感覺運動障礙物理治療

PTmanagementofpatientswithsensori-motordisorders

感覺運動障礙的物理治療Treatmentapproach-ICFImproveIndividualMinimizeReduceSocietyEnhancephysiologicalfunctionDisabilityActivityHandicapParticiputionHollsticapproachIndividualTaskEnvironmentPassiblesensoryandmotorimpairmentsBalanceCoordinationCognitionperception（感知能力）Altered

biomechanicalalignment（生物學力線的改變）LossofsensationPainWeaknessJointstiffness,softtissureshorteningMuscletoneMovementTaskAbnormalsynergySensoryre-educationTactile（觸覺）,hot,cold,2-point,stereognosis（實體辨別覺）Discriminative（識別）,protective（給予保護）Earlytraining–Detectionandlocationofstationaryandmovinglighttouchstimuli（刺激）Progression–size,shape,objectrecognition（確認）,2-pointdiscrminationHighlevelofattentionandmemorySensoryre-educationProtectfromnoxiousandinjuriousstimuli(防護來自物理和化學的傷害)IfsensationdoesnotrecoverCompensatione.g.visionfordeficitintactilesensation(靠視覺補償觸覺的不足)PassiblesensoryandmotorimpairmentsAbnormalbiomechalignmentSelectivemotionWeaknessMuscletoneBiomechanicalalignment“Normal”alignment–mostefficient“Abnormal”alignment–affectmovementAbnormalalignmentinstanding(posturalset)Markedasymmetry(明顯的不對稱)NoweightbearingoverRLLRLLadducted,planterflexRULflexedLtrunkisshortenedTreatmentCorrect(矯正)alignmentofthetrunk,ULandLLinsittingWeightbearing(負重)overRLLINamorenarmalposturalsetWeightbearingandstrengthingexMuscletoneSpasticityFlaccidity痙攣弛緩MuscletoneAmountoftensioninarelaxedmuscleTensionstiffnessMaintainposture(維持姿勢)–preventtoomuchswayMakemusclereadytoshortenPersonwithintactneuromuscularsystem,muscletoneisminimali.e.resistancetopassivemovementisminimalMuscletonecanchangeaccordingtopostureandanxiouslevelFacilitation(易化)i.e.CerebellomMotorcortex(運動皮層)Pontine(橋腦)Reticular(網狀結構)FormationInhibition(抑制)i.e.Bulbar(延髓)reticularFormationMuscletoneAbnormalmuscletoneHypotonous–flaccidHypertonous–spasticity,rigiditySpasticity–pathophysiology

痙攣的病理生理學LesionofCNS(中樞神經系統(tǒng)損傷)Lackofsupra-spinalinhibitorysignalsonstretchreflex(反射性伸展的上行性抑制信號不足)Definition:Amotordisorder(失調)characterized(特征)byavelocity-dependentincreaseintonicstretchreflexAcomparisonbetweenage-matchednormal&spastichemipareticsubjectsHyperactivetonicstretchreflexes-increaseresistancetopassivemovementSpasticity-pathophysiologyLesionofCNSLackofsupra-spinalinhibitorysignalsonstretchreflexDefinition:Amotordisordercharacterizedbyavelocity-dependentincreaseintonicstretchreflexVelocityResistanceManifestation(顯示,證明)

ofspasticityExaggerated(過強的)stretchreflexTonic:increaseresistancetopassivemovementPhasic:increasetendonjerkClaspkniferesponseIncreasetonetoacertainrangeandfollowsbyasuddenreductionoftoneClonusAbnormalposturingofthelimbs,contracture,painSpasticityBaclofen(巴氯酚)

Synapses(突觸)Rhizotomy(神經跟切斷術)Afferent(傳入的)

Botulinum(肉毒素)neuro-muscularjunction(神經肌肉接頭)TreatmenttoreducespasticityEnhanceinhibitionofstretchreflexPharmacologicaltreatmentBaclofen(oral,intrathecal)–aderivativeofGABABotulinum(Intramuscular)–inhibitingthereleaseofacetylcholineSurgicaltreatmentRhizotomy–removalofdorsalrootlets,toreducetheafferentinputsintothespinalcordSurgicaltreatment(外科治療)Rhlzotomy–removalofrootlets,toreducetheafferentinputsintothespinalcordReducespasticityovercalfmuscles

SpasticityEnhanceInhibitionofstretchreflex(增強對神肌反射的抑制)Prolongedstretch(持續(xù)牽拉)PositioningSplintSerialcastingStretch–6hoursIcetherapy–20minutesPhysiotherapyTENS–Spasticity

Enhancepre-synapticInhibition

(增強突觸前抑制)TENSappliedonfibulahead(commonperonealnerve)toreducespasticityofankleplanterflexorsParameters(因素):0.2mssquarepulse99Hz2×sensorythreshold60minutes5timesaweekfor3weeksFlaccidity(弛緩)

Enhanceexcitationofstretchreflex(增強伸展反射的刺激)Quickstretch(快速拉伸)BrisktouchQuicktapping(快速輕扣)QuickstrokeoficeMuscletoneandMusclestrengthNoclinicalorexperimental(實驗)evidence(證明)support:NormalisespasticityMuscletoneispoorlyrelatedwithfunctionaldisabilityIndeed,poormotorcontrol–lackofisolatedcontrol(分離控制不足)ofindividualmuscles,muscleweakness,impaireddexterity(靈巧性減弱),alongwithtissuechanges–isusuallymorelimiting……Improvedmotorperformance(運動績效的改善)Inadditiontostrength,

Isolatedcontrol

增強肌力,分離控制TheabilitytocontrolthemuscleforceisessentialLackofisolated(selective)controlStereotyped(常規(guī))Abnormalmovementsynergy(共同運動)AbnormalsynergyMassflexionShflexionElbowflexionIsolated/selectivecontrolAbnormalflexorsynergy(屈肌共同運動)Flexionofhipassociatedwithflexionofthekneeduringheel-strikeIsolatedkneeandhipcontrolSpasticmuscle

canbeweakSpasticityandweaknessDiplegiaWalkontip-toeSpasticgastrocaemiusSpasticityandweaknessMarkedweaknessofgastrocaemiusRhizotomySurgicalprocduretoreducespasticityingastrocaemiusStrengthemingwillincreasespasticity?Chronicpatients>9monthsofstroke10-weekprogramofaerobicandstrentheningexercise(concentric,eccentric)Improvement–Totalpeaktorqueofaffectedleg,walkingspeedimproved,QualityoflifewithnoincreaseinquadandplantarflexorspasticityIsokineticstrengtheningincreasedmusclestrengthandgaitvelocitywithoutincreaseinspasticityStrengthingCaremustbetakentostrengthenaspasticmuscleCorrectmovementpatternsandoptimalresistanceItisinappropriatetouseeffortfulexerciseoranyexercisethatelicitsassociatedreactionand/orabnormalsynergyStrengthening~IncreaseforceoutputFunctionalelectricalstimulationAssisted,activemovementProprioceptiveneuromuscularfacilitationTaskspecificAction

(concentric,eccentric,isometric)Velocity,AngleFunctionalelectricalstimulationReciprocalinhibitionofantagonistsContractionofagonistSensoryinputIce,tappingstrokingbrushingAssistedactiveandactiveexercisesProprioceptiveNeuromuscular

FacilitationPatientswithneurologicalandorthopaedicconditionsSensoryinput–toregainstrengthusingallavailablesensoryinputsTactile–manualcontacttoguidethemotionVerbal–simpleandpreciseVisual–patient’seyesfollowthemovementProprioceptiveMovement–tractiontostretchmuscletoenhancecontractionStabilization–jointcompression(approximation)toincreasecontractionmusclesProprioceptiveNeuromuscular

FacilitationSynergeticmovementpatternWhatpatientscan“DO”–IrradiationfromstrongtoweakmusclegroupResistancetogetOptimalResponsefrompatients–maxawareness,strength,coordination,enduranceStabilitybeforemobilityPromotefunctionsPNFbasicpatternFlex–add-ERFlex–abd-ERExt–add-IRExt–abd-IRFlex–add-ERFlex–abd-IRExt–add-ERExt–abd-IRFlex-abd-ERPNF–Tactile,proprioceptive,

verbal,visual,ActiveparticipationUpperlimbFlexion-abduction-externalrotationandExtension-adduction-InternalrotationProprioceptiveNeuromuscular

Facilitation–SpecialtechniquesRhythmicinitiationtopromoteinitiationofmovementpassiveassistedactiveactiveresistiveRepeatedcontractiontopromotestrengthofagonistsrepeatedstretch,repeatedcontractionDynamicreversalandtopromotestrengrhofagonistsandantagonistsfacilactivemovementinonedirection,followedbymovtinoppositeditectionProprioceptiveneuromuscular

facilitation–repeatedcontractionStretch–elicitcontractiontopromotemovementFlex-Abd-ExtRotProprioceptiveneuromuscular

facilitation–dynamicreversalStretch–elicitcontractiontopromotemovementFlex-Abd-ExtRotExt-Add-IntRotStrengtheningIsokinetictrainingTheraband,weightsTask-specifictrainingSit-to-standWalki