感觉运动障碍的物理治疗课件

PTmanagementofpatientswithsensori-motordisorders

感觉运动障碍的物理治疗敖丽娟教授Treatmentapproach-ICFImproveIndividualMinimizeReduceSocietyEnhancephysiologicalfunctionDisabilityActivityHandicapParticiputionHollsticapproachIndividualTaskEnvironmentSensoryre-educationTactile（触觉）,hot,cold,2-point,stereognosis（实体辨别觉）Discriminative（识别）,protective（给予保护）Earlytraining–Detectionandlocationofstationaryandmovinglighttouchstimuli（刺激）Progression–size,shape,objectrecognition（确认）,2-pointdiscrminationHighlevelofattentionandmemorySensoryre-educationProtectfromnoxiousandinjuriousstimuli(防护来自物理和化学的伤害)IfsensationdoesnotrecoverCompensatione.g.visionfordeficitintactilesensation(靠视觉补偿触觉的不足)PassiblesensoryandmotorimpairmentsAbnormalbiomechalignmentSelectivemotionWeaknessMuscletoneBiomechanicalalignment“Normal”alignment–mostefficient“Abnormal”alignment–affectmovementTreatmentCorrect(矫正)alignmentofthetrunk,ULandLLinsittingWeightbearing(负重)overRLLMuscletoneSpasticityFlaccidity痉挛弛缓Facilitation(易化)i.e.CerebellomMotorcortex(运动皮层)Pontine(桥脑)Reticular(网状结构)FormationInhibition(抑制)i.e.Bulbar(延髓)reticularFormationMuscletoneAbnormalmuscletoneHypotonous–flaccidHypertonous–spasticity,rigiditySpasticity–pathophysiology

痉挛的病理生理学LesionofCNS(中枢神经系统损伤)Lackofsupra-spinalinhibitorysignalsonstretchreflex(反射性伸展的上行性抑制信号不足)Definition:Amotordisorder(失调)characterized(特征)byavelocity-dependentincreaseintonicstretchreflexAcomparisonbetweenage-matchednormal&spastichemipareticsubjectsHyperactivetonicstretchreflexes-increaseresistancetopassivemovementSpasticity-pathophysiologyLesionofCNSLackofsupra-spinalinhibitorysignalsonstretchreflexDefinition:Amotordisordercharacterizedbyavelocity-dependentincreaseintonicstretchreflexVelocityResistanceSpasticityBaclofen(巴氯酚)

Synapses(突触)Rhizotomy(神经跟切断术)Afferent(传入的)

Botulinum(肉毒素)neuro-muscularjunction(神经肌肉接头)TreatmenttoreducespasticityEnhanceinhibitionofstretchreflexPharmacologicaltreatmentBaclofen(oral,intrathecal)–aderivativeofGABABotulinum(Intramuscular)–inhibitingthereleaseofacetylcholineSurgicaltreatmentRhizotomy–removalofdorsalrootlets,toreducetheafferentinputsintothespinalcordSurgicaltreatment(外科治疗)Rhlzotomy–removalofrootlets,toreducetheafferentinputsintothespinalcordReducespasticityovercalfmuscles

SpasticityEnhanceInhibitionofstretchreflex(增强对神肌反射的抑制)Prolongedstretch(持续牵拉)PositioningSplintSerialcastingStretch–6hoursIcetherapy–20minutesPhysiotherapyFlaccidity(弛缓)

Enhanceexcitationofstretchreflex(增强伸展反射的刺激)Quickstretch(快速拉伸)BrisktouchQuicktapping(快速轻扣)QuickstrokeoficeMuscletoneandMusclestrengthNoclinicalorexperimental(实验)evidence(证明)support:NormalisespasticityMuscletoneispoorlyrelatedwithfunctionaldisabilityIndeed,poormotorcontrol–lackofisolatedcontrol(分离控制不足)ofindividualmuscles,muscleweakness,impaireddexterity(灵巧性减弱),alongwithtissuechanges–isusuallymorelimiting……Improvedmotorperformance(运动绩效的改善)Inadditiontostrength,

Isolatedcontrol

增强肌力,分离控制TheabilitytocontrolthemuscleforceisessentialAbnormalsynergyMassflexionShflexionElbowflexionIsolated/selectivecontrolAbnormalflexorsynergy(屈肌共同运动)Flexionofhipassociatedwithflexionofthekneeduringheel-strikeIsolatedkneeandhipcontrolSpasticmuscle

canbeweakSpasticityandweaknessDiplegiaWalkontip-toeSpasticgastrocaemiusSpasticityandweaknessMarkedweaknessofgastrocaemiusRhizotomySurgicalprocduretoreducespasticityingastrocaemiusStrengthemingwillincreasespasticity?Chronicpatients>9monthsofstroke10-weekprogramofaerobicandstrentheningexercise(concentric,eccentric)Improvement–Totalpeaktorqueofaffectedleg,walkingspeedimproved,QualityoflifewithnoincreaseinquadandplantarflexorspasticityIsokineticstrengtheningincreasedmusclestrengthandgaitvelocitywithoutincreaseinspasticityStrengthingCaremustbetakentostrengthenaspasticmuscleCorrectmovementpatternsandoptimalresistanceItisinappropriatetouseeffortfulexerciseoranyexercisethatelicitsassociatedreactionand/orabnormalsynergyStrengthening~IncreaseforceoutputFunctionalelectricalstimulationAssisted,activemovementProprioceptiveneuromuscularfacilitationTaskspecificAction

(concentric,eccentric,isometric)Velocity,AngleFunctionalelectricalstimulationReciprocalinhibitionofantagonistsContractionofagonistSensoryinputIce,tappingstrokingbrushingAssistedactiveandactiveexercisesProprioceptiveNeuromuscular

FacilitationPatientswithneurologicalandorthopaedicconditionsSensoryinput–toregainstrengthusingallavailablesensoryinputsTactile–manualcontacttoguidethemotionVerbal–simpleandpreciseVisual–patient’seyesfollowthemovementProprioceptiveMovement–tractiontostretchmuscletoenhancecontractionStabilization–jointcompression(approximation)toincreasecontractionmusclesProprioceptiveNeuromuscular

FacilitationSynergeticmovementpatternWhatpatientscan“DO”–IrradiationfromstrongtoweakmusclegroupResistancetogetOptimalResponsefrompatients–maxawareness,strength,coordination,enduranceStabilitybeforemobilityPromotefunctionsPNFbasicpatternFlex–add-ERFlex–abd-ERExt–add-IRExt–abd-IRFlex–add-ERFlex–abd-IRExt–add-ERExt–abd-IRFlex-abd-ERPNF–Tactile,proprioceptive,

verbal,visual,ActiveparticipationUpperlimbFlexion-abduction-externalrotationandExtension-adduction-InternalrotationProprioceptiveNeuromuscular

Facilitation–SpecialtechniquesRhythmicinitiationtopromoteinitiationofmovementpassiveassistedactiveactiveresistiveRepeatedcontractiontopromotestrengthofagonistsrepeatedstretch,repeatedcontractionDynamicreversalandtopromotestrengrhofagonistsandantagonistsfacilactivemovementinonedirection,followedbymovtinoppositeditectionProprioceptiveneuromuscular

facilitation–repeatedcontractionStretch–elicitcontractiontopromotemovementFlex-Abd-ExtRotProprioceptiveneuromuscular

facilitation–dynamicreversalStretch–elicitcontractiontopromotemovementFlex-Abd-ExtRotExt-Add-IntRotStrengtheningIsokinetictrainingTheraband,weightsTask-specifictrainingSit-to-standWalkingUpstairsNormalisemuscletoneImprovestrengthPossiblesensoryandmotorimpairmentsPainJointstiffness,softtissueshor