神經物理治療學及實習 PT for cerebellar lesion Mat exercise ...

神 經 物 理 治 療 學 及 實 習
PT for cerebellar lesion
Mat exercise, coordination exercise
胡 名 霞
1

Cerebellum
• Vestibulocerebellum
(archicerebellum),
fastigial n.
• Spinocerebellum
(paleocerebellum)
interpositus→red n
• Cerebropontocerebell
um (neocerebellum),,
dentate → thalamus
(Goldberg, 1983)
2

Deep nucleus of cerebellum
(http://www.vh.org/adult/provider/anatomy/BrainAnatomy/Ch3Text/Section
08.html)
1. Decussation of superior
cerebellar peduncles
2. Superior cerebellar peduncle
3. Superior medullary velum
4. Fastigial nucleus
5. Globose nuclei
6. Emboliform nucleus
7. White matter of vermis
8. Dentate nucleus
3

Cerebellar peduncles
(http://thalamus.wustl.edu/course/cerebell.html)
4

Primary function of cerebellum
Regulation of:
• Postural control: vestibulocerebellum
• Eye movement: cerebropontocerebellum
• Voluntary movement, mental rehearsal,
perception of timing : cerebropontocerebellum and
spinocerebellum
• Proprioceptive input integration (Muscle tone):
spinocerebellum
Motor learning: all areas
Cognitive and affective function: Cerebellar Cognitive
Affective Syndrome (CCAS, Schmahmann, 2004 )
5

Supplementary:
http://www.robotic.dl
r.de/Smagt/research/c
erebellum/cerebellum
.html
7

Cerebellar diseases
(http://neuro.psychiatryonline.org/cgi/content/full/16/3/367)
• Head trauma
• CVA
• Degenerative diseases: Multiple
sclerosis, inherited disorders
(spinocerebellar ataxia, SCA)
• Tumor
• Alcoholism
8

Hain, 2009 (http://www.dizziness-andbalance.com/disorders/central/cerebellar/cerebellar.htm)
9

Impairments
• Balance
– vestibulocerebellum, fastigial nucleus lesions
– Increased postural sway, delayed equilibrium reactions
• Hypotonicity
– Spinocerebellum; ↓fusimotor activity
– Pendulum test positive, DTR typically normal
• Dysmetria
(http://www.youtube.com/watch?v=jnQcKAYNuyk&NR=1)
– interposed or dentate nuclei cooling
– a deficit in reaching a target, usually a past pointing
(over-shooting)
10

Impairments
• Movement decomposition
– Dentate cooling
• dysdiadochokinesia
– Dentate cooling, Purkinje in the intermediate zone
less inhibited
– Unable to perform rapidly alternating movements
• Asthenia
– Loss of cerebellar facilitation to the motor
cortex;↓fusimotor activity
– Generalized weakness (malaise) by 50% on
involved limb
11

Impairments
• ataxia
– Cerebellar link with rubrospinal, reticulospinal,
vestibulospinal tracts; lack of postural control
– In the trunk, extremities, head, mouth, tongue
– Ataxic gait (uneven step length, irregular width,
absent rhythm, highly lifted feet) is most
frequently seen symptom of cerebellar patients
– Ataxic gait without limb movement, muscle tone,
balance impairment: anterior cerebellar lesion
12

impairment
• Tremor (class reference)
– Dentate cooling
– 3-5 Hz intention tremor
– Disrupt proprioceptive feedback loop may
lead to postural tremor
• dysarthria
– 8.5% to 19% of cerebellar patients, higher
in left cerebellar lesion
13

impairment
• Ocular dysmetria
– Flocculus, paraflocculus of posterior vermis;
fastigial nucleus
– Unable to move eye accurately to peripheral
targets; saccade too large or too small
• Gaze-evoked nystagmus
• VOR dysfunction
• Optokinetic nystagmus (revolving drum test)
14

Schmahmann JD, Sherman JC: The cerebellar
cognitive affective syndrome. Brain 1998; 121:561–579
15

Differential diagnosis
• Spinal cord posterior column lesion:
sensory ataxia, tabetic ataxia
– Romberg test
• Multiple sclerosis
– Other systems symptom
– Muscle tone
• Basal ganglia lesion
– Resting vs. intention tremor
16

Recovery from cerebellar lesions
• Single cerebellar hemisphere involve without
nuclear damage: better recovery (about 2
months)
• More severe involvement: expect recovery
process to plateau within 6-12 months
• Slow movement recover better than fast
movement
• Complex movement also recovers
• Rehabilitation is effective (Topka, 1998;Isaacs et al,
1992;Klintsova et al, 2000)
17

Principles of assessment
Reading:
Umphred, p. 729-30
table)
• Observe basic mobility
– Evaluate both sides
– Assistant needed
– Time to completion
– Safety
– Incoordination/amount of effort
• Cerebellar lesion: symptoms usually unilateral
on the same side
• Consider other factors: sensation, muscle
strength, ROM
• Quantify
18

Non-equilibrium coordination tests
• Finger to nose
• Finger to therapist’s finger
• Finger to finger
• Finger nose finger (alternate nose to
finger), FNF test
– Sec / 5 reps
19

Finger-to-nose test (Feys et al., 2003)
• Observe intention tremor
21

Non-equilibrium coordination tests
• Finger opposition
• Mass grasp
• Pronation/supination
• Rebound test
• Tapping (hand)
22

Non-equilibrium coordination tests
• Tapping (foot)
• Alternate heel to knee; heel to toe
• Heel on shin (heel shin test)
• Drawing a circle
• Fixation or position holding
23

Equilibrium coordination test
• Normal stance
• Romberg test
• Tandem stance
• One leg stance
• Start and stop abruptly
• Walk on heels/toes
• Tandem walk
• Walk with head turns…..
25

Tests for coordination impairments
• Dysdiadochokinesia
– Finger nose finger test
– Pronation/supination
– Knee flexion/extension
– Tapping
– Walking, alter speed or duration
26

Tests for coordination impairments
• Dysmetria
– Finger nose finger test
– Finger to therapist’s finger
– Drawing a circle
– Heel on shin
– Placing feet on floor markers while walking
27

Tests for coordination impairments
• Movement decomposition
– Finger nose finger
– Alternate heel to knee
28

Tests for coordination impairments
• Postural Tremor
– Normal stance
– Position holding
• Intention tremor
– Observe during functional movement
– Finger nose finger test
29

Standardized tests
• Jebsen-Taylor hand function test
• Minnesota rate of manipulation test
• Purdue Pegboard test
• Crawford small parts dexterity test
30

Purdue pegboard
31

Principle of Training
• Repetition, repetition, repetition!
• Postural stability
• Functional transfers and gait
• Accuracy of limb movement during activities
– PNF practice before functional movement (Kabat,
1950; Kabat, 1955)
– Frenkel exercise (since 1889; Nakamura & Taniguchi, 1978)
– Add weight, Theraband, air splints, soft neck
collar, pool
32

Head and trunk control
• For cerebeller lesion:
– Prone
– Sit, forward lean with elbow on pillow
(Umphred, p. 731)
33

Frenkel Exercises: Principles
• Caliet 1899 (cited in Licht, 1965)
• Originally for LE, to↓dysmetria
• Supine, sit, stand, walk
• Supported then unsupported
• Unilateral then bilaterally
• Eyes open then closed
• With rhythm, count out loud
• Slow then to start and stop on commands
• accurate (to targets) and repetition
• Increasing range; add weight then no weight
• Followed by functional activities
34

Frenkel exercises (1)
• Supine-perform with eyes closed
– Flex and extend one leg, heel sliding down
a straight line on table
– Abduct and adduct hip smoothly with knee
bent, heel on table
– Abduct and adduct leg with knee and hip
extended, leg sliding on table
– Flex and extend hip and knee with heel off
table
35

Frenkel exercise (2)
• Supine
– Place one heel on knee of opposite leg and
slide heel smoothly down shin toward
ankle and back to knee
– Flex and extend both legs together, heels
sliding on table
– Flex one leg while extending other leg
– Flex and extend one leg while abducting
and adducting other leg
36

Frenkel exercise (3)
• Sitting
– Place foot in therapist’s hand, which will
change position on each trial
– Raise leg and put foot firmly on traced
footprint on floor
– Sit steady for a few minutes
– Rise and sit with knees together
37

Frenkel exercise (4)
• Standing
– Place foot forward and backward on a
straight line
– Walk along a winding strip
– Walk between two parallel lines
– Walk, placing each foot in a tracing on floor
38

Frenkel exercise (5)
• Walking: sideways for forward to a
specified count (may use targets on the
floor)
• Walking: turn around to a specified
count.
39

Guiding
• Guided movement therapy by Patricia
Davies (Steps to Follow, 2000)
• Task-oriented and handling
• Augmented information
• Motivation is dependent upon the
suitability of the task and the way in
which the therapist guides the patient (p.
20, Davies, 2000)
• Guiding when giving assistance
40

placing
43

Mat Activities
• Learns to move again, feeling in contact
with the firm surface
• Better orient the body segments and
limbs while moving
• For fear of falling: patient learns to get
down to the floor and come back up,
helps to become familiar with the
distance down to the floor
44

First time down to the floor

More experience –
Affected knee down
first
46

L’t hemi: kneel to R’t side sitting
47

Turn to L’t side sitting

Long sitting
50

Long sitting for sever patients
51

Scapular protraction
52

Lying down and sitting up
with trunk rotation

Trunk rotation
54

idging

Half arm and foot splint in prone lying
56

Patient with
tracheostomy
57

Prone kneeling
59

crawling
Watch UE rotation
60

crawling
Watch UE rotation
61

kneeling
62

Half kneeling on affected side
63

Standing up from floor
64

Case reports on line
http://www.thefreelibrary.com/Rehabilitation+of+balance+in+two+patients+
with+cerebellar+dysfunction.-a019441043
• Patient 1--Cerebellar Dysfunction After
Removal of a Cerebellar Tumor
• Patient 2--Cerebellar Dysfunction Due
to Cerebrotendinous Xanthomatosis
65

Evidence-based (self study)
• Martin CL, Tan D, Bragge P,
Bialocerkowski A. 2009.
Effectiveness of physiotherapy for
adults with cerebellar dysfunction: a
systematic review. Clinical
Rehabilitation 23(1):15-26.
66

Alcoholism
• Neurological signs-cortical and
cerebellar dysfunction
• vitamin and nutritional deficiency-PNS
deficiency
• Acute alcohol intoxication: reversible
– Passes out with hangover
– Drinking water and eating alleviate
symptoms
67

Chronic alcoholism
• Ataxia of trunk and Les
• Incoordination
• Peripheral neuropathy
• Seizure
• Vestibular deficit
• Psychological problems: delirium
tremens (DTs), dementia, Wernicke-
Korsakoff syndrome
68

Alcoholism-evaluation
• Mental status: MMSE
• Peripheral nerve function: sensation,
muscle strength, NCV
• Cerebellar function: balance
• VOR, nystagmus
69

Alcoholism-treatment consideration
• Memory and attention may be impaired,
thus goal setting and learning skills
hampered
• Prognosis difficult to predict
• General debilitated: progressive
reconditioning program effective
(Tsukue, Shohaji, 1981)
70

自 閉 症 與 小 腦
• 自 閉 症 的 主 要 症 狀 : 社 交 缺 失 ; 但 往 往 也
有 運 動 失 調 ( 小 腦 ) 症 狀
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