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Flashcards in CVA PT Management Deck (53)
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1

Acute Care General PT Considerations

- Early Mobility
Early intervention is key! (Once medically cleared)
Prevent learned disuse

- Prevent/minimize common secondary impairments

- Disposition planning
Skilled Nursing Facility (SNF)
Inpatient Rehabilitation Facility (IRF)
Home

2

What is the Drive to use compensatory techniques

Pressure to get patients to highest functional level
as quickly as possible in order for patient to go to
setting with lowest level of care ($$$)

3

Compensatory techniques use non-paretic limb exclusively to complete tasks:

- Eating and dressing using adaptive equipment to allow use
of only unimpaired side
- Use of walking devices that promote minimal weight
bearing on paretic LE
- Transfers with majority of weight on non-paretic LE

4

Early compensation has been shown to lead to

learned disuse
- Failure to recover the limb to its full potential

5

PT needs to find the balance between....
PTs are responsible to...

rehab for long-term benefit and speedy
return to function

to advocate for your
patient’s long-term rehab potential

6

Acute Care Goals (3)

Prevent complications
- Upright posture
- Frequent AROM/PROM.

Task-specific training
- Bed mobility
- Transfers
- Ambulation as appropriate (typically earliest is day 2)

Initiate forced use of paretic limbs

7

Inpatient Rehabilitation Admission Requirements

- Definable goals that can be achieved in a reasonable and relatively
predictable period of time
- Able to tolerate 15 hours of therapy weekly
- Requires 24 hour rehabilitative nursing care
- Of sufficient medical complexity that requires frequent evaluations from a
physician with expertise in rehabilitation medicine
- Requires at least two skilled therapy services

8

Goals of Rehab for CVA patients

Use of ROM, positioning, therex and modalities to:
• Increase function
• Increase mobility
• Limit Pain

Promote non-pathologic neuroplastic changes
• Changes in synaptic strength
• Circulating levels of neurotransmitters
• Axonal sprouting
• Formation of new synapses.

9

3 areas of the brain take over the role of damaged cells, and help form new tracts:

- Periinfarct cells
- Homologous contralateral regions of the infarcted zone
- Supplementary Motor Area

10

Constraint Induced Movement Therapy
(CIMT):
Theory

Learned non-use potentiates impairment
• Post-stroke, lack of use of the limb
makes it weaker and blocks
neurorecovery

11

Constraint Induced Movement Therapy
(CIMT):
EXCITE Trial:

• 2-week period of physical restraint
of the less involved UE

12

CIMT
Inclusion Criteria:***

- 10 degrees active wrist
extension
- 10 degrees active thumb
abduction
- 10 degrees extension of other
two digits
- Limited spasticity
- Good PROM
- Fairly good cognition
- Good mobility

13

CIMT protocol

- Mitt and sling on unimpaired
UE 90% of waking hours
- 5+ hours of therapeutic
exercise to paretic UE
- 2 wk course

14

Forced Use Therapy

- Modified CIMT
- unilateral exercises using paretic side, positioning to promote weight
bearing on paretic limb, shoe wedge in unaffected side shoe to shift weight to paretic side during gait training....

15

DVT risk with Forced Use Therapy: What to do

• Move, move, move!
• Mobilize ASAP
• Use of Blood Thinners (Heparin)
• Risk of excessive bleeding
• Compression stockings
• Intermittent pneumatic compression

16

Spasticity and Contracture Intervention

• Prevent loss of ROM
• Sustained Positioning
• ↑ WB (• Common with the UE
• 1⁄2 kneeling common with with LE to promote dissociation between flexion and extension)
• modalities (ice)
• TENS/Biofeedback

Deep Pressure
• Used to increased joint awareness and
decrease spasticity

17

Pressure Sores
• Treatment

• PREVENTION
• Diligent skin care
• Pressure relief
• 15-20 minutes in w/c
• 2 hours in bed
• Positioning
• Proper w/c cushion and back
• Pressure mapping
• No aggressive ROM
• No sliding board

18

Osteoporosis and CVA

• Notes:
• Bone depletion is rapid post CVA
• Pattern of depletion:
- Distal to proximal LE

19

Osteoporosis: Treatment

• Medication
• Weight bearing and muscle
activation activities
• Research Suggests that weight bearing
without muscle activation is
probably useless
• Treatment with increase muscle
activation appears to prevent
osteoporosis
• FES is a reasonable intervention

20

Locomotor CPG Recommendations

Clinicians MAY CONSIDER:

● Strength training at >/=70% 1 rep max
● Circuit training, cycling, or recumbent stepping at 75-85% HRmax.

- Do consider these interventions for Aerobic Capacity Intervention

21

Locomotor Training

• Split belt Treadmill Training

• Can be used to improve step length
symmetry overground

• Belt with intact LE set to self-
selected fast walking pace, belt with
impaired LE set to half that of the
intact side and then increased over
time

• Use harness and monitor vitals for safety

22

Locomotor Training: CPG Recommendations
How intense the walking training to have the most improvements in walking speed and distance?

Moderate- to high-intensity (60%-80% of heart rate reserve or up to 85% of heart rate
maximum) walking training was associated with the strongest evidence for improvements in
walking speed and distance.

23

Cognition deficits

MAP
• Memory Deficits
• Attention Deficits
• Procedural (Implicit) Learning

24

Treating Cognition in the Context of
Functional Mobility

- Dual Tasking
- Pathfinding
- Scavenger hunt
- Circuit training recall
- Patient-specific tasks (related to job, hobbies, other participation
level tasks)

25

Therapists, providers should be on alert as to stress on families and
patient and recognize signs:

• Personality change
• Cognitive loss
• Incontinence

26

The Many Forms of Neglect

Spatial neglect can occur in 3 dimensions of space

- Horizontal (R/L)
- Radial (peripersonal space/extrapersonal space)
- Vertical (up/down)
- Stimulus Centered

27

Evaluation of Neglect (4)

Sensitivity of these test is

Evaluation of Neglect

• Observation
• Line Bisection
• Drawing
• Reading/writing

Sensitivity of these test is very variable; NO GOLD STANDARD

28

Bell’s Test

• Ask pt to circle all bells in the
image

29

Ota Test
What is it and what does it test?

• Ask pt to put a circle around
all complete circles, and an X
through incomplete circles
• Image is of extrapersonal
neglect (when the person doesnt circle the circles that are away from him)
• Stimulus centered
neglect

30

Neglect vs Hemianopia

Hemianopia is not seeing from one side. Like one cannot see the left half of an image in Left Homonymous Hemianopia.

Neglect (cluttered scene) is not seeing half an image and the other half is blurry.

Neglect (uncluttered scene), image is blurry and various part s of the image is cut off

31

Most common to see L sided neglect with R sided lesions. Why?

• R hemisphere mediates attentional mechanisms directed in both
hemispheres
• L hemisphere is really only concerned with the R hemispace
• Therefore R sided neglect is less common because there’s back up
from the bilaterally supporting R hemisphere
• However, when R hemisphere is injured, L hemisphere doesn’t
support L sided perception

32

Neglect Prognosis

Recovery is variable!
• Spontaneous
neurological recovery
shows a natural logistic
curve up to 12-14
weeks post-stroke

33

Visual Scanning Therapy
What is it? What is special about it?

• Retraining patients to look toward
the contralesional side with visual
search, reading, and copying
exercises
• visual cues with red lines/anchor,
bookmarks, red lights)

• Most prevalent treatment for neglect

34

Visual Scanning Training: What is it?

- Multimodal dynamic cueing to
attend to neglected side
- Visual: red anchor
- Auditory: verbal cues from
neglected side, clapping
- Tactile: vibration, TENs
(moderate evidence supports
use as a supplement to visual
scanning training)

35

Visual Scanning Training: Activities and what they include (3)

Paper/pencil activities
- Reading, writing, copying, target tracing
- Visual Attention iPad App

Tabletop activities
- Reaching for objects, ADL activities
- Start at midline, progress to neglected side

Functional activities
- Scanning during transfers
- Can use brightly colored tape on WC parts ( put tape on wheelchair for patient to look for)

36

Visual scanning combined with ____ may be effective

trunk rotation towards neglected
side

37

Visual Scanning Training: Lighthouse strategy

- Specific scanning protocol utilizing visual imagery
- I.e. find objects by illuminating with beams

38

Prism Adaptation
What does it do?
What does it help with the patient?

• Prisms cause a shift in
subjective midline to
ipsilesional hemispace
• Helps improve ability to
copy an image.
• May cause a patient to
mis-reach for item
• With prisms off, may
help patient adapt

39

Eye Patching
What are the glasses called?
What do they promote?

• Applied to the ipsilesional eye to
promote visual attention to
neglected side visual side

• Hemifield glasses (aka Bilateral
Hemi-Occlusion)
• Half field patching of ipsilateral
visual fields

40

Limb Activation

• Movement of the contralesional side may function as motor stimulus to activate involved hemisphere to improve neglect

41

Visual scanning environment during gait

- Narrated walk/ “I spy” game
- Obstacle course
- Topographical navigation, i.e. looking for room
- Compensatory strategies
- Head turning
- Visual anchors, i.e. door - visual anchor on door frame,
numbering corners (put the numbers on the corners and ask patient to find the numbers before they walk into the door), etc

42

What does Transcranial Magnetic Stimulation (TMS) does for the brain?

• Stimulate damaged R hemisphere, inhibit the hyperactive L
hemisphere, or both
• Magnetic pulses applied to unaffected side of the brain side→ disrupts
neural activity →disrupts post-stroke ipsilesional bias
• Induce neural plasticity when applied to affected side of brain

43

Interhemispheric Communication by TMS

After stroke, reduced
inhibitory output from
lesioned hemisphere
causes increased excitation
of non-lesioned side

Inhibitory TMS
may help restore
balance

44

Transcranial Direct Current Stimulation
What does it improve immediately?

Line bisection, figure cancellation improved immediately after TDCS

45

Contraversive Pushing

Aka Pusher Syndrome
- Caused by a mismatch between perception of visual and postural
vertical
Typical presentation:
- Pushed towards involved/hemiplegic side with uninvolved/sound
side
- Impaired sense of midline orientation/subjective postural vertical
- Extends and abducts UE and LE
- May resist therapist’s attempt to correct

46

Contraversive Pushing Interventions
- Feedback about loss of balance***

- Have patient self assess and problem solve to correct balance***

47

Contraversive Pushing Interventions
- Visual feedback

- Mirror, vertical references for midline orientation
- Computer based programs

48

Contraversive Pushing Interventions
Minimize pushing behavior

- Set up of environment/positioning
- Forearm for support rather than hand when sitting at edge of
mat
- Can use wedge, stepstool, swiss ball
- Blocking foot: in a box/stool, on dycem
- WC positioning: full laptray, contoured back and cushion
- Wedge under pelvis on affected side

49

Contraversive Pushing Interventions
- Maintain midline in quiet sitting

- Can have pt place hand palm up on their thigh or place hand on
therapist’s shoulder or leg to gauge pushing

50

Contraversive Pushing Interventions
- Reaching toward unaffected side

- Requiring weight shifting toward the side they are pushing
from and correcting balance back to midline
- Progress reaching and rotating toward involved side

51

Contraversive Pushing Interventions
- Progress to maintaining midline with distractions

- Goal of progressing towards automatic postural control

52

Contraversive Pushing Interventions
- Transfers

- May start with transfers away from pushing side, then progress
to both directions
- Have patient hold object in unaffected hand or hold affected
side

53

Contraversive Pushing Interventions
- Progress to Standing

- Strand next to elevated mat with uninvolved forearm supported
or with uninvolved side next to wall
- Practice quiet midline standing
- Practice weight shift toward uninvolved side and back to
midline
- Reaching towards uninvolved side across mat