10/21 CVA Intervention Flashcards
Recovery after stroke - Initial Phase
Decreased cerebral edema
Absorption of damaged tissue
Improved blood flow
Reperfusion of the ischemic penumbra
Recovery after stroke - Reparative Phase
Regeneration via collateral sprouting
Reorganization of neuropathways
Regression of peri-lesional inhibition
Intracortical disinhibition of the contralateral motor cortex
Keys to stroke rehab
Early mobilization
Prevention of learned non-use
Recovery from stroke - Main points
Reperfusion of ischema Axonal sprouting Reorganization of motor cortex Alterations in behavior Prevention of learned non-use Promote plasticity
Stroke Recovery Timeline
Neurologic recovery generally takes place within 3 months
Further recovery may take place 6 months to one year later, but some motor function must be preserved in order for this to happen
UE vs LE Recovery After Stroke
UE recovery vs LE recovery after stroke may differ
LE can achieve function with less motor control than UE due to task requirements
Partial recovery in LE can appear to be more recovery
Stages of Stroke Recovery
Acute
< 1 month or < 8 weeks
Subacute
1-6 months
Chronic > 6 months
Stroke Prognosis - Sitting Balance
Sitting balance 2 weeks after stroke is predictive of walking ability after 6 months.
Initial sitting balance most correlated standing, walking, stair climbing at 6 months post-stroke
Stroke Prognosis - Gait Speed & Endurance
Normative velocity values for independent community ambulation:
Distance - 332 meters (approximate 6MWT)
Velocity -1.2m/s = 2.68 mph
Household ambulation (0.4 m/s), limited
Limited community ambulation (0.4 to 0.8 m/s)
Full community ambulation (0.8 m/s)
Stroke Prognosis - Fugl-Meyer
Fugl Meyer scores: >80 mild 56-79 moderate 36-55 moderately severe 0-35 severe
Fugl-Meyer scores at 5 days post CVA were
predictive of 6 month motor performance
Stroke Prognosis - Barthel Index
Mild or moderate motor deficits 5 days and 30 days - 100% were independent in ADL after 6 months
Severe deficit 30 days - 56% were independent in ADLs after 6 months
Stroke Prognosis - Orpington Prognostic Scale (OPS)
OPS at 2 weeks predictive of d/c if over 75 y.o.
5.2 req. LTC
Stroke Prognosis - Positive Indicators
Initial return of movement within the first 2 weeks
Active participation by patient
Specificity of and functional task oriented training
Acuity of stroke
Stroke Prognosis - Negative Indicators
Coma at outset Poor cognition Severe aphasia No motor return within one month Visual-perceptual-spatial disorders Inability to sit unsupported Incontinence 2 weeks s/p CVA Depression
Stroke Treatment - Prevention
Falls Injury Fracture Contracture Joint subluxation Skin breakdown Learned non-use Pneumonia Deconditioning
Stroke Treatment - Remediation
Muscle Activation Force production Balance Sensation Functional mobility training
Muscle Activation Tactics
Type of contraction
Position for task
Facilitation techniques
Constraint-Induced Movement Therapy (CIMT)
Neuromuscular electrical stimulation (NMES)
Force Production Tactics
Repetitious exercises Activities in kneeling and standing Quick Stretch Tapping Weight bearing
Sensation Tactics
Visual cues
mirror feedback
Proprioceptive input
Brushing
Stroke Treatment - Compensation
Muscle Activation
Force Production
Balance
Functional Mobility
Symmetry Training
Task specific reaching does not improve seated weight distribution or standing symmetry post-stroke.
Training awareness of body position can improve symmetry in sitting in the early phase of stroke rehabilitation for the short and long term.
Aerobic Activity Recommendations, post-stroke
50-80% maximal heart rate
RPE 11-14 (6-20 scale)
3-7 days per week
20-60 minutes per session
Strength Training Recommendations, post-stroke
1-3 sets of 10-15 reps
8-10 exercises of major muscle groups
2-3 days per week
Body weight Supported Treadmill Training (BWSTT) Rationale
Intensive task-specific locomotor training
Repeated segmental sensory inputs
May facilitate cortical and subcortical reorganization
Allows an individual to integrate weight bearing, stepping and balance
Minimizes the delay that gait training can be initiated for individuals who are not able to support their full weight
Body weight Supported Treadmill Training (BWSTT) Limitations
Equipment needed
Often requires 2 people to assist
Differences between treadmill walking and over ground walking
BWSTT - Subacute Phase
Low initial ambulatory status - better than over ground
Higher initial ambulatory status - not as good as over ground
Strength Training post-stroke, by level of function
Lower functioning patients:
Task-Related Training
Use more compensatory trunk motion to achieve improved reaching
Higher functioning patients:
Progressive Resistance Exercise
More isolated control for reaching in the involved UE
Constraint Induced Movement Therapy (CIMT) – Subacute Phase
14 consecutive days of physical restraint on the less affected upper extremity
Restraint is worn for 90% of waking hours
6 hours per day, 5 days per week of intensive training
Constraint Induced Movement Therapy (CIMT) Prerequisites
Higher functioning participants have at least:
20 degrees of wrist extension
10 degrees of active ext of each MP and IP joints of all digits
Lower functioning participants have at least:
10 degrees of active wrist extension
10 degrees thumb ABDuction
10 of ext in at least 2 additional digits
These movements repeated 3 times in one minut
Modified Constraint Induced Movement Therapy (CIMT)
1 hour of skilled PT/OT per day
3 days per week
10 weeks
Less affected UE restrained 5 days per week for 5 hours
Functional Electrical Stimulation (FES)
Longer term use
Used during functional activities
Evidence for shoulder subluxation
(prevention and compensation)
Dorsiflexion assist during swing phase of gait (compensation)
Increase motor unit recruitment
Increase rate of motor unit firing
Electric Scooter Advantages
May dissemble or chair folds down
May fit into trunk of car
Beneficial for long distances in community access
Electric Scooter Disdvantages
“Captain’s Chair”
Offers little postural support
Large turning radius
Difficult transfers
Functional Electrical Stimulation (FES) Evidence
Limited evidence may have some benefit when used in conjunction with traditional physical therapy (Faghri 1994, Faghri and Rodgers 1997, Chantraine 1999)
Moderate evidence that does not prevent loss of shoulder function (Linn 1999)
“FES in addition to standard therapy or no therapy is not more effective than conventional therapy or no therapy alone for improving functional independence in patients with acute stroke.”
“EMG-triggered FES in combination with conventional therapy is more effective than conventional therapy alone for improving functional independence in patients with sub-acute stroke.”
“FES in addition to bilateral motor training or conventional therapy is more effective than bilateral training or conventional therapy alone for improving strength in patients with chronic stroke.”
Not for improving for LE treatment in acute, subacute or chronic stages
