stroke rehab – Flashcards
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recovery results from
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recovery of the ischemic penumbra resolution of cerebral edam neuroplasticity and rehabilitation
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better outcomes associated with
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early medical care smaller strokes specialized stroke care centers early intensive multidiscinplary rehab
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ischemic stroke recovery pattern
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rapid in first month steady rate for 3 months progress may or may not be functional from 3-6 months functional status after 6 months remains constant usually
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hemmorrhagic stroke recovery pattern
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slow initial rate of recovery followed by rapid rate of recovery 6 months post Survivors usually have less long term disability and better functional outcomes
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Goals of Post-Stroke PT • ICU/Acute Care (7)
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o Patient and family education o Prevention of secondary complications o Positioning, splinting o Assess functional abilities (as soon as medically able) o Manage impairments o EARLY mobilization-low intensity, monitor status closely o Discharge planning
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Goals of Post-Stroke PT • Rehabilitation o Same as acute care setting and... (6)
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o Patient-family centered goals (What types of activities are important to them) o Maximize functional status and independence o Discharge planning with the team o Equipment (DME, Durable medical equipment (w/c, gait assistive devices) • Orthotics • Splints, slings, gloves, etc.
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Goals of Post-Stroke PT • Chronic Phase (6 months and beyond) o Home care o Community rehab • If more mobile and have access o Outpatient o Home exercise program • Goals:
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Maintenance/continued improvement in ROM, strength, endurance, balance, functional mobility, participation in recreational and vocational activities
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Principles of experience-dependent neural plasticity (10)
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• 1. Use it or lose it (o if don't engage a certain brain functioning will lose function in that area ) • 2. Use it and improve it (if do use function can improve it by specifically training it) • 3. Specificity(train experience to match functional outcome) • 4. Repetition matters(cant be passive repetition need some active problem solving. E.g. different intensity) • 5. Intensity matters • 6. Time matters • 7. Salience matters (person needs to be motivated) • 8. Age matters (neuroplasticity more rapid in younger brains) • 9. Transference (to other skills) • 10. Interference (not all neuroplasticity is good. If learn non use or maladaptive pattern)
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stroke primary impairments (6)
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o Motor control/activation o Altered muscle tone o Loss of sensation o Coordination problems o Impaired spatial and body awareness/neglect
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stroke secondary impairments (5)
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o Weakness, atrophy o Muscle length, ROM o Edema o Subluxation o Pain
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Positioning: Sidelying • Unaffected side
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o position limb so they can see the limb to understand where it is. Shoulder flexed, neutral rotation, elbow extended (don't want flexor synergy), forearm wrist in neutral fingers extended
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Positioning: Sidelying • Affected Side
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o can have shoulder in ER and some flexion, elbow flexed or extended, wrist neutral fingers extended
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Positioning: Sitting
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• arm in view, elbow extended fingers open and will likely need some type of positioning device to maintain this
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Shoulder Joint Integrity • __1_subluxation most common • __2_surrounding GH joint and gravitational pull of weight of limb leads to downward rotation of scapula and glenoid fossa, traction of humerus • Soft tissue surrounding GH joint and joint capsule __3_, muscle length-tension relationship changes
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1. Inferior 2. Weakness, hypotonicity 3. stretches and lengthens
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Shoulder Joint Integrity • Assessment: palpation, calipers, tape measure, xray o How many finger widths under coracoid process can fit • PT__1_ is key! • PT management: __2_ to prevent progression
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1. prevention. o No evidence for reduction post-subluxation. Cant reduce amount of subluxation once it occurs 2. FES, taping, splinting, positioning and alignment
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FES Guidelines • __1 where_ • Pulse frequency _2_ • Pulse duration_3_ us, 15 sec on/off period, 2-3 sec ramp up/down • _4_0min, 2-4 times/day for 5-7 days/weeks for 4 weeks to 2 years
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1. Supraspinatus, and posterior & middle deltoids 2. 1-45 hz 3. 300-350 4. 5-60
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FES Evidence • Acute Stroke*:_1_ • Subacute Stroke:_2_ • Chronic Stroke:_3_ • Meta-analysis (Ada & Foongchomcheay, 2002) o FES plus conventional treatment __4_ o No evidence __5_ • *Brosseau L, et al. 2006 Clinical practice guidelines for shoulder
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1. Clinically important benefits but not statistically significant after 4 weeks of treatment • No benefits seen after 8 week follow up 2. o Clinically and statistically significant benefits after 6 weeks or more of treatment (most likely use in this stage) 3. No benefit after 12 to 18 weeks of treatment 4. favored in early rehab 5. FES is superior to conventional treatment
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Supportive Devices • ___-protect from overstretching the supraspinatus and joint capsule, free up therapists hands but... o Do not reduce subluxation or encourage functional use of limb o Secondary adaptive shortening and contractures o Encourage learned nonuse and maybe neglect o Contribute to balance deficit
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Slings
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sling use during rehab
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• Minimize sling use during rehab o Cuff support vs. sling • Sling maybe initially for safety but move away from as soon as can • Cuff support is better option (more of strapping method to give external approximation without putting in position trying to avoid)
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Hemiplegic Shoulder Pain 1. prevention 2. education to caregiver
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1. support a flaccid limb and position properly, mobilization of scapula and UE, no prom beyond 90 degrees for shoulder flex and abd, promote active movement and weight-bearing 2. never pull on the hemiplegic UE to roll patient or during transfers (traction on this arm can make more susceptible to regional pain syndrome)
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Improving UE Function • Reduced motor control/muscle activation (8)
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o EMG biofeedback o Mental practice o FES o Robotic assisted movements o Task oriented retraining o CIMT (Constraint induced movement therapy of unaffected limb so are forced to use affected) o PRE (Progressive resistant exercises. If have some firing can strengthen. Can do some isolated strengthening but optimally back into functional task) o Virtual Reality and gaming
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Improving UE Function • Loss of sensation, proprioception 3 strategies
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o 1. Uptrain sensory systems with augmented sensory input/feedback • Weight-bearing, joint compression, tapping, brushing, stroking, air sleeves, vibration, visual input • Practice functional tasks o 2. Promote simultaneous bimanual activities • Activity and proprio in less affected UE can help improve activation and control of affected limb • UBE, rolling pin (moving forward on table with both hands), weighted wand (used with both hands to hit a ball), open a jar, dial a phone, typing, writing (stabilize paper with affected and write with unaffected) o 3. PNF • Lacks evidence to support use for return of function • Support for improvement in ROM
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Improving UE Function • Hypotonic limb
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o Positioning, protection, resting splints, weight-bearing with good alignment, tapping, moveable surface
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Improving UE Function • Hypertonic limb
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o Positioning, splinting, serial casting (cast for few days, work on rom and cast in improved rom is usually last resort), prolonged stretch, deep pressure on tendons, neutral warmth
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Improving UE Function • Impaired spatial/body awareness or neglect • Inability to register and integrate stimuli on one side of the body (__1_neglect) o Can go so far as to not acknowelding the limbs on that side of the body belong to them so keep arms stuck on spokes of w/c etc • Inability to orient towards or attend to stimuli on one side of the environment (_2_ neglect) o _3_-not using objects in arms length on one side • Only eating or using utensils on left side of the tray, not attending to objects on that side of the world in arms length o _4_-space beyond arm's length • Will bump into ppl or things walking down the hallway on that left side • Persistent neglect is associated with poor outcomes o Need to get them to compensate for input • Heterogeneity-not a consistent, predictable pattern • Limb activation-theory that _5_facilitates sensory circuits and better attention toward the side of neglect
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1. personal or body 2. spatial 3. Peripersonal 4. Extrapaersonal 5. motor movements
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Interventions: Unilateral Neglect • Behavioral strategies
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o Visual scanning (•Teach them to visually scan left side on a regular basis to get input ) o Sustained attention and self-alerting (• Place something on that side and redirecting them to look in that area. Can use visual motor or verbal cues e.g. piece of tape on floor in front of them and have them follow that tape. Imagery can help e.g. imagine you are a lighthouse beam and need to scan the floor from right to left ) o Limb activation therapy • Active preferred, FES as adjunct, mirror therapy (• Moving that side actively, increasing inputs to draw attention to that side • Sit in front of mirror especially useful if don't have control of hemperagic limb. Move uninvolved arm and perceive it in the mirror as their involved side doing those movements that is hidden from view. )
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Interventions: Unilateral Neglect • Sensory stimulation strategies (less common but can be effective in adjunct to behavioral strategies)
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o Neck muscle vibration o Optokinetic stimulation (•Moving Field of dots in background ) o Prism adaptation (• Wear prism glasses and supports visual input from side neglecting. When wear glasses objects are perceived to be oriented to right ask them to point to left and then feel as need to correct movement by reaching to left ) o Repetitive transcranial magnetic stimulation • Inhibitory TMS over contralesional parietal lobe
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Outcomes Measures: UE specific
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• Wolf Motor Function Test (o Timed UE motor tasks-truncated at 120 seconds o Stroke and TBI) • Action Research Arm Test (o Observational assessment of UE function o Stroke, TBI, MS o Fine motor: grasp, pinch o Gripping and arm movement to place hand)
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Outcomes Measures: General (3)
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• 1. Fugl-Meyer Assessment of Physical Performance 2. STREAM (stroke rehab assessment of movement) 3. Chedoke-McMaster Stroke Assessment
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o Gold standard for motor function assessment post-stroke o UE motor subscale (also LE, balance, sensation, rom, pain) o 3-point ordinal scale-UE subtest max score is 66 o Good construct validity and high reliability o Excellent psychomotor properties
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Fugl-Meyer Assessment of Physical Performance
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o UE, LE and basic mobility subscales o 30 items total-10 for each subscale o 3 point ordinal scale with 20 points max for UE section o Sensitive to change over time, predict discharge destination
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STREAM (stroke rehab assessment of movement)
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o Physical impairment and disability o 14 items scored on 7 point ordinal scale o Shoulder pain, postural control, arm/hand/foot/leg control
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Chedoke-McMaster Stroke Assessment
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Trunk Interventions (7)
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• Manage Tone • Promote proper alignment and posture • Stretching to maintain muscle length • Respiratory muscle training and breathing exercises • Positioning-bed, chair • Improve function • Perceptual deficits
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Trunk-Perceptual Deficits • Ipsilateral Pushing o _1_(area of brain affected) o Altered perception of body orientation in relation to gravity o -_2_ imbalance due to __3_ o 10% of people post-stroke exhibit pusher's syndrome o Do not __4_ o Facilitate__5_ o Provide __6_ o __7_on hemi side for sitting tasks and standing tasks/amb o Active __8_
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1. Posterolateral thalamus 2. Lateral postural 3. pushing with stronger UE and LE toward weaker side 4. manually correct-exacerbates condition 5. active weight shifting toward unaffected side 6. visual proprioception-mirror, plumb line, reference 7. Wall 8. problem solving and recognition • Are you in midline? Which way are you leaning?
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Trunk-Perceptual Deficits • Retropulsion o Trunk in__1_ o Tend to __2_ as they are unaware and do not exhibit postural strategies to correctàenvironmental modifications and safety o Work in __3_
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1. reclined position 2. fall backwards 3. forward trunk positions, use sensory inputs, visual cues
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Gait Essentials: Stance Phase • Hip __1_throughout stance • __2_ of pelvis and trunk o Small amount (5cm) but critical for loading and unweighting contralateral limb • Knee: _3_ at initial contact (for shock absorption and prevention of buckling), followed quickly by __4_, then __5_again in terminal stance
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1. extension 2. Lateral horizontal shift 3. 10-15 degrees flexion 4. extension 5. flexion
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Common Gait Deviations: Stance (6)
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1. Poorly aligned trunk/pelvis 2. Decreased peak hip extension (Spasticity of hip flexors, rom restriction hip flexors, weak hip extensors) 3. Knee hyperextension (oVery common problem, muscle weakness in quads and hamstrings so hyperextend to rely on passive structures, spastcity in gastroc doesn't allow tibia to move forward over limb) 4. Lack of extension (Shortening of gastroc or hamstrings, knee flexor contractors) 5. Decreased PF at toe off (Need ~20 degrees, joint contractures or weak gastrocs ) 6. WTB on metatarsal heads (Severe spasticity of gastroc and soleus heel never gets down wb always on metatarsal heads)
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Gait Essentials: Swing • Initial swing: _1_ • Mid swing:_2_ • Terminal swing: _3_
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1. knee flexion with hip extension • Lateral pelvic tilt downward direction 5 degrees 2. flexion of hip with knee extending • Forward rotation of ipsilateral pelvis 3.knee in full extension with ankle DF right before heel strike to clear ground
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Common Gait Deviations: Swing • Poorly aligned trunk/pelvis • Decreased peak hip flexion (7)
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1. Poorly aligned trunk/pelvis 2. Decreased peak hip flexion (Lack of forward swing and lack of hip flexion ppl do some gait deviations to achieve swing Circumduct or vault on contralateral side). Can cause short step length on that side, weakness in flexors or result of shortened step length on contralateral side 3. No UE swing on hemi side (Very common . Not getting opposite arm swing will effect gait as whole. Less trunk flexion and larger excursions of com) 4. Increased hip and knee flexion (ataxic) o Usually with ataxic gait which has lots of variability step to step 5. Decreased peak knee flexion (early swing) o Inadequate hip flexion and poor foot clearance, spastic quadriceps 6. Decreased knee extension (late swing) o Hypertonicity in hamstrings or weak knee extensors 7 Lack of DF/toe clearance o Spastic gastroc, pf contractures or weak DF
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Overground Gait Training • Pre-gait activities-stance phase control (5)
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o Paretic limb loading o Sit to stand • Focus on paretic by putting uninvolved limb further in front of them so have to put more weight on involved side o Unilateral stance • Onto to paretic side and lift uninvolved off of ground o Side stepping • Moves in and out of unilateral stance o Standing weight shifting activities
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• Pre-gait activities-swing phase (4)
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o Step to and step through o Toe clearance o Heel strike o Weight transference to hemi side with contralateral swing
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Functional Walking Categories
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• Physiological: Exercise only: // bars, BSWTT, robotic • Household Walker: Short distances, assistive device, difficulty with stairs & uneven surfaces • Community Walker o Limited: enter and leave home indep, manage stairs and curbs indep but slower gait speed and unable to indep negotiate crowded areas o Unlimited: faster gait speed, indep on uneven surfaces and in crowds. • 1.3 m or higher to be able to cross street with most traffic signals
