In addltwn. 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. Spasticity predominates in antigravity muscles Le.
If left untreated, spasticity can result in movement deficiencies, subsequent contractures, degenerative joint changes, and deformity. The therapi. During a pa.. Strength can a.. Muscles that look Ilat or COil cave are indicative of atrophy, Compan! Multiple limbs?
Proximal or distal" Fmcindarions are random. LMN d, Gir1h mea"lurement. TIanL:e abo yidd Important data about! TIU"I 'Ie performance. Strength te I the movement deficiencies observed , and.. What are the initial conditions requi. Starting position and Ual alignment.
What are the musculoskeleta components requi. Stability 6. What are the mOlor control strategies required for successful completJOn 0. Skill activity? What are the requirements for balance? How is the movement tenninated? What are the environmental constraints that must be considered?
How successful is the patient's overall movement in terms of outcome? Was the overall movement sequence completed? What components of the patient's movements are normal? Almost nonnal? What components of the patient"s movements are abnormal? What components of the patient's movements are missing? If abnonnal. Noncompensatory and nonfuncuonal. What are the underlying impairments thai constrain or impair the movements?
Is Ihis a mobility level activity? Are the requirements met? Is this a stability level activity? Are the requirement" met for slatic and dynamic control? Is this a skill level activity? Are balance requirements met? Is patient safety evident throughout the ta. What environmental factors constrain or impair the movements? Can the patient adapt to changing task and environmental demands? Whal difficulties do you expect this patient will have i.
Neurolog Secllon. The ahdlt to Ind 1t Ie d'lor "0 If the p. 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 IQj '46 , 9 It h Import.
L 'n lell II un.. Iihular dy IIII plhCd. L urt Inti bl cr. I or hJd. IUlldlllllal n. Forv'Jard 8. IOlllll:tl' 5 [ It-thht' of hl..
TI 'nll". Dunng Upptl! ReJction lime.. Ph 'sical Rehabililation Joint Inte! Retlex 1n te! She is unable to sustain R knee extension during standing. RLE moves in flexor and extensor synergy patterns with no variation. 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.
Ph ' Ther 'itl. D, t Impaired regulation of force and firing panem of! J eurol Neurosurg Psychiatry A: Dynamic motor capacity in spastic paresis and its relation to prime mover dysfunction. Scand J Rehabll Med B: The relationship of voluntary movement to spasticity in the upper mOlor neuron syndrome. Ann Neurol Am J Occup Ther Phys Ther Is the measurement of muscle strength appropriate in patients with brain lesions? Phys Ther 69, Bohannon, R: Is the measurement of muscle strength appropriate in patienl5 wilh brain lesions?
Phys Ther , A: Interrater reliability of handheld dynamometry. Arch Phys Med Rehabil A: Measurement of muscle tone and strength. Neurology Repon Phys Ther J, el al: Sequenlial isokinetic and manual muscle testing in patients with neuromuscular disease: A pilot study. Pbys Ther , R: Physiological analys-ill of skeletal muscle weakness and fatigue.
Clin Sci Mol Med J: Overview of exercise responses in health and Impaired st3te! J: Exercise and Dochenne muscular dystrophy. Neurology Report D: Guillain-Barre syndrome and exercise guidelines. NeurOlogy Report McDon and neural control dunng human muscular fatigue. Moo Sri Span F1SL, J. The Impact of fallgue on pallents with mu. Clin Orthop Mt Donnell.
I: A mel! Scand J Rehabl1 Med 7. JnJ Bbd,. I h,Lbl1futmRllun. S tu'H;1t1 Jet. Nle hypenllnt:i: Mc. U With hC1I1 Ip:lre! UId Ux. JAlllGenalrS I.. S, el JI Balaru.. S The luned "l'p dnd Go", A lest of b.
Ill ,. IIlJ", ,. Clinician pl J :e! The subject sltould lI'Ie hoth hands II hen! Itiull to line on floor or rug. Initial;un uf gait immedi. PPlOpf JJ! Figure 9. The needle i Becau'ic of the SIll:l1I diameter of these wires. Ire ot nC. IJI to thr electrode,. A MUAP can be likened 10 a piano chord. When using FM recorders. Therefore, a recording! 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. The tidelity of the digitally recorded data is dependent primarily on the perfomlance of the A-to-D convener. Insertion into a contracling muscle is uncomfortable. At this lime.
This is called insertional acth'ity and normally lasts less than 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. 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.
For example, the! 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.
This activily disappears by repositioning the nec:dle slighlly. Also the patient frequently reports that there is Ic Allhough the "itimulation of the nerve will evoJ Other example! From Nelson. From Nelson, RM.
P t. Ihe abductor hallicus or abductor digiti ffil Illm I. Small surface electrodes are usually used 10 record the evoked potential from the leSI muscle. The recording elenrode is placed over the belly of Ihe te5lt mu Accurate location of this electrode is important to Ihe accuracy of Ihe test.
The h. I1Ill' "'po. F"lf Ihe purpo,t'.. The fccl1rJmg eh:"lIrode I" l. Ihl' J. Thl' Jrli,'0. The aver. Di:'ltal latenCies and aver. The nerves that are most commonly studied in the upper extremity are the ulnar, median. Other nerves that have been studied are the axillary, musculocutaneous. The nerves that have been studied in the lower extremity include the tibial.
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. Although all axons are stimulated at the same point in time. 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. 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. 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. 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. For the same reason that motor axons are examined b recording over muscle. The baseline is more uneven because sen IUse terminal branching does not seem 10 be a significant lirniralion.
Nomwl sensory NCV ranges between 40 and 75 miser. The recording The stimulating electrode used for malOr electrodes can be surface or needJe electrode I"ouring antidromic conduction.
From Kimura.. With demyelinization. Sensory fibers may be affected before molor fibers. These include poliom elitis. II" polliu:o. For kinesiological EMG.
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. The simpleS! An epoch of noise must be recorded before the EMG signal is activated to estimate the noise level. The amplitude of the noise is represented by the shaded area in the lower RMS time plol.
The raw signal is not sufticiem to mark a clear differentiation between noise and EMG. Using the RMS value. This can be considered the "on" time of the mu,c1e.
Nonnalization For many II is nl'lt rea'. Ul be l:on'elated by repeaUnl tht: l. This maximal EMG y, uhin each arc is then used 3. Ion has been 10 l". In an attempt to maintain the leyel of active ten"ion in the muscle. After maxjmaJ contraction.
The precd. Levin alld HUI -Chan" 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. 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.
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. By understanding the in teraction between pain and lOr perfonnance, clinicians can directl y address motor impairments that wiJl impact functi on. Madeleine et aJl1!
These outcome'. Quc'ition s. It:nd thclllbelves 10 EMG study. A subject is shown positioned in the postural restraint apparalu. The subject's task is to produce a trunL. 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. With the palicnt po.. 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!
The patient practiced the task or excning i:,ollletri c trunk ex tension at targeted force leveL. After Ih r. After a brief rest period. Ideal body was calculated from a weight table established fo r men and women according to frame size. A rest period of 15 seconds was provided between e,ach contracti on. 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.
Similar results were apparent for the median frequency curves. For the control subject. It 'Ad Following a con X-ray films taken prior to The patient continued to have 0" of SUpll1atlon wilh 90 of pronation. 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.
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. Supination was 0, pronation was 0 to 90 degrees. This revealed a very small amplitude response with a normal condition velocity across the elbow of 60 mlsec. Recordings were made using needle electrodes. An EMG examination was also performed.
Table 9. 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. S 9 10 II Green. Commentary on lhe Effect of Electricity on Musculllr Motion. Elizllbelh Licht. Boca Ralon. Z BioI6b::J Ok EIa: 1ll;,1 and ub. Urelll nlS. I O Pre:. W:ncrloo, C:madll. In LRsmedl. Vol I. Mannion, AF. SplIle 1. IQ89 Jl WI" 1':"1. If lilt" li q;. Lon l,, 1 "' ll-'p ,uld.. In some instances, both kinematic and kinetic gait variables may be examined in one 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. 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. The patjent could co mpensate fo r the mabilit to dorsiflex the ankle by some method such as increa!
C ircumduction or hip hiking may be u anlle and fOOl l '! In an allcmpt to control for bolh h t:i1! S IIIlpJe mt! 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.
The only equipment necessary is a stopwatch, paper. 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.
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. The rate of change of the angular velocity of a body with respect to time.
Acceleration Angu lar accele ration The amount of time that elapses during one stride: that is. 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. The average stride length for adult females is 1.
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. The amount of time spe nt In the gait cycle when both lower extremities are in contact with the supporting surface.
Measured in seconds. 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. 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. Hil'cJ IlIllhL' hl'lon l,1 f,dlt ,m:t!
I 1". The force i LaUe nl. Inc AMTI. 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. In additi on 10 graphi ca l presentati on and stali:.
In comparison. Therefore, therapi sts "houl d be ca utioned about promoting that type of gait initi o ation becau Press ure i:-, eq ual to force di vided by area and I. III lh:. UI t" Reliability was high with ICC values ranging from. No significant differences were noted between sensors and gyroscope for gait cycle and stance times, stride length, and velocity.
SAM Moe. ICCs for all variables were 0. At fast walking speed all va riables had ICCs of 0. At I fast walking speed, all variables had ICCs above 0. Joint angles were measured with an electronic inclinometer. The only consistent error was with hip abduction and adduction using the APAS sottware '. Wilson , OJ , at ap. Step Actrvlty Mollltor oxygen con-. R, and Pfiaster.
Eftecb of unkle-loot o nhoses on hemiparetic gail. J Orthop Sporn. JJ, :md Plemr. DL: Jl1 anj:! Ie-lcndnu kngtheninc. J 'I B'. Phy" Ther Phys 'nler 74 ; Eastlac k. Phys The r 7 DE: Interpretation standards in locomotor studies. In Craik. C cds : Gait Analysis: Theory and Application. Lou is. P Ph ys Ther ,, WA , et al: Comparison of a clinical gait analysis method usi ng videography and temporal-distance measures with l6-m01 ci ne matography.
FA Davis. Ph ilade lphia. J: Functional ambulation profile. Phys "Ther Ph S The r Wolf SL. Catlin, PA. Yo rk. Santa Clara Valley Medical Cen ter 1. Ol1enbacher, KJ. CI al: lnterrater ag reemem and :. PF' B:ibnce comrol dunn!!
Dj Fabio. R: Dual ,! If gall.. HUllema, OB. Pn, IIK"fll1. J Pedlafr Ortllop C I IJU'rm:ln. Arch Phy, Med Rrhabl! J Neurol Neurosurg Psychiatry PJ: Interrnter re liability of the Functional Assessment Measure in a brain inj ury rehabihlali on program. Arch Phys Med RehabiI79 10 : 1. C' , ,:1J! Ional lenn.. 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. Testing Perspectives Function tests can utilize two highly divergent perspectives on what is to be tested or measured by the ph ys ical therapist.
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. 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.
Fo r example. Ultimatd y. The o ther approach quantifi es Ih e frequ ency that the diffi cult y is cncountered e. These notations Ill ay assist the therapi st in a quick identifi calion of some obvious impa irment Ihat limit fun ction. 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 Quantitative Parameters The timl' il tal,. Box I kill safety with no one present.
Super vision: pati ent requi res someone W it In ann iog assistance. I t f the activity Without assistance. Maxim um assista nce: patient is unable to assist in any pari of the actI vity.
Moderate assistance 5. Maxi mum assistance B Transfers. Arnbul at ion Independe nt- no cuing is given 2. Supervision -'. Close guardi ng. 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.
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. 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.
In ,nnlC ;n,tance III all bUi balhlll g , drt''''''' I1l 1;? 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.
Eallng B. Groomin g C. Dressing - Upper 41 mo nth s and 18 yea rs. Bladder H. Bed , Chair, Wheelchair J. TOilet K. Comprehension O. SOCial Interaction Q. The SIP contains items in 12 categories o f act iv it ies. These in clude s leep and rest, eatin g, work. A sample SIP measure of affec tive func ti onin g specifi c to emotional behavior is prese nted in Table The ent ire test can be either self-admi nistered or admin istered by an interview in Table I say how bad or useless I am; for exa mple.
I laugh or cry suddenly. I often moan and groan In pain or discomfort. I'lU'" fl-It'. 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.
UK-Unknown M 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. 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.
S-Unable to effectively participate in bathing and is totally bathed by another person. Prior Current 0 0 0 0 0 0 0 0 0 0 0 0 0 G-Able to independently transfer. 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. 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. UK-Unknown conIinu. M, et al,72 Cross-sectional participants of whom 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. Significant correlations were found between the SF scales and the other measures. Mental health scales correlated with Geriatric Depression Scale Describe the advi.
The liv The pro. Sht' i Jl11i nalion. UL'mecn Ih. IlOnal '. References Am1 4'1 k5. IW4 21 1"j,! Md Mt:d J Gucc ione. Am J Public Health 80 Ponne y. Prentice-Hall Heal1h. Upper Saddle Ri"'er. Arch Phys Med Re habil Relative mcrih of the 10t,,1 Banhel Index score and a four-ilem "ubswre in predicling paliem outcomes.
The lndex of ADL: A standardized meas ure of biologica l and psyc hosocial function. JAMA Gerontolog is t 10; A : Meas uring functional abil ily in chronic anhrilis. Am J Public Health AM: A.
Arthrit Care Res Top Geriatr Rehabil Arch Phys Med Rt:habil 7 Version UB Fotlndalion Activities. J Neural Neurosurg p,ych iarry 18X. Parallel rel i"bilit of the fun ction:.! O,,"bll Rehabll A doubk-bll nd. OF C ,m. Iden ti fy the roles and res ponsi. Understand the importance. Idemify common home. Identify the tests and m C3Su re 'i. Identify srralegies to improve pati ent func tion through environmental modifi cations.
Remember that a ramped entrance IS nol completely accessible II there are no curb cuts. 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.
In add'tlon to IndlCallng Ihat large pllnt verstons 01 books, pamphlets r'! Il' w. JJ AlSO videos t1. Sullivan book explores the world of physical rehabilitation management.
The focus of this book is on patient assessment, treatment planning, treatment techniques and care coordination. This book will take an individual with little or no experience in physical rehabilitation and guide them through the basic principles of assessing patients, developing treatment plans and providing effective patient care. Physical Rehabilitation by Susan B. Here is the only comprehensive, curriculum-spanning text for students and a key reference for practitioners!
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Physical rehabilitation is a challenging and rewarding career choice. Future practitioners must be exposed to the wide variety of therapeutic modalities within rehabilitation, as well as their potential applications. This timely text draws upon a wealth of experience from the authors and renowned guest contributors, to present a balanced approach to understanding both pathophysiology and clinical application of these concepts.
Susan B.
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