感觉运动障碍的物理治疗

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,Treatment approach - ICF,Improve Individual Minimize Reduce Society,Hollstic approach,Passible sensory and motor impairments,Balance CoordinationCognition perception（感知能力）,Movement Task,Abnormal synergy,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 discrminationHigh level of attention and memory,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 recoverCompensation e.g. vision for deficit in tactile sensation (靠视觉补偿触觉的不足),Passible sensory and motor impairments,Abnormal biomech alignmentSelective motionWeaknessMuscle tone,Biomechanical alignment,“Normal” alignment most efficient“Abnormal” alignment affect movement,Abnormal alignment in standing (postural set),Marked asymmetry(明显的不对称)No weight bearing over R LLR LL adducted, planterflexR UL flexedL trunk is shortened,Treatment,Correct (矫正)alignment ofthe trunk, ULand LL insittingWeight bearing(负重)over R LL,IN a more narmal postural setWeightbearing andstrengthing ex,Muscle tone,Spasticity,Flaccidity,Muscle tone,Amount of tension in a relaxed muscleTension stiffnessMaintain posture(维持姿势) prevent too much swayMake muscle ready to shortenPerson with intact neuromuscular system, muscle tone is minimal i.e. resistance to passive movement is minimalMuscle tone can change according to posture and anxious level,Muscle tone,Abnormal muscle toneHypotonous flaccidHypertonous spasticity, rigidity,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,Spasticity - pathophysiology,Lesion of CNSLack of supra-spinal inhibitory signals on stretch reflexDefinition: A motor disorder characterized by a velocity-dependent increase in tonic stretch reflex Velocity Resistance,Manifestation(显示, 证明) of spasticity,Exaggerated(过强的) stretch reflexTonic: increase resistance to passive movementPhasic: increase tendon jerkClasp knife responseIncrease tone to a certain range and follows by a sudden reduction of toneClonusAbnormal posturing of the limbs, contracture, pain,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),Treatment to reduce spasticity,Enhance inhibition of stretch reflexPharmacological treatmentBaclofen (oral, intrathecal) a derivative of GABABotulinum (Intramuscular) inhibiting the release of acetylcholineSurgical treatmentRhizotomy removal of dorsal rootlets, to reduce the afferent inputs into the spinal cord,Surgical treatment(外科治疗)Rhlzotomy removal of rootlets, to reduce the afferent inputs into the spinal cordReduce spasticity over calf muscles,Spasticity,Enhance Inhibition of stretch reflex(增强对神肌反射的抑制)Prolonged stretch(持续牵拉)PositioningSplintSerial castingStretch 6 hoursIce therapy 20 minutes,Physiotherapy,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 planterflexorsParameters(因素) :0.2 ms square pulse99 Hz2sensory threshold60 minutes5 times a week for 3 weeks,Flaccidity(弛缓)Enhance excitation of stretch reflex(增强伸展反射的刺激),Quick stretch(快速拉伸)Brisk touchQuick tapping(快速轻扣)Quick stroke of ice,Muscle tone and Muscle strength,No clinical or experimental(实验) evidence(证明) support:Normalise spasticityMuscle tone is poorly related with functional disabilityIndeed, 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,In addition to strength,Isolated control增强肌力,分离控制,The ability to controlthe muscle forceis essential,Lack of isolated (selective) control,Stereotyped(常规)Abnormal movement synergy(共同运动),Abnormal synergy,Mass flexionSh flexionElbow flexion,Isolated / selective control,Abnormal flexor synergy(屈肌共同运动),Isolated knee and hip control,Spastic musclecan be weak,Spasticity and weakness,Spasticity and weakness,Markedweakness ofgastrocaemius,Strengtheming will increase spasticity ?,Chronic patients 9 months of stroke10-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 spasticityIsokinetic strengthening increased muscle strength and gait velocity without increase in spasticity,Strengthing,Care must be taken to strengthen a spastic muscleCorrect movement patterns and optimal resistance,Strengthening Increase force output,Functional electrical stimulationAssisted, active movementProprioceptive neuromuscular facilitationTask specificAction (concentric, eccentric, isometric)Velocity, Angle,Functional electrical stimulation,Sensory input,Assisted active and active exercises,Proprioceptive NeuromuscularFacilitation,Patients with neurological and orthopaedic conditionsSensory input to regain strength using all available sensory inputsTactile manual contact to guide the motionVerbal simple and preciseVisual patients eyes follow the movementProprioceptiveMovement traction to stretch muscle to enhance contractionStabilization joint compression (approximation) to increase contraction muscles,Proprioceptive NeuromuscularFacilitation,Synergetic movement patternWhat patients can “DO” Irradiation from strong to weak muscle groupResistance to get Optimal Response from patients max awareness, strength, coordination, enduranceStability before mobilityPromote functions,PNF basic pattern,Flex add-ER Flex abd-ERExt add-IR Ext abd-IR,Flex add-ER Flex abd-IRExt add-ER Ext abd-IR,Flex - abd - ER,PNF Tactile, proprioceptive,verbal, visual, Active participation,Upper limbFlexion-abduction-externalrotation andExtension-adduction-Internal rotation,Proprioceptive NeuromuscularFacilitation Special techniques,Rhythmic initiationto promote initiation of movementpassive assisted active active resistiveRepeated contractionto promote strength of agonistsrepeated stretch, repeated contractionDynamic reversaland to promote strengrh of agonists and antagonistsfacil active movement in one direction, followed by movt in opposite ditection,Proprioceptive neuromuscularfacilitation repeated contraction,Stretch elicit contraction topromote movement,Proprioceptive neuromuscularfacilitation dynamic reversal,Stretch elicit contraction topromote movement,Strengthening,Isokinetic trainingTheraband, weightsTask-specific trainingSit-to-standWalkingUpstairs,Normalise muscle toneImprove strengthImprove isolated control,Possible sensory and motor impairments,PainJoin