
abi lity in individ uals undergoing in· palicnt l'eh(lhllilUll~n, and is useful for monilOrin g patienl progress !lnti cvalual lOg outcomes. The FII"Cfional ASS('S.\lIWIIf M l'lll:;lIrt' (1-: \ IIJ \\;L" developed as an adju nct 10 the FIMT'L . II include .. runclional areas nOI addressed in Ihe FIM"l thHl arcIJlLI)()rta~1I for individufLls wi th TB I a ncl stl'ot..c, 11lc other 11C1l1 .. l1ll' lu(l.· .' . ' .. com munIty UCCCS!
Functional Independence Measure and Functional Assessment Measure

------~--~~~~~-----­ Prognosis and Goal Setting

TIle FWIlIIOlW/ 11Il1t'pemlclIl'(' Mcasllrt' (l' IMn.1 P" 21 is a c:.:onunonly u'\Cd measure of funcli onal mohili ly lind ADL flll1c:.:t LtlO. The HM 'M wa!»' dCliigncd 10 m c:I... urc leve l of di!
Owing 10 the wulc range of cogn Ltl Ve, 11i0Ior, . II rohc huvlOru l ln1 pIL JI' m C nl ~ thnt UCC(ll1lpml) I1r I Ull 10lLL O '

Disability Rating Scale

.

•

•

..

•

and

I

jlt'll

Chapter 22 Traumatic Brain Injury be difficult to e
ual pallent~

Medical Management ~Iedical trealment for a patient with a TBI stans at the

scene of the accident. Early resuscitation with the goa l of stabilizmg the cardiovasc ular and respiratory systems is Important in order to maintain sufficient blood flow and O~)gen

to the brain.34 Patients who are unresponsive should be Intubated and ventilated . Once the patient arri ves at the medical center, the primary goal'\ are to stabilize vital signs, perform a comp lete e~amination of the injury, and establish a comprehensive monitoring system." The GCS is used to determine the 'le\.~rity of the brain injury. A complete neurological exam!natlon j., also done. Additional information about the tllent of the injury is obtained through X-ray films and fltu' . rOlmaglng studies s uch as CT and MRI of the head, "Pine. thorax, and abdomen. Large intracranial hematomas III'Dth I er mas'i lesions are surgica ll y evacuated . v "tracranial prcl\sure (ICP) is monitored. This can Ix! done ~~ ~atheter placed in the lateral ventricle, a screw in the PI~n~rted into the subarachnoid space, or a transducer ICp directly in the epidural space. Normal values for ~"' .re between 4 and 15 mm Hg. Medical intervention S I, t to maintain an ICP below 20 mm Hg." Elevated ICP 't.ted . wah the Use of sedating medications, moderale

t

90J

head up positioning (head elevated to 30"), ventriCIJlar drainage, osmotherapy. hypothenma., surgical decompression. and barbiturale\. '" McdicaJ scientists are researching the effectiveness of various medications to prevent the pathophysiological mechanis ms that cause secondary brain damage. No drug has achieved thi , goal so far. However, glutamate receptor antagonists, free radical scavengers, calcium antagonists, and cyclosporin have shown promise. J4 Owing to the severity of the injury and the potential for concomitant injuries. such as long bone fractures. patients with TBI often pre~ent with a variety of medical complications that can interfere with rehabilitation and the recovery process. One study found that 56 percent of patients with severe brain injury exhjbited neurological problems, 50 percent developed gastrointestinal difficulties. 45 percent developed genitourinary problems, 34 percent had respiratory problems, 32 percent had cardiovascular problems, and 21 percent had dermatological complications" Examples of specific conditions include ventricular dilatation. posttraumatic seizures, impaired liver function tests, urinary tract infections, hypertension, and decubitus ulcers. Medications may be used to treat these and other complications that may arise. The physical therapist typically spends more time with the patient as compared to the medical doctor, allowing the therapist an advantageous position of alerting the physician regarding a host of varied medical problems that can be treated with medications. This serves to enhance the patient's medicaJ status, which in tum maximizes the patient's ability to participate in therapy sessions. Areas that the therapist might logically provide recommendations include pain management. spasticity, motor restoration . and cognitive issues including level of consciousness, awareness, anention quality. speech. memory, and di sinhibited emotional, physical, and sexual behaviors. The physician has a similar responsibility to inform the rehabilitation team when doses are increased or when new medications are started. Because patients with brain injury are often on several medications at one time, all team members typically take an active role in monitoring side effects and determining the impact of the medications. Refer to Appendix A for some commonly prescribed medications with comments and side effects for each medication.

Rehabilitation Perspective Interdisciplinary Team The rehabilitation of patient. wilh TBI occurs across a continuum of care in a varielY of selling (Fig. 22.1). Palicnt~ who are in n minimall) con CIOUS Slate or in coma may receive on-going therapy In a nur ing homr or ocher

90-1

Ph}sical Rehabilitation Comprehensive Outpatient Services (with community re-entry program)

Acute Hospital

In-pallent Rehabilitation

Comprehensive Day Treatment (outpatient program)

Skilled Nursing Facility (subacute rehabilitation) ,,---- \

Community Reintegration (residential program)

Neurobehavioral

Long-Term Care Facility

!.----"IL(residential program) -_ _ _ _--'

lomHenn care facilit y once they are medically stable. P~uient s \\ ho are beginning to recover from coma with moderate 10 :-.e\ ere cognitive. behavioral. and physical impairments often continue rehabilitation in either an acute or subacute in-patient rehabi litati on facility. As patients progress in recovery, they will be di sc harged to other commu nitybased settings depending on the needs of the individual patienl. A ~ menti oned earlier. th e foundation for successfu l rehabilitation of the patient with a brain injury is an imer discipliJltlly lelll/l . No one person could possibly have the knowledge and skills necessar) 10 treat all aspects of a brain injur}. An interdi sciplinary team approach is essential to prov iding the mo:,t comprehensive care Ihat will lead 10 maximi zi ng the pat ie nt '~ funclional recovery. Although most re~earc h conducted in thb area is not controlled. an interdisci pl inal) approach 10 rehabilitati on for thi s populati on has bee n ... ho" n to be effec ti\'e for impro\ illg function and parti ci pat io n in societ). lb-w \Vithin the contex t of the team, individual members collaborate, contri buting their ex pertise in a ~ pe cifi c area, th ereby e nhan cin g the t c al11 '~ ove rall effec ti ve ness. Commun ication and open minded ness are kc) to any tea m. The di fferent me mbe rs I1lU ~ t ':. hare their ~ I...ill ~ and findin g~ " ith the ", hol e team and be \dll ing 10 learn from othe r team member.., to promote optimal return of fun cti on. The physicalthempist must be will ing to share a unique knowl edge of mOlOr control. but be open to learnin g from other tea m membe r\:. suc h a~ the r., peec h- Ianguage pathologist about cog nith e defici t!' . All team membe rs should rake ".. hat the) have learned trolll othcr learn members and inco rporat e it into the ir treatm ent. Thi ... will lead to a con.!)istent and comp lete approac h to ca re. Some mc mbe rs rna) play more promine nt role.!) depending on the s.elting. For exampl e, a rec reational thcrapi :-.t will not likely be in vol ved with a patient in thc acut e hospital, but would playa vital ro le in a co mmunit y reen try setting. The following section identities fo,ome of th e

Figure 22.1 Rehabilitati on seuings for ind ividuals with TBI across the continuum of care.

team members involved in the care of brain injury survivors and their roles in an acu te rehabilitation hospital.

Patient and Family It cann ot be st ressed enough that the most im portant members of the team are the pat ient and his or her fami ly. Both the patient'S and the fami ly's lives are likely to be dramatically changed as a result of the injury. Familial roles may change. The patient who previously took care of the children may now be on the receiving end of care. The team must gamer infO!lllati on regarding the patient 's work, school, financial status, and social histo ry. Famil y members should be questi oned to obtain info nn ation on the patient's lifestyle, favorite hobbies. and other likes and dislikes. Lnformation about the family dynamics should be ascerta ined. Who is the head of the household? Wh o is the breadwinner in the fami ly? Is the patient responsible for taki ng care of the c hildren ? What grade is the pat ient in? Is the patient in college or working full time? All of these and many other simil ar qu es tions should be answe red to deve lop a compre hensive plan of ca re. Education is another essent ial aspect of ca re that should begin as soon as possible wit h the fam il y and pat ient. when appropriate. The great majorit y of lay people are unaware of the implica ti ons of a bra in injury. They may think their loved one will wake up from a coma and retum 10 his or her previous lifestyle with little difficult y, like in a televi~ ion movie. Unfortunately, this is rare ly the case. It is the job of the entire interdisciplinary team to begi n ed ucating the famil y and patient about the affec ts of a brain injury and the long. arduous road to recovery. The family should be introduced to the Ranchos Los Amigo.!) LOCF Scale and what to expect at the different stages. It is often beneficial to provide educmional material for the patient and family. The ph) <.;ical lhe rapi ~t shou ld begin educatio n on basic compone nt ~ of care such as how to pe rform pa:-.sive range of mo tion (PROM ), to more complex i S~ llC~. such as why spasticit y develops and how the brain controb movement.

Chnplcr 22 Traumatic Brain Injury

., lily members o ften 11""- if tlw

pUli ell1

will return lu

tI

905

i ~ r.:u-lrC:tlmcnh with the OT. Huving two truined profc ..wurI..i ng Itt Ihe l.,UI11C lime with the patlcnt can be very

f.ITl 11'!I"lift:. 01' how Illllch function he or s he wi ll regain . "lion ' \lIU the in itial .... Iagc~ of recovery in the aClite ho ... pilal

s iollal ~

DU; n;u te rdwbilillilion hospitul . this qut! . . lion is diflicuit :1111'11l,\,cr. E- \cry ptll lCl1t ' I' fl'c rt!nt Iy an d HI d'I fler' recovers (I t"t' "',IC"', An (' nl'cli ve WHy 10 help unswa family questions l'n ,. I l'ul1<..'crn.., i ~ through educlltion.

h llnd~ llrc needed to c tTcc tivcly treul the patient. Ttw.. I, c~pccia ll y truc wilh pntient<; Ihat have ~eve rc motor control

.1I1(

-

producti ve. Mnny lime .. IWO "C I.. or cl(pc ri cnccd and truined

lind cog nit ive de neilS, The 01' wi ll "1'0 work clo\ely with thc nursi ng ~ t illT to edu cate them o n the bcM wuy, to a'ij,;j,1 the pm ic nt wi th ADL.

Ph),iciRn

1Illlw ,Icute rchlibi liullion hos pital. the physic ian over~cc­ 'nl! tht' car~ of Iht.! pali...:nl wi th 1\ brain injury is lIsliully II I';) \i:ll fi" or IICUl'ologist. T he physiatri st hus ex perti se and ;nllilillg in phy . . icn l medicine. rehabilitation , lind fUllcti on. f\ Ill'urnlogi . . t ':-, :-kills lie in th e rea lm (lU' .... y'll· l1l .

n'llIled

orth e bruin and !lcrv-

A ne uro logis t wi ll have parti c ular knowl edgc

Ihe brnin may recove r. and what impnirIV be ~ec n given the location and the t!\I~Il( nf the Injury, BOlh a phys iHlrisl und ne uro logist havc \ ;1"1 klU)\\ kdgc 111 neuropha rm acology. un c,\ tremely imporI.mt p,lrt llf managemen t with this patient popu lation. Ct'r1,lin Ilh"dil.'ationl., may huve hnmlful side etTects that may not be It',lllil) appare nt. For e,\U1np le. It physiatrist or I1CUroll)gl,t 11;1) t"IC: able 10 presc ribe a less sedming drug than \\ould Ill1nni.llly be used in n different patient populmion to In>;\! II n 'nm n dinic(ll problem. Illt'Jlb

10 ho\\

arc Iil-"c l)

Rehabilitation Nurse In a rchabilillltion hospital. the nurse il.,

rcspom~ibl e

ror dl"'.

pcn sing mcdi cations nnd clo~c l y monitoring th ei r efrcc t~.

T he nu rse wi ll initiate a bowel and bladder rctfl1ining progrHITl to assist the patien t in learning to become (;ontinen t agai n. Bowel and bladder co ntrol is ex tremely Im portant for self-es tecm and is related to di sc harge place ment. The nu rse pe rform s daily mon itOring of vital l.,ig no;; to make SUfe the patien t remai ns medicall y Mable. Thc nur~e Will inspect the p.atient 's skin daily to ensure there are no \ ign51 of skin breakdown, The nurse also has the difficult task of consistentl y following through with the tcam 's trealment plan th roughou t the day, For example. the th ird nursing shift needs to cont in ue 10 follow splinting schedules cMablished by the phys ical ,md occ upational therapists, The nurse often has the most inlcmction on a reg ular basis with the patient's famil y,

Spt't'Ch· L.l1lguage Path o logist Bt'l·;ltl,t: of to tht! natul't! of a brain injury, the speechlanguag~ pa tho log ist (S LP) plays an import ant and diverse rolt' in the rt'lUl bi litntion or th e pati ent. T he SLP examines, t'\aluatt" , tlnd treats co mmunication. swallowing. and cognil1\c impainnents in the patient. As can be seen fro m the pre,ent<1tion of impainne nts in Table 22.2. this ca n be a chlllenging Iask. It b important for the physical therapist to ~ in dose co mmunication wi th the SLP to provide con\blt'nC) of care in relation to cognitive, swallowing. and C'OmmuniL'allon impaimlents. \Vi th [he guidance of the SLP. the team will be able to devise the most effecti ve and co n'blem \\u: to commu nicate with the patient. He or she will also be able to instruc t the team in how the patient's cog ni lI'.e lrn.painne nt~ may impede new learning, whi ch in tum v.ilI affe t e\ef)one's in teractions with the patient and the u.atment plan,

OCcupational Therapist The OCcupational therapist (OT) examines, evaluates, and ItbI.m,.. and will often work with the SLP in treating cogImpairmenb, Basic ADL (BADL) includes dressing. ~~"dtng, bathing. and grooming, Instrumen tal ADL >boppL) tnclude, home management, houo;ekeeping. grocery II. mg. dmmg. and telephone use, In the rehabi litat ion ,:101. the OCcupaltonal and phy, ical therapi'" ol te n 'try closel) together, A u,cful treatment a pproac h

0{ dati}

nu;;"

Case Manager/ Team Coordinator The case manager acts as the coordinator for the team. The CHse manager is often a nurse, medical social worker. or ot her heHlth professional. The case manager will direct learn meetings, schedul e ramily conferences, and act as a liaison wi th third-party payers. He or she must promote good communication alllong all team members to ensure that the rehabilitation care being provided is trul y team oriented. The case manager wi ll also be in constant com munication with the patient and fami ly to ensure their needs are being met and that questions and concerns are adequately addressed, The case manage r will coordinate payment and insurance be nefit issues with the case manager from the patient's insurance company. In addition. the case manager is responsible for selting up follow-up and discharge services for the patient and family.

Medical Social Worker The medical social worker (MSW) provides much needed support to both the family a nd patient. During the fu>t few day s after the initial injury. the fumily i ~ in a ~tnlt" of c ri sis. They arc thrown into u world thut the), mO.'ot hld~. never knew existed. The MS\\f can support the f.untl: with ed ucu tion and co un seling . A s the patknt progl'l",~e .. with rccove ry. the IvlSW wi ll nlso provide l'oulbehng for the patient. This is particularl) IInpOt1"Ult a~ the pallenl bcgin~ to develop greater it" llrcne, \ "nuj IIblghl into hi" or her defi cit.... If th e patic..ont hu, ht' h.t\ 10r\11 1I11PJ1nn~nt .. , the MSW Cll ll he pl\oflll in !I\\i\ling bnlh thl" luticnt and

906

Ph~sical

Relulbililation

1.IIHlI) . B) prm Ithng coull'~llI1 g 10 bUl h th e I)uti c nt and tanHI). fhe MSW ill the dcvclnp llI c nl II I co pi ng 'Irall.'gl~l'I for \\ohal m~l ) he u lifelong dbuhilit y.

""i,,,,,

europ'ychologist TIle neurop ...)dlOlogi...1 play!-o nn impon:'lIlt role on the team . lie or ... he \\ ill often pc rfonn ne uropsyc hological l e~ lin g \\ hen appropriate to dctennine the pali en t 's buse l ine cogni· 11\i: funclloning . He or ~ h e will a lso a ~s bl fhe tcnlll in dC\l.'loping a behavioral managemcnt program. Wh en the patient \\ ilh a brain injury h
Other Team Members Many

p~Hi~nls

wi th severe brain injury may requ ire ve nt i· latory s upport . The respiratOl:V C{lre practi tioner is a vilal participanl in Ihe eva luati on and treatment of respirat ory impainnents. In the rehabilit:lIion hospi ta l, the respiratory thempi st contribute s to monitoring the p,lti ent's pulmona ry ~ Iatu ~ and providing appropriat e treatme nt. A recrellfiollai therap ist ass ists the patie nt's relUm to activities enjoyed prior to the acc ident. or in he lping ide n· tify new acti vitie s that the patient wi ll find rewarding. Thi s is an ex.tremely important part of re habilit ati on. Bei ng able to part ic ipate in some type of lei sure o r recreatio nal activ · ilie s is a signific:lI1t step in re tum in g to a fulfi ll ing lifestyle. Unfortunat e ly_ many insurance companies no longe r reim · burse for the services of a I'ccrealionalt herapist.

Physical Therapy Examination and Treatment A patient \\ ith a Illoder
a wlll~c l c hnir. while the other may be lJble 10 ambul pc ndcllIly :Jnd ha ve minimal phy\kal impa innent \.ale lOde.

Ranchos Los Amigos Levels I, II, and III. Decreased or Low-Level Response . Levels of Recovery Exam ina tion At these earl y stages of recovery. the patient is likely to be an acute hospital. However, the pat ient might al so be 'lee In an in· pat ie nt rehabil itation selli ng. A paliem with a Chr" 10 onlC injll ~ who has not prog re~se? reyond Ihe~ stages may be seen III a long·te nn care lac ility. In Level I, the pallent i unrespons ive to stimul i. In Leve l II , the parient react", lI1con~ sistcnt ly 10 stimuli. TIle response may be total body mQ\e. me nts, voca lizations, or ph ys iological c h an ge~. 'The re'lpon-.e is o ften the same regardless of the stimu li. Le\lellll is characterized by a loca li zed re~ ponse that is d irectl} related to the type of stimuli presented (see Box 22.2). Th e /irsl step in begi nnin g an exam ination at these stages o f recovery is 10 conduc t a complete chan revie\/' Because the pat ie nt may not be medica ll y ... table. a. . "ell as the preva le nce o f va riou s prec auti ons and complication~ ~ee n in this pati ent popula tion. it is important 10 ohtain all o f the c ritical infonn3ti on from Ihe chart before Jctuall~ see ing the palienl. TIle palienl may be on il ventilator. monitoring of le p may be ongoing. he or she m3) ha\ e \H'lghtbearing precaut ions .md nmge of motion ( RO~1) re,tnctiorn ow ing to orthopedi c injuries . open "ound .... or an e\temll fixator may be prese nt. By doi ng a co mplete ch.u fe' ie\\. the thc mpi st ca n begin 10 foml a compre hensive "'lclUre of the pati ent. a nd have a com plete undef\tandin,g. (1 1 (he precau t ioll~ and contra in dic3 tio ns that mu~t be ob~'f\eJ during the ex aminati on and subseque nt t re~umen'- B~\.·au~ the patie nt 's med ica l status ma) be d)nanw.: at tht'-.(' stages it is important to c heck with the pallent', primaI'} nurse before beg inni ng an) ses ...,ion ..JO The therapl'l ,hould asce rt a in what the patie nt 's vi tal siens are. Irthe p:ult'ntl" running OJ te m perature. ho\\ a lert th~ patient i.... and if Iht'rt are a ny co ntrn indications or precaution.. , in effect 0\\ JOg 10 the po~s ibil i t ) o f \ arious infec tion". team l11t'mbt'1" ~hould a "~ ays obse rve universal precaut ion, ilnd mJ~ need to \\ ear gO\\ ns. glO\ e !o. . and/or l11 as lr.. '\ \\ hen I£eJUnf the patie nt. After reviewing the chart and reee h ing an update on U1t' pat ient's "talUs fro m the nurs ing ' tatT. lhe ph~ , Ical tht'r3pist is rend) 10 begi n the e \ amin atlOn. The m illal p<1I11{1Il of the e~ am in3t ion shoul d foc u ... on ob,C'n inl! thl!' pJIlt'nl I n t/l< and documentmg ho\\ he or .. he re, pond, 10 ,n l1l11 I I e nvironment. Ke) que 'lion, to :lddrt'~' incl ude: \ hat posture I~ the pallenl in'..' " there ~-, IlklK~ (It pn im e po ,tu rc~ or refl c \ e,'! rc the patient', e\,e~ ont-n or do,ed'! • P- uIj I" Ihe pallt: nl .lblc 10 U";.!c )... 10 Jud ltor) or \ l,u.)1 , [1111 tion? lTl

Chnpfcr 22 Traumatic Brain Inju ry . h Ihe pa tient .nlli e to ~oca lj/ e '! , D()I.:'I the pallen t ex hlhu allY act ive move ment '! " rnCl'vcrnen l purp0'lclul or /H}/lpurpo ,t:: ful ?

th e

• DOC'! the p.IIICI1I re. lct 10 lac l ilc/painful stimul ati o n?

, 00 the "a tu:lll ..... v itlll , igm. chun ge w hen ex ternal ~Iimu l)rll11IIlVC po<., lu re\ m ay include tho~e assoc iat ed w ith dccor l ic~IIC or dcccrcbralc ri g idit y. dc~c ribed em l icr. Ch.lpll'r H pn.:<.,c nt <., a del ailed dc!'.c ript ion of ot her primiti ve rene.\ p.lllcrn, and po, tUI'C\ a...... ociHt ed wit h neurolog icnl lO ~ull

LX.1I1111h1110n of PROM and mu ~c le tone should be COIll -

pleled. Pallen\<., WIth '('H I are :ll

II

hi gh ri sk o r deve lo ping con -

tracture,11 OWIng 10 pro longed per iod ... o f immobil izati o n and .IPnnmlHlll'llt.:x lve po' luring. Beca use of these ri sk factors it 1\ pJrlJudarly in lporta nl to dOclllllent tone and PROM measurcllll'nt " One (,:(,lI1l1llHl <.:Iini c;'11 too l u... ed 10 eX
(1)(;

,"won"

moddll'c! " ... hW(Jl1 h Scale IIlVo l ve~ m ovi ng the palient \

ItmnIlm ll li'h till' avai labl e ROM and dctt:: rmining the amount (It rCl"ll"t.,l1"l· 10 pa'l ... ivc llJovement al the joi nt. II \I I, no t Illcdlc;t ll y co ntraindi cH tcd, the cx;.uni nal ioll ,huulll I, luill' ,III ath.:mp' 10 ~ il the pat ient lip un the ~ id e 01 the hl'd wII Il ...... I" i ... tam:e. T he Iher' IjJiM sho uld monit or \11,11 "~'Ih .lIlt! docum ellt Hlly c hange!>. ill to ne 01' head and trul1~ ('0111101 W hell it il.; appropriat e. Ihe pati ent ~ h ould be IriUl... kn rd In to II w lH;c lc hu i r. Th e,; pa l ienl may require th e il""liUlI'L ol twn to tll rt::e peopl e to tran sfer al th is sta ge. In fII(1,1 UI"'l'" it reclinil1 g 01' tilt - il1 ~l' pacc w hce khair is the 1ll'l"t uplulll l pi po ... it ion i ll g, wit h :, !'.pec.::i:dil.ed pressure-

Table 22.6 Mudified Ashworth SC:l le for Gnuliu,:t SI)U .. ,jci'y

Grade

o

:....-

Deter! :::.:c::NO inc reaso In muscle lone, Shg ht Incroaso In mu scle tone. Inanll stod by a ca tch a nd release o r by minim al resistanco a t the end 01 til e ROM Wll n the a llec lod part(s) Is moved in II xio n r 0x to ns lon.

II

IIghl iliCI aso in musc le lono, ma nlioSlod by a ca lch. lo llow ed by m lnhnol l osi I nco Ihrougll ou t Iho r molnd r (10 s tllan hall) 01 th e ROM .

2

Mo rc markod Incroase In muscle tono Iltrough m ost 01 til0 ROM , but a llec tod pOrt( ) cosily movod.

3

Con Id lObi incroas In musclo lana, plIsslvo movomo nt dlfllcult . All oel d po rl(s) rig id In lIoxlon or

O)(IOnslon , 10111 II.. , JV

IUllI10n uml

"' lIIl t h .~

red ucin . ,everal trea lmcnr . g c ushi ' o n . on.en .II may requIre ~C\"' I OI~!'. complet e the enlire ex amination. Whenever Ihe thcrapl~ t I ... working w ith the patieill. \l gn, of progre s\ or rcgrc~ ~ l o ll ~ h oli i d he ci.l rcfully munitored. .

'?

~valua(ion, Prognosis, and Plan of Care

1.lllon " pn.· ,cntcd'!

Wile

907

I

P 207 , wUII ponnlssfOIl

1 he data gathered during the initi al examination i"i used 10 evaluate the pali ent 's status ~md develop a prog . d · nOS I ~ an I () I c<.Jrc ( POC) . .Sch cnkman et al"() provide a clinically pall usc ful mod el 10 ass l s.t the clinicnl reasonin g and managc~

~nc.111 p,r~cc s!'. fo~' pa tl cnt s wi th neurolog ica l impainncnrs. r,h l s c linica l ~ecl s ion -making too l follow~ Nagj'~ model of ~ I s;:~bl~ menl from patho logy to impairm enl to functional 11111 1tation to di sabil it y. Based on the findings from the initial exam inati o n. primary and secondary impairments con tribut e to the pati ent 's fu nctional lim itations, which lead to disability, Goab and !o.pecific int erve nt ion s are then cMabli shed based on the impairments and fun ct ional limitations of the pati ent. Sec C hapler I for a more thoro ug h discuss ion of th is lopi c. When work in g wi th palient s who are slow to recover .md lllinil11i:lll y conscious. i t is important to consider thai not all of these individual s will emerge from their coma or minimall y consc ious state. A s di sc ussed earlier in the c hapt er, Ihe longer Ihe duration of cOl11a the less likelihood of f'unctionalrecovcry. Pa tients who remnin in thi s stage of recove ry are oftell placed in lon g-term residential nursing home,; fa c ilities where th ey receive c ustodia l care. It may be dif'licull to lind an approp ri ate long-term se lling for these

pat icnts. The fo ll owi ng is H li st of genera l goals and outcomes anlicipaled for palienl, in Levels I. II . and III (LOCF) adapled from Ihe Al11l!rican Phys ical Therapy A ssociati on's Guide to Physi('ol 1"lWNlpiSf PracfiCl' :H They emt be used to guide the dcvelopme nt of speci fic iln ti cip.lt ed goals and expected outcOlnes for Hil individual patient . Ph ys ical function and level of alcrtness are increased . The risk or secondary impairm ents i!>. red uced. MotOl' cOllt rol is improved. The t.: rfcc t ~ of lo ne are,; managed. Postural control is improved. To lerance or ac ti v iti es i.lnd position s is incrci.lscd . .I oint int eg rit y tlnclmobi lity arc improved or remai n fune · Ii onn I. F:II11il y and c:'lrcgivc.::rs ar!,,! ed ucated on pl.lti('nt'~ diagno~ is, ph ys icul th erapy int ervention s, goab-. Ilnd OlllL'O IllCS.

CarL'

i ~ cOlln lin:l tl:d

,1I11ong all team IllcmllCr,.

Inte rvention \VhL'!ll'\,cr pn " ihll', i' lI t:n~ nti on' !>.hllllid ~. :-.l' iL'l' tl'd Ihal add l'l'" 'l'\I\,.' I,lI goa l, at om' L' , For l'\Hlnpk'. "hl'1l PROM j, pCrfO fllll'd Joint I1l1lhllll) iIItd II\t\"'grit) ,m,' lIurnlH'd, n'~ ot 'ol'nIlHlm) illll'ninlll'lll'" 1'1 'dUl'l'd, lind 't~n,or) ~ll1nul!\­ IHlll I '

prm ukd,

t'rf,'rnllnlllndll't'l' t '1"lh11I'l1h'lll" thc' p,I!lI' m \ IIl.I11I111\ 11l1I1l1\l' lI\ IIn" I' 11'\I' h , iii' I'r .. ht' I' 'U~" ~Jlllhk' III IIIdll t" I IInl';1I11111'1I" ' Ill II ,,\ nlll tmdurr"III'\'lIhlll, rlll~'Ut1H\lIill , Ulhllkl' p \l' llIlhIlHllllt l\ l r, I, It IIW" .. 'hU lu!dlt" .. ,' d l',lIl ) III U' IHlhlhHllltlll , ,lit'''' IIl1pll ll 81"\:.l\hl" ,'I

1I11' nl\ IUt"

hf,.,\'1

hie." thf\·.IIl'I1I11~ .

11l lllllk.· ,ll· !IIIIIIl' IUt)!l Il·,:-" lIl1t1 l ,tll l'\I' III 'k· Prtl(lI' 1

"hl' t"h.:ltllU "~"I"Il' lllml

pll ' lIlllll/l1~ hOlh

tlt}od

III fwd IIIHI III II

will 1I , "II l\ t III pre\t' nllllg ,kill hl l' nktlnwl1 , (' OIIlIIlCIllII." , 11111'1 ,l VI,.' I'tli I1WI1.'lr) h ~IC lle ond cil\'ulBIIOIl, lind may IlH,dJl y 11I1I,dl' lone ... ·~ \' hen thL' ptlllL'ilI " III he ll , thL' ht! lId ~hl)ltld he h ' pt III m:utml . Thl' \\ III hdp prew nt IIt!Ct.. contmctllrL',., lind IIw y Jlu ... IlIt)/ll/Ij.!

le,')('.n Ih~ effech or tOllic nec k I'ctlexl'~ (Fi g. 22,2), Till' hlp'" lllld "'nee, should be sli ghtl y flcxt!d , but I~()M , lllIuld be mOl1l10reO 10 cn'lurt! 111111 con trm;llIre, do 11111 dcw lop,

'T1le IlUn,e, and r
FI{Jure 22.2 IlI'ud Hlld ( 1' 11)111 (' lmpII HUJ , JlI ~, II ) p

PI)!1 i0 1 11wd III 111'1) 1111111" 11111 I.. wd ~ l H(). WIIIIIII' rlt ll rt, /I)JI )

Iwd .

l'I'ljllI H'i.!. PlOjJl' / Jll·JVir Hlld IWi lt1 p .,\l t H' IIIIj V II/ I· lilt kt'Y dCIll ' lI h ill prolll OrJIIV j.toocJ PO!tl tJ H' III .1 wlr '· I·I, h.UI (Fi V. 22. 1). RI'Il' I tt ) (,l wp((' 1 .l i I t II 111 11 111"1 Il ,,, '" 1'111 1,1 tJII ~ lo pi (.. . SpJl II I~ IIwy :tho Iw " "'d 10 ;"" , ' III ji' l 1111111 in g, Mu llipodu, h ' )OI ., C!11l hL' u.,t·clIO 1'1''II IIOllllw lllllllt) preve lll

fOOl dfOp an d .,k lll bll· ,,~d ()w lI 1)11 till

Iw,.j

(Fig. 22.4) .

Table 22.7 Te<:hniqucs to Decrease Abnormal Posturing and 1'rimiHvc Rcflcxc s t'~-;

• ;;.~~ .' .YI'.A..II. ...-....-

Neutral position Roll placed behind neck to support hoad and neck curvature Roll parallel to head to prevent lateral flexion and rotation

Gentl e mngf3 of motion wtlCm Icr' fHlrj ( "I HI I perfusion stable Hands at base of skull or on twj o ~ (A h ~Ij

Roils behind shoulders Roll beh ind hip if rotation Is occu rMg Normal allgnmenl need s to be maintained

Hand on bCapula, arm 6 IJpprJrtlJ1t rh/ltll f IfA,l protraction/retraction, olovl.l t j()n/d(1prt~~blrlrl Hand on posteMor pOIVIi , log s"(J(JlJrt',<J rhythmical elevatIon and d(jpr...,&f,WJ/I (rtA,lJ(JfI, Whon patient stable : roiling $f;{JHuJlltally

Upper extremity

Roll behind shoulder Cone In hand If fingers In flexion Wedges between fingers if adducted When stable: turn onto side for weightbeanng into arm

Rolaxatlon of <>eapula (t aVrN" ) Hand placed In pal/Gnre hand Imlll I Jlni~r bide to help dOCreabG flm'or tOrlO ()f (,lbo'll ·NfU~ 1 and hand Range of motIon of fifth f,ngvr (,If thuu,t; t(; hl,lP broa " up flolO( tl}na Hand placed over bleep. vm~n IflC(IISr, (j e.t.tenf,.or tl)ne anrj oVljr UHf IW,f, r)t Iflt'fllI inGma56d thvor Il')no

lower el'lremrty

HIps and knees supported In a Slightly fle.ed p<)SItJon No pressure on ball of foot medially Rol be'''een legs rt strong a<Jduotltjn or Imernal rotatJOfl

Hand on lateral !',ldQ $i)1", (A fry), ' (}f f,. tl!J' (,II mohrJf1 kJOt YfJGO, anQ hlp HaM$ plarkd abl/le &00 t}f1iQlI "'If . fI "t1 I

Head

Trunk

ICP - rlfar..rarllat

--

p"........' .

Frt)"l' ~ PE"" ti¥1ltJ ~~Al

m

".Ir 6/ teroaJ fotl;lfitJt1 , tup HrJt1 Itfl (;t II«I /IIJlI Hand betllni1 rn6Q '(.If Ulr/l(,I(! I,(j fl /t"(fI'" rtA8"~'"jn'A tllP 11111....,0 fA YI I4t.

,#,

Pn~ \t~nli n1! Indi r~f.' 1 11111Wil"llicIlh B~L~1U'~ loll tlw ".IIICIlI', 1Il,lhllll~ tllIllO\\..'

or ,hI..'

.llllit."1:

k\I..' I-. .

ht:

I' 'U'\.·I..'}lIlI,k' 11.1 IIhhn'd II11P,llnlll'lIh ,w.:h .1\ COil

lr~ll.:tlln". dl..·~·uhll1, PIl~'lIl1){ll11.l .•Ind d.:.:p \1..'111 throlllho,l, If till''' I'" 11I.lI .Iddf\·"l·d 1.·.\l I~ 111 rl'il~lhllllaIHln. thl."C uup.llr menh .lft,-~ Ilkl.'l~ Il.lll11pcd\.· future pl'Ogn;". ,lilt! l'~111 C'\1!11 b\..' iiiI..' Ihl"t':lIelllng. Proper pO"'llIonin,!,! both III h.:d dlld 111 i.l \\ ht'ckhalr I'" c\\cntlal Good po,llIolllng "ill ;I"i"t 111 pR'\t'ntlng ... l...tn breakdo\\ II. contraclun:-.... improve pul mon.lr:. h~glcne and cm:uiallon. ilnd Ill;!) modi!) llIu\cle lOne '" \\'he n the p.IIICIII I ' 111 bed. the head ,houlll bl' kept In lleutr.ll. TIll'" \\ III ht'lp pre\ t:nt neck co ntracture ... and ma} Je"t'n the etfech 01 tome neck reOe7\.e'i (Fig. 22.2). The hlp:-- and knee ... :--hould be 'lightl) flexed. hut ROr.. l ... houlo be monnored to en~ure th at contmcture ... do not develop. The nUNe~ and famil) members ... houJd be im.lfucled 1I1 ho\\ lO properl) posilion tlnd tum the pal lent. Tuming Illa) help pre\ent sk.in breakdown and pneumonia. Palien!'" -.;hould be lumed e\ el] '2 hour:-. \\ hen in bt!d. Specialized air martres~e~ are another effective \\:1) to a:-'~I" l \\ ith the preQ \ention of pre~sure sores ..l Table '2'2.7 pre~enls ,tnuegies. for )X>sitio ning and handling. Proper wheelchair posi tioning IS imponant. 'u Becau,e of reduced pOMura l control a l thc ... c Ie\'c h. a reclinmg wheelchair or a till-in-~pace wheclclullr i~ t),pic
Figure 22.2 Head ilnd m:d.. pl..hltll'nt'd m ne 11' (From ChapmJ.n. PE. p ~S6. \'> lth ~nm 100

required . Proper pe" ie and he-3d P(hIlIOI 11,::. ckment .. in promoting good po .... rure 1 (Fig. '2'2.,) l. Refer to Charier ~~ fOf funher Ihi ... loplC. Spllllh rna) aJ'0 ~e u . . ed to .1 ......... ing. \l uil ir<'1l1u, boo" can ~e u ... t"d hl Pl"h pre\ ent roo t drop ~1IlJ ... k.1Il breJkJ (Fig . ~~ ..f)

Table 22.7 Techniques to Decrease Ab normal Posru ring an d Primith e Reflexes Area

Positioning

Handling

Head

Neutral posItion Roll placed behind neck to support head and neck curvature Roll parallel to head to prevent lateral fleXion and rotation

Gentle range of motion "hen CP perlusion stable Hands at base ot sklll or ('In $ de::.

Trunk

Rolls behmd shoulders Roll behind hip II rotation IS occurring Normal alignment noeds to be malnt<1l1l(1d

Hand 011 scapuIJ .1rm ::;uN'('1 t \. plotr.1ctlon letu\('II('1n. t t"\.1 Hand Oil postt'rh)1 pl."l, 1$ ~" ::. IhythtnlC,ll f'It."v,ltl(lI) .111\i dt Wll~ n p.ltlf'nt st.\l'lll'l '~'11 n~l ;...~ P

Upper extremity

ROil bohlnd shouldor Cone III IHlnd II flngorti In floxlon Wodgo:;; botwcon IInqtHti II ddduCll'd WhUfl ~t.tblo, turn onto Sldtl lo/ wt)lqllt bo,lrlng 11110 ,lIrn

('11.1\.111011 l'll ~('.1Ptll.1 \ 1 .1l ~'\\,

t j.lllli pl,ll~{'li In p.1t1t'tlt ~ 1'1.l ~l1 "\ 11.'1 Ih'lp dl~l~II.'.l~t' Ilt'\ l'll h)l" .. It . _ \ md ".lllli \,' I tll11W ,\1 llh'ltlt'lll I." tlltl) t I .. "1\\\ 1-. IIp Ih'\I" 1!'1llt' H.md pl.h'-I'd 1'\ \'11 bl\'1 l':... \\1 ( 'I, t t'\!t'I\:,t" 11\1\1' .llh1 t'\ 1 1 Ihl t \ I I \\ Uh'lt'.I~,t'd 11 1' \\'1 !I'll\(

Lc)w(,( fJ)(lrmrllty

I h[}'; "nfl knott'j '(IIPllortnl! 11\ II 'iUqlllly Ih uellf l 11011111011 IJ o prtl'jlllJlllllrl I,.tll ollonlllhhli.llIV 11011 IinlwlIlIlI 111Ij" II ·,trotH) .lIldlli!lOIl III

IntclIJltlllCltdth)ll

Il.md 1m tHIILl1 . 1111 ~I"t ,'I ,','I • tllc'ttnn ('IItII'1 1-.1\1 t .\,,\1lh' ,Lind, I'I.h I'd .1l\,\\c .\1\\11'1 _'\\ "!Ill

11

\11 111. \11\11.1111'11 rHII

Il.lI hl he Ilu\d I-.ne

1 11II

IIIt.l!!I \I' (1IIIIf' III \ 11\1\.

Will, POPIII

hU,

\11-1

II, \ 1.'1\ "I'. l

h l.

',1. \

\.

1416 "~,,J

"'1'lJ1J~

'11 II

\J~\iI)."I1 .")111 UI "'I"J P'.1I1II."I ."1\1'11 (HI" ")II.")lIl'd 10

iii

\ I' ld

I'

I

I! ","!."IIl.)II,)lI\,")

'PIIII"1

1.,,,;i,)II') pUp '.J,)tl"I.)U I

tlOPH.lIIJ)',' (1!ltlll.'l pilI! Itltl!ll:cl

;")"'.'1'11111."1\.) (I'UI pili' i'lul\"!lJI' IUI'ld IiIIlJI ,l\'1IJr. ~III IU."I,o,,;o 0 1 ll;in(lu ;' JIJO.!I'" 1011 ... 1 II '.11'1111' .111111' .1\1111 .'J,l.\;)'i 01 ~ II' _

~

\III" III.""I III!U .11p 101 [pnq·"II1·")j,1 to'l' lI Oi II! I ndt IU

11I,"IllI'd "Ill! HII .. ltW I:1tl.ld IIIHlPIlltllll '" ( 10'1I:l" III ,",1U.1,\1\ "1,)11,' ."'1'11 Inn ,)1 111

.It)

lJoddn ...

·llOll ... ,ll1h III

,X") ... 1111 10 ... ,.111."'1\111,"1 11 ,1 "."11 \,"IJ IUllil 11 ."1.""1'"

'V

,"Ill I

;nl~p ~TlI ~~

uOlll ... od .11'1UP

put!

IOOj

JOI

p."I"'n

looq ... nlxx1ll1n~\

I'I(j

tr·z, aJnB'~ \0

l

01 .1,1U,1P I \:1 ,"'I 1'-1'1Q.1J 011 ... 1

,'1l.)lIl "1,.1;ioin, \ll'llJq .111IutpO,) :1ll1 ~"'I III'ILI,"'II'\' IlI."I,)."I.l V

1011 \I'1lI

11'1 ;l{1,(1 " Iql. P~II ."llP lIO lI'r\('tP'1r.:'IJlI ll1 '1" IU:j.·~ld ('I p~

(q

P.111'Qtllld "."1 11\;"1.1

111)<'; ... 1 1I011Il ;'ltd:111111 0

',"'I.1I1 Jpl":I :ll'-W I'I!AI! ;1LJIIO

IN t'l \ 1,11\0;);1.1 IU "'Flh,1 1 .{pl!:l :l... :llll II!

' IImp l \IPUI III lIOIII!]I1UlIl<.; ,{ IO<.;U.1"'jO ...... :lU;1A lp:lJF'I JLJl c1lllU I

·llll~\.1 ....1IPIl) ... 11I.D,ll "' llI ,1"':l.uJ p.1IU:lllUl,l(lP

:XI

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Physical Rehabilitation

Evidence Summary Box 22.3 Selected Studies Examining the Effectiveness of Coma Stimulation Referencc

Subjects

Methods

Duration

Results

<.'ommcnls

lippertGruner, M, el al'" 2003

Ss ~ 24 Mean age: 38 years Mean Inillal GCS: 46: Mean lenglh of coma: 32.4 days

Prelesl, posttesl design; Mullimodal early onsel sllmulallon (MEOS) slarted f5.B days atter injury; Ihis Included consistent and structured sensory sbmulalion provided by Ihe rehabilitation team; Outcome measures taken at 12 monlhs after injury

MEOS provided 4-5 hours/day for a mean of 46.6 days

AI 1 year follow- up: 6 Ss died; 3 Ss in vegelalive state; 6 Ss With severe disability (GOS: 3); 6 Ss With moderale disability (GOS: 4); 3 Ss with minima! disability (GOS: 5); of the l B Ss who lived: 15 unable to work, 2 returned to prevIous profession, 1 10 a less challenging job

No conlrol or comparison group; no results provided after MEOS Interven· lion period

Gruner, ML, and Temaag,

Ss ~ 16 Mean age: 43.6 years; Mean GCS al slart of study: 6.5

Pretest, posttest design (A-B-A deSign); Mullimodal early onset stimulation (MEOS) after injury; this included consistent and structured sensory stimulation provided by the rehabilitation team; HR, RR, skin tempera· tUre measured in an A-9-A format while MEOS Interventions prOVided; A phases consisted of 10 min of no stimulation; B phase consisted of individual stimulation 01 the different sensations; GOS and return to work measured at 2 years after Injury

Two 1-hour sessions/day of MEOS until preset maximum score on GCS reached; mean of 9.8 days

Increases In HR during tactile and acoustic stimulation; 12 Ss fol· lowed up at 2 years: 1 Ss in vegetative slale, 2 Ss wilh severe dis· ability (GOS: 3), 6 with moderate disability (GOS: 4), 3 with minima! disability (GOS: 5)

No contro! or companson group; authors made conclusions that HR slgmfi· cantly Increased dunng sensory stimulation, but only A·B·A dala from one Ss presented; no results provided after MEOS intervention period

0" 2000

Johnson, OA, et al66 1993

Ss 14 males Mean age: 29.6 years; Mean GCS of 4.B

Randomized clinical trial to examine efficacy of mulhsensory stimulation program; E: 7 Ss, 1 hour of treat· menUday; each treatment session conSisted of 20 min pretreatment. 20 min of sensory stlmulation and 20 min posttreatment; order of stimulus was randomized; C: 7 Ss, no sllmulation dunng treatment time

Unclear; 6 days for bOlh groups or B.l days for E and 3.7 days for C

No sigmflcanl dlfferences in outcome measures at post treatment between groups except for lower levels of 3·methoxy, 4hydroxyphenylglycol In the E group; when Ss diVided Into groups of survivors and deceased, there were Significantly lower lev· els of 3-melhoxy, 4·hydroxyphenylglycol and acetyl· cholmesterase m the survivors

Small sample size; sensory stimulallon prOVided for a relatively short penod of lime

EVidence Summary Box 22.3 ~)eCte
fjfecO' ene Il~

of COlna StiInulation =""....,

Subjects

!\Iethods

Duration

11.<","11,

l 'ummenlo

Depeooeo, ou>:ome rT'IeaSIJfeS were· catedloIamroe ;evelS. seroloorl a<>!tyicIloIInesternse levels 3-melhoxy. 4-hydroxyphen)1gycolleVeiS, HR and skJn conductance; these ~ ere taken poor to pretreatment and after treatment

'.',eIs.

E Ss ~ 12 Mean age of 22.3 jean;: GCS range 4-6; C: Ss ~ 12 Mean age of 22.75 years: GCS range

4--6

Kafer, KM" 1989

Ss ~ 30 Mean age 28 years

Pretest. postlest noneqUIValent conlrol group desilln; Ss in control group matched to expenmental group for age. gender, type and location of brain injury, surgIcal interventton, and GCS on admission E: Received coma arousal procedure (CAP) a mean of 7.08 days after injury; CAP consisted of sensory stimulation C: No CAP at any time Outcome measures included GCS and duration of coma Pretest, pastiest noneqUIvalent control group design; conlrol group matched to experimental group for age, sex, location of brain injury, and GCS on admission E: 15 Ss, duration of coma ranged from 4 days to 6 months; received structured sen· sory sfimulation (SSS) C: 15 Ss, duration of coma ranged from 1 week to 6 months; received normal nursing care; outcome measures used were GCS and ALA LOCF scale al 2 weeks and 3 months poSllnlury

1-2 hours/day for 4 weeks; Ss family encouraged to provIde CAP as well

DuratIOn of coma significantly sho~al In E glOup comparad 10 C group; 22 days vs. 26.9 days; No significant diltarenca In GCS al 4 weeks between the groups

NO randOmllation

Two 45 min sessions of SSS/day for 1-3 months; Ss family encouraged to provide SSS as well

Ss who received SSS had significantly higher RLA LOCF score (mean 6.33 vs. 4.40) at 3 months

NOrandomization; Parametric lasts used fOl data analysIs; as tha ALA LOCF &COre IS ordinal data, nonpara·

metnc tests would have been more appropriate, GCS outcomea between group5 not reported

912

Pll\\it:al Rt-habilitarion

Evidence Summary Box 22.3 Selected Stud ies Examining th e E ffective ness o f Com a Stinlulation

«o",d ", ...
Refen-nee

Subjects

Methods

Duration

Results

Comment,.

P,erce. JP, etar" 1990

Ss 31 Mean age 24 yearn

Pretest, postlest nonequivalent control group design; E: 31 Ss in a coma or vegetative state for at least 2 weeks after ini· tial injury; received vigorous, multisensory stimutation (MSS); Outcome measures were length of coma, defined as abltity to fol· low ~slmple command" on two consecutive occasions al teast 24 hours apart. and GOS at 10-12 months post· injury; outcomes compared to a historical reference group consisting 01 135 patients in prolonged coma

Up to 8 hourn of MSSlday for 2·32 weeks: MSS provided by Ss family

No slgmflcant differences In length of coma or GOS at follow up between groups

No randomlzahon, Interventions lor hlstorl' cal reterence group not reported; data on actual amount and durallon 01 MSS not reported

C conlrol group ; E experimental group; GCS Glasgow Coma Scale: GOS Glasgow Oulcome Scale; HR heart rate ; RLA LOCF Ranchos Los Amlgos Levels of Cognttlve Function RR resplralory rale; Ss subjecls,

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proccv". Fami ly

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Ear l.\ Transitio n to Sitt ing Postures Uprighl ... itlll1g I:" e\'lremel~ import ant h ecJu,e I J "t''o d C IIl C lll ~ oftrc31mem go~\h for !he eJrI ~ le\"I ... j en A:.. :-001\ :h medical!) ~\;1h1e. the pat ie nt .. hould )t' f t' ITeo 10 a ~illillg pO~1l10n and OUI o f !)ed 10 J "h . . or ch;lir. All prcc3.U1ion~ :-hould be oh .. ef\ ed. 'T1lt' nl3d . . hollld hl' pn1perl~ . . upported . ;1:-. the p3tient ... no Il\e 10 h:\\ e ~\dcqllatt' ned. 3nd head ("ont rol 10 '11:H \. lIn .J. uprighl jll):-llIfC \\ ithmlt "lIPPClrt. Often. it I .. hencf <.131 to jlcrfonn CO-1IT'3Imenh \\ nh an l)cCup3lional therarl ...t \\ hen fir, t :-ltting ~llld ITalhfcning the r~uien t. Thl .. arrrl'l:.ll'h ;111<)\\, t\\O , hilled pfofc ...... il)IlJj.., 10 ;1 .....1SI the r.wenl. J'" 111~1 \' 11ll;l 1 ~h:-bl aIlCC i~ ()ftell requi red. l ... e of 3 lilt tJl'ik r... aiM) alh;l1ll;\p.eou ... hec.1l1,e il alJm\ ... earl) \\Clg,hl'N'.lnCllIhmugh the Im\(,f (' \. 11'('111111(' ... . TIle' upright ~"!"'I tlon. ,",()th on J tilt tahlc ;:m d in a \\ hcc1cluir. 1113 \ Il11r'll'("!n~ \,\('''31

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rotated to left v.ilh left LE ahducted. e tended In po ....... ihle ih~ nunclric IOniC nec~ reflex "-on ... ,,tcntl)

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Ranchos Los Amigos Level IV: The Confu~c d-Agitated Level of Recovery to t!m erge from coma. he or I"hc oflen d perl(xi o f acute po ~ ltraumatic .aglt
f ammation Iy hallcnglng 10 cx .JJmne the paW:n! who " in a' lI a /e{1 leve l of rnovcry. "he palu.'nl /lluy

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Patient"" enduran ce b improved, Joint mobility and integrity arc mainlained, RII"J.. or I"ccol1dary impainnen ll" i"i reduced, Tolerance of ac[i\'itic~ i~ incrca . . ed, The patienl's fami ly is educaled regarding patient's dl3gno~is. progno ... i:-.. physicallherapy intervcntion.I" and out<..:ome:-., Care i~ coord inated among all tcam member~, The overall goal\ of phl,ical Iherapl al Ih" le'el of rCCo\'cl)' arc 10 muintainlhe paticllI\ functional capabllilie ... , T hc 1110 ... 1 important goa l the whole Ie am . . Iri\'t~~ to i.lchie\e in Ihi ... Il!\'cl or recover) is to prevenl agitated outbUJ"\L. . and 10 I]\" ... t Ihe paticnt 10 conlrol hi" or her beha\ lor.

III! ,

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",

he :w J"1 ",

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. . III . . . lh'l\" . . Ill'l

Ih'll \\oll id 11."qUtn,· Ill'\\ Ic~UlllI\~ •• 1.... thc p ..ltll'l1t

h.l\l' !Ill' (;'IJli.lut ~ Ill! Ill'\\ k . lIlllllg ~It 1111 . . k\\.'1 ~,t I 'l'~" 'T\ Ihl' IIl'urn'''Yl'hologl'l CIII .1 ..... I .. t Ihl~ h.'.I111 b\ 111\1\ Illtn 1Il"'I~hl II11t1 dllkll"lIt \\.\~ . . t" 1ll.1l1.,~C' thl' p.lllI..I\t ...... 'Ilal("(j

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I

I n ~ III

Evaluation, Prognosis, and Plan of Care The following i~ a Ii~t or ge neral goal ... and outcome!, anticIpated ror patientl" in Level IV adapted from Ihe American Phy . . ical Therapy As:..ociation 's Guide 10 Phy.ucul lherapj,\1 PraClice47 : They can be used 10 guide the development or ~pccific anticipated goals and expected outcomes for an indi\'idual patient,

Inten-ention

M ' · •• _.,

r

I ... Ihe palll'ni "hie 10 follow l'ol11m;lJl{h: nllc kp. two .. tt..'p. or mulli ... tep lOml11i.lI1d ... ? I . . the palit..'111 onenlt:d to pcr\(JIl. place. or tllnc'! Doc ... the palienl rt..'cognllc farml )' mcmhcr ... ? It i~ beneliciallo COIbUI! \yith other leam member..... e,f>C ciall) the .... pecch· language pi.llholog"I, 10 Obl3111 add l. tlonal information ahoul the patienl's cognillve ... Ialu~,

1....

>.T R).

2P

.l1ld .. I,lIldlll).! II ,lpplllllrl.lll', ROM ..... l1l·l1l!lh, mol or lllllltoi. 10l1l', "'l'n"".1l1nll. and Il'l k\l' . . I hl' phy ... u.:al th\:I'!JlI''1l .hllu lrl .11 . . 0 hl'gln 10 dcll'IIIlIIll' till' palll'III'" lOPl1lllVC uhdUll" III Ilw.. kyel 01 Il'l'OVl"Y I h" Yvl ll IIKltlde olll'nl,lllol1, ,,!ten 11011 .... pan. memory. 1Il'lght, . . ~Ikl> .Iwarene ....... ,lilt! ~11t.'rtlU':, Kl'~ que"IHllh 10 addn: ...... Inl:ludc'

""1

lid III

II

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h

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I 111 ' 1

1111 polltt

III

tI,. 1.1111',1 11111 ,llIldlll

I""" V IlI l 11111,11.

,,," """ tI II,,,hIIIl V "II "'

II" lin '.tI'l r bUill III 111111

pltlpll,lll

,IP' 1111

1,,'h,1\ 1111 ....

Iltlkll'lIl llh·~hl.lll\\ll

Illhl

th thdl\ III 111.:11' 1\ 1h 1\,11\1\\ 1\' I

dlld 1111)'1\1\ Ill' pUll IpHhlll III 111.1\)

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('hJ.lh..'", 'III" t Ih. . ,1W\.·(" p,Uh.'!lt

'n \ :t'I.."':" 31 a'\'\ l l , cr r.lf\..' 1hJ..Il

l' h Ipd 1\.' dl.Ul!.!" an.' ,llk'n I11lll\''' lhtlil.'ult I,' 'cu,we \.In; ..'lll .. T\'1l1l11 Uf'I.'111I."ll tnll1l ,\\ Jtlah/...' l1' 'l'rtJll t' .:ft:"'\"tl\c:h d""li.llll..·nt dUll!.!\.', I,' '" fi'\\J.rU ~h.:hl':\\.·nlo..'''t l't" ,t:ll,.lt, ~UIJ h' IU' [\.JJn!;k' ,1C Jl 'UIlk'l1t.lnl'll .It thl ' .... k'~\.'I, klut..l.: . :"l.-

'rutll':J. ttl Id'[ \\ th kft l E JbJu".t,,'d. ~l"lh!~ J.'~ ~11 ll('tn..: tl'n!~ '1\."\", T\'tll'\

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'-'r (: \t1""('IllJtlt:"

;:0

d.r.!.\\' to p,Un'l.l .. nulUb l'n n~ht 'lJ~ l,f

Kan" o~ Lo' Amigos LeyeI IY: The ConfU, cd-Agitated Lere\ of Recoyery 't:'mc.;C '\)111 .:orn,i. h~ ur .. tIt"' I"ft('o xi of J..:ute }:'0 .. nr.lUtllJ.lI.: :.lgit.1lwn.-' ~ J.mnc.... ,.mJ dl'\.'nenrJ.tll'n Juring Le\ ('I , - ...gllJ:tiVn . .If:~''''''l\,."\n. n(ln\"-\.'mpli;ln('e. "'ehJ\ lor .- ...\ .. Je,.:ribeJ eJ.ril('r. \tltllJ.ge h.' atl flll.:al area., 31,,,-", .2"l,nmNue.. tl' Ihe,t.' "_ the a..:ute and (:hmmt2' 'taC"e:" "';:0

f1 ..

~

-

-

Funun.ltion ~

..,.:...·engmg to e\3.mme the' r.lUent \\hl..) I ' in ~a:- tJtoo rc\el of l"eco\er:, The ratlent mJ.~ ~ tated and prone w emollonal outbul'I .. , r _... from \erb.tll~ 3.\"-tmg out lO ph~ ,t~J.II~ ,",un them' l\~, or other-. 10 ...e\u311~ lOapha\ lor The patIent I' <'hen confu,ed, He or a JX'lOr m mof'). u,uJ.lI~ hOlh ,hort- J.nd I()ngTbe pallent "III ha\ e a dc\. rea . . cd atl('nlwn .. pan and d tractoo, Rl! cr III B \ 22.2 for further de,crip· Ie\. \galn. III .... oft('n hdrtul h' ha\c an('lher t "Ith the' c\amtn<:tllOn Thl' c(lulJ Ix' .ullliher the iJp t, an I..xl..upauonal Iherarl'[ or.1 '['el'ch I"1lholo~I>I

be 1"". ult 10 ~3ther dala (r('lm C\J.mlO,:UulIl pm ud\ a.' PRO\f or Ir gth. lx·l..au't.~ Ih(' p.lflelll !eO he ur ~I to \..()"""per",! ~ the th('r.1r"IIllU'1 ul,ltll.~ Ion III and the ahlhl\ 10 ( ! mall..' Tlw thC'rapl" ld e\amloc lundJOMI m lt~hl'. balan\, t--)Ih III Mttm~

F'alu.ltiOll, l'rugt10,i" and 1'1.111 01 Clfl' In\.~ kll~ll\\ m~ i, .1 h,t l..lf f.l'l1~ral glX1J... .mJ \'ut(\'Ill~' anti,,' . 1!,..Ul-,J h.lr p..HI('nl'- 11\ Le\d 1\

.1J ..lph;'\.I fnllll tlk' \ nll..'n\,.'J.J\ I h~ '1\.·..t1 !1tl'r.lp~ \ "'lx·i.ltil.lfl·' G., ..It" 'll Pin 'h III fht'nqJI"r r'~l"'~I:t" l~t.~~ ("ut ~, u:,,~"'d III flll\J~ th\.' lk~\ ·ll.lpll1enl ot '[,('th,,' ..tnlt\.'tr,ul.'\.t gl""r.. and ~\p'-"\,·k"'\.t OUI('oln~, tor JJ1 mdl\ IJU ..t.l p..1tle-llL

P. thent· .. t."ndur..uk't:' I' Impm\ t.'d. ]1.)ltlt nll'bltit~ ,mJ inh.:gril~ .1n'm,lintaint"J, Ri, "f '\.~('l.lOd~l0 IInpJtnlle-flh i~ redu\.~J. Tl'Ie-r..Ul(,t:' 1..1f ,\\.'1I\ lIIe' b l11\,'T"e.t"'t.',l The p~ltlent" famil~ j .. t."Ju("Jtt"J regantmg p.lIle-nt·, "hagOl"I". rn'gno . . ", ph~ 'I\,.'al ther..lp~ intt'c\ ("OIlOn ..... and out("l'11le:". C~ln' I' c("'niitMtt'd ~Ul\llng aU team m~m~f'. Tht." \.l\er.tll g\.XlI, of ph~~kal ther.\r~ .II lhb te\el of are to mJ.1nt.lin the (Xuient'~ functional capabllille . . . The ml.."l 111l1"-"lr1~U1t gl.xd mt." "hl.lk I ,ml "Irive .. to .lchie\ e in !hi, k\ el llf RYO\ t'T) I" to pl\:'\ ent agil~lled OU100l' h ,md to ~ .. i .. t the p,niclll tl.l control hi, or her beh~1\ lor. n."("o\l'~

In[en·entlon TIlt."" ther..tpl't .. hl"luld inl.-NlX'rate \.'reati\il~ JIld t1e\lbilit~ \\ hen d61going and pm\ Iding mIen ennon, dunng. thl .. tC"\eI of Te'("l"\\er: Genernll~. the lher.lpi:-t .. hould "orl ne.lC the p.nient· . . ph~ 'Icallt"\el of funclion ~Uld attempl III impro\e cndurJ.n~t."". rJther than pmgrt':"~ 10 nh're ('halkngmg .. lilf" th.u \\ould relJuire ne" learning . .1' Ih~ paltelll J\"l("" n\.ll hJ\ ~ the (,J.p.aClI~ for ne\' Ie~lming J.I (hi, It."\ d l't' rt"'O\ e~, The neurl"lp,~chologi'l can ~l"" " I'1 Ihe le,LOl b~ pn" iJmg tn'lghllT1lt."l dlllerent \\.l~" 10 nunagt' the r . ltlent' .. 3!!HJIN i:'ICllJ\ Illr ~Uld 11l;l~ ,et up a heha\ illrJI 1TI\.-xtiikatllll1 pC\.).. cr.Ull. Beh.l\ loral Illl.xiitk31wn It.'l..~hniyut.', ,ul.-h .b l"h"lh~ ~tntl'rl.'elllt'nt u,ing J romt \'r n'" 3N ,~ .. Iem. retiln..Ylil'U. Jnd comph~U1ct' Ir3inmg ~Ire u,l'fUllll m.m,lgUl~ Ihl"l' Illapprl'pri.lfC ht'h.1\ Ill ......lI1d Impnl\ Ill!! p~U1I"'lr.II".ln In th..'r .11'.\ Dllkn'nl 111t.'dll·.1I1on, 11l.1~ lx" ~Jll"'1.'I1\ ' to hdpm~ Ihl..' p.ltll.'nl IH~Ut.l!!\' lx'h.l\ Illl" Ii' "\"11 ll!t' hllll'\\ 109 ,pt... d.lll.l'n'ld..'rallOn, an' llltt'n.'d fl" 11I.m~elt1l~nl III p..1l1l'nt' ,I Ihl' }(" l'" (\1 n'n" l'l~

914

Ph)sical Rehabilitation

Consistent) Con..,i..,tency i~ importanL All team members. including fam ily member....... hould imeract and addre ... s inappropriate beha\'iof\ in a consistent manner. Remember that the palient is confused. To help decrease confusion. the patiel1l shou ld be seen by the ..,ame person al the same limc and in the same location every day. Establishing a daily routine is very important. It is calming and reas..,uring to have a ..,ense of familiarity. Additionally. orientation (i.c .. per:-,on. place. and time) should be provided frcqucn tl y and in a nonth reateni ng manner. At this levcl. it is orten better to provide orie ntation infonllation than to challcnge the patient to provide it. particularly if the patient i... not expected to slicceed. E'pee' No C~lrr.'oHr Teaching nc\\ ..,kills at th is level is unrea lbtic. The pa tien t may begin to perf0n11 a functional Ii1sk. suc h as brushing teeth or ambulating. However. Ihb does not indicate a general learning ability. as brushing one's teeth and especiall y walking arc automatic ~kills with an ingrained neural network. The use of charts or graphs may be L1sefulto help the pallent progre ... s each day. Without the use of such aids. the patient i" likely to have no recall of the previous day\ performance. Model Calm 8cha\ ior The patient is likely to perceive. anel may reflect. the demeanor of the caregiver. Therefore. it is important for the therapi ... t to assume a calm and focused affect. The patient may not be able to control his or her behavior and may not feel ... afe. To help the patient feel safe. it is important for the therapist to be perceived as in con trol of his or her cmot ions and behavior. E'pect Egoce ntricit )' At this level of recovery. the patient cannot be expected to see another's point of view. He or she will te nd to think only of him- or her"e1f and. at this point, It is unwbe to stres ... the patient with attempt ... to do otherwise. Flexibility/Option, The patient will have a limited allen lion span and Illay nol be able to concentrate on any given ac tivi ty for a very long lime. It is important to he prepared with numerous ac tivi ties. If the paticnt cannot be redirected LO the selected ta... k. it is appropriate to allemptto engage him or her III another. Treat the patient at an appropri ate age level. Give con trol to the patient when it is safe and appropriate. Control can be given whlie. maintaining focus on therapeutic goals by phra ... ing que . . tlom. a.... "Would you rather pl;'IY ball or go for a walk?" This prevents situation ... whe re the patient choose ... an undesirable or unreali ... tic acti\ily if
Safety Owing to the patient's often unpredictable and inappropn ate be havior .... it is important to keep the pallent and those interacting with him or her safe . In addition to utili/ing some of the above-mentioned behavioral st rateg ies, paticnt~ in this level of recover) may be kept 011 a locked unit of the hospital. Patient ... may require one-to-one ~ taff supervision and assistance throughout the day. Patient lllld Family Education As described previously, it is difficult to provide education for the patient HI Lhi " level; the patient has very lillie, if any, ability for new learning. However, it is extremely important to provide education for the patient's fami ly. Above all. the family should understand that the patient does not have con trol of his or her behavior. The patient is not striking out or swearing because of intent to hurt others. but because of agitation and confusion. Many times families do not und erstand why a patient is pe rforming these behaviors. They must. be told that these behaviors are a symptom of the brain inj ury j ust as the patienl's inability to walk or ea t is. II is important to ed ucate the family that entering this level of recovery is a good sign because it indicates the patieI1l is moving toward the next level of recovery. Aggressive behaviors are usually short lived. typicall y laMing only a few weeks at most. Family members should al&o be taught to use th e above strat egies when interacting with their loved one. Consistency is important for everyone. including famil y members. If a behavioral plan is being implemen ted, the family should be a part of devising it and carryi ng it ou t.

Documentation Documentation may read as follows: J. Passive ROM appea rs to be within functiona l limits bilaterally in lower ex trem it ies except for right ankle dorsiflexion. which appears to lack 10° from neutral. 2. Patient ex hibits full ac ti ve ROM at all joints. except for rig ht ankle dor..,iflexion. 3. Active movement in all four extremit ies i. . nonpurposeful and uncoordinated. 4 Patient exhibits impaired sa fety awareness and is di soriented to place and timc. 5. Unable toexa1l1ine fomlally owi ng to paticnt's dec reased ab ilit y to follow com mands and be havioral outbursts. 6. Paticnt unable to participate in phys ica l therapy today duc to aggres.l. ive behavioral outbursts.

Ranchos Los Amigos Levels V and VI: Confused-Inappropriate and Confused-Appropriate Levels of Recovery Examination At Levels. V and VI, tl lC patlcnt ' .IS conlu..,cd, . but wit h ..,tru cture IS able to follow simplc cOlTImltnci'>. \\h lch Illilkl!~ i.I

Chapter- 22 Traumatic Brain Injury 11l0re fonn:!1 and acc urate phy!-oi ca l therapy eX3minalion ptw',lble. Refe r 10 Box 11.1 for a de~c ription of patient beh,l\ ior 411 these levcls of recovery. The examinalion methods may need to be modifi ed bec
915

Examination of motor control should include tone, coordina tion . and movement patterns. Most st;'lI1d.mJllcd measures of motor contro l validated for individuals with neurological deficits were designed for u<.,c follo\\-ing strokc. Although mdividuals with TBI may present with hcmiparesi<". phy ... ical therapists should excrcisc cau tion when uSll1g these te~t5 v. ilh thi s population. Some of these measures include the Fugl-Meyer Assessment of Motor RecovcryXIJ.9f1 and the Chedoke-McMaSicr Stroke As"e~<"ll1cnt. 91 Chapter 18 contains more information on Illese and olher simi lar lests. Owing to impairments in motor control that th ese pati en ts exhibit, C mu st provide thi s carc, so it is essential to asceflain the level of family support carly 111 the rehabli itat ion process.

Evaluation, Prognosis, and Plan of Care The follow ing is a list of general goals and outcomes anticipated for patients in Leve ls V and VI adapted from the Al11l.!rican Ph}sical Therapy A!t!'ociation's Gllili£' to Physical Therapist PraClicc ...'j· Thc) can be u!-oed 10 guide the develOpI11l.!l1t 01' ~pec lfi c anticipated goals and expected outcomes for an mdi\ idual patit:nt. Performance of fun c llonal l11 0 bllily and ADL !t"'ills is Incrca"cd. Gait. mobility. and balance are improved. Motor con trol and pO!tlUral co ntrol are mCfI.!
916

Ph

Ic;al Rch.:ahdlt.ltion

Impalrm~nt . . '" n.'du("~J. and ~uf3nl.: dtr mut"a . . ~J S,ifer) \\1th tuncuon.ll mo"'t1u\ (J ... I0.. ... mJ \DL ... til ... 1'"

RI

of ~ odd1\-

~ trntgth

'mpm ed Parle-nt and 13mll) are edu,,-Jted l'n dIJgno . . ",. ph\ h • .11 thcr.lp) Int~l"\entwn,. ,mJ goaI-. .

prn~nl''''I''' '

r()kri.lnl.~

ot J(tI\ UI~' I' ImprO\ed, ldfl' I'" (,:llordInJleJ Jmong .111 team membt:-r-. Th~

O\CTal1 goal, during [hi'" ... tage of the rehabilit.ltlon pnxe-...... are 10 mJ"{imi/t" functional recmcr) of the mJ,· \ tdual and prepare hlnl or her antllhe famil) for di ... charge home Jnd to the cOl11l11unlt).

Intenentions Some of the ... arne ~l ra teg i e~ regard ing the pallent \ beh~I\·

Level IV ~ h ou l d be conside red \\ hen \\orlo..109 \\ ith ind i\'id uals In Levels V and V I. Indi\id ual.., at Ihe ... e leve'" \\ II I sti li pre~ent with bchadoral and cognlll\C ddiclI~ that \\ ill Impede the reacq uisi tion of motor ..,Io..ilb. Treatment s"",ons should be thoughtfull) planned (0 111(1\imize the patient \ motor leum ing capabl li tie ..... Practice should be dis tributed. Owing to cognitiYc impa imle nb. thc!otC patient s may expe rie nce ment al as well as phys ic;l! fati gue durin g treatment ses~ ion s . Signs of menta! fatig ue may Include in c re a ~ed irritabilit y. dec reased attent ion and conce ntrmi on. deteri orati on in pcrfo rmance of ph y~ i c :l 1 slo...ilb. and delayed initiatio n. Treatment ses:-. ions ... hould incl ude suffi c ient rest period s to min imize both phy:-, ical and me ntal fati gue and ma xil11i ze mOlor re lea rnin g. Feedbnc k is al so very important. Ow ing to cogniti ve. se nsory. and perce ptual impairmc nh. ex plic it feedback may be more benefic ia l in the ea rl y stages of mot or lea rnin g a ... oppo\Cd to Intrinsic feedback.ln Iloweve r. care ... hould he taken not to overwhe lm the patient wi th feedbac k, Re fer to Chaptcr 13 for an in-dc pth di sc ll s~ i o n of moto r lea rnlllg ior di ...<:u ......ed

In

pl1 ... ul. ch~~ ... 11 ltk..- nHJtuc I. n.:-, .tnd twx r. Current tht:\.)ftt: ... llt mot r 1.\.llltr\'1 In.! J\llo..: •.Ut.' lllr a u ... "n~'nrl"d '4'r

tnc mJI\ tJuah \\ 1m n~·w\.lll); ... a1 .,k·fi . . I traImng. ulIltling bl:'Id~ \\t.'l~h[ ... up~x~ B\\, and I mill. .mJ l"t'n... [rJm( mJul.·J Cl nh.'\cmt.' unpn.1\ mg l E. funl.·ul..m· .lft~ l\\ II Ulh.·["\ I..'nllll(h th.u ... hl)\\ n p~)It.'nlJa1. S\.'t.' Ch.lpt\.'T 1 ~ Loc\)(l\owr tr:.unmg \\uh B\\ ,.•\O~I,l tn'J.Jnu l!1\ \', ",u"'pcnJtng tht.' dtt-'nl 10 ,I r~\ral.·hllh.' it t.' l'\t'mt'.ld turu(" th.\(
p n nclp l e~.

A.., d l,cu ... sed earl ie r. an ea rl y. Int c ,.di..,c i pl lll ~II Y approac h to rehab ilitati on afte r TBI h a~ hee n .., ho wil to he beneficial. (·I.tJ' -I here arc many interve nl lon approw..:!I1:.., available to the ph YS ica l th erapl ... t that can PlOlllotc fUllctiona l recove ry foll OW in g brain injury, Two bas ic trea tme nt str<Jtcgics arc a U Jlf1Iu!II.wror y and a l e.\lorall l'e approm: h. The compensato ry approach sec"'- , to improve JUlicti onal ~kllis oy compcn,a tll1g fo r the lo ... t abi lit y. A ... lIn plc exa nl pie of thi' wou ld he leach ing onc Iw ndcd dre"", ng tcll l f1I4UCS If <J pi.ltlel1l prc"cntcd with H h Cllll p Hrc t K l Jl~. 'Jhe rC~ItJfalIVC approal:h ccks 10 rc,torc the " no rl11a l" u... e o j 'he "f(e
( \\,IJ"II •11(1 F iflllt,,22/J 1 011110 .. 1111 !1.11I1II11/1111 ( tlltll"\ I "H, , 'I'" tr llli r lu'" \' II til ,11111 III .trlm"l r hll 11.1111" I I I 11111 \

I!lIr! pdVH

'.I I IIII'~ IIl1d \',

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II ppl"" .1 1 1111 II II I I

1.,111 ,hrlll!!l'.

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11 IHI' I

• C1ullllt.·r 22 TrAumatic Brain Injury 'I

treadmil l ha .. a , olld theoretical ba , i, and has bee n

.!fItI • . . . c::\lcn,l\ t:I) ... llIchee! i n lIuhnduab \\ IIh ... trokc und 11\O~

. !lrkl!.!'

in l OI

917

Table 22.8 Dcvelopme ntal Sequc n ce Pos ture" and Trenlmcnt Benefits

splllal cord Inj ury.

COIl,,(r;lI nl Induced (e l) movement th er,lpy in vo l \c~

pro!Ill

ll illl! lhe II.'1C of ~

.

the 1l1 0~ 1 a ffected UE for u p to 90

.

'n:t'nl o f \\ " k ing hours and rcduclIl g Ihe u.!Ie of the Ical, l

Prone-onelbows

Improve upper trunk, UE and neck/head control Increase ROM at hip extensors Improve shoulder stabilizers strength Wide BOS, low COG

Quadruped

Improve upper trunk, lower trunk, LE, UE, and necklhead cont rol Weighlbeanng Ihrough hips Increase hip stabilizers strength Decrease extensor ton e al kn ees by weighl-beanng Increase shoulder stabilizers strength Weight-bearing through shoulders, elbows, and wrists Increase extensor ROM al Wrists and lingers Wide BOS, low COG

Bridging

Improve lower trunk and LE control Increase hip stabilizers strength Weighlbeanng Ihrough leel and ankles Lead up actIvity for bed mobility Wide BOS, low COG

Si tting

Improve upper trunk , lower trunk , LE , and head/neck control Weighlbearing Ihrough UE Functional posture Improve balance reactions Medium BOS, Medium COG

Kneeling and halfkneeli ng

Improve head/neck, upper trunk, lower trunk , and LE cont rol Weighlbeanng Ihrough hips Inhibit extensor tone a t knees Increase hip stabili ze rs strength Improve balance reactions WeIght bea ring through ankle In half-kneeling Narrow BOS, high COG (kneeling) Wide BOS, high COG (half-kneeling)

Modilled plan ligrade

Improve head/neck, upper trunk. lower trunk , UE, and LE control W elghlbeanng through UE and LE Improve balance reactions FunCtional posture Increase ex tensor ROM at wris ts and lingers Wide BOS, high COG

Standing

Improve head/nock, uppor Irunk. lowor trunk. and LE con trol WOIghtbeanng through LE Improve ba lance renctlons Functional p05l1lre Narrow BOS , high COG

~lt'lh:~d LE. Intem.i\'c. tas ,," orie nt ed I r~lln i ng is prov ided . r the ;tlfec led UE for up to 6 h our~ per day ove r a 2- to

,w~ T II ' . ,.\\ eek pen od. - \vo I,ma ~ tud le ... h ave exa11lllled the ~trt'clI .. cne., . . of C I move ment therapy in indi viduals wi th tIl

chronic TBI. Shaw and cO lleague ... repo rted improve me nt m Ihe .lnlOunt of use a nd caregivers' evaluatio n of usc of

the more affected UE 111 seven indi viduals with chroni c TB I. afte r CI movement therapy, lO l Page and Lev ine impleme nted a mod ified C I movement therapy program \\Ith three indi viduals wit h chroni c brai n injury. The ~ lJb­ Jec{~ demon~tra t cd an Improveme nt in the am ount and qualil) of L E use and fu nctiona l u\e of the UE.lOO Some treat ment approaches util ize the development al ..equeno! and muscle facili tal iol1 tcc hn iques. Development al po,rures can be used to fac ilitate and help restore mOVement .md functional mobility. Table 22.8 ide ntifies d ifferent pos[ure~ In the dc\c lopmental sequence and the benefi ts de ri ved from \\.Jrlmg in each posture. Figures 22.6 and 22.7 depict ..ampl trl'atIne lll ac tlv it ic\ wuh a patient using modi fication .. 0 Iht.: deve lopmental posture s. Because of indi rec t lmpalrrT't'lltli and accessory injuries such as long bone fraclure~. II nl . . Y be necessary to adapt activ ities. Bt."t. (cognitive i.l !>. well a\ ph y~i ­ call tu IpHmi.l1! Ijucce~., whil e progrc ... ~ i ve l y JOcrca ... in g the compl ny Jnd demand ., o f the lask and relating the Illtcrventle t( a meani ngful fun ctional goal. Patient an d Fami h Edu ca tion It n"'portJ.n! to ~mph a"'l/c safety awarcne~s education Ilh the pallen!. The mdl vidual 1\ beginning to exhi bit ImprO\ed mobility . . kill ~ al t h e~c levels, hUI may lad. the 10 ght to rccogni l-c that he or ~he m:..ty nOI yet be ~i.l l c 10 cunbulalt: or tran ... fer alone, Fam ily mcmberlj !>.hou ld le:II1' nov. to a M t the pallent with IUl1cll onal mobility. 1l, i... typi call) mcJude,> Ira lllll1g III bed mobI li ty, tran... fc r... , ambu laLJon, and ... heekhalf mobi lity ~kiIJs . They .,hou ld be In ... trw.: ted 1f prr'Ptr blxJ} med lanics when a... !>. i... ting with fUI1l:tionaJ n hdHy, MJ J. to avcuo fI '.J.lIlg lIlJury to Ihe pal l ent or them J amJly rn~rn bcr~ ~ho uld al , o he cou(,;atcd abuut hol,.l,: • the palj(~nt 1J. llh strengthelllllg cxer(,; hC~ and PIH)M ~I1y m r!loc r a.nd ca. reg lve rs should aho be aWi.ifC: 01 hOd tf) enhance dcc lwm .rnaklng ., klll .., and ... aft-t y All f,l I hc~ ~IIJ S arc IInpunanl lor famil y IIll' llI :he: If) lIn, is they nw y ht'U JIIIt" till' pomiir)' l"ar~J? I Vl' r 101 P';lIJerlt oJj>(1fI dl 'M.. hargc to hI/lilt'

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Chapler 22 TraumAtic Brain Injury

continuc their rdmbilit;uioll in i.I re~idenlial based COIllIllU nil) reentry program. whi le those with continued . severe behaviora l i.., ~ ue ~ Illay req uire a re..,identia l neurobehav ioml program ('co Fig. 22.1).

Examination, Evaluation, Prognosis, and Plan of Care and Interventions At Ihe~e leveb of recovery. the rc~tormio n of ph ys iccus:-.cd in Level':. V and VI should be u ~cd. Till.! foll ow ing i'> a li st or genera l !!oa l ~ and ou tc o me ~ for patient '> in Leve ls VII and VIII (LOeF) adapt cd from the Ameri can Physical Therapy A.. soci ati on',> Gllide to Physical Thempist PJ"(l(·tice'l1: They can be used 10 guide the development of speci fic an t ic ipated goah and ex pected o ut cOll1e~ for 0 1 trea tmcnt to approx im ate the demand,> of the real world. treatme nt 1 ()Cu\e~ on adva nced actlvll le., .,uch a., comm unll y ..,"ill.,. <.;ocial ~ "iJ\ ..,. and dai ly hVlIlg s"ill ,>. Example~ of thc\c "kill.., are prc\entcd in Table 22.9. The IIlterd l'iC lpllllary team cmpha.,i/e.., patient

Table 22.9 Coml)OnCnlS of Community Skills. Social Skills, and Daily Living Skills Programs

Daily Living rFood preparation Housekeeping Money management Meal planning Telephone use TIme management

Social Skills

Community Skills

Introductions

Shopping Public transport Map readi ng Leisure plannmg Commumty

Nonverbal communication Assertiveness Ustenlng skills GIving/receIVIng feedback

resources

919

a~",u lllpt ion

of "elf-rc)o.pon <.;i bility. BeG.lu~c the patient now some ill)o. ight into hi li or her own <.; trengths ami weaknes:-.e~. it i'> important to involve the individual in dcci\iollmaking. The patient i ~ now working 10 rcintegratc him or herse lf back into home and community. Therefore. the focu~ of trea tmen t i.., to maintain and improve pe rfonnance while decrea.,ing ex ternal ~ tru c ture and supervision. Independcnt 01\ we ll <1)0. cooperati ve work wi th others is encouraged. Group treatment ..,es..,io\l\ arc often the basi'i of interventi on..,. I-I one<.;t reedback froi1lthe therapi.,t and SUppOl1 group i., cru cial for the patient to Icarn how to function in society with hi s or her present abilities and lill1itation~ . Trial periods of independent li ving and su pported work are important. Adaplation s :Ire often requ ired by the family. work. and school to acco mmodat e to the needs or the individual. ha~

Patient and Family Education At th e~e Icve l.., of rccovery, th e patient should be educated in how to best compen\i dual imp:.urmc nt \ or di.."lbilitics. The palient and famil y ..,/lOuld conta ct loc;.ti '> lIpport g ro up.,. Talkin g to another ., urv ivor of brain injury who has go ne throug h <.;o me of th e .,amc diffic ulti c,> ca n be or grea t benefit. If nccc.,..,ary. thc patient and famil y membe r)o. sho uld co ntinu e with reg ular coull \el ing provided by a medi ca l soci al worker o r neuro p)o.ycholog i)o.!, Th e re arc man y co mmunity re)o.ource~ availabl e to as., i\ t th e paticnt and fami ly in mak ing th e tran\ ition to hom e and th e communit y. and mallY rcso urcc<.; call be fo und on the Int ernet. The Brain Inj ury A'\\ociat ion o f Amer ica i.., a national org
Brain Injury A~\ocia li o n of Ame rica. Inc. R20 1 Grcen..,horo Dr. McLean , VA 22 102 (XOO)

444 ~6443

http://www.hiau<.;a.org Mo..,t '> tatc\ have loc.: al chapter.., Ihal ca n provide information and \ upport a.., well. Anot her Importa llt a"pcct or patient ed uc:.ttion i.., wcll nc.,., and preVe ntion . Indi vidu al.., with TBI ,> hould be encouraged to partici pate III a regularl y .,cheduled ritne",s/exerci~c program . I h~"l'ar(;h 111.1 .., .., hown that an aerohic cxerci.,e program I.., henefi ci al for impmvi ng cxt;: rCl se capac it y a.., wel l ;:I'> p,»'Cho'>ocial and ge neral health .., talU "i.IO·~ lOll,

Documentation Ex:.tmpk., of documentat Ion for Leve l., V II and VII I in . . . lutic·

Pallent rl.!qulre~ thr~c to tou r verbal Cue,> to "atcl y ,> a strl.!CI al a cro,>\ w:.t1k with an
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Special Considerations \ bnorl1l ul Tone Indl\ldual, \\Ith TBI oftt"11 pre ... enl \\ith abnormal III!;!"" III mu ... de lone, One ... lUd) reported Ihal among indi\ Idual'i \\ith TBI \\ho 3re undergoing lIl-patiem rehab tlil:ltion. up to l',t percent developed co ntracture~ due (0 "'paslic h) pertonia ..~ The clinical characteri.!!tich of spa":.ticity are bri ... t.. deep tendon refle\e!-, involunlaI') t1e~or and extensor ..,pa . . m..... Babin'iki sign, and velocit) dependent increa~e In ,trelch rene\es . I n c rea ~ed tone 1113) have beneficial 3.; \\1."11 as delrimenrai effects. Increased tone may make per. . onal hygiene difficult. lead to co ntractures and pres... ure ... ores. and be painful to th e ind]\·idual. Full body ~pa~m!> may interfere \\ ith tran"fers, In other in stan ces. increa.;;ed lone rna) hel p impro\'e function, An inc rease in LE extensor tone rna) a11O\\ an individual to bear enough weight through lhe LEs 10 facilitate an independent bed transfer. or make the transfer ea.!!ier for the caregiver, Clinician") should weigh the potential risks and benefits to the individual patient before proceeding with treatmen t. The foundations of spasticity managemem are therapeutic ~ trelching and strengthening exercises with adjunclI\'e modaluie" and functIOnal retraining. PROM and seleclive ~ lIenglh e nm g o f th e antagonist muscles ca n help to decrea\e sp~li c il} .<;l ~ Positioning jo;, an importanl adjunct in the management of tone abnomlalilies ...\1( Mainlainmg the head and ne k in a neutral positIon IS importanl for minimizing the effects th at primitive postures may have in mcrea\mg lOne. Keeping th e whole bod) 111 proper align-

Figure 22.8 \1..tlcnal u~d h,r Kn.1I L
Figure 22.9 Sena l ca\l mg.: fir'>l a layer 01 padding around the

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ment i":. also important. Refer to Tahlc '22.7 lor Plhltlunlng. ":.Iratcgies. Seri a l casting i... ano lher II1ler\'cntion that JJ1~~ help decrca"c hype rt on ia,ul'} 11"' Serial ca"ting is ortell u"t:'d for planla rfl cxor or biceps contracture" rc:sulting Inll11 cuh cr IJ1crea\ed lOne or prolonged ... hort~ning 01 the mu scle. With a plantarflcxion contrac lure. Ihe Jn~k I" "tretched in to as much dor ... i11cxlOn as po ... sll1lc . Uld ,hl'll a short leg ca"t I, applied, In approximatcl) I \\t.'c~ the ca"t i, removed, Thc musc:le is ... treh;hed
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Summary

Figure 22.12 \'i,uallmage pre..enled 10 a pallen! \\ hlle performing balance traming in a \irtual emlronmcnl \\llh the JREX ,) lem. L,mg a camera-ba.'-t"d lracling 'i),lem.lhc pallen! i, able 10 ..ee him or her.elf on a "creen. The palicnl"" image i .. ..upenmpoo.ed mto the ,inual r
Questions

for

Review

1, Describe three different pathophysiological mechanisms that may be involved with a TBI. 2. De!>icribe how each of the following rating ... cale ... i ... utilized: Glasgow Coma Scale. Rancho Los Amigo':. Levels of Cognitive Functioning Scale. FIM in combination with the FAM. and Glasgow Outcome Scale. 3. Identify three neuroimaging techniques u ...ed in the diagnosis of patients with TBI. 4, Ident ify key prognoslic factor ... for individual ... with TBJ. 5. Describe the role of the physical therapi st in the man agement of Ihe patient with brain injury who i... in the no response, generalized response. and 10caliLed response levels of recovery ( LOCF). 6 . How wou ld a physical therapy plan of care need to be modified for a patient with post-traumatic amnesia'? 7. What is the signi fi cance of a patient's cognitive and behavioral status in relation to his or her physical therapy goah and outcomes?

Case

-\ TBI " a u!."\a"I.IIII1!! and hk·lh.mglO!! e\en! lor the mdl\ IdU.11 and ht ... or her lamll). The re . . uhll1g mpan J11L'nh nlil"e \\ orJ...mg \\ IIh Iht: pi1llC'nt \\ IIh hr."n II JU l."'\tTl.!I11L'I) rl."lJ. ardlllg and c.:h
8 . Li ... t ilnd dc .. cnix: kc~ t'lc11lt'nt ... In planlllng I lion ... appropriate for the pallt:nt in Iht' l.on1 propriate and confu ...ed arpropnillL' It.·h'l, t (LOeF V. VII). 9 . H o~ doc ... kllo~ledge of a patlcnl ,.I~IIII\ ( to learn ne\\ IIlfOm1.ulon •• fh:d .1 ph)'h..,lllhc plan of care') 10. De ... crihc the imponilncc of the It.'.un .JpPI treJting the patu."1lI \\ ilh hr.lln IIlJuT) D1.... cr he role~ of ke} mcmhcr ... of Ihl." tC.lln Inlhe .11..U hil it allon ... ell ing 11 . Li,1 the IInportalll a"pcl'l ... 01 p.III~111 ;lIld 1. educatIOn III the 10\1... mlddll.", .mJ hl~h Il'\{ rccover) 12, Wh} i... it Important til mOllllOT Ihl.' t.'lk ... h llt dl medication ... in thl'" patient populalion l 13. LI ... t and de ... trihe J...C) ell."mL'nt ... In pl.lnn" mll.. \-·ention<., appropriJl1." lor Ihl." p.lllt'nt In Ihl.' 1.. nfu agllaled ... Iage 01 r~l'mcr)- (lOCI 1\ I

Study

Nme' The case .\Iudy

1,\

di\'ided into rhe followill.'? sec-

tiom. Parr A (xuidillK questions 1-3), PlIrt B (gIlidillg queltiollS 4-6), and Parr C (xuidlllg ljlle.\I/01I.\ 7 (lnd R)

PARTA The patient is a 34-year-old female who wa ... Ilwolvcd 111 a motor vehicle aCCident (MVA). She wa ...... truc.;~ hl

another car a ...... hl." c\lIl."d hl."r l.,lr. I Ill.' p.IIIl.·nt ,ull hd ...ewre clo ... ('o hrain IIlJuT) She \~.I" 1.lh·n In.1 h .1 htl 1<11 CT ...can rl."\icalcd .1 nghl ICIllp',r.iI P,ITll.·I.1I h{lth rhagc. i.I lel l pari!.:'t;!1 hCl1ltlrrh.Ij.!t'". dlllth1..' l'dllll,1 .In.1 mulllph.. l·Ol1lu ... lnn .... _\llhl.· .!Lull.' hll"'PII,tI. lilt' p,lllll11 IIl1lk'r\\ CIlI a \-l.'JlIfll"lIln ... IOIll\. ~,I ... lhhltlm\ lubc pl.h l mcn!. illllllr.lt!ll.'o .. hHll; IIL'~ It '!, \\,1' ,II}!hll\ ll. LII.d I he \l'IlITlcul'l'IIOI11\ \1.. ,1 " rl.·mtl\~·d .lpPII1\11l1.IICh

(, 'hnph.' r 22 'I rllumuli-.: Bruin Injury

,

~l'l ' 'i ii H' I IlI l' InltlO l II I IUl y. A pP IIJX llJl tlll' ly (, Wl' l' k ..

.1 1i('1 hl'l Inll"\', I lll' ptl ll ~' 111 Wa "i I l tllI , I ~' l l l' d 10 a o ilu ll l' rt'h,lbl lll ,lllllI IIII I " PII III

Plll ll' lIl IIll'O" "' .. ll' lIl ly ex illbll , dela ycd cquJl tlmuf1I and jllll tC\: I I V\,' 1\"IIl.' I IOn , III ""II1 ~

PlIll,l'1I1 loil' latc d " l1 l1 n!! In! UPPIOXlI lllilc ly ~ 1I11nlll C'i, the n cx lll h l ll' d IIIUl' a,c III tOIll' and ,C" PII ,llor y IHl e

1',\Ii I I\U DleA L HI STORY IIl'IIII" . 11 ~l'UI !lId \.\.(lOhlli \\ 11111111 '" '1 l1l1 l'1l1 l1 pH .. 1

lilt "'\ "

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l'o llcgc.

the Cfll1 l1l1l1 ll1 ly. S he CllIoycd lIultiuOI pl ('~l{knl ti t Ihc hxa l "i ll'n .1 Cluh dmptcr.

\l'1\ •.Iltl\'l' III

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'ht:

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1<" lig ht handed

"II)'S I O \l TIIERAPY EXAM INATION IINI>I"IG ,)

Pal ll.' lIt I" 11111 ahk 10

I' I M

"(,.' 01 1..'''.

, t;lIld.

be d/t' hall llt1n .., le r.. ; I, walk: 1. w hce kh i.tlL I,

I

t.; 1 ~1 1I ":

MEDlO \TIONS Valll'olll y at' 1I1 2.~ () IlI g vi:, IV q 12 hour .. 101 ~ dd Y", l or the ill ln'l loli

Ilep,1I in; :C;OO() 1I ... " heulillleo" .., q 12 hour.., 10 prc\'l'l1l L)vr " Il va ll : 1 lu g VI:! (j luhc, PRN. q 6 hour.... III ca..,c 0 1 l' Il·n:: a .. l'd agi t,-' IHli l

l\l'" ,IIC npCII \\ltl! lill1dollll..'Yl' IlHI\CIIlC ll h, hut

1'.llIlnl

not ,Ihll III II:llk tn ilUtllhl1) III \.1 .. ulIl .. l lIllUII. Pat lc lH

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11111111

11011<.' .. ,,11111110

OTHE R FINDINGS P(III CIII

1m... 1J ~IChe o" IOI11 Y 1IHaet.

rllc 11:1111..'111 C\illbl'" dy' ph.lgia and I.., NPO tnol hlllg hy

I1IOUlh l t'\CC PI lor Iria l Ic:cd ing' \\ IIh Ihe !-I peceh I;tll gungc puthologl, l.

111011

\ ",1 '"

P.ll lt" H 11.1'" ' 1age thrce dcc uhlt l on both hec h .

Ih ,111 II. 7' I1lnnd pt.' "'UII' 12.tn

Sill' :1 1.. 0 hi.l .. all mk'ctlon,

Rni'll

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l 111111 0 1

1

I"

\\1111 dcclIllu. ate J10 .. tUllllg \,'nrll!," 1'!"!lll\l\Cllll~llllll ~ II " and LE,... b"~\lt' l ,\lh , 111111\ 11\11\ \'1111..' 111 nil l1e'llt ,uk than k it \ 0 II 1'\ dlll ... ,lk\!(lII (f)F)l'\!nbll cd 1\1 1 Clthcl' 'Ide hlllrl\ld c\k n .. m lOll\' Inlall'l al" 111 1 F " "' 1111 le n and ") nn n hI (11l1l(lJl1,-,d \ ... I1\\ollh .. G.lld lu,n,1 d Ik\tl \ lI1I1(, htl,ilC'ral" III I ll, .. , ., 011 Je ll ,Ill d 1 nn n 'hi Ill1o~hll('d \ ,h\\(11111 ,(illd \("llll 11 \nnl llHltlU' I.:itmn-. kit plallttllllc\t11'. ,Illd ") 10 1 1\".11 I Inllll .. l1,1:!hl pl~\llI;lllk\or'

and p ·",j\l' R:lllU,l'
II \ hilal(,lalh \\llhm nmmal l lll1 lh ( W 1 ) C\('-'Pl H ll hl ()l 1.1\ k .. I" hOIll l1l'lllWI ,111<1 kll J) F tid... , 2:"1 Irl'TlIIlClIltill

R, 1111 1 \\'1

l ,t 1 \\ '1 l'\u.'lli ... hould(,1 ,\hdu(llIlII {} S."l , lk'\IOIl n 11'\ l.\h'Il1;t1 , nll,-lIl1l1l. n ~\ . l'lbO\\ C\h.'ll"HlIl 1,\1..' ''''' Oil" ~ll1f('1 'lIhll"
1'a'1

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I'

(1\ IRSI\ l. II1 IUII);S: a.., :t n:..,ult .

0 11 cOlilac t Jlrccaul l nll ~: gown . g l ovc~. and

lila", \'" .. hould bc worn \\ hCIl \\ or!..ing \\1111 Ihe pall cnt

1',1tllllll'l \\'111 ..

"UHI Illtq!11 1\

.\!
fIIc I IIIClIlIll-rl',H\( CIlfI

t1

GUIDING QUESTIONS 1 C'alt'gm llC lhc p~ llI e nt \ lC\ cI

0 1 c On 'C IOlt ' I1C..... upo n mhlli ..... J(lnlo thc ~IC ll1 c n.'h:thli ilal lon ho.-. pi la l ba ..cd oilihe (,Ia"'go\\ COlll'-l ~kOl l c ,tIId lC\ cJ oj' cognlll\ c l unclIolll11g lli1 .. cd Oil the Ranchm Lo ... r\llll g0'> Leve b 01 ('ognltl\ t:

' .'Ullci lolli ng ( L()( ·F).

2: , Ct l.';IIC ~I problelll 11, 1alld l hfl cn.·llIlale tlm.'ct 111lp.llnnc lll .. , Illdl rc(.·' 1Il1pUlllllent .... and i'uncl l0na ll lll lllaIIOlh, "' Dc,cllhe Ihree Jlh) "' I I'~tI thcri.lp) int cn entlon .. lh;1I \\ o uld he applO jll liJll' 101 tl" .. pa llc nl :II Ihl ... lillie Inl'Jude al k:,... 1 Olll.· rl.' I
J1ART B rilC p.l l lenl de'lcnbc d ,Iho\ l' ha, l'onltllucd 10 p fll~n"'. Sill' I" , til l III Iltl' ;\cul c rl'lI.lbtlil.1Iwn hO"Pllili ,lilt! It I'" IIm\ 7 \\l'l'k. .. l,tl l' l . , ~ \\ Cl.'!""' , Hl'\1 1I\JUr~

PHYSIC \ 1. TIIFRAJ1Y F . AMI ,\TlO ' FlNI)) NG S \10'0,. Co"tnll il' " I I '. ' llil 11ll',,\iIt\,.'ll \ ,h\\onh l I Ik\llt hllll', .' "\1 IlWW.ltfil'd \ ... II\\\\rt h

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1.. ,\ .. ,..... 1 Rt.,h .• lulil .Hinn

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l

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kit. ,Illtll.ln d\','I\·.t,", .. \\ lilt IIIn,·,t,,'d

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t';\ .. '" d"lr:.tt'lt'd •• Ibk ID .I(k·ntt to.l 1,1,k

Ol'lIFR l. FOR" Ul():\

1t1l.ll Ilhhl\ll'lhllll hl\

1\' ,I,

1111,' '\t.'11l'UlIlIlt.llld, Palll'1I1l'\hlblh th.·":rt:.I,,,'" 11I'I!!hl Intll

1.1\ 11I1I"'h'Il'llI II)

"'"'11,.111011

1\ " ltll

111 .ttl lllx'n t'll\ tnllllllt:IlI, Ilk' pall1.·nt I' \'ml~ .I~h.' 10 Illllo\t,

P,ll1t'lll l',lublh l·\PI\.· .... I\ t' .11,h,hl.1 Sht' I" .ll:'Ilt· hI 111.1 \'

I.I\~" 10 IUltll "1'1111,11 lp.IIII.'1I1 11.1 .. , I

1'0

Paul..·llll.·,lubll, ,hon h:nn 1\I~l\Ior~ IInp.lInlll·llt.. ~hc I.. Ill\,.'OIhl'I'·lI'l~ dl .. ont:llIl'd III pial:\.' .1Ill! 11Il11' and Ofll'mecJ 1\1 pl..·r'lIl1 J()()l t III thl..' lilli\.' Patient .. hk· 10 10110\\ 1\\11 h thl"l' .. ll·P U11I1llI.IIllI .. \\ h,'11 III .ll'I",,·d 1..'11\ Ironmenl \\ 1

1',I"ll' 1I~·l·d .. kllll\\ n 1I .. lIlg \ l.·rb.tl I.III~lI.t~l· .lllli ~1.·"lurl'"

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·l 1\.· ..'" 'th'" thl " ~'.ill ..·nt .. 111,.'''h'T' In1t'.l {T1, .\r1.\:t \'h\ ,:,.1 dh'I.I·' IH,'I',.'Iltt.'U" .Ul~llh"\ .... tll ..·I.\~· , t .. ~l~·', ,I .I\t\~·: .m . .'"' . .·ath'l· .. h' . a I\'I ,,·In .. 'l','h'

... I

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ChaJ)tcr 22 Traumatic Brain Injury

Strength: Ri ght UE WNL; ri ght LE WNL except DF: F+; left UE G for all muscle groups: left LE G for all muscle groups except DF: F- and hip abd uction: F- .

Passive Rn ngc of \ l otion IVNL all four extremities except right DF. G- 100: left OF. 0°.

postural Contro1 Sitting: static. WNL: dynamic. WNL: balance reactions IVNL. Standing: sIalic. able 10 mainta in balance wit h minimal challenges: dynamic balance reactions minimall y delayed: Berg Balance Scale score: 40/56.

Ftttt cti o ttn\ \\obility Bed mobilil) : Rolling 10 le ft a nd right. independent. Moving to and from s itling and sup ine. independent.

Transfers: W/C 10 and from bed requires supervision with one to

IWO

verbal c ue s for sa fc ty nnd locking brakes;

noor-to-s land. moderate assistance. Wheelchair mobilit y: Independent in the home. Ambulation: Supervi sed 300 ft (91 m) in a closed environment (homc or in the hospilal) with bilateral hinged AFO.'). Patient uses a foreann c rutch in the rig ht UE: in an ope n environment. the pali ent requires contact guard to minimal assi.')tance to ambulate: ga it speed: 0.65 m/s (1 ft/s) gait endurancc ove r a 6-minute walk:

574 ft ( 175 111 ).

925

Sta irs: Contact guard up and down one n ight wi th bilateral AFOs and one ra iling.

FlM + FAM sco res: Bcd/chair trans fers: 5, wa lk : 5, wheelchair: 5, sta irs: 4 , ca r tran sfer: 5, comlllunity access: 3. Co~niti o n

Patient oriented to person, place, and time 100% of the time . Whil e patient has shown improve ment in short-tenn memory and new learning. she is still impa ired in th is area. She is ab le to follow four- to five -step comm ands in a closed env ironme nt. Palient performs bes t in a h ig hl y structured e nvironme nt. In an ope n e nviron ment, palie nt becomes easily d istracted, needi ng ve rbal c ues to complete a task. Patie nt 's insight a nd safcty aware ness have improved. but are still impaired. For exampl e, she requires ve rbal re m inders not to transfe r o r ambul ate indepe ndently.

C om mUll icatio l1 Patient ex hi bits moderate word finding defici ts and a nomia (inability to remember names of objects).

GUIDING QUESTIONS 7. Li st and priorilize the patient's direct impuinnents. indirect impainnents. and functional limitations. 8. Describe two interventions appropriate for this patient. At least one int erve ntion should focu s on comm un ity ree lli ry.

R e f ere n ces I.

Dob~m. B: The Clinical Science of \ eurologic Rehabilitation. cd 2. O\ford Lm\er<;it~ Pre'>'). Qdord, 2003.

2. Con~en,u~ Conference: Rehabtlitation of person" with lra um:lI ic bram IIlJuf}. \IH Con,emu~ Development Panel on Rehabil itation of Pel'on ... \\ Ith Tr::mmatic Bm in Inju ry. l AMA 282:974. 1999 3. Thunn:lIl, D. and GUCITI'TO. J: Trend ... in ho\pita[ilation a.'."ociuwd II Ith traumatic br.tin mjuT). JA \I A 2R2:954. 1999 4 ThumlJ.ll . DJ. et al: Traumam' br;ltn tnJur) in the United State ... : A publiC health per... pectl\e J liI:ad Trauma Rehabll 14 :602, 1999. \'angel. S1. et aL Long-ternl medIcal care uti hZ3tlon and (O\h among unumatic brain inJul"} 'lunl\OT'>. Am J Ph),> ~ I ed Rehabll 84nl:153.2005 6 :\Ia)cr, \. et JI: H)penonicity and mo\emenl di.,order-, In Ro,cmhal. \ 1. et .. 1 (cdq: Reh;lbll uJlLorl ollhe Adu[t and Chi ld \\ IIh TrJumallc BrJm InJur), cd 2. FA DJ\ I'. PhiladelphlJ. 1999. p 503. 7. Jennctl. B. and Te'l!ldale. G: f.. 1,magcment of Head I nJurie~. FA D'l\h. PhllJ.dc[phla. 1981. 8. GlaclIlo, JT. el a1: The mmi1l1a[h COlheiou, 'ltate: DefinitIon and dmgno' tn.: cntena. :'\eurolOi!\ 58:349, 2002 9 Shum"'J}-CooL A. and W~lIaeou. \HI: \IOIor Control: Theol} and PranKal Apphc:mon~. cd:! LlpplIlCOIl \\tlllJnh & \\Il~m~. Phll:!delphlJ.. :!OOI 10. Lezak. \10: "europ~~..:hologKal a... ~e"ment. ed.1 O\lord L\U\er'>lI) Pre". \ e", York. 1995. II Rapp.lpon. \1. el at: Head inJu!) outl;ome up [0 ten year. [,ller. Ar~h Ph\~ \Ied Rehabtl 70:885. 19H9 IJ Tea~da[e'. G. and Jenne\!. B: \,~e"menl ot coma and ]mpatred (On,ciou,ne" A practllal ",ale. L.anl"!!t 2:SI. 1974 Il Tca,da[e. G. el al Ob,ener \;lriJhlht~ m a~,e~,mg impaired l'OI1~Iou'ne" olnd comol J 'eurol \euro\urg P,~..:hIJIT) 41.6()~. JIPX

14. Thornhill. S. et al: Di,ability in yo ung people and lldults one year after head injury: Pro!!.pecti\e cohon ,tud y. Sr ~l ed J 310: 1631.

:WOO. 15 . Levin, HS. et al: The Galve!!.ton Orientation and Amnesia Te'>l: A practical scalc to asses!. cognition after head injury. J Nerv Menl D is 167:675. [979. 16. Katz. DI. and A[exander. MP: Tra umatic bram inJUry: Predicting cou r'le of recovcry :md outcomc for pmients admitted to rehabilitat]on. Arch l\ curol 51 :661. 1994. 17. Katz. OJ: "Ieuropatholog) and neurobeha vioral recove r} from cio_ed he:ld IOJIII) J Head Tra uma RchabiI7: 1. 1992. 18. R ancho~ Lo .. Amigo, Hm pltal. RehabilitatIon of the Head Injured Adult. O O\\,I1C). CA: Profe~siona l Stuff A .. "ociallon. 1979. 19. GOU\ ieT. WO, et al: Rehabillt} and valid It} of the DI ...ability Rating Scale and the Le,·e[., of Cognltl\ e Functioning Scale !II monitoring recovery from ~e\"c re head inJUry. Arch Ph) .. Med Rehabll 68:94, 1987. 20. Cilu. OX. Ct al: Acute predic tor, o f \ ucccv.,ful re tun! 10 work I year alter traum;lIic bralll mjur)': A multicenter analysis. A rch Ph)!!. \led Rehabtl7H:I:!5. 1997. :21. Jennett. B. Jnd Bond. :\-1. As.,e.<;menl of outcome after <.C\ere brain damage. LruKct 1:480. 1975. 2:! ..... nder-on. SI. et al: Gla<;go\\, Outcome Scale: An mter-rater reliabi ltt} \tud}_ Br,un InJ 7:309, 1991. 23. Jennctt. B, ct al' Oi ...abl[i IY aft er \evere head IIlJury: Ob.,ervallom on the u~e 01 the Glll\gO\\ Outcome Scale. J Neurol Neuro .. urg P,}chl.ur) 44:2H5. [()HI 24 Ra ppapon. \1. et "I Oi~abllit) rating ~c"le for \evere head trauma: Coma to cOO1mullll}. Arch Ph),,, \ ·Ied Rehnbll 0: 11 8. 1982. 25 GUide lor the L;llItonn Data Set for \-Ied ..::al RehabI litation: UB Foundal10n ,",em ItIC'. Inr.:. Buffalo. ~ Y. 2002.

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('/\

lit' lI1u~r.:!e, SCrili1

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Appendix A: COlun-.only Prc!.cribed Medications

\11 .1

,~-

itO,

NSAIJ)~ (N ... "t~·r"idal Anti inflammatory Drug,) •

( ' omlnt'n(~

mp.... Inlllhlt!' pro~I,lql\II'dlt' ynllwsls, Il1u~ N ~ Aln ~))(hlhlt ,mil 1I1UIU11m,llnry. n"lll lW',I( ,1I)d ,U\llpylt'IIC proPOIIIC's

U~.od

to prodllco

(1) df"l.llqnfil,l , (2) Hnll Inl1,lmm,lIory pUcct. (3) nnllpyr(~sls. nnd (4) Inl"bliion 01 platelot aggrogallon (o.g , In plOphylaXis 01 unsteble

a r1 f1.n'l)

ThO most Important adverso eHeet IS gaslnc bl cdlng or gastrlils Most commonly used NSAID, aSp'rin, IS toXiC when overdo~ed It may causa tinnitus , central hypcrventilatlOf"'l metabolic ACldo IS, lever, dehydratIon, hypoprothrombInemIa, coma, vascular collapse, and renal and respIratory faIlure Aspmn bInds very aVIdly with plasma albumins, displaCing other drugs from thelf protein binding slIes. Therefore. co-admlnlstra~ tlon of aspirin with other drugs (such as tolbutamide . chlorpropamIde. methotrexate or phenytOIn) may cause sudden elevation of plasma concentration. AspIrin IS contraIndIcated In chIldren who sufter from varicella or Influenza infection, as It IS be eved thaI aspmn use IS related to Reye's syndrom (brain and hver damage)

Acetaminophen _hen

nc name

Mec:t..nism of Action

Clinical U..,

Commeocs

It IS postulated that acetaminophen inhibits a third, not yet characterized, cyclooxygenase (COX-3) that IS expressed In the eNS. ThiS action IS assumed to be responsible for antipyretic and analgesIc properties,·

Induces analgeSIa and antipyresIs. Contrary to NSAIDs, acetaminophen does not possess antI-Inflammatory properties, and does not affect platelet aggregatIon,

AcetamInophen may cause fatal hepahc and renal necroses when overdosed Success..d detOXIfication can be achieved b~ prompt administration of N-acetylcyst ne

------------------~

Opioids

.w-===-C~ S~

...

.:

0'

s

$""

the

..ltO

:::

rato

~=t .

c;?"ter cough

5) m • s. (6) truncal t\ - ) nausea and \"Ormtlng: cc 0::;1 at on; \9) co slnchon of t "lusLies n the bl 3ry tra t. resslOn Of renal function d e

oecrease n re a \'

to It IS

\ ) s ~1hon; d€' f ess on b\ mhl Itlon ,

r;la~

0

_

... , ....... \\'·11

( t) <1nalgesi . (~) lcute pulmona edemn. () ugh. (4) diarrhea. (5) anesthesia [especially when mlnl mlzmg carchovascular effects of anesthesIA is important). and (6) oplolds are also used In epidural and subarachnoid spinal anesthesia

asma flo\\

abor [mechanism

ommen.. Oplolds Induce devolopmonl 01 1010"''''0 nd dependence Tolerance develops 10 .11 eHeets of OP10Ids except: miOSIS. constipation and seizure Induction potential. Oplolds are contraindicated for patients (1) with head Injury [Induced respiratory depreSSion leads to carbon dioxide retention and cerebral vasodilatation that In turn causes an Increase In Intracranial pressure); (2) with Impaired pulmonary function ; (3) pregnant women [opiolds may Induce dependence In the fetus ; administration during delivery may cause respiratory depreSSion in a newborn); (4) with renal and bili ary colic [pain may Increase due to contraction of smooth muscles); Note: Administration of naloxone, an opioid antagonist, quickly reverses all the toxic symptoms of opioids; administration of naloxone to an individual dependent on oplolds induces withdrawal reaction.

Insomnia Sedatives-Hypnotics E·

I lea

Clor1 azeoam n 'razeoarn a prazota , u trazepam' 2 oart> 'ura~es

[phenobart><-a pen'Oba 'a secoba1l
Mechanism of Action

Clinical Use

Comments

es
(1) (2) (3) (4) (5) (6)

Prolonged administration of these drugs (several weeks) induces tolerance and dependence (psychological and phYSical) WithdrawaJ syndrome may be life threatening; symptoms include: restlessness, anxiety, weakness, orthostatic hypotenSion, hyperactive reflexes, and seizures

receDtor s!e and \erdos 9

ay be used n drug

sedation. decreases time to fall asleep. anestheSia. anticonvulsant effect. muscle relaxatton. and anxiolysls

ZolpidCI11, Zn l cplon

Exampl...

Mechanism of Action

Clinical Use

Comment.

ZoJpldem. ZaJepJon

Both drugs aro slruclurally unrolated to benzod'8zep,nes or barbiturates. They both bind to the benzodt81eplno receptor, facilitating millbllory achon 01 GABA

Hypnosis

Flumazenil antagonizes acHon of zolptdem Both drugs exhibit hypnotIc action Zolptdem has mmimal sedative and muscle relaxmg properties, and has much smaller potential to Induce dependence and tolerance than benzad,azeptnes. With the use of zaleplon, no development of tolerance and wIthdrawal syndrome have been reported

Depression M""hani m of Action ------

(1) Selective sero· tonln reuptake Inhibitors (SSRI) (fluoxottnO, sertrallne, paroxettne, fluvoxom· me); (2) tricyclic anti doplessants (TCA) (mllpramme. des· Imipramine, nortryptl' hno clomipramine). (3) Monoamine oXidase Inhibitors (MAOI) (tronyl· cypromlne. phoneilin )

It IS believed thai antidepressive agonts exert their effects through Increasing monoamine neurotransmission (dopamme. sorotonin, norepinephrine).

Clinical Use

CommenlJl

DepreSSion, panic disorder, obsessive-compulsive disorder, enuresis, chronic pain, bulimia, social phobia, attention defiCit disorder.

SSRI: Are the most well tolerated antidepressants. Compared with TCA and MAOI, SSRI have lowest sedative, anticholinergic, and orthostatic hypotensive action. However, they may cause nausea, headache, neuromuscular restlessness Similar to akathlsia, Insomnia or sedation, delayed ejaculation or anorgasmia, Combination of SSRI with MAO I may cause fatal serotonin syndrome, due to markedly elevated serum serotonin concentration. TeA: The most common adverse effects Include: (1) cardiovascular effects-orthostatlc hypotension, conduction defects, arrhythmias; (2) antlmuscannic effects-blurred vision, constlpallon, confusion, urinary hesitancy; (3) sexual dysfunction-in men impotence, in women decreased arousal; (4) neurologiC effects-seizures. MAOI: Improper diet (food containing tyramlne--cured meat or fish, beer. red Wine, cheese, overnpe fruit) may lead to severe hypertensive criSIS with potential myocardial Infarction or stroke. Many over the counter cold and pain remedies that Increase monoaminergic transmission have to be avoided. MAOI may cause orthostatic hypotension. Phenelzine may cause somnolence, and tranylcypromine Insomnia and agitation

l

Antiseizure Examples

Mechanism of Action

Clinical Use

Comments

Carbamazeplne, valprolc acid , phenytoin , ethosuxImide , lamotrigine

Antiseizure agents acl on neurons depressing their activity by: (1) increasing GABAerglc transmission

The goal of the medical therapy is to

Adverse effects. Carbamazepine: ataxia , dizziness, diplopia, vertigo, aplastiC anemia , leucopenia, GI irritation , hepatotoxicity, hyponatremia. Valproic acid: ataxia, sedation ,

(direct action on the GABA channel: benzodiazeptnes , barbIturates; decreasing reuptake or metabolism of

GABA: gabapenlln, tlagablne, vigabatnn) , (2) refractory period prolongation of the voltage-gated Na channel (phenytOIn , carbamazeplne , topira-

mate), (3) reducing T-channel C-current in thalamIC neurons

(ethosuximide) ,

prevent seizures without inducing any side effects , preferably using a single agent. Antiseizure drugs have dIfferent effectiveness against different type of seizures. Therefore , the choice of an anti seizure medication depends on the

diagnosed seizure type, The first hne agents for tonic-clonic seizure are: valproic acid and lamotriglne; for partial seizures: carbamazepine , phenytoin, valproic acid, lamotrigine; for absence seizure: ethosuximide, and valproic acid. There are many other alternative

agents.

tremor, hepatotoxicity, thrombocytopenia, GI Irritalian, weight gain, transIent alopecia, hyperammonemia; when administered to a pregnant woman, induces neural tube defects in 2% of fetuses. Phenytoin: dizziness, diplopia, ataxia, incoordination, confUSIon,

gingival hyperplasia, lymphadenopathy, hirsutism, osteomalacia, facial coarsening, skin rash. Ethosuximide: ataxia, lethargy, headache, GI irritation, skin rash, bone marrow suppression. Lamotrigine: dizztness, diplopia, sedation, ataxia, headache, skin rash, Steven-Johnson syndrome.

Antipsychotic Examples

Mechanism of Action

Clinical Use

Comments

Chlorpromazine,

Depression of the dopaminergic neuron in the brain.

(1) (2) (3) (4)

In healthy subjects, antipsychotic drugs cause

halopendol, clozapine.

(5) (6) (7) (8)

Schizophrenia, mania in bipolar disorder, Tourelle's syndrome; disturbed behavior in Alzheimer'S

unpleasant combined sensation of sleepiness, restlessness, and autonomic effects. Healthy

subjects show impaired psychomotor pertorm-

disease,

ance. However, psychotic patients show better

psychotic features in depression, antiemetic [chlorpromazine] , antipruritic; and preoperative sedation,

pertormance as the psychosis subsides. Adverse effects include (1) pseudo-depression due to drug induced akinesia [usually responds to anti parkinsonism treatment]; (2) Parkinsonism; (3) akathisia; (4) dystonia; (5) tardive dyskinesia; (6) seizures [clozapine]; (7) anticholinergic reactions [urinary retention , dry mouth , blurred vision]; (8) orthostatic hypotension; (9) agranulocytOSiS [clozapine]; (10) may depOSit in the cornea [chlorpromazine] or retina [thioridazine]; and (11) neuroleptic malignant syndrome [life threatening],

---

\ntiL'nletic l>.-ugs Anlihi~llimllle>

Exampl'"

Mechanism of .\ction

C~

Al t; "

-----

Diphenhydramine. hydroxyzine

Antlhlstamlnlc activity at HI receptor.

These drugs have strong antiemetic activity. and are partlcularty effechve for the nausea and vomiting related to motton Sickness. ThiS predilection may be due to depreSSion of the vestibulocerebellar pathway.

Scopolamine

Muscarinic receptor antagonist.

Excellent agent for prevention of motion Sickness.

Thetr use may be I mtted by pronounced adverse effects sedatIOn d zzmess confusion. dry mouth unnary retenttOn cydop eg a Diphenhydramine s most commonly used n conjunction With other drugs n treatment of emesIs due to chemotherapy When administered orally or parentera y exhibits strong ant,chor,nerg'c e"eelS Therefore. It IS better tolerated on he fonn of transdennal patches.

Phenothiazines Examples

Mechanism of Action

Clinical Use

Comments

ProchlorperaZine. promethasine

Block histaminic. dopamine, and muscarinic receptors. Sedattve properties are due to antihistaminic activity. Antiemetic properties are mediated by blockade of dopamine and muscarinic receptors In the proemetic chemoreceptor trigger zone located In the floor of the fourth ventricle (area postrema).

These drugs are mainly used as antlpsychottc agents. but due to thetr strong antiemetiC properties are also used to prevent nausea and vomiting In selected clinical situations (sedation for endoscopic procedures, postoperative nausea and vomiting).

The most common adverse effect IS dyston a It can be decreased by concornttant adm n stration of diphenhydramine.

Metoclopramide .Ie ocJopramode

Mechanism of Action

Clinical Use

Commeo

Releases acetylcholine from myenteric plexus neurons through stimulahon of 5-HT. receptors. Metoclopramide IS a potent dopamine (0,) antagonisl In the chemoreceptor trIgger zone of the medulla

Gastrointestinal reflux disease. postsurgical delayed gastrIc emptying. diabetiC gastroparesls, prevention and treatment of nausea and vomiting.

The drug stimulates esophageal clearance, raises lower e ophageal sph -ter pressure. stimulates gastnc empl\olng and shortens smallinteshn transit time Th m t COIl moo advers effects Include sOl11n ness. and -ton .., 11 mal als sonts.n and !.lnd"

5-HTJ Inhjbitors Clio;"" Ondansetron. granlsetron dolasetron

AntJemetic action IS mamly mediated through blockade of penpheral 5-HT1 receptor on gastrointestinal vagal afferents. although central 5-HT 3 receptor blockade may play an Important role as well

~====~C~k~====~ s 0, lega

Ute

These drugs are mportant r" ca~r chemotherapy ow ng to the ' abl ~J 0 pre lent nausea and emesIS 8..SS()Qated II th the adm n stra on of chemo·!"1€rapeu\icS These drugs a'e a so e~ect Ie n contra ng pas -rad at 00 and pas.operatlVe nausea and 10m" fl9

Em~

"'Ij~.hd

tr Ed h _ E.rr:€$S. :;,'xur.,h':! :., "" ~r e 9 rna:;;r: r€'SS IS P""ff'j ' f f : · ... T"'ese

oj'-'ug5 a~~ he

~

') €:'a~ed a ...,d d'e

rema,.l"'a bf'/ sa.te

S pasrno Iytics Commenu

Clinical U..,

Examples

Mechanism of :\ctiOD

Gabapenbn

An an selZure crug that aD r..a:es

" san a'1' seZ.,l·S d-ug 'ra" e,;-"' 0" Vope"- es pa",i€f!.S

aJ1: soasrnOO;c

GABAa

1o":t .. e"S€ if"-ec..s -:;., ... ~ ~'': '-ess o ZZlI'os-::....s €ad.aCt;€ 'a· .::= ....e ~ ataoa

See seda - 5

Badofen

receO'or i.""as

~e"

SJgges:ed tha"

nas a presrapt C ... ., O-Q('} fur.

on

as

e~ect.e

as dazepa.....

"':'9 sc.as: Ci., :x.- c ·Od....ces n

;':;ooa~ '0 C<€

--or;.

'~uC­

€SS

SE":"'.....a-

~;.tSC.€ ..

SOas:.C-, ca_5&':l 0, ~"".a co(1 da""ag€ -:1a" ceeora da:ag.s

Oan

Poovce seas" Cl., sce.a

Ene

'oc Rjanoo"9 "aceotor s a cae ITT r9 eases cacn.• r'1 ."or. ·. . e

c'"anre ......a:

sa'cap as""'" ere' Cula' c"/s"e"-s 3 ocfl.as;:e c' 5 c"'a;"'€ :;"9 9"'15

-- usc € ccc:-ac: or

"'O",O€s r-:a

~

ca'

;-a; .. j'O€-"'~'- a

X

.. a'Y.! "'0-;

~ a.:---~otJc

actO": • --a/

c:a...lSE r-L..SCl€ ... sa..... ~ setJa'XXl ar'o:::! 'a'S,

"'eca-..s

Botulmum tOXin

This toXin is produced by baclena

Clostndium botulmum The tOXin ,nhib,ts acetylcholine release from the axon terminals of motor neurons. The

ThiS agent is used in treatment of spas.tiCity cerebral palsy. stroke and blepharospasm. A singlE- OXI:" .oJ€:ct on reheves muscle spas.m for several

Adver&e et1eC\s. rnaf Inc

site muscle

Ne?"!i~:"s.

hema orna m",y;\e

~?';::. P<:l·~

r

~

~ JI':='"~1.r:;,~

n.r::r;';~"- :.iY... '~

ftBC·':15:'.

a..-tj V '!:::)r.:,.

tOXin uptake by penpheral and cranIal nerves IS mediated by a receptor local· ized to the axon terminals.

months.

Cyclobenzapnne

Cyclobenzapnne IS a prototype drug for the large group of compounds used for treatment of acute spasm. The exact mechanism of action IS unknown, but the drug exerts Its action at the level of the brainstem and spinal cord .

Used to treat an acute muscle spasm.

Cyclobenzapnne IS not effecLrve r ce~:;:bra palsy and spinal cord Injury. Tt,£:, arug "P-E. strong antimuscarimc. propertIes ~9SPOI)5..iD ~ for severe sedation confuslDn a..-,d "1BJ J:;i"'ations

Tlzanid,ne

An alpha2-receptor agonist. Increases pre- and postsynaptIc inhibition.

BeneficIal in patients with traumatic brain injury, stroke, spInal cord Injury. multiple sclerosis, and cerebral palsy.

SImilar 10 clonidrne. out Droo~C5:s. fSSS carate.vascular effects. Adverse efects '-re..J%

-------------------

drowsiness. hypatenslor dry moJtr

~,,-~"'a

Equal In effectiveness as DaCI7Br s::j diazepam. but mD~e favorab -; 10 e"~ -From Botting RM Mechanism of aC1lon of acetaminophen: Is there a cyclooxygenase-3? Chn Infect DIS 31.5202. 2000_ Table prepared by MaCleJ Markowski. MD. PhD

(; If , \ I) 'J

IIARNING

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I

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the

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Spa~ II C Jl y

9_n

t'ortll lli llry D:l1ah:t ..c (NSC ID) Va nah l c~

918

( ·I,I .... dil,11101l o j Spl1l.l1Cord hl ju ric .. lJ-,X DI.! .. igna tioll ul LI.!'1 lon Leve l 919

('ompletc II1J u nc~, Incomplete Injurie<;. and ZOlle 01 Part ia l Pre'crvation 939 AS IA 11Ilp:url11cllt SC:llc 940 (,liIH~a l

Syndroml.!'1 940

\kchall1'11!l-. 01 InlUry lJ-l :! ('lll1ll'a]1\ I.lni fc'I tal lon .. 9-l ,1

Spina l Shod, 9·D o\ lotor and Scn..ory ]mpaimlcnt .. 9-l3 Autonomi c Dy,rcflc\in 9-lJ Po'tu r.,l ll )potcn .. ion 944

cllrd IIlJUI) (SCI) l~ a 10\\ -Illcidcnce, hig h-coM dl ...ll;llli l ~ l"Cl{uinng Ireme ndou::- changes in an individ ual'", ltlt.'''I~ It' It I ~ c, lI lllate;-;d thai appro ,\ i m atel) 11.000 OC'\I, (.he, 01 S( 1 (k.:cur 111 the Un ited Sta le!) annu all y. A fl\h, I!' tnll.llt' Indicate" tha t the re a re be tween ~25 .000 MId ~!\~.()()O mdl\ ,duab \\ nh SC I currentl ) li ving in th e l nned tJte,,"

S

rlll.11

~~----~---------------

Demographics

,.

H

l I ll d

III tl d 'l\ IIIl' IIUIIII'll llllpaI IIl WIII , ;lII d r.:Olll pJI

I

I~

. . from the 'JlIonal Spmal Cord InJur) Databa\ c ID pro\ d~ Impo nan! demographic information "tra mala; 'plIlal ~ord InJUf) . The '\SCI D \\-a\ c ... tabm 14- '" and Lontam .. Informati on on more (han lOdl\ Id ual "" ho , w,tatned traumatt c SC I... Hi e 'ederall) funded \todel SCI Care Sy"cm,

Impai red Temperature COnlrol 944

945 Bl adde r and Bowel Dy ... function 946 Sex ual Dy"func lion 947

Indirect Impa mnenl .. and Complicati on .. 950 Prog n m l ~

<)5,

Anile \ 1cd ir.:a l \ I "n ag~ m e nt Ph a..e Emergency Ca re 953 " racl ure Siabil ization 953 Phy!:> ica l Thempy Exam inati on 957 Physical Thc mpy Intervention 958

9~::I

At:l I\e Rc haililllatu)I1 Ph,I"C 960 Physical "n lcrap) E:...amination 960

Ph) sical Thcmp} Intervention 965

Su mmar) 9Xl}

have prov ided da Hl '0 'he NSCID. Informarioll from 'he NSC ID prov ide mallY of 'he " a,is,ic,,1 reference, reported in th e follow ing ... ec ti ons. 1•2

Etiology Spinal cord inju ries can be g ross ly di v ided into t\\ O brodd etiological categories : traumatic inj uric~ and IlOfIflWIIIIClIl( damage. T raumas arc by ntr thc 111 0~ 1 frcqut:nt t.: ;t U~t: of IIljul) In :.Idu ll rehabi litation population.... The) rc ... ult from damage c3u<.;ed b) a tra umatic eve nt ~ u c h <\5. a motor \c htde ,1I.xidt.'I1I. fall. or gu n... llOt wound. Bec3u...e of the ir hlghcr inndt.'rh"'\.'. managemel1l of traum atic inju ric" \\-i ll 1""It.~ dC'l'nbt:d In Iht,

lhdptcr: ho\\c\'cr. the tfCatment PlllK"'PIt.' .. dl'(th'l'd \\ III huve (/t reet <tppltcali on to nOlltraU lIlllt ll.· lc" illll' ., .. \\dl. S l ill l .., I I(': " fromlhc NSC ID lIHh e. ltl.' l hlll,ll"l."ldl'nh 111\\)1\ II1g motor Vl.'hl c lL"\ arc Ihe 1110\1 I n,· lj lll.'l1l l"IU'l' l)t It,Hlm,1t I(: SC I ("I i "n pcn,:clll ). I n Jl ~l\\l'd h~ I.tlh (I~) h 1""I\.' rn'IlI) , ,tt."h

9.~S

Ph~ r,ical

Rehabilitation

of violence (17.H pcn:ent). rccre;1I101l . tI ... "orh illjuric~ (10.7 percenl) .• lIlel olher ellolo!!ie . . (6.1 pcn:crll). \ Nonlraulll;:\!IC d,lmage in aduh poplIhHioll', ge neral ly rc\ulh from d .... lw.. e or pathologic .. ] II1tluellcc. Several c\;unplc\ olnon tr.IUI11;1 I1 C COlldlliom thaI may damage the ~plIl
Distribution by the National Spinal Cord Injury Database (NSCID) Variables The NSCID has collected data on multiple patient variables. The most salient statistics are preserued here. Of the patients for whom data were collected, 81.0 percent were men, representing a sl ightly higher than 4: I ra tio of men to women. More than half of the population (51.6 percent) was between the ages of 16 and 30 years, wi th a mean age at time of injury of 33.3 years. Ethnic di stributions indica te that whites represented 66.6 percent of the database, followed by African-Americans (21.0 percent ), Hispanics (9.7 pe rcent), and others (3.5 percent) ' Fifty-one percent of patient s ex peri enced cervical lesions. 34.6 percent had thoracic lesions, and 10.8 percent had lumbosacral lesions. At di scharge from the rehabilitation hospital, 18.6 percent had neurologically incomplete paraplegia, 29.4 percent of patients had neurologicall y incomplete tetraplegia, 26.3 percent had neurologically complete paraplegia, and 20.7 percent had neurologicall y complete tetraplegia. The proportion of patients with neu ro log ically incomplete injuries has increased since 1973 from 45.9 percent to 55.3 percent in 2004. This trend can be partially attributed to the improvement in emergen cy med ical services delivered at the scene of the injury.2 Data were also collec ted on employment status, residence, marital >tatus, length of hospilal slay. and life expectancy. At the time of injury, 63.0 pe rcent of Ihe paticnts were employed. Postinjury employmenl >latus is sl ighll y hi gher among individual!, with parapleg ia as compared to tho~ with lelrap/e!{ia (preferred over the term qllodrip/eIlia). Follow-up infO/mation indicates Ihat at 10 yea rs po\linjury, 31.7 percent of individuals wilh paraplegia were employed as compared 10 26.4 percent of those wilh tetrapl egia. At time of discharge, Ihe maJorily of palienls (88.3 percent) returned 10 a pri vate residence (010" 10 Ihell homes) and 5. I percent were diSCharged to nur",ing home~. Becau", the majority 01 individuals with SC ls arc you ng adults, more than half (53.0 perccnl) were si ngle al the time

of inJury. The average lenglh or ho"'pllal ... Iay in an aCute care lIni! wa~ 15 day!'. and Ihe average \ tay In a rehabilitation unit was 40 day!.. Th b is a dccrca\c compared to 1974 When acute ca re hospilaii.wtion la~led an average of 25 days and rehabi litation slays lasled an average or 11 5 day ...! Life expectancy has increased over the year, but b still ic!'ts than ror individua ls without a SCI. Factors that IIlnucnce life expectancy are age al injury and level and extent of neurological injury. For example. an individual who Was injured al 30 years of age with a high cervical injury (CI--C4) wou ld have a life expectancy of 58.4 year~ , whcre~ as a 30-year-old wilh paraplegia wou ld have a lire expectan_ cy of 66.8 years.' The financial impact of SCI is extremely high. The di sabi lity is characterized by lengthy hospitalization, medical compl ications, extensive follow-up care, and recurrent hospitalizations. The costs of medical care during the first year postinjury were $682,957 for high tetraplegia (CI-{:4). $441,025 for low tetraplegia (C5-C8). and $249.549 fo r paraplegia. Average lifetime costs fo r an individual injured at 25 years of age were $2.693.887 for high tetraplegia (CI-C4). $1,523.204 for low tetraplegia (C5-{:8). and $900,085 ror paraplegia. These numbers do not take into accou nt lost wages. fringe benefits. and prodUCli\ it)'. This brief presentation of demographic informatio n provides some important general perspectives on characteristics of SCI. II is a relatively low-incidence disabliit~ affecting a predominantly young population and is a"'~OCI­ ated with leng th y and costly care.

Classification of Spinal Cord Injuries Spinal cord injurie!' typically arc divided into l\\ 0 blOad functional categories: tetraplegia and pw-upiegia. Tetraplegia refers to complete paralysis of all four c\.tremilies and trunk. including the respiratory muscle!'. and re~ult:-. from lc . . i0!l'" of the cervi cal cord. Paraplegia refer... to compiL'te paral) "'1'" of all or pan of the trun k and both lower e\tre ll1 i l!~'" tLr ... ). resulting from lesions of the thoracic or lumbar "'p11lainmi or cauda cq uina. Before considering de~igl1atiol1 of ~pll1al l'ofll lesIon .... !I is lIsefulto review brielly the anatomical r~latiol1",h tp ll f tht: spinal co rd and nerve roOh to the '~I1~bral hodtl· . . (h g, 23.1 ).'1 There arc 31 pair~ of ~pinal nel\l's : H Cl')"\ )(.I\. 12 thoracic,5 lumbar. 5 sacral. and I coeq gCdl. rill' uPlx' r (l'! vical nerves arc rclalin!ly horil0llt~tl a. . tilt;;) I,.·\il till' \lltl'f' vC I1 cbrai foramina. Ilo\\ cvcr. thl' rCI11:1!!llll g lll'l \ L·... (.' \ \1 111 .1 downwarcl direction and do 1101 cllH:rgc al the l'on\· ... \xllldlllg vCrl cbra l It:vcl. During 11..'1\1\ dl'\'l'lupll1l'lll the l.'md fill . . tIlt' entire lengt h 01 the vc rt cbm \ cal1:1l. and IIll' ... pl1li\JIILT\l· . . n!1l ill a hmi /olltui dircction. A~ liw \l'fll'l1f. 11 l'01lHlllll'hlllg;rll' ' ' willi grn\\ Ih . the ~ pIIHlI COld . \\ hlcl1 dr)4.,.· . . !H)t cJollt,atl' .11 tIl\.' ... allll' mIl' or;.t\ !lIuc h. ! ... dnm 1\ UP" :ml. The nwb " ...... U\lll· ,III

Chapter 2,1 Traumatic Spinal Lord Injury FUNCTIONAL LEVEL MUSCLES PRESENT

1

-" .. ""'

Cl,C2,C.J

F..:,.I MUICI.1

C4 C'

Olllph.." WId l''lMtiul Deltoid 8fld 8~1tpI

C. <'1

_T,~

C-8. T t

- Hand WId Flngeu

~'1f1

h .....,lOn

919

The n c urhlogi c~1 level i ... defined a., Ihe mn..,' caud.tl leve l 01 the "pin .. l cord with normal motor lJnrJ ..,(~n\l)ry function on hoth the left tlnd fight NoltiCS of the body. r\1(,tor level i ... referred 10 ~"i the mO""t c.;;:uHI::d ...cpmcnI of Iht .. pmal cord with normal motor fUn(;IIOo bilaterally, Sen 'J ory Icvtl jl., defined in the ... ame way eXCCpll11 lerm, of ~tI"'ory fUTlc

tion. Sensory level is typically determined by tcstlnv the palicm\ ".cn"lilivi l y to light touch and pin prick 'm the lefl and right side 01 Ihe body al key dermatome, (o,ce hg. 23.2). Scoring of sensalion is based on " 3-pOint ,,,din.1 "calc where 0 - abl.,cnt, I impaIred, and 2 nonnal. MI,tlJr level is delermined by te"ing the ,Irength of a key mu",le on the right and left ,ide of the hody at myotome, adjacent to the ,uspected level of impairment (sec hg. 23.2

T·2 T·S

Hl T 12

for key mu".clc~), Key muscle 'ttrength i"i .,cored u\lng the 6-poim ordinal scalc commonly u\cd for manual muttele tesling,v.

LUI'IWr

-~

-=':J

"

"'''' _,M 15

'>--

(.;(,>r.c:'....

M'"

" s.,

.,

As..,igning a Single muscle to repre<;ent one myotome is a generaliatlion, MO\l mu<.;C!es are innervated by more than one r.,egmental nerve root; usually two nerve rool!" innervate each mu ...cle. For cX(lmplc, the exlenr.,or carpi radiali .. Jongu~ receive.., innervation from the C6 and C7 spinal nerve rcx)t'J.. For the purpo..,c of determining motor and neurological level, the key mur.,cle ir., defined £if) having intact innervation

_lag Musr.:11H

if it has a manual muscle te" score of at leaSt 3/5 (fair) .nd the next most ro"ral key muscic exhibits 5/5 (nonnal) strength on the manual muscle tc!.,!. If the rostral key muscle docs not demonslrate 5/5 "rength, hut the ther'pi;! fecls that

.. 2

$.1

""'i11

the mw;,cJc would le'\t normally except for (acto", that would

impede normal te"ing (e.g., pain with testing or difficulty

Figure 23 Rdatlfln .hlp hctwcen the ,pmlJJ cord lJnd nerve not rt brdi b<"lle ilnd inncrvatJ()n of mlJ/or mu\dt gr I lp f r 11 ( r)ogler, ( f~. , wah pl:rml ...... ion,)

wilh po'\itioning), then this information \hould lx! carefully documented, For myolome~ thal arc not clinically tC\[able

(i .e" C I ·C4, T2 LI, and S2-S5) the motor level is defined .mgJy (,hlique and downward direction, running in

c.r

un

mer-! If ·rlrc •.!1 dirC(;tJorr In the lumh
'hf,r\{'\ ltil!" (cauda. equlna).

as the ~
or

a patienl" ,en""y level may be at ('5 on the leli, CR on the righl Hnd the motor level may he C5 on the left and T I on

I)c~il(nation o f Le~jon Level r"Jnt'ly Imporwnl for (;iini(;Wll'" ~md rc~e"r(;hcrr., to he ~~,! tIl il(IHiII('!y dcl('rrnlne the extent oJ nClIrofo!!J(,;u l IrrtrMlrrrlf'nt In krrnl.. /)f Irllllor Hnd ...ell<,ory III ... !., when work Ifll( ',liHh Hl(lIvu!IJiIiS wJlh S(,f.1hc eXlent 01 motor alld Sl'/1 IJry fUIKtlflfl aftt:r 1I11"ry 11;1\ tI i;lr!!c IInpw:.: 1 fln Ihe medical ~hrl rd';lhlhUIII(m I1ted ... 01 the Incilvjdual 1 he AfllcricHIl 'Plh,11 Injury A<; (X. Jali(J1I (ASIA) (lcrJlf:(llhe InlcrnalHlllal ,fllll!;lrd, III Nf:IWJ!oj:'ICill CI,ll.,o.,dJUII;OIl of Sprnal Corel I;llilr y (I\NCS( f,o; (h,.. 21,2) 111 fill l'ffcHt 10 Io,landunlJ/,c

II I

X

J/'

j

'Iy HI whlc. II "l"venly 0/ Ililury II., dL;tl"1 tllrJwd and

/1'11

fill' ISN(,S( I

Illnl'llIl'd l.llllIll,IIIrI/i II Illy

I

11(jIUor

'tld, It

I

rlll'lhlJd

10

rJltlVHlt.: ... ,I ... IHl1dilrdlll'd

dl'lnfTIlIIl" 11Il' extent of In()ICJr

IHlIlHln /(, ... id1l'r il ~('f

" i l l low ...

/",

HI allOtl IW1Wt'('1l ,111<1 dll)01l1' prO/l· ... Io&IOIl:dl."

VIII/I.ItH t'

1II1I If!

,11111111,1

1111 f(JI

,tflblj"hJlI~' IIii' Ilrfl)-'IlOl.,j" 111111 iii IC· ... '-·;I'" Ii Inill ...

I' t

lind

(llId

IWlll'l

pro

i ...

,111

[he; rlgh!. fn thec..c cac..c~, il ir., nol appropriate (0 <.t!o. ... ign

a

.... ngle neurological level. as ,hi., can tx:: mi ... leading . Each of [he ... cn ... ory and motor levellt on the rrght and Idt SideS (If' thc hotly !o.hould be documcn(ed ... cparalcly,5

Complete Injuries, Incomplete Injuries, a nd Z one of Partial Preservation It. (;on1plcrc
An ill l' IIllIpil-' t! illJ ur,\ 1\ clJ'\llicJ 01\ ha\-mg: t)t. . lm\ Ihe ncurologl..:allc-H:I

1110101 ,lilli/or ...cn\llIY IUllc[It)Jl

940

Phy'tical Rehabilitation

•

Asnr.. STANDARD NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY MOTOR KEY MUSCLES

R

PIN PRICK

llGKT

TOOCH R l

C2

SENSORY

KEY SENSORY POINTS

R l

"0"'-:;_=---'

C2

~

~

CO

CO

2·~

g:

"'·""'·.... 1

~ ~ ~ ~e:':'" C7

T1 12 13

I

0•

101. petlllysd

f • pMpabM rx ~ conl1acf1on 2·~_,."

T4 T5

I

move,.,....

T9

..

T7

T8 T9

~-~-III_-.:u.._",.

no

r"

Tl0

againallul ruist~ , NT • not ffttM:JIe

T12

T 12

II

::;u ~ ~ :::':-.'::::-

::;

Atllde dl:nlf\a1Ulf'l' lDng toe ~

l5 S1

LA

L5 51

Ankle plant. I\ex(n

~ ~

c:J ~ ...... a;lf1/sad1on (YaINo)

54-5

TOTALSD+ 0=

CJ

~

MOTOR SCORE

~ ~

L......J Ant""...at.on (Y-..No) 0-0 ~ PIN PRICK SCORE TOTAlS {OoCf---... c::::J UGHT TOUCH SCORE 54·5

jWoo\XMJMl I~, 158J

1100\

R SENSORY 0

",

T11

L1

"'"_~~

0 -

TJ T.. T5 T6

~~ I .1 • .cIIn egem.I ~ ....y ". 1IdNe~.

T6 T7

18

NEUROLOGICAL LEVEL

$9

Ebow extal1loOl'S Cl Finger IlellOB (dlital pllIlanli of mIcIdIe ~) ell FII1g8f abductora CkWe finger) TI T2

C8

WA)',I,IUU· ""

1.1ff11»11f1d

~ ;. ••

L

0 MOTOR DO

(58) {!!Ill

COMPLETE OR INCOMPLETE? _'..,...-yot __

CJ

ASIA IMPAIRMENT SCALE

CJ

;o/U·ll

ZONE OF PARTIAL

PRESERVATION

c=.=.:.=r

R

L

SENSORYDCJ MOTOR

CJO

Figure 23.2 ""'Olor and \en"ory examinatIOn fonn recommended by ASIA. (From American Spinal InjUry A .....ociallOn. II' with pcnni ....;ion.)

Including ~cnsory and/or motor functIon at S4 and 55. If an individual ha\ motor and/or c.,cn,>ory function below thc neurological Icvel. but doe,> not have function at 54 and 55 then the areac., of mtact motor and/or c.,cnsory function below the neurological level are termed lon es of partial preserva tion

ASIA Impainnent Scale I ndlv ldual ~ with incomplete injuriee., may have va nable clinical prcc.,entallone., in term'> of motor and/or '>cmory function below thc ncurological level. For example. one patient may have (;)o'>c to normal e.,en~ory and motor runc lion below the levcl of the IC'> lon while another with the same le,>ion level may have impaired e.,emation and no motor funct ion below the neurological level. The ASIA impaIrment I..cale (Table 23.1)~ \lias crcated e.,o Ihal dlnl ciane., and rce.,carchcrc., could belIer communicate the degree of impairment of indivl(jual'> \li llh c.,p inal cord injuric~.

Clinical Syndromes Dcc.,pJlc the um:crtalnty ac.,c.,ociated With recover} 01 Incomplete Jc..,ion.., ....cvcral c.,yndromec., have t!me rgcd wJlh

Table 23.1 Impairment Scale = Complete: No motor or sensory function IS preserved in the sacral segments S4 to S5 . B = Incomplete: Sensory but not motor function is preserved below the neurological level and Includes the sacral segments S4 to SS. e = Incomplete: Motor function IS preserved below Ihe neurological level. and more Ihan half of key muscles below the neurological level have a muscle grade less than 3. D = Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more E = Normal : Motor and sensory function IS normal. A

Clinical Syndromes

J

Central cord Brown-Sequard Anterior cord Conus medullans Cauda eqUlna

From American Spinal Cord InjUry ASSOCiation. p 28, With permiSSion.

Chn))h.-,2.1 Truulllutic Spinal ('ord In;ury

ANTERIOR CORD SYNDROME

CENTRAL CORD SYNDROME

941

lind vlhr;lIory ... cn"'L' arlo: gcnerally prcl.,l"rvcd, hcC.lUo"C Ihey WIo: lIlCdWICd hy the po\ tcrior t:o lumll\ wllh a \C parlilc Vu\. cular "'lIppl) lrom the po\tcnnr , pinal MtcnC!'l. IU

Central Cord Syndrome

POSTERIOR CORD SYNDROME

BROWN SEQUARD SYNDROME

3 \rca .. 01 'pinal cord damag.e In Incomplete cord hl'nl Rlc ..er. T\. el afT I~ \\lIh pennl':t~lon.)

,oJn .. Il"Sf ~!.niI,."Jl feature\. Infon113tion related to the mtt.. ~n,oI) and mOl or funCIIOn\ of lh e~e ~) ndrome ... , I.Jut In e,tab h ... hmg goa)..,. o utcome s. and plan )t ~JTe Oe) The area of cord damage of each f..yndrome I' pn ,t 1 In Figure ::!3.3.~

Bro'- ll-<,equard S,ndrome RrO\\n.St:quard 'i~ ndrome occur... fro m heml'..eclion of .~ "p.' ,.Ii cord (damage to one ')ide) and , ... t) picall) . . .Ju'eJ "') penetration "ound .... i.e .. gun'iihOl or "'Iab. Partial ... on OCcur more frequentl): true hcmi~eclion ... are rare. 1Qe climcal teature, 01 thl'" ... ~ndrome are a ... ~mmet n c.i1 . On the If I/aTt'Td/ (,arne, ... ide •.1'\ the le"'lOn. there 1'.. 1m,.., of ~GS:1uon In the dermatome ..egment corre ... pondm g to the k\el 01 the le'lOn. 0\\ In!! 10 lateral column damage. there I! de .. rea~d retle'\c .... lad. of .. uperfic.:lal rcflcxc ... c!onul." and;] 1l1\C' Bahln ... kl "Hm. -\\ a rc .. ult of dor...al column bmJ,:-C' lh<:-re I' 10... " ot propnoccpllon. lone ... lhc .. ia. and .dOI) ·n...e On thc Ide cnnlrCliClu:rClI (OPpo Ite 110 Ihe on. dama1!e to the .. ptnoth~lan1lf.: IraLl .. rco"ulh In lo\s oj !'1.S,e f pam dnd h:mpt!ralurc 11m. lo!.s begin'" M,'\cral dermatome §.e!!mem helov. the Ic\cl (If lnJur) Thl\ dl~· epanq. 10 lc\d occurs hec3u",e Ihe laleral plIlothala tr.K1 a! end IV.O to lour -.cgmcnh on the ~amc ~I(k ~

fore (.r

~

In

\nr(-rior (. o rd ~,ndromc

\nltriur ((lrd \~ nd~om(: frequently related to fleXion f the een I J region \uth re!tuhant darn;J e to Ihe pan f the ... '.JTd and/or It a ular LJpply I rom mal anuy 'fI1ere I I)PlcaJI) compre 1(1" ( f II" ord born fracture dl J(1t,; liOn. Jf cerVi .1 ndnmc I acten,cd h I. I Pnlllru"o. Th m ronal It I dmla C I and <> I lhc:

per"=

lhc: I

",,"wille II... dam;o OJ Poopn< pU'OJ

Ce ntra l co rd \) ndrum e mo\t communly (><.:(;ur ... from h) pcrcxtCI1\IOn lIlJUflC!'I to the ccn,lc.11 reglCJll It al ,o hu, been a,,,,o(;J~lIcd wuh congenllll i or degcneratlvc narrowing of thc !'Iplnal cana1.? The re,ul t8111 comprc!'I,ive loree\ gIve fl\e to ht! r'norrhagc and edema. producll1g damage lO the 1110!'l1 ce ntral a!'lpc cts of Ihe cord. There i.., charm:tcri'lJ ca ll ) 1110 rc !'Ieverc ne urological involvemcnt of the upper e~trt!ll1i(ies (UE!'I)(cervical tract', arc morc centrally loc,lIed) than of the LE!'I (lumbar and ~ acra l tract, afe l oc~tled more peripheral I) ).ll .l:! Varying degree, of \elll.,ory Impaimlent occurl 1 but tend to be less severe than mOtor deficwl. With compl ete prc!'Iervation of sac ra l lracl ~, nonnal ..,exual. bowel. and bladder function \\ill be retained. Palientl., with central cord ..,yndromc typically recover the abil ity to ambulale wuh .,ollle remaining dlo,wl UE weakne\s. Surgical Intervcntion to rc llc\'e the \ouree of compreSSIOn h3.\ produced \igniticant Improvement In somc patient\.

Posterior Cord Syndrome Posterior co rd
Sacral Sparing Sacral \ I)... rin~ refer-. to an II1complctc IC\lOn 111 y.hll:h Iht:' rTI<."'{ cCll lnlll) loc.:atcu \acra l IraU I} arc ... pared_ \'J1)-lng le\el of IIlllcf\;uion from \aL:ral ,egmcnl\ rcmalll IIlt.:ln Clinll.11 "gn, IIlduJc pcnanal \c1l ... alion ;Jnd cXlernal anal .. phlllllt.:r con tr;Jc tIUI1 . Thc\C arc 1I11ponal1l I1curnlngJ(;.:I' III1JlIlg"l .llld oftc:n thc fin,1 ' Ign ... that a <.:cf\- Ic.:al h~'olon ,,1I1l·0111pil"lc 0

Cauda }' 'Iuina Injurie. Inco 'plO,11 ,:ord t;,IPCf\ dl\wlly 10 Imlll It\\.' l'tHlU, nll'dull.u I' ,II the: lm,"cf hordcr 01 Ihc hr ... t IUlllhJI Hlll'hr.1 \Ithouv. h ollie iUIiJIOIIIH,:a l \;Jlwllon, ext, .. th" I" thl' t~p'l.11 tt'lllll Hat 011 pOlllt of the: plllal (,;onl Ikhw. 1111, h,"\I,:II ... Ihl" lol la 11(111 oj 1011)' ner\!,.' roots klltl\"l .:1\ the (( 11/./11 ('/IIUI,I ({1I11J ·t 110111 Ilflll III till IIl'a IIM\ II(t,ur Ilmh\ f (·"lUda t'(luina h ,",il)fl\ Ill" It qu..:nth 1I1\.. lIlIIph I OY.IO, In Ihe gr. 11)111111 "l)1 J1(IVl" UNII j ll\ltlht"d lnllih ""1111 If blf\eJ

I

I

,'

... II ..

tllq

II "-,uul.11 1 glOlI ,""uuld 11\111\ JI

CIlIl.lllpa

unl iel, thai II IIIJUIY hI Ihl tllC urllK:C II .it pud .JlI I u , udM. etlUlIl.iI It" I II, HI "'HI or IIt·ur,, " (I \1'" II III un

C'

r

(Il'

1001

n f\l (1m" I th ) II \' Ill(

J.0It" l''''tl''nIlJI h.l n:' c:n...~r.th.· ;1, I ·nphcr.tl Ill'rh'", chc \\hc.'n" II1th" ~ h 11,l\\{'\ ...·r. lull n'lum 01 Inncn.llu,lIl I' not ..:,'Dun,ln tx· . .:~\1"'· (I) Ihc.'n· I' .t l..trgt" (h't.Ul ...·e N-I\h· ...·n the 1<."'1,\11 and tht:' ""lnt l'l mnen.1I10n; \.:!I ~I\lln.t! J'\"~enl'r aOl'n m.l~ n\'t lx . .·ur .111."'g the ongm;}! dhtrihution I." Ihe nc:nt", \. .l\,"lnJI n·gcner:.Hlon nt.l~ be b)(~J"ed b~ glhll \l,UJ!=cn "'1.':1.mng; (·n the end organ 11l.1~ no longer oc fUIKII,mmg l)flee remnt"nJllon lXXU": and (5) the rJte of regt"nerJ.lIl'ln ",10\\ '" and finall~ ",lOp, after about I ~ C.tf.

'I

lechanisms of Injury \:m0lL'" mech3l1i"'m .... often in combination. produce mJurie,

to the . . pmaJ cord. pmal cord mjw: mo~t frequem.l~ OCCll~ from indirect force", produced b~ 11l00emeni orlhe head Jnd t:runl and le ... ~ often from direct inju~ to a \enebra Y Common mecham~nb operrning m Cl include tle\.ion. compre"''''lon. hypere\ten!!>ion. J.fld lle\lOn-rotatlOn. TIle"e force ... re~ult In eithef a fracture and/or d is locat ion . TIle mtensjt~ and combmation of force ... impo ...ed ha\e direct mfluence on the t~ pe and locatton of fr.:J.clUrel~ l. the amoum of di,location. and the e\tent of "ott lis::;ue damage. to

Table 23.2 Mechanisms of

I h...• "'PlIll' dCI1HlIl",lr.tlc.·" \~trtOU' ul.'gfl..'e:", 01 ",u "'l~ rl1 blh "itllll~ .m.·,I'" .Ir.... IIlherC'nll~ more: \ ulnt.'rahle 1x....IU ... e 01 thC.'lf high mohlhl) and rd.lll\~ I.k" ul . . t.tb IIJly .l'" n'mp.U'Cu \\ IIh OIh~r ... egmcllh III Ihl.' "PIIlI,." Ie g. the. nglJ Ihoranc reglOn). 1 The arC'~I' oltht: ,pine' th.11 demnn. ",tf.He the hlghc"'l frequclK) 01 mJur~ .1fe ~t\\t:cn C~ ant.! C" IIllhe ccnical region .lntl ocl\\C'cn TI2 and L:! In the Ilwr.l('olumb.lf n:-gion. Tahle 23.2 pre ... cnt, a ,umnhlf) 01 Ihe m.IJor Olt.'<.:ha. ni,m, of inJur~ ill\ oh cd III SCI. ' I~ Althou p. h these force ... t~ picall~ OCCUf in combmatlon, the) ~U'e prt.' -.eme:d IIldi\ iduall~ lIla:-.much a'" each ha ... Char.lClen'lI c PJue:m of pfllnar~ i.H1d 'b~ociJted injurie ... . T\\o additional contributing mechanbm' Im oh ed In SCI ~lre shearing ..lI1d di~tracllon . Sln'ann..:: oc('ur", \\.hen d. hOrIzontal force i ... applied to the ... pine rela ti\e to the 3djacent segment. 10 Shearing rrequent!~ di , ru ph Iigamenh and i~ a,,~ocialed with fracture disl oca tion ... of the thor3co!umbar region . I ~ DistraCTIon im oh e", a tracllnn force and i~ the lea~t common mechani"m . It Qi.:'cur", \\ hen significant momentum of the head i" cre ated. :.b In \\ hip\a~h injurie~. Thi ... momentum create . . a len"'lie fon.. e in the cen ica! ... pine a, the head j.. pulled a\.\a~ from m(' bou). ' l~ III ItlJUf)

15. 17.18,19

• Head-on collision In which head stnkes steering wheel or Windshield. · Blow to back of head or trunk. • Most common mechanism of SCI.

Associated Fractures

Potential .\ssociated I

. Wedge fracture of antenor vertebral body (vertebral body compressed). • High percentage of Injuries occur from C4 to C7 and from T12 to l2.

• Tearing of posterior game " • Fractures of posterior e e . . . e ::spinous processes. lam ae pedicles • Disruplion of diS • Anterior d islocation ot \ erte .. J body.

Compression

• Vertical or axial blow to • Concave fracture of head (diVing. surfing. or endplate. • ExplOSion or burst falling objects). · Closely associated With fracture (comminuted) ____ _ _ _ __ .::fl::e.::::xion Injuries. _ _ _ _ _._".:.e.:.a.:.r.:: drop fracture . Hyperextension

• Bone fragments may ouge in cord • Rupture of disk

• Strong postenor force such as a rear-end collision, • Falls With chin hilling a stationary object (more commonly seen In elderly populations)

• Fractures of postenor elements: spinous processes. laminae , and facets . . AvulSion fracture of antenor aspect of vertebrae.

• Rupture of ante nor long Iva .1 ligament. · Rupture of disk • ASSOCiated With ce lea e~ . . 'S only of minor Influence n th~ ..1 columbar InJunes

Postenor to antenor force directed at rotated vertebral column (e.g .. rear·end colliSion With passenger rotaled loward driver).

Fracture of postenor pedl· cles. articular facets. and laminae (fracture IS very unstable If posterior IIga. ments rupture)

• Rupture of postenor ~l nd ntpr spinous Ilg~lI1lents • Sublll dllon or dISIc~(\lt l('ln l, j lacellolnts • In IhordCIC and 11Iml'~H Il'9 ...'\n~ lucels may loe,

( 'lillk.lll\lanifl'stations

I hi ... lhuH'it! '\ IHIrPlllt' PltltllIlt"1 1111 ,Iltllt' 011,,'1 "' IIUftl

II~ 11001l1lO\IIHI' , lulIlIlI ht'/tm lilt' It'\clill lilt' 1\"101} Alh..' l t' IH IIlPllt IWIll IlIt',e ... 1IIllld I 1t' lIl!! 11ll' ImH'r 111111 II\. · UUI\

Spiual Shock

' ))111,11 l 'Old

hnl!l~'\1i td\ 1\,lhm Ill!! SCI tlh'h.' I"

it

Iwnod 01

.lIdlt-\IH

~.llk\1 'pillal ,hul'" I'hl\ 1'\'1 Hl\ll'llt . ul'-II..·nt II.'rh', ll!"'pn. "

\'k'arl~ 1IlHiI..'l'lood II '\ hl'lll'\ l'lI 10 11.'\ lIlt from .lhIllP! \\ Ithdla"i.d of l'OIIlWl' lIolh Ol'!\\l'l'U 11Ighl.'!'

{lO\~l'l

Ihollllll' ,IIul '11('1111

,II l'il"l I

II lid 11I1I1iI!t- II

11,..·\ lIll1n~ IIl l 'lt'\1111I1Il 01 hloud Ph'S n~llh\II~, Ihl' lI11pul .....·, \11I11111.llt' Ihl' It'l,..·l'IHor, III lilt'

111;1 ...... Idll'\ It"PlIlhl' ' IIrI..'

,1\'111\ IIllt

l"tIlOlul \lIlLl ... dnd itOl l il, "hllh '1l!llllllht' \a ... oIlIO!OI (t'nll'r

th(,'

10 It:ltd)tI,1 pt' llphL' !ill re",lilIU 'l'

\\'1\

,md th\.' 'pillal conI. . . '(I It II" dlHlill'll.'ritt'd b\ \1' ,II tdk'\ Ul"ll\ It~, tlan:llhl~, .tnd 10 ....' 01 'L'I1\(I thlll 11l1.1 willi fUIH.:llon h... lo\\ thl' k\l'! 01 tlw Il"jon It 111,1\ 1.1" hI' \\.'\1.'),11 d.,~, to 'I.'H'ml \\l'C\...\, 'j In mldillOlilo Ih,'!lh' ll' dt'I,.:p Il'lldun rl'lk\~, tlwn.' "a In", of thl.' oulbll \'.1\\' 10' "1"I..'nl.'\ ttw l·!\·!llil\h...·lIl Idk:" and a dl'la\I.'d plant.l p\lJl'l' I'hl"\.' rdlt.'\L'\ 1.'\ 0" \.' O\l'r 'l'\I,:ral lIa, ~ 10 \I,l"~ k SCI DIll' 01 th,,' 111,1 IIldl,,';HOI' Ih"l ,plIlal ,hlXl r "ll\\ lug I' Ih,,' pn.·'"'lll:l' {li" H p o ... tt 1\ ,,' hulhol'H\'c'I' Illl'll' Il'l 'c\, I h" Il"1 i ... pm I of Itll' Ill'lImlngl'l" L'\mlllllU 11,,111 D I mg.1 dt~il.1i r~l't4d l'\,unilhilion,l hl' It.'f) ..'\ I' eltc il l'J b) ~"Lln.' applll'd tn Ih,,' ~dal1' )1"'IlI' or gla ll ' rllIlIl" 01' ~, mh,' I 1Itl'nlh "llI~!! lIIg" 011 ;11\ IlHh,dhng I.: alheter. It p!.1"IIIH, rdk\ ClHlIl'arlion 01 Ihl' alia I 'phllll"ll'r uround tht' l'\:tIl1I111ng {lIgtl \\ III lx' l'\ IlknL 'I ;\ hulbol.. l\t'II\O,u, rdll'\, ,,:n,'Il1,I,h.'nl rdk'\, or a lIol1nal pl:llll 'lI rL"polI'C Ill;!) l\: prl"l'llI '1,.'\'I,.'ral "Cl'\..' lx'fore dL'ep It'ndon r\.'fll'\C' ar,,' arp.In': 11 111 Iht' l h,. 1,(,'[1(1,1'

~, ..·nl,lro.'

l

tItlPIIl ,~, 110111

rOIl() WIII~ \('1 ,

Ihl' \ iI'lHllolor l''''1l1t'1 l'.II1I101 1'.1" 11lL'

IIIl' 1L"lllll HI l'l)llllle lilL'l lilt' h)j1Cllen\IOIl

lion

l

~" ,0

hOW,,'\lL'I.

II

hy

"'t' 01

\1\\0<./11.1

. 11' 1' .1 t1ll ll'itl, L' IIIl' I}!elll") ,1I1I;lllon OV.. IIlV 10

1I11' l ill'\.. 01 IIllllhlllOIi lrom 11I1-!Iwr l ·t /lll'r,. hypcnelhlon \\ III per'I,1 II nOI II'L'i\f('d PIOIlIPII ),. ))I,.'
Initi.lIing Stimuli rhl' l11(hl t.:Olllmon Cilll\t' 01 1111\

pathologu. ill

rellc\ 1\

hl lHld c l dl'll' llII OIl (urI n,ll') Il'II..' ntlOn). ()Ihel' Pl't' tlplt.lllng

,,"nult inl'lude It'rlal d l Slt'nlHUI , prt'''lIrl' ,ore." Ilrinilr\ ,llHlt". hlllddl'l Injel'tlon" nO\l(lll, CU IIlIlCOII' ,lllllUII ,

\..u,i

I\l') lll :d fllll l'11011 , urtlhnil 01 hl;Hldel' 11'rI11I110n, and t'll\ I lonnleltl ,11 Il' lll pl'l,lIure t.:hiln~c"

'I.

l ~pl'od,," 01 ""1011011111,.."

d) ,rl'lk\lil .11,0 hme IlL'l' lI a'port ed follO\\ IIlI-! P;hsl\t,: ' 1l'l'IL'hing at till.' hlp,lI

S) mptom' Ihe ') IllplOm, 111 ,IIIIOIlOlllll' dy,n.,nC\H\ Illl'Iude h) pCnl'!l 'lOll, hmd),c:trdl:t, hl',ldal'll c (ollcn ,evert: :lnd poullthn~), prof U'L' ... \\ l.'all11!!, inert'a'l'd 'PII, t il'i t), 1'C, tle" III.'.\'-, \' lI'IX:OIl ·

\1otor and Sensory Impairments

, lfl c tlOn hl'lo\\ Ihe le\t' l 01 le,u)U, VU'Odll:llIOIl (t1u,llJl1~)

folh l\\III!! SCllhl'I"I,.' \\ III he cllhl'r l'Olllpll'lt' or p;ulI.II 10" lit Illu'l'k fUIl\.:tHlIl hL'hm thl' kn'l of th l' k'HlIl. l)l',ruptulil 01 Ihl' a'l't:l1dlllg ,el1'OI') flhcl' follOWin g SC I

t!C, IIOIl , pdocn.'I.'IIUIl (goo,I.' bUlIllh),

n:\ult'lI1 1I11paired o r 'I h'l'nl '1.' 11':111011 bl'l ll\\ Ihe IC\l'1 of

Intervention

'ht' 11."1011

rtu,' onset 01 ') mptolll' , Imuld hl' Il ca ted a IlIcdlcoll 1.'lIl1.'rgt:IIC) II I~ 1It~ nat , Ihc p.IIII.' 1I1 , llOlIltI bl' hrouglu In it "tlmg pO,lIlon, 1IH1'lIIu(;h ", hlood prC"lll'l' \\ ill he hm l'II..'tI III thl' )1lhlllllll. Ikl'i IU 'C bladder d"II.'11i101l j~ iI pn 111:11) c all"" 01 :till 011011 Ill' dy"erlL',\ia, till' dlllill;l!!t' ~) ,ll'lII ,IHluld be L'\:IIIlIIIl'd 11I1I1Il'lll:lll.'l) , IIlh e pilI it' III ,,\\c;tfJllg a c bmped cillllI.'lt'r, II , Imuld I'll' rl.'lc'l,t'd Ihl' drallhl~t'

rht' clanil',,1 )11'1."1.'1110.111011 of IIHllllr ami 'l' ll 'lH") IIl1p:llr fll~nl\ I.kpcm,l, on Ihl' ' IX"I il L" I C
IndllUl' lilt:

nl'uro lll~il'al k"l.'I, Ihe CO l1lpll.'ll' IIL'" o f Ihe

lC'lon. ailli the 'Yll1ll1et ry of Ihl' Ic,ion (InIlIWCI'l' 01 nhllljllC).

\UtonOIllil' tI,' ~ .. cflc\.ia (It) pClTcf1t~\ia) i,

;J

palliologil'al

bt""" \:.

')"l11p ..11helK 'plalll: hl1l1.: olllllow). 1I00\l'\l' I, H IIii' ' I en reported 111 1' . 1111.'111"- V,III1 IIIJlIrll'''' at 17 ilnd I H. 'I,'

neu.h'nel.' 0 1 th" prohlL'lI1 " ..Inc'. Onc , tlllly 'I' Immd ,I ..JX

Il1alc\ II

111 a group 01" 2 1,1 pallel1l " Ro,c ll '

l" "

hit .1\ I1htll} a, X5 pcrl'c nl 01 Iho'e \\ IIh 11'1I;lpleg li.l itn\.l high·levd p.llapkgl ..1 C,"PC rlCIIl"L' till', prohll'lli dUllng Ihe tou r,c 0 1 rl'ilahllUatlOll Ep"Hde' uf ilulOnOlllll' dplt' 11 t'\1 ,. II iJ gradually ,uh\ldc ovel IlillC alld .lI t' Il'Iilll \t'ly n. . ()lnnl h 'ct'n nn, III nOI lare, .1 yc;u', lollml,.ln g Inlury II I' I, In pallen l .., with hOlh UlIllpklC al1d IlIt'Ol1lplt'lt' 1!~1I111

hlul1\'d \ 1\1011, 'to

p

""I

agt' or 1\\ I'tillg, I"lIl' patll' lll \ hod) ,Imu ltl Ix'l'Ill'l'h'd Ill!

rene\ Ihat typica lly Ol'C lIr\ III Il'\lOII !>, aho\l' T6

Pcr~enl OlTUrrCl1l'l'

and

luhl" al,o , 11(luld hI.' l'ilet: \..ed 101 Inlenl.11 (If t'\Il'llIal blod..

Autonomic Dysreflexia J.ulnnolllil·

"))O\l' the k'\l'1 01 Ihe !e'IOII, l'OIl'lfic tcd pupil" II;I';!/ COil

IlIl t;Jtl ll g , 111111111 ' UL' h ", Il g llt Cilllitill g, n." tllt' tlllg l.'alllt' lt'l " 1,111 \,01
II ')I11 PIOIlI ' do 1\01 ... uh'Ilit-. or II Iht' ' 0111'(.'l' 0111111,1111 111 ,,;I11110t bl' IOI.';ltt'd, Illt,tlil'al .Il1d/or IlU ... lIIg .'''I'IUllt"t' \il(luld h ..' ,oughl Illl1lll'dl . llt'l~ \ddlllOIl ,11 l)lt';I'III1." Ilhl' IIldudl' hl;lddl'l' IITlgallon (:t IlI ght'l !e\l' 1 hltxJ... 111.1, t'\ I.,Il. 1,,'lIun,11 ;lIld 11'pLil'l' lllt'lIl \\ 1111 it 1It·\\ ril lh t' lt'I, ;llld 1'\,III1I1\dlltlll 1\11 hl)\\t'llIllpal'IH)II. 1)11I!! 1111' 1.1)1\ (,lllllh~I"-'llt' II'I\l''') 1ll,1' lx' IIllll t', lIed 10 L'Ollllnl Ilrt"t' t'pl,udt'\ It II1lll\.' l'llll"l"I\.III\l' apllI()ildll" dlt' 1I11'UtTl'",lu/ I ht' ill1 t' llIlllI ~ ph~'It' I'III . IHII 'III}-! ' I,dl. ,Iud lIlht'l It'.1I1I IIlt'lll bt' l ' , ho ult! ill \\ iI) , Ilt.' 1I01111t't!0 r Ot'\'UlIl' lIn" til illi h I 1I01l"t' d) , rl' lIt'\l il II" , \\III ,tlhm l ,lIdtlllllOllllllllll~ ,II

9-1-1

Ph"ical Rehabilitation

the patient for ... t::\cral day ... follo\\ ing the epi!>ode anti will alert other... to the ri ... J... of future occurrence!>. The individual patJem\ . . ) Il1ptom .... precipitating stimuli. and method~ ot relief ,hould be documented.

Postural Hypotension Postural h) potension (orthostatic h) potens io n ) IS a decrea.....e m blcxx.l prc ...... ure that occurs when as ... ummg an erect or venlcal po"'Hion (c.g .. I) ing-to-s ilting or sluing-to~tandlng). It is caused b) a 10...... of ... ympathet ic \"asocomtriction control. The problem i~ enhanced b) lack of muscle lOne. cam,jng peripheral vcnou'l and ~planchnic bed pool mg. Reduced cerebral blood flo\\ and decreased venous return to the hean t) plcally occun.. producing ~ymptoms of Iightheadedne ....... dllz ine ....... or famtmg. 33 Inasmuch a... man) pallents may be immobilized fo r ,e\eral \\ eeb. epi~odes of po .. lUral h) potension are a fairl) common occurrence during earl) progression to a vertical poSillon. They lend to occur more frequently with leSions of the cenical and upper thoracic region.;;. Patien ts will often describe the on,:>et as feelings of "dizziness." "faintne ....' ... or Impending "blackout." Although the exact mechani':>m i':> not clearly under,:>tood. the cardiO\·ascular .;;ystem. over time. gradually ree~tablishes 5ufficie nt va~OI1lo[Qr lOne to allow assumption of the vertical posjtion.~.l A related problem i", edema of th e legs. ankle~. and fecI. which i~ u')uall) symmetric and pilling in nature. It occurs <;econdary to the above problem~ and is com plicated by decreased lymphatic re tu rn." To minimilC the"ic effects. the cardiovascular system ,:>hould be allowed 10 adapt gradually by a sIO\\-' progression to the \enical po..,itioll. Thi.., frequently begin.., with elevat ion of the head of the bed and progresses to a reclin ing v. heelchair with elevating leg rest<; and u':oe of a tilt table. Vital I.,ignl., .. hould be mOllltored carefully. and the patient should alv. a) s be moved very \Iowly. U~ of compressive ...tod..ing ... and an abdommal bmder v. ill fun her minimize these effects. Pharrnm:ologlcal themp) may be indicated (e.g., ephednne to increa"IC blood pre..,,,,urc or low-dose dIUretics to relieve per",islent edema of leg .... anh.les. or feel)."n A" va..,omOlOr ,:>tabilJlY relUnl\. tolemnce 10 the vertical posilion wi ll gradually IInpro\"e.

Impaired Temperature Control After damage 10 Ihe ')pinal cord the hypothahlmu.;; can no longer con tro l cu taneou\ blood flow or level of sweat ing. This autonomic (sympathetic) dysfunction results in lo':>s of intemallhermoregulatory rer.,ponses. The abil it y to ... hiver IS 10':>1: vasodilation does not Occur III respon<.;e to heat nor does vasocon':>triclion OCcur in response 10 cold. There i" absence of tht.: nnoregulalory ':>weating, which el iminate ... the normal cvaporative cooling effects of per..,piration in waml em ironment.;;. This lack of sweating i... often a... ':>oc i ated \\ jth exce..,sive compensatory dwpllOresis above the

level of le..,ion. Patients with incomplete lesion ... may abo demomtrate "spotty" areas of localized sweating below the lesion level. 3.'i Changes in thennal regulation result in body temperaturc being siglllficantly influenced by the e.\.temal environment This is a more frequent problem with cervical lesions than with thoracic or lumbar involvement. Pallen!.s mu.,t rely he.,,·j ly on sensory input from the head and neck regions to a... ,:> i... t in detennining appropriate environmental temperatures. Although some improvement in thcnnoregulatory respon'les occur':> over time. patients with tetraplegia typ ically experience long-tenn impainnent of body temperature regu lation. especially in response LO extreme environmental changes. H)

Respiratory Impainnent Respiratory function varies con5iderably, depending on the level of lesion. With high ~pinal cord lesions bet\\-een C I and C3. phrenic nerve innervation and spontaneous respiralion are significantly impaired or 1051. An artificial ventilator or phrenic nerve stimulator is required to ~ustainlife. I.n can· trast. lumbar lesions present with full innervation of boLh pnmary (diaphragm ) and secondary (neck. intercostal. and abdominal) respiratory mu scle~. All patients with tetraplegia and those with high-level pamplcgia demonstrate some compromise in respiratory function. The level of respiratory impainnent is direct l) related to the lesion level. residual respiratory muscle function. and additional trauma sustained at time of injury. as well as prcmorbid respiratory starus. RespiralOry Involvement represents a panicularly serious and life-threatening feature of SCI. Pulmonary com plications (especially bronchopneumonia and pulmonary emboLism) are re'pon;tble for a high monalil} during the earl) ~tages of tetraplegia. ~n, n There is a progressively greater loss of re':> piralOf) function wJlh IIlcreasingly higher lesion level'>. Multiple respiralol)' changes occ ur that are related to both the inspiratof) and eXpmllOr) pha~es of ventilalJon. The primary muscles of impiration are the diaphragm and ex temal inlercostals. A... the diaphragm co ntracts and de~cend .... the intercostal . . normally eleva te the ribs and increase the Imeral anteriorpo.,terior diamete r of the thorax. 111 Par~ly ... is of the interco..,tals resul ts in decrea~ed chest expa n",ion and ~ 100\cred inspiratory volume. With progrc.., ... ively Ilighe r·leve l lc..,ion"" increased invo lvement of the acce.., ...or) muscle ... of respi rati on will be noted. These mu ... cle .. a ... "'i..,t \\ ith eleva· lion of the ribs and include the ~temoc l eidoma ... toid. trapezii. ..,calcllI. pectorali"i minor. and serratu ... anterior. The pnmary muscles of expiration are the abdominaJs anti il1lern that occur.., through clastic recoil of th . . lungs and thorax, Hov.cvcr, the abdomin31s and internal intercostal':> contribute ... cvcral Imponant functi on.., rt.:lated to movement of ai r ou t of the lungs. Lo ...... 01 the...e mu ...c1e.., ..,ignifican tl y decrease.., expiratol)" efli cienc)

(hapt{'r 21 Jraumati(. Spin .. 1 (ord InjUry

\\1lt;n lull) mncn,tt\!d. the. ahdommal mu\t:!c ... play an anponant role In mamtammg IIltr,uhoral."ll' prc"l ... urc tor etl~U\C' rc ... pmuu,lO. nlC) ",urrortthc .lbdommaJ VI"l/.:cra ' J ~I ;Uld ~1 'I,tlfl mamt.linmg the pn . . JtlOn (lltht.! dUlphmgm. fht.!y .u'{) funf.:uoll to pu,h the dl~lphr..lgm up\\i.ml during forct.!d e\plrJlJ('In \\ tlh p,lralyw, 01 the ~ltxlomJnab thl!-. ... upport I ... jo,t,C3U"'lIl!! the llJ ,lphmgm to ac,,!-.umc an unu\ually low POSIlion in the: Lhc:,t.4 Thi . . lov.crcd poSlllOn and lack of abdomInal pre ,ure w mO\e the diaphmgm upward dunng forced ~\rlr.1tlon re . . ult"l in a decrea ...ed expiratory re ...erve volume, Thl' ,utN~4uen tl) deerea.">C\ cough effecti\'eness and the abdlt) 10 e\pt:1 ...ce retion ... , Paral. I" 01 the ex ternal obliques also mnuences expiratIOn Their no nnal function is to depress the ribs and ~ompre ...... the che ... t \\all to assist with forceful expubion .)1 Jlr, \Vith higher-level lesions this function becomes Ie, etfiCII,;nt v. Ith a further reduction in the patienl's abil11) to u;h and to expel secretions. These factors combme 10k. lhe palienl Wilh SCI parliculariy susceplible to re 1 c'1l1on of "Iecretion!-., alelectasi~. and pulmonary inlel'J n~ Paraiy~i., also res ults in the development of an altered breathing pattern"a.c.n This pattern (Fig , 23,4)3K is chara.::tenzed by some flanening of the upper chest wall. decrea"ed che~t \\-all expansion. and a dominam epigastric me during in<,pira tion, With relaxmion of the diaphragm, a negali\e intrathoracic pressure gradient moves air into the lungs, Over lime. this bremhing pattern ""ill lead to permanem po~turaJ changes, T\\o addit ional faclOr~ may further impair the respiratory 'tatus of the patient: additional trauma sustained at the time of injury. and premorbid respiratory problems. Effect of Respiratory Muscle Paralysis: Supine

l- vR-1 PbrmaJ resting position

Key:

=

VA VerUcallhoraclc diameter HA = Horizontal thoracic diameter PA intrathoracic pressure Resting

=

- ----- --- Active -_ ._._.- Passive

InSPIration Normal

Inspiration

VR HR PR

.......... .......+

Normal

In',malion Spinal cord Injury

J:lg I ure 23,4 Lllc(; t 1)1 P,If,II), " li

t'''",tthu\),"! lll\

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SCI

9'5

"r.tc.:turc\ (c,g., nn.... \tcmum, or extrcmllle~). lung (;OOlU \lOn!-., or \oft U.,\UC oilmilgc will al~J (;ompound rc~plfatory prohlcm,. The", "'wndary InJurie, arc particul"rly problem
Spasticity Spac,ticity results from release of intact reflex arcs from cen tral n ervou~ system control and IS characterized by hyperlonicily. hyperaclive welch reflexes. and cIonu,. Il lypically occurs below lhe level of le'JOn afler ,pinal shock subsides, There is a gradual increase in spasticity during lhe firS! 6 monlh, and a plaleau is us ually reached I year afler injury. Spaslicily is increased by mulllple inlemal and external stimuli. including positional changes. cutaneous stimuli. environmental temperatures, tight clothing. bladder or kidney stones. fecal impactions, catheter blockage, urinary tract infections, decubitus ulcers, and emouonaJ stre ss,IO.44 Spasticity varies in the degree of severity, Patients with minimal to moderate involvement may learn to trigger the spastici ty at appropriate times to assist in functional activities, However, strong spasticity interferes with many aspects of rehabilitation and can be a deterrent to independent function. In these situations. spastlcit) I~ often managed first through drug therapy, Drugs t}-picalIy used include muscle relaxants and spasmol}-1ic agents such as diazepam (Valium), to! baclofen (Uoresal),':' and dantrolene sodium (Damrium ),n Pharmacological management is usually not completely successful in alle\iating spasticity. and It!'. benefits must be weighed again~t potentially adver:-:.e side effects. tn addition. patienb often develop a tolerance to prolonged use of iodi\ idua.l drugs. Injected chemical agents also have been u~ed to decrease spasticity, Generally. Lhese are considered onl~ If resull', obtained from pharmacological management are deemed inadequate. The two approaches u~ are ~nrh­ aal nene hlockj" and Intrafhecal lnjeaW'l5. In Ilene blocb. the chemical injecllon I~ used peripheraJl~ to ...elcx{)ve!v bloc"- tranSml"lSIOn of the mOlOr nene lO 3 ,p.i.... U ..' mu . . ~le and therefore to Interrupt the IOt3("t retle" 3fC peripherally With mtr..llhel.' al IOJl.~tu..m~, J l.."entrJl ~"nhln the ",plnal Gillall ("henllcal IIlJecllon I' u...ed. 10<: rnx dun'''' pro\llk .1 temrx-'lnU) redudH:\O 111 'f\l-... u . 'm . .mJ Include (I) phenol ~nrhcr.11 nene t-.k,,;"-, .mJ (.21 pi'k:Dll' lTlolUr rOIiU /:Ill'lC"- . . 1\ Surglc,11 Jppm;.h.:hc ... ,\1,0 h,I\C tx"\:'n u,,,'\1 III \. :l I11Nt ... p,I ... llr.:Il~ III Ill""" ... ("~n.' \,:,t"'l" nlt'\ r.1I\~' t(\"'01 rdJ.u . . eh "'11l1rl(' orthofl\.'JII.: po'l\.'t.'dul"\' ... hl ... on,p"'-\. ncun' ... urgcf) OrihOpt~dl\: ",ul!!I,.:,1I rnxl'dur..: ... u,,,J Ul...TU~· m~ohlm.\ 'L'l"CI(lI1I11~ ~\r I"\'k',I"'~' III .1lllu,,,:le, Ill'un.'Ctom~ . a p.uu lor a

ptn~caJ

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\ numt-..·r of Ilhlfl" r,lll!\.al nt.·unl"'uf~IGII Int enl·nllon ... u 00 tl'l l"lmlln•.HC" c\lreml'l~ 'C"\CfC 'pJ'IICII) f he,\.: de: r.ru\.ID""\" arpn..1J\.·he, (neur.tlll ...... uc "damageti) Ic ... uh 111 p:rm3lk"Ol .tnd profound alterauon ... III 'pa ... ll cIIY These pnx"C'dure, an: u-.etul \\ hen 'pa'llcJt~ I ' at all mtolerable Je\ I and prohlblh Of 'Ignilicantly IImlh funcllonal acli\ itl , E\ample, of the'e Intenenllom mclude ~eve rance of nef'\e rOOI' frhilo fom.,) or of ...pinal cord nerve fibers fm)elolOm) I

Bladder and Bowel Dysfunction Bladder Dysfunction The efTee" of bladder dy;fune(ion folloWJI1g SCI po;e a ::.erious medical complication requiring consi"ilent and long-term management. Urinary tracl infections (UTh) are among the mO,>1 frequent medical complication during the mllial medical-rehabilitation penod. Durmg the \tage of !lpmal \hock, the unnary bladder I ') flaccid. All mu!)cle LOne and bladder refl exc"J are ab~ent:n Medical consideration., during thi., period are focused on e"Jtablhhing an effec.:uve "y.,tcm of drainage and prevcn Llon of urinary retention and Infectioll . The .,pmal integratIOn center for miclurilion I" Ihe c.:onu., medullari.,. Pnmury re fle x control originalc, from the \iJ<.:raJ seg ment s oj S2. 53. and 54 wi thi n thc callus mcdullafl..,. 1 olloWJJ1!! spillal ..,hock. one of IWO Iypes of hl<.lClticr comllliolls will develop, dcpcndlllg. on local ion of the le!<'lIull. Patient ... wi lh IC'> IOIIS Ih at occur \\Hhll1 thL' "' pinal <.:ord aouve the conu.., nH:dull~lr" I) pi ca II) dc\dop a .\fltl.\· /I( or reflex (auloma tlC,;) hli.lddcl. h) 1I0wlIlg a l e~lon or Ihe (onus IIlcdull'II" or cUlida CqUIIHI, a .f7ucnt! or nonrdlc\ 4

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947

Chuplt:" r 2.1 Trnumutic Spinal Cord Injury

fable 23.3

C IUlrncteri~tic!t

of IJflSlic and Flaccid Urinary D ysfuncfion

Spasl;" (Automat;") Urinary n,'sfunction (Upper MOlor Neuron)

flaccid (Autonomoua) Urm., Dy function (Lower MG!! IC! or ~!.!!!!!)L~

Occurs above mictUrition reflex center (52-54) located within the conus medullarlS.

Involves mictUrition rellex center (52-54) In the conus medullans and/or sacral nerve roots In the cauda equina

Stretch receptors In bladder wall and afferent neuron intact. Mlctunllon reflex Intact. Parasympathetic Innervation to detrusor muscle and bladder neck sphincter (internal) Intact. Reflexes may be intact depending on level of cord InJury.

Same as UMN.

• Nerve pathways between brain and spinal mictUrition reflex center (52-54) Interrupted; loss of Inhlbiling Influences on spinal reflexes from higher centers. • Ascending sensory pathways interrupted: loss of sensa lion of bladder distenllon and urge to urinate.

• Loss of final common pathway for trans· miSSion of Impulses between eNS and detrusor muscle and bladder sphincters (intemal and external). • Same as for UMN .

Results of pathology

• Loss of UMN innervation • Intact micturition reflexes • Spasllc bladder dysfunction.

• Loss of LMN innervation, • Loss of micturition reflexes • Flaccid bladder dysfunction.

PrognosIs lor bladder

Bladder traintng is aimed at using micturi~ lion reflexes and '1"gge( sllmulus to establish planned reflex vOiding.

Unable to establish reflex VOiding. ",terrM· tent bladder cathetelizatlon may be best method for bladder management.

Le\elof nnervation: I Local

2 Sp nal micturition reflex

,S2· 54) J SI mp,lhetlc Innervallon cord segments T1 to T2 ~

Bral "Igher centers , Motor

. S "sory

control~

Mlcturltron reflex center In conus medullans and/or sacral nerve roots destroyed Same as for UMN.

----------

----------------------------

From Dolan ..aa p 629. With permiSSion. Bladder Iralnlng depends on many faclors, such as level 01 inJUry, pnor bladder habits, patient. lam y caregIVer motivation, and teamwork eNS central nervous system: LMN lower motor neuron; UMN upper motor neuron.

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Phl~ical

948

Rehabilitation

Table 23.4 Characteristics of Spastic and Flaccid Bowel Dysfunction Spastic Bowel Dysfunction Flaccid Bowel ~ (Upper Motor Neuron) (Lower Motor Neanna) Level of cord Injury

Occurs above defecation reflex center (52-54) located within the conus medullaris.

Involves defecation reflex center (52-54) In the conus medullaris and/or sacral nerve rools in the eqUina.

Level of vertebral Injury

Involves T11 to T12 vertebra or above.

Involves T12 vertebra or below.

Intrinsic (myenteriC plexus) intact; responsible for weak peristaltic activity, which is not of sufficient strength by Itself to produce a large bowel movement. Defecation reflex Intact; parasympathetic tone to descending and sigmOid colon, rectum, and internal anal sphincter intact. • Nerve pathways between brain and spinal defecation reflex center (82-S4) interrupted: loss of inhibitory influences on spinal reflexes from higher centers. • Ascending sensory pathways interrupted: loss of sensation of fullness In bowel and urge to defecate.

5ame as for UMN.

---

Levels of mnervation: 1. Local

2. Spinal defecation reflex center S2 to 54 3. Brain/higher centers • Motor

• 5ensory

Defecation reflex center in the conu s meduliaris and/or sac ral nerve roots destroyed. • Loss of final common pathway for transmission of impulses between eNS and descending and SigmOid colon, rectum, and anal sphincters. • 5ame as for UMN.

Results of pathology

• Loss of UMN innervation. • Intact spinal defecation reflexes . • SpastiC bowel dysfunction with spastic contraction of bowel and anal sphincters.

• Loss of LMN Innervation. • Loss of spinal defecation reflexes. • Flaccid bowel dysfunction.

PrognosIs for bowel conlrol ol

With intact defecation reflexes, bowel training is aimed at using these reflexes 10 evacuate the bowel. Bowel and anal sphincters respond to rectal/anal stimulation, enabling a planned bowel regimen, which empties the rectum and prevents Incontinence. PrognosIs IS excellent for good bowel control.

With loss of spinal defecation reflex activity and LMN innervation, the bowel and anal sphincters are flaccid. They do not respond to planned rectal or anal stimulation. Arrival of feces in the rectum results In incontinence. Bowel training is deployed to evacuate stool from rectum. Presence of stool in rectum preCipitates incontinence. PrognosIs IS favorable for bowel control prOViding a routine of regular bowel evacuation removes the stimulus for bowel emptying.

Bowel Incontinence

Rarely occurs with good bowel management. Incontinence IS due to spastic contraction, Diet is a Significant factor In effective bowel management.

Occasionally occurs even with good bowel management, due to flaCCid sphincters. As with spastic bowel dysfunction, diet is a significant factor in effective bowel management.

Bowel training program

Regularly scheduled evacuation, usually every other day

Evacuation necessary on a dally basis to keep rectum clear of feces and prevent Incontinence.

Use of medications Including suppositories and laxatives

Responsive to a combination of laxatives (milk of magnesia), stool softener (dloctyl sodium sulfosucclnate [docusate, Colace]), and SUppositories (Dulcolax).

Response to medications less effective than with spastic bowel dysfunction.

Digital stimulation

Used to tnltiate a planned reflex bowel evacuation.

Nonresponsive to digital stimulation, manual removal of stool from rectum may be reqUired

From Oolan.'" p 627, wIth permISSIon

"Successful bowel traInIng depends on many factors, such as level 01 inJury, prior bowel habits. patlenVlamlly/caregl'Jer mOllvatlon, teamwork eNS

central nervous system; LMN

lower molar neuron. UMN

upper motor neuron

(h.aptcr 23 Traumntic Spina1 Cord Injun ,Ill. r, ,11

oller .,Iru,turco pm!!fJIll., to aV'Ii,t pauent., "'llh r'II.t! .lciJII,tn1CI1I 'I H .\lthough the 10nn,1I of the.,c prll ' l.UTl' \'Irll·~. l"IUlllllIlll .,hared go.lb mclude (I) threel r III III l,lll' IIlllucilup: l'\ ,lilt I 1l.1t ICln. prn~now'}. (realm!!nt. I}

,111. 1~"IJ"'rlll1g. (2) c.'clw,.allnn of lhc pallent and h" or her rWlllC1

.Iml ( ~) p'l'Il.Ir.illol1

III "l~lfl

member,

10

deal

\1,

lth

1I1l~m h.c." I1"

Ii

11.ldll.lil~ l'\p,IIHhng

hod} 01 11I~ralurc ,., avai la ble on 111,- llI,tlc .,c.'\\I.1I rt.'''pnn .. c lo1l0\I,-lIlg CI.~tt~1 Sc>.ual n"ptln"~' I" dln:<.:II) II:\;IICO to lev!!1 nnd completeness of ITllun \, \\1111 howe! ami bladder lunt:lton. !'!cxual cap:}h!1II1'" ,Ill' hnl.ld l)' dl\ ltled between UMN (dam3ge 10 [he ~,'rd .t!'II.)\l' Ihe.' UlI1U' l11~dl1l1an~) and LMN k:-.ion~ (dam.I\!(· 10 the uUl U ... ll1l'dull,IfI' or cauda I,;quil1l:l).

H'I,tled

SLIII"lI( ...

10

,cxlI:t1 capacit}

prmldc

Important

'n'l IlIlfollll.lIlOl1 rcg:tr
'ypc:-. of datil and Ihe tlll'n, llI)1 h('lwcc.:n ,C\,u;!1 3clivily and ,elf-image.

1(,11 do

lIitle, 111 c.·olkctlllg 1i1t.!,c

"nl(

,11 c.rq),1111..') Ill;!} e.'XI\' hel\\cen rcpol1ct! :lilt! :lclUal

~"u I 1'l1ll'IiIUl /,

In

I R'\

I~'\" nl till' ll1l..'f:lll1rc on :-.c'( uHI rc:.ponsc :1t'lCr

tilg"I1l' Jnd

(2)

SC I,

pre\t'l1ll'd two 1;01l"1."I\Cnl linding": (I) erec t i le

Llp.h.. ,I) I..

prl.'.IIl;r In UMN It;!'Iion., than in LMN lL'~ion ~, tncornplctt" lc:-.ion:-.

I.."ll'l't lk l';tpituty I ' greH Ic:r In

Ilull III ~ tllllpklC 1r..'''IOlh I hcle ,III,.' 1\\0 I) pc, l)lt'rCCliol1': ~hllC.C.'llll

\\.1\

d"Oc.:t:lled \\ IIh tnlpalfec.1 "'pcrnhltogcnc I

,lOll an m
IIUIl ma) IInprmc cJ:Jculalur) rc'ptm,c nod pnmw(C' hll(hcr .,clIlcn quail!} \b-1 The -.clnen 'nmple\ rroom'cd .IrC u'-t~c.I

for IlltnlutCrine In\COlmJllOn\ Orga~m

Orga,m and ejaculation are (\\.o ~ep'ifalc e\ent, Or8u,m I-. a cognittve, p~ychogenic t!vem. \\ hcrea, Cj,ICUlaliun 1\ a

\1i.1., R" 'poll'" \

01 knlll!}

9..&9

RI.."Il~'\()!!cnlc erCCIIt1lh

reflexogenic and occur

ill

P~Y­

re~J1on:-.e [0

phy ... ical occurrence. Relfilively little Information I-. av~u)­ able related to [he of SC i on org",m. Th" agmn re l:u(!s 10 inhercm diflicultie~ In collecllng . . uch dalu. ll iggi ns/'!5 also ~ugges ls (hal the fey. sludie~ Ihat have hecn done have demon:..trated se rious methodological naw,. lie idcntilic~ the major problems in thc\c ~Iudic" us n lack 01 crit(!ria for delining orgasm. con::,idenng ejaculmion and orgasm as identical evenlS, and a lack of reported dilt~l on ho\\ subject:.. achieved orgasm. Accurate dm ..1on the etTecl" or SC i on mule orgasm arc nOI available.

Female Response RcI of\\omcn f{)llowing SC I hnve been considered relatively unimpaired and givt:n comparatively lill ie rtltenliol1. Ho\... evt.'r, there b i.I growing lI\tere~1 in femnle .... e~u~iI respon ....e 1'0110\\ lllf', Cl.c¥l 7.1

e\ll·m.11 ph\ :-Oletl , lItnuLl1lon 01 Ihe- gCIllInI" or perineum . -\0 IOt,llI rdll"\ an.: I... rl..'qlllrcd (mcdt;1lcci Ihrough S2. SJ,

F'cmnic ,>;cxlI;11 rc . . pol1scs al~o [0110\" 11 pntlem rclrucd to loc;lIil)n 01 J...~ . . ion, In patient.... \\ jIlt Ut\ lN le:- Ions. th(' rene\

crt'ctH)il' ()l'cur through eognillvc They :Irc mcdlaled from Ihl' hr.tI ~ntln. t'llhl'l Ihmu),!h tht.' Ihor:lcolumhnr or ~:lcral

arc Will rcmnin iniac!' Therefore, compone.llI . . of :-.c\ua! :troll,JI (\agin:11 lubrication, engorgclllclll of the labl:\. ~\nd dllOral ereclion) will occur Ihrough renc\.ogenlc . . llIl1UI3lion, hUI p. . ychogenic re . . pon . . c will be losl. C01l\(,l".cl), wilh LJ\lN le,ion", p. . )chogenic re:-,polbt!~ \\ 111 he prc.,,(' .. wd lint! renc\ rc:-polhC:o, lo . . t.

and S4} P"cilogt'IlIC

a
(t)ft\ H'!lIa.. I,

\0

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' Iud y hy C()Ill.lrr,7 c\ul11incd ereclik c:lpubi l-

II\- In "'2~ {1,lllt'!1h wllh ,lktllh ,ll 'n

LIMN ie:-'IOlb. lit ... Ilndlng:. indi

r)(,:rl,.~'nt t){ Ihl' p:lIlcnh with comple tc le:-Iolb

.IM 'IX fk.·r~~·nt 01 Ihn~l' Wl lh IIIl..'l)mpkle k:-oion:- had I'"tlt.:'\

CrC."n iOlh. [hl.1 W~'ll' :aI,o C()l!ct'lr,;d on 15-+ Pil l lCllh "'!lh 1 V1'l k'Hllb . 'n Ihr,; grnup wnh completl.." LMN It Inn 7.1 rx'r~~'n! h,ld no crl.'i,.:' llon\ ;tnd 26 pCfl'l'nt h;ld ert'ltl(lO, on l)l hy p,yc.iltl!!l'tllt ... 1lIlHl I I Wilh IItcnrnpklt' I \1~ k"ltlfl', X, pl.;"IH'nl h,1(1 t're<.:IHllh, hut illl h~ p ... y. ho~ Illt Illl'.lIh Drup II1h:rvclllll1ll 11111)' :11'0 hl' 1I,~'d lil ,\,11 r;r~'~111c tUI1~lltlI\ 111 ,nllW (,hlilellt',

°t-:t'f11l

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e)lIul1.illlln \,\,1 111

(I) I J\IN

\t'r"II' : hCT If."HllClfd Inlnn" .HIlI (\) 'Iltompktt' II" ,.:olltll·IICd 11i.ln \l,.lIh l MN It'''lol'', (::!) Iowa kwl

In

(t111lpkh- It- Itlll)lo .'·'

~h('nh \,\,1111 \( I .... t·,t·

11 I'IOIllull j, 1l'I.IIIVI.:I, Ie" .Ihk 10 "Ifl' t hlititcil 1111 " 111\\ !l-\t'l

J\ ICII:-.I rlln t ilUl

Till' mClhtrtLll cycle Iypicnll) I. . inlcrruplt'd for ;1 period t1f I In J 11l{)nlh~ followin~ injury, Aftl'r thl~ IIIn~. l1onn,1I nwn,e" rC1Unl, Ft·l·tilil) nnd

1·I'Cg,flU Il<:)'

I hl' pnll'1H l.tI lor COIIccpllon n.'I1UIIII' IJlllIlIP,lU\~tl. Pt\'~Il.U1l·~ I" po""lhk tinder do . . e mClhc;ti "Upt'1'\ 1"1\)11 lIl.t"nllldl .1' Ihl~ Pdlll'llI I' phh,,'l'tI lit Iligh n"k lor 1Il1P;1II't'tI ,,·,plr.IIt)1'\ tunl· IIOIl In IIddlllnn, l)\\ Illf:, Il' Ullp,url'tt "I,.'I\"iltH)lllh,' 11111[.\11(\1\ t)t lul)\H' 11111\ not lx' !'X'I't'l'IH'd I ,Ih(lr ,1[.,0 m,l\ 1'1't'~·lpll.lI(' Ih(~ OIl"l'1 (II "UUlnnnlllll,' ,h "1\'l1l''\I,I Ct)lbt'qUt'lIlh, 1',1I1r..'nh .11\' Iil'qUt'lll!\ ht'''PII,tll/l'd 101 ;\ !X'IIl,,1 nl IllIIl' pUllr 1\\ lilt'

~'\.I'l't'll'd·

dl'!t\l'n

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n'f\ Il,tI dd,tlh1n NI

\llhOll~h 111l'lllIl' nHIII,ll·IH1II" .lIl· Ih)nthm,lll~ ,,:t\tlln\lkd

.Ind Ihll .1Hcl. 1t.·J In p,lI.ll~ "I'. p.IIU~·Ilt-. "l1h .111 in.thlltl\ W

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C\~nl'nL"e PH'llll;~t'\llW dlllKUh lill~)r tIla~ be I,'andldi.llc .. , Illr l.'c ..JI'\".lI1 .....·I.·lhl ll

h1l Ihc ph) .. Kal therap'",1 rcg,ml th.1I .1 p~IIICIlI \\ III often lllrel'l qU~I."lIlln .. Ill· tht' md" ,dual .. \\ IIh \\ hOI11 11l.' or .. hl' fect.. nll"l ('omh'rt.lhk~. II ,.. Iwt Ul1l.'lllllnlOIl for .. uch .1 dl .. cu .. .. ll'll '" ,m"t' dunng.l ph) "'l'at theraI') ..(' .... ion. The .. e lJue .. 11l'"" ll' I.... ue .... hould LX' .lddre .... ('d ope·ill) and hone~lt) In addlllllll, the tha;ljll .. 1 mll .. t illlllcip.He and be prepared for Iht>e .. lIl1~ltion .. b\ (I) obl.linIng accul.lte infonnation .100111 Ihe p;lIielll\ j'h):oilliogieal ~ I ale and anticipated .. e\.u;,1 hUll.'lion .• md C~) hin ing }.,nO\\ ledge of referral opllon .. .md "urpon .. el'\ il.·e:o ;1\;\ILtble 10 the patient for appropri;]Ie C\..U1l111.ltlon and coun:-.cling. \ 1ll.'Illl l'llll .. ,del.lI,on

lilt! .. nu,11

lh .. fun . .·'h\J1

, ..

indirect Impairments and Complications Jndn Idual .. \\ Ilh SCI are at great ri .. k. for .. econdar~ compltc.lllon .. dunng acute hospItalization and rehabilitation becau ..e of prolonged immobilization and the "ide-rang.ing effeeh of the SCI on multiple bod) .. ) .. tern ... The ' alional pJOal Cord Injllf) St:lIlstical Cemer reported that onl~ JR ..' percelll of p~llie:nh did not e\perienet' a .;;econdar) medical complication. The 111ft~e mO .. 1 C4..11111110n .. econdar~ cOT1lplication~ \\ ere pneumo1lI~1 (3-1...1 percenl of p~ltlents) follO\\ed b~ press ure ulcers (33.S percent) ~md deep , ein th rombosi (lS.O percen!).': Respiralo~ Complications Re .. pirJtof) ') ~tem dl:-.ea ..e.. Mt: the 1110q common C.lU .. e of death for indl\ idual .. "ith SCI. \\ ith -1.2 percent of lhe ..e

ca....e .. ocll1g pneul11oma.:: \\'eaJ.. and or pJ..r.ll~ It'd l11u,de .. of ImplrJIJOn lead .. to reduct'd \ entilation of Ihe lung .. InJdequJte or ab .. ent "lI"t~ngth of coughing l11u .. de .. l11 . tk.e .. II dltlicult to clear "ecn:'lion". Thl" lT1abllit~ 10 dear .. ecretwn .. lead .. to .1 build up of tluid in the lung ... "hK'h ('an re .. uh III J.lekcIJ .. l.. and pnt'umonia. Pre"",ure Sore. Pn: .... u~ .. ore .. ~decubltu .. uk'er...) are uker..UlOn .. of .. oft 0 .. .. u(' ( .. }.,m ~lr .. ulx·ul.meou .. 1i .... u(') cau ...ed b~ unrehe\ed pre .... ure .md .. hearing hlI'\:'e ... nle~ are "u0.1tx·t W IIlttXI1~'n. \\ l11d1 1,..111 1111gr.ue W t-M,lne P't\: .... Uf(' "I.'re ...W .1 ..enllU .. Oll·JI ....1I l..'ll11lpIK.ltlOll. a 111.I.I\'f 1.'.lU .. e \lf del.\~eJ rehabllll.JtHlf1. and ma~ e.:\cn 1t',IJ tllJeJlh. Pre .... u~ .... ore ...lre al1l\'lh! lhe 1l11'n: In:"yut'nt I11t'dK.lll.omrltcatu"n .. tl.'"l1\\tI1!! SCI':-" anti Un"' an Imp(ln.ml I.l...·h'r 111 ml'rt'.l .. mc dur.H1l1n .t;ld '1I~qut'nlh I,.o.. t ", h,l-.rll.lI "Ia\ JOl(\am."t1 ~ I~ IUlh.:tl\lI\ .U1d tht" 1Il.1~11t1\ tll n1.\~\.· rrmpn.llc 1'" ItIOfMI dl.lll,l!t·' .l~ th~' 1\,,1 111l"1 IIltluenllal t \ hx 10 th lk"\ dopme.: nt \,t pre.: .... un.· "l'n· .. nth ~r 11111 'r 13111 I lor: an.' I) hl ''(It \ 't)flh'h'r l..l'IHnll. \\ hl~·h I\",ulh III Ill"l"'nng ,'I II UI,.· rr ... tJnH hl rn.' .. un.·. t~I"r,l .. tI\..Il\.

"l1h le .. ull'lI1t .. he.lring lorr.:c .. hct"-Cl'n ... urlac.:c~. n, . kin mu rl' ration Irol11 C\JX1 ... ure W 1ll00..,turc (e.g, unnc); 14) If.IIII11.I ... ueh"l\ adhe .. i\'e tape or .. heet hurn .. : '~J nUlnllo . n •11 ddiuenr.:lc ... (10\\ \erul11 protem and anemia" III redu<;t li .... ue re .. i..,lance to pre .. ..,ure): (6) poor general ... kln COl1
Deep Yein Thrombosis Deep \enou" thrombo .. i .. ID\ i ) re .. ult ... irom \ ... of .1 thn.... mbu .. Jbnomlal bh..x-xl..:IN \\ Hhtn J \ ... ' l"ll.XUfITnce \'If -.;u('h a clot i .. a dangcn.: u.. nll.:J ... CJIll1n. II hJ .. the potential to bre.J... free llf t .. J. .md tloal freel) \\ ithin the \ enl.)u" hl~ tf(' mobile dot:- are no\\ n 3.... t n , The) .>If' h~el) to bl(1("~ pulnwnar: \ e.. I.. rulm lnJJ"\ (; \\ hlch I..'an re"uit 1I1 deJrn . . The m\' .. t 1111p..."IrtIDt fJ(,l0r cl'ntnbut.n; w t: r.. l11('nl (If 0\ T ft..'lIl"'\\ mg SCI 1" ,,"I .... (,f tht' '11ml

er elln\..' ·ntr:.ttion.. l,f

de\ t~~~'r

rn.. . . .'(l,lgulmh

e;.

k...·;l(llt.·J :.lre.;} ... Thl" to lum ~ .. tl h ' ... [X' .. III(\n 10 thl\.,\mt'll .. (I.)mutt\ n, '\,\11n ... u1.1I11" .In~ rarldl~ mi\..eJ. \\ IIh .i~t' ~Li.dlt1t ,: .. l to n.·lI1l'h'd III tht' h\t'r.' The n .... \,t D\ T.lft' \\ IIh .i~r..' .mJ rmll n~cJ rre .... ure t~ f ag.Hn .. t lhe tx-J I.'r "Ur(")rtlO~ .. urt .... (,. I.·.m d.l111.l~\.· the \ I.~ .... t'l \\.ill JnJ rrl'... pilate Ihl' ... h'tLn~ rn: t' .... In a ...iJlhl 1 1\ .... l't \ J.IlJ lmnhl~\lll\ runha . ·nh . n...'e th . ·l')(...· . u ~lf D\ 1 Oll1 ... r ...'\,"lnNtlOf. tJdl.'£' m..·lu III

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Chapler 23 Traumatic Spinal Cord Injury 13 gcne ral1y di ...couraged. High- protei n foods loi uc h a ... meat .... \\ hole-g ra in prod uc ts. eggs. and vi tamin -rich foods '1uch a . . cra nberrie ... or dried fnllt (e.g .. prunes or plu ms) are encouraged. In add iti on. the risk of calc uli fo nn at ion will be reduced by prevention o f urinary trac t infect ion ... and careful maintenance of bladder drain age to preven t urimlr) stasis.110

95.1

int ervent ions from the onse l o f inju ry until the frac ture Slit: is ... ta ble and upri ght ac ti vi ties ca n be 1I1luilIcd . The reha · bi lll ali on phase incl udes suggested treatm ent ac ti vities follow in g miti al on enta tl on 10 the verti cal pOS HIon through prepara ti on fo r d isc harge from the re habilit ation faci lity.

Acute Medical Management Phase Prognosis One of the mo!-t common q uestions that pati ent s and families have after a SC I is how much recovery of motor fun ction wi l1 occu r. T he potent ia l fo r recovery from SC I is directly related to the exte nt of damage to the sp in al cord and/or ner\'e roots. Donovan and Bedbrook llo have identi fied three primary influences on pOient ial for recovery: ( I) the degree of pathological c hanges im posed by the trauma. (2) the precaut ions taken to preven t fu rther damage du ring rescue. and (3) prevention of additiona l com prom ise of neural tissue from hypoxia and hypotension du ring acut e management. FOmlUlalion of a prognosis is in itiated after spi nal ..,hock has subsided and is guided by whethe r or not the lesion is comple te. Following spinal shock. a lesion is generally considered complete in the absence of a ny se nsory or motor function below the level of cord damage, with no anal sensat ion or motor func ti on present. Early appeara nce of reflex activi ty in these instances is cons ide red a poor prognostic indicator. III With comple te les ions, no 1110101' improvement is expected other lhan that whi ch may occur from nerve root return. An incomplete le~ion indicated by motor fu nction belO\\ the neurological level of the lesion with sensation and/or motor ana l function intact are good prognosti c indicato r~ of a likelihood of Significant recovery of motor function. - J It i'> important to note that wi th most incomplete ie'!ions improvement begin') almost lI11medlatel] following cessation of ~pinal shock. Many pallents will have ,>ome progressIve Improvement of mw.cle return. It may be minimal or, less frequently. dramatic and usua ll y becomes apparent dUfing the first several months follow'ing injury. With a consistent progression of returning function (dady, weekly. or even monthly) further recovt!ry can be expected at the samc rate. or a sl ightly .., Iower rate. Meticu l ou~ and frequent examination of se nsory and motor functions during thl'l period will provide Important information about the progression of recovery. In I1me. the rate of recovery v. ill decrease. and a plateau will be reached. When the plateau is reached and no nev. muscle aCl1\1ty ):-. ob:-,cf\o'ed for scveral weeks or month .... no additional recovery can be expected. The rem:.l1nder of thl.., chapter is dl\'ided 11110 the .H:utc medical management and active rehabilitation ... tages. The .,eetion on acutt: management addre ...... es treatmt:nt

E m e rgen cy Care Idea ll y, manageme nt of SC I b eg in ~ at th e location of the acc ide nt. Tec hniqu es used in movin g and man aging the patie nt imm ediat ely foll ow ing the traum a c
Fracture Stabilization Reduction and immobi lizat ion of ... pi nal inj uries can be achieved 'V ia com,ervilI ivc or operati\'e method .... There i... no clear evidence ... upporting the use of closed reduct ion over open n::duction or vict.! versa. I ~ Animal studies have demonstrated improvcd ncurological reco\'t!!) after earl} decoI11prc . . . . ion~ hm'vc\'cr, c~a(.;l time fml11c~ for ..,urgical IIltcf\o'cmion in hUlllan'! 11a~ not ~cn detemlinoo. 1J Clo-.ed reduction can he adl1c\cd with the usc of traction device .... Tr.u.:tion can he applied by the u . . e of long ... attached to tht' outer ... "ul\ (Fig. 2:\.5) or by" halo deVice (Fig'. 23.6 and 23.7).

954

PI" .. icaJ Rehabilitation

10 welQhts

,,------

1

Figure 23.5 Cervical tong~ . (Adapted from Judd. E led]: ;o.;ur;mg Care of the Adult. FA Da\"i", . Phil adelphi a. 1983. p .l82. \\ Ith penni .. ",ion .)

Figure 23.6 Halo de\ Ice on an indi\ idual \\ Ith a cen Ical coni le .. ion.

Surgical decompres!.>i on and stabili zat ion ma y be indicaled in patient~ with deteriorating neurologi ca l status. instability following closed redu ction. unstable fracture site. and bilateral facel di slocation .J .5· t1o. t1t Operative treatmenl usually consists of an anlerior or posterior arthrodes is with plate or rod fixation . Surgical intervention may occur as early as within the first 2-l hours postinjur). Prolonged bed res t in traction is on I)

recommended \\ hen other treatment option .. J.re not aya il ab le .1

Immobilization Follo\\ ing reduction of the fracture ~Jle. through caher conse ryaUyt: or surgical mean~. the ~pi n e i ... tmmoi1 lzefor a pe ri od of time through the use of tong .... hal" e\o L turning frame~. bed ... . and ortho~e ... to allo\\

Figure 23.7 11k r'Tll~n' \ lanJ...lIld lcdUl~ll~lC \ f'\ I r ~r.lrilltl· hail' '~'IC;\1 I" \I RI n'lllr. l1lhk IClllllll'''\ P\I r l rr Ch.Ulh.l ...... cn. \1' :':" .,

lOll/!' ""fH'r,tl (\1'....... of tOIlV'" ;\II,,' .I\,uLlhll' <..... !! .. ('llIllhlll'hl, B.IIII'Il. \1Ilk. ..' (i,lIdm'\ \\l'II'1.l';I\, h \\lIh ,\ 'lit!hlly dllh'1 enl ~k'lcn I hl' IOIil" ('I (.ll1pl"'" .Hl' lI1'l'lh.'d tatl'r.llh 011 tht' \lutrl 1.lhle {,I thl' ,kull (\l'l' II!! 2'.S) 1",.I4.lIon" . "tlll,h,hni h\ ,1I1.llhl11l'1l1 01 .I II,u..- llon (Ollt.' to till' ... kllil .I~l fi,.IIH1n \\ IIh thl' p.llll'l1I III

;J

\Upll1l' pO'IIIOIl. 1111'.. mpe "

Ihrl'.ukd IhTl1Ugh .1 pull ..,) or Il;tl'1101l (ollar \\ IIh Wl'lghh ,I[I.ll'hnl dl'.I.llly. Ihl' \\l'lglm. himp 11l.'l'I) \\1\hnUI touch 111£ thl' 1l11(1I Innl!' ,Ill' u\ ..'d prim'lld) ;.1\ ,I Il'mpol.IIY IIll'llk (11 .. "l'klal 11.1(11011 \\ IIIl Icplan.·menl \I',lIlg ~l haln Ill" Ill'

lIalo III \ in.'''' 11.111) I,

.lrl' lhl'd commoll1), to 111111lohlll/1' cervical rhC'l' traction dl'\ ]l'C' {~cc FIg .... .:!1.6 and \\111"-1,1 (11 .1 halo ring \\lIh lour ... tcl'! ... cre""'''' ~h ~hfl.'( ll) 10 the outa ... h.ull . rhe halo ]... Ill"

tr,il(1l1l" ~~

111.11 ,]It.]l

po,t Jl'\ u: ]11\

,I bo~l) .1dC\..ct or vc ... 1 h} four \'l~r1lcal ... Iecl IIH' In tht..'][ ,trucl III'ill cOllfigur;] lion, thc ... c

h I

\l

()

01 H,li

J~\I~1 1

I]C (ol1tl .undu.:aled wllh ... eVefC fl""'p]ratof) !l1,'nl. JCVll'l"

ha\'I..' ... cvcral

important

n:dtlC: 1Ilg Ihe ... ccnlld~lI)

ad\,~lI1tagc ... ,

cOlll plic~1I10n ... 01

I hc)

pro·

IOll~cd ht:d fl· ... !. pt..'rl11it carlici J1rogrc~"'lon to upright aCliv ·

]IIC', .llIn\\ c. ulter IIWOIVl'I11CI11 111 a rchahlillation program, and h:dUlT the knglh and co ... 1 oj hO'l1l1al "Ita},I " In ad<.iI I1nn, lor patl t..' l1h \\ Ilhollt neurologica l I11volvt:Illl:llt, dl\ dhll~l' h0111 tht..' ho,pllal Illay occur day' alter appliGliiOIl IIlhl' It.llo tin ICl..' lhl.."c pi.illCnh arl..' lhen followl'd 011 .. n IlUIP,III<"1l1

hil",,1 ,

r'QUtn 23,8 I 11\ I ,II c \ \ .tll,1 .1111\ t ~ 'fI,'t'c\\ nl til< h,,,d \ \\11.11

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llIi1td) l' \'tt..T~" I 'IJ IIIJ",III~' It'lI1o\,11. .1 H'IVI(.II ""hi, I r ilpplil',1
I flod f,tppro~l1Jl.lIdy 1 ttt (, 'he ler

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110 Ol\.'lpll,II l11illHhhl1l,II 1I11111Ohillll'r (~()\111 ((,I",cd 011111"", hal'd loll~lr (hg. 2 qq III lu\IOITl Itl.ld(" pl.l II (oj 1,11\ 'IIl' Irl'qlK'l1lly u\cd dllllll(! 11ll' 11.111 IWIIl pt.'fIIKI \l,llh progll· ...... I011 10,1 ... 01 1 lo.ulI toll.tr p"or III If.'''1l1l1lng un up P()flt..'d 111(IVel111'111

Turnin g

Frlllll c~

lI ud Bcd..,

Sl..'Vl'J;11 typl'\ 01 hillllC\ and hed . . are u"'l'd lor IllllJ1ohill/<J linn dunng the acute pha\e of ctlrc I":ac h hi! ... dlflcrcilt dC'Ign Chill'illlcn ... l lc\ dlld functlOll', I\l1lnng Ihe 1110\1 c.:olJ1JlHlnly u ...et! willing trallle ]\ Ihe Stryl-..er frallle I I c.:on'I'l\ 01 an antellOf' ,lilt! po~lenor Iralllc attached 10 it tumlllg l\e (hg 2.19), In IlIl'lllllg from ..I \UplllC PO"'IIIOI1. Ihe •.IIl1cnor frame , ... placed on top of the patient. A ~lrc.:lIll.lr ring ,I;.I111P'" In place to "'C(,'url' the IwO frame\ during IUmlllg. SJfel), ... Irap\ pnwide atldilional \cclirity. RotatIOn 10 the prone po"'IIJOn I'" JtTompll'.. hcd hy 111i1nually IlInlmg till: two fmmc\ ..... iJ uni!. rhe UPIX;llllw.. tlrillllc i ... then rl..'lllowd . Return to the \upme pn\,tinn 1\ accompli..,hed III the \al11C manner nlC primal) Ix;ndit of the ...c devlcc.., 1\ that they iJllow po.."tlonal ch~lngc\ \~hilc maintaining
o.

or

IIHIII~ '1 tl "'In'" '"1 1111\1 II 111\ 11"111" ,\,1 t1'~\II"IJ1 I..dlln ",\ \11 IIJIlI S I

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11

,,"11

Chapter 2.' Traumatic Spinal Cord Jnjury

Physical The ra p y Examination During [he <1l.:ute meJlcul managemcm pha\c Iherap~

h\,,\(JI

i.I

general

C\;.}11l1natlon 01 the patient I'> Indicated,

~!1l:ludtOg

rc"'Plr..lIor) function,

J ...... l... t [h~

therap''lt

\~In

condition. '>cn,)<1tion,

{l,n e. nlu . . de ... trength. and functional mobility. Re~ult ... will In

dCICmltning the IC'Jion level. idenll -

h lIf f.enerJI fum.:uonal expectations. and fOnTIulaling ;rP-0pna[~ treatment goab.. A'l noted earlier. the lesion level ,,~on"IJered to be the IO\\CSl segmental level in which 110fm.li mu,,'le ,rrength and 'en >at ion are present bilaterally. DuriDg the acute srage. ,pinal l",tability often preclude; a morough ph) '\icaI therapy examination. However. gross ~reerjng \\lll prm ide important initial data until the patient ,mcli"LlI) 'table and cleared for further activity. L . . :: 00J... for documenting results of the examination ~-e "CSC[ (Fig. 23.2) and the ASIA Impairment S- e T", 23 I) developed by ASIA. These tools improve ~_."

7111 n of the examination process for patients , ,C and "ere descnbed earlier.

Resp . on ' Examination De'"......... 3_

_ plrdlOr) ...,talu~ and function are eS5entiaJ. The ed ""Io\'. ,hould be addre,sed.

function of Respiratory \luscles \L • < J""gth and tone of the diaphragm, abdominals. ;tats ,hould be examined: respiralDJ) rate ,hould

"'"JJtr: =.

:e

Cb<s:t Expansion C ,.C"'ereolial mea;uremenl, ,hould be taken at the level , -~ aXilla and xiphoid process using a cloth tape me"", Cr-:0 -.6 tmJ at the XIphOid process.'

_=

==IOIl',

B·ta1hi~ Pattern r.-."...- -,atw- mould be made of mu'>Cles thaI are func, "'-..e ,. coombulions 10 re plrauQn. Thi1i rna; be

accompli..,hed hy manual palp,Hion over the chest ,tnd ahdominal region and by obl.,crvalion. Particular attention ... hould be directed toward Uc,c of ac(;c~"ory neck mu\Clcc; and alteration in breathing paUern when the patient I~ talkIIlg

or moving. lIS

Co ug h

Coughing allow~ the patient to remove ~ecretj(}n~. Ineffective cough function will nece~~Jlate I,uclionlng to avoid pulmonary complicationc.,. Alvarel et all h~ve defined three cough classifications: (I) j;'IfICIIOIIOi, wong enough to clear secretions; (2) weak JunClirJ/lol, adequate

force to clear upper respiraLOry tract secretion~ In small quantities; assistance is requi red to clear mucus c.,econdary to infection; and (3) non/ullc/iOIlOI, unable to produce any cough force. Vit a l Ca pac ity Initial measures may be taken with a hand-held spirometer. llS Vital capacity measures also can be used a~ a baseline for defining respiratory muscle weakness.

Integument During the acute phase, meticulous and regular skin

in'!'pection is a shared responsibility of the patient and the entire medical/rehabilitative ream. As management pro~ gresses into the active rehabilitation phac.,e, the paLient will gradually assume greater responsibility for this actiVity.

Patient education related to skin care Ie., crucial and .c.,hould be initiated early. Frequent poc;ition changec., and \kin inc.,pection may be viewed by the paLient a ... bOLher~ome or distracting from !)!cep if there is not adequate awarcne ... \ of the importance and purpose of the\(! activilie't. Skin inl,pe<> lion combJnc~ both visual ob~rvatJon and palpation. "I, The pauent's enUre body .hould be ob;erved regularly wllh par, ticular attention lO area.:; mo... t ')u';Ccpllblc to pre!ot\ure (Table 23.5). Palpallon " u;eful for IdentifYing sktn temperalUre ,hange~ that may be indicalive of a hyperemic rcat.:tlOn" Tlu\ I~ particularly important III c;xaminlng IIldl\>iuu,l!\ ","uh dark "km, because early ... kln re"poll~ to prcs!<.ure

Sap' • _ _",P :.:':"::"::I=-_ e • Ears • ShouldErs lIal(jral ;JsPQcr1 • Grealer

,

He~d

• ¥J

01

t(och~nlfj(

IitJul~

(j~ lml~j

aJ a

p4:~<.:l

Irom

VJ( \;;l..1btJ' II{Jfjn knlH;bl

........,

957

• La" ral rn.aJioOkJl Mad II IcrJf 1&(. tft11 "f
tteoIU$ )

I1M\ nnll 'I"\',hlll\ ,11'1'.1",'111 "1"11\ 11.'. ldum, It) 1,.'\\,:1..'" IUI.·'

111U\l·II,I,.·11I1H:I,.I,.',.. II,lll'd h\ hl!ahn .lUd pPt IIllalh

lIltllldt'll'dll1..·". "~.II \\.llllIlh. hk..,III,.·dl,.' III;I, .tIlO '1Il.111 oJ"l'n (If If.llh'd '''Ill ,III.'.h. CUt'lul .llIt·1111011 , huil id lx' lil n'l (l'd h"'.11 d .Il to: ,dl'IlI.,1 ," III ;Ihl ..... 1011 ' or hm "1..". \\ h Il' h 101.. n:-.I'c,' Ihl,.· JXu . . IlII.11 11.11 '''Ill hle.lkdm\ Il . II, It Ih .... P;lIII..·111 I' \H·.mn~ .I h.llo. \t."1 or olhl..'r Ol1 hOll t· dc\ il,.'C, nUII.ltl l'tllllh hc:1\\I,.'I,.'n Ihl,.' h{KI~ ,lI1d Ihe appli;IIKc,' IIlU, 1 ;1I .. n hI,.'

I I .11I11I t' "Ill.'''

"Tt

IO"x'\.·h.'d

S~nsation -\ d .... l,iilc.·d C\illlllllalioll nl ,upl.'rllcial and ucep '1..'11'> <111011\ ,hould I~ clll11pll'll'U (,el' Chapler 5). Parti cular 1'I1lpha'I' ,hould he placed 011 pin pn ck ~I nd l igh t louch re-'poll ... l· ... (I)pically u...ctl 10 iden ll fy ... en,ory levc l of II.! .. ion ) ;" wl..' lI .1'> propriocepllve re'lpOIN.!'1 . A.., noted pre\ iou .. I). the '1CIl '101) le\ el of IIlJlIry may nOI corre .. pond 10 Ihe ll1otOi It'vel Of injuf)

Tone and Deep Tendon Reflexe, .\lu'lcle (one ... hould he cxamillcd bec C hapler K) \\- lIh Il.'f erence to qual ity, 1l1l1 'c1c group, IIwolved. and faclOI ... Ihat appe~1r to incrc:,..,e or 10 dcc rt.:a..,e tOile. An exanllnatloll 0 1 deep tendon reflc xe~ i , II1dl(.:~lI ed. Level 01 til l.' Ic"on \'v lll mllucnce th e .. pccdic tendon, ~clec l cd for te'llng. 'I he deep tendon rcll cxc\ 1l10 ~t commonly CX~Hllil1ed and Ihl.' l!' levcl\ innervation nrc the bi cep' ( 5), ex lCI1 ..,m carpi rad",lus longu, (C6), tri ceI" (C7), quadri ce ps (U), alld

or

ga~lrocl1cmiu\

(S I ).flM

Manual Mu.c1e Test and Range of Motion In addition 10 tc ... ling the kcy mu ... cl e~ id entified JI1 th eISNCSCI (scc Fi g. 21.2), other nlU ,c/e grou ps , hn"ld he t e~ led throughout th e m yolomc, thai have lilt act IIII1CrVi.1 tion. For exampl e. If thc C5 myolome j, inl
a,

functional Statu, A dctalled. accurate, and !lJX"l:lfic determinatIOn 01 IUIll: 1I0nai s"III"i u!l.uall) delayed unlll Ihe aLlI\C rehabll".1 tum Mage ~hcn thc p.ll1ent 1'Ii rncdll:ally Mahle .lIul dc'llcd

I"

for Jtll\IIY, An HlIlial M:reelllllg of lunl:lICmal ahllll) Ulay he- done dunng the e.lrl> &.I(;ulc 'li14.lJ,!C. hUI Ihe thcrapl'lil mu';t he 4.1~ arc of an) e,:nntra,"dl(;allon~ or prcc.:alJlloII'j, II)

J

Li

Ph y. ica l T h e ra p y Inte n c n tion DUIIII!! Ihl,.' ;\t.:ulc ph;hC emph,1 I" I p1.ll

I, 1\ r p r I plC,'\1.'1I110n 01 Illdlll·1,.1 IlIIpalrTTlt'UI t l'Omplll'iIlIlUh, 1lI;1IJ11.IIIlIIll! l{()\1. ,Hid 1.ltlltt .. lltI lllovl.'ll\l..'nt 111 a\ "IIahle III u ... nd.IlUlc,' P\,'ndlllg (11th I j l·k',lIaJU..·l', 1IIIlllcd 'tll..·n~ l hl,.'lllllg ,ll"Il\ IIll'.., .Ihu iIl.l~ h(' In Ildlcd dU llllg Ihi 'l carl) pha,l,.· I llall,l~I..·lIll'I1I,

R(.·'pirntory Maiiagt' lnt' llt RI.''1j111 ;1I01 ) 1.... 11\· \\ III \M) al.'t·olllilll! 10 ,hI.' k'\t'l 0111\111I\.1rk.I IIldlvi ciual rl."p lralO!') "Ialll'. PIIIlIiIl') ~o,tI, 01 lll.tII,I'l·mt1l! IIldutlL' IInpl oH·t! \CllllbuOII, II1UI.:,I ..l·d 1,.·lkllJ\I,.·IIC' (II ulugh . ;lIld prcn..'nlLtl1l 01 d)I,.· .. III!!hllw ..... \JId mdh;C,IL\1: llh. ..,!llull..· hrt'dlhlll!! fl;ll ll·m... l A-pl·l1thll).! tlll 1111.' IIIdl\Lllull P:IIK'lIllhc lollm\ Lng 1Il.';UlIll·1I! .IUI\ IIIC," 111.1\ I'll.' .1]'PlllpO.11

I)l'cp-Urca lh illg E" I' ITi .. c .. J)"lplll;tgm;lllt· hlCillhlll~ , hllUld ,,,"' l'lInHIJ.I~l·d Itl f,I,.IlI laic diaphral-!Jllalll' 1Il0\CIIII,.·IJl alld lilul·.I'I,.' \1I.111,..lp.I,11\ Iht, IhL'lilpl ... 1 (;111 ilpply 1i!!ht ph.· ..... url,.· ~hlllll~' hUlh III (lLf.1 ILOIl ;llld 1,.·\jlll 'I!IUIl M,Hlllal Ultll.IL" ldil ht 1II,llk JU I hl·lllW 111l.' .. 1l.'lllJ llll I·hl ... \\1 11 .1 ...... 1.. ' Ihl,.· 1,.l ll t'ill hI 1.:1111\ II !lalC Olllll.'CP h rl.'a ll1Jll ~ pa!lc,·I Il .. 1,.'\1,'11 111 thl,.· ,dl,I,.·lIll·tlllhH fil l' It· and Hht!llIllln;tI 'l'n"I\ IOIl 10 I.ltllLl.lh· l 'p".11I1l1I 111:11I1L,,1 (." llillilll, illC 1I1illk OWl 111l.' Illtll,l\ \\ lIlt till It.llld :-opl l.'ad Wldl'. I hi ... lTc;lIc,;\ l'OIllPII'''I\L' hHll \111 1111 lhll 1';1\, fl· ... ulll llg III ;1 1l1011' Il1lt·l, lulL' pLI.IIIIIII lullll\\ d It) .1 Illtlll' 1.' 1111.'11..' 111 II1"'llIIaIH)J1 It, 1';1I11,.·l1h 1I11111ohtlii d \lL Ii"l tllll\ dL·VU,:l· ... 01 llllllll,.'d 10 Il,.'lllllllWll1 pll\lllllll III IX-II \II IWIll U,I,.' III ;1 illllrol 10 prll\Jtl1,. \1 1I.t! It til k durn the...l,.· ;aUl vIlIL· .... Inl b lloll holtl.III1II1IHIIIIV jlllt I ,,1"0 II..,I..'!II I ;U1JllIlC.h to dcl'p hlt',IIItIlI~ t' ('Itl ( ;Io",ujl h ar .v n~cal Brealhing 'II" ... ;aUlvlty "olll,.·Jl dppHIP""Ic,' Itll p.lllt'lIl lcrvu.::tIIL·,JOJl,. I hl'lnhlllljul' IlItil /( .Iltl fl'''plI;aIIOI1 Itlllllprow \i Jlall,.ap,IlJlj I hI 1'.111' II n cd 10 In..,p"l,.· ' 1I1i111 alllUllfll of .til 1l'j~·.11 11\ ping" 01 "V lllplllV pallt' " I Iltll' 1I1111/1Il1-' ,t\' 111..1,1 Ill'tk Illll..,t ll". By U'"IJ,! Ih" InllllHltH t /ltlil II III I all y III'I]111l'" 10 11111)1 ()Vl' tlll''11 \'·~p.II"'II'1i (il ]lIlt I ,II

II ,t

Ihl' pnll\wy 1I11I,dl,.'\ of le",lJl,JlIIIII

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uprI!!ht IICI1\tlil" C.111 he il1itl,llcd h} ... 111\\1, the hC'ld of the l~d and progrc ..... lI1g 10 a rcclJn . in~ or tiIHn· ... pJn.· \\ h('clclHlir \\ 1111 ('1('\,Hm!:!. leg fe . . I.... l ..\.' of the tdH.lbk pro\ Ide ... ,1I101I1L'r option for Ofll.'!lllng thl' pattent to i.l H·rtlcal PO,1I1011. Vilal ... lgll ...... hould he monitored ca~full) and documented during th1~ ~('c111na­ tion period. Patient!- \\ ho hun:: been Immobllilcd III hJln dc' ice ... or undergone .:.urgical ",PJIlC ... tabilization "Ill nOl be confined 10 recumbent po~ition ... for prolonged peri. 0(1.... For Ihe .. e patieills. the.: ... ame progressIOn i, u. . cd, ahhough a more rapid advance to the \'cnical po,ulOn ca n be 3micipated .

cll'\ .\lUlg

\\ llh pre" ""oU,," 01 pn>.... ure ro>l<1rx.- '" th< Ix>d~ :mJ
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_ 01 retublli13UOIl. aU remaining mu~cuiJ­ Ho\\c\er. during the ~~ crnam mID if". mu'" be ..(rengthened \ ef") ..'3D1JOIl.>;~ lo:noid ..lJ'e".. at the fracrure ",ile. During me -... r~ ,,~ (olkw..lI1g injUJ). applicauon of ret-htance ~ ~.:'O&U3indk3..led 10 I mlL-..cularure of the ~apula .md ~ m lelr.lplegia and C I mU.!ICulature of Lhe peln; and trnnk m paraplegia. \.:) unpcxi3.Dl consider.lLion in planrUng exercise pro;!3ID> dunng hie acme phase i m emphasize bilateral UE actJVlIJeS reo n ", ~ \\ill 3\oid of suengthening exereis· '" an: "I'I"llplll!le during this earl) phase: bil31eral manually ~ motion; In """gin plane,. bilateral FE propriocepu.-e neuronI1bCUlar facililaliOD W:\F) panems. and progreso .nc ~e e.<etrise> using cuff ,,'eigilis or dumbbells. 8iof. \\lill IelIaplegia. emphasis should be pbced OIl "",,"g!bening the anlerior delloid. shoulder exIenSOr>. biceps. and Iov.er trapezius. If pre<.enL the radial ..rut ~.Irieeps. and pectorals ,hould also be empha· •1Ud bec"me !he) "ill be of key imponance In improving functional capacity. \viill paraplegia. all liE musculature IhwId be suengil1ened .•. Iill emphasis on shoulder depres· ~. b1ceJ>'i. and latissimus dorsi. which are required for and ambulallOll. Early fm'olvement in functional activitie,> ~hould be ~Ieued. In addiuon to their intrinsic \'alue, many activities .fford me Important benefit of pro!?re"ive Mrengthcnlng. For .xample. ",1I·feeding and involvement In Ilmlled per· \tJOaI care oclivilie\ will a~~i~l with Mrenglhening the _"',ulder and elbow Another example of a func· tional aL1ivity (although not appropriate dUring the acute pha'ie' !lith impw1anl Mrenglhening bcncfjt~ i\ wheelchaIr prOpUI\JfJO (deltoid'i. hi(:e~. and \houldcr rotator~). IIIrt'

ilk:lJ

\10

~gtbmed fD3.'lmall~.

Ir"""rer;

no,,,,,.

Orientation to the Vertical Po~ition

rad"'graphl< lindin~ have e".bl"hed "abilllY or rhe fr~turc ,ite, (}rearly fra(;.turc .,labillt3tton method" are unnpJclc, the p"licnt iii cJctlrcd for upright activi!lc\, A., dl"ootU-.Aed, the p"t,ent Iypically will experience ltYlllptom., (If 1X' ,Iural hypotemlon if approa(.;h to management ha\ requJrClJ M,mt perJ(H:J (,f immohillty. A very J!radllal Hccll mOJWm t() upright p')'llUrC iii IOr,.,1 effective. f hc ll.,C of an

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Active Rehabilitation Phase Specific fUllctlOnal goals must be established as part of overall rehabilitation planning. Reasonable functional expectations. at various lesion levels_ for a young. healthy patient with a complete lesion and unimpaired by ...ec· ondary complications are shown in Table :23.6. Thi .. information may provide a useful guide in establishing realistic goals. However. it is important not to adhere too closely to established "nonns" and, hence, to limit the patient by your own expectations_ Goals should be e~lab· lished individually for each patient on the basis of exam~ ination findings in accordance with the level and extent of injury . The term ke}' muscles is a common expre~~tnn in the management of patients with SCI and is used III Tl.Ihlc 23.6. Key mu,cles are
t"

Physical Therapy Examina tion All the examination proccdure ... completed dllflJl~ 11 • acu te phase wJlI be continued al regular inter.. "I .. dun,l~ the active rehabilitation pha ... c. Inasmuch as gn.:ah r pall .,t mobJluy is now allowed, more complete tc ... tin ~ 01 !TIll dt: \trcnglh, ROM, and functional ",h.ilb can he- IX'!' l)nllcd. During MMT the Ihcrapi ... 1 Illll ... l he alt.:rt to thc dl ... llIldJllIl octwccn true voluntary c.:ontrm:tlon and J110\c!l1\.'nt .1 ..... lK:lutcd wnh "'pa'lticity or ..,uh",IJlUll01l A vancty or "!ltIntiardJl(:d outcome 1l1t:a'tun!''t Jrt.:: d\.IlI· ahle 10 the phy.,icul Ihcfilpl ... ' Some of Ihe mOrl' Ire.: quell!ly ll'tcd lool"! arc c.J1'tt:u ....·,ed herc. The / ·lIl1dI OIl i/1 IlIdl'ptII/(Jell('(1 Mea.w l'(l (FIM'I) IS u ... cd 10 JIll'J .. urt" (11'\/ f Ulltffllfl'

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Mobile arm supports, deltOid aid Adapted utensils and spllnllng Computer keyboard Hand sphnts Adapted typing sticks Some patients may reqUire mobile arm supports or slings Same as above Assistance required Hand sphnts Adapted eqUipment (wash min. adapted toothbrush, and so forth) Independent with manual wheelchair with plastic- coated handrim projections Power wheelchair with Joystick or adapted UE controls Dependent Overhead swivel bar Sliding board Dependent Independent with power tllt-In -space wheelchair Assistance required Van with hand controls Part-time attendant reqUired

s

:f:;I""SC"

-..Zl5S-.J..S ::c.r5I

Som dS~ISI(lnCe roqUirod Asslstdnc IS required In sottlng up patlont with nocessary equipment patient can thon accomplish activity Independently

fr;'" per,1

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at; rj prl".. ~

Some assistance to mdepende With use of Side rails on bed 0 overhead triangle Universal cuff Intertwine utenSils In flngi"rs Adapted utensils Utilizes momentum button hookS zipper pulls. or other clothing adaptations. dependent on mo11 n tum to extend limbs Cannot tie shoes Flexor hinge splint Universal cuff Adaptive eqUipment Independent With manu,tl wn ch;:Hr With prOjection or InClion l1r face tlftnd (lms power wtl I t a mal be required lor lon9 j. I me "nd community mobility Indnpt1ndr:nt wllh shdm9 bOdrd on Ie ,,-.,1 url~C(jS Ir rjopend(,rll

ROllI

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E,I

a E

r

r

p~,IIICU~

longus

.\ IS

finger I:txtensors

Elbow exlenslon Wrist Ilexlon Fingel extension

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dlpl Id(.hah~

• Sell care

T

Wheelchair skills Transfers Bowel dnd bladder care

Manual cough HOllsekeeplng

Dnvlng

CBloll F>;lnnSlC finger flexors Fle~or CarpI ulnans rltixor polhCls longus and Dft;lIJ'

Intnn Ie hnger flexor

Full Innervation of U muscles InclL/dlng tine coordlnallon dnd slrong grasp

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qulpm nland tan

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Carl !J~ l1lcJHjlbllrifml With flfjlllprnf",l dtJPOfldlflU ul\ !jlMI 1find hliJdd'lr IliUtlf Irl(iopelulofll

AutomoiJlle wilt, htHld controls dOO U &Ilaped cliff (illadlS!1 to &tb&rmq Wllllhi Usually ffjquues clSEubtanC& In gettmg wtleelctldlr In tu C,t( lImHed particIpatIon (I e tlowhn9 trshlng) Can be Independent WIth OCCd&IUOdl Ilgllt meals WIth dciapllve equipment

Inclepenclent Independent Independent Button hook may be requIred Shower chair Hand held shower non Ie Ada pted handles on bath room Items may be required Independent With manual whaetr.halr wllh fnctlon surface hnnd ri ms Independent (wilh or Wllhout slrdlng board) Independent Wllh approprrale eQuIp men! (digital stimulator Slippositone raised toilet seat urmary drainage deVice, and so forth) Independent lighl kl lchen acllvltles ReqUires wheelchair accessible kitchen and hVlng environment Aclapled kitchen lools Aulomoblle wllh hand control. Able to get wheelchair In and out of car Independent Independent In all soll·e.or8 "od personal hygiene Some adaptive eqlllpmenllllt\V be n.J required (e 9 . lub S~(11 . gl,lb btu so forth) Independent With "","ual wh Il h 1 r wUh standard hand 11m Indepllndent In light hou k.t oPII'9 "nd me,,1 plepdull1lm Some dciclpllv6 aqUipm III III \\ I~quuad (6 g , 10 \I. htH ) HtKlll1r9!i d wh t!lch \ 1 ' blu \

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WIIe't)lt h:\It ."llh

IllddprlHdllll1 willi IIItll1l1lll owlihlllll.tlf

~ ( IUh dlll1l1l1l1J III Wllelelle I\:tll

AIII(I It) IlUtJdllttltt (wh' II~IIIY I

!'fl\'I\\I,,1 ~Jlhtl(t :o1,Ihlll':(ld h\1

11ft

·Wlh)rlllll

hIt 11IUqllr i

I ull pIli Ilc

Ilhllillll

IIlIJ t.,hJt~ll:'O fl.11 1:lhll:.

II It IdJhHlt IIII "

l'II\,:.I\\llltJI\': II: IIUtl:11t1bJ (IWI

~;'llndll'tJ "Ihltl III II tUlle

!,IIll'Ih III h _" hUlt'lItIO:11

!\lIdhlllll "'hl(l ,III"le hllll Ollh\\·

:111 II \I 111111\ II I)

{hAt t :1} willI

1

·.plthll tllltil 1111111111

'sntlh plllh1llh IlltlV

Ilf .Ihlt 10

.Iflllllllnh' Illi :\1\011 c1hhllll

(I'

\"111\

:1:, ·.1'01.1111 '1 Intl(lplllld( IIl ' willI !lllllllh' Illlv"l( f~()qlll"I:' .1 wht1(llllhlll .In t"

1111,

IIVIIII! t'IlVUtllll1hlnl

1 :) h,' 11.' Lt.' ( .\tx1vtHUl,'1:;. I nh I ':-01,11:;.

IInj'llt)'t)t11I1J1llo.

1\11"ltlllll

{\nlrtll

hAl th

.Ind (:111ft lit

WIII"(}1 (hill" (IthllllV (lill' 1llllphOll

IIWI (")£\:.('I{1

hll ;llllhlll,llltlll)

t")ndlll:tnf"l)

WII(I(Ik'I',111 \I:.!ld Illl ( Ihlltl' ('t)t 1:.(11

, " l.' If ,h Jh~

~t .':-0 lJ,ll'1f.ltU$ IUI1'1l)l.'UlIIH R hl~ I nl liS

III

,

t tiP t tiP

lit))'Il.'"

r IIIH' ltnnt lltItHIHlltlllt)11

;lddlll'Ul)n

v, I III III

1\1111Ic11,tI

I\AI

t):

Wllt'lll, h.1II II:

KI1('1) l),lflll:.ltm

(Itt

.\lld

l'!llh

hI!

((11\\(

.llld (Hhllt]\, ('tIll' (11\ ,tll\'n

rt(.ll1l1~

L4 L5 It OS)I dl911 rum

Low bit k nHI~C'I( s M IAI hnm,lrmg$ lWt 0") P

I II f hblt,h~

.. Ifl"'9 I)IP

1It.,xlon t)):10n~llm

OllA fll'l'PS.

W~"\.\k

Tlbhlh nrlll flOf

II" 1011

r Iltll'llnt 1.11 Ill l1tH IlItll\I!\ '''111,1',

Iton!;l ~fh't'

Wht 1'11'11.\11 lI't d IlII .llId 1II1t1ltlV

I<.nnl'

ImprOVt,d II Ull" ('1111101

.. This, Itllo pit. tilt g, ntH'" hHlt Ilflll/11 (110;1'1)\ Iflli"l\'l .\1 \/flll,lll', 111'.11111 If\\II'" I .11 h I'ltl!lll)·.·.I\t.,\ r t IHfmlllllludtl Iht mUst'ltl!, 11('111\ IIlt'l JlltlVlllU!i 'tw,lh Allht1110fl 11111 1\11 ' 11111'.\ h.' II'," II 1111 Ql.IlU'IIly It I~t mn N,UIllll lIum '.11\'(111,1 IlIH' (\ I(lllt ·.t}qnhllll· 111(1\ 1111' Ihhld h,ltll .11 Illel 11cI1I1111\1\JII "I I vnls wht It thl II ,dlliu Itlnrllt'I",1 uulu~nh ,

Iowl

III

t

<-

l'

(III'! 1\ til

1

I

( ' hUllh.·I' 2,'\ TmulIlnji .., Spinlll ('urd Injury

9()S

ttl ll\: [Hlllal .llllI!!) III i.I \'ilr'ict) 01 ill'[I\lIll!, 01 tidily livin g 1 \1>1 1 ,uch a ... drl· ...... 1I1g and glOOllllng, II'lllhk", IOl'01110

Continuing Adivitieb

[!ll1l. ,tlld t()lll.·tllI~.

IlIen! ;H': !I Vi li ~ ... lllil1!llcti durlllJ' till' lll·ult.: period wi ll Ill'

Dillin g 11Il: 1I1.:IIW I'l.'huhdlliltion pllllfooC. mUll)' o j tIll' Ire-al

'lilt: I' IM !\! h.I" ht.'l'l\ "I!own to hl.' II r'l!li Itlk ,Iml \~llId 1l1l',I"'llfl' 01 IW1CIJ()Jwl ~lbililY lor illtiivililllll:-; :, Ilh St· " 1.1 Chapll'r' II pmvltk ... III(H'l' del:til I'l:gar(hllg

l' lHlIl!lllCd. 111 1L' I'VCllllllll'i lic'i I)' I1l'd 10 IIddrl'\\ J'~''tpHlItmy

,h,' I 1\1

patlL'llt 111 ...0 .

\ h"1 I1ldl\ Hlu'll ... \\ 1111 SCI wtll n:ly 011 a whcddwir
r1l

tltht r ~

It'lllnIUtH l~

rtlt'"dll'

lll" IOC'; OJIIOlll)JJ

\ ... "lll"h . It

lI11pOftillil

It) eXanHIll!

thc

pt'"ltunn .... hCl'kh
.lhtlllV

"

III theil' lIoll1c alltl

tbr~

!'tIl n t(

adl

l«J

Is

[l)

lIlt / OOl ,

lO ffllJllltlIl V,

and

lldl'lll/( ·('{.i:

ami the 'JclIlng III wlllC:h the ~ krlh arc J..,l!u. 1 he ~~" ('t'l cltlll/" Sf..../I/ \ Ie\! can hc ul.,cc.! a'J II\.. mea~ lIrc tu d e termIne whIch whccJch:'lIr \kilh .ludn.!'J\ccl In therapy and to dOc.:UIllt!1ll lI11prOVC -

menl du 1

,ROM . ulld pW.. JlIOlllllJ.!. will

Wi ll.

hL' Involved

l'()llllllllt'

I he

111 '' I .. " 'III'IIIUII) )!' , 111 1I l'Xpallt Il'lI

pro~llIIn 01 rC"'''IIVl' CXl'rCI'iC ... 1m al1l1ll1'rdc't thai I"l'I11IIIn IIlIlCI'VHtcd

(t:,g"

PN I'. progl\~\'rIVC

1t..· ... I\l!lIll:C

l'.IW IT I "'l'

I PRF.lusi ng Im1lltl!!1 rL''J i \ IHIIt·t!. wt:ip.hh. wul\ pldlt'y~. \ 1111 /:1 "'U"'pclhlon. and ~ro\lj1 cxcn': ll.,L' l'\a ... 'Ic\). t)cvc!npIIIClll 01 motor 1.'0111101 and I1I1J\l'lc ICCdUUIIH)Jl ICl,. itlliLltll,.''r tllI~c.:lcd

at appropll:tIC lllu'Jc!c", (h:hcd on 1~\Hln Il'vcl, .1I1! lmil l 'meL! , hlllpha ... l., i\ ~d\() placed Oil n,'gIUIl1l1p' po'ttllJ"ul COil 1]'01 and bal:ltlt.:l' by ... ub1"> [ illlllll~ lIppel body L'tHlIltJl ant.! VI "'IOI1

Uor 10\1 propnOCCplH)lIj Thl ... pha.,c 0 1

1]'~aUll~flt

will :11,,0 lueu ... Oil imj1mvcd c:tni!ova'll.: ular IC"POI1\C II) cxcn..: J... c. Th" call l'lic<.:t lvcly be :lu.:olllpli ... hcd hy u'c 01 lnlelval Jr:.tllllllg LI'IlIlg :111 UI ~ aerobic :llIlvlly (e,!!, lJl · Cl'gOlllctcl'j , l ! 1I

lila!

lull

I

1I111l1a gc llIl'Jl I ,

g reh abillwtion.

In d !tIon to cx alllllling whCl.!ldli.Ur mobility. Ihe phys .. at lherapl">t hould perform a thorough ,,>catlng and ~hee (,;h~Hr exam inallon to determine the mo\[ appropriate. ~dung ) ... tem and v.hcclc.:hair for Ihe patient. More dClilil 00 th proco" " provided below ; Chap,er 33 provide, a

.. mprehen ... lve rev Iew of thi "> topic. R«!gammg Ihe ablilly 10 walk i., a common goal for 1110\ ( I"dual v. ith SCI h ee later seclJon on galt trainmg). T""·J\;ommonl ) u~d OUlcome mca\urcs dc~ ign ed to exam JJe . .IklOg " btl"y after SCI are the Walk"'!: 1",/n for plnul Cord I njlll ) I\USCl j' '" and 'he Spinal Cord IIIJllry F n r, wJIAmblilalwn Imenlor} I.SCI-fAI)' (Fig . 23 .13).

Skin In'p"clion During tl1l't phu'tC 01 mantl!-!cl1lcnt. the pallent Will be JlhlrUL!cd ~!J ad uillI y II) a\,,>ul1lc n.!\pt lll'tihil II Y hir 'Jklfl lIl .. pec !ion, Thi\ will IIlvolvc pral,:IJt:c ill 1I'lC ul lon~~ h:ulljl~tI (£'Ill

23. 14) or adaplcd minor'; In allow JI1\PCt.:lll)lll,j' arc!a., IIOt ~tJ~ Jly vl.,lble, Wall Il1lrror\ adJt1CClIl It) the heLl Illay ~"''''''l 111 ;.t<.;hil!ving 1I1dcpcndcl1l:c with lhi"i at:tlvuy. P;ItIt!lIh wllh hllth level Ic\/On'J fIlay be 11l1.:;,Ipablc of "klll JlI">IJCc.;tl()I1 It I'" lI11pUr Wilt thai lhc"A! pallen"" be JIl~1I1H,;tcd JI1 !tow It) dlft!(;l OdlC('J 10 t.:olllplcLC lhi., l!x.iJllllnt ... hould be pl.u.;cu 011 Ihe ImpOI1.i..IlKt of ">kin 1l1'J1~I.:UOfl and the ratlOIlale lor prc~">llrc relief Skill IlI'Jf)((;tl(JIl ::md c.:arl! mu J bc(.'ol1lc a regular and "felon!! lompoll(!'111 ()f lhe p.IHeOl'b daily mUllne,

,\ -tat Program, \ltal

ac.;tivillc~ (.'OIl".tJlUlC

a major (.'(}JIIponclll of Ill:::aUuent

dunng the rehabJlil<Jtion pha"Je, I he :>et4ucnt..:c:: oj .u:tl,·jhc

Physical Th.erapy Intervention [}JOP.

the aCllve rehabilitation pha.,." the empha", 01

"'!'4Imc:nt IS on

maxImizIng functional mdepcndem.:.c.

!mOd!:, thi, me/ude, ba,ic ,kill> ,ueh a, bed mobll"y. 'Ian ler , and 'Aheelchair mobil,,) ,kill" A, the patient "'''
on ho',l, to instruct anOlher per'J.{)fi to perform

!he!4 Ie lor them. Ind,v/duah v.ho are not able 10 perfonn ADL uch a dressing. bed mobility ta'ks. and tran .. '" w:lcpendentl) require a pervon.1 care attendant for ::r.amp t an lO(h", Idu.al 'Nllh a high cerr leal leSIOn \It ho JS IlOI able to tum 10 bed Of feed hlm- or heT\e/f lOd
lypj(,;aJly PJo~rc''te..,

from aducvtlllcnt of ~labJllty vt'llhm a p()I~IUre and advancc!) Ihr<Ju~h (;OlllfOllcd J1l0bllll) to ~'klll in fUJl(;lJonaJ U\C :< I~arl)' aClJYltlc~ arc bjl.Heral iJrKJ ~)JII

'l1clncal . A progrcM.. I()O ' ''' Ih(:JI Jllad(: to welglll hIt Illig wid nH)\t:mem wJlhlll thc f'lj'JlUfC A J!r~ual erupha l\ I

placed

00

unproved timing
~at acUvltlCS arc ohcll wdiVlduaJ (;l.JlJlp<.HlCrtt oj 1I)Oft'

wmpkx fUlIwo"al . kill" 'I he) I.... ld be ""'1UCI.ced lrom .,...." e" to mO'>t difficult ." Ihat the I"'lie/t I l'afucm ru.: llv Illes "A Jthm . or air,)() t "Vt Iliun 11M! phere oj fJ1,;i , A. ma ...tef') oJ the \ anuu 1..0mpOHCJlt 01 mOl C' pi. dlffiwlt a""/lles I adllc·.cd. the 1'"1",, I IolwuJd pcrlmnJ thebe la k lJ1 the l:urre, 1 II, u C1J'V I IZ hO' f"",1 r<~JIll , or e, enltlllll) hOllle on .. lhe ,herop' t mu t dcl!:mlllle the approprl&l.C ... Ille lor """h J'at~lIl >Cd OIl eI f wlU II" JmpcrfUlll Iv not th.>I <:OI1:lpI,CIC aW,II, I ,101 all< ) De<;

Wheelchair Skill Te t (Manual) 3.2 Report NAMl

OAT

[n '>r IN~ORMATION

CD

WST

WST-Q

oj

Wheolchalr u.od . • !56J,7 54,:!!> 52 ,51 51 50 49 48

Oro" WI,. 11ft. on I 'i,,1 I rmln

o w

u

z

« > C Level chnngo! «

47 46 45 42

Incllne8

~ Inchne.

Z POI-Holos

::J

150m ascent 7.5° whoelle fwd descent Scm doscent Scm ascent

5° doscent 5° ascont 30cm across 15cm across

38 37

~ '" Rollin ReslSlnnce ~ Cros.-Slope Ob5lnclo. U raid/Unfold

Stationary No·hands fOst 15cm wheetie rwd doscont

15cm descont

44 43 41 40 39

Levol chnngos

Skill Moving turns bflckword Moving tllrns forward Turns In place Roiling backward ROiling forward

Gravel 13cm high Unfold Fold Stroet crossin

33 29

26

Whe61chAIf ROllin

14

ROiling roslfllnnca

36 32 31 30

ObflillCt08

Door" l mn fera

n

R ohlng

10 26

~ ';kIAWny" MnnLIfIVu1hl9

o MU'IItnU

High objoci Oround

n}1

to /1 Anrkwilrd. HI Ih f ()twllld<;

IWIL Z 1\Jfll~ In Plitc h - Halllll"

C

HI 11

11\

O,It;kwlud

1.1

I Drwnhl

H" .ll)Lp " 10 MU\lJ' AWI'¥ , 1 1.\

AIIIIIP"IIllI

H"!>I~tP

I •

, r,

1\J1lpl1lo.(I

I '

Apply

t; (1 II't

I 'AI

IIH I

h i l t df11alid

,

M~'\I" A~~y

H

II"~

I II .1, t

il·

Nt _\

11

1Il{1

HI

CnroQlw,r

L Scor. R Comnlent.a:

o o

o

0 0

oo

unablo to hold wheehe for fulllOs

------o

o o

seat ralls not fu I)' opened "to seat

Cnrpo\ 2cm high Op~n townrd Opel! Awny In10 wlleelchmr OUI of wheelchair

'Ii

[lLl

used left foot to help bndge gap

34,35

o

Whoolchnlr User

[SUI3J[CT

INn [ lllU

R

I~

N Nt'

Nl' I " ' " ' ' kl'

N I'

k I'

N I'

l'

0.71 mI,

~

l

J1

( 'huph'r 2.\1 ruulnuli(: "pinal ( ord Injur)'

W,7

SCi Functional Ambulation Imcntory (SC I-I'J\I) Session:

Date

p\R.\ \IFTER

CRITERIO

A \Ve ght shift

Shifts weight to stance limb. Weight shift absent or only onto assistive device .

6 Step ,,,dth

C SteP rhythm (relative time need d to advance sWing limb)

D S'e~ ~elght

E F vt contact

L 1

1

o

0

SWing foot clears stance foot on limb advancement. Stance foot obstructs sWing foot on 11mb advancement. Final foot placement does not obstruct sWing limb Final foot placement obstructs sWing limb.

o o

0

At heel strike of stance limb. the sWing limb: begins to advance in < 1 second or requires 1-3 seconds to begin advancing or requires > 3 seconds to begin advancing

2

2

1

1

0

1

1

1

1

o

0

2

2

Toe clears floor throughout swing phase or Toe drags at Initiation of swing phase only or Toe drags throughout swing phase

o

Heel contacts floor before forefoot or Forefoot or foot flat first contact with floor.

o

1

1

0

1

Swing heel placed forward of stance toe or Swing toe placed forward of stance toe or Swing toe placed rearward of stance toe.

F Step e gth

R

1

0 2

2 1

1

o

0

Parameter total

Sum '20

ASSISTIVE DEVICES Upper extremity balance welghtbearing

None Cane(s) Quad cane(s). Crutch(es) (forea rm/axillary) Walker Parallel bars

devIces

lower extremity assistlve devices

None AFO KAFO

Walks regularly In community (rarelymever us IV C) rogularly 111 hom%ccaslol1ally In commUni Occasionally In homo/roroly "' 111111UI11tl

rur Iy In 110ll1o/novor in commllnlty fOI ox ICIt;U only
W.ilklI1Q ",nhility ,.,'(11,'

w) HllfllJl', '1ot~"1 I-I'}

H' f

Iml~

1"r,1 (eJir,lfIl1u,

I>lr.l llI\e It wlllh.tltllll .' IllUlllh,)";

~ 'IIUlIllt,I,)

~Ilt "ttll '1f!l11'<.I~, ~A'

, • ' H ;I"S 11

n

kurU! rlllkiu fnn! oHlin'" litH'! Ifl\

t,,'H,11 ( IIId Illjlll Y I '1111111111111 \t)jhuh,!htll 111\1

4

3 2

3 2

3 2

3 2

1

1

Sur

Ti-,\1PORALIDlSTANCE MEASURES w, opposod to W/C usa)

4

o

Assistive device total

lIafoOg mobility (typical walking

R

2 0

RGO

r"r;'Cll(.t)

L

nh l l\

IlItl"',\I \j;\11 \\l1h\}'

\\

~ \\

I\t I I \1\. \ ,,,Ih 1""'\1"1''-''

1~

Ph u:-..I R

hahtlar~ftoft

~d I I"r pn."ssu,\." reb 'I) ~'"ll l i Jll''1'11\ ~ Rl~lIl11l! , ...\ II ljLl~J11

,tb \( 1

',Irunt/- PI'lIlt III IIUI PU) 'r.llm 1111 p.ltll'llh \\

.Ind pnl\ Ide

,Ill ~·,trl\ k,,"(HI

tern ... ot Il\ll\~nu:nt

tI' uC'\l'II'plu • IUlllllolI.11 P,I(

II r~qlllrl""

Ihl' p.lll('nt 111

It.lrn

III II ('

Ihe hl'.lU. ncl,.'io-, ..Il1U L11':' .•1' \'\'1..·11 .1'> IIHHlll'lllUlll. Iu I1hl\~' th\.' trun~ ,Ind/ln' l.E~, It I.., u ... u.1I1) l'.I'I~ ... 1 to tl('~HI Itllltng .ldll,lt.t!' Iwm the "urine iXl"'lunll. \\ln~lIlg 1,1\~,lId Ih..: pron~ pO .. UIOIi II J ... )rtlllll.!lflL tn\lli\l'l1le'llI ~\I"'I ,lu11111' ..,hould he 1IIIlIJted \\Itlt 1l1O\l'nk'nl !l1\\.trU the \\~·.I\.;t'l Idt: Thl' .ICIJ\tI) I~ trllliall) t.lu1!ht on .1111.11 Ihme\~r , rlllllll' mu .... 1 01.1'0 be 1Il,I,tercd on the ,url,IL~ 01 .I hc-d . . 111111.11 tlllht' one ch:.lI Ihe pJttent \\ III u... e at hlllTlC I"IJ llt~\elor 1ll.1\IIIHllil Illdepell(knce. bed nllh, rope'l, (.111\".., "1.ldder\, III \I\e-r head dc\ ILe., .,uch ~h lrape/e.., 'Ihlwlli be a\oit..1eu, II po...... , ble.IIO\\c\t:r,11 thc'le aUapI]\c lIC:\/l:e ... ~llh)\\ the pall!!'nt hi perloml the I.h\'; Independ~ntl) v. hen thco) Clluld nOl lHhcr· ~ I'le do Ihe 1,1'11... then [he) ... hould be 1Il1.'orpor.1t1:'1I Inlt) Ihe overall plan of (are (POC). In addliion. lhe p.lllent ... htluitl achlcve Indepemlelll rolllllg \\ hen Cll\ cred b) ... he!!'" .1Ilt! Figure 23.14 S!...in

IIl'lPC(;!UlIl y,.l lh U'IC

of long-hjndlcd mIrror.

ne:tl. At ... orne point., in rrcmme",, "ievcral component., of the mat progn!-,slon ",ill be 'Wor\.;ed on com:urrcl1Il}. "1a1 acl1Vllie., \hou ld be lIlitiJted a\ soon :1'1 the patient I'" cleared for aClIvilY. Progre.,..,ion through the .,equence 01 maL ac[tvltie'l develop., improved .,lrenglh and functional ROM , improve., awarene.,., 01 the new cent er of grav it y, promotes po:,lUral .,tability, facilitates dynamic balance, and a..,~i.,t') wllh determining the mo.,t efficient and funclionJI method., for accomplbhmg .,pecific ta.,b . It aha provide., [he opponunHy LO develop funCllonal pattcrn ... of movement (c.g .. u.,e of innervated musculalure or Illomen[urn to move body pan ... thai lac\.; active movement) . The foUowmg -,ection repre.,cnt., a sample progre.,.,lon of )(!Ieclt!d mal activiue.,. The degree to wh ich they can be pertormed ind.ependently and Ihe lime needed 10 learn them vary con'J iderably wah the level of le'lion and fhe mdlvidual Each component of the mat progre ... .., I(l/1 j., prenLed With It-, Junctiona l Implication., ~nd 'Ievera l \ugS.e~lcd lre:..tlment al.:tIVILte'l to factlu'.lle accompll'lhrncllt 01 the ilL{lvlty. It j., ImpOfutnlto nOle that the exa(;( mel hod 01 pcrfrJrmrng a fundlfmal ilLlIVlly may v;Jry lor IIllilvu.iual p:.dlcnl:. dtpt::ndlllg on m:my !",-tor., othtr Ih~n neurological k: J(m le . . . d ~u(.h :1:> p.,ychologici.ll ~dJu'llrnen ' , hody Weigh" bt/Jy IYp'· (I c, ",h(Ji1 arm J lear :JJld cardlOVa.,culilr cllndl fl(Jlfirn~ Th

wonh Inn

(J,

p

f

W/JnllIJ1 tn/lUI If

ther,spi I Jnt! pallt'nl often Il1U'I' expC'llIllt:J1I

tlfferefll fncthlJ('1 ,,1 fwrflJrrfllng Ille I'I,J or IJlkrvl.:'1I

J

,/IfTiC up wHh;. pC(IIIlIIWlhl,d Illal t (h.Jr'~( I ~ Ph

t {JI"

II/}

If

worh

wl'lI l or

,,11
rWIIIfIIlIOJ IWlIllJlp

fill'll/lIlt/III J<1,hflIJlllf,J{lfm

I

,Ifill

\j}//lril ( (J/(I

I Pfl'Vldt, ,lIldJllqlldllllll1

d l,ftl Ir ,dlflilll IWV.' /J1III,

blan~eh.

To beglll lmllllng allli approachc'l can be u'Jed.

IJt.:tllt~lh~

~e\(.'rl\l

rolling.

Flexion of lht! head and necl... \\ Jlh rotallon 111.1) be u ... ed to 3'1~I ... t movement from .. UpIllC to prone po ... lIl11n, EXICn.,lon of the head and n~d. ~ IIh rotallOn 1ll,1) be: u\ed 10 3'1'1 I.,t movement from prone 10 .... UpIllC rO,lIllm, Bilateral, ..,)mmelrical UE rocl...lllg \\llh UUhlrl.'lI.ht'd ;1rm., produce., a penliular 111001(.)n \\hen mtJ\lll~ Irlllll 'lupine to prone PO&II ion ..... The p;ltl~nt rh~ Ihm\l,.',tll) roeb the oll l\lretched arm ... and head lrom ... lde-tli-'Itieand then forcefully ·'I0 ... '1e ... •• Ihem 1l) the :...iJr: 10 "hll..h the patient rolling. The Irunl... ,lilt! hip., \\111 IlllI,m (Fig, 23.15). U'le 01 wri~1 cull v.elghh (:! 10 1 Ih ... ) 111.1\ be u.,ed tnHli.lIly (0 innea . . e \.;llle .. thcllL .m.lrene ..... ,lilt!

''I

momentum .

Cro~'llng

lhe an\.;le ... WIll ;\1 ... 0 Liultl.Ue flllhll~ f lib Clth"i~'" the pUIH.::nl ... an"-Ie llh.1I lht: lIppel hmb j , IOlAilI'd the liJ rec..: Iton tlllhr: ]ullit tilt' right ,1I11de would be I..:flh.,ed O\,el lilt:' 11:'11 \~JJlJl 11m IOward the lei!) Rolling 1..:;111 ht:' prnllltlit'd IUJlIt I b Ing Ihe hlJl ;Jlld \.;nee 1)llhe lOp I r ,I1lJ Pl.llllll II t ,II Oppthllc 11mb (I:'.g., Ihe hip .JIld \....1It'<: (,I th II wou ld he 1Iexed ilnJ pLll~d 0\(", thl' leli 1]( II 23. 15) . The therapI ... ,

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\\ 111 lal'liil~1t1' roll ing IOward the prone hit r,llh:rn '\IIIIJclii tdtc rolling loward n Ir 'n' ,".kl~ mg.

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Pu,jlion

won, 01 Ihl' actl\ II) art! Improved lor .t ...... Ul11l11g Iht: quadrupecl Thl' component of Ihe mat progrc ... ...... nu nc.!cIro. (.:ontrol a . . ,,,,ell a . . proximal ohuml!r~tl .1I1d ...l:apu lur J11u ...cul
g frllm ("Iho", to clbm", '\, 111 :111m", I J Ih' tl no", lorv,..ard Ulllil thl.'Y :IIC 2) or hod), v.t·'Vht «.:all he . . hilled po ... n--"", r und(" Ille .. twll/dcr... . po IIIOf) /JlIl'lt lx' u...l·d Willi call 1IIg' 11t",.llll jill!! hlllllMI II1)1l1ll· ... I JdJI ( lilt III Iflll'fille th,' llIlll' i l "t' cI

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hy h~vlng the patient lift one aml. Thi ... funher fadlJtJte co·contractlon in the ""eighlbearing limb. MovemcllI within thi s po~ture can be achic\cd b!- an ondbow~ forward, bad.\\ard. and "de-to-,ide progre"10n Strengthening of the ...erratu . . anterior and other ...,apular l1lu ...c1c ... can be achie\cd \lith prone·on-elbo\\, pu,h· up .... Thi~ i... ~ccompli~hed b!- ha\ ing the patient pu,h the clbc..w.... down mto the mat and lUd.. m the chin \\ hlh: hfting and rounding alit the shoulder, and upper th ...,\r3\. (Fig. 23. 16). Thi:-. i" ~Imilar to the ·\:al. camel" m,lOCU\er u. . cd in the quadruped po . . ilion. The patient 1cmcr... the chin and upper che:..t 10 the mat 3g~11ll b~ ~llk"'l\\ in~ the ..,capul a [0 adduct. Proll('-oil-ilands Position (" it h Parfl pl e~ill) The fUllctinn;\1 L':I rr)O\('r of Ihl' po:o.llillll ~Flg ~.~ 1Illclmk'" dL'\ ('\nplIlcnt l)f Ihe initi.ll h~ (X~n.'\.tt.'n . . il'n \"'11 th~

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A more common lcchnl(.l uc i'lo for the palIeni to ""'edge" the hand", under the hIp'" or to hook the thumb, mto pant"!

pocke" or bell loops. By Contracllng Ihe bIcep, and/or wrist extcn ... ors, thc patient can pull up parllally IniO the p05.lUre, By shifting weight from ",ide-lO-side, the elbow,,! can then be positioned under the shoulder ....

Figure 23.17 Prone-on-hand ... po..,ition.

Some pallent' may have difficulty assuming thi, po,ition inlllally, and a gradual acclimation may be indicated htrong pectoral" major and deltoid mu,cle, are required to accompli,h thi' activity). A gradual progression can be made by ,upporting the patient" upper trunk with a wide, firm bohter, wedge, or a 'l ing ,u'pen,ion ,ystem. A, the pallent gradually become, accu,tomed to the new po,ition , Ihe height of the ,uppon can be increased (if gradual acclimation i, needed) and eventually removed . Hand placement for th e prone-on-hand, po,i lion i, ,imilar to a ;tandard pu,h-up po,ilion except tha I Ihe hand, are ,lightly more lateral and the arm, arc externally rotated. It ,hould be noted that thi, po,ition wou ld not be appropriate for every palient with paraplegia owi ng to the exce,sive lordosi~ reqUIred to a<.;l.,ume and to maimam the po ... itlon. Lateral weig ht ~hifting with weight tran ... fcr between hand ... will increase joint approx Imation. Additional approximation force can be applied through manual contact<, to facilitate ton ic holding of proximal

musculature funher. Scapular depression and prone pu sh-ups may be utlliLcd a<.; ... trcngthcning cxerci ...es.

S upine-un -Elbuw, Pos itiun The purpo,e of Ihi, activity i, to assi,1 with bed mobllily

Finally, some patients may find it easiest to ..Io.,sume thl' position from sidelying, The lower elbow IS first po'litioned and pushed Inlo the mal. The patienl then roll, toward the supine p05.ition and quickly extends the upper arm, landing on the elbow as close to the shoulder a\ po~_

,ible. By weight 'hifting. placemen l 01 the elbow, tan then be adjusted. Much of the IIlhcrem benefit of thi s activity IS achieved in learning to assume the po sture and then move 11110 long sitting, In addition to its direct functional significance, thi'l activity IS al)'o an important strcngthcnll1g cxcn;j,e lor shoulder extensors and sC<.Ipu lar adductors, Latcml weIght shifting c<.In be practiced III thi '" pmllJOI1 Side-to-side movement in this poslUrc w ill en lHlntc the pati ent \ abili ty to align the trunk w ith the LEI., when III bed or 111 preparat ion for positional change",. Precautions should be taken with thI S posture a'" II may cause IJ1crea",ed shou lder pain due to the pres~ure c~crtcd on the anterior shoulder J0ll11 cap ... ule.

Pull- Up, (with Tetrap legia) The purpose of pull -u p... 1\ 10 ~trel1glhcn the hJl:cp" and \ houlder ncxoro., in prcparution for whcckhi.lll PloplIhlon. The patienl 1\ po<.,lllOncd III the supine PO"'ltlon . -, hL' thaa pis, u.,\umes the high-kneelIng pOSitIOn With (JilL' IJ~ 011 c.Kh side of the patient \ hip"'. The thcri.lpisl gmsp .. Ilw p.IIU.:nt's supinated rorearm s .iLl ... t above the wn",ts. " he p,Jtlell1 pull'i In siltIng and then lower ... hack to the mat. AltemaIL.lj .• IIII)\l.:r head 1r<.lpC7e bar c.:an he lIsed for tlUlllIllf!

Silt ing Both long (Fig . 23 Il») and ... hort (FI!!, 21.20) lilin' [l( I tHm ... arc e......cn llal for many m;tIVltlL' (If d;lIly 11\ JIl' dl

and to prepare the patient to a...... ume a long ... ittll1g po\i tion (Fig. 23.18). There arc ... everal approaches to a... sum1l1g the <.;upine-on-clbows pOSition. If control of abdominal muscles i ... present, the patient may have suffic.: ient streng th to achieve Ihe po ... ition by pushing the elbows into th e mat and lifllng into the po ... lllon,

Figure 23.19 IndiVidual """h Figure 23.18 SuplIlc-on-cloow ... PO'llllOn

l(ln~ "11I1Il!! Jl<"IIJ11fl ~lIhClUI

it T I lUJ11pldl: pdfllpl l J 'tuppon.

•

(")mph.' r 2] TnlUllutti(' SpiHUJ ('c)rd Injury

971

Iln,l!l"'" IS pilrtu.. IlIi1ll y lIr1pollant to ,.voul oVl'hlrl·KllIlIg. " III IrlH:rit..'n.' with iI 11111<: 11011011 tl'nodl"tl\ gr, ... p, Weighl 1\ Ihl'll hOfll l' 011 Ih l" hit\l' 0 1 II11'/Hllld Pillll'/lh wilh tllil tril'l'pS hlllLllon Lilli I'll' t.lII}!ht 10 iol'h. fhe clhow', n1 L'l·haniL'lIl1y. 1I\111 g ShOtl/tl L'1 VII'(III: IlI1Istuld ture. I he palicnt Ilrst lO .... cs the \houldn Ilito hypf,,: rextl'II'~I()11 with til L' IOfl."a nll \Uplllated OI1l:e tile hase oj the hand lTla~c . . L'OIlIilct with thl..' mat , the hUIHcru .. IS lIexed 10 tt!u ... c the elhow 10 cxtend . . Illec the :11111 1\ III II clo ... ed J...ll1ctlc..: <.;h.lln , Tlli.., i . . l ollowed by mpid shoulder dcprc ........ lon tu Ill<.tullilfn elhow cxtell\lOI1. Thl . . technlquc wi ll .. lahllt/C the ilnn 111 hypcrcxten . . ion and l'xtcrna l mtallon . rherc :Irc IWO ba\lc :.Ipproac..:hes to Inslructllll:! the pallcnt to a . . :-.lImc tll c . . llIlng posi ti on. Sta rling In the supine-ondhow ... P(hltlOIl , thc pallcnt is 1I1\trucll:d 10 \hilt weight from .. idc· to-.. . ide. Once . . ufticielll mOl1lcnlUln 1\ (It:hicvt:d . the palienl tosscs onc arm bchll1d and shd ..... the weight 01110 Ihal cxtended arm. The oppo . . ite arm i. . thcn los .. ed behllld into an ex tended po"ll ion, rrom thi . . point, the patient " walks" the ann .. forwa rd until a . . table SlIlJng positu)f1 IS achieved . From a prone-on-elbows poslllon, th e patient <.:fceps .. idl!ward . uSing th e elbows and forearms. ThiS will position the trunk In flexion and allow the patient 10 rea<.;h the LE ..... The patient then hook . . the uppermost forearm under the knee. pulls forward with this arm using the biceps, and then quickly to. . ~es th e oppo .. ile extrem it y behind. The UE ol'lginall y placed under the knee is then also thrown into an ex tended po..,ition. The patient th en "wa lks" forward until a stable si uing position is achieved. Numero us patient .. have developed their own variaLion':! on these basic techn iques. Ohen patient-devised approache~ rn"y be the most appropriate ror the individual and should be examined in terms of \afety, fUllction, and energy expenditure, In addition, during the early . . tage~ of rehabilitation. adaptive equipment \uch as an overhead lIape7e. rope ladder>, or graduated loops hanging lrolll over-bed rrames ma) be used judiciously to facilitate movement into Silting. Several suggestiolls that can be utilized in a silting position are li sted below. \\hll. h

Figure 23.20 Imli \ Idual with aT4 comp!t'lc paraplcgl:J 111 \hon·"ullng PO'iitlon \\- !thoul Li E "! uppm!.

a\d re,,~i n g.

,df-ROM . tran\rer~ . and wheelchair mobility. Good "iumg balance and the ability to move within this po~tu re are al \o criti cal prerequisite 'ikills to ~tandjng. 0 Pallenl s \\ ilh tetrap legia require approximately J 00 of

\1raigh t-leg ROM to assume a long-silting position. Without this available mOlion, hamstring ICI1\ion will cau\e a post~ r ior lilting of the pelvis. Thi s will result in the patient"" sitting on the sacrum (sacral si({fng). with rC':Iult· ant \tretching of the lower back musculature. It is Important to note that sitting pOMu re will vary con\iderably with lesion level. Patients with low thoracic leSIon, can be expected to sit with a relatively erect trunk.

Ind.ividua ls with low cervical and high th oracic le5ions will maintain \itling balance by forward head displacement and ::nk nexion. Pati,ems with high cervical le~ion~ will nHmstrate poor Sltllng posture. , . For patient\ with triceps and abdom inal musculHture :araplcgla), the "UIOg po"tion can generally be a"umed 1{)'~OUt dIfficulty. Patients with tetraplegia initially are wught h<. assume a stable silting position by placing the shoulders in . perextenslOn and ex ternal rolation and the elbows and 1I.f!,ts 1 . . .. • . • n extensIOn wJlh the fingers nexed (lIcxlOn of the

Initial activi ties will focus on practice in malJ1taining. the position. During early \itting, a mirror may pro\'ide Important visual reed back, Manual approximation force may be u\ed at the ,haul· deI'S to promote co-contraction. A variety or PNF techniques Illay be used. SpecIIiL'all) , alternating isometrics and rhylhmil: . . Iablillatlon areimportant in promoting ellri) stabilit) ill till' po:-.tU~ Balancing activities may be practiced ill \iltlllg . nl~ ha,": of support provided b) the liEs can he ~raduall) decreased. progrc\\ to smgle limh . . uppon. Of. \\ Ilh 'lU11C" patien t..... be eliminated (sec hg ..... JJ . 19 .lIld 2l~O). Thepatlcnt \ IlInlh 01 . . tabiltt) can IX' . .: halleng~d progn!' sivel) III e~\(.: h pO . . 1I10n. AL'II\ 11I1." .... ul."h ;.I, h.tll throv.ing or tapplllg a balloon tx"t"L'l'n Ihl..~ patll'J1( aJld lherapJ'1

972

Ph) ,ical Rchabililation

Ill!,!. through the hl p. . anti i'> u... r.:Iul rOt la L' t\Jtattllt' 11111 tal control of the availa ble ll1u '>c ulaturc 01 the lowe r trun k

--'Figure 23.21 Indi\ Idu,1! \~ Ilh a C5 lIlCOmplClc quadripleg ia III long-.. llllng pO .. ilioll. Pll"IH IP" are initially fac ilil alc<.l by manual a .... i.. l:lncc Irnml hc Ihcr.lpi .. 1 \~ilh ll"'C of .. alldbag .. for weighlbear· mg. Nole Ihal hand placcl11enl mai ntain .. tinger tlc\lon du ring wri .. t cxtcn.., ion to avoid ~I re l cllln g of the lOIl£ li nger flexor ...

(\\tth or \\I thout cull \"eight s) also may be incorporated IntO a progres .. ion of . . lII ing activi ties. S11Iing pu... h-ups are an IInportanl prelimi nary ac ti vi ty ror tran .. fe r.. and ambu lation. For tetrapleg ia. the pat ient i ... positioned \\ Jl h the ':>houlde r~ in ex tem ion. the elbows lockcd. and the ha nds pm.tcrior to the hips. T he patient Ican ,:> ror\\urd and depre ... ses the shoulde rs to clear the butloc k'i. In it ially this activi ty may be fac ili tat ed by manlI al <1''1 ... isw.nce fro m the therap ist and/or by u..e o r sa nd bag ... or . . mall. hard bobter... to prov ide II firm er weight bearing .. urfacc for the UEs (Fig. 23.21). For paraplegia. a progrc':> ... ion can be achieved by initialing the aClt vi ty ..... lIh \velghtbcaring on the base of the hand . . placed directly on the mat Hnd then usmg pu... h-up blocl..... (F ig. 23.22) with graded incn,.:mcnt .. in he ight. Movemcnt within thl'" po~ture can be accomp l i~ h cd by u... mg a sHllng pu ... h-up in combination With momcnt um created by movcment of Ihe head and upper hody. Th", momentum I... <.;reatcd by throwing the head ~11ll1 !'. hou lder... force fully 111 the dln.!C IIOIl oppo... t1e to the tlc ... trcd d lreulon 01 motion (hcad-hlp" rc!tcrior dircd ion can be ar.;hieved hy u~c ot a ~It!lng pu!'.h-up with ... imu ltaneou'i rapi d and fo rceful tlexion of the head and Irun"'. Th i'i ~a m c progrc!'.!'.ion of movemcnt i... u':>cd \\lt h the ,>wing-to and ... wing-through gai l paltcm .... Early moh ility ac ti vi ti c~ Itl both long and ~hort sttting ... hould cmpha ... i/c adequate de.trance of thc bUllocb for "'Ki n protc<.;tion, QuadrUI)cd PU"Iiliun The func tiona l lI11plicalloll oj this all-four... pO ... ltUHl i~ 11'> tmportancc
and hip .... Genemll y the paltcnt i... in ~tnu.; tl!d to a,>~lIrne ..1 quadmped po~iti on from thc prone-on -e llx )\\ ... po... ita)ll. From thl '> PO\j. ti on the pat ie nt can "\\-41 1"''' baC Kward on clbow~. progrc ...... mg 10 wdghthearing on han(b . one al a tllnc. FOTl,:L'lul Ilc;.. ion oj the head. neck. and uppe r tl1\11k while pu ... hlll g IIltn the Illal Wi th thc elbows or han(!\ will a~ ... i ~t With elevating the pclvi .... rhe pat ient cont inue ... to "\Val"' '' hack ward until the hip ... are IXN tlOned ove r the knee .... A sccond lec hnique is to as . . um e the quad ruped po:..ture from long . . ittin g. In thl :-' approac h the patient rota les the trun\.. to :lIlow weight bea rin g on the h and ~ with the cllx)ws ex tcnded . From thi s s idc~ ittin g po~i t i ol1 the patient then J11ove~ into the quad ruped po~ iti on by a combination of UE an d avail able trunk strcngth and momentum from the head and sho ul der:-. (mov in g oppos ite the di rec tion or the hips). Several ~ugge\ tcd ac ti viti e . . that can bc utilI/cd in the quadruped p()<" iti on arc listed be low. Initi al aCI\ \ ities wi ll involve practice in mailll ainlllg the posi ti on: rhythmi c ... tabili L
Figure 23.22 Indi\Jdual With a cmnplcll'lc"ion ,II II .:! 1I "ln~ plI .. h-lip hind... 111 preparatIOn 101 tran ... ll'r ... ,md .ullhulalll)1l

('huptt'r 2.J Ffraumatic Spinal Curci Injury

'17.1

,IL'll vny. h l.!cJJl~

one L E hom it dynamic ..,1:lbIiJl y uWlIlg 10 Iii u"'c lall ha"'l' 01 ..,upporl Jnd Ihe ..,11111 of (':1! 1lI ~ 1 01

) 23 .. 11

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111011 ..... 111 PfUllHJ11.:

LI(1pllllllll1lh Figure 23.24 Kneeling po"tuioll wilh use of mal crulche'l.

Iy Irl'l' lng one l E trom a wcightbeanng pO~Ihe u..,cd III the quadruped PO..,J!JOIl (Fig. 23 1 I llIs :,t. !lu.: -d}nal11ll: l:onlrol ClLllvity provide.., irl:atl:"l JIIJII I ,Ipproxllnallon IOfl:C.., on lhe .., upportlllg t:>.(fCI1I1Y alld Il1l'1l'iI'Icd 10111<': holding of lhe available po,""ul,t l IllU..,l'le.., (e.g., moving. Ihe dynamk IUllb III a dJ,I)!llI1;ti palll'rnJ. . ~111",clllt"nt v.llhlll the quadruped po..,lIlon (creeping) hi.l ~ unpllltJllt 1I11pli <.:atJon", for i.imbulation. Creeping can be u"'l,'d tl) llllpmvc ..,t Jcngt h (n,!..,i"tled forward progre..,..,Jon), 10 l ill' lhtall~ dynillll ll: halan <.:e rea<.: tJon"" and to Improve ,:\11

Jt

1I00, m,lY

(()()rdlll,1I10n and IlIlllng . h.nl'('lin~

Pu"tition pO"luion I.., particu larly illlportaJ1l for e\tabli~hlng lunl;tiolliil pallenh 01 trunk and pclvir..: control and for fur [hcl promlHlI1!! lIpnp.ht balan<.:e control. II 1\ all import ani ICJd-up .tlllVtty to ambulatlon u~ing crutches and bilaler~tI k.ncc-,II1J...Ie--loot OIth(hC"I. It I.., u.., uilHy l..'
Inlllal activities will concentrate on maintall1JJlg the po~i­ lion u..,lng available mu~culature and postural alignment (hip~ fully extended with Ihe pelvis ~Iightly antenor to the kJ1ee~) . thi~ po.,ition Bal'lIlcing ac tivit ie., may progress from ~upport with both UE.., to support from only one. A variety of Illat crutch activities can be used JJl the kneeling position: examples include weight shifting anteriorly, pol.,lenorly, and laterally, with emphasis on lower trunk and pelvic control; placing the crutche., forward, backward. and 10 the side with weight .,hiflS III each dm.!ction, alternately rai~ing one crutch at a tllne and returning it to the mat; hip hiking; instruction in gait pallern; and forward progression using crutches.

• The patient \ balance may be challenged in

T,.an.,fcr~

Tnlll..,fcr tnuning is generall y initiated on<.:c the patient has achieved adequate sitting balance. It is a nece.., ... ary prerequisite ~ki ll to many olher functional activities. \uch as tub tran~rer.." ambulalion. and driving. Trall1ing is u'luall) 1111tialed on a firm mat surface and p rogre..,~es to alternate "turfaces \ uch as a bcd, toilet, bathtub, car. <-,hair-to-floor (and rever"e), and so forth. Patients ".lith SCI mo..,t frequentJ) usc some va riation of a lateral scoot tram.fer (\\ JIll or '" ilhout the u..,e of <.t tran \fer board) (Fig. 23.25). Some e\perimentation and problem solvlI1g between the r~HIl"nt and therapist are generally required to delemline the mo'l etticicnl and \areSI mcthod for an Jndl\ idual patient . Palll'nt' uSJIlg wheclchair\ with tubular footre'li"l all~ll·heJ dln:'l·t1~ 10 the rralll l: (nonrcmo\i.lble. Ii\cu fnlllt t'nJ) t)ph:all~ transfer wnh the feet remaining un Iht' tuhlllUl 10\'1 ,uPP0r1 (Fig. 23.26).

Figure 23.25 Indl'idual" Ilh a T4 complele paraplegia Iran,ferring from \\ hcclchair \\ ith feet placed on floor.

In addition to neurologIcal lc\ion Inc\. three impona nt componcm\ of tran~fer ...,~ilb arc momentum . l11u ...cle sub"'lItution. and head-hip ... relat ion... hip. Mome ntum can be u... ed to facilitate movement at a joint(:-;) \\ hen the surrounding mu ~c lliature i... \\ca!.... Mu ~c lc :-;ub,titut ion can al')o be u\ed in thi ... W<1) . For exa mple. an individual with a neurological le\ el of C6 \\ Jlhout trice p":> IIlncrnuion can lock. the elbo\\ ... to as::.i... t \\ ith a tran ... fe r. Thi:-. j.., done b) placing the hand on the mat (or oth er :-.urf,H,;t:) luJ.-hip.\ r('lmiol/ship ca n be \'ic\\ ed

10

mat

a ... a fir::.t cia ...... le\er. \\then th e patient mQ\'cs the head In one d irect ion the bu lt oc~:-. will mo\e in the OPPO'IW d irec ti on a::. he or she PI\'OI:-' at the ...,houlder.... For exampic when attemp ting 10 Iralhfer. <1 patie nt mu...,t lift bod~ weight off the bUlloc ks . To assist with Ihi .... Ihe pal1t:'nl can place the hands on the tran ...,fer -.;urface and rock the head fOf\\ard and down. Thi..., mO\'cmcnt \\111 LJU'l' the bllttoc~s to lIft Up ..21 It i", lI11pOJ'lalll to notl.:! there i~ more to i1 transfer th,111 jUq th e ph ysical aspec t o r moving tht: body from pile ,urface 10 another. A:-. \\ Jlh all runctional sk.lib. the paIH~'~' must be in ~trucled In the component parts 01 thl..' ,let U\ (e.g .. pOSitIOning the \\hceJchalr. lod.. IJ1& he.:- br ("

Chapter 2.1 Traumatic Spinal Cord

h~jury

975

relllll\ Illg the.: .1fInrc ... t.... placi ng. the ~ lid ing boa rd) before thl' entire ...cquence i'l att empted.

Prescripthe Wheelchair ~ l o~t

patient .. \\itll CI \\ 111 u.. e a \\heelcha ir a!<. the primal) mean .. 01 Illobil ily. En:n the patient \\ itll paraplegia \\ho ha.., l1l~l'I t ered :lmhulallon \\ IIh crutc he" and ortho"e ... \\ ill choose 10 u... c a \\ heekh:ur a!<. a primary mean" of locomotion hecau ... c it pro\ Ides It 100\er energy expenditure Jnd grea ter .. peed and ... "rety. Be.:call!<.c most p:1l1el1l" will be u.. ing iI \\heckh~li r e\.ten .. in: ly. 11 ~ h ould be ClI!-.tO I1lordcrcd lpn.:',cribcd) for each indi\ idual. \Vhcll prc!'c rihing ;\ \\hcdchair con ... idL'ration ... hould be give.: n to the pa tie nt ':-; ~oab and cha r ac t e.:ristil'~ as wt! 1I ;I .. the activi ties and envi;011l1lcnt 111 \\ hich it wi ll he u..;ed. The fir..,t choice i... het\\ cell a po\\'e.:r and l1lanu al whee lchair. Ge.:ncrally. indi\ idual... \"ith illl:tct tri ceps funct ion are abk to IIldependently propel a man ual \\ heelc hair. Indl\idual ... \\ ith a C6 or C5 level inj ury Illay also be ab le 10 mdependentl) propel ,1 Illanual \\ heckhair. bUI the)' l11ay not h'l\ e the t!ndurant·c or ... trength for community \"ht!c l(h;ur Illobilil) . Indi\ iduaJ.., \\ ilh higher cef\'ical injurie~ genaall) rei) on
I"

Figure 23.27 Rig id fra me \" ith four whee l IOlIcpcnllcl1t su . . pcn .. ion providlllg .., hoc .... ah.,orption 0 11 unevcn tcrrain (Courtcsy of Color, in " lot ion, Anahe im, CA 92806.)

Power wheelc hai r... are ind icated ror all pat ie nt ... with C4 lesions and above. PatieIlls wi th C5 level lesion... may ah o c iCC I 10 use power whee lchairs. parti cul arl y ror commu ni ty mobill lY. A tilt-i n-space or rec lin ing '1eating '1yMc m pro"ides imp roved postu ml co nt ro l and it allows th e usc r to independen tl y pe rform press ure rel ief. There arc v ari o ll ~ types of cont ro ls. They range from a hand-o pe rated joyst id. to a si p-and-puff con tro l. A wheelchair prescription will vary accordi ng to the level and extent of injury. More specifi c infollllation i... presented in Chapter 33: however. some ge neral con'lidcratiOll'" follow: I . St:at dt.!plh should be appro\lI11att!ly I to 2 Ill. (2.5 to 5.1 cm) bac .... from the popliteal ... pact! to allow an even \. . cig ht dis tribution on Ih t.! thighs and to prevelll exces... ive pn.: ...... ure on the isc hi al tubero ... ities. 2. Floor-to-... em ht.! ight is importunt. If a ch~lIr has a ... llIlgtype seHt. a ~l:a t cu... hion Wi ll be rcqulred (SOIllt.: COI1toured. cu ... tolll-de ... igncd .. cats elll11inate the Ilet.!d fo r a "'l:at c ushio n). The type and dll11ension .. of Iht.! c u... hlOn or l:u~ t o m - ...eal Illu ... t bc . . nown so that !-.eat height ca n be mea ... ured accurate ly. allowi ng adequ atc ('1 in . [5. 1 cm J) dearance from th e 11001' to the foo t pedal .... and can pro\ide ... Iightly grealer lhan a 9ll ang le at the hi p.... ~. Bad.. height i'l al ... o a cons idt.!nttio\l, If the pa tient y. ill nol be pushing the wht.!clchair. a hi gh bacl llIay be deSIred for added comfort and st.lblilly. A patient \\i th tetraplegia v..ho \VIII be pu ... hlllg Ihe . . . heclchair rcqui re~ a had. height that is below the II1ferior angle of the ..capula ... 0 that the axilla i ... free of the handle ... during fUI1\.:lIollal a((IVllle .... Most patient ... "ilh paraplegia prefer i.I lower back. height. e ... pecially if they h.we 1I1tact abdominal muscle ....

976

PhY'Ioical Rehabilitation

-l. Scat width and depth i... "ilriable and ::-,hould Ix: tilled 10 the

anlhropometric charilctcristics of the patien t The patient . . hould be fiued in the narrO\\e ...t chair po . . sible. but have adc4Llate ~pace bet\"een the lateral edges of the th igh... and \\ heelchair amlre ... ts or wheels 10 avoid io.kin irritation. The patient \ pre\ iou ... weight should be considered. e. . pecially if there hw.. been a significant lo...s since the ini tial injury. and potential exi . . h 10 regain the weight If orthoses or Ihid.. clothing in cold climates arc worn. they mu ... t abo be included in the con ... idcnuioll of \\ idth. 5. PallenI'. v.. it h LE spa~t i ci l ) may require hecl loop ... and/or toe loops on the footrcs ts 10 keep the feet in place. A pelvic bell may be necessary for ex tensor spasms affcc tin£! the lower trun!" and hips. Elevating foo trests may be necessar) if circulatory prob lems are presen t. 6. Removable annresh and detachable swing-away leg reo..,[s are important components of wheelchairs used by many patient . . wilh SCI. On some chairs. the leg resh do not detach and the anllreq~ are of a "nip-up" design. The ... uitabilit) ofthe-,c feature!:.l11ust be considered with re-,pect to the transfer c;'lpabihties and techniques used by the individual patient. Additional \"hec1chair acce~sories may be reqUired to meet -,pccific pallelll needs. Several features that warrant con . . iderallon mc1ude enlarged relea~e mechani<:;llls on the leg re ... h. a friction surface on the hand rim .... brake extcIl. . ion.... anti-lipping devices. and grade aid)., (which decrease back\l.ard 11l00emcnt of Ihe chair while ascending inclined . . urface . . ). Some patlcnts ma) requirc more than one wheelchair. Many ..,tandard lightweight "everyday" chairs arc suitable for "'port and recreational activities. However. depending on the mterest.., of the palienl. a 'iccond chair specifically dC~lglled for a particular ... port !:>uch as tennis (Fig. 23.28) or racmg (Fig. 23.29 A and B) may be required. Other c\amples of "Iport and recreallonal chair~ are presented in Chapter 33.

Figure 23.28 Wheelchair dc ... igned "'pecifi(;all) lur ... ports . . u(;h a ... lenni . . , rCourte . .) of Color. . 10 \101ion. Anaheim. CA lJ2!:106.)

A

B

Figure 23.29 Wheelchairs de~lgned "'peclfically lor rac ing (..1 Courtesy of Invacare. Elyria. a l l 44035: B Courtcsy of Brike Inlcnlmional. Ltd. Tualatin. OR 97062.)

Because patient!:> with SCI are at high ri ~ k for sk in breakdown. a customized seating system includ ing a wheelchair cu~hion will be required. A large variety o f cushi on styles are commercially ava ilable. The cushi on should be comfort ab le. and provide a stab le seating su rface for fu nct ional use of the UE~. Figure 23.30 presents sevenl1 s t y l e~ o f ava ilable ...eat cllshions. W heelcha ir Skills The patielll ~hould be taught how to ope rate all the "Ipecific parts of the wheelchair. Management of the brakes. amlS. and pedals is crucial for all tran ... fer act ivities. Man) paltelllS with limited hand function afC tlble to propel the wheelchair by u~ing the base of the hand again ... t the hand rim. Some pallents require a...... islive de\ iccs 10 aid in propulsion. Vertica l or hori/ontal hand rim projcclton\ (Fig. 23.31) are useful for patienb with poor hand function. The u... e of cycling gloves will pro tect the sklll and <1 1... 0 will improve the patient .... grip o n the hand rim .... Whee lchair mobiltly activities ~ hou ld begin on leve l surf~lcc", (including doorway ... and elevator... ) and progress 10 oLltdoor, ulleven surfaces. Paticnts with ... ufficic llI UE strength and upper tnml... control also ... hould Ill.! in... tructed in .. \\hectic ...." \"hieh involve ba lancing on the bac k whee ls of the chair W lih the ca ... ters off the !loor Whccl ic ... arc required for lIldcpcndcnt curb ciullbmg. Many faciluie ... ut lil /e canV~l'" ... lr;:lp'" ",c(;urcd to the cciling to a ... <:;i ... t wlih teachi ng th IS tcr..:hnI4uc. The di ... tal end of each strap ha ... a C-clamp. which allachc~ to the push handle of the \.I.heckhmr. Thi ... a J1o\\~ sate practice by eliminating the danger of a p
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PhHicaJ R~habiJiLiuion

97

mnuc:nce the ",uccc,"" or ftlllurc In allammg Ihl' gfJul Pallenl' mu,t po'SC\\ adcqu.alc mU'o(;le ... trcngth . y., N tur(!1 . allgnmenl. ROM, and ,ufficlcnt cardlova\Cular en(lu

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Figure 23.33 Lateral ~eight shifl for pre\sure relief.

'!.'ri" around the pU-'h handle and leaning toward the opposite wheel (Fig. 23.33), and (3) hooking one elbow or wris1 around the push handle and leaning forward (if tnceps are available. hooking the elbow or wrist will be unnece"ary). Tho~

patients who wiJl

to fold and/or

di~semble

be driving a car must learn how the wheelchair and slide it in

and om of the car ar;, well as learn to drive with hand con-

trols. Transfer techniques should be considered with respect to the type of car the patient will drive. Vans with self-amtained ramp' (Fig. 23.34) or lifting platforms are a great ass.el for patients with tetraplegia and can increa"e their functional independence sIgnificantly.

Ambulation After Spinal Cord [njury Regaining the ability 10 walk is a common goal for mo... l

individuals following a SCI. A number of facwr> WIll

/1

funclional amnulal{Jr

follOWing S I" very difficult. Walking with (mho," and i1~SI\IIVe dcvice~ i\ slower and requm::, more energy Ih(m nonnal ambulatlon. Many Individuals With SCI Who learn LO walk with the~e devices may not contmue walkmg on(;(: they 'lOp rehabIlitation . When initialing a gait training program therapi I ~hould be realistic WJlh patlenh and provjde a dear PICture of the CO<.,l\ and potential benefJls. Pallents v..ho wi,h to learn to ambulate follOWing a SCI ,hould be given thi<' option even jf their pOlential for functional ambulation " small. Although ,ome patient rna) not become functional ambulalOr... sumdmg alone may pro_ vide other important benefit, such a~ Improved circulation, skin integrity, bowel and bladder function. Jeep and well-being. '" Individuals with complete SCI muq rely on onholle devices. aSSi'iolive devices, adequate RO\'1. and m:ngthtning neurologically mtact muo;.culature for standmg and walking. Inasmu ch w, spinal bracing i., t{JO re lric.tJ\C heavy. and Impractical for functional ambulatJOn adeqUC1lt: ROM and poslUral alignment arc crucial in achieVing _Ut-

bility of the trunk. Full RO.'v1 In hip extension I c senllat alLainIng balance In the upnghl po'llJon. The pallem leam ~ to lean into the anterior ligaments of the hlp to tabilize the trunk or pelvi,. The ab~ence 01 ~ ntt He Ii n I1nd plamarllexion contracture!, is abo Important 10 uamtn; upright ;tandlng balance. In

Adequate cardiovascular endurance al\>() J r for functional ambulalion." Becau c the. en r_

n

ambulation for a patient WIth parapltgl
important factor in determinmg UL f' (r funcllonal ambulator Although somt.: tramm be atLame.d with a program of endurance In

LE" the pallen!"s age. body "eight. and hi ' r v3<.,cuiar dls.ea~ or re'>piratory problem amount that can be achlC\o'cd, Other factors that rna) rc tnet .l1TIhu severe: spasticny. Je)<.,s of propnoccpuofJ pan u hips and .nees1. paIn. and the preM!ncc of c md pJicalJons uch a'l decubJtu uicer'i helerul P mallon at the hIps.. or dcfonmt) In addUI n IP motivation play~ a J ey role In dClCrmJnJOj:! UC(;e ure '" ambulaLJon. A hIghly mOlJval.ed paUt'nl

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thaI ~ noo b~ a molded peh·lc b3J1d "ith Ihorat:lc \.1 '100' The RGO ha~ :I dual-cable ,>Y5lem thaI run~ ' ''fl<'rl) and .nacho, 31 lhe hip joint>. n,e", cable anachmen:~ traIl,nlll force: ... l"'Ielween LEs and pro\ ide reciprocal mo\etllent. \1o\t::mcm at the hip in one direction facilitatel., roo\ em nt in orpo,>i~e direction on the contralateral 11 p. For nample. "-' weigll1 is ,hlfted onto the lefl LE the n£.ht ... mo\OO fon\ard. The dMaJ~cable s}'\tcm allo\\ \ contro) ofbolh flexIon and extension. Th~ cables functlOn 10 I.. rlm.1le·· ac..1jon bemeen the 1"\\0 eXlremitie'\ during am'h "', 00. A ... the ad,·ancjng leg is unloaded. it lS a(,~i~ted fle'\.1<m \l,hile the ...lance leg. is ...irnult.a.nc.ou"l) pushed exten(,JOn. TIlU.... the orthosis allov.s for unilateral leg ad,anremenl and a rec·procating gall pattern. \\Jth thi~ ~ ..... a 1"0- or fOuT-point gait panern can be u,ed in combination '" nh crutches or a reciprocating wal er M",'em"CIl I" • sealed .111On " acc:ompli,hed h) unJoe m.g the drop] C aJ the ee joint. 1<;4- 'if Peh ic band, and ,pinal an.chment; are rarel) I'l'e\CTibed j<>r u'" '" th conventional KAFO,. The"e aUMhmenu. c,everely re~'Tjcl dres'Slng acni\'lUes~ movement from tting-UHl.andlng. and ambuJaw>I1. by mrlucmg trunk and fle""J t) and by adding extra weighl (oiten .. much aio 4 b".1 Furthermore, the u~e of 1he...e componeDUi ~ ga t t;}Ql,.V laboriou an.d u'>uaJl) Doni UDctionai. Patient~ \I. ho would reqwre these at11:lchment are usuall) 'lot c.:andJdaIeS j or ,orthotic pre,LTIpUOn Jn~t.ead. lht.,~ patJ.or4~ can achJ!,"ve phyt.}ojogJcal \"1.andmg .'" th the u,.,e .if fOUln ~ frame iF g. 13.37 J. P..n1.le· 4001 ortholo,.es (AFO~ are often apPJopnatt j J patlent(, v.rth Jower-JeveJ Je~)On~ (e.g L~ and ht 0'" EIther" (;{mv~rltJomJ '"J1euJ."upnght OJ pla>;tJe: AFO rna he

me-

pen,-.

F gum 23_31 A I.and,! em'mnrnr;;nt Th.i.l. tJJ I

~

11

.tat TTl!)"' et: to prj ,l~nC)J PInr1

f)f>'·lerlol urn~hl

tiUUl' r ~

C

lWLr:.

I

mdJcated

Gait 7ruming $lrateguu•. A " .... mg-through T),pt oj b'-i.1 I pat1.errl F p 23.~fS) r,.;hould he the ulumate gum f01 funt' tiona.! amhuluton. with Y. AFO·. In reactuI1g thUi pallern, II u. Jmprn1anl to r,.;trefo;t, u hfTl()oth. t'"vefl cadence Cn./lc..:ht'!; hhr)uld b-; plac.:ed eqtlldit;tanl from hotb Ir)eb al Iftt- di ([tid Ix euu,dlhiurll jmm hrll h heeb, al heeJ o.;ll' } e JI I lrnr lflltllrll 1) arl )Vera J rhythm, a lmpJ"flved tJJtlUJ~' W J If'I pr ved .enerry t'ft"KJerlt:y and ("0' me .1 ~/~J. Wt! fWJIWf act

rIleb llldudt- Ih()b~¥

d"".t"J'lhed heln .....

Oft "rid f{,fflfII tllr (J,.rho~('\ Tht paw'HI I ilI I 'hI ht c'Jnec.,.1 ......... l! d'm and doff tht ortho'>.t:, The:

Purtlll" tat!

en

t:

pr

1ct"-dUl

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fwm\.II

"

I

m'l aJ

r 4.lijual d'Hit

H

rht

uprm

,I

JOlfir

f,alwnl TflU 1 h.... t:auIJolled 10 COIIIJl1unu 1.\ P'" ure: ,Ilea particular! allel htllLt:

."

(hapl(or 2.1 'Jraurnalic Spinal Lord Injury

2 ~Igure

, III/IIUl!; lifO/Old

3

4

98J

5

23 .38 S\\ III~ - through gmt pallem

Thi ... involvc!ot lifting and lowering the

bod) III \)(l lurn~ and changing hand~ from one bar to an(lther • JII. k-kfli/ill\!, Thi" entails con trolling the pelvic pm,ition U'lIl~ l!F .,upport and pO!-'lIioning (he head and ~ houlders lomard ahc,ld of the pelvis. This is an unstable po.\i Lion, Jml tht! patient must be laughl recovery 10 overcome and/or to prc\cnt thIs from happening during ambulation. ·.'t/llim/alum (lolt'ilies ill the parallel bars. Four- and Iwopomt ga lls require hip nexion or hip hiking. Palients with high lesions may learn thIs movement using the secondary hip hiker... (i nternal and external obliques and latissimus dOr\i). Those with low lesions wi ll have the quadratus lumborum inIac!. Trunk rotation on the ~w ing ~ide or laI-

eml nexion toward the ~ t ance side wi ll facilitate forward prog re~~ lon . Nare: Swing-to and swi ng-t hrough gait!) require vary ing degrees of body elevation and push off. The~e gail patterns involve !)ome jack-knifing and recove,). At pu,h off, the head duck> to gain increa,ed height , and at foot contact the head and back arch to help regain \tability. . As~i.\ll"e d(!\'ice. Forearm crutc hes are most often ~electcd for pat ten ts with paraplegia. These crutches proVide ~e\'eral advantages. They are lightweight; they allow Use of the hand without the cl"Ulch becoming disengaged: the) fit mare eru,ily into an aUlOl11obile: and, mOM importantly. they Improve function In 3mbulation Hnd ~tair c:llJnblng by allowing full hip ex tension and unre"otricted mOvement at the shoulder~. , ~'U"dlllJ: jrom 'he u "eelchmr wirl! cl"I/fcheJ. To begm thl\ aCllvlty the patient first places the crutc hes behind ~he chair. leaning agaln!>.1 the pu!>.h handlc«..). To assume iI Standing position with c rutchc~. the patlenl moves ror\Io'3rd 111 th"1 . s, crosses one leg c t lair, Io(;h both knee Jomt over Ilel,. the ot hef (F'Ig. 23.39), and then rolalC~ the tfunk and • \IS. Hand placement, on thc afmrest ilfe rcvcf\cd ill1d

the patient pushes to standing by pivoting around to face the chair. The reverse of this tech nique is used to return to the chair. Crutch balancing. Initially. the patient must learn to become ~eC Ufe in the tripod stance. This is best achieved by firs t balancing in the parallel bars or aga inst a waH. Weight sh ifting. aitemating lifting one crutch off the noor, and jack-knifing should be practiced. Amblllation acril'iries. Four-point. two-point. swing-to. and sw ing-through gaits s hould be practiced. The) demonstrate a progression from a slow. steady gait pattern to a faste r, unstable one. A gradual emphasis should be placed on improved timing and speed. TrOl 'el aCfil'iries. The patient should become profiCient In wa lk ing sideward and backward. turning. and walking through doorways. Changes in floor surface (e.g .. carpeting. tile) and terrain (sidewalks and grass) may prese nt probl el11~ for the patient if they are not in troduced during Lraining. All patients wi ll require proficiency in ambu lalion on level su rfaces to master these more difficult ac ti vities successfull y. EIl'\'atiofl Clctil'iries. The easiest pattern of a~cent or descent of Ioitairs is usually upstairs back ward (Fic.. 23.40) and downstairs forward (F ig. ~3.41). ~Io:t patients wi ll use a handrail: only the very exceptional patient can manage stai r" Wllhout one. Once some uegre~ of proficiency is attained, goi ng upstair.. forwurd Jnd downstair'i backward can be practiced:.l~ \\ elJ. The u\e of grad uated 'itcps wi lJ help make the mllial ta,'" of leam· mg cHsier. The theraplM nCl!ds to guard and It1 ,upport thc paticnt adcquatcl) . Tht: U\C or a prop('r1~ titling gliardlllg belt i:-. e . . sclltial. Curb\ .. hould N' .1Ih..'lllptl'U la\! , bcc
lJ 2

J'1t

jl:al

Rl h.bjlilltufJrI

Figure 23.39 Standing from wheelchair using crutches and bilateral knee-ankle-fom orthoses. The reverse sequence is used to return to the chair.

stable method. Swinging botb legs up together takes considerable balance and is for the more advanced ambulator. Falling. Controlled falling and getting up from the floor are important considerations for parients expected to become functional ambulators.

Locomotor Training for Indi vidua ls wit h [nco mpl ete Spinal Cord Injury Locomotor training using partiaJ body weight support mWS), a treadmill (TM), and manual assistance by

trainers is a relativel y ne\\ therapeuric IlUerH~ntlOn to reuain walking after SCI. Terms to describe lhis framing include body weighr supporred rreadmill rramilll? pafrial body weighT sllpporred treadmill rramilH!., or e r .. hT supported rreadmillfrailHflg. These terms empha<;LZl' the

exercise or training equIpment that IS cUITentl~ advocated for retrainin g walking by medical eqUIpment manu facrurers and by so me clinicians and researcher~. hcw.e\er the terms fail to describe the critical element~ LJ f'

0

~

\

,r:j;

=-4 1\

dD

\\ 2

3

4

5

Figure 23.40 A'iccildinp: ~t:Hr~ backward. TIle crutch is placed on the step to which the patient is a~cending . The head and trunk arc forcefully flcx.ed While depresslIlg the shoulder!) and extendillg Ihe elbow~ . ThIS m!tneuver unwelghl'i the LEs and crcules momentum for movement to the next 11l!lher step. POlilurul ulignmcnt is then regamed .

41 Descending ...laI.rS fOJ"\\ard . To begin. the crutch remains on the slep thal lhe palien l f)e u Qn of the head and trunk is immediately follov.ed b) fo rceful extension pr . g the ~houJdeJ') and extending the elbov.. This procedure unv. eigh15 lhe LEs and omentum for the mo'\emem to the next lov.er step. The crutch is then lov.ered and ;:-unent

'r~

regamed.

Vv hat doe!. a therapist actuall} do with a patient v.a~kjng USlflg

this equipment? As this inter't t n relati\el) new. i~ use is in transition from an e)
uppoJ1ing u;e of locomotor training following SCI.

Lo(.:omutor traming IS a product of translarional or hridl1e reJearch. Knowledge gained by basic !,(: I ~ n c.:e re'>ean.:hers concerning the neurobiological control ~Jf v..;d kmg laid the foundation for developing a therapeuII mterventlon v.llh application to human. clinical populaIJlm Ba~ i<.: \{;ienti..,h !o.teeking to understand the role and (()!ltnbutJOn oj the '>pinal cord to the control of walking used an al1Jma] model of complete SCI for their il1<.juiries. Ihl:) d, \(.;()vcred that when mid-thoracic ">pinalized cals At f e pl'Ked. ()fJ OJ. Ifeadmi II , ,>w,pended by a sling. and rC']>t IJIJvdy tfamed. lor hind-limb '>tepping with ass i ~ t ance Ilf Lr . lIIlCf'l for loadJll!!. and IUllb placement that the an imal., "' ..uned to hind iJl1Ib '>tep (011 the treadnlJlI) IIldcpendent 01 upra" plIJa] Input ,~ , I~II l-ul'tilcmlOre, till"> in tcn,,>e train ing ""il la,>k '>1>Ctl!U.; 111 that the spinaJJ/:cd cah could be lJalllt:d III Mi.lOd . or 10 step. bUI Iha t tralnmg 10 perform onc IW t.1 I<. duJ Il()t tlall'lkl h) pcrlonnancc o j the other w"k. \1'/))111011 1\.· ...ttJl'l'Il III 1111'1 aren.1 ,>lII11u laleJ J neufO'IC ICllli'lt ,llId phY"IH,al thclapl'It, 1lu~uc'l B arl~,lll , 10 att empt Ihe 11111' '>1r.iltt),!Y lor 1 \.· II :'III1I11~ wa llo. 1I1J.! 111 hUll1a ll 'l a lll!1 Irau IILlhl ')( -I lI'UI'Ii:.IIH)JI;11 Ic'>c;udl H.Ir!k',HI and 0) wcnkcl'I publl'lhed the,' 111'11 "'ludlC.~'1 111 ~ III' h 11111110111... ""('n' p;1I1I:11I y ,>u'>(1C ndcd wll h a hody "'t'\ I .' 11 UppOJl .111P;U;lIn'l ovn ;\ In::ldmlil Ie) e;\oIllllllC Ih 11I111.1t t 011 yalll'~' "01 and 111\.'11 prllvJ(kd 1)';111111112 '1l1ml;1I In 111011 ""'lk'llc'l\{ l'cI hy IIll' l',l1 "1 101 PI.' I'IOII'" Wllh SC I I' I" ()Up I1 .1 'I1J'>IK'I1"llIn "'Y'l!c'1I1 ;Ind 111.',1<1111111 ;IPIX'.11 leI tx' hIJIlV I. I1IllHltl1l cll-lUlI1l1n.IIOI , 1)1 Ihl IloIll1l1lJ.! the l'qtllP 111"111 I IIkt.,]" 1101 thl' dC)lIllll;llll I. llth.1I «(lI1lPI)I1l'1l1 I Ill' I'f~eaf£ h

equipment provides an effec tive and controll ed envi ronmem fo r consisten t and int ense practi ce of waJking that can closely approx imate the sensory ex perience of walking. The successes of the spinalized cats and improvement s in walking by humans after incomplete SCI were attri buted to acti vity-dependen t plas ti ci ty of the ne ura l axis. 163 Acti vi ty-dependent plastici ty or the responsiveness of the spinal cord to task-specifi c practi ce and its capacity to learn were new concepts and revolutionary for the rehabilitation of persons after SC I. 164 The spinal cord and neural axis were responsive 1O the ensemble of se nsory information specific to wal kin g and generated a motor response for stepping. Many resea rchers and cl inic ians, including Barbeau, cont inue to translate knowledge from bas ic science into deve loping a rehabilitati on intervention to rerrain walking after neurologic inj ury or disease. 165-169 In paraJlei, other resea rchers focus on tes ting thi s il1l erve nt ion's efficacy and effec tiveness fo r the recove ry of wa lking afte r SC I. 170----175 Hi ~lOrica ll y, rehabilitation fo r ambulati on after SCI has been built all the premi se th ai the spinal cord is nei ther "pla..,tic" (adaptable), nor ca n il can learn. Afte r SCI, c1imc ian.., th us I,e l goals to max imize use and Mre ngth of the mu..,cu lmu re remami ng under volu nrary con tro l tlnd 10 "ub"Illtute for weak or paraly7ed mu~c1e", \\-ith brace"l Jnd/or a"l"ll:-.tivc device:-.. ll1 U"l, Ih erap l ~'" taug ht Jltt!ma ll\C '1rr.neglt:.., for umbul ation Ihal incorponlled brace, and a","I'IU\e dcvJC.:e" :.lIld <.:ompen"l3IOry gait pJtlern:-.. In contr..l'tl, 101..'0J110Lor Ir:llnmg 1'1 J mean'l of IIllcn..,eI) pr~lt:llt:ing the dh1111<.:1 and "1)t!t:!lIl: la'llo. 0 1 \\~lIJ..lflg (pro\ Iding Ihe . . en,o~ c)'lX'nelll:c 0 1 \\allo.lIlg) \\-Jlh Ihe .lIm of 1.lprlOg IOlll Iht!' intnn"i( neural p;U IWhl}'I re"llxln"llhle for gl"ner.lIlll,!! "Il'," 1 hi" ... lr,lIe!!} Ill;}} he \ le\.. cc.! ,1"1 .1 Tl"I.UI\l" "hOI1c 10l-UP" .IPPltl;ll:h, l"l11ph,I'Il/lI1g Ihc "1"IN1~ e"penl'nll' (11 \\JU.IO~ It) dlIH' Ihl' IIHlll1r fl!'''Ipon ...c ~ll \\.1IJ..1II1-! In l.11nlr•• "I, h:.ll.h· In~ nc\!O' 'Ilr.IIC1!I\.'" III \\,IIJ.., "ulh ,h ·'hrdl..('·\\--;tU.. lOg" I" 1t'LIII\ \.' • 'Inp·dll\l, n" ,Ipph l.It h Il'lIlI1 rll'.' thl" Jl'\ c: IOpID('n! til ,I Ih.·\\ ... J..III \\llh ",1111..1. lel~' upnchl .lnll I .lmhul;.d

Wi'"

Ph",ical Rl.'habilitalion

Figure 23.42 G.ut pJ.Hc:rn of a per-.on \\Ilh an \\ alkel ;lIld right anl...k foot onho... i ....

in~omplctc

. . pinal cord injuT) u... mg a rolling

("'Cl~ pre\ IOU ...... cclion). Certainly ....cn:')or) and cognitive prC,.1("c ...... ing 1:-. required for both :')tr.lteglc!.. hO\\e\"er the rel.111\ e empha\l\ ma) differ. LllColllotor traming i:') to train like -"nu u·olk. It requires defining Ihe ta ... J.. of \\alJ...ing. ib. J...inemallc .... J...inelics. spaIt.ll lemporal patlcm. po ... lUre. balance. and adaplabilil). it .11'0 reqUIre ... an en\k of \\alJ...ing. Figure 23.41 cOlllain ... a ...erie ... of photos of a person \\~11J...1Ilg. \\ Ith a rolhng \\ alker and a righl AFO at a \\ alJ... m,g . . peed of 0.1 Jill ... uS1I1g a traditional approach to gail TCtT:.1l1llllg after SCI. I... thl'" indi\ idual effecri\cly practicing the ta,k of\\alkmg" \\1131 elements are con,blent with the ta,k of \\ alJ....mg and \\ hat element, are mconsi!!>tem \\ 1Ih the f3,k of \\llking? For in",rJnce. mO\'ing from pomr \ 10 ~)1Tlt B \\ htle urnght I'" con,j,tenr \\ nh the ta.,k of \\al"ing. Hm\e·\er,.1 tOf\\ard fle\ed trunJ.... and head aimed .11 Ihe gmund. \\('ighl~a..ring through the ann:.... hlP e\.[en'Ion 10 neutral. une\ en ... rep length",_ hik,mg the right hip. \3ulting on the left tCIe. no knee tle\ion on the right. .md Ihe ... k~\\ \\31k1l1,£. 'peed are not con"'t,tent \\im the 13",1, of

An appropriate BWS system and T\I pro\ld< th opponunit). The patient \\earing a trunk/pehi hame supported by an overhead and adju~table !ou\pen lon s~ tern o\er a T~1. Trainer. . require acce ... ~ to the trun pel and lo\.\.er limbs 10 facilitate upright po~lUre, "'e1ght hlft and limb mo\emenb. This en\ ironment afford (: ntr of the amount of lo"er hmb loading. assists 10 upr ght p lUre and balance. and allo" , contrul of the ,peed of" 109 (Fig. 23.~3). -, With 35 percent BWS. manual a lance at the trunk. and peh is to promote upr chI p e and minimize hip hiking. and lov.er 11mb tr' er pr moting 'tep symmetry. hip exten.,lOn.., and h n t n.. t ion on the right. the mdi\ Idual i~ able to v.a! of O.g to 1.0 m, ,ec The therapJ t mu t d
wallin£: Tram Jd.. c \" u \-\.1 ~ trJ.n,lat"~ into the folkm ing pr3('ti\. I tr3111mg gUlde-Iinl:' I th LE., lre ma\'lma1l~ loaded hlr Yo e-I~hlhe nng. mmlmllmc or elimlllaunc loa..imr: of I~ on,. .:; lh P("tu~. trun~. pel\ i:..., :md h~b 1, ne~.:it­ h..·' n: \.. . . ')rdtn3tC'J lnd 'pe'1.. . tfi ... III the t.1..'k. of \\ t<..m: . .md ~ \.~lm "'n 10[\ 'I atC':-,TC"fOrml)\emem ·.e ... lph\ng m nnnlll..: or hmm k\.1 A" \\ th amIDe \ 1... 1.

rune 1, trammg

practh.,

and

I :1.J.bl)n are m )I1ant:md ~~,,~ r \ nd P rm, Jth n... p cIt: ~ CI m \ Yo nl'" m the crun .

re~o

ho.,"lUL

Goal ... m

The :une tr. 0: the B\\ - ,}

(haprl'r 2,\

=- 9

~

B\\ 50 r! ••

.. ~

t". .

SCI

the 1:">I:"h \\ eii~hl ~. -

U"lIlt::

,,~<em

tn,

.:.Ilu

l

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re _3 ~ L... mNt....r tTllntng r .1 p?l"on \\ ilh Ml in. . .·(lmph."Il' '1. ~3Jnul1, ;md m.mu.ll J. ..... :-I ..Ul.:'e t'1\ tflUlt.'"1'

frdumatic ~pinal Cord InjuJ"\

J1lJ T\l h .l " .1I:h .U1t.lge .. ;md m.l~ ~ the JOnment f ..."lT conji .. t("m prn("ti("e. but the lr.lO_!='ph . . JIl0n W ~","'mn1Unll: lmDul.lIll'ln h abo

E~ ~~..:o

Wr rr..unmg prin.:-ipie--:-. 1.::Ul lhu, be- JPplied \, hite T\J "\\lth J. B\\·S .. ~ "tern :Uld ...·nergrounJ ii..""lr \.'001... ~!~ !Il100bH0n .mJ en. .~omr3.:- .. e" ooth Of tht>c em ,~ .......... t"~:-:-.. Tr.Jl:-femng ...lb :l("quireJ in one en' in"ln01em ber b J.n i.mpon:llll element lor le:uning .1nJ can ~ ~ ....... t\1 ~~ :! d:ul: \!"\.m1ln31l0n of the"\\aJ mg abihue .. ~7 und md on the treJdmill "jlh 8\\'S. - \ todlf~mg ')e ;'"..;-~elers of lrJining in both en\ m:lOment~ \\ III chal·e'C.:t 'he l..X of nt'\' ~ ills.. reinforce ne\\ p3tlem~ and -:'..,..pen.:k .....:e. and 31lord mfOmlJIlOn for g",'l:ll-:-.euing ~- ~:- ~r\ l.lOnmem ... G· ...... .11 guide)ine~ for locomotor tr.umng and for ... afl." --j e"fec-m e Us.C' of the- 8 \\'S ": ::-otern and T '\ t 3" ther..lpeu.. eqlupme-m are e .......enual lO the practice of e\ H.k·nce:-~ t>h~ .. i·ell therap~ for rehabilitation folio" tng SCI - ...~ ~ ; ... Jeline ... ha\ enOl "\ el been de\ doped: re'ean.'h i ... in !)e earl:. :-Llge:- 01 c\.JJ11ining etlicac) and efftxtI\ ene ...... ~r!:-c~ch finding ... are publi..,hed. ImiClan~ ,houh.l . . eek. ~ .:maUon to guide thelf ?eci .... ion-m~J...ing and prm.:tlcc. CI411 ... "")hould -..eel.. mfonnallon trom the htcrature .. Identih (I) \' ho \\ ill benefit from kxomotor ~ ,·,lth the' aim of impro\Jng the ability 10 \\ JII... I.C .• ~~ d.a.'':!ified accordine: to AS IA A. B, C. or 0 ImpalrIke Table ~3.1'. pe~n .. \, ho alre;:ld~ \\ al\.... but nOI t pt"!"\OIls v.ho ha"\c J pJJ1H.:ular dmu.:al motor or 't.'O! pr-e~nl.allon: or per ... un .. ;..It ,t p;.lr1Kular IlClIfll hlgll,)i .t."\fi...

':..lo.. ...

:.;..r.

Figure 23 ,44 I ("W,llm\lIM Ir.UIHIl~ pnTKll'lt'" .ll'l'lIc\1 h\ tlh" I ..... '" 01 \1.UlJlIl!' \\ tit! urn~hl 1"W, ..... !Uf\.· h"r .\ ""'f'llfl \\ 11il

1Il\."\lmpklt'

St·\

9 _-

A

B

Figure 23.45

LOC()lIH.1lOf IflU!1lllg

princip les appli ed

10 ... Ianding

upri gh t wh de pract icing loading


tH.",ldnllll \"1I1! hudy we ight \ UPport (A) and ovc rgro und wuh a wal t. . cr (13).

Figure 23.46 Ir,lIhl.llIon 01 :\10..111" .Illlulrl'd on 11ll" Irt.' adrndlto \.\.III'IIl~ (l\l"!!llIulHl.mil .. ommunlty
r lJ T,a ' _ _.-

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tlIerJ.p e ... mJ.~ J.u,;rn;."nt _t.... rn::'" ~ tiIe-..1.p ~... e- ' ...l.fi...\:" ... ;::-' I:: ~::ren;men'n;. fun..:t.loo:.!l .1uJ '<: ..: r .:fic ti'T ':> t~nlt [Q Ln dUll": .illJ p!'r"oone-L rermv{l[')e em ."'-"",~ ... .mJ \i '" \'0 the p..!! :::n[ mJ ("om\ .. i-,

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pt!'fUlt.U·II~'OUS

II' ~ "k<-m1\k, Tk ek< aI \\ tb.J...c Cf." h ... onuol.'i.lhc boo. R"",.mil reg:lrlling Ih< Il'
. . } ...tf'm ...

b OO~

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.... ~lp"'ro'

h

...

(',-"'tm""..:> tr.lmmifP'Jr..ued. u~e f"," 8WS 'y.;;Q.~m.;

Pn-,encion. H",.1Itb l'Tomotion. and WeUness

Ilne>,S,

Impn.." erT.k.~n ... ill. mali ~ \.'are~ retwbllitJ.HOO t<'liuuquc Jru.J. techoolog) h.J.\.t: lIlCre~b",,-d [h~ hf . . pan of mJI\ Idu " .\1' ·Cl Ba."aLL"< ot the "m~ of "e\.-on~ t:omphca non... Uwr the---e UWI\Hll1l.! . . :tee ill ns for d<:\tlopmg throu;h<>ut thuld"r p.un li rebli"l} common alia CL: ""

..

1he of ')houIder p~ LS ,b..;oci:.lted \\ u.h a \ ariel:'o of fu~­ [0..... ~ facEO~ ffi ...-luac: dtlf3uon of mjw}. \\ c!lghtbeanng. \" heekh~ use. ptJOr ~~ued po~mre. dfc!· bod:'o [il;..b ... mde\. 1('\el of lnJUI}. mu~de imbalance 3[ the shQulder joint compfe,. and decreased RO \ L:':-' ~ Gener. .dl) :tP"!' -'ng the p.lln b biomechamcal In namfe. The method III "hICh an tnJl\ ldu:li "1m a SCI mu>l perform ADL':lo m.J rnobiht} t Le .. ~fer "un weightbe3fm£ on the ~E..... reach Q\erhe.:ld from 3 seated po"ltlOn in u ;. hee-khau In an intemill~ rot.:lh!d shoulder po.. ture to rea..:h obJn: . on J counter. and propel a \\ heeh.. b.air for

~

( -omotion \.."3. the ... houlde.r comple"t. [0 be under cre.uer mechanical ...-rres.. . (hID m pC'I'OR!; \\ ilhoul SO. Fun\.."uons {tw.I are nonnJ.lI~ performed b~ lhe t.runl and LE ... mu.sl no\\ be performed b~ {he CE,_ Pre\ention -;hcu der pa.m b "lwL Proper pGSlUr.l1 alignment 1.... J L.e~ (3d ;b <;\ en J.:. "louenfrherung and "'{feh.:hmg 'houJder

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:

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'!:J.Uolr:.:~ - ~ -.. . -.;: ...e~ Evidel1clt SurtUIW..r) BLY,. S..u"= .wJ r~~1 biltty f -'r pro', dm; LT to fJItf'Qfu !J\~re SCI unn~ a..:ute re-b..J.blliouoo rus lL -'~ .. rr 0t.i.t"I .,.~~. w. For lllic.m. . .e. cEmi.:Jl J.JJ.pt.l..;.r.red. tv s;.!l'e ~ tr..un per"Ofu h;n mg .1 twlo. 1""
ether ~ro"dmg LT hCb b~nerit dunn;; ~ prw.:,.e \\-ar.;m.~ further LmnU;J.-

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1-

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bf:..t.dikr rnfecci n"i-: reduce or _~..: ~ t:n)p _ Do ~net'ib fo~ ne-3.lth cr'!a at .lL;l..re ....,... it} IT Clll roo He deVlce-e = t-t!ff~t:I' c:;. pro" Ide lh 'i

or

mu ...... ub.ture.= -

r-

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Jlbe.l."t 9>l.th IJldn Kiu.ah \\ ithou( di"",blli£). e\c:rci...;.e i ... ImPlY unt tor [ndr. kiuab "nh ("I A \\ell de--lgJ'k!d enduran\.."e rr: :. and re b[an.;e tr.lJDmg progr.un h.a.... been ,,00" n '0 UDpro ...~ fun...--tioo. ,crenglh. enduran.:e. re",pli.Jlt.1 n tUIl\.. P"!r... lI!'l,ed h<-ahh. and qUJ.hl~ ot lite. Tht.~ ~ ncan College f Sport; \1
rhr<e to fi\;c ume... d \\~

olt ~O

Commoo endur:Jllcr ..,en: '"

HR CIJlomder

to

n p:n:enl ot ~.t

mod.ht "" Iud< L E hceich= propulSlOll .. umnlllg anJ ","UII nuung Sum '" u"Bung n:comIll"!l
Ptn i.caJ Rf h.;ahiltUlIiOfi

Evidence Summary Box 23.1 e leded

tudies Examining the Use o f Locomotor

Rererence

Subjec:ts

Melbods/Proc:edure

Results

Comments

Nerrvg A. etal

E 5s 45 acute InJury, within ·weeks· oj Injury E 5s 44 chronic inJury. median ome Since inJUry' 12 months

Ouasl·experlmental with hlslorlcal controls, E outcomes In E group compared 10 historical group (C group) thai received conventional PT previously.

Acule E group: 92', Improved In walking ablll· ty 10 a 3-5 on FAC

C Ss 40 acule InjUry C Ss 24 chronic Injury, medIan time 510ce Injury' 24 months

Acute E group received 8WSn for 30 mlnlday, S dayslweek for 4 monlhs.

Authors d,d nol descnbe well how the actual BWSn was carned O\JI In terms of manual asslSlance and TM speed There was not a con· comltant Increase In LE strength wllh Improve· ment In walking ablilly ,n the E groups

t995

ChrOniC E group received 8WSn for 30 mlnlday, 5 days/week for 2.S months. Acule C group received "conven· honal PT" lor 4 monlhs

ChrOniC E group: 78', Improved In walking ablll· ty 10 a 3-S on FAC. Acute C group: SO", Improved In walking ablli· ty to a 3-5 on FAC. ChroniC C group: 7', Improved In walking ablll· Iy 10 a 3-5 on FAC.

ChrOniC C group received "conven· tlonal PT' for 2.S months Nymar1<, J,

et apn t998

Gardner, M8,

at aPll t998

Behrman, AL, and Harkema,

SJ17. 2000

Ss 5, ASIA 8-0, mean 38 days s/p injUry, under· gOing achve rehabilitation in rehab hospital. Initially none of the subjects could ambulale.

Case series. Ss received 8WSn 3 days/week for t 2 weeks. Initial 8WS 26%-83%, 3 Ss progressed 10 0'10 BWS by end. Initl8l TM training speed: O. t 5-0.30 mis, final TM training speed: 0.2-0.6 m/s. Mean duration 01 each Iralning walk Inl· Hally: 3-7 min, final: 6--9 min.

55 t , 28 years Old, 7 months post· injury. Incomplele C5-C6 Inlury Able 10 ambulale Inde· pendenlly wlthoul AD or orlhosls.

Single sublecl design: AI phase' 6 weeks 01 no Inlervenllon, 8 phase: 6 weeks 01 3 "/week of 8WSn 01 20 min of training using a modified 8ruce prolocol, A2 phase: 3 weeks of no Inlervention.

55 demonstrated Improvemenlln comIOr!' able walking and lasl walking galt speed dUring 8 phase and malnlalned dUring A2 phase

No manual prOVided dUrlnQ r ASIA SCOl£' 0 uu prOVided H, 11 f Ing 55 PriOI Ii Ire

S5 4.

Case senes. LT x 3 week

Ss I : 20 years old T5 SCI, ASIA A, t year posl· Inlury, nonambulalory

Ssl 85 sessions of LTwlth BWS and TM

Sst able 10 take 3- to consecullves sleps on TM wllh 10% BWS wllh manual asslslance only for foot place men I

LT protoco ~ desc"bed demonslr t j menl In m handicap ttr r

Ss 2: 20 years old T5 SCI, ASIA C, I months post·lnJury, nonambula· lory Ss 3: 43 years old C6 SCI. ASIA C, 8 monlhs posl-inJury Ss 4 45 years old T9 SCI, ASIA D, 3 monlhs post·lnJury

Ss2 64 sessions of LT wllh BWS and TM, 44 sessions of LT over· ground, Ss3: 27 sessions of LT with BWS and TM, 15 sessions of LT over· ground Ss 4 S seSSions of LT on TM, sub· ject did nol reqUire BWS. InlMI BWS ranged from 45'1, 10 0%, final 8WS ranged from 25', to 0%. TM speed of 0.7~ I 25 mls Goal of three 10·mlnule walks! session.

All SubjeCIS demonstrated Improvement In walking ability on the COVS ambulatlon subscore.

Specllics In lerms of how manual assistance provlded dunng BWSn nol prOVided

4 of 5 subjects demon· strated increase in slrenglh.

Ss2: FIM walking score Improved from t 10 a 6, galt speed Improved to 0.53 mls. and 2·mln walk dislance Improved 1067 m Ss3: FIM walking score stayed conslanl (6 at bOlh pre- and posllesl), bul pre·lrealmenl usod W/C as pnmilry mOllns of mobility And

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Questions

r0

r

MIIIIII~I'lIl1'lIl 01 III" 1",111 ,,' wit h

J I

,I

l halll ll,l.'lJ1~ I.,J In ..... ltll " If,IIllIlIlIty 1,1 t.

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11

funcuon

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4. 1l3I

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8. Idenll'Y Inree pnrn ry f.ltl "ff ;.ff,. J(7'IiIn{! plnaJ cU1d mJury 9. f~~n~1'" the "yay" advafftif?

. \Iotor functIOn

R
Ihr pal!"HI Ill'"

I{c\'i c\\'

1. Idenul) the clinical feature", of Brown-Sequard, itnlc nor. cenlrnl. and po.,tenor cord \yndromc,. 2. Define 'pmal ,hoc . 3 . De~nbe the Impainnenl~ a\s,oc'Jaled \0\ IIh c.pmal (.ord mju~ Your de~ripllon s.hould addle s ahCJ3UDn that occur in each of the follov. mg areal) n ~ funcuon Temper-.s1ure control

Il r

SCI

-

'f

rA y

t It

J""l} (

,_ "

<. h.lp.t·r 2\ lr .. um..lrj( 'pin .• 1 (. (.rd Injun \ I

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I'IH )\1

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991

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I·

11 nnd. ami light IOllch ('.1:. T-L "Ih'lcnt hdO\\ T-1-. '1c n,.ltion. '''plion inlact In hilateral UE~. ab'lcnt hc lo\\.

.101i.l1

II

"

\I"hi li!\

Bl'J 11",f"ltlil y moderate

ib'll'll~mcc

to roll lO tht: It!ft and

r' SUpll~ \- t ... hnrt 'oil: m~1\imul a'l~ i ~ lan cc Sup I' . t· • Inng ",it. m,nimal as ... istancc Tran,h:r wheclchair H bed: FI 1 score 2. (n:!4uirc\ maxlm.11 a''li~ lam:e wilh lran~rer board) Tran,kr \\ hcclchair H toile t: F I~l ,core 2 (rCtllll rc'l m.l'om.11 a'l'lI~lanCe with tran ... fer board)

1,01.'( Hllnt ic H1

Dn:..,'lIlg uPI-x:r holi y'

Bladl.lcr: FI~I 'l·OI"!..' I uu, t t"X:ganlllll'lnllllclll (.lIhch.'fl/.1 lion program ,l1ld J"t.'ljUln...·' lolal ;1"1,1 10 1Il.11l.lgl.') Bowe l: F I ~ 1 :-ocorc I UU,I bt..'g.1II bo\\ 1.'1 1lillllll1 g pi ngram ,,"h nllr'ill1g. h", bl.·cH IlIL·OIlIIIlI.·1II 01 bm\ .\ t1unng Iht..'

I . \Vh al I'!

P""
perform pr\!ss ure relief.

Wheelchair Sk.llb Tc ... t score: 41ft. Currently lI\lIlg a loaner folding whee lcha ir with COI1 ,oured high back and gel fill ed cu, hlDn . Tolerate~ slttmg in \\ heeJchair for 20 to ~O minute..,

pH I knl '0.;

:!. Itlc ntifY!c:llcgofl/c 1111' patlcnl', probk'llI' III h:nn . . 01 Direc t Il1Ip:l1rmen h • Indl!"e!.."1 illlP:I1J"1l1l.·llh

COmpO\l le Il11p:lln nl'nh (L·o mhlll l..'d .Intl indlrl..'l.·1 lIllP:lIJ"JlII..·III ,) FUJ1ctllllHll 111111 talloll,/LI, '1,lhi I i Ilc'

minimal a\..,i..,tance

\ Iotor l ull c tion incrca!o.cd ..,pa..,tic lI y in bilateral hlp nexor\. 2 on modified A'hwonh Scale

ul hOlh

~ Ilknltl }

tllrl..·c ~l11tlcIP;l t t..'d go.li, and thrl.·c C\ llI..'t·ll'd nul come!'. (rl..·Il\I.'diatloll of IUIII.·llllllal 1IItIIIilllon,/d l 'ilb llll\) for Ihl . . p'llielll. l-ormulalL' tIH·CI..· In:alll1ClIl 1I1It..'1"\,('II(IOII' \\11 11 (llll' pH' gre'''' lo lI tha t could Ill..' u. . t..· d tllIl"Ill~ Ihl.' lil 'l _l \\l·t..·k" 01

VI"'IOn

Shan ..,illmg: able 10 maintalll balance on edge of mal lo r I minute with UE\ III wC ightbcaring pO'lllion wi th

t..' rt el""

direct

Bal:IIH!C Long \ming: able to maintain balance Oil mat for minute with UE ... in wC lgh tbcarin g po..,lIion w ith 'lIpcr-

the paticnl', neurologica l 11.'\"1..'1 0 1 I"IUI ). lIIulnr

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GU IDING QU ESTIONS

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J{' ,Iil~ .1Ilt! differcnl i;:ue ve~ llhu l ar .,yrnplom "h1lllgy from ot her .~an.i fcsta l iom, 01 VC rll gu.

1

\. ·dlC"". and d) ..,cq ulhbn ulll. lIlt) and tle ... cribc the cxamlllalion proccdlU ... \ used to evaluate pallCnl S with vesti bu lar

(h :llilction to establi sh a d iagnm.i<.;, progno'> I\. and plan of (arc . .1. Allah 7t" and interpret exa mination datu and dt It:r.nlllc appropri ate interventi ons for lhe (lilm:ai problems presented. ·t [)c"ribt.' appropriate element ", of the rchabiilta(Inn program for parienls with ve"'llbu lar d~,runcllon.

Vestibular Disorders Michael (', Schubert,

PI , Phil

OUTliNE \nalorny 1000

Peripheral VC\l lbuJar Sy . . tcm ]()OO Centr,.! Vc.,tlbuJar Sy"lcm 1000 Phj\ mJu l-1 : and Motor (onlrol 101'11 101liC hrll1g RJIC [(KI2 VC'>llbulo-Ol,;ular Reflex and

Ve .. tlbuJn-O(;ll Jar Rene" (jilin and Pha~ 1002 Pu .. h Pull Methalu ... m IUCH InhIbitory Cutofl J 003 Veh)(;IIY SlOrage SY"It.:1ll IO(H b :ammatHJn /(,04 HI ... lory 1004 Te~t<j and .\lica\urc., \ i tJbu Jar S

'1' 1 I)

VCnll.!U JOIJ llllLucra l VC\IIOO I.II I l y~'ItIll(. II "'l JOI ~ Jl II'ltcr.11 Ve .. tlhu lilr Hypulum. lllm IOIH Cl'l1lr;11 Ve\llhular Hypo/until/ill IfI Jl, Pilileni LduL.ltJ(1Il l Ull 1J1.I~nr,

Sy

It III

III "I HI tlil v IIhuL.I.

IIJ.n

\IIclllcrc'· IJt'>t'a'>t: 1021

l'cnIYlliphiHJ(; h.wl.1 1024 "Jcuruma lCJ2-1 \IIorltm .";Idlll' lOlA '\.1lgralll!.! R(.·lated 1J/J'IItW \ UJ24 A(;nu~ltr.:

J(J(j4 til

110

lUll

Penpheral Pathology HJl I CcnlTal "-en-ou ... S)"'lcm PathullJgy WI2 Di\(;"crning Penpher,,1 Ve'ltlbul.:Jr Patbolog} from Ccntral Ve~ljbular Pathology 1012

p h~')iCaJ therapists are likel) to encounter patienl ""'Jth \e..,tibular dj~orders in a variety of clinical selling' It I" e"limated Ihat the incidence of dizllne\'~ In the Cnned StaIe\ is 5_- percen!. or greater than 15 mijJion people per ~ear v.ho de\elop the ~}mplom. The reported prevalcm.:c of dizzine\ a~ a medical complainr 10 communit} d\\elhng aduil') \ane!!t ba-.ed on !loubjec"· age. gender. and defmnion of the complaint (I to 35 percentJ . ...i.J l)lI/1nc s one of the mo')t common complaints adults report to II ph~ '))cians and pre\- aJence increase v. 1m age.-.II For j)"41 em older than 75 )can of age. diuInC!ss IS the mo t ~ mIn n re~ to ~ a ph~ ician.'" Patlenl v.ho expen trice dJ..ZZ.ine ~ repon a Significant dJs.abihl) thCl.I rc.du(;e the qualn) of life. - Funhennore. II ha. been reported !hat greater than -0 percent of pallent ""h ,mllal rom plama o dl.l.Z1Jle ~ilJ not hCl.\e a rewlulJon of .' mptQm at !: ~." ee, foUt1\\ -up. Of patient \.\ llh per J. tent du / ~ (:3 perc.en\ reported re<: rrenl !o)mptomt: wnf..Ul.Ll rg te~OQd 3 moo

lllklH"flllIJIJ Ill/ l Ilcn ltlll II;tnIAY .. IlMI Pf''''JI IIJllal

.'v1u lliplc Sdcm ..... 1024

\1uhtplt' S),"'I('II] Atfllphy 1fi24 ("crvltal VCr1IJ,lU I02S CIJlLtrall1dIL .. tIOIl'i III Vt'M,IK.lLiI Ul,!hab,llI.IIIIJrI /fllS

SUllltlwy Ifl2

Cay.thornc 4 and ('(}(Jhcy'~ were Ihe f l r~ 1 dl1l lll:m II) advocatc cxen.':I\C1j tor pcr..,'Jn\ ..,uffcrinp frolll dl/llne and \-ertlgo. h ha'i only been wJlllJn Ihe 1<...,1 1'1.-0 til ",ut, hov.c\'cr lh<J1 our knowlcdE!c 01 \lc'lilbular IUIlUJUIi ;JIIcJ rclalcd di'»order ha., profoundly (;hangcd the J\:.JlthcupJ t how e\ r rnu I t~nJlO: p
frum

is

cer !JaJ palholcJ!!) a '" IJ Co appfecwte u.e uHnpl \JI "' the H~\lJbuJ
1000 I ,

PI"" lui Rl hahllalatlon (OI1tam the ~

tom

tc1'COI..lh.J f tb: haJ.r ...-e

Pe riph e ral Vestibular Syste m Th hrt rrll11Jt') lun~lIon ... of the penph~ral \~ ... 1Jbular !i)MC'm Inl.lude· (II ... tahllllation at \1'Iual image ... on the tmea 01 the rcllna dunng head mo\cment to allo\\ dear \ I Ion. (~) maintaining po ... tuml ... tabiht). e ... peclall) dunng nH"I\ c:mcnt 01 the head: and (3) prm idmg infonTIallon u...ed lor "'pallal OrientatIOn.

membrane polc:nual 0:- t.he h.ur \. e

i.li:.J U1 e-..1t.:h h.ur ... (./ po/un:,,! and d-r For e\amplc. ib the head i... lUrlle\..I 1ft the n;h lh", In the right horizomJ..i CC are e\""HN. \\ rhe left honzomill CC are mlublled. 11>< directIon of head film ement b; 1.·",'mr~U'U1; Ulf'Ul f 0\:1113 h.}\\aro me'

''1m

S"micircular Canal. \\,ithm the pctrou ... ponlon of each temporal bone lie ... the mcmbranou ... \c ... llbular lab) rimh. Each lab~ rinth coma In'" the neural "Iructure!-o thai detect head acceler.:ttion : three \cmicirntiur (,cJlUlls and (\\-o otolith organ ... (Fig. :;4.1 ). The three <..emlclrcular canal<-, (SCC) (horizontal. po ... tcrior...md anterior) re ... pomj 10 angular acceler..uion and are onhogonal "ith respect to one another. Alignment of the CC in the temporal bone i~ ... uch that each canal ha" a cOnlr.:tlatem! coplanar mate . The horizontal canal ... foml a coplan.lT palf "hllc the posterior and contral:Hcral anterior CC foml coplanar pair.... The anterior a!lpect of the horizontal CC I.., mclined 30 UP" ard rrom 3 plane connecllng the c\temal audltot) canal to the Ii1teral canthu~. The po ... terior and anterior SCC~ are inclined about 92° and 90' from the plane of Ihe horizontal Sec. l tl Angular head rot~lIion ... tll11ulate ... each canal 10 \~Ir) lng degrees. l Thc arc lilled \\ ah L'"doi.r11lfJh thai ha!o.

sec"

COpl.lIlM

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IJb~nnthtn

nl.li('!,.

Otolith Organs The "'~lCcule ,Uld umde m.u..e ur the

; u t:' .. membr.lnou ... i.lb~ rinLh .md re"'f".'Ind III Im ..·.lf .11........... .. ~U1d ... t.uk head tilt. Sen:-o~ h.ur Ct~H ... r""l'l~\.·t Ulll'.1 _,: .. nou ... m.Herial th.u h.b I,,-.lkiulll .:.\r~-'O.Hl~ ..'~ .. t .... \. mOl) (,11l~dd('d Ifill. \\ hll'h IJ\.~ th.:- "'t\'lnh ,'r:...: ..... "

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(Fi~. ~~.3t SlillIl.lf tll thl' ~Cl'. 'U,'O,'O tll\\ ani the k.inl"lCili~1 L·.lU"'~'" e\('il.llil'll. \\ hik~ Ilh'lIl'll . \\ \

an meni.lI Illa ...... 1~~ld . . 10

inhil1l1wn. L·rr1.l·ul.tr t'\I."I1.\II\'11 (\...·l·UI" dUIlnf h,'rIlomal line.lf a(.·cl·kTJtwn .md ()r ... t.III\.· Ill·.hlldt .m.! ...\....'\! IJr e\Cllatlon occur,,; dunug \t'rI1('.llltnl'.U .lll',"k ' .lth'l1

J delhll~

..,lightl) greater than \\-~lIer.l:-1 Endol) mph 1110\ e.., fred~ "uhin

C e n tral estibular System

each canal In re~pol1 ...e to the dil~ction of the angular h(,~ld mt~lIlon. The SeC\ enlarge ill one end 10 fonll the .ullpulla. Withlll the ampulla hcs the cupula. a geialllloll" h~u,;er lhal

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('hapter 24 V'-«"tibular Di!.ord£""rJ

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Thalamus

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Stereocilia

Mesencephalon

I

I

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Vestibular AHerents

Medulla I ;

I: I ~

Figure 24.2 The cupula of the ampulla ic.. a flexible, gelatinous hamer that partJtion!\ the canal. The cri'>ta ampullari ... contains tht: kmoclllB and stereocilia sensory hair cell::.. The hair cell ...

generdte action po temial ~ in respom.e 10 cupular deflection. DeOeclion of the stereocilia toward the k.inocilia causes excita~ !Ion: deflecti on In the oppos,ite direction cau~es inhibition.

however. have identified extensive connections between the \e<.,tl bular nuclei and the reticular formation, thalamus. and cerebellum J'J-21 (Fig. 24.4). In addition, ve>ribular pathways appear to terminate in a unique cortical area. Primate studle~ have identified the junction or the parietal and insular lobes as the location for a vestIbular cortex. 2 J.-J.4 Recent evidence in human studies using functional magnetic

Calcium

carbonate

~~t.:L

1-'-"'~;~···~JliD:l WJ\'~~

MVST

"I;I I I I I

LVST

I

Figure 24.4 The ~emjcircuJar canal (angular) and otolith tlinear) input is ...enl to the vestibular nuclei. From the veMibular nucle i. the Inpu t traveb to the ocubr motor nuclei (lll, IV. VI) for mediation of the vestibulovocular reflex. For arou.:,al and conscious awareness of the head and body In space, infonnation

proceeds fUrlher 10 the thalamus and cortex. For maintenance of postural conlrol. the peripheral ve ... tibular input is sen! di'>tally a~ the medial and lateral vC"llbulo spinal traCLS (MVST. LVSn. Plve = Parielo-in'>ular vesllbu lar cart eA. (Adapted from Brandl, T, and Dle lcnch. M,27 p 343. with pemlissloll.) v

resonance imaging (fMRI) appear~ to confiml the parietal and in""ular regions as the conical location for proce5.~ing vestibular information.!'''; Conneclion~ with the ve~libular cortex, th alamus, and reticular f0n11ation enable the .. e~tibu­ lar syst.em to contribute 10 the integration of arou!o.al and of the body. as \\ell as to di ...criminatc between ll1o\"ement of self and the em' ironment ~I>.~- The con~ciou~ a\\"a rcne!>~

Gela.hnous

- - matnx Hair celis

Macula Vestibular aflerents

Figure 24.3 OlOCOllm arc calcium ClJrbOrHllC cry<.,tal., Ihal arc tllJl>cdrit.:d In OJ gcllllmOU., matnx whi ch provide .. an Illcrtiul fila .. I Anc:.ar acccicrallt)n .. hift .. Ihe gclfllmOlJ .. mUlnx [Ill( t X ', 1,; 1te" (JT 1011lbll .. Ihl.: vco.,lJbular uflcrcnl" dcpcndmg on lilc I lrelt · . II B. IUn III whlC.:h the ... lcrcoc lllU urc ucllCC1Cci.(AdlLP1C( rom dlljh, RW, amJ Ilnrnrubiil. V.lO p 4. w ith pCrnW,., IOI1.)

cerebellar co nn ections help mainli.lin calibration of [he ve~tibulo-ocul ar renex (VOR), contribut e to PO:-..IUl"C during ... wtie and dynamic activi li c~. and innuencc Ihe cOOrdillJv tion of limb movements,.

Physiology and Motor Control Knowledge of haslc \"c:.tibuiar ncuropll) ,ioln!!) .... lIllpt.'rt.UH for undt:;... tandlll g the ~ign . . and . . \ mplollh nl \ l, ... libul.u dy~fllnctioll. Imporlnlll pnm.·lpll· . . of [he \1.''1nhular s)~I~m llH:l ud c the toni c li rin g. 1',111..', VOR, pu ... h PUllllll't.;h ..ml ... m.

inh ibi tor)' c UlOfr.

iUld

Illl' \dot.'il) . . torage ...) .. IC11l (\"SS ).

'002

r'h\ 'tical Rdlubililalion

Tonic Firing Rate In rrunate,. rnn1J.I) ,c,IIDular afterl"nt ... 01 the health,

'c,uhular '~"'lel1l ha\L~ ~l "'· ... ung firing r.lte that 1'1 t)plcall) "0 h..l 100 ... plll·...... rhl" pft"'tence of the high Ionic firing r.Jte mt:'an, l·.h.:h \e,uoolar "')"em L'an detect head motIon thnJu!!h l'\.ctlallon or IIlhlbuion. During angular head rotalion .... l[hliJleral \e'libular afferenL'" and ipr"ilaleiJl central \ e-.. uoo)ar nl!uron'" are exclted,~'" Such head i11O\ementl:. al,o rc ull 111 inhibJllon of peripheral afferent..... and of many centraJ \e ... ul:lular neuron ... reeeJ\ Iflg innervatIOn from the conlraJalerallab) nnlh.

VestibuJo-Ocular Reflex and Vestibulo-Ocular Reflex Gain and Phase The \ es tibulo-ocular refl ex ( VOR ) j ... re~ponsiblc for maintaJlllflg .,Iabillty of an image on the fovea of the retina during rapid head movement":.. To do thi~, the VOR must generate rapid compcn~alory eye mo\-ement., III the tltrectIon oppo ... ite the head rotation. The VOR achieve ... thl'" with relatively .,imple pattern., of connectivity in the ccntr
Table 24.1 Jnn (.:rval;(m

P~lttcrn

Vnu Figure 24.5 From the anlt:rior ~ell1itlrcular c.lIlallAIlI S('C). afferentlllput travel ... 10 the \t· . . tibular lludt.'( (Vl\ul. Tht' '>1I:.nal contlllllC'> to the contralateral oculomotor nude I (1111. l'ron; then:. motont:urOlh ~) nap..e \\ lth the ",uperiol' rcclU'" nnhelt' th.lt IlIU\'C'" the eye Up\\Hnl. and the Infcmlr ohllque IIHl ...ck thaI mol.c'" the cyt: upwarJ and IOf'.ionall) \ho ... ho\\11 ,In' the (x;ulomolor nuclei I V, and V I (Adupled from Baloh. R\\. ,Uld Iionruhl
galll (\ ON gam) of the vl:,ubular 'y,lL'm (l')l' \l'klul\ 111'.ld Vl:Joclty

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t,

the ~H

II< ,lI h ,rnd Iht' "lIp~,' IIlI' .tlll! L1\lt'nor uhllqlll' 11111 .. nt· .. hll " "'I1.llh \\tlll "Olllt' 'I..'rlLl, .• 1 UII1l\ltmell! Ih ,\\(lH 1111111 11ll' 1111 .. \\11\.11 1I11.111t11l "1l0h,.'d .... It Ld •• lt·" In IIIl' ':.11'('0111 :~lll" III IIh' ".' ". .. lilt' "UIX'1111I "h h l ltlt' Illll .. dt' Hllille .. thf (\C .1.." 11\\.11.1 ,md !l'\\,ud Iht' 1\0"t·. \\ hert';1\ lilt' Lnlt-rim ,lbll'IU\.' 11111', It, 111\.lll·" Iht' t" t' IIP'\ ,11.1 .rnd Il\\iI) Irolll Ihe IlO""' Ill\.' "Up"'It\'1 llhhlltlt' lIIuwlt' Ir.l\eh Ihrou!!h Ihe !"thrnu .. t

,I. n! t

~L' ll l'l'H l e d

by move menl 01 the cupula I... bnef. i... defl ecled.11 rl he rC"'jxJI1\c I'" .. 1I ..1.IIIIl'd. ho'Wcvc r, by " c irculI of n CUfOI1 't In Ihe mcdla l \ l· ... llhllldl' nuck·,.... and In... ,.. longer than 10 \econd ... III people \\ Ilh norlllal ve ... tlbulilf funCll on. Thc purpo\c o f !'I U\ lillIlJllg la.. l lll/! oill y ,1\ long i./\ Ihe c upu la

Ihl

the vt.· .. llbllbr mpul I'" 'houg hl 10

hm In:qllcllc)'

:1\"",.. '

Ihl.! hr.:ull III dClccllng

h l'ad l o tH! io n .

A Left and

'. rlghl

He

In"hk.t \\ h i. h .1II .ll ht' " In till' .1I1lt'hlllWdliri "Upl'lltlf \1,11 10 1 tilt, rlft'tLl I I HIIIl ~whuh"' II, \Ie. ,\lid ~tltlllr, I B. \e .. l lhul\l-UUlhll rh"I\lhl!! ' tllld t' ll\lI\ ~ \e .. llhuldl h~poltlll(lIOll Ph) .. Tllt'l \~ ,-., ~nn. l, p 1111 Iwnlll ..... HlII . )

,ns. \\

m tht' lhrt' clll)n (IPplhlll..· Iht.' hend 1l100cI11enl) Iu IlIUm1a11l .I-r- llO lilt' IM~l'l \1 rhL' \OR Opcnlle ... ill head \ e loc llt c ... h

RIghI ..:AC J>cC:==-_-<::.._

B

!!rt"l1 .1\ 15010 100 "", P

Left, PC

,

lcchanism

l\I>h-Pull

"Ilk h r"lIn d~lel.; h he"ul 111m el11l'nt and lilrt'CIIOIl Ihrough \llfllP,lTI"\,.1!l III IIlput... 1)t.'I\\l·CIl Ihe t\\O "l""tihular .. ) .. ICI11 .. , Tht' ~(T .. ( "I\..h \\\,.lrl-. III I:Oplnllilr LbhlOIl a.. I11CIl II Onl'd t.':trIe .h Ihe h~"ld b tllrned 10 the righ l. Ihe nghl lion/onlal ':ICC \\111 hd\l" ,Ill lIlul'iI ..cd hnJl~ rail" \\ hilt.' Ihe Icl'! hori· lUlU,l1 sec IlIt ... a dCI:I"C.I .. t'd linng rail' , Thi ... \... culled Ihe p l/r PIli ' lil t'( Jwn/'m (h\.! . ~.~7). Tht: h n lln i ~ thcn n:"poll "Ibl c for ~l'u~lUllng Ihe dllh: relll'c ,md 1Il1crprl"llng I11m'e· Th:m -\ IIUlh) IllIl·rpf\.'I.IIHlIl \\ 111 kill! 10 Jlffil:uilit' ... \\ illl ;u~ ""lhllt',III1..IIl,I'I\hlllr,II"'htbllt l). dnu motton perceplion

RIghI PC

\" Figure 24.7 (. \ ) Orien tation (If thl' hon/nilial "t·l1lll"lrt:ul.lr ( lie) III "111I. \\ i!1t Ihe ht::ad neulr.llI~ illrgned, (m TIll' ""·111Il'lfI.:ular l·,1I1al ... (lp"IJ.llcmlllll lenor .tllt! nm lr.tI.ller.11 pO.. ll' " rh.lr. ;lIlt! c,Lch honfnolal) \~ orl.. III pal ...... nlt~ .Irnm .. IIldll'.lIl' Ihe .t1l,l!ul.u plll"h dlI'Cl'llt1n ul intli\'idual 11I1Il11.llltlll. nil' dli .. hl·d .lIld (;onllllutlu .. Ime ... IlIu .. lr:lle t"lt'h ">CC h.h .1Il l'l.lll.llh llJlpt"'lIlg erN!I\\.' Wille UppO.. IIC ,1IIgul.lr Pill'll \llTl,'IIlIII ollhe hcad, h'r ('\,unplt:, Ihe righl allh:rwr l',uhlllrl!!hl \('11' p.urt'd \\ IIh tht' Iell pthll'Tior l.lIl.II {It'tt PC1. { \d.IPlt~lllnlm B.lhlh . R\\ .•llltl IInmnlh,.I. Y, ~ I P 17. "llh fll,.. mu ..... H111 I ",.1I1IIt..

sec .

lnhibitory Cutoff k \.

sec. ..

Ihal dunng ,tOpllaf hL'.u..! I'01;11 ion ... Ip .. lli.llcml bluar ... tlc-ren .... l.Ul he t'\l'IIl"tiliP 10 .tOO ... pl\...C ... '.... ) \

Cuot:onUIJJlI h i·' \.W"

h~ p:rpt)I.UlI..Illllll

Iltl\\ C\ l'r.

lht- UPpll"lIl.'

thl..~

III thl" UpJlO\IIL' lah) nnlh

h\ pt.·Ill4.ll.lflf.lllon of Ihl!' IMlr t'.:II ..

l.lhHHlIh \:,\0 unl)

dL'nt.'~I"':

tht.' finng T.llc

II .,

~l·1lt'r.llI\ I"l:'\.{lglllll'lillull " I I Milt. ('\1'" llo:l"(,,(,1I II('

\ 11\ IIId ,pill" I,"-'r ~'l.' \\nd nl·uwl1.I1lrnng ralc

I \d\1

F . amination Hi tory Ph~,,\..·.'llht·r.\pl"'I'" t:'\.U11ining pearlt' \\ ho rerun tillllnc"" .uw II11NI.m('~ h~l\C the dinicuh l.b!.. 0f ... oning through r~..llcnti.ll ('.m ...(' ..... Captunng .1 thorough hi,(ol) i, ;1 cntical .. \'ml''1n~nt of the proce ...... _ Kt!'} elemenh of taking the hi ... · w~ .m." identification of,~ mplom, J'" \\ ell il'- their dUf.Hion

Table 24.2 Symp tom a nd Possible Causes Symptom

Possible Cause

Vertigo

BPPV UVH. un lateral ceo"a leSIon affecting the veSl bu ar

-==-

nuclei

-----

BVH. chroniC un1la era es: hypofuncllon. lower ext'em ty somatosensatlon loss. uoper bralnstem,ves bular conex

Dysequillbrium

mJ tht" (m.. um,t.tnC'e~ umit.'r \\ hu:h !.he ... ) mplOm . . occur

Identification of S)~ubols \ 1.U1) pallenb and clinician. . u...e (he lI11precj ...e Il"nll "cJLzli~ ne"," to describe J \ague ,en"';:lIion of Iight-hc-auedne, .. or il fn.'ling uut 1he) hi.l\C it Icodene), to fall. The impreci ... lon of the ternl can entangle clinical managemen! <.Ieci,lon .... It IS e-..entiallO derermine \\ hal the patient b c\periencing \\ hen the ternl di7.2iness i'\ u...ed. ~ IO!)1 complaint . . of bemg "dizz) " can be c:negorized a!-o \crtigo, hghl-headcdne\'~, d~::-equilib­ rium, or oscillopsia. Generall~. dizzine,,~ I~ \agud) delined 3..... the :-.ensation of \\ hirling or feeling ,1 lendenl'~ to fall. Idean~. palienb should be directed a\\ 3) from u"ing the \\oro. Yertigo is deti.ned as an illu.,ion of 1110\ emenl. :'\ Lm~ pallents use the tem1 "\ertigo" incorre~tl) and thu . . the dinician mu...t be cenall1 10 infom1 patient:-- of the U1le definillon 'b well 3S identif) Lheir unique e\perience. Patient.. . ma~ describe mal the) ~en . . e tJlcif em ironment hi mo\ til£! Of that the) see me en\'ironmem 010\ ing (!\pinning). \emgo lends (0 be episodic and to mdicate patholog) at one or mort" place ... along the \-estibular path\\ i1)~. It i.'l. rno . . 1 common during the acute smge of:1 umlateral \esllbular h~poflll1C1l0n (LYH). bUl rna) also manifest it'elf \ ia di'placed otoconia (benign pam\) ,mal positional \ el1igo). or an JCUle unll~\I("ri.ll br:lIn"tern lesion affecling the rool enID zone of the pt'ripheral \e
.

(Table 242). O l)ci ll o ps ia I" the "UbJC'(II\e c\I'lCflcnce of mouon 01 objC'u\ in the \ I,ual em Ironment that are lno\, n to ht· . . 1.1lIonal) O ...clllop"IJ call uc(ur \\ ilh head 1ll0\ ('menh 111 paliem ... '" ILh \c"IlIoular h)polum:llon ... ml'C Ih(' \t.',"huILlr ,,) ...tern h nOI geller
-----

Orthostatic hypotension hype. glycemia. anxiety. pan c d SO'tIe'

Llghtheadedness

a-

leSion, cerebellar and motor pathway leSIons

BPPV \Jeshbular hypofunction:

UVH

Duration and Circumstances of Symptom, mU~1 detemllt1t:' ho\\ recentl: the p.lill'm L, had an acute alli.lck of \enigo. hghthe.ldedne.;..... d\-.eqL bmim. or o:-.cillopsia and \\ hether the ,) mpwm I' ..... " or epl ... odic. If the s,:mpillm i, epl,odi..:-. the ..'11m .. ~mempt 10 determine the J\ erJge dur:.lIlOn \.1{ (he ::-p , in s('cond .... mmme .... l'f houI'. For e\J.mple. \ertl-=-, ~, 'econJ" to minute ... common1: ,ugge,t.... bem~n \ nul po,llional \t·_rtigo. Tn C(lntf:.l'i. \enigt'l J ... (Ul~ rr.

The ChlHCI;Hl

to hour:. . . ugge~t ~I eni~re·., dl,e~l't'. \\hile \eO -=-'

.'. ::

r("lr dJ:" implie ... \ e . . tibul.lr neuromti., ""r 1l1lfTJ ~Hed dinine". TIle ph) ,tc.u LherJpl ... t mu ... t :l.b<.. . Jelemun... CII"CUm ... t.:Ul.:-e" the patient e"\JX'rien ...'t:" ') TIlplt.....n ..

di"cl'rn \\ hether the r.meO{ e"\pcneTK ..·"" \ pa.nicutlr ml" ~nK'nt .... r,,",hHl('O,. l'r.j[ I"'l'-.... i, the r.ltient "cll,ith e 10 1l11)ti("Ii1 .1' thl'- ("\1 ......~1 ::-t ing car'.' Or. liel('''' the p.lllt~1lI ("\periell\."e ,\ \ ':--~ \\ h('11 thc head ,., rno\ cd mil' l~n.lIn 1"-.. .'1111.'11 ... ' t3nt

(0

\\ IUl

Tests a nd ~ Ieasures Visual c\naloguc Sc.lIc L'iC

\.,1'

niqul'

;1 \·,\,hll,m.lhh.lUt ,~ ·.11(

h1

Obtdin ... uhJe~ti\ t'

\ -\.\

IIllel\"'ll~

IIghthe.llkJne ... .,. d) 'eqUllibnum ..md

pallt.·nl '"

I,.m l~

r.n

1,·\.

'-

,-'I

1l!"

~~

h'

\."l'llh' ' .•

,hll'd to .Uh\\l'r.1 qll\.~'II\.)n .UlLt

III I

IlI1e \\ hefe 11tt., "') 11lrwlll'" e·,,'1 ,11 Ih,lt 1ll,'Ill~'lt

1'1.1I1 then

1l11'.1'Urt:' ...

till' hne .1Il...t ('f'l.llll' .\ '-ill,

It

,-'

Dil lint"""" H",ndic.n p h" t'nton n\(' J)':~lIh·\.\

//tll/dli -l.1' /m c 'Itc'I\

lb ...·t! hll\1\.'.'''\I1"(';\ ' ..... lllt·llI ....

,",,'it

. /lUI

..,.\

f\\ ,tI

1"£\."1\ ~"\.t h.lIhh •.", .,..

nl"

; ...

\." \\.',ltbul.u ...h ... ('nkr'" t 1.Ibk .'-t \\" PHI hi' ,'" .. "h.~",1 1"\·I\.' .... t 1\.'II,lhllll' (I P,ll"'l.md L!\",ltnk'n1.l1 \."'"\1 ...... reil.thlll!' ( (l.:,\l)l. 1'.111 . . n."p""lhl il' ~ ... 'lb'" Il ..

·1\..,

Chapter 24 \ '" ,tibulor Di",order\

1005

Table 24.3 Final Alpha Version of Dizziness Handicap Inl'entory with Corrected hem-Total Correlation Coefficients Dizziness Handicap Inventory' Inslructlons: The purpose of this scale IS to Identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please answer '"yes,"' "no," or "sometimes" to each question Answer each question as it pertains to your dizziness or unsteadiness problem only.

hem Pl Does looking up Increase your problem? E2. Because of your problem, do you feel frustrated?

--------------------------

kemTocaJ

F3 Because of your problem, do you restrict your travel for business or recreation? P4 Does walking down the aisle of a supermarket Increase your problem? F5. Because of your problem, do you have difficulty getting mto or out of bed? F6. Does your problem significantly restrict your participation In social activities such as going out to dinner. gOing to mOVies, dancing, or to parties? F7 Because of your problem, do you have difficulty readmg? PB Does performmg more ambitious actIVIties like sports, dancing. or household chores such as sweeping or putting dishes away increase your problem? E9. Because of your problem, are you afraid to leave your home Without having someone accompany you? El0. Because of your problem, have you been embarrassed m front of others? Pl1. Do quick movements of your head Increase your problem? F12 Because of your problem, do you avoid heights? P13. Does turning over In bed Increase your problem? F14 Because of your problem. is It difficult for you to do strenuous housework or yardwork? E15. Because of your problem. are you afraid people may think you are mtoxicated? F16 Because of your problem, IS It difficult for you to go for a walk by yourself? PH Does walking down a sidewalk Increase your problem? E18. Because of your problem, is It difficult for you to concentrate? F19 Because of your problem. is It difficult for you to walk around your house In the dark? E20. Because of your problem, are you afraid to stay home alone? E21 Because of your problem. do you feel handicapped? E22. Has your problem placed stress on your retallonshlps With members of your family or fnends? E23 Because of your problem, are you depressed? F24 Does your problem interfere With your Job or household responsibilities? P25. Does bending over Increase your problem? A

54

.34 .76' .39 50 69 .44 .54 ,43

.46 .5 1

.49 .43 58 .30

62 .58,

49' ,48

.27 ,41

46 41 56 57

es- response IS scored 4 pOints. A "sometimes response IS scored 2 points A "no~ response a points

IS scored

QuesllOns With the highest corrected Item-total correlatIOn for each subscale F Indicates functional subscale: E. emotional subsea'e. P. phySical subsca'e. From Jacobsen, GP. and Newman. CW.'" p 424 With permission ~ubgrl)upl'd 11110 '·UIh,.·ullllJI. ~mOll11Il<.lI. and ph~ "'Ic.li compo-

l\totion Sensith'itJ Quotient

n~llh.

The \/011011 .)cII.\uirin· Quoli('1/1 f \/SQ J \\ .l~ de, doped to prm IlIt..' :1 ... ubJt..'ctl\e ... core of an IIldl\ ItllI ..II· ... dill!ne ....... ~' The te ... 1 111\01\6 rJ.il.:ing p.llien .... into po ... itioll'J

TIle DHI pro\ ide ... qu.lIltiliclt1on of th~ r.lIl~nt\ p~r­ l'~plIon of d~ ...equillbrium and ib imp.IL·1 011 d.ul~ aeU\ II Ie .... II h u...eful to e ... I.lbli ... h ~uh.1ectl\ e impro\ el11el1l \ ka . . un:-... ot ~ub.1et'tl\ e Imp.llnncnt .lIld rh~ . . IOlogu.:.ll illlprm ement h.l\ ~ not i:x'en com. . I~lIed..t.:.'.~l: theref,,)re. II I'" IIl...el\ Ih~1I till·lm ... other Ih.U1 Org.UlIC ~l'O\ er:- of \ l' ... IINllar functl"'" are re ... pon~Ible tor ~lIbJeclI\ e Il11patnllenL

Functional Disabilit\ Scale The rlllll llOl/lll [)I ",hilil\ ~H (lit' \\ J .... dl'\ l' lopl.~J !() Jelcnllille a (Xl.Ile11l\ re"'!'I(lll ...e 10 rh~ . . Icdl tht..'r..1P~ (T.lhle 24.4)." rhe ~(ale I....ldlllilll ... taed hefore .lIld aitt'r rehahtlll.lIlnn. rhe

author-. reponed Ih.u p.Hlenh \\ ho heht..·\ed Ihelr \e"'lIbul.lr di~ord~l"' \\ ere more dl ....lbhng did IlUI IIUrnl\ l' .1'" mllch .1'" tho-..e patienh \\ ho pt."n:el\cd thcm~d\~ ... to l~ Ie ...... di ....lbled.

Table 24.4 Functional Oisabilil) Scale

o

No disability-negligible symptoms

1 2

No disability-bothersome symptoms Mild dlsabllltY'performs usual duties Moderate disability-disrupts usual duties Recent severe disability-medical leave Established severe disability

3 4

5

Note The phYSICill therapist assigns the patient a score before dnd after trecltment. based on Interview history (from Tehan et al .... p 90. With permission)

t"l"

1

1

\\ h\.·t rr t l\.' 11h' I' H1 nt

h\.\ll

,'f

~'.ntlrr

1",,1\

m\'h'':'th'n( I"\T,,"hll ,',

,It

r ,,' \10'H"'nl<'n('"

11\,'lh'll h' lkh'nHllh llh'"

d

1~ ~-t~)

n" 111)0; tl' lIw dln:1.'1

11

T,\fh .In l1h"I\'.\,\.'d ,\ l1\ph~m mh'll"ll' 11\'" llhl.

1ll,lll

.

r\

~(4-;...

tI'tH' \,ll1k

,'If 1('1()

fi,l' lluml'Cr I' lhen

1l\(,Jll' "'~'(r~ dl1l1l11..!',"1 III .111

";:\lmp,'IlCl1l

________________

Age _____

--

G~nder:

INTENSITY

8a1e.hne Symptoms

I

C,11l1ro"'l,'d

OURAnON

•

SCORE

I

2 Sup ne·to·hi1't Side .

---

l. $ujJme·to'-'flght sIde

;

...

Sup!lle·to~slt

I

5 Left Ha:ip.!k-e-O" test

II &- RetLJT'll from HaUp!ke·Dlx test

I

I

--_.

,

I,

a Rerum trom H.a'lplke-Dn( test

I

I !

7. Right Hal1plke·Olx test

,

I

, !

-

9 S,ltIng nase taward le11 knee

to Retllm to $ltnnl1

I

11 Sj~I'IQ nose toward nght knee

•

I

, 12. Rerum to s.lttmg ,

1l

Sj~ng

tlead rotatton 5 x

~ 14 SItting head fle);lon 8-nd extension 5"<

,

15. St~nd,ng turn nglitl180 I 1

16 Slandml1 turn len-{180 I

c;::::c: Intenirty rated from 0 to 5 (0

no symptoms. 5

Duration rated trom 0 to 3 15·10 sec

-

2 POints. :0-30 sec

3 pOlnts1

Total ~

------------

1

-

severe symploms)

1 pam!., 11·30 sec

1

m~[

1)1

hnlh ,111\\ .lnt} IJ:-I

c\c mmem~IH" The dlR.'"I.:th1n 1\llhe 11\"'.u::.mu\

______ Date. ______

1 S(ttmg-ro~$upmtt

I

rll

C:.1l

('1/11 \C,-n!1U!tJI" /(Hc 1r, l~

f"'lth""

~.m.

",_,.,1

fhrllst le:.I' h~Jd ·,h~\\...HlJ:! IlhlUl.:cd 11) "I.lgmus t l~S \j I, PP~l Ihl1l~ll k,'11Jl~, Jnd the ~h 11,U1l1C \ hUJI J"':\1I1\ I D\ \) IC~I '\!}'la~!Jnu~ lCOl the pnmJI"'\ dlJ).!Ilt1'(1( IIldlCth'r 1)\(..\1 In Id('nltrJ inl:! 111" ...t pcnrhcrai JIlJ lou1'a/ '{'\/Il%'!l1 I \( 'l\ , 'n 11\\\-)luI\IJn c~(' nW\Cl1lcnl. m'lJgmu' due I" J j'rflj'

\ n \ ""Q ''':1'1'1.' ('If 11'm tndK;l1', IW "mp

;1 "l1'\'IfC

1111,11'1"1;111((' 111 dcllllll1t; Jlld h"X..lh 1 111 ,

I

path,'l\'~' fhc j....~\ t "I~ tndUdc I,b"l'n ;1111'11 hlr I1HIJ" ~\;1I11Jl1;l(\I'1l \11 the \ OR .11 hl.!.!h .1~,,-df,,~r,Uh\n th ·1

','1.-I'nd, ,', rh~' '\llll'f"llllllh.;'W'II\ ~l1\d ,hlrJ hIm \ahh." .1f\." t!l\.'n ,ldd\.'d h':!\'lh~.r (,'r;.1 '(1'1',' rhe \ISQ , ~.Jr, t1t.\!~'d b\ mull1l'h 111:1 th. .• llumber I)f f'1l\,itHms fh~n dl\ 1\.11..'\1

1\ Ill\'

ntH'.

~l)

,(('re

~l.tt\l'I''''hLP 1"1\""('11 ""'lhul,tr rrcc ,mil \'\l' I1lt1\l'l11l'llh I'mdlJu'd 1 p •

, .hkd i'\ tl"'I'.H1,-'nll't,t\\,,\:n I lOllh\) ,Ilhl" ('Ch'n') 1"11 ...• d r.tt1,\n l't '\ mrh'm . . ,11'1.' .\1", .l"l~lh'd r,\lIlh lH'111 (1 It, ~ \ h' ''''\'''\1,1... t\ '\ h' I() '\'I.',md, I. 11 1\) 'I) ,~...'nl1d,

~'f\,\\,!..,,-'\t '\1l\{'t{'llb b\ Ihl:

1.'<11'

\()R . l1w C\~Ulllll,llh1n (lll'\C nl\'\l'nH.·nl~ \"1Il ,"". 'I

I",hlth'" Ilh.' II1kn'11\ h ,b'll.!l1,-"d .1 PI'1Il1.

m .' .1 pn"

1Il1h~ 111Ilcr

11'1'

N",. An MSO scor. of zero means no tymptoms and 100 muns selfere dl12mas Ln ,II POSlt!ons

cd b\ lilt.' dUC't:uolI oj lilt.' la ... 1 l'OIHIXHll'nI For Jlldl

,J , I

"

h \\llil.1 unil;tll'l.d \': \ lIhul.u k'lIlJI. rhe ... Iow (.'0111PO.. dUl'I(llt'I,IIt\~ C' \cll.IIH)IJ 01 Olll' "'Ide 01 lil L' Vl'\lthui< 1I nIt' l.t ... llOlllpl.lnL' llt I ... ,i.:!t'IlCr, II CU from the p.u;lpon J l'fIIUlwll 111 till' hr,lIlhlt'l11 .Uld Icpn ... Jlion ... Ihe \'enh'l ot Ihe orl1l1 h)r l.."~ aJllpl l!. III kit ·healln g

Illll\e ,10\\1) to Ilw right (VOR), and the let I (fa ... 1 component), lC Jlll.YlJOIl oppO'lfL.' Ihe- 4uit~ CUJJlPOJlC nI of (X allie, Iht.' 'Ide.: of Ihl' u· ... tibular Ic ... iol1. t.: due 10 a 'c,tibubr le-"'101l I) lllo~1 <.:ollll11onl y r")\,

t',

,

t\!."

t'

1110\ l'l1ll'll1 I'" 10

:il ute-

uOIl.lh:ral in ... uit, "',XJIlLaI1t'OU\ (al rc \O QC<.:ur... In rhe: ab~l1(;c of t: of t.he J,)mmc.:-l() lxlv..t!en Ihl' fUIlCliolllllg mg \c uOOhtr ... ) ... tcllh rile br~1l1 per(;cJve~ 'i J.llI\c: ,llJnulaIlOJ} from the healthy ... idc. f(}/leOlH IlnfllRIJ1Ul in Ihe It!!h! Iypicall y to 7 diJ)'" but ma) \ al) and II c.:an la ... t a\ tl1 4 Spontam:ou ... Jl) \tagmu~ may alway~ darh. ,iftC:f a unilateral lol.;s 01 ve~libu lar ~ d e'~. rc:'\.(»)utlOll of \fX)Iltaneou~ ny!>tagmus I :iarl occur, \\ hen \) nunclry betv. een IllC reMf hath \c: . . libular s)stcm ... i ... rt!e\tabh\hoo.4i1 I) pt." ot fl) 'IJ£mu ...

R ,

,

Ob~('T'atl

n for '~~taf:!,mu~ LZ,_ u ... c..: be uppre,-..cd m lighl and when

, fixate:, on ~ tar,gel. 49 A~ a rewit. the f n. (;j mu ,hould be perfonned under con the ~r-..on cannot M!e the \u1Tounding r t TI 1 can be aChlC\cd WIth FTc-nIt:! len~es or !'!lera ':' tern. Frcn/ei len"-es arc gogg.Jt~s that f:- U11! en",t" enablmg the cJiOJcian to ob~rve 1.1 ~et pr c:nting the pallen! trom fixalJllg on nlrared Can t:fa u...es Infrared lighl to illurJ1le though the patienr IS uHable 10 ,ee

Htad I hru't I" t a ihldeJ) ac.cepted cllmcal tool that J~ me rcular (anaJ lullctwn (e.0.JcaJ j, n Rf)~j) .hould be delermmed pm}r to per· t ... head IJ1ru t Ie t and tllt: chmcHUl h()uld e/,plam ad 1 mo.ed yured) The head Ihru,t te>! 3\ ng the palJent Ilf t fixi:ttc on a llt'.ar IJ /..Jan nose t\ t eo Ie lJog the honfleJ'·ed 1() J>aut:nI are a.: I cd II} , >ed on a target .h,le tht-lT head man pI e dJ1euJ()n U llg a aHgil..... leral (," nUl) tu 4i#J I ) 24 'i I
'i1.l(.TIIi.l cs l!ldlt'illt'~ Vl'!'t libullil il y pollll1tllOIl

jJ lj

dt'lernlill c tl

hy Iltl' he:Hd lIlliI'd Il'\I Ulld OC(: ur~ hc(.'lIU 'tl'

JllIlIhilJlUJ 01 vc ... "hul tll :dkrcnt.... and (';C llllaJ VC~llhLlhll Ilt'UIOJl" O/lIIH" 11)(;1(;1 !>o ld e (pl'I'M)/) .., With 1Illilalc ru/ vCloillbulm" hypo/une.: liOn) :uc Ie ...... dlcc.:IIVC III cm.:odlllJ! the ampiliude of II heml movem ent 111:111 t!Xl' itallon (ildlll."tory ("'111011), A patH'll1 who hi)'" 1.1 unilateral reriphc ral I C~If)l1 III pUlhology of IlIl' len tral vC!-,lihular llClIIOII'" will 1101 he able to malnl'lIll ~a/c when Ihe head I ... rotated ljuickly lowanl the .'t Hle 01 lilt' le ~,t1on . A pallenl wJlh a bilalcr:ll 10 ... " of vC~llhuJar /UII CIIOfi wil l makl: (;OITetllvC \accade~ alier it he,u.l thrll'" to ei lh(.'r ~Idc Tht:: head Ihru!o,' le,,1 provide" a M!Il\ilivc JIlc!ICalJOIl of ve\ libulur hypofuncllon III pall CI11!o. wilh complete lo ~!-' of fUllclion ill Ihe f.illccled Jabyril11h Illal OCCllr~ following ahlallve surgical procedures, \ uch a!o, Jabyrllllhec.:.lomy.....I.:H ~1 The lc ~t i ... l e~s M!n ~ ilive 1I1 dClecling hypofunction in pallenle, wilh incom plete Jo ~ ... of function .'i(rS'J Head·S haking Induced NYbtag mu s The head."haking induced nystagmus (IJSN) lest" a useful aid 1I1 the diagnosl\ of a unilateral peripheral ve~IJbular defcu, During tili s test vj~ ion i\ occluded, The paliem i~ instructed to close hi s or her eyes, The cIinicJan flexes the head 30' and oscliiales Ihe head horil.Ontally for 20 cydes at a freq uency of 2 repetitions per ,econd (2 HI J. Upon >loppIn g the o,clilation, Ihe patient opens the eye, and the d inician checks for nY>I.gmus. In bubJec" wah normal veslibular function, n yMag mu ~ will not be pre:,enL An asymmetry between Ihe peripheral veMibuJar IIlpub to central veM ibular nuclei , however. may res uJt 111 HSN TYPIcally. a pe"on with a UV H WIll manifest a hnriwntal HSN. with the qui ck pha,es of the nystagmus drrected loward Ihe healthy ear and Ihe blow pha;e, directed tnward Ihe le;roned ear.'''' NOl all patien .. with a UVH will have H5N Patient, with. complete 10>& of ve;t,hular [unctron bIlaterally w,1I not have HS "I beeau;e nei lher 'Yb tem I luncljeJnll1g As a rc!)ult, there h no as.ymrnelry hctween the Ionic finng rate~, The pres.ence of vertical ny"llagmu 'j after either hl)(j l"..ontal or verlical head &haki ng sugges. t ~ a central JeslfJJ1.

Po,>itional 'leMing PQ!o.JtJonaJ le!o.tmg' IS commonly u!-.Cd to Identify whether otocollJa hav~ been dJ~placed JOlo the Se( (auc,lIlg a on dJ1U)fI re1ern:-d to a~ J.>enign parox} bmaf pOc,j{ional HertiglJ (IlPPV) lhc addl""" 01 Ih. "t/Ko,,,a II1to I~ t (oJ)lTIph mah' lhe ~mJur( uhlI (mal ..c:n 111'Wt h ike· l)" le.t , th rno I lOmmOJI JAAJ1HJlJaJ It"' I u~d 10 e"aJlIIII' jor HPP\ ., he palJ{'"'Jlls J1Jo'rcd from ,HIIIM' 'huh Iht.. hf.:ad fIJI led-4 to (j1}C Ide III a UpUJt' po Iflon Vr IIh the hc4id c~h.::nd(d Jl) I.,y nd h""mll'al. I",ad t,lI II I ,I d l ~ 1/ I~ 24 IU/ 11 I 11 u't'tr pJa<.e t:ath (1# rJ '>( ( JU ii ~ l a'flly d pendcnl jJo(.J t I.JIJ ii1ud the dHIJ Jau hllOl'J',o r\c II eye tor n) lagmu I he dualHm oj Ihe lIy 148111U I lJlIJ'-luc to the _J hcd ~ (( J he dllC'(.h III b l uJ dUI IJjNI 0 ' lhe rc uita.nJ I , I gJDU ." help d< t IIIl I wI lher 11 patl<'nt ba

Figure 24.9 ' onll.11 ht:.ld IImbllt·,1 10 (ht' k'lI \ R ,lhn"1111;\1 h' Il1l' n~IH ( ) 1 ,u):: ..' "\",,"~ de nOl~ ' d i ~t:ll l'n Ihe he.ld \\ 111 nt, Ihm,,- ( \' Illtl],)l 'l.lMlI\~ 1"-"llh\ll 1'1:1, , " 'II ... " ...... ' ' h{'.1It, HI', .. \ i,a l fl e ,\10n : l" l' .. .1ft: I(l(.· lht'd I'll Ihl' 1.\~l'l tR) ll,,-'n .. h'l'l'l1lf II", Ill'.I,1 thru"L .\1,' ,111. on u nael .md n~l ('(lrf\'l'!l\e ...h.-,'.l(k .... (,h:('l'\l'll In ph\'\h'~r.lrh .. \ ,\Il,t R tht' .. ul')u 1, ,'"'' '1.\\ ti '\cd ~n Ihe l',\.\lllmer', lHhl' Ihmu!!hfHlllh,,' It'''1 \( ') In1l1,ll .. t,lMI11~ 1""1111\11 1'1.1,,'" 'Uh~' .. 1 ,111'.;'1.1 inlo cel"llc,11 llc,\ ul1l: t"t', ,11\' h'X'll~l'd ('11 tht' 1.ll,!!l'! In, \ .. Ill<' hl',l,' I, Ihnhl1.1l'hth '" 11h' llfhl Ihe e\(' .. t ill 0 11 the 1.I~t'l .\Iul 111(\\t' \, Ilh Ilk' 1ll',!,1 II ' nIl' ,,"1'1, d 11\IL .. 1 IlU ~•.1 "1'11,'dl\ .. ",'.. , ,hk (.. mJi l ,1m)" , ) In hnn~~ Iht' e~(' .. h,l(1.. hllht' !ol!!!l" ",I mll'rl' .. 1 II n'lll "dlU"...·11. \ I( ,'T .11.' l' '\

'h,,' ,'\,,,

\\ilh pe nl11"' lo n ,)

BPP\ or

\n ,II It' l'll. 11 I\(,' f{'"1l ('I 11\1..' Ihl.' p ,lI ll' llI It, I11 C,\l' ml(' ,I ' I dl'l~ Ill!! pt) ... ilioll (Fig. 2... II ), In bnlh \ L· I' llllI ... t1 hh ll.l ll'd. IhL' t" l1 um ard the ground i ... Ihe 1;111) IlIIlh hl..' l1\!! II'''' TI..'t! II h(\l I/(\I\ li.ll (,C BPP\ I' ' U' Ill'CI Cd , Illl' h l ll It',1 1.' .11 1 1"-.' u"'l·d m "'l t!ad (rt!!. 2 4 12), In Ihl ... I t· ... 1. Illl' P;lIl l' lIl I .. ll(h ll lt\llL' d ",urlne \~ nh Ihe hl.',ld Ill' ,\c d ~n R ,'Pld h )I,lIhllh hl I hl' ... ide... an,' done ...c p; lr;ll c l ~ Hlld till' ( 1i1l1 l'1,1t1 olhl' I \l' ... ,I

cl.' llI r:\1

\c " Il\n .

1I <111pikt!- D I \ 1t! ... 1 a ... l.. ...

"'I

n) ... 1.lgI11 U',

"

1 1~llIlh'\1"\' 1 I) I R'

(h,\1 I

n l.lhl'tIL

,11 ,

\"

1\l~'lhkd ,b Ilh'\

01 Il h' klh'I'

l'ih' 1',111\'111 tlh'1\ .1111 ml't' h'

\\hll~' II,,· {\tIlI,I,'"

IIIII1,"III,11h

il l',ld ,\I .1 II\'qll~'lh' ,'I

'II

\

,I,

la1

11\\'111'11"111 \\11

111 "'1',\\\' d U II1l~' Ih';lIlllll" \'1111 II ....

tl llnll ~ hl111 / 01l1 .ll IIHl1l{l1l II I Ihl' ill',hl

\

1hi ... , ,\l1 III 1)\ \ \ ' "I1 I',lh',1 \\ 1111 " ... 11.11 ,1\ 1111' "h ... 1111 \ Ihh',' \\1 1l1l1l\' IIlh' ,I," "'1\11'111 \1\ \ 1

" hcd' Ic.Ic " and l omplI l L' llI\.' d 10 1111 0 1 Ih l' 1\.· ... 1 (,Ul Ill' u ... \· t!

11I ~ IH'. h l tl h\\~'llh'll l I ... "'"' '\' ... 11\,' I'i \\ "111'1

'lh.:nttl y the 11I11l IUHWI ... 1t-! llIlt L·, U1f.,.'\.' hYIlOlulll:lto n /, ,,~ I k.ld \ 1' 1ol' I I h.' ... Ill'l' t!

tl\'l1/'\ 1 \\ 1 IW" l' l" \\ 1111 11111111.11 \, "'l1bl1\.11

10

100"/,

,,

'Iud\' ,,11 ,hal' I"{" hk lI111h'l1\l II 'hi II m

Rl'll1h'P,\lI\\

\\ 11 " " ,..."'1'\· ... 1111111.11111111111111.1111·'\\

\' ... L1111 ,Ic ul l y (D\ \ ) I .. 11 ll' IIll';I"' "l l' lIll' 1\1 \1 1

\ ' ... UJI aUIII )

.h_'UlI \

'h' '.

In ~'lI"'I1I~' Hlll\', I 1!"qU"lh' ,'I II", ,I 1111 I II

Uynami c Vi, "al " Cllil) n.~ . . t D } II ;.Ill1l l

'I " R l',ld Ilh' "m,"1 lul\' \\\l\ \.11\ '"

ill 11l L' 11I 1le..'

DVA

III 10

I ... 11IL't"dIl L'd til l' n "' lIl l' Illill

VC\ll b ul il l al le ' l' lll ' 1111111 IlI l' l 011 11 ,t1iLl l' l ,t!

'1110 IIlhlll JlIOIi IItl d

tIll..' \ {''''ltlm].11 Ill' j..'Il',I1\' ! th ,l1I

... ttl l'

,lte

,Il l' til t \ l' lI

til{' h.'lI l· ' ' ' al l' 1\111 hklltllln l \\ 111 1 ,I

' 1II1UJlh pUI"\ uit l'}l' lIlt I\C llH' 111

111 1ll' II I IIIIIII I1' Il· ... I , "'1, lll l

1111 )\,' 1\ 1\'111 1""," 11 , III

,til

l\\lIlI' ,II \' d

\\

( '11 111 (1 11 11'11.

,'d

tltt ' ,u k \\ 1 1\-""

11 11'

11\ \

hllh III Ill', III'.h l

h.l,

... tlll

h,III,.,

\

f 1'\

I'

1111\

I'

11\',' 1\ hHllld hI \ \llh \

\ 111 111 p. II II' ll h

\\ 11 11 1I11t1,I11 1.11

1,\1 "' 11 ~I'lh' I ;I h' d .l1l d 11111'1 I'd 11. 1.lhit'

ht

In I'

, 1 I

,1.1 1\111110 1

I I., fl

11111 I U II1

111. 1 I

I

I Ih ,

I

I

III

'

III III I 11 1' 11

~ 10

1 II \iI I.,.

th,

2

1111

.1 I

hi

111 1 'UI I

II · ht I " ' " 1111 1 II

1.1111'1'\ I t\~ 1 ~I ' h" IHIIII I J I III , li lh HI 1" ) III UI1III '

II

n I It I'

II I ',

II

II I

to.; 11t"\1I II b

' 11,," II Vi lI 'f"

,1'10 · , .1111 '"Ii III \ ' Itl. lilY 0 1 .... 1 \' lI d

IliI 1 I 11 11

, loll

I\I ~

I~JI, )o\

I ~ ' 11 ,

Colli' alul BHlal1t.·l~ ' Ic~(ing 1'"K ;UllliI!IIJlUI

til )'HlI lIlId hulall(.;c pl"ob ll.:llI'" 1\ IIl1pm1.Ull lor 01 a (14111 (;111\ hUlr..lional ... IOItu" "ICl,lIl1g ... houl"

(11'1\' 1111111;11 1011

,Hldll'\\ hotll ... I;tl l(," '.!IId (IYII.nltJ(,: halmH': C (c,g .• welghl 'hili" 1I1 ~, ;IILIIIIII,lIll p" ... llJI .. lll,.· ... I'0lhl'!\.lllld i.1l 11bulallon), (i:1I1 and h •• l.lIIn· I ~' "'' l ,nultH UllIqm: ly Idcnldy patho logy wllhin the 'V\, .. lthul.ll

"'y .. tl·11I

r.lhk

2" 1 C;

1I1l"lUlk .. 1,.;0111111011

balant"c

1\· ...... ,111(( npl 'l'll'd Inul"

V\-,tih .. lar "i(' lIl i\'i IT tlJ:t r

lilt,' IIIIIH'

I ~ unc.i() .. ~It.· '.'

( '1II1lI1 "14.:", 1t1l.:1udc ("Junl'

lOlllllHHI \'\.'''[Ihulal IUllI..IIOIlIC .......

Il· .. IIIIf! IIlId IOli") dl,II1 IL· ... I ... . ('alm;( ' 11'.\1111.1: IIIVt,)I\C"lI1lu .. Itl~' 111\' nl~'llIal dud l tOI ) 1.",111,11 wllh ;ltr or \\.111.'1 .Ii" ... 1I111J)dLU.' ~' ''' ;1 1f..' 1t1 1 ~'r;llUll' gli.ld ll' IlI f1d\ II ), Ilu, Il· IIII~· I . l tu l l,.' tlm\

01 l'ndol)lllph

Iltilt

gli.ldll'nt

dl'lku,

lI y' I;\~ljllll' \\ 111 111 1 lilt· hOI 1/11111011

Itl

11,.· ... ull ..

I hi' .. tim

till' P"""l·II""I,.' ot

III IlIl' l,."tlll\l·l"!IH'

I ltl' l"lIPUI.1 ,llId J.!l;'lIl"I.lll'"

S( '( '

11 11 .. 11,.',1 " p.Ulll.lI

1.11/,' u'l' !IIIIOi dL'h"'11lI1I1I1l1! till' ' Illt' olllll't,kltnl,

\',1\11 1.111)1111111" ,IIIIIIIi,lll'd ",,· p.II,tll' l)

\~.ll l'l

fl~lur 24 11 IliI

II"dlpl"I' 1)1\ II" ,I ( likh Itl~' I (J I 1111' 1"'111' 111 ')!l liI I " ' t III Ill<" ( \ ,1111111,111111 ",11k 1111" ~ IUll l l,1I1 111111 , Ih," II Il llllll h " , ' ) ' 'hI' t' \ ,mlll\, ' 1 111,11111 ,1111 IIt~' "1'\ hll hUll Iii P .IIr lil I" q\IL l "I ) 1I11I1I1'hi ,lImli hI Ih,' ' Ilk uppu" lh' ,

htol< l l' "111"" I PI~ 'UlI"

\~

1" 1 II ) 1,1 ' 11111

It II .I Ih,' Il r hi ,,11k)

hlillf'

1/11\\('\\'1

1'\'\" III'l'

fUIII.II\)f1

Ih~' 1.".110111.: Il· ... 1 plo\ld\,', IllIltll'd IlIhllm.IIH\fI

11111, Ih l' 11.'11111111 ,11 "Il '(', \II\,' ,111l1l11,illd .III\! Ih,ll

, I 111111 1.IIICItI \,\ltl\"lllIlUI, hl.IIIl· \jIU·I1\,\

1111"

" 111 h . ,h 1111111 I'" 1111111 I h,' nIh. lid,' ' " Ih"1\ 11·,11'11 , .. '\ ' 1'1 " 1'''1'' III I H, I ( 1II.IIIIh 1(, pi' 11111!1'" ~ hll Ih III VII ~ 't 1"11 11 \, 111 ' II I 1111\ l11ulI 1'10)." ,1111 "\ 11.,11", \1111"111 .111 .. 1111\ III " ·IIt. ,I",," "I I'lul i\I"'i liN" ph .... llh 11\ 11111 ""'1\

1l1111111hll

l' ' ' ' ' ' III tlil' H"llhlll.lI ,\,ll' lH IIlI p.IUl'llh \\lIh "1'\\'1,- 1,) ,

1 h\' l' ,11111111' 1

IUd \ 1' 11",,, , ,11111 Ihnl .. 111 \ \1\

I' " .. {'lttl II' lll'h"'IIIIIII\,' \\ IIl' lltl'l

t....·\,:.IU'...•

\ \iIt'htllOIi '\tlh I.. l'

Illtl l ll ""'l'l Ih. 1I1 till' 1t.tIIlI,t1llnltl\'lh I,'S,

{I

III '11 11 /)

I hI' 1111,11 \ I

(00' 11/11h,lIl' ,'1 h...· .ld 111\1\\111\'111

llt.11I 1\,·,1 '11111111.lh" \.

11I1 .Ilntl' \111'1,' \1\ III tlh d,lIl..

III

'I, II" !l.1I ilul.lI ulll\\h

"'1\111

,,"h

h,

Ihlmh"

Pll,~il. dl Rdluhilitl'tiOlt

tUtO

~

..

j

c

B

A

)

n ".~

.. o

E

Figure 24.12 Roll I L'~l lur I lwwmlill S~'IIIIIIHllllll ( iUlh lIJl'I' V IJlII/i,l ly, iii" Ijilll,JI! ~ IWild .llj'I~llj \"It. pl.Knlll) JO" L"trvil:,d tlc"UiII (\1 Ilu' pam'llll '" 1'1J'11l1f1Wd HI A/pHil' lIf! Ilw hr-"tl j~ IjIW Ily wmcd IXJ \Utlu: )1'11 ~uk. 'lilt l: h'Jlljllllllwu (; Iwt.k" 11" U)l1.lhpllllll! 111111 vt-/ln'I, I( ) lIlt' IIf" ul j. IlwlI pcnll~ rctlJrllt:d Iu lht 11':1111,11 "hlllillp p{l~JlIIIII (I) 1 , I lit: 11'".1 I Il""pr,llnl III Ill/"" I ,dirt ·.lljr fh· ,1111

qUld.. ly IlImctll~() 10 Ihe nj.!hl .. llkJ, Ihe Ihl'l,lf1' ,lllg;III1I1Hhl dlNI 1/11 lIyt.I'1I!IlHl

ve ... lloular runCl1on. nY"lltlpnu ...... h(Juld Ix: gC' IIt;lill~'d hy Ihi:

rutilllon .... In tht: plc!'.tnl:t 01 H vc .. , ibuILtr UJ'On.k:I, the (;xltlll of pathology CU ll he delel "lIntd by c(JnlpMlnp VO l, /-,11111 J.lld phll"c- from rolallUll1., IOwurd on!: CHI v.l1h 1(11[lII1JIII., IO\\;lrd Ihe. OPPO!"lIc

Citr.

In addltlun, VOR j,'ilJIl ilUd ph;Il,l' oj

peoph! "tth nonnul \l·,llhular funtllon tan be CIJI11piU Cd "Ith lhut 01 pt!oph: "lth ... Ul,I)CCh;d vCI,llbulur hYPO!U1H.:IUJO ROIJr) l:hair te"ling ,.. 1i001lt,:O hc{:!lu"'t: only the hClfll()n\,iJ1 ~ JJ\: roullndy Ic .. Il:11lo

S

dclt:nnlllc eXlc", "f P,IIIHII(lVY,

1I: ... t C'-p
l(J

thr

"llplll Itlfltl. tis, 'I l,tC:II1(.>(.kllifJlllil,.tlll/i (\( MJ 11J1l~ II- I' It:" jrll jl" , r")I~lItlhl .... 111 j1tOpJ,< wilt, III-:illthy vr . . ldtl,liu flltll hf"1

!iiI I JllhtbJIIJJ)' prlU·IJllitl

itfll" lilt'

d"r ".

,.JIll/III

(U~4 WIIllP ,II II illrJlt

fllll(Jw('":,d by ,HI /',. 11,1111'

1'1(1\'1(1(- 'p... ,)illt"fill JII.llhljl>1}'

Jl(ll,llJIlfU'/1

df1-.e

j()

rt" .pfJfl(.I;;r II) II

Iht f(,(llpLI!" vi It

ubJt", 1(. rn(' Il;JllICi11 1/111111 Ihe U/'Jf'll/lf'llua! ('fIlial l/ljll~IJII'al ,\\ /I J Ie;: ~ J

ilJC

a \enc, of \f>ud

Table 24.5 to

Common S.I.nee TC5iS and Expected RL"<"lt. ReI.led pecific Diagnosis

T_

BPPV

Romberg

NegatJVe

BVI.

UVI. Acute.

posj~j\le

Chronic negatrvf:

Tandem Romberg

Negative

Single· legged

NegatIve

- - -POSitIve - eyes closed ---

May be poSitIVe

.lance

ACuff!

~.

~

Chroo.c nt:g:;'

Acut.E: t)OS

Acute wlde~ba.sed S60N decreased arm SWIng

Normal

and trunk rQ!.alJOfi

Compensate(1 norma

Acu'e

'.If::

.... .c:::

ChronIC nega'

Galt

>If:

w~~b~.;ed

BPPV

May prOduce ;J'ghl unsteadiness

aen.gn pa.ro)"i$mal pos.tura

ve5lII>u1ar I6SOOn

AcUIF.: may not keep balance Compensated norma

ver1J9C Bvt

ow

decreased B'1Tl.

and .... Tot;:" Corr pensati:d ,..,.

~

()(;V5,dt

Tum head wh )e walking

"Iiln

IHI~ ,11 il Llll'W i of 21 m j " l 'Ifl'" ,I, ,Ill) f Vt,:r.,IJi>ul.11 ItYlnlfuI1lIJlm Ih,.. VI "v'lJ' i}f III!' It- 111'1 'lilt" ;J!4-ulr h,J 1""rrl ,roJII il!f/;::H'III .!lIl1UliIIlfJfl dlHlflP VI 'lI1f' ! 11K ~( M 111U';.(.11· 1/ ilfe

Recent advance .. III vt .. tlhular dl4:lg.fHJ'lIt It ... ,If1g havt c)'lCnded the re8ion of IdcnllfiiJhlc p;tt/lCllogy 1/) 1IH.:lullc (he ololuh org.ln ...t.'"' #I The '('.whulm ~{'\"(JJ...l'd m)IJ).:l'f1ll PO/I'I/' 'illJ~ (\ EHP; Ie\! ha ... gallled bro:.td chnlcal U\l.· In n;(;l'nt

VEMP

IJ~JJIJ1p'

(I)Cj III!}"II"

~ffL:'1,:1J1

01 01;lh Tes1-

) ear... : 1 The

,md \"rll l l-'11

Ma'l r")()t )or e:ep :..a: rl; or slows cadenCe

pert

m

ga

I '"

I.f

II

fl

Chapler 24 Ve't.ibulor Di ... ordcrN

1I1ricubr p.ltholot!), During the SVV tc<.;t. paticnt, arc asl-.ed \0 align .t d]ml) In IUI111110U, har (in an olhef\\ isc darl-.cncd room) "ith what thc) rcr~cin~
Vestibular System Dysfunction Peripheral Pathology Mechanical The 1110 ... t cOlllmon CalN? of \'ertigo. BPPV. is a biomechanical di,order. S) Illptoms of BPPY include \'c I1igo \\ it h change 111 head position. nau,c,1 \\ IIh or withollt \·omiting. allli d)seqUllihrium. in the most com mon rOm1. a lcIlCIlC) of on . .el olthe \cr1igo and n) stagllllls occurs within 15 ~econds onct' the head i... in the pro\ol-.ing. position. The duration is IIsuall) ie,s Ihan 60 'eco lH.b. The \enigo and ny ~ ti.lgl11us arc

1011

dm.!ct Illlpairlllcllh caused hy th e misplaced ot<)(':ollm . Man y indi\'iduals al\o ex pericnce I1nusca. vOlll lllng. and imbalancc. BPPV IS bc lJ c\'cd to occlir via OIlC of two mcc hani,llls: cupu/olilliiosis and Clmlilill,illsi.\. Both of the theo· ries in\'olvc thc otol itlb heC0ll1111g dislodgcd Irom the utn cJe and failing int o the see,. Schuknecht lirS! theonlcd Ihat fragments of otocon ia break away ami adhere to Ihe cupula of one of the sees (cu pulo lithia,is).711 Whcn the head is moved illlo ccmu n positions. thc weig hted cu pula is deflected by the pull of gftlv it y. This abnormal Signal rl'sult, ill vertIgo and nys tagmus. whi ch persists as long as the patient is in the provoki ng position. Cu pliiollthiasis, therefor!..!. does not explai n the brief durati on of the verti go common in BPpy.77 A second theory was proposed in 1979, cHnalit hi a,i" in which the otocon ia arc Ilmlling freely in one of the SCCs. 7X When a paticnt changes head position. Ihe pu ll of gravi l) ca uses th e freely f10allllg oloeon iH 10 mo\'e inside tht! sec re~ lIltin g in endolymph movcmCI1I and deflection of the cupul a. Figurc 24. 13 illustrates BPPY occurring from cupliiolithiasis or c
Decreased Receptor Input The most cOlllmon causes of UY II lead ing to decreased or eliminated recepto r inp ut are viral insult:." traum a, and

A Head upright

Posterior sec Posterior sec Figure 24.13 IIlu ... tratt.'d i, ocllign pmox) ... mal puslllOn;!1 \crtl£O oj the po..,tcnor seC'. note the cupular delleclIllll (, \) Canalithl
Free-floating otoconia

Hallpike-Dix position

B Head upright

Otoconia adhering to cupula

sec

Postenor sec

Hallpike-Dix posttton

\.l",l.:ular ('\enh," P.i1ICIlI' \\ho '11, 1,1111 ,I UV II \\ 111 l'xpe riencc dlrccl Illlpilmlll'rth of vcrtlgo. "'polllanco u'l n)"tag ~ IllU ... o'l.:lliop"iI \\ Ilh he.llI 1ll00cl11cnh. po'lWntl tlhldOllll ). and d) ,equi librium 1IIIIIall). thc ratlcllI \\ III experience the \Cl1lgo .lIld ny't;'glllll'l Illlpalllllclll ... duc to the a'lymmetry crealed \\ hen one \c, ublil ar ",y'te m 1'.. no longe r function ~ mg. TIll ... re . . o lvc s \\ IIhm 3 107 days H...... uming thc patient i... e\po~ed to comm on daylight cond llion .... K1 SpOnl :lneOU, n) ... tagmu, beyond lill'> lime period should a len the cilnicinn to J pO'I'Iible central le!'> ion or an un stable pe ripheral VC'Itlbular les ion . The (hrect 1I11paimle nt S of v isual blurnng. poslUmllllsw.bility. and dy ...equilibrium respond to physi cal therapy lI11erve mion . Becau'le vertigo ow ing 10 asymmetry lypically rewlve, v.ithin 7 days, per.., isle nt symptoms of vertigo beyond 2 wed.... should be com ide red c hro nic, abo necessilCuing \e, ti bul ar rehabilitat ion. The most common ca use of a bilat eral vestibu lar h ypo~ funct ion ( BVH ) is ototoxicity. Certain cl asses of antibi otics such as aminoglycosides (gentamic in , s treptomycin) are readily taken up by the h ai r ce ll s of the vestibu lar a ppa ratus and contin ue to bui ld in th e system eve n after the pe rson has stopped using the antibiotic. Less com mon causes of BVH include meningiti s, autoimmune disorders, head trauma, tumors on each e ig hth c rani al nerve ( including bilateral vestibular sc h wannoma), tra ns ie nt ischemic episodes of vesse ls s uppl y ing the vestibular system, and seque mi a l unila te ral ves tibular neuronitis. 82--84 The primary complaint is dysequilibrium thou gh oscillopsia and ga it atax ia are common cl in ica l signs wi th a BVH diagnosis, all direct impairments. Un less the BVH is asy mmetric, the pat ient will not experience nausea or verti go, because there is no asy mme try in th e toni c firing rate of the ve,tibul ar neurons. Hal magyi e t a l reported that patients wi th gentamicin o to toxicity have post u re and g ait abnormaliti es, decreased v is ual acui ty with head movement , and redu ced VOR ga in s res ulting in a positive head thrust test!\~ Th ese impairments are like ly pe rmane nt though pati en ts w it h BVH can return to hi gh levels of ac ti vity.

Central Nervous System Pathology Various central nervous system (CNS) inju rie~ can affect the vestibul ar system. H6 Cerebrovasc ular in s ults involving the amerior-illferior cerehellar artef}' (A I CA), posterior· inferior cerebellar artery (PI CA), and I'e rlehral artery may cau~e vertigo, thou gh o th er s ig ns assoc iated wi th these infarcts are present and help clarify the si te o f path o logy. Sign' and ,ymptoms between a n A ICA and P ICA in farct can be difficult to distinguish tho ugh hearing loss is usually morc common with A ICA infarct<;;. Les io ns of the vertebra l artery may affect the cerebellum o nl y and can InlmlC a peripheral vestibular hypofunction in its cl ini cal presenta tion . Mo ... t pati ent . . w ith cerebe llar lesions how. ever. wi ll have as~ociated . . Ign.., . . uch a . . dysdiadochokine~ta or pa . . 1 poirlling. H7 Individua l", w ith tran ., icilt i..,chemic attach may pre ..ent wllh ~ udden ve rti go th aI la,t.., minute\

and ill,o IIH.: ludc compla1llt of hC~trlng it)'....... For mOrc th Oro ugh n:adlllg dl 'lccrn lll g ty'.)e . . ()f ce ntral ve"'llhuhlr path 1III () ogy .... cc Brandt and Dieterich' and Dc.:lancy. Pallcnts w ho have ....u . . taincd a traumatic bralll mJu (1'8 I ) due 10 labynnthlllc or . . kull fracturc . . may (;()mplam ~ vcrt lgo. IIX A. . much as 78 pe rcent of patients .. u. . tlIch a . . drop allocks (sudden 10\5 of mu..,cle tone resulting in a fall). tran .. ient blindness, or dysan hria are associated wi th V BJ. One ~lUdy ide nt ified vio;,ual d y.,(unctJon . drop attach. a nd unsteadineso;/i ncoordination as the Ihree mO,t common symplOms a,sociated wilh VB J. 91 Demyeli nati ng diseases s uch ao; multiple . . clerm ls (MS) can affect c ran ial nerve V III where it enter", the brain.,tcm. In .. uch a case. sign s and symptom s may be idcl1Iical to a UV I-1. A magne tic resonance image sca n v.ill need to be performed to ensure an accurate diagnosis of MS.

Discerning Peripheral Vestibular Pathology from Central Vestibular Pathology Observation of nys tagmus is a usefu l tool for as.,i..,tmg In determining a d iag no!'li . . of eNS patho logy. Ny'lagmus from a cerebellar lesion may be 111 a pure venical direction:'; The ny..,tagmus may nOt have a slow component and the eyes therefore osci ll ate at equal speeds, called pendlllar fl.nlc1gmus. Pendular nystagmus is often II1dicati\e 01 congennal di . . ordeni . .!Iuch as the absence of central vi.!lion (conIcal vis ual processing). Another clue to discern a central, ersu'i a JX!riphcm l vestibular pathology is the recover) lime. Cnlike nystagmus fo ll ow ing a peripheral vestibular le'iion. np,tag~ mus from a central ve . . tibular lesion may never re,oh~ Verti go can be a symptom with central pathol(lgy hut i . . rare and if present. j.!l often much le.,\ lIlh::n ...c than v.llh a peripheral vestibular lesion. Yl Patienb wilh Ie' on &)1 the vestibu lar nuclei can present with \'crtigo. ny!'llagmu and dysequilibrlum ..,imi lar 10 the pallent \\ ith ,I ral vesti bular lesion. However. central lesion .. ah(\ I.. \e! of the vestibular nuclei will manit"e . . ' lateropul u lilt , and visual perceplUal difficultie, J\ \\ell ,I (lC n (If

"

signs. Lateropulsion refer . . to the person's h:nJ('11 to o ne side. Brandt et al clas~iry central ve'libular "ndwn f m a clinica l con\ensus of es tabli shlllg perct.;ptual JIJ.f motor. and po.,llIra l . . ign'i.!~ They report thai the n ~j live ... ign ~ of unilateral bralll . . tem mfarct ;,lfl,; till ,I th~ p'.lIiel1t \ SVV and ocular IOr... lon. (Jelllu,. tonTOTI rdt"r'" II hoth eyes rolating dO\\ nward toward the dlft~dill 0 lilt

Chllplcr 24 Vt.· .. libulnr

I)i .. ord(,n.

JO 1.l

infarct) syndrome. one-third of the ...c patlenl ... dClllnn ... tri.lll,,1 a compl cte am (Fig. 24. 14 ).''''

"Red fla p" thai should alert the clilllcian to a central vestibular etiology include horll ol1wl or ve rtH.:al diplopia lastin g longel than 2 weeks after th e onset of :-,igns or sy mptoms thou ghl 10 be du e to UV II. pe rsistent pure vcr· ti cal pmiliol/ol lIy.\1aRnllIs (ant erior ennui c upulolithinsls :-,hould be ruled ou!), and i] ~ pontan eou ... up beating nys tag mu :-, (ra rc). The therapist ~ h o uld refcr a pallent with these manife:-'Ialion... to a neurologist. It b not within the scope of thi .., chapter to expand on the differe ntial diagno.!tis within the eNS. identifying the !>itc of lesion, Ilowever. the physlc ..d thcrapist mm! rccogni lc th e difference between ce ntral and peripheral vcstibu· lar dysfunction becHuse this gu ides th e treatme nt strat egy, Table 24.6 can be used as a gUide 10 discern ce ntral ves tibular pathology from peripheral vest ibular p;lIhology.

B

Figure 24.14 The ocular 1ill reac ti on (OTR) COI1\;' ''.. of a tri ad of 'ilgn .. : (i\) Head tilting 10 the right. mdicaled wlIh the large

JrTO\\. c~e

(8) SI..e\\ de\ ialion

01 the eyes (ri ght eye

... upl. mdicated Wl lb Ihe bl'.;cctmg line and

i~

~ Irai g hl

arrows.

Benign Paroxysmal Positiona l Vertigo

(e) TOl"\ion of the eye.;; 10 the n ghl. indicalcd with the two

,mailer rounded arrov. s. (Adapted from Brandt. T. and Dieterich. \I.~" p 339. \... .th penni'>,) lon.)

Ocular torsion combined \\ ith head Iillillg and skew dev iallon encompass a triad of !o.ign::, lemlcd a complete ocular rilt reaction (OTR).'I5 Skew de\'iarioll of the eyes appears as

one eye being <.,uperiorly displaced in comparison with the other eye. In a ",ud y of

palient~

Interventions

down, left

wi th Wallenberg 's (PI CA

The deve lo pme nt of s pec ifi c anticipated goa ls and expected out comes for the individual patient with BPPV is based on the follOWing genera l goals: The otoconia will be ret urned into the vesti bule. Th e patient will demo nstrate reduced verti go aSSOCiated with head motion. Th e patien t will d c mon ~lrat e improved balance.

Table 24.6 Common Symptoms Associated with Central versus Peripheral Vestibular Pathology Central Vestibular Pathology

Peripheral Vestibular Pathology

AtaXia often severe .

AtaXia mild.

Abnormal smooth pu rsuit and abnormal saccadiC eye movement tests.

Smooth pursuit and saccades usually normal: positional testing may reproduce nystagmus .

SX usually do not include hearing loss; If so, It IS often sudden and permanent.

SX may include hearing loss (inSidious-may recover), fullness In ears, tinnitus.

SX might Include diplopia. altered conscious, lateropulsion SX of acute vertigo not usually suppressed by Visual fixation.

SX of acute vertigo usually suppressed by Visual I"ation. SX of acute vertigo usually Intense (more than central vestibu lar pathology).

Pendular nystagmus (eyes oscillate at equal speeds).

Nystagmus Will Incorporate slow and fast phases (jerk nystagmus).

Pure persistent vertical nystagmus perSists regardless of posillonal testing (persistent downbeat nystagm us In Hallp,ke·Dix may indicate anterior canal BPPV).

Spontaneous hOrizontal nystagmus usually resolves Within 7 days In a pallent With UVH

BPPV

Bemgn paroxysmal postural vertigo: SX

symptoms, UVH

unilateral vesltbular hypofunction

Table 24.7 T,,,,, of "\ ,,'a gm II.> Ba , ed on CC Location ;u1d \I ecb.ln ism of BPP\'

All be R

•

b

'"

Pers s~et":' US ana Trans UB aI'O

t post nor

Le poste

CupulOi' as s Cana th ass

Trans et"

RlQht antenor

Cu Cana thlas s

Pers s:e • ['IS Pers s:en! OS

Left antenor

Cupula ass Cana: th,as s

Pees ste DB a Pers ste"t DB~ a

Honzon1al"

Cu uio IthlaSIS Cana Ithl8S S

Pers sle ~ ageot Trans en' geot

• .,

sec

·TestlOQ for BPPV III the assumes the patoem <s n 1'Ic? a...."'Pft"IC :~ ~s I"l ~~S' ~ 'Stagmus s labeled b\ the rectlOll o· the iast cc ",: lS' ~~ as~ C'Qf""~' c· the n)stagmus s beatulQ up\\aros OS, OOW''I reat I'"I"stag"""'...s Ty,ent\-four percent f cases \H!re .stl J.s"la... t't?!'o\~ ~"S:e x a .. aei? ~ S;::C 5 0 ;::0 ~ The torsIOnal rotation S 00:00 as re 3~e$. 'he S.;.l"<e~"'V IX so' t"l<e e.es; - ~~ ~~-.e of the e);am ner.

·\Vhen BPP J occurs n the he "'oota sec n\'Stag-nvs \\ tlOOed to ether side ~geotroptC n 'Siagmus fast component bea:s a\\3\ • component beats to\\ard the ground

be

[,Il?:

The:' patient \\ III lkm ..... n!-tr:ltt" t'nh.U1\,'t",:I dt"\.'bh.l l1-I1l.1. tn~ ... lill , reg .mhn~ !>elf-lreallllt"lU ' Ir.m.·git.~~ ;1:- .1 t":,,"n l,f pn"lph) I.t \ j, . The p;.l1It.'nl \\ ill \,h.'11ll"lIl, {r.l1l' mdq:'-I:.:.·ndelh.'t' in \'Lul) .h.'I1\il~ (BA DL. L-\ DL) IIlH,h in~ he-,ld Hll'til'll. Bn~3U "'C

• ,\

,l ,k,.!.:: ..'

th.,--.

th.lI ~'nl\

('I{" "\

,utl' JKY,

I't't'\ t'nl

' ...

'''~''''~"

It '

n."; Ill!."" ...·tH...·al I.' nll ......• .... ,

(' ~ \

.IN'tl .....lb'fl tl' th,'

BPP\

...

I'lU.: h

",~"",,,\'

l.:r,'n .....

BPP\ I' tht' ll11h{ ,,'('I1\I11('1n rt'rlpha:.11 \ I,>tt 1l.lf I'ltholog). ph) ,I ..·.ll Iht.'mpI't . . . . hl"luld ~. Lumh.lr "'lh 1:re;]tmt' lll ,"-"If thl ' di ... l"lnkr, ' ~ ' t.lgmu , . g. .'nl;·r.l1ed ,1:- n',uh of rl.h.'lIlg tht' S III gr.l\ Il~ dt,pt.·ndt'nI [X"I,llll"lll'. lh ..'1.1h·' "hh,'h i ... 10\\"11\ "d tT.1~le 2-t,-_ .lnl.i I.hn,'{-. tht' dUlln.Ul to I.·h\""-',t· an .lppn"lpn.ltt' t '.\tm~'111 .lrrn\"h·h. Thl\';,' dltlt'f\'n! In'.lllnt'lll ,1PPI\\.\I.'ht', h.\\ t.' ~"'n 1.1 ...'\ ...'h,'1i '\1. \"'.,,'h ~,"t'd t.'1l r,\1h~'rh~ 'Ioh"l~il.' (ht'\."lrit', ('If thl!> Jbl'nkl lllt' t('('hnh.)llt" mdudl" tht' \" .uuhth [\'pt"",lli,'nin~ 111,\I\t'\I\ t'f. Ihe LI~r.Ho~ lS\.'l1h)nt) m,\I\t'U\ t'f. ,md Br.mdt P,ln)tl

l'UI'U .\ ,h~, ~..s I""

l'\.t"r\:I't"

.\' • It .1\(..'m.ltI\ .. tn.'. tUh,'"lt

sec

TIk.' (.III"llIh 't/""'I(',u,,,,.I..' '):,I1:c',j\t ('R " " l\.\, .."\t ,'It tht' \.",Ul.lllIlll,l'h tlk,\)f\. l,f t'n-: •. t1\,\1t1l1" dd'n ... 111 lh.. SL .. Ilk' p..ull'nt \. ht'.ld " I1h" t."\t inh) lhtl't.·I\·1lI 1,'hHll\lI' Ul .\ ~

tlk'I'k.:t" Ih.u \\ III tn(\\ (" thl' ~k'~n, t'ut ~lf th\' 11\\ llh l"\l S .md IIlIt' thl' \t.',UNlk l~l'lk'r.\1 It'm\ Il1f {h~' I, .\t1\,11\ ,'I th~' uln\.]l' .md ...t\:\.'Ull'. '\.' I:I~, ~'" ttl)!ll.·\· 11k' dd'II' I' til Itk' \(,'11Nlk,lh\' 'Icn, ,md '\l11l'hll1l' ,hl1Uld I\.',~'h,· Ilk'l "I lIl~" u ..~J 11\ ttk~ In·.ttllll'llI \,1 ",hll'nl'l .\11\1 .mlt'n\,ll Sl t I.J.n.lhlh!"", .U,(, Ih(' ',UlIl' l'l~un' ~~ I .... Ilh"tr.\t,·, tlh'l'R 1 .1'"

apphl'd hl \.'ttlk'r thl' ll'll l",hlt'IWI \'1£ kll .UlI'·Il"£ \ l t.... \ 1t,,'1 the.: tn' ,\lll\lnt. lh~ p.ItI~11I 11\,\\ t'l tit" Ith ,\ 'l'U "'lln,lI .J' .\ (\·I1\U\1.1I:1 hl ,I\\llli \l'l1ll'.11

h,,".\d

IIll"t'!1ll'uh th,It tn.\\ .\!!.Ull

~\.It

...·'ll ... ll' ...·llUUl "I

(t'\.'luk·[ ...'h.ur .

')1l1~ ,"'"

1 ....

R..Yll1T't" h: ...~ I.'

!

I.., du,\-.', th, If'. th{\'1u~t'l

I1h' • ~

Jd11 ..'ult h'lr Ih' '\.\t "

....

\.

hl ....;mat,."" II t ..' h' ...

o

Figure 24.15 C.lOalith n~po"ilioning Irt';1(111(,111 (CRT) for pOl<-tcrior or ~nlC'rior ,emiclfcular canal BPP\ Vn The p.lttem'... hc.ltl '" fi .... t rol.lIcd 45° 10\\:lr(\ the imohed ,ide, piclured here ii' the lefl. ~B) T ht' palienl j, th~ n l1uncd 11110 the H.lllptke-DI\ po~tlion \'liit Iht' :lffectet.lleft ear 100\iud Ihe ~fl) lI n d , te) \'C'\I , tltt' he.llI h rot.lled 9{Y to the righl. Ii .... impon;uH to mllllllain Ihe 30'- neck e\i t' lbi o n dunng Ihh :-tep. The hc;ul ,hould nO\\ be rHhlimllcd 45 ° to the right. (D) Thc paticll1 i:n"llkJ onto the ri ght ... houlLier .md ( E ) ,10\\ I) hrought up to ~ill1ng pO"'llion, head still rOiated 45° 10 the right The patient 111(1) then he tilled \\ lilt ;\ ... of! colLir. ~ole Ihe OriClll!l1iOIl of the 1:lhYfinth for e.lch ,I.lge. The alTO\\ poinb (0 Ihe free -tlo;lling dehri ... ,1I1d :-ho"" ih mmcmelll through the canal mIl) the common cru~ (Dl . AC - Antt~ rior PC po"'lcrior IIC horizonl;ll SCC. Bel" t'cn e~lch . . tcp. tht: cilnil.' jJ. n ~hollid \\ ,Ill ] 10 .:! minute ... or unu] Iht.! vertigo ;lIld nyslagmu ... hni) 'lopped 10 ensure otoconia 110\\ through the ('tlllai. (From Tusn. RJ : Can:lltth Rcpo;-.itionmg for Benign Positional Vertigo. Education Progmm Syllnbll~ . American Academy of Neurology . Sl. P~l l1 l. \1~. 1998. P 13. \\ IIh penni ...... ion.)

scc: =

prob.lbl! prm oke the p:ttient'!I \'emgo. Patiel1l education ,hould ... J...o include infom1ing the paticl1I that it b nonnal to hl\~ . .ome rt'siduai ,~mploms of d) sequilibrillll1 and nau!lca On complelmg the c\erci~e . The residual Sj mptoms are ll::;UJll~ temporat') and patiel1l!l need 10 continue the c\erCIScs. Th. ph) ,ienl .herap) goal of perfomling CRT and liber.ItoI'! procedures are to replacc the o[Qconia il1lo the \e~ubule . \\ here the calcium cf) !oItnls can be reab!olorbed. The Brandt-Daroff e.\ crcises. although original!) designed to habituate the peripheral \'e:-tibular re~ponse. hmc ul"iO led to a comple te remi\"iion of:-.) mptoms. sometimes after the first e\erci,c -,e\'ion yl~ Phy~ical therapy outcomes "illOu ld also Include teacrung the patient hO\\ to llse the appropriate tech~ ruqu~, at home. in the caM! of recurrencc. See Table 2-l.R for ugge'ted guidcline ... for u~e of the CRT, the Liberator) Semont ) maneu\'er, or Brandt-Daroff e\erci\es.

nilateral Vestibular Hypofunction

scc:

The patient will demonstrate improvcd stabilitj of gaze during head movement. The patiem \\ ill demonstrate diminished :-.cnsith it) to motion. The patient Will demonstratc impro\'ed stat ic and d~ n,unic postural ~tabi lil ) .

Table 24.8

Benign Paroxysmal Positional

Vertigo Treatment Techniques

Treabnenl Ptocedure

~ !2 _ !!·! . /~~iIto-

CRT

BPPV due to canalith.asis Posterior SCC canahth.asls is the most common

Llbera'ory maneuver

BPPV due to cupuloll.hlasis Pos.enor SCC cupulohthlasis IS the most common

Brandt~Daroff

PerslstenVresidual or mild vertigo (even after CRT) For the patient who ma~' not .o/era.e CRT

exercises

The de\ elopmcnt 01 "'peeltic anticipatcd goaJo.. ;lI1d expected ~h.:ome,> fo r the IIldlvldual pallclH with UV II i~ ba ... cd on e fOlio,," mg gcneral goah:

BPPV Bonign pRroxysmal posltionill vertigo. CRT S(lmlCilcular canal reposltlonlng IroHlmonl,

sec

canahlh

I 111' 11\11"

""hili'

I

"til"

"t

11\ \Ihl '\

I

111\"

~ \,11

Ih\: 1"'1

111' 1'\1,11 hllllllll' 1,,'1111,11

,hI'

I

I lIt

It. , ,

III \\ \

\1\

'I 'll,11 ""',\ hI 11111'1\"" 11h' 1\"111111 {" 111111

,,· . . tlt'ul.u " . . 1\·111

\I\'"UI'"

1

'"1111

hlllli

1\

llh' 1'1,1111 \ ,III hll III

11111\

,IIH~I\UII"" ~It \\"1111.11 . . 111'

\ \'1 ,,'\' ,\ I,ll orl \ h ,III, Ih, 1'111 111 11\l1 .... ! ll' hI I..\·\·P th,' 1,Il'rl III 1,,\11' t)lh ~ I\\1 h'll 1l\\'tn'lI llMt I' h~' 1.lpld \\ 1111\· . . \111 III \'\~ ,'".1\\ 1\'111111 III'

tho.'

\\\\1 1'11111.11\ 1',\I\ldl~'111"" \11 ,\., .... 1,11\11,11 ,1\1,11'\,ltlllll I.

1\1111\\.' ,1),111\,\

B

'\11111\"

')\"\\"UW\

111111\

1'1

\."\.' th~' 1'.\11"111 I' .' . . kn! h' 111\" \' 111\' hl.',nl hilI 1/11111,111, I uhl \\",ttH.-.lih 11 ,II'PIVPlhlll..·) \1' \llm"" ,I .... 1'\1\,1111," " lui 1\1,111\1.111\111' hx·u' 1m II 'I.!bk 1.11 "" 11\,· P,I\II.'U!lIl1hll '111 11.\ . . h\\\ Ih\' I":,I\! IIH)\1..'11I\'111 II Ih,' 1.11 '1.'\ 1~'\IIIII\'''' ""111\'(\ \ ~",\d "\I~~'I hI II .... \..' ".1 l'U'IIlI.·\. .... f,lId, ,""111\' II1\" plllrni 1\) r..~·I1"" "it ,\ \\111\1 \11,\ 11..'11\'1 \\1111111 ,\ \\Pld

c ,

~'""C"",

PC

11", \l.l\lm'

B

t

o Figure 24.16 C3Jlalilh repo"lllonlllg tfe.UI1wnt tC RT) tor nght oonzontal ,emicircular can.t1 BPP\. Imli;\H~. the p,ltIem'" Ill'ali ...hould be plal."ed in ~O'~ CCf\ lCullli'\ton. t, \ ) Fur lre.llm!;. .\ nghl... itied horuonlaJ canal BPP\. the p.menl', head i~ 1111110111) pla.:ed Q()" to the right. (BI '\e\1. the hl';ld "rot.lled 9{1" to Ih~ left. The Ihempl\{ "hould \\;111 in th1" posItion for 15 'cl'ond, or unul the \ertigo and n) ... Iugmu, :-.IOp~. tC) Thl' he~d ... hould 11 1t~n be roli:Hed. anomer 9()<' 10 the left. ag.'lin the therapl" nHl"{ \\;Ul for I j ~ond.s or until the \ enigo ~Uld 11) 'Iilgmus SlOp:". to) The patIent mu ... t lhen rollmto prone po,ltion and :!",nit the !'>ign~ or S) mptoms to slOp. The thempt ... , nm" attempt 10 leep the head in ~O' ne~ion dunng the lr..msLlion from C 10 D. If the CRT ha, been successful. n:-.tagmu'I and \enigo should re-.ol\c OIlCt! Ihe pJ.tlent I'> In the prone po:'1110n. The patient ma) need a~""I::.lancc 10 :o,U up from the prone po,ll1on.

The patient will be independent in proper perfonnanc~ of a home exercise program (HEP) (hal includes \\alking. Pa(jen~

Wilh UV H \ hould be informed (hat recovery time upon initlatlng ve~libu l ar rchabilliution averages 6 to 8 weeh. To enr..ure comp li ance wi th (he ve~(ibular rcll<\b ilItation exercise .... patient~ ... hould be encouraged freq uently and the mutually agreed upon goals and outcomes regu larly reinforced .

Gaze Stability The purpo\c of Ihese exerCI ... es i \ 10 I III prove the VOR and other ~ystelll\ thai are u..,cd to a ...... i ... 1 galc '1 tnb llil Y wi lh head Illotlon. VC\llbu lar adaptation cx.crci\cs afC designed to expo\c pa!ienh to retinal ... Iip Retmal ... lIp OCClII'S \\ hen

c

0

ff

~r

PC

~..

~),

~~

~

~r

Figure 24,17 lIbcrnloT) (Sell1ont) rnaneu\ er 1(lr n!!11I J)\ nor see BPP\'. The ph) . . icallhempl ... 1 . . Imuld 3"'" Ihe fIJI through Ihis po<.lIlolllng. procedure, NOle the oltx·O\1l,\ ,hill.:

10 Ihe c upula 111 A and B, (A) The heJ.d i, filiated ~5 1t,Ih It '>Ide. lB) With .I,<""tancc, Ihe palle-nl I' Ihe-Il IIlll\t'd Inll1l ,III to righl ,idelying and "Ill)" III 1111 . . p{l'IItioll for I Illlnut(' I{ The pruienl i, Ih~n rapldl) mo\cd IHO-, from ri!!hl 'lll.-hulI: t(l Icfl "id~l) mg . The head . . hauld he in Iht' llT1£lIlotl 't.lnln~ P'-"I lion, lett rotated (no",c (\(l\\n in linai pO~lIllln) \111111' t'\,Uur' Note the otoconiu haw hc~n dl,lm.l~l·d from Ihe 1,:upui,I.\I!~'r

Ill1nut~

III 1111'

pO~ 1I101l,

(I») the

Il.lti~nl

=

n.'[um' ill

,I((III!! .lfl~f ,,_

nUl) he titled \\ IIh a "otl collar. AC Anlt'nor ~ CC; PC ~ le.-ioT Sec. (Adaptt'd from John'oll, R, and Gnltin, J pit, wilh pcnni . . "oll.)

l

~JiI;

Th

~L. .,.,. f:'ft

S Br..utG-~Darotllre'.:llIne'm foe p....'"'t:n

sec

4. TIl<" pat!~ "'!;ins ut..! ,utm; F"-'" 11oo..mJ tUIT!' thee- '1..:k: .qi then qUI,:' ~ ll<' dQ\\ n \)(1 ~ ..:k • 8 ~ patle'Ul ,bould be m... rru ..~teU (~) . . ro--~n\)n for.3t ~'\"'OJ.... or unullhe \ ertlf.\."> ,top, then .. km l~ return, 10 ~ ~tdItm:g. PO"I(lOO --\. _ ~ head. rolanoo e:~r until ,mm~ upn;ht. ' (\t. ~..; the he-ad tQ ~ PP'hl1e ~,tioo ,. ~ and ,)!I the other shoulder l(,r',) (C). o~n ing the ... imihr

orro-

... "f',~""U(i\e d~~~_

P 10. \\ nh

¢....:- "'"

\

p".hl1100..ti le,!.--'

r

II .. l.fdt.{

1'0

\ ..'

'ThoC' pro\\.).

m~ ("\.errh':-, ~ JX"rfl)ml<"J

[rom l~ h.) fl\l:.~ lurk." , t'"~\("h. 1"0 to [hn.~ t Figure~":

1, J J.a\

21 Pr\)\ldt- .....Ul t':\i.unpl OLl HEP U'Ul-i- \i',ubu· tl. .umn~. Th< ~\.~n:bt'"' ~IJ"\" I..k"!plni l).

lac h:,bltuatioo

tune ;U1delll1e!>. l11e nerC"l'i-(' ... hould be done III w .. ' three ume--... per d.l~ umil !.he patlent i~ "UhOUl \ t'rtig.o

Gn

, .. ,

..k-\ .. .'\l \ ~f'. t... tKl(l: 1...... ( .. ~ ..,.oJ l"lC the ung,uW \\l t Ca'\lhvrt\.' C, ~\ .. , )(Tit .mJ. LX\\,·..·rUl.... anJ l>"\ , llUf \\ N';~U t~·\ ...·,·' a.r ... ~ te·l"ll~r\.)\~,.i:k.'''~\t, l.h..tn. \\ h..u hatt l "or orkr-. C lru ... :tn' ,h I t tlOi trt.> 41.1 \ ,!j p..Ulem, \\ Ith habltu,\II\')f! e,
F'" B

p't:"r ~-I

\ -\dapted from Johfuon. R. and

A r-____________________

~

penru:"''';lOn.)

targer dlSIanct' should be an arm'~ length U\\H). The ,,:; pJrJdlgm relJ.uire~ the patient to mme the head ~Ul.d (~u:geI m oppo:-.ite direcrion!i tFig. :;.1.19). Both p:tradigm~ ~hould ~ made increasingl) more difficult as the p~Hit'nt improve, Examples of increa~ing. difticult) include the use of a di~~ tracung bacJ..ground while the patient attempb 10 re,ld llt' lener or word (checkerboard. \ en~tian blimb t \ i.u:mg [ht" di~tance from \\ hich the pariem perfomh the e\en'l~e~, mO\ing the head more rapldJ), and perfom1mg the e\en::b~ v.hile sianding. The compflreri:ed D\ ~\ te~t i~ [I u~eful men,ure of mlpro\'~d gaze stnbllit) for mdl\ Idual ... \\ ith LI'H and TBI."'·IlP

B

Po,tural Slabilih

The purpo!:>e of postu~al !-.tabilit) e\ert·i~t$ i~ 10 impm\ to' b,ll~ iince by encouraging the deve lopment or balance ~tnllegle, \\'ithm the limiUltions of tht:: POUe-IlI, be the) SOIlUllost'IlS00 , VillllUI. Or ve ... tibuiar, The exercit;es ~hould L'hnllengt' Ih~ pallen! and be safe enough (0 perfom1 IIldt.·p('mkntl~ (Table 24.9). E)..crci:-.es mU~1 be updmed nnd progre:S't.·LlHl Incorporate more t:hallenge1
incorporate hL'Ht! nHl\ emellt Inw Ihi! C\t·\"\.·lS(', bccau\c many pUlit::l1h with \'e~llhLllar 100.;1, tc:nLllO dt'clt'u ... t" their head move men\.

ImpOrtum to

.~.

--

Figure 24.19 lIMt'

p,lIIl·nt "

1,"tllHtlIIHIIl!

lilt' Ill'ad

~1()1 IOn '

S

...

lJahlllwrloll Ira/111ft!.: is WnfranlL'U \\ lltll !I Pflllt:'111 \\ Ith

it

LVII ha~ tOllllllunl ~olllphtll1 l l, (II (hI/Int·" lIab,tu tlfUll/ I' dl:i"llll!d rl~ lhe rcdu<.:llUIl JII re~pDn,t' to a rtl't' lHt'dl~ pCI ·rhc<;l'

hxu\.

1 l,u",11

IlIl' t""\\.... \\tl .\1\,\1I 1.1I

\'11 Iht' 1.U\!\'1.

I ':\Ik

'Ill.

'd \\

,h\' 1'..111\·1\1 h"ll l~lI Ilh Ill,{ ~, .' i\'\hllh~'\Il ttl., l"lh 1\1

~t:t'Pl1'~ !l1l' "11~~'1 ~1I1l ,it)

hx II .... Ih\' t·' ~., \'11 ,I (1,',\1 1.\1 .\., \\ ht k th( h ... U I' tll
• ('Jl\lhHh'

fOflnl."d mO"t'lIlcnl

'(,II'lill\ t'\l'\\ 1'~'''' ~ \ ) "

ur"l1ul."lrd 1\' H~'u'"

t>.t'ITI,e-'" \\l'lt' IhL'

1,1..,1

""'lI l· ......

fUlllll·tIIOd-, u....l:.'d 10 Irellt PL'l"'(ln, \0\1111 \'l'", llhl lltl l d, .. \lflk,

111111" !I d.\\ 111,11\

1"1\'

1\·,,·.\lnlll till!

','111, .1 h, .lIt IIh'" lI\\'ut

\ 1\1111\ .I1'''n\,'II. I{. ,\11\1 \.\111111 I '" I' I' '11th I" f!HI

II .... ' 1

InlN

Ph,,,.i,,,IIt.·huhilihHinu

Tabl 24.9

Ulllull(·...• I",.· .. ·i"'l·~ Ulul Pl'ugl'l ',IoiNion"

Pro... 1 SltlllCi with fout "tluutdor wf(1I1I npw\, nrlllH urrotl~ 1110 C ll0~ t

Pta"'.....

To

BlIllq loni CIOflnl toqolllllr CtobO oyw, S tund 011 n nnll!

I nilullcn tim LHilJ of Vh!'JIlbulul r.IHI~

cl/!,llIOIl or 1011111

~JtlPpor

lor tllllll!l{;O hy dOClOflfll llq bllflfl 0 1

t

I YO!. i:lo',ucl IIlc:roll!I(!!' 1l 111itr1cn on

vO',lliluhll cuos for Imlllllcn 2 r'llcllcn ullklo SWdYS Illmllill

It UIUIII '" Ilin plltlonllo tII.lltl fall, 1.; 1

IUltll,11 line! nn!
Ililkio IIlltlloqy

3 . Alii mp i 10 wnlk wlill 11001 1()lIclllllq Ion on IIrrn Mlllnco.

Du Iho ',lIl1lfl

nXfll{:I~,(I

011 clllpOI

I ntutll CO 1110 1I 1 ,O 01 Vll'lhhllllll ClIo

101 hltlftllGO by <10(;1011 111110 h ll' ,1\ 01 ';IIPllOll ()Olllq tim nxorCI',1l 0 11 CHIPO! Ilit! I', proP,loCOIIIIVtl 1111)(,1 , IIltltltl',IiIH

tlllllCtil ly

4 P,ncllcn wlllkinu IIvo hiOP" 1111(1 lUi olng 180" (loll nnd IIq11l)

Mflkhl{J nllHllloI 11111111. C le>oo oyo n

5. Wllik (lnd 1110VO 1110 11 11(1 HI(lo 10

COllntlll(j Imckwf\l tlti hom 100 tlY

[ sldo, up nnd down

1111111110 prov"Jml /I qrotllw UII1IIi nqlt v{l',llhttlnl "Y!I IIIIII

10 1110

UbO cllh lr ltC.tlllq toqnilivil or 1110101 tIOllilIlHI', to clUllhlrlCllJ I lllhllUI'

thl om.

Nolo 1 hl ~1 h,\)1 PIO!o{l/llB II HIIlHnd llulIlbm 01 nXlHr It.Uh 1111111110 utltl~ I IVU dllrnplOvhl{j hUliliunu l t ncll 011110 tmlntlCO tl xm r.lstl!1 tlhoultlllU ptllltHnH l( llI lJwI Ilrnw, !L (IllY 101 I ? IIl lrHtlu h IIdt 11

b l ll llllet)

lopoiltlon 'I'PIOtllllT IIIL' til/litH' ...... ,llIdlllL' P,lIll'lIl .. lttltlltl he rl1LlIlIt ilfl' d Ihllllill' '), lIlpllllll "' IIII1II1,1I1\ t!nll',l'l' \\11 11111 1 \llT~

II ;1111" V\\" l l

\H'd., til l' "'\II IPlilll1 ' oIll'/lO hrlll'l Ilt l·l1,dHIII,lllLlIJ ....t· ..... hilLild 111 ... 1 hl' l 1I . 111 ~ 't·rI II 1111 ', " IInl hI Ipht! 1111 1

PUllt'lI1

\\ 1111

, holiid Ill'

Il'I l' ll t' t! III nlhl'l

" JllTlill (111111111)' III

1,l· ...

tthul .LI

,I P"\~ll,d 1ltll.II'I\I

Idl ,lhlllLllt llll ,llld/III ,I

ph ) " l l,11l 101 1IIIIltt' I l'\I IIU.1II1I/1

BilaC.,rnl

V.,~cihlll",·

tlypofll ...·Ci",.

I Ii\' dnl.'loplll l' II1 01 "'Pl't rllt .""ll lp,lh'd l.'II,t! 11 I hlll111' Hld"ld".1I jl,i1ll'llI 1\1111 1t\11 ! II

11,1

011110111(· ...

Ihl' 10110\\ III ~' ~'l'IIl'I,1I

111/1

.'0,11 ... lUll

pl.lIl1l ... III ,1'iI/t' IIht.thlhl }

I Ih '

Pitlll' lll

\\11

d Ylldlllll. h,ILuH l ilt' iI

1ll"1I11111 ... 11.1!l'

IIJljlltl Vi.t 1

1/111

I \I

L'

jl;.11\'1I1 1\ til Ill' IIl1lq ll' /ldl'!1I III pl0I' ~'1 1'1 II 111\ II

III I' IIi dl

I hI'

1

IlIdlldt· ... \\01 11..111).'

pilll l' II1 \\

111

, kIlIOIl , II,tl l' ('II i1 ,lIlll'lI

... 1..111 ... Iq.' i lldllll' 1'I't!tlllIl.lI'U'

11\ 1>1 11I1,lIk

IlItlll'

III 11lIlh

dhtlkll"III~'

,,~( t

L~111 I \PI dl III II ILIII II

.1111\111

'11\111}' 1IIIltl

1'\'ullllt'lIl O ll'illll'lll ... \\ 11II ,I B\ II .... Lli 1'111'.1 III 1,ltll I I hI

Figure 24 .20 I ~!I "IPh' '11.1 IIHll l' II IllllUl1

Iht' pi 1111 ,11 \ I IIllIpli1ll1l ... 01 h,LI,UII\' \'\l' I L 1'>\'.

11"'llIll.hl· p.I'll·111 III vl·II, I ) pial I' Itlll' jill ,I plll" l l till' UI1(1

h.lllt1IU· Yot lhtHIt 111I,> 11I1l ~' till' IUp 1111111111" IIII' IMlll'll' ... huuld 1)(> .nl"'I,>\'1I III 11 "1' ,I hlllHllltlld lin' ,'\t'U 1'>1" l,111 Ill.' "IIIVlt· .... t'LI"1 t'YL, .. tlthL·d.IIIIIHLllLllllll r l til .. kpplll~' \\hliL' ,dll"lrhlllllp lUll' phlll·,II,·ILI till ,II,' llip IIHllnlUllilltl'U

11111111111

"I

).',1/('

1I"'oIl1,1t1\

dv ... t·qUtltlIiHllli illul j.!1 1I1

,1111\101

111111

( "t/t

I

'

1.1

tilt IIIl

Iw "'"I1t1,11 III Ilt l' 1 p,II"dl~"1I I I I tI"d 1/1 1 I II I \11111 111',11111,·,,1 Itlt I IV II t 1\1' III 11\t' jlitl,1t WIll r III \ " III I IlIt' lIdl' " !til ,I P,illl'lll \\1111 ,I B\ II b\·lolll"\· III IIIHt rolll"'l' l'\Ct· ...... l\l· Il' ttll i " .. Ill' III 11.1111'111' \\ lilt H\

l'\t'lI .... 1· ... l,II'

1"" 11111 'hlllll

"If lit.. "",hllli

I'I,IIIIII,rulll' .1111" ,1,/11"1'" n,/I ',1' ut II 1/1 I ""Iri".1f • '111111111111 111111111111" 11111111111,"'11'1 IJtJ.UUlllItHIIIIIIII,h'IIIIIIII/I/ .", wI,I' ('''' f!f 111,,1. fI,t,l) fir , 1U. 1111111111 11111 111111111 •• w hir 1"I\l ltI , 111111111 lu . , II V"" do 1101 II/IHHIIlfIl II 11111 , /11'111'''''11 I" l' '" 'I flrt Iff' HI 1'1" t1§r' 1111 1111111 Nllw Ihr,1 '111111111\111 , .. IUIIIIIIIII' V,jllI Ii tIU!lIIU IHI'UW,II, ,lImll'" 1t",I! 1111 IfJ ,Itt '11,11. "~I I' f Ihllll1" , II yltlllllil 1IIIIV.IJIIII""li1llltllllllilllllllJ IflllIIl/J/ 1111 IlIhlI1II/II,,1 'I'/ lUll I;;, VII I,r.." 11M J (I( J Ihl. VIIII,IUIII IIhu .. .. willi hll~1II /'"1111"'"1 11"111111 111\1 .. 1ItIl'" tJtIIlll1,UIIIIIIH~U~'rtU 1111 1111111, Willi Itll III """111

"",n "(

,,,,'J,

1 IUlIlIllltl 111 I .,," I... ,

I I lIulI klV 1I111YII 1rllll1 11111111U 1Ill1lUhllulJJ1wllf1U 1IIIIIIIIIu"~ II II II. 1IIIII.h 1/IIJr /111 IIIUII'lIItIJII hi 1111, tlllli II, 1~IItU 1111' 11111 .11111/111 IUU 1111111 VUW lull Ullm tlU"1 '1111.,

It 1//

~t'll' hlfj"

1IIIw, ~IV II111 Yll lrrJl11 .l tlll1\1

Olllllltllllll. I", l!ttl 111""'111.1

tI,.·

f)llllll, Ihll 11111111111111','1 1 11II1111nll1 III II , IlIlntil I11"Y""jlUlllhtlIIJ"'\ltJ~II ' '/IIIIIIIJlII' n/.'t h Ilill"l t If II IIlIf III! IIIPIIIIII,' Iht 1I111 ~lI m"1111 1111 hI! luhlPf."I!r, tm II 1IIt,I "I Ihl 1111''''111', Imllt" Il/IJIt. fi II"}(,IPILII

Wud

MU ll

r !tu,

dC,H

lun

So.

I"

(I

1111111111111

III III '1111111 111

1 I

f 1\1111

I

II

1'1'11 1'1\

I ~

1

hlhUlII,tV

III

\L ' 111~\

~I)

'1'\

I I'~'" Ih .11

,I

111, '\ lfPIlI,lh'

Hhl th~ II ','

Ihl,,111

"

\,1U11'11 III , I

1'11'1'1.1111

1\11\\1

t

lit

",'qll"!lll'tll'''' ;Hld IIl'.llI

IllIilflll,lI\ 1;1t ~·" I ... 111.1, 1111PIIlVl'

\1.lbdll\ h, \'llh,IIh'llif n'lIlL11 PH'PH'ft;IIIHIHII!' nll'Yl'

11 1,lhk' 110 l'!tl,'1I, \llih It\ II \ll'lwlld

ltl\,l1l<

\111 \\HI\.lil)"l'Il\;\lIIU\

ami/III

,,1.lhllll\ B.tlillln: l'\l'ICI"l'\ \ md \nhulu,' lit" U"l' lIt Ihl'''!..· nlf.· .... ('all' 1Il1l'1 lx' 1,11..': 11 I tlh 1\'1\'1"\'" ,11\' \K""llll1l'd ,,;lIl'l\ Ix.·...-au ... l' pl'opk \UI" \ ,\11\ hI 111.11111.1111 jl\I"llIl,11

H\ 11,11,'

1I111n'

IIk"h

hI

LIII. II ' II I'"

IlIIIK'1.III\\.' 10

\ 11111 ,I \\ ,11 " 1I\l! I'Hl~I,l1ll. 1..1.111) II

IX.'~II I 11Il'

ttl1L"r;lIl'd. rill'" t.:an he

Table 24.10 Bil:1.<>ro l Ves lib"lar Lesion h~rt'i,,(',

to Impr(l' e Centro l Prc lJro gnlm nl in g

ofl\l.~ \to"~111cnts

P.....ITh HOld ~,a targets at arm s length from your '>ead Look With your e es' rst then tum your l>eao toward the target ! "'empt to do thIS for

Progress to increaSing the distance used to see the target Use a busy background (checkerboard, venetian blinds).

60 secones. 2. Pertorm exerCIse 1 In ':1e vertical directIon 3 :1:lld one target at arm s le'lgth from your heaa Close your eyes aoa tlJrn your head

away ·rom the target lit'~ ng 0 keep yo,,~ eyes focused on lar;)et Open your eyes O!1ly after havJng b.J ~::l your head

Same as above. Progress to dOing this standing. Progress to decreaSIng base of support.

PIO~ "l'''"'cI

10 ;lIl1hlllatfllg 011 lliiterclil ,urfru.:c~ (gras. ,and) and HI dtfh:rcn t cnvironment\ (gro<.:ery tore, 111:111 ). I{cl'overy from OJ I C~ I()I1 InvolVing both vc~tihul41f "Y" ll' lII " lak.e, 1l1Ulh longer than a unilaleral le\ion. Pallcnh "holi id he IIllonncd tlwt d\ long a~ 2 year, may be nc<.:c ...";I I Y to ell"'lII"e a ... COlllpil':IC a recovcry a, IXh\ible. For this n:a"on. palien t cdUCi.Hion emphw'Mmg daily actJ\lIy is a hi gh priority. Daily activllY I11U \t continue beyond [he cour"c of vC~libu l ar rehabilitation. Other recommended activities IIlcluoc cxcrci<;cs In a pool and Tai Chi. The pool provides an environment of reduced gravity. allo""ing the paticill !O move ,afcly without the rt,>k of falling quid...l) [0 the ground. Tai Chi incorporates ~ Iow. controlled motions u,co to improve balance. flexibility, and incre~e slrength. In mOM cases. a pcr~on wilh a BV H will incur a functional di ... abllit). Ccrtain activities may alway\ be limited. such lb \\:llking in the dark. night driving. or spons involving quick. mo\emenlS of the head. IIJ Older pa tients may ha\e to u...-.e an assi~tive device such as a cane for safe 3mbulation at night or on uneven wrfaces. Habi[uation exerci"e" do not wor\.. for the patient with a bilateral \'eMibular lo........ ~ Vc\tibular adaptation exercises are an e\celknt ... tanmg point for rehabllitalion of paticnt ... wi th \'e~tibul'1f h~ pofunclion (U V )-I and BV H). R e~carch ~upporh thl' ~n('ti· cial effcc[s of vestibu lar adapta lion C\CfCI'C . . on g.ut, Pl.'''' lure. and DVA (Evidence Summar) Bo\. 24.1), l' 1;\ \Il' I,

Central Vestibular H ypofunction The development ot "pec.:lfic.: illltil'ip.tll'd l!\l.lI, .l1ld expeLled outcome., for the Indl\ Idllitl p,lIil'lll "till .1 n'nl1.t1 \c,lIilufar le ... io1\ " ha"l'cJ 011 Ihe InIIO\\ Ill,!! ~"n"I,'1 };\l.lJ...

I he pJllcnt ",til "kill

fl'gar-dlng

dl·1ll0Il"ltl.tlt'

Ltil

l'nh.llIll'd

dl'l'I"hm m.lkm~

jl1CVl'il 11t11l 'tl.II'·Vlt· ....1I1t! I , ,

,,

11l'~ ~""'.II\

,

I'

Evidence Summary Box 24.1 OutCOllll' .

t\ldj(., ~

Ul'ing VeMibular Adaptation Exerc ise s to IlIlpmve Gail, Balance, and D yna mi c Vi10ual Acui ty ;11 Sllbjcct~ with Vc~libular Ilypofunc tion Dc.;"nl R.... ft.·r~n'·c HorAk , S. oj ill' 1992

~

S .. h cct!ll

Interven.ion

l)lIra.ion

Results

Comments

25 sublOCIs, ron· domly asslgnod 10 1 013 groups (1 E and 2 C groups)

ACT: Irealmonl oulcome sludy, 2 conllol groups E vestibular rohabilltation

E VA 2 tweek lor 1 hour uSing adaplat,on and habituation exerCises, general can· dltlonlng, balance rOlramlng, and pam control Interventions;

VA group showed

GC,PP group SIZ.

reduced sway for condilions 5 and 6 of COP and Increased lime SOLEO and SOLEC compared With medicationonly group

too small to use for compansons (aulhors' obselVa· lion); spec,lIc exerCises not IIsled; f,rsl study 10 report outcomes uSing vestibular adaptallon exercIses: habltualron exercises also used: thus. cannot dlfferentlale effect of either exerCise Iype

E: qu,c~er pre· lerred gM veloc,ty. reduced t1l11e m doubto support, lolerdled COM to dOViate from the COP 101 Increased distance; no ch''')90 In rotdr'\

Flrsl conlrolted study rnvest gat \Q elllcacv of vesttbu tar rehab I tatlOf' pallenls \I h 8\ H

E IN 13) C- I IN 4) C·2I N 8)

IVA) C·I gon ral condlhoOing exorclsos and pam prevonllon IGC/PP) C·2 m dlcahon only IMO)

C·I C·2

KI{'IhB, Dl, 01uP'" 19 3

I~CT,

'routmenl Olltcomo

Usublocls [ IN 4) llVIl MUllllngo 67 3

study: conlrot yroup [ Vo~Ubu lllr odaptohon

, IS.9 C IN 4) OVII

und substitution OX(l I CISl'~ c: ISOl11otrlc lIXlHCI!>l's \mtl

MOlin 0\10 6 1 I

~onorcll COlldihOlllllQ

GC/PP MO

EACh group oulpa· \I('Int PT oncE' por week and HEP I or 2 - ,day

, 12,2

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h'st. VVOR t('Ost 01 OHI SCOIt'sIOI ('llIlt'l

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( 'Iwplt.·r 24 VCfrotibular Oi'tunh·"

102)

Evidence Summary Box 24,1 outcome S tudi e~ U~ing Vestibular Adaptation Exercises 10 Iml)rove Ga it, Ba lance, and D ynamic Visual Acuity ill Subject .. wi th Vestibular H ypofunction (""";"""") Re'ferrnce

Sub'eets

Design/ Intervention

Duration

Results

Comments

<;.,

E IN II ), UVH due 10 AN resection, mean age 59 3 • 10.9 years, C IN 8), mean age 47.9 IDA years; EC. pallenls wllh noncerebellar and/or bramstem tumor encroach· men! or musculoskelelal def,clls

ACT, prelesVposttest treatment sludy wllh conlrol group; E: Vesllbular adaplalion exercises, ambulallon exercises C: Smoolh pursull exerclses (placebo) and ambulallon exercises

ExerCises started on POD 3 Each group performed exercises (adaplalion or smoolh pursUlI) Jor I mlnule, 5x Iday for a lolal of 20 minutes per day

COP main oulcome measure E. less dlsequlhbnum; al POD 3: 64% E subjects could do AomEC vs. 25% controls; al POD 3 E had Jess A-P sway for conditions
Filsi sludy aclvocaMg VA as an eany posl-operabon intervention for AN each subject (E and C) was agemalched due 10 significant difference In age

PI' M ot .11' '

39 pallenls wllh Siable UVH due to neuntls E (N 19), mean age 517 + II I C (N 20): mean age 524' 99 EC' reduced VISU.'ll acuity. diSeases Impamng mobllil11llOn, cen!ral v~5!lbular disordors, pnor hlSlory 01 vC:;!lhulop.'llhy

ACT; prelesVpcsllesl wllh control group: Intervention: bolh groups received general walking program; E group also pertOl1l1ed saccades. VOR. smooth pursUit. balance exerCises. and celVlco-ocular reflex enhancement

E pertol1l1ed unique exerCises 3x/day for 30 minutes each for 5-7 days: 10 be continued Independently for 3 weeks via video instruction C: received walking program: encouragement

No difference in ocular torsion, subjective Visual vertical. or mean slow eye velooty due to calonc imgallon; E group showed grealer reduction In total sway path dunng stance on plalfonn pcslurography

Outcome measures exarntned central vesubular lunclion

53 ,u"Ii'C1> Wllh chroniC v(ls!lbu' 10p,lllly. ,lssigned 10 I 01 3 group.

ACT, preICsl'pcsllesl nonconlrolled. Each group perlormed oxerclS S31 home only (HEP). Group 1 slow hl ad rot.lll0n while $( :ttc'd WithalJ! Visual \lx,lllOfl Group 2 qlllck 11, ,ld rOI" 11M "'Ittl VISlJ,l1 II\: lion

All 3 groups 5-10 mmutes of exercise 5" 'day al home (HEP), pcsnesl aner 4 w('cks 01 HEP

No difference between 3 groups In reduction of vertlgo mtenslty. \ierllgo Irequency or symploms gener· aled dunog ADL

nH

, lOO ~'"'

K·

Ifld

Ee MMIOrt"S

dl

,"s.

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nouTIII or

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I

I mod~

.\l1On

t ,'t~d

And

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S)..,11I5

(,hnpll'r 24 Ve,libular Di onl('",

J02.1

Evidence Summary Box 24.1 Outcome Studies Using Vestibular Adaptation Exercises to Improve Gait, Balance, and Dynamic Visual Acuity in Subjects with Vestibular Hypofunction (~"',',,"<.) Reference

Sub'eelS

Herdman. SJ. et al"41 2003

21 paloenls w,th UVH EN 13; Mean age 65.1 • 16.5 C: N 8; Mean age 649 • t6.2

I)csignl Inlcncn.ion RCT, double blond; repeated measures with control; E: VOR adaplat,on exerCises and balance retraining C: smooth pursu,t and balance exerCises; OVA measured weekly lor 4 weeks

.)uralion

Rcsults

( ·omml.'nts

E and C groups exercised 4-5xlday lor 20 to 30 minutes In addi· tlon to 20 minutes 01balance exer· ClseS

12 01 13 ,nd,v,duals ,n Ihe E group demonstrated OVA that returned to age matched normal values; no change ,n OVA for control group; only the type of exercise conInbuted to change ,n OVA

Important lorst study showmg the beneficial eHect of VOR adaptat,on exerCises to Improve gaze sta· bil'ty ,n persons Wlth UVH as measured by the OVA

AN Acoustic neuroma, BOS base of support ; BPPV benign paroxysmal positional vertigo; BVH bilateral vestibular hypolunclton, C control group; COP computerized dynamiC poSlurography: CNS central nervous system; COM center of mass; COP cenler 01 pressure; CVA cerebral vascutar accident; OHI diZZiness handicap Inventory; OVA dynamiC vlsuat acuity: E expenmental group; EC exclusion criteria; HEP home exercise program; M-L medlal-lateral; OKN optokinetic nystagmus; OKS optoklnellc sllmutahon; POD post-operation day: PT physical therapy: RomEC Romberg eyes closed; SOLEC stand on one leg eyes closed: SOL EO stand on one leg eyes open; UVH unilateral vestibular hypolunctlon; VVOR Visual vestIbular InteracllOn (visual vestibulo-ocular reflex).

. . akt) pr!.!l:auIJOlh to aBo\" . . ale function in g wit hin Ihc hOI11l' and l'lllllI11Unll). Thl' pat lcnl \\ ill dcmon~lri.ltc en hanced decbloll ma\..1I1g . . 1..111 ... rl'g. ..mlmg lhe 01 compen ... ,uol')" ... Iraleglc . . 10 a~sl ... 1 111 g
exc rci ...c~. Il owcvl' r, the exe rci...c-. ... hou le.! not be 100 aggrcs"in:. therl'by ilgg r,w'ltlllg Ihe patient \ cond iti on. In addi lion, ga ll and ha lance exerc ise ... uc ~ ' g n cd to IIll'o rporalc ..ol11aIO\!.!n ...o l'). vi'iual. alld vc . . libu lar conl nbll\ um ... are al...o effcclin' mea n... \\ith thi \ patient populalion.

Once all accural..: lilagno"' I'" 01 cc nml1 ve"'llbut:11 pa lhol made. thl! phY\Il·althcrapi ... 1 I11U\1 he.:- GIn.: lullll l'/l()u ... · IrIg rchahlllt ..1l10n ... tral!.!!:!.lc ... LXpeUl.ltl01l\ 1"01 rccovcry . . hould he dc ... nihcd II1l1li.1l1y 10 thl' patlcnt (,cl1t: lalf y, til l" tJml' to n,'(:O\l!r Will 11t: 61110111h ... or morc. and mil) 1"lC'IIll:oTllplct!.! I' \I1.tn) of thl! ,tdaptlvc !I1!.!chanl\nh thought 1"l· ... pOIl'>l hie for n.!co\"l'I) 01 the \c ... llhlllar ... y...1c1ll ilrl' l"l'lllral prucc"'~l'''' tha t may havc hCl!1l damagcd 111 till' Illllhti cen tral Ic\itlll PhY'>Il"i.11tlll.:I
I he ve .. llhlli ar \y\ tclll n.:qulfe\ movemen t to rl.'l'mcr from 1I10\t 11.'\IOlh. I hl \ ba,Il' tt.·lll" t ... (multl he thoroughl) <.I ..... cu.....ed \\ hl' n etluc.ttlllg. llallenh aboul le tlllll ing 10 d.lIl) al."1lvily, l'\l' rC1~lIlg IIlLil.: pendcl1tly al hUllle . ,lilt.! ,t .. it gcnentl gUldcl lIl1' for the ir rel"()\cl). r hl' \1' \ lIhll l,lf "'y\lern \\ III nol 1I11pnwe Ilia \ IIll.tll) withou t h!.!iltl l1Iot ion, nl e d\a! k nge for hoth thl' olitpatll'llt .tntl IIlpallelll ph)" lc.li thl' rapi\ t 1\ deter· I1\1I11n~ till' .tlllollnl nt l'\e1'tl0n Ihe palll'l\I C.Ul tolclillC, lTl" :ttm!,! all dkcll \l' \l·\tlhtll.1I n: hahllllallOlI ... triltl"gy Wl thoUI l·au ... lll!-! lk'll· ll'IltlU ... dll·rt ....

ng~ 1\

Patient Education

Diagnoses Involving the Vestibular System Menie re's D j, ease \1«.'nicrt.,·, di,ru,c I'" dlitgnO\l'd hy ,I tltll'lll\\l'llInl 11m IIl'qm'I1r~ hl·,tllI\).! 10 ..... ilnd cp t\Odll' \l'ttlgn. JIll' p.tlll'ni

1Il.1~ .11'0 (Ornpl.1I1I pi .1 "'l'n",I..' 01 lulll1l''''''' III Ihl' l",lf and 1111 lulu"'. r hl' "')l1lplllm'" J:!1'.lodium diet. Thi., i., the mo..,! IInportJll1 dictaJ) re ... lncllon to folio,"", Other .,ub.,tanc.c: to he 3\'oided are caffeine and alcohol. Sometime., mcthcal mamlgel11em include ... U\e of a diuretic [0 control the amount of \\ aler III the body. Surgery 10 eHher prevent the fluid huildup 111 the inner ear (endol) mphatic ..,hunt placement) or to ..,IOP the abnormal \e,>[ibular ~ignal {\e~tibular ne"e \(!Cuon. or LrnJbl~mpanic gentamicin injection, may be inclicated if the eplc..,ode\ are frequent enough to dJe.,turb dail~ function. Phy~ical !hemp) i.., mo ... [ beneficial in Ireallng the effect... of a UVH 0\\ ing to chronic \It!niere· ... diseac..,e. although the therapy will not ,top the epI..ooe, of ,enlgo. Gaze and postural :-,tabilit~ exerci<.,e" ma~ be appropriate. Ph) ,ical the rap) i, abo u",ful in the treatment ot d) seqUIIibrium occurring alier a \ e...tibular neurec[om~,

IIltludc progn' ",vt' Iwarmg 10 li nni lu\ ,ifill ely f~lIlhh­ 'rl'allm'n( u"lIldly I11Volv(', uq!JtIlI uu l/ill {If Itl ttlmor Prchpcrali . . . cly. YCrllp.0 I "lieu flf,l pr' fli hecilu the turnor '" .,Iow growing ,Ind the (;cnlriJl ve IlbuL,r ~ tern cwnpcn\iJlclli 10 Ihe groldwll rCflutlum HI 'ImUII", Po ... lopc:rativcly. many p
Motion 5ickne\s \1o(Jon ..J:nc h a n(,rma !teO :.alJltn dial n oocomc\ debilitating lhc pre(jl,mJn:J a xp motion !:olC.kne \ i~ the PfUf;ry ({jf//lu llhn;r lflput of proPTJoctplJ(nl v infonnalJCJo do Rot match Jf(;l'j nt; Jral ;; expec.:t to recognue .;. a re pe:r lor, nau\Ca. effie j apfKi:' Ph) leal lherap. h. oeen ~en\Of)

rno Jon

mo.'

OIl

'r,a.

lr: _

:

~

Perilymphatic Hstula Per il) mphatic fistu la I PLF"I I' mo,t commonl) C31l;ed n.

.\1i.waine-R elated D izziness

a rupture of the oval or round \\ indo\\ ,_ membrane tiu1 ,epar:ue me middle and inner e3f, 0\ rupture (J; I.he-..e mem· brane ... re'\ulh In leakage of the penl~ mph in 0 the fildd e ear The re,uh i, \enigo.ma he.arinf 10_", . -:nlZ.iJ ~­ il~ mph bathe, the CC... and ~n e, ~ .) pro~~ - e --;-e~ bet" cen the oon) 3JlJ me", r.m PLF u"o.>l.1y I ' ...-aU"oL~ from 01 tr.:mmau.: e\ en:.... ""- a... ex..:.~.. r P;-:!'~­ adl:-_--_ ... ure .:hJ.nge'" .1..' 10 deeP-\\,ll r dr\ -; \\ llht; ut .. ul ra.:lure. or e eme~

dl3.gn(h'i' ;.. '11u..:h cletuted .md .. mllhrh In hope, r

!>1ulaple

.~

ero -

( ' IUlpC{,f 24

thllll;ll!\'" l't:r~h~lIar ;lta\ia. autonomic dy ... fullclio n. P;lr\"'in,nn\ lh~ca ... ~ li\"'~ ,)mpto11l~. allli cortico~pilla l dy'lum:tion. t\ ISA hn, bccn found to hI.' a C~1l1~t.' of dilllllt.'!'I' ;lllllunh;llanL't.:. 1n rhc crfcct of ph) ... i{:all hcrap) for pCr'OI1'1 \\llh ~lS\ h~" nol bL'cH IIl\C,ll g;\lcd.

Cervical Vertigo [l'nil-al \ crlign I'

dlagno!>i, commonI) u...ed 11\ Europe l IlIlCd SIdle ... A large pcrccluagc of lX'N)Il' ,ulfcnng from molor \ ~hic!t: ;lcciliLnh. ho\\ c\l: r, do feport ,) Illptolll' of dilline" \\ arran llllg runh~r ill\ e,lig.atlOllllltO the 'mm..'e. Till' mcchani ... m ... of in\'ohcmctll :Irc oclll'\cd 10 be from at IC:l'II\\O "OUrl'l'''. Fir.. t. the upper CCI"\ il'al ,Pllk' 'end, propriocl'pti\ e input 10 the contralaleral \c ... lloular nudell ... ,1 \.J Soft II"lIe 1I1jur) and jOllll dy ... lunctlon l1uglll ;llter Ihe ;ltkT'L'nl lIlput coninbutlllg to ... patial oncntalion, \'c'l1bul~lr n:.'habtlit;l1iOI1 Ill:!) bc \varrantl:d for thc!>e indl\ Idual:.. p~ Sccond. a patient might ha\ e \ encbroba .. ilar lINllliclenC) (\,BIl, If \,BI i, ,u'lX'ctl.:'d. \'a,cubr com promi'L' lllu,t fir,t he mll'd out a:-. a C;\lI,e of the palicnl \. ~) mp· 10m .... The \,BI 1l'''1 I.:':tn be pcrfol1ned while Ihe subject is \eall.:'d. The p~lIil'nt lealh for\\ ard and e:\tclld ... the m~cJ.... The nl'c\... i. . then rot.Hl'd ..t5' 10 the ,tl'"plcioll'" . . ide. Symptom, of \'BI lIldude diplopia. d) ...al1hria, ...) ncope. headachc. and \ i,uill lield deliclh;b \\ ell as \l'rtlgo and 11) stagmu,. Per,ons ,u,[lt'ctcd of ha\ IIlg \,BI ... hOliid be referred to a neurologist lIlunediately, Repeated episode, of \cntgo \\'ilhout thl' as~o­ ci;tled \ ' BI ,) mplOIl1S usually suggc .. h a peripheral \'I.! .. tibular lhagno ... j .... ;I

~CIL'0l1lrO\l.:r"'I;l1 11\ Ih~

Contraindications to Vestibular Rehabilitation Ph),lt,:al themp) IS not appropriatc lor ull"table \c ... ubl1lar di,orue ........ uch a, MCI1lt:re\. di ...eiN,~ (\\ ilh the e\.cepIlOll111Cn-

Questions 1. 2.

3.

4. 5.

6. 7.

for

R

e y

Ve~libular

Ui ..onlt'r\

lO25

tiollcd abo\c) :lIlt! Pl,F. Other contfi.llndlcatlons the clin ician . . houltl be alert to Include , ut!del1 10.'1'" 01 heanng. lIu:rcascd feeling of rU'C'I:-.urL' or fullnc:-.s to the point of di ... col11fort in one or both car,. lind severe ringing in one or both ca rs. Whentrealing patlcn'" who IW\.'l: hat! a surgical procedure. thl' c1l11ieian IllU~t be ob'lerval1l for discharge of fluid from thl.: ears or no~e. vvhich may II1ciicaie ccrebrospinal fluid Ica l-. . P"!licnl, with ac ut c nee l-. IIlJlIric . . may not be able to tolerate some compone nt s of the physical exam, the CRM. or \OI11C of the gale ~tabili l y cxerci .. es.

Summary Ph) 'Ileal thcrapl\t'l 11l1l .. 1 rccognlll: \igns and \ymploms :" .. ocialed with ve\tlbular di'lorder~ becau"ie of high incidence and prevalence ratc~. It j\ essential to dlfferenllate a pcriphcr:1i pathology from a ccnlral onc. Peripheral and ce ntral le~ion, ha\'e ... cparatc manifestations and may require different il1lcrvention 'trategie~. In addition. all \'e~tibular disorder'l should not be treated . . imliarly. The 1110\1 common fonn of vertigo. BPPY. is a biomcchan ical problem rcadily treatcd \\ ilh a , in glc maneuvcr. This i . . in 'Ila rl-.. contrast to a palien l \\lth a BYH. which requ ire') a greater rehabilitation effort. E\'idcnce \uppon\ the u. . c of \'C\l1blllar aciaptalion c\.erci,e~ for patienb with \'c')tibular 11) pofullction, The \ 'e",ilm/ul' f)"wl'ders AS.WUUlioll ( \ fDA) ha"i a list of ph) .... ical Ih crapi,,, in each Mate, interested in treating paticnts \\ ith \c!'ltibular disorder~. VEDA can be contacted \ ia phonc number (800) 837-84::!8 (2-t-hour voice mail) (503) 229-7705 (answcring machmc) or e-mail http://\\.ww. vc'tibu lar.org. Thc suppleIlll.:lllal reading li'l contains other excellent literature for the reader intcrc ... tcd in pursuing a greater dcpth of I-..nO\\.h:::dgc 1Il \'e ... tibular rchabilitation.

c "

DIlTcrcnlJat~ thl.: t\\O lllmClllcnl ... l'nsor~ 01 the \e . . libular ') ,tCI1\, ~,cribe the ph) ... iniogK lllill1ik,lallon cau,ing a (..·orrecl" C' ... accade .llter the hcad Ihrll ... t le,1. Wh) doc, Ihe patient \\ nh an anllc unilalcral \e',(ibular Ic:-.i(Jn ('\pl.:'nence . . pont . lI1COU' n: 'Itaglllu,,') What I' the patholng) of BPP\ dllt' 10 cupulolithia" ... ·) What are thl' 1-..(') clelllcnh 111 t.ll-..in!! .1 hl ... IOI') ') r \plain inhihilllf\ l'ut (JIT. Dlffercntlatc the -x 1 e\en.:i ...l' 1);'lradigm from the x ~ C\CrCI't' paradigm,

8. In a pallenl \\ lilt \ic .. tibular nY'Itagmu .. , \\.hleh part of the cyl' mO\CIllt:nl ( .. 10\\ or f'l~t) " from tht: vc,tibuIdr ')'tel11') \Vh) ,) 9. De ... cribt: llO\\ the Ilallplkc-Di\ le't would elicit ny ... lagmlh for ro't~rior SCC BPP\. 1 O. Dltlcr(,l1tlal~ l'll't\\.L'el1 ~\daptalion ill1d habituation tf
S

t 11

d

--

c' ,

01 /.:),/.: I I.: I"'/,: lo r th l! rl!ma lllin p tlll/lIl e.., '} Wh.H a}')(IIJ11he nCl:k palll '!

CASE STUDY 1 'wu .\lX' ~rfonlll1lg ,Ill IIllli:1I t,'\amlll;.\ IIOn of

(I

patient

\'lIh L'ol11plallth of lI11balalH':c and dillim.: ...... In:' "ll1mg pO ... IIUll1 •• It n: ... I. the patient i . . ob~cr\'cd 10 have a pun:l) \l"r1tc.ll.md pendular 11) ... wgmu ... \\llh head tilling 10 the

left. The n) \tagmu ... , ... nOI altered \\ ilh allY change 111

CASE STUDY 3 A patlenl wit h a unilateral

VC ... tlhlll <.lr

hypofum:lu)J1

(UV II ) complai n... of Iccllng wor ...c <.lI ter 7 da} 01 'liJrtll1g

he.ltI po..,ulon. and the hc:,d-... IHI~ill g· indu ced n y~ ta gl11u ... Ie" (HS\I) i ... negUlhc .

a vc ... tibular rc h<.lhilJlation progr<.lm. 'I he pallent hiJ had no fal". The complainl '" con"'I"" o f Il1crc<.l ...cd dlllln( wi th head 1110li on, nau ... ca, and latigue.

GUIDING QUESTIONS I. Do )OU su:-.pect a cC llIra l or peripheral pathology a... a

GUIDING QUESTIONS

cau ...e of the imbalance and di lz il1es~? ~.

I. h yo ur rehabilitation program making the pallenl wor ... e?

'" ph) ... ical (hem p) appropriarc at this time'?

2. How can you modify the program '! 3. Wh at infonnallon wi ll you lell your paliem wilh a I VII regarding tim e to recover? What will you lell pallem

CASE STUDY 2 On ) our pmient"s return to ~ illing up after you have per-

w ith BPPV. BVH. or central ncrvou ... "'y'>tem pathology

fonned the canalith-reposit ioning maneuver (CRM) for a

regarding time!) to recover'!

left po.!oterior canalithiasis. you notice down-beating and left torsional nystagmus. The patient is complaining of vertigo.

CASE STUDY 4

GUIDING QUESTIONS 1. \Vhere is the otoconia now loc ated?

Three week ... after in itialin g ve!)tibular rehabilitation for a patient w ith a 8VH. the patient fall ... at home but IS not

2. How will you treat for benign paroxysmal po~ilional vertigo (BPPV) lhe seco nd lime" 3. Following the second treatment for BPPV. the patient comp lains of dizzine ss and neck pain. The vertigo and nystagmus are gone. Can you prescribe any other forms

injured.

GUIDING QUESTIONS I. Will you modify the physicallherap) ,"lenenllon

2. Wa ... your home exercise program too rigorou )

Refer e nc es I. Kroenke. K. and

') 3.

4 ~.

fl. f

\II ~mge bd orff.

AD: Common

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~(1 PIl'II'!1dl. \1. 1:1 ,II: r1\IR I ,ignallllcrc:hC\ nnd dccreu\c, III cortlca [ .1 ,I' dllllll!! ' 1ll;111 -lIdd optol..inetlC ,lllllularioll aud central tiXlII"ln I 'P Br.lin Rc' 14 tU [7. 200.1. l ' HI,II"II. I and Dieterich, t-.I : Vc\tibu lar ,yndrolllc, II1lhe roll pl.IIl' lupogl'.lphic Ih.lg lI{),r, frOIll brain'tem to cortex. Ann \. unll 't'l:_l'7. 1(1)4 ~~ (,I~,lb<.'r!!. J"I. and h:rnundC7 C: Phy,iology of pc rip hera 1 nCllron~ 11'11 .,.llIn!! 'crnicirc ular canal, 01 the squirre l multl..cy. [: Rc, trng ,h,jl.tI~l' and rc'pon,c 10 COT1'ltllnt :tngular acccler:llion,. J \LIHIlphY"IIl[ 14:6.15. 197 1. ~Q l ~,.t\..ll\\ '\..1, . \1\1. ct al : Phy, iological idcntlfication of morphologiLJlh dl,trnct .llfercnt cI'I\'C' innerhlt ing the cri'lae ampullarc, of rhl' "l.jtlllTd l1\ont..cy. J Ncurophy,ioi 73: 1270, 1~J95 . .\0 H.llllh. RW. ;\Il{\ \-lonnrbl;t, V· Clinical Ilcurophy,iolog) of the H',llttular ,~'tcm. FA 0;'''1\, Philadelphia, 1990. ,1. \k~cr. Cli. ct ;II : nlC upper limit of human .. IllOOlh PUl"UIl velocity. \ I"mll Re, ~5:S61. I '>R5, .\~ h:l1l.ll1l]c/. C .•lIld GOldberg, JM : PhY'10]Og), of peripheral ncuron~ IIlncr.,Lting .. emic ircular cunal, of the '>quirrel monl..ey. II : Rc'pun .. l' to ,in\L\()I(I;r1 'Iimulation and dynrunic~ of pcriphenrl \c'lIhul,lr "y,tem . J NellrophY'lol J 4:661. 197 I. _,1 0.11. \1. et al: Modc1·blhed 'Iud) of the hunmn clipullir lime ~'lln"tant. J \ c,l ib Re" 9(4):29 3. 1999. _\4 BJlllh, RW: DI l/ lIle,,: Neurological emergcnr.:il". NtJurol elm l(d05. 1998. 3S. GII1C'pIC. MS. and MlIlor LS : Progno<;is in bll!ltcral ve .. tibular h)pohmcllon. L,lr)T1go ...cOpc 109:35 . 1999. '6 Tch,\n, SA. er at : Bilateml vc,libular pare,i,: Diagr1o~b alld treatment. Ololal)ngoillcad Neel.. Surg IQ.I :67, 199 1. r; Bt'ke]. A Jr: Dandy', ,y nclrome. Am J Otol I: lSI . 1980. 1lt Bhan'lli. SA. el ;\1: O ...cillop<"llI In pauenh with lo,s of ve,t ibular luncuon. Ototll)ngoll-icad Neet.. Surg 109: 120. 1993. j~ Hcrdman. SJ. ct .. I: Recovery of dynamic \ i,ual acuity in unihuenrl \Nibular hypotuncllon Arch Otolaryngo l I-lead Necl.. Surg 129~S):S I 9, 2003. .m. Dl\on. J$, and Bird, IIA: Rl'producibilit) along:t 10 cm verllc:l[ \ I,ual analog scn[e, Ann Rhe um Di ... 40:87, 1981. ~I Ja(ob'en. GP. and Nev.lllan. CW: l1le development of Ihe dizzine" .. handicap inventory. Arch Otolal)'ngol Head Nect.. Surg 116:4:!4.1990. .p Ro~",c)l1. 0, and lrelund , D: Dluine .... handicap imentOry corrclate, of computerized dynamIC po,turography, J Otolnryngol 24 l iS. 1995 ·0. Jacoh..on, GP~ and I\1cC;L\hn. OL: Agreemcnt betwccn functiona l and dl'CtrophY\lologlc mea ... urc<. in pat ient<. v. It It IIniluteml peripheral \e,ubul.lr ..) ~tcm nnpainnent JAm ACIle! Audlol 14(5):231, 2003. -'4 Tehan. SA, et al: Ilahltu.llion thentpy lor c hrolllc ve'llbular d),!'un'tlon: Preliminary result ... Otolaryngol Hcad Necl.. Surg HHII):S9. 1990. ~'\. Smnh_\\ hedod. 1\1. cl al PhY\lcilllher:lpy program tur \'c,lrbular rehablluatlon \111 J 0101 M,ly 12(3):2 18. 1991 4fi Feuer. \1. !lnd Dlchgan,. J Adapt!\c mt:chani .. m, 01 VOR compen'>atum after unit.lter.11 pcriphcnrl ve,lihular tc"OIl' In human<. J \Nlb Rc,> 1:9. 1990. ':1 c.1.\~. SP. CI ill: Pullenh uf \l! .. tibu[ar JunctlOn follo'WlIlg vc,tlhul;1f nerve '<1:11110_ L.ll)ngo,cope 101:188, I {)9"2. ':1>; \1..IWll C. ct.ll, Short- ilnd long-term rnodlficauon ~ of \c,ubulo'lI.:ul ..r n:'pon~c d)n.Llnit:~ lollo'WlIlg. unilaleml ... c~ tlbulur nerve Ie IlIn~ III Ihe L.lt [._'(p Unlln Rc'> 50:159. 1983. ':1) \'.
1027

:"in. I hrhl1lll!YI. ClM , und Culrhoy .... I S A clmrcul ... rgll of cilnul pare~I"', Arc h NellroI4'i :7n. 1991-\ . .'i I . Iialmngyi, (1M. Cl al: rite hUlmlll hori/unllil vc~trbul.,-()CuJHr renex III re .. pOI1M! to high-acccleflrlion ~tllnuliLtion before ilnd after unrlil! ' crul VC~llbu llir neurcctomy, Exp Bmw ReI, KI :479. 1990. 52. Millar, LB, ct al; Symptom<. and .. i gn~ III <,upenor cimal dehl"-Cence ~y ndromc. An n NY "cad SCI 942:259. 20(J I 53, Aw, ST. elu[: Unilateral ve~tibul.tr deafferentation cuu..e~ perma· ncnt Inr pUlnnCl11 of the hum:m vertical ve"tlbulo-ocular refiex 111 Ihe pilch plane. Exp Bram Res 102: 121. 1994. 54. ('rcmcr, PO, ct al : SCllllClrculur cnnal plane helld impul<.e ... dete(;1 absent funCl ion o r indlvidun[ ..emicircu lnr callal~. Brarn 121 :699. 1998 . 55. FO~lCr, CA. et al: Func tiona l [o~", of the hori7olllal doll'\ eye renex 10[lov. rng unilateral ve~llbu lar l e\ ion ~. Laryngo,>eope 104:473. 1994. 56. Harvey, SA, and Wood. OJ : The oc ul ocephalic rc~pol1!.e 111 the eval uation of thc dizzy pntient. Laryngo.!.cope 106:6. 1996, 57. Harvey. SA, ct lIl: Relation ~ hip of thc hcad impulse le.!.t and head,Iml..e nystuglllUs III reference to culoric tc ~ting. Am J Otol 18:207. 1997. 58. Beynon, GJ. CI 'II: A cl1I1ical eval uation of head impu l ~e tc,\rng. Clin Ololaryngol 23: I J 7. 1998. 59. Schubert , MC. et al : Optimi:ting the senslIlvity of thc head thru .. t test for identifying vC~lIbu l ar hypofunction. Ph y~ Ther 84: 151, 2004. 60, llain, TC. ct al: Hcad-,haki ng ny'tagmu~ in patient ... with unilateral peripheral ve~ t ibuhrr le~ions. Am J O tolaryngoI8:36. 1987. 61. Dix, R, and Hallpike. CS: TIle pathology, ~ym p lomntology and diagno~i, of certain common di~order~ or the veslibu lar :.y~tem. Ann Oto[ Rhinol LaryngoI6:987. 1952. 62. Longridgc, NS. and Mallin,on, A I: The dyl1llmic illegible E (DIE) Ie"': A ,imp[c technique for assessing the ability of the vestibuloocular n;nc:< 10 overcomc \'cstibular p .. thology. J OlOlaryngol 16,97.1987. 63 . Herdman . $ J, ct al: Cornpule rilcd dynamic vi<.ual acuilY test 111 the us~e"'nent of ve~t ibul:rr delicit:.. Am J Otol 19:790. 1998. 64 . Tian, JR , et al : Dynamic vi~ua l acu ity during p:r~~lve and <;e[fgenerated transient head rotation in nomml and uniiatcrJ.lly vestibulopathlc humans. Exp Brarn Res 142(4):486,2002. 65. Gro~\rnan. GE, et al: Frequency and velocity of rotnt ional head perturbation~ during locomotion. Exp Brain Rct. 70:470. 1988. 66. Oat.. VE. et 11[: Head pcrtttrb!ltiom during walking while viev. ing a hc:rd-lixed targer. Avial Space Envi ron r-,'Ied 66:728, 1995. 67. Colcbatch. JG, ,llld HallllagYI GM : Ve .. tibular e\'oked potentia", in human nee\.. mu~cle~ before and nfter unilateral vestibu lar deafferentation. Neurology 42: 1635. 1992. 68. I ialmagyi. GM, et al: Tlipping thc hcad activl1\es the veslibul:1r ,)~­ tern: A new use for the clinicnl renc:\. IUlIlll11cr. Neurology 45: 1927. 1995. 69. Cunhoy" IS, et al: Human ocu lar torsional po~Ltion before and after unilateral \'e<;ribular neurectomy, Exp Brain Re, 85:2 I 8, 1991. 70. Ku~hiro. K. ct lIl: Succu lar and utricular tnput~ 10 'tcmoc1cldonm~­ toid motoneuron~ or dccerebratc Cat,. E,

1999. 1 I Young, ED. et al: Rc<.pon::.c,> of 'quirrel monl..e) \e~lLbular neuron, 10 :Iudio-frequency ,ound and head vibnrtron. Act.1 OtoluT)ngol 84:352.1977, 72. Muroru,hl. T. ctul: RC\JXlmc, 01 gUlIwa pig primllT) \e'tibular neuron' to clic\..,_ Exp Bnlln Rc, 101: 174. 1995. 71. Viurofu,hl , T, el ;rl : Rc\pon'c of glunea pig \e~lIbulilr nudeu, n~u · ron~ to click,. Exp Bram Rc~ 111 149. 1996. 74. Bohmer. A. ct al: Cun a unilmcr.:rl ll)<'~ 01 otolithic IUl1cl1on bt'dlll ically dClected by .l..'e"mcnl 01 the ,uh)I,.'\:U\c \1,u .. 1 \crll~·.lr) Roun Re, Butt 41 :423, IQ96. 75 TahiLl... S, t!1 ,11 : Dc\'illIIOIl of Ihe .. uhJC'ctl\C h,rtl(.Ill1l Ion!! , 'ralldlll~ ul1llntt!r.11 \'c,tlbulur 10" _Attu Otulal)ngClI 117: I. 1')117 76 Schu\..nedl1 . II F: Cupu1Llltthr:hl' _ \rr.:h OI1lIal)n~tlll)(.l:7b~. I%\) 77 1·lIru\,I . r-,1. ct al: LXpc.'rtlllcnt ill 'lIld~ lit 'jX'l'd-lkpendc.'IIII"'-"'· Ilona', n)" llIgl1lU' III bcnlgn IlLl;rn1\) '111;11 pil'll1tlll.11 \t'nt!o!ll, 'U.I Owl.lryrrt;ul I :!J{t'l):7()\1, :!OOJ 71(. 1Ii111. SF. el al Ille 1I1t'(h.II1II;' tit 1~lIIgn p.uO\\ ,/11,11 \~·rtlS." Otohlr) ngul H(2J: l:li I 197'1

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Ikl\IIll,\n S\ \l',uhubl Rch,lbilit.\ILOIl. l'lI 1. FA DllVis, Philnddphm. 2000.

1krdllHttL. SJ. 1.'\;11 Recovery of dynumic vbu{l i acuity 1/1 undalerdl

vc .. ,ibulal' hypollillCllOll }\n..:h Otohl1yn}l0lllctld Neck Surg

129:H11), 20m. I lcrdllH1n , SJ. Blall. PJ. rind Sci1uhcn, Me: Vc..ubular rchnhdlltlllOn of

pUllenl\ wl[h vc!;[ibular hypofulI(;[lon or WI[h bcnl1l:" paroxy .. miJl po\illlllHil vclligo. Curr Opin Ncurol 11:19.2000. Jol1n,>on. RT. Griftin, JW, and MucA ulhour. J(': Current Ther,lpy In Neurologic [)llooC:lSC, cd 6. Mo.,by YCllr~J3ook, SI. l..ou ... , 2005 .

(; " , \ I' T I~ H

25 NG

•

OBJECTIVES

. tx· lhl.' mJ.Jor cllologll'ai

fal:lm~

leaulIlg

m l!latHln ,urge£). n lh(' Ill.ljor cmKcp'" mvohed in ,I

'j.'

I ~ 1)"".

\l~TJII\(,

m.Ula~('ment.

cn~

JXhltlOnll1£.

allli cJemon,tITne proper re ... iduailimb

l:\.lllti..lpng

", [X\eil'p JIl c\crci ... e progr.lm 10 prepare the pallcnl lor C',cntu31 pn.hlhellc fittmg. Ii. Rc ('\ll1d (0 pallent'falllily from an 3\\3rene.,.. of the p,)chologicaIIOlpact of lo\\('r c\lremlt)

amputation. q

I'T. EdD. FAPT\

'lbe lhl.' major compon('nts of po ... ,JU\C

11\<.:1) c\amine a patient follo\\ IIlg 10\\er tJ~mlt) .Imputation. f" h:h p,IIICn! ~lnd famtl) 'lppropriJte po,, -

6 fk:

Bella J. May,

.llIon ... urge!).

l ~

Amputation

\na)~ Ie .md Interpret patient dala. fonnulal!! fe.III,I!C anticipated goal, and expected QU(come .... and de\ elop a plan of care \\ hen pre-
OUTLINE Ll'\l'h of ,\mput,nion 1m2

Trcatllll'nt hllCT\cntmn If~2 Residual Limb Care 1042 Resi dual LlInb Wrappmg 10. '3 . Shrinkcr\ 10+4 Positioni ng IO-W Managemcnt of Contracture!> 1045 TIlcrapeu ti c Exen.;i~c 1045 Ambulation and Gait Trainine lo·n Temporal) Prosthe~cs 1048Patient Education 1049 Bilateral Ampu tation 1050

Surgical Procc,\... 1032 lIealmg Process 10]4 ['~(;ted

OUiCOIllI"

nll' CliniC

1034-

Te.lln to.li

p\1 ... topcrati\l· Dre ...... in!! ... 10.16 Rigid Drc \si llg'" 1036 Semirigid Drc\sings 1037 Son Dre ..... lI1g <; 1037 E\.;tmin:ltloll 1037

Range of \Iotion 1038 \lu sclc Strength 1038 Statu ... of the Residual Limb 1039 Statu.., of the Unin\'olved Limb lO.. Functional Statu", 10000 Emotional Statu!. 1040

w

A'

~ou enter the ph) ... ical thcmpy department this \1(\ndJ) mornmg. )OU note several ne\\ referrals COI11nf. nut (\1 the computer pnnler. You reflect thai It is almost a ) ear 'tote }OU gradulted from school. The time hOI ... gone

h\ r".o fa ...l and \OU have learned \0 much. You arc pleased \ou 100 tJ1I'. po..,ition in a large regional ho",pllal becau ...c ou ha\e had the opponuOIt) 10 rotate through \ariou!t !;tf\;lce .... You are curren tl) \\orlmg with general medical and ... urgu.:al pa.!tlent~ including tho~e who have had vascultT urger) )ou rea~h !elr the pnnlOul of nev. referml" and ...ee one )f a 7:!"'ear-old v. oman \\.Ilh dlUrele ... and alhero,clero .. i .... )nu lIe~lIed hL·r ~\ eml month .. ago for an ulcer on the plan" l4r ~a(e of her nghl fin-t metJlar"al and knO\\ ... he had ''"'It' pr(lhlems \\ 1m dJahclJC control. The pallent had a n~ lIanstJhlaJ (helnw ~ nee) amputallon Sunda~ i.litemooll illld now TC'ferred for theri.lp) You are a little ad. The (lauc:Ol I it \\ Idnv. and IJ\ es alone although "'he ha'J three ~n ~Idren and IX grandchildren m tov.n You IL'JIlem bet ho~ he talked ahout her giUden and her othcr W.:II\ 1111.: ilnd W(ITI
Dctl'nninlllg Prosthctk· Potential 1051 Transtibial Levels 1051 Transfcmora l Le\'eb 1051 BIlateral Amputations 1051 Summary I 05~

Major improvemenls in non invasive diagnos i..,. revihcularization, and wound hea ling techn iques have lowered Ihe overall incidence of amputation.., fo r vascu lar dise.he 4--(, However. it ha.s becn reported that between 2 and 5 percent of individuals wilh PVO wi lhOltl diabetes and 6 to 25 pt!n::cm of those with PVD and diabclc", come to i.11llpul<1tion.t> 1 Perioperative mortality has been va ri ous I) rcp~)rled belween 7 and 13 percent and i.., u... ually ;t'J'Jociated \\ ilh other mcdical problems such as c<.l rdmc th "eil ... e ilnd ... troke..,.1' 14 Over the year.... the incidence nf ;llllpUI;\lIOII ... ror \"a ...cular disca ...c has decrca..,cd probahl) .1 ....1 re-.. u/t III improved reva.!..,cuJari,alion 1I.:l.:hlliqllc", .1lthough hu.tl number.., of ampu l:tt lon.., have IIlcrca'>L'd ,>cl..'llml.lr) III tncrea ... ed IOllgcvity. I' R~ccllt ... tudlc,> .!I.,l) Ilidil' ,IU'd th,lI

the rate of i.lll1putatlllll lor \a.,~uLIl dt'J('.I ...1." ,U1lllll~ \ 11 11,:,111 AJllt:ri~;J.m t.., l.:on"'ldl'rahl) hl!-,hl'l than Ih.1I 101 tullL't l.'IIIIIII,: group~ and .,CCllh to lx' 1tI(:tL'~1'> IIl11 I~ rhl' "l'l·tmd leadlll}' l· JU"'C 01 'lIlI]llllaIlOI1 I'" It ,111111.1. thll.1l h 110m motul \ dlJ(,.Il' .Ill Idl' lIh 01 !!lIl1 ... hnt .... Ind1\ IlILt.II ... "tlh II;tUlllatll,: ,1I1IpUlJtlon ....tH' u"'lI,dl) )OllHg .tdlll ..... md Illl1ll'IIl' quentl) II1l'lI 41 IllIplO\L'd 1I11a!ltt1~ lu.. hnlllul· . . , tlhH\' ('Ik, lI\c dlCIllOlhl'/.Ijl). and h~..·tll·1 IImll .... I/\oIl-'l· pIIX\lhll~" Il.I\\' Il.du("cd Ihl" Innd~'lIu til UJIlpm.tthlll 1111111 Il ... tl·n!-'llUl ....11 (Pilla

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l.u1\

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Trnn~n'l)lnlnl sol

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mldsoctlon 01 nil mOlatorSAls Symo 's

I ~'"ds of Amputation l'r.ldllhUl.lIJ).!t\I.'I, III ;1I11PIII;lItl)1l h.I\I,· h","'!l ](\(01\11111'<1 b) .l!l.th)!l\II.;ll 1""C.)n'lld¢I.IIHllh '1l1ch :1:-. Iwlo\\ !...111.'1.' .ltld ;,hml.,' )..nc~. In ItI?..j, lilt' 1'.,,)" hwl.,' (' "') St.lnd.IHIII.IIIt)\l oj Pnhlhc.'IIC Onhollt: n"111l1I1llh)~) clL'\'t"it)PI' ci ;'11 11111'111:1

nny PIli! 01 ono Or

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r X(:I'lon 01

Anklo disarticulation Wllh ollOchm0l11 01 ho I pod 10 distal and of Ilbia MAy Incilido I movAI of malleoli and dlSIAI IlblAl/flbular flar 5

long Irol1SIlDIAI (b low kne ) TransllblAI (bolow knoe)

Betwoon 20 and 50', of tibial longth

SI10rr 1rar1SllbISI (below knee)

Loss IhAn 20% Ilbial length

Knee dlsMlculallol1

Ampulatron Ihrough li1e kn a JOint; fomur Inlact

Long irAn femoral (above knee)

More tl1an 60% femoral lellgth

Gutlll)ltne ;IIl1PIII;IIIt1n" IlU) pn:-ccda:- '1CC{)l1ti:U) ciO:-'UI{,' Will) ,kin n:lp'~ lX'(';1'11011:llly, 11\'1.' Ih.' UC 11:1P"" 1:11...(,11 Irom '10tl1e OIller ;m.'.\ ()f Ih(' hotly. BUY he 1I'I('d 10 ('()VCI dl.~ll)mlill('''' .

Transfemoral ( bove knee)

Belwoon 35 and 60', femoral length

\mpUI,lIlt'll"" for V.l"U!:tf tIl"'(';'''!.''1 arc ~cn(,f.llly 1"'1'101 met! .n p.lnt.!1 10m, Ir.lIhllhl;1l. or 1r:U1"fctllOI ;11 I('\lek TIll' 11I11 ~

Short Ironsfemaral (above knee)

Less Ihan 35°0 femorallunglh

lied \.hcu!:tr '1upply 1l1t1lg.lIC, :Ig.lllh[ clfccl1\(' r(,'I<.iu;11

HIp disartIculatIOn

Amputatron Ihro ugh 11Ip 10lnt polvls Intact

Hemlpelveclomy

Resection of lower 11011 of Ihe pelVIS

Hemlcorporeclomy

Amputation boO) lowel ,~l)S el1d pelVI S below L4 l ''v I

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\mpuu.lion

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B

Figure 25.3 (.\) A llIlT lOI iind lrom J long po"'lL'nnr II Jp.

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1034

Phy'\ic.'ll Rehabilihllion

ti:-. ... ue of the resid ual limb. Neuroma ... that form close to . . car tilisue or bone genera ll y cause pain and may re4uin:: la ter re ...ection or revision. Jlel1losf(I,\'is is achi eved by li gat ing major vei ns and arteries; c(IIlferi:arioll is used only for sma ll bleeders. Care is ta~en not to compromise c irc ul ation to distal ti ssucs. particularly thc skin naps. \\ hi ch are important to uncomplicated wound healing. Bones are sectioned at a length to allow wound c1o_\ure "ithollt excess ive redundant tissue at the end of the re ... id ual limb and wi thout plac ing the in c is ion und e r great tension. Sharp bone e nd ... are smoo thed and round ed: in tran stibia l amputat ion!). thc ant erior portion of thc distal tibia iii beveled to reduce the pres . . ure betwee n the end of thc bone and the pro ... thetic soc ~ ct. Care is taken to e nsure that th e bone is physio logica ll y prepared for the pre ssures of prosthetic wear. Ti ... sue layers are approximatcd under normal physiologicallemion and the incision is closed. u.!:.ually wit h regular ... Ulure ..... A drainage tube may be in sened as necessary. In a traumatic amputation. thc surgeon attempt ~ to savc us much bone length and viable .. kin as possible and preserve proxi mal joint s wh ile providing for approp ri ate he aling of ti.!:.sues without secondary complication s suc h as infec ti on. In potent ially "d irty" (invo lving foreign su b~tances) amputations. the incis ion may be left open with thc proximuljoint immob ll i/cd in a functional position for 5 to 9 days to prevent invasive infection. Secondary closure ah o allows the surgeon to shape the residual limb appropriately for prosthetic rehabili ta ti on. Ampu tat ion fo r vascular disease is ge neral ly consi dered an elect ive procedure: the .. urgeoll determi nes the level of amputati on by exam inlllg li ssue \'iability through a v"rie ty of mcasure~. Segrnentallim b blood pressures can be de te rmilled by Doppler systol ic blood pressure measuremc nt. TranscUlaneous oxygen measurement. and ski n blood now by radioisotope or plethysmography are allio determined. Doppler systolic blood pressure mem,urcs have becn reported to be quite accurate in predicting via ble level of al11put~t­ tion. but have not been a ... accurate in predi cti ng ampula1l0''''' th at do not heal. \{I Improvel11ent~ in noninvas ivc examinati on techn iq ues have greatl y reduced the use of arferiograph) to determine amp utation level.

Healing Process The surgeon"" goal is to amputate only as much tissue as requ ired to e nsure success ful healing.~I .H Numerous factors innuence the course of th e healing proces ... in each patienL. One of the greate ... t pos toperati ve co nce rn s I.., IIlfect ion. whether from exte rn a l or internal ",o urcc!'!. Indivldualc., with contam inated wounds from injury. infected foot ulcers, or ot her ca u..,es are al greatcr risk of infec lloll. Rc ..carch indicates that smoking is a major deterrent to wound healing: one c.,tudy reported that cigarelle smokers had a 2.5 percenl higher ratt! of infection and rcamput at ion

than non sJ11 okc rs.-l~ There is somc indication that failed attempts allimb reva'Scularization may nega ll ve ly jn~lIcncc hea ling ar tran stibia l lcvels.35 -.ll! Other factor,\ alfcc tlllg wound hea ling mc the severity of the vasc ular proble ms. diabetes. renal di ~case . and other phy~ iologjcal problems suc h as cardiac disc ascYd7

Expected Outcomes What w ill be the most appropriate outcomes for the patient at th is time. you ask you rse lr. You wi . . h you had seen her just before thc amputation so you could have begun preparing he r for the rehabilitation prog ram . You know you wi ll have only a few days beforc she is discharged 10 go home and need to develop ou tcome ... that are a<.; functional as poss ible. You a lso wonde r if a home health referra l wi ll be possi ble after she leaves th e hospital. The c,trlie r the onset of rehHbiliration. the greate r the pote ntial for c.,uccess. The longer the delay. the more likely the development o f complications such ali joint contractures. general dcbilitation. and a depressed p ... ychological state. The postoperative program can be a rbitrarily divided into two phases: (I) the posts urgical phase is the lime between surge ry and tilling with a definitive prosthesis or until a deci sion is mude not to fit the patient and (2) the prosthetic phase start s w ith delivery of a pennanent replacement limb. The desired ex pecred outcome of the epbode of care is to he lp the patient regain the presurgical leve l of function . For some. it w ill mean return to gainful emp loy ment with an active recreatio nal lifc. For ot hers. it will mean independence in the home and comm unit y. For still others. it may mean living in lhe sheltered e nvi ronment of a retirement ce nter or nursi ng home . If the ampu tation resu lted from long-standing c hroni c disease. the re habilitation approach may be 10 help the person function at a hi ghe r level than immed iate ly before s urgery.-"! Primary aims of the postsurgical pcriod are for thc patient to achit:ve as hi gh a level of indepe ndent fun c tion as pos c., ibl e and to begin 10 develop the neces..,a ry physical skill s a nd e motIOnal adju ... tme nt for eve ntual prosthet ic rehabilitation. Another aim is to de termine the fea ... ibilHy of prosthe tic littlllg . Examples of general goal ... fo r the post..,urg ical pe ri od inc lude: • The pati e nt will be ind ependent in bed mobilit y and basic transfe rs within I week. · The patient w ill be mdependent in 'Wht!ek'hmr mobility and sel f-care w ithin I wee ~ . • The pallent \\ ill dClllonstra te proper n~ ... idual limb po... itlonlll g. bandagillg. and care", ithin I 'Wcek. • TI~e. pati ent w ill demunstrate modi lied dependen ce with 111111 1111 .11 aSSI ... HUlCC of one pcr ... oll in ambulatlon u ... ing crutc hes or a wall<..er wit hin I week. If the cau ...c

or 1.Impul
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I C

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1 propc..'r carc 01 th e re mailllllg extrellllty, 1114.: IIUe"i'" 01 th e I"ehabilitation program i.., detcnnmed In PI len t h) Ihc Ind"idual .... p\ychologlcal and physlolo"IL JI ,talU . . and Ihe phY"'lcal char;:t<.: teri .., tlc ... of the r1! IJual IImh. rhe lon ger Ihe rc\idual IlInh, the better pOll'ntl,d lor "ilH.'cc ...... lul pro . . thetic amhulation regardh.~ \.., 01 k\clol ,1I11putallon A y.cll healed, wcll -... hapcd limb with a nOIlJJhe rcllt ..,car I'" ea ... icr to tit thall one that i\ poorly · ,ha~d or hst..,urgical program and e ve ntual pro<.,theti c rehabili -

or

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Table 25.2 Amputation Clinic Team Functioru. ' PhysiCian

The Clinic Team

I

CliniC chief; coordinates team decision making; supervises patient 's general medical conditIon .

PhYSical therapist

Evaluates and treats patients through postsurgical and prosthebc phases, makes recommendations for prosthetic components and whether or not to fit the patient. May be cliniC coordinator.

Prosthetist

Fabricates and modifies prosthesIs: recommends prosthetic components; shares data on new prosthetiC developments.

Occupalional therapist

Evaluates and treats patients With amputalions of the upper extremitIes; makes recommendation for components

Social worker

FlIlanclal counselor and coordinator, liaison With third-party payers and community agencIes. helps family cope With soc181 and finanCial Issues

Dietician

Consultant for pabents ",th diabetes or those needing diet and nutntlOl'sl gUidance.

tatIOn.

rhe majority oj amputallon ... today arc performed by va ... ('ular \ urgcon ... who mayor may not be knowl cdgc
(Io, l' U)JIIIIIIIIII ( ,llrOIl 1M:lwc" II

l

Vocational counselor

Determmes pauent's employment potenll81. provldeS educaltDr and training, assists With placement

10 \h

Pin ~11..ll Rd",hilil.ltinn

r.1tII.~111

111.\) hrh.'I1) 'I.'\'~ .1 ph~ ' ll,1I 1111.'1,11'1,1 \\ 11Ik' III Ihl' h\hplI.11 ;uHI 111.1) Ihl'l1 lx' dl'l.'h'"~l·d \\ 11110111 10110\\ up In..·.lIment. \hllllh, 1.111..'1 . thl' ".111\.'111 mil) , hIm tip ill ;1 pm' thl~t1't\ "tfi~l' \\ Ith .1 l'I'l·'I..' nplhlll lor iI pn"IIH: \ I ~. I hl'\e and" IdU.II, 111.1) h.I\\,' l..·oll(l,II.·lull'\. Ihl' Il', idllal lilllh 111:1) he etielll.110U' .tllll thl' pCI'on m.l) not I!;l\ e hel' n ou t oj the \\ ht.'ekh.lIf dunng I11t"t llt th.11 pl.' rIod. It b 1I11~)(m.U11 for Ihe ph) ,11...11 therapl ~ 1 111 thc ilc ut l' l.~.U~ l:Clltl'r 10 tall' 1\"' POII:-OlbJlII) for cl hunn g that ... ollle h''lnll 01 follow-up cal'l.' \\ III IX' provided. either throu gh l.)u tp.lIlcnt tiler-Ip). home care. 01 n.'fcrra llo a rehabilitation l."cnh.'r. It 1\ :11'0 important for ph) 'Ica l Iherapi ... h to 1.: ... lahli~h do\e I'l.'liltlOn~hlp" with n:gional rro ~ l hcti c provider:... The pro,lhell ... t Illa) he l..no\\ Icdgcablc aboul referral re,ourcc ... for PO~hllrgic1.i1 carl.! a ... well " ... for pro,thetic trainmg \\ Hhin the patient' ~ co mmunity.·m

Postoperative Dressings Re3ding the chart berorc going to :-oee the patient. yo u note that the surgeon did not use a rigid pOi>!opc rath e dressi ng but rather applied .joft drc~'i­ ing. It is important for ,omc ... ort or ed..::ma cOl1lrol to be used becau~e exces"oive edema in the residual limb call compromi"oc healing and ca u ~c pain.

Rigid Dressings In the carly 1960s. ort hopedic surgeons in the Uni ted Stales started experi mcnting wi th a tec hniqu e dcvc lopcd III Europe that consisted 01 filling Ihe person wilh a plaste r 01 Pari'S socket made In the confi guration of Ihl! dclini ti vl! prosthesl..,. An attachmellt incorporatcd at Ihe di :..lal L:nd 0 1 Ihe drc""~ing allow.., Ihe laler addition of a 1001 and pylo n allOWing IimHed wcig hthca rlll g :.tmhulalioll wi thin a lew day\ or a week of .., urge ry (inlllll'dwle pO.Hoperalfl '{' /N O' Ilte\i\ or /l J O P )'lI .1\ "I he JPOP Illa y be handmade lrolll plaster of Paris by the ..,urgeoll or a pro ... thcll \1. These oWl' not adJu'tahlc or remova ble. 'I he \ocket lIlu st he (:lIl hJ...c a ca..,1 for remova l and a new one applied ...... Ih L: re\ld ll:d IIl1lh hcal ~. , uture.., arc removed. and the limb <.: hall!!es ... ha pe ,

Figure 25.4 AirLII11h (Collrte ... ) o f Allc ..... !. 11K Summit. \J 07901.).

There arc al~o l'l' I1101 'ah!t' rigid drl'\ ,\mg .\ (RRD) Ih;.ll mil~ be handmade from plasll.!!" or preLlhricated from pl.I . . lll· material s and come in differenl ~i/e~. Pn:fabrit:atl..'d RRD. . arc adju~lahle as the lim b change ... :IIlU 111<1) hI..' 1\'IlIl}\~J ,I'" needed for \\mllld in.spl.!ction. The l'olllmcrc l;lll ~ \\.lil,lbk AirLimb k (Ain.:ast Inc. uml1lit. NJ. 079(1) i, .1 pl.I'U( soc kl!t wit h inllal:tble bladde r... Ihal help Illailll.lIli ]11 (I[\. .'f iii a:.. Ihc residual IImh ... hrinl.."i (Fig. 25.4), TIlL' ,lddill\l[1ll l.1 pylon and fOOl allo" ... for ..::arly. Innltl'd , \\..:1 IIlhl'.II;n~ amhulation. LiJ..l! othe r RRD .... Airl .lmh I!'. !Cllhl\,lhk Illr wound inspection and carL: btl! i... saitilo be C.I"'Il'1 tllill ind use. 4 .1 Usc of imJ11l.!d l:ltc pm.topL'ratl\,e rigid dll· ...... JIl .Ir~ grea tl y and arc more pre"alellt ill ,nnll.' arl',I ' III h~ ulull Iry than (lthl.!r.... GL' lll.!rally, orthnpL'tiic ... mgl'nn ... iN !tIL' tec hnique Illorc than vascu lar ... urgL'on, Ri gid pll ... I,"r' ...11 . . . ) 111 till' drc"lng, whelher used immcdiate) I ,IItC! ... Ul glf\ earl y pOMope r:ltl ve p Crl.m.I IliI\'t~ I}Cl'll I'OUlil I ... tl Ll ",1111 HI reduci ng po:..lopera tive edL: nla. paill. and l.'lIh,IIll'II1,!,! hl'\~ 1 1I11 "1l!l" ing evc n 111 ca ...l.!s of delHycd heilllllg, " I Ill' .Il" of Ihc lechniqu e ... arc : 1 • II g. lelill y limih the tll'n'IOplllL' lIt 01 p(I\IIlPl·I.l1I \ l ' edl'III. II' t' P,llli III the rl!\ldu:d lllllh, Ihl·rl..·h~ I'L'duL'lIIg IW,Wlx'I,1 dlld clIhUlH.: ing \\(}l lIld hea ling. II • II .1110\'- " Illl l'lIrilL'1 alllhuJdlloli \\ Ith Ihe .I(lddlllll'nt {l ' py loll :t llll 1(l01

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Evidence Summary Box 25.1 PosIsurgical Amputation Dressings It

< t.~It.'rcn ... t..·

Su b'~l'C IS

Design/ Inlen'cn'ion

Duration

Results

Comments

21 Ss wllh reeeni fower hmb amputations

Expenmenlal design; 12 Ss treated with semirigid Unna dresSings; 9 Ss treated with elastic bandage

Until discharged from Inpatient rehabilltallon seNlOg

Subfecls treated with semirigid dresslOg heafed faster. were ready for fiNing sooner and more likely to be dIScharged ambulallng with prosthesis

Semlngld dresSings more effective In prepanng for prosthet. fiNing. fess expens~e. and less time consuming to app~

Waoobum, KA, et ai' 2004

Pallenls requIring transltblal ampulatlon: 46 Ss In Ihe E: 50 SSin the C

Multicenter randomized controlled Inal; E receIVed a rigid dressing; C received nonrigid dresSings

Rigid dressings removed at 7 day intervals for Inspection

Rigid dressing produced a reducllon in time to first casting for proslheSls: however thIS difference failed 10 reach slatistlcal sigmficance

Clled advantages of rigid dressing wound protection. reduCed frequency of dressing changes, decreased incidence of contraclures, early mobilization. Disadvantages lOabll· Ity to vlSuahze wound and Increased weight

Vlgler, S. et a~s 1999

All Ss with reeent transtiblal amputa· ~on (nol yet healed); 28 Ss In Ihe E: 28 Ss in the C

Randomized controlled trial: E rigid plaster cast; C elaslic compression bandage

5s were gradually trained to wear cast up to 5 hours/day

Rigid dresSing: accel· eraled healing, fasler 11mb shrinkage, reduced lenglh of hospitalization

Rigid dresSing produced Improved reepltheliahzatlOn and reduced formation of myoflbroblasls, deemed safe lor hmbs with no Ischemia

Wong CK. and Edelstein. JE"

2000

-Woodbum , KR , el at. A randomized trail of rigid stump dressing follOWing trans-tibial amputation for penpherat arteriatlnsufflclency. Prosthet Ortha! Int 28(1):22. 2004 C = Control group; E expenmental group; Ss subjects

therapil.,t needs to be imolyed in earl) di~charge planlllng 10 ml.,ure cOlltinult) of pm;tl.,urgical care. Careful examination or each indi\ idual i ... an integral pan of ph) ... Il:Jlthcrap) management. Examination data are obtamed contmuou ... l) throughout thi ... period a... the lI1ci"'Ion hcab and the per...on \, tolerance Il11proyCS . Bo\ 25.:! outlines the I) pl ctll daw needed during a complete P0l.,,,",Uf~ptal C\ilffilnatlon. Some of the data ctll1not be obtained until I.,Ollle heilllllg ha", taken pl,.ll"c and colicClIllg othcr data mu\t av.aJl complete hC~llmg . The availabilit) of some 01 thc-.e data \'-111 aho depend in pan on the treatment of the re"'ldual lunb b) the ... urgcOI1. At all time", throughout the po t.,urglci.I1 penod. the ph) ... ital thcrapl\t lllU ... t pnOrllllC data collculOn and IIllegrate Il v.lth 1IlIervclltlOn .... Jlwa) ... (;on idenng Immediate pallent. lamil). and caregl\er need ...

Range of Motion Gro . . r.u1gt:. 01 motIOn (RO~1) e... tml
\pccific goniolllctfic mea~urcmt.'l1l'" an.'

amputated ... itle and for the

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,"

Chapter 25 Amputation

r039

end of the bone. If th ere is co nsidera ble excess tiss ue di stal to the end of the bone, then length measure ment s are taken to both th e e nd of the bone and th e incision line. For accuracy of repeat meas urements, exact landmarks are ca refull y not ed. If th e isch ial tuberosity is used in trans femoral measurements, hip joint posi tion is not ed 3S well . Other information gat hered about the residual limb includes its shape (coni cal, bulbous, cylindrical redundant tiss ue), ski n condition , sensation, and joint proprioception.

The Phantom Limb

Figure 25.5 (Leir) Transtibial :-;hrinkcr. (Ri!{hr)

Tran ~fcmora l

~hrinker.

until most healing has occurred. With a trans tibial amputation. good strengt h in the hip extensors and abductors as well as the knee extenso rs and flexors are needed for satisfactory prosthetic ambulation. For the patient wi th a transfemoral amputation. good strength of the hip e,\tensors and abductor~ i\ a requirement. The strengt h of these muscJe~ should be monitored throughout the postsurgical program.

Status of the Residual Limb Residual limb measurements are generall y taken and reported in centimeter~ for uniformity wi th others involved in the care of individuals who have had an amputation. Circumferential measurements of th e residual limb ~Ire taken as soon as the dressing will allow. then regularly throughout the postsurgical period. Measurements are made at regular intervals over the length or the re~idual limb. Circumferential me<.lsurements of the tramilibial or Symes residual limb are started at the medial tibial plateau and taken every 5 to 8 Clll depending on the length of the limb. Length of the residual limb is measured from the medial tibial plateau to the end of the bone. Circumferential measurements of the transJ"emoral or through knee residua l limb are started at the ischial tuberosity or the greater trochanter. whichever is most palpable, and taken every 8 to 10 cm. Length is mea'wred from the ischial tuberosity or the greater trochanter 10 the

The majorit y of indi vid uals wi ll encounter phantom limb sensations fo llowing amputation. In its sim plest form , the phantom is the sensation of the lim b that is no longer there. The phantom, which usuall y occurs initially immediately after surgery. is often described as a tingling. burning, itching or pressure sensation, sometimes a numbness. The distal part of the extrem ity is mos t frequently felt although, on occasion, the person will feel the whole ex tremity. The sensation is responsive to external stim uli such as bandaging or rigid dressing; it may dissipate over time or the person may have the sensation throu ghout li fe. Phantom sensation may be painless although most people find it uncomfortable and often report it as pain; it usually does not interfere with prosthetic rehabilitation. It is important for the patient to understand that the feeli ng is quite nonna1. 49 Phantom limb pain often follows amputation. occurring in up to 80 percent of indi vid uals undergoing amputation from any cause. It is important to differentiate phantom pain from nonpai nful phantom sensation, residual limb pain. and nonpai nful residual limb phenomena. 5o Phantom pain is usually characterized as ei ther a cramping or sq ueezing sensation, or a shooti ng or a burning pain. Some individua ls report all three. The pain may be localized or diffuse: it may be conti nuous or intemlittent and triggered by some external sti mul i. It may diminish over time or may become a permanent and often disabling condition. The cause of phantom limb pai n has never been well defined. although today there is some agreement that the pain is related to reorganization in the somatosensory cortex. There has been some research on the relationship of cortical reorganization and chronic pain and there is some evidence that individuals who experienced intense preoperative pain we re more likely to have phantom limb pain. 50 -il The residual limb should be carefull y examined to differentiate phantom pain from residual limb pain or other cOllclitions such as a neuroma. Sometimes. wearing a prosthesis will ea:-.e the phantom pain. On occasion. in the presence of trigger points. injection wi th steroids or local anesthetic has reduced the pain temporarily. Although the literature is replete with information and studies on phantom ~ensat i on and residual limb pain. there is little agreement abou t the bes t approach to treatment of these phenomena. In some slUdie.s, pmticularly of individuals who experienced considerable preoperative pain. intrathecal or epidural anesthetic drips

1040

Ph}sical Rehabililation

Box 25.2 Postsurgical Examination G u id e Hi s lor~

• Pat ient demographics • Family and ,>ocial data • Preampuwtion status (work. act ivity level. in de pendence) • Financial status • Other u.... appropriate

S, stems Re\'iew • Cause of amputation (dis.ease. tumor. tmuma. congeni tal) • A" ...oci3led diseases/s.) mptoms (neuropnlhy. \ Isual dlsturbnnct:s. cardiopulmonar) di~ea:,e. renal fail ure. conge nital anomalies) • Current physio logical state ( po~tsurgical cardiopulmonary ... tatus. yital signs. shortness of breath. pai n) • Medications Skin · Scar (healed. adherent. invaginated. flat) • Other lesions (size. :,hape. open, scar tissue) • Moisture (moist. dry. :,caly) • Sensation (absent. diminished, hyperesthesia) • Grafl~ (location. type. healing) • Dermatological lesions (psoriasis. eczema. cysts) Residual Limb Len gth • Bone length (transtibiallimbs meusured from medial tibial plateau: t~nsfemorallimbs measured from ischial ruberos11y or greater trochanter) • Soft tissue length (note redundant tissue) Residual Limb Shape • Cylindric.al. conical. bulbous end. and so forth • Abllonnalities ("dog ear),:' adductor roll)

\\ ith opioid~ were used both prc and postoperatively with <,ucce . . :-.. However. others hiwe reponed no success \\ ith :-.uch tre<.ttments. Noninvasive treatments such as ultrasound. icing. TENS. or massage have been u...ed with varying success. Mild non-narcotic analgesic~ have been of limited val ue: biofeedback. guided imagery. p..,ychotherapy, nerve bloc~s. and dor ...al rhyzotornies ha\'e all been used wilh incons istent re . . ults. The treatment of phantom pain can be vel) fru ... tratmg for the clinic terull a... \\cll f.l.o; the patiem.,,\I,I-~K w

Status of the Uninvolved Limb The vascular statu . . of the uninvolved LE is determined and its condllion noted. Data gathered include condItion of the s~ill. presence of pubes. scn . . atioll. temperature. edema. pain on exercise or at rc.o;l. presence of wound .... ulceratIon. or other abnomlalitie'l.

Emoti ona l Status • Accepulllce • Body image Vascul a ril ) (both lim bs if amputati on cau <;e is vascula~) • Pu lses (femoral , popliteal, dorsaJis pedI s. posterior tibial ) • Color (red, cyanotic) • Temperature . • Edema (circum ference measurement. water di splacement measurement , ca liper mea~ ures) • Pai n (type. locat ion. durnti on. intensit y) • Troph ic cbanges Range of Molion • Residual li mb (specific for remaining joints) • Othe r lower extre mity (gross fo r major joints)

Muscle St re ngt h • Re,s idual limb (specific for major mu "cle groups) • Other e:x tremit ies (gross for necessury function) Neurolog ica l • Pain (phantom Idiffe rentiate sem;alion or pain]. neuroma, incisional. from other causes) • Neuropathy • Cognitive status (a lert , oriented , confused)

Fu nctional Status • Transfers (bed-to-chair. 10 toilet. to car) • Mobi lit y (anc illary support. supervision) • Home/family sit uation (caregiver. architectural barriers. hazards) • Activities of daily li\ ing (bathing. dressing) • Instrumental acti .. ities of daily living (coo ~ i ng. cleaning)

remaining extremity is very imponant and ~hou l d be e\
and de"'lre for a pro'>the,i, I ... bel!l1l1 and cOIllinue . . throughout the post'lurgical period. A~l) other problem ... that may affect the rehabilitation program and outcome ... are e\'aluatcd and dllcumentcu.

Ity

Functional Status Activities of da ily livi ng (ADL) and funcllonell mohility .,~i[]'" including lransfer and ambulatory st~l.1U~ are C,\ UlI1l11ec! and documented. Balance both ..,llIlng and :..tanumg on the

Emotional Status As you perform the milial t'X4ll1llllHIIOIl of the pallt.'1lI ;Jlld tal~ wllh her ,-,hOll! the amput ..l1ion. you rcaitle Ih.lI ... he \...

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S0m~ mdJ\lduab ma) tr) to avoid dL,tre""lng thoughts

Qf the kht ILnlb through con'nou ... ~tf-control or by ..l\·oidln~ 'Ituatiom or people thut rt.'l1und them of tht" lo'St 11mb. S,lmt" may dl'pla) t~mper tantrum ... Of lffiuional ("e,en(menf. Sl1me mi.l) revert [0 chlldllke ,(;.ate:;:. of hdples ... nes"l and ut.'pendt.'n\..'t.' . \lJn) mW\tduah are not fully aware of the curu.equences or <.lIT1putJ.tio n and may fear other phY"LI..·al lumtation... :I5 a re,uir of the ..;urger:- Fe~lf of Impotenct' llr stenhty may leau -orne men to m..u...e gnUl(.hose "'l ..llli'rnent" or dJ.'pl..t) red•.le':i... nehal,'Of to ma ... 1o.. tht' ft"af. Thorough e'(pl<.LIIutlon... of the .tmPUliltIon pr\:"'l't.',~ and lffipbl'auons by the surgeon or other heulth worb.er may allev Lalli' many of the:,>t' fea!' Generall~ . ~oplt: who ha ...·e had an amputatIon ma) ~,un aoout them~he'" a'!' ha\·mg ;.Ul mtal..·t 11mb. Thl'" IlTWge rna} be ";0 ... (Ii ,,1 t.hat they f4ul .1' they get up at rught and ilt[ mpl to ...... ~ (0 tht.'" bathroom \\ I[hour i.1 pro. . the ... l ... or truh.: h( " lnOI'" LUUdh whQ haVIt h.J':it (heir leg through lnJUl) trJ.l\ ~..ur\ about (he baul~ or al'"l'"ldent In \\ h(dl the) w~rt' 100}IJrei.!. ' ul'"h reenJ.dment ... rna\· lead to [IN.lOUIlJ.. wm him.;. tit. . . "pee!.:h lrtlfl\..ulment .... ~ml ddlinllty \\ Lth l·Orll'"l;.'nlrJ.tJ.on In g O:Ik:IJ.1. 10..1,\ u.lual ......... IUt nmgt'nltal amputi.lli\.m'" r 'Il:'4utred a rnput,.1Uon ... bc-fore the- ;'l~t." of :; dll nl.lt h~LW ,,~ Ill" the- problem' mentloneu Jbo'Ve bc\.·J.""~ [heir iUD.putaIlOO I'" oJ. part of their JCH~llJ~J . . Ctt·HIIJ~C.

1041

P,)chologicaJ Support The pallent nccth w receive reav.. ur..tnce 'Uld undcf\tanding 1rom the Cillm' reh;'lt"ltlIlJlIOn Icam. The 'taff \hould create MI o~n and receptl\t' environment and be "111m· "' I Th '" 0 'lien. c p.llIem ... hould ~no\\ what to expeci dunng Ihe en!· proc.:cl.;:,. Tht" ,urgeon and thcrapi\I"i ... hould carefully ex.PII~e

th~ \~ep~

(>~pcctatIO~\

AUdIOVb:~~

and of rehabilitation. mcdl~l. \uch t1, him ... or shde,. may be helpful.

Olhef' "Ilh mnputatlOIl, \\ ho have made ~uljfaclol) a~JlIq~ent" 111 their hve~ and ,uccc" ... tully completed reha~11,IlatlOn ,may provide ,upport.. mfonnatjon on life~()le ch,~g~~. and e~coumgemenl In private or group seS\lons . Prote''''lona..l'-l ,kilJ~d In group dynami~ and palient education

are help~J. e,ptXiaJI} for medical or technical advice regardI,ng ... uch Isslle~ as dmbetes. medicHlions. or PVD. Family and fnend~ are otten mcluded. A nonthreatening atmO\phere help ... ~divlduaJ ... e\press their feelings and f~[rntjon..,. Pmlt;:O["S have ·vc.uiou\ i.lnuudelj toward t.he prosthe~is. Some are partIcularly concerned about it!, appearance. hopmg. that H Will conceal their disability and give the iUu"Ion ot a~ mtnct body. Othef'i claim to be concerned primanly \"tth the re~toration of function. When the artificial limb j, fitted. [he patient must face the fact that [he natuml limb ha ... been lost irrevocably. Lf individuals with amputaHom have been told thal the prosthesis wilJ replace their 0\1, n limb. they rna) have unrealistiC expectations that appear.mce and fum:tion \\ ill be as good as in the nonamputaleu e~tremity. Reali.sric 'Idjm.tment will be neces5af) a'S the per-;on learn" [0 use the artilicial subs[itute. Good. predICtor':> for adjustmem to the pro... thesb are rnoti\arion to master the prosthesis and to return to an active lifestyle.

The Olde.r Adult Tht' older Imllvidual wlth a LE amputauon is not contem to :::.tlm . 1 wheelchair or limp with a \\al.ker. but seeks etl'ectiye rehabihtution 'St'nil..·es and :J. meanmgful ltfestyle. The unmeuiate reaction to amputauon is no ditIerent than that of m) Qther indi\ idum t'xcept that the amputation will usuall} not "."orne as i.1 "'urprise, The re'leUon may d~pend in part on the 'C'... erity of preoperJ.tfve pmn and the extent of anemplS to sav~ the limb, lndl\"iduals \\ ho ha... t:' sufi-ered l'Oruiidemble

pam rna) be grateful that [he pain h~ ended. Patien~ who under.\t:'nt t':'{telThl\e medICal and sUIg.tcal pnx.~ure ... to 'Sa""c the li.mb may h;.t'lt" a sen,t' of fadure. In gt'neral . the ft"l.lctiom of Qld~r Jk'ople re,t'mblt:' the reaction, of ...1lher J.duir' \. . ho ~\\e e,xperit"nl"'eu ;.Ul ~UllpU[..HlOn. Some rna) f~1 J ...en ...e of hopelt"'~'-Ine"l' amI dt:"pair.•Ul(j tw.. e a p.n'1.X' ...·upation I,Hth Impending death. SOntt.' ma~ ha\o: Im,mUlia.. .morl"\Ii.l. ami be \\ IthdrJ\\ n. Some oloer mdl\ idual.. rna) t'"'(pt'nt'"lIce a !o.., . . of ,df·e~tt"'em and ~ ~tfr:lld of beI..-l.lUUng dC'~noenl. Ln 'l)me m.. tJJ1I.."'t."', the pel"l..lfl mo.l~ I,.'\.l(uemplart" or .1ttt'mp[ ",uK·,ue. ~lL'I..'''' mg thJ.I he \.lr ,he ha.... nl..l(hin~ kft tv I" ..' for. Okkr ~opk ..,doom u't'" d~(uJl t>I,..>t·JU't;.'t.h,· fun('~ lIonJ.i .mu iUlO.HOmll..'".u ddku I" vtn illlb OIJa peN..lfl." ~ mort'

hld~

w Jrei.un th.lt th~ amputau....n h:.t.. . tJ!...t'"n pIJ. .~ J.!> llungt'"r mOI\ tJu..Ll... ("he- llldt.'r peN"l Ot..1~

l·ulllp.lr~u to ~

1042

PhYlioical Rehubilitation

"IC\~

Ihe ampUlalion a... 11l111Clldlllg dcath becau\c the re\ l of Ihe h(xl) I~ \ ulncrable. II prcopcmll\e altltude\ arc unre~llI..,tic.t1ly hOJX!lul. PO\ I operall\'e lh.. turhance ... may be more ...eVerL'. The old cr per· ... on ... houldllotl1C led 10 cxpCCI a 101al cu re. Le~l rnlll !! to u.. e an arlllic1
Treatment Interventions lithe patlcnt I... 10 rcturn to her own home. ~hc will need to he amolliatorj and ahle to ta~c care of her re"ldual limo. If ... he goc ... to her 0\\11 home ruther Ihun a rehabilitation t'Cfl tcr. ..,~u: will nced "'OI1lC homcmaklllg help w., wel l a"l homc ht!al1h care for t'ol1tll1l1ed rlur\lng and phy\icalthcrapy. On thc other hand. trml ... ler to a rehaolli tati on cen ler 1I11ght help her reach an adequatc 1!!\'cI of indepcndencc 10 hc ahlc to funcllOn at home with 1111nimal \uppo rt ulltli ..,he can he fittt.!d \\i!h a pro ... the\i..,. You deC ide 10 dl ..cu..,,, thi . . further with Ihc phY..,lclan and ..,oCI.II w()r~cr. In the I11C:II111m\!. you rei.lllle Ihal your Ireatment program willnced In focu\ on fum:llOnal JlloodllY ..,~t1 I ..,. rC"'ldua l limb care,
Residual Limb Care Indl\ Idual.., not lIlted wHh d rigid drc"'\lIlg or a fell/pOlan pl"O.\lI1('.H'.\ u..,c Chl\tlC ""rap or \hrin~cr ... to rcduce the \I/C 01 the rC\ltlllal 111110. Thc patient. lamlly mcmoer 01 PIO Ic\..,iol1dl . . Iall memher appllC.., the h,lI1di.lge. wh idl l\ worn 24 hour.. a (iJy, ex<.:ert when hathing. Removab le n gitJ dre"\II1!!" fOl ll"le wllh Ir
or hypc l1 cn ... ion. An IIltenl'1lllenl COl11rrc\\lon IUlII <:~H1 be U\c:u to reduce !!dem<1 on it lemporary hil \ I'i. I Illll ... lcmoral and Ir..lI1 \ tlhial ... Iccvcs arc commcrc iall y availahle Propcr hygiene and <.; kll1 (
Chapter 2.1; AmlJulation 1

the: prc,cm:c 01

c/\".II'(I,\CUllll

wn

,Ii'ca,r.: , rhe wlmlpoo l

~'" [ he the trcallncnt 01 . choICe . . I~CiIU"'C II 1I1lTCII"r... elr11:1\ no , . " lnu edema III thL' part under Ircmmcnl. 1 he ad van~IJI.III1) • II Ihe ,dllrlpoo l a\ a c!can\lng agelll for "'''-Ill probPi'''' \ • to 1IIIl'I..'ICd \\oUlllh. or IIlcidt!I1CI.' 01 delayed healing mu ... t kill", ,'_ ,. ' It." dl\atlvanl
.... dl'lt' l1ll1llcd tor

.111 , ..

.tIl)

mdlvidual persoll.

6

Residual Limb Wrapping 1/1

Ire

.,C\ c:ral ctlccl in: I11clhod ... 01 \\ rapping the rC"'ldual

Ilin n l\llicllI" lcnolo \Hap their 0\\11 rc ... itlual IlInb in a cir(ut.1I !Tl.IflIJl:r. ollen cn:allllg a tourniquet, which may COI11pn)J1lI ..... h('ali ng and fo,ter the development of a bulbolls t'n J. \lllulUgh the lran,tlbml n::",idual 11mb can be effectively

\\r.1111)(; 1111.1 ... uung pt)\itioll. it i\ difficult to properly wrap Jlkilnr the Irall!'oofemoml iJmb \I,.hile ~ilting. Older p;111Cllh oltcn cannot haiance thcl11 ...elve ... in the ... tanding f'lNt!110 \\ htlt: \Happing. An efTective bandage i ... ~l11oo th Jnd \\nnk.k free. cmpl1a\ize\ angular tum~. provides pres,un: IJ't,lll~. and encourage\ proximl.li joint cx tcn ... ion. The t!nd, 01 o,mdagc, are fa"ltcned wlIh tape, safety pins, or \dull r.Hher than dip. . , which can cut the ~kin and do not JIKht11 \\l'il. r\ <.;y ... tem of wrapping that u...es mo~tly angular llf lit!ure-of-clgill tum ... wa~ de\-'eloped specifically 10 meet .md

Posterior view

Moo

Anterior view

PosteriOf view

9

r:lgUre UaJ. Imh 25.6 1"'"",·,-1 ''''' 1'..

r

.• II Ifnll\\f.1J'1rtn~ • luua

RI

Figure 25,7 Tramfemoral re\iduaillmb wrapping.

Ihe need, or Ihe older palienl and has been ,ucce"fuJly in use for Ihe pasl 40 ye",,·' Figures 25.6 and 25.7 iJlu'lrale the t echnique~.

The Transtibial Bandage Two 4-in . ela<;tic bandages are u ~ualJy enough to v. rap most lranstibial residual limbs. Very large residual limb::, rna)' require three bandages. The tran!:alibial bandage::, should not be ,ewn logelher '0 Ihal Ihe "eave of each bandage can be brought in contrapoc;ition to the other to provide more support. Although an elastic wrap does not provide ru, much pre..,<;ure as a rigid dres!:aing. the development of po~lSUfgi­ cal edema must be deterred as much as possible: therefore. a firm. e\en pressure against all soft Ii sues is de::,irable. If the inci~ion is placed anteriorly. then an attempt should be made to bring the bandages from posterior to anterior o\er Ihe d'S1al end. The first bandage i\ started at either the medial or lateral tibial condyle and brought diagonall) over the antenor SUfface or Ihe limb 10 Ihe di>lal end. One edge of Ihe bandage ... hould Just cover the midline of the incision in an anteriorpO\lerior plane. The bandage is continued djagonall~ over e _ tum ~ the po~tcrior ~urface then back mer the beoinmnc: an anchor. At thi.., point. there is a choice: the band.age ma~ he brought direcll~ 0\ er the beginning point a, indicated III ~tep :!. or it may be brought acrm, ... the from of the re'lduaf limb in an "X" del.,ign. The latter technique l ' pan1l.:ularJ~ u... dul '"' ilh long re,idual hmb ... and aid", In baIhJa.;e "U'pen ... ion. An anl:horing tum 0\ er the oi . . tal thigh h m:tde making ~ure that the \\ r..tp 1... clear ot the patella and I' not light around the di .... al thigh. Altcr a 'lnglc anchoring tum atx}\r!' the knee, the.: b.md age I'" brought bal:k. around Ihe Oppthllt." ttrl~ I.:ond) I olnd do,", n to the di"tal ~nd 4.lt Ih~ IlIllh. ()n~ c."J ~c.' 01 th .. Nnd· .Igl.' .. hould o\~rl,lp tht' nlldiln 4.lt thl' 1Ih..1,,,""In anJ lht:' other ,",fap b~ ~It It'a ... t 1/2111, to ~lhUrc.· JC.'\IU3h." dl,bl cnd up-pt1ft 111C." ligur~ · ot c.'1 'ht pJIlc.'m t, c.ontmu~d a depl\ I d 10

10·14

PhHical Rehabililalion

... tep . . 4 through 7 until the bandage t~ u~ed ~p. Care ... hould ~ tak.en 10 completely covcr the rc ... idual illllb \\!th a !iml and even pre:.,:.,urc. Semicircular turn~ are ma~e po ... tcnor~y \() brine the bandage in line 10 cross the at1lenor .,urface In ..Ill am!.~lar line. This maneun.!r pro\ide~ greater pressure on the~ po~tcrior ... oft tI~sue \\ hile di.,tributtng prc ... sure anteriorl) where the bonc i. . c1o~e 10 the "'''In. Each tum should partiall) o\erlap other tum ...... 0 the whole res~dllal hl11.b \:., well co\'cred. The pattern i~ lI ... ually from pro.\Jmaito dl~tal and bac" 10 pf(nimal. starting 3tthe tibial condyles and CO\'cring both condyle ... a", well a. . the palell~r tendon. Usua l.I)', the patella i... Icft free to aid In "nee 1110tlon. although \!" Ith c\lremcly ... hort rC"'ldliallimbs. il may be necessary 10 cover it for better slI ... pcn . . ion. The ... econd bandage i... \\Tapped lik.e the fir ... !. except that it is . . tarted aI the oppo~ite tibial condyle from the first bandaQc (.~tep 8). Bringing the weave of each bandage in conlf3Position e\em, a more c!"cn pressure. With both bandil2C .... an effort i... made to bring thc angu lar lUrn~ acros~ e;ch other rather lhan in the ~ame direction.

The Transfemoral Bandage For mo~t re~lduallimbs. t\\O 6-in. and one 4-10. bandages \\ill adequatel) cover the limb. The two 6-i l1 . bandages call be :,CWll toeclher end-lo-end taking care not to create a hea\') ~eam~ the of-In. bandage il:l u!o.ed by itself. The patient I~ depICted ~idelying in Figure 25.7. \\hich allows a family mt!mber or therapl ... t easy acce~!'I to the residual limb. The palien! with good balance on the remaining limb can banda{!e the residual limb in the standmg position, bUI it is diffi~ult for the patient to self-bandage correctly in the sitting po",uion. The 6-io. bandages are used first. The first bandage is started In the groin and brought diagonally over the anterior surface to the diHai lateral corner. around the end of the residual limb. and diagonally up the posterior side 10 the tliac crest and around the hip ... in a spica. The bandage is ~larted medially so that the hip wrap ,,",pica) wII! encourage extension. After the tum around the hIps. the bandage i ... ",rapped around the proximal portion of the residual limb high in the groin. then back around the hIps. Although this is a proximal circular tum. it does nOt create a tourni. quet a~ long as II IS continued around the hips. Going around the medial portIon of thl.! residual limb high in the groin emurcs coverage of the soft ti!)sue III the adductor area and reduces the po~sibility 01 an adductor roll. a complication that can seriousl) IIlterfere with comfortable prosthellc v..'car. In most in.,tances. the first bandage ends in the ...econd hip spica and is anchored ~ith tape or pm. The ...econd 6-in. bandage is wrapped like the fIr",! but ir., started a bit more laterally. Any areas llot covered wllh the firM bandage l11u ... t be covered at thIS lime. The second bandage is al ... o andlOred in a hlp "'plca after the lir ... t figurcof-eight and after the second turn high in the grom While more of the fiT\t t\\ 0 bandages are u...ed to cover the proXImal residual limb, care mUst be taken that no tOUTllH.luct is

the band •....eoc directly lrom the prmllnal · created. B rmgll1g medial area IntO a hip spica helps to keep the addUl:lor tl-.· ' d prevents. rolling 01 the bandage to some ... lIe cove red dn

~= The 4-in. bandage IS u~ed

J

exert the greute ... t amount 0 areHS of the reSidual hmh. It pressure ov er middle and distal ' .IS usua II )'' not Ilc'cessal)' to i.l11chor this bandage around the ', , hips because friction with Ihe already applted ba.ndages and good figure-or-eight tum' limll ' lippage. The 4 tn, bandage IS generally started laterally to bnng the weavc across Lhe weave of prcvioll~ bandages. Regular fig~re-of~elght tum .s m varied patterns 10 cover the enttre reSIdual limb are the most effectivc. Bandagc~ are app li ed with linn pres&ure from the outset. Elastic bandages can be wrapped directly over a soft postsurgical dressing so that bandaging can bcglll Immediately after ~urgery. The e lasllc wrap comrols edema more effec tive ly if minimal ga uze coverage IS used over the residual limb. Several gauze pads placedju~l over the incl~ i on are usually adequate protection without comprom ising the effec t of the wrap. Care must be taken to avoid any wrinkles or folds that can cause excessive skin pressure particularly over a soft dressing. It is cTltlcally important for the bandage to be rewrapped frequently, e'pectall y during the early postoperative period. As has been previously staled. the elastic wrap is not as effec tive in con trollmg edema a& the rigid or semi rigid dressings. 10

Shrinkers The transtibial shrinker i&. rolled over the residual limb to midthigh and is designed 1O be self-suspending. Individual ... with heavy thighs may need additional suspen\tOn \\ nh ganers or a waist belt. Currently available transrcmoral shrinkers incorporate a hip spica, which provides good r.. uspension except with obese mdividllah (Fig. 25.5). Care must be taken that the patient under... tands the Imponance or proper suspcnr.,ion; any rolling of the edge ... or sJtppmg or the shnnJ...er can create a touml4uet around the pro.\imal part of Ihe re"'ldual limb. ShrinJ...cr<.; arc ea. . icr to app ly than clastic bandages and may be a hellcr alternative. particularly for the tr~lIl ... fel1loral rc ... idualltmb. Shrinker... are more expen ... ive to u...c than elastic wrap: the inlllal CO... I i ... greater. and then ne~ \hrinkers of smaller ... ilc ... mu ... l be purchased a... the limb volume decrc
Positioning One 01 the gre.lIe ... t deterrent ... to fum.:tional pro ... theul: rehJhtiltatJon I... contracture of hIp or knee eotHral.'turl'''' GUl

(haptN 25 \mputation Itljl I

,I

III 1111 1I/1II11,(h

lD45

IlIlh,.]'III( (' III / .. '>llt.] IIVhl

/rl1l1l ,11'"'Ii'lIIW Wllhdl,I Wil lll'/h- , 11110 hip illlCl knce

"II

1011 /11""

"

111.'_ 111 pl,ulIiII

,lit III 1.11111)

I'll III

lilt I

" 'II/llIlalllill IlIl'Xll'I1'110n,

flo\lllIlfllUP

11/11,1/

IlIlIh fill

""1. /1 iI

;I'"

or

1I"t

PlOlUIIV l'd '1 1t111V or

fI,lIow I he p;lIll'l1l ,hoilid

1/III IIu IIIlIHlIl,lflll' cd IIIOIX'I jlO",tIOIlIIlt' an cl J'cpu

I • III I'll'PillIlIV

101

l'WIlIU:d prO'~lhc llC': fil

tlnd

.111 1I.'vl'l" 01 I1I1 11UII:l1101I . full I~()M III hip II I lI lIn ,iI III illI\lWIII~ till' IIHilvldlml10 a,,'UlI1e iI

11111 II "till

I III

I IIpllrill

1111

p" . . IUIl'

lull ROM JI1 the hlp lo p,lIllllll'lIl} 111 l'\It.'n'"II1, 1"t lIecdcd , While . . 11 1111) II P Illl' III1.!l1i k{'l'P the kllt.,t., L'xIL'ndt.:d hy lI',i ng:1 POI.,\\ Iii III

11,lIhllhl.1I
11

.llId

1'11111 III ,I hu,lId allill'ill'd 10

It II

the wheelchair. The

\1111 ,I IIllmil'lIltllill illnputitlH>Il need, lull ROM in Ih hll I 111 11.' 111.111) Illl'\tL'n"'UlIl illlcl adduction Prolonged \11I1t I' In hl' .lvDllkd SOIlll' tlllll' l'arh day ,hou ld be ~1""llt 111 Ilil' II/niH' PIl", llon. 1 ~ l l'vlltltlll of Ihe re~idlia lliJl1b Ill! 1 pllhl\\ IIlll1l\\lIl}-' l'llhl" [1.1Il . . lcllloral or tran'libial ,I1I1PlIl.lth1l11.'. UI It.·tld 10 till' dl'\elopllll'l1l of hip flexion conU,u,l11r ,Iud ... hould hI.' ;l\oHkd ( h~ ..... :.!5.H and 25.9), The 1',lI" pll 1UIll'J.1I1\l' Pl'II0d I .... critical In c' t ah li ~h lll g po!-i[1\\' P,ll1l' ll1 '" III ;11.'[1\ II) Ihilt will .tid Ihl' palicnl Ihroughout Ihl' \l'h,l hdlliI1l\l' Pl'llOd, Ta)'dn g Ihe time [0 teac h Ihe 11,IIIl'nl 1\1 .1....... l1l1ll· Il· ... pOlh'hli1l) for her or hi, own care can Il'ld hi I.ltl·! hl'ndl'" 1'IIIt

Mllnagement of Contractu res S\lll1l' lIldl\

,du.li ... \\ JlI pn: . . l·nl \\ IIh 11Ip or hncc llcxion \llld l'I..l Iltracturl· ... Illa) rc . . pontl 10 manual

~\)ntl.ldllll''''

Figure 25.9 Improper po,>ilionll1g of re,>iduallimb on a pillow.

mobili7ation and ac ti ve exerc ises but it is almost impossible to reduce moderate to severe co ntrac tures by manual stretch in g, espec iall y hip rlcxion contract ures, Some practitioners advocate holding the extremity in a s tretched pos ition w ith weights for a cons id e rable length o r time . There is lillie ev idence that thi s traditional approach is successfu l. Fac ilit ated stretching techniq ue s ( PNF) are more errec ti ve than passive s tretching: hold- relax and hold- re lax active contraction that utilizes res is ted contrac ti o n of antagonist mu scles may in crease ROM, particu larly of th e knee (see Chap te r 13), One or the more errecti ve ways of reducing a knee Ilexi o ll co ntrac ture is to fit the patient with a patellar-tendon-bearing (PTB ) prosthesis aligned in a m ann er that p laces the ham s tring s on st re tc h with each step, Such prosthetic alignment provides an active stretch that is quite errective. Hip Oexion contractures arc more frequelllly round in per~ons with transfemoral HmpuHllions, It is difficult to 'walk out" a hip tle\ion con trac ture wit h th e transremoral prosthesis. In some instances, depending on th e severi ty of the contracture ;md the length or the residual limb. the contracture can be accommodated in the alignment or the prosthesh. A .... nee Oe>..ion contracture or less than 15° i':o not usually a problem. Prevention. however, continue . . to be the beq treatment for contractures.

Therapeutic Exercise

F

ure 25.8 lmprop.:r r- ltlunlll~ at rc Idu.;u 11m" un a plllo"

The c\erci"e program IS mdh luuall) de"'lgncu and Iflduoc:-... ... trengthcllIng. bal.mee, and cOOr0Il1.1I1011 ,KII\ Jlil'''. Th~ po,hurgical dr~I.,""lI1g, degree of po,tOpt.·r.ll1\c p.lln, and hcalmg of the lIlL'i ... ion \l!ll uctcnlllJ1c \\ hen n:-"'I ... II\\!' c\er· CI"'C'" for the lI1\ohcd c\tft'mu) t',1Il lx- ':ot..lrtcJ. The: IX,..,t· llrl\~rJ\I\e: C\CTt,:t,c: progr.un L',1n I,l"-e: man} 1I.1mh and a homc ("\Nt""''' prngr.ull tlILP) h IhXe:",iU). Th~ hip ('\ll.!'n ... or.... and 3txJUl'h~r ... , and "-net: I.!' h:n"ur and Ill.!' ors are

A

B

c - -" ~/ .~-=t~ - . ...L-

E

-- - - . Figure 25.10 (A-G) E,erche .. for mdl\iduah \\ith increase muscle ",reng.th and nexibilit~_

tran"u~i.lJ .unputalJ

particularl) Important for pro~thetic arnbulallon. Studie ... ha\ e ... ho\\ n a correlation bet" een 'trengrn of the le~ mu ... -

ele groups and abllit) to use a

pro"'lhe,i~

effecti\ el~.~ ~

Figu~ ... 2.5.10 and 25.11 depICt a ..erie" of e\erci~ ... panic-

ul3rh \\ell de.,iened to .. lrenethen c\ mu-.cle... 3.roUOO the --hip and knee. The~ c\crci ..c ... can be adapted for 3 HEP bec.JU'C lhe~ are ',mple to perform and ~Ull-e no 'rectal equlpmenl. E\crci-.e, ne-ed to he gr.\ded \\Jm Ifl("re~.;.ed n~'I'I.lrKe throughout the PO'-bUf!!IC,:lI period. -\ general 'lrenglhenmg program that lJK"lude~ the min and .1I1 C\lremlllc, l' oll~n mJIC3.tN. p.utl~ub.rl~ fl.Y the nld~r pl"r-t,ln \\ hfl mJ~ h.1\ e tx'Cn qune -.edent~ pol'lr h.l ,ul);~~ Pl\lrn(k.·l'rtl\~ neuromu'~,:ular C\Cn;:l..,e roul~..ve ~ncIiLI.11 tne ~'\c.-n::I~ Jlf\',f!r.tnl Ilt..~ ... to mdl' IJU3l1~ Je\ ell'lll'd MlJ el11rh3'll~ loo..e l11u ..... 1e ... liul .1l'(' l1ll"l-.t 'U\"(" 11\ rn"thc.-lI fUTl"lIll{l l ...."'l<'tn'-.' e\~n:l 3. d(VktN In hgull:'" ~ WD .lIlti 2' 11 -\ nl.l~ )(l1r.tu"Jh.. tor ... \ml("lIldl\1du.1h\\Hh.,:anh dl ~orh,pt"ne -.1OO.1kllh

-

-.

fl.'"

n

1

m3JnI..lin

e\eTCl-.,e-....-an

tx- mod fled

ll3'\

!he bun . ,off !he = 0 1 fT1O\Cment

The ~

n:er. more 3 ... lne" ~N--.JIl

lallon d"" DOl u,1I3! \

\lan) older ndrndu3i at-Ier 'UI£'cn .md neo::J e ,trenfth. ~,jmatJon. .md ... atcr 3IDOO 3non.

deal

l hapter 15 Amputation

7

L

J., '

L C

E

Figure 25.11 (A-F) Exercises for individuals with transfemoral amputations to mai ntain or inl~re;"e nlU,cle ... lrenglh ;md fle,ibiliry.

"Pll.1l J~ earl~ a ... a \\ eel after ~urger:. referral to a rehal-'I I.illt.'" (("nter or home health agenc) is important to ~\ Ide the nece ..... J.f) continuit) of care. Earl: mobllit~ i ... ll11portant to total ph) siologicaJ reeQ\~~ The palient need ... to resume independent acti\'itie~ a~ l'Ofl J...... p(h"'lble. \Io\t>ment tranSlIlons (sUpine-IO-sil. sit. ~ landl are prelimin3.f) to ambulauon activities. Care m . I be- taken dunng earl) bed and rransfer movements to J.'I'Otel"1 the re'ldual limb from an: trauma. The patient t ~ old\ I~d not lO pu h on or ,lide the residual 11mb t the bed o r l."halT The pauent abo need ... to be cau; l.tn I .. ~ndmg Dt

too much lime in an) one IXhltion

the de\elopmenr of JOtnt

contracture~ or

kin

for the older adult who may be afraid of fall,"g. Poor balance and fear of falling have been found to negallvel)

impact successful prosthetic rehabilitation.b.HIh Cpper ex:trem· it)' strengthening exercises with weights or ela\t1c ban(h are Important in preparation for crutch walk,"g. Shoulder depre ..,ion and elbow extension are particularly ne<.:e,..aI) to improve the abillt) to lift the bod) '" ambul.tlOn . Individuals with bilateral amputation, "ho have one healed re,idual limb will often u," that limb"" a prop for bed octlV Itie, and tran,fer<>. Often a debilitated pe""" v.lm ~llat=l amputation, who IS unable to lift II>< bod} "nh 1I><:urns 1U be able to tr.lrbfer when allowed to u..e II>< old 10 pu ... h on .

.... alnlnu. n

indh Idual \\ 1m unilaleral amputation, ha\e Htlc: U lln ... to the ~h3l1ge 10 balaJk:e that re ult ( a lunh ItlUlg:mJ l.Uldmg baJark-e Xtl\ I· II>< I" W'!'I a1l'W!'f3lI1. partl ul. b

t. ad

AmbuJation and Gait Training \\

.i.llm~ I

pendcnce

an e ce er' C en: J.til) lit (j tr.wnng

In

lor tan

earl

10-18

Ph),sical Rehabilitation

postoperative pha<.,e. and the pe rson with a uni latera l LE amputation can become qu ite independent using a threepoint gait pattern on crutches. Many older individua ls have difficulty learning to wa lk on cru tches. Some are afra id. ')ome lack the ncce<""aJ), balance and coordi nation. and OIher<., lack endurance. Walking with cru tches wi thout a pro<.,thesis requires a greater expenditure of energy than walking with a pro<.,the:,i". Independence 1Il crutch walking ie; an outcome worthy of considerable therapy time. The individual who can ambulate \\ ilh crutches \\lil deve lop a greater degree of general fitnes<., than the person who spends most of the time in a wheelchair. Crutch wa lking i., good preparation for prosthetic ambulntion and the per.,on who can learn to usc crutches generally will not have difficu lty learning 10 use a prosthesis. However. the individual who cannot learn to walk \\ ith crutches independently may still become a very functional prosthetic user. It may take considerable time for an older per'ion to learn to use crutches. but the benefits are worth the effort". Even if the individual can use crutches only in the sheltered environment of the home. such ambulation should be encouraged. An earl) graduated mobility program is abo Important for cardiovascular traini ng and the de\'clopment of endurance. Cardiovascular endurance is necessary for effective prosthetic ambulation, particularly at the transfemoral level. There are advantages and disadvantages to using a walker for suppon during the poslsurgical period. Certainly, walk ing \\-'ith a walker i~ phy,>ioiogically and psychologicall y more beneficial than sitting in a wheelchair. but it should be used only if the person cannot learn La walk with crutches. A walker is sturdier than crutches but cannOl be used on stairs and curbs. It i'i sometimes difficult for the person who ha ... used a \\alker during the postsurgical period to switch to crutches or a cane \!,,:hen fitted with a prosthesis. because the gait pattern used \\ ith a walker is not appropriate \\ IIh a pro"thesis. A walker encourages a step-to gail pattern whereas efficient prosthetic use requires a stepthrough gait pattern. A reciprocal walker I:' not safe during the poMsurgical period when the Individual is uSing a three-point gall pattern. All individuals with an amputation need to learn some fonn of mobility without a prosthec:..is for use at night or when the prosthesis is not worn for some reason.

Temporary Prosthese s Many individual<., are not fitted with an) type of prosthetic appliance until the residual limb is free from edema and much of the soft (I.,sue h~ shrunk. a process that can take many months of con"cienllous limb \\r.tpping and exerches. During this period. the patient is hmlted to a wheelchaIr or to ambulation \\ ith crutche.., or a v.alker. \10st individuals cannot return to \\ork or full) panicipate in ADL ",hile \\alling for the re ... idual 11mb to mature. Once fitted \\ah a definitive prostheo:.,l'i. the re<.,idual 11mb contmues to change in size and

Figure 25.12 Transtibial temporary pro"othe"ols.

a second prosthesis is often required within the fir\t two years. Early fitting with a temporary prosthe"l:' can greatly enhance the postsurgical rehabilitation program. A temporar) prosthesis includes a socket designed and constructed according to regular prosthetic principle:, and attached to s~me fonn of pylon. a foot. and some t) pe of su<.,pension. Figure, 25. I 2 and 25. I 3 depict two different temporary translibial pro<.,the.'loes, both "uspended by a sleeve. Figure 25.13 shows the socket itself with the <.,Ieeve removed. (See Ch~pler 32 for more detail~ on prosthetic components.) IndiViduals fitled with a temporary pro<.,thesis are tauQht to use the pro'the", correctly and, depending on physiol~gicaI statu .... use little if an) external support. A temporary pro':>thesio:., can be fitted as soon as the wound has healed, There are many advantages to u... ing a temporary prosthe:,i,:>: · I,t ..,hnnh the resldualltmb more cllel.'tivel) than the ela':>lIC wrap. • It allo\\s early bipedal arnbulauon. • Man) older people can v.alk safel) with a temporar) prosthe..,,,,, and a cane who otheru I'iC \IooulcJ not ~ amnu lator) dUring the postsurgical perioJ

( ·huph ·, ... 1I "'pl'n ... lIHl

"'llIIp".

lill y II vall.thll-

2~

"",p\lht.inn

"lilT JIlII1I '. ,IIHI

pylon ..

l il t'

IU'I)

now gl'lH' 1

11ll'Il' ,Il l' ill ... " iIf IIU, I
IlIl· .. l':o, Ihnl :u II U,1 '" till' Il'''(\ lIal 1111111 ·,IUlI l"' .... Whde 11111 IlIhr1(.·:lI\..'d It II till' IIHll vld l1 !t 1 pl· ' . . O Il . t"L'Y Ullne HI 11I1Il' l l'11I

.. Ill'" :md 11ll' Pl tJ ... thl'l i .. t can PIIlVH !t-IIl'll'''iIl Y i.U IJu .. llIlt':llt ... 10 CI1 SIII L'

plOpe i'

III . I t

I.. ca .. ll' l 10 lablll ·ale a Ir ,lI1\t lhlill

.. m:kel . but I Ill' lI"'l' 01 II IC11lPOl ,lfY plO .... thc!o, i, I ... ve ry II 11 pOI l an l 111 til l' rcilahdlt ;I1HHl 01 p;ltlel1t .. Wi lil Uill1 ... lclllIHili iHllpU Idli nn ... h1 I Il l' t l' lllpor~l1 y Iram.le mm al IlI o .. th l· ... " ... hould illCmporat l' a well dC.. I!! llcd .. ockt·1, , \I 1ll ul.lted h nee 101111 fnot. and py lon. Su .. pen .. ioll l11 ay be an:omph ... hcd 'Nuh Si lc!o,ia n handage 01' rH: lvic b;\I1d .

Patient Education A ... YOll wnr ~ wllh th e pa tlc nt. yo u an; glad that you ... 1i.tr1cd leuchlllg her uboul PYIJ ul1c11he L:un.: oj hcr leg ... when you we re iJIIllall y trea lln g her. II she I'" 10 return hOll1e lrom thc hospital. :-. he need ... 10 leHrn alld undcr"iaml enough to be a pmlncr in th e rchabd i tution proce .. s rathcr limn tI pa ... 'ilvc re<.: ipi c l11 01 informtltiol1 , You know that tea ching. IS not tellin g and thut you ha ve to devbe way., to act ively \I1volve th e patient ill Ie:." ning importalll conce pt<, and aCliviIIC". From ex perience you hu ve learned Ihal the belle r patien t .. understand Ihe ca re of their own bodl c .... Ihc gre ater the adherence wi lh horn e program.,. Palicn l cdu c:'llion IS an integra l and on going part of the

or

• Figure 25.13 Tram.t ibi al temporary pro ... tlll: .. i .. wilh \ lI "'PC II· ' Ion ... Iccvc

or

rc habi lila! ion prog rilill . Inform al iOIl 011 I he care the re.. ld utl l limb . proper ca re th t: uninvo lved ex tremit y. pO\l tioni ng. cxercise~. :md ui et, if th e p~ltiellt ha .. diabet e ......Ire n ece~s arY for the ptllie ntlo be a full panicipanl in the reha·

lowcrcll 10 ... how \o(',",cl.

· Some ind iv idual!-, ca n return to work .

· It provillc\ a meam, of eva luating th e rehabi litation potential of mdividual . . with a qu c . . tionabl c prognosi .... · It i", a pO\ltivc motivating faclor. providin g a replacement ror the mi ...... lng part of the bod y.

· It reduce ... the need for a compl ex cxe rci"ic program becau\c many people Cill1 return to full acti ve dail y life. · II can be u..,cd by individual ... who 11l~l y have diflicult y ohlam ing payme nt for a dc finili vc pro.." hcs ir.;. Ma ny temporary ... ockct", today a rc mad e u l li ghlwc ig ht

Ihermopla"'lic mat e ri a l... lhal ca n he formed over a po ... iti vc ea,! oj th e rC!':I ldual limb; \O l11 e an; COII \ lrut:led of a libe l gluv\ ITIHtcri allhal ca n be formed directly ovcr Ihe res idua l IImh. The prost hesIs is lIsually .s uspended by .1 Neop lenc ~ Icevc. 'I he prosth csis is worn With ;.t woo l sock 01 appro pnale Ihl<.:kncs,; w hen lhe rC'i idual IIllIb has . . hrunk sn thtlllhrce woo l 'ioch arc needed 10 111:.11111;\111 "'OC ~ C I III . a ncw 'if)(.:kct needs 10 be c Ol1 stI'lH..: tc d . ~I he Icmpormy plO ... · II . lCSJIi I'i usually lahri<.:ated by a pl"O ... tllell ... t hut ca n be lah n<':atcd hy a Iherapl ... I, phY"'IL iHIl, or any Indi vidual w ho iii ~k!llcu In the app lu':
bllitation prog r~lI1 . Many indiv idu:ll ., with va"'L ulal' di .. ca ...e who loo.,c oneleg wi ll he conce rned about the olher leg and receptive 10 learning proper care. I\ n unde r",wllding of the ph yslOlogl cal and fun ctional implicalion ... of PYD he lp .. the 1I1dl\ ill ual a ~s ull1 e I'espo n ~i bilit y for care 0 1 the re~ ldual IImh ami remaining ex trcmit y. Thl' educatiol1 programl1lu ... t Ix' IIlt..1I vidualty dc ... igncd 10 he re lcv'lIlt and 111:1 )" 1I1clucll': , A di ..,Cll \'i101l 01 th e dl..,ca,e proce ....... the phy . . lolnglcal effec t ... ollhe ... Yll1ptom .... and IIle ... lylc challgl· ... 10 rl'dul"l' ri sk faclor ... , Informal ion on thc bcnelil ... 0 1 exerci ... l' .... I l:. cle.llllinc ....... proper foot carc. and prop!:r .. hm.· IIttl"!! • Method ... 01 edema control • The lI SC o l l')"en: l ... c to Il11pmW l:Irl"lil.th'r~ "'ltlllI' Edcnw.

pl.llll . i1l1d dHll1gl· ... III "'~ 1Il

<."Oh11 or Il·l1llx'I.lIur('

may lIu.llL' dt e I1lljll·IHI!Il g. prohkl11 ... . It thl' 'x·"~ln I'" ,1I11~U lalory 011 Ih e l l' 1l1UllIllIg 1'\11l·1Il11). 11ll' ... , IIlph11ll'" 111,1\

rc Il l'!..: I too llIuch ~ I' l''''''~ II 11ll' l'Il' I"'PII "pl·nd ... ll1""'ldl'1.lbk tlll1C ... ittlnl-! \... ,Ih 11I1' Il'!! III a dl'Pl'lltll'lIl p""tn'll, It 11M) he lIl·lT ...... ilry 10 l' lL- h ll l' 1hl' l'\ IIl'lllll)

Inll'IlllIlIl'1lI l l.llIdll.l

11011 (n, llIlpIIlV 01 Ihl' r.1I11 dlllln~ ,1\ 11\ II) IIldll,"~' Ih llL'l'ti In ... Hlp .11 I\'H' I Il'1l1Ih11,HII\ 01

I h~ ltlll.llrl,tlllrlul.lllt1n

Ihl' ll'Ill.IIIlIIl~ l'\ ll l'lIlll\ I, lll'\l'Iul~\1

illY. 1\ thrtlu'h

10.10

l'h" .. ical Rchabilitalion

prot:n: ... ,I\C procl.llll

l·\l·r\.'I'C' and .ambu illt ion II 1\ IInpllnJnt to rl'l1lcl1lhc.:r Ih.1I IOn mud) ;1(,:11\ II } may ~ ii' h;lmllul ~I' h'kol IIIIIC' C.m: I11la...1 he t.lkl'n not to O\cf\\ hclTll the pallcn t \"llh h'ko) Tllu(h mlt1nn;tllon i-It one tllllC; IIlfOnll i.uion lwcrlo:'ld Ic.ld, tll lorgcllulnc", II 1'., more cffeclI\'c to priorJl llc thc IOllmn.IIIUI1 ,\Ill! ., ... l Ihc pcr\on 10 remcmber one new thing (.Kh 'l"'llli1 rJlllcr Ihan try 10 leach i.I com pic>. program al l\lle IlIllC Wnllcn m.llcrial... arc nc..:cc\sa ry 10 \upp lement Ihe Ic;\dllng ,1Ild help the pallent reme mber what is reqlltred_ II I.... ,1 \0 im portan t for the program LO be tai lored 10 the Ind l\ Idual' . . way of life. Invo lvi ng the patient in c,tJbll... hlng priont lc", enh ances ad herence. Adherence also imprm e. . it the program mcets the pe rson's own desired ou tcomc .... The same approac h can be used for thc HEP. Once thc pntient is disc harged. ei ther week ly c linic vis it... or home hea lth ", upcrvision throughou t th e posts urgica l pha,e prov ide a check on home ac ti vit ies. on the condition of the re ... idua l lim b. and is su pporti ve to the pm icll t. famil). and caregive r. III

Bilateral Amputation The pm,t ... urgical program fo r the person wit h bi latera l LE i.1mputation~ is lOimilar to the prog ram developed fo r 'iomeone \" jth a unilateral ampu tation except possibly ambul ation. If the indi\'iduu l was tilled and ambulated after unilateral amputat ion. the prosthesis is useful for transfer aCII\'uie, and lim iled ambu lation in the home. Some in(li~ nduals may be able 10 use the prost hesis wit h exte rn al . . upport to ge t around th e house more easily. partic ularly for bathroom activities. Fitting with a tempora ry pros~ the ... ' .... a ... mentioned. is advisable. particularly if the amputations are al transtibial levels. The higher the ini~ lIat level of amputa tion . the more difficult ambulation become .... All indi\'iduab \\ ith bilateral amputation, need a \\heelchair on a permanent ba.',ls. The chair should be a... narro\\ a... po ... "ble \\ ilh remo\'able dc"k aITns and removable leg rl!'h. Amputee \\ heelchair~ with off:-.et rear \\ heel ... i.lml no leg re' .... are not recommended unle ...... the therapht i.., ,ure that Ihe per,on will ne\er be fitted \\!th pro,the ...e: .... c\en co ... mcllcall) . It i ... e,1.',ier 10 add anu-tJP~ plllg de\ ICC'" to the rC'lr of the \\ heelchair or attach ,mall \\eighh to the front upngh .... for use \\ hen the foot re'I' arc renlll\ed. The' pl"hurgical program Im:lude . . mat aCli\ lite ... de'tgned to help the ~"on regain il 'en . . .e of bod~ po",ulon and balalKc. upper C\lrenllt~ Jnd I'e\lduallimb . . tremuhcmng c\cr!.:! C'. and regular RO\I e\erci"e,,_ Funl:lt~nal moblht~ trallllll~ ,hl'uld ,Ire" IIldepenJenl.."1! in bed ml.lt'llht\. tran,kr . ami \~ heell-haIr u,e \\ Ilh bilateral amputation, 1001\ IdUJh 'pend \.·on,toer.tble lime ,lI(lOe and an: therefore mon: prone III de\ elop tle\llln CtlnlIa..:~ lun:',. parth.ularl) around th" hip Illlnl'> The patient hould h.,.. Cnl.llUr.1geJ to ,I~cp prllne It P" 'Ible . )r at

lI.:a ... t ... pcnd ,OIllC IlInc In the proTlC pO\lIion cach day. I he Ihcrapy program i.l l... o cmph" ... lIc\ ROM 01 the rC"'llhJiJl IImh,. Some people move ahuut tlH:lr hm11c, on thl'lr lncc\. or the huttock .... Knee pad.., Illadc oj hca\-) ruhht:r u ... cd hy field wo rker... are effectlvc protcctor, for the rc ... idual limbs. Protector ... can al\o he fabricated 01 loam or rc lt. Temporary pro ... these\ arc of great "lilue in the relHlblh _ tat ion of pIubbie ... for ADL In the: home hut r I n

,

•

Figure 25.14

rubb~

Chapter 25 Amputation ~ I Oul Ide (he home ,\I(hough prcM:flbcd ralht.:r lhe.. r m
limn, or ""ho will nOI be able to ambulate wllh pr lhe5cs rcmporary PT""he"" 01 dIfferent heIght' d to determine ambulalof) potential but care • n 10 cn ure that the lcmporar) limbo;, are conH enough to IQlerale the Ire~M:!) generated in

Detcnnining Prosthetic Potential 1m of the po~lo;,urgical perrod is to delennine al ~ UILabilJl} for pw\thclic replacement. lS'0l I1h mpUlallOn\ arc candidate') for a pro\thc\i\. of pcr')l,"al de~irc. The cost of the pro... thc')i')

y dcm
m IJse

ndJ Jdual .... ant a pro.,the.,is is not enough. Many r not JWarc of the phyc,Jological demandto. of pro.,mhlJla!ion. partlcularl} at lran"femoral level\. -me :Je\ Iopm 1','II~htwclghl pro\thcM:.\. stance control knees. ~ra II mc(;h4lfJlc;.m ... , and energy concoervi ng feet have made If po Ihle 10 ue<.:ct,~fuJly fit many more imll vl duaJ\ t n 10 the pa t hfMocvcr • .,ome con\idcration for nonfrln_ neU;fi <.Iry.

Tramtibial Levcls '.1, '10,11 IrjwJI amputa ted at any lran\liblal level elln be fulJy filled wllh 1I pm .. thc'tllt, fl ex ion contracture". p4.1fJrJy hapcd rC'tldual Ilfn~. lind adherent ... kJll arc fmlr, ,IJlf I fkhtlilHIt'd Ix"a,,"'c of IlIh-(IIO Il I IIllh'll~ III (flfllrol ,HId III"" will plohO/lll y 1('J!llI lIlh, itll l" '>«'C"'I1' IflIIVII, ,lIld (IInlt IHlillJi)fJ Ie , 1IIIIh,Ii"III,/I • II, l; Ii "",II h,1 IWI If WI,,"VI'" (inwfilil y. 1I,,!l v l/hl . will flol III ,111ft III I 11'IUlflV "tlf 11,~r II' " ,1/1/ I1.1I till' l'fll,hl I

0111" '·lfl lll''' ''· ''! f'lfl HI

,I

1I111 "I IIJI IUIII II

1051

bcc.:nme'io lo.. t and finmg uch indl\'ldual .. mily be an mappropnale U'ioC of limned rc\Oun:c'i.

Transfcmoral Levels \1 any paticnt\ can become re lalively functional pro"thclIC u\er., with or ",ithout eltlemal suppon . The physiological demand" of walking ",ilh a Lransfemoral pro'.>the\i') are con\Iderably higher than walking with a tran\tibl3l pro~lhesi \ and not all individual\ have the neces\ary balance, ~trenglh , and energy rescrves.ft6 Severe hip flex ion contractures, obeSity, wcakne~') o r paralysis of hlp musculature, and poor balance and coordinalion may impede successful ambulalion. The per\on's level of activity and participalion in the postsurgical program hel ps in detennining potential for pro\thettc ambulation. A temporary prosthesi s is a good examination tool. \1 0S1 Individual ... amputated at hip level s are younger and learn to U'>C a prosthesis relatively easily. Although ea rl y filling i, ph ysica ll y and psychologically beneficial.

active involvement in chemotherapy or radiation therapy may delay fiLting. Radiation therapy often bums the skin making filling imposs ible umil the skin has healed. PaLJems undergoing chemotherapy may be ill. lose weight. and may not have the energy lO participate in a prosthetic tmining program. Th e posts urgical program is individually adju')ted and s upportive until the therapy is compl ete. If the per\on ha \ I O~ 1 consid erable weight. fitling may have lO be delayed becau~e it is difficult 10 adjust a proslhesis for In crcal.,C\ in weight. Decisions must be individualized and determined by Ihe individual's physical and psychological \1
Bilatcral Amputations FittJllg or not filtlllg "ol11cone with bilateral amputation ... is a diffi cu lt dcci... ioll. Young. agi le individuals arc general!) good cand idates for prosthetic fitting regardless of level of amputallon", Mo ... t patients wi lh bi lateral tran \ li bial amputati on", ca n become quile functional with pror..lhe ...e .... Most older lI1dI V idll ;d ~ wi lh bilatcnd tran",fcl11oral mnpuwlion' 1H1ve cO I1 "! iclcrahl c dd"liL'ld ly it!arning 10 w.e IWO prosthe~t:~. PlIIICI1t "! wilh Ollt! tran,,/"emoral und one 1l1In<,\ibwl al11pllt~~1I{1I\ gCllera ll y em1 learn 10 usc two pro~thc"I' If Ihl' fir" alllpUliI!!Dn WlI"! at tlle I r;:\ 11'" remora I le"el. and il the 1"lI.!"f'OIl !,!\lcl:(;!'I~ lull y Ll "cd II Irun ... lcl11onti pro ... lht . . i, hcfnr~ Ill~Ul!! 1111: (lthl'" I L'!~'

'JhL'

]11.."""011

who 1m ... h"l pOlliO'"

01 hOlh ( l~, 11L·I.·d,

II100 l' "'! l l'II!! !I1 , IWII l." 1 (."oordlll !lIil111. beilci h.IIIIIIl'I.'. .Uld r ll'atrl ,:lI I1IHH L· ... pll ;IIOr) Il· ... I;I"\"I.' ... Ihan 111L' Pl'I'Utl \\ hn h.I' 1"",1 it p1l1lH11l 01 11111.' I I ' OIX'\II) mil}..l·' hllll1!! ~11 bll.lIl'f.11 plll .. llrl."l· ... 111(11 1.'

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, 1"lot'l IIIIIIW , IIlId \\1111 Il1nll'!umll\llloll \011l1'\11\t'1l" h.l\l· (0 ,,1111111 I'd lilt' H'lhlhdll !IIIt111 1l
l

Ph K'al R habililalion

PUUI,Ofl 1be.m I of computenzru lne<: "omponcn h.1 e proll ",docJ:d!be encq;) ""Iulll,mcn~ flx ambulauon \\ th bl ler 1 Iran femoral amputation 11"",,,,<1' cllCfl!' requlfemem die 1111 quite h'~h and ",en .. oungcr mdl\-Iduat \\ tlh bllalcral Iran lemoru! ampul.1~ lion ~) net'd to usc a y,,"heckh tr "'lme 01 lhe lime. Indl\ Idual ... v. hH are nol faned '" Ith a pro the'I' need to hccome as muc!pendcnt a ... po"lble to a '" hc:ckhalr The Ihcrap) program mc.:lude ... traimng In aU lran,ter-.. \\ heelchair mobllil~. nnd .\DL The program empha,i7c, ,ming balanl.."C, mo\- tng .. aiel) In and out of Iht! \\ heeJchalr. and other adl' itic ... 10 ... uppan a ... Independent a lifc .. [~ Ie a ... the per~on· .. ph) ... ical and p .. }chological condition aIlO\\ .. . EducatIOn In lhe proper care of the re ... idual limb i... al ... o important. a lthough wrapping the rc ... idual limb rna} no

bil 1=1

longer nel:e ......ar) unle~ ... the pcr...on i~ more comfortable Vonh the limb covered.

Que~ti o ns

1.

f o r

Summan \1 t IIldl\,dual, "uh LE 3Illpul311011 , retum 10 • full and u...,ful hIe I I .\ pro~r.lm of po I pcrau\c! I..Me th.tt l~ \Ide lion 01 ph~"'1 .-1 and cmolIooai ~ \It, 11 en pallenh to he •.:om~ tunctlonal pr .. t 'II..: u Of' \1 lheu..: problem ... i.,"3n 1;'1(' 3'oh.ieJ t-.~ pro~r:\ prc,,,,,,,,indi\ IduJ.1 for pro ... lhet1~ \\eJ.r In Ihl' \.h3p[~r .. rel31ed (0 the [X1 ... loper.lti\c m:tnJgemem oflhe 1Od.1' "ilh J LE ampUlJlIOn ha,c ~en pre 'nI .. d Throo pnx-e ...... of areful C\ JluJlion Jnd open ..:ommun ...' II ~ l comprehen ... i,c progr.tm de ... lgned (0 meet (he nl"t.·d. ... l'r indi\ idual Pilllcnt can be J('hle\cd" Tht~ mdl\ IJuJ.II\ each per ... on pre ... enllng for rehJPilit.ltlon 1'" ("Inc f the challenge . . of ph! .. Ical ther.lp~ pr..h.~llCe

R e \' i e \\

DI ~ u ~~

the advantage~ and d i'-.advantage~ of the fol lo\\ing method ~ of po'-.t<., urgi cai rc~ idual i1mb management:

(a) rigid dre" mg: (b) AirLimb : and (e) ,of! dres>,"g. 2 . Discu s~ the proper method of wrapping (he tran stibial and the transfemoral re.s. idual limb. 3. A 72-year-o ld man with a hl'-.IOr)1 of diabete~, cardiovascular di ~c a.5.e, and PVD ha ... been referred for physi cal therapy 24 hour~ post right transtibial amputation for g angrene. What examinat ion daHl are needed to plan an appropriat e treatment program? \Vhic h are the most critical to obtain on the fir ... t visit ?

4 . De"'lgn an exercise progr.lnl tor ;\n ~~-:t'.lr-old l11\h \"idual "lIh a left tran .. temoral ;llnpUl.uhlll \\ hll ~ ... refcfTt!d ~ \\eek ... after al11pUI;1I1011 5 . Discu ..... the ad\ allli.lge ... and c..Ii ... alh .1111.\gl..· ... tt'.\dul1f: an older pcr... on 10 \\alk \\ ith cmtdl~'" \ a .. u . . \\ .llklllf \\ ith a \\ alka follO\\ lIlg .\ UlllJ..lleT:11 amput.ull'Il 6 . \\'hlch po ... hurgical .Ietl\ ilit: ... ~lrl' mtW~ lIn)'nTl,11lI \\ Hit bil:lteral <1mputallon ... a .. cOlllp~ln.~d III 1I1111,lIt'I.1I.UllpU" lations? 1-1 0\\ might )OU h:-Jch th~ ... ~ ;adi\ 1111.....

l,r

Case Stud~' ~~~~~~----------------------------------

REFERRAL

SOCIAL HISTORY

The patient b a 72-year-old remale slatu'i po ... t ri g ht

WidO\\ w ho li ves alol1e . Thrcl' grO\\/1 l.·hildrl'n.,lhl

tran ... lI bial amputa tion yestc rday secondary to arl c ri o~c1Cro t lC gangrene.

g randc hildrl!l1 in the.: an.:a.

CURRENT MEDICAL HISTORY Diabetes type 2 ... incc age 4K contro ll ed by insu lin 20 Ul1lt ... bid . Artcriosclcro ... i... ; hy pe rten ... lOn con troll cd by medic ation ; treated for ulce r plantar ... urr"cc of ri gh t fir .. t me t
PAST MEDICAL HISTORY Il y ... tercc tomyat age 42. otherwi ...l.' tlnr~ll1arkahll'

\1\

PHYSICAL THERAPY EXAMI ,\1 ro (INITIAL) C hart H.l.'," k" P:tti c nt ulert and ,make 111 110 appa rl'l1t (1I .. 'l"l· ...... RI!-!ht .u:lll .l1 nb \\ rappelI 11\ ... 011 )!.III /O: (10'" 1 . in"t- (\lh'll'd rcsld . . I . ·k.lIl llll \\II1h :111 cl a .. l1 c \\ rap. Dram III pl;tn' IIU .... {l1l l

drc ...... in g change, BP: 1..J 2nO. pul ... t: h(l, 1l.· . . pll".I\I0I1 R ~ ... p iratory ca l ~ prac tltlOnl.·r

Ilt)lI11al.

1 I !ilL' ~Pllll

rl.'pnrh p.U ll·n I'" " l I _ ". IIt Il· ... 'lIh meter prnpl'II). norlllal c(lu)!h. 110 l'\ IlllIlL lOry prohlem ....

l.,f '~"\'

11.' r.IITl

;n

~c~

dual limb.

pi.tlll

medH,atilJll

r I).I! l

L

h tn:ngrh of ktt llJ"ef c,,-tremity and both ::-C"'1'lI;It:" ... po ...... l) v. ithm funr..:uonal Imlh \iu ... It: srr("ng~h "f "lghl hJp nexion. abdudion on gro ... l~ WFL 'lip cxteIbJOn Iesled '>Ide· ~ g-noeo .... ~! .5 Fair t-), Dt:mon ... trd.teo, Kthe f nghl KI1cC: 'lcxlOn and extension v. ;th no ~ . : ~I\en al fhI:" tJme, nh 111:01 ,urcml.!ntl!. deferred until in1uitl healing (.

n 'a,:c. , of r. .m,on of left Joy, er eXlrcrmry and both ':-:1nie:-. \\"FL. Left hip exten~lOn me~ure~ _ .: .ed until pauent can he prone ur on right ) range f)f motion cf the right hlP \\. FL.., P extcn~lOn to 0 mea,ured :'Jdel)ing. Right , c. J!1d ~Xit:n:-'lUn g.ro::. ... l~ ~unctional. Spetwc .("nl deferred ..J.mil dre ...... ing can be remO\ed . . ,.'--emIt) I'" halrle ... ~ below the ankle. Skm _~ 1-, c OU~ 1 Poplneal pul ... e palpable Out nOI dor1\3.J pedl:' pube. Toe ... Me "'ann to touch. Pr pr x.e~ti\ e ,en ... ,:HiOn intacL. Dimini ...hed -..en~on () er JanI.u ... urta('e of left fOOl and aorsum oi flT~t '"'l;;; ..... I..1f . .11. '"\ e\Idence of edema m left 1o",er extr~IJ1H" Sen~
'r he pallt: nt will be mtkrx:ndeOl 1.1 all tr.ar fef 2 'Ihe p'.Juem will be JrIdtpelldem 10 amhulatJu ~ ... rulchc 0: W,41 r ff.lf 40 feet ~ The rr4l1ent will demonwatc """",ledge·~ 1fI'rc u"ual 1mb po 1l1t·01ng.. banaa;, .ngo lind itt 4. 'The Di.l.ue:.l 'ft .1 demm.cua1e ~~g.e t/J ~ 1 ua; unb eXo.;:rLI '. S.l he patient will dtrl'lOC!··'''' Im.~ .., """'" ~ ph) sicaJ therap''-l

Res.Jdual limb: Sutt!n;~ I.i pl.&cf:. m. .JmJ: drd.lnag<.ieog"JJ '6 om '.~ U1 If plateau "T? J. Cm;umferentia.l mc,"-.r.:remt""ill:s ;;'I(EI v.T'r

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left tndependent: rolhng IO right .md pL ne ['~ t .e:.ted. ) ..rme~[o-"lt md retum. modified mJ.epenucnl re<1 ... 1rt~ .,e f ·rope ladder"' at,-,(hod to ioot of bed .

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cd

E\pc""t~d OUll om ....... l\ •."h\ "H:31 ther-Jp\ epb.ode of L t J~ ll('\cd I'nOI 10 \.h"'(~J.Tg ff'( m hO:-.P1Ll

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ferenccs l.ev) .... , \fl)(>lrl1l! .,kl JlC't1ph~r.tI \ .. \4:UI.lr dhea'-C Chn Poth.1It 1<.'d \WJ 91M 199~ 2 Ritz (i,~, al [)1~N't JOJ penpheral \a ....:ular dl ..C.N': ClUl POdHiIr \I J lUI 9 l~'. I~~ \,~( nllum. rl lind \\aller. \ 1·\ \ IOlJor limb amputation for end· ~ rcnphc-ral \.I",-ul.lr dl-.ea-.c: Le\t~1 <,elecllon a nd a hCmUII\iC

Of'hons In Bll"lcr. HI. and \ 1Khael. JW (cd .. ): At la .. ot Limb ~hc:th.. , SUfp..:al. Pn.l.. thctic and Rchabllitation Prindple,. cd 2. ' 1\1 h) 'ear Bnlll. St Low ... 199:!. p :!5. '" QUlglc:\. Hi. et .11 ImfM..:1 01 Icmoro·dl\lal bypa').. o n major lowc r limb otmputatioll rJte. Au .. 1 I I. J Surg 68:35.1998. 5 IlJ.llcl1. J\\ J r.. ct al: Impa,' of a rterial .. urgery and balloon angiopla,l) on amputulIon: A popu litllon ba.sed study of 1155 procedure .. h(lween ,Q7J tlntI 1992. J Va ..c S urg 25:29. 1997. h Cu"on, Th l. and Bo ngionu . D R: Re ha bilitatio n of the older lower 11mb amputee: A brief revicw. J Am Gc ria tr Soc 44: 1388. 1996. 7. )eager. RA. e t a l: Surg ical m anage ment of severe acu te lower c\lremit) I""-'hemiu_ J YaM: S urg 15:385. 1992. F~rngla ..... J. c t a l Peripheral bypa.s .. ')urgery and amputal io n. .... onhem Ilhnoi.. demographic .. 1993-1997. Arch S urg 135:75. 2CX){I. Q Edelman. O. e l al: Progno')tic \'alue of the cl inical exami nation of Ihe dlabew.: foot ulcer. J Gcn Intent Med 12:537. 1997. 10. \Io ..~, SE. el al: TIle prevalence and incidence of lowcr el(lTcllllt y amputation rn a d iabet ic popululion. Arch Intern Med 152:6 10.

1992. II. Knighlon. DR, c t al: A mpulation prevent ion III a n independently re"lc .... ed at·rt\k diabetic populatIOn us ing a comprehell'.,ive wound care protocol A m J S urg 160:466. 1990. 12 KrJJc"" .. ki. LP. and Ol in. JW: Athe rosclerosis of the aort3 and lower eXlrem ilic .. an c ric\. In Young. JR. e l a l (cds): Pe ripheral Vascular Dl ..ea~e .. _ M o~ by- Yenr Book. SI. Lo uis. 199 1. p 179. 11 Ham<;. KA, c t a l: Rchabil it:lll on potc nlinl o f elderly patie nt s w it h major lIIlI\lutut ion... J CurcJ iova ..c S urg (To rino) 32:463. 1991. 14 Eb..,kov. LB : Relative mo n ality in lower limb amputee)., wi th dia· betc .. me lhtu ..,. Pro.,thct O rtilollnt 20: 147, 1996. 15. Fletche r. DD. ct a l: Trend .. in rehabilit ation afl er ampu talion for gen.u ric pitl lenl , with va ..cular disease: Implicat ions fo r future health re ..o urcc allocat io n. Arch Ph)",> Med Rehabil 83: 1389. 2002. 16. Dl lhngham. T R. Pen in. LE. and M3cKenzie. EJ: Rac ial d iffe rence .. '" the ITlcidence ot limb 10.... <;ccondaT) 10 peripheral vascular di .. · ea..e: A popul.ll lon ba ..ed ,Iud). Arch Ph)"s Med Rehabil 83: 1252. 2002. 17 KiI)', II W. ;lnd \Ie,," m:lIl. J O: Re lati ... e incidence of new ampu tal ions: Sialt .. tu:a l compari,on, of 6.000 new am putees. Prosthct Onhol 1m 29:."\. 197~,1M ",,~arajJ.n. R. et al: Limb sah age and amputat io n in <;ur. ivor-. of pcdlJtri..: lo\\-cr·exlre llllty bone lumon.: What are the long-tenn I mpli(at\Om'~ J Cll n Oncol :W:4493. 2002. It) Sloj
looll'll.)<,tcnur Ibp Br J Surg. ~~h~'- 2001

,)., KubLn'KW\ J...p ""L~ nJp ~I..w. ·L.nc!'C i.unput.1l1nn .\nn R (',II! Surg

In,ll"\

1'\ 190.)1

29 Ru'lJe~ C\'. SlOnebndgc PA. and Prc,,",o(l RJ SlC"-n"p \~n: ptl.. tenor nap III below-knee amputation .. : 'Iuil! ... ent('r Ina! J \ klo, Surg 11:42_l 1991. be 30. Moore. TJ: Planning for op"malluncllon in amputation '!ourge--y I Bo"-ler. H I. and Michael. J\\- (cd .. ): '\11." of Limb Pnl\the"... Surgical. Pro,.,thetic and Rehabilitation Pnnclp1e,. ed:!. \1, b\.YQf Book. SI. Loul ... 1992. P 59. . ."\ I Michael<;. JA; The ..,election of amputatIon Ic\el: An approach U\ll decl"IOTl analy,,~. Eur J Va ..c Surg ~A51, 1991 g 32. Sarin, S. et al: Se lection of amputation Icvel .. : A re\le". Eur J Va.\( Surg5:611, 1991. .13. Spence. VA. et al: Asses .. menl of 1I<;~ue \"iabilit, III relatIon to \('1«. tion of amputation leve l. PrOSlh Onhot IIlI 8:67. 1984 34. Li nd, J. c t al: The infl uence of smoking 011 complicalion.., aher pri. mm), ampulal ion!> o f the lower extrem ity. Clift Orthop 267:211. 1991. 35. Evan ... WE. et a l: Effect of n failed dislal recon ..truwon on the bel of amputat ion. Am J Surg 160:217. 1990. 36. Domlandy. J. et al: Prospect i\c .. tud) of 7n beIO\~-l.nee amputation., for ischaemia a nd the effects of a pro..,t,Kyclin ilnaillgu~ on healing. Br J Surg 81:333. 199-4. 37. Domlandy. J. e t al: Major amputations: Clinical panem .. and pTt"dIC. 10rs (re\·iew). Sem in Vase Surg 12: 154. 1999. 38. May. BJ: Amputations and Prosthetic .. : A Cl,e Stud} Approach. ed 2. FA Davj..,. Philadelphia. 2002. 39. May, BJ: A Mate\l,-ide amputee rehabilitation programme. Pro,lhel Orthol lnl 2:24. 1978. 40. May. BJ: TIle prostheti.. t and lhe ph)"ic:tlther;lpi,t: A cirnH:Jlteam. & P Bu~ines .. News. II :90. 2002. -41. Burge., ... EM: Amputal ions of Ihe lower c:\lremitie..,. In \"iclel. YL (cd): Orthopedic Rehabilimlion. Churchill-Li\ ing .. ton. I\e\~ Yorl.. 1982. p 377. 42. Sanll iento. A. et a l: Lower-exlrem ity amputation: TIle impa't of immed iate postsu rgical prosthetic fining , Clin Onhop6S:22. 1%7 43. Harrington. IJ . et al: A plaster·pylon technique for bcIO\\-llll,.'"e ampulation. J Bone Joint Su rg (Br) 73:76.1991. 44. Schon. LC, and Short. KW: Benefits of early proqhctic ntilllJgl! ment of transtibial amputces: A prospective clinical ' I ud~ 01 the! ,\If' Limb"'. Journal o f Proceeding..,: AOPA Sc ientific Se"i{ln~. 2J'Oil 45. Vigier. S. et al: Healing of open .. lump wound .. Jft~r \la~~'ular belo\\-·knce ampulation: Plaster cast ~ockel \\ itll ,ilinllll! ~k~\e 'lO, su~ daslic compreo;~ion. Arch Phy .. ~ I ed Rchahll Nft( lOt: P2". t9 46. Goldberg. T. Goldberg. S. and Pollal. J. Po,lOpI!mtiH' IIlJna~ nll.-nt of lo\\-cr extremity amputation. Phy, \1ed Rehabll Cho \,Irth -\, I I I :559. 2000. 47 Gendron. B. and Andrew.s. KL The u,e of rigid renw\.I!>1 drr ing.., for juvenile amputees: A ca .. ~ rcpon . JACPOC 1h( I .J 19')' 48. Wong, CK. and Edel .. tcin. JE: UnTlll and c\a'lit: po,t (IIX'ra 1\ ~ mg...,: Compari'ions of their effect on funl.:lion llf .Idulh Will ... tion, and nl..,cular di')easc. Arch Ph) .. Med Rehallli S I 1~91. 'l :x 49. Ehde. OM. et nl: Chronic phunlom ,cn<,;UIOIl'. ph,lIlh)o1 I" III j ual limb p:rin and other regional pain after 100\I.:r lII11h .uIlPllt t (1 Arch Php Mcd Rehabil 81.1 039. ::!O("O. 50. Flor. '-I: Phantom·limb pain: Chilracteri .. tlc ... J.:,IU'C' and .Iund l Neurology I: 182. 2002. .'i I Mell:lcl. R. et al: Central ncurophl,ticlI)- ,md p'ltI1ll111£K.11 p,liIl Ann NY Ac:rd Sci 911:157. 2001 52. Oakley. OA. Whitman. LG. and 1l.IIIIgan. P\\- · lI)]lnnlll' ItIl.l, ry it treatment for phantom 11mb pain: Two (,I,e rerM" Illd H\ C Om RdlabJI 16:168. 2(X11. 51 Halbert. J. Crom. \1. 3nd Cameron. 10: h Id..:Il<.·l· I(lt Ihl Ipll . mana~emcnt of ~(.:ute :rnd chronil.. ph.tnlom p.1I1I .\ !O~'I IlllUl re"'le~_ Chn J Pam 18:lS-4, 20()2. 5'" 0100m4u",- T' Ampulallon Jnd ph,mtl'nt hmh p.lln \ I" In r l \ lion model. :\.\~A J 69:211 ::!OOI 55. Belleggla , G, and Olrbaumcr.' lrl·,ltm..:ntll) ph.lJltnm limb pam 1 with c(lmbmcd E\IG and 'h...·nll..ll hlok('dt"o.I~·l \ C.I":' rt'p.rn,h.l.\\- . CO \n .rnc,lh..:lIl ,IPl'rll,J~ te1 .lIllput.I IOn \ drume .. Ph), \led Rch..lbll Chn 'wrth \111 11'''\. ~fJ(ln

o

Chapter 25 Ampulatiun '1

J, (rill!) \1. ,md elllWIIll!, II) 1,_\ IdClll"t" fOI 111l' IIjlllllhll It'1ll of OI(UI~ ,1111.1 dllOl\lt phiJIIIU1Il 1',1111 -\ ","Iem.llit ( m J "11lI I"I.~\ s-t ~oo:» 1. and I I h('r. K II\)\\ l!lll', LllulI"i('hng h~'p peuple \~ It II I JI'O 14 liP

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I

11.1I1I1.1~lIlg (lIthe Icl\\er C\lremll) ;unputec. Ph},,,, 1%4 Ii H,.lu('1. S. and h'l· .... R: OUlnlme .. lIller IT,II .... -tlhlal I Ihe r lalll,n ... lup nl:l"ec:n 4U1et .. I.mee .Ihllll)" ... lrcnEth ULt,lf iIllNk .. ;lml g,ut Ph)"'lIlh~r Re .. I nl7:20~. 2002, loJ I. l'l .11 hul-mellt .. trength ,lIld cnduram.:c 01' the knee IJ Ilnor . . III tran ... 11111.11 ampulee .. Pro.. thel Qr1 hOl [Ill

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(m

(H PU\\C' ..... , eM. CI ill 1111: IlIflUelll..C ollcw.-cr C1;lh'll1lty mu'><.:lC' 101\:0

nn gilllthar.II.. lcn .. llt . . III IIIdlVlduill ... wllh helm!' knce iUnrUliltiUn '>el"ondar) 10 \;t\l.:ular (h\Ca ..e Ph" .. rhef'111.169, I()I'J6 bS Miller. We. Speethlc), M . ,IIlJ I~.lthe. AI] BoII.mer"' wofid"nu~ among people \\-1I1! IO\Arer-hrnh ampul.ll lUm, Phy .. 111,'r K2:K~6,

'1txt! 66 . \hller, We. el.11 !lIt innucm:e 01 lallll1F . f~.Ir 01 lallmg. and bal anCl! confidence all pro'lhew.: mobil II) ami "uclal al.llvlly among IIld"iduah \\ Il h it lower eX lrcmll )' ampulatlon_ An:h I~y~ Med Reh.lbi l K'1: 1238, 200 I 67. Pan). M, ;lIld Morri\On. JO : U\C of the Femureu adJu ... lilble prf"'I~ ­ ....i In Ihe a~ .. c .... menl and walking lraining o f new above·kn« ampulee .. , Pro"lhel Onhot Int 11:16. 1989. 68, Perry. J : G:lil :1naly ..... : Nomml and palholog i<:a[ fun(:llon Slack, lllOrofarc, NJ, 1992.

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pl"rlpher.11 ;lnl'ri;11 cl ....e:l ..e tlf the lo\\er III e1tkrl~ p.lllcnl'> , J (iemnhll A Bioi SCI Mcd Sci. ~I) 1 '(104 llru II \, I ,II \(~.:.III1,lIl.t l rCII\ll'~r.lllnl1 .Itter iI 100\cr limb mnplllallon : \ 'Ill hl,IIIH' ... 11Il"- Plll .... hel Orlhol Inl 2'1:4. 1003. III n n (if(l\I\'>Lhnill'n. .\IId St,II11. IIJ D.lLl~ ph) ... ie:ll :lcm II) "~I h, III 1'.11(' fl''''I"!tIIl",,' 111 people \\lIh it llllli;lIemllramllhlal :unpulaIlllil lin \,hdll.l f dl~l'.I"'l', Arch Pin . . Med Rdlilhll 8.5:140, 2004, II h,iIl illi, ,md t'nndll' . MI· \ PthHI ....cll.lrge qll.lh l~ 01 hfe mil«Imo' nW.I"'UII,· Itlf hl\\er lnul'! .Imputee ... : Tt· ... I-rele ... t reli.lhilil) and nllblnld \,lhdll\ <-"11Il R~h,lhil 17:85S.10(n l,ln,ltl·. I . l'l .11 '11,1\\ n' h .lhllll.lIlnn 01.1 If.tum.ll ic 100\t!r limb :unpu lee. Ph\'h\lh~'r Rn Inl ."\:~."\.'. IlN~ 0 .. \ 1\ RI t'l .I!: Lll\\er -l'\lrenll1\ ,Impulatlon" III p.l\1t'n .... \\llh diJ.octe ... : I~r .111.1 I""~I-~III)!".:.II del' .... H)n ... n·I.lIed Il) .. ul'cc ...... fuln·hahlhl.llion. !)1,\h!.·I1.' ... \ltll.lh Rt· . . Rl'\ ':!O (Suppi I):S4:" .'ill.1C'104 nliltn ·h.lm. I R . Pe.' /IIl, I L ..1Ild \ I.ll'kt'nzll', l:-J. Di ... t·h.lf!!l' de ... lin,lIll)f\ .tI1l'! ,h ... \.t,~·ul.lf 1'l\\t·f-Itml"l.lmpul.ltlf.n.... \ n:h Ph~ ... \100 Rch.\bil ~4 IN"I~ ltl(U h~~lnl<'n, \. l'l .11 I ,m er hmh ,ltHrUI,1II0n ... III SllIlIhem Finland in ~I"l(\ .\I\J 1T,:nd ... lip h) ~()O\ 1-111 J \.1,,: Endo"' .. t· Surg ~~ \QJ. \rnOl

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ehler. MR. et al:: Functional outcome in a comemporary !.eri~ of major 100\er e'(lremll), amputalions. J V~ Surg 38:7. 2003. Payne ~ I W. and ~Iark:-. MS. Trall!>tibial ampulation managemem J Re habil Res Dev -to:;\vi-xvii. 2003. P;lysanl. J. et al: Transcranial magnelic stimulat ion for diagnosis of residu:t[ 11mb neuromru., Arch Ph)' ... ~Ied RehabiI85:'13'1. 2()()..t Pinzur. MS, and Angelico. J: A feasibility trial of a prefabricated immediate po"loperatl\\! proSthelic limb syslem. Foot Ankle 1m 24:861.

2003. Pmzur, ~tS. et al: Functional outcome of be\()\I,-knee amputation in peripheral \ascular in::.ufficiency, A mulucemer re,-ie'o1o. ain Onhop

:!86:'147.1003 , S;lIhi~hl-uma.r.

S. el al: A cO:.t--efTecthe, adjustable. femoral sod.et. tempro.. the::'l:> for immediale rehabilitation of abo\e-lnee amputation. 1m J Rehabll Re .. , T ·- 1.1()().l. Schoppen, T. el al: Ph~ ... ical. mema1. and c;ocia] predictor.. of fuoct.Jocu.I oUlcome in uniialeralloy,er-Iimb .lIllpulct~-\rch Ph~ ... \ted Reh.lbtl pora~

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2("0.1

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RM.tt- ' ar-.2'J '

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UlIC ~

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C /I , \ PTE 11

26 ,

NI NG

OBJECTIVES

) "\'Ilh~ the epidemiology. pathology. pathol:ne"L'. disease COUf'~e. and common clmical 'lIk .. lalions of arthritis. IHII) the medical diagnostic procedllres 'nhlfll~

used in the examination of patients

Arthritis Andrew A. Guccione, DPT, PhI), FAPT\ Marian A. Minor, PT, PhI)

'l! .!nhritl\. includmg labor~uory tests and

'graph)'. flbc the medical management of the indi1U tl \.. ilh arthritis. er~ntiale between rheumatoid arthritis jn I

o~[eoarthriti::;.

S. kentify the tests and measure~ commonly u~cd in e:\amining the individual with rheumawid arthritis or osteoarthritis. r.. Di~cuss the rehabilitmion management of the inlli\'!dual with arthritis. [)e"cribe responses to psychosoc ial factors associated with arthritis lhat affect achievement of anticipated goals and expected outcomes. ~. E\plain the importance of a team approach

the individual with arth riti s. 9. A.nalyze and lnterpret patient data, formulate realistic goals and outcomes. and develop a p(an of care when presented with a clinical ctbe study. for

OUTLINE Rheumatoiu Arthriti . . 1057 Classl fi callon Criteria 1057 Epidemiology 1058 Etiology 1058 Pathology 1059 Pathogenesis 1059 C1Jnicai Diagnostic Criteria 1059 Impairments and Complications 1065 Disease Onset and COur.,,, i 066 Prognosis 1066

O<;teO<.lrthmi.... 1066 Classification 1067 Epidemiology 1067 EtIology 1067

The tenns ··arthritis," "rheumatism," and "rheumatoid I djsease" are generic references to an array of more than 100 diseases that are divided into 10 classification categories. Two major forms of arthritis are cons idered in this chapter. Rheumaloid arthritis (RA ). a systemic inflammatory disease. is considered in detail; osteoarthritis IDA ). a localized process that has been known in the past a; degeneralive joinl di sease (DJD) , is also discussed. Taken toge ther. these two forms of 3rthriti'> account for mOst of the cases of anhritis thaI a physical therapist i . . likely to encounter in clinical practice.

Rheumatoid Arthritis RA IS a major '-Iubclass ification within the c.:ategory 01 tilf fu"te connc<.:tivc ti,,\ue disease, that ul . . o include ... juvcnllc iU1hrilJ~ .... y')tem lc lupu . . erythcmaww') (SLE), progrc ... ..,ivc !.)\temlc ""Iem ...... or ... cleroderma. polymyo\iti ... and dl'r rnalomyo~ul,). The fir,! clinical tlc\cnpliol1 of the tll<"C'
Pathology i 067 Palhogenesis 1068 Clinical Oiagnosl ic Criteria 1068

\lli.:dit:.J1

IvlunagemenL IOt19

Ph<.lfmacological Ther..Jpy in Rheumatoid Arthntis 1069 Phal1l1ucoiogicai Therupy in O . . tcoanhrili" 1071 Surgic"ll

\hul.lg~mt:nt

Ion

Rehahllitall'.e \tin,lgl:ment

1U7~

Physica l Therap> Exum indtlOn 1073 Physica l Therapy Intervention 1077 Surnmul'~

10K I

some evidence for the existence of RA in earlier time .... Early descriptive comparisons of paticlll symptomaw\og) were complicaleci by the lack of unifoll11 agreement about the clistingui~hing charactcrisltcs of the dist:a~e. a dillicull) that persists even Loday given the wide "'pectrum of ciullcal presentations a~socialed wilh Ihis di~easc. Although the lerm "rheumatoid nrthriti . . " was lin.. t used b)' Garrod in 1858, it wa'" nol accepted by the American Rheum~lli ... m Association (ARA) a~ the official ternlillolog:- untIl IQ-ll. The American College of Rhl'umtllolog) (ACR)' former!) the ARA, has revised the oiagnthtic tcrtllllloiog) and (nh,~­ ria ror RA several tillH:S 1I11hc Ll\I.+5 \cal .....lI1i.1l'ontuull''''' to monitor thi..'111 for m.:curucy lind \uhdlly. t

Classification Criteria ClinIcally. Illl' dilfcr .... llll ~tI LllIl~IHhl .... III

R'

upon Ihl' paul'IlI'.., ""Ign .... alld ')111pllll1l' .l1ld

I'" pfI,;dll.1tl,1 \.lIdul \',L!u

. . Ion of 0111\'1 dl""'ldl'l . . \VIll'rll~1I1dul'lrl\g l'l'hkllll,)h\~ll,1I and olhl..'l J...uuh III Il''''l''1I1..1l ,Iudll", It I' lllh'll II~' l'"", 11\ It' 1(\1:11111), h\)IIl(l~l'IIl'IIU" 'Ioulh Illilldl\ Idu,ll \\ IIh 1\ tlllh h . . 111111;11 'rglh ,Hlll '\1111*'111' 01 K' '1\\11 Ihl \\111\' I ~ 1111111111 ~ IlllIllIl Ph·""· I1I.tUII" . . '~'~11111 till dl ,1,\ \ltlwu h

10 S

PI"''''.(,81 RdlahiliLJlion

nthl.'r ... ~" 01

1I 11":1 1.1 ha\\.'

I,:i.I"lIll'aIIOI1 \\hl'th":l .111

L'lllIlHl'd

uitl'II,\

l'\'I'll'd

101 1111'" pili ptl ...l' , Ihl' A('I{

,Ill' lIlt"l o11L'11 u ... ..:d 10 dl' l l' l lIlIlll'

Il1di,idll,Ii\, l:lillKill Pll''''CllliitlOll ... holtld hl'

;h ,I L',I'~ 01

I{ \ I'm

1I10 ... t 01

the 20th

cen l ury. 1:11

len,l h.ld al hm ~d hili!' L'la ... "IIl::l1tOI1\ of RA ' cl" ...... lc:ll. de l lillie. J1mhahlc. ,lilt! pO"lblc. I'he laller two dc\ igIlOltIOIl\ '\\.'r~ ~'l"lltu.lIl) judg~d

10 be prohh:m
Epidemiology TIle "typc" of RA a person had at the lime the epidem iologIcal survey was conducted. as well <1\ Ihe criteria lIsed. can complicate the calculation of prevalence ratcs. It has been e ... timated Ihm the prevalence rate of definite RA among adulu.. in the Uni ted States is approximately 10 cases per 1000 people. or approximaLely 2.1 million persons.' RA afTects women two to four limes more often than men al all ages ..1 There i\ a general increase in prevalence ror both

"'l'XC'" Wil lt Illll l'a"' ln~

age Allhouph RA r"lounci around thl world, lhere '1Il' ... Ollie dtfl c rcllLcs IIlthl' rrcvalcnu.: 011('f\ III I'l' lt;lill \u hpopul i.ulon". Whl lh "U!!gl'..,t .. a po\slhlc role for gCllct il: or crWIIOlllllel1tHI hKtor" 111 the et iology (If tin' dl _ C
Etiology Like many othcr chronic di c.,ca ... c~, the etiology of RA I. . unknown. Current re~earch into th c c"uc.,c~ of RA i" ba"ed 011 a complex. hUI as ye t incomplctc. appreciation of the functlon\ or Ihe immune ~y.., t crn. Briclly. an antigen", il c.,ub"tancc. uc., uu lly forclgn to the ho ~ I , whi<.:h provoke... the immune c.,yc.,tel11 into aClion. Thc illll11une ... ,slel11 may rec.,pond to the antigen dlreclly (cellular IInmunlly) or h)' the production of ant ihodiec., thai circulate 111 the ~crum (humoral immunit y). Th c~c rc.c., pol1\c.., Involve two genera l kind e., of' lymphocyte..,: 'I ce ll .... which .ue rc"'pon"ihlc ror cellular lInmunit y. and B celie.,. which produce cm:ulating untibodlc ...... peclfk to the antigen. Antibodlc arc immunoglobulin ... , a type of c.,erum protein. I Ba\cd on the fact that individuab with RA prndun: antlbcx.llc~ to their own immunoglobulin .... there ie., \omc rC<J.\On 10

Table 26.1 The 1987 Revised Criteria For the Classification of Rhe uma toid A.-thritis

fl

Criterion

Definition

1. Morning stiffness

Morning stiffness in and around the joints, lasting at least one hour before maximal improvement.

2. ArLhrltis of three or more JOInt areas

AL least three joint areas Simul taneously have had soh tissue swelling or flUid (not bony overgrowLh alone) observed by a phYSician. The t4 pOSSible areas are rlghL or leh PIP Mep, wrist, elbow, knee. ankle. and MTP JOints.

3. ArLhrlLis of hand 10inLs

AL leasL one area swollen (as defined above) In a wrist. Mep. or PIP jOint.

4, SymmetriC arthritiS

S,mulLaneous Involvement of the same JOint areas (as defined in 2) on boLh Sides of Lhe body (bllaLerallnvolvemenL of PIPs. Meps, or MTPs IS accepLable WILhouL a so Le symmeLry)

5. RheumatOid nodules

Subcutaneous nodules, over bony prominences, or extensor surfaces, or In Juxtaar I regions, observed by a physician.

6. Serum rheumatOid facLor

Demonstration of abnormal amounts of serum rheumatOid factor by any method f which the result has been posItIve in 5% of normal control SUbJects.

7 RadiographiC changes

RadIographi C changes tYPical of rheumatoid arthritiS on posteroanterior hand ]nd Wrist radiographs , whIch must include erosions or uneqUIvocal bony decalc,flcat localized In or most marked adjacent to the Involved jOints (osteoarthritiS cha!"ge alone do noL qualify)

From Arnell. FC,~ p 319 WIth permiSSIon For claSSIfication purposes. a patlont shall be saId to have rheumatOId arthntls II he or she has satISfied at least four of these seven crltorla Cnteria 1 through 4 must have been prescnt for at least 6 weeks. PatIents WIth two cltnlcat dlagnosos are not excluded DeSIgnatIon as claSSIC, deltnlle, or probable rheumatoId arthrttlS IS not to be made.

( h.. pfl"r '26 \rthntl Illilt HA I Ilfl fllllollll""U/1 th\4)Jdcr II I~ nol deM, r Yo hClher Ihl ItIlihody procill!.:IIfHl 1\ ,I pmnar) C\'CIII II II' ,POIJ'ot.: III" p..:,IIII'; .mllgt·nlroll1 iln exll:mal II (lIff /II 'hrflr)' ,111(1 r..: .trth 0" Iht: lcllular h,I'o'''' 01 Jlcl 11111111/ 1.,. II '!!{' Ilh,'I •• I-x-rr,IIII IUfl(': IIfmlllg or ccll-mcdl ,,111111111'1' ,U11! ddi.·l IlH' I IYl11pIJlK.yte" may trigger Ihc 11111111 I IJClIJ 'iC Ih.11 tJlulnlac\, KJ\.' A "'JlCl:ifie ctio~ I I 'n l 101 RA ha\ not htTn ulcnllfitd , even thou gh r h .• vi. /)0.'('11 ,thll' to lIit'nllly lhat \peelfic external ,I I" ")'l'nl 1I1i.l y produu: an mflilll1malory arthralt\, for ( 1/111 1,.\ Illl' di,clI,c . 1 hl.' ( h ~ea","' that i, finally man ir I I III" /11 1II01l' dl'Pl,>fHklll Oil Ihe hO\I\ manner of f( I" II Ih,HI CIII 111l' "!.!l'l1l DI Ihl' IlIcl'lwI II ... m Invol ved, I Ill(: " " ~'l!l' ''' I \ ,h.tt a Viii icly 01 agcnl'" may initiale ,1It111 1 rillnu!.! h \\eight ill c urrent thel)fIt', I'll till' p,llhngcnl'w" of RA. RA occurs in the ab ...c nce ('Ir Rr III .1 ,ull .. tantlal numocr of illdi\ idual .... Individua ls \\uh R \ . h~l\\~\('r. \\ ho do h~,\·c RF. or \eropo~itive di ... · l he. h.'\l· ml·I\.·~,'etl frequenc) of ... ube utancous nodu l c~. \J,,"'uhu,. and pol~ artICular il1\ oh·e mcnl. l Rio; ent ,tUJh= ... ha\ c al'>o \ought to e ... lablish a genelic pre· 'Dl bon to the de\dopmel1l of RA. '" Human leukocyte ;·n, HL-\} an: found on the cell ,>urface of most human , and.in: ~JP3ble of g.enerJting an immun e re~p o n "c ~ u .. a1I~ m("ompatihle lIs,>ue'" are gmllcd 10 each .,. ~ e\ampk. during organ tran ... plants. Genes control~ HL-\ .ire found on the ... i\.th chromo,>ome. Four " h
I,·

" 0 R" heen a"oclaled "nh mcrea.",d HLA·D and D D re.lIed antJ!!cn'. u~[!e ..ting lhal certain genes mer a m~;e or Ie" . . a[ ri ... k tor an

m,;t!

.~i>Of",,!hal lead 10 RA ' A ··rhcumalOid den· rICd Ihrough D A I)pm~ liLA ·

or

1059

progre~.. um \anou.. ludle of JIlJerenl ethnh. ~roufK ha\.-e .11"'0 ho\\n Ih.11 panu:ular \'i.iIJallCJf"I 01 the HI \.DRfP allele
Pathology Long -\tandmg RA i... charaucfI/"t!d h) the gm\ Iy akmatou ... appearance of the ,,) nO\ illm v.llh \Iender \llIou" Of h;:ur-Itkc projcction\ mto Ihe jomt ca\.lIy. 1bcrc are dl\hnc live va<;clIlar change .... including venou\ dl ... lcnllon. ci1plllary ob ... lruclion. neutrophilic infiltration of thc ancrial wall .... and arca') of thrombosl'" and hemorrhage. S)nO\lJ proltfer. over the jOlllt cantlagc. Eventually. if RA continue~. the granulallOn ll~ ... ue v.ill result 111 adhesion ... , fibrosi'i or bony a nk) lo'tjs of the JOint Chronic inflammalion can al ... o weaken the jOlllt cap ... ule and II I:. supporting ligamentou s structure .... altering join! structure and funct ion. Tendon rupture and fraying Icndon shea th<; may produce imbalanced mu ... cle pull on Ihese pat hologica ll y a ltered joinls re!>.ulring 111 [he characteri~tic musc ulo ... kelctal deformitie!>. seen in advanced RA. .~

Pathogenesis T he key fealures tha t differentiate synm;ial joint ... from 01 her kinds o f joints arc exac tly t ha~e feature ... that make them susceptib le 10 per~istenl inflammation. Rapid change ... in the cel lu lar con lenl and vol ume of the synovial flUid fallowi ng a lterations in bload flow arc possib le owing 10 10\\ press ure in Ihe joint space a nd Ihe lack of a limiting mcm· brane bet ween the jo in t s pace and the sy novial blood vesseb. Hi gh mo lecular we igh t substances such a ... m acrog lobulins and fibrinoge ns can pass through the \ynovial cap ill aries during periods of in ll ammat lon and are nO I eas ily cleared, I Because the can rl agc i\ ava ...cular. dCVl'lnpmcllt In c<;labli ... hed ... ynovi ti\. polymmphuIlUi.'IL·,1I (P\IN) leukocytes arc chemotactically dra\\Jl Into thl' 10m 1 ""'\ lI\ and conl ribut c to Ihe II1fiHlllllldtnr) dl· ... IIIIl"IIOIl 01 IhI..' ,\11 OVIUIll. alrhough the cxaU mr:dl,lIl1"'m of 1111'. (k· ... lrtll'tlull I unknown. It , ... kl1()WII thiU Ihl' 1)' ... Uo.,Ollhll "II/~ Itll' .... ,,11I~ h arc rcJci.l ... cd from the \c Jl'Uk.Cll·yll·\, rilll dlll'lll~ 1Il11l1~' ,,1\ 0\,11.11 II ... lIC ... . 1 HI

-'-','-_.wI \eqOCflCe of ammo acidi common

rheumatOId arthnll

Further "ud.c


!be liLA [) reg on pee f,.ally !be 1lI.A 1)1< B f gene and ug modIfy d ""'''' c.pr ••", und

C lini cal Di:lgno,ti c ('rit('ri" IIIl ,lInlc,II cJt.IVIIII I "I I{ 1\ I h,1 II 1111 t.lIlllllllll1 Hit I 1110/1 uj IhICC' 1.111111 Ihe ~ Iilll~.d I" ('111. 1111111 ul Ih

l()f,O

Ph"ical Rehabilitation

p.lllelll. v,hu.::h I' ellu.::ld,lIed th ro ug h ill ' lOry- Ia"ing and ph}'IGll e\i.lmlll;}tlt'n~ thL' L·ol1l1huri.ltln g cvidclII.':c gat he red through laj:)(,'r~1101! I~"h .1I1d r,llhogrnp hy: and the c\c lu,Ion 01 other pO"lhlL' diagno . . c .... 1.1j

t:au..,cs lhl: cap ... ~"c Hnd the Iig:'lmcnt ... to become dl\tended and Ihllllled . JOint Sll rfuce~ may be eroded until the \houl. de r even tu ally become ... un ... table. In addition, lendiniti \ and burs itis may complicate management I Elbows

Sigm and S),mptoms S) "'Itemir \ tanife"'ltations \I or"'"~ .\lIUness h'\tlllg more than 3 minutes i" a hallmark ,~mpl\.'m of RA . Diffic ulty in moving upon awaken ing and g(.'neraliled ,t ifrness de~p ltc morning activity help 10 d ifferentiate thi .., ... ign fr0111 the ~ tilTness or a pa rti cu lar joint ... cen III o,teoart hriu":. follow ing inact ivit y.:! Morning sliffne ...... can be qualified in terms of its severity and durati on, both of \\hich arc directly related to the degree of disease aCll\'lIy. As wi th ot he r system ic di seases, anorex ia, weight 1m", and fatigue also may be present. 1.2.11 Joint In\ohcl1lent RA i~ mar"ed by a bilateral and sy mmetri cal pattern of joint involvement. C lini cally, th e pa tient presents wi th immobility and the cardinal signs of innamm:l.lion: pain, rcdne~.." swelling, and heat. I The term arthralgia is used to refer to pain in ajoint. nlejoint examination also Illily reveal crepitus. whi ch is audible or palpable grating or crun ching a... the Joint i... moved throu gh it!o. range of motion (ROM ). Crepitus i ~ the re\uit of uneven dege neration of the joint \urface.

'en icul Spine The c.:crvical "'pinc i... orten involved in RA. 12.1' Th~ atlantoax~ ial jOint :md the l11idce rvlcal region arc the most common "' lle.., of inflammation, whi ch l e~ld , 10 dec reased ROM , parlI c.:ularl y 111 rotali on. 50 pe rce nt 01 which ta"es place at the C I to ('2, In vo lvemen l of th ese two verte brae Ill ily produce IIfc-lhrcatel1l11g ... HlIullon ... IIlhe lrun wcr,c ligamcnt of Ihe alia, , hould luptUn.: nl if th e odontoid process should frac· ture or herniate Ihrough Ihe foramen magnum. M,lgIIL'!JC rc ... nnall<,:C Imaging (M R I) I, parlu.: ul arl y 1I,l.'iul lor \ ISIIUII I Illp huth the ",plllal colUlIln and Ihl' l'ord 1.1·1 Allk}lu,illg "'I1)IIfl(J}lili, I' all IIIf1 ulIlmatlun of ~l l ll' 0 1 lIIore Vl'lh:hr ac 01 Ihl.: ' P"ll.· Ihlll lIIa y :IlTOIII(l:III) Iheuma tOI(l c!i<.,l'a,C 11 Plllll~llIly alll.'l·l... thl' s.lno di;IL·, ' plllal bl'l: I . illlcll'I, ... l ovl'r l l· ht;IIIIHIlI 'l, :11\(1 r)j n~'ll''''l'' III l'\l' l1tl1:1 1 h hWl 1 (.llIkylo" ... , 01 Ih . . 1I1volwd 101111,

Inrlammal ion, ca psular and ligamentous di\ten\ion. and joi nl surface erosion may lead to elbow instability and irreg ular or catchin g movements. Flexion c.:ontracture~ fre, quen tly deve lop, the outcome of per~istent spasm \eCond. ary to pain.1.I6

Wrists Ea rl y sy novitis between the eight carpal bones and the ulna leads to a fairly rapid development of a flexion contracture, which ult imatel y d iminishes the individual's abilit) to execu te power grasp. Chronic in n ammation of the proximal row of carpals can lead to a volar sublu\3lion of the Yo ri .. t and hand on th e radius, accentuating [he nonn al 10 to 15~ of volar incl inati on of the carpus on the distal radIUS 1 Fi£ 26. 1). Chronic inOammalion lead::, to the loss of radiallig~ 3mentous support and destruction of the e\.ten~or Carpi uln aris and th e fibrocartilage on the di~tal ... ide of the ulna. The attenuation of these restraining strucrure~ allo\\", the proximal carpals 10 slide do\\n the distal radiu, to\\ard the ulna. creming a radial de\·ialion of the dil.,li.l1 ro\\ of clrp3.h in the wri~t relative to the t\\O bone, arthe- forearm. \\here normall y there are 5 to 10° of ulnar dc\iation (Fig. 26.2 ~ Stc n o~ing teno~j no\ iti, of the fir.t dor-al comp:lltment l" the \\Tbl (deQul'n'ail1' ~\ cii.H'CUe) IlU~ J.bo ()(.~('ur. Hand .Joints ,\1 l'ca cnrpophnlangl'ul. Soft-ti~su~ ," cHing .u('IunJ tht" 11ll: I:lcarpophalangeal (\ Iep) jOlllh i ... \ er: c<.)mnll'" 'f1l(' Hllar ~ub I1l\ ~U l011 and ulnar drift of th(." \lCP ... frc"lu~nth 'Cl'l\ 111 R \ art' thought to J"l· ... uh fmm .l\,:\,.'('ntll.\th,n \,It th..~ normal ,trm'\lIral .. lhlpt·, ~lf thl"(' j\)inh th,Ull1t IhI.' ,~n'\lm,

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)

Weakened lig:llnellt\ canna I rc\i\t a pull toward vo lar \ ublu\.Hlon Juring power pinch or grasp when flexor tcnd oll'\ "bo\\ ~lfing" acro\~ MCP~ through frayed tendon sheath, damaged by long- term !,y no vil1!,.16 The bowl)tring effect n:~ul" from moving the fulcrum of the nexor tendons di,,tall) v.hich places an ulnar and volar pull on the proximal phalanges (Fig. 26.3). Radial deviation 01 the carpab will fUr1her enhance Mep ulnar drift as the phalangc~ try 10 compemate for the 10l)s of nonnal ulnar deviation at the \HhL This is known al) the :;J.::ax effect, where forces in the

I Jr()):;mfli /1I1 l!rpJlll l flll J; I'fl l . SWCIlIIlV oj th c proximal 1I1tl.!rphalilllgcai (P IP, JOIIII, producc, a lur.,1I11rm or '\au\age" like appcII/anee 111 IIlI.! 11J1 ~cr'. ~I here arc two charattcri . , ti c dcIO"llIIJC ~ 'CCIl allhc PIP IIllllcJlvldual ... with RA. ci he fir.,t 01 Ihco,c i.., known a ... ,wan neck deformity and conl.,J,h of PIP hype rcxten.."on and d"lal Jlltcrpha langeal (DIP) rtexioll. Swan neck dcformllic\ an'I-C III three d"lIm.: t way'. depending on the ,He oj Inllml IIlvolvr

men!. 111.21 M()~t t:ollltnOll ly. ,wan nc<.:k deformity \ollow, from ini lia l "iynuviti , of the Mep. whe re the pain "j chronit ,ynovili \ lead, to reflcx rnu,dc "'pa,m 01 the intrin,ic (Fig, 26.4). The blomeehanieal fort:c of the 1I11rin,it:, then com binc\ wi th the hypermob ilJt y found in the chronically inOamed and ,lruClurally changed PIP. rc,uhtng JIl volar sublu xa tion and PIP hypcrexlen\lon. Swan ne{;k dcfonnllY may al"io re\u h when the vo lar capwle of the PIP I' stretched. the lateral band, move dOf\ally. and ten .. ion placed on the nexor digllorum profund" by the I'll' nexe Ihe DIP (Fi g. 26.5). In the,e InSlances, a rupture of the flexor digitorum ~ubltmu\ further predi\po\e" an individu.sl 10 \wan neck defonniLY. A third mechanic.,m for developing swan neck defonnilY involve ... a rupture of the cxlCnsor dig. ilorum communi" at it, in\CrtlOn on the DIP rC!o.ulung 10 DIP flexion and PIP hypcrexlen,ion owing to unrc= .. trained pull by the nexor dlgtlorum profundi, (Fig. 26.6). ' The other characteri,tlc defonnity of the I'll' IS known a., a boutonniere dejormit) and con ... ic"lS of DIP extcn Ion v.ith I'll' nexion (Fig. 26.7). As a result of chrume .}no,,· tic." the m...ertlon of exten\Or digltorum commUIlI\ Into the middle phalanx (known", the central itp) Jen~thtn • and the lateral bands ,Iide volarly to rorce the I'll' Intll neXiOll Bon} faonation or outgrm,-thli around the end cf d Juml atC

F

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Ulnar

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Figure 26.3 Inl1uenc..:e I)f the long flexor In mCla... arpopha· IMlgeaJ dnll deformll) I Adaph:J lrom \lcl\ In. J. 6 P 2M 1 v.lth Pc'nnL" lon ,

Figure 26.5 S .... an nc I II prf' Imal nlaphalan J toml p 2 " \\ Ith pcmu Ion I

( A,~""

1062

Physkal Rehabilitation

//Ililiialls-type deforlllity. Also known as opera glass hand, the

Figure 26.6 Swan neck defonnilY with init ial synoviti s at the dista l in terpha langeal jo int . (Adapted fro m Me lvin. J , lb p 287. \\ ilh penni ssion.)

temlcd osreophyres. Th ose found tt l the PIP are kn own as BOl/chard's I/odes. ~\Jld may be seen in OA. They are unre-

lated to RA . ail hough an indi vidual may have bOlh kind s of arth ri tis at the same time. 16

Distalillterphalallgeal. The di sta l interphalangeal (DIP) joints are most often uninvolved in RA. OsteophylCs are, however. common in OA and are call ed Heberdel1's nodes. Occasionall y. the tendon of th e ex tensor dig itorum communi s wi ll rupture. and the unopposed pull of the flexor digitorum profundis will pull the DIP int o fl exion. This condition is known as mallet finger defomli ly.16 Thumb. As in the other digi ta l joinrs. the primary ca use o f defonnit), in th e thumb is synov ial swe lling. The fibers o f the dorsal hood mec hani sm ove r the MCP. the joint capsule and the collateral ligaments. and the tendons of ex tensor pollicis brevis and extensor pollicis longus are particularly affected. The exact mechanism of thum b defomlities depends on the particular combin ation of affected stru ctures and may be class ified accordi ng to the criteria elaborated bi Nalebuff.2·~ Similar to other hand deformities. th e actual presentati on depends on the si te of in itial synovi ti s, the di rection of imbalanced mu scle forces. and the integrity of the surrounding joint structures. A f)pe I deformity, consisting of Mep flex ion with interphalangeal (IP) hyperexten sion with ou t involvement of the carpome tacarpa l (eMe) joint. is most commonly seen. Type /I defor//lity is ass igned when the CMe is subluxed and the IP is held in hyperextension. CMC subl uxati on and Me? hyperex tension is class ifi ed as a l)/Je III deformity , and is more commonly fo und in RA than a type II de formi ty. 16.23

transverse folds of the skin of the thumb and fingers resemble a folded telescope. Rad iogrJphic study of the bones of the hand reveal severe bone resorption. erosion, and shortening of the Mep, PIP, radiocarpal, and radioulnar joints especially. TIle negative impact o f this deformity on hand function and activities o f daily livi ng (ADL) is significanl. ' 6 Hip Although patients may present with complaints of pain in the gro in, often owing to trochanteric bursitis. the hip is less commo nl y invo lved in RA than in other kinds of arthritis. Radiographic hip disease is seen in about half of all patients with RA . Severe inflammatory destruction of the femoral head and the acetabulum may push the acetabulum into the pelvic cav ity. a condition known as prolrusio aCetabllli .I. I ~ . 16 Knees Because of the relatively large amou nt o f synovium in the knee, it is one of the most frequently affected joints in RA. Chronic synovi ti s results in di stens ion of the joint capsule, atten uation of the co llateral and cruc ime li gament s, and destruction of the joint surfaces. Painful knees may be held in sl ightl y fl exed positions, ultimately res ulting in fl ex ion cOlltractures.t.t5.16 Ankles and Feet Chronic synovitis accentuates the naturdl tendency of Lhe talus to glide medially and plantarward, resulting in pressure on the calcaneus and leading to hindfoot pronation. The spring ligament is also stretched by these occurrences, flattening the medial longitudinal arch (Fig. 26.8). The calcaneus may erode or develop bony exostoses known as spurs. As synovi tis weakens the transverse arch , the metatarsals spread

Mutlums Deformity (O pera-Glass Hand). Grossly unstable thumbs and severely de fanned phalanges are indicative of

Figure 26 .7 Boutonniere defonnit y. A. Synov iti ... of the proximal interphalangeal joint: B. Osteophyte, at the end of the joi nt (Bouchard's nodes); C. Rupture of the central tendinous sli p of the ex tensor hood. (Adapted from Mel vin . J.lt! p 287. with pemli ~' ion .)

~igure 26 .8 Posterior- medial view of the foot and ank le ~how· mg cal caneal v~lg.u s, pc\ planu\ (natfoot) and hallux va lgu".

( U~ed by pemm'llon of the Arth riti s Foundation.)

Chapter 26

Arthriti~

.06]

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Figure 26.11 Common defonnitic\ of the rheumatoid font. ,L',ed b} penni'),ion of the Amencan College of Rheumatology.,

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Figure 26.9 \IJJllr k)l,)t md ankle defomlitJe .....een in rheumawid :uthnu .... From Dlmonte. P. and light. H. P 11-1-9. v. ith f""rml ..... ICln

and a 'pla~ed forefoot (spla)JOot) rna)- de\eJop (Fig. 16.9). S~n()\Hi' of the rneta[ilI"\ophalangeaJ (\tTP) jomb i~ e,rremel: I.:ornrnon and mel(J[lIrslI/l.?iu (pam over the ~wtar\al head" rna) develop. A Ill//lm \"(/1~lu and hUlIlon 13 p.unful buf\11I ... o\er the medial a.. . pect of the fiT'lt ~ITP .lOmb rna: al~ be pre,em. \\''hen \ olar ... ublu'\alion of the \lTP combme, \\ Ith tle\lon of the PIP and h: pere-,.ten~ion of ';e DW jOmh. thl' ...:ondltion i:, commonl) referred to 3!-! hammer roes {Fig. ';6.101. The \1TP... rna: abo e\hiblt \olar

F"l9l1re26.10 \t tal rsophalan:-eal ublu:\lIlon. l~db) per th.;: \rr: - em ("lIe~e of Rheumatoh...gy ,

Ijubluxation of the metatar;al head \.I.ith flexion of the PIP and DIP join~. known a.~ cock-up or dun fOes (Fig. 16.11). A~ the capsule and intertarsal ligamenh are v..eakened and stre tched, the proximal phalange":. move dorsally on Ihe met31an>a1 head (Fig. 26.12). Similar to conditions observed m the hand. the long loe e"ten~ri .. b()\I....tnng .. over the PIP jomt~ \\ hlle the flexors are displaced mto (he imertar"aI space .... 1~.16..::-1~

\ 'Iuscle Imoh emen l J\lu~cle atroph~ around affected joinr... rna) be pre-.em early . II is nOt definill\el) kno\\n. however. \\hether this 3troph) i... the re:,ult simply of disuse or ,electi\e attrition of mu,cle ... 0\0\ ing to some unkno\\ n mechanbm "pec.:ificall) related 10 the di~ease i[.')elf. Atrophy in the Intnnsic muscle, of the hand and the quadriceps are particularly c'\'ident m long.. tanding disea~e. although the mechani"m ... for the-.e change" rna) not be thl! ,arne. It appear-. thai indi\ Idual-, vdth RA experience -,eleetl\e attrition of t)pe II Ipha,il:) muscle fiber" Ihrough some unkno .... n mechani ... m. .,There I~ also some c\ ide nee that type I (tonic) mu,c,;\e fiberi of the quadriceps v..ill undergo ,eledl\c atrophy follo .... mg antt!f1or cruclate Jamagl!.2i1 Lo, .. 01 mU ... I.·!e bull rna) J..!')o be

FlgLre 26.12 Relll or ,t trLI. ures II the metatarQ) heads 10 mctatan31g1a (F ~ \1, ,J\.~. C ...old Shields. \1 . P 10. "" th penms

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111

'If 1'1,..

,I IIII/IUIII.IIIIlII.III)I )' .1111,,111

!J.II'! wuh no dl"t(.'il ... l' A p
I" J

ilIIJ mil

.11111111" .... udl .1' IV\

1)() ...

tHt I

.111'" III I IKIIII 11111' III

.Jlllt, IIIfn 1J/lII ,Iflllllll

I

I'j

11111111/

tht: \.()n\.C.'pt c.ll the: \(ll\lfll'fl\' 01 .1 1c.· ... I, \\ 1m It IIltllc.dll" the I'fllpC.mWIl 01 II ul~ lh,e:,he:d Inll1\ .du,lI, \\ hn 11.1\ l' .1 1)0' 1

"' 1111

II III

.tIl 111

1111111'111 .lllri 1111 III

11Idll.lk~ 1,111 11111. III • l"IIII1~1

Lab0r310n h',IS

""

Iltud

I

1"111 111111 I

j

( ' I ~u.... ti.llf I'll til It. HJ(" 1III .. luII ul 10" ' '''I"Ihl.1 \ •• 111 f ...

II"" 'I 'Iu fl . 1 11 1h I NI~ III

Inll 1t\1 I II 111,1\

\ltlllullll).'HI1Ilil I

1111111.1111'11

1{, ldl lll' l ,l phh ,'111\1111 pi II 11111'"11' I 111,1)'

",h

'I\I ~" II . \hllll l I 1{, ldh 1f'llll,hll ,\ hll'll\

1

III ~,· It 111'"II'd

!I~'''I ~\tI'l h~~lhh ' IIII"\) 1 III IHh 11111\

I'"

dl' 1\11111\\1\ ILI .'\ III

Nil \111111

I"

01

Iq

wll h 01 1111,,"1 11 )) "1 1 Ilitl. I

I III

.dllll!lI jl h 111I111,ltllIlI II I 11111,1 t",,!tll

ddpllllll h

11\ 11111\ II\, j\11",rnt

\111 111 1'111 HlIl ~\ II, 11 11 HPh \ 1 \111 1 ,l llh Idlll '111 11 H "~ III ' t\' ·.llI tI ~ ~Ih "'IHI'I\ II\~\

III . .

Ii

11'41 111111111

Il nil

nlll\ hl'I'H""'1II

:-'Iu~,'

I

III . ~1 \ '1 ' 11\ I\,U1!11VHlphh 1'1 Id l'IlI\' 1. 1 \ ,1\11111 1'111 111 hlilH' II, .11111 1\\111

,llIdllil''' 1\1 \1'h'\lI'I!I\" I ~ "III h l l ~ , 111 1111\11111111. "IIUII I II I lull'"\ "I 11\ P,'h'\h' .. .. I~II\ . \\ 111111111 ""l illi', III h,," \ I HI~ \ III I

1\\

I ~",' , I,'" "t th,' "'1\\',,, Ilh, 11.11 ,1\ I~' II .. III" , \ '" ,t I', 1, '111 11"11'11 \11 Ilh.' \ U\\' I11 ,Ill

11'1111,11'1111 11111 \

\11

II' .111111'l!, I \I\" .11111. II ItIl '111 111 .... 11(· II ~ IIIII .... 'iH It ,I' 1111.111 11

I I \h'II'''I' n\\\ "

',,',,'111\11\11\' ,lhfl\1\\" IU.

h,' 1,' \1,' ..'

t ','

\'

\

\

'

.1\,"

~l l lh\

l'I\I\IIIl,II.llld dl'I,lI l ll llh.· ..

" tlh' lI tl\II1II,II '11,111,11 ,,·1.lthlll,hll"

.lIh l

"t ~'II,' ",, \\\'11 "llh 111\," "1\ ,{.-\\'II\ . 111 Ilh' .lb"~'\1,~· \,1 tI,ft't) ·

":\' 1\\,' \ 'lul.I":\.'

~", ,'It h ' l

1~\llh'

'f'''I .. ' h ' l.\ d ,\.' ','II"'" h.\I \'I' .h l\l,' ,\1\11 JIlIH,\ .Ind .1J'\W.1I ,',,' , ,t., r ,1'\1 1,'\.1 Ih l \\ \I ~lh\\tt rh,' \." 'llh.'\." 1,1 \.';I,' h h'lilt' .11'l'l\'l'".tll'i\ Ihh.'L ;Iml \\\'11 I.klllll,'11 " . ,' 1 "~l '" '\U 1\'U1"hll~ th,' 1"IlU' .. hnuld ,',111"'"11 h' '.'\ 1 ,'1,th'IH l,.II ,h.ll'· I'h\' Ih~·I.ll'I'1 ,1l\,\\1,11\"!1.· .111\ \.' ,t"IIIlI'1.

...

".,' ," . .·n m,,~ \.'\ I\kl1l

"ll th\.' 1.hh''.~!I.\l'h Ih.1I

Illl!!hl

":. I\' ll 1·: ll.\I1\. Ih\' Ihel.ll'l'l ,h,)llhIIHlI,· \\IWIIWI ,',' , ,'\,' n ';\\\,.' 11\::,1 ·1\\(.....·1\ thl.· .1"1111 '1IIt.h.' t"

. . . "\. " ,tt" . .·\1t

l unl·lI.

'l',k'Ill~ '1l~~1.·'1' 1("'(lf''.l\ltI .l ~l·

, 111\' \,'11\1 ,urf,k','" l)\l·I.111. Ihl" J"lnt ,mLI\.·l'

,lll'", ,hnllid

q , 'lh ..I 1\.t \.~ ,'nh'nn h' l-..Ih'" 11 ~Ul.lh)Il1t\.'.iI ,luJll' "lIh

\ ' .' . . ," t..' , 11k' l''''':!l\.'''I''11 l"f Iht' dl't"I"'C 1';11\ he (.·h.11' "~·,",,,·,t J!"l1::' h'ur

,I.l:!t.·' f"IIt,,\ 1Il~ Ix·nodll.' 1.lda'!!1 ;Ipllll..' ... \ "11.\11\"11 l Rl'\ .:(, I t The I.ht\()~r.lpllll: dl.I1l!!t" ,('ell {':If\ If:

the ,h'C.l't' ,\ '1l("lIl'('X.'I.' lfu: .•Uld ll'\I.III~ 11ll1lll'd hI

, .. I-f III

th,' ,um,undlll!! 'I..,n I1"Ut'"

joinl

('ITu:-..illll.

;lI\t!

':\..i13Jt (uLIT d t·Il\IIlCr.lltl.llll)l1. DI;lgUO,\lI(' (',mtirll\;lIH11l I ~ "3: 13."'1 fIn" t ncr III 11k' dhC;I'C pl,~e'::. "hen Ihe I)

' l'J ':c tum)\\ IIh! .H1d ......"'tr

h·I\II ... \

11w 11"'1.11'1'1 ,IH1I1hl

t.·(l'hinn . . Illihe

I1k';!1

h~lI1d . . and kt'l ,Ire

~ thl~ \.h.lf"J.~tC~ .. tK' hli,ltcr.ll dl,trihulion,I .~

Unpairments and Complications

"ltllJ,l'

i

v. rn R·\ are h:"

I'.

II" """ I t\· 1'11· ... "1\ 1

n ' 1'1II11111 1

I 1 11111111'

P I "1~1I\ 1111",

, l

lit

1111'11.1

It""

f

III

,hWI'

1,,1111 SIiHUll.1, hl'l . "hl' l'~ ' 1, ulld H I~" U "IIH (, ' d ~ 1. 1'111111'1 1111

1,11\' \1'11.1111 I h, ,'u,,", I'd 'I . \1\111111' I 11111111,,111111 \1 1,ltlla PIKK . " 'I H, \lllh 1" .,11" ...... 1\111 11,,' '1''

tl"' I I. II1II1 ,1

Ill'

1'"' ~I' IIIClll" " 'I\II I I , I "III,UlItUi

01 II

1'00111'UII1I

.HI\ \, ,1111,1\1,11 \"I~{' ~I ' I' I ' hk

hUI I" \.·\lIlI I"'IIIHk-d h, 1I1.IIk-qll.II ,· Inl'" lit 11.'l!III '1I ph ' ·... Il'.11 .11.' 11\ II, ~., 11 III .Iddlllll ll \11 IllI.' d l.'umd clltllUIl !! (11 Itl ill.ll\ II).

, lud1l.." ,)1 hn~h

nmlpO~ III1 l\l III Il1dl\

, lhl\\11 .1 1I1 .I\}..l'd dl·gn.'l' 01 111.1 ,,)

.\Ill.! l'l1.·';III.'d

nlu.tI, Wllh RA hll\\.' hod\ l'\Pl' lIlhll1ll' II ilPPl·.1I

((/11/('\/0

11..·'IiIl);! l'Ill'I);!)

(\\!II" IIII ~' 01 It:;ltl

Ih .11 11111111 1111..' .... ) .. 11.·1ll arll\lI) ,Iud Hlll .I IllIll;t!ion l'\'l'1l

1Il1l11h

'ldu. tI .. "1111 o,I(,II'lhl) \H'II rOl llmlk<1 dl ~l·iI'l'. l'tt..'a1t..' illl Illl..'n,':t'I..'d tl1l..· 1 . lhoil~1I1 " lilt ... uh . . l'q III..' UI 01 il',1Il hod)

1\"..,

11 .... '1I\.. , I'

Rh<'ulllu(oid Nodule. RllI'1I1ll:lI old

l1oduh~ . .

arc the tllo..,\ l ' Olll1ll011 L'\ I!';\-,U IIl'ul,lI 11l;lIlik~llI l i\lIl' 0 1 RA :l lld OCC UI' III nppn1\tlllltl('i) :!~ I'k.'r t'l'nl nfpalkllh. T hc) arc IIIOM 1..'0111111(111) lound III thl' .. uh cll lallenu ... or dl'cpel' Cnt 1l11.·C! I\C 11"lIl· . . III area' ... uhll·l·ll·d In rt..'pt';lIcd llIechanical prC:-'~lIrl' "'Udl u... Iht..' llk'l'I.l\wtl OUl ..,a\.·. Ihe l·\ lcll . . nr . . url~H.:l' .... 01' Ihe fmcann ...... lIld Ihl' \dull l" !('ndnn~ . Nndulc . . arc lI"'IHlII) :I,) Ulphllll.ltK •• Iltlhlll).!h lhl" \.';\11

Dl'CondillOmng

\1\1\

li nt!

hc Icndcr alld I1UI) t..';HI .... l· .... I-..HI hrl';lhhm II III 11I.,·\·I)Ull'

III I"l't'l cd, I rh~ ,u.:~lll~ til «(~lnJlorc . . ptr:.ilOr) .. 1.1

Inu ular tren~th .mJ endUrJJKC. tll!\ihilll), ~Ind l'll.)d) "'Olp""uon than Ihelr pc.'t:'f'o \\ Ithou! anhnll .... Rht..'UIll;1I0 · !.- .. ~-.e ar\.h Ie t.. o ndlllOllIllp. c:\cn.' ll"e hJI" UCIllOlhlr.llcd thJ il Ual.lOn I' no! cntlrd) due I" the dt ... c.II"C pU'K..· c .......

" .. ,,,uh.. COlllpli"Ulio,,, r-.. l o ... 1 fortn . . uf \;\ . . cu l.u 11.· ... 101\ ...1,\\l\·I.lIl·d \\llh !{,\ .I[t· ... 1It..·1I1. illthou gh 11ll' IU"1IIIl;lIll I\lnn nl ,hl"um.lhlill .1T1~nll" (.'1.111

he

iik Ihrl'.lll'nlll!-!. ilnd ill·l.·omp,lIl1l'd b~ 11l<.llnUt1111111l.

Infc."dlon. 1..\'ln!!~"'lI\t: h ~.1f1 ••lIlun.·. an\.1 .a ... tT\lll1h.... lm.ll t'tk ~JIO!! h'lt)1 ,-,r \\ n ... 1 Jwp nl.l~ \. \.'Uf ., ....\ (\· ... ull \'1 '.3' I..uitll, ", th" \J ....l ,lne..'n\hum Itl lhe..' I~f\" ,uprh l)1 Ilk' rJlilal or ,u(X'rtll..l.lll 'n\n~.ll n\.'f\(',

Table 26.2 \m~ri".. n loll ""r Rh Un", Re\ i .. t.'<:i ('.;(('nil for ('l.J... . ,"'fi~tlon of 1 Un t 1.1Ill.'

1n Rheumatoid \nh';ll..

""'al

C 50S

ellrologlcal :\LUlift."lation, \111..1 J'C'nrh\'ral n~un'r,lthh~' .11"'(' oft(,1l

'n 11\ R \, ('Jnll..'Ulart) III C'lJ('rl~ p~\lI('nh. ,lt1d .1W unrel.lIt.·J III \,,"\.'ullll' \ l(hl nc:un1pJlhil"'" rt"'ull fn)ll1 ncn t' l..·lllllrl"'("'ll'J\ \.'r l'ntrJp mCIlI. ,u",'h ~h "IIT/lel!fumlc'! n[ (,n\llllwllId '\\lIdmllh \ 't:

C ass II

Class III

Cardiopulmonary Complication, Pencan:tiu, c.m Ot;- Jt!'I1Hll1'lr,nc:d .It .\UIOp ... ~ of patient,. but

clil1ll'.III~

I~

Class

1I1111,trl~, pll'un.)pulnl\.)naf~ I1hllllfc,t.IIH'Il'

R .\ I' rare

From Hocht-et\1 10109\ 1921 Il?\ ~

Ilona

Ocular \\anifcstatiol1' OCUI,lf h:-.. ion .. arc u"'unll~ .t"o\.·latc:LI

St.)(U5 11

\\'Ih reml

,\ IIh Ihe: J[~ e:\ 1.."

"'<X'll'C<~·:l..l ..... 8\

ted I

.rt . . tes

III ,ltxlUl -l pt.'r-

dctt'\.· I.lble hCJrt JI .. C.t'1...· tn)1H .11"'(' Illlht <..'llI111l1lllll~ J') mptl'lllatu:, .11though pit'unll" I' ({ll1\monl~ found 011 autor'~ t.u l' ('nl

e t J:."€'

A

but n

me

~

\.I f

SJii~1"t'1I .\ \y"drnlllt' \\ I\lch I' .11\ IIlI1JIllI1J.lt\ln

dl'{lldl'l \.11 the lacrinl.ll and ',tll\.lr~ gl.lmb , Sl'knu ... amllh(' I'd.Hl\ch more bl:l1Ign cpl,c1enll' can al'l.l he IW\',"'nl. .1Ilt! ~\.}UH~ caft.'tuI1l1edlcalln:aIIllClltl.o.lI

C.HI"",'" t ,Ilk,nh

1':(Ulll1l~

R \ ;1' l'\.lll1p.1l 'd

Disease Onset and Course

{\1

Ih{'

dl"'''-:-,I''\,'

h'I"C' l..:ve.ll..:u Ihut ,lbm!,1 OIl 'C t ,IIH.lI.u gl' 1\1 1111 111\\11 \\"1111.'11 1.

.md

L\c!\

III r.III\.·nt, \\ lIh flU I d..:'l h'1111'

"'lgllll!\.'.UlI hllh.."IH'II,ll

.11, \\llh

\Dl

\1 1

h'"

R \ ~IPpC,l1 11' h.I\\.' .11 '11\.'1 IUlldh'Il.III'UI",\'n \\ Ilh (',11 h 1.'11"\.'1. 1~1I1 11 I' \nt\. k.ll

1X''''lIi1

\It

\ Iill I'Il·v lou .... l y. II \\-.1\ '" Idel)' hl'll l'\i\'d !Ilill I{ \ l .... l'Il \\ il '" 1101 u ... uall y ,I r, HI"'l' III tl l'.I II1 , 1I11'''lU)!h ltlillillHIII' , urh "'" Nil"" Ihl' ll·

1111 .11110.1 1.11 "u hhl\ lI lll1l1 lI llild il\.· ' .... 1 1'1l1y,. 111 ~ hod" HI nU ll'm"l' IIUII Imll

lal ,rI

1
I1w y 11111 II VI' .1" lOll ).! 1\'" Itwo lt11l1Ill'll'lIll"

V.I l llllll , .Ind

\lulu,ll, Wllh

v.!lIIOUI tI, "'e"',I' I''orlt.'' 14Cll v II Ih\' \';11 1\ \t',"'"

1I1,1I~"d hy 11 J..!~ I C""' I \ll' cli I'll"'" ;llld pOll I

pi I{ \

\\l'h

lum IIPIIIII .. \.\111 '"

"h\. th

1'1~1"'ltl',IIJ\lll

r \.' t \

,Ii,\.' I'

pI 11II1dh'II.11 d ... ,tl'JlII\ lu .. t

\1, IiiI.' \R \ II.' I"

Ih,

h~n IlIg th\.' dl'\."\"\.~ it'l ,I '11\'1h 1

\1 1 Ih l\ 1I1~ ,I \hll\.'I"\~l1t 1\'11\1 "I Ih\.·

( !;\bk

,hr\'dh

Ilh' I'''' .,'-',," '\. 1 I'" "I ltlu'lIl I" III 1111'

dhll,llll'lI·\.'

'c,

.lIllIl'lIt.IH\ 1t' "Ill~

d'''ll l ll1l\

"

,\\,1 Ip, lit

I' lll~I\'''1\\.' d\· ... llI1lIH'1I ,.,

llll1ll l1\ l' l

"h ,t \

"n I '1\

R \ ",lll·\\.·IHU"II\ h,n\.' m.ul...\."l.1 "til I" 1I\\.',I)',\(II.II\.'d IlId" htll"I, \\

() \ , ... (II,It~\.'i.II1\

qUl' 11(11) (II I1l1l1"l,llll y d ...... ()(.IUI..:d \\ 1111 I{ \ I"

\11111"1

\1 :I,

\,t

IIlIl,II11H1.i1I(,1I \l1I1I1I,\lC" IX''' uti , 111 ll'lIlt

Jlo.trllcul'1I1y 01 Ihc ... Il(luldl'l glldle..- , \\ ele It"ll\.' Ull1\llU ' 1l III the nluel group, I he eldetl~ (l11\l't f l(lUP (11 ... \1 IlHlI~ \."lI m 111(111) h.Jd k,llUre'" 01 l'0h"'\"lIl~'ll ,hn/m"t/( II, .1 \!Iqlllll th . . eiJ ... e UIlCl:llIlg the ,hUlI ldl'1 .Jlld PC''' Ic..' gudh.· ... , \\ 1111 Wilidl tlded)- (111'-1.:1 RA l:i.1I1 be ulIIlu ...c li II

Y!o. lelllll

II"

.Iml 11...'11,\1. 1..:"PIl ,lh'l \, ,U1J ~,I'tr"lI1h>~Hl

Dl'..~.I'C: on",c:t III RA 1'1110'1 lI,uillh ~ICl'OI11P,II1I('d h~ 01111 plalnl ... of gCll(,lali/ed .101111 p.1I1l ,lIld 'IInne ....." IlH"l ~)II(,II la'iing \\cd, ... 10 11101lIh .... D\, ~~I ... (' prngrc"loll I' hl ~hh "ariahlc. lligh Iller- of RF can IIldU.·,IIt'.1 nHlrc "'1.'\l'l~ dl'" cu ... e COUf'e Spol1wncou'" rCI11I ...... IOI\' call " l'l·ll !". il111HlUgh II oh..:n n:l11al11'" ullcle~1I rl Ihe IIldl' u.lual h"ld . \11 ,Il'CUI.lIc h dtagno .. ..:d c~\ ... e 01 R,\ or "'{l1lle 011H..'1 dl"'(',"c S\lml~ p .llu.·n" c\penence .. Ill 11lh.'111I1It":111 Cl1U\"'c..', l h ,II.II: tc 111('\j h~ p,uII.tl to complelc..· Icllll ..... ion ... I{mg.c!' Ihan Ihe P\"I uld .. \11 ('\,Il'(' 1 hallon ..... \ llllrd group 01 11 . 111(,111 '" C'Pl'lIl'm.:\.· thl' lull unrclllltlll1g d":'lllICll\ l' proCC ..... 01 plOg IC .... "\.· H \ •• ~ Compan",oll' (11 ch..lcll\·nn'cl R \ \\lIh c..' .lII~ \.11l'l'1 R \

I hl

lIWn:- In."'\tu<'tHl\

·t'lh.~r,,1 1'-'I'u1.lIh·t\ ;m:

1Il.1111I11 pi 1~1111\' ,\I Ihl 1II,1I£H1" tIl

Ih,

Pltl\.\'" tIl (l\ \.Plllllh·" 1(;.\'11 hllhl \.'\\,.'1.

t 111111 \. 1111

d. 1',1I1h.l,,, I\!I

ItlllIt1.11 \.

1"1111 tllul

III\' \1111';\11111\.'111. ltllh Ih'II,\I 11(1111.1111 1 11

" .. 11(( \'1 1 Itl (1 \ \.

,III n·,n II 1.11 !>c·\\·",llhl

,'\1

11111

l'('lIl11d

.1

ul i\l \.' 1I1"il~\> .lIId .. \11~ 1II'IId, II I'I'lIl I' II' ' II ,,11.,11\1111 l lil t-! Ih l' 1'1."'1'11,\ 1 ~1I11 1 '011\ 11', I. t J\\'I111\ II '11 \. 111 ~"

'l\P~!lIl1t'''' 11' ((111"'11.1111..

'P\. (11\', tllltlllll\.

It'IIl''

III

1~ 1111 I' • ,'n II 1

fUll I r dlJkl(l1tl,th,cI 111 1\1.0 d., !'III. d a lllifl/"lftfliu wit II lIlt ('IHltuP\ llllht d,..,t" ......, I UlI~1l0WIl Jdlltp.llIlIt ()A 11M\. Ix· 1a ..... tlJJ.t'j!lo.1 "Ilt'tltll 101111 of j;'tlll..l •• II,,'d .tll (,lIn~ IIlIrr ,1/ III,Ut 1'11111 ... <):\ 1 '/.I 11,<:".1 ~'forld,u\ \\h4."11 1'01114111-.. WJlh ()A l HI I

lll.dB II I

IfllplH

d

'J! I~

h\ lllC

III

1~lulld tlllh ,llkl t,~ n ,ull"l.flIJ.d till( uLtJ dC-:.:C'nLI.IIIOIl Iht' I ' IlIll.llIllI,UIU!l., l\pl1.1Ih

t'lll,.;uIluUll

if

I~ut

n

.UI~(

d

JtllJlf

!'11ll1d.iI

thl\H'\l"1 hI lit,,,,

l.1Il

~(t'li

III

III tphhllll~dll~ll.d ... !tulie''' t)A j .. n l.h110~L', h~ .f~l'lIdlU~ I~l lli.: ~llItll.t til

'IIII'.

d

t

iCII~t'

L1 L.1

u'IIIF

n IIldlll.1I 'l.d£' til 11\("

iuuhlful

n.1l11..

'~1I1~ ,'llht' IUilH 'p.il£' .wl! PO ..... I.

hit' ~i"l(l'I'h~k'"

e/1 II

.iud .Ih .. t-JJIOI ljUe' ... llol1.lhk

_IUt"lIl:' HI Iht' I"tlll "1.llC'

(111(" ' l kll ........ !IId

·1 Ltf~r "I

c"

.1

;-Lld

[Itt

pu..,.."hk dr'ldllllll)-

tOIll-'lllIl.tl III.IIlnllll.IIIOI). or .ul he IdrflllJ,('d

t

Epideminlog .1;.:('

(llil: pfc'e'mc ,II

dC'lln,le'

lllle"ilUn 1111 dcllllll'::' ..11..,('.1 ... (' .tllhnuFh

-\lIhlHI;_dl L1ljJtI~r.tf1ltll c\ h.tClllC' l11

u' 1I.11Il1'\III~ _IIILt u.,[C'dplt Ic" !H.I'

hdp

~~ll1lmn

It! llt.I~llll"h .tll...!

.1.1 .... 11' IIie' .. U:::c tlll):\ lilc ~ !!llll.iI"'ltI II j hll) .wll "'-lice' ll.-\ .-tlt" LIe'''lll~d In 1e'llIh lH 1'.(111 J 1I111.11ldn dlllhdllll\ j till\ -'0)1 +I R .1dlt1;.!t.1ph\ .it1.h

111('-.elll II h ''''ldt'\prt'.ld ttl .RIIlI!

.111e'1 .I~t 50

"omen h('ltlie' Ihe' .l,;.!t" oj 'ill nul 1l'\ie"I"oC'"

'llue" 11i.11l 10 111111all1 l'!C'()I'lc III Ihe t nllc"d

dl"PlhJlhlll ill

h, OA.v

(..)A h .l\c ) Iclt/cd ll)I1IlIl.IIIlf! d.II.I, depl:'udJO!!

E lio\og)' ')UIIII.II Itt R:\ !Ill \1I1~k I.ILit\! Ih.lt (llcdl'op'-ht' .... lI1llldl\ld IJ.tI

Itl l)A h.l\ I)e'e'n htenlllJe'd Althllup.h .1¥tn!!

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th (' r<.llt' of co / ymc p,odm;tHHI Ih ;~tl:.t( 'J IJlal(' tlt e dt:\tnlllu!II e,1 l-arI Ji
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deut""'l'" Wil li OA , it .... al ...o tru e Illal proll'oVlyt:;ul ;."d tfJ JJ :' J!l'rr ..,YJlIIIl!\I., 1I)t:rca~c'o unttllhe J;~tcr ,> taVl:., 'II rlw r1,.,ca'oc 'f hr ...

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II ...." to .,ewr;!) lI yp'Jll lt: \e", UIJICCrrllll.l! till: pat!rogcIIC"i'" 01 OA t Wllllll !I;I VC yl' t hi hc proven (ji vcn lhtltIH'/tl'ov l yc;m "y Jjth'~h l ') '"l H',J \C.., WJ1h OA , t( i ... pn\~lblc that 111 (; 4 LWlll y ()f Iins rH.:wly S.Y "tI)l· ... If(~d ",,,\lIKI rnay 11')1 ',e (;(,lual 10 11I(;l'tlll,l! Illl.' bl(}l/H' t ltulll cOl I load IInrJlI ;:dly rl'1cecJ 011 all

adult

J'lllil I

(Hl

all:d With (JA i ~ likely to oc<.:uror worsen only with motion. except in Ihe lalcr ~tagc') of the d;\casc,~ OA of lire hip commonly re,uit, in decreased ROM with a lendency for Ihe hIp to be held In a ,omewhat flexed, abI.Ju(;lcd, and externally rota led po\nion and the knee in liexIOI/ Decreased hip ROM" clearly a''',"lated with de(;rca ... cd walking ,pecu. decrea ... cd ..,tnde length. and J/Kn!u..,cO energy expenditure. MaXimum walking speed or I.X mJic s per hour I'> not uncommon III older pcr ... on\ with hlp OA al/o decreased hIp mOllon ." Overall, OA of the kn ee C
PU!i cnh with the mo.,l "'everc di\ca&,c may nOI move tliCI/' JfJJlll'. (I..,

oflt;:n or

10

rhe way' that exacerbate their .,evenlY In mdivid-

.,ylliptom .... '/ hcre/'orc, palll and tll"ca\c

ual., wlllr OA been

"ih.OWII, for exunrplc. thi;ll the functIOnal 10..,.., a ......,ocrated with .,eVerc radJl)gntphlc OA without ..,yrnptom ... IS more lIkel y tha" Ihe II'" .~ <.," . !)tld .. teu .. , Will I t Ilc pre.,cncc of. ..,ymp-

Clinical J)iagnobti c C rite ria Sig .. , and Symptom, ('JIIIH,:i.dly. ;1 chap]".,t., ;., ollCIi made

"Ie,

'pme, hIp', knee', and fir" MTP arc al,,' for OA. The Vlep" wris[!'. elbow,. and ,hould." are usually 'pared In pnmary (JA .'· UnlIke RA. OA does not have a bIlateral. ';ymmel ri(;al prc~nU:tJjon. A \mgle JOint or any C~)mblOatlon of jOint!) on one individual may be affected. OA It, not a \y~­ ternl(: dl~a\e, and i\ therefore not a,>\ociated with IiYIjl.emic complain{\, ,uch as generalized morning \tiffneljlj. fever, or 10"" of ~ppcljte, Jndlvidual,> with OA may experience ')ome IJ liifnc &'fJ In parti(;ular jCJinlS upon awakening that i') ~imilar 10 the "Iifnc" felt when mQbllwng the ,ame Joints after JIlacllvity during the day, but thl'; ",tiffne')., doe~ not 1a.)'1 m~arly a\ long as In mdJvlduahj with RA nor J'" ;t generalized tel th~ r.::nllre body,~4 CrcpilU'S jr, a common clinical finding in (JA a, well a, rn RA." Alth',ugh cartIlage degeneration i, the primary manifest""on of (JA , ,artdage i, aneural. and therefore not the ea u"", 01 a pc"on'; pain. Pain In OA may be attributed to Jncon,grucnt arlj(.;uJaIJOn~ of JOIn I \urface~. perJo\t~al elevatIOn ... ccondary to bone prolIferation at the joint margJJt. ",bnt)rmaJ pre~~ urc" on ... ubchondral bone, trabecular rnJl-rolnt(;IUrC\, and di'>lcnlJon of the Joint cap~ule. Many pat/ent ~ will al",,) experience a ~cc()ndary '>ynovitJ\, e ... pec lall y when Ihe knee i, involved." SymptrJm, do not alway, match the ,everity of the di,. r.::a\c 011 radiograph,;, Some patients may magnify the pain they cxp(;riencc. Mure Importantly, unlike individuah with Ioci-

lhe

/)<1 ... ,., of .,yrnp .

tom ., ,Ind ., Jgll., (c.j.!., pam and .,weJJ IIIJ! . lo',!'! of ROM , ,md hOI1Y ddnrnlJtYJ, Not all JOIIl! ., ;'Ire equo.rlly aJie(;ted by

OA

III the IIppn l'xtrl'IIIJly (I)J~), th e J)JP~ . PIP\, and (,M(' of Ihe thumb arc <.: olllrtJonl y Iflvc)lvcd . 'f lie ccrvlt:~d and lumbar

10111., but Imlder dl .,ca\c.'7 011(; cxpJanulJon of thi., Jindtng

" tiwi IlId'VI(/U'II , WIth ()A I Imll l1ell' I • fUllcllCltlal 'KlJvIlIC" 10 \UIIlC Ihat pallll., i.I pmnary factor ' I . , 111 lInllll1g IUf1ctHJIl 1.1\ 1\ the l:a ...(.' III p'ltlen" with RA A'I .. I .

t Inlta examInation prcdll:
Chapter 26 Arthriti, aS~lIIllp tiOJl co uld lead to the hasty co nclu ~ion thai the patien t\; functional statu "} is nonnal if pain i~ absent. Given

1069

In RA. joint des tru ction and irreversible damage are most pronounced in the first years after di sease onset. Therefore, medical management includes an aggressive approach to stop or retard the disease process as well as to control pain Jnd in nammat ion. It is cu rre ntl y believed thaI adequ ;:ue pharmacological therapy initiated in the earl y stages of the dIsease resu lt s in less joint damage and functional loss. There are two major classification s of drugs used in RA management: nonsteroidal anti -illnammatory drugs (NSA IDs) and disease-modi fying antirheumati c drugs (DMARDs). whIch include; the bIologic re; pon;e modifiers (BRMs), and corticosteroids. SR

longer tenn triab idcntified IhHI pa tient!'! who had been pre· scribed COX-2 inhibitors experienced seriou s and sometimes fatal ad verst.! eve nts compared to pati ents on traditional NSA IDs. Whileoncc thought to be the "wave of the future ," the clinica l use or these particu lar drugs is uncert<.lin at best. Concurrent prophylactic thcrn py to decrease gaslrointe.sllnal damage also is un option. O th er po . . sible side effects of co ntinuing NSA ID u'tc include dilL;iness, headache, drowsiness or tinnitus, kidney dysfunct ion, and elevallo n of liver en7y mes. Patients wki ng NSA ID<.; should be mon itored every 3 to 4 months with CSC and biochemical profiles , as well as stool guaiac ana lysi"l for occult blood. The origi nal NSAID wa'-l aspirin, whi ch is ';Iill co mparable in effectiveness. but requires up to 35 tabl ets a day 10 achieve an anti-inflammatory effecl. The decis ion of which NSA ID to prescribe is based on ril.,k factors. known toxiciti e~, dosing preferences, and cos I. Individual re"'ponse to an NSA ID is ex trem ely va riabl e inlcrms of both e fTectivene'ts and to lera nce. Therefore. it often req uires several monthlong trials to find the bes t prOduct. Taking more than one NSA ID inc rea ~es the ri sk of toxicity with no increase in benelil. NSAIDs are prescribed for patients with RA at the onse t of symplOms to provide rapid pain relief and control of inflammation whil e waiting for the slower-acting DMARD 10 become effecti ve. Table 26.3 li ,1S the NSA IDs curren tl y available.

Nonsteroidal Anti-inflammatory Drugs

Disease-Modifying Antirheumatic Drugs

,Vollsterou!a( anri-mj7ammatory dru{:s (NSAIDs) are a basic

Di.\ease-modllyillJ.: antirheumatic drllR.'I (DMAR Ds) are H heterogeneous group of drugs ex hibiting ~l wide range of chemi cal structures, modes of actions. cl inical indicatiom). and toxi c ities. To he classi fied as a DMARD, a drug must show evidence of changing the course of RA for at lea.." I year (improved function. reduced inflammation. and slowing or prevention o f ,;tructura l damage). DMARD't are slow actin g, requiring fr0111 3 weeks to 3 months to become e ffective. These drugs once were known as "second- line agents." deno tin g their late mtrodu cti on 111 treatment for fear of serious toxicity. However. evidence shows that these drugs arc no more toxic th an NSAIDs. and current philosophy is to initiate DMARDs ea rly and attempt to maintain trea tm ent for at lea<.;t 2105 years. Individ uals taJ.. ing DMARD<; should be monitored regularly for the toxicities accompanying the c" peci fi c drug. Some DMARD", were developed 'tpecificalJy for RA ; others were lirsl used to treat ca ncer. malaria. or to prevent rejection of tran'-lplanted organs. DMARDs arc most often lIsed to treat RA: however, some are u'-Ied to trem Juvellile RA. ankylosing c"pondyliti <.;. psoriatil: arlhritJ.<.;, and "'Y'-l temic lupus erythe-

that individ ual s with OA may reduce or eliminate their ,ymptoJ1lS by avoiding certa in activities. clinicians should explore functional limitations in pmieJ1ls with OA separate ly from the evaluation of symptoms.

Medical Management Pharmacological Therapy in Rheumatoid Arthritis

element in long-term treatment of RA. having both ona/~esic and allli-illflammatory actions. At lower doses, the t\SAID effect is analgesic, through the periphera l inhibition of pro-inflammatory pro~taglandin syn thesis. At hi gher do~es. the effect is anti -Inflammatory probably throu gh both pro~t aglandin inhibi tion and alteration in macrophage and neutrophil function. Although NSA IDs provide sy mptomatic relief. th ey do not alter the underl ying dbease process. The major seriou <, and mos t comlllon side effects arc gastromtesti nal compl ain ts ranging from nausea to gaq rointestinal bleeding and ul cers. There are a great many NSA IDs ava ilable over the counter and by prescription. The two major catego ries arc the traditional NSAIDs, many of wh ich are now avai lable over the counter. and th e newer, selec tive, COX-2 inhibitors. Traditional NSA ID r.; block bot h COX-2 and COX- I enLymes. The COX- f en£yme is important for the health or the stomach lining and kidneys. Individuals at IDcreased risk for gastrointes tinal compiJ cat ion . . arc the elderly, smoker~, ,ho<.;e laking corticOMero id~t and those with ~evcre arthriti . . , comorbidiu es. and hIstory of ga . . trointestinal ~ymp lOJ11 \. The COX-2 Inhibitors were de . . igned to reduce tht.! ri~k of ga~ troinlesti­ na l loxicity by blocking o nl y the COX-2 enLyme, whIch IS re . . pon . . ible for the pain and swelling a . . soc iated With mnam mation . Early evidence from ~ hort term tri als .,up· poned the decreased ri. . k of ga., trointest inal .,idc clfects and IOcrca . . ed tolerability of COX-2 inh ibitor.,.~<J However,

l11atoSlI"i.

A new group of DMARDs ha <.; bCl!11 deve loped that lllh ibit Inllummatory cyto kin e i.H.:tJvi ly. by blocking eIther tumor netroc"ls lac.:tor-alpha ur Interl euki n- I. ~r hey rep resen t a 't ignilkant adva nce In the treatment of 'tyste11lH.:, innammatory rheumutic dl c"cases. These so Gilled "hiolug It ... :' or hi%).:w I"('.\pOII.\e l1I(Jdif\'ill.~ (IJUM ) (/gt'III.\, ha\"~

1070

PhHical Rehabilitation

Table 26_3 Drugs in the Management of Osteoarthritis and Rheumatoid Arthritis Common

Drug

ames

c ....... ~~=::==~;;~~~~~~~II Allie•.., EIredB

Brand

= - -Analgesics Acetaminophen NSAIDs Traditional

==-

Tylenol, Excednn caplets, Panadol, Anacm-3

Potential for renal and liver toxicity

Not recommended with high alcohol consumption

OTC: Advil, Motnn IB, Nuprin, Actron, Orudis KT. Aleve

Gastrointestinal bleeding, ulcers. nausea. diarrhea, indigestion, rash. dizziness, drowsiness, slowed blood clotting, tinnitus, flUid retention

Sensitivity or allergy to similar drugs; kidney, liver or heart disease: hypertension~ asthma; ulcers; anticoagulant therapy

May result in serious adverse events includmg cardiac complications and less serious G I side effects than traditional NSAIDS; allergic reactions; elevated blood pressure

Same as above; allergy to sulfa-containing drugs for celecoxib

Prescription: Voltaren, Lodme, Nalfon, Ansaid, Indocin, Motnn, Orudis, Meclomen, Relafen , Naprosyn, Anaprox, Daypro, Feldene, Cllnonl, Tolectm COX-2 Inhibitors

celecoxib (Celebrex), meloxlcam (Moblc), nabumetone (Relafen)

Corticosteroids Systemic: oral or intravenous

Prednisone. prednisolone, methylprednisolone, triamcinolone, cortisone, hydrocortisone, dexamethasone

With long-termlhigh-dose: Cushing syndrome, osteoporosis, cataracts, insomnia, hypertension, immune suppression, elevated blood sugar, mood changes, restlessness, increased appetite

Diabetes, Infection, hypothyroidism. hypertension, osteoporosis, gastric ulcer

Triamcinolone, prednisolone, methylprednisolone, dexamethasone, hydrocortisone. betamethasane

Post-lnJeclion flare (4-24 hours) , transient systemic reaction, increased diabetic symptoms, soft tIssue disruption from direct Injection

Presence of infection, previ· ous failure to respond

---

-----

DMARD s Methotrexate

Rheumatrex

Injectable gold

Myochryslne, Solganal

Oral gold-Auranofin

Rldaura

Common adverse effects: decreased appetite. abdominal discomfort, nausea, diarrhea, skin rash, Itching, oral ulcers, photosensitivity, mfectlon, unusual bleeding/bruislng , bone marrow suppression

Imuran

Individual drugs may also have other specIfic toxiCities and increase risk for other conditions

Azathioprine Cyclophosphamide

Cyclosporin

---Liver or lung disease, alcohohsm, immune system or bone marrow suppression, Infecbon, pregnancy Kidney disease. bone marrow suppression, colitis PrevIous adverse reaction to gold compound. kidney. liver or inflammatory bowel disease Kidney or liver disease, pregnancy

Cytoxan

Kidney or liver disease, pregnancy, Infection Sand immune

Neoral

Kidney or liver disease, pregnancy, infection

1071

Gh..""" 26

ab e 26.3 Om in 'he \hnagem"D' of 0 'eoarthriti, and RheumatoJd ~ritU 'C'OItlonU«l

.·""""",,,10 oqu ne

P aQuem,

Antimelar.al drug r

nal atJ"j(lf'"

nancy CUpnmlnE Depen

P"r.cU • a If"'JY b\OO'.l " .... ease ar o"'ey 1JSeaS.e

Sut'la or as.pt ~ ahe:'dY .,. j."'I~y or lIer d.&e~ tAor..Y: dl&SalA; !>'!l'lCtlial

a.sthIT,c de

P.rava

1..; 'ef d S
t~JnOCIn

ogle Response (flers

Etanercep Enbre) adallmumab (Humlra) ana~Jnra Klneret nor IX mab Remlcade)

he cf1t:(;Lne and ,fler the possiblbt)- of controld s.ea.
are u...\eful conunue ... 10 expand a\ do the number and f ae~nu, 3\:uJabJe. Table 26.:' h~lS lhe mol.,l common

D\lARD and the BR 1

Lorticosteroid.. (n lefOld are analogue of the n41uraJl~ occumng !'!T'OJle conisone and are the most pov.erfu1 anu-mflamr) drug ... avaIJable. CoruC'CblerOld ... ma~ be gl\en ... ~ ... ~ VIa Drat (If Intra\ enous route. or locall) \ 13 mIraar or perianK'ular inJection. Ai~r the dt o'c0 of rm.one 10 the 1940, and untIl the ...eriou .... life threatemng Ide eifeus of long-tC!nn U~ "ere recogniled l1l me JaIt' If CCI1lsone"a thought to be OJ 'Mooder dru;.· Ide f~ f long-lenn. high-do-.e ,~,ternIC con,...o lero d, an~ n<J\A. knO\\n 10 melude o,teoporo"'I'. mu Ie \\.1 111l~. adrenal uppre IOn, mcrea-..ed .. u-..ceplIbihl)o 10 tnfe...ilon .... n paired 9iound ht!"ahng. cataract-., glaucoma. hypt'rhpldem a. and a<.;eplic hone necrosl' The u...e of ') Ie-Dh.... orTOld to halt lOflammalion I 1111 mdh. ted m 1,...1-< re tht.-n:: 15 unrcmlttJnl! dt.s.ease and se"\cre C\tra-a.nl-U ar flammauon H\J\IoC\er....lhc drug l' 3dmlru ... lered I~ a I..,..". a :1t.Kc as pos Ihk lor " ... hun a pt'flod 01 lim.: a ('I(......... ,bk ma\lffill"C ht-n('iil and mmlml/e alhep..e elf~1 \1001 n hould mdude blood I,..ounl • ....erum pol ... lum and I UCose JC'\cl . and o~f\allon for Ide elf t Local Injecllon mill a JOint. huT a. lendon. or I ndon dth rna) ~ u d \\-hen IOn mn1.ltllltl I If,,-ah/ed It I I:tnc:ral"~ a!!reeJ th t mira .Irll ular mJc~lIon pm .. ld

Soe""

Real) ,..s s;.1..L!JC..r.a.~.IEIOUS !"1 sctIor ~r r.3I/f:OO:.;ti

ilr:r j-

"'E""""

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Pharmacological Therapy in Osteoarthritis

""_""'<sic,,,

On.g therap. 0.-\ ha. 0 effect on dl=!.c and IS anc 4J) L.l the mor~ geucnJ meastIrei of Irol "hie Indude pmenHeWed u~ and c\.erc SC" 1be.e of .e :ap) v.lIh 0'\ Me '" reline pam and de..~ v. hen " 1- preTO the pnIIW) m..an.1£ement

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I able 26. ,,\ nlll'n u\cll or C11tl' c."rl"xI~ .. \\ Hh In C'PCl:ltxJ ITIOlIe .... rc\pon \c The l'k't" I' Ih~ nlth[ l'ommon ... lIe; ho\\ C'\ cr.... oft I' ...... ue injeclion ... fpr ,ubJ.cnlOlIal. an ...cnnc. and trochanteric bur ... ili . . al,o nu~ be ette,,'II\C'. \ I o,upplemenli.ltion or Intra-articular Injection ... of the Mlee \\uh a form of h~aluronjc acid ( HA ) is sometimes u~d There are a number of !'ynlhelic fo rms available ( ~ml c, H~algan. Anzal). HA is a naturall) occurring pol)-.a,..-charide that contributes to the thickne.!>s and \ iscosII} of JOInt fluid In the heallh) joint. In the OA knee, the IntrJ-mh.:ul~ \'\lrttl'lh lC'Wld IIIJlTllon .. Me

Ie\el of HA are lower and the joinl fluid i') thinner and le.!>s den ... , reducing the abih l)' of Ihe fluid to lubricale and

attenuate ')hock. Vi')cosupplemenlation Ihemp) con~i.!>l~ of a series of weekly inJection'). The reponed effects of treatment are reduced pain and improved function in people \\ ith mild to moderate knee OA. \\ hich may last for '-!c\crai month\. It IS not clear If HA II1Jeclions are morc clfectl\e than conlcostcTOId II1jeclioll'-!. NSA JD'-!, or placebo injeclIon\ I, The II1jc(;{ed HA docs not replace 110nnal joint !luid to at.hicyc It') effccI as mO\1 IS ahsorbcd nnd cleared from the JOint 'Wllhln a weck, Thc ri'-!k 01 Side e llen, 1,10\' , The 1110:..1 ~nqu .. rCJXjncd adYerse evel1t I ... an allergiC react ion and Ie:.., iC' r!(W \

cHc(,;" afC 1I1JCc.:I IOIl sil l' n:acllo n:.. i.lnd JOIl1I

:"\H:llll1g.

IIITlIIl J.! (II Ihe'" pro(t'dure Me trItIL.:tJ rh pr m"T1' IOdll.;d. 11011"1 lor ,urlo!t'ry Me p.l1n. 111,\ ,'fllnctlf)n. mil progr. 01 dctCJffJlrlY, .tilhough the 1.1 tt'Wo .Ire nr,1 al~ correlatr,.d Surgic .. ti ()UI<..OnlCS .Irl.: gte,illy Iffec.cd "y the ~ ,nat T .H.:tCT!S(H."' of the indIvidual p;lllent ~lIch ..I r.OI! J.t.u.n ~ Ihe qUdlH Y of po,,!opcrallve rehahIIU.Il.on. f'( 'allpet.J.1 rt.'h<.lhllllilllOn goals are tn r("(OTl: mOhlhty 0 the ..Iff JOint. promote ... Iahility "I,), Jlhln Ihe jOint.. and l'\:1!~hn leU

control of JOint mouon. I n general. there ilrt! three procedure'i thaI may be pep formed on ...oft u."ue ... : syno\ectom} ~oft lIs ue re ease and tendon trJJ1~fers. Slmd3r!~. there Jre ~ree gencnl bone and jOint procedures, ooiiileotom} . prl),thefl..: arthru_ plast} , and arthrodesis The chOIce of "pecltic P("I'[opcn. live ph} ... ical therapy procedure, \\ III depend (In ll1e !JJ.n!c~ ular surgical inter.:ention, the extent 11f Joint lIlV l\lem~Q[ prior to surgeI). indl\ idual charJcrens[}c . . ..if the nauent, ilnd m3mfe~tati on~ of the disease. [( 1" panl(:u!ariy .mr' r. tant to remember thJt a p;ltient \\ 1m R..\, I.:cmp<.ll"e\! t J peer with OA, WIll have multiple Joint m\ul\-ement \\ 'llC!l \\ ill ultil11atel~ affect the fUn~llOnJl outcome of the pn.'l:t:dure. A patient \\ Ith RA I:.. ill'll liJ...ely to ~ ;l 'U!£:JC"J.I ~Jn did ate .11 a mu("h ~ ounger Jge th;ln J. pattent \l.lti' 0-\ .\ lore th.to 500,lX.Xl ((ltlll {orn! £1rrhn nlil.}·l'\ TJ -\ .. ur..:cr les 1..11' the hip or J...nee art' perfllOlled Jllllu,tll!. thl.." 1:1.:1JO f\, 01 \\ hidl ~Irl' for P;Ul(,llh \\ Ith 0-\..61 The ....• ~t~h: 'U(~~I!"" lui pn.lceuuf("

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\ll\lh'l\ Jll ,'fJ\u'~

lU

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t074

Ph}sical Rehabilitation

N

Table 26.4 "Red Flags" Suggesting The ee

d

r.or Urgent Evaluation

and Management

History of significant trauma Hot, swollen joint Constitutional signs (e.g., fever, weight loss, malaise) Weakness Focal

Diffuse

Neurogenic pain (burmng, numbness, parathesia) Asymmetric Symmetric

---

Soft tissue mjury, .Interna I dement erang , or fracture Infection, systemic rheumatic disease, gou t, pseudogout Infection, sepsis, systemic rheumatic disease

Focal nerve lesion (compartment syndrome, entrapment neuropathy, mononeuritis multiplex, motor neuron disease, radiculopathy') Myositis, metabolic myopathy, ~araneopla.stlc syndrome, degenerative neuromuscular .dlsorder, toxin, myelopathY,1I transverse myelitis

Radiculopathy,' reflex sympathetic dystrophy, entrapment neuropathy MyelopathY,a peripheral neuropathy

History of significant trauma

Soft tissue injury, internal derangement, or fracture

Claudication pain pattern

Penpheral vascular disease, giant cell arteritis Uaw pain), lumbar spinal stenosis

• Radlcutopathy and myelopathy may be due to infectious. neoplastic, or mechanical processes.

When there: i~ OA \0 a hlp or k.nee. actl\e motion in

Juncllonal po.,ltion" ~hould be examinetl 111 all join!'. of both LE:-. . It j., 1I11portant to ob",c:ne motIOn for symmetry and ... moolhne ...... during gait. ... tair chmtllng. :lnd ..lri.,ing from a chair A<.,ce:ndlllg \lair ... require., the grC'ate\1 amount and \clocit, of k.nee Ile\ion and Illa) be one of the hl.'\1 acti\ille\ ior deten111natiOn of k.nce function. btl Decreased RO\l althe hlp and "'nee: II1crca.,e~ the: risk. for injur~ and fal!.... Nearl) 50 hlP flc\ion and 90- J...nct' flcxion are requlrcL! to rccO\cr balance from"l .,tumble dunng ".11J...lIlg.

Strength Application of .,tandard manu~11 mu ...de Ie ... ", 10 detcnninc .,1I"englh Illf'\ t're ddonlllt) and deranged Join", arl! inappropriate (andidatl.'\ for traditional te",'" of ... lrcngth ..\ IUIl(lIonai test of strength. lher('fofe. I... more indic ..uI\t! of rehahihtat lon need ... and" ill hdp idenlify the anticipated goab of \crcngthcnmg program., pnor 10 imtiating trealment. An additional compticalmg hlctor m the application ofconvemional mu\c\1.' tcsh l'> the frequent di ... play of the lag phenomenon" Becau ...c the

patient 1\ able to mm"e only partwa) waugh !he avaJlable range. traditiona l grading 5.) stems are not sensi tive to recording cha nges. becau.,e the gap bet\\lcen acti ve and passive ROr..t narrow" ,l'" a re:sult of treatment A therapi\t may wanl to comment speci fi ca lly on the degree ... of acti\'e motion and the grade of st:rt'ngth cxhiblted in that arc of motion. If 11 traditional le ... l1ng method i., u\cd. therapi"ts ~holi i d aJso document the: particular approach to te ~ti ng u~d (e.g .. break. te!)tmg. isometric holding at the end of range. or resi~tance throughout the RO~I). which \\ ill clarify the meaning of lhe grade a ...... lgned. Break. le ...ting genernll} yield5. higher grade... than would be received if full range testing were done. It IS aho IInponanl to record \\ hethe-r the patient \\oas receiving 3n) mcdication ... that might alter perfonllallCe or exercise tol· crance. The ther:.lpi.,t also ma) wish to document the lime of day to ac~ollnt for the effech of monting ... tiffnl!\.,. The: functional thre<:.hold for LE .,trength ha., yet to be detennined. Ho\\c\er. reporh from studies that ha\'e examIned J...nee ..,tre:ngth ,b ~l percentage of body weight sugge\t that i\ok.inelic ... trenglh measured at \'clocitie ... between 60° and I SO per \ccond ... hould be :20 and 30 percent body weight for I\nce c\len ... ion and 20 to 25 percent for k.nce M7n tlCXiOIl. bomctric knee c\ten'llon belQ\\- 10 k.g of force (mea\ured \\ Ith the hip at neutral and k.nee 31 90() corre. ... ponded 10 mark.ed di\abiht) 111 J. ... tudy of per'ion\ with OA of the J...nee.4~

<. h .. ple< 26 Joint tabilih "'If.; ;:-.1I1h:"'lOU'" .n.U~ ..'1 ~Ul\ ltk,,:h.."d Jlllllt ,houlJ ~ 'ull~ e .. r ::-...Lrl,.·J L ':":aIlh:nh.\U ... IIl't,lbilll~ Qf L ~ .tnJ Lf-< JI..1lllh ~ J 'I';r. 4h.:anf dt."h.";l.mt tl~ \DL and Jmbul;.HI\,m ...

('adUlt; l't Jl1 un ... ["lt'lk' j(.llrH 111.1) abll furthl.'f 1.:1,,)(1

t)

"m lt J.Ull.tgl,.· .tnJ p.UIl.

, ~ of the ') ... remh.: mamfe,tariom, of R.-\ and a \)) lIlJ,\ IIJuah Yo ith OA ,

trcqu..:'nt1~ rl.'p'-)n~d

..-ut: ...hllUIt: tx: ,.:;.m~full)o e'\J.mineJ both during the a ' lIlg Ie da) and 1..'\ er ,\!\ eraJ da) ... to obtain a full l~ _ n .:: o f lh pan ...'ro. The del..'rea:-.cd cardio\J.:,("u!ar "' . niJ :\luuJ.h ..... lth R-\ demand~ ~pedtk atten1t:.lr rare , re'plrato~ rate. blood pre"ure and far=

o

f'\='n.e lh~d e:\enion "houlli all

tx:- mea... ured dunng a

.h.·t!v ir~ tha: I, rea,onabl:- 'tre,:,.ful for the .... uren l le\e l o f fitne ... ,_ E,\("e, ... i .. e ncrea.'e ... rna\... the pre.;enl,.'e of mtlammation or impairment of .t.T mJ cardIa.: ~un\.· tion and require more e\.tenu . . ('phl . . tlcaled te..,h and mea. . ure ..... Be,au~e the co~""':Id I,:o .... to\ ertebral articulation!> are ~\no\ ial .:nl.!:-.t .e \ran~lon. breaililOg. J.nd coughing may be )[I\; , cJ ill the patient" ith RA and ,hould be e,am. Ii. , . . aho important to detennme carulo\il..'..\.."ular title .. n nd;\ Idual ... Yo ith OA. ~ C"ardiovfu,.\.."ular deticir::, are . . ear ~ J. ... ..,0\.lared \\ ilh long ..,tanding or ';)e\ere di~ea.::,e.- 3

Functional E xamination J.n~

long-term di...ea. . e proce ........ a number of differ.;nt wI\. tional te ... h may be indicated. Functional mctic ... and needs of the Uldl\ ;dual patient. the le\el and depth of infomlation requueJ. and ir.... predicti\ e \alue in gauging the efticaL'y of treahlenL 14--"'b -\';) \110 ith goniomeuit: mea\urement. the reliabUll:'; and \o aJidity of the instrument . . hould be knO\\ n if the .lata Me to be u~d for comparau\'e purpo.';)e~ The FUI/(onal SrcJlIh Index. ~hlch \\a.... de~lgned e\.pre ... :-.ly to be U~d m outpat ient rheumatologLc ~erting~. i:.. an in ... trument {nov. n tn be rellable and valid. a:-. \\ ell rt IJblIUml"nl 01 2-t-1ll:11I'" III thrL'L' L>IIL'g(lfll· ....... p'-'~IIiL tI,l \.., ;,1.1'

Arthrili.

HY1S

OA \)' the hlp anJ/l)f knee I pam. "tlftne ......... fUnLlIOO). The \\"0\1 \(' t~tkc ....thOUI J 0 rJllnu[c . . to admlfll . . ter and IS eas~ II) "'L'l'ft:J 0) halld. It I \dlbble In either Liken fonn

or v"ual ,Inalog ,.Ie,·" BOIh the 0\1\152 and the \\"0\1.\(" arc ... en . . ilivt: to dlOlCal IntC'TVcntlOn dod pr~ \ide e\cI!IIL'f1{ cllnl~alli k ...... Jolc ..... tanuardlled mea ure$ n the domain" of fun~lIon and dbJblluy to monitor <:hangc o\o'er time to-

-+)

\lobility and Gait A complete and uetallcd gaH examination is one of the mo:-.[ Important l·omribution . . of the phyo:.,JCJI th~rapls.t 10 the rehabilitation team· ... umJer..,LandlOg 'Jt the indlvuluaJ's functional abllitie ... and ~elVe') to idenufy additional areas for e\amlOation and imelV'emion (Table 26.: JS -.et: Chapter 10 for a complete dJ.';)cu ... ~ion .. SUb~tanlial differem:e", In knee RO:\I and gait \elocit) berv.·een palienb ,",Ith eithc:r 0..\ or RA and their peer';) without arthnti ... ha\-c bec:n demon:-.trated. ~~

Senso'") Integrity> Any indication of peripheral neuropath) or Dene involvement should be in\oe~tigated U..,.lOg standard eUI1UIlaUon procedure .. ,"'ee Chapter 5 i. Selbo~ change.., mal are concomitant ""im other conditions ... uch ~ diabete::, or the normal aging proce .........hould be con . . ldered v. hen appropnate. Ps~chological Status There is no personality type -.pecit1c to rndividu.a1, v..uh RA or any other kind of anhnus mat hib been demon..,{rated in any ...ciemificall) acceptable \01;3.)'. Indnridual ... \\-ilh chronic arthritis. e\perience ~ear ... of functionai and ~OClal los:.. that ~ould srre~.';) any pers.on·, abilH~ to cope and adapL" Report' of pam. ho\\-e\er. are . . lgnificantl~ correlated \110 ith ~lf-reporb of depre~jon. but n\J{ colTt"~ated \I, Ith functional level.""';' The ovemJI psychological ...rarn..... of the mdi\'ldual "ith RA I.., generally SImilar to tho-..e mJi\Jduab .... ith other chronic dj\ea.-,.e~ thaI threaten J '-C'O ere L'hange in body image anJ di ...ruption of ~lal lfltegr.uioo t . . ee Chapter 21. lndi ... iduab re . . pond to theX' thn.'"3L'" Vonh \mou..,. L'oping . . lr~Hegie:-.lO maintain p~y\.·holofl\..'J.I C\luiltbrium. ", 0 single -..rrategy i ... bener than another. alUh..'V.:;h . . orne "tralt:gie . . . ultunately facihtate the jdue\clTh.~[1{ of ~ ti\t,.' outcome .... \\ herea' othef\ hin.Jer J1llllJI\ IJU.J.l·... prog;re . . . toward . . elf-cho ...en goal-... E'ploratlOn of thL' paIl . .~nf ... .ltt1~ tude to" ard n:habdilJtlOn ..ob \1\ dl ~, mat of famll~ L be,.... L'an J."I .... [ [he thc-rapl"t In ..!\.·hle\ !llf gLl.1l ... .utd m ... ttU.1 reali"tic ~et IXhHl\e. oricnt.1W.m t\) tutun: fun . . uooal J. ity . Thl..~ mJI\ Idual \\Jlh R-\' l ' re-...IU\. . . I ... J to Imp ..... Ell ....ene ... of L·hangc . . . 10 d~uly !ttl" \\llh n.· ... r"-'d h\ n . . J . . .Ul C\I..'rl·l:-.e. Jnd '1..·It-L·J.n;~ f;:lIlun.~ (lh'\\mpl~ \\ltn p. )(c rc!.:ommellJatwlb " oftcn Ul[C-:-PI\..'( d ,a 1,..... n t lht.~ LML' pn.."'!\ Ilk·r· . . ,1 ........ I ....Un\.... r p . . hh\..\lcS.~J.lI. m ,IJaplI\L'!:x'h.l\lor. J.,,\ ph.\ . . L\,. lh . . r-.tp ..... rmu . . r l \ IiJ SJ l)lk' · .... I'll\I~~ .... ,l\Jl,11 "Uthl1tlt~ 1" a . . .l .... \.\fl 1(1 )Qtrol ll\~r .lil\llh"r 1.1 . . \111. \lkmll1 Lh ... Ilkh"duaJ!o .. ,

Table 26.5 Anal,sis of Gait De,;utlons. Ph sicnl E:utmination Findings. and Treatment Goals Ph,dcai & ...Inedoa FlI·D • Pronated foot Shuffled progression Decreased step length Initial contact with medial border of foot Decreased single-limb balance Prolonged double-support phase Late heel rise Plantartlexion of Ipsilateral ankle in swing Genu valgus with weightbeanng Hallux valgus Lateral and postenor weight shift Late heel nse Decreased single-limb balance

Metatarsophalangeal joint subluxation Diminished roll off Decreased single-limb stance Apropulslve progression Decreased single-limb balance Hammer or claw toes Diminished roll off Decreased single-limb stance Apropulslve progro Ion Decreasod single-limb btllonco

'n~~=====::J

Tenderness over subtalar midtarsal area limited inversion range Weak and painful posterior IIbialis muscle Pronated welghtbeanng posture of foot Lax medial collateral ligament of f..nee

ReI &we subta ar a mldtarsaJ uwerslOO Increase an Strengttlen posteOOf bas Stabl ze hype
Lateral deViation of great toe Swelling of firsl MTP )olnt Shortening of fie or hallucis brevis muscle Tenderness of great toe Weakness of great toe abduction

Accommodate foot w,th "ode to<> Increase extens) n of reat toe Relieve ,,,elghtbeclnng stresses

Painful MTP heads with weightbeanng Callus formation over MTP heads Ulcerations over MTP he3ds Limited MTP fleXion Prominent MTP hen s POSILHO of MTP J Int hyperE"\t€lnslon with pl\.")\lnkll and dlSltlllntol phalc1ngcoi,11 lilt fll'l\IOn Poslum of MTP \\I1d dlstfll IntE:'l ph,\ldI1ge; ~11 JOint h\ pi'fi"\ tonSlon with proxlnl
nil us 101 1ll11110n HI pl~\"t," tipS lInd dlHSlun of pu.")\lIn.ll Il\tl1Ipth\llll\~W,\II'''")II\t IlillItl\d M I P IIt'\ll)1l

Polntul h To huol plltlorn

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Chap,er 26 \nhri,.. ,'Ill \\1 tn..'.ltm,,~nt ;\1ld '" H'l~ Ih ..." l'\I"-'nl . . e (\1 the C~lre

'\

,

, ." , ,,' h'

.m.un th""M_' 'cit n.'!'
....' \ 11t\ "'I

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\.'hlhtll

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nnH"lll.tl n~lTttt.'·T. ~ ~\\\~U\' flf pll~"K'al b~lnie" m thl' .. ",\1 ~'m If(. .nmt.. .nh th.lt might rt"qllln' ~rx·citic ,'1 ,\ ).'\ ....'...'t'mnlcl'I ..i;l.th..\n" fl)f ch:mgc \;o.t.'e Chapter ...... _ "h'n ~'~'llt tht.." h('111(, .Uld "or ('11\ If'()nmenr... '.. . . ('t'l,1,t11."'lb th;\1 Impede reg3ming 1.."'c,.")mplt"le" mde-

.... 1' . .1 ,hc\\11...1 ,\

. ....

),1 In.l..}..t' Ilk- Inti1\ hhul 3\\ .we of the lX"):;...,i~iht1('s; ~ ,'~.:' ,'n\ 1\'nn)('nt:-.. The CI..).,I~ of :such changes '1 T1n~ fa . ~tor . t(")f lmrkmt.'ntil'l.g the:ile T&.'t'mmen~.: ,,('\r1... ~ll\ ll\.\nmCI1l .life-cts I:!mplo~ ment 3.l1d , '1\"\~'" '\ 3~' th~l11 thi" rh~ ~io.'31 ~t"ning and lob'!.. .' \ . :·,. . ...:-l'T.U . . . . and nnliC'f'.tanding b~ ,uren 1u.' \\,,'1rj...~p.. ...,1' tht" Jl .........:bC- and self-nunagement , . f 1.h~ ""'rk. . . -r ''It :trthritl~ an:" 1111p,)rtant ,,,'1'f ~l3.,nt3.mm:: ,,"nlrk")~n"k"nt ;lnd in..:-ome-

h . ,,~l The-mpy lntecve-ntion 'X'" !

~

,,")i ' 2-'-...... - Ln..... 111..:' ,p;1t.eJ ~"'\ll' ~ e\..f'C\.''too .n.:ii'lJ 1" th 3I'thnris l~ ~"".,.,j (,")[1 the fol-

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em f ..")f fun.....-

311;\1I1 .... d 111 the mm"t c\pcdlcnl mannt.~. Goal and ou1 C-01llC-"\ ...houlJ he "'~Clfi(311) lallorcd to meet t~ need of the..' p.\l1ent . .\OJ ... hould l"I\: . . tatOO dcarl} an term of t:nea! uTahle cnleria and Ihe I1me pcnod rro~d lor a.:hle\emen I (e.g .. lIll:rea'\e RO~1 0' lh~ lell "\houlder In 1, \\ee ~ and indepcndcnl amOOla",," "llh plallonn crulCbes 10r.1 lea~1 ~50 ft \\llhOUl fatigue \\lthin I month Stall:':!.! tU'D( franle ... for .lchic\t'mem of goa)... and outcome ~e as a "her for the therap1't. Failure to J.chle\.e a cert.lm ~ n 3 propo>ed penod of time ,ugge'b thaI the lherap' I Deeds to reeulU'le Ihe namre of the problem or reformula:" !he POe along different line, 10 produce the cfe.,ired effect. Goals and out(,ome:, should be re\!--ed to reflect dWl_ 0\\ ing to other facto:: that m3~ affect progre'>' or alter the prop<.. . ~ed time fr..lmes~

:\Iodalities for Pain Relief Theraphb m3.~ .:hoose from 3. '\ 3I1e~ of p ~ "ica! ao=- ~, pro\ ,M heal Of ('old to affected 3re3.>. lbe ~ purpo~e of the'~e modalit1e-~ b t(l manage pain :md iacib~ Tate more c('mfof!3ble e'\.eTCI~ and phYS.l.:-al xu, I ~ SuperficIal heat 15 \be'd tv pnxiL....--e loc3.1ized 3n.1l.;~ :!

m31

:mJ m.:reJ....e local .:ir.:ulanon to the .area to l., C i t .... arrhed. It renelI'3.te!- ool~ a feu mtllune:en. ~ doe-.. DO( enter the Jerth O!~ the ~~Th."'!\ .Jl ..":3.\ ~ ....perfi...i.ll .7311 t\t de 11\ re-d thn.'\>ugh :t number (, f f'Ilte:tfu: ClO' Sl t"ill: he >tin;, jUds mJ !arq>. p.tr.1ffin. ""j h~ droL.-=ap. There b. n ..::-onciusi\.ee-\· :::e'..u.lll~ IDd:bori .- 3p ..::nl('l.n ..l.:hl '\~.!- 3. :51gnlfi":-..l.."ltl~ n:~ ~~-C e'::'~L. NIl p.IDe'r. ....... 'l.' ~ e I'etxXt.3 gre.x:eT *r.m...~ 'for ~ ,..--omfC(! ~n\ ed in: ITk> -J !le.n. P.!ra:5n ~ l'> ~=~.

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dl. .,"'tl\t' '" In R -\. h.nlll ,10,t \\ n,1 \)nhl),c", 1ll.\~ he 1ht'd III Il111lhlhlhz ,(': 'Iti~' ,tfllllh .\1\\1 htlp I\.~d\ll't~ p~ll11 ,1Ild ," t"1I11l~ h\ r{\'\\ Idin~ It,,:ll n."'1 .md ,ur(,\)n. Srllllh m.l~ Ix'" fUlh:llon,11 'rlim'. \'-\.'\m"\.'11\ t" ,plIO". re,lIng 'pitn" Ih.\I .1I't.. "Ilm .11 m,;hl \.')r pt"n('lic.lll~ Juring the d .\~. l'\r ,llfl \.·nmprl.-·"Illn Je-\ 1\"(":-" Tht" u:-.r of fun,,'lil')tul \\ ri,t ,plinh 10 Jt"l're;tx(' p.lin and In\''rel,e- tun~lton In R-\ .lrpe'.lrx 10 h.\\ t.. . m('n!. Rniu",~e-J p~lln .\OJ Imrm\ cod grip .md plOch 'trenglh an: reJ"l"lned. There h 'Oint' c\ ide"l'h:e thai :-.trenglh ,mL! dC'\tcrn~ ma~ be lmp;)ireJ tnllull~ \\ hen a 'phnt I' applied. \ 'lUd~ m.ll m\e'ligated the- t:'tleC't nf fUllctlC'lnal \\ ri,t 'plinl \\ e.lf on t;c.. perfoml.ln.:e rep~)ned that \\ earing " cnmnlt:'r..:la11~ .1' ail able elaxuc \Hi,1 ortho!\l ... re ... ultt.'d III 'Ol11e dn."reme'nt In perforrnanee ::.peed on a number of common t~l '. though p.lin "a~ !\igniticantl~ reduced for all iii 'I " ,x<J Onho,e, abo n1.l~ be u:-'e'd to aile' irHe pam through biomechamcal ... uppon or correcllon for mdil iduab \\ ith "nee OA. FOOl onho,e" de:-.tgned 10 reduce calcaneal \'alglh or foOl pronation and reduce mechanical slre ... !\ al Ihe knee appear to reduce pam 111 ...orne mdividuab with knee OA.~I Other method ... that . . ho\\ promi ... e in treating knee OA pain are pateJlofemoral tapmgQ(l and load shifting knee brace,.~1 All OnhOIl inlenention'l require profe'lsional C\aIUalion. -.election. edu\.·ation. and monitoring of use. Complete ~d re ... t i ... rarel) recommended. Adequate qualil) and quantll~ of ,Ieep at night and shan re~h during the da) are preferred, InaCII\Il) is a common problem for people \\ Ith arthriti .... Inadequate ph) sical aCli\ it) re~ult ~ in decondllioning. depre~'1lon, lo\\er pain thresholds. dim ini~hed bone and '1ofl lI ... sue health , and increased risk for a number at seriow, condllion'l. Thu .... a major goal of care i~ to a ...... I"tlthe per...on to maintain or regain adequate levcls of ph)"'lcal aClJ\il} and a\oid the unncce ... ~af) consequences of Illactl\ tl),

Joint ,\ Iobility A major f;,J\..tor attetllTlg Joint mobllit) 111 IOdl\ iduab \\ IIh RA ii the It:,d of inflammation and posilion 111 \\ hi<.:h Ihe) are kept \\ ht~n not In mouon. Patient, should be taught proper posllJOnlng \\ hen rC'Iung and ... hould be encouraged to perionn ·If RO\1 to the eXlent pO ...... lble 10 ll1.unt.UIl mol1"n, Thcrapl t may appl} neuroph) '1lolog.il:i.11 pflm': lplc ...

,'l Ih\'l.II~·lIlh l'\,,·I\.I,(' hI h'II~'llInl .. hnlll'lInl , 1111 I Ie l'.IIII·lIh ,hnllill t,,· V I\l'll 111\' 11111'011111111\ III II'" I hlillt 1111 "h~'1\ 1'Il'IIII\Il\IIl).! IlIl'\I' L·\l·I .. lw 11,1111 .111111111 hi" ' I III.' h'd .11 .11I1IIIIt" ,lIld ,l1l1l1ld I,,· 1l1l1l11la.1I .tllt'l t' l'lll'l ( 1I!lIIIhll1 "1'111111\ h'" \\IlIllWlld, Ih,lI ( ' \ I / ( IH lIIalll (.1,'11111 ~II " "11 ( "II, \/1/, 11 tlJ/l1/ J 111'/11 Illht.' ".lIll'l1I It'pOI''dl''llllllllll',, I ILl' III I IWIII 111 ..... 1 ['kllt'IlIl,lllndl,,',11I1I IIMII'IIIlt'1 IIIl' 1111' 111\11\ III 11ll' dlll.lIl1lll \II Itil' ('\t'ltht.· \\,1, 100 !!II',11 ,11111 ,,11111111\ hi: h·..!UlI'd .lI Iht.· 1lt.'\1 l'\l'rn"'I' 'l'"UlIl P,lIlt'n" ~hlllltd h, l'lll'IHII,I!!l'" III t.'\I.-·II."I ... (.' l)l1 tlWl1 Imll dill Ill).! thlhl' 111llt', lit Iht'd.l.\ ,,1lL'n Ihl') kt"llx' ... 1 I.tllid pillI1 rdld 1110d,IIIIII' pllllr hllli hllhmlll!! Ill'illl11t.'nl dI'~ IIl1Ptllt.lIl1 UIIl,.tln,lIulll .lIld ,hoLlld he tl'..e-d ,I .. Intill',ltL'd In hlp ;ll1d knee 0", IlUIllldl Ilwrilp) Illil} nlll'l ~lIml' hl.'llt.'itl \\ tltlll1 .1 l'nmpreht.'lhl\ t.' lI~illllll'nl plopr.Llll Ih,lI lIll'1l1t1t" C\L'fU,t.'.'1\ t\ lnl1l1,11 Ihcrap} h nOI ~t.·Ilt:I'llIJ Ict. .lIHllll'lhlr:ti for Indl\ Idual, "llh R.\ \\ hi) hil\l' JOII1I Intbm lll.ltllUlllr re- .. ult,1I1t 1.1\11)

Strengthening D('crt.'~ht"t1

tnlhde hll1t.·IIOI1 (,trt.!ngth. e-ndurann' P{)\\ C'fj III pa.. on, "lIh arthnll, ilri'lc'I tmlll .1 IlUlllhl.'l tit "'{)lIrle ~, IIlIJ';l-.lrtll·ular and c\ lra-arl ll'u lar Inthmmalt)r} tll . . t.'.I ' !.' proCC'I'It" .. , ,iuc errCCh of mcdicallon, dl'lll~C'. fell!.'\. II1luhl ' lion in rC'Ipon ... c 10 pam and .101111 ellll ... lon. Imp:lII't.:'d plnpn · necpllon, .tnl! Ith'l of mechanical IIlIe-grit} afOLlnd tht: JOint. A \.tricl} 01 condillollll1g progral11!-' C11l I~ t.'ttl'ui\ C' 1m imprm Illg ~trcl1glh. endurance. and funlilOIl \\lIhout C\ v n to significalltl~ IIKrl'Li e nU articular pre ... ,ure and reduce !-')110\ lal cin:ul.lli llf) InMrucllons to a pmielll for l"'OlllctflC e'\.r: rcl ~ C ~Jw\JIJ includc Ihe caution ... 10: ( I) maintain thc cOlltractHlI1 f

v

( hapfu 26 \rlhrili

101i)

2 6 Puq)('""·,,. P.u.ml\'h·p'I dud Pn.'ulUtion~ for I~omcl('"i c and Ilynamic t

~

.. h"

\tr('Hf(th( nin,!

'--~~----

Dynamic Purpose

at ophy fu t on lind wOlghtbodring activity "m

.. Increase muscle power Improve funcllon • Promote strength of bone and cartilage .. Maintain/increase dynamic strength and endurance • Enhance synovial blood flow

Ie tOll6

1 e .1,

tutle strength and endurance

Parameters

m it tunCllOflailolnt angles I

IV

• Perform In pain~tree range I Use functional activities/movement patterns • Intensity: Progress to ::=;:70% one RM • Capable of 8-10 repetitions of motion against gravity before additional resistance • Duralion: Progress 10 8-10 exercises, 8-10 repelltlons .. Frequency: 2-3 limes/week on alternate days

70' one MVC

6 ::;econd contraction ncy 5 10 repetitions dally

Precautions

re·.1se blood pressure

liurmg contracllon, avoid Valsalva maneuver " 'lcre·.tse Inlra·artlcular pressure e Isecl mllscle blood lIow Iv

m uumal voluntdry contracllon; RM

• May. Increase. blomechanical stress on unstable malallgned jOints .. Avoid forces on involved hands and wrists • May increase intra~articular pressure

OJ

---

repetillon maximum

III d 1~111\t ... Ihlm daillag~. SIn..:nglhenlllg CXeI'Cl~C ~hou ld PCIiUIIHl,.'d \.\ Ltllll1 the paUl ih!C range rVla \111111111 bcncii! til..! 111 UIIH.:n.U1l·C !,.: •.LI\ be i.LdllCVcd 1"1) Incorporallllg func-

m t~

L 1\ Ii mml'l1ll'llh ,LIlli hod} po ... lllon ... 111 Ihc recommended { lI ... rOllin\\.' I h\,' patient ~hnllid h':ilill In pl!lfol1l1 cxcr~ I It" Ihmi\.dll~ "1111 \\cll-t"olllrolkd movcmenl Inward Itt\: \:1111 P,U-I \11 the range iUU.I to modify l"e~bli\l1t:C. ropcti~ Ihlll PI heqlll'l" \- llI\c 1I: ... lllh IHld

acceplable adherence.'>7 Evidence supporting the lise of exerc ise 111 the management of knee OA is presented in Evidence Summary Box 2n.3Y~ lOl

Joint Protection Theraplbts should larget func li onal aClivitie!:. Ihilt require ~pe­ cHic I .:c hniqllc~ joint proleclion."12 A randomileu conIrnllcd Iriallhm com pared the effcch of an educalion-behm-

or

~Iandard educallon (each 0 1 of t\\o~holll" se~~lon~), demons.trated Ihat p;}lienb 111 the joinl prOlcclion group adhered to joint protection slnlll!gics and hud signilican lly le~~ pain, mOlTIlIlg 'Iittne~~. di ... casc nares, vi~l1~ 10 the doctor, and difficultie~ \\ Ith ADL ,II 6 and 12 ll1onlh~ follo\\,l11£ the lTIten'enlion. P.ltienb ... hould be enl'our.lgcd 10 incorpor.llt:: Joint care min all ADL In Illlllimill.! p'lin anu consene ent:rgy bee Appt:"nJI\ Bt In addilion tn reducing pam ,lIltl unprm Ing tun..-thln. onho"e~ ubo 111,1) prm ide ~uPJ1ort .md proh~l.:tinn tor \ ulncnthlc HIllI palllflli joinl~. h)ot ol1hotil.: ... or "pc'-'Iall~ dt.!~lgnl.!d sh()e~ can sen to! the du.11 pUrptht: of rellc\ in!! hll"-lllechanlc.1I ~ trc~~l!~ .1Ilt! enh<m(lI1~ h1l1(III.)n h\r Ihl: !'X-'r:>L n \\ IIh R A fonl 111\ nh L'111t.!nl. l Ilil .~ J he U.hlllt ",pcll~1 ,ru"lo.:' Illil} not be I~imbllrsdhh: llnlkr nhlO~ Hhur.UI":' pn~f,lm, -\ good shoe \\ III pnn ide ~lIppon .md chnun,LI Ullih. ~Jn IOlnl Illlllilln III tht: 1~1r",,-·.lk ,m .... ,11 Ill'"t \\ uh a IIml and \\ llil.: h....d L"lllllll .... 1 II ... hnuld .11", hell) h.l Ill.unt.un nomul hom ILltgnm"'1lI .\Ild .IH \'l11ml 1.11<.: .lil c\ 'Hn~ hlUI !..k!f\ rm 11r.:~ \\ IIl\1n II Ill\.' b\l\ 111 .llk·~lu,lh. dlllh.:n!oolon!oo Po: MITe ,Illltiid Ix' l'\ L:nl\ dl,lllhHlCd .Ih'th~ the plJ.nt:u- ,urfa..: of th...

ioral ,Ininl prolectlon progrdm 10

cOll~i~lin g

I'bni I RdubiJ

KIn

Evidence Summary Box 26.3 Themp uti ExercLs in the Managem nt of Knee Ost ()arthritis (0 R..fenm~

Subject..

& · er Rat

4655

'..,na9069

2001

Thomas. RS. at aflO 2002

o.u.tion

Melhock AC +

6

Res.ob

2 _'OJI)S

'0 "l.i;tl" ~'I:rt

~ ':I-.go:

s::cr'~

Lafler eJ"1e

Kneepaaswl radoographocOA

strength tra '" '"

78655

ACT

• r..:s

EP 3)( I~ee home

;~

a~ ~ VI:JltO,"

.~~~~!.'

r,-s

,

~-Ern

,"

"~I"

lean age 62 :!: 9 self-reported knee pa..

Huang. MH. el a1'"

132 Ss

RCT

S; _ = "

2003

mean age 62 '" 5

Compall!d lSOtoruc. neilC. lsome nc slreng1h

a"

radlOQrapluc OA

"'- ""'..- ' - ...

traJntng 3>; \\ ee

Fransen, M. et ai'" 2002

HEP

1 RCTs 1633 Ss

home exercl-.( program; RCT

Systematic ",V1""

randrmll/ed dllllc31lnal. S'

fOOl during weighlbearing. To acllle'. lh" goal mal requIre lhe fabrlc.lIon of orthoses. A rocker .\O/e (shoe so le lhal " curved at the loe ) can be used to faci ilwte toe ofT \\ nil limited ankle motion. A controlled trial \\ a.., co nducted of the enecl of off-lhe-shelf e'lra-d eplh orthopedic fOOI\\ear for people with RA and at iC
the extra-depth

s h oe~.

The foo twear group Il11proved ..,Igml-

icantl y on self-repo ned di sabilit y. weightbcanng und 11011 weightbearing pain, and gait. In addition to e~ tra depth 111

the

~ hoe

toe box. the \ hoe ~ provided grealci rear foot o.,labl\-

"y_an arch , upport , a Sliff , hank , and a padded heel co llar above the heel counter for improved lit. Thl ...... tuO) reportell thal walking pam accou nted for 75 perce nt of th e variabJlJt) in phy\icaJ function level of the wbjcCh. ]/I~

Endurance Training The card lOva\cular ntne~1i 01 II1dl v idu a l ~ Wllh RA or OA ma y be co mproml ~eo . A number or we ll -controll ed trial ., have reponed th e ability to Improve thi ., Impi.llrl11Cnl through regu lar cardiovascul ar co ndit IOning Withou t aggrayaung Join ,.,. Progn,lll1., \J milar to tho ~c de~lgncd for decondlt]()fled mdi vi duab can he in..,tlluled I'm IIldl Vidual ., wuh arthntl.,. If we lghlhcaring i., a harri er to cxcrc i...c. a non-wclghtbcaring <.JPP<.Jru tU \ .,uch <1\ a l:Yclc crgo mclI Y 0 1 aquatic program may be u.,cd. For 1110.,t people. wa lking and ~ tatlon ary bicyclc\ arc it ... ale ami cffcU IVC mcan., 01 aerobic exe rc i.,e.')(' r· urth crm orc. pallcnt ... who h
'Ull}o.:l'

... creenll1g a ... appropnalC lor age anJ meJ. ... hould occur rrWf to i'egmnmg an ~\en:1

cntall.., milJkcd IIKrea"c 111

rh~

"I\,:a\ adl' It\

J'UI1Cllonal Trainln~

Funclional tral1l1ng l(1f the II1JI\ 1\ju.11 \\ Ill' Jrt reed" 111 the ... ame fa"l11on a ... h1[ Plher II1JI\ ldu 1 \\ liar deotl' ... Thclapl"t ... l11a~ \.:11\1\1 ... (' ttl I\: lu 1I0nai demand ... \11 JIl aUI\ It~ clther ICI11("1 1.1 h under condllion" 01 acute 1I111allll11.lt1\,111 lr I 11 lI1(orporattng i.l \ arlct~ (11 .tld ... Inltl 111 th t u I O~ 1 RO 1 ilno "lrcn!!lh, The"(' l11PdJll\.. 11 II long- handlell appllal1l:c'" .II1U dc\ H.\..'\, \\ III I' lor ea"ler gH\\p. r hcfe .tle .tld" I~ll df\:" III n a ... well i.\\ per"'ollal h~ g.lel1e UE lIl\'oh'elllenl 111 I{ \ . paltll'ul,Hh \'1 hi.Uld .... may l'o(l1plll:JIC lhe dlPllT ~ll ,Hl 111111 plccJud1l1g an) \\(,Ightbcann~ 1111 111( ...1.. .Itl \. tI1 C\C In<.,(al1l:c .... plJtlorlll .IIlJdlll1l'lIh 111 \'1( lorm the f(l rca nn II1lll i.1 \'CI~hllx'.lr1l1~ ",11 mg th e h OI11(, 01 worl.. cm II (lJlJl1CI11 .11,11 111 111\ ... on .... IUIH.:ll o ll al JI:1I1I{1c", R.II<.,mg 11<,(1 ... III dl \11 Ih c e fl ort needed 10 "",lIld up R'lIlilll!" pit I bcd. halh . ami allllJg ,'..III \\ 1.1\'" al"l1 l ,1Il Ii Ip 111 Indiv idual· ... Illtlcpcndcllll'

(;ait rr:.liuing

r

"

h

"I

\\ 111 he l'\ IlklH thltll1~htlUI illl j It: I cyc le I'hc"'(' ma y lI1c1udc gall U"" 1I1111( IT Il . .1 . I , I I' In) I vclol'l ty. l'm lclH:c and ... llIlle leng th . PIPllll!..:ll S pcclf lc lICVliJ1lllll'"

Chapter 26 \"hriti j

blc .. upport. madequate h~e1 .. trike ,lnd

I()C-ott ••lnd

dunlOl'~hed JOint e CUf"tlon through both . . " Ing and ",t.mce. (j;nt dC\ 1.lllnn .. In the paln!nt v.ith R.\. 'Ipcclficaliy f)\\ ing to

or detormllle'l, rna} 31 ... 0 he eVident hee Table ~n :; 1l1erap, ... t...... hould addre", ... the under!) 109 JOlOt and ~mVJ.mncnt... that contribute (0 the\(! de\' iatlOn . . 10 the mmg: progmm "ith per... on", "Ilh an~ t) pe of anhrHi". jegrce to "hlch Ihe galt of an individual with aJ"'Ji houhJ. or can. approximate normal, . . one of the I'll Ifll.. ult que ... uon\ In de:-.igOing a therapeutic prome "'abnonnaluie<;," '\uch a . . antalgic limping rna) reduce jo mt loading. jOint de . . truclJon may nece'l~ital t INrod uLlion of ambulatlon aid . . as cumber')ome a~ pia" on cu tche, or rolling v.alke" \\.lth platfonn attachmenl The g all of the JOdl\ idual w. ith RA or OA o,hould be ~f • funclio nal , and co ... mclically acceptable 10 the patient r (her than an unattainable ideali7ed ver'lion of the norm. Decreased v.alking \peed in arthritis is common. and there I general agreement thai Increa . . ed . . peed i . . a meanm~ful mea . . ure o f fum:. tlOnal improvement. For example. a per on's abilit) to v...alk fast enough to cro,,') the . . treet \\ilh the tmllng o f the traffic light i, important for functional COmm Unll\ locomotion . However. increased walking ... JXcd " lthom allentlon to joint biomechanic~ may be unJe \ lrable. In a clinical trial of a non~lerOidal drug for ~"on ... w.lth knee OA. all with a varus deformil}. gait variable ... "c rc Included a.. . outcome mca!;ures. The re~earcher~ found that ,elf-reported pam d,m,ni,hed and v.alkmg \pc!ed Increased In the active lhemp) group. At the ~ame lime. klnellc anal) ..,IS of joint forces \howed the increased "peed v.a . . accompanied b) Increa.!o,ed adductor moment at thc knee and greater loading of the mediaJ compartment. II~ Thl . . additIOnal loading of the joint and increased Mress on lateral ,upportmg ti"ue may not be v.orth the gams of mcrea ...ed . . peed. Attention 10 biomechanical factor\ thus \hnuld be con'\idered 10 comprehensive management. even \I. hen drug therap} decreases pain and ImprO\es gait speed. f!J01 ?am

-

I-.ducation P,Hlcnt education 10 the rheumatic dl~ea")es has been sho\\ n In rc,ult 10 po . . IlI\C change~ in kno\\ ledge. health beha\ iors. ""heh. ,md att'tude, that affect health 'taw>. quaht) of hfe. JnJ hc.lllh cafe Utlil/alion. 1~ AI) in an) chronic illne . . ~. educatmn ... hould IOciude IIlfonnation needed to deal \\ Ith the

Q uestions

for

1O~1

cOndlll(lO (taking medicatIOn". e~erCI~). sell-management ,kill, nece' . . af) to carry out Important \cX:lal4Jnd vocalJonal rolc ..... and rco,ource.., needed tCJ deal with the emotional con~ ...equenceo, or l:hronJc IlIne..,s "iuch a" depre ~Ion. fear. and fru'ltriJtlon. The e\ld~nce i, ovcrw.helmmg thal educatIOn de,igned to teach \elf-maniJgement ,kill and mcre:a.\e chent . . elf-efficacy for the~ t~k, i... the mo... t effective. 6 The ArthnllJ Fount/lilton (1330 We . . t Peachtree Street. Atlanta. GA 30309. ~04/872-7100: http://\\.ww.anhrill •. org). can ~upply the cliOician or the individual V.ilh a vanety of educational material,. pamphlet>. and \elf-help Cour'e . . that v.ill incre~ cogOlU\e under\tandmg of the d"ease proce" and ,elf-management sktl". \lan) local chapters of the Foundation hold individual and family ;uppon groups to increase psychosocial adaptation a", v.ell as run aquatic and land exercise programs in public faciIitie.,. The Association of Rheumatology Health Professionals, a dIVision of the American College of Rheumatology (http:// \\-w\\-.rheumatology.org). can provide the therapi~t wilh scientific and clinical enrichment for enhanced practice. as well as a network of professional colleagues \\ ho \\-ork in rheumatology.

Swrunary RA and OA are the two kinds of arthri tis that a physical therapist is likel) to see in clinical practice. The primary functional limitations of the individual \\ 'th RA or OA result from musculoskeletal impairments. lrreguJarities on the bone surface. loss of joint mobilit). muscle v.eakness. and atrophy contribute directly to limitations in ADL and the abilil) to work. Pain secondary (Q changes in nonnal joint structure and funclion oflen limits function as well. Musculoskeletal impainnents related to arthritis may also lead to impainnenb of other systems. such as decreased cardiovascular endurance for func tional actlvities. The ph) sical therapist is v.ell suited to evaluate and [feat these impainnents. remediale the functionallimilations. and educate the patient in self-management ,ktlls to avoid unnece slll) disabilil). Rehabilttation of the indhiduaJ \\ ith aIThritis is most often directed to\\ard re...[oring or maintaining joint mobiliry and srrength and empha"iizes functional retmining and health promotion.

Review

1. Wh.11 crlt.1en\iolllgi(.·~ll factor ... arc related 10 RA? 2. Wh.It..lre Ihe malt"lr p~Hhologlcal change ... -;cen 10 RA·~ 3 . SI.ilt' tw.o h~ j'l\llhc'c'" ("onceming Ihe: pathogene~l:-' of

R\ 4 . 1),:,..:nllC: Ihfl'c I.u..:h'''' Ihat Illi.l) preul"'po:-.e an IOdl\ 10ual hl (hlc(l.1nhnu .. 5 . 1l.;.·'I..'nt'llC 1\\0 (h.lOge' 10 .1nu.:ular ..:.lntlJ~e .1 ...... t)(lateo ",th () \ .

6. Name at lea:-.t 1\\-0 labor:llOf) h~'" u-.ed In the oJ.lgno· ... i... of RA and ... liJ[C their pUfPl),\e ... 7. E\plam three parJ.metc", for orienting to r<.tJlograph,. 8. ne . .cribe the t} pkal jOint I.:hJ.nge ......cen \\ Ilh R·' for the follov.lng JOint...: atlantllil\ial. tl'lnporomanoloolar c~lfpal'. knee" .md 1i.lI(x"llt"dnc.ll 9. Ddin(' ttl<: folh:m.lOg dctl)mlll1f:~. ulnartlntt .... v.atl ftc:·k boutoIlOlcn:. hamme.'r llX' . dJ" tll( • .md hallu valE

R ,eI..bi htah, n

1tl tl, . . l.u ...... 1"''.1\ 11 h.' I\( .111\.·111.111\\.· ... h'l 1Il\:I\'I'\1I11' R()\I 17 t~·'I .·" II \',II\IH1\."llll,1I l \llhhIUIIIIII~' l'ttl~1 •IIII I \11 11\ IIId1\ nlu.11 ,\ tlh I I 1~11111 111",1\ l'll1l"1I • 18 St.II\.'.tt k.t,t hlllt pllm'tpk, ~ll IOIllII'lllll'llll III .11h I ~1 \l·.1 Pllldtt",I.tpphr,lIl\,lllll!l',ldl

19. \\ h.lI

t re lbe geni'r.ll ~t"\3b. ,,-"'I rh~ '1("~11 tlk'r~II" 11\ 1 .3tmg mdt, Jdua).., " tth RA t'f O. \ ,1 5 . E plain the g\"3" and rrogrt", ... ion of ~t :-trt"nglht:'ning

.:.

r

l'llIl'\ hi

l.!ullk thl' ... l'Il'l'!IUI111t

•

... hOt"

101

III t' !l1l1!

\ \llll,l! \\ 1111 R \ 'J 20. \\'h.\1 ,U\.' tilL' purpl"l" 01 'phil"') 21. Dl''''l.'nlx· ~dll t.!t.'\ Idlllll\'. u)1I1Il\olll~ 1I"'''\)("Ial,-'1I "nh R\ 22. Dt, ...t'ribt'" hal kind ... 01 ;1'.. ,i ... \I\l' lit" Il' l" ,lIld illllhul,lllun aid, .11"1: IIlll,,! ottcn Ill'l'dL'd h~ till' lI1dt\ idu.tI \\ IIh

gram.

Stu d y T"o :1...-< ,rudie=", are pre!
\\ nh o ... leoanhritl:-..

CASE 1: RHEUJ\,fATOID ARTH RIT IS IIi ' tory The patIent is a 35-year-old married woman who has two children in elementaT') school and is a ta\. accountant. At this time. (.;he \\ orks about 20 hours a week. She has been referred to physical therapy by her rheumatologist \\ hom she has just seen for the third time. Her history indicate", a 2-year period since her initial complaints of joint ",welling and pain. fatigue. and increasing weakness. She had been diagnosed over this time wi th carpallUnnel syndrome, knee osteoarthritis, fibromyalgia. and Lyme di')ea\e; however, her symptoms continued to wor\en on NSA IDs and anlldepressants. and she was referred to the rheumatologist 3 months ago. History, physical examination, laboratory, and radiographic e\'idence have confinned a diagnosis of seronegative RA . She began a co urse of methotrexate and NSAID, I monlh ago.

Phy,ical Therapy bxmninatiol1 At the initial examination by a physical therapi<;.,l. she

reports that her morning "'tiffness is now less than 30 mlflutes (previous high of 3 hours), pain and swelling in hands. feet, and elbows is markedly les", and she is feeling more energetic, SYMCm\ rev iew of the integu mentary "ystcm IS unremarkable except lor a sligh t edema and rednc" of Ihe diswl JOIOl s or Ihe UE. Il er blood

pressure and resplftJtory rate arc wJlhin normal limit .... Her resting heart rate i.., 72 but increases lO 96 with modest exertion. ROM i\ IlInlted al the ... llOuldcr, elbows, wri..,h. and MCP..,. She lath JO of knee cxte/l..,IO/l and has no anh.I!! dorsiflexion 01 hip extcn..,IOIl beyond I1!!Ulral. Sl r!!nglh I.., good Illinu", 10 lair. She exh lbils a forward head, rounded (hou lucr p"..,lurc, wllh Ihe hcginlllllg 01 H marked kyphoSl"'. She (;omplalll<" 01 Ihe 1110\1 P<J11l In wri.., t..,. elhow .... ,ifill

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GUIDING QUESTIONS 1. \Vhal arc Ihe anlicipatcd goa).., and c\pC'ue:d oulcOllll', of intervl!l1tion in thi:-; case? 2. FormulaiC a phy,icallhcrap) plan 01 care. 3, What rc'->olll'f.:e'-> arc available 10 hCI III the: C()llll1H1nll~ ii' part of her program of paticl11-rclah:d IlhtrUL"lIO!l·' 4. What support ive devicc~ might bc u\ed to deCfl'lI'l' symptom":. ,mel increase function? 5. How would her physicallhcrapi .. t ()ptlillall ~ ...{:hcduk her return vi... ih 10 clinic?

CASE 2: OSTEOARTHRITIS flbtory The patient i... lon. '11lti hypC'!f.:hllk~h I ,knJl,1 for which . . he take ... prescribed medlc'lt HHl . ", he II~ v. II/! her daughter\ family, lake ... carl' 01 the t\\lI, lenlent.lr) ,->chool-agc granckhildrl'l1 .• tIld help, '-" llh li lll l "t\,{l lj., dur IIlg th e day while the parent ... arc ill v. or!" ";h' Iii trouble gelling up and down Imm ... lIllill;!.. u... n' IJr getting in and out of the car, bathing lhl' lit Ilr n h.ld walking for more Ihm, I() l11inlllt.~ ...
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/'rHll ....·Il. M. et .. 1 Ilwr.lIJl'l.tll eK('fI' It". f't"1,k: \01,1111 f "·(2I.rdlnl Iltllll' 11IJ1llr ~.lIf"e A ..y II'III .• IK trVIIIW I f(h(lIfn .. e/,1 2" I'll '1t12 ("unklY, J( JIIIIII pllltc~tHlII. ,I (I" ptlf' IblhlY III the ht uptlll(lftal Iher,'peq AII1 J 01.(111' IIlC( Jf) 2K~, IIJ(,~ 1..or.l-l', M cl ill Ankl<: .1IId uhl'II .., ff1',III"1 dUring In arlhnu(; p.lflt'llt !'hy .. IllI't (,,1 ~1)4, 19M M;.r~'. H\1 "nd Myt't 1111. M'i J fJl'IIIfIIIII,,~It" I ,tJ In rheumsfmd "rt/mll. Bull Hheum '). 4(, I. I''''J? people I r,lI1wn. M, lind ' :..f/rwllld J ()II 111<: hl'11 'urll .... ur Wll h d ll'lutlolt()Jd Ilrthnll'l, Anhnll (" .. re Het Ie) lSI). 1'1'J7 IIl1rkt(JIlI,'/ M. et ifl I ht'rdf)C'ulJI vollue III ~r,,(kd ~fllbK: eutCI~ Ir.llniJl~ ,n rheum .. lfluJ .,nllnll\ Arltmll Rheum 2X 12 1'1'1.$ EkhlolO, I ~. el ill 1.llc,1 of ~hurl lerm phy Ital If.uomK tIn p"".c~ With rhcumato.d anhnt" I Scand J Rheum 4~', 197.5 F.khlwn. B el .. 1 J-.fJeU oj h'lrt term phY'lcdllrallllllg nn palll:nl wllh rhcurnatflld anhnl ... 11 \(',md J Rheum.$ IS? ICJ7S Nordcrnilf, R, 1:1 al: Phy .. italltlunmg rn rheum,lu'ld al1n,.11 A controlled long-Ierm "Iudy. r Stilnd J Rheum 10: 17. ilJli , Nordem'lr. R: Phy~I(;lillramlllg m rheumal(IIIJ arthOIl A con· trolled I(IOg-lerm "lUdy. II f·urll.llonal Capatlly and Jcneral au· tude ... SCilndJ Rheum 1():2:'i, 19k1 Minor, MA. clil l 1./ficilCY of phy!'.!tal cflnlhlJfJflIng eurc,;l\e In palJenl .. wllh rheumil toid anhnll\ and o'lleoilnhntn Arthnll!o Rheum 12: I 396, 19k9 Kovar, PA. el al: Supervi..cd filn(:~ .. walkllll( in pallt"nl ..... Ih o"leourthrJI ... of the knee. Ann Imem Med Ilfi·529. I'J"J2 Melton· Roger .. , S. et a l. Cardlore"plralOry re .. pone "lUdy. lIealth Edue Q 19:~55, 1992

,.111

"If'

Readin~

Olla.... a Pililel Evidence· Ba ..cd Clinical PmCIJ(.;e Gu ideline, for Thera· pi!utIC f'_xcrcl..e .. III Ihe Managemenl of RheumatOId Ar1hnll .. III Adult .. , J>hy\ Ther 1014 934, 2004

Ollawa Panel Evidence·Ba...ed Clinical Pru:tlce GU l deh~s for EICI:trothe rapy and Thermotherapy mlhe \ianag-cment of Rheumalo.Jld Anhnl ... III Adul" Phy .. Thcr~· 1016, 2~

PI' ndi A: Functioll' I StHtus Ind t ) , hi,1I W Iklng Inslll Climbing up stnl," hom n chnh

R""'Q

Personal Care Putt,n on pants Buttoning R shh Lblollse Washing all p , ts of 1I1e body Putting on a shil Vblouse Home Chores Vacuuming a , ug Reaching Into low upboa,ds Doing laund, y Doing yardwOl k Hand Act,villes Wntlng Opening con tainer Dialing a phone Social Activities Performing you r job Driving a car Attending meetings/appointmenls Visiting wilh friends and re latives

l

Used by permission 01Alan M Jelle KEY ASSISTANCE ' 1 independent, 2 uses devices; 3 uses Ilurnon AQRiRtfillt.O, 11 UCln9 rJIlVit09 and human assistance; 5 unable or unsafo to do Ille Activity PAIN 1 no pain, 2 mild pain; 3 moderate pain, 4 sovelo pnln DIFFICULTY 1 no dl1l1cully; 2 mild dil1lcully, 3 mode",'. dillirully 4 Revore dlilicully TIME FAAM

On average during Ille pasl 7 dAYS

'X

Appendix 13: Joint Protection, Rest, and Energy onservation .J«lInl l 'IHh.,·Ci ull \: P \lft1d'11tlImpllf,.IfIC"\ L'

111.1 lhw.n III 11111111111,' IOllll!. tlhlY !tltlll III pruqltb It IIIH Itlll[) ~II Itlc1 Illilli i\lld Ih SUI rOllndillq U~.:',lhl~' H IIllll 1:0 Iltll·t,~.~ •• IIV III PIllh1ct jUinh., Ull~'\}rv\\ ~

ld pit _,Ill 1,',1 hltH: Ilnrl ,dr'ltv \\ flUt 111.11 1\11111 IS PWIP{'tll(j by 1110 mu!-> IUld II th.l\ t\bsorb lilt' 101 t'!, 01\11)0 JOII\l, prtwor\l 1111) Ad

llilt

Il,un d 1',)1111 ltd ~"hll h l-.Ul dllll ,lq.llllt t

.,

no

ule

t'

llllltW h)'ldOIlS IHltUnnnl~, IHK! Htilltlqil I!'> Ilh1dl.Hllrllllv won!>. t\nd poorly ~It\hl Conll,hlltl' 10 Ihtl OVt)I~lrt""tC:hlnq 01 tllo 10 11 I\I~. (\lHI d.Ulh19fl to tho C.HlrlnQCl TllI~

1St d sllt)s.s l.tIl U)l'I\ Os,) thl) dostlll lion ollh,' JOlnl

dnd l' lll', IflCIt\\!'t1d

plttn

H.:m ) JOJflt~ 8d Pwtcll'tc)(j" lht m,un It.h),1 H1IOlnl prOll)cllOn I~ I mlnlml/£, Ih('l sllilln on 1'.)lnls In d,\lly .lCIIVIIi S JOint prOloctlorllocl1nlqul ~ try

10 rndllnl Ihu lI.uc( on 11\1 101nl. 10 -.Iow dDwn 111 10lnl tlrllnmlt1 Guml pO~UtllU tlnu pO!iIIiOnlnt), clliHlUlnQ Itl Illullmd 0 1 nil nCUvily. l ind plIclnq 11III1OIp 10 p'OI I th jU1111

W/IJr.II JOlllt!. Nt.'(ld Prattle/Ion'} Ptlopln WI III It I ililypt Oll1llhnll(•. Ilk 01.1 urllltlll, nOfld 10 pay clo~.o nt/orlllon 10 11m jOint. tllHI fir 'Iwohmd wllh Ih 11111\1111, Pnoplo will, " "-Y910mlc 01 whol llodV IVil( 01 IUlhrlliti. U"lI IIloumlllold nrthnUti, !lood to IttdllC 11\ ~trt!' S un t\IIIIIOIl Jolnl!1 In f\(l{tltlon \0 111 JOint PIOlt 110" prlnetpl s Iltltl tl)(i\mpln~ lIr.tpd bot W, pnoplo Will, IhlltlllllltOld IHlhrll1 ~I\olll(j look ,\1 tim f.flc tion bolOw omlllN.! Addilionill Rflmlmtol~l lor Prol£lCllon 01 1110 RhtlUll'Iilluld Hllfld In pl.lnnlnq your JOIn t proll CIIor'. ~I lIllY conc nlf ling on 1I't! jOlntt> thot ilit CUlIt)nlly gIving YOll Iho mo t IroUblu Chock all Iho prtnclplo~; 111m Ilpply mo. I sHon Iv 10 you imd 1i~1 s vOl! Il))(Il1'nplo~ 01 how YOIl cun npply lhul prlnel pill 10 YOUI pfOblom JOints

JOINT PROTECTION PRINC IPLES Rt)s!..le}('( p,W)

tl /I IS UllPOI tlml to dlsltngUlsh bOlW('I('ln dl!"comloll llnd p lin b PllIll thtH It,slS 101 mOl Ihnn 1 10 ? 110111S {lflOI nn nCHvlty Indlcnl0S IhOI 1110 nCllvlly Is \00

2

3

stw$slul and Iloods to bo modlflon C If Ihol IS ,\ sl1nrp Incronso In pOln dUring nC!ivlly. ~IOp nnd IOSI. Ihon modlly Iho ncltvl ty d If IhNO IS lInu~uol pOln 01 slIlin('ss Ih no I dl1y. look bile" nl tilt, pIlW\OUS dny's nCllvlllrs to sea II Ul('1Y woro 100 strenuous. AVOid POSltlOIlS of D< formlty Tho loromosl pOSillon 01 d lormlly lor mosilolnl' IS 11,)"'011, b I1dll"l <>1 U, 101111 MI Intalnlng a ben! pOSHlon Incr~oso_ Iho posslblil ly 01 dololll1Hy a Stand recl, With W Iqhl ev nly dlvld d on bOlh 1001 b Lay as fl,lt as pas Ibl In b d, do nOI curl up 01 prop vOtlisoli liP on ",wornl pillow' c Work Will, your hnnds IInl d AVOid lighl gnp or squeeZing AVOid Awl.wnrd POSltlOIlS Use each 10lnt In lIs most Sloble And luncllonol pOSltlOn I Xllll sln'ln IS plnet tt on 11 jolnl Wll n II IS a b c d

IWlst d or rOlaled Rise SlrOighl up Irom Sl uing, rolher Ih,\n lo,nlnn 10 0119 Silit 101 .lIPPor! Reposition 10 t mll,or Ih n IWlsling Irunk or kl100S Siand on
til,,,,

10. ,

Phnical Rehabilitation

g Move large oblecls Wllh bocy welghl behind II, Ihe push coming Irom Ihe legs h. Push with open palm or forearm rather than fingers , 5. Use Adapted EqUipment. Find equipment that will reduce the stress on the JOint or make the Job easier The Self·Help Manual (or People with ArthfltlS IS a calalog at adapled eqUipmenl available from Ihe local Arlhnlis Foundallon. a EqUipmenl can be mocltled by: 1 BUilding up the handle so It is easier to grasp. 2. Extending the handle so It is easier to reach . b. EqUipmenl available: Walking aids Self·care aids Balhroom safety Homemaking equipment Job modification equipment JOInls Ihal need proteclion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Activities to be modified : _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ _ _ _ _ _ __

ADDITIONAL REMINDERS FOR THE PROTECTION OF THE RHEUMATOID HAND Through exercise, maintain wrist extension (ability to pick hand up off table) 10 ensure power gnp. 2. Through exerCise, maintain supmatlon (ability to turn palm up) 10 ensure ability to hold and to carry objects. 3. Avcld positions of deformity. 8. Finger flexion 1 Avoid making fist or lighl gnp-use built·up handles. 2. Work with hand flal-use dust mitts, sponges. 3. Avoid prolonged holding of oblects: pen, book, pan, needle. 4 Avoid putting any pressure on bent knuckles. b. Ulnar deviation (tendency of lingers to slide to little finger side) 1. Avoid pressure toward little finger side of hand 2. Any twisting of hand, open door knobs, jars, etc., should be turned loward thumb. 3. Gnp objects parallel across palm, not diagonal; for example, hold utensil like dagger to cut fooc, slir with wooden spoon. 4 Avoid stress on small joints of hand a Use two hands whenever possible b. Substitute larger stronger joints: for example, hft or carry with palms or forearm, not small finger joints; carry bag over elbow or shoulder. not in fingertips . c. Avoid activIties Involvmg pinching motions. d_ Avoid twisting and squeezing motions with hands. GETTING ADDITIONAL REST Rest IS Important because It reduces the pain and fatigue that accompany arthritiS. In addition, It aids the body's heahng process and helps control the inflammation, Rest also may reduce the stress on Jomts and protect them from further damage. All of these benefits are Important In managing arthntlS. Each day you need to make sure you get enough whole body rest, local Jam! rest, and emotional rest There are

many oplions: Mark off the options thaI may be poSSible for you. 1. Plenty o( Nightly Rest Gel the usual 8 10 10 hours of nightly rest. It IS nol as importanl that you sleep for that length of time, bul make sure you stretch out with your joints supported. so that your body can rest. 2. Daily Rest Peflods Ideally, several times a day you can stretch out for 15 to 60 minutes with your joints supported. Again, It IS the body rest , not sleep, Ihat IS most important. 3. Five-Mmute "Breathers " Partway through a task, Sit back and lake II easy for a few minutes, This will allow you to finish the task almost as quickly but more comfortably and wllh less fatigue 4. Local JOint Rest When a JOint hurts, stop and rest If your hip or knee hurts while walking, sit down for a few minutes With your legs supported: If your hand hurts while writing. stop and lay it flat for a few minutes Splints can be used to rest painful wrists or fingers. If your neck hurts, lay down with just a small prllow supporting the curve of your neck. Any painful JOint can be g ven extra rest. 5. Take Time for Relaxing Activities listening to music, reading. plaYing cards or !her light leisure aCllvites all can be a pleasant ch nge of pace and can be restful and refreshing for you There are unlimited options for getting add t on res! t takes creativity to find ways to fit extra rest t vo r schedule; then It takes self-diSCipline to make follow through, Incorporating the additional e t n ff n activities. Making the effort to get more rest P { a reduction of pain and fatigue. Ways to get more rest: Systemic, whole body rest Local/oint rest Emotional rest

o

o o

o

o

('h .. pler 2(, Arthrili.. ENERGY CONSER VATION TO REDUCE FATIGUE ~HU IS Energy ConservatIon Important? One of the major symptoms of arthntlS may be t,lt gue- getllng tired very eaSily. In the Inflammatory types of ar.hntls. fatigue may be port of the disease process. In al typos of ar thritis. pain and difficult movement may use l.:'\ it ergy. 50 you tire more easily. II ; mportant to avoid getting overllred Fatigue may Incr '. ~.' tile possibility of a lIare-up In inflammatory types of t :\ 5 II"a rheumatOid arthri tiS. In all types of arthritis. lat", rPllY make the pain and stiffness seem worse , and I'N lake acllvltles more difficult. We hope to reduce thiS 1311';# 'tIy conserving energy and using it carefu lly Ho ( /. You Reduce Fatigue? Some people try to conserve energy and reduce fatigue b\ slaVing In bed all day. Olhers slop dOing anything that is nol lbsolulel y necessary each day. Unforlunalely. Ihe act vilies thai are usually cut out are the leisure actlvltlesIhe enJoyable Ihlngs people do for Ihemselves or for fun. Tl-tese are not good ideas.

You can conserve energy and redu ce fatigue by modifYing and simpli fYing your activities, pacing yourself. gottlng addItional rest . and uSing adapted eqUIpment. Energy Conservation By conserving your energy, you may be able to do as much or more actIVIty Wllh less pain and fatigue . Wa are trYing to aVOid both overactlvlly and underactIVIty. Consarvmg your energy and slmpllfymg your work IS not being lazy. It is not sensible to overhre yourself. Overwork Will not keep your JOints mobile, but It may damage your JOints furIher. It is not so much what you do, but how you do II that can help control your fatigue . An attempt should be made to modify any actlvilles that leave you overly tired or cause pain that continues for more than 1 to 2 hours. You will need to identify ways that your own daily activIties can be simplified. As you read through the energy conserva tion strategies, check off strategIes that may work for you , and list several of your own examples. t. Plan the Task.

o

Your Examples a Think Ihe lask Ihrough. b. Decide when and where the Job is besl done. c. PJan out Ihe simplesl approach 10 Ihe Job. d. Galher all supplies before you begin. e. Arrange step sequence so that it moves in one direction (usually left to right) . f. Use fewer. more efficient movements to complete task. J 2 Eliminate Extra Trips. a. Organize your shopping list according to how the store is laid out. b. Slay In Ihe laundry room unlil your laundry is finished . c. Clean one area at a time . ~ 3. Use Good Posture and Body Mechanics. a. Sit to work; you will be more stable and use your streng th more efficiently. b. Use large strong muscle groups, rather than straining individual muscles and joints. c. Lift wllh your knees ben I, your back slralght. d. Carry objecls close 10 your body. e. Push obJecls, wllh body weighl behind iI, ralher Ihan pulling or carrying. f. Avoid awakward bending, reaching , and twisting . - 4. Don't Fight GravIty. a. Slide, ralher Ihan lift obJecls. b. Use wheeled cart. c. Use Iighlwelghl equipment. . . d. Slabllize pilcher on surtace and 111110 pour, ralher Ihan picking II up. U 5. Pace Yourself. a Gel plenly of nlghlly rest. b. Plan several resl peneds dunng Ihe day. c. Resl beJore you gel IIred. d AVOid a rush. e. Work al a sleady rale with resl period. f Develop a rhythm to your movements. 8 6. Use Energy-Saving DeVices. 8. Convenience foods. b. Adapled equipment. Slralegles 10 be Ined' _ _ _ _ _ _ _ _ __

I , ~ "MI I ... CIII rllrn II 1.1,),

"tn",.."')IOl ('h

Acllvlties 10 be modliled . _ _ _ _ _ _ _ _ __

I) II ..111<.:, 1'. 'I """,· ,nt'IIII,I .\nhllll., IkH'II1plll/ol. '"IUI (1\\11 Pl.1Il ' .. '1 mn.... LI'M1 II ..,I" I r~l'd h~J 1,,:nnl.,\111Il "I III\' .rulh,11

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r; /I , I I' T

-

lEARNING

H

27 OBJECTIVES

1. ne,cni'k: the an.Horn> .md phy\'ology of the ,\..m J' an organ In Ih~ health) .. talc and damJfcd ~ondltion Ihat occur-. \\llh a hum Injury , [)c ...cnbe the patholo!:!) .... ) mplonh. and ,equda of hum in.luric ... . .l. E,plalO the treatment for a pal lent \\ ilh ,.triou" depth .. and e\ICnl 0 1' bum injury in rclJIIOn to medical. \urglcal. and phy ... ical ,htrJp) manageml!nt. ... Idenur) the con ... equence ... of COniraliurc formalion afler bum mjury and the treatment of fhi ...

condillon. 5. Idenllf, approachc') to management of hyperIrophic \car..,. ,... PrO\ ide a rationale for the I) pe of .. km care f)tcc .... ar; after bum ,'aund healing. Analyze and interpret patient data. fonnulale anllclpated goa]., and expected Outcome .. , and

dc\dop a plan of care when clinical case .. IUd}'.

prc~ented "",ilh

a

Burns Reginald L. Richard, PI , \JS R. Scott Ward, PI , Phil OUTliNE !THk·mlolop. v (\1 BUfJ1 InJul c

(lIlJ

S~1n ,\natlll11~ mJ Burn \\ound P,lthol()~)

Cla"'>lfILlllon" 11

Burn Injuf)

1{)9?

Superficial Bum 1093

Superficial Panml-Thicknc<;<j Bum 109~ Deep Par1ial-Th i ckne~s Bum 1095 Full-Thicknes!. Bum 1095 Subdennal Bum 1096 Elc(:lrir.:al Rurn I f)l)~ Bum Wound Zones 1097 E>;tcm of Burned Area 1097

um InJunes are one of the major health problem'> of the tndu ... lrial world. In the United State~. more than I million I'<"on, are burned each year (4.2{10.000) Wllh approximatel) 4500 to 5000 related dealhs.' ' In addition. it has been e'limatt:d that bum injuries account for 45,000 ho'>pitaiiz3I""" per )ear. ,,"h half betng admilled to specialized bum tre-.umeOi ceOle" and halflO other t) pe' of medical fac tl,'ies.' Allhough the", data report Ihe exlent of the heallh care problem cau(",ed hy bum Injury. recent medical advances ha\C ~ignlfit:antly reduc.:ed the number of deaths from bum tnJun~s and ha\e improved the progml'>is and functional ahllulc, of 'urVI\ Ing patlcnt~ 4 "i The (",urvlval rate has tmprO\tcd annually ml,.lng to Improved resus<.:itation tech· OlqUC\. the a<.:Uh: medical and surgit:al carc that are now avallanl" and continued n:~car<.:h Into the management and Cille of the patIent "JIll hum .... As i.I rc ... ult 01 improvement In ~re. IrC4ItIllCIIl. mtl SUT"\ i\al 01 humeu pi.lllcnto,;, mon..PhY\It:411 therapl'-r.ts \1,;111 Dclomc: rc~pon"'lb/c ror treating

Hu \\( Ilk,11i Epidennal Healing 1100

Dcnnal Healing 1101 Inflammatory Phase 110]

]092

(omphc
B

I~

Proliferat ive Phase 1101 Mmurallon Phase 1101

\1, II II \1.10. :menl r,1 Hurt 110, 100tiai Managemem and Wound Care 1101 Surgical \1anagement of the Bum Wound 1102 Skill Grafling Procedure J 103 Surgical Correclion of Scar Contracture 1104

Ph) \1I.:al nll'rar~ \lana 'Clnt'nl Examination 1105 lnlervcmion 1106

r olh'

r (' J,L

Communll\ Pro

SUllun.tr)

105

'f01m

II

J

112

these patients for a significant portion of their rehabilitation in sett ings other than a hospital bum center (e.g., outpatient clinics, community hospitals), Thi s chapter introduces the problems that occur 'With Ihe different dep th ' of bum injury and the complication, that can result from thennal destruction of the ... kin. Current techntques u<;ed in the medical, surgical. and rehabilitative management of the patient who ha~ been burned Will be described. For more in-dep th informallon regarding the examination and treatment of the patient \\ tlh a rum mjury. the reader i... referred to addJlional o,;ourc.:eo,;,6-9

Epidemiology of Burn Injuries Although the morhldjt~ .II1U 111011.llIt) (lr p.IIII..'nh "lIh t'ltim, ha ... dramiltically dCt'll.'ilo,;Ct! JIl n."(.'l'n1 ~l",If'. 11k' ('pllklmulog~

pi hUIll' 1"\.'111,1111' h,I'Il-,IIl\ I hI.' '.lillI.' I h l' ll.· , ... a pc..·ilI-. IIIl'I d,,·l1ll.· 01 hum IIlllll) 111 d"ltlll'lI I 10 S yl'~lr' ol age. prill1.mly In,", 'l,lId, IH)111 hOI liquid... . rh1..· plllll . U)· ('au ...c 01 hurn 1Il11lT) 111 ,\dok'l'Cllh .l1ld llliulh i ... an:idc:nh with llaJ11Il1,Jhle IIlJUld ... \ kn t'll:I\\,,'cn Ihe '-'!!c", 01 In and 40 have the hlghc ... t 111(I(.1":I11''': llj 111.111r") , hn.~ ... thai ()(.'cur 111 home ... and mhel ,lnl(tur.ll d\\clling ... arc rc..,pon..,iblc for Ie..,.., than 5 perccnt of thc hl''''pll
body surface area (TBSA). 2. Full-thickness burns in any age group. 3. Bums that invol ve the hands, fe et, face, perin eum. gen ita li a. or skin overlying major joints.

4. Electrical burn s including li ghtnin g injury. 5. Chemical burns.

6. Inhalation injury. 7. Bum injury in patients w ith preexis ting illness that could complicate managem e nt.

8. Pat ient w ith a burn and coex iste nt trauma (e.g .. fraclu res).

9. Patie nts who require special soc ial. emotional. or longterm rehabilitation, includin g cases invo lving suspected

child abuse.

,uccc\ ... luJ hc(;
illC

01 each pallent . II

Skin Anatomy and Burn Wound Pathology The 'kin is the largest organ of the body. comprising approximately 15 percent of a person's total bod) "eIght. Anatomically. the skin consists of t\liO distinct layers of u:,sue: the epidermis. which is the outennost layer exposed to the environment. and the deeper layer. renned the demJis. ~ Although not part of the skin per sc. a third layer Involved in the anatomical consideration of the skin is the subcutaneous

rat cell layer directly under the dermis and abo,e muscle fascial layers. These layers are illustrated in Figure 17.1. The epidenni s is avascular. but it perfonns several vital functions. The stratum corneum gives the skin its \\"aterproof characteristic and serves the role of protection from infection. The stratum granulosum is the layer responsible for water retention and heat regulation. The stratum spinosum adds a layer of protection to the underlying stratum basale layer. Cells in the basal layer enable the epidemlls to regenerate. This la) er a lso contains melanocytes. the cells that detenrune skin pigmentation. The interface between the epidennis and me derm is is tenned Lhe rete peg region. This area consists of an extensive series of ep idennal-dernlal ridges and yalleys that serve to increase the swface area between the epidennis and the de nnis. TIlese ridges act as a resen·oir of skin and are needed to overcome frictional forces that skin is e:xposed to in daily activity. Lack of these ridges in the heaJed bum wound will result in blisters from abrasion and poor adherence of the new epidennal tis~ue when it comes in contac! \\.' ith clothing or other surfaces.

10. Chi ldren wi th bums in hospita l settin gs without qualified bum management personne l o r equ ipme nt. Twenty-five year') ago. there were only 12 specialized bum center~. Today there are approximately 135 specialile d centers for the care of pa t ien t ~ w ith bum injuries and othe r sk in di\order..,. Thi') acCount"i ror approximately 1700 beds in the United St<.ltc..,.12 FUrlhennorc, bum cente rs now have begun to undergo the procc..,\ of vcrificH ti on (vo lu ntary quality a..,\urallce review) through the Amt,;rican Burn A..,:-,ociation. Ll A hum center 1\ \!a lfed by \pcc iali\ I"i- physician'>. nur...c.." phY"'H.:al thcrapi\l .... occupational therapi\!..,. dietician .... P\ychlatn ... h, p,>ychologi\h .... ocial worke r..,. c hild Ilic thcrapi ... t.... chaphtlll .... ph al'lll<Jc I "i .... vocatio nal rc hilbili tallOI1 "peclall"h, and olher ,>upport pcr'>onncl \\ho din:ct alllhcir expel1l ... e tuward the tan::. lreatment. and rchah li llation 01 the pallCllt with a hurn III IL1ry. Each Illcmbc r I ... an IIlIl!gntl pan (lilhe team, and Iht,; 1110 ... 1 dkulvl! burn CL'II I1.~r ...

Ret!cular dermiS SubCulaneous tissue

Figure 27.1 Cro-.-.--.c('llOn

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.lIId

~l'l

III "phll"nn.tI,','11 '. 1'1II..' , Il'lllll'

Ih.1I1 [hl-'l'llllknlll, II" \'UIIII'I'1

nll't\\\lH'!I ""I I.1!!,'11 .llId l'I,h[II.:

,~lIl

I

'l"

Ilh('\, • \ \ IIII'II

.\

2010 \0 I

pI tlll.ln \ l\1 plm Ilk [hL'

"'1I\.·Il~(h dlld l'l1'lll'lI\ 11'1' I I I • _ t " \ L\" 01111.1 pal.IIIl·ll l nt'IlIIII' I ' I , • .. 11 \' Ihl! 111" "lll Ihl' ,kl1lll' " ,hlll'I\'1I1 [hm the \\ 11 \.'1'1.. 0 I \..'0 II Ul!l'n •

",lIh 1h IL'I1,.k

1 Ililll. I h,' pl"t'dI 1l1l1l.IIHh

Il\!\'t\ 111

" 1\1'11",lIh \,','11 III 'l';lr 1"'l1t' Ih,lI \\." 1111 11'0111 . _ . nle bll'I,t1dlll'.llll'l(.',1I1011 01 't'lh\11\ fl""'I'I'"

I" 11 .II

III 11111'\)11,1111 U~lhldt'I,111011 hll dl'Ic!"ll1111111'

I

...

'

•

111)111 \.

~ Iht' p,lpdl.lt' \ll lilt' paplll,lr~

I

I I

1.I)t'l I'l\ljt'l'l up\\ard

to Ilouri,h till' l'pllh:r\Iorpholl'glclIlt), th l ., !d\t'l 1', 1,'0111Pl-hl'd \11" .1 111lhC h;h~l'I-" t';I\ t' m'l \\ nr~ l1f ClllI~H!.l'n lih('r... Illt' ,,·lIl'u!.Jr lIt'l1ll1' Itt'" Ix'lo" Iht' p;\pllIan dl'l~IlIS ,lilt! IS plt'\U,t"

that

't'nl" 11\ pMt .

Ill!' Ihn)u:!h \htllO:-.I:-.

l'\)I11I1\,hl'd

nf dell,,\.·I) 1111\.'1'\\0\ l'n l'ollitt!t'n 11tx.'r~ . The I\.'lIt'-

ul,lr tlt'om,
D .. )nthe .. b, "l'I";lIlon. ;lIld co .. melic apl~ar­ ;md II.It.'ntil) h Ihl' rc"\l1I of a bum inJul). somt.' or all {If 1Ilt'.. ' IUI1Ctlllll., ilia) be imp;lireli .ltlli/ or 10M. ;lIld Ihl' POUlt'llI'., ddl'I"t' 1llt.·t·h;lIlbm!o. \\ III bc C'ompronl1::'l'd. Ollt.' h;I"IL· p,ilhoph) "Iological consldt'rtlllOn III 1\ hurn tnJUI') "Ihl' ,tllt.'r.llion of \,Iscular 1I11~gril). \"Hch re .. uh::. III tht' tUI'1Uatlllll 01 t.'lll-l1m 1I1 Ihl' 11111;" .... 1111;11 Sp.tl·C .. . Eth:m;1 ,lIIel'

ii' in adjacl'J1I l'OIll't'rn of Ihl' ph) .. ic;11 tht.'r;lpl"l 011 Ihl' dC'l,;n..'i\::'l' III JOIIII nll1gt~ of mOllOI1 lROt\\)

fllml.llIO llllL'ClI l '

1I"Ul'.,

\n

IIllhe .lre;1 of burn it .. \\l'1I

IIlII!.11

bum Ic.un h ;1

Jut' 11.1 '''t.'lIl1lg. rhe ,11l10tlt11l)! "~In lk .. tfll\.·llon 1::. ha"l'd 011 11'lllpl'ra I 11ft' ,IIlJ It"nglh of IIllll' Ihl;,' II .... U\.· i .. t.'\pn~l'd 10 ht.·;lI 11'1 rhl' I~ pl' III m.,uh (I.t'., 1l.11llt'. ill/llll!. l'Ilt'Illical. or l'(t't'ail',Il) ;11 .. 0 \\111 ,lffclIlht' allllluni or I I"" lit.' dt, .. lrUl'llOll. -\ 11'l'IllClli.lOlb

!able 27,1 l.ocation of enso!,) Receptors to .he Lu) en. of the Skin

Struct\Ut'

LOl'al;on

Funcl;on

Free nerve endmg Free nervo endmg

EpidermiS DermiS

Mer'el's d'sks

Stratum splnosum Papillary dermiS Papillary dermiS PapIII,lIY dorm IS Rettclllnr dermiS

Pdln, Itch Pain Touch Touch

Meissner's corpuscle RUffini & corpusclo Krause s end bulb Paclnlan corpuscle

11\

I

(.1·1 (.J. 10t.1!

1I""lt'

\llt'lll-

d,IIlI.t)!l' \ql\

unk ... ., thl' l'\j1lhU I I.' I" 101 pllllon~l't1 pt.'IIOd .. , III III I ,lIull':!·1 I (·11 ( tn ."1 ('),lill.' l.tll' 01 l'l'I I lI!.1I lk',lIh dOllhk .. \l,lIh l'.Ith dq'll't' 1101 un" III

1lll.'lt'mpn,IIIIII.'llIll!!I.' 111..'1\\1.'1.'11

II ",,'

III

Il'lllrl' l . IIUl l', ilml .,htll l t'\P{I.,Ull'" \\111

kat/to

l"e!1

dl,.,1111\.. 1I01l , 1'1 I \1 It'mp\.'ratll I I.'" III t·\ll'., .. 01 I.:!·I I. I" I ( I. t'\IHhUfl' Illll l' Ill'l'lkd 10 d,llIlilgl' tl .... lIl" ... l'\IIl'll1l"} hnet

1\

Illd mradl!.:,II'lt(' \\ Ilh Ihl' ('11Idl'nnh . I h., , . .. 1'11'111, , ,t' 1'01l[jllll \,I ..dll.lr

111"1;lIlIll'" hl'hm

I',· 1'llIllt"rdllh

','). g l ('PI I 0 lurn 1111111\ l I.lblt' - 7 I ), I Ill' dLTI11I' L';111 hI..' ,uhdi\ ilbl 111101\\0 1.lh'r" rill' ,UPI,.'lltl'I;11 p,lplll,lI ~ b~ l'r ,llld Ihl' tll-l'P 1\'l lt'ld,lI' 1,IH'r.

,1111011111 (II Ill'.!1 ... 1101 It'qllllt'd 10 l,ll"l.· d.lIll.l~t·

Worm Cold PrtlsSurO.

Vibration

Classifications of Burn Injury lInrl1 ['l'l'e lll!) , hurn 1Iljurie-.. \\ el"l.' d.t .... tI"icti m.:t'ortilllg to Ihnr "l'\\.'rit) ;1 .. flr .. t, "l'l'ond. anl! Ihml tkgree .•\lthoug.h [hl' I.I~ public lila) "lIlt u..e lill'''l' d;""IIIC,lIlon ... 1110 .. 1 medIC;I! Illl'ntlUft.' 110\\ da .... IIIl· .. hunt IJljUflCI" b} Ihl' deplh of ..~ill lI .... ue lk~lro)\.'ll.l The GlIak 10 Ph) .. u:al Thcrap"l Prlll' lIl'l' al~o de .. crit'k.·., unpatnllt:nh of Ihl' integument 10 J'l'lntmll 10 Ihe depth of the lI"Mle injur).11i The degree 10 \\ hich .1 hurn l'au"-C" "~1O damage dcpenlt... on man) faelor~, lI1r1uding the dural ion and intenslI) of heal, .,~in Ihic~lIe!'.., and ,trca c\po~cd, \"a~cuIHril\, uno ace. Thl' dIlTC'I'l'11I cla""lfit'iltiolh of bl1~l \\ound., will prc: .. l'lII dlllt.·(,C'1I1 l'illlica l pk'1l1re::., nod em.:h can changt: drornillll:al1) dunng tht: COUI'~t: of tre ..ltmcnL In i.lddlllUn to Ihe lImount of direci li ...·;uc damagc from a bum. a pallt:nt's metaholic, plt)'~io l ogic:t l. and p:.)chniogical condilion can greali) illTcct Ihe patient'::. dinical .. !illu ... Thi .....ection \\ ill prc:"Ctll gellt.'ral l'iinKal ~ign~ nnd ~) mplom, .. t't.'n In each of Ihe hurn "mmd l'itp... ificntiou .. (Table :!7,:!).

Superficinl Bum ;\ MI(1l'rlkial. .. ull1t'limt.· .. i\lso referred 10;t., an t'pldenn.\l bum, l\llIsC::. Cl'll dall\;tge onl) 10 t he epllknlll' lFig. ~ .... .:!l. 'nli~ tit.'plh ofbuOl l'Om.'(att..: .. lll pr:.\l'IlCC p:1Itcm '"'B. hnpam'li .. hlh.:gull1l'lllar) Inlegril) A!hOcialed \\ Ilh Sur~rft 'j.,l Skin Imohl'mt:nt, Illlhe (;wt/t' (tl PhY.\h"d/ rht'rapr" Prtlt"llt"t' .:-i. The l'Ia., .. ic •· .. unhurn .. I. . the bl.·::.t c\ampk ..,r'l .. upt'rfil'i,\1 hunt. C'ltnll';t1I), Iht' .. ~in ;lrrl'ar~ n'd llr l'~tht'm;lh)u" 19 nle l'l') them:l I.. a n,.,ult of cpitienn,l) d.ll1\.l~l~ .1I1J dcnll,t1 irritallon, but Iht'l\:" i, no tniur~ 10 Ihl' dl'11lMI 11 .... 11(' Inl'l\' I~ dll/u"lon of IIltlarmnalOr) 111l'tli.llll" ff\'111 "Ill' .. of t~rl4 t1enn.tl dill1lil!!t' and Idl,,,.,t' tlf \,l"O,Il'It\~ .. l\~'I,U\l..'\" lila .. ! cdl., TIll' .. urtlt'l· ..,I' a "ulx'rtin.11 bum i .. tin, BIt ... h.'" \\ ill I ' ,ll"'l·lIl. bill ,It!!hl t'Jl'IIM m,l) tx, .lpP,II\'J\t \th,'r J "Upt'rfil'l.tl bum, IIWrt' I" IhU.III~ ,I tld.l) 1111111.' d~'\l'lt'pml'nt ~lr p,lin. ,II "hld, r~'1111 tilt' ,\f~,l ix'lllllll'" Il'lIl,.kr h' thl·

r",Ol

1I1I1l'h,

Ihl' 11\11,11111\1,\1111' ,'.ll'th\ll \\ iii (~""'l' ••md thl..' 1111Un.'lI l'Pldl'l1lU" \\ III 't'\llill11 lk .. qu,t111,lIl' tn"! Il' ~ l1.1\ .. Ut"'a.lU\i! I" "1:l\l\II.l1lt'~)U"; Ih,1t I", th,,' "~111 \\ III hl"ll \'11 Ih l'\"t .uhi 11\) "l·,\1 "III 1,,-' 1'1 '''l'lll

r".

1094

Ph, \1(.·.. 1 Rehabilitation

Table 27.2 Bum \\ o llnd C las< ificalio ns: Differenlial Diag:.:,.:.,o;;.<.:.i.:.S-:;-~_-;:=::;;:::-~~-::~'"7'_ _ __ Surfaet" Appearance Pain

Swelling Healingl Scarring

SuperfICIal

Erythemalous, pink or red; Irritated dermis

No blisters, dry surface; Minimal edema; spontaneous delayed pain, tender _ __ ..;.:. he:..a:..hng. no scars

Superficial partial· thickness

Bright pink or red , mottled red; Inflamed dermis; erythematous with blanching and capillary refill

Intact blisters. mOist surface. weeping or glistening; painful; senSitive to changes In temperature, exposure to air currents, light touch

Moderate edema Spontaneous healing: minimal scafflng: discoloration

Deep partial· thickness

Mixed red , waxy white; blanching with slow capillary refill

Broken blisters, wet surface; sensitive to pressure but insensitive to light touch or soft pin prick

Marked edema slow healing excessive scarnng

Full·thlckness

White (ischemic), cha rred, tan, fawn, mahogany, black, red; hemoglobin fixation; no blanching; thrombosed vessels; poor distal circulation

Parchment·like, leathery, rigid , dry; anesthetic; body hairs pull out easily

Area depressed; heals with skin grafting; scarnng

Subdermal

Charred

Subcutaneous tissue evident; anesthetic; muscle damage; neurological involvement

Tissue defects; heals with skin grafting ; scarnng

------~~

Superficial Partial-Thickness Burn With a superfic ial pa rtial-t hickness burn (Fig, 27,3) damage occ urs through the epidennis and into the papillary layer of the dennis, The epidenna l layer is destroyed compl etely. but the dennallaycr sustains only mild to moderate damage. This depth of bum corresponds to practice pattem 7C. Im paired Integument ary Integrity Associated with Partia lThickness Skin Involve ment and Scar FOflllatioll. in the Guide to Physical Therapist Practice. 18 The most comlllon

sign or a superlicial partial-lhick.ne~s bum I.., the pre ..en~t: of intact blisters over the area that ha!-> been IIlJured, Alt hough the intemal environrncJ1I of a bh ... tef I.., felt (0 be sterile. it has been sho\\ n that hli ... tcr fluid contain ...... ubstances [hal increase the inflal11l1lJtor) re~poIN;~ ;lnd retard the healing process. and it i!- recommended th
~~~ _ EpidermiS

+ Papillary dermis

+ Rellcular dermiS

_Papillary

,~~!I~~!~~~~I~~A ~

subCuluneous Itssui."

tissue

Figure 27.2 ~h,ltl in~ n':JlI~'''l'lIh dl'lllh oj "~ 111 IIl vlll\ c:d III ;1 ,upcrhL'I,11 hUlIl

dermiS

Rolleul., dcrnllS

<-

Figure 27.3 Sh,uitll!!

"'IIIlI,'l ll l'I.11

l'pllI

r~pll''''l'II''' \ I

p'IIII"llhll~lll''''''' bUIll

I

\l I ... ,,111

111\

I

)"~'dln,1

(haplrr 2i 8um:

flamed The

\It.

lund

\It.

1

I

109"

t of the nen

III t,c

:l

ured

("ndln

cau

mo t

derm .. lTD\. c:d ~ep pantal·lh u:ne . . "lurB apxar a mt red r "al; \ Ie c ~ The deeper the 10 uf) th moe; \\ Itc II

\\ ill be tu

eo-

~A.

hJ~ en Jllve to :nr. ~ lig.ht lOuc.:h In be pre5eDl If areas become

..He

te\er .rna~

S 'u e p La121l1I'm OOPtal c.:re--.:Utl "Ill C"du,e the \hound Ii< e QP. gelat n·1 jlim that e\entually ~ill peel off. t the d~uamation that occurs Vonh !>unburn. eUJd t~ &l coagu urn of Jle ((Pita! anubJOuc u~d to ~t"j urlc-\..1J n and serum that ~ep lrom the y.ound ~ ~e t f the n t to c.:ap1Ilar: megnl~ S perf al p"fual·thlcl.nes bum heal ~ ahoUl ;Ufp,al . nor on. ~ me-"", of epJlhelial cell pfoduCtlon and ·~alJon

lrorn the:

Qund

pt:npher: and ..,un 1\ mg . . km

~g

Coverdge by ne-. epahehum re,ume, the bar· '1fr fuOCUon 01 the • m. and complete healing ,hould occur 10 da) There rna) be !,ome re!>idual ... kin color n&e ov. r g Lu de tructlon of melCUloc) Ie .... but -,carring I~ nal.

Deep Partial-Thickness Burn .xp p Ifll" ·th.d ne bum injury (Fi g. 27.4) involve, ..1e
.. I appe-.tr C apll df) ref~1 " oc lu. ~ I h dlter Ih dPph . . allon f ryre ure on the "ound. Tbe swtace u uaIl~ J'" "et from ~ro t-.hS1Cn. ~ alICT~ aUon of the dermal \,,-..cular ""t\\ork. wltlch I pl..mt:1 flwd " arked edema " a hallmark "go .-.t thO' bum depth There l~ i3.lan~e amount ,)f e-.apctr.ill\e \\aler 10 ... (1 5 to:!O time.. nonna! reC".1u-..e of u ... :-.ue and \ a-.cular de: lrucllon «, An area of deep panial·thic 'ne~", bum hil!t dimini hc:d -e\eraJ days as the dead tissue beglns to laugh. Hair follicles that penetrate into the deeper dermal regions belo" the bum level remain viable. Preservation of hair follicles and ne" hair gro\\ th "ill indicate a deep partial· thickness bum rather than a full-thickness in]Uf). and there I'> a cOITC'>ponding greater potential for spontaneous heal ing. Factors that determine which epidermal strucrures sur· Vlve and v.hich die include the thickness of the skin in a particular location and/or the distance of the area from the e.,ource of heal. Deep panlal-thlckness burns that are allowed to heal spontaneously will have a thon epithelium and rna) lack the u\ ual number of ,>ebaceous glands to keep the ~"'-in lubricated. '\e" tl~ ,> ue u!>ually appears dI)' and ~caly. is itch). and 1\ ca~ily abraded. Creams are necessary to anificiall) lubncate the new surface. Sensation and the number of ac.:tJve ~ "eat dUCI\ will be diminished. A deep panial-thickne,", bum generally heal on 3 to 5 weeke., If it docs not become mfeeted. II IS cnticallO h.eep the wound free of IOfccllon, because IIlfeClIOn can com'en a deep panlal-Ihickness bum inlo il deeper IOjury Th~ development of hy pe rtrophic and J..dohl \Can ;.Ire a frcyut:J1I l:onscquenc:e of a dcep pi.lflJal-Lhlch.n~s.., bum.

i

",II

Full-Thickness Burn III

il

full-Ihieknc ... s burn (f-i},'. :>7 .5) ,III 01 thl.' l.'pll.knnal i.l(C dc..,tro}I..'d I..·(lll\rkll..'i~. In uddulon.

.1Iul dl'l"IIl;.Ii ia),crs

the sutll:utill1l..'UlIS lal la)Cf lila}

Figure 27 .4 t.;t filii I pi i· f·.ml,d Ilul ~ fl "'Jf/I

III

111 11111 III

~ III

IlI'ouJ cd III 1

1111 ... hUIII

dCJlth

Ix.- d.lI1hlgl..'\! Hl ... ,lIth.:

p.llk'm 71l , Illlpallcd Inll..'gulllc.:l1t.lI~ 1I1tq~fII\ \ "',)(,.I.th.'d \\ IIh I till Il1Id,lll' S Skill 111\ 01\,,'1111.'111 .uhf S".H I Orlll.lIH'Il, 111 I Ill: (1IIIIIt /0 ,~ /1\ \ 1/ III I II, , ''I'' \' I' f"1 III I

c" ll'nl

I'" l.'onsh"..'nl \\lIh I'r.II.:III. ·,,"

r,;:-,,;,j .... Epidermis "-Papillary dermis

IIiIII'
1

dermis

..- Subcutaneous tissue

Figure 27.5 Shading representl, depth of skin im olvcd

In

a

Figure 27.6 E~charotomy of the nght upper e\tremu) From Ri chard and Sta ley.6 p 113. \\ nh pen11l ....... ion.1

full-Ihidnes ... bum.

A fuIJ-thickness bum is characterized by a hard. parchment-like eschar covering the area. Eschar is devitalized lissue consisting of desiccated coagulum of piasma and necrot ic cells. Eschar feel s dry. leathery. and rigid. The color of eschar can vary from black to deep red to white: the latter indicates total ischemia of the area. Freq uently. thrombosis of superficial blood vessels is apparent and no bl ~Ulc hing of the tissue is observed. The deep red color of the tiss ue is due 10 hemoglobin fixalion liberaled from destroyed red blood cells. Hair follic les are completely destroyed. so bodily hair will pull out easily. All nerve endings in the dermal ti ss ue are destroyed. and the wound will be illsellsale (without feeling): however, a patient may ex perience a ~ i g nifi c:l.I1t amount of pain due to adjacent areas of partial - thid.. ncs~ bum that usually surround a full -thi ckness injury. A major problem that arise~ from deep burns is the damage to the peripheral vascular sy~ tem. B ccau~e large amounh of Ouid leak into the interstitia l space beneath unyielding esc har, th e pressure in the extrava~cular ... pace increases, potentially co n ~lri cti n g thc deep circu lation to the point of occJ uI.,ion of blood now, BeC3U\C c\char docs not have the elasti c quality of nonnal skin. cdema that forms In an area of circumferential burn can C
differences will become e,ident after several da).., With a full -thi ckne s!) burn, th ere are no ..,lIe,:> available for reepit he lializati on of the wound. All epithelial cells ha' e bixn destroyed. and ski n grafling of tissue O\'er the "ound \\ ill be necessary . Grafling will be di!)cus..,ed in detail in the "el'llon on surgical intcn·ention in the treatment of burn~.

Subdermal Burn An additional ca tegory of burn. the .\"lIne/amal hum, involve ~ complete destruction of all tL..,..,uc from the cpldermi!) elm\ n to and through (he ... uocu taneom. 1I""ue lFlg. 27.7). Thl!>. depth of injury corr~bk'''' \\ ilh prJctil,x' pJllt'rn 7E, Impaired Inlegumcntar) Int ~grit) \ ~"oC'ialt'd" Jlh Skin In vol,·cment E\lc nd in g 11110 Fil"'l'i,l. \iu ...c1e. ('If BOIlt' :lI1d Scar Formation , in (he Gllidr III Phy\/{·al The r "I JI '! Pra(,lh 'c. l ~ ~ lu ~c1e and bone . 11'1: "'lIbJ~c ( 10 neL'W'I" \\ llt'll burned. Thi ~ I) pc of burn ()L'Cur ... ,,"h pHllonged l'(1I1t.h.:t

~.;:::.>-:~~~-~-~.~lii~~~~~;,:?91

nlS

+ ~

Ep,den PapllltlIY

darnm,

I II 11 I , ...' 111 II I' , ,I\nllli Figure 27 .7 ~h'lIllI l ~ Il'IH\"l'1I1" Il'pl "lI h (l l' II1 ..tI hili II

01

•

( 1, .,I'h', 27 II \lh.1 1l.111I~' ,1\ h,'1 Ihlilld .Illd 11llIlllh'l\ .ho \ 111'" .1'.1 I\" III( \It ,"llI,h' \\uh .·1 ..·.111 .. ·11\ I \1t.·ll'I\~' 'Ut~·I\,I1. lIld (h~'I,llho' ll1l\ 111.III,I~""h"lIl' ll~' .. \"',11\ 1\11\' 111111.1 p,III~'IU hI ' .Inl~ ' .1,'1' 1,'\'

.,t

IILllo'lh l ll

Fk~' (I' ical

~'IIIII' II \,lIhlll"'lltd\\ 1 111 11II1t· 1I11i,1I11.I"

1f19 7

HUllt,

1... 1~1I1

plIl,d

1'111

'1'1"'111.11 11.111 1111' (11111<,,111\ III "t P,III lit \111 11 .1\\' ' 1".... 111 p.IIt" I' htll 111,1' III rll.l' 1It11 h,l\\ .Im II 111\ p .IlIt\\.I\ d"III~'\'" 11\1'1 1111\~I IIIIII ,LlH ,11\',1 If! '11.1,11111\

11.1111.1"1'111

Burn \VOllnd Zun ...· ...

Burn

1It ..'

\11,'

'Ifoll' ,111.1 '\Illjlhlll" I" .111 dl'l'lril'ul hlll'n 11\,1\ \,It\ N.lII1f. h' Ihl' 1\ pl.' III l:tli 11'1\1, I11 ll'lh ll\ \\1 Ihl' n Ul l·1I1. .m.. 111w ,11\'.11'1 I hI.' 1'1\'lt.1~ Ihl' l'kdll~' <'1111,-'111 p.I"l" ""'lll~h " \ 1'110\ rl"lIlt, f\llll! Ihl' P,I"...Jf..I.' ,'I .111 d l',.:tnl.' (1IIfI.,·nl Ihhlllfh Ihe !)o"d, .llIl·\ thl.· '\..111 h,I' 1lI,ldl' \',1111,1(( \\ nil ,III ~'kdll\',!1 , ,'lIr\'l' F ItYI 11\' \'111'11.'111 1"lltH\, thl' ,'\llll'l' III k,l,t n'" ,I.1I1\'\'t 1tl l·rl'd h~ \.Irlllll' 11"\11,' \' 1'1\l·,.lnll,l\\l'd ~\ 1,\1,,\ \l'''l'I,. lllll.·r Ihl.' It"l" 11."\'1.111 ..'1.' Ihllll' ol!l.'r, Ihl' 111lhl rl."I'I.II11.'(, ,it'

hpll."III~. 1." 'IlI.leI ,ttl" \\111 ..'\1,1 \\hl.'1'l' Ihl' p.1111'1I1 lir'l \'.1111,' I\ll(ll'l,nt.h.:1 \\ IIh I he l'lcl'tl"ll.' lI) ,\Ild.1 'l'L'nnd 'Ih..' \\ hl.'l'e th\' p.lIll·nl \\,1' f,flllllh,kd. Thl' \\oUlld \\llL'!'e 111ltl.11 L'llnt.lel \\,1' m.ld\;' ( 1ll.1~ IX' I~k'~d III ;1' Ilk' 1.'1IIr..U1ce \\lltllld) \\ III

,IPIlt:,lr I.'h.un-d ;md dl'pl'l'''l.'d. ,lIld 11\;111: 111111.", I' '111;1111.'1' tll.mlhl.' gmund 'il L'. rht' '\..111 .IPI~,II"' :t'lIo\\ ;Ind 1'I.:hCllllC. 11k' gnllllld 'It..' \ 1ll;1~ lx' rcl~rn.:d 10;h Ihl.' C\l i \\tlIIlH.1) "'1)\lletunt" ,lppC.ll' ~h though thel'l' \\.h 'lIll'\p/o'inn \)lll ollhc tl"' 'Ut'.11 the 'lit: . It I' dT) III <.ippcar..lIll..'e. rl"lIl." .!long thl.' path \\,I~ 01 lh~ ClIrT"enllll,l) be d~ll11agl.'d .1';1 n;'lIlt 01 thL' he.1I th.1I dt·\t'lllJXd . .-\ n e\lR'nlll~ or arl';\ Ihal appear... \ 1;lhk' .lncr.1Il IIlJul) Illa~ hcl'OIll L' lIeGolic allli gang.rl.'lll11h In ,I 11:\\ d:I) .... -\nene, nl.l~ undergo "'P;1'I1I, .1I1d thcl'l' m;!) he llecm"'I' of the \<.i't'u lar \\.111. TIlL' blood "'lIppl) 10 Ihe ..,unl)Ulllling 1\..,'Ut". me/uding mu..,dc , 11\;\) bl' ahcl"I.'d . Dal11'lgl'd Illll,d~ \\111 fed ,oft. Be(,,':lu ... c: Ihe (.'our'c 01" II""UI' de..,t rUl'IIOn I.., unprCdlCIJblc, thaI.' I11J 1 be unequal and unc\cn l1Iu"c1 ... d.U1l<1gC. Time \\ III be required to dctl'nllllll.' \\ Im:h 11 ...... tlc.., \\ III relllain \ lahl ... and \\ hl ch \\ III nol. There are other con ...eq uL' nc.:c, of cil'clriui: p.h..,lIlg through the bod). One of the ca rdlal' cllect... I, anh) thl1l1.I .... Jnd po" lhle C;lU.., ... .., III death frlllll c it:un ca i burn... arc \ ell-

III )..' 1 Kt Illlhe d.UI1.ll'l'II.JllI! '~ 1 1l d,'.111I ..... l'III '. 111" ,l\l'.II'" l\IIII \,II \' 1I1 Itl.1 1IIIIIhll.\..111' "i hUIIl .1I1t! \\ 111 I l.'qulI I' ,I '\..I\l ~ 1.lllltl 1t,,',11 Bl'I..IU"',,' Ilillh' I.ll\.. III \ 1.lhk' tl"'''lIl.· .lIId Ihl' .1I111HIIII tIl ..•... 111.11. Ihl' II '\.. ,II IlIkll\lll\ I' 1I1L1 1.' ,1'l'd 1111' PII!l' III1,d 1.1111\1'11..:.111\11\ I'lIlpha","c" Ihl' Ill'l't! Inl (.11 l'l III IIhllllhlllll!!, IllI.' "'1.' 01 .lIuillllllll' .... and IiiI' 11 1.',111111.' 111 01 ;\ burtll.'d p,lIll'llI III .1 "' IX·lI.dl/l'd hU11l c.:l·lI1l'r 11K' "0/ /1 01 "(1\/\ UlIIl.tllI' IIlJurl'd cd]", Ih.lt nJ;\~ dll.' \\lIhm 2·1 ttl 11:'\ IH1UI" \\ Ilhoill dlhgl'nt IrL';1I 1111'1II It I.., IIllhe l"lll! 01 "'I.h l'" th,lI 1II1cl'ltnll. til") mg. ,\IId/t,r 1II,ldl'qU'llt..: ]"'II:rlll .., I(111 nl the \\\lund \\111 fl' ... ull III COlI\l'r..,1011 III pOIL'I1II
\\llund ulIl'l,h

1111111\'1' 111111

11111 11/111"~lI/l l fl
ahll' 11"111.' hll'Olllpll' ld) nec lntll' II"ue .lIld ellbr!!CIlICIII 01 I he Inlle Ill' L'll,lgulallllll . S plllll ' or l:\)lIlprl'''''loll b;lIld;lgc', II .lpplll.'lI 100 IIghll). C;lll complllll ll..,1' Ih", .lrCJ hll~tll) , the

of In.,,('/ (/1/I1/ I" Ihe 'Ill' 01 1111111111.11 cdl d.II11.lgC ••lIld thl' ""tie ... Imuld reL'tl\-eJ' \\-lIhll1 ... e\er:1I dJ)'" \\ Ilh nlll,hllllg

;:O//('

cllcch .~"

Ex(ent of Burned Area In addlllOIl 10 dc..:plh ul burn IIlJUI) .• IIHJ1her millor 1.IClor tll I.'OI I'ldl'r \~Ilcli tktenllllllllg til l' ...e\l'llI) 0 1 .1 hum I.., Ihe 1.'\11'111 01 bod) hurtl 1;) cak ul.1I1' f.lludly LlI1 e ... l1m.lIe 01 the I1l'R'c nl.lgc 01 1\)1.11 hody ... lIrl:lce .In';l hUl1lcu. PllJ.hll .nll] Te:nnl ... oll\4\ dl'\dopcd Ihl.' Rul e ul' "inc.,. Thl' rul e olnllle' dl\ Ide ... Ihe bod) ,ml;ll'c mlo arc;'" th;ll .m: 9 11l'n.:e:nt. or llIllitlpk" of9 pl'rt.:elll. o llhe IOwl 1I\'It!) "urf,lce, hgun.· 279 ... liO\\" Ihe l1l'fl'elll;lgl.'''' lI'lll!,! the full' of II 11l!..·.., lor adulh ;lIld dllidien . Lund .md I1ro\\lJl'r'l modilled th.: percelll;lgc, 01 body ..,urLicc :tl'l';\ Itl accounl lor;\ c.:OIllIIlUUIl1 01 agl' .mJ III

Ineu!;.lr fib nllatJon or rl"plratnr) ..IITL' ... I Th L' re a1 ... o ilia) he renal C:OIl'CljUCIlU:.., lL'adl ng 10 rcn.1I t.1I1l1rc .1, a re ... uli

;ll'l'OlllllHKiate lor gr,'\' th 01 Ihc dlfkrclIl hod) 'c-gmcllh 1'In... mel hud " the ilion..' :HXUt;I1L' mc.lII.., III Ihl' 1\\0 IIIclh· Oll.., 10 dctL'rTIl1llC thl' 1.'\:11.'111 of hum IIllllr) h ~un' 21 J(l

01 e\ce"''''I\e prolelll breal...dO\\ n ,lIld Ihe ... Iwcl... 1<.> 'he: 1...11I ne~ ,hal follm\'l a major traum'l One of Ihe 11l(),,1 ... c\cr~

... 110\\ .., Ihe rcLtll\c Ix'rL'L'IlIJgl'''' III bUnll'd .11"1..'.1 ",,. dllld~n ,lIId adult... ,11."l'ordll1!! It> the: l _lIlld ;md BJl..mdl'r h1lllllll.1

Zone 01 hyperemia Zont! 01 sl,l 15 lOM of

FigUre

re ull 01

27.8 hJUl'"S 0111 J. burn IIlJur\

lie

d.UTlI

DermiS

•

Suocul Inoou liS ut'

•

.1 Illl'

t(

\qul.11000

e ( )~ ~

45%/

18%1

Infection Infct:llon, In con~um:tlOn with organ "'y..,tem failure. i.., a Icnding Cl1U"'C of mortl1ll1Y from hum.." ' Some vlrul

. ..,tralll..,

) ~

9%

,

.

lI('nt~I"(),\lI •

ent

and Hap"\/"'., , J( ("11\

arc resistant LO antibiotics and have been re"'pon ble for epidemic infectIon s in bum centcr..,.l' SY"'le~llc

4.5%

anlloiotu;s arc u..,cd to treat hoth hurn and general system infections once they have becn documented. \~.\4 A hatter_

ial count in excess of I O~ pcr gram o! tissue constitute." burn wound IIlfCCIiOn and leve l.., 01 10 to 1011 arc u..,uall)' <Jssocialed wit h lethal burm•. Most wounds are treated \\ ith topic;:!1 antibioti cs, and lhc..,c will he discussed In the scclion on medical care o f burn..,.

9% \

'/

" / p .\i'II('Of1l0Il(l,\

£1111'£'1/.\

10/.,1

/)

0

Pulmonary Complications patient who h<Js been burned 111 a closed ..,pace ..,hould suspected of having an inhalation injur.l .'~ Among

Any be

A

pati ents w ith bums. the incidence of "moke inhalation ma) be in excess o f 33 percent.'1l a nd Ihis rise.., 10 66 percell! 111 p,-Hienls wi lh facial burn.., Y Several st udies haw Inclil':lled thai the incidence of pulmonary (;omp li cation~ 1"1 e\trcmel) hi gh afler seve re burn .... and that death due 10 pneulllonia

8.5%

"lone i ... a llribut cd 10 a Illiljonl) of the dcath~ (0110\\ 111£ bum injury. "( Signs of an inha lali on injury include facial bum~. "'mgL'J

4 .5%

nasa l hai rs,

harsh cough,

h oar"'L'n~.,s. abnormal

hrL'illh

so und s. rl!,. . p inllory di ... tr\!ss, all<.1carhon'lccollS "'pulunl amVor hypoxemia, \1I

The pnmary comp lication ... a ...... ocJatcd \\-lIh

65% 6.5%

<-Ire

Ihl'" IIlJtlr)

ca rbon l11ono\.i(k POl"'Ol1l1lg, Iracheal danwgL'. tlppL'r

ai r way o hslrUC l i( )I1 . pulnlOn,lr) edema. ~Ind pnL'UIlHlIlIII

Lung damage from inhallllg n(niou", ga ... c ... and ... mo\..t·I1h1) be klh:!!. '1 '0 determine Ihe c\h:1II o llll hablion IIIJlIr). 't" era l dia gnoslic procl'dllrc~ ca ll hL' pl'rrontlcli. r hl' 1lI11" Ilclpful diagnoslic procclilln: IS hrondlOSI.'opy,l"

B Figure 27.9 Ru le of Nine!>' to determine pCfcc l'lIagc of hody .. urfacc ;)re .. burn 111 adul t" (A) and c: hildn:n (/1).

Metabolic Complications Thermal IIlIIII) pOSL· ... a gn.'at I11l,t.lIlOhL' and cll.lblllic rh,tI

Although Ih,\ formul a provrdt· .. an accurate l"x :Ulllllalio ll of I BS A, the U.,c 01 till! lule 01' /lill e .. " more pratlical in the

Ilca l lllt'nl :111<1 reh"hlllt.III{JlI hd\l' COIlK' dll\.·cll.\ 1111111 Illl'

emergent triage of ,. pal lent with a burn Injury.

il1l'1'l'a ...t'd Jllldl'1st,\lHllIlg 01 tilt' l1K'I,lhollc lk'IlI,\I\I).. llt il bUill

Icngc 10 Ihe hody. (\10 ... 1 01 IhL' It'Cl'l lI

mj\l1 y and

I W II1 Ihe

ah ilil )

Iiolial ... laW ... IOl llcel l lit.· ...t·

to

.llh,llIn· ... 11\ 11I1I1l

IIIlPIO\C till' , ,., , .,

dl'llld\1{'"

(1!lIll'nl\ nulll • 1I'lIn"

Il'l'IllI'lq l

10110\\ III!! ,I 1111 ,' ' '\lIIIH.!~'1l b,l • I1q!.IIIH I.

1I 1L'IL'a't'd II1 t'lilho ll t' .l1ld l';llilhlllll' .ll'ln 11,

Complications of Burn Injury

;trL'

n

1.lpl( l dl'l'fl';I',C III

hud,

,

\H'I!.! II .

"I

1 1

, • 'II II hI Ihl ; \ll t'L'. ,llId II dl'tTL,,,,t' 111 l'lIl'I~\ ... IOIl· ... [l,i1 .lll •

Ikpt.'ndlll,!!

011

IIIl' (.'X ll',1I of hU 11i

IIll ll/ Y,

lin' dqHiI

01

till'

hUlIi. alld the tYlll' of hUIII,IIIl'Ie ma y he \cl"()l1lli u y 'y, ll'll l1L' lOllJpllLiltlOIl\, 1 111 illlc lil HllI, III\'

lwa lth.

:' fl', mI(l

p,yclHl

IO~'Il:1I ... lalu ... of II 1':111<"111 w ho .\ hmm'd w ill a fll'l l IIH...·.t' lOIllpllli.llllm\

11 11 ... '1('ltHlI l

wil l

hi~lhlll'"1 ,mill' ... y .. h: IIIH.

lflillplllilllCllh il pal'l'llI IIlay l'XPt.'IIl' ll ll' i.II L' 1 i l \ ' VII III <..'a lll

hUlII 1I1Jury.

hl·all ll!.! pnK.·l· ....... 11l ,II I Iheu' \\ As il H.' ... 1I11 01 Iill' I1K'll"I'l'd Im'I,lhlllll' ill'l l \ 1\ . , , Il' )·(·)lIlnll\·[~111 hl' 11 11 II l11 l'lI"'l' III LX 1' 1(1(' I ( h I , I t Iltl'ln pill 1.1

Pl' lil l lIll'

llli1l

"'l't'l lI ~ 10 Ill" dill' 11'.I II· ... l·tllll~ II

,

I

I

\\

dllllll"

10

.

1'1 .1

1I'II1I)1.·I!1ll1l l· n'llIt' I ' III Ill' '1.ll ll "II 'I II ... hlJ'I~ ·[\\ll lt ypot l!l, ... 1I1·d Ihdl Ihl'Il' .... ;\ 'lflldll, 11I 1 H .1111 I . I ,~111 I 1111 Ill\' IlIlJl,lln \ I lit' ItIlll''' '''l'd t'\ .tpnl " I IH' IH'.II II''''' " 1I1llf

j

•

(fMplcr

Burn Es timate and Di agra m A ge vs Area

27 Rum,

1099

Burn Diag ram

Imtlill [xamln;}1I0n

C!IU'.tl 01 Burn _ _ _ _ _ _ _ _ __

Dillu 01 Burn _ _ _ _ _ _ _ _ _ __

TIOle 01 Burn _ _ _ _ _ _ _ _ _ __

Ag" _ _ _ _ _ _ _ _ _ _ __ Gender _ _ _ _ _ _ _ _ _ __

Color Code

W·,OI1I _ _ _ _ _ _ _ _ _ _ __ Dille 01 AdmI5slon _ _ _ _ _ _ _ __

Red - FT Blu e - PT

Slgnnlure _ _ _ _ _ _ _ _ _ _ __

Dille _ _ _ _ _ _ _ _ _ _ __

Area

Healj ~tJl!S:I\ ,~nterlor

_

Birth yr. 19 -

-£ f--13 13

li' unK ~sleflor If unk

~1B~tiOck ~~tL Bult0ck

~~ha RlOhl Upper-Arm ~e« U.PI<er Arm ~.'.ahl Lower Arm Lett Lower Arm RIg)11 Hand Left Hand Right Thigh _ Le« Thlfl!1. . R,gtll Len Le« Lao ~,ghl FoqL lett Foot

1-4 yrs.

2 3 13

10-14 yrs.

15 yrs.

Adult

9

2

2

2

13 13

13 13

13 13

2'/2 2"2

2'/2 2'/2

3 3

2'/2

2'/2

2 , '

2"2 2'/2

2'/2 2'12

I 4 4 3

1 4 4 3

1 4 4 3

3

3

3

3

3

2'/2 2'/2 5'/2

2'/2 2'/2

2'/2 2'/2

2'/2 2'/2

6'/2

8 8 5' ,

2'/2 21/2 8'/2 81.2

6 6

5 ' /2 5 5 3 ' 12 3i"i2

6112

5 5

1 4 4 3

9 9

3'/2

5'/2 3'/2

3'/2

6'/2 6 ' /2 3'/2

3'/2

3 ' /2

3'/2

3 ' /2

PT

FT

Total

Donor Areas

7

11

2' , 1 4 4 3

-

17

5-9 yrs. 13 2 13 13

1 4 4

2'/2 2'/2 9'/2 9 '2 '

7 7

3 ' /2 3 ' /2

Total

Key FT Furl Thickness PT - ?art Thickness

Figure 27 10 \h.xhtied Lund .md 8ro\\lkr I.'hillt for J~tcmll"'ltIOn of pcrccnl.lgc of bod) ,urfnce an',l ~m tor \anou, ag""'. (t\)ur[e'~ Shnna' Bunt, Hl)'Pll~\l. Cindnn,ul, OR)

h.tm~r ~)\a i.l bum and thl' h)- pennetaoolic ~IJtt: In .my e\ ru It mOI\ ldual, \\ ith bum' are pl,lced In a room \\ ilh 110f~ I1Jtd"ll~nt t~Ill[XT.HUn.~,l·\~t.'''I\e ht:'.lt 10" "ill Ix- e\hib11 and thl' \\ III further e\"\cH'emte the "IreS'.. re .. t'" rw)n"'e "et:n III th\.'x' patll:nt, .l fhct\.'h.H1:, it i, rt'l:ommemkd th.H room Itm '!"'.:ltun: ~ \.·pt at So ~ ('0 C). \\hll'h \\ill 'lgl1ltkafHl~ ~e th~ Oll""tabol1( late \, part (It the p•.ltI\.'Ill', altered nll'[Jboli'nl. prolC'in rom mu...! h"UI? I' prekrentlall} u... t"d J. ... J. "OUfl't.' of e et! r2\ llu ... '!ILlatIon.. I.:ouph:d \\ uh the dlel:h ot bed re ... t. au e... m ...Ie ... to atIoph) and render ... p..ult"nh \\t"aJ... front ~\th tht"lr burn InJu£: ;1J1d ho ... pHalllalH.m e-~

\lllch of the unproved manageme nt of bum" hi.!'" ~en attributed to the greater fOC l" of research on the nutritionJ.1 ne-ed ... of patient ..... It i ... beyond the ... cope of thi ... chapter to tlt'tail nutritional 'Supplementation. and the- interested reader i... referred to ,e\ t~ml e\.ct'llent re\ IC'\\'" of .u.h ,U1l'e, III bum nutnlion .• ' ....

Cardiovascular Complications H\..'rnllll~ 1M mil"

I.:h,mgt::' n: ... ult from a ,hilt III tlulJ hl the: \\ hil'h ... ut'hcque:nlh f\.'du\..c:, pla ... rna Id IOtr,lhl"'l·ul.lf nUll.! Hlluml' FoUl'" IIlg th -.,,: I.:hange .... lh\."re

Inh.'r ... tiIlUItl.

\~ IlIl",' ,I tn'l1lt'ndl1U, UIIII.II d\'l"!\"I'\' n1.\~ 1\',lt'h

1"11"'1\:\'111

\\1I11I111I1l'III'>,,111I.11\1 ,II Il'l 1111111\ 1\ II>

Iklll.lt\.ll~l,~!H,. ,\1 ,Iud ,I '\.'\l'I'\'

hum IIlIUI~

IIIl',IIlII.ll- oUtpUI . ,\ Illlil

(lIl'lIl,lIl'"

Ih""'l'

dl,IIl~l"

dl,lIl!!l"

.tI'll11l'UII ,llll'l

Illl'lud\.'

,t!tl'I,IIItHl' III

platekt \'l'lh'\.'nll.lIllll\ ,Hid !UIIl'IIUli. dlltllll~ 1,ll' WI', .md \\hltt' hk'l'l\ll·t'lll'lll11pi,)IK'nt,. I\'d hllllld l'\.'11 d~'llIn(,:ti()ll . •t1Id d",'\'(\:,.I"'"," 11\ ht'l1111g111blll and hl'Ill;II11lTII. I Ill l"l' rh~ 'l(,llll~1l..·.tl ,lltt-ratll ll1'. l'uupkd \\ itlt cMdia\' dl:1I1gl" ,Uh.t lltJul\.·d \,l'l'ul.lr !"x'd" \\111 'lglllltl'~lI1tl~ lI11pacl 111111.11 l\.':--U'l'ltaIlOn dforb .lIlli. II th",' p.IIICllt ,un 1\";'. ho\\ rapIdl~ ht' or :--h",' \\ III I'(Ttl\t'r. III .Iddilion. p,t1It:'llh \\ ill t:\!lIbll dc?'\'llOlrx-n:--.ulon fronl ,Ill l·nduranl'l.' 'lanlipoillt .

Heterotopic Ossification P-J,tienl!- \\ i[h bums are highl) :--u'ct:'ptible 10 the del. dopII1cnt ~hown b~ pro . . pt.'l,ti\t· $lUdies demonstnlling ~l \t'r~ high reponed IIlCidt:llL,(,.J' -~I HO\\e\er, lhe actual numbt.·r of ca,e~ that progre ... , on 10 becoming c1inicall~ problematic i~ relali\el~ 10\\."'51 \\"h) HO occurs in patients \\ ilh burn injurie~ is unc~rlain. Suspe-cred etiologie;:-. include greater than ::!O percelll TBSA bum. inmlObilization. microtrauma. high prole in intake. and sepsis. The mo;:-.( common areas affected are Ihe elbo\\~. 1'01100\ed b) the hips and shoulders: ho\\i;~H~r. HO can appear any\\here throughout the bod).5051 U:-,uall) HO OCCllr~ in areas of full-thickness injUf) or sites that remain unhealed for prolonged periods of time. S) I11plOlllS appear late in a patient's course of reco\"er) and include decreased RO~d . point-specific pain. and a qualit\ or reponed pain that differs from th::u experienced by patients \\i lh u genem.lized bum

of ht'{t'n){I)pit o:nijicalloll (HO J. a:--

injUf).

europa thy Peripheral n e urop a th~' in patients \\ ith bum:-. can lake [\\0 forms: polyneuropath~ or local neuropalh~.'~ The cau,e of pol)neuropathy is unkno\\n. As \\jth patients \\i[h HO. patients with peripheral neuroparh) generall) have a large TBSA burn. and [he condition rna) be ue ....... uch as compre')')ion bandage,:> applied too [ightl~. poorl) lined splints. or prolonged and inappropriate po ... ilioning of J pauenL~; The mo~t common ... lte,:> of in\-olvement are lhe brachial plc\u'). ulnar nene. and common peroneal nent:".

Pathological Scars Bum f..a.r ... oU,:ur In J.reJ ... 01 deep partlal-Ihid,ne, ... bum thaI are allm\.cd to heal ... pont.meou ... l~ .lnd In full-thILkne, ... bum that ha\c hcen ... k.1n ~raftcJ. hut \\hae graft l"U\~r~lge I ... !nf..omplcte, Sf..ar... ~t.:ome pJ.tholll~!II.:al \\ hen the) t.lkt: un tht: tonn ot h>rcnmph). cOlllrJ,<.:ture or bOlh E~ILh 01 lhe~ 'Lar LonJItJOn ... I... unl~uc and ,htluld nm he \ Ic\\ed .J 'I)non>mou ... , \ patlcnt LJ.n hJ.\c.1 hH~nfl)phIL "'1.·,lr th at

Burn Wound Healing rhl' bum \\ OlUld ha . . bccn dt: ... cnbcd and the CJU'-!C,-! and complicallon ... 01 burn IIlJur) h
Epidennal Healing \\'heo a bum injure"! ju ... t the epldemli:-,. or If there are \iable cell.., lining tht' ... kin appendage s. epithelial hea ling can occur on the ,urface of a \\ ound. The . . Ilmulu, for epithelial gro\\lh i ... Ihe pre ... ence of an open \\ound e\po~­ ing ~ubepil h elial ti..,:-,ue of the bod~ to the em Ironment The intact epithelium attempl,,! to co\er an e\po,ed \\ound through mito~i, and the ameboid mo\ement of celt... from the basal 13)er or the ;:-.urrounding epidenni, 11110 the \\ound. The epithelial cell ... ,top migration \\hen the~ art' cOl11ple[el~ in comaet \\ ilh other epithelial cells. After thl~ coman fllluiJi{iol1. cell... can begin to differenllare to fonn the \ariou~ l
healtn~

,.. '" 1 , . 1 r fllbklll . \\(lUnl,I Lb· u rtl,llion 1,..11 l~ .

ne\\ ,kill -I'> Lh"lrJClen'IK.III~ d~ .md mJ~ .. phi . I ' l.._ • . lu .. e m.m\ III Dr\ n(' ... '" 111.1\ contlnw: lor a ong IImt:. ll\;\'· .' ' !."!iJnd ... do not retum (0 IIlelr non1131IU I1 I.·[lon lhe. ,('b3ceoll' J TIlef,lrl'r... nee l i l(l t·Ju ...·J1c' lher.1 \\(lund -I ... epllhdlalut:. •r~lll~nh .ltx)ut Ihe I)pe.lreque . "h 1l11lue" of nllll '", nc) .•1111I ItL lurtllng \.'fe-.lln .lppl,,:.1I10n to I ubnc.ile ne\\." he •lied [I .... u'and

the

I)cronal I kaling \\IWIl .111 lUlU!) 11I ... lIh ..·... II\\tW dlTIW I • I 11.111 till' "pIlk-rlill dt'fllllll hl'u hllg. til 'l,11 11\f1J1.llltllll)(I' S t .... , • l.1I IOllllilllll1l III Ill: dl\.l(ktlllllo IhllT ph'\ 'l": 111 11111111 ' , ~. , hi OIY. plolikrilllW uld 111.11111,1111111 . \11110111-'11 Ihl"l' Illl'I \' , , ' 1\ WI, II I)t' ilnc.:IJix'd. fl',lr,LIl'h. lil ..,) OH' W on" 1'01111111111111 I I ' .l1l( om- p 1il'l' 0111'11

UH'd,IP'" ,1110111\,:1.

Innammatory Phase Ihl' plllll.lr:r Il';II:IIOI1 (If

viahlt,.· ["'lIl' ",... IlUI II

Wotln( I ,\

Ult1,tlllllliIIIOIl. \-",llId, plcpml· ... the wound I", I 'I I I . , . .' , ll,l IlIg t lrOU!! I hl'1110,lillll. v.,\nll.II, Illld t'l'lluli\l t'V".. " " • I 11 I I·.U1l1Tlat l on 1ll"TIIl' ill [hL' [ l llll' ollllllJlY " l'Ill!, In 'Iho", "
,} °

I' dl
Plaldct ... aggrc..·gaIL·. ilnd fihnnl ... dcpn... ilcd 10 form:t clol ovc;' Ihl.' an:i.1. I limn ...L·rvl· ... a Ihlcl'lold 11Illtilon. (I) 10 parllall y rt'l.11I1 hody I1lll(l .... (2) prolc(..'1 Ihe underl y ing ce ll ... from de,,1((;111011. (lnd 0) In provide H film coagu lum su lhlancc from \l,hlch l'cll ... "'an IIlflllrulC. Therdorc. fibrin CH Il be thoughl 01 iI\ lonlllllg a lallice nelwork. trom wh ich cel l ... call cli mb :mcl \.. or~ IhCIlN.:lvc" Inlo Ihe hcaling "' lruClurc. ·\ftcr iI Iran"icl1l va",oco n\ tnctlOll 0 1 Ihe vilo,;clll aiure. which lao,;1\ about .5 to I 0 1l1InU le~. ve~~cj>.; vil o,;od llaH: 10 lIlL're:.t"c hlood flow 10 Ihe area. T hcrc i ... in cn.:a"ed pcrmc allllJl} 01 thc hlood vcs..,el". w ll h leak lll g of pla... nHI inl o Ihc Inlcr"'lllia l "pace and sLlb~eq ll e nl edem a f ormati on. Lcu~ocylc", II1fi ltratc thc area and beg in 10 rid the ..,itl' or (OJ1lamln:.tlioll 01 part icula r Imporwncc i ... thc pre..,cnce of the macrophagc. \\'Im;h I ... n:\pon ... ibl c for alt racli ng fi brobla . . I\ mlo the area.

Proliferative Phase Durmg th" pha ... e, re-epllhe lial i.lation j<., occurring il t the \urfacc of the wound. whllc dcep wi lh l11 the wuu lld, fi brobla'l\ ,Ire migrating and pro l i ferat ing. Fihroblast\ arc Ihe cel l... thai 'Yllthc\i/C '-Icar li ...... ue. wh ich II., compO\cd 01 col· lagen and protein poIY'-I
1 )t11I/I~' Iht IHOld l·, .. ll v,' phd' WIIIIIHI UlIIlr.HI!t1ll Ot lIJl\. Woulld lflllll.uluIII ,.. 1/1 .1111 ! fllfK' III tlllh Ih l hody ,l llt-lnl'1 • III l ill t· •• ,"""und wl.·ft d 10 ,,1 II II! 11;1 \ Ol ('111 II'" J II(' 111111111111 of lllll!ril(II(11I 14j rkh'rtllIIwd hy 1111' ill1 I ()I III I 01 ,lva J!ahh IIlflbJlt ~ III il1lll1lU I IIII' ddeu. It IIlvolvc"i IIIOH' lm'lIl 01 CXJI.IIIJV II ,ue .11 Ihe WOUlld edge lo\\.lId tIU·u.'lIll·r, nol 10111111110/1 "Im'w II ' "Ill' WIII/flri (;1m tl'1l'IIOIl I ...... IOPPl·d Whl'lI ( I, Ihl' clive,", 01 Iht· w(Julld lI1eel 01 (2) Il'lhlO/l 1I11hc \ WroUIl(1l1l 1! "~III cqu.11 fH c:IH:ct·cI Ih~ lorl·l· 01 l"Ol1llal·IHHI. S~JJl g rafll1lg !nay clcoc
Maturation

Pha~ c

1\ wound ... con"ii
the '-ourf'l<.:e; howcver, wound hei.lllllg involve .. remodeling 01 Ihe "'(;ar I""'-oue, During 1he maluration pha\(;, there II., 11 reduc· lIon III Ihe number 0 1 fl brohli.l ... h. a deercu\C In va~ularlly due 10 a le:--.o"cr metahol ic demand, and remocie llllg of c.;olla~ gell, wll1(,;h hccomc:--. more. p
or

Medical Management of Burns Advance ... 111 the medical management of bu m ... hme re.... ulted in the ..,urv ival o f Ihou\and.., of pal lent.., "",ho 15 or 20 yea r.., ago would have died o r their inj uri e\.'i~ T he rC'-ocarch b:.tse and Icc hnique:--. avai lable loday ill modem hu rn cen lcr.., have enabled pallenl s 10 receive ocller care Ihrough the u..,c o f more \ophio,;t icated h:c h ni4u~", for Ihe Irealmcnt of major burn injuric"i. Tl1i ... "1:<.: 110n \\ III c..Ii,,(u, ... the IIll l ial Ireal menl of burn lI1.lune ... Hllti tht: "'UQ!IC,tI prl)l·edun:.., a:--,..,oclaled w il h C\Ci ... IOll and grall mg 01 ne\\ ... km onlo a burn wou nd.

Initial Management and Wound Care rilL' goal ... 111 Ihl..' 111111;.11 managl'l11l.·n t (11 .1 p.1I11.·111 \\lIh .1 hU 11l Me 10 addn:~~ tttl' 1lI:lllll Ii Il·-t hn:alt·l1lllg pn'hkm" ,mti ... Iahlillt.:' till.' P:IIICll t Ihmugh Pnll'l.·tiUI\.·, dt"I~Ill'd IU:

I I :... I,lhl ... 1l allti 111,lInl;l1l1 ,Ill .111 \\.1\

2.

Pll'Wllt nlllll1'> I \. \ I Hll"~ .• 1I1d hl'I11111lIhlgl'

, "\I;lhll ... h h.l\t'ItI1(· d.lI.l ~llllhl' p.1I1I:nl, \ulh ., .. nll'11I.lOd ~kplh 01 bUill II1lll1 ~

4 PT~\('nl or T~ du\.:c !l un l 10 "l'S p.llu:nl .lI1d \\,OIlI HI fl . [ ' "umn ItlIUri l'S 7 PTl' \l'nl pU1111011.1T) .lIld l'l/ (h ,IC l·oll1pll ra IIO/l \.

5 (,Ic.m Ihe

rn.l £ l~ UWI!! lhl'..,C

pron·durl· ... ,Ippllc..·... tn m:IIClr btlln t!
hum l:cllIer. ra lhe l than to ,I ho ... pll portatlOn pha....c. pallcnt hi ... lOry and pcr\onc:d daw arc ~a th crcd \.\hen fKl\ ... lhlc. The Iype 01 agent causmg !he hurn I ... notcd . •md in itial CX :'l ll1 l n ~l tl on 01' the hum inj Llry ta ke\ place Ll11ergency medical pcr\onnel may u...c lhe ru le 01 Il lne\ to c..,lImalc the percen t of burn injury. I~ urth c nnore, they will prepare Ihe Individual for triage at thl: burn cent er by remov, mg all burned clothing and Jewe lry and inillating the ad mln I,-t rat lon of nUl d through an II1tra ve nou ,- line. One of the major advance\ m hum care hal., heen In flUid volume replacement InJl ia ll y <:I nc! th roughout a pallenl \ treatme nl. Research has led to an Improved LJndCr\ landing of the physiOlogical change \ that occ ur in a patient after a burn inj ury and of the nuid volumes necc\\ary to Improve the chance fo r \urvival. 44AIJ In formation aboul the ph y\ iologica l change, re ' po n, ible for Ihe ' hifl , In hod y n uid, and protein has led to the u<,e of intravenou \ \OIUllOn\ in an amo unt necessary to rep lace vi lal n uid and electrol ytesYl After a patient arn vcs at U burn ce nter and adequate nuid res uscitati on has been initia ted. the burn team determines the ex ten t and depth of II1jUry, and begin ... il1llJal wound c1ean\ing, Wound cleansing may be perform ed u\ mg a variety of approaches, alt hough the majority of burn center\ still Incorporate hydrothe rapy.s ·51.1 The initial wound care s.es!:'ion allows the team to establish body weight, examlllC a pati ent ful ly. re move hair where necessary, and start th e debridement process by removing any loose \ klll. The goal\ of wou nd clean... ing and debridement are 10 remove dead ti s~ sue, prevent infection. and promote revasculari zalion and/or epitheliali / ation of the area, Depending on the (ae Jlny, phYSical therapists may be Involved m the wound c1canm g procedu re.1I1lJl').61 A large hydrotherapy tank or whirlpool tu b u, uall y Will have some form of di ... infec tant in the water (Q a\S i\1 111 infection controI. 5H2 ,(jl Wa ter te mperature \ hould be between 98.6'F and 104 f r3?" C to 40' C), While. pallen t is in the water, adherent dre\\lI1g\ (if prese nl) arc removed. Care mu \ t be taken when remov ing the drc\\JI1 g.., 10 cn... urc mil1lmo:tl or no bleedin g. The removal of drcI.,s lngs In the water III les", painful than dry removal. Some burn unit ... have (;(mve rted to th e U\C 01 \hower\, "' pray ing. or "hed hath,;' lor Ihe removal of drc\\ ing\ and da il y <.:leaning of W()UIHh .f>4 Rcg" rdl c\\ of the wound (;(ca n... lI1g ap proac h. mo... t pati ent\ require palll Illedi(;ation prior to wound (;(lrl: Alter dre~\lIl g\ arc rClllovcd. the wound shou ld he lIl \pcued carefu ll y. 1 he i'ppci.lra nc.:c. dcpth. \lIe cxudale. ~ cnC)

,IIIC I odOl ,In 11 1)(('"

In/,"

IlfJlI I

l h,lId(

kill d',Jlllilgl", 0/1111, leve l .. IHIIVwlll

tl'II/I'd hy I) Ii blild Iii

,

lit,

(f) I

plln ,

fll'lllllI"1

r.lpH I \l'p,Jr.lllfll1 of c\(;h.u, ho" HI ,J(II'KCIiI II u hr 1I)j"1 VC I 1011 01 ,I eIL-ep parll. iI IllId II{' hurn til" full II ' II( '.he lIllll ry, WC lIl llcllill l' I', lilrrief l (HI t tJ'>flll! t lealllt'( /1111(1 11 ,I., If I lI'r ile 1I1\llt llll(·I1 I\. " \ Iwq) dchridl'JlU'1I1 (till II\(' III IIr)..'II,;,1I U\sOl~ or \(afpcl aJl(I fOICTJI to rt'JrIO"t e thar, I r"l formcd ..... loIlJ!Ilf'd c..'pulefllll' alld h)(,'>(:. l;...(lwf cd iii the Ircl.ItfTIl'nl oj hurn ... fhc led! 1lI(IUC of applyi ng
Surgical Management of th e B urn Wound Prima ry exci,ion 1\ ,urglcal remm'' the s,Jme pe(""I' u.. uall~ "jd.I\l.'r "'Ill The "ill I"

If:;;

(h;lptt.."r 27 Burn..

fable 27.3

Common Topicul Medication.!'. U~cd in Trcutmcnt of Burn ..

Medication

Dest'ription

Method of Applic:.ation

Silver sulfadiazine

Most commonly used topical antibacterIal agent; eHectlve agamst pseudomonas Infections.

White cream applied with sterile glove 2-4 mm thick directly to wound or Impregnated into fine mesh gauze.

Mafenlde acelale (Sulfamylon)

Topical antlbactenal agent; effective against gram-negative or gram-positive organisms; dIffuses easily through eschar.

White cream applied dlreclly to wound wilh thin 1-2 mm layer twice dally; may be lefl undressed or covered With thin layer of gauze.

Mafenlde acetate solution (sulfamylon So 0 solution)

Topical solution with antimicrobial function against gram-negative and gramposItive organisms. Maintains moist environment.

SO gram packet of white powder mixed With either 1000 mL of stenle water or 0.9°'0 sodIum chloride soaked gauze.

Sliver nitrate

Antiseptic germicide and astringent; will penelrale only 1-2 mm of eschar; useful for surface bacteria; stams black.

Dressings or soaks used every 2 hours; also available as small sticks to cauterize small open areas.

Bacltracln/Polysponn

Bland ointment; effective against gramposItive organisms.

Thin layer of ointmenl applied directly to wound and left open.

Collagenase, Accuzyme

Enzymatic debnding agent seleclivefy debndes necrotic tissue; no antibacterial action.

Ointment applied to eschar and covered with moist occlusive dressing With or without an antimicrobial agent.

11')1('11 III ... J...111 hallb for prnk)ng~d period .... Allngraft!'l arc k'l1lpt)r.11) gr;lfl ... u ...ed to cnvcr Llrgc hUrlb \\ hen Ihere l.':t lI\~ullklCn l ,llIlogr;\ft :l\ ;libble. Xenograft (hctcrografl ). i.':t ~J...1I1 from .1110111l.'f ~pcck .... u... uall) tl pig. Allografb or \C"nngrafh ;m: lhCd until there i...... uOiclcnl nonnal ... J...in .1\;\!I.lhk for;1I1 ;Iutogrdll. P~rh;lp",

pmgrc ...... 1\ ~ ~Ilh :lIh..:e-lllclll III the care (\IIl;\lIl'll h \\1111 hunh III rel'cn t )c:lr... I ... th~ u ... c of ski n 'lIb~liltJlI~ ... for Ul\ crage of ;\Il e,\l'lscd \\ ouml. M 'I Skill 'IIt"'lIl1t~ ... "nih lsi of cultured ;Hlllllogou ...... kin. \\ hieh I~ ~r0\\ n III ;\ bhor;lh)r~ fmm :1 Imlp:-,) of;1 pal ie-nt· ... 0\\ n I is,tiC". Ihl' lI ... e nl ;Iltcrcd l.:ad;l\cr ... J...II1. mother hiologlcall) l'n~Hnl'L'rt'd 1I ...... lIL· .... Skill ... Ul·hlltul~ ... ~Irc u ... cd \\ hell large .ITt';l .. 01 hurn L'\i ... t ;lIld CO\C1".lgC I... I\CL'L· ...... ar) for:l palient"" ~t1nl\.l1. CulturL'd .lutolngou ...... \....1Il l
111()'.1

10 m.lIl.1 glll,!! Jl.lIll·Jlh \\lIh L1rgc

hum \\lHll1(i.... \ k\\

lyJll''''

III J...1Il ... tlh . . IIIUIL· ... IIldudl' I/'h/ll/llIIlllllll'~/(llt., ( '/ \I: \ ... J...1I1 hH1Jl ... , I... lIht.llIll·d 1[(111).1 p.llll·III, ;md nnl) Ih(' L'pll krnl;11 L'clb ;11~ lullurl'd (,t/tlli l "111(/,1/111-:(111' '111I//'/HIlI i.!lclf'.\ \ ... J...1I1 bHll"h~ I... nhl. lI l\llllhllll .1 1'.1111..'1\1, .lIld htllh l'tHtknn.1i .lIld dl..·ll1l.1l ldl .... lrL·l\lIIUII..~d 11\1'" It II 111'" .1 !l11.l'l·1 ~ lnl l'lml'

(It/twed

, ..

I un

---

------

3. Allogenic skill :m/)sfifwe: The epidernlal layer of skin

and ..111 immune cells are removed frolll cadaver skin. Thb ti:;sue b applied to the graft bed and once adhered. a Ihin epidermal autograft or CEA is applied.(\)! -L elf/lUred dl'l"mis (tt!11IporGlY): Cultured dennal malri\. i!') seeded wilh human neonatal libroblasts and used ru. a lemporal") cm ering in place of cadaver skin. Thi::-. ::-.ubsii tUIC c\cl1tuall) I!:) l"l:moved and replaced with an aU{Qgraft.(l~·""lO

5. elf/fllred dl'rmls (defll1ifh'e): This skin substitute is compo~ed

of cultured bO\ine collagen \\ ith a silicone outer laycr. Pore:. in the material allo\\ for con trolled gro\\ Lh of a ncodenlli:-,. After appro\imatd) I-l- da)s. the .siliCOile L\)l:r is removed and a yet") thin ~kill graft or CEA i ... applied. ""l l

Skin Grafting Procedure rhl' re1110\:11 of ,j., in 10 graft 01110 a bum \\ Olll1d i... done "'U[under ane ... the ... ia. The ... kin lbed for a gmfl u:-'lI~\II~ i... remo\t"'d \\ ilh ;\ c!{'rmcltO/11c. Till ... 1Il~lnullcnt 111..11 onl) alkm ... tht"' ... urgl'on 10 Ohl;\il1;\ brge amount of ... k1l1. but ;lIllOrt' l'l'n ... "'tL' 1l1 thieJ...nl.' ...... (1" ... kin C;\11 he obt.lIlll'J. Tile de-nn.tll..ll1h· i... ;ldju ... ll.'d 10 n':1l1m e ,I prcdt'Il'11111l1~d Ihie\....nl':-. ... l1f ... k1O for a ...plit-Ihic"-ne....s ,"-in graft \ ... pllt-tl1i('knt.· ......... klll gran conI.un ... l'ptdl'l111I'" .1Ilt! ol\l~ Ihe- ,upcrtil'i.ll I.\~ I.'f'. l)f thl.· JClllll .... ;1 ... ()PI)(bl'd hl a fttll·thichtll' .......... "-in gnlft . "hll'h L"l'l1 ... I"'I"'I..,1" 11ll.' full dL·l1n.lllhlCJ...IlI.· ...... 1Ill' "'11l· fnll1l \\ 1111.'11.\ ... J...111 !!r.\ft t... 1.1J...l~n l"'l...dlt.'d.l donor ,itl' ( \)Il Ulllm dnllllf ... llt· ... Int"!udl' tlk' thigh .... Nllh.X·k .....UllI giC~ll1)

Figure 27.11 Sheel gran on dorsum or len hand. po .. lopcratlvc (From Ri chard and Slalcy.t'1 p 183. \\i ith pc nm", .. lon. )

Figure 27.12 Mc<.,hed .. plit ·tlllcknc ...... kin grail applied I reshly excised wound and .. ceurcd \\ IIh .. Iaple ....

back. These wou nd s heal by re-epi lh e lializalion , li ke a partlUl-lhickness bum. and require appropriat e care to pre"em addi ti onaJ demlal damage wi th resultant ~car fOI111alion. A full-thickness ski n graft has the di sadvantage of leavmg a full- th ickness wound that wi ll req uire e ither primary cJo~ure or grafti ng wi th a spli t-th ickness skin gra ft. Generally, Ih e Ihinner Ihe ski n graft. Ihc bellcr Ihe adherence. and the thicker the gra ft. the bette r the co~me ti c rc!-tult. Ln addition. a thin gra ft will contract more than a thick sk in g raft o nce il ha s adhered 10 Ihe wou nd bed. Selection of depth de pend s on many factors, inc luding wheth er or not the donor si te needs to be used again for anolher sk in g raft. Taking a Ihicker gra ft adve"c ly afTects the possibility o f taking anoth er graft from the ~ame ~i te for a prolonged period of tim e. Harves tin g from spl itthickness ski n gra ft sites may be re pealed in 1010 14 days, depending on th e amount of time the donor site takcs to heal. A s heet graft is a sk in graft applied to a rcci pien l bed without al teration following harvesting from a dOllor site (Fig. 27. 11 ). The face, neck , and hands arc covered wilh thiS type of graft for optim al cosmesis and function. When limited donor 'ik in i... availablc. most areas arc covered with a mesh graft (Fig. 27.12). T he meshing of a graft con>islS of processing the sheet graft through a device th at mak es tiny para lle l incision .. in a linca r arrangcme nt. This proces~ permits the sk ill graft 10 be expanded before II is app li ed 10 the wound bed.72 Thi .. tet hlllque allows cove rage of a largcr area. and ante the graft adheres, the inter .. tlccs heal through rc·epitheliali/ution, A skill graft usually is held 111 placc wi th ... ulurcs. staplcs, or Sleri ·Strips (ela ... llt.: skin t.:lo ... ures). Once H gra ft 1.., fixed III posllion. any blood or serul11 Ihat I11lgh! have become \()luted hetwccn Ih l! graft ~lI1d tilt: n:c lpICIl[ "lie hould he rcmoved Applila lJOIl of a PIL''''''UI"L' dI'C ..... IIl!! ialllJlates conl<.l(;l bctween Ihe grilf l Hnd ICllpJCll1 .. ilL' One ullhe ha . . le nct:c ....'1 lllc .. lor ... un:c ....·.luJ adlu.·'L·IKC 01 a grail I') ... ullillelll va ..t: ulilnty wllhlll Ihe wO\lnd Ill·d (iralt ...

will not adhere to poorly va.,culari7cd area'), such as tendon. Once a sk in graft has been applied. separation of a gmh frol11 its bed muM be prevented. Separation may rc\ult from shear forcc. mechanical trauma. or hematoma fonnallan. Initiall y. an area is immobilizcd with a dresslIlg that provides liml. e\'en compression on the wound. Othcr rca~on .. for graft fa ilure include inadequate exci~ion of necrotic tI~­ ~ue and infection. Survival of a skin graft depend . . on several factor.,: (I) ci rcu lmioll. wh ich provides a nutritive !)upply to thc gmll: (2) inosc ulation. or the pro ce~s by which a direci connection i~ establh.hed be tween a gr~11t and the hO~1 \'es~eJ..: Jnd (3) penelration of the host vessels into a graft "'lIe. E\ccpl in d<Jrk ly pigmented per"!on .... graft ... are \\ hlle 111 color al the time of tran splal1l3tion and begin lO sho\'v a pinkl . . h hue within a maHer of hours after their placement on an adequate va ... cular bed. The rc-c"ltah li c.;hmcnl or Circulation ill a ... kin graft \1,.111 take place through the formation of direci an:l\t0I110"" bClween respective ve:-,scl .... lIwa"lOn from the hm! bed forming nev.: chanlle l ~. or both. lv.·cllI)"-four hour .. "fief grafting, 1111mcrou~ ho ... t vc .. ..,cl .. will have pt:nelralcd Ihe graft.'" The lI1\"a ... ion of new caplilarie .... eeill" 10 he Ihl' 111mt Important COIl\ldcratioll in \"a",clll~lnzati()n. onl,.III). wi thin 72 hour ... ino ..cu l ~lIio n lIa .. proceeded 10 Ihe prllll! where the .. k 111 gra f I .I~ ~eclln.:. I nllia II y.... true'l ur'll ...."()llIlCC' d I .• lion"! are fihrou .... Collagcn I... tlicn Iillu ()\\ n ()"ct.·un: the

d3~ 7

10

allm.: hmcnt of the graft.

Surgical Correction of Scar Contracture .l.",llIl III • un"lIl l 1I1111l1ll" .I[l I I aVl'ltlflll "1(;.11' L"(ll lt rac IUI"L' IOlllliltl(lll. nllt I I I ' I II e-I . .. tllfl·'. 1 .d 1l01L'c.i III ROM and IUIICIJ(lIl. "lIl~L'r~ mil) )L'lll! II .. pO\qllllll tilL' P:I"1. ICUIII .. IllICII'·L' .. tll gC!) U"'U:I ~ \\<1 . ' {II lUll' ph.l\l v,,·lulL'.1 burn wound W;I'" III IIiL' "L"lnc. IIIUnd ..• "Iul • I I '\L"r .. Ulll II ph Y~It.·tll !herilpy

IIH L'nl' lItIOIl '"

.IIL'

"L"·II" 101 IIl"1l Hlil . i\.!Oll· Il·CCIII~. 1{)\\I.:. . ' ' . ,"I'Ill' "L·al" nl
I," '

Chapter 27 Burn...

110.1

2

1

4

1- -t--J-L

4

Figure 27.13 Schemallc d 13r.lfll (II Z-pla .. t) prol:edurc U:n!:"!lhcnmg of \car II\\UC mtm. du ... e normal u ...... uc on each "Ide

01 the dongutt:d .. car band . •From Richard dIld Stale)." p 19~. v.llh pcrml\ .. loll.'

3

Contracture

been documc nr cd. -' Eac ' an . . h patie nl \. ,~ca r w',ll re qUire mdl\ iduahzed eva lualJon a nd trea lme nr. S urgical (rcalmenl option \.; are beyo nd th e scope o f thi s c hap ter, bu t common proced ures to e limin a te ~c ar co nLraClUres are

.. km grail .. and Z-plaslics. A ZM plas ty i .. shown in Figure 27.13. The Z-p lasty ,e rves to le ng th e n a scar by in terpos -

109 norma l l l .,\uc In th e line of th e scar. Skin graff ., are u. . ed for morc severe CO lllraClurcs.

Physical Therapy Management Treatment of a pati ent with burn" begin .. the momcnl he or ,he arnve\ at th e hospHal a nd ic; an evolvin g process Ihal may need 10 he modifi ed dail y.7 'J.7~ The prcv iou ~ seclion \ 01 th" chapter have di ,c ussed th e patho physi o log ica l

change\ and <J ltcratlOo o., o f the ~ kin Ihal m;cur In th e bu rn \I.{Jund and th e c lo., ure o r Ihal wound. IIlc luding variou.., Iypt·\ oj .,km gra ft m a t e rial ~. Whi le th e ~ ki n b healing, it is Impera ti ve that phy.,ica l thcrapy in terventi on occ ur.., COI1 currently. T re,llmcnt j..,: d lrccted towa rd preve nti on of \caJ' lOlllract urc, prc\crva tion o f no rmal ROM , prevc ntion or mmlllli / atllm 01 hypc rt J'O phlc '1car forma tHHl and deformity. mallltCl1<JII(;C or improvc ment in lI1u ~c ular ~ tJ'c ll g th iind l;m!Jova..,c ul ar endura nce. re lUrn 10 prchurn functi on, and pCrfOl/ mIlH':c of f.I(.: tivi II C'" of dH ll y li ving (A D!..)./) Thc phY"'Jt:a l tlH.: rap l..,t llltc rucl.., with other I11 c mbcl'\ of th e burn ItCiIJl 10 i,.,., i..,1 pa ti ent , 111 ohti.l llllllg the..,e outco mc..,. hJl lJIany patlellh. the 1110..,1 d lli ll ult pha ..,e of rehahilitatlon I)("lllh alkr th e wo un d., ha ve hca ll'd and the '1<,:ar !I 'IMIL' flt:~'l/h II) (:Ol1llac.:1. b ill y phy.,lCal tlle/a py intcrvl'llti on to C' l<Jbll"'Ih ,I PIOV Illill 0 1 eXt'n: I"'\.:.' and f"um:llol1i1 1 /l1 0vc.· I11CIH III lllllJUIIl 111)/1 v.- IIII the woun d hea ling 1110('"1..'''''''. wil l 1
Lines of Incision

Result of Z-plasty

Examination After the initial examinalion of the dcpth of bu rn and amount of T BSA involved, the physical thcrapiM then examines the paticnt to determine the presence of impai rments and functional lim itations. TIle therapist must also consider the potenti al for development of indi rect impai rmc~t s as the ~urn wou nds heal and mature. For example. aCti ve or passive RO M may be lim ited as a result of edema restr ictive eschar, or pai n, and an initi al baseline measure ~ ho lii d be obtai ned. in add itio n, the therapist needs lO obtai n an accurate history from Ihe paticnt and famil y members rega rd ing any preexisting limitati ons or prev ious inj uries th at may affect re habilitati on potential. Ot hcr lests and measures discllssed in thi ~ tex t can be included in the init ial examinat ion and reexamination of a paticnt fo ll owi ng burn inju ry (e.g., gait, functional status). Beca use hcali ng of a burn wou nd is a dynamic proces.., <.ind changc\ may occur dail y, the physical thera pi ~ 1 mu ~t ex am inc and monitor patients routin ely for changes, in skin integ rit y, ROM , and mobi lity. Freq uent evaluation will keep the physical therapist and other member:.. of the burn care team abrca!'l t o f potential problems so th at inten·ention can occur before a potential problem become, a rea l one . in addition to Ihe ph y..,ical damage a burn ha.., on a patient. Ihere al!o.o may be an c n ormoll~ p,ychological illlpact. 7tl•17 The physica l t h era pi ~1 shou ld be cognil ant of a potenl ial problem durin g ongoing C\·aluallon,. bccau~e P')chological trauJIla Illay affect the pallcnt \; prog rc'l" Hnd outlook Inward hi... or her fu ture and n: hi.lbilitation. Rcferr.tl 10 a ll app ropriate profc ..,.., iona l for intervcntion /lUt) l ' IICl'L'"Silry.

Anticipated Goal., and Fxpc("tcd Outcom('s BH"'l'd Oil IhL' l'\illu.1I101l , till' l· \t L' 1I1 .1Ilt! dqHh or hum. 4111d

IIll' JlillJl'll l"" Clil rL'1lI hL'itlth , Ialll ' .• t!!L·, .lIld ph) , Il·.tl ano II1l' I1I11 I l" oI1(IIIIOII. (he pil lll.·l1l .... jllogl1n .. ,.. l ..111 t~ t· ... lIll1.lIcJ h) thl.' hU11I l·; II I,.' 11.'.1/11 (; ~1.11 ... lI1d ~l utL'lll11e , 01 pll\"IL,tl

t 106

Ph, ical Rehabilita tion

thcrar~

I11U ... I ht: l,Ul:-fulI~ II1dl\ Idu
n

1 \\nund lnt! ... oft ti ...... ue healtng j"" enhanced. ::! R"k of IIlfectioll and complication ... i ... reduccd, ' . Ri,k l)f "'ecolllli.lfj impamnent ... \"" reduced, 4 \1 3\101.11 RO \l i, achie\ed. 5. Pre-injuf) le\ el of cardio\'ibcular c:ndur.mcl: i... rc~torL'd. 0, GO<.xi to nonnal ~Lrenglh I~ achic\ed, 7 Independent ambulatiol1 i"t achie\"ed. \. Independent func tj on in BADL and lADL b incrca ... cd. 9, Scar fomlalion i5. minimi zed. ](I 10, Patient. rami l). and caregh'ers under:.. land ing of e\pcctation ... and goals and outcoll1e~ is inc reased. II II. Aerob ic capacity is increased. I:! 12. Self- management of symptoms is im proved. The optim al o ut come of rehabi li tation is the return of a pat ient to pre inju ry function and li fes tyle.

Intervention Patients with bums usually will begin physical therapy on

the day of adm ission. The in it ial examinal ion of a palient

\\ ill dc..'ll'fIllll1C: \\ hll h .lIl·,. 1l("C'd Itl lx, addl t " " I t:l IIr I (\llltwi ,lI1d re..",,,IUIUlflllt e..'dc..·Il1,I.lfld r 'CI\ Ill' RO\I . .111\. .IIC fir'l pri01"1l1l". Fit'\,l\llllI 01 lhc l'\1rt'l11lll <·W UU JL:II\ t' 11111\ e..'llll'nl. C'IX'(l.llI~ ot Ihe..' h,lllth ,md .mH.; , h I III 111111 IIII ill..' e..~d(,l1hl fOllll.lIUlIl Prc\e..'nllon lit "'\. .II ...(·n ' • Ir.ItP turC\ \..';111 tlL' ,ll·l'omp" ... he:d through PO'llIlIllIng. "'phllli ng ,lIld C\l'rI..'N=- r\crl.'I'c. ,lIld ,lInhu\Jtu)1l .I"() \\111 h'l • P 10' III I III III Ill' th e deiL'lcflllu ... clkl..'h 01 hc:d rc: . . , I 'oll\l\\ I Ill! \\ound dll""url'. l11il .......lge and l'(llllpre"""ull1 \\111 J"I" \\lth III 111 1111 lIing l'Onlr"Klurl' fonn,Hlon .lIld Il1.Ul,tgL'lllenl ()I bunt scar .... nH:~ scar that f0n11 \ aero .......1J(JlIlt ,kill l..'fe.I'e..' \\ 11I\e he.ll. lIlg i:-- cOlllpo ... ed of 11ll1l1~lIuf(" collagC:1l -\ 'L,lr \\ ill ,Imnl'n a:-- a re ... uit of Ihc cOlllraclilc or jlulIlIIg ron'''''''' 111 "'clr 11..... ue and limil ROt\l and fUllction unle ...... 1Ilh..'n.c:ntilln... ,I~ I.thocn again~t thi\ proce ... ~. ·\ lthough JI1ca ... ure ... 10 Pl"l'\l'llt .\ COn. Ir..lcture are undcrtakl'1l in C:\\1ect. llion 01 thl' hc: . . t R"lIit, Ihere wi ll be pat iellts \\ ho tll'\ clop ... car COlllr;ll.·IUn:.·.... l'hefl' are sc\"cral intl'l'\'cntiolh a\aiLlhk 10 the ph~ "ll.';tl 111I.:r.lp"t tn aid in the prc\cntion ~lI1d/or tn:at111t'nt of ... car cnlll rar tufl', As ..,taled. po:o: il ion ing, ... pl inting. HIH.! c:\cl"ci ...e arl' thrl'c intef\'c ntion~ effecti\"e in OppO~illg thl..' ... car l'ontral'ture process, Active c\cn: i""c and p~lIi e nt participation III fu nctional act ivi lic!'. are thc hc\t trcatllll'n t. . to IlI'C\CIII or mi nim ilc contracture,. Ilo\\"c\"(:: r, OWlIlg tn thl' rekntll':--.. force~ of scar tissue fonlHllion and pain ,b",oci:lIl'd \\lth

Table 27.4 Positioning Strategies for Common De fonnities

~~~~====~C~~' cn ~'_ ==Defo ==l'IIll =·ty ~=M =oti ~·~ODS =~tO=Be=S~tre =osed ====S~~es_t~e.d:....-Approaches Flexion

Hyperextension

Use double matlress: POSition neck in extenSion (Fig. 27 14):

with healing use rigid cerVical orthosis Shoulder and axilla

Adduclion and internal rolation

Abduction, flexion and external rotation

Posilion wllh shoulder flexed and abducted (airplane spltnt)

~-----------------------------------------

Elbow

Flexi on and pronation

Extension and supination

Splinl In exlenslon

Intrinsic minus position)

pophalangeal flexion, proximal

to decrease edema. Posillon In intrinsic plus position: wnst in extension. melacarpophalangeal In flexion , prOXimal Inlerphalangeal and dlstalmlerpha-

--------------------------------------------Hand Claw hand (also called Wrist extension; melacarWrap fingers separalely. Elevate in te rphalangeal and distal inlerphalangeal extension; thumb abduction

langeal in extension, thumb in abductton Wllh large web space HIp and groin

Flexion and adduclton

All motions. especially hip

HIp neutral wllIl slight

extension and abduction

abduclton Posterior knee splint

Knee

FleXion

Extension

Ankle

Planlarflexlon

All motions espeCially

dorsiflexion

PlastiC ankle-loot orthOSIS With cutout at Achilles tendon and

ankle posItioned in neutral

Chapfer' '2;- Burm

po_irioning and \ ... t

P'

11 .,.

plinting

lUll,:;,

~rJ.m

h,,- u d re:;m on hI! da 0 pt run: pr I!f:tr."' Jrf.! ro! ent ue dc,rrud'l n Jnd n a!l otl n=;}ted sUte General

pr

l)url... ffiei

.1

pr per rl stU 'om,; are pr "ldt!d 2- 1- hr u~h 1-. - Burned

_1

r' cowed .1.... .lfl e ten:'\um f the p(),u..;,on:;- pr _;lIT! Thcr!! Me ... erLlJr. .oanudefoITIUt!" Pll",IUOns Ifl h ryat en ~ener..1.l~~ J.re pLmfed: nO\.\oe"er. me ther.1p1 [ :1t!t!d: c!'<.Jrmne the 10\::luon t WI! urn.md \\ohl~h mO'we-

;:Ien .lft: dLificu t for me partent t achlc"e \\ith the e'(cep,'r. t .mrnf'hl lzmg J ... k:m grJft after "urger:- . ..,pLint-. .. hould :e fJ.rnLJteJ fur pallenr. nly RO\l or funclloD ~ould be t \\0 If-Jout them. General nJh.:atJpn for the u"e of "plints c ude pre'\ienti0n f ..:omrJ(:[Ure,. ]: maintenance

RO\l Jt...rue'lled during an e erci e 'e,,,ion or ..;urgtcaJ ~..! e~ e. J c rrecuon,. f contr. h;:ture . JIld 4 protecuon of J m r t!ndon. Splmt de'il;rI ... hould be k.ept ... imple '0 r.."'.J.[ J plint b ea...,~ to appl). remm·e. and clean. Splint-. u..,uJ are ~om at mght. vohen J patient IS resting. ur conunuousl. for ..e... eral day.. follov" ing ,,"-in grafting. Splint'S u d conform to the bod} parr. and care must be taken to .#

cure: that thae are no pre..,..,ure pOint" that may cau:..e J rcakd von In healing or normal ~ -in. Splinb ... houlu ~ heL:ked ruuund~ for proper lit and re ... i ...ed If nece";"'
-

~

Figure 27.14 p. an nUr le, k f

III

R

Figure 27. 5 PlNli(lrung In red ,,1t rar1t~nt v. 1m hum:.. the ..l.'tilla. Fmm RII.:hani..mrJ Suley p ~2-':_ With {:'emu "'Ion.

\l~)..;[ ... phnb used for bum LfiJune ... are ... uti,,:. Th.b ~re of 'ipLint ha:---. no m(I\oeable parb. and mJ..mca..m, J. po'ition Qr Ifnmobltue' an area folio" mg '>kIn grafting Fig_ ~ - L" OJ-namic -.;plml'> a.i..;o ha... e been u..'>ed '>ucce,sfull} in the care of patient'S Yo ith a burn injllI) t Fig. ~ - t Q ).~: Thc:-se ~plinl' ha\oe ITImeable paft!, thaI ailo\\. joint mo .. ement O)nami,,' ~phnl' apply a IOYo-load. prolonged 'tre..;.., thJ.[ ,,'an ~ adjusred [Q a panenr', wLermt.--e. The~ offer greaI potentIal for correcnng J de\ dopm,;; conO''Jt.:[ure and the eJ.rl~ rerum of acri\e function in areas of c\ren... i\e bum and gr,lfting."l The use of continuous passi\e morit")n de\i,,'(,' aJ , o is appropriate for certain p;Jtien[~ \I,- irh bum injuries ....... -,~:..

:\cti, e and Passive Exercise _-\~ti\e e\er('l~e

begiru. on the da: of J.dmi~ion.--· ..........) \0 .. patient \\.-ho I~ aJ~n and able to follo\\ commanm. IS encouraged (Q perform J('ti\e c\.er,,'i'e-.; of lfi\ol"eJ t~.:)(jy pan, frequeml: throughout the da}. _-\ patient ... hould perfonn JI..'rt\e exerci",e of all e'Uremitie... and trunk. induding unburned

Figure 27.16 l\hHHllling or 10

ru

hed f I
Pi.lllcnt \\0 Ith hurn

of the

p.!2'i "'Jlh P'!nm

1011 I

urr~.. r l'\!!'" IHlll'" hI n"lu,,:l' '1.ll\ r-'~I \IUh

cdclll.l"hdl· ......lIl·d (lnllli Rh.h,ud.lI1d IlI:nlll ..... ltlll

I'I,,~"

l1H

,I

~( · h , IIHIII , UlttU

Flqurt' 2719

1) ~I1i1tl' H \ plllllll Wi llll PllIVLlll' ,.Iow

II),Id .

plllhlll~'t ' d .. Il l· ..... III "'C.II 1....... IIl·

FIQure 27.17 I k\.ULIIIl

[\,11 . .

\11

IIt'I' "

1111

hl·d. \\ lIlt u... ,' III tn.1I1I

l·n~.\ ... ..:d 11\ t' I.I,III.: Ill'HI1l~ , NOl l': 1111, I\'t'hlll\llll'

Ix' u.. ~~1 \'lIh hUll" III \dull l· ... 1"lhll'l1

"Iwlt! nnl

,111'.1

I'll' \ lIhWl'Il'd

III .. \.' Iltl' lI 11101101\ 111;111

10 11ll' aclduIOIl.I! p.lln

11t"1 OtT tll :-- Wllh 1lI0\'l'llll' lIl II 1 "' " i1 II ) I ... d lllll'liit ,11111 men 1.!Il y dl.l1l1l1l ~ Oil Ihl' pltY"'ll'al tll l·Llpl .. ' 10 pu ... h jlalll'lIh 10

l'\t:Hl ... \.· III .lIlt! Ihl'O\I!! h palll , hili II I ... LTIIH.; allhill Ihe Iht:r . •\I\'.l'. Dll· ...... lIlg changl':-- ,Ill' illl 0PPOltUlll' tlllll' 101 allL'x\.'r

l'I"" ... '· ...... IOIl ht'CiHI ...t· 11lL' hum \\OI1tH!I ... \ I:--lhk' • •llld IhL' tll l'l ,\1'1 ... 1 ClIl 1110111101111c \\llul1d d\ll1n~ th l.: ...L·:--... Illll . h.h

Ilhl rl'I'CI\L'd a ... 1..111 gl.llt . ;ll'li\c ;tnd

II

iI

p.. tklll

pa .. :--i\l· C\l' I L' I"'l' 01

thl' ;11(';1 1I1il) l'll.' dl"'L'onlllHlcd 101' J 1\) 5 da~:-- 10 ;llhm I Ill: gr.lll It) ildhL'l'L'. ·\.'I(l.~1 ,\IICI Ihe ... mgl'nn dl'll'rtllllll· ... II I'" ... ak

In

~gllll'\Crt·l ...e ;\gi.llll, g(,llliL'

p" ... :--I\C. If ncc\.k'd

ROt\l

lir... 1 aCl!\l' and Ihl'lI

i ... 1\'lIhtllUIl.:d,

\I'IiH>a:--:-- I~lh(' ;lnd p"",:"'\l' l'~l'f(:i ... l' ... hoilid 11(' Illili :\lcd

if ,\ paliL'l1Icannnt rull) ilchIL'\l,: acll\!.: ROt\l v. ec I ~\ !lll'nce Summar) SO\ 27.1), 1'0 !-.L·l'P Ihl.:' hl':tkd hurned area llloi ... 1. it ... Imultl IX' luhnc;l1ed hcfore c\ci'(..' i ... c i ... 1I11lialctl. Can: ... hould I~ lilh'l1 ;It"(lUl\d arL':1::o of :-' ~111 graf", and ... lfC:-.:-. ... llOUld I~ applll:d 111 :t gCl1l k . prohlllgL·d. :lI1d gradual r~hh 101\ II Iht.' hurn \\{)llnd ... arc \\dl hl.:'akd . heall1lg lI1od,liII ie ... (c.~., p~lramn, ullr;l:-.{lllud) Ill") he ll:-.ed 10 im: rea:-.c Ihe pli

,

'

I

apl '1 1 he !It,.· r ., I... IL' I11. ( '()Onllllilllll !!. ; 111 1'>'l'rU "'l' ...t:" ... 101l "" lIh the adlll1lll ... II:IIIOIl 01 P:1I11I11l'dll,\I1011 Will k .. "cn Ihl' pamlul C\ IK'l'Il'lIl't:

1'01

RO

pollnfll1. ;.IIld 11l<.l1l) palient:-. \\ III indicatc thL') \\(H Lld ralher

711N

Ph ) "'!l,t! Ihl'rapl 'l'" '1 hould

L' IIL' il 111l' a"':--I' lann' 01 I Ill' lanlll ) III I..el'plll!! IhL' 1);IIICI1 I 111OII\;UL'1I and !llohilL' ;1'1 IIlIlL: h ;1 '1 po...... l blc.

Rf..·~i~ti" ...-.

and Conditioning I',xcrci'\("

;\ ... a pal'l' 111 continue.,

10 rceOVL' !". Ihl' n:hablillillion

pro-

gl:\l ll call be pro gr~"''''L' d 10 Illclude ..,Irl'nglhl'lllng l!\cr .

C i "L'~, 7.hn.l\'I Pall clll ... \\

1111

111:1101 hum ..

ma y 10 ..(: hody \\c lghl,

,\lId I(,an lIlu",cil' Ill" ...... c:t n dcc rl'a'le rapldl). F \cn:l ...c 111;\)

cOlhi ... 1 01 l...,o"lnt:lIc. "010111(. or olhcl' re..,i .. II\ C' Irilllling dt:\ ICC .... CiL' l1l'r;!I plll1clplc:-- 0 1 C\L' rCI...,c Irallllllg and "'ll'l'nglh

he Illoddicd 011 the ha ... l ... 01 a P:lIll'III \ co ndllHlIl and . . 1~Ig.C oj wound healinQ , Re ... i .. lh e dev il'L':-- "' Ucil :I ... frl.:'l.:' \\(,lg hl " and II II prm I.:I1I L' 1\1 ... huuld he follO\\I,.'d , bUI Ihe) lila) I1l'cd 10

'),1-')\

;\hlhl\ of the 11" :"1I~ helorl' L'\I'f'CI:-.C 11Crap). 1 III the arca of Ullhl':!Il'd hum ... can hL' L·\ll'l'IIH.' ly

Ihl.:' !lall l'1l1

pllllc) ...

C
h~ u"'L'd

10

prC\l' III

In:., ... or ... lrel1 glh III art:a.., nol

bllrnL'd . WIlL' n a p:I1ICIllIIIlII;IIl) heg llb ... In.'ngthening orcndur,lJlL'l' e\L'l'ci ... c ... , Ihl' phy:-icaIIIK' rapl "' l ..,hou ld TIl0nllor \ 11,11 "'Igll\ 10 c\amil1c c.l rdio\ a..cu lar and rC"'[111~11(1) re .. pon ...e .. 10 lre;i1Ill c nt ,'1fI O\crl.:\CnIOIl 111:1) Ol'C \lI . !\tonilOring. 01 jluhc, bilxxl I · ...\Il l I ;\ II t:'r L'\er· PI'L'''U I'C, ilnd 1"l''''pir:llOl) lil1l' ht'IOfl" (unng

I 111 lie I rL'cO\cl) . ' lX'l,.u:X.I <·,11 l:',. ..... ",,,,·,""C CiM.'. panl.el! I;II'! . • \\!l1 yll'ld \:llll:ll1ll' infollll<.lllOn :I ... 10 Ihe '1.llu'" olille card lln,l"

nila!" and [1u!nlOll:ll) .. ) ... 11.'111"' . P'\llt'lIh ... IHluld he L' nL:OUragL'd 10 p.1I1IClp.I1L' \IIt' \l'rn"C"

. Ihal ,\\ III

I Iill' :--In.:: . . !<. Ihc C;\HIO\;I",Cl!

... ) .. ICIll.

'I, '1" "'lII..,

\\ 'ilJ..llH!

IHlI1l Ihe huJ'll tiltH 10 IhL' pIn .. ical Ihcril[1) (kp.IIII11

k

CIII

Ill!! agolllClI), tlL\llI1111 II \\" I" mg., .. t'ilrclllllb' I I ! I1\.' CLll'llur·I IIl g. and nlhL'1 fOl'llh 01 ill'l'Cl I'IC L'\l'I"e .... l· .. llHI I cardl( ;I!.!L·d . I'hl·... e ill'll\ 11lL'''' "I II not 011 I) \\011\.' I 0 1IIlTC'I"C ' Cycllll!! \lI'

•

· I I ' I hcnl'lll 01 I'lIlhll,lIlL'l', hilI ca n I Hl\ l' IIll' ,lllll l )L1, - 11l .'lddlllrl' I LlIIIH\l\IIl ~ .. lrL'nglh alld R()~I \lIIIL·L·\II'L·I1lIIII.:.... ')";1111 It Ilin IIl1ltldun' \ illIL' I\ IlltLl Ihl.:' 1\.' I1;1 I)1 I1l,l\lon pro!! ' . I . n l\ L\lH' hl ph ~ .. lc. L1 IlIl'I;I[1I ... 1 IIL·cd .. III I'll.' L·n:.l1I\C .lIlt 11\ l ' IlIl11l\ ;ll l' p.lll t: n" 10 InCIL';, ... e Ihl'II\.'\el\' I-.l' 1'.lp~II,'tI \ \;I ... CIII:II

Figure 27 .18 "i1.l\ll lop! 1I11111.1111l1lIlnhLll/l·'" Iht' .. hlllddl·1 III Ihdu 11111\ IIId 11ll' 11"1\\ 111 l'll·n-.UIIl

1'(1\\

(haph.·" 27 Burn..

1109

Evidence Summary Box 27.1 Passi\ e Range-of-'\Iotion Exercises Following Burns Il~~

Subjec:ts 6Ss

SP'" aod par.:a -t'llC~ness hand Oums

".;;-

Methods

Duralion

Results

Commenls

Pretest pos:-:est design treatJnent conw

1 treatment Se5S,,"

SignifICant Increase In fmger JOint fiexlOn, mainly MCP _measured In all digits followlOg PROM versus stabc wrapping (p' .001); Increases In mohon noled With static wrap· ping In PIP 10lnts

Overall Import of the study demonstrates varying passIVe stretch methods to Increase lo,nt ROM

80'0 of fingers In both groups achieved the goal ROM WIthin the same pened of lime (9 days); nerther group reported more pain than the other dunng treatmen~ no complications fnom the motion were reported

Authors recommend reg· ular passive stretch for jOints with burn wound or scar contraction

a.~emat:ng

T1 PROM bJ tnerap,st T2 Stane wrap of digits

~anage

35 5 years

ecte,

MH

"ar 'JO
"","'om LE e:a 1979

1055 8t areral deep hand bums mean age 45 years

Pretest. posttest desrgn; one hand of each subject randcmly ass'gned C: Conventional hand therapy E Continuous passl'w'e motion; both groups camed out acbve motion exerC1ses and setf-care when not being passrvely exercised

222 hand bums (deep hand burns not

Pretest. posttest deSign; hands were randomly assigned to a group at postbum day 10; C: Hand burns allowed to heal spontaneously; E Hand burns grafted after 214 days of postburn nonhealing; Both groups participated in the same program of splinting and ROM exercises

Followed for at least 35 days; appears that long term follow·up may have occurred In many cases, although not specifically reported

Eventual outcome listed as "perfect function" in hands of both groups

Although It was reported that measurement of ROM was taken-the numbers were not reported or analyzed; therefore, only increases In ROM can be assumed

955 14 JOInts exammed: mean age 36 years

Pretest. posttest deSign, 14 UE JOints were randomly aSSigned to a group C: Placebo unrasound E Ultrasound Both groups recerved passrve slretch,ng to the test JOint between outcome measures; each JOint treated and examined 6 bmes dunng the study, for a total of 64 jOint examlnallons

Measurements taken pnor to and follOWing each session; a total 01 6 sessions were held for each patient dunng the study pened

The majority (87%) of JOints in both the treat· ment and control groups demonstrated an Increase in ROM With passive stretch; 12% of the ,oints showed no increase in range and 1% exhibited a loss of range

Although the aim of this study was to examine the effect of ultrasound on ROM and pain, the results are applicable because passive ROM exercISe was the pnmary intervention to gain range

52 cases oj burn scar contracture: mean age 22 years

Retrospective review of patienls with burn scar contractures; T1. Treated With mulUple Inter· ventlons including exerCise, massage. passive stretch T2. Included either dynamiC splints, and senal casts or splints

Reports of the Iypes of treat· ments Initiated and the outcome of scar contracture

The scar conlractures treated with splinting, which stretched the scar as passive ROM exercise might, Improved In less than half the time of the con· tractures of patients treated With varying mtervenllons

This study examined eXlstmg contractu res related to scar formation and may not be applica· ble to burn wound con· traction or to scar contmchon that has not ach,eved the level of contracture

healed WlthlO 14 days poslbum)

l'/aro. AS. el aJi5

1994

R
1000

C; 30 min 2xday; E 2·8 hours dally; Tests were diScontinued when a subject would reach a ROM goal

PAC COntrol, E expenmental. Mep metacarpophalangeal; PIP proximal Interphalangeal; 11 0 1.1 P<:isSlve rangl't of mOllon, ROM range 01 mOllon; SIP status post. Ss subjects; !realmen! group 1 T2 treatment group 2, UE upper extremity

\mbulalion \rt1pulatlon ... hnuld t~ IIlJlI.III,.'d .11 Ihe earlu: ... , apprnpnillt.:: tlll1~ It the kmCT C'\lrcltlllll" .He.' ... "'in ~!lallc:d. ;ll11bulallon ma) he dl",collllllUt'd untIl II , ... 'ilk tn rC..,lIme,'" IOn When Jll1oolJtI"m I' 1Il1l1.1h,'ll .tfter J ,kill gr..tft. lhe lower c'\ln:milic\ ... houlJ ~ \Haplx'd in c1."ri(,; bandage ... in a figure-or-eight path:m 10 ,UppoI1 the IlC\\ graft... and promote \ enou ... return. If a palit:'111 1.·.mIlOI tolemte Ille upright PO,IIIOIi lx'causc or onho,I.It!C intolerance or pam fmm the 100\(::r cXln.:mitie, III J dependent pt.l\Ulon. gradual incrca:o.c ... in tiil-table treatment ume \\ III a.·.. "I ... ' 111 preparing the patient for ...tanding.IIJI-lOl 100Uall). a patient may require an assi"'live device to ambu-

late. Ho\\c\er. Independent 3mbulation \\ ilhoul an assisti\'c de\ ice ...hould be achieved as soon as possible. The ph) ... ical therapist \\ ill spend a great deal of time \\ ith an indi\ idual patient during each exercise session. The re\\ ards of a successful treatment program are tremendous when a patient \" ho has suffered a life-threatening bum is able to walk out of the hospital a nd relUm to productive community involvement.

Scar Management Following wound closure. a skin graft or healed bum wou nd is vasc ular. flat. and soft. Durin g the following 3 to 6 months. dramatic changes may occur. The newly healed areas may become raised and finn. Pressure has been used successfully to hasten scar maturation and minimize hypertrophic scar formation . I04 However. no one study va lidates the mechanism by which pressure alters scar tissue. Pressu re may exen control over hypertrophic scarring by ( I) thinning the dermis. (2) altering the biochemical structure of scar tissue. (3) decreasing blood flow to the area. (4) reorganizing co llagen bundles, or (5) decreasing tissue water cont e nt. Constant pressure dressings or garments exening press ure exceeding 25 mm Hg wiiJ decrease the vascularity. decrease the amount of mucopolysaccharide~. decrease collagen deposition. and significantl y lessen localized edema,7.1OJ.I05 The early hypertrophic scar is readi ly innuenced by compressive forces and thus w ill respond to press ure the rapy. The earlier the scar ti ssue is exposed to pressure. the better the result.'l""·I07 Usually. if the sca r is less than 6 months old. it will respond to pre;sure therapy by conformi ng to the pres5.ure. remaining nat on the surface. and nm developing into a hypenrophic scar.l07 However, jf the scar is sti ll active or I.,hows evidence of vascu larity (red co lor). pressure therapy may be successful, even if the scar is 1 year old. In general. If a patient\ wound~ heal in less than 10 to 14 days, which wou ld be indicative of a superficia l partia lthickness burn. pressure may not be needed. If woun d healing l<Jkes longer than 1010 14 days (as in a deep parual-thickncs ... burn, or is . . 1..111 grafted. pressure usually i., indicated. Iff Prcs\urc Dressings Ela.,tH": wrap'" can he used to provide va ... culal slIppOrl of ..,klll grail., and donor .,lIcs a ... well a ... 10 control cdcma and

"l'.lfrlng. r'I,I\11l \Hil l'" ... hould be u\cd until :t patient\' skin or ... car ... call toler.lle the ",hcilring force 01 prc",..,urc garment applicHtion. ilnd open arc;'l ... arc minimal. ElastiC wrap., arc applied 111 a figure-or-eight pattern on the lower extremi_ tic ..... A ..,piral wrap can be used on the upper extremities and a clf(;ular \\ rap on the Lrunk.lf~ A self-adheren t elastic bandage can be used for the hand and toe ..... lr~.IO.). II() Thi-; b;:lndage adhere~ only to itself and can be u ... ccJ over dre!-,~jng!-' before the wound\ have healed. It helps to minimize edema and control ",car formation. 11 may be u~ed before application of a glove or a~ definlti .... e prc~sllre on an infant\ hand. Tubular ~upport bandages come in variou~ circumfer_ ences and garment sty les. They provide a moderate amount of compression and may be used as interim garments before a custom-made garment is fit. 1().l.1I1 The tubular suppon bandage is especially useful for small children \\ho grow rapidly and require frequent alterations in gamlent size. Severa l companies manufa cture press ure garments. Some are ready made and come in several sizes to fit most patients: others are custom made for the individual patient. For the custom-made garments. a physical therapist uses a tape measure to de termine the circumference of each limb every 1.5 in . (38 mm) of it s length to fit the garment exactly to the limb with the proper pressure. Garments are measured when a patient has only a few remaining open areas. The garments are very tight. and difficult to apply. bu t the pressure is necessary to prevent scar hypertrophy. Garments can be ordered for any or all body parts, includin g the face and head, and they come in many styles. options. and colors (Fig. 27.20).'1\.> Garments can be worn when the skin or scars can tolerate the shearing force of ap plicat ion. Pantyhose may be used under waist-height press ure gamlents to assist with donning. Gannents usuall) are worn 23 hours a day (removed for bathing) for as long as 12 to 18 months to assist with ';car remodel ing. Gannents should be washed daily to pre'ent buildup of perspiration and moisturizing cream. which may lead to scar maceration. The pati ent usually receives two sets of gamlents, one to wear and one to wash. Adequate pressure may not be obtained with elastic wraps or presl,ure gannents over concave surfaces. such a'; the sternum or axilla. and an insert may be necessar).I1~· , In serts can be made of many mate rial s including foam. sil. d. 104 III 1I4- WI lcone e lastomer. e laMomer pUlly, and gel pa s. . . These item ~ need to be removed and cleaned regularl) 10 prevent maceration of the underlying ti ~sue. Early. consi'-ltenl u,;e of pres"iure \... ill rc"ult In l1at, pliiti z
Ma,<,sagc Ma v.,agc l"i lIseful to a...... I..,t \, Ilh ROf\ t c\en.'!'>t! b) Illaking . .cllon 111.:!'> ... agl:. \... 'hou c. nht to the Ils...,ue 1111..11'1': pliahk. Dcep In • •. ue IrO]]1 loosen ..,Citl II"''''UC by llwhdl/in g CIII.Illt:OllS II"''''

Chapter 27 Burn...

J 11 J

color.... They al<.; o arc w:.ttcrproo l and can be worn during a ll acliv llie .... Thcse products ca n he purcha ...cd In large r departmcnt sture .. or where theatri<.:al products arc "iold.

Follow-Up Care

Figure 27.20 Pressure gannents such as gloves. vest. and wais{height pants are worn to minimize hypeI1fophic scar fonnation.

underlying tissue and act to break up adhesions. 7. 117 Wh en massage is used in conjunction with ROM exerc ise, the Immature scar can be elongated more easily, and contracture ca n be corrected. Although no st ud y has vali dated the use of massage for patients with burn injuries. li B in the long term, ski n pliability and texture appear improved by the use of massage. Finn scars th at are routinely mas)aged tend to soften. Edges or seams of grafts or any area that is rai~ed and firm may benefi t from massage. Scars \hould be ma')saged in a slow, finn manner for 5 to 10 minUtes. three to six times da il y. Camouflage Makeup For scar... of the face, neck. and hands, ca mouflage makeup can be used.'J·ltH This type 01 makeup may be useful when ii person has ei ther hypcrplgmcntation or hypopigmcl1tatllm of the ':>ki n due to the burn inj ury. In add ition. make up can be used befo re ...car maturation. when the sca r is ... till rcd. and a paticlll want<., to go ou t In publi c wit hout hi ... or her prc'J':>urc garment ... or dcvi<.:e~ for ... hort period . . 01 tllllC. 1 he Cosmetic,:> arc opaque. coll)r c()rrcc t burn <.;car.... and arl' "' iii'I
Before pati ent"i are discharged from the hospital , the therapist should provide information regarding a home exercise program (IIEP), splinting and posi tioning program. and ~k in care. A HEP should continue to S lres~ frequent ROM exercises in combination with massage. In addition, patients should be enco uraged to perform as many ADL skills as poss ible indepe nd ently. Therapists can videotape the patient's exe rcise program to provide the patient, family, and outpatient therapist with the actual ROM and movement patlern used in each exerci se. A video facilitates educalion of those involved in the patient's rehabilitation program and helps to e nsure consistency of treatment after discharge. I 19 Thc splint ing sched ule and pressure program that was followed in the hospital just before the patient's di scharge should be continued at home. Before discharge, the patient family members. and/or caregivers should be able to apply and remove all splints and pressure appliances independently. Proper skin care requires specifying the type of soap and cream a patient is to use. fn general, soap should be mild without perfumes or Olher irritants. A moisturizing soap can be used after all open areas are healed. Mois[urizing creams should be applied two to three times daily and should not contain perfumes or have a significant alcohol content. Patients should be instru cted to massage the cream completely into their skin to avoid buildup on the surface. If a patient will be ex posed to the sun. a sunscreen with a skin protection factor of at least 15 should be used and reapplied freq uently. no Patients should be cautioned to avoid the sun if at all possible and to use hats or cIOLhing to help protect their skin aga inst the sun 's rays. Small, superficial open areas may plague a patient for many months after wound closure because of the fragilit) of a healed burn wound. The patient should be insrructed to was h these areas twice dail y. appl y a smull amoun! of antibioti c ointment. and cover the areas with a nonadherent dre~s ing. Further irritation or maceration can b<:! pre\,enteu by avo iding shearing forces, improper tit of clothing. bri ...... clea nsing. and soaking in water too long. or application of too much crea m. Itching Illay intcns lf} \\ hen wound ... h.\\ e he,lleu. \ pa tient "hould be instructed to pal. rath!:f Ih"l11 . . cr.lIl"h. the IITlImed areas. Application o f Cl'e ..11ll l1lU~ hdp deL·!'t'.ISC itching: h()\\cvcr. SOll1l' p.llil..'llts ma) fl.'qulre oral mcuIl'ution to Ill'lp l·O llt rol thl . . pmbll~ 1l\ Some patil'n t... \\ Ith burn 111.111 1) 111,1) l'C'ljlllft: outpatient thl-'rapy ttl . . tlppk·ml·1lI thl' IIH') and monitor and adjust

1 t 12

Pin !t.it.d R,,'hahili(.afion

their phnllng '1I1U prc ...... UR' prol-!r.lIll. ITetlut,.'nq 01 OUlp.1 IIl'l1IlhcrJp) 1'" ha ...cd on 111dl\ Idual pallen I need Regallllc", ... (ll "hclher or not a pallcnl 1\'(CI\l'''' outpatie nt therapy. he or ... he ... llOUld be 11l01ll10led ,It f'l"gular IIltl'rval ... through an outpallent clinic nll", \~ III .\110\\ burn Ic.un mcmber", to monitor the p.1I1CI1I' ....Idju",uncnt bad. !Illo society and alter the rch.lhiltt:UIOIl program accordll1g 10 thc patient'!) physical .Ihilluc, .lnd c\tent of scar maturation. When an adult p.ltlem\ bum ... ha\'c matured and full ROM i!) achieved, furtht'r follo\\ -up care is unnecessary. However, a child will IlCCtl to be monitored until he or 'lhe I ~ fully grown, because hum ,car.-. ma) not ~eep pace with a child 's growth; surgi cal release of scar ti s~lIe may be necessary.121

Community Programs There are vari ous co mmunit y programs available to indi\Jduals who have survived a bum injury. The therapist should be aware of those in the patient's home community so that an appropriate referral can be made, If programs are not avai lab le, someone in the hospital or community may wan t to initiate a progra m. Programs may include: I. Burn Preve nlion Progra ms: The American Burn Association , 625 N. Mich igan Ave., Chicago. IL 60611: (800) 548-2876, has a Burn Prevent ion Committee with

a myriad of printed material s. 2. School Re-entry Program s: Prov ided by the hospital per-

sonnel for the students and staff in the chi ld's sc hool. Q• 121 3. Bum Camps: Weekend- to week-long camps provide an opportun ity for children 10 interact in a controlled, outdoor environment with peers who have sustained a similar injuryy·121 T he American Burn Association has ;] Bum Camp Speci<.ll Interest Group with rcadil y avai lable information about camp!' throug hout the Un ited States and Canada .

Quest i ons

for

of each.

2. Descri be the differe nces between superfi cia l, partialIhi ck ne ~s,

and full -thi ck ness bum ....

3 . Explain how a deep parl ial-Ihlckncso'l burn yen to a full thl ckncv, burn .

CII Il

co n-

4. Comp:Jrc th e trcatment ... lo r lkcp partml-tilickl1t!,s and full thl l:knc!o,!o, burn ... . 5. I)cM; nbc thc primary C0l11 plH': 1II1 0m or the pulmoll ury ~Y"' l em due tn cxlcn"'lvc hurn .... 6 . What LIre the major ITIClilholic complicati on ... a"'Mll' l alcd Willi hurn .... and how iIIl' Ihl'y Ifl..' al l'd'! 7 Li .... Ihe thrct' phll ... c ... thilt Ol:l'lll III the hl'il lill1J, o l a hurn wound. 8 . WhLlI a ' l' till' "oill ... o j Ihl'

lar injuries, 171

Summary Bum injuries represent a major heallh problem m teIllb of management and care of surviving patients. SpeCific impairments and complications val) according to the extent and depth of themlal destruction of the skin. The c1as,..,ification of bum injurie~ is based on the depth of tissue det,tro)ed and includes superficial bum, superficial pafllal-lhickne . . .., bum. deep paJ1ial-thicknes~ bum, full,thic~ne5.s bum, and -,ubdermal bum. The mle of nines ~l and the Lund and 8m\\ der ' fomlU la were de\'e1oped to assist with the initial detemlination of the extent of bum injuf) . The specific clinical "'Ign~ and symptoms lhal resulI from a bum injury \ aT) according to the different classifications. Indirect impaimlenh CJn include infection, and pulmonary, mctabolic, .. ~eletal, muscular. neurological. and cardio\ ascular and pulmona~ complications. Mcdical management addresses Iite·threatenmg problems and stabilizat ion of the patient. Dre ...... ing .. with topical medications, debridement. ~urgical e\CI"'lon. JIld skin graft ing arc primary freaUncnt measure .... Skin .;.ub,u· tutes are slo\\\) becoming a practical altem;ui\c 10 .. ~in grafling. Phys ical therap) management focu .. c:-. on the pre· vc nt ion of scar cont racture, maimcn:Ulcc of !lonnal RO)'t. developmcnt of muscular stre ngth and endurancc, imprmement of cardi m
Rcvic\V

1. Identify the two primary laye rs of sk in and Ib tt wo funct ion~

4 Adult Suppor1 Group..,: ProVide an OpponUlll1) for Indi. vidual ... wuh or without their familie.., to ~hare e'tpen. cnces and gam suppon from other!> \l.ho h'1\·e had 'ilm\,

9, DL' . . cnhe the \ ;lriOlI:-' t) pc . . of '~III gr.tl'". 10. Differcntiate bc t\\l'l'll iI ,pilt-Ihll,km· ...... ;lIld full thi c~ lI t:ss :-' ~1I1 gmft. . ' 11 . Li ~t th ree l'ssL'lltial (,ICIOI''' fOt 'lllTl'",fu\ "'~1Il ~1';.11t ad hcl'cncc: .

12, Di,clI"'s thl'

1I1 11I a ll1 ll'd ll.:al 1Il, 1I 1Ugl' IlIl' II1

pc, of l''\l·rCl\.C th,lI

rc ha bll ll;lIllll1 progr;un, 13. What IIltCI'\ l' nltOlls l';\n hc l'ollt rac tllll"? 14. What Int l'J\ l' lll ioll:-

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Chapler 27 Hurn..

CHSC

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Study

p:llieTlI IIi ... tol·~ ,~ ~9~)C:lr-o l d man "u~ l aincd a JOc( TBSA burn 6 wed, ... before 1111" OUlp.llielll examination and eva lu mio n. The l<1lienl '\:1'" burncd al homc "hile he was refueling a TlrnO\\cr \\ Ith gasol ine. which ignited. Area::. of the lXlJ~ <.lili:c led b) Ihe burn includcd the righl upper e\lrCI1l11) ( E). pori ions of Ihe posterior and antcrior lru n!... lateral neck. right !->ide of face. and thi g h. Areas s!..in grafted in cluded the right dorsa l hand. [oreann. and ;lnll up 10 Ihe axillary crease. The remai ning burn wounds healed secondari ly. The neck, face. and thigh bum" were superficial. The pati en t was initiall y treated 31 a regional burn center and now is refe rred to the local hospital for follow-up outpatienl physical therapy due to decreased right elbow extension. decreased sho ulder nexion. and inability to reach overhead.

:3\\

PhY:'Iical Therapy EXaJllinarioll

Fillding~

The righ l UE lacks 15° degrees elbow extension (i.e., 15 0 to 120°) and flexion of the sho ulder is limi ted to 0° to 155°. Scar co ntracture bands are nOled at both locati ons 3t the end of available range with movement. The patient stales he has some difficulty donning shi rts and his jacket. All other movements are wi lhin functional limits

(WF L). Thc pal lcn t \' ... trcngth ovcrHIl i ... (.;on ... idcrcd WFL. a~ arc o thcr phy ... ica l parametcr .... IIi ... wounds nre all c lo!<.cd. The pulicllI li ve,,;; with hi ... girlfricnd and ha ... medical bCllcfih through hi ... employer One week after hi ... discharge from thc ho~pital, the patient presen ted for hi ... initial ou tpat ient examination weari ng interim pressure gannent .... a ... in ... trutted. li e al ...o brough t Ihe Matic elbow ~p l illl that had been issued to him during his acute hospi tal ization. but which "doesn 't fit right anymore:' Th e expected outcome for this patient is to regain full ri ght UE ROM and func ti o n.

GUIDING QUESTIONS I. Describe how yo u wou ld approach the clinical problems presen ted. Your answer should address posi ti oning, spl inting, exe rci se. and sca r~manag e ment inlerventions. 2. What patient educat ion would you provide? Would thi ~ differ if the patient is adherent versus nonadherent wi th the therapy program? 3. What is the antic ipated rehabil itati o n potential fo r this patient? Your deci sion making shou ld co nsider time from bum injury and stage of hea ling.

References I. American Bum As.. ocialion: Bum Incidence and Treatment In the lS: 2000 Fact Sheet. American Bum Association. Chicago. IL. 60611 Relneved October 14. 200·t from hup:/Iw" w.ameribum.org. Prum. BA. Jr, and Mason. AD. Jr; Epidemiological. demographic and outcome!, characteristic .. of bum injury. In Herndon. ON (cd): Total Bum Care. WB Saunders. Philadelphia, 1996. p 5. 3. Baker. SP. el al: Fire. bum ~ and liglumng. In Baker. SP. et a I (cds): The InjUry Fact Book. Oxford Uni"er3i lY Press. New York . 1992. p

t6t

~ Herndon. D'\:. el aJ: Teamwor~ for total bum care: Achievemenl\.

duectlon .. and hopes. In Herndon. D~ fed): Total Bum Care. WB SaundeT\, Philadelphia. 1996. p I 5. Same. JR. el al: Recent outcome., in the treatment of bum IOJury in the Loned State .. : A repon from [he American Bum A .....ociation patient regl'll'). J Bum Care Rehabll 16:219. 1995. 6. Richard. RL and Staley. MJ (ed .. ); Bum Care and Rehabilitation: Pnnciple.. and Practice. FA Davi ... Philadelphia. 1994. 7 Ward. RS: Phy.,ical rehabilitation. In Carrougher. GJ (ed): Bum Care and Therap). CV Mo... by. SI. Loui ... 1998. P 291. 10\ \toore. \1 The bum umt. In Campbell. SK. et al (eds): Ph)"ical Therap} for Children. WB Saundch. Philadelphia. 1994.

p76J. by de LlOde. L. Rehabilitation nilhe f.:hild "lIh bum .. In

<J C'.ing

Tec.khn. JS (cd). Pediatric PhY"Jl.al Therapy. cd ll.lPPlllcll1I Pl'uladelphla. 19'19, p 46~. 10 )h
t.t. Holbrook. KA. and Wolff. K: The "truc turc and deve lopment of skin. In Fitzpalrick. TB. et al (eds); Dcnnatology In General Medicine. McGraw-HilI. Ne" York, 1993. p 97. 15. L:mir. Y: The fibrou ... lolructure of (he ..kin and its relation 10 mechan~ ical behavior. In Marks. R. and Payne, PA (eds): Bioengineering and the Skin. MIT Pre..s. Cambridge. MA. 1981. P 93. 16. Moncrief. JA : The body's response to heal. In A n z. CPo e t aJ (ed~): Burn'>: A Team Approach. WB Sa u ndt!r~. Philadelphia, 1979. p 2.t 17. Johl1 ..on. C: Palhologic manife.,tation" of bum injury. In Rlchanl. RL. and Staley. \1J (eds): Bum Care and Rehabilitation: Pnn~lple, and Practice. FA Davis. Philadelphia. 1994. p 3 1. 18. Guide to Ph), .. ical Thernpi .. t Practice. ed 2. American Ph,<."aI Therapy A",ociation. Alexandria. VA. 2001. 19 !\orri ... PG . t!I al: Acute effects of uh ra\ iolet rodlauon on the ,1..10 In Fitzpatrick. TB, cl al (eds): Dennatolog) in Genernl -'1edh:tne McGrav.--Hili. New York, 199). p 1651 20. Hegger... JP. ct al: Evaluation of bum hli'lcr Iluid. PIN Ret:on'l

Surg 65:798. t9RO. 21 Rocl..\\cll. WB. ilild Ehrlich. HP: r·ibrillllh·,I, inhibition 10 human bum blt ... te r Iluld. J Bum Care Rehabll II'. I. I QQ(I 22. Gamer WL.. e[ .11 The cilect, 01 bum blt ... tef !lUIlJ llil 1..(', 'II1noc) te replit:atlOn J.11l1 dlilercnllallon. J Bum Care Rt'h.t-oll 14.127. IlJlJl 2:"\. Ono. I. et ,11:\ ... tlld~ tit qtol..lOe, In tmm hh,t~'r IlUll!r\'! taJ to "
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.. ,>fI\ 't ... ,- \)\ P'Il'II"~ ,'II' )1IU111 I ",H\' ".11111'1"" h'l ,'W' ,,11 •.,,1,,11.1 \ ')1111'\" 1111'1"'11"'.'1 '11111'11,(\ \"P HI ' llIl 'II' I~1 i~ . ,(>(.1 I: ~ II IU,\I"I ,drl·''1II'''.'-''I,1 I,1·'I"III\,.IIIII-'I"\IU ."11,'1" 'I'\' U ,11111\11\_" '11111'111(\ \\ ,,'\1',\ 1'111' N PWII'q.\ IS '1"'\I·I .. I .. 1'41·tl"~I"II'.)1I11\\l1 II.l,bl .•",'" ,1111111'11 a" 11111"1 IhllViI \""11.11'.1\1", "111 11 \.1,,'11'(\1 1"" 1 1~1 'l'lI'll'I}1 liS ,I, d I hi' I "1'111,1\"1'1'\111,1 , .,1\\ \ I ,1,'1 1" ".1 pill' ",\.11 'UI 1,\ Ihllll'I'I'Q"'\·'}l \,ur,lI" )UIIIII 1'1',111\\ \,'11'1:-.1'111' nl 'I'II'q'I~I" 1 11I.IIII', lull1 11 .'ql h11 ,,'III1UIII,' ,' 1 ;(UII1111dS I ""11]0. l 111' ) pLLI' 1\ \11 .11 1,"11'( 1 1~:- d 1'(l{,1 'l'U I"I ·'PI'1L11.! ', 1\1\1 \ 1 ,"II WI.! pili' ',11" 1,,1111.1 UlIII"ll l"II'II,' N pll1' ,11 1', ) 1111111 ,\'1',1) 11\ \"jI'I S IU!1' I}I 'l'l1'II'I~1 111 Ilul ln[ 1111hl ,'III ,1ILIIIIIIII",d "I ,.Ill w"IIII1 \ P' 1,1' I '1,1 1,1 \ h;1 II 'S(,(1i " 11\11 I I.., ''1'''1\ \,) \,h'I.111 1 pili' ,\ 11'. ) 1111111 (p.I) I' 1 '1.111,111\'111') III \I,ll., 1,1' 1"lh1I1"LLI,' 1'111' ,\I;~"I,' q ·l \'" 11'1.1 (~ I ''1'''''1'\ I f,(d l'uI.ll"I'I'I"[,I"'ll·(1 \ I .nIlWI,II'"1' ','ldl 1ml,1 Ihllll'III1tII·II·l~1 I'Ul' .11t·.) UII1I1 :\'1',1) 11\ 1,'11'1, pilI' HI '1' " "1 II}I 111 111.\1I1'd 11111\( ,1111 II' )1I.IUl.1;1I'II1'111 IIII'd pilI' !l1,dd,,, ll,illllllj "',I 1" 1,1 III ·",11 \ 111. d 1"hIII "l1ld1,'I'I'IIII. I "II1·( 1 \ , ,'''1'1'1.1 ptn' "'IIIL11L11.1 11.lIlL'lIpql'II,IN 1'111' .UI') 1l1l111 '1'1',11 11\ 1.'11'1, p111' nl 'I' LI'II"N II( ,~11I11111'1" )1I,11l111',111 pLll' I1IIW'lll""l )11.1111',1 L1UIU 11\ '-'P'I, jilll' I}! ' jlI1'II"}1 11.c11 'hi j'l P'II'Ij,'N ,\ u' ) 1111111 1 '11I1I\jlll1\\ ' 111,ll ll',1 "Llmp,I.1 111 ',11111 "'lIIh11 \ 11'111\1' 1" '"''''1''' '1'1'., ,''II 1" ).I'~}( 1 ' 1I,i plll ll ,',"~) 'I'll II 'h, hll'UIIII ,lfI"IIII, 1 " ' .11'11111'\ U \\ 1,.11'1 ",Id\ 1IL1',1 1 \ ' LlI1lI1 :( ... ",11 1" 1,1 d ) .11\ "I ,'IIl).\I' I\UIII 11''' 11111'11" 1I1,1ILlII'."1 jll11' IhilllL.1"ll, 1 P' 1,1 '11 '1I11~1l"

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tf1(ll ·( lh'!I · I I"P ' q ·I ~ 1

,Ill' ) L111111 r '1I11~ III 'I"" 1I1'.;f 1l1'l"' II1IIII\I'111 hl l ~ III ,I I '\' 1.111,,1111 Ill" ""'111'"111'111' 1,111111' 1 ,11111" 1l' ''ILI'(hll\~1 \ III L.I }I 11l1IL I "~ 1 SS,,, 'j 1\ ':-:11." ~illlS 1111\ 111111 pTlL llqll',111111t1IHlI'l ' .,11 u.n')jllI11 \ '11111\1 IIlh'llI 1111 "111 1.11' 1"llIPII\ 11' 1,1 '(I ' q 111'11111 ,1 11 t hlll ';'" Xl 1 1t11ll1-'~ 1 ,1 11'. ) 11 11\11 1 '!lUlUI" 1I111111',hl,l\,1 III .hil' l,I,,'1 111' '' ld ll1,'L "' 1 111'1 ' 1.1\1'111' ,1 111'1111111 p.,\.,h.I .,!,I\j lllL1\\ P"II''' 1I1111 ) 1 1 11'1 ~~ I' IIII,11 1 111.\11. ,1,111 111,11 UI'l~ '11.I1III1I"U'l I' I" jI' ILL P' 11111 1' 1,111I ,1" lpl111 \ [I ' " \ ') ,IlIJlLlI.! j hhl '1 I S I I'III'IP~I .'11' ) 11111\1 I ~Plll hl\1 1I!11IJ P," "\ ,' 1\l·1~I'I.'\1l1 \ 1I'."II I1 I,IL 1I'1111'1~ 1.1\1'1"" 1II'1I1l1l1 jI.II I .I~.I I\I"\ I ' '111\\ P,'II'\lIII,\\ '~1Ul 1.1" I. J 1"111111"'11' '1 III' l,i l'tIll. l( I ·)LL.ltIl,1111111.1 1 111'1" \1I-1 .... hll,'.,1plll"\ '"I1 II' I" ' 111 11 jI ' 'Ull I ) p'l·1 I ''1 ,il1l'lq' " I'11 :'fLld '£1'1 SI 1''11'11.\>1 .1 ". "1I1I1i I ,.)\1',) ,',"1111" L1I11L" \ 1'''''1 p111' jlunl ,11111 " '.1111111 ,·..111'1 '" 11 1111,111111'1;111111' P·1II1.'1' 1I1,IW'WI,,, 1 I' I" ,"" .'111 1" J.l \ '1 11 '111' I lhfll I,' I I I 1'11"11">1 "11', ) L111111 I 'l ll ,lIl1'tlIIWq I" 'I1.UU,~ '·III'111 :>1 11111 'q lh'.'~" lllI · 11 '1111.'1'111.1 ",'1II'1" ) I\!\ ·l.Il ... lJtl l 'II 'I!-lId 1~lllkllM P'III' I \1111111 IIl11tj 1.1111' 11I "1I1.1\1!I,l.Il Ll11" '" '.I II, ••il lll' 1 1111"11 1'111' ,11''1,111 1111' P'IIII.'jlltl.ll'.lIl1lll1ll11 '''' 1 (I' J.I ) " IIII1U) " ,I IIIh! ·1'lljdl ·l111'jllj,j ,1.\1'1 1 \ I .111111'1.11'1111 ',1 1111 11111.1 lI<1II1'III"ll'lj·I)1 \,111' _IJ\' ) 1111111 1~1',')jl'll -\,III'I \,' pHil I>! j1JI '11"}1 111 1Ij.\llI'd 111l1lj .!lp In 111 .1I11.I1 .111' I II III It 1 ,II"IIIII!!' .I ILJ"Pt ",,1\ 11"1111111" III t:"IJ.I,j,,") .hllll·,)11 1"111'1" Itill' 11 '111 11 1.1111'11 I" 1.1 , I' . 1",1'/,' 11 11-,t! H H 111(1"(.1>/ '11" )1111111 I .11 " ) 1111"1111 ,IlI'II'II''1'1t1 11 ,1111 !'lol~IW""'III'III' t " '1'11'11'111111'11 ,)11 1 >1\' 1"1111(11'111' ) .III'\ "N

mu

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101 It ,

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t " " ,In h'

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\\1111 bUill 1'.IIt, lit ...

J IIUIII t .111' lid,.,I-d II I'lh, PINS

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1', ,111111 H" I'" /,1 I If I HlIo I 1 ,It, I

hlllll' 1 Ihull f Ih' 1<..11.,1111 I I I, PIIH 'II \111\\.lIIhl,lI, ( t'l "I \ I !l1II1'.1l1'.I'" 1,1 I11I1 tllu 1,111 ,\'1'1,11 'pilI 111Id,lIl' .lLItu~'I, .1I Ip, Ihl' III\T I.l vr 1,1 tlnll p.11I11 "ltlll III tlw \rl~ }'IJlIII~ pnli.tlill p.IIWIII I I It II II ( ,III Hdl,.I'11 II 'I,

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lit, ,I" I

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I 11 '111111"

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1111' \\,ud 1/ '. '1 111 1 ,,11""'111 II ,,11t'1·,,1 "'1"",,'1/11 lit HI "I "".11'"111 It'lltill'l III ',I' l'lu,t! 11111111 I 'II' I" h ,1·11 1/ I 1""1 1I!IIn\\, II ,ro. lllulll1!rllll 1/\,1 1j"I>1I11 I ,II l.jh. P III VIllI' I'll lIlt 11111 ,"111 111111111'"111 III ""1111.111.11111 \., 111,1 , I IIHIII I '1 111'11 ,,1011 'I ''; I. 'IKII

1'1 111 I{I~h.1111.

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l'ISl'I

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1"!-1M

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~., \11 \111,1", I I' ,11,,1 .... d.1

sn

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HI

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28 LE ARNING

OBJECTIVES

t. Unocr\land the u\cfulnc" . . and limll
pam. III. Generate un approprinte plan of care based on objective and subjecti ve exam inati on data . II Descnbe th e COilIfibu tioll!,! of the member') of an IOlcrdlsciplin;.lfY pain manageme nt team.

P

Chronic Pain Lisa Janice Cohen, I'T, MS, oes OUTLINE lil"tor) of Pa in 1117 Pain TllI.: ori c~ I I 18 Earl y Medica l Mode ls 111 8 The Gat e Con trol Theory 11 20 B iopsyc h o~ocia l Models 1120 Nemopl ast icity. Wind ~ Up , and Learn ing 11 2 1 The Biology of Pa in 11 2 1 f\.k d l~;Ll Management o f p.Hn 11::!2 Pharmacologica l Intervention 11 22 Intervent ional Pa in Management 1124 S urgica l Pa in Management 11 25

Clime,,1 PrC'''L'ntation of Pain 11 25 Acu it y 1125 Ti~s ll e of Origin I 126 NILnd- Body Duuli ~m [[ 26 Pain \ ka"urclm::nt 1127 Vi~u al Ana logue Scale I 127 Bod y Oia gra1l1~ 1128 Pai n Queslion na ires 11 30 Func! iOllal Illlp:ll nm: nt/ Hea lth-Reiat ed Qualit) of Life r-.l ea~ ure:. 11 30

ati e nl ~

\\ho present wit h ch ronic pain pose ~ i gninc;] nt chall e ngc~ to the ph ysicalll1crapist. The cli ni cal pic ture 1\ complll:ated by functional limitati on ... that do not .secm \upportcd by ph YS ical il11painncnts and physical impai rment ... thaI do no l ~eelTl re lated to the dlscasc process or mcc hal1l ~m of II1JlIry. r",yc hological dbtrcsl'l. dbtorted se lf lOlagc. and ICH r OftCIl accol11p:my the impairmen l... ami confound Ihe c\allllllation and treatllleni proCl'ss . Mal1~lgc l1le llt 01 chronll palll IS :l Si g nificant healt h cure lOlllc rn . I rc all11c nl 1m hac l-.. pam alolle accounted for 2.." Pt' lle nt (lilhe (,; oUIIII Y \ 101 ,11 heal th c :\re (1ulla} . \\'lIh 75 r": rlc lll 01 tl1(: ro ... t~ dllv l' 1l hy 25 pen.TIlI of palie nt .... ehrollir \~mJll 0111 '" ilu':lIllnteu 1m l11Ucli 01 Ihe dlllcrl' IIlf..,.1 A llh o llp h 111 ... li~cl y that th e p l
IlII1 "'t U lo ... I.. {· ho t;J 1,

IH" III 011 If

i{'; \1

{ill t litH .I W II 1.11

Physlt:~tI Therapy EXiIIl1lnalton 1130 The Subjective Interview 11 30 TeMS and Measurements 11 31 Eva luation and Treatment Plannin g 1133 P~ychosocinl Factor... 1133 Fear-Avoidance 11 34 Coping, Catastroph izing, and Acceptance 1134 De press io n 1134 Pain and Trauma 11 34 Social Reinforcement 11 34 Rapport, Relationship, and Compliance 11 35 Re lat ionship Building 11 35

Phys ical Therapy Lnlen.ent ion, 11 ~b Pain Control Modalities 1136 111erapeutic Exercise 1137 Patienl Education 11 38 The Interdi,ciplinary Team 1139

Summary 1 1.l9

puI111011:.u'). and integumentary. Since pain and chronic p~lin can accompany diagnoses associated Wilh any of these :.lre..b. understanding the multidimensional aspects of pain is crucial 10 a physical lherapist practicing in an) setting.

History of Pain The histor) of pam is a", old :I" lIw hl"to~ of mank..IIlJ.. In all~I('111 Cll1t ll '~"', pam and I1llle:-." \\ t.'1't" il\s~para~lt.· 11\'111 "'pll lilla! helit.'l\, ~LIIl) or the ... e l·lIltllJ\.· ... lx-hL'\cd Ih.u "utlt'nll!! \\iI'" l·HU"'I..'d h) Ihe 11l;lhl· lnll ... 1Il1l1ll'llL' C \It ""Irih III lht.' ~kJJ or tlit' !!od ... ( \' !L' ll'lll F~)ptl:\I" , \11('11.'111 tI~~k . . ) ~lr punI ... h Illl' 11 I 101 1l1l ... ~h.'l'd ... { \ k"OPt.ll,ll1\l,m ... l, In ,U1\ IL'1l1 IndiJ. tilt' 1I111\t'r"';lhl~ III thl' p.UI\ L'\I~'ItL'IlL'L' \\ ,I" ."tnbutl',1 ttl 1I1l111111l1L'd dc ... I1\.' ... . llw ,lIlt'll'llt Chllll· ... l·lh.'ld 111.1I1"UI\ \\,...,.\ Il' ... 1111 {II an lI11h,II.llll·l' {11 \ III ,Illd \ .Ul!!. I •... Uhlll' 111 r."ltha

JIJ

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h_ th(.~ ... ,,"lUN Ie" .1JlJ 11: ... \~f\ !' c\ kk'", ' that l>.'ih lO""" :mJ R,'m , \ .:";11.",, 11~ :t \"r um ck n\"3.I1\I.:' h.: r p.llP. ft'her In Eun'i~ Jun _ beD 1. 1 \lIJI.Ue -\fi", the . .·hun·h tx--x:tJne the:' f\"Io..:Ll' .... ~ and 1l"arnmg. Pam.. Infk~", anJ l"'l"\.""'O\CT\ \\ere eft t I.: \\ ill I..")j G\"ld \ 1u~h l"\f the G~ J.nd R~ m.m m<..""'li .. n('I\\ k-..Jge \\1.' panned 3..., berett "a1. tn fact, J.ltlli."l\l~h Ga cr Je"cntx....... the rudinlenb (If l"\UI ~llJl\"m n~f\t)lh ...~'~m eJ.] ) ill the :Th:f ...~ntul). hi, ((,.:l.:hmg ... \\ere t\lnne-d b\ t~ ,hurr and" re l3.rgel~ forgotten. l ' PI k""\ Jedu . .--ed . th:lt pain and ple.b\ll\', thoug.h l'P[X.h[t(' ,<,n-....Jtion,,-, \\ ere lInked together on .:1 C\.""\f1tinuum. ongmJ.tm~ from the he.:lr1 :md repre'i'ming pa, ... ion' of the '(lut An'lotle {;lUght th:u pain arose from 3n imb.1.l3.n..::e l"'lf hOi intlu('fk.'e' ... from the hem :lIld cool intluenl..'e ... from £he br:.un ~alli Ari:N:ooe'::- \ ie\\ s \\ ere supported b.:- the ('hun.:-h, the~ remained to profOWldly intluefk..'e the de\ ek"'pment "'f !:tCten.:-e In the \\'e,tem \\orId, Despite descriFtlOn;; of pam rel3.ted to inflanmlation b~ Cebus and Galen..;:, (he l'OI ~P[ de!-l..Tired b.:- .-\ri:..totle pre\ ailed for 23 nrurie.s ..1lnibutin::; pain to 3 ··pa..~ion of the soul... ·"; The Ii bet\"\t"'en paUl ,mJ ph~:--iolog~ \\~ not re-forged until \\ell ~tt'r[he Renais.....:;;.Ul~~ m the I-th and I th centuries. In 1628. H<.lne:- discovered the nrculation 0f blCk.,J. Di~ clion of human bodies \\ as still largel: forbldd~n bet...""'aLlSe of the ~trong ~ligious con\-ktions that hJ.d predomU13ted for centunt"!'i. A~ long as the heart \\ as considered the

nter of the soul and mind. the church forbade the
poinL the center of the brain. [)e:::;.cartes pro~~ed th.u for ~l pen.on to be con,ciO\C:) of :::;.omething. the e,"\perieIlCt.' had to go through thl' center. lbe pineal b...""XI: then \\~1'1 ~lie\e.J to be the pomt at \\ hich the ph) "icai [rJ.n~nU~lOn of infomlanon along the ner. O~ "': 'item be....:ame tr:.msti...1nned into C~lI1~iou.., thOUghb. tee-hng .... and emonon..... IX..,....:artt> rl~h.·~d the brain a.'" the center ot perception and d6Cribc-d the ner.l.'''' as tube-, contammg delicate thre~"\~ that connect~d ...~n"i.ltton m the penphel) \\ tth a\\~\.ren~ss lFig. :2<..'.1):' [)c'pitt' huge

ad\aJll:e, m "-Cience. thl'" "'impll"tic \ ie\\ of thl:' Ill:'r. \lU' ... ~ ... tern conl1nu~d to domm3te medical ~\ t:nl1

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Pain Theories Early Medical Models Lf"' nux.!\.:nl "I! .... l~rn m,,:oll:lnt' until thl:' Illid 20th ...·l·rHuf', pam 'ha . . J.'i,;umeu to h..: u ... ~ mprom llf .iIl ulH,krl) rng ph),

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( ' hapter 28 Chronic Pain

1119

Table 28.1 Historical Theories of Pain Author Theory Summary Intensive (summation) Theory

Erb t874

This theory, built on Aristotle's concept thaI pain resulted from excessive stimulation o f the sense of touch, was described by several authors In the 18405. Erb maintained that every stimulu s was capable of producing pain If It reached sufficient intensity. The theory was further developed by Goldscheider In 1894, who described both stimulus intensity and central summation as critical determinants of pain. It was implied that the summa ti on occurred in th e dorsal horn cells.

SpecIficity Theory

Von Frey 1895

This theory is based on the assumption that the free nerve endings are pain receptors, and that the other three types of receptors are also specific to a sensory experience. Pain perception was viewed as a function of the amount of physical damage alone.

Strong's Theory

Strong 1895

Strong believed that pain was an experience based on both the noxious stimulus and the psychic reaction or displeasure provoked by the sensation.

Pattern Theories

Nafe 1934

Early pattern theories suggested that all cutaneous qualities are produced by spatial and temporal patterns of nerve impulses rather than by separate, modali ty-specific transmission routes.

Central

Livingston 1943

This theory proposed that the intense stimulation resulting from nerve and tissue damage activated fibers that projected to internuncial neuron pools within the spinal cord. Abnormal reverberating ci rcuits were created, with selfactivating neurons. Prolonged abnormal activity bombarded cells in the spinal cord, and information was projected to the brain fo r pain perception.

The Fourth Theory of Pain

Hardy, Wolff, and Goodell 1940s

This theory expanded on Strong's theory and stated that pain was composed of two components: the perception of pain and the reaction one has to it. The reaction was described as a complex physiopsychological process involving cognitive functions of the individual , and influenced by past experiences, culture , and various psychological factors that produce great variation in the "reaction pain threshold ."

Sensory Interaclion Theory

Noordenbos 1959

This is a description of two systems involving transmission of pain and other sensory information with a fast and slow system. The slow system , composed of unmyelinated small diameter fibers, was presumed to conduct somatic and visceral afferents. The fast system, composed of large fibers, was said to inhibit transmission of the small fibers .

Gate Control Theory

Melzack and Wall 1965

This theory proposed that the neural mechanisms in the dorsal horns of the spinal cord act like a gate that can increase or decrease the flow of nerve impulses fro m peripheral fibers to the spinal cord cells that project to the brain . The soma tic input is therefore subjected to the modulating infl uence of the gate before it evokes pain perception and response. It is suggested that large·fiber inputs tend to close the gate, whereas small·fiber inputs generally open it. Descending con trols from the brain also influence what is experienced.

Summation Theory

L

----------

------------------------------~

wherea~ another individual\. re~pon se falb outside these cKpcclations. Livmgqon\ theory of'l Cellfral Summation of Impulses h~ been expanded by many of the curre nt thcorish. Livingston proposed a "vicious cycle of reflexc:-," involv ing it chronic irritation of a peripheral se n..,ory ncn:e with Increased afferent impul-,.cs. This irri tation resu lted in abnormal activity In an II1tcrnuncial pool of neurons III the lateral and antcrior horn of th e spllla l <.:md. and III tu rn increll'led "'ympmhcuc reflc:\ efferen! activi ty. induding lIlt: rca:-,cd hea rt

rate, va~ocon stric li on , and muscl e \pasm. llw, heightened thought to produce further abnorma l input, thereby creating u Iccdbad. loop thaI perpetuJted the experience. The prolonged exciti.lbi lit) of the II1tt.'muncin l pool 1<" furtht.:r maintained by fear ..lilt! :U1\iet) SUL'h pa in was though! to no longer be trigg~rll1g .111 al.tnn 01 Imminl!lll lIanger, but to hm..:: become ihellthl: patholog) , rc ... illlllg wi thin the nervou~ "')~II..'I1l. TIll' pilln p.lIlma~" \\r.=rc thought \0 iiI'\..' althoug.h 110 lHl\inu .. "U 111111 i \\crt" pl\!..,ent. ~y mpatheti c activit y was

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lit.

Thl! \\ or!.. 01 Mel!::".:!.. and \Va ll led to tht.' developm ent of co gll1tin:/beha\ ior:11 or bioJlsyc hosucial lIIodels or paIn

alld Ihe \\ idc"' pn,: ad acce ptance of the LIlt erd t:"c lpllllary pam m ,It1ag c111 c IlI program , The bl op.. yc hm ocial approach ~ce l... s

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InhIbItory control

Large

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Small

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Ihl'OI) (h1l1l1 BUllIl,1. P 10, .... IIh pc nll1 ..... .on.)

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lH'IVl 1'11111111'

III '11f'1

IIl1ltr 11 "'11

11',l1pll

!ly

!,

"I,Ir,

/l1I( 1/"1-' .• llId I'm" .11I11111.IlIQl1

1111

I'h

I", , '111 Ih"f

1111111 H,/ '

III 1M 'Il'h, /,11 I'llfl

hV 1111 I 11II11I1.t! 11a, Ilfl II III' h ,A tI, 11.1 ,IIH\ ( 11111 I 'Ilil It 1/

11I1

111l """ I,'V Ihul III1IV,III III 1111 111 I,d 111 Ih, 11'1111,11111 I Villi V.II III I'hi" I I" I~' l'('I'IIPIl 111 1!l1 Il ld" 11111111 1,1 .1111111" ,I p,11111111 " ull", ' II V J ,I ',l1hll'\ 11\11' \,,1111,, 111111 pl.III" 1111 Ihl r 1M III III f' III P 1111 It ti n' Irt'lll1l ' 1I',~I1t IlIuiI Wllh .",IIIIP,IIIIIII III III HI 1(11111 Illff,1I III 11\11 W{ 1/ hnn" P:l l l1 " dUI\'''' ' , Ihl I,I! .crv.lhl ,llIHII1', 0 1 .111 1111 I1vlI 111,11 III II',PIIII ' If! I" III I,," CJJIf rt " 111 pal11 ;I"d/Ol .. " Iklllll' In 1111, p.Il.II11J.!IIl, 111111c1.IIlCl hfldy .IH· 111 'p.H,lhlr 11111 d Pl'll'l'pll1 l1l ,mil phYl, lfllll1lY 1I1Il·,.II I III "I~'hly (1III1plr'T w,ly Ih il l .. ut'1ll1' I 111'.1 hl'!;1Il1J111J! 10 IUllln.I.llld J IIrlilrr Iho I'" 1111 11111' In 011\' l( llInpOl1lll'm (. ht'lwc{'11 1101 j{ I pWm ,ulIl p1l 11l . Jlil111 .111(1 ... u f k l lllV III .1IIJcrtl1~ ,lIul fMIIJ heh 1''''fIT 1'11111 . "'\l If CIII I ~'. il nd \1;11 11 llt'hilVHU tan ;!l1 OtUlf Klf/lflill (I( 1/101 \//lIIIIIO(/(1I/ (I/I'(lfll \f' /I( (fill' \ ., h(
,,'I

Pall1 bc hav ior I... onc D r Ihc mmt pUI/IIIl!! and challen~mg a"'l">ecl ... 01 palll management. It lend ... II\CJf 10 mNnlerprcla lion ami ob .. crvcr bta ... and COJ11pl l cHtc~ the p
I""

I.bers

Figure 28.2 \kl/.Il).., .1Ilt! Wall\ 1()Xl Rl'\i ...ed

III\(

I,ll

Pain Bchaviol"

Biopsychosocial Models

fibers

,,1 1111

lUI hlllllll' nil' /f ''I'fl(ll/ 1'(1111.

Nllrit lpt llll1 II kl

Ill{' (;,,1.·

11111 HI 111111

1III1I11pli

II I 11111' .lllul III

(jale

COlltrol

Chapter 28 Chrcmic Pain

Autonomi c Dys1unctlon Dysfunctional autonomic responsivity Increased sympathetic activity Increased muscle tone Hypersensitivity Hyperimtability

eNS Dysfunction Decreased pain tolerance Decreased pain th reshoki Decreased endorphin level Decreased serotonin

t t 21

Metabolic Chang es In Pai nful Tissues Decreased blood flow Increased edema Decreased nutrition Localized muscle Ischemia

,~I_ / CHRONIC PAIN

Flguro 28.3

('Olllll\lIl\'nl, 01 'h~' (,;Olllp!l:\

P'Y

dll\l'h\\IIIIII~'I~. 1I 1IIIlIl 'II \H IIl \ til dllOIlIl: p.l1l1 .

IIll' I lcat m c llt

Overwhelmed

Decreased movement skill Decreased proprioception Dysfunctional movement strategies

Pain out of control GuilVsham e Decreased self·worth Identity crisis

he lim ping 110111 b.ll ~ p,lIll. hilt he l1la~ abn I'll' limplIlg frolll a prce\.· I"'IIII~' Il"}' k'llflh dl'lH·p. ' IIL,) f\ l a~ lI lg "!1 1m.' JwJl! l1l elll ... 011 thr h",', pi ph"'l'!Vl'd hl'!liI\ 101 I ... 11 0 1 compllllhie \\Iuh a p.IIIt· llI \\11\1 IlIlIp '" IlItt)

100m Ill Hy

tIWI.I Il1.'U ll l· Il·l.lIltllhhIP

N(·l1mplaSlicily. W ind-Up, and Learning \,1\\'1 ItII,tgllll-! Il'l'llIliqUl" h.th'

kd 1\\ 1111

and (I(h ano.:,

III 1I\..·urD"'CI~IlCC

1IIl' I\',I"'l'd II tHil' I'tilndlll,;!. o r Ihl' role Ih a l pe.:r·

~\'PIIl'II, . U"I ~I I'.t1U\lI. ,lI1d pa ... ' l'\.j1I.: l ll·!ll'e.:

,\·IIII.lllIl·I\OI.... "'\'II.'1ll

h.l ... olll hc hu man (t'NS) Nt.·uropla ... tll'lI) , ... Ihe l'01l-

~l'Pt Ih.t! ')111 { 'N S !\·orgdill/t· ... III Il· ... pOIl 'l· 10

Self

Motor Control Dysfunction

pt'rtphcml

Psychosocial Isolation Depression Somatization Sleep deprivalion Vegetative state Interrelational stress

preempti ve analgc:,i a in the rcduction o f postsurgical pain ha~ been mixed. Several contro lled !:oItudies have fo und no ditTcrcnce in amount of anac\lhes ia required for su rgery o r se lf-rcport of pain after surgery wi th lise o f preempLive analge ... ia. 1" 1(, Olhc r ... tudies have fo und signi ficant differences in pO~I . . urgic.. it y and guide optimum practice and resea rch.

IIIplil \\\" ~Ul'" th.11 tlll' . . \.· l·h.tllgl· .......lTUI Hlld tha t ",ollle ur 111",\· dl.lI1~n IHl'lh'Pll'l' Itld1\

idual ...

p.lln '(\'~hd l l'l .11 .. h..' \.1..'1'1 1'1.'

. . 1rllL't II I'a 1 dtlft'rClll'l"

hi l"pc-Ilcllel' chnlllil'

III the

~1.t1l\ .tlld hl.llll .Idl\ .ltllUl , .... IIl,!! IUlictlOlla l IllllgIlL'IIC fI_· ... O· n.u,~-\, 11\I.1!,!1I\k! II \ II{ I) d.H,\ Illllll \ ll\ulllL'cr ... \\ ho tlL· ... cnhcd

Iht'l\hd\\'\ Ihl'rl' 1\

.1"'~ llhll\'·lH Ie ......

1 "'CI''Itl\C III p.IIII_ '

l..·llI1lIX'III1I~ .ltlllllalllHllkl

ami

hUIlI
and "'plIl.1I p.llnful' . . lIIlIulI . ~kl/;\d. l'l 011'1 III Ullr 1.'011'\'111 kl\O\\ h.:dgC' III thi~

The Biology of Pain " wo rking I..nO\\ ledge of pain phys io logy is esse nt ial to nmig;lI~ the literature in pain manage men t. ru. well as rationall) c\:ullinc and !o.c\cct appropriate pain management [ool~ in palil'nl car'L'.

III (h.IIICl.... III thl' "'llIlMll"L'n"Or\ \'tWlt'\ Ie> '\1 lwd

'\\ lIh C\'I',hlllt' III

rl \·'l'lIt.m 1.'\\.:L'lklll 1\'\ It'\\ 'J

\\.f.t '1'1, .. 1 ,(x'\."Ili\,.· I~ IX' III Ill'Un\pl.l"ll·tI~ 111\\ hidl thl' ('Plth'lIl'll!, ~lll":-; Ill'unm' t'\.ll.Ind. 'l'lbltl/lllg Iht' 111..11' llJ.1 \ I1t'P,l'U' ... , ... t~·1ll ,\lid dkl.:lI\t'l) Ill\\ aing Iht.' thl\',h· J to th...· IraJh11l1''''hln l,1 nr"".;h:l'PII\\..' Il11pul,l· .... StudlC'''' llf 'C\llt..hr\.\llh. p.UIlIIl.UlIl11.llllll'l\!t·\, ... uggt.· ... tlhal \\lIld·up

~ U 'dl\l h t-ll'l\,:k1.'d \\ Hh I'" 1!!II'''''t' 11II0/1.;1·\ltl 1'!t'<111In!,'\ .mal -'1.1 1\ Ihl.' ,ldlllllll,tr.\t101l 01 1'.1111 rdlC" IIlg

\..luon. III

11'lIl'n

lll.1 '1X'..:'ltil..'

II"UC'. priOI Il"\

1m nl O~ Ihat I' It}..~·I~ hl

lh

It

U

gl\1.' rl't.· Il'

I1ll·JIl.1i nlX·I"''t..'p-

D.lt3 'WIll hUIlMIi lIl\C',II!!.lIWIl

nl

Nociceptors ~()cicepturs are

the pai n ~pt!cific nc::rve endll1gs III Ihe IX'rtphcry. The) lire III re:o.pon'\e to potential 'I ~slle lJJmagc rht:) ..lre ahundnnt III the ... klll and ml"l' ulo . . keleti.ll S) ,Icm. n...-iccpll1l'S COtbi:-t of fn.·c !len-e clu.linp: ,\ ·dt'/fd. anJ C fibt'n rhl' \ delta tilxr-... !'("pond 10 mcchanl('ul ..md IhemMI ... l1llluli.ltlon ,1Ild ('hcil tht: li""t. localized ... harp p.lln. The) .m.~ Ihnught In product.' the 1I1t11t/raml! n:tln and .tI'C ,,"If . . 11\.\11 lilll.llion. C tiher-... an:- pol) nllxbl n:ceplol". ·nle~ 1'(',[,,\'nJ 10 ...·h\..·l11ll..'al. Ihenna!. itl1llmechalllca! '111llull .md pnxlult.."c tht" '>t'n'ndar) ,Iching or humin!! pam illHI .H\' of Itln~ duration. Palll 1ll00luintiOll l'.1Il Ul·t.'l!r III Ihe l'alphC'r~ h~ the ... llI1l1ll.lIiOIl III \ /It'tll .1 I"kl 1.'11". rh1.' ... t' .Ire tug\..' UIJ.llll!h!r,

1122

Ph"j(.al Rc habilit.llioll

non nl'M..·h.:~Pt1\~ 1h..'Ullllh Ih.11 ,,:.Ul "dO"t' Iht' galt'" \ la ;KI1 ~ \ alllln 01 Ih~ SCi 1111" .KII\ .lIhll1 1111111111'. .hl.:l"ndillp. r~"rOlht' al lh~ 'pmal (llrd k\ d ,1(1

01 th~lr clku

nn dl"rrC'i-... IOI1, In iltlditJOIl. cndorphm'i. and l'l1J...cphaJllh aUto IIlh.hlltrall'olllhSIOn 01 !o.uh. . tant:e P. I

Peripheral Mechani.m, \,ccnding Path" a~ s nl~ \111~ "1"/1,,,11, Irilt'l I...'''lrril'~ th~ IIlfOml~lIion for pam

dl'I.'nmin.lIltlll ("" hat. \\ here") from "pinal h~\ ~I to thal<.1mu", Thh r ..llh\\;.\) .... ene~ 10 localll~ the nOCil:epli\e input •md rnmanl) tr;neb to the . . om.llo"'en"Or) (·orte\, The ,\p11,orl'liClIJOIhIlJllmic .\ystl'm carri~ . . the allectl\e (fee lin g] mterpretiycl component of pain, TIle . . e pathway . . Ira\el from '1'1031 leyel to Ihabmu~. h) pothalamu~. limbic ~) 'Item. and . . en ... o~ cone\. The ~pinoretJculotha l amic !:>yslcm connect.... nocicepllon \\ ith the older Celller\ of our bralll that mediJ.le me mOT) ilnd emotion, Chronic pain i... neuro logicall) hard \\ ired to link. pain and affect. '0

Descending Pathways The brain is able to modulate the intensity and frequency of J....\Cending tract cell firing through the action of desce nding pamways. ~\ The descending pathways can inhibn the ascending pamwa)s \"ia intemeuron~ in me dorsal hom of the spinal cord, Descending impulses tf3\·el from the periaqueductal gr.) (pAG) to the raphe nuclei in the upper medulla and to the dorsal hom via reticulospinal fibers, Other pain~uppressing impulse!:> pass from the PAG 10 the dorsal hom via the locus coeruleus. Communication between pat!l\\;ays occurs \-ia neurotransminers. Cogniti\"e and emotional fac tors either enhance or inhibit activity in the descending pathways 10 alter pain perception. Treatment technique s like rela"(ation. meditation. image!). and distraction are thought to enhance me actiyit) of me descending path\\-ays (Q inhibit pain. Release of endorphins (endogenous morphine ) and enAephaJins via exercise or relaxati on respon~e can inhibit pain. l' These substances are located in the periaquaductal gra~ (PAG) malter. thaianlUs. SG. and the limbic system.

;'IIeurotransmitlers '\;eurotransmitters are used for communication between neurons, The) are I,ynlhesized in the neuron that ~tores it and are !:>tored in the Ye~icle~ of the neuron . The) a re relea~ed \.\ ith nerve impulse~ and bmd/acth ,.lie a ~pecific receptor. "\eurotransmillcrs are able to be inacti\ a ted by olher neurotransmltte r~. Ex.ample!:> of ne urotransmi tte r.., IOciude dopammc. serotonin. norepinephrine. acetyl-

choline. glutamate. gamma-ammobut) ric acid (GABAl. and gl)cme . .'\euron ... rcc.:CI\C a con..,lant barrage of s) naplil: ... ignaJ.... ~()mc mhlbltory ...ome e"\c.: itatol) . hnpube ... an.: . . ummed i.ll the le\'el ullht" nen·c c.:ell. and if the hJ.lam.:e f01\"or... C\clt;.nion. the Ilene \1,111 tirc 11 the halam':l! laHl[". mhibition. thc nt:n·c cell \.\ III not fin.: \1 an) ot th~ {urr~m drug . . u . . cd Ull:hronlc pam are Ihought 10 ad on nt.'urotr<.tJ1 . . mlltcr-. that may ~ rt.'l ('\.1111 10 pam moJulau(lIl. f·or c"\i.unplc. 'OI11C of Ihe .lIllide prc-,sant medll.\i1101l fSSR I. . , or !'.e..·h..·UI'~ -.crohuUIl rcupl;.lh' IIlhlhnof',) C.m hc..~ ctkUI\t! In p.IIU m.tn ..lgcllll..'nt Rc~ .. m..:h tta' 110"n their p.IIU modul.lllon dll'u to he..· Illlk'pcmklll

The Int1ammator~ Re'pun,c Th~ IIlllamrnalOf) re"'pon,c ha... been Identifi ~d ali a crutlal peripheral modulalor of pam. - . Inflammatol) medlatoJ'\pro ... taglandin . . ami leukotricllc", mcrca ...e peripheral noci . ccplion. Abo in local cdt!Il1
The Sensiti.lalion of ~ociceptors Repeated no\ious ~timu!J to the pol) modal nociceplO~ lower their threshold lO .... urnulation. Thi.., I') thought to ··open the gate" at the "'pinal cord level. \\ hich increa.'e"i the barrage of pain impuhe~ on the C'\iS. Thi') also can he lp e.\plain the phenomena of allod~ nia . in which nonpainful st imuli such as light touch or air mO\ing acro')~ the ... kin can be perceived as painful..! Peripheral 1\'en e

Injur~

nen'e~ regenerate at a ... 10\\ rate of approximatel) I mm/day. If the path for nen"e regeneranon is blocked. ne uromas fOffil. Sprouts \\ ithin neuroma are sensi tiye lO mechanical ~timulJtion. in addition. e"\ciwtion of the neuroma ma) occur and be ~u~lained b) electncal "cros!:>talk.·· bet\\een bare a\on ..... This can be a . . ource of neuropathic pain .

If injured. peripheral

Medical Management of Pain .\ledical management of chronic pain may include ph:lIl11il' co logical inten ention!). intef\ entional I minimally in\ ~I\ el pain management. and . . urgical pain management. Treatment mil) be pro\'ided by prirnar: care ph~ 'Ician ... or tertian pam . . pecia li..,h. Chronic pain i... be . . t addre~-.ed b) collat~.lrJllH~ team mana~eJ1lent: inten enlion' pro\ ideJ \\ithin thi, frame\\ork a~ ~lore likel~ 10 be ,U!.:ce~,fullhJll tho . . e prO\ ided on a unimodal b~bi,

Pharmacological Intervention -\nalge ... i(", an: the mo,t common da..",,,, llf 111t.'l.h .. ~H1on~ u..eJ for P;1Il m;macel1lt"nt. The,e in ..·!ude ll11n ... tt"rotdJ.1 'S.-\ID~. ~1l:el"U11Inophe~. and n;ln:otic tllPIOld) medll.:.lIlon",. Other c..:Ia . . . . e' of dntg' U'tX.l1Il p.un tTt.'~lIlllenI Include ;.m[iJepre . . ~JJ1[ and ..111111.·l.ll1\ UJ.....lnt medlGUlllll. Topical prep..lralll1n'" .lft" , )1" l)pI(IIJ. . tll al . . o u-.cd. rangmg Irom Iran',-Ie-mM I d e II\e~ l

<.. "hap(£'r

Table 28.2 Common Cia>Se< of \ledicarions Used ;n Pain \tanagemen(

,1 fi .C

CIu-

2~

<.. hrnnic; Polin

112 \

. onlC

a../

,kN-e

F

ilea

Acetar:: nOOMen ~sp

-,SA Os

.-

bup~o

en

Roxcoo ()ptOtCS

Attie'IE F..frecta '.~Jd 0 moderate pa n, no an' -mf am ..... a~ory e~ect

Uver toxiCity

.~ a '0 ':lOdera:e pa n ant ..,1 am!":'latory effect

GI bleed n9 nausea

A"'" nf:a'T:matory e~ec:. G! syrrptom spanng MOderate to severe pain

Tolerance. addiction, sedation.

consllpatlon, Immune suppression

______________~ O~x~ycooo_~_e______ A"'T

oeprassa":s

Am:np ne rJor...- pty "e Gabaoen " Carbamazeplne

AntlCllOlinerglc e eels (dry mouth. constipation, blurred vision). sedation. insomnia.

Chronc pa n

europathlc pain

O't;!"Hbe-coumer cream... for temporal} pain relief. Example'i of t!3l.h of the-.e cJa.... .;;e, ot drug .. are presented in Table.1 .2. The u...e at analge.;,ic.;, for acute pain management i... common. The function of medicauoru. h to mffilmize u .....ue damage and to ma"<.irnize tissue healing. Reducmg pallent an,(I~~ and fear abo reduce'i the . ympathetic arou~ Je\el. aJj()'.l.mg for increa.;,ed blO<Xl flo\\. and change~ in pain percepuon. Prolonged U'ie of an~ medication can be: problemall\... becau-.e acJ\.er<;.e side effect-. ma~ develop over time. GeneraJl~ nonaddicti\'e medication~ ma~ be taken for a longer ume if ... ide effecb do not become a problem. \"SAlih are available a... both o ... er-the-coUflter medicatIons and pre ... cription medication'). Some of the ney.est

me-se

ci",,,,, of ""SAID> are the COX-~ mhibltors. The« drugs prO\lde pO\l"ert"ul and effecti\e antiinflammatory action \\.Ith l~ g:~lTomte ... tina1 side effect-.. Se....eral ')tudje~ have ~hoy.n the effecti\ene... s of COX-:! inhlbltoPl m chronic pain. 36 "" :tn,:otll..: analge"ic~ are often both ph~ -.iologicaJly and ~}chologKall) addicting. but re-,.earch e\ idem.:e ... hov. ... that "hen the medIcation i, proper!) adJlt;ted to the pam level. p )chololJlcai addiction i.., Ie ...... like"'. J The U\C of narcotH.: e analgesics m chronic non-cancer pain i~ contro\er"lal. \edel)ko\ IC et at pro\ ide (VoO morough re\ ie",," of the literature and I~ ue ... a ... -,oc..'lated \\-Ith the pre')(.-ription of narcoUL medlCaIion In pauenb \\ nh chrom<.: pain. J9.!f) Some of the majOr \,.:oncems mclude Issues of ph~ ... iologH...:aI 10Ieram..:e. addltuon. 0pJOld-mdul.:ed pain sen Ill" It~. and immune f"uni,;lton ctTec.l . \1ore mlflor ~ide etkch mduJe naU'iea and (on· Jp'dlJOfl In adJitlOn.there are certam t}pe,;; of pam In v.hJch narto{J~ arc nut cffCdl ... e. mO'->t notanl) neuropathK palO. Pitllc:nt~ on nan.;olh.. pain mcJH.dtJtm~ mw,t he c.trcfull} S(;r~encd cUlU monitored Some mil) I.JY on the~ '11CJu,;.I' lions tor \ears enahlmg them to rcal,;" a le\l:1 of act!'. t} 'With signilil ant!) h(~her funt..:llOn' Parle,t u in

DIU1ness fatigue ataxia. liver damage

properly managed narcmic'il !)ometimes report the} per-

cei . . . e the nocicepti\ e component of their pain. but "it no longer bothers them:' (i.e .. !.here b le-..s suffering associated wuh the pain experience). The use of narcotics designed w fill the same recepwr sites as the endorphins made within the body re'iults in a decreased produclIon of endorphins. Endorphin depletion can occur v.:ith prolonged U:il! of narcotics and. with such depletion. me need for the drug increases. ~ew advances in phannacolog) are enabling narcotic medication dosage!) to remain stable for long period of time. The use of pumps 10 continuously infuse narcotic medication locally or systemically has been dC'o'eloped for immediate postoperati\'e use as well as long-term pain management. Amidepressan( medications are thought to have analgesic propenie\i ~parate from their effect on depre...... ion. This rna} include both central and peripheral mechanl,m>. Amidepres ... ams ha...·e been ~ho\\-n to block reuptale ot noradrenaline and 5-hydrox)u}ptamine. They al,o ha\e dired and indirect actions on oplold re~epto£',. Some anlJdepre ......ants al~o potentiate the a<..:li\ it) of ,,) ... temic morphine ..~t Antlcon\ulsive medication ... are u ...ed primaril) 10 neuropathic pain. There i') ')trong ... uppon for therr u-.e m animal model ... of neuropath it.: pain.-u GabJ.pemm ha... ix""t:"n "ho\\-n 10 be effecti\e in animal model ... of all(."ld~m3" 3nd 46 in human treatment 01 trigeminal neuralgIJ. A ... pain oct:orne ... ...:hronic. adJu ... tmenb mu .. 1 ~ I1\.ll.k b.l the: medlCJuon re~mlen. \ledlcallon ... that ""ere helrful Ul the J.4,,;U(c: phase are tlhc:n no longt:'r helptul tn hmoh.: fUJn D.na from pam (;\1011.: .... uttt:'11 the 1a. . 1 ...tup h'r p..111C'Oh .....:d.. '"8 help \I"ollhm the medh..'al mod~l. looh.atc.:' ltu~ the mo..t Ifflportmt tai..tPr III UK.."Te.hlfig 'C\e-I of tUnctlon and SULI..C' fulh man· aemg the pam &~ the:- n...·t!uc;;uon l1f C\ ,,, Ux of mulupl addICII"" medl uon P'"dUCnt \\ltr. ... hruOl pam otten cOO

lip Ill) .1 \\ Id~' .\11 .\\ 01 (!III!! .... Ilil lUd1ll )! pilm II1l.(\lt.lIIOIl ... . n~lh\':Il' rl·I.I\,"lI ..... 11111 .1I1\ll·l) ll1l'dllitlIOII. ilnd tlitllqUIIIICI ... . ( hnll1l( U'l' nl ,"dl I11l'dl l'.I 110n 1I1;1 }' l'Olllllhulc to Illl' w llh

10

101..';11 p.Hholc)gy lrom rene x mU~{:le "'p:l'111 In ... uth d .... ordLT ... i.h lonicoll! ... 'Inti Ihe p I • If! ormiil "'YlldrOllle ddkrcl1llall'

dl,mll. dl'Pll'''l'd .IPPl.';U.lIll'l· 01 'OlllC pillI CIII ... \\111 1 pam.

Int c n c ntiona l Pain Managem ent \1ll"lhl'lil' hind...... 11lJl'l" llOlh. 01 othcl protcd llll'''' may hl' IX'I!\lll11l'd 101 'l'\l' laJ rl';hOIl"':

10 dl'(l'f1ll1lll' thl' ililalOl1lll'al ",u lIIn'

In ll1

.

(lllhc

pain

'11l.'cllk IKK.' ICCPII\l' palhw:I)'" 11l.'1\\ cC II local and rCfClTl'd ",01ll1l1 Il' palJl 10 dl'h.' ntlllle Illl' mil' 01 the "'Ylllpathl'lil.' nenou'" ... y ... tl'lll III the palll l"J1l'rl l' IlI.'C ;\'I..·CI"I.11II

(hlll'rl'nll;lIl'

rll l''''c pr()(':l'durc~ abo Illay be u...ed 10 bl""k "... p.un 10 tIl'tennillc the IXlllenl' ... rc~pon ... c 10 the climinallnn of pam, By hlol:J..mg atkrellt (noCI(:epllvc) or efferent hympa. IhetH':) Ilocr... lor ,cvcral hour .... aononnal aCllvlty may nOI return Vvhcll the olol:J..a(1\.: weJr ... oft In addition. dunng Ihal tllllC rehaoilllJIIOn " factlll.tlcd anti more aggre"'..,I\'e Ihl'rap) call be performed Ihat o lhcno,.'l ...c might nOI be 101. crated. The n: ... turalion 01 nannal, ITIm-cmcnl pallem.., rna) l'nhallce Ihe perpe t uat Ion or rc llel ill ler the blocJ.. wear... oft Ihe ...c prol"cdurc~. \\ hu.:h mil} hc diagllo,til:
Table 28.3 Intervc ntionai Pa in M a nage m c n t Procedure Diagnostic

Therapeutic

Facet block

Identify locati on of pain In facets rather than disks.

Epidural Injection done with lIuroscope

Considered best interventIon when paIn is

In some pallents, may be repeated every 1-2

one sided (e. g., lateral foram lnal disk herniation): 1-3 steroid Injections done when

years If symptoms relieved for several months

Not repeated routinely but may be used If longterm relief (months) obtained by Interrupllng reflex cycle.

nerve root IS pain generator to decrease

swelling 51 inlectlon

Dlskogrom

Identify 51 as source of pain ; sterOid Inlec-

If 51 IS prtmary pain generator steroId Injection

tlons to determllle duralton of pam relief

may be repeated only when severe IrritatIon/inflammation limits function up to maximum of 3 per year

Used prior to surgery when fUSion consld·

New techniques Include Jntradlscal steroId for annular tear or Internal disk derangement

ered. several disks are Injected. including one normal to Identify disks causing

symptoms Nerve block

Iden ltfy nerve as palll generator; may Includo steroId use to decrease mflaml118tlon

May be repeated in some patients If SIgnIficant rehef IS followed by return of SIgnifIcant paIn

PlrllOrmls/othor

Identify pain generator; steroid Inlected to

muscle block

docrease muscle tone Gnd decrease InflammatIon 01 nerve

Allows aggressive rehabIlItation eHorts to stretch muscle, decrease nerve enlrapment. relIeve pain, may need to be repealed for full

therapeutic effect 5ymp"thcliC blocks

DoterlTI1Il8 rolo of complex regional p..1l1l syndromo III p,lln Compt..llnl

May be repeated 4 10 times 10 reverse com· plex regIonal p~Hn syndrome cycle: done .n conjunction WIth aggressive therapy and pnor to sympathectomy

Dorc,.,1 column IlrTlul.ltor

DolorlllH10 II p~lHl C~Ul bo controlled ~ltter aU othor consorv.lIlvC ~lttempts h,we f~lIlod

ConSIdered lor neuropathetlc p 1m, Implanted lor long-term Pdln conlrol

Indwplhnq P lin PlJlTlP

NA

Indlcllted for nOClceptl"e pdln m.w be used lor long turm pdtn control II surgery IS not dn opllOll and p 1m cannot be llh.ned PrOVIdes Detter p.lln llhtn.lgOJ11tmt Ih.1I1 ora! medications, or InJoctlons

lh-,pttrl

~n pJthl",l\."'p ...~ann(\( ~ ...\'\ffi:: 'h,"\J 'lln.:!l\.\dh ~U t It 'lk' r.>!..'If'e\i ...x ~3...'I"'\flallreJtmcnt U'lnf" ~kl,..·"', ..'I' In. \-.r" nlJ~ unr n "" C I\lO':O,"'n 3' \\~, .,1... qU3hl' fit hf(.' ..... t.. ...·.ill '1nlplanrN .1.kl{lf ~ 'r'UU! \.'\.,N G.ut ~~..~[J'l'l ~ ~ w hi, ~ l'ltn IOlT'U\...e, tn"\{ll lrJ't.~lln~ t ....I~· ,\ ~'n' ~n:-erl1 .."£l I."'t pam l'-= 'l1l' Tht, rnx UR.~. Uk: 'l ,'l.: 1"''f11~ u"'-~ I.."", f.u1e-d ll'" tu...;.. 'YTh.1n"£ll(".l'l.'\.luU't;~, ..~.m.'i ·r. ..·nl xk""..."u,,"'fl. h nlJ~ ~ ml."'f'e :-u..".......,ful uun J.1t mJ.[l\t"" ~h 3..' .hiJllIl"'ll31 "urgt'~ tl)r ...egm mJl ,wrlliz.Hh.'n. ~· ....r..lmle"' .•mll f·mfh . . '~('ll.... mte' .&~ The de, ek"'rlllem ..... t .......JI' r,~tk·. lltt'reJ n.... . . ·i . ...'epme t't."e'dN(' I(,,-'If\' ..lllJ ~mu~n! n....'ue ...'I."'I11rroml..e from either the mj~ or 'urgeI') mJ~ '"t' ~,.,lt1,'Ifl" t\..")r pJJn m,utJgemem pro'IJni b, the ,11k"· '!'!;."I"lll"lgl~1 The,e Inh.'T' elll ...... n, .~ ,gener:lll; .1(\.\....mp..l"

~ ~~

p.1uent m.. (JU 'flon m --elf-m.uugement. p..tin nle'd.I(';}10 ....'II11C' ..:-aX'.;', ,md rehablht.lUl."'n eft'l"'n-... BI(",·;''' m.l~ lle u,eJ. .lfter .. urg.e~ 10 reliu('e p'-l .. tl.... ~rJ­ [.\e" rJtn ,"'r In tht' ear\~ .. t.1ge .. of chronic re-gionn l p!lin :-0

,\ndrome lC RP ... 1 to re-du('t." pmgre~'I,,"'n to full CRP'"

n:r.1reuti,,~ ~k\02b tor CRPS IIlh:~rrupt Iht' l."y('le l,i nlntm)W. PlIO 1r.m:-mi"lOn ~Uld 3.1I"l\\ l:'re ..umem to mobilize :mJ R" ... lOre fun('tlon. The efft'(,1 of J. bIOI: mJ~ e'\tenJ ~~\"ll1,j

the dUf3t10n of the drug, . Jllo\\ f0r 11l"lrnlJ.lizJ.lil.ln

n'" n I\un

,u..

III

11'

tbrum.in

~"'n C'Il1 t

.., R(',...• r

11\ (\lUl In'. men!

.!U .....• m..1I1\

,tud

Jllfl,.'rcllfl.\!(' r.lll(.'llb \'\( tn.'.llm nh \\

.. I.lmr.m: m,;dl .. :lU 'n' l r mf('f\rnUll 1 pa ph' ",ll ,....r.l!'; .' tl"ph" ,1I u,.,c \\ \;,'0(1(\(1 It , .. h.mIh "urrn'm~ th.ll .. "h,tui1l<" "rh~ '1,,"., t 'r.lr' u tn.'J.[Jll<'1lI' ..\,...... ful 10 t!X' Ilt!""~mc"" .."'I p.un. Far m .."'R.' n·x.m:':lIk."Ut, t 1 Jooc th t Wl\.JI ..

.1rr "pn.lle [n'J.U1k'm' III the arpn'Pll.1tl p.ll mt .. m .. tuJ~ ,( ('..Ull Il1,Ul,lf.~n1(·nt,

:\cui~'

P,un ...' .ut mkk.'f'h xl .1' ..1 fw 'UI..'flt,1 It-.. .!h."'UII~ \ \.111\ "'t UlH!,l{l'- 'lIllply n·l.ltc ."-,,uit\ l,l.J n~tJ lml(' tr::tn~ If. r t''\,unrle. (l Illl."lflth.. P.un tl( l~" rn.ll1 (\ llk"lluh, JUr.ltk~ t, ...h . . Ull': . "hll p..un b,ung. k....lfer th.m (l nk."Iflth, I' ... "hnll .. TIll' I".l ,unp\hti,,' Jdiniu,'II1.mJ I' Il\.l( ultmlJ.t l~ hdrful Ul ~'\."nt'llllg tht' u'kl "f pn-..bkm... It in dlm.:~:t1 pr..t..: x .\ lx"na lieti.mlll.."\{lt,l acuh.' pain lu ' , .ill Wlpl .\......utt ,
~t ~n'.."l1') f~dbJ('k h:~. . . p'.

~h.l' II.."lr:11 rt"P'"'fi-..e' ":

!'h~'l':ll

Cli~ical Presentation of Pain

C hrunil' pain I..':.ill ~ ddint"'d .1' ('('1"1't 'nt pam th.U bt~~ I.lnJ the ~'\r<.,"'I~J ume fr.ul1t.' t,"r II"u' h ".\I ·nf. hrtlfll(, p.lin kilt! ... 1I,df 1('1 boeh", ll"'r:.ll ,mJ. \.lr t,'I1\\.lll\. nJ.1 IIlIt."rpret.1twn, J.nd 1~ J mull1f..l,,·('ted pmt'tI(,Ill. I" ,tl " II' (.' If\.'.ltl\k'nl mu.;:t ,lddrt'" Ih~ "ld rJn~t~ ~... ( 1"\1 ' 11\\\.l"t"d: t'lttlk'lgiI."JI. p'~dllll"~K.ll. .mJ .. , ·I.d Rt.~,,,,~,\I\:'lk"f' ,,1'0 ddint' chnmil" pnin s~ ndrume ,t, J. ,ut'l,,,'l,lt ...-hn: 01(' p.lIn III \l hldl 't.~('''llhj.lf) ImrJJnnetlt' (£\.'tll JI';\l' • ,krn~"I ..'n ..m ..! Il'" ,... f ,elf-enk ~h.'~ t .1J l.."l "1f.ll\fi·a! I d~ ,fUlll..~lllln th.u I1lJ' ~ llUl l'f rnlpt."'nl(.ll1 11.'" ph' ' 1~111.",~1 ...• tinJIIl!:!' ~. II Idltc I 1m I' '\'11h;'" h.lt 1.1f a pUl..11 '. II dl. " I It h~, .1 ,tntl..'tUrt'l.l dctltHtll.l tl. Nil e'\t'" W C'\pIJUl th ..• 'J'I.' 'Irun, ' p.lIn "'\rlc:ri~n.. ' Ix.. t,\ t.."t.·n Ihc..~ .1Io"ute .U1J tht~ ,,' hnll\l,,' Su ..'Uf(." p.lIn I' .1lt,dui ..~.ltt·f.1.1t) fl1r p,lllt.'n{-.. "hll hJ.' ' ('lin ' '4\1(: \\ h.u \'H~(.·r Ih.m hl~,lhng tmw "1.'ull..l.1I.......I.'ltlll f,~r hut \\ .....~ p.lIn I' (1\'1 ,~, l~'l\~ .. t.ullhng th.lt 11 h.t, "..\\I, ..'\.I '1 'luti ...UlI !'x·h.l' l~lml .lIlt! ~lr ph~ "'I\"ll~'gl"-'ll .tlk·r.Ull.ll\, 111" ,11'~l 1.."111111.".111\ ",\'fut h'l th,tlngUl ,h tx·", '11 ... hn'tu, p.llll ,1Ih1 ,'1l!!1..' 1l\!! I."lr mlt..'nmltcnl ..l...'Ul(.· 1'..1111. I 'If (.',\.unp (.' l'.ltl1 t[\lIH '1\.'1.,1..' ldll..'n'I' l"lr 'plIl.ll tunWl' nt.l' l.,'t I,l( ~"r Ih.\I\ ('I Ilh 1nth .. , hll 11l.i\ twt h.l\\" lllh(.'r k,lIun" ,"It d n l~· p,lIn \\'\'. It .1~·lIll' p,lIn ....'1" Ie l..'.tIl \ ·...o.ur'ill 'nml h" t .11'.ttll.llt "1I1t.l 111'1\'1' 1..'1 d\nll1l ..'I 1111 ~'r\hnlnl, 1 In "Ud,,'n,,' 1111.' \,1 " '111.\11\'11 \'1 (h' .',·Ufl' ".;un I' " Ul' h IIld" hlu.ll, "lilt, '1~lHtl,,;U\th ..htkn'"nt th.:Ul III I \(1

~,

"lIh I',UII ll.lI\\~ Ilt'I"'\!'" ,t~ Ill' n 'I ~ ~I • t 'm J. \, 1~.lLl ·h.l\l\l ml .tnt! I'h"",I"·.,.ltll,,·unh, 1••\I .. h.; 1

Jnd pro, Ide 'l.ll11t' rt'lit'f fmlll plIO. PJ.ttent .. oti n are llll"'re able to \\ork .mJ o·un.:uon .It J higher It" el "ith .ill in('re~l.;:ed ~en~e I.lf ('I)n· trol ('\, er the paIn. pJtient" nu~ abo be more \\ illlTl~ III \\ ' on the p") ('ho.;('...:1.11 .bope(,h (If their It, e~ lh:1I IIUr.l(,l 'he- pJin e'\penence ~,

Surgical Pain l\lana.g ement Te'lhmque, .. uch J. ... rhllotonlle ...md ('ordolomH:~' h.ld pre\lOU'l~ been ~(ln"'ldered l.t'l-re'on tel'hnique, In m.\I1~ , ~'. the ,hon-Ienn n',ull'- \\ ere t''\I..~ellent. t'lut th(.~ II.'ng:tnn re,ulh "ere found to tx' JXx... r: the p.un found . . . tha tr.k:h llr neuron ... on "hldl 10 Ir,1\ el. and (he p.U1\ n'tunl"d lfter 'lriabl(' time pcnl..xb of 't" er.1\ n1l.lnth, to ~ (,J.f'.I' \

Pennan!."nt . .ymr.Hhe('tl.lm~ fllr .11l~ \.If th(.~ CRPS 111.1\ tie 'el') "UI.'I.."(' ... ,ful. l "U.ll1y, Illultlpk 'y mp,Hhl.'tll' l1("rh' bl(\(~, Jre (X'rhlOll('d lir-..t 10 d(,lcmllllC Ihe etk\.'II' (.'11('''' I..'t the bl('l(l.Jdc II the hhx:k rdR''''''' p.lIn but Ill(.' dur.itll..l1\ l'l ttl( rehef dl'lC''' Ollt IIKr('~\ .. " \\ Ilh .. e' (.~r.li I;lk~,. . k, ..1 pt.'nn.\· ntm ')mp.1thedllll1~ nllght Ix' ""r~ bcnt'til."i.ll. TIll" 1"I.'h· ntque I' mor(' 'UI.:(l'"tul III th(.· (.'.\rha .. I.t~(''' l'l Ihl~ d"lll dcr J l..(lmpJn:d III Ih(' 1.IICI ,I.l!!l"

\I

nul I IIlgtc- CI1I1I\. nnl ..·.111 II lx' dl·.ul, ~ .III,'g\lll \~d l\.HhuphuJlIh'g) H,lIhll. r.lln, ,I'- (.·,.ll\1.IIH'1\ .•md \1'-

~atnlC'nt ~ l11ullll.\1o: II,.~t It, .h.lUT.lIl'1~ n.lln.III.' .l1Id 11\.;11 age paUl. the ll11\I.. 1.I11 11111,1 .111\'1111'1 II' ~ ,11~·I.!.\ll1l(' 11ll' p.UI1 r'Pc'n hl(.' nn th h,hl' \,1 ~ll.!ns."~ IlIphHlh. md p.ltlt·nl ~dl

1'\'1'

lhl'" I

I \'11 "Ith t.'ilh'llh

~ .. quil

1'.111\ "I\'U~ \

1l1\' h~,I .. h' Ul, ..·'II~.ltl·lIh\ ,,'

....

,tau"

('IUIII1\" Ihl 1I\.11\'r "llkl 'II ..'.." I 1\\ • n. ,I 1'.111\

1'''.... '1l1,lIh 11\'

\J

u\ \ ,

Table 28.4 DitTl'rt,' utinting Acuh_' from (,hronil~ Pain ('hronic Pain Pilln IS a symptom Onset IS well defined Pathology IS Idenflflable. Signs of autonomic acllvlty Response to tlSSUO injury, Has biological functron Responds to pain treatment. Responds to medication, Associated With anxIety, Affecls Ihe Individual. Fits Ihe medical model.

Pain is 0 dIseuse, Onset is III dohnod Pathology is olt('11 unldontlf,able Nono or t1dapted dutonOllllc respons£? Responso to chango III norvous sysl('lm Unknown biologlcul function Less responsIve 10 pain trNltl1l0nl Loss responSive 10 modlcatron Assoclatod wltl, dopresslon Involves socrnl network Poor frt to modical modlll

Adapted from Wlltink H, and Michal T (ads) Pain Mllnllgemonl for PhysIc.,! Thtll"PIst~ ed 2 Heinemann, BasIon, 2002, p 5,

Tissu e of O rigin Puin can be categori zed as origin:HlIIg from one 01 three maJor !-Iructurcs: l11 u ~c ulo :-, "c l ew l . m'umpath1(.', ,md vis cera\. Mu"culoskcl elal pain ari "es trom lII.J lIl )" or illl tallOll of rascia. 111m,cle , hone, and/or joint slru c lll l'('S, II IS easil y locn illcd and thc lllosl ca"il y llnder:-,lmKi h) p ..ll le n l :lIld c lIn ic ian , LigHlllcnlous slrain s. I'1I Uo.;c!C Ic ar:-., and anh illie pam arc all examples 01 l11u ...culo··,I.',clcwl pam prohlem ... , Neuropa thi c pain i ... pai n trom Injury 1001' irrilatlon of Ihe ner vous sys lem, The puin i ... de:-'L' nhcd a... mOlc d lnu "L', and often c haractcriicd a... " buI"1llllg" lind " :ll:hing" pum Trigeminal neuropu lhy and diabel1l: nClllopalhy all: common examp les of Ihi 'i t y pe 01 pain , eRPS can be calcgori/cd :.I" a Iype 01 neuropalhlc p ll ll1 , CRPS is recent tenlllilology applied to whal was j11 l:v lou" ly "causalgia" and n'fk\\YIII/ualU'fir dv" ,mph,' (I?SI>J. A rece nt consensu" Mate11lcnl Is... ued by 'I he Nall oll :.11 In... lilute ... 01 I lcalth (N il I) call 'i C RPS a di ...c a"c olll1c eNS

called

Patient . . WIth CRPS ex hlbil changes in "OIlHltuscll ...ory, "'YI11 pathetic, and mot or sy... ICI1I " thai aJ"L' likel y rdal ed to changc'i III the C'NS. ' I here ..li e wi dc ... prcad el lcch 01 CRPS lIIc1udlllg allodyniu. "'lH.iOl11otOI· chan gc'i, poor Inohll conlrol , and p l oh 1ell1 ... w nh I11U"'C\c recrultmcnt. CR PS oll cn O( l'llr" a... a le sull of penpheral !n.luma , '111(: mCl hanl <., nl<.; 1I1ltlL'r ly lllg CRPS lind

II {'\I',I,

/hl' ~nlf"lill

mtllr fIIlIll.(A lilt' /1'IIIf'll (/r,W"1 IIlId grol\'l I/lIrllhll', af/d Ilrt' !de ( /In'f/l/I/'\ alll/"'/I , nfllf/a/f,r

It ...

\ 1 fht' f,am /m

(l1'/,il((/('(1/I

"1'('(/11/('\

ollrllw\ (/ 10(11.

III

II

/'t11l11n \

fll/d \lIl1f'1l11,~

laulillt.' (I/o 1II'III/Jel/''''. (/ h/I'lIrh III/II/lin

(I,

f'f (//1

I

/hl

II/I' 1/.'f! Ilf

ro,'1 rlit' lI'clld. f/rt' I"Ibllll/lll/\ I (II/Ie'''

h\ .,

/111/11111\' /'(/Ild, III r/it' ,hOI I. 01 rllf" fITr '" lI'f"AII/~ gil'I ',\ I'/.\(' to fll/ Illc /C'iI\(' fI/ I'll/II I V i"ll'tirl pil1ll ;III W" IHl1II 111 1111 \ PI 11111.1111111 III II111.'nJ.ll

1lIg,IIl S, Thi" pill 11 I ... (l ll l'n IITllallOl1 (I ('/a/I'd /,ell/r),

lea'"

qUill'

tll"I""1 1I 111111hl' "I ll' 0111''''111' a rOIl"'l' \jU l'lIlt', II I'" "lll'lI

:lilt!, ;,,,

h\ palll'lIi" 1'.1111

1I1Il'l ... tlllall\"'UII'" lind 11111:lhk hll\\cI ") I1t1lorm' ;II\, l'\,I111pk " \1 1 \'I"'U'I,II 1',1111 Vi ... t"l' l al pa1ll pallcII1" \llll'lI 111111llL 1I1l1"'l'lIlo"'~l'kl,11 1',1111 FOl Cl(l1111plt.. l-"dlll'Y dl WU ... l' olll'n 11Ial1r1I, ... I" (I" l'I\\l'l h,llk pa III , (I,dl hlmldl:1 (h"l'a"l' n ll1 1ll,lIl1k"'l II" ... \.11'111.11 1',1111 II I'" Il11 p{JlI,rnt 101 Illl' d1ll1l.'Hl11111 hl' LIIIII II;II \\ llh [l1l"I' \1' u· tid Icll'I"l'ill pilll1 paUl' l n" III IlJdl'I In lUll- 111 (II IIIII' IlllllUllI ll1u ... l·tll tlsh.ell'li, 1 ('\llIlllhllllll ... It I pall1.'~ In ~I'm'llIl, \'I'rl'I;.1 p :1I1I W IIII1\l1 Lh ill1!!l' 111 1\..·" j1011"1..· 10 pnl\lIl';.\lttll1ll..· ... 1... ot 11K IIJl1 "l lll n,, ~d c I .rI :Jll',lllll'lL'r" ltl, \'1"'l"l"l.11 l'il1l1 11111,,1lx' wlnl out. Jill l'X; lIlIPIi..'. 111 :1 "alll'll l ,\-'lliN' 111\\ h.ldl. 1'.1111 ,h'l'~ nt1[ l irangl' 1/1 Il'''pon'''l' 10 j1alp,l1HII1, "q'llll·I1IIL· ... llII~, 01 pl1\"'IP h'!.lXIII 1110VCl11L' llt I{l'Il'lI;rI 10 a p lr)<"Kran 1111 (h,'~IIP"IIt Ul1lkl ... tOOt!

/111111

Il· ... lm!! III .... I...l· ... hh.l' IIIL'''l' j" l· ..... l·llllal

cxprc . . . . lon arc 1101 ye t k nown, It I'" lIkely Ih:11 al!l'tal I01l'"

oculr III thc 11Il1l1llllC sy ... telll, Ihe eNS (",p ll1 al (."()I'(.I alld hi .her Imun slrutlU rc ... ), :lI1d Ihc inl eg ralloll ot 1I1\1111plc llCI"V, Ol~'" ...y. . telll Inpul ...... ' Thl ... cOl1lple x dl sonlc l ,1m" lll'l'l1 rl'lo~

lor mOil.! Ih;'111 a l'CJ1 l lllY 1)1 Wl' lI MlltilL'II. .1ph y"'ll"llIl l dUring Ihe ArncrH:tt n C i v il Wm, dOl'UI1lt! l1l etl h ~'i (:h;. .CIva l 1011'"

nl/ed

of ...old ll·'<';

"'Ufll'l"l ll J!

from w hal we now til l! ( RI S

I f', 1I1(('n\ll\, 1'(11//'1 /llitII

I f(l/III('11 f

\Ifill' (/

"/('/1(If/l'II/I\,/'"

rllf'

11/(1\1 (1/1'/0/

h/llll/ll~

f O f/

/ • 1/1(1 '\/11/' , rl fhl' ((II /.\ 111"0/(/1"(1 h\

a

('(1/ 1'

,,-hit h

,\1'1'11/\

alH/lld IImlli/m/

Iii 'hod ( (1 \1'\ 1.1'('1,1111' lilllld (,(II/\lrll/II\' 1\1", !ll/rllI/X

I ,f'lII"/I /1/

fJ

J

IIII' 11/(l1\f/l1(' flllh('1 f 1(//1 /II

/', II

((/(1

/111'11,4 ,hi'

Mind- Body

J)u"li~rn

S lr al") Ill!! palll'l1l'"

hy .IUIII)" .lIIt 1/III I1) 1I

"lit

' III Pllflll I

" II I'" 1,IIl' Inr olliv pilll 11 1 Iltl' tl lill!IHI ... ltL p,nH' ," I II pl"lllll , . pi 1~11 ~ 1"'.. 111.'111 '" 10 Pll'''t:1I1 Wl lh
~,K'~' l"h~' ph!,' . .·~\l rh""rapht tn.·.l(Ul~ d\~' ,,·hrvlH...· p.UIl ~'lrU· t.tU .. lt1 11lU'{ h.'ml~·r hl ' \....r

h...·r (\.·nd\'u..,: (\l U','...• '[1\1.:1 tu\.·r,lf ,'h,\.·,tl \It,t~lhohU,' ...·nt.·ri.t hlf Id~'lUlt: tn~ tt',u,' p.utl\)h'~:. ,u,'h ,I' h\'nu.Hl,\i loll,\.' llr 'pm,1I 't~lh"'b. ,\11\1 k~.)k ml.)l\' ~!\\'Idl: ,It ,utl:"'nng .m,1 d:,fulh:U\'Il, In .1,·Uh· p..Htl \If mu"...·ull)"~\;·ktal i.lrigm \I.',g., ,U\ ,mkk <~r.Hn). '1~11' ~:-\\odhn~. Rl)\1 hmir,Hl\)U::-. jl.lllH 1.·.lp"uk n:::h11h:-...' \\ illl.·ll.h\,'I.! IllIlT\lf ': mph.llll' \j1~un. SEllIll..."'_ lilt' ';:'UI(\ \\.\t\.lIl~) ,U1J I.l~"'·f\\·d ph:,!...·. ll t'utl...'ti~)Il. rhc IIh)\\.' ".~ \'W,' ,\ I'I1)pkm I'.

(h. .• k~~

tht:'ft· l~ tx'(\\,,'\.·1\ <..:::n', ': t11Jl{\lm::-, .Uld flUh'(h.lll. nl. .·l\.' ,nt' both ph: ,i~'ll'gll.\\1 .m,i . .\x.·t\. . I~)gt . .·.ll rt'.\>:\lll ' fllf till:- TIt...' Lt . .·( th.lt th...' "'PH\\wlh.·ul\)dul.uHK fr..t ...·( i~ .h:tt\ . .' 1I1 l..'ht\.lHh.· pain .md ha~ rh.. h .:\.Wh.'\.·ItI.)Il";- \\ tth rh...• hm~I\' ::-: "tt'm k·.lds fl.) til\.' atfc\"H\ " ,.'\ltH,"lho·nt l,f r.uo. SO~'t,ll ~md I.'llhuml f.h.'ro. III p.llU ::'dl.l\ hlf ,u\~l l'\:'m(\l1\.'t'tllt.·m k.\d [\1 \:h.u1.g'·.s Ul ~df-lln,I~'· ,Uld rh,' tx·n:'\,·PU\lll \'f mt·.uun~ \)f p,lin. Bi~lp.s:\.·tn,lS(l\.·i;tl 'll...\.k+, d\l .J ~'na J~lb of ,1,"\.'\lUtHlIlg fl~f a full r.tnge llf I"t..... P\lIl"o;,· .. [\) p.lin [h~m dl) the llh',h..:.t1 mr~h:.·l.s,:'I:'''~ In (J't'.IOlh·(1[ \:.If p~lin. H nM~ lx' u~"t't\ll t"\x tilt.· dink·I.Ul ttl :\I\l~ ,It d1;;·~n.'\' l,lf \.'\m~',xd~Uh..'t' '.s di\ ,'['&0;,'11...'0;,' ,mh)ng. sign~. ... ~ mp{Otlh. ,md fun("tl . .)n. In . .'aM·'::; \\ h,·R' thl:"'n.· i~ high \.·on~\'"l{\lUl\."'t.'. lI11r'.unu,'lU- ,\s...'i.i [Tt·.\[nh..'nr~ \\ ill lik.t'1: bt· 11ll1ft· ,H,\.'t·~... iuL In \.'~l~::- \\ht.·("t· thl:·rt, I!' hl&h dl\erg,·n\.'t· ..1 fun...·~ n\'(" ,Ill: t\.l::-ni ,Irrn.xl,."'h 111.1: N' nll.'ft· ,1PPl\lpri,Ut:' tFig, 2~.··n, T.lilt..- ':~.5 rn'~'IH':': ~l \'\lmpariS\lH of the-- ph:Sh:.\1 (ht'rJr~ \·\.U 1111.Ulllll tin,jHl~~ tn'l1l [\\\) p..Hle'nts \\ Ith ;.lnb.k io..1Urlt' .. The tindings \,If: gR'.HI: dt"'pt.'nding lHl \\hl·ther 1.·01"·\. . n.1.U1..Y

r..Hh"'m rn'~o;,'ms \\ Hh .I\.·lltt' \ \'("$11:-- du\'ni\.· IllJUI:. In th,' .1.:UfI:' p.1in o;,'\,Hupk. (hat' I"S hi~h \'\It\\.'oru,lm:o;,' .unllng .... ~ mrtom~ tr,UK'm . .·. .,mpl.unt$)., si~ns It;·\..lOlllUtlllll llk'

findmg ... , .Ul...t full ...·ril..... n. Tn',ltllho'IH ,llilled r(l\\ ,lfd ,1111t·[il.1rJung tht' ph: ~I ...·,ll tindin~' ha::- .1 high pn)b,lbilu: llf ~u . .·\~" \\uh Ih,' p.. ntt'!U·-!> ,·\t·I\tU,l[ n'HlIll (u fUl1l'ri\ll1. In tht' .:hn)nit' r.Hn t',.Hurk. th\.'n· I' ,1 high dl\t'rg'·(\I."'t· ,mlOng '~mrt\ll1b. ·qgn~. ~Uht fml\.·tioll, \\ nh titl' P:Hlt·tH'~ n'p-l.1rt llr t'UIl\.'lwn .m...! \,·\lmpl.unt::- ,lpr.m... ntl~ \lut of pfOr~.lflll)(\ [0

ISymptom I

ph~ '1 . . ',11 nHdln~' H~

Ul (hi'

High Concordance

Figure 28.4 Rd In ~ t\n:I(\I~ ('J.1Il

High Dlvergonce

1\ l ... f Ip nm'Il' , "I\'. ,\l1lph ' I1I'"

,11l~IIUI\\ Ihlll

I"ha\.' .IPpt" ..u, hl ~. 't~OItl..:,ml Jh,\bll Ph: 'K.llrht'r.lp' tn.·.Htnl'm t\ u . . cd t"nl \10

unp.urnh.'Ub I" unh"d~

.ml.!

t\l

k,1J 1\) n· ... I..)IUlh.ll1

\It "mr1\'T1\ ....

f\.'tUn\ 1\) hUh:tt\lH.

Pain .M easurement P,lin l' .\ pun'l: ,uoJt:"i.·li\ t" rho;,'lll11llt'non. L nhk.e RO\1 Slft'ugth, \1r li"sul:;' t'\,t~n~lbillt:. p..un h,l' m.l ,l. .·\.'umk Of .. pt" \."itit· tn~,ISUft'mt'nt tOI.1L Ho\\ ," ~f, tht:' m.:.bun·m...·nt or (Xun h~l::; tx' ...'l1I1lt· ,1 ,ual pan ("If p;'ltknt e\,unimmon. The J01m Cnmmls . . lnn on~\c\.'rt'\liution l)f Ht:';.\lth\.·,tre Orgiillll.mon . . tJC.-\HO)"'" h,l::' t'mphJsizt'd th· im(>\"'mUl~""e' of (>-;\1n ,md p~lin tn.-.ltl11..·nt D: suggesting. Ih~\t p.. nn ~ reNgnl?t'J ..h '~(hC' tifth \ ital ~ign" in he,llth \'.\ft' ~~uing.' P;'lin rnt.",\.suremt~nt llllO\.\ ~ the lh('r-..lpi~t 1\1 ~~(.\bli'h Iht:' b~lS't'hlh' Ie\ ('1 vf a p~ltit"'n1':$ pnin i.Uld dctt'nninc- if th~ inh.'r\1:... ntiOI1~ hu\t' altrred fhi' P,llll in a ~ignitkt\fl( \\~l) . ThCFt· ,lIT' ll\Ullipl' w\. . b in u:-<;t:' to e\~Ulline p.lin. Some- of Ihe \"01111111..101) u~ed h.lols indude tht' \ ,st.,11 ,'·hl.lIVf!lIt· Snl/t"

1\ -\S t/""I<.h di .. ,grtU'IS. llo.lin qClfsliot:lhlirrs. tmdjimclwn.I/

imp.. ,in It·1I1 IIt\dlh-fYll.i.fed ,/u~,lil\' l{ lift- mt'tlSUIY) Tht.·re j,lft· ad, :U1[,lg('S ,uhi dh~.1th antug.o;,·, of t"at:'h t)-pt' of 1(""-)1. 1

Choosing .1 ((>01 d('(>ends, in P~\rt, on [ht'" I~ pc of ~-('tting tn \\ hid\ rht' diniLHUl is prn~rking .m~l the ;.ml0um of (imt.' a\ .lilut"lk fOf puin m{"l$Uremt"tlr.:'-.l

Visual Analogue Scale Th;;:'" \ :-\S is Dllt'\.lftht' most lx1Si,'" (\'\In mi..\"Suremt~nt h.x"b. It l"'\.lnsi$[~ III ,I 10 l"'t·mlmt:'It.'f lini.·. ootltllkd D\ tcmlln.u ~UldlO~. Fkn~·.uh th\.· andlon. ,m:'" \\ rilh:"'U l·U('$ tt:'~g .. (\,\in.b h.I . .t "$ it ~"\.)lllll t~·, no pain m allt Rt:x.m.·h on 'he' Y.~\: h.b ~lIO\\ n il Il' tlt' ,\ IHL1t\'" rdbhk £\0'1)1 \\ ht.·n (he lin.t" It..~~ Ih"\l h,\\~' mUllanl marl.lll&~ llll it .md Illt' p<..uknt is .\111."1\\ t"'\.1 ttl nurl... tht:' 1m?" lx'tali\ I.' II.) th,'" intt'n~lt~ l)1' till.' p;.\in. Th.... I.'lilll~ d.Ul \.',\11 11k'.l$Un· tht'" rLk't' nn rht' hnl.· \uhl \'(ll\\eo it 1llhl.l ~\' ...'rt' l~t\\t.'t·n ll,Uld ill, \\hen' 0 i .. l\\l p,~in ,It .tll.md 10 I' p,lIn ,I' holJ ,l~ it \'\luld~' 111t' \ .\ ..:' t!-, \\ ld.:'l~ lI$\."i.i :"\.'.Hl',,' it \. . t"'-'II: ,ldll\ttH"St~·rt'\i and I'-',.tuin',::- link t\" n\.' lnllllll\g l'r t'qlltpm~·nt. I kl\\. t'\l'r. it h;\~ :::.Y' \T.1I hlllltll\\lHS in dn\t. ."tI lh't·. R(,\.\HI~ ...• p.UI1 I~ "ubj('. .·tth'. tiN' din"t·I\·\h"\:.· ~·t\\ t't'n ,\ 'l'\ln' llt 1 .uhi 3 I' l\l11 nt'i.'t·:o.;~,lril~ tht' ,,\I\ll' .\' tilt· lMl~'l\'1 :\.' t'\t·t\\~·l·11 .1 '\'\)1\' \)1" ~ .Uld 10. I..'\t.'1\ tlh)u~h tll>.' Ilf,'n.11 tx't\\t't'1l thl..' IHlllllx'f' "thL' :-...lUlt.' n\,'n.~h)n.', It b I"h."\{ ,\ \,1I •...t U'l' \If

FuncttOI\

\0,1",'

thl'

'\'.11t- III ",\\

th,H

.1 p~IO\ ...·Ul.U

p..ltl<.·nt

\\ h\ ""~

\ \:'\

"",'\'n:'d dnlPl '\1 fn)11l 10 h\ :' h.b \.·\.l '1"1...'1\,"\.,\1 .l .'ll "'I\"\.'ut n,'~ltl~'{hln 11\ hi" t)llh'l p.HII. It I' hk-t.·h (h.lt th,' 'll\',..'llh.1 \;"'.",.(fi. \I'U '1;\lIh 11"/ ~l( p... UI\, but \h' ~'.\I\I"\l \kko\lUh' tlk' l'\t'i\.'\'nllll' \bm~ \ \S '\'\11"\" \ ,.UHPi...' \ \~ h f'n', ..'Ilt."I.t 11\ \Pl','ndl\ \ rh\.· I \CT.:\ ,\o.lk \l-t~ "\~ ' l I' .m ,kLtpl.ltl\'41 \\1,1 \ b\l.\1.1I\,111'~u\· , ..'.Ik' h'l dul\h 'n

Table 28.5 Hri"f (';1''1 '-' F'\.ll mplc: eel Examination 1).lI.

\nlte.-

SocIal Illstory

\ CllC ,,' \ .\. (,Ilronic Pnill

'''in

( 'hronjc Puin

38-year-old marned mon, monager at

o major corporation HIstory of presont Illness

3 weeks status postsurgical repel! of ngl1t Achilles tendon complete rupture. sustained plaYing softball on the company team

38-year-old married man. last worked 1 year ago as manager at a major corporallon 1 year ago. history of R Achilles complete rupture at company softball game; successful Sur. gical repair 1 day post~lnJury; patient reports cast was fabricated too tightly and caused "nerve damage;" he has active litigation agaInst the community hospital where he was treated; 116 repor1s that physical therapy (exercise and gait training) In the past made him worse; refernng physiCian has cleared him for full weightbearrng .

Chief complaint

R LE pain at rest. difficulty walking

Severe pain, unable to walk , unable to work. spends most of the day on the sofa at home.

Patient's goals

Full funcllon without ankle pam, independent ambulatlon without crutches. return to softball

"Get rid of this pam." "Have a normal life."

At rest: 2110; when ambulating: 7/10

At rest: 8/10; when ambulating 10+/ 10

Significant limitations of AROM R ankle PF: 5°-45°;

Patient is unwilling to move ankle owing to pain.

Pain measured on 10 cm VAS

a

Range of motion (ROM)

INV: 0-5·; EV: 0-5·

---

JOint mobility

Limited calcaneal mobility

Unable to test due to pain.

Obse rvation/palpa tion

Adherent surgical scar, moderate swelling Rankle

Well-healed scar; smooth. hairless limb; signtfi~ cant atrophy throughout R LE: mild swelling R ankle/calf; unable to palpate R LE due to complaints of pain .

Galt

Independent PWB w/axillary crutches. cast boot

Independent NWB w/axillary crutches. cast boot; patient unwilling to attempt weightbearing RLE due to pain

--'------

lower extremity; AROM = active range of motion; EV = eversion; INV Inversion: LE partial weightbearing: R = right ; NW8 non-welghtbear[ng; PF plentarllexion; PWB VAS visual analogue scale.

Body Diagrams (Fig. 18.6) con~isl of a line tlm\\ ing of (he figure, gt.'nerally frOJ1\, bad.. and side Yi~\\~, with 11 key l'onsl~ting of s)'l11hol!-. ror diffcJ"t.'l1t kinds of pnin. Thtt

BlWY

dl&.lgr~lm:;

hurn~1n

pali~nl is instnlclcd to mark. lht! bod) diagram using (he symbols to represent the locmion of his or her pain, 1l1t'~e are ~ome\\ hal more timt: consuming to adminiMer..md requires p:uient instruction in hO\\ 10 complete the di;\g.r::lI11. The data ohtained from boo) diagrams is more dillicult III

5 3 2 Hurts Hur1s Hurts Hur1S Hurls Whole Lot Worst Even Mort,) LIttle More LIllie 811 Figure 28.5 ",\('I·S (hom \\\lIl~ . 1)1 . l't ,II \\"Il g'~ h~l·tltl.lh pI Pc~lmlrk N1l1"o1ll!!-. l'.! tI (\hl~h~. SI t IHII\.10tll . p 1"\01. ,,1111 pl'rnll'~mll)

o

No Hurt

( h;Iph"

fronC

Sth.'\\

" t\\ P.\111

Left

~

p,lln IS

112'1

( IIIHni, P;lil1

RIght

Dock

l'" tIl(l l",,-1\

\\h(l~ \~'\JI

1M

'J

,

\ \ \

~u(,!lIIlg

Numbness OOc.hl TI11911n9

, R

Figure 28.6

ll~JI.'CIJ\cl) ~Uli1I)IC

L

L

)

R

nnd~ dl;l ~ r'lIll 1(\(1\

than thai ()hl~lInl'd frol11 \AS (Ir olhcr

p.:un too].. , Oh"cr\ l'l hl~I" ha" l1\:cII "ho\\ II to IIlI1UCI1CC anal)

bod) lh.lgrallll..!;H;If>1 Bod) olagri.lI11" ha\c hcel1 "ho\\ II to ha\ t' good Il'h.1 hIlI!) III Pi.lIICllI' \\ IIh P:IIII .I>·",,1 f\1:ugoh' et all11ca"lIlcd te~t-rl'te: . . t rcJiilhilll ) 111 51 Pi.ltlCllh \\ltll C hrol1ll' l' ~lIl1 B\ld) dIagram", \\ erc "c(llcd fOI pcn.::Clllagc hod) ~Irca In pall1 111 add1l101l 10 p.l111 IOC:111011 The l111cn~iI tx'\\\CC!l hod~ dl.lgral11 tc, llll g ,\\ cr;lgcd 7 1 d;I)' . Till' 'I" of

or

;1\llho1'''' found ~I Ic",t - rete,t rcllablltt)

coclltl.:lcnt of

0 .85 (0\ rite: (h'lgri.lIll' C;.I1l l1\: "",cored" .1' orgdl/lC (11\ 1'0111'llnl.UK"C \\\lh ,1\\;.\10111IC;11 P;IIICnt'" of p.UI\) I..lr f/(mO(l!dll/c · (not 11\ ;\cconllllcc \\ IIh anatomical p,Hl1'111" 1..11 paUl) ("1.'(' Fig .... 2~ "' ;\IId 2:t~n, Thcr~ I'" "Ollie e\ Id~lICI.' of a com: I,1I101l l~I\\('('n ll~mllJ"g;lIli c lxxl~ dl,lgrum" \\ lilt P') d\(Ilogic~\1 lh,tl"l."" ~Uld (10~l]' \lUlcnme.f'.l 110\\ 1.'\1.'1". llther ,tuuil"'''' ha\c ,11l\\\1I little Ilrc\l lc tl\l' \:\Iul.' hl.'t\\el"'11

Back

Front

~l1"gan\C

;md 11l1ll(lrgall11' h()d\

Right

j

, \\

'<.'I

!

~

L

H

Len

)\

Iit'

11 '\0

PhHical Rehabilitation Front

X· XX

Back

Lefl

RighI

~XX

xx

Figure :::!8 8 '(mdcm1.,:( ul r·lln (411h 1 I \..,11 I ~ ct ;1 n(lll.\Il.II<. mil l{'lldcrnl,II()I'J',.11

l'·llIt'm {'I "( II fi.'I"t'lh ,I '" 1m'll .. !'.un TIlC I ,ll1<.'m ." {I '!l"lnhul ('1ft 01 1',1111 (t('k~' ()l" 1t,1I(,\\ IhC' )

.1II.1I('1Il1, .11 (h'lnNIIII\t1

R

L

L

R

Ltk.<.'

Ihe J\tPQ. tIW'L' Ilk',\'.,Ul'<.', C.Ul .II,,) Iw fllltllr.llI)

l1l:1ppmrn.Hc. p.l1flclIl.lrh If Ilw\ .l~}... .1

or her .Ihllll) 10 fl<.'l fC..1nll

Ih<.'

language ~l pnticllI l1~es 10 descnbe p:lin. The nll)!\1 \\ ell researc hed 1001of Ihb Iypc i. . [he McGill Pam QW. )SflOIllltlll'1 ' (MPQ J. It consist,:., tJlf'eC portion ... ; ;1 lxKl) (hagr.lm. :1 pam inlcn~IIY r:lI ing. :l ncl ~1 ( i~ 1 of \\larch :\ p:lIlt.~n l I. . ;hJ...ed Itl

or

describi ng hb or her pain.

II l!\ k~nglhl('l'

dun

cl dlcr Ihe VAS or n body di:lgr:ull nlone. and II flU) be cui fo r pat i c n [~

who I11flY no!

h a~

been

I!tCnlllll't'. \\1111 diver...c POpu lHllon ... Jnd di:lgnlbcsr>)l I and relinCI11Cllh of Ihc 1001 nrc ongoing. "T.'·1l Ap[1(!lld l)" B PJ'C ...CllL... Il\e \\OI"d cholet'''' ll:-.cd C)" IClblVclj ill

the pmient is ;hked [0 u,c in

Ihe

:Ill rhe

und<.'r:-. [:11ld

Or :-.OI11C of the vocabu lary u..,cu 10 descnbe Ihe P;1I1l

MPQ

!"HI<.'11I Ie' l.t!l'

hI'

th.1! \\ 11111d nnt IX't'uhurJlh TII<.'''' 1\ lX', nf mt'."'I1I",

C:\11 ,11-.0 lx' time.' {Yllhllml1l~ It, .ldl1l111h!<.·1 ,md 10 'l'tlf'( .h

Pain que~ t ionna i rc~ seek to cX:1111ine 11:1111 through

IUmlly mapproprialc

LhJ... ...

Jppn)prUll'. rC~.Hdl(', ... ().- p.lIn

Pain Questionnaires

from in

let,

n(hL't......1

(\I1I,)(lc til!.' u\nhn<', (\1 Ihi;" r.-"h

diagrams, physical findlll~~. and Irealn11!1lI outCOI11C . . in chronic back p:1in.b.41

choo"c

t"

III Ih<.' ["k.'lll'hl;'(' 1'.11I1!_

dc~ 'l"ihlll,!!.

polill

Ill s Of 11('1' Plllll ,

comp;II'(~d

,\ 1111 tht' V\S

Ph),sical Therap) Fxaminatioll rhe ph} 'It' .11 (ht'r;lp~ <.' \ .\111111.11 hlJ I I'll" Idc." I<)

.111 t'I'I'IH fUll II \

L)bl.lIll nh.l<"Cllh' '1}!lh ,md hI :ldllllllhlc.'1 .IPI'1l11'11.ill'

It' ... "" ,llld

I1\l'.I\III'(', 11.11,<.) (HC)\

Idl"

.\11 (11'1'('"01l1I\ W hlille!

rnpport c.~ ...... ('nll.11 Il)1 .1 l'
rht~l'(, ,Ill' ... C\l'LIl L1CItU, Ih,1I l1uJ...t' Il\t' l'\.lI)iIl\.ilH11l ,11 ('hrnlllC p.1I1l Illnrl' ch.IIIL'Il~1I1).! Ih.11\ .I Clllt' p.WI .)C.'Cl)II(1.11\

dJ!\fUllL' lh1n dll<.' III dl'lhl.'. It\\1 .1\ {Ud.lIll'(', dll.1I dl.I:'l1ll .. I'.

;lI11l/nr

[l.hl [1l.'.l1lllt'lll 1.111111<.' ... \';111 ··lIllldd\ thl' \\,Ilt'I'" III

1I11L~rpll'lill!l[h(' 1<.' ,Ulh \11 .111 t'\.IIlIlIl.ltUlll

Functional Impairment/ Health-Relate d Quality of Life Measures Thc,~ rnen ... un,"!", :t il t!1ll pI 10 e\lll11inc 1I1IP:ll'1 01 ]1:1111 Ull .1

(.!tilly Ilk I"II lhel th.m Illc.l"uring tilL-' pam II'\L'II They ;Irc ..,cl l fCPOJll0oi'i; lilt..' pmien l l'" 'ihm\11 II It" nj !ll' [I\ IIll· ... along wlIll a l:OIn:'ipoJldlJl~ I lJ...crt SL':J1l' rill' P:III(,01 I... u... kt'd 10 111:lrk the dl!Il":c tn which Pdll1lll1l'IIt.'IC\ 01
The

S ul~ie c li "e

Inl e n ie w

J'ilt.' ,uhl<.'l'[I\t' 1111l'1\1l'\\ dfkl' .111 "PPlllltltll[\ h' I'\{';llll h\

dt'\ c'I()p ,I Jllhlll\(.· lh(·Llpl·IlII~·

h'l.ilH1Ihi1IP \\ IIIi 11l<.' p.1I1l'lll

P:ltlCllh \\ Ill! l'IlIt11lll· JlHII1 ,)'It'll ])1<.,,('111 ,,1111 hl"hllt~'''' \ll 1l1l1111\1k 11<.'.111111.-'111 I.ldull'" ,lI1d .1I1<.'lld.lIl1 .111\1('[\ .Hld 1111' pnlc llfl.tllm ('\Plt'''"lnll \)1 .111~~'1 \1' 1111 ... 1111'[ II 1lit'LlPI,1

11Il'LlIlr U•I!-ll' u... t'., In ;hld!l''-' Illl' 1'.111t.'1I1 <.'1111 Iwlp 1II;II.. l' [iii'

111 ... 1 1I11CI.ILiIOII.1 pthlllH' ,\11<.' t'nlllp(llll'llh 1~llht' ,1111,('( (1\1<..' Illll' I \IL'\\ .111' 1\,ll-'lIldll·tllll I.lhll'

L'lkl't1\l' IIltl'l\ It'\\ "til IIICt)lptll.lll' .1 1,.'(lIl1bJlI.IIII I11 opell l'lldt.'d ,I lid Chht'd ('Ilded Ijllt·,lltHI", Opt'li L'lIdt'd All

nl

2N,{)

(,haph.~r 2R ( 'hruni,,' P~,jn

Table 28.6 C01llpOnCnlS ~ Component

11.l J

of the Subjcclh ~ Intcn ic\\

Guidi,.. Qu-tion( ) _~_ _ _ _ _ _ _-'--'-_-'="==-

Chief complaint

Tell me about your problem

~Iode and time of onset

When did Ihe pam problem start? How did It start?

History of treatmen t since onset

When did you flfst seek treatment for your problem? Who did you see? What happened then?

History of progression since onset

Over the past 6 months, has your problem gotten better, worse, or stayed the same?

- - ----

Pain • Location • Intensity

• Pattern • DeSCription

Where is your pam? How strong is your pain? Can you rate II on this pain scale? [ms truct patient in use of VAS or other pain measurement device] What makes the pam better? What makes the pain worse? Show me where your pain is.

Patient's general health

Have you gained or lost weight recently? Has your appelIle changed? How are you sleepmg?

Current medication list

What medications or supplements do you take? Do you take any medicatIOns or supplements not related to your pain?

Current functional limitations

What can't you do because of the pain?

OpportUnity to add Information

Is there anythmg we haven't discussed that might be important to your problem?

Establish goals and ways to measure improvement

How will you know you're better? What will you be able to do when you're better? What do you want to be able to do better a month from now that you 're unable to do now?

VAS

VIsual analogue scale.

que"1I0n,, are que ... tion~ that cannot be il.n~\\ ered with a

partial e\arnple of a subjective inten'ie\\ can be found in

"~e"'"

Table

or "no" re ... pon~e. but require Oi.UTati\'e e\.planation ....

For e\ample. "n 'hlll happened OIl [he day of your ace;· JOIl ," or "U h')' are you /u.'I'l"" Open·ended question" encourage di ...cJo ... ure. The\ can be used to clarify re~pon~es orha\e the patient elabora'te on a pre\'ious answer, The~ are

gOOd "'Laning place for an~ in ter\'ie\\. Cln"ed·ended que..,tion ... are u ... ed \\ hen the de"lred re . . pon-.e i ...... uccinct. ... uch a ... "\e~." "no," "al\\ay"':' "somelime :. or '·ne\er." For c\.3.mpl~, " N OH' IIllllly surgeries han' \ 'u had .• or "D,d \0/1 11,1\ l~ a /u'iioll."· are example ... of clO\ed--ended 4 ul.: ... l1on .... The du ...ed--ended qut: ... tion ... allo\\ the Ukrapi ...t to control the I1m\ of infomlallon. The~ Jre USed to naow"," dov. n or c1arih a narral1\C re ... p<.lO ... e, The~ lire also helptul In lo~,;u"'lJ1!! ~d rediredmg an afl\IOU'" or tTl\. taJ lI"e palll'nt. 1he talk.ul\C patient Yo III require more ..,lIllLture (cln"'l'd· tnded que~lOm,) 10 an Inh:n lev. ll1C rellcent pallent \\ III Iletd to ~ drJVr. n out Vr. Ith th~ use of o~n-ended 4UI.:'llOrt' ~hernatmg bc:t\\een lh c IHl<:S ot quc ... llons \\ III help tnsure a thornugh. organll d. 1Ild aCl.:ur.tl~ wtCT\ le\'\. \

:1

~8_7_

There i!:l no substitme for a thorough patient inten ie\\ During J face-to-face con\'ersation, the therapist can 3",k [ollow·up questions, take the inteniev. 111 a different direction, ob...ene pain behm'ior and affect. and e!:ltabh ... h the panner... hip that is es..,emial to the therapeutic proce~,. An imcr\ le\\ takes time. particularl) for the patient \\ nh chronK pain \\ hose hi..,tol') rna) include decade ... of If'C'atl11t!nt,

Tests and Measurements Thc IIlfonnalJon obtained during the "'uPJe,,:li\e mten It'\\ and the ph) ... ical lherapi ... t·... 1001lai ob,en al ton of the J.',UI~nt \\ ill guidl.: the therapi ... t III Ihe ... eledlon of the nhhl appropni.lll' te,"" and l11eihUTt.' ... , Tht" h"' ... ",, .lnd 111t:3 ... llrt:· ... u't:'J for p.IIICI1"" '" IIh chrolllL' pam an: not llltkn:11I1hJIl ththl,' u . . ed 111 .111) ph~ ... Kill tht.'r;Jp~ t"\;1I11In,lIlon Cen.ull ('kille-nl'> ut Ihe ph\ 'h,:al e\.UllIn.IIWn '" III lx- appl\lptt.lh,,' 111 nt.'.:tr'\ II 1'..Ilh,,'I1(-. \\ IIh ,:hronlL r.1111 \ 1t.,1 . . 'gn I\'fre\ IOfl1!TII\. §C'h\lf) Intt.·!!nt~. pthturl' RO\1. mu,d&: (,,(,rtonnanlt

Table 28,7 A Parlial Exnml.le of n Subjective Interview

PIa,. . . nerapiac (apeD and cIoeecI-ended questions) --~-

Tell me why you are here (open) How did the pain start? (open)

Patient Response I have neck pam and headaches. I was rear ended at years ago.

a

stop fight by

a

newspaper truck 4

Were you able to walk away Irom the accident on your own? (closed)

Yes , but I was dizzy and my neck hurt fight away.

So what happened after that? (open)

They look me to the hospital and took x-rays. They said nothing was broken so they sent me home with pam killers,

What tests did you have? (open)

More X-rays and an MRI

We re yo u able to go back to wo rk? (closed)

No, are you klddlng?1 I couldn " even Sit 5 minutes and when I try to use a computer, my head lust throbs and my arms go numb.

What do you hope to achieve working with me? (open)

The pam pills don't really work and I don't know what else to try My doclor laid me to try phYSical therapy again.

Starting with the time you wake up, what do you do in a typical day? (open)

I get up before 5 and can't get back to sleep, I usually gel out of bed so I don't wake my husband, I take B hot ba th. Then I lie down on the sofa In the IIvmg room.

Are there th ings that yo u are unable to do because 01 pain that you would like to be abl e to do? (open)

I wish I could use a computer or go out to dmner and 8 movie with my llUsband

How will you know you are better? (open)

L

I don't know, maybe I could Sit through a movIe WI/hout

pain.

Note: Questions are abstracted from a thorough interview and are presented here prrmanly 10 Illustrate the differences between open and closed ended questions With sample responses

and gai l. O lher elc mc nl !oo o f the ph y~ica l exa m i nat ion w ill be diagno:-. i s spec ific o r :-.pec tfi t: 10 parli cular pal k ilt c()mp l a i nt~, Some of th c!ooc Jllc1 udc ( hul arc nol limit cd to) examina ti on o f aerobic ca pa<.: lI y. IUl1 tlJOn: d ... ki ll .... circula lloll. body m cc h a lli c~. j0 11l1 l1loblllty and 11 1010 1 con tro l , o rthot ic d cv ice!oo, and wo r k/l u ll t.: IIOJ1 i1 1 II l t q..! I H lion, The~e exam inations w ill g i ve the Ihcra p ... 11I ba'r.: lt nc measure of sign .... ~yll1plom\. ;'I nc! l unC:llol1:iI ,d1Ilil y. a~ well at., a determ lnallOn 0 1 Ihe lIecd lor orr ilfll It or a.. ~'" live deVice, and the ahlii ty 10 rei 1I 111 to W01k (W(Jf' ~ pl :ru: evaJwllioll), '"f able 2~,H Illustra ll's l'X;llll p ll'S 01 sl.· lnll'd cxamU1fI!JOIi tcchnlCllIl'.., illid I Ill' II j{'lilllIllI,IrJp 10 tllIllIlIl fW1r1

f rnd rnV'" ,

bWJ1l1nall l JII IIIJ(IJII~' IIwy Ix- 11(1111111 1 III till' pul ll'ln" 01 IgII find ylflpltJJI1'o IIIi1Y IX' lIJ1llfilliu, lofY· S0I1Il' IIl1jlllll Hl"ut arc cllwtl l.HId wlllll'd 10 Iltt' 11111,,11 IIljllr y 01 dldl'lIo...... (Jlhr', arl IlIdll(~( I. (JWI/IV II) d ll.,IJ'l· (II l 11I 11Ix·/I.,HI/IIY 111/11111

p:lIl~fII thai lIave
,,11"11 <11'"1/('101'

1IIIfIli'IIr.lld y

1ll0VC llll' I1I p:ll Il'lI1, I"hl' 11 10\1:1111.:111 P
.llId !!lI.udnl

hI rotlllx'''''Ul'

fl l ... 1 10 1 Ilrl' pllm :llItl la ll'l It ll halalll'l' dl'llI1h,II11'l" IIr.IIIII.I\ :II""C I nllll l lll' I1(""tll l ;r 1 ~1'ylllllll'llll", 10111t, dl,I.1I1I !1\111Ithr

on t'l l1 al

III JllI Y CVl'IIIUillly

t l'.. Yll1 llll.tlH.· ....

11111,

I'll' 111l1l1l'd 111

hl'UlIlll' l l llllll1l'

IXTOllll· ... a pl"pl'l ual Ill!! Idll\ll 1I 1I 1Iai ptlllrohlfY ....

1{()~1 ,I'

f\hl\l'llIl' l1l

11)

,lIld 11M,

,lll"\'

(h,ltllllltl)11

pl·",'1 hlllf .rlll'l lhr

Il· ...111\\·\I \\lIil \,\ll'I1'I\(' pP'IIII;rI .md

IIH I \ll'lIll' lI t dV, tU liltIOI1. IIll' p.ll l('nl 111.1\ I"\.· pllil \

1I1lI.llh

,Ill

to hl' 1'111111111 t\ I O\l'1I1l'lIl' "I'll 111,1\ Ix' 1lIllIll'd hy ki ll ;l'" Il ll' Pil lll'lll 1" Pl'III'IIl'I" 1111111 11 1 .I'l·,I' til , I,II11 11\1111 I hl' 1I IIIIil i IIIII"Y, 1I" l lll t' 1{()~1 III 't,III\1l1lf ,I lid Ihl'll HI.I ' I \I I II I' 1l ' 11\ 1" III 1111111 I"om' pO .... 111I1I IlIiI) Il',,, II III 111,11 "n

II ltIVl' II 11'II I'"

l"'a lll ~ H II I

k ... 11111'

III 11111,' 1

I l""llrp.11Il

1\"

till'

1111\11'1'11'

til IIUI ' 11 'H'IIIl'111 I I I "0 11 lI " Ul' 111\"11"1'1 III I II' II" I I

('''II iI ..... ""11 11 (ktl' lI l1 l1l1l1f

tho ..

, 111'1 ' III 1,1'" I II J\\II I I l I

t il l ' .... 111 1\·

III

"d I Ul'lIl\' 111,.11 11111'111111'

1111(1111), ' lid\l' II(TII

1111 li lt, Pil ll l' l1 l dllt ' lIll'l l lIf 1(1

•

I

III" r

' I' ~1I 11111111 \Vt' l! I1\ \lIIlH , I I " III I\',dll\

..

IlIltl ,I IPI

1 11 ~'\; lI·plt· ... ~· (l 1 d l lll' lrm \., III , dn l lllil

. 111'111

to I 111\1\\1

•

~ ll ,ltl

I

"'1111{()~1,1l11 1111 <, l'irt"lltllllt'IiPII pi 11 1'1',11\ III \ 1,!llP II I 111111111,,11 111'.11 1\ 1110\11' (111' 111 ', II , III'1'H '~ (.llIlw I I(, IIIPlh I 111 \ t I I ,\' " 1II 'II I' 1'"t11 III 1 1\ "1 111 1"t 1'.11'. \\1' 11 t md",\u", 11 I ,II I 1111\'''1 \

, 1'11'<'

,

I

J Il:\

Chap(("'r 2M ( "Jiron;(" J'a;n

Table 28.~ Com~nent.' of the Phy,ical Thcral'y Examination and

CoOlt11on FlIldlllgS

11'

Pnbcntb \\ ith Chronic Pain

CODlponents of Examination

Common Fmdinp with Chronic Pai::n=--__________-'''''-~

ReHex Integnty

Often Inhibited oWing to muscle hotdlng

Sensory Integnty

May be inconsistent, impairments nondermatomal, hypersensItivity to cutaneous stimulation common.

Posture

Muscle dysfunction, poor sense of body posilion, and disuse often contnbute to postural asymmetries "

ROM

Changes in ROM may be InconSistent and related to both pnmary and sec· ondary symptom complaints.

Muscle pertormance

Adaptive changes in muscle length and tension, and myofasclal trigger pOints are often prevalent; strength may be Inconsistent; trigger pOints and pain may inhibit muscles dUring break testing (MMT) as a reflex protective mechanism. Pastllral asymmetries and poor self-awareness may lead to antalgic gait

Galt

tients may have long-standing habjt of self-limiting actjvity; aerobic exercise without pain is not pOSSible, so they avoid.

Aerobic capacity

________________<.O)!ttt<e"n....i'mOippa"'i"'~e",d;l""."'NMaa"re"n",,eSS-OWhese ir:r:1pairments is ofhir::t poor ErgonomiCS and body mechanics -''-_ _ _ _ _---'_ _ _ _ _ _ _ _<.Iltimwitations are more commonly a res' lit of muscle bolding, mllscle shortening, JOint mobility pain related inhibition as opposed to actual joint restrictions. Often impa ired as a res!!l! of long-term djsllse and pain related changes in kinesthetic awareness and movement.

Motor control

= manual muscle test; ROM =

MMT

range of motion"

palient~. and low endu rance combi ned Wilh rapid muscle fatigue may result in incon')istem testing.

assume Ihat the pain arises from small tears of knee ligaments if COnfin11ed by the physical exam. It would ah.o be reasonable to develop a POC ba,ed on the goal s of decrea,-

Evaluation and Treatment Planning Climcal decision making mu')l lake inLO account both th e phJ~lcal and p"iychoJogicaJ change) a~socjated with pain. The o. . erall goal of treatment is to decrease pam-re lated d, abiht). This can be accomplis hed with a coordi nated treatment plan thai focuses on improved function along With re\olution of treatable direcl and indireCl impainncnh. FunUl(Jnal goah mu..,1 be mea"iurablc. "'pec itie, and attainitble and mUlUally agreed upon by the phYSical therapi ... , and patient"

\\kclfic In:almcnt ... m:.tllcr less than the malching the treatment lo the ~pc(;d Jl. fum.:tiollal prohlcm\ and goab prcsc:nu:d by cadi pi.lllcnl. In adulilOli. the Ihcrapi'il Illust undtn,tand the phll(, ... ()phlcal dlflcrclu.:c helween 1};I11l .lrL'i.ltrllenl and pam 111i.IIWgCIIU:111 a ... thai dllfl'll'l1(;C appIIL· ... In hrflllil palll (hulIIlC.. P:III1I' IIIOfl' III ae lilt

p.IIII

1'!..L'ly

In

pmdm:c

dJlIlI'....:

and

lIllI\'-

illld I IJlIl I IOllill ruohkl11" thilll I" anlll'

II

I'" applOjll lah.' It) Itll'lIlIl) 11 "pl'ulll

IInp,Urtlll'lIl 111,,1 I" Il'"pCIIl ... ,hk' till Ihl' 1I1,lltllll) tIl )ll\jllcml

1,1111\ it

~,IIl't' p;\lIIIl'''\lIIII1~ II wOlild hl' I l'.!'>OI1,lhk In

III'i'oh.ed IlIlhl' l il t' III ,I(.ult'

'nt"11l

Psychosocial Factors I hl'n.'

lIt"1 IInp.Jlftnl"1l1

~oJlli

ing innammaJion, instability, and pain u..,ing a variety of passive modalitie~ and acti\'e exercise. The patient \\"ho presents wilh knee and lower leg pilin tha l is diffuse, long standing. and not con~istenl \\ith a "J)ecific impairmel1l typically demon"itra{cs Significant funclional limitations. It i.. not 10glc~1I to look to Identi~ .:1 ... ingle "pccific li'i sUC as the root cau\(! of Ihe problem" A better fit ht!re is lrem melll gean,xl IOwanl improving function and managmg pain. This type of pain rehabillli.ltion I" con ... i... tent \\ 1m Ihe philosophies of funcllonal re"lOr•.nion. \\on.. hardening, ('oglllll\"C bchaviorallhcrapy. and pam rch;'lhllll.Hlon.' '1

~lllIg "1J UI )'

IIW\

ht'

hllk'

"111(' p.un Ihl"

t'tllll'l..lld,llll"C ,IIlHmg. ""gll',

Inm .... ,wd 11I11t.:l1nn IIllht' p.llll'lll "llh \·hnlllll... ("an kill! In i. 1i11J l'ult~ III tht' 11lIl"I'I\'t,lTh\1l "t I !hlm!!'" .Uld ,hI..' tk'\I..')npl1l\'1l1 1)1 .1 hH!I\",ll ,Ill" \",,1\1..'1 'Ilt P('l. Indll""d Ihl' ,,"III ... i.)!m.lldllll!-! "'Uhll..'\"II\l' \"mpl.lIn .... It' t:"\olI1UnJ tHIIl

IllIdlllg ... lh.11

"til" ",

,,11,lIghlli.lI\\.ud ,Ilul\,.' p.1I1l

\\\,1\ II

1.",1111"

p,lIlllIl'> \\lIh III R'

lll ... k,hhng

• nI..l m",,1

11.14

Jlh"ical Rchabilil3Cio n

be l'arefull) l'\aluatl'd Palll related dlsahrlity is ml'\ ln canl) linked to prohlcm ... 01' lC:Ir-;.I\Old~IIlCl'. indlcclln: cn.pl~lg. derrl' ...... ~llil. Irauma. and InapprOpl'i:lIC M1cial rellllnrcel11el~t .. 1 hl"e p ... )"Chlhocial i ....'1l1l's ma) co nfu ... l' thc p;lIIern ()I luullng'" thell clmic ian ... rely 011 In treatmcnt p L.1I1 n IIl\! .

Fear-Avoidance Chronic pam invoh'es the l imbic ~y!-.tcl11 and evokes an emoti~na l re:-,pon~e along wi.th eNS recognition of pain IIllensll.) an~ locallzallon. Pallents wi th chro nic pain orten have histories or trea tment fai lures and pain flares a~ a result or functional activ it y. These past expcricnce!-. lead to :mticlpmol') anxiety and pain. Thus, a paticnt may be locked mto a cycle in which activity ca uses pain that increa!-.es fear and decreases physicill activity.R~ A long wi th Ihi!:. cOIl"l trail1ing of activity come secondary impairments of dislise that c~n incl ude, but are not limited to, ROM limitations. joint stlffne33, muscle atrophy, dccollditioning, and coordin~ltion Impainnents. Fear-al'oidallc(! can often be misinterpreted a~ nonadherence.KMl8 Fear-avoidance ca n be addre3scd by paticnt educa tion and close monitoring of home exercise and activity program s. Exercise prescripti on must be carefull y planned and monitored so that the palient will ex peri ence !o, lI C(;C!o,S from the beginning. In addi tion, the program and it!>. progression must be matched w ith the individual. Exercise prescription is full y addressed later in thi !-. chapter.

Another variahle i ... (.·OICl\lfO/}/'i.·/l/f'."1' or Ihe P'crceptlon . • 0,' pain as tern hie. 1IlC
Depression Thl! relatioll"lhip be tween dcpn.!!-'\lon and pam is H cample\ onc. Rccclll ... tudl cs confi rm deprcs!-.Ion a~ i.I ~ignific"lIl( and independent ri\k. I:lctor ror developmcnt of back. pain"" 11M) and neck painYKI Back. p:lin i'i also a :-. ignilicant ri ... k. factor for development 01 major dcprc",ion.1!1l Thi ... rcl ..illOn ... hlp appear~ to be a "ncar one. \\-ith increa ... ed palll inten ... l1) associa ted with higher ri"k. of dcpre~~ion. Funhermon:. pain appears to adver"cly alTect the outcome of trcatment for depre!-.:-.ion in a . . ignilic:tllt majorit y of p:lticnts pre ...enting with depreSSion in primary cart!. HI! The comb ination 01 pain i.llld dcprcs:-. ion is as ... ociated with higher raIl''' oljxrceived cli ... abi lity th an pain or deprl! ... sion :l1011l!.1II1 WllIll' no specific cml\ati\e rclaliomhip het\\-ecn pain and depn.~ ... · il lOIi has beel! found. thc cov:l ri ance or palll ilnd Jcpl"I:, ... ,ion is a "Iigllilicant and con lollnding; variahll' in the dfecti\l' treatmen t of chronic paill .

Coping, Catastrophizing, and Acceptance In the case of chronic pain, Ihere is littlc dircct co rrc~ pon ­ dence among impainnent3. experience of pain. and fum:ti on. Clinician ... and researchers have investigated p!-.ychosocml mea\ure~ to identify criti ca l ri "lk fac tors in chronici ty. One of th e measures ex ten"lively studi ed is copin,.;. or Ihe ind ividua l 's ability to mal1Clge hi 'i or hc)" distre . . s. It has been Iheori.fcd thaI preexisting poor copi ng !-.Iy lcs may place an indivIdual at higher ri sk l or developing chromc pain frum an injury thaI a more effect ive cope r wou ld n!(;()veJ' l rom. Rc\Carch with the Mullidl1l1('miollall.Jaill I m'('lIlOn' (MPI) has shown II to he ci reliable <Jud valid 1001 JI1 cxamllllllg; coping styles JJ1 a chron ic pain POPUI:lliulI .H') Palll!III'" 01 answer... on the MPI tjucsl!onmurc g;roup patlenl\ 0/1 Ihl' ha\i\ of coping into one 01 three Sllbsel\: dr·,ll/lIl"",,"', 1111('1 p(JnOlwlly dr.\1 re.\ H'd, ;.IIId ada/" 1\'(' ("Opt'l S t lid ie~ u'>in~ thi ') da\Slfit:
lOPIJlV may hl' l"rulwl

Pain and Trauma T here ha"l been a long !-.wnlill1g anl'cdotal IInkmg of chronic pain v" lIh ahll ...e and trauma. 1/1\10[") of pl1y ... lc ..11 ..lI1d {lr ...c\ lIal ilhll!-.C ha" been !-.it(m II 10 IIItl'rferl' with pall! J1I,1IlilgC11Il'1l1 in palielll'" with chron iC pall1. 10 1 I'hl're I... e\ IdcIK'l' fOI ,I high corrci:llion 1"lClwccn ...C\ual ahu ...c ,lIld dlnlllir IX.:" Il' palll III women. 1m ch ildhood abu"'l' or Ill'gll'l.' t and rlbrolll);dghl. IIl ' clil ldhood ;Ihu"lc or IlcgleC..'1 ,mel dUOIIIC..' 10\\ h;ll'k. pillll. IClh ami childhood p... ycho logic:tI traullla :111(1 pOOl' OlitCOllll' III IO\H'1 r had palll (I UP) "'lIlgl'I ).lI1 II "'" ""d) III;\t ;1 pIlY"'ll,;tilllcJ".1 pi ... t \\ 01''' Illg \\Jlh palll plOhIl'IJI ... " Illl'lll'OlllllCI palll'lI" "Ill) arl' ... urvivOl" of 1'I1I Idhood phy\lc:l1 atH.I/III ... e\uill ;lhll'C, Ir;IUI11I1. alld Ill'gll'l:t. II I ... vllill 101 till' lllllll"I;1II ((I dl'\l'IOP the ...CIl ... IIIVIl Y and ""IJI ... Il'ljllll l'd Il) \VOl" \\ltll tl",IIII1I:1","1""\ 1\01' All l'1\cl'lll'1I1 re... Ollll'l' 101 cillli(' lan ... I'" ;1 ... lIId\ hy Sdl,tdlll'l l'l ~1 1 11l thai l'lllplc»)ed "'l'I1l""'lllIl'tUIl'd IlIll'I\ll'\'''' \\llh .Idul l \II I vivO!" 1)1 dllldl\(1\1t1 110111111;/ dlill 1IIl'II l·\lx·lll·IKl· ... \\lllt phY\ll·;t1tlll'lap)" IIl'aUlll'lI1

Social Reinforcement P,lIll·lIl ... willi dllUli ll P,IIIl olll'll rai l P,ll1l IIll' 111\ 1\lllk 1.11, ilhtlily. 1'.1111 ""'.I ... lIhll·lIIH· nlll ... 1i III I ,lIlti l"11l 111IHlIlll",1I11111 tIl

( haph" 21S (hronit: Pain

,h\[l l'\\ 1k.'1IJ1' WJlIlIIl a "'Ol l;1I Illtlll'lI Ih ull'an Illllltdl' latH Ih, Im: luh , l'O WIII)..(,'I-., ;lIld Iwalth t al l' W()IJ.. l" " ,IIl~ Soc.;Jal rt;llIhIlCL'IIIL', lIlu,rlx-
Rapport, Relationship, and Compliance fJ1t:rc 1\ II perce ption amon g c l inlcian~ Iha t patient ... wi th chron H,: palll are diffi c ult paticnt .... Although there are pallcn" who ma y be difficult to work with , LI ... e or th e lahel "difficult patie nt " i ~ at be~ t unh e lprul and at wor~t dc,tructl vC tn th e th e rape utic proce~ ...,. In th e m~ljority or ea~e\. the dtlTlculty ..,teJ11~ rrom mi~matche~ between pallent and thcrapi ~ t expectations, The clTective c lin ician dcvelop.., qratcgi cs ror identifying and dealing wi th dirfleult beha vior to e nhan ce patient adherence and red uce the chan ce of rru~tratiol1 a nd burnout. Str<Jlegies to diffu..,e anger, anxie ty, e liminate amb iguity, and maintain appro pnatc profess ional boundaries arc as important to cli ni cal practice a ... the skillrul application or any trealment tcc hnlqu e,lll II ,'

Problematic Behaviors There arc many t y pe~ of proble matic behavior. Thcy ca n Include intcn~e e motions exprcssed verbally, demands expressed verba ll y, nonad herence, manipulation , and disruptive co nduc t. Any or these bchavior~ can interfere with the therapeulic process. There arc seve ral di stinc t behaviors and res ponse patterns that may e merge within the treatment process that Can affec t both the clinician and patient. These include: , Pa..,s lve· Dcpendcnt response . Overanxlou... res pon..,c , lIo. . tlle response , p(t!',sivc··Aggre ...... ive response , Help Rejcctlllg re"'ponsc

a po,nh 'c depellciellf mod e Illay co ntinuously demand re;:lssurancc. defer to the clinic ian , 01' act POwcrlcs..,. The cli nlci:'ln may be ove rl y ~o li ciIOUS, fail to IOllow through Oil plan~. or avoid making dec i ~ions, The fJ1'l'I'Wl\iOll \ patient ma y appear 10 be magnifyin g :\YI11 Ptrnn .... cxpn.::.., ... high anxiety. or inLcrmdi /c hlame for the cllndJlI()II . The ovcranxioll~ dil1l cian may be overly C:l II trIm\, Iccl i.tnxH}U .... unpre pared, or tal-..e rcs pon..,ihility for the patient'" "'lUtu .... 'I he patient who :II,.;I'- With Junfillf.\' Illay he SU'PI(,; IOU ... 01 dlllil'l .. l1 .... 1110ll VCS, fcc ll11i .., trc,tted ;IIH.I/OI Per,,,"'(.:.Uted , or reJcc t a ll Or' pitl t 0 I tlI C. I'(J(' ' .. Th l! c linKlan Who rC!o,ponds wJlh ho ... ltllt y may hl' \ U' Pll;IOU.., of thc patient 's motives. Icel taken advmllilgl' 01. or IgnoH..' thl' rhl! patient

111

1 J 15

p:tIJl' n" .., IIlI HII. In a P" HI\' (' (lMKtI'H JH' rc\ pon~ lyle, the patlcllt ltIa y ur.,c ~I "yes, but .. " rc s pC}n~c pattern. appear to be h e lpl c~s. or blamc other't for hi ... or her (;OndltlOn. The dllm.. mll who rc~ponds In a pa ~s ivc aggrc sive manner may he help rCJec tln g. co mplain about lack of IiiUPP0rl. or blame thc patient for lack of progres .... ~I he patient 10 the help rl'JN'IIII)!. palLcrn may have difficulty asking for help, " 01 bc lll gcrcni ly. or minimi/e symplom,/di,ablilly. The clinician may feel threatened by supervision. act overcon fid ently, or minimize problem .... In clinical ... ituations, responses arc often mixed. A patIent may present in a way that is both passive aggrcs-"Ive and help rejecting. The clinician may react to this patient with features of hOMility and anxiety. It is important for the clini cian to be able to identify emerging behavior/respon~ patterns so that he or she may employ Lechniques LO enhance rapport. I I 1114

Managing Problematic Behaviors Two of the main techniques for managing problematic behav ior in the clinic are relat ionship building and good commu ni cation, These tcchniques are closely related. The specific componenlS of relalion ship building include (I) sellin g c lear expeclalions.(2) mutual goa l setling, and (3) the trea tment co ntract.

Relationship Building If there is a mismatch in Ihe overall expectations of the therapy process between th e clinician and the patient. it is likely that treatment will rail. In the arena of chronic pain, a common mismatch is that of pain management versus pain elimination. The philosophy of pain rehabilitation for chronic pain is simi lar to Ihe philosophy or treatment of any chronic illness: patient education and self-management. In the case of Iype I diabetes. treatmcnt goals might include patient selr-monitoring or dicL and blood sugars and independence in administering insul in, In the biopsyc hosocial model of pain rehabilitat ion, treatment goals include self-monitoring of aClivity and body mechanics. pacing and home exercise, and self-appl ication or independent pain conlrol modalities such flS hcat, cold. and se lr-ma~sage, If the pallent e\pel't~ the clinician to " take away th e pain" using pas::.i\'c tre~\lmt!nt modalities, then the stage is se t for significant conlliet ;md poor outcomes, The ... killed clinician willu ... e the lI1itiul c\JJl1inalion i.lI1J the goal setting proccs~ lJ\ an 0PP0I1UIlJl) 10 ... hlll'l: and ... hare ex per.; taliolls or the trealment proces .... QUC . . tIOlb "'Udl .1'" /lOll'

will

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the goal ..... lIld help 10 1110dl'ralr: In,'al men! d"pulc ... Ih;u Illa) an'l' , II I... Important 10 rl'l1lt:llllwI thai lhe conlra,1 bind, bOlh partie, the L:liniu:ln a ... wdl a ... Ih~ patient. Comm unicatiun Ski lls Difficuhic, wi lh communi Cat loll often Ulll.h.:rilC \Irc ... \ lll i professional and/or patienl II1lemctl on~, There arc "'llCcifiL communicm ion \kl ll \ lhat the effecllve cllllICHlIl can cmploy to decrease ambiguity and confl ict. II 1 They lIldude: " ' " statemellls Reference to standards/rule~ Active li stening Reflecting emotion Use of "we" or teambui lding Limit selling

"I" Statemellts, Beginning a sentence wi th "YOll" at bc\l widens the gap in the relationc,hip between patienl and clinj· cian, and at worst can set up an expectation of ho"uluy and blame. "You didn't do your home exercises la"t week." and "You always make me wor\e when I comc to lherapy" arc examples of accusaLOry statcmcnu, that incrcac,c friction and stress in a worki ng relationship. Statement~ thai begin with "I" help to diffuse an emotionally laden Interchange and do not confer blame, " I am concerned about your homc cxer· cise program" and " I keep gelling pain flare, after phY>lcal therapyo"

Reference to Standards and Rule;. Referring to >tandard, can help to remove per.,onal conflict from a stre.,sful situ· alion. Rather than argue or persuade an individual that a cour~ of action I') "right" becau')c the clinician believc.., II j,), he or ..,he can reference the Mandard of care, the re"earch literature. or the rule ~ of the Institution For example. "'According to physical therapy rc..,earch. active exercl ...e '" more helpful than hot pack' and uitra\ound for }our condilicJ!1." Thi~ j\j an extremely u..,eful tool whcn objective confrontation of behavior i~ necc\j..,ary.

AClive Liltening, listening \kllls arc Ju~t ao; Important to commUlllcallon a arc !lpcaklllg , ~- Iliso 1he attive l!\lCner 1\ empathic. nlJnJudgmcntal. doc!) notll1terprct. and entouragc", apprcJpnalt dl')(;lo... urc, '111C a(;IIVe I!Mcncr j" willlll,IA 10 ~u ... · ~nd dl..,belief and h,lCn tomplclely and ob)c(.lIvely ~llhf'UI Jumplllg to conclu lC}n~ or drawlIlg ha'>ty a 1o.Umpllon ...

H'llf'lI"'1: 1 "''''/'111

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l'llhlllllll .ltld h,ll~ 1I11t) Ill',dllty 1''111'1111 I{I LIIIII}' 1.111 I \,l"ly pm'vI·111l1 1001 10 1t.llldll'llIl·dllllkl',l.ltldlll~1

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pk Olll· ... t.ltlll)! I~ l ,l'IlIll'llI;I\.." 1I1l· 1 11111/11 1.llld wit,11 ~I'\j all' ... ayuw II ... tHlIld~ ,I, II YOll bdll'W yllllJ tllI( "" dl)l 11'1 W.IIII 10 jlll· ... udw YOIII l!lt'd lL UIIIII " ;UIY"lft'" I lit,11 wh.11 YOIl ;111.' 11.' 11 II I).! Illl''.'' Bollt In 11IIltjtll." (II IIt,( I III}' ;illd /I' I.tI 1Il~) t:.111 lx' u ... I,'d IOpl'lhl·1 10 Vll',lll'llnl u'\e of "WI,II or 1"11111/)",1(/1111:. J Ilt, 1.1lIVII,I~'(· \1.(' u ledp 'lei up l'XPl'll.uitlll ... , l l ... llll-' lilt' wlII,h WI.- ;tlld "u I,LIItI;I Ihan ... I" and "you" 1.::111 IIl·lp 1I'IIt1I)fU' Iht, Ill',L\IJil"IJlUIilIr .Ill (;Ont:cpl 111 whH.h hOlh Pit/Ill' .... (lhl'I,II)I,1 ,lIld P;lIWIII) Iw,,(' riVhl'" and 1()t!Clhcl ,Ill' Ie' pcm ... lhll.' JIJI Ihl: Ollllllllit' "lu('.11 lllelll Some cxalllpk· ... 01 Icamhllcldllig IIldudt" I h,w t.1/1 we "olvc Ihl\ plohlclll"" 01 'J.l'I" 1(1)Y, ,1\ Ihl\ willi your df)l tor\ Input ," afld "Where ... hould we go Ie 0111 1II.°lc·!"

Limit SenillK_ DIlII t:ult

hch;IVIOI /l1)1

ollly wake

Ihe

J"buf

rehab,llIilllOI1 h<Jrdcr, II ,11 ... 0 t:fl'alc"i all 1J1I..,;'lI." ,-,,(ur. JIll

cnvln)l1ll1el1l lor ailihe pallenh Jrld .tall uillic ;m,';j l III' dear and J10nat!!!re, ... IVC lall!!"agc l'"'' help II) el JPproprl "tc IlIn lls and III<.:fea..,c ... alcly ;'lIlt.! adhcll'lllC, h" cxample "Shouting dj"ruph the cxcrt:l",c da" .... 01 'It 1\ nol apf)tIJ pnate 10 fUl\e your vOIt:e 1/1 the dll1J(', or' I till1 only help you when you allend chedu lcd \C'!rIum .'
PhYl>ical Therapy Interventiom Bccau')C Impalrmenl\ aJ1d funt:IJ(JfIal InoUalloll HI ,hrooM.. pain can ari"e from Jnd t:iJn allc(;t the 'flU culo J.:e1elal neuromu\Cular, t:ardJ()pulmtJ!1ary. or mlcgurJlentary }\klll thcrapi..,,,, can ernploy a 'lvlde \allcty oJlrcalllltllllcdlJlIYues The\(! Icthnique" run thc ~;.Ilnut from modJJrlJc It) p'J\JC'1I1 cducatICm, rnobill/allO/l and ma <.age. Ihcrapeullc exrrll\e and gall training and ccmdllJOrJlng. Jn1Cf\CIIIJOIi Ihal arc no( dJagno'li\ and ImpalTtllCJ1l lripe<:Jfit lIIc1udc pam control mooaiJlJcs. lhcrapc:ullt cxcrt:l\.C and pallclIl rdociJlJlJf1

Pain Control Modalitie, Pi.! I\C I1I1Xbllllt UI lJ 1 ht II HlOI I hOI pad. OUJlhcrTf1\ ultra""undJ, lold mi.!f1Uallhcri.lp~ (rna s.agc wI/hllI/JIlOfl lind eic<.lro Ihcrap)· CCICllrH.al IlIllul.:Jllon IIlltrlt::rcnlJ.ai hlgh-\ol!avc !!<.ehalilc IlI1Iul<.elUni 111\ (}SII ",re lor the:

( hapler 28 ('hrlmic POlio (11( .. 1 p,il l u ...dullll ,Hhlll·"'III}.; ' Pl'llfll I' '>'''lll: I!:\l. j JlIIIMII rt1elll~ \IIIItHI~h IIH,''>l' IIllp.lllllll·IU ... If..·!!, IllflaJll1110111011 .

II~"U( rl"·lIIl1l t1l1 . Inlill r-.1"lm's~ll.1J1 "t/l'X"'1 \.'01111 l hll)rll l' Ill. IB.o,tHlIl·OI 1lIllIll'd ttl ,ltldlf..·''> IIl ~ 1I1l pallllll.' lIt '> \\111 11111 pJ'llIlll.lIlIl, dl,lII~l' 1),1111 Il'l.tll·d dl .. ;.thllll~ "UrthCfJ IIUl C " (,pill.111111I 01 In'.Ullh:11! tn.hlllqlll· ... lliat Il'ljlllrC the pi.lllI: nl tI(' j P,I,"'IH' Il'l'IJlll'lIIl'JllOlll,I~C'> dl ... "hdl1j" by n:l1llon,,:

"

i1~ th,illhl"

h.t ... 110 PO\.'o': I 10 dlcll t:hJI1~".! 111 h .... 01 hd 1111.: I hl·lf.: I'" ,I hudy I)f 1i1t..'1 'II Urt,,' 011 th e t:OJlCC pt of II'u' 01 (tlilillli ,lilt! C\ IdcJll'l' Ihal ,Iii t:>.tcrnallo(..'u\ 01 (..'Oll trot I'" (0/1 ... 1... 1t.'1I1 \\ nh ,I IIIt-!hcl dcgn:c 01 perce Ived di ... abJl , Il~ I'. P,III1 1I:1t •.Ihilll.Hltll1 l'on"'''lclit \\ Hll the blOp,y' • ho"')(la I 'IIOtkt allll ... It) )1I,,·rea ... c ,>clf -d fH.:acy, IIllrl;!U')e )fltl.:n1.11 hllu" 011,.'0111101. ,1111..1 reduc.:e PUll) rel
P.llll'lIl

a hwlJ,!c utltil Illc pallent l.'an ac tlvcly partIcipate 111 Ihe phy . . ical therap}

rn.'\lllbt..'t! l·Xl·lll'''e .... 1111..' l',>nU;'I'"tlUlcs of

rI1ana~CIllCI1I of

(h rulIl( pam arc Ihcr'lpeUIil.' cxcrci"e i1nd

r,UIC" 1 Cd Ut;;l IIOiI

Thenlpeutic Exercise nit.'

COdlrillie CoJiab(lIiJtJvc.: glOlItJ

mel,1

;111,11)", . . of Ihl.'

~1\;JII;lhlc

w" . . Llilubh! 10 perfol'ln

"Iud.,.!,> nn

p~lin

i.I

and cxerci:;c

~(.Ju",c 01 '> 11:!1 1I1'1l":11l1 IlctCrogCIlCIlY of ... tudy population.;,

C\Clt,;l ...l' pn)[olol ... and lIuh':OrlH.' 1l11!""'urc .... They conl.'iude there I'" IJ1Ik'!.!\ Idcm:e ... upportlllg
chronic low !lack

1\11",

11 0\\I..'\l'l, ,\ 1I.'\1t!\\. h) 1.ltJdk L'I al idcnttlicd 16 ral1dl1tnlll'd ({lIl llOlI cd In;\! ... 01 c\c rc l"c and chronic pam ill

JIH

IU)II ... tlllttllrl'tl ,L!flHIP iJluJ till': tfuclurctl gr(~up (JfI mea: ur of pall I pt.'lu·plmfl alld !unc.;lJonal tatu 'ml!asuretJ h) palJe-m lllJc ... tlollll<Jtn.') I f)c ~ Pllc l>OtlIlH,.:lIng lcvrl of C'VH1(m;c Ihnc I'> J t.lln . .en ... u.... ho ..... evcf. that txcn.:ll)C Lan decn.:aie t.llrOlm: pam .Uld dl ..Jhdlly,1 hl 'l t:lJIllIllO/l lor pallCI1l'. to be fnghtened of cxeru"C and t!>'lx: ricm:c dtfJkulty 111 phYSical therapy h:ar/avOIdance ha it lar~c pan 10 play III Ihl \ difficulty The phy~lCaJ thcrapi t mu .. t employ tcd1l111,juCS (0 mlOlmllC fcar/aveJldance and ga ll) tht! pallclll', trust. In order for any exef(:I~ program to be cIlC<.:IIVC. it need, to be: (I) indlvlduali,ed to the pallent s

goaI-.. (2) matched to the patlent\ current physical abiIHle<;• anti 0, progrc, ...ed at a rate thal will build funclitm \Io'llhout inc.:n.:!<'lsillg di"lre,,~. Thl,) rcqulre~ i.I high level of ...kill on the purl oj the phy'Sic to be effecli\'e and help the patient reach his or her expected outcome,

.... hldl ~"'lIt\l.' cll 'cl' h 01 l'\c rl' ''C on chronic bad. pa1l1 wt!re

Jt"lllnn'>\I;]tt"d

h\ll nlll11l1011 k~lture,> In Ihe"c .. uccc~\ fullri ­

,ldcqll.lIl..· "'UPCI'\' I... toll 1'01 c\crci ..c :.II1d palicllI adherI'~~ "'Hh Ihl! PIt)~I;lIl1 I~O One "'I~nlrll'allt "nutatIon of Ih~ ...c \Iudlc ... I'" 111.11 lhl'lI 0l11(.'t)1I1e HlC. I'>UfC\ dill not adequately 1~1I\ (111 lllllllHlI1 ,lilt! It>l'u'>l'd 11I,>Il'ad on 11l1pOlllll1Cnh, Staal

,11'1 \l,1"1t:

('I all1.~I)(1111'd .1 '>1~ n"I (,II11 dl'l.: ll'a"'I..' !1l uh'>l"l1cC from \\ork. U'IIl~ ,\ "'IIlKll1rl'd ,1(11,,1\ ,111e1 l"\t,:T,,'I'IC prugr.ll11, 11lJ\\C\'l'T'. I~'tt" \\.1'" IIIl .. 1.11"11\.'.111) ·'> I ~ lIlliGUIl dlllel'c lll"c OCI\\CCU till'

Selling Initial Exercise Baselines Becau\e of dillicullle~ \I. IIh fear/avoidance and poor o,;elfa\'1l'\"mcnt/:-,elf-regulauon, the physical lherapbl mu~t carefull) . .ct the bcgllllling le\'el of exercise in order [0 allo\\ the be done- by pre""rib111ft ...c\,cral e'(erci~e~, which the p3l.ient i, ill\truC'ted to do U\'I..·r the (OUfiC of several days" while IllQnitonng "')~t nII.lIl\, llil' f'o/H'W fS ahle to c/o bljore Ilain orji.lfIl.!lIt'mlt·,j":rn. ~ pi.llit!11I to l.·xpt·rience ... uccess. This can

Table 28.9 E~crci .. l.' i\n .. I )~i~ and Prescription ["pected Outcome

functional Limitation

\nticipated Goals

Go 10 the mOVI(lS

POllent IS currently Irmlted by poor sitting. sta nding. and walking tolerance; stIffness of the lumbar spine and loss 01 balance when walking

Slttmg

·2 hours

Walking

2 city blocks

Stcmdlng

15 minutes

• Aerobic lramlng statlonarv bicycle. treadmill • Lumbar mobility exerCises • Functional strengthen ng exerCises stand'lg • Standmg btl ,1nce and coordination exerCises

,',I vll 1111

Ih"lylny II

!I

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II hll

III

II" fl,~111

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II I

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If' IU /IIVIIII I!UII "

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wilit Ii

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pill II I}' 111111 111 <.; 11111111111 III pll'Jlfl 1" ,,11l llll .. 11 t'll I11(' I If,. 0 1 Ihl' PIIIII Idl1 OIiP ... IIUlI III IJ' PHI)! p ll.I III I" h/ldy It lrlllh

If'It,I III/IIY,

hlld y 1111 ( h ,\ II"

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Sump",' Q,mt,. ~h "('f f, ..

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Chapter 28 Chronic Pain

'\'r,i f llf p.ll1t rdicf. '('0.11" \ ppcnlil\ C l'Onl all1:-' p :1I1 c n l :itft'l'lllHl' f(1r I~rfl)rnlln~ ;\11 Il'l ' 1lla...... agc. p.llll'nt' l' ,lIl tx, taug ht In (hl' ;1 \ ancl) of "' llHph: too\<" I'm ,"\.' If-In,I,,.I~l' OUt' 01 thL' 111O ... t u ... t'fll l 0 1 Ihc . . t' lotl b i ... a lell nl' ~111 , \ 'lIlgk Il'llIll' b,tll l' ;111 bt' u ...ed for , hiahLl-lilc pres,un' 1'\ )lI1t m.i";lgc t)J1 nt.'arl~ all~ Illu... cle bell: . ThL' patient 'lInl'l~ pl.ll."t." the h;llI bet\\~ n hi.., or her lxxi) am.l a finn \ urf~I\'I..' .Uh.! Ihl' \, t'l~ht of the bod~ P;U1 o n the ball pro\ loes Ihe Ill'X,dt'd

(l'rct' . Llrger ba ll . . can be u . . ed fo r large r Illuscle ~n'lIr' Sulll.X'(,lpital relt'a~e IS a lIseful too l for pat lenl.S \\-ilh ~ 'I..'k pJ.1I1 ;uid /or headaches, T\\ 0 tennis balb are tethered t\)~l'lhCT in .1 ... oek. or e \ ..lInination glme . The patie nt is 1I1: U1II.' !Cl.i to ht' , upine i.U1d place the balls benemh his o r her O(\.'k in the !-ubt'll.:cipital area. The ape \ of each bal l provides \'\' UJ1tt'r pre ....:-ufe against the \ uboccipit not mean danger. II is particularly im portant that the patient understand that de layed onset m uscle soreness DO~IS ) is likely to accompany an) change in h is or her J~'I1\'i~ " Patienl.S with chronic pain ha\ e d ifti cult y d iffere nUJting between types of discomfort ow in g to the ce ntral neurological changes that accompany chro nic pain.

The Interdisciplinary Team Chronic pa m is not genera ll ) amenable to unimodal tre--d.lment_\\ hether medical, sur2:icai. rehabili tative , or psycilological. ' . ..:. Ph",ical therapy is likely to be mos t effectl\e for long term ~func tional improvement of individ ua ls v..th chroni~ pain when it i~ integrated wi th medical and ~cholo21\;al treaunent~ in an intcrdisciplinaf) team-b<escd PlogrdlTl .....The compo~ iti on of Ihe team in pain rehabilitation Inay \ at;. , but ali t, core are !-Jpecialbt\ in medicaJ care (e.g .. !ieurolog}. orthopaedi c'i. phy ~ i3lry, ane.., the ~ia. nu r"',ing ), rr:habllLtatlo n care (e .g .. ph )S icai th erapy. occupational

1139

th emp). voc all ona l re habIlitatio n ). I.lI1d p..,ychosoc la l care (L'.g .. p..,yc hia try. p..,ycho logy. \oc ial work ). The fi mCllOl1al H'stom rioll llpp roacit . po puJari7cd by Maye r et aP \OJ con!-Ji..,ts o f intensivc phys ical rehabilitati on III a behav ioral managem ~ nt mili eu. Mos t tcam-base d rehabilitati on program s incorporate element s of fun cllo nal restoralio n. The re is a wea lth o f lite rature in suppo rt of IIltcrcli ..,c i· plinary re ha b ilitatio n of chronic pain . In a Cochrane Coll aborative Rev iew. 10 rando mi zed trial s o f nearl y 2000 palients were anal yzed . The rese archers concl uded there i..,: ( I ) " . .. strong c\'idence that i/ltens/ve mulridisciplinary biopsychosocia l rehabilitation with j Ullctiono f restoration improves j w u:lion wh el/ ('ompared with inpatiem or owparielll llOl1 -nlll!tidisciplinary relwbilEratioll." and (2 ) " ... moderm e el'idence thO( inrens ;\'e lIlu f(iliiscip fiIlOl)' biops)'cllOsocia/ rehabihtatioll with jUl/ctionaf restoration reduces pain when compared w;th ollipatient lioll -m ulridisciplinary rehabifilar/on or uSlIa l care:' 140. p f5J.1

Sununary Chronic pain is a distinct diagnostic entity and differs from

acute pain in its pathology. physiology. and psychological meaning. It al so differs in its emotionaL behav ioral, and fun ctional sequelae. Pain behavior. difficulties in motor planning/motor leaming. and fear/avoidance can complicate the clinical picture of individuals with chronic pain. Effective management of chronic pain addresses biological, psychological. and social realms and is best provided in an intens ive rehab ili tation setting by an interdisciplinary team. The physical therapist is an essential member of the chronic pain management team. Physical therapists need to employ strong communication and rapport building skiUs in order to foster a healthy therapeutic relationship and pa tient se lf-re liance. Specific physical therapy interventions do not differ s ignificantl y in chronic pain versus acute pain: the major focus is on active rather than pass ive inlervent ion with the ex pected outcome of improving function rather Ihan the primary elimination of s pecific impainnents.

Acknowledgment Ackno\\-ledgment is ex tended to Bi.ubara J. Headley. \\ ho",e earlie r ve r ~ i o n of thi'.; chapler prO\ided the fo undati on for the current worl .

~~_u~e~~_t~i~(:)~I:l~S~~f~o~r___R __c__\'__i_C__~_'__________________________________________~ 1. arne three Wa\ S in v.. hich p... ychological di ..,tre~~ IT' ght be mallJf~"ted 111 a patient wllh chronic pam.

2. D1herenllate bc tIJ.-l!cn open and clo'.;cd I! ndcd que'.;tlon .. r If .,.athenng pauent daIJ. Dc"tC nbc the

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3. Your pa tlc nt had Il ot donc Ill .. home ('\('('(' I,C pfllgr.llll ( HFP) ro r :2 \\cel<... The fir... t \\ ec.~k.. he hht the quot.t ..hee t Ihe ... ccond \\ cd. , h l~ cnmpL.l1l1l'J of mlTt~a\~ U palll alter ph) "Gil Ihc.' r.l p) I hm \\ III ~ llll de lenlll lle- I f

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Study

The palient IS a S3-year-old right-hand dominant, "ingle \\ oman. currently not \\ork.ing. \\ ho pre"ents 10 ph) sical themp) \\ ilh chief complaint of left ~nec pum and qilTne~s ~ months status p0.:.1 left total ~nce arlhroplw,ty.

PATIENT HISTORY The patient rcp0l1s n multiyear hbtory of left ~nec pain \\ ilh episodes of patellar dislocation \\ hilt: ambulating in the communit). She underwent left ( L) IOIHI ~nee arthroplnst) :! months ago and reports medical ion complications during her hospital stH) that dela) ed the start of inpatient ph) sical therap). Pos.toperative care included use or a constant passh'c mOl ion (CPM) machine and referral 10 outpatient physical therapy following discluu·ge. The patient reports significant ditTlcult) participating in physical therapy \\ ith anxiety and panic attacks during sessions. Patient reports experiencing nashbac~s of childhood abuse during therapy. This was particularly problemaric \\ hen her knee ROM was being mea~llred \\ ilh a goniometer and Ihe therapi st would forcefully hold her knee into ne\ion. The palient has been laId by her surgeon thaI ir she does not gain sufficient range of knee mOlion. :. he \\ ill need to undergo manipulation under ane~lht!~iH.

FUNCfIONAL LIMITATIONS The palient is Illnitcd m ambulation 10 household distances u",ing a \tnllght cane. She demonstnlles significant g~lit deviations and i ... unable to bend L ~ne!.! to nllo\\ for ci.t\e of 'Htlng, uSlJ1g ... tairs. and actlvlli!.!, of dllily li\ IIlg (·\OL) such us dre ... sing Hnd hathing.

PAST MEDICAL HISTORY MUltlJOlOt o ... lcoarthnll .... chondromalacia palell ..\. epilep..,y. bIpolar di..,ordcr

l\JEDlCW)ONS Depakow. Tegretol. l\I'\il . Lllhlllm , T) lenni pm

PHYSICAL THER c\PY EX\I\IIN \nOl\ FINDINGS Pa l patit)(I/i.)h~l'n

r..IHr~ed sWt'lling or the L I...nee, \\ tlh marl...ed lightnc ...... 01 Ihe L I...nec llnhroplast) \car!l\ \\ell n... n.! ... 11 iL,tions in the fascia Ihroughoul the L thigh , L ~nee . and L It)\\ er It~g. Sign ificHIlI 1I11'\iCI) \\ hen L knee t ... louehed.

,srn.'Il!.!th . IH )\1.

The patient lives illont!. She I'" on I1Icdlcal di ... ablhl). Sh~ ha ... a hlswr} 01 st!vcre childhood ahus\.! allli traullla.

ilIllt ~L·II~ H lii.lll

ROt\l or L J...nec limned b) pam; 110t mei.\..,url~d 0\\ Illg 10 al1'\ieIY. B) observat ion. r\RO~l appeared 10 be quitt! hmiled (appro\imate l) 5- 75°). Strt:ngth o\" ad.llll't:nt mu ... dt" . . (L hip, "" ~1
( i <1i t Antalgic. \\ iIh slo\\. lalt:'ral \\ hip Dr 1 LE dunll!!, ,,\ In g phase. Pal lent unable to a... cellli or de"'l:t~nd ... lalr...... tt'P O\t!r stCp. She u ... es H slnllghtl'nnt:' III till' R lIF Paill Reported 1\ ... 0/10 111 "tiling, 7 X/IO durtng \\i1I~lng, ilnd l) 10/ 10 during c,\erci . . e ... (VAS).

GUI DING QUESTIONS ACTIVITIES

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PSYCHOSOCIAL HISTORY

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"fill' r,HI~nt h.I'" Ill'l ""-'Ill' It!..'f 11ll1ll1' t·\~r..·l .. e progr.l111 tilEr) 1"'f.2 \\ed... . l~he til'l \It.'d..... he report ... h .l\ Illg I,hl III<.' 4 U(lt,1 ,het.'r. 1 Itt' '1..'~l1nd \l eel-.. .... ht: co mpl.ul1t:d ll!lIl((\'.I,,,'d r· lln dunng. ..Ind ,Itter 1'\~n;I ... e .... Hm\ \\ ill ~,lU dt.'tt.'nlll11t." If (hi, pallt.'nt h"I' high feaf'.l\ old.met: Of

114.

fhe f)ll/i( ull HdIO\ ror UOf AJhn I helm-. pru Hie exam pie' 01 pOIl'nlhll p.U1l'nt \crhal rc pon'iC A \1.III.:h Ihe \crb.11 fc"'ponS( 10 Iht" re ponse I)PC §C'e

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I,.:..R_".;.PO~nse ~=l',=Ype ,===-_Exam _ pIes of Patient Ve~rbal~~R~es~po~n~ses~--==:-::~Dea~ ~~ee ~D~~lffi~icuk~~.!B~s!!h~'_~_ _J Are you Sure thiS IS safe? My doctor says I have brittle bones. you know. Wel l. you know best. dear.

-----

The exerCises are no problem . I'm fine. I'll do It myself.

I tried to do my exercises. but I Just had too much pain. You worked me so hard last session! It's no use. I'll never be able to Sit at a computer again. I'll just end up right back where I started. My last phYSical therapist put me In bed for 2 weeks. If you ask me to lift those weights. I'm out of here. Response Type PaSSIVE-Dependent. OveranXIOUS, Hosllle, Passive-AggreSSive, Help Rejecting

References l x. et J.J Esumate!o and panem, of direct health care e'\pc:nditore-- among mdl\ldua.b y,nh back pam in the L'ruted State, Spme ~ I ~<.). 20CU \menC3Jl Ph~"lea.11berap~ As..ociation: GUide (0 Ph~,ical Ther..lpl .. t ~!i..-e. ed 2. Ph)" TIter 81{ I ): I • .:!OOI 3 Bonk'a. JJ: HhlOI) of paIR eoocepb and theraple<:. In Boniel. JJ ed ~ \1.m.1gement of Pain. Lea & Febiger. Philadelphia. 1990.

p:

\ldueL R. and Will. PO: Pam mechanl'nb A ne'o\ lheor)- Science 'WJ-9 1 ) 1965 ~ I Setal -\n empmcailme . . ugatlon of the Biop!>~cho,_oclal

13. ;\Iehrabian. A· Silent me .. ~ages: Imphcit communication of el'll<>uom and allllude,. ed.::!. Wad:.v.onh, Belmont. CA, 1981 14 Peter-.en-FeIi,(J. S. and Curntolob. \1 : ' europl~tlcily-an impauru factor in JCuie and chronic pain. Sy,iss \Ied \\1J) D1:273. ~~ 15. Coghill. R, \kHJ.ffie. J. and Yen, y . !'\eura1 correlale~ of 1Olennd.:!· \idual dinere nee .. in th~ ~ubjecti\e e\.perience of pain. P;\:AS 100( 14 ):8538 . .:!OO3 16. Dru~hl.). K . et .11 A!lern.tion of the 'iOmalo-.e n~1) cortiCal m.llp Ul peripherol mononeuropalh~ due 10 c3.rpaltunnel ,~ndro~ ~euroRepon

I"

Dt~ Corucqueoce \Jodel: fl.,~~'hologlcallmpJ.JOnenl. dl .. abll-

and handICap m chrome pam p3!ient'_ DI'>Jbll Rehab,! 6 2:>.: 995 ~ Ft;"d\ce \\t On the rw.rure olillne" and dl,abtlit) An ednonal Om'Onhop 116 .J~ 199'1 Boruca, 11 Ge~ra.J con lde'rauon .. of chroru..: pain. In Boruca. JJ td P1r \I.l!la~ment nl p..un. Lea &: Fetllger. Philadelphia. 1990. pI ~ PL. and Dc\aul RA TIle .. brOOIC pam patient E and m:utal!ement In Gl1..knherg PL (ed, Pam "nd Headache ge:r. '~'or" )Q'l5 Mxd V.E Pain and uffenng .\ reilppra,~1 Am P ~ .. OO! I~

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200J 16. Fine. P: The role of rofecoxi b. n cyc!ooxygcna<;c-2- ,pccific m hiblto r, for the Ire'lIllle nt or non -C an c ~r pain : A rev ic w. J Pain

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139.

140.

Jodw;mal f.zgonornic> and s.te1OI'~ 5'12 S.hvonen.. T. et at EIectrK: hthrrict' of bN haL,; .mttSdes Jurm2 lumbar pelvtC rhythm oac .. pam pallCllU and heahm coo. trrns Arch Ph) 'led Rehabil-:!_IO~· 1991 • Mel..u:k. R et at let rnauage and tr.Irl!oCulaoeO ekctn.:al RImIJb.. tKlll. Compan~ of treatment for kM--bac· pam. Pam 9o:! _2UJ \1elzack R. GUIre. S. and Gon$hor A: Relicf of dental pam bY tee mauageof lhe hand. Can \1ed.-\ss.oc J 1:!2(2 ·189. 19:-.) • Bogduk. S· 'Ianagemem of chronic IQ\It haL,;k pam -'led J AiJ I J 80(2,:19. ~ \1ayer. TG. et al: A pro<.pectJ\e tv.o-)ear !'J:udy of functJonal re.. toration in indu<,triallO'A- back: injU1Y An obJCCti'.e ~-.meot procedure. JA\1A 258()3):1763. 19 Guzman. J. et at: \1uludbClphnary Bio-p.,>coo.SociaI RehabibUlJOn for Chronic Low Back Pain. B\U 3214 i301 r 1511. 2001.

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JOim Comm i.... ion on Accreditation of Healthcare Organizations: Pain: ('urrent U nder ~ lanchng of A'-'M!",,,ment, Management. and Treatments (JCA IIO Pam Management Monograph) Retrieved October 28. 2005 rrom hltp:/Iwww.jcaho.org/news+ room/heal lh +care+ i5sues!pain_ mono npc.pelf (www.jcaho.org) JOInt Commiti.-.ioll on Accreditation of Hea lthcare Organization!.: Improving lhe Quality of Pain Management Through Measu rement and Action. (JCA HO Pain Management Monograph) Retrieved

October 28. 2005 from hup:II~'W\\<.jcaho.org/new5-room!health­ care + issues/pain_monojc.pdf (wwwjcaho.org) Main. O. and Spanswick. CC: Pain Management: An lnterdisciplinat) Approach. Churchill Livingstone (Elsevier). New York. 2000. Monga. T, and Grabois. M: Pain Management 10 Rehabilitation. Demos Medical Publishing. New York. 2002 . Wittink H. and Michel T. (eds). Pain Management for Physical Therapists. ed 2. Heinemann, BaSIOn. 2002.

Appendix A: Visual Analogue Scale Visual Pain Scale Name _

- - - . -_ _ _ _ _ _ _ _ _ Date:

/n.I(fIlCllO fW N~merjcaJ ~corc~ can be obtained by mea~uring the placement of the mark along a 10 em line. Scores may Pe compared wlIh repeat admlni~tratlon of the ~cale.

Please mark an "X" along the line to show how your pain has eHected your level of function. 1. At what level do you perceive your pain? No pain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Worst possible 2 At what level do you expenence pain at night? No pain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ Worst possible 3 Has the pain effected your level of activity? No problem _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Total change 4 How well does medication relieve your pain? Complete relief _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ __

No re lief

5. How stiff IS your backlneck? No stiffness _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Totally stiff 6. Does your pain interfere with sitting? No problem _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ Cannot sij 7 Is It painful for you to walk? No pain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Cannot walk B. Does your pain keep you from standing/sitting still? No problem _ _ __ _ _ __ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __ Cannot do It 9 Does your pain interfere with your normal household chores? No problem _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Cannot do them

10. Does your pain effect your driving time in a car? No problem _ _ _ _ _ _ _ _ _ __ _ __ _ _ _ _ _ _ _ _ _ _ _ _ Cannot do it 11. Do you get relief from your pain by lying down? Complete relief _ _ _ _ _ _ _ _ _ _ __ _ _ _ __ _ _ _ _ _ _ _ _ No relief at all 12 How much have you had to change your job responsibilities? Nochange _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ __

So much I can't work

13. How much control do you feel you have over the pain? Total control _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ No control 14. How much control have you lost over other areas of your life due to the pain? No control lost _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Total loss of control DevelOPed by Barbara Headley, PT, MS.

Appendix B: The McGill Pain Que tionnaire rt"",

'-_I

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11 Tiring Exhausting

12 Sickening Suffocating

13 Fearful Fnghtful Ternfylng

14 Punishing Gruelling Cruel Vicious Killing

15 Wretched Blinding

16 Annoying Troublesome Miserable Intense Unbearable

17 SpreadIng

18

19 Cool Cold Free zing

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9 Ou Sore

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Perc ng

Tight Numb Drawing Squeezing Tearing

tndutJes 20 categories of word descriptors covering 3 main classes: sensory (1-10) , affeclive 11 15) e."aJuatrve ( 16); mISCellaneous properties of parn are inctuded In 17-20. Scoring can Include: (1) rIJfTlbef of words chosen (NWC), and (2) pam Intensity (the first word in 8ach c81egory Implies the least pam anct IS ICOred as a 1, the next word Indicates higher Intensity and is assigned a value of 2, and.a 10m) a 80C0(9 can be obtained for each category and a total score for all categones. Repclfu,o from MelzacJo: A The McGill Pain Oueshonnalre (M PO) : Major ProporllOS and Scoring Me~odo. Paift. 1 277 1975. P 281 With permiSSion from the International ASSOClallon for the Study at Pain

20 Nagging Nauseating AgonIZIng Dreadful TortUring

Appe ndix C: Patient Instructions for Ice Massage kt'111.1".tf!i' t:.lIl he 3 po\\erfullooi for pain relief. lec In.I" .lge I' ,\bo effecti\e In rcduclIlg ~\\elling. )~)U "Ill need:

. -\ PJpef or

peel

3" J~

t~ rofoam cup of completel) frozen \\ aler;

the

lOp

panlon of the cup so about an inch or

m('1(e of the Ice i~ e\po::-.ed: an ice cube can also be used . .-\ to" el

Directions: .-\ppl~ the ice 10 the prim~ place of pain or to the v.eb,pJce of the thumb (or as indicaTed by your therapist).

2. Apply the ice to bare skin. I/ you Gre wllng an ue (JIbe,

use 011 insulating cloth between Ihe ice and the hand holding the ice. 3. Move the ice in slow circles (two or three circles per~­ ond), lightly on the surface of your skin. 4. Continue icing for 3-5 minutes, or until the part iced becomes numb.

5. You may feel four distinct stages of icing: cold. burning . pain/ache. and numbing. 6. Stop icing when the pan feels numb. You may dry oft any water that remains on the skin. 7. You may repeat the icing every 2 hours as needed for pain relief.

Appendix 0: Patient Instructions for Cervical Self-Massage Relt'a"'lI1g tcn:-'Ion bchllld th e neck (;<1 11 be a powerful tool for rda\ation. pam re licf, and range of motion .

You \\ III need: . T\\ 0 tenni~ bulb A ,ock or latex-type glove A small rolled towel (you ma y need to place th e towe l undemeath your neck if thc balls roll or slide down yo ur neck [optio nal])

4. Place the tethered tennis balls horilOntally behind your neck, pre~~ing on the muscles at the juncture of the head and neck. Thi~ is your suhoccipital area. Your spine shou ld rest in the space between the two tennis balls, so there is no pressure on the bones of your spine .

Directions I. Place the tennis balb inside the sock or glove so they are close together. 2. Tie a knot in sock/glove so the tennis balls are tcthered together.

3. La) on a finn. nat surface (not a bed). You may place a pillow under your knees, or bend your knees if desired.

Tethered tennis balls

5. Lie on the tennis balls for 2-1 minllles.

C// .\PTER

29 LEHN I NG

OBJECTIVES

R'-"'..'"C'gmze the .. ign... of cogmll\e i:U1d perceprual Jetj~II'

De ::ribe ho .... cognlli\e and perceptual deficlI ... lfftCt the abdlf) of the palJem to panlcipale in rehabluurion . J E:tplain 00\\ a patient can be as~l ... ted to com+

pffi-.aIe tor bod~

Cognitive and Perceptual Dysfunction Carolyn A. Cnsworth,

OTR . PhD

heme andlor bod} Image

diwrder. ..f [)e....llbc

ho.... spatial relation ... impairment . , can

atfec.1 tM patIent\', abilit) to folloy. direcIIOn\.

.' E\.plain the effect of the \ anous agnoo;; ias on me pallent'" abllit) to recognize ~ ti muli in the

em-uonment. 6. DII:rerentiaIe betVroeen ideomOior and IdeatIOnal

apra.-,,;:ia. De'-Cribe ho\\ a patient "lID apra-,,;:ia DUght beha\ e In re">ponse [0 di fferent instruc-

uorul

~b

commonl}

e mpl o~ed

in rehabJ!na-

uoo De...cribe ho\l. the p o,) chological and emotional ..,taru ~ of a paltenr \10 ith cogn it i\e a nd percepro.aJ deficib rna) affect parti ci pation in rehabilitation. IS. :\ nalyzc and interpret patient data. form ulate realistic antici pated goals and expected outcomes. and identif) appropriate interventions 'l\hen pre.;,ented v.tth a cl inical ca~ study.

OUTLINE C

_n

... U

Pcn"\;I,t

:,()

Cogrution and Higher-Order Cognition 1150 Perception 11 50 RI.:"pc. S.bll!tle ... of the Ph\ "lCal 'TherOJp, ..t anJ [he O~~ u patl o n al Theraphl 11 5 1

C mK... 1 ' ndllator

"I

Ii pnahz
1153 The .'\euro functional Approach 1153 The Rehabil itative/Compensator;. fFunctional, Approach I 153 CogOltl\e Rehabil ilation and the Quadraphonic Approach 1154 E:o.ammauun of Cogmu\ c and Pen.:eptua! De fiCit .. 1156 Pu rpo~ of the Examinallon 1156 Factors Influencing Palien t El!';amination

Dist inguishing Bet\1.een Sensor) and Cognill\e and Perceptual Defici~ 1157 Standardized Cogniti\e and Perceptual Tests 1161 Inter.enllon 1161 T reatmem Approaches 1161 Refocusing Inter-ention 1164 The Impact of ~1anaged Care 1164 Di.,..:harge Planning I

().l

Re\ lev. of Cognithe and Perceptual Detici'" 1165 Attemion Deficits 1165 ,\Iemory Impairments 1166 Impairments of Executi\e Functions

LI67 Body Scheme and Body lmage Impairments 1168 Spatial Relations Disorders (Comple,. Perceplwn ) 1175 Agn o~ ias (Simple Perception) 1179 Apraxia 1181 SummaJ) 1 UP

1157

C

ognitive and percep tu al de fi cits are among th e chie f of con fu ~lOn about and lac k of progress in :- jtlent~ v.ho have su~ t a in e d brain dam age. even among tho.,e v.ho..,e motor ~k i Il 'S have returned. Cog nit ive and perceptual deficits are 'Some of the mO!l t puz7 ling and r:l1 ablmg difficulties that a pe rso n ca n ex pe ri ence Thlnkmg. remembering. reasoning. and making ~e n ... e of the '.I.orJd around u~ IS fu ndame nl al to carryi ng Qui dai ly lJ\Jng aCllvJtle~ . When I n d i v l dua l ~ cxpc ri ence problemli Volin tnc\e c"pacltlc". I t can have a devasl311ng effecLon theu Itve and the live., of thei r famil y" These peo pl e may nf)! be able to live alone. fu lfi ll the rc., pon..,ibllillcs 01 P'4Jd employment. or ., u ~ta in a famil y life and rt.! latl oll · hlp "Jhus. effeclIvc treatme nt o f many pallc nt .., with cauc,e~

brain damage depends on understanding perception and cog niti on. The brain may be damaged through se\"eml mechanisms incl uding infeclions such as encephalith: ano"\ia as may occ ur following near drowning: cardiopulmonM) arres t. or carbon monoxide poi')oning: tumor... that are beni gn or malignant: trauma resulltng from motor vehicle accidenls. fall s. or \- iolent tncidents (e.g., traumatic "'lxm,related injul") , gunshol \\- ound ): tOXIJ1~ ... uch as alcohol or su b..,tilnc.:c ilhu ...e: and vascular dlsea ... c, which ma~ rn. xlUI."~ ;'10 infarct or hemorrhagic "'Irole. The Iarge ... t t\\O gnlup, \..If people \\-h o aC4ui rc cog nlli\c . lOti pen:eplu.ll imp.Un11ent... fo llow ing hr:.un d::unllgc arc per... on .. \\ hll t·"\pt.'rit'lh":~d ... trokc ami LraUtll i.lIic hnllll inJlIr~ I Thl' ph) 'll',II .I ... pt.'l" '" of

f the patl III U~!I .sdch d In n =PC"C· ,.1\ patient ~ho ha U laHu:d.m mil, 1(; rchlal V2~u lar ticnt (( \ \ I th ught to ha\c fC)('dl or It)(aTued ~e 10 d, I area'\. cl the br.un. often n.~ulllng m dl _ ~te rull\c or peIL~ptual delillt . In contras.: palH: 1 u. ho ha\ l" ustatned a lraumal!( hnm IOJUJ") are pr 'lllmed 10 ha\t: £(:nerahzed br,un damage: re ... ultlOg III cogmu\e unpaumem v..nh £c:ner.,dlzcd ddklls In attention. memorY, IcaJ1l1n~. and Ml forth. rather than "'pcclfic difficulties In dl~~ LT~le OOgrutJ\e or pen:eptual fum:tHJO , Ho\\e\cr. elemenu of both perceptual and cognlll\ e d) ~funclHm rna) occur III brain damage ov. rng to either C\'A or trauma. The di~unc­ lion net"een the tv.o group ... of patientl, become partiCUlar!) hluI'Ted "hen one con\ider... the patient v.ho ha... suffered multIple ~lroke~: thJ~ palJent ma~ in fact preM:nt \\ llh combmed element, of bOlh focal and generalized brain damage. Throughoul Ihis chapler. lIle pallenl ,,"h hemiplegIa in v. hom bram damage har., occurred a ... a rer.,ult of a lrOJ..e will be lIle focus. The pnmary objeclJ\e of Ihis chap· ter h to introduce the reader to concepb relating to cogniu'e and perceplual dysfunClion folio", ing brain damage. An importanl focus for !he physical IherapiSl should be an unde"tanding of how a particular cogmllve or perceplUal unpairrnenl mighl be manifeSled clInically. and ho" examinalJon and treatment of movement disorders might be adjuMed to capitalize on the abili tie:, and minimize the cognith-e or percepruaJ limJllllions of lIle palient. DeficilS in lIle cognili\ e or perceptual domam m ust be conSIdered 10 aceuralel)' delermme lIle patien.. s lIUe residual abiJilies. Usmg "'IS of direction~ thaI would confuse a patient with apraxia during a specific examinauon p rocedure may paint a picture of a greater or differenl motor disabili l)' lIlan lIlal "hich aClUally exlSlS. Often lIle first cl ue 10 a cognilive or perceptual problem appears during initial sensorimotor te~ting. Awarene5.s of the po\Sibilil) and nalure of cognlllve or perceplUaI defiellS will signa1!he !herapiSl to redirecl lIle melllod of lesting. panICU-

Iluau n

Ch:IpI r I and

me

Iarly !he inslIUclional selS and cues.

Cognition and Perception The perceptual-molOr proce" is a chain of even IS Ihrough wh.ch lIle individual seleclS. inlegrates. and mterprets sumuli from Ihe body and Ihe surroundmg cn'!ronmen!. Cognlllon can be conceived of as Ihe melhod used by lhe central nervous 'y"em (C"IS) 10 proce" mfonnauon. Cognitive proces~e~ include knowing: un?er~tandl~g. and deei"on makmg. rhe dlffieu, 1dgemenl awarenes5.. J U. _, _". I)' of separallng pereeplual and cognlllve defle.1S " readd) apparent. both in patient bcha\lor and In contmdlcWI) c~n­ {,;cptuaIi /a tion5. of the~ two domalO~ of IU.I1(:lIon, _For -xample accoroIOg to ~()mc author~, cognitIOn I~ conccl\cd eo I a~ a .gencra. I I.•'- rm Ihal Illcludc ... rw-rl:cpllOn, attentIOn. ,'~.• _ ory] Al:(;ordmg to other author .... perLCp t h In k mg. an d mem '

nn an umhrella lenr that "ll mp bOIh cogn ~or Ind \ I uaJ pc--- :e-ptll n III uhc(;npone'1t Nih Illne there l!!o nsuff (lent resLri.h C'\'ldeoce 1t u ge v.h approath IT'oM accurately reflects the \loa) Voe 'hmt about and pcn.clvc mformalton \\11at l~ dear I at..- rmaI .. fUnLtlOOlnp- perceptual 'lnd \.ognul\e ) U"m .are a ~ e Sdr} tC) 10 uccessfUJ Interac.Hon with Ihe eOVIr n. mcnl. Bccaur"c the majOTlI) of Yo Irk In Ih,S field doe ,j, Ilngul~h netv.een cognilJon dnd perception and Qecal1!.C It probahl) ca\Jer 10 learn dbout the e proce ~ tnd. \ ldualJy. the) are defined separately for the purpose\ t thi~ chapter. Cogniti\ e and perceptual capac Hies are dearl) prerequiSJle ... for Icarnm~ and rehabihtauon 15 largely a learrunfOe proce ... \, 1.1llU"O, It I~ not ... urpn 109 thaI pdueOl \10 Jlh ccgmthe and perceptual dis.ordl!~ are limited In theIr abill1~ II learn -.elf-care and actl\ 'tie ... 01 dail~ Ji\ing CADL, blh. hence. a ... a group. the) are more limned 10 their pOlenlial for achieving independence: In an) rehabilitallon program geared tov.ard achie\ement of maximum tnckpendence. there i~ a compelling need for therapi ... t ... to learn 10 recog· nize beha\'ior related to perceptual deficn .. _The therapI'>I S modification of examination and treatment approaches in light of the~c deficits \\ ill en~ure that patient... recei, e the full benefit of the~ .,en ice~.

Cognition and Higher-Order Cognition C og niti o n I~ the act or proce~ ... of kno\\tng. includmg awarene~~. rea5.oning. judgmcnt. intUition and memo0, E\.ecuth e fun ctions are ...omelime ... di-.cu ......ed under thl'" heading as \\elL ExeculJ\e funellon-. include the capaL-n~ to plan. manipulate infonnallon. initiate and tenninate act I\!tie~. recognize error... problem ...olye. and think ab ..tractl~ Commonl). executh·e funcllon ... are categorized a... Tz:l:iJcr order CO~lIill\'e JUlIctionl or mCIU((}f!llIl1lt"/UlIlIlOnr,

Perception Lezak'! define ... per cep tion a~ the integrauon of ...en ..or) impres ... ion ... into infonnation that 1':1 p'\~ chologicaHy meaningful. Thu<,. perception" the abilit) to ... ele"-t tho:-c .. urnuli that requue anenlJon and action. to mtegrJte tho,e_ .. urnuli with each other and \~ ilh prior infonnallon. and tmall~ to mterpret them. The re<.,ulting awarene ...... of object-. an~ expenence~ v. ithm the en\,uonment enable .. the mdi' Id~a to make ... en ...c out of a complex and con .. tantl~ (hangmg mtemal and c\.temal ...en"'OI] ennronmenl. _ . n arc 0 Iten alOlu .. eJ The tcnl1~ perception and se nsa llo . Vvith each other. Sen~ation mil) be defined a .. the Jprrel..lall on of ... timuli through the organ .. 01 .. pe,,:IJI ,en ..e {e_~ •• ')'e, ear ... no ... e. and ..0 forth I. the peripherJI \,:utJJlCl1U" c . . h and "ll ... cn ...Of\ ... , ~tem le.g,. temperJture. la~te. lOue . .1 .. . . d P f(' . ~rtor.. 10 mu .... e forth). or mternal receptor... (e,g,. ee lX d I , - ed a.. lOde-pen en , d j·Olllh) ~ P~'f<.·cpllon c.mllot be \ le\\ ... .111 ' , 1 lar mllft: of <.,cn .. a1l0!1 Howe\er. the l.JUalil) of pern'pllon ..

Chapter 29 Cognitive and Perceptual Dysfunction complex than the recognition of the individual sensatio nY Perceptual deficits do not lie in the sensory ability itself. but rather with the individual's ability to interpre t the sensation accurately. and therefore respond appropriately.l

Responsibilities of the Physical Therapist and the Occupational Therapist Occupational therapists are the members of the rehabilitation team who are specially trained to exami ne and treat cognitive and perceptual deficits in relation to functional adaptation. They are responsible for the selection and administration of an appropriate constella tion of tests and measures. accurate interpretation of results. and fonnula tion of an overall plan of care (POC) for cognitive and perceptual rehabilitation. If appropriat e. the occupational therapist may refer a patient to a neuropsychologist for specific intellectual testing. In thc ho~pital setting, the physical therapist is often the first member of the rehabilitation learn to see a patient wilh brain injury. The physical therapist must understand the nature of cognitive and perceptual dysfunction and recognile that individuals in certa in diagnostic categories. such as those with stroke or traumatic head injury. are likely to behave in ways that indicate the presence of particular cognitive or percepnlal deficits. lO When this occurs. the physical therapi~t should be awa re that it is approp riate to refer the patient to occupational therapy for evalua ti on and treatmen t. The tests and measures described in this chapte r are included 10 assist the reader in understanding the nature of the different cognitive and perceptual disab ilities. They are not Illeant to be used as a substitute for an intensive evaluation by a trained occupational therapist when it is deemed necessary. An understanding of cognitive and perceptual dysfunction may go a long way toward alleviating much of the potential frustration that often accompanies treatment of a patient with brain damage. most of which is the result of inappropriate expectations on the part of the therapist. the patient. and the family. By collaborating wi th the occupational therapist, other members of the rehabilitation team. and the family, consistent treatment strategies may be developed and carried out. with obvious benefits to the patient.

Clinical Indicators Cognitive and perceptua l dericits ought 10 be ruled out as a cam,e of diminished functioning in all patients who have experienced brain damage. Such problems are particularly

115J

likely cu lprits in cases in which the patient seelTIs unabl e participate fully in self-care tasks and has difriculty participating in physical therapy for reasons that cannot be accounted for by lack of motor ability. sensation, comprehension. or motivation. Cognitive and perceptua l dy s function resulting from acquired brain damage mu st be differentiated from premorbid cogni ti ve perceptual deficits (from previous trauma , illness, congenital abnonnality, or de menting process) and from the general confus ion and emotional sequelae that often accompany stroke and brain injury." Often. patients with cogn it ive and perceptua l difficullies may display the following characteris tics: inabil ity 10 do sim ple tasks independently or safe ly, difficulty in initiating or completing a task, difriculty in swi tching from one task to the nex t. and a diminished capac ity to loca te visually or to identify objects that seem obvious ly necessary for task completion. In addi tion. they may be unable to follow simp le one-step instructions, desp ite apparently good comprehension. They may make the same mistakes over and over. Activi ti es may take an inordinately long time to compl ete, or Ihey may be done impu ls ively. Patients may hesitate many limes, appear distracted and frustrated, and ex hibit poor planning. They are frequently inatt e ntive to one s ide of the body and extrapersonal s pace, and may deny the presence Or extent of their disability. These characteristics, all or some of which may be present, often make participation in daily living activities and therapy seem an insurmountable problem. These clinical features are explained and expanded upon throughout the remainder of this chapter. Two typical scenarios are presented to give the reader an idea of when to suspect perceptual dys function. The first case invol ves a patient with a right hemisphere stroke who presents clinically with a left hemiparesis and good speech. Upon observation in the nursing unit, the patient appears to have functional strength in the unaffected right extremities and fair retllrtl Oil the affected left s ide. Yet the patient seems to have difficulty w ith simpl e range of motion (ROM) activ ities, even in the intac t ex tremiti es. appearing confused a nd unabl e to move the arm up or down on command. The patient cannot seem to follow instructions for wall..ing w ith a quad cane, cons tantly confuses the proper step sequence, and is unable to maneuver a wheelchair around the co rn er w ithout c rashi ng into the wall. This patient shou ld not be dismissed as uncooperative. intellectually inferior. or confu<;ed. In this ins tance. the patient is likely experiencing difficulty in spat ial relations, right-lcft discrimination, and vertica l disorientation, or perhaps left-sided neglect and apraxia. Further observation and examination ... hould reveal the prcci ... e cause of the difficulties. The second case involves a patient with left hemisphere damage and a resulting right hemiparesis and mild ~11)ha­ s in. The patient can respond reliably to "yes/no" questions 10

:~I~d I ....Ihlt' In lolh", '''npit' ~lll\,.' ,1.lpc I..'OIllIll;lmh "'1If..:h a.... J UI tht' I~nnl (lll Iht' 1;lhk,," or "(il\t' Illl' Ihl' ..:up" 110\\ t'\t'r. II .l'-l...l,..1 hl p~lllli I\lllll' arm. or iI,l...l'd hllllillil!t' Ih~ I h~r.lpl"'I·' 1I1(\\\.'l1Il'n" dunng all aCII\l' R()t\ll l'~ ll'\l'll \\ tlh thl' un.llll'\.'It'd IlInh .... Ilw pat ll'1I1 dOL· ... IllH rL''''pOlld alld .lPI~.\I'" 101.11l~ UIIl.'()tlllt.'rall\l'. Dunng thl'rap). thl' "'''11IC P;\lIl'lIt I'" ~lll ;1 mat 1.lblt' Tht' thcfapi ... t t'\.p l ~lIIh illld thl'n d('nlOn"'lr.I1l'~ thc proper I cchlllljtl('~ for rolling. to l)lIl' ~itk. 11K' p.III(,111 dol'''' not 1110\'('. Il o\\c\('I'. a mOlllcnt lalL'r \\ ht'll hi ... \\ lie arri,~~. Ihe patient tllli el..!y inill ,lt c~ roilin g 111 all .lItempt to ... 1I llP 10 greel h i ... \\ ife. T he astu le Ih crapi .. t \\ ill fea lllC thm thi ... paticnt Ill<-l) n OI be co nfmcd. ~ Iu hh()rn. 01 ullcoopcrati,'('. a ... indeed he ma y appear. Rather. he 111:1) hl' "uffe ring from a lad., of aw arene... s of body stru ClUrl' alld relation"hlp ofhody pari s (somatagnosia). a ... evidel1l:ed by the ROM te"" incident, and an inabili ty to perform a IiI "~ on co mmand or 10 imilale ge~ llIre ... (ideomot or apra\.ia ). a~ demon\ trated in th e ro lling episode.

IIII1UlIlpltl,:lt~ 01 "'l'n ... m\. HlJlll'" bomb 'l\~\lI lid ... II,,· "" ...... \,

Il·llI. 1·,l·1I II Olll'1I1In~ 1\.· ... I)(lll'l· ....tll· 11rl· ... '·'\·1 II

n

Il'll'

-

I'" I

plOlolilld ,en ...c 01 10 ...... 01 (ol11ml I h" "'l'I"O,\ I_ • . ~ I.:rllllg l• IIll'nl l'oll1pnund ... the plohlL'1I1 ... laL'\.·d h\ II". I' ." ll·nt \\ Ith bl.l111 d;liIti.1gL'. 1X'l'au ... l' thlhl' \l'1 '\ .lh""ll· ... Ih , II ('" .1 II' \ t: t h(' Inul\ Idualto ...elcl·t, "ItCI" mil •• llId 1I11\.'gr.llL' IIlI..'Unllll1.!, 'l'lI. ... ;tllOlI'" to orgill1lll.' th,-' "ell 101 ilppropnall.' .llllOlI Ultl'lI Lui

III Ihl ...... en ...onall)

bII
10 g.'llIl ""Ight 11110 Ihe e\lx'nl'lIL'l' nl the p.lIll·1lI under ... ueh .l'i rClllll'olanl'C" II i . . ellliphtl'lIll1g 10 hnm,l" through the hlOgrapllll'al :llId autogr;lplllL';l1 1,-'POI'" nt "'Ol11l' IllltL'd

lIeurolo!,!"" :Il1d Il l"urn p ... ) l'illllngl ... t .... thl·m . . l·hl· . . \ Il'l 111'"

or l elalives of VIl"IIl1~ 01 eVA .... ParIIL'lII.III~ 11I"'ll'lll'II''''' .IT~'

th e

1"(,,'POlb

of

Bac!l-y

Rilll. IJ BIOd:Il.I \ ;1IIl!

(,ardlll'I'YI

Theoretical Frameworks The thcOI'cllca l ba ... e... ot Ii\\.' appmadll· ... 10 Ihl'laJl~ ,Ir\.'

Hospitalization Following Brain Damage

exmn illl'd ill lhl '" ... ecIHlII. rhe Ihelilpl ... 1 "dllx- gllldl'd 1II1hl" ... dcc tion olc.\;.tminatlon ;1Ilt! Il'e,\llIIenl ;Ippnui,:hl" L'(11l"'1'"

The brain Ihal ha ... been damaged fUl1clions as II whole. j U'I 1 as it do e~ in indi viduals wi thout brain damage. When olle part is damaged. Ihe beh~lVior observed is not merc ly the res ult of the brai n operating prec ise ly as in Ihe ill tilct indi vidual minus Ihe fUll ctiOIl o r th e arca Ihat wa ...... uhj cc i 10 anoxia. Rather, it is an otHward manifestatioll of th e J'(;OI' galli/alion o f th e entire e NS. al multiple level-.. workill g to

pisl ... u... c a cOlllhlnation ofappro,u.:hl· .... !!u idlllg ...l'll·l'lhl1l h~

compc n ~a lc for Ihe loss, I I

Beca u')c of the brain damage. the patient 1I1u ... 1 cope with a nerVQlI't sy~ t c l11 operat ing w itholll normal se nsory input at all Icvel't, both co rlic al and ~ lIbcorti c al. " Normal rc\ponses 10 env ironll1elllal "lilTluli arc dinicult to ohl ain when the Input on w hich they have 10 act i ... deranged 01 incomplete, Recovery of function ca n be attributed 10 \ tru ctu ral reorgani/alion o f the eNS 1I1tO a new dynalllk system w ide ly ui"per... cd With in the ce rebral cortex :.tnd lower

~cgmcn l s,ll.11

A ~ignifkant contributor 10 the clinical pictu rc 01 a patient alter a eVA i .. the Ic"'pOI1"e to ho .. piwli/alioll , I'H un a cognitive and percepllial pcr.. pect ive. when a pal lent i . . hOspltali/eo (w ilh or wil ho lll brain d:HlI
lent \\ il h I hl" thcoreli l'a l lIIodel It I'" 1I11Jlort .lllt In lIoll' Ih.1I the ... c approache" arc 1101 1I111tll" l l~ l'\LlII ... I\l· 1\1.111) thl'liI Ihell' clilllc;1i l:x perl i... e and Ihl' p;l1l l·l1t .... Il"pon"'l' 10 Ihl' l ech n iql1e~. Specilic appl l l·:1I101l ... 01 lhl· . . ~· applll;tL'hl· ... \\111 Ix: pre ... ellteti fnllowlI1g lhc de'l'I'ipllOIl 01' 1lIt11\ lliu,d i,'of lll li ve alld pel'l.:l'ptu:II dellelh illlhl' IllIal ....... et1\,)" 01 Ihl'" dlilptl'l l ~lIrlh c r

illfonnalil)11

0 11 :1 \'il ll l't)' III thl·orl·tll·al .lpplllilL'ht"

1I ,cd hy ol'c llpatiolla llhl'rapI'I'" \\ 11L'11 \\111 ~IIIF \\ 11h palll'lIh who ha vc coglll ll\e ilml pl'rL'l·plll.tI plObklll'" L';II\ t'X· IIluml in l\.vcrhuch and Kat/ 11 ;\IId l ln... "ollll.1

The Retraining Approach Till ... apprnal'h wa ... dl'SlIdx'd hy !\\t.·lhll(.'!1 .1111.1 !...;tl/ I .Ind I t)l'u",c", 011 Ihe rl'lI ll·t!wtlOlI III lIll(kd~ 1I1~ ... 1-.111 . . Ihl' p.llll·llt ha ... 10 ... 1 SOllll·t IIlIC ... th" .lpplO:ldl " Il'lL'lIl'd 10 il' thl' Ir(/fl\ll'I III ttal/lllig oPlnmuli. I hl' ;II'PIO;ldl I ' ha ....... d till thc a ...... lIlI1pll011 thai II dl'lllptl(l1l III {llIl' hlilill H'~'HIII l.1I1 have a Ill'g allvl' Ill1pacl 011 hlalll 111I 1l 1 HII1II1~' .1'.1 \\lInk \11 II l1(k rl y lll ~ i1 ...... llIlIptIOIl 111 till ' ;tppl llllrll I'" 111.11 ... ~tlt... Icalill'd IIl l OIiC I : I "' ~ l',H I ~~' II~'lillt/l' tll o'h~'I"' . III IIlhl'l WO l d ... 11,1II,k l 01 ",I!lIIII}! I' jI" ... ullwd I hl' jlll'IIIIW IIlldl'l lylllg lmmkr 01 Il alnll1~1 I'" I llill PI,Il'IIU' Itl lUll' Iii'/.. \\llh PHrll l' ul:u

L:O~'" I IIVl'

III

lWllTpllla i rrqlllH'lIll'II'" II til

l'lllllllllL' Pl'ri()lIIIUI1l'l' 11I 1111 1l'1 I.I ... /.. ...

\\lll! .... 11111.11 IWI ~\'p't"ll

III 1'/ I II u.... dlllll!! ' IWI" II Il i\l h "'l' I ~'~ Il'd ,)('1\ 'l'plll,11 ~'\l'Ill'l'''' . .... Ilh a"'lll.,.llIl'l l d .1\.11\' 1111' .... 111 , .. IIIIlll·ll\ hll}(~' ;llId Inlllk' ... Wi ll Il· ... ull III 1IIII'rtl\'llif tlh' IWIU'plll,d ... kll ... Il'l l lIl l l'd 10 jll' II IIIII1 1111l ....., IlIlIl11l111,11 I. I "'~"" I ·tll l'\.llIlpk YUllllr ~'I ,tI 'f! dl'lIl1l1l ... lI illl·d Ih.11 ".III1II1~' p,lIll'lI" \\ II11 kit Ill' rnlpk~'liI III hllilk dl· ... WI1. III ,ldll ll lll!I\(1 1'/1/1111 1111I1I/l1It:

(\\.'111,111(\ .... I

;Lild \'/\Iwl ((/ludlo//(II/

(U\hl, 1\· ... 11111·"

III IIl1prll\l'111l'"'' \II Iltn l '

H'iltltll~' alld WI IIIII~' . .. lllt()lI ~d l 1111 "' IIl'~ illl 11.l1l1ll1f III

"rca' \\a .. otli:n:LI. BCl"\ll~~ all I'hb rcqullI: Ihe U"l' nllllu! tiPit' ~n'cplll;\1 ,kill .... It j ... thllil.'ult III a"'l:t:rt ..111l pn..·(, I,d,\ \\ hll.'h ~rL'('p(lIal ,1...111, .In: ix'lIlg Ir;lilll.'d during ;11l) one ,~!>'Ion.

.,

Rc,e;lfL'h 10 dat(' h;h nOI lIl1l.'qUI\'Ot',1I1) dClllon,lralcd a "l'!lt'r.1hz.tlion [r0111 pL'n..'cptliai motor trainin
The Sensory Integrative Approach -\)re", de\eloped the theory of sensor) integration (SI) in an elTort to t:\plain the relationship between neural funcnoning and Ihe behavior of children with sensorimotor or leanllng problems.:!:: The theory. Mrongl) intluenced by the neurobehm ioml literature. describes nonnal se nsory iIHCgrnti\c de\clopment and functioning. defines patterns of . . en"o~ inlegrati\'e dy~function. and suggests treatment lechniques.~~ Sensory integration can be defined as the organization of sensation for use.::~·::..\ integration of basic sensorimotor functions (tactile. propnoceptive. and ves tibular) proceeds in a developmental ~equence in the nonnal child within the context of goa ldirected. meaningful activit). 11 is assumed thaI the produclion of an adaptive response facilitates sensory integration, \\hich in tum enhances (he abilit) to produce higher-level adapllve beha\ior1lo. Scnsory integration i~ thought to occur at allle\'eb of the nervous syMcm. The underlying as~umption for treatment is that. by offering opportunities for controlled sensory input. the therapist can effect nonnal eNS processing of sen~ory information and thu~ elicit specitie desired motor response1lo.:::~ The performance of these adaptive re~ponses. in tum. inf1uence~ the wa} In \lyhich the brain organize~ and Pfocesse~ ",en~atjon. thus enhancing the ability to learn. Some of the treatment modalities employed include rubbing or Icing to provide sensory input. resi\tance, and \l,clghtbearing to impart proprioceptive input. and the usc of '1pinning to pro\. ide vestibular input. FolIO\\-ing the contfollt:d \cn\or) input. an
gmllvc dy .. lwH.:tioll 'Imllar 10 that of t:hlldrl'n wtlh IC;:lmmg. dl ... "bdllic\. and Ihal th" i\ IlCl·ilu ..e 01 the ph}'''llogle.11 ch ..mgc .. a ......ol·li.ltcd with aglllg along ",lIh emlronmcnt;:lll) Induccd "'CIl'-iO l"} dCPflV
T h e Neurofunctional Approach The lIellrofimctiolial approach was first described b) Giles and \Vilson in 1992~'l and is based on learning theory. In cOlll rast to the retraining approach. which assumes that transfer-of-training cun occur. the authors of the neumfunctional approach assume that patients with acquired brain injury must practice ever) activity in its true conte\! in order to recover function. Hence. the focus of this approach i~ on retraining rei' I world h!...ilh rather than on retraining ~pccific cogni tive and perceptual proce ... ses. I . G ·II e... '" argues. tlat reme d·muon approache ... arc largel) unpn.wcn and thus may re~ult 111 little functional impn'l\e· ment for the patient. He abo "IuggcSh that compt:Jl"'Jlo~ s!...ilh. or techniques are taugh t to i.l patient \\ ithout ...·on~HJ· ering it" the gain ... t1li.U.!e in term ... of 4Ui.tlitj of life JU'.. lIh thl' cOI1~iderabk effort reqUired.

The Rehabilitative/Compensatory (Functional) Approach Pmhahl) the 1l10 ... t \\ ldel~ u"l'd ,IPPfll~ld\ 111 tr\'.I1I11~ pt'r cl'ptual dl.'lkll... " Ihl' II'hahlb/tltll ''''/,( 'J\,UIl(\ ll 1II'I"0(u1I \ (abo ICiL'lI l'd hl "' Ih",'/'I11(/1 "PI'Il'euhl. \\-tlll It 0111..'1 ... 11;1\.\11 lIl".11 ~ll pr.l~ Ill,lI 'UPf"-'11 tur Ihl' ph\"I .....tl thl'I,II'I't I lit' h,l ... ll· ,,"''''Ul11ptu11l''' undl'rh Ill!! thl .... Irrrll.a\,.h

!"",

1154

Physical Rehabilitation

arc thtu adu lt., with brain trau ma wi ll have diffic ulty genera li zi ng and IC:.trning from dissimi lar tasks.·1-1 Direct re pe titi\·c practice of specific functional ~k ill s that are impaired i!o. an elTicien t means of e nh anci ng the pat ien t's independence in those specific ta~k~. More recently. Fi she r~~ ex te nded the work of Trombl) b) ( I ) articulating more exp lic itl y ass umpti ons made about people within the rehab ililHtive/ compensator) model: (2) generali zin g this mode l beyond persons with physical d isabi liti es 10 those wi th developmental. cognitive. or psychosocial di sabilities: and (3) add ing coll aborati ve co nsultati on to ed ucat ion and adap tation as stra tegies used to effect change. The proponents of thi s approac h favor address ing the functio nal problem ove r and above the trea tme nt of it s underlying cause when workin g wi th an adult post-stroke population. For e.xample. a pat ient wi th difficulty in depth and distance perception. w ho is th erefore unab le to navigate a flight of stairs. wo uld be made awa re o f Ih e defici t, provided wilh external cues 10 compensate for the perceptual disorder. and wou ld repetitively pract ice adapted techniques for safe !o.tair climbi ng . The more closely the therapeutic practice situation resembles the home s ituati on in terms of stair depth and he ight, amount of traffi c. lighting. and !o.O forth. the less general izing is required and the morc success the pat ient is likely to have when he o r she returns home. However. problems might still be displayed in depth and distance percept ion in olher areas of daily function. tn this funct ional approac h. the rapy is viewed as a learning procel.,s that takes into cons ideratio n the un ique . . trength!o. and limitations of the individual patient. It is composed of two complementary components: compensation and adaptation. I Compensation refers to the c hanges that need to be made in the patient's approach to tasks. Adaptatioll refers to the allerations that need to be made in the human/social and phYl.,ica l environment in order lO facilitate relearning of ~kills. In relation to the human/ social e.nvlronmenl. the therapist is concerned with altering the actIOns of others' funCtioning in the environment to enhance the patient\ performance. To compemate for the dil.,ability, the patient lirst has to be made aware of deficiencie~ (coMnitire awareness) and must t.hen be taught how to circumvent them using intact

sensalIon, and perceptual ;kills. The patient ,hou ld be instruct~d il~ spe~ific techn iques and assisted in developing success ful lunctlona l habits. The pa tient w ill need to be taught to attend to cues from the environment to enhance ski ll performance. The therapist helps the pat ient identify an~ then call upon the~e new cues. For example, jf the patient h'ls a v isual field cut, the therapist should explain that because of a visual problem, the patient is seeing only one half of the environment. The pallent should then be shown how to lurn the head to compensate for the deficit. Environmelllal scanning could be IIlcorporated into general therapy sesSion ... as well. A few geneml suggeqions when tcaching compensa-

tor) tcchl1l(jucs arc: (I) use 'iimple directions: (2) estab-

li sh and ca rry o ut a ro ut ine; (3) d o eac h activity In a con sisten t manner: a nd (4) e mpl oy repetition as much <.IS necessary. Adapta ti on refe rs to the a lt erat io n not o f the patient\ 'i lrategy. but of the env ironment. For exa mpl e, if the patient ca nl1 0l differe ntiate between ri g ht a nd left. o r lends to neg-

lect the left , ide of the body. a piece o f red tape on th e left shoe d urin g gai t trainin g wi ll a ll ow the patient to attend

more easily 10 the le ft side and lhus to follow the therap ist 's instruct io ns more accurately. The th e rapist can use this fun ctio nal approach to assist palient ~ in improving ~ pec ifi c motor skill s related 10 trea tm e nt goa ls . The re are several inhe re nt be nefi ts to the rehabilitation/compen satory (functional) approach. First, in the c urrent managed carc e nviro nm ent th e re is a limit ed amount o f tim e for inpatient re habil ita tion .16 Th e refore, th e rapiMs need to co ncentrate on outcome-d irected re <.ll - life functional activ ities because independe nt performance of these act iviti es at home is the ultimate goal of the rapeutic intervention. In terventions d irec ted toward spec ifi c funct iona l outcomes arc typica ll y reimbursable.31 In addition, the (\ct ivi ties are age appropriate. spec ifi c, and clearly re levant to the patient's concern s. For thi s reason, they tend to be the most moti vat ing. The tasks can also be incorporated into a daily hospital rout ine. Dress ing can be reinforced at

bedside by the nursing staff, and eating skills can be reinforced at each mealtime. T he major lim itation of thi s app roac h is that the methods le arn ed in on e task are not typ ically ge nera lized to th e pe rforman ce o f a n o ther ta s k . Th e functional approac h has been c riticized as the teaching of s plinter skill s, in w hi c h the ca uses of the d ys function are not

addressed.

Cognitive Rehabilitation and the Quadraphonic Approach C?gni tive rehabilitat ion focuses on trallling IIldi viduah with brain injury to stru c ture and organlle II1formation. 37 It addres ... es me.mory, hig h la nguage disorder.... a nd perceptual.dysfunclJon under o ne 11mbrella.·"~ Ini"omlHtlOn proc~ss lng. problem solvi ng, awareness. Judgement. and decis l ~ n making ~r~ among the areas included. The Iherapi ~1 lISlIlg a ~og l1lll ve re medi at ion approach mi g ht be concerned wuh the patient's perceptual style. IIlciuding pe rceptual st rategy, response to dlilerem types of c ue ... , and r~le and con"'l.stency of task perfo rm ance.1
Gordon"" proVide . ~ . a review

0

f Ihe lit erature penaming to

tntcrventlon stratl!gles for cognitive deficits. Research has demonstrated that even III a nOI1-bralllInjured population, skills learned in one la,k do 1101 automatically transfer 10 olh . er tas ks." Hencc. cogni ti ve ... tratcglc,. can be l I,e d t0 f aCI IHate the carryover of skill, leamed III therapy to functIOnal' t ... ~ ac 1\lt IC'. In her multlconlC\t (reatment approuch to cognition. ToglJa-lI proP(h~, th It learnIng can be conccptu' I d . a I/.C it\ a dynamiC inh..'rplil) lx'l\\l'l'n

('h"pll'r 29 (ugnici"l' and P(·ru:plual O",,(uJl(liun

plilCIIl ..d gUJlJl'Iml..'~ to the c\alul!l:tlvC the reader .'0 referred to Toglia and Anreu" Ahrcu I~ ha ... dcvclorM!d these tre.llmC·llt lntlcglc as the {lum/rap/JlII/I( approac" The yuadmphonlc ..tpproa(.h IS an 1I11cracti\"c rchahilttallOll approal:h that prov de a h h IIC pcr"'pcclI\"e for the management ot ~tIO~e-. traumallC hram Injury. hrain tumor..... l:crchral pal ... }. and other neuwloglL l:OndillOn .... The quadraphonic approach u~cs both a rOltrf) and i.I macro per"'pecllve for evaluation and trc<Jtmcnt The macro per"pcctive pro\·ide ... guidelines for the management of lunclional performance and real !tfe occupations. Eva luati on and treatment is accompli,hcd through the use of narrative :.malyc..i ... and synt he,i s of real life occupatlon'i to cxp lall1 and predict the behavior of an indi vidual bac..ed on four characten ... tics: lifestyle. Iife.HuRe, healtlt. and disadl'llfllClge SlaWS. Real life occupation, include ... hopping. cooking. mcal preparation. money management. and mobIlity. The use of thi ... dual perspective provide, a holl . . tic ba ... l\ for the quadraphonic approach. The micro perspective pro\'ides guidelines for the management of performance compone nt s or subskills that include attention. vi ... ual perception. memory. motor planning. poo,turdl control. and problem solvi ng. Evaluation and treatment of Ihe l-le performance components is based on a frame of reference that incorporates four theories: (I) infomlation processing; (2) teaching/leaming; (3) neurode,elopmental; and (4) biomechanical. Diagrammatic presentation ... of the componenb of the micro and macro per,pectivel-l are provided in Figure; 29. 1 and 29.2. An example of a therapi't usi ng thi s approach when working with a patient who has mcmory and leaming problems may be found 111 Abreu 53

(h,lr;!L'ICn,,11C" 01 Ihl." pallL'llI. Lharat:tcri ... tH.: ... 01 thL' liI ... k. IOJ the cn\'lnUlI11I.'llt III \\h ...:h 11 .... pt:rlormcd. I hi ... !la ... It:nnl~d i.I dn/tulllc fIIfcra("/l(nwl aplumu Ii ~~ ll charadcn . . I1I.· ... (II the lI11il\ Idll~tI pallcnt that mighl alrel:t Ic.trJllng inl.'ludl." JI11nnnal10n prOl:c ...... tng ... tralcgic ....

:Ih necll

!1l~taL·ll!!l1ltJOn ( InLlutilllg ..I\\i.lrcnc ...... 01

one· ... own

pcr-

and pnor t:\periclKe. aUllut!e". and emotion .... n"k·(l'"I;lIcd \ariah lc ... that are propo ... et! 10 arrect learning h 1nll;ltlo:)

Hl!.:lutic the natun: of the w..,~ it ...elf (famil iarit y vvith the I;\"J... ... palial arrangemcnt .... in ... lructlOn ...eL and movement .\OJ po ... lural requlrcment..,). and the criteria that arc llsed 10 cletcmll ne thc learner\' abili li c .... Environmental variabl e ... tncludc the ...ocial ,1I1d cultum l environment in which treatment occur .... <\ ... well a ... the phy:,ical context. The cognirin' {reallllem approach proposes a number of treatment ... tratcglc", that Illay be relevalll 10 Ihe practice of phpicaltherapy. Thc ... e treatment ... trategie ... include41 : • L\ing muillple em ironment.., in \\ hich to carry Ollt the trainlllg activll) to enhance tram.fer of learni ng. • Analping the characten ... tic\ of the tas~ to e~tab li ... h criteria to determine if tran~fer of learn ing in fact took place. · Providing training to make the patient aware of abilities, the level of difliculty of the ta ... k. and promote se lf-exammation of performance. • Relating new information or sh.ill\ to previollsl) learned

oncs. Although these treatment ... trategies are well known within the field of cognitive- perceptual rehabilitation. the efficacy of the techniques remain') 10 be establi\hed with the POSI\troke populat ion. For a comprehe ns ive understanding and

The Quadraphonic Approach MICro perspective Teac hing an d learn ing theory

Client's changes tn occupatIonal performance

'"c

'iii

1l'" Ie

0. C

o

~

E

.E FI9ure 29.1

Ih~ qu.uJr.lpllclIIll.

apprlJ,l. . h I1III.TO per r~l.Il\e I rOIllAhrl'u ~ p IX", \I, IIh pnllll

:>.11111 )

1155

Blomechanlcsl theory

The Quadraphonic Approach Macro perspective

Lifestyle status

~~~IlI

Health ca;.

system ~

Individual's and ca retaker's therapy Individual 's balance, sallSl actlon.

and Interdependence of occupations Client's capacity for action

Figure 29.2 ' -he quadmphonic appnmch m.llro pt.'P,Pl'l"II\t,' (From Abrl'u,-I p IX7. \\llh Jl('mU"'Hm.1

Ll festage status

Examination of Cognitive and Perceptual Deficits The u'\c of "'y\tcml.ltic clitia collection provides th e sc icnIdie ha"i\ for guiding in tervention. 11 '\ imporl nm:c cm1l101 be ovcrcmphHsilCd wi th n;~ pcc t to a ll ril cct~ or the rapeutic intervention , including remediation of cognit ive and perceptual dy\fullclion. Task anal.ysi o;; is the brc:tkdown or an aCll v lly or 1 ~I'.. k into its componen t parts together with II delJllcalion of the \pecifit: motor. pe /'ce plll:l l . and cognitlvc abilitle~ nece ~~al'y 10 perform each cornpollcnl. T:v.. k analy\i~ I~ another 1001 c r i l ical 10 ap proprla le 111L:/'ape lltH: InterventIon , For examp le. Ihe sireng th, ROM . (Inti balan ce ahilllie~ I1cccl.,l.,ury to accol11pll l.,h bed mobi l ily alld amhu lallon a(:tlvitie~ can be dear ly dennt..:d hy th e ph Yl., icHI Ih el' " npi ... !_ IIowcvcr. Ihc I.,pc<..:lfit: perceptual
ct.'pllwl ami cog niti ve rcquircllu': lIt '" lor ... uccl· ... "' ful

CO lli pie

lIon 01 a la ... k. th e Ihcra pi ... 1 ClIllllot "' lIl1plil y th t: In... k 101 [ht: palR'nl i.ll1d proJ! rt: ...... l vc Jy upglade II

P urpol>c of th c Examination J lu

pH:' eUlT

01 (O!!l1 ll1 ve and jlt:n.:qHuill

dy\IIIIlClllll1l1l1l ... 1

hl' llll1l l1l1l l'" d II I ...... U. . pl·c.: l l'd 10 hi.' Illl l' IIl'IIII ~' w illi Ih c pallcnl\ "hiJlly 10 l.IIIY 0 111 IUII('"Ilol1:11 itlIlVllll· ... ,1 Pt'llt'Plll;,1 IX'r!Ollllilfll-l'" ]l0\lllvl.'ly U)II i.· ldll·d WI lli ahll ll Y 10 pnfOJll1 A DI howevl'l, II I ... ol[l'n ddllulll [(I nUIl·III Ii.· JiIK'<.:d ll IWln'plllill tll·lll'lt... ,1,dl·;tlll·d lrolll tl· ... IIII ~ ", llh \ I)l'

llill l'll ""-111,01 tumtum,,1 ,"lIltt y II lId I O\~ ,1 I~ 11111'. 1111 1I1i11 Il'SIIlI~ I II Ult l,II i.·d wlll'lI tlll'H' I ... iI I II ill I IUllit! Ill ......

uncxp lalm:d by mOlor deficil, ",cl1"ior) deficit, or lIt'liL'IL'nl cOll1prehcn ... ion _ " \ hould be nolcd Ihal 1101 all arc.I' 01 fUIK l lonal llh"i llI'l! Iyp lca ll ) detl'l'led \\ ilillll thl' 11O"'plial \c l1in g, It l "i 1101 Unl'OIllIllOn for Ihe p.llli.'111 In pcrform ,Ide. qU
(hnplcr 29 Cognilive and Pcru'plual 1>,.1;fllnCliull

A f
Factors In fluencing Patient Examination Psychological and emotional status plays an important role in the patient's abil ity to cope with d isab ilit y and with the testing situation. The therapist needs to be aware of behaviors that reflect a patient 's psyc holog ical response to illness rather than particular cogni tive o r perceptual ab ilities. Psychological adjustm ent to disabili ty depe nd s o n m any faclOrs. inc luding age, vocational statu s, ed ucati on, economic situation. atti tude toward the reacti ons o f oth ers, family suppon. and feelings of com petence prio r to the onset of disease (see C hapter 2)""4' When examining psychological and em otio nal status the following should be noted: whether the patient is confused; the level of comp rehension fo r verba l instru cti o ns (wri tten and spoken); whether communication is enh anced through the use o f visual c ues and demonstration: the ability 10 recognize errors: the leve l of cooperatio n and init iative (whether the patieOl is realistic abou t capabilit ies and goals): and emotional stability.50 Distu rbances o f emot ional response are evidenced by rapid and frequen t mood changes and low frustration tolerance. Difficult tasks may cause a catastrophic reaction. 45 The patient's abtlity to detect relevant cues from the environment or to discriminate between relevant and irrelevant stimuli (necessary for cognitive and perceptual competence) may be adversely influenced by poor judgement. fatigue. and prior expectations. Poo r judgment is a major Contributor to accidents in pat ients with hemiplegia. This i ... related in part to the dim ini ... hed awareness by these patient; as to their altered capabilities. The amb iguity of having one ~et of limbs that works norma ll y and one set that I'" not functional may lead the pa tient to rely on sol ution s to the problems of daily living tha t are fam iliar but noV. inappropriate.J~ Anx.iety over capabilttic ... may Inh lhlt opllmal perform ance dUring ex.amlnatlOn and treatment. The pa tu:n t \ capaCity to perform optimally on tC"illng and 10 IC"lfIl I...

1157

cnhalll:cd II anxiety can be rcduced:'~ Motivation i<; Innllcnccd by many faum .... among them premorbid personality. It l"i of utmo... t Import<mce tor the therapl"it to ... truc ture the therapeu tic environment ~o that the pallent wi ll be pO"'llive ly motlvatcd to leam to hi"i or her maximum abi l lly.-I~ To this end, therapeutic ta,h lihould be structured to el1"iure succe..,..~. thereby dimlllishing fru~lration. Other factors that may limit a patient"" perfonnance on cognitive and perceptual tes ts include reduced receptive and expressive commulllcation skills, depre!;sion. and fatigue . Prior to a fonna l examinati on, the the rapi!;t shou ld consider the patient's language sk ills, and confinn these observations wi th the speech- language path ologist. The therap iS! shoul d also be aware of any med ications the patient is taki ng and how these may affect perfonnance. For example. many med ications produce d rowsi ness as a side effect that would affect patient perfonn ance during testtng. Fo llowin g stroke . 30 to 50 percent 12 of people are sa td to experience depression, the symptoms o f which can easily be mi staken fo r cogniti ve o r perceptua l problems. Finally, a detenn inati on s hould be made of the patient 's level of fati gue prior to any ex amin ation procedure. The patient 's behavi o r should not be m isi nterpreted because o f a cultu ral bias, such as a lack of ex perience in takin g tests. Premorbid inte llectual ability should be ascertained from an interv iew with family or friends. because inte llec tual abilities may a ffect perfonnance o n some of the tests and measurements as well as affecting behavior in genera i. Premorbid memory should al so be dete rmined. Finall y. it is ve ry impo rtant to conduct a se nsory ex ami nation prior to cog ni tive or pe rcep tua l testing to establis h wheth er th e patient has s ufficient se nsory abilities to proceed with testin g (thi s includes v isual screeni ng as we ll). D is ting ui shing between senso ry and cogn itive or pe rceptual problems is ex plored in m o re de ta il in the ne\.1 secti on of thi s c hapter. Each o f these problems may adversely innu ence perfo rm ance and may also reduce the pati en t's perfo rmance in treatmen t and ca pac it)' to learn fro m treatme nt. The the rapist should be aware of the pote nt ia l fo r th ese problems ari s in g. and see k to mi nimi ze th e ir im pac t.

Distinguishing Between Sensory and Cognitive and Perceptual Deficits Cogn itive and pe rce ptua l dys fun ction m us t be dltlerentlated from sensor) loss. lang uage impaimlent. hearing 10"" motor los!o, (wea kncs!>. sptl"illcil). incoord lll tlllOnl. \ I,ual disturbance ... (poor eyeSight. homon) mO llS h rmiullop, ill ) dlsoric nt atio l1 , and luck of comprehen:-.ion. The;!' lhero.lpi"i l I11U\{ rule out pure sensory llnp ..lInllenh pnor to tt:'\llIlg for cognitive ,md percertu~l l deficih. otht'f\\ i't' tht' therapl... t Illa) IIlcom.!c t l) att nbutt.' POt) 1 rll'rf0nn.Ulce ttl perceptlldl pronlcl1h ami dC'I~n trc:atnu:nt .k'cortltngl) \\hen m fa t the pro hll'111 ha, II "iC:ll'or~ t'I,I"''''' .Inti ,hould be tre.lleJ 4Ullt' d"k l t..'nt l ~. l' hl' lht..'r.lpl'l ,hould (onduct le ... h llf ,.k P

pUlpll1

CPll\~

1 r.IIIIIII)

tou,h .mil P' ( h:r

en ,llllIn

upc·lln.I,tl

un:) la III

(~II\

Iii

('11 ,IIIPII

lI1d

1,1

po IlifllI

(p.III1.ll'11I1

•

II

f,llInc ".111

lOlllhll1l'c! lorIlL.a1

en ,111011

hK,llI/.lllIlIlll,\.o r01ll1 dl"c.;rnl1l1\,111f11l

r,tphl; Illes I.! ,I lid rec.;o~nlllOn oj It:xtUf ) U 10 111 Ihod t!t:Slllhcd 111 (h.lrler 5 I he pi.IIICnl's JII':.lr

,,~ I I I

I I

109 prohkm, hould Oc mled ou l hcforc more cxtcn'iIVC langll.Jl.!~ .mo c.;ngnlll\C le,t ... ,m! conducled "T he thcrapl~1 ma~ need tn conlinn \.\ Ilh the family if the patient wC<.Irs a heanng au.l ano en ... un: II ' avai labili ty during therapy, If In d,)uht. the thcrap" t may need to request te'ting by the 'I"'cch ~ Ian guagc pathologi,t or aud iologist. The Iherapi,t mu\{ al.,o dctcnnine If lhe patient ha~ any \ I\ual Jmpalnncnl~ because they can ea~i1y be miC:;lakcn for I"'rceptual problem,. Given the prevalence of __ nsoryba...eo \J,ual problem.,. the fotlo\.\mg section focu-,e ... on Identification of the ... e Impa irments and the importance of dt ... ungui ... hing between visual and perceptual origins for treatment purpo ...e ....

,I (

Figure 29.3 'ormall) functlonmg visual

~

tern nght and

lefl vi\ual fields. See text for explanation (From Sharpie

p 247, with permis\ion.)

A

L

o

00

2. Total blindness of right eye due to complete lesion of right OptiC nerve, such as trauma

Visual Fields Horiwnta l section of the visual fields

L

A

L

I

(7

A

1. Circumferential blindness ("tubular vision"). May be due to hysteria, optiC or retrobulbar neuritis,

A

O ()

()() Lateral geniculate

3. Bit emporal hemianopsia

due to chlasmalleslons, such as pituitary tumors.

4. Right nasal hemianopsia due to leSIon InvolVing penchlasmal area such as calcified right tMerna,

; OOdY

carotid artery

Occipital lobe

+.....j'-~Genlculocalcanne

tract

Optic radiation

L

L

A

7

5 Right homonymous hemianopsia due to lHlon of left parietal temporallobea with pressure on left optic tracl

Figure 29.4 VI,>udlllcltl ddil.;ll

A

()()

()() Of

6 Rlght homonymous Inf.rlor quadrantanopsla due to partlallnvolvemenl 01 optic radiations (upper portion 01 lefl optic radiation In this caael

dnd

I

I

mg II ~l n.:qlllfl~ Il'~tlng I'or c\.mlplc, II the palu:nt doe m"l, !
L

I

.1'>\(K;I,ltr:d

le:<.lon .. "IIt;S.

cr rnm Chu ... d.

Rloht homonymous hemianopsia WIth no pupillary change due 10 complete Involvement of Ine left optIC radiation

P 114. ",llh pcrml .... lon)

Chapter 29 Cognilhe ilnd Perceptual »Ylofunction

"isual Impaiml.,nts \'j .. ual lI11paJnl1cnh

an:

llIll'

of the nu.l""

l'OlllmOIl

lonn ... oj

,en,~)r) 10 ....... ~ltTcl..'linl! the pallen! \\ nh hCl1liplcgla.~I.'i~ The

k"ion re .. uhmg from a .. (mh' 11M) affect the eye. optic rJdl.lIlon. or \ i ... ual ('orlc\. ~Uld ..,ub'equcllIly the recepuon. trJll'IllI .... ion. and 'lpprecl;.tt Ion of an) \ i.!>ual arra). Vbual unp.llnncnh common!) encountered by patien .... \\ IIh ht'OllpJegli.l mclutlc poor c)c..,ight. diplopia. hOl11ol1Yl11ouo:., hel1uanop"ia. damage to the \ I~ual corte\., and retinal dam,I!!e. A\\~trene ..... of the pre::.ence of these deficit:.. b imporI:~nt ~O ,h not 10 confu...,e them with \'bua\ perceplUai deft-

clencie .... and to en!)ure their con:-.iderarion during treatment planning and therapeutic intervention. The critical nature of the ba~ic \'isual skill s (i.e .. acuity. oculomotor control. and intact visual fields) in forming a va!'>'" for higher le\'t~1 yisua l perception is highlighted by Warren~ ··5~ in a hierarchical model for the e\ aluarion and treatment of \isual perceptual dysfunction. In this developmental model. the ba\ic \isual skills enumerated above foml the foundation for the next level of visual skill ~. \\hich include nsual attention. \'isual scanning. and patlern recognition. These ~kills. along with memor). are required to facililate Ihe highest le,el ,isual sk ill lemled ,i"ual cognition.~J·~~ This model has implications for the c\aluation and treatment of visual perceptual disorders in a bottom-up sequence~ (i.e .. working from !.he "bollom" irutiall) focusing on underlying skills that will then promole reco,er) of Ihe neXl level of skills). Impairments of oculomotor control (control of eye mO\'cments) are a common occurrence follo\ving a eVA. Poor visual acuity is another frequent finding following ;;;trake or brain injul). even in the absence of other visual problem~.~~ Therefore. it is recommended that the patient recei\'e a comprehensive eye examination and have his or her c)eglass prescription checked. Diplopia. or double \'(sion. is often present follo\\ ing brain damage. The patient sees t\\O of the enti re environment. Diplopia is usually the result of defective function of extraocular mu~c1es in which both eyes are used but not in focus. Treatment usuall) consists of exercises for the eye muscles. In addition. the patient usually is insLrUcted to "'ear a patch on alternate eyes until the condition clears. If the condition doe~ not clear. the optometrist may recommend pri~ms. Visual field deficJl IS probably the mosl common visual defiCit affecting patient~ \I,--ith hemiplegia 56 and occurs mOSI frequenlly foliov.mg damage 10 the middle cerebral artery near the II1ternaJ cap:-,ulc.1,I The diagnostic tenn for this deficit I.., homonymou.., hemianop~la. Studies indicate that the frequency of heml3nop>ta following a righl-hem"phere lroke is around 17 percent. - In addition. there i\ a :-,ignifiCam corrt:!atlon bet\.\.een the pre~ence of visual field defiCits and Visual neglecl.~- Mo~t important. the presence of a \ I~Ual field deficit j.., a ~Igillficant prognostic sign, pre diCltng both a higher dealh rale following stroke and poorer performance in ADL. even follOWing rehabilitation ~,

1159

Flgur~ 29 .., demon ... tratc ... the nonnallunctuming 01 the \i ... lIal field .... In v,:hich Ihe 1l!lt ""de of the environment (the hOll ... c) 1\ perceived by the na ... al relma of thc left eye and the temporal retma of the right eye, and the right "'Ide of the cm Ironment (the tree) I~ perceIved by the na ... al retlOa of the right eye and the temporal retina 01 the lelt eye. I The le~ion producing homonymou~ hcmianop,ia IOlerrupts II1flow to the oplic pathway~ on one "'Ide of the bram. Thi, produces a loss of Ihe oUler half of Ihe vI\ual field rrom one eye and the inner half of the \,I ... ual field or the ot her eye. The result is a loss of incoming inronnallon from half of Ihe visual environment (Iefl or righl) contralatcral 10 Ihe side of the bion. Thus, Ihe loss of Ihe left half of Ihe visual field accompanies left hemiplegia and loss or the right visual field accompanie~ right hemiplegia. Fig ure 29.4 illustrates visual field deficils assoclaled wilh a number of les ions to the visual system. ~q The presence of a visual field cuI mal inhibil perfonnance in many daily activities. The patient is usually unaware or the condition and does not automatically compensate by turning the head unless specifically instructed. One or the dangers In this condition is street crossing (Fig. 29.5).60 Another example of Ihe elfecls of a visual field cuI is illustraled in Figure 29.6' When presented wilh a tray of food. a palient with right homonymous hemianopsia may attend to the plate and fork on Ihe left side and fa il 10 see Ihe knife. spoon. and cup on the right side of the plate. The patient might read only one half of the newspaper page. either to or from the midline. Because of its prevalence. it is essential for the therapist to detennine whether hemianopsia is present or not. A number of testing procedures are currently employed. In the confrontation method. the patient sits opposite the therapist and is instructed to maintain his or her gaze on the therapist's nose (Fig. 29.7)." The lherapist slowly brings a larget. such as a pen. into the patient's field of view simultaneously or alternate I) from the right or left. The patient is instructed to indicate when and where he or she sees the targets. To help Ihe palienl compensale for Ihe ,isual field deficit. the patient can first be made aware of the deficit and then be in~tructed to tum the head to the affected ~ide. Patient~ usually require constant reminders at fil1
runCUonalalgnlUcance 01 hemianopsia

-

",

,,, .,

DANGER 1

1

I

I

1 1 1

1

Figure 29.6 A table ~lImg as it might appear to a patient "'Ith right homonymous hemianopsia follOWing a \lroke. The dOtted linc~ indicate thai she may be unable to locate her kmfe. "poon. cup. and so forth. (From Sharpless.'J p 248. With permis$ lon.)

1 1

I

1\\

Figure 29.5 The functional sig nificance of hemianopsia-it may lead to accidents. (From Tobis and LowenthaI ,60 p 78. \.. ith permission.)

Red tape can be placed on the Ooor, mat. or parallel bars to attract the patient to scan to the side of the environment that is not seen. The patient should be taught to look for these cues. These external cues can be slowly tapered off over time. Patients can be instructed that they can devise their own cues to clue them into the unseen side of the environment in situations that have not been addressed per se in therapy. Exercises that require motor crossing of the midline can be used to reinforce visual crossing of the midline and turning of the head. 6 I.fl:! Oculomotor impairnlent is the third potential area of deficit in ba~ic visual skills that is common in patients who have had a Mroke. Eye movements. which are controlled by the extraocular mu..,c1es. arc used to detect. Identify. and derive meaning from object~ and the environment. The) allo", a pcr. . on to become oriented to and explore the critical \'isual a'pcct'" of the envIronment 11 Two type'" of eye mo\ement'S arc important to examine· (I) \ isual fhalion . "' hH.:h allow, the paucnl to mamlain t('K:U'o. on an object a~ Jl I~ brought nearer or farthcr i.l\\.;JY: and (2) ocular pur~uit-.,. v.hH.:h enable the eyes to 10110"'" .IIllO\JIlg ohJCCI and \1 uall) ~(;Jn the environment. Often th~ c}e, \\111 nOllol·

Iowa moving object visually, although the patient ~rru aware of the presence of that object and can locate it if asked. The patient is vi.sually h) poaclive. Oculomotor d) sfunc tion often accompanies visual-perceptual d)sfunc· tion 63 and is frequently related to anention deficits.b-1 Visual scanning can be tested as follows. Sit 0PJxhite the patient. Hold up a pencil with a colorful pencil topper 18 in. in front of the patient's eyes. Slowly move the pencil horizontally. then vertically. then dlagonall). Repeat each direction two 10 three times. Kate the smoothness of eye movements. the presence of a midline jerk or jump. and whether the eyes move together.:!·'" Aside from the vi~ual sensoI) impairments outlined above. many patients suffer from visual-perceptual impalfmen!. Damage to areas of the conex upon which \ isual infonnation converges with information from other ~nse~ may interfere with the recognition and interpretation of visual information. even though the \·isual stimuli ma~ have arrived at the visual cone.x uninterrupted. A lOW failure to appreciate incoming visual sensoI)· infonnation Therapist

B

A

o Patient

Pens nltlally beside patient shead tpoSillon A

and

then moved

Into

t/"le

pa\lent s field of "ew (poSition B )

Figure 29.7 \1ethod for te"ung hemianop"13 (\tcdlfied rr(lTll Predrelll. b r W. \.. nh penn' ... "lon )

<. h ••pll.' 1 2 ') (1\\ III~ III ,I Ic ... ulIl III IllL' I.:lll!l..·, " rL'lL'IIL'd In .1' l'o r l ica l hli n t1ut' ...... f\\ IIH.'n· I'" Ih) ... 1.111'11\..·.11 l·tllll.."PlllldL'lII..'L·

IhL' pll· ... \.·'II..·t· 1.,1 \ , ... u,1I 11I..· ld l'Ub .tIlL! Ihl..' prL·'I..· lll'L' llf \ .,11.11 P~·ll'l·plU.1I dl'tlldcl'f''' Sllll1l.lIl~. tllt'IL' I ' nn l't)!' 11..... pl.U1dl..·lll·\..· ]\\·I\\l·1..'11 .lph"'la. agl· .• 1Ilt! tlllll..' '1I1\..'\..· 1111:111..'1. .md 11\1..'.I ... UI\.· ... ()I \ \... u.II jll,.'I\'\..·PIU.iI d) ... IUIlCIU) Jl .f\' I hm 1..'\1,:1'. \\ lIhlll Iht' n.·.lltl1 III \ i .. H.11 pt'Il't·jllU.li Imp'llnnl..'lll, . thl..'rt' I ' ,I "'1~llIfil..'.1Il1 dlllt'n..·l1l'l..' bl..·t\\L·\..'11 Ihe pl..'I""rOrl1l;\l1\..'I.." of p.lIIL'lll" \\ till ll,;!hl ht·1ll1p!t.·gl.\ .1IlL! IhlN.~ \\ 1111 IL'l I hl..'llllplc .. !;,!I.l p.\lII..·n" \\ Ilh IL'lI hl..'llllpk'gl,1 h;l\L' frel)ul..'llIl) bl..'l..'ll Itllllld 10 p('rfnlln Illl)n.' pnorl~ on 111L·;"Ul"\.·' of \ I,ual pcr1.·t'jHu.11 d~,fun\.·ln)n than p:lIll..'lIh \\ Ilh ri ghl ht'llllpleg!;1. I hu .... lhl..'rapl'h ,hould he ,1\\ ;In.' 1"1' Ihl' Pll"lblitl) of \ 1'1I.11 1~(\·l'p[u.1I ddiclI'. p~lI·[lL""llL.lrl~ 111 Ihe population \\ I(h kit ht'l1l1plq! I,1 1,,'1\\1.'\.'1\

Standardized Cognitive and Pe rceptual Tests \ ,1.Uld.lrdllt.'d 11..'",[ I~ onl' Ih.1I h;t~ .1 unifonll procedure 10 .ldlllllll,lL'r .md ,COn;'. pro\ n.lt:", opt.'ration~" ddinitio l1s fo r

Ilcu"lIl-refCl'elll'ed. oo ;1Ilt! infonlli.IIIOn i~ :1\ ail . Iblc .... olh:"-'nllllg II' rdiabihl~ and \aJidll). \\ ItICIt is e,sell11,11 h,r ,,-,orrt:'ct 1IIh..''1'ret~1I101l of re::'lIlt~. (I" Reslllt~ from ,1.md:mhlL'd le,b of L'Ogl1lt Wll .111d perccption call be coml1Iull1c~lted 10 olhn thcraplsh \\ ho \\ ill ,hare an under'l.mJlIIg of Ihe palient', cap;ICilll" or abilllle~ . SUlldardized [61 .. ('.m ~ ;ldlluni~tered both at admi,sion and al dis('hJrge 10 pro\ Ide thL' therapi",t \\!th a reliable and \ alid llleJ,UI't:' of Ihe ourCOI1It:' of Ih e l.l.p~ .

.111 It.·nn,.

I'

standardl lt'd te~t. the patient ,houlJ be- '1II11lg l'omrLlrtabl~ and \\l'aring glas::.e:-. and/or .1 he;mng .ud If nel'ded. Ide~lll:. the roorll ,hould be quiel .md free of di,lr.lc tion Tht:' therapI,t ,hould be pO:-'lIioned oPp4..),!tt" or ne\1 10 Ihe p;ltlcnl. Ag.e . gender. Jnd hand dOnllIlaI1Ce ",hould be notet!. In addllion. the perfonllance of J pJllent \\ ho h;17'> had a -.trok.e ma,) \ i.lr~ from dLI) 10 dol: . .I 'ingle tL''-!lOg ,e,:..ion I:". there fore. uSlli.llly unreli\\ hen L'lll1t1uc llIIg

(uJ,!lIifiH'

;lnd Pt.' rc,·t.· ptual l)y ... fUlll·tiull

1161

On:upallOll.tI Ihcr.l pl,I' U'l' iI \anCI~ 01 ... t.ll1dardi/t::u II.."h to dt' ICrtlll1ll' till' prl"t'liu' ot l'ug nlll vc and perccptual IInpalrn l\..·11" and re'lIltmg <.h . . ahillli e,. When ,",elec tin g. J , 1.lIld.lr<.il/cd 11.',1 the Ihcrapl , IIl1U ' 1 cOrl"der 11li.11l) fauor.,. l "he.! ...ekc tllm til..')1l!ml' 011 \\ hat Ihe thl..'rdpl't \\oanh 10 leam .tholll the pall l! ll!. and \\h.1\ the t l!~ t C'1Il pOIl!I1t1all> re\t!al 111 1Il ~11l) c'l,e ... a ... lI1gle le,1 \\1111101 pro\'ldc all the Infor. mation n:qllln~d b) ;\ Ihenlp l't 10 plan Ircat mCllI , ~o ... c\;cral 11.."" lila) be ati1l1ini,tcred (Table 29.1 ),"'" In addition to tho~e pre",entcd In rable 29.1. othcr more global In ... trul1H: n" u'l'd 10 1llca\ure the outcomc or rehabllitallon are the {l /(telical OIlfCOIIIl'S SlIIdr (\lOS), Shorl Form IIt?ulth SlIn't'Y (SF _3()).l'ol rhl'I"UPY Oll1come IH easlire (rO:\'-I).8~ Ihl! Callueliall Gcnt/wliollal P(n/ormwll'e \leasure (CO P \/ J,t'f\ R/\'('mu.'acl Rl'Jwlnliwfioll C£'11fH' LIfe Gou" QlIl'.\lioIlIlClire,s, Rt'i llll'grarlOli 10 Normal Linllg Index ( RI\ L l. os;.. ami the F /llIclJOl/al II/dependence j\'leasure ( FIMHR\\T ).so.) Some of tile::;e ins trumen ls also incorpordle ilems that meas ure cogn it ion and perception. Fo r example . the Fl i\ I\IR ~\I i nc l ude~ three cognitio n-relatt:d items (memor), problem ~olv i ng. and soc ial interac lion}. The lest... d e~c r ibeJ 11l the section on spec itic cogn itive a nd perceptual defici l::. are used wide ly in the cl inic. Alt hough some of the instrument s presen ted arc 1101 standardized. the) are ~ti ll

to

useful. particular!) for e.xamining the quali ty of re~ponse te::.t slimu li.

th ~

Intervention

.1

able ':-\ number of ,hort ,e, ... ion, ..;chcdulcd on succC!'t"I\e dJ.:' are preferable. To enhance Ib practte ..11 value. pen-eplu.ll le ... lIng 1l1u ... 1 oc dOlle ill conjunction \\ ilh ob,enalwn III ... elf·care and ADL 'h.ill" \\here Ih e pJuem', Judgel11t~nt .111d di"crllllln:l[i\'e .lbililie, \\Ith regMd to real·life I.l">h., C.111 he detenllllled. II I' not un(ommon for PJII~llh 10 te . . t poorl) for \i ... ual-pCfceptua1 kill, hut 10 perfonn JdequJtel,) III \DL \\ ilh 1ll1l1im.11 ('tlon or J''''ht.LOl·e.1!>-I The 4uallt~ of the p.Hlcnt', rc'poll'c to IhL' tc'l 1lh..·lh.1 e g hl)l,l. Ihe t.I'h. h ~Ippro.\('hed. ho\\ and \\ h,) the amr i, mad) I' J~ Impon.1Il1 to noll' ;.I ... Iht' ... UCCI' . . . . or f.lllurt' III ~omplclmg Ihl' L'lcctcd t.hh.. SUIllL' .I . . pech o f re'pon . . e III the te't1n~ ,lIualiOIl or dunng .\D L c.m ~ ~fem.'d 10.1:" the patlem' Ino)\ IdU.ll pc 1{t'/ullal \"/,. Included undt'r thl rut'lnL' .lfe lhL' pallL'nt', pc.'rl.Crlll.1 1 'Ir.lleg~. ft"POI1'l' hl \JIltlU ... cue, ('Udl ;,J, .Iuttum). \ \,.lI.d, .11ll! 1
T r eatme n t Approache s Fiw major approaches 10 cogni ti\'e llild perceptual rehabih· Hltion are cOlllmonl) employed bj occ upat ional Iher:lpi ... t~. The) are Ihe rt'traillillg approach. the Si'IISOI,)' illlegralin' approach. the I1l'IIrojilllC(iol1al approach. the reizahilittl(ioll COlllpl'lISa(Ory approach. ~md the cogll;/;\'(' rdldhilitario" c/ uuelrul'Jumic approach . These approaches \\ere

de'cribed earlier in the chapter. Although research dil1."C(l~ comparing the etlicI,llh ttl\.' rt.·I1ll'JI.t1 .1I1d l"l)1l\IX·lh.lIt.lr~ .lppr\'.ll'hc .... \ dt.',\.·nplI\.ln 1t

Table 29.1 Suntma.., of Sla n chu-din·d Tc.!'>.~ Description Arnadottir OT-ADL Neurobehavloral Evaluation (A-ONE) '

This test was developed to measure a patient's neurobehavlor through dally lIVIng tasks (dressing, grooming, hygiene, transfer and mobility, feedmg , and communicatiOn). Occupational therapists must undertake a 5-day trainmg and certification course to qualify to administer thiS test. A wide variety of cognitive and perceptual Impairments can be detected with this Instrument.

Structured Observational Test of Function (SOTOF)"

The SOTOF was designed to examine older persons' level of occupational performance and neuropsychological functioning following neurological damage of cortical ongtn.10 Th e instrument consists of a screening test, neuropsychological checklist, and four ADL scales (eating from a bowl, pouring a dnnk and drinking, putting on an upper body garment, and washing and drying hands). AHer analYZing observalional data , a wide variety of neuropsychological deficits are extrapolated. 59 ~~~~--~--------~--Allen Cognitive Level Test The ACL is used as a screening tool to estimate a person's cognitive level. Although (ACLr ' n originally developed for use with cl ients who have psychiatriC problems, thiS test IS also used with people who have acquired brain damage, or experience a dementlng illness such as Alzheimer's disease. Following an interview to gain information concerning the client's educational and work background. the client is observed performing the visuomotor task of leather lacing . It is assumed that the client's cognitive functioning is reflected through his or her motor actions. 1 Chessington Occupational Therapy Neurological Assessment Battery (COTNAB)73

The COTNAB was designed to examine cognitive and perceptual deficits in patients 16 years of age and older following stroke or head injury. The battery consists 01 12 tests divided into four sections examining visual perception, constructional ability, sensory-motor ability, and ability to follow instructions. Further information about this instrument may be found in Stanley et al 74 and Sloan et al. 75

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA),6

The LOTCA is a battery-style test lasting 35 to 40 minutes and composed of 20 subtests that examine four areas : orientation, visual and spatial perception. visuomotor organization , and thinking operations. The instrument was developed for use with people who have experienced stroke, traumatic brain injury, or tumor. Further informat ion about this test is contained in Katz et al. 77

The Behavioural Inattention Test (BIT),8

The BIT was developed to examine clients for the presence of unilateral visual neglect and to provide the therapist with information concerning how the neglect impacts the client's ability to perform everyday occupations. 79 The BIT consists of nine activitybased subtests and six pen-and-paper subtests. Many of these test Items have been used in the past in a nonstandardized way to examine for the presence of neglect.

Rivermead Perceptual Assessment Battery (RPAB)80

This instrument was designed to examine visual perceptual impairments in patients following head injury or stroke. The RPAB is a battery conslsllng of 16 periormance tests that examine form discrim ination, color constancy, sequencing. object completion. figure-ground discrimination , body image, inattention, and spatial awareness. The test can be completed in approximately 1 hour. For further Information on the RPAB, the reader is referred to Jesshope et al. 81

Rivermead Behavioural Memory Test (RBMT)82

This battery was designed to examine everyday memory abilities. It offers the therapist an initial determination of the client's memory function, an indication of appropriate areas for treatment, and enables the therapist to mOnitor memory skills throughout the treatment program. The RBMT can be administered In approximately 30 minutes by occupational th erap ists, speech-language pathologists, and psychologists For further information on the RBMT. th e reader is referred to Wilson et al62 8J

the kc) componenh 01 thc ...e two maIO approache ... i .. ou\Imed belew•. A di ... l:u ...... lon on educa ti on I... al ... o provided bc(.'au!<.c no intervention program wou ld be (.'omplcle with out the prm I.. ion 01 education In hoth the pallent and the carcgi\4,,:rs "10<.111). J dl ...cu ...... ,on 1'0 proVided on II1leglilling Ihl!:-.t: threc clcll1cnh w ithin a n.:hahtlltatlon proglalll.

The Remedial Approach

RClllcdiai approachc .. flX.:U.., on the p~lIiL'nt'.., deficib .md allclllpl 10 il11prmc functional abl1l1) h~ retr.ullIng ... pedtic pcn.:cplu ..11 cOlllponcllh 01 heh~l\ I Of. ~~ "Illt' d ...... umptltlO unitIng 1111'0.....cl 01 I,KIIl'''' I'" Ih.lt Licilit~ltIon of. or tr.umng tn. untlcd} In!;! "'~111 ... \\ III enhalll'l' the recO\ cr) or reorg all1l,1II0 n

I1l1d P,·(n·.,III,,1 I)Ylrjiwl( liun ( ' 11I1I)1""r 2'/ ( '"lIuiIiH' ...

C,"

ddl~'Ll'l1l IU'h. lh'1111l~ '\ 1'111"'. III 111111. \\ III .nlln ',dh 11.1I1,1.lh.' lIlh.l 11I1PltlH'Ilh.'1I1 III IIUh.- IIPIl.tI ,}..,dk 11\·1 II ~ •

I"

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.11l.' ,11"0 n..'km:d III .1' hOllUI11 Up

rill"\,.' ,Ippm.h..-Ill"

\\llt}..,

hU1I1

IIlL' hlllhllll,

thl' n,'Ul\l'I\ 01 Ul1dl'd~ til!! ,1-..111 .... ;Jnd d".. UIllL' th;1I ,,!!IIx: .Ink- to !!I.'l1l'r.lhll.' ,}""II, 10 nn'up.IIHH1;\! fxrt"llnll,Ull'L', ,dlld, ,....11 .1 h'glll" k'\L' 1 1 I \dudl

I'

1h\' p.IIII..'tll

Inl.' .ld,lpt1\ L' the

llr t.:o11l1X;n,.II~)r) appro;ll'h 1lli.1I1dilll· ... (iln:ct fUIlCtion.11 ... 1'1.111,

th.1t .ln~ dL'licil'llt II dOl"'>

Il· ... pcllul

10 Ihl'

\\ mid h.'l'dhal"J... I'" 1.' ...... l·III I.1 1 10 till' pal ll'lIl\ k'illllillg. 1hl' P l of a \t.:rhal COnfiml i.IIIOn by the thcrapi ... t n... 10 whcther or not the patient fCachcd Ihc end of the;: para llel bars. KP m ight includc eOJ1lment:.. by thc therapist conce rn ing thc adequacy of the patielll \ vi ... ual ~canl1l1l g, pOSit ioning of thc lower cx tre;:mitic .... correct po. . . turc. and appropri ate usc of the upper h mb~. For thc palien t w ith com municati on IInpai m1enls. the feedbac'" would have to be vbua l. Tacti le input abo can be u"tCd dTecli ve ly to cue pmients \\ ith eilher right or left hemiplegia. A comblllalion or i n pll t~. lIsing a num ber of scn..,ory modnlities. ortcn facil itates patient success :'1( a givcn tas k, W hen involvi ng the patient i n ed ucati on sess ions, Lhe pallenl mus t be addrcs~ed as a com peten t adult. and not pa tron ilcd. He or she m u::. t be regarded as the principal participant in the rc habi litation process. In situati ons 111 \\ hich the percep tu al deficit does not interfere wtth

ur

The\dapti\e Compensatory Approach tr:.UIlJllg III

hUI 111m hl' ti l ... hl' l'\Pl·lll·IIU· ... ilnd 11111 ...

11/0.1

nOI

.l"UIlK' .IUIOII1;IIK l'arr~ OYC'f

fro1l1 1.1'1..., that arC' not ob\ I \111,1\ ,"11IIar III the fUIH:lI11nal ta,!.. 10 ht... lei.lnled. and thu ... 1l\1Il;nll/C:, thl' Ilced lur gencral11at1on In an adaptl\e 01' ''Wr.Jn\\n'' Llprrll~ll:h, Ihc therapi ... t \\or"' ... \\ IIh the p.lliel1t pt'l'ilk 1;1 ... ", ... Ihal .\n': reqUIred, or thme that thc paticnt \\J]U" 10 ;1chlt:\C'. In other \\oru ... , tIlt., ther;:lpi,' .. tal1 . . at the tl'P, \\llIeh 1'" the dc,irt::u func tlollell ollteome. ra ther than ,\I,r\"'lIlg \\ IIh the pat ..:nt on the underi) IIlg perfon1l3nce lll!1lp<.mL'IlI ... , I~ Table 2<).1 pre~cnh ;t compari'lon 01 the J"umptl(111'" underl~ IIlg the rC1I1t!'dlai amI adapt1\'e

1)11 ...

Jppro.ll'I1C ....

Patient, Family, and Caregiver Education EducalJon for tht!' patll'nt. ral1l1l), and can.!gi\'cr ... i'i es ... ell l1al for COnI1J1 Ull~ of care. The p~lIicnl and careg i \'er~ ,hould under ... l~lnd wh) il I' ina(h i~ab l c or lI11pO"'~lbk 1'0 1' the pallent to do some Ihing ...... afel) or Independcn l l). and \\h) olher 1i1l1lg, 1I1u')t bc done in a "'pec i fic W,:l), E\plall1l11g Ihl! rea,oil". why the patient hchan: ... 111 a partll'ular \\Jy reduce ... the lIJ...el1hood of lI1Uppropriatc e\pe(talion~ from tho,e \\ Ithout the bucJ...ground to J...no\\ that brain dUI11i.lge utTech not ani) hO\\ the p:.uient 1110\'CS

Table 29.2 Common Assumptions of Adaptive and Re medial Approaches Remedial A ch

-----

The adull brain has limited potential to repair and reorganize Itself after Injury.

The adult brain can repair and reorganize itself a~er InJury.

Intact behaViors can be used to compensate for ones that are Impaired

This repair and reorgalllzation is Influenced by environmental stimuli.

Adaptive retraining can facIlitate the substitution of lIltact behaViors for Impaired ones.

Cog11ltlve. perceptual, and sensorimotor exercises can promote brain recovery and reorganization.

Adaptive AOL prOVide training In functional behaviors.

Cognitive, perceptual, and sensonmotor exerCises prOVide Iralnlng In the cognitive and perceplual skills needed for those exercises.

Training In specific, essential actiVIties of dally liVing tasks IS necessary because adults With brall1 Injury have dlHlculty generalizing learning

Remedial Iralnlng In cognilive and perceplual skills Will be generalized across all activities requinng those skills

Functional actIVIties reqUire cognitive and perceptual Skills

Functional activities require cognitive and perceptual skills

Adaptallon and compensation Will lead to Improved functional per1ormance.

Cognl1lve and perceptual remediation Will lead to Improved functional porformance.

1164

Physical Rehabilitation

a ... "lmilauon of mformation. the patient should have the major role in the deci . . ion making proce ..s regarding the goah of therap).

Refocusing Intervention ~lany clinicians begin an intervention program by adopt-

mg remedial ~lrategie ... In the ..e circum\tan.;e!'... therapi\t.., are aimmg to ma:"omize reco\el) of function and educate their patient<., about the problem" expenenced and way.., that can Imprme their fundlon. Ho\\ever. some patients rna) not make much progre...,.~. In some ca"e". [he patient rna) have inadequate language .. kills to be able to work \l.lth the therapist. or rna) have limited im.ight to hi') or her problem .. and merefore \\ill not \\ork \\ith the therapi .. t. In other c~~ still. Improvements simply do not . . eem to occur for a \ariet~ of rea..on!'.. that the therapist may not be able to pmpoint. Finall). m the current climate of managed care. the therapist rna) not ha . . e very much time allocated to \\ ork \I. ith the patient using remedial techniques. The patienr"s di",charge ma)- be imminent. and yet he or she may not be mdependent or ...afe enough to be dl,>charged. In ... ueh ctbes. the therapist may s\\itch from a remedial approach to a compen ...atory one. \\ben u... ing an adaptive compensatory approach. the therapi",t \\ ill addre... s education of the caregi\ers 3.'. welJ as the paIlenl [nt.er.ention .. trategie"l will focus on changing the em ironment or the "trategy for task completion so that the patient can be ...afe and mdependent as quickl)- as po'o .. ible. In man)- instance'). therapists u...e a three-point approach to mfer.·ention y. here they educate patient... and caregiver.... begin the program u~ing remedial technique~. and then wdtch [0 compen'>allon lechnique .. when the patient· ... impro....ements ha\e plateaued and/or dl....charge i", immment.

The Impact of Managed Care The mtroduction of managed care in th~ L.S health care s)"Item ha.. many implication'> for treatment of patient .. \\Ith cogniti ....e and perceptual deficit .... The mo . . t 'otriking of the..,c i., the reduction in time allocated for mpatient e . . aluatlon and treatment. '(:; Cognitive and p-:rceptual problem" are not readily \ i. . ible and are therefore more ea.'>il)- O\erlooked than ph)'oical problem are discharged to a safe en ... ironmem. Although inpatient rehabilHation time is reduced. there 10; more opportunity for outpatient "en.·ice ... conducted In the cliniC or in the patlent":o. home.'/1 The ad . .·a ntage of home care 1'0 that theraplo;ts ha....e an opportunit) to y.ork \\ith the patient in hiS or her own t:nvironment, and tailor therap), to the patient ..

current circumstances. Patient .. \\i1h cognitive and perceptual defiCIt:, often perform better in their oy.n famHlar environments. The major disadvantage of reduced inpatient treatment lime for many patients. including those with cognitive and perceptual deficits. i~ that a home discharge may not be ..afe after only limited inpatient rehabilitation. The SItuation il;, complicated by ha . . . ing (0 discharge a patient who doe~ not have family support to another type of institutional care (possibly a nursing home or sk.illed nursing facilit . . . ) when \0 the long term this level ofeare may not be neces~ary. It I .. distressing for patients 'Who are confused OIJ. ing to cognitive and perceptual problem., to be moved. particularl} when they rna} believe the move is permanent.

Discharge Planning Discharge plannmg begins as soon as the patient is admit· ted for rehabiJitationY; The mo!'..t important question LO be answered during this stage is where the patient \\ill h .... e upon discharge. There are tv.·o major types of housing avaiJable to persons \\ilh di~bilities: community-based accommodation and ~upported aceommooalion. Community-based accom· modatlon includes private homes. retirement villages. and hotels or rooming houses. Supported accommodation rna) be defined as any accommodation mat provides pef\onal care and medical services on a consistent. continual. or per need basis. and includes nursing homes. s.killed nursmg faciliriel). tbs.isted living centers. and sheltered or group hou~ing.9-1 'J~

The key (0 discharge planning IS (0 consider the match between the pauent\ skills and the demands of the environment. and then factor 10 [he s.upport system . . available from a "pause. friends. or famil) to as"lst . . . . ith tasks that the patient cannot rnanage.<J:I % Thi!'.. approach works well \\hen patients and their familie . . hav'e msighl and an under· "tanding of the parient\ problems. Howe .... er. cognitive and perceptual deficits are often not . . Cf) \' bible and it may be difficult for the family and the patient to under . . tand the functional impact of the...e deficit". For example. a pauent may regain full motor function follow 109 a stroke. but experience ongomg difticultie~ \\jth unilateral neelect. Thi.:; problem b not readil} apparent to the untr;ined onlooker. HOlJ.e.... er. (hl'i patient cannot drive and may be JO danger \\hen ,>irnpl, cro... ..,ing the road. The ... e problems have major life ... t} Ie implicariom, for the patient. In(ervention~ that facililate a patient\ return to commu· nity-ba ...ed housing u ... ually center on enabling the patient to carT) out ADL ... kill ... 10 an acceptable and .. afe manner. If thl'S cannot be achie . . ed and the patient doe~ not have a live·Jn caregiver, then ... upported hou..,ing ... uch a..... a nUf'iing home rna) be the only aiternalJl.e. Re ...ean.:h e'<.ammine: the di'ocharge proce ... " for a sample of 6"2 pallenr... follo~ing o;troke revealed thallhe majority \\ere relu(;tant to con . . ider

,11 1I.' 1I1;IIIH· ... It l H' WIII II1 I! 1I 0 11 1l' ( k "' pll f..' hit' Itl ~ "' 1 ~'lllll l'; 1I11 ,dl (,Il l' dd U. II .. 'If> ()III h llll ' ll1 t' ., 4.l' III,,1I 10 \ \ ht) WI.' m l' a ... III,iI\,li u.ll .... llld 11 1' \4,."\ 1111 114.' uII IOi pall l· nl .... palll l' lIl ;ul ) thiN' \\l l h 1l l11 lh: d 11 1'1~ h l. 11 ) tlIIIJl' I ' I ,11lt1 .lIld m.:l:l'pt Ihal ,hl'\ l.t ll Ihl 11l 1I l-!c,,' j 1I \l' III 111(,' l:OllllllUIlII )

Table 29.3 Summary uf Cognitive and l'crCl'pt11U1 Irnl)uirmcnlh

Are. of DeAdt Cogn ition

Attention disorders Susta ined allentlon Selective attention D,v,ded allentlon Altern ating allen tlon Memory disorders Immediate recall Short·term memory Long· term memory

Higher-order cognition

Executive functions Volition Planning Purposive action Effective performance

Perception

Body schemelbody Image disorders Unilateral neglect Anosognosia Somatoagnosia Right-left diSCrimination Finger agnosia Spatial relation disorders (complex perception) Figure--9ro und discrimination Form discnmlnallon Spa tial relations Position in space Topographic diSOrientation Depth and distance perception VertIcal disonentation Agnoslas Visual object agnosia Auditory agnosia Tactile agnos;a Apraxia Ideomolor apraxia Ideational apraxia Bucco!ac;al apraxia

Rc,iew of Cognitive and Perceptual Deficits 1'1 11" "l'llH Hl ,,,

di vided

IIlttl "'l'Vl' 1l

l11emo!") l111I li llrTll Cllt .... 1I1Ip:tlrnlc lIl ...

par!.. . : allc I111011 d c li c ih . 01 cxec utl ve func tion ,

Il(KI) ... duo-' llIe a lld hod) IIllage 1Il1P:l11111CI1I "i. ~pallal relation ... IInpal lll1l'l1h. aglllh !". :lIld :.tpru x ia (Tabl c 29.1), Each c.:al~p.or) l' IlC{l IllP" "'l'" :1

c() I1 ,,'t' lialulIl or dcllcih. which :n e l!nHljl\.'d I( )gl' lh el I l U l'a ... e 01 ulld c r ~ tal1dln g. Information rll..' r1 ,lIlllllg tn cal'll ddk ll will he orgallllcd Identically :1\ hllhm' I DclllllllOll(') 2. Clll11cal F \ ,1Il1 plc ... , Ll" UlIl \rc~1 4 I l'\t lllg ). Irca llllellt SU ggc\IIOll ... l hl' value 0 1 u\\ c lllll g Oil prohable arca ~ or cortical ril e 1Il(l1 c alion of" c orti c al loc i i:-.

d,lIn~lgc 1\ l..'OJ1I l'()\ c l \ ial.

an attcmpt 10 n.: L.lIC thc .,Iud) of neuroanatomy 10 actua l jlal tcnl hdw \. tol Ill\olving co gniti ve and perce ptual dysM fU llcllon All ex.H1111WIIUI1 of c 0l1icai loci \"ill g hc the Tl'adcr :1 .,cn.,c 01 \\ I1I1.=h cogni li\c and pc rceptual dcli c il ~ arc h\..cl) to he \ce ll togcth cJ'. \ ., thcrapi .,h , \\ C ~Ire reqUired to a"ls il:!l Ihe Ixni ent 10 Ilndgc thc gap hc t\\ cclllllaladapltvC bc ha\ior and independ-

cnt Imll tlo n III \DI \ \..1\1 \, \Vhc thcr or not the arc ~\ of the Ilr,ull purpo l1 cd 10 produce a partic ular dy \ funclion appcar~ dillll.lgcd 011 a cOl1lput ed IOl1logr~lph) (CT) \C"11I OJ' otht: r Ill'umloglGl1 0 1 radiolog ical 1t:\1 I.., 1101 a kc) determinanl o f Ihe rch.lhillliHI \C ~Irprnac h 10 Ihl' r;.lp). Thc pal1t:nt .... approac h 10 la,\.. pCrl(lI111'I1Kl' ,Iud IIlc n..: I ~\tl\ l' :>.tn: ugth\ or \\ ca\..nt:\M.~~ (11 Ihe patu:nl (1110tOl. ( Og llltl\'C. ,\I'ld pc n.:l'plll:.l l). \\hic h tht: therapl\t ;\\(C I1i.Hll \ Ihrou gh tho roug h oh:-'l' f\ ~ltl on and te\t IIlg.• \rI..' 111\1I.:h l1 1(llC I)(,It1l11..' 11I 10 Illc '!e1ectlOn 01 app ropn..ll e Ihcltlpc ut K ' tliltl·!!ll· ... thalllhc loe u\ o lthl' Ic:-. ioll . ·h'\tllle ton l\ ~1I1.' dl..''!n ilK'd fo r cach ('Ogl1lll\t;; or p t: 1 CCptua l lil' I1 Ut III l' n ll,lIKc thl' rcade r \. ;.t\"arC IlC:>.' of the lO1I1Plc\ ll\ 01Ix' h;\\ 1(11 .1\(l l bcd to PCIt:l.' plual d c fi t: ll' ll t:ic\ 1 .1J1lJ".I1 I I~ \\ IIh t h e Inol, U'l'd 10 l'"IIIlIJ1l' ( o g lllt i\c 0 1 PCI l\'Jllu.1I dl'lKlh l;HI \ ...' 1\1..'

;1 \

;\11

,lid

111 1"IlIllIllUIII ...·;\!l o n

hct\\l'('11 ph\\1I..\11 .1IIt! o((Up atulIlit! thC I,IPI ~h 1'1l!!i.I!!t"d III 11\'.111111..'111 0 1 Ihl' ,:lnll' p .Il It.' 1l1 I hl~ Illlln\, Ing '-l'''' t 10 11 ,Ii '0 11K I lIdl'\ .,pcl-'I I il-' I rc,n 111l'nl

III

'U).! 'nlhll1"\ 110m Ihl' 'l'l1"lI I111 0 10 1. 1I ,lI h l l'r oj 'I.HlI lIIg.

and

dl"( l llx' d I hl' 1n..' ,IIIl11" nt In h IllqUI" lI\(hl 1l'ln,lllI .lI l' tl1n'l ( k .t"l1 ~ \, IIh Ihl' IU lldlt l1l ,II dppln,ldl ,tnd .ld.lpl.II IIHl III tlll'l'l\\ llIlI1l11l' nl In Ihl"l' 'l'l hlll( 1101l.11

.IPllHMl h l"

---

lio n'!, c\a11lpl e~ are g lVt'1l of ho\\ 10 faciitl;ltt.' Ih~ p,lIit.'Ill·' :-. u cn.~\\ \\ Oil

t1hin a 11\: atl11t:1l1 't:'\101\ . Ill r(lnl\~1I1\l1l " pf'\l\ hh... d hm\ th t: thcmpl\t 1I1Ighi gt:ar language . dCJlHJIl'lr.\t1l'Il'.

u' c of mcdla ,l11d till.' 1..'11\ IIWll1lt.'1lI Il'thl' 1I\dl\ H.l ui\l Ilcclh of thc t"o g nlll\cl~ ll' p\."r,,'c(,lu,tlh Il1lpa ll t"d pallclll The C\ Idl' llI..'C ba'l' illr 11"\.',\1111CIll I' Iwl ' l Inn!:! lor lIlan~ olll1(', c l1~ aI1l1t.· 111 k ·dullqtll." . •tnd turthl'r It"l' dh' IC\.. , ,lIld thl'

Il':>'l',Ul-'ll I' Il'llUII"t"d In ,uPI"\\lrt Ihl' lI dlh: ,t~· \

Attention Deficits n f/Hllt/Oll\ !"Ill' nl.lhlhl~ ,)1 m .ul\ p.tll nl'- \\!th 11I..'oH I'kg l.l hl 111.11111.1111 ,llIl'l\lh' l1 dill In • Ihl·l .lr~ I .1 f1 'qu nt

1166

l'h),icnt RchllhililRlion

l:nlllp lauH 01' Ihl~r;lpl"''''' \Henlion i, Ihe ah iht ) lo ... del't and .w e nd 10,1 'Ill'l'illl' ... tll ll u lu ... \\ hi k ' "llUll anI'OIl ... I) ... uppre ...... lI1g l'\ tr'lIll'lllh ... lI lll ll li.<J· A pa tie lll \\ ho i ... lIIat Il'I11I\C: 01' d l... lr.ll' tlhk \\ 111 11 ;1\"(' diffic ult) in proce ...... lng ~lnd a"ll1lllal lng Il l'\\ In for mat io n 01' tec hniq uc .... 'I)! Oftc:n. palle n" \\ 110 ha\c ,uffc rl'u a eVA \\ ill ha\'c 10\\ am ll";11 k\c:b, .Iml requ ire a g reat dea l of ~e n ... ory input to bt.' alerted to Ihl' em ironme nl. Lo\\ arou ... :l l thus mu ... t be: con,u.lcrc:d a ... a caml' fo r seem ing inath.!ntioll . Four d ilTere nt kind . . o f alt eilli o n are ge nera ll y eli ... cu ... ... cd in the lit era ture. Th t!~e are susta ined attention, focu~ed or se lc clin: ~\Il c nti o n , alt e rnating att ent ion, and di v ided atl entio n. S us tain ed att e nti o n is a ca pac it y to all end to re le\ ant information du ring ac ti v ity. Sustained atl entio n implics thut a perso n ca n ma intain a cons iste nt re .s po n~e durin g a cont inu ous acti v it y. Focused or sclcctire att e nti o n i ~ th e c apac ity to attend to a tas k despi te en\' iro nme mal yi s ual o r aud it ory stimu li. Alter na t ing a tt e nti o n is the ca pac ity to moye Oex ibl y between tasks and respond appropriate ly to the de mands of each task. Dh id ed a tt e nti o n is the capac ity to respond s imullaneo llsly to two o r more tasks o r stimul i when a ll Mim u li are re levant. l 2. Clinical Examples. C linic all y. the patie nt with a d isorder o f s us tained att cn tion Illay re port that he o r she starts to watc h a TV prog ram and the n "just drift s o ff." A patient wh o has to sto p a dress in g activit y 10 talk to the therap ist may be de m ons trati ng diffi culties with focused attenti o n. Pat ien ts who are eas il y di sturbed by m us ic o r other fo nTIs o f bac kg roun d no ise m ay al so be ex perienc ing pro bl em s wi th foc used att enti o n. Hence. a prob lem w it h focused attent io n is o ft en re fe rred to as dis trac tibi lity. Div ided atte ntio n is req uired whe n mo re than o ne response is needed o r more than one stimul i needs to be mo nit ored .99 Selecti ve attentio n is loo required when cen a in ~t i ll1ul i need to be ig nored . Patient s who have d iffic ult y w ith d ivi ded ,md alte rnating attentio n may have g rea t diffic ulties wi th more complex da il y li vin g acti v ities such as cooking a meal or driv ing. 3. L eliofl Areas. Multiple bra in regions are thought to be respon~ ibl e fo r prod uci ng attent ion. T hese incl ude the retic ular fonn ation (whi ch regu lates arousa l), the various ~en sory ~yhte m ~ th at deliver and code relevant sensory info nnati on. and the lim bic ..md front al reg io ns th at underlie thc dri ve and affecti ve compo nen ts o f conce llt ration.I!X) 4. Te.HII1K. Gcncr:,!1 sc reen ing tesb s lich as the Loewe11steill

·· A " " o·I OC('fI{)(J l ional r I1('rapy C nglll!I\'l' ssessm('11 CheutllglOlI OeCl/pli/ioIlUI Therapy Neurological AueS.Hll£'1lI Bollen' (COTNABP' include subte~t~ th at

examine allentlon~1 ab ill ues. To inve~t i ga[e prob lcm ... of altelllion, neurop~ychol ogi~t~ general l) adm ln i~ter the Stroop !£'.\I,Hll the Paced Allditory Saini Alfl'II/t(J1I TeM ' 7·e51 If" (PASA!').lO· and the I ra; I M a/l.lfIg 5. Tn'utllll'llt Sll.f{M(',\1iol/.\ The p ll rpo~e of thcrap) is t ~ Increase [he patien t \ attenllon to appropria tc ~ tllllu it . and dl~rega rd inappropriate ~t lmu li .

Ne'lI/l'e/ial Ap,Jmach, Cl l1l1cally. the ability to attend to a ta ... k ha.., ll11plic:lIlOn~ for the thcrapeutlc process . Pat ient ...... hou ld be lri.uned to scun the vi~ual cn"lron_ ment 111 ~l slow and ",y ... tcm
iI

Memory Impairments Memorv can be defi ned :.1 ... a "mental proce~\ that allo\\~ the ind i'v id ual 10 store expcril! nces and perception... for rt.!c all at a later timc:"J!\· p 7!\ All memo r) i~ not localiled in one particu lar p lace in the ner\ou!'. sy~tel1l: ratha. man) ~1Ild perhaps <111 reg ions of the brain Iml) contain neur(lJl~ w tlh adequate plaslicit) for memor) ... loragc."l(l 1entor~ comprisc\ acq uisition or learning. ~toragl' or relenllo~l. ,U1d rc tric\ al or recal l. 107 Learnlllg I'" a crucial ckm!.!l1t 01 rcihlbil itation. Ir the patient" unab le 10 leam thcllllme in reha· bi li t~Hion may not be well \pcnt. I. tenec. it i... \'cr) il11portanl for the therap, ... t to tal-. e slep~ to e",lu.lte the pallcnl\ memo ry hefon~ beglllni ng ph) sical retra ining progf(lllh. Three level~ of memol") will be c\amined: imtnt'dialc ree:lli. ...ho rt -te rm memory. and long-term memor).

Chupwr 2') ( 'oKnitj,I.' nnt! Pl.'rn·l)(uul Dy",func: lion

IntlttediBle Re",,11 and ShorlTerm Memol") [k/illiliow. 111I111~d iall' "l'l'all 1m (,I \ t" n:lcnlltlll or 1111 nr· nl;lIUlIl that h:l ... 1X'l'1l 'hllt'd fur il fl'\\ ... econd,. Shurlterm I1ll' I1HII' ) IllL·li1.ltt· ... n~ll'nllon (1j" c\Cnb or Icanllm!

1

Ih.1I h;t" t.lk(,11 piaCl..' \\ Ilhl1l ,\ Il~\\ minutt.::-. hour-.. or da, . . ~l Chllll"clil \lImp/n " p;lIil'llt \\ ith illll11Cliiall' recall ~hf fiI.'Ullit· ... m.l~ not t~ "hk 10 relllcmber the in"trucllOlh gl\(,,11 onl) 'l'l.'ol1ll ... lxfofe h) the Iherapl!\1 for \\ h ~\I the palll'l1 l i ... to do. A pmil'll l \\ ilh a ... hort -Il' nn 11lCmOf) problt:m ma) 110t 1..'0111(" had, 10 the ph) :-ic;ll Iherap)

dep;lrt11l1'1l1.

l'\

CIl though Ihe therapist " ... ked him or her

to n.'llInl in <11\ hOllr. t-\l t l'rn;l1i \t.~l). the [haapis l ma y teach the pi.lIil'lH a nc\\ Iran:-;fcr technique. a nd on the

follm\ ing da) lind [hat the patient ha ~ not retained any of the "tep:-. IIwol\'c.~d , P'lliellls wi th :\e\ere :-.hort -term memor) problclll~ may nOl even bc able to hold a si mple comer"at ion. 1 J. Ll'shm Art'as. ~1cl11or} IS a compl..::x capacitj invo lvi ng mJn) brain regions inc luding four of the major ~ truc ­ lUres of the cereb ral corte\ (the frontal. parietal. temporal.
1167

mallilgl' their dati ) IIvlI1g "1I.:IlV ltu.~ ..... llowl'ver. the j1atlt.:nt Ilc:cd . . to haw "Ullll:ll'llt Illl'mOl)1 to u .. c thl'" . . y. . t~lll . hl\ lroll1l1Cn tili prompt ..... ut:h i.1....1 hce-per or a \\ all l'i.llclld,lr l'an hc u. . dul In as"'I ... t p.lllen .... tn rl'111cmhc r thclr rOlltlllC. or tn loo!.. . II their dli.lry. When l'\lc rn ,ll i.1Il!... Jrc u...cd. thc pallen! necd ... 10 he ti.lught hm\ to u. . c tht: lIl. Guidcllne .. for the u. . e 01 ... uch dcvlccs ma) be rou nd In Sohlbcrg and Mateer.l<»I

Long Term Memory l. /Jt'.lillitioll . Long~tcrm memor) co n ~i~ h of early ex pc-

rknces and info rm ation 3cquired over a pe riod or YCi.lrS, Pat leills who do not have long-term memory arc often de . . cribed . 5. Trellflllcw Suggestions. Treatments for assil.,ting patients overcome long-te rm memory impairments arc Similar to those ou tlined abo\"c for immed iate recall and .,hortterm memory imprtinnents. Further infonnati on on the management or memory impairnlenb ma) be found 111 \Vilson and Morral. 1lO Although the li terature contains many studies e\ploring i.1 variety of memol), treatmenlS. fe\~ of these were de~igned a. . randOlni lcd controlled trials. A rece nt Coc hrane Re\ie\\ 111 found ollly one comrolled trail in which al lci.l~t 75 percent of partici pant . . had a ..,tro!..e. The study I~vie\\-cd "ilS condw.·IL'<.I by Doornhellll and De I-Iaitn ." ~ and :-.hO\\ ed that memo!) training had no signilical1l enect on memory IllllxlIllnclll or subjective memory cOJ11plaint ~. The.: C()('llmnc n.'\ IC\\L't" concluded that there is currentli ilhurticiL'nt C\ Itkmx' lit thi" tlillC to SlIPIXll1 or rei'lIh! the eITccthenc .. " of cogllll1\C: ~h.\· bllll~lIioll for 11lL'lIlor) problem .. aflcr ..;tro!..e

Impainnenls of Executive Functions l./>t1iniIl0l1 A . . dcflllcd b) LczaJ.... "l'\cnlll\l' tulh.:lIll n . .

(ons i.. t ul tho:-.c cupaL·I IlC., th ot cll.lbk .llx'r. . LlIl III cn~,lge s uel'C'"" fu \1) in mdc:pe mit'm. pUi po" 1\ l'. ....eI f· . . cn 1118 hchuvim ,,' r"~ LC /iI!.. goe . . on tll de . . "'-nt'ic C\CI..'UIlH'

II hS

Ph~ ,ical Rt~hahiliwlion

IUIll.'IHlll . . a", com.I'tlllg 01 10m 0\ ~ rl;lrrlll g l'tlmplHlt..' IlI,: 'Olillon. planillng. PurPO.. I\l' ~ll· 1I 0 1l . and ~ lkLlI\ l' p•.: r t onn.IIlI.:C. \ (lImon I'" th~ \: .lll.Il· lI y 10 dCll'nnine \\ ha t olle ne~d ... .lnd \\.11\1-. III d(l. It ;11 ""0 l·llr Ompa .....e...

a ltllurc n: alllOlllOl1

(\I1e .... Ill'Cll-. ilnd \\an l .... Voilt lOIl entompa ... l.,c ... goal r l.mnlng and 1;1:-.).. 1Il1l1;lIion....elf ·,marcIle ... s. awan:ncs ... 01 the ~Il\ Ironm~nl. and "ocial
('I

I~Xl'C llfi\..·l' FUllu wl/.\ B('h{H'IOUral Ralfflf.:

Scale. I 11

.

5. "[rearm ellf SIIKKl'.\ffOlI .\ The co mbination of Il1lpu l <'; l ve~ nes .... poor Judgment , poor plannmg abi 1it~, ".nel la~ h of foreSight . whi ch is partu.: uJarl y problemallC III patIe nts wllh left hemip legIa, docs not bode we ll lor Independent func ti oning. The .,event y of th ese impitir1l1l'llh !TIt! ) dlm im.,h .,omew hat ove r tll11e.l ) Allhough SOIllC ge n.cral rcmed lal and adapti ve Ireall11enl ... u gge~l l on ... arc ,Ic:.,cnbcd

he re, lor morl' "'pcl:Jill: dl,t.ul'i rcler to Pon ... lord SI . .lClJ • nan , ..tnt! [)uran and h ... hl'r 11 a Remn/iul \ppWClC/i By prnvlOll1g qructUrt', kcdh.lLk and fO utllle.
Body Scheme and Body Ima ge Impairments Hod v image

1<"

defi ned a...

it \ l ... lIal

and me nta l

Il1wge

of

on e'~ bod y Illal includ!.!s Il'd lll g'" aholl t one"" bod), e... pe·

ciall y III reli.ll ioll to health ~l n d dl... !.!" ... e. IQ The teffil bod.\ !o.c h c m c rd er... 10 a pO\l ura 1 111()(1C1 0 I· ,h'~ bod) . inc ludllu!Ihe rcLulon ... hlp of bod) parh 10 each OIher and Ihe rd.l· lion.. hlp of Ihe bod) 10 tht! en\l ronmenl Bod ) 41\\ Jrene"

Ch ll piL'r 29 C"gniliH' dnd Perc'." ptudl J)",[um.: lion

I' den\l'J from the Illtegr.tllon 01 tacull.. propnoCl·fH1\I.." J,nJ int('rtX~I..·PtJ\e 'l..'lbatllllh. III ,ll..khtl~lfl to th~ IIldl\ Idual", ,ubje\..·I1\~ kding' .\b,,)ut thl' \xxi).! 1" An .I\\arene ... , uf bt..xI~ ,dl~llle I' Cllfl'llkreJ olle of the e~,enlJil l foundatlon ...

h.1r th .... perfonll,lIlL't:: of ~\II purpo~eful motor beha\ 10r. 1111 \\..<:"l,rJing tl) \'.tn Due ... en. bod) Image I~ "j) d) l1anllC ... ) 1\Ihl"I' l1f Ihe txxi) ... chema and thm,e elwironmcntal mpuh rrll\iJing rele\ant emotional and conceptual componl'n["" . . The t\\O tenn .... bod) unage and b(:xly ,",cheme. ;lre often 1I,ed Interchangeably: therefore. \\ hen re ...earch ing Uti' wpic. close attention ... hould be paid to the particular ddinition put forth b) each individual aUlhor. Specific mlpainnenh of body image and body scheme are unilateral neglect. som~uoagnosia. right-left discrimination. linger agno~la. and anosognosla.

Unilateral Neglect Definition. Cnilateral neglect is the inabilit) lO register and integrate stimuli and perceptions from one side of the bod) (bod) neglect) and the em ironment or hem ispace t..,patial neglect of the area ..,urrounding one side of the body). \\ hich is not due a senso ry loss, L' nilateral neglect is also referred to as unilateral spatial ne~!Iect. hemi-inattemion. hemineglect. and unilateral v,;ual inattention.l~ It is important for the therapist to be familiar with this disorder because it is a frequent clinical finding. Neglect following right cerebral infarction has been reponed in be(\veen 12 and 95 percent of patients.'~' The reporting rates vary enonnously due to differences in time selected for reporting and techniques used to detect the nee.lecl. Unilateral neglect usua ll y. althoUQh not always. affects the left side of the body or hemispace. and for purposes of this discussion. we will assume that it is the left. If a patient has unilateral neglect. he or she seems 10 ignore the left side of the body and !oJtimuli occurring in the left personal space. This rna} occur despite intact visual fields. o r ~oncomitantl?, with right or left homonymous hem~anops~a: I~;wever. It is not caused by homonymous hemmnop!oJJ3. \Vhen ".orking with a patient who has unilateral neglec~. the therapist should also detelTIline which senso?, modalities are affected includine "isual, t.actile. and auditory. One or all of these modalities ~ay be neglected. Neglect can al..,o be understood in tenns of the area of space that is neglected. For example. unilaLeral neglect may expr:ess.it.self as a di~rdcr of anenl10n and goal directed behaVIOr 111:

'0

, I fined'" pertaining · Contrale..,lOnal persona I ..,pace ((C I -' . to the body) ,uch a' ;having only .he (lgh. half 01 .he fal:C. or failll1g to wa..,h the left ~ide of the body. or ' . I :,'pace (tha t area 01 ~pacc · Contrale..,ional penper..,ona _ \l,.Jlhm arm di<.;tance). for examp Ie I,aJ'I'109 10 U<.;C OblCCh J on the contrale\lonal .."dc of the meal tray, or ' e (111'•11 arca of <.;pacc · Contrale\l(mal cxtrapcr..,ona I "'p.IC - th) ,u"h be \on d arm Icng ... a~ I'llhng to ncgnllate oh"I'1 11'0 • dc'\, doorv. a} ~ and <.;0 Iort I1 ( IU rill"~ 10<:0111011011

1169

UIlIL.lIcr.Ji Ilcgku I'" 1.11 ... 0 dl'mon<.;lruted h) an Impaired ahillt) 10 att~nd 10 l'lthcr the obJclI or th em Ironment ;), .1 \\ hole It I" pO~"'lble that \\ hi Ie ... ome patlent\ may neglect half of the enVIf{JIll1lcnl. othcr ... rna} neglect half of OhJcch 111 the total em ironment In the tir~1 casco the patient may neglect the left ..,idc of the cnttre vl,ual ~cene (Fig. '29.8). In the ..,ccond ca ... c. a patient may neglect the left "ide of an object. regardle\
/

B

'

Figure 29.8 E,ampll' of ,I dr.1\\ ing h~ .1 p,ltlCnl \uth umlal,·rJI nl'gkl.:l. I hcrapL ... t· ... dr.", in~ III ,I hOll'l' ,lilt! \ .ml \ \ ) hnp.1In."\I I.:llP)Lllg

by

u pal!t'nl \\ IIh UIllI~ltl·r.LlI1l'glt.·d

,'11\ IhllUlll!nt nl!g

Icct foillm 1Ill!.1 , twl..c: (I:n. (I nml (\lrht'n .1IlJ l p 1{)O. \\ !Ih pcnlH ...... H1n.)

n'\\llnh,

1170

ir

Ph" lc.:aJ Rehabilitalion

tIl

£l3 Ef1

ffi

>

A

bB tfI

/ B Figure 29.9 Exam ple of a drawi ng by a patient with unilateral neglect. Therapi<.; l"s drawing of a hou!<.c and yard (A). Impaired COP) ing by a patienl wi th unilateral neglecl-object neg lect folloy.ing a stroke ( 8 ). (From Corben and Unswort h. l20 p 363. wi th pe nni s~ i on.)

head. [n ex treme cases the pa tie nt appears totally indif· fe rent to the le ft side of the body a nd environm ent. and m ay deny th at the le ft ex tre m ities be long to him or her. 123 M ore time seems 10 be req uired to leam to compensate fo r this impai rme nt lhan fo r he mi anop'iia. There is great di ffic ulty in integ rat ing a ll sti muli fro m the left half of the body and persona l space for use in ADL ~k j ll!) . As with hemi anops ia, th e patie nt with visual unilateral neglect often avoids cross ing the midline visually or motoricall y·2 2. Clinical Example.l. The patient may ignore the left half of the body whe n dres; ing a nd fo rget to pu t on the left sleeve or left pant; leg. Often a ma le patien t will forge t to shave the left ha lf of his face. A woman may neglect to put makeup on the len <.;ide of her face. 124 The patient may neglect to eat from the left half of a plate and wi ll ~wn reading
Il,IIICllt\ bCl:illl'iC the IInp.mlll 'nl rna) he manlfeMed dlf krclltl} 111 cilt.:h patll'l1I ,I. Thl' Ikha\"ulI/rallnut/{'IIfIfJlJ {('\I fIJI I J .. .to be used 10 cxamlne ulllle to cueing. b. The purpo<.;e of themp} j", to mcrea... e av.arene ... sof the left side of the bod} and 'pace. Current beheh con. cerning Ihe mechani<.;mc., underlying Unilateral neglect gUide the majonty of treatment approache<.;. Rizzolatti and Berti .!fl combine the popular allemional and reprec.,enlallonal models in their premotor theol) of neglect. The bac.,is of this theory is that spallal attention I~ dependent on several Independent neural circuns. AttentIOn. and therefore perception of ... timuli. i... enhanced as a direct result of acti, alion of mOLOr circuits. as occurs when a person moves. Hence. activating motor circuits of the ipsilesional hemisphere (via volunlary movements of the left upper or 100\er limbs) may facilitate associated sensor) circuit .... Such mo\emenl may in tum lead to Improvements in the processing of ... timuli from the contralesional (left) side. i~ 5. TreOlmem Suggestions. a. Remedial Approach. Capitalizing on the rationale of [he premotor rheor)' of neglect. the following suggestions are proposed. Stimuli that are !)pecialized for the right side of the brain. such as shapes and bloch. shou ld be used to enhance right brain activation. At the same time. the pre<.;ence of stimuli that are kno\\n 10 aClivate the left side of the brain. ~uch a~ letters and num be rs, should be minimized. Use of \'e rbal instructions should be minimized. Simple verbal instrucriom should be used to encourage the patient 10 tum the head to the left to anchor hi.~ or her anemion to that side of spaceY'" In addition. research <.;ugge..,~ that conducting motor ac thities \\ith the left body side. such as simply clenching and unclenching the fist. can improve attemion to the left bod) side and hemispace. R obert~on et ap:!- conducted a study with !<.h indi\ iduals wi th hemiplegia who were as"-ed to \\an.. through a doorway. Each of the subject'~ \\al"-ing trajec lO 0 (palhway) was measured. and il \\a~ found thai all trJjectories were significantl) de\"iated 10 the right of center. The \ubjech were Ihen a...,"-ed 10 clench ;.lnd unclench their len hand<.; pnor 10. and during. \\alking. through Ihe doorwa). The re~earcher" found Ih~lI 1111" proced ure ... igni licantly a''''lo.,ted I,ubjcch 10 center their walklllg trajectorie .... Dlher technique, that h.l\c been u...ed to treat pallen"" \\ IIh ulliialcral negkct Include cye-patchlllg and pn'l1\ gb",L'\'. The,c h~\.' 11I1I4ue" are 1101 l:On 1l1101l III ther.lp) and a fe\ It\\ 01 their tllecIIVe lle ...... I ... illclUllt:d III F\ Idcnce SUlllmilr) Bo\ 29.1 11, Compt'I1.HlfOI\' \ppnwc/i. rhe pmielll i., II1ll1all) educaled .Ihout thL' condilioll. ilnd then ... tri.lt~gll'" 10 a,'I,1

l 'hnp"" 2"

( 'oj.!lItth,· ulltll'(·u:\' IHllull),. .. fun c linn

11 7 1

Evidence Summary Box 29.1 I~Yi(k.~(., .., Add,'..'ssing th e Use til' Cognitive Re habilitlltion kd.nl(lncs tu (ne n 'usc Activit y in Patie nts with U nilat era l N c g lt.-e t Following S tnlkc I 2" Deslgnl Intervention

Rc.,rcrcnt.'t.'-

Subjects

F,lnlh0m€' .11'

Ptltnmts With loct:'nt RH $Iro~.

t~1

1~~5

E

9. C

9

Gondel 1M F). E 63 C 63 Time post-onset (monlhs) E 1.0: e 0.6 Ie ~ 80 yoars ,' gB. no history of dementlfl or psych"lnc problems, nolllnwell, righi-handed, score ...... 6 on Abbrevlaled Menial Tesl, sCO'" , 130 on BIT

Dun,dun

Results

Commenls

RCT Blinded eXdmmer E: Ss wear speCially modified glnsses which provide 9 reminder beep II pallent lalls to move eyes to the left In tl IS-second tnterval C: No t",almenl for visual Ina ttention

<1

w(\eks E Traalmenl2 hours 40 mtnutes per week C No treo tmanl

Altor the 4 weeks, no slgnlhcant difference between groups tn either eye movements or BIT scores

E and C groups eppeared adequately melched on demographIC and clil1lcal dela elthough control group slightly older than 6)cperimental; no baseline BIT data

Pnnciple behind approach: Movemenls of aHecled limb in the defiCit hemlspace led 10 summation 01acliv.tlon 01 allectad recepllve fields 01 2 dISIInCI but linked spatial systems lor personal and extrapersonal space: IhlS resulted in Improvements In allenlional skills and apprecietlon of spatial relationships on the aHected side

Kalra et a\,Jl 1997

Pallents 2- 14 days post-stroke with VN E 24: 23 Mean age (SD) E 78 (9): C 76 (10) Median tmle postonset 6 days (2-14 range) EC TIAs, reversible neurological deficits, hemianopSia or seve", dysphaSia

RCT (blinded examiner) E Spatlomotor cueIng based on attentIOnaHn%( mtegratJon model: early emphasis on restoration of f unc~ lion: C Conventional therapy locuSing on restoration of tone, movement pattern, and motor actlvlly before addressing skilled lunc1I0nai activity

12 weeks Inlliel baseline measures and loll oWing the 12 weeks: meAn Iherapy lime 47.7 hOllrs

6 Iypes of outcome dale

Robertson et al'lj'

30 pallents with lelt vISual field neglecl on BIT: E ~ 17; e 13 Mean age: E 642(12.6):C 63.1 (96) Gender (M/F) E 9111 : C 1016: Onsel of neglect In weeks: E 192 (21 .1); C 10.8 (6.3) IC: presence of neglecl (failure on at leasl lI9 behaVioral tesls); onented to time and place:

RCT Random blinded allocalion of pallents to conditions With blocks of severe versus mild neglect pallen Is; E computerized scanmng and attentional training (Intensive bnehng about nature of subjects problems. feedback on Land R latencies, trainer reinforcement and encouragement)

7 weeks E 15.5 hours (14 sessions of 75 minutes each; 2 per week) C 11 A hours of recreallonal computing

6 types 01 oulcome date

1990

e

collected: (1) mortality: (2) 61; (3) discharge desIInalion; (4) length 01 hospital stay: (5) duralion of Iherapy input: and (6) RPAB (cancellation subtest and dIScharge home) Patients Wllh VN have similar discharge destination despite lower BI scores (compared to petlents withoul VN): spatiomotor cuemg Improves (p '- .05) outcome In patients With VN collected: (1 ) BIT (pnncipal oulcome measure): (2) WAIS-R subteslS (Picture Completion and Block Design): (3) Neale Reading Test: (4) Leiter cancellation; (5) Observer's report 01 neglect: and (6) ReyCFT (copy only): blind lollowup "Ilhe end ollralnlng and 6 monlhs aher revealed no statisttcaHy

Findings suggest thiS Iype of computenzed lralnlng may not be useful on a routine basts: lurther study IS warranted 10 establISh Ihe Iype, Irequency, and durallon of Irall1lng Ihel could produce Clil1lcally signlhcant changes In undalerdl visual neglect

11;-~

Ph, ..ical Rehabilitation

Evidence Summary Box 29.1 E,'idence Addressing the Use of Cognitive Rehabilitation Techniques to Increase Activity in Patients with Unilateral Neglect Following Stroke l29 (ro,,"n"ed ) Reference

ROSSI

et aI'33

1990

Wiart et al'J.!

1997

Subjects

Designl loten-ention

Duration

Results or clinically slgmflcant resulls between groups

ability to consent; abilIty 10 concenlrale suHIc1ently to sit at compuler-based lask for 15 mmutes

C recreallonal compuling (such as games, qUizzes and simple log~ lcaf games)

39 pabents following stroke Wlth HHA or VN E =18:C=21 Mean age: E = 72.6; C= 633: Gender (MF): E = 10,8; C = 9 12 Mean weeks post'stroke E = 4.4: C = 4,7: Side of stroke (ftl ): E = 16:2; C = 13.8. IC: Presence of HHA or VN (HHANN): E = 1216 C = lSi6; EC: besl·corrected visual acurty less than 201200: Inability to comprehend and cooperate with testing

RCT E = 15 diopter plastic press-on Fresnel pnsms (to fit on InSide of spectacle lenses for all daytime activities); C = no prism treatment; Eight types of out· comes data collected; (1) Modified MMSE; (2) MVPT; (3) Line 8lsecllon; (4) Une Cancellation; (5) HFVS; (6) Tangent Screen Examination (7) 81; and (8) Frequency 01 falls

4 weeks; outcomes examined at basefine, 2 weeks, and 4 weeks

Pnsm·treated group per· formed significantly better than controls on the following: (1) MVPT, (2) Une 81sectJon Task: (3) line Cancellation Task; (4) HFVS; and (5) Tangent Screen Examination; there was no slgmficant difference in 81 scores at 4 weeks

C group younger but otheIWlse groups were Similar on demographIC and chmcal background factors Including 8f: while treatment uSing the prisms Improves visual percepuon test scores, " does not seem to lead to Improvements In ADL function 10 patIents With slroke With HHA or unl· lateral VN, Ihus limiting its use

22 pabents posl· stroke wrth severe left lateral neglect (posi· live findings for neg· lect on 31esls): E = 11. C = 11. Mean age. E =66;C=72 Gender (MF): E 615. e 6/5: nme post-onset (mean days): E = 35; C = 30: EC: hIStory of stroke; alteration of general status: cognllive dlfficullies Jnccm· pabble Wlth rehabllrta· bon

RCT E = expenmental treat· men! is Bon Saint Come (one of the authors) method; thora· columbar vest wom WIth attached metal polnler above head; patient POJnts to target on mobJle panel: audible and luminous Signals proVide biofeedback when lafgets are touched; therapist par· UClpates aCliVely dunng the session, stlmulatmg, gUiding, and correcling: C - l-4 hours tradlOOn· al rehabllitabon per day

E = 1 hour/day (20 days) of experimental treatment followed by Iradi· 1I0nai rehabilitatlon (phYSical therapy for 1-2 hours and 1 hour of occupational Iherapy) C - l-4 hours traditIonal rehabllltatlon per day

Two types of outcome data collected: (1) quanti' tative scoring of neglect (line bisection, hne can· cellalion, bell cancellalion); (2) aulonomy (FIM). Data collected: day O. day 30 (after therapy) and day 60. All quantltallve and FIM scores Improved signlf,· cantly more In the E group than In the C group

E group was younger and had a higher Initial FIM score (66) Iltan the C group (54); C group had more, but not slgnlficanlIy so, omiSSions on hne cancellallon (C - 16: E 14) and nght devla· tlons on hne bJSecliOl1 (C 53%; E 50%) at baseline compared Wllh E group: the Bon Saint Come method shows promise and should be further tested

81 = Banhel Ind('x. BIT B~ha\louraJ Inattcntlon TeH, C r.:nnlmi group: I C\pt"nmcntoJl ~roup, I ( e\dusiOO r.:nteria: FI\I = funcuonaJ Indcpcodcm:e \fca~urc J IfVS IIdTTlngton J-1()d,~ Vi II"J l,d,1 '\Ue('IWI

= homon~mQu~ hemianopia. Ie"'" incJu~lon ,"nlena; \1\1<)1:. \1m,·\knl.Jl S,.i1U f'l.Ulunauon \1\1'1 \hltor-Free \'i~ual PerceplUaJ Test RCT .. randoml.fed cumrnJ1cd mal, Rc)(TI kt~ (ornpk, hgure I~t. RH right hem,.~phere: RPAB := Rj'emlcad Pcn.:eptual.o\~se ~ml.'nt Batl~r). S, S uhlnl. uh)a;t 11.,\ transient ,.,..:hemlC alla(~. LK = L'nned KlOgdom: \.... \-J,UoiJ negl«t \~.o\J~·R \\t'(h' Adult HHA

Imeillgenr.:e

Comments

S;':.J.k·Re\,~ed

Chuptc-r 29 ( 'ognilivc .. nd Pcrceptuu' Oy.\functjon :U.' lt\tlt ~·~ HI \..' tkv l",\,,·d. 1:( 11 e,\:lt l1 pk. "lIl'lI Il·.ldlll~' II hoo!.. 01 Ih'\"'PIl IH.· t. a Icd Il hholl

tlhlll.1fttlf

l" \t' l\d u)

Ill.t' tw pl.It.'l'lI

on

Ihl'

!l' 11 lll.lr !! 'tJ allli 1111:

palienl '"

I.UI}! III III "'l"lIIl Itdd.. 1III h, .... [1\11111 a lt l'1 t't)t1lpklin g each

hnl' I ht' l'lI\ 11\111111 1..' 11 1 111 ;1) :t]..,o hl: a clnpl l'd wil[lln thl'" .lfl[ HOlll' h 1'11 1..' PUI IL' tll i . . addn.:~ . . cd alld given 1k'llltlll ... l l illl\lll:>O tmlll Ih l' ullaflL'c ted . . idc. ' I 'he llursing ~t.11I ~h(lutd pl,ll'l' tlt l' plIli L' IlI 'S cal l hulton, lek phone. •lllti tHlll'1 •.·~ ... l'rl1i;t 1 lle ll l~ on thc unalTcctl!d . . ide. A 11111d Il'd 11lll" 111;1) he dr;1\\ II 011 IIII..' .. idt: or lill: pagc Ih,1I I' 1I1'p'1l'l:tl'd . t I" A Illlrrm may he placed in front til thl' p,1I 11.'11 t \\ hill' hL' or shl' i, drl: . . si ng or ambul at Ill!! It) tl t;I\\ :IIIl'lltillll to thl: ll l:gleCIl:d sidl: . r Sl'\l'CII COl' hra ne Rl'\i l' w:\ have been cond ucted conl'l'nllll~ the l..'I'fI..'l'ti\cncs~ of cog nitive and pcrccptLml rdl,lhlht;ltlOll. An u\t'T\ iew o f lindi ngs from small Clll·h r,ItIt.' Rc\ic\\ ~ in tltc arcas of :lIt t! nti on and m C Ill Ilr~ n:h;lh llil:lt ion \\l'rc prl:~l'nled L'artkr. A more 1..'\ll'II~1\ 1..' COl'hralle R.:vic\\' l.!lJ was conducled concern. mg Ih~ clTl'l'lI\ ~Ile.s~ of lh~ rap) for unilateral neglect as then.' h;l~ l~en an abundance of studies
-\nosognosia I Df. 'nlll If Anosognosia I'" a ..e\'ere conditIOn inc luding demal and lacl of aVo arene .. .., of the pre ...encc or . . everil) III (Ine' parJI~,i .... '" Ano~ogno~la i.. delined ....... lack. 01 J'ltarene • or dental. of a paretic extremit) a-, bc longlllg to the p:rson. or a lal.:1\ of m'ight conceming, or denial t. paral)!,!1 Prc~nce of thl'" dl~ability may compronus.e rehablitl<£tlOn potenllal greatl). becau ...e 11 IlIllll ... the pauent' .1bllll) to rl!cngnllc the ne~d for, and thu... ro li-.e. cumpen'ato~ Ic(;hmquC', - C It .1 EXtlnzp/e\ T) pICJII) the p.lIu:nt mJlI1t,lIn ... th.u there nothm£ \\rong and rna) dl ll\"n the: p,lr,th/l't!

J J 7.3

IlIlIb. . :Jlld Ic lusl" to m:cepl rc\pon<.,ibJllt y for them. The pa ti ellt Illll y clfJim tha t the limb hac., a mind of It '; own or t hal II wa . . Ielt at home. or in u c1o\e!. 1. I~ (' .';()II Area. Th e palhogenc<.,i\ of ano\ogno ... ia remain'" lItlc l e Hr.~1I a lthough Ihe region of the c.,upnlmargina l gy ru s hll e., bee n proposed:'1lJ 4. Tl'.\fill~ . Anosognosia is idcntilicd by talk ing to lhe patient. T he patient is
Somatoagnosia [. Definition. Somaloagnosia , or impainnent in body scheme, is a lac k of awareness of the body structure and the relalionship of body parts to oneself or to others. Somatoagnosia is a lso referred to as aUlopagnosia or simply body agl1osia.1 36 Pati ents with thi s deficit rna) di splay difficulty foll owing instructions that require distingu ishing body part s and may be un able to imitate movements of the Iherap ist. 68 Often patients report that the affected arm or leg feel s undul y heavy. Lack of proprioception may underlie or compound thi s di sorderY" 2. Clinical Examples. The patient may have difficulty per· fOlming transfer activities because he or she does not perceive the mean ing of tcnns re lated to body parts: for exam· pie. " Pivot on your leg and reach for the armrest with your hand:· In add it ion, a patient with a body scheme disorder will have difficulty dressi ng. Patients may have a hard time participating in cxercises that require some bod) parts to be moved in relation to other body parts: for example, '·Bring your ann across your chest and touch your shoulder." 3. Lesion Area. The lesion si te is often the dominullI parietal lobe. 59 Therefore, this disorder is 'cen primml) \\ ilh right hemiplegia. l-Im\e\ er. Impi.lImlent 10 txxh "cherne ma) abo OCcur \\ Ilh left hemiplegia .

4.

7i.'.Hillg .1

The pallent i ~ requc ... tcd to POint to txxl) r~tn' n.uHl~J b) the therapi~t, on hll11- or hl'r-..cIL on th," th~rJr\'t, . Uld on a picture or pUlzle of ,I hUI11.Ul ligure 1 . .1II,U1 pmvioe ... dC lalb of lhe~c h.~ ... tlllg rn:;x'Cd\II~"_ ·\n ,",,\.tfllplt.' 01 \ahal (lirc-(>tl\C'" .-mlll the~ Il"'h I'. ""hl1\" me- \I..\ur kct Sho" Illl..' your \ h1l1 P<.lllli III HllIr N ...l." "11k" \"on!... "rlglu" .1Ilt.! "kit" ... twlIlJ not lx- u...ed b.xau lhe) 11M) It.''ld 10 .UlIll,l!..·t:ur.l1e dlJgnlhh III p.tllent ... nho

h.I\I..'
Right-Left Discrimination 1. Definition. A right-left discrimination disorder is Ihe inabilil Y to ide ntify th e ri ght and lef! sid es o f one's ow n body o r o f thai o f th e ex amine r. 122 This includes the inability 10 execute movement s in response 10 ve rbal co mmand s that incl ude th e le rms " ri ght " a nd ·'Ieft ." Pa ti e nts are ofte n unable 10 imitate moveme nt s. L22 2. Clinical Examples. The patie nt canl10l le ll the the ra pist w hi c h is th e ri ght arm and w hi ch is the left. The ri ghl shoe cannOL be di scerned from Ihe left shoe, and Ihe paLie nt is un abl e 10 fo llow instrucli ons us ing the concept o f ri ght- left, such as " !Urn rig ht at the corne r:' T he pal ient cannot d is ting ui s h the ri ght from Ihe lef! side o f the the ra pi st. 3. Lesioll Area . The les io n s ite is the parietal lobe of ei the r hemi sphe re. 122 A cl ose re lati onship between aph asia ( u ~ ua ll y owi ng to left hem isphe re damage) and de fi ci ts in r ight- left di scriminati on ha s bee n re ported . In pat ie nts with out a ph as ia (usuall y Ihose with ri ght he mi s phere da mage ), a re latio nsh ip has been re ported between general men tal im pai rme nt and right- left d isCrimination dborde r.l ~ft 4 Te.HIIIR The pali e nt is asked 10 poin t to body pa rl \ on command. sut:h as: ri ght ear. le ft fOOl . righ t arm . and so fonh . Si x respon ...e ... should be elici ted a ll the pa tient's own hody, on that of the Ihe rap ist, and all a model or picture of Ihe human body.llb To ru le .OUI
s. h('(I/lJu:lI~ .\IIJ.:.~('\llOfI\ If U\ lng a (;()Il1 J1Cn ...:.uory approach. w hc:~ gl ~ ~lIg JIl ... trUf,; tI OIl\ to the p'ili cnt . thc word\ "ri!!hl ' lind Iell \hould he i]vo lded . In stcad . pO III IIll!! or pmv ld IIlg l: ues. uSlllg di \ linguI ... hlllg f calure~ of the limh may be more effec tive (e.g., " the a rm with the walth"). 'The\(! gllJdclJlle\ are part ic ularl y \
Finger Agnosia I. Definitioll . F in ge r ag nosia can be defin ed as Ih e in abil· il y to identi fy the fin ger... of on e's own hand ... or of Ihe hand \ of the examin er. 122 2. Clillical Examples. The di sorde r i ~ characleri/ed by dlf· fic uhy in naming the fin gers on comm and, Ident ifying which finge r was tou ched , and , by some de fi ni l ion~. mimicking finge r moveme nts. Th is de fi cll u ~ually occ urs bi late rall y and i') more common 111 the middle Ihree finge rs . 138 Finger agnos ia corre l a t e~ highl y wilh poor dexterity in tasks that require move me ni S of mdividua l fin gers in relalion to each olhe r. 1 ~ u c h a~ bu lt oning. Lyi ng laces, and typ ing. 3. Lesion Area. Finge r agnos ia may be the re~uh of a lesion located in ei lher parietal lobe,1l9 often in the region or th e angul a r gy rus of the left he misphere. It is o ften foun d in conjuncti on with an aph asic di sorde r,1l6 or wi th gene ral mental impa irme nt. 122.1l6 Bi lat eral fin ger agnosia alon g wi lh righl- left di sc rimination probl ems. agraphia , and acalclIlia is te nned Gerstmaull's syndrome .122 Gerslmann's syndrome wiuall y is associaled with a foca l lesion of Ihe dominant h emi ~ phe re in the reg ion of Ihe a ng ular gyruS . ~9 4. Testing. A pal'l ion of Sauguet' s test 2. 116 i ~ recommended. Saugue t's lest includes asking the patie nl 10 move or poi nt 10 his or her finge r whe n named by Ihe therapi \1 10 deteml ine if fin ge r agnosia is present Belween five and ten commands from the the rapisl is adequale. The lest IS not siandard ized. a. T he patient is asked to name the fin gers touched b) the the rapi st. with (he eyes ope n (fi ve l i me~) and if success ful. wil h vi sion occluded (five limes). b. The pati e nt is asked (Q point to the fin ger!o. named b) the Ih erapisL on Ihe pa ti e nt 's own hilnd ~ ( I 0 lJJ1le~). on the Ihe rapi sl 's h.mds ( 10 limes). and on a \che m~lIic model ( 10 tim es). c. T he pati ent is asked 10 point 10 the eq uhale nl fi nge r on a life-s ized picture when each lin ge r IS (Quehed b~ Ihe therap i!)1. d . The patie nl is asked to imilalC fi nger mo\·emenl~: for exa mple. c url Ihe index fin ger. touch the Ihumb to the middle fin ger. 5. Tre(l(m eflf Suggesriolls. There is ve l') limited evidence to ~lI pport treatment techniques for pmien ls With finger

I t 7~

Clmp'''' r 2'1 ( 'ngniliH' nllcl ""' r"·"pll1.-1 t>)o",fundicHl

·Iglllle-I:! Whl'1l tI ... iug .. n.' l11 l'lilal .IPPI\I;\l'h. Ihl' pal 11..'111 \ di",':rlIl1111:lIl\l' 1;\Cllk' '~'II..'III'" OOlll'h ;lIId pl~'''''III''') ;!lI..' e-11I\lUI.II~·d \ lllugh L'lolh l';\n hI..' u'l'd 10 ruh Ihl..· dm,;!1 . . url;IL'l' of 11K' .Itlt,\..·tl..·d ;lnn. hand •• 1Ilt! rlllgel .... ;\Ild Ihl..· \l'Il!)';\! 'l1I'l;IlT III thl..' .lIlL·l..·ted fln!!lT' . Pn.· ...... ull· ran Ix' ;Ipplil..·d tn Illl' \ L'lItlal 'lId'lrl..' nl Ihl..· hand. For :Hldillonal dl·t;lil . . ,hl' Il';((iL'r I'" IL'lL'lh'd t(l lolt.HI.'

JQJ

Spatial Relations Disorders (Complex Perception) Sl'lIlial rdalium, di .... wdl'P'I elll·Olllpa .......1 l'On~tl'il.lllon 01 I1JlP;\lOJlClih that ha\l' III t.'ll1ll1ll11n ;1 dlnk-ult) 111 pl'I't.'l'1\'I1H! tht' rt'LiIIt.Hl ... hlp bl..'I\\L·l'1l thl' ,l'il and 1\\0 or 11101'1..' ')~I..·.:t .... I.1t1 Rl''''l';ll't.'h ... uggl· ... h th:u Ihl' ught pilriet,li 11..11)1,.' p1;\) ... ;\ pnlll.lr~ roll: III 'p;II..·L' perl'L·plioll. TlllI .... ;\ 'patbl l'\.'ialltll1' imp;unnelll 11\1..1 .. t fr('qul'l1tl) Ot.'l'l\I'" 111 patit'nh \\ 1Ih nglll-.'llkd k ... ion~ \\ lilt n..'sultlllg kfl ht.'IlHpart."i~. 1-10 Sp,\II;11 n:l.lliOlb di ... ordl·I' includl' impailllll'IH' of lig· 1\1'\.' gnl1l1ll1 dl'L'1'iminalion. 1"01111 dl ... t.'rillllll;l1ioll. 'P,III,II n:btI011 .... Pll"lllllll III ... pan:-. ,md tOI1()gclplllt.'a l dl"ont.'IlI,lIiOll. \ddllllln;11 \ l"l1o'patialllllp:Ul1n~nh. :-ut.'h as deplh alld dist;l1I ...·t· pt'rt'l'Jlltllll ;\110 \t'r11l';11 di"orlL'IlI;1I10n \\ ill .1I'll be lh,l'u ......ed 111 thl'" 'l'clmll. In .1 ... tud~ comparing Ihe L'lll.'CIIVCIlC"'" 01 tilt: cogllltl\ l' 1\.'Illt.'lh;lIion t ..olllt'tilllCS rd"'c;:rn:d to as Iht: rr,lm/j'r (~r {rellllill,1.! (('('hlli(/II(I) \cr:- lI :- Iht' !'ulH.-tio na l .lppnl;lch, &Iman ... , \\'d"tL'r, and LIIlL"'olnl",1 found Iha l both .Ippnlill'llt· ... \\I..'1\.' t'quall) ",ulTt' ... ,ful III Ire;IIUlg pcrct.'plUal IIUp.lIlll11·nh. llll\\t.'\t.'r. "'lIlre thl" SlUd) did 1101 control for tht' l·!ll.·Ch of "'p...1lll.IIlL·UU'" ft.'ClWt'1"') III huth groups, furtha o.·'l'.I.o.:h I'" ft.'lJul1~d.

-

Pt=l=i=

-

ne

•••

\Y lJ, ~

3

1

c:::G

~ 4

~ 5

6

Figure 29.10 An l",IIUpl t: (If Ihe ligun:-ground percepllon Ie" (From A) rc~. I4.1 Phllc lA, \\ IIh PCnlll'..,IOIl.)

le:-I picture . from a pO~Mble 'eleclion of ,,1\ Hems (Fig. :!9. 10). This It.':>,t WiI:-; siandu rdl lt:d on cllIldrcn bUI may be u... du l as H t:iilllcal tool 111 identil') ing perceplual I..lt'on.icrs 111 adult, \\]Ih br:.lln damage."' '\IomlJli\e ll;lu ha\"t,~ been gcner..lled for nonnal adult male,. -" b. Funcliolldl It'.,r.,' A \\ hilt: tll\\el can bt.' placed on J. \\ hill' .. ht'ct. and the palicm I" a~ked 10 find the lo\\el. Tht.' IXll lent l'i.tIllx· 'I .. k~d 10 point oul the -;Iee'e. ooU011". and l'ollar of;t \\ hilt' ... hirt. or to pick oul a 'poon tmm an UIl'Ol'tl."d ;\rra) of t:allng ult.'n~ib. II I" nece ........lI) to rule out poor c)e"'lght. ht.'l11mnop"la. \ l"lIi.1l agno ... iJ • ami poor comprt'hell,ion to ImprO\c the \J.lidlt) 01 Ihe'c 1t.'''ling lechnique".

Fih".re- Ground Discrintinution /),1;1I/{iOI/ \n impalnllt.'llt III \ I... ual tigUft.' groHmi di,,tTI1l\lIhlllllll I" Iht' 111abilll~ 10 \ l"u;llI) di ... ungm ... h ,\ tigun: tnll1\ tht' b.ll·kgrllund III \\ hlt.'h II I'" ~11\bt'dtlctl. ~ hmCIIOnall). 11 IIlI('rfcl\.· .. \\ IIh the p~ll1enl'", abilll) to Ilx"uc IIHI'X.)rtallI Oh.lt.'l·h Ihal ;It\: nOI prOlllllll'll1 III .1 \ i ... u,1I •lrr.l) Th\.· palll'lll h;I' dlltkult) Ignonng Irrcle\,lIlt \"1"'\1.11 "'IIII1UIt .l1ld l'annot ,l'It·l·ttht' ,lppropn,llI..· nit.' 10 \\ hidl 10 fl· ... plllld ~ rhi ... Illd~ 1I:;\d tlllh"'lr;\t.'lIhllil). n: ... uhlllg III .1 ,hon\.·ned ,lItL·lltil.lll ... p.ln,P· fru'tialillll, and dt·lTt'.I't·d I1lllt'['I('nJl'1lI ,lIld ....Ift' t'UIlCtllllllllg.~' 2 ('[lIl1t till \,U"plt \ nit' p.HIt'1l1 cannot lo(:;ul' 1h.·Ill'" III a ll\.xkt.'lhllok Ot dr,\\\ L·1. Illl'ale bllll('Il'" on .1 ... tun. l\r til' IUl!!lIl ... h the .lnnhl,k Inlll1 Ihl' rl'I\l;\l1lliL'r 01 ;J "oltd l'Olllfl"U ,hlft rhe 1',1111..'111 111.1\ not ,Ihle 10 Idl \\ hell Unl.' 'tep 1.'1hl .... lI1d .UlPlhL·1 hl,'gllh ~ln .1 Ill!!ht ~ll '1.111'. C'Ill'CI.llh WhL'1\ dl·'l'l'ndl1lg.. It \1." \/1" P.U'll·!\l ("'...... lpll.l1 k"I(lI\' ullhl' n~llI hl'1ll1 phl.'r'\.' .U\d It, , I~LJl1t'nll\ Ihl.' kll h\.'II1I'phel\.' Ulllllll\lnly pwdul..l' IllI' u''''llrdl'r " I. \WIR ,I Ihe hrt I n:/(Ic (""lIl1d In{ ' ... Uhtl· ... t ot thl' \lllith"" {a/ij, r",,, \,.,It " t""Jt:/IIlrIII/ II \(\.1 ~ ft·qUII\.'''' 11ll' UhJ~d hi dl IIngul h tht: Ihrt'\." ,It'llt·\,.'I' In .111 l'lIlb,:ddl'd

-l4~I-'~

5.

rrCIlIUl('fI{

Suggnlioll.\,

;1 NCIIIC'd/al \l'l'l'cl(le1l. The tht'r"lpl"t ,hould .UT-mge fllr pr.ll'lIct.' III \ "uall) locating ObJt'Ch til .1 ... imple Jrr.l~ \ 'UL'h .1"; three \ l:r~ ditl't:rem obJet.'t'- L ,1110 pmgre ...... III Illllre dlflicul l 011\.'" tfour llI' li\ c di",',mil.lr obJCl'"I'" .mJ thrl'c similar om: ... ). h. (""'/I'('1/\llIfJl"\" '/'/II"(I,/l'/J The p~Uit'l1l \... 1,IlIght It.' lx'L'Olllt' a\\.I1~ ~ll the l~\I"'ICIll',"' .l11d n.tlun: llr th\.' dL'lil'1I The ".Ull·1lI ,hnuld lx' 1..·.llll1llIlCd 1\) t',\.mlll1l· ~roup' l)1 lll-il'..'t'b ... 10\\ 1\ ,11\d . . \ ... lem.lIKJII) ,U1d ... h~lUld ~ IIhlrth,:lcd III u . . e lltha. 1111 ....:1 "'(,Ihe ... It' , h'llt'h) \\ hell 't·.lrdllng II" Ilt·m ... "'Udl .1'" d\'lhm~ l\r ,i\\\,·I\\.II\· \\ hl'1l k.tnllng III k",,:k .1 \\hl·l·kh.ur. the p,lIll'lII . . lllluld Ix' .1..1\ I'\.·I..I!\\ I~X,I'l' till' br.lh· k'\\,'r, h\ !\\ut'h r,lIhl'l Ih.1I1 t"l, "'l',U\.hlllt:. h\r Ihl'l1\ \1'11.111\ RI..'\I 1,1Il\,.· 111,1\ lx' pl.lt'l·d In l'r th' \\-'k T\l ... tr ,II' ,11 Ih\.- ... hl

,lr OT1ho ... l ... hl ,lid thl' p.Ull'llt III h X,1I1I1g II h '\\ lICIll ... ... Imuld t"lc: ,,1.Kl'd III lhl' P,lIll'l1l .... dld\\lT ... 0 1 Ill ~hl ... I.llld . ,lIld thl..'\ ... Ihluld 11\' Il'p lac('d III the "' allll' 10Cil Il\lll l',ldl 111111..' Bnghtl) cu lurl..'d lape ca n hl' u,ed to m,lI}.. Ihl~ I..'dgl..'''' nil "'(;IIP.. , Repell tlon 1', a !...c y eicllle nl l)t 1111 ....lppnlOll'h and rq1C ,ltl'd praclicc I, u,cd 111 c<Jeh ,!"It.'I.:If"II..' .Irca 01 dlillclIh) . The , a1l1 c procedure ,ho uld bl..· I..'mplo) cd during eilch pnlctic(' ...c ...... ioll. 1I1corpo r:'11 IIlg \crh.11 cue ... and louc h as adjun c t ... (0 viSion .

Forn1 Discrintination I. Dtlillltion. Impainncnl in form discrimination is thc mahllit) to perceive or attend to subtle differences in fonn and ... hape. The pntienl is like ly to confuse objects of "'1milar shape or not 10 recognize an object placed in an unusual position. 2. Clinical Examples. The patient may confuse a pen with a toothbrush. a vase wi th a wa ler pitcher. a cane with a crutch, and so forth. 3. Lesion Area. The lesion site is the paricto-temporooccipital region (posterior associalion areas) of the 110ndominant lobe. 4 4. Testing . A number of items similar in shape and different in size are gathered. The patient is asked to identify them. One set of items might be a penci l. pen. straw, toothbrush, watch, and the other mi gh t be a key, paper clip, coins, and a ring. Each object is presented several times in different positions (e.g. , upside down ). Visual object agnosia must be ruled out as a ca use for poo r perfonnance by first presenting objecls separately and ask ing the patient to identify them or to demonstrale how they are used . 5. Treatmellt Suggestions. a. Remedial Approach . The patient shou ld practice describing, identifying, and demonstrating the use of similarly shaped and sized objects. The patient should ~ort like objects and should be assisted 10 focus 011 differentiating clies. b. Compell.wrory Approach. The patient must be made aware of the specific deficit. If the patient can rcad. frequently used and confused objects ca n be labeled. The patient ~hould be encouraged to use vision, touch, and se lf-ve rbaliLati on in combination when objects are confused.

)

, ( 111111 01 I \(l/III /t',\

I he pallcnt IllI ghl fino It dlfikull to plat'l' Ihc Clil lc lY. pla tc, ilno ... poem In the proper PO\lIion w hcn ... ctlJlIg Ihe tablc. 'I he palJcnt may he unable to tell the time from a cit)(;k bccau ... e of difficulty 111 perceiving the rcl~H~ve PO"'1I101l:\ of the hand\::! ."J 'I he pallent mil)' have dlfltculty learn1l1g to po\itlon hi\ or her Mm\. leg and trunk III re lation to Ihe wheelchai r to prepan: for

tran \ferring. 1. Lesum Arl'u. The le~ion ~IIC is prcdomlnantly the infenor parietal lobe or parieto-occipital-temporal Junction. u\ually of the right 5. ide.~ Amadottir WI explain\ ho\l. a patient with perceptual deficit~ may have difficulty putting on a shirt. This is illust rated in Figure 29.11. Since the eNS works in a holi sti c way, the !<""k of pUlling on a r.,hin require ... v i ~ua l. tactil e, and auditory infonnation as well as mtenti onal and memory capacities and motor output. Figure 29.11 s ugge~lS that while damage in a variety of brain areas Jllay affect vi5.uospatial processing, the rnO'lt common lesion site is the right inferior parietal lobe. 4. Testing. Recom mended tests include the Ril'ermead Perceptual Assessmem Boner}' (RPA B )sO and the Amadon;,. OT-ADL Nellrobehav;ollral El'aluarion (AONE).5 To improve the val idit y of these test~, un ilateral neglect and hemianopsia should be ruled out a~ the causes of poor perfonnance. If these impaimlents are present. the stimulus array should be posi tioned appropriately. 5. Treatment Suggestions. ~'h e n lIsing a remedial approach. patient abili ty to orien! to other objects can be improved by giving the patient instructions to position himself or herselr in re lation 10 the therapist or another object. The therapist might say. "Sit ne\t to me." "Go behind the tabl e," or "Step over the line." In add ition. the therapist can set up a maze of furn iture. Having the patien! copy block or mat chstick. designs of increa~ing difficult) \\ ill increa ~e awareness of the relationship between one objec t (block or mat chsti ck) and the next. If the patient avoids crossi ng the midline. activ ities that re4uire crossing the midline both motorically and visually can be incorporat ed in to olher therapelltic activities. One spec ific aC li\ ity is to have the patient hold a do\\ el \\ nh both hands. The therapist gu ideh it from the uIl1l1\'01\'ed side to the involved side. Later. the patient can progress to manipultlting the do\\ el with only \'erb::\! or \ l-'lIal cues. and fi nally to guiding it indt:pendently.14(1

Position in Space Spatial Relations IJejinitirJll A "patial rehltions dis.order. or ~ pat.i u l (Ii~­ orientatioll, i\ the inabilit y 10 perceive th~ rclatlon>.;h1J? 01 one object 111 ... pace 10 another object, or to one~ell. 1 hi ... may lead 10. or (,.'o mpound , prohlem.., in con>.;truc tllJllal ta ... ~ ... and drc ...... lng.~ Cro ...... JI1 g th t! midline ITli.l y he •1 prohlem for pillient ... wllh ... patial relatIOn.., dcr1(': lt ~.HCl Sp
I . /)(fillitio/J, Position in SI>Hce impairment i . . the in.lbliity 10 percei\'e <\Ill! to mtcrpret -,p~lIial COl1cr:p" ... ueh "o,

up. dO\\ 11 . undt:r. over. in . OU I. in rronl of. and behilld 2. Clil/ical E.Hmlpll'.\' If " p,ttien t " a . . h·d 10 r;lI~I..· the .Iml "above" the head during ROf\l ;.!ell\ Hie ... or i ... a ... ~t:J 10 placc th e lecl "Oil " Ihe I'ootre ... h. Ihe J1i.lI ll' nl 11M) behavt: a ~ 11 hl' or ... hl' doc ... not "no\\ \\ lUI 10 du . ., 1 l'.\I(n/ \reo The le ... ioll \" w,u;llIy Im'atel! U1 the non· dom1flilnl pa ricl;11 1\lhe .14 \

(,hupler 29 Cognilivc and Perceptual DYlifunction

I J 77

Task 0' PU!1I1lQ on Ihlrt

.

SENSORY INFORMATION

VISual Sbmuli (see shon)

SomahC sumull (touch shin)

+

Auditory Stimuli (InstructIOn)

FURTHER PROCESSING pmcesses (Imnrallobe) ~ Memory processes (Ironlal and tempo1'll lobes) ~ EmotJOOaJ processes (Ironlal and lemporal lobes) ~ Hpi order thought (frontal lobe) ~ Cogllllrv8 'uOCbOflS (Ironlallobe) -ldeallOn (IrO!1tal and pane tal lobes) -Inlenbon (Irontallobe) - MOllVabOfl (Iromal and !emporalt0be3) ~AIt!!nnon

1

•

RESPONSES MOIQf, Emo!lCIf\at or ThoU9h!~

Motor ptalO5 and

~Qf e~tlon

'frontal and panetailoOes) PlC~ up short

\~ r

i")~~

-

~~

J

"-'..:::::...:c-~V

ConIlnUOUS leedback movemenlllltaracuon regarding po$IllOOlng of shirt and how to lind COi'l'8Cl holes

- somabC sensory leedback _ visoaJ feedback regarding spat,., POS~1On of shin _thoughl regarding how 10 tum shirt and scIocbOn of appropnale I\OI8S

Figure 29.11 Spatial relution proce ...... mg a... a man put s on a shin. (From Amadoltlr.t.w p 405. with permi"o.,ion .)

4 TeHink To tc~t function, twO objects arc used. suc h a~ a hoe and a ... hoebox. The patie nt is a ... ked to place the ,hoe 10 different poc,uions in relatIOn to the shochox; for example. 10 the box, on top of the box, or next to the box. Alternallvely. the patien t IS prese nted w ith two obJell., and a.,ked In deSCribe their rclatlon ... hlp, Flu example. a toolhbru\h <.:an he pli.l<.:cd In a cup, undel il

CLIp, and ~o forth. and the pi.ltient i ... then i.l ... ~ cd 10 IIldl· ca le the locinio n o f th e toolh bru ... h. Another mode or te ... ting i-. to h a\~ the p.ltienl l'Up' the thempl ... t .... mallljluli.ltioll \ with .Ul llk'nth...1i 'l'l of ohjecls, For t.!xa rnpk. th e tIH:raplo.,( h,lIlll, lhl' p.IIIt.'111 .J comb ,lI1d .1 bnl ... h. rhe thcrapl-.1 Iht-'n l.th', .111 tlkn lh.:al "'L't .1I1d placc ... th cm 111 .1 p;lrtlnd,1I rl'i.llll\lblllp Il' t.'.ll"h

uch Ih \:omh 0" 101' 01 Ih hru,h rhe p.JlICI1I I r 'I~ I 110 rrangc 111 Ilf lu:r ~l)lJ1h ,Inei hru'\h In till' arne W,lY SUI.:C~ III 1111 t.1 ~ Illily rqn Cl.,t'n t !'ufll l ll"llt llbillty I ) 1/ pu Ilum 111 SIMlC IUlluumall y. Ilgur.: round dlllllUli v ,lpr,''''''I, Illllxmlln.ltJOn, alld I.l( ~ of ,-olllprch TI Illn tumid he rull"d out whl"1l per lunnm' Ihese It'''1 OhJt'l:I, ... hould he po, JllOll cd 10 i1\oltl llJITlpnund ll1!! 0 1 rC !1 11It \ wi th ht·I11H.1Il0p", ,
Hltl) illl'lt hCIllI"pherc 1.1.k In thl" 1O"lance we l.i.tke the !-opall 'll ta .. }.: of rClncrnncrlllJ!, routes (right-hemisphere la"k, and \ uh\IIIUIC ...cquenll~II.::II1dmarh (\Cqucnc.mg l'i Iypically a Icft hcml . . phcrc !-.Ircnglh, to arxomph ... h the goal of gcttmg from place 10 place. "I he palu:nt ,hou ld he remmded nOI to leave the.: dmic. room. or home unattcnded, OcLau ...e hc or ... hc may get 10... 1.

Ulul,ller ,tl "'p.lllitl Ilcglcli ~ Ilf 111mI'm \'u;:X{'\f/fJ1/\

If u ,lOg
Topographic Oi.orientation /Jt1iml/Of/ If,pogmphic dl ...orientation refers to difficulty In uru.lcf\lamhng and relllembering the rclallCm ... llIp of one icx:alUHl to another.147 A ... a re!-tu It , the palient '" unable 10 gel from one plaLe to another, wil h or wlI hout it map. ' ( hi !-t dl ...order 1\ frequentl y "'eell III conjunclion wllh Olilcl dlfficu ltle!-t In ... pati'lI rela l iol1"' :~~ 2. ('111//("0/ 1~. \olIIpl(' .\ 'I he pUll enl can not find the way from hi ... 01 her room 10 Ihe ph y ... ica l therapy cillli c, dc!-tplle hellig ..,howli repea ted ly. The pal lent cal1nol dt.:",c llbe the ... pati ~tI charac teri ... tics oj" lamiliar "' Ufroumilng ....... uch a... Ihe layout of hi ... or her bedroom <'1 1 home 1·1 I A/('(I\. The 111aJority of e
Depth and Distance Perception I. /)eji nillol1 (h c patient w ith a di..,ordcr of deplh and di ... lance perception cxperiencc!-' inaccurate judgment of dlre(.:llon, di ... lancc, and depth. Spatial di-,orienlation may be a cont ributing factor in fault y di\tance perception. 2. C/i"it all~,mmple.\. The patient may have difficulty navigat ing sw ir!-t, may mi ...... the chair ""hen allcmptlllg to "'". or may continue pounng Juicc once a gla\\ i.., filled. 13. Lesioll Areas Thi \ impairment may occur w ith a le\lon in the po!-tterior ri ght hemi sphere III the ~upe ri o r vl~ual as\oc iation co nice<.,; may be eviden t wi th right-s.ided or bilateral le... ion!-t. 14

4. Te.w I/M. a. h)r a functional le ... t o f di <.,t ance perception, thc pallen I i~ a... ked to take 01' to gra ... p an object thai ha~ been placed on a lahle. The objeci may "I", be held In fronl of Ihe pal ient. III the air, and the patient i ... again a... kcd to gra,<,p it. The impmred pat ient will ove"hoot or undel'\hool.~ b. To determine deplh percep ti on flinctlol1l:llI y. the patient ca n be <.I !-tkcd to fill a glas... of watcr.:! A palient wilh a depth perception deficit may continue pouring onl:C

Ihe gla" is filled .

1/,{'.H ol/

5. 7relllllll'fIf SUf.:Ke.Hiol/.\ The patient ... hou ld be a\\i\lcd III becoming aware of Ihe deficit (Cdllculion to increa...c cognitive awarencs:-,). Empha ... i.., \hould be placed on the importancc of wa lking carefully on uneven <., urface .... parlicularly the slai,..,. a. /? ell/Nllal Approach The patient i ... rcqllc!-ttcd to place the feet on designated "'pOb during ga ll training.~~ Abo. block s can be arranged in piles 2 10 8 in. high. The palient is a... kcd to tOllch the top o f the pile s wilh Ihc foo\. Thi, i \ done 10 rec!-tlabli ... h a <.,cnse o f depth and dl\tance.l oIt, b. Comfl('malOr), Approoc/t. Practice in compen!-tatlng for (listurbances in dcpth and di!-tlancc perception occur... intrin\lcally in many ADL ... J..ill'i, both th o... t: involving moving through space and tho ...c th;lllll\"ol\ c man 1pu lat lOll .

Vertical Disorientation I . OtIinillOlI. Vedic'll di.,uriciltation rdl' r... 10 a di ... lOl1ed pcrl:CpliOn 01 \\ hat I " \ ~rtical. DI"placclllcllt of the H;111cu i po"itlOll can conlnhu l ~ 10 dl ... turbnllcc of motor pt=r. gall. E~ ar) I .111 fl.;"<.:O\cr) fornl!lllcC', hoth in po ... turc an d III Illl)"t patil'llh po ... t ('VA dL'1ll0n"tralc some imp<'lInnent III

th L' "cme 01 \"t~rl1c;j lit y.141\ Thi ...

j"

nol inllucllccd b) the

Chapter 29 ('ogolth'e aod Perceptual Oyr.function

Degree of verticality

.-::-:: ,-

1119

all)-tl1mg {l'.g 1~1u.' .... 'OlllHJ.... colors. lallililar or Ic..,~ tamll 1;11 ohJechl. ·\hhou~h there Iii lin inahtlny 10 rc(o~ntJe I011111 liar ohle(:I\ U\lIlg onl' or two of the \clhory moci.llllles. Ihl' ahillty 10 recognllC the ..,ame nhJeclu,mg olht'r srn-.ory m()d~llitic\ I ... lI",ually prl.! ...cllI 1141,1

-

I

Visual Agnosias /)(1,,,iliOlI\ ,lilt! 2. CII"'(,(II !:wmpfn . Vi~ua l object agno'iil1 i ... the 1110..,1 common (Ornl of agno ia, ~ h i

---.

--Figure 29 .12 \'enH.:~ll d ....onentJlion mJ) con l ribuh:: to dlStUfb.m(c'l of po .. ture and gall. ( From Tob .... and LowcnlhaLr.() p 37. '" Ilh penni ... ..,ion.)

pre:,encc of homonymous hcmianop"lia,os Score") on one

te ... t for visual perception of the \'Cl1icai pO"lilion were found 10 correlate \\ Ilh differences in \""alking ability/'x

2 elm/cal Example." An c\3mple of the wa} in which a person with dbtortcd verticality view!'. the world and the \\3)

thi ... may affect posture i.., depicted in Figure 29.12.

1 Lt'.HOIl Area. The IC"lion ..,itc is in the llondominJIlI parietal lobe. 4. TC.\1ill~ The thcrapi"lt hold ... a cane vertically and then

..,idc\\ay'" 10 a horizontal plane. Rc:-.carchers u..,e a luminou ... rod with patient") ,eated In a darkened

1um ... II

room,14" The patient i~ handed the cane and
turn 11 back to the origllli11 po~itlon. If the patient \ perception of the vertical po..,lIion I.., di..,torted. the cane ""III !TIO"" likely be placed at ,\n angle. rcpre~cntlllg. the patient .... com:eption of the \\orld around him- or hcr"lelf. 5. Trl'atnu'llf Sugr,:c.\r/oll.\, The paticllI I1lU~t be made ;l\vare of the deficit. The patlcnt ... hould he in ... tructed 10 compen· \atl.! h} u... mg touch for propL'r ..,cll-orientation. e ... pcn.lIl) ""hen gmJlI;! through doorn'ay"', III and out 01 c!C\alor..,. ,md nn the ... I.ur...

Agnosias (Simple Perception) \gno ... ia

Ihe In
IIll:nmlng

1

dclincd a ... the inability to rccogni/c familiar object\ dc:-.pite normJI funclion of the eyc~ and optic IraCI\,1411 One rcmar\...ablc a ... pcct of thi~ di ...ordl!r 1\ Ihe readmess '\l1h which the p~ilient can Idelltify an object once it i... handled (I.c .. information is received from anOlher ~n· ... ory modality).'~fJ The patlcnt may nol recogni/_e people, po\se ... ",ion\. and cOl11mon object.... Specific Iypes of vbua l agno~ia ilnd some clinical presentalion\ are de ... crihcd bclo\\. Si mult i.l n ag nos ia. also known as Balint'.; syndro!TIe. 4 is the inability to perceive a visual ~timulu5 as a whole. The patlcnt percei\'es an entire arra), one pan al a Lime. The lesion is u~ually in the dominant occipital lobe . P rosop~l g n osia v. as traditionally com,idered to be the inability to recognize familiar faces. This phenomenon is now thoughl to be re lated to any visually amb iguous \(imulus, Ihe recognition of which depends on evoking a memory conlexl, such as different species of birds or diffe rent makes of car~, Prosopagnosia i~ usualJ} accompanied by \-i~ual field impaim1cnts. Bilaterall) symmctric occipital lesions are thought to be re~ponsi­ ble for this impainllent.50.L~1 Cnloragllosia i:-. the inability to recognize colors: it is not color blindnes .... The patient is unable to identify or name co lor~ on command. although color chips can be corrcctly paired.~() Ilowe\'er. the meaning of color i"lost so Ihat the patienl no longer a ...."lociate~ a duckline ~ \el10\\ or the sea as blue. 14<1 Color agno..,ia is f~que~ll~ associaled ,\,-itll facial or other \isual object agnosia, ...\,14\ 11 i ... u..,ually the rcsult of a dominant heml:-.pherc le ... ion .. \ The Slll1ul!anCou:i occurrence of left... ided hcminnop::.ia. alexia. and color agnosia IS a da ... sic occipital lobe "'} ndrome .. \ J. LC.\/oll Art'cI_ The leSion .....""ociated \\ ilh \ i... ual Object agnosia~ arc thought to occur in the OCCiplio-telll[X1ro· parietal a ...... ociation area ... 01 eilher hemi .. phere Th(.',c area.., are re'pon,ihk for Ihe intcgf"Jllon of \ i... U.11 ,tim uli "ilh n:"peci 10 Illl'1ll0r) ~. -t /i'.\ling, To te,1 for thi ... ddil..·it, ,e\Cf:tll'ol1lnwn Obll·d .. Ml' r!;ll'l'd 111 front of Ihe p.lIlel1l Thl' p.HII'IlI I' ,t,kc.~d In n.lllll' the OhJl·C"'. to point 1I).m llh.ll..'l'l n.lllll·d h\ Ihl" Ihl"rapi,l. or In lkmoll,trall' I" Il\l', II I' Imp\'rl.1111 III ruk oul ,lpha\l,l ,\Ill! ,lpr.\\I.1. .lIllwll~h 1111, I' I1l'l l~.I'1 I~ thull' nt'lad, 01 llthel Ihln,t.lIld.lrdtll'd .U1d 'I.mdaldllt'd It'\{IIlf! ph)l'l'lhill" .\fl' PW\ Idl'd 111 l,t\t'1 .lOti l 11\\\\lllh

11 n

I'ln .. i, .• 1 .h·h.\hili(~t(inn

"i InIItI1lI'fJ! ,,,~('( \tll'!/\

a. Rnnt dhll ' ,'pmOt It DIlII , lh'l.I'lInlll~IIU1l11x·I\~l·l'll

l""1

tx'

lI'l'd 10 p T
!.In', IIl.tI ;IIL' IIII POrl;t1l1In th L'

p.Ull·1lI {U'II1~ rh~lhl!-!',lph,),11l dl'l"rlll1lllilIIOn hl'\\\l'en (~IItIJ' •• llld l"lHlllllon nhJl·LI,.

1"1ll.' Ihc-rapl ... 1 ... hould .1",,1 111l' p.lllcnl III pld,lIl!:! o ul ,a he lll \ I'U;\ll' UL" for rL'!:1I111g. n.lllll" 10 1,ln', \, \\ ilh 111 ~1Il) (ognlll\c ,lIld pen.:eplual delu.:I1 .... a Ihl"r.lpi'\tmJ) trt.!at a pallcllI \\ IIh v"," ual agno...aa 111 an Lh) Strcci Flwlronment lhe,e eln-ironmenh have been incorporatcd illlo rellabllll
Figure 29.13 A client v.lIh an agnmia leam' In u'-t! an ·\1 \1 wllh hC!lp from iI Ihcrapi.,t m till: E",>, Street LIl\ Ironment

(Counc.,y of bl'Y Sircel LnvlrflllmCnl.,. S(,;othdale ..\/

X~261J.J

Tactile Agno'ia or A,tereogno.i, I. DeftlllllUl1 . TaCllic agno ... ia. or 1I.\1l'rl'().~Il(J\i.\ is the lIlabll ity 10 rccogn i/c form ... by handling them. although ti.If..:til e, proprioceptive. and thennal ... ell\atiolh may he mUlCI. Th,~ 11l1painnenl commonly cau'tes d,flicultle ... In ADL \ klll .... ma ... much a\ man} ... el f-carc aUlvlIlC" Ihal are nonna ll y done III the ah ... cnce of con .. tant ~ I... ual monnoring require the malllpul;]tion 01 obJect\. If tactile:

Auditory Agnosia I. Definition . Auditory agnosia refers to the inability to recognize non.!topeech ':oounds or to di scriminare between them. Thi s rarely occurs in the abse nce of other communication disorders:' 2. Clinical Examples. The patient with auditory agnosia cannot tell , for example. the difference between the ring of a doorbell and that of a telephone. or between a dog barkmg and thunder. 3. Le.\iol1 Area The leSIOn is localed in the dominant temporal lobe' 4. Je \ llIlg. Tc\ting i\ u\uall} carried out h) a \pccch"·languuge palhologi\l The patient i... il ... ked 10 clo~c the eyes and 10 Ide nllfy the ...oun.:c 01 \:knou ...... oumb. The thcra~ pi ... t rin gs a hell. hon" ... a horn. nnp a telephone. and ~o lorth . and ;.I..,"'" the pallelll 10 idelltif) thc ,\oumJ (\c:rhaJIy or by ptUl1tlllg to a plt:ture) 5. llt'allI/c/ll SIIgl,fnlloll.\ '( rcallm:nt gCl1crall) nlll'I'" 01 drilling the pallent nn .,ound,. hut 1111, ha., nut occn fuund to he parlll' ulilll ) cllcl.ll\C ....

Figure 29.14 (1ll!nt ~llh agnosia md man) other"" IU r and perLcplual delicu.~ .. an pr.1'tICC" d.;ul) h\"lOg ~III n he '~>n ct.11·..J.~} ~lf('C~ F-mllunmenl w.:h prm m the: tll.1H.(' l(1rl.'" , <- oufte) J La " '-Itret' f "" roomcrll S\.o(l

.lIe

\/

''':'..0

ChUI)ter 29 Cognitive llnd Perceplual Dysfunction

agnosia Iii prese nt in combinatio n with uni l:ue ralncglcct or ~cnso ry loss. performance ill ADL . . "i ll s may be scvercly hampered .('!! 2. C/tJII(ul t. \(/IlI/}!e.\ Ir a pat knt is handed an objec t (key, co mh .... alet y pin ) with vision occluded. the pati ent will fall 10 rccognile It. 1 /.1',\1011 \ reel The lesion is in Ihe paricto-tc mporo-occiplIill lohe (posterior association a rca~) of eit her hcmi sphere: 1 4 7t'MlIlg, The patien t b asked to iden tify objec t... pl aced in the hand hy exa mining them manually without vis ual cues. 5. Tn'(I/l1Il'lII Suggc,\lioll,\. a. Rll l1ll'lillll Approach . The pa tient practices fee ling variou ... coml1lon object<;, shapes. and text ures with vision occluded. The patient is ilh tructed to immediat ely look a[ the objcct fo r vi-; ual feedbac" and note . . pcc ial charactcrbti cs of th\,; objec t. b, CmllpclI,\(/lOr\' Approac/t, To imp rove cogni ti ve awareness. th e patie nt i... educa ted conce rnin g the nature or the ddic it
Apraxia Apn" ia is :In il1'lpainm:nt of volu ntary ~"il k: d learned movcmcnt. It IS charac t\,;ril\,;d by :tn inabilit y to perform purposcful move mcnt s, whic h can not be accolllll \,;d for by Ina
tl· ... 1

\\ tilt apha ... t:t AltlHHlgh oltC1\ OCl' lIl (OgL·tlil'r, Iherc I '" 1101 a '''110 1l ~ l"01 ll,lil l1t11l IK'IWl'C I1 [liL' ... evL· nl ) \11 Ih L' "phil"' ,,\ ,llId Ihl' "'L'\rrll'r ul till' ;lll1,IXI;1 A tlmd 101111 of ''1";\'la. hl/( ((I/flfW! "('/(Il/li I'" .llllla ll y.1 I y' ''l' Ill' Idl'Ol\lohu apl.l\.liI ,111\1,,,, l h;\I ;\l ll'llIl'(\ h, ddltrultll· ... Wl lh pc dpIlllill f thl'

d llhl'U It 10

111 11 11..' pall t:1 11

"pll,I"'I;\ ;tlld "pI,IXI.1

jltuj1uw !ulllll lVl'lIll'lIl ... that IIlVUh l' 1!1(lIti 11IU "'t.:ll' ... ll'laIL'd til Il w

11I0\llh I hi '" mil y IIKhlLk

ll· ... IHHl(illI!! In thl'

r om

1I1,IIUI ·'I"l·It,· 11l1 11\ 1,1 11'" IllIt .1 l',J lul1 l·." III 1'll1dll l'llIl! illl

Bilk-II,

1klll"\'. til ... ktlkd nHI\'L' Il H' lIl alld 'Ill! .1 lilll ,11,oukl \41 S\lI1U' Il·hdh llll.llllill Il'\h .11 . . 11 dl· ... ll llw "'l'ljlll'IIl"l'

01

plHlIll·I1H.·s III plOdlll .... "' p l'\,'l' h

.II'I,IXI.I , ... .I tll ... tlllh', ~I"t~l'

lllll ... tIUltlllll.tI .nlt! dl\· ...... III~· .tPI.I\I.I ...

Ihmn l'l, It I '" gl' lI

t,'I,tlh hl'!ll'\\'d Ih,\1 till"\"
u... ed 10 desc ribe specd ic dd ncult i c~ wi th a construclion or drawi ng task or dress ing. BOlh t h e~e problem ... are mo re frequ en tl y a~so c ia t ed wi th right hemisphere les i ons.l ~6

Ideomotor Apraxia I . Dejinition , Ideomotor a praxia refers to a breakdown

betwecn co ncept ~lI1 d performance, There is a disconnec tio n betwcc n the idea of a movement and its mOl or execut ion. It appea rs tha t th e informa ti on ca nn ot be transfe rred fro m the areas o f th e brai n th at conceptu alize to th e cente rs for motor exec ut io n. Thus the pallen t wi th ideo motor a praxia is able to ca rry ou t ha bitual tas ks automat icall y and desc ribe how th ey are done but is un ab le to imitate gestures or pe rfonn on comm :l1ld , 1~7.1~1I Patient s with this form o f a prax ia orten l)crSCvenltc~9: that is. Ihey re pea t a n acti vit y or a seg· ment of a task ove r and ove r. even if it is no longe r necessary or appropriat e. Th is makes it d iffic ult for the m to fini sh one tas k and go on to the nex t. Pat ie nts wi th ideo motor apra xia appea r mos t impaired whe n requ es ted to pe rform tasks th at require usc of m any imple ment s and th at have many steps. This form of apraxia ca n be de monstrat ed separate ly in the facial " reas, upper ex tremity, lowe r ex tre mity. and ror to tal body movement::;, L~') Pmie nts with aprax ia are o ften obsl!rved to be clulllsy in the ir ac tual handling of objec ts. lmpai n nent is oft en suspected when observi ng th e pati e nt durin g ADL or duri ng a ro ut ine mo tor exa m inal io n" 2, Clinical Ewmph's, Severa l exa mpl es of ideo motor tlpr~l x i a follow. T he pal ient is un ab le 10 "blow" on comm:tJld, Il owcvcr. i f prese nt ed wilh a bubble wand. tht! pa tit; nt will :-o poll t:'lIlcously bluw bubbles. The patient nm) fail to wnl l-. if reqm:::-.t~d to in a trad itio nal Illilnn\!r. Il owcvcr. if a l'Up of coffee is placed on :1 table at tht: ot her end of the roo m ami Ihe.: patie nt i ... told. "Ple;l~c havc ('orrt'~:' tht: pa ti ent is likdy 10 W\\cn.e the room to f,e l i1. 1\ A male paticllt i~ lI!'''ed IOl'omb hi'" hair, I-k lila) h l.: ahle 10 idt:l1t if) thl' com b ~I!ld evc n tell ~ou \\hat 11 i ... U... l·d 1'01. llOWC\L'r. ill' \\ III not aL'lIml1~ USl' the l'l'1l1h ilpplopriatL'ly \\hl.:11 11 I'" hiludnl to 1\111\, DL"PIIL' Ihi' 0[,"'l.:1\1I11011 \11 tilL' ~lllliL'. l ll'" \\ Ifl' I'I,.·porh that he comb ... In ... hall "' IWIlt.llll'nu ... l) l'\I,.·I"\ llllJrtltng . \ fL'IlI.11c p.ult·1lI I'" :\ ... kcd to "'qlll'l'/L' ;\ dYI];ItllllIllL' IL'r She aplx.. l1 ..... 1101 hl kill)\'I \\ II;! [ tll do \\ Ith 11 . althnugh hcr L'lltllpn.·lll'Il'I\ll1 I' .tdL·lJ1H\lL·, th,' t:I ... " lw ... Iml heell lkll111Il,lr.I1\.·d, .lIld 11 I' l k.1I II1.t! ... h l· 1t.1' ;\dl'quatl' ~ th.· Il~lh 11"/1111 \ /1'11 \pI;t\Ii1 \1,''''u lt, lIH"'1 11\'ljU~'llIh 1'1\1111 k"'l\ lll ... III 111l' kit. d\lllllll;lnt h~' IllI'phl'I'-' rht'I\.· I' l~\ I d l' l1l'l' 111.lt h\1111 1111111 .11 k ... lllll .... tlld 1',"'1,' 11\11 p.Ult·t.ll Il· ... IOII ... l";\11 Il· . . UII III ,11',;\\1.1 INI II'I""X 1h,'

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1181

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t t 82

Physical Rchllbilitntion

"10 (o rlh. It i~ ha~L'd 0 11 \\ hal th e :lllthnr:-. l"o llsi dcr a Ill crarc h) o f d ifli l' ult ) for putie nts w ith a pra xia. FirM the pa ti e nt 1"1 a~ "' c d , "S how me how yo u wo ul d ban g a nail \\ itll ,I ham Ill e r." If th e pati e nt fai ls to do thi s or U~~"1 h i~ or hc r list as if it we re a hamm e r. the patient is to ld. "Pre te nd to ho ld th e ha mm e r." If th e patient fa i)... fo ll O\\ ing th is ins tru cti o n. the the rapi st demons trates the act and as ks th e pa tie nt to imit atc it. The p3l ie nt wi th aprax ia ty pica lly w ill not imp rove a ft e r de mon s tra ti o n but w il l improve w ith use of the actua l impl cmc nts. 4 The abil ity to co rrec t o neself o n fo ll owing \' e rba l cue ing is co ns ide red 11 0t ind ic at ive of a praxia. Add itiona l ap rax ia tests may be fo und in BUl le r. 156 or the wor k of va n He ug te n e t a l,I61 who have adap ted th e A rn ado tti r OT-ADL Ne urobe ha vio ural Eval uatio n (A -ONE)5 as a n observa ti o na l method of testing fo r apraxia. 5. Treatmem Suggestions. a. Remedial Approach. In the remediati on of aprax ias, it is advised that th e th erapist speak slow ly and use th e s hortest possible se ntences. O ne command sho uld be given at a ti me, and the seco nd command sho uld no t be given until the first tas k is co m pleted. When teaching a new task, it s hould be broken down into its component parts. One com po nent is ta ught at a time, physicall y g uid ing the patient throug h the task if nece ssary. It sho uld be compl eted in precisely the same manner each tim e . 156 Whe n a ll the indivi du al un its are ma stered , an attem pt to com bi ne the m s ho uld be made. A g reat dea l of repetit ion may be necessary.6R Family me m be rs mu st be advised to use th e exact approac h fo und to be s ucce ssfu l in the cli nic. Pe rfo nnin oo ac tiv ities in as no rmal an envi ro nm ent as possible is also he lp ful. A case exam ple of a yo ung woman re learning how to dri nk from a cup using th is tech ni que is provided by Butle r. 156 Usin g the sensori motor a pproach , mu lt ip le senso ry input s arc used on the affected body parts to enhance the productio n o f appropriate motor responses. T he reade r is re fe rred to th e work of Okoye l62 for addi tion a l de ta ils o n thi s approac h. b. Compensatory Approach. Donke rvoot et al liH report a random ized contro lled trial that , howed th e eI'fcctiveness of an occupationa l the rapy treatme nt prog ra m includ ing "strategy trai nin g" ovc r regu lar oc~ u ­ pati o nal therapy. Strategy tra ining invo lves tcachll1 g the pati e nt compensatory tec hniqu es to overco me the aprax ia '>Uch as use o f pict ures in Ihe co rrect sequ ence to support A DL ski ll ,.

command. bcca u!-.e the patien t no longer understand') the overa ll co nce pt of the act, cannot retain the idea of the task . or cannot formulate the mOlor patterns required. Often th c pa tient can perform i..,olated compone nt s of a task but ca nn ot combine them into a complete act. Furthermore. the patient cannot verbal_ ly dcscri be the process of performing an activity. desc ri be the fu nct ion of objects. or use them appropriately.I64,165

2. Clinical Examples. When presented in the clinic with a tooth brush and toothpas te and told to brush the teeth. the pa tient may PUI the lUbe of toothpaste in the mouth. or try to put toot hpas te o n the toothbrush witham removing the cap. Further. the patient may be unable to describe verball y how tooth-brus hing is done. Similar phenomena may be evident in a ll aspects of ADL (wa::'hing. meal preparation. and so fort h) and so may limit the safety and potent ial independence of the patient. s It has been show n tha t pat ients with ideational apra\ia \\'ho test poo rly in the clinical situat ion appea r more able to perfoml A DL ski lls a t the appropriate time and in a familiar sctl ing. 162 3. Lesiofl Area. T he lesion ca using ideational apraxia b tho ug ht to be in the dominant pa rietal lobe. This deficit also may be seen in conjunction wit h diffuse brain damage. such as ce rebra l a rteri oscJero~is. ~9 4. TesTing. The tests fo r idea tional apraxia are ~imilar to those fo r ideomoto r aprax ia. The major c\pected res ponse di fference is thaI the patie nt wi th ideomolOr apraxia can perform a motor act spontancou~ly and au tomatica ll y at th e appropriate time. but the patient with idea tiona l aprax ia is un ab le 10 do ~o. Refer 10 Butler l56 fo r full tes ting protoco ls. 5. TrearmeJl( SuggesTions. The trea tment tCl" hniques are the sam e as those for ideo motor apraxia.

Buccofacial Apraxia I . Definition. Buccofacial or oral apraxia II1vo l \'c~ dillicu lti es wi th performing purposeful movc nh,:nts wi th Ihc lip~. tong ue, cheek:--., larynx, and pharYllx 011 command. An unu sual conditi on. Pede rso n c l alII!(, report tht.! pl'cvalcllcl' rate in rehab ilitat ion patic nt ~ a~ around 6 pcrccnt. 2. Clinical E.Wfllp/es. A paticnt Ill ay have dillic ult) 1'l'~I)Ond­ ing to th e COlllllland "pretend to blowout a c.lIldlt.:" or "blow (I k is~:' I lowcvc r. in a normal cuntext \\ hl'n.' Ihl.' patie nt may perform th c~c a(,; t loll ~ allIOJl Jatil'~lJl), JR" rOJ'mance b not impa ired. In additioll, while pallen1'- lila) be able to prod uce the indiv idua l phonemes Icqulrl'd Inl s peec h, the patien t may have ddTic uit y lJ1 p rodllCllIg ;111 o rckrl y M:lj UC II CC ph OI H..' l1ll'~. Fnrn llllau.: ", p l 'cdl. (11' automati c expres~ i oll'" ... uch ilS " hav!.: a nice dOl)" lil a) hl'

or

Ideational Apraxia I . De/initlOn, Ideational apraxia is a f:'li lu rc in the ~o n cep tu a li/ atlOIl o f the task. It i... an in i.l bil i t ~ to pe rf ~)rm a purposc l ul mo to r act, ei th e r au to mati ca ll y

0 1

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Chapler- 29 ( 'ognithc and Per-ceptual D)'sfunclion ...-ula. anterior in,ula. and a 'mall Me-a 01 the li"t telllpt). raJ g~nh (adjacent tn the- Irontal and l:cn lntl o pCrCUL1 ), While blKcol.lclal apra\IJ often L'l~XI\h \\Ilh Broca .... Jpha'IJ. the t\\O I11J) be 'cen inJ1!'pcntJcntl) ..l TdIll 1,!- The pallen! .. hnuld be examined by a \pcech· language pathologi,t. :; TroJ1nlt'flI !."'~IH_'.';tioJl\ The \pccch-languagc pathoJo. f!1 .. t can Jd\ I.. e the heahh care team on ~trateg i es to communicate \\ith patIen t') \\-ho ha\e buccofaclal Jpnl\,I3..

Summary CogntllOn and perception. the proce.,ses by wh ich an indi\idualthinh and !>eleu..,. Integrate\, and intc rprel\ .,timuli from the body and surrounding environmen t. are c ritical 10 the nonnal func tioning of each human being. The patient ",ilh brain damage may be lacking in those ab ilities th at alloy, one to make sense of a nd to respond appropriately to the outside world. It is esse ntial for the physical therapi ~t to be able to recoglllze whe n a pa lient is experiencing ,orne type of perceptual dy.,function a nd to have the regul \lte tooh. to understand the causes of the behavior.

Questions 1. What general

for

charac t c ri ~tics

118.1

TllI' \\' lIhln the context of lhe rchahi lilation M:lIlOg. The impor lance of differe ntiating cogl1ltive and pcn.:cplua l deficJl~ from problems related to lac k 01 motor ahIIJl>. Inadequate ..,cnsmian. poor language \ki ll \, and \im ple uncooper<Jti\ic nc'!)!> ha\ been emphasi7ed . Although alluded 10 In a VCr} abbreviated fashion. activity analysis and \ystemauc data co llection remain ty,.a of the mo ~ t powerful tools at the dis· posal of the therapi\t attempung to develop a finn rationale for. and to empiricall y ju~tify the efficacy of any treatment selected. Treatment in the fonn of adaptati on of the physi· cal e nvironment and instructional sets and the teaching of compensatory techniques has been singled out as the most effective avenue for intervention ,

Acknowledgment Gratitude is extended to Chaye Lamm Warburg, who~ earlier version of thi s chapter provided the foundauon for the cu rrent work.

Review

are displayed by pati e nts wi th cognit ive and perccptual deficits during execu· tion of a task? 2. Idenufy the underlymg premise of the trom!er-o!training approach to treatment. 3. What is the underlyi ng ass umpt ion of the semory illle,-:rarin' approach to treatment? Provi de exa mple~ of the treatmen t modalities emp loyed with thi~ approac.:h. 4. How I~ tht! pc rfonna nce of ~ pec ifi c functional ~k ill s enhanced using Ihe/ulle/iollal approach to treatment? What an: the IIlhcren t benefi ts of u.,ing the funct ional approach'! 5. Describe general ~ugge.,t i on ~ fo r optimi7ing teac hing/ learning ~trat egie!>. whe n using compe nsatory techniques, 6. Identify the four treatment slrategie~ included III the ("01-:1II1i\'(' approach to trea tment. 7. What potcntial influenci ng fa ctor!>. mu\l he UJIl\id· ered when examlnlllg a patient with cognitive and perceptual di\abilitlc\'! 8. What examination procedure ... wi ll u\,.,ist the thcrapi\t In dl'lungul\h ing betwee n SC I1 \ory and cogn JlI Vl! or Pl.!fl"cptua l problelll\'}

9. Di5tinguish the difference between feedback provided in th e fonn of knowledge of results (K R) versus knowledge of performance (K P). 10. Identify and deline the four different types of attcntion. 11 . What i., the purpose o f memory retraining? Compare and cont ra5 t the focus or the remedial approach and the fompemarory approach to memory retraining. 12. Defi ne the foll ow ing tenn\: unilateral neglect. ~oma­ t oag n o~ia. right-left di .,c rimination. finger agnosia. and anosognosia, 13. Ide ntify four spati al re lation., deficits . What geneml clinical manife\tation do the\e di~order.. have in common? Define each or the four delicih Idcntiticd a nd provide an ex ample or how each woulll intluem:c patient performance of a ta ... ~ . 14. Provide cX
11S-l

Ph)\ical Rdlahilitalioll

ense

S llJ dy

the p.llll"IlIIS.1 72. \r:.U (lid \\()J11an \\ho ha'Ju..,t br:r:n .Idntlllcd h'.1 rr:h.lhllll.1I10n l;:Inlit) tollO\\lng a "'Iroke . The p.lIll'llt r:\pr:nr:m:cd a nght panetal hemorrhagic ... tn1kl" \ C 1 "'(an n!\caleu a 1,5 In. (4 cm) hemorrhage Ih~1l \\.1'" ,uh ... equelltl) drall1ed, She will be able to ... tay In 'he reh •• h,li,,,,,on I;,cili'} for 20 day,. Allhough 'he p.lticnt ha ...... ome ph, ... ical prohlem .... thc cmphasis of thl'" ca ... c ... tud) i\ on cognitive and perceptual tests and Inter\t~l1tion..,. The occupational therapist and the phy ... ical therapi't are collaborati\'ely using a combination of cognit ive rClraini ng and the fU l1 clional approach in ,herapl·

PAST MEDICAL HISTORY The patient's pas t med ical h istory inc ludes insulindependent diabetes and m il d rheumatoid arthritis in her righl shoulder and bOl h hands.

SOCIAL The patie nt lives alo ne in her own home. Support ive friends and famil y. he r IWO chil d re n and Ihe ir fam il ies live nearby. She is insured b y a local HM O. She is retired fro m the po lice fo rce and enjoys gardening. reading. and wa tching te levis ion. S he previo usly drove an au tom o bile w ith an a uto m ati c transm issio n.

PHYSICAL THERAPY EXAMINATION When Ihe palie nl was ap proached fro m Ihe lefl, she seem ed to ig no re the physical th erap ist and did not respond to greetings. However. w hen the therapist sat in the chair o n the pa tient 's right s ide. she seemed to have no problems talking to the the rapist.

Range of .\Iotion. r.luscle Tone. and Balance Exam inali o n revealed full RO M. reduced streng lh in ' he left arm and hand and so me red uced dynam ic st.andi ng balance reactions.

Sensation The phy\ical therapi~t tes ted sen\a tion and noted normal sensation 111 all areas hharp/dull, light touch. temperature. proprioceptive r.;en ... atiolls. cortical ... ensations) on the right \ide. However. the patient r.;cemcd to have (Ilfficult ies on the left Side and her performance In detecting ... timuli ...eemed IIlconsi')tcnl. Becauo:.;e Ih\! physical Ihcrapi ... t \U!oopected cognillve and perceptual delicil\. a completc Sl!Il'Ory te ... t W~I'" deferred until the occupational thcrupi ... t cou ld fully examllle the palicn1.

I' ullctiollal Status 'I he phy ... i<.:aJ thcrapi..,t examincd JJ1structed her in

J ... aler

way to

r

thcrapJ . . t ... cored the patient on the Wit ilOIlO! Independen( e \1l'Clwrc (f /.W /" and found :

'iclf-Car<: Eallng: Ft\1 level = .) Groommg: FI\1level = 5 Balhing: FIM level = 3 Drc;smg-upper body: FIM level = 5 Dre;sing-lo\Ver body : Ft\1 le\"el =.) Toileting: FI'v1 le,el = 6

Transfers Bed. chair. wheelchair: FIM level = 5 Toilel: FIM level = 5 Tub: FIM level = 4

Locomotion Walk: FIM level = 5 The physical Iherapisl asked aboul her famil} and she was able 10 provide many details. However. she seemed puzzled about \\-here she was and was concerned thaI she \I, 3!. nO! looking her best and needed 10 do her hair. The Iherapist suggested that she might like [0 brush her hair. The brush was on Ihe lable on Ihe palien!"s left side. and she said she did nOI have one. The physical therapisl cued her 10 check her bedside table. bUlan checking she mamtained she did nOI have a brush. Al the end of Ihe session (\\ hich lasled aboul -10 minules) Ihe therapist asked her 10 demonstrate the bed transfer technique again [har she had been taught at the beginning of the session. She seemed confused and cou ld nOI do \\ hal Ihe ph) sical therap'" had taught her.

OCCUPATIONAL THERAPY COGNITION AND PERCEPTION EXAMINATION The occupational therapist conducted two ~tandardized teSb: the Ri\,l'rmead BellOl'iourll!\.lemory Tcst (RBMT)s'! becau'>e the patient demon\tfale:-. memor) i mpainllent~. and the Arnm/ott;,. OT-ADL N£'flrobe/ul\'ioral El 'u!lIlII;nll (A-OI\'EJ"~ to c\amint' the impacL of the patien ..... problem.., on ht;!r daily Iidng activities. Thc occupational thempi ... t al..,o re~h('lnt'd thi.tt further tests of the paticnt'~ IADL ... including home i.U1d drivinQ. abili tic\ would necd 10 be conduClt'd clo .. er 10 her di~charge . The patient\ FIM ... cor\.· ... for the Soci'll Cognition 1tl!11l'" were:

Sodal

CO~llitioT1 FI~I

Social II1tl!raCllon: thl!. patient""

gC I

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01

hed , f ile

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Problem ... olvlIlg.: F I ~ 1 k\'c i Memory: FI M level 3

6 6

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( hapl('r 29 (ogniti\ '-

GUIDING QUES TIONS I. Wh;u .\T"t; ,\)I11e 1..,1' Ih~ IUlldh.'I1J.l JIIliI,.'Uitlt.'" the pal lent 1 h.\\ 111g .mJ \\ h.u \,:\ll!OItlh' .mJ pcn.:cplu.ll Jdi":ll'- mlfht bt. .·.1U'mg thl,.'''c'? Plc..~.hl· 111..)1t.' thJ.ll~rc nu~ oc 11101'\' 1hm ~ lX""Ij:lk lI11p;unnenl t,x Ilk.' lun('II()l101l pn)bleill" nOk~. r~.', dop .1 1..'IiIllI,:;\1 ;]"1,.'[ .UlJ pn)blem 11'1 , IJentlf~ J.nth.~lr.Ut.·J £:l,.II .. and e\pe('ted ouh.'l'me, approrn.Ut' 1M thl' pJ.lIent.

P('r( epnul Ih,;function

1185

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1'I11111,:.,1 ,HId 1-,"penmenl,, 1 Studl{·~. 1.4I\\.orcm:e I.rl haum 11'"e I')\)\'pX7 . " Rnl'll·rbnn. III. CI al: \'v';llkmg tr"lcctnry .lflt! h"nd IIIm-erneni III UIIII"lcI;llldl nC,!:k'-l, A \cl 'il.mllll!. K \1. ct Oil Whcckhan lfamfl'r Ir,lInlng Ir,r flll~lI cert:bral t.i),IUln:lIl,"' An mlcrdl'uphnary 'pprnach_ Ardl Ph .. \1r.;J Rch,ll:l1l 1)4:276. 191(.1 ' Ru\\cn. ,\. l'~ ,I I: CogOllI\t rehab,litallon lor \patl ..1 ncgltll loll(J\/oo III~ ' trol.e (Cochrane Re\1t:\1.), In Tht C(x:hralle I.lhr,tfy I uc '\ l pd.lte S(IINafC. O\.lord. 2002. 1;\0 bnthomc. Y. (I al: The Irtallnenl 01 \1,u ... 1 neglect u mg l.:edhatk u t c~e mll\em~nb A pllOl"ludy. Di,abll Rthahll 17:41 l. 1tj(}S. 1;\1 "alra, L. et al: Tht Influence of \'i,ual neg lc..:t on 'tfllke rehabilita. liOn. Strol.e 18: 1:\86. 1997. 1.12. Robcn..,un. l. 1.'1 al: \hcrocomputtr-ba-.ed rehablll1atlOll for uniJateralleft \ I'u .11 neglect: :\ randomi~d COntrolled trial , Arch Phy \Ied RchllbI1 7 1:663. 1990. I .n Ro .. ,i. P. Kheyfeb, S. and Reding. \1J: Fre'nel pn,m.. Imprme n.,u,11 p.:n:epllon In ..Irol.e p:tl1enl... \\ Ilh homonymou"I hemianopia or 1I1l1Jaler.lJ \ l~ual neglect. :"Jeurol -W: 1597. 19YO. D4. Wian. L, et al: Unilalcral neglect ,yndrome rehabilitation by trunk rolatlon and '>Canning lraining. Arch Ph), \Ied Rehabl! 78:424,

19<17. 1J5. \tae ... hml:t. S. 1.'1 a1: Rehabilitation of patienb \\im ~00">i.a for hemiplegia due 10 intracerebral haemorrhage_ Brain InJu .... 11' 691. 1997 . 136. 5auguet. J. el at Di')turOOncc., of me body <'cherne in reiallon lD hnguagc Impainnenl and hemisphenc locu!> of \c.,I00. J _'eurol 'euro"ul]: P,~chiatr} 34:-1.96, 19-1 LP John'lone. \1: Re,torntion of ~totor Funcnon III the Strole PallenL ed~. ChurchIll Li\ing,lone. Se\\. Yorl... 198;\. 138 Hecaen, H. et aJ: The o;yndrome or apmctagno:.la due to Je..iorb or the minor \enebrnl hemisphere. Art-h '\euTOI P-.)chiaU) 75Aoo. 1956. Uq. Gainotti. G: Emotional behaviour and heml'>phC'nc ,uk of Jle blon. Cort~x 8A I. 1971_ 140. Amadonir, G. and Gudrun •.A: E"aluation and mler.entlOll v. 1m comple\. perceptual dbordcr. In L·ns .... orth. CA led I: CogniU\c and Perceplual O~ ..function: .-\ Clinical Re:lSOning Approach 10 E\'.:llu:tlion and lnlcf\cmion. FA 03\i:.... Phil3delphi3, 1~. p 393. 1.11 &imam.. JA. \\'eb"ler, J. and Lincoln, .... B: A compan:o.OO of 1'1100 :lpproache, III me DeaDUenl of perceptual problem' after ,trol.:e_ Ciin RehJ.bil 14:230, :!OOO. H~. H31perin, E. and Cohen. BS: Pcrceptual-molOf' d) ,function. Stumbhng blocl.lo rehabilitation. ~!d \tecH ~0:U9, 19-1. 143 Benton. A. .md Trant!' D: \-~---uoperceptu.il. \boo-.pat:aal. and 'l"U'-'''.:OO'tnK'U\e dl...orders. In Heilman, K\I, and \,:Ueo ..letn. E eJ.... Ciini..:.t1 'europ,,~cbolo~. ed 3. O\.ford Lru\..:f'>lt) ~ .... C'A Yed.. 1~3. P 165. .w \~I'\"". J.\. SI.'lUwm Californi3 SerL~ InlegmiOO Teot... \\Nero P'~..:hlllo£l.:aJ Scn I~ LCb Angelc-.. 19- ::. 1.15 Pelef'OO. P. .:md WiL.off. RL 1be periornun..-e 01 :kiuJ1 nuk-- 00 the 500wm C;Ulfomia fi~ \ bU3l pC'Tttpoort te..l, <\Ju J o.:cup ThC'r F:55J, 19'_, J .I.(> \rkk1'ol.'Ill.. E. and Cbo~. E: PaneuJ lol-e . . ~ nd.romc:-- m beuuplep.a: A program i('lt' tre;t.lmenl_ Am J o..-.:up 'Thcr ~~ 1~. 19"'), 14- \t.ifwre. EX lb! retfD'<.plenul ,-'OOtribuuoo 10 human D3\'lpbOO: .\ fC'\ le\lo oj le .. l(lO and neurtnn13glDg fUlding-. ,,-:.utd J r..hOOl ,122::5. ~OOI. J 4... , elrul., AP, el .11' Pl!:rcepnoo ot \ cru":J.ht) after fC'\:enI ..:t"ft"tnJ heml .. pben..: ,m: e. Stroi...! 3.':2.~·r ::l~: qo U\eT• .-\J, and l-n'....-orth. Co\. E\.1huuoo and 'lJIt""eatKa v. tb 'lJDpk rm:epnal l1llp.mmetl! 1"IJk".1.' In lr.,,"'utb. C" M (~U,~ md Pt1i:-t'~ ~ ..fun..:tlOIl: .\ ClirJ,.--w Ro: .\ 'h If! b non 3lld la:('f'oet:".KXL F~ D:a\ ~ lQ99 r:Q9 .;, l \\ak_ LH c:1 at "'lrd•.:' \ CnD":~ ~ T~

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r-rlndJ,IC' 1'1 1),.1 '1111 I dnd VI,Ifl,I~{,f1U III. VII) I BUlh:l"\\lInh !!(,lOman" I undllil. Jljlll, P I J 7 1.Ii" n"l(l~(""n(lt. \1 tl .. 1 1"t...."'lentc III apnt'tl,J ,11111111/1 pall/:n'" v.rth it fi I kft henu ph1.:rt' Ifll~e In rch.lhllll
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Phlhuldphl,l. 1999. P 2:'i7 157 Raadc. AS. Roth. U. and Heilman. K.\1 rtll': relaliono;hlp bclwccn Ouctofatial and limb apr-d~ia. Snun Cognluon 16; 130, II]<) I 1.0; \1ouz. \1. ct al: Apra-\Ia in a pmient with I(:':oion located In right uHor1lcal area: AnalY"'I~ of crror.. Conex 26;651. 1990. 159 Guodgla.':o~. II. and Kaplan. E: TIle A':ose,;!;mcnl of Aphw..ia anti Related DI~orde"". cd 2. Lea & Febiger. Philadelphia. 1983. 160. Hahband. li. ci al: The role of the pre*motor and the !;upplcmcn· lary motor area in the temporal control of movement in man Bra," 116:243. 1993.

Supplemental

V,lli 1f, 111'11" (M A rIAapr;UHJ InlN/Ial I (k('IIP l!ltT J f' I'I ~~ 1'1'" 1(,2 (Jkf,ye fi Hlcdpril1l,J InAhr I W 'tIt, l'ty I f.I;;,,>t;IIiI,.. \o1ilnual fiu'J{"n f'rl' il y,,,S- If)~ I JJ 241 J (" I Jonr-crvofl! ~ "1 OIl Uh fj/,;y 1,1 lJill#'gy Ir If , 11 har, phere IHlke patient WIth aprand ;.. rdr "Iff ./1:J1 :-';cornl)40.yth'J' Pen,lhr' Il'54fJ 2IIJI J(,4 /)f~ f<en/1. f~, and Luu;he-lh, IdelllllJflil "r411 H, r I~I '17 Ifd

r

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(.'1

ai' UlJllerlng a h(It (;UP

the Iud)' (,I em", (,f rKllOn

In

fir v,(fu An 1ff1pfw«.

,

p'4tlCT I Nllh bram dam.1t • h

ropper, IJL. alld ( ic;errme KIJ (ed ): 'me Neur/",-..ydvJl("-£j rA I.:.vcryday Life: A 'oC menl anti Ha Ie (IHOpett::OCJt: YI!Jh~ London. I fj()i}. P 25') 1M. Pcder1ioen. PVI. el al. :\1allLlaI ifnd (11aT apra.uil m aclJtt: urKe frequency and mfluence flO funcli(Jnal (1UU:fnne. Am J f1ly 1.1ed RehahiJ fSO:6fs5. 21)1)1 1(}7. ileilman. K'-1 and Valen lein f.. ((:Ij ): r.hmcaJ :"ieoJOp"'ychology. ed 4 Oxf()rd Lnwer Jly Pre: ZOO).

!'tie<... Yost

R e adin gs

Banich. MT: Cognitive Neur~ience and Neuropr.;;ychology, cd 2. Houghton M ifOm. BO!iton. 2004. Cohen. H (ed); "leurO!iCiencc for Rehabilitation. ed 2. Lippincoll. Philadelphia. 1999.

Sirub. RL and Black. FW: The .\.1ental Statu" Exanunatl("KI 10 Neurology. ed 4. FA Davlft. Philadelphia. 2(j'iJ. Stuss. DT. WinocuL G. and Roben';OO. IH led\l: CognitiH: "ieurorchabilll.alion. Cambridge linjvero,ilY Prc Cambridge. LK

Gravell. R. and Johnwn, R (cd~): Head InJul) Rehabilitation: A Communit), Team Perspective. Whurr Publisher." London. 2002. Pon.!tford. J (ed): Cognitive and Behavioral Rehabilitation: From ~eurobiology to Dinical Practice. The Guilford Pres~. New York,

lin ... worth. C (00): Cognitive and Perceptual Dr function: A OmlCal Rea~ning Approach 10 E\'aJualion and 'nterVention. FA Da\'IS.

ZOO4. Sack.,;. 0: The

~an

who Mi')took hiS Wife for a Hal Harper & Raw.

"ow York. 1985.

1999.

Philadelphia. 1999.

C/I,I /'TEH

30 LEARNING OBJECTIVES 1. Explam the organization of language with

respect to the role of phonological. lexical. "Iynt3clic, and ~emantic systems. 2. Gam an under<;landmg of the role of the mOlor speech system In the speech production proces~

.

•l Explain and characterize the classic aphas ic '>yndromc!S. -'. Jdemify and explain the critical fa ctors in the evaluation of the recovery and rehabilitation

of aphasia. 5. Identify and describe genera l approaches to aphasia rehabilitation and some specific treatment methods.

6. Describe the primary types of dysanhria and ralionates for dysanhria treatment. 7. Describe speech apraxia and its trea tment. S. Gam an understanding of neurogenic swallowing disorder. 9. Describe the goals and rationales for the use of

augmentative communication systems.

M

Neurogenic Disorders of Speech and Language Martha Taylor Sarno, \1 A, \1D (hon ) OUTLINE The Organll<J.llon of Language J 190 Speech Prodm.:t ion 1191

Verbal Aprax ia 1202 Treatment of Dyspraxia 1202

Apha<;la 119-l Classification and Nomenclature 1194 Aphasia Measures 1196 l-lislOrical Perspective 1196 Recovery I 198 Psychologica l and Related Factor'i 1 199 Treatmem of Aphasia 1199 The Patient with Aphasia 1200

Dysphagia 1203 Trealmenl of Dysphagia 1203

Dys:mhria 120 1 Classification and Nomenclature 1201 Treatment of Dysarthria 1202

Summar) 1205

ost people take the abi lity to produce and understand peech for gran ted and pay little att ention to the nature and funclion of the processes involved in communication. Yet speech. like tool making, sets us apart from anima ls and is one of our most human behaviors. Even in primitive societie~, human~ have used the oral-moLOr speech code to share experiences, ideas, and feelings. Not all communi ties have developed writing and reading systems. The use of speech for communication conlri bu tes to our Identity as human beings and to the perception of "self." As a re~uh. disruptions in the ability to communicate. whether caused by structural abnonnalities (e.g .. cleft palate). neurological conditions (e.g., stroke. Parkinson's disease). or nanorganic condition~ (e.g .. nonorganic articulatory di~or­ ders) may impact on a per~on's daily life in important \\ays. For s.ome. the acquisition of a communicalion disorder may have suffiCient impact to cause an Individual 10 'Withdraw from the workforce. For those whose commuOlcation dl\ordl:ro, have persisted ~lI1ce childhood. Ihe dtsorder may represent a significant vocational handicap. In other ca ... e~. a di\ordcr that doc ... not impede an Individual \ \'O<.:allonal life noncthclc"os IIllCrft.:res with everyday ~o<.:ial Ilation, Communication dl~ordcr ... arc complex. nlUllltac

Altemati-..c/Augmenlatlvc Communication Sy'tcm, and Dc\ icc') 120-l ImplicatIOns for the Physical Therapist 1204

e led behavioral impaimlents often associated so closel} wit h a person's self- image as to threaten the qualit y of his or her life. The tenn communication encompasses a ll of the behaviors, including speech. that human beings use to transmit information and interact with others. Speech comprises a de licate and rapid sequence of sensory and motor events requiring the coordi nal ed activity of several parts of the body. The use of speech for communication involves man) levels of human ac tivity. ranging from the fine motor coordination of components of the oral-motor systcm to the subtle shades of meaning that occur at the cognitive/seman· tic level. GeMurcs. pantomime. and other nom'crbal pragmatic language behaviors .... lIch as tum taking. are also e ... sential elements of communication. Among unimpaired speakers. speech beha\ lor \ arie ... greatly. yet the oral-motor ... } ",tern i, efikicnI for the exchange of cven complicated IOfomlation. The range 01 \ariabihty i ... sO 'Aide that indl\iduals geIH..'r.llI) produce dillerent ... ound \\aves \\ilh different ch.lr.lctcri ... ul.· . . e\en v.hcn produt.'ing Ihe ... amc \\onl. BUI h'll·n~r... dll not rd) ... okl), on IIlformution dcri\cd IrOI11 . . rx·I..·I..·h \\.I\C', \Vc ahll dL'llClld on CUl· .... "hH:h arc..' nmlp~lJlCn" of \\hal 1'" rde~d

,t

,1"'P\,.'Ch 01;1 l,.'(l IllIlHlnlcat IV\,,' .. h.UI!!~ "'lKh.1'- thC' pmp~he: oj tht.' .letl\ It\ , th e: iUl.:atioll 01 the: «!\l'h.lnt!C'. thl' I\t1ll\\ kdc ..- 01 tht.' p;lnlt.~lp;lIl1"'. the roil· ... \If eaL:h r.lnh..'lp.UlI .tIltl Ih\,.' It~\ c:1 nl lonnahly l'C'qulred h} the ... ltllal1l'n, Thl ... dl.lptt.·r .\ddn: ......C'~ the nC'ul'Ogenic t.1I ... ordcr.., 01 com munk.lt1l'Il, .1 ..·.ueg0J! 01 communicillion dl ...onJcr... reprc· x·nt..~ h~ th ...' majority of paticllh recelvmg ~peec h -language r.llhl)hJf!~ ,en ice ... in rehabilitation l1l t!ui ci nc program ... , The mt.ht common of thc ...t: di ... order... :Irc aphasia, a languagl! JI"'('Iruer. and d~ ...arlhria. a motor--\peech disorder. The lield of ... peech-Illnguage pathology. which came IIlta bemg III 19:!5 \\'1Ih the e)lablishm en t of the American peech-Language-Heanng A;sociation (AS HA). is dedic.ned to the diagno ... i... and treatment of in dividual~ with congenl1Jl or acquired di sorders of speech and language_ Communication di~orders exac t a large economic loll , co~ting the Uni ted States economy an estimated $30 billion a )ear in 10 ... 1 productivity. special education costs, and medical co~t~. The alional Institute on Deafness and Other Communication Diso rders (NIDCD ) est imated the number of individuals in the United States with a speech. \·oice. or language disorder at 14 million.1 Approximately 28 million Americans have a hea ring loss. Fifty-five percent of those with hearing impairments are older th an 65 years of age and 12 out of every 1000 children younger than 18 has a hearing impainnent. 2. 3 In the population older than the age of 65, 10.8 percent have speech and language disorders. whereas among those younger than 45 years of age, 9.9 percent have speech and language disorders. The largest population of communication impaired are children with language disorders (43.7 percent) and articulation disorders (32. 1 percent)_1 Aphasia affects approximately 15 percent of the adult speech- language impaired population.~ The speech-language pathology profession has grown rapidly. Affiliates (members and certificate holders) in the American Speech-Language-Hearing Association increased from 1623 to 35.000 between 1950 and 1980. Speech- language pathology i':o a mru,ter'~ degree entry field and more than 85 ~rcenl of all ~tates require a license to practice. The ASHA awards the Certificate of Clinical Competence (Ccq 10 speech-language pathologi~l5 who meet specified academic and clinical experience requirements, which includes a Clinical Fellowship Year (CFY). Today. there are ove r 100.000 peech·language pathologists certified by ASHA, of whom more than 95.6 percent are female_ Health care facilitie~ account for about 35.5 percent of the ~elting~ in whi ch ccnlficd "'pcech-Ianguage patho l ogi~ls arc cmployed with 14.1 percent workmg 10 ho..,pital settlOgs. The tcrm 'W't'( II lallkuuKe pOlll%XiH I'" the offiCial dC~lgnatioJl 01 profe sion<Jb In the Held who hold the ('ce. The term .\fJl'l'{h tlwrapl t. although no longer tOIl~ldered profes~ionally apprt)pndtc 1'\ <s term Ihilt 10.; nflen u'\Cd mlonllally_ In order that the prc~ence and degree 0 1 ..,peclh OJ" Ian guagc pathology manilc'!.tco by a give n pt'l\on can he: In d ... « t lilt

COnlt.'\I lI1\,:llIdt.· ...

Idl.' lllllll.'d and I1IclI ... urcd III ... or her performance mu~t be t.·olllp.lrI:d with a ... tundanl of '·l1onnul.·· One may thoo ..e as the ... tandard (1) the language tommon 10 the cultural COmmunity of ullll11 pimed per..,on.., in which the pallcntlive ... In whic h case an 1Il(lJvidual'~ verbal function would be tom~ pa red wllh thut of others In the same cOlTImunity of ,Imiiar age. gender. education, and achievement. or (2) the patient's verhal behavior prior to the on~et of tllne~s or trauma. The latter will vary from indi vidua l to individual and I~ ba..,ed on prcll10rbid educatIO nal achievement. ~pecific cultural characteristic~. per\onality, and other facto rs. A patient i~ verba ll y impaired when he or ~he deviates in any purameter of language and/or speec h processing from the "nor4 mal" communicati on behavior of the community in which he or ;he functioned prcmorbidly. A " norm al" standard is implied in th e terms impairmellt. disability, and halldicap. In 1980. th e World Health OrganiLation (WHO) pre~ented a c l as~ifica ti on schema that di stingu ished among the terms: impairment is the pathology itself (i ts location . measured size, and '0 forth): disability is the consequ ence of an impairment and its impact on eve ryday personal, social. and vocational life; and ha11dicap is th e va lue the individual, family. and community place on the di sability and the degree to wh ich the ind ividual is di~advantaged.6 In 200 I. the classification was revised. The term disability was replaced by actirities. defined as the nature and ex tent of functioning: and handicap was repl aced by participarioll, defined as a person's involvement in life situatiom•. 7

The Organization of Language When an individual gene rates an idea that he or ~he \\ant. . to exp ress. it i~ trallsfonlled into word ... and sentence~ by calling into play ce nain phy~iological and acoustic c\·ents. The message is converted into Iingui .. tic fonn at the listener \ end. The I i ~te n e r. in tum. fit5. Lhc auditory infonnation into a sequence of words and ~e nte nce~ thm are ultul1a1cl) und cr~lOod.

We refer to the sy)tem of ~)"mbol\ that are slrung together into scnte n ce~ expressi ng our th oughts and the undcr... tanding of those messages a'; language. In the fir ... t few year.. of life. infant... and chi ldren gai n a grea t deal of praclit"c and experience in the usc of language. until II become ... h. tbilUJI and 1\ u... ed Wit hout con..,clou", aWi.lrene .. ~. Pflf)ll%gy refer!oo 10 the !ooludy of the ... ound ..,y .. tem of 1,111gUl.Igc. Word) arc m:lde up 0 1 ... ,>cech "'Ollll(l\ or plltIlU'lfIf.\. wh ich arc generall) chl'~l fl ed " .. cilhcr I'OU('(\ or nIllH)' Iwlll.\ Phoncme~ III and of them ... el"c . . do not . . ) IIlhollle idea .. or object ... hut when PUI IOgclhcl thc) an: the ha . . K IUIgUI ... u(.· unih thaI lIlal\c wont.... Wonh cOlllpn . . c tht.' le~inlll. or v()(.."abulary, 01 ,J languagc. In Fngli .. h. Ihcrc arc 16 \ 0\\ toJ... ilnd 22 con ... o nanh . whidl oIn: COl11il lllCd int o larger IIll1b (.:;\ l lt.·d \yffllfJ/t'.\

There are bel\\een 1000 .md .2000 ') liable ... III Ln!!li ... h. .1' .t cl'ntr.d phnlH:rnl' "'Ufrounded b~ one Of more ('(,)\1'on.II1"_ 1\ 10"'1 li:IIH!U'H!I'''' h>l\ l' Ihelr ()\\ n rule ....,DOlil ho\\ phoneme ... mil) ~ l'~mbined 1010 1,1f'.;er uni,,_ ror example. 111 Cngh ... h. ,~lIable ... neH~f ,1.1ft \\ IIh the II":: phoneme. The mO . . 1 frequent" u ...ed \\ord .. in Engh ... h are ...cquence ... of from 1\\0 10 fiv~ phoneme ... SL1me h.1\ e .b 111i.l1l~ a, 10 phoneme .. or a!'. fe\\ a . . I. Geller.dl~. ho\\e\er. Ih(' 1110 ... 1 frequeml) u.. ed \\ord\ hme fe\\ phL1neme~. '\e\\ \\ ord ... are added (0 the Engli ... h lang.uage e\er: dJ). e'en though onl) il ... mall number of phoneme cOlllbmuuon ... are po ..... Jble. Ahhough there are ~C\"eral hundred thou"and Engh .. h \\ord .... \\C lise a repertoire of onlv Joout 5000 10 10.000 \\ ords 95 percent of the lime. . The granunar. or SYlIIlLL of a language delerminef> the ,equence of \\ ord .. that are acceptable in the formation of :.-entence .... In English. for example. it is po ... slble 10 ~a) "The black bo\. is on the table:' but the sequence "Box blad.. table on the" i~ unacceptable. Another example is 'The old radio played well." is ~yntacticall) correc t but "Old the \\ ell played radio" b not. The sentence. "The bo, \l,alked lO Lhe store" is meaningful. but the sentence. "Th~ book \\ alked 10 the store" is not. The language system that refer~ to the meanings of words is called semantic's. In addition to the phonological (sounds). lexical (vocabulary). o:;ymactical (grammar). and semantic (meaning) ~)!)Iems of a language. \\c also utilize prosody (stress and mtonation) 10 help make distinctions between questions. statements. expressions of emotional feelings. shock. exclamations. and so fonh. \\ hKh u'lIall~ cnn ... i ... 1 01 ~I '0\\ d

Speech Production The ~peech organs consist of the lungs. trachea. laT) nx ''''hich contains (he \ocal cords). pharynx . nose. and mouth. When considered together. these organs comprise a ··Iube" referred to as the l"OCallraCf. which extends from the lungs to the Iip~. Vocal tract shape if> \'aried by moving the tongue. lip"». and an~ other pans of the tract. Changes in the can figurallon of the \ocal lfact act to modify the aerodynamic quahue ... of the air ~tream during speech (Fig. 30.1) The pnmary function of the \'ocal organ\ relate ... to ba'lic life-sustaining functions such as breathlllg and <,y.alloy.ing. Thel.,e organl., not on I) take on different roles for speech. but function differenlly when engaged In \peech production For example. breathing for lifeU .. taining purpo ... e~ ie.; far more rapid than for e.;pcech prodU(;lIon. A full c)c1e inhalation/cxhaialJon take ... appro.\!matel}" 5 c.;econd~. \l.herea<-, during speech \\c control the breathll1g rale according to the demandc.; of the \I.ord .. and tentence~ y..e are producing. sometimes reducing the fa Ie of breathing to 'I'i little as 15 percent dc\oted to inhalation, Thb 1\ dictated in part by the fl.lct that, y..hen ... peaklng. y.e generally take In enough air to vocaille a complete

Soh palsh

Figure 30.1 The human ....ocal organ.

thought and we exhale the air gradually during the aniculation of the thought. The steady stream of air exhaled from the lungs is the source of energy for speech production. which is made audible by the rapid \'ibration of the \'ocal cord~. During ~peech. \ve continuousl) alter the shape of the vocal tracr b) moving [he tongue. lips. and other parts of Lhe ") .. tern. By moving parts of the vocal tract. Lhereb) modif) ing it ... acou~tic propertie~. \\ e are able to produce the different I.,ounds. That is. by altering the shape of the \ oca} lI1lct upon phonation. \\ e lrolI1sform lhe air streanl into a re~o­ nanee chamber (Figs, 30.2 and 30.3), The larYllx acts as a barrier to pre' eot food from entering the trachea and lungs b) cimlllg JUlOmallcall) during the act of swallowing. which i... 31 .. 0 helped 0) the .ldion of the epigloui .... B) opening and c1o ... tng lhe tllm (',r air from the lung ... the laryn\ JCt-. ii' ,1 \ al\(: bet\\ t'en the lung!>, and the mOllth. The laI)ngcal \ahe a)..o .1ch W k".:
All. Important componcnt oj the leeth ridge j~ the ah-eo/us wluch IS Ihl' are;'1covered by thc gum.... . rile .term arfuulatlOlI refers 10 the articu lating . or'. meetmg," 01 the variou ... organs of the oral-pharyngeal cavity to produce the ... ound ... or ... peech. Speech IfIteIlIXlbil,f} refcr~ to how a person "sounds" when speak ing. A number of factor, can innuence judgment.') of intelligibility ~uch a\ the presence or absence of visual cues or of extraneous movement" (i.e., tremor). The precision of the production of consonant sounds is one of the primary racton. that contributes. to

speech intelligibility. Consonanu. are described by specify109 then place and manner of articulation and whether they are voiced or unvoiced (Table 30.1). The "places" of aniculation are the lips (labia l), teeth, gums (alveolar). palate. and glottis. The manner of articulation refers to the piosive. fricative, nasal, liquid. and semivowel categories. P/osi ve sounds, sometimes referred to as "stop" sounds. are those produced by building up air pressure in the oral cavity and suddenly releasing it (e.g., p, I). The blockage

can occur by press ing the lips together or by pressing the tongue against either [he gums or soft palate. There are plosive consonants that are labial, alveolar, or velar. Fricatives are produced by making the air turbulent

(e.g., f, \'). Most consonants are produced with the soft

Phonetic

Figure 30.2 Outlines of the vocal tract during aniculation or \arlOUS vowels.

symbol

X-ray picture of mouth

t,.. '"... -"

the back. We refer to the space between the vocal cords as the glottis. When the cords are pressed together, the passage of air is sealed off and the valve is shut. Because the cords are held togeth er at the front where they articula te

.5

with the Adam's app le, the open glonis is V-shaped, opening only at the back. When we speak, we vi brate the vocal cords in a rh ythmic fashion , opening and closing the air passage from the lungs to th e oral/nasal cav it ies.

The frequency of so und produced by the vocal co rds is directly related to their mass, tension. and length. We alter the tension and length of the voca l cords continuous ly

Acoustic spectrum

t -."

aw

~

·in

while ;peaking. In normal speech, the range of voca l cord frequencies is from abo ut 60 to 350 cycles per second (cpS). Most people use a vocal cord frequency ran ge th at

.5

abou t one and a half octaves. The pharynx is th e area of the vocal tract connecting the larynx wllh (he nose and mouth. We hoIate the nasal cavity

t

cover~

from the pharynx and back of the mouth by rai si ng the soft palate. The most adjustable component of the voca l tract is

the mouth. whose shape .md site can be modified morc th an any other organ of th e oral motor ~ystem by changing the relatIve po... illon of the palate, tongue, lip .... and leet h. The lips arc rounded, ~p read. or closed to alt er th e shape tl nd length of th e vocal Iract or to ~ top :lIrfiow. The lee th and their relation ... hip 10 th e lip ... or lOngue lip t: hangc the ni rn ow.

00

P

.."E."

~

~•

Frequency

~

Frequency ----to-

~

Frequency ---+

Figure 30.3 Voca l trflcll'Onfigurallon and com!!>ponding spt"cIr'lI tor th ree eli tfen.: "t vowel:--. The pen"-!> or Ihe !>pcctm represent vocal Irael rc .,olluncc.,. The venicllJ Jines ror ineli\"idual lw.1ll10 nIC:-- lIrc nOI ., IHlwn.

Chupter JO Nt-'urog('Jlj(: Oi .. order.. of Speech and Language

119.3

Table 30.1 C I.bSir.calio n o f E n g li bh Con .ona n l., h y Place and Manner of Arlic ula ti o n

Manner of Articulation Place of Articulation Labial

Plosive

Fricative

w

pb

Labiodental

Iv

Dental

oth

Alveolar

~"'" Velar

td

sz

y

kg

m

Ir

n

ng h

palme raised. thereby clo~ing orf the now of air to the nasa l cavity. except for the nasals (e.g .. 111. 11. 1If.!). whic h are made by lowering the ~oft palate Clnd block ing the oral cavilY somewhere along it5. leng th. Liqllids are sou nds made with the soft pa late raised: / r/, /II. Sl'mi\'oU'els refer to those !)ound.-.. prod uced by mai nt aining the vocal trac t in a vowel-like po~itio n , then c hanging the position rapid ly for the vowe l that fo llows (e.g., W, y). Speech sound . . are affec ted by thei r context, that is, the sounds that immedia tely precede or fo llow. A speech sou nd wave is a continuous event rathe r than a sequence of discrete segmen ts. The ident ificat ion of a speec h sound depends on relating acoust ic features of the sou nd wave at differen t pOints in time. A standard reference for the qualit y of vowels is the eight cardinal vowels (Fig. 30.4). Th i5. schema of thc pos itions of

r---- - - -- --------,u \-______________________

~o

CI

a Figure 30.4 The canJmal vowel ... rcprc.,cntcd ,,\ .1 vowel qUadrilateral rhc cardinal vowel., arc extremely plm;l.!d rdefence PCllOl\ for vowel
tal hne are ~lI cvcd 10 have an equally high longue.: helghl wIllie . . Ol,l,ch in Ihe left ri!!hl pO\ ilLOn afe a.,.,umcd to be equally bal ked and fronted _(Adapt ed Irom I.atkfogcd. P: A COLlf'i C

In

PhoncllI.;\. llarcourt Brace J()vlIIUJv ich, NL'W Y{)rJ.. , 197.1 , Will,

Pt= r ml \\lOn .)

Nasal

sh zh

Glottal

e

Semivowel

Liquids (including laterals)

the tongue for the production of the vowels of the language help us to visua li le the tongue's movements during speech. It is, in a sense, a map of the tongue positions fo r vowel producti on. Tong ue placement is described by specifyi ng the location of the main body of the tongue at its hi ghest point. For exampl e, for the sou nd lee/ as in the word beal, the tongue tip is pointed in a high fro ntal confi guration. whereas fo r the so und /ah/ as in the word /atile!: the highest point of the Longue is low and posterior in the oral cavity. All vowe l so unds and so me consonant sounds are voiced. That is. the vocal cords vibrate du ring their produc lion. When a sound is prod uced without voca l cord vibration. we say tha t it is /l1II'o iced (e.g .. p, s). Tab le 30. 1 shows th at ma ny consonan t sou nds are art ic ulat ed in the same manner. and differ only wi th respec t to voicing (e.g., p-b; s-;;f-,'; k-g). Speech be hav ior comprises a complex motor eve nt that goes well beyo nd the skilled move me nts requ ired of the oral-motor system. Yet we prod uce l) peech without thin ~ ­ ing abo ut it, even whil e simultaneollsly involved in other ac ti vit ies. Howeve r. to transform th oug ht into l)peech take~ some vol un tary. conscious behav ior th at allows us to take infonnation ~tored in me mory and trans late it int o a coherent production of words and utle rances that 1'0110\\ certain grammatical rules. In addition to its linguiMic a,\pects. neurogenic commulllcation disorde rs often involve cocxh.ung Im ld to severe cognitive defici t"i thaI may not only aggl1l\'ate the communication di\ordc r but abo make il difficull 10 dirferentmte cognlll\ e from cOllllllunication dcficlI:". Although the c01l1111unicl.Ition di:-.order l11ani rC:-.h 111 pallCI1t:-. \\ 1111 right hrain Ui.lI11;1gl' \\ til nol be aclcl rcs:-.cd in Ihl:-' chapla. it 1'1 an c\,lllIpk 01 a lh ... or· dcl' in \\< hi ch Ihe cognill\'c compolll'nt 1... ;\ 1ll~lJl'r i ...... lll· The 1I11P0I1:IIlCC or Ihe: l'Olllmllnll'~III'.ln pr('k,·l' ...... ,\Ild lh underly ing :-.y:-.lelll ... Ix·cOIlle ... apparent \\ hl'll \\ l' con ... iuer Iht' two 1110:-.1 COllllllon 1\L'urngl'llH,: l' ~llllnHlIlll:.ltllln lh'llrd.... "" ul,/iwia and rlntJrtlmll 1111 ... L'i1,lph.'r flll'U'l· ... prinhlril)

119-1

Ph) ... i,·al Rehabilitation

on aphas ia and dyt-.arth ria and \\-'ill also co n ~ icler verba l apraxia. dy'phagw. and the use of aug me ntati ve/alternate .,\ stem ... of com muni cation.

Aphasia The propon ion of pe r\on., older than 65 years of age is projected to reach 21 to 22 percenl o f the 10lal populalion by the year 2050.i! It is estlll1:.Hcd thallhere are more than I m illio n indiv iduab wit h apha,ia in the Uni led Stat es alone'J·lo and that there are approxlIl1alcly 84.000 new patients with apha",ia in thc Un ited Stale.., each year. most o f whom desi re treat men!. II The majorit y are o lder than 65 years o f age and acquired aphasia as a ret-.u lt of a stroke. A smaller num ber ~u'e the con",equence of head trauma and neopla~ ms. Aphasia is also fn::quently present in the early stages of Alzhe ime r's disease. It "a . . estimated that the co,t of spcec h-languuge apha ... ia in the 1969 ca lendar year was S 13.2 mill ion. I:! Th is number ha ... probabl) tnpled in the intervening years.

Classification and Nomenclature In thi", chapter. the ternl aphas ia refers to the acq uired communication disorder tha t is manifest in indivi du als \\ ho were pre,iou ... ly capable of using lang uage app rop ri ately. It doe~ not refer 10 those developmenta l language dl ... order\ lhal may be pre:-,e nl in in div id ua l::; who neve r deve loped nonna l language and for who m the abilit y to u\e language ma) ne\er reach age-appropriate performance lc\'eb. In acquired aphasia. celllral nervous ~ys t em d isease or trauma compromi.,e ... certain structures in a focal rather than generalized fa~hion. The study of the neuroanatomica l correlate~ of the apha.,ia~ has engaged ne uro l ogi~ts since the late nineteenth century. and thc correlati on between apha ... ic "') ndromcs and cerebral localization is relati ve ly con ... istent. HO\\l:\cr. reccnt advance ... in ne u roradio l og i c~1 1 technology h
and is referred to asj7l1en l aphasia. Fluency judg me nt \ are made d urin g ex tended conversation w ith a patie nt and are de fin ed as foll ows . Fluent apha!; ia is charact erilcd by impaired audll o ry com p rehc n ~ ion and flu ent speec h th at is .of no~a l rate ~nd me lody. Fluent aphas ia is usua lly as~oc wted wnh a leSIOn in the v ici nit y o f th e pos te rior po rtion o f th e fi rst te mporal gy ru s o f the left hemi s phe re. Whe n Ou cnt aph asi a is se:ere, word and so und substitut ions m ay be of such mag nllude and frequency that s peech may be rend ered ll1eaningl e~s. Patient s with fl uent aphas ia tend to have g rea tes t diffi culty in retriev in g those word s th at are subs tanti ve (no uns and ve rbs). They al so tend to have some deg ree of Impaired awareness and arc ra re ly phys icall y di sabl ed , bec au se their lesions are located in the posteri or po rtion o f the brai n, di sHull from motor areas. T he re are seve ral types of syn· drome~ subsumed under the flu ent aphas ia cl ass ification (Tabl e 30.2). No nfl uellt a ph a~ i a is charac terized by limited vocabu · lary. s low, hesit ant speech, some aw kward art icul ati o n, and restricted use of g rammar in the presence o f relatively pre· served aud itory comprehens ion. o nfluent apha~ i a is asso-ciated with anterior les ions usua ll y invoh'ing the th ird fro ntal convo lut ion o f the left hem is phere. Patient s with non· fl uent aphasia tend to express themse lves in vocabulary that is io-ubio-tantive (noun s, ve rbs) and lack the ability to retrieve less subs ta ntive part s o f speec h (pre po\i ti o ns, co njuncti o n ~. prono uns). Patient s with no nnue nt aphas ia tend to have good awareness o f the ir de li cit and us unll y have impa ired moto r fu ncti on on the ri gh t s ide (rig ht hemipleg iaparesb). A seve re aphas ia with m arked dysfunc tio n across all lan guage modalit ies and wi th severely lim it ed resid ual use of all commun ication modes for oral-aural 1I1terac tions IS re ferred to as global aphasia. G lobal ap h a~ia is not a type of aphasia but rathe r a designation of ,c\'e rity. T he pat ient wi th globa l aphasia generally has exte nl) ive damage. whi ch may be anywhere in the left hernbphere. and j, .,ometimes bi iateral. 14 G lobal aphas ia has bee n c ited a ... among the 1110 ... t cOl11 mon type of aphasia in patients referred for ~pcech rehabil itat ion ..,erv i ces.I~.lb The most com mon cmego!) of fluen t aph<.lt-. ia

IS

Her-

IIIcke's aphasia (also re ferred to a., sen,or) apha'i ia and/or

receptive aphas ia). Wern icke's Hphas ia i... usua ll y the res ult of

a lesion in the posterior pon ion of the tir... t tempor.l l gy rus of the le ft hem isphere. It is charac terized h) Impaired aud itory comprehension and fluently articulated ... ~ech marked b) word ,ubstitu tion,. Reading and writing are u... uully \Cverely Impaired as well. Although patient ... \\ ith \Vem ickc'" aphaSia may produce what seem like complete ulter..mce.., and u.,e comp le),. \crb tcnt-.e~. they often add a word or phm. . e and "augment" ... pcech production. Th~) may abo ...peak
Table 30.2 CI,,,,,ificalion by Aphasia Syndro mes

Area of Infarction

Postenor portion of temporal gyrus

Third frontal convolution

Third frontal convolution and postenor partlon of superior temporal gyrus

Panetal aperculum or postenor superior temporal gyrus

Angular gyrus

Supplemenlary

motor areas

Both Hesch!s gyn or connectlon between Heschl's gyrus and

posterior supenor temporal gyrus

Spontaneous speech

Fluent

Nonfluent

Nonfluent

Fluent or nonfluen!

Fluent

Nonfluent

Fluent

ComprehensIon

Poor

Good

Poor

Good

Good

Good

Poor

Repetition

Poor

Poor (but may be better than spontaneous speech)

Poor

Very poor

Good

Excellent

Poor

Naming

Poor

Poor (but may be better than spontaneous speech)

Poor

Poor

Very poor

Poor

Good

Reading comprehenSion

Poor

Good

Poor

Good to poor

Good to poor

Good

Good

Writing

Poor

Poor

Poor

Poor

Good to poor

Poor

Good

1 t Qb

Pin ,i,:al Ih' hahilitation

\\l.'nlh,:J..I.'· ....1(1h""'1.1 mil\ 1.'\111\t' Into .IIlOmit, .lpll.I ... la III \ 1lttmll cll,ha,\Ic1 l ... t'har;ll'Il'rIIt'd h\

the.' C(lur"'t' 01 rt'I.."'\e.'1\

'l~nlllL.lIlt \'(lld IlIldlllg dllhullt) III tilL' ('Ol1ll'\t (II t1ul'n;. ~r.lInll1.lIll,lIh \\c.'11 h l 11l1l'd "'Pl'IXh.-\uditor) comprl'iu:n "dOn I' rl.'I.lllh'" pre."l'nl'd I'm 1110 ... t 'l1Ca"-lIlg ,ilUalion" ~pc.·('l·h "utput m;l) hl' '01111.'\\ hat \ague and Ihl' patll'l1I T1l,l~ ~ rn)lll'ic.'nt Ul producing cllnllll/o('I/f/OI/,\ to ,"-"llhl' 1,ll'''- III '~(1fil'il) of languagc u ...c, ,1

B,"pc"«(\

aph'Bicl i ... a nonllut'nl

t) pc of aplla . . lil al,o

rrcosod \\

put, dlOJ1, .U1KUI,I1JOIl, phra..o;c ICIlc-th. d u lullOn\, .md (lmJ"IOIl~. "I't'fllwn of df~l~ mg e ~ r IllU II ") liable \\ord\, .U1d 'Cnlence 01 ocr~a mg lcn_:h cOlllpk\I1), {Omprdlt'J/\IOII

{'p t.

'J

un

ta

t'

i

10_ e

\~onh, of ...elllenl'l:" that reqUire 11111~ ~e -no porn • ~ pOllltll1g on command: u vrd r( mn ,11 (y, (lrd findtn~ Q')(:

mg the ilhlhl) 10 generale \\llrJ, hegmnm~ "Ith parth,\1l,Jf IClter 01' Iht' alphabet or In .1 panlcular x'manth': (Jk~ on aru.

relerT't:'d In ;.... c\ pre . . ' I\c apha,ia, motor apha,ia, and/or \l'r. hal ~lph~hla. Broca ..... ;lpIHl .... ia i ... Ihe n~,ult of a le.,""on IIlvoh

ma]..,): fcatilllt: and \1 nflfll! Irom Jll"IJ.tll\l1 and 'ronta. I1cou,I), SOl11e \qdcl) lI'I'J ,lph,l'i,l I1ll',"Ure, tnl.:ludt' the Boston DiagJlOJIi<\I,hmili r \IIWIII,lIW/I Rn·\EI. til(- \

ing thc third front al CO/1-"OIUIIOn the left hemi . . phcrc. Ihe ,uoconical \\ hitc mail er. and eX lend ing pO!o. lcriori) 10 thl' inkrior ponion of the mot or !o. tr ip (prcecllI ral gyru,). It "

(I\'CC/-\J,!(l,lI1<j the

or

chnraCIl!ri7cd by aw"-ward arti culation . re ... lricted \oc!lhulal'), and restri c t ion to simple g ra mmal ica l form ... In thc pre . . ence of a relati ve preservation of audit o ry comprchcl1 ,ion, \ Vri tmg !<."-ilb generall y m irror the patlCIll of ' pccch,

Reading may be Ic!<.s impai red than speech antI" riting. The patient m3) be linliteo 10 o ne and two word prod uclions fot' e\prc~siol1 and lind it impos:-.ible 10 combll1C \\ord\ 11110 ..,ent encc!ot. Articulation may be <1\\ "-ward and effonfu l (.see the sect io n o n Verbal Aprax ia ), Nonn uc nl Broca "" "ph:!,i:! i~ rarel y found ill apha . . ia aft er traumali c brain injury ( rBI), Anom ie di.., turbancc ... predom in ate in aphihia scco ndat') 10 TBI. In c hildren, apha !o. ia after TB I i, gent.! r:tll y characteri zed by a reduc ti o n or o utpUI w ilh hes il:ln cy. dlfficull Y ill ill atlllg ~ pecc h , and so mc tim es l1luli !o. lll ,l1 Man y m easures of apha sia and related d i:..ordcl s haw bee n deve loped for usc in bo th c l ini cal and I't.!,c:m.' h :"t't ling ..." I n an inpallcnl se ttin g, p~Hi c l1l s w ilh apha sia an.! gt'll ' erall y sc ree ned al hed . . idc , Th e purpo:..c 01 a hc(j.., uk

or

screening i ... 10 obtain a genera l idea II palicl1l ':" pi lIlt Ie 01 defic its and pn!ser ved are:!\ of language fum,'li on ;ls;1 ha\ i, for recO l11mendalion, for m ore co mpn: hcl1\ive Il" llIIg and poSSible rehabi llt ~lIi o n , Obv iou sl y, :..crce l1lllg 11.',1, h aH.' lun ited va lue bccf.tu')c they o lTe r Ie\\ dc t:li b ahout Ihe l yPt' ,tIld 'tCvcrit y 0 1 aphusic dc /ki l'" Ihal Icad 10 a ,ymlrolllL' da\'1 11 CHllon, An IInpon anl pU'lJOse 01 a comp l dll!Il \IVc.! C\illIlI ll a tt o n i, 10 prov idc a hiJ \c lll1c Illca:-. urc again ' l wlw,,:h 10 g: HI !!l.' prog re... .., In the cour,e 0 1 rehahilitation ,

Aphasia Measures language tl!!o.h dcs iglH: d 10 Illt':!\U ll" :lphll,I\,: lin p<J In nellt genera II y ("0111ai II "' 1}l'C I fie dom:IIII \ 01 pt" l 1(J\ III .111(;1.::. In addi ti on 10 thl' !!(.'l1 cral I'cqulrl'llll'lll\ 101 I Ill' CO il ~tru((JI)n 01 tC\t .... \uth :\\ Il'lIahlllt y. \ 1;lIH.I:II( II /:l ll
COl1lprCh Cfl '\lVC

m,\l'lI.\cw\' ('elllf'l" Cc l l1lprc'lwll.\l\ t'

r \''''II11
\\(,,\(cTlI \1'110.\/11 8l1ttOl"

\."'1 .. , " '

In ;IJdllion 10 the lllL';I\Urement ()I pc.~r1"lmll,U1c.'~' t'll "'pt'l:lfi.." IlIlgul,lic t;I'''-', an apha'l:! e\;lI1HIli.lIh'll ,I]..,() n'~uln:, ,urr1e • Illcl11ar) 11lC';bUrc" ofJillll'litllll1l nmmlWUt ,111 m 1111'" I' ~",". l'"ar) lX'C;llI\C :111 indl\idlkl!" ,h.'II1.11 U'l' "t I.IIl~U,l~l' III e\ erytla) Ilk 1ll:J) not cnm:-'J"X)lld w tht~ dt'.~!T\"'t, ,'I r,lth,'Il'~~ Illci"urcd h~ 'I~cilic langu,l.t!c 1,""- !'t'rh)nn,ltllt' i-un( llOl1al cOllllllunication ll11';"UTt', .11"\' u,u;llh pl\,lul.'I.'d III Iht~ form of rillmg 'C;llt-, \\ tlh high IIlll'rr,lIt'l l\'lI.lhl1l1-' Tnt' /"IIIICIIOlIol ('01111111111/("(11101/

lil'(,

\c-lll"illl ',\

~~ ("I 'IIUIlIll'J,.1

Pr(l/i/( I I ( P

01 f)t1Ilr IH'/Jlg ( ' \1>1 1.

,md \SII \\ I II \,\11 \ f \(\

1

1101101 \\\1',\.\11/('1/1 l!ICcJl)lIlIIlIIh'alh 111 \~,II,

\\ hlL'h h;l\ l' lugh IIlIL'n'.lIl"l rL'ii;lhlltl\, ;In..' \\ Ideh u'l'd h'l Ihl' pllq)(bl' ,

Hislorical PcrspcClivc I :lngu;t gc dl ' Hl rhalll'l'~ \\l'!\.' I L'C"I(kd ,I' C,II" ,I' ,,\()jJ IlC :11 1(1 !llIl'!lIP" \() "rt'lr: utl '" IIldl\ hlll.lI, \\ tlh ;ll'h,hl,1 h,I\('lX~t'li Il"l'(lIdL'd I hlntlght)ul h"l ll ! ~ '~Stll lll' '\llh,'III'1 d,x'uml'III~'d c l,e, 01 h(uh \1;11111 ;11 Il'l'O\\'I~ ,lilt! Il1h' l\l'nlhHl \\~'I\' Ih~' pat it'lih 01 it'olo r-'.la",1 ,\lid 1'I,III\' I'l"11 \1\"(.'" III I \"'\~..., In ;I I.lIltiln:u I.. IXIjX'! 111 Ihl' 1,lIl" II II \\' It·,'111 II ,','llIU", "'1111 'U:.'!!l' dl' 1;1 1,1L'Ultl' d u 1;llIt',l t't' ;lIlll"nlt' .. I'.utl Hltll..1 \\,1' "lit' 01 tilt' 111,1 10 d"n J~' till" jltl"lhiltl\ III 1"II,IIII\lI~ III ,Iph.1 '1;1 In 1)1 ('I!;u!c.', I-. ~ltll, \\,1' Ih,'III,lltl,ldd1t'" 1\','11\\"1\ and Il'l Ulhllll ;lIHHl III ;lph,I ' I,1 III ,III i-Ilfll ,h I.l1Iftl,I.I'I· 1'"1'11 I Ie.' I L" p ! II led I Ill' 11 ;lIllIllg III ,I p.lllt' lll \\ II It pI "I ,I II IJ..,' ap llil' ..1 \\ hom Ill' .lIld \ )OIl,lId BIII,llIh"11I 11,',II,'d, " 'III)! II Il'lhl ld, 1.1I ~·l"h d,·It'1111111I't! 1\\ III,' P,IIU' III. \\1111111'1',\11 "\ 'I' ,Y\ Il' 11I1111 l', d ly Il' I ll'a1 111 ~' kill''''' , \\\llt", ,lilt! 1'111,1"" M tll \ .... IIh \\'1 \ ,II ICH" ;llld .tPPI,l;Hh II 1 ,l pli ,I'I,1 h'lt,llll Iil,tllt Ill, l'uhlJ , ht' d O-'t'1 .1 ll'l1ltll) ,11'tl , ,IH' " ' II I,IIJ..,IIII\ ' 1II1d.1\ hI IlIUdl j1 l l"t'IH di!) pl .K lln' ,lIul Illtlll)·1l1 1\1111, Ih ll,·tllit,t11h l l ,til jllI l ll' lI h Ill"II\' 11I 11\1111 H·II.\II II II~' 10 II", ' .1111,' dq'l\"\' ,lI1d ,lllo.IHtWll' d ,.:t'd l il,1 1 ' IHU II,I Ill'IIII' 1"'11\1'1\ 1I111·it! 1"1\\' .111 ndllU'IIl'l' olli lil' l'011l'1" ,lIult'\I('1I1 111,,' \0\1"1\ \Vwld \V,II I ;lI ld hi ;1111 IIqUl".! \ IHllh,1I 1\ 11'.1 10 I hl' l'\I. 1I11l,h lllt'III 01 11\',111111'111 ,,'I1ICI' \\hl'h' fl,IIII'III ' . . " \,•• ,I,.1, \"III"I .. lih In I \\ 1I1i PII :-. lll dtJlIl, ll ll" ,lpl,."" \\11\ l' allOIl

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11'17 11, ..1111 rIlIUlW .... 01 \.thom 90 10 100 \\l'I\' hllhl\\ cd lor.1 I () ~ l',n pt.'llnd. \\ i'\ prondl'd h~ KIII t ( iolt! ~Il'm III !r.lIlldlllt dWlIlg till' Sl''':Olld \Vorld War rill!! \\odd \\,11 II. 1t.'pOII ... 01 1'~lr'llnlllg l'I\III,I I1\ with p
,dHl ,uttered ,Ill .tproUl'1I1 \,.I\l:u!.tr 1I11~1n':1 aile I' a lull -Il' nn dC'\I\l'r~ ilnd ,ho\lcd \"'ollltl1lIOU\ language l111pro\Crncnl ,\,lh nm ... '''CIlIII.UIlIlll.! O\l'r'l

In

.1

10-),l'ar penod

II>

I,lnthllilrk :"I-year o.,fud) ,upP0rlcd h) thl" C011l1ll01l-

\\l..ilth I'lind. WC'\l'nhurg. and ~lcBnde addrc ..... cd the genl'rallOpll' 01 ~lpha"'J:I and \,.'Olllll1cnlcd 011 the c!lccllveIlC ...... 01 recducatlon. \ l'ill' "'!lllly concernl'U 60 p~Jtlenl'" \\ hn \\L'rr \'ollnger th.1I1 60 ~ car ... of agc .•1 Illajoril) of \\ hum 11:Id "ulh,.'rcd qrnf...c ... and concllJ(,k d tllUl rccducatlon IIlcrt:a .. cd thc J'i.ltc of rcl'o\,cry. a ...... l\lcd 111 f;,ICillli.lllllg thc u .. t: or COI11-

pcn ....llory mei.ln .. of l'llIlllIlUniCi.tllOll. and impro\'cd morale \\01'" al .. o dOl'UIlH,,'llICU Iht: p .. ycholherapeutic bcncIiI'- pi trcatlllcnt \ph ..I"I.1 .lIul I'" concomitant l1t:urologlcal dcliclh in thc pam'nl \\ \til \lmk.t: \\ere gellerally \Iewed a .. nalural and Ilc... c ......lry c0l11pont:11I .. 01 the aglllg proc.: ..... 111 Ihe period hcforl' World \V~lr II . The trcatment of apha\la 111 the civi lIan populallon \\ i.I' 1101 COIl'ltlt:red an option. \1 .1I1~ \ .. Irlable, h.td .. til IIltluence on maf...lI1g the treat ment 01 ,lph.l\liI the cOJl1mon practice Ihnt II 1\ lOuay. The Jlhl'nt llf 'peech patholog) a' a health profe""loll, the ~I1lL'rgl'l1l'l' of n:habdltatlon lllei.liclIll' .. ' a mt:dical 'pe(laity. the 111.1 ...... I1lctlta c\p lo"'lOn, a larger and more aftluel1t nmldlt: cia". all ITH:n.:a",e 111 Ihe life "'pun, the number of "U'(l"'C: and br;lIn Inillf) 'ur\ iHW,. <.Ind public t!\pcciatlon .. oj l11L"dl(mc In the i.lge of lL"chnnlngy an= among Ihem. The la'i h.I" t"lL"l'n partu:ubrl) IfIIe H1 Ihe IIldU\lrialiled \\orlt!. \\hen.· \I I'" \\ Ilkl~ hehc\l.·d that there I.. i.I trealmCIlI for c\e~ human ill I Joum,lh dc\ otl'd 10 bram/1i.1ngllugc 1...... lIC ... hi.ln~ bt:come md"llCll'JhJc Inftl11l1!.1tloll 'llUn.,'C\ for ;Jph;l\iologl'I'" (c.g .. -\l'h"\/fI/O\!\' H'clill tllI.II,({IIi,!lIt1i,!C and COHn). The \ cauClll~ oj \ph.I'''I.;\ ... dHllarl~ "'UL:Il'ty unlicated to the ,IUd) UI,lph.hla. \\a ... l· ... I.lhh,h\..·u In 1462 rhe Naltonal ..\pha\li.l ,-\ .....rll.:latIOIl t~ \ \) \\it ... hllll1ded 111 till: lilltcd St,u(', III 1{)~7 1'01 thL" purro ... e uf rnl\ Ilhng IIlfOrlllatJon 10 thL" puhlll' ,Jholll .Ipha'hl. ,ldHlL:;IIII1!:! 1~11 the ,ll1h" ... II..' L"o1l111lunit). and tl\\.'t)lll,lglll~ th\..· ,,· ... I.lhl1 .. llIl1l..·111 of ... upport group, callc:d \ph.I"I.1 CUIllI1\UIlIt~ {ilnll,"" ( \('(1 ... ),1. \L"\L"I.iI IIllpl1l1,HHHl.tI puhh",Jtllll1' dl..·'lglled for "'L" h:thc I.mlllll:" ,llld Inl'l1lh llf p,ltu:nh \\ IIh arh;I ... ".1 at...l) aplJ(.ucd In th~ Pl'II\~1 Illlltmlll~ \\nrld \\'"r 11 .4I.\...~~ ()ne ~lf thc:\C'. l Ill! ' I 1.l1hllll" \ph,I ... I.t." I' ,It II \\ Illcl~ rcad .md h.t hc-en pUhh'hcd 111 I~ 1.IIl~u.II.!I..·,.~\ ThL'lr

1· \ dlu ..uion of R",,:o\- ,,·n It \:nl11plC'te 1':('1l\("1\ Ih'lll .~ph.I'I.l h rrtn

~ t ()n(e ,lph.I'I.1

I,ll) (l\,XUI

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i.I

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IS 11

u.llly

lilt.' (,' \l'CPIIO/l M,,,t patll'l1h dll nol ulIlo;ldcr them t;I\o'l'i fC(f/vcred link..... Ihl' Y havc lully II..'CIlVCll'c! 10 prcvlfHI~ levels "I !.1Il glwfl' p~"lrOlIlWnll' II WhcIIUIlrL"t'o'r'crcd ".Iliellt. are 'II

I,bl·t! \\ Jlil thl'lr Icvcl 01 COlllpcll'/Kl' alld 'O"'IdCf th m· 'ch,l.· ... n,:covcIl'd. Ihl' J~ ;'1 p"ydlOlogl,.11 pcr(Cptlofl illlO ,ho uld ntH ot: t·onfu .. ed With an OOIClIIVC cvaluatlOli of t'om1TIUllItilllOI1 i.thililies. Thc true te .. t of apha'I;1 rchi..lhill· tallOn oulcome I" tht: pallen,,' pcn.:eplloJl of the quallt) of their li\I.!~ . Mca .. ure~ of life funt'tlon that mc..:ludc a,llvity lcvel .... ,0cialll rcgamcd langungl.! ab",tle ... : ;lnd a \econd. which in humani~lic term\ milY be more Important. that mea~urc~ the rccovery of functional communication. Thl.! concept of a functional dlmen\IOn of communication beha\ ior emerged logically from the expenence of trculm£. patlC11l\ \\ Jlh aplmsia in Ihe rehabilitation medicine ~I.!tling. lIi<"{oricall), rehabilitation medlc1l1e has acknowledged that the ability of patlenls 10 function in their dail} I!Vt;J.. (aclivilic~ of daily living [ADLj), doe\ nOI necessari I) corrclate with the extent of ph) sical di~ability. Improvement 111 quantitali\,e measures of language performance doc ... not neccsr.,u rl ly correlate \\-'ilh improvement in functiol1<1 1 cornmunication':~11

Efficacy of Treatment in Post-Stroke Aphasia ~Ii.lny methodological problems ha\e limited the number of ~ttJ(lic\ thm examine the eftieae) of aph~ia rehabilita• lion ,~'1 ~~. " ...c\-ert jlC j es ... treatment account a b·j" I II) I..... UC\ are compclltng and a focu~ of profc:. .. ional concern. luthe ... thai 1I1ve~tigale treatment efTect..... "'pecific techIlIque"i, and approaches ha\c been reponed stllee the lale 19':;(1..,'1'1 \'ignolo.:P Hagen. "s and Bas~o et ai"'! hu\e utlII/cd umreUll.!d control and treated group ... and ,ho\\ n a treatment clleci. The worf... of She\\ an ..Uld Kerte,z' and Puccf... ct al":: \\ nh Irealed and untreuted group ... ha~ al . . o ~ il'ldl'd pO ... III\C lrealment effech. \'ariable ... ,uch i.h "'p(ln1,U1~OU'" reco\er~,h'--t>~ i.lge, (!to,,,~ duration and lreatment illtl..·n ... ity." and "'pecific treatment techniqut',,'" 69 h.1\ e tx~e:-n ..tudic:d. .\lttH,ugh ,tudie, h;\\(' \aried 11Iethodolol!h,,·J.II\ J.nd h~ r,,"'l..'an.:h hl\.·U,. the:- rc ... uih prO\ iuc: 'tfLlng'" IIldl~'attllfl fnf P~hlll\ e treallllt:'nt dlt:'Ch Some h.l\ e:- 1Il.1Ji1t.I1I1e:-d th.lt 'lIlgk ('.I"'C 'llIliIe, rather tit.," r.l11dll11li71..·ll. ,,'llntwlkJ tn.ll, Me thl~ IIll"t .lppropri,Hc me:-lh"lJ I,lr ~ Jdrt.""mg Irl..·.1tnll'llt dlil...tl..') -I \ ,ingll" 1.',1',,' .lppn.1:lI..-h to (he ... tlld~ ul .lph.I"'I,t trt.',\tntL"nt CItII..·.lI..·\ h.I' nllt l-, ... apeJ I..-nti 1..'1"'111 nul I' l.if k, ... frl.'quellt Ih,m dUII.'I'm llf 'IUUIC' b.t"'l..·d 1.111 grtHIP' llf Pl... llpk \\Jth .lphJ'IJ :\q!31I\l· \ Il'\\' lit Ihl' gfllUp ,tud~ I1Wl.k I .He OJ,C"d prim nh n

lh

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l· ... IWl·I; 111\

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R(':(l'l1 ll~ 11ll' \l.hkt11\ III \JI'UIIlhlpll' ( '()llltlIUlll c;t luHI [)I"(lr~k" .\IId '-nl·lh.l· ... ( \ ' ( ·IlS) h" ... IX'l' ll L· Il )!.I~'l·d 111 .\1 1 l'non to lk-\l'I,,1' l'\ "k'nn' h.''''I.·d PI,KIIL·\' !! UIIIL·llIIl· ... 101 Ill'lI rO'l·l1l\.. u l llll1HlIIll.IIHlIl dl"'\lldn ... , ·\1 Ih .... \\ 1111111-' 1Ill' ,cn~ 1I1111.1I1\t· I'" ... 1111 111 pmfl'l· ...... ;Ind 11lL' "' P t.'l·L'1l 1.IIlI.!U.lgl· p,lllwlng) ploll· ...... lnll l·Ol1lnllll· ... 10 dl'llL'lld un

\

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01

dlil.:.ll'\ ... Iudll· ...

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hit ... hn'lI 1\'llIHIl'd il'> .1

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,

(11011\ (;1,.'1\(/1,.'1 dl .....• ... IIOI !lPI X'd l 10 hd\l'.llIllJljlilll.lllt 1II11t11'lll~ 011 Utll(, 111111,.'

'~l lUI \dllll' h.IIHkdlll,.·, 111.1\ h,I\1 111 l'ik I 'I,

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tll.IIIH) ... III;IIII11 ,I II L" dpll.I ..... ' h..... ,I h':1 IVI pItIVtlo ... i ... IlIdll ilplli'''01 "'l'l'ClIHhIl Y III \,1\l,.u l,1I 11,.· ... 11111... III I ill· I ... tllIl l· lj ....V... 01 .Ipllil"" "'l·lOIIl I.!I ) \I I IlillI.lh· l"II.rll Il·porll,.·d 10 Il'lOVl' l l·Olllpk'! t· l y II 1411 I Ill" 11I 1I 11I1~ 111.11 11.111 lIlillll' ;lph;, ... I;l l·; IIII L· ... it 1"k'l k l 1IIIIf'llIt ... ", IlL'" \ ..... lIIL " ,'ph.I' 1.1 nwy ht.' 1IIIIIIl'lIll.·" hy Ihl' Lilt lilill 11.Il lt·lIh 111 \,01\1,.'11 'lIfr ,11I It

Illi1l1 t l'Wlll ... m I,.' )!L'lIl'lidly Ill·I IIOlo~· l l. dl y IIt'j dlll y \\- Ill'll'.I\ p"lll'/lI'o

R ecovery

1:11

\pha'I •• I'" mO ... 1 olten of ... udden on'lcl ,1'1 Ihe Ic ... ull 01 a ... troke" or head trauma . Gelleral!} ... ome d Cgrt!l' 01 natural rcnncl) ta~c, place 111 the maJorily 0 1 pat ient ... willi 01 "lthOUI intervCllllOn 111 Ihe period uTImcdlalcl y IOI/OWltll! on-..et.. HO\~cvcr. Ihere 1\ a lac~ of COlhen'l tl 'l aholll Ihl.! dunl tlon of the .\pOIu(Jlleolts rec()\,l'I"Y perlmJ . II• 7~ ('uiIOIl rcp0l1ed rapid ~pontancous languagc rl.!<.:()vcry in thl.! Ilr!o.t month 101 lov..ing the on~c l of apha!o.lct, "I A numbcr of '1tudlc'l have concluded Lhat the grcatc~t improvcmcnt O<.:l,: ur ... in Ihe lif'll =': to 3 month!o. pO"I -om,ct ~'J.f>1.r'J)1I Butl lcld LlIUJ Zang . '" ill. '- Sand\ ct al,"· and Vignolo found thai Ihe rc(;()very rale dropped \/gnJii<.:antly aflcr 6 month .... Olher" have reported that "ponlanCOU\ rc<.:ovcry doc ... not occur afler 6 month\~!i or I year. w 'J Samo and L.cvila ll4 rcportcd that the grt.!aler change Look pla<.:e within a 3-month than a 6-monlh po.,t-On\el period in a ~ample of paticnL\ with \evere aphLi ~ia ...ecn up to 6 month \ alter , troke".

In a ,urvey 01 850 pallen" lollow lng "cule , troke (INithin the pa~t month), apha " ia wa'l prc\cnt In 177 pallent\ during the acute pha~ . In the four 10 twelve weeh follow· ing the <,troke, apha,ia Improved In 74 percent of the pallen! \

and cleared in 44 percent." An cxceptlon to the pO\\lhl e o<.:curfcn<.:e of " pontanco u\ recovery eXi\L\ in the ca... c of pnflW/) propre \\ire ap!1fl\W

IPPA). a conditIOn fiN de ,crlbed

In

I Y~2 whlth has

become a diagno,\tic category.' PPA i... a ",lowly progrc\\lve i,olated apha,ia I!.hich h" becn de..cribed ,uffic lently to be con\idered a di' tinct clinical behavioral en tity. II <.:an C,ltI,L in the ab\Cncc or relativc ah\Cn<.:c ()f gcncrali / cd cognlllvc impairment."" II It generally beg,"'" a't a dilfi<.:ulty Yo nh a particular language fun<.:tion (c,g .• nam'"g, ..... hu.;h gradually wOr!.ens over a period of at least 2 years betore <.:ognJlI\c dcficH, OCj!ifl to bc<.:ome e\idcnl. Invcstlgator'; v.ho have addrcs!o.Cd progno,u(; faum In apha~la recovery h:lve generall) <.:oncludcd that fac:tor such as age gender .md lJandednc s do not affell rc(;overy

I rom aphru.la In toc health) aged. language per10nnancc decl""" • mficantl) betlAoccn the SC\enth and cl1!hth de.cado (ornprc ~n "'" p"rtonnance heglll!> lu declme In the L\lh deode wJd .:anlmu"," through the eighth decade \/thOUgh age

wllo ha w had ... lIl1kl· ... In"y hil vl

"Ilk pII',HI Vij'>lll

IIIV(t l VL'l lll' llt

Hoth

I ypl' dnd ... l'VI..· lll y 0 1 i lph~t "' liI .IPl'l·11 101...111> Pll

wll h ploll;d ;qtha 'l lil hil Vl tl ~I thl' pOfUl'''IIII1IJ~ 110'1 ..... /'/1,10} UH B:t 'l'lIlIl'PIJlll'd "liIl Wllt'li p ill/e ll! , wnli llw·1I1 :lnd 1l0nllll t: 1I1 "ph;,...I;, 01 Ihl' ... i lllll,.· "'L'W lll y We l t' lfH111J.Unl Ihere Wl' l c no lid icJt'IIU· ... HI (k~' I t't' 01 !l't OWl Y III XX I \ 011 ... c<.: ull vc aull t: '1 lrokc
llIi''''''

w ith lIuCrll aplw'lw 1(~;lL lwd Ihe 11I ~' ll l''''1 kwl "I IIi JIl I Jt/Il,d WliCICl ' '\ p:tlll'lIh w illi 1I1J1II1IWIII .111.1 !! Ioh.al :tpha'lJa tIIade "'1Ii:dln ~';jlJl" III lilt H If! ~2 .... l'L ~ po, t . .,'roKI' pcnoclllJ! (.101",1 ilphil,l;1 (Jlfll'lllill t..\llllv( III .,cvere BIO<.:a., aplta ... w w lwlJ tl wlt' I") "")!IIlI't .ulily H!tI)llIved <':(Jl11prehCIl'II)Jl HrIJc.::J) ;'l'liil'Jla Illa y Iw( 111111 11111111//1 ap/W \ /(J ,
flfllimfl/ f, I 10# WlwlI pallf'1I1 wllh ,JjJIiJ la rcoJVcr a l'rl.',11 deal oj LUIj1H;IJ.!1,! IUlJ{ 111m III/ y.1I U lj,tJly left Willi rc:.,u!ual fJllfJlllfll Pall cllh wll(J ...t lOllllWU'd IlJlfIIJJ.!fi.lpJ,y (( J) 1;(:.111 hllw large dOllllltal1l ItclrI''-.plu:n- II' ,JlHI!;. rlljJliY 1I1,ll! It ,IJIj Ilr hilaleral II' 1()11 arc Ie '" hh:ly It} fI '-.t)V(, Illali IJiII wllh

{1JJ1dw fllJlI

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I

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aur

lht)'1c tllat eT.tl!lId (CJIJrc PI) k/Flfly "f1d lead 10 and PCf\,,>tcnt apha w , I he nl"uIlJraJ:!JoloVH,; al (, 111 lal apha.,l
I :
per"onJI II ~ lra lh hm e been I denlili ~ d .1' lI11pOl"lal1l progno, He f.u:tll ~ . Ei,en,on ant! I krm lilllll fe ll Ih at P;III Cllh with (lUlgoing pef\Onallllc, had .1 ~ lI t:r progllo..,I' than tho..,c \\ Ith mtro\erted. dcpende nt . ur ri gid pa,olli.llit ic.."II-l lin II I'" the ge na.,1 con't' n' u, tha t language gain.., in apha,IJ lake place e.l rlte r ra ther than later. and that tllne ~ m cc on,ct I' an Impon ant rccO\cf) \ ,u i ab le. H1 \·II"'-I'1

Psychological and Related Factors p,~ ehological

fac tor:, ~uch a.s de pres~ lOn. an\lclY, premorbid per,onalit) . fa ti gue. and paranOia are often cited as deterren t... 10 recovery and comm unica tion. The social isolallon e\perienced by people wi th aphas ia and th eir fami lie ... ha ... a profo und impac t on their qual it) of life.Sol The etTecl of aph i.l~ i a on the ind i\ i dual '~ se nse of " ~e lf' is ofl en e\[remel) negati ve . leading 10 a loss of self-esteem and feelmg') of he l p l e"~ne~~. The opportunllY for "healing con\er~a t io n :' ~o essential to indIviduals who have suffered lo')~es. I ~ often un avail abl e to tho.!oe with aphaSia. Dee p dep ression b freque ntl) the res ult o f this combination. The influence of these psychosocial vari ab les is u ~ uall y nega11\ e and is believed to be co nsiderable.

Treatment of Aphasia Literally hundreds of speci fi c treatment techniques are cited III the aphasia literature. Aphasia treatment is rarely the same in any two settings. The lac k of therapeutic unifonmt) ha, und oubtedl y impeded carefull y controlled \tudies on the effects o f language retrai ning. MO.!o tmethods derive essentiall y from trad itional pedagogic practi ces. relyi ng hea" i1 y on repelltion.I:!1 The primary assumption in treatment of aphasia is that language in the brai n is not "erased:' but that retri eval of it s mdlvidual unib has bee n impaired. Approaches to aphasia therapy have ge nerall y fo llowed one of two models: a .w b!j(lIwe skill model or a dtreu rreat mem model, both of .... hich are based on the assu mption that the processes that ~ub ...erve normal perfo rm ance need to be und e r~ tood If trcatment is to succeed. I:!:! An example of the .subslUlile ~klll model can be fo und III deaf ind ividuals. some of whom U<.,e "peech readtng. a visual inp ut ra ther than an auditory input. a~ an aid to comprehend 'ipoken languagc. If a (!tree l lrearmem model i~ fo ll owed, speci fi c exc rc i "ic~ indi" idually deS igned to ameliorate specific li nguisllc de fi cih art! the ba",is of treatmen t In general. tre.:l.tmenl me th ods ca n be ca tc~o~,~ cd a~ tho..,e that are largely IIld lrec l stllllul utl on-' ac illlaItOn and Iho,c that arc essentiall y direc t \tructured· pedagoglc.IOI I I I .~ The twO pnnciplc.., tha t under· lie most lrl!atment ml! thod~ reflect con tra~tln g VIl!W" 01 apha ... la <.1\ euher i l1lp~lIred acCCS!) 10 language or a " I o~\" 01 language. The sll mu lallo n met hod., ge nerall y follow an Impaired access theory and pedagog ic approac hc . . art' ba\ed on a theory of aphu'lla a.., a langullge lo~ ...

In prm: lu:c. howeve r, Illlu.: h of apha\l u treatment addre . . 'ic", Ihc In-tlt)l IIIm /n' il"o PC(; t M language In whlt h repeated prm: tKc and "tcac hlllg" \l rat cg lc\
(P.\CI" }. i...

ac tion betwee n rlllm:lan .. ilnd pLltH~ llh mtll more n.uuml C()l1llllllnICail VC: C\ Ch,ln gc'. iIKludt!, ' t" \ cr.11 pragmi.ltlC' component ... (.· lmlIllO Il 10 nalUr.1I nll1\l'~.1I10n . " ,

In ~tJdlll(lfl

((1

th~"l' .lpp"l.ldll' .... "('I1l~

111\ c ... tlpalo"

haH'

rer~-'11l'd thl" U"'l' ('II lh.l\\ 1I1~ ;..... 1 P(1IL'III1;11 IIIL·an .. 01 COlli.

mUnll.1I1l111 I "Othl"" tll..... l'llhl· IIltl..'r.tctln: ilprroachl..'~ to tfl'.HIllI..'I\I llt .Iph ..... ,.' rh~"l' .tpprnachc" Ilicludc : thc c ommunl, IIflcll: l'elrtlll'D ~JlProal'll 01 L)OIl.IN 1·11 a treal me-Ill rl.lJl dL''''lglit'd to en h~tlH..·e COIllIl1UnI C:.It lon anti we ll· ~lIlg 10 ... t .. ttlllg ... \\ here the per .. on \\ 1111 aph':hia and the 1.:.:.J.n'gl\l..'f li\t~: thl' \lIl'l'ortl'd cOIII'('nllff()1I approach introdu("t'"d b~ l\.~lgall.14; 144 in \\ hich volullIccrs arc trained as 1..0",1..'l'-.ltlon partner" to faci litat c conversati on in the per,on \\ ith aph3!'1ia b) U\1I1g a ll anlllabic m odalit ies. thereby re' ealing the II1di\ idual 's compc tence and permitting a commullIcal!' ·e int e racti o n: and the social model oj aplwsia JPpro~lc h imroduced by SimnlOns-Mackie l45 and S im mon!'!-~lad.. ie and Dami co146.147 which focuses on the fu lfillment of soc ial needs and the e ncouragement of a greater conversational burden on the part of communication partners. Panne rs are tra ined to facilitate interaction by modifymg some of the ir int eractive behavio r. The unfortunate real ity is that once the condition of aphasia has stabi lized, very few patient s recover nonnal comm unication function, wi th or without speech therapy. Accordingly, aphasia re habi li tation sho uld be viewed as a process of patient management in the broadest sense of the tenn. That is. the task is pri maril y one of help ing the pati e nt a nd his or her intimates adjust to the alterati o ns and limitation s imposed by the disabi lit y. Effect ive aph as ia re habil itation management requi res the participation o f a variety o f d isc iplines. including medicine. psycho logy, phys ical the rapy. occupational the ra py. social work , vocationa l counseling. and. most criticall y, aphas ia the rapy.

The Patient with Aphasia It has been observed that the variabil ity or patients' psychologi cal reactions is rare ly dete nnined by th e type or loca tion of their les ions but is an expressio n of lhe w ho le li fe experie nce of the person who has had a stroke.47.88.111148 In a study of patients with aphas ia part ic ipat ing in a gro up psyc hotherapy program , Fried m a n investigated th e nature of psycho logi ca l regress ion wi th impai red reali ty testin g in aphasia. 149 Beyo nd the co mmun icat io n diffi c ulties po,ed by aphasia, he observed that pa tients remained psychologically i ~o l ated. They d id not ma intai n a cons iste nt level of group parti cipation and ex pressed inte nse fee lings that they were very different rrom o the r peo pl e. Both w ithdrawal and projection were ;:tpparent as each patient aCled 111 J,olation and yet complained of thi s c ha ractc n s ti c in other~.

The 'lClective and dl~criminating lI ~C of speec h thera py to ~ lIrnul at c and ~upporl the pallent throug h the va ri olls . . . I f 7K. I~U.I~ 1 Mage~ o f recovery j, ;:til e ff cUIVe mal1.Ig.C I11 Cl1t 00 . I::.xpericm:cd aphH\ta Ihemp"t\ rc('"ogI11/"C thut wh d ~ wor" mg Oil apha\lc uefu.:Jh, they afC " JIllUI I<.I1ICOu\ ly dcallllg p"y dlOthc r:.t pcutlcu ll y With :.t n:adJu\llng, p<..'1 \ol1al II y. 11 \ S.pt:cch Iht!r<Jpy, t hercf()r~ \C IVC\ d lffere1lt PllIPO\CS 1.1 1 dlllen:lll

POl11I\ along thl' way. Sometimes 11 allow~ pallent~ to ··borrow tl111C." :1\ Barell and Stcphcn"ol1 have aptly \taled.'~" Ol:GI\lonally dcpre\s lon l1ft\ after \pccch thcr. cO lllribllling 1llcllllX'r' 01 the fami ly. PHtie nt ~ Ileed to be all m\ cd :-oOIllC ,en ... e o f COIltrol. Includin g the pall elll 111 n: h ;lb llt t~lIion plalllllllg pro1\1OIe" n:~toratioll 01 kelinp of .. l' lf-\\orth . In thl" reg;lrd. til t: elllph:l\ is O il rllll (' ti o ll r;lIhcr thall compl ete rcco\t~r) . P()llltlllg 0111 "'11l'ee.,s rathcr tllan pcrfonnanct' fa ilure .. ,ldd .. 10 a p11llenl '!>. :-,e u..c o(~c l r. It IS ~~~e lltia l lo li >;wll 10 pallt:l1h.

( ' hllptcr .,0 Nt.' UI'"Ogl' uit.: Di ..ordcr't "fSPCl'ch nnd I.•angu~,g('

p.lrtKUlarl) 10 Ih~lr (''"pn: ...... lon ... 01 1m.... ,

COlll1ll1",l'mllOIi "

often more com lortln g than npllllll ... t\ C prngllm,tir.: . . Iatc Tlll'rll ...

Group 'pl'l'l' h

tlll"";IP) .

'IroJ...c club .... and other ... oe ial

!!fOUP' ;\~ In.:qucntl) u ...cd rc ... ourcc ... that en l1 be dlt.!clivc ~()llh in the management of "Ollle pati ents \\ ilh chron ic ,lpha"hL The <.Itionai Apha:-.ia A ...... ocialion (NAA) \\:1.., i'llUlllkd 111 the L HIICd SI:lIC~ in 1987, fo llO\\'Ing the lend of t',\I, IIIlg. organizations c~tah li s hed in Fin land in 197 1, Ger-

m.lIl) in 197R . the United Kingdom in 1980. and SWc.!den in IQ~ I . An e'\tcll ... I\ e array of educational and resource infor111;[(IOn ;lppropnme for p~\lients, families, and profes~ionab j, J\ atlab le on the NAA \Veb site (http://www.aphasia.org). Knlm ledge that one is not alone often hel p,!o, to rcduce depression and loneliness.77.111 Group therapy \\.ith peers abo provides 3 comfortable ;Ionosphere in which pa ti ents can mcet new fri ends and . . hare feelings, although not all individuals with aphasia find it benclicial. A positive effec t sec ms related to level of comp rehension, time si nce onse t, and personality facto rs, Although group therapy generally plays an importan t role in apha::.ia rehabi litation. it shou ld be noted that much of its effect iyeness depends on the sk ill and experience of the group leader,l "".1 ~6 In our prese nt state of knowledge, aphasia rehabilitation remains eclectic and specifically tailored to the individual patient. Fundamental 10 thi!:! therapeutic philosophy is the ac~nO\\ ledgement and app reciation of the uniqueness of the individual. No two perso ns with aphasia are exactly ail ~ e in palhology, perso nality, linguistic deficit~, reac tions 10 catastrophic illness. life experience, spiritual va lues. or 11 ho!:!t of other factors, The inOuence of these factors ca rri es di fferent weigh t and stre ngth at different stages of recove ry and they are all related to recovery outcome, Experience suggests that. except for seve rel y depressed IOdi\'idua l ~ with aphasia, patients generall y participate as fully a~ poss ible during rehabilitation. Th e r(\pi s t ~ must not allow their ex pectations to cont amina te the therapeutic Interaction: thi ... i"i not unco mmon and I~ usuall y moti\',-lIcd by laudatory a"ipiration~ the rapists want to ~ee their patlcnt"i improve-but i"i nonetheless counte rp rod ucti ve. Patlent"i \'.lIh IIwolvement of "iubcortica l ;Jr(!JS may have low Ic\eh 01 act ivation, a purcly phy~iolog i ca l proce~~ Independent 01 p<.;ychologlcal motivation. Thc di ... tHlction bctv.cen thc"ie two proccs ... es mu~t bl: understood. ~any ethiciJ\ moral dilcmmas fuee those \\ho manage th~ rehabilitation of patient-. with ~Ipha s m , One of tht.' pnncipill I\I.,U~I., 1\ a rc ... uil of the nccc~\l ty to se lcl·t tho"e Illdlvlduals . . . ho \'.'111 recc lvc trealment. Rehubililallon Illclileilll.' "'C I'\'IC(''''
.I Ii

l.tI

IH..' ,IIIIll'1I1 P I.' IIIXIIO dl.·ll'l n1l1l ..'

1201

thcli l:: lI1dldm;y ror lurlhe! Irl'~llll1l'nl and lh ::11 trwl .... hould he

pmvidl!d at dift cn.'111 POint'; III th e recovery (;Ollr\c. GO<J\ c,c 14 ling. the patient\' right to ...cll·dclcnmn4.l1Ion. and the crllena appropriate in dch.:nllll1l11g Iht.: IcnninalloJl 01 therapy .m.: al"o .Illlp0rlant cl I· lu.;a I ,"...... lIc.... I II .,I,ll

Dysarthria The term dysar thria refers to an impairment of speech production resu lting from damage to the ce ntral or pcnpheralnervous sy~ t em, which causes weakness, paralys,"I, or incoo rdina tion of th e motor-s peech sy~ t em, Anyone or all of the components of the motor-speech sys tem (respiration. phonation. articulation, resonance, and pro~ody) may by compromised by neu ral damage. The type and degree of dysarthria depends on the underlying etiology. degree of neuropatho logy, coexistence of other disabilitie~, and the individual response of the patient to the condition. It is not unusual fo r dysart hria to coexist with aphasia in patients who have suffered ce rebrovascu lar accidents or TBI. The severity of dysarthria may range from the production of occasional imprecisely articulated consonant sounds to speech that is rende red totally un intell igible b) the degree of impairment to the underlying sys tems. \Vhen patient ~ arc tota ll ) uninte lligible as the result of severe motor-speech system impai rment. they exhibit ana rth r ia , The incidence of dysruthria in the population of individuals with neurogenic disorders is approximately 46 percent. representing a significant proportion of the patiems \\Jlh communication impainneIlls see n in medical settings,M Dy ~ arthria is generally reflec ted in defici ts occurring in multiple motor-s peech sys tems, bu t ma) sometimes occur in a si ngl e!-j :-,tem (i.e .. an impainnent of soft palate movement resultll1g in hypernasa li ty). lt is most notabl) prevalent in cerebra l pals). TB I. cerebrovascular accidenb, demyelinating disea~e~ (e.g .. multiple sclero'l:-') Parkin ... on'~ disease. amyotrophic lateral ",c1ero~i", and neoplasm. There arc li\c prinulI") types of dy~arthriu: spa,\lic.j1tl(·· cill. £litHi c. h-"pokim'lic. and hYfJerkilleti" \\'hen two or more types coc,!.... !. the term ",,-\('eI thstlnhri,l i~ u"ed . Coe"i ... tlllg phpdcal di"'
Classification and Nomencla ture .\'/1//\li( eI\'\t/r(hncll" ... hal';.lC'tt.'I'III..'d bi 1I11pr\.'l'l"l~ .lrtl..;ulatl(\Il,

... hm Iilhn~d artltUlatloll, h~ pl'm,I',llll~, h,lI'h tll "'Ir,III1t.'d phollatum, ;md Illt)JlIl!onou ... pHd}. S~ Il.lt'lk ... m,l~ lx' ~I' t"1

l'qui-II ... tll· ... " ilnd IlIlk\.'llon I'hl'le I" \1!tt'III\.'\lul·l'd (~mtn.ll ~ll n hal.llioll. w 1111 ... haIlO\\ mlt'II,IIUllh .\lId ,1(\\\ III ..nh, .... ,ta, III.: d".lIlhnil h Ih .., r!.' ... uit 01 hll.lIl'r.11 l',r.lll1h.l.t1 ... ~'Il'm t 1,lIll.l gl.· 111\ l)1\ Ill!! 1h.., Ull 1In Ihul b,1I tr .1l·" (uptx'r ml.llllr nl'" 11m ... ). ti ll' p.lIholp!!~ 111,1\ l',IU"t' Wt"I).,Ut''''''' ,IUd p,IIl.·"I' l\t tho

1202 t.I("·C:

Pln·-.ical Rehabilitalion .lnd

100WlI ~ C' t:

1ll1l\(,.·U I.Hure on Ihe \Ide 0PPO\J1C 10 Ihe high IIlndl'!ll·1..' 01 'p~I'11C dy,arthn ..1 among

k'I\)I1. Then.:- h ,I IIl(hC \\ IIh l'c~hr,d pa"~ ~!1 Flt/(·( Id J\ 'elfrhlla

I ' .... haractcrl/cd b) ,Iow/htbored h~ I"k:ma,aitl). and hoar\c. breathy phonation. Phr.be, 11l~1) he 'hon. IIlhalation 1\ \hallO\\, anti the control 01 c\hal.1l1tl1l 111a) l~ redu ....ed. There i, often a rcduc.:tloll in the \~1f1.Ulon o!' pill:h and loudnc:\s \\ ith audible in\pira~ 1101h. \ Ios( 01 the,c deyiant \pcech charactcri~tlCS are rt'1.Hed to Illu\cular \\ca"ness and reduced muscle tone. \\ hlch ..llTect the \peech, accurac). and range of speech 1110\ erne IllS.

,tnlCU t.UIOIl.

characlCrized by disturbances of 11lllll1g . moycme nt. range. a nd cont ro l and coordination of the muscle~ of "peecil and respiration. Speech is imprecise. slo\\. . and irreg ul ar. T he re may be intermi tt en t period ... of e\ploshe inflec tion . sy ll able s tress. and loudness patterns. Pho nemes ma) be pro lo nged: pi lch and loudness are mo no tonous. T he les io ns producing ataxic d) sanhria a re b il atera l. gene ralized lesions involving the deep midl ine nucl ei a nd pathways of the cerebellum. Patien ts \\ ith mult iple sc lerosis often manifest atax ic d) sanhria. Hypokilleric dysarthria is cha racterized by variable art icu latory prec ision . slow rale of speech , hars h. hoarse \ oice qua ljl). excessive and ove rl y lo ng pauses. prolonged sy ll ables and reduced phonati on. Pati ents w ith Parkinson's 4.rU".u( dy.wrthna

IS

overall di,i.lblilly by u.. lI1g ... tralcgic, Ihat m I' . . . ay actually Irorn normal (I.C .• ,lOWing down the rate or ... peech production 10 lI1l:rca..,c intclligihillly of c()m~onant production).

I.l:Vlalc..:

The primary objcclive of dysarthria treatment i\ t improve ' .the inlclligibilily of ~pecch ,whICh n ecan gbea _0 tively affected If the speaker io; in a dark, noi..,y place Pallcnp·. and comm~nication partner,:> rnu..,t be tramed 10 seck the 1110s1 optimal situations for communication JJ11eraClions. Exerci ... cs are generally admini'tered to IIlcrease the preci~ion, strength, and coordination of movement.., of the mOlor~speech sYMem and the coordl~ nated action of various componcnb of the system. How~ ever. the general focus of dysarthria treatment i.., pho~ netic. because it is articulatory precision that contributes 1110stto overall intelligibil ity. Clearly. as a patient's over~ all physical coordinatIOn and precision of mo\'ement increase. corresponding improvements occur in the con~ lrol of Ihe motor-speech ..,YSlem. and hence in speech in lelligibi Iity.

Verbal Apraxia

Dysarthria trea tme nt mu st be indivi du a l! ) desig ned and

Some patiems with nonfluent (Broca's) aphasia pre~ent wit h anicularory difficulty lhat manifests as imprecise and awkward articulation. distortion of phoneme production. and some literal paraphasic (sound substitution) errors in Ihe absence of impaired strength or coordination of the moto r speech system. This characteristic. 'Which may be so severe !.hat the patient is barely imeJligible. can appear to be independent of difficuhy in language processing and i.., referred to as verba l a praxia (or speech dyspraxia. apraxia of speech. conical dysarthria. phonetic disintegration/. Unlike dysanhric speakers. apraxic speakers do not generally have deficits in perfomling non:-.peech mo\ements of the oral musculature. The possible independence of th,.., deficit from the language disorder of Broca\' apha.-.ia remains controversial.

account for the profile of tmpainnen t "' well as the ,ariability of i" disabling effects. The performance of compo-

Treatment of Dyspraxia

or parkinsonian-like symptoms often man ifest hypokinetic dysarthri a. wh ic h is caused by lesio ns of the substant ia rugra. Hyperkineric dysarrhria is c haracter ized by vari ab le articu lato ry precisio n. vocal harshness. prolonged sounds and inte rvals betw een wo rds. mo notonous pitc h, and lou dness_ Patients wi lh Hu ntington's d isease man ifest hyperk i-

netic dysarthria. which is caused by lesions of the basal ganglia and/or their extrap) ramidal projections.

TreabnentofDysarthria

nenls of the mowr-speech sys tem does not necessarily

re,ult 10 changes in the disabling etTects of the dysarthria: that ". the lOtellig.b.llt) of 'peech'" Goals that relate 10 the le\'e1 of di~abi"tv rather than nonnal speech are gener·

all} more reallM.c ~cause they do not focus on nonnale}. '"' hl(.:h h u·mall} an unachic\able goal. or improvement III

the perfonnance of a "ngle component of the molOr speech ') stl!m. v. hlch may not. III the overall picture. be functionaJl} Important There I'" reIUIl\el) little dala-based infonnaIJOIl avaJlable on the long-tcml progno ... i... for pallent-.. \\ Ith d) aJ1hna. fhe focu uf d)sarthna treatment i ... \omctimes ba ... ed on un approach that ... tres,es (ompen ... alory 'k.i1.". Thc ... e tec.hnlt.J.ue tend to encoura~c the patient 10 Illllllllll/t! the

The disorder of aniculation referred to as speech d) ~pra\la seldom. if eyer. is manifest in the ab~ence of a coexisting Broca's apha~ja. hO\\eycr mild. The \peech dyspra\ia component of Ihi"> multifaceted communication dl\order appear\ to be e~peclall~ amenable (0 direct therapeutic intenentlon using approache ... adapted primanl) from [rJ~ ditional articulallon Iherap) technique\. IIlcluuing ~tn: .. " and Intonation drills. The ...e approache\. de . . lgned 10 lmprO\e phonelic placement accurac). I) picall~ depcnd on ,mua· tion. 'Ire ....... and progre',i\e apprO\lmallon. "hlch a.re drilled u. . ing "Illesthellc. \ i ... ual. ilnd auduo~ cue'. Gener· aih-. the \t1~lUh u ... ed J' the bJ~e, for the\e C\CfCl,e .. are "'t- I J....,. n~~\\Hh ...elected 111 a pn: ... umcd order ot ul flcu I). I..lCgll101 =

Chapfer 30 nOlloral illlll:.ltioll . foli o " cd 11) .. oulld ... word .... phra . . e .... and

lin:llI) utter~IIlCc",. Treal lllcnt tcchnlquc . . for .. peceh dy ... pf
Dysphagia The s\\aIlow ing process is composed of a number of com plex neuromu sc ular events. No rm al swal lowi ng require~ that an individua l be able to move food or liqu id from the mouth (oral pltase of swallOWing) . through th e pharyn\. (pharyngeal phase of 'swallowing). and into th e e,>ophagus. In the oral swallow phase food is collected in the oral cav ity in a single mass. or bolus. whic h is then propelled into the pharynx and further propelled under prl!ssure into the esophagu
~eurogcnic

Dj'tordcr.. of Specdl and Language

120.l

... eVl'rc. 17to 17'1 In ... ome ca'l's dy"'phag la l"i onl y prc~cnt 111 the acute phil..,e wnh rapid recove ry of ... wallo\\.lI1g fune tion takin g place In th e lir' t 1 weeks PO"it-\trnke.l!'IfI Swal 10\\ ing defi cit s In post 'itrokc patiellh arc often due to a co mbination of \Veaknes ... and IIlcoordmalion of the oral. pharyngea l. and laryngeal mu..,c ulalure. rc .. ultmg 111 ineffic ient propulsion of a food holm) or liqUId through the oral cavity. pharynx. and Into the csophaguo,. Delayed triggeri ng of ~wa ll owing i~ common after \trake. Oral or pharyngeal tran~it times may be ..,Iow. Reduced elevatio n or clo~ure of the larynx may re<;uit in matenal belI1g mi5directed into the airway (aspira ti on ). Dysphagia is also often present in patients with Parkin<.;o n·s disease. Hun tington's disease. the dys tonias an d dyskinesia~, amyotroph ic la teral ~clerasis . multi ple sclerosi.... neoplasm. deme ntia. A lzheimer's disease. and other degene rative neuro logica l condi tions, as we ll as cerebral palsy. In add llion. dys phagi a is ofte n see n in traum at icall y brain inj ured ind ividuals. 177 A dysph
Treatment of Dysphagia D y~ph
treatmcn t is des igned to improve s\\ allo\\. ing effic ienC) for nUl rit ional pu rposes and to in crea~e s\\ aUO\\.ing ~afe t y. Th is ca n be accomplished b) compensator) strategies and/or techniq ues de.!. igned to change s\\ alIo\\ing physiology and red uce the ris k of ~lsp i ra t ion. Compensatory strategie~ 1I1c lude postural changes thai affeci the way food passes thro ugh the mou th and phar) n\.. ulctar) management. and placing food in the moulh in optimal positions. Po~ tura l technique ... may 011:-'0 be introduL"t~u 10 reduce the possibili t) of i.1!-pirat i on .I~" SPCCllil' e\.cfl'j,c, (and maneuvers) ,Ire u~l'd to lIlCfC""e the l·(.)QIUlIli.1IIl1n, range of lllotion. 'itrength. and ,cn'0l) IIlpUI of Ihe lllu,dc.·, i.UlJ "t ructurc~ llI\' ()ln~d 111 the oral and phar) nge.l! ph.l'c.·' c.1 f s\\itllowing. The ...e t·\.crci,c, arlO dC"lgm.'d to IInpl\\\ l' Imgu,ll 1I1iti;uion. IlllglHl l propul ... lon. l.tf)ngei.ll dl·\.ltl\lIl, l·ll"Ur\.' and lOngue ha ...t.' appm\ IIll,1I1011 W thc pO'ICrllW ph.\r;ngc.lI \hlll Il'>l I hc ph}'ICdl ther.IIlI, t GI1l pl.\~ .11l III1P\\rt.lIl1 r\lk" III p'''ltlOlIlI1~ the: p.. tll'lIt t,ll nptllllulll ,,,.\II\l\\lng, .•IIlU r fl1 . . tdllig. tr\' illlIll'nl 10 fl'dun' lI\u,de .. p..... lh:II\. Imrn)\t'

Il1U \L Il' .. tn..' n ~t h

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n: n ~ \ p ~lIh.' nh !r01ll I 11 It..' , h.' rI ll!! \\

lilt , ,,,;1110\\ Ill g, III III

Alternative/ Augmentative Communication Systems and Devices ' eo\\ lechno\og) , c'Ipccia lly :-.ynt hctic -:pccch
Implications for the Physical Therapist PhYSlca ltilerapist.. orten work 111 ...elllng .. wlicr!! they may be the I"lr, t to become aware of ~I pallc nt 's COmmUi1Ic.:.ltlOn dl ' Of· der, and ... llOu ld n.: . fcr <., lI t h patient .. to a ..,peech language pa tholog ist for evaluation. The phys ical therapl... t cun con· tn hul c to the p
Ihey ;\1"1:

pO ... lllo n c.;d III ... uc.: h H WlI} I li al IlIn: 10 f:Il'l' CtlnlllHI

nicallOll i'lIW ...... lbk. IIldlldlllg tltl' vi... uall/a1lol1 01 !!l· ... I11 I(: ... ilnd f:leial t.:'prt.: ..... lo!l\ . FOIIIlI ... I l':I ... OIl, 1'00111 Itl!h li llg lIcec.J... 10 he .. ulficiellt. Patlcnl-. \~ 110 lllallll'c ... t neurogcnIC .. pccch language dl ...ol der'l, c'11I.:cially Ihlhe with aph" ... i" po... e It con"' ldcrab lt.: chal leng.: to cflecllvc COllll11l1nlCa llon . The indIv idual nature 01

1l1:111lfc."latlon of apha ... ia arguc!-I for a clo. . c work illg rela Iloi1'ihip \~ Ilh the ... pccch-languagc patllologi ... t. Till ... will en... urc thai Ihe 1110..,t cl'fecti vc cOlllmunication ... trat cgie ... arc u. . ed \\lIh an individual pati ent. One of the greatest difficu lt ie~ in addrc ..... ing th e need!) of p:.llienl\ with acquired apha .. ia ha!) to do with de termining and accounting for the paticnt '~ leve l of aud it ory comprchcn!)i on. Virtually all pat i ent~ with aphH~ i a have \o me deg ree of difficulty in comprehend ing spoken language. Physica l therapi sts need to become :-.kil led at recogni zing and dealing wi th auditory comprehension dc Jj ci l~ because th ey can be a major deterren t to ..,uccc ... ~ful rehabilitation. Mbconception.., of th e auditory comprehen..,ion level of a patient with aphasia can range from the a%umption Ihat a patienl understands everyth ing to the ac,..,umption that th e patient comprehends nothing and must be excluded from conversation. A guiding principle to keep in mind is lhat auditory comprehension can vary greatly, depending on the context and complexity of the task at hand. Switching top ics quickly, 'peaking too quickly, background noises, talking while a patient is engaged in physical activity, and conver:-.iog wi th more than one person at a time can impede the ind ividual's ability to process auditory information. Sentences should be sholl and ,imple and the patient should be given sufficient time to process the information and formulate a response. Questions that require elaborate answers, such as ',ell me about yo ur vacation" or " What do you think about the latest news?" are generally diflicult for patients with aph~ia to answer. It is best to ask questions that can be answered with "yes," "no," or another single word. Physical cues to comprehension such as gesture~, facial expression, and VOIce inflection can facilitate and enhance a palient \ understanding. It is Important for the phySical therapi st to know that patients with aphasia often find it eas ier to respond to .. hole body or axial commands ('''tand up," "Sl! down") than d"tal commands ("point," "pick UP"). It can Ix: tempting to try to remedy a labonous communicatIon . . ituatlOn by "talking down" to a patient wah apha... ia a.c, jf ~peaking to a child. or rai ... ing one\ voice as if ~pcaking to ~omeone IJ.nh impaired heanng. #nlC tx.- ... t strategy I., Ie) peak a httle more slowly, U'iJOg language that iot nfll 100 c:omplcl( and remaining c(Jn ... i~tcnt In gIving In ... tnJctJOrt can be particularly Important In the phySical therapy r,eUmg. v.here verbal tommanch are a fundi..lmcnllil clem nt 111 the palJent rherapl'>t JOtenKlion. Al lImCllo, II may he ne" e S
n",

",ulIl(l ...... pokt.'11 liIIlPUilVC PhY... ll ill thcrapl ... t" wht.'n r q " I hie ... liuuld 1111'1\ to th c .. pt.'ct. h Ii.HIJ!IIi1J.!t" IMlhologl . . 1 for (III imllt'll tlOIl 01 Ihl' P~II I CIII\ pfl·... crvcd lIudltory t omprclH'1l 'i lon . It ma y hl' 1Il·l:l· ...... ary 10 rcphrw.(· quc, IIOIl ' <Jnd ... upplc I11CI1I wllh hod y IUlIgu:ll!e 10 CII"'"fC lOIlII'It.'l1l·""'IOII. 'I he u<.,c of accclIllpallyllll! vi .. uaJ (.;tll'\1 ... udl ,1\ }.(l'\IUrCs ;.m <.l fa cial exples..,lon ... , l:UII be cxtrclIlely helplul tor , OIJJC paliCl1h. Olhcrs /IIay uIH.Jcr... tand he ... t If a IIIc ...... a~l· I...... up plerncilled by wnllell cucs. SOITICtlll1f:" onc L~n a",slst hy a ... king t.jlH.: ... tions tha t can he tlll ... wcrcd by }l'\ or flO in a ·'2U t.juc ... tion..," format. When ...omeone with aphasia i.. haVing lrou ble cxp rc~:-.i n g him or hCf\clf, It usually help ... to allow th em extra limc to !\pcak . If the paticnt bc(;olTlcS vi ... lbly fru strated, it is desirable 10 rcmain calm and suggeM that th c pHticnt w,lit and try Cigain laler. During physical therapy intervention .... patient ... with aphasia can be encou raged to produce ... ingle-word, repel! li ve :-.pecch th at coi n ci dc~ wi th physical movements a ... a mean s of providing supplemcnLal .., pecch practice. Actlvi tics :-.uch as cou nting movement ... in ... erics one to ten, and u... ing words li ke up, down, left , and ri ght whilc performing phy:-. icfd movements (lrc exam ples of ... uch Lechlllques. The physical th erapist, however, ... hould alwaye.; rcmtlJO \cn ... itive to the poss ibility of making .., pccch dcmand ... that arc beyond a palicnl \ level of preserved communicative kill.

Summary Ever si nce World War II , ... pcech language pathologist .. hilve played an imp"l1ant role on the rehabilitation team 111 the management of pati ents wnh neurogenic ... pcc<.;h language disorder>, especially aphasia and dysal1hria. For the ph} Ic,,1 therapist, an under... tanding of norma l and pathologl(;al com· munication behaviors Can not only make Ihi ... popUlation 01 patient... more intere ... tlng to work with, but can all'to enhance the quality of treatment he or 'he proVide". Communication u... lI1g ... peech is a cnmplc • pelle .. specific behavior lhat (;on'-olsts of the C(X>rdJOdlcd JOle'r tion of cognlllve, motor, ~en .. nry, p,ych()logu.:,II. and SOCial ... klll .... The neurogenic di ...orderc. of speech ~nd I.ang:ud C' ')pcurically apha"il3 and dY'
QII~'ti(}II'

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2. I~'"'ril~ Ihl' d,lh.'I\.'lll'l'''' Ih.1I di . . tmgUl,h llonlluclIl trom tlu~nl .\ph.hl\,: "ndl\lllll· ... ;lIld &1\,(' clinic.1i e\itlllpiL",. 3. D"I.'U,' thl' '-·~lIllp\llll.'nh 01 a comprchl'nsivc lang uagc 1(' ... ( dC"!!lll'd to II\t.'.I"'lI~ aphasic impainllcnt. 4. Dt.· ... allx· ... \lIl\C L'rllical faclor ... that inllucncc rct:ovcry from .\ph;l"ia. 5. r\· . . l·ril~ Ihe- 11'<.) choiogical ...cl(uelac thai may have a ncgall\,\.' clkct on the outcome of aphasia rehabilitation.

ens c The patit!I1I

6. 1)L'lII1C dY\
Study I~

a 62-year-old man who teaches high school.

He "u"tillllL:U a right hem iplegia and difliculty communicating a~ the result of a hemorrhagic stroke, which occurred 8 months ago. At this time. except for dress ing, he i~ ADL independent and ambulates with a cane. At one month post-stroke, the patient was limited to yes or no responses and a vocabulary ranging from 30 to 50 nOlln~ and verbs as we ll as everyday greetings (hello, goodbye). In the COurse of a communicalive interaction, he often resoned LO writing a letter or word or gesturi ng to help in his communication efforts. He appeared to understand most of what was ~a id especially when the topic was familiar. He received rehabilitation serv ices during the acu te poststrokc phase while hos pitali zed and received 20 sessions of speech- language pathology serv ices as an outpatient. At 8 months post-stroke, th e patient's com muni cation disorder is marked by a slow, he sitant production of one- and two-word ullerances: easily produced auto-

ma,ic speech (i.e .. everyday gree,ings): difficulty expressing complex infom1ation: awkward and labored articulation. which causes occasional articulatory imprecision; impaired writing: and some difficulty readII1g lengthy or comp lex material. A lthou g h the majority of his speaking vocabulary consists of nouns and verbs, adverb\ and adjectives are now used with greater frequency. There is a pcr~i~tent lack of conjunctions. anic1e\. and prepositions in speech. which causes him to have impaired grammar. The patient has no apparent

difficulty unders tanding spoken language except when it is rapid, complex, and/or unfamiliar. Both the patient and his caregiver report Ihm the frequency of social interactions in his current life has been curtailed dramatically. He continues to see close family members on a regular basis but he rarely sees friends or work companions. The family reports that he is frustrated and deprc~sed over this and fee ls isolated from the community much of the time. They also indicate that there has been a gradual but noticeable increase in hi s speaking vocabu lary. ability to write, and reading skill. He has recently joined a local stroke group where he hopes to meet others with similar communication difficulties.

GUIDING QUESTIONS I. A team conference IS scheduled the day after you ass ume treatment responsibilities for the patient. What types of infonnation would you obtain in consultation with the speech-language parhologist? 2. What communication strateg ies arc ge nerally useful with patients who have s ustai ned a stroke? 3. What approach might you use if the patient became frustrated trying to express him self during a physical thcrap) treatment? -I-. As a ph ys ical therapist, \'vhat might you do to decrease the patient's se nse of isolation and enhance his emo· tional well·being? 5. In what ways can physical therapy treatment sc..,,,ions serve to reinforce coml11unicalion behavior?

References 'iaU{)llatln~lllUle Ull ()cafnc",~ ilnd Dlher Cornmunit .. \lon Di ...order f~IIXUJ. RC!j~·:trdl in lIum .. n Communltalion. NIII publica lion "in. 92 J317. UCllw...da. MD. t995. 2 "'LX U I\allonal Slraleillt Rc ..ean:h Plan for Hearing .lIld Ileimng tmp.unTlt:n", Belhc!oda. '\.10.1996. Adiun • pr- lIendt·r~hol. 01 .• and MMano, MA Currell! c .. limulc~ frum Ihe 'allOnal Heahh IlI1crvl(~w Survey. 1996. Cenle'" lar 01 .. · el5C Control .lIld Pre.. ~nIIO/1/Nullonal Cenler lor IIt::alth Slal"UC .... Vllal Health Slat {2fXJ}: 1 lW?

4 Slater. SC: Ponrall af the Prole .... ion ... : t 991 Omnihu .. Su .... \.') \SIIA .14:61. 1992. :Ii ASHA I·hghlighl~ and Trend,: ASHA "tember Count' Rod" 111e. ~ID. 2006. Rctnc\cd \til) 18. 1006lrom http:'I",,\,a .. ha.org! aboUl/mcmbcr.hlp-ccrufic.lllOnJmcmber,couJlI,.llIm. 6. World lIe.lllh Organizmion (W HO) ICIDH·2: InlcmalllllHlal '\'thalo\l. fkallon of impainncnl. dl~abllil1e, .lIld handllup. \\orld ea OrgalllzatlOn. Gene\ n. S .... Illcrland. 1980.

Chapfcr 30 'curogcni(: Di"tordcr.. of Speech and I.ang-uage \Ii 110:: ~ cw.Uf~311OO of functloolllf dlsabiluyand

1

lJuhh Or to

on. Gctr\a. """ ItZCrlanJ. 20( I R.ar1nCd O;t.ober ~~. ~ • rom """"\10 J 'Abo mljKl lef l ~ 8 rnu l S Jruerun Pn 'p:tH)flS b:o -\g'" Se:A f(lCC.'..t tfuparuc Onpn. RetJ1C'\-ed \It.y I >I. :lliJh frt)fD t.qr. ...."".ccmm gO\ I~"'''' Inkrtmproj!• .!fJf)J ,aDonaJ JnstJttlln of Hc:alth 'lH Aph.bla. Hope! throu);:h ~ 'lH Pubbc31IOfl ,,) go. WI BetheM1a. \10, IlJ7<J J Imtitutc on lkafnn.\.and Other CommUOIca(Jon O,-.or· ~ mxo fact Sheet Aphas.... IH Pubhcatlon 'I7...l:!~7 Bc:.'x3do. \f [) ""Bnnl J( euJ "phMJa In .:ulC lrole StroLe 7:167. J'J76 ~ IH De:I.~ rJf roean:h Arnwen through 5C.lentlfic re5Can.:h. TIle 1'i.dlOftll Ad ..wry .... eurQlogKaJ and C'mlmUlllcatl\t: DIMJrder. and Suo ~ Council The 'auona! JmutUh.~ ol i lealth. Bcthe..w. \10. \\ ;wid

' 0.

'I)

-to.

41 -l:!.

·n 44,

JOY Goodgla Ii rl al The:\ \e1 men l 01 Apha'ia and Relaled lJl!iCrdcr cd J Llppmc)tI 'Adhaffi\ &. WIII",n\. Ph ll adclphl
45.

2«JJ 4 Dmtatlo. -\ Signs of dpha la. In Smtu. \ iT led,: A~qUlred Apha ta. cd] Acadc:1Tuc Pre s. 't'\Io York.. I <J<J8, p 25. J'" Sarno \1' A ~f\oe) of 1(..-J Ciptw;K \ kdk.1fe patlenli in a ~pt=ec h pathology program JAm Genatr \fx; IIS',HI. 1970. )f, fIn R tt ul ~e..:"'oC' ry Jwrn apha la: Sponlaneou, !.pecch \er,u, Iang~t,ompreht:n Ion. S ram Lang (,-1<)2. 1978. I" 1..evm II'; Llngul'uc rC(..I,vcry apha'ia ch>'>ctJ hcad· mJury, Oram Lang 12 V-JJ. ICJxl 1\ Sprttn (J. und KI\scr. A: A 1!oC'i!.mcnt o f aphJ.."a. In Sarno. \1T (cd ): Acquued Aptw 14, ed 3. Academic Prt.."M. '\:ew York , I ~R. P 7 1 19 I)prcen (J. JlIlel KI"i-kr, All A"ie \mcnl of A pha ~ia. Oxford LJni vcr· Ity f're \, Yt,rk 2(..-JO. 20 f)prt'<."fl (J. ,nd Befltun. AI. '\ ':ufH1Cn ..ory Ccnter Comprehcn'll,,"c "urrunotlllm If,r Apha..,la. cd 2 I" lIIvcnllY of VI(;uma.l>epanmcnt ()f I~ y(.h'JIi,).!y. C"urup'y\;holug)" Lah()faICJrY. ViclOna. BC 1977. 21 r1e , A Wr:.'\errl Apha., liJ Banery. Gru ne & Stranon, 'Jew York

46.

,.:-w

47 48.

49. 50 . 51

52.

53.

19~2.

2" Sarno \1'1 Ihe fUrI<.:uQnal a~~!'>\ m cn t of vcrballlnpalrlncfll , In G (srJIliby (cd, U C(;l'nT ildvance, III rclwbilllatiun mcdi(" lnc. Alnl4Ui , ' &. Wlktot"ll. "' lid holm. 19X3. p 7~. 2 WIJnal!. I J A C1JIlctPIUili fr;uilL"wurk fur a funct ional approach 10 ItCqUifed n('umgI:'OI(' dl\(Jrder, of (.!)"Ullumc" tlon In Wo rrall , LE ,jUld Ir,ilt.lli, ( VI f«hr 'cuHI).!enn; Com munical ion Di..,m dc,,: A I uliLilljJI,11 Aflpru.u.h. Th lellle. New York. 2(I{)O. p 1. 24 ~anll'. VI I A mra"urcme nl III luncllflllal comm UOi<:atJOn III apha 1.1 Anll Ph)'\ VIed H.ehilbJl 46: 107 1%5. ]'i 'i.I(III1. M I Ihe l·unt. IIIJI1al C()IllIllunlt:;lUUJI Prufil c: Manual!)f IJw'c 111m (I~(·l ja t)J IJI 'IIIIJI1 M/Jw'!' f"pll Nil. 4 2). I'<ew York Umvcr· II)' M'·"I, .. I ('4·lII cl. ItlJ..,k I" "' IIIIJI ~' 411 KL" 114IbJlilllli{)tJ MediCine, Nev.- Y4)1 l , II)(jl) HI 111111.11111. AI (IIU IIIIUJl I(. iltI VC Ablhlle\ HI lJail y Li v lJl ~ UUi VCf"l y 1 '.If ~ I're ,H.ll tUIIUfC IIJHfJ J.7 1-r,llIah ( \1. t" 1 al I UlIl IJ IIII;lI A\\C', llIcnl 01 Cummunication ';~III l'Ir Adult· Ad IlIll U<.Ir;t IIWI 'I/lfl 'ilU rllI).' Manual Amcric;1Il "llCCCh &. I kilrll lJl A MK 101111)11, Rud villc. MD , 199) 2M 11"lltOlI A I (·Oll lllhuI IOI1'6I Il .I" I1 ;I" I;I tx' lorc Bn x.; 0.1 COrle,," I ] 14 I'H)Il 2') HI 1111111 A I .JJ1d J O)' l1 t. KJ I.HI )' dn ulplHm, 01 aphil'I;I. Ardl Nr lll lll t iC 14), I'J(,(J

to Bl nl.1 I' 011 ,II'Vl' Ii(' 1,1 I.It lI ht· 1111

I;III J.' u a~'c '

arl u.:ulc BIIII SOl.

A flli ll opClI 6 \17 IHH'i

\I Hro.IiIl,,·ul J) A t,;,Iij,J 411 pc( wi .1I .11h-(. II OII 0 1 ' peec h. wllh \,.0111 IU"nt,uy 11f .1 1II I ·IX· I IX7'} '2 \1,11. ( ~ . 11 1".11 11 11'111 <,I il jlh.I"' liI hy Ir,1I1lI1I1--' JAMA ,I \ I IJ 10. IIJO·I n 114.11 1, II Aph""' 101 .1IIe1 Kmclll'd 1>1' 111411' 1' III ~ IX'c dl, vuh. I ,lIld ) I,IIIIIIII< IYI I IIlver'lly 1'1l'~', C"llll bJld /--,(.· 1 K. 192(1. 'I Nu I 4'11. J A~I Ill " l a. Apl'11I.I.1. A ph.hJU 111\"' 11 Vu lll\,.' 111 ( ·(· I'd u.11 I ,ll. ,1 11 /.IIIClII IIl1dw l. Nl"o~' YIII~ I I).If) 1"1 (u llt! h'l lI K A l h' l l' ll n t, u llll ,lInIIlILIII I" III W,II 'I hell 1·:".IIl!1I 11"11 , 11 11\ 114',/111 11" 111 (jllll1\' IV Slr,llIlllI , Nt'w VUll , 11).11 II I \ III VI' I II .11 1111 ow. A 1111' hi 11 111 III . 1 t·. IW , II lIlotlll apllil..,.d III .... 1111 Ii 1I1 11" " vc' 1I 1(' 1I1 I Kt III II'!! W Illi 11 ,1111111)..' All'll N\' lIfol 1',,),\ II hi I " ."1 II ,'. II, H q ""'I'K'lIhllJ ~ I .11 111 MI II"III', K A ph .I ~ 11I A ( 'llI1l lil l . 1I 1l 11' ,\,~ 1111 IIIVI~ II \ ll11ly (ollll11l1l1\""" lIh hWII . NI'w YIII ~ Pl l'i

54

55, 56.

1207

Samo \11 J{c OVl"ry and rchab,llfatll.-l In Jpha 13 In Sarno. M T ·ct!·A\;qUIn:dAph , N' A~ml Pro Siln[)lego 1998 p'iY'i Klein. K CommunJly-hibeti n: (,ur(..c for pc-r'oOrl .... lth apha Ia and Ihclf families I'up Str()~e ~ehabl' 2 J IS. 11!')fJ. Amem:al1 H and PuhlJ,her... Dam tllc. IL. I'))i-l Sarno. JE. and Sarno. \IT: Stroke: A GUide f"r f'atlent\ and Their Famlhe • ed 1 \1cGray, · HIII . ' cw Yurk, IlJtJ I Simon..clrl. J: According 10 the aphilq(; adu lt Cmver.it!< of Texa'J, (Southy,c . . lern, \1/o:d ical School. Dalla .... 1'171 Sarno. \.1T: LndcNanding Apha.'la: A GUide for Famll) and Fncnd.., ..\.1onograph "10. 2, ed 4 Ru..,k In..,lItule of RehabllilOrd 37:3. 1972. Pnns. R. ct al : Efficacy of two different type!! of !\peech therapy for apha.., ic \ Irokc palient!!. Appl P!>ycholing 10:85. 1989. Wen, . RT, ct al: VA cooperalive ~ tudy on apha\ia: A comparu.on of indi\ idual and group treatment. J Speech Hear Di'iOrd 24:580, 19&1 Wen? RT. et al : Compari"ton of clinic. home . and deferred language Irealment for aphasia: A VA cooperati"e study. Arch '\eurol 43:653. 1986. Went , RT Language lrealment for apha<;ia I!> efficacious. but for v.- hom') Top Lang Di !!ord 8: I. 1987. Samo, MT: Recovery and rehabilitation 10 apha!tla. In Sarno. MT (cd): AcqUIred Apha<, la, cd 3. Academic Pre\~. San Diego. 1998. r 595. Ba..,<;o. A: Apha~ i a and 1t.'I Ther.tpy. Oxford Un ive",ilY Pres'). r-...ey, York , 2(Xn. Mark ,. M. CI al : Rehabilitation of the apha\ic patient: A \uf'\'ey of three yea"" experience tn a rehabilitation ')euing. Neurology 7:837. 1957.

57 _ Vi gnol!). LA : Evolution of apha!>Ja ami language rehabilitation: A retro"'pcctivc exploralory <,tudy. Conex 1:344, 1964. 58. Il agen , C: Communication abil itie.., III hemiplegia: Effect of ..,peech therapy. Arch Phy,,- Mcd Rehabil 54:545, 1973. 59 Ba ..,~ o , A, el al : ElUde controlce de la rc~ducalion du language dam I'apha!> ic: COinpami<,on entre apha~lque.., trailc!> etllon-lraite~. Rev Ncurol (Pari . . ) 11 1:607 . 1975 . 60 B a..,~ () . A, CI ,II : Influence of rchabdll. 1 Lxprc ... \I\'e languOIge rccml'1) III ;lpha'l;J u"mg the Shew,1Il Sp(llll iU1 C()U '" Language: t\ n ;ll\ ~I" {SSI \ l S, ,tem . J Cllf1j mun J)" llJd 17' 17 ~ . 19KH. b6 . Weill , RI and Dronl..cr..., IV Ht Ct,,,, (\1 .tg\,.' ('In .lph."I.l )I,lpcr pn."~c nt cd .11 Ihe Aml'fJr.: ..1Il Specul ·1 _, III,1Wa}!I.." Ilearlll!! • \ "IKI;lllllll Ih"eMI..h SYJ11jll,,,illl1lnn COIllJ11t1nil',llulll Sl'l~' n~' I.." ,U1U DI'vnkr. ,111(\ Ar m).!, \Vil'. hm!! ll1l1 , D(', J qs~ ()7 S.IIIIO, r...r l 1-111,11 KCpnfl . '\ gc .l l nl.!UI~lll· C\\IJulllln • .1I1t1lIU.llll~ 01 lik-lIIIIJllliI ~ J..1 ))11 lis (jranl1\; ll (\1\" Rill t)C00412 ·()4 NII>C», 11)1)7 fiX Ill' lin I ~ 1 . lhIOOk. ~, N•. llltl R ,III1,Ill' I}:I..·' ( ; Irl',lIl1k'llI \ll.I~r.1J1Ulutl'm mlnll).! tl'lIll Bnll.. .I'" " ph,I' M Iii J Dl'0I11('ulllillun 21 W. It.).'b

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Chapter 1.1(}. \\'elllrteh. M. l"t al : Trallllllg. o n ,Ill It Wilt c,;OtllIllU IlICUtlOn 'y~ l e l11 lor ,,:\ere .lr IM 'I;! can unprme 1l,ltural language prodm:llon. Apha 'llllo!!~ IJ,'·D, I '-N5 111 Ht'IIIl, . and Bt'Il'on, ])1 ' \ '.... ual ,IUlon ther.lpy lor glohal aphn '1;\ P"" CI1I ,ltIOIl ~lIthc 161h -\nllllal fo,'tl'l'tlrlg 01 the Academy 01 ...\pha' l,l, C hll';Ig0, 1978 11~. IIdlll-E,I.ll'Irook" N, et ,L]: Vi,u.11 itCIII)Ij Ihe .... p) lur apha ... I:I, J Speeeh 11e.1f DI~ ord 47:385.1982. pl. Skdl),.l\ I, ct ilt~ American Ind ltln ... ign (AMER IND) (I, a fucilitalOr ,,1 \erb.1I1l;1I10n tor the oral "erbal'lpr.txic. J Speech I\car DI ... ord .N:-l45. 197.1 1.'-' RJ.o. P. ,LIld Homer. J : Gc ... ture a<; a deblocking modalilY III ,I ..everc arh,I'w; p.lIIelll, In Brook,htre, RH (cd): Clinical A pha<;lology: Conlerenee Proceed lllg~. BRK Publlcatlon!-', MlOneapoh<" 1978, p 180. I.l5 Rao. p, et al: The u,e of American- Indian Code by ..cvere apha<,ic adu lh. In C hapey, R (cd): Language Intervenlion Str.LtCgIC!o 10 Aphlhta .lIld Rela ted Neuroge nIC Communication I)i~ord c r, . ed 4. LlpplllCOU WilJi;lm, & Wilkin ~. Baltlillore, 2001. p 688. 136. Alen. JL..et a l: The efficacy of rune tio nal communicmion therapy for chromc aphasic patient ... J Speech I lear Disord 47:93, 1982. 137. Atl"n. J L: Function commulllcation treatme nt . In Chapey. R (cd): Language Intervention Strategie\ in Adult Aphasia, ed 2. William<; & \\"ilklll<;, Baltimore, 1986, p 266. 1.38. \\ IIe0X, \1 . and Oa\"i~, G: Promoting aphasics' communicative effecti\Jcne<;s. Paper presented 10 Ihe American Speech- LanguageHearing A ..sociation. San FrnnC I\eo. 197 8. 139. L)on. JG : Drawing: Itl) value 11.. a communication aid ror :.dult ~ with aphasia. Aphasiology 9:33. 1995. 1-40. Lyon, JG: Coping .... iIh Apha~ia. SingullLr Publishing Group, Sun Diego. CA. 1997. 1.. 1 Lyon. JG: Commun icallon use and panicipation in life for adults .... Ith apha!>ia in natural sell lngs: The scope of Ihe problem. Am J Speech Lang Patholl:7. 1992. 1.1~. Rao. PR: Ora\!' ing and gesture a... comm unication optiom 10 a per· ..on .... lIh ~evere aphasia. Top St roke RehabiI2:49, 1995. I·U. Kagan, A, and Gailey, GF: Func tional is not enough : Tmining conversatIon panners for aphru.ic adu lts. In Holland. A. and Porbc ~, \1\11 (edq: Aphasia Treatment: Wo rld Perspectives. Singular Publi"hing Group, San Diego, 1993. p 199. [-+-1. Kagan, A: Revealing the competence of aphar-ic adu lt" Ihrough comer<,ation: A challenge to health prores,>ionals. To p Stroke RehabiI2:15.1995. 1-15. Simmons-\1ackie. N: An Ethnographic investigation o f Compen'atol) Strategies in Apha'iia. Unpublished doctoral di\'>Cnalion Loui\iana State University, Baton Rouge, 1993. 146. Slmmon<;-.\1ackie. N. and Damico. J . Communication competence in apha~ia: Evidence from compemalory "Irategies. In Lemme, I\1L fed): Clinical Apha~ i ology. vol. 23. Pro-Ed, Au\tin. TX, 1995.

pl.

1-l7 Slmmon ... \1ackie.~. and Damico, J : Refonnulatll1£ the definit ion of compen..atol) strategies III apha'>ia. Apha\iology 11 :761, 1997. 1-1rs Ullman. \1: Bcha\ioral Change<; 111 Patient.. FollOWing S troke~. Charle.. C Thomas. Spnngfield. IL. 1962. 1-19. Friedman. \1 On the nature of regres<;ion. Arch Gen P'loy~hlall)'

l:17.1961 15Q. Brumfitt. S. and Clari;c, P: An appilcallon of p'lo),chothcrapeulic: tet:hmque.. to the management of apha.. ia. Paper pre..ented at Sum· mer Conference: Aphru.ta Therapy. Cardiff, England. Jul)' 19. 148fJ. 151 Tanner. D' Lo, .. and grief Implicalion\ for the ~peech-Iangullge pathologl,t and audiologl\t. J Am Speech Hear A\..oc 22:916, Il)Kf) ":! Bareu. R. and Stephen..on. G' l nre .. lI,uc patient ..... YS J \kd 76:54 IlJ16. 1'13 Kubler.RI}\'i, E: On [)eath and D)lIlg \1a1.;mliian, '\.:w Ycrrk. !')69 1:<.4 E prn.uk, S' Stroke before lift\ A lollO'Ao-up tud) 01 \ocalllln JI n.J psythoJogKal adJu,tment x~ J Rehab \led (Supph 2, I. l
~6 B\llhnge- R. cl aI A tudy (,I,HOUP commullIldllnR IfIlt"rvntlO(J

u. th \:

11(;

aplu.'\,t( J'Cnufl'/, \ph»lolo,y 7:\01

'1'/1

J(J Nf..'urogf..'nic I)j,ordt.·ro~

of Speech "ntl J.anguagt.'

1209

1'\7 <':'pIUIl, AI l·t.!!: 1 ·t1H~al lind pnlllY I"UCS In rchal'llhl.oilHm mccll nne. A 1I,1"1II1g' Cenici Kcpnrt, Hrwrdlfl \i,lI1m, "Y Special Sup plcl1lelll , IIJH7. 158 lia\\, J. et ,II C"c ~ lUdi c .. in ethll" .1Ild rdJ.ltullt.-tlon The II.L,I IIlg' Cen ter, BrmrclLlf Manor. NY. 19~H 159. Sarntl, M I I·hl.! (" "'c of Mr. M I he \CICllllltl and Irc.-tmcnt flf aphn"lc pal lent... Ca<;e "ludiC,) 1/1 etlu(.;'. and rch'lnllllalll)l1 rncdl(:lI1C Thl.! 11 ,"lmg' Center, DriarcJifi Munor. NY, I 9HH, P 24 160. Surno, MT: 'Ille , itcnl mlnori lY: The patient With "'ph... ".-. Ilcmphlll Lecture. Rehahtllla\lon hl \l ilute 01 Chicago. ("Jm:ago, 19K£' . 161 Yor~'tOIl, KM . et OIl (cd ..): C linical Managemellt of Dy~arthnc Speilkcr<;, lillIe, Drown, Bo .. ton. 19HK. 162. Deal. J. and H amnce, C: Mod ificat ion 01 the clghhtcp cootllluum for tremme nt or apl1lxiu of .. pet."ch In adult ... J Spce(;h Hear OI'>Ord

43:89. 1978. 163. Iialpern, II : Therapy ror agnosia. apraxi a, and dy ..arthria. [n C hapey, R (cd ): Language Intervention Strategie\ 111 Aduh Apha .. ia. Willium<; & Wilklll\, Baltimore. 1 9~1. p 420 , 164. RO ~C llhck , JC: Treating apraxia of ... peech . In John<;, OF (ed): Cllnl' cal Marwgernem of Neurogen Ic CornrnuniC:Ltlon Di<;orde ..... Little . Brown. BOSlon, 1978. p 191. 165. Ro~c nbcl-, Jc. et al: A trealmcn! ror apl1lxl3 of ~peec h 10 adult... J Speech Hear DI<;ord 38:462, 1973. 166. Hou~t o n Wied!. 1M: l11e bas-ic (oul1d .. ll on approllch for dec rca.\lng apha .. i" ;md verbal apraxia in adu lt<; (BFA). In Brool-~h1re, RH (cd): Cl lIlical Aph l~iology: Conference Proceeding ... BRK Publi· cation .. , Minnc .. po1i~. 1976. p 209. 167. Roscnbck, JC: Advanccs mthe cv .. luation lind trcUlmenl o("pccch apraxia . In Ro,c, FC (cd): Advllnce, in Neurology. Progre ..... 111 Aphas-io10gy, vol. 42. Rli ven, New York , 1984, P 327. 168. Wertz, RT. et al: Apraxia of Speech in Adull\: The Di-.order and II ' Managcmelll. Grune & Slmtton. New York. 1984 . 169. Werll. RT: Language dlsorde ..... in adull\: Slate or Ihe clinical an. In Iloll:lIld, A L (cd): Language DI'ordcr. If1 Adult~. College HIli, San Diego, 1984, pl . 170. Rubow, R. e l al: Vibro tactile " imulati on for imcr\y .. temic reorgalll Lation in Ihc trcmment of apraxia of speech. Arch I'hy, Med Rch.l· biI6J:97,1982. 171 . D .... o rklll , J P, et a l: Dy~p raxia or <;peec h: The effcclivene .... of u Ireatment regimen. J Speech lIear Oi ..ord 51:289, 1988. 172. Rosenbck, JC. et al: Treatment of developmental apmxia of \peedl A ca<;e <;tud y. Lang Speech Hear Serv Sch 5: 11, 1974 173. Shane. II. and Darley. FL: lllC erre(;1 or :lUdllory rhythmic '>tlmulatlOll on aniculatory acc umcy in apraxia of 'J'Cet:h, ('onex 14 ·444, 197K 174 Sand~. E, et al: Progre\\ive change .. If1 anlcul:IIOI)' pallcm<; III \cr· bal apraxia: A longitudinal calle <;tudy. Bram Lmg 6 :9 7 , 197X. 175. Bu(;hholl () F..dJlorial : What 1\ dy .. phllgja'~ Dy\ phagm 11:23, 1996 176. Groher, MD, ilnd Bukulman , R The prC\Cllce of \wallowing cll\(lr. de" in IWO tcuchlllg ho ~ pilah , Dy' phugt:L 1:3· (" 191'16. 177 Vel\, S, tlnd Logcmann. J: The natllre <;w,lllow ing dl,ordc ..... III CVA patlent<;. Arch Phy .. Med Rehabi[ 66:172, 19H~ 178. Wade, 01'... nd Ilewer, RL: MOlor 10\\ and \"-"IJOWIn1! dillilult) after <;Iroke: Frequency, recovery, and pmgnn\i ... Ac,;ta "cuwl Scand 76:50, 1987 179 Chemey. I.R : Dy~ph.. gia In adul" With nl'urtllnglc d ....urdt·r ·\n OveTVlc..... In I.R Chemey (t::dj: Clinical \1ana ~l"m(" nl 01 D~'plw t.I In Adult\ and Children. A .. pen Publl ,hcT'\, Galthcr burg. \11). ICJ9·t pI IHO. wgemann, JA: I;valuat lon and ., rCdllT1l'llt ll! Sy..allul,\.lng D"llf der". 2nd ed I'TO-Ed. AU~ lin , TX . 1991< I HI Logemann. JA, and Kahnla\. P' Rclc.Lmln~ hI ,"-.LI'IM' ['lOU {'\ 0\ Appl icallIm nl rnaneu\cr .. and IIldlrc... t ollllc,;"C'llh.u L. '\ l'a.~ ,too .. \ieurolugy .10. 111", III'XI 1H2 I,Maru (.,l/Icll,f'~Cl1l.!nn,J S\I,aJIrMIIl"llwmk mdUSC."lJ he-...,[ IT.tUm.. pdtll'nt \rch Phy \kd l~c uhJ«t nil tw"c p lIent n::h Ph) \1 J f{ch d hI11.t I()(,(I. 11J9\ !1-1 ["un....a. (I. l"IJ.ttU • ( anti Lugcmaun J \ 1tttpJi.1 "Ilhenna! Idtl'mllrltllC'tn~t"fInl!!,,1 v.aI1I.Wo1J1,retb l)v~ 11.1986 Xolj I.ugcm,.nn. J.\ ,·r al ( lu ute m twill," III Ivy ~I \' ubu5e .llIfll18 wall"v.·lnl!l ·\rn I Ph) )ul '1(1:: '11"1 r. '8 I9'P 1\6 \1.L11111 liJ\\- d ...1 Numl.li 1"1)' I\ I ":ttllr"m dunn, lht breath hold mane vcn \ ptluc I Inn. ~ I jq

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1210

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RII \hcrucomputenzed auditory comprehen'\lon It n ~llIre RII, ed I Cllmcal Ap~ lotog:) Conference Pr <e>ed<,np. BRI\: Publu;.allort IUlJkapoh llJxl P ). r1 \1 RH. and H()ffer. P Computers. and c.mng An integratIve ~h to lb: trea.br'lcnllo.1( .lpha! .'" and head UlJUJ) In \lac

'upplcmental A~em.

Readin ~s

JR. \bnwl of Cooperalive Group Treatment for Aph.1."ua. BOltJ;:r ..

v.onh-Hememann. 8ch1OO. 1m. Bbama~. 5: 'eurOSClence for the 5rud} of Communicatiloe D",order\ uppm.-ou \\iUiam~ & Wilkmun. TX. ::!OO3.

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Orthotics, Prosthetics, and the Prescriptive Wheelchair

C /I i l I' T I~

f(

31 LEARNING

OBJECTIVES

I, Rl'[,lIe the m.ljor p:lTh \,.f tht' ... hoc to Ihe rt.'quirement~ of ind1\ idual:. fitted \\ ilh

lo'\t'r-limb orthlJse:.. , Comp;lft' the chaF.ll'teri:-.tic.:.. adqml~u!e .... and dl',l(h~tage.., of pla . . tic .... metal .... ami OIher

Orthotics Joan E. Edelstein,

PT, \I A, FI SPO

lll.lIt' rial ... used III onhose".

J. IX,..-ribe the component, of ('onlempomr) f(lot. JJll}~roo[. l..ne~'ln!..le-foot. hip-I.. neeankle-fool. lTUnk-hip-knee-anl..le_foot. and

mmi.. onnost'''

-t E\plain the onhOlic optiom p;uienb

"1m pamplegia.

3\ J.ilable for

5-. Identif) the features of 10\\ er-limb and lrun!.. orthoses lhat are considered during Ihe e,ami-

nation

pnxe~.

b. Outlme the physical thempi.:.(:; role

~.

III management of p.:lIienh fined \\ilh lower-limb and !J'llIlk on.hoses. Anal)ze and interpret patiem dma. fannulate realistic goals and outcome,:,. and develop a

plan of care \\ hen presented with C35e

stud).

:1

clinical

OUTLINE T~'nninolog.) 'lIldl~ pe~ of Ortho~c,

1213

Lo\\cr-Limb Ortho~e" 1214 Shoe:, 1214 FOOl Orthoses 1215 Ankle-FOOIOrthose!; 1217 Knee-An kle-Foot Onh os~ 1223 Hip-Knee-Ankle-Foot Onho$es 1125 TrunJ..-Hip-Knee-Ankle-Fool Onhose:, 1226 Onhotic Options for Patients with Pamplegia 1227 Trunk Onho"c, 11~O Corset 1230 Rigid Orthoses 113 I Cef\ ical Onhoses 1232 Scoliosis Onhoses 1233

II n .orth osiS is an e\ternal appliance worn to restrict or asI"'\;,I't mouon or (Q transfer load from one area to another. The older term. brace. is a synonym. A splinr connotes an orlho. . ~ mtended for temporary use. An orthoris( is the health care profe . . ~ional Yt ho designs . fabricates. and fits orthoses for the Ilmb~ and trunk.. \\ hile a JXdonhist is the health care profe"",ional \\ ho de~il!m,. fabricates. and fits only shoes and fOOl onho:;.e,_ art/lOci; i ... an adjecti\ e. al!.hough some use the \\ord ~ a noun. Archaeological e\ idence indicates (hat or~ ha\e been u~ at least "ince !.he fifth Egyptian dyna t~ C!7S0 to 2615 Be). The term onho ... i ... appears to have been comed in the mid-twentieth century. 101, chapter pre...ent ... the mo"t frequentl} pre . . cribed ortho'>C for the lo\\er limb and the trunk. as well as ne\\ de\elopmem tn the field Ke} elemen l~ tn lralOmg patiem~ to u-< onhose are dlo;,cu.., ...ed. The fcx:u.., i., on orthotiC de~ign charaden~tlC . their biomechanical ralionale. men'" of pel'llic malenal ..... and cnteria for judgmg the adequac) 01 onhouc lit. fundlon. and con..,trunlOn.

Onhm ic Vlaintenance 1234 Shoes 1234 Shells. Bands. and Siraps 1234 Uprights 1234 Join ts and Locks 1234 Physical Therapy Management 1234 Preorthot ic Examination 1234 Onhotic Prescription 1235 Onholic Examination 1236 Facilitating Onhotic Acceptance 1240 On hotic Training 1240 Final Examinalion and Follow-up Care 1242 Funclional Capacities 1242 Panplegia 1242 Hemiplegia 1242 Summaf) 1242

Tennmology and Types of Orthoses Generic terminology is superseding the traditiona l use of eponyms. Nam ing orthoses by the joints they encompass and the Iype of motion control facili tates communication among clinicians and cons umers. Thus. foor orthoses (FO,) are appliances applied '0 .he foOl and placed inside or out..,ide the shoe. such as metatarsal pads and heel lift~. Ankle-foOl orthoses (AFOs) encompas.., the shoe and termInate below the knee. The kllee-a"kle-fool orthOSIS (KAFO) ex tend ... from the ..,hoe to (he thigh. A hi,-rkJlt'f unkl£'-foOf orthosis (IIKAFO) i.., a KAFO \\ith J pel\il~ b;:tnd (hat ... urround'i the lo\\er tllJn~, A (rullk-hip-~flt·t·-..m­ He-fool onliosi.\ (THKAFO J cO\er.., part of (he thor." .1" \\ell a.., th~ lower IlIllb". A kllt't' orthcw.\ (KG) .U1d J Jill' llr lhmiJ (1/01 are other appl icatIOn.., 01 (he .. JOlt' ..,~ ... tem l)1 nomt:Ol:lature

1214

Ph, ,jul Rt.·hahilit.1tiUII

Lower-Limb Orthoses Lll\\cr-ltmh llnhll't." r.mge IrOI11 ... hlle' u ...elilor dlll lGII pur III n IK -\FO,. C'h.lr,ICh!ri ... lH:' Jnd fUlh.:l1on ... M the pnnclpal 1-0" \FO,_ K .\FO" Hf"AFO" and THK \FO" ~lnd Irun .... llnhlN~ .... logether\\Jth Ihe cJ inicall) impCIl1anl atIribt.lIe, of ,IH_le .... \\ III be de ... cribcd. (\hhough ph) ... icallh('rapl'b al,o encounler KO .... HO .... and onho ... e ... for ... pecial purpt1'e ....... uch a ... managemenl of Legg Cah e Perthe ... · dl ... e~. the ...e onho...e ... are nOI induded becau...e Ihe) are u\ed Ie ...... frequentl) than the appliances thm do
Figure 31.2 Lo" quarter ... hoe ... ; ( 4.) B1Ul.:her J.I1d IB J Bal (Balmoral). TI,e Blucher lal:c ... Iol) i ... gener.1ll) prelerred for onhotic u...e 0\\ IIlg 10 ea ...e III donning and adju ... IJblllt)

Shoes The shoe is the foundalion for most lower-limb onho::,e~. Each part of the shoe contributes to the efficacy of onhotic managemenl and offers man) options for se lection. I Shoe~ transfer body weight to the ground and protec t the wearer from the terrain and the weather. The ideal ~ hoe should distribute bearing forces so as to provide oplimum comfort. funclion. and appearance of the fool. For the individual with an orthopedic disorder. footwear can sen'c t \\iO additional purposes: ( J) it reduces press ure on sensi tive defonn cd SUl1ctu res by redislributing force toward pain-free areas: and (2) it serves as the foundation for AFOs and more extensive bracing. Unless the shoe is correctly fitted and appropriatel) modified. the alignmem of the onhosi s will not provide the designed pattern of weightbearing. The major parts of the shoe are the upper. sole. heel. and reinforcements (Fig. 31.1). These features are found in both the traditional leather shoe and the mhletic sneaker.

Uppe r The portion of the shoe over the dorsum of the foot is the upper. It consists of an anterior componem called the "amp and the posterior pan, the quarter. If the shoe is to be used with an AFO having an in sen as its di stal alt3chmenl. then the vamp should extend 10 the proximal portion of the dorsum to ')ecure the shoe and thereb) the re\t of the onhosis Counter Upper

Toe boxing

Sole

Toe spring

Heel

Figure 31.1 Part ... o f a low tjllMlcr ... hoc wilh a Bluchcr lace \lay. "ole Ihallhc.: t:()unler and Mrul.;lUrc\ o j the ... hoc

hi2.h o nto the fool. In a laced ~hoe. the \ amp contain... the la~e ~1a) .... \\h ich ha\c eye Ie"" for ... hoelace~ {Fig. 31.~ J. Lace~ pro\·ide more precise ildju~tment Q\ er the emire open· ing than do ~)(Tap clo\ure .... The laller. ho\\ ever. enable ... orne indi\"iduab \\ ith limited manual de\terit~ 10 manage the shoe more easil y. For 1l1 0~t ort hotic purpo\e .... a Blucher lace S1a) is prdcrable: il b di~tingu i ~hed by the separation between the anterior margin of the lace "'Ia~ and the vamp. The alternate design is the Bal. o r Balmoral. lace sta~. 111 \\hich the lace ~tc:l) b continuou ... with the \amp. The Blucher opening pennil s substantial adjustabilit). an lI11ponalll feature for the patielll \\ ilh edema. It abo offer... a large inlet into the shoe. ::'0 that one can detennine whether paral) led toes li e fl at within the shoe. An e:\lra depth ... hoe i ... one ha\ing an upper conwured with additional \"enical space. The shoe is manufac tured with a second inne r ~ole that call be re· moved to accommodate an insen or thid.... urgical dre" ... ing. Quarter height is ::moliler con ... ideration in ... hoe pre"'l'ription. The low-quarter tenninates belO\\ the malleoli and i... sati sfactoT) for most clinical purpose .... Thi ...... t~ Ie doe ... not restrict foot or ankle motion. If the patient \\111 be \\earing a plas tic onho\is molded aboUlthe anh.lc. it I . . not nece<:. ... ar: 10 go to Ihe addilional expense ofpro\ iding a high·quarter shoe for all .... le su ppo n . A high·yuaner shoe. co\ering the malleoli. i~ indicated to cover the fOOl ha\ IIlg rigid pe~ equmu,. It is al so approprime to augment foot stabilit~ IIllhe absencc of an AFO . The hi g h-quan er shoe. ho\\ c\c r. i... morc dinicult 10 don and more expensive Ihan a comparable low-yuaner one

toe ho.'tmg arc Illlenial rl'lnton':lng

The .\oll' i. . the bottom portion of the ... hoe. For u ...(' \\ ilh;, TI\ eled metal attachment bCl\\cen . . hoe and ortho~I"'. the ...ok should haw 1\\ 0 pan~. the outer and the inner "'01('. hoth Il\i.tde of leather. Bc t\\ Ceil (he I\\ol ic~ a metal n:mforct.'mcnt th;1I recei\-'c~ thc n\ e t,. TI,i \ t~ pc of ... tux' . hO\\ e\ cr. i... h1."3\ ier than an athlctic ... Iux' with a "' lIlgk ,olc. LC~\lhL'T ... ok ... ab!<'(lrb lillie impacl ... hrlCh. and prm ide- 1llll\ll11al (Tact 1011 a . . COl1lraI\:~ (0 rubbe r . . ole .... To ab<,orb , hoc k thc ~h{)(: mil) ha\'l' a rt',dlcnt outcr ...ok. Inllcr ...ole. or in ...cn. 1

(h"p tcr .l l Regardlc"is of l11:lh:ri.II, Ihe Olilel . . ole ... hould 1101 (,.'0111;1('1 Ihe floor al the dl~tal cnd, thl: ... lI ghtl i ... e oJ the "iolc I.., 1..11(1\\on .\ ... {(U' .\pnllg (:-.cc Fig. ~ 1. 1), whi ch allow\ it J'Ol:l..er cHert :.11 kllC ..,rancr. Ifalill I~ added to the ... o le to compcll <.,:.ItC lo r lL'g length di ... L'repa lH.:) , thl' lift ~hou ld be ocvc led to achicve toe

..,prlng.

Heel

Orthoti(:~

121S

COlll put l: r gc ncrlltl:d tlc ... ,!! n, rl:Il1 i.lln ... WIth the lIunuillL' tun: r: the.: ... hoe.: ... hapl.' dupli(,·illl.' ''' the la ... 1 .., L'OlitOlIr. ,\ given ... hoc Sl/e may be i.u.:hievcd "" itll many I.",,,",. ("alil Irano.,mJl !lIlg dlill:rL'nt forL'e s 10 the fool. COIl"'l.'ljul'lltl y. the phY<"IL',11 therapist ... hould a"'ccrill in that the ... hoc ... h<Jpc: lit.., the f(H1I ",i.ltisf<.lClonl y, ratller than rei) ing on i-\ partlL'ular ,Iwe silt: The patient with it I1wrkcdly deformed InOI requln.!"I a shoe mad e over a \pec inl la ... t. cllhc r factory or L'u..,lOm·made

The hal i.., the porllon 01 the ~hoc adjacent to the oute r ...ole, lInde.:r the anatomical hcel. A broad, 10\\ hcel provide~

greate"lt stabil ity and distributes force betwecn the back. .md front of the fool. For adults, a I in. (2.5 cm) heel tilt .., the cen ter of gra vi t) slig htl y forward to aid transition through "tance phase. but docs not disturb 110rl11;,11 knee and hip alignmen t significantly. A hi gher heel places the ankle in ib ext reme plantartlexion range and forces the libia for\\ard. The wearer compensates either by retaining slight I-.nee and hip flexion or by extending the knee and exaggerating lumbar lordosis. The hi gh heel transmit<., mo re stres5. 10 the metatarsalIi. Nevertheless. transferring load anteriorly may be des irable if the patient has heel pai n. The higher heel also reduces tension on the Achilles tendon and other posterior st ru ctures and accommoda tes rigid pes equi nus. Although most heels are made of firm material wi th a rubber plantar surface. a low resi lient heel is indicated to peffilit slight plantarnexion if the ank le cannot move because of orthotic or anatom ical limitation.

Reinforcements Reinforcements located at strategic points preserve the shape of the shoe. Toe boxing in the vamp protect') the toes from stubbing and ve rti ca l trauma; it should be high enough to accomm odate hammer toes or sim ilar deformity. The shank piece is a longitudi nal plate that reinforces the ~ole between the an terior bo rder of the heel and the widest part of the sole at the me tatarsal head<.;. A co rrugated <,teel ,hank is necessary if an onhotic attachment is to be riveted to the shoe. The COlli/fer st iffens the quarter and generall y tennmates at th e an te rior border of the heel. The patient ~lth pes \algus. however. should have a shoe with a long medial counter that provide\ reinfo rcemen t along the medial border of the foot to the head of th e fir\t metatar... al, thu, ,e,i,tlng the tendency of the foot to collap,e mediall y.

Last The faH I~ the model ovcr which the .., hoe 1\ made. The la \t. ~hether of traditional wood. cU~lOm-made pla... ter. or

Figure 31.3 Pia Ill: 1.lr,.:rcc! heel pur tu hlon "" Llh oi,:onc.lVc rduof If, rl'du(':c pres t.ure l~ hadcJ area .)1 the hoc fin ,he fM fight In(ilL..tt the rd ... ll .. e po 111011 01 ,be htel pur ..... tn.·n ph,,;~11I1 OJ hoc:

Foot Orthoses Foot o rthose~ are appliances that apply force ... to thc fOOl These may be an /IIserf placed 111 the ,-;hoc, an II1tcmal mod ificat ion affixed inside the shoe. or an ex ternal modification attached to the solc or heel of the shoe. They can enhance function by relieving pain. Thi.., may be accompli, hed by transferring weig ht bearing stresses to press ure-tolcrant si tes. protecting painful areas from contact wllh the ... hoe. correcting alignm ent of a flexible segment. or accommodat ing a fixed deform ity. Inserts can also imp rove the wea rer's tr;.msition during stance phase. by altering the ro llover point in late stance and by equalizing foo t and leg lengths on both li mbs. In many i n~ta n ces, 11 particula r therapeutic aim can be achieved by a va riety of devices. M

M

Internal Modifications Generally. the close r the mod ificat ion is to the fool.lhe more effective it is. Con~equen t ly. inserts and internal modifications are wide ly used. The insert pernlits the patient to transfer the orlhosis frolll !-.hoe to shoe. if the shoes have the same heel heigh t: otherwise. a rigid inc;ert may rock in the ~hoc. Most inserts tcnnina lc j ust behind the mctatar... al head,,: thu"i. they Illay slip forward. particularly if the ~ h oe has a rt.!la tively high heel. Some in ~e rts cx. tend the full length of the solc, preventing slippage. but occupying the often lil11it~d space in the aJ1lerior port ion of Ihe !-'hoc. Interna l modi ficati ot1~ are fi xed to the ":.hoe's inlcTlor, guar~lI1 t eeing the destred placement , but limiting the patient to the ... ingle pair of modified shoes. Both inserts and internal mod ification ... reduce ... hoe vo lume. "'a proper ... hex: fit mll ... t be judged \\ IIh tht.!..,e components in place. Insert"i made of" ~()ft m
1216

Pln .. ical RehabilitaliUIl

)

Figure 31.4 SCJphOld pau' (h j ll arc ;.l\adablc with ...el f· JJhe' I\ ( t'lJ.ckmg; . ,1.: aphOll.l pad (rig ht) glued to the Im ide of the ,hllC'.

\i ... coela."Itic pla ... tic or rubber.-I The onho~ i!) ~Iopcs anteri orly 10 reduce load on the painful heel. In additi on, the o rthosis ha ... a concave relief to minimize pressure on the tender area.

Longinldtnal arch supporu. are intended to prevent depre!)... ion of the subtalar joint and flattening o f the arch (pes planus). The OI1hosi~ may include a \\.o·edge (post) [0 alter foot alJgnment. The minimum support is a rubber scaphoid f>
Figure 31 .5 l

d l Hl m rt

111\

II

~

llf

t ahfonl1.J

Hil

n!('\.haJIII.' t

.Il"lo.,lr.Hl1f'o

Figure 31.6 Rubber metatar<;,al pab. Whether used" an internal modification or a.. part of an m~rt. the pad "hould be ori· en ted a.., ~how n on Ihe .,keletal model

The metatarsal pad (Fig. 31.6) 10; a convex:it; that may be incorpo rated in an ino.,ert or may be a resilient domed component glued to the inner \ole "'0 that it... apex: lC\ under the metatar')al o., hafts. The pad transfer.., I,tre~ .. from the metatarsa l heads [Q the metatar..,al ')hafts. ' ~ Occa")ionall}. mod ifi cations are .,andv.iched between the lOner and outer sales: for example. the patient with marked anhritlC changes in the front of the foot probably" ill be more comforu.ble if the shoe has a long steel spring betv. een the ... ole.., [Q elim· inate mo tion at the painful joints. The same effect can be achieved \\ith a ri gid in~ert.

External Modifications An external modification en~ure~ that the patient \\-ear the appropriate "hoes and dCJe.., not redu~e .. hoe \olume. but Wi ll erode as the pattent \\alk~ and IS ... ome\\hat (on plCUou~_ In addition. the client j., lunited to \\eanng the modIfied .;,hoe. ramer than being Jble 10 choo-.e from a \\ide~­ lec tion of shoe .... A heel wedQe (Fig. 31 - ) b a frequen:.!~ pre...... ribe~ e tem al modification. It alter~ alignment of the (akaneu., ....\

Figure 31 - \t ..

l hnph." ,li Orthutic..

1217

lI1~lil:l1 h~d \\CdgL', (1) ilPpl ) llIg lah..'I,III) dln!l"IL'd hllLT,

L'; 1I1 illll lll rL'illi gnlllg Ile\lhll' pc~ \algll~ 01 l'iUI :ll'l'OlllrnO d;lIc lI ~lId pc, ,anl~ b) filll1l!! thL' \O ld lx.-t\\CCIl Ihe ,ole ;lnd Ih~ floor on tilL' IllL'dlill ' ILl!: A IIIL'dial w~dg.L' 1;-. lII cor pOI;lIed III ,\ rhom,,", 111'1'1. lIltcnded for Il c\l hle pc, v;ilgtl',

(Fig. J I.X). rhe :tntl'rior border 0 1 the T11011Ia , hecl e\ h: ncl ~ !nn\ ani 011 IIll' medinl 'i idc In ;\ugrne lll the e ffec t of Ihe Illedial" edge in "upporling the longitudinal arch. !\ CII , h1l)1I heel 1;-' made of re, III CII[ matenal 10 lIb,orh ~ hOl'k
Ankle-Foot Orthoses The APO i\ compo ... cd

(If

a ['oundatloll, an kl c cOll trol , ['on l

control. and a supe l'''i lrU cllIrc.

Metalarsal bar

Stilndard heel

...---":T Rocker bar

ThOln.l',

hHnt

Figurf' 31.8 IIhhll,I,,·d 111 w ,lit 111-/1/ ,IIIWr.ll.1I .11 h,lI ,Hid rilil d.mJ h!"' 1;ll1d 111 1;"" .llod,n h,lI ""111i ,J I hum., IU'd

Figure 31.9 J\FO wllh pla , llc :-.hoc m..,c rl.

Foundation The foundatio1l of thl,' orth O!'! I ~ (.'onsl, l ... 01 thc ,hoc tlnd a pla' li c or I11clal component. Insert A pla ... li c or l11 e tallll :..c rt 01 1001 pIalI,' loundatlon (Hg, ~ I C)) h..l ......cveral adv :.lI1tage .... BCC:l l"e IllternalmodiilclItlOIl' (.;;.111 be incmpora ll,'d III it. the III,el't provide, good cOlltrol 01 th~ [001. It Illu ... t he worn w ith d ~hOl' Ihall'1o ...c . . hi gh unthl.' dllr "'1 1111 0 1 lI u..: root 10 fl' tam Ihe orl i1o!'! I .... I hl! Ilher! [i1C1ht ill~' donl1l1l g Ihe ortho,j, bel'au,e Ihe ... hoe Ctll l be ""'p;lralcd !101ll the re,t 0 1 the hrace. The 1I1,elt al'to PL'II1III'" IIlh:r· chang lll g :.. hOl: ~, a ... , ullllli g that all 'thoe ... haw hl'l'lll1ladc Illl till' 'alile 1;1 ... 1. I.e ... :.. ex pen:-' Ivc shoes, ,lIlh :I' 'lleaker', l:.m .11'0 he wo rn , hl'c:tu,e th e Inund a li on dOL· ... Ilot Ill'cd ttl lx' IIVl'ted 10 th e ... hoc.' l he ollho,i, wilh ;\1\ IIhl'lI" Il'Iallh·1\ h!!htwl'lght. the lII ...e ll i... LJ'lIally madl' 01 it IheI1l1l1pl,'''lIl' IIl:1 l eri al , 'lic h
Figure 31.10 Solid "Iirrup. NOle thallhe "t in'up il1lhe foreground i.., a.., il appearli from the manufacturer before it iii ti lled

III the ..,hoe.

Figure 31,12 Pl a~l i c foO( plale on pO\lcrior leaf "pnng AFO

the paliCnl mi ghl cx peri ence knee in stabi l ity. The in:-,ert rcduce~ interior ~hoe volume, and thus I11U:-, t be u:-,ed with ~uitably spacious shoe:-,. Custom -molded foot plate:-, may be more expcnsive than olher t ype~ of foundations. If the orthosi s is to be used by a very obese or excepti ona lly active individual , a pla sti c foo t plat e may no t provid e adcquate supporl.

interchanged. The ext remely activc client may di'ilodge a side piece from li S receptacle unintcntionally. The sp lit ..,lIrrup is bulk ier and heav ier than a so lid stirrup or foot pl ate.

Stirrup The traditional foundation for the AFO is a steel slirmp , a U-shaped fixture, the center portion of which is rivctcd to the shoe throu gh the ~ hank. The arm s of th c :-, tirru p join the brace uprights al the Icve l of the anatomi cal ankle. provi ding cong ruency between ortholi c and anatomica l j oinh . The solid STirrup (Fig. 3 1. 10) b a one-piece att achment that provide s ma x imum stab ili ty of Ih e ortho!-.i.., on the shoe. The ,\pltfHirrllp (Fig. 3 1. 11 ) ha:., three scg l11 cnt ~. The cen tral portion has a tran svcrse rec tangular openin g on each ... ide. M edial and lateral angled side pieccs lit into the openings. The "'plit sti rrup si mplific ~ donn ing thc ortho..,is becau"c the wea rer ean cl claeh the upright" from the ~hoe. If a cc ntral piecc is rivcted 10 other \hoes, thell shoes can be

Figure 31 .11 Spilt "urfup.

Ankle Control M ost AFO ., are pr!.!scribcd to control ankle motion by limiting plantarflexion "nd/or dorsiflex ion. or by a~'i i .., ti ng motion. The pat iellt wi th dor..,i fl exor weakness or paralysis ri sks dragging the toe during swing phase. Dorsiflexion assistance can be provided by a pO.\ lerior ll'uI.\fHin,f!, that arises from .\ pla!'>tic insert (Fig. 3 1.1 2). During early stance. a.'-I the patient applies force to the braced 1'001. the upright bent]'" baek\\ard ..,Iightl y. When the patient progres\e.., into ..,WlIlg ph'he. the plastic reco ils forward to lift the fool. T hinner, narrower pl.htic permih relatively greater mOlion . Motion w')..,i..,wnee can abo be achieved wi th a "tcc! dor..,itlcx ion "'pring a..,.., \..,1(Klcnzakj oinl ) (Fig. 3 1.13) incorpor:lt(!d Into each "Ii rrup. The I.:oil spring compl\::.,..,es in ..,lance and ft::bollll{['" during s\\mg. The tlghtncss of the coi l can be adjusted. An ortho"'I'" \\ lIh a dm"j tlcx ioll "'pring a""ist i.., notil.:eabl) bLJ I ~ler than the po... lcrior leaf "'pring model. Both type.., 0 1 ... pring a..,,,i,,,,, ) icld ... lIghtl) into plantarll ex ioll al hed conta(.'t, affording Ihl' wearer prt)· tecti on again..,t inadverh:nt "-nl.!c lle\ lon. Other A I'{ ) tk-:" 'gn" arc prc..,ellled in Fi gures 31. 14 and 11. 1S. The altl!rnatc dppfoach 10 preVl"nt Inc dr;tg I" planl;\ .. I1I.'\ 1011 re" l"t:tncc, wh ich pre\'cllh IhI.' loot from plal1[arlll.'\lll!! ..,0 111111 the patIent wilh drop loot "tll not ci.lll.: h Ih~' Ilk..' and ... tumble dUlln g ..,\,.\I ing pha,,1.' Adul t" WIt h hl.'lluplcgia \~ 110 W()I "C A FO:., dCll1011 "tral l.'d Illcn'::I\~'d l'atiL'Jll'L', \\ :ll~ lll g "rll.·~'d. step length , ;1111 1an"lc dm"l n L'\ lon .l~ AjOll1l pl.'L'L'll III ;t pl'l" lil' hlllged ..,olid an"lL' A I'() ( Fi,l!" _~ I 16 ) III
ChapteT.>1 Orthotk.

121<j

divided lransvcr'>Cly al the ankle. with the two ~tion<; hinged. creating the hin~ed solid ankle-fool orthosis (see

Fig. 31.16,. It provide, 'light ,agittal motion. fo'tering achievement of the foot-flat pm.ition in early ~lance and enabling \.Orne patient\ with hemiplegia to walk with increased \tride length and cadence. 21J Children with ~pa'tic

diplegia preferred the hinged AFO. rather than the .alid AFO. although gait velocity. cadence. and '!ride length were unaffected? The joint at thc hinge may be a pla~tjc overlap or a pla... tic roo. A ver\a!ile option i", a pair of metal hingcs that can be adjusted to alter the excursion of ankle motion. An alternative to the plastic o:,olid ankle AFO is a metal joint that re,j!!ots both plantarflcxion and dCJrsif1exion. known as a limited motion joint. One type of limited motion joint j,) a pair of bichannel adJuuahle ankle lo( h fBiCAAiA) (Fig. 31.1Y) which cons),l of a JYdir of jointr;. each of which ha~ an anterior and a po~terjor ~prjng. Ordi-

narily. the 'pring' are replaced by metal pin •• the length. of which detcnninc the amount of m(Jlion provided by the C)rlh()si~. To compcmate for lack of pJantarflexion in early 'lancc. thc ",hoc u
Flgurt:: 31 13 Steel d(1T lf1c

J()rt it

•

l

Foot Control An anh::nr,r tCJP limit d(lr,>if1exlon. aiding the individual ;.nh p-aralysl "tlhe triceps wrae te) achl(.."Ve late Sownce."J Limning all f(}flt and ankle: mrllion can be achi(."Ved with 21 ph". li(; jf/ltd anl'le· foOl onho-.is (fig. 31 J~); itt; trimline I antencJr u) [he malleoli ~Jhc \(Jlid anHe orth(}.,!~ may be

Figure 31.14 Tocf)H- anYie fh(J<:I • -[hi

{Jrth()'\1

f(lI")1

\!fedial· lateral motion can be controlled with a solid ankle AFO. The rigidity of the orth~i\ can be Jncrca;w by u ... ing thicker ()r stIffer pla~trc. corrugating the pla... uc, forming the edgec, INith a wiled ClJnlour. Of embedding carbon fiber reinforcement\.. A ~t)ljd ankle AF(J (<;ee Fig. 31.1 k' or a hinged

{Jr.

I de ,12ncd II, pm-

a: I lance in the pn':-'lCn(;t: (If rmld to ..e...... re frll"JldrrJp ac VJffipanu::d h) rmld 10 m(}(Jeralc allY e "Ide (\(Jr Int;~Jrm

In ,Iahllny. It I fabrkatcd rrom jiber glil . (;ilrhlm filx."T. and KeY/elr_ 'ote. 'rhl ()rth()-\!') would not be mdlcated In the prc')Cn(;c of moderate tlJ ~vcrc

pa-Iltlfy or ClJcma. (Courte 'j ot C\ \<W \(ilndlOaVla AB ')f-~ 254 f)7 Hcl IOgixJrg. Sv-eden.

f

-..

-

Figure 31 .15 Yp .. II(J1l ankle Inol ol1ho"I~.IIw; (ill hOll U'1IlPO\lll' "10 ,\ d l''' I)!lled to prmmll'
'"

...ol
,, '''--~

,olid ankle AI'O hee Fig. 3 1.16) "I,D conlrol, lronlal "nd Iran \ve rr.,c pl<.in l: foot motion . L c", ... c l'l cc li vc i.., a metal ~lI1d leather ortho"i.., to whic h a lea ther va lgu ... (va ru ..,) co rrec ti on

... trap is allached. The va lgu.., correction strap (Fig. J 1.20).\ \cw n to the medial portion o f the ..,hoc upper ncar the \ok:.

and buck le ... ,tround the lateral upright, cxerling a lateral ly directed rorce to rcr., traln pron ation . The varu. . correction

_,

---.

II

(Illl'c ba!. lalcr.II, and 1{J1.llHtIlOlIIll{J\lCmelll' I he prm;1 Illal Y .. h'lpc pro\-Uk .. llhl;t cre ... t ch:.lr'UllC "mll'"lh, mIIHl ..... would 1111\ he IIldlciited 101 all 1I11 ... 'ilhlc OInk It JOln l III 111 th e prc . . encC' II I moderale to !.e\lC; l e "pa .. IIf,: fly or (:dema (Courte .. y of CAMP SLlll(iln.lvl
SI 2'l·l67 I h:1 ... nphorp \v.c;(kn.,

Supcr.\ trudurc T he pro xlIllal port ion 01 thl' ortho,,,. th e , uper"rLluure, COn,i.,l, o f upright " :.tnd H , hell . hand. Of hrlm 1'1 ..1\11(; A I-(h u.,ually have
",trap has oppor., itc attachment s and force application . Ei ther

... trap. although adjur., tablc. complicates donning.

FIgum 31 17 .Sll,.'1

~IHItII'

l'w l SlOp I" \(1 III.: kll

\\11 / 1

t" "ll"IIOI

'01' oil II

/111.'1111.11

Chapter .lI Orthotic....

~

1\

r-

A

If f'....

"-

1221

....-

'"

Valgus correction strap

Iii

J ./

Figure 31.20 Va lgu<; correction 'itrap (a l<;o called a "T-M rap"). The arrows denOied the three-point pres'\ure system created by the correction rorces (right lower ex tremIty). Figure 31 .18 Pla\lIl' ...olld AFO.

(Courte~)

or 0110 Bod•.

\IIIUlt·,lpt)lI ... , \1'\ 55,~-,n).

B.( \\1..

leg. thus providing excellent medial-lateral cont rol and a broad surface to minimi ze press ure. The posterior leaf ~ pring AFO (see Fig. 3 1.12) has a s ingle posterior upright th at does not contribute to frontal or transverse plane control. The sp ira l AFO (Fig. 3 1.21 ) is a design in which a si ngle upright spirals from the foot plate arou nd the leg. terminating in a proxima l band. It may be made of polypropylene, nylon acry li c, or carbon fiber. Th e sp iral orth osis controb. but does not eliminate. motion in all planes. 12 Orthoses \vith piaMic shell~ or uprights are molded over a cast of the patient', leg and are designed to fit snugly for maxImal control and minimal conspicuousness. Such AFOr., are comraindicated for the individual 'Whose ankle and leg volume nuctuates markedl}. because the onhoses cannot be adju'ted readily. \Ietal and leather onhoses usually have medial and lateral uprighh to maXI01iLe ~lructural stability. OccJ:.. ionall) a ~ingle ,ide upright \\ III ~uffice \\hen the pattent 1I1'I\t\ on a Ie" con ... picuou~ onho\i\ and the per,on " not C!\~cted to e,en undue force ..Aluminum upnghh arc lighter 10 \.\elght than ... teel. Carbon gmphJtC! and tHallium Upn!!hl \\cigh apprcclahl} Ie ...... than aluminum and n\.11 th!' ... trength 01 h:cl hu\\c!\t:'f onho ...c ... matlt.- 01 the n('\.\(r rna tt:n.ll ... .Ire more e'IXn ... l\c. \Io~t onho-.c ... ha\c .t p"-l ... (C!nor \,; >11 band mad!." of p Uc or leather-uphohh!red me-Ial The hand ha an ten'r hulkl .J ~r pr' ure d ,ure tr.. p t Fig 11:2 The f.uthcr the band I trom (he 111 Ie Jomt. the more e U'C' :he le\er of Ih orthosl hml"e, r ,he t-and mu I not urpmge on

1222

•1

Figure 31.21 Spiral AFO.

Figure 31.22 AFO \\ Ith ,tlITUp J.IlJ.:'hmeni. limned mllllon In!"Ie jOlnl'>, bllaleiJI upri£hl'>, ;lno uphol.,tered mel "I t:alf b.lI1d.

the peroneal nerve. An anterior band that is pan of a solid ankle AFO imposes posteriorly directed force nearlhe k..nce. enabling the AFO to fc!:.bt knee nexion. Such an ol1hosis is ~ometime ... known as afloor reacriol1 or/hosl!, (Fig. 31.23), In fact. all lower-limb orthoses are innuenced b) the noar reaction when the wearer !)Iands or is in the ... Iance phase of gait. If the AFO is to reduce the amount of weight lransmitted through the foot. it may have a patl,lIl1r-lelldrJll-beanllg brim (Fig. 31.24). re se mbling a tran 'l,ibia l (below-k.nee) prosthetic socket. The plastic brim has a slight indentation

over the patellar tendon. and j<., hmged 10 faciliti.lte donning. The brim mu,' be used with a pla:-,tic 'lolid anlde or a '1leel limited-motion ank.le joint. Tone-reduu'IIR onllO.\es arc pl3"lic AFO" dC"lgned for children wllh ~pa"t i c ccn:b ral pab)' and adult" \\ IIh "jXI\lIC hemiplegia. The fOOl pl~lIc nnd broad upright arc deslgncd to modify rcncx hypertonicity by applylllg con"'lant pres..,ure to Ihl.! planlarflcx()r~ and JJ1H:rtor... Thc) are particu larly u~cllli lor JJ1chviduals who have moderate spasl icil) wllh varu\ 1Il"I<.Ihlllly, but do nol have fl\cd detormll). They cOl1trol the tClldell<.:)' of the 1001 to ,ISSllllle all equinnvaru" po .. turc: III addition. \()IIU: vc..' r .. ulIl" han.' a 1001 pl.I1e lhat JlliwJlalfh Ihl' toc .. III :tn n.1t'ndcd or h) pcrl'\h.'ndcd

1'0.. 111011, Ihu, a"" I'>IIf1!! lhildn:1l wllh "'p;I ... lIl·lI ) 10 \\al"""Jlh hl'lIl' I foot and I..lll·l' l'tlI11IOi. :1, SlInilar \('1"'>1011'" ha1ll" provcd ~ucxl',!>llIl with ..ulllih \\ ho haH' .. u ... t'llIlL'd

u'rd"'lal "',I',ull,1I ,ll·UC.k'IlI".

Ihc\IIIUtllllu/JI,"/rll o,lluH/\.

Figure 31 .23 I 10111

I l',ldll'll h'h:l'

,.lIh,1'> ..·'>

PII" Ilk ,11..11\'\' ,'\

1l'II"HlIl I1Hlllll'lI1 I II \"1'1111"111 !"Ill'l' tk\lllll III .,I,IIll't' It \'\111."\ ,II

()llhn Itlllllll', l

,l bol .lh'l\

llh..... ,ltlill

{):,llll'

I',ttl... '\ '\ 1IJ '{1

(hapter .11 Onholin

Figure 31 .24 (/ (1n Al 0 ",rlh !'urrup. hIHt!l'd ;tn~ It.! JOWl tC'ci upnJ!hl~. and r1a\Ul paldl,u tendOIl- hcannt! Imlll. /f(IMhn

Pla\tJt; AI () v.nh p
he.rml).' hI uli Lo rcdu(.:c v.C'lghtheanng on IIMJr /CourtL''ty 01 Orlho Blol]lt.: ... Lrbor
"'H11~llIlle ... prl' ... crtbcd for children with spa,,>tic diplegia. oller . . Ic~ ... re ... tllc..lrOIl of ankle motion than a 50lid ankle IIh) > ,

Knee- Ankle- Foot Orthoses Illlllvrclual ... with more extr.:n..,rve puraly..,is or jimb deformity Illay bendll from KAFO .... which consh,( of a ... hoe,

l(Jundallon. <-lnkl(;! conlrol. knee t.:olllrol. unu super"trllclllre. K,'\H}, o11L'1l IIlclude fool control. The ..,hoe, foundation. anJ..Jc {-'Ol1lrol. and 1001 (.;l)l1lrol or the KAFO may be seh."tlcd frolll the component ... ~tlrcady de ... cribed. Donning a pla'lIH.: and rnctJI KAHJ i ... ;,tppreciahly fa..,t!!r thall pUll i ng

Oil a met,tl
Knee Control I he

!o,1IJ1pk· ... t

knt."l'

.I01ll! I!o,

a hinge. Bcc;:IU~c mo.) t KAFO:,

rnLiudc" pall oj uprlg.ht.... the orl lHhl ... ha~ a p<1ir of knee hlllgc'l tilal provICk 1l1l'dtiJI lateral and hYPl!rcxlen::.ion re· '1II1CI[OI1 v.-ll1le PCII11Ililll!!, knl'C ril!xioll. 1he II/t:wl /0I11( (Fig_ 11.25) i ... a hinge plal't:d pO~lcr i or

It) Illc 1111<11111L' 0 1 the leg. I he p:'llll.:nl\ weight Jin!.! 1'1.11'" an terrllr to the nlh!!1 .1oln1. ... tablli/lllg Ihe h.nl.!c in (!). [(;!tl!o,ion UUrJllP Ihe early ... t.lI1CC pha'le 01 gaJl whcnlhe wcarcr i\ 011 .1Icvcl ... urlilLc. I Ill' olf"'Cllornl doc ... not hamper h.nee flc\ lun dUl"lng "\\l1lg m ..,lIll1lg The .Io1ll11l1:.l)" however. ric>., 111advertcl1Il) \\-hen thc \\-earcr \.\,1110...., 011 ramp .... I he 1ll0'll cllmmon knee conlrol 1'1 the drop nng loc\.. (hg. 11.2(1). When thl' dielll '1t'llltl ... \. . lIh the kncl' tully C'\· tended, Ihe !'lilt-! drop .... prevcl1t1l1g the uprighl'l Jrom IK'nd Ing. Allhough hmh lI1t!ulal alltl lateral IOlnt.., ... hould he:

122..\

. .,

•

r,

A Figure 31.26 Hinge with drop rin g lock.

locked for maximum , tability, manipulating a pair of drop ring locks is inconvenient, unless each upright is equipped with a spring-loaded relemion /Jullon. The bulton permits the wearer to unlock one upright. then 31lend to the oth er one without having the first lock drop, The buttons a lso enable the physical the rapi st to give the patient a tri a l period of walking with the knee joints unlocked, The pawl lock wifh "ail release (Fig, 3 1.27) provides simultaneous locking of both uprights. The pawl is a ' pringloaded projection that fits into a not ched disk. The patie nt unlock s the brace by pulling upward on th e posteri or ba il. Some people are agile enough to be able to nudge the bail by pressing it against a chair. The bail is bulky and may rclease the loch unexpec tedly if the wearer is jostl ed aga inst a rigid object. Th e off~el joint and knee joints with basic drop ring or pawll()ck~ are contraindicated in the presence of knee nexion contracture. If one cannot achieve rull pa!-.sive knee exten"on, an adjustab le ,errated knee joint ( Fig. 3 1.28) is required Such joinl ~ have a drop ring lock fo r ~ta bility in the partially flexed attitude. Sagittal ,tabilJty "augmented by a kneecap (Fig. 3 1.29)

B

..

Figure 31.27 Pawl lock: ba\lc component (A) and paw l lock im.talled in KAFO with bail \haped 10 curve po"erioriy (B).

the knee and applies a posteriorly directed force to oppose any tende ncy of the knee to nex. The kneecap require; the patient to buckle two straps when donning the orthosis. Wh en the straps are tight enough to stabilize the knee, the

or an anterior hand Of ~ trap Ihat COJ11pIClc~ the three- point

prc~~urc 'y~tcrn I1cCC~~f.lry for ~lJb ilit y. The cap or hand applies a po~tcriorly directed fon.;e to COll1plc l11 L:l1t th e an teriorly dlft!cted force~ from th e buck of the ... hoc and th e thi gh band. The IC4Il her kneecap i... th e trad lti on:1 1 COlliponcnl. It

Figure 31.28 SC'rr,llco I-..ne'l' 10el-... 'nle' Ihe 101.:.111011 ollhe I-..net:' lu nge and IIIl' ... err;Lleti dl ... l-... (I 'WIll 1~ I ... hLllall. S. el ,\1: l.o\\er-iLmb OI"l ho ... I.' .... 11I Amefll..:an\('adeLll) 01 Onhopaetfic Surgeon ... : Alia ... 01 Orthotic .... L'tI 2. Mo:-.b) , St I .oui .. , 19H5. P 11~. \\ Ifh

has lour ... trap'" buckled to bOlh upnp. hl '" ahove and below

pcrnll ...... . on )

( IMptfor ,\1 Orth"t;Cfl

A

Figure 31.29 KAIO Wllh knt!.: car,

J 225

B

Figure 31 .30 KA I'O wl l h (;omrUler-(;Onl rolied knee joint. CHeder b Knee. Becker Onhopcdic, Troy, MI 4ROX3.)

p.Jd 1'-. likely 10 rc,lm,lllcxlCHI when th e wearer .. Ill." A more u ngld anterior band , eHher a prell bIill hand or (I ... uprapalellar hand, both of whith apply po ... ICrlllrl,. {hre<.:lcd fOI l"c, '/ bul do 110t Interfere with ... lIl1ng. ,md ;IIC ca ,ICI In dOll ~I he nf.Huj .. gCllcndJy arc moldcd of pl;J\tlt iHHJ thll I., not rc.ullly
upright. T he oppo.,ite to rce app licat ion i, Indicated for the pal len l who ha" genu varum. The ... he ll doe., not require IlInc 111 donlllng and aprile, fo rce ovcr a broad area wllhout IllIpingi ng on Ihe pop litca l (0"\.1.

Supcr'tructurc

IIll' JOint. Ihe palielll 01 illtIO"" (I J ,lmllT c0l11ro l whll.:h i ... ill'lCfI)..'.IJ,!.l"iI dllll"~' WIIIJ! "h""'l', (2) flO ,tallcc l'(lnlrol, dnd

'rh lgh hand ... provide "rue iliral ... tah ility 10 the ortho" ... , If the d"'lal portion of the tlmb cannOI IOlcra te full \.\l.'lght hearing, thcll the proxlIllal thigh hand m~ly he ... haped to form a wClgh thcaring hrim, Ei ther the quadrilateral or Ih.: I ... <.: hial cOllli.ullmenl dc ... ign can be u ... ecl, ro clilllll1"lIl- all wl'lghtl"X.'ari ng Ihrough the entire Icg, the ortho ... I' ITIU,t m· dude a wClghthearing hri m, a locked ~nl'l' .101111. and a IHlIIl'lI hottom, 1he pal ten i, a di ... tal c\tcn ... ion th.lt J...l'l'r' Illl.' ... llIle tmlhc hnlcl'(/ "'1(11: o f f Ihl' nom_ 1(1111'-11111 ..1111 ;'lll'\l,1

(jj 11K k III filii l ' h'lI"'Jflll I'rclllllll1i1ry IIwe ... II!!i.ltlon lIuh

pl"IVI', tlil' palll'lll IllU'\

adull' wllh lower IlIlIh p:u,-dY'I ... wal~cd fil "' h..'I, wllh IIH !(';1'H,'c! l,u lt'IIl'l' iHld ,.tql !cIlVlh, illld fLown l'O1l1 Ilfll HIlly IrulI~, IlIfl Vt' lIWllh, i'' ' l'flllljlillL'd Wi th Uo.,L' 01 a

~ "f)e;

p'lltl'lI

II(.~cd ~~"I (' II KAI'()

Hip KnccA nklc-Fool Orlho""

ph.I'.C'

Ity lI1f1vil1!! ,I h'vl'l ollthl.' 'Hie 01

.11i !.t ll'l! the

II('

1Jlf)(fl'

Ihill

.... llh l OlIlPIIII'/ LOllllolIL'lI "'-lilT 1'11111 ,1/1 .11 III1V.lllo1hh- (I I!' \ 1 HI) , I rlllll.1I pl.1I1C (l!ltlmIIlM), Ill' ilLllIl'vnl WIth pl" "tll' l',,11 h.1I ,h'IP~ d If) "I'ply lOl Il'l llVt" Iflll~' 101 ~l' lIlI \'a l ~1I1II 01 ~lllll \',11)"11111 Ihl' IIH'IIIal plllllllll lIt III ht III 'IClld Ilfo,o, lIl1.dl y III will'I III .Ippl}' 1"ll' ldll , dlll'lll'" hJl~fo. II Iill' "'-Iwe lilt' ~III1IWld ~ IIl' 11 I'" IIHIII d I IIVC,' til ,11I ,I v.I I ~'1 1I1I (1111[\.(11111 11,11', ",!Ill It I .11-.1I1"'l,IP J,(t'lJlI

\:lrUIII

"'II!, 1111111

10

11dl)

al... n \\l';.tr .t lill on 11ll' oPfw'-.lk' thr..' hClghl 01 thc l ilt ... hould l'ljll,1I thl' hl'l~ht \ll Ihl'

,\11<1 1110/1 of .1 pl'l\ Il 0.11111 .1IIt! IIII' 10111" l'~lll\l'r" lh('

",\to '0 ,III II" \I() ,

II'cillll'

dl' 1 ~'IIl'tlllI

Ilt hilt

~ It-d

dlllllild 1111' 1.111'1.11

IIiI' Joint IIH' 1"11,11 IIII' 1111111 I' .1IlIrl,d hll1 ~l d I' '\ I III Ihatl'Ul1 thl "- \I 0 III ,I pehlc band \lor I hlp

1If,'ll~ llt l' 1.11':1.11 IIpll 'it l III

•

Figure 31.31 Ilip joint with drop ring lock.

rotation. If the patient requires only contro l of hip rotalion. a si mpler alternat ive to the hip joint and pelvic band is a webbing ~ Irap. To reduce internal rotation, the sirap resembles a proslhcric Si lesian ba ndage. To reduce ex ternal rotation. the strap joins the lateral uprigh ts of the KAFOs and passes anteriorly at the leve l of the groin. If flex ion control is required, a drop ring lock is added to the hip join!. A two-position lock stabili zes the patient in hip extension for standing and walking, and at 90 of hip fl exion for silting.

Fi g u re 3 1.32 J-IK AFO with ,tirrup: sleel upright...: hinged an"le. "nee. and hip-joints: drop ring lock ... at the knee and hip and pelvic b'.IIld.

Pelvic Band An upholstered metal band (Fig. 31.32) will anchor the HKAFO to the trunk. The band is designed to lodge between the greater trochanter and the iliac cres t on eac h side. HKAFOs are not used very often because they are much more awkward to don than KAFOs, and, if the hip jOints are locked, they re~trict gail 10 the swing-to or swi ngthrough pattern. The pelvic band is likely 10 be uncoml"onaole when the wearer ~il\.

Trunk-Hip-Knee-Ankle-Foot Orthoses Pallent') who requIre more \labiJity than provided by IIKAH), may he filled wi th TIIKAFO, (Fig. :11.33), w hi ch Jncorp()r~ltc a IUl1lboc.,acral orthoc., l ~ 3l1m.: hcd In KAFO .... Tht.; pclvu.; band of the tftlllk. orlho",ic., ~ervc' a:-. the pclVI~ I?ilnd u,ed on IIK AI'Os. Because the ' III KAFO i, ve ry (1Iltlc ul1 10 don and i, hcavy and CUl11bcr<;oJ11c, it 1\ ,cldom worn

Fig ure 3 1.33 TII~I\FO \\ Ithl"lUI UpIH11 . . tcr~ .

Chapter 31 Orthotic, · th~ .!ltcr

1227

i ... d"ch'lr'" ' 1 t I1L' n:hablhlat lo ll pro ' • toll I I1011 gr:U!1. \!It'nl;111\ ('onho ... \.· ... pnn Idlllg ... tand ing ... t:l h dll),. \\ i l ll (If \\ IthOUI prm \"d011 Ill!' \\ alJ..lIlg. are ;l\OIilable for 111<1 1\ idu.

;Ih \\ Ith

C\JCllt

parapiL'gi;l.

Orthotic Options for Patie nts with Para plegia Orth()"c\ ;m:! OftCIl prescril"k:d for paticnts \\ ilh :-.pillu bifida. ,pul
Mass-Produced Orthoses Several appliances are readily available for ch ildren with ~p,"a binda or other di ... orders res ult ing in paraplegia. The ma ...... -produced ortho:-:.cs provide the you ngster wit h COI1.. iderable function and are less expe nsive and easier to don than mall) CU\tolll-lllade dev i cc~.

Standing Frame and Swivel Walker De",igned for children, the slalldingframe ( Fig. 31.34 ) COI1of a broad base, pos terior 110llart iculated upri ghts extending from a fla t base 10 a midtorso chest band. and a

"'I..,t~

Figure 31.35 Adult standing frame. (Counesy of A ltimntc Med ical, Inc. MOlton. M N 56270.)

pos terior thoraco lum bar band. Anterior leg bands contribute 10 sta bility. The child wears ordina ry shoes \... ithout any special att ac hmen ts. The shoes are strapped to the buse of the frame. A simi lar ort hosis is the ~ \I'i\'e/ n·a/ker. \\ hich is made in both chi ld and adu lt s i zes.~~·.n The major difference is the base. wh ich has two distal plates that rock. slightly 10 enable a swiveling gail. A variety of standing frames are also available for adults (Fig. 31.35)

Parapodium The parapodium (Fig. 3 1.36) differ':! from Ihe ~Iantling frallle b) virtue or joints that pennlt th e \\carer to ... It. The hase i~ nat. The sta bili7ing poinl~ on the ... tanding fr..nne. sv. iwl wal "-cr. and the parapodium :trc the ..,~mlC . One 'aslon 01 parapodiulll has a prm·i . . ion for "-ceplng the "-nee ... lod.ell , .. hill.: thc child unlocJ... ... the hips for leaning rllr\\~lrd 10 pid up objcct... from the 1100r. Tht~ Il\;t ....,·rr . .,oul·t·d ..,t'lI1dlllg fr:Ulle. \\ alJ...er. amI p,mtpodium art.' k ...... l·\lx·n .. l\ l' [han cu ... toll1-madc nrlho..,e .... They pauli! Ihe \\('.lrt.'r h'

... Iand \\ lIhout crutch ... uppor!. fn.·l·mg Ihl' h.lIld ... \oi.:allollal a ...·II' Hie .... \\ lilt 'lome (lltht· ... c

I~lr rJ..~ l'r

tIl'\ Il'\.......

tht.· l'hlld

l',lIIl11o\l' Imlll pbl'C 10 pl.tt'\..· tn flJI.I1Ul!! Illl' IIPlx'r hlr... \) III

Figure 31 .34 Stilndlllg ",HIll' (('oUllt''') III VaTlct) \ill,lgl·. U\'qrn 1 IIlIh PUKhKtllHl ('l'lIlrt' ~l.lIhmHlI~h [101011101. OIlLlnn. ( ·,IIl.ld,I.)

... hllt \H'lghl, r.HI"'lIlg Ihl~ lI,nllt' W rtX~ .Uld I\ll.tlt' •• ltl'r Iwtl'l~ 011 l'lll' l'd~t' Iht'n Iht.' ,'tht'l. hlt \\ .11k.l1lg hlnga lit ... t.IIIl"\· .... 'ht' \ OUII.!! ... I,'I U ......• ... l'llItl"ill'''' {lr ,t " •• Ih'r III thl'

-

Figure 31 .36 Parapodlulll. (Coline..,) ofVarielY Village. EIc:<"lro Lllnb ProdUC'IIOIl Cent re, Sca rborough lToronlo).

Figure 31 .37 Sianding balance wilh lumbar lonJow·, U'_II1J.! "1,1 bilizing boots ~el In approxlnwtel> 15 degree, of pl;lJll;.\rtlC.'~lon . (From Kent , up 304. with penni ... ..,ion.)

Onlano. Canada.)

..,\\ II1g-lo o r swing-Ihrough pallern. The appliances are

\\.om on the oUhide of trouser",. \\ hi c h school-age c hildren c\ enlually find cO' l11 ollcall ) objeclionable.

Cu,tom-Made Orthoses \\'hereas the:: mass-produced devices afford co nsi derable function to Ihelr users. man} indi\iduals see k m ore "rcarnhncd orlho,",. Cuslom-made AFOs. KAFOs. and THKAFO, proude ,ufficienl rigldilY. eilher by metal J(Hnh or onholu: alignmenl. 10 enab le ~elecled in dividual 10 ... tand. Ambulatton require.., cfutche~ or simi lar aid ... , lOgclher \\.llh \\ell-coordinated u~e of Ihe upper trun"'- and upper limb,. Some palienh 013) not realize Ihe c t III of thc rh~ 'Iell condilioning program reqUired to prrparc IhC'm for .tmhulatlOn. Con ... equenll). a trial penod I d\ I Jhk U IIlg ma, ... -produced . adju..,table. temporar> onhose

StabiliLing Moo" FO ck>1gne<1 lor .uluj~ ,,"11 parJple~la rnclud,- a pair 01 pi SUI. l.Jftho molded 10 c. ~nlCY.1n 10 the." palll.·rll· ... Ie~ ....md ~ I r I 7 the f{l<'1 pl.llC I angled JI aprr", "n3ld~

I

planurfl

1011

to

hlftlhc,"

1131

Jhe pi.., II.. I 11

I

;arer

e.en1<~r Lli gr.l\ II~ .1OIL··

WillI"

It'

ncnl I ",""od lOin Ihu Ill' '",cd 1" to

pal "I mamw n

standing ~(abi l ity by leantng backward. with the iliofemoral ligament\ resisting a backward fall. Cn.llchc\. a wi.ll~cr. 01 J pair of canes are needed for IwO- or four-poll1t gml Amhula ti on req uires shift ing the upper lorso diagonally fOf\\aal to al low one leg to swing ahead. The ortho\c., arc ea,) to dOll ;.1110 do not re:'iIfict sitl ing. The candidate I11U ~t 110l have i.ln) hlp or knee flex ion conlracture!'>.. and mu't be ahlc 10 extcnd the illp' and lumbar trun1- fu ll y.

Craig-Scott KAFOS A P"1r of Craig-Scc)({ KAHh (r-ig. 31 .1M) l11"y he P" \cnbed for aduil\ \\ollh paraplegia. Lach ortJ10..,11i Intiudes either a ~hoe reinforced \\ ilh tran,,"cr..,t: and IOl1gltUlllIlJI plate" and BiCAAL an"'-Ie joint\ .,etln .,Iight dorsI Ill"\ IIIf1 or a pla.,tic \olid ankle ">celion. a.., \\.cll a-.. a prcllhlaJ hand .•1 pa\\ I lock \\ ith bail rcka ...e. and a 'Ingle thigh halld. rill: (lr tho ...e ... enahle thc pallent to .... and \'>Ilh ">ulflllCI1I h~I(.~,v. Ird lean '0 a ... to prc\Cnl U1llo\\.anJ hipor trunk flC\lon J he all pattern u ... ually I' ..,\\Ing-tn or s\\lI1g·throu!.!h. \l.llh Ih did of l:ruh.:hc ... or a \\alkef Although the ortho\C du W I rc ... tnl:l hip molJon. the patIent'" IIh Ihofdu(: pmal nJun t.annot Ill' the tllP \oluntanh .md the f1.h, I ha. NJ 1lll'<.hJ.flI'IllWdld nglc Ie progre H In', d pcrf{lnn a 1"0- Of fOUf J lOt g I b\ e."n('ugh 10 Jilt.;.\ th k I l "n~ f T"F. nc

Chapter- .11 Or-Iholic,"

1229

•

,

Figure 31 .38 Craig-Scon KAFO.

Figure 31 .39 Reciprocating gni t on hos i... (Coll nesy of Fill aue r Companic<;. Inc. Chattanooga. TN 37406.)

The Walkabout orthosis cons ists of a pair of KAFOs v. Hh a hinge mechanism joining the med ial uprights of the

s itting. the wearer releases the cable(s) to enable the hips to flex.

1\\0 ortho\e~.

The mechanism permits hip nexion and

eXlen<sion. bu t restricts abduc tion. adduction. and rotalion.'\f, ~7 A pair of KAFOs with a mediaJ hip joint that is hnked to the ank le joints e nabl es palienlS to walk \.,.ith greater cadence and velocil y.J3

Reciprocating Gait Orthoses Both children and adult..., can be filled wilh a reciprocating (RCOI (Figs. 31.39 and 31.40). a THKAFO In v.hich the hip..., are joined by o ne or two me tal cab les or rod\.'~'----45 The knee..., are ... tabilil.cd with knee locks. offset knee joint...,. or pretibia l hands. and the feel a rc encased in \oild ankle ortho!o.c .... To walk. the wea rer u ... e ....1 four-",age Pn>ccdure: (I) "hin we igh t to th e ri g ht leg, (2) lUck !he PClvi" h) extending the upper thorax. (3) press 011 the crutches. and (4) allow the left leg to "w in g through. The procedure j" rever"ed for the next stCp. The ,,(ce l cab lc('I) Or rO(h prevent Inadvertent hip ncxion on the <,upportlllg leg. ReCiprocal lour- or two-point gait i<.; ... wh le, hl"ca~.. c one foot alway" on the 1100r. hut the pace ,,10\\ I'or

gUlf Ortl/oS;5

I"

I"

Externally Powered Orthoses Orthoses may be co mbined with pneumatic foOl CO/1rro/ J6 ,47 or /unuiol1al elecrrical stimularioll (FES ) to enable se lec tcd pa tie nt .. [0 achieve household. or in rare c.lse ... comm unit) ambulation. Jll This technique ill\ohe ... Ihe usc of electri cal c urrent to produce Illu"cular contracli on .... Typically, "limulation is prO\'i ded to the quadricep ... and glu teus maX lillU S. If the anJ.. l c~ arc nOI "upp0rled b) A FOs, Ihcn the sys tem also include ... ..,urface eleclrode" over the peroneal nerve" 10 lIlili
wr)

11I!:!h.~<J·~(l

12 III

A

0 (10 l (l'l lfltOt ' IIIlI ~' )',11 1 1111 1111 '1 1" . J !l1 '1 ,>",11'1 11 II llllu k

Fi gure 31.40 'I II\.' AI«JU

I

jlnnllll.llh

I l w ~ ,rln' W llldl l'X h : l ld 11l l' )..l l l'I'" ,lIld j' I I "II I V J Il\~ " ,lI l' !"I I)',I}'I'" 01 1 " t ,lIldIII V (I "Wi!-

lill i '

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Sh"'IWI RII~ l ll· .. 1e1 Kl' llI MI '.2 I I JI ; 11111 11,,1 Kltl~',hll ' l ) h'lIl/ l lIlI.1i I r ~'H I ,> Irmlllll '

Trunk Orthol.cl.

11 ).'1d hill

1 1l1I1~ O llhO \l'\ IIl ily he tI \l' d II I a..,.,O(' 1:I111I1I W llllluWl' 1 1111111

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Imlll/al rl'V11I1I wllir 0/ W IIIIIIUI 1I1{11itlll llllJlrll1 ;tilt! () J lIw y «(IIIII'W')S tilt' ;thdllII WJI to IIlIpIOVl'

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rlHuru ~t141 ~,lIrll Itlllll" •. Ill.d "~I I' .. It",,! 1.1 tit poly II\!'IJ ~lrlllt'''11 \,..j. I" I" '". If "'lir e If "I f .Hllpll, ,.hlIL II /4111'01,111011 lill. 411' MI t4J.~111 I

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aJ

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rdln. m that In lOU abd 'mmal n PO'lC lpr pmal :nu'lul.J!ufl. d n tht" lumbar lien end'lf.ll n rc:du I on 01 J.ixlPl1llnal and 'TIU l ular JI..L!\ It.\' ~ Iher<Jpt"uth, . J(ln!!-tC'ml J l IT e-t lan promote mU"l"ular atrop';, and a \\C'H a p )l..hologlCaJ dependenlt~ ~n the'

Ill..

Rigid Orthoses umbc denl and Ihorac:olumbo,acra! orth Qlo,~'" in uoe J lor,el or a fabnc abdominal front 10 compTe ...., the .It'tJumen. Rigid OI1ho,~ ... an: dl"'lingui'hed b) the pre ...ence I honzontat a v. ell a . . '~rtlcal. rigid pla\tic or metal com. ponent~ \f otlon limitation 1\ accompli\hed b~ a \erie ... of three-pomt pre ...... un: s~ It:m .... in v.hich force In one direction IS cQunh:ractt!d b) I\\.O force ... In the oppo,ite direction . \i( ,

I.

Figure 31.43

Pol~eth)

lene lumh(h.lcral

n~\lon ·~ \teI1\IOn­

lateral control t1nho'I'. (Cou ne,~ of B{,,,on Br.ll·c intenl.ltlOIl.1l. Inc. ..\\011. '1A O:!~:!2.)

Lumbmacral Flexion, Extension, Lateral Control Orthoses -\ l~ pieal

example of a rigid trunk onho<.,i ... i ... the

11117/·

hl)!Jor ral jlnlfm. extenHOJ1. lateral comrol (LS F EL) ortho· IS (Fig" 1.42). al\o knov.n a ... a Kl1if{ht spinal orrho.Hs.

TIlls applIance Include, a pelViC band. which ,hould pro\Ide finn anchorage m'er the mid<.,ection of the buttock .... and a thoracic band. Intended to lie horizontally over the IQv.er thorax without Impinging on the c;,cap ulac. Th e band." v.hJ(.: h may be foam-Imed rigid pla ... tic or leather-uphol ... tercd metal. are joined by a pair of pO\lerior upright<.,. v.hlch lie on either "'Ide or the vertebral ... pines. and a pairof

•

'11 I

~

( I[

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,-

h)/

•

f

•

Figura 31 .42 lUlriho

"'"

,I'

r,d III

;';1011 OIt'TI

1"11 I.lln,,1 (0 1111111

lateral upright ... placed at the lateral midline of the tor... o. :\ cor ...et or i.lbdommal front complete ... the LS FEL onhlhl" The ortho~i ... reslrain!) nc\ion h} a thrcc-polllt ') 'tl'rn ("011..,i<;,ling of po ... tcriorly directed force from the top ..111(.1 hot 10111 or thc abdomi nal front or cor.,e l and an anterior!) dlrecled forc~ from the midportion the pm.tenor uprighls. EXlcn..,ion is con i rolled by po:o.teriorly dlrecled Inrcl' fmrn the l11id..,cClion of the Hbdol11l1lal front or COI" cl and i.UlIc.:ri orly lllrccted force from the thoracic ..\Ill! pcl\ it' ham!.... Thl' lateral uprights rc",1 laler.." IkxlOn. ~~ Other ngld IUIIl bo... acral (LS) orllio'I' arc l11~tdc en tirel y 01 Pol)l'lh)ll'ne wllh removable replacc'lblc liner... (Fig. ,1 I A.1), A pL.lstu.: IUl11bosncml Jad,l'l rC"lricls mollOIl III ;til tllI\.'\.' lion .... An alternate ver\1OIl comb1l1 11lg Ihl' -"Irhoet \\ IIh till" L S I FL ha ... been ... ho\\l11 to be dfecII\l" ..II cOlltwlllllg 'l"lt.lIIti) loli ... thc\l .... ~l rhe efficacy of orthotu..• IlItl'rH'nlton 10 rl' dlH':C ·1 ~~ or prevent 10\1..' ba<.,'ho paI1l1\.'IlW III '" l'(l1l1rO\ l'I ..... 11 \f,

or

Thoracoluillbosacral Flexion , ('ontrol Ortho,c.,

F"\.tc..~n,ion

AI",,, c:llled a 10\'/01 bra(T, Ihe tIJowf"fl/lIIlI"OH'f tell /If \ IOfl, (' \fe'I/IIOI/ c/il/fml ( II S II ) 01111\''''1' l'OI1'I'I' pi .1

pelvu.: balld. pO\ tl' nOI upnfhh tl..' llIlIIlallll!! .11 11lld'l'.ljltll.lI kVl'l . ill! <.Ihdolll111,11 110111 1111..'(11'1..' 1. ,lI1d .1\111.11\ '11.11" ,II tal"iu:d IO.Ulllltl..·'\l"ilpul;1I hand I hi ... (lIthll'I' Inlu~'l" Ik\ lOll hy a Il1Il'l' pOl1l1 ... )",11.."111 l'OIl'I ... tll1~ III 1'0''''11011\ til Il'\ ted IUII."l' I1011l111l' <1\111.11) ,tl.'I" .lIld Ih~' ],tllIlIlIIl,llhl' .lhclt Hll lllal InUII ell (,'(11 wi, .Ind ,mil" nIl I, IIII{'~ Il'd [lllll 1111111 till' IIIHipIHIU)1I 01 thl" P,"h"'ItH IIPII ~h t~ 1\1\'11 "'11 Il· ... "I.Ilil"l· I " plmHh-d h\ !""it'lIl llh dlltltl"tI hlll\: IJPI1I till' 11IHI 'l'l IIOII III thl' .lbd,IIl1II1.1 111111I1 Illl(lI CI .IIHI IIl1lll lilly dlll· . . lt·, ' IllI ll' 110111 thl' 1\\'1\1(. .Illtl 11I1l'1 Ipullr h11l1d ... AddlllOlI III 1.lIl'I.11 IIpllghl (01lH' 11 Ih 11(111\\ I

I

1:

Figure 31.44 ThorJ.('olumbo"';i,,'ral tle\lon-e,ten'loll-I:.ueral . . trol ortllo... i,

TL FEL orthosi~ Fig. 31.+-l). Although TL 0.., reduce ... egment3.1 :md gro~", spinal mm emenl~. the amount of rno\ emenl reduction yaries greatly from one person to aflotber.h A pl~lic mOf3C'olumbo.;,acr.1l jacket limits trunk motion in the frontal. 'agittal. and tran~\ef'\e plane~. and provide:-- ma.\.imum ..uppon.

10

:1

Figure 31 .46 PhilJdelphi3 collar. ! Coune . . ~ of Cunp Healthc:ue Corporation. Jad,on. ~1I4Q20. .U

I

has mandibular and occipital e\[en"ion~ and .1 rigid aml!rior ... lIUt: it '" ... ometimes u::.ed for upper cenicaJ injurie'i.t'(l For moderate control. a jour-po.H orthosis (Fig. 31.·.., i IS used. L'sually it h3!)

l\\ 0

aillerior adju ... table

Cenical Orthoses Cen"ical onho...es are c1a.-.~ified according to deSIgn char3clensue," ~linimal mouon control i ... provided by collars I FI£"_ 31 A5 that encircle the neck \\ ith fabric. re ... i1ient 10";;'. or rigId pla.
Figure 31 .45 lOiofl loam robber .. (thar ( urt.:,) (11 C~mr HealthtMt' ( rporallon b("son \fI4Y~(U

Figure 31 .47 l 'our'j'Xl,t cer.IC.lillrtho'h

pO~b

jommg a

<':haptcr 31 OrthOliu

123.1

Figure 31.49 An terior view of the p lastic and metal Figure 31 .48 Ilalo-vc"l orlh o~I<". (Fillaucr Companie~, Inc. Ch. l.Ilanooga. TN 37406.)

Milwaukee orthosis,

. .Iema l plate to a mandibu lar plate and two pOMerior upright . . con nect in g a thorac ic p lale 10 an occipital plate. The ..,Iemal plate I '" ~ trappcd 10 the thoracic pl a te and the occ ipItal plate I ~ \ Intpped 10 the mandibular plate. 61 -61 MaxImum ortho ti c co ntrol of the neck may be ac hieved enher with a Mil1en'a or a halo orthosis6-\.--66 (Fig. 3 1.48). The MlIlcrva orthosis is a noninvas ive app liance that has a ngid plastic po\tenor section extendi ng from the head 10 the midtrunk: the superio r portion is held in place by a forehead band. The halo o rth os is has a ci rcu lar band of melal that IS fixed to the sk ull by four li ny screws. Uprights connect the halo to a th oracic orthosis.

not cx tc nd as high as the Milwaukee orthosis; its fou ndati on is a mass- produced plastic module that the orthotist alte rs 10 meel lhe needs of the individua l pati ent. The Wilmington orthosis'4 is another option; it is a c ustom-made thoracol um bosacral j ac ket intended to guide the trunk 10

fo rces. The 8 0sIOI/ orthosis"-73 (Fig. 3 1.50) usuall y does

Scoliosis Orthoses Children and adolesccnts wi th kyphoses or thoracic, thoraco lumb:'lr, or lumbar scolio\es may be filled with a TLSO that applies forces to realign thc vertcbntl co lum n and thoraclC; t:age. Although substantial improvement is ev ide nt \l,hcn Ihe ortho"' ls i... worn. long- term follow lip indi cates that the major a<.:hlcvCl11cn t i-.: that the ort hosi~ prevents thee llrvc f rom lI1ucasmg . beyon d liS ong ·lllf.l 1contour. !1(1'} The M,IU'lIl1/...('l' orfllO,\I\7fl, I (Fig. 1/.49), the o luest 01 C~nlelllp()rary ... co llo\I S ortho\c.." is still prescribed. II can" 'I ... t\ oj a Irame <.:om po ...e u of i.t pelv ic girdle. two po..,tcrior Upnght .... an i.lIl tcrior up, ighl , and a superior ring Ih al I ic s on the upper l:hc ... t and GtIl he 11Iddc.!1l hy 1110'.1 dOlhlllg. Vari ou ... pad ... an! 'U',tpped to tl1\: flame [0 apply cO llcc.:llw

Ir~lIghlC'r ilhgnmcllt rhe,,"" lilld 1111"'1 nlhl" ",:olio,l, III tho C, .1rl' 1110'1 l~fkl'II\l' \111 p.ltll·I1" \\ hn hil\l' 1I11l11;lIua' pllll" and Ilhltlt'l.llt' \t'!ll' hl.lll'ur\l·" II1lhl' Illldlhoracll' 01 Ill(lr~ IOf,,'II()r p(llllllih III thl' tlun" ·\\thou gh paTI 111111.' \\eJnng I' lx'ltl'T 1\1Ia.lh:d h~ adok ... l:l'llh. thl' t:la"l"lic plO-

hX·(ll. \\ 1111.. h requlTt." thl' ) oung,tL'r to \\ car Iht: ortho"i ... ,"ugh ~, h\)ur, c.ldl da) I' a ... ,ot·Il.lled \\ IIh more L.I\'orahlc

rt',ul" -\nolha ~tpproach to "l'olio,i . . lTIal1agL' ll1cnt rC4uire" the p.llll'm w \\Caf an onho ....... ani) at night" hen the efJ"cct~ t,)1 gra\ it) are Jl1lnimi/cd. Both the CllOrle.\lon hendlng Im.}( (' -... ~Uld th(' Pro\"idt'lIU' hruce"'o provide overcorreclion of the ,pinal cu rn!.

Orthotic Maintenance To obtain the best .!oervice from

IIIl'I;11 aI\.' l'\pll'l'tI.

IlI'W

It:.uht:rv.-nrk I... rCtjulrcd Lealher

'1Iap'" l'\'l'lllUally hl'l;t)llll' hrullt: and may hreak, A 10....... of

Ik"hility indlcctl e ... Ihat it I. . limc lore Ihey hrei.!"

10

replace thl' . . Ir"['>\. be-

Uprights In i.I pla ... ti c tlnd metal KAFO ror tI ch ild, Ihe metal upnght i... ~crcwcd or ri ve ted to the pla . . lic ... hell. The ()nho~I'" can be le ngthe ned by rClllovi ng the fa . . tener ... and in ... ening them in new hol es drill ed farther up on the cal f shell and fanher down on the thi gh , hell. In a metal and leather AFO Of KAFO for a child, the uprights are overlapped and secured with sc rews. The sc rews tend to work loose. reducing the "ability of the o l1ho,i,. This problem should be reo ported to the orthoti "ll. The orthosb is lengthened by removing all sc rews, setting the upright ... at thc appropriate distance. and reinse rting the <;crews.

orthose~.

the patient should ob,ene basic routine inc;pection and care procedures. Written in!:.lTUctions help reinforce the recommendations of the onhotist and therapist.

Shoes Whether or not the shoe is attached directly 10 the ortho.!ois. II is imponant that footwear be kept in good condition , ",1m replacement of the sole and heel as .!ooon as moderate wear is evident. The replacements should include whatever \\edges. bars. or elevations were originally pre.!ocribed. The patient who tends to strike on the toe may need metal toe plates to preserve the sole. Shoes that are outgrown or di!:.toned will not afford the wearer optimal function from the orthosis. if a stirrup is attached to th e shoe, the patient should In!:.pect the rivets to make certain that none have separated; if they have, the shoe s hould be returned to the orthotist for repair_ Clean hose without holes or repairs ~ho uld be worn. III addition. long hosiery or coli on leggings shield the leg from pre"ure at the edges of the brace uprights. bands. and shells.

Shells, Bands, and Straps PI",,,c bands and shell s should be wiped with a damp cloth to r~move any surface ~o jl. It i~ inad visa ble to try to ha ~ t e n

drying by u~ing a hair dryer or other heat ~(}urce that mi ght ",often the pla ~tic. The patient should check the pla')tic pcnodlcally for any cf<.Icking; If allY is noted , th e orth o~ I '" sho uld be brought 10 th e ort hollst for IIllmetiiatc rc pail Prcss ure o,trap" eve ntuall y bccomc infillrated with lint. whICh II1tcrfcre . . with the hook and loop c:I0~ lIlg ;u.:IIOI1; Ihe slrap" ~hould be In"pc(;ted 10 dctcrlllll1c when they "I houl tl be replaced. Lea the r band . . rC411lrc penodlC dCillllng and (;JIl he v..a . . hcd With mJld ... i.uJdl c ... oap. fllh L' ori pi nalll'alhl'r dclcnorat c~ to tIll' pOlIll tlwt r)(IIII()J1 .... 01 thl' lIlHlL'llylllg

Joints and Locks Metal components should be kept a",ay from ~and_ liquids, and other foreign substances. If the joints do not ani culate smoothl y or become noisy or if the locks do not engage properl y. then cleaning and lu brication may remedy the problem. Othe rwi se. professional attention is req uired.

Physical Therapy Management PhY.!oical therapists participate in manage ment of the wearer of an ortho.!ob (I) prior to onhotic prescription, (2) at orthotic prescription . (3) upon delivery of th e orthosis. and (4) during training to faci litate proper u...e and care of the onhosi s_ In the ideal situation. thc therapis t l.!o a member of an orthotic clinic tea m. working directl y with the physician and orthotist to develop the onhotic prescription and exami ne thc patient and onhosi<.; before and after traming. The physical Iherapist i... also re ... ponsible for wHning the patie nt. Whether or nOI th e hospital or rehabilitation center has a clinic team. the phy~ical th r.: rapi ... 1 i't ex pected to accompli sh the following:

Preorthotic Examination Contribute 10 th e 011hotlc prL'''Icription (ana IY/!.! potl'lllJal of orthotic c()l1lpon cJll~ to n:l1led iatc It1lpaIfl11(,1l1. fUlll'lIonal lunitallol1, or di ... abi lit y).
Chapter J 1 Orthotic.

[hL'

\!.lll:hlllg the patielll\' hlom cdl:11 Hl:;,1i ro.!ljuirclllclll'" 10 'lrrropnato.! ortho"'I'" rcljulrl· ... carelul c\:lll1l11at ion.

Joint Mobilil) A thorough gOl1lomctnc C\tU11I11a lion. inc ludl11g bO lh ac-

pa ... ..;l\o.! range of motion. i... a prerc4ui~ it e to o rthoUC prc ... criptlon. If the pallent ha<.;;'1 fixed foot defoll11 it y. t'ltht:r the '1hoc "ill have to be modi tied to accommodate [ht' fool. or all in ... ert \\ III have to be fabricated. In cuher in~tanco.!. the goal b to achie\"t! comfortable contact of the entire plantar ... urfacc of the foot on the inner so le of the ~hoe. Knee tle"ion contracture neces~itate~ pre:':.c ri pti on or acC0l1l111odatiYe joinb. because the reg ular drop ri no0 and pa\\ I loeb can be used on ly wi th a knee that ca n be brought to the fully extended position. Hi p flexion cont raclUre preclude~ the prescription of orthoses that depend on aJignmelll for stability. such a<.; the offset knee joi nt. ~tabi­ lizing boot~. or Craig-Scott KAFOs. 11\(' ;UlJ

~

Limb Length The therapist should ascertain w he the r there is a discrepa ncy in leg length. If the patient can stand. o ne can c hec k the pel\'is to determ ine if it is level. For the recumbem individual. one can measure each lower ex tremi ty (LE) from the ante rior superior iliac spine to the mediaI 111alleolu~. With a difrerence of more than III in. (I cm) there shou ld be compensa ti on by a shoe elevation. For the pa ti ent w ith weakness in one limb. a Ill-in. (I-cm) li ft on the contralateral shoe wi ll ai d clearance of the involved LE duri ng swin g phase.

Muscle Function The manual muscle test (MMT) shou ld be augmented by an examination of functional activities to detennine what ~u b­ !:.titution~ the patient is ab le to make 10 accompli~h slanding and walking. Although the muscle tes l may revea l marked weakness. if the patien t can manage wi lhou t an orthosis, it i!:. unlikely tha t it will be accepted. Fo r exam ple. the pe rson "'nh dor~inexor weakness who can ambulate by exaggerating hlp nexion during swing phase may not agree to an AFO with a posterior stop. An important consideration in exami nallon of muscle function is that tradit ional MMTs may be inappropriate in the presence of marked spasticity. In ... uch li1'\tances. functiona l le~ IS of molOr performance are e ... <:.ential.

Sensation The cli ni cian \ hould record Ihe extent or any sensory 10 ....... Intimatel) fitted pla~tlc ortho... es are sati\factory for individuals with se ll ')ory lo"s If the cdgt:s of the orthosl<.; arc !!.moOlh and the orthosi<.; docs not pinch the pa tient's IJc,h Proprioceptive loss may indicate the need for orthOlic <.;ta bill/aunn. \ouch ,,\ a solid ank lc A FO 10 control a Charcot nturopathlc anklc. Paticnt ...... hou ld be taught to rt:gularly in\!>Cct the <.;kll1 (Illcludlllg prc<.;encc of vo lume cl1.lIIgl· ... ) and m"ltruc.;lcd to bnng any <.:h.mge<.; to the <JltenllOI\ oj thl' Ph)~qcalthcrJpi"l.

12.15

Upper Limbs Although the patient 1"1 being con<';ldcrcd 1.1'\ a candidate for LE or trunk ortho<.;e<.;. the therapi ... t mu\1 determine the mo· bility and Illu ...clc power or Ihe upper cxtrcm illC\ (lJEs). Sign ilica nt weakne<.;s, (,tiffne ...... , or dcform ll Y will I11terferc wi th donning the o rth o ... i .... Sub~ti t ul l on of pre~surc closu re, fo r leather buckle.., may ..,ufficc. If the individua l can not ambulate wit hout canes or crutches, the therapi't ,hould de termine whether ... tandard aid<.; will be ~atisfaclory or vvhe th e r mod ificat ion of the hand piece ... i~ requ ired. If the uppe r lim b.., arc very weak. the pa tien t will not be able to use the LE ort hoses for walking. A lternate ')tan d ing arra nge me nt ... lTI ay be prefe rab le, such a~ the use of a ",tandin g frame. standing tab le, o r stand in g whee lc hai r to pro-

v ide we ight bea ring stress.

Psychological Status Rea li '5 ti c o rthoti c presc riptio n requires asce rta ining that the patient is wi lling to wear the ortho tic dev ice. The pat ien t wit h a rece nt spina l co rd inj ury may still de ny the perm ane nce of paral ysis and thu s be ag ain st wearing orthoses that a re v isib le reminders o f di sabil ity. The adol escent w ith sp in a b ifi da m ay pre fe r to s it unbraced in a w heelch a ir rathe r tha n struggle w ith do nn ing o rthoses a nd wa lki ng s low ly. in a lTIanne r very di ffe re nt from the ind ivid ual\ peers. The pati e nt w ith spinal cord inju ry mus t be prc pared to work vigo rou s ly to inc rease uppe r limb a nd trunk stre ng th a nd aerobic capac ity. The pe rson wh o has ~ u,!, ­ ra ined a cerebral vascu lar acc ide nt resulting in severe percep tual de fi c its may not be abl e 10 wa lk , even w ith o rthOlic ass istance. because the e nvironme nt now see m s unfam iliar. A n orthos is fo r prevel1!io n of defornlit y may be prescribed. rather tha n one that is designed to aid ga il. T he the rapist shou ld detenn ine the e xte nt 10 \\-h ich Ihe patient is likely to comp ly w ith in struc tions pe rta ining to o rlho tic use and care . For exam p le . if it is do ub lfu l thai the individual w ill wear a ppropriate shoes w ilh a n insert orthos is, then the presc ript ion shou ld s pec ify stirrup att achment 10 suitab le shoes.

Orthotic Prescription Lower-l imb orthoses benefit ind i\i dual ... \\ Ilh a \\ide \anel~ of muscu loskeleta l and neuro l og l c~\1 disorder.... The partH.·ular d iagno..,is is less im portant 111 formulating Ihe pre"'<"ription than consideration of the pat ienl \, I1np~lImlen" and funclional limi lation<.;. Progno ... i\ a l...o IIltluence ... pre"'I.Tlplion. The pcr...on \\ ho i... likC!ly to Teet.>' a pamal or full fUJIl"lion ... hould have an ortho,,"1 that can lx' adju ... ted h.l .1l'\.'()111mod ate the changlllg ... taw.... \n indl\ IdU'li "lth rt.·l·l'lH hemiplegia. for example. 111a~ l'"hihit 1l1~lrh'd "'r;l . . tll·It~. 111· (IlC
rtU.lenai!oo ~plH ~Im\lps, tPI e\,llllp!...- 11l,1~ nol Ix' ,IPP101'1I.lIl' ~ au,,:' the, Lan spnnl! k~l'>t' h()1ll till' n:l'l'pt.llll' 011 Ihl' shoe If l'\ll' .. ,\(' medl.11 1.IIl'r.11 .. In: .... I" ..tpplted. Ihl'P,1 lIcnl\ \. nt:c..'m \\ Hh .lrrll.'.tr.Ult.:C: I'" ..tnolha pral"lll.:al t.:on .. ld crallon; 11 m,l~ dh:t.Uc..' the..' ()I it ... ht~ lI1\Crt ..olhal rc" ...onaoh la..,hh\U3hk .. h(\t" .. 1Il.t\ lx- \I, om. Silniiarl). pla .. tit: ... hell ... ar~ r ... , hl.d~) than metal uprighl ... and calf bilnd~. and do not pre '('01 a 'hll1~ metal ..tppearanct!. Although m()~t pt:oplc \\J111 the ortht.hl'" to be a, Im:on'picuou ... a ... po... ",lble. "'om!.! lhllJren and adult ... Opt for brighl color~, which can be 3dlle\cJ \\ 1111 ,ariou ... pla ... lic ....

Ankle-Foot Orthoses The pnm"" candid",", ror AFOs are those with penpheral neuropath). ",peclall) peroneal lesions. and hemiplegia. Tho'e "ith rool drag can be fitted with an AFO with a posterior "'lOp: lhi~ de~ign. however. tends to cause the knee to fle\ e.\ce~!o>i"el) in early Siance \\ hen coni rolled plantarfle.\ion i; normally achie,ed. In the absence or plantarflexion. the patient may flex the knee to effect a root-flat posl£ion. The alternative is a resilient shoe heel. or an AFO \Iolth a plastic po~lerior leaf spring or a metal dorsiflexion spnng as;i't. both or which permit controlled plantarflexion earl) in stance to prevem knee stress. Orthotic management of a patient with hemiplegia depends on the extent or spas ticity and paralysis. Ir the motor loss is confined to poor dorsiflexion. the posterior leaf spring AFO ;uffices. An even simpler and less expe n; ive option is a 1/2 in. (I cm) lift on the heel and sole or the contralateral shoe to provide clearance for the weak limb during swing ph.,e. Those with medial-lateral and sagittal plane mstability require an AFO with limited-motion ankle joims or a plaMic ~piral AFO. With pain or ~evere 111stability. a solid ankle AFO is required. In the presence of severe spasticity. a spring asMst for joint motion is contraindicated because the spring action may Ic.en:e to 111crea~ spastlCIlY.

Knee-Ankle-Foot and Other Lower-Limb Orthoses A KAFO may be used to compensate ror paraly,,; of the entire LE. The physical therap"t ;hould allow the patient the U~ a temporary orthosis 111 order to proceed more confidently with prescription of an expensive, custom-made onhO\is. Several versions of temporary ortho~e~ are manuractured and prove exceedingly u,erul In demon'tratlng ... hether the patient" likely to benefit rrom orthotic knee control. SlablilllOg AH),. (raig·Scott KAFO-. HKAFCh the reclprcx:aung galt ortho ... ls. are ~()me option, for patit!nts ... ,th IYdraplegla. f-or the child, the onhutic program ,hould !'lart With a iiimpic !!otandll1g frmnc eJnd progress to the pampodIUm before mvoh'lng the child III the greater cxpcn'tc and donning dilflt:ulty of fonn-flltJJ1g braCing Chlldrcn and Ddult f03) Oc1!10 Ydth a lW.I .. cl 'Walker or lt~hty.clght modular frames

'I runk OrtllO'C' t\ c.:or"ct l11a} he adcyuatc 10 lIluca\e IIltra-atxlominal pre~­ surc ,lIld therco) may rcducc the dl\(;omfort of loy. back palll, \Vhere greater mOil on re ... trtction 1'1. Indicated. !oouc.:h as for Ihe indlvidueJl with lrunk paral}SIIi, the LS f-EL. TLS I-E. or l·LS FEL ortho ... i ... \l,.ill proVide suh... tantlal upport. Pla ... tic lumho~acral or thoracolumbo,acral Jac.:ket\ offer maXJIllUm ..,upport. Cervical ortho~e..,. \l,.hethcr collars or IX"t dcvice .... re..,(rain motion and rt!mind the wearer not to move the head in an abrupt manncr. Collar!') al ... o retain bod) heat. which may prove therapeutic. For maximum neck control, a Minerva or halo onho..,i ... i ... reyuired. An array of ortho~e~ i~ available for management of patienh with scoljosi~. The~e include the Milwaukee orthosis. which is the most extensive. a... well a!') the 801;,Ion and Wilmington orthoses. which do not tenninate qUlle ~o high on the trunk. The ProVidence and Charle~lOn brace ... are de... igned for nighttime use only.

Orthotic Examination Examination is an essential element of ortholic management. The physical therapist ;hould be certain that the or(ho~l~ fit ... and functions properl) before attempung to tram the patient to use it. Analysis rna} be conducted under the aegis of a [onnal orthotic clinic team. If so. when the or· thosis is delivered. the team should determine the adequac) of the onhosis a~ pass, provisional pa~",. or fatl. Pass IIldicates that the orthosis is altogether sati ... factory and the pa· lIent is ready for training. Prm·jsional pass mean.., Ihat mi· nor fault~ exist. generally having to do with the co ... metic finishing or the appliance: the patient can wear the orthosis in the training program without harmful errect. Failure Signifies that the orthosis h~ a major defect that \l,ould interfere with training: for example, ",hoc", that are too light for the patient. The problem mu't be re,ol,ed before training can beg,". If the ortho~ilc. is not pre~crtbed by a climc leam. then the physical therapist should u ...e the examInalton procedure to as~ure that the ortho ... is meets the patient'" need .. , Final examination is performed at the conclu~ion of trallling to judge the fit and runction of the orthoSl' and the patient \ ~kilJ in u~ing It.

Lower-Limb Orthotic Static lo.xamination Examination tnvol\'e~ .Hcllle e.tamlllllllOfI of the orthn ... i .. on the patient \I, hlle .",tanding and ..,Hung. a ... \l,ell a.., c\al1lll1a· lIOn of the dC\'Ice off the individual. DyncJf1l1c ('wmlllllllO fl refer, 10 analy ... i\ of Ihe wearer"" gall. The orthm,)\ i . . m..,pecled a ... tl1(! \\l~arcr ... t..toth and ... It .... The pallent ... ..,klll and the ton~truc:tlOn of the (lnho" ... are checked wtlh Iht! ortho,)I" of! the pallelll lhc orthO\l' ... hould he: (:omparcd \I, Ith tht: prl'''l'nptl(Ul. I)cparturcs from the onglllal "'rec.:ilicalloll't I11U,t tlC apprmcd 0) thc mdl \ ".luaU.." \I, hi) dc\ eloped the prc ..c.:rlpllon . Inc patlcnt .. hould !\otand m parallel har~. or othcr secure CI1\ Ironl11ent, and ... hould altt:l11pt to bear cyuai VtCI!!ht (Ill

Lhapler.31 Orthotiu

both feel. TIle shoe ~hould lit "t ... houlc.J InspeCI the patient\; ... klllto delect any Irrit:lIion~ allribul;!hlc 10 Ihl: ortho . . i.... Onc should move thl' jOll1h ... 10\\ I) to check f:lIlgl' of molton. n"IC"n~ rekr ... to IIltlllg of the di'li.ll porI ion of thejOlIll 111 relution 10 the pro\inml I11cmher:-.o " ... ILl HlIcrfl'ft' .... 1Ih movement. II' the mClh;ti and iah..'ral ,top:-. do not (nll t,let their rc ... p~t:tlvc ... lOp:-' at lhc ... ~lInl..' tllllC. Ihl' ,top th,lt CUIlIi.Kh Ilr ... 1 \\-liI erode r~lpidl) dnd Ill;!) l'ontrihutl..' to tY.I""II1~ 01 thc ortho,I ....

Dyn31nic Examination rhl! gail p,lttern I..'\lllhllcd h~ thl' IX" ... OIl \\ Illl \\1..',11"... ,III 01 thml ... rcllet:h htHh thl' lontnhUlll)l\ 01 Ihl..' \\t.'.lIl'r',. !!l'nn,ll

Ill7

hCHith ... WIll ... and tht.: orthotK mOtion control and a,si-.tam. r..: "bhlc 31 I relate ... orthotic ilnd analOmlca.l cau\.C\ of the mm.t comOlonl} ob~ened gall de\latlon ... Sligilta.l plane de\la· lIon~ are easier to judge than arc Iho ...c lhllt (x:cur In th~ frontal or tran.."Cf\C plane. During early "'Iance, the plitlent ma} e.l(hlbll fOOl ... Iap. ~triking \\ iLh toe~ fir,!. or flat-foot contact. indlcatmg III abili() 10 re,(rain plantarfle\ion or failure of the onho..,i~ to ~upport t.he fOOl and anlsle. Excessivc mcdial or Iliteral con~ tact may indicate (hat the ortho~is doe ... nOI track the \l.a) the patient's limb does. Knee hyperexlension or exces ... i\e fle\ion indicates that the onhosis is not appl) ing adequale control. A pm.terior ,top on the AFO should pre\ent the la;\ knee from hyperextending. If the patient \\e~ a KAFO and has knee hypere\tension. the SlOpS in t.he Isnee joint are sel improperly or ha\e eroded. or the calf and Ihigh shel" or bands are 100 deep. Anterior and posterior trunk bending are seen at earl) stance \\ hen Ihe patient anempt ... to control a weak knee or hip. If the quadriceps are weak. the patient \\ ill bend fon\·ard. The person \\ ho fears that the knee ma) collapse mal benefil from an AFO \\ ith a solid ankle and an anlerior band. or a KAFO with a knee lock. If the gluteus maximus is weak. the indi\'idual is apt 10 lean ba kward. Lordosis indicates hip flexion contracture or a KAFO Ihal does nO! fil properl). Lateral trunk bending In earl) stance phase ma~ result from hip abductor \\eakness or hip instabilit): however. uncompensated shortness of the limb \\ ill also gi\ e rise to this problem, U!I will a medial upright on J KAFO Ihat is too high. or an abducted peh'ic joint on an HK.AFO. A wide walking base may be the patient's compensation for a medial upright or shell that impinges into the perineum. The client may have difficult~ during late ::-.Iance either delaying \\ eight tran:sfer or being unable to r.rn.n,fer \\ eight. o\er the affected foot. The problem can be mitigmed with un anterior ~top and a rock.er b~lf_ One should be certain thJt the trim lines of Ihe ... olid ank.le .-\FO or the SlOp' on the !'lUmp funclion properl). During s\\ iog phase. the patient must be able 10 cleM the floor \\ ith Ihe braced leg. HIp hik.ing oc~un.. w hen the hip ne\or~ are \\ eal.... ;\~ \\ ell a!l \\ hen the limb I::. fun~ri(ln.lll~ longer (h,m the ("'OTHraialerallimb. Inc ~:tsed It~ngth mJ~ beproduced b) i.1 fault~ po::.terior ::.lOp lh.1t no longer limib plantarl1e\ion. or b~ ;\ lo("keu knee joint. Tht' rn.",~Ic:"m :;.hould be Ollllicip.lted ;md. for the unilatt"ml K \FO \\c,Wr, l'an ht.' prc\cmed h) .ldding ,I 1 ~ in. \ ll'm) lift Il' the I,.'\....ntr,ll.lIl'ral ... hoe. Intent,ll or l'\h:ntal hip n'lal1on nt.\\ tx~ c:1usl..'d h~ 11H1lOr IInh,II,Hh.'l' hc-t\\ eell ml~Jl.11 .mlt btt~r..ll I1lIl'l'ul,lIt1ft'; the orthOtll' l·.IU~t" 1"\'l.lIt' '" 1l1.1l.lhfnmellt ,-,t the hran'. ~ IInil,\rl~. t~\I..'C""I\l' 111t"dt.11,lr I.ul"fal h ,t l'\\{\ 1.1l"! I\la~ 1111..111.',111..' th,1t the ~'rlhll"l" d\.x', 11\.'t trad, Ihl' \\;1.\ tltt' p,ltIcnt', IlIllh d(x" \" .llkmg h,bl' th.u I" .lhlh'nn.ll\ \\ Ilk' l';l1\ l't' 1.:,lIhl..'d b\ ,I hmh Ih,1I b I,\n~l'r th.m th,lt ,'11 the lll'l'll'" til..' ... Ilk· \ ,HI It lit!! I\.'k ...... h' l'\.'~~~·r,H 'd 1'1.\llI~\rtl~'\ 1\.\0 lll\ thl' cOnll,ll.lh.'r,lllllnb dUlIll!! ,\\ III~ ph,I'I..' l't th\.' .\ITl"\.'(t.: I 'Idt' \,ulllln!! lX'l'lII' t't',.:,IU',: th,' hl,lll'I tl'~ I" hlodl\"ln.llh

Table 31.1 Orthotic Gail Analysis Deftation Earl) Stance 1 Foot slap: forefoot slaps the ground

Inadequate dorsiflexion assist Inadequate plantarflexion stop

Weak dorsiflexors

2. Toes first tiptoe posture mayor may not be maintained throughout stance

Inadequate heel lift Inadequate dorsiflexion assist Inadequate plantarflexion stop Inadequate relief of heel pain

Short LE Pes equinus Extensor spasticity Heel pain

3. Flat foot contact entire foot contacts ground Initially

Inadequate tracti on from sole Requires walking aid (e. g., cane) Inadequate dorsiflexion stop

Poor balance Pes calcaneus

4. ExceSSive medial (or lateral) foot contact medial (or lateral) border contacts floor

Transverse plane malalignment

Weak invertors (evertors) Pes valgus (varus) Genu valgum (va rum)

5. Excessive knee fleXion: knee collapses when foot

Inadequate knee lock Inadequate dorsiflexion stop Plantarflexion restriction (stop) Inadequate contralateral shoe lift

Weak quadriceps Short contralateral LE

contacts ground

6. Hyperextended knee: knee hyperextends as weight IS

transferred to LE

Genu recurvatum inadequately controlled by plantarflexion stop Excessively concave (deep) calf band Pes equinus uncompensated by contralateral shoe lift Inadequate knee lock

7. Antenor trunk bending: patient leans fOrNard as weight is transferred to LE

Inadequate knee lock

Knee pain

Knee andlor hip flexion contracture Flexor synergy Pes calcaneus Weak quadriceps Lax knee ligaments Extensor synergy Pes equinus Short contralateral LE Contralateral knee and/or hip flexion contracture Weak quadriceps Hlp flexion contracture Knee flexion contracture

----

8. Posterior trunk bendmg: patient leans backward as weight IS transferred to LE

Inadequate hip lock Knee lock

Weak gluteus maxlmus Knee ankylOSIS

g. Lateral trunk bending : patlent leans toward stance leg as weIght IS transferred to LE

ExceSSive height of medial upright of KAFO

Weak gluteus medius

--------------------------------Excessive abduction of hip jOint of HKAFO

Abduction contracture

Requires walking aid (e.g., cane)

Dislocated hip

InsuHlcient shoe lift

Hip pain Poor balance

Short leg

10 W,do w
11 Internal (or external) rotation' LE Internally (or externally) rotated

Lute Stance Inadequate tranSlllon: delayed or absent transfer of weight over the forefoot

ExceSSive height of medial upright of KAFO Excessive abductIon of hip jOint of HKAFO Insu fficient 11ft on contralateral shoe Knee lock Requires wal king aid (e.g., cane)

Abduction contracture Poor balance Short contralateral LE

Uprigh ts incorrectly aligned in transverse plane ReqUires orthotic contro l (e.g., rotation conlrol straps, pelvic band)

Internal (or exlernal) hip rotators spastic External (or Inlernaf) hip rotators weak Anteversion (retroversion) Weak quadriceps: external rotallon

------------------------------~~

Plantarflexion stop Inadequate dorsiflexion stop

Weak plantarflexors Achilles tendon sprain or rupture Pes calcaneus Forefoot pain

1 Toe drag: toes maintain contact with ground

Inadequate dorsiflexion assist Inadequate plantarflexion stop

Weak dorsiflexors Plantarflexor spasllcity Pes equlnus Weak hip flexors

2 Circumduction LE swings outward in a semicircular arc

Knee lock Inadequate dorsiflexion assist Inadequate plantarflexion stop

Weak hip fl exors Extensor synergy Knee andlor ankle ankylosis Weak dorsiflexors Pes equinus

3. HIp hiking: LE elevated at pelvis to enable the limb to swing forward

Kn ee lock Inadequate dorsiflexion assist Inadequate plan tarflexion stop

Short contralateral LE Contralateral knee and/or hip flexion contracture Weak hip flexo rs Extensor synergy Knee and/or ankle ankylosis Weak dorsiflexors Pes equinus

4 Vaulting: exaggerated plantarflexion of contralateral LE to enable the 11mb to swing forward

Knee lock Inadequate dorsiflexion assist Inadequate plantarflexion stop

Weak hip flexors Extensor spastiCity Pes equinus Short con tralateral LE Contralateral knee and/or hip fle)'lon contracture Knee and/or ankle ankylosis Weak dorslflexors

Swing

-

~ ..,

LE

Lower extremIty

too

I ng. po Ihl\ ~CaLJ'l' Ihl' p(l'h.'flOI ~11l~k \top h.I'

cmd d or ;3 I-.n<."~ It k 1, U d I hl' IL'" .1.l!11L· p.lllent Illil" o lam Inot dl',lr.ml'(' h\ hip III I-. II1g. thilt I', l'h.:\i.lIIIl1.! th~ peh t' on lhe- ,v, Il} 'Idc

Trunk Ortho.,i., Static Examination Lumht' lral and Ihoracolumbo,acral ortho\e~ u"tually indude IhorJ\..'h_ ami pelvIC band" \,,'hlch \hould fit nat a~;'l[n I Ihe trunk \\ I1hoUI edge prc\ ... urc. Lpright ... \hould not pre ... agaln"It bon} prominence"I, panicularly when the pallent \lh. The abdominal front \hou ld extend from just 1><10'"' the "phoid proce" to just above the pubic symph~SIS The cenical onhoslS should hold the head," the best tolerated po,ition. Rigid components, s uch as a mandibular plate. occipital plate. 'temal plate, or thoracic plate should I>< shaped to apply maximum area to the body segmen t.

Facilitating Orthotic Acceptance Clinic team management IS valuable in fostering accept-

ance of the onhosis by the patient. The team also enables clinicians to join efforts to help the cliem achieve the maximum I>
Orthotic Training Orthoses are designed to provide the individual with a ma"lmum of function with a minimum of dio;comfon and effort. ~o ~jngle training program suits every ortho~i.., wearer bccau')C of the wide range of dlsordcr~ for which Ofthl)tic management I'" Indicated To tht: extent possihle. however, the phy ieal therapic,t should in'·Mucl the pallen I In the corrett manner of donn 109 the orthoc.,i .... developing t;tandlOg balance, walking safely, and performing olher ambulatory atllVJlICS Optimal pcrfc1nn'H1(;C depend, on the favorable IOter· ac.:lJon of rTI<Jny lat\()r\ "orcmO\1 " the ex lent of c.,kclcl.t1 and n uromu.."ular IOvolvelflcfll. lhe rnohllity. "'Ircnglh. and lC)ordln3t10n of all hody ~cglTlcnh, cspc(;ially In the LLs ..tnd trunk, are lIllporlarll. it"i arc the indlvidual'\ rnu cle lOne l.ardlovar,<.:ular <.Inti pulmonary hc.tlth, hmly

Yol'lght, r\yt:hologltial \Iatu",
cnc'"g the underlying pathology. Training prepare, the patient for lifelong activity with an onho,h. Per,on \\.ith n:versible di\orders, such as peroneal ncrve Injury, often benefit from temporary u,e of an onhosi,. Such II1dlvidual, \hould learn proper use of the ortho,l\ to prevcnt !ooceondary di\orders and ~hou ld receive reexamination \0 that the orthos i, may be altered as the condition changes. Patient, with progressive disorder", such as muscular dystrophy and multiple sclerosis. require vigilant reexaminallon so that the extent of physical de teri ora lion may be reflected In orthotic changes, as well as continual training to cope \\.lIh alLered functional abilities. For all silUalions. a cardull} devised exercise and act ivity program should enable the patient to manage efficient ly for maximum independencc.

Donning Orthoses Regardle" of type of LE orthosis, the patient should wear clean, properly r,uing hose. The AFO with shoe Insert IS most easily donned by applying the onho,i, to the loot and leg. prior to placing the braced limb In the 'hoe. If the AFO ha s a spIll stirrup, the 'hoe should be donned r,rst; then the onho,is should be r,ued Into the box caliper on the shoe. If the AFO has a solid stirrup. the pallent will have to insert th e fOOL into the ~hoe. then fasten the calf band. The same gene ral procedure, are u,eful wnh KAFO .... The patient may r,nd donning eaSier If the brace" appllCd while lying on a bed or a mat table. If the KAFO i, donned while the pallent 'its, the therapISt should check the lightness of the kneecap, If this component is part or the orthosis. A kneecap that IS comfonablc for ,iu'"g .... ill probably be too loose for effective knee control when thc WC IIlg 111 II, Then the patient don, the "hoc!oo and f
Standing Balance rhe problcm 01 ... t"l1(ling ... alcly 1\ 1110 ... t dliticlilt lor the 111· dl\ldual v.ho ",car, ~I pair 01 K \r·o, or more: c\ten"l'.e hrdt:Jng. In ordillill) ""
~'nl".·h!.' ... Illl' p.ItIl.'1l1 11111 .. 1 k·.lIll hl dl'llIh\lh.' '\~'I!!hl 1'.\I11~ \.'Illh~· h.IIII.I ...md \,.1111\ ~ln Ihl..· fl'l'l rill' hll,' ,l, ~I.I\ 11\ 1.111, \\ Ilhlll .1 1111~~t IlI,lUlhh..·d Il\ Ihl' h,II"I ... ;ll\d Il'I..'I. lin' II Ill\ld I .. •1 lllmprll11l1"I,' 1""'(\\l·I..'\I k.lI\lIl~ hll.' I.u- Inl\\;ml \'11 (hl' h.\lh k h l 11\1..'1\' .'''c..' .. I,.hllt I~ .11 lilt' I'lll'l' ("1 f.llt);!tllIl,!! I hl' .11111 ' . .uhl k·.lnHl~ Il"" I.u h.ld. \\ .In.l. \\ Illdl I 'duc..'l'''' ,11111 ... 11.1111 hUI 1Il.1!..", .. t,.ll.llh,.'t,'I''''c..',lrlllu" \' 1'.II.IIlI.'" IIHpnl\l· ... llw 1'.1111..'111 u....•.. Ih,,' h,l1ld .. "'111\ flll h.II.lIllY. 1,lIill..'l th.m tOI "llh,I.IIIII;\1 \\ "'I~llIl"'.lIill~

Iwr.. {'1l "IH' \\ L·.lr, hll.I1L'I'.\I t.... \H) .. \\ til Ill'l..'d ,:I1IIc..'hl''' l'r l)lhl'l .111.,1, fl'r 11Idl'pc..·lhh.·1I1 g..111 \ I'rl'rl·qll1"ul..' f"'1 l'rnl!.'h .lInhul.llIl'n \... Ihe .Ihlhl~ In ,111ft \\l'l1!hl Shlfl \I\~ \\ l'l!!hl hl thl' lll'd, 1.1k.1" prl..·"uI't.' lIn' thl..' h.\Ild:o :0(1 Ihl" l·.\11 hl' 111ll\l'd. l '1Il~ 1'.Ir.llkl b.lr,. 11ll' hq!inller .. 1111(" ,III \\ l'I~llI Il' Ihl..' ft.'I..'I ;lIld r.I1 .. I..'''' .md It", a .. lHlI' lund. thl..'l1 thl' llthl..·l lund. rhc ~(,l.l1 I" In he .l\lk h' Ii 1'1 fltllh h,md . . :0111l1l1t.II\C{lll'I~, .1" I1U~ hI..' d01l1..' \\!lh crtllL·ht." ,\ h,,'11 rafl)nlllll~ .1 dr.Ig.-lo l,r :-111111.lr g.lI1. Olll'1..' Ihl' paIH'I\I I" .Iblt- w . . 111f1 ,\ l'lghl trl'lll Ihl' (C('I Il' Ihl' h:1lHh .lIld !'l.h..' l.. III tht' fC("1 ("onlilknll~, Iht.' ".ll1\l· ,,·\'l'rci ... l· ... Ill)llid he dl'llc \\!th emldlc .... \lh .IIKtxl ... k.ilh .... llch :l' IlW\ Illg Iht' h.md ...11ld t'\1'1l1t1.l1l~ Ihe cmlchl". hdlllld thl' hod:. .. Iwuld ht' pr.Kllc,,'d Tho~e \\ ho \\ 111 \\ ;1Ik. 11\ rcclpftlc:ll 1.I .. hil'l1. ;llIl'm,lIl1l~ fl)OhlCP:O, !ll'l'd 10 pr.lClice dl,lglHlal \\('lghl .. llIftmg. rhl'

C.li! Training TIlt' \ ;inlltb cnlll.'h g:l1l:- dltT~r III Ihl..' :-l'qUI..'I11·1' or cntll'h ;\I1d f(\\..) hlt'p", Pallem~ ,.tr~ 11\ :-p,,~('d. :o.lt'cI~. ;lIld ;IIlI01111l of 1..'11t'rg~ rt'quift'd. TIll' p~llIcnt ;;hould kam ;\;; 1ll~Ul~ gait:- ;1' p(l~­ "Iilk 'O.b 10 l11(xhf~ \\ .tu.,lIlg 11\ efll\\ (1.... 0\('( long dl ... I.UlCI' .... .U1d III "1I\I,1til'n" III "hlch :-rx:cd I... de:-m.'d, In :lddllHlll In \\,tlklng tl.ll\\ am. lill' clit'llt Ilccd:o Illl~ able.: 10 \\ .11k. :-idc\\ ani, lurn COnll'I'.. J.nd m.U\l'U\ ('f on ditl'crcm surLlce;;. ,"ch as rug'. gr.n('1. gr., ........md Ihrough unon-., A ~pt"noi~ of gall" pt'nnih the ("hent to .,dju;.;1 10 ell\ In.lnmcnt:11 rcquin:mcllI:-. G.UI . . decuoll dq'l'l\lh 011 Ihe mJi\ idu:II .... flllh:ttlliul .Ihlltt~.

mdudlllg:

SI(P ilhility' C.U1 the p:lIlcnll:Ik.t' ,tcp'" \\ illl cilh('r or both LE,'l \\('II:htbctlrt"t: "lid hultllll·C liN/if.\': (':til the P:1I1(,flI 1"'IC;lr "elglll ;ind remJII\ b:li.1I1ced nil onl' or hOlh LE ... ·l l PJla·/"l1h PII\\"('I"" Can th~ palll'lIl pthh th~ hod) olT Iht' I1rl()r b~ pre"lllg do\\ 11 on Ihl' h~ll1d ... ·")

Rl'dprocal Gait ... The lour- ~Ind l\\o·pnll1l galh rl'qulfc Ih"1 Olll' 11I0\c Ihl' I.b .lltem.II!!I) h~ hlp tl~\lOn m pl..'hic l'k':1I101l I he pa Ilem ... hlll .. \\t.'lghl .\', l'.lt.h I I ~ 1~ mO\~d. Th~ fOlir-pollll "e'1ut.'nl"C.~ I~ t I) righl h.md. (2l left fl)OI. l.') kft hand. i\nd (4) nght foot. lite (\I,ll-point ... ,,·qUl..'llCe rl'qulrt.· . . gre;\II..'r 1:l.lbnl:e and coordlllilllt)l1. htll I'" ~ll,I ... It.'! 111o(k of \\all..III~· \ I) right h~U1J ~l1\d ktt kg. (2) lelt h:lml ;lnd n~l\I kr 11ll' PJttl"rn ... :11 ... 0 ;Ire u ... dul \I,hl'n (lillo.' I'" l:tlll!rolll"'d \\lIh

I1H"~' ~,l1h .1H' ... 1I1{",1 In pn "'I\i," "Ill' I,h!.. Ilh' lllnldln.1I11111 .Illd h.tI.III\,{· nn'drd 101

ll\'" It.. l'l ... hpp"·I' "'UII.Kl·' ,\1IU IIt.II \l'llll'" ~.lIh

~il1111 ll mH'tHl'" (;uil'

11 both I I·.... 111..' Ilhl\l'd ,nllull.lIIl·tHI ... I\. Ilw p.lllt'nl 1'1.1"~·" l'I\iI'ld"'I.lbk 'In.· ... ' olllhl' HPl''''! Il1nl" Ih~' ... 1.·lll· ... Il1lludl" Ihl..' dl.h!-I(l, '" 1I1~ hi. ;lI\d '" 1Il~ Ih\(HI),!h p.llll'l'l1' \1 thlHHl.h '1Ill' ... \\ ml! IhlO\lgh p:1I1 l';llI hI..' Pl'rtllrl1ll'd 1.lpldl~ "'"1ll111.lH"'llll' g.lIh g"'ncLlll~ .11 1..' .... Ill\\ ;\l1d \~'1~ 1.IIIP.Ull1g. bc,,·,nhl..· !Ill' tlppl.·! Illllh ... ;lIl' l'llnll~ .HI.IJlICd t"1 .1l1lhuI.1 II", IUllcIH'n: .1 "'lI,lhk ,II110llnl nl IlnI1II1IKI\()I1I11~ bnth" ... 1I·{I~·III1\' nHI ... 1 hI..' (·~lIlIHllkd h~ :1 ,1I\.llkl llIu"'(III,H .ll1p.1 ralll .... fh l' \\ I'lghl Ihl' ()IIIHhl'" ,lIlli. III Ihc l"hl' of 11 pa 111..'111 "lIh ... plII,,1 t.·{lrd h>lOll. :\h"''''\1cC nl pCllphaal 'cn~.l tlOlI ..1g.gCl\;IIC lilt.' plOhlclll 01 1I ... lI1g.1 "'l1llulI,I1Il'OU'" g.1I1

t,r

".lllnn rhc dr:I)!,·t(l ~.I\I I... lhe 1I\1."'ll..'ll'lI\l·nt •• r~ ot the group. hUI 11 I ... 'l'n S'"l ll\\ ,'" rite :-'l'qUClll'l' 1:- (I) ;ld':lI1Cl' hoth h;'\lId~, IiI,,'n ~:!)·pu~h 011 Ihe c1"I.1Ich(':., enough 10 drag Ihl' fc('1 tnr\\ .Ird. The (eel do 1101 11I\',:- ;Ihead of thl..' h:lIld .... The ,\\ Ill £, III p;lIIl'rn I' mOll..' r:lpld. bCC~lII"'l' (hc p;lllcni ... " Ill£,:-. rJlhcr Ihal1 dr:lg:o Ihl' I Fs. $" 1I\~lIlg 1:0 .1ccompli:-.hcd b) 1..'\ll..'m.l ing Ihe c1bO\\:- .l1Id depres si ng Ihl' :-. houldcr girdle (0 cie· ,:\11..' Iht: (runt.. .Ind I Es. The ~\\ II\g- lhl'ough gail j" Ihe n1\):-,1 :Ilh ;lI\ced p.lllern. ~quinllg much bal:U1l't: .... Ircngth. :lnd coordin;lIion of Ihe upper 1l1ubs. bcc:lu"c Ihc pal1~nt ... \\ mg.:- Ihl' LE ~ he~ ond Ihe h.\Ild~. or cru lch IIp:-. The ...e qUI'I\l'1' is ( I) :Ilh :tnCt: bO lh hunds. (.2) $\\ ing hOlh LE ... 10 a pOint in frolll of Ihl' h:tnds 10 rc"er~e Ihe b.l:-'ic Iripod po~ ... illon .•lIld lJ) ;H.h allce both halld~ 10 Ihe :-Iarllllg 1)(1"llion. rhl' ... \\ 1I1g.-l hrough gall rl..'quirc!:I c\.len!:lh c prl'iilll1n~lr~ 1i":t1l1l1Ig. includlll g push-ups 10 strengthcn Ihe arm .... The gai l i:-. rapid hilI requires morc floor sp:'cc Ih:l1l the olhel (l;Jlll'ntS. 10 p(,rlml alternalc ;;winging f LEs .\IId crulche ..... Dt..'I:llkd \1l"lrUcllon~ 11\ gait Iraining afl' pro'ided In

Chapter 14. Tht' ultllnall' Il'q of" alk.lng prolicient..'j I~ Ihe abiltl: to con du c i ;\ rom crsation "hile :llllbul:tling, an aClh It) p~ltlcrn Ihat inuie.lle ... $01111..' dl'gl'CC llf automalie fum> lIolling. Pral.'lict.· In Ihe clinical :-.etting "llllUiu he l'\ IClldcd 10 "~lik.l1lg on ':tl'i..:d Il'rrain. lIldoor~ ;llld llUt door ....

Rl'Iatcd lcthitics Thl' palienl ,houkl learn ,I ... 1II.1ll) aC11\ illl'~ .1 ... ph~ ... It.'.11 \.."\'nditloll permit... n 'lIl~ Ilk llft":l\ \l1\ohe ... negl)lt,Hl1lg ~1,lIr .... curb". ;11ll1 r:l1llps. a~ "ell ~h Ir.l11\krrlll g fWlIllhl' chair 10 Ihl' IIpn g hl pO~lIiol\. alld mlo all ;\ulnllll)h\k In . ... liUl·lInn l1\ drl\ ing ~I ... utt:lhh l'qUIl'Pl'd .H11l)lIlll11lle I... ,III IlllpOIli1ll1 piln ul" I'l'Il;lhlhl,lIlllil all II\dl\ Idu.ll ... \\ h,,' '~l'.lr \11111\, ... e ... :l1..'I1It."1' Ihl' lulll,l1\gl'l,f ,111\pul.I1\.'[\ .11..'11' Illl·". ~et 11ll') hl'm'fil tn'lIl p.III1,11 Illdl'I'I.·IHk·!Il""· 11\ .h· l'01l1plt ... hlllf I:hl.. .... :11 il';I,1 tWill Ihl..· p ... ~ l·hl)hlgll'.tI .lI1d ph, "1\ ~I nl! Icll \ .tllIl· ....1tI,,'lhl.lIlt III .11n \llll.! III'11.

'nt

1 -Il

I· in.11 F nmillalion .lJ\d Folio\\"-

upl.lh' In ... 111.111 In pl' llllIl mOil' Ih,lI1 110111111 II ltk·I.lhh 1.1 . . ln "'PlTd I h· , I I ' .. \:\1:1, lI};ll"lh:r') ~I"( 111.1, bl..· In.·IHIII(~·d 1111 h\ Ihl'jllllhllli '11 . 'll P,u.lh 'I'" Il·l.lt~"l'~ 111,11 IIll' IIllll\ Idual Illtl\L' h\ IIppl..·r limh .1I~d IIH\I.ll~l ,tllHIIl, u... tlall) III a "'\\Iug 10 or "'\\III~ IhrnU~h l!.111 1111 ... P"Ul'lll I'" l'\lrl'll1l'l) '1 1l'IlIlUU ". 1.l\lIlg nnlllil .thlcd ;tdulh h) .11 11..'.1.,1 7" pl' rl'l'lll mun.' l'I1", ... 11111 ... !-.t • I I1l1r mil I \\ i\1~lllg 11\\ 'l'll ,I HIII ..

Functional Capacities The p.H!co(· ... 3mbulalOr) abilil) and capacit\ ror other ~h~ 'Ical aCt!\ Ities renCL't both orthotic :lnd 'anatonllcal tlctOr-.. Energ~ meaSliremenl is a \ aluabk' gUide 10 funculJn.:t) cap.:tcit). Enag) Cost I!- calculatcd Ih.~n the allloullt l~t 0\) gen ~on~lImed 3!> the subject pcrform!-. ConsumptIOn ma~ be determined either per unil of di":mce tr:l\ef'\ed or per unit of lime. One tel1d~ to sc k'ct a \\alking ::-opeed that require!) the lea~1 energ) per unil of di~lance. ii' the energ) co!>t I.., too high. the patient \\ ill reali7e that ambulation j, nOI a practical mode of locomotion. Somelime .... high energ) COSI i~ talemble for shon di.,tance.,. as in hou ... ehold ambulation. Communit) tlmbulation. hm\ e\er. demand~ su!)tained effort for longer di~.;(:Hlce~. plu::, the abllit} to manell\ er m-er curbs and other irreglilaritie~ In the \\-alt....ing surface. 1any energy ~Iudie!> h;ve been conducted \\- ith the 1\\ a largesl groups of individuals who \\-ear orthosc~ . namely (hose \\- ith paraplegia and those "lIh hemIplegia.

Paraplegia The level of spinal cord damage is a critical determinant of functional capacily. "w cstigator~ gc nerally co nclude that funcllonal ambulation is 1101 ft!asible for those \\ IIh le\ion ... above [he T I I segment of (he spmal cord. Children \\-earing the reciprocating gail onhosi:-. \\ hite performing the ~wll1g-through crull'h gait ha\'e appnnimately the ... ame cnergy cxpcnd llurc as whell propelling a v.hceJdll:llr.1'> Adult ... \\Ilh (horncll' IIIJuries con<.,ul1le nine times the energy cxpended b) nOIllIi,abled 111<.11\ iduab per meter. v.l11lc those wllh lumhar leSIOn., n:quirc Iriple the normal amount 01 ox)!:!cn, \\-hcn walJ...lIlg. al ..,elf-,cleclcd peed\ 'J ho.,e \huh I1ll-'h kvcl parapleglil usc thn:e tlllle, thcli nv.n ba"utl oxygt.'n r.:lle amhulatlllg \\ IIh Cnllg-Scott KAI·()s: the) dlllm~l' '-' vcr) ,10\\ \\-alJ...lI1!! p.ICC. Suhjcch y.llh Ie""";; hcl\\l'l'/1 I II and 1,1 \\canllg hdilh.·ral KAJ'Os ~clClt W.t1klll!! ,pn'(1-. In ... (h;tll half th;t! 01 JlOIIfJI ,Ihh:u pt.'I .. on .. , \... lIh O\y~l'll IIplilkc .,1\ tlllll'" 11(11 111.11 \\'hcl'ldl.Jlr proplIl",u)J1 h) thl' '.1I11l' group 1I1l'11..·""l·"

OJ k ...... 'lgtlllH:.1ilCC III dl·h.TIll1l1 I1lg IUIll"lloll.d l'ap.ILI!\ I... Ih~' .(~ Ill' 01 onIHhl .. _Rl· ... trdlnlll!! hoth pl.tlll.lrtlC\lOIl .iIl~1 lh)f'III~\H)Il, ;h pnwl{k'd h) Cr,lIg SnHI K \Hh. r~dlll'c", l'lll'!"!!) dcmand \l'r) .. llghtl). Ankle r~ ... Ir~lInl. h(m~\l.!f Illak~ ... no appr,:clah1c dllTclcncc in the cnerg) rL'qulfed 10 Ill'goliatt' ... talr... and !";!lIllh. Perlormancl' I'" 'OI11l'\\ h.1I IlHWl' eflicicill \\ith Illoltil'd pl~h(ic KAFO.,. \\hlch \\l'lgh "'''gllll) Ic~, (hall IratltllOnal mctal anu iL':1Ihl'r hrace~. ~ l L1~( '~lb.W~" n.lt~d \\ ith iI rCClproC;Jtlllg g:ut orthn"'I' pre krred II pnmanl) hccau ... e of it... arpc~lr"1I1l·1' and pefl.:cplion or ~titbilil). One !>hould not lose .. ighl of Ihe principal J1urpo ... e 01 ilmbulation, n:.uncl) 10 get from one place to another. rathcr than to e\eCllle . 1Il e\haU~llI1g phy~ical .,lUnl. The ncar UIlI\'cr.!.al ab:'1I1donll1~nt of ol1ho .. e., b~ Indl\ iduab \\ ith thoracic ... pinal l'ord 1I1jUl) upon di ... chargc from the rch:tbilllalion center altc't~ 10 the fact that 1110~1 decidt.: Ihal accompli"hing vocational and r~creation:ll t"l:-.b i... mor~ imporlant Ihan !-truggling with brace dOl1l11ne. and cllerg\ cO~II) .:lmbui:uiol1. ... ....

Hemiplegia Although thc increa!-ed ellen!\- demand occu ... ione:d tn hemiplegic ilmbulalion i~ nOII1~:lrl) a... dramalic a, Ihal f~r paraplegic gait. the co"t .,hould be con:-.idereo in piann1l1,g reasonable goal.... Ener£!-) co ... t risc~ 111 proportion 10 the amount of spasticit). The 1I1crea,e range ... from no ;lppre:ciabk difference for person ... \\ ilh hel11lpiL'gia to a I00 ~r­ cent increa"e for relativel~ inl'xpericilced \\-alker .... On ;.1\eragc. com fonablc gait IS apPf{nillli.tlel) half Ihe: 'pecd of thai for nondi"abled individu;lb.~ .:' Tht.: I) pe of ortho .. i.. does not appear III maJ...e lIluch dllTcrencl! in functional capacil). although patient, \\Ith hemiplegia perform more efticicntl) \\ ilh ... nme fmm of AFO than \\ IIholit an) braCing. Il1\e ... llgation of Ihe factor . . Ih;1I infiuem.-e cnerg) t·\pcnditurl'. c",pl'L'iall~ ph~ ... kal ... t. llt1s. help Ihe elinirial1 plan Ihe Illo . . t .tppropn ate n::habdJl:Jtlon progrilIll and fort·ca ... t Inng-tl.·l"m j1L'fform:lllce .

Summary nil . . dl;lpll'r hit ... !nrusl.·d (Ul 10\\ CI-llllll1 and IfIlIlk (mIH) . . t· ... I"hl' Illll" Ilcqtll'nth pll.·,nilx·d onho ... l· .... lI1d onhotll' com plllll'n" hil\l' bl'l'lI 11I"l.· . . cllll'd In .lddllll)ll. Ihl' 1~"'pOIl"'lbillll(,"

(. hllptt.·r .31 Onhotic'i

01 the ph) ~ica l therapl~t III orthoti c 1l1anagr.! Ill r.! 1I1 ha ve.: hCl' l1 eUlpha\ilcd.

IdeaH). an ort h?""",

1\

prc ... cnhcd hy . Ill orthotic clinic

Il!anl cOI:lpo ...ed 0 1 a phY"'lcian. phY"'lcal theruri ... t, and ortl1oll..,(. 1 he p~l.! ... cn ptlon ... hou ld be ha ... ed 011 a thorou gh l!Xi\llllnall o ll •

\\!l1l partl(.:ular Hltcnti on 10 the ... pecitie factor ... dl:-.cu ... :-.cd In tl1\', c haptl.!r. Input frOlllthe patient and all team memher ... dUring the deci ... ion l11a]..jng procc ...... i!-! critica l.

Questions

for

hl'

9. Desc ribe the three-point sys tem in a lumbosacral, flexion , ex tension control orthosis. 10. Outline a maintenance program for a plastic and mela l KAFO wilh sol id ank le and pawl lock. 11. What data should be gathered prior to formulating an orthoti c prescripti on? 12. What features of the AFO are co nsidered in stati c examination? 13. Delineate the tra ining program for a person with paraplegia who has been fitted with bi latera l KAFO s. 14. Compare and contrast the 011hotic options for a patient with hemiplegia. 15. What are the anatom ical and orthotic causes of vaulting?

PAST MEDICAL HISTORY

The pati~nt b a 55-\ear-old woman \\ ho had polioIll\ehtl ... at the age ~f 3. She sustained complete paralysis ol·lh? righl LE ;nd lefl fool and ankle. During childhood .. he \\O~ bilateral ]..nee-ankle-foot (KA FO ) orthoses and amblJlat~d \\ lth ~l four-point gall \\ ith the aid of a pa ir of .1\illJn crutche",. \\"hen ... he \\ a... 18.... he haLl a left ankle .lfill ",ubt.llar fu",ion She \\ a... filled \\ ith il right KAFO. "hlCh tndmleJ a ... tirrup foundalion. po .. terior Jnk.k ...,top. drop nn\! ]..ne-e It",,-:]... ]..nee pad. antl Ieather-co\cred calf .J.nJ Ihl\!ll h.md .... For the ne'\l 30 ) ear....... he \\()re the ..arne ~r JLt' , .lnJ had th~ le.tlher ,md ... hoc replaced \\ hcnc\ er tht') ht-1. m(" \H'm .. he u... ed .1 ('.me In the lett hand \\ hen ,he- \\J.n,ed (lutJoor... She returned to the rehabilitation &pmment tOOJ\ L l)mpLlInlll,t! of pJin In the knee and f. u~u ~hl.' .11' 0 a.Jd that ha hraL'e tear... her ... tl'".:]..lI\,!!", at ' 01

unci an appropriatc onho.."s capahlc of pcriorillinl! II ... 111 te nded function. Once th e orlho..,i ... ha .., beell pres<.:rihccl . II ... hould be eval uatcd 10 ensurc sati ... ractory lit . tUI1CIHln. and con.., tructioll. and thc patient ... hmlld ha ve the heneflt of a ~ lIitable train ing program for donning th e ortho..,i\ Hncl us ing it effective ly.

Sttld~'

PATIENT HISTORY AND CURRENT PROBLEM

th~ n~

Tlli ... approach will CIl'lllrC an optmltll11 miltch hctwl'e.:f1 till' ratlCIU \ hl ol11cc hani cal alld (l'lytholo!! lca l Icqll lrcIlIL'nl'..

Review

1. De... cribe the major parts o f the shoe. What is the advantage of the Blucher opening? A low quarter? 2. Specify the purpose and placement of a metatarsal bar. 3. What are the advantages and di sadvantages of the !-.Iloe insert as compared with the solid sti rrup? 4. Indicate the clinical use of a posterior leg band, an ant erior leg ba nd, and 1.1 patellar-tendon-bearing brim. 5. How do tone- inhibiting AFOs improve the patient 's function ? 6. What orthotic knee joint is indicated for the patient \",itll knee nexion contracture? 7. How do
Case

.24.'1

I'"

lUnClU

~Ihc:lut ne\\

1.1nhoth.

Je\e1up

Excepl for Ihe poliomyelitis. she enjoyed good health alt hough her endurance was always less than that of her friends.

SOCIAL HISTORY The patient i~ a reference librarian y,ho li\'e~ y,ith her hu ... ~ band. She enjoy~ visi ting her grandchildren. attending the:: theater. and participating in pohucal campaign ....

PHYSICAL THERAPY EXAMINATION FINDINGS Rc\ iew of '-;v:-.tem:-.

Cognitl\t" ... tatu..., -\Iert. onentt"d. memo(\ lilt l't Enduranl'e' Lmlllcd. rnmanl~ rc .. tnd J h\ dl omfun to hl.'r right knee She c.;an "al)" for three (11\ bJex before ha\ 109 to rl.... ( \ IOn Int.J(( '" IIh lOfrl"lll'H- len

ll4-t

Ph, 'lie." Rc.' habilitutioll

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()rtho ti e l·~ .\allljllatioll

Ran!!l.' nt \Iotion E\.:lTltiuatioIl

Uprights malahgned permitting 20 knee hypere
Hlp

Left

Flexion

WFL

WFL

Extension

WFL

WFL

Abduclion

WFL

WFL

Addu ction

WFL

WFL

External rotation

WFL

WFL

Standing Static: Good: able to maintain c.,talic poc.,itlOn for unlimited period Dynamic , Good on level surface. "ot tested on ramp: pallen t reports that balance on ramp" ic, precarious Sitting: WFL

Internal rotation

WFL

WFL

(,ait

25-0-120"

WFL

Dorsiflexion

0-5'

Plantarflexion Inversion

0-40' 0-10'

0' (no motion) 0' (no motion)

Eversion

0-5'

Knee Ankle

Balal1ce

Right

0' (no motion) 0' (no motion)

-Right lnee e,hLbll , 150 of hypere:,( len"ion.

"'cn~ntion

• All modalities WFL bilaterall) in both limbs • Sen,atlon In both upper limbs WFL

HIp

(:rades

Right

Left

Flexion

2 -/5

45

Extension

0 0 0 0 0

4 '5

Abduction Adduction Inlernal rolatlon External rolatlon FleXion

Knee

Extension Dorsiflexion

Ankle

Plantarflexlon InverSion Eversion Upper 11mb strength "IC

Prli\. t'lie CM'1I11l hllu l'tO \\ 11

4 '5 4/5

45 3 +/ 5

0 0

4 ,5

0 0 0

NA

0

NA WFL

WFL

Overall decrease in speed of rno\ emem Broad walking base Circurnducts right leg Right knee h) perextends within the ortho,is Right ankle plantarfJe\lon limned b) orthOSIS Left foot and ankle fused in neutral posilion

Functional Status

( ~I:\IT )

'-,trel1gth, \lal1",l1 :\Iuscle Test

Patient walks slowly wnh a nght KAFO ",nh considerable lateral trunk bending to the rieht. Trunk bending reduces when she uses a cane In th....e left hand. She .... reports that she has great difficulty ascending and descending ramps. Additional finding~ include :

3+ 5 NA NA

.... Illun 11II"-II,'"lll ltlll ('i

Independent in transfers: . . it-to-... tand: tloor-to- ... rand transfer IndeP<'ndent in all BADL Independent 111 appro\'lmJ.lel~ t.: 5 percent of I.-\DL (iirnitJlion~ irnpo ... ed b) pain. fallgue. and 10\\ ambuJatol) lolerance )

PATIENT-DESIRED OUTCO'lE .\ND GOALS \ \ all... \\ Ilhout knee p~lln lmpfll\ e emlur.Ul(,t:' lnlpro\ e .'p~ar..m('e Reliu('e frequelK~ of lllnl "h.:,,:king." III thL' \ ktmt~ \.,f thL'

knee

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222". 1.:)(1:0'.l\\(X",zen .. kl. DA • .lJld I.ud..." I,!!. }l\1 ,'\11.."(1 ,'I "'1'1,'1\",1.111.1 mh po... ttng orthollC de"lglh I'll ti ...... IIllCI.1I;Ir.',ph;II.III)o! ..·.II,.11111 kinematiC' ... dunng. galt. J Orthop $1'1,111, PI" ... Ihel q·ll-:, ,'t'KW 10. BII'd.AR. Bendrup" AP. and P.\~nc, CR lill,' t'lh'l 01 h'\l," '\\'d~lIl,l1

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Ill( 22:35, 1998. I"". Richard"on. JK: Rocker·..oled .,I\I)C\ .1Ilt! wull","~ dl~hllllC III P;IIII"III .. .... ilh calfclaudlcauon. Arch Phy" \1ed Rdllll'lIJ 72::-;:'\·1. IINI 18. Gok, H. el al: Effect., or .mklc-fo()1 orthu'oC" on hCtllllMlell\. J,lilll elln Rehablll7:l37. 2003. 19. LCS, (lUi ()rlhop 18R:97. 1993. 20. T}Mln. SF. and Thornton. HA: (lIe dfe<.1 01 "hmVl"d .lI1kk l'If" (lrtho'>l''' on hcmlplegH': gaiL ObJCLl,"e rn a ure illld uscrs "pllll"" ClIO Rehabll 15:53. :WOl 21 Smile,. SJ. el al: -\ compan'ion of the C"fh'l of (!11I1, IrlJl;ui.II,·1j and ~ten'lI" leaf-!o.pnng ankle·fonl ortho\c\ and hili; alllue' I pll and energy el~)d)(htl.ire Ifl children'" Ilh 1'01 Ii dlp1c 'Ie <.:ef hr I palsy Onhopcc:lic!o 2S 41 J ~"J2 ...... Armeno DG. c:T aJ: Onhotic dt Ign With ad Jf)I.ed m,lter J and Olethods. A pdot!J.udy Rriub I JOt:! Y..near AlttJ rJ<: clI 1/J7 P Repor. Dep:mme:nt of \\;.enn Affm Hall [Wit 2" Shamp J~' "=m,.,tn xthoi:.iC de PI n the If Ojm , :'21 'X'1'\'OUS ,. de- J Pr Jet (Jr1 14 2111 J S aI J1r

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,lilt! I plt'l. " II ()lIhlllll" 11111111.'11011.1] Rdl.lh,ltl.1 tHl11 1IIIhl' I ~l\\l'l I IInb \\ n S,lundl'''. PIIII"ddpht,l. 11)1) Ih'd l lli d, J l'1 .11· (lltho11" {'llIlll,ll PI,llllt~' ,11111 1{I'II,lhlltl"tlllll I l'l"IIIIIII\I~\ ('hu'l'hlll I 1\ 1111-"111111.', ' l ' " 'Ill". !1)11'ii Sl'\ 11\111'1 , R 1)1Ihllll'lll" ,lIld f)tllllllll' J Il\\t'l 1IIIIh .llId Splll.I' IIPlltlllll11 \\1111,1111' ,\ \\II"lth. Plul,lIklphl,l, '(10' Sliudi. (II (l'd) (i,1I1 III Rd .. ,bdll.llltlll ('hmdllill \\ 1111-',1<1111· \l'\\ N.I\\OUl·lh"l, n \

n.

'"I".

Jlj!j(l

I.. I.. hllll Ollh'''l'', I"III~ Ipk, ,1I)t! ('!llIh, .11 \pl'h~ .1111111' \\ ''It,IIm A \\11"111" H.llllllhll'·. I')IH)

\\ II,

Appendi.x A: Lower-Limb Orthotic Examination .. the ()nh(hl' .1 ... rn.~'.:n~d l Can Iht~ ..~h('nt ..1"'11 the ('r1h(''''I' (,,:"lh

l

lQ, \n: the l'l('lthllll {lr the Illl~h ... h(,1 nr dl'ltcll thl h hand ,md the tnp 01 tlll~ caU ,hell ~ll hand Nluultstan, Irom the

20. In

Ankle IN the mechall1.::.1 an Ie joint .. cOincide \\ IIh the :lIl~n,-)ml("al ankle I an~ltolllic anlle joint a.\.j, }.. appro\.! mated b~ ;1 honzLlntalline lx'-h\een the malleoli al!eH:1 (It the dl .. 131 np of the medial malleolus)') - J.., there adequate dear.mee bel\\ cen the 311310l11i"31 ankle and the mechanical ankJe jomts'~ \ IA~, the \ algu .. or \ am .. correctlon ... trap control lilc toot r<'"aion}

(:I.

l' there .\(.kqU.lk~

I'm\ I

Ion lor

Weight-Relieving Compone nts 21 In a patellar-tendon-bearing hrim. I' Ihere .h.icqU.ttc rc lief for Ihe he~\d of the fibula" \\nh'l quadrilaterJ.l bnm. 1:-. the chelll free tn)111 I.'\U,,'''' . . 1\ e pre . . 'ul"1.' in the antcroll1cdi~\1 and medIal a"'rcd of the hrml'? :!3. \vuh a qu'ldnIat('r.ll brim, doc ... the l'chial luh<.'n, ... it\ n: ... t on the i ...chiJI ",c~lI? 24. \\ 1111 ;\ p;\tcllar-tendon-ocaring hrtl1l ..... there adequ.Hc redu('tion 111 \\eightbearing through the ortho,I .... ) "

Hip 25. J.., the ('el1lel' oflhe pc]\'ic j01l1t ,Iighll~ al-Xl\C and ahead of greater trochanter? 26, '" the hip lock '1ccure and ca:-.) to opcrjtl.'? 27. Doe", the pd\oic band fit the lor... o ~lccurale l ~ ,)

Knee 9. f)cIe, the mechanical knee Joint{ ... ) coincide \\ ilh the anJtomical knee ( ..--.-5 in (12-19cmJ)abO\cmedial ubJaJ plateau r"' ]... !here adequate clearance bet\\cen the anat01111cal ;..nee 3J1d the mcchal11cal J....nce Jomt? t 1. I, the l..nee I(X ....... e~ure and e.h~ to operate')

Shells, Bands, Cuffs, and U prights

:: rx

dll1d, {lnho ... I ....

kng.lh('nlTlg the ot1h(hi ... ·)

Standing b the ,h\~ ,.1I1:-.fa('to~ and dlX" it tit proper1~ '! J Art' th(, ,("'Ik Jnd ht'ei of the ,hoe f13t IJIl the t1lX)() .:; 1t l ,hl~ lO ....cn 1, u,('d. I .... there minimal n)C\"in~ het" ('en m,..'rl and ... hew. . ·'

l..nee'~

.1

the "hell<>.. hand .... cuth. and upright~ confonnto the of the leg and thigh'!

l..Ontour

3 I there adetluate clearance bcl\\een the top of the calf bell or band and lhe head of lhe fibula'? -l h there adetlualc clearance bct\\een the onhm.i ... and the penneum') I' Is the onho I'" helo\\' the greater trochanter hut at lea ... , 1m I:!_" cmJ higher than the medIal . . hell or upright') 16 Are the upn~hh at the l111dlll1(, 01 the leg and Il1Igh') Do the hell . hand. and ,'ul .... confoml to the lontour...

the leg md thIgh' 8 I an) nc h roB Ibove the "hell or (land minimal"

Stability 2X. Doe ... thl.' onhlhi, pro\'ide adeqlhlh-: ... tah iht) to the client?

Sitting 29, (";\11 the patIent ... 11 comfortahl) "Hh hlp ..... 1Ilt! kl1('I.'''' tlc\l,.·d 90' .) )0. (\1I1 Ihe palicnt lean fon\ Llrd tn IOllch the ,hrl(.,'''' I

Walking ."\( J.., Ihl' pat1ellt .... Ix~rlnnll.1nCI' III k\l'1 \\.11J..1I1l! .... llI,I.ll· hll) ,)

L

"\2 J.., till" 11.I1Ien' .... Ix·rlnnn;Jlll.'l· (ll1 ... t.III' .lIld I.Rto!)

I

1.1111,,..,

'.111'

1248

Physical Rehabilitation

,3. Is the orthosis suffic iently rigid? 34, Docs the varus or va lgus correction strap provide adequate support? 35. Does the orthosis operate quietly? 36. Does the patient consider the orthosis satisfactory as to comfort. functi on, and appearance?

Orthosis Off the Patient 37. Is the skin free of abrasions or other discolorations at-

tributable to the orthosis? 38. Is the construction satisfactory? 39. Do all components function s3tl'.factoril)?

Appendix B: Trunk Orthotic Examination I I

rhCIIIIIHhl'> II

lUI

Z ( ,1/1 lilt' \ IIt'lll dOli

,{rltwd'.'

tht,

flllh"..,lo.,

Abdominalhont ca",dy"

Standing

I). I ... th e ;.,bdoHllnallrol1l of mlcquatc .., I/C '}

Cervical Ortho&ib 10. l"i th e heHd

Pelvic Band f)fK'

the pc1vlI. h.m!! lie flat ol1lhc trunk helow tht, po",· rhat "'pIl1C~'1 the pdvl(; h.mel pa,\ hetween the Iroch'Ullcr . . fi nd

Il"lfH "'11 IX' I 1111

.t

(JUl'"

III

the prc\l:nhcd

1'0 ... 111011'1

11 lJo all fI!! ld cornpol1cr1l''i fil properly'l

Sitting

Ihal <.:rc'-!,,"

12. ('an th c palicnt , It <.:omfortahl y w ith the hip' and kncc\

Thoracic Band 'i

i)fK.:

the.: Ihof;1(. Ie hand lie lIat 1m the trunk helow th e

ff exed

')1) "/

11. Doc, thc patient con ... idcr the orthm.io; ... :.tll\! .lctory a... 10 comfort . fun ctIOn , ;and appC'UC.llH;C'!

c.aplll~lc"

6. Dot Ihe thoriJlH. halld II c hOfllontally on the trunk'! Upright~

7 Do the P"""CflfJl upllJ!ht., ;WfHd I"c ...... urc lin hOllY pronllllt·lltc .... ..,uth
Orthol>is Off the Patient 14 l "t the ... kin frec o f Hhnl,ion.., 01 othcr di ,color:'lIlom••ItIrihu wb lc 10 the orlho,j,'! l.'l." the l,:f)/1"tt l uUIOIl ,ali , la<.:lOry? If). 1)0 all COl11pol1Cl1h fUI1(;lioli ,ali ... l m;lonl y"

(; If ,\ I ' '/' I'; /(

32 IIAANING I lt'~ul llt,

Prosthetics

OBJI CIIVIS

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Joan E. E(h·bl!'in.

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1'1. M \ . IISI'O

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. I h;' pnnupal Im\L'r I1mh pm'the'l· ... '1I1.' pallial loot, S'l11l' '. tr~II"lihl.l1. ;1Ilt! tlillhkl1\~)r;(1 (ahml.' !...nce). a... well:J~ klll'L' ;Ind hlp di"U1H.:ul;1I101l. Illl' phY ... H.::a lthclapl'1 ... IIOUld 11<.' 1.\lllIiI'\I \\ Ilh thell charal.'tL·n,tit·, :I11t!m:linlcnillll:e.:I, well
Partial Foot Prostheses Tht:' purpo:-;c~ of partial foot prostheses arc to ( I ) re~tore, 'h much ;1\ possible. fon t fun ction. partic ularl y in walking and (2) simulate the shape the missing foo t segment. Tht..' patient who has los t one or more toes may simply pad thc toe 'cetion of the shoe to improve the appearance of the upper portion of the shoe. Standin "g wi ll nal be affected , i.I ...... llll1l1lg the metatarsnl head.., remain. When the individual wa l!... .... late stance will be less forceful. particularly if the phalanges of th e great toe are abse nt. An arch support he lp ... to maintain ali gnmen t of the amputated fOOL .! Transmetatarsal amputation di sturbs foot appearance more noticeably. A prosthesis prevc nts the ~hoe from deve loping an unnatural c rease in th e forefoot area. The patient bea rs most \\ eight on the heel and reduces the amo unt of time spent on the alTected foot during wa lking. A particularly useful prosthc ... i ~ consists of a plastic socket for the remainder of the foot. The socket is affixed to a rigid plate that l!.\.tends the full length of th e inner sole of the shoe. The plate has a cosme tic loe filler. The socket protects the amputat ed ends of the metatarsals. while th e rigid plate restores root length so that the person can spend more time duri ng the swnce phase of g;.tit on the ilffcctcd ~ide than would otherwise be the case. To aid late slance. Ihe bottom of the prost hesi, or tht: sale of the ... hoe mil) have a conve\ rocker bar.' Ampulation or disarticulation through thl! tarsab poses the
or

IImh, lin proving pro ... thcllC <.:ontrol; in addillon. the indlv l(.Iua. "I wu h a .Symc's amputation may be able 10 lole rale s. lglllf lcant weIght through the end of the limb. Pro...thcl:.cs

I.or both the Symc's and tran ... tibi al levels include a an kle;! a ... selll bl y and socket; th e tramtibial prm.thesi'-. also ha ~ a shank and a suspe nsion component. 1001

Foot-Ankle Assembly The prosthetic foot restore ... the general contour of the patient \ fool. ab~orb... \hoc!... at heel COni act. plantarnexes in early ~tancc. and simulate ... metatarsophalangeal hyper. extension (toc-brea k action) in the latter part of stance pha\e (Fig. 32.1). The foot is in the neutral position during swing phase. Many a.,scmblie ... also provide slight mOllon in the frontal and transver...e plane~.~ -9

Nonarticulated Feet In the United States. the most popular foot type j'-. nonaniculated. without a cleft between the 1'001 and lower portion of the shank. As compared with aniculated feet. nonarticulated components are lighter in weight. more durable. and more attractive: some version~ are made to suit high-heeled shoes.

B

A

, I

-

Trallstibial Prostheses

/

q ( H f oot

~ =~ cu ared d iJ'JJ:/~ ushl n h,,1 154(' H ~b • the roo t \,. mmor.:)o pre nbed loot m ~urrent

~-uce see FI:- 12 I \ hen t of J \I,(xx!.en or metal 't\ tuc:h h:rnJ.mate at is pOim corre"ponding to the ocotaf"Ol'haJangeal JOInt The keel i, eo'Cred "'th rub~ ~ pa,.ten r ponlOflI IS re"'lhent, to ab orb ~hc:x k and perm t planlarfJe~(Jon In earl) ~tance. Ameriorl). the june • the keel and the rubber loe "'clion, allo" , Ihe foot ~ peTe tend In late stance. The S.-\CH fOOl i.., manu -

fJ ... tured m a Vtlde range of \.ze ... 10 accommodate mfant .... JCioIe.;cent • and adult~. Il J'\ a\ailable \l.irh heel cushions . allmg degrees of compre~"'Jbill1} fo r tho .. e \\h o strike the' beel 't\ th different amount.., of force. 33 v.e ll a.., in seyerJ.1 plantarflC:ril0n angles to fi t shoe~ \l. ith d i\e rse heel t)e. _hr The heel cu\hion alia"".., a ve l) small amount of 111CU .iI-lateral and tran"'''er''le motIOn . Olhe r ," ona r ticu lated Fee t .\ er IOn ,f the SAC H fOOL is the stalionary attachment ;7enhie endmleieton (SA FE) fOOl (<,ee Fig. 32.1 B). It has a ng.d ankle block joined to the posterior ponion of the ked .1 a 45' ang le. w hi ch is comparable to Ihat of the . analOmical !)ubtalar jOint. The Juncti on permit~ the wearer W maintain contact w ith moderately uneven te rra in, because of the greate r range o f medi al- lateral motion permmed in the rear foot. The SAFE foot, however, is some.... hat heaVie r and more ex pensive than the SACH fool. Feet Ihal have a springy ,ole Slore e nergy In earl y and mid· lance as the weare r moves over the fool. bending it ilghlly. In lale ' tanee. as Ih e wearer tran sfers loadi ng 10 lhe oppo,ne foo t. Ihe ' pTlng in the proSlhe IJ e fOOl recoils. returning ,>orne o f the ~ tored energy. Such fee t are dC'ouibed ali e ne rgy storin g/ene rgy releasing, or dynamIC. 14 r o r example. Ihe Carholl Copy II fOOl has I'." carhon fibe r lo ngl ludlna l nexib le plale,. When Ihe ;..carer walks a t regu lar speed, the di stal plate bends, then pflngs. hatk to Its res ting shape. Wh en the wea rer runfi, "olh pl.I. bend . Ihc n straI ghte n" The Seal/ie fOO l incorpor.I. a sllghlly n ox lDle plastic keel. whic h bends some"'hat at hee l co ntac t. storing ene rgy. If, At latc stan ce, the keel rccoJls as the wea rer unloads the foot. releaSing energy for a "pringy te rrnmallon to stan ce. Both the ,...J,, \. rool <Jnd Ihe .\ptlllJ{ /t/f' fO ()1 (see h g. 32. 1f) Include a long h;lIld 1,1 carhlm fi b<· r rn atc ri ~11. which ex tends from the toe It) the prOX imal ., ha nk , as we ll H'" a posterior heel ~ccti()n Ihe Ifmg hand ac t ) " ') a leaf spring. e nahll ng the foot 10 tllre t{)n"'ldcra hl e c ne r~y III carl y iJ nd ml tl\lancc. and then hI rt ICd !'Iwrgy at the e nd of ~ t .a ncc ph ~I "'c. Acll ve wcar er . II( h iI', 111C> ... e who play hasketba ll or run , utill/C Ihe en r~y ~ltlrl n .'! and ene rgy rel caslng caplu': lty of thc ...c let t 'I M il llY of Illl· ... C fe el :Irc avail
Figure 32.2 Co... metic fOOl co . . . ef"l Viejo. CA 92656 )

(Cou rte~)i

of Ossu r, Ali so

the needs of the individ ual with consideration to the wearer's activity level. weight. level of amputation as well as Ihe lenglh and shape of Ihe res idu al limb.

Articulated Feet Manufactu red wi th separate foot and lower shank. sections. articulated fee t have the sec ti ons joined by a metal bolt or cable. The ease of fOOl motio n is controlled by rubber bum pers. In the rear is a resiliem bumper to absorb shoc k and comrol plantarfl ex ion excursion; it is easy for me prosth etist to 5. ubstitute a firm er or softe r bumper, depending on the force whi ch the patient applies in early stance. A heavy or very acti ve client requires a firm bumper. whereas a frail indiv idua l needs a bumper that is soft -e nough to permit the foot to pl antarflex with minimal loading. At early stance, weightbearing on the heel causes the foot to plantarfl cx, ensuring that the wearer achieves the stable footfl at P05.ilion. Anterior to th e ankle bolt is finner rubber or <;i milar material. the dor&iflexion stop, whi ch resists dorsiflex ion as the wea rer tranl;,fers we ight forward over me foot. Art ic ul ated fee l arc ~ ubj ec i to eventual loosening, whI ch may be "gnaled by a sq ueak ing noise. Single-Axi< Feet The mm, t common exampl e of an articul ated fOOl i... the single·axiJ foot (see Fig. 32.1 C). It pe rmi t') plantartlexlOn and do rsifleXIon. as we ll as toe-brea k aCllon, but doe ... not a ll ow medIal lateral or Iranwc r",c Illoti on. Some people prclcr thi '" "' lll1pJicity of conlrol. M ultiplc. Axi, Fcct The ... c compone nl s move ... Iigh ll y in all plilllc", to ,lid till..' we arer In mltlllltuning m a"'< Im um con tau \\ IIh the \\ ,11J...mg ... urfal: e. l'wn lithe ... urfacl,' "lope ... or h" ... ,II!-!hl I rft·~ul~lfI · lic .... Mfllffl,h'" (/\I\ }t'C'I o.lr..:- hL'.lvier o.lIld k" lim.lok· th.m ... In!-!Ic -ux i ... (lr nOllarll<.: ul at cd k l'l I he L"l1I1I l: lillIl',1Il 'ol'klt Irom .1 \\ Ilk ,\H.I\ nt tOOl .mJ...lc a ...... l·lI1blll' ... , In .. tld ll UlIl 10 Ihl.' Il' pn.." l·IlI.lIl\l' l:OmpOIlCIII'

dt· ... lI lrn.·d hl'l l'.

A

c

B

o

E

(J

H

F

Flqurf"J "i2'j LJWUIJI'"

,,1 pm',llwlle: Ief'l (A, Rl' r'!ex V~P ..iI]d H. ~

flJJ Llffl1: ((, (j""ll1' " " ~I(t.· (/) 'I (If \,,111

rlJ} V;". (( nllfl~!ty

(( I/IHII

11}1 1'.Hlltlll", (/'l1lnvdj,· M~.. '"i'\447 4,lf,7,

Ie); VS P loll"" IJrofllc 9265h), It, lhc IIl lr l't'dow Inllovallon,; htyt'lIl' 1I /' H.Jh.101. ((;) Ihe /,/11 L (JlJ 11:'i/I~r),. '!IId (1/) 1.11 J<,d\:1 (('(Jurr ..·.,)' 010110 IIUll..,

H·x (( 'ourlr'!otY lit

J

(h<;U/ AII~o VU.'Jrl, ('A.

MUI/te:Jf.otIJ.

hy

j<,If.tf/,r \

A lof Jlir, til II

f

.ij 111111$111'"

III pLH j·d ,.1.0\11' 1Ijj' l'/o'1IIH'IH foor

'"b hli'r "I I1I1 '/1111 v, I ~I pLulf' JIll ., HI '11111 [HII it r tt"", Jill I hahllJ! wilJl II wllulf! ollwlw,.,(,

r (,It (lI.h, 1/1'" Ji' /1'11111 d t l, lilLIit' ,11,alll'1 ' rl w ~ " J/,,. ,11 If .H' ""/ I (,flf" II .. ,I Wllh JlIJ.d,· ;1.1(1 ftol'l ;tlil l !

VCIY ;1t'lIVI..' IlldI Vl(hwJ .... c"pt:l.·I~III)

rhm,e" \\lIh

tr
li..' lllOl'aJ illllJlIlIHlltln ...

" hank Jil l" .., lId .. k

J ..

Ihl! .., uh;lllllIl' lor llit' hUIll.1I1 Icg, rc-;tonn!! Ie!!

Il:Jlplli ,Illd .. hl/pc I Ill' ;h;lI11.. .; IOLill.!U i1lx)\c [hc foot Jnkh:

(,hapt('r .1 2 I'ro'ttlu"i("

(or rotalnr) allLl helm\ the ,"od.cl III a II';ln ... llhial pro . . thC ... I ... . Th e- SYIllC \, pro ... tlll...· ... i ... doc ... not han: a ... hank beC;JU"c th e ,"OI.:l...ct clH.:a... ln g Illl' amputated 11mb e,"lem'" 10 the foot ;\11l...lc ~l" t.·lllbl) . Two I}pe ~ of ... hank arc u . . cd : fllJ.\J.. £·it'flIl ilnd l'm/m Ade/ul. ;l', ...clllbl)

Exoskeletal Shank The l'\o.~J.dt'llIl shan l.. (Fi g. 32.4). sometimes called cr/l.\Ic1Il'WI . i ... made of wood or rigid plastic. The rigid t \tcri or i. . shaped to ... imulate the COntour of the anatomic leg. Although the .., hanJ... is u~llally finished with plastic (lnted 10 match the wearer· ... skin color: some individuals opt for a multicolored or pallcmed shank. The exoskeletal ~hanJ... is very durable and, with the plastic fini sh, impervious to liquids and most abrasives. Because they are less lifelike and do not permit changes in angulation of the pro"hesis. Ihe) are less frequenlly prescribed.

Endoskeletal Shank The elldoskeletal (Fig. 32.5. see also Fig. 32.4), or modular sliallJ. consists of a central aluminum or rigid plastic pylon covered with foam rubber and a sturdy stocking or similar fmi sh. \Vith its cover. the endoskeletal shank is more natural in appearance than the shiny exoskeletal shank. In addition. the pylon has a mechanism that penn its making slight adjustment of the angulation of the prosthesis; thi s may contribute to comfort and ease of walk ing. A variety of prosthetic foot- ankle assemblies, s uch as the Flex Foot,

Illcorpon.11t.' an cm!o ... kclctal ... lwllk. SOJ1lctimc~ U l111'lha

ni"lll I... IIIl'OI'flOrated 111 the ... hank 10 ah ... orh vC:rlU::,IJ !\ho<.:k. I thereby redut:ing ... tre ...... on the arnpuHlllon Jnnh anc! adJ~ cent Jom!s.

Sockel The amputated limb 1Ir... into ,] pla ... lIc rct:cpta<.:lc called the ... ocket (Fig. 12.0). Although the origmal name lor the modem tran ... tthial socket wa ... the parellar-ll'lIdfl/l ·heunIlX (PTB) ,,,ckel, Ihe ,ocket " dc"gned 10 conlact all ponlons or the amputated limb ror maximum di\lnhuliOn of load, a~ well a ... to assbt venous blood circulation and provide taco lile feedback. The PTB socket fealures a pmminenl Indenlation over the patellar tendon. Newer ...ockel varialiOnc, are the hypobaric, in which soft tis~ucs are drawn inferiorly 10 increac,c dista l cushioning, and total surface bearing. which has Ics ... anterior indentation. Sockets are custom made of plastic molded over a model of the paLient's amputation limb. The model may be produced from a plaSler caM of the amputation limb or by complller-oided de,Hgtllcompliler-aided mallufaclure (CAD- CAM). The lalter involves an electronic sensor, which transmits a detailed map of the limb to a computerized program cons isting of socket~ hape variat ions: the prosthetist selects the appropriate shape, which io; transmitted to an electronic carver that creales Ihe model over which the plastic is shaped. Whether Ihe model is made by hand or by compuler, il provides reliefs ; these are concavities in the socket over areas contacting sensit ive structures, such as bony prominences:

Figure 32 5 Tr.m tlb,:u Figure 32.4 1/ fin I

\t) ...

kdcl.d Ir.m ... k moral pnhmC'sl.... (/0(,

b\d,\\lelC'l.tllran ... tt'mtlrJI pro"thC... I... "11h \,: n... !n(' Ul ltl\C'(

hl)

r~nlO\~

J25,i:i

the.

~ndo ~e'cL1.1 hank patell3r-t l nd ~ l.ar uspcn ion "nh aDd "

rl'lil" .tll' Inc.lI..:d mel thl' Ithular hl'ad Ilhl;ll l'Il'''' uhJaI lnnd~ Ie.;

,lIld .lI1ll'llIll dl,,",,11

tnl11JT1l'd 10 plm ,dl'

.Idl'llll.lh:

l,hl,l. lin," PO\Il'1 lin h'I/I1 1\ room 1m the Illl'(ilill .111(1 l.tI

\.'1.11 h,l1ll"'lIl11g Il'IHlon", "u Ih,1I the p
/I/II/.JI//H .trt' l:OIlVt!XIIIC'" 111 the \o<.;J...ct (lve! prt.', .. url.'·!olerant li ...... uc .... ,uch a .. Ihc helly III thl' g•• ,tn'lulL'Il1IU"; Ihl' l'KIICliar tendon; proxil1lol11c(iI.d IInt,l ....:nrrc"'pondlllg In the pc ... i.1I1\CrmU'; and the IIblal and lihul.lr ,h.,I" \\ hen \ lC\\t'd from above. the ~ockc t rc~cl11blc~ a trian gk. th~ apl!~ 01 \\lhich i\ fonned by the relief for the tibial tubcrdl! and crl!~t. and the base angles of which are the hal11\tring rclici\, The anterior wall tcnninales at the mid patella. or above. The medial and lat e ral wa ll, extend at lea.." to the femoral epicondy les. The posterior wall lies across the pop liteal fossa, The socket ,s aligned on the shank in sli ght nexion to enhance loading on the patellar tendon, prevent genu recurvatum. and resist the tendency of the amputated limb 10 slide 100 deeply into the socket. Flexion alo;,o facilitates contracti on o f the quadriceps muscle. The socket is aho aligned w ith a slight lateral lilt 10 reduce loading on the fibular head. .lrl',h lillll.ll"IlIll:!

Hamstring Channels

Patellar Tendon Pressu re Area

Li Il(·d Socket I he tritll ... lJnml

'iockct "I'C' the pro\thctJ t can add rnatC:rlallf, the {Jut Ide 01 the liner reducJflg the volume of the (K.ket while pre,.. ... crving ..,moCJlh interior contours. lht hner. hIJWevc:r. add ... to the bulk of the pro'ilhe\l\ and II, a heat In ulall)r whICh the wearer may find uncomfortable in the summer T( he Syme\ prm.thc,>i\ ha'> a liner that a\.,il"l~ entry of the bulbous distal end of 'he amputated limb. enablang the wearer to don the pro\the\l\ ea'iily. Indivldual\ with Syme\ and tran!:ltibial amputation\ u\ually wear cotton. woo l, or ,>ynthetic fabric ,>ock\ to enl"ure a \nug ~o(;ket fit An altemallve to the polyethylene liner 1\ a ~healh made of c,ilicone or \Jmilar material. which filS ,,"0 ~nugl) that the wearer has little ri.,k of abra~ion bet\l<een the !.ocket and skin.21-24

Unlined Socket Although the unlined !:locket is sometimes referred to a'i a hard ~ocket, that lenn is a mi.-,nomer, because the v.earer hac, a o;,oft interface provided by socks or a .-,heath \loom

--+1+--,"""7\

'+-'.;,,;H '--f-./---

Gastroc Bulge (shaped like metatarsal pad)

, R b u t a r Head Relief

"-1+-

!!cntrally mdudl's a rc Ihent pIlI

loam IlIler In addition t<, cu hlf)nlng the ampu I
Medial Tibial :-:---'\\t:'--::;s,~ -f1Lf"". ""'~H--=Plateau (MTPJ line

r.

~och'l

('fh~/",u'

Medial TIbial Pressure Area

Lateral Tibial -ttt-t'~ '
::

Relief

\ ~t'-i;-'-t-hf----Dlstal Fibular

----'I+f-+-'4-j

Reliel

~z,,<

_ _ _ _ _ Distal Tibial

----'
Relief POSTERIOR VIEW

ANTERIOR VIEW

~;:;;'=::::lI..;;: Patellar Shell Fibular Head Perooeal Nerve Reliel Fibular

A,ea

Terminal ---\-;Fibular Rehef

LATERAL VIEW

Figure 32.6 Anlenor, po . . tenor, 0Uld lateral depiCllon of patdlar-teooQn-l:leanng -.ocket Area.... of rellel (ai..o caJled huMt S are pro' Ided o'er pre ...... ure n .. ill\e u .....ue .. , Pr~ ...... un- area (aho called nUl dups or hllll;t's I mdl~ale I.ontar.:( "Ilh pre,,·ureIOler.m1 u ...... ue ... I From Sandel'. GT' loIAer Limb .\mput.Jllon .. : .-\ GUide 10 Rehat'tIIJl.illon. FA OJ.\ I .... PtlilaJelplllJ... IQX6. P 176. "1m pennl"'lon)

\\ lth the unhnt'd 'OI.:l..l't ()n: a',oll.dl~ , it rt' .... lil·1I1 l);Id I, pl,lced 111 Illl' houOI1l III Ihl' unlined 'I..ll l.. L'1 to I.:U, III O I1 IhL' JI'I.IIl'lld 01 tht' '111111 111 ,lIl'd Ilillh. I hI..' un lll1cd ,ocl..l.'l I'" it JIll"'·' ',III,l;ldl.lr~ ,,:hOlt'l' for tht' pl.'r,on \\ h lN: IlInh hll ...... liI llllill'd III \llhlllll', l"l..:-cau .. l' II i, (' ..h lt'r to clean; h()\\cvcr, II I' IlHl!"C' dlllil"uit III :Ilil.'f Ihl' ... hdflC 01 tht.:: unlmcd ... m:l..el III ~'~\lI1p.Ir1"OIl

!l)

Ihl' lll1l~d "'Ol'I..CI.

\ Ilt'\\L'r 1)111..' of unlined ... od,ct i ... madt.:: of thin thcrmorl.l,liL" III a rigal frame. The pla!\lic can be "'pOI- healed [0 1~Il'illl.lIe ~11tl'raI10n of ... ocl..t.::t fit. It adhcre~ to the ~ I..ill better Ih;Ul doe, rigitl pla ... tic. then.:b) improving ... u~pens i on , It conInbule:'\ to comfort b) dlM,ipating body heat more e rrectively ,U1tl re'lxlnd ... to cha nge ... III amputation limb shape llii the patient contract... and re laxes variou!-. muscles.

S,me's Socket The patient \\ith a Syme's amputation can u~ually bear sigmticJI1t \\eight through the dhila l end or the amputated limb. Con"'queml). the Syme"s ,ocket (Fig. 32.7) does not need to pro\ ide proximal loadi ng. The socket Lrimlines (edges) are . . lightl~ lov.. er. and the fromal and sagiuaJ plane alignment le~..; tilted. as compared to the lranstibiaJ soc ket. Rel ief for th~ tibial cre!-.I remains an important feature of the socket. If the dt>tai end of the Syme 's limb is markedly bulbous. the lower part of the medial wall can be made removable; the patient dons the socket. and then fastens the wall section in place.

{ 'nil Variant . . The 111O
co ndylar lu l l (h~ ..t!.XJ, Willdl ,\ ~1I 11 wllkly u cd J he cuft, a Icather ... trap CIll': lfl:JlIlg the Ihl).!11 IlIIlTIl'd'
Suspension During the sw ing phase of wa lking. or whenever the wearer is not standi ng on the prosthesis, such as when climbing <;Ialrs or jumping. the prosthesis requires some ronn of suspe:n . . ion to ho ld it in place.

•

A

B Figure 32 8 I r Uhld-'I.tilC111(JOr.11

Figure 32.7 'i 11(' 109 III) ocl..el'tlltllh

'''" II

IIlmw U Yo III

", \..tl Yo

Ilh medl.1I open

lIullk Ihk IlIIn

~hlhhl.u l:1I1I

II 1l('11 1011 \J( pylllil h III<. \\ Ih "t \( II h1(t

'I

!\

ttl dl ... I.l1 .III,lI.hllll'1I1 1\ I...ntmn .\, I hl' "'Ulfl'OIl l111pI.1I1I, 11\1.".11 po" ... III Ihl'

' UI!!II. . t1 ,tpPHl.lI.h

O\,\('(llIIfI'.I.tI(IIJtIll

1.1"'1:11 bonL' r ilL' po", PIOllll tk ,11101l J...tl lhl' "'~IIl.lItd IIX\...III10 a IlU.'Chilll i'lll III Illl' I'IO,ll1l'''', () ...... I.·(lIIl1l·~I.I\HI!l l·ll1nll1.I1(,.... lilt: Ilt:t:d for nthl'r ,u"'r'll'n ... lon ,ll1p.II,IIII\. Iltml·\.l'r, Ihlld draumgt: . 111(1 Inlt:lIl()1l
Brim Variants The pro'lhc ... i, mOl) Ill' ... U'Pl·l1lkd h) II, ,nl"I...I.'t \\.111, eX lcndl!d pro.\llIlall y. With ,\III"CII(lI/cl1/(ll (.\( ) \/I'/kll\l(l/, (Fig, ~2.1 1 ), th l! medial :llld Llll'l al W~I II , 1.'\11.'11(1 ,Ih\l\'l' 11ll'

Figure 32.9 Tramtibial S u~pen s i on Sleeve. (Courtesy or Otto Bock. Minneapoli,. MN 55447-4467.)

femora l cpi!';olld ylc~, Thl.' Im'dlill \~a ll h,l\ II pl.I\IK \"l'd).'l· When donning the pro,lhe ... I.... Ihe du..·11I 11.· 1110\\.· ... IhL' \H·d~l.·

plll!';CS Ihe arnpu l ati on hll1h III IhL' "'()l"\...l·l . Ihl.'l1 pl.lll·" Ihl.· wedge bel ween the ,oekl.'t and Ihe IIIl'drill l.'plI.:ondyk 10 retain the proslhes i, on IhL' IlI1lh. Altl.'l'IliIl IVc,,'ly. I lk' "l·tI).!.l.· ca n be incorporated In it hll L' l' : 101' dOlllllll}!. IhL' palll'lIl appl ie . . Ihe liner, and thl.'l1 IIl 'l.'fh th e !rlllh. \Vllh 11I 1l'l 11110

Distal Attachment Very secu re uspension is ac hi eved wi th the usc of a ... ilicone sheath wit h a di stal metal pin (Fig. 32. 10). The sheat h clings to the skin. The user inserts the sheathed limb into the prosthesis, g uiding the attac hed pin into a receptacle in the socket. During swi ng phase. the pin mechani sm prevents the prosthesis from slipping.

the sockel. SlIpmcondylal "'lI'PCJ1"OIl IIllll''''''l'S IlWdl,rI l
adju'table.

liner with distal locking pm

$.or./f:!t 001

(

Figure 32 11) Tr r erred a i l e Iotl

"I l OS al

ng mecJ;jr ' m

J"

~ 'Y./I

Flyurl. 32 11 (',1111",1 ,I "If' III J "Wllh ',N 11111111 ,"" J I III h III~ I' ,I 1/" I. wl/.II I .,IIlV ,,' J I fI.l 111'/ 0"",1." wcd U Jlc /j Ifill

ChapIN 32 P""theti",

1239

Figure 32..12 -, ran<.ub,al prO\thesis with ~upra.condylar/

uprap".dteJJar (SC/SP) "oUc,pensicm. Figure 32.13 Tramlibial pr~thesi'i with leather thigh corse! "uspen:<~lon.

hC\entmg a contour of medial and lateral wall~ c,imilar the supracondylar <"u')pension, the s upracond ylarl su pro potcll o r (SC/S P) , u; pension !Fig. 32.12) 01;0 fealure·, an anterior wall. which termjnate~ above the patella. The ,hort amputated 11mb is well accommodated by SC/SP \u\pcn\i(Jn. -fhe high anterior wall may interfere with kneeling and prc\Cnt<., a con\picuou\ appearance when the wearer \ltS. If)

Thigh Corset S(lme individual, with very ...en .. itive skin may benefit from thigh cor~l \u.,pcnsion (Fig. 32.13). Metal hinge~ attach (h':.tally to the medial and lateral a .. pects of the "ockel and pr()ximally to a leather or flexible pla.,tic cor~et. Cor ..et height., v,,-ry and may reach the i<.,chia] tubero.,ity for maximurn weight relict on the amputated limb. The hinges Incrca<.,<; frontal plane stability, and the cor<.,ct incrca ..e\ area frJr welghtbcanng lo<.tu di<.,tribu(ion. The rc~ultlng pro~the­ "11\. however. if; heaVier <.tnd apt to fOf;lcr pi\ ton acti on hc<.:<.tu\C the hjngc~ have a ~ingle pivot joint thfJl cloe ... not l:Irtl(;ul<.llc col/incarly with the <.tOl.ilomical knee. Prolongeu u"oC {)I
Syme's Suspension The Syme's pro~the"i~ is suspended by the contour of irs brim" and socket waJJ~, withou t a cuff or other su')pension mechani ... m.

Vacuum-Assisted Socket System Used le~s frequently with tran~libjal amputation~ oWing lO reduced surface area of the residual limb. vacuum a..~sisted ~U\penslOn may be another alternative for wme pallent!). rhc flarmon) Volume Mana,:emem S.ulem (Fig. 32.I-U uniquely combine\ u~ of a pump, liner, and ... lec\e to achieve elevated vacuum in an ainlght environment TIle vacuum is believed to promote fluid exchange. reduce moi~­ ture buildup, regulate volume fluctuation.,. and mcrea.'tC pmpnoceptive awarcne<.,<., of where the limb i<., in space.

Transfemoral (Above-Knee) Prostheses IndIV iduals """h mnpu[ulu)fI Ix't\l.l't:n Iht' kmoral t'PIcondyle .. and grcHIL'r trnc.:I1.IO(r.:r .Ire liltr.:d \l.lth In.lnsfemOnil

I IIl h:l Ihl' .. turd} L·,mlo..l·kt.11 .. h.mlo.. or the cndo ... kdelal Ilt: u ... t:d hL'L' hi'e .",'_.-4, " ·fl,·to: I." a er l .reate ... a

... h.1l11o.. 111.1\

more pk',l"'lIlg i1ppt..'.\LII1((', paIlIUII.lrI) III Ih\.' Io..nt::e art::a . •lIld \... adlll ... I,lhle: III "lddJllOn. II i .. hghlcr than.1Il e,\o .. kele_ till ... hanlo... l.lInitcd n: ...can.:h I" mcolll:lu .. i\L" reg.lrdmg the Illern 01 light pro ... thelll· \\eight.~') Problem .. of durahtlll\ remalll.p.lnlcul.IIl~ at the Io..nee. \\ here con ... tanl bending

(;1

Ihe JOIll!. e .. peciilll) kneelIng. accelerate .. delCriorallo~ 01 the rubber cm cr_ A rOialOr \\ilh or \\ ithout a .. hlX;\., ab...orhcr l11a~ Ix IIlcorporaled 111 the ... hanlo.. ...

Knee Unit The pro ... tht::lic knee enable .. the u... er 10 bend the Io..nee \\ hen . . ining or lneeling and. III mo .. t tn ... tance ... al ...o penTIl"" knee fle\ion during the laner portion of the .. tance pha .. e and throughout the ~\\ tng pha . . e of \\ulking. Commercial knee umt... l11a~ be de .. cribed according to four feature,: II) 3'\is: ( 2 ) friction mechanis m: (3) extension aid . and -I mechanical .'irabi!i:er. ~1an~ combinalion~ of reature~ are ayailable: nOi C\·ef) knee unit ha!> all four component ....

Axis System

Figure 32.14 The H3JTTlom Volume ~ 1JJlJgernent S\,lern. ~Coune ...~ ofOno Bock.. ~h~ne.apo1i .... ~1:\ 5:,~..n.) .

prosthe . . e ... _ Tho::-.e \\ ho"-e limb ... retain the di ... tal pan of the femuT can \\ ear a l..nee disanlculation pro ... Lhe.;,is. which diffel' from the rran ... femoral pnhthe ... i!:> in the 1) pe of lnee unit and -.oc et. If the amputation i ... proximal to the gremer trochanter. the patient cannOl retaIn or control a tran ... femoraJ pro ... the"'l ... and i ... therefore 3 candidate for J hip di ... aniculation pro ...the:'-l:'-, The rran"femoraJ prcNhe"'l ... con ... i ... b of (1 t ll-ankJe a.;"....emhl~, ~ I ... hank: 13) l..nee umt. tof I ... cx'ket: and I:' ... u ...pen"'lOn de\ Ice. -\Ith .•ugh the ACH fOOl i mo ... t commonl~ u-.ed for trdIl remoral pro the...,e .... the ,mf1e-3.\.I'" 1001 i ...... ome\\hat more frcquentJ~ pre,,-nhed for tran ... feITh rallhan tor lr.ffi,tib-

at pro thc'!-C .... The . . ingle-a\l'o

fOOl rea(~e ...

The thigh piece can be cOiUlecled to the .shank either b~ a .. mlple s;I111le-atis hill1?t' (Fig. 3::!.15). \\hich i ... the u.. ual arrangement. or b~ polycclllric lill/..Olll" hee Fig. 3~ 151. Polycemric "'~"'Iem.s (Fig. 32.16) ha\e four or more pi\OlII1g bar .. and pro\ ide greater ~tabilit~ to the lnee. ina~much as the momentary center of knee rotation i ... po"'lerior 10 the \\earer"~ \\eight line during mo ... t of ... tance pha ...e.:'" Th, .. !:> I~ Ie i.., le~s common becJU',e of greater comple\lI~ and becau .. e other mean ... are J\ ailable to ... Iabilize the "'-nee

I'"

Friction Mechanisms In the :,imple .. t ..en . . e. the leg of the tran~fem(lrJI pro ... the," i ... a pendulum ... \\ inglllg about the knee. For {he elderl~ indi\idual \\ho \\alk... ... lo\\I~ for ... hon di ... 1Jnce .... 3 ba"'lc pendulum b adequate. \ lore energetic \\ alker,. ho\\ e\ er, benefit from adju'ltable fncllon mecham ... m .. Ihat modlf~ the pendular 31.:1ion 01 the J...nee 10 n:dul.'e the a ...: mme10

the loot-l1at

POSltlOO \\ 1..P. mWlma) J.J"Irlu.:~uon of \\clghtbe'anng load. e en k<.: ... any f t mdudtng the energ~ ... tonn&m~ de-s ~ CJ.f'I ~ ffilorpcr.:Jted III 3 Ir:m ... lemoral prosthe I A ( mpaTt.-d "lIh "carer... ..,f tr.m ... llhlal pn..'1 ..... these hOYoc\cr m) t \Ioe' :-crs <.'f tram.femoral pr: ... lhe~ ... do not 3d the ~the l ru.' ::or. U .) (\.'mM:'qucntl~ It· ... ' ~ v.ou d be lored.md n: I a..~d U:.l d namh.. "~"ron'c

rei

fOOl

Figure 32.15

\1 :;-IC:· ..

(hapter :12

Pr..,~thctju

J26J

I,

UIl\!iH)'lrl~ . 'fhe d'lrnp c'.'Iy 10 h}()'\en or lighten 10 change the ca'>C of hlt l." Tnnllon. A more V>phl\IIL
dampen impact.

Medium

Figure 32.16 I'oly(;cnlm; knec unrl dc\igncLlIO providc \wbil II)' dunnJl \1.1I1(:C (Courtc<.,y of O\\ur. AII\o VieJo, CA 92flS6.)

hctWCCIl thc motion~ 01 thc sound and prosthetic legs. If the knee docs not have <.,ufficicl1I friction to retard Its natuwi pcndular a<.:lion, the individua l who walk\ rapidly expencncc\ exccs~IVC knee flcxJ()11 al the beglllnmg of ~wing pha<., c ,md ilorupt, ollen nO I ~y, knee extension at the end of \ wlng pIHl..,e. Friction rncchani ... ms change the knee swing hy modlfymg the "'pecd of knee mot ion during various palh I)f 'lWlIlg pha'lc .md by affec ting knee '>wi ng accordin!! to walkll1g sp(:ed. Two intcrrelated issues involved in Irict lon mechanism are the time during swing phase when II"I(;tIOIl alfech the knee unit and the medi um through whi<.: h the lllec!1<.IIlI..,m operatcs.

The medium through whJ(;h friction i ... applied mflueni.:cs pcrformam;c . The u.. ual medium i., .\/i(/tm: Iric/if'" contact of one .. olid ... truclUrc on another. A clamp ~lidmg about the knee boIL i\ \implc and JIlexpeno.,ivc. but it doc!; not accommodate automatically to change~ in walkmg speed. A more complex approach i\f/uid /rinion. either oil (hydrauluInui()Jl) (Fig. 32.18) or air (pneumatic/rinton). Unlike ,>Iiding rriClJoll, nuid friction varies directly with velo(;Jty. Tlms with a hydraulic or pneumatic unit. if the wearer suddenly walks faster, the knee increa~s friction instantly to prevent excesr.,ive knee Oexion and abrupt extcn\ion. Consequently. the movemenLS of the prosthetic and sound limbs arc morc symmetrical than would be the ca<;e with c;liding friction. Oil or air is contained in a cylinder in the knee unit. A pir.,ton dc<£ends in the cylinder during early '>wing. causing the knee to flex. The speed of piston de,cent depend' on the type of nuid and the walking speed. L ater, the piston ascend,>, extending the knee. ll yd raulic units provide more friction than do pneumatic device,s. Both types are more expensive than the simpler slid ing rriction designr.,. Va ri ous combinations of friction

Comiant and Variable Thl: mo.." popu lar knee unit has con ... tant friction (Fig. 31.17), generally a c lamp tha t grasps the knee bolt. 1l1roughout a glvcn swing phasc, the amount of friction is

Socket - - - \ Friction --::-~:::JJ"7:~_+adjustment

Clamp around knee bolt

Shank - - - + t - -

Figure 32 .17 ('IHI 'lI,tll! fmtloll .\ uc.:hil'wd hy" clamp Ihul Clll.:lrdl.' \

Ihe

Io.nl.'l'

hull and pro\lIdc ..

iUlec Ihroul!hoUI \ W1Ilg pha",,'.

IlIl.' \ilrlll" arnOW' 1 of

Il'",,,,,

Figure 32.18 i\ I,UIl'h 'lIl!!k .1\1' ll\dr,llIlt ... \..Ill·~' lIlIIt ,\qll~ IS'S I; Ilw 'l.m ...·\·l'tl1lhtl

'.; olllloim '\\1111-' .Lnd ,1,II1U' \ '{llllllli

Il',LIIH\' ,dlm\\ Iuul {tH'1 ItI\11 'I.HI dl" l'L'1l1 \t"~ILL[1l"\ {If ()"ur, ,\lhll VIL'ILI , (

\ 11,"(1"1(1 , \

Stabilizers :\10')t k11l':1.:, Ulllt do 110t haw a ~petlal devJ(;c to If: "I!a~ La hlllly.1 hI.: patient conLrols knee aciiOIl hy hlp mfJtJOn. 1 by thc alignment of the knee 111 rdalllJll t( other c mpc;,. Ilcnh of the p~o"'lhe ... i"' .. , he pro..,tht;IJC knee JOllll IS, U ually allJ!lled po ... tenor to a ltne extcndll1g from the trochanter to the ankle (lKA Imc}. The patient y,:ho ha<; excellent I)al '1I11.:e and Illuo;,cular control may have the knee bolt plaCed on the line thu ... treating TKA alignment F.lderl)- or debilitated pi.llienh may benefit from a stabilinng mel.:hani m a.., do some people who walk on ver), rough Lerrain .... uch CIS hUIlLer').

Manual Lock

Figure 32.19 0110 Bock C·Leg i!, a microproces~or· con trolled knee with force ~e n <;o rs that detcci loading or the fool and ankle and the prcci"e angle or the knee joint. (Co urt e~y of 0110 Bock, Minneapolis. MN 55447.)

de')ign<; are manufactured. !)uch as constant sli ding friction. variable sliding friction , and va riable Ouid friction. Microprocessor control (Fig. 32. 19) utilizes electronic sen')ors. which delects the rate and range of shank move· ment 50 or more limes per second, providing almost instant fricrion adjuo;,tmcnt to changes in the gait pattem. 29 Units are programmed with a computer, and may provide stumble recovery. accommodation to walking on various terrain and bicycle riding. while olhers have a lock ing oplion.

The ~imple~t mechanical ... tabilJzer is a manual lock I Fi!!. 32.20), in which a pin lodges in a receptacle and 10;, relci:l~d only when the wearer manipulates an unlockIng le\ cr. \\ ncn engaged. Ihe manual lock prevent", knee fie:\ion. The u-.er I'" sccure nol only during early ~tance. but throughout the entire gait cycle. To compcn~ate for difficult) In ad\anl.:lOg the locked pro~thesis, the shank should be shonened approximately 1/2 in. (I cm). Another problem IIlherent with the manual lock i<; the need 10 dl..,engage Jl ""hen the \\earer "'Ib. Nevcl1hcles5. some older adult.., prefer the ~tabilit) of the locked knec.lO

Friction Brake A more elaborate stabilizing . . ystem. the friction hral.l' (Fig. 32.21). provides very high frictIon dunng earl) stance. resi~ting any tendency of the knee to fle\. One design. IIlcorporated in a o;,liding friction unit. imohe'l the mating of a wedge and groove upon loading. a..,~umlng the

Extension Aid A mechanl')m to assist knee ex lcmion during the lalter part of .. wing pha:-.e is common. The ... impl cst type is an cxtem
Figure

32.20 \1anulIl ]...nee 10(;]... on

it ... Ingle .1\1'"

Io..ncc UlIIt

Nute thai tIm configuration hil' a pro:\lmal rclcil ...e attal:hed b) a ]ugh-den ..... ) pla.,tll: \\lre 10 the Io..nee.

<- haptcr- 12

Pr-mthef:J~

B

A

Figure 32.22 Quadrilateral <;ockets. IA) Retible socket rigid frame. (B) Rigid pol}ester lamlnale socket. Figure 32.21 Single-a"i ... lnee unit ~ith con.,t3I1t friction and el,£ht·;.I!.:uHted fnction brake. The \\edge-... haped surfaces in the knee unit and upper . . hank are forced togelher during 'o\elghtbearing [0 lock the knee.

knee is nexed les ... lhan 25'. Anolher ve~ion of friction brake I., found in several h)draulic units: during early !)tance. additional tluid resistance markedl~ retards piMon descent wuhin the flUid Cj linder and thus stabilizes the knee. From mid~tance through heel contact. friction brakes do not Interfere \\ ith knee motion. In addition. they do not Impede the patient y. ho transfers from standing to !)itling Such de\ ices add to the cost of the prosthesis and. if improper!) u.,ed. rna} not protect the patient from falling.

1263

In

Quadrilateral Socket The traditional transfemoral socket shape is quadrilateral when vie\\-ed from above (Fig. 32.23). The socket fea tures a horizontal posterior shelf for the ischial tuberosit~ and gluteal musculature. a medial brim at the same level as the posterior shelf. an anterior \\a11 2.5 to 3 in. (6 10

A

Socket A.. v.ith all pro..,thetic ..,ocket". the transfemoral one should be a lotal-contact receptacle lO distribute load o\er the max-

Imum area. thereby reducing pressure. Total-contact titling

at\() pro\ ide.., counterpre..,wre

lO assist venou ... return and pre\ent dic;,ral edema. and enhances sensory feedback to foster better control of the pro<;Lhcsic,. \10"'1 tran-.femoral ..,ockets are made of a flexible pla.... he c,ocket (Fig. 12.22) encac,ed in a rigid frame ... 0 that the '4earer rna) lran ... mit ",eight through the distal component~ of the pro"the\l\ to the ground. The Ilexible plasllc provtdt:'i sensoI") mput from external objects. ~uch as chair.... Tramlemoral ~ocke[\ are designed 10 empha"'llI! load In:;: '" pressun:.tolerant ..,trU(;lures. o.,uch as the gluteal musculature. sidc~ of the thigh. and. 10 a le ......er c\h.'nt dl\tai end of tilt! amputatcd Itmn. Thc ..,o<.:ket Olll .. t a\OId nees J\C prt! ...... ure on the.:: puhu.: ,,)mph)'>I" and ~mll.'lIlll

c Figure 32.23 QU.ltlnl ..lh'ralllL'"hll' '1,1.1'1 III n~ld tram,,\ lev,l,."d IrlHn ,Itltl\l' I \) \l1Icmlr \\JIl tR \kdlal "all it l "(hi rnu \\,111 Illl l.IICf,1I \\,111

1 ~h~

1

1 )"",4..11 Rd,.,hilil.Uiun

\.111.

hl~hl'l 1t1 dppl~ ,11""1'.14.'11011\ dlTl'l'll'd lorl'l' to Ihl'

thigh (()ll'I.lIn Ihl' l,dll.llll1hl'IO'II; Oil ,'" ,hl'll. alld a 1,.11 l'r.tl \\.111 th~ ',IIlW h\.·I~hl ,h Ih~ ;!IlII'IiOI \vall 10

;tid III m~dl,lI 1.lIl'r,11 ,t.lhllll.II"'1l CnllCi.I\C n.:lll'h arl' (I) anle nor Illl·dl,ll. It)r thl' pl~''''lIrc'\Cn\IIIVC adduc.:tor longu\ tl'fh..hlll, (~) I'n'It.'l'Io1 mcdlal. for Ih e \cll'o.illve ham\tring l\.ndtl!1' ,md 'l"jalll' ncr\'l,~; (_~) po,terior I'Heral . 10 permit lh\.~ !!Iulclh 1lli.l\lI1lU, 10 contraci :.Ind hu lge without being ('rt)\\lkJ: 411H.I (4) antcrior 1~lIcral, to a ll o\l. adcquate room tl)r Ihl.:' rl.:'clu\ fCl11ori,. T he anterior wa ll has a convexity, S\..·.lfp.l .... bulge, to maximllc prc:-,su re di:-.tribuLion III the \ iCIIlIt) of the femoral triang le. The la teral wall may have rclich for th e gre~lI cr trochanter and the di s tal end of the femur.

Wl'.III.'/"" uU1troi oj the pro,thc"ils, SlIght Mx:kct OexlCm I') dL',lIahle lor several rca\on,: (I) to factlilatc contraClJon of the h'l) CXlcn,or,; (2) to rcuu(;c lumbar lordo',ils; and OJ to prnvl(,lc a lone through which the thigh may be extended to pcnnJl the weltrer to take SlCP\ 01 approximately equal length. For wearers of quadrilateral ...ockcts .... oeket nexlon al ... o enhances positioning of the ischial tubcro,ity on the posterior bnm."

Suspension Three means are used 10 suspend the Iransfemoral prosthesi,; (I) total suct ion, (2) partial ,uction, and (3) no ,uction.

Suction Suspension Ischial Containment Socket

Suction refers to th e pressure difference II1side and

An aiternate de,ig n (Fig. 32.24) type is sometime, called the ('ol1lollred adducred trochonrer-colllrolled ali~nmeJ/t mCI/lOd. 3U2 It ~ wa lls cover the isc hial tuberosity a nd part of the i~chiopubic ramus to augment socke t stabi li ty. To increase fronta l plane s tab ilit y and minimize bulk between the th ig hs, th e m ed ia l- la tera l widt h of the socket is narrower th an thal of th e quadrilateral sockel. The anterior wa ll is lowe r than in the quadrila teral socket, whereas th e lateral wall covers the g rea ter trochanter. Weightbearing occurs on the sides and bOll o m of the ampu tated limb.

the socket. With suction suspension, internal socket pressure is less than external pressure: consequently, atmospheric pressure causes the socket to remain on the thigh. The soc ket brim must fil snugly; a one-way air-release va lve located at the bOllom of the socket enables residual air 10 be expelled.

Fit and A lignment Regardless o f s hape and mate ri als, the socket s hould fit snugly to minimize the risk of c hafing and maximize th e

Figure 32.24 I {lllal If

~I'I NCIIl It II IC'I,IIIV,'ly 1I,II111W Melil,d hllill (( ) l'o,It'l lllr hilln

tA) A/lllfl'" blllil In, _ _ _ I I.

Itl'x,hk Ilil'I,ll'lIllll il l IIll'd'ill Idlt· I,.1 d'llIt'll\ltlll

(11/11.11111111'111

J

,,, •• 11

.. ,01

out~lde

Total Suction Maximum control of the prosthesis, without any encumbering aux ili ary suspension, can be achieved only if the socket fits very snugly to give IOta I s uction (Fig. 32.25). If the patient expe ri ences changes in amputated limb volume, s ucti on w ill be lost and an auxiliary suspension will be requ ired.

Figure 32.26 Qu.lJnl.nt'rJI r.1nl.11

'th:11011 '(X'~el

\\ IIh ile,i.lIl

t\.nkt..!~t'

Partial Suction -\ .. (..... l't th.u t .. ,lightl~ loo .. ~ m.lY ~11.\ble part!.ll :::.uetion ...... ~lbl\Jn The pJlielll \\eal"' l''In(' or more ... oc!.." or a liner mJ.I.:k- l1t '11i("OIlc.' or other .. ~ nthellC nlJ.lenaL Bee~lU..,e "I.:\.'~t'l tit I' kx',er. ;m 3U\lliJ~ ,u'pen"'lOn ,1Iti I' needed. either J I.1PrlC ile,iafl bandage lFig. 3'=!.~6>' or .1 rigid plJ .. II": l'r met~11 hlP joint and peh ie band tFig. J:!.~'). Th 'C' JIll, enl.'ircle the peh i .... The Sile,Lm bandage al ... o ..: 'ntO"I .. the tr.ln'\('l"'e plane onent,uion of the pro ... the,is on the thigh. \\ hile £he hlp JOInt oc,trict.. t.r.U1<;\ef'e and frontJl mlJlton .u the hip. The JXh ie b.md add ... \\eight to the pro,the'I' and mJ~ Intpt..'..,e un -omfortable pre ..... ure 3£:.11n"{ the hJf'l' \\ hen the \\ earer ,It..

Figure 32.27 Quadnbteral part131 !lUCllon ,ocJ...et \\ 1m rigid pla::.tic ~h ic b.md J.tl3chment (to \\ hich a leather or fabric belt i ... ..,ecured Ihal \\ rap' J.TOund the pehi..,).

10\\ er Ie\ e)~. An:

pro~lhetic

foot can be used \\ ith either an

endoskelt![J.1 or e\ol.\l..eleml shank. The major distinction, therefore. i"

'\0 Suction If the 'lXi-.c:t hJ' J. di .. tal hole but no \ahe. then there I.. no pre",ure dltterence bet\\een lIl,ide and oUI,ide the ,od.c:t. The ..:hent \\ear-- one or more ,(X,,!.., and reqUloc' ;1 pel\ Ie f'I.:mJ, The relall\eh Ilx"1 ... e ,(x'!..et make, donning e.l!>~. but hmder' ,-ontrol the pm,the'I' and 'itting I.:omfort \nOlher J.ltemJti\t~, I' the addition of ;1 tmn .. femoral ,u,pen'llm "Iee\c (Fig. ~.:!.~~). Q"eoIntef!r.l11on i, the Ilc!\\e"[ allemati\!! to ,UClion One or mor; metal po,t" Impl.lnted tn the femur 101.:!.. lIlt f\lure c:mbedded tn the di .. tJI portJl"1n of the

0'-

In

the prm,lmai portion of the prostheses.

Knee Disarticulation Prostheses \\ben amputJtion I" at or distal to the femoral epicond: Ie ... the pallent ,hould ha\ e e:\cellent pro:-.thetie control

,et

Disarticulation prostheses Jndl\ Idual '" Ith knee or hip J".lrtl(ul.1Ilt1" \\eJ.r rrlhlhe,c, thai ndud

Ihe 'dIlle: lll ... t.11 (,(llll[Xlllent ....1' rnhlhe"l" Itlr

Fig ure 32.28 fran .. tt'nwr.JI .. u'pen .. ,\'" 'Il"\.'\~ Otll,lk",,:1.. \hnne.II'Io"h ... \1' "" ..·r

l \lurtC"

\It

1266

Ph) ... ical Rt'h:thililation

h.:~au,~ ( I ) thl ~ h h~\t.·I;I~I..' 1'.11 ,I 1lI<\\11111111l : (2) IlHl't (lllhl"

hod) \\ CI!!ht call lx' horne Ihrol1!!h thL' dl,I'11 I..'nd (ll IhL' femur: ;tnd (Jl 11ll' hroad c plc(lIldyk, prO\ Itk rot.Hlllllal 'I.lhiht~ The prnhkm prl.."l..'ntl"d h) "'[11..'1..' dl'Mtll'lILII[~)1l I' prim;lril) l'll:-.nH~tic: \\ hell the IIld1\ idllal 'II'.. thl" thigh 011 the al1lput~lI(!d 'Ilk 111.1) protrudc .... lighti). The "'11(,(, (11 ......11 licuiatlon pro . . tI1l..·,I, ( f-\g. ~2.:!9) h:h it stre'llnillled "'111..'1..' th~1I IlHnil11ilC, prolru,ion. a, \\ e ll as a 'pcTiall) de'lgncd ,~X'k('t .

IlHlllnllll..·

h~tlfilllll .....

.Iddt'd

!!lIgh

h:nl:lh,

()Ilt' 111.\\

pUt·lIm.lIll', and ... !Jdlll~

\ lh\(hi,'

un\log

trldl~\n lIIll", \\ Ilh III

\\ IIIHlU! pol) lTnlnL' link,I!!L' I 'l'n \\ tlh ,\ "','\(.'\."1.11 "'nl·\,.' UUII, thl' Ihl!!h \\ III he ... li ght l) h\n~l'L (\lJ\'I..'4UL·IlII~, Ihl~ ... Il.lnk " ,hnII L' l1l'd ~LJIII\i1kntl), "'0 Ih ,\I \\ IlI..'n tilt., IX'I"'(IJl .. 1,lIlll ... tht.:' I'd, i ... i .. I l'\~ 1. \\ 'lll' lI 1111..' mdl\ Iliu ,}1 'II-.. tht' thn:h \\11 the pn)sthl..'tic ,uk \\ ill Pl't1It'l'\ ... Ii~hll)

Hip Disarticulation Prostheses

Socket

\ 11Ip dl ,arllc uJ.illoli pl\l ... lht· ... I... (I I!! '~'(H I'" rlllt't!

Two types of . . Od,!;!h :Irc c urre ntl y in u.sc, BOlh arc Jll;\lk of pla . . tic and usually term in ate helo\\ th e ischial ll1hl"rn,it). Generally. no additional . . u.spcn.sion aid ... arl" needed , One \cr~ion feature .... nn anterior opening. 10 accommodatc ~l bulbolh amputated limb. After the limb IS in'l"ri l"d. the wearer closes th e soc"'ct wilh lacing 01' pre:-.. . ure- Ioop tape . . . The other de . . ign ha . . no anterior opening. and IS :-. uit ::tble for limbs thai arc no t bulbou . . ,

hl,\

"'lln \\ IIh amplI t,1I 10n ;lhm L' Iht' g r1.'iIlc.'r IIl'l\.."h.IIlIl..' 1 l' L'I)

tr;\Jhkllh)raIL Ul lllll

1\' 1110\';11 01 [h~'

Ilt.'r

. . hllil

knH'I.ll hl';\llirom thl.· .IlY[.lh

l h ip di ,;lrtil' ubtillll), ~ll IL' IIHl\.lIl1Ith L' knllll dml ... tlJlll'

pmllol1 ~l l [ill' p~I\IS ( fnlll ... pt'l\k llllllHltntinn. ;\ls\I "'lh\\\JI i.h hl'JlIIIX'hl'('tnl11) ). PIO ... lIlL· ...I.., ... hll pW\lllul k\t'\ ... ,\\.11\' commoJl hip, "'nec, ;Hlti Innl .1"L'm hlil" ilnd .liI!!IIIlh'IlI, hilt (hlTer \\ illl 1"I..'!!.ml to "'lld.. l' t dl" I~n_ rill' l'ndn"''''l'!t't.tI IluJ!h and , han'" prl'dOllllllall' hl'l-; Iu ,e Ihl') alhlld ,lppll'(I,lhl\' \\l'lgllt :>. ;\\In g Illtil csl' 11l;\ ...... l\ l' Pfl):>. thC"'l"

Knee Unit Several units are sp(:c ifi ca lly manufactured for "'ncc di . . articulalion. All have a thin proximal attachment plate 10

Socket rh ('

IIlg

Figure 32.29 Knee d' .... IIIIU Jlalio ll

111O\ llIl' ... . ... ", 111i SAC' IIII)\)I,

c ndll ... kch:tal .. hall~ pol yn' IUnt hylil;lull(,: !r K' lil1L "r lt'i,' UIlI1. ,Jlld quadrilateral ,>(x.!-,.cI w llh \ Ul lIlII l ,1l"pi.'n \ IlJll

h.l ... ic 'O('!...I..'I I... p1.I ... 111..' Illulded 10 PH)\ Ilk \\1..' I!!hthl'.lroJllhe '1bILitl'I;II I ,dl l illllll'k' hhlt ~ ,Inti huthll..'''' (j!hlll·,tI

Figure 32,30 I tiP ,li .... lIlIlL ll.IIIOIl prml ht· ... I ... \~ 1111 S:\{ II h,MI,1 , lIalll. . "' 1Il ~k .I ~ I '" 1. 1ll'l' ,11\lIl'\ l l'lhltlO .lId ,rtl~ It ,1\ 1" hip .... 1111 l'\ll'Il'oIlIlI'1Il1. .Iud II ~Ld 'II(, "l'l

l'lIdo,"L'il' I ,tI

(.'hapll"r .'l2 Prolt.hclin

1267

11lU ... ( ulatllre), I"he pcr"'(HI \\ Ith tf;\n "'!ll' I\ IL" :.IInputatlnll ", hn

dnc'" not rct.lIn the Ip ... IL.l! e l.tlluhcro"'lIy Or Ili aL nc ... 1 hOI ... a . . (K~ct \\ 1111 :1 hlghcr pnl\lI11allllll1l1nl', "'0l11etlil1e.., CI1 t:nmp" ...... illg Ihe 100\I,~1 thora\, I hi ... Illth"u.lual ", upporl \ weig ht on tlK' I'cmi-lllldcr III the pel vi .... o n the abdol11en. and per thlP'" un t IK' 10\\ er ri b .... Hip Unit JOin'" provide hlp ncxlOn. The joint\ have a n C\tcn ... l011 aH.1 to bia~ the pro .... the ... i... toward the .., tabl e neuIral po ... lli on. Po-,itioning the mechanical hip anterior to a poinl corrc..,po nd ing to the anatomical hip al"o con tflbut e" to Illp "ability. The jOll1t i, ,e t below th e nornlal hip , '0 that \\ Ith . . ittl ng. th e pro..,thctlc thigh will not protrude unatlrac tive l) . \;lI'IOU'"

Stability Se\cral atlribute~ comblllc to make the hip disarticulation pro~thesis vc ry ~tab l e. namely the hip extensIOn aid, anter ior placement of th e hip JOIl1t. pos te rior place m e nt of the knee unit. and a kn ee ex te n ~ ion aid. The pro"the,i, mal be shortened s li g htl y. primarily to aid clearance during 5'" ing phase. but al~o to encourage Ihe wearer to apply maximum weight to the prosthesis and Lo inc rease stabllit) .

Socks, Sheaths, and Liners All indIViduals wi th LE amputations. except those wearing trans femoral prostheses suspe nded by total SUClion or tho,e usmg a sheath . require a supply of clean socks of appropriate material. ~ize . and shape. It is expedit iou!:, to order at lea~t a dozen ~ock~ at the time the pro\the~is is pre,cribed. '0 that third-party payment may cover thi ' relall\el) ine:\pensive bUI Important accessory. Fabric socks are \l.oven in vanour, thicknesses. referred to a, pi) de>Ignaling the number of thread, knitted together. COllon ,;ock.s absorb perspiration reachl} and are the lea... t allergenic: the) are made in 1\\0-. three-. and fj\c· pl~. the I",t bemg the thicke,t. Wool sOCKS proVide good cu ... hloninl!. v.o"en in Ihree-. the·, and six-ply: they arc e'p
but doe nol ab ... orb much persplfallon. A nv on heath crealc") a mooth ~urface

0\ cr

Figure 32.31 The Jceros~ ~ Dermo is an example of a locking silicone gel Imer Ihal provide~ a cu .. hioned residual limb environmenl ac., we ll as suspend .. the pro.,thesi.,. (Courtesy of Ossur, Ali,o Viejo. CA 92656.) cotlon or wool. Silicone. urethane. and other "ynthetic ~heath " provide excellent shock ab.,orption and abra... ion resistance; they also can aid in c,uspending the socket on th e patient 's limb, and are de,igned to be worn next to the skin . They arc, however, more expcnc.,ive than fabric sock~ or sheath s. It is common practice to add more socks as the amputated limb shrinh. Nevertheless. when the patient require" a lotal of IS-ply of socks to achieve sn ug fit, the '>OCket should be altered or replaced by the prosthetist. Exce,,;ve sock paddlJ1g d"tons the welghtbearing characteri'tics of the socket. losmg the effect of 'trategicall y placed buildups and reliefs. Rega rdl e" of material, the ' hape of the ,ock or ,heath is important for comfort. An interface of proper .. ,ft tit ... smoothly "ilhout Wrinkling or undue ' tretching. The or sheath should be long enough 10 tcnnina le abo\c the most proXimal part of the ,ocket. Silicone gel \uspen.,ion liner... are another fann 01 Mxt..:cr· re"'lduallimb interface. Thc\.C liner... provide cu.,hiolllng ilnJ added comfon to the rec,idual 11mb a, ",cll a'i funcllClO a a primary or secondary \u\pc.:n\lon s)~tem. Some mdUlh.- 1 n\ Ion outer cover. v.llh hner Ihld.ncsC) t,(penn!! UI 1.111) IUkJ ~a) be mdlcated for panlLularl) aClI\c U'k.'fli and thu~ "uh fragile or ~n 111'-'.' rc . . ldu;tl hmtx rhey ilrc ..... allahle In both oekmg IF m "\2 ~ I) .md ~.JI·1n de I~n\.

"x:.

the Ion

then... • reduclOJ!: the n . . k of (' h a 1-mg. cspet..:lalh. In h{)t .• much 5(.;arnn". Some .... C01lher md amclOg tho\e V. 111: t:' Iramllblal pro the I \\can:rs ilfl: able to usc a ",oman knee-hIgh mlcn wdtng If-he ampuldI
Prosthetic Maintenance (Jpcun:d

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PI.hll~ "'1K.~l· I '" ... hould hl' WtI,hl'd willi it dOlh dWlIPl'l1l'd III \\,11111 w,l ll' , Ihlll hll ... ,I w ' y "trail (l1I 1(lUIlI 01 ,"r1d 'Oil I' dl ... III II I hl' ... olkel 1\ Ihl'1l wllwd wilh a d'I !lIp. ,nap lilT dolh, .lIId <111('(1 wl lh n I,,: ... h lowel. III wtllnl l: hI1Jal c~, Ihl' "'mh'l ... IJOu ltl he wa . . hed CVl"Y l·vl· nlll!! ... o tlHlI II will 11(' l'OI llpkll'ly dry whell 11Il' pnill' /Il tlrl· ...... l· ... Ihl' lollowi rr g 111111 II Illlo! I Ill' II 1.111 ... 1<.'11101 al Mll'llOll v:dve , hould he hlu ... hed darl y 10 rtl1lllVl' WIl'lllll :lIId 11111. whi ch Il1lghl do!! IlIl' Imy apel lun.' Ilrl' VitiV(' ... IIOlild hl' In \l' lkd alld ICllloved only wuh om''''' 11I 1}!er .... hl'l:uu1'IC tool ... an: apt HI d:lIlltlge Ihe ilitern:rI IIll'LhOlIl,.., llI 01 ouler Ihread ... . Lt.'allll' l ('01 ... 1'1'" ... huuld he ~l'pt dry, U ... e 01 ... addle . . oap "'III kl'ep ka llll.·1 (: Ienn. If the Plllicl1t j, itlColltlllent. the tlll£h l·OI ... l' 1 ... hould I c made of lIexlhle 1}(Ilv('.,'('/' lOll/iI/au} 01 polypropylene. which arc Illlpe,violl'" 10 urine, SOl~l'l IlIlell'< illUde 01 polyct hy lcnc fOillll (;111 be w:I ... hed by hand 1I11l'J1ld wllte l wi lh mild .. c)!t j1. rin .. cd, Hild air dri ed (lV(·IIII!!"!. "1hey ... llOuld nol he .. uhjel:lcd 10 dll ccl "ullli ghl wllt'li Il'movcd 110111 Ihe pro ... lhe ....... .

,,"t'"

Knee Unit Slld,"~ friction 11lt.'l' halli "'lII' Il'lld 10 looscli wi lli wu l ~irrg

;.Ind Ihu ... ll'qUlrl' Ill'llmlll' Ilghtl'tling tn rclalll Ihe ollginal adlu"'lllIl'lll. Till' Il l·ljUl· tlCY oJ li!!hl elllllg dcpl'lltl.. 011 how llI11t.'h Ihl' Wl',IIl'1 wnl k.... Mn . . llInll , ha ve iI pail or Sl' I'C W~ ill llOll! or III Ihc Il'ill oJ Ihe kne.:l· lIllIl Ihat ean be fUrncd l'h)l~\\IW WillI .III AIIL'11 \'\lL' lll' h 01 l'OIIlIIlOIl "'L're.:wdri ve r. Allel 11lI11111!-! l'Ul h "l'll'W a qU:lltl'r turll . the.: clit.'J1t should v....J1~ Itil .11 il',e-.I) ,IlIIlUll"" 10 a ...n· ,lalll Ihl' cfll'ctl Vl'ne .... of Ihr adjll\lllll'nt. Sqlll.:'ilkll1~ ,II IIll' klll'l' 01 ;lItil'ulall'd tlnh.k imlie.:nte.: .. Ihe IlI,TtI 1111 011 Illl' luhlll'r OJ k it l',ll'O .. IOI1 hurnpt'l III Ihe klll'l' 111111 v...dll·lnth' ;lItl'1 plt)hmgl'd vigomu ... U\C, and Ihe.: \1,(';\1\'1 v... III 11\(: 11 llOlll'l' IIml Ihl' ~IIl'l' hl,'~lllh 10 hypl·n.'x tnlll I hl' h\llIlPl·l. v .... lhk v...!ll·lIlhl· ~J1l'l' I'" lil.':\l'd, l11u .. 1 hI' Il'pJ.lll·d h) Ihl' pl., ... lhl·"'" I ht· n . tl"lllid ~Il'~ .. llilp l'K l l'lI ... IOIi illd ).!IiHhta ll) Inw ... JI' l·I.1 til JI)- I hl' U"'l'l will Iltl'lI t"!"'l'l Il'IIl'l' III!!" Ill'l"I n "'l' III 4,.',11 h' \\ III).! .1Ilt! ... 1".... ~lIl·l· l'\ll'lI"'lOl1 al Ihe.: l'nd 01 "IIII-! ph" .... I Ill' .. lIlIpll· ... 1 app rtl ill'h 1... ltllI~hll·lIlhl' ... 1I.ljl

I It II 111).1 11 II hili ~ h' J vel1tl/ally. Ita pHI Ihl 11.1 Will Hel·t! II. II 1'1.111' lilt ('I.I,Il{ Wl:htullg IUltTllal eLI lie C~lerl 11m

11/,1 IIhll'( I If, r"htll"g ffllrfl tt." Irflu~r leg fIr .tlld 11111 , dfl "fll If, ,f' ria II( lIy ,I It'ilrilly \Iccl ' 11f1l1J! 1I1lelllai ill", H"lillIJ Illtn dftLllvcrw fflr Ihe I,f~ fli Itll' IHClC,th{"<,J, JlIII' IIl1li1IU.: "lid Il yd,all '" urnl IfIU I h" prc,tc:<.ted ,,).'''"1 . . 1 11 ';'11 Clf Iltl' ruhl)!'r ..,hwld prr,lttllng the pi trm. I hi IlI',lOIl 11111 I 1101 hl ...ualti)f'rI OCti.JiJ C Ihl would allow illI t: tnred nprtplil , with Iill' knee eXlended 10 cxdude aIr from the t:ylindcl

"d,

illl

. ~ III

Foot-Ankle Assembly Onc \hould HVOlcl gCIlII1!! the rro~lhclJe 1001 wet, co:..pct lall y " thc fOOl I~ an articulated model /I this happen!). the ... hoe and ~otk ... hould be removed to allow the fOOl to dry completely. away from dtreLi heat. The wearer o:..hould al... o aVOId ~ I epplng inlO ~and and ~"n!lar materialo:.. that mighl enter the cleft between Ihe loot and shank o:..ecllon and re\tru,:t the extur"lOJ1 of the foot. The prosthetist would havc to di .. a~\emhle the fOOl to clean it. The client ~h()lIld in'pect the foot periodica lly to ~pot c.:rm.:king al Ihe lOe· break or lip of Ihe keel ; .,uch a crack wi ll cu d the lOe ... and prevenl ~moolh Iran c., ilion during lale ... Iance, A deteriorated hcel cu .. hlon or planlar bumper will cau.,e onc 10 appear 10 be w~llking in a hole, Although most fcet arc now molded to ~Imulate loe~, the patient ..,hould nol wa lk without i.I ~ ho e bccHu~e Ihe ... ole of the pro~thetic 1001 i"i not IIllendcd to re ...,i.." much abrao;,ion, FOOl ...och wetlr much more quickly on the proqhetic ~ide, beca use fhc hard foot -ankle a..,..,cmbly and shank rub agi.lin~1 Ihe fabric , Swir ri ... ers also ~cuff the ~ock, Some people lind Ihal wearing two ~ocb hclp.., cu..,hion the outer one againsl prcmature format ion of holcs, The II1dividual ,nusl be instructed regarding wearing ~ hoc~ of the .'tame hcel hClght a.., wa ... the C~I\e when Ihe proslhc,j.., wa~ aligned, Too low :t heel mlcrrllpt~ lale .,Iance; an undul ) high heel l1la~e~ Ihe ~nee Ie,') ..,Iable, If th e pnhthl!~ i s ha ... the u\ual fOOl de~igned for low-heeled ~ hoc1'l. and Ihe wearer wi .. hc~ to wear Oal-heeled ~hoe .. , a 1/2 11 1. (I cm) ... him ... hould be placed in .. ide bOlh ~hoe ... at Ihe heel. lI igh-heeled .. hoc ... require Ihal Ihe fool be ch:lIIged. ei lher hy u1Iboltin g il and rcplacing il \\ ilh ;1 foot wi th all appropriate planl:lrt1c\ion angle, or b) adJu . . llIlg a hed hl'ighl scrc\\ found in certain rnodcb of /\:o.CL Booh ;1/1(\ ollll'r rOOI\\C:lr \\lilh still' uppe.:r ... c(,.' li()n ~ rc::.(ricl (he at.·tum of an) fool " ..... clllhl) thaI I... dc . . lgncd 10 pro\ ide ... uh:-.lallllallhlr . . llk\IOIl and plalllilrllc\ioll, RL'IlHI\ iug Ihl' ... hoe.: I~ l·a ... icr " Ihe pro ... lhcsis I... nol \\om. Wilh the ... IJOe.: unla ced cornp lctcly, one gra!>.p~ the l'Ollllll'l, then pul" the ht:.·cl of Iht:.' .. hoc otT Ihc back of Iht' runt. Finull). the ... hoc is llIovt:.'d up\\aru off Ihe i"orl"fool.

Chapler 32 Pro ... thel;c.. The .. hoc .. hould be PUI of:l ... hochorn.

011

th e proMhcllc 1'0 01 wilh th c a id

Exterior Finish The \I::.ual ti~lb.h of c\o::.kcletal :shunk::. is polyc:stcr lam iIMtC. \\ llieh I::. ImperviOlls to mo~t liquid~. It needs to bc "iped onl) periodicall) \vilh a cloth dampened wit h di lule dt·tergt!1lI to remQ\ e surface so il. Mark s can be scoured gentl) with kitchen cleanser: excessive abrasi on will dull lhe lini;-.;h. The son foam cover of the endoskeletal prosthesis req uires reasonable caution against expos ure to direct heat. penetrating objects. and so hents . The ou ter covering will nt:ed replacement \\ hene\·er it becomes unacceptably so iled or 10m. The trans femoral version tends to deteriorate at the I\nee. e:speciall) if the wearer kneels a great deal.

Physical Therapy Management Ph~ sical therapists panicipate

in the management of patients

\\ iill ampu tation at se\cral key stages: (I) preoperative: (2) poSloperati,'e-prepros thetic: (3) prosthetic prescription: (-I) prosthetic e'\ammarion: and (5 ) prosthetic tmining. The first two stages are described in Chapter 25. The followmg discussion emphasizes the responsibilities of the physical therapist with regard to the patiem and prosthesis. Ideall~. the therapist works as a member of a clinic learn. together with the physician and prostheti st. Others. such as a !-Deia! worker. vocational counselor. and psychologist ma~ participate in the team on a regular basis or as needed. The dimc team provides the best environment for exchange of information and \ ie\\-poinrs regarding the patient and fO~Iers efficiem treatment. The tearn meets to formulate the pro;,pecti\ e prescription. examine the ne\\ Iy delivered prosihe":)b. and ree'\amine the patient and pro:;thesis upon .:ompletion of pro,theti training. The therapisL therefore. ha5 .m integral pan to play in these critical points in rehaQuitltIon. as \\ ell as conducting prosthetic training. If a fonn ..:linil". team IS not established ill the therapist's work. ~rt.mg. then one mu ... t coordinate the recommendation;:, of me ph~ .. klan and pro .. thetist. . \\1m eaber admini ..rrati\ e ~i£U31Ion. the phy "teal therapl~;

• A.ddre~~ .. prepre~l1puon con .. lderation .... • Con -. Ie h) pro ... theut.: pre" ·'riptlon. • Exanune the pro ..1he... I ... · Fa.: rw"C pr the c ..t ... ..:-eptan..:e · T !be pauen! to don. u...:. and mamLlln the pro the "

Preprescription Considerations

J269

to a pro!o. thc!\l!\ compo..,cd of ca refull y ,elcc ted compo· nent.,. Allhough everyone who wea r, a prosthc.,i\ has tin amputation or comparabl e limb defIciency. the revcr,;e i\ nOI truc. That I~. c.,ome people wit h amputatinnc" are not candidat e!'> for pro$theses or prefer not to uc.,c pro""theloie~.}5 Pro ~ lh e~e!; are con traindi catcd for pallent, with licvere dementia or depreSS IOn , or advanced cardiopulmonary dis· easc. If the person di:o:.plays .,igni fican l changes associated with organic brain syndrome. then pro.,thcti c fitting is contraindicated. Indi vid ual s with bil ateral amputations who are unable to tran sfer independently or don underwear by themselves are unlike ly to benefit from a definitive pros theses. Similarly, a patient with bilateral amputations who had sustained unilateral amputation previousJ y and was unable to don and walk wi th a prosthesis is not a candidate for prostheses. Some people with high amputations, especially hip di sarti culation. find thaI a prosthes is is unduly cumbersome: they prefer to ambulate with a pair of crutches or depend on a wheelchair. Several sports. panicularl y swimming, are easier to perform without a prosthesis.

Physical Examination The physical therapis t should examine joint mobility and active and passive range of motion of all joints on both LEs. Knee and hip flexion contractu res compromi.se prosthetic alignment and appearance. A knee lock may be needed in a transfemoral prosthesis. and an alternative socket design for a transtibial prosthesis. Severe contractures preclude fitting with conventional components. or may contraindi cate provision of any prosthesis. The deleterious effects of comractures are especially serious with bilateral amputations. The length of the amputated limb should be measured, The individual with a short transtibial amputation ma~ require SC/S P suspension, Ever)' attempt should be made to fit the patient with a shan transfemoral amputation \\. ith suction or partial·suction suspension to retain the prththeSIS on the thigh. Strength of all limb and trunk muscle, should be eJWIlined. Frequently. the elderly patient v.lm \3SCular di~a.;e experience~ reduced ph) ~ical aCli\"it~
12.0

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Tbt- therapi ( houlell· .l1l1ll1l~ the- ralll'IlI'!'. .,hlll!)

10

k.1I11

and rela.ll1 nt:"\\ mlorm.tlullI IIllluUlJIg hOlh ,horl alld lOll).!. tenn mc:tncll~ ' eurologu...t1ulIllhIIOIl\ \lu.:h a ... l'l'h,:hIOViI'i

cular a Il"il'nl. lomplll'.lIc tillln!! "IIIU 1I<11J1111g Ilhll'llnal henupleglJ I nol 3') c..ktlllllCJ1laJ 10 proqhC11(" Ich"brlllillioll l."ontraJateral rar.tl~~I'i, 111 nOlh IIhtanu.:s. tIll' pro\lhc!'.I'i should be lk"'lgncd tor rnaXlIllum ... t
areas of abra\lon ...0 thatl:orrcUlve mca,urc, lIlay be 111 \11 tuted helore ulceration or Jllic<.:1I01l ell .. ue" In additu)Il. the pallent .. hould be tau~llI 10 keep the ,,,uno 1001 dean and houJd we:ar clean ho ..e and i.t wcll 1111111/1 ,hoc hee Chapler 17 for addJlJonal gUH..IcJlJ1C"i lor lIli.ll1i:1,!!llI,!! Ihe p:tlJclIl with penpheral va\.l:ular dJ'·.ca\C). Scquclillal mea .. · un:mcnh of amputated IHub <':lrl:Ulnlerelll:e a... well a\ I>alpa tJOn will mdJ(;atc whcthcr thc pallcnt ha .. cdellw. Mca ... Ulc, hould be Hl,tlluleO to .. tablll/c illnb volume .. 0 Ihat the pallenl <.:an rcLam the III ollhc pr<>"ilhclJ(; \o<.:kc1. The patl cnl y.Jlh vao.,t.;ular lmpalfltlCnl may bcncfll from pro"'lIH!IIC': III

which tran,lcn"

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IUllo. In addition. ,hould the I>c"on <.:OJ1lC 10 bll<.ttclal :,II11pU LJtlon. prcviou, cxpencn<.:e wllh (,h)l1l1iJ1~ ~nd cOlllmlllll,!! ;j

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P~ycho~ocial Con~idcration" (),dlllu(.;ees'i One \hould rllard agaln..,1 ulllcali"ilJ<.: cXIx:<.:tatloll ... Illvoh 109 the patient alld family 111 J!fOUp "iJluallon .... "'lIh olher ptr· ~(II1' wllh amputallC>r1. 111 Ihe phy ... ieal Iherapy dcp.mrm·nl. and 111 \o(,;lal cnVII"()JlIllCllh 10'1(;(\ lon'.,(fUctl\'C allllUdl's, The thclapl\l ... hould aI,,, weigh Ihe Irkellhood that the IIldl vidual wJlI be ablc 10 l:CJrc lor l:olllplex pro ... the:11t: rneeha 1I1 '1lI"i and have Ihe 11IlaIKi~i1 rC"iOurcc .. 10 obtain pr""lhelll" 'C rVIl:lIl j!, c~pct:lally of <.:omponenh • ..,uch a'l the: /oarn ruh· Ix!r <.:ovcnrW 01 the cl1do ... kcle!al ... hank, y.hldl 1\ Ic~\ durablc.

UIIJI<J1cml pro..,lhe:-,1\ I'" IllvCJluahlc in CJdJU .. tlll)! II) a p.llr 01

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Chapter 32 p,.o .. thetic:o;

1271

had been 1I1Ied \IoJth

,1 §'Implc trano;femoral pro .. the .. i.. lhe \101 h to panilipatl..' in .. pons 8) demon ... trt:pcnillllg on the IOh:rval hctv.ccn amputation ..,urger) and prNnplloll. the wnpulfJled limb rna) not have \labililed 10 U1lurnc. the p i.I well rllllllg \(K.ket. ",ulIublc ... u\pcn\loll. pylon. and 1001 wllh Ihe IrOln\h:l11or<J1 mcx:lcl. II u\ually ha .. a knee unit. I he lL'mporary pro"othc ... " .dlnw ... prcilmlnaJ)' gall and activi· III!: 1I,lIl1l1lg. l'he: I11
Dpr

SC'

I

Temporary Prostheses Tr•• mlibiOlI (lIe1ow Knee) '1"'1I1ponll")-

Pro,thc ... i,

Mo\tllilll ... llhidl h..'lIlpmmy pnhlhc ... c .. have socket .. made of Ih~·'lnllpl.I .. lil· IHall'rlal Ihal becomes malh:able al tcmpcraIIIn:\ hl\\ l'l\out!h 10 pt.'ntlll fnrllllng three tl ) on Ihe patient. Oll~' l'.111 ;tI"'~1 llhlam lIla ...... ·pn.xluct.'u ndjllslablc \ocJ...cts: II 111.1'., Ix' 1I1.·I.·l· ...... ,II)" HI p.ll! thl.' ,Ol.'J.;.et ixmom so that the mnpu· 1.ltl·d IlIuh dtx· ... 1101 dl.·\l'h,IP di ... tal cdcma. orne temporal) Phl\lh,,· ...,,·\ h.I\L' ,I pb,tcr 'O(J.;.CI molded to the ampulated IImh PI.I"''''·I I... IIIL·"\lx·n ... l\c. rl.'at.hl) a\.\llable. am.! e . L... ) to lhl' Ihl' 11.· ... U!tllh.! "'l'li..·J.;.t.·I. tU)\\l'\t:T. i... mther hea\) and bulJ.;.\ '\\I"'IX'I1,I\\ll " u"'lIall) b) ;1 l'ufl or thigh COf\Ct. The 1'\ \tIll L',\II hI.' .m .lhIltIlJlUl1ll·lllllponcnt Jl\;lJ1ufi.lctureu for this PUIj"-I ...t.· .... ud! .1 p\ lUll h..... ,I rn.)"\unal li"\ture that pem111s "111.111 I. h.IIl,.l· ... III pt\l ... tllL'tll' .ll1gnlllt.'nt. ~ "'Impk:r p} Ion can lx· In.ldl· \\ IIh l"I\ll\ \ 111\ khlt.lriLit." plplllg .... ueh i." u'\eu for phllll~l11g Ih,,' PII"-' " h~ht\\l'l~ht and l·i.UllX' ... pt)t·he~ued to t·Il.Ibk· ... Iu:llt .lltt.·I.ltl~m III .lli!!1l11lt."1lt. \ "iACH ft.Xlt I'" eu ... • Mutull, lI"'t'd \)(1 tl'IIlI~"al\ pn,,...thc ... L:"

\r.III,I'·",or .• 1 ( \bOH' Knee) l\' mpor .1£\ Pn",ht.",i, lbe: a I 'I appn1,h. h I" III U'l' .1 ~ll~ prl..'p) lent.' 'lxJ.;.ell Fig \' \ 1 \\hh:h l 1lI.II1UJ.h:tun.:J Ul ... e\t.'r.t1 "'lle, and h ... r I'r m,:umft.·, 'un 1 dJU"Ulll·nI. Tht." "'"x·J...et (an t'C . . t' Ilkd \\ uh ·lll· ... tan .1!lJ.l~l· I.'r ~l\ h.: t'I.UlJ. anI... I 1 l ..ann \\ hh. h m;l~ J1lluJe J. m.w.ual h..x ... 1 lit I...l:'n . . h:J'l ·J.;.el or plJ. ... lt!r ('Ir 10\\ ... l \: f.:ar: u . . . . d. S m<..· mJI\ ldU:l oral an 'utJ.t '0'" u 1... d fI ..ur tu"'Ill';'" Thl;; I.: Me n ,artlt.;ulatcd

Figure 32.32 Transfemoral temporary prosthesis with adju'lable polypropylene socket. pelvic band. knee unil with manual lock. and adjustable pylon shan k wilh SACH fool.

prostheses: the sockets are mounted on short platfonns. drasrically reducing the wearer's height in order to increase balance stability. The platforms each have a rearward proJection '0 protect the patient from a backward fall.

Prosthetic Examination The prosthe,is should be examined before the patient engage ... in proslhetic training and should be reexamlllcd at the conclu\ion of training. The procedure is intended to detemlinc the adequacy of prosthetic fit and function. a~ \"ell a ... the 'Wearer's opinion of appearance and overall ... alisfal.:tion. ThiS process typically follo'W, a ,cqucncc of c:\.unining the pro"ithesi') v.hile the patient ,t•.lI1d\ (\tatic.: anal)'\i ... l. c\.amming the patient .... gail (d)"namic anal)"'I')' anJ tinall) c"(amining the pro"ithes" off the patient (~lddl 110nal ,taul.: anal}"",). In man} lIl\tIIUtlOn~. the ph),,,,".11 mcrapl ... t e:\amme.., (he pro\the\l ... and prc ...cnh J ummary ot tmdmg ... to the dmK It.'am. The (cam m.lkes thl' nn I detenmnallon regarJing the acccptab,lll~ of th pm the",", t tnlllal C"'\.Jffi1l1alH'n. the learn ha., three opl'lm I ) r~ s. - pruv •• 0n.11 P'" . or (1) la.1 I"" ,"d.cale thai 110 unge arc ncedeJ 10 the pro the and the pall nl can nx:.. I to tr.ttnmg Pro\. lonal pru that on or

12i2

Pin ... ical Rt.'h"lbilihllioll

mon.~ mmor prohlem ... R'4UI1\.' U1Irl'(.'IIOH. nOlle 01 \\1111:11 \\ouIJ IIltc:rten.'\\.lth Ir~lInll1p. LlIlme I ... the tcam \' Jud g ment that Ih(' plO\thl, .. t ... h;l ... a major laull IhUi ~ h()llid be COITc..'l'lcd to tht' le.llll', '~Itl ... laclion before comlllencement 01 pn.hlhclh.: Ir.llIu~!.! . For example. poor linbh1l1g of the Pro,thl'Ul' loot mcnh a prO\ i ... ional pass. whcrcm. a ... ockcl th.lt .\hradt· ... the
Transtibial (Below-Knee) Examination Most items on lhe c hec klist in Append ix A are selfexpla natory. Eac h contributes to fo rm ing an accura te judg-

ment of the adeq uacy of the prosthesis. Static Ana lysis The prosthes is is exam ined while the wearer stands and sits. In addi tion, the amput ated lim b and deta ils o f the pros thesis are examined. The prosthesis sho uld be compared with the presc ripti o n. Departures from the orig ina l specifica tions must be approved by the ind iv idua l who authorized the prescri ption. The new wearer sho uld st~U1d in the parallel bars or other secu re env ironment, attempting to bear equal weight on both feet. The therapist should solic it subjective comments about com fort. Estimates of anterior-posterior and medi al- lateral alignment are aided by sl ipping a sheet of paper under vari-

ous parts of the shoe. Ideally, the patient should stand with both heels and soles nat on the floo r. Ma lalignment, ind icated by excessive weigh tbearing on one portion of the shoe. may be confinncd by subsequent analysis of gait. MO~1 prostheses are constructed so that when the individual ~tand~, the pelvis is leve l. 16 If the pelvis tilts. the therapist should place lifts under the foot 011 the shorter t.ide to reMore a leve l pelvis. If the lotal lift mea~ures 1/2 in. ( I em) or Ic~s, no attention is needed. For greater discrepancy. one ~hould ~ek causative factor",_ An amputated limb that sinks too far Into the '-locket will make the pro'-l thetic ~ide appear "'hort. and the wearer will probab ly complain of di<.;comforl. Pi ..,ton action refers to venie:.11 motion of the sockel when the patient elevates the rclvb. Socket sl ippage i", caused by loo..,cncs ... lIladcquate ",u"'pen<.; ion, or hoth. Soekr.:t wall.., ... hould fit snug ly_ a~ ... hould the thigh cor<.;ct it it i", pan 01 the

pro .. thc ... is.

Comfortable "' Itllng i ~ a primary need for all people ~he postenor bri~ ... hould not Impinge into the popli,eai los ... a. and ham ... tnng re llcfs ~hou ld be adefluate e . II y '. ... ,Spccla I medial .s lde where the '-Iemltendino~u~ and semion tlC membranosu~ IIlsert relative ly di~lally. Placement of the tabs ' inn uences . . of the cuff or the joints of the corset also s lltlllg comfort. Dynamic Analysis Analysis of the gail paltem and performance of other ambulatory activities is an essential part of rehabilitation. For most patients, a major reason for being fitted with a prosthes is is to resume wa lking. Neverthele%, no prosthesis eradicates entirely the anatomical and physiological changes produced by amputation. When walking, the person who wears a prosthesi s compensates for anatomical a.nd prosthetic deficiencies. Some are inherent 10 ampUlatlon: others are abnormalities of the body or the prosthesis. Because virtually all people walk with a prosthesis in a manner different from the nondisabled walking panern. prosthetic gait represents compensation for the patient's altered locomotor apparatus. The term '-gait compensation" may be a more accurate descriptor than the more commonly used "gait deviation" inasmuch as the patient with amputation is mOSI unlikely ever to walk exactly like a nondisabled person. No prosthesis restores sensation. skeletal continuity, muscle in tegrity. and full body weight. Anatomical deficiencies are aggravated in the presence of pain, COnlracture, weakness_ instability, or incoordination. Similarly. prosthetic components do not replace every function of the missing limb. For example, most prosthetic feet do not move through the full excursion of the human counterpart. Inadequac ies in the prosthesis compel the wearer to adopt gait compensalions. Such problems include a poorly fitted socket. prosthetic mal alignment. malfunctioning components. and improper he ight of the prosthesis. Compounding the problem are incorrect donning of the prosthesis and wearing inappropriate shoes. The physical therapi st must detemline when gait compensation exists and what its cause is likely to be so that remedial action may be taken. Otherwise, the patient is compelled to expend more energy \~alking and to exhibit a more conspicuously abnomlal gait. The Ile\\ wearer will ha\'e had brief experience walking in Ihe prosthesis during rhe course of prosthetic fabrication. Although a !:. moolh gait is unlikel) on the day of the initial examination. gross deparTure from the lI~lIal gait exhibited b) others with similar pro~the,f's should be nOled and causes sought. Tran!-.tibial mmlysis focu ses on action of the knee on the amputated side during ~1
C-:hapter ,'\2 Prosthetic..

Table 32.1

12H

Transtibial Prosthetic Gait Analysis

Compensation/Deviation

Prosthetic Causes Anatomical Causes -----~--~----~~ ----~~

Early Stance 1 Excessive knee flexion

-----------

2. Insufficient knee flexion

High shoe heel Insufficient plantarflexion Stiff heel cushion Socket too far antenor Socket excessively flexed Cuff tabs too posterior

Flexion contracture Weak quadriceps

Low shoe heel Excessive plantarflexion Soft heel cushion Socket too far posterior Socket insufficiently flexed

Extensor spasticity Weak quadriceps Anterior-distal pain Arthritis

Midstance 1. La1eral thrust

Excessive foot inset

2. Medial thrust

Excessive foot outset

Late Stance 1. Early knee flexion: also referred to as "drop off"

High shoe heel Insufficient planlarflexion Keel too short Dorsiflexion stop 100 soft Socket too far anterior Socket excessively flexed Cuff tabs too posterior

Flexion contracture

2. Delayed knee flexion: perception of walking uphill

Low shoe heel Excessive plantarflexion Keel too long Dorsiflexion stop too stiff Socket too far posterior Socket insufficiently flexed

Extensor spasticity

that wearer. Conversely. insufficient knee flexion results from posterior displacement of the socket or inadequate ~ockettilting. When viewed in the frontal plane. the socket brim should maintain reasonable contact with the leg; excessive lateral thrust of the prosthetic brim suggests that the prosthetic foot has been positioned too far medially. Table 32.1 summarizes the prosthetic and anatomical causes of gait compensations/deviations.J7~1 At the initial examination. perfonnance on stairs and inclines may be omitted becaU"ie the patient has not had traming in these activities.

Inspection of the Prosthesis Off the Patient After conducting the dynamic analysis. the therapist ~hould examine the amputated 11mb for slgn~ of proper loading. The postenor wall should be at the same level as the buildup for the patellar ligament when the patient stands. Bccau!'!c one cannot a~certain this relatlonr.,hlp when the prosthesis IS bemg worn. a 5ubstllutc check is pcrfonnt:d. Stand the pro~thesis on a table; pi act: the end of a long pencil or

ruler on the anterior socket bulge and rest the ruler on the posterior brim. In a well-constructed prosthesis. the ruler will slam upward toward the rear. indicating that when the individual stands in the prosthesis and compresses the heel cushion. the wall will be at the proper height. Any straps or cuff should provide reasonable adjustability. Construction is a guide to future durability. u:, \I,.ell as cont ributing to acceptable appearance of the prosthesis.

Transfemoral (Above-Knee) Examination A similar checklist is used to examine the Lran!o.femoml prosthesis (Appendix B). It is important to recognize that seldom is one item of major significance. The thernpi ... t and entire team should look. for patlerns thutl1light hernJd future difficulty. For example, malahgnment dele"ctt'd in ,talic analYSIS should be con finned during gi.lit Sialic Analysis The pallent who hi.!' a ne,h roll abo\e Ihl~ 'l"k.:k.el either did not don the sockel properly or ha ... a thigh that j, larger th.m

IhJ I lor \~ hl(h Ihl' "(\\'-!...~ I \\ a .. 1ll.llk· PCI IIl l'~11 pn.·.... url' rc .. ulh I mm .. harpn~ .... 01 11h..' l11L'd lil l hrlm or in.. ul l!clcncy of the: .Idduclnr h'n~lI' Il.· lid 111 .1 quadril. tll' r;.iI "OC"l'1 nl(' "n~l' UIlI t ,hou ld IX' .. tahle enough to \\ lIh .. ta nd a t'lh.)~' lll'h ' ~n..'d b) th l' Ihc rapi .. t 10 the pn.. teri or a .. peci of the UIlI!. Su hihl ! i.. mtl ucnccd by the aligllml'1I( oj the knee tTl rela llOn to the Ilip and prm.the ti c an kle. The farther JXh lCrtOr the knee bo lt . the more .. tab le the !.. nee wi ll be. Poi!ccill ric lin"age ,md mcc hanical ~t abi li l.ers also contribut(' to .. tabi lity. If the soc" ct i .. opaque. th e only way to j udge it.... nug ne .... i.. by palpat ing tissue protruding through Ihe \ al\-e ho le \\ he n the \'al ye b removed. T he chec klist b designed to help the cl inician determine the ti t of the soc ke t. regard Ie» o f shape o r material. If the p ro~the .. i" has a quadrilateral socket. proper locati on of the adduclOr longus te ndon and ischial tuberosity ensures that the pati ent has donned the socket correc tl y. A hori zont al po~ terior brim allows weight to be borne on the gluteal musculature as we ll as th e isc hi al tube ro~i t y. The i ~c hi a l containme nt socket is intended to cove r the ischi altube rosity. ye t allow the client to move the h ip in all directi ons com fona bl y, w ithout socket gappin g. The lateral auachment o f the Silesian ban dage should be superior and posterior to th e greater troc hanter for best control of prostheti c rotati on. Anteriorl y, the 3tlachment
Analysis

Gait analysis gives the cli nic team members the opport unity

to determine the adequacy of socket fit, and of pro~l he~ i ~ alignment and adj u~tment. The patien t also influences the walking pattern by the timin g and force of musc ul ar contraction and the presence or absence of contractu res. The goal of walking with a transfemora l prost hesis is a comfo rt able. ~fe. efficient gail. mther than duplicating the galt of ~meone wearing a transtibial pro'>thesis or one who doe .. not have amputation, Table 32.2 summari/es transfcmoral prO">thetic gait compensation .../deviations.

C:ompen mlions/Devialioll s B e~ t Viewed from Behind. \.1an) Indlvlduale.. with tran ... fcmora l amputation abduc t the pro...the,i .. to improve frontal plane balance. flip abd uct io n contracture prcdi<.,poo,.e.., patient" 10 thie., dcvlU tioll. which IS seen In t.tancc pha~. Inadcquate ,ockct adducllon, b-od':et loo'>Cnc!'ls. or medial ""comfort cau<.,c .. the 1,1U 1l ( 1rI::umdu<.:lion Ii a (iI'>plac.:cf1u:nl exhibited III "wing r ha"c Jf the' pre Iht: '0; 1\ too !cmg or II the P
.. I:\m.:c pha"c gcncra ll y ill:I.:OmpanIC!'. ahduLtcd gill!. It . . hould be noled, however, th;'11 .111 IIldlvidu.ll . . With Iran ... femoral amputation have an 1I1compietc aoduuor IllCdl;'l. ni ... m, and t!! nu 10 compen"atc by bcndlllg towurd the pro .... lhelic ~idc. Alt hough the hlp JOint and glulcu\ Incdlu" an! u.. ual ly III good conditIon, lack of \kelctal continuity to the ground comprom"c" the clfetllvcne.,,, 01 abduL:tor l.:ontrac lIOn. II the proqhc\i\ i, too long, the patient will abdutt: if it is too .. hart, the pat ient will bend laterally \\lIl1out abduct ing. Wlups re fer to rotation of the heel at late "'Iancc. If the ,ocket doe, not fit well. contraction with bulging of the thigh muscu lat ure will causc the pro\thesi .. to rotate abruptly a.. II i... being unl oaded at the end of stance pha.e.,e. Although le\.., likely. ma lrotation of the knee unit or foot-ankle assembly may contribute to whipping. Rotation of the foot on heel contact is a much more serious deviat ion. It II1dicate .. inadequate compression of the heel cushion or plantar bumper and can result in a fal l.

Compensations/Deviations Best Viewed from th e Side. Forward trun k ~hifting in stance pha\e is a compen\ation th at ~ome patient!'. use 10 cope with knee in~tabilily. If the walker or crutches are too "hort, the ind ividua l will lean forward. Lumba r l ordo~ i ~ re~ u lts from inadequate socket nexion and i\ aggravated by a hip nexio n contracture. Improper adju~ t me n t of the knee unit gives rise to /lllerCIl heel rise (excessive knee nexion) and rermina/.HI-;n.!: impact (abrupt knee exte nsion). If both deviations are present. the probable cause is insufficien t friction. If the knee exhibit, impact wit hou t undue heel rise. it ir.; more likely that the ex tension aid is too tight. To compensate for reduced knee mOlion. the vigorour.; wa lker may \'lI1I/r. ex(;e!',~ i vely plantartlexing the \ound an kle to afford ex tra room to clear thc pro'the\i" during pro!-.thetic swing phase. A le~\ Slrenuou~ compl!ll,atlOn for actu al or fun ctional pro\lhe\is length is hip hikil/g. when the patient elevates the pcl\'i!', on the prosthet ic 'ide. Step lengths will be unequal if the patient ha" a hip nexion contracture or inadequate balance: a longer "tep 1<., taken wit h the pro .. the .. i... The longer prosthetic .. tcp gi\'es the person more time on the sound limb. A nexion contractu re prevent" the \ound limb from pa\'ing the pro .. thctic side during ... wing pha"e on the "ound 'idc. In'>pcctiun ur the Pro .. th csi" OtT th e Patient Following the .. tatic c\i.lll1ination. the therapl . . 1 . . hould exam1l1c the pro\lhesi .. and ampu tated 111110 a .. II1di'Jt~d on the checkli.., t. A rcsilicJlI had.. pad cmlblcs the patient tn "It tllIictly wit hou t undue Il'Ou"'er or skin ahra ... ulIl. f he p;ld i. . unncccs.,ary WIth a OC\lhle .. od.c!.

Facilitating Prosthe tic Acceptance AmpUl
Chapter .\2 Pro ... th{·lit:~

1275

Table 32.2 Tra ns fCl110ral (Above-Knee) Proslhc lic Gail An a ly.is Compenalion/Deviarion

Anatomical

.......tbetic: Cause

Lateral Displacements 1 Abduction : stance

2. CIrcumduction: swing

Abduction contracture

Long prosthesis Abducted hip joint Inadequate lateral wall adducllon Sharp or high medial wall

Weak abductors Lateral/distal pain Adductor redundancy mstability

Long prosthesis

Abduction contracture Poor knee control

Locked knee Unit

Loose friction Inadequate suspension Small socket Loose socket Foot plantarflexed Tru nk Shifts t . Lateral bend: stance

Short prosthesis Inadequate lateral wall adduction Sharp or high medial wall

Abduction contracture Weak abductors Hip pain Instability Short amputation limb

2. Forward flexion: stance

Unstable knee unit Short walker or crutches

Instability

3. Lordosis: stance

Inadequate socket flex ion

Hip flexi on contracture Weak extensors

Faulty socket contour Knee bolt externally (or internally) rotated

With sliding friction unit. fast pace

Rotations 1. Medial (or lateral) whip: heel off

Foot malrotated Prosthesis donned in malrotallon 2. Foot rotation at heel contact

Stiff heel cushion Malrotated foot

Excessive Knee Moti on 1 High heel rise: early swing

Inadequate friction Slack extension aid

2. Terminal Impact: late swmg

Inadequate friction Taut extension aid

Forceful hip flexion

Reduced Knee Mot ion 1 Vault: sWing '----2. HIp hike sWing

See above: circumduction

With sliding friction uOlt. fast pace

See above: circumduction

Weak dorslflexors Plantarflexor spasllclty Pes eqUinus Weak hip flexors

Uneven Step Length

Uncomfortable socket Insufficient socket flexion

Hlp flexion contractur Inslability

-----

the p.HU:llt .tnd Jamlh .Iuqll the: re:altt} 01
not onh the ht:ndll' 01 ht:t1cr pro ... lhcllC provi ... ion but abo hnng ... thl' mdl\ luual1l1 con tac.:l With c.:lmician ... who <.:onvcy

e

pc:ncm:c Jnd c.:onlidcnc.:e

III

dealing with prohlem ... th,]!

Ihe ('1\'''011 rna) have c.:on"'ldcrcd uniquc.

oon a ...

\

po ...... lble.

the ho ... p lli.tli/cd patient \hou ld be

lre..lled III the phy ... ical Iherapy dcpanmel1l, rather Ihan at

hcd"de. The bU'llc 01 Ihc depanmcnl ,hou ld help (lI'pcl de ... pondcncy. Although po\topcrative mourning 1\ expcc ted , prolongcd dcpre ... ".ion i\ nOI con ... tru cli vc. Peer ... upporl group ... are often very effective in aldlllg acceplallce (}f the pro".thc\i ... and in learning "'pec lal procedure ... for accorn pli~hll1g aclivilie.... Observation and even tu al parllc.:lpation In ..,peclally de ... lgned spo n ". program". i ... anoth er way peopic learn to cope and gain Ihe mo .... from rehahilitation. ~I he phy".icallhcrapist, by v irtue o f close dai ly con tClct w i th th e pallent. I~ al".o In a po ... illon to recommend \0 the cli nic tho".e who mi ght profit from psychological coun ... eling and p~ychiatric ... erv i ce~.

Prosthetic Training Learning to UIoaC a prosthe ... i\ effective ly invo l ves being abl e to don it correctl y, develop good Intlan ce and coordin:IIIOJl. wa lk in a ".a fe and rca ... onably ... ymmclri cal mann er, and per form other ambulatory ~Ind ... elf-ca re HctlvitIC .... A nticl pa tcd goa l ~ and expected outcomes depcnd on thc pallcnt"" physical and p~yc holog i cal stalu .... prepro ... thc tl c experience.

and

~uality

of pro,lhc,;,. lh; ng Ihc pro,ll1c,;, onl y 10

a",".I\1 In tran ". fcrnng from the wheelchai r 10 Ihe toilet ma y he an appropriatc outcome for elderl y per\on wi th ll1ul tiplc di",,,bllilic!oi, w hc rca ... th e prognlln for Ihe young ... lcr wilh traumatic ampu tation might ex tend to a full I'I.mge of

,II'

~p()r""

Donning ('()rretl applic.:atioll flf the pro ... the ... i, and fn:qurnl III ... prc.: tHm of the amputated Ilfllh arc vcry IInpOltal1t . espn:tally h" the hcvinner iJnd Ih"..,c wi tli 1'001 c.:m':lI lilI IOIl P"IH:II'" wilh partlill fonl , SYflle\, anci trHl1 stihwl :IInplIllilI0n... (;H I1 t1(m lilt' pro ... lh{!\J" willie ~('"H I('d . afll'1 ha vlIW iIP1:11l'l1 111l' lhrr(.ll nllrnt)(~r alld '..e<jIH·nu' III \()( k ... 01 \hl·,lt ll I lll'll, III ru(, 1111 1
the I'llcr t(, lilt: ,IITll'lItat('(1 11111". tlll'lI HI . . t"I" Iht' IIIlIh ilnd IJller 1111') til(" (Jf~t't fllt" 1I1IIHlI t'lI lI y 111111 till' "'mkl' 1 With «(,r {I Il ,WIl lOll Illily he (lIacll' willii' '01 111111' , "OW(' Vt": filial Ilghknrll~' 1)1 1,1' f' I)' IIiI" ... ,"fllIld 1)(' dlllll" III Iht lalldlllV po 1111111 If) til Illf' Ihal IIII' hlllh I . . 10d,·I·/l ·.IIII,llll y . I Ifl 'h' I~ kct I hh C willi Ir.ltl I. IIlf)l,d .111111111,111011 aJ.,o (.111 IWI'ul I If" willI! l.I(f·d l ot;.! IIC tlOIl Wl, llt' l , IIlll y

lI"'l'l' rt hl'l a pullll1g 01 pl"llIllf.! IIll'lhodlo pull one: ...elt 11110 Ihe 'Olkl'l. IIll! pallent "pplte'" a lighl ciU .... llI1g 01 1.II(,;ulI1 powder 10 Ihe: thigh 10 reduce Iric.:liol1. Th en one apphcl, ,I flu l111lg r..,m;k. a IUhulHr (;OUOIl ... toc.:klllci approximi.lIL'ly \{J 111 . (76 (; 1l1) long. a roll 01 cla ... 111,; band;'lgc wound arollnd the thigh. or a ny lon \ tol:klll g Whatever Ihe donning .ud. II ... hould he plal:ed high in Ihl: grolll to pull In proxlilial II ... Ul: .... After pla<':11lg the ... cx.:k-clH.:i.lr..,ed thigh Inlo Ihe ... cx..kl't olle draw ... the di\lal end 01 the i.lld through the valve hole Allhough 11 i ... pO\ ... lhle to l:()!11plete the donning prolC w hd e ",ci.lted, !11o ... t peoplc prefer 10 ... land whde pullIng the ... ock or other aid ou t through Ihc valve holc By leeke t. taking G irl' Ihat thl' thlfh I... l'OI rCl:lly oriented; pullr.., Ihe dl ... tal end 01 the ... od.. dlmll throu gh the valve hole enough 10 en..,ure Ih'lI thL' ,kill 1'.. I,l11ooti1 ; tu(;ks the \ock bad... 1111 0 Ihl' ... (lCket: ilnd ill ... l.:rh the: va l ve. "'nally, one ... eclIIe'" the pt:lVIC hand or SI!L· ... 1i1ll handag.e. II ... uction '" nol u"'l'd, donn ll l!! " ... lImlal 10 thl' method u... ed with partl.1i "'uc.;llon, exc.:ept that thl'll' i ... 110 va l ve.

Balan(.·(· and Coordination I·.xel'cl\l· ... arc ... 111111<11 101 all patll·nt ... ,""IIh J I ampul.ltlon .... ai tholll!h the lIuil v](Jual w it h" tlitmiL'IIIOI;1I 01 hip dl"',IIIIl' ul.rl lon plO ... thcsl ... Illay bt.: (;Xpe:l tl'd to l' IKountl'l IIHlIt' ddll CUll Y c.:oJl trol lt ng. tl1 1.: tnl'r h:lIllral klll'l', a.,l·Ol11pall'd 10 Ihow wi th IWo Hllll tOIlIlC: tI klll"l"\. AlIlllu"" iL' .. IIrlO hill.lIll"l' 1111 till' ampu tated "' Ide A gli tdllal l'd PIO!'''1I1l 101 IIIl'll·,t.,IIIg JlIO'" II1('t lt toklalll"e 1IlIIlIlIlI/l· ... till" d.tll!!l'l 01 ... kll1 .. h, ..... IIII1 . p.1I tll"lI l:lrl y II Ih(' illnputiltl'd IIInh plnt'lll<., ,kIll !·I •.th. 1'001 c.: II u ili.lt 1011. (II dlrnllll ... lu·d ...l"II ... "tIOIi. I hl" p.rtll·nt ... !roule! allclllilll'ly ('Xl'n':I"'l" :tIll I 1'· ... 1. v..·llh l.tldI01HIIIlHI1I;tI) 1110111 1011 111-' :IIOIIIIIle pill I 01 I Ill' PIOJ,'I,tll1, l'''pl'l lidly 101 Jllt,h ""'~ II HII Vl cllll1l ....

SOl Ill' l JIIHtlilll ... '· ...l!ll·\!y p.llalkilldl'-. b\·l,l\l ... r thl" k •• llnl patll'nt pult... Oil 111,'111 v.. lllth wil l lx' ltuIII~'~'" \du'lI 1'"1 t. Il....... II !).! III ill'a/Il' Whl'lI h,lI'" ,Ul" l"l'll 1111' tlll·I.lpl,1 ... luHlld l"1I<'III1 I .I~'t" till" IMlll'lIt til Inl III\' nlx'n 1r.IIHI tlll IIIl h.1I IIlI ,.11111'011 tilthl' l tlwn "'"If iI .... hl·ll~l· ).!lIp. \ pllllih PI '1IIId\ I.!llk otll·l ... lirl' elllili ;lI lv. IIII.lt"· 01 PIO"'HIIII~ YOlld '111'1'1111 011 tllil y (JIll' ... Hlt·, Oldlll,lIdy Iflr lllllll,d.lh·l .d ,H I\', ,IIHIIIIII cllIl.( IIIIlIid t oll l lOJ hn ,111'1' IJIt· p.IIII·lIt l dl1l1l1it t'1I .. 1r. IIl'H'1

1'1111. 101 hi.t ,lIH t·

II

\t,IIH c'w"1 h.. I.IIIU: "'11111411111(1" IlIl' lIP ... ll'· III 11I1t{·c ,I 11 1I'11111I'lIt .hollitl ,111\1\ /III In\' 1pI'I .... , lilt! ,liPid 1" .... I 1I 1l ' I I II ~ w llhoul l·U,· .. , I"'· 11111 11,1"', ,1111 elf!·1 dl'I'o, VI'r l ll,1 I IIII II .

Chapter.12 Pro.-.th('lic.-. \\ eightocaring. The thl'nqll'~t ,Imu ltl guard ami a"I\( the pallellt a, l1ecl..'"ar). \\'hell (he ph)'lcal Ilicrapi\1 \t;.Ii1(~\ near Ihe pro,tIlC'I" till' cneomagl.." the pallelll to , 11111 hi,

or her \\clght onto it. rn ,uggc:-.t ",Yllll11clru.:a l performa nce. reler 10 Ihe 11mb, '" "right" ;lIld "lc lt :' or "!-oollnd" and "prosthCIlI..~," rather Ihan liJ,couraging the paticnt \\ ilh "good" and "b;ld." The Clil..:nl Illust karn to ulili.le pro~il11al ,cn... ory receplllr.. to mallltain balance and perceive the po, it ion of the pro ... the'Ii'I \\ ithout 10o"-.lIlg at thc noor. Some pat ient .. re ... pond \\'cll to increased usc or visual feed bad. (c.g .. u,ing .1 mirror). D)n:unic e\crcl~e!-i Illlpro\C medial-Iatcnl l. ~agilUlI, and rotar) control. The patient leams that hip Ile\ion caU!-iC!-i the l..nee to bend. and hip extem,ion stabilizes the knee during ~tance pha::ie. PI::Icing thc sound foot ahead of the prost he... i::; makes the prosthetic knee more "itable. Patients shou ld be in ... tructed In weight shifting in both symmetrical and ::;tride po~ition ... and in ",tepping nlo\'emeI1ls. Stepping on a 10\\ ... tool or Mep platfornl with the s.ound leg obliges the patient to shift weight onto the prosthesis and inc reases stance phase duration on the prosthesis. Symmetrical pe rfonnance is fo::.tcred by having all exercises pe rfo nned rh; thmlcall) \\ ith both the right and left LE,. k

Gail Training \Valking is a natural progression from dynamic ba lance cxcrci'>es as the patient taJ...es successive ~teps. Some people respond well to propriocepti\'e neuromuscular fac ilitation ..l4 Rhythmic counting and walking in time with music III '2/4 time also improves gait s)mmerry and speed. In the physical therapy department. an apparatus that includes a suspension harness provides a protected environ ment for the patient to learn gradual weightbearing on the prosthesis.~" A balance apparatlls providmg clectronic feedback~6 \\lIh or \\ ithout emphasis on p~ychological awareness of bodily position~'" is another training option. Either a cane or pair of forearm crutches is an appropriate aid for the client who is unable to achieve a safe gait withollt undue fatigue. Sometimes the cane is used only outdoofl; to aid in negollatlllg curbs llild other ground irregularities and to signal oncoming traffic. Ordinarily the cane is used on the contralateral Side 10 enhance frontal plane bal~U1ce. If bilateral assi\tance is reqUired. a pair of fore:.mn crutches is preferable to t\\o·o canes. The crutches remain clasped around the foreanns when the user opens a door. Axillary crutches tempt the patient to le.m on the axillary bars. ri ... king impingement of the nldlal nerve\: they are also inconvenient when climbing stairs. An alumlI1um walker proVides maximum ... tabtlity. which is partll.:ularly u'-Cful for patlCnl~ "Jlh gcncr..Ili/cd \\cakne ....... me w;.tlkcr ...hould be <.Idju ... tcd ...0 thaI thc user doc~ not Ican tou far lorv.:ard. Patlcnt ... with trall ... llbml amputJtlon walked Ia... ter .... Ilh a t\l.o-wheclcd \\al"-.cr .1'> compared \\ol1h a lour footed v.alkcr r'car 01 Jailing <.:al1 undermine \I..lIl..lIlg .Ind ...tx:i.1I ,Il'tl\! II) partiCipation Imprm'lng tht: patlClll's h.tlallcl' 1..'01111 dem.:e 1\ es,cntlal to lessen Ihl' t:Olll'crn 1'1

1277

Functional Training The pro ... the ... l ... wearer who I'> learnlllg to walk al...o ~hould gam eXpeflCI1l:c III pcrforl11l11g .1 wl(lc variety 01 tunttlonal l110hd ll y ... kiI I.... Activitlcs such u\ tf;.tn\ferrmg to various cha lr\ add interc ... t to the program and. for 'orne patlCnh. may he morc l111portant than long-dl ... tancc amhulation. The Inllni ng program for vigorou\ individuals includes stair climblllg. negotiat ing ramp ... , retrievmg objec .... from the noar, knec llllg, silting on the noor, running, driving a car, and engagll1g in spor1\. The fundamental difference between these nctlv it ies tlnd wa lking is the way each LE is used. Walking implies symmetrical usage, but the other act ivit ies are done asymmetricall y, with greater reliance on the strength. agi lity. and sensory control of the ~ound limb. Gene rally. the patie nt should have the opponunily to analY.le eac h new situation a nd arrive at a solution to the problem. rath er th an depe nding on direct ions from the therapis t. Mo\t tasks can be accomplished safely 111 several ways. The lea rn er profits from observ ing othe r pro ... thesi~ weare rs as well as from professional instru cti on. Tra nsfers Ri ~ing fro m different c h ai r~, the toilet, and ca r are pri mary skills even for people who are elderly or deb ilitated. Most patie nts enter the physical therapy departme nt in a wheelchair. Initiall y. the pati ent ca n park the chair at the parallel bars or at a plinth. After locki ng the wheelchai r and raising the foo tres ts. the patie nt shou ld sit fOlWard and transfer we igh t to the intact leg. then push dow n on th e chair ann rests. The ind ividual wi ll fi nd th at placi ng the sound foot close to the chair enables rising by ex tending the knee and hip on the sOllnd side. Silting is accomplished by placi ng the sOll nd foo t c lose to the c ha ir and lowe ring oneself b} con trollcd hip and knee nexion on the ~o u nd side. For bo th standing and ~ ittin g, the begi nner should ha\c the advantage of a chair with annrests that enable U\ie of the hands 10 control and ass ist trun k move ment. Later the person should practi ce sitti ng in deep upholstered sofa", and low chairs. as we ll as benches. the to ilet. and other seats that do no t have ann rests. Transfer into an automobile shou ld be an integ ral part of the training activities: otherwi~c . the patient faces a gloom) future, confined to home or dependent on special transportation ') ,(em,. To enter the righ t (passe nger) side of an automobile. the pro'thetic wcarer faces toward the front of the car The pc!t'on with a right prosthesi<.; put ... the fight hilnu on the do...'r po ... ! and the left hand on the bad.. 01 the front 'l'at. then ,\\ Ifl!!' tht! lel't leg into the car, ,hcit!, onto the car ,~at. and fin"I1~ plac~, the pro,the ... i ... in the car. r he 1I1dl\ Idual \\ ilh J lett pro,lhe" ... may find that 'IItmg 'Idl'\\a~ ... \\ Hit txlth h,'l..'t llUt the car door I'" ea,je,t 01lL' thell PI\O" ~ln Ihl' '1,.',11 "hale ,\\ illglllg thl' pro,thc'I' IIlto thl..' 1..\lf. Ihl..'l1 put, thl..' IIH,ld ri~ht lo(}t lfl'llk the t:.II. (' Iimhinj.! Sl air\, u'lImp .. , unci ( ' u r lh Piltll..'nt\" Ith S~ 11ll", .lIld lI,til,tlbl.ll ,llI1put.lIllm, gCIlI..'r.t.lh .1"l'I..'nd ,tlltl dl''''l'~'I\t1 '1.111' ,1111.1 Indlnl" \\ IIh ,tl'P'" ~ll eYll.lt

1278

Ph~ctical

Rehabilitation

length in '1tcp-over-\tep progres~ion. -~o Those wilh unilateral tranl.,fell1oral amputation. in contrast. ascend by leading \\ Jlh the <.,ound foot and learn to descend by fi r<.,t placing the prol.,thesi'l on the lower step. A few individua ls with transfemoral amputation subsequentl) learn to contro l prosthetic J..nee flexion in order to descend step-over-<.,Iep. Curbs present a slight ly different problem. because there is no handrail. The techniques are basically the same. however. If the '1tair'l. ramp. or curb are too steep. the individual may climb diagonally or sidestep wit h thc prosthesis kept on the dow nhill :-.ide.

Final Examination and Follow-Up Care Economic . . trictures may compel the therapist to conclude the training program after the patient is able to walk and to negotime basic tram.fers and stair climbing but before the full range of training activitie~ is completed. Before discharge. the patient and prosthesis shou ld be reexamined to make certain that socket fit. proMhetic appearance. and function are acceptable. The checklist used for initial e1'.amination can be used. The physical therapist should instruct the patient with regard to the patient's responsibilit) for reponing sJ..in redness and any loose or missing pans from the prosthesIs. The new prosthesis wearer should return to the training site at regular intervals so that the clinic team may examine sockel fit. Most will require major socket revision or replacement during the fir>:.t year 10 accom modale shrink age. Follow-up visits are good opportuni lies to augment training and to encourage the individual to engage in the widest pos~ible range of activities.

Functional Capacities Functional capacitlc", refer to the individual \, ability to wa lk , lfansfer from chaif'l. climb ..,tair~. and perfonn other ambulatory activities. including recreational endeavor..,. A primary responsibility of the clinic team is to predict the probable function of the peNon with a new amputation. to dctennine whether the individual would benefit from a prosthesi .... and what degree of activity i~ likely. ~'·~ Bec;'lUse many peop le with LE amputation arc elderly wit h severa l medical problem.." the need for accurate forecasting and ongoing moniloring is especially critical.~~-61 Walking \Nith a prosthes i<., increases energy CO))(.61 M Compared with those people with two ...ound limbs. the individual \I,,·ith a unilateraltran..,tibial prosthesis requires slightly more oxygen when walking at a comfonable ~peed: the person wearing a transfemoral prosthesis con..,ume.., nearly 50(',f more oxygen than nonnal. The prosthesis wearer choo..,e ... a comfortable pace. becau..,e at a speed that is natural for the individual, the energy cost per minute is similar to that of the person" ho doe.., not require a prmthesis. although specd I..,

slowe r.67.6K The lower the amputation level. the le..,s the rnet;j bolie disadvantage. Among per-;ons with tnll1'1l1bial amputa· tions older than 40. those with long amputated lim b.., average minimal increase in energy. but peT'Jons with shoner 11mb.., work harder. Those with bilateral lranstiblal amputallon.., expend less energy than those with unilateral lran..,femoral amputations. Ind iv iduals \Vho~e amputation was traumatic pcrfollTI more efficiently than tho&c whose amputation was caused by vascular disease ar eve!), ampulation level. People who \u~t ainecl trauma walk faster and use less oxygen th an the ir dywascu lar counterparts. T he increased metabolic expend ilUre re~ ult \ in part from [he socket, whi c h ~ lIrro u nd<.; 1-.cm inu id tissue. g iving im pe rfect anchorage. The resulting pseudoarthrosis is more diffic ult to con trol than in an intact limb. The foo t-a nkle assembly transmits no plantar tacti le or proprioceptive se nsation. does nol mOve Ihrough as large an excursion as thc nomla l foot. and doc.., not initiate the dynamic propuls.io n characteris.tic of normal gall. The trans femoral prosthesis also incorporates. a knee unit th at provides. no propriocept ion to the wearer. The problem is aggravated by the fact lhat a prosthesis i.., opera ted by remotely located muscles that contract longer and more forcefully than in nonna) ga it. With transfemoral amputation. fo r example. the prost hetic foot is placed by hip motion. The resulting alteration of motion is renected In asymmetry of timing, further disturbing gail smoorhness. Individuals with prostheses walk wi th greater venical movement , inasmuch as the knee. whether proM het ic for the transfemora l prosthesis wearer or anatomical in the lrans ti bial weare r. does not flex as much as the con tralateral knee during stance phase. With the exception of patients on bcta-blockers. heart rat e respon<.;e is an imponant indication of the metabolic cost of prosthetic use for most individuals. Re spon..,e from those wea ring a unilateral transtibial prosthesi.., 1\ not appreciab ly different from that of people of comparable age who did not have amputation. although the latter group were more ac tiYe.6" Sports panicipation (Fig. 32.33) i.., an e\cellent C\lenof rehabilitation for patients of all ages. Older adult... may enjoy fishing. golfing, dancing. Tai Chi CilUan. and ..,huff1eboard. and you nger people may add basketball. tellnlS, archery. and track event .., to their range of al:tl\;ities. Most ..,pons do not rcquire any adaptatIOn to thc pro..,the..,is. Horscback riding i.., a ... Llperb actiyity that lo..,tcT\ trunJ.. control an~ scaled balance. The hiker ..,hould pack t'>. tra amputated 11mb ..,ock.., or a sheath to protCl:1 the ..,klll: a wellfilling. comfortable hiking boot IS es..,emial Bowling and partlClpatlllg.lI1..,hot put arc facilitated by empha..,l/lllg balance on the mtact LE. For "'ports Ih;'11 Involve running. an encrgy stonngJrcleasmg loot I"; mo\t ..,ullable. The ..,(x:J..ct ..,hould lit ..,nugly with very "'ecure ",u"'pcn..,lon to minll11w: ahrasl.on of the amputated limb. Chen", with Syme\ or trans.llblal amputations u..,ually run wilh n:a..,onahb, . " m. mc.neal "cp Icng.h, • all hough .hecJ..... "III I·.1\·01' .h·· C "'OlllltI .., 1011

1279

(hnpj(.r ,1 2 J'w-.lhl"ti
I' u"," ,lIl y played Wllh01i1 it pro ... tlll' ,I \l.llh Ihe pJIIYl' / U... 11l1! it pi/II 01 UlIll'hl· ... , SOI11t.: IIIcitvuluah cnloy p lily lll)! 1L'lIni .. and l icit! evenl .. 111 i.t whcckh"llr. 1',.(llIlpmelll
Sonl'l

... on \ IUl1cliona l l.:ap:U.: IlY ~\Ild quali ty of life. ()vcnl ll ... all ... Ia<.:II()I1 with pro... thctlc rchahliltallon depend 011 many laclOr.... Dltlit: ulty w ith wound heal mg and pro... · I ht.:1ic iii delay re lUrn 10 wo rk. 7"i w hile women and adults with higher cd uc;tlional levcl arc more l ikely to exprc" \ati\faclion w ilh rc hahil ilatioll. NCilhcr amputati on eti ology nor level Illilke a "'Ignl fi can t Impact on Ihc pati ent \' pcrceptions.1(, FlqUrfJ 32.33 1',ltll~'q"'Il I ' tit il dl,> li1m l' lUll (/1'/1) ,tlld IOilj! IlImp l'\TI1I (e ·oUllt' ... y 01 ()..,,,111 AIi .. fI Vll'jCl. ('A 1)2(,'i6 .)

/I/I(I/n

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nlC patient 1'" ,I (l7 ~l';lr-old mall \\ Ith diahctic arteriosclc. m ... i.... lie ... 11 ... 1.Ulll'd ;1 right tran ... ut·llal ampu tallon :) 1110nths agll. Ill' \~;h In.'.IIl·d 111 the IIlPi.ltICl1t physical therapy departmcnt for, \\ed..... The wound healed satisfactorily. I Ii ... rh~ ... ical therapist taught him to transfer independently and .unouiatt! lI'\ing a tcmporal) pro~thcsis and a walker. lie \\ i.h di ...charged \\ it h ~I home program cOI1"ist 109 of C\l'fCl ...e" 10 promotc ... trength. joint mobi lity. and endur.mce. He wa:-. a"'o told to keep an elas tic ~hrinkcr on hi ... amputated limb whenever he was not weari ng the temporary prosthe:-.i.... In addi lioll, the physica l therap ist in ... lmcted the patient in care of the left fOOl, including thorough foot \\a:-.hi ng every evening: in!:.pecting all surfaces of the foot. using a mirror: weari ng a clean sock and well-fining shoe each day; and careful naillrimming. He was fitted \\ ilh a pennanent prosthesis 3 monlhs after surgel)·. nle proMhesis consisted of a SACI-I foot, endo!:.keletal ... hank. total contact socket. and cuff suspension. He returned to the rehabilitati on department today complaining of difficu lty keeping his balance on the in·egu lar terrain on the golf co urse where he had gone for the first lime since his surgery. He also mentioned that his golf score was poorer than it had ever been.

PAST M E DICAL HIST ORY The patient was in fairly good health until 6 months ago, when he went on a long-awaited trip to Europe. On the trip he did much more walking than usual. even though he had to stop every 50 fl because of cramping pain in his l eg~. His wife noticed that Ihe hallux and second toe on his right foot we re discolored. The discolored area became painful. Upon his return home, he was exami ned by his primary care physician and was diagnosed with gangrene and adu lt-onset diabetes. Despite aggrcs.,ive wound care. the gangrene progressed to involve the en tire fool. An amputation was requ ired. His diabetes is now stabilized with diel.

• Blood pre",,,ure: 140/H6 • RC"'jnratory rate: WFL Hangc of :\iotioJl

GonioJ11etric exam ination of both lower limbs: WNL

Oh,ernltional (;ait \naly,b (~cneral findin~') Overall decrease in speed of movement Dimini&hed. awkward weight tran,>fer. lIip/J'cJyb (Bilateral) • Decreased pelvic rotation • Diminished hip flexion

Knee • Diminished right knee flexion

FootfAnlde • Minimal medial- lateral motion of the right foot Gait The patien t is a functional ambulato r using a transtibial pro!o.lhesis. Gait is slav... wilh longer s tep~ on the right side; without the cane he leans to the right side. \Vhen outdoors he uses a cane in the left hand. He can climb stairs slowly, using the handrail. On uneven surfaces. he widens hi~ walking base and walks slowly. Sensation • Lower limbs: sharp/du ll. lighl lOuch. temperature. proprioception : WFL bilaterally. • Sensation in both upper limbs: WFL Strel1~th ~lal1ual

,\ Iuscie Test

Hip

SOCIAL HISTORY The patient is a retired accountant who live~ with hi., wife. F()r years. he played golf on vacations. Upon retirement last year. he had looked forward to more frequent golfing.

PHYSICAL THERAPY EXAMINATION FINDINGS

Knee

FooVAnkle

Upper 11mb

N/A

Grade,

Righi

Left

Flexion Extension Abduction

4/5 4/5

4/5 4/5

4/5

4/5

Adduction

4/5 4 -/5 4 ~/5

4/5

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Ih:\ ·jcw of ~y~tclII"" Cognllivc ,talU"': Alert. oriented. memory int
(~l\IT)

4 15 4 15

FleXion ExtenSion

4 -/5

4/5

3+/5

4 15

DorSiflexion Plantarflexion InverSion EverSion

N/A N/A N/A

4 '5 4 '5 4/5 4/5

WFL

WFL

WFL

N 'A

not applicable owing to amputation; WFL -

Within funcllonal limits.

Chapter ,'\2 Pm'f,hClic,", Patient i.., independent In all BADL.

Pro . . thetic E:\anlinatioll Socket

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1281

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lllllica[cd by pl<.,ton action

crance),

Swnding Stalic: Good; ab le to maintain stalic posi tion for unlimited period D)namic: Fair +: difficulty maintaining balance on uneven terrain SiUlng: \VFL

PATIENT DESIRED OUTCOME (GOALS) Play golf al previou.., level of proficiency Walk wi thout depending on cane when outdoors Improve endurance

GUIDING QUESTIONS J, Fonnulatc a clinical probl em li st.

Examination of FllTll..:tioll Patient independent in all transfers: bed, chair (FIM level = 7): requi res minimal a% iSlanCe in floor-to-stand transfer':>.

2. Formulate a paticm asset lisl. 3, E S labli ~ h anticipated goals and expected outcomes. 4. FormulaiC a plan of care.

References Epidemiolog) of 100I.er e.'
H5.1993 " Edel ..tem. JE: Current choice .. in pro.. theuc feel. Clin Rev Phy., R~h;.tb \Ied 2:213.1991 6 8<:!rth. 00. el al: Gail analy~i .. and energy CO\t of below-knee amputee'! wearing \jx different pro.. thctic feet. J Prosthct Orthot .1.1)3, 1992. Hu4ltlg. GF. Chou. YL. and Suo Fe· Gal( analy ..i .. and energy

con umpuon of belolM-knce amputee.. wearing three differem pr..,.,dlt:uc feeL Gall Po"ture 12: 102. 20()O. w C I.t:ml~kl, JM. and GHler, AJ: Pro.. theuc feeL: A scientific and dml(.al rt:"~ Ie"," of current component ... State An Rev PM&R 1'1 I(f}. I'J'J-I. PrfINer C\1. el aJ: Influence 1)1 pfo.. lhtllC foot de .. lgn Oil ..ound 1mb loadmg In adult ","Ilh umlateral below-knee amputation .. Ar h Phy \.1c:d Rchl:lbd 75:825, 1l)l;4 [(I \1 'lard \oW c:;I af Comtyoif:"V 12 l/JI) IfJI)'5 "' r 1 .. 1 "-Ilef ~ e r...:ndll1Jr dUring Muhul.,1Ir1ll 111 d)' \,1 helt,w kfle .Impurec A Cllmpl1t1 hflilf hVt" 1 f'eh.shll k· fJt.."V 12 I J I 11)")", I I HI }rOCI h mil al UlfIlIJ"fI "'JU hf Ihe C·/I{·fJ(Y ,1I,fHI' (,I C,A( II ;Hld ( ,rb~1r1 «('P)' II Pf/' ,lhtHe ItTI rlllfll1j! ph j>('f ",1 With IIdeo. klJ 'C .HIII'III.H'IIlI

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17, Lehmann , JF. et al: Comprehensive analy .. is of energy storing proc;lhctlc feet: Flex Foot and Seattle foOl versus standard SACH fool. Arch Phy" Med Rehabil 74: 1225, 1993. 18. Macfarlane, PA , et al: Trans femoral amputee physiological reqUJremenls: Compurisons between SACH foot walking and Flex-FOOl walking. J PrOSthCI Orthot 9: 138, 1997, 19. Ehara, Y, el Ophy, Proslhel Orthol 1m 17:49, 1993 , 22. Dallu, D. et al: Outcome of fining an [CEROSS pro.. ,hesis: VieM of tran .. tlbiul amputees. Pro<;thct Orthot 1m 20: 111 , 1996, 23. Sewell, P, e[ al: Dcvelopmenl.~ in Inln ..-tlbi,,1 pro!'(hetic <;ockel 111tlOg procev.;: A rev icw of past and pre~em research, Prosthei Or1hol Inl 24:97,2000. 24. A<;lrom, I. nnd Slen.,lrom, A: Effect on gai l fm d ..ockct comfort HI undV a~cular Imn,]emornl ,lmpulee,,? Arch Phy.. Mcd Rehubll 84:1057, 20m. 27 Van der Linden. ML, Twi~tc,!'i, 1111(1 RIIIMlm. S\ Inc hiomet;h.UlI. II toHlue ,Ih~orhcr on IrilOvtem(lral cal e(fe(;l~ of the mdu"l0!1 IImpuli.:c gU ll Pro~ tl1lj1 Orillol 1m 26'l:'i, 2002 28. Rndt;ldfc, ('W: r-our·hur llIlhUgC pru~lhl'II(" "nee mct.:h,lIlt\rn' Kmemullc" :l tJgn rncllt lind pn.'<,(,:rlpllun ult,'rHl Pm,theIOr1ht'l Inl IX: I :'i l ), 1994 29 (·hlll. I l'1 ill IlIet:1 o f ull lnldltlH'I1! PW'lh~·"I' IIPI till thc y,;.t11.1Il 'Ibllll)' III )'IlUI1}.! 1f,1I1 .. kmor;a1 iIIllPllll't'" (''''Hp,In'!ln Ilf II' U'\Cf w!lh ablt: bodied III.·opic .-\111 J Ilh) \I'ed Kl'fMhd ~~ 4l loOI l/) IkyIJII, M t" 1 ,II l',allt·1lI prdt·rl·n~l' ,ll1d ~.HI I.'III~ 1,'11,,, \11 .l ,en IJlflt.: pllpUllllllll1 loIiilh !rlllhklllllt,11 ,11111'111.11(111111\111' 01 It \'1II~ !tIy Vl'r 11 .. 11K ~l'd f1m~l lwlI l lin!!c IPII1I \Id, 1'11\ \1.:.1 Kch.lhll

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'1,'h'l 1'\. "I ., 1 \ ,III11P,HI'IIU ,'III"dllll'II,II"I"\I III'11I 11;11111111' \('1\'1'1; 1'11'1'1111'1'/111'" 11\'\1111111,,,,"1.11 I,ll Ihl,II,,," 1,""'111,' t';1I1 11.11!t1l1~ \\ll h II (Ui' 11'11\111,,1 ,1!HIlUl ,'," 1'1,,"lh"llhllhll lilt 'h 'I '. 'Iltl} 1 ((lIIh'l. 11,,111.1 "iIIlLIIL ('Ilk I I linn 1"llt'lIdl ll lll' III I~""\\ !.I"·'11111'"1\'(" IIwlI1lo' h ,11I1I"" '''PP"I h'" Ih':IIIrI11I1 ,lIlIhlll"(II Itl I ( 111 1hl1' .... ' ...1" 1'1", I h,' l ' 1 'IlS.ltjq., \1 .111.1,1\ "I lind Ih ll t/"I, II I hll;UlII, I1.ILI!1\\" 11.1I11l1lt! ,IIHIIII' ~1,Ul"IIIJo1. Hllx'''l' k \,"It 11.111' IIhl;II ,1I111'1I1.II'"11 \ plltll , l lh" 1'11"'11\'1 (hl !hll Inl ,. ' I I '110 \ -'; I''I\I.lhl.( ,'1 i" e ;illlll11 l '111'l'In~'111111 1 III IIilt"I; , II ' ;1I1,1~' III 11litl ,lIl1l'ul,'," h\ ,I ,IItll hull'd 1""hllln~I,,'1 IIlld "II"1I11I h'I;I I"'11I 11 1n',l1l11\'111 I I{d l"h,1 I\ktl I I " I '110 1 , .11. II \ . "I ,II \"k.t ~';III,'1 1"'''1'1\' \\ III! 111\\\'1 1111111 ;llIl p"I:LI"II1\ ("'1111';111'"'' III -1 1. ,01,'.1 ,11111 1 ,,!t\'l'k'! ,,;LI""I\ \1\11 Ph" 1\11",' Heh,lllt! X I '1H I . ' 110 \ '\t llk, W( l'l ;\1 , tll' I11 l h l,'I1\l' "I \" 'Ii "~!, k:1l 111 1;111111)1. ,111, 1 h:11 ,111\\' \ "\l l lIkll\,' Illl I",,,,lL,'11I IIIIIhllll\ .l\Id ,,'1\ 1.,1,1, III 1\' ,111111111' ",,(1\1"".1" \\11 11 Itmn C\LII'!1111\ .1111 1'111;1111111 \11 h I'h\' 1\11',1 t{rh.lhll !p I "H, .'Oel! PO",'I' ( 1\1 .1'1 :, ' "ililll 1II11hll llltllltl ll1 l'\'I\""~ \\ll h 11;111,,,1>1111 .1I111'1I1.lll" lI \ 11 ;1l1(l l'~I ... ,\I lh,' "i,'.llIk I l~hll''''1 I I~dl'lh l i I{,',

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"11,1),1,,11 to;, "IoIIItIlUIIIII~ 1,< t"11 IlIlh '111"11" 'lilt II.UI It 111"1 II '1111'111 '1t'''1 \ IIt\'1 \' .,1 "II .111 ", , I, I't! I I II Y V" , 'II, 1,,,1', 111' 1'1,' Ih, I IIIlh"l hit '" f' '11111 " 1).1 {I \ .11111110 111,11111 1'\ ',111". 1111111 III III I II ""'It'l "il\ .... 111\\,'1.1' Ih'lI "I .lIh .11''>1 I, IlIlh '"wl I IlIlIh ,11111'"11 I I. II Ilulll II, ~ 'K I~ 1'1'11

I II 1.111 I, .11111 11, 1111," I ,1\1, I 1 II"" I'". lit, III , ,1111""111 III II, I," I 11th 11,'11 ,Ill" 111""11' h,lII11 .111'1111" tlh ~ \, 11.1t' 1'lllh'I',III .. I., hllll. I 1.11 '1111111.1 I" 1111 111\ '1111' 11,1111 I~ .111.1 1"""11,1 1111111 \1111'111,,111'" 11,1111 \, 11111"" l~dl.I I 'I"I,tlhlll { 11.11'''1.111 ,\ 11,,11 1,11,,1"11 1""1

h'

ChAph:r J2 Prn ... hcti<-.. l rlhl ,'ctu:~ III L u...U\h. \\", .lIld 'id ... cn. ce· Onh()""~ •""" Rehat'lllltatl,lll. BUIIt't\\\\rth IkUlcm.illtl. Ilrhlun. ~nO(1

\tJ~. BJ \mpUI.ll1\ln, .11111 l'Tn'lht'Ih.', \ C,I'l' StUlh -\p,;rnadl. cd :! f \ DJ\ I'. PhlI.1ddphl.l. ~tX\:!, . \ttll,,'h. G ••md Hh ... P" Ph~"'h.:.11 IlH:mp) \1.mngement 01 U't\\t'r 1"I(\'nlll~

\01I'II[;UIOI\".

11,}~('l

\Iunlfl•.-h. G. et ,,\

-\'~n. Galther-,burg, MD. ~

,\mpm:ulnn: Surgl(,'Ji Practice and Patient \1.ln.lf!t'mCnI, BUIH'("\\(mh !-lCIl1Clllann. Oxford, 1996. \l"lh):

12KJ

P;lrkcr J""l. and PM\.l."r, PM fed .. )' Ampula,iun A \-itd1 al [)lC1lonaf). Blhhngraphy &. AnnOl4lu."d Rt'~;Hlh (iulde: 10 InlcmC'1 Rdcft'ncet.

WON Health Puhllc;l\I(w.. , San TJICg n . (A. 2('n Rehah.hl;lllon hl,>IIIUI(" 01 Chitll)!ll. 1..(1\11("1 1-_~'rCmll) AmpuLltJOn "

Guide \0 rum.llonlll Outcome- In Phy"u.;lll Therapy \1.lNg:emmt Pro-Ed. Au ..tin. TX. 2005 Se}mour. R: Pro... thetic .. and Orthotic,,: L...owC-T Llmh and Spm.ll I.lppincoll Wilham .. & Wilkin'" Phtladdphla. 2(;,2. Smith. DG. ct al (ed!»: AlIa.,> of Amputation<; and Limh £kftt.:tenC'" ed J. American Academy of Orthopaedic Surgeon'i. ClHC3g0. 21104

Appendix A: Transtibial (Below-Knee) Prosthetic Examination I... the.: rllhlhc-'l~ ;.1'- pl"(',cri~d? ~m the diem don the pro'tthe"is easily?

tanding .3 I... the client comfortable \\hen standing \\ith the heel midline" 6 in. ( 15 em) apart? h the anterior-po\lcrior alignment sat isfactory? .; h me medial-lateral alignment satisfactory? b. Do the comour, and color of the prosthesis match the opposite limb? - J... the pro!>lhesis the correct length? h piston action mimmal?

-1.

Q

Does the socket contact the amputation limb without pinching or gapping?

Suspension 1(;.

Does the suspension component fit the amputation limb properly?

II. Doe, the cuff. forI.. 'trap. or thigh corset h,,·e adequate provision for adJu"mem?

Sitting I}. Can the cliem sit comfortably wi th hIps and knees flexed 90"?

Walking 13. " the chem·s performance in level walking sati,factory" 14. h the client's perfonnance on stairs and ramp~ satisfactory? 15. Can the client kneel satisfactori ly" J6. Does the suspension function properly" 17. Does the prosthesis operate quietly? ) 8. Doe.., the chent consider the prosthesis ~ati",factory as to comfort. function. and appearance?

Prosthesis Off the Client 19. I the ~km free of abra~ion~ or other di\coloralion~ attributable to thi" prosthesi~? 20. J., the . . ocket mtenor ",mooth?

21 . I the po,terior '" all of the ,ocket of adequate heigh!"' 22.1 the con\truclion "ati . . faClOl")? 2:1. D,. all componcnh function . . atisfactoril) '!

Appendix B: Transfemoral (Above-Knee) Prosthetic Examination I... the pro ... IIH.· ... I'·, a" prc..,{;lIhcd') 1 Call the dle" 1 dOll Ihe plo,tIH: ... I\ ca ... dy'!

Standing t

I ... thl' <:lIl' lIl <..'olll101l:1hlc when l.iIHl1ding with the hcc l lTlidlincs 6 in. ( 15 em) apart? I, ,IllY lIe ... h roll above the \ockCl 1I1111ill1al'! ~ . I ... 111\: then! 'rcc IIOIl1 ve rti ca l pn.: ...... llfC III the perineum? fl . Do till' t'onloun.
7 I,

fil l'

1>1O ... 'lIl· ... ' . . the

( 'Of

reel length'?

X. I ... th l' ~I1L'C \whlL''!

() Whell the \(J(..I-.CI val ve , ... IClIl ovcd. i:-. the

di ~ lal

tissue linn?

Quadrilateral Socket to Dill· ... 'hl' " l' hialllll)Cl(h ll y IC",' on the po\,crior brim'? t I I, til L' PO,ll'lIl1l h11111 app lo.\llllllll.: ly parallel 10 lil t.: fl oo r? 11 J... Iill' "ddlll.'l0l IOIl1!tI \ h.'lIdoJl 100:al cd illilie :lIl1c.:rior-lllcciia l co rner'!

Ischial Containment Socket I \. 1)IIt" 1111..' 1'11,11..' 1101 Illl'tllal co rrll'l' oll lll' 'Ol:h.L'1 cover the ischiallubcrosily? 1·1 ( ',1111111.: (" lll'll1 hYJ1l'I'l'\teIHI tlh.' hip on Ihe amputaled side comfo rlabl y? Ie;

( \ 111 IlIl'

",: 111: 111 til-x Ihl' hlp

l)() ' t.:olllfurt:thl), wilhou t ~od,c t gapping?

III (",III III",'\' lIl' llI ;lhdUl'1 Ih\,' hlp onille mnpUli\h..'d \Ide comrortably. without socket gapping? Sll~p .. n~ion

11 1)111',111\' Slk'I.11I hlllHlul-!l' t.:1I111101 plw·,tlll'lll' mltllioll and adduction mh.:qualely? 1X I )n~"

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h.

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Iht ' lI'I""I1'U11l1lIlh'lh11l11lPPt'll) I pIP 1111".' lll'l'l,lIt' ll\llrlh " 1111 \ 11\ 111 u11l'hkl Ih\ 1'1,"11ll"1' ',111,1,1\'1111\ ,b h' \"t'1111\'11, IUlld\\lll, ,Uld .1rIX'.U,Uh.:,,·1

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III In

! I

I the'

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k. •• IIlll'II\1( ,month'! \\ , '1Ih' I fl"lh 'I lull) tlc\cd on a lahle. can Ih~ Ihlgh piece he broughl to at le",t the \ertLCal p"'lIion7 II Ih " ." I " 1'11.111) ngld, " a bac" pad alladll'IP ,

l

h th'" I..:un'lrurllon \ati,laCIOr) .)

, ( \ .111

'·''''lpon~nh

function ""isf,,clorily'?

e/l , \

I'T/~ U

33 LEARNING OBJECTIVES I. (demif) the poSlumt :-.upport componenlS of a wheelchair .,caling ... y ... lem. 2. Idcntify the component'> Ihal make lip a wheeled mobility base. J. Dc.,cribe the component<., of the patient exam-

.s.

The Prescriptive Wheelchair Adrienne Falk Bergen,

1''1', AT!'

inal;on procc!>s . Describe the mcar;,urementr;, required for COf-

rect fiHlIlg of a prer;,criptivc wheelchair.

S. Underr;,tand the function and II1dicalions for common \\ hcclchair feature'i and postural \UPport componcnI\,

6. Recognize the functional impiic:llions of a properly prescribed wheelchaIr for environmental access.

7. Analyz.e and interpret patient data and identify appropriate prescriptive elements when presented with a clinical ea,,>c study.

OUTliNE n lC

Examination Proc('s'i 12Rl't

Phy~i c.iI

Exam il1ting Equipment 1289 Supine Examination 1289 Scated Exam ination 1290 ·\nticipatcd Goal-, and E'pcL' led Outwmcs 129] Intervention 1291 Postural Support Sy~telll 1292 Tile Wheeled Mobi l ilY Ba... c 1296 Thc Wheclchair Seal [300 Thc Wheclchair Back [303 The Pelvic Positioner [304

hysical therapi ':l ts are orten called on to pre~cribe a whee lchair. I.:! A properly prescribed wheelchair can be a useful device in reintcgrating a person with a di sability into the communi ty, wherca~ a poorly prescribed one can actually exacerbate the problem\ associated wi th funct ional limitation.., and di sabi lity. This chapter presents a sys tematic approach to determining the appropriate componcnh of a prc~cf1ptive wheelchair, beginning with a thorough examination and culminating with a plan of care ( POC) Ihal includes the proper ,. ,eating syslem and wheelcd mobi lity baie. The seating sYitem and mobility base combinc to creale 11 prescriptive wheelc hair, a seated environment from whkh the patient can achieve maximum funclion, A whee lchaIr is trul y a mobility ortho\is. An orthosis i<.; a device u<.;ed to provide ~ upport or to straighten or In cor· rect a deformity. It i\ Iypically II hrace made of I1lct~11 or pla'lllc that increases or maintains ;'1 pe rson \ level of function. II properly pre\cnbcd. a wheelchair will proVide ~u l IIclI:nl \upport to help delcr Ihe ellcct of deforming fon.:cs or weake ned \truct urc\ on IUl1uion 01 Ihe ~y!-.tcl1l. In ~ 1I11 · pier tcrms, II ... houJd \UP port the U... r.: 1 a ~ nct'dcd 10 allow maximum lunu]()Jl Ina ... nllH.:h a... II I... Oil whel'I ... , IlIl' "'Y'" lem C'1I1 he called
P

Footrest,; and Lcgre\I'i 1305 Armresl\ 1306 Wheeh. I land Rims, and Tires 1107

The Frame 1J08 Acccs<;OriC<; 1309

S pcl.: lali /eJ WheekhalP, I :lOY Positioning 1309 Power 1310 SPOr!~ and Rccreation 13\\ Whcck ha ir Traini ng St rateg ic <; 1~ t :l T he Role of thc Certified Rehatuiit.ulon 'I~c hn o logy Suppli er I J 1J Summary IJ 14

Like a we ll -made orthosis. th e wheelchair should fit correctly. It ~ hould be reasonably cosmetic to the u..,er, It should al~o be a~ lightweight and yet a~ strong as pO\~tble. It ca n be obtained frol11 a stock supply when appropriate, bUI IllOst oneil individual modifications for the patient', spec ial needs arc requi red. Like a well-made orthosis, the wheelchair ,hould be prescribed by qualified professionals. The enllre tcam \hould make the decision concerning a prescriptin~ \\ heel~ chair. It is important that all tho~e concerned \\ Ith the pcr~ "ion 's pre~el1t and future function be a part of thi ... 1l"U11. This lI1t:1udes the wheelchair U"'cr, Iherapi\ t"i, ramil) I1lCI1l bers, caregivers. nurse~, phy\ician" educmor', \oratton.1I cou nselor<.;. and a l/lItllilicd rchabl1l1i1IiOIl lechllllll1p) ... up plier. To cn ... urc thaI the J110~t ... uttablc,: dc\ Il'C j-.. llbhUlll'J. th c tcam IlIU ... 1 have ;1 clear idt::I of \\ho \\111 Ix' u'lIlg II. what functlollal IC\'t!! i~ C\pt.'l'tl'll. and \\ here..' thl' l,:h.l11 \\ III he U,Ctl. All Ihe Illt!mbcr...... hould l'lllltnbute III the l'\.lIll1· nation repolI ... and 1t!ltt!r of lllt!dl(al lll'l'l'''lt', ,\ hl(h II1U't he Pl'l: ptll\.'d 10 'Cl'IlIl' lundlng Oll\"t' lht' dhllf I'" ",upplle..'ll. Ihe ICHIIl I' rl"pon ... lhk lor ,td'U'III1~ .unl IllIm£. th ..., 1111.11 dl'Vll'l', it ... \\l'lI i1'" tl'iu,:hll1!! Ihl' ",lIll'n! ,lIld .111' l',lrl' 'IH'r' hoy, tn U"'l' ,IlUlm,ullt,lIl1lhl' dl,.'\ In' Il,ll'n,url,.· 0plll11.lllon8 Il'll11 pl'rltllllhIlU.:l'.

\ pI""',,:,,!'Ii\\..' '\hn'h:h.11I

1.... 1 tll lllhllHlIIll1I

ti l d po ...

(UI.lt "'UpP(ll t ""'I,,'1Il ,llld.1 IlHlhllll\ haw 1Ii,II ,Ill' 11)llll' d

.tt I ). rh l' Ihlll \..'(1111.11..1 Ihl' ""'t', \. hlllh dll\..·l' II ). I'll, ,, IllclUik· ... th l' ~l'al, "',Ie]... ,lIld h)1.1t "'UPPO'" .1'" \\ l' II;\, :Illy addl li olla l co mpo IWllh l1l'l'lkd to 1ll,lInt ,II n po ... turnl :dl g nm c lll. \1 .111l1\..'Il.\I\~(, 01 po,lm;11 alignm l' nt lIla y rl'ljllJn.' ~ll(.:h .IJdlll()lh .1 ... ,I hl'a d ... upport : bln:.1 ... uppor!.. . fo r thc trunl-... lllp .... ;11ll! "IICl' . . ; Illcdial ... upporl for th e knees: and ur~r \!\Ircmil) (UP) ... uppa rt ... u l·fa cc .... as we ll as st rap s (lr band" lc-.g ...lIltc-rior chc- ... t or pelvis ) needed to keep tht: u"c-r tnlt' rfacc-d \\ 1111 the s upport s urfaces. Th e lIIohll11Y />(1.\( c:onsi . . h of (hI! tubular frame. arm res ts, foo t su pport-.. and \\ heels, Once the deci s ions arc m ade about th e t) pc of "lIPPOTt sys tc m needed. th e tca m mu s t th e n decide \\hat type of mobilit y base bes t s ui ts the user 's functional level and e nvironm en tal needs, For so m e patient!). caregiver needs are of param o unt importance, Clear IIlformation wi ll be need ed to e ns ure that the posIUral suppo rt sys te m and the mobilit y base illl e rface properly. For use rs w ho utilize m ore than o ne mobility bas e (e. g .. power and manual ), the most cos t-effec ti ve approac h is to have o ne support sys te m illlerfa ce wi th a ll the mobility bases. Th is is no t a lways p rac ti ca l, a nd sometimes it is best to have th e full -s upport sys tem on the cha ir used mos t freque ntl y, and fo rgo opt ima l postural su pport in the backup sys te m to fac ilitate tran sport fo r sho rt lrips. Creating a dy namic seali ng sys tem involves three steps: (I) exami ning the patie nt/client and eva luatin g the data; (2) detenn ining the diagnos is and prognos is. anti ci pated goals and expected o utcomes; and (3) planni ng the intervention. This process w ill aJlow appropriate recommendations hl n,,'.I1,,· .1 d\ 11.111111. ,\..·.1I1..'d 1.'11\ mUlllll' llt ( "' g,

Jh "WIlI \Ul'/)jl,t \\\lc'/II I' madl'

lip 01

Ih l..' ,url'al·l''''

Figure 33.1 A prcM,:npllvc whcckhai r con..,I ... I ... 01 Ihe !1o:-.llIrHl WPP')rt ~Y"' lcm tlnJ a lllobllllY ha ...c,

illid pmdul'tllJoI U· .... A ... notl'd , the overall deSired OUIComc I ... to l' ll'a ll' U dy n:tllIi t: ... ca llll!! "'y\lclll that I ... .a comfonable ha . . t· Imlll whl(; h thc u. . er can atl