Neglect/ Pushing

Question 1

Vital inputs for standing

Answer 1

vision, vestibular, and somatosensory

Question 2

stable position of standing

Answer 2

• impact of BOS on LOS - foot position matters, UE support matters
• LOS affected by feet support and UE support

Question 3

the greater the balance dysfunction…

Answer 3

the lower the discharge functional scores are likely to be

Question 4

what is postural control dependent on?

Answer 4

patient, environment, and task

Question 5

what does postural control involve?

Answer 5

controlling the body’s position in space - including both orientation and stability

Question 6

when working on postural control, what should you consider?

Answer 6

the ability to maintain COM within BOS

Question 7

what might compromise ankle strategy?

Answer 7

tone, AFO, contracture, weakness

Question 8

what might compromise hip strategy?

Answer 8

• weakness, tone, decreased trunk control, timing, initiation

Question 9

what might compromise stepping strategy?

Answer 9

weakness, trunk control, tone

Question 10

following neurologic incident patients may have:

Answer 10

problems in timing, motor activation, sensory input, cognitive processing, adaptation, sensory organization, learning

Question 11

UE balance control

Answer 11

Monitor patient use of trying to grab furniture,
parallel bars- utilizing UE support for balance control which is not where we want to provide intervention

Question 12

steady state control considerations

Answer 12

• Alignment
• Muscle tone
• Stability limits- sway strategies (motor control/coordination)
• Visual, vestibular, somatosensory inputs with integration
• Task-dependent weighting

Question 13

What does anticipatory control require?

Answer 13

• Recognition of need for postural response
• APAs for movement
• UE, Trunk, LE –Strength, Isolation of muscle
  activity, Timing
• Sensory input to provide accurate information to
  system

Question 14

when should you focus on impairments?

Answer 14

• If they are interfering with balance or balance reactions
• prevent new impairments

Question 15

when thinking about ankle strategy, what should you do?

Answer 15

consider ankle ROM

Question 16

influence of impairments - strength

Answer 16

relationship of improving strength and its impact on balance is mixed
- a threshold of strength is needed for stability and movement components of balance and balance reactions

Question 17

Interventions to improve strategies of postural control

Answer 17

facilitate development of sensory, motor, and cognitive strategies that are effective in balance control –> alignment –> sensory strategies –> cognitive strategies –> balance training

Question 18

alignment

Answer 18

maintain COM within BOS, move COM within stable BOS, move COM in moving BOS

Question 19

sensory strategies

Answer 19

learning to organize and select most appropriate sensory input

Question 20

cognitive strategies

Answer 20

attentions need fro postural control, carry over of learning from one task to another

Question 21

balance training

Answer 21

practice progressively challenging tasks that facilitate the development of postural control and behaviors

Question 22

context of intervention

Answer 22

• predicable vs unpredictable
• simple or choice of reaction
• predictable vs unpredictable environment

Question 23

neglect of body

Answer 23

◦ May not recognize parts of body as a part of them
◦ Reorient them to limbs on involved side
◦ Continual emphasis of attention to the limb

Question 24

neglect of environment

Answer 24

◦ Decreased attention to side of environment
◦ Will not eat food if on side of neglect, may run into obstacles/doors on side of neglect
◦ Increased awareness to side of neglect, activities/cues to encourage attention to that side

Question 25

neglect is primarily a disorder of what?

Answer 25

Primarily a disorder of attention where patient fails to orientate, report, or respond to simuli on
contralateral side

Question 26

what is unilateral spatial neglect correlated with?

Answer 26

increased length of stay in inpatient rehabilitation facility, spending an average of 11 days longer

Question 27

patients with unilateral neglect have a slower what?

Answer 27

progress and less functional improvement per day
compared to individuals following stroke with a similar admission status

Question 28

when is recovery of neglect most rapid

Answer 28

over the first 10 days and plateaus around the 3 month mark with a majority of patients demonstrating recovery

Question 29

what does neglect negatively affect?

Answer 29

disability one year post stroke and is a valid predictor for dependency but not of death one year post stroke

Question 30

does neglect have to occur directly at midline?

Answer 30

nope

Question 31

common interventions for neglect

Answer 31

Visual interventions
Prism Adaptation
Body Awareness
Mental Function
Movement interventions
Non-Invasive Brain Stimulation
Electrical Stimulation
Acupuncture
Reward

Question 32

CPG for neglect

Answer 32

Clinicians should provide rehabilitation for neglect that enables people to meet their goals

Question 33

Contraversive Pushing: Pusher Syndrome

Answer 33

• Perception of body posture in relation to
  gravity is altered.
• No disturbed processing of visual or vestibular
  inputs determining visual vertical.

Question 34

what is pusher syndrome typically associated with?

Answer 34

lesion to the posterolateral thalamus

Question 35

Clinical Presentation of Contraversive Pushing Behaviors

Answer 35

◦ Perception of body as upright when actually tiled towards brain lesion
◦ Tendency to push with non-affected extremities into abduction and extension toward hemiparetic side
◦ Resistance to external correction

Question 36

Are patients with pusher syndrome capable of reaching same functional outcomes

Answer 36

◦ Yes, can take up to 3.6 weeks longer
◦ Insurance and Medicare does not automatically give longer time in therapy to patients with
contraversive pushing, however level of assistance needed at admission, may impact

Question 37

If given the same length of stay at those with stroke without pushing behavior?

Answer 37

◦ Poorer functional outcomes
◦ Increased caregiver burden
◦ More likely to discharge to SNF

Question 38

Scale for Pushing Syndrome

Answer 38

Burke Lateropulsion Scale
5 Testing Positions
◦ Supine
◦ Sitting
◦ Standing
◦ Transfers
◦ Walking
0= no evidence of lateropulsion
17= maximum lateropulsion

Question 39

Initial treatment for pusher syndrome

Answer 39

Initially help them realize their disturbed perception of erect body position

Question 40

treatment for pusher syndrome in sitting

Answer 40

• permit contraversive body tilt within safety limits
• As they perceive the body tilt or fall ask patient to find a way to get upright again
  ◦ Support them if unable to return to upright.

Question 41

What should you encourage for patents with pusher syndrome

Answer 41

• active exploration of visual surroundings.
• Have them align with visual vertical environmental cues
• Windows, pillars, pictures, mirror, door frames, therapist’s arm (vertical)

Question 42

Progression

Answer 42

If pushing, the therapist may be able to subvert this
maladaptive action by having the patient perform an action toward the non-paretic side (reach for an object and use auditory cues to direct attention).

Question 43

How to optimize pusher syndrome training:

Answer 43

• maintaining vertical while distracted or performing other activities
• Use conversation and/or head or arm movements while maintaining vertical.

Question 44

what do most recent studies continue to emphasize for pusher syndrome?

Answer 44

visual feedback for orientation to vertical