感觉运动障碍物理治疗

1、PT management of patients with sensori-motor disorders感觉运动障碍的物理治疗Treatment approach - ICFImprove Individual Minimize Reduce SocietyPassible sensory and motor impairments Balance CoordinationCognition perception（感知能力）Sensory re-education Tactile（触觉）, hot, cold, 2-point, stereognosis（实体辨别觉） Discrimina

2、tive（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 memorySensory re-education Protect from noxious and injurious stimuli (防护来自物理和化学的伤害) If

3、 sensation does not recover Compensation e.g. vision for deficit in tactile sensation (靠视觉补偿触觉的不足)Passible sensory and motor impairmentsAbnormal biomech alignmentSelective motionWeaknessMuscle toneBiomechanical alignment “Normal” alignment most efficient “Abnormal” alignment affect movementAbnormal

4、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 shortenedTreatmentCorrect (矫正)alignment ofthe trunk, ULand LL insittingWeight bearing(负重)over R LL IN a more narmal postural setWeightbearing andstrengthing exMuscle

5、 toneAmount 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 lev

6、elMuscle tone Abnormal muscle tone Hypotonous flaccid Hypertonous spasticity, rigiditySpasticity 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 inc

7、rease in tonic stretch reflexSpasticity - 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 ResistanceManifestation(显示, 证明) of spasticity Exaggerated(过强的

8、) 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, painSpasticityBaclofen(巴氯酚) Synapses(突触)Rhizotomy(神经跟切断术)

9、Afferent(传入的) Botulinum(肉毒素) neuro-muscular junction(神经肌肉接头)Treatment to reduce spasticityEnhance inhibition of stretch reflexPharmacological treatmentBaclofen (oral, intrathecal) a derivative of GABABotulinum (Intramuscular) inhibiting the release of acetylcholineSurgical treatmentRhizotomy removal

10、 of dorsal rootlets, to reduce the afferent inputs into the spinal cordSurgical treatment(外科治疗)Rhlzotomy removal of rootlets, to reduce the afferent inputs into the spinal cordReduce spasticity over calf muscles SpasticityEnhance Inhibition of stretch reflex(增强对神肌反射的抑制)Prolonged stretch(持续牵拉)Positio

11、ningSplintSerial castingStretch 6 hoursIce therapy 20 minutesTENS 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 2sensory threshold 60 minutes 5 times a wee

12、k for 3 weeksFlaccidity(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 iceMuscle tone and Muscle strengthNo clinical or experimental(实验) evidence(证明) support:Normalise spasticityMuscle tone is poorly related with functional disa

13、bilityIndeed, 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 limitingIn addition to strength,Isolated control增强肌力,分离控制Lack of isolated (selective) control Stereotyped(常规) Abnormal movem

14、ent synergy(共同运动)Abnormal synergyMass flexionSh flexionElbow flexionIsolated / selective controlAbnormal flexor synergy(屈肌共同运动)Isolated knee and hip controlSpastic musclecan be weakSpasticity and weaknessSpasticity and weaknessMarkedweakness ofgastrocaemiusStrengtheming will increase spasticity ?Chr

15、onic 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

16、and gait velocity without increase in spasticityStrengthing Care must be taken to strengthen a spastic muscle Correct movement patterns and optimal resistanceStrengthening Increase force output Functional electrical stimulation Assisted, active movement Proprioceptive neuromuscular facilitation Task

17、 specific Action (concentric, eccentric, isometric) Velocity, AngleFunctional electrical stimulationSensory inputAssisted active and active exercisesProprioceptive NeuromuscularFacilitationPatients with neurological and orthopaedic conditionsSensory input to regain strength using all available senso

18、ry inputslTactile manual contact to guide the motionlVerbal simple and preciselVisual patients eyes follow the movementlProprioceptive Movement traction to stretch muscle to enhance contraction Stabilization joint compression (approximation) to increase contraction musclesProprioceptive Neuromuscula

19、rFacilitation 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 functionsPNF basic patternFlex add-ER Flex abd-ERExt add-I

20、R Ext abd-IRFlex add-ER Flex abd-IRExt add-ER Ext abd-IRFlex - abd - ERPNF Tactile, proprioceptive,verbal, visual, Active participationUpper limbFlexion-abduction-externalrotation andExtension-adduction-Internal rotationProprioceptive NeuromuscularFacilitation Special techniquesRhythmic initiationto

21、 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 dite

22、ctionProprioceptive neuromuscularfacilitation repeated contractionStretch elicit contraction topromote movementProprioceptive neuromuscularfacilitation dynamic reversalStretch elicit contraction topromote movementStrengthening Isokinetic training Theraband, weights Task-specific training Sit-to-stan

23、d Walking UpstairsPossible sensory and motor impairmentsPainJoint stiffness, softtissue shorteningPainShoulder painIncidence: 72% of patients with hemiMinor causes: subluxation of shoulderPoor HandlingPoor LiftingTechniquesGlenohumeral malalignmentWeakness of rotator cuffSpasticityFlaccidityPoor tru

24、nk postureImpringement i.e. supraspinatus,Biceps, bursaAdhesive capsulitisPreventable Good transfer techniques Good positioning Alignment and Control of shoulder complex scapula, glenohumeral jointsTreatmentPhysical agentsSteroid injectionRe-align GH jointCareful ROMactivitiesImprove Jointstiffness

25、andmuscle lengthNon-neural components shortening, soft tissue changesStretching, Resting splintPractical12 hoursUL, LL, TrunkReview VCD You MUST change into T-shirt and Shorts for ALL PRACTICAL CLASSESBiomechanical alignment “Normal” alignment most efficient “Abnormal” alignment affect movementSpasticityBaclofen(巴氯酚) Synapses(突触)Rhizotomy(神经跟切断术) Afferent(传入