movement system diagnoses neuromuscular conditions · patricia l scheets, pt mhs dpt ncs infinity...

Property of Scheets, Bloom, Crowner, McGee, Norton, Sahrmann, Stith, Strecker – DO NOT COPY WITHOUT PERMISSION January, 2020

MOVEMENT SYSTEM DIAGNOSES NEUROMUSCULAR CONDITIONS

Patricia L Scheets, PT MHS DPT NCS Infinity Rehab / Washington University

[email protected] or [email protected]

Collaborators from Washington University Nancy J Bloom, PT DPT MSOT

Beth Crowner, PT DPT NCS MPPA

Patricia N McGee, PT DPT PCS

Barbara J Norton, PT PhD FAPTA

Shirley A Sahrmann, PT PhD FAPTA

Jennifer S Stith, PT PhD LCSW

Susan K Strecker, PT DPT

Updated from Scheets PL, Sahrmann SA, Norton BJ, Stith JS, Crowner BE. What is backward disequilibrium and how do I treat it? A complex patient case study. J Neurol Phys Ther. 2015 Apr;39(2):119-26 (Appendix).


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INTRODUCTION

The following pages contain descriptions of the movement system problems we have identified among people with neuromuscular conditions. While

many of the people in the categories described in this set of diagnoses may have a central nervous system pathology, many will have non-specific and/or varied

health conditions. What the patients have in common is one or more limitations in their ability to move within the environment, manipulate objects, and /or balance

in a given position for reasons other than pain. In this set of movement system diagnoses, rather than being sorted by traditional health conditions or diseases,

patients are categorized by their type of movement system problem. This allows for the grouping of patients along parameters that physical therapists both

examine and treat.

We believe that the movement system problems described apply to both the adult and pediatric population. There are differences between adults and

children in the health conditions associated with a given movement impairment diagnosis and the tasks examined. In the descriptions of the diagnoses, we have

used the following symbols to designate characteristics of the diagnosis applicable for all age groups and those associated predominantly with pediatrics:

The Clinical Examination

We have described the clinical examination required to identify these movement system diagnoses in an accompanying document. The examination

consists of tests of body structures and functions and observational analysis of specific tasks. The examination focuses on movement system aspects of the

patient’s presentation only. It does not include tests that measure prior function, care giver burden, or personal and environment factors that are considered when

managing an entire case. Likewise, the examination does not include all tasks or activities that may be of interest to the patient. This examination only consists of

tests that are believed to be diagnostic in determining a movement system diagnosis. As such, there is a heavy emphasis in the examination of movement

analysis during key tasks. This movement analysis is critical to making a movement system diagnosis.

KEY • Observed in all age groups

Observed in pediatrics


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The Labels

Selecting a label for a condition identified from clinical practice has been one of the greatest challenges in developing these ideas. You will see, that the

labels we have selected often reference a primary impairment, but it is important to note that there is no single test that determines a patient’s diagnosis. For each

category, we have outlined the critical examination findings that describe the movement problems of patients in each diagnosis. The examination and diagnosis

descriptions describe how the results of traditional tests of body structure and function coupled with analysis of critical tasks (impairments in motion, if you will) are

used to identify the movement system problem. It is important to read beyond the label to understand the true picture of each movement system diagnosis. Read

the descriptions of the diagnoses and the examination so you see how the combination of test results leads to a diagnosis. Focus on how the diagnoses are

different from one another.

Modifiers

At times, a patient presents with additional impairments in body structure or function for which we do not have a diagnosis. If you feel the presence of this

impairment will impact the patient’s expected outcome or intervention, you may consider adding a modifier to the diagnostic label. You may also want to do this to

highlight important personal factors with which the patient presents. Examples of these modifiers are listed below:

• Disregard/ Neglect • Agitation • Confusion • Decreased attention span • Memory loss • Apraxia • Balance confidence • Decreased ability to dual/multi-task • Structural joint deformity


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Treatment

In addition to the diagnosis descriptions and examination, we have outlined treatment principles for each of the diagnoses. One of the greatest challenges

to adopting movement system diagnoses as a foundation of practice is that much of the literature related to rehabilitation intervention is sorted by health condition

rather than movement system problem. We are hopeful that, over time, researchers will consider that perhaps some of the variability in responsiveness to an

intervention within a group of subjects with the same health condition may be attributed to the subjects’ movement system problem. We encourage researchers to

design studies to test this hypothesis. In the meantime, use the treatment principles as a guide in determining whether or not a studied intervention is appropriate

for a given movement system diagnosis and how it might be nuanced for different movement system diagnoses.

Frequently Asked Questions What if it’s early in a patient’s recovery, and I don’t know how much movement the patient will have after a stroke, an MS exacerbation, an extended illness, etc.?

We encourage you to know the literature related to the recovery of impairments after a particular health condition. This element of determining the

prognosis is where the patient’s health condition becomes important. If you are seeing a patient in the very acute stage of a change in health condition, you need

to observe the patient over more than one session or over a few days to determine the patient’s prognosis. If the prognosis is a critical factor in determine the

diagnosis, we encourage you to develop a working diagnosis based on the information that you have available. In developing a working diagnosis you will need to

determine what additional information you need and over what time period it will be collected. You will also need to outline your differential diagnosis(es).

Can I give a patient more than one diagnosis?

We feel there is value in focusing on the “big thing,” so in using this system there is an emphasis on sorting out the primary impairments affecting the

patient’s movement. Using the diagnosis descriptions and clinical examination as your guide, pay attention to the level of impairment for each diagnosis. How

weak does a patient need to be to have Force Production Deficit? How much sensory loss does a patient need to have Sensory Detection Deficit? If the patient

has an impairment but the level of impairment does not meet the threshold for a given diagnosis, consider adding it as a descriptor to the primary diagnosis. This

practice will remind you that you may need to modify your approach to the patient slightly or you may have a different expected outcome.


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If the patient meets the examination criteria for more than one diagnosis, feel free to use more than one diagnostic label. Just be sure that you’ve done a

complete examination and that providing more than one diagnosis reflects the true nature of the patient’s movement system problems and not lack of clarity on

your part. In our experience, providing more than one diagnosis is not required often but it does happen. We have a case report that illustrates the use of more

than one diagnosis being published in the Journal of Neurologic Physical Therapy sometime in 2015.1

Does the diagnosis change?

Because the diagnosis is to direct the therapist’s treatment, we have discouraged clinicians from changing the diagnosis. When therapists have gravitated

toward this practice, they have often been using more trial and error intervention and search for the diagnosis that fits the treatment they would like to provide.

This use of the system does not aid the therapist in focusing treatment. Occasionally, however, the patient’s condition actually changes resulting in the need for a

new diagnosis. In these situations, change the patient’s diagnosis and align your treatment accordingly.

What about the patient’s activation in their care, social support, or other factors which influence the patient’s outcome and how I interact with them? We understand that there are a number of factors that influence a specific patient’s outcome, however, when determining a movement system diagnosis,

we are focused on the movement system issues. Once you determine the patient’s movement system problem and diagnosis, you then consider the contextual

factors that may influence a particular patient’s care. These contextual factors include the personal and environmental factors that may be facilitators or barriers to

that specific patient’s outcome. While these are important considerations for each individual patient, they do not change the movement system problem.

How do I document using this system?

At the back of the examination document, we have provided a sample clinical examination form. We have sorted the tests by test position because we

feel this flow provides the easiest use for point of care documentation. We have also provided checklists for movement analysis to assist the clinician in making

observations and in documenting the observations using appropriate language relatively quickly. We have had success in implementing this type of language into

a number of electronic documentation systems. Movement analysis is a critical step in making a diagnosis, and we encourage users to not take short-cuts in this

dimension of the examination.


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What if the patient has pain?

Our diagnoses describe patients who have difficulty of mobility tasks for reasons other than pain. For the patient’s pain re lated problems, we encourage

the use of a specific examination of these problems. The movement impairment syndromes2,3 described by Sahrmann and colleagues are recommended for use

in these circumstances.

Why not just label patients mildly, moderately, or severely impaired? Wouldn’t it be simpler? You will see that some of our diagnoses describe patients who are more functionally impaired than patients in other diagnoses. However, we feel the

“mildly,” “moderately,” or “severely” impaired designation is insufficient in guiding a specific patient’s treatment. Many of the patients in these diagnoses will be

taught compensatory movement strategies, but the strategies needed are varied by diagnosis. Similarly, many of the patients with these diagnoses have the risk

of developing secondary movement system problems which are also different across categories.

What about standardized tests? Aren’t these important?

The examination we described does not include specific outcome assessment tools. We highly encourage the use of these tools in documenting patient

status and outcome; however, they are generally not designed to identify specific movement system faults affecting a patient’s overall performance. These tests

are generally not diagnostic in nature and therefore insufficient for making a movement system diagnosis.


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DIAGNOSIS DESCRIPTION: MOVEMENT PATTERN COORDINATION DEFICIT The primary movement dysfunction is poor timing and sequencing of either intersegmental movements or of postural responses (anticipatory and reactive) relative to balance demands. In the lower extremity, the movement problem is primarily observed during tasks which require stability prior to and during limb or trunk movements. In the upper extremity, the movement problem is primarily observed during in hand manipulation and grasp and release of different objects coupled with reach. Motor performance typically improves with practice and instruction.

Subjective/Medical History Key Tests and Signs Associated Signs Differential Movement

System Dx Expected Outcome

Associated Conditions:

• Stroke (mild)

• Multiple Sclerosis

(remitting)

• Parkinson’s Disease

(mild)

• Generalized debilitation

• Multi-sensory

gait/balance disturbance

• s/p LE surgery

• BPPV with postural

instability

Down Syndrome

Intellectual Disability

Prenatal Drug/Alcohol

Exposure

Developmental

Coordination Disorder

Autism Spectrum

Disorder

Prematurity

Developmental Delay

Fragile X

Idiopathic Toe Walker

Motor Apraxia

Pt / Caregiver May Report:

• Feels unsteady; possible

fall

• Fear of falling

Clumsiness

Task Analysis: Sit to Stand:

• Altered sequence of

movement components

during execution (usually

insufficient DF of leg over

foot)

• Posterior sway at ankle

and may step at

termination

• Unlikely to require

significant physical

assistance

Step-up:

• Delay/hesitation prior to

swing limb movement

• Multiple starts/stops prior

to swing limb movement

• Loss of balance during

single limb stance

• Loss of balance

posteriorly when returning

swing limb to the floor

Additional Transitional Mvts:

Altered sequence,

instability, and lack of

fluidity when executing

transitional movements

appropriate to age (or

Movement:

• Generally fractionated

movement against gravity

throughout

Muscle Tone:

• Normal or mild

hyperexcitability, mild

hypotonicity or mild

rigidity

• Grades of 0-2 on

modified Ashworth

Sensation:

• Normal or no more than

mild loss of JPS at great

toe or ankle in LE

• Normal or no more than

mild loss of sharp/dull or

numbness in UE

Non-equilibrium Coordination:

• Normal or mild (to

moderate) ataxia with

reciprocal and synergistic

movement

• Normal or mild ataxia with

tests of accuracy

• Force Production Deficit

• Sensory Selection and

Weighting Deficit

• Sensory Detection Deficit

• Dysmetria

• Stable with standing ADL

tasks

• Independent ambulation

in home and community

(at least in familiar

environments)

• Ambulate without device

or with cane at most; may

need an AFO but unlikely

• Ascend/descend stairs

reciprocally

• Gait speed at least 75%

of normal for age

• Coordinated, smooth, UE

movements


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Occasional falls

Delay in fine motor tasks

Overly messy when

eating and dressing

Started walking later than

other children

Awkward compared to

peers

Poor performance in

sports activities

adjusted age)

Gait:

• Variable foot placement or

line of progression or may

be guarded with slow,

small steps

• Assistance for balance

may be needed

Jump, Run, Skip and other advanced motor skills:

Altered sequence,

instability, and/or lack of

fluidity

May need assistance for

balance

Reach and grasp:

• Slowed or awkward

• Difficulty adjusting grip

during transport of objects

• Difficulty controlling force

relative to task demands

Lack of age appropriate

grasp

Postural Control:

• Increased latency in

postural movement

responses and/or

• Inappropriate amplitude of

postural adjustments or

responses

• Increased posterior sway

during stance activities


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TREATMENT PRINCIPLES

GENERAL CONSIDERATIONS

• Understanding the patient’s preferences and goals is a foundational element of all care and always important.

• Interventions designed to increase the patient’s engagement and activation in their care are complimentary to the selected motor/sensory interventions appropriate for any given diagnosis.

• Framing interventions in the context of meaningful tasks may improve transfer of motor behavior to activities.

• An emphasis on aerobic conditioning is important for overall health for all patient diagnoses.

• The patients represented by these diagnoses may be at risk for falls and environmental adaptations to promote safety should be considered.

MOVEMENT PATTERN COORDINATION DEFICIT

• Patients in this category have relatively mild deficits impacting movement capacity, i.e. they have relatively little to no muscle performance deficits, generally fractionated movement, and generally intact sensation. As such, interventions from external literature that are aimed at the following movement characteristics are likely to be appropriate for these individuals:

o increasing limb use and refining movement strategy o improving movement speed and amplitude o improving coordination of anticipatory and reactive postural responses relative to balance demands in all positions and during creeping, cruising,

walking, and running o generating consistency, flexibility, and efficiency of motor behavior during changing environmental demands


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DIAGNOSIS DESCRIPTION: FORCE PRODUCTION DEFICIT The primary movement fault is weakness as illustrated in the performance of tasks and in testing of body structures and functions. The origin of the weakness may be muscle, neuromuscular junction, peripheral nerve, or central nervous system dysfunction. The presentation may be focal (one joint), segmental (generalized to an extremity or body region), or related to fatigue (of skeletal muscle rather than cardiopulmonary capacity).



Associated Conditions: Good potential for Impairment Recovery:

• Generalized debilitation

• Disuse atrophy

• Peripheral nerve contusion

• Guillian Barre Syndrome

• Stroke (mild)

• Brain injury

• Multiple Sclerosis (remitting)

Prematurity Developmental Delay Down Syndrome Fragile X CP (mild) Transverse Myelitis Hypotonia

Poor potential for Impairment Recovery:

• Stroke

• Brain Injury

• Multiple Sclerosis (primary or secondary progressive)

• Chronic Inflammatory Diffuse Polyneuropathy

• Myopathies

• Muscular Dystrophies

• Spinal Cord Injury (low ASIA A or B paraplegia)

• Polio/post-polio syndrome ?

Strength:

• Less than 3+/5 to 4/5 muscle strength throughout a limb or limbs or

• Difficulty moving through full range against gravity or

• Focal weakness at one primary joint or

• Deterioration in range of motion/speed of movement with repetition

Task Analysis: Prone on elbows:

Unable to maintain head at 90 degrees when age appropriate

Pull to sit: Maintains head lag after age appropriate

Floor to stand Exhibits a + Gower’s sign or requires use of UEs via ½ kneel after age appropriate

Sit to Stand:

• Failure during initiation phase typically requiring assistance or accommodation

• Extension of knees before hips during first half of execution

Movement:

• Fractionated if present Muscle Tone:

• Normal or mild hyperexcitability, mild hypotonicity or flaccid, mild rigidity

• Grades 0-2 on the modified Ashworth

Sensation:

• Normal or no more than mild loss of joint position sense at ankle, loss of sharp/dull, or numbness


• In more severe forms may be unable to test due to weakness

• In milder forms, likely to be slow but accurate

Postural Control:

• In early stages of recovery, unable to sit or perhaps stand unsupported; would fall without support

• Movement Pattern Coordination Deficit

• Hypokinesia

Good potential for Impairment Recovery:

• Stable with standing ADL tasks

• Independent ambulation in home and community (at least in familiar environments)

• Ambulate without device or with cane at most (may need AFO)

• Ascend/descend stairs reciprocally; may need railing for balance/support

• Gait speed at least 60-80% of normal for age

• Able to use hand in all functional tasks

• With nervous system problems, may reach a plateau in improvement in strength and notice ongoing difficulties with musculoskeletal fatigue, power, and speed

Poor potential for Impairment Recovery:

• Varies with degree of involvement

• In all but most severe forms, improved independence with functional activities using compensatory movement strategies but may still


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Cerebral Palsy Myelomeningocele Hypotonia


• Increased need for caregiver assistance

• Fatigue History of prematurity Delay in acquisition of motor milestones appropriate for age

Gait:

• May need manual assistance or a device to bear weight and maintain upright

• Deviations are often significant

• In severe forms will be unable to attempt ambulation

Reach and Grasp:

• Difficulty or failure with reach above 60° shoulder flexion and/or with sustaining reach position

• Unable to maintain force for gripping objects especially during transport Unable to bring arms to midline in supine when age appropriate Unable to hold bottle in sitting

Postural Control:

• Unable to stand unsupported or loss of support moment at hip and knee during single limb support

• Limited improvement in performance with practice; may worsen with repeated trials

• In more severe forms may be unable to sit unsupported

require assistance

• Use of wheelchair at least for distances likely; degree of independence with wheelchair mobility relative to involved extremities

• In less severe form, ambulate short distances with device and/or bracing and/or physical assistance at very slow speeds

• Able to use hand as an assist with activity in less involved forms

• In more severe forms requires 24 hour care


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FORCE PRODUCTION DEFICIT

• The prognosis for remediation of impairments is an important consideration when determining the appropriate intervention for this group and is largely related to the patient’s health condition, time since onset, and/or treatments of their health condition(s).

• For patients with a good potential for recovery of strength: o Resistance training at sufficient intensity (load) is critical. o The external literature often supports varying intensity based on the patient’s health condition—this information should be applied appropriately to

tailor intervention to a specific patient. o Performing resistance training in the context of a task may improve transfer of strength gains to activity. o Be cautious with the degree of limb loading during activity until the patient has built sufficient strength to protect weight bearing joints. o Short-term compensatory movement strategies may be necessary during the strength recovery phase.

• For patients with a poor potential for recovery of strength: o Adaptive and compensatory strategies are the long-term solutions for improvement in activity limitations. o Orthotics, assistive devices, and/or wheeled mobility are considerations for locomotion. o Patient education about the potential for secondary musculoskeletal pain and possible prevention strategies is important.


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DIAGNOSIS DESCRIPTION: FRACTIONATED MOVEMENT DEFICIT The primary movement system problem is the inability to fractionate movement associated with moderate or greater hyperexcitability. May describe the upper or lower extremity or both. Always associated with central neurological deficit.




• Stroke

• Brain Injury/hypoxia

• Spinal Cord Injury (ASIA C or D)

• Multiple Sclerosis Intraventricular Hemorrhage (IVH)

Periventricular Luekomalacia (PVL)

Brain Tumor Meningitis CP/static encephalopathy

Pt / Caregivers May Report:

• Difficulty with mobility, falls, slow walking, poor use of upper extremity

• Stiffness of the limbs and/or pain

Complicated perinatal history, ie documented PVL, IVH, hypoxic ischemic event

Movement:

• Unable to fractionate movement

• Slow; unable to make rapid reversals in movement

• Unable to generate force rapidly

Muscle Tone:

• Moderate or greater hyperexcitability

• Grade 3 or 4 on the modified Ashworth

Reflex Testing:

• May exhibit +ATNR, +STNR

Task Analysis:

• Consistent non-fractionated movement pattern across multiple tasks

Task Analysis: Pull to sit:

Neck hyperextension with shoulder elevation

May exhibit LE extension, adduction, and hip medial rotation (LE extensor pattern)

Prone on elbows:

Neck hyperextension with shoulder elevation

Floor to stand:

Pulls up with UEs with LEs extended; unable to fractionate or dissociate LE movements

Sit to Stand:

• Stiffness of involved limbs

• Slow

• No dissociation of movement at one joint from movement at another

• May see associated reactions with increased effort

• In forms with less anti-gravity movement, unable to stand

Creeping:

May exhibit bunny hopping or commando


• Related to degree of antigravity movement

• In forms with more antigravity movement, stability in sitting and with reaching; ambulation in home and community with significant deviations and significant reduction in speed with or without a cane; ascend/descend stairs step-to with or without a railing

• In forms with 4 limb involvement wheelchair for locomotion (probably electric)

• Able to use UE as “assist” with ADL


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crawling rather than assuming a 4-point position

Gait:

• Compensatory movement strategy of hip hiking, vaulting, or circumduction to initiate swing of involved extremities

• Stiffness of hip/knee flexion during swing

• Scissoring

• “toe walking” or “equinus gait”

• Hip and knee often flexed during stance of involved extremities

• Likely to require AFO to control foot position for weight bearing

• Likely to require assistive device at least early in course

• In forms with less anti-gravity movement, unable to stand

Reach and Grasp:

• Able to reach in very limited range(< 60-90°)

• Hand closure with minimal relaxation or minimal opening

• Finger flexion associated with wrist flexion and pronation

Postural Control:

• In forms with more antigravity movement,


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able to sit unsupported but asymmetrically or with posterior pelvic tilt (sacral sitting) and hip medial rotation with compensatory thoracic flexion

• Stability may improve with practice but symmetry will not








FRACTIONATED MOVEMENT DEFICIT

• Improvement in activity limitations is achieved through compensatory movement strategies and adaptive strategies (particularly in the UE). Patients are unlikely to be responsive to interventions designed to “normalize” movement.

• Provide appropriate orthotic support to the foot, ankle, and knee to promote safe and consistent stepping.

• Practice to maximize speed and endurance of movement, recognizing that some deficits in these areas are likely to remain.

• Practice to maximize the timing and amplitude of postural responses (including stepping strategies), recognizing that some deficits in these areas are likely to remain.

• Providing a maintenance program to maintain pain-free joint range of motion in the upper and lower extremity is important.

• Patient education about the potential for secondary musculoskeletal pain and possible prevention strategies is important.


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DIAGNOSIS DESCRIPTION: POSTURAL VERTICAL DEFICIT The primary movement system problem is inaccurate perception of vertical orientation resulting in postural control deficits and the tendency to resist correction of center of mass alignment. The condition may be in the medial/lateral or anterior/posterior direction.




• Stroke (med/lat)

• Brain Injury (med/lat)

• Psychomotor

Disadaptation Syndrome

(ant/post)

• Backward Disequilibrium

(ant/post)

Rhett’s Syndrome


• Backward falls

• Fear of falling

• Visual or visual

perceptual deficits

Postural Control:

• Shifts center of mass

beyond limits of stability to

side or backward without

weight acceptance

• Resists correction or

becomes

fearful/agitated when

center of mass

alignment is corrected

• Deficits may present in

sitting, standing, or with

walking depending on

severity

Perception:

• Sensation of “falling”

when shifted toward

correct vertical alignment

• May have disregard or

neglect of involved

extremities

Movement:

• Presentation is variable

although movement in at

least 60% of muscle

groups in the LE is

expected

• Movement may not be

fractionated

Motor Planning:

• May have difficulty

planning or organizing

movement patterns into

purposeful actions

Sensation:

• Likely to be impaired to

light touch and joint

position sense (med/lat)

Behavior:

• Impulsive

• Poor judgment

• Fear avoidance behavior

such as clutching or

grabbing with UE and

shifting base of support

• Sensory Selection and

Weighting Deficit


• Fractionated Movement

Deficit


• Related to severity of

behavioral/cognitive

deficits, motor function,

and natural recovery of

perceptual deficit

• Assisted ambulation with

uncomplicated

devices such as wheeled

walker or along a wall

• Many are non-ambulatory

and require significant

assistance with transfers


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POSTURAL VERTICAL DEFICIT

• External literature related to the management of individuals with contraversive pushing behavior applies to patients with the medial-lateral form of this condition. These principles include:

o Relax overactive uninvolved side o Teach controlled active movement o Teach awareness of involved side o Increase weight shift toward uninvolved side o Maintain center of mass in midline during transitions from one posture to another

• External literature related to the management of individuals with backward disequilibrium applies to patients with the anterior-posterior form of this condition. These principles include:

o Relax postural extensor muscles o Teach controlled active movement o Teach awareness of true vertical o Maintain center of mass over base of support in sitting during limb movements o Maintain center of mass over base of support during transitions from one posture to another o Maintain forward progression with walking


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DIAGNOSIS DESCRIPTION: SENSORY SELECTION AND WEIGHTING DEFICIT The primary movement system problem is difficulty with postural stability and/or orientation as a result of decreased ability to screen for and attend to appropriate sensory inputs. Patients may demonstrate sensory seeking or sensory avoidance behaviors. Patients in this diagnosis have sensory processing issues as their primary movement system problem which may impact steady state, anticipatory, and reactive postural control as well as limb movement (especially in children).




• Stroke

• Brain Injury

• Unilateral vestibular hypofunction

• Bilateral vestibular hypofunction

• BPPV with postural instability

Sensory Integration Autism Spectrum Disorder

Pervasive Developmental Disorder

Rhett’s Syndrome Asperger’s Syndrome Sensory Processing Disorder


• Loss of balance or feelings of instability when walking in crowds, on/off escalators, visually complex environments, or compliant surfaces such as thick carpeting or sand

• Symptoms when riding in a car, when walking along patterned walkways, or in visually stimulating environments

Repetitive non-purposeful movements

Impaired social behaviors

Task Analysis: Quiet sitting/standing:

• Increased sway or other instability with head movement and/or changes in sensory conditions such as eyes closed or use of compliant surface

Gait:

• Deviation in line of progression to one or both sides

• Instability with head turning

Turning Around:

• Loss of balance or increased ankle or hip sway at termination

• Worse with faster movement

• Dizzy Postural Control:

• Able to stand unsupported but may require practice

• Increased sway or instability with eyes closed or other change in sensory conditions

• May demonstrate hip strategy during static standing tasks

• Postural responses may be delayed or exaggerated; exaggerated

Movement:

• Fractionated Non-equilibrium Coordination:

• Intact Head Thrust Test:

• May be positive Dynamic Visual Acuity:

• May be positive Sensation/Sensory Behavior:

May show signs of gaze aversion

May show signs of self stimulation behaviors such as rocking, spinning and banging


• Postural Vertical Deficit


• Ambulation with straight line of progression and no loss of balance in all regular sensory environments

• May have decreased tolerance to prolonged exposure to highly visually stimulating environments

• May have symptoms with head/body turning tasks with mild to no instability


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Aversion to a variety of sensory stimuli

Delayed acquisition of motor milestones appropriate for age

responses lead to postural instability

• May improve with modification of sensory needs and practice, instruction and encouragement

Dizziness:

• Dizziness associated with head turning

Sensory Sensitivity:

• Symptoms with smooth pursuit and/or saccadic eye movement or in situations with visual motion cues.

• Symptoms with transitions from one sensory environment to another


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SENSORY SELECTION AND WEIGHTING DEFICIT

• The overarching goal is optimal, purposeful movement and postural stability in both simple and complex sensory environments.

• External evidence related to improving postural stability and orientation through the manipulation of the sensory environment are appropriate for this diagnosis.

• Progressive exposure to and movement practice in increasingly complex sensory environments is important for improving postural orientation and management of symptoms in adults.

• Children present with varying sensory profiles and sensory stimuli should be adapted to promote optimized motor performance. Focus on limb movement and postural stability and orientation through the manipulation of the sensory environment. Ongoing adjustment to the sensory environment should be made in order to achieve the overarching goal.


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DIAGNOSIS DESCRIPTION: SENSORY DETECTION DEFICIT The primary movement dysfunction is the inability to execute intersegmental movement due to lack of joint position sense or multi-sensory failure affecting joint position sense, vision, and/or the vestibular system. May involve UE, LE, or both. Patients in this diagnosis have loss of joint position sense as their primary movement system problem.




• Stroke

• Brain Injury

• Incomplete spinal cord injury (ASIA C or D)

• Peripheral polyneuropathy

• Multi-system failure

• Bilateral vestibular loss Pt / Caregiver May Report:

• Unable to stand still

• Falls Exposure to vincristine for childhood cancer

Child trips while walking; unable to run

Can hear child walking due to foot slap

Sensation:

• Moderate to severe impairment of joint position sense

• Mild or greater loss of joint position sense and touch sensation of one or both UEs

Task Analysis: Sit to Stand:

• Failure during the execution phase with hyperextension of the knee(s) before hip extension, instability of the ankle, and/or stepping to alter base of support

Gait:

• Variation in foot placement, hyperextension of the knee during stance, loss of eccentric ankle control (foot slap during gait)

• Requires assistance

• Some improvement with visual guidance if possible

Reach and Grasp:

• Slow and dyscoordinated

• Improves with visual guidance

Movement:

• Poor timing and coordination of limb movement during tasks


• Slow and clumsy

• Some improvement with visual guidance


• Postural Vertical Deficit

• Sensory Selection and Weighting Deficit


• Ambulation with assistive device

• Increased difficulty in conditions of poor lighting and uneven surfaces

• Limited standing stability for functional tasks

• Lack of hand function without visual guidance


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Postural Control:

• Unable to stand unsupported or difficult

• If able to stand unsupported, significant increase in sway or LOB with eyes closed

• Limited improvement in performance with practice








SENSORY DETECTION DEFICIT

• Provide compensatory and adaptive strategies to compensate for the lost sensory information including, but not limited to: orthotic support, use of visual information, reducing movement speed, the use of hands or a cane as a location guide, and the use of assistive devices for walking.

• Specific strategies may be specific to the extent, type, and/or combination of sensory loss.

• Absent sensory information, particularly in joint position sense, may impair motor learning with postural control tasks and as such patients are not likely to respond to practice of balance tasks in varying sensory conditions.


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DIAGNOSIS DESCRIPTION: DYSMETRIA The primary movement system problem is related to the inability to grade forces appropriately for the distance and speed aspects of a task. Rapid movements are generally too large, and slow movements are generally too small for their intended purpose. Performance deteriorates with faster speeds. May involve UE, LE, or both. Generally associated with cerebellar dysfunction.

Subjective/Medical History Key Tests and Signs Associated Signs Differential Movement Dx Expected Outcome


• Stroke

• Brain Injury

• Cerebellar degeneration

• Multiple Sclerosis

Cerebral Palsy Agenesis of the Corpus Collusum

Fragile X Ataxia


• Falls

• Messy when eating or other fine motor tasks

Is clumsy Has frequent injuries

Non-Equilibrium Coordination:

• Difficulty directing movement toward a target resulting in undershooting or overshooting

• Abnormal rhythm and incoordination during rapidly alternating movements

• No change with practice Movement:

• Able to move against gravity

• Lack of fluidity Task Analysis:

• Overshooting or undershooting of targets; repeated stepping and wide base of support in standing tasks; excessive sway at trunk

Sit to Stand:

• Wide base of support; may see excessive sway at trunk; uses UE to stabilize

Reach and Grasp:

• Unable to reach to targets

• Difficulty grasping small or light objects

Postural Control:

• Generally able to sit with UE support; may be able to sit unsupported

• Unable to stand unsupported or stands with wide base of support and high guard

Task Analysis: Gait:

• Variable foot placement in step length and step width

• Generally requires assistance



• Ambulation in home with device and perhaps bracing

• May require wheelchair in community

• Limited independence with UE ADL tasks with adaptive equipment


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DYSMETRIA

• External evidence related to the management of individuals with cerebellar disorders is likely to be appropriate for this diagnosis.

• Strategies to simplify movement so that one segment moves at a time or moving slowly may be useful.

• Fixed ankle orthotics may be a strategy for simplifying walking.

• Assistive devices are likely to be needed for walking.

• Weighted vests may provide additional stability.

• Supporting the elbow and/or forearm may simplify manipulation tasks.

• Adaptive devices for UE tasks may be needed.


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DIAGNOSIS DESCRIPTION: HYPOKINESIA The primary movement system problem is related to slowness in initiating and executing movement. May be associated with stopping of ongoing movement.

Subjective/Medical History Key Tests and Signs Associated Signs Differential Movement Dx Expected Outcome


• Stroke

• Seizure Disorder

• Parkinson’s Disease

• Extra-pyramidal syndromes

• Parkinsonism or Parkinson’s Plus

• Psychomotor Disadaptation Syndrome

• Dementia IVH Seizure Disorder

Movement:

• Able to move against gravity

• Arrests in ongoing movement during functional tasks

Postural Control:

• Delayed timing of postural adjustments or absent postural adjustments in response to or in preparation of a movement

• Loss of balance posteriorly

• Inability to use appropriate postural control strategy in context

Task Analysis: Sit to Stand or Floor to Stand:

• Slow or lack of preparatory movement

• Assistance with initiation

• Loss of balance on termination

• Unable to shift center of mass forward

Gait:

• Difficulty initiating ambulation

• Often requires assistance due to arrests in ongoing movement

• Unable to regulate step length

Muscle Tone:

• Rigid with passive movement of U/LE and/or trunk


• Undershoots movement when aimed toward a target

• Slowness or arrests in reciprocal movement

Reflexes:

Delayed integration of early/primitive reflexes



• In milder forms may see improvement in step length and consistency of foot placement

• Improvement in use of adaptive strategies in more severe forms

• Likely to fall


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HYPOKINESIA

• Interventions from external literature that are aimed at the following movement characteristics are likely to be appropriate for these individuals: o improving movement speed and amplitude o improving coordination of postural responses relative to balance demands including stepping responses if needed o generating consistent motor behavior during changing environmental demands

• Improvement in activity limitations is achieved through both compensatory and remediated movement strategies

1 Scheets PL et al. What is backward disequilibrium and how do I treat it? A complex case study. JNPT, 2015: in press. 2 Sahrmann et al. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, Inc. St. Louis, MO, 2002. 3 Sahrmann et al. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines. Elsevier Mosby. St. Louis, MO, 2011.

movement system diagnoses neuromuscular conditions · patricia l scheets, pt mhs dpt ncs infinity...

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