Efnisyfirlit

• Front Matter
  • Contributors
  • Preface to the first edition
  • Preface to the second edition
  • Acknowledgements
• Part 1 Introduction: adaptation, training and measurement
  • Chapter 1 The adaptive system: plasticity and recovery
    • Plasticity of the Intact Brain
      • Figure 1.1 Repetitive use of fingers 2, 3, 4 caused expansion of the cortical representation of these fingers. Outlines of regions in cortical area 3b represent surfaces of fingers before and after training. Maps of glabrous fields are identified for recording sites within area 3b before and after training.
      • Motor learning, training and plasticity
    • Plasticity Following a Brain Lesion
      • Figure 1.2 Functional reorganization in bilateral motor and sensory systems illustrated by increases in regional blood flow when the subject's paretic arms are moved passively. Area of activation: (top) before training, (middle) after task-oriented training of the experimental group, (lower) in the control group.
      • Recovery of function
      • Effect of the environment on behaviour and recovery
    • References
  • Chapter 2 Training motor control, increasing strength and fitness and promoting skill acquisition
    • Introduction to Training Motor Control
    • Task-Oriented Exercise and Training to Optimize Functional Performance
      • Specificity and transfer in exercise and training
        • Figure 2.1 Left: Hip, knee and ankle muscles contract in synchrony in kinetic chain (closed-chain) exercises such as step-ups. Right: An exercise for quadriceps femoris that isolates movement to the knee joint, an open-chain exercise.
        • Specificity in sensory training
      • Muscle strengthening and physical conditioning in neurorehabilitation
        • Figure 2.2 (A,B,C) Elastic band exercises focussed on shoulder and shoulder girdle muscles, and on knee extensor muscles in an open-chain exercise.(D) Isokinetic dynamometer training to increase strength of quadriceps muscles concentrically and eccentrically. (E) Reck MOTOmed® provides resistance or assistance in response to the patient's performance. (F) Pedalling a stationary bicycle can improve lower limb muscle strength, control and flexibility, endurance and cardiorespiratory fitness- depending on the mode (dosage) of training.
        • Figure 2.3 (A) Step-ups/downs on a tilt table- a modified closed-chain leg press exercise to train flexion and extension of the affected L leg and increase muscle force generation.(B) Two stations in circuit training. Left: Heels raise and lower with wall as security. Right: Modified squats against the wall.
        • Figure 2.4 (A) Reaching to pick up a tray in sitting- the task was to avoid spilling the water and dislodging the cutlery. (B) Squatting to move a stool on wheels introduces instability. (C) This girl who has ataxia and balance difficulties after a head injury is carrying a tea tray upstairs and downstairs to practise steadiness.
        • Figure 2.5 Diagram showing lower limb segments and eight functional muscle groups affecting segmental rotation.
        • Weightbearing strength training exercises for the lower limbs
          • Step up and step down
          • Heels raise and lower from a step
          • Squatting
          • Sit-to-stand
        • Non-weightbearing strength training exercises for the lower limbs
          • Figure 2.6 (A) Left: Repetitive practice of step-up exercise to train concentric control of the lower limbs & strengthen limb extensor muscles of L leg. He could do 10 reps without a pause. The table is there to give him confidence – he touches it only when he must. Right: Repetitive practice of step-downs to train eccentric control & strengthen limb extensor muscles of L leg. He could do 6 reps without a pause.
          • (B) Training of step-ups and downs in harness. Left: Her R leg extensor muscles are very weak and the therapist guides her knee movement preventing an uncontrolled movement into hyperextension. Right: On this occasion she can do only a few reps with a short pause when she places her foot on the step. She will progress on to more reps with no pauses, with the right foot at the edge of the stool.
          • Figure 2.7 Heels raise & lower is an exercise to practise controlling the 3 joints of the lower limb, strengthen and actively stretch the calf muscles.(A) It is difficult to control the right hip and knee while lowering the heels to the floor and raising them.
          • (B) He is getting the idea and although he can lower the heels (an eccentric action) it is difficult to lift them higher (a concentric action) as the calf muscles are weak.(C) This woman has progressed and can do the whole movement on one leg. She is actively stretching and strengthening calf muscles.
          • Figure 2.8 Squatting exercise is modified according to the person's ability- the method of practice is progressively challenging as the person improves. (A) He does repetitive small squats with the weak left leg taking most of the load. He alternates legs as his right leg is also weak. (B) This man has progressed and can now squat down to pick up the cup from the floor. He has a rather wide base. (C) A more difficult squat, with a narrow tandem stance.
          • Figure 2.9 Repetitive standing up & sitting down exercise. At this stage she practises from a higher seat which requires less extensor muscle force at hips, knees, ankles. As she gets stronger with more control over the movement the seat will be progressively lowered. (A) The foot of her stronger leg is automatically placed back as this enables the left leg to bear the body weight load. Done this way the exercise will not increase the strength of the weaker right leg. (B) The therapist reminds her to corrects her foot placement so that the weaker right leg is placed back. Now she practises a maximum number of reps with the right leg bearing more of the load. This will increase extensor muscle strength.
          • Active muscle stretching
            • Box 2.1 Guidelines for functional strength training
          • Physiological effects of strength training
            • Figure 2.10 Passive and active stretching of calf muscles.(A) Prolonged stretch to calf muscles using a wedge on a tilt table, with loading of the affected leg. Note that positioning the other foot forward ensures the leg is loaded. She can also practise raising & lowering her heel.
            • (B) Short periods of active & passive stretch to the calf muscles between exercise practice. He tries to push his right heel down on to the floor, activating his anterior tibial muscles. (C) As she does repetitive heels raise and lower she actively preserves calf muscle length. (D) Repetitive step-downs actively lengthen calf muscles through full range. (E) Repetitive STS/SIT exercises with the foot of the weaker leg placed well back actively preserves the length of calf muscles.
      • Training for cardiorespiratory fitness
        • Table 2.1 Recommended dose of aerobic exercise for post-stroke patients
    • Motor Learning and Skill Acquisition in the Restoration of Optimal Functional Performance
      • The process of learning
        • Adaptations
          • Figure 2.11 After stroke, adaptations to weakness or paralysis of shoulder flexors & external rotators includes for this man activity of muscles that are innervated. The resulting movement is made up of shoulder girdle elevation, lateral flexion of the spine with some spinal rotation. These movements allow him to move his hand forward and place it on the page.
        • Reducing unnecessary muscle activity
        • Modifications
        • Perceptual and cognitive factors
        • Motivation
      • Focus of attention: instruction, demonstration and feedback
        • Internal and external focus of attention
          • Concrete versus abstract goals
            • Figure 2.12 (A) He can stand up on most attempts but he produces horizontal momentum to move his body mass forward over his feet by swinging his arms forward.(B) An example of observational learning- he watches as the therapist demonstrates the topology or shape of the movement as she swings the upper body forward (shoulders forward over the knees) and up into standing. She emphasizes to him that the legs must do the work. He could practise repetitive STS-SIT with arms folded over chest.
        • Instructions
        • Demonstration
        • Augmented feedback
      • Practice and intensity of training
        • Specificity of learning
          • Repetitions
        • Mental practice
    • New Approaches to the Delivery of Physiotherapy: Providing Opportunities for Practice
      • Computer-aided, virtual reality, robotic and electromechanical training
        • Figure 2.13 (A) An overview of a lower limb circuit class.
        • (B) Part of a balance and upper limb class.
        • Robotic systems
        • Electromechanical systems
          • Figure 2.14 Tai Chi class in rehabilitation centre.
    • References
  • Chapter 3 Measurement
    • Introduction
      • Matching the test to the objective
    • Global Measures of Function
      • Barthel Index
      • Functional Independence Measure (FIM®)
        • Box 3.1 Barthel index
    • Measures of Motor Performance
      • Biomechanical measures
        • Box 3.2 Functional independence measure®
        • Box 3.3 The Motor Assessment Scale for stroke
      • Global clinical tests
        • Motor Assessment Scale (MAS) for stroke
        • Rivermead Motor Assessment (RMA)
        • Fugl-Meyer Assessment (FMA)
      • Specific performance tests
        • Gait
          • MAS walking item
          • 6–10-Metre walk test
            • Box 3.4 Functional reach test: age- and gender-related norms
          • Measures of specific temporal and spatial variables
        • Balance
          • MAS balanced sitting item
          • Functional reach test
          • Sit-and-reach test
          • Standing balance test
            • Box 3.5 Standing balance test: scoring
          • Step test
          • Timed ‘up-and-go’ (TUG) test
          • Berg Balance Scale (BBS)
          • Choice stepping reaction time test
          • Standing postural sway
          • Clinical test of sensory interaction in balance (CTSIB)
        • Falls-related measures
          • Falls Efficacy Scale (FES)
          • The Activities-Specific Balance Confidence (ABC) Scale
        • Upper limb function
          • MAS upper limb items
          • Nine-hole peg test (NHPT)
          • Frenchay arm test (FAT)
          • Action research arm test (ARAT)
          • The spiral test
    • Measures of Body Structure and Function (Impairments)
      • Figure 3.1 Spiral test results of individuals with cerebellar ataxia (Left) and Parkinson's disease (Right).
      • Muscle strength
        • The Medical Research Council (MRC) grades
        • Motricity Index
        • Dynamometry
          • Box 3.6 The Medical Research Council grades
      • Functional strength
        • Lateral step test
        • The timed-stands test
      • Joint range of motion (ROM)
      • Spasticity
        • The Modified Ashworth Scale (MAS)
        • The Tardieu Scale
      • Cardiorespiratory fitness/exercise capacity
        • Heart rate monitoring
        • Borg Rating of Perceived Exertion (RPE) Scale
        • 6-Minute walk test (6MWT)
          • Box 3.7 Formula to determine training heart rate (HR)
        • Human activity profile (HAP)
      • Sensation
        • The Nottingham Sensory Assessment for Stroke Patients
          • Box 3.8 Borg scale giving RPE values
        • Tactile sensation
        • Kinaesthetic sensation
        • Stereognosis
        • Two-point discrimination
        • Find-the-thumb test
      • Visuospatial function
        • The behavioural inattention test (BIT)
      • Memory
        • Mini-mental state (MMS) examination
    • Health-Related Quality of Life Scales
      • Box 3.9 Glasgow Coma Scale
      • The medical outcome survey Short Form-36 (SF-36®) health state questionnaire
      • The Nottingham Health Profile
      • Self-efficacy scales
      • Patient Health Questionnaire-9 (PHQ-9)
    • Diagnosis-Specific Measures
      • Traumatic brain injury (TBI) or post-surgery coma
        • Glasgow Coma Scale (GCS)
          • Box 3.10 Glasgow Outcome Scale
          • Box 3.11 Modified Hoehn and Yahr staging
        • Modified Oxford and Westmead Post-Traumatic Amnesia (PTA) Scale
        • Glasgow Outcome Scale (GOS)
        • The Galverston Orientation Amnesia Test (GOAT)
        • The High Level Mobility Assessment Tool (HIMAT)
      • Stroke
        • The Stroke-Adapted 30-Item Sickness Impact Profile (SA-SIP30)
      • Parkinson's disease
        • The Hoehn and Yahr Scale
        • United Parkinson's Disease Rating Scale
    • Environmental Analysis
      • Behaviour mapping
      • Behaviour stream analysis
    • References
• Part 2 Task-related exercise and training
  • Chapter 4 Standing up and sitting down
    • Introduction
      • Figure 4.1 This drawing illustrates in a simplified form the essential kinematic features of standing up in the sagittal plane.
      • Figure 4.2 Note the smooth continuous curvilinear path of the shoulder marker, recorded as an able-bodied person moved from sitting to standing.
    • Biomechanical Description
      • Standing up
        • Kinematics and kinetics
          • Figure 4.3 Sagittal plane stick figures taken from a biomechanical study of standing up and sitting down. (A) A typical young adult. (B) A typical older adult. Note: 1) movement of the shank segment (ankle dorsiflexion) in both activities. 2) Greater hip flexion in SIT in younger compared to older person.
        • Muscle activity
          • Figure 4.4 Typical vertical (z) ground reaction force profile of an able-bodied subject standing up at a preferred speed of approximately 1.5s. Vertical line indicates thighs-off. Arrows indicate movement onset and movement end.
          • Figure 4.5 Mean and standard error of time-normalized onsets and durations of six lower limb muscles as able-bodied subjects stand up at their preferred speed. TA: tibialis anterior; RF: rectus femoris; BF: biceps femoris; VL: vastus lateralis; GAST: gastrocnemius; SOL: soleus. 0%: movement onset, 31%: thighs-off, 100%: movement end.
          • Figure 4.6 Anterior view of the R psoas major – the major muscle contributing to flexion of the trunk and pelvis at the hip in standing up.
          • Figure 4.7 Preferred foot placement (approximately 75° ankle dorsiflexion) requires less force generation to stand up.
        • Biomechanical factors influencing performance
          • Mechanical effect of different foot placements
          • Timing and speed of trunk rotation
          • Seat height influences STS
          • Contribution of upper limbs to balance and propulsion
            • Figure 4.8 As seat height is raised, note that moments of force at the knee decrease.
      • Sitting down
    • Age-Related Changes
    • Motor Dysfunction
      • Figure 4.9 Asymmetrical weight-bearing. Failure to move paretic L foot back forces his weight on to the stronger R. leg. Note also the wide base of support.
      • Box 4.1 Common limitations and resultant adaptations
        • Standing up
        • Sitting down
    • Task-Oriented Training
      • Figure 4.10 Although she can stand up independently, note that she loads the more posterior (stronger) L leg more than R, evident as early as thighs-off.
      • Figure 4.11 Failure to move her body mass far enough forward – she flexes her lumbar spine instead of her hips. Note the use of her arms – using the arms interferes with learning of independent standing up – it prevents the generation of horizontal momentum.
      • Figure 4.12 Failure to move his COM far enough forward (↓ hip flexion and ↓ ankle dorsiflexion). Note how he uses his R arm as he attempts to stand up.
      • Figure 4.13 Sitting down. Failure to control descent causes her to ‘fall’ back on to the seat. Her hips, knees and ankles should be flexed. Note tibialis anterior should be working strongly to stabilize the ankle, keeping the knees forward and controlling the backward path of descent.
      • Figure 4.14 The therapist models the action to demonstrate the extent of trunk flexion at the hips (A) beside the patient so he can line his trunk up with hers, (B) providing a sagittal plane view to show him how far forward shoulders are moved.
      • Standing up: foot placement and loading the weaker leg
        • Figure 4.15 She is practicing STS/SIT with the paretic leg placed well back, loading the L leg. Here, she is focusing on swinging her shoulders and trunk forward a little faster in order to develop the momentum to rise to stand.
        • Figure 4.16 Practice of standing up and sitting down. (A) Therapist stabilizes paretic foot on the floor by pushing down along the shank. (B) As she stands up therapist moves the L leg sideways to increase loading of this leg. (C) Lateral view – she has not moved her shoulders far enough forward (i.e. flexed at the hips sufficiently) – she can focus on this during her next set of repetitions.
        • Box 4.2 Training guidelines at a glance
          • Standing up
          • Sitting down
      • Seat height
      • Pivoting the trunk forward
      • Controlling descent in sitting down
      • Repetitions
        • Figure 4.17 Sitting down on to a high seat. The therapist is stabilizing the paretic foot on the floor while keeping his knee forward. This gives him the idea of the amount of flexion necessary. The exercise trains the ability to control descent of the body by eccentric muscle activity of the quadriceps.
        • Figure 4.18 Partially supervised repetitive practice of STS and SIT. She is getting feedback about loading the limb from a limb load monitor and is recording the number of repetitions on a hand-held counter. 
      • Simple exercises to encourage muscle activation and encourage movement
      • Loading the paretic leg and training balance
    • Functional Strength Training
      • Figure 4.19 A towel reduces the friction between the shoe and floor while she practises activating hamstrings and muscles crossing the ankle to move her foot back. Her goal is to move her toes behind a line on the floor.
      • Figure 4.20 This woman was afraid of moving forward over her feet to stand up. With a table to rest her arms on, she is getting the idea of moving the shoulders forward and backward over her feet (flexion and extension at the hips) to improve her confidence.
      • Figure 4.21 Reaching forward beyond arm's length. (A) Initially she does not move her foot back and therefore cannot reach the bottle. (B) She can now extend her reach and is loading her L leg. Note her thighs are leaving the seat. This type of exercise boosts confidence in use of lower limbs.
      • Figure 4.22 Reciprocal leg lifting – as one leg lifts, the other loads. Note she is moving backward. She tries to keep her knee flexed – if it is too difficult the therapist can place a block in front of the foot. She also needs to practice lifting her knees higher.
      • Figure 4.23 Repetitive practice with arms folded increases lower limb extensor force strength. Focus can also be on increasing speed.
      • Seat selection
      • Mental practice
      • Maximizing skill
        • Figure 4.24 Balancing the mugs changes the focus of attention from standing up to steadying the tray. It encourages keeping the body mass forward over the feet at thighs-off.
    • Measurement
      • Figure 4.25 An exercise for improving balance that involves stopping and changing direction without losing balance.
      • Figure 4.26 Hip (solid line) and knee (dashed line) joint velocities are almost perfectly coupled at MAS 6 (A) whereas there was significant independent activity (lack of coordination) at MAS 2 (B).
    • References
  • Chapter 5 Walking
    • Introduction
    • Biomechanical Description
      • Biomechanical and behavioural criteria for effective walking
      • The gait cycle
        • Figure 5.1 Time dimensions of the walking cycle.
        • Spatiotemporal characteristics
        • Kinematics
        • Kinetics
          • Figure 5.2 (A) Position of the R leg in the sagittal plane at 40ms intervals during a single gait cycle. (B) Sagittal plane joint angles (degrees) during a single gait cycle. IC = initial contact; OT = opposite toe-off; HR = heel rise; OI = opposite initial contact; TO = toe off; FA = feet adjacent; TV = tibia vertical.
          • Figure 5.3 Averaged horizontal (top trace) and vertical (bottom trace) ground reaction forces. Horizontal force has a negative phase during the first half of stance, indicating a slowing down of the body, and a positive phase, indicating forward acceleration of the body, during the latter half of stance. Vertical force has the characteristic double hump, the first related to weight-acceptance and the second to push-off. CV: coefficient of variation.
          • Figure 5.4 Ensemble averages of power patterns of able-bodied subjects walking at their preferred cadence plotted over a single gait cycle indicating the most important power phases for hip (H), knee (K) and ankle (A). 60% indicates the beginning of swing phase. CV: coefficient of variation.
        • Muscle activity
      • Stair walking
    • Age-Related Changes
    • Motor Dysfunction
      • Research findings
      • Evaluation of motor performance
    • Training Gait
      • Figure 5.5 (A) L mid-stance – decreased ankle dorsiflexion and hip extension. Normally extension at the hip occurs as the COM moves forward over the stance foot. Compare with figure on the right. (B) Start of L swing – lack of push-off and pull-off. Compare with figure on the right. (C) End of L stance – lack of push-off (concentric ankle plantarflexion). Note the flat-footed gait. (D) R mid stance – knee remains flexed showing poor control of the limb. Knee position in stance is normally controlled by the muscles that cross the joint plus soleus that controls movement of the shank over the ankle. (E) Note the wide base compared with the figure on the right.
      • Figure 5.6 The splint is a temporary aid to prevent his knee from collapsing. He practices stepping with the L leg while loading the paretic R leg. (A) He is reluctant to load the R leg and does not move his COM (by extending his hip) over the L foot. (B) When the therapist directs him to step to her foot (a concrete goal) he is more successful.
      • Loading the paretic limb
      • Walking-treadmill and overground
        • Figure 5.7 This exercise improves control of the limb, particularly hip extension – stepping with the non-paretic leg to load the paretic leg. As she practices she is able to move further forward over the L leg with confidence. She will progress to stepping with alternate legs.
        • Overground walking
          • Figure 5.8 Walking sideways early after stroke – one leg loads, other leg lifts. Note she steps forward with her L leg rather than holding her hip extended while abducting it. She is successful on her next attempt. A line on the floor or a small object can provide a concrete goal.
        • Treadmill training with and without body weight support
          • Figure 5.9 Treadmill walking with body weight support. The therapist may need to assist the path of the foot (toe clearance) and step length during swing phase of the paretic L leg.
          • Box 5.1 Treadmill training – effects
          • Box 5.2 Treadmill training – details
            • Body weight support (BWS)
            • Speed
        • Electromechanical-assisted gait training
        • Functional strength training
          • Step up and down exercises
            • Figure 5.10 Stepping down requires eccentric activity of hip, knee and ankle extensors to lower the body mass. Shoulder elevation shows how difficult this action is. He needs to practise many repetitions of stepping down and back up repetitively in this range (eccentric changing to a concentric contraction).
          • Heels raise and lower
          • Non-weightbearing exercises
            • Figure 5.11 Heels raise and lower is controlled by concentric and eccentric action of the calf muscle. This exercise preserves optimal muscle length of plantarflexors as well as training the muscles to generate force (8–10° dorsiflexion to 16–19° plantarflexion) in the relevant range for push-off at the end of stance.
        • Activating weak or paretic muscles
          • Figure 5.12 Simple exercises to elicit and gain control over muscle activity during movement of one joint or several. (A) Training control of hamstrings. Therapist flexes the knee to 90° and the patient attempts to lower the foot (eccentric contraction) then immediately flex the knee (concentric contraction) without rotating at the hip. As she gets more control she can practise stopping and starting in various parts of range. (B) She is now getting the idea of walking backward (extending her hip as she flexes the knee to take a step. (C) This exercise involves complex action by mono- and bi-articular muscles that cross the hip, knee and ankle. The goal is to raise the hip off the bed (hip extension) by pushing down through the heel. Poor limb control is evident if the foot slides forward (quadriceps action unopposed by knee flexors) and if the heel is lifted (plantarflexors unopposed by anterior tibials).
        • Preservation of soft tissue extensibility
          • Figure 5.13 Activating the quadriceps initially with an eccentric contraction followed immediately with a concentric contraction. The therapist assists with knee extension and the patient attempts to control the weight of the shank while lowering the foot. This can also be performed without the dynamometer.
          • Figure 5.14 Gluteal taping helps the person get the idea of extending the hip at the end of stance phase.
    • Maximizing Skill, Speed, Endurance and Fitness for Gait Competency
      • Figure 5.15 Her husband supervises as she practises stair walking in a circuit class.
    • Environmental Modification
      • Figure 5.16 Walking up and down a ramp. She needs to be reminded to use her calf muscles for push-off when walking up.
      • Figure 5.17 Squatting to pick up an object from the floor on a circuit walk. His narrow base is encouraged by lines on the floor.
      • Figure 5.18 Walking over obstacles. He has caught his heel on the step with his trail leg and needs to lift his leg higher. Note he is wearing a belt with grab handles and is confined to a narrow base by lines on the floor.
      • Figure 5.19 Marching on the spot – as one leg lifts the other leg loads. Hip flexors need to be able to generate sufficient power for pull-off.
      • Figure 5.20 Walking on an uneven corrugated surface. Therapist gives support at the start.
      • Cueing
    • Measuring Treatment Effects and Retention
    • Aids and Orthoses
      • Walking aids
      • Ankle–foot orthoses
      • One-arm wheelchair
    • References
  • Chapter 6 Reaching and manipulation
    • Introduction
    • Reaching to Grasp: Description of the Activity
      • Figure 6.1 A cinematographic study by Jeannerod of reaching toward an object. Dots represent successive positions of the hand every 20 ms and illustrate fast movement of the hand toward the object, slowing down on approach. Lines represent the size of the grasp aperture (between thumb and index finger tip) every 40 ms. Note that aperture formation starts when movement starts and that the aperture reaches a maximum of 3 cm then decreases until it is the size necessary for grasping.
      • Figure 6.2 Drawing to illustrate position of markers used in digitizing transport and grasp components of reaching to an object.
      • Figure 6.3 The two grasping tasks, (A–C) show the approach, grasp and place components of the task ‘Place Cylinder’, (D–F) show the grasp and lift, the transition from initial to a firmer grasp and the shake components of the task ‘shake cylinder’.
      • Figure 6.4 Different patterns of the reach action made to a target in the same part of the workplace by a stick figure with 3 degrees of freedom.
      • Bimanual reaching actions
        • Figure 6.5 A single trial of the bilateral task. Three traces on Right: wrist velocity (top), wrist acceleration (middle) and grip size (lower) during the reach to grasp (R hand) and pull tab (L hand) tasks. Traces on Left are for a trial in which the tasks for each hand were reversed. Note that in both cases peak velocity, acceleration and deceleration occur earlier for the precision grip hand. The ‘can’ (inset) used in the experiment.
    • The Upper Limbs in Weightbearing
    • Manipulation: Description of the Activity
      • Figure 6.6 Task-related grasps showing the different ‘oppositions’ used.
      • Figure 6.7 Ulnar grasps. (A) A locking grasp: 4th and 5th fingers exert force to stabilize the cutlery in the palm. (B) A supporting grasp: 4th and 5th fingers support the plate and keep it level.
    • Recovery of Upper Limb Function
    • Motor Dysfunction
      • Muscle weakness, impaired coordination and dexterity
      • Muscle stiffness, muscle length changes, contracture
        • Figure 6.8 Post-stroke. (A) An attempt at reaching to take a glass. The 2-joint muscle, biceps brachii, flexes the shoulder but also flexes the elbow in the absence of triceps brachii activation. (B) A common resting posture with the paretic limb supported on a pillow in GH joint internal rotation and adduction, elbow flexion, forearm pronation and wrist flexion. In the absence of movement the muscles held short will develop adaptive changes including contracture. This position must be avoided.
      • Motor Performance
        • Reaching
        • Grasping and manipulation
    • Training of REACHING AND MANIPULATION
      • Figure 6.9 (A) It is difficult to hold and manipulate objects if wrist extension and forearm supination are absent. Note the difference in hand and forearm alignment between the arm with weak muscles and short long finger flexors and pronators compared to normal (on Right). (B) Thumb extension to release the glass takes the place of thumb abduction when abductor pollicis brevis is weak. (C) Weakness of hand muscles means the hand is unable to assume a cupping posture of palm and fingers and the thumb and 4th and 5th digits cannot be opposed. (D) Grasping the glass is normally made possible by the extensible web space between thumb and index metacarpals (Left). Shortening of web space soft tissues (including thumb adductor muscle) forces an abnormal posture at the MCP joint (Right).
      • Figure 6.10 Dystonic movement is evident after a stroke as the hand reaches to pick up the glass. Note that grasp aperture is formed by thumb and side of index finger.
      • Figure 6.11 Grasping and lifting a polystyrene (deformable) cup gives feedback about excessive force generation. Therapist is temporarily holding her wrist in some extension to restrain a tendency to flex as she grasps the cup – focus of attention is preserving the shape of the cup.
      • Figure 6.12 Using an EMG device to monitor activity in deltoid muscle during attempts at reaching forward on the table.
      • Figure 6.13 He is able to reach forward and pass the glass by sliding his arm over the table. Weak activation of the deltoid muscle, which would normally be the response to friction from the table, is evident. He should be able to raise his arm above the table after many repetitions – then he would practise without it.
      • Task modification
        • Figure 6.14 Hand class: repetitive shoulder flexion and elbow extension in the sagittal plane to train interjoint coordination – he is aiming for continuous smooth rhythmic movement (up/down, up/down). A metronome can be used to help him focus on timing rather than the movement itself.
        • Box 6.1 Task-oriented training method
          • Supplementary methods
      • Task-oriented training and practice
      • Simple repetitive exercises
        • Box 6.2 Simple repetitive exercises
        • Figure 6.15 (A) He reaches forward to take the glass. As he cannot supinate his forearm enough to take hold in the usual way he tries to pick it up with his hand on top of the glass. The problem is compounded by reduced GH external rotation(B) After some simple repetitive pronation/ supination and external rotation practice and brief passive stretching of his stiff pronators, he can overcome the stiffness and although the glass is placed out to the side he can shape his hand appropriately for picking it up.
        • Figure 6.16 (A) Independent practice of forearm supination/pronation on the Upper Limb Exerciser. The computer game linked to the manipulandum provides motivation and quantitative feedback.
        • (B) The results after 6 weeks training.
      • Functional strength training
        • Figure 6.17 Some examples of actions that require different finger groupings.
        • Box 6.3 Strength training
      • Bimanual training and practice
        • Figure 6.18 A selection of exercises while holding arm(s) raised. (A) Pouring water from one vessel to the other. He is living at home and wants to improve dexterity and avoid clumsiness with kitchen equipment. (B) It is important to organize practice of actions performed with arms reaching above the head. Even when arm elevation can be achieved, muscles often lack the endurance to keep them elevated longer. (C) Tracing the circle requires smooth controlled action. Arm elevation increases endurance of active muscles.(D) Some examples of elastic band exercises. This exercise to strengthen external rotator muscles is particularly important and can be started early in rehabilitation with the easiest of the bands. (E) Arm cycling is useful for independent practice.
        • Figure 6.19 Practice of bimanual actions gives opportunity to regain the ability to time movement and coordinate actions of both limbs. (A) It is an effort pouring accurately while holding arms at shoulder height. (B) Exerting the appropriate amount of force takes practice. (C) When folding a towel the two hands work together(D) Reaching above the head. (E) Lifting the lid.
        • Figure 6.20 Tasks requiring external timing control or precision are also practised in an upper limb training class. (A) Catching keys. (B) Rolling a ball between hands. (C) Basketball.
      • Forced use of a limb
      • Supplementary methods
        • Mental practice
          • Box 6.4 Protocol for task-specific training plus constraint
            • Criteria for inclusion
            • Constraint
            • Behavioural contract
            • Programme of exercises
            • Measurement
        • Electrical stimulation
        • Computer-aided, robotic and non-robotic mechanical training devices, virtual reality
          • Computer games
            • Figure 6.21 A non-robotic training device, the Sensorimotor Active Rehabilitation Training (SMART) Arm (NeuroTrac 5, Verity Medical Ltd). Note that positioning can be set up so that the reaching action includes external rotation of the GH joint as it is flexed forward. Shoulder movement can also be practised in standing by elevating the mechanism.
          • Robotic and non-robotic devices
          • Non-robotic training device
          • Virtual reality
        • Orthoses and passive stretching
          • Figure 6.22 During the day, when the person is not involved in active practise, positioning of the limb for approximately 30 mins may prevent stiffness and contracture from developing in vulnerable muscles. (A) & (B) To stretch GH internal rotator and adductor muscles(C) A gutter with thumb piece to prevent pronator and thumb adductor muscle shortening.
    • References
  • Chapter 7 Balance
    • Introduction
      • Fig. 7.1 Balance is learned during practice of a task and ongoing practice of a skilled activity.
    • Sensorimotor Interaction
    • Biomechanical Description
      • Quiet standing
        • Fig. 7.2 A portable ‘sway meter’ used to measure body displacement at the level of the waist. (A) Standing on the floor. (B) Standing on a foam rubber mat.
      • Balance during self-initiated movements
        • Fig. 7.3 An example of specificity of muscle activity. An arm muscle (biceps brachii) and a leg muscle (gastrocnemius) were monitored during different task requirements. (A) Subject pulls on the handle. (B) Unexpected movement of the handle when the subject leans against chest support. (C) As in B but subject is free standing. (D) Unexpected forward movement of the platform.
        • Shifting from two legs to one leg
        • Walking
          • Fig. 7.4 A translational plot showing the body's COG and foot COP for one walking stride. Note the COG never passes over the foot indicating that walking is essentially an inherently unstable activity. HC, heel contact; TO, toe-off.
        • Sitting
        • Standing up and sitting down
          • Fig. 7.5 Fast reaching to a target. (Top) Laboratory set-up; (lower) trial from one subject showing typical EMG traces from ipsilateral vastus lateralis (VL), biceps femoris (BF), tibialis anterior (TA), soleus (Sol) and anterior deltoid (AD) in a forward reach. Note, TA is the first muscle to turn on and it turns on before the focal arm muscle AD. Fast reaching beyond arm's length is an effective way to activate TA.
      • Postural responses to perturbations
        • Fig. 7.6 Muscles that contract during unexpected support surface perturbations adapt to counteract the disturbance, i.e. appropriate anticipatory responses to postural disturbance can be learned. (A) Movement of the platform backward tilts the body forward. This stretches gastrocnemius triggering a reflexive response that stabilizes posture and prevents a fall forward. In successive trials the muscle response occurs progressively earlier. (B) When the feet are unexpectedly tilted toes-up, action by gastrocnemius is attenuated (i.e. it gradually disappears) since it would have a destabilizing effect.
    • Age-Related Changes
    • Impaired Postural Control and Functional Limitations
      • Table 7.1 Sensory and neuromuscular factors associated with falls in the elderly
      • Box 7.1 Some experimental findings
    • Balance Training
      • Box 7.2 Adaptations to instability
      • Fig. 7.7 (A) No active support through paretic R lower limb – it falls out sideways at the hip. (B) He increases the base of support by externally rotating the R paretic leg when he turns to speak to his wife. Notice how ‘stiff’ he is.
      • Fig. 7.8 This man has a paralysed L arm and leg and has just started exercising. (A) It is difficult for him to move sideways away from a stable position. He uses his R arm for support and balance and is reluctant to move further to the L in case he falls. (B) He is able to move further to the L as he gets the idea of loading his L leg which gives him more stability.
      • Fig. 7.9 He avoids movement sideways over the weak R leg as he reaches laterally to touch a target.
      • Fig. 7.10 Reaching sideways. (A) He moves the body forward and reaches back to the glass. (B) Note, he can move his body sideways when the reach distance is decreased.
      • Fig. 7.11 This man is actively stretching his R calf muscle as he practises push-ups against the wall to improve control of his R arm.
      • Loading the lower limbs
        • Fig. 7.12 Training sitting balance, i.e. the ability to move about in sitting without falling or holding on. (A) On her early attempt at reaching to the cup she is reluctant to move her body over to the L; (B) some improvement is evident after a few repetitions. She is able to reach further and is more confident in her ability to regain the upright position. The therapist is supporting the paretic arm, as she cannot move it herself, but she moves her body actively to the L side. (C) Using the L leg for support and balance she reaches forward. (D) Using the L leg for support and balance as she reaches to the side and back. (E) Reaching bimanually is practised also. (F, G) Moving the feet back forces loading through the paretic R leg. The further the object is from the foot, the more loading.
        • Fig. 7.13 Training balance in a harness. (A) Notice that he loads his R leg more than his paretic L leg. (B) Reaching to the cup on his L, his instability is evident as he tries to turn his hand and take the cup. (C) After several practices he is more confident and is reaching across the body to the L. Note that his attentional focus is on the cup (a concrete task) and not on his balance.
        • Fig 7.14 A belt with grab handles gives some reassurance to patient and therapist without interfering with the action.
        • Fig 7.15 Getting the idea of balancing during small movements of the body mass. (A) Looking up at the ceiling to locate a target. (B) Turning to look over her shoulder to find out the time from the wall clock. She also practises turning to the R. As she becomes more confident the foot position can be changed to half tandem and the task can be changed. (C) She is not confident about picking up the cup as it means moving her weight over the L leg. (D) She reaches across her body. At first she is doubtful she can pick up the cup but with stand-by reassurance and instructions to bend her knees she succeeds. (E) He is practising moving about in standing. He turns to put the glass down on the bench behind without losing balance backward. (F) Holding himself stiffly with flexed hips in step standing – he is plucking up courage to pass the tray to the assistant.
        • Fig 7.16 Once she gets a sense of balance in this position of considerable instability, she reaches toward her head.
        • Fig 7.17 The task is to move the tray from bench to floor without spilling the water or dislodging the cup, i.e. the focus is on concrete goals.
      • Functional strength training
        • Fig 7.18 Squatting practice: (A) practising with the cup on a box develops confidence to reach even lower (B).
      • Maximizing skill
        • Fig 7.19 Stepping to touch a plastic cup requires careful foot placement while loading and balancing on one leg then changing to the other leg.
        • Fig 7.20 Having fun in an exercise class: passing the ball. Focus is on the ball.
        • Fig 7.21 Stepping out and stepping across the supporting leg are difficult actions for someone with poor balance when asked to do it quickly but are normally critical responses to prevent a fall from a stumble.
        • Feedback devices
          • Fig 7.22 Stepping on markers on the floor. (A) Tandem walking
          • (B) Cross-over stepping.
          • (C) Walking on an obstacle course – stepping over objects. Attention is directed toward height or width of objects, i.e. focus is on the obstacles rather than on body movement and balance.
          • Fig 7.23 Computerized devices such as the Balance Performance Monitor (SMS Healthcare) can be used to give feedback about postural sway.
    • Summary
    • References
• Part 3 Body function and structure, limitations in activities and participation
  • Chapter 8 Upper motor neuron lesions
    • Introduction
      • Figure 8.1 The positive, negative and adaptive features of the upper motor neuron syndrome.
    • Negative Features: Primary Impairments Following Central Lesions
      • Figure 8.2 The effects of passive stretch of biceps and triceps brachii in a normal subject. (Left) Abrupt stretches of 70° amplitude do not evoke any reflex activity in either muscle. (Right) The degree of amplification of the EMG trace when the muscles are contracted strongly by the subject (biceps in flexion; triceps in extension) is provided for comparison.
      • Paralysis and paresis (muscle weakness)
        • The mechanisms of muscle activation
        • Weakness arises from two sources
        • Central voluntary activation failure
        • Decreased motor unit firing rates
        • Distribution of muscle weakness
        • Differential degrees of muscle weakness
        • Weakness of an agonist muscle is not due to spasticity of its antagonist
          • Figure 8.3 Distribution of muscle weakness in two subjects with hemiparesis. Note that the subject shown in the top bar chart (infarct of corona radiata) shows greater distal than proximal muscle weakness; the subject in the lower chart (distal occlusion of basilar artery) shows a similar degree of involvement in all muscles tested.
        • Bilateral muscle weakness
      • Slowness of muscle activation and movement
        • Figure 8.4 Time to develop peak joint torque. Clear column, able-bodied subject (non-dominant arm); cross-hatched column, less affected arm; filled column, most affected arm.
      • Impaired coordination and loss of dexterity
    • Positive Features: Newly Emerging Phenomena
      • Figure 8.5 Response to passive stretch: (A) stroke subject with normal stretch reflex, (B) a stroke subject with hyperactive stretch reflex. Top traces: angle through which the elbow joint is moved. Middle traces: muscle response. Lower traces: IEMG on L illustrates no muscle response; IEMG on R shows the similar timing of the hyperactive response to the passive stretch of elbow flexors.
      • Evolution of spasticity (stretch-sensitive muscle hyperactivity)
        • Resistance to passive movement (hypertonus)
          • Figure 8.6 Two mechanisms considered to underlie hypertonus (1,2). Additional mechanisms (3,4) may relate to effects flowing between reflex hyperexcitability and altered passive mechanical properties.
    • Adaptive Features: Secondary Physiological, Mechanical and Functional Changes in Muscle and Other Soft Tissue
      • Figure 8.7 The relationship between muscle length and tension (muscle stiffness). Normal trace: normal state of reflex threshold and stiffness; θt,K: represents both decreased threshold and increased stiffness; θt: decreased threshold only; K: increased stiffness.
      • Figure 8.8 Normally the amount of contractile force a muscle can generate depends on its length, i.e., the degree of overlap of thick and thin filaments. Around the muscle's resting length, 2.0 µm, maximum force is attained and force is progressively reduced above and below this length. No active tension develops when sarcomeres are extended to 3.6–3.7 µm because cross bridges cannot form.
      • Contracture
        • Box 8.1 Summary points
      • Connective tissue in muscle
      • Change in joints
      • Adaptive patterns of movement
    • Clinical Intervention
      • Clinical testing
        • Figure 8.9 Task-specific functional exercise: (A) Practising step-downs as part of an exercise class. Note the active stretch to the soleus muscle (of the affected R leg) as it contracts eccentrically to lower the body mass. (B) Therapist holds the L foot steady as another person practises stepping up and down with the R leg. The step can be lowered if this height is too difficult. This exercise trains intersegmental control of the leg and balance, and also actively stretches the calf muscle.
        • Box 8.2 Summary points
    • References
  • Chapter 9 Cerebellar ataxia
    • Introduction
    • Functional Role of the Cerebellum
    • Functional Regions of the Cerebellum
      • Figure 9.1 Three functional regions of the cerebellum showing outputs (above) and inputs (below).
    • Role of the Cerebellum in Adaptation and Motor Learning
    • Aetiology
    • Clinical Signs
      • Ataxia
        • Dysmetria
          • Figure 9.2 Typical clinical signs in cerebellar diseases. (A) A delay in the initiation of movement. When asked to flex both arms on a signal ‘Go’, subject moves L arm later than R. (B) Moving a hand from above the head to touch the tip of the nose exhibits dysmetria, with increased tremor as the hand nears the nose, (C) Dysdiadochokinesia seen on the lower trace.
          • Figure 9.3 When reaching to pick up a pen top, dysmetria is illustrated by the over-wide grasp aperture.
          • Figure 9.4 When asked to stop walking, there may be difficulty decelerating and halting the action.
        • Rebound phenomenon
        • Dysdiadochokinesia
        • Tremor
        • Dyssynergia
        • Hypotonia
        • Dysarthria
        • Nystagmus
      • Adaptive motor behaviour
        • Figure 9.5 Balancing is usually difficult, particularly where a movement (in this case standing up from sitting) requires decelerating a considerable momentum. Note the wide base of support which is also typical of poor balance.
      • Motor performance deficits
        • Ataxic gait
          • Figure 9.6 (A) This task makes little demand on coordination. (B) Practising pouring water from one cup to the other without arm support, however, increases the demands.
          • Figure 9.7 Dysmetria is adapted for by using the table to brake hand movement when reaching to pick up the pen top (see Fig. 9.3).
          • Figure 9.8 Putting one cup into the other is difficult so she uses the cups to brake the arm movement.
          • Figure 9.9 The hands are often used for support. Here they are also used to aid in propulsion of the body mass vertically.
        • Postural adjustments
        • Rising on tiptoes in standing
        • Postural sway
        • Upper limb actions
    • Clinical Assessment, Measurement and Evaluation
      • Clinical neurological tests
        • Finger-to-finger and finger-to-nose tests
        • Heel-to-shin test
        • Rebound test
        • Test for rapid alternating movements
        • Romberg test for postural sway
      • Tests of motor performance
    • Training
      • Figure 9.10 Jumping (A) from side to side keeping the legs together and (B) jumping off a step. Both of these actions involve the production of a rapid burst of agonist extensor activity to propel the body upward from the flexion counter-movement without a pause.
      • Figure 9.11 Jogging involves rapid bursts of muscle activity in a cyclical fashion. Stopping and starting in response to a command or as part of a game are also practised.
      • Figure 9.12 Playing cricket enables her to improve balance and coordination along with eye-hand coordination and predictive time-to-contact from a relatively stable position (A) with the ball on the ground and (B) raising the bat to hit the ball.
      • Figure 9.13 Goal throwing. Note that she has not been able to generate a sufficiently rapid and powerful burst of muscle activity to propel her on to her toes. Heel-raising exercises may increase strength and control in calf muscles.
      • Figure 9.14 Walking sideways with some support, keeping her body mass forward.
    • References
  • Chapter 10 Somatosensory and perceptual–cognitive impairments
    • Introduction
    • Somatosensory Impairment
      • Joint position and movement sense
      • Tactile impairments
      • Pain
      • Assessment
      • Training
    • Visual Impairments
      • Visual field loss
        • Figure 10.1 Visual field deficits produced by lesions at various points in the visual pathway. 1: Lesion of R optic nerve causes loss of vision in R eye. 2: Lesion of optic chiasm causes loss of vision in the temporal halves of both visual fields (bitemporal hemianopia). 3: Lesion of optic tract causes complete loss of vision in opposite half of visual field (contralateral hemianopia). 4: Lesion of optic radiation fibres causes loss of vision in upper quadrant of opposite half of visual field of both eyes. Partial lesions of visual cortex lead to partial field deficits on opposite side.
    • Perceptual–Cognitive Impairments
      • Apraxia
      • Visual perceptual impairments
      • Unilateral neglect or hemi-inattention
        • Figure 10.2 An individual with hemi-inattention may only eat food on one side of the plate.
        • Figure 10.3 (A) Variation in recovery of mobility in 12 patients with R hemisphere stroke. All were severely impaired 1 week after admission to rehabilitation; at 7 weeks, they showed varied degrees of recovery. Mobility measures were performance on getting in and out of wheelchair, wheelchair driving, ambulation and stair climbing. (B) Variation in mobility of 7 of the above patients as a function of low, medium and high cortical atrophy by CT scan.
      • Assessment
        • Figure 10.4 The type of drawing made by individuals with R hemisphere parietal lobe lesion.
      • Training
        • Some guidelines
          • Impaired verticality
          • Not noticing food on the left of the plate
          • Avoiding attention to the left side during training
    • References
  • Chapter 11 Stroke
    • Introduction
      • Aetiology and pathology
        • Incidence
        • Blood supply to the brain
          • Figure 11.1A Blood vessels of the brain. Dark areas indicate common sites of atherosclerosis and occlusion.
          • Figure 11.1B Cerebral arterial areas.
        • Classification and prognosis
          • TACI (total anterior circulation infarct)
          • PACI (partial anterior circulation infarct)
          • LACI (lacunar infarct)
          • POCI (posterior circulation infarct)
          • ICH (intracerebral haemorrhage)
        • Survival after stroke
      • Acute Stroke
        • Admission to hospital
        • Medical management of all strokes
          • Early diagnosis and management
          • General care
          • Modifiable risk factor management
            • Hypertension
            • Atrial fibrillation
            • Diabetes
            • Hypercholesterolaemia
            • Smoking and alcohol use
      • Recovery after Stroke
        • Respiratory function
        • Musculoskeletal integrity
        • Early mobilization
          • Figure 11.2 (A) Early mobilization: When she first sat up she was very dizzy, so she is monitored carefully before progressing into standing. (B) Her first experience of standing upright after her stroke. Her condition is monitored before she progresses on to more active practice.
      • Problems in Body Structure and Function
        • Sensorimotor impairments and secondary adaptive changes
      • Rehabilitation
        • Figure 11.3 Both bed and chair are adjusted to a suitable height to enable practice of STS and SIT with (A) manual guidance to stabilize the foot and (B) stand-by assistance.
        • Task-oriented training
          • Treadmill training with and without body weight support (by suspension harness)
          • Constraint of non-paretic limb and task-oriented practice
          • Training balance
        • Functional strength training
          • Lower limb strength training
          • Upper limb strength training
        • Sensorimotor and perceptual–cognitive training
        • Physical conditioning (aerobic fitness)
        • Intensity of training, increasing practice and dosage
        • Technological developments
          • Aids
            • Ankle–foot orthoses
            • Orthoses
            • One-arm drive wheelchairs
            • Walking aids
      • Language, Cognitive and Affective Impairments
        • Aphasia
        • Cognitive function
        • Dementia
        • Depression
        • Other emotional and behavioural disturbances
        • Dysphagia
        • Bladder and bowel function
      • Patient and Family Education
      • The Role of the Family in Stroke Recovery
      • Discharge Planning and Return to the Community
      • References
    • Appendix: The shoulder
      • Glenohumeral Joint Subluxation
        • Figure 11.4 Mechanism for stabilization of the dependent arm. With the arm relaxed by the side, the downward pull of gravity is opposed by passive tension in the rotator interval capsule (superior capsule and GH ligament, coracohumeral ligament). The resultant of these opposing forces stabilizes the humeral head on the glenoid fossa.
      • Pain
        • Complexity of shoulder movement
          • Figure 11.5 Muscles of the shoulder girdle and major forces acting on the shoulder girdle.
          • Figure 11.6 Position of deltoid and supraspinatus with the arm at rest by the side. In this position the superior capsule is taut and the inferior capsule is slack.
        • Effects of weakness, loss of coordination and adaptive soft tissue changes
        • Pre-existing degenerative changes
        • Trauma to the unprotected arm
        • Difficulties with diagnosis
          • Figure 11.7 Scapular-humeral anatomical relationships: External rotation of the humerus during abduction ensures that the greater tuberosity of the humerus rotates out of the way of the acromion process.
          • Figure 11.8 (A) Without downward sliding of the humeral head's articular surface as the arm abducts, the head will roll up the glenoid fossa and impinge on the coracoacromial arch. (B) With downward sliding of humeral head as the humerus abducts, a full range of motion can occur without impingement.
        • Pain prevention
          • Shoulder pain prevention programme
        • Major aspects of training and exercise
          • Figure 11.9 Examples of positioning to preserve length in shoulder muscles, (A) sitting at a table, (B) lying down. A sandbag can be used to keep the arm in position. (a) In this position, exercises to improve grip strength (particularly of 4th and 5th fingers which are weak), finger extension and pronation/supination can be practised.
          • Figure 11.10 (A) Post-stroke: Practice of raising the arm and lowering it in an elevated position. The therapist guides the path of the limb and encourages her to keep the arm close by her head as she moves the arm off the pillow and down again. The distance moved is increased as her muscle control improves. (B) Practice of eccentric and concentric activity of shoulder muscles (principally pectorals) as she tries to move the elbow to touch the therapist's finger and to control an eccentric contraction as she moves the elbow back to the pillow.
          • Figure 11.11 (A,B) Strapping to provide some support for the upper limb. Fixomull stretch tape (BSNmedical) is used under the Sports Tape or Leukoplast (BSNmedical) to protect the skin. (A) Upper: The first piece passes over the front of the shoulder to a short distance down the scapula. Lower: 2 pieces are pulled upward over the shoulder and held in place by a lower cross-piece.
      • References
  • Chapter 12 Traumatic brain injury
    • Introduction
    • Epidemiology
    • Pathophysiology
      • Mechanism of brain damage
        • Table 12.1 Classification of mechanisms of brain damage following trauma
        • Primary brain damage
        • Secondary brain damage
      • Measures of severity
    • Management of acute traumatic brain injury
      • Respiratory function
      • Musculoskeletal integrity
        • Figure 12.1 Standing on a tilt table. Note the footplate is angled upwards and there is a serial cast on the right ankle to apply stretch to the calf muscles. A high table may be placed in front of a tilt table to enable participation in cognitive, reaching and manipulative activities while adjusting to the vertical position.
        • Figure 12.2 A tilt-in-space wheelchair (Quickie IRIS Tilt Wheelchair) allows a patient to be sat upright to engage in therapy and assist with postural control. The chair can be tilted back to change the distribution of pressure and allow rest. The headrest can be removed to encourage strengthening of neck extensor muscles. Footplates are adjusted to keep ankles in a plantargrade position.
        • Figure 12.3 Application of cast, (A) Application of stockinette and padding over bony prominences prior to casting, (B) Soleus muscle is stretched into maximum obtainable dorsiflexion using a board placed on the plantar surface of the foot while the cast is applied. Note that with the knee in flexion, the gastrocnemius muscle is not lengthened over both joints.
        • Figure 12.4 A torque-controlled measurement procedure. A known torque is applied to produce passive ankle dorsiflexion in a standardized testing position. Ankle angle is measured using skin surface markers and photography.
      • Altered levels of consciousness
      • Recovery from coma
        • Figure 12.5 Critical to early rehabilitation is the need to establish meaningful communication with a patient. This young man is able to use eye gaze with this double-sided communication board to answer simple questions.
      • Bladder and bowel function
    • Rehabilitation: an overall view
      • Cognitive and behavioural impairments
        • Cognition
        • Behaviour
        • Communication
      • Task-related training
        • Figure 12.6 This young man requires full thigh support and a table to support his arms to enable him to stay balanced in sitting with minimal support. The therapist is encouraging him to look at some pictures placed directly in front of him.
      • Cardiorespiratory conditioning
        • Figure 12.7 Jogging is an important motor task to train for many people to enable return to pre-injury work and leisure activities. Jogging involves large rapid bursts of muscle activity in a cyclical fashion. Stopping and starting in response to a command or as part of a game are also practiced.
        • Figure 12.8 (A) Hopping, (B) jumping off a step and (C) leaping. All three of these actions involve the production of a rapid initial burst of agonist extensor activity to propel the body upward (A) (B) and forward (C) from the flexion counter-movement (without a pause between the two phases).
        • Figure 12.9 Practicing soccer skills enables him to improve balance and co-ordination along with eye-hand/foot co-ordination and predictive time-to-contact. In this task he has to dribble a ball around a figure-of-eight path. Other activities can include kicking a ball against a wall or between two people, and catching a ball to prevent a goal.
        • Figure 12.10 Using computer games. This patient is playing the ski slalom game on the Nintendo Wii Fit to improve balance and co-ordination.
        • Figure 12.11 Progressive resistance strength training. The triceps can initially be strengthened (A) in supine with a weight added as the muscles become stronger, and (B) progressed to triceps dips.
        • Figure 12.12 Walking on a treadmill with or without bodyweight support enables task specific practice of walking as well as providing a cardiorespiratory fitness training effect if the intensity (speed and incline) and duration are sufficient. A heart rate monitor can be used to ensure the patient's heartrate is within their training heart rate zone.
        • Figure 12.13 Circuit class. This circuit class includes a combination of task-related training and cardiorespiratory fitness stations.
      • Community reintegration
    • References
  • Chapter 13 Parkinson's disease
    • Introduction
    • Pathophysiology
    • Aetiology
      • Clinical signs
      • Classification
    • Motor Control and Motor Performance Deficits
      • Reaction time and movement time
      • Execution of sequential movements
        • Figure 13.1 An attempt to stand up illustrates decreased amplitude of trunk flexion at the hips and dorsiflexion at the ankles. He has difficulty initiating horizontal momentum and changing from the horizontal to vertical sequence of the action. Note he has not moved his right foot back.
      • Execution of simultaneous tasks
      • Gait
        • Figure 13.2 Illustration of a man with Parkinson's disease (shaded) showing relatively flexed posture compared with an able-bodied man at the point of heel contact of the right lower limb.
      • Balance
      • Reaching and manipulation
      • Respiratory function
      • Oromotor function
      • Adaptive motor behaviour
    • Non-Motor Deficits
      • Mood disturbances
      • Cognitive deficits
    • Medication and Surgical Intervention
    • Physiotherapy Intervention
      • Figure 13.3 Framework for physiotherapy intervention in Parkinson's disease: goals and possible interventions according to stage of disease.
      • Task- and context-related practice to improve activity levels
        • Walking and balance
          • Figure 13.4 Treadmill walking. The patient practises starting/stopping the treadmill, changing speed and stopping unexpectedly with supervision from the physiotherapist, before walking on the treadmill independently. (A) The magnetic safety key on the treadmill is connected by a cord to a clip which is attached to the patient's belt. The string is kept relatively short, so that if the patient moves too far back on the treadmill while walking, the magnetic safety key will be dislodged and the treadmill will come to a stop. (B) Instructions and safety guidelines provided by the physiotherapist are attached to the wall. The patient holds lightly onto the handle bars, concentrates on taking big steps and bringing the toes forwards towards the white visual cue on each step. Notes: (i) independent treadmill walking should not be performed if the patient is OFF, and (ii) full supervision (including the use of an overhead harness) is required for patients with cognitive impairment, postural instability and/or freezing.
        • Standing up and sitting down
        • Turning over in bed and getting out of bed
        • Performing dual tasks
          • Table 13.1 Framework for classifying cueing strategies, parameters and modalities
      • Cueing and attentional strategies
      • Cognitive strategies
      • Exercise to promote physical activity
      • Exercise to maintain flexibility
        • Figure 13.5 Supine lying on a firm surface with a small towel roll under the thoracic spine. Both arms are abducted and externally rotated to put a further stretch on soft tissues likely to become stiff and short. A small pillow under the knees may be necessary to prevent excessive extension of lumbar spine if spine is very stiff.
      • Exercise to maintain muscle strength and power
        • Figure 13.7 Exercise to promote maintenance of spinal rotation. The right hand is used to assist in stabilising the legs and pelvis while she rotates her trunk and neck to look over her shoulder. She concentrates on maintaining hip flexion and spinal extension while turning. Rotation to both sides is practised.
        • Figure 13.6 Maintaining an erect posture. (A) She concentrates on keeping her upper back against the wall while contracting the gluteal muscles and attempting to move the hips forward. Excessive cervical spine flexion is avoided by drawing the head and neck back towards the wall. (B) She raises and lowers her heels, while maintaining spinal and hip extension. Note that this exercise also challenges her balance, as she holds her hands near the wall, but only places her hands on the wall if she loses her balance.
      • Evaluation and measurement
    • References
  • Chapter 14 Multiple sclerosis
    • Epidemiology and Aetiology
    • Pathophysiology
      • Figure 14.1 An MRI image showing MS lesions in the brain (A) and spinal cord (B).
    • The Disease Process
    • Clinical Symptomatology
      • Sensorimotor impairments
      • Cognitive and affective symptoms
      • Personality and psychosocial behaviour
      • Special senses
      • Fatigue
        • Figure 14.2 A cooling vest is useful for MS patients who suffer heat intolerance.
      • Autonomic involvement
      • Other manifestations of brainstem involvement
    • Medical Management
    • Physiotherapy: An Overall View
      • Strengthening exercise
        • Figure 14.3 (A) Positioning can be used to prevent contracture in people with advanced MS. (B) A tilt table can be used to strengthen knee extensors if the patient is too weak to practise standing up from a seat. It can help prevent/slow down ankle contracture; (C) Specific equipment is used for upper limb strengthening exercise for people in a wheel chair (UpperTone, GPK Inc, El Cajon, CA, USA); (D) Weight is used to help reduce tremor and ataxia during functional exercise of the upper limb; (E) Eccentric exercise by walking backward and downhill on a treadmill can help improve dorsiflexion and passively stretches the calf muscle in people with MS who are still walking.
      • Aerobic exercise
      • Preserving musculoskeletal integrity
      • Managing fatigue
      • Coping with reduced activity and participation
      • Measurement
        • Figure 14.4 A hoist decreases the physical burden for carers and ensures greater comfort for the individual when being moved from one place to another.
    • References

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    Rafbók til eignar þarf að hlaða niður á þau tæki sem þú vilt nota innan eins árs frá því bókin er keypt.
    
    Þú kemst í bækurnar hvar sem er
    Þú getur nálgast allar raf(skóla)bækurnar þínar á einu augabragði, hvar og hvenær sem er í bókahillunni þinni. Engin taska, enginn kyndill og ekkert vesen (hvað þá yfirvigt).
    
    Auðvelt að fletta og leita
    Þú getur flakkað milli síðna og kafla eins og þér hentar best og farið beint í ákveðna kafla úr efnisyfirlitinu. Í leitinni finnur þú orð, kafla eða síður í einum smelli.
    
    Glósur og yfirstrikanir
    Þú getur auðkennt textabrot með mismunandi litum og skrifað glósur að vild í rafbókina. Þú getur jafnvel séð glósur og yfirstrikanir hjá bekkjarsystkinum og kennara ef þeir leyfa það. Allt á einum stað.
    
    Hvað viltu sjá? / Þú ræður hvernig síðan lítur út
    Þú lagar síðuna að þínum þörfum. Stækkaðu eða minnkaðu myndir og texta með multi-level zoom til að sjá síðuna eins og þér hentar best í þínu námi.
    
    
    
    Fleiri góðir kostir
    - Þú getur prentað síður úr bókinni (innan þeirra marka sem útgefandinn setur)
    - Möguleiki á tengingu við annað stafrænt og gagnvirkt efni, svo sem myndbönd eða spurningar úr efninu
    - Auðvelt að afrita og líma efni/texta fyrir t.d. heimaverkefni eða ritgerðir
    - Styður tækni sem hjálpar nemendum með sjón- eða heyrnarskerðingu