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STROKE:
Transient Ischemic Attack (TIA)
Temporarily interruption of blood supply to the brain
Neurological Symptoms < 24 hours
No evidence of Neurological damage on MRI
Cause:
Occlusive episode
Hypotension
Arrythmias
Cerebralvascular spasm
↓ Cardiac output
Hypotension
*Precursor for a stroke or myocardial infarction
Ischemia: 80% of strokes
Interruption of cerebral blood flow
Thrombus, Embolus causing ↓ O2, Metabolism = Neural Tissue Death
Thrombotic Stroke:
Caused by:
Abnormal vessel wall
Atherosclerosis
Hypotension
Hypertension
Embolic Stroke:
Caused by:
Blood clot
Blood Plaque
Causing occlusion or infraction
Cardiac or vascular emboli
Management of Ischemic strokes:
Haemorrhagic Stroke: 20% of strokes
Anti-thrombotic meds (Clot busting agents)
Antiplatelet
Anticoagulants
Aspirin
Heparin
Thrombotic Therapy tPA (3.5 – 4h window to be effective)
Neuroprotective agents
Alters the course of metabolic events
Antiedema Agents
Corticosteroids
Intraarterial treatment
Clot extraction
Bleeding from ruptured cerebral vessel or trauma
Types:
Hypertensive Intracerebral Haemorrhage
Aneurism
Arteriovenous Malformation
Posttraumatic Haemorrhagic Stroke
Intracerebral Haemorrhage:
Putamen, Pons, Thalamus, Cerebellum
Develops over Minutes
Aneurysm:
Ballooning or rupture of large arteries (ICA or ECA)
Acute, abrupt onset, severe headache
Arteriovenous Malformation: (AVM)
Can occur anywhere in brain
Abnormal capillary bed, large tangled vessels
Posttraumatic Haemorrhagic:
Traumatic brain injury after head injury (SAH/ICH)
Axonal injury
Management: Control ICP, Decompression, maintain perfusion
Stroke Syndrome:
Vascular Syndromes:
- Common Carotid/Internal Carotid (CCA/ICA)
- Middle Cerebral Artery (MCA)
- Anterior Cerebral Artery (ACA)
- Posterior Cerebral Artery (PCA)
- Vertebrobasilar Syndrome
- Lacunar stroke Syndrome
Contributes to major distribution of the MCA
Homonymous Hemianopia:
Vision loss on the same side of visual field in both eyes
Neural location of stroke will determine the severity and impairments
Internal Carotid Artery (ICA)
Contralateral Hemiparesis:
Paralysis on opposite side of body that brain damaged occurred in
Contralateral Hemianesthesia:
Loss of sensation on opposite side that brain damaged occurred
Global Aphasia:
Wernicke's Aphasia -> Talks clear, but words makes no sense
Brocha’s Aphasia-> Broken speech
Middle Cerebral Artery (MCA)
Anterior Cerebral Artery (ACA)
Supplies the Frontal Parietal Temporal Lobes, Internal Capsule, Globulus
Pallidus, Corona Radiata.
Homonymous Hemianopia:
Vision loss on the same side of visual field in both eyes
Supplies Medial Aspect of the brain, frontal and parietal lobes
Contralateral Hemiparesis and sensory loss:
Paralysis on opposite side of body that brain damaged occurred in
LL > UL
Urinary Incontinence:
Aphasia
Unable to produce speech if lesion occurred in left hemisphere
Contralateral Hemiparesis:
Paralysis on opposite side of body that brain damaged occurred in
Sensory loss to face and UL & LL. (Face and UL more affected)
Perceptual deficits (if lesion is in R hemisphere)
Personality / Disinhibition:
Aphasia:
Unable to produce speech if lesion occurred in left hemisphere
Apraxia:
Unable to perform task on demand if lesion occurred in R hemisphere
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Posterior Cerebral Artery (PCA)
Supplies the Occipital Lobe, Temporal Lobe, Upper Brain Stem, Pons,
Thalamus
Thalamic Syndrome -> Unable to process information of pain
Memory Loss, Tremor, Hallucinations:
Webber syndrome -> Eyes are down and outwards, Ocular Motor syndrome
Prosopagnosia -> Unable to recognise faces
Visual Agnosia -> Unable to recognise Objects
Ataxia -> Imparted muscle coordination, motor control, impaired balance /
gait
Cortical blindness -> Total or partial loss of vision
Lesion here produces both Ipsilateral and Contra Lateral signs
85% Mortality Rate
Other symptoms include:
Vertigo/tinnitus in ear
Wallenberg’s Syndrome
Dysphagia, soft voice
Nystagmus:
Uncontrolled shaking of eye
Lacunar Stroke:
Basal Ganglia Stroke:
Stroke here will affect ability to:
Prepare and execute movement
Activation and Inhibition of movement
Organising behaviours, Verbal Skills, Problem solving, mediating socially
appropriate responses
Procedural Learning
Evaluation of sensory Data
Compare motor demands with proprioceptive imputes
Internal Capsule:
Stroke affecting all three parts of the IC will contribute to no motor function
Associated with Hypertensive haemorrhage and diabetic microvascular disease
Affects small vessels deep in the Cerebral cortex -> Executive Function
Accounts for 20% of strokes
Symptoms include:
Can be either pure motor or pure sensory
Ataxic
Sensory Motor
Dysarthria -> clumsy hands
Hemiballismus -> Undesired movement of limbs
Anarthria Pseudobulbar -> Unable to articulate words
Left Hemisphere Lesion:
Right Hemisphere Lesion:
Behavioural:
Visual Perceptual Issues
Impulsive
Poor judgement
Inability to self-correct
Poor Insight
Falls risk
Vertebrobasilar Artery Stroke:
Supplies the Cerebellum, Medulla, Pons and inner ear
Intellectual:
Poor Abstract Reasoning
Poor Problem Solving
Memory Issues
Spatial/Perceptual Issues
Negative Emotions
Fluctuation is task performance
*Visual ques will be less effective
*Need to give clear Verbal Instructions
Behavioural:
Speech and Language affected
Broca’s & Wernicke’s
Global aphasia
Slow and Cautious
Very aware of disability
Intellectual:
Disorganised
Difficulty with initiation
Processing delays
Memory Issues
Language/Preservation Issues
Emotions – Positive
Good task Performance
Speech Apraxia
*Verbal ques and commands will be less effective
*Could use visual cues
Complications associated with a Stroke:
Physiotherapy Assessment:
Need to consider the following complications and Rx planning
Our assessment is guided by area of pathology
i.e. ICA vs MCA stroke
-
Altered consciousness
Speech and language issues
Dysphagia -> aspiration pneumonia
Cognitive issues
Perceptual Issues
Seizures
Bladder bowel issues
Cardiorespiratory
DVT
Osteoporosis
Falls Risk
Stroke Subjective Examination:
Establish Pt goals
Shx
PMHx
Home situation
Works status?
Interests/Hobby’s?
Premorbid activity level (exercise tolerance & establish Base Level)
*Goals need to be SMART
i.e ask the pt what is the Top 3 things they want to focus on during the 5
weeks.
Have a functional approach to Rx
Establish a Clinical Pattern
Base treatment around Patient ST & LT goal
Plan for DC / referral
Stroke Objective Examination:
-
-
Have functional approach -> test full arm function rather than individual
Muscles
Movement analysis
o
Observe posture
o
Look at how they Initiate, can they sustain, can they finish the
task
Compensation OR substitution
AROM/PROM
Strength: Concentric/Eccentric
Tone: Hypo/hyper
Sensation: Sensation extinction?
Mobility, Bed transfers, Ambulation
UL function
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Multiple Sclerosis:
Features of MS:
Progressive demyelinating disease of the CNS
Can occur anywhere in the
Brain, Spinal cord or Optic Nerve.
Oligodendrocytes are affected
Nodes of Ranvier is damaged
This ↓ signal volleys & ↓ their amplitude anywhere in the CNS
Involves white and grey matter
CNS inflammation:
Cytotoxic T-cells and Macrophages attack the myelinated sheets
This leaves scar tissue and causes hardened patches
↓ Impulse conductivity
Destruction of oligodendrocytes
Responsible for the production of Myelination
Caused by:
Epstein Bar virus:
Genetics (IL&RA & IL2RA)
Environmental Factors: Place of residence, Smoking
Affects more women than men (20-40 years old)
These lesions can occur in the:
Cerebellum
Periventricular Region
Brain stem
Optic Nerves
-
Types of MS:
Exacerbating Factors:
Relapsing or remitting:
-Discrete attacks with full or partial recovery
-85% of pts w MS
Secondary Progressive:
-Begins as RRMS progressive axonal loss
-Progressive axonal loss
Primary Progressive:
-Steady functional decline and progression
-10% of patients
Progressive relapsing:
- Steady deterioration
-5% of patients
-
Medical Management:
Symptoms:
Immunotherapies:
Works by modifying the activity of the immune system
Sensory:
- Parenthesis > anaesthesia
Pain:
- Paroxysmal limb pain
- Optic Neuritis
- Lhermitte’s sign
Motor Symptoms:
- Paresis or paralysis
- Spasticity
- Coordination/balance
- Gait Mobility
-Speech/Swallowing
-
Disease modifying Therapies:
CRAB Drugs
Steroids:
Exacerbation is managed by easing the inflammation
Symptomatic:
Spasticity -> Baclofen
Fatigue -> Ampyra
Pain -> Lyrica
Helpful for balance and gait, but ↓ alertness
and motor learning
Physiotherapy Evaluation:
Age
Diagnosis
PC
History
HPC, PMH, Social
Pain
Falls
Meds
Previous therapy
Goals ST & LT
Fatigue
Thermosensitivity
UMN signs
Need to evaluate
-Endurance, Timing, Different Terrains.
-MMT
-ROM
-Spasticity/Tone
-Use of gait aids
Relapse is treated by Immunotherapies
Pseudoexacerbation:
Temporarily worsening of MS
Symptoms normally dissipate >24H
Adverse reaction to heat
All these Factors can increase the risk of
Pneumonia
Falls risk
*When the disease is stable, MS is not life limiting
Coordination and Balance:
-Ataxia
-Tremors
-Truncal Weakness
Gait and Mobility
-Ataxic Gait
-Scissoring Pattern Gait
-Fear of falling
Speech and Swallowing:
-Dysarthria, Dysphonia, Dysphagia
Visual:
-Diplopia
**Fatigued**
Treatment:
PROM
AROM
Sensation
MMT
Cognition
Ballance
-Berg Balance Scale
-Dynamic Gait Index
Cerebellar
-Ataxia, tremor, dysmetria
Vestibular
-Vertigo, nystagmus, VOR testing
Gait-> Pattern, endurance
Gait Training:
-Foot drop (Increased tone in calf and decreased push-off)
-Plantar flexion contracture
-Dorsiflexion weakness
-Decreased push-off (Look at Hip Flexion and Plantarflexion)
-Trendelenburg Gait (Weak Glute Med)
Viral OR bacterial Infection
Disease of Major organs
Stress
*Aim to maintain functional strength as it will improve quality of life*
*Be aware, these patients fatigue fast*
Balance Training:
Posture:
-Task Specific training
-Hip Strength
-Functional Training
-Core Stability
-Progressive strength Training
-Scapular Retraction
-Vestibular training
-Pectoral Stretch
-Task with eyes close
- Head movement
-Change surface
Intermittent Exercise:
-Reduce fatigue
-Break exercise down into core components
-Rest at first mention of Fatigue
Diminished Knee flexion (Need 60 degrees Kn F)
Could be caused by:
- Spasticity of quads
Stretch in various positions
-Weakness of Hamstrings
Focus on eccentric control of hamstrings
Diminished Hip Flexion:
Tight or weak Psoas Major
Cause reduced swing phase in gait cycle
Emphasis eccentric loading (lower leg down slow & controlled)
Outcome Measures:
EDSS
MSQLI Fatigue severity scale
MSFC
FAMS
EBP-> MS Society Australia
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Parkinson’s Disease:
Tremor:
Chronic and progressive neurodegenerative condition
Disorder of the basal ganglia and substancia nigra
Caused by a loss of dopamine
Caused by the presence of Lewy Bodies
Can lead to both motor and non-motor impairments
-
-
Imbalance of neural connections between BG, Thalamus Cerebellum and
cerebral Cortex.
Initially presents unilaterally in the hands
Gradually progress to Face, LL, Shoulders and Bilateral involvement
Rigidity:
Cardinal signs:
Tremor
Rigidity
Akinesia -> Inability to initiate movement
Bradykinesia -> Slow movement
Postural instability
-
Affects both the agonists and antagonist muscles
Proximal involvement initially then progresses distally
Two types:
-Cogwheel
-Lead pipe
*test around the wrist for rigidity
Akinesia / Bradykinesia:
Other motor signs and symptoms:
Caused by impaired activation of the SMA
Motor planning deficits
Major cause of disability
Cause freezing of gait
Difficulty w Buttoning Shirt, Clicking of Mouse, Typing
*Add cognitive component to treatment. i.e walking and count back from 100
Shuffling gait
Stooped posture
Freezing when turning
↓ arm swing
Falls risk
Postural Instability:
Pre-PD Motor Clinical Features:
Anosmia
Constipation
Colour discrimination
Depression
Flexor dominant -> stooped over position
Loss of rotation
Difficulty w bed mobility -> can’t roll in bed
Festination-> walking on balls of feet
Retropulsion -> Taking steps backwards to maintain balance
-> taking more than 1 step backwards = negative result
Dystonia of leg/foot (Uncontrolled muscle contraction)
Dysphagia
Dysarthria (Motor speech disorder)
Masked face (Little expression)
Sialorrhea (Drooling)
Pre PD Non-Motor Clinical Features:
Depression
Apathy
Anxiety
Dementia (60% prevalence towards end of PD)
Insomnia
Types of PD:
Classification of PD:
Primary Parkinson’s:
Idiopathic, 78% of cases
Hoehn and Yahr scale:
1
Unilateral disease, min or no functional disability
2
Bilateral or midline involvement, w/o balance impairment
3
Bilateral involvement, Mild to mod disability, physically
indep, mild to mod post instability
4
Severe disability, can walk/stand unassisted
5
Wheelchair/bed based unless assisted
Secondary Parkinson’s:
Brain Injury from strokes, toxins, trauma (boxing), Infections
Parkinson-Plus Syndromes:
Progressive supra nuclear Palsy
Multi system atrophy (CNS more affected)
Lewy body dementia -> App start friendly but then get defensive/angry
Alien hand syndrome -> Ask to lift both arms but only lifts one
Huntington’s Disease -> Rigid variant (genetic motor for PD)
Surgical:
- Pallidotomy
- Thalamotomy
- Deep Brain Stimulation
Physiotherapy assessment:
Pharmacological Management:
Levadopa/Carbiopa:
Side effects include nausea
Dyskinesia
CV issues
Orthostatic Hypotension
Medical management:
Pharmacological:
Levadopa/carbidopa
COMT Inhibitors
Anticholinergics
Dopamine Agonists
Anticholinergics:
- Artane, Benztrop, Cogentin
- Reduces tremors & dystonia
- Mood changes,
- Drowsiness
- Nausea/Vomiting
COMT Inhibitors:
Stalevo, Comtan
Dopamine Agonist:
Makes more L-Dopa available
- Sifrol, Simipex, Permax, Parlodel
Diarrhea
- Act and mimic dopamine
Dizzyness
- Nausea/Vomiting
*Drugs have on and off periods
*Therapeutic response becomes shorter w time
Posture
Coordination
Balance
Gait
Range/Flexibility
Tone
Strength
Pain
*Establish patient goals and base treatment around that
*Identify what cause the patient to move in that pattern
*It’s important to identify ADL that they have difficulty with
*Need to identify ON/OFF periods of medication and perform treatment in both
*Involve ADL with Rx. Personalised contextual
1) Postural Assessment:
2) Objective assessment:
↓ Trunk extension
↓ Lumbar lordosis
Stooped flex position
↑Thoracic Kyphosis
↑Posterior Pelvic tilt -> Tight hip flexors
Scoliosis
Pisa syndrome -> Lateral trunk flexion
-> Tight Obliques
-> Use verbal cue’s mirror to show
Antecollis.
-> Excessive forward flexion of cervical spine/neck
-> Difficulty swallowing
Camptocormia -> Thoracic and Lumbar flexion >45
-> Weakness of antigravity extensors
Strength:
-> flexor dominant
-> Reduced extensor strength
-> Ask to actively go into Ext (antigravity)
Coordination:
-> Dysdiakokinesia
-> Finger to nose
-> Finger to finger
Flexibility:
-> Hamstrings
-> Rigidity (check at wrist)
->Akinesia/Bradykinesia
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3) Balance:
4) Tone:
Delayed equilibrium reactions
Lack of ankle, hip, stepping strategy
Lack of anticipatory postural control
Instability to adequately respond to perturbations
↓ Sensatory adaption
Muscle weakness
Postural hypotension
3) Postural Control:
Test in Sitting and Standing
Reactive: -> Perturbations
Static
-> Sternum & Pelvis
Anticipatory -> Give them a nudge
-> Reach out BOS.
Adaptive: -> Surface
-> Turn head
-> Environment
Lead pipe:
Slow, sustained resistance
Smooth resistance throughout range
6) Gait Assessment:
Outcome measures:
Shuffling, high step rate gait
Slower speed with shorter steps
Festination: Walk on Balls of feet
Shoes scuff on floor
COG out BOS
No heelstrike, Flat foot/ foot slap
Chace their COG
Rigid trunk w reduced Arm swing
↑ falls risk
Narrow BOS, COG anterior to BOS
Difficulty in initiating and terminating a step
Gait Freeze -> Motor block prevents initiation of movement
Motor block causing the freeze
Commonly occurs during complex motor sequences (Direction changes, narrow
spaces, distractions, doorways)
Body Structure and Function:
UPDRS revision part 3
UPDRS Part 1
Activity:
Mini BEStest
6MWT
10M Walk
5x STS (LL strength)
9 Hole peg test (dexterity)
Freezing of gait:
FOG questionnaire
Fatigue:
Parkinson’s disease fatigue scale
Exercise therapy and PD:
1)Sensorimotor agility training:
Freeze gait:
Used to increase:
-Speed
-ROM
-Gait
Cogwheel:
Jerky, ratchet, catch & release
5) Pain:
Musculoskeletal
Dystonic
Neuropathic
Central
Akathisia
Fear of falling:
- ABC Scale
Dual Task:
- Tug Cognitive
- get them to walk and give then a
a cognitive task such as counting
from 100 backwards.
360 Turn Test:
- Measures dynamic balance
- Time to complete circle
- PD =6 sec or 9.5 sec
Perform each circuit for 10 mins
-Endurance
-Motor Control
-Posture
-Ballance
-ADL’s
-Flexibility
Improve intensity by adding sensory integration, cognitive tasks, speed/resistance
Other exercises include Kayaking (rotation), Boxing (Balance) Lunges (alter COG)
2)LSVT BIG:
Exercises needs to:
Axial Flexibility
Limb ROM
Loss of Strength
Improve cardiovascular endurance
*Needs to be functional
*Needs to be high intensity and challenge their balance
Exaggerated training
Get them to perform big “flicks” before activity (↑ Neural activity)
4) Dance for PD:
Adds a cognitive aspect to training
Low Impact
Improves Balance
7) Gait Training:
3)Tandem Cycling:
Forced Exercise
Good for reduction in Tremor and Bradykinesia
Helps provide autonomy
Forces them into lumbar and thoracic extension
More COB out BOS
↑ Balance
↑Arm swing
Early stages of PD:
Address amplitude and symmetry
Add in dual tasking with cognitive and motor loads
Vary the environment Open VS Closed
Mid Stage of PD:
Pt’s may present with motor fluctuations
Strategies needed for “ON” “OFF” phases
Start addressing festination and retropulsion and LOB
Mid-late stage of PD:
*Ask pt what they would like to work on
FOG present
*Practice weight shifting and stepping
↑ Falls
*Practice in open and small spaces
More Cues needed
*Practice stopping starting and turning
*Squeeze when you freeze
Freezing of Gait:
Freezing Treatment Ideas:
Identify triggers and don’t rush them
Lean onto one side and allow opposite foot to take step
Train patient to unweigh leg and take a bigger step
Encourage high step and big movements
-
5) Yoga for PD:
Positions force the patient into Extension
6) Nordic Walking:
7) Dual Task Training:
Helps to improve functionality
Adds a cognitive and motor aspect
Can be achieved by:
High intensity exercises
Multidirectional gait changes
Various surface areas
Example exercises include:
-Battle ropes
-Tug of War
-Drum roll on gym balls
Agility exercises-> to train to increase automatic response
High Stepping
Skipping
Large amplitude movements/directions
Make it contextual- Work on these activities through doorways/obstacles
Work on quick turns/close to walls and corners
Turning Treatment Ideas:
Avoid pivoting
Take wider turns when possible
Slow down
Feet apart
Take a bigger step with your outside foot until it passes your inside foot
Quick turns close to walls and corners
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Bradykinesia Treatment Ideas:
-Boxing Movements
-Speed, Dual Tasks
-Jab, Hook, then combinations
-Move while punching, forward back, sideways
-Power Punch w trunk rotation
Rigidity Treatment Ideas:
-Slow rocking
-Reciprocal limb Movement
-Kayaking
-Tai-Chi
*Lay them on their back to get them out of flexion
Balance Treatment Ideas:
-Rhythmic stabilisations (concentric/eccentric)
- Use the outcome measure as treatment
-Postural control
ORTHO:
Total Shoulder Replacement: (TSR)
Indicated for:
Complex humeral fracture
Advanced OH RA
Decreased functional use
Contra indications:
Rotator cuff insufficiency
Deltoid paralysis
Unable to participate Rehab
Total Shoulder Arthroplasty / Hemiarthroplasty:
Titanium stem -> Humeral Head
Polyethylene capsule -> Glenoid fossa
Cut through Deltoid muscles
Release subscapularis tendon (IR)
Recovery is longer and more painful
Rehab Assessment:
SE:
Other Strategies:
External Ques:
Auditory: -> Music, Rhythmic Auditory
Visual:
-> Marked lines, Laser pointers
Tactile: -> Taping on floor
Attentional Strategies:
Think about big steps
Choose a point of reference
Making wider turns
Rocking, Weight, Shifting
Taking a step backwards before starting to walk
Rocking backwards and forwards to do a STS
UStep
Teracycle
Reverse total shoulder Arthroplasty: (RTSR)
Anterosuperior approach
Not cutting into muscle -> faster recovery
Deltoid becomes the primary elevator
Latissimus dorsi is the primary rotator
Post-surgical Instructions for TSR:
Shoulder immobilisation: (4-6weeks) -> muscle atrophy, frozen shoulder,
↑scar tissue, ↑stiffness. Use PROM to increase range.
Limited Abd /ER
ER 40o w Humerus 0o Add
Post-surgical Instructions for RTSR:
Unstable in Add / Ext
Not able to reach behind and scratch back or push out of chair.
Rehab exercises of TSR:
OE:
History:
- Cause
- How long ago
- RA, OA, Pain?
Prior Injuries/surgeries
Hand dominance (LHS vs RHS)
Work
Recreational interests
Functional Limitations
Outcome measures:
-Quick Dash
-The ASES
-SST
-ROM (↓subacromial impingement)
-Rot cuff integrity (Facilitate Sh Abd)
-Scapulohumeral rhythm (↑ ROM)
-Tenderness / crepitus
-Strength (RC, Deltoid, Biceps, Tri)
*Crepitus is normal, arm been in
sling for 6 weeks
1) Joint Protection:
Avoid pushing or pulling on shoulder
Use a sling initially, even when sleeping
No active shoulder movement -> can do submaximal shoulder Isometric
No lifting heavy objects -> 1-2kg
2) Subscapularis Protection:
00 ER for few weeks
50-600 by week 6
Start w shoulder girdle isometrics and scapular stabilisation
-
Determine where scapula resides on thoracic spine
Determine potential restrictions to arm elevation: (Tight Levator scap, Pec
Minor, Subscapularis, Infraspinatus Rhomboids)
Start w passive exercises -> (wall/table slide, broomstick, their other arm)
Elevation in Scapular Plane
Shorter lever arm
Use of theraputty pulling -> ↓Edema & Inflammation
Squeezing ball and resist Elbow F (isometric contraction)
Above mentioned exercises will cause RC and Deltoid to start firing
Objectives of Rehab:
1) Joint Protection
3) RC function
2) Subscapularis Protection
4) Deltoid Function
3) RC Function:
Most patients have a weak RC
Start w short lever arm, involve ADL’s in Tx
As patient improves, gradually increase lever arm
4) Deltoid function:
Humeral Head elevator
Contributes to dynamic stability of shoulder
Start with isometrics early. (Squeeze ball and resist elbow flexion) this
will cause the RC and Deltoid to fire but is not contra indicated.
*can be depressed if RC is weakened
*can be elevated if Pec’s are too tight
Expected ROM:
Factors affecting outcome:
2 – 3 weeks
6 – 8 weeks
12 – 16 weeks
Passive ER – 20°
Near full PROM
140 – 160° active
elevation
Passive elevation
to 100 – 110°
140° active
elevation
50 -60° active ER
40° active ER
Able to do Apley’s /
Scratch test
Better outcomes:
-No previous surgery
-Minimal RC pathology
-Better health status prior to surgery
-No history of OA
Poorer outcomes:
-RA or Trauma
-Sever loss of PROM
-Comorbidities
Return to sport:
6/12 w permission of surgeon.
-Subluxation on X ray
-Loss of posterior glenoid bone
-Degeneration of subscapularis & Infraspinatus
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Total Hip Replacement: (THR)
THR Physio Assessment:
Posterior Approach:
Precautions:
Surgical separation of gluteal muscles
Longer recovery time
Post-operative restrictions for 6-12 weeks
No Hip flexion past 90o
No hip add past neutral
No IR past neutral
Anterior Approach:
Precaution:
Surgical separation of TFL and Sartorius
Shorter recovery time
↑ROM sooner
No Hip Ext past neutral
No hip ER past neutral
No bridging
Seat goals early -> treatment determine by patient goals
Determine pain levels
Establish PROM & AROM
Muscle strength
Postural Control
Assess bed mobility
WB tolerance (guided by surgeon)
Mobility Assistance
- How much assistance
- Need of gait aid
- Home environment
*Metal ball with polyethylene cup most frequently used
THR Rehabilitation:
Balance training:
Interventions early post op < 8week include:
Early mobilisation
Treadmill training w/BWS
Task specific, repetitive and intensive training
NMES for those who can’t perform resistive exercises
Need to target dynamic balance -> functionality
Falls Prevention
↓ Hips strategy and ↓proprioception -> no proprioception
Strengthen Hip Rotators, Gluteus Medius and Hamstrings -> Eccentrically
Postural Control:
Interventions late post op < 8 Weeks include:
Combination of AROM, WBing and hip Abd eccentric training
(Side lying hip Abd)-> elongation of muscles
-
Balance training
Postural/pelvic control
Eccentric muscle training
-Tight Psoas and QL
-Weak glute Medius
Activation of lower abdominal and glutes
Elongation of trunk and hip flexors (from pelvis)
Place hip on pelvis and tell them “don’t let me rotate you”
*Put hand on their shoulders and ask them to stand tall
*Progress it to stepping and walking tall
Facilitating Hip Stabilisers:
Total Knee Replacement: (TKR)
Stretch hip flexors (Tight Psoas)
Address tight QL’s & Psoas -> They will use hip flexors in swing phase of gait
QL is used to hitch the hip upwards and swing leg forward
Consider UL elevation when Weight shifting -> Isometric contraction of Hip Musc
Get them to perform Clams
4” incision over the patella
Minimally invasive and does not severally affect the quads
Precautions:
Pain
DVT -> Homan’s test (+ve = no rehab)
Other issues to be aware of:
Length discrepancy -> tight TFL & Add
Trendelenburg -> tight Psoas and weak glute Medius
WB exercises for glute Medius activation -> more functional
TKA Physiotherapy Assessment:
*Return to sport:
Surgical clearance, able descend 8 steps w/o sxs, LL strength symmetry
Set goals ASAP
Pain management
Mobility -> Sit to Stand
PROM, AROM
Swelling
Strength (glutes, hamstrings, quads)
Assistive device
-Stick
-Walking frame
TKR Rehabilitation:
Quadricepses Facilitation:
Rx will be protocol based -> check w surgeon
Emphasise early mobility -> better outcome
Use of NMES
Exercises -> Consider pain
-> Involuntary quads contraction
Factors affecting function following TKR:
Quadricep muscle function -> stabilising factor
Motion and balance -> Artificial limb, no proprioception
Proprioceptive training to ↓ Falls rate
Patient motivation education and compliance. (Need to be active to get better)
Quadricepses function -> retro-stepping
-> Sway back and forth w toes/heels on ground
-> Make sure there is a chair behind them
Consider hydrotherapy, exercise classes, and Pilates
Peddal on a stationary bike w heel = greater Flexion/Extension
Stiff Knee:
Consider multiplane stretching
Stretch above/below the knee
Eccentric loading
Return to Sports:
~ 3-6 months (clearance from surgeon)
ROM must be complete, Muscle strength must be sufficient, Balance must be
adequate.
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Gait Cycle:
Gait Assessment:
General:
Safety
Independence or assistance required
Fear of movement
Previous mobility level
Environment tested in
Evaluate footware
Evaluation of walking aids and Ortos
Gait assessment:
*Start assessment at ankle/foot
and work your way up*
1) Step Length:
2) Step cadence:
-Is it Symmetrical?
-Is it symmetrical?
-80cm for males
-Shorter stance time
-60cm for females
-Cadence = 117/min
3) Base of support:
-Wide/Narrow BOS
-Distance between heels 7-8cm’s
-Angle of feet Toe in or Out?
Also Look at:
-Heap posture
-Reciprocal arm swing
-COG to BOS
3) Extensor Thrust:
Forceful extension of knee on loading limb
Flick leg backwards into extension
Weak quads
4) Circumduction:
Combined hip Abd, flexion & hip hitching
Associated with ↓ knee flexion
Functional Mobility Assessment:
Need to determine the patient is:
Safe
Independent
Amount of Assistance they require
How movement is achieved
That involves assessing their ability to:
Walk in different directions
-Carrying objects
Turning corners
-Pick up objects from the floor
Managing doorways
-Navigate crowds
Uneven surfaces
-Crossing roads
Steps/Stairs
-Running, Hopping, Jumping
5) Trendelenburg gait:
Lateral pelvic tilt
Weak glute med
Pelvic drop on LHS = weak glute RHS
6) Glut med gait:
Flicking of pelvis side to side
Lateral trunk flexion to affected limb
PD Gait pattern:
Ataxic Gait Pattern:
-Freeze During turning
-↓Arm Swing
-Hitching of Hip
-↓Step length
-Hips are fixed
-Difficulty initiating/terminating step
Hemiplegic Gait Pattern:
-Slow
-↑ stance time on unaffected limb
-↑Hip F, ↓PF at toe off
-↓stance time on affected limb
-↓DF at IC
-↓Kn Flexion in swing
1) Foot slap:
No controlled movement (weak dorsi flexors)
2) Contralateral Vault:
PF stance
Bobbing upwards onto toes
Assist limb clearance in swing phase
4) Endurance:
-Gait speed m/s 3m 5m 10m
-Number of overbalance/deviations
-2MWT/6MWT
-Speed needs to be functional
- Make it across the road
-Narrow BOS
-↑ Cadence
-Slow/Shuffling gait
-Ridged
↓ Kn Flexion
↑Trunk Flexion
Pathological gait conditions:
- Poorly timed muscle contraction
-Kn hyper Extension in stance
-Hip hiking/circumduction in swing
-Kn Flexion at IC
- ↑ BOS & ↑ER
-↓Arm Movement
-↓Step length
-↓Velocity
-Rigid Trunk
-Uncoordinated limb movement
-Drunken appearance in gait
- Falls Risk
*Hip extensors facilitate the swing face
*Hip flexors are stretched and resales the stored elastic energy
*Plantar flexor spasticity will cause Knee hyper extension
*Knee needs 60 Degree flexion for foot to clear floor
*Shock absorption in gait is via Hip Flexors
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Treatment Planning:
-Need to base treatment on O/E findings
-Treat what we see
-Focus on their abilities
-Determine what is causing their weakness (Strength? Length?)
-What prevents them from being independent
2)Assessment:
Functional Mobility:
-Bed Mobility
-Transfers
-Sitting
-Standing
-Walking
-UL function
Setting will determine treatment
Modbury = Transfers, Mobility, Gait aid
*O/E will help identify the impairment*
3)Address Impairment:
1)Goals:
Need to be patient centred
STG & LTG
SMART
What would the they like to achieve in 5 weeks
Use hobbies/interests to guide treatment
Consider D/C planning: ->Rehab in home
-> Exercise program
5)Progression:
4)Types of Practice:
-Amount
-Whole vs Part
-Distributed vs Massed
-Variable vs Constant
-Discovery vs Guided
-Mental Practice.
-Strength
-Range
-Sensation
Does it relate to function. Does it ↑Balance ↑Speed, ↑Range
-Endurance
*Promote their skill acquisition but slowly withdraw feedback -> Promote Indep
->as much as possible
->whole is always best (except reach & grasp)
->distributed is better, massed for ↑fatigue
->variable= neuroplasticity constant= motor learning
->guided used for cognately impaired, initial Rx only
->Lights up the same amount of neural content
Use of feedback/guidance:
Use external feedback
Auditory, Visual, Tactile, Proprioception
Have pt look at hands, feet shoulder
Treatment Planning for stroke:
Increase intensity and slowly build capacity
This can be done via:
-↓Assistance
-↑Distance
-↑Time
-Use of Cues
-Change environment
6)Reassessment:
This will help recruit motor
neurons and ↑ accuracy
(Target affected leg)
Strengthen Hip Ext/Abd & PF
- Abductors will help restore balance (walk sidewasys)
- Hip Extensors will help release kinetic energy from Psoas in swing phase
-Gastrock and Soleus will help w propulsion in push-off
CV Endurance training
-Treadmill (increases speed if safe to do so) 60% of HR
Balance training
-Turning (help with visual input)(use of foam mats, SLS,
-Reactive PC (help reduce falls)
Exercises include:
Single leg push-off (PF)
Bouncing: Dynamic (Balance)
Alternate push off
Claw
Heel lifts (Hip Flexion)
Hip Extension (step backwards)
Quantify results via Outcome Measures
Reassess:
Balance, Strength, ROM, Endurance, Mobility
Why it worked/why it did not work?
General Information:
Principles of neuro plasticity:
1
2
3
4
5
6
7
8
9
10
Hippocampus
= Memory
Cerebellum
= Controlled movement, tone of trunk
Parietal
= Sensory
Thalamus
= Relay Station
Occipital
= Vision
Postural Control we need Vison, Vestibular, Somatosensory
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AC Abbreviations:
ABG
MAP
PaO2
PaCO2
HCO3
FiO2
SpO2
CVP
CVC
ECG
ICP
EVD
IVT
NGT
IDC
UWSD
TED’s
PEG
PPC
Arterial blood gasses
Mean arterial pressure
Partial Pressure of Oxygen
Partial pressure of Carbon Dioxide
Bicarbonate
Fraction of inspired oxygen
Blood oxygen saturation levels
Central Venous Pressure
Central Venous Catheter
Electrocardiograph
Intercranial Pressure
Extra Ventricular Drains
Intravenous Therapy
Nasogastric Tube
Indwelling Catheter
Underwater Sealed Drain
Thromboembolism-Deterrent
Percutaneous Endoscopic Gastronomy (Feeding Tube)
Post-Operative Pulmonary Complications
Rehab Abbreviations:
TIA
tPA
ICA
ETA
AVM
ICH
SAH
CCA
ICA
MCA
ACA
PCA
SMA
FOG
SLS
STS
SOEOD
SOOB
LOB
TSR
RTSR
NMES
W/O
SXS
Trans Ischemic Attack
Thrombotic Therapy
Internal Carotid Artery
External Carotid Artery
Arteriovenous Malformations
Intracerebral Haemorrhage
Subarachnoid Haemorrhage
Common Carotid Artery
Internal carotid Artery
Middle Cerebral Artery
Anterior Cerebral Artery
Posterior Cerebral Artery
Supplementary Motor Area
Freezing of Gait
Single Leg Stance
Sit to Stand
Sitting on Edge of Bed
Sitting Out Of Bed
Loss of Balance
Total Shoulder Replacement
Reverse Total Shoulder Replacement
Neuromuscular Electrical Stimulation
Without
Symptoms
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General abbreviations
ADL
activities of daily living
A/E
accident and emergency
A-P
antero-posterior
A & W`
alive and well
BP
blood pressure
Ca
CH
CNS
C/O.
CRP
CSF
CT
CVS
CWMS
D/C
DD
DM
DVT
E/O
EOD
FALB
FBC
FH
GA
GH
GIT
Hb
HPC
IDC
IDDM
ICU
IM
ISQ
IVT
LA
LMO
MSS
NAD
NIDDM
O/A
O/E
OPD
PAC
PC
PCA
PE
PH
PMHx
R/O
RIB
RMO
Cancer
current history
central nervous system
complaining of
C-reactive protein
cerebro-spinal fluid
computerized tomography
cardio-vascular system
colour, warmth, movement, sensation
discharge
during day
diabetes mellitus
deep veined thrombosis
excision of
end of day
fasting after light breakfast
fluid balance chart
family history
general anaesthetic
general health
gastro-intestinal tract/system
haemaglobin
history of presenting complaint
in-dwelling catheter
insulin dependent diabetes mellitus (juvenile)
intensive care unit
intramuscular (or, intermittent)
condition unaltered (in status quo)
intra-venous therapy
local anesthetic
local medical officer
musculo-skeletal system
nothing abnormal detected
non-insulin dependent diabetes mellitus (adult)
on arrival/admission
on examination
outpatient department
pressure area care
present complaint (present condition)
patient controlled analgesia
pulmonary embolus
past history
past medical history
removal of
rest in bed
resident medical officer
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ROS
RS
S/B
SH
SOOB
TLC
TPR
TSD
UTI
WBC
removal of sutures or review of systems
respiratory system
seen by
social history
sitting out of bed
tender loving care
temperature, pulse, respiration
to see doctor
urinary tract infection
white blood count
Tests
ABG
AXR
CBE
CBP
CT
CXR
Dx
ECG
EEG
ESR
ERCP
FBE
FI
FOB
Hb
LFT
MBA 20
MRI
NAD
PFT
ROS
TPR
WBC
WCC
XR
arterial blood gases
abdominal x-ray
complete blood examination (Hb, WCC and platelet count)
complete blood picture (interchangeable with CBE)
CAT Scan
chest x-ray
diagnosis
electrocardiograph
electroencephalograph
erythrocyte sedimentation rate
endoscopic retrograde cholangiopancreaotlogy
full blood examination
for investigation
fibre optic biopsy
haemoglobin
lung/liver function test
multiple biochemical analysis (20 tests) blood test
magnetic resonance imaging
nothing abnormal detected
pulmonary function test
review of systems
temperature, pulse and respiration
white blood count
white cell count
x-ray
Orthopaedic abbreviations
#
Fracture
ACL
Anterior Cruciate Ligament
AE
Above elbow
AFO
Ankle foot orthosis
AK
Above knee
AMP
Austin Moore prosthesis
AO
Arbeitsgemeinschaft für Osteosynthesefragen
AVN
Avasular necrosis (better known as osteonecrosis)
BE
Below elbow
BK
Below knee
BMP
Bone morphogenic protein
CMC
Carpo-metacarpal
CPM
Continuous passive motion
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DB&C
DCP
DCS
DPC
ECRB
ECRL
ECU
EDC
EPB
EPL
EUA
F&A
FCR
FDS
FDP
FPL
FWB
GH
HA
IRQ
KAFO
K wire
LA
MA
MBA
MCL
MCP
MRI
MUA
MVA
NOF
NOH
NSAID
NWB
OA
OOP
ORIF
PCL
PIP
POP
PTB
PWB
RA
ROP
SIJ
SLR
SOOB
SG
SQ
THR (THA)
TKR (TKA)
TPT
Deep breath and cough
Dynamic compression plate
Dynamic condylar screw
Delayed primary closure
Extensor carpi radialis brevis
Extensor carpi radialis longus
Extensor carpi ulnaris
Extensor digitorum communis
Extensor pollicis brevis
Extensor pollicis longus
Examination under anaesthesia
Foot and ankle exercises
Flexor carpi radialis
Flexor digitorum superficialis
Flexor digitorum profundus
Flexor pollicis longus
Full weight bearing
Glenohumeral joint
Heavy assist
Inner range quadriceps exercises
Knee ankle foot orthosis
Kirschner wire
Light assist
Moderate assist
Motor bike accident
Medial collateral ligament
Metacarpophalangeal
Magnetic resonance imaging
Manipulation under anaesthesia
Motor vehicle accident
Neck of femur
Neck of humerus
Non-steroidal anti-inflammatory drugs
Non weight bearing
Osteoarthritis
Out of plaster
Open reduction internal fixation
Posterior cruciate ligament
Proximal interphalangeal
Plaster of paris
Patellar tendon bearing
Partial weight bearing
Rheumatoid arthritis
Removal of plaster
Sacroiliac joint
Straight leg raise
Sit out of bed
Static gluteal exercises
Static quadriceps exercises
Total hip replacement (arthroplasty)
Total knee replacement (arthroplasty)
Total plaster time
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VMO
Vastus medialis obliques
WBAT
Weight bearing as tolerated
Physiotherapy outpatient abbreviations
Abd
abduction
Add
adduction
AROM
active range of movement
C1
1st cervical vertebra
C1/2
posterior intervertebral joint between C1 and C2
CE
cauda equina
Cx
cervical spine
DF
dorsiflexion
ER
external rotation
E/Ext
extension
Exs
exercises
F/Flex
flexion
HBB
hand behind back
IFT
interferential
IM
intermittent
IR
internal rotation
L
limit of range
L1
1st lumbar vertebra
L1/2
posterior intervertebral joint between L1 and L2
LF
lateral flexion
L/S
lumbosacral
Lx
lumbar spine
MMF
modulated medium frequency
MMT
manual muscle test
nerol
neurological examination normal
obs
observation
p
pain
P1
onset of pain
P2
limit of pain
PAIVM
passive accessory intervertebral movement
Palp
palpation
PF
plantar flexion
PIV
posterior intervertebral joint
PPIVM
passive physiological intervertebral movement
P&N
pins and needles
˚p&n/numb
no pins and needles or numbness
PROM
passive range of movement
Pron
pronation
P√R√S√
power, reflexes and sensation normal
R1
onset of resistance
R2
limit of resistance
R/Rot
rotation
RD
radial deviation
ROM
range of movement
RSC
resisted static contraction
Rx
treatment
SB
side bending
Sl
slight
S√√W√√
sensation test performed and passed, warning given and understood
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Sup
Sust F
SWD
T1
T1/2
Tx
UD
US
VBI
Wt
WL
supination
sustained flexion
short wave diathermy
1st thoracic vertebra
posterior intervertebral joint between T1 and T2
thoracic spine
ulnar deviation
ultrasound
vertebro-basilar insufficiency
weight
weight loss
Medication abbreviations
PRN
as occasion arises (as required)
Daily
once daily
BD
twice daily
TDS
three times daily
QID
four times daily
Meds
medication
nocté
at night
mane
in the morning
T
one tablet
TT
two tablets
PO
orally
Cardiovascular System
AB5LICSMCL
apex beat, 5th left intercostal space, mid clavicular line
AF
atrial fibrillation
BBB
bundle branch block
BP
blood pressure
bruits
added sounds in the heart
CCF
congestive cardiac failure
CVP
central venous pressure
CVS
cardio-vascular system
HS
heart sounds
J,A,(or P)Cl,Cy
jaundice, anaemia, (or pallor) cyanosis, clubbing
JVP
jugular venous pressure
JVPNE
jugular venous pressure not elevated
JVPNR
jugular venous pressure not raised
MI
myocardial infarct
PVD
peripheral vascular disease
PWP
pink warm and perfused
SOA
swelling of ankles
SBE
sub-acute bacterial endocarditis
SVT
supraventricular tachycardia
Respiratory System
AE
AFB
BE
BS
CPAP
air entry
acid fast bacilli
basal expansion
breath sounds
continual positive airway pressure
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FEV1
FEF 50%
FVC
FRC
haemoptysis
IMV
IPPB
IPPV
mmHg
OSA
PaO2
PaCO2
PE
PEEP
PEP
PN
PND
PS
RS
RV
SOB
SOBOE
TML
URTI
UWSD
VC
VF
VR
Vt or TV
forced expiratory volume in 1 second
forced expiratory flow when 50% of the vital capacity has been exhaled
forced vital capacity
functional residual capacity
coughing up blood
intermittent mandatory ventilation
intermittent positive pressure breathing
intermittent positive pressure ventilation
mercury (millimetres)
obstructive sleep apnoea
arterial partial pressure of O2
arterial partial pressure of CO2
pulmonary embolus
positive end expiratory pressure
positive expiratory pressure
percussion note
paroxysmal nocturnal dyspnoea
pressure support
respiratory system
residual volume
shortness of breath
shortness of breath on exertion
trachea mid-line
upper respiratory tract infection
underwater seal drain
vital capacity
vocal fremitus
vocal resonance
tidal volume
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CNS:
CVA
T.I.A.
RIND
SDH
EDH
SAH
HI
CHI
TBI
AVM
N.P.H.
ICP
LOC
T.P.P.
STM
F.F.F.T.
PERLA
EOM
A.J.
K.J.
B.J.
T.J.
S.J.
F.J.
J.J.
Pl
AER/P
VER
SER
BER
GCS
cerebrovascular accident
transient ischaemic attack
resolving ischaemic neurological deficit
subdural haemorrhage (or haematoma)
extradural haemorrhage
subarachnoid haemorrhage
head injury
closed head injury
traumatic brain injury
arteriovenous malformation
normal pressure hydrocephalus
intracranial pressure
loss of consciousness
time, place, person
short term memory
fits, faints, funny turns
pupils equal & reacting to light and accommodation
external ocular movements
ankle jerk
knee jerk
biceps jerk
triceps jerk
supinator jerk
finger jerk
jaw jerk
plantar response (Babinski sign)
auditory evoked response / potential
visual evoked response
sensory /somatosensory evoked response
brainstem evoked response
Glasgow coma scale/score
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Gastro-intestinal tract
BNO
bowels not open
Ca
cancer
GIT
gastro-intestinal tract
haematemesis
blood in vomit
LUQ
left upper quadrant
LSKK
liver, spleen, kidney (R) & (L)
malaena
blood in stools
Genito-urinary system
CRF
chronic renal failure
CUD
continual urinary drainage
dysuria
painful or difficult urination
GUS
genito-urinary system
Haematuria
blood in urine
HNV
has not voided
IDC
in-dwelling catheter
IVP
intra-venous pyelogram
MSSU
mid-stream specimen or urine
nocturia
getting up to urinate at night
PV
per vagina
PR
per rectum
TUR (P)
transurethral resection (prostate)
UO
urinary output
UTI
urinary tract infection