Definition• Coordination refers to using the right

muscles at the right time with correct intensity, extensive organization within the central nervous system is necessary to guide motor patterns, coordination is the basis of smooth and efficient movement, which often occurs automatically.

• Coordination and gross or fine motor skills are a highly complex aspect of normal motor function

Factors affecting on coordination:

• Anatomical Factors – Deformity – Asymmetry – Mal posture

Environmental factors :– Temperature – Pollution – Mental and psychological

stress

• Pain • Occupation • Life style • Fullness of bladder • Any medication • Repeated pregnancy • Overweight • Age • Type of muscle tone

Consideration before evaluation

• The presence of parking.• Rail way of stair up & down. • Light at entrance. • Ramp for wheel chair.• If there is lifter or not

A- Outside the clinic

B- Inside the Clinic • Clearness of room. • Silence and privacy.• Suitable temperature and light. • Comfortable and relaxed position for the

patient. • Adjustable and wide bed. • Explain procedure to patient. • Patient pared skin or with light clothes. • Avoid air draft but maintain good ventilation. • All equipment near the therapist to avoid

interruption. • Evaluation sheet should be present.

Consideration during evaluation

• Pain • Sweating • Abnormal heart rate. • Abnormal B.P. • Fever • Fainting. • Hypermobility• Infection• Recent wound and injury

• Avoid position that may exaggerated muscle tone or patient complication.

• Mental stress. • All tests done with tolerance of patient

and according the stage of the disease. • All tests are done within the limit of

pain. • All tests from zero starting position.

Decision Making • Diagnostic interview.• Screening examination • Comprehensive examination. • Special tests. • Long term goals. • Short term goals. • Out come

DIAGNOSTIC INTERVIEWPersonal History:•Name: To be familiar with the patient•Age: occurs in people aged 40-50 years (cerbrovascular stroke)•Sex: affects men and women equally •Marital status: Married or single•Style of life: his habits, activities and if he living a sedentary life. It assist in providing the therapist with hint about causes and the expected prognosis.

• Occupation: Know the patients interests and hopes

• Habits: Smokers, non smokers, alcohol drinkers, coffee or tea drinker.

• Weight: obesity increase the difficulty in performing activities.

• Environmental assessment: A) Outside door• - Surrounding home.• - Stairs (height – width) – (sharp,

smooth) .• - Entrance .• - Noisy – pollution. • - Light at entrance .• - rails of stairs – height of pavement .

B) Inside door

• - Entrance• - Carpets • - Type of floor • - Furniture • - Arrangement • - Devices and accessories

Work assessment:

• Desks. • Height of table and chair. • Width and height of weed chair .• How communicate with people.

B- History

• To know precautions. • To know Contra-indications. • To decide the plane of care/treatment.

The importance of History taking:

•Onset & duration of the disease. •Site and extent of the lesion: (It affect level of consciousness and prognosis as the site either Rt of Lt determine aphasia and speech affection)•Etiology of the disease. •Mechanism of the lesion.•Distribution of paralysis•Past history: any disease (diabetes- hypertension- congenital heart disease), any previous operation, any previous trauma. •History of functional A.D.L:

Functional A.D.L is divided into:

• Transfer activities.• Hygiene. • Feeding. • Dressing & undressing. • Gait & ambulation. Grades (He can do –He can do with minimal

assessment – He can do with maximum assistant- He can't do)

Family history:

• Any hereditary disease • Heart diseases • diabetes • Neuromuscular diseases due

congenital or genetic factors

• Psychological history: IQ. Level, Cognitive level, Education level, Affection (emotions – nervous - fairs), memory, judgment, depression, how to solve problems.

• Social History: Relationship between patient and his family members and if they accept or reject the patient.

Pain History:

• (time of pain – location of pain– If movement increase or decrease the pain –– severity of pain – distribution of pain).

Chief complain• Difficulties in performing ADL

• Difficulty using arms to dress, feed self, or perform other tasks

• Urinary incontinence • Problems with balance• Decreased sensation, numbness, or

tingling on affected side of the body • Difficulty speaking and/or or

understanding words• Difficulty walking • Depression

Problem list

• Spasticity .• Muscle weakness • Loss of balance • Loss of coordination• Inability to do functional activities .• Shoulder pain.• Poor hand function.• Respiratory and circulatory problems.

Medical record – Medications – Associated handicapped (Vision, Hearing,

Speech)– Associated reaction. – Any epileptic fits. – Incontinence. – Bed sores. – Vital signs (B.P.- Heat rate - Temperature) – X-ray - C.T Scan – M.R.I

Respiratory and circulatory disorders.– Orofacial dysfunction.

Screening examination

• Any abnormalities. • Asymmetry. • Distribution & Pattern of paralysis. • Position of head in relation to spasticity.• Position of head in relation to spasticity.• Associated reactions• Imbalance

General observation:

• General heath (out look of face). • Gait & ambulation. • Assistive device. • Way of taking off clothes, way of

getting up & down bed. • Handling of the patient with his

family. • If the family reject or accept the

patient.

Specific observation: with the patient pared skin. Postural assessment from three views (lateral – anterior - posterior). Dermatological system (Scar – operation

– skin disease). Skeletal system (size of bone – mal

alignment of bone). Muscular system (atrophy – asymmetry

– hyper trophy). Join system (edema – swelling). Breathing pattern.

Palpation

Tender point Muscle tone Soft tissue Mobility Trigger point Fascial restriction. Skin texture& temperature.

Comprehensive examination

Vision Hearing – speech Way of solving

problem Judgment Excitement. Interest.

A- Communication abilities

By Pantomine. Communication board

B- Mental Status

IQ level Cognitive level Education level

C- Arousal status: see the response of the patient to any movement and see if the arousal status is low or high.

D- Motor control stages:

Muscle test : Group muscle test (voluntary muscle test because of spasticity or in pattern of movement) (gross movement)

Functional ROM test : as feeding – dressing – undressing – hygiene

a- Mobility stage

Flexibility test (Sound, Affected, and associated areas

Examples: long sitting test Straight leg raising test Cross sitting test Standing with forward bending test Supine and hand stretched overhead

b- Stability stage

Elbow prone test:

importance

Sitting position on a table Sitting position on an armchair. Then

sitting on a stool: Test patient ability to maintain position against gravity

Standing position

For head control

– raise head and sustain position for 30 sec

– If collapse quickly poor – If can't take or sustain in the position

zero – If maintain it for 30 sec normal

Sitting on the edge of the bed or table, test the patient ability to maintain position against gravity .

Sitting on arm chair then on a stool to test the patient ability to maintain position against gravity

Maintain postural alignment

Sitting position

Standing position

Test the patient ability to maintain position against gravity.

C- Control mobility stage

Change position with maintaining postural control1) Rocking (body shift): Bushing from different

directions, and from different positions or by lying on rocking plate .

Done from different positions (Elbow Prone, quadruped, sitting, kneeling , standing)

Rocking plate from supine - prone and raise from different direction all testes done 2-3 times before giving grade.

2) Quadruped position raise one hand, then the other hand, raise one hand with opposite leg, raise one leg then another

d- High Skilled activity stage

Swallowing test. Speech test. chewing test Cranial nerve assessment. Hand function test: a- Volk's man

angle test & b- Metacarpal stability test Hand

Gait and ambulation test: also test patient ability to get up & down stairs.

E- Voluntary movement

Observe pattern and sequence of movement from different position

*Supine: do flexion –extension – abduction – rotation- abdominal exercises

*Sitting: the same movements +trunk rotation + trunk bending.

*From supine to standing: observe the sequence of movement: some patients make side bending + rotation of trunk then stand while others take the kneeling position then stand.

F- Functional A.D.L test:

Physical Affection (emotion -

psychological) Mental (IQ level –

Cognitive level - education)

Social.

Causes of disability of ADL:

ADL are assessed by: *Questionnaire or Self questionnaire*Multi dimensional function: it include physical examination to detect if patient can do ADL or not.

factors affecting muscle tone

Anxiety Temperature Tension Drugs Fear Fullness of bladder Position of the head Environmental condition Vision and hearing Pain

G- Assessment of Muscle TonePassive MovementAshworth Scale : To perform this test, the part is moved

through the joint range-of-motion (ROM).

Ashworth Score Criteria: 0 No increase in tone 1 Slight increase in tone, giving a

“catch” when the limb is moved in flexion or extension

2 More marked increase in tone, but limb easily flexed

3 Considerable increase in tone; passive movement difficult

4 Limb rigid in flexion or extension

H- Reflex assessment: Assess superficial and deep reflexes (tendon reflex,, and babiniski sign).

I- Postural assessment testes:

Shobber test Adam's test Forward bending test.

J- Sensation & perception tests:

Superficial sensation: assessment of pain, touch, and temperature. Sensation test is done by pin pricking or test tube.

Deep sensation (Proprioception): Dynamic sense (sense of

movement) Static sense (sense of position) Vibration sense

Joint sense:

Rate of motion Velocity of motion Direction of motion

Combined sensation: stereognosis, two point discrimination,

tactile localization, vibration, paragnosis, and texture of different materials.

Perception can be evaluated by observation: patients with perceptual defect have the following criteria:

Can't follow instruction. Suffer from confusion Difficulty in performing A.D.L. Repeated mistakes Can't repeated movement Can't discriminate between body

image and body parts (Summate). Can't do purposeful movement

(Apraxia). Can't do any construction form.

IV- Special test

Righting reaction Equilibrium test Upright position

test

A- Manual Test

Special tests for coordination

Finger to nose: The shoulder is abducted to 90o with the elbow extended, the patient is asked to bring tip of the index finger to the tip of nose.

Finger to therapist finger: the patient and the therapist site opposite to each other, the therapist index finger is held in front of the patient, the patient is asked to touch the tip of the index finger to the therapist index finger.

Non-equilibrium coordination

Finger to finger: Both shoulders are abducted to bring both the elbow extended, the patient is asked to bring both the hand toward the midline and approximate the index finger from opposing hand .

alternate nose to finger: the patient alternately touch the tip of the nose and the tip of the therapist's finger with the index finger.

Equilibrium coordination tests:

Standing in a normal comfortable posture. Standing with feet together (narrow base of

support) Standing with one foot exactly in front of

the other in tendon (toe of one foot touching heed of opposite foot).

Standing on one foot.

Arm position may be altered in each of the above postures (that is arm at sides, over head, hands on waist) .

Displace balance unexpectedly (with carefully guarding patient).

Standing and then alternate between forward trunk flexion and return to neutral.

Standing with trunk laterally flexed to each side . Standing to test the ability to maintain an upright

posture without visual feedback. Standing in tandem position from eyes open to

eyes closed.

B- Mechanical test

Instrumentation used to assess coordination

Pivot turning mat Side turning matFrenkle's mat

II- Rehabilitation program.

A- Rehabilitation team Physician – Nurse – Therapist – Social

worker –vocational counselor occupational therapist – psychiatrist – Dietician – relatives of patients.

B- Goals

Return subject to be independent or partial independent in ADL and to be productive member in his society.

1- Long term goals

2- Short term goals Enhance functional activities Improve range of motion Restore symmetry of both sides Improve sensory awareness Normalization of muscle tone Improve balance Improve co ordination Improve gait pattern Strengthening weakened muscle.

Consideration during rehabilitation:

Avoid exhaustion for the patients Avoid the bad habits and poor

positioning . Avoid position that may exaggerated

muscle tone or patient complication. Mental stress. Check for precautions and

contraindication Rest in between the exercise There should be goad fixation and

stabilization Rehabilitation should proceed according

to stages of motor learning.

Physical problems of motor control stage:

Defect in postural tone. Defect in postural balance. Defect in functional pattern.

C- Program of treatment

– Avoid any thing or position that increase spasticity (excitement, fatigue, pollution, air drafts)

– Suitable clothes not tight or restricting, it should be made of cotton.

– Ask visitor to seat at affected side to allow weight bearing and encourage symmetry.

– Avoid over weight (diet that give energy but reduce carbohydrates intake).

1- Instruction

– Wide and stable bed – Turning every 2 hours to avoid bed

sores. – Massage back & buttocks – Rearrangement of furniture– Head should be deviated to sound side

to ovoid retraction of shoulder also make elongation of the neck muscles on the affected side.

– Encourage symmetry: by engagement of the sound and affected upper limbs.

2 -Positioning:

Put the patient in anti-spastic position.

Head deviated to the sound side. Long pillow under pelvis – thigh to

avoid retraction of pelvis, prevent lateral rotation, and assist turning. Put small pillow under the knee.

Pillow under the axilla. Shoulder in abduction and hand in

functional position.

Use board or wall to put the feet at right angle to avoid drop foot.

7- Put pillow on his abdomen or in front of him and he engage his hands on it.

8- Abduct the sound LL apart.

3 -General & Local relaxation

Reassure the patient and encourage him

Massage Hot back Bio-feed back Small pillows Towel or small pillow under the knee Suitable & comfortable bed Temperature room, music.

4 -Breathing exercise

Diaphragmatic Costal Ask patient or his family to open windows

to allow good ventilation.

Proprioceptive training for hemiplegic patient:

a- Bridging exercise & Single leg bridging

A- Mobility stage:

b) Placing exercises:

in placing exercises we can use wall as function tool proprioception, placing, inhibition, facilitation)

For example: Raise leg on wall in certain points this position used

in (1) function standing (dorsiflexion -planter flexion- stretching – proprioception – prevent deviation). Also it is used as a coordination training for leg from supine.

Supine and place hand on wall by hand contact on certain markes on the wall this position used in prevention of drop wrist as well as coordination.

Proprioceptive neuromuscular facilitation (PNF)

P.NF is a very important exercise to improve co ordination between agonistic and antagonistic muscle groups, and to improve limb co ordination in general, in the Mobility stage we can use it in the form of active free exercise.

Frenkle's exercises:

The main principles of frenkel's exercises are the following :

– concentration or attention.– Precision

- Repetition

frenkel's exercises from supine

Flex and extend one leg by the heel sliding down a straight line on the table.

Abduct and adduct hip smoothly with knee bent and heel on the table.

Abduct and adduct leg with knee and hip extended by sliding the whole leg on the table .

Flex and extend hip and knee with heel off the table .

Flex and extend both legs together with the heel sliding on the table.

Flex one leg while extending the other. Flex and extend one leg while taking the

other leg into abduction and adduction.

C- Controlled Mobility stage: 1- Quadruped position: the patient at this stage can

support weight on the affected limb effectively so he can do reciprocal movement between the affected upper and sound U.L or the affected and soured L.L or between upper and lower limb. This improve coordination between patient extremities and improve self-esteem.

In the controlled mobility stage we can use be PNF in the form of active resisted exercises

Frankle's Exercises for the legs in sitting:

One leg is stretched to slide the heel to a position indicated by a mark on the floor.

The alternate leg is lifted to place the heel on the marked point.

From stride sitting posture patient is asked to stand and them site.

Rise and site with knees together.

Frenkle's Exercises for the legs in standing:

In stride standing weight is transferred from one foot to other.

Place foot forward and backward on straight line.

D- Highly skilled activity stage:

Walks along a widening s teps . Walk between two parallel lines. Walks sideways by placing feet on

the marked point. Walk and turn around. Walk and change direction to avoid

obstacles.

Sideways walking Pivot turning From sitting position : we can improve

coordination (eye – hand coordination) by using puzzles and big board.

also we can use roller and move it using both hands to improve co ordination between both hands

Squatter and trolley for the leg and move the foot forward, backward and sideward.

• use roller and move it using his both hands

Home program and advices

1- Regular maintaining antispastic position.2- Always use affected side together with

the sound side to decrease the associated reactions.

3- Patient instructed to do movements in functional pattern.

4- Patient trained on defensive mechanism.