Ch 1 - Stroke: Rehabilitation Flashcards
What are predictors of poor prognosis of motor recovery in stroke?
Complete arm paralysis at onset No grip by 4 wks Severe proximal spasticity Prolonged "flaccidity" >9 day before return of proprioceptive facilitation >13 days of proximal traction response
What is Step 1 of the Brunnstrom process of recovery following stroke-induced hemiplegia?
Flaccidity*/no voluntary movements immediately after the onset
What is Step 2 of the Brunnstrom process of recovery following stroke-induced hemiplegia?
Spasticity* appears
Synergy pattern
Minimal voluntary movements
What is Step 3 of the Brunnstrom process of recovery following stroke-induced hemiplegia?
Patient gains voluntary* control over synergies
Inc spasticity
What is Step 4 of the Brunnstrom process of recovery following stroke-induced hemiplegia?
Some movement patterns out of synergy are mastered
Dec spasticity
What is Step 5 of the Brunnstrom process of recovery following stroke-induced hemiplegia?
More complex movement combinations are learned as the basic synergies lose their dominance over motor acts
What is Step 6 of the Brunnstrom process of recovery following stroke-induced hemiplegia?
Disappearance of spasticity
What is Step 7 of the Brunnstrom process of recovery following stroke-induced hemiplegia?
Normal function is restored
Describe traditional therapy for stroke.
Positioning ROM exercises Strengthening Mobilization Compensatory tech Endurance training
Describe Proprioceptive (peripheral) Neuromuscular Facilitation (PNF).
Uses spiral and diagonal movement with goal of facilitating movement patterns that have functional relevance.
Describe the goals of Bobath approach/Neurodevelopmental technique (ND).
- Normalize tone
- Inhibit primitive patterns of movement
- Facilitate automatic voluntary reactions
Describe the Brunnstrom approach/Movement therapy.
Uses primitive synergistic patterns in an attempt to improve motor control through central
facilitation
Describe the Sensorimotor approach/Rood approach.
Modification of muscle tone and voluntary motor activity using cutaneous sensorimotor stimulation
Describe Motor relearning program/Carr and Shepperd approach.
Goal is for the patient to relearn how to move functionally and how to problem solve during attempts at new tasks
Describe requirements for Constraint-induced movement therapy (CIMT) in the EXCITE trial.
At least 10° of active wrist extension, at least 10° of thumb abduction/extension, and at least 10° of extension in at least two additional digits.
What is the MCC of hemiplegic shoulder pain?
CRPS Type I
Soft-tissue lesions
What is complex regional pain syndrome I also known as?
Reflex sympathetic dystrophy [RSD]
Shoulder-hand syndrome
Sudeck atrophy.
What is complex regional pain syndrome II?
Causalgia: pain limited to a peripheral nerve distribution
What is the gold standard for treating sympathetically mediated CRPS type I?
Sympathetic blockade of the stellate ganglion using local anesthetic
What is the sign of a successful Stellate ganglion block?
Ipsilateral Horner syndrome
What can be used to help diagnose CRPS I the first 3 months after stroke?
Triple phase bone scan that shows diffusely increased juxta-articular tracer activity on delayed images
What medication do patients with CRPS I and positive bone scan respond well to?
Oral steroid therapy
What is shoulder subluxation?
Subluxation of the humeral head from the glenoid fossa inferiorly
What did Friedland say about sling use in shoulder subluxation?
Do not prevent/correct subluxation and not necessary to support pain-free shoulder
What did Hurd say about sling use in shoulder subluxation?
No difference in ROM, subluxation or pain with or without slings
What is the etiology of brachial plexus injury in stroke hemiplegia?
Traction injury to plexus/nerve
What is seen on EMG of brachial plexus injury in stroke hemiplegia?
Lower motor neuron findings
What joints can heteroptic ossification (HO) develop in stroke?
Extensor surface of elbow
Shoulder
What is seen on exam in Inferior shoulder subluxation in hemiplegia?
Acromio-humeral separation
Flaccid
What diagnostics should be done in Inferior shoulder subluxation in hemiplegia?
X-ray in standing position Scapular plane view
What is the treatment of Inferior shoulder subluxation in hemiplegia?
FES
What is seen on exam in rotator cuff tear in hemiplegia?
- Positive abductiontest
- Positive drop armtest
- Flaccid or spastic
What diagnostics should be done in rotator cuff tear in hemiplegia?
- X-ray
- Arthrogram
- MRI
- Subacromial injection of lidocaine
What is the treatment of rotator cuff tear in hemiplegia?
- Steroid injection
- PT/ROM
- Possible surgical repair
- Reduction of internal rotator cuff tone
What is seen on exam in CRPS Type I in hemiplegia?
- MCP compression test
- Skin changes color
- Flaccid or spastic
What diagnostic tests should be done in CRPS Type I in hemiplegia?
- Triple phase bone scan
* Stellate ganglion block
What are treatments for CRPS Type I in hemiplegia?
- Oral corticosteroids
* Stellate ganglion block
What is seen on exam in Adhesive capsulitis in hemiplegia?
- ER <15 degrees
- Early dec scapular motion
- Spastic
What diagnostics should be done in Adhesive capsulitis in hemiplegia?
Arthrogram
What are treatments for Adhesive capsulitis in hemiplegia?
- PT/ROM
- Debridement manipulation
- Subacromial/GH steroid injections
- Intra-articular steriods
- Oral steroids
- Reduction of IR cuff tone
What is seen on exam in Impingement syndrome in hemiplegia?
- Pain with abduction of 70°–90°
- End-range pain with forward flexion
- Usually spastic
What are diagnostic tests of Impingement syndrome in hemiplegia?
Subacromial injection of lidocaine
What are treatments of Impingement syndrome in hemiplegia?
- PT/ROM
- Scapular mobilization
- Subacromial steroid injection
- Reduction of internal rotator cuff tone
What are exam findings of Biceps tendinitis in hemiplegia?
- Positive Speed’s/Yergason test
* Flaccid or spastic
What are diagnostics/treatments of Biceps tendinitis in hemiplegia?
Tendon sheath injection of lidocaine
How does spasticity present in stroke patients (pattern, timing)?
Days to weeks after stroke in upper-extremity flexor and lower-extremity extensor patterns
What are negative risk factors for return to work post-stroke?*
Low score on Barthel index on discharge from rehab
Prolonged rehab LOS
Aphasia
Prior alcohol abuse
What is the Barthel index?
Functional assessment tool that measures independence in ADLs on 0 to 100
scale
What are the functions graded on the Barthel index?
Feeding Bathing Grooming Bowels Bladder Toilet use Transfers (bed to chair and back) Mobility (on level surfaces) Stairs
