感覺運動障礙的物理治療課件

PTmanagementofpatientswithsensori-motordisorders

感覺運動障礙的物理治療敖麗娟教授Treatmentapproach-ICFImproveIndividualMinimizeReduceSocietyEnhancephysiologicalfunctionDisabilityActivityHandicapParticiputionHollsticapproachIndividualTaskEnvironmentSensoryre-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(rèn)）,2-pointdiscrminationHighlevelofattentionandmemorySensoryre-educationProtectfromnoxiousandinjuriousstimuli(防護來自物理和化學(xué)的傷害)IfsensationdoesnotrecoverCompensatione.g.visionfordeficitintactilesensation(靠視覺補償觸覺的不足)PassiblesensoryandmotorimpairmentsAbnormalbiomechalignmentSelectivemotionWeaknessMuscletoneBiomechanicalalignment“Normal”alignment–mostefficient“Abnormal”alignment–affectmovementTreatmentCorrect(矯正)alignmentofthetrunk,ULandLLinsittingWeightbearing(負(fù)重)overRLLMuscletoneSpasticityFlaccidity痙攣弛緩Facilitation(易化)i.e.CerebellomMotorcortex(運動皮層)Pontine(橋腦)Reticular(網(wǎng)狀結(jié)構(gòu))FormationInhibition(抑制)i.e.Bulbar(延髓)reticularFormationMuscletoneAbnormalmuscletoneHypotonous–flaccidHypertonous–spasticity,rigiditySpasticity–pathophysiology

痙攣的病理生理學(xué)LesionofCNS(中樞神經(jīng)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(diào))characterized(特征)byavelocity-dependentincreaseintonicstretchreflexAcomparisonbetweenage-matchednormal&spastichemipareticsubjectsHyperactivetonicstretchreflexes-increaseresistancetopassivemovementSpasticity-pathophysiologyLesionofCNSLackofsupra-spinalinhibitorysignalsonstretchreflexDefinition:Amotordisordercharacterizedbyavelocity-dependentincreaseintonicstretchreflexVelocityResistanceSpasticityBaclofen(巴氯酚)

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

Botulinum(肉毒素)neuro-muscularjunction(神經(jīng)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–20minutesPhysiotherapyFlaccidity(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TheabilitytocontrolthemuscleforceisessentialAbnormalsynergyMassflexionShflexionElbowflexionIsolated/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-standWalkingUpstairsNormalisemuscletoneImprovestrengthPossiblesensoryandmotorimpairmentsPainJointstiffness,softtissueshor