PT management of patients with sensori-motor disorders 感觉运动障碍的物理治疗

1. PT management of patients with sensori-motor disorders感觉运动障碍的物理治疗 昆明医学院附属第二医院康复科 敖丽娟 教授

2. Treatment approach - ICF Improve Individual Minimize Reduce Society

3. Hollstic approach

4. Passible sensory and motor impairments Balance Coordination Cognition perception （感知能力） Abnormal synergy Movement Task

5. Sensory re-education • Tactile（触觉）, hot, cold, 2-point, stereognosis（实体辨别觉） • Discriminative（识别）, protective（给予保护） • Early training – Detection and location of stationary and moving light touch stimuli（刺激） • Progression – size, shape, object recognition（确认）, 2-point discrmination • High level of attention and memory

6. Sensory re-education • Protect from noxious and injurious stimuli (防护来自物理和化学的伤害) • If sensation does not recover • Compensation e.g. vision for deficit in tactile sensation (靠视觉补偿触觉的不足)

7. Passible sensory and motor impairments Abnormal biomech alignment Selective motion Weakness Muscle tone

8. Biomechanical alignment • “Normal” alignment – most efficient • “Abnormal” alignment – affect movement

9. Abnormal alignment in standing (postural set) Marked asymmetry(明显的不对称) No weight bearing over R LL R LL adducted, planterflex R UL flexed L trunk is shortened

10. Treatment Correct (矫正) alignment of the trunk, UL and LL in sitting Weight bearing(负重) over R LL

11. IN a more narmal postural set Weight bearing and strengthing ex

12. Muscle tone Spasticity Flaccidity

13. Muscle tone • Amount of tension in a relaxed muscle • Tension stiffness • Maintain posture(维持姿势) – prevent too much sway • Make muscle ready to shorten • Person with intact neuromuscular system, muscle tone is minimal i.e. resistance to passive movement is minimal • Muscle tone can change according to posture and anxious level

15. Muscle tone • Abnormal muscle tone • Hypotonous – flaccid • Hypertonous – spasticity, rigidity

16. Spasticity – pathophysiology痉挛的病理生理学 • Lesion of CNS (中枢神经系统损伤) • Lack of supra-spinal inhibitory signals on stretch reflex(反射性伸展的上行性抑制信号不足) • Definition : A motor disorder(失调) characterized(特征) by a velocity-dependent increase in tonic stretch reflex

18. Spasticity - pathophysiology • Lesion of CNS • Lack of supra-spinal inhibitory signals on stretch reflex • Definition: A motor disorder characterized by a velocity-dependent increase in tonic stretch reflex Velocity Resistance

19. Manifestation(显示, 证明)of spasticity • Exaggerated(过强的) stretch reflex • Tonic: increase resistance to passive movement • Phasic: increase tendon jerk • Clasp knife response • Increase tone to a certain range and follows by a sudden reduction of tone • Clonus • Abnormal posturing of the limbs, contracture, pain

20. Spasticity Baclofen(巴氯酚) • Synapses(突触) Rhizotomy(神经跟切断术) • Afferent(传入的) Botulinum(肉毒素) • neuro-muscular junction(神经肌肉接头)

21. Treatment to reduce spasticity Enhance inhibition of stretch reflex Pharmacological treatment Baclofen (oral, intrathecal) – a derivative of GABA Botulinum (Intramuscular) – inhibiting the release of acetylcholine Surgical treatment Rhizotomy – removal of dorsal rootlets, to reduce the afferent inputs into the spinal cord

23. Surgical treatment (外科治疗) Rhlzotomy – removal of rootlets, to reduce the afferent inputs into the spinal cord Reduce spasticity over calf muscles

24. Spasticity Enhance Inhibition of stretch reflex(增强对神肌反射的抑制) Prolonged stretch(持续牵拉) Positioning Splint Serial casting Stretch – 6 hours Ice therapy – 20 minutes Physiotherapy

25. TENS – SpasticityEnhance pre-synaptic Inhibition(增强突触前抑制) • TENS applied on fibula head (common peroneal nerve) to reduce spasticity of ankle planterflexors • Parameters(因素) : • 0.2 ms square pulse • 99 Hz • 2×sensory threshold • 60 minutes • 5 times a week for 3 weeks

26. Flaccidity(弛缓)Enhance excitation of stretch reflex(增强伸展反射的刺激) • Quick stretch(快速拉伸) • Brisk touch • Quick tapping(快速轻扣) • Quick stroke of ice

27. Muscle tone and Muscle strength No clinical or experimental(实验) evidence(证明) support: Normalise spasticity Muscle tone is poorly related with functional disability Indeed, poor motor control – lack of isolated control(分离控制不足) of individual muscles, muscle weakness, impaired dexterity(灵巧性减弱) , along with tissue changes – is usually more limiting……

28. In addition to strength,Isolated control增强肌力,分离控制 The ability to control the muscle force is essential

29. Lack of isolated (selective) control • Stereotyped(常规) • Abnormal movement synergy(共同运动)

30. Abnormal synergy Mass flexion Sh flexion Elbow flexion

31. Isolated / selective control

32. Abnormal flexor synergy (屈肌共同运动)

33. Isolated knee and hip control

34. Spastic musclecan be weak

35. Spasticity and weakness

36. Spasticity and weakness Marked weakness of gastrocaemius

37. Strengtheming will increase spasticity ? • Chronic patients > 9 months of stroke • 10-week program of aerobic and strenthening exercise (concentric, eccentric) • Improvement – Total peak torque of affected leg, walking speed improved, Quality of life with no increase in quad and plantar flexor spasticity • Isokinetic strengthening increased muscle strength and gait velocity without increase in spasticity

38. Strengthing • Care must be taken to strengthen a spastic muscle • Correct movement patterns and optimal resistance

39. Strengthening ~ Increase force output • Functional electrical stimulation • Assisted, active movement • Proprioceptive neuromuscular facilitation • Task specific • Action(concentric, eccentric, isometric) • Velocity, Angle

40. Functional electrical stimulation

41. Sensory input

42. Assisted active and active exercises

43. Proprioceptive NeuromuscularFacilitation • Patients with neurological and orthopaedic conditions • Sensory input – to regain strength using all available sensory inputs • Tactile – manual contact to guide the motion • Verbal – simple and precise • Visual – patient’s eyes follow the movement • Proprioceptive • Movement – traction to stretch muscle to enhance contraction • Stabilization – joint compression (approximation) to increase contraction muscles

44. Proprioceptive NeuromuscularFacilitation • Synergetic movement pattern • What patients can “DO” – Irradiation from strong to weak muscle group • Resistance to get Optimal Response from patients – max awareness, strength, coordination, endurance • Stability before mobility • Promote functions

45. Flex – add-ER Flex – abd-ER Ext – add-IR Ext – abd-IR Flex – add-ER Flex – abd-IR Ext – add-ER Ext – abd-IR PNF basic pattern

46. Flex - abd - ER

47. PNF – Tactile, proprioceptive,verbal, visual, Active participation Upper limb Flexion- abduction- external rotation and Extension- adduction- Internal rotation

48. Proprioceptive NeuromuscularFacilitation – Special techniques • Rhythmic initiation • to promote initiation of movement • passive assisted active active resistive • Repeated contraction • to promote strength of agonists • repeated stretch, repeated contraction • Dynamic reversal • and to promote strengrh of agonists and antagonists • facil active movement in one direction, followed by movt in opposite ditection

49. Proprioceptive neuromuscularfacilitation – repeated contraction Stretch – elicit contraction to promote movement

50. Proprioceptive neuromuscularfacilitation – dynamic reversal Stretch – elicit contraction to promote movement