10/21 CVA Intervention

Question 1

Recovery after stroke - Initial Phase

Answer 1

Decreased cerebral edema
Absorption of damaged tissue
Improved blood flow
Reperfusion of the ischemic penumbra

Question 2

Recovery after stroke - Reparative Phase

Answer 2

Regeneration via collateral sprouting
Reorganization of neuropathways
Regression of peri-lesional inhibition
Intracortical disinhibition of the contralateral motor cortex

Question 3

Keys to stroke rehab

Answer 3

Early mobilization

Prevention of learned non-use

Question 4

Recovery from stroke - Main points

Answer 4

Reperfusion of ischema
Axonal sprouting
Reorganization of motor cortex
Alterations in behavior
Prevention of learned non-use
Promote plasticity

Question 5

Stroke Recovery Timeline

Answer 5

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

Question 6

UE vs LE Recovery After Stroke

Answer 6

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

Question 7

Stages of Stroke Recovery

Answer 7

Acute
< 1 month or < 8 weeks

Subacute
1-6 months

Chronic > 6 months

Question 8

Stroke Prognosis - Sitting Balance

Answer 8

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

Question 9

Stroke Prognosis - Gait Speed & Endurance

Answer 9

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)

Question 10

Stroke Prognosis - Fugl-Meyer

Answer 10

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

Question 11

Stroke Prognosis - Barthel Index

Answer 11

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

Question 12

Stroke Prognosis - Orpington Prognostic Scale (OPS)

Answer 12

OPS at 2 weeks predictive of d/c if over 75 y.o.

5.2 req. LTC

Question 13

Stroke Prognosis - Positive Indicators

Answer 13

Initial return of movement within the first 2 weeks
Active participation by patient
Specificity of and functional task oriented training
Acuity of stroke

Question 14

Stroke Prognosis - Negative Indicators

Answer 14

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

Question 15

Stroke Treatment - Prevention

Answer 15

Falls
Injury
Fracture
Contracture
Joint subluxation
Skin breakdown
Learned non-use
Pneumonia
Deconditioning

Question 16

Stroke Treatment - Remediation

Answer 16

Muscle Activation
Force production
Balance 
Sensation
Functional mobility training

Question 17

Muscle Activation Tactics

Answer 17

Type of contraction
Position for task
Facilitation techniques
Constraint-Induced Movement Therapy (CIMT)
Neuromuscular electrical stimulation (NMES)

Question 18

Force Production Tactics

Answer 18

Repetitious exercises
Activities in kneeling and standing
Quick Stretch
Tapping
Weight bearing

Question 19

Sensation Tactics

Answer 19

Visual cues
mirror feedback
Proprioceptive input
Brushing

Question 20

Stroke Treatment - Compensation

Answer 20

Muscle Activation
Force Production
Balance
Functional Mobility

Question 21

Symmetry Training

Answer 21

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.

Question 22

Aerobic Activity Recommendations, post-stroke

Answer 22

50-80% maximal heart rate
RPE 11-14 (6-20 scale)
3-7 days per week
20-60 minutes per session

Question 23

Strength Training Recommendations, post-stroke

Answer 23

1-3 sets of 10-15 reps
8-10 exercises of major muscle groups
2-3 days per week

Question 24

Body weight Supported Treadmill Training (BWSTT) Rationale

Answer 24

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

Question 25

Body weight Supported Treadmill Training (BWSTT) Limitations

Answer 25

Equipment needed
Often requires 2 people to assist
Differences between treadmill walking and over ground walking

Question 26

BWSTT - Subacute Phase

Answer 26

Low initial ambulatory status - better than over ground

Higher initial ambulatory status - not as good as over ground

Question 27

Strength Training post-stroke, by level of function

Answer 27

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

Question 28

Constraint Induced Movement Therapy (CIMT) – Subacute Phase

Answer 28

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

Question 29

Constraint Induced Movement Therapy (CIMT) Prerequisites

Answer 29

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

Question 30

Modified Constraint Induced Movement Therapy (CIMT)

Answer 30

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

Question 31

Functional Electrical Stimulation (FES)

Answer 31

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

Question 32

Electric Scooter Advantages

Answer 32

May dissemble or chair folds down
May fit into trunk of car
Beneficial for long distances in community access

Question 33

Electric Scooter Disdvantages

Answer 33

“Captain’s Chair”
Offers little postural support
Large turning radius
Difficult transfers

Question 34

Functional Electrical Stimulation (FES) Evidence

Answer 34

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