Neurorehabilitation 1

Stroke / TBI / MS / PD / GBS / ALS / Examination / Balance/ Bed

Mobility / Transfers / Gait
 Pathology Review:
Stroke, TBI, MS, PD, GBS, & ALS
P 641 Neurorehabilitation 1
Indiana University Physical Therapy Program
Kristine K. Miller, PT, PhD
Spring 2021
STROKE
 Stroke Severity
• Modified Rankin Scale (mRS)
– 0= no symptoms
– 1= No significant disability despite symptoms; able to carry out
all usual duties and activities
– 2= Slight disability; unable to carry out all previous activities,
but able to look after own affairs without assistance
– 3= Moderate disability; requiring some help, but able to walk
without assistance
– 4= Moderately severe disability; unable to walk without
assistance and unable to attend to own bodily needs without
assistance
– 5= Severe disability; bedridden, incontinent and requiring
constant nursing care and attention
– 6= Dead
 Stroke Types
• Ischemic (blockage)
– Thrombotic: clot formation in brain arteries
– Embolic: clot from periphery that travels to brain
• Hemorrhagic (rupture)
– Hypertension
– Aneurysm: subarachnoid hematoma
– Arteriovenous (AV) malformation
– Traumatic: epidural or subdural hematoma
 Medical Management
• Ischemic strokes
– Tissue plasminogen activator (tPA): IV admin, best results
within 4-6 hours of stroke symptoms
– Long term anticoagulation: for clot prevention
– Thromboendarterectomy or graft: atherosclerotic arteries

• Hemorrhagic strokes
– Control blood pressure
– Surgical removal of clot
– Aneurysm clip: close off balloon
– Coil embolization of aneurysm: block hole that balloon
caused
– Steroetactic microsurgery
Anterior
Medial frontal lobe Contralateral LE movement
Medial parietal lobe Contralateral pelvic floor
Basal ganglia movement
cerebral Anterior fornix
Anterior corpus callosum
Contralateral sensory loss
(primarily LE)
artery Apraxia (sup motor & corpus
callosum)
Anosmia
Incontinence
Grasp & suckling reflex
Executive function
Initiation

Middle
Lateral frontal lobe Hemiparesis lower contra face
Lateral temporal lobe Hemi contra extremities (UE>LE)
Lateral parietal lobe Contra sensory loss
cerebral Corona radiate
Basal ganglia
Ataxia contra extremities
Aphasia
artery Hemispatial neglect
Anosognosia
Apraxia
Homonymous hemianopsia
Internal carotid artery MCA & ACA distributions Coma
Death

Lacunar syndrome Deep structures from Hemiparesis

penetrating arteries Dysarthria
(pure motor, ataxic Posterior limb internal capsule Dysphagia
hemiparesis, Corona radiate Cerebellar symptoms
Red nucleus Ataxia
dysarthria/clumsy, SCA distribution Clumsiness
pure sensory, & mixed Basal ganglia Lack of coordination
Thalamus Numbness
sensory motor) Midbrain Tingling
Lateral pons Pain
Burning

Posterior cerebral Occipital lobe Homonymous hemianopsia

Medial & inferior temporal Cortical blindness
artery lobe Dyslexia
Brain stem Memory deficits
Midbrain structures Contralateral hemiparesis
Involuntary movements
Vertebrobasilar
Cerebellum Paralysis
Medulla Ataxia
Pons Vertigo

artery Internal ear

Multiple CN
Nystagmus
Diplopia

syndrome - XII hypoglossal

- V trigeminal
- IX glossopharyngeal
- X vagus
- VI abducens
- VIII vestibulocochlear
- VII facial

PICA
Lateral medullary syndrome or Contralateral trunk & extremity
Wallenburg syndrome sensory deficits
- Vestibular nuclei Ipsilateral facial and CN sensory
- Inferior cerebellar peduncle deficits
- Spinothalamic tract Nystagmus
- Spinal trigeminal nucleus & Vertigo
tract Ataxia
- Nucleus ambiguous (vagus Dysphagia
& glossopharyngeal CN) Horner syndrome
- Descending sympathetic
fibers
AICA
Lateral pontine syndrome Vertigo
- Vestibular nuclei Nystagmus
- Principle sensory Vomiting
nucleus Hemiataxia
- Facial nucleus Contralateral pain &
- Cochlear nucleus temp body & extremities
- Spinothalamic tract Ipsilateral facial sensation
- Middle & inferior Ipsilateral facial paralysis
cerebellar peduncles Ipsilateral loss of taste
- Descending from anterior 2/3 of
sympathetic tract tongue
Hearing loss
Tinnitus
Horner syndrome
 Recovery After Stroke
• Natural recovery
– Resolution of “penumbra”
– First 3-6 months
• Therapy induced recovery
– Promoting restoration
• Promote learning motor process
• Try to get patient back to before stroke
– Teaching compensation
 Natural Recovery
• Natural recovery
– First 3-6 months after
stroke
– Quick changes occur
• Resolution of penumbra
– Area around the infarct
that experiences
decreased blood flow
and oxygenation that
may resolve after acute
phase
 Aphasia
• An acquired communication disorder in
individuals who could previously use
language appropriately.
• Receptive aphasia also fluent & Wernicke’s
aphasia.
– Demonstrates poor auditory comprehension
and word substitutions
– Reading comprehension and writing are
generally impaired
– Not a cognition pathology
 Aphasia
• Expressive aphasia also non-fluent or Brocca’s
aphasia
– Demonstrates slow hesitant speech, awkward
articulation, and restricted use of grammar
– Reading comprehension good
– Writing frequently poor
– Auditory comprehension preserved
– Good awareness of deficit
• Global aphasia
– Demonstrates limitations across all language
modalities
 Aphasia
• If aphasia symptoms persist beyond 1-2 weeks of
insult, full recovery is not likely
• Encourage patients with aphasia to talk as much as
they tolerate (especially non-fluent aphasia)
• Keep instructions simple
• Allow extra time for patients to respond
• Ask yes/no questions when information is needed
• Ask simple questions when information needed
• Use communication boards and devices
• Use gestures & demonstration
• Use written communication if patient able
 Speech & Swallow
• Dysarthria - Speech impairment caused by weakness, paralysis, or
incoordination of the motor-speech system.
• Dysphagia – interruption in eating function or maintenance of hydration
• Normal swallow
– Oral phase – bolus held between tongue and upper palate and propelled to back
of tongue
– Velopharyngeal closure – pharyngeal contraction, laryngeal elevation and closure
, and esophageal opening
 Swallowing Concerns

• ‘Wet’ voice
– Not getting all food down

• Pocketing food
– Keeping food in mouth

• Food consistency
– Thickened liquids
– Cannot give thin, regular
water

• Aspiration pneumonia
 Visual Deficits
• Unilateral spatial inattention (unilateral spatial
agnosia) – failure to orient to, respond to, or
report stimuli on the side of the body
contralateral to a cerebral lesion.
– Often seen with decreased sensation and active
movement of UE and/or homonymous hemianopsia
– More frequent in right hemisphere lesions but present
in both
– Inferior parietal cortex most typical lesion
– Inferior frontal cortex, dorsal lateral frontal lobe,
superior temporal gyrus, cingulate gyrus, basal
ganglia, thalamus, and putamen
Spatial Neglect
Homonymous hemianopsia – visual field loss on the same side of the vertical
bisecting line in both eyes

Lesion: Primary visual cortex (occipital lobe) or optic tract or radiation

(internal capsule)
 Visual & Motor Deficits
• Visual agnosia – unable to recognize or
name an object, but can use it
• Apraxia - difficulty motor planning
– Ideomotor apraxia – can’t perform motor
actions with declarative memory recall or
on command
– Ideational apraxia – can’t perform multi-
step actions
 Pusher Syndrome
• Active pushing of COG towards the hemiparetic
side by the non-hemiparetic side
– Inappropriate orientation to midline
– Loss of balance/postural control
• Occurs in both right and left lesions - more
frequently in right lesions
– Right lesions often also have spatial neglect
– Left lesions often also have aphasia
• Posterior thalamus & post central gyrus (parietal
lobe)
 Pusher Syndrome
• 3 features
– Consistent body
posture/alignment with a
lateral tilt towards the
hemiparetic side
– Use of non-hemiparetic
extremities to produce
the lateral tilt
• Abduction and extension of
extremities
– Resistance to physically
guided correction
TRAUMATIC BRAIN INJURY
 Mechanisms of Injury
• External forces to the head causing the brain
to move (coup vs. contrecoup)
• Severe acceleration/deceleration
• Blast injuries
• Penetrating injuries
 Primary Damage
• Contusion
– More common with occipital blow
– More common where cranial vault is irregular
• Anterior poles
• Undersurface of temporal lobes
• Undersurface of frontal lobes
• Lacerations
• Epidural hematoma
• Subdural hematoma
• Diffuse axonal injury: tearing of axons
 Secondary Damage
• Increased intracranial pressure (ICP)
– Normal 7-15 mmHg
• Cerebral anoxia/hypoxia or ischemia
• Intracranial hemorrhage
• Electrolyte imbalance
• Infection
• Seizures
 Behavioral Changes: any or all of the
following
• Lability: emotional, cries easily
• Uncontrolled anger
• Irritability: hard for families
• Euphoria
• Intolerance
• Inappropriate sexual behavior
• Perseveration: pt. gets stuck, adamant on idea
• Impulsiveness
• Hyperactivity
 Changes in Consciousness

• Diffusely extensive and

bilateral cerebral
hemispheric depression
of function or direct
depression or
destruction of the brain
stem activating system
 Changes in Consciousness
Coma Stupor Obtundity
• Paralysis of cerebral function • General unresponsiveness • Sleeps a lot
• State of unresponsiveness • Usually mute • When aroused
• Eyes closed • Temporarily aroused with by vigorous & – Reduced alertness
• No localized response to pain, stimuli repeated stimuli
– Disinterest in the
• Brain stem responses
– Grimacing to pain
environment
– Reflexive motor response to pain – Slow responses to
– Abnormal palate or tongue stimulation
movements
Amnesia
• Retrograde
Lethargic Delirium – Loss of ability to recall even
immediately proceeding the
• Quiet confusion • Disorientation
• Anterograde
• Distractibility • Fear
– Inability to learn new inform
• Faulty memory • Misinterpretation of sensory stimuli
time of injury
• Slowed response to stimuli • Loud
• Posttraumatic (PTA)
• Less severe than obtundity • Agitated
– Time between TBI incident
• Offensive memory function
– Duration linked to severity o
 Other States
Persistent vegetative state Locked-in syndrome
• Wakeful • Has eye movement
• Reduced responsiveness • No other body movement
• Some eye tracking • Is conscious
• Minimal spontaneous • Can think
motor activity
• Do not speak
• Do not respond to verbal
stimulation
 Glasgow Coma Scale
• Eye opening (E)
– Spontaneous = 4
– To speech = 3
– To pain = 2
– Nil = 1
• Body Motor Response (M)
– Obeys = 6
– Localizes = 5
– Withdraws = 4
– Abnormal flexion response = 3
– Abnormal extension response = 2
– Nil = 1
• Verbal Response (V)
– Oriented = 5
– Confused conversation = 4
– Inappropriate words = 3
– Incomprehensible sounds = 2
– Nil = 1
• Coma score = E + M + V = 3 to 15, higher score=less severe
 Injury Severity
• Defined as mild, moderate, severe

Measure Mild Moderate Severe

Glasgow 13-15 9-12 3-8
Coma Scale
Loss of <30 min 30 min-24 hr >24 hr
consciousness
PTA 0-1 day >1 day to < 7 > 7 days
days
 Glasgow Outcome Scale
• Vegetative State
• Severe Disability
– Conscious
– 24-hour dependence
• Moderate disability
– Functionally independent with adaptations
• Good recovery
– Reintegrate into normal social life
– Able to return to work
– May be mild persisting sequelae
 Rancho Los Amigos Scale
• Used to follow behavior and cognition
progression
• Used in Rehabilitation
• Patients can plateau at any level
• Patients typically demonstrate transitions
between levels with periods of time
demonstrating behaviors in both levels
• Originally 8 levels adapted version now with
10
 Rancho Los Amigos Scale
• I - No Response
• II – Generalized response
• III – Localized response
• IV – Confused, agitated
• V – Confused, inappropriate, non-agitated
• VI – Confused appropriate
• VII – Automatic (in controlled environment) appropriate
• VIII – Purposeful (in open environment) appropriate
• IX – Purposeful, appropriate: stand-by assistance on request *
• X – Purposeful, appropriate: modified independent *
 Disability Rating Scale
• Designed to track progress from coma to community of severe TBI
• Includes body structure/function, activity, & participation
• Maximum score 29 (persistent vegetative state)
• Eight areas assessed
– Eye Opening
– Communication
– Motor response
– Feeding cognitive ability
– Toileting cognitive ability
– Grooming cognitive ability
– Level of functioning
– Employability
 Coma Near Coma Scale
• Provides reliable and valid assessment response to stimuli in
persons in persistent vegetative state
• Designed to measure small clinical changes
• Domains
– Auditory
– Command response
– Visual
– Threat: making quick movements around pt. to check for fear
response
– Olfactory
– Tactile
– Pain: nail bed compression and sternal rub
– Vocalizations
 Interpretation
Disability Rating Scale Coma Near Coma Scale
• Level of disability • 0.00-0.89 = no coma
– 0 = none • 0.90-2.00 = near coma
– 1 = mild
– 2-3 = partial • 2.01-2.89 = moderate coma
– 4-6 = moderate • 2.90-3.49 = marked coma
– 7-11 = moderately severe • 3.50-4.00 = extreme coma
– 12-16 = severe
– 17-21 = extremely severe
– 22-24 = vegetative state
– 25-29 = extreme vegetative
state
 Coma Management Rancho I-III
• Ongoing rehabilitation limited depending on placement
• Consults for specific prevention and family training
• Orient pt. to surroundings and what you’re doing as a PT even if you don’t
think they are aware
• Monitor alertness cycle (CNC or similar protocol)
• Mobility activities with vestibular, tactile, and verbal cues
– Bed mobility
– Short sitting
– Transfers
– Standing program
• PROM program
• Splinting & casting as indicated
• Bed positioning program
• Seating system
• Family & caregiver education
 Splinting/Casting
• Serial casting: resets muscle spindle in static position to
promote stretching and prevent contracture.

• Dynamic splinting: treat contractures, progressively stretch

in opposite direction to reset golgi tendon organ (GTO) and
activate antagonist muscle
– Biceps brachii contracture progressively extended to activate
triceps

• Static progressive splinting: like serial casting but it’s a

splint instead of cast, can be donned on and off.
 Rancho Level IV
• Control environment
• Limit stimulation: few people, low lights, VC’s and TC’s
• Reassure patient
• Tell patient what your relationship is to them: be casual
• Monitor for physiological signs of stress
• Alternate easy & pleasurable activities with difficult &
unpleasant activities
• Short treatment sessions: 15 min
• DO NOT LEAVE UNSUPERVISED
 Rancho Level V
• Orient to person, time, & place at each session
• Simple concrete commands
• Set limits that you can enforce
• Follow through on all limits set
• Monitor for physiological signs of stress
• Maintain control of session by adjusting demand level before an outburst
occurs
• Do not respond emotionally to inappropriate behavior
• Re-direct inappropriate behavior
– State the inappropriate behavior
– Remind patient of consequences of inappropriate behavior
– Thank the patient if they modify the behavior
– Always redirect with age appropriate tone of voice and word selection
• Give patient choices for therapeutic activities
• Always thank the patient for working with you
• Let patient know when you will see them again
• DO NOT LEAVE UNSUPERVISED
 Escalation To An Outburst
• Early stages
– Physiological signs of stress
– Refusal to participate
– Verbal challenge to caregiver
• Increasing escalation
– Threats to caregiver
– Verbal tirade: get pt. to safe surface, most likely in chair or bed.
• Escalation complete (maximum energy expenditure)
– Physical acting out (patient is out of control)
• De-escalation (energy expenditure decreasing)
• Debriefing
 Outburst In The Clinic
• Early stages
– Get patient to a surface if moving around
– Therapists directed break between activities
– Initiation of therapeutic activities that the patient perceives as more
pleasant or less challenging
– Re-direct inappropriate behavior
– Follow through on all therapist set limits
– Limit interaction to that which is absolutely necessary and allow
processing time between each therapist initiated interaction
– If escalation stops complete therapy with one more therapeutic activity
– Give patient appropriate reward
– Thank patient for working in therapy
 Outburst In The Clinic
• Increasing escalation
– Take threats seriously
• Make eye contact with support staff in clinic to have help available if
needed
• Succinctly state that the threat is not appropriate
• State that therapy will not end if the patient follows through on threat
– Allow patient to burn off energy during verbal tirade if possible (patients
can de-escalate at this point)
• Once energy level decreases listen for opportunity for therapist directed
return to therapeutic activities
– Control environment
– Limit stimulation
 Outburst In The Clinic
• Escalation complete
– Safety for patient
• Physical restraint
• Safety room
• Medication
• Guide/assist patient to a surface (bed or floor)
– Safety for therapists
• Help from other team members
• Stay beyond reach of extremities if unable to restrain extremities
• Utilize defensive techniques to release self if necessary and
trained
– Limit verbal re-direction
 Outburst In The Clinic
• De-escalation
– Re-engage with patient
– Re-establish therapeutic rapport
– Communicate to patient the plan for ongoing therapy
• Debriefing
– Answer questions the patient has about escalation
– Accept patient apology if offered
– Reassure the patient that your therapeutic rapport with the patient is not
changed
– Encourage the patient to move forward with therapy
– Support the patient in putting the event behind them
 Rancho Level VI
• Review orientation x3
• Be prepared for regression in behavior especially with new
situations and more difficulty activities
• Re-direct inappropriate behavior as needed
• Increase complexity of verbal directions
• Work on more multi-step commands
• Provide environmental cues to help with cognitive deficits
• Supervision still required, but can be line of sight supervision
with some patients instead of direct physical presence
• Allow increased autonomy for therapeutic task completion
• Instruct patients to self monitor behavior
• Participation in group sessions can begin
 Verbal Interaction With Confused
Patients
• Remind patient of who you are and your relationship with them
• Orientation x3
• Giving commands
– Simple
– Concrete
– Short
• Own your reality
• Re-orienting
– Restorative cognitive function patient
• State accurate reality up to 3 times
• Redirect to a different topic if the patient is unwilling to accept accurate reality
– Non-restorative cognitive function patients
• Operate within patient reality
• Redirect to a different topic
• Allow time between interactions for patient information processing
• Provide information on an as needed basis
• Reassure patient
• Do not respond emotionally to inappropriate behavior
• Re-direct inappropriate behavior
• Talk in age appropriate manner
 TBI Complications
• Complications from bed rest & immobility
– Skin integrity
– Exacerbated ROM & active movement impairments
– Respiratory compromise
• Feeding/nutrition issues
• Heterotopic Ossification – skeletal tissue growth
outside the skeleton. Caused by surgery or
trauma – frequently seen after TBI with other
orthopedic injuries.
MULTIPLE SCLEROSIS
 Diagnosis
• Patient History
• Neurological Exam
• MRI
• Laboratory Profile
• Evoked Potentials
• Eliminate Other Diagnosis
 Types of MS
• Clinical isolated syndrome (CIS)
– Pre-diagnosis
– Symptoms up to 24 hours
– 63% eventual diagnosis of MS
• Relapsing Remitting (RRMS)
– 85% of MS cases
– Clearly defined relapses
– Periods of remission
– Some residual deficit
– Average 1-2 ‘attacks’/year
– 90% transition to secondary progressive after 20 years of
disease or 40 years of age
 Types of MS
• Secondary Progressive (SPMS)
– Initially RR
– Progression without periods of remission
– Less inflammation
– More neurodegeneration – believed to be due to
accumulating damage from earlier inflammation
– Brain atrophy
 Types of MS
• Progressive Relapsing (PRMS)
– 5% of MS cases
– Progressive disease from onset
– Acute relapses
– Disease progression continues between relapses
• Primary Progressive
– 10% - 15% of MS cases
– Progressive from onset
– No definable relapses
– Continuous worsening
 Medical Management
• Goals
– Relapse Management
• Shorten duration
• Reduce Severity
– Disease Management
• Reduce number of relapses
• Decrease development of new lesions
 Relapse Management
• Corticosteroids
– Oral – typically 1-2 week tapering dose
• Prednisone
– Intravenous – typically 3-5 day high dose IV
• Methylprednisolone (Solu-Medrol)
• Dexamethasone (Decadron)
– Injection
• Adrenocorticotropic Hormone (ACTH)
 Corticosteroids
• Side Effects
– Stomach ulcers
– Weight Gain
– Acne
– Cataracts
– Osteoporosis
• Deterioration of head of femur
– Chemical diabetes
 Disease Management
• Disease Modifying Drugs (injectable treatment)
– Betaseron (interferon beta-1b)
– Avonex (interferon beta-1a)
– Copaxone (glatiramer acetate)
• Glatopa
• Glaterimer
– Rebif (interferon beta-1a)
– Plegridy (pegylated inter feron-1a)
– Extavia (interferon beta-1b)
 Disease Management
• Disease Modifying Drugs (oral treatments)
– Aubagio (teriflunomide)
– Gilenya (fingolimod)
– Mavenclad (cladribine)
– Mayzent (sipomimod)
– Tecfidera (dimethyl fumurate)
– Vumerity (diroximel fumarate)
– Zeposia (ozanimod)
 Disease Management
• Disease Modifying Drugs (IV infusion)
– Lemtrada (alemtuzumab)
– Novantrone (mitoxantrone)
– Ocrevus (ocrelizumab)
– Tysabri (natalizumab): can't combine with any
other drugs
 Disease Modifying Drugs
• Most drugs approved for RR and active
secondary progressive
• Novantrone
– Only drug approved for primary progressive
– IV infusion 4x/year
– Lifetime limit 8-12 doses
 Drug Side Effects
FDA approved for relapsing MS &
active secondary progressive
– Flu like symptoms
– Injection site reaction
– Depression
– Low white cell count
– Elevated liver enzymes
– Mild anemia
– Heart problems
– Anxiety
• Tysabri & Tecfidera
– All above
– Progressive multifocal
leukoencephalopathy (PML)
FDA approved for primary
progressive MS
• Novantrone
– Blue-green urine
– Bone marrow suppression
– Low blood cell counts
– Nausea
– Hair thinning
– Bladder infections
– Mouth sores
– Liver damage
– Heart damage
 Neurorehabilitation
• Aims to improve independence and quality of
life by maintaining activity and participation
– Restorative approach after relapse
– Compensatory approach with progressive
functional loss

Thompson, 2005
 Kurtzke Expanded Disability Status Scale

• Eight functional systems

– pyramidal
– cerebellar
– brainstem
– sensory: ALS/DCML
– bowel and bladder
– Visual: optic nerve
– Cerebral: white matter
– other

Multiple Sclerosis Encyclopedia. (2002).

 Kurtzke Expanded Disability Status Scale
• 0.0 Normal neurological examination
• 1.0 No disability, minimal signs in one FS
• 1.5 No disability, minimal signs in more than one FS
• 2.0 Minimal disability in one FS
• 2.5 Mild disability in one FS or minimal disability in two FS
• 3.0 Moderate disability in one FS, or mild disability in three or four FS. Fully
ambulatory
• 3.5 Fully ambulatory but with moderate disability in one FS and more than
minimal disability in several others
• 4.0 Fully ambulatory without aid, self-sufficient, up and about some 12 hours
a day despite relatively severe disability; able to walk without aid or rest some
500 meters
• 4.5 Fully ambulatory without aid, up and about much of the day, able to work
a full day, may otherwise have some limitation of full activity or require
minimal assistance; characterized by relatively severe disability; able to walk
without aid or rest some 300 meters.
• 5.0 Ambulatory without aid or rest for about 200 meters; disability severe
enough to impair full daily activities (work a full day without special
provisions)

Multiple Sclerosis Encyclopedia. (2002).

 Kurtzke Expanded Disability Status Scale
• 5.5 Ambulatory without aid or rest for about 100 meters; disability severe enough to
preclude full daily activities
• 6.0 Intermittent or unilateral constant assistance (cane, crutch, brace) required to walk about
100 meters with or without resting
• 6.5 Constant bilateral assistance (canes, crutches, braces) required to walk about 20 meters
without resting
• 7.0 Unable to walk beyond approximately five meters even with aid, essentially restricted to
wheelchair; wheels self in standard wheelchair and transfers alone; up and about in
wheelchair some 12 hours a day
• 7.5 Unable to take more than a few steps; restricted to wheelchair; may need aid in transfer;
wheels self but cannot carry on in standard wheelchair a full day; May require motorized
wheelchair
• 8.0 Essentially restricted to bed or chair or perambulated in wheelchair, but may be out of
bed itself much of the day; retains many self-care functions; generally has effective use of
arms
• 8.5 Essentially restricted to bed much of day; has some effective use of arms retains some
self care functions
• 9.0 Confined to bed; can still communicate and eat.
• 9.5 Totally helpless bed patient; unable to communicate effectively or eat/swallow
• 10.0 Death due to MS

Multiple Sclerosis Encyclopedia. (2002).

Rehabilitation Focus Based on Level of
Disability
• Minimal & Moderate Disability – Defined by
Expanded Disability Status Scale (EDSS) score up to
6.5 (Multiple Sclerosis Encyclopedia, 2002)

– Diet
• Avoid malnutrition; Low intake of saturated fat; and High intake of
vitamin D and calcium (Schwartz, 2005)
– Exercise
• Aerobic
• Resistance/Strength Training
• Flexibility
– Healthy Lifestyle
– Adaptive Equipment
– Energy Conservation
– Functional Mobility
Rehabilitation Focus Based on Level of
Disability
• Severe Disability – Defined by EDSS score
> 6.5
(Multiple Sclerosis Encyclopedia, 2002)

– Continue with Aerobic, Strengthening, and

Flexibility Exercises as Able
– Respiratory Exercises
– Seating Systems
– Bed Positioning Aids
– Alternate Feeding Strategies
 Rehabilitation Participation
• Fatigue
– Fatigability
– Lassitude: slowness and weakness
– Inactivity
• Thermosensitivity
– Cannot tolerate heat keep cool environment
• Primary Weakness
• Depression
• Fear That Exercise Will Advance Disease
Progression might exacerbate symptoms from
overheating but does not advance disease
 Alternative Rehab Options
• PT modalities
– Aquatic Exercise
– Pre-Cooling
CEREBELLUM
 Cerebellum “Little Brain”
• More neurons than the rest of the brain
• 10% of the weight of the nervous system
• Receives extensive sensory input
• Is not involved in sensory discrimination or
interpretation
• Significant influence on motor function
• Lesion does not lead to paralysis
• Lesion leads to motor deficit “asynergistic”
movements
• Plays a role in motor learning and higher mental
function
 Traditional Divisions
• Vestibulocerebellum – connections
predominantly to vestibular system
– Can cause central vertigo symptoms, such as
those w/ MS
• Spinocerebellum – connections primarily to
the ascending somatosensory tracts of the
spinal cord
• Cerebropontocerebellum – connections
primarily to the cerebral cortex
 Etiology of Cerebellum Lesions
• Developmental abnormality
– Hydrocephalus
– Hypoxia at birth
• TBI
• CVA
• Tumor
• Infection
– Encephalitis
 Etiology of Cerebellum Lesions
• Demyelinating disease
– MS
• Familial or hereditary disease
– Friedreich’s ataxia
• Degenerative disease
• Metabolic disease
– Myxoedema
– Wilson’s Disease
• Vascular disease
– Vertebro-basilar artery insufficiency
• Drug and/or alcohol intoxication
 Impairments
• Hypotonicity
– linked to damage to the spinocerebellum
– Decreased excitation from deep cerebellar nuclei
to regions of brain that excite alpha and gamma
motor neurons
• Dysmetria
– Deficit in reaching a target (past pointing)
– Inaccurate direction, extent, force, and timing of
limb movement
 Impairments
• Movement decomposition (dysynergy)
– Movement patterns performed in a sequence of steps
instead of one smooth pattern
• Dysdiadochokinesia
– Inability to perform rapid alternating movements
• Ataxia
– Uncoordinated movements of any combination of trunk,
head, mouth, tongue, and extremities
– Multi-joint and complex patterns of movement more
affected than single joint movements
 Impairments
• Asthenia
– Generalized weakness
– Sense of heaviness
– Excessive effort for simple tasks
– Early onset of fatigue
 Impairments
• Tremor
– Active (intention) tremor
– Hand oscillates back and forth as they try to
perform a specific motor task
– Oscillations 3 to 5 Hz
• Dysarthria
– Speech disturbance
– Disruption of motor component of speech
articulation
 Impairments
• Eye movements & gaze
– Ocular dysmetria
• Corrective saccades: unable to control eye movement, must
correct
• Lateral gaze by vigorous head movements
– Gaze evoked nystagmus: focusing on something
causes nystagmus.
• Can causes dizziness and headaches
– Vestibulo-ocular reflex impairment
– Blurred vision
– Diploplia
Parkinson Disease & Huntington Disease

BASAL GANGLIA DISEASES

 Basal (Nuclei) Ganglia
• Subcortical structures
• Neostriatum
– Caudate
– Putamen
• Paleostriatum
– Globus pallidus
• Associated structures
– Substantia nigra
– Subthalamic nucleus
– Substantia innominata
 Basal (Nuclei) Ganglia
• Direct pathway
– Facilitates flow of information through thalamus which
leads to excitation of motor cortex
• Indirect pathway
– Decreases activity of thalamus and decreased activity in
the cortex
• Primary function
– Planning and initiating movement sequences
– Generating programmed movements
 Basal (Nuclei) Ganglia
• Impairments
– Hypokinetic disturbances PD
• Akinesia
• Bradykinesia
– Hyperkinetic disturbances Huntington's
• Ballismus: ballistic movements
• Chorieform movements
• Athetoid movements
 Basal (Nuclei) Ganglia
• Disorders of the Basal Ganglia
– Parkinson’s Disease
– Huntington’s Disease
– Wilson’s Disease
– Tardive Dyskinesia
 Parkinson Disease
• Degenerative neurological disorder that leads
to a decrease in dopamine stores in the
substantia nigra and a hypokinetic movement
disorder
• Decreased putaminal excitation of the cortex
• 2 types
– Akinetic/Rigid (all SX except action tremor)
– Tremor Dominant (Primary feature resting and
action tremor)
 Motor Symptoms
• Inability to initiate and perform purposeful movements
– Bradykinesia
– Akinesia
• Rigidity
– Cogwheel
– Lead pipe
• Tremor (resting)
• Postural instability
• Gait
– Decreased velocity
– Decreased step length
– Freezing
• Initiation and execution of motor tasks
– slow
 Perception, Attention, Cognitive
Symptoms
• Decreased cortical excitation from the caudate
nucleus
– Attention
– Memory
– Visuospatial perception
 Other Symptoms
• Hypothesized to be a result of dopamine
deterioration in the medulla
– Loss of sense of smell
– Vivid dreams
– Orthostatic hypotension
 Medical Management
• Slow down dopamine loss in brain
– Sinemet (L-dopa) & Symmetrel
• Increases dopamine in brain
• Long-term side effect involuntary movements
– Treating bradykinesia makes PD patient have tachykinesia
• Activate dopamine receptor
– Requip, Mirapex, Neupro
• Increases binding of dopamine in the brain
• Short term side effects – nausea, vomiting, dizziness,
lightheadedness, confusion, hallucinations
 Cortical Stimulation
• Deep brain stimulation (DBS)
– Surgically implanted device
– Electrode placed in subthalamic nucleus (STN)
– Decreases motor symptoms of PD
• Stem cells
– Making embryonic stem cells that produce
dopamine in the lab
– Have been tested in humans
– Short duration of improved function
 Staging PD: Hoehn Yahr Staging Scale

Stage Progression of Symptoms

0 No signs of disease
1 Unilateral symptoms only
1.5 Unilateral and axial involvement
2 Bilateral symptoms. No impairment of balance
2.5 Mild bilateral disease with recovery on pull test
3 Balance impairment. Mild to moderate disease. Physically independent
4 Severe disability, but still able to walk or stand unassisted
5 Needing a wheelchair or bedridden unless assisted

Hoehn and Yahr Staging Scale for Parkinson

Disease
 Rehabilitation Management
Considerations
• Patients make most functional restoration benefits in
stages 0-3
• Unified Parkinson’s Disease Rating Scale (functional
measure)
• Use visual and auditory cues
– Marks on floor
– Target to walk towards
– Metronome
• Flexibility
• Trunk segmentalization
• Postural alignment
• Boxing
 LSVT
• LSVT LOUD
– Intensive training
– Practice communicating loud speech
– ‘Think’ loud

• LSVT BIG
– Intensive practice
• 4x/week x 1 month
– Practice big movements movement
– ‘Think’ big
 Huntington Disease
• Autosomal dominant neurogenerative
disorder leading to impaired muscle
coordination, cognitive decline, and
psychiatric problem
 Symptoms
• Uncontrolled movement
– Arms
– Legs
– Head
– Face
– Upper body
• Gait
– Ataxic, dancing like
• Decreased executive functioning
• Depression
• Anxiety
• Uncharacteristic anger
 Progression
• Early symptoms
– Incoordination
– Clumsiness
– Jerkiness
– milk maid’s sign: unvoluntary hand movements
• Psychological symptoms onset later
• No effective treatment
• Symptom management as needed
 Rehabilitation
• Early
– Energy conservation
– Compensation
– Light exercise
– Encourage activity
– Functional training
• Late
– Patient/family education
– Safe mobility
– Self-care
ALS & GUILLAIN BARRE SYNDROME
 Amyotrophic Lateral Sclerosis (ALS)
• “Lou Gehrig’s Disease”
• Progressive, degenerative, & terminal
• Pathology
– Degeneration of Betz cells in the motor cortex
– Demyelination and gliosis of the corticospinal tracts and
corticobulbar tracts
– Significant loss of anterior horn cells in spinal cord
– Significant loss of motor cranial nerve nuclei
 Etiology of ALS
• Not specifically known
• Theories
– Toxic theories
• Lead levels
• Aluminum levels
• Calcium levels
• Magnesium levels
– Deficiency of nerve growth factor
– Excess extra cellular glutamate
– Autoimmune response
• 10% inherited – Gene mutation on superoxide dismutase 1(SOD1)
– An enzyme for removal of free radicles
 ALS Diagnosis
• UMN & LMN signs in three spinal regions or two
spinal regions with bulbar signs

• Symptoms not used to make primary ALS diagnosis

– Sensory dysfunction
– Autonomic dysfunction
– Sphincter control problems
– Oculomotor nerve pathway abnormalities
– Significant movement disorder patterns
– Cognitive deterioration
 ALS Diagnosis
• 70% of patients have elevated creatine
phosphokinase
• Mutation in the superoxide dismutase-1 gene if
family history
• EMG – show spontaneous fibrillations and
fasiculations with voluntary activity
• Rule out other neurological conditions
– Biochemical markers in blood and CSF
– Neuroimaging techniques
 Clinical Symptoms
• Fatigue
• Loss of exercise tolerance
• Fasiculations
• Cramps
• Weakness
– Becomes evident to patient when functional impairment noted (often
up to 80% loss of motor neurons before patients perceive weakness)
– Distil typically before proximal loss
– Flexors typically weaker than extensors
• Atrophy
 Clinical Symptoms
• Bulbar symptoms
– Dysphagia – CN V, VII, X, XI
– Dysarthria – CN V, VII, X, XI, XII
– Dyspnea – CN VII, XI, XII (also spinal segments C )
3-7

– Typically later in disease progression

• Pyramidal tract dysfunction
– Hyperreflexia
– Spasticity
– Babinski
• Paralytic progression of spinal musculature & musculature
innervated by cranial nerves
• Death usually secondary to respiratory failure
– Average duration of disease 27-43 months
 Clinical Symptoms
• Progression variable between patients, but
consistent for each patient
• Patients with bulbar signs & respiratory
weakness tend to progress quicker
• Individuals with psychological well-being
– Longer survival times
– Slower disease progression
 Treatment
• FDA approved
– Riluzole – inhibits presynaptic release of glutamate
• Research therapies available through clinical trial
only
– Gabapentin – decrease synthesis of glutamate
– Supplemental tocopherol (vitamin E)- an antioxidant and
free radical scavenger
– rhIGF-1 – insulin like growth factors
– Viral vectors to introduce gene products
• Nutritional cures – none of which have been
effective in clinical trials
 Treatment
• Symptom management
– Muscle spasms & pain
• Quinine, Baclofen, etc.
• Pain medication using caution with opiates if the
patient has respiratory dysfunction
– Dysphagia
• Dietary consult
• Percutaneous endoscopic gastrostomy (PEG)
• Salivary glands
– Severing parasympathetic input to salivary glands
– Excision of salivary glands
 Treatment
• Symptom management
– Dyarthria
• Speech therapy
– Respiratory dysfunction
• Medication for infection/disease
• Short term respiratory support
• Postural drainage
• Long term mechanical ventilation
 Rehabilitation Management
• Disuse atrophy
– Strengthening
– Endurance training
– Make sure not to overwork to fatigue
• Exercise or overwork damage
– Exercise with walking
– Exercise with daily activities
– Avoid excessive eccentric strengthening
• General guidelines for strength training
– MMT 4/5 to 5/5 – mild progressive resistive exercises
– MMT 0/5 to 3/5 – avoid strengthening, focus on energy
conservation
 Seven Exercise Prescription
Recommendations
• 1. Formal exercises combined with enjoyable
activities
• 2. Include activities with opportunity for social
& personal development
• 3. Strengthening should emphasize concentric
forces
• 4. High resistance training programs have no
real benefit
 Seven Exercise Prescription
Recommendations
• 5. Muscles with less than antigravity strength
have little capacity to improve
• 6. Periodically monitor muscle strength for
changes
• 7. Activity prescription should include periods
of rest
 Rehabilitation Management
Sinaki Phase One & Two
• Clinical presentation • Intervention
– Stage 1 – Stage 1
• Mild weakness • Continue normal activities
• Clumsiness • Increase activity if sedentary
• Ambulatory • ROM
• Independent in ADL • Strengthening
– Stage 2 • Psychological support
• Moderate selective – Stage 2
weakness • Continue ROM
• Slightly decreased • Strengthening for muscles
independence with ADL greater than 3/5 MMT
• ambulatory • Orthotics
• Adaptive equipment

Sinaki M. 1988
 Rehabilitation Management
Sinaki Phase Three
• Clinical presentation
– Stage 3
• Severe selective
weakness in ankles,
wrists, & hands
• Moderate decrease in
independence with ADL
• Easy fatigue
• Ambulatory
• Slightly increased
respiratory effort
Sinaki M. 1988
• Interventions
– Stage 3
• Continue ROM &
strengthening per stage 2
being careful not to
fatigue
• Maintain physical
independence
• Deep breathing exercises
• Wheelchair
 Rehabilitation Management
Sinaki Phase Four
• Clinical presentation • Interventions
– Stage 4 – Stage 4
• Hanging arm syndrome • Heat
• Shoulder pain • Massage
• Hand edema • Edema control
• Wheelchair dependent • AAROM
• Severe LE weakness • Isometric exercises
• May have spasticity • Arm slings
• Performs ADL with fatigue • Arm supports
• Motorized mobility

Sinaki M. 1988
 Rehabilitation Management
Sinaki Phase Five
• Clinical presentation • Interventions
– Stage 5 – Stage 5
• Severe LE weakness • Family training for
• Moderate to severe UE transfers
weakness • Home assessment &
• Wheelchair dependent modification
• Increasing dependence recommendations
with ADL • Hospital bed
• Risk for skin break down • Adaptations to
accommodate respirator

Sinaki, M. 1988
 Rehabilitation Management
Sanaki Phase Six
• Clinical presentation • Interventions
– Stage 6 – Stage 6
• Bedridden • Modified diet
• Dependent with ADL • Tube feeding
• Decrease saliva flow
– Medication
– Suction
– Surgery
• Tracheostomy
• Respirator
• Medications for dyspnea

Sinaki M. 1988
 Amyotrophic Lateral Sclerosis
• Psychosocial issues
• Caregiver issues
 Guillain-Barre Syndrome (GBS)
• GBS also known as acute inflammatory demyelinating
polyradiculopathy or Landry’s ascending paralysis
• Disorder where the immune system attacks part of the
peripheral nervous system
• Syndrome vs Disease
– Syndrome – medical condition with a characteristic set of
symptoms and signs
– Disease – caused by a specific disease causing agent
• Distinguished from axonopathies (dissruption of
axons) & neuronopathies (disruption of cell
bodies)
 GBS Pathology
• Autoimmune reaction
– Autoantibodies against myelin
– Autoantibodies against gangliosides – component of the
plasma membrane which modulates cell signal
transduction events & play a role in the immune system.
– Autoantibodies against glycolipids – provide energy and
serve as a cell recognition marker
– Immune system less discriminating after infection leading
to some lymphocytes and macrophages attacking myelin
• Sensitized T lymphocytes work with B lymphocytes to produce
antibodies against meylin
 GBS Pathology
• Most susceptible fibers
– Most heavily myelinated
– Motor fibers
– Sensory
• Joint
• Proprioception
 GBS Diagnosis
• Diagnosed via set of symptoms
– Motor weakness
• Rapidally developing progressive motor weakness
• Relative symmetry of motor involvement
• Weakness progression from distil to proximal
• Areflexia of distil tendon reflexes
– Mild sensory symptoms
– Autonomic symptoms
• Tachycardia
• Arrhythmias
• Vasomotor
 GBS Diagnosis
• Absence of fever at onset of symptoms
• History of flu like symptoms
• Laboratory tests
– Elevated protein in CSF
• Electrodiagnostic testing
– Nerve conduction velocity
• Recovery typically begins 2-4 weeks after
plateau
 Clinical Presentation
• 4 clinical presentations
– Ascending GBS
– Pure Motor GBS
– Descending GBS
– Miller-Fisher Syndrome
 Clinical Presentation
• Ascending GBS
– Most common variant
• Starts in the lower extremities
– Numbness, tingling
– Weakness
• Advances to trunk, UE and finally cranial nerves
 Clinical Presentation
• Pure motor GBS
– Involves significant muscle weakness
– Limited sensory involvement pure motor

• Descending GBS
– Least common
– Weakness with cranial nerves
– Progressing to
• Trunk
• UE
• LE
 Clinical Presentation
• Miller-Fisher Syndrome
– Weakness with eye movements
– Limb movements
– Ataxia
– No sensory involvement
 Clinical Symptoms
• Rapidly evolving, symmetrical, ascending weakness
• Flaccid paralysis
• Diminished tendon reflexes
• 20% to 30% require assisted ventilation due to weakness of intercostals
and diaphragm
• 50% develop CN involvement typically facial weakness, but can also be
oropharyngeal and oculomotor deficits
• 50% demonstrate ANS symptoms
– Low cardiac output
– Cardiac dysrhythmias
– Marked fluctuation in blood pressure
– Edema due to peripheral blood pooling
– Ileus & urinary retention
 Clinical Symptoms
• Sensory symptoms
– Hyperesthesias
– Paresthesias
• Tingling
• Burning
– Numbness
– Decreased vibratory sense
– Decreased position sense
– Stocking-glove pattern: distal moving proximal
• Pain
– Muscle aching
– Associated with vigorous exercise
– Believed to be due to muscle changes from neurogenic origin
 Clinical Symptoms
• Progression
– 80% reach maximal paralysis by 3 weeks
– 70% reach maximal paralysis by 2 weeks
– 50% reach maximal paralysis by 1 week
– Some experience progressive paralysis for up to 1-2 months
– Gradual onset of recovery typically 2-4 weeks after plateau
– 50% demonstrate persistent minor neurological deficits
– 15% demonstrate persistent functional deficits
– 80% become ambulatory within 6 months
– 5% die
 Clinical Phases
• 3 Clinical Phases
– Phase 1 = acute onset
• Begins with onset of weakness
• Rapid
• Continues until symptoms of deterioration stop
• 1 to 4 weeks
• Considered in this phase until pt. reaches plateau
 Clinical Phases
• 3 Clinical Phases
– Phase 2 = Plateau phase
• No change in symptom
• Few days to several weeks

– Phase 3 = Recovery phase

• Regain motor and sensory function
• Last a few weeks to several years
• Statistical numbers indicate
– 60 to 80% achieve full recovery
 Clinical Phases
• 3 Clinical Phases
– Phase 3 = Recovery phase
• Schwann cell survival
– In most situations
– Remyelination
» Multiple segments often replace 1 segment
 Clinical Phases
• Predictors of poor outcomes
– Age older than 60
– Rapidly progressing disease
– Axonal loss
– Prolonged mechanical ventilation
 Treatment
• Hospitalization with availability of advanced
respiratory and cardiac care
• Plasmapharesis – plasma exchange involves
removing whole blood from the body and separating
red and white blood cells from the plasma and
returning blood cells only to the patient (beneficial
up to 30 days after initial symptoms)
• High dose immunoglobulin (limited benefit)
• CSF filtration – experimental early data encouraging
• Steroid hormones have not been effective in clinical
trials
 Rehabilitation Management
• Respiratory & dysphagia dysfunction
– Medical management
– Speech therapy
– Respiratory therapy
– Physical therapy
• Postural drainage
• Pain
– Medication
– ROM
– TENS
– Compression wraps
 Rehabilitation Management
• Skin integrity
– Positioning
• Contractures
– Positioning
– Splinting
– ROM
– Heat applications
– Manual therapy & massage
– CPM
 Rehabilitation Management
• Strengthening
– Avoid muscle fatigue
– Frequent rest periods
– Increase exercise intensity if status remains unchanged or
improved for 1 week
– Strengthen for function
– Limit fatiguing exercises and return to sports for 1 year
• Endurance
– Series of short duration with breaks
 Rehabilitation Management
• Functional activities
– Vertical tolerance
• Elevating head of bed
• Tilt table
• Standing frame
– Bed mobility
– Transfers
– Locomotion
• Wheelchair
• Assistive devices
• Orthotics
– Advanced gross motor
 Rehabilitation Management
• Measuring progress
– MMT
– ROM
– Function
• FIM
• Psychosocial issues
– Quote from a patient
• “They acted like I was already dead, and I thought I would be from the way they
were talking. The thing I hated the most was when the night nurses from registry
would come in and ask how to make the ventilator work! I felt panicked. Can you
imagine having your life depend on a machine and knowing that the person who
was supposed to make it work had no idea what to do if a tube came unconnected?
They were always worried about my blood pressure. Who wouldn’t have high blood
pressure in that situation! The thing I liked about my therapists was that they told
me what they were going to do even when I couldn’t respond. They didn’t just start
doing things or pulling on me like other people did.”
 Neuro Pathology Scales
• Stroke
– Modified Rankin Scale (mRS): higher on scale=worse
• Traumatic Brain Injury
– Glasgow Coma Scale: higher score=better
– Glasgow Outcome Scale
– Ranchos Los Amigo I-X Scale: higher on scale=better
– Disability Rating Scale: higher on scale=worse Persistent
– Coma Near Coma Scale: higher on scale=worse vegetable state
• Multiple Sclerosis
– Expanded Disability Status Scale (EDSS): higher on scale=worse
• Mild to moderate: <6.5
• Severe: >6.5
• Parkinson’s Disease
– Hoehn Yahr Staging Scale: higher on scale=worse
• Anterolateral Sclerosis
– Sinaki Phases I-VI: higher stage=worse
• Guillain-Barre Syndrome
– Clinical phases I-III: higher phases=better/recovering
Conceptual Framework:
Neurological PT
“Movement occurs out of a need to solve
problems in the environment. Solving these
problems is not dependent on any one
system but rather is a collaborative effort of
multiple systems.”

Umphred, 2013, p. 59
Movement System
• Collection of systems
that interact to move
the body and body
parts
– Movement observation
& analysis
– Core standardized tasks
• Sitting, standing, sit to
stand, stand to sit, step
up, step down, reach
grasp, manipulation
 Big Picture Movement Categorization

• Normal & functional

• Functional but limited in adaptability

– Mod I
– Remediation to make normal
– Compensation to improve adaptability

• Dysfunctional & abnormal

Goals of Examination with Movement
System Framework
• Organize observational skills for any
movement pattern
• Identify components of the movement
• Identify missing or abnormal movement
patterns
• Select and administer interventions
– Incorporate missing strategies
– Normalize missing components
 Sensory-Motor-Performance
• Neuroanatomy
• Neurophysiology
• Motor Control: Ability to regulate or direct
mechanisms of movement (minutes)
• Motor Learning: Process by which movement
is acquired or modified leading to a
permanent change in motor behavior
(hrs/days/wks)
• Neuroplasticity
 Hands
• Open

• Tension

• Finger tap

• Brushing

• Passive guidance
– PT taking control

• Active Guidance
– Tactical cues
 Targeting Receptors
• Cutaneous
– Touch
– Pressure
• Muscle receptors
– Muscle spindle: quick stretch, TC’s
– Golgi tendon organ
• Joint receptors
 Facilitation Inputs
• Tapping
• Quick stretch
• Quick brushing
• Joint approximation: ballistic inputs into joint
• Resistance
• Light tactile input
• Traction
• Manual contacts
• Vibration
 Inhibition Inputs
• Slow rocking
• Gentle, slow rotation
• Neutral warmth: wrap in blanket
• Sustained stretch
• Slow stroking
• Sustained pressure
• Prolonged WB
• Prolonged icing
 How Much Pressure?

• Grading: start lighter and work your way up

• Transitions: slow progression of pressure

application, except during safety concerns
– “You can always give more, but can’t take away
what you’ve already given”.

• Quick response
 Motor Control

• Knowledge Base
– Movements emerge from
reciprocally interacting
elements
• Individual, task, environment
Task
– New movements emerge from
a critical change in one system
– Control parameter – facilitates
change in the entire system
– Rate limiting factor (constraint) M
is the variable that is restricting
motor performance = physical Individual Environment
therapy problem list
– Variability
• Promotes optimal function
• Over-learned skills with minimal
variability = deep attractor well
= difficult to change
Systems Approach
 Individual
• Capacity for motor
Cognition
&
behavior
Emotion
• Body structures &
functions that support
individual preparedness
for motor behavior
Individual
• Personal factors
Sensation
& Action
perception
 Task
• Requirements of task
• Activity level function
ability Postural
• Stability
• Controlled
control mobility
Task • Mobility

• Transitional
Skill movements
• Manipulation
 Environment
• Context for task
performance
regulatory • Potential to improve
participation level
environment
function

Non-
regulatory
 Motor Learning
• Knowledge Base
– Follows progression early to late learning
– Influenced by augmented feedback (verbal or
tactile or visual)
– Influenced by practice prescription set-up
– Leads to permanent change in motor behavior
– Ability to transfer between skills
 Motor Learning
Early Late
• Fast changes • Slow changes
• Cognitive • Consolidation
• Verbal • Autonomous
• High degree of variability • Retention
• Degrees of freedom • Transfer
constrained • Associative
• Less variable
• Released degrees of
freedom
 Motor Learning
Feedback (Augmented) Practice
• Verbal • Massed
– Knowledge of results – short rest breaks
• After movement – Stroke
• Movement outcome
• Distributed
– Knowledge of performance
– long rest breaks for conditions that are easily
• During or after movement
exacerbated
• Movement parameter or component
– GBS, MS, ALS
– Descriptive
• Describe movement error • Blocked
– Prescriptive – one skill at a time
• Describe movement error and how to correct • Random
• Physical guidance – multiple skills randomly ordered
– Passive • Part
– Active – Component of skill
• Visual feedback – Skill made easier
– Mirror • Whole
– Video – Entire skill
• Continuous
– No change in skill parameters
• Variable
– Skill parameter (component) changes between
practices
 Motor Learning
Near transfer Far transfer
• Similar skills • Similar motor control
• Different surface components
parameters • Different skills
• High degree of task • Focus on capacity for
specificity movement
• Task specific • Link body function to
activity
 Neuroplasticity
• Knowledge base
– CNS can recover from disease or injury
• Spontaneous self-healing: resolution of penumbra
• Medical management
• Physical exercise and activity
• Balanced nutrition
• Opportunities to learn: sensory rich environments,
pushed past their comfort zones, make sure they don’t
return to negative lifestyle afterwards
 Neuroplasticity
• Knowledge base
– CNS can adapt negatively
• Repetitive atypical patterns of movement
• Structural anomalies
• Abnormal biomechanics
• Bad habits

Initial and chronic

compensation
 Same Thing ?!!?
• Neural plasticity –
changing of the
structure, function, and
organization of neurons
in response to new
experiences
• Motor learning –
relatively permanent
change in capability for
performing skilled
movement from
practice or a novel
experience

Selzer ME. et al. (2006) Neural Repair and Neurorehabilitation; Shumway-

Cook & Woollacott (2012); Schmidt & Lee (2005)
 Observation/Measurement
Motor Learning – Physical
Neuroplasticity -Neuroscientist Therapist
• Assessed through neural • Inferred through behavior
network changes – Change in MC holes
– fMRI – Motor skill performance
– DTI: shows axon tracts • Retention testing
– TMS – Skill transfer
– MEP
– EEG
 Influencing Neuroplasticity/Learning
Neuroscientist
• Cortical stimulation
• TMS
• Minimize inflammatory response
• Modify neurotransmitter activity
Physical Therapist
• Handling
• Practice prescription
• Feedback
• Compensatory training
• Restorative training
• Improving motor capacity
• Patient education/HEP
• Task practice
Neural Plasticity: Principals of Activity
Dependent Plasticity
– Use it or lose it
– Use it & improve it
– Specificity: train for functional skill
– Repetition matters
FITT
– Intensity matters
– Time matters
– Salience matters: why it matters, why are we doing
that exercise, walking, etc.
– Age matters
– Transference: transferring skill from one to another
– Interference: OT vs PT vs SLP, assistive devices

Kleim JA, 2008

 Principles of Neural Adaptation
• Think positively about health & recovery – believe in ability to get
better
• Clear patient-centered goals
• Encourage family involvement
• Learning activities
– Goal directed
– Repetitive
– Progressed
– Variable
– Spaced over time
– Rewarded
– Complemented feedback on accuracy
• Linking activities spatially & temporally
• Training with functional activities

Umphred (2020)
Principles of Neural Adaptation
– Integrate training across multiple sensory modalities
– Age-appropriate training activities
– Practicing in different postural orientations and different
environments
– Match activities to state of recovery and development
– Reward positive responses meaningfully
– Make it difficult to use unaffected side CIMT
– Avoid activities that stimulate dysfunctional activities
– Maintain appropriate attention and cognition
– Nurture self-esteem
– Focus outwardly – how to engage with others
– Focus on overall health and well being, fit and balanced

Umphred (2020)
THERAPY INTERVENTION STRATEGIES
AFTER NERVOUS SYSTEM LESION
Remember…The Outcome Objective

Facilitate motor behavior that

is whole task performance
without augmented feedback!
 Therapy Induced Recovery
Restoration Compensation
• Return to previous or • Establish a new way to
maximum performance of function through a ‘work
damaged systems and around’ for damaged
behavioral functions systems and behavioral
• Reappearance of elemental functions
motor patterns present • Appearance of new motor
before the injury patterns resulting from
adaptation of remaining
motor elements or
substitution
Levin MF. et al. (2009) Neurorehabilitation and
Neural Repair; Takeuchi N et al. (2012) Neural
Plasticity
Goal of Neurological Rehabilitation

Maximal
Restoration Compensation
function

Recovery
 Big Picture
• Neurological Intervention Strategies have
developed coincident with increased
understanding of motor control
– We started with the reflex model & have now
landed with the systems approach of motor
control
– Interventions drawing on earlier models of motor
control are neurofacilitory approaches
– Interventions drawing on later models of motor
control are task-specific training approaches
 Neurofacilitory Approaches
• In the emerging conversation:
– Fall into 2 big buckets
• Impairment-based interventions (body
structure/function)
• Guidance during task-specific practice
– Historically :
• Were considered stand alone intervention philosophies
• Described by pioneers in our field & named individually
(Rood, Brunstrom, NDT, PNF)
 Neurofacilitation Approaches
• Neurophysiology (basis for handling & NS
impairment-based interventions)
– Reciprocal innervation
– Co-innervation
– Autogenic inhibition
– Reciprocal inhibition
– Sensory Stimuli are inhibitory or facilitory
 Neurofacilitation Approaches
• Motor Control (individual)
– Skill development
• Rostral to caudal
• Proximal to distil
• Gross motor to fine motor
– Postural control (static & dynamic)
• Achieve vertical
• Midline orientation
• Head & limb movements on stable trunk
• Movement of COG across BOS
– Rotational movements
– Diagonal movements
– Abnormal synergies described for UE & LE
 Upper Extremity Synergy Patterns
flexion extension
• Scapula - retraction, • Scapula – protraction
elevation • Shoulder – IR, adduction
• Shoulder – ER, abduction • Elbow – full extension
90° • Forearm – pronation
• Elbow – flexion • Wrist – extension
• Forearm – supination • Finger - flexion
• Wrist – flexion
• Finger - flexion
 Lower Extremity Synergy Patterns
flexion extension
• Hip – flexion, abduction, ER • Hip – extension, adduction,
• Knee – flexion ~90° IR
• Ankle – dorsiflexion, • Knee – extension
inversion • Ankle – plantarflexion,
• Toes - extension inversion
• Toe - flexion
 Neurofacilitation Approaches
• Motor Control (task)
– Transitional movements: changing BoS, change position
– Fine motor (manipulation)
– Accurate task analysis
– Accurate movement analysis
 Neurofacilitation Approaches
• Motor Learning
– Repetition required repetition matters!
– Functional movements specificity matters!
– Functional situations transference matters!
– Personality needs of patient (patient
preferences) salience matters!
 Task-Specific Approaches
• In the emerging conversation:
– Considered functional training but only at activity
level of function on ICF
• High intensity repetitive whole task practice
• Forced use: of paretic/weak side
• Visual imagery: mirrors, video of yourself, thinking
about doing the movement
 CIMT
• Intense functionally oriented task practice with the
paretic UE while the non-paretic UE is retrained for
90% (6 hours/day)
– Modified – reducing practice/restraint time
– Must have some UE movement including wrist
• Therapeutic benefit suggested with limited evidence
• Encourages paretic UE use (use it or lose it, use it
improve it)
• Encourages functional use (specificity matters)
• Eliminates non-paretic option (intensity matters,
repetition matters)
 BWSTT
• Gait training that involves unloading the lower extremities by supporting a
percentage of body weight
• Evidence supports improved functional walking & speed but not to a
superior degree than progressive exercises (Duncan, 2011; Charalambous,
2013)
• Advantages
– Dynamic & task specific
– Repetitive stepping
– Safe for patient
• Disadvantage
– Labor intensive
– Requires multiple helpers
– Equipment cost
• NOTE: Intensive gait training can be done overground without equipment
 Visual Imagery
• Imagining performing a motor task
– Watching self – visual imagery (3rd person)
– Imagining self practice – kinesthetic imagery (1st
person)
• Back door to accessing motor systems
• Greatest improvement noted when imagery
combined with physical practice mirror or
think before you do!
• Can be performed at all levels of recovery
 Bilateral Movements
• Bilateral extremities perform the same task
simultaneously
• Bilateral movements have been shown to:
– Reduce compensatory trunk movements
– Improve shoulder ROM
– Be more effective when used with patients with
severe deficit
 Robotic Therapy
• Use of robot exoskeleton to move, assist, or
resist movement
• Improvements in UE function reported with
robotic assisted therapy but:
– Not clearly superior to traditional therapy
– Expensive
• LE data demonstrate improved walking
symmetry
 Technology In Neurological Rehabilitation

• Electrical stimulation (NF)

• Biofeedback (NF)
• Computerized balance equipment (TS)
• Body weight support (TS)
• Neuroprosthesis (NF)
• Virtual reality environments (TS)
• Robotic devices (TS)
Merging the Newer with the Older
• In the clinic ideally
– Pull forward relevant concepts from older ideas
and integrate into newer ideas to optimize
movement and maximize functional recovery
• In the clinic reality
– Lots of variability on application of intervention
strategies
• Some holding tight to older ideas
• Some trying to throw out all older ideas
• Some working to integrate the newer with the older
 Important Things to Consider
• Older ideas are more philosophies than specific
intervention protocols
– Makes them difficult to standardize and test
– Creates variability based on clinician and patient individual
characteristics
– Building capacity for movement
– Components of movement patterns
– Potential for meaningful evidence in the patient
preference leg of evidence-based practice through
qualitative methods and patient-reported quantitative
approaches
– Need to use expert opinion to find ways to standardize
interventions for testing
 Important Things to Consider
• Newer ideas are specific intervention protocols
– Makes them easy to standardize and test
– Can be implemented consistently independent of clinician
and patient individual characteristics
– Improving functional mobility at activity level of function
– Standardized protocols for limited number of motor skills
• Limited outcomes influenced
– Potential for meaningful evidence in the patient
preference leg of evidence-based practice through
qualitative methods and patient-reported quantitative
approaches
– Need to use expert opinion to identify important motor
behaviors not addressed by standardized interventions
 Important Things to Consider
• We are not even close to having all the answers yet
– Can some of the robotic technology applications provide a
way to standardize interventions that fall into neurofacilitaory
category
• Modifying components of the motor skill during practice
• Computerized motion analysis
– Can we combine neurofacilitory interventions and task-
specific practice in a comprehensive intervention protocol that
promotes adaptive neuroplasticity and more efficient
movement patterns and increased quantity of movement
– Can we design intervention protocols that minimize long-term
secondary effects of CNS injury & rehabilitation
• Musculoskeletal pain
• Sedentary lifestyle
• Difficulty reintegrating in the community and satisfactory function
at the participation level
 Important Things to Consider
• We are not even close to having all the answers
yet
– We need a more robust evidence base that considers
ALL 3 legs of evidence-based practice equally
• Available evidence
– What’s there
– There is a difference between not addressed in the evidence &
shown to be ineffective in the evidence
• Expert opinion
– To have an expert opinion on an intervention you must be
educated on the intervention by a qualified therapist and
genuinely try to implement it
• Patient perspective
– We have a long way to go in understanding how to use patient
reported data of any kind
 Integrating Now – Given the State of
the Evidence
• Step 1: Physical Therapy Examination
– Subjective/history info
– Systems screen
– Measure capacity for movement (body structure/function)
– Measure functional mobility in clinic (activity level
function)
– Measure functional mobility in community simulated
environment (participation level function)
– Comprehensive
• Levels of function
• Types of data (observations, patient performance, patient report)
 Integrating Now – Given the State of
the Evidence
• Step 2: establish therapy goals
– Based on examination findings
– Patient goals & preferences
– Relevant health and prognosis factors
 Functional Outcome Goals
• PT must decide functional outcome goals
– Motor skills/Activity (long-term outcome)
• Discharge functional level performance with
compensation vs. restoration (performance goal)
• Write long-term SMART goals
– Motor skills/Activity (short-term outcome)
• Next functional level (performance goal)
• Most critical components (MC task/ICF body function)
(process goal)
• Write short-term SMART goals
 Integrating Now – Given the State of
the Evidence
• Step 3: select interventions
– Impairment Interventions
• Improve capacity for movement (ROM, active
movement, etc.)
• Facilitory/inhibitory techniques as needed
• Part practice
• Any developmental posture
• Far transfer activities
 Integrating Now – Given the State of
the Evidence
• Step 3: select interventions
– Task-specific Interventions
• Utilization of a functional task
– Can include use of therapist guidance, augmented feedback,
or equipment to assist with tone, positioning, movement
pattern, or motor control during task practice
• Part to whole practice
• Functionally relevant postures
• Near transfer activities
• Maximize repetition and intensity of whole task
practice
 Function
• The natural action or intended purpose of a person or thing in a
specific role.
• Functional impact through interventions targeting the nervous
system by applying principles of Neurophysiology, MC, ML, & NP
relative to understanding of neuroanatomy.
• PT’s integrate NS observations with other systems (CV, Pulm, Endo,
Musc, & Integ) in the movement system to analyze movement to
determine dysfunctional components of body movement.
• PTs consider all categories of function & all patient roles when
designing interventions.

• GOAL: Optimize movement and maximize recovery of function.

ICF: REHABILITATION FUNCTION
FRAMEWORK
 Levels of Function
• Body structures & functions

• Activity

• Participation
ICF: Body Structures

• Structures of NS
(neuroanatomy)
• Eye, ear & related structures
• Structures for voice & speech
• Structures of CV,
immunological, & resp systems
• Structures for digestion,
metabolism, & endocrine
system
• Structures related to
movement (movement
system)
• Skin
ICF: Body Functions

• Mental functions
(neurophysiology)
• Sensory functions
(neurophysiology)
• Voice & speech
• CV, hematological, immunological
& respiratory function
• Digestive, metabolic & endocrine
• Genitourinary & reproductive
functions
• Neuromusculoskeletal &
movement functions
(neurophysiology, motor learning,
motor control, neuroplasticity)
• Skin functions
ICF: Activities & Participation

• Learning & applying

knowledge (motor learning,
neuroplasticity)
• General tasks & demands
• Communication
• Mobility (motor learning,
motor control)
• Self-care (motor learning,
motor control)
• Domestic life
• Interpersonal interactions &
relationships
• Major life areas
• Community, social & civic life
ICF: Environmental Factors

• Products & technology

(robots, orthotics, AD,
adaptive equipment)
• Natural environment &
human made changes
to environment
• Support & relationships
• Attitudes
• Services systems &
policies
ICF: Personal Factors

• Age
• Gender
• Lifestyle
• Upbringing
• Education
• Race
• Food preferences
• Fitness
• Habits
• Coping styles
• Social background
Framework
Task

Individual Environment
FUNCTIONAL TRAINING
 Functional Training
• Guided by outcome goals
– Task practice for motor skills/activities
– Part practice based on components included in
short-term outcome goals
– Physical assistance & AD based on patient
performance & outcome goals
– Handling (verbal & manual cues) based on patient
performance & outcome goals
 Functional Training
• Maximize repetition
– Plan for at home activities from the moment
intervention is initiated
– Turn over the motor skills or parts of motor skills
patients can do without your help as part of HEP
– Practice the motor skills and parts of motor skills
patients cannot do on their own during therapy.
– Always try to end with practice of complete motor
skill
– Promote learning during motor skill practice with
variability between practices & random practice
sequences
 Remember…….
• The patient is learning with each repetition

• Neural plasticity is influenced with each repetition

• EVERY repetition counts – in therapy, at home, at work,

at school, or anywhere the patient is engaged in motor
behavior

• Patients learn that which they repeat the most &

adaptability requires variability in practice which
requires capacity for alternative movement strategies.
 Think It Through
• A patient walks 350 feet with a WBQC and AFO modified
independent without falling.

• Which situation is the most functional:

• 1) the patient can walk without the AD and AFO slowly and
cortically driven to get to the bathroom safely at night
• 2) same as above except has to have bed equipment to get
up due to inability to perform supine to sit independently
• 3) Patient can not walk without the AD & AFO so uses a
bedside cammode for toileting at night
• 4) same as #3 except can’t get up either like #2 so wears a
diaper at night incase there is an accident
Neurological PT Evaluation

P641 Neurorehabilitation 1
Indiana University Physical Therapy Program
Spring 2021
Kristine K. Miller, PT, PhD
 Task

Individual Environment
SOAP: SUBJECTIVE
 The Interview
• Medical history
• Family support
• Work/school status
• Premorbid function
• Goals for therapy
• Exercise/activity level
• Home set-up
SOAP: OBJECTIVE
 Objective Examination

• Measure individual motor capacity

– Body structure/function

• Quantify motor task performance

– Activity/Tasks

• Describe participation restrictions

– Participation/Community/Home setup/Return to
work/hobby
Measure Individual Motor Capacity
• Capacity for motor
Cognition
&
behavior
Emotion
• Body structures &
functions that support
individual preparedness
for motor behavior
Individual
• Personal factors
Sensation Action
&
perception Motor
 Quantify Motor Task Performance
• Requirements of task
• Activity level function ability
– Bed mobility
– Transfers • Stability
• Sit to stand Postural • Controlled
control mobility
• Stand to sit
Task • Mobility
– Walking
– Advanced gross motor
• Floor transfer if appropriate
– Balance • Transitional
Skill movements
• Sitting • Manipulation
• Standing
– UE function
• Reach and grasp
• Manipulation
 Describe Participation Restrictions
Where Task & Environment
Intersect
• Life application of task
performance
– Health related quality of life
– Confidence
– Self-efficacy
– Community integration P
• Environmental cues
– Regulatory cues
– Non-regulatory cues
SOAP: ASSESSMENT
 Referral for Further Medical
Assessment (differential DX Phase 1)
• Identify symptoms suggesting an undiagnosed
medical condition
• Identify symptoms suggesting a medical
condition may be worsening
• Identify neurological manifestations that
suggest an acute or life-threatening crisis
– Vitals, observations
• Identify symptoms suggestive of occult
disorder or medication side effects
 PT Diagnosis (differential DX phase 2)
• How is it different than a medical diagnosis?
– Determine the cause of the patient’s functional problems (rate
limiting factors)
• motor capacity (could be neurological or other system)
• motor skill performance IFC Model
• participation restrictions
• Where did you observe a deficit in objective measurements?
– Try to think ICD 10 if possible
• Lack of coordination
• Abnormality of gait
• Dizziness/giddiness
• Ataxia
• Hemiplegia
• Diplegia
• Cognitive/communication deficit
• Muscular wasting & disuse
 Your Professional Opinion
• The therapy diagnosis confirmed by what….
– Pt. presents with….
• Patient will benefit from PT because…..
– To improve independence/function in said tasks
• What personal factors &/or health condition
specifics will impact patient progress/prognosis….
– Look at subjective and objective data
• Patient has good or excellent outcome to achieve
what long-term outcome…..
– Prognosis based on subjective/objective data, Dx, # of
therapy, home setup, family support, prior function
 Goals for this Episode of Care
• LTG’s
– Outcome by discharge from this level of care
– SMART goals
– Generally ‘activity/skill’ focused
• STG’s
– Outcome by next report period (varies per setting)
– SMART goals
– Can be mix of ‘activity/skill’ and ‘body
function/movement component’ goals
SOAP: PLAN
 What Are You Going to Do?
• Detail intervention plan for next report period
• Think in terms of CPT codes:
– Therapeutic exercise (97110)
• Strength, ROM, HEP
– Neuromuscular restoration (97112) inducing neuroplasticity
• Inhibiting tone, balance, gait pattern/quality, coordination
• Moving through motor learning process (early to late)
– Gait (97116) lowest paid CPT code from CMS
• Walking practice (CPG), without thinking about quality/pattern
– Home management (97535)
– Manual therapy (97140)
– Variety of codes for modalities
• State why each intervention will be used
• Frequency and duration of intervention
 It Should All Link Together
• Assessment 4 basic statements
– Patient has (PT diagnosis) abnormality of gait, lack of coordination, and
spastic hemiplegia
– Secondary to (motor capacity impairments)increased muscle tone and
spasticity, dysmetria, decreased active movement in the involved extremities,
decreased sensory awareness, and impaired equilibrium responses
– leading to (activity limitations & participation restrictions) significant
limitations in walking, transfers, functional balance, and ADL’s
– The patient should benefit from skilled PT and has excellent potential to reach
modified independent with all mobility skills but will require additional time
and feedback due to sensory deficit.
• Plan
– PT 2x/week for 4 weeks to work on; increasing active movements with
therapeutic exercises, improving equilibrium responses and coordination with
neuromuscular restoration, improving walking performance with gait training,
and improving sit to/from stand and floor transfer with home management
and ADL training.
 It Should be Supported by Objective
Measurements
• If you mention it in the assessment or plan it
should be measured and reported in the O
section of your note!!!!!
• If it’s not documented – you didn’t do it!
 Clinical Decision Making (complexity)

Complexity Components Low Moderate High

History No personal 1-2 personal > 3 personal;
factors &/or factors &/or factors &/or
comorbidities comorbidities comorbidities
Examination *1-2 functional *3 functional *>3 functional
impairments impairments impairments
Clinical presentation Stable Evolving Unstable
Face to face time 20 30 45
needed (minutes)
CPT code 97161 97162 97163

*Functional impairment = limitation in body structure/function, activity, &/or

participation per the ICF
What if the patient has low, moderate, or high in different categories: choose the
complexity that is the “lowest” 1 low and 2 moderate = Low complexity
 The patient is a 67 y.o. female
diagnosed with L CVA 3 months ago.
Documentation
– Assessment (Initial Evaluation)
• The patient presents with significant muscle weakness and
elevated tone in the right UE and right LE. The patient lacks
voluntary control and underlying ROM in the right LE resulting in
decreased walking speed below community levels, difficulty
maintaining standing dynamic balance and negotiating stairs. The
patient also exhibits poor strength and motor recovery in the right
UE limiting her ability to manipulate objects and perform dual
tasking. These limitations are preventing the patient from driving
independently, resume her occupation, performing ADLs , and
assisting with childcare. Pt. has good prognosis given Hx of CVA
and implementation of skilled PT x5wk for 4 wks to restore
function to premorbid condition for tasks and participation.
 Student Problem Solving
• Based on the assessment
– What objective measures data would you expect to
find: decreased strength, decreased ROM, poor to fair
balance, lack of “X”
– How would you expect the measurement to be
completed: MMT, myotomes, ROM, 10 meter walk test,
BBS, DGI, Modified Ausworth
– Is anything missing in the assessment? Outcome
prognosis/potential, skilled PT justification,
comorbidities (added on previous slide)
– Write out a plan:
• X2/wk for 4wk with “intervention TherX, NR, Gait, TherA” to
address “task restrictions” and “participation”
 Test-Related Factors: Type of Test
Performance-Based measure
• Therapist assessment of
performance
• Benefits:
– Used to establish baseline for
goals
• Limitations:
– One instant in time
– Equipment/time
– Generalizability
Self-Report measure
• Patient perceptions of
performance
• Benefits
– Adjunct to PBM
– Gain information on
performance when patient
unable to participate
– Patient’s perspective
• Limitations:
– Reliability of patient/tester
– Communication/cognition
 Test-Related Factors: Type of Test
Quantitative measure Qualitative measure
• Uses • Uses
– Provides objective data – Understand why a person is
regarding the degree to which dependent
a person can perform a – Insight into adaptability of
movement or task movement pattern
• Limitations • Limitations
– Does not explain how the – Subjective; observations may
patient performs the task vary
– Limited to one instant in time – Limited information defining
and specific environmental normal strategies
circumstances
 Test-Related Factors: Psychometric
Properties
Reliability • Consistency of a measure

• The extent to which an instrument

Validity measures what it intends to measure

Sensitivity/ • Measurement's ability to identify or

Specificity rule out a condition

• The capacity of a measure to detect

Responsiveness change
 Test-Related Factors: Psychometric
Properties - Interpretations of change
Minimal Detectable Change Minimal Clinically Important
(MDC) Difference (MCID)

• The smallest amount of • The smallest amount of

change that reflects a change perceived as
“true” difference beneficial by the patient
• Beyond measurement • Anchor-based
error • Considered “clinically
• Considered “reliable relevant”
change”
• Helps for goal writing
 Standardized Measures
Norm-referenced
– Normative sample: people
of same age who are
‘typically developing’ or
‘healthy’
– Score compared with
average performance of
normative sample
– Helps mark progress of pt.
with norm
• Healthy 50 yof can walk
“X” feet
Ipsative-referenced – performance is compared to previous performance
Criterion-referenced
– Assessment based on a cut-
score which relates to
expected behavior
(criterion)
– Not compared to ‘typically
developing’ or ‘healthy’
people
– Ex.) DGI: >19/24 Low fall
risk
 Norm-referenced
• Determine % or degree of
disability or impairment
• Establish medical
necessity for intervention
– Justification for skilled PT
in assessment
• Develop treatment goals
• Focus interventions
 Criterion -referenced
• Predict behavior
• Link patient performance
to functional limitation
across ICF domains
• Determine % or degree of
disability or impairment
• Establish medical
necessity for intervention
– Justification for skilled PT
in assessment
• Develop treatment goals
• Focus interventions
 Ipsative-referenced
• Track changes over time
• Justify interventions
• Develop and modify
treatment goals
• Focus interventions
• Motivate patients
Body Structure & Function: Active Movement, ROM, Somatosensation,
Coordination, Vision, Cognition, Affect

MEASURING INDIVIDUAL MOTOR

CAPACITY
MOTOR/ACTION SYSTEM
 Active Movement
• Ask patient to move through all planes x 4
extremities
– Antigravity strength
– Synergy movements
– Movement timing
– Movement speed
– Movement accuracy
• Observational, qualitative data
– Can be quantitative if movement measured with
goniometer
 What Does Active Movement Tell Us
• Voluntary movement against gravity (mobility)
– Functional activity limitations (skill)
• Synergy movements present
– Assess muscle tone
– MMT not valid with hypertonicity
• Movement timing, speed, & accuracy problems
– Further assess coordination
• Other important observations
– Be aware of what the trunk is doing during extremity
movements
• Observed movements may be limited by trunk
• Insights into stability & controlled mobility
 (P)ROM
• Passively move extremities through available
range measuring as needed
• Neuro tips
– UE don’t forget the scapula
– CVA shoulder screen for subluxation
• If subluxation is present do not raise >90 into FLX or ABD
– Remember 2 joint muscles
– Lower trunk and pelvis can easily become immobile in
poor alignment
– Motion limited by muscle tone does not necessarily
indicate joint limitation
 (P)ROM
• Try to decrease muscle tone
– Slow rhythmical rocking or rotation inhibitory
input
– Deep pressure to tendon inhibitory input
– Relaxed posture
• Put into posture that is more supportive, maybe its
supine
– Sustained WB inhibitory input
 Muscle Tone
• Spasticity
– Velocity dependent resistance to passive stretch
• Rigidity
– Resistance to passive stretch
• Cogwheel
• Lead pipe
 Modified Ashworth
• Place the patient in a supine position
• If testing a muscle that primarily flexes a joint,
place the joint in a maximally flexed position and
move to a position of maximal extension over
one second (count "one thousand one”)
• If testing a muscle that primarily extends a joint,
place the joint in a maximally extended position
and move to a position of maximal flexion over
one second (count "one thousand one”)
• Score based on the classification on next slide
Bohannon & Smith, 1987
 Modified Ashworth
• 0 = No increase in muscle tone from normal
• 1 = Slight increase in muscle tone, manifested by a catch
and release or by minimal resistance at the end of the
range of motion when the affected part(s) is moved in
flexion or extension
• 1+ = Slight increase in muscle tone, manifested by a catch,
followed by minimal resistance throughout the remainder
(less than half) of the ROM
• 2 = More marked increase in muscle tone through most of
the ROM, but affected part(s) easily moved
• 3 = Considerable increase in muscle tone, passive
movement difficult
• 4 = Affected part(s) rigid in flexion or extension

Bohannon & Smith, 1987

 Tardieu Scale
• 0 = No resistance throughout course of
passive movement
• 1 = slight resistance throughout the course of
passive movement, with no clear catch angle
• 2 = Clear catch at precise angle, interrupting
the passive movement, followed by release
• 3 = fatiguable clonus (<10 seconds)
• 4 = infatiguable clonus (>10 seconds)
 Tardieu Scale
• R2 = angle of full ROM at slow speed
• R1 = The angle of muscle reaction during
quick stretch
• R2 – R1 = “dynamic tone component”
 Coordination

• Components of
Coordinated movement
– Speed

– Distance
A B

– Direction

– Timing
 Coordination
• Types
– Intralimb
• Single limb movement
– Interlimb
• Integration of two or more limbs
– Visual motor
• Integration of visual and motor activities
– Have pt. close eyes with finger<>nose
• Eye-hand coordination
 Coordination
• Gross motor – body posture, balance,
extremity movements involving large muscle
groups
• Fine motor – movements involving small
muscle groups for skillful, controlled
manipulation of objects
Impairment Description Structure

Asynergy/Dyssynergia/Mvmt Loss of ability to associate muscles together for C-bellum

decomposotion complex movements; Mvmt performed with
component parts
Dysdiadochokinesia Impaired ability to perform rapid alternating C-bellum
movements

Dysmetria Inability to judge distance or range of C-belllum

(hyper/hypometria) movement

Ataxia Inability to regulate force, direction, speed , & C-bellum

accuracy of movements

Ataxic gait Ataxia during gait with wide BOS, postural C-bellum
instability, & high guard

Rebound phenomenon Inability to halt forceful mvmt after resistive C-bellum

stimulus removed

Athetosis Slow, involuntary, writhing, twisting, worm like BG

movements
Impairment Description Structure

Chorea Involuntary, rapid, irregular, jerky movements BG

involving multiple joints

Hemiballismus Large-amplitude sudden, violent, flailing BG

motions

Bradykinesia Decreased velocity and amplitude of BG

movements

Hyperkinesia Abnormally increased muscle activity to BG

movement

Hypokinesia Decreased motor response especially to a BG

stimulus

Dystonia Sustained involuntary contractions of agonists BG

and antagonists
 Assessing Coordination

• Observe
– Extraneous movements
– Awkward movements
– Inaccurate movements
– Excessively slow movements
– Inability to sequence motor activity
– Inability to integrate motor activities
 Assessing Coordination

• Non-equilibrium – address components of

limb movements

• Equilibrium – static & dynamic postural

control with gravity
 Non-Equilibrium Coordination Tests
Test Impairment

Finger –to -nose Dysdiadochokinesia, dysmetria, dyssynergy

Finger/toe – to – therapist’s finger Dysmetria, dyssynergy

Finger – to - finger Dysmetria, dyssynergy

Nose to therapist's finger Dysmetria, dyssynergy

Finger opposition Dyssnergy

Pronation/supination Dysdiadochokinesia
 Non-Equilibrium Coordination Tests
Test Impairment

Tapping hand; tapping foot Dysmetria

Drawing circle Dysmetria,

Pointing and past pointing Dysmetria

Alternate heel – to – toe; heel – to - knee Dyssnergy

Fixation or position holding Ataxia, tremor

Heel on shin Dysmetria

 Quantification of Non-equilibrium
Coordination Tests
• 4 = Normal performance
• 3 = Minimal Impairment: Able to accomplish activity;
slightly less than normal control, speed, and steadiness
• 2 = Moderate impairment: able to accomplish activity;
movements are slow, awkward , and unsteady
• 1 = Severe impairment: able only to initiate activity
without completion; movements are slow with
significant unsteadiness, oscillations, and/or
extraneous movement
• 0 = Activity impossible
 Coordination Testing
• Standardized instruments
(Fine Motor)
– Jebsen-Taylor Hand
function test
– Purdue Pegboard test
– Crawford small parts
dexterity test.
Balance – Equilibrium Coordination
• Postural Control
– Stability
– Controlled mobility
– Segmental mobility (active movement)
• Specific tests covered in balance lecture
SENSATION/PERCEPTION
 Somatosensation
• Always test/screen
– Light touch
– Localization
– Proprioception
• Add as needed
– 2 point discrimination
– Sharp/dull
– Stereognosis
 Somatosenation
• Tips
– Light touch stimuli should be light and brief
• If you do not get accurate responses can try longer and
heavier stimuli to determine absent vs. diminished
– Ask patient to tell you when and where your touch is
felt
• If you ask –”did you feel that?” you may get a false positive
on light touch
– Test proximal and distil to elbow and knee
– Try not to be predictable with touch sequence
– Test affected and unaffected extremities
 Somatosenation
• Tips
– It is okay to screen with eyes open touch to
bilateral extremities “Does this feel the same on
both sides?”
• Does not count as sensory testing
• Great way to build therapeutic rapport before touching
with eyes closed
– Proprioception
• Start distal and move proximal
• Stop when reach an intact joint
 Vision
• Acuity – Snellen Chart
• Tracking & smooth pursuit higher center
– Follow my finger or pencil
• Smooth saccades CN
– Look back and forth between my fingers or finger & nose
• Visual fixation
– Watch my finger/pencil – should be able to maintain focus
as you move the object nearer and further to patient
• Visual field
– Start behind patients ears and bring fingers forward. Ask
patient to tell you when they see your fingers.
 Visual Spatial Neglect
• Observation
– Ignores side of body
• Examination
– Copy simple drawing
– Read aloud
 Vestibular Screen
• Dynamic visual acuity: reading Snellen chart
during head rotations
• Slow VOR: slow head rotations with pt. looking at
fixed object
– Central: brainstem
• Fast VOR: fast head rotations with pt. looking at
fixed object
– Peripheral: otoliths dislodged
• Fukuda test: marching in place, look for veering
off of about ~30
COGNITION & EMOTION
 Cognition
• Screen during physical therapy evaluation
– Orientation
– Attention
– Memory
• Other deficits to observe
– Judgment
• Poor planning
• Impulsiveness
• Lack of insight
 Orientation

• Person

• Time

• Place
 Attention
• Ability to select and attend to specific stimuli while suppressing
extraneous stimuli

• Potential areas of deficit

– Sustained Attention - Prolonged attention to activity
– Measured by how long the patient can perform the task
– Counting backwards from 100 – (normal individuals can recall 5 backwards)
– Focused Attention – Sustain attention within distracting environment
– Measured by how long the patient can perform task while distractions are present
– Alternating Attention – Ability to transition from one task to the next/
moving between tasks
• Two step commands
• Add two numbers, subtract two numbers , add two numbers
– Divided Attention- Attend to more than one task at the same time.
– Perform two tasks simultaneously
– Walking and talking, Walks and looks for object on floor
 Memory
• Short-term – immediate recall
– Say 3 words and ask patient to repeat immediately
• Long-term – working
– Ask patient to repeat 3 words after some time has
passed and the patient has attended to a different
activity
• Remote
– Ask about personal history (make sure you know
the answer already)
 Standardized Cognition Screen
• Mini-Mental State Examination (MMSE)
• 11 simple questions or tasks grouped into 7 cognitive domains
– Orientation to time
– Orientation to place
– Registration of three words
– Attention and calculation
– Recall of 3 words
– Language
– Visual construction
 Standardized Cognition Screen
• Montreal Cognitive Assessment (MoCA)
• 12 simple questions or tasks grouped into 8 cognitive domains
– Visual spatial
– Executive function
– Naming
– Memory
– Attention
– Language
– Abstraction
– Orientation
 Cognitive Assessment
• MMSE
– Levels of impairment have been classified as: (Tombaugh & McIntyre
1992)
• None: score = 24-30
• Mild: score = 18-24
• Severe: score = 0-17
• MoCA
– Levels of impairment have been classified as: (Rosetti, 2011; Waldon-
Perrine & Axelrod, 2012)
• None: score 26-30
• Mild: score 23-26
• Severe: score 0-23
 Affect
• Screen for affect impairments during PT
evaluation as indicated
– Depression
– Anxiety
P641
Lab 2 Neurological Physical Therapy Examination

Primary Objective: Students will develop and demonstrate productive habits of a clinical physical
therapist in performing PT examination techniques.

Specific Objectives:
- Apply PT evaluation skills to a healthy normal classmate
- Apply PT evaluation skills to a classmate with a ‘role-played’ cognitive or communicative deficit
- Apply PT evaluation skills to a classmate with ‘role-played’ neurological motor control disorder
- Synthesize knowledge of neurological clinical symptoms to ‘role-play’ a cognitive or
communicative deficit
- Synthesize knowledge of neurological clinical symptoms to ‘role-play’ a neurological motor
control disorder
- Evaluate appropriate use of measurement tools
- Create an assessment and plan based on objective findings

Required Lab Activities:

- Practice BS/BF/Impairment screen on a classmate
- Review and answer questions on the rest of lab 1 worksheets

Activity 1: cognition & affect

Level of Alertness:
1. Alert – awake and attentive to normal levels of stimulation
2. Lethargic – general slowing of processing, appears drowsy and may fall asleep if not being
stimulated, open eyes briefly when questioned, attention will wander and lack focus
3. Obtundation – dull or blunted sensitivity, difficult to arouse and once aroused appears confused,
very slow responses, little interest in surroundings
4. Stupor – localized response to strong noxious stimuli
5. Coma – no response or generalized response to strong or noxious stimuli
Level of Orientation:
1. Person: What’s your name?
2. Time: What’s today?
3. Place: Where are we?
4. Why am I here
Memory:
1. Ask patient to remember 3 words
2. List 3 words (ball, table, & penny)
3. Ask patient to repeat back to you
4. Ask the patient to recall the 3 words 1-2 minutes later

Assess alertness during introduction and confirm by patient’s responses throughout examination. Screen
orientation early in the examination. Ask the patient “What’s your name?” “Where are we?” “What’s
the date?” & “Why are you here?” Also, screen memory early in the examination.

Document as Patient is (level of alertness) and oriented times (1-4 based on number of correct
responses to orientation questions)

This is a screen. If you identify impairment in orientation or memory, you may need to administer a
standardized test of cognitive function such as the MMSE or MoCA.

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Lab 2 Neurological Physical Therapy Examination

Affect:
Observe and make notes about the patient’s emotional responses throughout the examination
(laughing, crying, sadness, fear, anger, etc.) If you notice anything unusual, you may need to administer
a standardized screen for depression or anxiety.

PRACTICE
1. Your introduction including memory and orientation screen
Problem Solve:
How would you accommodate during the rest of the examination and subsequent treatment sessions if
you discover a memory or orientation deficit?

Use simple explanations on what I’m about to do and give the pt. extra time to process that
information. I’ll be sure to repeat what I’m doing and why I’m doing it. With Tx, I’ll focus less on the
pt. restoration and more on compensation since the pt. is less likely to remember principles that are
needed to make meaningful gains.

Activity 2: Sensory Awareness Screen

1. Light touch – Ask patient to close eyes or block vision and instruct patient to tell you when the
touch is perceived. Can use finger-tip or cotton ball. Screen all 4 extremities in proximal & distil
locations.
2. Localization – Ask patient to close eyes or block vision and instruct patient to tell you where the
touch is perceived. Can use finger-tip or cotton ball. Screen all 4 extremities in proximal & distil
locations.
3. Proprioception – Ask patient to close eyes or block vision and instruct patient to describe limb
position or move opposite limb to match. Grasp patient’s body part with as small as surface area
as possible and move joints. Start with distil components first (fingers and toes) and move
proximal until a joint with no errors or impairments noted. Screen all 4 extremities.

PRACTICE
1. A sensory awareness screen on a classmate. Try to mix up the role play with ‘normal’ and a
cognitive or communicative deficit.
Problem Solve:
How would you adjust a sensory screen for a patient with a cognitive or communicative deficit?

Be sure to explain what you are doing and why you are doing it multiple times. Simple yes or no
answers to my questions (close ended) should be used for cognitive and communication deficits. I’ll
need to build a sense of trust with the patient first if I’m going to have them close their eyes while I
perform the rest of my sensory examination.

How would you accommodate your intervention strategy if you identified a sensory awareness deficit?

If I find a sensory issue, and there are active LOB deficits, I’ll incorporate balance training into my POC.
Intervention strategies will consist of uneven surface practice, EC, segmental mobility with less
reliance on dual limb support. Education on consistently checking feet for wounds should also be
incorporated as well as changing posture routinely.

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Lab 2 Neurological Physical Therapy Examination

Which health conditions are likely to cause sensory awareness deficits? Stroke, diabetic neuropathy,
MS, PD, amputees, PVD,

What are some other sensory awareness modalities that could be tested if relevant?

Two point discrimination using microfilament, pain reception, mCTSIB, stability test, Romberg

Activity 3: Visual Screen

1. Acuity – screen with eye chart

2. Smooth pursuit (tracking) – Instruct patient to hold head stationary and follow finger or tip of
pencil with eyes only. Keep finger or pencil tip ~18 inches from face and move in all directions
including diagonal. Patient’s eyes should follow smoothly with no loss of object.
3. Saccades - Instruct patient to hold head stationary and switch gaze between 2 objects. Perform
on the right & left sides in vertical & horizontal directions and at varying depths. Keep objects ~
18 inches from face. Patient’s eyes should move smoothly from target to target without
overshooting or undershooting.
4. Visual field – Instruct patient to hold head stationary and keep eyes forward. Ask patient to
report when visual stimuli are first noticed. Present visual stimuli on the lateral side of the head
in a posterior – anterior direction.

PRACTICE:
2. A visual screen on a classmate. Try to mix up the role play with ‘normal’ and a cognitive or
communicative deficit.
1. Problem Solve:
Describe how a visual deficit might impact activity level function. We rely heavily on vision, especially
the elderly and many with vascular diseases that cause ischemia of nerve ending in distil extremities.
A vision deficit significantly impacts activity function and will likely cause less participation in said
activity if vision is not corrected.

Which pathologies are likely to cause visual deficits? MS, stroke, homonymous hemianopsia, visual
agnosia

Activity 4: Vestibular Screen

1. Dynamic visual acuity – instruct patient to read eye chart while head is moving at 2 Hz (2
cycles/second). A drop of 3 or more lines is indicative of a peripheral vestibular lesion
2. Slow VOR – Tilt patient’s head to 30° flexion and instruct patient to focus on therapist’s nose
while the therapist rotates the patient’s head slowly (1 Hz). Patient’s eyes should remain fixed
on therapist’s nose. A deficit is indicative of a central lesion
3. Fast VOR - Tilt patient’s head to 30° flexion and instruct patient to focus on therapist’s nose
while the therapist rotates the patient’s head quickly (> 2 Hz). Patient’s eyes should remain fixed
on therapist’s nose. A deficit is indicative of a peripheral lesion
4. Fukuda Step Test – blind fold patient and instruct the patient to hold UE with shoulders at 90°
flexion and march in place for 50 cycles. Rotation deviations greater than 30° are abnormal and
indicative of a central lesion.

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Lab 2 Neurological Physical Therapy Examination

PRACTICE:
3. A vestibular screen on a classmate. Try to mix up the role play with ‘normal’ and a cognitive or
communicative deficit.
1. Problem Solve:
Which neurological structures would contribute to vestibular lesions of a peripheral origin and which
ones from a central origin?

Peripheral: otolith dislodged in semicircular canal, CN VIII tract lesion

Origin: Medulla lesion (PICA stroke), other BS lesions

Compare and contrast your overall strategy for managing a peripheral versus a central vestibular
impairment.

Peripheral: corrective techniques such as Dix Hallpike, time, avoid head turns until symptoms
corrected

Central: Saccade training, focus training (random practice with other Tx), EC & uneven surface  force
vestibular reliance, head turns while focusing (can do during rest breaks from walking, during walking
if appropriate)

Activity 5: Muscle Function Screen

1. Active movement – Ask patients to move extremities in all planes and observe degree of
movement, quality of movement, & stability during extremity movements. You also need to
observe symmetry of movement and presence/absence of synergistic movement patterns.
2. Passive movement/Muscle tone – Passively move and measure ROM of joints where
observation of active movement suggests a functional limitation. Passive movements must also
be performed to assess muscle tone. Move each joint through normal movements noting any
resistance to passive stretch. IF you notice resistance to passive stretch, you need to move the
extremity quickly to determine if the resistance changes with quick movements.
3. Use Modified Ashworth or Tardieu as indicated to quantify muscle tone impairments.

PRACTICE:
1. A muscle function screen on a classmate. Try to mix up the role play with ‘normal’ and a
hypertonicity role play.

Problem Solve:
Describe the following muscle tone abnormalities:
A. Flaccid: No resistance to PROM, no active tone needed for ROM or gross/fine movement
B. Hypotonic: reduced tone, poor stability, high fall risk, limited ROM, limited activity
involvement
C. Hypertonic: increased tone, high fall risk, poor ROM, contractures likely, limited task
involvement

A therapist documents in a patient chart the following description of active movement. “The patient
demonstrates left UE movements ~50% of normal range in a flexion synergy pattern.” How do you
interpret this statement? Be prepared to demonstrate what this might look like.

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Lab 2 Neurological Physical Therapy Examination

Pt. likely cannot perform overhead activities with UE due to contraction of muscles (synergy)
preventing full ROM. Manipulation, reaching, and grasping all limited due to inability to recruit ROM
needed from flexor synergy.

A patient demonstrates the pictured movement when asked to flex the hip in a short sitting position.

How would you document the active movement of the right LE?

Pt’s presents with R. LE flexor synergy hypertonicity that is automatically coupled with voluntary hip
flexion.

Describe all motor control task components that may be impaired based on the movement pattern
demonstrated.

Gait, sit<>stand, transfers, quiet stance, ADL’s (donning on and off pants)

Based on this motor behavior, what body functions in addition to active movement, should also be
assessed and why?

Tone (changes over time, worsening of tone), coordination (needed for many tasks)

How do you expect abnormally high muscle tone to react to physiological stress? Not good, we tend to
tense up or become stiffer with stress and anxiety.

When and how should you perform a MMT with a patient with a primary neurological pathology?

MMT is contraindicated for those with hypertonicity. MMT should only be used with normal tone,
flaccid limbs, and hypotonicity. Look at functional strength instead, against gravity.

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Lab 2 Neurological Physical Therapy Examination

Activity 6: Coordination Screen

1. Non-equilibrium coordination – test fine and gross motor components of limb control to
determine the presence of dysmetria, dysynergy, or dysdiadochokinesia.

PRACTICE:
1. A coordination screen on a classmate. Try to mix up the role play with ‘normal’ and a cerebellar
lesion.

Problem Solve:
Which neurological structures contribute to non-equilibrium coordination? Spinocerebellar and
cerebellopontine tracts

Activity 7: Bed Mobility & Transfers & Gait

What to Evaluate
Transfers Bed Mobility
Sit to/from stand Rolling S/P
Sit/squat pivot transfer Rolling S/L
Stand pivot transfer Rolling S/R
Car transfer Scooting L
Floor transfer Scooting R
Scooting U
Scooting D
Sit to/from supine

How to Evaluate
Name the activity/skill
Determine assistance level Postural control components - what is missing in
- Independent the patient’s performance
- Modified independent - Stability
- Supervision - Controlled mobility
- Stand-by assistance - Mobility (segmental)
- Contact guard/touch assist
- Minimal assist Biomechanical assessment
- Moderate assist - Observe and describe movement pattern
- Maximal assist - Gait deviations
- Dependent

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Lab 2 Neurological Physical Therapy Examination
Independent
- Patient is able to consistently perform skill safely without environmental compensation
(orthotic, AD, etc), with no one present, and with no safety concerns
Modified Independent
- Patient can consistently perform skill safely with no one present but with environmental
compensation such as orthotic, AD, increased time etc.
Supervision
- Patient requires someone within line of sight supervision as a precaution to provide occasional
verbal cues: low probability of a patient requiring assistance
Stand-by assistance
- Patient requires within arm’s reach assistance. Therapist positioned to assist if needed, hands
raised but not touching, full attention on patient, fair probability of patient requiring assistance
Contact guard/touch assist
- Patient requires hands on steadying assistance but no physical assistance. Therapist is
positioned close to patient with hands on patient; high probability of patient requiring
assistance
Minimal assistance
- Patient requires 25% physical assistance to complete the activity. Therapist is positioned close to
patient and providing 25% physical assistance with activity
Moderate assistance
- Patient requires 26% - 50% physical assistance to complete the activity. Therapist is positioned
close to patient and providing >25% up to 50% physical assistance to complete the activity
Maximal assistance
- Patient requires 51% - 75% physical assistance to complete the activity. Therapist is positioned
close to the patient and providing >50% up to 75% physical assistance to complete the activity
Dependent
- Patient requires > 75% physical assistance to complete the activity. Therapists is positioned close
to patient providing >75% physical assistance to complete the activity

Bed Mobility
1. Position for safety
2. Ask the patient to demonstrate the skill
3. Augment patient’s efforts with verbal feedback and physical guidance to complete the
task

Scooting in Bed
- Lateral scoot (left or right) 1) bend knees and place feet on bed/mat in hooklying
position; 2) push through feet and lift buttocks in the air; 3) shift buttocks to left or right
in the air; 4) lower buttocks back to mat/bed surface; 5) perform chin tuck and crunch;
6) move upper trunk left or right while in chin tuck crunch position; 7) lower head and
shoulder blades back to mat/bed surface
- Upward scoot 1) bend knees and place feet on bed or mat in hooklying position; 2) push
through feet and lift buttocks in the air; 3) exaggerate lower trunk extension; 4)
maintain exaggerated lower trunk extension while lowering buttocks back to mat/bed;
5) perform chin tuck with partial sit-up and allow exaggerated trunk extension to correct
or stretch out; 6) lower back to bed/mat with normal alignment

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Lab 2 Neurological Physical Therapy Examination

- Downward scoot 1) bend knees to ~ 30° with feet on mat/bed; 2) lift buttocks just off
the mat; 3) Pull with legs while feet planted and push with arms on bed surface to move
body towards feet

Is this a simple or complex movement pattern and why?

Depends �, simple to those without cognitive/motor planning or pattern defects but

difficult for those with.

What are the postural control components (stability, mobility, controlled mobility)?

Stability: bridge when stopping at top of lift, glute contraction throughout, isometric chin
tuck
Controlled Mobility: weight shift to move pelvis A, P, L, R
Segmental Mobility: Bending knees and ankle for hooklying position, lifting bottom, lowering
bottom, moving torso/shoulders

If you have a low functioning patient how much time are you going to spend asking the patient
to perform this task during an evaluation and why?

I would say up to 3 attempts, then intervene with TC’s. The purpose of the eval is to let the
pt. do as much as they can without your help. But your intervention is needed at some point
to move the eval along.

If you don’t spend much time allowing the patient to scoot in bed, how will you change the bed
position if needed?

HOB tilted down to allow gravity assistance for scooting up in bed, inflate if able (return to
setting after scoot) so pt. can bear weight easier

Rolling
Acute pathology – At least look at supine to sidelying both directions and others as time allows.
Chronic pathology – Look at all supine to sidelying both directions; supine to and from prone

Which direction is easier with supine to sidelying and why?

Dependent on condition, if a hemi on R., rolling to R. will be easier to allow L arm and leg to
assist with momentum. Also depends on how pt. normally gets out of bed at home.

What is the ‘normal’ rolling pattern? (fill-in observation table) Either arm or leg initiation, with
pt. using L. or R. side to roll using momentum and gravity.

How do I decide what is ‘normal’ for my patient? Ask them what they do at home!

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Lab 2 Neurological Physical Therapy Examination

Supine to Sit
- Stable in sidelying
- Move legs over edge of mat
- Move trunk lateral out of gravity with trunk and UE mobility (assist with pt. pronation of
forearm to assist with tricep extension if needed)
- Stable in short sitting

Where do you provide physical guidance (more than one correct answer)? At legs when lowering off
EOB, at trunk to get into sitting, at forearm to assist with arm extension, at head to stabilize.

How do you manage your own body mechanics for someone who is max assist with this motor skill?
Make bed height at the right level so you can maintain a lordotic lumbar curve. Move patient as close
to your body so your not reaching, wide BOS, raise HOB to 90 degrees, have pt. use bed rails. If pt. is
max assist or is mod assist being overweight, dizzy, etc get a second person!

Practice supine to sit with a classmate. Problem solve where you can provide physical guidance and
how you will manage your body mechanics with your classmate role playing no more than touch/CGA.
Once you feel comfortable with your handling and body mechanics – ask an instructor to come and
watch and proceed to practicing with your class mate role playing more impairment after the
instructor tells you you’re ready.

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Lab 2 Neurological Physical Therapy Examination

Transfers
Static short sitting is the starting point for transfers & you need to know what the ‘stability
holes’ are before you transfer for the first time!!!! This is a good place to do a quick screen of
sitting stability and controlled mobility.

Lower extremities provide the power for transfers & you need to know what the ‘antigravity
mobility holes’ are before you transfer for the first time!!!! If you haven’t done a LE active
movement screen yet, this is a good place to do one.

Sensory awareness & cognition deficits can degrade transfer performance even without sitting
stability and LE mobility holes!!!!

Safety precaution recommendations

- Anticipate dependent or maximal assist transfer – get a 2nd person

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Lab 2 Neurological Physical Therapy Examination

- Anticipate moderate assist transfer with challenging circumstances ie transfer to high

surface, heavy person, pass out/dizzy risk etc. get a 2nd person

Basic Transfer Components

Sit/squat pivot transfer
1. Short sitting stability
2. Trunk & hip flexion mobility
3. Anterior weight shift (controlled
mobility)
4. Lift off of buttocks (LE mobility & trunk
stability)
5. Lateral weight shift (squatting
controlled mobility)
6. Lower buttocks to support surface (LE
mobility)
7. Returning to upright posture (trunk
mobility)
8. Short sitting stability
Stand pivot transfer
1. Short sitting stability
2. Trunk and hip flexion mobility
3. Anterior weight shift (controlled
mobility)
4. Lift off of buttocks (LE mobility & trunk
stability)
5. Unfolding to full stand (LE & trunk
mobility) [for sit to stand transfer
you’re done]
6. Lateral weight shift to one foot
(controlled mobility)
7. Lift and turn unweighted foot
(Mobility)
8. Items 6 & 7 in opposite direction
9. Continue 6-8 until directly in front of
surface
10. Knee flexion (mobility)
11. Hip & trunk flexion (mobility)
12. Folding down into flexion until
buttocks back on support surface
(trunk & LE mobility)
13. Return to upright posture (trunk
mobility)
14. Short sitting stability

Which transfer is the most typical functional transfer used in the normal population? Squat
pivot transfer, we rarely get into full hip extension and upright trunk when moving from one
close seat to another.

Which direction should you transfer for your first transfer with a patient? Noninvolved side.

Key points of control

- Knees – prevent buckling and assist with extension mobility
- Hips/pelvis – midline alignment, hip extension mobility, lateral weight shift
- Trunk – upright or supported

If your patient is sitting on the edge of the mat or bed and the feet are planted firmly on the
ground with the knees blocked so the femurs cannot translate forward and the trunk is in

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Lab 2 Neurological Physical Therapy Examination

upright or slightly flexed posture so the COG is within the BOS which consists of the buttocks,
thighs on the mat, and feet –the patient is protected from sliding forward onto the floor.

Safety points for your mechanics

- Squat to the patient’s level
- Block knees
- Keep patient’s trunk forward
- Maintain appropriate spine curves in yourself
- Use natural momentum
- If need more than natural momentum with good body mechanics – GET HELP

Dependent transfer
- Patient’s trunk forward with head resting on your shoulder or looking over your
shoulder opposite the direction of the transfer OR
- Patient flexed all the way forward with trunk resting on your hip opposite the direction
of the transfer
- Knees blocked
- Rock back
- Lift from gait belt or hips
Max assist transfer
- Patient’s trunk forward with head resting on your shoulder or looking over your
shoulder opposite the direction of the transfer
- Knees blocked
- Rock back
- Lift from gait belt or hips
Mod assist transfer
- Patient’s trunk forward with head looking over your shoulder opposite the direction of
the transfer
- Knees blocked
- Rock back
- Lift from gait belt or hips
Min assist transfer
- Patient’s trunk forward with head looking straight forward
- Knees blocked – if needed OR
- Provide a boundary for the knee as a precaution OR
- Maintain contact with the quad muscle to facilitate as needed
- Weight shift with the patient
- Lift from gait belt or hips OR
- Provide directional cue from trunk without lift

Practice set-up and mechanics of dependent, max, & mod assist transfer with a classmate. If
you are not sure about your mechanics for these transfers find an instructor.

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Lab 2 Neurological Physical Therapy Examination

Practice at least 3 minimal assist transfers each with different handling points and problem
solve the types of motor control problems for which you might use each handling point.

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Lab 2 Neurological Physical Therapy Examination

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Lab 2 Neurological Physical Therapy Examination

Walking begins from stable quiet stance. The starting point for examining walking is an assessment of
standing balance.

In Quiet standing:
How is the patient’s stability (static balance)?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

How is the patient’s controlled mobility (simple dynamic balance)?

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

What other standing positions might be informative to gait?

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Should I go to ll bars for walking or not?

_____________________________________________________________________________________
_____________________________________________________________________________________

When should I not walk on the evaluation?

_____________________________________________________________________________________
_____________________________________________________________________________________

Always ask yourself – can I handle the patient’s body weight and facilitate LE extension with the
physical help and clinic equipment that is available to me.

Low Level Walking (moderate or maximal assistance)

Safety first:
- Position self to be able to maintain hip & knee extension or block a quick decent into gravity
o Front – knee block(1 or 2), hips handling into extension
o Back – support anterior/lateral trunk, posterior hip block, immediately behind patient to
mimic knee flexion if needed
o Side – 1 knee block, lateral pelvis block, anterior/posterior trunk support, chair
immediately behind
Points of Control
- Stance
o Ankle – block inversion, inhibit exaggerated plantarflexion, facilitate tibial translation
(dorsiflexion)
o Knee – block knee buckle, inhibit knee hyperextension
o Hip/pelvis- assist/facilitate hip extension, block exaggerated lateral weight, facilitate
more lateral weight shift if inadequate
o Trunk – facilitate/support upright posture

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Lab 2 Neurological Physical Therapy Examination

- Swing
o Ankle – inhibit foot drag and ankle inversion (foot scoot is ok), assist with knee extension
terminal swing
o Knee – facilitate/assist knee flexion
o Hip/pelvis – facilitate ‘pelvic release’ and hip flexion, correct weight shift if needed
o Trunk – facilitate/support upright control

Spend some time with at least 2 partners with different height and build:
1. Practice the key safety points of control from all 3 positions (front, back and side).
Which position is easiest/hardest? Does it matter which partner you’re working with?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Practice with a partner each phase of gait by itself using all points of control listed above (you
may not be able to do them all at once – that’s ok).
3. Once you’ve practiced each phase separately now put it together in 1 full stride.
4. Finally – add an assistive device and practice the key points of control while instructing in the
appropriate gait sequence for the device.
Which point of control was easiest/hardest? Which phase of gait was easiest/hardest?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Higher level walking (minimal assist or better)

Focus shifts more to gait pattern and maximizing efficiency and function
- Use same key points of control as needed
- Observe gait without assistive device
- Which assistive device (if needed for safety)
o Least restrictive without bumping up assistance level
- Orthotics?
o Try to avoid for evaluation
o Use ace wrap or bungee cord to block PF during swing
o Use augmented verbal feedback or physical guidance for knee control issues
- Mobility issues during swing
o Use augmented verbal feedback or physical guidance as needed
Spend some time with a partner:
1. Set up and practice the 10MWT and 6MWT if you have not administered them before
a. Practice giving instructions as you would to a patient
b. Use a gait belt
c. Check vitals first
2. Practice minimal assist walking assessment with a partner role playing 1) hemiparesis and 2)
ataxia
a. Start at standing stability assessment
b. Use a gait belt
c. Do one assessment with an AD and one without
What position did you choose for assessing minimal assist gait & why?
_____________________________________________________________________________________

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Lab 2 Neurological Physical Therapy Examination

_____________________________________________________________________________________
_____________________________________________________________________________________

Which parts of the assessment from previous labs are most important for informing how you will assess
gait & why?

Balance, available ROM, core stability, synergies, posture

Activity 8: Differential Diagnosis

1. Differential DX phase 1 – determine need for referral for further medical assessment
a. SX suggesting undiagnosed medical condition
b. SX suggesting a worsening of a medical condition
c. SX that suggest an acute or life threatening crisis
d. SX suggestive of occult disorder or medication side effects
2. Differential DX phase 2 – determine PT diagnosis
a. Determine cause of functional problems
b. Name therapy problem (think ICD 10)

PRACTICE & Problem Solve:

Read the following case studies and answer the questions.

1) Mr. S had a CVA 6 months ago with resulting left hemiplegia. At the time of discharge from rehab, he
was deemed independent with gait and transfers (FIM 6) as well as with most ADLs. The patient had
residual Left UE weakness and motor coordination deficits. He returned to outpatient therapy 2 months
later with complaints of diminished functional skills. Mr. S states he has been less active and just needs
some help regaining his motor function. History reveals: dull, deep aching sensation in the lower lumbar
spine and right buttock. He assumes it has developed because of inactivity and compensation with
movement on the right. Other complaints with history include constant deep ache in the right shoulder
that he relates to increase use of this right arm to compensate for the left sided weakness. Examination
findings reveal these symptoms do not vary with active or passive ROM, resistance testing, or postural
holding. Overall ROM is WFL with appropriate motor activity.

1. What do you think about the patient’s reported signs and symptoms? The compensatory
strategy of the R. side has caused overuse injury and LBP that radiates to the buttocks, likely
due to poor body mechanics relying on R. UE & LE.
2. What additional information would you want to know? What relieves the pain? What
aggravates the pain? Does it wake you up at night?
3. Does this patient need referral? Yes, ROM and MMT, as well as postural stability testing did
not change symptoms. Likely not a mechanical issue.

17
P641
Lab 2 Neurological Physical Therapy Examination

2) A 55 y/o elementary school teacher was referred with a diagnosis of cervical degenerative disk
disease at C5-6 and C6-7. Her chief complaint was poster cervical aching and a sense of neck weakness.
Functionally, the patient’s primary concern was her increased difficulty with making it through her
workday. She teaches first-grade students, so much of her workday is spent with her neck and trunk in
forward flexed position. The patient stated this persistent flexed posturing is a significant factor for the
worsening of her symptoms. She also noted that rest and lying down decreases her pain. She does take
over the counter medications for pain. She also noted that she has been experiencing tremor in her
right hand. She reports the tremor started 4 to 5 months ago and is persistent at rest, she did not report
it to her physician.
1. What additional information would you consider? Is it better in the morning? Questions for
tremor do you drink, any family history of PD?
2. Does this patient need referral? Yes, tremor is not usually a sign of nerve root compression,
possible early onset PD.
3. How would you proceed? Educate of sitting posture to relieve forward head and kypholordotic
posture. Provide TherX to treat neck pain. Keep tremors in mind as you wait for MRI from
physician.

18
PT Examination of Balance

PT641 Neurorehabilitation 1
Indiana University Physical Therapy Program
Spring 2021
Kristine K. Miller, PT, PhD
 Big Picture
Postural control – controlling the body’s
position in space for the dual purposes
of stability and orientation.
 Postural Control
• Requirements of postural
control
– integration of sensory
information to assess the
position and motion of the body
in space

– ability to activate motor

components to control body
position
 Sensory Organization
• Visual input
– Central visual information
• Relationship to vertical
horizon
• Detects image shift on retina
– Peripheral
• Motion sensitive
 Sensory Organization
• Visual efficiency
– Dependent upon
• Visual acuity
• Visual contrast
• Object distance
– Best when object distance is within
2m (Brandt 1986)
• Room illumination
– Evidence suggests that when the horizon is
manipulated so that vision and vestibular
systems are mutually contradictory, elderly
individuals rely on visual cues
(Pykko, 1988)
 Sensory Organization
• Somatosensory
– Position and motion of body
– Segment relationships
– Types of somatosensory
receptors
• Muscles
• Joints
• Tendons
• Cutaneous receptors
 Sensory Organization
• Somatosensory
– Essential inputs for quiet
stance
• Ankle/foot
– Key muscle groups
– Joint receptors
– Pressure sensors on the feet
• Neck muscles
– Provide information concerning
head movement and
relationship to trunk
» Postural orientation
 Sensory Organization
• Vestibular inputs
– Position and movement of
head with respect to
gravity
– Angular & linear
acceleration of the head
– Organs responsible
• Otoliths: linear
• Semicircular canals:
rotational
– Not as active under quiet
stance
 Sensory Organization
• Vestibular inputs
– Otoliths
• Velocity changes of body
• Head righting
– VSR
• Activates muscles of
postural control
– MVST = cervical muscles
– LVST = Trunk and proximal
limbs
• Integration of head and eye
movements
– Quick adjustments
– Don’t confuse with VOR
 Sensory Organization
• Vestibular inputs
– Semicircular Canals
• Velocity changes during
head movement
• .2 to 10Hz
• Active at the
beginning(acceleration) and
end of movement
(deceleration)
– VOR
• Stabilizes vision by
controlling eye movements
during head motion
 Sensory Organization
• Integration of
sensory input
– Visual
– Somatosensory
– Vestibular

• Frame of reference
for maintaining
COG safely within
the BOS
Dynamic Equilibrium

Postural Stability
 Sensory Conflict

• Disagreement
– Three senses
– Right vs. Left

• Resolution
– accurate vs.
inaccurate

FALLS
 Motor Output
• Reflexes

• Automatic postural responses

– 4 strategies: ankle, hip, stepping, stooping to prevent
falls

• Overlearned motor patterns

• Adaptive motor behavior use information from

feedback to make appropriate response
 Postural Control/Balance: Individual
Motor Capacity or BS & Function
• Motor output • Sensory function
– Strength, ROM, active – Vision
movement/segmental mobility – Somatosensation
– Trunk control stability, controlled – Vestibular
mobility
– Stability (sitting & standing)
• Sensory organization
• Midline & upright orientation – Neurocom
• Maintain or right with perturbation • SOT
• Neurocom WB squat • Motor Adaptation
• Limits of Stability
– Controlled Mobility (sitting & standing)
• Weight shifting (controlled movement – Romberg/sharpened Romberg
of COG within BOS) • Teases out somatosensation problem
• Dynamic trunk – Modified CTSIB
• Neurocom LOS
– Mobility
• Active movement esp. trunk & LE
• Trunk Impairment Scale
– Automatic postural responses
• Neurocom motor adaptation
– Evidence of learning
– Isolated vs. mass movement patterns
 Postural Control/Balance: MC Task or
Activity
Activity Balance Tests
• Functional Reach
• Multidirectional functional
reach
• Berg Balance Scale (BBS)
• Performance-Oriented
Mobility Assessment (POMA)
• Dynamic Gait Index
• FGA
• TUG
• FAB
• Stops Walking While Talking
Test
Motor Tasks
• Skill
– Reaching in sitting/standing
– Tandem walking
– Side stepping
– Braiding
– Kicking a ball
– Catching/batting a ball
– Swinging a bat/club/paddle
– Any individual item on
functional balance scales
• Quiet Standing (time)
• Quiet Sitting (time)
MEASURING BALANCE: BODY
STRUCTURE & FUNCTION
Sitting Balance: Motor Capacity/Output
– Trunk Impairment Scale (TIS)
• Developed for people with stroke
• Tested in CP, MS, PD, TBI
– Domains
• Static sitting (0-7)
• Dynamic sitting (0-10)
• Coordination (0-6)
• Total (0-23)
– Healthy adults - median score = 23
– Chronic stroke
• Median total = 11
• Median static = 6
• Median dynamic = 3
• Median coordination = 2
• Median total (ambulatory) = 14
• Median total (non-ambulatory) = 8
 Sitting Balance: Motor Capacity/Output

• Trunk Impairment Scale (con’t)

– Referencing
• Data early – if trends hold
– Normative reference = 23
– Criterion reference ambulatory vs. non-ambulatory
somewhere between 8-14
– APTA EDGE recommendations
• Stroke – recommended
• MS – recommended except EDSS 0.0-3.5
• TBI – reasonable to use but limited study in target
group
 Standing Stability
• Romberg
– Considered a test of dorsal column function
• Patient stands with feet close together with eyes open
– Eyes closed
– Sharpened Romberg
• Patient stands with feet in tandem with eyes open
– Eyes closed
– Time 30 seconds in each position
– Arms across chest
• Stop if arms reach out or PT puts hand on pt.
– Positive Romberg
• Fall
• Use protective step or reach to maintain balance
 Standing Stability
• Quiet standing
– Feet shoulder width apart, arms at side
• Somatosensation primary sensory input during quiet
standing
– Stability
• Postural alignment
• Midline orientation
• Postural maintenance
– Add controlled mobility
• Weight shifting A,P,L,R, AL, AR, PL, PR
 Standing Stability
• Unilateral stance
– Each leg
– Timed
– 30 seconds
– EO & EC
• Tandem stance
– Each leg in front
– Timed
– 30 seconds
– EO & EC
• May have already been tested as part of another
balance assessment.
 Sensory Organization
• Modified Clinical Test of Sensory Interaction & Balance
(CTSIB)
– Arms crossed over chest
– 4 conditions
• Firm EO: fall indicates mix problem, continue with test to pinpoint
• Firm EC: fall indicates somatosensation problem
• Foam EO: fall indicates vision problem
• Foam EC: fall indicates vestibular problem
– Each position for 30 seconds
• Time stops if arms or legs change position (protective reach or step)
• 30 seconds on first trial go to next condition
• < 30 seconds on first trial complete 2 more trials and average for time
on that condition
– Tells you that the system is able to learn potential for motor learning
 Sensory Organization
Modified CTSIB (con’t):
populations tested
• Alzheimer disease
• Post-concussion (athletes)
• Whiplash
• Older adults
• Parkinson disease
• Peripheral neuropathy
• Spinal cord injury
• Stroke
• Traumatic brain injury
• Vestibular disorders
Modified CTSIB (con’t):
referencing/interpretation
• Norm – scores <30 =
decreased efficiency in
equilibrium responses
• Criterion
– Condition1 (<30) – increased
fall risk in a variety of settings
– Condition 2 (<27) – increased
fall risk in dark or low light
areas
– Condition 3 (<26) – increased
fall risk on compliant surfaces
– Condition 4 (<20) – increased
fall risk with head movements
or visual conflict
 Sensory Organization
• Sensory Organization test (SOT)
– Allows for quantitative assessment of each sensory
system and sensory combinations
– Stability
– Assessment of the three different systems that
contribute to balance control
• Visual
• Vestibular
• Somatosensory
– Integrative test
• Looks at each system
 Sensory Organization Test
Six different testing
1 
conditions.
Each condition is designed
2

to challenge a different

?
combination of the parts of
3 the balance equation.

4 ?
5 ?
6 ? ?
 Standing: Dynamic Stability
• Adaptation test
– Assesses an individuals automatic postural response to change in
surface orientation
• Uneven surface
– Test protocol
• Repeated exposure to forward and backward tilted surface
 Adaptation Test
Magnitude of the force response
to control sway
• Outcomes
– Measurement of
amount of force
needed to offset sway
response
– Measurement of the
amount of increased
control as it relates to
learning with
subsequent trials
 Adaptation Test
• Functional Implications
– Abnormal performance would indicate an increased
chance for loss of balance when encountering irregular
surfaces, inclines, or declines
– The inability to respond appropriately is often related to
two things
• Limited neuromuscular response
• Ankle ROM limitations and weakness
 Standing Controlled Mobility
• Limits of Stability (LOS)
– Maximal limit of an area of space in which the body can
maintain its position without changing the base of
support.
 Limits of Stability
• Computer assessment
– Measurement of limits of
stability
• Measurements 12
– Anterior/Posterior
• 12 degrees 16

– Lateral direction
• 16 degrees
 Limits of Stability
• Limits of Stability
Testing
– Output
• Directional control
• Endpoint excursion
– How far they got and
was maintained
• Maximum excursion
– How far they got
• Movement velocity
• Reaction time
 Limits of Stability
• Limits of Stability Testing
– Output
• Directional control
• Endpoint excursion Dynamic Motor Capacity
• Maximum excursion
• Movement velocity
• Reaction time
 Standing: Dynamic Stability
• WB Squat
– Stand on platform at (4)
knee angles
• Full extension
• 30° flexion
• 60° flexion
• 90° flexion
– Platform measures WB
symmetry reported as
%body weight on each
foot
MEASURING BALANCE: ACTIVITY
 Standing Balance
• Functional reach
– Populations tested
• Older adults
• Parkinson disease
• Peripheral vestibular disorders
• Spinal cord injury
• Stroke
• Vestibular disorders
– APTA EDGE Recommendations
• Stroke – highly recommended
• MS – recommended with EDSS 0.0 – 5.5
• TBI – reasonable to use but limited study in target group
• SCI – unable to recommend
 Standing Balance
• Functional reach (con’t)
– The patient is instructed to stands close to, but not
touching, a wall and position the arm that is closer to the
wall at 90 degrees of shoulder flexion with a closed fist
– The assessor records the starting position at the 3rd
metacarpal head on the yardstick
– Instruct the patient to “Reach as far as you can forward
without taking a step”
– The location of the 3rd metacarpal is recorded
– The difference between the start and end position is the
reach distance, usually measured in inches
– Three trials are done and the average of the last two is
noted
 Standing Balance
• Functional reach (con’t)
• Norm reference
Functional Reach Norms
Age Men (inches) Women (inches)
20-40 yrs 16.7 + 1.9 14.6 + 2.2
41-69 yrs 14.9 + 2.2 13.8 + 2.2
70-87 yrs 13.2 + 1.6 13.2 + 1.6

• Criterion reference
– < 7 slow walking, high fall risk
 Standing Balance
• Multidirectional functional reach
– Reach forward, left, & right; lean backwards
• Lateral normative values
Lateral Reach
Age Reach (inches)
20-29 yrs 9 + 0.3
30-39 yrs 9.1 + 0.3
40-49 yrs 7.5 + 0.2
50-59 yrs 7.2 + 0.2
60-69 yrs 6.7 + 0.2
70-79 yrs 6.2 + 0.2
 Standing Balance
• Berg Balance Scale (BBS)
– 14 functional tasks
– Objective measure of both static and dynamic balance
– 5-point ordinal scale
– Maximal score of 56
• Populations tested
– Older adults
– Stroke
– MS
– PD
– TBI
– Vestibular dysfunction
– Spinal cord injury
 Standing Balance
• Berg Balance Scale (con’t)
• Normative data Berg Balance Norms
Age Male Female
60-69 55 55
70-79 54 53
80-89 53 50
• Criterion reference
– <46 increased risk of falling
• MDC
– Older adults 8 points
– Stroke 6-8 points (acute); 4-5 points (chronic)
– Parkinson 5 points
 Standing Balance
• Berg Balance (con’t)
– APTA EDGE Recommendations
• Stroke – recommended to highly recommended
• SCI – recommended
• MS highly recommended except EDSS 8.0-9.5
• TBI – reasonable to use to recommended
• PD – reasonable to use stages 2-3
 Standing Balance
• Performance Oriented Mobility Assessment (POMA)
– Tinetti Balance Assessment
• Static and Dynamic Balance
• Gait component as well
– Scale
• 3-point ordinal scale
– Balance max score = 16
– Gait max score = 12
– Populations tested
• Older adults
• ALS
• Hydrocephalus
• PD
• Stroke
 Standing Balance
• POMA (con’t)
– Normative data POMA Norms
Age Male Female
65-79 26.21 25.16
> 80 23.29 17.20

– Criterion data
• < 19 High risk for fall
• 19 – 24 mod risk for fall
• >24 Low risk of fall
– APTA EDGE Recommendations
• Unable to recommend has not been tested enough

Tinetti, 1986, 1987

 Standing Balance/Gait
• Dynamic Gait Index
– Dynamic walking (walking balance) measure
– 4 – point ordinal scale 0-3
– 8 items max score 24
• Populations tested
– Brain injury
– Older adults
– MS
– PD
– Stroke
– Vestibular disorders
 Standing Balance/Gait
• DGI (con’t)
– Normative data DGI Norms
Age Score
30-39 24
40-49 24
50-59 23
60-69 23
70-79 21
80-89 18
– Criterion Data
• < 19/24 increased fall risk
 Standing Balance/Gait
• DGI (con’t)
– MDC
• Acute stroke = 4
• Chronic stroke = 2.6
• Older adults = 2.9
• MS = 4
• PD = 2.9
• Vestibular disorders = 3.2
– MCID (older adults)
• 1.80 for DGI Scores < 21/24
• 0.60 for DGI Scores > 21/24
– APTA EDGE Recommendations
• Stroke – highly recommended
• SCI – reasonable to use
• MS – recommended
• TBI – reasonable to use
 Functional Gait Assessment
• Modification of the DGI
– 10-items
– Scored 0-3 (severe impairment to normal ambulation)
– High score =30
– Can be performed with or without an assistive device
• Populations tested in
– Parkinson’s
– Stroke
– Vestibular
– Older Adults
 Functional Gait Assessment
• MDC
– Parkinson’s 4 points
– Stroke 4.2 points
– Vestibular 6 points
• MCID
– Stroke 5 points
• Criterion reference
– Older adult
• Scores < 22 increased fall risk
• Scores < 20 predictive for serious fall in next 6 months
– Parkinson’s
• Scores < 15 predictive of fallers
 Functional Gait Assessment
• APTA EDGE Recommendations
– Parkinson’s
• Highly recommended Y&H levels 1-5
– Stroke
• Reasonable to use
– Vestibular
• Highly recommended
– TBI
• Reasonable to use
– MS
• Not recommended  lack of data
 Standing Balance/Gait
• Timed Up & Go (TUG)
– Patient sitting in chair
– On command to ‘go’
• Rises from chair
• Walks 3 meters at comfortable pace, turns, walks back
to chair and sits
– Populations tested: acute medical, AD, OA, CP,
older adults, frail elderly, healthy children, LBP, LE
amputation, MS, PD, RA, SCI, stroke, vestibular
 Standing Balance/Gait
TUG Norms
• TUG (con’t) Age Male (s) Female (s)
– Normative data 60-69 8 8
70-79 9 9
80-89 10 11

– Criterion data (increased fall risk)

• Older adults >13.5 s
• Stroke >14 s
• Frail elderly >32.6 s
• LE amputees >19 s
• PD >11.5 s
• Hip OA >10s
• Vestibular >11.1s
 Standing Balance/Gait
• TUG (con’t)
– MDC
• AD 4.09 s
• Chronic stroke 2.9 s
• PD 4.85 s
• SCI 10.8 s
• APTA EDGE Recommendation
– Stroke – highly recommend
– SCI – highly recommend
– TBI – reasonable to use
 Standing Balance
• Fullerton Advanced Balance Scale (FABS)
– 10 performance-based items
– 5-point ordinal scale (0-4)
– Scores range 0-40
• Populations tested
– Older adults
– Breast CA post-chemo
– Fibromyalgia
– PD
– TBI
 Standing Balance
• FABS (con’t)
– Normative data
• Not established
– Criterion data
• <25/40 increased risk for falls
– MDC & MCID
• Not established
– APTA EDGE Recommendations
• MS – unable to recommend
• TBI – reasonable to use
 Standing Balance
• Stops While Walking Test
– Divided attention task to walk while talking
– Measure walking speed & compare when talking to when
not talking
• Normative data (healthy older adults)
– Walking no talking 104.7 cm/s
– Walking with talking 76.7 cm/s
• Criterion data
– > 20 seconds longer for same walk when talking =
increased risk for falls
• APTA EDGE Recommendation
– TBI – reasonable to use
 Standing Balance
Possible skills
– Reaching in sitting/standing
– Tandem walking
– Side stepping
– Braiding
– Kicking a ball
– Catching/batting a ball
– Swinging a bat/club/paddle
– Any individual item on
functional balance scales
How to assess
• Observe performance
• Identify missing
components
– Stability
– Controlled mobility
– Mobility
• To identify missing
components must be able
to identify ‘normal’
components
P641
Lab 1: Balance
Spring 2021

General Instructions:

Each student will participate in 4 lab sections

1. Neurocom
2. Measuring motor capacity for balance
3. Measuring motor skill performance for balance
4. Wrap-up

Students will participate based on group assignments and time table posted in CANVAS

Students are expected to come to lab prepared to initiate lab activities immediately.

Time is limited during the laboratory sessions so some students may need to finish answering questions
outside of structured lab time.

Objectives:

Learners will:
- Identify sensory system status based on conditions of SOT and modified CTSIB
- Compare and contrast intervention strategies focused on restoration vs. compensation of
identified sensory impairment
- Assimilate data from measures for balance in to the motor control task framework (stability,
mobility, controlled mobility)
- Hypothesize clinical manifestations during balance testing as a result of specific health
conditions
- Interpret motor control implications of balance measure(s) scores
- Determine appropriate motor capacity/sensory organization measure based on observed
sensory deficits.
- Identify motor control task components (stability, mobility, controlled mobility) of identified
balance/coordination skills.
- Select appropriate functional balance measures to assess for fall risk in patient populations

1
P641
Lab 1: Balance
Spring 2021

Section 1: Neurocom
1. Report to the musculoskeletal translational research laboratory on the 2nd floor in Coleman at
assigned time
2. ‘Actively’ observe (participate as needed) in a neurocom demonstration
a. Sensory organization test (SOT)
b. Adaptation test
c. Limits of stability test (LOS)
d. WB squat test
3. Answer the following questions

For each condition on the SOT fill in the following table (hint: each sensory system – vision,
somatosensation, and vestibular should be listed once for each condition or row in the table & there
may be more than one sensory system listed in a column within the row)

Condition Accurate sensory input Absent sensory input Inaccurate/conflicted

sensory input
1 – EO; floor no Vision
motion; walls no Vestibular
motion Somatosensation
2 – EC; floor no Somatosensation Vision
motion; walls no Vestibular
motion
3 – EO; floor no Somatosensation Vision
motion; walls motion Vestibular
4 – EO; floor motion; Vision Somatosensation
walls no motion Vestibular
5 – EC; floor motion; Vestibular Vision Somatosensation
walls no motion
6 – EO; floor motion; Vestibular Vison
walls; motion Somatosensation

If a patient falls which sensory system(s) during each condition is most likely impaired or the rate
limiting factor? (hint: it could be more than one)

Condition 1: Vision, Somatosensation, Vestibular

Condition 2: Somatosensation

Condition 3: Somatosensation

Condition 4: Vison

Condition 5: Vestibular

Condition 6: Vestibular

2
P641
Lab 1: Balance
Spring 2021

Based on the system identified as impaired how would you focus an intervention designed to restore
the impairment and how would you focus an intervention designed to compensate for the impairment?

Condition 1: More tests needed to focus impairment

Condition 2: Diminished sensory

Restore – progression of surfaces (firm uneven, foam); progression of BoS (wide narrow, tandem,
SLS), EO EC

Compensate – AD, proper footwear, train reliance on vision (eyeglasses, head turns)

Condition 3: Diminished sensory

Restore – progression of surfaces (firm uneven, foam); progression of BoS (wide narrow, tandem,
SLS), EC

Compensate – AD, proper footwear, train reliance on vision (eyeglasses, head turns)

Condition 4: Diminished vision

Restore: adding uneven surface to make pt. rely on vision for balance.

Compensate: give glasses, AD, practice listening and hearing of surroundings. Practice vison focusing;
progression in environment lighting (dimming), covering one eye.

Condition 5: Diminished vestibular (central)

Restore: head turning, saccade practice, EC & uneven surfaces, awareness in space practice

Compensate: minimize head movements

Condition 6: Diminished vestibular (central)

Restore: head turning, saccade practice, EC & uneven surfaces, awareness in space practice

Compensate: minimize head movements

Is the motor adaptation test testing feed forward or feed back mechanisms of postural control & what is
your rationale? Initially feedback and then feedforward from then out. Pt. initially recognizes balance
challenges and prepares for subsequent challenges if stimulus is repeated.

Why does the amount of sway “normally” observed decrease with each subsequent perturbation on the
adaptation test? Feed foward mechanism

3
P641
Lab 1: Balance
Spring 2021

Describe the individual capacity for postural control data the LOS test provides? (hint: think stability,
controlled mobility, mobility, & skill)

A persons capacity for motor learning depends on the ability for feedforward responses in future
testing

Describe the problems you expect to find on the LOS test with the following medical conditions &
symptoms:
Stroke with hemiparesis: limited excursion on hemiparetic side, increased reaction time, decreased
endpoint, decreased directional control, decreased movement velocity

MS with ataxia: decrease directional control, increased excursion (dysmetria)

Parkinson with trunk rigidity: increased reaction time, decreased movement velocity, decreased
endpoint and excursion, decreased directional control.

Describe how the data from the WB squat is relevant to balance and postural control? Shows if the pt. is
favoring one LE over the other by how much weight is being placed through that limb. If there is
asymmetrical weight distribution, there is likely a postural issue due to motor inability, pain, etc. that
will cause balance issues when stooping.

Section 2: Measuring Individual Motor Capacity for Balance

1. Report to PT classroom in Long
2. Practice the trunk impairment scale – remember to step into the role of a therapist and practice
how you would communicate with a patient.
3. Practice/observe the Stability Test on the portable neurocom.

For each condition on the stability test fill in the following table (hint: each sensory system – vision,
somatosensation, and vestibular should be listed once for each condition or row in the table & there
may be more than one sensory system listed in a column within the row)

Condition Accurate sensory input Absent sensory input Inaccurate/conflicted

sensory input
1 – firm, feet together Somatosensation Vision
EC Vestibular

2 – firm, SLS, EC Somatosensation Vision

Vestibular
3 – firm, tandem, EC Somatosensation Vision
Vestibular
4 – foam, feet Vestibular Vision Somatosensory
together, EC
5 – foam, SLS, EC Vestibular Vision Somatosensory

6 – foam, tandem, EC Vestibular Vision Somatosensory

4
P641
Lab 1: Balance
Spring 2021

4. Complete a balance examination on your lab partner for the following clinical scenarios:
a. Bedside eval in the hospital with a patient who does NOT have a primary neurological
health condition. What did you include and why?
TUG, FIST, mCTSIB, & 10MWST all three access stability, controlled mobility,
sit<>stand, gait, balance, and gait speed; all of which are important for successful
activity completion
b. Clinic eval in an acute inpatient rehabilitation facility with a patient who has had a
stroke and is minimal assist with transfers and able to step in II bars with maximal assist.
What did you include and why?
BBS, Romberg, & TIS all three access balance and postural stability needed for
functional activities for stroke population.
c. Clinic eval with a patient who has MS and can walk modified independent but holds
onto furniture for safety and has had several “almost falls.” What did you include and
why?
10MWST, DGI, BBS , TUG, POMA all access gait biomechanics, balance, and gait
speed need to activities and community participation.

5. Answer the following questions:

Impairments in which sensory system(s) is/are most likely to contribute to poor performance on the
stability test and why?

Somatosensation, vestibular, and vision are needed for balance and good performance in the stability
test

How would you expect the changes in BOS during the stability test to affect postural control & why?

Applying an uneven surface or eliminating/reducing LE extremity recruitment (SLS, tandem) affects

one’s ability to maintain COG within BOS.

Could you administer and quantify a similar test battery without technology & how/why or not?

Yes, with an Airex, similar to the mCTSIB

A patient who had a stroke 4 years ago comes to PT due to poor balance and frequent falls. The patient
scores 12/23 on the trunk impairment scale. Based on this score what motor capacity parameter(s)
does this patient need to work on & why?

Stability and segmental mobility

*FIST measures dynamic, controlled mobility, which the TIS does not measure

5
P641
Lab 1: Balance
Spring 2021

A patient with MS reports dizziness during the patient interview. Which motor capacity measure(s)
might the therapist use to screen for vestibular dysfunction?

Head turns while reading, asking pt. to focus on PT’s nose w/ slow and fast head turns, mCTSIB

A physical therapist observes impaired somatosensation during an evaluation. The PT assumes the
patient will have balance impairment(s) as a result of this finding. Which motor capacity measure(s)
might the PT use to test this assumption and why?

mCTSIB, stability test, microfilament test, soft touch distal to proximal with pt. feedback, Romberg

6
P641
Lab 1: Balance
Spring 2021

Section 3: Measuring Motor Skill Performance for Balance

1. Report to the CAVERN sections 3 & 4 in the basement of Coleman Hall
2. Practice assessing static postural control (stability) and weight shifting/reaching (controlled
mobility in short sitting and standing with your lab partner.
3. Practice administering two functional balance scales to a classmate. Pick scales that you have
not previously administered or the one with which you have the least familiarity.
4. Observe 2-3 classmates performing braiding and kicking a ball. Based on your observation list
the ‘normal’ components of the observed skill. After you’ve identified the ‘normal’ components
of the skill, perform the skill by eliminating one of the ‘normal’ components and observe and
write down the compensatory strategies you employ or observe in your classmates.

Skill Stability Mobility Controlled Compensatory

components components mobility strategies
components
Braiding Good standing Full hip ROM Weight shifting to Wider BOS
balance Ankle strategies SLS UE support
Coordination for Hip circumduction
limb in front and Trunk side leaning
behind to stronger limb

Kicking a ball Good standing Ankle strategies Weight shifting to UE support

balance SLS

5. Answer the following questions

Describe how a physical therapist would position the patient, themselves around the patient, and
provide cues (tactile or verbal) to promote patient safety during assessment of sitting and standing
postural control.

PT stands to the side (hemi) and behind pt. for standing postural control, PT provides VC’s for upright
posture, wight shifting over toes, glute contraction. TC’s as necessary if inability to maintain quiet
stance without compensation.

PT stands in front or to the side (hemi) of pt. for sitting postural control, PT provides VC’s for upright
posture, UE support on bed if needed, feet flat on floor. TC’s as necessary if inability to maintain quiet
sitting without compensation.

A physical therapist wants to determine fall risk for a patient. Which functional or activity-based balance
measure(s) might the physical therapist use?

BERG, POMA, FGA, TUG, 10MWST

7
 Neurological Evaluation: Bed
Mobility, Transfers, Gait, & Multiple
Domain Measures
P641 Neurorehabilitation 1
Indianan University Physical Therapy Program
Spring 2021
Kristine K. Miller, PT, PhD
 Observational Assessment
Assistance level Movement pattern
• Independent • Identify postural control holes
• Modified independent – Mobility
– Environmental accommodation – Stability
• Supervision – Controlled mobility
• Stand-by assistance • Assess transitional movements
and manipulation skills from a
• Touch or contact guard assistance biomechanical or kinematic
• Minimal assistance perspective.
– Pt. performs 75% work
• Moderate assistance
– Pt. performs 50% work
• Maximal assistance
– Pt. performs 25% work
• Dependent
BED MOBILITY
 What to evaluate?
• Rolling supine to/from prone
• Rolling supine to/from left
• Rolling supine to/from right
• Scooting right & left
• Scooting up in bed
• Scooting down in bed
• Sit to/from supine
TRANSFERS
 Transfers
• Static short sitting is the starting point for
transfers
• LE mobility provides the power for antigravity
movement for transfers
• NOTE: UE can compensate & PT handling can
accommodate if needed
• Sensory awareness & cognition deficits can
degrade transfer performance even without
sitting stability or LE mobility impairments
 First Transfer
• Prepare for more dependence than you predict
• Prediction based on degree of:
– Sitting stability deficits
– LE mobility deficits
• Set-up transfer for ‘easiest success’
• If you anticipate dependent or max assist transfer – get
a second person
• If you anticipate a moderate assist transfer with
challenging circumstances (high surface, heavy person,
dizziness/pass out risk, etc.) – get a second person.
 Transfers
Transfers to assess Steps to initiate basic transfers
• Sit/squat pivot transfer • Sitting with feet firmly on
• Stand pivot transfer the floor stability
• Sit to/from stand • Flex forward in trunk and
• Car transfer hips segmental mobility
• Floor transfer • Shift weight from buttocks
to feet controlled
mobility
• Lift buttocks from surface
segmental mobility
GAIT
 Normal Gait
• Gait Cycle
– Definition
• Heel strike to heel strike

– Two Phases
• Swing
• Stance
 Normal Gait
• Stride
– Stride length
• Point of Heel strike of one
extremity to point of heel
strike of the same
extremity
– Step length
• Point of heel strike of one
extremity to point of heel
strike of the opposite
extremity
 Qualitative Kinematic Assessment

• Description of gait patterns without regard to

forces involved

• Describes movement patterns

• Description of movement of the body as a

whole or segments
 Kinematic Gait Assessment
• Establish an observation sequence
• Use a standardized checklist
• Observe with and without AD
• Observe with and without orthotic
• Use technology as available and appropriate
– Video
– Walking track with sensors
• Be objective in reporting
• Identify motor capacity limitations that relate to
observed gait deviations
– Rate limiting factors
Quantitative Kinematic Assessment
• Spatial and Temporal Parameters
– Speed 10MWST
– Distance 6MWST
– Time TUG
– Step characteristics
• Step length
• Step width
• Stride length
• Stride width
• Double support time
• Single Support time
 Quantitative Kinetic Assessment
• Examination and analysis of the forces
involved in gait
– Ground reaction forces
– Joint torque
– Center of pressure/mass
• Instrumentation
– Complex and expensive
– Force plate
 Key Points of Control
• Standing
– Stability - starting point
• Knees
• Pelvis
• Upper trunk
– Controlled mobility – required for gait
• Quiet stance: weight shift left<>right
• Stride: weight shift forward<>backwards with one foot
forward
– More than minimal assist for standing stability and
controlled mobility – first walk in parallel bars
 Key Points of Control
• Evaluating stance
– Ankle
– Knee
– Hip/pelvis
– Upper trunk
• Evaluating swing
– Ankle
– Knee
– Hip/pelvis
– Upper trunk
 Common Observable Gait Deviations
• CVA
– Stance
• Decreased hip extension
• Excessive pelvic lateral shift
• Knee hyperextension
• Knee buckling
• Decreased PF at push off
• Lack of heel strike at initial contact
• Lack of tibial advancement over foot
 Common Observable Gait Deviations
• CVA
– Swing
• Limited hip flexion movement and control
• Decreased knee flexion at initial and mid swing
• Decreased knee extension during terminal swing
• Decreased DF at mid swing (foot drop)
– Trunk
• Forward flexed trunk
• Forward flexed head
• Trunk rotation towards hemiparetic side
– Arms
• Limited or absent arm swing
 Common Observable Gait Deviations
• Cerebellar involvement
– Wide and fluctuating BOS
– Lack of consistency in step length
– Inconsistent movement trajectories
– Ataxic movements
– Frequent LOB
 Common Observable Gait Deviations
• Multiple sclerosis
– Variable depending upon involvement
• More impactful as patient ages with disease
• Spasticity
– Scissoring gait pattern
– Limited control of step length and width
– Poor control of the proximal stance phase
• Trunk weakness
• Cerebellar signs if cerebellum affected by pathology
 Common Observable Gait Deviations
• Parkinson disease
– Decreased velocity bradykinesia
– Decreased stride length
– Festinating gait
– Loss of heel toe progression
– Locking up
 Common Observable Gait Deviations
• GBS
– Similar to CVA but bilateral loss
• Distal return
• Limitations in postural control
• Hip control in stance phase
• Often will not be able to ambulate initially
• Mild ataxia
STANDARDIZED GAIT MEASURES
 Gait Speed
• 10 Meter Walk Test
– Walk 14 meters on a straight marked walkway
– Time the middle 10 meters (2 meter warm-up & 2 meter cool down)
– 3 walks
– Average time on three walks and convert to m/s speed
– Can do comfortable or fast walking speed
• Populations tested
– AD
– Brain tumor
– Older adults
– Movement disorders
– Hip fracture
– Lower limb amputation
– MS
– PD
– SCI
– CVA
– TBI
 Gait Speed
• 10 meter walk test (con’t)
• Normative Data
Male Female
Age CWS (m/s) FWS (m/s) CWS (m/s) FWS (m/s)
20’s 1.39 2.53 1.41 2.47
30’s 1.46 2.45 1.42 2.34
40’s 1.46 2.46 1.39 2.12
50’s 1.39 2.07 1.40 2.01
60’s 1.36 1.93 1.30 1.77
70’s 1.33 2.08 1.27 1.74
 Gait Speed
• 10 MWT (con’t)
• Criterion reference
– Stroke
• <0.4 household ambulators
• 0.4 to 0.8 limited community ambulators
• >0.8 community ambulators
• MDC
– Hip fracture 0.17 m/s
– PD 0.18 m/s (CWS); 0.25 m/s (FWS)
– iSCI 0.13 m/s
– CVA 0.05 m/s
 Gait Speed
• 10 MWT (con’t)
• MCID
– Older adults 0.13 m/s
– SCI 0.13 m/s
– CVA 0.14 – 0.16 m/s
– TBI 0.15 m/s (CWS); 0.25 m/s (FWS)
• APTA EDGE recommendation
– Stroke – highly recommend
– iSCI – highly recommend
– TBI – recommend to reasonable to use
 Gait Endurance (Distance in time)
• Six-minute walk test (6MWT)
– Walk as far as possible at self- selected comfortable walking speed.
– Can use assistive device
– Can stop and rest during the walk but the time keeps running
– Walk along a 100 foot walkway
– Record distance covered in 6 minutes
• Populations tested
– AD
– Older adults
– Heart Failure
– MS
– PD
– Pulmonary disease
– Osteoarthritis
– SCI
– CVA
 Gait Endurance
• 6MWT (con’t)
• Normative Data
Age Male Female
60-69 572 (m) 538 (m)
70-79 527 (m) 471 (m)
80-89 417 (m) 392 (m)

• Criterion data – not established

 Gait Endurance
• 6MWT (con’t)
• MDC
– AD 33.47 m
– COPD 54 m
– Older adults 58.20 m
– OA 61.34 m
– PD 82 m
– SCI 45.8 m
– CVA 34.37 m (chronic); 60.98 m (subacute)
• MCID
– COPD 54 m
– Older adults 50m
 Gait Endurance
• APTA EDGE recommendations
– CVA – highly recommend
– SCI – highly recommend
– MS – highly recommend
– TBI – recommend to reasonable to use
 Gait Distance
• How much do we need?
Location Distance (m) Distance (f)
Bank 57 187
Pharmacy 206 676
Dept. store 345 1132
Grocery store 380 1246
Hardware 565 1853
Superstore 606 1988
Club Warehouse 676 2217
 Gait Distance
• What are the universal distant markers used in clinical
practice & why? Arbitrary, chosen due to convenience
– 50 feet
– 150 feet
– >300 feet
• Steps /day
– <5000 – sedentary
– 5000-7499 – low active
– 7500-9999 – somewhat active
– 10,000 – active
– 12,500 – highly active
 Finishing the Gait Evaluation
• Consider floor surfaces
• Consider uneven terrain
• Consider orthotic applications
MULTI-DOMAIN MEASURES
 Multi-domain Outcome Measures
• Patient reported outcome measures that provide
information on more than one functional construct
• Quality of Life
– SF 36 (32 questions)
• Physical Health
– Physical functioning
– Role physical
– Bodily pain
– General health
• Mental health
– Vitality
– Social functioning
– Role emotional
– Mental health
 Multi-domain Outcome Measures
• Quality of Life
– Stroke specific quality of life SSQOL (62 questions)
• Self-care
• Vision
• Language
• Mobility
• Work
• UE function
• Thinking
• Personality
• Mood
• Family roles
• Social roles
• Energy
 Multi-domain Outcome Measures
• Quality of Life
– Multiple Sclerosis Quality of Life Inventory (10 scales)
• Health status -SF 36
• Modified fatigue impact scale
• MOS Pain Effects Scale
• Sexual satisfaction scale
• Bladder control scale
• Bowel control scale
• Impact of visual impairment scale
• Perceived deficits questionnaire
• Mental health inventory
• MOS modified social support scale
 Multi-domain Outcome Measures
• Quality of Life
– Quality of Life after Brain Injury (QOLIBRI) 37
items
• Cognition
• Self
• Daily life & autonomy
• Social relationships
• Emotions
• Physical problems
 Multi-domain Outcome Measures
• Quality of Life
– Parkinson Disease Questionnaire (PDQ-39)
• Mobility
• ADL
• Emotional well-being
• Stigma
• Social support
• Cognition
• Communication
• Bodily discomfort
 Multi-domain Outcome Measures
• Functional Independence Measure
– Motor
• Eating
• Grooming
• Bathing
• Upper body dressing
• Lower body dressing
• Toileting
• Bladder management
• Bed to chair transfer
• Toilet transfer
• Shower transfer
• Locomotion: walking and WC
• Stairs
– Cognition
• Cognitive comprehension
• Expression
• Social interaction
• Problem Solving
• Memory
 FIM Scoring

Score Description
7 Complete independence
6 Modified independence
5 Supervision or set-up
4 Minimal contact assistance (25% help)
3 Moderate assistance (50% help)
2 Maximal assistance (75% help)
1 Total assistance (>75% help)
 Multi-domain Outcome Measures
• ICF-based Questionnaire to Measure Activities
and Participation (IMPACT) 33 Questions
– Learning & applying knowledge
– General tasks and demands
– Communication
– Mobility
– Self-care
– Domestic life
– Interpersonal interactions & relationships
– Major life areas
– Community, social & civic life
 Participation Measures
• QOL measures
• IMPACT
• Return to Normal Living Index (RNLI)
• Self-efficacy measures
– Activities-specific Balance Confidence (ABC) 16 items
• Normative data – older adults 80%
• Criterion data
– Older adults <67% fall risk
– PD <69% fall risk
– Stroke >81% low fall risk
 Participation Measures
• ABC (con’t)
– MDC
• PD – 13%
– MCID – not established
• APTA EDGE recommendations
– Stroke recommended except in acute care
– MS – recommended
– TBI – reasonable to use
– SCI – not recommended
P641
Lab 4 bed mobility progression

Basic technique terminology

PNF techniques
1. Isometric hold – grade perturbation force with verbal cue to ‘hold don’t let me move you’ to
facilitate isometric muscle contraction. If alternating between directions, try to grade input so
transition is smooth.--> Graded resistance, start light
2. Rhythmic stabilization (rotation isometric holds) use both hands to apply a rotational force
through body segment with instructions to ‘hold don’t let me move you’ to facilitate muscle
activation. Alternate between rotation directions.--> Graded resistance, start light
3. Slow reversals or weight shifting – can be passive (rhythmic initiation), active assistive, active,
resistive and if resistive can add a hold at end range. The therapist controls the movement
direction and intensity with hands. Verbal cues can be ‘shift to the left/right, push into my hand’
etc.
a. You can add a quick stretch, approximation, traction, tapping etc. at the beginning or
throughout the movement to further facilitate muscle activity.
4. Agonist reversals (resisted eccentric muscle activity) – provide a movement force into gravity
with verbal cue ‘don’t let me push you down or lower slowly…’  eccentric control
5. Hold relax active movement – a) Move (P/AA) patient through partial range; b) ask for an
isometric hold; c) passively move back to starting position; d) ask patient to actively move (can
add assistance or resistance) as needed.
LE Mobility
PNF patterns
1) D1 flexion – flexion, adduction, external rotation with ankle DF & inversion
2) D1 extension – extension, abduction, internal rotation with ankle PF & eversion
3) D2 flexion – flexion, abduction, internal rotation with ankle DF & eversion
4) D2 extension – extension, adduction, external rotation with ankle PF & inversion
• Clinical thought: LE mobility practice can be used in any posture for strengthening, skill transfer
(mobility task using LE), or part practice (stepping practice in stance)

Facilitation techniques – approximation, traction, visual input, quick stretch, & resistance

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P641
Lab 4 bed mobility progression

Bed Mobility - Starting in Supine

How many handling techniques can you use to help someone perform bridging (be prepared to
demonstrate your techniques)? Quick stretch, tapping, joint approximation

Keep your patient in bridging and practice:

1. Isometric holds: L<> R, A<>P (up and down)
2. Rhythmic Stabilization (rotation isometric holds)
3. Slow reversals (weight shifting) with and without a hold at the end : L<>R, A<>P (up and down)
For which functional problems might bridging be an appropriate intervention? Sit to stand, stair
climbing, gait, scooting in bed, etc.
*Looking for symmetrical weight shifting and up down of bridge, especially in a hemi pt. Don’t let one
side dip down, that might be were you have to focus your TC’s.

Point to Ponder: How can you facilitate unweighting of the upper trunk for scooting? Scap retraction,
back widow, chin tuck

Rolling out of Supine

1. Segmental trunk movement
2. Extremity movement (multiple combinations)
a. Early therapy or very low level patient use strongest components to improve
performance, increase likelihood of success, and build self-efficacy
b. Later therapy or higher level patient use weak components during rolling activity for
functional strengthening of weakened segments
c. When using UE instruct patients to follow their arm(s) with their eyes to help with head
turning
3. Practice facilitating rolling supine to sidelying with the following conditions:
a. Point of contact at shoulder
b. Point of contact at pelvis
c. Single UE as point of contact (D1 flexion pt. reaching across their body)
d. Bilateral UE as point of contact (Strong arm helps weak arm reach across)
e. Single LE in hooklying as point of contact (Performed with unilateral bridge and then
finish rolling)
f. Bilateral LE in hooklying as point of contact (Lumbar roll out essentially to initiate roll)
g. Single LE flat on mat as point of contact (D1 flexion leg reaching across midline)

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P641
Lab 4 bed mobility progression

h. Try 2 points of contact in any combination (as many as you can) (Combine B. UE use
with LE really good for hemi pt.)
How can you do prep work for rolling in supine with the extremities and trunk? D1 flexion in UE and LE,
unilateral bridge

Keep your patient in sidelying and practice:

1. Isometric holds
2. Rhythmic Stabilization (rotation isometric holds): opposite shoulder and hip rotation
3. Slow reversals with and without a hold at the end
4. Hold relax active movement: PT passively moves you forward, hold with resistance in opposite
direction, passively moves back to starting, pt. performs actively
*If a pt. has a significant trunk problem, try bending their knees for greater BOS (rather than out
straight)
For which functional problems might sidelying be an appropriate intervention? Supine<>sit, rolling

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P641
Lab 4 bed mobility progression

Let’s Go Prone
Point to Ponder: why do you want to be here? Trunk and hip extension practice, loading arms

Keep your patient in prone on elbows and practice:

1. Isometric holds
2. Rhythmic Stabilization (rotation isometric holds)
3. Slow reversals with and without a hold at the end : Can incorporate UE reaching during
*Have pt. prone on elbows (baby cobra)
For which functional problems might prone on elbows be an appropriate intervention? Stairs, gait,
sit<>stand

4
P641
Lab 4 bed mobility progression

Quadruped
1. Prone approach
2. Sidelying approach
Keep your patient in quadruped and practice:
1. Isometric holds: can be at shoulders and/or pelvis
2. Rhythmic Stabilization (rotation isometric holds) can be at shoulders and/or pelvis
3. Slow reversals with and without a hold at the end: quadruped to child’s pose reversals for A<>P,
side to side for L<>R
4. UE movements: reaching with slow reversals (back off slightly pressure so you don’t pull pt.
towards you)
5. LE movements: hip flx and knee ext. (think of a mountain climber ab exercise)
For which functional problems might quadruped be an appropriate intervention? Floor to tall kneeling
transition, falls

Tall Kneeling
1. Quadruped approach
2. Side sit approach
Keep your patient in tall kneeling and practice:
1. Isometric holds
2. Rhythmic Stabilization (rotation isometric holds)
3. Slow reversals with and without a hold at the end: avoid A<>P for safety, do L<>R and diagonal
4. Agonist reversal: tall kneeling <> sitting back
5. UE movements
6. LE movements
*Give pt. UE support during this activity
For which functional problems might tall kneeling be an appropriate intervention? Gait, stair climbing,
floor to stand transition

5
P641
Lab 4 bed mobility progression

Half Kneeling
List the postural control components of moving from tall kneeling to half kneeling. Weight shifting,
Keep your patient in half kneeling and practice:
1. Isometric holds
2. Rhythmic Stabilization (rotation isometric holds)
3. Slow reversals with and without a hold at the end: A<>P, L<>, diagonal
For which functional problems might half kneeling be an appropriate intervention? Floor to stand
transition

6
P641
Lab 4 bed mobility progression

Floor to Stand

tall kneeling (UE) half kneeling (UE) standing

*Which leg should be forward in half kneeling for rising? Textbooks say strong leg up front but may try
working with strong leg back to allow PF of back leg, weight will then transfer to front leg (think of a
lunge position)

Start in middle of mat

TC’s at knee for preventing buckling and at hip for HE

7
P641
Lab 3 UE Progression & Sitting Progression

UE function
- Support: Used in light WB to assist with stability and controlled mobility during functional tasks
- Balance: Used in light WB to increase BOS; Mobility for protective reaching
- Grasp: Used to obtain or retrieve objects
- Manipulation: Manage objects during motor skills (fine motor control)
UE function components
- Trunk postural stability
- Scapular stability & mobility
- Shoulder active movement (mobility)
- Shoulder PROM
- Shoulder stability (co-contraction/isometric hold)
- Elbow active movement (mobility)
- Elbow PROM
- Elbow stability (co-contraction/isometric hold)
- Wrist active movement (mobility)
- Wrist PROM
- Wrist stability (co-contraction/isometric hold)

Think through a couple of reaching tasks and list the postural control components at each segment in
the UE and trunk.
1. Reaching for a tissue from the box on a table beside you while sitting in a chair.
UE: distil to proximal initiation with segmental mobility for reaching, stability at shoulder once
hand reaches tissue.
Trunk: initiated before UE, trunk performs controlled weight shift to one side, segmental
mobility to turn and than stability to face direction UE is moving.
2. Reaching for a cup in a high kitchen cabinet while standing.
Controlled mobility wight shifting to contralateral LE that UE is reaching up for. Used
contralateral UE for support on counter surface.
IMPORTANT POINTS
1. Scapular mobility is required for glenohumeral mobility
2. Wrist extension mobility is required for most grasping activities
3. Voluntary release is harder to learn than voluntary grasp especially with spasticity and flexion
synergy biased movements
4. Much of the UE’s normal function is in open kinetic chain
5. Normal reaching patterns typically initiate from the distil segment
6. Normal closed chain function of the UE involves light WB and support – not heavy WB

Opening a spastic hand:

1. Flex the wrist to relax finger flexion
2. (Option A) Hold hand with your fingertips on 1st & 5th metacarpal; spread metacarpals as you
extend the wrist. (Option B) slide your hand along inside of rays making a firm grip on the
MCP joints; extend fingers & wrist together
NOTE: Do not put pressure directly on the palm of the hand – this will facilitate grasp.
3. Once the hand is open place it in light WB

Practice with at least 2 people scapular mobility and opening a spastic hand.

1
P641
Lab 3 UE Progression & Sitting Progression

2
P641
Lab 3 UE Progression & Sitting Progression

Weight Bearing Progression

- UE in light WB during static/stability activity
- UE in light WB fixed with movement of trunk on arm controlled mobility
- UE in light WB with movement of trunk & UE together segmental mobility
- UE in light WB with movement of UE independently (still closed chain) on a stable trunk (doesn’t
- UE open chain with movement of UE on a stable trunk: reaching
o Try hooking the thumb to keep the hand open during reaching
o Avoid crossing UE over midline or performing kinesthetic movements that are same as
flexor synergy

Work your way through an UE WB progression with a classmate roleplaying a slightly spastic UE.

List at least 4 handling inputs (facilitation or inhibition) that you used and how you used them to
move through the WB progression (be prepared to demonstrate your techniques).
Faciliatory: brushing, tapping, joint approximation, quick stretch
Inhibitory: sustained pressure, prolonged WB, slow rocking, sustained stretch

3
P641
Lab 3 UE Progression & Sitting Progression

UE Mobility
PNF patterns
1) D1 flexion – flexion, adduction, external rotation with wrist and finger flexion (“pull up and
across the face”)
2) D1 extension – extension, abduction, internal rotation with wrist and finger extension (“push
down & out”)
3) D2 flexion – flexion, abduction, external rotation with wrist and finger extension (“lift up and
out”)
4) D2 extension – extension, adduction, internal rotation with wrist & finger flexion (“pull down
and across the body”)
• See IOF text book page 46-53 for pictures
• Facilitation techniques – approximation, traction, visual input, quick stretch, & resistance

Try bilateral movement with combos of D1 and D2

Clinical thought: UE mobility practice can be used in any posture for strengthening, skill transfer
(reaching), or part practice (UE contribution to motor skill ex. Rolling)

Practice assisting, facilitating, and resisting D1F, D2E, D2F, D2E in sitting and supine; remember to
instruct the patient to follow the arm movement with the head & eyes.

PROM AAROM AROM Resisted AROM

PNF activity can help with bed mobility rolling progression part practice

Incorporate PNF patterns into reaching activities

For reaching, focus less on if they reach the target and more on their trunk (maintains lordosis, engage
core, looking at hand/target). For the PT, sit on the weak side with the knee behind your pt. and
palpating QL, and ability to perform anterior pelvic tilt.

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P641
Lab 3 UE Progression & Sitting Progression

Hemiplegic Shoulder Issues

Shoulder Subluxation
- 81% of people with stroke with no shoulder muscle activity
- 40% of people with stroke with some UE movement
- 7%-15% of people with stroke who regain UE activity in 1 month after stroke
Types of subluxation (onset mostly in acute care, where UE is flaccid after stroke)
1. Inferior (most common)
a. due to severe weakness and/or flaccidity
b. usually occurs in acute stage
c. downward rotation of the scapula
d. humerus internally rotates and subluxates inferiorly
2. Anterior
a. Due to atypical patterns of return and trunk rotational asymmetries (scoliosis)
b. Downwardly rotated scapula that is also elevated and tilted forward on the rib cage
c. Humeral head separated anteriorly from the glenoid fossa
3. Superior
a. Due to imbalanced muscle activity and co-contraction around the shoulder complex
b. Scapula in abduction and elevation with neutral rotation
c. Humeral head lodges under the coracoid process in a position of internal rotation and
slight abduction
Subluxation management
1. Protection & support: don’t hang arm; support on armrest, pillows
2. NMES – supraspinatus and posterior deltoid (sometimes middle deltoid too): in acute and
chronic phases
3. Taping: can go passed 90 if pt. can tolerate in range without pain
4. Slings: can go passed 90 if pt. can tolerate in range without pain

Haynes (2013) JOTA

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Capsular tightness/frozen shoulder

- Can develop in subacute & chronic stroke secondary to spasticity and immobility
- Can develop in a stretched capsule after subluxation
Shoulder Pain
- 8%-35%
Potential causes
1. Soft tissue effects of subluxation
2. Inappropriate ROM above 90°
3. Glenohumeral ROM without appropriate scapular movement
4. Capsular adhesions/frozen shoulder
Complex Regional Pain Syndrome type 1 (CRPS-1)
After stroke related to:
1. Shoulder trauma: subluxation
2. ANS changes
3. Motor deficits
4. Spasticity
5. Sensory deficits
6. Initial coma

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Stage 1
- Painful shoulder
- Discoloration (pale pink and cool skin) at the hand and wrist
- Skin hypersensitive
- Patient guarding against movement
Stage 2
- Subsiding pain
- Muscle and skin atrophy
- Vasospasm
- Hyperhidrosis
- Coarse hair & nails
- Osteoporosis
Stage 3
- Pain & vasomotor changes rare
- Progressive atrophy of skin & muscles
- Severe osteoporosis
- Hand contracted MP extension & IP flexion
CRPS-1 management
1. Prevention
a. Support flaccid arm
b. Avoid lying directly on effected arm
2. Reduce pain
3. Improve/maintain appropriate PROM
a. Scapular mobility
b. Gentle mobilization
c. Avoid range past 90°: let pain be your patient’s guide
4. Manage edema
5. Avoid infusions into veins
6. Pharmacologic – analgesics
7. Injections – corticosteroids
8. Surgery – nerve blocks
UE Task specific interventions
1. CIMT
2. Bilateral movement
3. Robotic therapy

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Lab 3 UE Progression & Sitting Progression

SITTING

Basic technique terminology

1. Isometric hold – grade perturbation force with verbal cue to ‘hold don’t let me move you’ to
facilitate isometric muscle contraction. If alternating between directions, try to grade input so
transition is smooth. Both hands go one way
2. Rhythmic stabilization (rotation isometric holds) use both hands to apply a rotational force
through body segment with instructions to ‘hold don’t let me move you’ to facilitate muscle
activation. Alternate between rotation directions. One hand goes one way, the other hand goes
the other way.
3. Slow reversals or weight shifting – can be passive (rhythmic initiation), active assistive, active,
resistive and if resistive can add a hold at end range. The therapist controls the movement
direction and intensity with hands. Verbal cues can be ‘shift to the left/right, push into my hand’
etc.
a. You can add a quick stretch, approximation, traction, tapping etc. at the beginning or
throughout the movement to further facilitate muscle activity.
4. Agonist reversals (resisted eccentric muscle activity) – provide a movement force into gravity
with verbal cue ‘don’t let me push you down or lower slowly…’
5. Hold relax active movement – a) Move (P/AA) patient through partial range; b) ask for an
isometric hold; c) passively move back to starting position; d) ask patient to actively move (can
add assistance or resistance) as needed.

Short Sitting on the Side of the Mat

Practice getting into short sitting on the side of the mat.

1. From the wheelchair (stand/squat pivot transfer)

2. From supine (roll to side, scoot legs over the edge, lift trunk out of gravity into sitting position)

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Ideal short sitting position:

- Hips, knees, ankles at ~ 90 degrees

- Feet flat on the floor
- ~2/3 of thighs on support surface
- Lower trunk in slight lordosis (anterior pelvic tilt) with co-activation of anterior & posterior trunk
muscles
- Upper trunk extended with shoulder blades in neutral position
- Arms resting comfortably in lap or in light WB
- Head & Neck – head positioned over body with neck in natural lordosis posture
- Trunk upright without lateral lean

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In short sitting, practice:

1. Isometric holds
2. Rhythmic Stabilization (rotation isometric holds)
3. Slow reversals with and without a hold at the end
4. Facilitate dynamic trunk
a. In front of patient
b. Behind patient
c. On side of patient
How do you decide where to position yourself? Weak side, best body mechanics for the PT

5. Facilitate lower trunk elongation & shortening

Point to Ponder: How can I use my whole body or a therapy ball to facilitate dynamic trunk and lower
trunk elongation/shortening for lower level patients? Therapy Ball roll outs to work on isometric end
range core activation and back extensor activation.

6. UE reaching (keep in mind the UE WB progression)

a. Unilateral
b. Bilateral
c. Assisted you can have the pt. use their other hand to help guide: interlock fingers
(Prayer hold)

How can you facilitate UE mobility in short sitting to build capacity for UE reaching (think PNF patterns)?
Incorporate UE reaching that is the same as the PNF patterns very functional

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7. Scooting forward (lateral weight shift) TC’s at QL rather than ischial tuberosities can help
facilitate muscle activation of anterior hip rotation (remember to not dig your thumb in)
8. Scooting backward (squat)
9. Scooting sideways (squat)
10. Anterior translation of COG in preparation for transfer
a. With UE in WB
b. With UE reach
c. With UE on a mobile surface
d. With therapy ball use other uninvolved hand to hold spastic hand on ball

How can you increase or decrease the difficulty of sitting activities?

Increase difficulty: lower chair/bed height, no backrest, no armrests, put a block under stronger LE so
weaker LE works harder.

Decrease difficulty: raise chair/bed height, backrest, armrests, put a block under weaker LE so
stronger LE works harder.

Ready to Transfer

1. Sit to/from stand

2. Stand pivot transfer
3. Squat pivot transfer

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Sit to/from Stand

1. Move into upright/stable trunk position – facilitate upright trunk with good pelvis alignment &
midline orientation
2. Scoot to the edge of the surface
3. Maintain upright trunk and flex forward at the hips
4. Translate COG from buttocks to feet (maintaining dynamic trunk)
5. Lift off mat
6. Unfold to standing
7. Sit back down – initiate hip flexion first
Handling: Lower trunk to facilitate/assist trunk alignment & co-activation; Hips to facilitate/assist hips
extension; Knees to facilitate/assist with extension.

Put a block/box under stronger leg so that the weaker leg works harder to WB and is the primary LE for
transitional movements.

Remember to always end treatment with whole practice, so if we are using the block/box method
above, end the Tx without the block and just normal B. LE use for sit<>stand.

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Squat pivot transfer

1. Move into upright/stable trunk position – facilitate upright trunk with good pelvis alignment &
midline orientation
2. Scoot to the edge of the surface
3. Maintain upright trunk and flex forward at the hips
4. Translate COG from buttocks to feet (maintaining dynamic trunk)
5. Lift off mat
6. Weight shift to move hips direction of transfer
7. Lower back to mat

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Handling: Upper trunk to facilitate/assist with forward flexion and/or weight shift; Lower trunk to
facilitate/assist trunk alignment & co-activation and/or weight shift; Hips to facilitate/assist weight shift;
Knees to facilitate/assist with extension.

Stand pivot transfer

1. Move into upright/stable trunk position – facilitate upright trunk with good pelvis alignment &
midline orientation
2. Scoot to the edge of the surface
3. Maintain upright trunk and flex forward at the hips
4. Translate COG from buttocks to feet (maintaining dynamic trunk)
5. Lift off mat
6. Unfold to standing
7. Weight shift away from direction of transfer
8. Step toward direction of transfer with closest foot
9. Weight shift towards transfer
10. Step towards direction of transfer with farther away foot

Handling: Lower trunk to facilitate/assist trunk alignment & co-activation and/or weight shift; Hips to
facilitate/assist hip extension and/or weight shift; Knees to facilitate/assist with extension and/or flexion
as needed to move feet; Ankles/feet to assist/facilitate flat foot in WB and/or move feet as needed.

During a stand pivot transfer a patient can use assistive devices or a safe hand hold assist on the
therapist.

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Lab 5 Standing/Pre-gait/Gait Progression

Basic technique terminology

1. Isometric hold – grade perturbation force with verbal cue to ‘hold don’t let me move you’ to
facilitate isometric muscle contraction. If alternating between directions, try to grade input so
transition is smooth.
2. Rhythmic stabilization (rotation isometric holds) use both hands to apply a rotational force
through body segment with instructions to ‘hold don’t let me move you’ to facilitate muscle
activation. Alternate between rotation directions.
3. Slow reversals or weight shifting – can be passive (rhythmic initiation), active assistive, active,
resistive and if resistive can add a hold at end range. The therapist controls the movement
direction and intensity with hands. Verbal cues can be ‘shift to the left/right, push into my hand’
etc.
a. You can add a quick stretch, approximation, traction, tapping etc. at the beginning or
throughout the movement to further facilitate muscle activity.
4. Agonist reversals (resisted eccentric muscle activity) – provide a movement force into gravity
with verbal cue ‘don’t let me push you down or lower slowly…’
5. Hold relax active movement – a) Move (P/AA) patient through partial range; b) ask for an
isometric hold; c) passively move back to starting position; d) ask patient to actively move (can
add assistance or resistance) as needed.

Quiet Standing
Practice getting into quiet standing.
1. From the wheelchair
2. From the mat table
3. From an elevated mat table
Ideal quiet standing position:
- Feet shoulder width apart (a little more narrow)
- Weight distributed evenly between LE
- Feet flat on the ground
- Trunk in natural neutral alignment (lower lordosis, upper kyphosis, cervical lordosis)
- Co-activation of lower trunk anterior and posterior muscles
- Scapula in neutral position
- Arms resting comfortably at side or in light WB
- LE in hip and knee extension and ankle neutral
- Pelvis level
- Head upright and center aligned
- Trunk upright and center aligned
In quiet standing, practice:
1. Isometric holds
2. Rhythmic Stabilization (rotation isometric holds)
3. Slow reversals with and without a hold at the end

For a subluxed shoulder or with low level standing, support the UE with a bedside table, counter, etc.
UE support can build confidence in standing still do PNF techniques

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Lab 5 Standing/Pre-gait/Gait Progression

Hand holds:
Bilateral shoulders
Bilateral hips
Shoulder and hip
From which positions around the patient can you facilitate? Front, side, back

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Lab 5 Standing/Pre-gait/Gait Progression

Picture shows stride stance

Add UE reaching to your practice:
- Unilateral
- Bilateral
- Assisted
Point to Ponder: How can I ‘force’ increased WB on a leg that is not very active? Move more active leg
forward

Add LE mobility and different support surface to your practice:

- Practice specific foot placement (over obstacle, place in floor square, etc.)
- Step onto step (one & two legs)
- Step to side
- Step forward
- Step backward
- Squat
- Lunge
- Stand on compliant surface

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Lab 5 Standing/Pre-gait/Gait Progression

This is a lot to think about and handle – How can I decrease difficulty to make it more manageable
especially for lower level patients? Modified plantigrade

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Lab 5 Standing/Pre-gait/Gait Progression

Preparing for Gait

1. Weight bearing control of the impaired extremity(s)
2. Swing through of the impaired extremity(s)
3. Decide what to do with UE
Typical progression – establish WB control first followed by swing mobility
WB control practice in quiet stance and stride stance
4. Isometric holds: on the diagonal for stride stance
5. Rhythmic Stabilization (rotation isometric holds): on the diagonal for stride stance
6. Slow reversals with and without a hold at the end: on the diagonal for stride stance
Be sure to include points of control at the knee to facilitate knee extension & block buckling. Practice
points of control at the foot and ankle to control inversion.
Can add table or counter for UE support for low level or those that need to train to use a walker long
term
Be on the weak side
Weight shifting should never go to full excursion (small weight shifts and light input) for those with
ataxia
Translation of tibia over the foot
1. Step forward and back with unaffected leg while facilitating/supporting affected leg in
anterior weight shift.
2. Practice stability in unilateral stance
Swing through
1. Release pelvis: TC’s at greater trochanter & ischial tuberosity (scoop)
2. Let femur swing forward producing hip & knee flexion
3. Slide foot forward
Step back
1. Release pelvis and let femur swing forward
2. Slide foot back with hip extension and knee flexion

Remember to incorporate the UE during pre-gait activities

1. UE on ll bars
2. UE on assistive device
3. UE on table or mat
4. Modified plantigrade

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Lab 5 Standing/Pre-gait/Gait Progression

GAIT

With hemiparetic distribution of motor impairment, start affected leg with WB sequence first during
gait.

General Rules:
1. Allow patient to do as much as possible
2. Fill-in the gaps with your handling, physical assistance, and feedback
3. Plan to remove your feedback and give control back to patient as soon as able
4. Add assistive devices & orthotics as needed to support function and safety – remember both
are compensatory strategies that can impede restorative changes so be thoughtful about
using.
5. Practice walking forward & backward
6. Practice turning
a. Turn heels one at a time in the direction of the turn in ~ 45 degree angle
b. Continue sequence until turned completely around
7. Practice stairs
a. Easiest if go up with strongest leg first and down with weakest leg first
b. Therapeutically appropriate to reverse – therapist’s judgment call
c. General guarding guidelines – therapist should stay on the down side of the steps
If a pt. isn’t swinging their foot forward coming down from a step (heel is catching), give a VC of “kick
your foot out”

For a handhold, put your elbow on top of your ASIS and interlock thumbs with patient.
8. Practice uneven surfaces
9. Incorporate walking into functional task practice (different environments, with manipulation,
etc.)
10. Advanced gait and coordination tasks
a. Side stepping
b. Braiding
c. Compliant/uneven surfaces
d. With head turns

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e. ‘Special steps’ DGI and FGA

i. Long steps
ii. Lunge steps
iii. Heel/toe walking
iv. Tandem walking
v. Over obstacles
vi. Speed changes
vii. Resisted walking
Practice facilitating gait from the front and side while sitting and standing.
- Practice gait requiring a lot of handling
o Maintain control of the hips and pelvis (hands or body)
o Direct each component of the gait cycle with your handling (verbal cues & physical
guidance *safety note – it is okay to slow a patient down so you can maintain
control of the gait training session
o Assist with swing through (pelvis or thigh or knee or foot)
o Provide support of knee during WB (knee block but still allowing translation)

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- Practice gait requiring minimal handling

o Provide handling during stance of 1 leg during several steps
o Provide handling during swing of 1 leg during several steps
Have your partner walk in real time and provide a light tactile cue at the hip during stance with every
step now try every 3rd step. Practice the same activity providing a light tactile cue on the quads during
stance.

Have your partner walk in real time and provide swing assist with every step now try every 3rd step.

- Practice special circumstances

o Provide a boundary for someone with ataxia
o Provide tactile cues to help a patient initiate and keep going
Whole task practice interventions
- BWSTT
- Intensive gait training

Practical: 15 minutes early, like first practical, Pt. will have a goal, design intervention and plan, build
capacity, part whole practice, bed/chair starting, stroke, MS, PD, TBI cases, provide TC’s and VC’s
Goal: bed mobility goal, transfer goal, gait goal, step goal, floor transfer goal