Case Report A1 The Application of Posture and Movement Analysis to Accurately Evaluate, Plan Intervention, and Achieve Functional Outcomes for an Individual Poststroke
A1.1 Introduction
An accurate examination and evaluation are critical for identifying the effect a neurological event has on a client’s social participation and activities and for identifying the system impairments contributing to the activity limitations. It is essential to link system impairments to activity limitations to establish functional outcomes with specific performance criteria that reflect changes in the degree of impairment.
The clinician improves the client’s quality of life by minimizing disability, optimizing activities, and remediating system impairments. The development and implementation of the intervention plan reflect how functional outcomes are achieved and system impairments are reduced. The clinician considers the client’s goals, objective findings, as well as didactic information from the neuro- and movement sciences, applied kinesiology, and evidence-based clinical trials to guide the clinical decision-making process. Clinical outcome measures are used to determine the changes in the client’s abilities and the intervention’s efficacy.1
The examination begins with evaluating the client’s activities and activity limitations. Assessing the client in function is consistent with the dynamical systems approach for motor control.2 How a person functions reflects how multiple systems, such as the musculoskeletal, neuromuscular, visual perceptual, and cognitive systems, organize to produce a desired outcome following a neurological event.
Although general descriptors of a client’s functional status provide an overall picture of an individual’s activities and activity limitations, it is critical to analyze posture and movement during functional tasks to identify specific system impairments.3,4,5 A client’s movement strategies for completing functional tasks should be analyzed and compared to the those of a healthy individual to correlate impairments to activity limitations, determine the most significant impairment affecting all areas of function, establish outcomes that reflect both the desired functional outcome and neurorecovery, and develop interventions that specifically address the impairments limiting the client’s activities.
Physical therapists are expected to demonstrate a basic level of competency in observational gait analysis, and the clinical application of the Neuro-Developmental Treatment (NDT) Practice Model extends this expectation to clinical competency in observational posture and movement analysis of functional tasks. For occupational therapists, posture and movement analysis is a critical extension of task analysis.
Because functional tasks are complex, identifying the component parts or subtasks first (task analysis) and then the movement components necessary to efficiently and successfully complete each subtask (posture and movement analysis) helps to more specifically identify the differences between the standard performance criteria and the client’s current level of performance.6 When simplifying tasks into subtasks, the clinician should consider whether these subtasks are arbitrarily defined components of a continuous activity, such as the stages of gait or whether the subtasks have a discrete beginning and ending. Differentiating between discrete and continuous tasks will influence how the motor skill should be taught to maximize learning.7
As clinicians observe and analyze the movement strategies used to complete functional tasks, they can begin hypothesizing or differentiating possible system impairments that may be limiting the client’s activities.8,9 The clinician pursues answers to the following questions: How does the client’s movement strategy differ from that of the healthy population? Are the client’s differences within the range of normal variations observed between individuals in the healthy population? If the differences are outside the range of normal variation, why are the client’s options for movement limited?
To compare the client’s movement strategies to those of a healthy adult, the clinician must understand the typical movement components of various functional tasks. Researchers have identified in the healthy adult population discrete invariable movement components for basic functional tasks. These are considered typical and are used as the standard or norm for such activities as sit to stand, gait, stair climbing, and upper extremity (UE) function.10,11,12,13,14,15,16,17
Although the invariable events in these functional tasks are the foundation for what is considered the norm, in the healthy population there is significant movement variation between individuals of the same age and within the same individual repeatedly performing the same task.18,19,20 These variable events may be due to several factors, such as the method of motion analysis used, the intrinsic characteristics of the individual performing the task, the environmental conditions, and the context in which the task is performed.
Unfortunately, there isn’t a resource that identifies the invariant events or the standard performance criteria for a wide range of functional activities. The clinician must integrate information from a variety of resources, such as motion analysis studies and applied kinesiology and bio-mechanics, as well as human movement studies, motor learning principles, and motor control theory, to develop an expectation for the standard performance criteria.
The following case report demonstrates the clinical application of the NDT Practice Model. It focuses on the critical role of posture and movement analysis in the examination and evaluation of a client—establishing functional outcomes, developing an intervention plan, and implementing intervention strategies. It also illustrates the integration of information from the neuro- and movement sciences and the application of motor learning principles within the NDT problem-solving framework.
A1.2 Case Description
Mark is a 51-year-old, white man with a past medical history (PMHx) of uncontrolled type 2 diabetes mellitus, coronary artery disease with status poststent in 2006, and hypertension. He reported to the emergency department on May 27, 2010, complaining of right-sided weakness.
A1.2.1 Health Condition/Diagnosis
Acute left frontoparietal ischemic stroke with mild subcalcine shift and resultant right hemiparesis.
A1.2.2 Course of Care
• Acute care hospital neurology floor for 1 week.
• Acute inpatient rehabilitation unit; received physical therapy, occupational therapy, speech-language therapy; 5 days/week for 3weeks.
• Skilled nursing facility (SNF); received occupational therapy, physical therapy 5 d/wk for 8 weeks.
• Outpatient therapy (OP therapy); physical therapy and occupational therapy 3 d/wk for 12 weeks.
A1.2.3 Social History
Mark was unemployed prior to his stroke. He has a degree in finance and previously worked in the financial field. He is presently working on developing a Web site for a financial venture.
Prior to his stroke, Mark resided with his grandmother and returned to her home following his discharge from the SNF. The home is on one floor and accessible. Mark is an avid golfer and played on a regular basis prior to his stroke. His plan was to relocate to Texas in 12 weeks after his OP therapy to temporarily reside with his parents while continuing to work on his recovery.
A1.2.4 Personal Goal
His primary activity goal was to resume golfing, using both hands on the club as he did prior to his stroke. When questioned about additional goals, Mark replied, “I figure if I can resume golfing, then I would be able to do most anything else.”
A1.2.5 Examination and Evaluation
Several general descriptions of Mark’s functional activities and activity limitations provided an overall impression of Mark’s functional status at the initial evaluation. Observational posture and movement analysis was used to describe three functional tasks Mark was asked to perform during the initial evaluation. These descriptions reflected more specifically Mark’s current level of performance and helped identify his system impairments. The three tasks were: (1) ambulating without an assistive device, (2) opening an upper kitchen cupboard door with his right hand, and (3) grasping and releasing a cylindrical container.
Activities
1. Ambulated independently in indoor environment with a wide-based quad cane on low-pile carpet, stopping frequently due to right lower extremity (RLE) muscle fatigue and difficulty clearing the RLE in swing. Demonstrated a step-to gait pattern; at velocity.
2. Independently ascended three to four steps, placing quad cane on step, initiating step up with unaffected left lower extremity (LLE), followed by placement of RLE on same step.
3. Independently descended stairs using the left handrail, stepping down with RLE first while shifting weight back onto LLE until right foot was placed foot flat on step below; supported body weight on left upper extremity (LUE) as he stepped down to the same step with LLE. Assistance of another person was necessary to transport Mark’s cane to the bottom of the steps.
4. Independently placed golf club in affected right hand, by using unaffected left hand to passively extend his right fingers, abduct the thumb while wrist was flexed and ulnarly deviated. Once club was positioned in right hand, fingers involuntarily flexed around golf club handle, thumb adducted, and wrist remained flexed and ulnarly deviated.
Activity Limitations
Activity 1
Mark was unable to ambulate functional distances (> 60 feet) in indoor environment on low-pile carpeting without an assistive device and close supervision.
Current Level of Performance for Task 1
Task: Ambulating a short distance without an assistive device. Functional stages of gait (RLE reference limb) were as follows:
• Weight acceptance (WA) with initial contact (IC) and loading response (LR)
Upper trunk flexed forward, laterally flexed to right, rotated back on right.
Lower trunk, pelvis rotated back on right.
Right hip, knee slightly flexed.
Right scapula elevated, abducted on thorax.
Right upper extremity (RUE) anterior to hip at client’s side; shoulder internally rotated; elbow flexed; forearm pronated; wrist flexed, ulnarly deviated; fingers and thumb fully flexed (fisted).
Initial contact lateral aspect foot; foot flat.
As weight accepted, increased upper trunk right lateral flexion; lateral shift to right; increased right hip and knee flex.
• Single limb support (SLS): midstance (MST), terminal stance (TST).
Upper trunk, pelvis rotated back on the right; increased right hip, knee flexion with un-weighting LLE for quick step forward up to R foot.
Upper trunk laterally flexed, laterally shifted to right.
Hip, knee move between small ranges of flexion and extension.
• Swing limb advancement (SLA): preswing (PS), initial swing (IS), midswing (MS), and terminal swing (TS).
Weight shifted forward and laterally onto LLE (lateral greater than forward); upper trunk shifted left, rotated forward.
Right upper trunk and pelvis rotated farther back on the right.
Right hip externally rotated; progressed RLE forward with hip adductors, minimal right knee flexion; ankle dorsiflexion assists with foot clearance; ankle inverts slightly; foot contacts floor up to or slightly behind L foot.
Activity 2
Unable to open an upper kitchen cabinet with his RUE while standing at the counter.
Current Level of Performance for Task 2
Task: Open a kitchen cabinet located overhead with his right hand.
• Starting alignment.
Feet greater than shoulder width apart; right foot slightly behind left; pelvis rotated back on right; right knee slightly flexed.
Left hand on quad cane; upper trunk shifted laterally to left, rotated forward; thorax flexed forward.
Right scapula winged, abducted, elevated on thorax; shoulder internally rotated, adducted; elbow flexed 20°; forearm pronated; wrist flexed, ulnarly deviated; fourth and fifth fingers, metacarpophalangeal (MCP), interphalangeal (IP) flexion; first and second fingers MCP, IP flexion; thumb end range metacarpal (MC) opposition; MCP, IP slightly flexed.
• Movement strategy: transport stage of reach.
Shifted weight onto LLE.
Flexed upper trunk laterally to left; rotated L upper trunk forward.
Elevated right scapula; rotated right upper trunk back.
Abducted, internally rotated and flexed right shoulder 30°; elbow remained flexed; forearm pronated; no change in wrist and fingers.
Rotated right upper trunk forward; flexed hips R greater than L to position hand closer to handle.
Repeatedly moved right upper trunk between forward, back; initiated first and second finger IP extension until he hooked first and second fingers on handle
• Opening cupboard door.
Moved from left lateral upper trunk flexion toward right upper trunk lateral flexion; rotated right upper trunk back; increased weight shift onto LLE.
Released hand from handle; rotated trunk back to the right, extended thumb IP joint; initiated extension first and second IP joints to release handle.
Activity 3
Unable to use his right hand to grasp and release a cylindrically shaped container he was attempting to move while standing in front of the kitchen counter.
Current Level of Performance for Task 3
Task: Grasping and releasing a cylindrical container with his right hand.
• Starting alignment.
weight supported on LEs (L greater than R); upper trunk shifted laterally to left, rotated forward; upper trunk, pelvis rotated slightly back on the right.
LUE on countertop.
RUE positioned at side—trunk, scapula, UE alignment same as noted above in the description of the starting alignment of the second activity limitation.
• Movement strategy.
Elevated right scapula; rotated right upper trunk back; forearm moved from pronation toward supination (does not reach midposition); wrist and fingers remained flexed.
Used left hand to take object to right hand.
Pushed cylinder in left hand between right thumb and index finger.
Initiated release of right grasp by flexing upper trunk to the right, rotating upper trunk forward and back; initiated forearm supination; elbow, wrist, and fingers remain flexed; unable to release cup without help of other hand.
Interpreting Observational Postural and Movement Analysis
Movement analysis of the second task Mark performed, opening an upper kitchen cabinet door with his right hand, was compared with the typical or standard performance criteria used to accomplish the task. The standard performance criteria are based on the kinesiology of the shoulder girdle complex, the biomechanical and musculoskeletal requirements determined by the context and environment, and the neurophysiology of reach.
There are invariant events that occur with forward reach, but there is also significant variation in the possible movement strategies that could be used to accomplish the same task. In Mark’s case, factors such as his height, distance from the cupboard, the type of cupboard handle, and the direction the door swings were all variables the clinician considered when trying to identify the invariant standard performance criteria for opening the cupboard door.
To correlate system impairments to activity limitations, the clinician compared the movement strategy Mark used to position his hand on the cabinet handle to the standard performance criteria for the activity. The proximal UE movement strategy he used differed from the standard performance criteria in the following way: Mark’s thoracic spine was flexed rather than extended, his upper trunk was shifted to the left and the right scapula abducted further from the already abducted starting alignment and moved into end range scapula elevation. The glenohumeral joint moved into abduction and internal rotation without a change in elbow flexion or forearm pronation.
The movement strategy Mark used proximally to initiate RUE forward reach suggested that there may be either a limitation in range of motion (ROM) and/or weakness in the thoracic spine, scapula, and/or glenohumeral joint. To differentiate between musculoskeletal or neuromotor causes for the activity limitation in forward reach, a more specific assessment of the trunk and shoulder girdle complex was indicated. Because the shoulder girdle complex does not function in isolation, further evaluation of the shoulder girdle complex considered all related body segments and, in particular, the base of support (BOS). In Mark’s case, his LEs served as his BOS, as he reached forward to open the cabinet.
The interrelationship of the shoulder girdle complex to other body segments is clear from a strictly anatomical perspective and is supported by kinematic studies.21,22,23 Muscles attach from the pelvis; lumbar, thoracic, and cervical spines; and the rib cage to the shoulder girdle complex. The strength, alignment, and ROM of these body segments affect UE function. A more specific assessment of Mark’s trunk and LEs was performed to determine possible impairments contributing to his limitations in UE reach.
Identifying Client-Centered Goals
In establishing functional outcomes, a primary consideration is identifying the activity or activities that are meaningful and significant to the client. The client’s motivation and participation in the learning process are essential for motor skill learning.24 In Mark’s case, at his initial evaluation, his personal goal was to resume golfing. His rationale was that if he had the physical abilities to golf, he would most likely be able to do almost anything. Mark recognized that if he could golf, it meant he would have a functional grasp and release of his right hand, adequate strength and coordination of his RUE to move through extreme ROM with selective movement at each joint, adequate RLE strength for balance and power needed to drive the ball, and also adequate strength and balance to walk the greens and maneuver over uneven terrain.
Mark’s personal goal was addressed in intervention; however, due to the activity’s complexity, number of subtasks, and specificity of training, an alternative goal will be used as an example for establishing functional outcomes. In preparing for his move to Texas, Mark wanted to assist with packing the contents of his office. The following example illustrates task and movement analysis to identify the standard performance criteria for lifting a box and Mark’s current level of performance when he attempted this activity.
Functional Activity Analyzed
The activity identified was stooping to pick up a lightweight box off the floor using both UEs, carrying it to a nearby countertop, and placing it on the surface. The standard performance criteria compared with Mark’s performance of this activity is outlined in Table A1.1.
A comparison of Mark’s performance to the standard performance criteria for this activity and the previously described activities demonstrated noticeably limited variety in the movement strategies Mark accessed. Each task had different requirements, and in each task, Mark consistently established the same BOS in standing and demonstrated the same UE movement strategy for forward reach; or as in this case, he failed to use the affected UE in this bimanual task. Based on this analysis, the analysis of his golf swing, and other functional tasks observed throughout the evaluation, as well as more specific evaluation of individual systems, Mark’s system impairments were identified. The impairments listed refer to Mark’s right side unless otherwise indicated.
Table A1.1 Comparison of performance criteria
Abbreviations: BOS, base of support; GH, glenohumeral; L, left; LE, lower extremity; LLE, left lower extremity; R, right; RLE, right lower extremity; ROM, range of motion; RUE, right upper extremity; UE, upper extremity.
System Impairments
Musculoskeletal
• Decreased passive range of motion (PROM) lumbar flexion.
• Decreased PROM end range thoracic extension.
• Decreased muscle length.
Scapula elevators; abductors.
Shoulder internal rotators, especially > 90° flexion.
• Decreased PROM into wrist extension (0–30°) secondary to the following:
Decreased muscle length wrist, long finger flexors.
Decreased mobility proximal carpal arch.
Decreased mobility distal radioulnar joint toward pronation.
Decreased carpal joint mobility—proximal row radially deviated; distal row ulnarly deviated.
Neuromuscular
It should be noted that muscle weakness is defined as the inability to generate sufficient tension in a muscle for the purposes of posture and movement.25
• Decreased right upper trunk strength (all groups); cannot increase/sustain muscle force.
• Decreased initiation muscle force scapula depressors, adductors, stabilizers.
• Decreased initiation muscle force shoulder external rotators.
• Decreased shoulder flexion and abduction strength.
• Decreased selective movement RUE (UE Fugl–Meyer 22/66).
• Increased muscle tone right wrist flexors; third, fourth finger lumbricals; opponens pollicis.
• Decreased hip extension and abduction strength: cannot increase/sustain to support body weight in single-limb support phase of gait.
• Decreased hip flex strength > 10° antigravity for initiation swing.
• Decreased hamstring strength between 30 and 60° antigravity.
• Decreased ankle eversion strength.
• Decreased ankle plantar flexor strength.
• Decreased RLE selective movement (LE Fugl–Meyer 20/34).
• Unable to sustain adequate muscle force simultaneously in RUE, RLE, and trunk to engage RUE in functional activities in standing and gait.
Sensory
• Decreased proprioception RUE and LE.
Cardiovascular
• Compromised cardiovascular endurance to sustain activity.
Prioritizing Impairments
Given the list of specific system impairments, it was important to identify the impairment(s) that most significantly influenced all aspects of Mark’s functional activities; that is, the impairment(s) that, if responsive to intervention, would most significantly improve his functional abilities. In Mark’s case, the most significant impairment that contributed to his activity limitations was his right hip weakness. Mark’s hip weakness limited his ability to transition from sit to stand, increase his gait speed, manage the stairs with a step-over-step pattern, stoop to pick up objects off the floor, generate adequate power for a golf swing, and use his RUE for support, balance, or to perform functional activities in standing.
Mark’s ability to generate and sustain muscle force in his right hip as well as his trunk was imperative to achieving and maintaining postural control necessary for RUE function. A prerequisite of UE function is postural control.26 In standing, a stable lower extremity (LE), one with adequate strength to support a person’s body weight, contributes to postural control, freeing up and allowing the upper extremities to engage in functional activities without displacing the body.
This relationship has important implications for clinicians attempting to promote UE recovery for a client in standing. In Mark’s case, before the RUE was successfully engaged in function, the clinician, regardless of the discipline, had to address the right hip weakness. Adequate postural control had to be established before the potential for UE recovery was realized. Although hip strength is a prerequisite for functional use of the UE in standing, it is not addressed in isolation, sequentially, or to the exclusion of other system impairments. This control will be explained in more detail in the section on intervention.
A second impairment that significantly affected Mark’s activities was his right scapular weakness, specifically decreased approximation, depression, and adduction strength. Scapular muscle weakness alters muscle length–tension relationships of the shoulder girdle complex, limiting the ability to use the UE for support, balance, or reach.27 Scapular weakness also influenced Mark’s ability to sustain trunk and hip extension in standing because the weight of the unsupported RUE created a forward and right lateral flexion moment of the upper trunk and a forward flexion moment at the hips.
Identifying the most significant impairment(s) did not minimize the effect of Mark’s other impairments on his activity limitations. Prioritizing impairments allowed the clinician to establish meaningful functional outcomes with specific performance criteria and to develop intervention strategies that consistently targeted Mark’s primary impairments.
Establishing Functional Outcomes
The following is an example of a long-term (LT) and several short-term (ST) functional outcomes established for Mark to measure achievement of the first subtask in the activity previously described. Identifying the performance criteria for these outcomes served as a frame of reference for determining the impairments targeted during the intervention session. Other variables that affected Mark’s potential for recovery, such as the site and extent of the lesion, comorbidities, type and degree of system impairments, his motivation, and his ability to learn, were also considered when identifying performance criteria.
Because the objective was to achieve the desired functional outcome(s) and to promote neurorecovery by reducing system impairments, the functional outcomes included both quantitative and qualitative components of task performance. Inclusion of the qualitative performance criteria allowed the distinction of improved functional abilities due to neurorecovery versus compensation.28 The specific performance criteria reflected the anticipated change in the degree of impairment necessary to achieve the outcome.
The motor learning principle of adaptive training was applied to determine the short-term outcomes.29 The short-term outcomes were modifications/adaptations of the functional activity. They were structured to require movement strategies similar to those of the long-term outcome, challenge Mark’s abilities, and require the remediation of system impairments for successful completion. Each of the three short-term outcomes outlined for physical therapy and occupational therapy progressively challenged Mark’s abilities by manipulating variables that made the activity more difficult to perform.
The variables are identified for each discipline-specific outcome in the sequence.
Functional Activity
The functional activity consisted of stooping to pick up a lightweight box off the floor using both UEs, carrying it to a nearby countertop, and placing it on the surface.
Subtask 1
Stoop to the floor while reaching toward the box, placing hands on opposite sides of the box.
Long-Term Outcome
Mark will stand in stride with the right foot ahead of the left, shifting weight from the LLE to the RLE as he reaches down toward the floor with both UEs, placing his hands open and flat on opposite sides of the box.
Key Performance Criteria
• Sustained dorsal and ventral trunk muscle activity; graded eccentric release of trunk extensors.
• Generate RLE hip extension and knee extension muscle force moving eccentrically into gravity; activate hip abduction muscles force for lateral stability; generate hip external rotation muscle force to align LE.
• Approximate scapula on thorax; initiate shoulder flexion 0 to 45° in neutral scapular rotation as elbow extends; forearm moves from pronation to midposition; wrist extends past neutral; fingers and thumb extend.
First Short-Term Outcome
Physical therapy: Mark will squat to a low surface (50% of distance to the floor), narrow stride position (in the frontal plane), right foot ahead of left, assistance for sustaining right hip extension and abduction muscle force as he weight shifts forward onto the RLE and eccentrically moves into gravity using both UEs for support on a surface, with assistance to maintain the right hand on the surface.
Occupational therapy: Mark will use the RUE for support on a flat surface, tabletop height, in squat position with assistance for scapula approximation; isometric glenohumeral external rotation, shoulder flexion, elbow extension; right hip stability while stepping forward and back with LLE and minimal LUE support for balance.
Second Short-Term Outcome
Physical therapy: Mark will squat to the floor with his feet in the wider stride position in the sagittal plane (5–6 in apart), the right ahead of the left, with assistance sustaining right hip extension and abduction muscle force as he weight shifts forward onto his RLE while he eccentrically moves into gravity, sliding the LUE toward the floor in contact with a surface for balance with assistance maintaining the RUE for support on a surface.
The variables manipulated were an increased width in stride; increased ROM for LE weight shift; increased demand of RLE strength; decreased BOS by moving the LUE on a surface.
Occupational therapy: Mark will use the RUE for support on a flat surface, tabletop height, with assistance for scapular approximation; isometric glenohumeral external rotation and eccentric release of shoulder flexors, elbow extensors; right hip stability while stooping (50% distance to the floor), sliding the LUE toward the floor in contact with a surface for balance; with assistance to initiate right concentric shoulder and elbow extension to move against gravity.
The variables manipulated were to alter the type of RUE muscle contraction from isometric to eccentric; initiate concentric activity; increase the ROM the entire body is moving through; increase the demand for RUE postural adjustments.
Third Short-Term Outcome
Physical therapy: Mark will squat to the floor with his feet in a wider stride position in the sagittal plane (8–10 in apart), right ahead of left, independently sustaining the right hip extension and abduction muscle force as he weight shifts forward onto his RLE while eccentrically moving into gravity, reaching to the floor to pick up a golf ball with his left hand with assistance, maintaining the RUE for support on a surface (Fig. A1.1).
The variables manipulated were to increase the width in stride; increase the ROM required for LE weight shift; increase the demand for RLE strength; decrease the BOS by taking the left hand off the support surface.
Occupational therapy: Mark will independently use his RUE for support on a flat surface, tabletop height, eccentrically releasing shoulder flexors and elbow extensors as he reaches toward the floor to pick up a golf ball with his left hand, returning to a squat position with concentric shoulder and elbow extension, and assistance to achieve balanced muscle activity between wrist flexors and extensors for initiation of finger extension with his hand on a surface with assistance for hip stability.
The variables manipulated were to decrease the amount of manual feedback, increase the number of degrees of freedom to control, and increase neuromotor demands of the right wrist and hand segments.
The performance criteria in these functional outcomes addressed Mark’s most significant impairment—right hip weakness. Additional impairments that limited Mark’s ability to perform this activity, such as decreased ability to sustain trunk stability; weak scapula depressors, adductors, and serratus anterior; weak shoulder external rotators, flexors, and abductors, were also addressed.
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