Pavel Kolář et al.

CLINICAL REHABILITATION XXXI FOREWORD

Th e main motivation for me to begin work on this In this book, I focused on the treatment component textbook was an eff ort to refi ne knowledge of the of rehabilitation and devoted more space to it than the qualifi ed public about rehabilitation and provide educational, social and occupational areas. Given the a framework regarding the true objectives of this fact that the diagnostic and treatment approaches of fi eld. Our profession is sometimes misconceived as rehabilitation are focused primarily on the movement massage therapy, exercising aft er orthopedic proce- system, this fi eld reaches into practically all clinical dures, rehabilitation and sometimes it is reduced to fi elds (neurology, orthopedics, internal medicine, only the use of therapeutic agents (modalities). I have oncology, immunology, psychiatry, etc.). Movement also encountered the opinion that it is linked to or function plays an important role in all of these clinical even directly considered some kind of an alternative fi elds. Th is is because physical activity and its repeated treatment. Another important motivation for me was action manifest themselves by a change in function in the lack of current study materials for physicians un- a number of systems (cardiorespiratory, immune, cen- dergoing residencies, for graduate and post-graduate tral nervous system and metabolic changes), which physical therapy students, as well as for physicians of allows for infl uencing these systems through modula- other clinical specialties who want to be introduced to tion of its intensity, frequency and form. Another re- the methods of treatment rehabilitation used in their ason why rehabilitation reaches into several medical specialization. fi elds is the fact that the sensory aff erent inputs from In my view, I consider it essential that the foundati- the entire body are always processed not only within on for rehabilitation treatment approaches be neither its own sensory modality (visual, acoustic, proprio- a trend nor a school of thought (chiropractics, osteo- ceptive, integumentary, etc.), but also within an inte- pathy, musculoskeletal medicine), but rather a wide, grated motor function. Our eyes, respiratory muscles, general foundation in the fi elds of clinical physiology tongue, etc. serve not only the function they are do- and neurophysiology. It also needs to be appreciated minantly selected for, but they also participate in pos- that rehabilitation is not only limited to diagnostic tural and locomotive functions. Th is is well observed and treatment methods, but it also attempts to limit in athletic performances in which maximal force or the extent of psychological, behavioral and social a precisely accurate movement needs to be accomplis- changes related to the consequences of an injury or hed. For example, to strike a ball with required force, illness. Th erefore, rehabilitation should not be perce- a tennis player makes a movement with their extre- ived as strictly a medical fi eld but a fi eld that over- mity, which is linked to a face expression, movement reaches these boundaries and extends into the social, of the tongue in the direction of the stroke, eye mo- academic and work arenas. Comprehensive (integra- vement in the direction of the stroke, modifi cation of ted) rehabilitation applies to individuals whose health breathing by diaphragm activity (a grunt, Valsalva) to was compromised to a varied extent as a result of an facilitate trunk stabilization, position of the contrala- illness, injury or a congenital defect and who require teral extremity into the opposite (reciprocal) position special assistance to achieve the highest possible level etc. It is an overall involuntary movement pattern that of independence. A person with a disability perceives interlinks individual sensory modalities and, thus, it limitations that they are unable to overcome while is related to the majority of medical fi elds. Th is princi- performing certain activities but they feel able and ple of modality integration within postural locomotor healthy in a number of other activities. Removing and functions is a component of CNS development and it solving these limiting problems is one of the particu- was established based on this principle. Th e fact that larly important tasks of rehabilitation. Th erefore, the the described integration occurs at higher levels of concept of rehabilitation must complement not only control than the spinal cord and the brain stem is sig- the treatment process but also the subsequent rehabi- nifi cant. Th is can also provide hypotheses regarding litation process. the eff ects of a number of alternative approaches who- From this point of view, rehabilitation is a very se justifi cation of spinal cord and brain refl exology is broad fi eld which cannot be covered in detail in one not suffi cient and is therefore substituted in clinical book. Similarly, it is not possible to cover this extensi- practice by alternative explanations. Th ese central ve subject by one specialist. Success is based on a co- programs are organized above the brain stem level ordinated eff ort of various specialists. and can explain why functional pathologies become XXXII Clinical Rehabilitation chained in predetermined sequences; why needle ap- O. Stary played an important role. Stary and K. Lewit plication in a single point has functional consequen- demonstrated the signifi cance of painful functional ces in a completely distant area of the body including defi cits of the movement system. In this aspect, the the visceral region; why an internal dysfunction does large contribution of Professor J. Jirout who was the not only show refl exive response in the corresponding founder of functional radiology of the spine, needs segment but in quite distant areas and in various af- to be remembered. Th anks to the work of Professor ferent modalities (skin hyperalgic zones, changes in V. Janda, the basic signifi cance of movement patterns dermographism, muscle trigger points, joint restricti- was gradually underwood and the term “functional ons, etc.); why respiratory function can be infl uenced pathology of the movement system” was established. through eye movement (eye movement automatically Th is presentation was even further strengthened by causes change in the breathing pattern); why breathing the infl uence of scientifi c studies and personal con- pattern changes with a change in hand position, and tact with D.G. Simons and J.G. Travell to whom we are a number of other phenomena. Th e control system grateful for providing detailed knowledge of muscle of the postural locomotor functions then provides us trigger points that also cause a limitation in joint mo- with a program that off ers a completely new approach bility, so called joint restrictions. To understand the in the understanding of rehabilitation approaches. function of the movement system, individual dys- Clinical diagnosis focused on symptomatology or- functions, such as trigger points and joint restricti- ganized within postural locomotor functions should ons, need to be understood in the context of the entire not be considered an exclusive component of treat- movement system, i.e. the laws of chaining of functi- ment rehabilitation but also a component of the rema- onal dysfunctions. Th e key to this understanding was ining clinical specialties. a better knowledge of the control function of motor I based the structuring of the General and Special skills. Th e new approach of treatment rehabilitation Sections of the textbook on the function of the move- during movement re-education is based on utilization ment system in relation to individual clinical special- of knowledge about human motor development. Th is ties. Th erefore, I did not base them on diagnoses but new trend enriches the current empirical and physical rather on the functional manifestations of the disease. approaches by fi ndings originating from the control Th e General section of the textbook includes functio- processes of the CNS that mature during motor de- nal symptomatology and syndromology in dysfuncti- velopment. Dr. Vaclav Vojta, whose work we are cur- ons of the nervous, musculoskeletal and internal sys- rently trying to continue, has a signifi cant role in this tems and their clinical and laboratory examinations. approach. Professor Vojta also came from Henner’s Th e majority of treatment approaches are also presen- department and his conceptualization is an inherent ted in this context meaning that the treatment based component of contemporary clinical rehabilitation on symptomatology and syndromology dominates. In practice. Unfortunately, the neurophysiological prin- the Special Section of the textbook, treatment rehabi- ciple of the entire approach to developmental kinesio- litation is presented in individual clinical specialties – logy is still not fully appreciated due to disagreements neurology, orthopedics, internal medicine, oncology, about indication and the type of application of the gynecology and psychiatry. Vojta method. However, not many critics understand I purposely devoted less attention to occupational the true basis of the Vojta approach. What is essential therapy, balneology and therapeutic agents (moda- and substantial is not only the way that rehabilitation lities) than these treatment approaches deserve. Th e of movement dysfunction is utilized, but also the fact reason is not to underestimate their value, but rather that the concept of developmental kinesiology is com- them already being reasonably available and suffi ci- bined with the neurophysiological view relying on the ently described elsewhere. fi ndings of neurosciences associated with the current- In clinical approaches of the General Section of ly predominant physical mechanical views. the textbook, I have extensively drawn from and ex- In this book, I was also trying to respect and em- panded on a trend known worldwide as the “Prague phasize more certain general principles that condition School.” In rehabilitation, the roots of this school of the treatment eff ect, however, to convey the informa- rehabilitation can be found in the Neurology Clinic tion in a written form is signifi cantly limited for some of Professor Henner whose concept of neurology of them. Th e respect for a comprehensive patient per- was very broad and therefore included even vascu- spective is one such principle. Th e fact that human life lar diseases and movement system diseases within occurs under specifi c biological, psychological, soci- neurological symptomatology. Treatment rehabilita- al-psychological, materialistically economic and eco- tion was promoted by K. Obrda who, together with logical conditions needs to be implanted within the J. Karpisek, wrote the fi rst rehabilitation textbook for diagnostic, treatment and preventative approaches. neurological diseases and organized an international Diseases and injuries cannot be viewed in isolation congress in 1965. On the theoretical level, F. Vele and but rather need to be integrated within the context Foreword XXXIII of such relationships because the treatment processes It is almost impossible to express in written form and rehabilitation are signifi cantly aff ected by them. some principles that signifi cantly aff ect the results of I also aspired to prevent this textbook from beco- a rehabilitation treatment. Th is, for example, includes ming a proponent of only one method but rather sup- the mutual trust between the patient and the reha- port a variety of rehabilitation approaches based on bilitation specialist, which cannot be substituted by a person’s individual needs. Th e problem is that this a client-expert relationship or by a work performance does not allow for providing a clear-cut treatment ap- contract. Th e importance of eff ective communicati- proach for movement dysfunctions because these ap- on, charismatic approach, suggestive appeal and one’s proaches need to also be modifi ed to the patient’s, and own experience developed by sensory perceptions are sometimes even the therapist’s, personality. In this additional examples. context, protocols based on one uniform foundation Despite these limited options, I believe that this outlining what and how much needs to be done can- book will assist in better orientation in the broad fi eld not be implemented. Th ese approaches are a method that rehabilitation truly is and thus will help fulfi ll the of choice, off ering the option of fi nding individual so- purpose for which it was written. lutions to how to eff ectively proceed and how to best modify the approach for a specifi c individual. Pavel Kolar 252 General Section B. Therapeutic Methods body” exercise sessions, in which the entire body does ab not exercise all in one day, but rather the training of individual muscle groups is spread over several days. Exercises commonly used in treatment rehabilita- tion usually do not put signifi cant strength demands Fig. 1.1.4-1 Individual on the exercising individual. Th eir goal is mainly in- segments of the skeleton ter-muscular coordination. Th e low intensity of such need to be reinforced by a balanced activity exercises generally does not cause signifi cant exhaus- of muscle antagonists. tion of metabolic muscle supplies and, therefore, can (a) – physiological state, be repeated several times per day. (b) – postural instability

(biomechanical chain) can be quite insuffi cient and 1.1.4 Dynamic Neuromuscular the muscle fails in this function. Stabilization If the muscle is weak during the stabilization of a segment(s), postural instability occurs (Fig. According to techniques of dynamic neuromuscular 1.1.4-1b). Incorrect muscle recruitment during stabi- stabilization (DNS) by Kolar, muscle function is in- lization is automatically and unconsciously incorpo- fl uenced within its postural locomotor function. Th is rated by the individual into all performed movements concept contains general principles and, therefore, and exercises. Th is results in stereotypical overload- it is included among the general physiotherapeutic ing, which is an important etiopathogenetic factor in methods. a number of movement defi cits. Common muscle strengthening is based on ana- It has already been described in Chapter 1.1.1 Th e tomical function. Strengthening exercises are derived Assessment of Postural Function in Section A of the from the muscle’s origin and insertion. Th is principle textbook, that postural instability cannot be assessed is also utilized for the majority of strength training by a muscle test, but rather by specifi c postural tests equipment found in fi tness gyms. In treatment reha- and several of these tests were mentioned. An ex- bilitation, this principle is utilized for exercises based ample of such postural instability is the lumbosacral on muscle testing. deviation from its neutral alignment which can be ob- However, when developing muscle strength, not served in a patient in prone when slowly lift ing their just the muscle’s origins and insertions need to be head and the upper part of the trunk (extension test) considered, but also its inclusion within the biome- (Fig. 1.1.4-2a,b). chanical chains. However, these cannot be deduced Postural instability of the lumbosacral area is man- only from anatomical connections (how they are pre- ifested by an anterior tilt of the pelvis. Similarly, this sented by the majority of authors), but also from the postural instability is manifested during hip fl exion aspect of CNS control processes (central programs). assessment in supine and sitting, in which insuffi cient If, for example, the pectoral muscles are exercised, stabilization at the insertional region of hip fl exors the muscles that stabilize their insertions are also (inserting to the pelvis and the thoracolumbar region) always activated, i.e. the back muscles, diaphragm, leads to an anterior pelvic tilt, lateral shift of the pelvis abdominal muscles, etc. Th is function is automatic and an extension or lateral co-movement at the thora- and, in many people, under very limited volitional columbar junction. Th is implies that the muscles (in control. In addition, the deep muscles that are es- some scenarios together with ligamentous structures) pecially important for postural functions (stabiliza- tion, tightening). a Under static conditions (standing, sitting) and dur- ing movement (locomotion), individual movement segments are reinforced by the coordinated activity of the agonists and antagonist – co-activation activity (coactivation synergy) (Fig. 1.1.4-1a). b Postural activity accompanies movement like a shadow (Magnus, 1924). Perhaps this statement could be corrected to say postural activity precedes and accompanies every purposeful movement. Even though the muscle in its anatomical function (derived from its origin and insertion) can reach maximum Fig. 1.1.4-2a,b During trunk extension, pelvic movement into an anterior tilt occurs. (a) – starting position, (b) – trunk potential (when assessed by a muscle test), its integra- extension and anterior pelvic tilt and often cervical spine tion into a specifi c postural (stabilization) function hyperextension. 1 Physical Therapy Methods and Concepts 253 that should be stabilizing this segment are weak or the muscle pattern is incorrectly learned. Th is postural instability is not limited only to the lumbosacral re- gion, but also signifi cantly infl uences the muscle co- ordination of the extremities. To prevent overloading of soft tissues and the skeleton, the muscle activity, or rather the CNS and ligamentous structures, must ensure that stabiliza- tion of the segment(s) occurs in a centrated (neutral) B joint position (see section A. Diagnostic Approaches, Chapter 1.2 Kinesiology and Clinical Assessment of Fig. 1.1.4-3 Abnormal postural pattern in prone the Joint System, Centrated Joint Position). For this to occur, a balance among the muscles in the entire body posture is strengthened, including its dynam- biomechanical chain, as well as, between the exerted ics. This is the reason why, during strength train- stabilization muscle force and the external force being ing, the principles of a functionally centrated posi- overcome and, thus, form the basic presumptions. tion and the movement in it needs to be respected. A defi cit in segmental joint stabilization is oft en Only in such a case do physiological stabilization caused by the following: muscle synergies strengthen together with the pri- 1. Improper neuromuscular control. Its main causes mary movement and, thus, the exercise will have include: a positive effect on the entire movement system. a) Disturbance in postural ontogenesis. A deficit in 3. Ligamentous insufficiency and deficits in local, muscle interplay occurs in relation to abnor- regional and global anatomical parameters. The mal postural development. It is an incorrectly properties of mesenchymal tissues and the anatom- established posturally locomotor pattern (Fig. ical parameters (torsional and colodiaphysal angles 1.1.4-3). of the hip joint, shape of the patella, alignment of b) Habituation of incorrect dynamic stereotypes. the glenoid fossa, etc.) are important factors that A deficit in muscle interplay develops by an in- influence joint stabilization during the activity of correctly learned and fixated activity (incorrect external forces. In contrast to muscle function, this practice, profession with a unilateral postural situation cannot be significantly influenced by ex- loading, cultural and esthetic factors, inability ercise but, can at least, compensate for it. In certain to relax and the associated deficit in selective cases, corrective surgeries are an option. movement and so on). c) Defensive (protective) CNS or muscle functions. General Principles of Practice Techniques CNS adaptation to a pathological situation leads 1. With a goal-oriented effect on the stabilization to characteristic changes in muscle tone, as well function, general principles are used, which are as, the entire posture. based on the programs maturing during postural 2. Insufficiency of muscles that ensure segmen- ontogenesis (global patterns – ipsilateral and con- tal joint stabilization. Motor programs ensuring tralateral locomotion patterns, joint centration and stabilization of muscle interplay have a “strength its reflexive influence on stabilization function, fa- dimension”. This means that, under normal condi- cilitation by trigger zones, support functions, resis- tions, the stabilization function works physiologi- tance against planned motion, etc.). cally and it can be used in this fashion only to a cer- 2. Exercises begin by influencing trunk stabilization, tain extent under loading from external forces. This or the deep stabilization system of the spine, which is often used in diagnosis by adding resistance to is the basic prerequisite for a specific function of a defined position or movement or challenging the the extremities. external conditions, which assist in accentuating 3. The muscles are trained in developmental, postur- the movement, or rather the postural pathology. ally locomotor lines. Inclusion of these muscles into The example can be a leaning test in which the in- chains, or the central biomechanical programs, al- dividual in kneeling with hands on the floor shifts lows for the modulation of automatic muscle acti- weight onto the upper extremities. The quality of vation in its postural function. the muscle synergy can determine the insufficiency 4. When selecting an exercise to influence (segmen- of the stabilization, especially in the shoulder blade tal) stabilization, it needs to be considered that and shoulder girdle area. Correctly performed ex- segmental stabilization is never linked only to the ercises strengthen movement and muscle syner- muscles of the corresponding segment, but it al- gies ensuring an adequate postural stabilization for ways functions within the global muscle synergy this movement. With every strengthening exercise, arising from support. 254 General Section B. Therapeutic Methods

5. Postural (reinforcing) force must always correspond of the textbook, Chapter 2 Treatment Rehabilitation in to the muscle strength that executes the move- Orthopedics and Traumatology, 2.4.1 Spine, Vertebro- ment (phasic motion), which means that the force gennic Pain Syndrome, Rehabilitation). Within this executing the movement cannot be larger than the context, we originate from a body posture that emerg- strength of the stabilizing muscles, otherwise the es as a program during postural ontogenesis and we movement emerges from an alternate source (they can elicit this program (synergy) refl exively. are performed by compensatory, stronger muscles). In the majority of therapeutic concepts and pre- Note: Th e choice of an exercise is determined by ventative approaches, an erect spinal position is pre- the desired goal to be accomplished. Volitional con- ferred as a starting posture. We all have heard the trol of an automatic postural muscle function is one command “straighten up”. Th e individual concepts of the main goals. A learned synergy of the stabiliza- are not diff erent. Th e diff erence is in the view of the tion muscles can gradually be included in common chest, shoulder blades and pelvic alignment and, thus, everyday activities. the muscle synergy that ensures their stabilization. An erect spinal posture is recommended from an er- Practice of Postural Stabilization gonomic perspective during common movement ac- of the Spine, Chest and the Pelvis tivities (housework, lift ing objects), as well as, during In patients with postural instability, trunk stabilization specifi c stabilization exercises and exercises against needs to be addressed at fi rst. Th e infl uence of the deep resistance. From this perspective, for example, Brüg- spinal stabilization system must be preceded by exer- ger’s concept is well known. Th e so called back school cises in developmental lines. Th ese exercises are based is based on this concept. Th e initial model is Brügger’s on the basic postural pattern (trunk stabilization) for sitting position which is called for as the basic work- a specifi c movement of the upper and lower extremi- ing position (Fig. 1.1.4-4). ties. No movement of the extremities (locomotion) ex- To achieve the desired erect position of the spine, ists without stabilization (tightening) of the trunk as a slanted support surface under the buttocks is recom- a whole. Every phasic movement requires trunk stabi- mended to tilt the pelvis more forward (anteriorly). By lization whose control is usually defi cient in the major- tilting the pelvis anteriorly, the elicited lumbar spine ity of patients demonstrating defi cits in the movement curvature leads to the straightening of the spine. Th e apparatus and it needs to be corrected. In refl ex loco- shoulders are pulled backward, the lower extremities motion, the stabilization activity of the trunk (linked to are shoulder width apart and the feet are supported the breathing pattern) is the fi rst activity that emerges with its entire surface on the mat. Th e lower extrem- during refl ex stimulation regardless of starting position ity joints are at 90 degrees. Th e described position of (supine, prone, in initial position, etc.). the spine, pelvis, chest and shoulders is included into Th e chest wall, spine and pelvis form a common common movement activities and it is used when base for all movement activities. Th e stabilization exercising against variable resistance. Sitting and ex- function is integrated into all movements automati- ercising in this position on an unstable surface, most cally and non-volitionally. Th e muscle synergy that commonly on a ball, is popular today. In contrast to ensures it needs to be viewed as the foundation for all the developmental concept (Fig. 1.1.4-5a,b), in this exercises. Th e main prerequisite is, again, the knowl- positional model, the role of the chest during the for- edge of the physiological synergy, or the so called ideal mation and control of intra-abdominal pressure is not pattern of deep spinal stabilization (see Special Section adequately understood (Fig. 1.1.4-5b).

a b

Fig. 1.1.4-4 Brügger’s sitting Fig. 1.1.4-5a,b For correct body position, next to straightening of the spine, the position: recommended body caudal alignment of the chest and the neutral position at the lumbosacral and position during work activities thoracolumbar junctions are important 1 Physical Therapy Methods and Concepts 255

B Fig. 1.1.4-6a, b, c (a) – neutral alignment of the thorax during straight- ened thoracic spine; a b c (b, c) – co-movement of the thorax and the spine

From a biomechanical perspective, the recom- bilization. With an erect thoracic spine, the thorax mended alignment of the chest or a defi cit in its dy- should be in an inspiratory position and should ex- namics do not allow for the required activity of the hibit an isolated movement, meaning that the thorax diaphragm and the corresponding control of intra- should move independently of the thoracic spine. abdominal pressure via the lateral group of abdomi- A co-movement of the thorax with the spine is patho- nal muscles, which predisposes the anterior stabilizers logical because an insuffi cient movement occurs in of the spine to weakness. A similar situation involves the costovertebral articulations and during expiratory the pelvis, which is positioned in excessive antever- and inspiratory movements of the chest, a fl exion sion in patients with an infl exible thoracic kyphosis and extension co-movement of the spine occurs and during straightening of the spine. Also, this concept originates mainly in the thoracolumbar junction (Fig. insuffi ciently takes into consideration the level and 1.1.4-6a, b, c). distribution of muscle tone in starting positions, Th is defi cit is most oft en linked to the shortening when performing a specifi c exercise and during com- of the accessory respiratory muscles (mainly pecto- mon daily activities. rales and scalenes) and upper scapular stabilizers of In patients with a disturbance in anatomical pro- the shoulder blades. While working on the inspiratory portions (i.e., an increased pelvic tilt) accompanied by alignment, a release of the chest wall stiff ness is per- a disturbance in the control of intra-abdominal pres- formed (this is considered especially signifi cant) pri- sure, these facts are considered especially important marily in the lower rib area. Only in an unrestricted because during stabilization, the patient uses exces- thorax can the chest wall expand when the diaphragm sive force in the superfi cial spinal extensors, which expands, leading to widening of the intercostal spaces leads to an imbalance in the internal forces and over- (mostly between the lower ribs). loading of the lumbar spinal region. During trunk stabilization, the focus is on the fol- Practice Example lowing: Patient lies on their back, lower extremities fl exed and The influence on tightness and improvement of in slight abduction (shoulder width), feet supported chest wall dynamics The influence on spinal straightening Postural breathing pattern training and the stabili- zation function of the diaphragm (intra-abdominal pressure control) Postural spinal stabilization training using reflex locomotion Deep spinal postural stabilization training in mod- ified positions Exercising postural functions in developmental lines

Infl uence on Tightness and Improvement of Chest Wall Dynamics Alignment and the dynamics of the chest wall are important requirements for physiological spinal sta- Fig. 1.1.4-7 Soft tissue release 256 General Section B. Therapeutic Methods

a b

Fig. 1.1.4-8a, b. Resistance generated on the lower aperture of the thorax during inspiration. The chest is positioned into caudal alignment (a), prior to inspiration, the lower aperture of the thorax is manually compressed (b). on the fl oor. Th e thoracic spine is straight. In this po- bilization techniques are used and straightening of sition, the soft tissues of the lateral chest wall are being the thoracic spine is practiced. To achieve this, cor- released (Fig. 1.1.4-7). rect stabilization of the shoulder blades is important. In the same position, the thorax is passively posi- Stabilization of the shoulder blades by a muscle pull tioned in the most caudal position. Th e pectoral and toward the spine (into adduction) does not allow for abdominal muscles must be relaxed. In this align- its straightening and blocks the straightening activity ment, a slight pressure against the lower ribs is gener- of the deep paravertebral muscles. For these reasons, ated and the patient breathes in against the therapist’s extension training, or erection of the thoracic spine, is resistance (Fig. 1.1.4-8a, b). performed. Th is is performed at fi rst with the upper Full excursion of the lower part of the thorax is extremity supported and, therefore, in a closed kinetic pursued (including posterior direction) without the chain. thorax moving cranially and without activating the superfi cial spinal extensors. Th e abdominal muscles, Practice Example as well as, the accessory breathing muscles must stay Th e patient lies on their stomach, forearms are sup- relaxed. Th is exercise can also be performed using re- ported on the mat, palms are placed on the mat and sistive exercise bands (Fig. 1.1.4-9). the head is straight. Th e patient leans on their medial epicondyles and by pressing them into the mat, the Infl uence on Spinal Straightening head is lift ed with the intent of forward movement Training of spinal straightening is another requirement along the longitudinal body axis (Fig. 1.1.4-10a-f). for physiological stabilization of the spine. Most oft en Th e head lift originates in the mid-thoracic spine. in patients with defi cits in stabilization in the thoracic During head lift ing, the cervical spine straightens spine move as a rigid unit; lacking isolated movement without sagging in its caudal portion. Th e shoulder at individual segments. For treatment, traction mo- blades adhere to the chest and have a tendency to move toward the points of support. For thoracic spine straightening, the activity of the serratus anterior is very important with respect to scapular stabilization. Its stabilization activity is only possible with activa- tion of the lateral abdominal muscles that, together with the diaphragm, form the punctum fi xum. Th e proper function of the shoulder blades and shoulder adductors is important. Th eir direction of pull should not be toward the spine, but rather toward the support on the medial humeral epicondyles.

Training of the Postural Breathing Pattern and the Stabilization Function of the Diaphragm A correct breathing pattern is another requirement Fig. 1.1.4-9 Inspiration with resistive band use for physiological stabilization of the spine. However, 1 Physical Therapy Methods and Concepts 257 the opposite is true as well: posture very sensitively Practice Example infl uences breathing, which is known as postural re- Th e patient lies on their back, legs slightly apart, knees spiratory function of the diaphragm. Th e goal is to bent and feet resting on the mat. Th e patient moves include the diaphragm into breathing and thus into their knees several times together and apart and then stabilization functions without participation of the maintains them in a position that does not require accessory breathing muscles. Straightening of the a conscious eff ort. Another suitable position includes spine and caudal chest alignment are required for this the lower extremities in shoulder-width abduction function. During inspiration, the ribs move laterally with the hips and knees at 90 degrees and the calves (wing movement), the lower chest aperture expands, resting on a foot bench. In this position, the patient B the sternum moves ventrally and does not elevate with exhales, holds their breath and, without breathing in, breathing. Th e abdominal muscles serve as a support moves the thorax and the abdominal cavity similarly for the diaphragm. It is important for the abdominal as if they were breathing. Th e abdominal content be- wall to expand not just in an inferior direction, but haves more or less as a liquid. Th rough this exercise, rather in all directions (i.e., laterally and posteriorly). the pressure in the abdominal cavity changes. During Th e umbilicus should not move cranially (its move- instruction, the pressure from the abdominal cavity ment refl ects an undesirable muscle pull in the cranial needs to be distributed equally in all directions, in- direction). cluding in the backward direction against the mat Diaphragm activation has a fundamental role not and, in particular, the lower abdominal area should only for breathing, but also for physiological stabili- expand (the increased pressure should be directed zation of the trunk (see Fig. 1.2.3-5). Th e training is down in the direction below the umbilicus into the performed in various positions. During this exercise, groin and the pelvis). Th e same exercise is performed the patient is taught to recruit the diaphragm, whose during inspiration. function during stabilization is not fully understood. Another version of this exercise in the above de- Aft er some practice time, with awareness and correc- scribed position includes breathing training during tion, we can indirectly distinguish its position without increased intra-abdominal pressure. In this exercise, knowing its anatomical location. the therapist gently presses in a dorsal direction into

a b

d c

Fig. 1.1.4-10a-f Physiological (a) and pathological (b) pattern in a 4-month-old child. Spinal straightening training with upper extremity support e f in a physiological (c, d) and pathological (e, f) position. 258 General Section B. Therapeutic Methods

Fig. 1.1.4-11 The patient expands the abdominal cavity against resistance

Fig. 1.1.4-12 Refl ex stimulation according to Vojta – refl ex rolling version the patient’s groin area above the femoral heads (Fig. superfi cial muscles and so on. Th e motor pattern of 1.1.4-11). stabilization of the spine, thorax and pelvis precedes Th e patient must feel that the area of the abdominal the stepping forward and the support functions of the wall above the hip joints presses against the therapist’s extremities, that is, purposeful phasic mobility. It is fi ngers. It is important for the force the patient exerts a component of all versions of refl ex locomotion – the against the palpating fi ngers to not cause any cranial fi rst phase of refl ex rolling, the second phase of refl ex movement of the umbilical region or narrowing of the rolling, the fi rst position and other positions. lower aspect of the thorax. In contrast, it must expand Th e goal of refl ex stimulation includes eliciting in all directions. Th en, the patient practices breathing muscle synergies and setting up an experience that without relaxation activity of the lower part of the ab- during activation allows for somatoesthetic percep- dominal wall during expiration. Th e patient can also tion, which can later be transferred into exercises with perform the exercise in sitting and in other modifi ed volitional control. positions. In the next exercise, the patient is in the supine po- Practice Example sition. At the completion of the expiratory phase, the In the supine position with the lower extremity in caudal position of the thorax is held and passively – by a tri-fl exion position (with supported lower extremi- pressure from the therapist’s hands – pressed toward ties) and slight abduction (shoulder width), the 6th the center (proximally) at its lower aspect. Th e patient and 7th intercostal spaces are stimulated in the mam- attempts to expand the thorax laterally against the millary line by a slight pressure. Th e stimulation can therapist’s resistance and without inspiration, that is, be expanded by activating the nuchal line region on similarly as if they were breathing in. Th e movement the contralateral side and the anterior superior iliac cannot be accompanied by accessory breathing mus- spine on the ipsilateral side of the stimulated thoracic cle activity or a co-movement of the thoracic spine zone. into fl exion. Th e refl exive response is demonstrated by a change Arching of the lower thoracic and abdominal cavity in the breathing pattern. Lower, or diaphragmatic, without breathing is another version of this exercise. breathing occurs without participation of the ac- For accentuation, resistance is required and can be cessory breathing muscles. Th e diaphragm fl attens, administered manually by a physical therapist (which meaning the punctum fi xum is on the ribs, not on allows for control of the executed movement’s qual- the centrum tendineum of the diaphragm. Th e tho- ity). In the next phase, a resistive band can be used. rax is positioned in a caudal alignment. At the same time, the spine straightens. Th e abdominal muscles Postural Stabilization Training of the are activated and act against the fl attened diaphragm Spine Using Refl ex Locomotion and pelvic fl oor, thus leading to an increased intra- In an early phase of education, a refl ex stimulation abdominal pressure. Th e stabilization function of the model is used for the well-balanced co-activation of abdominal muscles together with the fl attening of the muscles of the abdominal brace (the diaphragm, ab- diaphragm (punctum fi xum in the rib region) mani- dominal muscles and pelvic fl oor) and the back mus- fest themselves by a caudal shift of the umbilicus. cles (Fig. 1.1.4-12). Th e patient is aware of the activation and the thera- Individual components needed for physiological pist strives for the given pattern to come under voli- stabilization are integrated into this model – auto- tional control. Th is can be achieved by the involve- matic positioning of the thorax in a caudal alignment, ment of the abdominal brace during diaphragmatic spinal straightening, postural diaphragmatic breath- breathing and by gradual unweighting of the lower ing with lower thoracic aperture expansion, based on extremities. Th en, the upper extremities movement the position also a neutral support function of the ex- against resistance is added into the exercise. Th e exer- tremities, symmetrical involvement of the deep and cise can be performed in other positions. 1 Physical Therapy Methods and Concepts 259

abc

def B

gh allowing the transition from one position to the next, i.e. a transition from side sitting to the all fours posi- tion, from all fours to bipedal standing, from supine to side sitting and later to standing, or locomotion. Th us, the posturally locomotor development that oc- curs as part of CNS maturation serves as the base for the starting position (Fig. 1.1.4-14 through 17). ). During selected locomotion (i.e., the transition from side sitting to quadruped), individual parts of muscles, or individual muscles from muscle groups, gradually participate. Positioning in individual mo- Fig. 1.1.4-13a-h Modifi ed positions for training of deep ments of locomotor movement also allows to selec- spinal stabilization tively infl uence the postural function of parts of in- dividual muscles, or muscle groups. It is exercising in a somewhat “frozen” position of a locomotor phase. Training of Deep Postural Stabilization Later, the entire transitional phase of the locomotor of the Spine in Modifi ed Positions movement can be practiced from the starting side sit- As soon as the patient at least partially masters con- ting position to a quadruped position (Fig. 1.1.4-18 trol of the stabilization function and the physiological and 19). postural breathing pattern, the exercises can be per- Th e selection of the original position is based on formed in modifi ed and more challenging positions the patient’s individual predisposing factors. Th e rule or can include resistance (Fig. 1.1.4-13a-h). During is to advance from positions with lower postural de- treatment, it is important to select adequate exercises mands (for example, supine position with trifl exion of to avoid muscle substitution and compensatory pat- the lower extremities) to positions that are posturally terns which the patient may have been using. Th e more challenging, which can also include unstable exercises can be modifi ed to place greater emphasis support surfaces and resistances. Th e initial education on various muscle groups, for example, the deep neck requires a therapist’s assistance. fl exors. Th e established starting locomotor position re- fl exively activates the deep stabilization system of Exercising Postural Functions in the spine, ensuring trunk and spine tightening (see Developmental Lines (Sequences) above). Th e upper and lower extremities become Th e starting position for exercises is derived from the involved in the support and stepping forward func- basic locomotor positions of postural development tions. Th e stepping forward and support functions (development of body posture and verticalization are part of two basic developmental patterns – ipsilat- process): supine, sidelying, side sitting, on all fours eral and contralateral. Based on the position selected, with support on the knees or the feet, tall kneeling, the extremities on one side are stepping forward and stepping forward in tall kneeling, etc., as well as from the contralateral extremities are supportive – the ip- positions derived from locomotor transitional phases silateral model – or their function is reversed, i.e. if 390 Special Section toxication or metabolic dysfunctions. In children, the cerebellum can be aff ected by cerebral palsy. A defi cit of the cerebellum results in an inhibitory function, which is manifested as disproportional, uncoordi- nated movements, apraxia, clumsiness, tremor and defi cits in stability, gait, gaze and language.

1.13.2 Basic Clinical Manifestations of a Cerebellar Lesion

A ATAXIA Ataxia is a basic movement defi cit that occurs in the presence of a cerebellar lesion. It is a defi cit in the co- ordination of volitional movements, their decompo- sition, clumsiness and inaccuracy. Th e movement is incorrectly timed or targeted, not smooth or effi cient and shows many deviations into directions other than these intended. Based on the area or function aff ected by ataxia, it can be gait ataxia, postural (trunk) ataxia, B extremity ataxia or language ataxia (cerebellar dysar- thria). Standing ataxia is characterized by unsteady Fig. 1.13.2-1 Test of upper extremity coordination. A – cor- standing with a wide base of support with a tendency rect execution; B – dysmetria (hypermetria) and intention to fall in various directions. Gait ataxia is manifested tremor by insecure wobbly gait with a wide base of support and a tendency toward falling (drunk walk). Step is slowing of the movement prior to reaching the length is asymmetrical; the patient is unable to am- target followed by several compensatory movements bulate in a straight line. Patients oft en interpret their to the side and only aft er that does the patient’s fi n- gait insecurity as dizziness; however, it is not a true ger reach the target (nose). On the lower extremity, vertigo. Hypermetria, adiadochokinesia and asynergy are A also components of ataxia.

HYPERMETRIA Hypermetria denotes incorrect estimation of move- ment in a sense of overshooting. Movement begins and occurs too quickly, it is rushed, without a target and is inaccurately completed as a result of delayed and insuffi cient activation of the antagonists. Clini- cally, this defi cit is most oft en assessed as an upper B extremity dysmetria via the fi nger-to-nose test (Fig. 1.13.2-1). A patient with their arm stretched in front of them attempts to touch the index fi nger to the tip of their nose as accurately as possible at fi rst with eyes open and, if accomplished successfully, with the eyes closed. Th e assessment can be even more accurate by C having the patient touch alternately the examiner’s index fi nger and their nose. Th e movement becomes gradually faster and the examiner changes the posi- tion of their index fi nger. Dysmetria denotes missing the target, overshooting is called hypermetria (see Fig. 1.13.2-2 Test of lower extremity coordination. A, B – Fig. 1.13.2-1). Volitional eff ort to compensate for hy- correct execution; C – defi cit in lower extremity coordination permetria is manifested as bradyteleokinesia, which in a patient with cerebellar dysfunction 1 Treatment Rehabilitation in Neurology 391

ADIADOCHOKINESIA Adiadochokinesia is a defi cit in quick, alternating or repetitive movements. Th e alternating activation of agonists and antagonists is aff ected. Th e patient performs, for example, quick pronation-supination of both forearms. Movement typically lacks regu- lar rhythm and individual phases are asymmetrical. Sometimes the movement may overshoot or under- shoot and the physiological movement deceleration prior to reaching a target is absent. A certain degree of adiadochokinesia is physiological during preschool years when the cerebellum is still “maturing” and is frustratingly persistent in the non-dominant upper extremity. Adiadochokinesia can also be assessed in Fig. 1.13.2-3 Assessment of adiadochokinesia of the tongue the tongue. Th e patient is asked to slightly protrude 1 and the upper extremities their tongue and quickly move it from side to side. Th e movement is non-rhythmic, uncoordinated and the movement of the heel on the shin of the oppo- the tongue does not reach the corners of the mouth site lower extremity can be tested. Here, movement (Fig. 1.13.2-3). decomposition can be observed easily. At fi rst, the patient lift s the leg excessively, fl exes the knee and ASYNERGY only then aims and attempts to touch the heel to the Asynergy is a defi cit in the coordination of a muscle contralateral knee. Th e patient is asked to slide the or a group of muscles during movement. Th e timing heel on the shin toward the foot. If a cerebellar dys- of activation of individual muscles into movement function is present, the movement is uncoordinated, is missing. Th e muscles work without mutual func- “zigzags” (Fig. 1.13.2-2), and protective movements tional continuity and more complex movements lack are excessive. During examination, we suddenly smoothness. Movements are separated into individual push a patient (preferably seated) or pull on their phases and the movement lacks timely activation of shoulders or trunk. Excessive protective synkineses the antagonists to appropriately decelerate the move- of the extremities are then observed. Hypermetria ment. Th is lack of coordination is typically manifested is also seen in writing as macrographia. Excessively during a test in which the therapist stands behind the loud speech is also a demonstration of hypermetria. patient and pulls them by the shoulders. With a cere- Th e patient “thrusts” individual vowels (explosive bellar defi cit, a physiological synkinesis of knee fl exion saccadic articulation). With cerebellar dysfunction, is absent as the knees remain extended and, thus, the slurred, slowed, drunken speech is also present (cer- patient has a tendency to fall backward – manifestation ebellar dysarthria). of asynergy (Fig. 1.13.2-4). At the same time, exces- sive defensive synergies of the upper extremities can be observed and are manifestations of hypermetria. Asynergy can be also tested by the supine-to-sit test or sit-to-stand test, in which uncoordinated movement can be observed. A patient places their crossed arms across their chest and attempts to sit up from supine position. If cerebellar dysfunction is present, the pa- tient excessively lift s their lower extremities above the mat. In the case of ipsilateral cerebellar hemisphere

Fig. 1.13.2-4 Asynergy. A – With backward bending, a pati- ent does not fl ex their knees and falls backward; B – Physiolo- Fig. 1.13.2-5 Supine - to - Sit Test: asynergy of the left lower gical reaction, with backward bending, knee fl exion occurs extremity 392 Special Section involvement, the defi cit is observed on the ipsilateral PALEOCEREBELLAR AND lower extremity (Fig. 1.13.2-5). NEOCEREBELLAR SYNDROME

To a certain extent, the phylogenetic-anatomical di- FLACCIDITY vision of the cerebellum also possesses functional signifi cance. Th e verminal (medial) part mainly coor- Flaccidity denotes decreased muscle tone and, there- dinates movements of the eyes and the body in rela- fore, it is also known as cerebellar hypotonia. Range of tion to gravity and movement of the head in space. motion is increased as a result of decreased resistance It especially aff ects the trunk musculature, balance from the antagonists which lack timely deceleration and erect body posture. With a simultaneous defi cit of movement. Th is is demonstrated by the rebound in the archicerebellum, eye movement disturbances test (Fig. 1.13.2-6). Increased synkinesis of the upper and gaze paretic nystagmus are present. Th ese medial extremities during ambulation is a sign of fl accidity. (verminal) lesion manifestations correspond to the Deep tendon refl exes are pendular. Joint play is in- paleocerebellar syndrome, which can be combined creased and many signs typical for hypermobility are with archicerebellar involvement. seen. Elementary postural refl exes are decreased or absent. Hypotonia manifests itself in endurance tests, PALEOCEREBELLAR SYNDROME i.e., during the Mingazzini test, a slow lowering of the Clinically, the paleocerebellar syndrome is manifested raised extremity occurs. mainly as defi cits in standing and walking with stag- gering and a tendency of falling in various directions (trunk or axial ataxia). Paleocerebellar (previously known as large) asynergy is manifested by a coordina- tion defi cit mainly in the trunk and the proximal lower extremity muscles, incorrect judgment of movement to maintain standing, transition from sitting or from supine, backward bending or straightening. Sponta- neous falls in various directions, especially backward, are common when the central part of the cerebellum (vermis) is injured.

Fig. 1.13.2-6 Test to assess fl accidity: the examiner pulls on NEOCEREBELLAR SYNDROME and quickly releases the patient’s raised forearm; a patient Th e neocerebellar syndrome develops when the cer- with cerebellar syndrome cannot stop forearm movement in time and it hits their chest ebellar hemispheres are injured and it is manifested mainly as movement defi cits in the ipsilateral ex- tremities. In contrast to pyramidal pathways, cerebel- lar pathways cross twice and, thus, each hemisphere CEREBELLAR TREMOR always aff ects the ipsilateral extremities. Th e neocer- A cerebellar tremor is an intention tremor which ebellar syndrome displays hypermetria, dyscoordina- means that it is manifested during a specifi c move- tion and adiadochokinesia of movement in ipsilateral ment. It is most prominent at the end of a movement extremities. An extremity asynergy (small asynergy) and is best observed in the fi nger-to-nose coordina- is demonstrated mainly in fi ne motor skills of the up- tion test (see Fig. 1.13.2-1) Titubation is a rhythmical, per extremities. Purposeful movements are disturbed slow head or upper trunk tremor occurring mainly in by an intention tremor and increased passivity; neo- the anterior-posterior direction. cerebellar ataxia occurs. Lower extremity involvement leads to defi cits in standing and walking. Pathological lesions usually overreach the anatomical boundaries EYE MOVEMENT DISTURBANCES of cerebellar regions and, thus, clinical symptomatol- ogy is mixed. In a cerebellar dysfunction, eye movement distur- bances are manifested by non-continuous movements PSEUDOCEREBELLAR SYNDROME consisting of a series of twitches. In principle, it is an Pseudocerebellar syndrome develops with a frontal uncoordinated movement of the eyeballs with signs of lobe injury. Th e clinical picture is similar to paleo- asynergy, hypermetria and an intention tremor. Cer- cerebellar syndrome with gait dysfunction known as ebellar nystagmus is gross, occurs toward the side of frontal ataxia being the most obvious. Ambulation is the lesion and becomes more prominent when look- wide-based, very unsteady and the patient feels like ing toward the aff ected side. they are being pulled backward and shows a tendency 428 Special Section to their home environment and continuity of care describe it in 1859. It is defi ned as the neurodevelop- needs to be ensured for such patients (rehabilitation mental and non-progressive involvement of the child’s institutes, skilled nursing facility). When the progres- motor development due to sustained (and completed) sion is favorable and the patient has an appropriate prenatal, perinatal or early postnatal brain damage. home environment, the patient can be discharged to Th e damage, which occurs during the prenatal or home care. Some patients aft er a CVA need to utilize postnatal period, is not stable and continues to prog- caretaking services to a various extent following their ress. Postnatal scarring, progressive atrophy, gliosis discharge to a home setting. with retraction or cavitation develop. Brain imaging Mobility defi cits, limited independence and a sym- methods may or may not show clear signs of distur- bolic function defi cit greatly aff ect the patient’s life. bances – microcephaly, macrocephaly, hydrocepha- To accept this new reality is one of the hardest tasks lus, porencephaly, agenesis of gyri, lissencephaly, etc. that the patient and their caretakers need to deal with. In patients with CP, motor defi cits are regularly seen; Here, an important role can be played by non-profi t however, in many cases other systems can be involved and public organizations. In the Czech Republic, the as well. Association for Rehabilitation of Persons aft er Cere- brovascular Accidents was formed from an initiative Epidemiology of patients aft er CVA and healthcare workers. Integra- Cerebral palsy aff ects 1.5–2.5 out of 1,000 newborn tion back into the society of patients aft er CVA is the children. Its incidence has not been linked to a de- main goal of this organization. Th e public organiza- crease in newborn mortality in recent years. Long- tion “Afazie” off ers programs and counseling for pa- term incidence is being monitored in Australia, Den- tients aft er CVA with a speech defi cit. mark, the USA and, especially, in Sweden. In conclusion, it needs to be emphasized that pa- Data about the incidence of children with cerebral tient care during hospitalization aft er a CVA is pro- palsy in the Czech Republic is quite diff erent. In the vided by an entire team of collaborating specialists. Czech Republic, there are 16,000–20,000 children No less important is the assurance of appropriate with cerebral palsy and about half of them require care when the patient is being transferred to a home continuous rehabilitation. setting. In the entire system of care for patients aft er CVA, the family physician has an irreplaceable role Causes of Onset and oft en is the fi rst person in contact with the pa- Th e causes of brain damage can be diverse. Th ey can tient during their transition to their home setting and be divided into three groups: ensures further follow up care. 1. Prenatal – intrauterine infections are prenatal fac- Comprehensive balneologic treatment in patients tors that most often cause brain damage. This cate- aft er a CVA is indicated when the acute stage sub- gory often includes TORCH (toxoplasmosis, rube- sides, especially in cases when it is presumed that the olla, cytomegaly, herpes infection). Other causes aff ected functions are recovering. It is mainly benefi - include developmental malformation, drugs used cial in assisting in the renewal of mobility, improving by the mother, etc. A number of these factors can independence and the patient’s quality of life. A state- lead to various degrees of premature birth. Prema- ment from an internist regarding the patient’s ability ture birth is one of the etiological factors of CP for to handle physical demands from the cardiovascular two reasons – it involves delivery of a very fragile perspective also needs to be provided. Comprehen- head of the baby through a firm birth canal and, sive balneologic treatment is administered based on at the same time, the child is being born without the recommendations from a neurologist or a reha- completely matured biological functions. Genetic bilitation physician. It is contraindicated in patients factors are being continuously discussed, but so far who suff ered a CVA more than twice and also in pa- they are not a proven etiological factor of CP. tients with a severe phatic defi cit or cardiac insuffi - 2. Perinatal – abnormal childbirths are perinatal fac- ciency. In the Czech Republic, balneologic treatment tors that most often cause the onset of CP. They for patients aft er a CVA is available in Dubi, Karvina, result in a brain trauma, especially ischemia and Msene, Velke Losiny, Vraze and Janske Lazne. hypoxia. Ischemia and hypoxia selectively damage individual brain structures based on their level of maturity and vulnerability. The key role in brain 1.21 CEREBRAL PALSY damage by hypoxia or ischemia is played by excit- atory amino acids (aspartate, glutamate) and by the activation of N-methyl-D-aspartate receptors with Cerebral palsy (CP), also known as infantile cerebral subsequent influx of calcium into the cells, which palsy (ICP), was originally called Little’s disease aft er leads to cell death if cells do not show sufficient London physician, John Little, who was the fi rst to activity. In pre-term babies, hypoxia and ischemia 1 Treatment Rehabilitation in Neurology 429

are a result of periventricular leukomalacia. In tive methods are indicated (specifi c metabolic screen- term babies, a selective neuronal necrosis occurs ing, neurophysiological examination, ultrasound or in predilected areas, such as the hippocampus, cer- other imaging methods – CT, MRI, genetic and other ebellum and the basal ganglia. Periventricular leu- testing). A diff erential diagnosis of motor function komalacia (PVL), especially its cystic form (cPVL) defi cits (elimination of etiology other than CP) must is considered to be the main predisposing factor be performed no later than the child’s adjusted age for the onset of CP. Bilateral occipital PVL, identi- of nine months. However, the actual identifi cation of fied by an ultrasound during the neonatal period, CNS involvement needs to be established much ear- predicts occurrence of CMO with an almost 99% lier, no later than at two months of age. certainty. Timely identifi cation of children with CP allows 3. Postnatal – these include mainly early newborn for the indication of early care and means earlier ini- infections, most often bronchopneumonia or gas- tiation of therapy. Th is approach can signifi cantly de- troenteritis. crease the functional consequences and prevent motor and cognitive complications of a late diagnosis. Dur- Etiology and Pathogenesis ing the assessment of postural functions, the question 1 Etiology and pathogenesis of CP are a multifacto- remains how to defi ne the criteria outlining the sever- rial interrelation of individually predicted factors of ity of a defi cit that requires the child to be included in development and are a subject of constant clinical- therapy. It is important to identify the children with epidemiological reassessment. It is primarily a severe a non-signifi cant central defi cit in muscle function in prematurity (under 32 weeks of gestational age or whom spontaneous correction occurs. under 1,500 grams) that predisposes the immature Vojta’s screening of postural development, as well newborns to cerebral morbidity and severe defi cits in as, other methods are used in the assessment of new- neuromotor and mental development due to structur- borns and infants at risk who are suspected of delayed al and functional immaturity of the CNS, circulatory psychomotor development (see General Section of instability with a tendency of pressure passive cerebral the textbook, A. Diagnostic Approaches, Chapter III circulation, insuffi cient activity of the anti-oxidative Neuromotor Development and its Assessment). defense system or increased sensitivity in regards to toxic activity of excitatory amino acids. Occurrence of CP and its manifestations vary depending on the 1.21.2 Types of Cerebral Palsy level of prematurity or birth weight. Jessen at al. found and their Clinical Presentation that over 40% of children with early cerebral mortal- ity, without taking into consideration gestational age Despite the overall diversity of the clinical picture of or birth weight, later demonstrated a severe defi cit in CP, usually a movement defi cit is the dominant mani- movement functions. Th ey also pointed out the fact festation, which is usually visible in the earliest stages that the frequency of involvement in physical abilities of the disease and poses the greatest problems to the does not vary among individual birth categories, but patient. Th e character of the motor defi cit is given by the incidence of involvement of cognitive abilities in- the involved CNS area. Based on the clinical picture creases with the infant’s decreased birth weight. (dominating signs), several forms of CP can be distin- guished. Th ey develop gradually during brain matu- ration and have diff erent prognoses, diff erent predis- 1.21.1 Screening for Risk of CP positions for development of contractures and joint deformities and also respond diff erently to the same Cerebral palsy occurs in 8–10% of children born pre- therapeutic approaches. maturely. Approximately 40% of all children with CP are born prematurely. Screening aimed at neuromo- SPASTIC DIPLEGIA tor development is an essential step in timely recogni- It belongs among the most frequent forms of CP. Nu- tion of children with CNS involvement. Children who merous incidences of diplegia are reported by various show abnormal models during spontaneous motor authors. Th e data ranges from 41% to 65%. Th e se- behavior and with positional reactions are included verity of motor involvement diff ers. Spastic diplegia in a clinical unit known as central coordination dis- aff ects patients who achieve independent bipedal lo- turbance (CCD). It is important to realize that CCD comotion without support, but also patients who are does not mean that the patient will develop CP. Cere- completely apedal. Even if the patient is capable of bral palsy develops only in a very small percentage of independent bipedal locomotion, gait always shows children in whom CCD has been identifi ed. pathological features. In a classic form of spastic Based on the grade of CCD (grade 3 and 4), repeat- diplegia, the lower extremities are always more af- ed neurological assessments are performed and assis- fected than the upper extremities. Spastic diplegia 430 Special Section usually develops as quadriplegia in which neither present mass generalized movements of the entire extremity fulfi lls its basic function, such as support body in the patterns of tonic neck, tonic labyrinthine and grasping by the upper extremity and support and or other primitive postural refl exes or in their various stepping forward by the lower extremity. By gradually combinations. including one upper extremity into a specifi c mo- Dysmorphic features such as a gothic palate or tor function (even if it is a pathological motor skill) pseudoharrison’s ridge below the ribcage (it is present spastic diplegia develops in a stage of triplegia and, in rickets) are typical in children with spastic dipare- by including both upper extremities, spastic diplegia sis. In more severe forms, approximately 20% of chil- occurs. Oft en, the plegia is asymmetrical and, in some dren with spastic diplegia show some signs of rigidity patients, the dysfunction can result in monoplegia, (more commonly in fl exion types). which can be observed, for example, in unilateral leukomalacia. Spastic triplegia is being reported as SPASTIC HEMIPLEGIA an independent form of CP. Th e number of children Hemiplegia is a unilateral defi cit in mobility most with spastic triplegia has increased with the increased oft en spastic in nature. Th e entire half of the body is number of children who survive signifi cant prematu- aff ected, including the facial and hypoglossal nerves. rity. A half of these children demonstrate epilepsy and Spastic hemiparesis can be divided into congenital only a third of them present with normal intellect. It and acquired. If the acquired hemiparesis develops in is a very severe motor defi cit that is very diffi cult to infancy, it is diffi cult to distinguish it from congenital infl uence with therapy. Etiologically, intraventricular hemiparesis, especially if the episodes were present bleeding with asymmetrical infarction is common. prior to the hemiparesis being identifi ed. Pseudofl ac- Severely involved patients who demonstrate a more cid stadium and central paresis of the facial nerve are signifi cant defi cit in the upper extremities or in whom more likely to indicate acquired hemiplegia. Acquired all four extremities are equally aff ected have a bilateral hemiparesis of vascular etiology requires a specifi c di- hemiplegia syndrome. It is reported that the incidence agnostic and treatment approach. In contrast to con- of this syndrome is 27% out of all patients aff ected by genital hemiparesis, aphasia also occurs in left -sided spastic diplegia. In most cases, the patients with bilat- involvement. However, it is also possible that when eral hemiparesis also show mental impairment. the genotypically dominant hemisphere is aff ected, no Approximately a third of children with spas- developmental delay may be observed. Epilepsy poses tic diplegia are born prior to 32 weeks of gestation, a signifi cant complication in children with spastic a third are born between 32–36 weeks and a third are hemiplegia. It aff ects more than one third of patients. born at term. Prematurity is linked to high incidence Th e seizures are focal or secondarily generalized. Most of perinatal factors. of them can be controlled by treatment. Th e presence Th e fi rst manifestations of spastic diplegia can al- of epilepsy is signifi cantly linked to mental retarda- ready be observed in the early stages of development tion. More than 50% of children with epilepsy suff er through an assessment of the child’s motor behavior. from mental retardation. In patients with hemiplegia, During the fi rst months aft er birth, especially in con- mental retardation can be identifi ed in almost half of genital motor defi cits, a pathological motor pattern patients; in children without epileptic seizures, about is visible, but it is not yet defi ned. It is non-specifi c one third presents with mental retardation. Th e sever- or common to a number of later developing forms of ity of hemiplegic involvement, which is distinguish- CP or other syndromes. Th e clinical picture becomes able mainly from the upper extremity involvement, is more distinct only during the second or the third tri- also closely linked to mental retardation. Hemiplegic mester aft er birth. form of CP aff ects more boys than girls and right-sided In any case, motor development lags behind the hemipareses occur somewhat more oft en. Divergent quality of motor patterns that are typically observed strabismus may also occur. Homonymous hemiano- during physiological motor development (see Gen- psia can also be present (it can nearly be eliminated eral Section of the textbook, Chapter III Neuromotor by treatment). Development and its Assessment). Th e growth of the hemiplegic extremities is delayed All children with spastic diplegia present with in comparison to the healthy extremities. Hemihypo- a pathological postural foundation followed by path- genesis is more pronounced on the upper extremity, ological phasic mobility. Th e normal developmental which is almost always more aff ected than the lower pattern of eye-hand-mouth is not present; however, extremity. It is measured based on the severity of in- so called dystonic attacks are observed. Th ey oc- volvement. Th e extent of the involvement can be as- cur following acoustic or visual stimuli linked to an sessed by the ability to perform an isolated movement emotional component – when the child attempts to and by the ability to assume a joint position that is accomplish a specifi c task, for example, when grasp- developmentally typical of a younger age. In a mild ing an object being passed to them. Dystonic attacks form, the fi ngers can perform isolated movements. 1 Treatment Rehabilitation in Neurology 431

In a moderate form, only the entire extremity can be dillo sign. Next, the fl exibility of the knee and elbow moved and in a severe form, no isolated movement of fl exors and extensors is being assessed followed by the hand or any other upper extremity segment is pos- ankle range of motion, hand, thumb and fi nger fl ex- sible. Isolated movements are also linked to the ability ibility, arm raising test, etc. to attain a position in a movement segment. A child Hypotonia in childhood age is not the only mani- with spastic hemiparesis attains newborn position- festation of cerebellar involvement, but oft en, it is ing, which includes shoulder protraction, adduction a mere transitional stage of CP. Quite diff erent syn- and internal rotation, elbow fl exion and protraction, dromes may arise from hypotonic forms. Th e onset wrist fl exion and ulnar deviation, and fi nger fl exion. of hypotonia is time-dependent on CNS maturity or Active shoulder fl exion, abduction and external rota- rather its immaturity. Hypotonia in infancy always tion and elbow extension and supination are assessed. needs to be assessed for diff erential diagnoses. Some In a hand, wrist extension, thumb opposition and level of relative hypotonia can also be considered nor- abduction and fi nger extension are being assessed. mal between 2–5 months of age. Th e more the child is able to attain a position close to Joint range of motion and muscle fl exibility are not physiological development, the lower the level of their only dependent on the extent of the pathological pro- 1 involvement. In severe forms, the patterns typical for cess, but also on the physiological state of the nervous a newborn persist. system and its developmental stage. In children with spastic hemiplegia, not only the Refl exes are preserved or only slightly decreased. bones, but also the muscles are delayed in develop- Th irty percent of children exhibit epilepsy. ment and hemihypogenesis of the corresponding side Dysmetria develops (leg length discrepancy is on average 1.5 cm Th is is the incorrect targeting of a movement. Th e with 1–3 cm diff erence in circumference). direction of the movement is correct, but the end of the movement shows hesitation. Th us, movements CEREBELLAR FORM become inaccurate. A cerebellar form as an individual occurrence is al- most never present. Prenatal factors contribute to Intention Tremor a great extent on the onset of involvement. In the ma- Th is is a tremor observed prior to reaching the target jority of children with a cerebellar syndrome, mental of movement. Th e movement is rough, irregular, rath- retardation is also observed but it usually is not se- er slow and with large amplitudes. Typically, an inten- vere. Sometimes, a cerebellar syndrome is accompa- sion tremor subsides prior to movement completion. nied by autism. It is seen in the upper and lower extremities. A cerebellar form of CP develops in relation to Trunk Ataxia brain maturation and the specifi c signs of cerebellar It is a lack of coordination of the trunk caused by involvement appear gradually based on brain struc- a disproportion between contraction intensity and the ture maturity and their inclusion within motor func- type of movement. tion. Clinical signs, which include muscle hypotonia, trunk ataxia, hypermetria, intention tremor and trunk Asynergy ataxia all occur gradually during the process of CNS Asynergy is a defi cit in cooperation of various muscle maturation. groups. Adiadochokinesis Clinical Picture Adiadochokinesis describes the patient’s inability to perform alternating movements. Hypotonia Central hypotonia, and with it, related delayed loco- Cerebellar Diplegia motor development dominate the clinical picture of Th e cerebellar form as an individual entity is rare. a cerebellar syndrome. All muscles are fl accid and the Oft en, spasticity is found along with a cerebellar syn- joints can be bent to large angles. Joint excursion and drome. Given the extent of motor involvement, it is muscle fl exibility, as criteria of muscle tone, are mani- classifi ed as a separate form of CP. fested by scarfs sign in which the patient is able to Th is form demonstrates typical symptoms. Th e hy- cross their arms around their neck like a scarf. It is as- potonic picture begins to show spasticity in the sec- sessed whether the elbows are away from each other, ond half of the fi rst year of life. Spastic fl exion phe- above each other or are crossed over each other. An- nomena are observed and extension phenomena are other sign is the drawing compass during which the usually not present. Th e increased tone begins espe- lower extremity can be bent at the hip joint all the way cially distally, most oft en in the triceps surae, which to the trunk. In sitting, a child’s trunk can be bent to later develop contractures. Th e picture of primitive their lower extremities, which is known as the arma- refl exology lacks or shows a decreased tonic grasp of 432 Special Section the lower extremities. Trunk lateral fl exion as a re- In the fi rst three months of life, dyskineses have yet sponse to unilateral paravertebral skin stimulation is to manifest themselves. In this period, primitive re- either absent or decreased, thus, the Galant refl ex is fl exology and central acoustic defi cits can be prelimi- decreased. Pseudoclonus emerges with the develop- narily used, which are oft en associated with dyskine- ment of distal spasticity. sis. Th e inability to elicit the acoustic-facial refl ex is Motor development depends on the severity of in- a warning sign. Disrupted dynamics or the persisting volvement, which varies in this form, similar to spas- presence of primitive refl exes and a diff erential diag- tic diplegia. In an ideal scenario, the children can am- nosis together predict the severity of the injury. bulate at two to three years of age. More severe forms Persistence and an exaggerated response to the Gal- achieve verticalization between the fi ft h and the tenth ant refl ex are typical signs of dysfunction. In contrast year at the latest. Verticalization and bipedal locomo- to spastic forms of involvement, the grasp refl ex of the tion are not achieved in the most severe forms. lower extremities is accentuated and persists aft er the fi rst year of life or even for several years. In contrast, DYSKINETIC FORM OF CEREBRAL PALSY refl exive grasp of the upper extremities is diminished A dyskinetic form of CP is characterized by abnormal and ceases as early as in the second trimester. Th e movements or postures. Th e corresponding form of cause is a predominant tendency toward fi nger exten- CP is classifi ed based on whether hyperkinesis or dy- sion, especially the thumb and the index. Th e Moro stonia predominate. refl ex persists into the third trimester and becomes In the hyperkinetic form, irregular, repetitive and a stereotypical response to various external stimuli. excessive movements dominate the clinical picture. In Th e heel refl ex already cannot be elicited in the sec- CP, these movements are most oft en divided into two ond trimester. Th e suprapubic and crossed extension forms: refl exes become absent in the fi rst trimester. Gait au- Athetosis – the most typical; described as writhing, tomatism persists for a long time, which is known as inconsistent, fluctuating and involuntary move- stepping (child moves as if to push off ). eTh Babkin ments that affect proximal aspect of extremities refl ex persists longer than normal. Lower extremity Chorea – it is distinguished from athetosis mainly stretch refl exes are normal or increased. by the speed of involuntary movement; distal as- Th e fi rst signs of future dyskinesis can already be pects of the extremities are primarily affected recognized during the second trimester. Dystonic at- A dystonic form is characterized by abnormal tacks begin to emerge. Based on external and some- changes in muscle tone resulting in typical changes times also internal stimuli, the infant reacts with a hy- in body posture. Th e dystonic subgroup also presents pertonic change in muscle tone, usually in the pattern with non-volitional movements, but not nearly to of the tonic neck refl ex (TNR), the tonic labyrinthine such a great extent as the hyperkinetic subgroup. refl ex (TLR) or opisthotonus. Th ese are present main- An isometric contraction disturbance is one of the ly in athetoses developed from hypertonic stage. In main problems that are characteristic for a dyskinetic children with hypotonia, dystonic attacks are less pro- syndrome. Th erefore, volitional movements recruit nounced. Th ey are provoked by a sudden change in muscle groups from the entire body. position. Dystonic attacks also develop as a reaction An athetoid syndrome can develop from a hyper- to sounds. Th e children struggle with head control. tonic, as well as, a hypotonic syndrome and it is ob- In addition, signifi cant changeability in muscle tone served in the fi rst three months of life. Most future is observed. At rest, the infant is hypotonic and sud- athetoses develop from neonatal hypotonia. Hypoto- denly as a reaction to external stimuli hypertonia ac- nia is mainly axial (trunk) and proximal. Trunk hy- companied by opisthotonus may occur. When it sub- potonia can be confi rmed by the Landau reaction. In sides, hypotonia dominates, especially in the trunk. the third trimester, an infant’s head and pelvis almost Th e severity of hypotonia shows a positive correlation fl accidly hang toward the mat with trunk instability, with the severity of involvement. In addition to dys- which is not seen as much in other syndromes. Th e tonic attacks, athetosis of the distal lower extremities trunk turns toward the jaw side. Th e extremities are emerges in the third trimester. fl exed, however, a sudden opisthotonic posturing can Swallowing poses signifi cant problems. During occur with the lower extremities positioned in exten- swallowing, tongue support against the upper palate, sion. In contrast to spastic diplegia and hemiplegia, which the child is unable to accomplish, is important. athetoses show more diff use involvement throughout Th is results in malnutrition. Stimulation of the orofa- the entire movement system. cial region elicits dystonic postures. Similarly, every Trunk instability is clearly manifested during axil- attempt at movement results in grimacing. lary suspension. During a traction test, no neck fl exion Feeding dysfunctions are most pronounced in the activity is observed during the entire fi rst year. During third trimester. In the past, many children died dur- this test, the lower extremities remain in fl exion. ing this period. 1 Treatment Rehabilitation in Neurology 433

Th e children cannot chew and they constantly drawing compass and armadillo signs are present. salivate. Th eir biting is homologous without lateral Next to hypotonia, this type of diplegia presents with co-movement of the lower jaw. In some children, pro- a more severe degree of mental involvement, usually truding of the tongue occurs long-term in a similar at the level of oligophrenia. In the fi rst months, the fashion as can be observed in a newborn as a reaction children are considerably apathetic, not interested in to unpleasant gustatory stimuli. Th is phenomenon is their surroundings, do not reach for objects and do the so called “tapir’s mouth”. Food that is moved dur- not recognize the mother. Th ey react to external stim- ing feeding accentuates tongue protrusion. uli by dystonic attacks. Typically, the postural pattern Th e clinical picture also includes autonomic labil- practically does not include the lower extremities un- ity (increased perspiration) and emotional instabil- til the third trimester. ity. Mental abilities are usually normal. Some chil- In the fi rst year, the child lies with the thighs ab- dren show above average intelligence. Scenarios in ducted to 90 degrees. Plagiocephally occurs as a result which mental involvement is present usually include of being in a supine position. Nystagmus is typically athetosis combined with another type of involvement not part of the child’s clinical picture. (cerebellar, spastic, etc.). Postural dysfunctions cause Th e dive refl ex is associated with forward fl exion of 1 a vocalization defi cit and a signifi cant delay in speech the upper extremities with clasped hands. During ax- development. Th e patient shows diffi culty with pro- illary suspension administered in the third trimester, nunciation and articulation. Th e speech is throaty, ex- the lower extremities remain in fl exion and muscle plosive and less intelligible. When the child attempts tone increases. to speak, they breathe in and the entire posture re- fl ects co-movements. Given the normal mental devel- opment, the patient’s speech is signifi cantly expres- 1.21.3 Rehabilitation sive, meaning that they can express a large content by in Cerebral Palsy using few words. Th e children show decreased facial expressions. DESIRED OUTCOME AND COPING MIXED TETRAPLEGIA PROCESS Mixed forms of CP include patients in whom more forms of central involvement are combined. Oft en, DESIRED OUTCOME for example, spastic diplegia, ataxia and dystonia or Cerebral palsy includes patients with varied severity spasticity and dyskinetic syndrome are combined. It of involvement. Rehabilitation therapy depends on is usually a diff use brain injury that also includes sig- the extent of involvement and the “desired outcome”, nifi cant mental retardation – most oft en at the level which can be expressed by the term treatment expec- of oligophrenia. Th is can also include children whose tation. Given the extent of motor and psychological psychological development is not as severely involved. involvement, the children can be divided into several Most of such children can only live in an institution; groups and each group needs to be approached in an none of them will be able to live independently in so- individual and specifi c way: ciety in the future. Th e patients show a decreased life span. More than 50% of the children have epileptic Patients with a Severe Motor Defi cit and Severe seizures that are mostly severe in intensity and are Mental Retardation diffi cult to control by medication. Central dystrophy Verticalization should not be expected in such pa- is typical as a result of a swallowing defi cit. Th e neu- tients and, in the majority of cases, sitting is also not rological fi nding corresponds to the type of involve- accomplished. Th ey are fully dependent on the care ment. from others. Th e main goals for such patients include In some cases, amaurosis or mostly divergent alter- prevention of contractures and joint deformities, pre- nating strabismus are present. vention of pressure ulcers and chest wall deformities As far as kinesiologic development, upright postur- that make breathing diffi cult. Treatment mostly con- ing shows signifi cant delay. For a long time, it remains sists of rehabilitation care and prophylactic methods. at a newborn level. Patients with a Severe Motor Defi cit and only a Moderate or Mild Degree of Mental Retardation ATONIC DIPLEGIA In such patients, it is especially important to begin Sometimes it is referred to as an atonic-astatic type of rehabilitation treatment as soon as possible. Contrac- CP according to Forster. In this type of CP, the cer- tures and neurogenically developed deformities pose ebellum is not aff ected, but the brain’s frontal lobes the main problem. Even with intensive, correctly ad- are involved. Some signs are similar to a cerebellar ministered and timely initiated physical therapy, the syndrome, especially signifi cant hypotonia. Th e scarf, eff ects of spastic or hypotonic manifestations cannot 562 Special Section

2.5.5 Lower Extremity Orthoses AB Considering the weightbearing function of the lower extremity, which fulfi lls static and dynamic functions, the selection of an appropriate functional orthosis is extremely important for the patient. Th e following criteria are taken into consideration when selecting Fig. 2.5.5-1A,B FO. A – foot orthosis infl uencing forefoot an appropriate orthosis: adduction; B – stabilization of a fracture at the base of the fi fth metatarsal Assessment of the extremity’s functional state Assessment of the extremity’s weightbearing status A Range of motion and stability in individual seg- ments Muscle strength Possible extremity shortening B

Fig. 2.5.5-2A,B FO. A – night splint to correct hallux valgus; BASIC CLASSIFICATION OF LOWER B – Hallux valgus strap EXTREMITY ORTHOSES

FOOT ORTHOSIS – FO Foot orthoses are applied either when correcting incorrect foot and toe alignment or to decrease the demands of weight bearing (orthopedic insert) (Fig. 2.5.5-1A,B), which can decrease the defect on the plantar surface. In severe deformities, toe correctors are applied (Fig. 2.5.5-2A,B).

ANKLE-FOOT ORTHOSIS – AFO Ankle orthoses are applied to correct foot and ankle deformities, to stabilize talocrural articulation and to Fig. 2.5.5-3 AFO – an or- Fig. 2.5.5-4 AFO – leather ensure decreased lower extremity weight bearing. Th e thosis with an option to set orthosis overview of orthoses includes rigid ankle orthoses, range of motion at the talo- those with options to preset range of motion at the crural joint TC joint (Fig. 2.5.5-3), ankle elastic reinforcing braces (Fig. 2.5.5-4) and a dorsifl exion-assist orthosis (Fig. 2.5.5-5). An orthosis with a fi rm ankle provides maximum immobilization of the ankle and foot complex in all planes. Th e anterior fl oor reaction AFO is another type of AFO. Th e principle of this orthosis lies in the slight ankle plantarfl exion, which causes an extension force moment at the knee and increases its stability in the sagittal plane. An unweighting type AFO known as a patellar tendon bearing AFO (utilizing Sarm- iento principles) is another modifi cation to an AFO. Its main goal is to decrease the axial loading of the distal segment of the lower extremity during gait. It is used, for example, during functional treatment of fractures or to allow for complete healing of defects Fig. 2.5.5-5 AFO – dorsifl e- Fig. 2.5.5-6 AFO – posterior on the plantar aspect of the feet. Th is device, however, xion assist orthosis leaf spring can only be used if the skin is intact in the areas the orthosis applies support and if the quadriceps femo- ic AFOs, they allow ankle movement in the sagittal ris demonstrates suffi cient strength to maintain knee plane. Th e posterior leaf spring (PLS) AFO is a ther- stability. moplastic orthosis whose medial and lateral edges Dynamic AFOs include plastic, metal and also are positioned behind the connection of both mal- composite fabrication materials. In contrast to stat- leoli (Fig. 2.5.5-6). Th is design allows for movement 2 Treatment Rehabilitation in Orthopedics and Traumatology 563

mid-stance. Th e plastic AFO with a joint consists of a plastic ankle joint built-in between the foot and the shin portion the orthosis made from thermoplast. For the orthosis to function eff ectively, the ankle needs to have at least 5º of dorsifl exion. Th e degree of plantar- fl exion can be limited by a stop. An AFO made from a composite material uses the accumulated energy in an elastic skeleton of the plantar segment of the orthosis during heel strike. Th ese orthoses are designed for active patients (Fig. 2.5.5-8 A,B). Th e full eff ect of AFO wear also depends on the type and condition of the patient’s footwear. Fig. 2.5.5-7 AFO – with Fig. 2.5.5-8A AFO from Diff erent heel heights of footwear signifi cantly al- a mechanical ankle joint composite materials ter the orthosis’ biomechanical function.

KNEE ORTHOSIS – KO The most simple knee orthoses include infrapatel- lar straps, knee elastic reinforcing braces and knee orthoses with joint bars. If more rigorous stabiliza- 2 tion is needed, orthoses with constant rigid flexion or orthoses with restricted movement are selected. In severe combined instabilities and knee joint deformities, orthoses with firm construction are indicated and the TC joint is used as a secondary joint to stabilize the device. Corrective KO influ- ences the knee alignment based on a three-point principle. Most often they are equipped, similarly to other KOs, by lateral or medial bars with a joint Fig. 2.5.5-8B AFO – aluminum orthosis and adjustable straps. These KOs can correct knee as partof footwear varus or valgus, or even a genu recurvatum defor- mity (Fig. 2.5.5-9 A,B). in the actual ankle joint and its range is given by the thickness of the material used for the orthosis fabrica- KNEE-ANKLE-FOOT ORTHOSIS – KAFO tion. Dorsifl exion assist AFO, in contrast to the PLS, A knee, ankle, and foot orthosis is selected mainly uses a mechanical ankle joint with a built-in spring in patients who require stabilization and movement mechanism (Fig. 2.5.5-7). Th is orthosis assists with control in the knee and ankle joints. foot dorsifl exion during the swing phase and ensures A KAFO is an orthosis spanning from the patient’s smooth transition between the initial heel strike and thigh to the foot. Th is extent allows for function of the

correction of valgus correction of varus limiting fl exion limiting extension

M LLM

Fig. 2.5.5-9A Schema of correction of knee valgus and varus. Fig. 2.5.5-9B Schema of correction of knee fl exion and M = medially, L = laterally extension 564 Special Section

Fig. 2.5.5-10 KAFO – plaster-made orthosis

Fig. 2.5.5-11A,B KAFO – special carbon AB orthosis actual AFO and, at the same time, allows for control tient’s individual measurements. Th eir light weight of the knee joint in the sagittal and frontal planes. is the main advantage. Th e disadvantages include A classic AFO is made from metal bars that con- relatively lower contact area in the area of the ortho- nect the knee and ankle joints of the orthosis with sis arches, which due to possible intolerable pressure leather or Velcro straps for attachment to the extrem- points does not allow for correction and stabilization ity. Firmness and durability are their advantage. Th e of signifi cant knee joint deformities. Given its light durability, however, is achieved in exchange for heavi- weight, it is used in patients with lower extremity pa- er weight. Another disadvantage of this type of KAFO resis (Fig. 2.5.5-11 A,B). includes a smaller range of contact surfaces, increased Th e function of a KAFO depends on the type of demand on the insole of the footwear and a less ap- joints that are used in its construction. A singe axis pealing cosmetic look. knee joint allows for unlimited fl exion and extension A plastic KAFO is constructed from a cast of a pa- in the sagittal plane. Th is type of joint is suitable for tient’s extremity. Th is ensures tighter contact with the patients who demonstrate suffi cient muscle strength larger surface area of the extremity thereby decreas- to maintain stability in the stance phase, but, at the ing pressure points and increasing movement control same time, demonstrate initial deformity of the knee of the entire extremity. Th e individual components of joint: recurvatum, valgum or varum. Single axis knee this orthosis are connected by joints. Th e advantages joint with a lock will lock the joint in extension and of this orthosis include low weight and better cosmet- thus, provides the knee with rigid stability in all ic appeal. However, a plastic KAFO is limited by skin planes. Th is type of joint is suitable for patients with condition and extremity size/volume (Fig. 2.5.5-10). a decreased ability to control the knee joint through- A special KAFO is fabricated from light construc- out the stance phase, leading especially to sudden tion materials (carbon, titanium) based on the pa- knee fl exion with gradual loading at the beginning

Fig. 2.5.5-12A,B HKAFO – an orthosis stabilizing the hip, knee and ankle joints

Fig. 2.5.5-13 A B HKAFO – reciprocal gait orthosis 2 Treatment Rehabilitation in Orthopedics and Traumatology 565 and during the stance phase. Th e orthosis’ knee joint Simple hip orthoses are used as stabilizing orthoses can be utilized and locked at various degrees of knee in cases of instability following total hip endoprosthe- fl exion. Th is is utilized in patients who are unable to sis or to ensure hip abduction positioning in children. fully extend the knee, for example, in knee fl exor con- Th ey serve as an important device in the verticaliza- tractures. Mechanical or microprocessor controlled tion of patients following proximal femoral traumas knee joints in orthoses that aff ect the stance and swing (Fig. 2.5.5-14) or in patients with neuromuscular in- phases of gait are among the more complex mecha- volvement following trauma or in cerebral palsy. nisms used with a KAFO knee joint. Th is type of joint automatically locks when loaded during the initial contact of the heel with the fl oor and remains locked 2.5.6 Trunk Orthoses during the entire stance phase until it is unlocked at the moment when the heel comes off the fl oor at the Application of trunk orthoses is an integral part of end of stance phase. Th e patient’s cognitive functions treatment of many problems linked to spinal instabil- need to be considered when selecting this type of knee ity following traumas or for the treatment of spinal joint as the patient needs to understand this mecha- deformities. nism to utilize it. Th e recommendation for a trunk orthosis in pa- tients with spinal conditions is based on an accurate HIP-KNEE-ANKLE-FOOT ORTHOSIS – HKAFO assessment of spinal instability and the state of the Th e indication for a HKAFO should always be preced- myofascial system. Trunk orthoses are in such cases ed by careful consideration and consultation with the indicated to stabilize vertebral fractures or as a sup- 2 interdisciplinary team. Th is type of orthosis is a typi- plemental device aft er surgical stabilization. cal example of an uncomfortable device and donning In patients with spinal pain, soft lumbar belts are and doffi ng can be very complicated for the patient oft en routinely issued, which enhances the patient’s and the treating assistant (Fig. 2.5.5-12A,B). passivity as they use it as a “crutch”. In contrast to the previous orthoses, these orthoses Th e treatment of spinal deformities in pediatrics is also consist of an elastic or rigid lumbar socket and primarily with custom trunk orthoses. Th ese devices hip bars with limited range of motion, which ensure should be indicated only by an experienced physi- stabilization of the hip joints. Some types of Recipro- cian in clinical centers specializing in the treatment cal Gait Orthoses (RGO) (Fig. 2.5.5-13) are equipped of scoliosis. Equally, the corset fabrication for scolio- with Bowden cables interconnecting the hip joints of sis should be performed at a well-established orthotic the orthosis. When the center of mass shift s and one and prosthetic center with suffi cient experience, tech- hip joint is in a swing phase, extension is elicited in nical profi ciency and trained personnel. the other hip joint, which is in stance phase. Th is leads When applying trunk orthoses, a patient’s comor- to the elimination of simultaneous fl exion in both bidity, which can lead to worsening of the patient’s hip joints and the decreased risk of the “clasp knife” condition, needs to be taken into consideration if si- phenomenon during gait. Th is orthosis is indicated multaneous cardiopulmonary involvement is present. in children with myelomeningocele, in patients with During orthosis selection, the functional demands traumatic paraplegia and in patients with muscular need to be considered. It needs to be defi ned whether dystrophy. the orthosis should provide fi rm trunk stabilization Th e indication for this orthosis must be preceded following traumas, infl ammatory spinal conditions, by careful examination and assessment of all aspects vertebral damage or if it is supposed to serve as a sup- important for application of this device. portive device in painful spinal conditions caused by muscle weakness. Th e patient needs to be thoroughly educated in the use of a trunk orthosis.

BASIC CLASSIFICATION OF TRUNK ORTHOSES

Th e terminology involving trunk orthoses is not unit- ed. Th e terms orthosis, corset, lumbar and abdominal belts are used. When selecting a trunk orthosis, it is recommended to use the international classifi cation of trunk orthoses that includes the location on the Fig. 2.5.5-14 HO – orthosis for stabilization of the proximal trunk and simultaneously describes the construction femur and the hip joint design (fi xation, reclination, fl exion, extension, dis- XI CONTENTS

I GENERAL SECTION

INTRODUCTORY SECTION Pain and Movement System Dysfunction ...... 21 Karel Lewit, Pavel Kolář Pavel Kolář REHABILITATION CONCEPT AND DEFINITION ...... 2 A. DIAGNOSTIC PROCEDURES Jan Calta, Pavel Kolář Current State of Providing Rehabilitation ...... 2 TREATMENT MEDICAL REHABILITATION ...... 2 1 ASSESSMENT APPROACHES FOCUSED SOCIAL REHABILITATION ...... 5 ON THE FUNCTION OF THE MOVEMENT TOOLS OF SCHOOLBASED REHABILITATION ...... 5 SYSTEM TOOLS OF VOCATIONAL REHABILITATION ...... 5 Pavel Kolář, Karel Lewit, Olga Dyrhonová PREVENTATIVE ROLE OF REHABILITATION ...... 5 FUNDAMENTAL PRINCIPLES FUNDAMENTALS OF A CLINICAL ASSESSMENT ...... 25 OF REHABILITATION ...... 6 PATIENT PRELIMINARY CASE HISTORY INDIVIDUAL TYPES OF REHABILITATION ANAMNESIS ...... 25 SETTINGS ...... 7 OBSERVATION ASPECTION ...... 28 CLASSIFICATION OF FUNCTIONAL CAPABILITY, PALPATION ...... 29 DISABILITY AND HEALTH ...... 8 Karel Lewit AUSCULTATION ...... 32 TREATMENT REHABILITATION – Petr Bitnar DIAGNOSTIC AND THERAPEUTIC APPROACHES 1.1 NEUROMUSCULAR FUNCTIONS AND THEIR CLINICAL EXAMINATION ...... 33 Pavel Kolář REHABILITATIVE CARE Muscle in Reflexive Context as Part of the Movement System ...... 34 Pavel Kolář Motor Patterns ...... 34 REPOSITIONING ...... 13 Movement Stereotypes ...... 35 Indications for Repositioning ...... 13 CLINICAL MANIFESTATIONS AND EXAMINATION Principles of Repositioning ...... 13 OF NEUROMUSCULAR DYSFUNCTIONS ...... 36 Goals of Repositioning ...... 14 Types of Repositioning ...... 15 Pavel Kolář, Jiří Kříž I FUNCTIONAL AND NEUROLOGIC VERTICALIZATION ...... 17 SYMPTOMATOLOGY PATIENT MOBILIZATION ...... 17 Mobilization goals ...... 17 1.1.1 Examination of Postural Functions ...... 36 Prevention of Heterotopic Ossifications ...... 18 Pavel Kolář Types of Mobilization ...... 19 POSTURE ...... 37 Active Movement ...... 20 Postural Function – Normal ...... 37 Development of Posture ...... 37 TREATMENT REHABILITATION Reflex Model of Posture and Locomotion...... 39 FOCUSED ON RESTORATION Circumscription of the Term Posture ...... 39 OF A FUNCTIONAL DEFICIT Postural Stability ...... 40 Postural Stabilization ...... 40 Pavel Kolář Postural Reactibility ...... 40 Functional Emphasis of Methods in Treatment Postural Disturbances ...... 42 Rehabilitation ...... 21 STANDING ...... 44 Karel Lewit, Pavel Kolář Examination of Individual Body Regions ...... 44 XII Clinical Rehabilitation

Modified Examination of Standing ...... 49 Kinesthesia ...... 73 ASSESSMENT OF STANDING IN NEUROLOGIC Perception of Vibration ...... 73 DISORDERS ...... 50 Two-point Discrimination ...... 73 GAIT ...... 50 Topognosis, Graphesthesia ...... 74 Petra Valouchová, Pavel Kolář Stereognosis ...... 74 Phases of the Gait Cycle ...... 50 Clinical Sensory Syndromes ...... 74 Types of gait according to V. Janda ...... 50 1.1.4 Assessment of Reflexes ...... 75 Examination of Gait in a Clinical Setting ...... 51 Pavel Kolář Laboratory Examination of Gait...... 52 MYOTATIC REFLEXES ...... 75 Typology of Gait Dysfunctions from Upper Extremities Myotatic Reflexes ...... 75 a Neurological Perspective ...... 52 Myotatic Reflexes of the Lower Extremities ...... 75 Examination of Postural Stabilization EXTEROCEPTIVE REFLEXES ...... 76 and Postural Reactibility ...... 54 IDIOMUSCULAR RESPONSE ...... 76 Pavel Kolář PATHOLOGICAL REFLEXES ...... 76 1.1.2 Examination of Muscle Tone ...... 60 Pathological Reflexes Elicited Pavel Kolář in the Upper Extremity ...... 76 Reflex Regulation of Muscle Tone ...... 60 Pathological Reflexes Elicited Connective Tissue Component in the Lower Extremity ...... 77 of Muscle Tone ...... 60 Clonus ...... 78 DEFICITS IN MUSCLE TONE ...... 61 Mediopubic Reflex ...... 78 Hypertonia and Spasm ...... 61 1.1.5 Examination of Involuntary Movements ...... 78 Contracture ...... 61 Pavel Kolář Local Hypertonic Changes in Muscle Tissue ...... 61 TREMOR...... 79 Zdeněk Čech SPASMS ...... 79 Trigger Points – Clinical Characteristics ...... 62 MYOCLONUS ...... 79 Histological Findings in the Area of a Trigger Point ...... 62 FIBRILLAR AND FASCICULAR TWITCHES ...... 79 Localization of Trigger Points ...... 62 CHOREIC AND ATHETOID HYPERKINESES ...... 79 Foundation of Trigger Point Formation Athetosis ...... 79 in Muscle Tissue ...... 62 Chorea ...... 79 Trigger Points versus Tender Points ...... 63 TICS ...... 80 Local Muscle Twitch ...... 63 1.1.6 Examination of Muscle Strength ...... 80 Trigger Points as a Source of a Spontaneous Myofascial David Smékal, Magdaléna Lepšíková Pain ...... 63 MUSCLE WEAKNESS ...... 80 Examination of Trigger Points with the Help MUSCLE STRENGTH ...... 80 of Instrumentative Examination Methods ...... 64 Assessment of Muscle Strength ...... 80 Spasticity ...... 65 Assessment of Muscle Strength ...... 81 Pavel Kolář Rigidity ...... 68 Paratonia ...... 68 II NEUROLOGIC SYNDROMOLOGY Hypotonia ...... 68 MUSCLE TONE DISTRUBANCES AND THEIR 1.1.7 Primary Myogenic Lesion ...... 83 POSTURAL LAYOUT ...... 69 Petr Bitnar, Pavel Kolář Pavel Kolář Weakness in Myopathies ...... 83 Upper Crossed Syndrome ...... 69 Pseudohypertrophy and Muscle Contractures Lower Crossed Syndrome ...... 70 in Myopathies ...... 84 Layer Syndrome ...... 70 1.1.8 Deficits at the Neuromuscular Junction ...... 84 Assessment of Shortened Muscles ...... 70 Petr Bitnar 1.1.3 Examination of Sensory Functions ...... 70 Myasthenia Gravis ...... 84 Alena Kobesová Lambert-Eaton Myasthenic Syndrome...... 84 SENSORY TESTING ...... 71 1.1.9 Peripheral Nerve Deficits ...... 84 Examination of Individual Sensory Modalities ...... 72 Petr Bitnar Touch ...... 72 Examination of Deficits in the Sensory Fibers Temperature ...... 72 of the Peripheral Nerve ...... 84 Pain ...... 72 Examination of Deficits in Motor Fibers Joint Position Sense ...... 73 of a Peripheral Nerve ...... 85 Contents XIII

1.1.10 Spinal Cord Syndromology ...... 85 Deficits in Gnostic Functions ...... 95 Jiří Kříž, Veronika Hyšperská Deficits in Practical Functions ...... 96 GRADUAL TRANSVERSE SPINAL CORD LESION ...... 85 LIMBIC SYSTEM ...... 96 SUDDEN TRANSVERSE SPINAL CORD LESION ...... 85 Examination of Motor Functions from the Perspective PSEUDOPARETIC SPINAL CORD LESION ...... 85 of Cortical Plasticity ...... 97 SPASTIC SPINAL CORD LESION ...... 85 Pavel Kolář, Magdaléna Lepšíková MIXED SPINAL CORD LESION ...... 86 Examination of Selective Movement ...... 98 CONUS MEDULLARIS SYNDROME ...... 86 Examples of Clinical Tests ...... 99 CAUDA EQUINA SYNDROME ...... 86 POSTERIOR CORD SYNDROME ...... 86 BROWNSEQUARD SYNDROME ...... 86 III NEUROMOTOR DEVELOPMENT INTRAMEDULLARY SYNDROME ...... 86 AND ITS EXAMINATION 1.1.11 Cerebellar Syndromology ...... 86 Pavel Kolář CLINICAL EXAMINATION VIA MOTOR FLACCIDITY ...... 86 PROGRAMS ...... 100 HYPERMETRIA ...... 86 Pavel Kolář ASYNERGY ...... 87 SCREENING OF NEUROMOTOR DIADOCHOKINESIA ...... 87 DEVELOPMENT ...... 101 OTHER CEREBELLAR SIGNS ...... 87 Central Coordination Disturbance (CCD) ...... 101 1.1.12 Extrapyramidal Syndrome ...... 87 Developmental Kinesiology as an Assessment Pavel Kolář Method – the Examination of an Infant 1.1.13 Thalamic Syndrome ...... 87 in the First Year of Life ...... 101 Pavel Kolář Postural Activity ...... 102 1.1.14 Brain Stem Syndromes ...... 88 Postural Activity in Individual Phases of Development Pavel Kolář (0–15 Months) ...... 103 MEDIAL SYNDROMES ...... 88 Postural Reactivity ...... 112 LATERAL SYNDROMES ...... 88 Pavel Kolář, Marcela Šafářová 1.1.15 Syndromes of Meningeal Irritation, 1. Traction Test...... 113 Intracranial Hypotension, Hypertension 2. Landau Reaction ...... 113 and Ventricular Syndromes ...... 89 3. Axillary Suspension ...... 114 Pavel Kolář 4. Vojta’s Tilt Reaction ...... 115 SYNDROME OF MENINGEAL IRRITATION ...... 89 5. Collis Horizontal Suspension ...... 116 INTRACRANIAL HYPOTENSION SYNDROME ...... 89 6. Peiper-Isbert Vertical Suspension ...... 117 INCREASED CRANIAL PRESSURE SYNDROME ...... 89 7. Collis Vertical Suspension ...... 118 VENTRICULAR SYNDROMES ...... 90 Primitive Reflexology ...... 118 1.1.16 Cortical Syndromes Pavel Kolář and their Examination ...... 90 Functional Relationship between Postural Activity, Pavel Kolář, Rastislav Druga Postural Reactivity and Primitive Reflexology ...... 121 FRONTAL LOBE ...... 90 PSYCHOMOTOR DEVELOPMENT IN EARLY Primary Motor Cortex (MI) ...... 91 CHILDHOOD ...... 121 Premotor Cortex ...... 91 Irena Zounková, Pavel Kolář Frontal Eye Field ...... 92 CENTRAL COORDINATION DISTURBANCE Broca’s Speech Area ...... 92 IN PRESCHOOL AND SCHOOL AGE ...... 125 Prefrontal Cortex ...... 92 Irena Zounková, Pavel Kolář Signs of an Injury to the Frontal Lobes Monitored Areas in a Neurodevelopmental of the Motor Cortex ...... 93 Examination ...... 126 Axial phenomena ...... 93 Physiotherapy in Central Coordination Paraxial phenomena ...... 93 Disturbance ...... 130 Other Disturbances with Lesions to the Frontal Cortex ...... 93 1.2 KINESIOLOGY AND CLINICAL Assessment Tests for Frontal Lobes Deficits ...... 93 EXAMINATION OF THE JOINT SYSTEM ...... 133 TEMPORAL LOBE ...... 94 Pavel Kolář OCCIPITAL LOBE ...... 95 Joint Motions...... 133 PARIETAL LOBE ...... 95 Joint Categories Based on the Number of Axes Deficits in Phatic Functions ...... 95 and the Shape of Articular Surfaces ...... 134 XIV Clinical Rehabilitation

Classification of Joints according to the Number Anamnesis ...... 165 of Articulating Bones within the Joint...... 135 Aspection ...... 165 Joint Innervation ...... 135 Palpation ...... 165 Assessment of Joint Range of Motion ...... 135 Passive Movements ...... 165 David Smékal Active Movements ...... 166 1.2.1 Kinesiology of the Spine, Functional Tests ...... 166 Pelvis and the Thorax ...... 137 Instability Tests ...... 166 Pavel Kolář Lateral Epicondylitis Tests ...... 166 SPINE ...... 137 1.2.4 Kinesiology of the Wrist and the Hand ...... 166 PELVIS ...... 140 Petr Bitnar THORAX ...... 141 WRIST ...... 166 ANATOMICAL PARAMETERS INFLUENCING MOVEMENTS OF THE CARPAL COMPLEX ...... 167 SPINAL FUNCTION ...... 143 CARPOMETACARPAL JOINTS ...... 168 Regional Anatomical Parameters ...... 143 HAND ...... 168 Global Anatomical Parameters ...... 144 MAIN TYPES OF GRIP ...... 169 EXAMINATION OF THE SPINE, PELVIS ASSESSMENT OF THE WRIST AND THE HAND ...... 169 AND THE THORAX ...... 145 Anamnesis ...... 169 Patient History (Anamnesis) and Physical Assessment ..145 Aspection ...... 170 Neurological Assessment ...... 145 Palpation ...... 170 Assessment of Motor Functions ...... 147 Passive Movements ...... 170 Functional Assessment ...... 147 Active Movements ...... 170 1.2.2 Kinesiology of the Shoulder Girdle Functional Tests ...... 170 (Plexus)...... 154 1.2.5 Kinesiology of the Hip Joint ...... 171 Petra Valouchová, Pavel Kolář Magdaléna Lepšíková, Pavel Kolář BONES OF THE SHOULDER GIRDLE ...... 154 HIP JOINT ASSESSMENT ...... 173 JOINTS OF THE SHOULDER GIRDLE ...... 156 Anamnesis ...... 173 MOVEMENTS IN THE JOINTS OF THE Aspection ...... 173 SHOULDER GIRDLE ...... 156 Palpation ...... 174 SHOULDER GIRDLE EXAMINATION ...... 157 Passive Movements ...... 174 Michaela Tomanová Active Movements ...... 174 Anamnesis ...... 157 PEDIATRIC HIP JOINT ASSESSMENT ...... 174 Aspection ...... 158 1.2.6 Kinesiology of the Knee Joint ...... 174 Palpation ...... 158 Pavel Kolář Joint Play ...... 158 MOVEMENTS OF THE KNEE JOINT ...... 174 Passive Movements ...... 159 KNEE JOINT ASSESSMENT ...... 176 Active Movements ...... 159 Anamnesis ...... 176 Adduction and Internal Rotation (Apley’s Scratch Test) ...159 Aspection ...... 176 Abduction and External Rotation ...... 159 Palpation ...... 177 Special Tests for the Shoulder Girdle ...... 159 Passive Movements ...... 177 Assessment of Movements against Resistance – Active Movements ...... 177 Resistive Tests ...... 159 Functional Assessment ...... 177 Instability Tests ...... 160 Examination of the Menisci ...... 177 Anterior Instability Testing ...... 160 Assessment of Knee Joint Stability ...... 178 Posterior Instability Testing ...... 161 Patellofemoral Joint Examination ...... 180 Clunk Test ...... 161 Patellar Stability Test – Apprehension Test ...... 180 Inferior (Caudal) Instability ...... 161 Planer Sign...... 180 Multidirectional Instability ...... 161 Zohlen Test ...... 180 Tests for Long Head of the Biceps Brachii Fairbank’s Test (Zohler’s Sign) ...... 180 Tendon Pathology ...... 161 1.2.7 Kinesiology of the Lower Leg Rotator Cuff and Impingement Syndrome Tests ...... 162 and the Foot ...... 180 Acromioclavicular Joint Tests ...... 163 Pavel Kolář, Ivan Vařeka 1.2.3 Kinesiology of the Elbow Joint ...... 163 ANKLE AND FOOT JOINTS ...... 180 Petr Bitnar MOVEMENTS IN THE ANKLE AND FOOT JOINTS ...... 182 ELBOW JOINT MOVEMENTS ...... 164 FUNCTIONAL RELATIONSHIPS BETWEEN ASSESSMENT OF THE ELBOW JOINT ...... 165 THE ANKLE AND THE FOOT JOINTS ...... 183 Contents XV

ASSESSMENT OF THE ANKLE AND THE FOOT ...... 183 3 PSYCHOLOGICAL FUNCTIONS Anamnesis ...... 184 AND PAIN Aspection ...... 184 Petr Knotek Palpation ...... 184 Passive Movements ...... 184 3.1 PSYCHOLOGICAL DIAGNOSTICS Active Movements ...... 185 IN REHABILITATION ...... 207 Functional Assessment ...... 185 Tests for Ankle Instability ...... 185 3.2 ASSESSED PROCESSES AND METHODS OF THEIR TESTING ...... 207 1.3 SOFT TISSUES ...... 186 Reactivity to Painful Stimuli ...... 207 Petr Bitnar Pain in the Pathological Process ...... 208 1.3.1 Skin ...... 187 Beginning Phase of Psychological Pain 1.3.2 Subcutaneous Tissues (Hypodermis) ...... 191 Processing ...... 209 1.3.3 Fasciae ...... 191 Cognitive Processes ...... 209 Affection ...... 210 Behavior ...... 210 2 VISCEROMOTOR RELATIONSHIPS Interpersonal Communication ...... 210 AND THE AUTONOMIC NERVOUS SYSTEM 4 EXAMINATIONS BY FUNCTIONAL Petr Bitnar, Hana Marčišová, Pavel Kolář LABORATORY METHODS Milan Zedka, Pavel Kolář 2.1 VISCEROSOMATIC AND SOMATOVISCERAL RELATIONSHIPS ...... 195 4.1 LABORATORY EXAMINATION Petr Bitnar OF MOVEMENT ...... 213 2.1.1 Viscerosomatic (Visceromotor) Milan Zedka Relationships ...... 195 4.1.1 Kinematic Analysis ...... 213 Visceral Pattern ...... 195 Milan Zedka 2.1.2 Somatovisceral Relationships ...... 196 4.1.2 Kinetic Analysis (Posturography) ...... 215 Movement System and Visceral Pain ...... 196 Ondřej Čakrt Movement System and Functional Deficits Physics Basis of the Examination ...... 215 of the Internal Organs ...... 197 Posturography in a Clinical Setting ...... 215 Movement System as a Trigger Factor for Factors Influencing Postural Stability ...... 216 a Latent Internal Illness ...... 198 4.1.3 Electromyographic Analysis Movement System as a Tool for the Treatment in Biomechanics ...... 216 of Internal Illnesses ...... 198 Milan Zedka, Petra Valouchová 2.1.3 Overview of Basic Visceral Patterns ...... 198 Examination of Muscle Coordination ...... 216 Examination of Force ...... 218 2.2 EXAMINATION OF THE AUTONOMIC Assessment of Muscle Fatigue ...... 218 NERVOUS SYSTEM ...... 200 Hana Marčišová 4.2 SUPPLEMENTAL NEUROLOGICAL 2.2.1 Anatomy and Physiology of the ANS ...... 201 EXAMINATIONS ...... 219 2.2.2 Function of the ANS within Milan Zedka the Movement Apparatus ...... 201 4.2.1 Electromyography ...... 219 Vasomotricity ...... 202 4.2.2 Electroencephalography ...... 222 Somatosensory System and the ANS ...... 202 4.2.3 Evoked Potentials ...... 224 ANS and Muscle Function ...... 203 Somatosensory Evoked Potentials ...... 224 2.2.3 Anatomical Vegetative Syndromes ...... 204 Visual Evoked Potentials (VEPs) ...... 225 Pavel Kolář Auditory Evoked Potentials...... 226 CENTRAL AUTONOMIC SYNDROMES ...... 204 Motor Evoked Potentials (MEPs) ...... 227 PERIPHERAL AUTONOMIC SYNDROMES...... 204 Claude-Bernard-Horner Syndrome ...... 204 4.3 EXAMINATIONS BY IMAGING Posterior Cervical Sympathetic Syndrome ...... 205 METHODS ...... 227 GROSS VEGETATIVE SYNDROMES ...... 205 Pavel Kolář, Martin Kynčl REFLEXIVE VEGETATIVE SYNDROMES ...... 205 4.3.1 Radiologic Methods ...... 227 XVI Clinical Rehabilitation

XRAY EXAMINATION ...... 227 5.3.5 Frenchay Activities Index ...... 244 Pavel Kolář, Olga Dyrhonová 5.3.6 Factor Assessment according Shoulder Joint ...... 228 to Tardieu ...... 244 Wrist ...... 228 5.3.7 Other Tests ...... 245 Hip Joint ...... 228 Knee Joint ...... 228 Ankle Joint ...... 228 B. THERAPEUTIC METHODS Spine ...... 228 COMPUTED TOMOGRAPHY CT ...... 229 Pavel Kolář, Martin Kynčl 1 PHYSICAL THERAPY METHODS MAGNETIC RESONANCE IMAGING ...... 230 AND CONCEPTS Martin Kynčl, Pavel Kolář Pavel Kolář Functional Magnetic Resonance ...... 231 TRACTOGRAPHY ...... 231 1.1 GENERAL PHYSICAL THERAPY Martin Kynčl, Pavel Kolář (MUSCULOSKELETAL) APPROACHES ...... 248 SCINTIGRAPHIC EXAMINATION ...... 231 Pavel Kolář, Martin Kynčl 1.1.1 Passive Movements ...... 248 POSITRON EMISSION TOMOGRAPHY ...... 231 Pavel Kolář Pavel Kolář, Martin Kynčl 1.1.2 Active Assistive Exercise ...... 248 SINGLE PHOTON EMISSION COMPUTED Magdaléna Lepšíková TOMOGRAPHY ...... 231 1.1.3 Muscle Strength Exercises ...... 248 Pavel Kolář, Martin Kynčl Zdeněk Čech NEARINFRARED SPECTROSCOPY NIRS ...... 232 Kinesiologic Notes ...... 248 Pavel Kolář, Martin Kynčl Input-Adaptation Relationship during 4.3.2 Examination by Ultrasound ...... 232 Strengthening Exercises ...... 249 Zdeněk Hříbal 1.1.4 Dynamic Neuromuscular Stabilization ...... 252 Pavel Kolář, Marcela Šafářová General Principles of Practice Techniques ...... 253 5 ASSESSMENT OF THE SEVERITY Practice of Postural Stabilization of the Spine, OF MOTOR INVOLVEMENT AND Chest and the Pelvis ...... 254 LIMITATIONS IN THE ACTIVITIES Influence on Tightness and Improvement OF DAILY LIVING of Chest Wall Dynamics ...... 255 Influence on Spinal Straightening ...... 256 Pavel Kolář Training of the Postural Breathing Pattern and the Stabilization Function of the Diaphragm ...... 256 5.1 METHODS USED FOR MEASUREMENT Postural Stabilization Training of the Spine AND ASSESSMENT IN REHABILITATION ...... 235 Using Reflex Locomotion ...... 258 Training of Deep Postural Stabilization of the Spine 5.2 ASSESSMENT OF THE EXTENT in Modified Positions ...... 259 OF MOTOR INVOLVEMENT ...... 236 Exercising Postural Functions in Developmental Lines 5.2.1 Gross Motor Skills Assessment (Sequences) ...... 259 by the Gross Motor Function Measure ...... 236 Movement Assistance during Exercise ...... 262 5.2.2 Developmental Kinesiology as an Facilitative Elements of Training Techniques ...... 262 Assessment Method of a Motor Deficit ...... 237 Exercise Examples ...... 264 5.2.3 Additional Tests to Assess Motor 1.1.5 Soft Tissue Mobilization ...... 266 Deficits ...... 239 Karel Lewit Post-Isometric Relaxation ...... 266 5.3 TESTING AND ASSESSMENT Examples of Other Techniques ...... 268 OF RESTRICTED ACTIVITIES 1.1.6 Dry Needling for Muscle OF DAILY LIVING ...... 239 Trigger Points ...... 270 5.3.1 Functional Independence Measure ...... 242 Pavel Kolář 5.3.2 Barthel Index ...... 242 1.1.7 Traction ...... 271 5.3.3 Katz Index of Activities of Daily Pavel Kolář Living ...... 244 1.1.8 Relaxation Techniques...... 271 5.3.4 Activity Index ...... 244 Pavel Kolář Contents XVII

1.1.9 Exercises Aimed at the Restoration THERAPEUTIC SYSTEM ...... 288 of Sensation (Somatesthesia) ...... 271 Activation of Reflex Locomotion ...... 288 Pavel Kolář, Magdaléna Lepšíková Reflex Creeping ...... 288 Activation System Positions 1–6 ...... 290 1.2 METHODS AND APPORACHES Reflex Rolling ...... 291 USED IN REHABILITATION OF PATIENTS TREATMENT EFFECTS ...... 294 WITH CHRONIC RESPIRATORY SYSTEM PRINCIPLES AND FUNDAMENTALS INVOLVEMENT ...... 271 OF THERAPY ...... 294 Pavel Kolář, Jan Šulc INDICATIONS AND CONTRAINDICATIONS ...... 295 1.2.1 Methods of Pulmonary Physical 1.3.2 Sensorimotor Stimulation ...... 295 Therapy ...... 272 Michaela Veverková, Marie Vávrová Libuše Smolíková 1.3.3 Feldenkrais Method ...... 298 1.2.2 Corrective Physical Therapy Magdaléna Lepšíková for the Postural System ...... 273 1.3.4 Proprioceptive Neuromuscular Libuše Smolíková Facilitation ...... 300 1.2.3 Respiratory Physical Therapy Irena Zounková, Pavel Kolář Approaches Utilizing Postural Respiratory 1.3.5 Brunkow’s Method ...... 301 Function of the Diaphragm ...... 275 Pavel Kolář Pavel Kolář 1.3.6 Brügger’s Concept ...... 302 Role of the Diaphragm during the Physiological Dagmar Pavlů Breathing Cycle ...... 275 1.3.7 Sling Exercise Therapy ...... 304 Breathing Biomechanics in a Pathological State ...... 278 Alice Hamáčková, Dagmar Tomisová, Posturally Locomotor Function Ctirad Tomis of the Diaphragm ...... 279 1.3.8 Exercise with a Therapy Ball ...... 305 Respiratory Physical Therapy Techniques Utilizing Pavel Kolář Postural Locomotor Functions ...... 280 Positional Influence on the Postural Respiratory Function of the Diaphragm ...... 281 2 MODALITIES 1.2.4 Respiratory Physical Therapy – Bronislav Schreier Methods and Techniques for Respiratory Pathway Hygiene ...... 281 2.1 CLASSIFICATION OF MODALITIES Libuše Smolíková BASED ON THE TYPE OF APPLIED Active Cycle of Breathing Techniques ...... 282 ENERGY ...... 309 Autogenic Drainage...... 282 PEP System of Breathing ...... 282 2.1.1 Mechanotherapy ...... 309 Oscillatory PEP System ...... 282 2.1.2 Thermotherapy and Hydrotherapy...... 309 Respiratory Physical Therapy and Breathing 2.1.3 Electrotherapy ...... 309 Muscle Training Devices ...... 284 2.1.4 Phototherapy ...... 310 Intrapulmonary Percussive Ventilation ...... 284 2.1.5 Combined Therapy and Combination Inhalation Therapy – A Component of Respiratory of Modalities ...... 310 Physical Therapy ...... 284 Respiratory Physical Therapy for Patients 2.2 CLASSIFICATION OF MODALITIES in Intensive Care Units ...... 285 BASED ON THEIR PRIMARY EFFECT ...... 310 Control Mechanisms of Respiratory 2.2.1 Modalities with an Analgesic Effect ...... 310 Physical Therapy ...... 285 Modalities with Primary Analgesic Effect ...... 310 1.2.5 Breathing Exercises Modalities with a Secondary Analgesic Effect ...... 311 (Breathing Gymnastics) ...... 285 2.2.2 Modalities with Dominantly Libuše Smolíková a Myorelaxation Effect ...... 312 1.2.6 Fitness Physical Therapy Ultrasound Therapy ...... 313 and Pulmonary Illnesses ...... 287 Combined Ultrasound and Electrotherapy ...... 313 Pavel Kolář Electrotherapy ...... 313 2.2.3 Modalities with Anti-Inflammatory 1.3 SELECTED PHYSICAL THERAPY and Trophic Effects ...... 313 CONCEPTS ...... 288 Vasopneumatic Therapy ...... 313 1.3.1 Vojta’s Principle: Reflex Locomotion ...... 288 Electrotherapy ...... 314 Irena Zounková, Marcela Šafářová Ultrasound Therapy ...... 314 XVIII Clinical Rehabilitation

Phototherapy ...... 314 3.2.2 Use of Peloids ...... 321 Galvanotherapy ...... 314 3.2.3 Use of Gas ...... 322 Contrast Baths...... 314 Cryotherapy ...... 315 3.3 SPAS IN THE CZECH REPUBLIC 2.2.4 Electrodiagnostic Testing and Electrical AND INDICATIONS FOR Stimulation of Skeletal Muscles ...... 315 A SPA TREATMENT ...... 322 Electrodiagnostic Testing ...... 315 Electrical Stimulation (Neuromuscular Electrical Stimulation) ...... 316 4 OCCUPATIONAL THERAPY Electrical Stimulation (Electrogymnastics) ...... 316 Veronika Schönová, Pavel Kolář 2.3 GENERAL CONTRAINDICATIONS 4.1 AREAS OF FUNCTION OF MODALITIES ...... 316 IN OCCUPATIONAL THERAPY ...... 325

4.2 SPECIALIZATIONS ...... 326 3 BALNEOLOGY Jan Kálal, Ivan Vařeka 4.3 OCCUPATIONAL THERAPY PROCESS ...... 326 3.1 CLASSIFICATION OF MEDICINAL SOURCES ...... 319 4.4 AREAS OF OCCUPATIONAL THERAPY INTERVENTIONS ...... 326 3.1.1 Waters ...... 319 3.1.2 Peloids ...... 320 Motor Skills ...... 326 3.1.3 Gases ...... 320 Sensory Skills ...... 327 3.1.4 Climate ...... 321 Cognitive, Communicative and Subsequent Social Skills ...... 327 3.2 USE OF NATURAL HEALING Activities of Daily Living ...... 327 SOURCES IN BALNEOLOGY ...... 321 Assistive Devices ...... 327 3.2.1 Use of Water ...... 321 Pre-Return to Work Rehabilitation ...... 327

II SPECIAL SECTION

1 TREATMENT REHABILITATION 1.2 OVERVIEW OF PHYSICAL IN NEUROLOGY THERAPY METHODS ...... 335 Pavel Kolář Pavel Kolář, Ondřej Horáček Sensory Training ...... 335 Exercising with Conscious Awareness GENERAL SECTION as a Component of Sensorimotor Practice ...... 335 Sensory Stimulation Method Based on Affolter ...... 335 1.1 NEUROPHYSIOLOGICAL Perfetti’s Method ...... 335 FOUNDATION OF PHYSICAL THERAPY Rood’s Method ...... 335 APPROACHES ...... 332 Movement Rehabilitation of Patients Pavel Kolář with Hemiplegia Based on Brunnström ...... 336 NEUROPLASTICITY ...... 332 Dagmar Pavlů, Pavel Kolář Vladimír Komárek Sensory Integration Based on Ayres ...... 337 Evolutionary Plasticity ...... 332 Veronika Schönová Repair Plasticity ...... 333 Neurodevelopmental Treatment Concept Based Neuroplasticity and Sensorimotor Programs ...... 333 on Bobath ...... 338 SENSORY FUNCTIONS IN Irena Zounková NEUROREHABILITATION ...... 334 Movement Therapy According to Petö ...... 340 Pavel Kolář Irena Zounková, Pavel Kolář Contents XIX

Vojta’s Method ...... 341 OTHER FORMS OF MUSCULAR DYSTROPHY ...... 357 Pavel Kolář MYOTONIC DYSTROPHY...... 357 Sensorimotor Stimulation ...... 341 CONGENITAL, METABOLIC, INFLAMMATORY Pavel Kolář AND TOXIC MYOPATHIES ...... 358 Proprioceptive Neuromuscular Facilitation ...... 341 ION CHANNEL DYSFUNCTIONS ...... 358 Pavel Kolář PERIODIC PARALYSES ...... 358 Hyperkalemic Periodic Paralysis ...... 359 1.3 NEUROPSYCHOLOGY ...... 341 Hypokalemic Periodic Paralysis ...... 359 Kateřina Chamoutová, Pavel Kolář Paramyotonia Congenita ...... 359 1.3.1 Neuropsychological Approaches ...... 342 MYOTONIC SYNDROMES ...... 359 Neurobehavioral Approach ...... 342 Myotonia Congenita ...... 359 American Neuropsychological Approach ...... 342 Atypical Myotonic Syndromes ...... 359 Neuropsychology in the Czech Republic ...... 342 1.3.2 Neuropsychological Assessment ...... 343 1.8 PERIPHERAL PARALYSIS ...... 360 Most Commonly Used Neuropsychological Ondřej Horáček Tests ...... 344 1.8.1 Causes, Degrees and Diagnosis 1.3.3 Utilization of Neuropsychological of Peripheral Paralyses ...... 360 Approaches in Rehabilitation ...... 345 1.8.2 Rehabilitation of Peripheral Paralyses ...... 361 Physical Therapy ...... 361 1.4 SPEECH THERAPY ...... 346 Occupational Therapy ...... 362 Pavel Kolář Modalities ...... 362 DEVELOPMENTAL DYSARTHRIA ...... 346 1.8.3 An Overview of Peripheral Pareses APHASIAS ...... 347 Based on Location ...... 363 DYSARTHRIA...... 348 PERIPHERAL PARESES OF THE UPPER Deficits in Swallowing and Management Options ...... 349 EXTREMITIES ...... 363 Orofacial Therapy ...... 350 BRACHIAL PLEXUS PALSY C5T1 ...... 363 RADIAL NERVE PALSY C5C7 ...... 364 1.5 ORTHOTIC CARE IN NEUROLOGICAL MEDIAN NERVE PALSY C5T1 ...... 365 DISEASES ...... 350 ULNAR NERVE PALSY C8T1 ...... 366 Petr Krawczyk LONG THORACIC NERVE PALSY C5C7 ...... 366 1.5.1 Orthotic Management for Patients SUPRASCAPULAR NERVE PALSY C5C6 ...... 367 with Cerebral Palsy ...... 350 AXILLARY NERVE PALSY C5C6 ...... 367 1.5.2 Orthotic Interventions for Patients MUSCULOCUTANEOUS NERVE PALSY with Charcot-Marie-Tooth Disease ...... 352 C5C7 ...... 367 1.5.3 Orthotics for Patients Following PERIPHERAL PARESES OF THE LOWER Poliomyelitis ...... 353 EXTREMITIES ...... 367 1.5.4 Orthotics for Patients Following CVA ...... 353 LUMBOSACRAL PLEXUS PARESIS ...... 367 FEMORAL NERVE PALSY L2L4 ...... 367 1.6 OCCUPATIONAL THERAPY ...... 354 SCIATIC NERVE PALSY L4S3 ...... 368 Veronika Schönová PERONEAL NERVE PALSY L4S1 ...... 368 TIBIAL NERVE PALSY L4S3 ...... 368 FACIAL NERVE PALSY (C.N. VII) ...... 369 SPECIAL SECTION 1.8.4 Peripheral Pareses in Diseases Involving Motor Neurons of the Anterior 1.7 DYSFUNCTIONS IN NEUROMUSCULAR Spinal Horns ...... 369 TRANSMISSION AND MUSCLE DISEASES ..... 354 1.8.5 Rehabilitation Following Peripheral Petr Bitnar, Magdaléna Lepšíková Nerve Surgery ...... 370 1.7.1 Dysfunction in Neuromuscular Transmission – Myasthenia Gravis ...... 354 1.9 ENTRAPMENT SYNDROMES ...... 370 1.7.2 Muscle Diseases ...... 355 Petr Bitnar, Ondřej Horáček MUSCULAR DYSTROPHIES ...... 356 1.9.1 Etiology, Pathogenesis, Clinical DUCHENNE AND BECKER MUSCULAR Manifestations and Diagnosis ...... 370 DYSTROPHY ...... 356 1.9.2 Overview of the Most Common FACIOSCAPULOHUMERAL FORM Entrapment Syndromes ...... 371 OF DYSTROPHY ...... 356 ENTRAPMENT SYNDROMES OF THE UPPER GIRDLE FORMS OF MUSCULAR DYSTROPHY...... 357 THORACIC APERTURE ...... 371 XX Clinical Rehabilitation

SCALENUS SYNDROME ...... 372 1.13 DEFICITS IN CEREBELLAR FUNCTIONS ..389 COSTOCLAVICULAR AND HYPERABDUCTION Alena Kobesová SYNDROME ...... 372 1.13.1 Functional Anatomy ENTRAPMENT SYNDROMES OF THE UPPER of the Cerebellum ...... 389 EXTREMITY AND THE SHOULDER GIRDLE ...... 372 1.13.2 Basic Clinical Manifestations SUPRASCAPULAR NERVE ...... 372 of a Cerebellar Lesion ...... 390 MEDIAN NERVE ...... 372 ATAXIA ...... 390 ULNAR NERVE ...... 373 HYPERMETRIA ...... 390 RADIAL NERVE ...... 373 ADIADOCHOKINESIA ...... 391 ENTRAPMENT SYNDROMES OF THE LOWER ASYNERGY ...... 391 EXTREMITY AND THE PELVIC GIRDLE ...... 373 FLACCIDITY ...... 392 FEMORAL NERVE ...... 373 CEREBELLAR TREMOR...... 392 SCIATIC NERVE ...... 373 EYE MOVEMENT DISTURBANCES...... 392 PERONEAL NERVE ...... 373 PALEOCEREBELLAR AND NEOCEREBELLAR TIBIAL NERVE ...... 373 SYNDROME ...... 392 1.9.3 Treatment Rehabilitation ...... 374 PALEOCEREBELLAR SYNDROME...... 392 NEOCEREBELLAR SYNDROME ...... 392 1.10 POLYNEUROPATHIC SYNDROMES ...... 375 PSEUDOCEREBELLAR SYNDROME ...... 392 Alena Kobesová 1.13.3 Rehabilitation in Cerebellar 1.10.1 Hereditary Motor and Sensory Dysfunctions ...... 393 Polyneuropathies ...... 375 1.13.4 Prognosis of Cerebellar 1.10.2 Diabetic Neuropathy ...... 378 Dysfunctions ...... 394 DIABETIC FOOT SYNDROME ...... 378 1.10.3 Inflammatory Polyneuropathies ...... 379 1.14 BALANCE DEFICITS ...... 395 GUILLAINBARRE SYNDROME ...... 379 Ondřej Čakrt, Michal Truc CHRONIC INFLAMMATORY DEMYELINATING 1.14.1 Balance Control ...... 395 POLYNEUROPATHY ...... 379 VERTIGO AND ITS MOST COMMON CAUSES ...... 395 1.14.2 Clinical Presentation of a Patient 1.11 POLIOMYELITIS AND with a Vestibular System Disturbance ...... 396 POST-POLIOMYELITIC SYNDROME ...... 381 EXAMINATION ...... 396 Ivana Wurstová 1.14.3 Theoretical Bases for Rehabilitation ...... 397 1.11.1 Poliomyelitis ...... 381 1.14.4 Rehabilitation of Individual Clinical 1.11.2 Post-Poliomyelitic Syndrome ...... 382 Presentations ...... 397 UNILATERAL VESTIBULAR LESION ...... 397 1.12 SPINAL CORD INJURY ...... 384 BENIGN PAROXYSMAL POSITIONAL VERTIGO ...... 398 Jiří Kříž BILATERAL VESTIBULAR DEFICIT ...... 399 1.12.1 Etiology, Neurological Presentation ...... 384 BALANCE DEFICITS ASSOCIATED 1.12.2 Systematic Approach to Treatment ...... 385 WITH CHANGES IN THE CERVICAL SPINE ...... 399 1.12.3 Medical Consequences of a Spinal CENTRAL BALANCE DEFICITS ...... 399 Cord Lesion and Possible Complications ...... 385 VERTEBRAL ARTERY SYNDROME ...... 399 AUTONOMIC DYSREFLEXIA ...... 385 PSYCHOGENIC VERTIGO ...... 399 ORTHOSTATIC HYPOTENSION ...... 385 1.14.5 Biological Feedback in Rehabilitation DEEP VEIN THROMBOSIS of Patients with Balance Deficits ...... 400 THROMBOEMBOLISM...... 386 Ondřej Čakrt, Rudolf Černý, Jaroslav Jeřábek URINARY DYSFUNCTION ...... 386 Brain port ...... 400 BOWEL DYSFUNCTION ...... 386 SEXUAL DYSFUNCTION ...... 386 1.15 EXTRAPYRAMIDAL DEFICITS...... 401 INTEGUMENTARY DYSFUNCTIONS ...... 386 Alena Kobesová SEPTIC CONDITIONS ...... 386 1.15.1 Basic Characteristics, Classification ...... 401 PAINFUL CONDITIONS ...... 386 HYPOKINETIC DEFICITS ...... 401 SPASTICITY ...... 386 HYPERKINETIC DEFICITS ...... 401 PARAARTICULAR OSSIFICATION ...... 387 1.15.2 Parkinson’s Disease ...... 401 OSTEOPOROSIS ...... 387 OBJECTIVE NEUROLOGICAL FINDINGS ...... 402 1.12.4 Rehabilitation for Patients HYPOKINESIA, BRADYKINESIA, AKINESIA ...... 402 with Spinal Cord Injury ...... 387 RIGIDITY ...... 402 Contents XXI

TREMOR...... 402 1.21 CEREBRAL PALSY ...... 428 POSTURAL DEFICITS ...... 402 Pavel Kolář 1.21.1 Screening for Risk of CP ...... 429 1.16 NEURODEGENERATIVE DISEASES ...... 407 1.21.2 Types of Cerebral Palsy and their Barbora Danielová, Alena Zumrová Clinical Presentation ...... 429 1.16.1 Basic Characteristics SPASTIC DIPLEGIA ...... 429 of Neurodegenerative Illnesses ...... 407 SPASTIC HEMIPLEGIA...... 430 Ondřej Horáček CEREBELLAR FORM ...... 431 1.16.2 Amyotrophic Lateral Sclerosis ...... 407 DYSKINETIC FORM OF CEREBRAL PALSY ...... 432 Barbora Danielová MIXED TETRAPLEGIA ...... 433 1.16.3 Friedreich’s Ataxia ...... 411 ATONIC DIPLEGIA ...... 433 Alena Zumrová 1.21.3 Rehabilitation in Cerebral Palsy ...... 433 1.16.4 Autosomal Dominant DESIRED OUTCOME AND COPING PROCESS ...... 433 Spinocerebellar Ataxia...... 412 DESIRED OUTCOME ...... 433 Alena Zumrová COPING PROCESS ...... 434 Rehabilitation in Cerebral Palsy ...... 434 1.17 MULTIPLE SCLEROSIS ...... 412 Vojta’s Reflex Locomotion in Children Ondřej Horáček with Cerebral Palsy ...... 434 1.17.1 Diseases Characteristics ...... 412 Neurodevelopmental Treatment Approach 1.17.2 Rehabilitation in Multiple Sclerosis ...... 414 in Children with CP ...... 435 Petö Movement Therapy ...... 436 1.18 DEFICITS IN CONSCIOUSNESS ...... 416 Exercises Aimed at the Development of Somesthesis .....436 Pavel Kolář 1.21.4 Cerebral Palsy from the View 1.18.1 Causes ...... 416 of an Orthopedic Physician ...... 436 LEVELS OF QUANTITATIVELLY LIMITED Alena Schejbalová CONSCIOUSNESS ...... 417 INDICATIONS FOR SURGERY ...... 436 SOMNOLENCE ...... 417 INDICATIONS FOR SURGICAL PROCEDURES SOPOR ...... 417 IN THE HIP JOINT AREA ...... 436 COMA ...... 417 INDICATIONS FOR SURGICAL PROCEDURES ASSESSMENT OF LEVELS OF CONSCIOUSNESS ...... 417 IN THE KNEE JOINT AREA ...... 437 1.18.2 Neurorehabilitation Approaches INDICATION FOR SURGICAL INTERVENTIONS for Unconscious Patients ...... 417 IN THE ANKLE AND FOOT AREAS ...... 438 INDICATIONS FOR SPINAL SURGICAL 1.19 CRANIOCEREBRAL (BRAIN) INJURIES ... 418 PROCEDURES ...... 438 Ondřej Horáček, Pavel Kolář INDICATIONS FOR UPPER EXTREMITY 1.19.1 Causes and Clinical Picture ...... 418 SURGICAL PROCEDURES ...... 439 APALLIC SYNDROME ...... 419 1.21.5 Neurosurgical Treatment ...... 439 1.19.2 Rehabilitation for a Brain Injury ...... 419 Pavel Kolář 1.21.6 Botulotoxin in the Treatment of CP ...... 440 1.20 VASCULAR DISEASES OF THE BRAIN ... 421 Pavel Kolář, Josef Kraus Ondřej Horáček, Pavel Kolář 1.20.1 Ischemic Cerebrovascular Accidents ...... 421 ISCHEMIA IN CAROTID CIRCULATION ...... 421 2 TREATMENT REHABILITATION ISCHEMIA IN VERTEBROBASILAR IN ORTHOPEDICS AND TRAUMATOLOGY CIRCULATION ...... 422 Pavel Kolář, Jiří Kříž, Olga Dyrhonová CLASSIFICATION BASED ON DISEASE PROGRESSION ...... 422 1.20.2 Hemorrhagic Cerebrovascular GENERAL SECTION Accidents ...... 423 DIFFUSE HEMORRHAGES ...... 423 2.1 INFLUENCE OF FUNCTION FOCAL SUBCORTICAL HEMORRHAGES ...... 423 ON MORPHOLOGICAL TISSUE CEREBELLAR HEMORRHAGE ...... 423 RESTRUCTURING ...... 445 BLEEDING INTO THE BRAIN STEM ...... 423 SUBARACHNOID HEMORRHAGE ...... 423 2.2 CLASSIFICATION ACCORDING 1.20.3 Rehabilitation for a CVA ...... 424 TO SYMPTOMATOLOGY ...... 447 XXII Clinical Rehabilitation

2.2.1 Edema ...... 447 Camptodactyly ...... 454 Olga Dyrhonová, Jiří Kříž Clinodactyly ...... 454 2.2.2 Functional Changes in Soft Tissues ...... 447 Syndactyly...... 454 Olga Dyrhonová, Jiří Kříž Thumb Hypoplasia ...... 454 2.2.3 Range of Motion Restrictions CONGENITAL DEVELOPMENTAL DEFECTS in a Movement Segment ...... 448 OF THE LOWER EXTREMITES ...... 454 David Smékal, Pavel Kolář Congenital Developmental Defects 2.2.4 Hypermobility ...... 449 of the Hip Joint ...... 454 David Smékal, Pavel Kolář Congenital Developmental Defectsof the Knee Joint ...... 454 CAUSES ...... 449 Congenital Knee Dislocation ...... 454 COMPENSATORY HYPERMOBILITY ...... 449 Congenital Patellar Subluxation ...... 454 HYPERMOBILITY IN NEUROLOGICAL DISEASES ...... 449 Patella Bipartita ...... 455 STRUCTURAL HYPERMOBILITY ...... 449 Congenital Developmental Defects LOCALIZED PATHOLOGICAL POSTRAUMATIC of the Lower Leg and Foot ...... 455 HYPERMOBILITY ...... 449 Club Foot (Talipes Equinovarus, Pes Equinovarus TREATMENT REHABILITATION STRATEGIES ...... 449 Congenitus) ...... 455 2.2.5 Deficit in the Nervous System Pes Metatarsus Adductus (Pes Calcaneovalgus)...... 456 Regulatory Mechanisms ...... 450 Congenital Flatfoot (Vertical Talus, Pes Planovalgus Pavel Kolář Congenitus) ...... 456 CHANGE IN AFFERENTATION FROM Metatarsus Varus (Pes Adductus) ...... 457 THE RECEPTORS ...... 450 Congenital Deformities of the Toes ...... 457 MOTOR LEARNING DEFICIT AT THE LEVEL Congenital Hallux Varus ...... 457 OF THE CENTRAL REGULATORY Digitus Quintus Supraductus ...... 457 MECHANISMS ...... 451 Syndactyly...... 457 TREATMENT REHABILITATION STRATEGY ...... 451 Polydactyly ...... 457 Macrodactyly ...... 457 2.3 CLASIFFICATION ACCORDING CONGENITAL DEVELOPMENTAL DEFECTS TO ETIOLOGY AND PATHOGENESIS ...... 451 OF THE THORAX ...... 457 Pavel Kolář Pectus Excavatum (Infundibuliform) ...... 457 2.3.1 Congenital Developmental Defects ...... 452 Pectus Carinatum ...... 458 Pavel Kolář, Martin Švehlík Rehabilitation in Congenital Developmental ETIOLOGY ...... 452 Defects of the Thorax ...... 458 REHABILITATION TREATMENT PRINCIPLES IN CONGENITAL DEVELOPMENTAL DEFECTS CONGENITAL DEVELOPMENTAL DEFECTS ...... 452 OF THE SPINE ...... 458 POSTSURGICAL REHABILITATION ...... 452 Diastematomyelia ...... 458 CLASSIFICATION OF CONGENITAL Meningomyelocele ...... 459 DEVELOPMENTAL DEFECTS ...... 452 Klippel-Feil Syndrome ...... 459 CONGENITAL DEVELOPMENTAL DEFECTS Spina Bifida ...... 459 OF THE UPPER EXTREMITIES ...... 453 2.3.2 SOFT TISSUE INJURIES CAUSED Congenital Developmental Defects BY OVERLOADING ...... 459 of the Shoulder Girdle ...... 453 Pavel Kolář, Jiří Kříž, Olga Dyrhonová Sprengel’s Deformity ...... 453 ENDON INJURIES ...... 459 Cleidocranial Dysostosis ...... 453 ETIOLOGY AND PATHOGENESIS ...... 459 Congenital Clavicle Nonunion ...... 453 DIAGNOSTICS ...... 459 Os Acromiale ...... 453 Clinical Picture ...... 459 Congenital Developmental Defects Tendinosis ...... 460 of the Elbow Joint ...... 453 Enthesopathy ...... 460 Congenital Dislocation of the Elbow, Paratenonitis, Peritendinitis, Tenosynovitis ...... 460 Congenital Dislocation of the Radial Head ...... 453 Imaging Methods ...... 460 Congenital Radioulnar Synostosis ...... 453 Differential Diagnosis ...... 460 Congenital Shortening of the Radius ...... 453 LOCALIZATION ...... 460 Congenital Developmental Defects of the Wrist ...... 453 Upper Extremity ...... 460 Manus Vara Congenita ...... 453 Lower Extremity ...... 460 Madelung’s Deformity ...... 454 THERAPY ...... 460 Congenital Developmental Defects of the Fingers ...... 454 REHABILITATION ...... 461 Contents XXIII

2.3.3 Degenerative Joint Diseases ...... 462 SPECIAL SECTION Pavel Kolář OSTEOARTHRITIS ...... 462 2.4 CLASSIFICATION ACCORDING ETIOLOGY AND PATHOGENESIS ...... 462 TO LOCATION ...... 476 Primary (Idiopathic) OA ...... 462 2.4.1 Spine ...... 476 Secondary OA ...... 462 CONGENITAL DEVELOPMENTAL DEFECTS ...... 477 DIAGNOSIS ...... 463 DEFORMITY ...... 477 LOCATION ...... 463 Pavel Kolář, Marcela Šafářová Coxarthrosis ...... 463 SCOLIOSIS ...... 477 Gonarthrosis ...... 463 Classification According to Etiology TREATMENT ...... 463 and Pathogenesis ...... 477 Pharmacotherapy ...... 463 Non-structural (Functional) Scoliosis ...... 477 Surgical Procedures ...... 464 Structural Scoliosis ...... 477 Rehabilitation ...... 464 Idiopathic Scoliosis...... 477 Olga Dyrhonová, Pavel Kolář Congenital Scoliosis ...... 481 Arthroplasty ...... 464 Neuromuscular Scoliosis ...... 481 Martina Votavová Scoliosis in Neurofibromatosis ...... 481 Rehabilitation Following Arthroplasty ...... 465 Other Types of Scoliosis ...... 481 Martina Votavová, Věra Cikánková Rehabilitation ...... 481 Hip Joint Arthroplasty ...... 466 Klapp’s Crawling Method ...... 482 Knee Joint Arthroplasty ...... 466 Schroth Method ...... 483 Ankle Arthroplasty...... 467 Vojta’s Method ...... 483 Shoulder Joint Arthroplasty ...... 467 Modifications of Physical Activity ...... 484 Elbow Joint Arthroplasty ...... 468 Orthotic Treatment ...... 484 2.3.4 Inflammatory Diseases ...... 468 Surgical Treatment ...... 484 Pavel Kolář, Olga Dyrhonová, Jiří Kříž HYPERKYPHOSIS ...... 484 ETIOLOGY AND PATHOGENESIS ...... 468 Pavel Kolář STERILE INFLAMMATION ...... 468 Juvenile Kyphosis (Scheuermann’s Disease) ...... 484 INFECTIOUS INFLAMMATION ...... 468 LUMBAR HYPERLORDOSIS ...... 485 Classification Based on Etiology ...... 468 TORTICOLLIS ...... 485 Classification Based on Location ...... 469 Congenital Muscular Torticollis ...... 485 Pyogenic Arthritis ...... 469 Muscular Torticollis in Adults ...... 486 Osteomyelitis ...... 469 Acquired Muscular Torticollis ...... 486 Spondylodiscitis ...... 470 Post-Traumatic Torticollis ...... 486 PRINCIPLES OF REHABILITATION ...... 47 Spastic Torticollis ...... 487 2.3.5 Traumatology of the Movement System ...471 Acute Torticollis ...... 487 Olga Dyrhonová, Pavel Kolář VERTEBROGENIC PAIN SYNDROME ...... 487 HEALING PHASES ...... 471 Pavel Kolář WOUNDS ...... 472 ETIOLOGY AND PATHOGENESIS ...... 487 CONTUSION ...... 472 CLASSIFICATION ACCORDING TENDON INJURIES ...... 472 TO ETIOLOGY AND PATHOGENESIS ...... 488 MUSCLE INJURIES...... 472 STRUCTURAL CAUSES ...... 488 DIAGNOSIS ...... 472 FUNCTIONAL CAUSES ...... 488 CLASSIFICATION ...... 472 Intervertebral Disc Involvement...... 488 Muscle Cramp ...... 472 Intervertebral Joint Degeneration ...... 489 Muscle Soreness ...... 472 Spinal Stenosis ...... 489 Muscle Strain ...... 473 Abnormality of the Spinal Canal ...... 490 Muscle Tear ...... 473 Spondylolisthesis ...... 490 JOINT INJURIES...... 474 Osteoporosis ...... 491 BONE INJURIES – FRACTURES ...... 474 Ankylosing Spondylitis ...... 491 FRACTURE CLASSIFICATION ...... 474 Infections ...... 491 BONE HEALING ...... 474 Tumors ...... 491 FRACTURE HEALING TIMES ...... 475 Deficit in the CNS Control Function ...... 492 TREATMENT ...... 475 Deficit in Processing Nociception ...... 493 REHABILITATION ...... 476 Psychological Disturbance ...... 494 XXIV Clinical Rehabilitation

CONSEQUENCES OF STRUCTURAL CONGENITAL DEVELOPMENTAL DEFECTS ...... 520 AND FUNCTIONAL DEFICITS...... 494 OVERUSE SOFT TISSUE INJURIES ...... 520 Discogenic Pain ...... 494 ENTHESOPATHY ...... 520 Radicular Syndrome ...... 494 Lateral Epicondylitis (Epicondylitis Radialis Humeri) ....520 Pseudoradicular Syndrome ...... 495 Medial Epicondylitis (Epicondylitis Ulnaris Humeri) .....520 SPECIFIC TREATMENT ...... 495 Triceps Brachii Enthesopathy ...... 520 Rehabilitation ...... 495 Olecranon Bursitis ...... 521 Pavel Kolář, Karel Lewit, Jiří Čumpelík, DEGENERATIVE DISEASES Veronika Kubů OF THE ELBOW JOINT ...... 521 Pharmaceutical Treatment ...... 505 ELBOW JOINT ARTHRITIS ...... 521 Pavel Kolář TRAUMATIC LESIONS ...... 522 Invasive Procedures ...... 505 DISLOCATIONS ...... 522 Jan Štulík FRACTURES IN THE ELBOW JOINT REGION ...... 522 Intervention Methods Guided REHABILITATION IN TRAUMATIC LESIONS ...... 522 by Computerized Tomography ...... 505 POST-TRAUMATIC COMPLICATIONS ...... 523 Surgical Treatment ...... 505 ELBOW FLEXION CONTRACTURE ...... 523 Simple Resection ...... 505 AXIAL DEFORMITIES OF THE ELBOW ...... 523 Osteosynthesis ...... 506 Cubitus Varus ...... 523 Bony Fusion (Arthrodesis) of the Surrounding Cubitus Valgus ...... 523 Segments ...... 506 VOLKMANN’S CONTRACTURE ...... 524 Mobile Spinal Stabilization ...... 507 2.4.4 Wrist and Hand ...... 524 2.4.2 Shoulder Girdle ...... 508 Petr Bitnar, Pavel Kolář Petra Valouchová, Olga Dyrhonová, CONGENITAL DEVELOPMENTAL DEFECTS ...... 524 Jiří Kříž, Pavel Kolář, Michaela Tomanová OVERUSE SOFT TISSUE INJURIES ...... 524 CONGENITAL DEVELOPMENTAL DEFECTS TENOSYNOVITIS ...... 524 OF THE SHOULDER GIRDLE ...... 508 Trigger Thumb, Finger (Digitus Saltans) ...... 524 SOFT TISSUE INJURIES ...... 508 De Quervain’s Disease ...... 525 IMPINGEMENT SYNDROME ...... 508 DUPUYTREN’S CONTRACTURE ...... 525 CALCIFIC TENDINITIS ...... 510 DEGENERATIVE JOINT INJURIES ...... 526 SUBACROMIAL BURSITIS ...... 511 RHIZARTHROSIS ...... 526 ROTATOR CUFF TEARS ...... 511 ARTHRITIS OF THE INTERPHALANGEAL SYNDROME OF THE LONG HEAD JOINTS OF THE HAND ...... 526 OF THE BICEPS TENDON ...... 512 TRAUMATIC LESIONS ...... 526 Tendinosis of the Long Head of the Biceps ...... 512 SOFT TISSUE INJURIES ...... 526 Subluxation of the Long Head of the Biceps Tendon ...... 512 DISLOCATIONS ...... 527 Biceps Tendon Rupture ...... 512 FRACTURES ...... 527 FROZEN SHOULDER SYNDROME ...... 513 Distal Forearm Fractures ...... 527 DEGENERATIVE DISEASES...... 514 Navicular Fracture ...... 527 GLENOHUMERAL ARTHRITIS ...... 514 POST-TRAUMATIC CONDITIONS ...... 528 ACROMIOCLAVICULAR ARTHRITIS ...... 514 WRIST INSTABILITY ...... 528 TRAUMATIC LESIONS ...... 514 NAVICULAR NONUNION ...... 528 GLENOHUMERAL DISLOCATION ...... 514 GENERAL REHABILITATION PRINCIPLES ACROMIOCLAVICULAR DISLOCATION ...... 515 FOR WRIST AND HAND INJURIES ...... 528 STERNOCLAVICULAR DISLOCATION ...... 515 2.4.5 Hip Joint ...... 529 PROXIMAL HUMERAL FRACTURES ...... 516 Magdaléna Lepšíková, Pavel Kolář, INSTABILITY ...... 517 Olga Dyrhonová GLENOHUMERAL INSTABILITY ...... 517 PEDIATRIC DISEASES ...... 529 Post-traumatic Instability (Recurring Dislocations) ...... 517 CONGENITAL HIP DYSPLASIA ...... 529 Multidirectional Non-traumatic Instability Clinical Assessment of Newborns and Infants ...... 529 (Habitual Dislocation) ...... 518 Examination by Imaging Methods ...... 530 DIFFERENTIAL DIAGNOSIS OF SHOULDER Classification according to Radiological Findings ...... 531 GIRDLE PAIN ...... 518 Treatment ...... 531 GENERAL PRINCIPLES OF REHABILITATION SLIPPED CAPITAL FEMORAL EPIPHYSIS SCFE ...... 533 OF SHOUDLER GIRDLE DYSFUNCTIONS ...... 519 LEGGCALVEPERTHES DISEASE ...... 534 2.4.3 Elbow Joint ...... 519 TRANSIENT SYNOVITIS OF THE HIP ...... 536 Pavel Kolář, Petr Bitnar, Olga Dyrhonová ADULTHOOD DISEASES ...... 537 Contents XXV

OVERUSE SOFT TISSUE INJURIES ...... 537 TOE DEFORMITIES ...... 553 Hip Adductor Enthesopathy ...... 537 Hammer Toe (Digitus Hamatus) ...... 553 Rectus Femoris Enthesopathy ...... 537 Club Toe (Digitus Malleus) ...... 553 Hamstring Enthesopathy ...... 537 OVERUSE SOFT TISSUE INJURIES ...... 553 DEGENERATIVE DISEASES ...... 537 PERITENDINITIS TENOSYNOVITIS, ACHILLES Osteoarthritis of the Hip (Coxarthrosis) ...... 537 TENDON TENDINOSIS ...... 553 TRAUMATIC LESIONS ...... 538 TENOSYNOVITIS, POSTERIOR TIBIALIS Groin Injuries ...... 538 TENDINOSIS ...... 553 Hip Joint Dislocation ...... 538 ENTHESOPATHY OF THE SHORT MUSCLES Proximal Femoral Fractures ...... 538 OF THE SOLE OF THE FOOT, CALCANEAL REFERRED PAIN TO THE HIP JOINT SPUR CALCAR CALCANEI ...... 554 FROM OTHER SITES ...... 539 TIBIALIS ANTERIOR SYNDROME ...... 554 2.4.6 Knee Joint ...... 539 TRAUMATIC LESIONS ...... 555 Pavel Kolář, Jiří Kříž ACHILLES TENDON RUPTURE ...... 555 CONGENITAL DEVELOPMENTAL DEFECTS INJURY TO THE ANKLE LIGAMENTOUS OF THE KNEE JOINT ...... 540 APPARATUS ...... 555 OVERUSE SOFT TISSUE INJURIES ...... 540 Acute Ankle Instability ...... 555 TENDINOPATHIES ...... 540 Chronic Lateral Ankle Instability ...... 555 Patellar Tendonitis (Jumper’s Knee)...... 540 Rehabilitation Treatment Following Injuries Rectus Femoris Enthesopathy ...... 540 and Surgeries of the Ligamentous Apparatus Hip Adductor Enthesopathy ...... 540 of the Ankle and Foot ...... 556 Enthesopathy of the Biceps Femoris Tendon...... 540 ASEPTIC NECROSIS OF THE KNEE ...... 540 2.5 ORTHOTICS ...... 557 Osgood-Schlatter Disease (Aseptic Necrosis Petr Krawczyk of the Tibial Tuberosity) ...... 540 2.5.1 Classification and Technical Sinding-Larsen-Johansson Syndrome Overview of Orthoses ...... 558 (Osteochondrosis of the Patellar Apex) ...... 541 OVER-THE-COUNTER ORTHOSES ...... 558 Osteochondritis Dissecans ...... 541 CUSTOM-MADE ORTHOTICS ...... 558 DEGENERATIVE DISEASES...... 542 2.5.2 Functional Indications for Orthoses ...... 558 PATELLOFEMORAL JOINT DISORDERS ...... 542 FUNCTIONAL DEMANDS OF ORTHOSES ...... 559 GONARTHROSIS ...... 543 ACTION PRINCIPLES OF ORTHOSES ...... 559 TRAUMATIC LESIONS ...... 543 2.5.3 Contraindications ...... 559 Miroslav Dobeš 2.5.4 Upper Extremity Orthoses ...... 559 SOFT TISSUE INJURIES OF THE KNEE...... 543 SCS CLASSIFICATION ...... 560 Physiology of Healing of the Knee Structures ...... 543 DESCRITPION OF ORTHOSIS FUNCTION Physiology of Soft Tissue Healing ...... 543 ACCORDING TO SCS CLASSIFICATION ...... 560 Physiology of Ligamentous Healing ...... 543 BASIC OVERVIEW OF UPPER EXTREMITY Physiology of Autogenous Graft Healing ...... 543 ORTHOSES ...... 560 Rehabilitation Following Meniscal Injuries HAND ORTHOSIS  HO ...... 560 and Repairs ...... 544 WRIST ORTHOSIS, WRIST HAND ORTHOSIS  Rehabilitation following Medial Collateral WO, WHO ...... 560 Ligament (MCL) Injury ...... 546 ELBOW ORTHOSIS, ELBOW WRIST HAND Rehabilitation following Anterior Cruciate ORTHOSIS  EO, EWHO ...... 561 Ligament Injury and Reconstruction ...... 547 SHOULDER ORTHOSIS, SHOULDER ELBOW Actual Rehabilitation Program ...... 547 ORTHOSIS, SHOULDER ELBOW WRIST HAND 2.4.7 Ankle and Foot ...... 550 ORTHOSIS  SO, SEO, SEWHO ...... 561 Miroslav Dobeš, Pavel Kolář, Olga Dyrhonová 2.5.5 Lower Extremity Orthoses ...... 562 CONGENTIAL DEVELOPMENTAL DEFECTS...... 550 BASIC CLASSIFICATION OF LOWER EXTREMITY TREATMENT OF CONGENITAL ORTHOSES ...... 562 DEVELOPMENTAL DEFECTS IN GENERAL ...... 550 FOOT ORTHOSIS  FO ...... 562 ALIGNMENT DEFORMITIES ...... 550 ANKLEFOOT ORTHOSIS  AFO ...... 562 FLAT FOOT ...... 550 KNEE ORTHOSIS  KO ...... 563 Classification of flat foot ...... 550 KNEEANKLEFOOT ORTHOSIS  KAFO ...... 563 HALLUX VALGUS ...... 551 HIPKNEEANKLEFOOT ORTHOSIS  HKAFO...... 565 HALLUX RIGIDUS ...... 552 2.5.6 Trunk Orthoses ...... 565 METATARSALGIA ...... 552 BASIC CLASSIFICATION OF TRUNK ORTHOSES ...... 565 XXVI Clinical Rehabilitation

CERVICOTHORACIC ORTHOSES  CTO ...... 566 2.6.2 Prosthetics ...... 574 THORACIC ORTHOSES  TO ...... 566 Structure of a Prosthesis ...... 575 THORACOLUMBAR ORTHOSES  TLO ...... 566 Gait with a Prosthesis ...... 575 THORACOLUMBOSACRAL ORTHOSIS  TLSO ...... 566 Indication Criteria ...... 575 CERVICOTHORACOLUMBOSACRAL Residual Limb Care ...... 575 ORTHOSES  CTLSO ...... 566 Gait Training ...... 576 2.5.7 Most Commonly Applied Orthoses Prosthesis Prescription ...... 576 in Pediatric Orthopedics...... 566 Categories of Amputees According to Insurance Congenital Pes Equinovarus (Club Foot)...... 566 Companies Regulations ...... 576 Metatarsus Adductus ...... 567 2.6.3 Complications in Amputations ...... 576 Pes Calcaneovalgus...... 567 Foot Deformities in Arthrogryposis ...... 567 2.7 REHABILITATION TOOLS ...... 577 Flat Foot ...... 567 Jan Kálal Osgood-Schlatter Disease (Patellar Ligament Tendinopathy)...... 567 Patellar Dislocation ...... 567 3 TREATMENT REHABILITATION Genu Varum, Genu Valgum, Genu Recurvatum ...... 567 FOR SELECTED INTERNAL Congenital Developmental Hip Dysplasia ...... 567 AND OTHER DISEASES Legg-Calve-Perthes Disease ...... 568 Miloš Máček, Jiří Radvanský, Limb Reduction Defects ...... 568 Libuše Smolíková, Pavel Kolář Scoliosis ...... 568 2.5.8 Most Commonly Applied Orthoses in Orthopedics for Adult Patients ...... 569 GENERAL SECTION ORTHOTIC OPTIONS IN COMPLICATIONS DURING APPLICATION OF TOTAL 3.1 PHYSIOLOGICAL MECHANISMS ENDOPROSTHESIS OF THE KNEE UTILIZED IN REHABILITATION AND HIP JOINTS ...... 569 INCLUDING ADAPTATION ORTHOSES APPLICATION IN RHEUMATOID TO PHYSICAL ACTIVITY ...... 585 ARTHRITIS ...... 569 Miloš Máček, Jiří Radvanský LEG LENGTH DISCREPANCY ...... 569 3.1.1 Cardiac System Adaptation ...... 585 ORTHOTIC CARE FOR THE TREATMENT Jiří Radvanský OF FOOT DEFECTS ...... 570 3.1.2 Pulmonary System Adaptation ...... 586 NOTES TO APPLICATION OF TRUNK Miloš Máček ORTHOSES IN LOW BACK PAIN ...... 570 3.1.3 Metabolic Adaptation ...... 588 ORTHOTIC DEVICES FOR FOOT DEFORMITIES Jiří Radvanský IN ADULTHOOD ...... 571 3.1.4 Immunity Adaptation ...... 589 ORTHOTIC OPTIONS FOR ACUTE AND Ondřej Suchánek, Pavel Kolář CHRONIC JOINT INSTABILITIES OF THE LOWER AND UPPER EXTREMITES ...... 571 3.2 FUNCTIONAL STRESS TEST ORTHOSES IN SPINAL TRAUMA ...... 572 IN PATIENTS WITH CARDIOPULMONARY ORTHOTIC OPTIONS IN TENDON INJURIES DYSFUNCTION ...... 591 OF THE HAND ...... 572 Jiří Radvanský FUNCTIONAL TREATMENT OF TENDON 3.2.1 Laboratory Stress Test ...... 592 INJURIES IN THE LOWER EXTREMITY ...... 572 3.2.2 Basic Terminology of a Functional FUNCTIONAL TREATMENT OF LOWER Stress Test ...... 592 EXTREMITY FRACTURES ...... 573 3.2.3 Fitness Testing in Less Fit Individuals ...... 593 ORTHOTIC CARE IN PATIENTS AFTER 3.2.4 Fitness Assessment Based CRANIALTRAUMA ...... 573 on Submaximal Stress Tests ...... 595 ORTHOTIC MANAGEMENT FOR PATIENTS 3.2.5 Assessment of Stress Test ...... 596 FOLLOWING BURN INJURIES ...... 574 3.2.6 Assessment of Activity Including Assessment of the Functional Ability 2.6 REHABILITATION OF PATIENTS of an Elderly Patient ...... 598 AFTER EXTREMITY AMPUTATION ...... 574 3.2.7 Specific Stress Test Adaptations Jan Kálal for Patients with Ischemic 2.6.1 Reasons for Amputations ...... 574 Heart Disease (IHD) ...... 598 Contents XXVII

3.3 FUNCTIONAL LUNG ASSESSMENT ...... 599 3.5.2 Rehabilitation following Jan Šulc Cardiac Surgery ...... 618 3.3.1 Causes of the Onset of Pulmonary Pre-Operative Fitness Improvement and Correction Dysfunctions in Patients with Deficits of Musculoskeletal System Dysfunctions ...... 618 in the Movement System and in Certain Post-Operative Rehabilitation Approaches ...... 618 Organ Systems ...... 599 EXERCISE THERAPY ...... 619 3.3.2 Diagnostic Approaches ...... 599 Post-Operative Complications ...... 621 Methods in Pulmonary Function Testing ...... 601 Description of Pulmonary Function Parameters ...... 603 3.6 ISCHEMIC HEART DISEASE (IHD) ...... 621 3.3.3 Interpretation and Implementation Jiří Radvanský of Conclusions from a Pulmonary KEY COMPONENTS OF A COMPLEX Function Test ...... 604 REHABILITATION PLAN ...... 622 Restrictive Lung Dysfunction ...... 604 Lung Hyperinflation ...... 604 3.7 METABOLIC DISTURBANCES ...... 624 Obstructive Deficits ...... 605 Jiří Radvanský Changes in Lung Elastic Properties ...... 605 3.7.1 Diabetes Mellitus – Type 2 ...... 624 IMPLEMENTATION INTO CLINICAL PRACTICE ...... 605 3.7.2 Diabetes Mellitus – Type 1 ...... 627

3.8 RHEUMATIC DISEASES...... 627 SPECIAL SECTION Irena Koudelková, Pavel Kolář 3.8.1 Rheumatoid Arthritis ...... 628 3.4 RESPIRATORY DISEASES ...... 606 3.8.2 Juvenile Rheumatoid Arthritis Miloš Máček, Jiří Radvanský, (Juvenile Idiopathic Arthritis)...... 631 Libuše Smolíková, Pavel Kolář 3.8.3 Ankylosing Spondylitis ...... 632 3.4.1 Rehabilitation for Bronchial Asthma ...... 606 3.8.4 Osteoporosis ...... 635 Miloš Máček 3.8.5 Fibromyalgia Syndrome ...... 636 EXERCISEINDUCED BRONCHOSPASM ...... 607 Petr Knotek, Pavel Kolář 3.4.2 Rehabilitation in Chronic Obstructive CLINICAL MANIFESTATIONS AND DIAGNOSIS ...... 638 Pulmonary Disease (COPD) ...... 609 Differential Diagnosis ...... 638 Miloš Máček Biological Aspects of FMS ...... 639 PERIPHERAL MUSCLE DYSFUNCTION ...... 609 Psychological Aspects of FMS ...... 640 Rehabilitation of Patients with COPD ...... 610 TREATMENT ...... 641 Program for Patients with Mild and Moderate COPD ....611 Assistive Methods with Exercise Therapy in COPD ...... 611 3.9 OTHER DYSFUNCTIONS AND DISEASES ..644 3.4.3 Implementation of Rehabilitation Pavel Kolář in Other Respiratory Dysfunctions...... 614 3.9.1 Lymphedema and Treatment ...... 644 Miloš Máček Martin Wald, Hana Váchová Respiratory Insufficiency in Neuromuscular ANATOMY OF THE LYMPHATIC SYSTEM ...... 645 Disturbances and Thoracic Deformities ...... 614 MECHANISM OF LYMPHATIC FLUID Rehabilitation of Patients Following Spinal FORMATION ...... 645 Cord Injury: Effect on Lung Function ...... 614 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS ...... 645 Jan Šulc TREATMENT ...... 645 Rehabilitation of Patients on Breathing Support ...... 616 Manual Lymphatic Drainage...... 646 Libuše Smolíková Pharmacotherapy ...... 646 3.4.4 Methods and Approaches Used Treatment Frequency ...... 646 in the Rehabilitation of Patients with EDEMA PREVENTION ...... 646 Chronic Pulmonary System Dysfunction ...... 617 PROGNOSIS ...... 647 Libuše Smolíková, Pavel Kolář 3.9.2 Treatment Rehabilitation of Bowel Incontinence ...... 647 3.5 SURGICAL PROCEDURES Pavel Kolář IN THE THORACIC REGION ...... 617 Lenka Babková 3.10 GERIATRICS ...... 648 3.5.1 Rehabilitation following Zdeněk Kalvach Pulmonary Surgery ...... 617 3.10.1 Aging Phenotype and Involution Breathing Preparation ...... 618 Deterioration ...... 649 XXVIII Clinical Rehabilitation

3.10.2 Geriatric Frailty and Geriatric ONCOLOGICAL DISEASES OF THE SPINE ...... 663 Syndromes ...... 649 ONCOLOGICAL DISEASES AND SURGICAL GERIATRIC SYNDROMES OF HYPOMOBILITY, APPROACHES FOR THE EXTREMITIES ...... 664 DECONDITIONING AND MUSCLE WEAKNESS ...... 650 4.5.2 Metastatic Involvement of the Brain HYPOMOBILITY ...... 650 and the Spinal Cord ...... 666 DECONDITIONING ...... 650 SARCOPENIA ...... 650 4.6 PARANEOPLASTIC SYNDROMES ...... 666 GERIATRIC MODIFICATIONS AND CONTINUITY OF REHABILITATION ACTIVITIES ...... 650 4.7 SIDE EFFECTS OF ONCOLOGIC 3.10.3 Principles of Movement Activity TREATMENT ...... 667 Selection in the Aging Population ...... 651 NEUROLOGICAL SYMPTOMS ...... 667 Miloš Matouš, Pavel Kolář 4.7.1 Cerebellar Syndrome ...... 667 Assessment Prior to Exercise Program Initiation ...... 652 4.7.2 Peripheral Polyneuropathy ...... 667 Exercise Programs ...... 652 4.7.3 Hormone Therapy ...... 669 Reconditioning Stays...... 653 4.7.4 Immunotherapy ...... 669

4.8 SOFT TISSUES AND MUSCLE TISSUE ...... 669 4 TREATMENT REHABILITATION IN ONCOLOGY 4.9 RADIATION THERAPY ...... 669 Vítězslav Hradil 4.10 LYMPHEDEMA ...... 671 REHABILITATION SPECIFICS FOR PATIENTS WITH ONCOLOGIC CONDITIONS ...... 657 BASIC GOALS AND ASSESSMENT 5 TREATMENT REHABILITATION OF REHABILITATION TREATMENT ...... 657 IN GYNECOLOGY AND OBSTETRICS REHABILITATION TREATMENT COMPLICATIONS ...... 658 Martina Ježková, Pavel Kolář

5.1 OVERVIEW OF GYNECOLOGICAL GENERAL SECTION SYNDROMES WITH CONTRIBUTION OF FUNCTIONAL DEFICITS ...... 673 4.1 PAIN PATTERNS IN PATIENTS WITH Martina Ježková, Pavel Kolář ONCOLOGICAL DISEASES ...... 658 4.1.1 Pain Pattern and Its Treatment ...... 658 DYSFUNCTIONS OF THE MENSTRUAL CYCLE 4.1.2 Classification of Oncologic Pain ...... 658 AND FUNCTIONAL STERILITY ...... 674 AMENORRHEA ...... 674 4.2 PARAMETERS FOR THE DYSMENORRHEA ...... 674 INTERRUPTION OR MODIFICATION STERILITY ...... 675 OF A REHABILITATION PROGRAM ...... 659 4.2.1 Laboratory Values ...... 659 5.2 PREMENSTRUAL SYNDROME 4.2.2 Long Bone Metastases ...... 659 AND MENOPAUSE ...... 678 4.2.3 Other Parameters Modifying PREMENSTRUAL SYNDROME ...... 678 Rehabilitation Treatment ...... 660 MENOPAUSE ...... 678 MENOPAUSE, PREMENOPAUSE, 4.3 REHABILITATION APPROACHES ...... 660 POSTMENOPAUSE ...... 678 4.3.1 Modalities ...... 660 MENOPAUSAL SYNDROME ...... 679 4.3.2 Physical Therapy Techniques ...... 661 SYNDROMES THAT CAN BE AFFECTED 4.3.3 Contraindications ...... 661 BY REHABILITATION ...... 679

4.4 SPECIFIC FACTORS INFLUENCING 5.3 PELVIC INFLAMMATORY DISEASE ...... 679 REHABILITATION TREATMENT ...... 662 5.4 ANATOMICAL DEFICITS IN GYNECOLOGY ...... 680 SPECIAL SECTION 5.5 GYNECOLOGICAL SURGICAL 4.5 METASTATIC INVOLVEMENT ...... 662 PROCEDURES ...... 680 4.5.1 Metastatic Involvement of the Skeleton ....662 Post-Operative Complications (Post-Surgical Incisions) ..683 Contents XXIX

5.6 URINARY INCONTINENCE ...... 683 7.2 TREATMENT ...... 711 Martina Hoskovcová 7.2.1 Biological, Psychological and Social Context: Non-Specific 5.7 PREGNANCY, BIRTH AND THE Rehabilitation Factors ...... 711 POSTPARTUM (POSTNATAL) PERIOD ...... 686 7.2.2 Treatment Rehabilitation ...... 713 Martina Ježková, Pavel Kolář Barbora Danielová, Petr Knotek, Pavel Kolář PREGNANCY ...... 686 7.2.3 Psychotherapy ...... 714 BIRTH ...... 686 7.2.4 Psychopharmacotherapy ...... 714 POSTPARTUM ...... 687

8 REHABILITATION IN PSYCHIATRY 6 TREATMENT REHABILITATION IN PAIN MANAGEMENT 8.1 REHABILITATION IN THE AREAS OF SOCIAL AND VOCATIONAL Jiří Kozák, Pavel Kolář FUNCTIONS ...... 717 Ondřej Pěč, Lenka Vachková, Jan Mužík 6.1 CLASSIFICATION OF PAIN ...... 691 8.1.1 General Aspects of Psychiatric Acute Pain ...... 691 Rehabilitation ...... 718 Chronic pain ...... 691 Current Schools of Psychiatric Rehabilitation ...... 718 Target Group of Psychiatric Rehabilitation ...... 718 6.2 FOUNDATIONS OF Principles of Psychiatric Rehabilitation ...... 718 NEUROPHYSIOLOGIC PAIN ...... 691 Recovery ...... 719 8.1.2 Process of Psychiatric Rehabilitation 6.3 PAIN MANAGEMENT ...... 692 and Possible Approaches ...... 720 Process of Psychiatric Rehabilitation According 6.4 COMPLEX REGIONAL PAIN to the Boston School ...... 720 SYNDROME (CRPS) ...... 695 Process of Psychosocial Rehabilitation According to the Netherlands’ School STORM ...... 721 8.1.3 Specific Levels of Psychiatric 7 TREATMENT REHABILITATION Rehabilitation ...... 721 IN PSYCHOSOMATIC DISEASES Vocational rehabilitation ...... 721 Assisted Education ...... 723 Petr Knotek, Pavel Kolář Rehabilitation and Housing ...... 723 Rehabilitation in the Areas of Social Interaction 7.1 MODERN PSYCHOSOMATICS ...... 701 and Leisure Time ...... 724 7.1.1 Psychosomatics and Current Science ...... 702 8.1.4 Psychiatric Rehabilitation Assessment .....725 7.1.2 Psychosomatics and Irrationality ...... 702 7.1.3 Biological, Psychological 8.2 PSYCHOMOTOR THERAPY ...... 725 and Social Approach ...... 703 Běla Hátlová, Milena Adámková Psychosomatic Integrity ...... 704 8.2.1 General Aspects of Psychomotor Normality ...... 705 Therapy ...... 726 Psychobiology and Sociocultural Norms ...... 705 Research in Kinesiotherapy ...... 726 Cognitive Processes and Adaptation ...... 705 Physical Self-Concept ...... 726 Failure as a Pathological Adaptation ...... 706 Role of Movement Activity in Stress Coping ...... 726 7.1.4 Placebo and Nocebo ...... 706 Somatic State and Movement Abilities of Patients 7.1.5 Charisma ...... 708 with Mental Illness ...... 726 7.1.6 Physical Manifestations as Signs Why Movement Therapy? ...... 727 and Symptoms ...... 708 8.2.2 Kinesiotherapy ...... 727 7.1.7 Deficits and Signs ...... 710 Circumscription of the term Kinesiotherapy ...... 727 Acute Psychological Reaction to Stress ...... 710 Actions of Kinesiotherapy ...... 727 Neurotic Disturbances ...... 710 Types of Kinesiotherapy in the Treatment Psychosomatic Disturbance ...... 710 of Psychiatric Patients ...... 728 Psychosomatic Diseases of Organs Integrated and Focused Kinesiotherapy ...... 728 and Organ Systems ...... 710 Kinesiotherapeutic Activation Programs ...... 728 Systemic Diseases ...... 711 Kinesiotherapeutic Active Relaxation Programs ...... 728 Somatopsychological Disturbance ...... 711 Perceptive (Attention) Focused Kinesiotherapy ...... 728 XXX Clinical Rehabilitation

Kinesiotherapeutic Programs Increasing Kinesiotherapy for the Treatment of Neuroses ...... 730 Self-Confidence and Confidence in Others ...... 729 Kinesiotherapy for the Treatment Kinesiotherapeutic Communication Programs ...... 729 of Personality and Behavioral Disorders ...... 731 Therapeutic Utilization of Athletic Exercises ...... 729 Principles of Kinesiotherapy Administration Suggested Forms of Kinesiotherapy in the Mentally Ill ...... 731 for the Treatment of Psychological Illnesses ...... 729 Kinesiotherapy for the Treatment of Dementia ...... 729 BIOGRAPHIES OF INFLUENTIAL FIGURES ..... 733 Kinesiotherapy for the Treatment of an Addiction Syndrome ...... 729 ABBREVIATIONS ...... 747 Kinesiotherapy for the Treatment of Schizophrenia ...... 730 Kinesiotherapy for the Treatment of Manic Illnesses ...... 730 INDEX ...... 749