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The Physiotherapist's Pocket Book is an exceptionally comprehensive, handy reference that is ideal for clinicians in their daily practice and students on core. download The Physiotherapist's Pocketbook - 2nd Edition. Print Book & E-Book. ISBN , Jonathan Kenyon’s books. The Physiotherapist's Pocket Book: Essential Facts At Your Fingertips. The Physiotherapist's Pocketbook E-Book: Essential Facts at Your Fingertips (Physiotherapy Pocketbooks).
Participation of patients and carers enables the planning, development, delivery and evaluation of services that are effective and responsive to diverse needs Commission for Health Improvement The opinions and ideas of patients and carers should be taken into account in order to optimize rehabilitation and support. Enabling patients and carers to be actively involved in these activities is a core skill for neurological physiotherapists and the rehabilitation team. Although this chapter uses examples from stroke rehabilitation, the general principles and best practice described apply to all patients and carers regardless of the underlying condition. These frameworks suggest that different types of involvement are appropriate to different situations, and that one type is not inherently better than another.
Type is categorized according to the impairment: Motor impairments of weakness and spasticity, with bone and joint deformities, spinal curvatures, and pain. Hemiplegia — one side of the body primarily involved. Diplegia — lower half of the body involved. Quadriplegia — entire body involved. Cognitive impairment is common. Associated complications include: The neurological lesion will slow the development of movement patterns often resulting in adoption of asymmetrical postures and limited ranges of movement.
Underdevelopment of affected body parts may occur. Muscle and bone will develop differently resulting in muscle imbalances, and deformities of joints and bones. Different distributions and types of CP result in different patterns of deformity.
Physical management e. Botulinum toxin may be used to reduce increased tone in selected muscles, to establish new motor patterns and reduce contractures. The effects last for several months. Time course Varies according to severity. Lifestyle and opportunities have improved and many adults live independent, supported, lives. Spina bifida A neural tube defect NTD in which the neural tube fails to fuse somewhere along its length in the spine.
Pathology Types of spinal lesion: Meningocele — no neural tissue outside the vertebral canal. Myelomeningocele — neural tissue and nerve roots may be outside the vertebral canal. Spinal curvature may be congenital or occur during development. Some problems are caused by structural neurological abnormalities during brain development: Physical management aims to promote sensorimotor development within the limits of the neurological constraints, and to achieve as much functional independence as possible through: Most common deformities are: Growth spurt in adolescence may accelerate progression of spinal deformity.
Many adults live independently. Mac Keith Press, Oxford. Baer G, Durward B Stroke. Stokes M ed Physical management in neurological rehabilitation, 2nd edn.
Elsevier, London, pp 75— Belderbos R Oxford specialist handbook in paediatric neurology. Oxford University Press, Oxford. Bromley I Tetraplegia and paraplegia, 6th edn. London, Churchill Livingstone. Campbell M Acquired brain injury: Elsevier, London, pp — Warlow C ed The Lancet handbook of treatment in neurology. Elsevier, London, pp 89— Costello K, Harris C Differential diagnosis and management of fatigue in multiple sclerosis: Journal of Neuroscience Nursing Spinal Cord 38 4: Stokes M ed Physical management in neurological rehabilitation.
Physiotherapy Cambridge University Press. Royal College of Physicians, London. Motor neurone disease. Paddison S, Middleton F Spinal cord injury. Pountney T, Green E The cerebral palsies and motor learning. Journal of Bone and Joint Surgery Br Quinlivan R, Thompson N Disorders of muscle and post-polio syndrome. Reviews in Neurological Diseases 3 4: Elsevier, London.
Thompson N, Quinlivan R Muscle disorders of childhood onset. Warlow C The Lancet handbook of treatment in neurology. Accessed from: Furthermore, since neurological conditions usually result in impairments that take time to resolve, common secondary impairments such as contracture, shoulder subluxation, and swelling arise as adaptations to the primary impairments.
Maintaining balance on any base of support is a complex functional motor goal, and its loss is neither an impairment nor an activity limitation. In neurological conditions, it is usually the result of various impairments e. The only situation, in which loss of balance may be thought of as a primary impairment, is when balance is affected due to a lesion of the vestibular system. This chapter examines the more common motor impairments that arise from neurological conditions and offers some general suggestions for training interventions; other chapters see Chapters 13—16 cover non-motor impairments.
See Chapter 6 for an overview of common conditions. See Chapter 9 for assessment of impairments and activity limitations. Weakness is the only motor 74 Common motor impairments and their impact on activity Box 7. However, the mechanism is different between the two types of lesion see Box 7. Weakness is a major contributor to persistent activity limitations Canning et al ; Morris et al See characteristics in Box 7.
See Box 7. Loss of dexterity and ataxia We consider loss of dexterity to be synonymous with incoordination, loss of selective movement or lack of motor control. Primary motor impairments 77 78 Common motor impairments and their impact on activity 7 Box 7. However, these two terms are commonly used synonymously to describe both reduced velocity and amplitude of movement.
Bradykinesia and akinesia are seen in lesions of the Primary motor impairments 79 Box 7. The most common impairments of tone are presented in Box 7. Spasticity is often used interchangeably with hypertonus; this is incorrect and confusing.
It would appear that the major contribution to movement disability after stroke is the result of the negative impairments, e. Evidence for reducing spasticity is presented in Table 7.
Where spasticity is mild, intervention should focus on improving activity. Where spasticity is severe, intervention should focus on making the patient more comfortable see Box 7. Box 7.
When severe, intention, action and postural tremors can impact heavily on activity Bain et al Interventions to decrease tremor are presented in Box 7. Dyskinesia The most common presentations of dyskinesia are tremor, chorea and dystonia Box 7. Dyskinesia is an umbrella term for involuntary movements of whatever Primary motor impairments 83 Box 7. The relationship to activity limitations is variable.
Dyskinesia may be primary e. Interventions are unlikely to prevent or permanently reduce dyskinesias see Box 7. If severe disabling dyskinesia persists with optimal medication and 7 Box 7. Although the implication is that secondary impairments should be preventable; the fact that their incidence is still so high means that they are not very easy to prevent. There are neural, musculoskeletal and environmental contributors such as: Secondary musculoskeletal impairments 85 Contracture Contracture is a clinical term meaning a decrease in passive range of motion ROM at a joint.
It may be the result of loss of length in muscle s or periarticular connective tissues cartilage, capsule, and ligament with increased stiffness in these structures. All neurological conditions which involve muscle weakness and spasticity are prone to developing contracture. The most detrimental effect on activity when muscles shorten and stiffen tend to be in those muscles where the full range is needed in everyday tasks, e.
Evidence for interventions to decrease contracture is presented in Table 7. Subluxation of the shoulder Subluxation is a partial dislocation of the head of the humerus in the glenoid fossa; it is more associated with weakness than pain Joynt There is very little evidence to suggest that once the shoulder is subluxed that it can return to normal.
Furthermore, the shoulder cannot move normally when it is subluxed. Interventions to prevent subluxation are included in Box 7. Any neurological condition, acute, chronic or degenerative, that is severe enough to effectively immobilize the person in an upright but seated position with both the upper and lower limbs dependent, will exhibit swelling of the extremities.
The main causes of swelling are dependency of the limbs as a result of early resumption of upright position, and lack of muscle pump due to severe weakness. The major contribution to movement disability after stroke is the result of the negative impairments e. Brain Archives of Physical Medicine and Rehabilitation Physiotherapy Canada Movement Disorders American College of Sports Medicine Progression models in resistance training for healthy adults.
Position Stand. Medicine and Science in Sports and Exercise Journal of Neurology, Neurosurgery and Psychiatry Barclay-Goddard R, Stevenson T et al Force platform feedback for standing balance training after stroke. Cochrane Database of Systematic Reviews 4: Journal of Neurophysics Ben M, Harvey L, Denis S et al Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries?
Bernstein NA On dexterity and its development. A new book by Bernstein: Journal of Motor Behavior Experimental Brain Research American Journal of Physical Medicine and Rehabilitation Burke D Spasticity as an adaptation to pyramidal tract injury. Advances in Neurology Journal of Neurological Sciences Chapman CE, Wiesendanger M Recovery of activity following unilateral lesions of the bulbar pyramid in the monkey.
Electroencephalography and Clinical Neurophysiology A randomized controlled trial. Journal of the Neurological Sciences Scandinavian Journal of Rehabilitation Medicine Faghri PD, Rodgers MM The effects of activity and neuromuscular stimulationaugmented physical therapy program in the recovery of hemiplegic arm in stroke patients. Clinical Kinesiology Hallett M, Khoshbin S A physiological mechanism of bradykinesia.
Harvey LA, Byak AJ, Ostrovskaya M et al Randomised trial of the effects of four weeks of daily stretch on extensibility of hamstring muscles in people with spinal cord injuries. Jones L, Lewis Y, Harrison J, Wiles CM The effectiveness of occupational therapy and physiotherapy in multiple sclerosis patients with ataxia of the upper limb and trunk.
Joynt RL The source of shoulder pain in hemiplegia. Physiotherapy Theory and Practice New York, McGraw-Hill. Parkinsonism and Related Disorders Lance JW Symposium synopsis. Feldman RG et al eds Spasticity: Miami, Symposia Specialists, pp — A systematic review and methodologic critique of published research.
Levin MF Interjoint coordination during pointing movements is disrupted in spastic hemiparesis. Stereotactic and Functional Neurosurgery American Journal of Occupational Therapy Michaelsen SM, Levin MF Short-term effects of practice with trunk restraint on reaching movements in patients with chronic stroke: Neurology Physical Therapy Morgan MH, Hewer RL, Cooper R Application of an objective method of assessing intention tremor — further study on the use of weights to reduce intention tremor.
Journal of Neurology Neurosurgery and Psychiatry Morris ME, Iansek R Effects of strategy training compared to exercises for gait rehabilitation in Parkinson disease: Mortenson PA, Eng JJ The use of casts in the management of joint mobility and hypertonia following brain injury in adults: Current Opinion in Neurology 9: NeuroRehabilitation Pollock A, Baer G, Pomeroy V, Langhorne P Physiotherapy treatment approaches for the recovery of postural control and lower limb activity following stroke.
Cochrane Database Systematic Review 2: Ponichtera-Mulcare JA Exercise and multiple sclerosis. Clinical Rehabilitation 8: Ruhland JL, Shields RK The effects of a home exercise program on impairment and health-related quality of life in persons with chronic peripheral neuropathies. Annals of Neurology 2: Schleenbaker RE, Mainous AG Electromyographic biofeedback for neuromuscular reeducation in the hemiplegic stroke patient: Sethi KD Tremor.
Current Opinion in Neurology Neurology, Neurosurgery and Psychiatry Turton AJ, Britton E A pilot randomized controlled trial of a daily muscle stretch regime to prevent contractures in the arm after stroke.
Verplancke D, Snape S, Salisbury CF et al A randomized controlled trial of botulinum toxin on lower limb spasticity following acute acquired severe brain injury.
Physiotherapists in neurology base their assumptions about intervention on different philosophical perspectives, which determine how patients are assessed and treated Lennon Therapists need to incorporate a wide range of strategies that are supported by the current evidence base into their treatment programmes regardless of their philosophical origin Pollock et al Movement re-education and the practice of functional activity are two essential components of neurological physiotherapy see Figure 8.
Movement re-education Functional task practice 8 Figure 8. Therapists use a common assessment process across neurological conditions supplemented by standardized measures with published reliability and validity Chapter Final elements within the assessment form, the treatment strategies and outcome tools selected, will vary according to the aims of intervention and other management priorities see Chapter 10 for physiotherapy interventions at different stages of care.
Maintenance of function is just as important as recovery, and should be viewed as a positive achievement. There is also some evidence to suggest that disease progression may be modulated with physiotherapy Heesen et al Adaptation compensation is another important issue in neurological physiotherapy.
It can be viewed as both a negative and a positive contributor to movement dysfunction following brain damage. Therapists focus on promoting compensatory strategies that are necessary for function and discouraging those that may be detrimental to the patient; e. The initiation of compensatory strategies into intervention may depend on the health care system as much as on philosophical perspective. Different philosophical approaches treat restoration of function with varying degrees of actual functional task practice; e.
It is important to remember that for the patient to regain a functional arm and hand, you must practise reach and grasp activities Winstein et al The key message is that interventions should always focus on the function and goals of the individual, and not simply be aimed at improving impairments without carry over into functional activity Edwards , p.
Recovery is usually emphasized in a lesion like stroke, but progressive diseases usually require compensation especially if disease progression is rapid, i. However, there are always exceptions to this rule so understanding the nature of the pathology is essential to determine which aims [recovery vs adaptation compensation ] should be emphasized by the physiotherapist.
For example, in the complete spinal cord injured patient compensation needs to be emphasized, as recovery is not an option. Physiotherapy in this setting normally includes prevention of secondary complications from immobility Box 8.
As predictors of recovery vary according to the neurological condition, therapists also need to consider the usual patterns of recovery time windows for each condition, and the type of pathology when making the decision to aim for adaptation rather than recovery in their interventions.
If the patient is being discharged home quickly, then the priority may be interventions which teach compensations for a safe discharge Rundek et al Service delivery issues will also affect the aims of physiotherapy management. The variation in time window is large, with the Copenhagen cohort study reporting Another example from patients with incomplete spinal cord injury suggests a time window for rehabilitation focusing on recovery of up to 8 weeks post injury to determine whether they will recover ambulation.
This gives the patient an opportunity to recover optimal movement and function rather than to use compensatory strategies which may hinder movement recovery because the patient is learning how not to use a limb see Chapter 5 on training principles for neuroplastic change. Patient and family preferences Collaborative communication and involvement of patients and caregivers in deciding on treatment priorities, and setting their own rehabilitation goals, leads to improvements in self care and satisfaction with services see Chapters 2 and 3.
Negotiating with patients and carers when devising the treatment plan will help the therapist to decide whether to aim for recovery or compensation in conjunction with maintenance and prevention. These principles which represent a conceptual framework to guide assessment and treatment in neurological physiotherapy are outlined in Table 8. The therapist always starts by asking what is the activity action level e.
Box 8. These elements are not hierarchical; they all interact together. Always consider starting by practising the chosen activity. When a patient practises a particular task, the therapist should see Table 8. Consider how the patient is able to actively move their CoM with respect to their base of support BOS to target postural control balance. Select the best movement to start with, try minimizing gravity and friction. Consider degrees of freedom single joint and multijoint movement patterns and putting movements into actions for task performance.
Consider the components of the task and the environmental set up to determine how best to modify the task for success. Variables of practice Practice for the purpose of skill acquisition is essential; in general the more time that is spent learning a skill the more performance is improved e.
When looking at the variables that affect practice and learning, therapists often manipulate multiple variables simultaneously without thought to how these variables might interact. Some tips for structuring therapy using these variables are outlined in Table 8. Abnormal tone Should physiotherapists treat hypertonus or hypotonus see Chapter 7?
The bottom line is if abnormal tone is exacerbating patient problems, hindering function and leading to complications; it should be treated NCGS Amount intensity or dose — Kwakkel Frequency number of repetitions.
Duration number of minutes per session. Variety alter regulatory features — Gentile e. Choosing the practice schedule depends on a number of patient centred issues such as experience, age, memory, and task. All or some of the time? An adjunct to physical practice, it is not better than physical practice Braun et al Associated reactions Do we view associated movements during the execution of a motor task as abnormal or just part of the learning process?
However, proponents of the Bobath Concept believe these associated reactions are a sign that the activity that the patient is practising requires too much effort, and would voice concerns that these stereotypical patterns will become ingrained and prevent further recovery. Whatever the preferred explanation, therapists would agree that associated reactions exist Edwards , pp.
They tend to manifest themselves when patients perform tasks that are effortful and new. Therapy intervention will vary according to treatment philosophy. In this case the patients will require either hands-on assistance from therapists or support from assistive technologies, e. With regard to return of upper limb recovery, most large randomized controlled trials agree that patients need to have a minimum level of residual movement to demonstrate functional improvement Van Peppen et al This means that therapists will need to use both impairment- and function-focused strategies depending on the patient.
Therapists must remember that therapeutic handling is only one of many strategies, which can help elicit return of movement. Therapeutic handling is a form of manual feedback. Therapists also need to consider that allowing patients to make errors can be a valuable training strategy.
Whenever possible a task-oriented training approach should be adopted [tasks to improve ambulation may be either task related e. Stroke 35 4: Butterworth Heinemann, London. Dean C, Shepherd RB Task-related training improves performance of seated reaching tasks after stroke. Edwards S An analysis of normal movement as the basis for the development of treatment techniques. Edwards S ed Neurological physiotherapy.
Churchill Livingstone, London. Gentile AM Skill acquisition: Carr J, Shepherd R eds Movement science foundations for physical therapy in rehabilitation, 2nd edn. Aspen Publishers, Maryland. Expert Reviews in Neurotherapeutics 6 3: Movement Disorders 22 4: Kwakkel G Impact of intensity of practice after stroke: Disability and Rehabilitation Laguna PL The effect of model observation versus physical practice during motor skill acquisition and performance.
Journal of Human Movement Studies Lennon S The theoretical basis of neurological physiotherapy. Elsevier Mosby, London, pp — Elsevier, Oxford, pp — Mayston M Problem solving in neurological physiotherapy — setting the scene.
Churchill Livingstone, London, pp 3— Multiple Sclerosis Clinical Guideline 8. London, National Institute for Clinical Excellence. Pollock A, Baer G, Pomeroy V, Langhorne P Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke.
Cochrane Database of Systematic Reviews, Issue 1: Physiotherapy 89 Physical Therapy 84 7: Neurology 55 8: Routledge, London. Winstein CJ Designing practice for motor learning: Lister MJ ed Contemporary management of motor control problems: Foundation for Physical Therapy, Alexandria, Virginia.
Research Quarterly for Exercise and Sport 64 4: This chapter presents an overview of the components of assessment that lead to goal setting and intervention planning.
Further key information to guide treatment of impairments, activity limitations and participation restrictions is provided in Chapter The medical chart screening provides data about past and present medical histories and helps the therapist determine if the patient is medically stable and ready for therapeutic intervention.
Observational Neurological assessment: There are a few simple points to remember before the therapist starts the objective assessment see Box 9. During examination, the therapist should refrain from physically assisting the patient, but may offer verbal cues or demonstration to determine potential for improved performance.
As the patient moves, the therapist analyses the resulting movement patterns in terms of key questions Box 9. Following the assessment of independent voluntary movement, physiotherapists use therapeutic handling techniques to gather Clinical decision making: Are there asymmetries in weight distribution and postural deviations?
See also Chapter 7 on common motor impairments and their impact on activity. Although it is essential to assess range, weakness, and functional performance similar to any other type of assessment, there are several impairments that are unique and important in neurological assessment see Chapter 7; see Table 9.
It is these relevant impairments linked to the appropriate activity limitations that become the focus of goal setting and rehabilitation intervention strategies to improve motor performance. However it is important to remember that interventions should always aim to improve activity and participation; they should focus on the function and goals of the individual, and should never be simply aimed at the improvement of impairments. An example of a neurological assessment form is presented in Table 9.
Normally, during assisted movement, the limb or trunk follows lightly and stays positioned when the touch is released. Resistance to passive movement occurs with increasing tone, especially when the limb is moved quickly. This decrease in exercise endurance is attributed to co-morbidities such as cardiovascular disease or metabolic disease such as diabetes and the effect of general aging.
Additionally, decreased endurance may result from inactivity due to muscle weakness and loss of postural control. A patient case scenario is used to illustrate how the assessment process leads to goal setting and intervention planning see Table 9. Weakness and loss of control in trunk. Impaired lower leg proprioception. Clinical decision making: Hospital number: Date of hospital admission: Tel No: Date of assessment: Date of Onset: If assistance is needed, how much and to what part of body?
Lying to sitting: Sitting to standing: Past medical history: Diabetes mellitus, high blood pressure. Social history: Retired teacher, lives with wife, three grown children who live nearby. Plays golf weekly.
Previous mobility: Active, independent with no limitations. Expressed goals: Return home, regain mobility and participate in recreational activities. General observations: Activity level: Complaints of L shoulder pain when lying on L side for more than 2 minutes. Holds L arm in lap. Takes 6—8 sec to rise to stand with assistance.
Arm movement is slow and jerky. Arm feels heavy, but shoulder follows movement; cannot hold positions when handling withdrawn. Soft oedema noted on volar and dorsal aspect of hand. Activity restrictions Relevant impairments 1. Unable to balance and perform washing and dressing activities in sitting. Unable to move from sitting to standing independently. Weakness in leg, especially hip. Weakness in trunk loss of trunk-limb linked patterns.
Loss of upper body stability. Table 9. Independence in bed mobility; rolling to either side, side lying to sitting. Independence in daily washing and upper body dressing in sitting.
Independence in washing and dressing in standing. Independent sit to stand. Assisted ambulation: P—Plan for the therapy session. Observe how patient moves limbs and trunk when unassisted by therapist.
Use handling to assess movement of limbs and trunk, tone, ROM, muscle strength, balance, sensation. Document with objective measurement tools as appropriate.
Human Movement Science Bernhardt J, Hill K We only treat what it occurs to us to assess: Elsevier, Edinburgh, pp 15— Dewald J, Pope P, Given J, Buchanan T Abnormal muscle coactivation patterns during isometric torque generation at the elbow and shoulder in hemiparetic subjects.
Edwards S ed Neurological physiotherapy: Churchill Livingstone, Edinburgh, pp 35— Freeman JA Assessment, outcome measurement, and goal setting in physiotherapy practice. Churchill Livingstone, Edinburgh, pp 21— Horak F, Anderson M, Esselman P, Lynch K The effect of movement velocity, mass displaced and task certainty on associated postural adjustments made by normal and hemiplegic individuals.
FA Davis, Philadelphia. Lance J Symposium synopsis. Feldman R et al eds Spasticity: Chicago, Year Book Medical Publishers, pp — Churchill Livingstone, New York. Although this chapter uses examples from stroke rehabilitation, the general principles and best practice described apply to all patients and carers regardless of the underlying condition.
These frameworks suggest that different types of involvement are appropriate to different situations, and that one type is not inherently better than another. In a therapist- or service-centred perspective, patients and carers are encouraged to feedback ideas but control lies with the therapist or organization who ultimately decides if, and how the information is used.
In a person-centred perspective, power is shifted away from the therapist or organization to the service user who is directly involved in decision making and planning. It lies at the heart of providing quality services. Such approaches have often helped to make services both more responsive and cost effective.
By involving users and carers during planning and development, there is less risk of providing inappropriate services and more chance of services being provided in the way people want them. The views and values of patients and carers need to be considered alongside clinical evidence and professional judgement. See Fig. Although patient-centred care is not a new concept, it is increasingly evidence based, with studies showing improvements in quality of life and satisfaction with care, increased engagement, and reduced anxiety Stewart An approach which recognizes the values of the patient and their family, and enables them to express their wishes, is likely to result in a plan of care which will have the best outcomes for all concerned Department of Health Promoting involvement in care 19 Box 2.
Evidence Service-user values, knowledge and decision making Professional knowledge, judgement and values Figure 2. We need an annual review to help us do this and to look at things like blood pressure, and mobility.
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