Neuromuscular 2 Unit 4 Dx Specific Interventions: CVA, Pusher Flashcards

Question

According to the CPG, when should FES and an AFO be used for Post-stroke patients?

Answer 1

For individuals with Acute and/or Chronic post stroke Hemiplegia

Answer 2

Locomotor training is a task orientated approach can take many forms including: -Overground training -**Treadmill with and without harness** -**Body Weight Supported Treadmill Training (BWSTT)** -Robotic Assisted training -High intensity stepping -Motor Imagery -VR - The majority of these ARE contemporary approaches with the exception of overground training.

Answer 3

- There was improved maximum gait speed and step width across all phases of post stroke rehab. - However there were no significant improvements in comfortable gait speed Considerations: - The Patient has walking ability and is safe to walk on a treadmill

Answer 4

- The patient is placed in a harness that has capacity to unweight the patient while they are positioned over a treadmill. - Therapists can provide assistance for weight shifting and appropriate pelvic rotation along with foot placement. Depending on the level of involvement of the patient, this can take from 1-4 additional therapists and assistants to perform. - Progression can include progressive lowering of the body weight support for increased limb loading

Answer 5

- This intervention has been shown to result in improvements in gait speed and distance. - It is also found that early intervention may improve functional walking ability - However there is no significant evidence that shows it is superior to other forms of physical therapy interventions. - **What matters most is intensity**. Conderations: - As long as the patient is medically stable, and you can get them up into standing and walking, even if they do not have the ability to walk currently.

Answer 6

- Split Belt Training - Unilateral Training The goal would be to forward weight acceptance on the affected limb, while the unaffected limb is forced to take a longer step

Answer 7

- Speed - Incline - Amount of assist - Amount of body weight support (if doing BWSTT) - Should be followed up with task specific gait overground --As the clinician, you will need to be sure of which parameters are best for your patient’s current status and consult the literature for guidance as well.

Answer 8

If safe and feasible, it is also recommended that all bouts on the treadmill should be followed up with overground stepping for carryover of task as the dynamics of the treadmill are different than overground and at the end of the day, our patient need to be able to walk overground.

Answer 9

*Another Type of **Contemporary Approach*** - This has been used to address deficits in both UE and LE post-stroke - Also been studied for use in the treatment of phantom limb pain for those with amputations and in chronic regional pain syndrome

Answer 10

- A mirror is placed in the patient’s midsagittal plane. - The unaffected limb is placed in front of the mirror so that it’s reflection can be seen in the mirror. The affected limb is placed behind the mirror and out of sight. - The patient then performs movement with the unaffected UE and observes these movements in the mirror with an eventual progression to attempting to move the unaffected limb behind the mirror. - This will create an illusion that the affected limb is moving, thus tricking the brain into believing the affected limb is moving.

Answer 11

The goal of mirror therapy in the post stroke population can includes improved attention to the paretic limb, improved motor function and reduction of pain.

Answer 12

- Patients with motivation to commit to treatment - Ability to follow instructions - Hemispatial neglect may benefit - Low level motor functionin g

Answer 13

- Not recommended for those cognitive and attention deficitsl aphasia, dementia - Severe hemispatial neglect with limitations in turn the head may not benefit - High level motor functioning

Answer 14

- Demonstrates effectiveness in ADL performance, Motor activity, Function and recovery - Improvements in spatial neglect and cortical reorganization - May increase activation of the hemisphere, including the primary motor cortex - Reduction of pain, including shoulder pain are also reported This type of intervention is recommended in conjunction with other therapies

Answer 15

- Improved motor recovery, specifically in ankle dorsiflexion - Improved mobility and gait in subacute and chronic stroke

Answer 16

*Another Contemporary tool* - This is a tool with a goal to improve UE function in individuals post-stroke - This app helps guide clinicians through an algorithm for upper limb interventions post-stroke - This is based on a model called SAFE (which stands for Shoulder Abduction and Finger Extension)

Answer 17

*Another Contemporary approach* - This has implications of both UE and LE - In the LE there is emerging evidence to support its use on a treadmill for improvements in gait speed in both subacute and chronic stroke; this is an area of rapid development - In the UE, VR has been shown to enhance use of the upper limb and also included in the via therapy app

Answer 18

Constraint Induced Movement Therapy - This was **designed to address the more affected UE in individuals post-stroke** - The CIMT protocol was ultimately birthed as a response to the learned non-use in order promote behavior change and ultimately recovery of the affected limb. Since the birth of CIMT, numerous studies have explored the efficacy of CIMT with positive finding in both the **subacute and chronic phases post stroke.**

Answer 19

1. Repeatative and intense task specific training of paretic UE over multiple days 2. Shaping 3. Transfer package, to real world environment 4. Restraint of non-paretic UE via safety mitt - Repetitive and intense task specific practice is considered the most imperative element of these four in facilitating recovery. Conversely, the physical restraint is believed to be the least significant.

Answer 20

The premise is behavior change and is facilitated by: - Repetitive training under Supervised Therapy -For **3 hrs a day, 5 consecutive days a week for 2-3 weeks** -With this the patient will also perform shaping and functional task practice - Home Program -15-30 minutes a day on specific assigned repetitive UE tasks -Once the patient has completed the program, a home program is individualized for 3 specific repetitive tasks 15-30 minutes a day and 7 selected ADL’s using the affected UE indefinitely

Answer 21

To overcome learned non- use and promote neuroplastic change

Answer 22

Shaping is based on principles of **behavioral training and ultimately described as small successive steps to make the task more difficult all with the goal of meeting the motor objective**. - When selecting which movements to work on, the recommendation is to **focus on joints movements that have the most pronounced deficits along with the greatest potential for improvement**. ## Footnote For exapmle, let’s say the patient needs to improve in their ability to perform elbow extension, which would be the motor objective. The therapist can facilitate training of a task that promotes repetitive elbow extension by having the patient perform a task that required a small amount of elbow extension and the target is positioned near the patient. Then, in order to shape the task, the therapist can position the target gradually further away from the patient. The number of reps can also be increased along with reducing the time permitted for the task.

Answer 23

On positive reinforcement, all with the intent of promoting behavior change. - Immediate feedback (KR: # reps completed in 30 sec) - Coach the patient - Modeling the task (demonstration) - Encouragement - verbal rewards

Answer 24

This refers to the **patient’s ability to transfer their gains from the clinical or research world to the realworld environment.** Within the transfer package a number of strategies are employed to hold the patient accountable for adherence to the program. - All are employed to assist in promoting self-efficacy and overcoming perceived barriers, both of which are the two strongest and most consistent predictors of adherence to exercise.

Answer 25

- **Monitoring**, in which the participant uses a measure to track activity called the motor activity log. - **Problem solving** interventions are also employed by developing a partnership between the therapist and participant in order to identify potential barriers and instruct and equip the participant on how best to overcome them - **Behavioral Contract** in the form of a formal written agreement between the therapist and participant is also established. This contract specifies the activities in which the participant will use the paretic UE and also specify the condition of the mitt outside of the sessions - **Social support** is also addressed by recruiting the caregiver and educating on the appropriate amount of support for the participant. There may be a caregiver contract as well

Answer 26

- The motor activity log is a valid and reliable measure. Its a 6-point Rating Scale. It’s purpose is to **track progress during the treatment by asking the participant to rate how much and how well they used the paretic UE during certain ADL’s**. - These ADL’s are actually a standardized list of 30 specific ADL’s - This MAL is administered on the first day of treatment, each day of treatment, immediately after the treatment program and once a week for the first month after treatment

Answer 27

- The ultimate premise behind wearing the mitt is to **promote forced use of the UE by preventing the urge to using the unaffected UE**. - The recommended **goal of the protocol is for the patient that has mild to moderate motor deficits to wear for 90% of waking hours** - Ultimately the purpose of having this mitt is to serve as a reminder to not use the unaffected UE. In doing so, this can help reduce the amount of verbal cues required by the therapist or caregiver to remind the patient to use the affected UE. ****this mitt is not the magic ingredient of the CIMT protocol, the repetitive and intensive forced use of the paretic UE is most significant****

Answer 28

- Shoulder Flexion and Abduction ≥ 45° - Elbow Extension ≥ 20° (Starting from 90° flex on table) - Wrist Extension ≥ 10° (Starting from full flexion) - Finger Extension ≥ 10° in a least 2 digits

Answer 29

- Overcome learned non- use and promote use dependent cortical plasticity - Increase speed and efficiency of movement - Increased use -New movement strategies (not pre-stroke movement patterns of coordination)

Answer 30

This is the most commonly used outcome measure pre and post CIMT and is referenced a great deal in the literature, along with the MAL. - The Wolf Motor Function test is composed of 2 components, Strength and Functional task items: -The strength component can include grip strength assessment and amount of weight the extremity can lift during a movement. -The functional task component includes timed trials are used to assess the average the amount of time required to perform a movement (3 times trials)

Answer 31

*A modification for improved clinical feasibility* - 30 minutes of shaping and functional task practice in therapy, 3 days a week for 10 weeks. - The restraint is to be worn 5 hours a day for 5 days a week, as opposed to the 90% of waking hours in the original protocol - While the timeframes are different, the home exercise component and behavioral contract still remain the same. This creates opporunity to deliver this modified protocol in an outpatient setting.

Answer 32

*This is Peculiar behavior* - This is when a patient post-stroke will lean/tilt towards the paretic side - The non-paretic arm/leg (unaffected) are used to "push" away from the non-paretic side in sitting/standing - This does create postural instability/**falls**/fear of falling - This can be either L or R CVA (however more often with R) ## Footnote The fear of falling is comes when you ask them to move back to midline

Answer 33

They would resist this motion and push more, which then increases their instability and falls

Answer 34

This can help the clinician determine if the patient has Contaversive pushing - This as a max score of 6 points - Contraversive Pushing is diagnosed when there is >0 in **each of the 3 categories**

Answer 35

- Spontaneous Body Posture - Abduction and Extension of the Non-Paretic Extremities - Resistance to passive correction of tilted posture (**This is the HALLMARK characteristic of people with CP**)

Answer 36

Value 1 = Severe contaversive tilt with falling to that side

Answer 37

Value 0.75 = Severe contaversive tilt without falling

Answer 38

Value 0.25 = Mild contraversive tilt without falling

Answer 39

0 = Inconspicuous

Answer 40

Value 1 = Performed spontaneously, already when at rest

Answer 41

Value 0.5 = Performed only on changing position (e.g., on transferring from bed to wheelchair)

Answer 42

Value 0 = Inconsipicuous

Answer 43

Value 1 = Resistance occurs

Answer 44

0 = Resistance does not occur

Answer 45

- This has been advocated as being superior to the scale for contraversive pushing. - This has been shown to be much more sensitive at detecting mild pusher behavior when compared to the scale for contraversive pushing. - **More importantly it is more responsive to small changes** (that's critical when you're trying to show progress and recovery of pusher behavior in response to your PT interventions) - **This is considered Gold standard** cause its more sensitive

Answer 46

There are 5 Testing positions: 1. Supine Rolling (resistive to passive rolling) 2. Sitting (Resistance to passive postural correction based on degree of tilt) 3. Transferring (resistance and assistance during transferring) 4. Standing (resistance to postural correction based on degree of tilt, past midline) 5. Walking (resistance and assistance during walking) - Max Score = 17 points - **> 2 / 17 is diagnostic for contraversive pushing**

Answer 47

- Severe hemiparesis - Severe Sensory deficit - Neglect *These patient have a higher incidence of pushing behavior* *There is also a higher incidence of pushing in those with R CVA than L*

Answer 48

- Gravi-ceptive impairment -*Vestibular and Visual input likely normal* - Mis-match between sensory systems results in contra-lateral tilt and pushing behavior

Answer 49

*Prognosis is good* - Transient behavior for most - Pushing resolved in 6 weeks in 62% of patients, and 3 months in 79% of patinets - R CVA and pushing predicts slower recovery - Neglect and pushing predicts slower recovery - Patient who push take **LONGER TO RECOVER functional mobility** -**Longer length of stay by 3.6 weeks**

Answer 50

The Posterolateral Thalamus, and Parietal Lobe - *The Thalamus is involved in our control of upright posture*

Answer 51

- Avoid "**Passive**" correction -Hand-off approach - Make patient visually aware of their tilted body position -Mirrors, use of tape line - "**Actively**" regain midline in sitting and standing -Reaching activites with the non-paretic extremities are carries out -Acoustic signals (clapping, knocking on the bed frame) - PREVENT pushing -Raise table may up to prevent non-paretic LE pushing -Use unstable surface under nonparetic LE - Promote alignment with vision using vertical structures -Door and window frames,pillars, picture frames, broom handle, yard stick, your arm, mirror & shirt with vertical tape line, etc. - Provide feedback about their body orientation - Promote **weight bearing on the nonparetic side** followed by the paretic side

Answer 52

- Firstly work on alignment - Prevent falling and minimize therapist effort - Begin by reducing fear of falling while flexing forward - Utilize **visual vertical cues** throughout the transfer - Prevent LE pushing/abduction by blocking knee - Prevent UE pushing/abduction - Squat pivot transfer, not stand pivot

Answer 53

A) Towards the Paretic side - At the beginning of rehab it is easier to transfer toward the paretic side, since pts tend to push in this direction - In the early days patients DO NOT want to move towards the nonparetic side, as **it induces a fear of falling** and they will therefore resist and push against you if you try to transfer towards the nonparetic side. This pushing makes the transfer more difficult. - HOWEVER, from a therapeutic stand-point you should begin immediate training of transfers to the nonparetic side ## Footnote As PTs we will need to work on both directions, - use visual verticals is critical especially when transferring towards the non-paretic side

Answer 54

- Begin gait training with the **patient's non-paretic side against a wall** or a raised mat -Pt tend to be less fearful of falling and tend to reduce pushing when there is a sturdy surface on the nnparetic side -**Work on nonparetic weight bearing** (standing sequence, parteic foot up on 1'' step, etc) - "Glue your shoulder on the wall" - Use a mirror and visual verticals

Answer 55

1. Early on let the patient "fall" safely towards the paretic side -Trial and error learning -Teaches the patient that leaning to the paretic side is NOT a safe position to assume 2. Use vertical visual cues, tactile cues, and auditor cues to align patient to midline 3. Promote active alignment via reaching past midline for objects on nonparetic side -Reduces fear of falling when the body moves towards nonparetic side 4. Promote auromatic postural control by adding: -Distracting environments -Dual Tasking (Cognitive and Motor)

Neuromuscular 2 Unit 4 Dx Specific Interventions: CVA, Pusher Flashcards

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