Physical Rehabilitation

Description

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Front Matter
PREFACE
CONTRIBUTING EDITORS
Case Study and Multimedia Editor
Test Bank Editor
CONTRIBUTING AUTHORS
CASE STUDY CONTRIBUTORS
ACKNOWLEDGMENTS
ABOUT THE AUTHORS
SECTION ONE Clinical Decision Making and Examination
Chapter 1 Clinical Decision Making
LEARNING OBJECTIVES
CLINICAL REASONING/CLINICAL DECISION MAKING
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (ICF)
Figure 1.1 ICF Model of Disability. The WHO classification of functioning, disability and health (ICF).
PATIENT/CLIENT MANAGEMENT
Examination
History
Box 1.1 Terminology: Functioning, Disability, and Health
Systems Review
Figure 1.2 Elements of patient management leading to optimal outcomes.
Tests and Measures
Figure 1.3 Types of data that may be generated from patient history.
Box 1.2 Sample Interview Questions
Evaluation
Box 1.3 Categories for Tests and Measures
Diagnosis
Table 1.1 Sample Prioritized Problem List for a Patient With Stroke
Prognosis
Plan of Care
Goals and Expected Outcomes
Box 1.4 Examples of Outcome and Goal Statements
Interventions
Coordination and Communication
Patient/Client-Related Instruction
Figure 1.4 The three components of physical therapy intervention.
Procedural Interventions
Discharge Planning
Implementation of the Plan of Care
Box 1.5 The FITT Equation for Exercise Intervention
Box 1.6 Elements of the Discharge Plan
Reexamination of the Patient and Evaluation of Expected Outcomes
PATIENT PARTICIPATION IN PLANNING
Box 1.7 Questions Designed to Engage the Patient in the Treatment Planning Process
Box 1.8 Levels of Participation Scale
DOCUMENTATION
Electronic Documentation
CLINICAL DECISION MAKING: EXPERT VERSUS NOVICE
EVIDENCE-BASED PRACTICE
Box 1.9 Evidence-Based Practice: Electronic Medical Databases
Table 1.2 Levels of Evidence for Treatment Effectiveness
SUMMARY
Questions for Review
CASE STUDY
References
appendix 1.A Preferred Practice Patterns: APTA Guide to Physical Therapist Practice4
MUSCULOSKELETAL
NEUROMUSCULAR
CARDIOVASCULAR/PULMONARY
INTEGUMENTARY
appendix 1.B Defensible Documentation—General Documentation Guidelines From APTA
appendix 1.C Overview of Evidence-Based Practice Concepts
Dimension
Format
Reliability
Validity
References
Chapter 2 Examination of Vital Signs
LEARNING OBJECTIVES
NORMATIVE VITAL SIGN DATA
Table 2.1 Comparison of Normal Vital Signs for Various Ages Reported as Ranges
Table 2.2 Comparison of Normal Vital Signs for Various Ages Reported Using a Combination of Averages and Ranges
Figure 2.1 Mean systolic and diastolic pressure for men aged 18 years and over, by age and hypertension status.
Figure 2.2 Mean systolic and diastolic pressure for women aged 18 years and over, by age and hypertension status.
Table 2.3 Resting Pulse Rate Estimates for U.S. Males, by Age Group National Health and Nutrition Examination Survey, 1999–2008
Table 2.4 Resting Pulse Rate Estimates for U.S. Females, by Age Group National Health and Nutrition Examination Survey, 1999–2008
ALTERATIONS IN VITAL SIGN VALUES: OVERVIEW OF INFLUENTIAL VARIABLES
Lifestyle Patterns and Patient Characteristics
Culture and Ethnicity
Table 2.5 Population by Hispanic or Latino Origin and by Race for the United States: 2000 and 2010
PATIENT OBSERVATION
Box 2.1 Common Skin Color Changes
Figure 2.3 (A) Clubbing of fingertips is associated with long-term hypoxic states; (B) normal nail plate angle of 160°; (C) a nail plate angle of 180° or more occurs with clubbing.
TEMPERATURE
Thermoregulatory System
Figure 2.4 Thermoregulatory responses. The thermoreceptors provide input regarding changes in body temperature that signal the preoptic nucleus of the hypothalamus. This physiological thermostat compares incoming signals of actual body temperature with the set point value. If body temperature is lower than the set point value, heat gain mechanisms are implemented. If body temperature is higher than the set point value, heat loss mechanisms are implemented.45,46
Thermoreceptors
Regulating Center
Effector Organs
Conservation and Production of Body Heat
Figure 2.5 Physiological adjustments during heat acclimation. Increased body temperature activities heat (loss) dissipation to maintain normal body temperature.
Loss of Body Heat
Abnormalities in Body Temperature
Increased Body Temperature
Figure 2.6 Mechanisms of heat dissipation from body. Conduction is the transfer of heat by direct contact between two objects (hand on wall), radiation occurs through electromagnetic waves between objects not in direct contact with each other (subject’s body and wall), heat loss by convection is accomplished via air currents (wall fan) after the heat is conducted to air, evaporation converts liquid (perspiration) to a vapor.
Box 2.2 Types of Fever
Decreased Body Temperature
Factors Influencing Body Temperature
Time of Day
Age
Emotions/Stress
Exercise
Menstrual Cycle
Pregnancy
External Environment
Measurement Site
Ingestion of Warm or Cold Foods
Types of Thermometers
Glass Mercury Thermometers
Figure 2.7 Comparison of Fahrenheit and Centigrade scales indicating ranges of normal and altered body temperature.
Figure 2.8 Shape of tips (bulbs) on mercury glass thermometers. The long slender shape (A) is for oral use and the blunt round shape (B) is for rectal measures.
Automated Thermometers
Oral Thermometers
Tympanic Thermometer
Temporal Artery Thermometer
Figure 2.9 (A) Hand-held electronic thermometer with disposable probe covers reduces the risk of cross-contamination. (B) This device interfaces with the electronic medical record (EMR). By scanning the patient’s hospital identification bracelet, two-way wireless communication links ID numbers to patient names for positive identification at the bedside. The unit measures temperature, blood pressure, and oxygen saturation levels (pulse oximetry). The device reduces time required and potential errors of manual documentation as data are relayed directly to the EMR. Manual data may also be entered (e.g., respiratory rate).
Figure 2.10 Hand-held automated oral thermometer.
Figure 2.11 (A) Tympanic (ear) thermometer. This thermometer incorporates a sensor that detects infrared radiation from the tympanic membrane (eardrum) and converts the warmth into a digital temperature reading. (B) Temporal artery thermometer. As a measurement site, the temporal artery is easily accessible and poses low risk of injury as there is no contact with mucous membranes.
Disposable Single-Use Thermometers
Oral Thermometers
Skin Surface Thermometers
Hand Hygiene
Box 2.3 Evidence Summary: Studies Examining the Reliability and Validity of Measuring Body Temperature
Figure 2.12 Disposable single-use thermometer in Fahrenheit (top) and Centigrade (bottom) scales.
Figure 2.13 The chemical dots on the disposable single-use thermometers change color from green to black to reflect the temperature (Fahrenheit, left, and Centigrade, right). The green dots turn black from left to right. The last dot to turn black indicates the temperature. Note there are two grids of dots on each scale (left and right). Values that fall in the right grid indicate fever is present. In the example on the right, 38.1°C (100.5°F) represents fever.
Box 2.4 Factors Considered by WHO in Recommending Hand Rubs
Measuring Body Temperature
Measuring Oral Temperature: Automated Thermometer
Figure 2.14 Hand rubbing technique.
Figure 2.15 Hand washing technique.
Measuring Axillary Temperature: Automated Thermometer
Figure 2.16 Positioning for monitoring axillary temperature. Placing the patient’s arm across the chest forces cool air out of the axilla that could potentially result in a lower temperature value. This positioning also places the probe near the vascular supply to the axilla. The proximal portion of the thermometer should be angle toward the patient’s head.
Measuring Tympanic Membrane Temperature: Automated (Ear) Thermometer
PULSE
Rate
Rhythm
Quality
Figure 2.17 Normal (top) and abnormal pulses, as reflected in arterial waveforms.
Table 2.6 Numerical Scale for Grading Pulse Quality (Strength)
Factors Influencing Heart Rate
Age
Sex
Emotions/Stress
Exercise
Medications
Systemic or Local Heat
Pulse Sites
Monitoring Pulse
Table 2.7 Pulse Sites, Locations, and Indications for Use
Figure 2.18 Common sites for monitoring peripheral pulses.
Measuring Radial Pulse
Box 2.5 Evidence Summary: Studies Examining the Reliability and Validity of Pulse and Heart Rate Monitoring
Measuring Apical Pulse
Measuring Apical–Radial Pulse
Automated Heart Rate Monitoring
Figure 2.19 The apical pulse is located approximately 3.5 inches to the left of the midsternum, in the fifth intercostal space.
Doppler Ultrasound and Pulse Oximetry
Doppler Ultrasound
Figure 2.20 Heart rate monitors (HRMs). (A) Wrist monitor with chest strap transmitter worn directly on the skin and positioned at heart level. (B) Example of wrist monitors with two fingertip sensors above and below LCD; the index and middle finger are placed on contact points to obtain HR. (C) Monitor with neck strap and fingertip sensor. (G) Wrist monitor with lead wire and fingertip sensor. (H) HRM worn on dorsum of hand with finger sleeve.
Pulse Oximetry
Figure 2.21 Pulse oximeters provide data on arterial blood oxygen saturation as well as pulse rate. (A) Standard pulse oximetry unit. (B) Portable hand-held pulse oximeter.
Figure 2.22 Oximetry sensors. (A) The fingertip (transmission) sensor and (B) forehead (reflectance) sensor.
RESPIRATION
Respiratory System
Figure 2.23 Cross-sectional drawing of a fingertip oximetry sensor illustrating the dual light sources, photodetector, schematic connection to oximeter and hypothetical oxygen saturation measurement output. Note: In the fingertip (transmission) sensors, the light sources are positioned opposite the photodetector. In the forehead (reflectance) sensors, the light sources and photodetector are positioned on one side of the sensor.
Figure 2.24 Structures of the respiratory system.
Inspiration
Figure 2.25 Structure of cartilaginous airways, including the trachea and major bronchi.
Expiration
Regulatory Mechanisms
Figure 2.26 Schematic illustration of the functional zones of the respiratory tract. The top area from the trachea to the terminal bronchioles is called the “conductive zone” because these airways transport (conduct) inhaled air to and from the respiratory zone. The bottom area of the illustration represents the areas where air exchange takes place. The air exchange occurs in progressively increasing increments in the respiratory bronchioles, alveolar ducts, and alveolar sacs. Collectively these areas constitute the “respiratory zone.”
Factors Influencing Respiration
Age
Body Size and Stature
Exercise
Body Position
Environment
Emotions/Stress
Pharmacological Agents
Parameters of Respiration
Patterns of Respiration
Figure 2.27 Normal (top) and abnormal respiratory patterns. When examining respiratory patterns, consider the rate, rhythm, and depth of breathing and describe what is observed using these terms.
Respiratory Examination
Monitoring Respiration
Box 2.6 Evidence Summary: Studies Examining the Reliability and Validity of Measuring Respiratory Rate
BLOOD PRESSURE
Blood Pressure Regulation
Factors Influencing Blood Pressure
Blood Volume
Diameter and Elasticity of Arteries
Cardiac Output
Age
Table 2.8 Classification of Blood Pressure for Adults Ages 18 Years and Older
Exercise
Valsalva Maneuver
Orthostatic Hypotension
Arm Position
Risk Factors
Equipment Requirements
Box 2.7 Evidence Summary: Studies Examining the Reliability and Validity of Blood Pressure Measurements
Figure 2.28 In clinical settings, sphygmomanometers may be (A) wall-mounted or (B) placed on a mobile stand.
Figure 2.29 Sphygmomanometers. (A) Mercury gauge manometers have a vertical glass tube containing liquid mercury with a 300 mm Hg scale marked in 2-mm increments. (B) Aneroid manometers consist of a circular glass-covered 300 mm Hg gauge in 2-mm increments with needle marker.
Figure 2.30 (A) Automated clinical sphygmomanometer with (B) differently sized cuffs.
Figure 2.31 Personal-size automated sphygmomanometers (A) arm cuff and (B) wrist cuff.
Figure 2.32 Stethoscopes. Standard acoustic stethoscope with a single tube leading to diaphragm (left) andSprague Rappaport type stethoscope with two separatetubes leading to diaphragm (right).
Korotkoff’s Sounds
Figure 2.33 Combination design stethoscope head with one side bell-shaped (left) to auscultate low-frequency sounds and the opposite side a flat disk diaphragm (right) for high-frequency sounds.
Figure 2.34 Automated stethoscopes. (A) Standard automated stethoscope and (B) automated stethoscope with headset to block out environmental noise designed for use by emergency medical service (EMS) personnel.
Measuring Brachial Blood Pressure
Figure 2.35 Placement of blood pressure cuff and stethoscope for monitoring brachial artery blood pressure.
Measuring Popliteal (Thigh) Blood Pressure
Recording Results
RESOURCES
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 2.A Measuring Oral Temperature: Glass Mercury Thermometer
appendix 2.B Measuring Axillary Temperature: Glass Mercury Thermometer
appendix 2.C Resources for Patients, Families, and Clinicians
American Heart Association (www.heart.org/HEARTORG)
Chapter 3 Examination of Sensory Function
LEARNING OBJECTIVES
SENSORY INTEGRATION
SENSATION AND MOVEMENT
SENSORY INTEGRITY
CLINICAL INDICATIONS
Box 3.1 Examples of Pathologies, Impairments, Functional Limitations, Disabilities, Risk Factors and Health, Wellness, and Fitness Needs Associated with Changes in Sensory Integrity (Note: ICF terminology has been parenthetically added)
Pattern (Distribution) of Sensory Impairment
Figure 3.1 Anterior view of skin segment innervation by dorsal roots (left) and peripheral nerves (right).
Figure 3.2 Posterior view of skin segment innervation by dorsal roots (left) and peripheral nerves (right).
Spinal Cord Tracts
AGE-RELATED SENSORY CHANGES
PRELIMINARY CONSIDERATIONS
Arousal, Attention, Orientation, and Cognition
Box 3.2 Evidence Summary: Research Exploring Age-Related Changes in Sensory Function
Box 3.3 Sample Questions for Examining Orientation
Memory, Hearing, and Visual Acuity
Memory
Hearing
Visual Acuity
CLASSIFICATION OF THE SENSORY SYSTEM
Sensory Receptors
Superficial Sensation
Deep Sensation
Combined Cortical Sensations
Spinal Pathways
Anterolateral Spinothalamic
Dorsal Column–Medial Lemniscal System
TYPES OF SENSORY RECEPTORS
Cutaneous Receptors
Box 3.4 Classification of Sensory Receptors
Free Nerve Endings
Hair Follicle Endings (Hair End-Organs)
Merkel’s Discs
Ruffini Endings
Krause’s End-Bulb
Meissner’s Corpuscles
Pacinian Corpuscles
Figure 3.3 The cutaneous sensory receptors and their respective locations within the various layers of skin (epidermis, dermis, and the subcutaneous layer).
Deep Sensory Receptors
Muscle Receptors
Muscle Spindles
Golgi Tendon Organs
Free Nerve Endings
Pacinian Corpuscles
Joint Receptors
Golgi-Type Endings
Free Nerve Endings
Ruffini Endings
Paciniform Endings
PATHWAYS FOR TRANSMISSION OF SOMATIC SENSORY SIGNALS
Anterolateral Spinothalamic Pathway
Dorsal Column–Medial Lemniscal Pathway
SOMATOSENSORY CORTEX
Figure 3.4 Anterolateral spinothalamic tract carrying pain and temperature.
Figure 3.5 Dorsal column-medial lemniscal tract carrying discriminative sensations such as kinesthesia and touch.
Table 3.1 Features of Pathways for Transmission of Somatic Sensory Signals
SCREENING
PREPARATION FOR ADMINISTERING THE SENSORY EXAMINATION
Figure 3.6 (A) The somatosensory cortex has three main divisions: The primary (S-I) and secondary (S-II) areas, and the posterior parietal lobe. (B) The sensory homunculus. Areas of the body used for tactile discrimination (e.g., lips, tongue, and fingers) are represented by large areas of cortical tissue. Areas with reduced cortical representation, such as the trunk, are reflective of body parts with lesser roles in sensory perception.
Testing Environment
Equipment
Figure 3.7 Single use protected neurological pin. The image on the left shows the pin prior to use with the protective cap intact (although schematically presented to allow visualization of pin location). On the right, the protective cap is removed and the pin exposed. On the opposite end of the pin is a smooth rounded surface used to randomly intersperse application of a dull stimulus. After use, the point is destroyed by compressing it against a hard surface and disposed of in a biohazard receptacle.
Figure 3.8 The Tip Therm® is a thermal instrument designed for patient monitoring of gross temperature perception of the feet. The instrument is 4 inches (100 mm) long with a .59 inch (15 mm) diameter.
Figure 3.9 A handheld aesthesiometer provides a quantitative measure of two-point discrimination. The two-point threshold is determined by gradually bringing the tips closer together as it is sequentially applied to the patient’s skin. The scale is calibrated to the nearest 0.1 cm and measures up to 14 cm.
Patient Preparation
Figure 3.10 This circular two-point discrimination instrument consists of two joined plastic rotating disks with rounded tips placed at standard testing intervals.
THE SENSORY EXAMINATION
Figure 3.11 Sample Sensory Examination Form.
Superficial Sensations
Pain Perception
Table 3.2 Terminology Describing Common Sensory Impairments
Response
Temperature Awareness
Response
Touch Awareness
Response
Pressure Perception
Response
Deep Sensations
Kinesthesia Awareness
Response
Proprioceptive Awareness
Response
Vibration Perception
Response
Combined Cortical Sensations
Stereognosis Perception
Response
Tactile Localization
Response
Figure 3.12 A sensory testing shield can be used for examining stereognosis in the presence of speech or language impairments. In this simulation, the subject manipulates the object without the use of visual input. Following manipulation, the subject points to the matching object pictured on the ledge of the testing shield.
Two-Point Discrimination
Response
Double Simultaneous Stimulation
Response
Graphesthesia (Traced Figure Identification)
Response
Recognition of Texture
Response
Barognosis (Recognition of Weight)
Figure 3.13 Discrimination weights are identical in size, shape, and texture. The only distinguishing feature is their variation in weight.
Response
RELIABILITY
QUANTITATIVE SENSORY TESTING AND SPECIALIZED TESTING INSTRUMENTS
TSA-II Thermal Sensory Analyzer + VSA 3000 (Medoc, Ltd., Durham, NC)
von Frey Aesthesiometer (Somedic Sales AB, Hörby, Sweden)
Figure 3.14 TSA-II Thermal Sensory Analyzer + VSA 3000. This system provides quantitative measures of both thermal and vibratory stimuli using a variety of patient interfaces. Note the small handheld vibratory device on the far left.
Figure 3.15 Thermode placed in hand for measuring perception of thermal stimuli.
Figure 3.16 Foot support vibratory stimulator.
Figure 3.17 Computer-generated data from thermal testing that presents a comparison between the two sides of the body. Note the data for the right foot presents consistently higher threshold values than that of the left. Values are generated for each foot as well as the total difference between the feet. All values are in Celsius. Conversions for the temperature scale on the left border are 32°C = 89.6°F and 50°C = 122°F.
Figure 3.18 von Frey aesthesiometer. This set contains 17 monofilaments mounted on Plexiglas handles.
Touch-Test Sensory Evaluator (North Coast Medical, Inc., Morgan Hill, CA)
Rydel-Seiffer 64/128 Hz Graduated Tuning Fork (US Neurologicals, Kirkland, WA)
Figure 3.19 Individual monofilament.
Rolltemp (Somedic Sales AB, Hörby, Sweden)
Figure 3.20 Schematic illustration of the Rydel-Seiffer tuning fork.
Figure 3.21 The Rolltemp provides a quick screening tool for thermal sensation. The rollers are mounted on handles and stored upright in the two square insertion points on the storage unit. One roller is maintained at 40°C (104°F); the other at 25°C (77°F).
Bio-Thesiometer (Bio-Medical Instrument Co, Newbury, OH)
Vibrameter (Somedic Sales AB, Hörby, Sweden)
SENSEBox (Somedic Sales AB, Hörby, Sweden)
Figure 3.22 Bio-Thesiometer for measuring perception of vibratory stimulus.
Figure 3.23 Vibrameter for measuring perception of vibratory stimulus
MSA (Modular Sensory Analyzer) Thermotest (Somedic Sales AB, Hörby, Sweden)
Figure 3.24 (A) SENSEBox. Viewing counterclockwise, to the left of computer is the electronic patient response visual analog scale (VAS), von Frey transducer for touch evoked potentials, pushbutton patient response device, algometer transducer for measuring sensitivity to pain, and data collection unit. (B) Algometer transducer for SENSEBox.
Figure 3.25 MSA Thermotest. In the right foreground is a 1 × 2 inch (25 × 50 mm) standard thermode for application of thermal stimuli.
CRANIAL NERVE SCREENING
SENSORY INTEGRITY WITHIN THE CONTEXT OF TREATMENT
Table 3.3 Functional Components of the Cranial Nerves
Box 3.5 Screening Tests for Cranial Nerves9,63
Figure 3.26 Elements of patient management for sensory impairment. KP refers to knowledge of performance (feedback about the quality of movement produced) and KR refers to knowledge of result (feedback about the end result or outcome of the movement).
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 3.A Two-point Discrimination Values for Healthy Subjects 20 to 24 Years of Age
Two-Point Discrimination Values for the Upper Extremities of Healthy Subjects 20 to 24 Years of Age (N = 43)
Two-Point Discrimination Values for the Lower Extremities of Healthy Subjects 20 to 24 Years of Age (N = 43)
Two-Point Discrimination Values for the Face and Trunk of Healthy Subjects 20 to 24 Years of Age (N = 43)
Chapter 4 Musculoskeletal Examination
LEARNING OBJECTIVES
PURPOSES OF THE MUSCULOSKELETAL EXAMINATION
EXAMINATION PROCEDURES
Patient History and Interview
Figure 4.1 An example of a medical history recording form.
Opening Question
Onset of Symptoms
Location of the Symptoms
Quality of the Symptoms
Figure 4.2 This body chart can supplement the patient’s verbal description of the location of the pain.
Figure 4.3 Sclerotomes from the anterior and posterior aspects of the body.
Behavior of the Symptoms
Figure 4.4 Two types of numerical pain rating scales.
Figure 4.5 Visual analog pain rating scale. The line is usually 10 cm in length. The patient’s mark is measured from the left (no pain) end of the scale and is recorded in centimeters.
Figure 4.6 Thermometer pain rating scale.
Figure 4.7 The McGill Pain Questionnaire. The first 10 groups of words are somatic (describing what the pain feels like), 11–15 are affective, 16 is evaluative, and 17–20 miscellaneous.13
Behavior of Symptoms During the Last 48 Hours
Previous Care of this Problem
Specific Medical History
General Medical History
Medications
Social History and Occupational, Recreational, and Functional Status
Anticipated Goals, Expected Outcomes, and Time Frame of Recovery
Figure 4.8 Questions used to rate a patient’s function. The patient circles the percent of activity that he or she is able to perform.
Concluding Question
Mental Status
Vital Signs
Observation/Inspection
Figure 4.9 The location of the line of gravity from the lateral view.
Palpation
Anthropometric Characteristics
Range of Motion
Active Range of Motion
Passive Range of Motion
Figure 4.10 A variety of metal and plastic universal goniometers in different sizes and shapes. All universal goniometers have a central “body” with a protractor and fulcrum to center over the patient’s joint, as well as two “arms” to align with the patient’s body parts.
Figure 4.11 An inclinometer, with a bubble to indicate the position of the goniometer relative to gravity, is used to measure the beginning (A) and end (B) of lumbar flexion ROM.
Figure 4.12 Measurement of the beginning (A) and end (B) of shoulder flexion ROM with a universal goniometer. The universal goniometer is moving from 0° toward 180° during the motion.
Figure 4.13 Range of motion recording form for the lower extremity. The multiple columns on either side of the centrally listed joints and motions are used to record the date, examiner’s initials, and ROM values from serial measurements.
End-Feel
Capsular Patterns of Restricted Motion
Box 4.1 Evidence Summary: Outcome Studies on Reliability of Using Universal Goniometer to Measure Elbow Range of Motion
Table 4.1 Normal End-Feels
Table 4.2 Abnormal End-Feels
Table 4.3 Capsular Patterns of Extremity Joints
Noncapsular Patterns of Restricted Motion
Accessory Joint Motions
Figure 4.14 A glide (slide) is a type of linear accessory joint motion in which points on a moving joint surface comes in contact with new points on the opposing joint surface.
Figure 4.15 During a roll, new points on the moving joint surface come in contact with new points on the opposing surface. The axis of rotation also moves, in this case to the right.
Figure 4.16 A spin is an accessory joint motion in which all the points on the moving surface rotate around a fixed axis.
Muscle Performance
Figure 4.17 Diagrammatic representation of the concave-convex rule. (A) If the joint surface of the moving bone is convex, gliding is in the opposite direction of the angular movement of the bone. (B) If the joint surface of the moving bone is concave, gliding is in the same direction as the angular movement of the bone.
Table 4.4 Accessory Joint Motion Grades and Implications for Treatment
Resisted Isometric Testing
Manual Muscle Testing
Table 4.5 Results of Resisted Isometric Testing
Table 4.6 Manual Muscle Testing Grades
Figure 4.18 An example of a manual muscle testing recording form.
Handheld Dynamometry
Figure 4.19 Measurement of the strength of the left hip abductors with a handheld dynamometer. The handheld dynamometer measures force at the point of application, which should be converted to torque by multiplying the force by the distance from the joint axis.
Isokinetic Dynamometry
Figure 4.20 An isokinetic dynamometer is being used to measure muscle performance characteristics of the right knee extensors (quadriceps). Peak torque is the most frequently noted characteristic.
Special Tests
Table 4.7 Grading of Ligamentous Instability Tests
Additional Tests and Measurements
EVALUATION OF EXAMINATION FINDINGS
Figure 4.21 Manual muscle testing recording forms that aids in determining the site or level of a nerve lesion.
Table 4.8 Myotomes2,3
SUMMARY
Questions for Review
CASE STUDY 1
CASE STUDY 2
References
Chapter 5 Examination of Motor Function: Motor Control and Motor Learning
LEARNING OBJECTIVES
OVERVIEW OF MOTOR FUNCTION
COMPONENTS OF THE EXAMINATION
Patient History
Systems Review
Tests and Measures
FACTORS THAT MAY CONSTRAIN THE MOTOR FUNCTION EXAMINATION
Consciousness and Arousal
Table 5.1 Effects of Autonomie Nervous System Stimulation
Cognition
Orientation
Attention
Memory
Communication
Sensory Integrity and Integration
Joint Integrity, Postural Alignment, and Mobility
ELEMENTS OF THE MOTOR FUNCTION EXAMINATION
Tone
Hypertonia
Spasticity
Table 5.2 Positive and Negative Features of Upper Motor Neuron Syndrome
Rigidity
Decorticate and Decerebrate Rigidity
Dystonia
Hypotonia
Table 5.3 Typical Patterns of Spasticity in Upper Motor Neuron Syndrome
Modified Ashworth Scale
Special Tests
Table 5.4 Modified Ashworth Scale for Grading Spasticity
Documentation
Reflex Integrity
Deep Tendon Reflexes
Box 5.1 Evidence Summary: Reliability of Measurements Obtained With the Modified Ashworth Scale (MAS)
Superficial Cutaneous Reflexes
Table 5.5 Examination of Deep Tendon Reflexes
Primitive and Tonic Reflexes
Table 5.6 Examination of Superficial Cutaneous Reflexes
Documentation of Reflex Integrity
Cranial Nerve Integrity
Table 5.7 Examination of Primitive and Tonic Reflexes
Documentation of Cranial Nerve Integrity
Muscle Performance
Muscle Atrophy
Table 5.8 Examination of Cranial Nerve Integrity
Examination of Muscle Bulk
Strength and Power
Examination of Muscle Strength and Power
Documentation of Strength and Power
Muscle Endurance
Examination of Fatigue
Documentation
Voluntary Movement Patterns
Abnormal Synergistic Patterns
Examination
Documentation
Activity-based Task Analysis
Table 5.9 Differential Diagnosis: Comparison of Upper Motor Neuron (UMN) and Lower Motor Neuron (LMN) Syndromes
Table 5.10 Differential Diagnosis: Comparison of Major Types of Central Nervous System Disorders
Taxonomy of Tasks
Box 5.2 Functional Task Analysis Worksheet
Videography
MOTOR LEARNING
Table 5.11 Categories of Motor Skills
Stages of Motor Learning
Measures of Motor Learning
Performance Observations
Table 5.12 Measures of Motor Performance
Retention Tests
Transfer Tests
Adaptability
Resistance to Contextual Change
Active Problem Solving
Learning Styles
ELECTROPHYSIOLOGICAL INTEGRITY OF MUSCLE AND NERVE
Concepts of Electromyography
Recording the EMG Signal
Figure 5.1 The motor unit is composed of one anterior horn cell, one axon, its neuromuscular junction, and all the muscle fibers innervated by that axon.
Figure 5.2 Cross-sectional view of muscle belly with needle electrode inserted. Differently shaded fibers represent different motor units.
The EMG Examination
Figure 5.3 Single motor unit potentials as seen on an oscilloscope or computer. Each unit has a distinct shape.
Spontaneous Abnormal Potentials
Figure 5.4 Normal recruitment of the triceps brachii in a 44-year-old healthy man. Activity was recorded during minimal contraction (A) when single motor unit potentials are visible, during moderate contraction (B) when motor units are recruited, and during maximal contraction (C) when an interference pattern is visible.
Figure 5.5 Spontaneous activity of the anterior tibialis in a 68-year-old woman with amyotrophic lateral sclerosis. Positive sharp waves (A, B) have a consistent configuration with a sharp positive deflection followed by a long-duration, low-amplitude negative deflection (B). Fibrillation potentials (C, D) are low-amplitude biphasic spikes.
Polyphasic Potentials
Figure 5.6 Repetitive discharge from the right anterior tibialis of a 39-year-old man with myotonic dystrophy. The waxing and waning quality of these discharges will result in a “dive-bomber” sound.
Figure 5.7 Motor unit action potentials. (A) Normal potential. (B) Long-duration polyphasic potential (shown twice). (C) Short-duration, low-amplitude, polyphasic potential.
Nerve Conduction Tests
Motor Nerve Conduction Velocity Testing
Figure 5.8 Sites of stimulation for motor nerve conduction study of the median nerve.
Figure 5.9 Recording of the M wave from a nerve conduction velocity test of the median nerve. The upper trace is from the distal stimulation site, and the lower trace is from the proximal stimulation site. The stimulus artifact appears at the left of both traces. The latencies are measured from the stimulus artifact to the start of the M wave.
Calculation of Motor Nerve Conduction Velocity
Sensory Nerve Conduction Velocity Testing
H Reflex
The F Wave
Disorders of Peripheral Nerve
Motor Neuron Disorders
Myopathies
EVALUATION
Figure 5.10 Large-amplitude, long-duration motor unit potentials from the first dorsal interosseus (A) compared with relatively normal motor unit potentials from orbicularis oculi (B) in a patient with polyneuropathy. Note discrete single-unit interference pattern during maximal voluntary contraction.
Figure 5.11 Low-amplitude, short-duration motor unit potentials recorded during minimal voluntary contraction from the biceps brachii (A) and tibialis anterior (B) in a 7-year-old boy with Duchenne’s dystrophy. A high number of discharging motor units during minimal contraction reflects early recruitment because of decreased fiber activity.
DIAGNOSIS
SUMMARY
Questions for Review
CASE STUDY
References
Chapter 6 Examination of Coordination and Balance
LEARNING OBJECTIVES
EXAMINATION OF COORDINATION
OVERVIEW OF THE MOTOR SYSTEM
The Motor Cortex
Figure 6.1 Primary areas of the cortex involved in coordinated movement.
Figure 6.2 The motor homunculus indicates the somatotopic organization of the motor cortex. The relative size of body parts reflects the proportion of the motor cortex devoted to controlling that area.
Descending Motor Pathways
Cerebellum
Basal Ganglia
Dorsal Column–Medial Lemniscal Pathway
Figure 6.3 The motor circuit of the basal ganglia provides a subcortical feedback loop from the motor and somatosensory areas of the cortex, through portions of the basal ganglia and thalamus, and back to the cortical motor areas (premotor cortex, supplementary motor area, and motor cortex).
FEATURES OF COORDINATION IMPAIRMENTS
Cerebellar Pathology
Basal Ganglia Pathology
Dorsal Column–Medial Lemniscal Pathology
Table 6.1 Common Coordination Impairments Associated with Pathology of the Cerebellum and Basal Ganglia
AGE-RELATED CHANGES AFFECTING COORDINATED MOVEMENT
SCREENING
Examples of Screenings
Range of Motion
Strength
Sensation
FEATURES OF COORDINATION TESTS
Movement Capabilities
ADMINISTERING THE COORDINATION EXAMINATION
Preparation
Testing Environment
Patient Preparation
Preliminary Observation
Examination
Table 6.2 Nonequilibrium Coordination Tests*
Table 6.3 Sample Tests for Selected Coordination Impairments
Recording Test Results
Table 6.4 Coordination and Balance Examination Form
QUANTITATIVE COORDINATION TESTING AND SPECIALIZED TESTING INSTRUMENTS
CATSYS System
Choice Reaction Time Analyzer
STANDARDIZED INSTRUMENTS: UPPER EXTREMITY COORDINATION
Figure 6.4 The Jebsen-Taylor Hand Function Test includes a subset of seven functional tasks allowing examination of a broad range of skills requiring coordinated movement of the hand and fingers. Common items are used such as spoons, paper clips, cans, and pencils.
Figure 6.5 Minnesota Manual Dexterity Test consists of two operations: placing and turning. After a practice trial, scores are based on the time required to complete each of four trials for each operation.
Figure 6.6 The Purdue Pegboard Test includes a pegboard equipped with pins, collars, and washers. Scores are based on the number of assemblies completed within either a 30- or 60-second period.
Figure 6.7 The O’Connor Tweezer (left) and Finger Dexterity (right) Tests examine fine motor coordination. Each board is 11 × 5.5 inches (28 cm x 14 cm) with 100 holes and shallow wells to hold the pins. The black covers slide through grooved channels to keep pins in place during storage.
Figure 6.8 The Hand Dexterity Tool Test utilizes ordinary tools for removing and remounting the nuts and bolts. The test is timed from initiation of task (picking up first tool) until the last bolt is secured.
Figure 6.9 The Roeder Manipulative Aptitude Test is scored by counting the number of nuts and washers assembled within the allotted time.
EXAMINATION OF POSTURAL CONTROL AND BALANCE
Postural Alignment and Weight Distribution
Figure 6.10 Normal postural alignment in standing-sagittal plane. In optimal alignment, the LOG passes through the identified anatomical structures.
Examination and Documentation
Sensorimotor Integration in Postural Control
Figure 6.11 Normal sagittal plane postural alignment in sitting: (A) In optimal alignment, the line of gravity passes close to the axes of rotation of the head and neck, and trunk. (B) During relaxed sitting, the line of gravity changes very little, remaining close to those axes. (C) During slumped sitting, the line of gravity is well forward of the spine and hips.
Figure 6.12 Postural sway. Recording of the movement of the center of pressure for 60 seconds in a subject standing on a balance platform. Values: mean amplitude of sway path in inches = .13 × .15; length of path = 32.2; and velocity = .45 in/sec.
Romberg Test
Sensory Organization Test
Figure 6.13 The Sensory Organization Test.
Table 6.5 Sensory Organization Test Conditions
Clinical Test for Sensory Interaction in Balance
Movement Strategies for Balance
Fixed Support Strategies
Figure 6.14 Strategies for correcting balance perturbations.
Change-in-Support Strategies
Examination and Documentation of Movement Strategies
Standing Control
Seated Control
Documentation
Anticipatory Postural Control
Dual-Task Control
Table 6.6 Functional Balance Grades
STANDARDIZED INSTRUMENTS: POSTURAL CONTROL AND BALANCE
The Berg Balance Scale
Performance-Oriented Mobility Assessment
Reach Tests
Table 6.7 Functional Reach (FR) Reference Values (NORMS) by Age
Timed Get Up and Go Test
Timed Walking Tests
Table 6.8 Multidirectional Reach Test (MDRT) Reference Values
Dynamic Gait Index
Dual-Task Tests
Stops Walking While Talking
Sitting Balance Tests
Perceived Balance Confidence
Activities-Specific Balance Confidence (ABC) Scale
The Balance Efficacy Scale
Table 6.9 Examination of Balance Using the International Classification of Functioning, Disability, and Health (ICF) Model
Box 6.1 Evidence Summary: Functional Balance Tests
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 6.A Berg Balance Scale
appendix 6.B Performance-Oriented Assessment of Mobility I—POMA I (Tinetti) BALANCE
GAIT
Chapter 7 Examination of Gait
LEARNING OBJECTIVES
PURPOSES OF GAIT ANALYSIS
SELECTION OF APPROACH TO GAIT ANALYSIS
Reliability
Sensitivity and Specificity
Validity
GAIT TERMINOLOGY
The Gait Cycle
Figure 7.1 The eight phases of the gait cycle. Stance, the period when the reference limb is in contact with the ground, is comprised of the following five phases: initial contact, loading response, mid stance, terminal stance, and pre-swing. Swing, the period when the limb is off the ground, is comprised of the following three phases: initial swing, mid swing, and terminal swing. In addition, there are two periods in gait when both limbs are in contact with the ground: initial double limb stance (initial contact and loading response) and terminal double limb stance (pre-swing). Also, there is one period, single limb support, in which only one limb is in contact with the ground. Single limb support includes the phases of mid stance and terminal stance. Note that the contralateral limb is in swing during the reference limb’s single limb support.
Phases of Gait
Figure 7.2 A right stride and a left stride. Right stride length is the distance between the point of contact of the right heel (at the lower left corner of the diagram) and the next contact of the right heel. Left stride length is the distance between the point of contact of the left heel (at the top left of the diagram) to the point of contact at the next left heel. Each stride contains two steps, but only both steps in the left stride are labeled. The left stride contains a right step and a left step. The right step length (shown in the middle of the diagram) is the distance between the left heel contact to the point of the right heel contact. Left step length is the distance between the right heel contact and the next left heel contact. Step and stride times refer to the amount of time required to complete a step and to complete stride, respectively.
Table 7.1 Comparison of Gait Terminology
Table 7.2 Ankle and Foot: Normative Sagittal Plane Data and Impact of Weakness32,35
Table 7.3 Knee: Normative Sagittal Plane Data and Impact of Weakness32,35
Table 7.4 Hip: Normative Sagittal Plane Data and Impact of Weakness32,35
TYPES OF GAIT ANALYSES
Kinematic Qualitative Gait Analysis
Observational Gait Analysis
Digital Video Recording
Figure 7.3 Full Body Gait Analysis Form.
Figure 7.4 Biomechanical Gait Evaluation Form for Observational Gait Analysis.
Figure 7.5 GHORT.
Figure 7.6 Recording points of evaluation on GHORT.
Observational Gait Analysis Process
Overview of Common Deviations and Underlying Causes
Guidelines for Performing an OGA
Table 7.5 Common Ankle and Foot Deviations32,35
Table 7.6 Common Ankle and Foot Deviations32,35—cont’d
Table 7.7 Common Hip Deviations32,35
Table 7.8 Common Pelvis and Trunk Deviations32,35
OGA in Neuromuscular Disorders
Ambulation Profiles and Scales
Functional Ambulation Profile and Modifications
Iowa Level of Assistance Scale
Functional Independence Measure
Table 7.9 The Functional Independence Measure (FIM™) Instrument Seven-Point Scoring System for Locomotion—Version 5.1
Functional Assessment Measure
Table 7.10 The Functional Assessment Measure (FAM) Items
Community Balance and Mobility Scale
Gait Abnormality Rating Scale and Modifications
Dynamic Gait Index
Functional Gait Assessment
High-Level Mobility Assessment Tool
Fast Evaluation of Mobility, Balance, and Fear
Figure-of-8 Walk Test
Figure 7.7 Individual performing the Figure-of-8 Walk Test, a tool developed to quantify walking ability in older adults with mobility disorders. Time to complete, number of steps, and smoothness of movement are used to score an individual’s walking performance of a single figure-of-8 path around two cones spaced 5 feet apart.
Kinematic Quantitative Gait Analysis
Spatial and Temporal Variables
Measurement of Spatial and Temporal Variables
Simple Methods of Measuring Spatial and Temporal Variables
Table 7.11 Gait Variables: Quantitative Gait Analysis
6-Minute Walk Test
Figure 7.8 The solid line on the gait graph represents normal parameters for height. The dashed line represents data plotted for a normal 6-year-old girl whose height was 45 in (114 cm). A similar chart is available for boys.
Timed Walk Tests (5 m, 10 m, and 30 m)
Low-Cost Instrumentation for Quantifying Spatial and Temporal Variables
Figure 7.9 The Step Watch Activity Monitor 3® (SAM) is a pager-sized instrument worn at the ankle for long-term monitoring of gait function.
Instrumented Systems for Determining Spatial and Temporal Gait Parameters
Figure 7.10 Individual with Parkinson’s disease walking across the GAITRite® mat while temporal and spatial gait characteristics are recorded including walking velocity, stride length and duration, cadence, and step length and duration.
Box 7.1 Evidence Summary: Studies Addressing the Reliability and Validity of Measures of Temporal and Spatial Gait Variables Using the GAITRite® System
Evaluation of Joint Kinematics (Motion)
Electrogoniometers
Video-Based Motion Analysis Systems
Optical Motion Analysis Systems
Figure 7.11 Oqus Series-3 cameras Qualisys track motion of passive reflective markers placed over known anatomical landmarks and in clusters on body segments as the subject walks along a 6-meter walkway. Marker data will be used to reconstruct joint motions of the upper extremities, trunk, and lower extremities throughout the gait cycle.
Figure 7.12 Visual 3D computer display of kinematic data recorded using the Qualisys Motion Analysis System and surface electromyographic data recorded using the MA-300 EMG system during overground gait for a 31-year-old male. Reflective markers, applied over known locations, provided the anatomical reference for displayed skeleton and for subsequent analysis of joint motions. To the right of the skeleton, sagittal plane joint motions for the knee and ankle are displayed in the top two rows while surface EMG data for the vastus lateralis and tibialis anterior are displayed in the bottom two rows.
Figure 7.13 A typical computer-generated graph from a motion-analysis system. The graph shows knee and ankle range-of-motion patterns, which are plotted against time for both lower extremities.
Figure 7.14 Another format for presentation of the data from a motion-analysis system is computer-generated stick figure representations of one complete gait cycle. In this particular case, the pattern of knee motion is graphically presented below the stick figures.
Electromagnetic Motion Analysis System
Kinetic Gait Analysis
Kinetic Variables
Figure 7.15 Graphs and EMG data for motion of the knee in the sagittal plane for one gait cycle of the three motion patterns. Each patient represents only one of the three motion patterns (extension thrust, stiff knee, and buckling knee) associated with a slow gait velocity. The solid dark red line indicates the motion pattern and the lighter red line represents the normal. HFS, foot strike (initial contact) on the hemiplegic side; OTO, toe off on the contralateral (unaffected) side; OFS, foot strike (initial contact) on the contralateral (unaffected) side; HTO, toe off on the hemiplegic side.
Table 7.12 Gait Variables: Kinetic Gait Analysis
Figure 7.16 Computer-generated graph of the vertical, anterior-posterior and medial-lateral components of the ground-reaction force obtained as an adult walks across an AMTI force plate.
Instruments for Measuring Kinetic Variables
Force Plate Technology
Plantar Pressure Measurement Systems
Isokinetic and Isometric Torque Measurement Systems
Figure 7.17 Magnitude and location of peak pressure during one complete left foot strike. The highest pressures are shown on the heel, first metatarsal head, and great toe.
Figure 7.18 Pedar (Novel, Inc.) pressure mapping while walking barefoot (top row) and in shoes (bottom row) at self-selected comfortable (left column) and fast (right column) speeds for a 29-year-old male revealed higher pressures under the heel, metatarsal heads, and great toe during barefoot walking at a fast speed compared to the relatively low pressures while walking in shoes at a comfortable speed. Numbers within each square represent the peak pressure (N/cm2) experienced during the walking trial.
Software for Processing, Analyzing, and Displaying Kinematic and Kinetic Data
Summary of Kinematic and Kinetic Gait Analysis
Figure 7.19 Prediction regions.
Gait Pattern Classification
Normalcy Index
Cluster Analysis
Energy Cost Analysis During Gait
Physiological Energy Cost Measures
Mechanical Energy Cost Determination
Heart Rate Data
SUMMARY
Questions for Review
CASE STUDY
Goniometrie Examination of Passive Range of Motion (Degrees)
Manual Muscle Test (MMT)
Sensory Examination
NUMERIC VALUES REFER TO THE SENSATION SCALE BELOW.
References
Supplemental Readings
appendix 7.A Recording Form for Observational Gait Analysis
appendix 7.B Temporal and Spatial Measures Gait Analysis Form
appendix 7.C Manufacturer Contact Information for Gait Analysis Hardware and Software
appendix 7.D Simple Tabulated Output from the Stride Analyzer System
Chapter 8 Examination of Function
LEARNING OBJECTIVES
A CONCEPTUAL FRAMEWORK
Table 8.1 Terminology Used In Historical Disablement Frameworks
Figure 8.1 Schematic representation of the ICF.
Table 8.2 ICF Classification of Body Functions and Body Structures
Figure 8.2 ICF Classification of Activities and Participation.
EXAMINATION OF FUNCTION
Purpose of Examination of Function
General Considerations
Table 8.3 Environmental Factors in the ICF
Testing Perspectives
Figure 8.3 The Institute of Medicine model of the enabling-disabling process. Disability is a function of the interaction between the person and the environment. The amount of displacement represents the amount of disability that is experienced by the individual. Displacement is a function of the strength of the physical and social environments that support an individual and the magnitude of the potentially disabling condition.
Types of Instruments
Performance-Based Tests
Self-Reports
Instrument Parameters and Formats
Descriptive Parameters
Box 8.1 Functional Examination and Impairment Terminology
Quantitative Parameters
Response Formats
Nominal Measures
Ordinal Measures
Interval Measures
Ratio Measures
Figure 8.4 A visual analog scale for measuring pain or other symptoms. The patient is instructed to mark the line at the point that corresponds to the degree of pain or severity of symptoms that are experienced.
INTERPRETING TEST RESULTS
Table 8.4 Sample Case Vignettes
Determining the Quality of Instruments
Reliability
Validity
Sensitivity and Specificity
Meaningful Change
Table 8.5 Examples of MDC and MCID Values
Considerations in Selection of Instruments
Box 8.2 Critical Questions to Ask in Selecting an Instrument
SINGLE DIMENSION VERSUS MULTIDIMENSIONAL MEASURES OF FUNCTION
Table 8.6 Items Covered in Selected Multidimensional Functional Assessment Instruments
SAMPLE INSTRUMENTS TO ASSESS FUNCTION
The Barthel Index
Table 8.7 Items Included in the Barthel Index
The Functional Independence Measure
The Outcome and Assessment Information Set
Figure 8.5 The Functional Independence Measure (FIM) instrument scores function using a seven-point scale based on percentage(s) of active participation from patient.
The SF-36
Table 8.8 Outcome and Assessment Information Set (Oasis): ADL/IADL
Table 8.9 The SF-36: Physical and Role Function
Box 8.3 Evidence Summary: Reliability and Validity of the SF-36
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
Chapter 9 Examination of the Environment
LEARNING OBJECTIVES
UNIVERSAL DESIGN
Principles of Universal Design
DISABILITY ACCESS SYMBOLS
PURPOSE OF EXAMINATION
EXAMINATION STRATEGIES
Figure 9.1 Disability access symbols.
Interview
Table 9.1 Environmental, Home, and Work (Job/School/Play) Barriers: Types of Tests and Measures Used, Tools Used for Gathering Data, and Types of Data Generated
Self-Report and Performance-Based Measures of Function
Measures of Environmental Impact on Function
Visual Depictions and Dimensions of Physical Space
On-Site Visits
EXAMINATION OF THE HOME
Preparation for On-Site Visit
On-Site Visit
Exterior Accessibility
Route of Entry
Figure 9.2 (A) Wood bevels placed under nosings minimize the danger of “toe-catching” during transition to the next step. (B) Abrasive strips improve traction and depth perception.
Entrance
Figure 9.3 Handrail height for (a) stairs, (b) ramps, and (c) level walking surfaces in inches and millimeters.
Figure 9.4 Handrail extension at top of stairs. A similar handrail extension of 12 in (305 mm) is placed at bottom of stairs.
Figure 9.5 Handrail extensions should run a minimum of 12 in (305 mm) beyond the top and bottom edge of ramp.
Figure 9.6 Powered residential vertical lift. This lift has a 600-lb weight capacity. The platform measures approximately 36 inches wide and 48 inches deep (91.44 × 121.92 cm).
Figure 9.7 Lever-style door handle (a frequent universal design element) is particularly useful for individuals with limited grip strength because they can be activated with other body parts (e.g., fisted hand, forearm, elbow).
General Considerations: Interior Accessibility
Furniture Arrangement and Features
Box 9.1 Bariatric Considerations
Electrical Controls
Figure 9.8 Rocker switches do not require fine motor skill and can be activated without using fingers (e.g., fisted hand, lateral aspect of hand, distal forearm). Rocker switches are available with an illuminated surface and with occupancy light sensor that turns on or off upon entering or leaving the room.
Floors
Doors
Figure 9.9 Common materials used for threshold ramps are wood (shown) and aluminum with a lacquered nonslip surface. They can be used between rooms, if threshold cannot be removed.
Windows
Stairs
Figure 9.10 Powered stairlift. When not in use, the stairlift folds up against wall. It has a rack-and-pinion drive system that can safely transport up to 350 lb. The seat measures 19 inches (48.26 cm) wide and 14 inches (35.56 cm) deep.
Heating Units
Specific Considerations: Interior Accessibility
Bedroom Area
Figure 9.11 Manually operated wardrobe lift. Wardrobe lifts are available in a variety of sizes and some allow placement on either back wall or sidewalls.
Bathroom
Figure 9.12 Sample dimensions and features of an accessible bedroom.
Figure 9.13 Location and dimensions of bathroom grab bars. Values denoted in inches and millimeters. The bars should be mounted horizontally 33 in (840 mm) to 36 in (915 mm) from the floor.4 (Left) The sidewall grab bar is 42–54 in wide placed at a maximum of 12 in (305 mm) from rear wall. If anchored on or near rear wall, it should extend 54 in (1,370 mm) from the wall. (Right) The rear wall grab bar is 24–36 in wide (36 in is considered minimum if wall space allows). When 36 in long, 24 in of the bar (from center of toilet) is placed toward the side used for transfers.
Figure 9.14 Bathtub with grab bars secured to back, foot-end, and head-end walls. The hand-spray faucet attachment facilitates control of water flow direction from a sitting position.
Figure 9.15 Two tub transfer bench designs each providing a wide base of support, a secure back rest, and a long seating surface to facilitate transfers.
Figure 9.16 Combined toilet and shower seat into a single assembled seat.
Figure 9.17 Shower stall with collapsible shower seat, grab bars, and hand-spray attachment.
Kitchen
Figure 9.18 Accessible bathroom with knee clearance below sink and insulated piping. The shower entrance includes a small ramp to accommodate a difference in floor surface heights. Note that the shower hand-spray is held by a vertical slide-bar (to change height) allowing for a seated shower. Alternately, the hand-spray can be handheld to direct water flow to specific areas.
Figure 9.19 Over-sink mirror with top tilted away from wall to allow use from a seated position.
Figure 9.20 Minimum space requirements of a residential bathroom with (A) a shower stall and (B) a bathtub. The dotted line indicates lengths of wall that require reinforcement to receive grab bars or supports.
Figure 9.21 Slide-out counter spaces provide over-the-lap working surfaces. Positioned here below a built-in wall oven, the pullout surface allows for ease of transfer of hot dishes.
Figure 9.22 Glide-out under-cabinet shelves improve ability to see and access stored items.
Figure 9.23 A motorized adjustable-height sink can be raised or lowered for comfortable use from either a seated or standing position. Height-adjustment controls are located on the anterior panel of the sink.
Figure 9.24 Motorized storage cabinets that can be lowered from the resting position to allow countertop access. Height-adjustment controls ([A] high and [B] low) are located on the right anterior panel of the cabinet.
Figure 9.25 Cooktop with front-mounted controls and smooth surface that allows sliding (rather than lifting) from burner to heat-resistant countertop. Knee clearance beneath is accessed by folding doors.
Figure 9.26 Front-loading dishwasher elevated 9 in (228.6 mm) with front-mounted controls.
Figure 9.27 Front-loading clothes washer and dryer elevated 9 in (228.6 mm) with front-mounted controls.
ADAPTIVE EQUIPMENT
ASSISTIVE TECHNOLOGY
EXAMINATION OF THE WORKPLACE
Interview
Box 9.2 Categories of Assistive Technology
Job Analysis
Table 9.2 Ergonomics and Body Mechanics: Tests and Measures, Tools Used for Gathering Data, and Data Generated
Table 9.3 Suggested Interview Questions Appropriate for a Clerical Position
Functional Capacity Evaluation (FCE)
Figure 9.28 Simulator II Functional Capacity Evaluation System.
Figure 9.29 Examples of task simulations: (a) auto repair; (b) driving a bus; (c) using a screwdriver; (d) working overhead; (e) turning and (f) opening a jar.
Work Hardening/Conditioning
On-Site Visit
Figure 9.30 Work hardening equipment allows development of progressive therapeutic exercise (conditioning) programs based on simulation of a variety of tasks and assembly activities using sound ergonomic and body mechanic principles.
Figure 9.31 (A) Series of boxes of different shapes, sizes, and weights (progressively added) for lifting activities. (B) Table top unit includes bolts, washers, and nuts used for either manual or tool (e.g., use of a wrench) assembly.
External Accessibility
Internal Accessibility
Figure 9.32 Overview of recommended features of workstation chair: (1) breathable, medium-texture upholstery; (2) adjustable lumbar support that moves up/down; (3) adjustable armrests; (4) seat with rounded front border (waterfall design); (5) adjustable seat that moves up and down and tilts forward and backward; (6) a tilt mechanism that tilts forward and backward; and (7) five-caster base with a full 360-degree swivel.
COMMUNITY ACCESS
Figure 9.33 Overview of positioning recommendations for computer workstations: (1) monitor screen top slightly below eye level; (2) body centered in from of the monitor and keyboard; (3) forearms level or tilted-up slightly; (4) lower back supported by chair; (5) wrists free while typing; (6) thighs horizontal; and (7) feet resting flat on the floor.
Transportation
Figure 9.34 (a) Unobstructed high forward reach is a maximum of 48 in (1,220 mm) from the floor and the low forward reach is a minimum of 15 in (380 mm) from the floor. (b) High forward reach over a 20-inch-deep (510-mm-deep) work surface is a maximum of 48 in (1,220 mm) from the floor. (c) A work surface depth of 20 to 25 in (510 to 635 mm) allows a maximum forward reach of not greater than 44 in (1,120 mm) from the floor. (d) For a reach depth of 10 in (255 mm), the high side reach is a maximum of 48 in (1,220 mm). With a floor obstruction of 10 in (225 mm), the high side reach is a maximum of 48 in (1,220 mm) and a low reach of 15 in (380 mm) minimum. Values denoted in inches and millimeters.
Figure 9.35 A kneeling bus lowers the steps to within 3 to 6 in of the curb. Buses designed to kneel typically display a sign (Kneeling i Bus) either on or next to the door.
Figure 9.36 Bus lifts are able to accommodate wheelchairs and motorized scooters. The international wheelchair symbol for accessibility is typically displayed on the doors of the bus.
Access to Community Facilities
DOCUMENTATION
Figure 9.37 Examples of motorized scooters suitable for outdoor travel. (A) This lightweight scooter has a weight capacity of 275 lb (124.74 kg), a maximum speed of 4.25 miles per hour (MPH), and a turning radius of 35.5 in (90.17 cm). (B) This model includes a heavy-duty drivetrain with a weight capacity of 500 lb (226.8 kg), a maximum speed of 5.25 MPH, with a turning radius of 50.38 in (127.96 cm). (C) This unit features a reclining back with headrest, large pneumatic tires, a weight capacity of 400 lb (181.44 kg), a maximum speed of 8.25 MPH, with a turning radius of 82.5 in (209.55 cm).
FUNDING FOR ENVIRONMENTAL MODIFICATIONS
LEGISLATION
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 9.A The Principles of Universal Design
The Principles of Universal Design
appendix 9.B Usability in My Home—A Self-Report Instrument
appendix 9.C The ADL-Staircase
DEFINITIONS
ADL-STEPS IN I AND P-ADL
appendix 9.D Home Examination Form
Type of Home
Entrances to Building or Home
Location
Stairs
Door
Hallway
Approach to Apartment or Living Area
Steps
Door
Elevator
Inside Home
Bedroom
Bed
Clothing
Bathroom
Bathing
Living Room Area
Dining Room
Kitchen
Slink
Shelves and cabinets
Transport
Stove
Other Appliances
Counter space
Laundry
Cleaning
Emergency
Other
appendix 9.E Guidelines for Completing Essential and Marginal Job Function Analysis Form
Purpose and Use
Help Table
POSITION SUMMARY:
FUNCTION STATEMENTS:
POSITION CONTEXT VARIABLES:
COGNITIVE PROCESSES:
DEGREE OF PUSH/PULL ACTIVITY:
PHYSICAL REQUIREMENTS:
EQUIPMENT, TOOLS, ELECTRONIC AND COMMUNICATION DEVICES, AND SOFTWARE:
PHYSICAL SURROUNDINGS AND HAZARDS:
GENERAL INFORMATION:
appendix 9.F Web-Based Resources for Clinicians, Patients, and Families
SECTION TWO Intervention Strategies for Rehabilitation
Chapter 10 Strategies to Improve Motor Function
LEARNING OBJECTIVES
MOTOR CONTROL
Information Processing
Figure 10.1 Model of information-processing stages of movement control.
Systems Theory
Coordinative Structures
MOTOR LEARNING
Theories of Motor Learning
Stages of Motor Learning
Table 10.1 Characteristics of Motor Learning Stages and Training Strategies
Cognitive Stage
Associative Stage
Autonomous Stage
CONSTRAINTS ON MOTOR CONTROL AND LEARNING
MOTOR SKILLS
Table 10.2 Categories of Motor Skills
RECOVERY OF FUNCTION
Spontaneous Recovery
Function-Induced Recovery
Figure 10.2 Patient is executing a task practice activity involving folding towels and stacking them during (A) early and (B) later stages of execution.
Box 10.1 Evidence Summary: Constraint-Induced Movement Therapy (CIMT)
Table 10.3 Principles of Promoting Function-Induced Recovery
INTERVENTIONS TO IMPROVE MOTOR FUNCTION
Box 10.2 Examples of General Goals and Outcomes for Patients with Disorders of Motor Function
Figure 10.3 Movement emerges from interaction between the task, the individual, and the environment.
Box 10.3 Interventions to Improve Motor Function and Functional Independence
Motor Learning Strategies
Strategy Development
Feedback
Practice
Table 10.4 Types of Augmented Feedback1
Distribution: Massed Versus Distributed Practice
Table 10.5 Types of Practice and Practice Parameters1
Box 10.4 Key Questions to Promote Active Patient Decision Making and Autonomy
Functional Training
Table 10.6 Functional Postures and Potential Treatment Benefits
Environmental Context
Behavioral Shaping
Safety Awareness Training
Impairment Interventions
Box 10.5 Functional, Task-Oriented Training Strategies
Interventions to Improve Strength, Power, and Endurance
Strength Training
Table 10.7 Exercise Guidelines for Strength Training
Muscular Endurance and Fatigue
Aerobic Training
Interventions to Improve Flexibility
ROM Exercises
Passive Stretching
Facilitated Stretching
Stretching and Positioning for the Patient with Spasticity
Serial Casts
ROM for the Patient with Hypotonia
Interventions to Improve Postural Control and Balance
Interventions to Improve Static Postural Control
Interventions to Improve Dynamic Postural Control
Interventions to Improve Reactive Balance Control
Interventions to Improve Sensory Selection and Utilization for Balance
Interventions Using Augmented Feedback
Strategies to Improve Safety and Reduce Fall Risk
Box 10.6 Fall Prevention Strategies: Modifying the Home Environment
Interventions to Improve Coordination and Agility
Interventions to Improve Gait and Locomotion
Relaxation Training
Augmented Interventions
Neurodevelopmental Treatment
Neuromuscular Facilitation
Table 10.8 Neuromuscular Facilitation Techniques
Sensory Stimulation Techniques
Table 10.9 Sensory Stimulation Techniques
Biofeedback
Neuromuscular Electrical Stimulation
Compensatory Interventions
Patient/Client-Related Instruction
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
Chapter 11 Locomotor Training
LEARNING OBJECTIVES
Box 11.1 Overview of Complementary Interventions and Specific Locomotor Training Strategies
LOCOMOTOR TRAINING COMPLEMENTARY INTERVENTIONS
Strength
Sit to/From Stand Transfers
Standing Balance
LOCOMOTOR TRAINING ENVIRONMENTS
Parallel Bars
Assuming the Standing Position
Standing Activities
Overground Indoors
Circuit Training
Box 11.2 Strategies for Varying Locomotor Task Demands
Box 11.3 Evidence Summary: Selected Studies of Circuit Class Training for Patients with Stroke
Body Weight Support/Treadmill
Overground Community
Nordic Walking
Body Weight Support/Overground
Figure 11.1 Body weight support overground locomotor training using a walker.
Figure 11.2 Body weight support overground locomotor training without an assistive device. Hand placements allow the patient to move and steer the unit during forward progression.
EMERGING INTERVENTION STRATEGIES
CLINICAL DECISION MAKING
Figure 11.3 CAREN (Computer Assisted Rehabilitation Environment) Extended System is comprised of a treadmill mounted on a motion base (tilting platform), a 12-camera real-time motion capture system, 120- to 180-degree cylindrical screen projection system, and a surround sound system. Standing on the treadmill and safeguarded by a harness, the curved screen engages the patient in the activity of a virtual environment. The system is used for balance as well as all gait applications.
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 11.A Ambulatory Assistive Devices: Types, Gait Patterns, and Locomotor Training
TYPES AND GAIT PATTERNS
Canes
Box 11A.1 Clinical Descriptors of Weight-Bearing Status
Box 11A.2 Bariatric Ambulatory Assistive Devices
Types of Canes
Standard Cane
Box 11A.3 Evidence Summary: Canes
Standard Adjustable Aluminum Cane
Adjustable Aluminum Offset Cane
Figure 11A.1 Shown here are (A) standard wooden cane, (B) standard adjustable aluminum cane, and (C) adjustable offset cane.
Figure 11A.2 Shown here are a variety of large-based quadruped canes.
Quadruped (Quad) Cane
Figure 11A.3 A variety of small-based quadruped canes.
Hemi Cane
Figure 11A.4 Hemi cane.
Rolling Cane
Laser Cane
Figure 11A.5 Rolling cane.
Figure 11A.6 The Laser Cane projects a bright red laser beam across the floor in front of the patient. During a freezing of gait episode, the beam provides a visual cue for the patient to step over.
Figure 11A.7 The U-Step II walking stabilizer includes both visual (laser) and auditory (beat pattern for gait speed) cues. U-shaped base surrounds the individual for increased stability. It also includes a seat, a small projection over posterior casters to assist moving onto a curb, and a control to set rolling resistance.
Handgrips
Measuring Canes
Gait Pattern for Use of Canes
Figure 11A.8 Gait pattern for use of cane.
Figure 11A.9 The client is ambulating using bilateral offset canes with a four-point gait. One cane is advanced and then the opposite LE is advanced. For example, the right cane is moved forward, then the left LE, followed by the left cane and then the right LE.
Crutches
Types of Crutches and Attachments
Axillary Crutches
Figure 11A.10 Axillary crutch (left) and forearm crutch (right).
Figure 11A.11 Push-button handgrip adjustment with reinforcing clip-lock.
Platform Attachments
Forearm Crutches
Figure 11A.12 Platform attachment to axillary crutch. These attachments can also be used on walkers.
Measuring Crutches
Axillary Crutches
Forearm Crutches
Crutch Gait Patterns
Three-Point
Partial Weight-Bearing
Figure 11A.13 Three-point gait pattern.
Four-Point
Two-Point
Figure 11A.14 Partial weight-bearing gait; modification of the three-point gait pattern.
Walkers
Figure 11A.15 Four-point gait pattern.
Figure 11A.16 Two-point gait pattern.
Types of Walkers and Features
Glides
Folding Mechanism
Handgrips (Handles)
Figure 11A.17 Walker in (A) open and (B) folded position. The features on this walker include plastic posterior glides, a built-in seat with a molded back bar to support the user during rest intervals (the seat flips up for folding), large front wheels (6 in) to improve ease of use on multiple terrains, a second set of handles set at approximately the seat level to assist sit-to-stand transitions in the absence of chair armrests or for movement on and off a toilet, and a removable walker pouch for storing personal items. Handle height adjusts using a collar and pin mechanism that eliminates having to turn the walker over to change the height.
Figure 11A.18 The design of these walker glides incorporates a tennis ball within a fixed housing, a spring-loaded brake for intermittent braking during walking, and brake lock-out clips used to deactivate the braking feature for uninterrupted forward motion. The tennis ball can be manually rotated to unworn areas or completely removed to “snap in” a replacement.
Platform Attachments
Wheel Attachments
Braking Mechanism
Figure 11A.19 The front wheels of this walker swivel freely in all directions. The back wheels rotate around a single axis. Handbrakes allow locking the rear wheels. A seat surface accommodates rest intervals.
Tripod Rolling Walkers
Storage Attachments
Seating Surface
Figure 11A.20 Walker seat (A) positioned for use and (B) flipped up for ambulation. The 5-inch fixed front wheels of this walker rotate around a single axis. Features of this walker include rear spring-loaded brakes, a flexible backrest for sitting, a dual-paddle folding mechanism, and adjustable seat-to-floor height.
Reciprocal Walkers
Figure 11A.21 Three-wheel walker with handbrakes and polyurethane tires to improve performance on a variety of terrains.
Measuring Walkers
Gait Patterns: Conventional Walkers
Figure 11A.22 Walker basket (top) and walker pouch (bottom).
Full Weight-Bearing
Partial Weight-Bearing
Figure 11A.23 Reciprocal walkers allow unilateral movement of one side of the walker while the opposite side remains stationary.
Non-Weight-Bearing
LOCOMOTOR TRAINING USING ASSISTIVE DEVICES
Overground Indoors
Box 11A.4 Assuming Standing and Seated Positions With Assistive Devices
Stair Climbing
Figure 11A.24 Anterior (left) and posterior (right) views of guarding technique for level surfaces, demonstrated with use of crutches. The same positioning is used with canes and walkers.
Ascending Stairs (Fig. 11A.25)
Descending Stairs (Fig. 11A.26)
Adjunct Training Devices
Limb Load Monitors
Box 11A.5 Stair-Climbing Techniques*
Figure 11A.25 Guarding technique for ascending stairs.
Figure 11A.26 Guarding technique for descending stairs.
References
Chapter 12 Chronic Pulmonary Dysfunction
LEARNING OBJECTIVES
RESPIRATORY PHYSIOLOGY
Figure 12.1 Anatomy of the distal conducting airway, the terminal bronchiole and the respiratory unit, the respiratory bronchiole, alveolar ducts, alveolar sacs, and alveoli.
Figure 12.2 Lung volumes and capacities. ERV = expiratory reserve volume; FRC = functional residual capacity; IC = inspiratory capacity; IRV = inspiratory reserve volume; RV = residual volume; TLC = total lung capacity; TV = tidal volume; VC = vital capacity.
CHRONIC LUNG DISEASES
Chronic Obstructive Pulmonary Disease
Figure 12.3 The process of external and internal respiration.
Risk Factors
Pathophysiology
Table 12.1 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Classification System for Severity of Chronic Obstructive Pulmonary Disease
Clinical Presentation
Figure 12.4 (A) Normal thoracic configuration. (B) Changes in the configuration of the thorax with chronic obstructive pulmonary disease.
Figure 12.5 Accessory muscles of ventilation are those used during times of increased ventilatory demand. The right side of the figure shows some of the anterior superficial muscles of the thorax that can be accessory muscles of ventilation, and the left side shows the deeper accessory muscles of ventilation.
Course and Prognosis
Figure 12.6 Alteration in alignment of fibers of the diaphragm due to hyperinflation. Note that the configuration of fibers is more horizontal than vertical and the normal dome shape is minimized.
Figure 12.7 Lung volumes of a healthy pulmonary system compared with the lung volumes found in obstructive disease.
Asthma
Diagnosis
Table 12.2 The Prognosis of COPD Using the BODE Index13
Etiology
Pathophysiology
Clinical Presentation
Figure 12.8 (A) Airways of a healthy pulmonary system; (B) airways showing chronic inflammation of asthma; and (C) airways during an asthma exacerbation.
Clinical Course
Cystic Fibrosis
Etiology
Pathophysiology
Figure 12.9 Autosomal recessive trait (Mendelian) requires that both parents be carriers of the disease or have the disease in order for their child to have the disease.
Diagnosis
Clinical Presentation
Course and Prognosis
Restrictive Lung Disease
Etiology
Pathophysiology
Clinical Presentation
Course and Prognosis
Figure 12.10 Lung volumes of a healthy pulmonary system compared with the lung volumes found in restrictive disease.
MEDICAL MANAGEMENT
Smoking Cessation
Pharmacological Management
Table 12.3 Drugs Commonly Used in the Medical Management of Patients with Chronic Pulmonary Disease
Table 12.4 Suggested Pharmacological Management Based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Classification of Lung Severity5
Table 12.5 Suggested Pharmacological Management of Patients with Asthma According to the Global Initiative for Asthma (GINA)
Maintenance Drugs
Rescue Drugs
Antibiotics
Supplemental Oxygen
Surgical Management
PHYSICAL THERAPY MANAGEMENT
Goals and Outcomes
Examination
Box 12.1 Examples of General Goals and Outcomes for Patients with Chronic Pulmonary Dysfunction
Patient History
Tests and Measures
Vital Signs
Observation, Inspection, and Palpation
Auscultation of the Lungs
Figure 12.11 Digital clubbing is a sign of chronic tissue hypoxia. (a) Normal. (b) Early clubbing with increased angle present between nail and proximal skin. (c) Advanced clubbing; tip of distal phalanx becomes bulbous.
Figure 12.12 Auscultation of the lungs. A global assessment of lung sounds requires that the therapist listen through a stethoscope, which is placed anteriorly, posteriorly, and laterally on the upper, middle, and lower thorax.
Measurement of Dyspnea and Quality of Life
Measurement of Function
Table 12.6 Baseline Dyspnea Index
Measurement of Strength
Laboratory Tests
Exercise Testing in Patients with Pulmonary Disease
Box 12.2 Graded Exercise Test Termination Criteria
Exercise Prescription
Table 12.7 Exercise Testing Protocols Used for the Patient with Pulmonary Disease
Mode
Intensity
Exercise Intensity as a Percent of VO2max
Exercise Intensity as a Percent of Heart Rate Reserve
Box 12.3 Evidence Summary: Exercise Training Intensity: Interval versus Continuous Exercise
Exercise Intensity by Rating of Perceived Exertion or Rating of Perceived Dyspnea
Table 12.9 Rating of Perceived Shortness of Breath
Duration
Frequency
Pulmonary Rehabilitation
Aerobic Training
General Strength Training
Extremity Training
Ventilatory muscle training
Box 12.4 Evidence Summary: Ventilatory Muscle Training
Exercise Progression
Program Duration
Home Exercise Programs
Multispecialty Team
Patient Education
Figure 12.14 An exercise log that can be used to follow a patient’s ability to exercise both during and independent of the pulmonary rehabilitation program.
Box 12.5 Education Topics
Secretion Removal Techniques
Manual Secretion Removal Techniques
Postural Drainage
Percussion
Shaking
Airway Clearance
Active Cycle of Breathing Techniques
Figure 12.15 Positions used for postural drainage.
Box 12.6 Precautions for Postural Drainage
Oral Airway Oscillation Devices
Figure 12.16 Active cycle of breathing begins with breathing control. All choices are made from the breathing control phase. After each choice is made, thoracic expansion or forced expiratory technique, the patient returns to breathing control to rest and make the next choice.
Figure 12.17 The Acapella® device used for an independent program of secretion removal.
Positive Expiratory Pressure
High-Frequency Chest Compression Devices
Figure 12.18 The PEP system for an independent program of secretion removal.
Breathing Exercises
Activity Pacing
SUMMARY
Questions for Review
CASE STUDY: PATIENT WITH COPD
References
Supplemental Readings
Chapter 13 Heart Disease
LEARNI OBJECTIVES
INTRODUCTION AND EPIDEMIOLOGY OF HEART DISEASE
Figure 13.1 Surface anatomy of the heart.
CARDIAC ANATOMY AND PHYSIOLOGY
Surface Anatomy
Heart Tissue
Figure 13.2 Layers of the heart.
Coronary Arteries
Figure 13.3 Coronary circulation. (A) left main (LM); (B) left anterior descending (LAD); (C) left circumflex (CX); (D) right coronary (RCA); (E) posterior descending (PDA). The branches of the LAD are known as diagonals; the branches of the CX are known as marginals.
Heart Valves
Cardiac Cycle
Blood Flow and Hemodynamic Values
Figure 13.4 Heart sounds of the cardiac cycle.
Table 13.1 Hemodynamic Variables
Neurohormonal Influences on the Cardiovascular System
Cardiac Output
Figure 13.5 Left ventricular (LV) function curves. (A) With normal LV function, as the left ventricular volume increases, stroke volume will also increase. (B) With LV function impairment, the curve will shift to the right, and for any given length, stroke volume is decreased compared to normal (point b has a deceased SV compared to point a). (C) When normal LV function experiences an increase in sympathetic activity, the curve will shift to the left and SV will increase (note that point c is greater than point aa).
Electrical Conduction of the Heart
Myocardial Oxygen Supply and Demand
Figure 13.6 Schematic representation of the heart and normal cardiac electrical activity. The ECG is the body surface manifestation of the depolarization and repolarization waves of the heart. The P wave is generated by atrial depolarization, the QRS by ventricular muscle depolarization, and the T wave by ventricular repolarization. The PR interval is a measure of conduction time from atrium to ventricle, and the QRS duration indicates the time required for all of the ventricular cells to be activated. The QT interval reflects the duration of the ventricular action potential.
Laboratory Values
Table 13.2 Laboratory Tests and Reference Values
CARDIOVASCULAR RESPONSES TO AEROBIC EXERCISE
Normal Responses
Abnormal Responses
CARDIAC PATHOLOGIES AND PHYSICAL THERAPY IMPLICATIONS
Figure 13.7 Cardiopulmonary response to acute aerobic exercise.
Box 13.1 Indications of Exercise Intolerance That Warrant Modification or Termination of an Exercise Session
Hypertension
Medical Management of Hypertension
Table 13.3 Stages of Hypertension as Defined by JNC VII 24
Implications for the Therapist
Acute Coronary Syndrome
Clinical Manifestations
Angina
Injury and Infarction
Figure 13.8 ECG following an MI. (A) Zone of infarction: when infarction occurs through the full thickness of the myocardium (transmural) an abnormal Q wave usually appears. (B) Zone of injury: ST elevation occurs in the area of injury. (C) Zone of ischemia: ST depression and/or T-wave inversion occurs in an area of decreased perfusion (ischemia).
Evaluation of Acute Coronary Syndrome (the Evaluation Triad)
Figure 13.9 Evaluation triad for patients with acute coronary syndrome.
Figure 13.10 Referral pattern for chest pain.
Patient Complaints
ECG Changes
Figure 13.11 Normal 12-lead ECG from 50-year-old woman; slight ST elevation is insignificant. Twelve leads are presented; at the bottom of the page is a rhythm strip from lead II. Heart rate from the rhythm strip is approximately 52 (there are 5.8 large boxes between complex 3 and 4; therefore 300/5.8 = 52).
Enzyme Levels
Figure 13.12 Anatomic pathology and ECG interpretation. Leads I, aVL, V5, and V6 depict problems in the lateral aspect of the left ventricle due to occlusion of blood flow within the circumflex artery. Leads II, III, and aVF depict problems in the inferior aspect of the left ventricle due to occlusion of blood flow within the right coronary artery. Leads V1 to V4 depict problems in the anterior aspect of the left ventricle due to occlusion of blood flow within the left anterior descending artery.
Medical Management of Acute Coronary Syndrome
Revascularization Procedures
Percutaneous Transluminal Coronary Angioplasty
Table 13.4 Cardiac Enzymes Associated with Myocardial Injury and Infarction
Clinical Implications for the Therapist
Coronary Artery Bypass Graft
Clinical Implications for the Therapist
Pharmacological Management
Heart Failure
Epidemiology of Heart Failure
Table 13.5 Effects of Medications on Heart Rate, Blood Pressure, ECG, and Exercise Capacity
Causes of Heart Failure
Types of Heart Failure
Box 13.2 Causes of Cardiac Muscle Dysfunction
Table 13.6 Example of Hemodynamic Pressures Associated with Heart Failure
Pathophysiology of Heart Failure
Clinical Manifestations of Heart Failure
Table 13.7 Functional Classifications of Patients with Diseases of the Heart
Medical Examination and Evaluation of Heart Failure
Radiological Findings in CHF
Laboratory Findings in CHF
Figure 13.13 Radiographic examination to confirm CHF.
Echocardiogram and Nuclear Imaging
Pharmacological Management of CHF
Mechanical and Surgical Support
Valvular Heart Disease
Electrical Conduction Abnormalities
Ectopic Beats
Supraventricular Ectopy
Ventricular Ectopy
Ventricular Tachycardia
Figure 13.14 Examples of ectopy and arrhythmias. (A) Atrial fibrillation. (B) Atrial premature beat, also known as premature atrial contraction (PAC) (note third complex). (C) Supraventricular tachycardia (SVT). (D) Premature ventricular contraction (PVC) (note third complex). (E) Bigeminy (note second, fourth, and sixth complexes are PVCs). (F) Trigeminy (note second, fifth, and eighth complexes are PVCs). (G) Couplets (note fourth and fifth complexes are PVCs). (H) Ventricular tachycardia (V-tach). (I) Ventricular fibrillation (V-fib) (V-tach deteriorates into V-fib).
Ventricular Fibrillation
Automatic Implantable Cardiac Defibrillator
Atrial Fibrillation
Conduction Delays and Blocks
Figure 13.15 (A) Multifocal or multiform PVCs; (B) R-on-T PVC; (C) first-degree AV block; (D) Wenckebach rhythm; (E) second-degree type II; (F) third-degree AV block; (G) bundle branch block.
Pacemakers
Heart Transplant
CARDIOVASCULAR EXAMINATION
Medical Record Review
Table 13.8 Pacemaker Classification System
Patient Interview
Physical Examination
Heart Rate and Rhythm
Figure 13.16 Calculation of a heart rate from a rhythm strip. Begin with the fifth complex (which falls on a large black line) and count each large black line to the right of this complex in the order of 300, 150, 100, 75, 60, 50. The sixth complex falls between two large lines (i.e., 50 and 60). There are five small lines between each large line. Between 50 and 60 there are 10 beats, therefore each small line in this case would be two beats. The heart rate would be 60 − 4 = 56. An alternate method would be to count the number of complexes in a 6-second strip and multiply by 10.
Respiratory Rate, Rhythm, and Dyspnea
Box 13.3 Dyspnea Scale
Angina
Blood Pressure
Box 13.4 Angina Scale
Observation and Inspection
Heart Auscultation
Figure 13.17 Anterior view of the chest wall of a man showing skeletal structures, heart, location of the heart-valves, and auscultation points.
Lung Auscultation
Jugular Venous Distention
Figure 13.18 Auscultation of lungs.
Pitting Edema
Exercise Tolerance Tests
Figure 13.19 Examination of jugular venous distention.
Figure 13.20 Estimated oxygen requirements for step, bicycle, and treadmill. The standard Bruce protocol begins at 1.7 mph and 10 percent grade (roughly 5 METs). Oxygen requirements increase with progressive increases in workload for all modalities.
Table 13.9 Metabolic Equivalent (MET) Chart
Assessment of Aerobic Capacity and Endurance
PHYSICAL THERAPY INTERVENTION FOR PATIENTS WITH HEART DISEASE
Intervention for Patients with Coronary Artery Disease
Box 13.5 Coronary Artery Disease—Anticipated Goals and Expected Outcomes
Table 13.10 Risk Stratification Criteria for Cardiac Patients by the American College of Physicians (ACP) and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)
Exercise Prescription
Exercise Intensity
Exercise Frequency
Exercise Duration (Time)
Mode of Exercise (Type)
Cardiac Rehabilitation: Myocardial Infarction
Inpatient/Phase 1
Documentation
Home Exercise Program
Outpatient Phase II
Table 13.12 Inpatient Cardiac Rehabilitation Program
Strength Training
Intervention for Patients with Congestive Heart Failure
Exercise Prescription
Box 13.6 Congestive Heart Failure—Anticipated Goals and Expected Outcomes
Aerobic Exercise
Box 13.7 Criteria for Modification or Termination of Exercise in Patients with Heart Failure
Strength Training
Ventilatory Muscle Training
Box 13.8 Evidence Summary: Studies Investigating the Effects of Exercise on Patients with Congestive Heart Failure
Activity Pacing and Energy Conservation Techniques
Box 13.9 Resistance Training Recommendations for Patients with CHF
EDUCATION FOR PATIENTS WITH HEART DISEASE
Box 13.10 Suggested Topics for Patient, Family, and Caregiver Education and Counseling
PSYCHOLOGICAL/SOCIAL ISSUES
PRIMARY PREVENTION OF CORONARY ARTERY DISEASE
SUMMARY
Questions for Review
CASE STUDY
References
Chapter 14 Vascular, Lymphatic, and Integumentary Disorders
LEARNING OBJECTIVES
ANATOMY AND PHYSIOLOGY OF THE VASCULAR, LYMPHATIC, AND INTEGUMENTARY SYSTEMS
Vascular
Arterial
Venous
Lymphatic
Integumentary
WOUND PHYSIOLOGY
Normal Wound Healing
Phases of Healing
The Role of Oxygen in Wound Healing
The Role of Moisture in Wound Healing
The Role of Nutrition in Wound Healing
Wound Characteristics
Wound Closure
Primary Intention
Secondary Intention
Figure 14.1 Wound dehiscence following appendectomy.
Tertiary Intention
Abnormal Wound Healing and the Chronic Wound
Infection in Wound Healing
Factors Contributing to Abnormal Wound Healing
Intrinsic Factors
Extrinsic Factors
Iatrogenic Factors
Complications of Chronicity
Figure 14.2 Chronic wound as a result of diabetic neuropathy.
VASCULAR, LYMPHATIC, AND INTEGUMENTARY DISORDERS
Arterial Insufficiency and Ulceration
Clinical Presentation
History
Tests and Measurements
Intervention
Figure 14.3 Clinical presentation of arterial insufficiency.
Venous Insufficiency and Ulceration
Clinical Presentation
Figure 14.4 Venous insufficiency with leg ulcer.
History
Tests and Measurements
Intervention
Lymphedema
Figure 14.5 Primary lymphedema of bilateral LEs with one extremity more involved than the other.
Figure 14.6 Secondary lymphedema of unilateral UE.
Clinical Presentation
History
Tests and Measurements
Intervention
Pressure Ulcers
Clinical Presentation
History
Tests and Measurements
Figure 14.7 Pressure points of bony prominences.
Figure 14.8 Sacral pressure ulcer.
Intervention
Neuropathy
Figure 14.9 Chronic wound as a result of diabetic neuropathy.
Clinical Presentation
History
Tests and Measurements
Intervention
EXAMINATION AND EVALUATION
Examination History
Systems Review
Tests and Measurements
Aerobic Capacity/Endurance
Anthropometric Characteristics
Figure 14.10 Volumetric examination for edema.
Figure 14.11 Tape measure examination for girth measurement.
Figure 14.12 Use of footboard with ruler to establish consistent intervals for measuring lower extremity circumferences.
Additional Tools
Staging or Grading of Lymphedema
Palpation/Pitting Scale
Arousal, Attention, and Cognition
Assistive and Adaptive Devices
Circulation
Temperature
Arterial Perfusion
Figure 14.13 Skin temperature examination using a skin thermometer.
Figure 14.14 ABI test performed using Doppler ultrasound probe.
Table 14.1 Ankle-Brachial Indices with Corresponding Indications
Trophic Changes
Pain
Special Tests
Venous Patency
Lymph Vessel Integrity
Gait, Locomotion, and Balance
Integumentary Integrity
Observation and Palpation
Trophic Changes
Fibrosis
Coloration
Temperature
Wounds
Size and Depth
Drainage
Staging
Wound Healing Tools
Risk Factor Assessment
Table 14.2 Descriptions of Drainage by Color and Thickness
Table 14.3 Pressure Ulcer Staging Criteria Revised by NPUAP
Muscle Performance
Orthotic, Protective, and Supportive Devices
Pain
Posture
Range of Motion
Self-Care and Home Management
Sensation
Figure 14.15 Semmes-Weinstein monofilament used to assess presence of protective sensation. Bowing of the filament indicates that appropriate pressure has been applied.
Ventilation and Respiration
Evaluation
Diagnosis, Prognosis, and Plan of Care
INTERVENTION
Coordination, Communication, and Documentation
Patient/Client-Related Instruction
Procedural Interventions
Cleansing
Whirlpool
Pulsatile Lavage with Suction
Figure 14.16 Physical therapist’s fingers mold PLWS shield to sacral wound surface.
Nonforceful Irrigation
Commercial Skin and Wound Cleansers
Figure 14.17 Wound cleansing with nonforceful irrigation.
Figure 14.18 Wound cleansing with a spray cleanser.
Débridement
Nonselective Débridement
Box 14.1 Evidence Summary: Outcome Studies Using Wet-to-Dry (WTD) Dressings as Part of Wound Care
Selective Débridement
Figure 14.19 Use of scalpel and forceps for sharp débridement.
Figure 14.20 Maggot therapy for a cavity wound.
Medical-Grade Honey
Autolytic
Topical Agents
Antiseptics
Antibacterials
Analgesics
Growth Factors
Topical Agents and Acute Wounds
Mechanical Modalities
Ultrasound
Figure 14.21 Application of ultrasound to wound and periwound tissues with hydrogel sheet coupling.
Electrical Stimulation
Figure 14.22 Application of noncontact, nonthermal, low-frequency ultrasound treatment to leg wounds.
Thermal and Nonthermal Diathermy
Figure 14.23 Conductively coupled bipolar treatment electrodes of opposite polarity positioned on opposite sides of a wound.
Ultraviolet Radiation
Figure 14.24 Leg wound covered with Provant® treatment pad.
Hyperbaric Oxygen Therapy
Negative Pressure Wound Therapy
Figure 14.25 A Stage IV sacral pressure ulcer with reticulated foam dressing, tubing, and polyurethane sheet covering the entire wound to maintain the vacuum during treatment with vacuum-assisted closure.
Cold Laser Therapy
Dressings
Figure 14.26 Application of infrared photo energy to the foot using an Anodyne® Therapy foot pad.
Gauze/Fiber
Figure 14.27 Samples of gauze dressings.
Impregnated Gauze
Transparent Films
Figure 14.28 Application of a film dressing.
Foam
Figure 14.29 Samples of foam dressings.
Hydrogels
Hydrocolloids
Figure 14.30 Sample of a hydrogel sheet dressing.
Figure 14.31 Application of an amorphous gel dressing.
Alginates
Figure 14.32 Sample of a hydrocolloid dressing.
Figure 14.33 Samples of alginate dressings.
Hydrofibers
Skin Substitutes
Figure 14.34 Sample of AQUACEL®, a Hydrofiber® dressing simulating the change in consistency from dry to gel as wound drainage is absorbed.
Innovative Dressings
Manual Lymphatic Drainage
Figure 14.35 Manual lymphatic drainage on the LE.
Compression Therapy
Elevation
Unna’s Boot
Four-Layer Bandage System
Figure 14.36 Unna’s boot application.
Figure 14.37 Profore™ is a four-layer bandage system consisting of a cotton, crepe, and two compression layers (top to bottom).
Long-Stretch and Short-Stretch Bandages
Figure 14.38 Sample of short-stretch bandage.
Lymphedema Bandaging
Compression Garments
Figure 14.39 Application of lymphedema bandaging to fingers and hand.
Figure 14.40 Use of foam padding to enhance the effects of lymphedema bandaging.
Figure 14.41 Lymphedema bandaging of the UE.
Figure 14.42 Lymphedema bandaging of the foot, ankle, and calf.
Figure 14.43 Patient wearing custom-fitted UE compression sleeve and separate glove with open fingertips.
Limb Containment Systems
Compression Guidelines
Figure 14.44 Individual wearing a custom arm garment for nighttime lymphedema management.
Figure 14.45 Quilted channel compression garment for venous insufficiency.
Intermittent Pneumatic Compression
Figure 14.46 Intermittent pneumatic compression pump.
Sequential Pneumatic Compression with Truncal Component
Positioning
Figure 14.47 Flexitouch® system: Sequential pneumatic compression with truncal component designed to retain and support the benefits of in-clinic lymphedema therapy at home.
Pressure-Redistributing Devices
Figure 14.48 ROHO® QUADTRO SELECT® HIGH PROFILE® Cushion for pressure redistribution and skin protection.
Figure 14.49 SelectAir® MAX, a low-air-loss support system for pressure relief.
Exercise
Orthotics
Splinting
Total Contact Casting
Neuropathic Walker
Cast Shoes
Figure 14.50 An ankle-foot orthosis specifically designed to allow distributed weight-bearing for individuals with neuropathy.
Extra-Depth Shoes
Figure 14.51 Extra-depth shoe.
Scar Management
Figure 14.52 Application of a silicone gel sheet to scar tissue during the maturation phase of wound healing.
Figure 14.53 Application of elastomer putty to scar tissue during the maturation phase of wound healing.
SUMMARY
Questions for Review
CASE STUDY
References
appendix 14.A Patient Education: Skin Care and Footwear Instructions
INSPECT YOUR SKIN
TAKE CARE OF YOUR SKIN
CHECK YOUR SHOES
SEE YOUR HEALTH CARE PROVIDER
appendix 14.B Special Tests for Arterial and Venous Function
appendix 14.C Sample Wound Examination Form
appendix 14.D Web-Based Resources for Clinicians, Families, and Patients with Vascular, Lymphatic, and Integumentary Disorders
FOR CLINICIANS
SELECTED LIST OF PROGRAMS FOR SPECIALIZED EDUCATION IN CDT AND MLD
FOR PATIENTS AND FAMILY MEMBERS
appendix 14.E Selected Wound Dressing Manufacturer Web Sites
appendix 14.F Dressings by Treatment Goal (Purpose) and Wound Type (Indication)
Chapter 15 Stroke
LEARNING OBJECTIVES
EPIDEMIOLOGY AND ETIOLOGY
Figure 15.1 Preferred sites for atherosclerotic plaque.
RISK FACTORS AND STROKE PREVENTION
Box 15.1 Stroke Early Warning Signs
PATHOPHYSIOLOGY
Management Categories
Vascular Syndromes
Figure 15.2 Cerebral circulation: circle of Willis.
Anterior Cerebral Artery Syndrome
Figure 15.3 Cerebral circulation: a diagram of a midsagittal view of the brain illustrates the distribution of the anterior and posterior cerebral arteries.
Middle Cerebral Artery Syndrome
Internal Carotid Artery Syndrome
Posterior Cerebral Artery Syndrome
Lacunar Strokes
Table 15.1 Clinical Manifestations of Anterior Cerebral Artery Syndrome
Figure 15.4 Cerebral circulation: diagram of a lateral view of the brain illustrates the distribution of the middle cerebral artery.
Table 15.2 Clinical Manifestations of Middle Cerebral Artery Syndrome
Table 15.3 Clinical Manifestations of Posterior Cerebral Artery Syndrome
Vertebrobasilar Artery Syndrome
Table 15.4 Clinical Manifestations of Vertebrobasilar Artery Syndrome
NEUROLOGICAL COMPLICATIONS AND ASSOCIATED CONDITIONS
Altered Consciousness
Disorders of Speech and Language
Dysphagia
Cognitive Dysfunction
Altered Emotional Status
Hemispheric Behavioral Differences
Table 15.5 Hemispheric Differences Commonly Seen Following Stroke
Perceptual Dysfunction
Seizures
Bladder and Bowel Dysfunction
Cardiovascular and Pulmonary Dysfunction
Deep Venous Thrombosis and Pulmonary Embolus
Osteoporosis and Fracture Risk
MEDICAL DIAGNOSIS OF STROKE
History and Examination
Tests and Measures
Cerebrovascular Imaging
Computed Tomography
Figure 15.5 CT demonstrating an acute intracerebral hemorrhage (star).
Magnetic Resonance Imaging
Magnetic Resonance Angiography
Figure 15.6 Coronal MRI without contrast enhancement on a pregnant patient with headache and visual field defect. The T1 hyperintensity of the greatly enlarged pituitary (star) indicates subacute hemorrhage. ICA = internal carotid artery.
Doppler Ultrasound
Arteriography and Digital Subtraction Angiography
MEDICAL, PHARMACOLOGICAL, AND NEUROSURGICAL MANAGEMENT OF STROKE
Medical Management
Pharmacological Management
Neurosurgical Management
Box 15.2 Medications Commonly Used to Treat Patients with Stroke38,39
FRAMEWORK FOR REHABILITATION
Acute Phase
Subacute Phase
Chronic Phase
EXAMINATION
Cranial Nerve Integrity
Sensation
Box 15.3 Elements of the Examination of the Patient with Stroke41
Flexibility and Joint Integrity
Motor Function
Stages of Motor Recovery
Tone
Reflexes
Voluntary Movements
Coordination
Table 15.6 Obligatory Synergy Patterns Following Stroke
Motor Programming
Muscle Strength
Postural Control and Balance
Table 15.7 Common Postural Alignment Deviations Associated with Stroke
Ipsilateral Pushing
Gait and Locomotion
Box 15.5 Gait Deviations Commonly Seen Following Stroke
Integumentary Integrity
Box 15.6 Functional Walking Categories
Aerobic Capacity and Endurance
Functional Status
Stroke-Specific Instruments
Fugl-Meyer Assessment of Physical Performance (FMA)
Stroke Rehabilitation Assessment of Movement (STREAM)
Chedoke-McMaster Stroke Assessment
Stroke Impact Scale (SIS)
GOALS AND OUTCOMES
PHYSICAL THERAPY INTERVENTIONS
Box 15.7 Examples of General Goals and Outcomes for Patients with Stroke
Strategies to Improve Motor Learning
Strategy Development
Feedback
Practice
Interventions to Improve Sensory Function
Interventions to Improve Hemianopsia and Unilateral Neglect
Interventions to Improve Flexibility and Joint Integrity
Box 15.8 Positioning Strategies to Reduce Common Malalignments
Figure 15.7 Range-of-motion exercises for the hemiparetic UE. The therapist carefully mobilizes the scapula during arm elevation.
Figure 15.8 Sitting, with extended arm support. The therapist assists in stabilizing the elbow and fingers in extension.
Interventions to Improve Strength
Exercise Precautions
Figure 15.9 Partial wall squats using a small ball; the therapist assists in control of knee.
Interventions to Manage Spasticity
Interventions to Improve Movement Control
Strategies to Improve Upper Extremity Function
UE Weight-Bearing as a Postural Support
Task-Oriented Reaching and Manipulation
Figure 15.10 Standing in modified plantigrade, both UEs extended and weight-bearing; the therapist assists elbow extension of the hemiparetic UE while providing approximation through the shoulder.
Figure 15.11 Standing in modified plantigrade with hemiparetic hand positioned on small ball; the patient practices rolling the ball from side-to-side; the therapist stabilizes the elbow and shoulder.
Constraint-Induced Movement Therapy
Figure 15.12 Constraint-induced movement therapy (CIMT). The patient practices a pegboard task using the hemiparetic hand while the less affected hand wears a mitt. The therapist times the activity while encouraging the patient.
Simultaneous Bilateral Training
Electromyographic Biofeedback
Electrical Stimulation
Robot-Assisted Therapy
Management of Shoulder Pain
Supportive Devices
Strategies to Improve Lower Extremity Function
Figure 15.13 The patient practices bridging, combining hip extension with knee flexion; the therapist assists using tactile and proprioceptive cues to stimulate the hip extensors on the hemiparetic LE.
Interventions to Improve Functional Status
Bed Mobility
Figure 15.14 Early mobility activities: rolling onto the unaffected side. The therapist assists the movement through contacts on the knees and clasped hands.
Sitting
Sit-to-Stand and Sit-Down Transfers
Figure 15.15 Sitting, patient practices PNF lift pattern (less affected UE leading). The pattern promotes upper trunk rotation, bilateral UE activity with the hemiparetic UE moving out of synergy, and crossing the midline.
Figure 15.16 Sit-to-stand transitions. The therapist assists the patient in straightening the hemiparetic knee while bringing the center of mass forward. Hands are clasped together.
Standing
Transfers
Interventions to Improve Postural Control and Balance
Force Platform Biofeedback
The Patient with Ipsilateral Pushing (Pusher Syndrome)
Interventions to Improve Gait and Locomotion
Task-Specific Overground Locomotor Training
Figure 15.17 Assisted overground gait training. The therapist provides assistance in stabilizing the hemiparetic knee and weight transfer onto the more affected side.
Locomotor Training using Body Weight Support and Motorized Treadmill Training
Figure 15.18 Locomotor training using body weight support and a motorized treadmill. One therapist manually assists pelvic motions while a second therapist assists stepping of the hemiparetic left LE.
Robotic-Assisted Locomotor Training
Box 15.9 Evidence Summary Post-Stroke Locomotor Training Using Body Weight Support and Motorized Treadmill Training
Functional Electrical Stimulation
Orthotics and Assistive Devices
Wheelchairs
Interventions to Improve Aerobic Capacity and Endurance
Exercise Precautions
PATIENT/CLIENT-RELATED INSTRUCTION
DISCHARGE PLANNING
RECOVERY AND OUTCOMES
SUMMARY
Questions for Review
CASE STUDY
References
appendix 15.A Fugl-Meyer Assessment of Physical Performance
appendix 15.B Web-Based Resources for Clinicians, Families, and Patients with Stroke
Chapter 16 Multiple Sclerosis
LEARNING OBJECTIVES
ETIOLOGY
PATHOPHYSIOLOGY
DISEASE COURSE
Exacerbating Factors
Box 16.1 Four Major Clinical Subtypes of MS1
SYMPTOMS
Sensory
Pain
Box 16.2 Common Symptoms in Multiple Sclerosis
Visual
Motor
Weakness
Spasticity
Fatigue
Coordination and Balance
Gait and Mobility
Speech and Swallowing
Cognitive
Depression
Emotional
Bladder
Bowel
Sexual
DIAGNOSIS
Figure 16.1 Coronal contrast-enhanced T1 MRI. The contrast enhancement of a periventricular white matter lesion (arrow) indicates that this is an active MS plaque. Other (older) plaques in this case that were T2 hyperintense showed no enhancement.
MEDICAL MANAGEMENT
Management of Acute Relapses
Disease-Modifying Therapeutic Agents
Table 16.1 Disease-Modifying Therapeutic Agents for MS
Management of Symptoms
Spasticity
Pain
Fatigue
Tremor
Cognitive and Emotional Impairments
Bladder and Bowel Impairments
FRAMEWORK FOR REHABILITATION
Figure 16.2 Clinical manifestations of inactivity.
PHYSICAL THERAPY EXAMINATION
Patient/Client History
Systems Review
Tests and Measures
Cognition
Affective and Psychosocial Function
Sensation
Table 16.2 Stages of MS: Common Impairments, Activity Limitations, and Intervention Strategies
Box 16.3 Elements of the Examination of the Patient with Multiple Sclerosis53
Pain
Visual Acuity
Cranial Nerve Integrity
Range of Motion
Muscle Performance
Fatigue
Temperature Sensitivity
Motor Function
Posture
Balance, Gait, and Locomotion
Aerobic Capacity and Endurance
Skin Integrity and Condition
Functional Status
Environment (Home, Community, and Work)
General Health Measures
Disease-Specific Measures
Expanded Disability Status Scale (EDSS) for Patients with Multiple Sclerosis
The Minimum Record of Disability (MRD)
MS Functional Composite (MSFC)
Multiple Sclerosis Quality of Life—54 (MSQOL-54)
MS Quality of Life Inventory (MSQLI)
Functional Examination of Multiple Sclerosis (FAMS)
Multiple Sclerosis Impact Scale (MSIS-29)
Goals and Outcomes
Box 16.4 Examples of General Goals and Outcomes for Patients with Progressive Disorders of the Central Nervous System53
PHYSICAL THERAPY INTERVENTIONS
Management of Sensory Deficits and Skin Care
Management of Pain
Exercise Training
Strength and Conditioning
Box 16.5 Evidence Summary Exercise and Multiple Sclerosis
Aerobic Conditioning
Flexibility Exercises
Figure 16.3 Side-lying hip flexor/rectus femoris stretch. This position allows the therapists to control the hip and ensure that excessive lumber lordosis is prevented while also modulating the amount of stretch between the iliopsoas and the rectus femoris.
Management of Fatigue
Figure 16.4 Seated trunk stretch. The pictured position allows the therapist to control the pelvis to ensure trunk stretching while maintaining control of the individual’s trunk to apply the correct emphasis to the desired muscle groups.
Management of Spasticity
Management of Coordination and Balance Deficits
Figure 16.5 Dynamic postural control is promoted through weight shifting and upper trunk rotation to the right.
Figure 16.6 Sitting on the ball, the patient practices dynamic postural control activities: (a) unilateral resisted overhead reach, (b) reciprocal stepping and overhead arm swing, and (c) resisted bilateral symmetrical PNF D2 flexion patterns with extension.
Figure 16.7 Dynamic postural control activities. This position demonstrates an advanced stepping and reaching activity with the added challenge of a resistance tube.
Figure 16.8 Sit-to-stand movement transition. The sit-to-stand transition is an important component of pre-gait/gait training, transfer training, and balance training.
Figure 16.9 Head turns for vestibular training.
Locomotor Training
Figure 16.10 Patient practices cross-stepping. Dynamic standing activities are an integral component of an exercise program geared toward improving gait/locomotion.
Orthotics and Assistive Devices
Figure 16.11 Patient is wearing an ankle-foot orthosis (AFO) to stabilize the ankle and prevent foot drop.
Figure 16.12 Locomotor training with a front-wheeled rolling walker.
Figure 16.13 An individual with MS using a power wheelchair with joystick control for mobility. The correct power wheelchair prescription can encourage proper alignment of the pelvis, trunk, head, and limbs.
Functional Training
Management of Speech and Swallowing
Cognitive Training
PSYCHOSOCIAL ISSUES
PATIENT AND FAMILY/CAREGIVER EDUCATION
SUMMARY
Acknowledgment
Questions for Review
References
Supplemental Readings
appendix 16.A Modified Fatigue Impact Scale (MFIS)
Instructions for Scoring the MFIS
Physical Subscale
Cognitive Subscale
Psychosocial Subscale
Total MFIS Score
appendix 16.B An Expanded Disability Status Scale (EDSS) for Patients with Multiple Sclerosis
FUNCTIONAL SYSTEMS
Pyramidal Functions
Cerebellar Functions
Brainstem Functions
Sensory Functions (revised 1982)
Bowel and Bladder Functions (revised 1982)
Visual (or Optic) Functions
Cerebral (or Mental) Functions
Other Functions
EXPANDED DISABILITY STATUS SCALE (EDSS)
appendix 16.C Multiple Sclerosis Daily Activity Diary
INSTRUCTIONS
appendix 16.D Web-Based Resources for Clinicians and Patients/Families Living with Multiple Sclerosis
Chapter 17 Amyotrophic Lateral Sclerosis
LEARNING OBJECTIVES
EPIDEMIOLOGY
Table 17.1 Motor Neuron Disorders
ETIOLOGY
Figure 17.1 (A) Known risk factors for ALS. (B) Possible risk factors for ALS. ALS/PDC = amyotrophic lateral sclerosis and parkinsonism dementia complex.
PATHOPHYSIOLOGY
Figure 17.2 Luxol Fast B stained cross section of spinal cord at the high cervical level from a patient with classical ALS. Marked pallor, secondary to degeneration of the lateral and anterior corticospinal tracts, can be seen (large arrows). The ventral roots (V, small arrows) are atrophied, especially compared to the dorsal roots (D, small arrows).
Figure 17.3 Sprouting: (A) normal motor neurons; (B) denervation; (C) reinnervation.
CLINICAL MANIFESTATIONS
Table 17.2 Common Impairments Associated with Amyotrophic Lateral Sclerosis
Impairments Related to LMN Pathology
Figure 17.4 Marked head droop in a 65-year-old man with ALS who first developed progressive weakness in both upper extremities.
Impairments Related to UMN Pathology
Impairments Related to Bulbar Pathology
Respiratory Impairments
Cognitive Impairments
Rare Impairments
DIAGNOSIS
Figure 17.5 El Escorial Criteria for the Diagnosis of ALS.
DISEASE COURSE
PROGNOSIS
MANAGEMENT
Figure 17.6 Multidisciplinary approach to the care of the individual with ALS. ALSA = Amyotrophic Lateral Sclerosis Foundation; MDA = Muscular Dystrophy Association.
Disease-Modifying Agents
Symptomatic Management
Management of Sialorrhea and Pseudobulbar Affect
Management of Dysphagia
Figure 17.7 Algorithm for nutrition management. Note that bolded text represents evidence-based information; text in italics denotes consensus-based information.a For example, Questions #1 to 3 (bulbar questions) from the Amyotrophic Lateral Sclerosis Functional Rating Scale—Revised (ALSFRS-R), or other instrument.b For example, prolonged mealtime, ending meal prematurely because of fatigue, accelerated weight loss due to poor caloric intake, family concern about feeding difficulties. FVC = forced vital capacity (supine or erect); IV = intravenous; MIP = maximum inspiratory pressure; NG = nasogastric; PEG = percutaneous endoscopic gastrostomy.
Figure 17.8 Algorithm for respiratory management. Note that bolded text represents evidence-based information; text in italics denotes consensus-based information. FVC = forced vital capacity (supine or erect); MIP = maximal inspiratory pressure; NIV = noninvasive ventilation; PCEF = peak cough expiratory flow; PFT = pulmonary function tests; SNP = sniff nasal pressure.
Management of Respiratory Impairments
Management of Dysarthria
Figure 17.9 Mechanical insufflation–exsufflation (MI-E) device.
Management of Muscle Cramps, Spasticity, Fasciculations, and Pain
Management of Anxiety and Depression
FRAMEWORK FOR REHABILITATION
Figure 17.10 Framework for rehabilitation for individuals with ALS.
PHYSICAL THERAPY EXAMINATION
Cognition
Psychosocial Function
Pain
Joint Integrity, Range of Motion, and Muscle Length
Muscle Performance
Motor Function
Tone and Reflexes
Cranial Nerve Integrity
Sensation
Postural Alignment, Control, and Balance
Gait
Respiratory Function
Integument
Functional Status
Environmental Barriers
Fatigue
DISEASE-SPECIFIC AND QUALITY-OF-LIFE MEASURES
Disease-Specific Measures
Quality-of-Life Measures
PHYSICAL THERAPY INTERVENTIONS
Cervical Muscle Weakness
Table 17.3 Amyotrophic Lateral Sclerosis Disease Stages and Common Intervention Strategies: Framework for Rehabilitation for Individuals with ALS
Dysarthria and Dysphagia
Figure 17.11 The Headmaster Collar.
UE Muscle Weakness
Figure 17.12 Types of collars.
Table 17.4 Types of Semirigid and Rigid Cervical Collars
Shoulder Pain
Respiratory Muscle Weakness
LE Muscle Weakness and Gait Impairments
Activities of Daily Living
Decreased Mobility
Table 17.5 Common Types of Adaptive Equipment
Figure 17.13 Prefabricated blocks.
Figure 17.14 UpLift Seat.
Figure 17.15 Swivel cushion.
Muscle Cramps and Spasticity
Psychosocial Issues
EXERCISE AND ALS
Disuse Atrophy
Overuse Fatigue
PATIENT/CLIENT-RELATED INSTRUCTION
Box 17.1 Evidence Summary: Exercise and ALS: The Evidence from Human Studies
Box 17.2 Evidence Summary: Exercise and ALS: The Evidence from Animal Studies
SUMMARY
Acknowledgments
Questions for Review
CASE STUDY
ALSFRS-R Scores
Grip and Pinch Strength Values (Pounds) for Men 35 to 39 (n = 25)
References
Supplemental Readings
appendix 17.A Schwab and England Activities of Daily Living Scale
appendix 17.B Amyotrophic Lateral Sclerosis Functional Rating Scale—Revised
appendix 17.C Web-Based Resources for Clinicians, Families, and Patients with Amyotrophic Lateral Sclerosis
Chapter 18 Parkinson’s Disease
LEARNING OBJECTIVES
INCIDENCE
ETIOLOGY
Parkinson’s Disease
Secondary Parkinsonism
Postencephalitic Parkinsonism
Toxic Parkinsonism
Box 18.1 Classification of Parkinsonism
Drug-Induced Parkinsonism (DIP)
Parkinson-Plus Syndromes
PATHOPHYSIOLOGY
Figure 18.1 The major structures of the basal ganglia. (A) Coronal section through the rostral part of the frontal lobe showing the relation of the caudate nucleus, putamen, and nucleus accumbens to the surrounding telencephalic structures. (B) Coronal section through the caudal part of the front lobe showing the location of the lentiform nucleus later to, and the body of the caudate nucleus dorsal to, the diencephalon.
Figure 18.2 The direct loop through the putamen and the connections of the striatum with the substantia nigra pars compacta. The striatonigral fibers represented in this diagram arise in the putamen. However, most striatonigral fibers arise from the caudate. C = caudate nucleus; cc = corpus callosum; GPe = globus pallidus pars externa; GPi = glogus pallidus pars interna; P = putamen; VL = ventral lateral nucleus of the thalamus.
STAGES OF PARKINSON’S DISEASE
Figure 18.3 The indirect loop through the subthalamic nucleus; also represented are the efferents from the globus pallidus interna and substantia nigra pars reticulata to the superior colliculus and midbrain tegmentum. C = caudate nucleus; GPe = globus pallidus pars externa; GPi = globus pallidus pars interna; ic = internal capsule; IL = intralaminar nuclei of the thalamus; P = putamen; VA = ventral anterior nucleus of the thalamus; VL = ventral lateral nucleus of the thalamus.
CLINICAL PRESENTATION
Primary Motor Symptoms
Rigidity
Bradykinesia
Tremor
Postural Instability
Secondary Motor Symptoms
Muscle Performance
Motor Function
Gait
Nonmotor Symptoms
Sensory Symptoms
Dysphagia
Speech Disorders
Cognitive Dysfunction
Depression and Anxiety
Autonomic Dysfunction
Sleep Disorders
MEDICAL DIAGNOSIS
CLINICAL COURSE
Hoehn-Yahr Classification of Disability Scale
Unified Parkinson’s Disease Rating Scale (UPDRS)
Box 18.2 Cardinal Features and Clinical Manifestations of Parkinson’s Disease
Table 18.1 Hoehn-Yahr Classification of Disability
MEDICAL MANAGEMENT
Pharmacological Management
Levodopa/Carbidopa
Dopamine Agonists
Anticholinergics
Monoamine Oxidase B Inhibitors
Implications for the Physical Therapist
Nutritional Management
Table 18.2 Pharmacology of Parkinson’s Disease80
Deep Brain Stimulation
FRAMEWORK FOR REHABILITATION
Therapeutic Care Continuum
PHYSICAL THERAPY EXAMINATION AND EVALUATION
Table 18.3 Parkinson’s Disease Stages, Common Impairments and Activity Limitations, and Intervention Strategies
Box 18.3 Elements of the Examination for a Patient with Parkinson’s Disease97
Cognitive Function
Psychosocial Function
Sensory Function
Musculoskeletal Function
Joint Flexibility and Posture
Muscle Performance
Figure 18.4 In standing, patient with PD demonstrates the typical flexed, stooped posture with kyphosis, forward head, and hip and knee flexion.
Figure 18.5 In supine, the patient with PD demonstrates the typical flexed posture (shadow pillow posture).
Motor Function
Rigidity
Bradykinesia
Tremor
Postural Control and Balance
Gait
Freezing of Gait
Fall Risk
Fatigue
Dyskinesias
Swallowing and Speech
Autonomic Function
Cardiorespiratory Function
Orthostatic Hypotension
Integumentary Integrity
Functional Status
Profile of Function and Impairment Level Experience with Parkinson’s Disease
Global Health Measures
Disease-Specific Measures
Box 18.4 Examples of General Goals and Outcomes for Patients with Progressive Disorders of the Central Nervous System,* adapted from the Guide to Physical Therapist Practice97
PHYSICAL THERAPY INTERVENTION
Motor Learning Strategies
Box 18.5 Evidence Summary: Effect of Visual and Auditory Cues on Gait in Individuals with Parkinson’s Disease
Exercise Training
Figure 18.6 The patient with young-onset PD steps “Big” to the side with bilateral “Big arms” and hands open, palms up.
Figure 18.7 The patient with young-onset PD steps out and lands “Big,” pushing the left foot into the floor while reaching with bilateral “Big arms,” hands open.
Relaxation Exercises
Flexibility Exercise
Figure 18.8 The patient with PD performs bilateral symmetrical PNF D2 flexion patterns while sitting (note the difficulty in achieving full shoulder flexion with the LUE).
Table 18.4 Common Areas of Limitation and Suggested Stretching Exercises
Figure 18.9 Shoulder ROM with scapular mobilization performed in the side-lying position.
Resistance Training
Functional Training
Figure 18.10 The patient with PD practices bridging (note the difficulty in achieving full hip extension).
Figure 18.11 The patient with PD practices sitting on ball with UEs abducted to the sides, hands open.
Figure 18.12 The patient with PD practices maintaining a step-up position while performing resisted UE shoulder abduction and flexion using elastic band resistance. The patient is encouraged to turn and look at the hand.
Balance Training
Figure 18.13 The patient with PD practices contralateral UE/LE lifts in quadruped over a ball.
Figure 18.14 The patient with PD practices kneeling on a BOSU™ disc. The therapist provides resistance using an elastic band to promote full hip extension.
Figure 18.15 The patient with PD practices half-kneeling on a BOSU™ disc while performing resisted UE shoulder abduction and flexion using elastic band resistance.
Figure 18.16 The patient with PD practices standing on an inflated disc while reaching across, promoting upper trunk rotation.
Figure 18.17 The patient with young-onset PD practices standing with one foot on an inflated disc with bilateral “Big arms” and hands open, palms up.
Locomotor Training
Figure 18.18 The patient with PD practices walking using two vertical poles.
Figure 18.19 The patient with young-onset PD practices cross-step walking.
Figure 18.20 The patient with young-onset PD practices stepping and juggling a set of scarves.
Spinal Orthotics
Figure 18.21 The patient with young-onset PD and primary impairments in postural stability and gait walks with the assist of canine partner.
Pulmonary Rehabilitation
Speech Therapy
Aerobic Exercise
Group and Home Exercises
ADAPTIVE AND SUPPORTIVE DEVICES
PSYCHOSOCIAL ISSUES
PATIENT, FAMILY, AND CAREGIVER EDUCATION
Box 18.6 Elements of a Patient, Family, and Caregiver Education Program
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings and Materials
appendix 18.A MDS UPDRS Score Sheet
appendix 18.B Yoga Sequence for Early/Mild Parkinson’s Disease
appendix 18.C Web-Based Resources for Clinicians and Patients/Families Living with Parkinson’s Disease
Chapter 19 Traumatic Brain Injury
LEARNING OBJECTIVES
PREVALENCE AND IMPACT
MECHANISM OF INJURY AND PATHOPHYSIOLOGY
Primary Injury
Blast Injury
Secondary Injury
SEQUELAE OF TRAUMATIC BRAIN INJURY
Box 19.1 Impairments Commonly Associated With Traumatic Brain Injury
Neuromuscular Impairments
Cognitive Impairments
Neurobehavioral Impairments
Communication
Dysautonomia
Post-traumatic Seizures
Secondary Impairments and Medical Complications
Box 19.2 Secondary Impairments and Concomitant Injuries
DIAGNOSIS AND PROGNOSIS
Figure 19.1 Glasgow Coma Scale.
Table 19.1 Characteristics of Mild, Moderate, and Severe Traumatic Brain Injury
CONTINUUM OF CARE AND INTERDISCIPLINARY TEAM
Figure 19.2 Rehabilitation settings for individuals with TBI across the continuum of care.
Patient and Family
Physician
Speech-Language Pathologist
Occupational Therapist
Rehabilitation Nurse
Case Manager/Team Coordinator
Social Worker
Neuropsychologist
Other Team Members
EARLY MEDICAL MANAGEMENT
PHYSICAL THERAPY MANAGEMENT OF MODERATE TO SEVERE TRAUMATIC BRAIN INJURY IN THE ACUTE STAGE
Examination
Outcome Measures
Arousal, Attention, and Cognition
Plan of Care
Outcomes/Goals
Interventions
Preventing Secondary Impairments
Box 19.3 Rancho Los Amigos Levels of Cognitive Functioning (LOCF)a
Box 19.4 General Goals and Outcomes Anticipated for Patients With Severe to Moderate Traumatic Brain Injury in the Acute Stage
Figure 19.3 Multi-podus boot used for ankle and foot positioning and to prevent skin breakdown on the heel. This type of positioning device may not be beneficial for the patient with moderate to severe tone at the ankle; it is not strong enough to prevent the ankle from plantarflexing.
Figure 19.4 Materials used for serial casting: fiberglass casting material, rubber gloves, stockinette, a layer of padding to wrap around the lower leg and foot, and padding for the malleoli and proximal and distal ends of the cast.
Figure 19.5 Serial casting: first a layer of padding is wrapped around the lower leg and foot.
Figure 19.6 Serial casting: then the fiberglass casting material is wrapped around the lower leg and foot. One clinician does the wrapping, while another holds the leg and foot in the proper position.
Early Mobility
Sensory Stimulation
PHYSICAL THERAPY MANAGEMENT OF MODERATE TO SEVERE TRAUMATIC BRAIN INJURY DURING ACTIVE REHABILITATION
Examination
Outcome Measures: Body/Structure Function
Balance
Box 19.5 Elements of the Examination and Outcome Measures
Attention and Cognition
Behavior and Safety
Outcome Measures: Activity and Participation
Global Functioning
Community Reintegration
Locomotion
Plan of Care
Goals/Outcomes
Interventions
Motor (Re)Learning Strategies
Restorative Versus Compensatory-Based Interventions
Restorative Interventions and Neural Plasticity
Table 19.2 Motor Recovery and Compensation Across Three Levels of the ICF
Table 19.3 Compensation Versus Restoration: Guiding Questions to Consider
Task-Oriented Approach
Table 19.4 Principles of Experience-Dependent Neuroplasticity
Locomotor Training with Body Weight Support
Figure 19.7 Locomotor training utilizing a body weight support system and treadmill. One trainer is assisting with the trunk and pelvic stability and weight shifting, while another trainer is facilitating stepping at the left LE.
Constraint-Induced Therapy
Aerobic and Endurance Conditioning
Resistance Training
Electrical Stimulation
Dual-Task Performance
Patient/Family/Caregiver Education
Behavioral Factors
Community Reentry Programs
Table 19.5 Special Considerations for Confused and Agitated Patients
Table 19.6 Components of Community Skills, Social Skills, and Daily Living Skills Programs
MILD TRAUMATIC BRAIN INJURY
Physical Therapy Management of mTBI
Return to Play/Activity
Box 19.6 Areas for Physical Therapist to Examine and Intervene in Patients With Mild Traumatic Brain Injury
Table 19.7 Graduated Return-to-Play Protocol
Examination
Arousal, Attention, and Cognition
Vestibular and Balance
Self-Report
Other
Intervention
Vestibular, Balance, and Dual Task
Box 19.7 Tests and Measures/Outcome Measures Commonly Used in Patients With Mild Traumatic Brain Injury
Other
Patient Education
Box 19.8 Evidence Summary Evidence-Based Summary of Selected Studies of Physical Therapy for Patients With Mild Traumatic Brain Injury
SUMMARY
Questions for Review
References
Chapter 20 Traumatic Spinal Cord Injury
LEARNING OBJECTIVES
DEMOGRAPHICS AND ETIOLOGY
CLASSIFICATION OF SPINAL CORD INJURIES
Neuroanatomical Organization and Structure
Figure 20.1 Main ascending sensor tracts: dorsal column, spinothalamic, spinoreticular, spinotectal, and dorsal and ventral spinocerebellar tracts. Main descending motor tracts: lateral corticospinal, anterior corticospinal, lateral and medial vestibulospinal, lateral and medial reticulospinal, and rubrospinal tracts.
Designation of Lesion Level
Figure 20.2 Relationship between spinal cord and nerve roots to vertebral bodies.
Figure 20.3 International Standards for Classification of Spinal Cord Injury.
Complete Injuries, Incomplete Injuries, and Zone of Partial Preservation
ASIA Impairment Scale
Clinical Syndromes
Table 20.1 ASIA Impairment Scale
Brown-Sequard Syndrome
Anterior Cord Syndrome
Figure 20.4 Areas of spinal cord damage in clinical syndromes.
Central Cord Syndrome
Cauda Equina Injuries
NEUROLOGICAL COMPLICATIONS AND ASSOCIATED CONDITIONS
Spinal Shock
Motor and Sensory Impairments
Autonomic Dysreflexia
Initiating Stimuli
Symptoms
Intervention
Table 20.2 Initiating Stimuli and Signs and Symptoms of Autonomic Dysreflexia
Spastic Hypertonia
Cardiovascular Impairment
Impaired Temperature Control
Pulmonary Impairment
Table 20.3 Neurological Level of Spinal Cord Injury and Muscles of Respiration
Bladder and Bowel Dysfunction
Bladder Dysfunction
Bladder Management
Bowel Dysfunction
Bowel Management
Sexual Dysfunction
Male Response
Female Response
Secondary Medical Complications
Box 20.1 Common Complications Following Spinal Cord Injury
Pressure Sores
Deep Vein Thrombosis
Pain
Nociceptive Pain
Neuropathic pain
Contractures
Heterotopic (Ectopic) Ossification
Osteoporosis and Skeletal Fracture
PROGNOSIS
EARLY MEDICAL AND REHABILITATION MANAGEMENT IN THE ACUTE STAGE
Emergency Care
Fracture Stabilization
Figure 20.5 Roto rest bed.
Immobilization
Cervical Orthoses
Figure 20.6 Halo orthosis.
Figure 20.7 Minerva cervical orthosis.
Thoracolumbosacral Orthoses
Figure 20.8 Anterior and lateral views of a thoracolumbosacral orthosis/plastic body jacket.
PHYSICAL THERAPY MANAGEMENT IN THE ACUTE STAGE OF RECOVERY
Physical Therapy Examination
Motor and Sensory Function
Respiratory
Integument
Table 20.4 Areas Most Susceptible to Pressure in Recumbent Positions
Passive Range of Motion
Early Mobility Skills
Physical Therapy Interventions
Respiratory Management
Deep-Breathing Exercises
Glossopharyngeal Breathing
Air Shift Maneuver
Respiratory Muscle Strengthening
Figure 20.9 Inspiratory muscle trainers.
Coughing
Abdominal Binder
Manual Stretching
Figure 20.10 Assisted cough using abdominal thrust maneuver to clear secretions.
Skin Care
Figure 20.11 Ankle/foot positioning to prevent skin breakdown and contracture.
Figure 20.12 Air fluidized bed.
Figure 20.13 Push-up in wheelchair for pressure relief.
Figure 20.14 Lateral lean in wheelchair for pressure relief.
Figure 20.15 Skin inspection using a long-handled mirror.
Early Strengthening and Range of Motion
Figure 20.16 Patient extends the wrist, which causes the shortened long finger flexors to passively flex allowing a grasp.
Figure 20.17 Intrinsic-plus splint.
Early Mobility Interventions
Education
ACTIVE REHABILITATION
Physical Therapy Examination
Box 20.2 Commonly Used Outcome Measures and Tests and Measures Categories
Aerobic Capacity/Endurance
Arousal, Attention, Cognition
Environmental or Work Barriers
Gait, Locomotion, and Balance
Box 20.3 General Guidelines for Wheelchair Accessibility in the Home
Motor Function
Muscle Performance
Figure 20.18 Wheelchair Skills Test (WST) Version 4.1 Manual.
Figure 20.19 Spinal Cord Injury Functional Ambulation Inventory,179 with permission.
Pain
Self-Care and Home Management
Work, Community, and Leisure Integration or Reintegration
Neuromuscular Recovery Scale
Figure 20.20 Spinal Cord Injury Independence Measure,192193194 with permission.
Prognosis and Goals
Box 20.4 Factors That Affect Functional Outcomes
Table 20.5 Functional Expectations for Patients With Spinal Cord Injury*
Recovery of Walking Ability
Box 20.5 Examples of General Goals and Outcomes for Patients With SCI
Physical Therapy Interventions
Box 20.6 Common Precautions to Take Into Account When Performing Interventions With People With Spinal Cord Injury
Strengthening
Cardiovascular/Endurance Training
Bed Mobility Skills
Figure 20.21 Functional Electrical Stimulation powered lower extremity ergometer.
Rolling
Figure 20.22 Rolling from supine to prone using UE momentum and crossing the ankles.
Transitioning Supine to/from Sitting
Prone on Elbows
Figure 20.23 Transitioning from prone (A) to prone on elbows (B) with shoulders initially abducted and weight shifting.
Supine-on-Elbows
Figure 20.24 The prone-on-elbows position can be used to strengthen the serratus anterior and other scapular muscles.
Walking on Elbows to Assume Long Sitting
Coming Straight to Long Sitting From Supine
Figure 20.25 Patient transitioning from supine (A) to supine-on-elbows (B) by stabilizing hands under pelvis, forcefully pulling up by contracting the biceps, weight shifting side to side, and placing elbows further underneath the shoulder joints (C).
Figure 20.26 Patient transitioning from prone-on-elbows (A) to long sitting (B); walks into a “C” position (C), pulls trunk up to long sitting position (D).
Figure 20.27 Patient transitioning to long sitting from supine-on-elbows (A). Bears weight on one elbow while the other UE is thrown back into shoulder extension with the elbow extended to bear weight on the other UE (B), then weight shifts onto the other UE and throws other UE back into shoulder extension with elbow extended to come into long sitting (C).
Sitting Balance
Figure 20.28 Individual with a T4 ASIA A injury in long sitting.
Figure 20.29 Individual with a T4 ASIA A injury in short sitting.
Transfers
Figure 20.30 (A) Preparatory phase of the transfer; trunk is flexed forward and laterally away from surface transferring to. (B) Lift phase; buttocks are lifted off the seating surface as the trunk rotates. (C) End of the descent phase when the buttocks are on the other sitting surface.
Floor-to-Wheelchair Transfers
Locomotor Training
Box 20.7 Complementary Skills Necessary for Independence With Transfers
Locomotor Training for Individuals with Motor Complete SCI
Figure 20.31 (A-C) Floor to wheelchair transfer using a backward approach.
Figure 20.32 (A-D) Floor to wheelchair transfer using a frontward approach.
Orthotic Prescription
Figure 20.33 (A-C) Floor to wheelchair transfer using a sideways approach.
Locomotor Training Strategies
Figure 20.34 Swing-through gait pattern.
Figure 20.35 Standing from wheelchair using forearm crutches and KAFOs. The reverse sequences is used to return to sitting in the wheelchair.
Locomotor Training for Individuals with Incomplete Spinal Cord Injury
Figure 20.36 Gait pattern of a person with an incomplete spinal cord injury using a rolling walker and a right ankle-foot orthosis.
Figure 20.37 Locomotor training for a person with an incomplete spinal cord injury using body weight support, treadmill, and manual assistance by trainers.
Figure 20.38 Locomotor training principles applied to the task of standing with upright posture for a person with an incomplete spinal cord injury.
Figure 20.39 Locomotor training principles applied to standing upright while practicing loading and extension on the left lower limb while the right lower limb is unloaded and flexed on the treadmill with body weight support (A) and overground with a walker (B).
Figure 20.40 Translation of skills acquired on the treadmill to walking overground and community ambulation.
Box 20.8 Evidence Summary Selected Studies Examining the Use of Locomotor Training
Activity-Based Upper Extremity Training
Health and Wellness
Patient/Client-Related Education
PRESCRIPTIVE WHEELCHAIR AND WHEELCHAIR SKILLS TRAINING
Wheelchair Skills
Propulsion on Even Surfaces
Inclines
Figure 20.41 Propelling wheelchair forward.
Wheelies
Figure 20.42 Performing a wheelie.
Figure 20.43 Technique to safely spot a patient while she practices performing wheelies.
Figure 20.44 (A-C) Ascending a curb in a wheelie.
Figure 20.45 (A-C) Descending a curb in a wheelie.
NEUROTECHNOLOGIES
SUMMARY
Questions for Review
CASE STUDY
References
appendix 20.A Web-Based Resources for Patients, Families, and Clinicians
Chapter 21 Vestibular Disorders
LEARNING OBJECTIVES
ANATOMY
Peripheral Vestibular System
Semicircular Canals
Figure 21.1 Anatomy of the vestibular labyrinth. Structures include the utricle, sacculus, superior semicircular canal, posterior semicircular canal, and the horizontal semicircular canal. The three semicircular canals (SCCs) are orthogonal with each other. Note the superior vestibular nerve innervating the superior (anterior) and horizontal semicircular canals as well as the utricle. The inferior vestibular nerve innervates the posterior semicircular canal and the saccule. The cell bodies of the vestibular nerves are located in Scarpa’s ganglion (Gangl. Scarpae). Also note that the semicircular canals enlarge at one end to form the ampulla.
Figure 21.2 The cupula of the ampulla is a flexible, gelatinous barrier that partitions the canal. The crista ampullaris contains the kinocilia and stereocilia sensory hair cells. The hair cells generate action potentials in response to cupular deflection. Deflection of the stereocilia toward the kinocilia causes excitation; deflection in the opposite direction causes inhibition.
Otolith Organs
Central Vestibular System
Figure 21.3 Otoconia are calcium carbonate crystals that are embedded in a gelatinous matrix which provides an inertial mass. Linear acceleration shifts the gelatinous matrix and excites or inhibits the vestibular afferents depending on the direction in which the stereocilia are deflected.
Figure 21.4 The semicircular canal (angular) and otolith (linear) input is sent to the vestibular nuclei. From the vestibular nuclei, the input travels to the ocular motor nuclei (III, IV, VI) for mediation of the vestibulo-ocular reflex. For arousal and conscious awareness of the head and body in space, information proceeds further to the thalamus and cortex. For maintenance of postural control, the peripheral vestibular input is sent distally as the medial and lateral vestibulo-spinal tracts (MVST, LVST). PIVC = Parieto-insular vestibular cortex.
PHYSIOLOGY AND MOTOR CONTROL
Tonic Firing Rate
Vestibulo-Ocular Reflex
VOR Gain and Phase
Figure 21.5 From the anterior semicircular canal (Ant Scc), afferent input travels to the vestibular nuclei (Vnu). The signal continues to the contralateral oculomotor nuclei (III). From there, motoneurons synapse with the superior rectus muscle that moves the eye upward, and the inferior oblique muscle that moves the eye upward and torsionally. Also shown are the oculomotor nuclei IV, and VI.
Table 21.1 Innervation Pattern of Excitatory Input from the Semicircular Canals
Figure 21.6 Muscle insertions of the left eye. Six extraocular muscles insert into the sclera and can be considered as complementary pairs. The medial and lateral rectus muscles rotate the eyes horizontally, the superior and inferior rectus muscles rotate the eyes vertically, and the superior and inferior oblique muscles rotate the eyes torsionally with some vertical component. By convention, the torsional rotation is noted as it relates to the superior poles of the eyes. The superior oblique muscle rotates the eye downward and toward the nose, whereas the inferior oblique muscle rotates the eye upward and away from the nose. The superior oblique muscle travels through the fibrous trochlea, which attaches to the anteromedial superior wall of the orbit.
Push–Pull Mechanism
Inhibitory Cutoff
Figure 21.7 (A) Orientation of the horizontal semicircular canals (HC) in situ, with the head neutrally aligned. (B) The semicircular canals (ipsilateral anterior and contralateral posterior, and each horizontal) work in pairs. The arrows indicate the angular pitch direction of individual SCC stimulation. The dashed and continuous lines illustrate each SCC has an equally opposing SCC, sensitive to the opposite angular pitch direction of the head, for example, the left anterior canal (left AC) is paired with the right posterior canal (right PC) an collectively recognized as the left anterior right posterior (LARP) plane.
Velocity Storage System
PHYSICAL THERAPY EXAMINATION
History and Systems Review
Identification of Symptoms
Table 21.2 Symptoms and Possible Causes
Duration and Circumstances of Symptoms
Tests and Measures
Visual Analogue Scale
Dizziness Handicap Inventory
Functional Disability Scale
Table 21.3 Sample of the Types of Questions Included in the Dizziness Handicap Inventory, Based on the Three Sub-Components
Motion Sensitivity Quotient
Examination of Eye Movements
Figure 21.8 Motion sensitivity quotient.
Observation for Nystagmus
Head Impulse Test (Examination of the VOR at High Acceleration)
Head-Shaking Induced Nystagmus Test
Positional Testing
Figure 21.9 Normal horizontal canal head impulse test to the left (A, B), abnormal to the right (C-E). The examiner applies the head impulse test (HIT) to the patient. Large arrow denotes direction the head will be turned. (A) Initial starting position places subject’s head into cervical flexion; eyes are focused on the target. (B) On stopping the head turn, the eyes are still on target and no corrective saccade is observed. In photographs A and B, the subject’s eyes stay fixed on the examiner’s nose throughout the test. (C) Initial starting position places subject’s head into cervical flexion; eyes are focused on the target. (D) As the head is turned rapidly to the right, the eyes fall off the target and move with the head. (E) The subject must make a corrective saccade (small arrows) to bring the eyes back to the target of interest. For patients with cervical spine pathology, the clinician may choose to perform the horizontal canal HIT by first positioning the head in 15 degrees of rotation and then returning the head to center.
Dynamic Visual Acuity Test
Figure 21.10 Vertical semicircular canal head impulse test (HIT), examiner’s hands not shown here. There are two ways to investigate the VOR from each coplanar pair; methods A–C and D–F illustrate the two methods for the left anterior right posterior (LARP) VOR. (A) The head is placed in a neck neutral position. Next the head is rapidly moved pitch down while being rolled to the left (B) as if the head were moving diagonally. This examines the VOR from the left anterior SCC. From here, the clinician should return to (A) before rapidly moving the head pitch up and rolled to the right (C). This examines the VOR from the right posterior canal. Alternatively, the head is rotated 45° to the right (D). From this static position, the head is rapidly pitched down (E) examining the left anterior SCC. The head should be returned to the start position (D) and then the head rapidly moved pitch up to examine the right posterior SCC (F). In this figure, the HIT is normal for the LARP plane, since the eyes remain gazing straight ahead.
Figure 21.11 The Dix-Hallpike test. (1) The patient sits on the examination table and the clinician turns the head horizontally 45°. (2) As the examiner maintains the 45° rotation, the patient is quickly brought to a supine position with the neck extended 30° beyond the horizontal. The examiner must look for nystagmus and ask the patient if vertigo is being experienced. The patient is then slowly brought back to the starting position, and the other side is tested. The side that reproduces nystagmus and vertigo is the side that has the benign paroxysmal positional vertigo (BPPV). Shown here for testing right posterior or right anterior semicircular canal BPPV.
Figure 21.12 The Dix-Hallpike test (side-lying). (1) The patient sits on the edge of the examination table. The clinician turns the head horizontally 45°. (2) As the examiner maintains the 45° rotation, the patient is quickly brought down to the side opposite the head rotation (pictured here as the right side). The examiner checks for nystagmus and vertigo, and then slowly brings the patient to the starting position. The other side is then tested.
Figure 21.13 Roll test for horizontal semicircular canal BPPV. The patient is positioned in supine. (A) Initially, the patient’s head should be placed in 20° cervical flexion. (B) The head is quickly turned 90° to the left side. The clinician then checks for nystagmus and vertigo. (C) The head is then gently returned to the neutral starting position. (D–F) The test is repeated to the other side (head is quickly turned 90° to the right side). The therapist again must check for nystagmus and vertigo. The head is then returned to the neutral starting position.
Examination of Gait and Balance
Vestibular Function Tests
Semicircular Canal Tests
Otolith Tests
Table 21.4 Common Balance Tests and Expected Results Related to Specific Diagnosis
VESTIBULAR SYSTEM DYSFUNCTION
Peripheral Pathology
Mechanical
Decreased Receptor Input
Figure 21.14 Illustrated is benign paroxysmal positional vertigo (BPPV) of the posterior SCC. (A) Canalithiasis indicates free-floating otoconia within the SCC. When the head is moved into a position that places the SCC parallel to the pull of gravity (e.g., Dix-Hallpike position), the free-floating otoconia move to the dependent position within the canal. The movement of the free-floating otoconia results in deflection of the cupula. (B) Cupulolithiasis indicates otoconia adhering to the cupula. When the head is moved to a position placing one of the SCCs parallel to the pull of gravity (e.g., Dix-Hallpike position), the cupula is continually displaced. Illustrated is BPPV of the posterior SCC; also note the cupular deflection. Note that the cupula is drawn with the superior aspect detached from the ampulla.
Central Nervous System Pathology
Discerning Peripheral Vestibular Pathology from Central Vestibular Pathology
Figure 21.15 The ocular tilt reaction (OTR) consists of a triad of signs: (A) Head tilting to the right, indicated with the large arrow. (B) Skew deviation of the eyes (right eye is down, left eye is up), indicated with the bisecting line and straight arrows. (C) Torsion of the eyes to the right, indicated with the two smaller rounded arrows.
INTERVENTIONS
Benign Paroxysmal Positional Vertigo
Table 21.5 Common Symptoms Associated with Central versus Peripheral Vestibular Pathology
Table 21.6 Type of Nystagmus Based on SCC Location and Mechanism of BPPV
Figure 21.16 Canalith repositioning maneuver (CRM) for posterior or anterior semicircular canal BPPV. (A) The patient’s head is first rotated 45° toward the involved side, pictured here as the left. (B) The patient is then moved into the Dix-Hallpike position with the affected left ear toward the ground. (C) Next, the head is rotated 90° to the right. It is important to maintain the 30° neck extension during this step. The head should now be positioned 45° to the right. (D) The patient is rolled onto the right shoulder and (E) slowly brought up to sitting position, head still rotated 45° to the right. The patient may then be fitted with a soft collar. Note the orientation of the labyrinth for each stage. The arrow points to the free-floating debris and shows its movement through the canal into the common crus (D). AC = anterior SCC; PC = posterior SCC; HC = horizontal SCC. Between each step, the clinician should wait 1 to 2 minutes or until the vertigo and nystagmus has stopped to ensure otoconia flow through the canal.
Unilateral Vestibular Hypofunction
Figure 21.17 Canalith repositioning maneuver (CRM) for right horizontal semicircular canal BPPV. Initially, the patient’s head should be placed in 20° cervical flexion. (A) For treating a right-sided horizontal canal BPPV, the patient’s head is initially placed 90° to the right. (B) Next, the head is rotated 90° to the left. The therapist should wait in this position for 15 seconds or until the vertigo and nystagmus stops. (C) The head should then be rotated another 90° to the left; again the therapist must wait for 15 seconds or until the vertigo and nystagmus stops. (D) The patient must then roll into prone position and await the signs or symptoms to stop. The therapist must attempt to keep the head in 20° flexion during the transition from C to D. If the CRT has been successful, nystagmus and vertigo should resolve once the patient is in the prone position. The patient may need assistance to sit up from the prone position.
Gaze Stability Exercises
Postural Stability Exercises
Habituation Exercises (Motion Sensitivity)
Figure 21.18 Liberatory (Semont) maneuver for right posterior SCC BPPV. The physical therapist should assist the patient through this positioning procedure. Note the otoconia adherent to the cupula in A and B. (A) The head is rotated 45° to the left side. (B) With assistance, the patient is then moved from sitting to right side-lying and stays in this position for 1 minute. (C) The patient is then rapidly moved 180°, from right side-lying to left side-lying. The head should be in the original starting position, left rotated (nose down in final position) in this example. Note that the otoconia have been dislodged from the cupula. After 1 minute in this position, (D) the patient returns to sitting. AC = anterior SCC; PC = posterior SCC.
Figure 21.19 Brandt-Daroff exercises for posterior SCC BPPV. (A) The patient starts in a sitting position and turns the head 45° to one side (left) then quickly lies down on the opposite shoulder (right). The patient should be instructed to remain in this position for 30 seconds or until the vertigo stops. The patient then slowly returns to the starting position (A), maintaining the head rotation (left) until sitting upright. (B) Next, the patient turns the head to the opposite direction (right) and lies down on the other shoulder (left), observing the similar 30-second time guidelines. The exercise should be done 10 to 20 times, three times per day until the patient is without vertigo for two consecutive days.
Table 21.7 Benign Paroxysmal Positional Vertigo Treatment Techniques
Figure 21.20 Gaze stability exercises. (A,C,E);1 paradigm: The patient is instructed to focus the eyes on a near target. While maintaining focus on the target, the patient horizontally rotates the head keeping the target still. (B,D,F) ×2 paradigm: The patient is instructed to focus the eyes on a near target. While the focus is maintained, the patient horizontally rotates the head and the target in opposite directions. Both ×1 and ×2 paradigms require vigilance of the patient to ensure clear vision during the motions. Both exercises are typically performed for 1 to 2 minutes, five times a day. It can be repeated using vertical head movements.
Table 21.8 Balance Exercises and Progressions
Figure 21.21 Example of a more difficult balance exercise. Instruct the patient to gently place his or her foot on a plastic cup and maintain his or her balance without crushing the cup. Initially, the patient should be advised to use a handhold. The exercise can be progressed to eyes closed, no handhold, or stepping while alternating foot placement on the cup.
Bilateral Vestibular Hypofunction
Figure 21.22 Example of a home exercise program using habituation therapy. Intensity refers to symptoms (or dizziness) on a five-point scale (0 = none; 5 = most severe).
Table 21.9 Bilateral Vestibular Lesion Exercises to Improve Central Preprogramming of Eye Movements
Abnormal Central Vestibular Function
Patient Education
Box 21.1 Evidence Summary Outcome Studies Using Vestibular Adaptation Exercises to Improve Gait, Balance, and Dynamic Visual Acuity in Subjects with Vestibular Hypofunction
DIAGNOSES INVOLVING THE VESTIBULAR SYSTEM
Ménière’s Disease
Perilymphatic Fistula
Vestibular Schwannoma
Motion Sickness
Migraine-Related Dizziness
Multiple Sclerosis
Multiple System Atrophy
Cervicogenic Dizziness
CONTRAINDICATIONS TO VESTIBULAR REHABILITATION
SUMMARY
Questions for Review
CASE STUDIES
References
Supplemental Readings
appendix 21.A Web-Based Resources for Clinicians, Families, and Patients with Vestibular Disorders
Chapter 22 Amputation
LEARNING OBJECTIVES
LEVELS OF AMPUTATION
Table 22.1 Levels of Amputation
Figure 22.1 Transtibial residual limb with incision from equal-length flaps.
Figure 22.2 Transfemoral residual limb with incision from equal-length flaps.
SURGICAL PROCESS
Figure 22.3 (A) Anterior view and (B) lateral view of a transtibial residual limb with anterior incision from a long posterior flap.
HEALING PROCESS
POSTSURGICAL DRESSINGS
Rigid Dressings
Semirigid Dressings
Soft Dressings
Elastic Wraps
Table 22.2 Postsurgical Dressings
Elastic Shrinkers
Figure 22.4 (Left) Transtibial shrinker. (Right) Trans-femoral shrinker.
PHASES OF CARE: POSTSURGICAL26 AND PREPROSTHETIC
Postsurgical Phase
Box 22.1 Postsurgical General Goals
Box 22.2 Early Postsurgical Evaluation
Intervention
Positioning
Box 22.3 General Plan of Interventions
Balance and Transfers
Mobility
Figure 22.5 Proper transtibial position: (A) supine; (B) side-lying; (C) prone; (D) sitting.
Residual Limb Care
Care of the Remaining Lower Extremity
Patient Education
Preprosthetic Phase
Examination
Residual Limb
Box 22.4 Preprosthetic General Goals
Range of Motion
Muscle Strength
Box 22.5 Preprosthetic Examination Guide
Figure 22.6 Hip flexion contractures prevent balanced standing.
Status of the Uninvolved Limb
Functional Status
Phantom Limb
Emotional Status
Psychological Support
The Older Adult
Intervention
Residual Limb Care
Residual Limb Wrapping
The Transtibial Bandage
Figure 22.7 Transtibial residual limb bandaging.
The Transfemoral Bandage
Figure 22.8 Transfemoral residual limb bandaging.
Shrinkers
Skin Care
Range of Motion
Exercises
Figure 22.9 Transtibial exercises: (A) quad set, (B) hip extension with knee straight, (C) straight leg raise, (D) extension of the residual limb with the knee of the other leg against the chest, (E) hip abduction against resistance, and (F) bridging.
Balance and Mobility Activities
Figure 22.10 Transfemoral exercises: (A) gluteal sets, (B) hip abduction supine, (C) hip abduction against resistance, (D) hip extension prone, and (E) bridging.
Figure 22.11 Standing balance exercise on a compliant surface.
Figure 22.12 Kneeling on a pillow on a chair provides an opportunity for some weight-bearing.
Temporary Prostheses
Patient Education
Bilateral Amputation
DETERMINING PROSTHETIC POTENTIAL
Box 22.6 Medicare Functional Classification Levels
PROSTHETIC TRAINING
Box 22.7 Factors that Contribute to an Efficient Prosthetic Gait
Table 22.3 Critical Training Elements
Advanced Training
Box 22.8 Evidence Summary Balance and Gait
Steps and Ramps
Table 22.4 Advanced Activities (Transfemoral)
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Reading
appendix 22.A Web-Based Resources for Clinicians, Families, and Patients with Amputation
Chapter 23 Arthritis
LEARNING OBJECTIVES
RHEUMATOID ARTHRITIS
Epidemiology
Etiology
Pathophysiology
Laboratory Tests
Figure 23.1 Progression of joint changes due to RA inflammation: Early to advanced disease.
Radiography
Classification and Diagnostic Criteria
Box 23.1 Classification of Progression of Rheumatoid Arthritis
Disease Onset and Course
Table 23.1 The 1987 Revised Criteria for the Classification of Rheumatoid Arthritisa
Table 23.2 The 2010 American College of Rheumatology/European League Against Rheumatism Classification Criteria for Rheumatoid Arthritis
Table 23.3 American College of Rheumatology Revised Criteria for Classification of Functional Status in Rheumatoid Arthritisa
Clinical Presentation
Systemic
Joint Impairments (Articular and Nonarticular)
Cervical Spine and Temporomandibular Joint
Shoulders and Elbows
Wrists
Hand Joints
Figure 23.4 Ulnar drift (deviation) of the fingers. This drawing depicts the impact of metacarpophalangeal joint swelling, soft tissue laxity due to synovitis, which leads to ulnar deviation of the fingers in RA.
Figure 23.5 Volar subluxation of the wrist seen with rheumatoid arthritis. The chronic inflammation of the proximal carpals can eventually lead to a volar subluxation of the wrist and hand on the radius, accentuating the normal 10° to 15° of volar inclination of the carpus on the distal radius.
Figure 23.6 Influence of the long flexors (F) in metacarpophalangeal drift deformity.
Figure 23.7 Swan neck deformity is characterized by PIP hyperextension and DIP flexion.
Figure 23.8 Features of a boutonniere deformity include DIP extension with PIP flexion.
Hips and Knees
Ankles and Feet
Figure 23.9 Posterior-medial view of the foot and ankle showing calcaneal valgus, pes planus (flatfoot), and hallux valgus. Used by permission of the Arthritis Foundotion.
Figure 23.10 Major foot and ankle deformities seen in rheumatoid arthritis.
Muscle Involvement
Figure 23.13 Relationship of structures to the metatarsal heads in metatarsalgia.
Tendon Involvement
Deconditioning
Rheumatoid Nodules
Vascular and Neurologic Complications
Cardiopulmonary Complications
Ocular Complications
Activity Limitation and Participation
Restriction
Prognosis
Remission Criteria
OSTEOARTHRITIS
Epidemiology
Etiology
Figure 23.14 Early-advanced osteoarthritis joint changes. Early joint changes are characterized by superficial damage to articular cartilage and mild inflammation. Progression to moderate joint changes includes joint space narrowing with full-thickness damage to cartilage and thickening of the subchondral bone. Advanced joint changes are marked by bony hypertrophy (marginal osteophytes), significant joint space narrowing, and possible angulation (deformity).
Pathophysiology
Box 23.2 Risk Factors for Osteoarthritis38,39
Normal Cartilage
Joint Pathology
Figure 23.15 Osteoarthritis: cartilage, clefts and fibrillation (histological specimen).
Figure 23.16 Osteoarthritis: knee, gross pathology.
Radiography
Disease Onset and Course
Figure 23.17 Osteoarthritis: Mild degenerative changes right hip, total hip replacement in left.
Classification and Diagnostic Criteria
Box 23.3 Clinical Classification Criteria for Knee, Hip, and Hand Osteoarthritis
Clinical Presentation
Signs and Symptoms (Impairments)
Joints
Figure 23.18 Osteoarthritis: Heberden’s and Bouchard’s nodes, hand.
Figure 23.19 Bilateral genu varum.
Activity Limitations and Participation Restrictions
Figure 23.20 Spinal stenosis: lumbar spine, MRI image.
Prognosis
MEDICAL MANAGEMENT
Pharmacological Therapy in Rheumatoid Arthritis
Nonsteroidal Anti-inflammatory Drugs
Table 23.4 Drugs in the Management of Osteoarthritis and Rheumatoid Arthritis
Disease-Modifying Antirheumatic Drugs
Biological Response Modifiers
Corticosteroids
Pharmacological Therapy in Osteoarthritis
REHABILITATIVE MANAGEMENT
Physical Therapy Examination
History
Range of Motion
Table 23.5 “Red Flags” Suggesting the Need for Urgent Evaluation and Management
Strength
Joint Stability
Cardiovascular Status
Functional Examination
Mobility, Gait, and Balance
Sensory Integrity
Psychological Status
Environmental Factors
Physical Therapy Intervention
Box 23.4 Examples of General Goals and Outcomes for Patients with Arthritis
Modalities for Pain Relief
Heat
Cold
Electrical Agents
Orthoses, Splints, and Braces
Rest
Range of Motion and Flexibility Exercise
Strengthening Exercise
Cardiovascular Training
Box 23.5 Evidence Summary Therapeutic Exercise in the Management of Rheumatoid Arthritis (RA)
Functional Training
Box 23.6 Evidence Summary Therapeutic Exercise in the Management of Knee and Hip Osteoarthritis (OA)
Gait and Balance Training
Joint Protection
Table 23.6 Analysis of Gait Deviations, Physical Examination Findings, and Treatment Goals
Table 23.7 Outcome Measures for RA and OA Organized by ICF Categories
Education and Self-Management
SURGICAL MANAGEMENT
SUMMARY
Questions for Review
CASE STUDIES
CASE 1: RHEUMATOID ARTHRITIS
CASE 2: OSTEOARTHRITIS
References
Supplemental Reading
appendix 23.A Functional Status Index
appendix 23.C Joint Protection, Rest, and Energy Conservation
JOINT PROTECTION
Why Is Joint Protection Important?
How Can Joints Be Protected?
Which Joints Need Protection?
Additional Reminders for the Protection of the Rheumatoid Hand
GETTING ADDITIONAL REST
ENERGY CONSERVATION TO REDUCE FATIGUE
Why Is Energy Conservation Important?
How Can You Reduce Fatigue?
Energy Conservation
appendix 23.D Web-Based Resources for Clinicians, Families, and Patients with Arthritis
Chapter 24 Burns
LEARNING OBJECTIVES
EPIDEMIOLOGY OF BURN INJURIES
SKIN ANATOMY AND BURN WOUND PATHOLOGY
Figure 24.1 Cross section of skin.
Table 24.1 Sensory Receptors, Location by Layer of Skin, and Sensation Mediated
CLASSIFICATIONS OF BURN INJURY
Epidermal Burn
Table 24.2 Burn Wound Classification: Differential Diagnosis
Figure 24.2 Red shading represents depth of skin involved in an epidermal burn.
Superficial Partial-Thickness Burn
Figure 24.3 Red shading represents depth of skin involved in a superficial partial-thickness burn.
Deep Partial-Thickness Burn
Figure 24.4 Red shading represents depth of skin involved in a deep partial-thickness burn.
Full-Thickness Burn
Figure 24.5 Red shading represents depth of skin involved in a full-thickness burn.
Figure 24.6 Escharotomy of the right upper extremity.
Subdermal Burn
ELECTRICAL BURN
Figure 24.7 Red shading represents depth of skin involved in a subdermal burn.
Burn Wound Zones
Extent of Burned Area
Figure 24.8 Zones of tissue damage as the result of a burn injury.
Figure 24.9 Rule of Nines to determine percentage of body surface area burn in adults (A) and children (B).
COMPLICATIONS OF BURN INJURY
Infection
Pulmonary Complications
Metabolic Complications
Figure 24.10 Modified Lund and Browder chart for determination of percentage of body surface area burn for various ages.
Cardiovascular Complications
Heterotopic Ossification
Neuropathy
Pathological Scars
BURN WOUND HEALING
Epidermal Healing
Dermal Healing
Inflammatory Phase
Proliferative Phase
Maturation Phase
MEDICAL MANAGEMENT OF BURNS
Initial Management
Wound Care
Surgical Management of the Burn Wound
Primary Excision, Types of Skin Grafts, and Skin Substitutes
Table 24.3 Common Topical Medications Used in Treatment of Burns
Skin Grafting Procedure
Figure 24.11 Sheet graft on dorsum of left hand, postoperative day 7.
Figure 24.12 Meshed split-thickness skin graft applied to freshly excised wound and secured with staples.
Correction of Scar Contracture
PHYSICAL THERAPY MANAGEMENT
Physical Therapy Examination
Figure 24.13 Schematic diagram of Z-plasty procedure.
Box 24.1 Evidence Summary Studies Addressing Assessment of Burn Scar
Anticipated Goals and Expected Outcomes
Box 24.2 Suggested Goals and Outcomes for the Physical Therapy Plan of Care for the Patient with Burns
Physical Therapy Intervention
Positioning and Splinting
Table 24.4 Positioning Strategies for Common Deformities
Therapeutic Exercise
Active and Passive Exercise
Figure 24.14 Positioning in bed of patient with burns of the anterior neck.
Figure 24.15 Positioning in bed of patient with burns of the axilla.
Figure 24.16 Proper positioning of upper extremities to reduce edema while seated.
Figure 24.17 Elevation of heels off bed, with use of foam rolls encased in elastic netting.
Figure 24.18 Static splint that immobilizes the shoulder in abduction and the elbow in extension.
Figure 24.19 Dynamic splint used to provide a low-load, prolonged stress to scar tissue on volar aspect of forearm to gain wrist extension.
Resistive and Conditioning Exercise
Ambulation
Scar Management
Pressure Dressings
Silicone Gel
Figure 24.20 Pressure garments such as gloves, vest, and waist-height pants are worn to minimize hypertrophic scar formation.
Massage
Camouflage Make-up
Follow-up Care
COMMUNITY PROGRAMS
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 24.A Web-Based Resources for Patients, Families, and Clinicians
Chapter 25 Chronic Pain
LEARNING OBJECTIVES
INTRODUCTION
Definitions of Pain
Acute, Persistent, and Chronic Pain
The Biopsychosocial Model of Pain
Box 25.1 Pain Terminology
Table 25.1 Core Set of World Health Organization’s International Classification of Functioning, Disability and Health Classifications Relevant to Patients with Chronic Pain23,25–28
Box 25.2 Characteristic Behaviors in Chronic Pain Syndrome3
PAIN PHYSIOLOGY
Table 25.2 Features of Fast and Slow Nociceptive Pain
Figure 25.1 Central pain pathways. (A) Projection fibers from A-δ afferents retain a somatotopic organization, cross and ascend through the lateral spinothalamic tract to the ventral posterior lateral thalamus, then to the primary and secondary somatosensory cortex. These fibers transmit information about pain localization, intensity, duration, and quality. (B) Projection fibers from C afferents ascend through the medial spinothalamic, spinoreticular, and spinomesencephalic tracts to the medial thalamus, reticular formation, hypothalamus, limbic system, autonomic centers, and cingulate gyrus. The medial pain pathways contribute to the affective, autonomic, and cognitive experience of pain.
Pain Processing and the Evolving Gate Control Theory
Figure 25.2 The Gate Control Theory. Pain fibers (A-δ or C fibers) synapse with both an inhibitory interneuron and a secondary neuron, which transmits the pain signal to the brain. Sensory nerves, such as A and Aß, also provide input into the inhibitory interneuron. With sufficient stimulus to the Aα or Aß nerves, the inhibitory interneuron “closes the gate” on the secondary neuron and prevents pain stimuli from being transmitted to the brain. Descending regulation also modifies output of the secondary neuron.
Peripheral and Central Sensitization
Physiological Changes Occurring with Chronic Pain: Neuroplasticity and Learning
Classification of Pain
Table 25.3 Subjective and Objective Characteristics Associated with Different Types of Pain and Tissue Sources44,58,64
CAUSES AND RISK FACTORS FOR CHRONIC PAIN
The Effect of Lifestyle Factors
PSYCHOSOCIAL FACTORS ASSOCIATED WITH CHRONIC PAIN
The Mind-Body Relationship
Table 25.4 Psychosocial Assessment Tools by Construct
Table 25.5 Alert Flags for Chronic Pain144
Pain Beliefs and Coping
Anxiety and Fear Avoidance
Figure 25.3 The fear-avoidance model shows how the pain experience can resolve in the absence of fear or become a vicious cycle in the presence of pain-related fear. Negative affect and poor coping skills cause the pain experience to be perceived as a threat; pain catastrophizing increases pain-related fear, hypervigilance, and avoidance. Activity avoidance leads to secondary problems such as deconditioning, depression, and additional disability, which further exacerbate the negative aspects of the pain experience. On the other hand, individuals who do not perceive pain as a threat are more likely to progress back into activities that had been painful, leading to recovery.
Catastrophizing
Depression and Grieving
Stress
Nonorganic Findings
Personality Disorders
Social Support
EXAMINATION OF PAIN
Box 25.3 Mnemonics for Pain Assessment175–177
Pain Questionnaires and Outcome Measures
Table 25.6 Pain Assessment Tools Appropriate for Chronic Pain*
Examination of Pain in Special Populations
Box 25.4 Pain Expression and Factors Affecting Pain Expression175
Narrative Examination of Pain
MEDICAL MANAGEMENT OF CHRONIC PAIN
Medical Diagnostic Testing
Pharmacological Management of Chronic Pain
Table 25.7 Medications for Chronic Pain218
Interventional Medicine
Table 25.8 Interventional Procedures for Chronic Pain18
PHYSICAL THERAPY EXAMINATION
The Therapeutic Relationship
Box 25.5 Mnemonic for Managing Difficult Patients: GUT REACTIONS240
Subjective Examination
Systems Review
Box 25.6 Examination Elements Relevant to Chronic Pain24
Box 25.7 The 1998 Brighton Criteria for Hypermobility Syndrome, or Ehlers-Danlos Syndrome, Hypermobility Type247
Tests and Measurements
Body Structure and Function Measures
Activity and Participation Measures
PHYSICAL THERAPY EVALUATION, DIAGNOSIS, AND PROGNOSIS
Evaluation
Diagnosis
Prognosis
Table 25.9 Environmental Contextual Factors Affecting Prognosis, Using ICF I Terminology25–27
PHYSICAL THERAPY MANAGEMENT OF CHRONIC PAIN
The Multidisciplinary Pain Management Team
Box 25.8 Anticipated Goals and Expected Outcomes
Box 25.9 General Principles of Chronic Pain Management3
Figure 25.4 The pain management continuum starts with independent exercise, progresses to over-the-counter medications, physical or occupational therapy, cognitive-behavioral therapy, prescription medications, and medical (interventional) procedures. The order of intervention may change based on the patient’s preference.
Collaboration, Communication, and Documentation
Patient/Client-Related Instruction
Box 25.10 Goals of Educational Components of Chronic Pain Management16
Figure 25.5 Behavioral management of chronic pain. Patients should be educated so that they recognize the various cognitive and behavioral strategies they can use to manage their pain.
Procedural Interventions
Therapeutic Exercise
Manual Therapy
Neuromuscular Reeducation
Assistive Devices
Physical and Electrotherapeutic Modalities
COMPLEMENTARY AND ALTERNATIVE APPROACHES
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 25.A Pain Catastrophizing Scale
appendix 25.B Primary Care Post-Traumatic Stress Disorder Screen
appendix 25.C Evidence for Various Chronic Pain Interventions Based on Clinical Practice Guidelines, Cochrane Reviews, Meta-analyses (151618216220231232233234235236237238)
appendix 25.D Personal Care Plan for Chronic Pain
appendix 25.E Web-Based Resources for Clinicians, Families, and Individuals with Chronic Pain
Web Resources with Clinical Treatment Guidelines for Chronic Pain
appendix 25.F Resource Books for Patients
Chapter 26 Psychosocial Disorders
LEARNING OBJECTIVES
Table 26.1 Lifetime World Prevalence of the Most Common Psychiatric and Personality Disorders9
Box 26.1 Elements of a Mental Health Examination
PSYCHOSOCIAL ADAPTATION
Grief, Mourning, and Sorrow
Phase Models of Psychosocial Adaptation
Shock
Anxiety
Denial
Depression
Internalized Anger
Externalized Hostility
Acknowledgment
Adjustment
Chronic Illness and Disability: Differences in Adaptation
Post-traumatic Rehabilitation
PERSONALITY AND COPING STYLES
Personality Types
Personality Disorders
Box 26.2 Common Defense Mechanisms
Coping Styles
COMMON DEFENSE REACTIONS TO DISABILITY
Anxiety
Causes of Anxiety
Anxiety and Rehabilitation
Table 26.2 Signs and Symptoms Associated with Low, Moderate, and High Levels of Anxiety
Table 26.3 Behaviors Associated with Low, Moderate, and High Levels of Anxiety
How to Address Anxiety
Relaxation Response
Guided Imagery
Desensitization
Cognitive-Behavioral Therapy
Treatment for Panic Attacks
Box 26.3 Evidence Summary: Research Examining the Effects of Cognitive Therapy versus Antidepressants for Depression
When to Make a Referral for Anxiety
ACUTE STRESS DISORDER AND POST-TRAUMATIC STRESS DISORDER
Table 26.4 Effects and Adverse Side Effects of Commonly Prescribed Antianxiety Medications
Box 26.4 Behavioral Features (Warning Signs) of Possible Post-Traumatic Stress Disorder (PTSD)
Depression
Depression and Rehabilitation
Table 26.5 Signs and Symptoms Associated with Mild, Moderate, and Severe Depression
Table 26.6 Behaviors Associated with Mild, Moderate, and Severe Depression
Treating Patients with Depression
When to Make a Referral for Depression
Suicide
Table 26.7 Effects and Adverse Side Effects of Commonly Prescribed Antidepressant Medications
SUBSTANCE ABUSE
Substance Abuse and Rehabilitation
Treating Patients Who Abuse Substances
Education on Substance Abuse
Table 26.8 Common Physiological, Psychological, and Behavioral Manifestations Associated with Substance Abuse
When to Make a Referral for Substance Abuse
AGITATION AND VIOLENCE
HYPERSEXUALITY
PSYCHOSOCIAL WELLNESS
Barriers to Wellness for People with Disabilities
Social Support
WELLNESS IN REHABILITATION
INTEGRATING PSYCHOSOCIAL FACTORS INTO REHABILITATION: CASE EXAMPLE
SUGGESTIONS FOR REHABILITATIVE INTERVENTION
Table 26.9 Behaviors Suggesting Pathological Response Patterns
Optimizing Patient Involvement
Use of Jargon and Labels
Table 26.10 Patient Behaviors Warranting a Mental Health Consultation
Box 26.5 Examples of General Goals and Outcomes for Patients with Psychosocial Issues Adapted from the Guide to Physical Therapist Practice108
Box 26.6 Outcome Measures for Psychosocial Issues Organized by the International Classification of Functioning, Disability, and Health (ICF) Categories109
Rehabilitation Team Members’ Self-Awareness
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 26.A Holmes-Rahe Social Readjustment Scale
appendix 26.B The Hassles Scale
appendix 26.C Web-Based Resources for Patients, Families, and Caregivers
Improving Community Accessibility
Depression Resources
Substance Abuse Resources
Anxiety Resources
Post-Traumatic Stress Disorder (PTSD) Resources
Chapter 27 Cognitive and Perceptual Dysfunction
LEARNING OBJECTIVES
COGNITION AND PERCEPTION
Cognition and Higher-Order Cognition
Perception
RESPONSIBILITIES OF THE PHYSICAL THERAPIST AND THE OCCUPATIONAL THERAPIST
CLINICAL INDICATORS
HOSPITALIZATION FOLLOWING BRAIN DAMAGE
THEORETICAL FRAMEWORKS
The Retraining Approach
The Sensory Integrative Approach
The Neurofunctional Approach
The Rehabilitative/Compensatory (Functional) Approach
Cognitive Rehabilitation and the Quadraphonic Approach
Figure 27.1 The quadraphonic approach—macro perspective.
Figure 27.2 The quadraphonic approach—micro perspective.
EXAMINATION OF COGNITIVE AND PERCEPTUAL DEFICITS
Purpose of the Examination
Factors Influencing Patient Examination
Distinguishing between Sensory and Cognitive and Perceptual Deficits
Visual Impairments
Figure 27.3 Normally functioning visual system; right and left visual fields. See text for explanation.
Figure 27.4 Visual field deficits (with functional loss) and associated lesions. Vision is shown as clear and visual loss is colored in examples A–E, which denote (A) blindness in one eye; (B) bitemporal hemianopia (tunnel vision); (C) homonymous hemianopia; (D) quadrantanopia; and (E) homonymous hemianopia.
Figure 27.5 The functional significance of hemianopia—it may lead to accidents.
Figure 27.6 A newspaper as it might appear to a patient with right homonymous hemianopia following a stroke. The shading indicates that the patient may be unable to read the right side page.
Figure 27.7 Method for testing hemianopia.
Standardized Cognitive and Perceptual Tests
Table 27.1 Summary of Standardized Tests
INTERVENTION
Treatment Approaches
The Remedial Approach
The Adaptive/Compensatory Approach
Patient, Family, and Caregiver Education
Table 27.2 Common Assumptions of Adaptive and Remedial Approaches
Refocusing Intervention
The Impact of Managed Care
DISCHARGE PLANNING
OVERVIEW OF COGNITIVE AND PERCEPTUAL DEFICITS
Table 27.3 Summary of Cognitive and Perceptual Impairments
Attention Deficits
Memory Impairments
Immediate Recall and Short-Term Memory
Long-Term Memory
Impairments of Executive Functions
Body Scheme and Body Image Impairments
Unilateral Neglect
Figure 27.8 Example of a drawing by a patient with unilateral neglect. Therapist’s drawing of a beach scene (left). Impaired copying by a patient with unilateral neglect—environment neglect following a stroke (right).
Figure 27.9 Example of a drawing by a patient with unilateral neglect. Therapist’s drawing of a beach scene (left). Impaired copying by a patient with unilateral neglect—object neglect following a stroke (right).
Anosognosia
Somatoagnosia
Box 27.1 Evidence Summary: Evidence Addressing the Use of Cognitive Rehabilitation Techniques to Increase Activity in Patients with Unilateral Neglect Following Stroke
Right-Left Discrimination
Finger Agnosia
Spatial Relations Disorders (Complex Perception)
Figure–Ground Discrimination
Figure 27.10 An example of a figure-ground perception test.
Form Discrimination
Spatial Relations
Position in Space
Figure 27.11 Spatial relation processing as a man puts on a shirt.
Topographical Disorientation
Depth and Distance Perception
Vertical Disorientation
Figure 27.12 Vertical disorientation may contribute to disturbances of posture and gait.
Agnosias (Simple Perception)
Visual Agnosias
Auditory Agnosia
Figure 27.13 A client with an agnosia learns to use an ATM with help from a therapist in the Easy Street Environment®.
Figure 27.14 Clients with agnosias and many other cognitive and perceptual deficits can practice daily living skills in the controlled Easy Street Environment® such as provided in the Market Store.
Tactile Agnosia or Astereognosis
Apraxia
Ideomotor Apraxia
Ideational Apraxia
Buccofacial Apraxia
SUMMARY
Questions for Review
CASE STUDY
References
Supplemental Readings
appendix 27.A Web-Based Resources for Clinicians, Families, and Patients with Cognitive and Perceptual Deficits
Chapter 28 Neurogenic Disorders of Speech and Language
LEARNING OBJECTIVES
THE ORGANIZATION OF LANGUAGE
SPEECH PRODUCTION
Figure 28.1 The human vocal organ.
Figure 28.2 Outlines of the vocal tract during articulation of various vowels.
Figure 28.3 Vocal tract configuration and corresponding spectra for three different vowels. The peaks of the spectra represent vocal tract resonances. The vertical lines for individual harmonics are not shown.
Table 28.1 Classification of English Consonants by Place and Manner of Articulation
Figure 28.4 The cardinal vowels represented as a vowel quadrilateral. The cardinal vowels are extremely placed reference points for vowel articulation. Vowels on the same horizontal line are believed to have an equally high tongue height while vowels in the left-right position are assumed to be equally backed and fronted.
APHASIA
Classification and Nomenclature
Fluent Aphasia
Nonfluent Aphasia
Global Aphasia
Acquired Aphasia
Primary Progressive Aphasia
Table 28.2 Classification by Aphasia Syndromes
Historical Perspective
Aphasia Measures
Recovery
Efficacy of Treatment in Post-Stroke Aphasia
Psychological and Related Factors
Treatment of Aphasia
Management of the Patient with Aphasia
COGNITIVE-COMMUNICATION DISORDERS
Examination of Cognitive-Communication Disorders
Treatment of Cognitive-Communication Disorders
Box 28.1 Strategies for Improving Communication in the Presence of Cognitive-Communication Disorder
DYSARTHRIA
Classification and Nomenclature
Treatment of Dysarthria
APRAXIA OF SPEECH
Treatment of Apraxia of Speech
DYSPHAGIA
Treatment of Dysphagia
Box 28.2 Communication Disorders: Implications for the Physical Therapist
Table 28.3 Speech and Language Disorder Web-based Resources for Patients, Families, and Caregivers
SUMMARY
Questions for Review
CASE STUDY
References
Chapter 29 Promoting Health and Wellness
LEARNING OBJECTIVES
THE IMPORTANCE OF HEALTH PROMOTION AND WELLNESS INITIATIVES
Figure 29.1 Obesity trends in US adults.
Figure 29.2 Fruit and vegetable consumption by U.S. adults in 2009.
Figure 29.3 Physical activity levels of U.S. adults in 2009.
Table 29.1 Healthy People 2020 Framework
Figure 29.4 Ecological approach to achieve the goals of Healthy People 2020.
Table 29.2 Healthy People 2020 Physical Activity Objectives
THE ROLE OF PHYSICAL THERAPISTS IN HEALTH PROMOTION
KEY TERMS IN HEALTH PROMOTION
Health and Disease
Wellness and Illness
Figure 29.5 Domains of wellness.
Quality of Life
Health Promotion Models
Primary, Secondary, and Tertiary Prevention
Figure 29.6 Primary, secondary, and tertiary prevention.
Population Health Management Model
HEALTH PROMOTION AND HEALTH EDUCATION
Figure 29.7 Population health management.
PHYSICAL ACTIVITY AND EXERCISE
THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH AND HEALTH PROMOTION
MEASURES OF HEALTH, WELLNESS, QUALITY OF LIFE, AND HEALTH BEHAVIORS
Clinical Measures of Health
Self-perceived Health, Wellness, and Quality-of-Life Measures
Disease-specific Measures of Self-perceived Health, Wellness, and Quality of Life
Assessing Health Behaviors
KEY MODIFIABLE PERSONAL HEALTH BEHAVIORS
Box 29.1 Body Mass Index (BMI)
THEORIES OF BEHAVIOR CHANGE
Health Belief Model
Box 29.2 U.S. Preventive Services Task Force Recommendations for Physical Activity Counseling
Theory of Reasoned Action and Theory of Planned Behavior
Transtheoretical Model (Stages of Change)
Figure 29.8 Health Belief Model.
Figure 29.9 Theory of Planned Behavior.
Table 29.3 Key Constructs in the Theory of Planned Behavior94
Table 29.4 Key Constructs in the Transtheoretical Model98
Box 29.3 Transtheoretical Model: Stages of Change88
Social Cognitive Theory
Table 29.5 Transtheoretical Model: Processes of Change88
Box 29.4 Sample Stage of Change Questionnaire
Table 29.6 Sample Self-Efficacy Questionnaire
Figure 29.10 Social Cognitive Theory.
Table 29.7 Key Constructs in Social Cognitive Theory88
Physical Activity Model for People with a Disability
Box 29.5 Evidence Summary: Studies Incorporating Social Cognitive Theory Constructs to Promote Changes in Levels of Physical Activity
Box 29.6 Strategies for Enhancing Self-Efficacy88,101,102
Community Models
MOTIVATIONAL INTERVIEWING
Box 29.7 Key Principles of Motivational Interviewing112
HEALTH PROMOTION AND WELLNESS FOR INDIVIDUALS WITH IMPAIRMENTS AND DISABILITIES
Examination and Evaluation
Interventions
Physical Activity/Exercise
Table 29.8 Physical Activity Guidelines
Smoking Cessation Counseling
Healthy Weight and Healthy Eating Counseling
Box 29.8 Helping Smokers Quit: A Guide for Clinicians
Box 29.9 Conditions Associated with Overweight and Obesity
HEALTH PROMOTION AND WELLNESS AT THE PROGRAM LEVEL
PHYSICAL THERAPISTS AS ADVOCATES
SUMMARY
Questions for Review
CASE STUDY
References
appendix 29.A Perceived Wellness Survey
PWS Scoring Sheet for Use with Individual Clients
appendix 29.B Web-Based Resources for Clinicians
SECTION THREE Orthotics, Prosthetics, and Prescriptive Wheelchairs
Chapter 30 Orthotics
LEARNING OBJECTIVES
TERMINOLOGY AND TYPES OF ORTHOSES
LOWER EXTREMITY ORTHOSES
Shoes
Upper
Figure 30.1 (A) Parts of a low quarter shoe with a Blucher lace stay. Note that the counter and toe boxing are internal reinforcing structures of the shoe. (B) Parts of a low-quarter running shoe.
Figure 30.2 Low-quarter shoes: (A) Blucher (open lace) and (B) Bal (Balmoral) (closed lace). The Blucher lace stay is generally preferred for orthotic use owing to ease in donning (provides greater foot entry space to accommodate orthosis) and adjustability.
Sole
Heel
Reinforcements
Last
Foot Orthoses
Internal Modifications
Figure 30.3 (Left) Plastic tapered heel spur cushion with concave relief to reduce pressure (available in multiple densities as well as with a removable central plug). (Right) The shaded area of the shoe on the right indicates the relative position of the heel spur cushion when placed in a shoe.
Figure 30.4 Scaphoid pads (left) are available with self-adhesive backing. They are positioned (middle) medial and plantar to the longitudinal arch; scaphoid pad (right) positioned inside of shoe.
Figure 30.5 University of California Biomechanics Laboratory (UCBL) foot orthosis exerts control at the subtalar joint via a force couple (A) and three-point counterforces to control calcaneal eversion (B). A second counterforce system (C) restricts forefoot abduction.
Figure 30.6 Rubber metatarsal pad. Whether used as an internal modification or as part of an insert, the pad should be oriented as shown on the skeletal model.
External Modifications
Figure 30.7 Illustrated here are (left) a metatarsal bar and standard heel, (middle) a rocker bar with a Thomas heel (note the medial extension), and (right) pivot point of rocker bar.
Figure 30.8 Illustrated here are (left) a metatarsal bar and standard heel, (middle) a rocker bar with a Thomas heel (note the medial extension), and (right) pivot point of rocker bar.
Ankle-Foot Orthoses
Foundation
Insert
Figure 30.9 AFO with plastic insert.
Stirrup
Figure 30.10 Solid stirrup. The stirrup in the foreground is as it comes from the manufacturer before it is U-shaped and fitted to the patient and shoe.
Figure 30.11 Split stirrup.
Ankle Control
Figure 30.12 Plastic insert on posterior leaf spring AFO.
Figure 30.13 Steel dorsiflexion spring assist.
Figure 30.14 ToeOFF® ankle-foot orthosis. This fiber glass, carbon fiber, and Kevlar orthosis is designed to provide dorsiflexion assistance in the presence of mild to severe foot drop accompanied by mild to moderate ankle instability. This orthosis is contraindicated in the presence of moderate to severe spasticity or edema.
Figure 30.15 Ypsilon™ ankle-foot orthosis. This carbon composite AFO is designed to provide dorsiflexion assistance in the presence of mild to moderate isolated drop foot. It promotes free ankle movements (medial, lateral, and rotational movement). The proximal Y-shape provides tibia crest clearance. This orthosis is contraindicated for an unstable ankle joint or in the presence of moderate to severe spasticity or edema.
Figure 30.16 Plastic hinged ankle-foot orthoses.
Figure 30.17 Steel stirrup (left) with posterior stop at its proximal end (arrow). Posterior stop (right) incorporated into a stirrup. A posterior stop is designed to allow dorsiflexion and prevent or stop plantarflexion.
Figure 30.18 Plastic solid AFO.
Figure 30.19 Bi-channel adjustable ankle locks (BiCAALs). Note that this ankle joint includes two channels. A spring placed in the posterior channel (shown) provides a dorsiflexion assist. A peg (or pin) placed in the anterior channel (shown) provides a dorsiflexion stop. A peg placed in the posterior channel creates a plantarflexion stop.
Foot Control
Superstructure
Figure 30.20 Valgus correction strap (also called a “T-strap”). Arrows indicate the three-point pressure system created by the corrective forces (right lower extremity).
Figure 30.21 Spiral AFO.
Knee-Ankle-Foot Orthoses
Figure 30.22 Conventional AFO with stirrup attachment, limited motion ankle joints, bilateral uprights, and upholstered metal calf band.
Figure 30.23 Floor reaction AFO with anterior band provides a knee extension moment in stance without preventing flexion during swing.
Figure 30.24 (Left) AFO with stirrup, hinged ankle joint, steel uprights, and plastic patellar-tendon-bearing brim. (Right) Plastic AFO with patellar-tendon-bearing brim to reduce weight-bearing on foot.
Knee Control
Figure 30.25 Two examples of offset knee joints (left and middle) and one of a drop ring lock (right).
Figure 30.26 Knee joint hinge with pawl lock: basic component (A) and pawl lock installed in KAFO with bail shaped to curve posteriorly (B).
Figure 30.27 Knee joint hinge with serrated knee lock. Note the location of the knee hinge and the serrated disk.
Figure 30.28 (A) Conventional KAFO with knee cap. (B) Plastic KAFO pictured on a subject together with schematic of same orthosis. (C) This orthosis allows conversion between an AFO and KAFO based on patient requirements. The knee component that provides more proximal alignment and stability is detachable to create an AFO.
Figure 30.29 (A) Computer-controlled KAFO. (B) Close-up of knee joint. The E-Knee™ pictured here is a force-activated, computer-controlled knee unit powered by a lithium battery. The pressure-sensitive footplate signals the microprocessor to lock knee when pressure is applied and to unlock in the absence of pressure. The unit is recharged using a standard electrical outlet.
Figure 30.30 Patient moving from sit-to-stand wearing the Tibion Bionic Leg (Tibion Corporation, Sunnyvale, CA 94085). This is a KAFO with electronic knee control designed to support the rehabilitation process. A computer allows the therapist to program the amount of support the orthosis is providing during various tasks.
Superstructure
Hip-Knee-Ankle-Foot Orthoses
Figure 30.31 The patten bottom is the distal component of an orthosis designed to eliminate weight-bearing from the limb. The patten bottom prevents the foot from contacting the floor.
Hip Joint
Pelvic Band
Trunk-Hip-Knee-Ankle-Foot Orthoses
Figure 30.32 Hip joint with drop ring lock.
Figure 30.33 (Left) Conventional HKAFO with stirrup; uprights; hinged ankle, knee, and hip joints; drop ring locks at the knee and hip; and pelvic band. (Right) Plastic and metal HKAFO with hip and knee joints unlocked.
Figure 30.34 Conventional THKAFO without upholstery. This image illustrations the foundational structure of these cumbersome orthoses. To this large heavy metal frame, the additional weight of the upholstery, needed straps and pads, and shoes was added. Patients once leaving the rehabilitation setting often discarded such extensive bracing.
Orthotic Options for Patients with Paraplegia
Mass-Produced Orthoses
Standing Frame and Swivel Walker
Parapodium
Figure 30.35 Standing frame.
Figure 30.36 Adult standing frame.
Custom-Made Orthoses
Figure 30.37 Parapodium.
Stabilizing Boots
Craig-Scott KAFOS
Figure 30.38 Stabilizing boots.
Figure 30.39 Craig-Scott KAFOs.
Reciprocating Gait Orthoses
Figure 30.40 Reciprocating gait orthosis.
TRUNK ORTHOSES
Figure 30.41 ARGO reciprocating gait orthosis. This system includes pneumatic struts at the knee that extend the knees and ensure locks are engaged on standing.
Corsets
Figure 30.42 Lumbosacral corset (cotton/elastic polymer) with front hook-and-loop closure.
Rigid Orthoses
Lumbosacral Flexion, Extension, Lateral Control Orthoses
Figure 30.43 (Left) Conventional lumbosacral flexion, extension, lateral (LS FEL) control orthosis, and (right) custom-fabricated plastic LS FEL control orthosis with corset front.
Figure 30.44 Prefabricated, adjustable lumbosacral flexion, extension, lateral control orthosis.
Thoracolumbosacral Flexion, Extension Control Orthoses
Cervical Orthoses
Figure 30.45 (Left) Conventional thoracolumbosacral flexion, extension, lateral control orthosis (TLS FEL). (Middle) Custom-fabricated plastic TLS FEL.
Figure 30.46 Soft foam rubber collar.
Figure 30.47 Philadelphia collar.
Figure 30.48 Four-post cervical orthosis.
Scoliosis Orthoses
Figure 30.49 (Left) The halo cervical orthosis provides maximum stabilization of the head and cervical spine. The graphite ring (halo) allows placement of titanium pins into outer table of skull. (Right) Noninvasive halo devices are also available. They are effectively used as transitional bracing after removal of a halo cervical orthosis. Pictured here is the Lerman Non-invasive Halo.
Figure 30.50 Milwaukee orthosis (plastic and metal).
Figure 30.51 Boston thoracolumbosacral orthosis.
ORTHOTIC MAINTENANCE
Shoes
Shells, Bands, and Straps
Uprights
Joints and Locks
PHYSICAL THERAPY MANAGEMENT
Preorthotic Examination
Joint Mobility
Limb Length
Muscle Function
Sensation
Upper Limbs
Psychological Status
Orthotic Prescription
Ankle-Foot Orthoses
Knee-Ankle-Foot and Other Lower Extremity Orthoses
Trunk Orthoses
Orthotic Examination
Lower Extremity Orthotic Examination
Static Examination
Dynamic Examination
Table 30.1 Orthotic Gait Analysis
Trunk Orthosis Static Examination
Facilitating Orthotic Acceptance
Orthotic Instruction and Training
Donning Orthoses
Standing Balance
Gait Training
Reciprocal Gaits
Simultaneous Gaits
Related Activities
Final Examination and Follow-up Care
Functional Capacities
Paraplegia
Hemiplegia
SUMMARY
Questions for Review
CASE STUDY
PATIENT HISTORY AND CURRENT PROBLEM
PAST MEDICAL HISTORY
SOCIAL HISTORY
PHYSICAL THERAPY EXAMINATION FINDINGS
Range of Motion Examination
Sensation
Strength: Manual Muscle Test (MMT) Grades
Orthotic Examination
Balance
Standing
Sitting
Gait
Functional Status
PATIENT-DESIRED OUTCOME AND GOALS
GUIDING QUESTIONS
References
Supplemental Readings
appendix 30.A Lower Extremity Orthotic Examination
Standing
Ankle
Knee
Shells, Bands, Cuffs, and Uprights
Weight-Relieving Components
Hip
Stability
Sitting
Walking
Orthosis Off the Patient
appendix 30.B Trunk Orthotic Examination
Standing
Pelvic Band
Thoracic Band
Uprights
Abdominal Front
Cervical Orthosis
Sitting
Orthosis Off the Patient
appendix 30.C Web-Based Orthotic Resources for Clinicians, Families, and Patients
Chapter 31 Prosthetics
LEARNING OBJECTIVES
PARTIAL FOOT AND SYME’s PROSTHESES
Figure 31.1 Syme’s prostheses. (Left) Socket with continuous walls. (Right) Socket with medial opening.
TRANSTIBIAL PROSTHESES
Figure 31.2 Lo Rider foot for Syme’s prosthesis.
Foot-Ankle Assemblies
Nonarticulated Feet
SACH Foot
Other Nonarticulated Feet
Figure 31.3 Cross section of nonarticulated foot-ankle assemblies. (A) SACH. (B) SAFE.
Figure 31.4 Springlite foot.
Figure 31.5 C-Walk foot.
Figure 31.6 Nonarticulated energy-storing prosthetic feet. (A) Re-Flex VSP® and Re-Flex VSP Low Profile®, (B) Talux®, (C) Ceterus®, (D) Vari-Flex®. (E) Renegade. (F) ELITE 2®.
Articulated Feet
Figure 31.7 Cosmetic foot covers.
Single-Axis Feet
Multiple-Axis Feet
Figure 31.8 Flex-foot Cheetah® foot.
Figure 31.9 (Left) Single-axis foot. (Right) Cross section: anterior bumper controls dorsiflexion, posterior bumper controls plantarflexion.
Figure 31.10 Multiple-axis foot.
Figure 31.11 ProprioFoot®.
Rotators and Shock Absorbers
Shank
Exoskeletal Shank
Endoskeletal Shank
Figure 31.12 Rotator/shock absorber intended to be installed in pylon.
Figure 31.13 (Left) Exoskeletal transfemoral prosthesis. (Right) Endoskeletal transfemoral prosthesis with cosmetic cover removed.
Figure 31.14 Endoskeletal (modular) shank on (left) transfemoral prosthesis and on (right) transtibial prosthesis.
Socket
Figure 31.15 Transtibial patellar-tendon-bearing socket. Areas of relief (also called channels) over pressure-sensitive tissues. Build-ups (also called bulges) contact pressure-tolerant tissues.
Lined Socket
Socks, Sheaths, and Liners
Unlined Socket
Suspension
Cuff Variants
Figure 31.16 Silicone liners: (Left) Iceross® Dermo locking silicone gel liner. (Middle) Custom liners with fibular head padding. (Right) Seal-in designs.
Figure 31.17 (Left) Supracondylar cuff suspension for transtibial prostheses. (Right) Patient donning a transtibial prosthesis using a roll-on sleeve that includes a pin and shuttle lock assembly.
Distal Attachments
Brim Variants
Figure 31.18 Transtibial distal pin attachment. The pin fits into a receptacle in the socket bottom and is then tightened into place.
Figure 31.19 Harmony® Volume Management System.
Figure 31.20 (Left) Transtibial prosthesis with supracondylar (SC) suspension. (Middle) SC suspension using wedge insert. (Right) Transtibial socket with supracondylar/suprapatellar (SC/SP) suspension.
Thigh Corset
TRANSFEMORAL PROSTHESES
Figure 31.21 Transtibial thigh corset suspension.
Foot-Ankle Assemblies and Shanks
Knee Units
Axis System
Friction Mechanisms
Figure 31.22 (Left) Polycentric knee unit designed to provide stability during stance. (Right) Polycentric knee unit in place on a transfemoral prosthesis.
Constant and Variable
Figure 31.23 Constant-friction knee unit with clamp that encircles the knee bolt.
Medium
Figure 31.24 (A) Mauch® (SNS®) single-axis hydraulic knee unit with swing and stance control. (B) The 3R60 Ergonomically Balanced Stride (EBS) hydraulic system controls the knee during swing allowing greater ease in initiating swing and a greater range of walking speeds. Note that this prosthesis includes a flexible socket supported within a rigid frame.
Figure 31.25 C-Leg®.
Extension Aids
Stabilizers
Figure 31.26 Power Knee®.
Manual Lock
Friction Brake
Figure 31.27 Single-axis knee unit with manual lock. Note that this configuration has a proximal release attached by a high-density plastic wire to the knee. For patients with impaired balance, the proximal release eliminates the need to flex forward and reach down to the knee unit for unlocking.
Sockets
Quadrilateral Socket
Figure 31.28 Quadrilateral socket viewed from above. (A) Anterior wall. (B) Medial wall. (C) Posterior wall. (D) Lateral wall.
Ischial Containment Socket
ComfortFlex™ Socket
Figure 31.29 Ischial containment flexible transfemoral socket. (A) Anterior brim. (B) Medial brim. (C) Posterior brim. (D) Lateral brim.
Figure 31.30 (A) Frontal view of the femur and pelvis in the ischial containment socket. (B) Medial view of the pelvis in the ischial containment socket.
Figure 31.31 ComfortFlex™ socket design. (A) Anatomical orientation of transfemoral socket. (B) Overhead view of transfemoral socket (thumb and finger pressure illustrating socket flexibility). (C) Socket without carbon graphic frame. (D) Transtibial socket design.
Suspensions
Suction Suspension
Total Suction
Partial Suction
Figure 31.32 Transfemoral suspension sleeve.
Figure 31.33 Silesian belt.
No Suction
DISARTICULATION PROSTHESES
Knee Disarticulation Prostheses
Knee Units
Sockets
Hip Disarticulation Prostheses
Figure 31.34 (A) Anatomical orientation of the ComfortFlex™ hip disarticulation socket; additional components of the completed prosthesis included a hip joint, rotator, knee unit, pylon, and foot. Note that the socket covers the amputated side and wraps around the pelvis and is secured with anterior fasteners. (B) Hip disarticulation prosthesis with Helix 3D® hip joint.
Sockets
Hip Units
Knee Units
BILATERAL PROSTHESES
Bilateral Syme’s and Transtibial Prostheses52
Bilateral Transfemoral Prostheses53,54
PROSTHETIC MAINTENANCE
Foot-Ankle Assemblies
Shanks
Knee Units
Sockets and Suspensions
PHYSICAL THERAPY MANAGEMENT
Preprescription Considerations
Physical Examination
Psychosocial Considerations
Temporary Prostheses
Transtibial Temporary Prosthesis
Transfemoral Temporary Prosthesis
Figure 31.35 Transfemoral temporary prosthesis with adjustable polypropylene socket, pelvic band, knee unit with manual lock, and adjustable shank with SACH foot.
Prosthetic Prescription
Prosthetic Examination/Evaluation
Transtibial Examination
Static Analysis
Dynamic Analysis
Inspection of the Prosthesis Off the Patient
Table 31.1 Transtibial Prosthetic Gait Analysis
Transfemoral Examination
Static Analysis
Dynamic Analysis
Compensations/Deviations Best Viewed from Behind
Table 31.2 Transfemoral Prosthetic Gait Analysis
Compensations/Deviations Best Viewed from the Side
Inspection of the Prosthesis Off the Patient
Facilitating Prosthetic Acceptance
Prosthetic Training
Donning
Balance and Coordination
Gait Training
Functional Training
Transfers
Climbing Stairs, Ramps, and Curbs
Final Evaluation and Follow-up Care
Functional Capacities
Figure 31.36 Participants in a distance run (left) and long jump (right) event.
SUMMARY
Questions for Review
CASE STUDY
PAST MEDICAL HISTORY
SOCIAL HISTORY
PHYSICAL THERAPY EXAMINATION FINDINGS
Range of Motion
Observational Gait Analysis (General Findings)
Hip/Pelvis (Bilateral)
Knee
Foot/Ankle
Gait
Strength
Manual Muscle Test (MMT) Grades
Prosthetic Examination
Balance
Standing
Sitting
Examination of Function
PATIENT DESIRED OUTCOMES
GUIDING QUESTIONS
References
Supplemental Reading
appendix 31.A Transtibial (Below-Knee) Prosthetic Examination
Standing
Suspension
Sitting
Walking
Prosthesis Off the Client
appendix 31.B Transfemoral (Above-Knee) Prosthetic Examination
Standing
Quadrilateral Socket
Ischial Containment Socket
Suspension
Sitting
Walking
Prosthesis Off the Client
appendix 31.C Web-Based Prosthetic Resources for Clinicians, Families, and Patients
Chapter 32 The Prescriptive Wheelchair
LEARNING OBJECTIVES
Figure 32.1 A prescriptive wheelchair consists of the postural support system and a mobility base.
EXAMINATION
History Taking
Overview: Tests and Measures
Strength and Endurance
Sensation and Skin Integrity
Vision and Hearing
Health Status
Functional Abilities
Toileting
Bathing and Washing
Dressing
Eating
Communication
Transfers
Ambulation
Wheelchair Mobility—Manual and Power
Environmental Issues and Transportation
Cognitive and Behavioral Issues
SEATING PRINCIPLES
Principle 1: Stabilize Proximally to Promote Improved Distal Mobility and Function
Principle 2: Achieve and Maintain Pelvic Alignment
Principle 3: Facilitate Optimal Postural Alignment in all Body Segments, Accommodating for Impairments in Range of Motion
Principle 4: Limit Abnormal Movement and Improve Function
Principle 5: Provide the Minimum Support Necessary to Achieve Anticipated Goals and Expected Outcomes
Principle 6: Provide Comfort
WHEELCHAIR PRESCRIPTION
Function and Posture in Existing Equipment
Mat Table Measures
Supine Position
Range of Motion
Figure 32.2 The examiner must monitor the lumbar curve as the hips are flexed.
Figure 32.3 The examiner must monitor the lumbar curve and hamstring tightness behind the knees as the knees are extended.
Figure 32.4 (A) In the supine position with the hips and knees flexed the examiner can measure the undersurface of the thigh from the popliteal fossa to a firm support surface (B). Note that this position can also be used to measure leg length from the popliteal fossa to the heel.
Seat to Back Support Angle
Figure 32.5 The amount of hip flexion determines the trunk to thigh angle. If the degree of hip flexion for seating is 75°, the trunk to thigh angle is 105°.
Seat to Leg Support Angle
Figure 32.6 (A) If the degree of hip flexion for seating is to 95°, the trunk to thigh angle is 85°. (B) Seat to back support angle does not always correlate with trunk to thigh angle. In this example, if the seat to back support angle is set at 85°, tolerance to sitting in this position may be poor and cause the person to fall forward or constantly be working to hold himself or herself upright. Body shape, center of mass, and sitting tolerance must be addressed. (C) Opening the seat to back support angle to 100° better accommodates body shape and center of mass and tolerance to sitting upright improves.
Figure 32.7 Thigh to leg angle is determined during mat examination and is based on the degree of knee extension limitation when the hip is positioned in available ROM.
Figure 32.8 Seat to leg support angle and lower leg to foot support angle are final seating angles determined during seating simulation accommodating range of motion, tone, and comfort at the knees and ankles.
Lower Leg Support to Foot Support Angle
Seated Examination
Figure 32.9 Lower leg to foot support angle is determined during mat examination and is based on ankle range of motion.
Figure 32.10 Planar seating simulation chair.
Figure 32.11 The sitting position can be used to determine the amount and location of required support.
Figure 32.12 The following measurements are added to those taken in the supine position. (A) Sitting depth from behind the buttocks to popliteal fossa (right and left side); (B) leg measured from popliteal fossa to heel (right and left side); (C) knee flexion angle; (D) back height from sitting surface to posterior superior iliac crest, (E) from sitting surface to lower scapula, (F) from sitting surface to top of shoulder, (G) from sitting surface to occiput, and (H) from sitting surface to crown of head; (I) hanging elbow from sitting surface to the elbow or forearm; (J) width and (K) depth of trunk; (L) width of hips; and (M) measurement of foot length.
Wheelchair Testing
INTERVENTION
Problem Solving Model
Box 32.1 Example of Problem Solving Model Grid
Clinical Problems, Objectives, Property Recommendations, and Product Specifications
Clinical Problems
Objectives
Property Recommendations
Product Specifications
Postural Support System
Figure 32.13 Patients seated on planar surfaces may show increased pressure over bony prominences.
Figure 32.14 Some types of foam will contour as a response to body weight.
Figure 32.15 An option for creating contoured seats is use of varying density (firmness) of foam.
Figure 32.16 Firmer foam shapes can be placed under a more flexible foam to create a contoured cushion.
Figure 32.17 Custom-molded cushions match the patient’s body contours.
Seat Support
Figure 32.18 Overall poor sitting posture and asymmetries created by a sling seat.
Figure 32.19 A firm sitting surface enhances sitting posture and provides a stable base of support.
Box 32.2 Questions to Consider When Finalizing the Seat Support
Back Support
Box 32.3 Questions to Consider When Finalizing the Back Support
Pelvic Positioner
Figure 32.20 The pelvic belt should cross the pelvic-femoral junction at approximately a 45° to 60° angle to the seating surface.
Figure 32.21 A belt placed over the upper thigh (at a 90° angle to the sitting surface) will free the pelvis for natural anterior tilting.
Upper Extremity Supports
Lower Extremity Supports
Secondary Support Surfaces
The Wheeled Mobility Base
Figure 32.22 Sitting alignment with the hamstrings on slack and the knees flexed (left) and positioning assumed with feet resting on elevating foot rests (right) causing tension on the hamstring that pulls the pelvis into a posterior tilt.
Manual Mobility Systems
Figure 32.23 Wheelchairs with large front wheels and small rear casters may be easier for some patients to push, but are more difficult to use outdoors.
Box 32.4 Evidence Summary Studies Addressing Pain Associated with Wheelchair Propulsion
Figure 32.24 A double handrim on one side allows the user to drive a one-arm drive wheelchair with one hand.
Power Mobility Systems
Control Options
Hand Controls
Figure 32.25 (A) Motorized wheelchairs offer patients with poor coordination, weakness, or paralysis an opportunity to move around in their environment. This chair is also equipped with a power-operated seating system. (B) Patient seated in a motorized chair; note that this chair includes a storage space for canes behind seat back. (C) Close-up of platform flip-up footrest.
Head Array Systems
Sip ‘n’ Puff System/Breath Control System
Single Switch Systems
Scanning Array System
Other Systems
Power Wheelchair Bases
Scooters
Rear Wheel Drive Bases
Center Wheel Drive Bases
Front Wheel Drive Bases
Seating System Features
Adjustable Tilt-in-Space Seating Systems
Adjustable Recline System and Elevating Leg Rest System
Figure 32.26 (A) Tilt-in-space wheelchairs tilt through space with their angles preset. (B) Patient performing pressure-relief maneuver in tilt-in-space chair. (C) Close-up of goal-post joystick.
Power Seat Elevator
Standers
Power Assist Wheels
Specific Wheelchair Frame Features
Sling Back and Sling Seat Upholstery
Back Angle Adjustment
Seat Frame Angle and Height
Footrest System
Figure 32.27 Foundation components of a prescriptive wheelchair.
Figure 32.28 Lightweight rigid frame chair with adjustable suspension system, seat back angle, wheel base, and footrest lengths. The chair has knobby tires on spoked wheels.
Armrest System
Wheel Options
Seat Width and Depth
Figure 32.29 A wheelchair that is too wide will make wheel access and propulsion more difficult for the patient.
Figure 32.30 A narrower wheelchair allows easier wheel access and propulsion.
SPORTS AND RECREATION
Figure 32.31 This court chair is shown being used for tennis play. It can also be used for basketball. The back is very low to allow free trunk and arm movement. The wheels are radically cambered for stability.
Figure 32.32 This court chair is being used for basketball.
Figure 32.33 This tennis chair has a single front caster and a very low back.
Figure 32.34 Some sports chairs are designed for high-contact sports such as football, rugby, and hockey. This chair has a rigid frame with larger than standard tubing and a very wide front end.
Figure 32.35 This wheelchair has been designed for use in Quad Rugby, which is a high-contact sport.
Figure 32.36 This wheelchair and its tires and casters have been designed for use on sand and in the water.
Figure 32.37 This wheelchair is designed for all-terrain use.
WHEELCHAIR TRAINING STRATEGIES
ROLE OF THE CERTIFIED REHABILITATION TECHNOLOGY SUPPLIER
SUMMARY
Questions for Review
CASE STUDY
GUIDING QUESTIONS
References
Supplemental Readings
appendix 32.A Features of the Wheelchair Postural Support System
Back Matter
GLOSSARY
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X–Z
INDEX

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Physical Rehabilitation

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