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Motor control Assessment

  2. 2. Motor Control Assessment -Neha Yadav 1st year MPT (Neuro)
  3. 3. Motor Control : The ability to regulate or direct the mechanism essential to movement. Refers to dynamic regulation of posture and movement. Our daily activities demand both postural and movement control. Movement emerges from the interaction of three factors i.e. Individual, Task and Environment.
  4. 4. Requirements of Efficient Movement • Balance • Postural Control • Selective movements • Strength and Endurance
  5. 5. The assessment procedure: • History • Functional activity • Body structures and functions. • Outcome Measures. • Evaluation and documentation.
  6. 6. History • Detailed history I. medical history, II. Surgical history, III. personal history, IV. drug history, V. medical examinations and tests, VI. previous treatments) • Social aspects- occupation, environment. • International Classification of functioning , disability and health. • Understanding patients goals, hopes and needs.
  7. 7. Functional Activity  To find the patients degree of independence and their ability to co-operate and interact.  Assessment can be done by : Interview, observational analysis and hands on assessment.  To assess the patients ability to carry out ADLs.  This informs the therapist about the patients - General condition - Functional activities ( quantity and quality) - Use of aids
  8. 8. Body Functions and Structures  Assessment is by : Observation, Hands on assessment.  Assessment of : 1. Stability and mobility ,Quality of movement, movement pattern. 2. Sensations, perception. 3. Pain
  9. 9. Stability • Analyse posture and movement through the alignment of key points in relation to each other and in relation to BOS. Observation and analysis of the patients LOG in relation to the BOS. • Observe for symmetry/asymmetry, weight distribution. • Note if any use of assistive devices Quality of Movement • Analysis of movement, sequence and task performance enables us to identify the activity limitations and determines how movement differs from typical motor behaviour.
  10. 10. Gait Assessment • Assess for the phases of gait. • Assess for the spatial and temporal variables. • Alignment of the body . • Muscle activity. • Pattern.
  11. 11. Sensations, Perceptions and Learned Non-use • Sensation : touch, pain temperature, pressure, proprioception, vision, hearing, taste and smell. • Identify if the sensory problems are organic or perceptual. • Learned Non-use: Patients may exhibit sensory problems as a result of inactivity or non-use
  12. 12. Pain : May limit recovery and learning process Assess for the factors aggravating and relieving the pain. Assess for the severity of pain. Muscle strength : Weakness limits recovery of motor performance. Strength of the muscle can be assessed by observational analysis and by handling.
  13. 13. Outcome Measures Body Domain  Stability : Postural Control and Balance Performance Oriented Mobility Assessment Dynamic Gait Index Trunk Impairment Scale.jpeg
  14. 14. Title Methodology Conclusion Comparison of static and dynamic posturography in young and older normal people. Robert W, Kathleen J, Karl. B, Honrubia. V The study included 10 normal healthy individuals, 10 patients with bilateral vestibular loss and 10 patients with cerebellar lesions. Static and Dynamic posturography was carried out to assess for the amplitude, velocity and frequency of the sway in anterior-posterior and medio- lateral directions. The test was performed for 10 seconds with eyes open then eyes closed. Performed under 4 conditions: platform still, foam platform, platform moving in a-p direction, platform moving in m-l direction. The tests were successfully able to distinguish normal subjects from the patients but were not consistently able to distinguish body sways in patients with vestibular and cerebellar lesions.
  15. 15. Outcome Measures Tests : Rhomberg test Sharpened Rhomberg test Timed single leg stance test Functional Reach tests Multidirectional Reach test Retropulsion test Timed up and go test.
  16. 16.  Self-report Measures Balance Efficacy Scale Activities-Specific Balance Confidence
  17. 17. Gait Analysis 1. Qualitative (observational techniques, scales) 2. Quantitative ( stopwatch, foot switches, videography) 3. Kinetic analysis ( force sensor, electric goniometer) 4. Kinematic analysis (gyroscopic sensor, accelerometer, extensometer)
  18. 18. Scales  Functional Gait Assessment  Performance Oriented Mobility Assessment  Hauser’s Ambulatory Index Tests :  6 minute walk test  10 meter timed walk test  Timed get up and go test
  19. 19. Title Methodology Conclusion Results of Using a Wireless Inertial Measuring System to Quantify Gait Motions in Control Subjects. Iris Tien, Steven D. Glaser, Ruzena Bajcsy, Fellow, IEEE, Douglas S. Goodin, and Michael J. Aminoff The inertial measurement units were attached to the shoe using the foam- padded mount, to the wrist using a Velcro elastic wrist support, and to the sternum using a pair of specially designed elastic suspenders . Wearing these sensors, subjects walked along a predetermined path on the UC Berkeley campus. This path included a segment of walking outdoors at a constant pace and slightly downhill, before turning around, walking slightly uphill, and going indoors to walk up stairs, then down stairs. The cadence, stride length, velocity, arm swing and 3D foot analysis was carried out The analyses that have been performed so far, and that have been described in this paper, show that the system is a viable way to quantify gait.
  20. 20. Motor function Assessment Tone - Initial observation of resting posture. - Palpation - Passive motion testing Scales to assess spasticity : Tardieu scale Modified Ashworth Scale Special tests to assess tone : Head drop test Pendulousness of leg Shoulder shaking test Arm dropping test
  21. 21.  Postural Tone Assessment TWISTER 
  22. 22. Title Methodology Conclusion Method to Measure Tone of Axial and Proximal Muscle. Victor S. Gurfinkel, Timothy W. Cacciatore, and Fay B. Horak The study involved development of a device (Twister) to study tonic regulation of axial and proximal muscles during active postural maintenance . Twister rotates axial body regions by 20º relative to each other about the vertical axis during stance, so as to twist the neck, trunk or hip regions. This twisting imposes length changes on axial muscles without changing the body's relationship to gravity. Because Twister does not provide postural support, tone must be regulated to counteract gravitational torques. We quantify this tonic regulation by the restive torque to twisting, which reflects the state of all muscles undergoing length changes, as well as by electromyography of relevant muscles. Twister can be used to provide a quantitative measurement of the axial and proximal postural tone and assess the efficacy of intervention.
  23. 23. Title Methodology Conclusion Tonic Stretch Reflex Threshold as a Measure of Ankle Plantar-Flexor Spasticity After Stroke Andreanne K. Blanchette, Aditi A. Mullick, Karina Moïn- Darbari, Mindy F. Levin In 28 people after stroke, plantar-flexor spasticity was evaluated twice on the same day. Plantar-flexor muscles were stretched 20 times at different velocities assigned by a portable device. Plantar- flexor electromyographic signals and ankle angles were used to determine dynamic velocity-dependent thresholds. Lower the TSRT, higher is the spasticity. Tonic stretch reflex threshold inter evaluator reliability for evaluating stroke related plantar- flexor spasticity was very good. The TSRT is a reliable measure of spasticity.
  24. 24. Voluntary Control of Movement The ability to isolate the muscle activity in a selected pattern in response to the demands of voluntary motion or posture. Gross testing of sensory loss • Passive motion sense of upper limb • Passive motion sense of lower limb • Proprioception • Kinaesthesia • Sense of force • Sense of change in velocity
  25. 25.  Special test • Heel shin test • Finger- nose- finger test • Distal proprioception test • Contralateral join matching task
  26. 26. Voluntary Control Grading for UL( shoulder and elbow) Stage 1 : No movement initiated or elicited. Stage 2 : Synergies or components start developing. Spasticity develops. Stage 3: Basic limb synergies or some components are performed voluntarily. Spasticity becomes marked. Stage 4: Spasticity begins to decrease and some movement combinations that deviate from basic synergies become available.
  27. 27. 4a : Placing the hand behind the body 4b : Elevation of the arm to a forward-horizontal position. 4c : Pronation- supination , elbows at 90º Stage 5 : Relative independence of basic limb synergies. Spasticity decreases 5a : Arm raising to a horizontal side position. 5b : Arm raising forward and overhead. 5c : Pronation-supination , elbows extended. Stage 6 : Isolated joint movements now freely performed. Co-ordination near normal.
  28. 28. Speeds test  To assess spasticity in any one of the recovery stages provided there is sufficient range of active motion to carry out the movements  Applicable from stage 4 to 6  Two movements are studied 1. Hand from lap to chin 2. Hand from lap to opposite knee  Number of strokes completed in 5 seconds are noted.  These two tests give information concerning spasticity of the flexor and extensor muscles of the elbow.
  29. 29. Voluntary Control for Hand Stage 1 : Flaccidity Stage 2 : Little to no active finger flexion. Stage 3 : Mass grasp; the use of hook grasp but no release; no voluntary finger extension Stage 4 : Lateral prehension, release by thumb movement; semi voluntary finger extension, small range. Stage 5 : Palmar prehension; possibly cylindrical and spherical grasp, awkwardly performed and with limited functional use; voluntary mass extension of fingers, variable range. Stage 6 : All prehensile types under control; skills improving full-range voluntary extension of digits; individual finger movements present, less accurate than on the opposite side.
  30. 30. Voluntary Control for Trunk and Lower limb Stage 1 : Flaccidity Stage 2 : Minimal voluntary movements of lower limb. Stage 3 : Hip –knee-ankle flexion in sitting and standing. Stage 4 : Sitting knee flexion beyond 90 with the foot sliding backward on the floor. Voluntary dorsiflexion of the ankle without lifting the foot of the floor. Stage 5 : Standing , isolated non weight bearing knee flexion with hip in extension or nearly extended. Standing , isolated dorsiflexion of the ankle with knee in extension.
  31. 31. Stage 6 : Standing hip abduction beyond range obtained from elevation of the pelvis. Sitting, reciprocal action of the inner and outer hamstring muscles, combined with inversion and eversion.
  32. 32. Title Methodology Conclusion A Robust and Sensitive Metric for Quantifying Movement Smoothness. Sivakumar Balasubramanian, Alejandro Melendez- Calderon and Etienne Burdet. The experimental data consisted of planar reaching movements performed by stroke subjects undergoing robot-assisted rehabilitation therapy, and by a healthy subject performing experiment to targets located radially outwards from a starting position. The movements presented are unassisted trials. Spectral arc-length metric, 6 other smoothness measures were also used to quantify the smoothness of the experimental movement data The paper introduced a novel measure the spectral arc length metric for quantifying movement smoothness, and validated and compared its performance on experimental and simulated movement data.
  33. 33. Title Methodology Conclusion Kinematic Variables Quantifying Upper-Extremity Performance After Stroke During Reaching and Drinking From a Glass Margit Alt Murphy, MSc1, Carin Willén, Katharina S. Sunnerhagen, 19 participants with chronic stroke and 19 healthy controls participated in the study. They reached for a glass of water, took a sip, and placed it back on a table in a standardized way. An optoelectronic system captured 3- dimensional kinematics. Kinematical parameters describing movement time, velocity, strategy and smoothness, inter joint coordination, and compensatory movements were analyzed between groups. Kinematic analysis in this study identified a set of movement variables during a functional task that may serve as an objective assessment of upper-extremity motor performance in persons who can complete a task, such as reaching and drinking, after stroke
  34. 34. Scales to assess Motor Performance ( stability and mobility) Fugl meyer assessment scale Wolf motor function test STREAM Chedoke McMaster Stroke Scale
  35. 35. Muscle Strength  Manual Muscle Testing ( MRC Grading, Oxford Grading, Kendall Scale)
  36. 36. Range of Motion Assessment Goniometers Electric goniometer Bubble Goniometer Wireless sensor devices
  37. 37. Title Methodology Conclusion The Modified Sphygmomano meter-an Instrument To Measure Muscle Strength: A Validation Study. A. Helewa, C. H. Goldsmithsa Nd H. A. Smythe 25 participants took part in the study and were evaluated by 5 therapists. The patient were asked to lie flat on the back, arms by the sides, thighs supported on a standard adjustable board so that the hip and knee are flexed at 45º and 90º respectively from the neutral position. For the cuff and bag methods, the valve was closed tightly then the system was inflated to a baseline of 20 mm Hg providing a measurement interval of 20-300 mm Hg, the cuff or bag was placed above the ankle longitudinally. The observer raised the leg to a position of 30º at the knee then asked the patient to hold that position and applied pressure gradually for 5 secs, then held there for 2 more secs at which time the scale was read. The study concluded that the clinically available sphygmomanometer can be adapted at little cost to measure isometric muscle strength.
  38. 38. Title Methodology Conclusion Hand-Held Dynamometer is a Reliable Tool to Measure Trunk Muscle Strength in Chronic Stroke Suruliraj Karthikbabu and Mahabala Chakrapani Patients with chronic stroke aged between 30 and 80 years and an ambulatory capacity of 10-meter distance volunteered in the study. The strength of trunk flexors, extensors, rotators towards most and least affected sides and bilateral lateral flexors was examined by break test using hand- held dynamometer and the isometric strength was reported in pounds (lb.). These tests were carried out by two physical therapists independently at two time points and the assessment procedure was standardized. Hand-held dynamometer showed excellent intra and inter tester reliability to quantify the trunk muscle strength in patients with chronic stroke. So this tool can easily be administered in clinical and rehabilitation settings for diagnostic and prognostic purposes.
  39. 39. Title Methodology Conclusion Accuracy and reliability of knee goniometry methods Graeme Ethan Hancock1, Tracey Hepworth and Kevin Wembridge Knee flexion and extension angles of three subjects were assessed by 3 users: one consultant orthopaedic surgeon, one orthopaedic surgical trainee and an experienced physiotherapist. 5 methods were used to assess knee angles. At each angle, measurements were first estimated visually (VE), then measured using a short arm goniometer (SG), followed by a long arm goniometer(LG), an iPhone 7 Plus and final measurement was taken with the Halo Digital Goniometer This study demonstrates that the Halo Digital Goniometer is the most reliable of all devices assessed with the smallest minimum significant difference of measurements.
  40. 40. Functional Activity Status  Katz index of ADL  Barthel Index  Functional Indipendent Measure  Instrumental Activities Of Daily Living Scale  SCI Independence Measure
  41. 41. Title Methodology Conclusion The validation of a novel activity monitor in the measurement of posture and motion during everyday activities. P M Grant, C G Ryan, W W Tigbe, M H Granat 10 healthy participants wearing three activPAL monitors , performed a range of randomly assigned everyday tasks incorporating walking, standing and sitting. Each trial was captured on a digital camera and the recordings were synchronised with the activPAL. The time spent in different postures was visually classified and this was compared with the activPAL output. The activPAL activity monitor is a valid and reliable measure of posture and motion during everyday physical activities.
  42. 42. References  Grant PM, Ryan CG, Tigbe WW, Granat MH. The validation of a novel activity monitor in the measurement of posture and motion during everyday activities. British journal of sports medicine. 2006 Dec 1;40(12):992-7.  Gjelsvik, B. E. B. (2008). The Bobath concept in adult neurology. Stuttgart, Thieme.  Sawner, K. A., Lavigne, J. M., & Brunnstrom, S. (1992). Brunnstrom's movement therapy in hemiplegia: a neurophysiological approach. Philadelphia, Lippincott  Houglum, P. A., Bertoti, D., & Brunnstrom, S. (2012). Brunnstrom's clinical kinesiology. Philadelphia: F.A. Davis.
  43. 43.  Baloh RW, Fife TD, Zwerling L, Socotch T, Jacobson K, Bell T, Beykirch K. Comparison of static and dynamic posturography in young and older normal people. Journal of the American Geriatrics Society. 1994 Apr;42(4):405-12.  Xu X, Chang CC, Faber GS, Kingma I, Dennerlein JT. The validity and interrater reliability of video-based posture observation during asymmetric lifting tasks. Human Factors. 2011 Aug;53(4):371-82.  Tien I, Glaser SD, Bajcsy R, Goodin DS, Aminoff MJ. Results of using a wireless inertial measuring system to quantify gait motions in control subjects. IEEE Transactions on Information Technology in Biomedicine. 2009 May 5;14(4):904-15.
  44. 44.  Gurfinkel VS, Cacciatore TW, Cordo PJ, Horak FB. Method to measure tone of axial and proximal muscle. JoVE (Journal of Visualized Experiments). 2011 Dec 14(58):e3677.  Blanchette AK, Mullick AA, Moïn-Darbari K, Levin MF. Tonic stretch reflex threshold as a measure of ankle plantar- flexor spasticity after stroke. Physical therapy. 2016 May 1;96(5):687-95.  Weiss A, Herman T, Mirelman A, Shiratzky SS, Giladi N, Barnes LL, Bennett DA, Buchman AS, Hausdorff JM. The transition between turning and sitting in patients with Parkinson's disease: A wearable device detects an unexpected sequence of events. Gait & posture. 2019 Jan 1;67:224-9.  Balasubramanian S, Melendez-Calderon A, Burdet E. A robust and sensitive metric for quantifying movement smoothness. IEEE transactions on biomedical engineering. 2011 Dec 13;59(8):2126-36.
  45. 45.  Murphy MA, Willén C, Sunnerhagen KS. Kinematic variables quantifying upper-extremity performance after stroke during reaching and drinking from a glass. Neurorehabilitation and neural repair. 2011 Jan;25(1):71-80.  Helewa A, Goldsmith CH, Smythe HA. The modified sphygmomanometer—an instrument to measure muscle strength: a validation study. Journal of Chronic diseases. 1981 Jan 1;34(7):353-61.  Karthikbabu S, Chakrapani M. Hand-held dynamometer is a reliable tool to measure trunk muscle strength in chronic stroke. Journal of clinical and diagnostic research: JCDR. 2017 Sep;11(9):YC09.  Hancock GE, Hepworth T, Wembridge K. Accuracy and reliability of knee goniometry methods. Journal of experimental orthopaedics. 2018 Dec;5(1):46.
  46. 46. Thank you