Adult Rehab with IM: Interdisciplinary Best Practices

Application to Adult Rehabilitation

1.   Is IM treatment applicable to adults?

Yes, the fundamentals of neuromuscular and cognitive training are very applicable to adult rehabilitation.

2.   Does the research support adult best practices?

Yes, research showing the effectiveness of IM is seen in the areas of cognitive, auditory and visual training, attention, motor control and coordination, memory, timing and in sequencing.

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Application to Adult Rehabilitation

3. Is IM applicable in “my” treatment environment?

IM is currently used in many adult treatment facilities. IM is used in acute hospital settings, rehabilitation centers and hospitals, outpatient clinics, community centers, assisted living, nursing homes and in Home Health.

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Why IM? Adult Rehabilitation

v  By facilitating cortical organization through repetition and the development of new and established neural pathways, including Interactive Metronome as part of a comprehensive rehabilitation program has the potential to bridge the brain body gap and facilitate permanent functional neurological change.

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IM and Neuro-Rehab: Active Ingredients for Effective

Neuro-rehabilitation

v Task practice is the single most important variable for motor learning.

v “What” is practiced is more important than mere repetition.

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IM and Neuro-Rehab: Active Ingredients for Effective

Neuro-rehabilitation

v Motivation and meaning are critical to skill learning.

v Problem solving and implicit processes are required for skill acquisition.

Winstein, 2005 III Step Proceedings Motor Learning: From Behavior to Social Cognitive Neuroscience Perspectives

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Why choose IM? v  By setting the appropriate

tempo, difficulty, volume, etc the provider exposes the client with positive feedback and shape behavior.

v  As the patient understands the objective of IM and demonstrates ability to modify speech/language/cognitive and motor patterns, the clinician can tighten parameters to further modify skill set.

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What is Neuroplasticity? v  The brain’s capacity to change (Robertson et al.

2003). w  Virtually any change in the brain, from the chemical level

to the formation of new neurons (i.e. neurogenesis) to the remapping of larger regions.

v  Any functional change within the nervous system outlasting an (experimental) manipulation. (Classan et al. 2003)

v  Plasticity (systems level) may refer to change in brain networks that carry behavioral implications over time (Ward 2004).

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When is IM Indicated? v  IM can be used on inpatient or outpatient basis v  Indications for IM:

w  Recent falls w  Changes in cognitive processing and/or

sustained attention w  Inability to initiate LE movement during gait or

turn without a loss of balance w  Increased shuffling gait and/or hesitations with

movement

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When is IM Indicated? v  IM can be used on inpatient or outpatient basis v  Indications for IM:

w  Increased assistance to perform ADL’s w  Significant effort and time required to perform

ADL’s safely w  Reduced ability to control UE movements during

functional tasks w  Difficulty with expressive and/or receptive

language skills

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Brainstorm: Who, What & Where do you IM?

v  Where do you typically treat your IM clients?

v  What key problems do your clients present with? Give 3 examples

1.   _________________________________ 2.   _________________________________ 3.   _________________________________

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Brainstorm: Who, What & Where do you IM?

v  List any secondary problems that you have identified while using IM.

v  What clients have NOT benefited from IM? Why do you think this was the case?

v  What are some of the concomitant issues that the adult population presents? Give 3 examples

1.   _________________________________ 2.   _________________________________ 3.   _________________________________

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Areas Commonly Identified for Treatment

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PHYSICAL v  Reflex integration

v  Posture

v  Environmental limitations

v  Vision impaired

v  Hearing impaired

v  Sensory-motor impairments

v  Tone

v  Range of movement

v  Endurance

v  Gross motor coordination

v  Fine motor coordination

Areas Commonly Identified for Treatment

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COGNITIVE LINGUISTIC v  Delayed processing

v  Auditory processing delays

v  Language processing delays

v  Memory impairments

v  Attention to task

v  Organizational skills

v  Poor insight/judgment

v  Decision-making skills

v  Following directions

v  Delayed working memory

v  Poor sequencing

v  Verbal fluency

v  Decreased receptive and/or expressive language skills

Areas Commonly Identified for Treatment

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SENSORY

v  Sensory-seeking

v  Sensory-avoiding

v  Visual sensitivities

v  Tactile sensitivities

v  Auditory sensitivities

v  Olfactory sensitivities

v  Gustatory sensitivities

v  Vestibular sensitivities

v  Body-in-space awareness

v  Internal drive

v  Impaired modulation skills

v  Impaired behavioral regulation

v  Inability to attain/sustain a ready level of arousal

Where to Begin?

v Short Form Test (SFT) w  As part of your overall assessment…Is this

patient a candidate for IM? w  May use unaffected or less affected side

to determine the patient’s ability to time movements to the ref tone

w  Assess cognition •  attention span •  memory •  ability to follow instructions •  frustration tolerance •  timing tendency

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Assessment

v Long Form Assessment (LFA) w Can test only unaffected side to

determine the patient’s IM timing and learning capability.

w Be prepared to modify LFA for motor, cognitive, and communicative deficits.

w This will give the clinician an indication of the unaffected side’s coordination for comparison and goal development.

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Modifying Trigger Access

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v Use only the unimpaired side

v Use the unimpaired side to assist the impaired side

v Place trigger on stationary surface and have patient move extremity to touch it

Treatment

v  Weight bearing on foot trigger (sitting and standing)

v  Adapted Side hit: Wrist v  Shoulder Shrug v  Synergy Hit v  Elbow Hit

Slide 19

v  Table Slide v  Lower Extremity Weight Shift v  Balance With Affected Side Stomp v  Functional Reach

Left Hemiparesis

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Use of Adaptive Equipment

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Treatment

v  Shoulder v  Elbow v  Hand v  Hip v  Knee

Slide 22

v  Ankle v  Functional Upper Extremity

Activities v  Functional Lower Extremity

Activities

Awareness of the Affected Side

Patient practicing regard to right side (affected side) of hemi-body, sequencing control of hand trigger to named body parts.

Slide 23

Lower Extremity Spasticity

v  Use of office supply postural foot bench to position foot w  to decrease

plantarflexion & dorsiflexion components of task

w  to reduce exertion efforts of hypertonic muscles

v  This task may be done while patient is lying supine, with knees bent, or while seated

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Symmetrical Movement v  Hand-over-hand assist to

facilitate symmetrical upper extremity movement

v  Hand trigger placed on less affected extremity

v  Guidance given to weaker extremity as hands are lifted/lowered to tap on legs in unison to the beat

v  Helps patient sync each side of body together and increase awareness of more densely affected limb

Slide 25

Patient Assisted Movements

Use of unaffected upper extremity to assist weaker side to tap up and down onto right knee, activating hand trigger as a form of hand-over-hand assist

Slide 26

Treatment

v  Alternating UB weight-shift prone over mat table v  Prone extension over treatment mat while activating

variable height IM triggers. v  Alternating UB vertical reach activity. v  UB sequencing over IM trigger in side lying

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Therapist Guided Movement Patterns

Guided motion to assert motor patterns sufficient to facilitate functional reciprocal gait sequence

Slide 28

Positioning and Trigger Access v  Quadruped positioning to

work on dynamic upper body/lower body weight bearing and weight-shifting

v  Patient positioned on bilateral

hands and knees with bedside table positioned at shoulder girdle height directly in front of body

v  Hand triggers (x 2) attached to the table edge with the use of self-adhesive Velcro

v  Computer positioned to R of patient

Slide 29

Activity Facilitated Movements

v  Patient may tap switches with open hands, isolated digits or, in this case using a cylindrical peg to mimic modified tripod grasp with elbow extension

v  Patient holds peg with R hand and taps triggers, alternating L-R-L

v  Head position may be at midline or turned to the side to view visual feedback on computer screen

Slide 30

Reaching v  Patient stands perpendicular to

wall with affected side facing the target, at a distance just greater than arms reach when fully extended

v  Wrist weight applied to ataxic extremity to provide increased proprioceptive feedback and facilitate inhibition of tremor

v  Patient reaches away from center of mass, supported by trunk and lower body weight-bearing skills, to hit target with palm of hand.

Slide 31

Positioning: Prone

v  Prone positioning with weight-bearing through bilateral flexed elbows

v  Trigger placed on treatment mat directly in front of patient (with non-slip matting)

v  Computer screen directly in front of patient

v  Modifications: w  Adjust to increase bilateral skills by

alternating R/L hands onto trigger w  Address cognitive skills by hitting

with each hand in numeric order •  EX: hit 5 times with your R hand

then hit 3 times with your L hand, repeat

Slide 32

Positioning: Side

v  Patient lies on L or R side, propped up onto elbow v  Trigger placed on mat in front of patient v  Patient reaches forward and strikes trigger with free

hand v  Engaging environment for patient to participate in

dynamic weight-shifting through contra-lateral shoulder girdle and also support forward flexion patterning

Slide 33

Dynamic Movements Patterns

v  Use of IM with symmetrical upper body positioning and strengthening exercise

v  Patient lies supine with legs extended, or flexed over a bolster should excessive trunk tone be an issue

v  Patient grasps weighted bar with hand placed at each end

v  Patient raises bar in sync with ref tone to tap trigger placed overhead, affixed to adjustable-height bedside table

Slide 34

Dynamic Movements: Standing

v  Upper body-lower body segmentation skills with use of multiple triggers

v  Patient stands on 2-step stool to dissociate abnormal tonal patterns in trunk and lower body

v  3 triggers placed in triangular pattern at shoulder and eye level

v  Computer placed to R of patient

v  Patient stands on step stool, with lower leg extended and upper leg flexed to support dynamic balance

v  Patient reaches forward w/ R hand and taps hand triggers in L to R sequence

Slide 35

Positioning and Tone Management

Slide 36

Using gravity to assist movement with active or passive pendulum exercises

Stabilization

v  Lower body strengthening and tone management

v  Patient balances on unaffected leg while striking forward with affected leg to activate trigger with ball of foot or toe on the wall.

v  Ankle weight applied distally to the affected extremity to

provide resistance, proprioceptive feedback and facilitate inhibition of abnormal tonal patterns

Slide 37

Kineso™ taping Kineso™ taping to upper extremity extensor surfaces to facilitate increased agonist/antagonist synergy during IM activity sequences

Slide 38

Parkinson’s: Rhythm v  Focus on the few IM exercises that patient

can participate in while seated or with minimal physical assistance to maintain a standing position using tempo set at 54 for up to a minute.

v Determine what changes you can make to maximize patient’s success and build on those strategies so that you can “prime” the patient to use rhythm as an auditory cue.

v Have patient demonstrate movements prior to starting exercise set with the reference tone.

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Tempo !! v Adjust tempo

w  Faster tempo (at least 60) for all 3 UE IM exercises

w  Slower tempo (45-50) for alt toes or heels w  54 -60 for tapping toes and heels will make it

easier for patients to match the movements with the reference tone

v Different tempos for each of the exercises that you focus on can be helpful.

v You may wish to focus on the first 6 IM

exercises

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Rhythm Techniques v  Demonstration cues

v  Verbal cues repeatedly as needed throughout the exercise

v  Counting cues

v  Physical assistance

v  Assistive device

v  Visual mode

v  Move foot onto/off of trigger on each beat

v  Eliminate guide sounds

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Visual Cues

Visual targets w  Place contrasting targets on the floor w  Targets can include numbers or colors to cue patient

Slide 42

Whole Body Movement v  For more severely involved Parkinson’s patient, focus

on gross trunk movements (i.e. swaying hips) using the sound of the reference tone without a trigger; or attach hand trigger to wall so that patient can “bump” the trigger with one hip.

v  Work toward decreasing amount of physical assistance required to perform this motion.

v  Add more traditional IM exercises after patient is successful coordinating larger movements.

v  Alternative: Start by using familiar music. Proceed as above so that IM exercises can be performed.

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Treatment ideas for Parkinson’s

Slide 44

Foot Trigger

v  Examples of dual trigger for foot placement exercises:

1.   Ankle eversion and plantar flexion

2.   Ankle inversion and plantar flexion

Slide 45

Mirroring and Imitation

v Patient mirrors the hand movements of the IM provider within a defined spatial environment – hitting above and then below of the noodle to define smooth movement transitions.

Slide 46

Apraxia/Dyspraxia

v Weighted balls to add momentum to movement

Slide 47

Dynamic Stabilization

v  Motor planning sequence – tapping triggers on wall

v  Using gravity and right body stabilization by leaning into the wall – allowing for isolation and focus on left body weight shift and motor sequence.

Slide 48

Guide Movement Patterns

v  Providing guidance for stride orientation during gait-training

v  Pool noodle placed on floor between patient’s feet to act as guide/‘buffer’ for foot placement on either side of foot trigger

v  As patient progresses this can be graded to colored tape across foot trigger and then move to verbal cues only

v  In this instance, patient is also wearing weighted (20#) vest to provide increased proprioceptive input

Slide 49

Working the “Core”

v  Firm pressure provided through patient’s proximal body to cue him to the beat.

v  Allows patient to ‘feel’ beat

and concurrently engage in tapping foot trigger with his right lower extremity

v  It is critical that provider’s own timing is as close to SRO (0-15ms) as possible as cues are provided

Slide 50

Using a Ball for Core Activities

v  Tempo 54

v  No trigger used

v  Patient squeezes ball between her legs and then releases in sync to the beat

v  This provides not only a rhythmic sequence for this movement, but also specific proprioceptive input on the beat

Slide 51

Dynamic “Core” Activities

v  Alternating sit ups to touch ball to the beat

v  Trigger could be placed on right, left or bilateral to progress this exercise to be interactive to the beat

v  Could also place trigger UNDER ball and lift ball up/down with bilateral feet as a lower abdominal exercise

v  Towel/sheet could be placed around patient’s upper body to help to initiate sufficient flexion to tap ball and to facilitate increased engagement in initiation and control of movement

Slide 52

Rolling from Supine to Sidelying

v  Place trigger on clinician’s hand.

v  Patient then reaches

across to tap the trigger.

v  Placing the trigger on the clinician allows difficulty of the activity to be easily graded - clinician can move trigger closer or further from patient.

Slide 53

Sidelying to/from Sitting

v Patient is seated at edge of mat.

v Place trigger on mat so

patient can practice moving from sitting into lateral trunk flexion with forearm on mat.

v  Trigger is placed under patient's elbow.

Slide 54

Sidelying to/from Sitting

v  If patient unable to achieve this position comfortably, the surface can be elevated with bolsters.

v  Patient hits the trigger on every

other beat.

v  Purpose: Practice pushing to upright position by extending elbow, and the reverse of preparing to get into bed by lowering onto elbow.

Slide 55

Sit to/from Stand v  Anxiety about falling forward

can be decreased by placing table in front of patient.

v  Place 2 triggers on table, far

enough from patient to generate anterior weight shift in order to reach triggers.

v  Ask patient to tap triggers, alternating right and left hands, unilaterally and crossing midline.

Slide 56

Sit to/from Stand v  To improve anterior weight

shift when moving from standing to sitting, place trigger on arm rest of chair behind the client.

v  On each beat, patient performs a “mini-squat” and reaches back with hands to touch armrests/trigger.

v  If the patient has knee pain, perform low number of repetitions.

Slide 57

Dynamic Sitting and Standing Balance

v  Patient can be seated on solid surface with/without back support or a physioball, depending on individual’s ability.

v  Triggers are placed on clinician’s hands or on wall.

v  Patient crosses midline to tap trigger, alternating right and left.

Slide 58

Dynamic Sitting and Standing Balance

v  Patient seated on physio-ball and trigger is placed on floor

v  Patient taps trigger with foot, alternating right and left.

v  The further from patient the trigger is placed, the more difficult the exercise.

v  Patient should maintain proper sitting posture - including anterior pelvic tilt.

v  Patients will tend to lean backward/place/brace hands on ball to compensate for decreased sitting balance.

Slide 59

Dynamic Sitting and Standing Balance

v  To promote unilateral stance on affected leg, place trigger on a 3” block (on non-slip surface).

v  Patient stands on affected limb and taps uninvolved extremity on the trigger.

v  Patient can tap trigger each beat or every other beat, depending on tempo and individual ability.

v  Wooden dowel with a rubber base is useful if client needs to hold something for balance.

v  Dowel is tall – placing patient’s hand at shoulder height minimizes trunk flexion often created by balancing on a cane.

Slide 60

Dynamic Sitting and Standing Balance

v  Place triggers on wall at shoulder height 30-48” apart.

v  Patient stands at wall and crosses midline to hit trigger on opposite side.

v  Triggers must be far enough apart to require trunk rotation with a change in lower extremity weight bearing.

v  Patient should shift from foot to foot when this exercise is performed correctly.

Slide 61

Training with IM In-Motion Triggers

v  In-Motion trigger goals may include: improve biomechanics, alter gait speed, or increase stride length.

v  Walking on the treadmill with the IM In-Motion is a powerful tool as the repetitions can be set very high and the client can practice walking for several minutes.

v  Clinician can use tactile cues to improve patient’s gait pattern.

v  Improvement in gait pattern will be rewarded with more accurate auditory biofeedback from the IM.

Slide 62

Training with IM In-Motion Triggers

Slide 63

Training with IM In-Motion Triggers

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Treatment

Scapula v  Scapula elevation v  Scapula retraction v  Scapula depression

v  Scaption

Functional Activities v  Shoulder/Ball (closed chain) v  Weighted activities v  Theraband exercises v  Feeding v  Reaching v  PNF Movements

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Shoulder v  Shoulder flexion (isometric) v  Shoulder extension (isometric) v  Shoulder abduction (isometric) v  Shoulder flexion v  Shoulder extension v  Shoulder abduction v  Internal rotation v  External Rotation

Upper Extremity

v Use of IM to support grasp and shoulder skills

v Pulley is used to counterweight the arm, allowing for free upright movement with decreased effects of gravity

Slide 66

Upper Extremity

v  Use of IM to stabilize and strengthen L shoulder extension and hand grasp with counterweight pulley system

v  Patient stands facing trigger placed on top of therapy ball

v  Patient grasps pulley and pulls down into extension to place hand over trigger to activate with graded force pressure in sync with the beat

Slide 67

Treatment

Functional Activities: v  Weighted Flexion v  Weighted Extension v  Weighted Supination v  Weighted Pronation v  Endurance

Slide 68

Elbow movement: v  Elbow Flexion v  Elbow Extension v  Elbow Supination v  Elbow Pronation

Treatment

The Wrist v  Wrist Flexion v  Exercise: Wrist Extension v  Exercise: Wrist Radial Deviation v  Exercise: Wrist Ulnar deviation

Functional Activities

v  Finger Dexterity v  Object manipulation v  Hammer v  Multi-joint

movement activities

Slide 69

The Fingers v  Finger Flexion v  Finger Extension v  Thumb Abduction v  Thumb opposition

Fine Motor Skills

v  Grasp hard rubber ball with one hand and repetitively tap the tape switch (within the foot trigger) with the ball, in sync to the beat

v  Size and density of ball can be modified according to patient’s hand size, grasping range, available upper body range of motion and wrist/hand strength

v  Tempo may be modified to accommodate delayed mental processing speed, fluctuating muscle tone or motor coordination needs

v  Prehensile grasping patterns, intrinsic strengthening and wrist flexion/extension patterns

v  Foot trigger placed on non-slip surface, positioned directly in front of patient on variable height table

Slide 70

Fine Motor Skills

v  Finger abduction with trigger placed on non-slip surface

v  Patient sits facing trigger set-up - positions fixed palm onto matting with index finger resting against lateral border of trigger

v  Patient gently elevates and abducts index finger to tap top of trigger in sync with the beat

v  Modifications: increase distance of hand to trigger, increase tempo, increase repetitions or increase the height of the switch

Slide 71

Fine Motor Skills

Positioning of IM trigger to facilitate activation and strengthening of finger adduction patterns

Slide 72

Fine Motor Skills v  Intrinsic hand strengthening

with use of trigger

v  Patient sits facing a variable height table at waist height

v  Place non-slip matting surface onto table to provide traction for positioning

v  Patient flexes ulnar portion of hand into palm and holds trigger between thumb-pad and palmar surface of index finger

v  When positioned, patient squeezes trigger between thumb and index finger in sync with the beat

Slide 73

Fine Motor Skills

v  Use of graded-force clothes pin to activate a suspended hand trigger

v  Patient sits facing computer screen (or it may be out to the side)

v  Patient holds trigger by the wire (fingers close to the switch)

Slide 74

v  Patient holds clothes pin with other hand

v  Patient activates trigger by opening and closing clothes pin on and off the trigger in sync with the beat

Fine Motor Skills v  Graded pressure clothes pin used to

activate trigger with pincer grasp

v  Top photo: Non-preferred ‘collapsed’ thumb with hyperextension at the CMC and DIP thumb joints

v  Bottom photo: Preferred positioning with thumb joint co-contraction and rounding for stability

v  Trigger is attached to edge of variable height table with trigger hanging over edge to allow access for contact with the clothes pin above and below

Slide 75

Fine Motor Skills

v Use of graded force clothes pin to work grasp/release patterns in sync with the metronome beat

v Patient supports trigger with unaffected hand and operates the clothes pin with the affected hand, facilitating pincer grasping patterns

Slide 76

Fine Motor Skills v  Modified tripod grasp and step

horizontal sequencing

v  Patient provided with cylindrical peg to grasp

v  Instructed to tap trigger in L-R-L sequence in sync to the beat

v  2 triggers attached to edge of variable height table

v  Activity may be progressed to facilitate w  Reaching forward/back w  Reaching up/down w  Reaching under/over

Slide 77

Fine Motor Skills

v  Facilitate grip strengthening, wrist extension, left-to-right sequence progression in standing posture

v  3 triggers affixed to wall at shoulder height in horizontal sequence

v  Patient taps each trigger in L to R sequence while grasping a ball large enough to fit into span grip of hand

v  Patient is standing with one foot elevated onto foot-stool to facilitate lower body weight-shifting, decreased tonal extension patterns at the pelvis and decreased overall base of support to encourage upper body tone activation

Slide 78

Fine Motor Skills

Wrist extension/ flexion positioning with a soft sports ball to support hand grasping patterns while using IM

Slide 79

Fine Motor Skills v  Fine-motor pincer grasp and

graded force pressure activity using IM trigger and 2 stackable pegs

v  Patient places one peg lightly onto hand trigger with non-dominant hand

v  To metronome beat, patient then taps the second peg in and out of the base peg

Slide 80

Fine Motor Skills

IM used in conjunction with Bioness H200 to maintain finger extension while using active shoulder muscles

Slide 81

Fine Motor Skills

v Using Bioness in combination with IM to maintain a grip on the pulleys

v Pulley is

counterweighted for the weak arm

Slide 82

Fine Motor Skills

v Use of IM to facilitate digit manipulation

v Patient sits with trigger stabilized onto L upper leg (placed on non-slip matting)

v Patient taps trigger with alternating fingertips to synchronize to the beat

Slide 83

Fine Motor Skills

v  Use of IM to replicate and facilitate R forearm supination-pronation

v  Patient seated in front of variable height table with 2 triggers placed approximately shoulder width apart (on non-slip matting)

v  Patient holds soft rubber cylindrical shaped object and taps each switch in a L-F-L horizontal plane with right elbow held securely to R side to improve forearm isolation

Slide 84

Fine Motor Skills v  Use of IM to facilitate “flicking”

motion onto trigger to promote index and thumb extension while in standing

v  Trigger placed on wall directly in front of patient

v  Top photo: Patient reaches up to trigger with index finger flexed into thumb web space

v  Bottom photo: Patient then releases index finger into extension to activate trigger in sync with the beat.

Slide 85

Fine Motor Skills v  Placement of 2 triggers

onto a non-slip matting material on a variable height table

v  Cover triggers with

aperture sufficient for forearm access (EX: cardboard box)

v  Patient sits either directly facing or to the side of aperture and makes contact with triggers by touch only (stereognosis)

Slide 86

v  Patient coordinates hand placement from one switch to the other in alternating sequence

v  Many patients

compensate for poor ‘sense of self’ through vision. The more the demands of fine-motor skills develop, the more this skill will be challenged.

Treatment

v  Lifting – safe max v  Lifting – endurance: no greater than 3

minutes v  Reaching activities work height

(shoulder) v  Reaching activities work height

(overhead) v  Posture – kneeling v  Posture – stooping

Slide 87

v  Posture – bending v  Posture – squatting v  Cognitive endurance v  Push v  Pull v  Stairs v  Rotation-fork lift driver

Balance on Bosu

Slide 88

Treatment

v  Knee extension v  Hip abduction v  Alternating toes v  Pelvic anterior/posterior

tilt on T-ball v  Prone on Theraball v  Wall Squats v  Pelvic Thrust

Slide 89

Unilateral Stance

90

Cooperative Work

91

UE Exercise

92

Crossing Midline

93

UE and Grasp Activity

94

Shoulder External Rotation

95

Forearm Supination

96

Speech/Cognition Activities

Speech Related

Expressive Language

Yes/ No Questions Naming

Word Finding Melodic Intonation Intelligibility Drills Oral Motor Ex’s

Picture ID Following Directions

Receptive Language

Cognition Related

Safety Awareness Problem Solving Impulse Control

Insight Judgment

STROOP Activities Alphabetizing

Sorting Sequencing

Trails Impulse Control with Slowed Tempo

Identifying pictures as safe or not safe Attend in distraction

Divided and Selective Attention Task Visual Attention

Delayed Recall (Short term Memory)

Attention and Focus Processing

Memory

97

STROOP Exercise

98

Cognitive Tasks

99

Cognitive Tasks

100

Trunk Rotation and Cognition

101

Control of Movement & Working Memory

102

Group Therapy

103

Auditory and Cognitive/Motor Task

104

Sports Enhancement

105

Whole Body Movement

106

Ankle Eversion/Inversion & Plantar Flexion

107

Brainstorm: How are you using your IM?

1.   List 3 activities that you feel blend well with IM treatment activities.

2.   List 3 items that are useful to have on hand when applying IM to the adult population.

3.   What is your best advice to caregivers when using IM with the adult population?

4.   What areas do you find most challenging when using IM with the adult population?

Slide 108

What are some ideas to assist in treatment planning v  Likes and dislikes

v Motivation

v Barriers (medical, physical, emotional, educational etc)

v Support

v Patient and caregiver education regarding this modality

Slide 109

Equipment Needs

v  Extra triggers

v  Velcro

v  Foam

v  TheraBand

v  Walkers

v  Parallel Bars

v  PhysioBalls

v  Picture Cards

v  Visual Stimuli

v  Gait Belt

v  Balance equipment

v  Speakers

v  Dominoes

Slide 110

Equipment Needs

v Colored Tape v Self-adhesive Velcro strips v Non-slip matting v Cable splitters v Variety of headphones v Sanitizing Hand Wipes v Bosu v Balance Disc v Weighted Items

Slide 111

Environmental Issues v Size of room

v Seating options

v Balance assist

v Lighting

v Storage

v Loud vs. quiet

v Mobile vs. stationary

v Floor Space

v Wall Space

Slide 112

Sample Pictures of IM Room with Desktop Computer (Clinic Setting)

Desktop IM Set-up in a Home Setting

Portable IM Unit with Use of Rolling Carts

Portable IM Unit with Use of a Rolling Computer Bag

Patient 1 v  65 y.o. right CVA with left hemiparesis with

subluxation

v  Left visual neglect

v  Moderate tone in upper and lower extremities

v  Moderate word finding deficits

v  Poor reading and writing skills

v  Only oriented to person

v  Wants to return to Bridge Card playing group 117

Patient 2 v  47 y.o. TBI with right hemiparesis

v Slight hearing loss in left ear

v Ambulating with AFO and quad cane

v Right sided foot drop

v Mild dysarthria with rate and prosody deficits

v High level controlled executive function deficits

v Wants to return to work 118

Patient 3 v  19 y.o. right BKA with prosthesis

v  Anoxic event during surgery

v  Demonstrates upper and lower body ataxia

v  Breathy voice quality due to vocal cord paralysis

v  Demonstrates moderate sequencing and initiation deficits

v  Wants to drive

119

Patient 4 v  55 y.o. patient with Parkinson’s Disease.

v  Flat affect

v  Monotone speech inflection

v  Diminished speech volume

v  Mild intentional tremor

v  Fallen in the home X2

v  Requires min Assist with ADL’s

v  Wants to return to playing and interacting with grandchildren 120

Modifications Domains To Be Considered

v Computer setting challenges

v Postural challenge

v Cognitive/Linguistic challenges

v Extremity challenges

121

Identify Signs of Fatigue and Distress

v  Irritation, agitation v  Autonomic System

Changes (BP, Heart Rate, Respiratory changes)

v  Worsening of IM scores

v  Sweating v  Changes in skin

color v  Marked increases/

decreases in postural control

v  Aversion to sensory input

v  Changes in respiratory rates

v  Increased fidgeting behaviors

v  Increased verbal distress

v  Decreased attention/engagement

122

Pre-IM Activities v Heat application v NMES v Soft Tissue manipulation v Sensory activities v Making sure adaptive equipment is

accessible and working •  Hearing aids •  Glasses •  Appropriate shoes

v Pre-medicating

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Rhythm Techniques v  Demonstration cues

v  Verbal cues repeatedly as needed throughout the exercise

v  Counting cues

v  Physical assistance

v  Assistive device

v  Visual mode

v  Move extremity onto/off of trigger on each beat

v  Eliminate guide sounds

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Contraindications for IM v  Inflammation

w  Usually accompanies LMN damage

w  IM may increase inflammation, especially with nerve damage related to scar tissue build up and compression as a result of repetitive tasks.

w  To proceed: •  Wait until inflammation subsides before

initiating IM. •  Carefully monitor throughout treatment to

ensure inflammation does not increase beyond acceptable level.

•  Modalities that decrease inflammation can be employed to minimize inflammation with the high repetition activities that are part of the IM treatment philosophy.

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Contraindications for IM v Pain:

w  Can be debilitating and slow to recover w  Strong contraindication for IM w  IM activities that elicit nerve pain should be stopped

immediately

v Edema: w  Swelling is indicative of inflammation and may facilitate

nerve damage. w  The clinician should continuously monitor the patient for

signs of edema and terminated activities when edema is identified.

v Medications: w  Patients frequently on high doses of pain and

inflammation- reducing medications w  May impact ability to process information and thus learn

the IM program.

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Acute Care Low Level Patient

v  32 y.o. brain stem CVA

v  Unable to sit on side of bed without max Assist

v  Unable to perform UE/LE dressing without max Assist

v  Global aphasia with minimal ability to imitate bilabial sounds

v  Poor safety awareness and impulse control

v  Fall risk

v  Dysphagia

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Lab: Addressing Use of IM with Low Level Clients v  Demonstrate 3 activities suitable for this client group.

1.  ____________________________________ 2.  ____________________________________ 3.  ____________________________________

v  Consider environmental barriers that may hinder IM success with this client group.

1.  ____________________________________ 2.  ____________________________________ 3.  ____________________________________

v  Practice 3 modifications for this client group. 1.  ____________________________________ 2.  ____________________________________ 3.  ____________________________________

Lab: Incorporating IM into Your Discipline Specific Functional Goals

v  List 3 goals that you may typically work on with the adult population.

1.  _____________________________________________ 2.  _____________________________________________ 3.  _____________________________________________

v  Review the benefit of IM use in achieving those goals. 1.  _____________________________________________ 2.  _____________________________________________ 3.  _____________________________________________

v  List 3 custom IM activities for each goal. 1.  _____________________________________________ 2.  _____________________________________________ 3.  _____________________________________________

Marketing IM with the Adult Population

v Budget…. v  Target group v  Treatment setting v Payment sources v Referral sources v Advertising v  Local competitors v Prepared

information v  Intake process v Budget …..

Communicating with Other Healthcare Professionals

v By example

v By results

v Literature

v In-services

v Peer review/case studies

Communicating with the General Public

v Community sources articles/advertising

v News-media interviews

v Word-of-mouth v Literature flyers v Free IM screening v Parent-friendly

inservices

Home Program for Maintenance

v MP3 players

v Songs from a patient’s own music collection

v Boom boxes

v Portable metronomes

v  IM-Home

Slide 133

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135

Question 1 1. According to the Winstein, 2005 III Step

Proceeding, the Active Ingredients for Effective Neuro-rehabilitation are?

a.   Task practice is the single most important variable for motor learning.

b.  “What” is practiced is more important than mere repetition.

c.   Motivation and meaning are critical to skill learning. d.  Problem solving and implicit processes are required

for skill acquisition. e.   All of the above

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Question 2 2.   When starting the patient on the

IM program, the therapist should:

a.   Have the patient listen to the reference tone for ten minutes

b.  Have the client use the affected side c.   Use shoulder shrugs d.  Introduce the IM to the unaffected side

only.

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Question 3 3. IM may be introduced into

treatment programs at the following levels, as medically indicated:

a.   Acute care b.  Sub-acute care c.   Home health/outpatient care d.  All of the above

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Question 4

4. True or False: The IM In-Motion Triggers are only for ambulation practice.

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Question 5

5.   True or False:

It is not appropriate for more than one discipline to be using IM at the same time.

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Question 6

6.   True of False:

IM can be modified to meet the needs of the low-level patient.

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Question 7 7.   There are four domains that can

be modified to challenge the patient:

a.   Postural Challenge b.  Cognitive/Linguistic Challenge c.   Extremity Challenge d.  Computer Setting Challenges e.   All of the above

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Question 8 8.   What are some of the barriers

that can negatively impact a patient’s performance?

a.   Medical b.  Physical c.   Emotional d.  Educational e.   All of the above

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Question 9

9.   True of False It is important to make sure that adaptive equipment is accessible and in working order before treating with IM.

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Question 10 10. If a patient has a Right UE

hemiparesis, when completing the Short or Long Form, you should:

a.  Modify access to the triggers b. Cue the patient c.  Skip those exercises that they

are unable to perform without cueing or clinical assistance.

d. A and C

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Contact Information Interactive Metronome, Inc 13794 NW 4th St., Suite 204

Sunrise, FL 33325 Toll free: 877-994-6776

Clinical Support

877-994-6776 x 253 avega@interactivemetronome.com

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