Download Kelly McGivern SG For Written Tx Plan NM II Rubric Requirements: 2

Kelly McGivern
SG For Written Tx Plan NM II
Rubric Requirements:
 2 well written LTG- level of assist, functional activity, timeframe, measureable aspect
o LTG 4 weeks ish. Avoid independent, since that includes all conditions (dark, drunk, etc)
 Tx plan: Appropriate for functional level, rational for each tx, enough detail for covering therapist
to follow, show progression during session, application of motor learning principles, 45 minutes in
length
o Handling? Mobs? Make it sequential and include learning principles. What stage are they
in?
 Progression & regression
o Progressions- from front to side blocking etc. 1 of the activities you will need to show a
regression, 2 progressions. Make sure the progression & regressions change difficulty
while still maintaining the goal
 What other members of healthcare team might you refer the pt?
o Ask for OT referral or SLP (swallowing, communication, etc)
o Include appropriate referral ID & rationale
Information for Write Up
 Full community ambulation >.8 m/sec <.4m/sec= household only, .4-.8= house hold to community
 Stages of Motor Learning: Cognitive, Associative, and Autonomous
o Cognitive- develop an overall understanding of the task, performance is usually variable,
trial and error process, movement guided primarily by vision, tx enhanced during this
stage by demonstrations, verbal instruction, manual guidance, mental practice
o Associative Stage: Now refining the strategy for the task-improving coordination and
efficiency, more consistent performance, proprioceptive cues more important than visual
cues as the patient refines the movement, tx enhanced by video self-assessment, less verbal
cues needed
o Autonomous Stage: movement is refined, automatic performance of movement, able to
accomplish task in variety of environmental settings, able to do secondary tasks in
addition, tx enhanced by a variety of environmental situations
 Feedback: Intrinsic & Extrinsic Feedback
o Intrinsic- sensory feedback, vision, proprioception, audition, may vary based on
impairments
o Extrinsic- KR- information about the overall outcome of the movement or about the end
result
o KP- information about the quality or patterning of movement that may have influenced the
success of the performance
 Feedback schedules
o Immediate post response feedback- given after each trial- XF XF XF XF
o Summary feedback-given after a series of trials- XXXXF XXXXF
o Faded Feedback- gradually reduce with ongoing practice- XF XXF XXXF XXXXF
o Bandwidth feedback- only if performance falls outside a predetermined criteria or
bandwidth, F/ \F
o Performance is best with more immediate feedback but delayed feedback is most effective
for learning
 Massed/Distributed Practice
o Massed- a session in which amount of practice time is greater than rest between trials
o Distributed- a session in which the amount of rest between trials is equal to or greater than
time for trial
PNF techniques
 Foundations
o Irradiation: the spread of a muscular response. Used to facilitate weaker muscles by giving
resistance to stronger muscles. Ex. Stroke pts can use the abdominals to facilitate hips
o Traction: Improves movement or with a painful joint vs. Approximation: Improves
stability of a joint
o Timing: used to optimized coordination and efficiency of muscles
 PNF Techniques
o Rhythmic initiation: used to teach the pattern, take pt through movement passively “Help
me help you”, then actively w/ or w/o resistance
o Combination of Isotonics: strengthening & mm re-education
 Strengthening= combo of isotonics. Concentric, Isometric, Eccentric (start to move,
midrange push against me (don’t let them move), then hold contraction, lighten it up
and maintain movement backwards (ecc.))
 NM Re-Education= Isometrics, Eccentric, then Concentric (start maintained,
eccentric, then quick stretch, and concentric)
o Reversal of antagonists- go in opposite direction to work on coordination and helps with
smooth movement going both ways
o Rhythmic Stabilization (isometric reversals): stabilization, must have stability before
mobility
o Repeated Stretch: When feel weak use repeated stretch. For strengthening- from the
beginning of the range through the end of the range.
o Contract-Relax: to increase ROM. Pt or pt moves joint or body section into end of passive
ROM, strong contraction of the restriction mm or pattern, joint or body part repositioned to
new end range, and repeat (ON MIDTERM)- 32 in PNF book.
 Hold Relax: for decreased PROM, pain, or pt too strong for therapist. Goal to
increase ROM. Pt moves to end of pain free ROM, pt asked not to move and PT
resists with emphasis on rotation (no movement occurs), reposition limb (33 in PNF
book)
o Timing for Emphasis: To emphasize one component of the pattern. Strengthens the
weaker component through irradiation. Higher level skill
o Progression: Rhythmic initiationpassiveactive assistedactiveactive with
stretchtraction
 Goals of PNF
o Facilitates specific modes of strengthening…
 Increased mm strength, extremity/trunk coordination, increased proprioception,
increased strength of antagonists of spastic muscles
 Can fatiguing a mm spindle decrease spasticity? YES! Strengthen under spasticity
and antagonists to help with spasticity, won’t get worse with exercise
 Function PNF
o UE EXT/ADD/IR- throwing a baseball, flower girl, sword
o D1- Feeding, self care, bras, scratch your back, seat belt
 Scapular PNF patterns
o Alignment: sidelying, neutral spine, knees 60-90º (pillow between knees), top UE will begin
humerus parallel to trunk, slightly extended w/elbow flexed to ~90º
o Setting the scap for AE/PD- elevate, downwardly rotate, and retract
o Setting the scap for AD/PE- move shoulder posterior, elevated, compress and upwardly
rotate
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o AE- facilitates Anterior elevation (start in PD), one hand on scapula with lateral hand on
medial scapula, other on anterior surface (RI). Resistance- hands w/lumbricals of fingers
on top of AC then resistive anterior elevation of shoulder
 Function: Rolling forward, reaching in front of body, swimming
o PD- facilitates PD, lateral border of hand against medial border of scap, other on anterior
surface (RI). Hands- web of hand between thumb and 1st finger to inferior angle of the scap
and the other on pts elbow (active), then resistive anterior elevation of shoulder
 Function: Trunk extension, rolling backwards, using crutches, pushing up with a
straight trunk, transfers when use depression of shoulders (SCI)
o AD- (RI) one hand on scap with lateral border of hand against medial border of scap other
on anterior surface. Traction shoulder into protraction (RI). For active &/or resistive ADplace pressure in hands at axilla area. VC- pull shoulder toward fron of your hip, then pull.
For reversal- into PE- heel of hands at AC joint, lift fingers, pt push into hands.
 Function: Rolling forward, reaching forward, throwing a ball in sport activities,
reaching down to the feet to take off socks and shoes
o PE- (RI) one hand lateral against medial border of scap, other anterior. For active and/or
resistive PE of shoulder lace heel of hands at AC, lift fingers and have pt push into your
hands. VC: push into my hand
 Function: Moving backwards, reaching out before throwing something, and putting
on a shirt
Pelvic Patterns
o AE: Hands on top of iliac crest
 Function: swing phase, rolling forward, kicking, running
o PD: On Iliac crest/IT
 Function: Terminal stance activities, jumping, walking stairs, making high steps
o AD: Hand position on posterior superior iliac spine/greater trochanter
 Function: Used eccentrically for going down stairs, terminal swing, loading response
o PE: Hands on posterior superior iliac spine/Greater trochanter
 Function: Walking backwards, prepare to kick a ball
PNF Gait
o Where is anterior elevation most apparent during the gait cycle? ISw MSw
o Where is anterior depression most apparent during the gait cycle? TSwIC
o Where is posterior depression most apparent during the gait cycle? MS TS
o Where is posterior elevation most apparent during the gait cycle? PSwISw
o Pelvic patterns do NOT change the amount of pelvic motion. The pelvic motion comes from
activity of the trunk muscles. Do not allow the leg to push the pelvis up. The muscles
involved in pelvic depression are the contralateral pelvic muscles
Combination Patterns for the Scapula and Pelvis/Trunk Patterns
o Symmetrical-Reciprocal: scap PD with pelvis AE (trunk shortening with rotation), scapular
AE with PD (trunk elongation with rotation)
 Functional: stimulation of gait; trunk shortening and elongating
o Asymmetrical Pattern: scapula and pelvis move in opposite diagonals. Scap AD with Pelvic
AE (mass flexion), Scap PE with pelvic PD (mass extension)
 Functional: supine to prone and backwards- used with those who have hemiplegia
UE
o Flexion/Adduction/External Rotation (D1)
 Facilitates: Flexion, Adduction, ER, wrist flexion, radial deviation, thumb adduction.
 Hands: therapist holds opposite hand into pt’s hand and the other wraps around
upper arm. Pt squeezes PTs hand then initiate flexing of the wrist while flexing,
adducting, IR
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 Functional: Reaching, rolling to prone, strengthen weaker components of UE/trunk
o Extension/Abduction/Internal Rotation (D1 extension)
 Facilitates: Shoulder extension, abduction, internal rotation, elbow extension,
forearm pronation, wrist extension, ulnar deviation, thumb abduction
 Hands: same hand on top of pt’s hand with thumb and 5th digits on opposite sides of
wrist and therapists finger on dorsum of patient’s hand to facilitate extension of the
wrist, forearm pronation and extension of fingers. Other hand wraps around
patient’s upper arm to facilitation IR, extension, abduction
 Functional: Rolling to supine, reaching behind
o Flexion/Abduction/External Rotation (D2)
 Facilitations: flexion, abduction, external rotation, forearm supination, wrist
extension, radial deviation, thumb extension, abduction
 Hands: opposite hand on top of pt’s hand with thumb and 5th digits on opposite
sides of wrist and therapists fingers on dorsum of pt’s hand to facilitate extension of
the wrist, forearm supination, and extension of the fingers. Other hand wraps
around pt’s upper arm to facilitate flexion, ER, and abduction
 Functional: Rolling to supine, reaching, pick up an object across midline
o Extension/Adduction/Internal Rotation (D2 Extension)
 Facilitations: extension, adduction, internal rotation, forearm pronation, wrist
flexion, ulnar deviation, thumb flexion, add., opposition
 Hands: Therapist’s same hand is palm to palm in pt’s hand. Therapists fingers are
NOT on dorsum of hand to facilitate wrist flexion, pronation, and flexion of wrist and
fingers. Therapists other hand ‘wraps’ around patients upper arm to facilitate
extension, ADD, and IR at the shoulder
 Functional: Rolling to prone and reaching across midline
LE Patterns
o Flexion/Adduction/External Rotation (D1 flexion)
 Facilitates: Hip Flexion, adduction, ER, knee flexion, ankle DF and inversion, toes
extension/medial deviation
 Hands: one hand on dorsum of foot so pt can extend toes into therapists hands and
other NOT on plantar surface of the patient foot except when teaching movement
 Functional: Tying shoes, checking skin on bottom of foot, controlling soccer ball,
rolling, gait
o Extension/Abduction/Internal Rotation pattern (D1 extension)
 Facilitates: Hip extension, abduction, internal rotation, knee extension, ankle PF,
eversion, toe extension
 Hands: dorsum of hand on lower thigh/lateral/posterior surface, as leg extends
palmer surface of the hand will change to the upper gastroc region of the lower leg.
Therapists other hand is on plantar surface
 Functional: TS, push off, jumping
o Flexion/Abduction/Internal Rotation (D2 flexion)
 Facilitates: Hip flexion, abduction, internal rotation, knee flexion, ankle DF/eversion,
toe extension/lateral deviation
 Hands: Lower thigh/lateral/anterior surface, other hand on dorsum of foot w/
lateral border of hand proximal to the toes so pt an extend toes against therapist’s
hand.
 Functional: Hacky sack, yoga, rolling, getting scissoring pattern gait
o Extension/Adduction/External Rotation (D2 extension)
 Hip Extension, Hip adduction, ER, knee extension, Ankle PF/inversion, toe flexion
 Hands: Medial lower thigh, other on plantar surface/met head area of the foot just
proximal to the toes so pt can flex toes against hand
 Functional: Ambulation, stairs, stomping on cans
 Summary of PNF on pg 28-31
 Bilateral Arm and Trunk Patterns PNF
o Chopping- bilateral asymmetrical UE extension with neck flexion. Lead UE performs
shoulder extension/abduction/IR and assisting performs shoulder extension/adduction
 Facilitates trunk flexion with rotation
 Function: Rolling
o Lifting- bilateral asymmetrical UE flexion with neck extension. Lead UE performs shoulder
flexion/abduction/ER: ‘assisting’ UE performs flexion/adduction
 Facilitates with trunk extension with rotation
 Function: Side to supine
NDT Techniques
 Aims: achieve best alignment for functional task, utilize WB of extremities to maintain proper
alignment, incorporate both sides of the body to facilitate more normal sensorimotor experience
facilitate active participation of patient
 Facilitation into neural alignment front approach:
o Hands: bilateral hand placement at lumbar paraspinals superior to PSIS
 Side approach
o Hands: posterior-open at lumber paraspinals superior to PSIS, forearm supinates slightly to
apply tension to hypothenar border of hand, anterior in V shape at sternoclavicular region,
tension up and out
 Lower Trunk Initiated Movements
o LTIAWS- side approach: Hands- posterior at lumbar paraspinals, tension in and up with
forearm supinated to guide movement, anterior hand lightly cuing at abdominals
o LTIPWS side approach: Hands- anterior hand cues the abdominals to flex, posterior hand
provides tension to control eccentric movement posteriorly if needed
o Do the above to start scooting
o LTIAWS-front approach- hands lumbar paraspinals, tension in and up
o LTIPWS- Front approach- hands rotate downward, 4th & 5th digits shift anterior, cueing at
abdominals
o LTILWS- hands- lumbar paraspinals, hands on weight bearing side cues in a downward
direction while hand on unweighting side cues in a medial superior direction
o UTIAWS- hands- proximal lateral ribcage bilateral, distally- supraclavicular region
bilaterally
o UTIPWS- hands- proximal- lateral ribcage bilaterally, distal- supraclavicular bilaterally
o UTILWS- hands- lateral ribcage bilaterally, hand on shortening side closes and hand on
elongating side opens
o UTIDWS- lateral ribcage bilateral, direction of cues change to guide diagonal direction
 To improve bed mobility
o Hooklying: hands guide LE into position with pressure below tibial plateau, add WB cue
o Bridging: more assistance- on glutes, proximal facilitation- open hand increase tension to
facilitate lifting hips, less assistance- distal femur
o Scooting in supine- laterally- facilitate into bridge, therapist weight shifts in direction of
movement to promote pt’s weight shift. Facilitate upper trunk WS at pt’s scap in anterior
direction, therapist WS in direction of movement to promote UTILWS
o Rolling (hemiparesis)- supine towards less involved- hooklying affected LE, facilitate WB of
involved LW into hooklying to promote LTIADWS, provide guidance at scap in UTAD to
reach across body. Supine towards involved- hooklying less involved LE, protect shoulder
protracting it, pt can roll over affected UE without damaging shoulder
 Tx strategies to improve rolling
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o Start position, progression from small to full ROM, limb movements and momentum can
assist when trunk mms are weak, reposition of limbs to make harder or easier
PNF for rolling- UE F/Add/IR, LE F/Add/ER, chop, lift. Rhythmic initiation, reversal of antagonists
Supine to Sit NDT
o Rolling into involved side: roll to sidelying, facilitate pt to flex hips and knees, at lower
trunk in posterior direction. Involve UE in forearm WB, facilitate extended arm to bear as
able.
o Roll onto uninvolved side- similar to above, but therapist promotes forced use and WB as
affected UE in front of pt prior to elbow prop on the uninvolved UE
Sitting to Supine
o Onto Involved: facilitate UTILWS and LTILWS or LTIPWS, encourage elbow prop, facilitate
pt to tuck elbow as they descent
o Onto less involved- same as above but PT promotes use of more involved UE to control
descent
Mobilizations of Lumbar Spine
o Anteriorly- front hand- forearm across upper chest in contact with upper sternum, back
hand palm down over erector spinae in lumbar area
Mobilization of Thoracic region
o Extension- front hand- contact clavicles bilaterally, mid to superior clavicular region
provides a stabilizing force and gentle upward and posterior force, back hand over
paravertebral mms at lower end of stiffness in thoracic curve. Cup hand so contact is on
mms not SPs. Fingers and arm pointing down
Challenge pt’s stability control by changing BOS
o Long sit vs short sit versus EOM
o BUE’s in WB, on in WB, no UE support
o BUEs arm folded across checks
o BLE’s in WB, one LE WB, one LE support on floor while standing
o Firm vs soft surface
o Pt back against chair vs not
o Eyes opened vs closed
o Manual perturbations
o Stabilizing reversals
o Rhythmic stabilization
Challenge pt’s controlled mobility (dynamic postural control)
o Active WS with extended BUE’s on mat next to pt, onto large therex ball, reaching, one UE
reaching, BUE’s reaching together, BUE’s alternating reaching, one UE diagonally reaching
from floor to overhead, BUE’s diagonally reaching from floor to overhead, manual
perturbations during reaching activities
Scooting
o Symmetrical: manual contacts at lumbar paraspinals for anterior LTWS
o Asymmetrical: lateral lower trunk WS to unweight hip, anterior or posterior diagonal WS
for mobility for asymmetrical scooting. Hands on iliac crest- diagonal toward mat with
fingers pointing posterior to the IT’s (forward), moving backward- lumbrical trip at
PSIS/posterior pelvic crest. Force is toward IT’s/femoral head to facilitate unweighting of
the pelvis and pushing backwards
Sit to stand
o Front approach
o Side approach- hands anterior- infraclavicular region, posterior-fingers pointing down at
lumbar spine to facilitate forward lean then pivot up to facilitate upright
Sit pivot transfer
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o Facilitate, use own Body weight by leaning back so shoulder are behind hips, help ring pt
over feet, facilitate lift off and cue at leg for lateral weight shift
Facilitation to improve UE skills- put in WB helps activate mms in involved limb, increase mobility
of scap, lengthen tight muscles between trunk and arm, flexor hypertonicity decrease
o Extended arm WB- increase stability of body with balance challenge, trunk support without
back support, transition sitting to standing etc.
o 3 positions- 1 EOM fingers over edge, 2- hands toward hip joint, 3- sitting on edge with
hands behind hips (increase as get stronger)
Timing for NDT
 Supine, sidelying, sit up, scoot to EOM, sit EOM- 2-3 minutes, Mob LS/TS- 5min, mob scaps-5min,
sitting balancebulk, sit to standbulk, xfers bulk of tx
Improving standing control and balance
 Ankle strategy- wobble board, ½ foam roll, min perturbations, stand facing wall and sway forward
until head taps wall
 Hip- tandem stance on ½ (lateral hip), mod perturbations at hips, larger tilts on wobble board,
tandem standing, start with poles for support then progress to no support
 Stepping strategies- lean forward, back, or side until COM exceeds the BOS, small steps to wider
and wider steps, circles on floor to encourage symmetrical stepping in all directions, theraband
resist then release for more reactive balance
Balance Progression- pg 173
Pregait Activities- 174
Improve standing control and balance-175
Locomotor Skill-177