10-04 Stroke Flashcards
(113 cards)
1
Q
Types of Strokes (2)
A
- Ischemic (Clot blocks blood flow)
- Hemorrhagic (Blood vessel ruptures)
- Ischemic is most common (80% of strokes)
2
Q
Transient Ischemic Attack (TIA)
A
- Temporary interruption of blood flow
- Lasts few min or hrs, but less than 24 hrs
- No residual brain damage
- “TIA only lasts a day”
- Greater risk of stroke (15% of people)
3
Q
Stroke
A
- Deficits last longer than 24 hours
- Permanent effect
- 4th leading cause of death in US
4
Q
Motor Deficits (3)
A
- Hemiplegia (Paralysis on one side)
- Hemiparesis (Weakness on one side)
- Opposite Side (L infarction results in R hemiplegia/paresis; R infarction results in L hemiplegia/paresis)
5
Q
Atherosclerosis
A
- Plaque formation
- Continues to grow along wall after formation
- Wall narrows, blocking blood flow
- Forms in bifurcate, angled areas
6
Q
Arteriovenous malformation (AVM)
A
- Congenital condition
- Cluster, tangle of arteries and veins
- Progressive dilation eventually bleeds (50% of cases)
7
Q
Stroke Risk Factors (Modifiable)
A
- Hypertension
- Heart disease
- Diabetes
- Smoking
- Diet
- Obesity
- Stress
8
Q
Stroke Risk Factors (Non-modifiable)
A
- Age ( >55 yo)
- Gender (Women b/c they live longer)
- Family history
9
Q
Stroke Risk Factors (Other)
A
- Atrial Fibrillaton (Abnormal heart beat - blood pools in heart, clots and comes out)
- TIA
10
Q
Classic signs of stroke
A
- Sudden
- Numbness or weakness of face, UE, LE on one side of the body
- Confusion, difficulty talking or understanding
- Loss of vision in one eye
- Difficulty walking, dizziness, LOB
- Severe head without cause
- FAST - Face, Arm, Speech, Time
11
Q
FAST
A
- Face, Arm, Speech, Time
- Face (Assymmetrical)
- Arm (Weak)
- Speech (Slurred)
- Time (How long)
12
Q
T-PA
A
- Clot buster
- Given within three hours
- Used for ischemic, not hemorrhagic CVA
- Determine type of stroke with CT Scan
13
Q
Stroke Pathophysiology
A
- Interruption of blood flow for few minutes –> Lack of oxygen –> Cellular damage and death within few minutes –> Cerebal Edema –> Tissue Necrosis
- Cerebral Edema increases pressure, shifts brain. Use shunt or cut skull out to relieve
- Edema subsides within 2-3 weeks
- Circle of Willis: Union of anterior, middle and posterior cerebral arteries that form in brain
14
Q
L Hemispheric Damage (R sided deficits)
A
- Difficulties in communication
- Difficulties in processing info in sequence and linear
- Cautious, anxious, disorganized, more hesitant behaviors
- Needs lot of support from PTA/PT
15
Q
R Hemispheric Damage (L sided deficits)
A
- Difficulty with spatial-perceptual tasks
- Difficulty understanding the whole idea of task/activity
- Overestimates abilities, Unaware of deficits, poor insight to problem, impulsive, impaired safety insight (affects motivation to get better)
16
Q
CT Scan Imaging (Acute)
A
- Stroke less than three days old
- Rules out other brain lesions
- Identify hemorrhagic stroke
17
Q
CT Scan Imaging (Sub-acute)
A
- Stroke 3-5 days old
- Development of cerebral edema
- Cerebral infarction
- Extent of CT lesion does not correlate with clinical signs of changes in function
18
Q
MRI Imaging (Acute)
A
- Stroke 2-6 hours
- Identify cerebral infarction
- Detail extent of infarction or hemorrhage during first 2-3 weeks
- Can also detect smaller lesions than CT scan
- Do not use if metal in body (i.e., pacemaker)
19
Q
Primary Impairments (7)
A
- Sensation
- Motor Function
- Postural control and balance
- Speech, language, swallowing
- Perception and cognition
- Emotional
- Bladder and bowel function
20
Q
Sensation Deficits
A
- Frequentlty impaired, rarely absent
- Common pattern: face, UE, LE on one side
- Deficits affect opposite side of damage, can also affect ipsilateral side to a lesser extent
- Leads to impaired spontaneous movement
- Affects proprioception, light touch, pain, temperature, neglect, graphesthesia
21
Q
Sensation: Thalamic Pain
A
- Central Post-Stroke Pain (CPSP) affects 70% of patients
- Constant burning pain
- Intermittent sharp pains
- Exaggerated pain response to stimuli
- Intolerable
- Delayed onset of pain (weeks to months)
- Spontaneous recovery is rare
22
Q
“Shoulder Syndrome”
A
- Thalamic pain
- RSD (Reflex Symathetic Dystrophy)
- Shoulder-hand syndrome
- Arm is on fire (4 stages - first two are reversible, last two are not)
- Treat with joint mobility, ROM
23
Q
Homonymous Hemianopsia
A
- Loss of vision in the contralateral half of visual field (nasal of one eye, lateral field of other eye)
- R sided damage will affect L visual field
- Incorporate mirror, PNF to cross midline
24
Q
Visual Neglect
A
- Visually unaware of the left side of the world (left side does not react to stimulus)
- Head often turned away from hemi-side
- Problems with awareness of body parts, awareness of environment, depth perception, spatial relationships
- Treat by covering good eye, force pt to see with left side; force patient to use left side (mirror therapy, set objectives so patient has to literally turn to left to recognize that there is a world on that side)
25
Diplopia
- Double vision
- Both eyes are working, but not together
- Treat using patch, enables pt to see world as it should be
- Refer to OT to see how often to change patch position
26
Alterations in tone (Flaccidity)
- Hypotonia
- Acutely, altered by cerebral shock, followed by increase in tone)
- Temporary, but can persist for few days to few weeks
27
Alterations in Tone (Spasticity)
- Hypertonia
- Predominate in gravity-dependent muscles
- Occurs in 90% of patients
- Occurs on side of body opposite lesion
- Graded by Modified Ashworth Scale (MAS)
- Sx includes scissoring gait
28
Synergy Patterns
- Inability to perform isolated patterns
| - Unable to perform isolated movements without producing movements in the remainder of limb (movements are grouped)
29
Stages of Motor Recovery (6)
- Stg 1: Flaccidity
- Stg 2: Early synergy, min to no voluntary movement
- Stg 3: Voluntary movement in strong synergy pattern
- Stg 4: Synergy declines; voluntary movement out of synergy pattern
- Stg 5: Movement independent of voluntary synergy movement, some residual spasticity
- Stg 6: Isolated volitional movements, near normal movement patterns, no spasticity
- (Stg 7: Normal motor function restored)
30
Altered Coordination (Motor deficits) (5)
- Ataxia
- Motor Weakness
- Timing and sequencing
- Bradykinesia (slow movement caused by basal ganglia)
- Involuntary movements: choreoathetosis, hemiballism
31
Ataxia
- Uncoordinated movement appears when voluntary movement is attempted
- Lack of proprioception, trying to walk across floor
32
Choreoathetosis
- Rapid worm-like movements
33
Hemiballism
- Jerking movements on one side of the body
34
Motor Praxis
- Ability to plan and execute coordinated movement
35
Apraxia
- Impairment of voluntary learned movement
| - Characterized by inability to perform purposeful movement
36
Ideational Apraxia
- Inability to produce movements either on command or automatically
- Complete breakdown in conceptualization of task
37
Ideomotor Apraxia
- Inability to perform task on command and to imitate gestures, even though patient understands concept of task
- Able to carry out habitual tasks automatically
38
Reactive postural control
- Postural control based on reaction to an external force
39
Anticipatory postural control
- Self-initiated postural control
40
Factors causing postural control deficits (2)
- Timing and sequencing of muscle activity (postural sway, uneven weight distribution)
- Abnormal co-contraction
41
Postural control compensations (2)
- Balance issues
- Excessive hip movements
- Excessive knee movements
42
Pusher Syndrome
- High fall risk
- Ipsilateral/contraversive pushing: Active pushing with stronger extremities toward hemiparetic side --> fall towards hemiparetic side
- Patient may have aphasia
- Deficit in processing somesthetic info (sensory perception of body sensation (light touch, pain, etc.)
- Can last up to six months and disappear
- Interventions: Sit to stand with mirror/tape to show midline, reaching exercise across midline, relying more on stronger leg to balance
43
Pusher Syndrome (Functional Complications)
- No fear or sense of "pushing" from patient
- Pt strongly resists attempts to passively correct
- Results in instability (scissoring), asymmetry, deficits in transfers, standing
44
Aphasia
- Communication disorder
- Impairment in formulating, comprehending and/or use of speech
- 30% of patients affected
45
Receptive Aphasia
- Wernicke's aphasia (fluent aphasia)
| - Can talk, but does not understand
46
Expressive Aphasia
- Broca's aphasia (non-fluent aphasia
| - Difficulty talking, but understands
47
Global Aphasia
- Receptive + Expressive Aphasia
48
Dysarthria
- Motor disorder
- "Slurred Speech"
- Deficits in speech articulation (speech errors, timing, vocal quality, pitch, volume, breath frequency)
- May be accompanied by aphasia
49
Dysphagia
- Swallowing disorder
- Affects 50% of patient - delayed triggering
- Cause: Muscle weakness or paralysis
- Cause: Cerebral damage
- Cause: CN IX & X (glossopharyngeal and vagus nerves)
50
Dysphagia (Ways to eat)
- NGT
- PEG: Percutaneous endoscopic gastronomy (prevents aspiration, penetration of food/liquid into airway, acute respiratory distress)
- (NPO - not by mouth)
51
Modified Barium Swallowing Test (MBS)
- Barium Dye
| - X-ray exposure used to track swallowing
52
Fiberoptic Esophogeal Evaluation of Swallowing (FEES)
- Fiberoptic inserted through nose
| - Patient swallow; can see through camera
53
Body Schema
- Relation of body parts to each other and environment
| - Deficit can affect feelings regarding body parts
54
Somatoagnosia
- Awareness of body parts
| - Includes unilateral neglect, R/L discrimination, Agnosia, Anosognosia, Spatial relationships
55
Unilateral Neglect
- Neglect of half of the body
- Can be a complete or visual cut
- No reaction to visual/auditory stimulus on affected side (most common side is left side)
- Intervention: PNF (chopping movement)
56
Right/Left Discrimination
- Inability to identify the right and left sides of one's own body or that of the examiner
- Inability to execute movements in response to verbal commands of "right" and "left", or imitate movements
57
Agnosia
- Inability to recognize familiar objects
| - Object (visual), Auditory (nonspeech sounds), Tactile (by touch), Finger (cannot recognize fingers)
58
Anosognosia
- Lack of awareness or insight
- Perceptual impairment including denial, neglect, lack of awareness of the presence or severity of one's own paralysis
- You can teach them, but they still don't think they need treatment
59
Spatial Relations
- Usually R sided brain lesions, weakness in L side
- Visual-spatial: Inaccurate depth perception
- Spatial relationship between body and object
- Safety is challenge because they cannot discern space relationship between body and object
60
Delirium
- Clouding of consciousness: Acute state of confusion, dulling of cognitive processing, impaired alertness
- Characteristics: Inattention, incoherent, Fluctuating LOC, sometimes hallucinations or agitation
- Metabolic imbalance for stroke patients
- Test with orientation test
61
Attention
- Ability to select and attend while suppressing extraneous stimuli
- Sustained attention, selective attention, dividing attention (dual task), alternating attention
- Isolate patient if deficits in attention
62
Memory
- Storage of experiences and perceptions for recall
- Immediate memory, short-term memory, long-term memory
- Affect on PT intervention: Carry-over
- No carry-over with STM
63
Confabulation
- Pt fills in missing info with embellishment
- Info missing because of lack of memory, lack of knowledge
- Not attempt to be deceptive; patient believes what they are saying
- Lesion in prefrontal cortex
64
Perservation
- Patient is "stuck"
- Continued repetition of words, thoughts, actions
- Usually unrelated to current context
65
Executive Function
- Complex, inter-related processing to produce action (normal)
- Ability to engage in purposeful behaviors: volition, planning, purposeful action, effective performance
- Deficits include decision making
66
Executive Function Impairments
- Impulsiveness
- Inflexible thinking
- Lack of abstract thinking
- Impaired organization and sequencing of actions or thoughts
- Impaired insight
- Impaired planning ability
- Impaired judgement
67
Affect
- Emotion or outward expression of emotion
| - Labile, Apathy, Euphoria, etc.
68
Labile
- PBA (Pseudobulbar Affect)
- Uncontrolled or exaggerated emotion
- Can move from one extreme to another (ex: laughing to crying) with quick change
- Inconsistent with mood or circumstance
- Pt unable to control emotional fluctuations
69
Apathy
- Dulled/blunted response (Shallow affect)
| - Misinterpreted as depression or lack of motivation
70
Euphoria
- Exaggerated feeling of well-being or happiness
71
Depression
- Affects 35% of patients
- Refer to psychologist/neuropsychologist for treatment
- Pt will not want to participate; ask about hobbies, etc. to engage
72
Other emotional deficits
- Exaggerated irritability
- Exaggerated frustration
- Social inappropriateness
73
Bowel and bladder deficits
- Disturbances, especially acutely
- Deficits generally improve quickly
- Toileting schedule: Retrain body to run on schedule; work with nursing to develop
74
Musculoskeletal Deficits - Stroke (6)
- Loss of voluntary movement
- Immobility
- Contractures
- Edema (dependent position - no mobility cannot push fluid
- Disuse atrophy and weekeness
- Osteoporosis (not WB)
75
Neurological deficits - Stroke (2)
- Seizures (more acute stages)
| - Hydrocephalus (excessive CSF in spinal cavity, shunt to drain)
76
Cardiovascular/Pulmonary - Stroke (3)
- DVT (47% of patients, can result in embolism)
- Underlying CV disease: cardiac output, cardiac decompensation, rhythm disorders
- Aspiration
77
Stroke Recovery/Prognosis
- First 4-6 weeks = fast progress )most neuroplasticity takes place)
- Slower process follows - anticipate recovery up to 2 years or more
78
Stroke Rehab Phase (Acute)
- Early mobilization
- Early stimulation and use of hemiparetic side --> functional reorganization
- Foster positive attitude, minimize depression, apathy
- Goals: resume ADLs, independent function
- Before beginning treatment: vital signs, look at MD orders, reinforce with positive attitude
79
Stroke Rehab Phase (Post-Acute)
- Inpatient rehab (17 days average); goal is home health or outpatient)
- Outpatient = higher level of recovery
- Focus on neuroplasticity and neurorecovery vs. compensation
- Team approach to treatment
- Team includes patient, family, caregiver, MD, MD assistant, nurse, PT, PTA, OT, ST, CM/SW, neuropsychologist, psychologist, dietician, RT, vocational rehab/therapist
- Inpatient Rehab (SNF) = 1.5-2.5 hrs/day
- Inpatient Rehab (Hosp) = 3 hrs/day
80
Stroke Rehab Phase (Chronic)
- Outpatient
- Greater than 6 months after CVA
- Goals: HEP, community activities
81
Stroke Outcome Measures
- Fugl-Myer Assessment of Physical Performance (FMA)
- National Institute of Health Stroke Scale (NIHSS)
- Stroke Rehab Assessment of Movements (STREAM)
- Motor Assessment Scale (MAS)
- Chedoke-McMaster
- Stroke Input Scale (SIS)
- FIM
- Upright Motor Control Test
82
Focus of PT Interventions (12)
- Sensory function
- Motor function
- Flexibility/joint integrity
- Strength
- Management of hypotonia
- Management of spasticity
- Initial movement control
- Motor learning
- Postural control and functional mobility
- Pusher syndrome
- UE function
83
Strategy: Improve sensory function
- Direct pt attention to stimulation and task
- Eyes open, then eyes closed; encouragement/feedback; visual, tactile, proprioceptive stimuli on involved side (limit amount of input)
- Stroking, brushing, icing, vibration involved side
- Stroking hand with different textures
- Press object into hand or draw shape/letter
- Approximation through extended UE during WB
- Approximation through LE in standing (WB)
- Inflatable air splints
- Safety education
- Unilateral neglect: Active visual tracking/scanning with head and trunk rotation to involved side (red line on floor or mirror), imagery, direct pt attention to neglected/hemi side
84
Strategy: Improve motor function
- Flexibility/joint integrity (prevent contractures)
- Strength
- Spasticity management
- Initial movement control
- Motor learning
- Postural control and functional mobility
- UE function
- LE function
- Balance
- Ataxia
85
Strategy: Improve Flexibility/joint integrity
- Soft tissue mobilization
- Joint mobilization - grades 1 & 2
- ROM - Terminal stretch, self-ROM (start with AAROM to preserve ROM/flexibility)
- Arm cradling
- Table-top polishing
- Sitting and reaching toward floor
- Supine, hand clasp together (chopping)
- Mirror therapy
- Positioning: Strategies, US on lap tray or arm trough, splinting of hand
- WS in sitting or standing onto feet in PF
86
Strategy: Improve Strength
- Graded exercise training (Specificity of training - functional, task-specific, combine resistance trg with functional activities)
- Concentric/Eccentric (Ecc = less CV stress)
- Powder board (gravity-minimized), skate, sling suspension, free weights
- Aquatic PT
- Contraindication: Valsalva
87
Strategy: Manage Hypotonia
- Facilitation techniques
- Approximation
- WB
- Support (slings, orthotics, w/c: arm troughs, laptrays, leg rests)
88
Strategy: Manage Spasticity
- Early mobilization (elongation of spastic muscle, prolonged stretch, sustained stretch through positioning)
- Rhythmic rotation (on elongated limb, combined with axial trunk rotation - side-lying, sitting, hooklying - to reduce trunk tone: chopping limb followed by trunk)
- WB (slow rocking over elongated limb - UE, quadruped, kneeling)
- PNF upper trunk patterns (chopping or lifting)
89
Strategy: Improve initial movement control
- Focus: Dissociation of body segments(able to move body areas separately); selective movement patterns; functional activities (reaching, walking, stairs); activate muscles with variety of activities with varied contractions; practice eccentric (ex: wall squats) before concentric
- Guided --> assist --> active --> resisted --independent
- Assisted/guided movements progress to active control
- Manual (tracking) resistance
- Proprioceptive loading (WB)
- Tapping
- Practice: Sit --> Stand, Stabilizing in stance, Stand --> Sit
90
Strategy: Improve motor learning
- Pt fully engaged, meaningful activity (important to pt)
| - 3 aspects: Strategy development, feedback, practice
91
Strategy: Development for motor learning
- PTA demonstrates task
- PTA assists pt in learning desired task
- Pt begins to practice - if multiple components, practice parts, then whole task
92
Strategy: Feedback for motor learning
- Intrinsic (internal) and extrinsic (external - PTA verbal, manual cues; environmental) feedback
- Visual input: Mirror
- Proprioceptive input: manual contacts, tapping, tracking resistance, antigravity postures, vibration
93
Strategy: Practice for motor learning
- Practice, practice, more practice
- Essential for motor skill learning and recovery
- Stroke patient: Closed environment (if distracted) --> open environment
- Motivation: Ask patient, show patient how to progress
- "Easy street" internal mini-town to acclimate patient to open environment
- Blocked practice: One single task, constant repetition, a "building"
- Random practice: Few tasks in one session in no specific order; depends on patient, work easiest to hardest
94
Strategy: Improve postural control/functional mobility
- Focus on trunk symmetry, using both sides of body, progressing from guided movements to active movements
- Posterior alignment, move COM away from BOS, Impatient for strategies they face in everyday life
95
Strategy: PC/FM (Rolling)
- Roll to both sides (roll to strong side is more difficult)
- Attention to hemi side not left behind (hand clasp - prayer position)
- LE push off in hooklying position
- PNF D1 Flexion of LE to facilitate movement
- Rolling, esp with hooklying push off, with involved LE into sidelying-on-elbow promotes early WB
96
Strategy: PC/FM (Supine Sit)
- Supine to Sit
- Sit to Supine
- Practice from R and L
- Emphasize from more involved side
97
Strategy: PC/FM (Sitting)
- Symmetrical posture
- Spine alignment
- Pelvic alignment
- Feet on floor
- Progression: Holding posture (stability); Moving in sitting (controlled mobility = dynamic stability); Dynamic challenges (reaching)
- INT: Dissociate
- INT: Therapy Ball
- INT: Can use lateral WS: Hard flat surface --> Airex --> Physioball
98
Strategy: PC/FM (Bridging)
- Develop trunk
- Hip extensors
- LE out-of-synergy control
- Simulates early WB through foot
- FA: Bedpan
- FA: Pressure relief
- FA: Initiate bed mobility (scooting)
- FA: Sit stand transfers
- FA: Simulates early WB
99
Strategy: PC/FM (Sit Stand)
- Tech: Symmetrical WB
- Tech: Active trunk flexion --> use momentum to shift body forward
- Tech: Feed positioned posteriorly, in DF --> assist with forward momentum
- Tech: Pt's eyes on visual target (head up)
100
Strategy: PC/FM (Standing, modified plantargrade)
- Early standing posture
- Increase postural control
- Improve extremity control
101
Strategy: PC/FM (Standing)
- Progression: BUE support --> light fingertip support --> 1 UE support --> No UE Support
- Pt may still lean, can lean on PTA
102
Strategy: PC/FM (Transfers)
- Bed chair
- Practice toward STRONGER side (As control, practice toward weaker side)
- INT: Change seat height to increase/decrease challenge
- INT: Practice transfer to both sides
- INT: UE placed by side or in prayer position (to protect involved UE)
- INT: Assist with manual assistance or manual cues
103
Strategy: PC/FM (Other positions)
- Prone on elbows
- Table top WB
- Quadruped
- Side-sitting
- Kneeling
- Half-kneeling
- Floor Chair or stand
104
Strategy: Pusher Syndrome
- Pt pushes with stronger extremities toward weaker/involved side --> stronger WS to weaker side
- PTA attempts to correct --> stronger pushing
- Intervention focus: Vertical position (postural orientation) - verbal/tactile cues; Active movements and WS toward stronger side; Visual cues (mirror, lines, environmental prompts - walk around table, push into wall)
- Intervention techniques: Ball; Cross weaker LE over stronger/pusher LE; Air splints - promote muscular activation; Tapping - promote muscular activation; If use cane, shorten to facilitate WS to stronger side; Environmental boundary (doorway, corner) to facilitate symmetry; Block stronger extremities from moving into postures that result in pushing; Engage pt in problem-solving
105
Strategy: UE Function (UE as postural support)
- Promote proximal stability: WB on extended UE with hand stabilized (counteracts flexor synergy)
- UE WB activities: sitting, modified plantargrade, standing
- Intervention progression: static holding --> dynamic stabilization
106
Strategy: UE Function (Reaching)
- Requires scapular upward rotation and protraction (might have to mobilize), elbow extension, wrist/finger extension, accurate visual-perceptual processing
- Intervention progression (Sidelying): UE forward reaches and holds --> eccentric --> reciprocal movement
- Intervention progression (Sitting): Supported reaching with hand on table top --> slide hand along table top --> reaching against gravity (PNF)
- Standing
- Vary height of reach, distance
107
Strategy: UE Function (Manipulation/Dexterity)
- Meaningful, task-oriented
- Grasp and manipulation
- Voluntary release
- Facilitate extension: stretching, positioning, inhibitory techniques if spastic
- Use uninvolved hand to stabilize or assist (hold paper while writing with other hand)
108
Strategy: UE Function (Enhanced Training)
- CIMT (Constraint Induced Movement Therapy): constrain strong side, force pt to use weak side; 6 hrs/dayfor 10-15 consecutive days; compliance is issue
- EMG Biofeedback: increase use of motor limits in hyperactive motion
- NMES: reduce shoulder subluxation; combine with functional activity
- Robotic assisted technology: Exoskeleton; targeted for med-to-severe deficits
109
Strategy: UE Function (Manage Shoulder Pain)
- CRPS (complex regional pain syndrome), RSD, Shoulder-hand syndrome
- Sharp stabbing pain, more often with movement than at rest
- Intermittent (early stage) or constant (later stages; progresses to debilitating
- Interventions: Positioning/handling, NMES, Supportive devices, normalize tone, mobilization for pain, cryotherapy, relaxation, EMG biofeedback, PROM
110
Strategy: UE Function (Supportive Devices)
- Especially for hypotonia
- Especially for early transfers/GT
- W/C position: arm board, lap tray, UE support
- Slings
- Humeral cuff sling, figure-eight harness
- Other alternatives: taping, NMES
111
Strategy: LE Function
- Reduce synergy pattern: PNF LE D1, lateral side-step
- Stress hip ADD with hip/knee flexion activities: PNF LE D1, standing, step-ups
- Hip ext, knee flex: Bridging, Supine hip ext with knee flex over side of mat, push dowm through heel, standing post hell raises
- Rotation: stting, sideling, modified plantargrade, hooklying, kneeling, half-kneeling
- Therapy ball
- Reciprocal action: Smooth reversals, flex/ext movements
- Increase challenges
112
Strategy: LE Function (Balance Training)
- COM over BOS
| - Limits of stability (LOS)
113
Strategy: Manage Ataxia
- Frenkel's exercises: Instruct with slow, even voice, activity multiple times, slow and precise; visual track to guide correct movement; regain movement control through cognitive compensation
- Weighting ataxic limb or trunk
- Ataxia increases with stress, anxiety, excitement
