Proprioception

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Coordination
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Definition

• Coordination refers to using the right muscles at
  the right time with correct intensity, extensive
  organization within the central nervous system is
  necessary to guide motor patterns, coordination
  is the basis of smooth and efficient movement,
  which often occurs automatically.
• Coordination and gross or fine motor skills are a
  highly complex aspect of normal motor function

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Factors affecting on coordination

• Anatomical Factors
• Deformity
• Asymmetry
• Mal posture

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Environmental factors

• Temperature
• Pollution
• Mental and psychological stress

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• Pain
• Occupation
• Life style
• Fullness of bladder
• Any medication
• Repeated pregnancy
• Overweight
• Age
• Type of muscle tone

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Evaluation
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Consideration before evaluation
A- Outside the clinic

• The presence of parking.
• Rail way of stair up down.
• Light at entrance.
• Ramp for wheel chair.
• If there is lifter or not

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B- Inside the Clinic

• Clearness of room.
• Silence and privacy.
• Suitable temperature and light.
• Comfortable and relaxed position for the patient.
  
• Adjustable and wide bed.
• Explain procedure to patient.
• Patient pared skin or with light clothes.
• Avoid air draft but maintain good ventilation.
• All equipment near the therapist to avoid
  interruption.
• Evaluation sheet should be present.

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Consideration during evaluation

• Pain
• Sweating
• Abnormal heart rate.
• Abnormal B.P.
• Fever
• Fainting.
• Hypermobility
• Infection
• Recent wound and injury

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• Avoid position that may exaggerated muscle tone
  or ? patient complication.
• Mental stress.
• All tests done with tolerance of patient and
  according the stage of the disease.
• All tests are done within the limit of pain.
• All tests from zero starting position.

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Decision Making

• Diagnostic interview.
• Screening examination
• Comprehensive examination.
• Special tests.
• Long term goals.
• Short term goals.
• Out come

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DIAGNOSTIC INTERVIEW

• Personal History
• Name To be familiar with the patient
• Age occurs in people aged 40-50 years
  (cerbrovascular stroke)
• Sex affects men and women equally
• Marital status Married or single
• Style of life his habits, activities and if he
  living a sedentary life. It assist in providing
  the therapist with hint about causes and the
  expected prognosis.

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• Occupation Know the patients interests and hopes
• Habits Smokers, non smokers, alcohol
  drinkers, coffee or tea drinker.
• Weight obesity increase the difficulty in
  performing activities.

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• Environmental assessment
• A) Outside door
• - Surrounding home.
• - Stairs (height width) (sharp, smooth) .
• - Entrance .
• - Noisy pollution.
• - Light at entrance .
• - rails of stairs height of pavement .

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B) Inside door

• - Entrance
• - Carpets
• - Type of floor
• - Furniture
• - Arrangement
• - Devices and accessories

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Work assessment

• Desks.
• Height of table and chair.
• Width and height of weed chair .
• How communicate with people.

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B- History
The importance of History taking

• To know precautions.
• To know Contra-indications.
• To decide the plane of care/treatment.

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• Onset duration of the disease.
• Site and extent of the lesion (It affect level
  of consciousness and prognosis as the site either
  Rt of Lt determine aphasia and speech affection)
• Etiology of the disease.
• Mechanism of the lesion.
• Distribution of paralysis
• Past history any disease (diabetes-
  hypertension- congenital heart disease), any
  previous operation, any previous trauma.
• History of functional A.D.L

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Functional A.D.L is divided into

• Transfer activities.
• Hygiene.
• Feeding.
• Dressing undressing.
• Gait ambulation.
• Grades (He can do He can do with minimal
  assessment He can do with maximum assistant- He
  can't do)

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Family history

• Any hereditary disease
• Heart diseases
• diabetes
• Neuromuscular diseases due congenital or genetic
  factors

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• Psychological history IQ. Level, Cognitive
  level, Education level, Affection (emotions
  nervous - fairs), memory, judgment, depression,
  how to solve problems.
• Social History Relationship between patient and
  his family members and if they accept or reject
  the patient.

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Pain History

• (time of pain location of pain If movement
  increase or decrease the pain severity of pain
  distribution of pain).

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Chief complain

• Difficulties in performing ADL
• Difficulty using arms to dress, feed self, or
  perform other tasks
• Urinary incontinence
• Problems with balance
• Decreased sensation, numbness, or tingling on
  affected side of the body
• Difficulty speaking and/or or understanding words
• Difficulty walking
• Depression

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Problem list

• Spasticity .
• Muscle weakness
• Loss of balance
• Loss of coordination
• Inability to do functional activities .
• Shoulder pain.
• Poor hand function.
• Respiratory and circulatory problems.

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Medical record

• Medications
• Associated handicapped (Vision, Hearing, Speech)
• Associated reaction.
• Any epileptic fits.
• Incontinence.
• Bed sores.
• Vital signs (B.P.- Heat rate - Temperature)
• X-ray - C.T Scan M.R.I
• Respiratory and circulatory disorders.
• Orofacial dysfunction.

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Screening examination
General observation

• Any abnormalities.
• Asymmetry.
• Distribution Pattern of paralysis.
• Position of head in relation to spasticity.
• Position of head in relation to spasticity.
• Associated reactions
• Imbalance

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• General heath (out look of face).
• Gait ambulation.
• Assistive device.
• Way of taking off clothes, way of getting up
  down bed.
• Handling of the patient with his family.
• If the family reject or accept the patient.

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Specific observation with the patient pared
skin. Postural assessment from three views
(lateral anterior - posterior).

• Dermatological system (Scar operation skin
  disease).
• Skeletal system (size of bone mal alignment of
  bone).
• Muscular system (atrophy asymmetry hyper
  trophy).
• Join system (edema swelling).
• Breathing pattern.

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Palpation

• Tender point
• Muscle tone
• Soft tissue Mobility
• Trigger point
• Fascial restriction.
• Skin texture temperature.

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Comprehensive examination
A- Communication abilities

• Vision
• Hearing speech
• Way of solving problem
• Judgment
• Excitement.
• Interest.

By Pantomine. Communication board
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B- Mental Status

• IQ level
• Cognitive level
• Education level

C- Arousal status see the response of the
patient to any movement and see if the arousal
status is low or high.
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D- Motor control stages
a- Mobility stage

• Muscle test Group muscle test (voluntary muscle
  test because of spasticity or in pattern of
  movement) (gross movement)
• Functional ROM test as feeding dressing
  undressing hygiene

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• Flexibility test (Sound, Affected, and associated
  areas
• Examples
• long sitting test
• Straight leg raising test
• Cross sitting test
• Standing with forward bending test
• Supine and hand stretched overhead

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b- Stability stage

• Elbow prone test
• importance
• Sitting position on a table
• Sitting position on an armchair. Then sitting on
  a stool Test patient ability to maintain
  position against gravity
• Standing position

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For head control

• raise head and sustain position for 30 sec
• If collapse quickly ? poor
• If can't take or sustain in the position ? zero
• If maintain it for 30 sec ? normal

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Sitting position

• Sitting on the edge of the bed or table, test the
  patient ability to maintain position against
  gravity .
• Sitting on arm chair then on a stool to test the
  patient ability to maintain position against
  gravity
• Maintain postural alignment

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Standing position

• Test the patient ability to maintain position
  against gravity.

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C- Control mobility stage

• Change position with maintaining postural control
• 1) Rocking (body shift) Bushing from different
  directions, and from different positions or by
  lying on rocking plate .
• Done from different positions (Elbow Prone,
  quadruped, sitting, kneeling , standing)
• Rocking plate from supine - prone and raise from
  different direction all testes done 2-3 times
  before giving grade.
• 2) Quadruped position ? raise one hand, then the
  other hand, raise one hand with opposite leg,
  raise one leg then another

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d- High Skilled activity stage

• Swallowing test.
• Speech test.
• chewing test
• Cranial nerve assessment.
• Hand function test a- Volk's man angle test
  b- Metacarpal stability test Hand
• Gait and ambulation test also test patient
  ability to get up down stairs.

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E- Voluntary movement

• Observe pattern and sequence of movement from
  different position
• Supine do flexion extension abduction
  rotation- abdominal exercises
• Sitting the same movements trunk rotation
  trunk bending.
• From supine to standing observe the sequence of
  movement some patients make side bending
  rotation of trunk then stand while others take
  the kneeling position then stand.

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F- Functional A.D.L test
Causes of disability of ADL

• Physical
• Affection (emotion - psychological)
• Mental (IQ level Cognitive level - education)
• Social.

ADL are assessed by Questionnaire or Self
questionnaire Multi dimensional function it
include physical examination to detect if
patient can do ADL or not.
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factors affecting muscle tone

• Anxiety
• Temperature
• Tension
• Drugs
• Fear
• Fullness of bladder
• Position of the head
• Environmental condition
• Vision and hearing
• Pain

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G- Assessment of Muscle Tone

• Passive Movement
• Ashworth Scale
• To perform this test, the part is moved
  through the joint range-of-motion (ROM).
• Ashworth Score Criteria
• 0 No increase in tone
• 1 Slight increase in tone, giving a catch
  when the limb is moved in flexion or extension
• 2 More marked increase in tone, but limb easily
  flexed
• 3 Considerable increase in tone passive
  movement difficult
• 4 Limb rigid in flexion or extension

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• H- Reflex assessment Assess superficial and deep
  reflexes (tendon reflex,, and babiniski sign).

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I- Postural assessment testes

• Shobber test
• Adam's test
• Forward bending test.

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J- Sensation perception tests

• Superficial sensation assessment of pain, touch,
  and temperature. Sensation test is done by pin
  pricking or test tube.

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• Deep sensation (Proprioception)
• Dynamic sense (sense of movement)
• Static sense (sense of position)
• Vibration sense

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Joint sense

• Rate of motion
• Velocity of motion
• Direction of motion

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Combined sensation

• stereognosis, two point discrimination, tactile
  localization, vibration, paragnosis, and texture
  of different materials.

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Perception can be evaluated by observation
patients with perceptual defect have the
following criteria

• Can't follow instruction.
• Suffer from confusion
• Difficulty in performing A.D.L.
• Repeated mistakes
• Can't repeated movement
• Can't discriminate between body image and body
  parts (Summate).
• Can't do purposeful movement (Apraxia).
• Can't do any construction form.

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IV- Special test
A- Manual Test

• Righting reaction
• Equilibrium test
• Upright position test

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Special tests for coordination
Non-equilibrium coordination

• Finger to nose The shoulder is abducted to 90o
  with the elbow extended, the patient is asked to
  bring tip of the index finger to the tip of nose.
  
• Finger to therapist finger the patient and the
  therapist site opposite to each other, the
  therapist index finger is held in front of the
  patient, the patient is asked to touch the tip of
  the index finger to the therapist index finger.

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• Finger to finger Both shoulders are abducted to
  bring both the elbow extended, the patient is
  asked to bring both the hand toward the midline
  and approximate the index finger from opposing
  hand .
• alternate nose to finger the patient alternately
  touch the tip of the nose and the tip of the
  therapist's finger with the index finger.

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Equilibrium coordination tests

• Standing in a normal comfortable posture.
• Standing with feet together (narrow base of
  support)
• Standing with one foot exactly in front of the
  other in tendon (toe of one foot touching heed of
  opposite foot).
• Standing on one foot.

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• Arm position may be altered in each of the above
  postures (that is arm at sides, over head, hands
  on waist) .
• Displace balance unexpectedly (with carefully
  guarding patient).
• Standing and then alternate between forward trunk
  flexion and return to neutral.
• Standing with trunk laterally flexed to each side
  .
• Standing to test the ability to maintain an
  upright posture without visual feedback.
• Standing in tandem position from eyes open to
  eyes closed.

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B- Mechanical test
Instrumentation used to assess coordination
Pivot turning mat
Side turning mat
Frenkle's mat
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II- Rehabilitation program.

• A- Rehabilitation team
• Physician Nurse Therapist Social worker
  vocational counselor occupational therapist
  psychiatrist Dietician relatives of patients.

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B- Goals
1- Long term goals

• Return subject to be independent or partial
  independent in ADL and to be productive member in
  his society.

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2- Short term goals

• Enhance functional activities
• Improve range of motion
• Restore symmetry of both sides
• Improve sensory awareness
• Normalization of muscle tone
• Improve balance
• Improve co ordination
• Improve gait pattern
• Strengthening weakened muscle.

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Consideration during rehabilitation

• Avoid exhaustion for the patients
• Avoid the bad habits and poor positioning .
• Avoid position that may exaggerated muscle tone
  or ? patient complication.
• Mental stress.
• Check for precautions and contraindication
• Rest in between the exercise
• There should be goad fixation and stabilization
• Rehabilitation should proceed according to stages
  of motor learning.

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Physical problems of motor control stage

• Defect in postural tone.
• Defect in postural balance.
• Defect in functional pattern.

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C- Program of treatment
1- Instruction

• Avoid any thing or position that increase
  spasticity (excitement, fatigue, pollution, air
  drafts)
• Suitable clothes not tight or restricting, it
  should be made of cotton.
• Ask visitor to seat at affected side to allow
  weight bearing and encourage symmetry.
• Avoid over weight (diet that give energy but
  reduce carbohydrates intake).

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• Wide and stable bed
• Turning every 2 hours to avoid bed sores.
• Massage back buttocks
• Rearrangement of furniture
• Head should be deviated to sound side to ovoid
  retraction of shoulder also make elongation of
  the neck muscles on the affected side.
• Encourage symmetry by engagement of the sound
  and affected upper limbs.

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2- Positioning

• Put the patient in anti-spastic position.
• Head deviated to the sound side.
• Long pillow under pelvis thigh to avoid
  retraction of pelvis, prevent lateral rotation,
  and assist turning. Put small pillow under the
  knee.
• Pillow under the axilla.
• Shoulder in abduction and hand in functional
  position.

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• Use board or wall to put the feet at right angle
  to avoid drop foot.
• 7- Put pillow on his abdomen or in front of him
  and he engage his hands on it.
• 8- Abduct the sound LL apart.

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3- General Local relaxation

• Reassure the patient and encourage him
• Massage
• Hot back
• Bio-feed back
• Small pillows
• Towel or small pillow under the knee
• Suitable comfortable bed
• Temperature room, music.

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4- Breathing exercise

• Diaphragmatic
• Costal
• Ask patient or his family to open windows to
  allow good ventilation.

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Proprioceptive training for hemiplegic patient
A- Mobility stage

• a- Bridging exercise Single leg bridging

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b) Placing exercises

• in placing exercises we can use wall as function
  tool ? proprioception, placing, inhibition,
  facilitation)
• For example
• Raise leg on wall in certain points this position
  used in (1) function standing (dorsiflexion
  -planter flexion- stretching proprioception
  prevent deviation). Also it is used as a
  coordination training for leg from supine.

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• Supine and place hand on wall by hand contact on
  certain markes on the wall this position used in
  prevention of drop wrist as well as coordination.

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Proprioceptive neuromuscular facilitation (PNF)

• P.NF is a very important exercise to improve co
  ordination between agonistic and antagonistic
  muscle groups, and to improve limb co ordination
  in general, in the Mobility stage we can use it
  in the form of active free exercise.

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Frenkle's exercises

• The main principles of frenkel's exercises are
  the following
• concentration or attention.
• Precision
• - Repetition

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frenkel's exercises from supine

• Flex and extend one leg by the heel sliding down
  a straight line on the table.
• Abduct and adduct hip smoothly with knee bent and
  heel on the table.
• Abduct and adduct leg with knee and hip extended
  by sliding the whole leg on the table .
• Flex and extend hip and knee with heel off the
  table .

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• Flex and extend both legs together with the heel
  sliding on the table.
• Flex one leg while extending the other.
• Flex and extend one leg while taking the other
  leg into abduction and adduction.

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C- Controlled Mobility stage

• 1- Quadruped position the patient at this stage
  can support weight on the affected limb
  effectively so he can do reciprocal movement
  between the affected upper and sound U.L or the
  affected and soured L.L or between upper and
  lower limb. This improve coordination between
  patient extremities and improve self-esteem.

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• In the controlled mobility stage we can use be
  PNF in the form of active resisted exercises

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Frankle's Exercises for the legs in sitting

• One leg is stretched to slide the heel to a
  position indicated by a mark on the floor.
• The alternate leg is lifted to place the heel on
  the marked point.
• From stride sitting posture patient is asked to
  stand and them site.
• Rise and site with knees together.

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Frenkle's Exercises for the legs in standing

• In stride standing weight is transferred from one
  foot to other.
• Place foot forward and backward on straight line.

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D- Highly skilled activity stage

• Walks along a widening s teps .
• Walk between two parallel lines.
• Walks sideways by placing feet on the marked
  point.
• Walk and turn around.
• Walk and change direction to avoid obstacles.

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• Sideways walking
• Pivot turning
• From sitting position we can improve
  coordination (eye hand coordination) by using
  puzzles and big board.
• also we can use roller and move it using both
  hands to improve co ordination between both hands
  
• Squatter and trolley for the leg and move the
  foot forward, backward and sideward.

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use roller and move it using his both hands
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Home program and advices

• 1- Regular maintaining antispastic position.
• 2- Always use affected side together with the
  sound side to decrease the associated reactions.
• 3- Patient instructed to do movements in
  functional pattern.
• 4- Patient trained on defensive mechanism.

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Thank you