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Neuro Eval II > Hemiparetic UE > Flashcards

Hemiparetic UE Flashcards

1
Q

Normal Upper extremity movement and control

A
  • Trunk Postural Stability
  • Shoulder stability and mobility
  • Elbow stability and mobility
  • Wrist stability and mobility
  • Grasp and Prehension patterns
  • Thumb and Finger manipulation
  • Bilateral UE movements
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2
Q

Gross grasp

A

object is in contact with palm and palmar surface of digits

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3
Q

palmar prehension

A

tripod grasp
thumb poses one or more fingers

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4
Q

lateral prehension

A

thumb opposes radial side of index and middle finger (key grip)

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5
Q

Key components of upper extremity control

A
  1. Locating an item/target- coordinated movement of the eyes, head, and trunk
  2. Reaching for an item/target- includes transportation of the arm and hand in space as well as maintaining postural control during task
  3. Grasp- Includes grip formation, grasp, and release
  4. In hand manipulation
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6
Q

prior to unilateral arm raise, what do you see?

A

increased muscle activity in the hamstrings, gastrocnemius, and erector spine muscles are evident
to counteract the destabilizing effects of the arm raise

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7
Q

Assessments for UE clinical deficits

A
  1. spasticity: modified ashworth scale (elbow and knee!)
  2. fractionation: Fugl- Meyer Scale
  3. upper extremity function: action research arm test and Chedocke McMaster Impairment Scale
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8
Q

Action Research Arm Test

A
  • Assesses UE function and dexterity
  • 19 items designed to assess four areas of function- grasp, grip, pinch, and gross movement
  • Each item scored 0 (no movement) to 3 (normal
    performance)
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9
Q

Prognosis of UE recovery

A
  • proximal shoulder and elbow control on admission is good
  • finger AROM is key component
  • Finger ext AROM within 72 hrs regain full recovery at 6 mo
  • 98% that some degree of dexterity is achieved at 6 mo for CVA survivors who have finger ext and shoulder abduction on day 2
  • greater the non-motor impairments that accompany the motor deficits, the less likely they will be independent
  • earlier improvements in motor function increase likelihood of reaching
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10
Q

What level should a hemiplegic UE be before full rehabilitation efforts designed to restore function in the arm are attempted?

A

Stage 4

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11
Q

Will you be successful with attempts trying to rehabilitate an upper extremity of a person with a score less than level 4?

A

nope
a more palliative compensatory approach is recommended

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12
Q

CMS Stage 1

A
  • Flaccid paralysis is present
  • Phasic stretch reflexes are absent or hypoactive
  • Active movement cannot be elicited reflexively with a facilitatory stimulus or volitionally
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13
Q

CMS Stage 2

A
  • Spasticity is present and is felt as a resistance to passive movement
  • No voluntary movement is present but a facilitatory stimulus will elicit the limb synergies reflexively
  • These limb synergies consist of stereotypical flexor and extensor movements
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14
Q

CMS Stage 3

A
  • Spasticity is marked
  • The synergistic movements can be elicited voluntarily but are not obligatory
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15
Q

CMS Stage 4

A
  • Spasticity decreases
  • Synergy patterns can be reversed if movement takes place in the weaker synergy first
  • Movement combining antagonistic synergies can be performed when the prime movers are the strong components of the synergy
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16
Q

CMS Stage 5

A
  • Spasticity wanes, but is evident with rapid movement and at the extremes of range
  • Synergy patterns can be revised even if the movement takes place in the strongest synergy first
  • Movements that utilize the weak components of both synergies acting as prime movers can be performed
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17
Q

CMS Stage 6

A

Coordination and patterns of movement can be near normal
- Spasticity as demonstrated as resistance to passive movement is no longer present
- Abnormal patterns of movement with faulty timing emerge when rapid or complex actions are requested

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18
Q

CMS Stage 7

A
  • Normal
  • A “normal” variety of rapid, age appropriate complex movement patterns are possible with normal timing, coordination, strength and endurance
  • There is no evidence of functional impairment compared to the normal side
  • There is “normal” sensory perceptual motor system
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19
Q

2 Focuses of rehabilitation

A
  • enhancing or facilitating recovery
  • encouraging transfer from unaffected limb
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20
Q

Enhancing or facilitating recovery

A
  • Repetitive practice
  • Strength Training
  • CIMT
  • FES
  • Robot Assisted
  • Sensory stimulation
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21
Q

Encouraging Transfer from unaffected limb

A
  • CIMT
  • Bilateral activity training
  • mirror therapy
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22
Q

What is the goal of training

A

recovery of movement components composing functional tasks and recovery of performance of the whole complex task

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23
Q

What principles is treatment based on?

A

movement practice as close to normative as progression of training was based on the recovery of volitional capability and motor task difficulty, according to the motor task difficulty hierarchy

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24
Q

Role of errors

A

patients should work around 80-90% of accuracy with reaching tasks

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25
Q

6 strategies for reducing or preventing pain in the hemiplegic UE

A
  • careful handling
  • electrical stimulation to prevent shoulder subluxation
  • splinting and sling use
  • spasticity and contracture management
  • movement with elevation (remember scapular rhythm)
  • AVOID OVERHEAD PULLEYS
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26
Q

should you distally fix a flaccid limb?

A
  • no
  • be careful with lifting machines
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27
Q

Definition of priming techniques

A

Interventions that may prepare the sensorimotor system for subsequent motor practice, thereby enhancing its effects

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28
Q

sensory stimulation for priming

A
  • These methods provide sensory input that engages the patient’s attention and orients the individual to the paretic limb
  • Passive movement has similar effects while also providing sensory feedback to the motor system
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29
Q

4 principles of sensory stimulation

A
  • treatment/augment
  • treatment/recalibrate
  • treatment/substitute
  • treatment/predictive strategies
30
Q

sensory stimulation - treatment/ augment

A

increase sensory perception by repetitive stimulation
* only rehabilitative one

31
Q

sensory stimulation - treatment/recalibrate

A

teach to equate new sensations with reality

32
Q

sensory stimulation - treatment/substitute

A

teach use of another form of sensory information

33
Q

sensory stimulation - treatment/predictive strategies

A
  • teach person to move by anticipating what must be done vs being dependent on sensory feedback during the task
  • kind of like a memorization
34
Q

how to improve sensory discrimination

A
  • Play games with eyes closed
  • Place coarse and unusual surfaces on objects
    frequently handled to help with feedback (fine sandpaper on pens, toothbrushes, eating utensils)
  • Place hand in box filled with rice, beans, and
    retrieve objects
35
Q

How to improve graphesthesia

A

replicate drawing of letters and numbers on skin of hand/digits

36
Q

how to improve localization

A

touch subject on the digit and hand and have subject put finger on spot where touched

37
Q

stereognosia

A

interpret information about object through touch

38
Q

kinesthesia

A
  • Using the index or middle finger for pointing, move the patient’s UE to a location in space and have the patient replicate the movement
39
Q

Bilateral priming

A
  • Active Passive Bilateral Priming
    prior to UE task specific training: Same activities performed by both limbs simultaneously
  • Unaffected active wrist flexion/extension drives passive ROM of affected wrist
40
Q

bilateral priming exclusion criteria

A

Complete sensory loss, Neglect, Cerebellar stroke

41
Q

action observation

A

Performance of a motor task while watching a mirror image of another individual perform the same task
* Thought to increase cortical excitability

42
Q

mirror therapy

A
  • Use visual input for priming
  • The patient observes specific movements or
    tasks performed by the therapist or by their nonparetic limb reflected in a mirror placed at the body’s midline
43
Q

evidence behind mirror therapy

A
  • Frontoparietal circuitries respond not only during one’s own movement but also during the observation of others’ movements
  • Observation may promote activation of these circuitries
44
Q

mental imagery

A
  • Used to internally generate somatosensory and visual input to the motor system.
     Some neuroimaging studies show that mental practice and imagery can activate regions in the motor system.
     Conceptualized as motor plans without execution.
     Repetitive generation of motor plans may promote
    physiological patterns of activation in motor cortical circuitries that are either directly damaged or functionally impaired
45
Q

what does aerobic exercise promote?

A

cerebral blood flow
- increase in BDNF which improves neuroplasticity

46
Q

things we know about individuals following a stroke

A
  • Reduced Speed / Amplitude due to decreased motor control
  • Decreased descending input onto motor neurons Abnormal and excessive cocontraction
     decreased presynaptic inhibition of antagonist prior to movement
     impaired reciprocal inhibition of antagonist muscles during voluntary movements.
  • Changes in visco-elastic properties of spastic muscles restrains movement
47
Q

neural factors affecting force generation

A
  • decrease in overall number of motor units available
  • decrease in fast motor units
  • decrease in motor unit firing rate
    *** overall, decreased descending input
48
Q

how to treat the neural factors affecting force generation

A
  • NMES; EMG-BF
  • Type and speed of contraction for strengthening
  • isokinetic exercise and facilitation of agonist
49
Q

biomechanical factors affecting force generation

A
  • altered length tension relationship
  • altered moment arm
  • altered force velocity relationship
50
Q

How to treat the biomechanical factors affecting force generation

A
  • optimize muscle length
  • optimize moment arm
  • practice fast movements
51
Q

neural factors causing decreased speed/amplitude

A
  • decreased presynaptic inhibition of antagonist –> treat with inhibition techniques as needed
  • impaired reciprocal inhibition –> treat with EMG-BF
52
Q

biomechanical factors causing decreased speed/amplitude

A
  • altered passive properties of spastic muscle
  • treat with slow stretch/serial casting
53
Q

abnormal synergy patterns

A

– Decreased access to dorsolateral descending systems (which innervate more distal musculature). Recall medial motor systems tend to be involved in more axial (proximal) (gross movements) control. (neural)
– abnormal sensory information. (neural)
– biomechanical advantage: moment arm; L-T
– practice/habit/learned disuse (behavioral)

54
Q

How to treat synergy

A
  • activate muscles in functional patterns
    – limb activities which are slightly more isolated than
    present capabilities
    – facilitation to desired muscle groups
    – bilateral symmetrical activities
    – position limb
    – closed chain activities
    – restrain unaffected limb (forced use)
    – Electrotherapeutic modalities: EMG-BF / NMES
55
Q

task specific training

A

o Place limb and the trunk in postures where tone in the hand and arm are decreased; practice using normal movements to manipulate objects in this position
o Place the limb and trunk in positions that positively
influence / exploit the biomechanical factors and/or
constraints on movement.
o Supine for early shoulder, elbow control
o Sidelying for early reaching
o Write / trace pictures
o Hold, deal, organize cards
o Type on a keyboard – let gravity help with fingers o Stack objects o Use affected hand as much as possible o Grasp objects of different shapes, sizes

56
Q

how constraint induced movement therapy works

A
  • Includes forced use
     Wearing a mitt on the unaffected UE during most waking hours which forces use of the hemiparetic UE
     Home activity
     2 weeks Includes one-on-one training for as much as 6 hrs/day over several weeks
57
Q

select group of patients to use CIMT with

A
  • 20 degrees of wrist extension
  • 10 degrees of finger extension
  • No sensory or cognitive deficits
58
Q

what does CIMT include

A

repetitive task and adaptive task practice

59
Q

repetitive tasks in CIMT

A

continuous efforts to execute movements that usually are repeated – eating, grooming, brushing teeth

60
Q

adaptive tasks in CIMT

A

– “shaping” / operant conditioning
– repetitions of a defined movement such as picking up blocks and moving them toward a bucket in a series of trials.
o Coaching and encouragement is done by the therapist.
o Performance records are kept as a means of motivation.
o Make the task more challenging as success occurs through – distance, direction,
load, speed

61
Q

modified CIMT

A
  • “Distributed” practice
  • Mitt is worn for several hours each day over a 10-week period.
  • Home based practice is supplemented with outpatient therapy several times / week
    – still need inclusion criteria
62
Q

3 types of task practice

A
  • performance
  • repetitive
  • adaptive
63
Q

performance practice

A

looking at ultimate end of movement for ideal performance

64
Q

repetitive practice

A

no alteration/manipulation of variables

65
Q

adaptive practice

A

Modification of task or environment to progressively challenge patient with use of encouragement and log for performance

66
Q

manipulating output variables and task parameters

A
  • speed, direction, distance moved
  • end goal
  • position of performance
  • properties of the object/surface
67
Q

severe impairment

A

o Maintain a comfortable, pain-free, mobile arm and hand
o Positioning, support at rest, careful handling.
o Self-ROM training via a qualified professional
o Avoid overhead pulley systems
o Use some external support for UE in stage 1 or 2 during transfers, mobility, and in wheelchair
o Use compensatory techniques and environmental adaptations

68
Q

when should you ditch slings?

A

when they have enough motor recruitment to shrug the shoulder up

69
Q

moderate impairment

A

Engage in repetitive and intense use of novel tasks that challenge the stroke survivor to acquire necessary motor skills to use the involved upper limb during functional tasks and activities

70
Q

minimal impairment

A

focused fine motor tasks that apply to the individuals return to life roles

Neuro Eval II (17 decks)

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