Test 1 Review for Final (Review) Flashcards
(148 cards)
1
Q
IV STEP’s Four P’s
What is Prevention?
A
Prevent the onset of disease (or disability) to stop its progress and minimize consequences
2
Q
IV STEP’s Four P’s
What is Prediction?
A
Optimal response to intervention choice is fundamental to effective practice; begins with meaningful system diagnosis and measurement
- Task Analysis
3
Q
IV STEP’s Four P’s
What is Plasticity?
A
Capacity of cerebral neurons and neural circuits to change structrally and functionally in response to experience
- In other words, capacity for CNS to change
4
Q
IV STEP’s Four P’s
What is Participation?
A
“Involvement of people in all areas of life or the functioning of a person as a member of society. Participation restrictions are problems an individual may experience in involvement in life situations” - WHO ICF framework
- Quality of Life
5
Q
What are the 3 different Intervention Categories to improve Motor Function?
A
- Restorative Interventions
- Impairment-specific and Augmented Interventions
- Compensatory Interventions
6
Q
Interventions to improve Motor Function
What is Restorative Interventions?
A
Restorative Interventions focus on targeted movement deficiencies and are using activity-based interventions and motor learning strategies to work to improve motor function. Also implementing elements of neuroplasticity principles
7
Q
Restorative Interventiosn: Motor Learning strategies
With Augmented Feedback, what does Knowledge of results (KR) mean?
A
- Terminal feedback about the movement outcome
- This is provided by an instructor or clinician
–Usually verbal
–Can be visual or auditory
8
Q
Restorative Interventiosn: Motor Learning strategies
With Augmented Feedback, what does Knowledge of Performance (KP) mean?
A
- This is information about the pattern of a movement
–Kinematic feedback: speed, velocity, displacement
–Kinetic or EMG feedback if equipment: force and muscle activity
–Quality of movement: no reference to goal or outcome
9
Q
Restorative Interventiosn: Motor Learning strategies
What is Summary Feedback?
A
Feedback after a set number of trials
10
Q
Restorative Interventiosn: Motor Learning strategies
What is Faded Feedback?
A
Feedback given less frequent with ongoing practice
11
Q
Restorative Interventiosn: Motor Learning strategies
What is Bandwidth Feedback?
A
Feedback given if performance falls outside a predetermined error range
12
Q
Restorative Interventiosn: Motor Learning strategies
In Practice Progression, What is Massed vs. Distributed progression?
A
Masses: has more practice time vs rest time
Distributed: has more rest time vs practice time
This depends on the patient, either can be chosen, however usually progressed TO massed in the autonomous stage
13
Q
Restorative Interventiosn: Motor Learning strategies
In Practice Progression, What is the difference between Constant vs. Variable practice?
A
Constant: Task is practiced in the same way with no variety; This is better for performance
Variable: Task is practiced in variable conditions and parameters; This is better for learning
14
Q
Restorative Interventiosn: Motor Learning strategies
In Practice Progression, What is the difference between Blocked vs. Random practice?
A
Blocked: 1 task repeated throughout whole practice time; This promotes performance
Random: A variety of task are practiced during practice time in random order; This promotes learning
15
Q
What are Augmented Interventions?
A
These interventions include aspects of guided movement. These movements are guided or facilitated to try to promote some voluntary control and help jump start the recovery or promote positive neuroplastic changes by maybe incorporating a more involved body segment
16
Q
What are Compensatory Interventions?
A
This involves the resumption of function using less involved body segment(s)
17
Q
With Compensatory Interventions, what is Substitution?
A
Substitutions are going to be changes that are made to the individual’s overall approach to a functional task
Ex. a pt has a Right CVA, L Hemiparesis is taught to do all there dressing tasks with their R UE as opposed to using both UE
18
Q
With Compensatory Interventions, what is Adaptation?
A
Adaptation is going to be the modification of the environment to facilitate the relearning of skills or the performance of movement and to optimize motor performance
19
Q
Augmented Interventions (Neuromotor Approaches)
Augmented Interventions are Indicated to those patients who:
A
- Lack voluntary movement control
- Demonstrate insufficient motor recovery
- Have difficulty initiating or sustaining movement
20
Q
Why would you use Augmented Interventions?
A
These interventions can help bridge the gap between absent or severely disordered movements and more active and controlled movements. Once the patient develops more adequate voluntary control these interventions are generally conterproductive and should be discontinued
21
Q
Intro to NDT Augmented Interventions
NDT was designed to emphasize what?
A
NDT was designed to emphasize inhibition of abnormal reflexes and abnormal tone prior to focusing on function
Neuro-developmental treatment (NDT) is a hands-on therapy that helps people with neurological challenges improve their movement and function
22
Q
Intro to NDT Augmented Interventions
With NDT, what are 5 body segment that offer key points of control for postural control and movement?
A
- Head and Neck
- Upper Trunk
- Lower Trunk
- UE
- LE
23
Q
Which Neuro Conditions would benefit from Restorative Interventions?
A
- Stroke, Incomplete SCI, TBI, GBS, RRMS
24
Q
When is Augmented Approach Indicated and Contraindicated?
A
Indicated
- Lack of voluntary movement
- Demonstrates insufficient motor recovery
- Difficulty initiating or sustaining movement
Contraindicated
- Demonstrates sufficient active movement control
25
What are the 3 Principles of Neuroplasticity that are imprortant for Neuro patients?
26
When should you not use NDT?
Pt has sufficient motor control to create effective movement
27
With NDT, where should you start?
Create proximal stability and then add distal mobility
- **Always start at the Lower Trunk**
28
What are different Outcome Measure used to assess Balance?
- Romberg
- Sharpened Romberg
- BERG Balance Scale
- Tinetti Performance-Oriented Mobility Assessment
- Functionl Reach
29
# Balance Measure
With the Romberg OM, what does it assess and what ICF category does it test? What is the Critera to stop the test?
- Static standing balance assessment
- ICF: Body Structure and Function
- **Criteria to stop test**: Stop the test if the patient moves their feet, changes their arm position or opens their eyes. The test should be timed and can also be rated on the amount of sway observed
## Footnote
Lacks reliability and validity
30
# Balance Measure
With the Sharpened Romberg OM, what does it assess and what ICF category does it test? What is the critera to stop?
- Static standing balance - Tandem Stance
- ICF: Body Structure and Function
- **Criteria to stop test**: Stop the test if the patient moves their feet, changes their arm position or
opens their eyes.
## Footnote
Lacks reliability and validity
31
# Balance Measure
With the BERG Balance Scale, what does it assess? How many task are there? What score indicates fall risk? What ICF category does it test?
- Static/Dynamic standing balance/Functional mobility
- There are 14 task each with a rated score from 1-4 for a total of 56 points
(The lower the score = Decreased balance)
- **< 45 = functional (lower has been associated with fall risk)**
- ICF: Activity
## Footnote
Excellent Test-Retest and inter/intra rater reliability
32
# Balance Measure
With the Tinetti Performance Assessment OM, what does it assess? How many items are there? What score indicates fall risk? What ICF category does it test?
- Static/Dynamic balance/Gait Screen
- 2 categories: Balance (9 items) and Gait (7 Items)
- **< 19 = Fall risk**
- ICF: Activity
## Footnote
Excellent reliability for most neuro diagnosis
33
# Balance Measure
With the Functional Reach OM, what does it assess? With what conditions is it recommended for? What ICF categoty does it Test?
- Quick standing balance screen
- Maximum distance reached while in static position
- Modified for sitting
- Highly recommended for use in Stroke and PD; Recommended for MS
- **< 6in is indicative of significant fall risk**
- ICF: Activity
## Footnote
Excellent reliability
34
What are some different Outcome Measure that assess Balance and Gait Measures?
- Timed Up and GO Test (TUG)
- Timed Walking Test (6 minute Walk and 10 Meter walk)
- Dynamic Gait Index (DGI)/Functional Gait Assessment (FGA)
35
With the Timed Up and GO Test (TUG), what does it assess? With what conditions is it recommened? What score indicated Fall risk? What ICF category does it Test?
- Quick screen of dynamic balance and mobility in elderly
- Highly recommended for elderly, PD and MS
- Community dwelling adults: **>13.5 seconds = fall risk**
- Frail elderly: **>32.6 seconds = fall risk**
- ICF: Activity
36
With the 6 Minute Walk Test, what does it assess? With what conditions is it recommended? What ICF category does it test?
- Measures functional endurance/ Activity tolerance
- Highly recommended for most neurological diagnosis
- ICF: Activity
## Footnote
Excellent Reliability
37
With the 10 Meter Walk Test, what ICF category does it test?
- ICF: Activity
- AD may be used
- Assist may be given
## Footnote
Assesses Gait Speed
38
With the DGI and FGA, what does it assess? What ICF category does it test?
- Assesses higher level functional mobility
- ICF: Activity
39
What is the Fugl Meyer OM?
An OM with objective measure of neurological recovery at the impairment level following stroke.
40
What is the Cut off score for DGI?
- The DGI has a total score of 24
- **< 19 is considered a fall risk**
41
What does the PASS OM focus on?
- Assessment of the ability to maintain a given posture and to maintain equilibrium when changing postures
- Applicable to stroke survivors, even in the acute phase of recovery, who demonstrate poor postural control
- Assessment should contain components of increasing difficulty
42
# Balance Measure
What is the PASS OM?
Assesses postural control in stroke survivors
43
What are the Cut Off score for the 10 Meter Walk Test?
- Full Community ambulation gait speed (able to safely cross street) >1.2 m/s (2.7 mph)
- Community ambulation gait speed is >0.8m/s (>2mph)
- Household to limited community ambulation gait speed is 0.4 – 0.8m/s (1-2mph)
- Household only gait speed is < 0.4m/s (< 1mph)
44
What is the ICF category for PASS? If (+) what is it an indicator of?
Activity
**Indicator of fall risk**
45
# Stoke OM
With the 5x Sit to Stand OM, where does this fall in the ICF category?
Activity
46
# Stoke OM
With the Fugle Meyer Assessment OM, where does this fall in the ICF category?
Body Structure/Function
47
# Stoke OM
With the Stroke Impact Scale OM, where does this fall in the ICF category?
Participation
48
# Stoke OM
With the 10 M walk test OM, where does this fall in the ICF category?
Activity
49
# Stoke OM
With the STREAM OM, where does this fall in the ICF category?
Body Function and Activity
50
# Stoke OM
With the Chedoke McMaster Stroke Assessment OM, where does this fall in the ICF category?
Body Function and Activity
51
# Stoke OM
With the Postural Assessment Scale for Stroke (PASS) OM, where does this fall in the ICF category?
Activity
52
# Stoke OM
With the SF-36 OM, where does this fall in the ICF category?
Participation
53
# Stoke OM
With the Functional Gait Assessment (FGA) OM, where does this fall in the ICF category?
Activity
54
What is the Chedoke McMaster Stroke Assessment (Sequence of Motor recovery)?
This OM is expanded upon the Brunnstrome stages
- This can help us establish a baseline of motor function, track changes over time and It can predict motor recovery (Prognostic implications). This can aid in goal setting.
## Footnote
- If this is ≥ 4 then we do Augmented/Restorative Appoahc
- If this is < 4 we do a compensatory approach
55
# PD
Where in the ICF would you place the MDS-UPDRS pt. 1?
Body Structre and Function
56
# PD
Where in the ICF would you place the MDS-UPDRS pt. 3?
Body Structre and Function
57
# PD
Where in the ICF would you place the MDS-UPDRS pt. 2?
Activity
58
# PD
Where in the ICF would you place the PDQ-8 or PDQ-39?
Participation
59
# PD
With Specific Constructs of OM, what does Freezing of Gait Questionnaire assess?
Freezing Gait
60
# PD
Where in the ICF would you place the Montreal Cognitive Assessment?
Body Structre and Function
61
# PD
Where in the ICF would you place the PDQ-8 or PDQ-39?
Participation
62
# PD
With Specific Constructs of OM, what does Parkinson's Fatigue Scale assess?
Fatigue
63
# PD
With Specific Constructs of OM, what does ABC Scale assess?
Fear of Falling
64
# PD
With Specific Constructs of OM, what does TUG Cognitive assess?
Dual Task
65
What is the Overarching Role of the PTA?
Assists the PT in the provision of physical Therapy
66
What are the Specific Roles and Responsibilites of a PTA?
- Reports to the PT in all practice settings
--In-person OR via telecommunication
- Attend regularly scheduled and documented conferences with the PT
- Request the PT to perform re-examination, POC modifications, and oversight with changes in medical status prior to initiating novel treatment
- Attend supervisory visits by the PT at least once per month
67
When treating PD patients, what would happen if the patient has postural hypotension (drop of 20 SBP or 10 DBP and 10% increase in HR) and/or have bladder urgency/infrequency? What can we (the PTs) do?
They may have dizziness, falls with blackouts, and/or injury
- They may need compression stockings, salt on food, hydration, pause with STS
- They may need pelvic floor exercises, MD referral
68
# PD across the continuum of care
What is considered the Early/Mild stages of the Hoehn and Yahr Scale?
Stage 1 - 2
69
What is considered the Moderate/Middle stages of the Hoehn and Yahr Scale?
Stage 3 - 4
70
What is considered the Severe/Late of the Hoehn and Yahr Scale?
Stage 5
71
With the Hoehn and Yahr Classification of Disability, what is Stage 1?
Minimal disability, unilateral symptoms
72
With the Hoehn and Yahr Classification of Disability, what is Stage 2?
Bilateral, or midline involvement (no balance impairment)
73
With the Hoehn and Yahr Classification of Disability, what is Stage 3?
Postural instability present but can still live independently
74
With the Hoehn and Yahr Classification of Disability, what is Stage 4?
All symptoms present, standing/walking only possible with assistance
75
With the Hoehn and Yahr Classification of Disability, what is Stage 5?
Wheelchair or bed bound
76
What is the Treatment focus with the Early/Mild stages (H&Y 1-2)?
**Restoration**
- The interventions should be **focused on strength, execution, task-specific training, preventing inactivity, improving flexibility and preventing possible deformities by working on postural endurance and postural training**
- Additionally you want to address any asymmetries in gait, such as arm swing, and also address any impairments that you know at this time
- **Fall prevention and disease progression education is ideally started at this stage**
77
What is the Treatment focus with the Moderate/Middle stages (H&Y 3-4)?
**Compensation, while also training restoration**
- This is the stage where **sensory cueing becomes very important and the importance of assistive devices may be warranted**
- There is typically **more difficulty with dual tasking**
- Creating a fall log might also be benefical at this stage to give you an idea of how falls are affecting their ADLs and how you can help to prevent them
78
What is the Treatment focus with the Severe/Late stages (H&Y 5)?
**Compensation**
- We will be providing **a lot of caregiver education for transfer safety and skin integrity awareness**
- It can take a long time to reach this stage, however its important to prevent things such as contractures, pressure sores, and pneumonia (unfortunately, people with PD die with aspiration pneumonia)
- Emphasis on providing family education especially with transfer training can help improve patient care at home
- This may also be an appropriate time to educate the family and the patient about the possibility of moving to a skilled nursing facility
79
With Aerobic Training, what is the goal of intensity (based on the ACSM guidelines)? What is typically encouraged for PD patients to complete in terms of time and intensity?
How can this be beneficial?
**Goal of at least 150 min/week at moderate intensity (30min 5x/week)**
- **It typically encouraged for PD patients to engage in at least 20 min of High-intensity exercise**
- It can help with:
- Deconditioning, its also been shown to decrease or slow the disease process and help stimulate neuroplastic changes (this will increase nutrition and growth factors to stimulate neuroplasticity and help preserve the dopamine-producing neurons
80
What are the Characteristics of Stooped Posture?
**Most common**
- Flexion of neck and trunk
- Shoulders rounded with IR
- Flexion of hips and knees
81
What are the Characteristics of Camptocormia Posture?
- Extreme involuntary forward flexion of thoracolumbar spine in standing and walking
- Subsides in recumbent positions
82
What are the Characteristics of Pisa Syndrome Posture?
- Increased lateral flexion
- Subsides with passive correction in recumbent positions
83
What type of External Cueing is used most commonly for gait training? What can this cue be beneficial for?
Visual Cueing is the most common
- Improve Stride Length
--**150% longer than current**
--Target = 40% of patient height (24-28in)
- Improves turning
- Improves initiation of Gait
84
What is Auditory Cueing? How can it help patients with PD?
Rhythmic cueing with use of metronome, music, clapping or snapping
- This can be used as a mode to improve speed of gait or cadence, as well as speed of any movement or intervention
--**With Stepping, it can help 25% faster than baseline**
--**100-125 bpm can be used for higher functioning patients**
Rhythmic cueing can be used with interventions, such as PNF patterns to improve axial rotation, resistance training or boxing
85
With Freezing of Gait, What are the 4 S's?
If you find that your patient is stuck in a freezing episode,
- You first teach them to **STOP**. Its important to not try to force or push your patient out of their freezing. this will only result in frustration.
- Once they stop, remind them to relax and correct their posture by **STANDING TALL** to get their COM over their BOS
- Next, they will **SWAY** laterally from side to side
- Once they have initiated movement from side to side a few times, they can **STEP LONG/BIG** and begin to initiate their gait again
## Footnote
If a caregiver is with the patient when they are having an episode, they can also aid the patient by placing their foot perpendicular to the patients and giving them a visual cue of something to step over, so that they can help to break the freezing episode
86
With Festination of Gait, what are the 3 S's?
Similar to Freezing of Gait, except there is only:
- Stop, Stand Tall, and Step Long/Big
- As soon as they recognize their steps quickening, they need to **STOP** so that they can reset their COM over their BOS. Some patient do not recognize when they do this, its important to educate them about the signs so they can train themselves to stop as soon as they can.
87
With Task-Specific Training, what stage of PD is Sit to Stand/Stand to Sit beneficial? What will PTs typically notice during this stage?
During H&Y Stage 2 progressing to Stage 3
- Their problems with postural instability will start to progress, this will be evident in their execution of a sit to stand
- We will notice the patient will start to fall back into their chair as a result of poor dynamic postural control
- Also bradykinesia will slow their movements which will not allow them to translate their weight far enough anteriorly at a quick enough pace to be able to stand up
88
What is LSVT BIG? What are its 4 principles?
A training program specific for PD patients
- **1.** Amplitude
-Max effort (8/10 on modified Borg scale)
-Speed increases with large movements
-"THINK BIG"
- **2.** Sensory Re-calibration
-What feels like normal movement to patient is actually hypokinetic
- **3.** Mode
- Intensive standardized exercise program
- Intensive and High Effort
- 16 one hour sessions, 4x/week, 4 weeks
- **4.** Empowerment: "You dont look like you have PD"
## Footnote
This is organized into 16 treatment sessiosn with 4, 60 min training sessions per week
89
With Cardiovascular Training, what is recommended?
**Increased Intensity = Increased Neuroplsticity**
**Recommended**: (Make sure to know this!!!!)
- 30 min / 5x per week (Mod intensity)
- 20 min / 5x per week (high intensity)
- 50 min / 5x per week (low intensity)
90
With LSVT Methods, In Week 1, How long is the Max Daily
Exercises, FunctionalComponent Tasks and how long is the Big Walking, Hierarchy Tasks?
Max Daily Exercises, FunctionalComponent Tasks:
- 45 min
Big Walking, Hierarchy Tasks
- 15 min
91
With LSVT Methods, In Week 2, How long is the Max Daily
Exercises, FunctionalComponent Tasks and how long is the Big Walking, Hierarchy Tasks?
Max Daily Exercises, FunctionalComponent Tasks:
- 40 min
Big Walking, Hierarchy Tasks
- 20 min
92
With LSVT Methods, In Week 3, How long is the Max Daily
Exercises, FunctionalComponent Tasks and how long is the Big Walking, Hierarchy Tasks?
Max Daily Exercises, FunctionalComponent Tasks:
- 35 min
Big Walking, Hierarchy Tasks
- 25 min
93
With LSVT Methods, In Week 4, How long is the Max Daily
Exercises, FunctionalComponent Tasks and how long is the Big Walking, Hierarchy Tasks?
Max Daily Exercises, FunctionalComponent Tasks:
- 30 min
Big Walking, Hierarchy Tasks
- 30 min
94
What are the Therapist Condiserations when teaching LSVT to patients?
- MODEL: Do what I do
- SHAPE: Optimize alignment first
- DRIVE BIG EFFORT: Increase motor output
- STABILIZE: Repetitions, reinforce, motivate
- CALIBRATE: Teach self monitoring
95
Post-Stroke its important to have to patient perform Cardiovascular and Strength Training. What types of Training does this include?
*High evidence supports the use of muscle strength and aerobic training post-stroke*
- Eccentric Training
- Cross Education Training
- Power Training
96
Post-Stroke, why should we do Power Training? What does it have implications for?
It has **Implications for Fall Prevention and improved Gait speed**
- **This type of training has a fast concentric phase followed by a slow eccentric phase**
- By training this burst of fast concentric activation, we provide opportunity for the pt to react quickly in the event of a loss of balance, followed by control in order to reduce the risk of falls and walk more safely at a faster pace
97
Post-Stroke, what does the Power Training Dosage look like?
Power Training should start at about 20-40% of 1-rep max and then progress over time to 60-70%
- Develop strength base, then increase speed of the contraction
- 8-12 reps, 1-3 sets
- 2-3x per week
98
With Post-Stroke interventions, what is Functional Electrical Stimulation (FES)?
This is electrical stimulation delivered to the peripheral nerve and muscle **during a functional task**
- This is considered an **Augmented Intervention** and is coupled with restorative tasks specific practice
- FES has been utilized to promote both UE and LE recovery post-stroke
- The electrodes are placed on the desired muscles of activation and the stimulation is timed during a certain movement
99
With Post-Stroke interventions, what is Locomotor Training?
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.
100
With Post-Stroke Interventions, What is the Body Weight Support Treadmill Test (BWSTT)?
- 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
101
With the BWSTT, How can this intervention benefit the patient? What are the conderations for this interventions?
- 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.
102
With Post-Stroke Interventions, what is Mirror Therapy?
*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
103
What are the step of performing Mirror Therapy?
- 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.
104
What are the goals of Mirror Therapy?
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.
105
Who is most appropriate for Mirror Therapy?
- Patients with motivation to commit to treatment
- Ability to follow instructions
- Hemispatial neglect may benefit
- Low level motor functionin g
106
Who is NOT appropriate for Mirror Therapy?
- 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
107
With Post-stroke Interventions, what is CIMT?
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.**
108
With CIMT, what are the 4 elements of the CIMT protocol?
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.
109
With the 1st element of CIMT (Repetitive and Intense Task Speficic and training of paretic UE over Multiple days), What is the Premis behind this Element?
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
110
With the 2nd element of CIMT (Shaping), What is the Premis behind this Element?
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.
111
With the 3rd element of CIMT (Transfer package), What is the Premis behind this Element?
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.
112
With the 3rd element of CIMT (Transfer package), What are 4 interventions to promote adherence?
- **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
113
With the 3rd element of CIMT (Transfer package), What is the Motor Activity Log (MAL)? When is the MAL administered?
- 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
114
With the 4th element of CIMT (Physical Restraint (Mitt)), What is the Premis behind this Element? What is the recommended goal for this protocol?
- 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****
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# **KNOW**
What are the Minimum Active ROM requirements when deciding if your patient is appropriate for CIMT?
- 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
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What is Contraversive Pushing?
*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
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What would happen if you (the PT) try to align the patient with Contaversive Pushing?
They would resist this motion and push more, which then increases their instability and falls
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What is the Scale of Contraversive Pushing (SCP)?
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**
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With the Scale of Contraversive Pushing (SCP), what are the 3 categories tested?
- 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**)
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What is Burke Lateropulsion Scale (BlS)?
- 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
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How is the Burk Lateropulsion Scale (BLS) scored?
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**
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What is the Prognosis for those patients with Contraversive Pushing?
*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**
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Which direction do you think it is easier to
transfer a patient from bed to wheelchair if
they have contraversive pushing?
A) Towards the paretic side
B) Towards the nonparetic side
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
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What is Brain Derived Neurotrophic Factor (BDNF)?
## Footnote
What is BDNF involved in?
- This is a **key mediator** or motor learning and "priming the brain" for neuroplasticity
- Its secreted by 2 mechanisms: Constructive and activity dependent pathways
- Evidence that **30 min at 60% maxHR is effective for increasing BDNF in pts with chronic disorders**
## Footnote
Its involved in:
- Neuroprotection
- Neurogenesis
- Neuroplasticity
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What is the importance of screening neurological patients to exercise?
**CDC recommends 150 min of Mod. intensity exercise**
- With this, we must take a complete medial hx to ensure it is safe for the patient
- We assess strength, balance, cognition, behavior, and communication as well
- Assessment of vitals before, during and after must be done
-consider the position of the patient (Supine, sitting, standing)
- Submax testing may need to be performed to ensure proper prescription intensity
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How is 1RM calculated?
1RM = Weight / Coefficient Reps
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Ex. If a patient performed 5 good reps at 35 lbs for paretic leg press, what is their 1RM?
- What is 50% of their 1RM?
| *5 Reps has a coefficient of .856*
*5 Reps has a coefficient of .856*
35 / .856 = ~ 41lb (1RM)
- 41x50%= ~ 20lbs (50% of 1RM)
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For those patients that are very weak (< 3/5), what type of strengthening should they do?
Isometrically and Eccentrically biased exercise may result in better gains.
- Eccentric strength is relatively more preserved than concentric, epecially those post-stroke
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What are the Strengthening Considerations specific to MS?
- **Fatigue is a critical consideration in MS: Circuit training can improve work capacity**
- 8 weeks of individualized PRE program can improve strength
- Consider closed chain activities to promote strength in the presence of ataxia
## Footnote
Overwork can cause a pseudo-exacerbation
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Using the FITT Principle, what is recommended for Aerobic Training?
**Frequency**
- 3-5 days/week
**Intensities**
- 40-70% HRR
- 55-80% HRmax
- 60-84% or 77-93% HRR and HR max for high-vigorous aerobic training
**Time** (per session)
- 20 min, 30 min, 60 min (pending intensity)
- Muliple 10 min bouts (for prior sedentary, greater fatigability)
**Type**
- Steady state versus interval training (Consider the mode of delivery)
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What is the AHA/ASA Cardiovascular Guidelines for Stroke?
**Frequency**
- 3-5 day/week
**Intensity**
- 40-70% HRR pr 55-80% HRmax (11-14 or 14-16 RPE)
**Time**
- 20-60 min per session (or multiple 10 min sessions) (additional 5-10 min warm-up and coo down)
**Type**
- TM walking with BWS, recumbernt leg and/or arm ergometry
## Footnote
- Recumbent stepper is often the safest choice for those patients who may not be able to tolerate walking on a TM without support.
- Use of a harness for protection while on a TM is recommended, and this is functional as it relates to training for task specificity
- Recent protocal has been supporting HIITprotocals for chronic phase of stroke
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What are the Intervention Guidelines for Cardiovascular Training for TBI patients?
**Frequency**
- 3-5 days/week
**Intensity**
- 60-90% age predicted HR max (208 - (.7 x age))
-This is in the vigorous zone
**Time**
- 20-40 min per session, depending on intensity
-Inverse relationship: higher the intensity, the less time needed
**Type**
- Traditional: walking, jogging, elliptical, cycling
- Circuit training
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What are the Intervention Guidelines for Cardiovascular Training for MS patients?
**Frequency**
- 3-5 days/week alternating days
**Intensity**
- 60-85% HRmax or 50-70% peak VO2
**Time**
- 30 consecutive min or three 10 min bouts
**Type**
- Cycling, walking, swimming, water aerobics, circuit training
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What are the Contraindications to Begin a Cardiovascular Exercise Program?
- Medical Instability of diabetes, angina, arrythmias
-Consult physician to establish stability
- Uncontrolled HRrest > 100bpm or < 50 bpm
- Resting Systolic BP > 200mmHG or < 90mmHG
- Resting Diastolic BP > 110mmHG
- Oxygen Saturation < 90%
*You should recommend formal submax ETT when indicated by patient factors.*
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What are the Indications to **STOP** Aerobic Exercise Training
- Lightheadedness or dizziness
- Chest heaviness, pain, or tightnes; angina
- Palpitations or irregular heartbeat
- Sudden SOB not due to increased activity
- Volitional fatigue and exhaution
- Abnormal response in BP values
- Chills, headaches, nausea, blurred vision
- Pain that does not improve
- Muscle burning
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With Exercise Intensity, for HRR% and %PHR max, what is considered Low Intensity?
**%HHR**
- < 40%
**%PHRMax**
- < 64%
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With Exercise Intensity, for HRR% and %PHR max, what is considered Moderate Intensity?
**%HHR**
- 40-59%
**%PHRMax**
- 64-76%
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With Exercise Intensity, for HRR% and %PHR max, what is considered Vigorous Intensity?
**%HHR**
- 60-84%
**%PHRMax**
- 77-93%
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What is the equation to get the Predicted HR max?
How about with patients that take Beta-Blockers?
Normal
- 207 - (0.7 x age)
Beta Blockers
- 164 - (0.7 x age)
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# Types of Exercise
With Exercise, what is the purpose fo Cardiovascular Exercise?
Challenge release of BDNF
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With a deficit of Perception, what are the impairments for Agnosia?
- Visual object
- Auditory
- Tactile
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With a deficit of Perception, what are the impairments for Apraxia?
- Ideamotor (inability to motorically execute use of an object)
- Ideational (more severe, you comletely lose the idea of of how to use an object or do the task at all)
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With Perceptual Treatment, using the Remedial and Compensatory approachs, how can we treat Unilateral Spatial Neglect?
Remedial
- Simple verbal instruction
- Use of shapes to stimulate the right brain
- Minimize numbers and letters to avoid stimulating the L brain hemisphere
- Encourage client to turn their head and trunk to side of neglect
- Encourage motor activities on the left
- Eye patch, prism glasses, optokinetic stimulation, neck vibration, VR
Compensatory
- External cues to draw attention to the left side
- Arrange the environment for successs such as objects on the less affected side (right)
- Mirror to draw attention to that side
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With Perceptual Treatment, using the Remedial and Compensatory approachs, how can we treat Visual Agnosia?
Remedial
- Photographic drills to discriminate objects and faces
- The easy street environment
Compensatory
- Encourage patient to use other sensory modalities like tough
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With Perceptual Treatment, using the Remedial and Compensatory approachs, how can we treat Apraxia?
Remedial
- One command at a time and allow time for patient to complete
- Breaks tasks down into their components
- Guiding
- Repetition
- Perform task in a normal environment
Compensatory
- "Strategy training" such as a use of picture sequence
