Neurological Physio

A stroke is a medical emergency that happens when blood flow to a part of the brain is blocked or a blood vessel in the brain bursts. This stops oxygen and nutrients from reaching brain cells, causing those cells to die within minutes

L Hemisphere – This is your dominant hemisphere, controlling right sided voluntary movements and is responsible for verbal and analytical activities (Language centre)

R Hemisphere – this is your non-dominant hemisphere, controlling left sided voluntary movements and is responsible for visuo-spatial functions

An ischemic stroke happens when a blood vessel carrying blood to the brain is blocked by a clot or fatty plaque buildup. This is the most common type of stroke.

• Thrombotic stroke: A blood clot forms inside an artery directly in the brain.

• Embolic stroke: A blood clot or piece of plaque forms somewhere else in the body (like the heart) and travels through the bloodstream to block a vessel in the brain.

A hemorrhagic stroke happens when a weak blood vessel in the brain leaks or ruptures, causing bleeding in or around the brain.

• Intracerebral hemorrhage: Bleeding occurs directly inside the brain tissue.

• Subarachnoid hemorrhage: Bleeding occurs in the area between the brain and the thin tissues that cover it.

Often called a "mini-stroke," a TIA is a temporary blockage of blood flow to the brain. Symptoms are identical to a stroke but last only a few minutes to 24 hours and do not cause permanent damage, though it is a major warning sign of a future major stroke

B.E. F.A.S.T. test: Balance loss, Eyesight changes, Face drooping, Arm weakness, and Speech difficulty. If you see any of these signs, it is Time to call emergency services (000 in Australia) immediately.
Warning Signs of a Stroke
• B - Balance: Sudden dizziness, loss of balance, or trouble walking.
• E - Eyes: Sudden blurry vision, double vision, or loss of sight in one or both eyes.
• F - Face: Sudden facial droop or an uneven smile when asked to smile.
• A - Arms: Sudden weakness or numbness in one arm; one arm drifts downward when raised.
• S - Speech: Slurred speech, trouble speaking, or inability to understand simple sentences.
• T - Time: Call 000 right away if you observe these signs, even if the symptoms go away.

The Bamford classification system (also known as the Oxford classification system) is a system that categorises stroke based on the initial presenting symptoms and clinical signs. This system does not require imaging to classify the stroke, instead, it is based on clinical findings alone.

A total anterior circulation stroke (TACS) is a large cortical stroke affecting the areas of the brain supplied by both the middle and anterior cerebral arteries.

All three of the following need to be present for a diagnosis of a TACS:
• Unilateral weakness (and/or sensory deficit) of the face, arm and leg
• Homonymous hemianopia
• Higher cerebral dysfunction (dysphasia, visuospatial disorder)

A partial anterior circulation stroke (PACS) is a less severe form of TACS, in which only part of the anterior circulation has been compromised.

Two of the following need to be present for a diagnosis of a PACS:
• Unilateral weakness (and/or sensory deficit) of the face, arm and leg
• Homonymous hemianopia
• Higher cerebral dysfunction (dysphasia, visuospatial disorder)* *Higher cerebral dysfunction alone is also classified as PACS

A posterior circulation syndrome (POCS) involves damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem).

One of the following need to be present for a diagnosis of a POCS:
• Cranial nerve palsy and a contralateral motor/sensory deficit
• Bilateral motor/sensory deficit
• Conjugate eye movement disorder (e.g. horizontal gaze palsy)
• Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
• Isolated homonymous hemianopia

- Sharp Blunt discrimination

- Light touch

- Tactile location test

- Double simultaneous stimulation

- Two point discrimination test

- Graphseology

- Stereognosis

The physio has a sharp edge and a dull edge of an object/s and in random sequence they touch the patients desired area with the objects. The patient with their eyes closed must discriminate between whether the sensation / object used was sharp or dull.

Cotton bud touching on both sides of the patients UL/LL and reporting out of 10 whether the sensation was the same

Baby powder on one side of the arm and get the patient to locate with their finger where the baby powder was placed. Eyes must be closed

- Joint positon sense test (JPS) / Static Test

- Passive movement / Dynamic (Up or down test)

Joint Position Sense (JPS) / Static Test is where the therapist takes the desired affected limb into a movement in which the patient mirrors the movement with their nonaffected side. Eyes must be closed

Passive movement / Dynamic (Up or down) Test is where the therapist takes the affected desired limb into movements where the limb or joints are either moving ‘up or down’ eg; hip flexion is moving up. The Patient must say whether the movement is ‘Up or Down’. Eyes must be closed

Double simultaneous Stimulation is where the therapist is either tapping one limb or both sides of the limb and the patient must report whether they felt it on both sides or one side. Eyes must be closed

Two-point discrimination test is where the therapist uses a tool with two point and a single point edge and moves down the limb. The patient must identify whether it is the two point of contact edge or single point. Eyes must be closed

Graphseology is where the therapist draws shapes or number or letters on the patients arm and the patient must report back which symbol/item it was. Eyes closed

Stereognosis is where the patient reaches inside a bag and fishes out on object in which they must make out what the item is. Eyes must be closed

Raise eyebrows → frontalis
Frown → corrugator supercilii
Close eyes → orbicularis oculi
Puff cheeks → buccinator — helps compress the cheeks and prevent air escaping.
Clench teeth → masseter — very easy to palpate over the angle of the mandible.
Open jaw → lateral pterygoid — assisted by suprahyoid muscles.
Jut jaw forward → lateral pterygoid
Purse lips → orbicularis oris
Cough → forced expiration, primarily involving the abdominal muscles and internal intercostals.

For many of these such as clenching jaw or opening the jaw, the therapist may chose to applght slight pressure or resistance to the movement

We assess reflexes with a reflex hammer. We tap on the insertion of the following muscles to ideally produce a reflex action.
1) UL muscles such as biceps and triceps
2) LL muscles such as knee (patellar) and achilles
3) Babinksi / Plantar

For the Babinski/Plantar we use the pointy side of the reflex hammer and starting at the calcaneus we drag it towards to toes. A positive test is the extending/flaring out of the toes (BAD) and normal/negative if the crunch or flex there toes/foot.

This is defined as ‘The failure to respond, report, or orient to stimuli presented to contralesional side of the body or space and this failure cannot be attributed to either sensory or motor defects’. It is often accompanied by sensory and motor problems eg hemianopia, decreased sensation and paresis.

Types of unilateral neglect:
Sensory – unaware of sensory stimuli on the contralesional side. Can be visual, auditory and/or somatosensory

Motor – failure to generate movement responses to a stimulus even though the person is aware of the stimulus and cannot be explained by weakness

Extinction – the failure to respond to or recognise a stimulus on the affected side when simultaneous stimuli are presented on both sides of the body in the same area. Think a positive finding on the double simultaneous stimulation test.

The eye has six pairs of muscles, controlled by CN 3, 4 and 6
- Medial and lateral recti
- Superior and inferior Recti
- Superior and inferior obliques

We can assess:
- Visual acuity (Snellen or LogMAR charts)
- Smooth pursuit
- Convergence / Divergence
- Saccades
- Visual Field (Wiggle finger test)
- Visal Bias / Extinction

CN I – Olfactory (smell)

- Patient is asked to close one nostril at a time with their hand and is asked to smell an odour (coffee, apple cider vinegar etc).

- Patient reports whether they had smell on both sides, one side or weaker smelling sensation on one side

CN II – Optic (vision)

- Normal Eye chart (Snellen) to Test sharp focus at a set distance (usually 6 meters / 20 feet) and near range. Patient closes one eye at a time and reports which letter line he can see last

- Visual Field or Wiggle Finger Test: Patient is asked to close one eye at a time and look at the therapists nose. The physio uses the four quadrants of vision and one or both wiggles fingers and must get patient to report when they see it in their visual field.

CN III – Oculomotor (pupil size and eye movement)

- Saccades Test: Two targets (fingers or colored stickers) are held 30 cm apart; the patient rapidly jumps their gaze back and forth between them. Look for Undershooting or overshooting (dysmetria) and initiation delay (latency)

- Convergence and Divergence Ax: The same slow-moving target is moved slowly towards the bridge of the nose (convergence) or outwards from this crossed position to evaluate the eyes ability to spread apart smoothly (divergence). In convergence we measure the break point where double vision occurs (patient sees two fingers, assuming therapist is holding up one) or the eyes drift

CN IV – Trochlear (downward and inward eye movement)

- Hold a pen or finger about 30 to 40 cm in front of the patient's face. Keep the head still, Instruct the patient to follow the target with their eyes only. Trace an H-pattern by moving the target through the cardinal directions of gaze, pausing specifically down and in (towards the nose), which tests the superior oblique muscle controlled by CN IV

- Saccades in 'H' formation: Holding fingers about 30cm apart horizontally, ask patient to look between the fingers (that is, to the finger on one side, then to the other side). Repeat this vertically by having the therapist place their fingers 30cm apart on top of each other.

CN V – Trigeminal (face touch and sensation)

- Using cotton wool or any soft touch material the therapist touches one side of the patients face/head with it and repeats in the same spot n the opposite side. Patient then reports whether they feel it on both sides or if it feels the same. Repeat in various spots on the face and head with both sharp and soft touch.

CN VI – Abducens (outward eye movement)

- Tested in many of the previous eye tests. Anything with outwards eye movements

CN VII – Facial (facial expressions and taste)

- Same/similar to orofacial Ax + Testing taste

- Physio palpates jaw and asks patient to clench jaw, Physio resists patients opening of mouth my applying upwards pressure to their chin

CN VIII – Vestibulocochlear (hearing and balance)

- Can the patient hear clicking or the rubbing of fingers behind both their ears while looking ahead.

CN IX – Glossopharyngeal (swallowing and taste on back tongue)

- Test patients tase with certain flavours (sweet, salty)

CN X – Vagus (heart rate, breathing and digestion --> sympathetic)
- Can’t test but is assumed positive. Test by coughing

CN XI – Accessory (neck and shoulder movement)

- Ask patient to shrug their shoulders, physio applies downward resistance to resisit shoulder shrug movement

- Then ask patient to look over one shoulder at a time and observe movement. Then repeat while applying pressure to the patients cheek

CN XII – Hypoglossal (tongue movement)

- Ask patient to open mouth and move tongue side to side

- Ask patient to open mouth and keep tongue poked straight out and still

UL Coordination Tests

- Finger to nose / Finger to Nose to Therapist finger (10x / high rep to see any deficits)

- Pronation/Supination as quick as possible on a table

- Hand Tapping (Can do it to a beat, for cognition)

- Finger Strumming on table

LL Coordination Tests

- Leg Slides: Patient slides foot up opposite leg to above/around the knee

- Marching on the spot done seated.

- Foot tapping

- Marching but in supine (alternate hip flexion and knee flexion)

- Cycling performed supine

Perceptual deficits after a stroke are disruptions in how the brain organizes, recognizes, and interprets information gathered by the senses.

Personal - The person's own body
Peripersonal - Space immediately surrounding the body / within reaching distance
Extrapersonal - Space beyond reaching distance / the wider environment

Neglect is a Motor-intentional deficit where there is reduced spontaneous movement toward the contralesional side

Egocentric neglect - Neglect based on the person's own body/viewpoint

Allocentric neglect - Object-centred deficit — neglects one side (usually left-side) of individual objects regardless of where they are located

Apraxia is a neurological disorder that stops a person from planning and executing purposeful muscle movements, even though their muscles have normal strength and no paralysis.

Dressing apraxia = A visuospatialody-schema deficit — difficulty orienting and putting clothing on correctly

Ideomotor apraxia = Motor planning/programming deficit — difficulty performing learned purposeful movementsestures despite understanding the task

Ideational apraxia = Motor sequencing/conceptual deficit — difficulty organising a sequence of purposeful actions

Post-stroke lateropulsion, is a balance disorder where a person actively pushes their body toward their weaker side and resists attempts to push them upright. It happens because the brain damage alters their physical sense of gravity and vertical alignment.

Key Signs
• Leaning heavily toward the weak side.
• Using the strong arm or leg to push the body sideways.
• Fighting back when a helper tries to move the body straight up.
• Believing they are straight when they are actually tilted (visual vs perceived body verticality)

Relaxation of the unaffected side
- Activities to promote selective trunk activation on the affected side
- Positioning, handling, use of verbal cues to relax unaffected side and / or stimulate muscle activation


Regain central alignment and awareness of upright / verticality
- In lying, sitting and standing
- Visual (mirror), verbal and tactile (manual handling) cues
- Scales and Limb-load monitor

Use of external / environmental cues to orient the patient in space
- These may be used in sitting, standing, during transfers and walking
- Use of a table, box or rail alongside the patient’s affected side
- May also use another object in front to “box’’ them in

Use of automatic activities to promote weight shift (Internal Displacement)
- Reaching to the unaffected side and forwards (always forwards before lateral reach)
- Produce self-initiated displacement

Mindfulness of Over-handling

- Use of mirror

- Relaxation of unaffected side: Take patients unaffected side (hand) and placing it in PTs lap or hands to prevent pushing

- Internal Displacement: Have them perform forward reaches and progress to lateral lean and then reach. (lean on wall on unaffected side and progress to hand on wall)

Environment Modification: Bars, plinth, walls to lean on and help orientate the patient in space

Visual cues (mirrors, may or may not work)

Verbal Cues

Tacticle cues avoiding manual handling (walls and objects to lean and rely on)

Limb load monitors and scales for feedback

The Motor learning approach is the process of acquisition and/or modification of a skilled action. It is the process of learning to do something well after a stroke. This is how we leverage neuroplasticity as a physio. Neuroplasticity is use dependent, specific and time sensitive. And as phsyios, it is influenced by:
• Repetition and intensity
• Salience, motivation, feedback and attention
• Features of the environment
• Adjunct therapies
• Patient characteristics (motivation, cognition etc)
• Some pharmacology

Spasticity is a velocity-dependent increase in muscle tone (tonic stretch reflex) and exaggerated (hyperexcitability) stretch reflexes caused by damage to upper motor neuron pathways.

Core Mechanisms
• Loss of Descending Inhibition: Damage to the brain or spinal cord removes inhibitory signals normally sent down to spinal circuits.

• Hyperexcitable Stretch Reflex: Lower motor neurons become overly sensitive because they lack normal suppressing controls.

• Velocity Dependence: Quick stretches stimulate more muscle spindle fibers, triggering an exaggerated, rapid contraction

The Modified Ashworth Scale

How It Is Performed
• The patient lies relaxed in a flat, face-up (supine) position.

• The clinician moves the patient's limb quickly through its full range of motion over about one second.

• The clinician grades the amount of resistance felt during the movement.

Scoring Levels (0 to 4)
• 0: Normal muscle tone; no increase in resistance.
• 1: Slight increase in tone with a "catch and release" or minimal resistance at the very end of movement.
• 1+: Slight increase in tone with a catch followed by minimal resistance through less than half of the remaining movement range.
• 2: Marked increase in tone through most of the movement range, but the part still moves easily.
• 3: Considerable increase in tone; passive movement is difficult.
• 4: Affected part is rigid and stuck in flexion or extension

The Modified Tardieu Scale (MTS) is a clinical evaluation tool used to measure spasticity by assessing a muscle's resistance to passive stretch at different velocities  The differing velocities is important as this is what separates it from the Ashworth scale, spasticity is velocity-dependant and thus to get a comprehensive Ax we must examine at various velocities

Key principles:
o Apply passive stretch to relaxed muscle
o Maintain consistent position to proximal segments
o Measure (accurately) angle at which resistance interrupts passive movement
o Measure at different speeds, from extremely slow to rapid to determine the spasticity angle

There are four measurements found in the MTS:
o R2 (Full Range of Motion): The angle obtained when moving the joint as slow as possible (V₁). Measure with Goniometer

o R1 (Angle of Muscle Reaction): The angle where a catch or clonus is first felt during a rapid, fast-velocity stretch (V₃). Measure with a goniometer

o Dynamic Tone Component: Calculated as the difference between R₂ and R₁ (R₂ - R₁), indicating the spasticity severity and dynamic tone component of a muscle.

o The quality of muscle reaction during V₃. This is measured under the following parameters:
0: No resistance throughout passive movement.
1: Slight resistance, no clear catch at a precise angle.
2: Clear catch at a precise angle, interrupting passive movement, followed by release.
3: Fatigable Clonus (< 10 seconds when maintained at that precise angle)
4: Non-fatigable Clonus (> 10 seconds when maintained at that precise angle)
5: Joint is immobile

As you may have noticed, we have differing velocities (V’s). These are:
o V₁: As slow as possible, slower than the natural rate of the limb segment falling.
o V₂: The speed of the limb segment falling under gravity. (OPTIONAL)
o V₃: As fast as possible, faster than the rate of the natural drop

Performing this test on UL muscles

1) Place muscle in the contracted/shortened position
2) Then take muscle through full ROM very slow to the lengthened position (V₁)
3) Take muscle through full ROM as quickly as possible (V₃)

1. Balance Section (16 Points Max)
• Evaluates sitting balance in a chair.
• Tests rising from the chair without using hands.
• Checks standing balance by a gentle nudge to the sternum to check stability while standing, repeat with the patients eyes closed. Then lastly ask patient to do a full circle, that is to turn a full 360 degrees.

2. Gait Section (12 Points Max)
• Ask the patient to walk a 4.5m walkway. As the clinician we assess how they comfortably initiate gait, step length (even step length, drop foot gait), how continuous is their walking, how well are they sticking to line, is their postural sway or arm movement etc. Do it twice
• Checks step length, height, symmetry, and continuity.
• Observes trunk sway and walking stance

Total score: Out of 28 points maximum.
- Low fall risk: 24 to 28 points.
- Moderate fall risk: 19 to 23 points.
- High fall risk: Below 19 points (scores under 25 also signal a notably higher chance of falling)

Measures dynamic balance during an activity requiring weight-shift and movement while in Single leg (SL) stance. It requires the patient to place one foot onto a 7.5cm step and down again as fast as possible. Counter number completed within a 15 second timeframe.

- Measure both sides but generally start with weight bearing on good side

- Try and push the patient to perform the test without needing the examiners assistance for balance (this may mean doing some initially while holding on)

Normative data:
18-35 years – 20+ steps
Healthy elderly population – 17 steps
Stroke population – 4 steps

- Patient is to stand with their feet placed directly together. Keeping their arms either at their sides or crossed in front of their chest. Stand still for about 30 seconds with eyes open.

- Then ask the patient to perform it again with eyes closed for another 30 seconds while an examiner watches closely to guard against a fall.

- We can then reassess this test in tandem (one foot in front of the other) with eyes closed.

- Ask patients for comfort and or feelings of unsafety/instability

This test measures the maximum distances a person can reach forward with a clenched fist while standing in a fixed position. This test allows for 2 ‘practice’ trials and 3 ‘test’ trials. The patients score is the average of the three ‘test’ trials. Should be hinging at the hip with a clenched fist and shoes off

- The frail or elderly population will indicate a score <18.5cm which indicates high risk of fall

Measures the maximum distance a person can reach sideways while standing in a fixed position. Maximum reach position is to be maintained for three seconds. With a clenched fist and barefoot, the patient would hinge at the hips reaching to the side in a fixed position. 2x Practice test then Repeat 3x for test and average scores


Normal values = 20cm (pop of older women – age 73)

Measures functional lower extremity strength and ability to complete the transfer skill of STS. It requires a standard height chair and no use of hands for STS (hands on shoulders). Allow one practice ‘trial’ before test trial. The patient is to sit and stand 5x without the use of hands

A score of > 15 seconds indicates falls risk (unsure if this is for stroke population too or just Musculoskeletal population??)

Assesses mobility, balance, walking ability and falls risk in older adults. It is the time taken to stand up, walk 3 meteres, turn and walk back to the chair and sit down. Walking aid is allowed but must be recorded if used. One practice trial and one test trial.

A score >13.5 seconds indicates a risk of fall

In addition to the normal TUAG, we as phsyicians can call upon cognitive and other motor challeneges such as complete test while counting backwards by 3 from a randomly selected number or Complete test while holding a glass of water (both functional and muscle active)

Tests the ability to withstand an external perturbation (external force).
You will tell the patient instruction such as ‘ I am going to give you a brief tug from behind and I want you to resist the backward movement’.

Rate the result on a scale from 0-4. A normal score is between 0-1:
0 = Normal (no steps)
1 = Retropulsion but recovers unaided
2 = Absence of postural stability (would fall if not caught)
3 = Very Unstable, tends to lose balance spontaneously
4 = Unable to stand without assistance

Measures postural control under various sensory conditions. There are four stance conditions, each timed for 30 seconds:
- Feet together Eyes open
- Feet together Eyes closed
- Feet together on foam Eyes Open
- Feet together on foam Eyes closed

Any activity that seeks to imrpove the functional capacity or quality of movement is valid. For example some include:
- Bed mobility
- Supine to sidelying (remembering not to roll onto affected side)
- Sidelying to SOEOB
- Balanced sitting (although this is assessed in Tinetti)

The patient repeatedly attempts to use it: Attempt → failure → frustration → stops trying

They then increasingly rely on the unaffected limb and suppress behaviour on the other side

Eventually: Less use → less practice → poorer motor performance → even less use
This is known as learned non-use.

Physiotherapy Response? Constrained induced movement therapy (CIMT)

Constrained induced movement therapy (CIMT) is a management tool in which relies on three components:
1) Restraint of the non-affected UL for 90% of day
2) Massed practice of the affected UL – 6-7 hours a day of intense practice for 2-3 weeks (5 -7 days a week). Ultimately it needs to be intensive if we are to recruit new neuronal networks.
3) Ultimately means the patient is forced to use the affected UL

There is a Strict inclusion criteria:
- 10-20 of wrist extension and at MTP and Ip joints
- Need to be able to engage in 2hrs of intensive training a day
- Need to have adequate balance with arm
- Need to have no/minimal cognitive impairment
- Need to score 3 on item 6, and 1 on item 7 of MAS

Other Limitations to CIMT:
• Compliance problems
• Safety issues
• Mentally and physically fatiguing (frustrating for patient)
• Intensive practice

1. PROM (Yes = 3)
Pt is positioned in supine. First test shoulder flexion with neutral rotation and then ER with shoulder adduction to the patient’s side. Max range is when available passive range is reached or patient withdraws.

2. Ritchie Articular Index (Pain) (Yes = 2)
Pt is positioned in supine. Hemiplegic arm is passively abducted to 30’, elbow 90’, forearm neutral. The patient’s shoulder is stabilized with one hand while the other slowly externally rotates the shoulder whilst gripping the pt’s humeral condyles. Max range is when available passive range is reached or patient withdraws.
1. pt has no tenderness (visible discomfort, or when asked if pain was present)
2. The patient complains of pain (voluntarily or when asked)
3. The patient complains of pain, winces, and withdraws

3. MAS item 6 (Yes = 3)

4. Subluxation (Yes = 1)
The patient is positioned in sitting. The distance between the lateral ridge of the acromion and the highest point of the humeral head is measured

5. Tardieu Scale (Yes = 1)
The patient is positioned in sitting, elbow flexed at 90'. Test at V1, and V3. Record Y at each speed and x = quality of movement (0 = no resitance,1 = slight resistance, 2= clear catch followed by a release, 3= fatigable clonus, 4= infatigable clonus, 5 = joint immovable)

Rating of Risk:
High = 4-10
Low = 1-3
None = 0

Transport (Reach Phase)
• Displacement: Hand moves from starting position toward the target object.
• Velocity: Follows a “bell-shaped” velocity profile (accelerates rapidly, peaks about halfway, then decelerates smoothly as hand nears the target).
• Goal: Position the hand in space near the object.

Grasp (Pre-shaping Phase)
• Displacement: Fingers open wider than the object (maximal aperture), then close around it.
• Velocity: Finger opening peaks early, then slows as aperture is shaped to match object size/shape.
• Goal: Form grip type appropriate for the object (precision grip, power grip, etc.).

• Shoulder Muscles (Deltoid, Rotator cuff):
o Initiate and guide arm movement (flexion, abduction, rotation for hand positioning).

• Elbow Muscles (Biceps, Triceps):
o Adjust arm length to bring the hand closer or further.

• Wrist Muscles (Extensors/Flexors):
o Stabilise wrist position for optimal hand orientation.

• Intrinsic & Extrinsic Hand Muscles:
o Lumbricals/interossei + flexor digitorum + extensor digitorum control aperture (opening/closing).
o Thumb muscles (thenar group) crucial for opposition in precision grips.

Think about using slide sheets, skateboards or manual handling to facilitate ease of movement. Also think about length of lever (or muscle during movement), i.e its easier to perform shoulder flexion with the elbow flexed than with the elbow extended. UL movements to assess in Sidelined position (antigravity) or seated (with friction and gravity eliminated).

Grades 0-2: Purely strength focus

Grades 2-4: Strength and Task-specific focus (slowly introducing more motor and task specific Rx)

Grade 5: No more Strength focus, only task-specific practice and sequencing (High cognition and high intensity)

- Protraction
- Flexion
- Extension
- Horizontal abduction
- Horizontal adduction
- Elbow extension

This is different to MMT grades > 3 where we train and build strength of the muscle. Here we are still making strength improvements but the major focus is a regain of function for everyday life. This may mean
- Picking up objects (resisted shoulder flexion)
- Pushing objects away (resisted elbow extension and protraction)
- Putting Objects away
- Bringing objects too you

- Be task-specific (eg; reaching to grab a mug in the morning or glass of water on bedside table)
- Incorporate mental imagery or practice.
- Use a variety of objects – different weights, sizes, shapes and surfaces)
- Vary where the object is related in relation t the body
- Vary the patient’s body position (sitting, lying standing)
- Use the same object for different tasks to challenge cognition. Eg; keys in pocket v keys locking a door.
- Alter the speed and or rhythm of the movement
- Train strength and endurance of the hand, wrist and forearm muscles.

RAHHAHAHHA --> Picking upsing fork is Slide 59 and 60 of manual

Think about which Rx is specific for what pathology

1) Heel strike (Inital contact)
2) Flat Foot (loading response)
3) Midstance
4) Heel Off (Terminal stance)
5) Toe off (Pre-swing)

1) Early Swing
2) Midswing
3) Late Swing (terminal swing)

Ankle: neutral - Concentric to eccentric contraction of dorsiflexors to control ankle

Knee: 5° flexion - Quadriceps contracting eccentrically to control movement

Hip: 30° Flexion - Concentric hip extensors and eccentric flexors

Ankle: Rapid PF to 10° - Eccentric dorsiflexors

Knee: Further flexion to 10-15° - Eccentric quadriceps and concentric hamstrings

Hip: Gradual extension - Concentric extensors (gluteus maximus and hamstrings)

Ankle: Gradual Dorsiflexion - Eccentric plantarflexors and concentric dorsiflexors

Knee: Beginning to extend - Concentric Extensors

Hip: Gradual Extension - Concentric Extensors

Ankle: Dorsiflexion until 10° then PF begins - Eccentric then concentric PFs

Knee: Continues extending until near full extension 5° flexion - extension is driven primarily by momentum and external ground reaction forces

Hip: Extends until 10° maximum and then begins to flex - Eccentric hip flexors to control hip extension

Ankle: Rapid PF - Concentric plantarlfexors to propel the body

Knee: Begins rapid flexion - concentric contraction of hamstrings

Hip: Begins to flex - Concentric iliopsoas

Ankle: PF until 20° before dorsiflexion to clear the ground - Eccentric dorsiflexors before concentric dorsiflexors and eccentric plantarflexors

Knee: Knee flexion until 60° - Concentric contraction of hamstrings (rectus femoris)

Hip: Continues to flex - concentric hip flexors (rec fem and iliopsoas)

Ankle: maintains neutral position - concentric dorsiflexors

Knee: begins to extend - eccentric flexors

Hip: Continue to flex - concnetric flexors and eccentric extensors

Ankle: Remains neutral - concentric dorsiflexors to hold the ankle in position for iniatial contact

Knee: Extends until full extension before flexing slightly in preperation for initial contact - eccentric flexors to decelerate the swing (preventing hyperextension) then concentric flexors

Hip: Flexes until 30° - concentric flexors and eccentric extensors before transitioning to concetric extensors (glute max and hasmtrings)

- Sensory Stimulation: Use of different textures, pressures and objects

- Sensory Discrimination or Object Recognition: Patient must distinguihs between objects and different textures ⬆️ with eyes closed

- Graded difficulty of these somatosensory discrimination tasks ⬆️

- Use of vision and unaffected hand to facilitate relearning. Eg; Encourage the patient to look at the affected limb when sensation is impaired, helping them monitor its position and interaction with objects.

- Focus on functional tasks / ADLs (activities of daily living) eg; gettign dressed

- Repetitive Delivery: Typically 2-3x per week, 70 min sessions for 4-8/52 or SENSE approach 10 or more 45-minute sessions over a period of 3 to 4 weeks

SENSe therapy is an evidence-based sensory rehabilitation program designed to help stroke survivors regain and improve their sense of touch and hand function. The acronym stands for Study of the Effectiveness of Neurorehabilitation on Sensation. It incorporates:
- Texture discrimination
- Limb positon sense
- Tactile object recognition
- Integration of sensation in ADLs (activities of daily living)

Typically SENse is delivered in 1on1 sessions 3x a week with 15-20 mins on each task. A total of 10 sessions for 45 mins over 3-4 weeks is recommended.

• Line Cancellation – Patient is given a page containing multiple lines and asked to cross out/cancel every line they can see. Look for missed lines, particularly on one side.

• Star Cancellation – Patient is shown a page containing small and large stars mixed with distractors and asked to cross out all the small stars. Missing stars on one side can indicate spatial neglect.

• Objects Around Room – Place/identify objects around the patient's environment and ask them to find or identify objects in different areas of the room. Observe whether they consistently miss objects on one side.


• Coins – Present four of four different coins and ask the patient to identify/name or distinguish them, potentially placing them in different visual locations. Place all 5c pieces on the contralesional side to assesses visual recognition and neglect

• Fruit – Present pictures or actual examples of different fruits and ask the patient to identify/name them. Can assess visual recognition, with errors potentially indicating perceptual problems.

• Menu – Give the patient a menu and ask them to locateead specific items (e.g., find a particular meal). Observe whether they miss information on one side of the page.

- Scanning and cancellation tests are useful for diagnosing unilateral spatial neglect and in Rx as task-specific practice

- Verbal or visual cues to look to contralesional side (particularly useful during Rx)

- Sit on patients left side when speaking to them (making sure they understand you are there)

- Encourage visual scanning such as the lighthouse method

- No standardised dosage however when planning Rx is still patient-dependant such as severity of deficit, timeframe and patient response. Patient response involves monitoring tolerance, fatigue, frustration and attention loss,

Tilt Table

Electrical Stimulation (ES)

Bodyweight Support Treadmill Training (BWSTT)

The tilt table may be used as an adjunct in the overall physio management of a patient. It is most often used when there are concerns about a patient’s ability to tolerate being upright for several reasons: unstable BP, following prolonged bedrest, decreased communication etc.

- Improves and stimulates the patients sense of verticality

- Provides a sense of weight bearing through both hells with the hip and knee extended as if normally standing

- STS alternative in early stages of rehabilitation

- Increases level of arousal or consciousness

- Stretches tendo-Achilles and hamstring contractures

- Cover tilt table with sheet or sanitise bed and place pillow at head of table with all four wheels locked before patient is moved on to table. Secure the footplate in place
- Lower strap - placed over knees position towel under knees
- Mid strap - positioned over pelvis
- Upper strap - placed over chest, under arms
- Explain what is happening and why to the patient
- Note blood pressure, plus rate and colour as appropriate
- Encourage patient to keep eyes open
- Tilt the table slowly upwards with frequent pauses to allow patient time to accommodate
- First treatment should not go higher than 60 degrees
- One person must stand in front of tilt table so that patient can be always assessed
- Proceed with rehabilitation activities as appropriate
- Spend 5 mins at 30°, 5 mins at 60° and 5 mins a 80°

Cease treatment and bring patient back to horizontal position and seek medical advice if the patient develops any of the following:
- Severe shortness of breath (SOB)
- Sustained increase in HR of > 10-15 beats per min
- Dizziness
- Loss of consciousness
- Cyanosis
- Chest pain
- Clamminess/ cold sweats
- Systolic Blood pressure (SBP) falls below 90mmHg
- Significant decrease in BP (if base SBP > 150mmHg a decrease of >20mmHg)
- Significant decrease in BP (if base SBP > 100-150 mmHg a decrease of >10mmHg)

Clinically ES is used to selectively evoke muscle contraction through stimulation of the peripheral nervous system. It is used as an adjunct method to facilitate functional recovery. ES can:
- Prevent disuse atrophy from immobilization or inactivity
- Maintain or improve range of motion
- Facilitate voluntary motor control
- Decrease oedema (muscle pump action)
- Decrease spasticity (reciprocal inhibition)
- Act as a substitute for missing motor skill allowing for performance of functional activities (FES or ETS)
- Prevent shoulder subluxation
- Reduce pain (by improving the resting position of joints and spasticity)

There are few absolute contra-indications. The following should be considered but may be used under the direction of the neurologist
- pregnancy
- pacemaker
- ↓ circulation (looking for cyanosis and pale skin)
- ↓ sensation (use sensation Ax --> Sharp-blunt discrimination)
- ↓ communication
- broken skin
- skin infection in the treatment area
- uncontrolled epilepsy
- SCI above T6 (due to risk of autonomic dysreflexia)
- malignant tumour

We generally aim to place the active electrode on the motor point of the muscle – this refers to the area of least resistance to stimulate the muscle. But these locations vary between people and are not always the location where the nerve enters the muscle. You may have to adjust the position of the electrodes several times to obtain the muscle response you are aiming for. You can then mark this location for future use

Key Principles
- Use largest electrodes feasible
- If using non-adhesive electrodes, cover whole surface with gel
- Ensure the whole surface of electrodes is attached
- After removing non-adhesive electrodes at end of session, clean them with alcohol wipes
- Always make sure the machine is turned off before touching / moving the electrodes (very important for independent practice)
- Black electrode (+ve) goes on motor / nerve entry point and the red electrode on proximal muscle belly

"When having electrical stimulation, you should feel a tingling sensation and then a muscle contraction which will hold for several seconds and then relax for several seconds. If you feel anything other than this or any pain, you must alert a therapist immediately: otherwise, you are at risk of skin and other tissue damage under the electrodes. If in doubt alert a therapist. If you become uncomfortable, alert a therapist. Do you understand what I have said? Do you have any questions? Are you happy to proceed?”

PC1 is the Shoulder subluxation prevention setting:
- 35Hz,
- Pulse width 250
- 10 on / off (machine will do this automatically)
- ramp 1.5sec (the time it takes for the electrical current to gradually build up to its full strength or ease back down to zero)
- Black electrode goes on supraspinatus fossa above scapula, red on proximal muscle belly – posterior delt)
- Observe to see that flickering and diverging of muscles (should look like the skin or muscle is squeezing together)

Electrical stimulation is also helpful when applied to ankle dorsiflexors (tibialis anterior plus peronei to produce neutral dorsiflexion movement), knee extensors, elbow extensors and wrist and finger extensors. Small hand and thumb muscles and facial muscles may be stimulated using small electrodes or a probe. In these cases, the patient is asked to try to assist the effect of the stimulation thereby re-enforcing the recruitment of the movement

PC2 is the muscle stimulation setting:
- 50Hz
- Pulse width 250
- 5 on 2 off (machine does this)
- ramp 0.5 sec (the time it takes for the electrical current to gradually build up to its full strength or ease back down to zero)
- Black goes on nerve entry point, red on proximal muscle belly