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January 27, 2010

Today's Practical Exam

Since it's on my mind, I thought I would talk about today's practical exam. I'm not allowed to give any details about the case or my answer because some of my classmates have not taken the exam yet. But the focus of the exam was to evaluate a patient by video who has an upper motor neuron lesions (an injury to the brain or spinal cord). Strokes, traumatic brain injury, spinal cord injury, Parkinson's disease, multiple sclerosis, etc. all qualify as conditions that we could be tested on.

Restoring motor function in this population depends on an assessment of function. Lower functioning patients may have to be retrained to do the basics, such as rolling over in bed, propping on their elbows, moving onto their hands and knees (quadruped), or bridging. Higher functioning patients may need help with stability while sitting, kneeling, half kneeling, propped standing (plantigrade), independent standing, stepping, or walking.

Lower functioning patients need help with mobility, that is initiating movement or moving from one position to another safely. People who have had a stroke may have difficulty with rolling to one side in bed because they are weak.

The next level of motor function involves stability or static postural control. This involves the ability to keep your center of mass over your base of support while the body is at rest. This description reminds me of the process a child must go through while learning to walk. As we move further away from the ground, sitting to kneeling to standing, maintaining stability becomes more challenging.

Next we develop controlled mobility, or dynamic postural control. This is the ability to stay stable while moving the limbs. This category of function can look like sitting unsupported while doing something with your hands, or it can involve shifting weight to one side in order to reach for something (static/dynamic control).

Function can be progressed even further into the category of skill. Skill involves the ability to perform coordinated movement for the purpose of investigating or interacting with the environment. Motor skill can be broken into three categories: discrete, continuous, or serial. A discrete movement can be as simple as kicking a ball -- there is a start and an end to the movement sequence. Walking would be a continuous movement -- having no recognizable beginning and end. A pianist performs serial movements when they perform a piece of music -- it a series of discrete actions strung together.

When you consider injuries to the brain, whether from trauma or stroke, cognition can be a factor in teaching functional skill. Patients may be confused and only able to follow very simple commands. Depending upon where they are in recovery, they could be agitated and combative, or cooperative, but automatic in their actions, only moving when cued to do so. It is important for the therapist to recognize when they have worked the patient to the level of fatigue. This usually results in reversion of cognitive status, such a irritability, seemingly uncooperative behavior, a delay in initiating movement, or just poor performance.

While functional performance can be described in general, every patient will behave differently. This can be for many reasons including level of function and skill before the injury, to where the injury is located in the brain, and how severe the injury is. A patient may not be able to roll over in bed, but stand them up and they may be able to walk across the room! Walking may be an automatic movement for this patient whereas rolling over in bed is a sequence of movements they have to plan to accomplish. Never doubt that the mind is an amazing thing and the potential for recovery may be unlimited.


Posted by linda at January 27, 2010 3:38 PM

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