Exam 2 Content Flashcards
Loss of trunk control is common in those who have had a …
Stroke
Impairments in trunk control includes…?
weakness, loss of stability, stiffness, and loss of proprioception
weakness, loss of stability, stiffness, and loss of proprioception causes?
Dysfunction in upper/lower limb control
Increased fall risk
Potential for spinal deformity/contracture
Impaired ability to interact with environment
Visual dysfunction resulting from head/neck malalignment
Dysphagia due to proximal malalignment
Decreased independence in ADLs/IADLs
Decreased sitting and standing tolerance, balance, and function
What movements are available at the trunk?
Vertebral Column ROM: Flexion Extension Lateral Flexion Rotation Normal spinal alignment and curvatures Cervical, thoracic, lumbar, and sacral curvatures (see pg. 362 for image)
Stroke patients often assume postural …?
malalignment both observed and palpated
Assessment: Trunk Control Test
Trunk Control Test
What are the 4 functional movements?
4 functional movements:
1) roll from supine to weak side,
2) roll from supine to strong side,
3)supine to sit,
4) sitting EOB 30 sec (feet off the ground)
Scored 0 = unable, 12 = able to perform but abnormal, 25 = normal
Scores 0 - 100
Assessment: Trunk Impairment Scale (A) & (B)
What the starting position?
Trunk Impairment Scale:
Starting position EOB or mat, feet flat on floor arms in lab (no back or arm support)
3 static items, 10 dynamic sitting items, 4 trunk coordination items
Scores range from 0 – 23
Assessment: PASS
Postural Assessment Scale for Stroke (PASS)
What’s assessed in the PASS?
12 items scored from 0 to 3
Higher scores = better performance
Sitting without support, standing with and without support,
standing on nonparetic leg, standing on paretic leg, supine to affected side, supine to non affected side, standing and picking up a pencil on the floor
What are the Eval Trunk Movement Patterns?
Trunk Flexion
Trunk Extension
Lateral Flexion
Rotational Control
What are some treatment for trunk control in stroke patients?
Position of Readiness
Remedial
Purposeful tasks and activities that encourages:
AROM of trunk in all degrees of freedom: rotation, lateral flexion, flexion and extension, to increase strength and endurance
Mirrors for visual feedback, self-correction (OT can ‘mirror’)
Work with client on moveable surfaces
Prevent loss of PROM of spine
Handling (AAROM)
Rote exercise
Treatment:Posturing in stroke patients?
Seated with legs crossed Seated with forearms on table Prone on elbows Kneeling Hip flexion (varied degrees)
Treatment: Pushers Syndrome
What is it?
What are signs?
Occurs when the pt pushes heavily to the affected side and resists passive correction
“Resistant to accepting weight on and actively pushing away from the nonparetic side”
Signs:
Holding on to bed or mat as if they were falling
Head turned away from affected side
Decreased ability to detect stimuli from affected side
Resistance to attempts to transfer weight to stronger side
S
Treatment: Visual Feedback & Mental Practice for Trunk control in stroke pts
success in increasing symmetrical weight bearing in CVA clients by training them with a combination of visual feedback and mental practice.
Visual Feedback = subjects stood on a platform with sensors connected to a computer screen that monitored their posture;
participants needed to try to align their posture in accordance with equal (B)
weight shifting utilizing visual feedback from the computer screen image.
Mental practice = mental imagery on proper posture and symmetrical (B) weight shift.
Treatment:Compensatory
Environmental Mods & AE for Trunk control in stroke pts
Lateral supports to maintain trunk stability during tasks
Cushions, armchairs, lab tray
Place items within reach
ADL AE: long handled AE, elastic laces, reachers, tub seat, commodes, grab bars, bed rails
What are some EPB for trunk control in stroke pts
Evidence Based Practice
Trunk Training Exercises (TTE): sitting or supine, aimed at improving trunk performance and functional sitting balance
Sitting Training Protocol
(STP): program designed to improve the ability to balance in sitting by reaching beyond arm’s length using the unaffected hand while focusing on 1) smooth coordinated motions in trunk and hand, 2) appropriate loading of the affected foot, 3) preventing maladaptive strategies
Trunk Exercises (TE): movements of the upper and lower trunk and raising UE in supine or sitting
TTE improved maximum reach using the modified Reach Test
Results: Moderate evidence to support the use of TTE to improve trunk performance and sitting balance
What is neuroplasticity?
Neuroplasticity is the brain’s ability to change (for better or worse)
The process of neuroplasticity involves …?
forming neuronal connections in response to sensory stimuli from the environment and normal development
Cortical Maps:
Changes in the cortex occur in association with adaptive responses to the environment through everyday activities
Neurogenesis
Adult stem cells can generate new differentiated neurons in the hippocampus, dentate gyrus, and olfactory bulbs
Born with a number of neurons and them build more, this is then pruned off (branches/synapses)
The production of new neurons in the brain
Amplified by certain mental activities: Such as what?
Synaptogenesis
The formation of synapses between neurons in the nervous system
Explosion
Synaptic Pruning
Types of Neuroplasticity: Experience/Practice Dependent
What’s Hebb’s rule?
Hebb’s Rule: it is a learning rule that describes how the neuronal activities influence the connection between neurons, i.e., the synaptic plasticity
Occurs when a person performs a task repeatedly to learn or re-learn a skill
“Neurons that fire together, wire together”
Types of Neuroplasticity:
Competitive Plasticity
Positive Plasticity
Compensatory changes that take place at the cellular and molecular level that form new pathways for function
Natural selection process that occurs with use or disuse.
“Use it or lose it”
Types of Neuroplasticity:
Negative/Positive Plasticity
Compensatory changes that
Negative plasticity: learn things negatively, rigidity, neurons that fire out of sync and fail to link ( fear of falling after 1st fall, follow the same routine/rutt/increase tone/)
Example: bus drivers
Positive Plasticity: take place at the cellular and molecular level that form new pathways for function (ex: taxi drivers- different route compare to bus drivers)
Types of Neuroplasticity:
Competitive Plasticity
Natural selection process that occurs with use or disuse.
“Use it or lose it”
7 Tenets of Neuroplasticity
1) Change can only occur when the brain is in the mood
2) Change strengthens connections between neurons at the same time
3) Neurons that fire together wire together
4) Initial changes are just temporary
5) Brain plasticity is a two way street (Positive and Negative)
6) Memory is crucial to learning
7) Motivation is key
What are 4 Tips for Optimal Plasticity ?
Think how the following can be applied to OT Practice:
(as we get older
1) Heart needs to be in shape: heart supplies O2 Cardio is needed to help develop neuron)
2) Training should be incremental (occur in steps- just right challenge)
3) Taxing, systematically improving (be challenging but successful).
4) Should be interesting to engage the motivation circuits in your brain (motivation)
Process of Recovery
1) Diaschisis – sudden change of function in a portion of the brain connected to a distant, but damaged, brain area
2) Behavioral compensation –
3) Adaptive plasticity –
Edema
Denervation Supersensitivity
Regenerative Synaptogenesis
Collateral Sprouting
Motor relearning and recovery is possible via the ….. of the brain
plasticity
With …. skill is gained and less areas of the brain are recruited to perform a task
repetition
Repetition also stores a motion in…
memory
Limbic system: critical for generating … and … with other areas of the brain
motor tasks and communicating
Cerebellum: critical for …
communicating with frontal lobe
Basal ganglia: critical for …
habit formation
Types of learning:
Procedural learning
Occurs for tasks that are particularly automatic (without attention or consciousness).
Learn through repeated practice in varying contexts
Verbal instruction little help, need hands on practice, practice
Learning is expressed through performance
Appropriate for who?
Types of learning:
Declarative Learning
Created knowledge that can be recalled.
Learning can be verbalized by naming the steps of the task
Mental rehearsing is commonly used (review the activity mentally or by verbalizing the steps/process
With repetition declarative learning can become procedural
Appropriate for who?
Application to OT
The process of …, engaging in tasks (ideally motivating, and, novel), facilitates positive neuroplasticity!
doing
Application to OT
Conversely, …., leads one down the path to negative plasticity – apoptosis (death of neurons).
not doing
Application to OT
…….. – doing again and again (Hebb’s rule) repetition - automaticity
Practice - dependent plasticity
Application to OT
…….. – doing again and again (Hebb’s rule) repetition - automaticity
Practice - dependent plasticity
Increasing the … of a task - enhanced neuroplasticity
complexity
Other types of Application to OT
Virtual Reality/ Computer Gaming
Neurofeedback Trainings
About87%of all strokes are…., in which blood flow to the brain is blocked.
ischemic strokes
Stroke is a leading cause of serious long-term….
disability.
What is stroke?
preventable disease with known risk factors:
What are the risk factors for stroke?
CVA/ Stroke:
TIA: Transient Ischemic Attack:
Infarct:
What’s CVA/ Stroke
a disease of the cerebral vasculature where there is a failure to supply oxygen to the brain
What’s TIA: Transient Ischemic Attack?
Either thrombic or embolic with reversible defects, effects must resolve in less than 24 hrs
Define Infarct:
a localized area of tissue that is dying or dead, having been deprived of its blood supply because of an obstruction by.
What are the types of stroke
Ischemic
Hemorrhagic
Types of Strokes: Ischemic
Embolic
Most common type of ischemic stroke.
Abrupt onset, usually no warning, often caused by emboli that originate in cardiac system, 2nd most common is emboli from atherthrombic lesions (artery to artery)
Thrombic
Most commonly caused by abnormal arterial vessel walls (athersclerosis).
Occlusion of a vessel due to a clot forming in the brain
Usually a more gradual onset, may have warning signs (TIA)
Describe a Hemorrhagic stroke
A hemorrhagic stroke is when blood from an artery begins bleeding into the brain.
This happens when a weakened blood vessel bursts and bleeds into the surrounding brain. Pressure from the leaked blood damages brains cells, and, as a result, the damaged area is unable to function properly
What are the types of Hemorrhagic
Deep Hypertensive Intracerebral
Spontaneous Lobar
Ruptured saccular aneurysms
Bleeding from an arteriovenous malformation
What type of hemorrhagic stroke is described below:
Found throughout the body and can occur in any part of the brain.
Usually congenital.
Headaches and seizures are common
Bleeding from an arteriovenous malformation
What type of hemorrhagic stroke is described below:
Characterized by acute, abrupt onset of a severe headache, brief loss of consciousness, nausea, vomiting, focal neurologic deficits, and stiff neck.
Ruptured saccular aneurysms
What type of hemorrhagic stroke is described below:
Occur outside of the basal ganglia and thalamus in the white matter of the cerebral cortex.
Often associated with clients with AVMs (arteriovenous malformation), bleeding diatheses, tumors, aneurysms in the circle of Willis.
Acute onset of symptoms, coma/stupor much less common, headaches common
Spontaneous Lobar
What type of hemorrhagic stroke is described below:
Small penetrating arteries in the deep brain that have damage from HTN.
Develops in minutes to an hour. Rapid recovery in first 2-3 months.
Pt usually awake and under emotional distress when it occurs. Vomiting and headache common.
Deep Hypertensive Intracerebral
What does FAST stand for?
F: Facial drooping
A: arm weakness
S: Speech difficulties
T: Time (call 911 ASAP)
What are other symptoms to watch for due to a stroke other than FAST
Other Symptoms to watch for:
Sudden NUMBNESS or weakness of face, arm, or leg, especially on one side of the body
Sudden CONFUSION, trouble speaking or understanding speech
Sudden TROUBLE SEEING in one or both eyes
Sudden TROUBLE WALKING, dizziness, loss of balance or coordination
Sudden SEVERE HEADACHE with no known cause
What does a CT (Computed Axial Tomography)
scan rules out, helps determine but what may it not rule out?
Readily available, often the standard. Rules out other conditions and helps determine if there is evidence of a bleed. An acute CT scan may not show stroke but may rule out non stroke (tumors).
What’s an advantage of getting an MRI (Magnetic Resonance Imaging)?
More common today as cost and availability have improved.
Advantage is it allows earlier detection of infarcts. Can rule out other conditions and screen for acute bleeding.
What are 3 things to do for acute management in a stroke patient
1) Identify cause of stroke
2) Preventing the progression of the lesion
3) Treating the stroke
Treating stroke:
Want to reestablish blood flow, decrease neuronal damage, and decrease edema of damaged tissue (done through pharmacology and surgery)
if ischemic:
need to get blood flowing – blood thinners to decrease clotting:
Aspirin (anti-platelet)
Heparin (anti-coagulation)
Also, t-PA (tissue plasminogen activator) –
Immediately restores circulation must be administered w/in 3-6 hours of onset, and after hemorrhagic CVA has been ruled out
Stroke: if hemorrhagic: what needs to be control? What needs to be decreased?
need to control pressure and vasospasm, and decrease chance of re-bleed.
What is an OT’s role in acute care hospital ?
OT role:
- Evaluate and make recommendations for d/c
- Patient and family education
- Decrease risk of complications
- Initiate OT rehabilitation
OT’s Role in acute care hospital: Describe Evaluate and make recommendations for d/c
Check to make sure you have orders
Review the medical record and communication with RN/MD to ensure OT is appropriate
Begin with gross assessment of mental status, strength, and vital signs. Assess motor skills, cognitive functioning, and ADLs
See table of common acute care assessments Gillen pg. 29
OT needs to be confident with monitors (HR= 60 to 100, BP= systolic ,20 Hg, diastolic <80 mm Hg), Oxygen= 92 to 100%what are the normal ranges? and ICU equipment (catheter, IV lines, feeding tubes, spinal and cranial drains, ventilator)
common acute care assessments
NH Stroke scale; Mini FIM; Glasgow Coma Scale, Orpington Prognostic Scale; Barthel Index; JKF Coma Recovery Scale;
OT’s Role in acute care hospital: Describe Patient and family education
What is a CVA and what are the implications for the client’s ability to function?
What are the symptoms the client is presenting with, and what are the specific functional implications?
What can family and friends do to help? (bring in clothes and familiar items, stand on neglected side, etc.)
What is occupational therapy?
Recommendations for d/c (this will depend on the setting they are being discharged to)
OT’s Role in acute care hospital: Describe Decrease risk of complications
- Contractures
Prevalent in paretic limbs. Only 10% recover limb strength and mobility enough to prevent contractures.
Can begin within days to weeks after
Usually a pattern of flexion, adduction, and IR
TX How?: ROM;prolong stretching, splinting, deep heat, possible surgical release, botox) - Fall Prevention
Increased risk due to acuity of balance, visual perception, and spatial perceptions deficits
TX How?: balance, cognition training, removing hazards, use AE) - DVT
Deep Vein Thrombosis in 23-75% of strokes.
Risk factors??: immobilize, post operative state, history of cardiac, obesity, pregnancy)
Symptoms: swelling, tenderness, redness, pain (confused for gout, cellulitis)
What do you do if you client presents with signs of DVT? let the nurse know, dont move the limb, put client on hold till can further assess)
- Skin Integrity
At risk of pressure ulcers due to??: abnormal sensation, Contractures, malnutrition, immobility, soft tissue atrophies
Prevention??: pressure relief mattress, frequent re-position, up and down schedule, training staff caregiver for positioning, nutrition to encourage skin health
OT’s Role in acute care hospital: Describe initiate OT rehabilitation
What you choose to focus on depends on how long you anticipate treating the client for. May be days or weeks. Need to prioritize based on where they are being d/c’d (Home vs a SNF)
- Splinting: correct malalignment and protect joint integrity, prevent shortening of soft tissue/contractures, maintain skin integrity
- Positioning: OT will develop a positioning schedule (up down schedule)
-Bed mobility: rolling B sides, bridging, sidelying B sides
Weight bearing for Function: encourage use of B UE in tasks and in support. Sitting and standing
-Edema Management: communicate with RN, is it cool or warm, skin color, firmness
Tx: elevation above the heart, Active or AAROM, manual massage
- Shoulder Management: prevent or increase shldr pain/subluxation with proper handling and positioning
- Dysphagia: Stroke higher risk of aspiration pneumonia. NPO (nothing by mouth), See Gillen pg 36 for oral motor screening
Recovery from stroke: Describe Neurologic recovery
Neurologic recovery
Intrinsic = remediation of neurological impairments (return of movement)
Many do not regain full movement of UE (65% one study)
Proximal to distal movement
Mass patterned undifferentiated movement to selective coordinated movement
Recovery from stroke: Describe Functional recovery
Functional recovery
Compensatory adaptive = regaining the ability to perform meaningful tasks with compensatory strategies (neuro not fully regained)
10% recover complete function, 25% recover with minor imp, 40% moderated to severe imp, 10% 24 hour care, 15% die
EBP: OT practice guidelines for adults with stroke:
Use of occupation based interventions to improve ADL performance
Use of activities/occupations to increase leisure participation
Visual scanning training (VST)
Repetitive task training (RTP) for motor impairment to improve UE balance, balance, and mobility, and activity participation
Combining a task oriented training with cognitive strategies to improve UE function (repetitive task training and action observation (AO) = example)
Finish these statements:
1) Clients with a decrease in disability awareness can pose a danger to self and others by ….
2) An increase in disability awareness correlates w/ an increase in …
3) Rehab interventions should be adjusted according to the patient’s level of awareness; if poor, OT should …
4. Disability awareness should continually be …
- overestimating their abilities
- ADL performance
- should pursue compensatory strategies (changes to the environment, recommend more supervision, etc.)
- assessed throughout the rehabilitation process
Theoretical Assumptions:
Systems model of Motor Control
Emphasis on the interaction between the person and the environments and suggests that motor behavior emerges from these interactions with the environment and unique tasks
Nervous system seen as one system among many that affects motor behavior
Theoretical Assumptions:
Ecological Approach
Emphasis on the interaction between the person and the environment during functional tasks and the link between perception and action
2 concepts in Ecological Approach: Object accordance
Variability:
Object accordance: objects characteristics : influence motor output of the individual
Variability: role of the muscles determine the context the muscle is being used
EBP Article: Object Affordance
What 3 categories of object accordance manipulation
What were the Results and Clinical Implications?
Review of 35 articles Looked at 3 categories of object affordance manipulation: 1) Number of objects, 2) Functional information, 3) Functional goals:
Results: increasing object affordance can produce beneficial effects on immediate motor performance and learning
Clinical Implications: Clinicians should use tasks with high object affordance during both assessment and treatment to promote optimal motor performance.
Theoretical Assumptions: Dynamic Systems Theory
Behaviors emerge from the interactions of many systems and subsystems
Even with many degrees of freedom, individuals tend to perform tasks using the same stable patterns of motor behavior
Behaviors can shift from stable to unstable throughout our lives
When unstable new behaviors emerge either gradually or abruptly = called phase shifts
Control parameters are variables that shift behavior from one form to another
Theoretical Assumptions: Systems View of Motor Development
Changes are caused by multiple factors such as the nervous system, biomechanical constraints and resources, and the physical and social environments.
Normal development does not follow a rigid sequence
Behaviors observed after CNS damage (stroke) result from patients attempting to use the remaining resources to achieve functional goals
Theoretical Assumptions:
Contemporary View of Motor Learning
Define random practice:
Define Self controlled practice:
What’s dyad training?
Feedback:
- Random practice: (repetitive practice of several tasks in varied sequence, varied context, whole task) is better for motor learning than blocked practice (repetitive practice of the same task, same context, part of task)
- Self controlled practice (person decides when and how feedback is given and if AD is used) is better than instructor-controlled practice.
- Dyad training in which the person can observe and practice a task is beneficial to learning a new task
- Feedback: can interfere with long term learning, decreased feedback better than increasing, summary feedback after multiple trials is better than feedback after every trial
Systems Model of Motor Behavior Cognitive = Psychosocial = Sensorimotor = Physical = Socioeconomic = Cultural =
Person made up of:
Cognitive = ability to do tasks etc (ex: orientation, attention, memory, problem solving, learning, generalization)
Psychosocial = interest, coping skills, self concept/expression, self control, interpersonal skills, time management
Sensorimotor = strenght, endurance, ROM, pain, sensory function postural functions
Environment of:
Physical = objects, tools, furniture, plants, animals, nature, man made
Socioeconomic = family, friends, caregiver, community, financial resources
Cultural = customs, beliefs, tradition, activity patterns, behavioral standards
Evaluation: What’s the 5 steps for Using a top down approach
Step 1) Role Performance
Step 2) Occupational Performance Tasks
Step 3) Task Selection and Analysis
critical control parameters
Step 4) Perform specific assessments of client factors, performance skills, and performance patterns
Step 5) Evaluation of the environment: context and activity demands
TOA: Treatment
Treatment:
Help the patient adjust to role and task performance limitations
Create an environment that uses the common challenges of everyday life
Use as close to real work environment as possible - why can this be difficult in OT settings?
Practice functional tasks or close simulation to find effective and efficient strategies for performance
Provide opportunities for practice outside of therapy time
Use contemporary motor learning principles in training or retraining skills
Minimize ineffective and inefficient movement patterns
Remediate an impairment (client factor) if it is the critical control parameter
Adapt the environment, modify the task, use AT, or reduce the effects of gravity
Constrain the degrees of freedom
Constraint-Induced Therapy
EBP article: Task Specific Training
What are the 5 R’s
1) RELEVANT: task specific training must hold importance to the client and be within context
2) RANDOM: order and sequence to training
3) REPETITIVE: practice specific task over and over
4) RECONSTRUCTION: practice the whole-task
5) REINFORCE: effective feedback from clinician
TOA: What are the 3 phases in reconstruction?
1) Acquisition phase:
Occurs during initial instruction and practice of skills
client will be slow, clumsy, rigid, utilizing as few degrees of freedom as possible
“phase shifts” here
2) Retention phase:
Occurs after initial practice period as individuals are asked to demonstrate how well they perform the newly acquired skill
Often called Carryover
3) Transfer phase:
Individual uses the skill in a new context
Use strategies learned in real life settings/situations
Efficient movement
Less concentration needed for movement
May be able to ‘multi-task’
Movement may become habitual and automatic
TOA: Reinforce:
Describe task-related; movement related and semantic priming
Task-related : “Take this can from the shelf and place it on the table with your left hand. Pay attention to the can: Think about where it is on the shelf and how big or heavy it is.”
Movement-related: “Take this can from the shelf and place it on the table with your left hand. Pay attention to your arm: Think about how much you straighten your elbow and how your wrist and fingers move.”
Semantic Priming: An action word provided as sensory input prior to performance of a task semantically primes (activates) the motor cortex, enabling the person to process the directions and execute the task more quickly and efficiently.
priming words= lift, grasp, reach
Foundation: Neurophysiological
Hierarchical – nervous system is the overriding system to control motor behavior – with CNS at the top
Sensory input elicits movements
Foundation: Heterarchical
nervous system is only one of the many systems interacting to control motor behavior
Environmental input and task demands elicit movement
Intervention: Neurophysiological
Sensory stimuli facilitates normal motion
Recovery follows a predictable sequence
Changes in behavior reflect neurophysiology
Intervention: TOA
Functional tasks organize normal motion
Recovery is variable
Changes in behavior are an outcome of compensatory efforts to complete a task
Evaluation: Neurophysiological
Posture control Muscle tone & ROM Reflexes Sensation Vision Perception Developmental level
Evaluation: TOA
ROLES & OCCUPATIONAL PERFORMANCE: Role identified OP: BADL/IADL Task selection & analysis Specific performance components necessary for function for individual selected for assessment
Common Deficits of UE After Stroke
Postural Control
Weakness
Spasticity
Contractures
Restorative Interventions of UE
ROM CIMT Manipulation Mental Imagery Mirror Therapy Bilateral Training UE External Technologies
Deficit: Weakness
Changes in the nervous system resulting in weakness after stroke:
- Motor neurons: loss of agonist motor units, changes in firing rates
- Changes in peripheral nerve conduction
- Changes in mechanical and contractile properties of muscles
Hemiplegic: Evidence to support strengthening interventions:
What can the OT manipulate to increase strength?
TOA augmented by resistive exercises using elastic tubing with substantial results
Strength training has no adverse effects on muscle tone
Strengthening interventions increase strength, improve activity, and do not increase spasticity
Hemiplegic: Evidence to support strengthening interventions:
What can the OT manipulate to increase strength?
TOA augmented by resistive exercises using elastic tubing with substantial results
Strength training has no adverse effects on muscle tone
Strengthening interventions increase strength, improve activity, and do not increase spasticity
Hemiplegic: Deficit: Spasticity (what are some type of spasticity that can occur?)
A motor disorder with persistent increase in the involuntary reflex activity of a muscle in response to stretch = a catch all term for multiple problems
*Clinical presentation of Spasticity
Hypertonia
Hyperactive deep tendon reflexes
Clonus
Spread of reflex responses beyond the muscle stimulation
*Clinical presentation of Spasticity
Pts have difficulty initiating rapid alternating movements
Abnormally timed EMG activation of the agonist and antagonist
Fluctuation of spasticity as a result of a change in position
Usual patterns include UE flexion and LE ext
Hemiplegic: Treating Spasticity
What are the -Risks if Not Treated?
-Manual Stretching:
Sustained stretch for 10 min led to significant reduction in spastic hypertonus
Tension applied to soft tissue
-Mechanical Stretching:
Using splints or serial casting to stretch
Wearing schedule and tolerance
-Nerve blocks
Long term blocks such as Botox = reduces muscle tone
-Risks if Not Treated:
Deformity of the limb
Impaired upright function caused by soft tissue contractures
Tissue maceration of the palm - why?
Pain syndromes
Impaired ADLs (UE dressing, bathing of affected hand and axilla)
Loss of reciprocal arm swing during gait activities
Risk of falls because of postural malalignment
Hemiplegic: Deficit: Contractures
Contractures stiffen tissues, immobility creates contractures. Spasticity preserves the contracture by excluding the intramuscular fibrous tissues from the stretching force
Associated with loss of elasticity and fixed shortening of involved tissues including:
Skin, subcutaneous tissue, muscles, tendon, ligaments, joint capsule, vessels and nerves
Hemiplegic: Evaluation of the UE
Motor Activity Log Manual Ability Measure (MAM-36) Self report ABILHAND Questionnaire Self report Arm Motor Ability Test Wolf Motor Function Test Chedoke Arm and Hand Activity Inventory Jebsen Test of Hand Function Action Research Arm Test Motor Assessment Scale Box & Block Test Nine Hole Peg Test The Australian Therapy Outcome Measures
Hemiplegic: Restorative Interventions
ROM CIMT Manipulation Mental Imagery Mirror Therapy Bilateral Training UE External Technologies
Hemiplegic: ROM
Mobilization benefits include joint lubrication, prevention of secondary orthopedic problems (impingement), maintain soft tissue length, and reduce spasticity.
Active preferred over passive whenever possible
Move through complete ROM
Range of Motion
Areas to focus on after Stroke:
Scapula protraction and upward rotation External (lateral) rotation of the glenohumeral joint Elbow ext Wrist ext Composite flexion of the digits Composite ext of the wrist Digit range in intrinsic plus and minus
Constraint Induced Movement Therapy
Traditional protocol:
Modified protocol:
Traditional protocol: protective safety mitt on less impaired UE 90% of the time for 14 days. Weekdays included 6 hrs of training.
Modified protocol:
1) 3 days a week 1 half hour for 10 weeks, Restrained every week day for 5 hours using a sling.
2) training 2 hrs a day, 5 days a week for 3 weeks with limb restrained 5 hours each day outside training.
3) 14 days constrained 90% with 3 hrs of training per day
Motor inclusion criteria: control of wrist and digits is necessary: 20 degrees of wrist ext and 10 degrees of ext in all digits or 10 degrees fo wrist ext and , 10 degrees thumb adb, 10 degrees of ext in at least 2 digits, or able to lift a wash cloth of a table and release.
Hemiplegic: Mental Imagery
- Activates cortical representation and musculature that correlates with the imagined movements. Improves learning and performance. Reorganizes the motor cortex.
- Person imagines a muscle contraction but is not actually activating the muscle. Often audiotape is used with a few minutes of relaxation and several minutes of mental practice of tasks.
- Positive effect on UE recovery. Works in combination with other treatments to improve UE functioning.
Hemiplegic: Mirror Therapy & Bilateral Training
- Patients seated close to table with a mirror (35cm x 35cm) vertically placed. Involved hand behind mirror unaffected hand in front of mirror.
- Patients should only see the uninvolved side. Patients watch the mirror image and try to move both hands in the same movement pattern.
- Results: improves occupation based performance after stroke and UE functioning.
- Patients practice identical activities with both UEs at the same time
Nonparetic limb provides a template for the paretic limb
Protocols vary. Most use functional tasks or repetitive arm movements
Push and pull with B UE (drawers)
Wipe a table with B UE
B cycling
B reaching and place objects using both hands
Hemiplegic: UE External Technologies
E-Stim
Most consistent at improving ROM and reducing pain. Impact on ADLs/function less clear and inconsistent
Improves strength and activation of antagonist muscles. Can also be used to fatigue the hyperactive muscles.
E-Stim Orthoses:
MyoPro :
Spring Action Orthoses:
Saebo:
Most consistent at improving ROM and reducing pain. Impact on ADLs/function less clear and inconsistent
Improves strength and activation of antagonist muscles. Can also be used to fatigue the hyperactive muscles.
E-Stim Orthoses:
MyoPro :
Bioness:
Spring Action Orthoses:
Saebo:
Resistive digit flexion, with, spring (A) extension
(view picture of saebo-stim glove – electric stim version of Saebo)
Key Components of PNF:
Key Components:
- Developmental sequence of movement
- Balanced between agonist and antagonist in producing volitional movement
- Mass diagonal movement patterns for limbs and trunk
- Sensory stim through tactile, auditory, and visual input to promote motor response
- PNF patterns often used within activities, placement of objects
Used successfully for stretching and increased ROM
PNF and Rood: What are the 11 principles of intervention
1) All human beings have potentials that have not been fully developed
2) Normal motor development occurs cervicocaudal and proximodistal
3) Early motor behavior is dominated by reflex activity
4) Early motor behavior is characterized by spontaneous movement (extreme flexion to and from extreme extension)
5) Developing motor behavior is expressed in an orderly sequence of total patterns of movement and posture
6) Motor behavior grows in cyclic trends. Antagonists help develop muscle balance.
7) normal motor development has an orderly sequence but does not necessarily go step by step
8) Locomotion depends on contractions of flexor and extensors and posture for adjustments in imbalance
9) Motor learning is needed for improved motor ability
10) Frequent stimulation and repetitive activity promote motor learning and develop strength and endurance
11) Goal-directed activities combined with techniques increase motor learning
PNF and Rood: What are the 3 components of motor learning
- Auditory System
Verbal commands should be brief and clear ( be aware of your tone of voice)
Timing of command should not be too early or too late
Verbal mediation - say the steps out loud - Visual System
Visual stimuli to initiate and coordinate movements
Track in the direction of motion - Tactile System
Touch is the most efficient form of stimulation
Manual contact to guide the client so they feel the coordinated and balanced movements
Part task and whole task practice = emphasis on parts of the task client has difficulty with then move to whole task
PNF and Rood: Initial assessment to determine client’s abilities, deficits, and potential
1) PNF assessment starts proximal addressing breathing, swallowing, voice production, facial and oral musculature, and visual-ocular control
2) Head and neck for tone, positioning
3) Upper part of trunk, Upper part of extremities
4) Lower part of trunk and extremities
5) Observe during individual movement patterns and during functional tasks
Intervention: Diagonal Patterns D1 flexion: D1 extension: D2 flexion: D2 extension:
D1 flexion: shoulder flex., add., ER, sup.,wrist & digit flex.
D1 extension: shoulder /, abd., IR, pron., wrist & digit /
D2 flexion: shoulder flexion, abd., ER, sup.,wrist & digit /
D2 extension: shoulder /, add., IR, pron.,wrist & digit flex
Review for Techniques Isotonic = Isometric = Antagonist = Agonist =
Isotonic = (of muscle action) taking place with normal contraction., (Have resistance with movement resistance, moving a heavy object up)
Isometric = relating to or denoting muscular action in which tension is developed without contraction of the muscle. (have no movement (pulling on a bar) but still have contraction)
Antagonist = a muscle whose action counteracts that of another specified muscle (relaxes when agonist contracts) triceps relaxes when biceps contracts .
Agonist = a muscle whose contraction moves a part of the body directly. - biceps flexes elbow
PNF and Rood: Intervention Techniques
What are the 4 types of Relaxation ?
1) Contract Relax
Passive motion to the point of movement limitations, followed by isotonic contraction of the antagonist pattern with max resistance - repeated where needed
Used when no active range in agonistic pattern
2) Hold Relax
Isometric contraction of the antagonist (no movement) with resistance followed by relaxation and then active agonistic pattern
Hold static contraction for 3 sec
(Schultz-Krohn, Pope-Davis, Jourdan, McLaughlin-Gray, 2013)
3) Slow reversal- hold relax
Begins with isotonic contractions, followed by isometric contraction, relaxation of the antagonistic pattern, then active movement of the antagonistic pattern
4) Rhythmic Rotation
Effective in decreasing spasticity and increasing ROM
Therapist passively moves the body in the desired pattern
When resistance is felt the therapist rotates the body part slowly and rhythmically in both directions
Once relaxed, continue ROM
Current View of PNF
- PNF techniques are still studied and implemented in various disciplines (OT, PT, Athletic Training , etc.), however . . .
- Overall, modern outlook = there is little (if any) practical use to intentionally facilitating reflexive movements
- A number of research studies have been conducted on PNF in various disciplines during the past decade: most find that PNF is no better than various other intervention techniques
Rood & PNF
3 Similarities
1) applying controlled sensory stimulation to activate reflexive arcs in the body in order to bring about a desired motor response.
2) simulating progression through the developmental sequence will promote motor recovery
3) Focus on promoting balance of stability and mobility
Key components to Rood
Key Components:
-Use of sensory stimulation to evoke a motor response
May inhibit or facilitate muscle tone
Types of stimulation include: tapping, slow rolling, deep pressure (insertion to decrease tone)
- Use of developmental postures to promote changes in muscle tone
- Currently used as adjunctive or preliminary interventions to prepare clients for engagement in occupations
- Multiple limitations exist:
Spasticity & Flaccidity
Flaccidity: Low muscle tone; muscle is soft, extremity feels heavy.
When this abnormal muscle tone is present therapy seeks to: increase strength, AROM, increase awareness
Spasticity: Increased muscle tone; tightness and possible rigidity; involuntary reflexive and contractile activity of the muscle increases in response to stretch.
When this abnormal muscle tone is present, therapy seeks to: decrease tone, loosen up
What are facilitation Techniques?
Facilitation Techniques
1) Tactile Stimuli
Light touch
Light touch or stroking activates the low threshold sensory fibers (A-size) for a reflex of the muscle
2) Brushing
Fast brushing stimulates C size sensory fibers. Max affect 30-40 min after stimulation. Seen more in LE not UE.
(Rust, 2008)
3) Thermal Stimuli A-Icing 3 quick swipes of ice to evoke a reflex withdrawal (similar to light touch) C-Icing Stimulates postural tonic responses Hold ice in place for 3-5 seconds (wipe away water) Similar to fast brushing Precautions:
4) Proprioceptive Stimuli
Quick Stretch
Low threshold stimuli that activates an immediate phasic stretch reflex and inhibits antagonist
Quick movement of the limb or tapping
-Vibration High frequency (100-300 Hz, 100-125 preferred to the belly or tendon if the slightly stretched muscle
-Vibration causes a tonic hold contraction with increases strength
-Stretch to finger intrinsics
Facilitates co contraction of the muscles around the shoulder
-Forcefully grasping a handle
-Heavy Joint Compression
Facilitates co-contraction of muscles around a joint
Done by compression of the therapist or additional body weight by the client removing a support
-Resistance
Causes overflow = more and more motor units are recruited to fire
Rood inhibition Techniques
Inhibition Techniques
-Tactile Stimuli
Slow stroking
Over the posterior primary rami produces general relaxation
Pt lies prone or sits unsupported in a quiet environment. Therapist’s hands move from occiput to coccyx with one hand always in contact, done for 3-5 min for relaxation
-Thermal Stimuli
Neutral Warmth
Over area to be inhibited, flannel or fleece for 10-20 min
Prolonged Cooling
Cooling of the skin to 50 degrees F, may use a cool pack for 20 min
-Inhibition Techniques
Proprioceptive Stimuli
Prolonged Stretch
Limb held for more than 20 sec to lengthen muscle
May be done through splinting, casting, and positioning
Joint Approximation
Light joint compression
Commonly used to relieve shoulder pain, hold until spastic muscle relaxes
Tendon Pressure
Pressure on the tendinous insertion
-Vestibular Stimuli
Slow rhythmic movement is inhibiting
Slow rolling (log roll) supine to side lying decreases hypertonicity
Current views on Rood
There is limited evidence (or none) to support that any motoric gains made via these techniques translate to functional gains.
Current thinking reflects that ‘normalizing’ muscle tone is not necessarily paramount – rather, improving function is the focus: functional use of the musculoskeletal system is possible despite abnormal tone.
Limitations of Rood include: Passivity of client Unpredictable outcome/response Effects very short-lived Poor modern evidence base
Brunnstrom
- Idea that clients with a CVA go through evolution in reverse
- Clearly outlined motor recovery in stages in synergy patterns
- Emphasis of treatment is facilitation of movement from reflexive to volitional
Brunnstrom:
Complete the statements below:
- When extremity is completely flaccid, encourage ….. …… and use reflexive responses to promote …… through ……. stages of recovery.
- As muscle tone and active motion is gained, further utilize reflexive activity combined with sensory input to gain further …., ……., …., and ……
- As active muscle control is gained, ………………and promote movement postures away from massed patterned …… motions towards individual joint control and isolated motions.
- When extremity is completely flaccid, encourage reflexive activity and use reflexive responses to promote progression through predictable stages of recovery.
- As muscle tone and active motion is gained, further utilize reflexive activity combined with sensory input to gain further AROM, endurance, strength, and function.
- As active muscle control is gained, normalize spastic tone and promote movement postures away from massed patterned reflexive motions towards individual joint control and isolated motions.
Flexor Synergy of the UE What is the position of each? Scapula = Shoulder = Elbow = Forearm = Wrist & Digits =
Elbow flex is strongest and occurs first
Evoke flexor synergy by applying pressure to shldr elevation or elbow flexion in the uninvolved UE
Develops 1st (before ext synergy)
To test state “touch your ear (or chin)”
Extensor Synergy of the UE What is the position of each? Scapula = Shoulder = Elbow = Forearm = Wrist & Digits =
Pectoralis major is strongest with shldr horizontal abd and IR appearing first, pronation next strongest, elbow ext is weakest
Can be evoked by applying pressure to horizontal abd of the uninvolved UE
To test state “reach out to touch your opposite knee”
Brunnstrom: Treatment Principles
Treatment Principles
Treatment progresses developmentally from reflex responses to voluntary movement to automatic functional motor behavior
Utilize proprioceptive (resistance, tapping tendon) and exteroceptive (tactile) stimuli to elicit movement
When voluntary movement occurs, 1) ask client to hold (isometric contraction), if able progress to 2) eccentric (controlled lengthening) contraction and finally 3) concentric (shortening) contraction
Always stress movement in both flex and ext once client is able to move voluntarily
Repeat correct movements once completed, should involve functional tasks/goals to increase willed motivation
Brunnstrom: Views & Evidence
Brunnstrom’s traditional theory. Currently, in practice, intentionally promoting associated reactions and reflexive movement is NOT advocated, as we now know such reflexive movement does not lead to development of purposeful, functional motor control.
Current thinking reflects that ‘normalizing’ muscle tone is not necessarily paramount – rather, improving function is the focus: functional use of the musculoskeletal system is possible despite abnormal tone.
Wagenaar et al., 1990 - Evidence shows no significant difference than NDT, both resulted in improvements but not control group to determine if improvements were spontaneous or not.
What’s NDT? (Goals/techniques)
- Goal to normalize muscle tone, inhibit primitive reflexes, and facilitate normal postural reactions
- Techniques include: handling, weight bearing over affected limb, positions for B use of body, avoid sensory input that may impact muscle tone
- NDT continues to be revised and updated with new evidence
What are the principles of NDT?
Principles of NDT:
- Belief in recovery
- A problem solving approach to restore movement and participation in those with UMN lesions (CP and hemiplegia in CVA)
- Regain movement, postural control, and quality of movement
- Compensation is discouraged - Why do you think this is?
- Approach: facilitation, mobilization, practice motor skills for certain tasks, practice task themselves, teach caregivers proper positioning
NDT: After the top down approach (occupational profile and goals) What are the 4 next observation of performance in occupations?
1) assess client’s ability to maintain alignment in postures needed for occupations
2) Determine the typical motor skills needed for the task
3) Assess client’s alignment and movement during basic motor skills needed for everyday tasks = reaching, sit to stand, transferring, and functional goals established
4) Determine underlying impairments that may be contributing to the movement dysfunction
What is the intervention sequence for NDT?
1) Preparation:
Analysis of movement components needed for occupation by looking at body in segments and flow of movement
Setup the environment to promote participation and proper alignment
Mobilization for needed ROM prior to task
2) Movement & 3) Function
Tasks setup to work on specific motor skills
Skills usually addressed outside occupation then incorporated into the whole task
Use of Handling and guiding with the client an active participant decreased as function is gained
Closed chain to open chain
What is are the 2 intervention for NDT handling?
1) Inhibition
Used for abnormal tone and coordination, goal to decrease spasticity and block/eliminate abnormal movement patterns
Restore normal alignment in the trunk and extremities by lengthening spastic muscles
Teach methods for decreasing abnormal posture of UE and LE in tasks
RIPs (reflex-inhibiting patterns) =
2) Facilitation
Used when muscle tone is normal or when spasticity is not present
Used to activate automatic postural responses
Provides sensation of normal movement to the hemiplegic side
Stimulate muscles to contract isometrically, eccentrically, or isotonically
Practice movements with therapist providing some resistance
Teach ways to incorporate the involved side in function
Interventions for NDT handling includes..?
1) Normalize tone
2) Activate movement responses
3) Provide re-education on normal movements
4) Provide sensory input (tactile, proprioceptive, kinesthetic) to counteract loss of sensory memory
5) Address secondary impairments
6) active use of involved UE
7) Weight bearing
8) Practice increase motor performance
Evidence for NDT
NDT as a ‘living concept’ – expected the theory to change and progress over time.
Criticisms of NDT include accusations of the techniques being too passive (some NDT clinicians discourage client movement if they are only able to move abnormally).
On the positive side, because of the emphasis on incorporating the hemiplegic extremities (vs. compensatory one-handed techniques) NDT can send a more hopeful message to the client for neurological recovery.
NDT techniques can be hard to research, as they are individualized to the client, and techniques such as handling are hard to quantify.
Overall limited lower level research (primarily case study report of clients and therapists)
No support that NDT is a superior treatment method but also no support that it was not effective.
Hemiplegic Shoulder: Subluxation Palpation
Client is seated with UE unsupported at the side in neutral rotation
Therapist palpates the subacromial space with the index and middle fingers
Palpate both shoulders for comparison
# of examiner’s finger width is recorded to document amount of separation.
Hemiplegic Shoulder: adhesive changes
Typically result from immobilization, synovitis, or metabolic changes in the joint tissue
Found in 30% of patients with an affected glenohumeral joint
Immobilization can result in capsular restrictions such as frozen shoulder/ adhesive capsulitis
Early PROM important and correct positioning
Adhesive capsulitis:
painful and disabling disorder of unclear cause in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain.
Hemiplegic Shoulder: Brachial Plexus Injury
Diagnosis: flaccidity and atrophy of the supraspinatus, infraspinatus, deltoid, and bicep muscles in the affected UE with increased muscle tone
Treatment: Positioning and PROM/AROM
Prevent traction
Position:
Sling while ambulating
Do Not sleep on affected side
Hemiplegic Shoulder: Shoulder pain
Pain impacts function and linked to depression
Studies: Shldr pain linked to loss of motion, glenohumeral malalignment,
Studies: subacromial area is pain producing, area is prone to trauma without correct handling/ROM
Avoid scapula retraction with forward flexion
Scapula should be protracted with upward rotation during activities
Where should you place items to encourage this?
What are the DO’s for preventing shoulder pain ?
DO’s
Maintain/increase PROM of ER of glenohumeral joint
Maintain scapula mobility on the thorax/ribcage
Educate pt, family, caregivers of precautions
Educate pt to avoid pain
What are the DONT’s for preventing shoulder pain ?
Avoid PROM/AROM beyond 90 in flex/abd (unless there is upward rotation and ER of scapula)
Avoid dangling of affected UE
Avoid traction and forced overhead movements during daily tasks
Where would you see this to avoid?
Use overhead pulleys, forced overhead ROM
Shoulder Hand Syndrome
AKA Complex Regional Pain Syndrome (type I) (CRPS), Reflex Sympathetic Dystrophy (RSD)
Begins with…..?
What are symptoms?
Risk factors:
Begins with severe pain and progresses to stiffness in the shoulder and pain in the entire extremity
Symptoms: Can progress (if untreated) to Frozen Shoulder and cause permanent hand deformities
Cause is unclear (common with stroke), associated with autonomic nervous system changes. Thought to be initiated by a peripheral lesion.
What are the 3 stages of shoulder hand syndrome?
Three stages
1) c/o shldr pain and hand pain, tenderness, and vasomotor changes. Recovery/reversal of symptoms is high
2) Early dystrophy, muscle and skin atrophy, vasospasm, hyperhidrosis, and signs of osteoporosis. Difficulty to treat.
3) Pain and vasomotor changes are rare, soft tissue dystrophy, contractures, and severe osteoporosis. Irreversible at this stage.
Diagnosis: with differential nerve block, stellate ganglion block to see if symptoms alleviate
Protocol to Prevent SHS/CRPS/RSD
- PROM via OT:
- PROM via patient:
-PROM via OT:
Shoulder flexion & abduction only to 90
IR/ER w/ humerus adducted
Respect pain – perform in pain-free range only!
Fingers: move one joint at a time
Flexion w/ wrist supported in neutral
Extension w/ wrist supported in flexion
-PROM via patient:
Do not range affected shoulder w/ intact UE
Shoulder AROM below 90 YES!, but NOT > 90
AROM IR/ER w/ humerus in adduction
PROM of elbow, forearm, wrist OK in pain free range only.
Do not range digits w/ intact UE
Supports are used to …
align, protect, or support the affected UE
Pros and Cons of supports
PROS:
Protects client from injury during transfers
Allows therapist freedom to assist with trunk control
May prevent soft tissue stretching
Prevents prolonged dangling of the UE
May relieve pressure on the brachial plexus
Supports weight of arm
CONS:
May contribute to neglect of UE and learned nonuse
May hold UE in shorted position
Fosters dependence and passive positioning
May initiate shoulder-hand syndrome
May predispose for shldr pain
Does not reduce subluxation
Approximates head of humerus to malaligned scapula
Prevents reciprocal arm swing in ambulation
Blocks sensory input
Prevents balance reaction of the UE
Supports: Overall Findings
Therapists should minimize sling use
May be effective to support affected UE in initial transfers and gait training
Slings that position client in flexor pattern should only be worn when client is in an upright posture
Evaluate each client using Pros and Cons, and continually evaluate as needed
Therapist needs to be aware of sling options
Review options for taping or strapping
Supports: Overall Findings
Therapists should minimize sling use
May be effective to support affected UE in initial transfers and gait training
Slings that position client in flexor pattern should only be worn when client is in an upright posture
Evaluate each client using Pros and Cons, and continually evaluate as needed
Therapist needs to be aware of sling options
Review options for taping or strapping
