Methods of rehabing hemiparesis Flashcards
(18 cards)
What therapies for upper limb rehab are suggested in national guidelines?
FES
Repetitive task practice
Mirror therapy
CIMT
Robot-assisted movement therapy
Mental practice
What are drawbacks of repetitive task practice?
It is the common view of what is done
However
Need to be set a just right level like with sports coaching
Need hundreds of reps to be effective
Which therapies are best for if a patient does not have upper limb movement?
FES
Training in how to care for the limb (patient and carer)
- large group of individuals who never regain function in the limb
What are positives and negatives of CIMT?
Based on sound scientific principles
Evidence of the highest level to support its clinical effectiveness
Has inclusion criteria and requires commitment of patients
Service issues (NHS doesn’t have much funding)
Many therapists don’t believe in CIMT
What are draw backs of CIMT?
Expensive and other service issues
Patients don’t like it / want it
Therapists unwilling to deliver it
Richard Greenwood suggests that “CIMT seems to work very well on paper”
Ward (2008) suggests “patients were selected, not on basis of exhibiting ‘learned nonuse’ of the affected limb, the theoretical foundation of CIMT, but on the basis of clinical phenotype; all patients were able to initiate extension at wrist and fingers”
What is learned non-use?
“characterised by a motor deficit that is greater than appears to be warranted by the organic status of the individual” (Taub et al., 1994)
“an index of learned nonuse would be the difference between a measure of what a person can do in the laboratory when requested to do the best he can and a measure of what a person actually does do spontaneously” (Taub et al. 2006)
Considered major problem after stroke that mainly affects patients with R hemisphere damage and mainly affects pts with non-dominant hand limb paresis
How does learned non-use develop?
Draw diagram and check notes
Stroke -> depressed central nervous system and motor activity - >
less movement -> contraction of cortical representation -> movement becoming more effortful -> decreasing movement further
unsuccessful motor attempts ->
Punishment (pain, failure, incoordination) -> behavioural suppression and masked ability
Compensatory behaviour patterns -> positive reinforcement -> less effective behaviour being strengthened
How can learned non-use be overcome?
CIMT leads to:
-> increased motivation -> affected limb use -> positive reinforcement -> further practice and reinforcement
-> use-dependent cortical reorganisation-> further practice and reinforcement-> use-dependent cortical reoganisation -> learned nonuse reversed: limb used in life situation permanently
Which population benefit from CIMT?
Individuals who’s dominant hand affected by stroke demonstrate less impairment than those whose nondominant hand is affected (Harris and Eng, 2006) - thinking that there is greater motivation when dominant limb is affected or possible link to hemispheres.
What differences have been found in learned non-use dependent on hand preferences and hemispheres?
Arm use after left or right hemiparesis is influenced by hand preference.
Left hemisphere damage appears to create less learned non-use
Mani et al., 2014 tested:
Used air hockey like table to deweight limsb and found that contralesional arm preference depends on hemisphere damage and target location in unilateral stroke patients
Found contralesional arm performance was similar for both L and R hemisphere damage but ipsilateral arm performance was worse in left hemisphere damage compared to right hemisphere damage. Shows when R hemisphere damage there is a greater Right arm preference. However, overall there was actually no real difference between limbs
How can research be moved effectivley from bench to bedside?
Consider select patients in a theoretically / scientifically coherent way
Develop and define the intervention carefully and clearly
Should be prepared to look at subgroups
What are neural and behavioral implications of training for compensation vs restoration?
If no intervention, rely on non-paretic side leads to contralesional synaptic addition and maturation
If the non-paretic limb is trained, then these changes increase
Rehab of the paretic limb supports maintenance and re-emergence of ipsilesional motor maps (normal, compensatory or a combination of movement results)
These effects are reduced if they are preceded by training of the non-paretic limb
What is anosognosia
unawareness of impairment
How does anosognosia occur in stroke?
For hemiplegia affects those with RH damage (relates to ‘neglect’)
Typically paralysis combined with sensory loss
However, pts have false belief that there is nothing wrong with the paralysed limb
Can be subtle
What is an example of anosognosia?
Relatively spared function on left
More impaired during bilateral activity (extinction)
Impaired inhibition on the right
awareness - see vision during bilateral attempt
What process occurs / fails to occur in anosognosia?
see and write model from notes
What did Garbarini et al (2012) test and find?
Asked to draw line with one hand and circle with other hand
Asked to imagine drawing circle with affected limb. Those with anosognosia circle became merge of line and circle.
Shows interference that occurs such as when picking up a tray will still use as if have both arms not knowing that the right arm can’t pick up the tray
What happens with pusher syndrome?
Interference means that forget that one side is not working so push e.g. with left hemiparesis push onto left side whereas without anosognosia would compensate onto right side.
Most people with pusher syndrome have right sided brain damage and think left side is still working
