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1. CC and referral: Your 82-year-old patient presents to therapy with a referral for “vestibular rehabilitation” from her neurologist. Her chief complaint relates to an ongoing problem with unsteadiness/feeling “woozy” that has been present for the past 4-5 years and has gradually restricted her ability to do activities she enjoys. Symptoms and history: She does not recall any coincident injury, illness or change in medication at the time these symptoms started. She has no history of ear infections, but reports her father had Meniere’s disease. She has bilateral high frequency hearing loss and wears hearing aids (Miracle Ear) on both sides. She has a sensitivity to loud noises. Her symptoms are reported as relatively constant with some variability from day to day, worsened by: position changes (when she gets up at night to go to the bathroom, rolls to the right then sits up); being in the dark; and walking (especially over uneven surfaces or outdoors). Symptoms improve with sitting or lying down. Symptoms do not change with cough/valsalva, use of salt/MSG and there is no clear pattern associated with time of day. She reports stumbling, staggering and sometimes veering to the left when walking. Recently she fell (tripped over a curb) going to a familiar restaurant. She landed on her R knee with minor discomfort that persists. She is embarrassed when this sort of thing happens. She is concerned that people will think she is intoxicated. She also has problems with foot pain, accentuated by a hammer toe (R second toe, crosses over great toe), and severe valgus of the L great toe (metatarsal varus, and hallux valgus, meaning that the great toe is deformed towards the smaller toes on that foot). She wears knee high TED hose bilaterally. Cervical range of motion is relatively limited (unable to extend and rotate fully on either side). Her medication list is short, reflecting her relative health. You identify no medications that have side effects that you would associate with her subjective complaints. Functional status: Completely independent with ADLs. Ambulatory without assistive devices, but is cautious. Is able to drive, but only to familiar places. Will usually allow her husband to drive instead. Participates in water aerobics (2x/week) at the Y and walks outdoors with her husband for exercise (prefers to have him there “just in case”). Social and goals: She moved to the area from the mountains a few years ago to be closer to her son and his family (including a granddaughter who is now 6). She has 4 other children who live as far away as Alaska and Minnesota, but all are supportive. She has lived a life of being very active (used to hike very often in the NC mountains) and would like her symptoms to improve so that she can exercise regularly without being self-conscious about her balance A. Identify elements of her history and presentation that are suggestive of peripheral, mechanical (BPPV) or central vestibular involvement, or other potential contributor(s) to her balance issues. B. Based on this description, what problem(s) do you suspect could be causing her symptoms and functional limitations? Describe your reasoning. (HINT: it is very possible that patients have more than one issue contributing to complaints). C. What examination components and associated questions would be a PRIORITY to clarify the complaints of unsteadiness and feeling woozy? Provide a rationale for the items you include. (NOTE: Do not include standardized measures here). 2. You administer several balance and gait assessments you learned in your functional assessment class and discover the following: Berg Balance Scale score: 36/54 (has difficulty with items beginning with reaching, turning (head or 360), alternate stepping, tandem and single limb stance Dynamic Gait Index: 19/28 (has difficulty with speeded walking, head turns/nods, pivot and stairs) Four-square step test: 18.9s, tentative stepping backwards over cane She demonstrates patterns of reactive postural response that are typically appropriate and functional, although she is sometimes slow in timing, requiring minimal assistance to regain balance in more challenging conditions. Given sufficient time, she anticipates postural conditions necessary to be safe. She is very cautious as she attempts new balance tasks, often hesitating before she starts to move. What self-report measure(s) would be ideal to track important issues in this case? Provide a rationale. Based on your examination, you conclude there are multiple factors contributing to her balance dysfunction that influence both gaze and dynamic postural stability, although you have ruled out disorders that require canalith repositioning. A. Describe the components of her home exercise program to encourage adaptation and gaze stability. B. Outline 3 activities that you will have her work on in therapy sessions that require your 1:1 guidance/assistance to improve her balance abilities. 3. Jawad is a 17-year-old male who experienced a TBI as a result of motor vehicle accident 2 months ago. He is currently receiving outpatient PT three times per week. Jawad is 5'10" tall and weighs 150 lbs. He can move his L shoulder and elbow in a flexor synergy pattern, but has no active movement of his L wrist or hand. Jawad has significant weakness of his L lower extremity, with fluctuating muscle tone and influence of both flexor and extensor synergy patterns. He is able to perform wheelchair transfers with SBA. Jawad ambulates short distances with contact guard to minimal assistance for balance using a lofstrand crutch in his R hand. During ambulation, he tends to rotate his shoulders and pelvis to the left. His gait is slow and is characterized by decreased L knee flexion during swing, diminished to absent L heel strike, L ankle/foot inversion, decreased time in stance phase on the L, and a tendency toward L lower extremity circumduction. When Jawad attempts to pick up his L foot to place it on a step or to step over an obstacle, he often demonstrates excessive L hip flexion, along with hip abduction, knee flexion, and ankle dorsiflexion with inversion/ supination of the foot. Jawad tends to roll his L ankle and has had two mild lateral ankle sprains since his accident. He is cooperative but easily distractible, and he fatigues very easily. PROM of the L lower extremity is WNL. a. Describe how you would use a PNF extremity diagonal to promote L lower extremity movement out of synergy for improved gait. Be specific as to which pattern you would start with, and how you would implement it in your practice with him. Explain the rationale for your choices. In working with Jawad, you determine that part of his difficulty with advancing his weaker leg relates to lack of control at the pelvis. b. Describe a PNF approach that you could use to encourage this control. Be specific as to what pattern and techniques you would use to encourage better pelvic movement. (NOTE: Our emphasis on PNF is primarily to ensure that you can choose patterns appropriately if you were to use this approach, not to imply that they are your first priority with exercise). c. Describe one specific exercise/activity that Jawad could perform safely at home with his parents' supervision to promote increased independence and efficiency during gait. Explain your rationale. (Note: This does NOT need to be a PNF activity). d. Indicate the specific type of orthosis you would recommend for Jawad, any special features you would like to see in the orthosis, and the factors you would consider in making your recommendations. Explain your rationale. After obtaining the ideal orthosis for Jawad and through work on improving pelvic and limb control, his gait is much improved and you wish to implement strategies to consolidate the gait pattern he is demonstrating. e. Describe your approach in your therapy sessions to drive neural plasticity from a behavioral standpoint over the two months remaining in his coverage. Explain your rationale. 4. Prior to his injury, Jawad was a junior in high school and a strong student. He lives with his parents and two younger siblings. He plays percussion in the high school band, and enjoys shooting hoops with his friends. He used to spend a few afternoons a week at the Y nearby. He and his family are very active in their church where he assists with the music for Sunday services and helps with the youth group as a volunteer. He has returned to school on a part time basis using a wheelchair, but is having difficulty keeping up with the pace of things with classes changing, carrying what he needs to and cognitively managing the complexity of the environment. His Mom comes to therapy with him, and is very eager to do whatever they can to get him back to his usual routine. A. In order to encourage continued neuroplasticity and progress with his mobility, describe how you would advise Jawad and his Mom to optimize his physical health and wellness. Provide a sample "script" of how you would initiate the conversation about this with them. Identify at least two activities that could be goals to focus on for this purpose based on what you know about his pre-injury interests. 5. Mary is a 45 year old female who sustained a TBI and many other injuries, including right pelvic and femur fractures due to a pedestrian vs motor vehicle crash 3 months ago. They performed operative management for her fractures – per the physicians, she is now allowed full ROM and weightbearing as tolerated. You are working with Mary in inpatient rehab. She is alert and oriented x 1 (self). She requires moderate assistance to initiate tasks such as reaching for the rail to roll. She has a right gaze preference, right sided lean, and mild left inattention. She has some antigravity strength in all four extremities (at least 2+/5) but does not follow commands for more formal MMT testing. You note she has increased tone in her bilateral plantarflexors: 2 on MAS. She has the following decreased PROM: right shoulder flexion and abduction limited to ~70 degrees each, R hip flexion to 90 degrees, R knee flexion limited to 30 degrees and R knee extension is lacking 20 degrees from full extension. She has some edema in distal bilateral lower extremities, but RLE > LLE. You notice C-curve scoliosis with apex at right mid-thoracic spine, posterior pelvic tilt with right pelvic obliquity and rotation – all noted to be flexible. Short sitting edge of mat, Mary requires moderate to maximum assist for static sitting balance – and you note how her R foot is further out due to her reduced knee flexion PROM. She has a forward head position and tendency to keep it flexed down with sitting balance trials, as well as posterior pelvic tilt. Mary requires total assist +2 for slideboard transfers and requires a ceiling lift/hoyer lift for family and nursing staff to assist her. She has poor command following and is easily distractible. She is married and has 2 children (5 and 7 year olds). Prior to the accident, she was independent, a kindergarten teacher, enjoyed hiking and spending time with family. Her home is one level and her family has had a ramp built. Together, her husband and her mother will be providing 24/7 assistance. a. What type of wheelchair and specific components do you recommend? (Be comprehensive) Include the rationale for your choices. 6. Dan is a 54-yr-old man who had 2 strokes, the first on Jan 3, 2023 and the second 3 days later. Both strokes affected his R (dominant) side. A CT scan acquired after the second stroke indicated involvement in the left premotor and motor cortical regions, consistent with middle cerebral artery distribution. He has a history of musculoskeletal problems and pain affecting R shoulder and R hip. Social History: Prior to his strokes, Dan worked as a body shop estimator. He was laid off 10 months ago. He lives with his wife in a single-story home. Dan states that his goal is to "be normal". He wants to be able to use his R arm and to walk without a cane or brace. Range of Motion: Dan shows mild tightness in R ankle plantar flexors. He has been performing heel cord stretching exercises at home. Sensation: Light touch and proprioception are intact throughout R extremities. Motor Function: Dan shows active movement at all joints in RUE and RLE, with moderate influence of flexor synergy pattern noted in the RUE. R shoulder flexion and abduction are present through partial range against gravity, limited secondary to pain. Active isolated R elbow flex and ext are present through almost full range against gravity, and wrist flex and ext and forearm pronation and supination are present through approx 50% of available range. Dan shows weak grasp and active finger abd and ext. He is able to oppose his R thumb to the index finger only. He can reach right hand to post R hip, but not to sacrum. In the RLE, Dan shows mild influence of the flexor synergy. He has 4/5 to 4+/5 strength of hip flexors, extensors, and abductors and knee extensors. Active knee flexion is present through partial range against gravity in standing, with strong tendency toward simultaneous hip flexion. Ankle DF is present through full range in synergy and through partial range out of synergy, and is typically performed with some calcaneal inversion and supination of the foot. Dan demonstrates only 1/5 contraction of peroneals, with no active eversion past neutral. Active great toe extension is present through almost full range, and is often used to assist attempted DF when knee is extended. 4-beat R ankle clonus noted. Balance: Dan’s score on the Berg Balance Scale is 50 out of 56. He has difficulty maintaining balance with narrowed base of support and when performing stool touch (placing alternating feet on step) without upper extremity support. He is able to perform SLS on R for approx 2-3 seconds without his AFO. Pt's forward functional reach is 11 inches. Gait: Pt ambulates independently using a R articulating AFO and standard cane in his L hand. His gait is asymmetrical, with decreased step length on the R. He exhibits toeing out bilaterally (R > L) and a tendency to hyperextend his R knee during stance. Pt is able to walk without the cane, but with exaggeration of gait deficits. a. Dan is considering enrolling in a study using transcranial magnetic stimulation (TMS) to improve UE function. Describe the type of TMS that would be used in this situation, and explain two different options for stimulation frequency and location to improve Dan's motor control in his R UE. b. B. As part of the above research study, Dan will complete a diffusion neuroimaging scan that will enable researchers to quantify the integrity of his corticospinal tract at the level of the posterior limb of the internal capsule. Based on the location of his injury, how would you expect the fractional anisotrophy (FA) values to compare between his left and right tracts? c. The last part of the above research study involves a cognitive task that requires Dan to press a button every time a specific pattern appears on the screen. The researchers want to examine whether Dan’s stroke affected the speed of his cognitive processing. What neuroimaging tool should the researchers use to answer their research question? Explain your rationale. d. Using concepts of locomotor adaptation, design a treadmill intervention to promote a more symmetrical gait pattern for Dan. You have a conventional (NOT a split-belt) treadmill in the clinic. What exactly would you have Dan do during the training sessions? Explain your rationale. e. Distinguish between motor adaptation and motor learning. How could Dan learn to walk consistently with a symmetrical pattern? f. Would you recommend a trial of the Bioness L300 Go for Dan? What are 3 key factors (be sure that these are distinct/separate factors, with no two in the same category) that you should consider in making this decision? Explain your rationale.