HAVE FUN. THINK OUTSIDE THE BOX. BE . ... Trunk motor impairment in stroke is linked to poor...

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Transcript of HAVE FUN. THINK OUTSIDE THE BOX. BE . ... Trunk motor impairment in stroke is linked to poor...

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    To comply with professional boards/associations standards: • I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. •Requirements for successful completion are attendance for the full session along with a completed session evaluation. •Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.

    Session 206: The Key to Restoring Balance, Gait, & ADLs Faster Michelle Green, PT, DPT, c/NDT, NCS

    Leading the Way in Continuing Education and Professional Development. www.Vyne.com

    OBJECTIVES:

    1. Participants will be able to discuss the evidence supporting the role  of trunk in basic functional task completion

    2.Partipants will be able to identify and name various trunk motions  and correlate each to associated functional tasks

    3.Participants will be able to develop interventions aimed at  restoration of specific trunk motions as needed for task  completion useful for a variety of diagnosis in any clinical  setting

    HAVE FUN. THINK OUTSIDE THE BOX. BE BETTER.

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    PROXIMAL CONTROL BEFORE

    DISTAL MOBILITY

    TRUNK LIMBS

    WHAT IS ‘THE TRUNK”

    Skeletal

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    WHAT IS ‘THE TRUNK”

    Muscles More important will be the discussion of the MOVEMENTS these muscles produce in synchronous movement control, versus identification of individual muscles

    ROLE OF THE TRUNK IN FUNCTION

    STABILITY • Provides stability through lumbopelvic region to prevent

    collapse of the vertebral column • Allow to body to be upright • Pre-requisite for distal limb movement

    MOBILITY • Sustain equilibrium during perturbations • Restore equilibrium following perturbations (reactionary control) • Adjust weight shifts for function (anticipatory control) • Control the lumbopelvic segments during movement/gravity

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    Schenkman M et al. PHYS THER 2006;86:1681-1702

    ©2006 by American Physical Therapy Association

    The temporal sequence identifies 5 stages of task performance that can be considered during task

    analysis and the specific features of importance for each stage.

    Each task we assess and write a goal for will improve to a greater degree when the whole system is taken into consideration

    Application of limb strength

    Body has to be ready to move-

    aligned for success

    Needs control, activation of trunk, ROM

    TRUNK LIMBS

    FOUNDATIONAL TRUNK MOVEMENTS SEATED REACHING TASKS

    Note how much movement occurs that is NOT UE or

    LE?

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    FOUNDATIONAL TRUNK MOVEMENTS Transitioning to Single-Limb Standing

    Successful weight transfer is PRECEDED by the ability of the

    CONTRALTERAL trunk muscles to activate

    for initiation of movement

    FOUNDATIONAL TRUNK MOVEMENTS GAIT: Transitioning into and through mid-stance

    To get ONTO the foot (mid- terminal stance)

    Contralateral trunk

    muscles activate to

    drive weight shift

    And STAY on for successful swing

    Without excessive anterior or posterior pelvic tilt.

    BRIEF SUMMARY OF LITERATURE SUPPORTING ROLE OF TRUNK IN MOVEMENT

     Recruitment of trunk precedes recruitment of limbs  Latissimus Dorsi has role in ipsilateral stabilization as well as contralateral

    movement  Rectus Abd / Ext oblique activation precedes hip flexion, to a higher degree

    on same side -Dickstein 2004

     Movement of the deltoid is preceded by core muscle activation - Hodges 1996

     Lower trunk more correlated to maintaining/planning balance and upper more correlated to responding to external forces

    -Van der fits 1998

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    ICF MODEL International Classification of Function

    Werner AS, Use of the ICF Model as A Clinical Problem-Solving Tool in Physical Therapy and Rehabilitation Medicine. Phys Ther 2002: 82:11; 1098-1107

    What can’t they do

    The reason WHY they can’t do EACH specific

    task

    Impairment(s) Activity Limitations

    Participation Restrictions

    Impact of Neurological Conditions and Aging on Trunk and Pelvis  Delayed trunk activation in response to limb movement (Palmer 1996, Horak 1984)  Bilaterally trunk muscles are weak, contralateral lateral trunk most involved (Karthikbabu 2012)  More spasticity in limbs when LESS proximal control is present (Karthikbabu 2012)  Impaired multidirectional peak torque in flexors, extensors and rotary muscles, lateral trunk flexors

    weaker on hemi side (Bohannon 1995)  Excessive use of upper versus lower trunk to initiate movement (neuro Messier 2004)  Stroke pts with excessive pelvic instability and asymmetry in gait (Tyson 1999)  Trunk function predicts outcome after stroke (Franignoni 1997, Duarte 2002, Hsieh 2002)  W/S asymmetry due to frontal plane asymmetry is common, should include pelvis assessment in neuro

    patients (Szopa 2017)  Postural righting responses delayed in MS significant contributor to falls (Huisinga 2014)  Trunk control in stroke predicts outcomes in gait, balance and ADL’s (Verheyden 2006)  Static control is more impacted in Huntington's (Kegelmeyer 2017)  Trunk motor impairment in stroke is linked to poor mobility and trunk instability. Treatment should

    target trunk control (Isho 2016)  Improved trunk control via external support improves hem arm function, RX should address pelvic

    and trunk control to improve arm function in stroke (Wee 2015)  Reduction in head and trunk mobility increases fall risk and decreases balance confidence in aging

    adults (Hewtson 2018)

    Schenkman M et al. PHYS THER 2006;86:1681-1702

    ©2006 by American Physical Therapy Association

    The temporal sequence identifies 5 stages of task performance that can be considered during task

    analysis and the specific features of importance for each stage.

    The TRUNK and PELVIS are the BASE of all functional movements and improvement in task performance has to begin with an understanding of how the trunk and pelvis are impacted by the neurological diagnosis or aging process.

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    HOW TO DO A TRUNK

    ASSESSMENT

    A VALID AND RELIABLE FORMAL OUTCOME

    MEASURE DOES EXIST!!

    TRUNK IMPAIRMENT SCALE Correlates to ADL, Gait and Balance Outcomes

    after stroke (Verheyden) WHAT IS IT: Measures motor impairment of the trunk after stroke through the evaluation of static and dynamic sitting balance and coordination of the trunk (Verheyden 2004)

    Score is 0-23. Over 20 is considered normal. 17 Items. Only need score sheet, stop watch and treatment table without back/arm support

    FIND IT: Verheyden, G., Nieuwboer, A., et al. The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke." Clin Rehabil 2004;18(3): 326-334

    www.youtube.com and search for TIS (Trunk Impairment Scale) to watch execution of the test

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    TRUNK IMPAIRMENT SCALE

    RECOMMENDED for patients following a STROKE and those with Multiple Sclerosis only if their EDSS is greater than 4.0 (all the way to 9.5) -Academy of Neurologic Physical Therapy

    LIMITED STUDIES supporting its use in patients with TBI, Parkinson’s, Aging and Spinal Cord

    Alternative: MANUAL ASSESSMENT OF TRUNK MOVEMENT PATTERNS

    What to Include?? 16 motions

    8 Upper Trunk & 8 Lower Trunk 4 Planes of Motion

    SAGITTAL, FRONTAL, TRANSVERSE, DIAGONALS 2 in each plane (ant/post or side/side)

    Alternative: MANUAL ASSESSMENT OF TRUNK MOVEMENT PATTERNS “I’m going to move you. Don’t help me or fight me, just let me see how easily you move in these directions”

    Begin with Upper Trunk

    Move to Lower Trunk

    Check passive (to see how much range/length is available)

    Check active-assisted (to see if motor control is available to help)

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    Correlate limited trunk motions and limited motor control with LIKELY DEFICITS in function.

    This will DIRECTLY guide treatment selection and prioritization. This is the beginning of understanding

    WHY your patient is unsuccessful with a task.

    TRUNK MOVEMENT PATTERNS

    UPPER TRUNK INITIATED MOVEMENTS SAGITTAL

    •Flexion: bend down to pick up pen •Extension: look at clouds above

    DIAGONAL •Flexion: reach to opposite side foot; sit- supine •Extension: reach up and behind (seatbelt)

    FRONTAL •Flexion: place glass on floor to side

    TRANSVERSE •Rotation: look over shoulder behind you

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    NORMAL TRUNK MOVEMENT UPPER TRUNK INITIATED MOVEMENT

    NOT Point of Initiation for Most Tasks in Patient Goals

    Need LOTS of this!!!NOT a Weight shift

    TRUNK MOVEMENT PATTERNS

    LOWER TRUNK INITIATED MOVEMENTS SAGITTAL

    •Anterior Tilt: sit – stand •Posterior Tilt: lifting foot to tie shoes

    DIAGONAL •Anterior Tilt: Reach outside BOS at angle •Posterior Tilt: crossing legs to put on shoes

    FRONTAL •Lateral reach outside of base of support

    TRANSVERSE