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1、PT management of patients with sensori-motor disorders感觉运动障碍的物理治疗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昆明医学院附属第二医院康复科敖丽娟敖丽娟 教授教授Treatment approach - ICFImprove Individual Minimize Reduce SocietyEnhance physiological functionEnhance physiological function Disability Activity Disability ActivityHandicap Participut
2、ionHandicap ParticiputionIndividualIndividualTaskTaskEnvironmentEnvironmentPassible sensory and motor impairments Balance Balance Coordination CoordinationCognition Cognition perceptionperception（感知能力）（感知能力）AlteredAlteredbiomechanical biomechanical alignmentalignment（生物学力线的改变）（生物学力线的改变）Loss of Loss
3、of sensationsensationPainPainWeaknessWeaknessJoint stiffness, softJoint stiffness, softtissure shorteningtissure shorteningMuscle toneMuscle toneSensory re-educationTactile（触觉）（触觉）, hot, cold, 2-point, stereognosis（实体辨别觉）（实体辨别觉）Discriminative（识别）（识别）, protective（给予保护）（给予保护）Early training Detection a
4、nd location of stationary and moving light touch stimuli（刺（刺激）激）Progression size, shape, object recognition（确认）（确认）, 2-point discrminationHigh level of attention and memorySensory re-educationProtect from noxious and injurious stimuli ( (防护来自物理和化学的伤害防护来自物理和化学的伤害) )If sensation does not recoverCompen
5、sation e.g. vision for deficit in tactile sensation ( (靠视觉补偿触觉的不足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 alignment in standing
6、(postural set)Marked asymmetryMarked asymmetry( (明显的不对称明显的不对称) )No weight bearing over R LLNo weight bearing over R LLR LL adducted, planterflexR LL adducted, planterflexR UL flexedR UL flexedL trunk is shortenedL trunk is shortenedTreatmentCorrect Correct ( (矫正矫正) )alignment ofalignment ofthe trunk
7、, ULthe trunk, ULand LL inand LL insittingsittingWeight bearingWeight bearing( (负重负重) )over R LL over R LL IN a more narmal IN a more narmal postural setpostural setWeightWeightbearing andbearing andstrengthing exstrengthing ex痉挛痉挛弛缓弛缓Muscle toneAmount of tension in a relaxed muscleAmount of tension
8、 in a relaxed muscleTension stiffnessTension stiffnessMaintain postureMaintain posture( (维持姿势维持姿势) ) prevent too much prevent too much swayswayMake muscle ready to shortenMake muscle ready to shortenPerson with intact neuromuscular system, Person with intact neuromuscular system, muscle tone is mini
9、mal i.e. resistance to passive muscle tone is minimal i.e. resistance to passive movement is minimalmovement is minimalMuscle tone can change according to posture Muscle tone can change according to posture and anxious leveland anxious levelFacilitation( (易化易化) )i.e. CerebellomMotor cortex( (运动皮层运动皮
10、层) )Pontine( (桥脑桥脑) )Reticular( (网状结构网状结构) )FormationInhibition( (抑制抑制) )i.e. Bulbar( (延髓延髓) )reticularFormationMuscle toneAbnormal muscle toneHypotonous flaccidHypertonous spasticity, rigiditySpasticity pathophysiology痉挛的病理生理学痉挛的病理生理学痉挛的病理生理学痉挛的病理生理学Lesion of CNS ( (中枢神经系统损伤中枢神经系统损伤) )Lack of supra
11、-spinal inhibitory signals on stretch reflex( (反射性伸展的上行性抑制信号不足反射性伸展的上行性抑制信号不足) )Definition : A motor disorder( (失调失调) ) characterized( (特征特征) ) by a velocity-dependent increase in tonic stretch reflexA comparison between age-matched normal & spastic hemiparetic subjectsHyperactive tonic stretch refl
12、exes - increase resistance to passive movementSpasticity - pathophysiologyLesion of CNSLack of supra-spinal inhibitory signals on stretch reflexDefinition: A motor disorder characterized by a velocity-dependent increase in tonic stretch reflex Velocity ResistanceManifestation( (显示显示, , 证明证明) ) of sp
13、asticityExaggerated( (过强的过强的) ) stretch reflex Tonic: increase resistance to passive movementTonic: increase resistance to passive movement Phasic: increase tendon jerkPhasic: increase tendon jerkClasp knife response Increase tone to a certain range and follows by a sudden Increase tone to a certain
14、 range and follows by a sudden reduction of tonereduction of toneClonusAbnormal posturing of the limbs, contracture, painSpasticityBaclofenBaclofen( (巴氯酚巴氯酚) ) SynapsesSynapses( (突触突触) )RhizotomyRhizotomy( (神经跟切断术神经跟切断术) )AfferentAfferent( (传入的传入的) ) BotulinumBotulinum( (肉毒素肉毒素) )neuro-muscular junc
15、tionneuro-muscular junction( (神经肌肉接头神经肌肉接头) )Treatment to reduce spasticityEnhance inhibition of stretch reflexEnhance inhibition of stretch reflexPharmacological treatmentPharmacological treatmentBaclofen (oral, intrathecal) a derivative of GABABaclofen (oral, intrathecal) a derivative of GABABotul
16、inum (Intramuscular) inhibiting the release Botulinum (Intramuscular) inhibiting the release of acetylcholineof acetylcholineSurgical treatmentSurgical treatmentRhizotomy removal of dorsal rootlets, to reduce Rhizotomy removal of dorsal rootlets, to reduce the afferent inputs into the spinal cordthe
17、 afferent inputs into the spinal cordSurgical treatment( (外科治疗外科治疗) )Rhlzotomy removal Rhlzotomy removal of rootlets, to reduce of rootlets, to reduce the afferent inputs the afferent inputs into the spinal cordinto the spinal cordReduce spasticity over Reduce spasticity over calf musclescalf muscle
18、s SpasticityEnhance Inhibition of stretch reflex( (增强对神增强对神肌反射的抑制肌反射的抑制) )Prolonged stretchProlonged stretch( (持续牵拉持续牵拉) )PositioningPositioningSplintSplintSerial castingSerial castingStretch 6 hoursStretch 6 hoursIce therapy 20 minutesIce therapy 20 minutesTENS SpasticityEnhance pre-synaptic Inhibi
19、tion( (增强突触前抑制增强突触前抑制) )TENS applied on fibula head (common peroneal nerve) to reduce spasticity of ankle planterflexorsParameters( (因素因素) ) :0.2 ms square pulse99 Hz2sensory threshold60 minutes5 times a week for 3 weeksFlaccidity( (弛缓弛缓) )Enhance excitation of stretch reflexEnhance excitation of st
20、retch reflex( (增强伸展反射的刺激增强伸展反射的刺激) )Quick stretch( (快速拉伸快速拉伸) )Brisk touchQuick tapping( (快速轻扣快速轻扣) )Quick stroke of iceMuscle tone and Muscle strengthNo clinical or experimentalNo clinical or experimental( (实验实验) ) evidence evidence( (证明证明) ) support: support:Normalise spasticityNormalise spasticit
21、yMuscle tone is poorly related with functional Muscle tone is poorly related with functional disabilitydisabilityIndeed, poor motor control lack of isolated controlIndeed, poor motor control lack of isolated control( (分离控制不足分离控制不足) ) of individual muscles, muscle of individual muscles, muscle weakne
22、ss, impaired dexterityweakness, impaired dexterity( (灵巧性减弱灵巧性减弱) ) , along with , along with tissue changes is usually more limitingtissue changes is usually more limitingImproved motor Improved motor performanceperformance( (运动绩效的改善运动绩效的改善) )In addition to strength,Isolated control增强肌力增强肌力, ,分离控制分离
23、控制Lack of isolated (selective) controlStereotyped( (常规常规) )Abnormal movement synergy( (共同运动共同运动) )Abnormal synergyMass flexionMass flexionSh flexionSh flexionElbow flexionElbow flexionIsolated / selective controlAbnormal flexor synergy( (屈肌共同运动屈肌共同运动) )Flexion of hipFlexion of hipassociated withasso
24、ciated withflexion of the kneeflexion of the kneeduring heel-strikeduring heel-strikeIsolated knee and hip controlSpastic musclecan be weakSpasticity and weaknessDiplegiaDiplegiaWalk on tip-toeWalk on tip-toeSpasticSpasticgastrocaemiusgastrocaemiusSpasticity and weaknessMarkedweakness ofgastrocaemiu
25、sRhizotomyRhizotomySurgical procdure Surgical procdure to reduce to reduce spasticity in spasticity in gastrocaemiusgastrocaemiusStrengtheming will increase spasticity ?Chronic patients 9 months of strokeChronic patients 9 months of stroke10-week program of aerobic and strenthening 10-week program o
26、f aerobic and strenthening exercise (concentric, eccentric)exercise (concentric, eccentric)Improvement Total peak torque of affected leg, Improvement Total peak torque of affected leg, walking speed improved, Quality of life with no walking speed improved, Quality of life with no increase in quad an
27、d plantar flexor spasticityincrease in quad and plantar flexor spasticityIsokinetic strengthening increased muscle strength Isokinetic strengthening increased muscle strength and gait velocity without increase in spasticityand gait velocity without increase in spasticityStrengthingCare must be taken
28、 to strengthen a spastic muscleCorrect movement patterns and optimal resistanceIt is inappropriate to use effortfulIt is inappropriate to use effortfulexercise or any exercise that elicits exercise or any exercise that elicits associated reaction and/or abnormal associated reaction and/or abnormal s
29、ynergysynergyStrengthening Increase force outputFunctional electrical stimulationAssisted, active movementProprioceptive neuromuscular facilitationTask specific ActionAction (concentric, eccentric, isometric)(concentric, eccentric, isometric) Velocity, AngleVelocity, AngleFunctional electrical stimu
30、lationReciprocal Reciprocal inhibition of inhibition of antagonistsantagonistsContraction Contraction of agonistof agonistSensory inputIce, Ice, tapping tapping stroking stroking brushingbrushingAssisted active and active exercisesProprioceptive NeuromuscularFacilitationPatients with neurological an
31、d orthopaedic conditionsSensory input to regain strength using all available sensory inputslTactile manual contact to guide the motionTactile manual contact to guide the motionlVerbal simple and preciseVerbal simple and preciselVisual patients eyes follow the movementVisual patients eyes follow the
32、movementlProprioceptiveProprioceptive Movement traction to stretch muscle to enhance contractionMovement traction to stretch muscle to enhance contraction Stabilization joint compression (approximation) to increase Stabilization joint compression (approximation) to increase contraction musclescontra
33、ction musclesProprioceptive NeuromuscularFacilitationSynergetic 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 functionsPNF basic patt
34、ernFlex add-ER Flex abd-ERFlex add-ER Flex abd-ERExt add-IR Ext abd-IRExt add-IR Ext abd-IRFlex add-ER Flex abd-IRFlex add-ER Flex abd-IRExt add-ER Ext abd-IRExt add-ER Ext abd-IRFlex - abd - ERPNF Tactile, proprioceptive,verbal, visual, Active participationUpper limbUpper limbFlexion-Flexion-abduct
35、ion-abduction-externalexternalrotation androtation andExtension-Extension-adduction-adduction-Internal rotationInternal rotationProprioceptive NeuromuscularFacilitation Special techniquesRhythmic initiationRhythmic initiationto promote initiation of movementto promote initiation of movementpassive a
36、ssisted active active resistivepassive assisted active active resistiveRepeated contractionRepeated contractionto promote strength of agoniststo promote strength of agonistsrepeated stretch, repeated contractionrepeated stretch, repeated contractionDynamic reversalDynamic reversaland to promote stre
37、ngrh of agonists and and to promote strengrh of agonists and antagonistsantagonistsfacil active movement in one direction, followed facil active movement in one direction, followed by movt in opposite ditectionby movt in opposite ditectionProprioceptive neuromuscularfacilitation repeated contraction
38、Stretch elicit contraction toStretch elicit contraction topromote movementpromote movementFlex-Abd-Ext RotFlex-Abd-Ext RotProprioceptive neuromuscularfacilitation dynamic reversalStretch elicit contraction toStretch elicit contraction topromote movementpromote movementFlex-Abd-Ext RotFlex-Abd-Ext Ro
39、tExt-Add-Int RotExt-Add-Int RotStrengtheningIsokinetic trainingTheraband, weightsTask-specific trainingSit-to-standSit-to-standWalkingWalkingUpstairsUpstairsPossible sensory and motor impairmentsPainJoint stiffness, softtissue shorteningPainShoulder painIncidence: 72% of patients with hemiMinor caus
40、es: subluxation of shoulderPoor HandlingPoor LiftingTechniquesGlenohumeral malalignmentWeakness of rotator cuffWeakness of rotator cuffSpasticitySpasticityFlaccidityFlaccidityPoor trunk posturePoor trunk postureImpringement i.e. supraspinatus,Biceps, bursaAdhesive capsulitisPreventableGood transfer
41、techniquesGood positioningAlignment and Control of shoulder complex scapula, glenohumeral jointsTreatmentPhysical agentsPhysical agentsSteroid injectionSteroid injectionRe-align GH jointRe-align GH jointCareful ROMCareful ROMactivitiesactivitiesImprove Jointstiffness andmuscle lengthNon-neural components shortening, soft tissue changesStretching, Resting splintPractical12 hours12 hoursUL, LL, TrunkUL, LL, TrunkReview VCDReview VCD You MUST change into T-shirt and Shorts for ALL PRACTICAL CLASSES
