COORDINATION.pptx

Coordination

1. EXAMINATION OF COORDINATION

2. LECTURE CONTENTS Coordination (Definition/Purpose) Define functions of Cerebellum & Basal ganglia & their associated pathologies Features of coordination impairments Testing protocol of Coordination Examination Non-equilibrium & Equilibrium Coordination tests Grading for Non-equilibrium & equilibrium tests Tests of coordination impairments

3. LECTURES OBJECTIVES At the end of the lecture the students will be able to; Understand the purpose of performing a coordination examination Describe the functions of cerebellum, basal ganglia & its associated impairments Differentiate between tests used to examine non equilibrium & those used to address equilibrium coordination Explain the testing protocol for performing a coordination examination Describe the sample tests for selected coordination impairments

4. COORDINATION Coordination is the ability to execute smooth, accurate, controlled motor responses . The ability to produce these responses is dependent on somatosensory , visual & vestibular input as well as fully intact neuromuscular system from the motor cortex to spinal cord. Coordinated movements are characterized by appropriate; Speed, distance, direction, timing, & muscular tension

5. COORDINATION EXAMINATION (PURPOSE) The purpose of performing a coordination exam of motor function is to determine the : Muscle activity characteristics during voluntary movement Ability of muscles or group of muscles to work together to perform a task or functional activity Level of skill & efficiency of movement Ability to initiate, control, & terminate movement Timing, sequencing, & accuracy of movement patterns Effects of therapeutic & pharmacological intervention on motor function over time

6. CEREBELLUM Function: Regulation of movement, postural control, & muscle tone. Theories of Function: Cerebellum functions as Comparator & Error correcting mechanism

7. BASAL GANGLIA Function: BG play an important role in several complex aspects of movement & postural control BG play an important role in maintaining normal background muscle tone The anatomical positioning of the BG provides insight into its contribution to motor performance

8. FEATURES OF COORDINATION IMPAIRMENTS Cerebellum, basal ganlia & dorsal column-medial lemniscal pathway provide input to, & act together with, the cortex in the production of coordinated movement. Lesions in any of these areas impact higher level processing & execution of coordinated motor responses.

9. CEREBELLAR PATHOLOGY Asthenia Generalized muscle weakness Asynergia Loss of ability to associate m/s together for complex movement Delayed reaction time Increased time require to initiate voluntary movement Dysarthria Disorder of the motor component of speech articulation Dysdiadochokinesia Impaired ability to perform rapid alternating movements Dysmetria Inability to judge the distance or range of movement Dyssynergia Decomposition of movement Hypermetria / hypometria Overestimation /underestimation of distance or range to accomplish movement Nystagmus Rhythmic, quick, oscillatory movement of eyes Rebound phenomenon Inability to halt forceful movements after resistive stimulus removed; pt unable to stop sudden limb motion Intention tremor Oscillatory movement during voluntary motion Postural tremor Exaggerated oscillatory movement in standing posture Titubation Rhythemic oscillations of the head

10. BASAL GANGLIA PATHOLOGY Akinesia Inability to initiate movement Athtosis Slow, involuntary,twisting , wormlike movements Bradykinesia Decrease amplitude & velocity of voluntary movement Chorea Involuntary, rapid, irregular, jerky movements Choreoathetosis Movement disorder with features of both chorea & athetosis Dystonia Sustained involuntary contractions of agonist & antagonist m/s Hemiballismus Large-amplitude sudden, violent motions of the arm & leg of one side of body Hyperkinesia Abnormal increased muscle activity or movement Hypokinesia Decreaed motor response esp to a specific stimulus Rigidity Leadpipe Cogwheel Increased in muscle tone causing greater resistance to passive movement Uniform, constant resistance as limb is moved Series of brief relaxations or “catches” as limb is passively moved Tremor (resting) Involuntary, rhythemic , oscillatory movement observed at rest

11. FEATURES OF COORDINATION TESTS Coordination tests can be divided into 2 main categories Non equilibrium tests: Address both static & mobile components of movements, when the pt is in a sitting position Involve both gross & fine motor activities Tests should be performed first with eyes open and then with eyes closed 2. Equilibrium tests: Address both static & dynamic components of posture & balance, when the pt is in a upright standing position Involve primarily gross motor activities

12. TESTING PROTOCOL

13. GATHER EQUIPMENT The coordination exam should be administered in a quiet, well lighted treatment area sufficiently large to accommodate walking activities Coordination assessment form Pen or pencil to record data Stopwatch Two standard chairs mat or treatment table Method of occluding vision

14. PATIENT PREPARATION The coordination examination should be administered when the patient is well rested. A full explanation of purpose of the testing should be provided Each coordination test should be demonstrated individually by the therapist before actual testing Testing procedures require mental concentration & physical activity Fatigue, lack of clarity or fear may adversely influence tests results

15. TESTING PROTOCOL Does increased speed of performance affect quality of motor activity ? Can appropriate motor adjustments made if speed & direction are changed ? Can a position or posture of the body or specific extremity be maintained without swaying, oscillations, or extraneous movements Does occluding vision alter the quality of motor activity ? Does patient fatigue rapidly ?

16. NON EQUILIBRIUM COORDINATION TESTS FINGER-TO-NOSE-TEST: The patient is asked to bring the tip of the index finger to the tip of his or her nose. Alternations may be made in the initial starting position to observe performance from different planes of motion. Observe intention tremor

17. NON EQUILIBRIUM COORDINATION TESTS Finger to finger test Finger-to-therapist’s finger Alternate nose-to-finger Finger opposition Mass grasp: An alteration is made between opening & closing fist, speed may be gradually increased Pronation / supination

18. NON EQUILIBRIUM COORDINATION TESTS Rebound test: The patient is positioned in sitting . The PT applies sufficient manual resistance to produce an isometric contraction of biceps. Resistance is suddenly released. Normally the opposing muscle group will contract & “check” movement of limb. The patient with dysfunction will be unable to arrest the progress of the arm, and it will rebound markedly off your arm.

19. NON EQUILIBRIUM COORDINATION TESTS Heel on shin: From a supine position, the heel of one foot is slid up and down the shin of the opposite LE

20. NON EQUILIBRIUM COORDINATION TESTS Tapping (hand): with the elbow flexed & forearm pronated , the pt is asked to tap the hand on the knee. Tapping (foot): The pt is asked to tap the ball of the foot on the floor without raising the knee; heel maintains contact with the floor Alternate heel-to-knee; heel to toe: From a supine position, the patient is asked to touch the knee & big toe alternatively with the heel of the opposite extremity.

21. EQUILIBRIUM COORDINATION TESTS Normal stance Stance (narrow BOS) Tandem stance One leg stance Perturbations: displace balance unexpectedly Standing, functional reach test: forward trunk flexion with UE reach Standing, laterally flex trunk to each side

22. EQUILIBRIUM COORDINATION TESTS Romberg test : Standing EO to EC; inability to maintain an upright posture without visual input is referred to as positive Romberg sign. Sharpened Romberg : Standing in tandem position EO to EC

23. EQUILIBRIUM COORDINATION TESTS Tandem walking: Heel to toe walk Walking along a straight line or place feet on floor markers while walking Walk sideways, backward, or cross stepping March in place Start and stop abruptly Walk and pivot on command (turn 90,180 or 360) Walk with horizontal & vertical head turns on command Step over or around obstacles Stair climbing with or without using handrail Jumping jacks Sitting on a therapy ball

24. GRADING FOR NON-EQUILIBRIUM & EQUILIBRIUM TESTS 5. Normal performance 4. Minimal impairment: Able to accomplish; slightly less than normal speed; requires supervision/minimal contact guarding 3. Moderate impairment: Able to accomplish activity; movements are slow, awkward, and unsteady; requires moderate contact guarding 2. Severe impairment: Able only to initiate activity without completion; requires maximal contact guarding 1. Activity impossible

25. TESTS FOR COORDINATION IMPAIRMENTS DYSDIADOCHOKINESIA Finger nose finger test Pronation / supination Knee flexion/extension Tapping Walking, alter speed or duration

26. TESTS FOR COORDINATION IMPAIRMENTS DYSMETRIA Finger nose finger test Finger to therapist’s finger Drawing a circle Heel on shin Placing feet on floor markers while walking

27. TESTS FOR COORDINATION IMPAIRMENTS DYSSYNERGIA Finger-to-nose Finger-to-therapist’s finger Alternate heel-to-knee Toe-to-examiner’s finger

28. TESTS FOR COORDINATION IMPAIRMENTS TREMOR (INTENTION) Observation during functional activities Alternate nose-to-finger Finger-to-finger Finger to therapist’s finger Toe to examiner’s finger

29. TESTS FOR COORDINATION IMPAIRMENTS TREMOR (RESTING) Observation of patient at rest; limb or jaw movements Observation during functional activities (tremor will disappear with movement Tremor (postural) Observation of steadiness of normal posture; sitting, standing

30. TESTS FOR COORDINATION IMPAIRMENTS ASTHENIA Application of manual resistance to determine ability to hold RIGIDITY Passive movement Observation during functional activities Observation of resting posture BRADYKINESIA Walking, observation of arm swing & trunk motions alter speed & direction Movement or gait activity be stopped abruptly

31. TESTS FOR COORDINATION IMPAIRMENTS DISTURBANCE OF GAIT Walk along a straight line Walk sideways, backward March in place Alter speed & direction of ambulatory activities

32. REFERENCES O’Sullivan SB, Schmitz TJ, Physical Rehabilitation, Fifth Edition, F.A. Davis Company, 2007; Ch.7

33. QUESTIONS !!!!