感覺運(yùn)動障礙的物理治療課件

1、PT management of patients with sensori-motor disorders感覺運(yùn)動障礙的物理治療昆明醫(yī)學(xué)院附屬第二醫(yī)院康復(fù)科敖麗娟 教授Treatment approach - ICFImprove Individual Minimize Reduce SocietyEnhance physiological function Disability ActivityHandicap ParticiputionHollstic approachIndividualTaskEnvironmentPassible sensory and motor impairme

2、nts Balance CoordinationCognition perception（感知能力）Alteredbiomechanical alignment（生物學(xué)力線的改變）Loss of sensationPainWeaknessJoint stiffness, softtissure shorteningMuscle toneMovement TaskAbnormal synergySensory re-educationProtect from noxious and injurious stimuli (防護(hù)來自物理和化學(xué)的傷害)If sensation does not rec

3、overCompensation e.g. vision for deficit in tactile sensation (靠視覺補(bǔ)償觸覺的不足)Passible sensory and motor impairmentsAbnormal biomech alignmentSelective motionWeaknessMuscle toneAbnormal alignment in standing (postural set)Marked asymmetry(明顯的不對稱)No weight bearing over R LLR LL adducted, planterflexR UL

4、flexedL trunk is shortenedTreatmentCorrect (矯正)alignment ofthe trunk, ULand LL insittingWeight bearing(負(fù)重)over R LL IN a more narmal postural setWeightbearing andstrengthing exMuscle toneSpasticityFlaccidity痙攣弛緩Muscle toneAmount of tension in a relaxed muscleTension stiffnessMaintain posture(維持姿勢) p

5、revent too much swayMake muscle ready to shortenPerson with intact neuromuscular system, muscle tone is minimal i.e. resistance to passive movement is minimalMuscle tone can change according to posture and anxious levelFacilitation(易化)i.e. CerebellomMotor cortex(運(yùn)動皮層)Pontine(橋腦)Reticular(網(wǎng)狀結(jié)構(gòu))Format

6、ionInhibition(抑制)i.e. Bulbar(延髓)reticularFormationSpasticity pathophysiology痙攣的病理生理學(xué)Lesion of CNS (中樞神經(jīng)系統(tǒng)損傷)Lack of supra-spinal inhibitory signals on stretch reflex(反射性伸展的上行性抑制信號不足)Definition : A motor disorder(失調(diào)) characterized(特征) by a velocity-dependent increase in tonic stretch reflexA comparis

7、on between age-matched normal & spastic hemiparetic subjectsHyperactive tonic stretch reflexes - increase resistance to passive movementManifestation(顯示, 證明) of spasticityExaggerated(過強(qiáng)的) stretch reflexTonic: increase resistance to passive movementPhasic: increase tendon jerkClasp knife responseIncr

8、ease tone to a certain range and follows by a sudden reduction of toneClonusAbnormal posturing of the limbs, contracture, painSpasticityBaclofen(巴氯酚) Synapses(突觸)Rhizotomy(神經(jīng)跟切斷術(shù))Afferent(傳入的) Botulinum(肉毒素)neuro-muscular junction(神經(jīng)肌肉接頭)Treatment to reduce spasticityEnhance inhibition of stretch re

9、flexPharmacological treatmentBaclofen (oral, intrathecal) a derivative of GABABotulinum (Intramuscular) inhibiting the release of acetylcholineSurgical treatmentRhizotomy removal of dorsal rootlets, to reduce the afferent inputs into the spinal cordSurgical treatment(外科治療)Rhlzotomy removal of rootle

10、ts, to reduce the afferent inputs into the spinal cordReduce spasticity over calf muscles SpasticityEnhance Inhibition of stretch reflex(增強(qiáng)對神肌反射的抑制)Prolonged stretch(持續(xù)牽拉)PositioningSplintSerial castingStretch 6 hoursIce therapy 20 minutesPhysiotherapyFlaccidity(弛緩)Enhance excitation of stretch refl

11、ex(增強(qiáng)伸展反射的刺激)Quick stretch(快速拉伸)Brisk touchQuick tapping(快速輕扣)Quick stroke of iceMuscle tone and Muscle strengthNo clinical or experimental(實驗) evidence(證明) support:Normalise spasticityMuscle tone is poorly related with functional disabilityIndeed, poor motor control lack of isolated control(分離控制不足)

12、 of individual muscles, muscle weakness, impaired dexterity(靈巧性減弱) , along with tissue changes is usually more limitingImproved motor performance(運(yùn)動績效的改善)Lack of isolated (selective) controlStereotyped(常規(guī))Abnormal movement synergy(共同運(yùn)動)Abnormal synergyMass flexionSh flexionElbow flexionIsolated / se

13、lective controlAbnormal flexor synergy(屈肌共同運(yùn)動)Flexion of hipassociated withflexion of the kneeduring heel-strikeIsolated knee and hip controlSpastic musclecan be weakSpasticity and weaknessDiplegiaWalk on tip-toeSpasticgastrocaemiusSpasticity and weaknessMarkedweakness ofgastrocaemiusRhizotomySurgic

14、al procdure to reduce spasticity in gastrocaemiusStrengtheming will increase spasticity ?Chronic patients 9 months of stroke10-week program of aerobic and strenthening exercise (concentric, eccentric)Improvement Total peak torque of affected leg, walking speed improved, Quality of life with no incre

15、ase in quad and plantar flexor spasticityIsokinetic strengthening increased muscle strength and gait velocity without increase in spasticityStrengthingCare must be taken to strengthen a spastic muscleCorrect movement patterns and optimal resistanceIt is inappropriate to use effortfulexercise or any

16、exercise that elicits associated reaction and/or abnormal synergyStrengthening Increase force outputFunctional electrical stimulationAssisted, active movementProprioceptive neuromuscular facilitationTask specificAction (concentric, eccentric, isometric)Velocity, AngleFunctional electrical stimulatio

17、nReciprocal inhibition of antagonistsContraction of agonistSensory inputIce, tapping stroking brushingAssisted active and active exercisesProprioceptive NeuromuscularFacilitationPatients with neurological and orthopaedic conditionsSensory input to regain strength using all available sensory inputsTa

18、ctile manual contact to guide the motionVerbal simple and preciseVisual patients eyes follow the movementProprioceptiveMovement traction to stretch muscle to enhance contractionStabilization joint compression (approximation) to increase contraction musclesProprioceptive NeuromuscularFacilitationSyne

19、rgetic movement patternWhat patients can “DO” Irradiation from strong to weak muscle groupResistance to get Optimal Response from patients max awareness, strength, coordination, enduranceStability before mobilityPromote functionsPNF basic patternFlex add-ER Flex abd-ERExt add-IR Ext abd-IRFlex add-E

20、R Flex abd-IRExt add-ER Ext abd-IRFlex - abd - ERPNF Tactile, proprioceptive,verbal, visual, Active participationUpper limbFlexion-abduction-externalrotation andExtension-adduction-Internal rotationProprioceptive NeuromuscularFacilitation Special techniquesRhythmic initiationto promote initiation of

21、 movementpassive assisted active active resistiveRepeated contractionto promote strength of agonistsrepeated stretch, repeated contractionDynamic reversaland to promote strengrh of agonists and antagonistsfacil active movement in one direction, followed by movt in opposite ditectionProprioceptive ne

22、uromuscularfacilitation repeated contractionStretch elicit contraction topromote movementFlex-Abd-Ext RotProprioceptive neuromuscularfacilitation dynamic reversalStretch elicit contraction topromote movementFlex-Abd-Ext RotExt-Add-Int RotStrengtheningIsokinetic trainingTheraband, weightsTask-specific trainingSit-to-standWalkingUpstairsNormalise muscle toneImprove strengthImprove isolated controlPossible sensory and motor impairmentsPainJoint