10/21 CVA Intervention Flashcards by Zach Overgaard

Recovery after stroke - Initial Phase

Decreased cerebral edema
Absorption of damaged tissue
Improved blood flow
Reperfusion of the ischemic penumbra

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Recovery after stroke - Reparative Phase

Regeneration via collateral sprouting
Reorganization of neuropathways
Regression of peri-lesional inhibition
Intracortical disinhibition of the contralateral motor cortex

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Keys to stroke rehab

Early mobilization

Prevention of learned non-use

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Recovery from stroke - Main points

Reperfusion of ischema
Axonal sprouting
Reorganization of motor cortex
Alterations in behavior
Prevention of learned non-use
Promote plasticity

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Stroke Recovery Timeline

Neurologic recovery generally takes place within 3 months

Further recovery may take place 6 months to one year later, but some motor function must be preserved in order for this to happen

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UE vs LE Recovery After Stroke

UE recovery vs LE recovery after stroke may differ
LE can achieve function with less motor control than UE due to task requirements
Partial recovery in LE can appear to be more recovery

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Stages of Stroke Recovery

Acute
< 1 month or < 8 weeks

Subacute
1-6 months

Chronic > 6 months

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Stroke Prognosis - Sitting Balance

Sitting balance 2 weeks after stroke is predictive of walking ability after 6 months.

Initial sitting balance most correlated standing, walking, stair climbing at 6 months post-stroke

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Stroke Prognosis - Gait Speed & Endurance

Normative velocity values for independent community ambulation:
Distance - 332 meters (approximate 6MWT)
Velocity -1.2m/s = 2.68 mph

Household ambulation (0.4 m/s), limited
Limited community ambulation (0.4 to 0.8 m/s)
Full community ambulation (0.8 m/s)

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Stroke Prognosis - Fugl-Meyer

Fugl Meyer scores:
>80    mild
56-79 moderate
36-55 moderately severe
0-35   severe

Fugl-Meyer scores at 5 days post CVA were
predictive of 6 month motor performance

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Stroke Prognosis - Barthel Index

Mild or moderate motor deficits 5 days and 30 days - 100% were independent in ADL after 6 months

Severe deficit 30 days - 56% were independent in ADLs after 6 months

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Stroke Prognosis - Orpington Prognostic Scale (OPS)

OPS at 2 weeks predictive of d/c if over 75 y.o.

5.2 req. LTC

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Stroke Prognosis - Positive Indicators

Initial return of movement within the first 2 weeks
Active participation by patient
Specificity of and functional task oriented training
Acuity of stroke

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Stroke Prognosis - Negative Indicators

Coma at outset
Poor cognition
Severe aphasia
No motor return within one month
Visual-perceptual-spatial disorders
Inability to sit unsupported
Incontinence 2 weeks s/p CVA
Depression

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Stroke Treatment - Prevention

Falls
Injury
Fracture
Contracture
Joint subluxation
Skin breakdown
Learned non-use
Pneumonia
Deconditioning

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Stroke Treatment - Remediation

Muscle Activation
Force production
Balance 
Sensation
Functional mobility training

Muscle Activation Tactics

Type of contraction
Position for task
Facilitation techniques
Constraint-Induced Movement Therapy (CIMT)
Neuromuscular electrical stimulation (NMES)

Force Production Tactics

Repetitious exercises
Activities in kneeling and standing
Quick Stretch
Tapping
Weight bearing

Sensation Tactics

Visual cues
mirror feedback
Proprioceptive input
Brushing

Stroke Treatment - Compensation

Muscle Activation
Force Production
Balance
Functional Mobility

Symmetry Training

Task specific reaching does not improve seated weight distribution or standing symmetry post-stroke.

Training awareness of body position can improve symmetry in sitting in the early phase of stroke rehabilitation for the short and long term.

Aerobic Activity Recommendations, post-stroke

50-80% maximal heart rate
RPE 11-14 (6-20 scale)
3-7 days per week
20-60 minutes per session

Strength Training Recommendations, post-stroke

1-3 sets of 10-15 reps
8-10 exercises of major muscle groups
2-3 days per week

Body weight Supported Treadmill Training (BWSTT) Rationale

Intensive task-specific locomotor training
Repeated segmental sensory inputs
May facilitate cortical and subcortical reorganization
Allows an individual to integrate weight bearing, stepping and balance
Minimizes the delay that gait training can be initiated for individuals who are not able to support their full weight

Body weight Supported Treadmill Training (BWSTT) Limitations

Equipment needed Often requires 2 people to assist Differences between treadmill walking and over ground walking

BWSTT - Subacute Phase

Low initial ambulatory status - better than over ground Higher initial ambulatory status - not as good as over ground

Strength Training post-stroke, by level of function

Lower functioning patients: Task-Related Training Use more compensatory trunk motion to achieve improved reaching Higher functioning patients: Progressive Resistance Exercise More isolated control for reaching in the involved UE

Constraint Induced Movement Therapy (CIMT) – Subacute Phase

14 consecutive days of physical restraint on the less affected upper extremity Restraint is worn for 90% of waking hours 6 hours per day, 5 days per week of intensive training

Constraint Induced Movement Therapy (CIMT) Prerequisites

Higher functioning participants have at least: 20 degrees of wrist extension 10 degrees of active ext of each MP and IP joints of all digits Lower functioning participants have at least: 10 degrees of active wrist extension 10 degrees thumb ABDuction 10 of ext in at least 2 additional digits These movements repeated 3 times in one minut

Modified Constraint Induced Movement Therapy (CIMT)

1 hour of skilled PT/OT per day 3 days per week 10 weeks Less affected UE restrained 5 days per week for 5 hours

Functional Electrical Stimulation (FES)

Longer term use Used during functional activities Evidence for shoulder subluxation (prevention and compensation) Dorsiflexion assist during swing phase of gait (compensation) Increase motor unit recruitment Increase rate of motor unit firing

Electric Scooter Advantages

May dissemble or chair folds down May fit into trunk of car Beneficial for long distances in community access

Electric Scooter Disdvantages

“Captain’s Chair” Offers little postural support Large turning radius Difficult transfers

Functional Electrical Stimulation (FES) Evidence

Limited evidence may have some benefit when used in conjunction with traditional physical therapy (Faghri 1994, Faghri and Rodgers 1997, Chantraine 1999) Moderate evidence that does not prevent loss of shoulder function (Linn 1999) “FES in addition to standard therapy or no therapy is not more effective than conventional therapy or no therapy alone for improving functional independence in patients with acute stroke.” “EMG-triggered FES in combination with conventional therapy is more effective than conventional therapy alone for improving functional independence in patients with sub-acute stroke.” “FES in addition to bilateral motor training or conventional therapy is more effective than bilateral training or conventional therapy alone for improving strength in patients with chronic stroke.” Not for improving for LE treatment in acute, subacute or chronic stages