:

.dorsi-plantar flex

) ( ,
.
.
)
(.

 :
.

.
:

cadence & step length
single support phase -

double support phase

3

:stance -
:
.Varus

Equinovarus
push off-

 :stance -
:
Genu-Recurvatum
:mid stance -
DF- PF-

quad-
.
ext
) (
:
,
5

 :stance -
:
)

(.

 :swing-
:
) Drop foot TA dorsi flex
=> (

 :swing-
:

) mid swing -
(quad -

) QUAD
(flex-contraction

 :swing-
:
)
(.

:
Hiking pelvic obliquity clearance

 -
stance
.1
.2

Lateral bending

forward lean .3

.2 .

.3

DF-

.4

10

.1

.4

 -
swing
.
clearance

11

Circumduction
lateral bending+Hiking
Backward lean
vaulting

?
?

?
:
(6 minute walk test ).
) 10 meter walk test (


(macko et al 2005) treadmill

.
(Teixera et al 2001) .
; , ,....

) , ,
( van de Port et al 2009)(....


) , (....
CKC OKC
) ,(...
) , .(...

; , .....

 :
.

.

) (


:
:Ankle foot orthosis-AFO

) Drop foot D.F- clearance

( IC
Knee Recurvatum

.
Equinovarus

T.H. Cruz, Y.Y. Dhaher / Gait & Posture 30

(2009) 312316
pelvic obliquity-
) AFO ( clearance

,

AFO

:
Task-oriented training includes :
treadmill training
walking training on the ground
bicycling programes
endurance training
sit-to-stand exercises
reaching tasks for improving balance

arm training using functional tasks such as grasping
constraint-induced (movement) therapy (CIMT
mental imagery

Rensink et al.2009
20

Task -specific training

Hubbard et al. 2009
(5) Rs :
Relevant

Randomly assigned

Repetitive
Reconstruction massed practice
.

Reinforced "
21

.
) (

22

:
)-(

primary
somatosensory cortex ).
(.

:
unimodal
:multimodal
Posterior association area (parietal-temporal-

occipital complex )
prefrontal association area
Limbic association area

 CVA
11-60% 80%
)
( .

.
.

.
Tyson et al 2008


:
.
.

.
/ )/(

.
)
(


)
(.

) , , ;
(( .
) Stereognosis , , (....

Two points discrimination

"


:
Compresion
Placing holding
Tapping
)Sweep / (
:

Neglect

- )
( ,

:-
Disorders of input and output

Neglect:
,
: -

MCA- Rt. Posterior parietal-

Temporo-parietal junction

 :
)Behavioral Inattention Test (BIT
.
) (.
:

 :
.

.
.
.

???

Pusher Syndrome

Pusher Syndrome

)
(.

.
.neglect

contraversive pushing
.
) upright
(.

perception
.

/ .
Karnath and Broetz 2003

 pusher syndrome

)
(.
3.6 -

: 3
(1) spontaneous body posture
(2) increase of pushing force by spreading of the nonparetic
extremities from the body
(3) resistance to passive correction of posture.

:
posterolateral thalamus (Karnath and Broetz 2003)
Right Parietal Lobe
Supplementry Motor Area, Superior Parietal Lobe

(Reding 2005)
Postcentral Gyrus and surrounding wight matter,
Posterior Insula
(Reding 1997)

Cerebellum (Johannsen et al 2006)

 Pusher Syndrome-
.
.
) , (

) (.

.


Glenohumeral subluxation

Pectoralis major & minor, : ()

>= ,subscapolaris, romboide, levator scapula, latissimus dorsi
scapula elevation or humerus internal rot or downward rot of
inferior subluxation or anterior subluxation >=scapula
) (
=>
.
rotator - trapizius & serratus ant -
>=downward rot of scapula >= cuff
inferior subluxation

 -
Glenohumeral subluxation
) (
.
assisted act
.

.

) ,(.

???
Taping

SHOULDER PAIN
limited shoulder external rotation (ROM)
adhesive capsulitis
Supraspinatus & Bicipital tendonitis

Impingement
subluxation
Spasticity

complex regional pain syndrome (CRPS).

Acromioclavicular lesion
Brachial Plexus traction


positioning
.

) (,
-



handling

.
CKC &OKC -
.

Complex regional pain syndrome

.

Kocabas et al. 2007

Pertoldi 2005

 CRPS-
Immobilization
.

rotator cuff


,

/ => -
CRPS
()Pertoldi 2005 Kocabas et al. 2007

 CRPS-
.
) (.

Glenohumeral subluxation

biofeedback
) NSAID (.

 :CRPS-

) knesiophobia (CRPS

:
.
.

 :
: Constraint-Induced

.

.
5-6 90%

Amyotrophic lateral sclerosis (ALS):

neurodegenerative disorder .

, ,
, .
"Amyotrophy

.
" "Lateral sclerosis
anterior and lateral corticospinal tracts -

 ALS:
(UMN) upper motor neurone
) lower motor neurone (LMN
ALS .

:UMN , , ,
....
: LMN , , ....

 2/3

.
Fasciculations
cramps '

 ALS:
.
" =>

Bulbar Symptoms IX, X, XI

>= XII .

.
: ,

 :
.
.
.
.
, Hoffmann's sign ,
Bulbar Symptoms :
,dysarthria

 :

) (Respiratory failure .

' 'totally locked-in state

:

Magnetic resonance imaging -MRI corticospinal

EMG

 :ALS -
,
), ( .....

(activities of daily living ) ADLs -
.

.

:
.Transfer aides
Splinting and bracing
:
)ankle foot orthotic (AFO
A wrist cockup Splint
slings Shoulder
Neck support
-

 :
Fatigue
???

 :
:1999 Aitkens & Kilmer
.
eccentric .
,
.

electrical stimulation
.

 Multiple sclerosis
MS ,
, .20-40

: .
.

 Multiple sclerosis
:
)(inflammatory demyelination

:
) MRI ,
(
)Lumbar puncture CNS-
.

, -.

:MS-
Relapsing remitting
Secondary progressing
Primary progressing
Progressing relapsing

 :

Expanded Disability Status Scale
:

Paresthesia
Dysesthesia

:

Diplopia

Nystagmus
,
, .

Trigeminal neuralgia
fatigue

botulinum toxin baclofen

,...

 :MS
:

stride

double support phase

?? Cadence .

 MS:

, .
sway -
.
: clearance in
swing.
)anklefoot orthosis (AFO
) knee-ankle-foot orthosis (KAFO


KAFO

AFO

 :MS-
.

.
Electrical stimulation
) tibialis anterior muscle - (drop foot
.
.

 :MS-
:
MS
-
, ,

.
-.
.


) ,,

:
) (
)(B12
Alcoholic polyneuropathy

) (

) Guillain Barrs syndrome-
- -
carpal tunnel syndrome


;
glove-and-stocking
( ) :
Paresthesia
,




.
, .


/:
, ,
=>

.
=>=>
ulcer .
,

: , , '.

, .
) EMG (.

)

.

polyneuropathy
) (soma
30% 10% :

, .

: )

ataxia
.
;
glove-and-stocking

 paresthesia.
, , , (allodynia .

- .

=>=> ulcer

 Diabetic Neuropathy
.

,
"
.

,
.retina

:
.1

.2

.3

Electrostimulation )
(

Critical illness neuropathy

)
(

: , ,
.axonal degeneration

'

" - "
Guillain Barrs syndrome

AIDP

Acute inflammatory de-myelinating polyneuropathy

lower motor neuron

 :GBS

5 4.

GBS monophasic- 6%-7%

/
.
" ) GBS-
, , , ....

.1

:

) (.

.2

, .
.5%-

 :GBS
.
" .
)( flaccid paralysis

- Areflexia
: )

(

 : GBS
:Myalgia

:Dysarthria , .
: Dysphagia .
) CN "(.
) , ,
,...

:
) (
(LP) CSF ( ) .

) Electromyography (EMG
:
.

 :GBS -
:acute phase
4.

:plateau
, 4-.
) (upright.
:Recovery
.

: GBS
acute inflammatory de-myelinating (AIDP)
polyneuropathy

.1

- acute motor axonal neuropathy (AMA)

.

.GBS acute motor sensory axonal neuropathy

.1

, Miller Fisher syndrome

Acute dysauotnomia

.1

:
.
.
10% to 20% .

4% to 15%
:
.
- .
.
.

:Multidisciplinary

,...

) DVT (...
)
)(non-ambulant

:

.

.
muscle fatigue
) (overworking
) (denervated .

, , :
.

.
.
.

 :
:
hands on

 )post polio syndrome(pps

poliomyelitis anterior horn cell -
.
poliomyelitis post polio

syndrome
PPS- .
( )

.

.

) (lifestyle
.

 :PPS
fatigue .
) (myalgia.

cold intolerance/

deconditioning .
) ,
/ ,( .

:
.
.
: ,,
,'....
: ,
.
: )
, (.....


Parkinson's disease


Basal Ganglia

60,000
.
40% 60

"

 PD-
substantia nigra
Dopamine
: ,

, )/(
? 15-20% .

:
.
Encephalitis

)
(.


60-50 )
.(30-40

.

.

 :
.
.

.
.
)" (

- ,
(

 :
Bradykinesia

(
/- mask face
.

shuffling

 :
:akinesia
.

freezing of gait

: Resting Tremor

"

 :
Rigidity :
.

Led Pipe Rigidity

Cog wheel Rigidity

BG .

 :
) (

- , ,
orthostatic hypotension )
( , " '
.

) -
, , .
Procedural
memory

) (
.

 : Postural instability

.
.
:

 :

:

 :PD
:Shuffling gait

, ,
/
.

" : Turning "en bloc )

(.

 :PD
) Festination gait (
:Gait freezing

) Dystonia
(

 PD -
.

,
Repetitive finger movement

micrographia
:" Berg balance test
Andrew J Lees, John Hardy, Tamas Revesz2009

UPDRS- Unified Parkinson's Disease

Rating Scale
) (3:
) 1 , , (
)ADL (2
3

1 .4 -
.
) (.
, .
(.

Modified Hoehn and Yahr Staging:

0

1

1.5

2
. pull test
. 2.5
.
3
.
Disability
4
.
5


: )

, , (.
: ADL
:

 :
:

......

 :
:
:External cues strategy
... )(
) , ...

Attention
strategy .
),(dual tasking

Huntingtons Disease
.
35-55
:

Dystonia .
.
Chorea

Bradykinesia

 :
Rigidity
Dysartheria

Dysphagia
incontinence
,

:
dopamine blocking ,


Traumatic Brain injury

TBI ,
=>
.

 TBI :

):Glasgow Coma Scale (GCS

10% ) GCS of 13 =mild (
66%) 912 moderate (
8 severe ) 100% (

extension

flexion

5
6

 )Rancho Los Amigos Level of Conciseness (LOC

, "
.

: TBI
Post-traumatic amnesia (PTA) "posttraumatic
confusional state
Subarachnoid hemorrhage
2
Subdural hematoma

epidural hematoma
" Diffuse axonal injury

, , ,
, , /
, , , ,
, , ,

 :
:

.
:

 : ICP

:

/
.

papilledema

:
loced jaw
hetrotropic ossification

.
Posttraumatic epilepsy

:
Locked-in syndrome
:Vegetative state

.
:coma
Decerebrate rigidity(hip ext, add, int rot, shoulder int rot , ext .
Elbow ext pronation wrist finger flex

Decorticate rigidity:lower limb ext . Shoulder : add int rot ,

elbow flex pronation , wrist flex

:Retrogard amnesia

:Posttraumatic amnesia

Spinal muscular atrophy

) (lower motor neuron

3:
:Acute infantile SMA .
2-3 ) (.

: , , ,

 Type (2) chronic SMA

2-18

Kugelberg- welander SMA

18

UMN
/LMN

UMNL

Ne

-
MCA
Rt. -
Posteri
or
parieta
l

(
")
"

"

)
(

MRI , CT

UPDRS-
Unified
Parkinson's
Disease
Rating
Scale
Modified
Hoehn and
Yahr
Staging

MRI CT


),
, , , ,-

(.......-
:

: posterior cranial

fossa
: 2/3 .


.
:

" "Benign
.
" "Malignant
.


)(ICP

:-
.
.

) (.
) (.
papilledema - .

) (


ICP -
cerebellar tonsil .
:
.
.
.
, )
" Betemporal hemianopsia optic chism"

(
, ...

:
:
CT " "Benign

.
MRI .

" .
EEG .

 :
Gliomas

ASTROCYTOMAS
OLIGODENDROGLIOMAS

MEDULLOBLASTOMAS
MENINGIOMAS

 :
:Meningioma
.
:

) (.
:Pituitary adenomas .

 :
Medulloblastoma:
" "Malignant -
posterior cranial fossa .
" 1-5
" .
:
.
.

.
, .
' Abducens 6
""Decerebrate

 :Medulloblastoma -
.

V.P shunt
.

Glioma
3-
:
) Ependymomas" ( ,

Astroytomas

Oligodendrogliomas
" )
(

 :Ependymoma

intracranial
.C.S.F

85% of ependymomas are benign

10% -

5 35 5%
.

 Meningitis

.


.

Brudzinskis sign

Kernings sign

 Meningitis
" LP
:

pain -

Pain-
An unpleasant sensory and emotional experience associated
with actual and potential tissue damage or described in
terms of such damage

 :
/ :


Pain

Nociception

,
.

Nociception
?

 :
" ":
, , , , ,.....
=> ) ( =>

.

:
.

)
) CNS- ( .....

 :
/ "
) , .
.

:
" )" /= .(...

:
) "

 :
, .
,.
.

:
.

, .

 :
, /.

) ( , :
, ) ,(CTS ,...

!
.

 projected pain
, ," .

referred pain


/.
( ). .
?



) (

) A- delta (
) C(

CNS

,
, "
....

 :
FREE NERVE ENDINGS :

:
.
:-
: ) (.

: .

 :
Mechano Nociceptors ) ,(....

Thermal Nociceptors \
Chemical Nociceptors ) PH ,
,(

Poly modal Nociceptors

Transduction

 :
: ,
, " , ,
.
(INSENSETIVITY TO PAIN) FAMILIAL DISAUTONOMY
.
:


:


:C

)
.
, ,, ,
Burning .
: A

C-
, Pricking
, -
Drosal root ganglion

, .


) specificity theory (19

, .

.

: Intensity theory
) (.

:Patter theory ,

 :
:1959 Sensory interaction
.
.
CNS -
.
:Melzack wall 1969 Gate theory

.

C : A -
.

 :
:Wide dynamic range
: Nociceptive specific

:
: , ,SUBSTANCE P ,,

GABA :

 :
.
'

, descending inhibition
PONS
descending inhibition

 :
)(
)(

)(
, ) . ",

, , (

:
.

,
, , ?
)

(.

,1,2,3 (S1) 5,7(S2) 40-


CINGULAT CORTEX HYPOTHALAMUS
AMIGDALA HYPOCAMPUS FRONTAL CORTEX

=>
) " (.....
-

) ?(
)(

INSULAR CORTEX )
(

CINGULATE CORTEX
FORNTAL CORTEX

 :
: .
: descending inhibitio
.

)(WDR ,NS

.

 )
( prefrontal -
, ,
....
) Periaqueducatal Grey

(
:

, ) (
- IN -
.

.
( , ' )
-(.

Central and Peripheral

Sensitization
: => =>

=>
substance P ,,
=> )(
=> .

=> =>
.
) (silent nociception

 :



.

Central Sensitization
>= C
=> WDR

A -


:
, ,

.
, , , " .
:- , ,

....
:....

.
, , .
:
:
.

 : , ) ( ,
, ,
,,

 ?
:

:
) (Avoidance )
(....

-.
:

 :


) pre emptive analgesia -
(

 ,Hyperalgesia -
=> .

,Allodynia -
). , ,, (