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Define Coordination

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The ability to execute *smooth, accurate, controlled movement* In order to SAC the quarterback you need to be coordindation

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What is coordination characterized by?

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speed, distance, direction, timing

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When you do an examination of coordination and balance you look at various things such as...

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-Muscle activity - are they working synergistically together? -Efficiency of the movement -Ability to initiate control and terminate movement -Timing sequencing and accuracy -Assess the affect of pharmacological and therapeutic interventions on movement

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What systems contribute to coordination and balance?

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-Sensory system -Neuromuscular system

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What are the sensory systems that contribute to coordination and balance

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-Somatosensory -Visual -Vestibular

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What are the parts of the neuromuscular system that contribute to coordination and balance

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-Motor cortex -Descending tracts -Cerebellum -Basal ganglia

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Describe how the somatosenory system affects balance and coordination

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-feedback to the motor system on how to respond to the demands of a task

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Describe how the visual system affects balance and coordination

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-even bigger role if somatosensory system is impaired, picks up slack and assesses for change in position, the ones somatosensory would normally identify

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Describe how the vestibular system affects balance and coordination

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assessing changes in head position

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Describe how the neuromuscular system affects coordination and balance

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has to be intact to have good balance and coordination

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Describe how the *motor cortex* part of the neuromuscular system affects coordination and balance

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-*Primary motor cortex* (supplies the majority of the corticospinal tracts) -*Supplemental motor area* (initiation of movement, bilateral tasks, sequencing tasks, and the orientation of the eyes and the head) -*Pre-motor area* (input to the reticulospinal tracts controlling the trunk and proximal limb musculature, helps with anticipatory postural control

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Describe how the *descending tracts* part of the neuromuscular system affects coordination and balance

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-provide efferent control to musculature (most important tract is the cortico spinal tract) because it is the largest- relays signals from the motor cortex down through the spinal cord

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Describe how the *cerebellum* part of the neuromuscular system affects coordination and balance

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-regulation of movement and regulation of postural control and muscle tone -error correcting mechanism, comparing what the movement was suppose to be to what is was an trying to make adjustments from that (not fully understood how this works)

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Describe how the *basal ganglia* part of the neuromuscular system affects coordination and balance

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-initial, regulation, and planning of movement and basic initiation of tasks (not fully understood how this works)

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What are some age-related changes in coordination

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-Decreased strength -Slowed reaction time -Decreased ROM -Degenerative joint disease -Postural changes (hump in back) -Impaired balance (postural control) -Impaired sensation -Perceptual impairments (muscles and joints get tighter)

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Asthenia

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generalized muscle weakness

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Asynergia

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loss of ability to associate muscles together for complex movements

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Delayed reaction time

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increased time required to initiate voluntary movement

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All the definitions listed are

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commom coordination impairments associated with pathology of the cerebellum and basal ganglia

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Dysarthria (cerebellar)

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disorder of the motor component of speech articulation

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*Dysdiadochokinesia* (cerebellar)

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impaired ability to perform rapid alternating movements

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*Dysmetria* (cerebellar)

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In ability to judge a=the distance or range of movement

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Dyssynergia (cerebellar)

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movement performed in a sequence of component parts rather than as a single, smooth activity, decomposition

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Gait disorders (cerebellar)

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Ataxic pattern, broad base of support; postural instability; high-guard position of UE's

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Hypotonia (cerebellar)

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Decrease in muscle tone

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Hypermetria (cerebellar)

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overestimation of distance or range needed to accomplish a movement

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Hypometria (cerebellar)

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Underestimation of distance or range needed to accomplish a movement

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Nystagmus (cerebellar)

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Rhythmic, quick, oscilatory,

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Rebound phenomenon (cerebellar)

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Inability to halt forceful movements after resistive stimulus removed, patients unable to stop sudden limb motion

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Tremor (cerebellar)

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Involuntary oscillatory movement resulting from alternative contraction of opposing muscle groups

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Intention tremor (kinetic) (cerebellar)

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Oscillatory movement during voluntary motion, increase as the limb nears target; diminished or absent at rest

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Postural tremor (static) (cerebellar)

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Exaggerated oscillatory movement of the body in standing posture or of a limb held against gravity

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Titubation (cerebellar)

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Rhythmic oscillations of the head, axial involvement of the trunk

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Akinesia (basal ganglia)

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Inability to initiate movements, associated with fixed postures

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Athetosis

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Slow, involuntary, writhing, twisting, "wormlike" movements, frequently greater involvement in distal UE's

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Bradykinesia

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Decreased amplitude and velocity of voluntary movement

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Chorea

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Involuntary, rapid, irregular, jerky movements involving multiple joints; most apparent in UE's

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Choreoathetosis

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Movement disorder with features or both chorea and athetosis

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Dystonia (dystonic movements)

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Sustained involuntary contractions of agonist and antagonist muscles

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Hemiballismus

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large amplitude sudden, violent, flailing motions of the arm and leg of one side of the body

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Hyperkinesis

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Abnormally increased muscle activity or movement

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Hypokinesis

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Decreased motor response especially to a specific stimulus

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*Rigidity*

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Increase in muscle tone causing greater resistance to passive movement, greater in flexor muscles

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Lead-pipe rigidity

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uniform, constant resistance as limb is moved

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Cogwheel rigidity

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Series of brief relaxations or "catches" as limb is passively moved

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Describe the components of a coordination exam

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-General screening -Tests -Movement Capabilities -Difficulty Progression

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When conducting a coordination examination what is included in the *general screening*?

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ROM, MMT, Sensation

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When conducting a coordination examination what is included in the tests?

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Nonequilibrium tests

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When conducting a coordination examination what tests are included examining movement capabilities?

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-Alternative or reciprocal movements -Movement composition -Movement accuracy -Fixation or limb holding

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When conducting a coordination examination what is included examining difficulty progression?

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-Unilateral tasks -Bilateral symmetrical tasks -Bilateral asymmetrical tasks -Multi-limb tasks -Addition of balance components (goes from easier to harder)

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*Describe the *finger to nose* Nonequilibrium test*

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The shoulder is abducted to 90 degrees with the elbow extended. The patient is asked to bring the tip of the index finger to the tip of his or her nose. Alterations may be made in the initial starting position to observe performance from different planes of motion.

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Describe the *finger to therapist finger* Nonequilibrium test

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The patient and therapist sit opposite each other. The therapist's index finger is held in front of the patient. The patient is asked to touch the tip of his or her index finger to the therapist index finger. The position of the therapist's finger may be altered during testing to observe ability to change distance, direction and force of movement

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Describe the *finger to finger* Nonequilibrium test

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Both shoulder are abducted to 90 degrees with the elbows extended. The patient is asked to bring both hands toward the midline and approximate the index fingers from opposing hands

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*Describe the *alternate nose to finger* Nonequilibrium test*

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The patient alternately touches the tip of his or her nose and the tip of the therapist's finger with the index finger. The position of the therapist's finger may be altered during testing to observe ability

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Describe the *finger opposition* Nonequilibrium test

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The patient touches the tip of the thumb to the tip of each finger in sequence. Speed may be gradually increased.

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Describe the *mass grasp* Nonequilibrium test

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An alternation is made between opening and closing fist (from finger flexion to full extension). Speed may be gradually increased.

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Describe the *pronation/supination* Nonequilibrium test

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With elbows flexed to 90 degrees and held close to body, the patient alternately turns the palms up and down. This test also maybe performed with shoulders flexed to 90 degrees and elbows extended. Speed may be gradually increased. The ability to reverse movements between opposing muscle groups can be examined at many joints. Examples include active alternatio between flexion and extentsion of the knee, ankle, elbow, or fingers.

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Describe the *rebound* Nonequilibrium test

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The patient is positioned with the elbow flexed. The therapist applies sufficient manual resistance to produce an isometric contraction of biceps. Normally, the opposing muscle group (triceps) will contract and "check" movement of limb. Many other muscle groups can be tested for this phenomenon, such as the shoulder abductors or flexors and the elbow extensors.

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Describe the *tapping (hand)* Nonequilibrium test

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With the elbow flexed and the forearm pronated, the patient is asked to "tap" the hand on the knee

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Describe the *tapping (foot)* Nonequilibrium test

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The pateint is asked to "tap" the ball of one foot on the floor without raising the knee, the heel maintains contact with floor.

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**Alternate heel to knee, heel to toe** Nonequilibrium test

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From supine position, the patient is asked to touch the knee and big toe alternately with the heel of the opposite extremity.

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Toe to examiner's finger Nonequilibrium test

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From a supine position, the patient is instructed to touch the great toe to the examiners finger. The position of finger may be altered during during testing to observe ability to change distance, direction, and force of movement.

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Heel on shin Nonequilibrium test

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From a supine position, the heel of one foot is slid up and down the shin of the opposite LE

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Drawing a circle Nonequilibrium test

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The patient draws an imaginary circle in the air with either UE or LE (a table or the floor also maybe used). This also maybe done using a figure-eight pattern. This test maybe performed in the supine position for the LE.

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Fixation or position holding Nonequilibrium test

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UE the patient holds arms horizontally in front (sitting or standing) LE the patient is asked to hold the knee in an extended position (sitting)

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*What are the different tests you can conduct for dysdiadochokinesia*

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-Finger to nose -Alternate nose to finger -Pronation/supination -knee flexion/extension -Walking, alter speed or direction

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What are the different tests you can conduct for dysmetria

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-Pointing and past pointing -Drawing a circle or figure 8 -Heel on shin -Placing feet on floor markers, sitting, standing

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What are the different tests you can conduct for dyssynergia

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-Finger to nose -Finger to therapist finger -Alternate heel to knee -Toe to examiners finger

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What are the different tests you can conduct for hypotonia

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-Passive movement -Deep tendon reflexes

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What are the different tests you can conduct for tremor (intention)

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-Observation during functional activities (tremor will typically increase as target is approached or movement speed increased) -Alternate nose to finger -Finger to finger -Finger to therapist's finger -Toe to examiners finger

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How would you test for a tremor (resting)

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-Observation of patient at rest; limb or jaw movements -Observation during functional activities (tremor will diminish significantly or disappear with movement)

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How would you test for a tremor (postural)

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Observation of steadiness of normal posture, sitting, standing

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How would you test for asthenia

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Fixation or position holding (upper and lower extremity) Application of manual resistance to determine ability to hold

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How would you test for rigidity

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-Passive movement -Observation during functional activities -Observation of resting postures

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How would you test for bradykinesia

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-Walking, observation of arm swing and trunk motions -Walking, alter speed and direction -Request that a movement or gait activity be stopped abruptly -Observation of functional activities timed tests

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How would you test for disturbances of postures

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Fixation or position holding (upper and lower extermity) Displace balance unexpectedly in sitting or standing (perturbation) standing, alter base of support (e.g. one foot directly in front of the other, standing on one foot)

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How would you test for disturbances of gait

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-Walk along a straight line -Walk sideways, backward -March in place -Alter speed and direction of ambulatory activities -Walk in a circle

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How do you grade non equilbrium coordination tests?

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Scale of 0-4 *0 Activity impossible* *1 Severe impairment*- only able to initiate activity without completion, movements are slow with significant unsteadiness, oscillations, and or/ extraneous movements *2 moderate impairment*- able to accomplish activity movements are slow, awkward, and unsteady *3 minimal impairment*- Able to accomplish activity, slightly less than normal control, speed, and steadiness *4 Normal performance*

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What kind of notations should be made under the comments section

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if... -lack of visual input renders activity impossible or alters quality of performance -Verbal cuing is required to accomplish activity -Alterations in speed affect quality of performance -Excessive amount of time required to complete activity -Changes in arm position alters sitting balance -Postural instability is evident: unsteadiness, oscillations, extraneous movements -Fatigue alters consistency of response -Performance affects patient safety, requires contact guarding

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How many nonequilbrium tests should you do?

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Do a test or 2, compare left vs right

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