COORDINATION

Coordination is the ability to execute smooth, accurate, controlled motor responses.

Coordinated movements are characterized by appropriate speed, distance, direction, timing and muscular tension.

In addition, they involve appropriate synergistic influences (muscle recruitment), easy reversal between opposing muscle groups (appropriate sequencing of contraction and relaxation), and proximal fixation to allow distal motion or maintenance of a posture.

Schmidt and Lee define coordination as the “behavior of two or more degrees of freedom in relation to each other to produce skilled activity.”

Balance is said as the maintenance of postural stability, or equilibrium, and is mostly used with the term postural control.

Features of Coordination Impairments:

As the cerebellum, basal ganglia, and dorsal column-medial lemniscal pathway provide input to, and act together with, the cortex in the production of coordinated movement, lesions in any of these areas impact the higher level processing and execution of coordinated motor responses.

CEREBELLAR PATHOLOGY

Ataxia is the most common term used to describe motor impairments of cerebellar origin. Cerebellar ataxia is a general term used to describe loss of muscle coordination as a result of cerebellar pathology. Ataxia may affect gait, posture, and patterns of movement and is linked to difficulty initiating movement as well as errors in the rate, rhythm, and timing of responses.

Asthenia is generalized muscle weakness associated with cerebellar lesions.

Dysarthria is a disorder of the motor component of speech articulation. The characteristics of cerebellar dysarthria are referred to as scanning speech (one word at a time). The speech pattern in slow, and may be slurred, hesitant, with prolonged syllables and inappropriate pauses.

Dysdiadochokinesia is an impaired ability to perform rapid alternating movements. Movements are irregular, with a rapid loss of range and rhythm especially as speed is increased.

Dysmetria is an inability to judge the distance or range of a movement. It may be manifested by an overestimation (hypermetria) or an underestimation (hypometria) of the required range needed to reach an object.

Dyssynergia (movement decomposition) describes a movement performed in a sequence of component parts rather than as a single, smooth activity.

Asynergia is the loss of ability to associate muscles together for complex movements.

Hypotonia is a decrease in muscle tone. It is believed to be related to the disruption of afferent input from stretch receptors and/or lack of the cerebellum’s facilitatory efferent influence on the fusimotor system.

Nystagmus is a rhythmic, quick, oscillatory, back-and-forth movement of the eyes. It is typically apparent as the eyes move away from the midline to fix on an object in either the medial or lateral field.

Rebound phenomenon, described by Holmes, is the loss of the check reflex, or check factor, which functions to halt forceful active movements when resistance is eliminated.

Tremor is an involuntary oscillatory movement resulting from alternate contractions of opposing muscle groups. An intention or kinetic tremor occurs during voluntary motion of a limb and tends to increase as the limb nears its intended goal or speed is increased. Postural or Static tremor may be evident by back-and-forth oscillatory movements of the body while the patient maintains a standing posture.

Titubation typically refers to rhythmic oscillations of the head (side-to-side, forward-and-backward, or they may have a rotary component.

BASAL GANGLIA PATHOLOGY

Patients with lesions of the basal ganglia typically demonstrate several characteristic motor deficits. These include i) decreased and slowness of movement; ii) involuntary, extraneous movement; and iii) alterations in posture and muscle tone.

Akinesia is an inability to initiate movement (seen in late stages of Parkinson’s disease. This deficit is associated with assumption and maintenance of fixed postures (freezing episodes).

Athetosis is characterized by slow, involuntary, writhing, twisting, “wormlike” movements. Pure form of athetosis is relatively uncommon and most often presents in the combination with spasticity, tonic spasms, or chorea.

Bradykinesia is a decreased amplitude and velocity of voluntary movement. It may be demonstrated in a variety of ways, such as a decreased arm swing; slow, shuffling gait; difficulty in initiating or changing the direction of movement.

Chorea is characterized by involuntary, rapid, irregular, and jerky movements involving multiple joints. Choreiform movements demonstrate irregular timing and cannot be voluntarily inhibited.

Choreoathetosis is a term used to describe a movement disorder with features of both chorea and athetosis.

Dystonia (dystonic movements) involves sustained involuntary contractions of agonist and antagonist muscles causing abnormal posturing (dystonic posturing) or twisting movements.

Hemiballismus is characterized by large-amplitude sudden, violent, flailing motions of the arm and leg of one side of the body. Hemiballismus results from a lesion of the contralateral subthalamic nucleus. Associated terms include hyperkinesis, which is abnormally increased muscle activity or movement; and hypokinesis, which is a decreased motor response especially to a specific stimulus.

Rigidity is an increase in muscle tone causing greater resistance to passive movement. The increased muscle tone is in both agonist and antagonistic muscles.

Leadpipe rigidity is a uniform, constant resistance felt by the examiner as the extremity is moved through a range of motion (ROM).

Cogwheel rigidity is considered a combination of the leadpipe type with tremor. It is characterized by a series of brief explanations or “catches” as the extremity is passively moved.

Tremor is an involuntary, rhythmic, oscillatory movement observed at rest (resting tremor). Resting tremors typically disappear or decrease with purposeful movement. Tremors associated with basal ganglia lesions (e.g., Parkinson’s disease) are frequently noted in the distal upper extremities in the form of a “pill-rolling” movement.

COORDINATION EXAMINATION:

The purposes of performing a coordination examination of motor function are to determine the:

1) Muscle activity characteristics during voluntary movement

2) Activity of muscles or groups of muscles to work together to perform a task or functional activity.

3) Level of skill and efficiency of movement.

4) Ability to initiate, control, and terminate movement.

5) Timing, sequencing, and accuracy of movement patterns.

6) Effects of therapeutic and pharmacological intervention on motor function over time.

Preparation for Administering the Coordination Examination:

ð Testing Environment:

The coordination examination should be administered in a quiet, well-lighted treatment area sufficiently large to accommodate walking activities included in the equilibrium portion of the tests.

ð Patient Preparation:

The patient should be well rested. A full explanation of the purpose of the testing should be provided. Each coordination test should be described and demonstrated individually by the therapist before actual testing.

ð Preliminary Screening:

The patient should be performed with other examination procedures like ROM, Strength, and Sensation before performing coordination examination.

ð Preliminary Observation:

Patient should be observed for

- General level of skill in each activity (amount of assistance or assistive devices required).

- Occurrence of extraneous movements, oscillations, swaying, or unsteadiness.

- Number of extremities involved (unilateral and/or bilateral).

- Distribution of motor impairment: proximal and/or distal musculature.

- Situations or occurrences that alter impairments.

- Amount of time required to perform an activity.

- Level of safety.

Coordination Tests:

Coordination tests can be divided into two main categories: gross motor movements like crawling, kneeling, standing, running, etc., and fine motor movements like skilful, controlled manipulation of objects.

Coordination tests can be further subdivided into nonequilibrium and equilibrium tests.

ð Nonequilibrium tests address both static and mobile components of movements when the patient is in a sitting position. These tests involve both gross and fine motor activities.

ð Equilibrium tests consider both static and dynamic components of posture when patient is in an upright standing position. They involve primarily gross motor activities and require observation of the body in both static (stationary) and dynamic (body in motion) postures.

NONEQUILIBRIUM TESTS

1. Finger-to-Nose – The shoulder is abducted to 90 degrees with elbow extended. The patient is asked to bring the tip of the index finger to the tip of his or her nose.

2. Finger-to-Therapist’s finger – The patient and therapist sit opposite each other. The therapist’s index finger is held in front of the patient. The patient is asked to touch the tip of his or her index finger to the therapist’s index finger.

3. Finger-to-Finger – both shoulders are abducted to 90 degrees with the elbows extended. The patient is asked to bring both hands toward the midline and approximate the index fingers from opposing hands.

4. Alternate nose-to-finger – the patient alternately touches the tip of his or her nose and the tip of the therapist’s finger with the index finger.

5. Finger Opposition – the patient touches the tip of the thumb to the tip of each finger in sequence.

6. Mass Grasp – an alteration is made between opening and closing fist (from finger flexion to full extension).

7. Pronation/Supination – with elbows flexed to 90 degrees and held close to the body, the patient alternately turns the palms up and down. This test is also performed with shoulders flexed to 90 degrees and elbows extended.

8. Rebound test – the patient is positioned with the elbow flexed. The therapist applies sufficient manual resistance to produce and isometric contraction of the biceps. Resistance is suddenly released. Normally, the opposite muscle group (triceps) will contract and “check” movement of the limb.

9. Tapping (hand) – with the elbow flexed and the forearm pronated, the patient is asked to “tap” the hand of the knee.

10. Tapping (foot) – the patient is asked to “tap” the ball of one foot on the floor without raising the knee; heel maintains contact with floor.

11. Pointing and past pointing – the patient and the therapist sit opposite to each other. Both patient and therapist bring shoulders to a horizontal position of 90 degrees flexion with elbow extended. Index fingers are touching or the patient’s finger may rest lightly on the therapist’s. the patient is asked to fully flex the shoulder and then return to the horizontal position such that index fingers will again approximate. A normal response consists of an accurate return to the starting position. In an abnormal response, there is typically a “past pointing”, or movement beyond the target. \

12. Alternate heel-to-knee; heel-to-toe – from a supine position, the patient is asked to touch the knee and big toe alternately with the heel of the opposite extremity.

13. Toe to examiner’s finger – from a supine position, the patient is instructed to touch the great toe to the examiner’s finger.

14. Heel on shin – from a supine position, the heel of one foot is slid up and down the shin of the opposite lower extremity.

15. Drawing a circle – the patient draws an imaginary circle in the air with either upper or lower extremity. This also may be done using a figure-eight pattern.

16. Fixation or position holding – UE: the patient holds arms horizontally in front (sitting or standing)…LE: the patient is asked to hold the knee in an extended position (sitting).

EQUILIBRIUM TESTS

1. Standing, comfortable posture with normal base of support (BOS).
2. Standing, feet together (narrow BOS).
3. Standing in tandem position, with one foot directly in front of the other (toe of one foot touching heel of opposite foot)
4. Standing on one foot.
5. Arm position may be altered in each of the above postures (i.e., arms at side, over head, hands on waist, and so forth).
6. Perturbations: displace balance unexpectedly
7. Standing, functional reach: forward trunk flexion with upper extremity reach.
8. Standing, laterally flex trunk to each side
9. Standing: eyes open (EO) to eyes closed (EC); inability to maintain an upright posture without visual input is referred to as a positive Romberg sign.
10. Standing in tandem position eyes open (EO) to eyes closed (EC) (Sharpened Romberg).
11. Tandem walking, placing the heel of one foot directly in front of the toe of the opposite foot.
12. Walking along a straight line drawn or taped to the floor, or place feet on floor markers while walking.
13. Walk sideways, backward, or cross-stepping.
14. March in place.
15. Alter speed of ambulatory activities; observe patient walking at normal speed, as fast as possible, and as slow as possible.
16. Stop and start abruptly on command while walking.
17. Walk and pivot on command (turn 90, 180 or 360 degrees)
18. Walk in a circle, alternate directions.
19. Walk on heels or toes.
20. Walk with horizontal and vertical head turns on command.
21. Step over or around obstacles
22. Stairclimbing with and without using handrail; one step at a time, step over step.
23. Jumping jacks.
24. Sitting on therapy ball: alternate flexing and extending the knees (coordinated movement with upright balance).