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  1. 1. CO-ORDINATION Prepared by Ahmed Shawky Ali
  2. 2. Recommended texts • S.B. O’sullivan, T.J. Schmitz, Physical Rehabilitation: Assessment and Treatment, F.A. Davis Company. 3rd ed. 2012. • R.L. Braddom, Physical Medicine & Rehabilitation, W.B. Saunders Company. 1st ed. 1996.
  3. 3. Introduction • Coordination: “ability to execute smooth, accurate, controlled movements.”
  4. 4. • Motor coordination is the combination of body movements created with the kinematic (such as spatial direction) and kinetic (force) parameters that result in intended actions. Motor coordination is achieved when subsequent parts of the same movement, or the movements of several limbs or body parts are combined in a manner that is well timed, smooth, and efficient with respect to the intended goal. This involves the integration of proprioceptive information detailing the position and movement of the musculoskeletal system with the neural process in the brain and spinal cord which control, plan, and relay motor commands. The cerebellum plays a critical role in this neural control of movement and damage to this part of the brain or its connecting structures and pathways results in impairment of coordinaton, known as ataxia(Tresch, MC.; Jarc, A. (Dec 2009)
  5. 5. • Coordinated movements are characterized by: 1. “Appropriate speed, distance, direction, rhythm, and muscle tension.” 2. “Appropriate synergist influences.” 3. “Easy reversal between opposing muscle groups.” 4. “Proximal fixation to allow distal motion or maintenance of a posture.”
  6. 6. • Incoordination (coordination deficit): “abnormal motor function characterized by awkward, extraneous, uneven, or inaccurate movements.” • Coordination deficits are often related to, and indicative of, CNS involvement including cerebellum, basal ganglia, and dorsal columns.
  7. 7. • Examples of diagnoses that typically demonstrate coordination deficits: 1. Multiple sclerosis. 2. Cerebral palsy. 3. Cerebellar tumors. 4. Parkinsonism: elderly; degeneration of basal ganglia; bradykinesia, rigidity, resting tremor, and impairments of posture, balance, and gait.
  8. 8. 5. Huntington’s disease: inherited; adults; fatal; degeneration of basal ganglia and cerebral cortex; dementia, chorea, and disturbances of tone, posture, and gait. 6. Sydenham’s chorea: infectious; children; self-limiting; rheumatic fever; chorea, disturbances of balance and gait, and impairments of speech and memory.
  9. 9. Cerebellum  Primary functions: 1. Coordination of motor activity. 2. Equilibrium. 3. Muscle tone.  Lesions produce: 1. Incoordination. 2. Impaired balance. 3. Decreased muscle tone.
  10. 10. “The cerebellum compares the commands for movement transmitted from the motor cortex with the actual motor performance of the body segment.” “This occurs by a comparison of information received from the cortex with that obtained from peripheral feedback mechanisms.”
  11. 11. If movements deviate from the intended command, the cerebellum sends corrective signals to the cortex.
  12. 12.  Clinical features of cerebellar dysfunction: 1. Hypotonia and hyporeflexia. 2. Dysmetria: • “Disturbance in the ability to judge the distance or range of a movement.” • Hypometria = underestimation. • Hypermetria = overestimation.
  13. 13. 3. Dysdiadochokinesia: • “Impaired ability to perform rapid alternating movements.” 4. Tremor: • “Involuntary oscillatory movement resulting from alternate contractions of opposing muscle groups.” • Intention (kinetic) vs. resting (static) tremors.
  14. 14. 5. Movement decomposition: • “Movement performed in a sequence of component parts rather than as a single, smooth activity.”
  15. 15. 6. Disorders of gait: • Broad base support. • Unsteady, irregular, staggering, and deviated gait pattern. • Slow initiation of forward progression of lower extremity. • Difficulty in slowing down the forward progression of the lower extremity once initiated.
  16. 16. 7. Ataxia: • General term used to describe uncoordinated movement that results from the combined influence of cerebellar dysfunction (especially dysmetria and decomposition of movement) on gait, posture, and patterns of movement.
  17. 17. 8. Dysarthria (scanning speech): • “Disorder of the motor component of speech articulation.” • Speech pattern is slow, slurred, hesitant, with prolonged syllables and inappropriate pauses. • Word selection and grammar remain intact.
  18. 18. 9. Nystagmus. 10.Rebound phenomenon: • “Absence of a check reflex; when resistance to an isometric contraction is suddenly removed, the body segment moves forcibly in the direction in which effort was focused.”
  19. 19. 11.Asthenia: • “Generalized muscle weakness associated with cerebellar lesions.” 12.Difficulty in initiating, stopping, or changing the direction, speed, or force of voluntary movements.
  20. 20. Basal ganglia  Components: 1. Putamen. 2. Caudate nucleus. 3. Globus pallidus. 4. Substantia nigra. 5. Subthalamic nucleus.
  21. 21.  Primary functions: 1. “Initiation and regulation of gross intentional movements.” 2. “Ability to accomplish automatic movements and postural adjustments.” 3. Inhibitory effect on motor cortex and posterior fossa brainstem to maintain normal background muscle tone.”
  22. 22. 4. Cognitive and perceptual functions.”  Lesions produce: 1. Slowness of movement. 2. Involuntary movement. 3. Disturbance of muscle tone. 4. Diminished postural reactions.
  23. 23.  Clinical features of basal ganglia dysfunction: 1. Bradykinesia: • “Abnormally slow movements.” • “Decreased arm swing; slow, shuffling gait; difficulty initiating or changing direction of movement; lack of facial expression; or difficulty stopping a movement once begun.”
  24. 24. 2. Rigidity. 3. Dystonia. 4. Resting tremor.
  25. 25. 5. Akinesia: • “Inability to initiate movement; seen in the late stages of parkinsonism.” • Associated with fixed postures. • “Tremendous amount of mental concentration and effort is required to perform even the simplest motor activity.”
  26. 26. 6. Chorea (choreiform movements): • “Involuntary, rapid, irregular, jerky movements; clinical feature of Huntington’s disease.” 7. Athetosis (athetoid movements): • “Slow, involuntary, writhing, twisting, “wormlike” movements; clinical feature of cerebral palsy.”
  27. 27. 8. Choreoathetosis: • Chorea + athetosis. 9. Hemiballismus: • “Sudden, jerky, forceful, wild, flailing, motions of one side of the body.” • “Results from a lesion of the contralateral subthalamic nucleus.”
  28. 28. Dorsal columns Primary function: • Mediate proprioceptive input from joint and muscle receptors.
  29. 29. Lesions produce: • Coordination and balance deficits that are less characteristic than those produced by other CNS lesions due to compensation from visual feedback. Thus, these deficits are exaggerated in dark or with closed eyes.
  30. 30.  Clinical features of dorsal columns dysfunction: 1. Dysmetria: visual feedback reduces the manifestations of dysmetria. 2. Slowed movements: because visually guided movements are more accurate when the speed is reduced.
  31. 31. 3. Disorders of gait: • Wide base. • Sway. • Uneven step length. • Excessive lateral displacement.
  32. 32. • Watching feet during ambulation. • “Advancing leg may be lifted too high and then dropped abruptly with an audible impact.”
  33. 33. Changes in coordinated movement with age 1. Decreased strength. 2. Slowed reaction time. 3. Loss of flexibility. 4. Faulty posture. 5. Impaired balance.
  34. 34. Assessment of coordination • Assessment must be done bilaterally even in unilateral lesion • Assessment must be done in quiet place to avoid distraction • Age and psychological state must be considered
  35. 35. Assessment of coordination contain:  Motor assessment including muscle tone and muscle test  Sensory assessment including superficial and deep sensation  ROM  Orofacial function assessment including facial expression ,lip &jaw closure  Senstivity of face  Coordination of respiration with swallowing and speech
  36. 36.  Coordination assessment including non equilibrium and equilibrium subtypes  Non equilibrium coordination tests  Finger to nose  Finger to finger  Finger to doctor’s finger  Adiadokokinesia  Rebound phenomenon  Buttoning and unbuttoning  Heal to knee  Walking along a strieght line
  37. 37. Coordination tests • Preliminary considerations: 1. Initial observation of functional activities guides the therapist in test selection. 2. Initial assessment of motor and sensory functions improves validity. 3. Apprehension, fear, and fatigue. 4. Lack of reliability. 5. Safety.
  38. 38. • Classifications of coordination tests: 1. Gross vs. fine motor activities. 2. Non-equilibrium vs. equilibrium tests.
  39. 39. • Coordination tests focus on assessment of movement in four areas: 1. “Alternate or reciprocal motion, which tests the ability to reverse movement between opposing muscle groups.” 2. “Movement composition, or synergy, which involves movement control achieved by muscle groups acting together.”
  40. 40. 3. “Movement accuracy, which assesses the ability to gauge or to judge distance and speed of voluntary movement.” 4. “Fixation or limb holding, which tests the ability to hold the position of an individual limb or limb segment.
  41. 41. Recording test results • Arbitrary scale. • Timed tests. • Videotape recording.
  42. 42. Coordination Requires integration of: ◦Motor system ◦Cerebellar system ◦Vestibular system ◦Sensory system
  43. 43. Assessed by: ◦Rapid alternating movements ◦Finger-to-Nose / Heel-to-Knee Test ◦Romberg’s Test ◦Gait
  44. 44. Finger-to-Nose Test Finger-to-nose with moving target Stationary finger-to- nose with eyes closed
  45. 45. Heel to knee test
  46. 46. Rapid Alternating Movements • First with hands • Repeat with feet • Diadochokinesia = ability to perform RAM • Dysdiadochokinesis = slow, irregular, clumsy movements
  47. 47. Romberg’s Test • Station & Stance – Pt stand with feet together – First, eyes open – Then, close eyes – If okay with eyes open, but sways w/ eyes closed = + Romberg – Mainly tests position sense (Vision can compensate for loss of position sense)
  48. 48. Ahmad Alghadir M.S. Ph.D. P.T.
  49. 49. Standardized instruments for coordination assessment 1. Jebsen-Taylor Hand Function Test: • Measures hand function using seven functional activities: writing; stacking; card turning; simulated feeding; picking up small objects; picking up large, lightweight objects; and picking up large, heavy objects.
  50. 50. 2. Minnesota Rate of Manipulation Test: • Assesses hand dexterity in five operations: placing, turning, displacing, one-hand turning and placing, and two- hand turning and placing.
  51. 51. 3. Purdue Peg board Test: • Assesses hand dexterity using a test board, pins, washers, and collars. Subtests include prehension and assembly using right, left, and both hands.
  52. 52. 4. Crawford Small Parts Dexterity Test: • Assesses hand dexterity using a test board, screwdriver, tweezers, pins, screws, and collars.
  53. 53. treatment  Methods of treatment:  PNF technique 1- Rhythmic stabilization to improve proximal stability 2-Reversal tech. to improve ability to alternate movement from agonist and antagonist 3-Approximation to improve proximal fixation
  54. 54.  Tapping and weight bearing increasing stability  Using ankle and wrist weight to decrease tremor  Balance can improved in antigravity position in normal base of support  Postural stability is improved by using antigravity position in the developmental sequence  Frenkel’s exercises improve co ordination
  55. 55. Frenkel’s exercises • Definition : a series of gradual progressive exercises designed to increase coordination Aim : Establishing control of movement by use of any part of sensory mechanism which remain intact as sight & hearing to compensate for the loss of kinethetic sensation
  56. 56. Frenkel’s exercises contain • I-lying --------- • flexion-extension • Abduction – adduction • Each movement will be performed unilaterally fast then slow then interrupted by hold • bilateral performance simultaneusely then alternatively
  57. 57. Frenkel’s exercises contain • Sitting : • 1-Slide heel to reach a mark on the floor • 2-change standing and sit again • Standing : • 1-transfer weight from foot to foot • 2- walking side ways • 3-placing foot on specific marks
  58. 58. Frenkel’s exercises cont • For arms : • Sitting with arm supported on a table and placing hand at specific mark • Try to reach an object • Picking up objects • Put the hand in a ring or hole
  59. 59. ‫ل‬ ‫الحمد‬