Lecture 4 Flashcards by Alexander Lee

What percent of patients will walk post-stroke?

80%

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98% of patients walked at 6 months with a (Functional Ambulatory Category Of 4+) IF….

Independent _______

LE strength of at-least ___ in _______

Independent sitting balance

LE strength of 1/5 in hip flexors, knee extensors, and ankle dorsiflexors in first THREE days

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If the patient does not meet the criteria of:

Independent sitting balance
LE strength of atleast 1/5 in hip flexors, knee extensors, and ankle dorsiflexors in 3 days

What percent walked after 3 days with the criteria unmet?

What percent walked after 9 days of the criteria unmet?

27%

10%

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Upon admission to inpatient rehab

If BERG balance scale is under 20 and the FIM-L is 1-2 (total or max assist)

This accurately predicted who will be __________ by __%

Accurately predicted who will be home bound 92% of the time (unable to leave home)

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What are the main predictors of UE recovery in stroke?

AROM of shoulder and middle finger predicted the variance in UE function at 3 months

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What did the AVERT study test?

(A very early rehabilitation trial)

The experiment group received 1st PT mobilization by first 24 hours

Sitting or standing, whatever they could tolerate

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What did the AVERT study find?

No sig diff in death, adverse events, or falls

Sig diff in: Time in PT, Time to first mobilization, cost of care at 3 months, functional improvements

Overall the study showed early mobilization leads to better functional outcomes

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What did the Winstein, Gardner, and McNeal Standing balance and gait study test?

One experimental group of patients received normal therapy and extra therapy on ONLY standing balance

Control group received only regular therapy

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What were the conclusions of the Standing Balance and gait study

That there is no difference in outcome in patients who received extra standing balance training when it comes to walking

Standing balance does not improve gait training

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Chronic stroke gait speed for unlimited household ambulation?

0.27m/s

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Chronic stroke LIMITED community ambulation gait speed?

0.58m/s

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Unlimited community ambulation speed in stroke survivors?

0.8m/s

Note: normal community ambulation in adults is 1.2m/s

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How fast must you walk to cross a commercial street?

2m/s

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What study categorized functional walking with chronic stroke patients according to gait speed

Perry at al.

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How was gait proven as the 6th vital sign?

Studies compared survival using the combinations of

age, sex, gaitspeed
Age, sex, asssitive device,
Age, sex chronic conditions, smoking, BMI, Hospitalization

And found that gait can predict survival as effectively as the other predictors

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How does supported treadmill ambulation help patients

Reduces gravity, postural instability, and protects against inadequate balance reactions

Helps motor learning w/ repetition that’s less asymmetrical than over ground

Allows PT to challenge patient in ways they can’t when they’re busy supporting the patient

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Are these essential, important, or accessory for walking:

Muscle and peripheral nerves

Spinal cord pattern generators

Essential

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Are these essential, important, or accessory for walking:

Ventrolateral and ventromedial spinal cord pathways

Medullary reticular formation

Essential

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Are these essential, important, or accessory for walking:

Mesencephalic locomotor region

Subthalamic locomotor region

Essential

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Are these essential, important, or accessory for walking:

Sensation, DCML

pontomedullary locomotor strip

Important

Are these essential, important, or accessory for walking:

Cerebellum, red nucleus, substantia Nigra, limbic cortex

Important

Are these essential, important, or accessory for walking:

Motor cerebral cortex

Pyramid tract

Accessory

Why is the medial medullary reticular formation essential for walking

Final integrative center for locomotion before the spinal cord

Driving center for locomotion in all animals

Provides drive to CPG in spinal cord

Interlink coordination that provides feedback to detect symmetry and asymmetry

How can PTs modify gait training to influence the medial medullary reticular formation more

Increasing the speed

Faster = more feedback provided to cerebellum via stretch sensitive muscle receptors

Why is the mesencephalic locomotor region essential for gait

Area may modulate **speed** of walking May be involved in exploratory locomotion

Why is the subthalamic locomotor region essential to gait

Responsible for **spontaneous goal directed** gait

What do the “important” gait structures in the brain do?

Interact with regions that are essential to determine: * Timing of swing/stance * Detection of sensory gains during walking * Coordination * Motivation to walk

What part of the brain controls “motivation to walk”

Hippocampus

What might the cerebral cortex do to help with gait that makes it an accessory structure

May influence timing, initiation, transition of swing/ stance, and positioning of foot Cortex may also interfere with walking if attention is required for another task

What are the three key inputs to central pattern generators If these do not happen, walking does not happen!

Stretch of hip flexors Unweighting of triceps surae (hamstrings) Weight bearing to facilitate extensor tone in stance limb (muscle receptors in hamstring, pressure receptors in foot, and joint receptors)

What input resets the central pattern generator

Stretch of hip flexors

What input gives the leg permission to take a step in the CPG

unweighting of triceps surae

What phases of gait does hip extension occur in to trigger the swing phase via activation of the muscle spindles What spinal cord segments are important for this?

Mid stance to heel off (AKA the key phase of gait) L2 L3 L4

When walking, the COM is outside of the BOS what percent of the time?

80%

How can a patient progress on a lokomat

Increase speed, time Decrease BW support, decrease guidance forces Can adjust R and L sides independently

What is the max speed on the lokomat?

2mph Manually assisted gait training can achieve higher speeds

Why is it important for the patient to wear as little as possible on the foot during gait training (no big heeled shoes)

So the patient gets tactile feedback from their feet about their gait mechanics

How fast should a patient move on a treadmill How symmetrical should their limb movement be

As fast as possible As symmetric as possible

How can learned nonuse of a limb occur

Overuse of other UE, compensation May start with decreased sensation and motor abilities post stroke (initially )

How can CIMT help learned nonuse

Use dependent or treatment-induced cortical **reorganization** can occur with **appropriate aggressive** treatment

Cortical reorganization that helps learned nonuse comes from _______ practice and requires high ______

**Massed** practice - several hours every day Requires high **motivational drive and concentration**

How does CIMT work?

Learned nonuse masked the recovery of limb V Increase patient motivation V Affected UE is used V Provide reinforcement V Further practice <-> user dependent cortical reorganization V Learned nonuse is reversed and UE is used in life situations permanently

What are the absolute requirements of **candidates** for CIMT treatment

Extent wrist 10-20 degrees Extend atleast 2 fingers Ability to understand and follow directions

What are the components of the CIMT protocol

Repetitive task training Adherence enhancing behavioral strategies Constrained use of less affected UE

How does CIMT achieve constrained use of less involved UE

mitt restraint with a sensor to document wearing time

What did Grotta JC et al test in their study on UE function post CVA

Intervention group has **constraint** of less affected UE and unilateral UE training control group received bilateral therapy Found that **forced use** works to improve motor function

What did the EXCITE trial test?

CIMT in stroke survivors Significant improvement seen in Wolf motor function test Motor activity log Stroke impact scale

What are drawbacks to robotic assisted locomotor training in adults

Time lost due to set up Deconditioning

What did Lang C find with research into dosing and timing for plasticity and participation

Pt randomized into 100, 200, 300, or individualized max rep groups for UE task All groups besides 200 reps saw significant improvement **Proved more is not always better** 90% of patients saw meaningful change Did not change use of UE at home