Exam 3: Stroke Intervention Flashcards
What are the four facilitation models we can combine to create evidence based practice?
- Brunnstrom’s
- Rood’s
- Bobath or NDT
- PNF
What are the two task oriented model approaches we can combine to create evidence based practice?
- MRP
- Constraint-Induced Movement Therapy
What theory is Brunnstrom’s Movement Therapy in Hemiplegia based on?
Hierarchical model
What are the two main components of Brunnstrom’s Movement Therapy?
- Synergies
- Stages of motor recovery
What would treatment look like via Brunnstrom’s Movement Therapy?
Early stages reinforce synergies, and do not practice movements that deviate from synergies until stage 4 of motor recovery
Does evidence support or refute encouraging movements within synergies as a form of treatment?
Refute – current evidence does not support reinforcing synergy as once it is established, these primitive patterns are difficulty to change
What is the definition of associated reaction?
An involuntary automatic movement in involved limb with active or resisted movement of another body part
What is the definition of homolateral synkinesis?
A flexion pattern of the involved UE facilitates flexion of the involved LE
What is Ramiste’s phenomenon?
Involved LE will abduction or adduction with applied resistance to the uninvolved LE in the same direction
What is Souque’s phenomenon?
Raising involved UE above 100 degrees with elbow extension will produce extension and abduction of the fingers
What is the Rood Sensory Motor Approach?
Use of sensory stimulation to facilitate and inhibit motor responses. Believed that exercise must provide sensory feedback in order to be therapeutic
What facilitation techniques are used with the Rood Sensory Motor Approach?
Approximation, joint compression, icing, light touch, quick stretch, resistance, tapping, traction
What inhibition techniques are used with the Rood Sensory Motor Approach?
Deep pressure, prolonged stretch, neutral warmth, prolonged cold
What is NDT?
Individualized intervention that seeks to promote normal movement patterns via key points of control, facilitation, and inhibition
What are the four stages of NDT treatment?
Preparation, progression, simulation, and function
What is considered when choosing the correct theoretical approach for intervention in stroke patients?
No one approach is right of all individuals. Facilitation may be beneficial when motor control is limited. Task training and CIMT require active control. Compensation may be indicated if necessary to achieve functional goals
What are general considerations when planning interventions for patients with stroke?
Sequence of activities, stages of motor control, sensory and motor function, active control in all three planes is essential for function, function requires asymmetrical and reciprocal movements as well, and tone must be managed
What are the risks of mobilizing patients in acute care following stroke?
Adverse events, increased inflammation, expansion of ischemic lesion, worse functional outcome
What are the benefits of mobilizing patients in acute care following stroke?
Use it or lose it, release BDNF and promote neurogenesis, promote neuroplasticity and functional mobility, reduce secondary complications associated with bed rest
What is the grade A evidence recommendation from the CPG when considering patients following acute stroke?
It is recommended that early rehabilitation for hospitalized stroke patients be provided in environments with organized interprofessional stroke care
What treatment is most harmful according to the CPG for acute stroke care?
High-dose, very early mobilization within 24 hours of stroke onset should not be performed because it can reduce the odds of a favorable outcome at three months
True or False: High-dose early mobilization less than 24 hours post stroke is contraindicated
True
When is a lower dose, early mobilization program indicated following stroke, and what are the benefits?
24-72 hours post stroke. No increased adverse events and improved outcomes
How frequently should a pt be repositioned to maintain ROM?
Every two hours
When should you do PROM with terminal stretch daily?
Early intervention to prevent loss of ROM
When should you do PROM with terminal stretch at least twice a day?
If a contracture starts to develop
What are two other considerations in order to achieve full ROM?
Edema and tone management
What are ROM precautions for working with the UE?
Need ER and distraction paired with a mobile scapula if the shoulder is flexed above 90
Should you use overhead pulleys to achieve ROM with a stroke patient?
No - they are contraindicated because they do not have a mobile scapula or normal GH rhythm
What are examples of safe self-ROM that can be taught early?
Arm cradling, table top polishing, reach to floor in sitting, lying on the beach if scapulohumeral rhythm is intact
What are examples of interventions to improve spasticity?
Optimal positioning, early mobilization, daily stretching, position in lengthened position with weight-bearing, slow rocking, modalities
What modalities can be used to decreased spasticity?
10-15 minutes of cold to decrease nerve conductivity, massage, e-stim to antagonist for reciprocal inhibition, botox
What are the results of progressive resistive strength training in stroke patients?
Improve strength, spasticity does not increase, ROM is not limited
What are two key principles for strength training in patients following a stroke?
- Specificity of training
- Combine with task specific training
What are the parameters for strength training in patients following a stroke?
3 sets of 8-12 reps
2-3x per week
What are three precautions for strength training in patients following a stroke?
Hand function, impaired sensation, risk of falls
What interventions should you avoid when doing strength training with stroke patients who also have hypertension or cardiac disease?
High intensity sustained max, isometrics, valsalva, supine exercises
What are examples of sensory retraining programs?
Mirror therapy, repetitive sensory discrimination, bilateral simultaneous movements, task practice
What are examples of sensory integrative treatment?
Normalize tone, augment cues, practice function
What are examples of sensory stimulation intervention?
Compression, weightbearing, mobilization, e-stim, thermal stimulation
What are interventions for hemianopsia and unilateral neglect?
Teach visual scanning, direct attention to involved side with cuing, encourage active movement of involved limbs
Following an acute stroke, what intervention is recommended to work on aerobic capacity?
Minimize bed rest with early mobilization (following 24 hrs). Can follow with traditional training as time passes
What are exercise precautions for interventions targeting aerobic capacity?
Monitor HR and PRE, avoid holding breath or valsalva, be aware of medications that can decrease cardiac output
What screening is recommended with the CPG for aerobic exercise in stroke patients?
Screen for CVA and TIA. Can use submax stress test
What are the parameters for aerobic exercise in stroke patients according to the CPG?
3 days per week for at least 20 minutes. Duration of at least 8 weeks, but continued indefinitely. Should continuously monitor HR as well as RPE and BP
How should aerobic exercise be progressed according to the CPG for stroke patients?
Increase duration by 5-10 minutes every 1-2 weeks. Increase intensity by 5-10% every 1-4 weeks.
What are the 6 general considerations for interventions to improve UE function?
- Maintain pain free ROM
- Maintain or restore normal shoulder mechanics
- Encourage active functional movements with the hand and arm involved
- Maintain and re-train the sensory system
- Avoid trauma
- Educate pt and family
What is the SAFE Model?
Tool to predict UE function at 6 months within the first 72 hrs following a stroke
What motions are examined with the SAFE Model?
Shoulder abduction and finger extension
How will a pt present if they have a 98% probability of regaining arm dexterity at 6 months according to the SAFE Model?
Some voluntary finger extension and shoulder abduction
How will a pt present if they have a 25% probability of regaining arm dexterity at 6 months according to the SAFE Model?
No voluntary finger extension and shoulder abduction
If a pt is considered to have recovered arm dexterity, what would the ARAT cutoff score be?
At least 10
What are examples of interventions if a pt does not have voluntary movement following a stroke?
Maintain PROM, prevent and manage edema, sensory retraining, manage spasticity, positioning, pt education, motor imagery, mirror therapy, e-stim, supportive devices, avoid splinting, compensatory techniques
What are examples of interventions if a pt does have voluntary movement following a stroke?
Maintain PROM, AAROM, sensory retraining, manage spasticity, pt education, motor imagery, mirror therapy, e-stim, supportive devices, robot assisted therapy, bilateral arm training, trunk restraint
What are examples of interventions if a pt is able to perform shoulder abduction against gravity following a stroke?
Sensory retraining, motor imagery, mirror therapy, e-stim, EMG triggered e-stim, robot assisted therapy, bilateral arm training, trunk restraint, task-specific training, video games
What are examples of interventions if a pt is able to perform finger extension following a stroke?
Sensory retraining, motor imagery, mirror therapy, trunk restraint, task-specific training, video games, strength training, CIMT
What are examples of interventions for pt who have or are at risk of shoulder pain following a stroke?
Education, gentle mobilization, e-stim for subluxation, analgesia, team prevention, avoid strapping, botox
What are strategies to reduce the risk of shoulder subluxation?
Position in supportive position with arm board of lap tray with lateral elbow guard, NMES, biofeedback, taping
What are benefits of using a sling following a stroke?
Protect from traction injury to soft tissue, nerves, and vasculature. Therapists are then free to help with mobility
What are the cons for using a sling following a stroke?
Little reduction of subluxation, arm position can increased flexor tone and contractures, increase neglect and learned non-use
What are the recommended guidelines for using a sling following a stroke?
Minimize the use, select the appropriate sling for the individual, consider alternatives such as taping the humerus and scapula, putting the hand in their pocket, NMES
What are the four main categories of shoulder pain?
- Flaccid presentation
- Shoulder impingement
- Adhesive capsulitis
- Complex regional pain syndrome
How will a pt present who is in the flaccid category in terms of shoulder pain?
Lack of tone, proprioception, and muscle activation. Subluxation that is not initially painful, traction, chronic pain
How will a pt present who is in the shoulder impingement category in terms of shoulder pain?
Impingement symptoms occur with flexion and abduction when there is not normal GH rhythm
How will a pt present who is in the adhesive capsulitis category in terms of shoulder pain?
Hypertonia will restrict movement. Secondary tightness of ligaments, tendons, and joint capsule. Intrascapular inflammation can also occur
Why might a pt experience complex regional pain syndrome following a stroke?
Changes to the ANS
What activities should be avoided when a pt has shoulder pain following a stroke?
Avoid PROM without adequate scapular mobility, traction, pulling on UE during transfers, overhead pulleys
What interventions should be considered for a pt with shoulder pain following a stroke?
Mobilizing the scapular in sidelying, work towards approximation of the humerus in the glenoid fossa, establish normal scapula and GH rhythm, reduce subluxation
What does CRPS stand for?
Complex Regional Pain Syndrome
How will a pt present in Stage 1 of CRPS?
Pink discoloration, cool, hypersensitivity, guarded movement. Is highly reversible
How will a pt present in Stage 2 of CRPS?
Decreased pain, dystrophic changes, early osteoporosis. Has a variable prognosis
How will a pt present in Stage 3 of CRPS?
Atrophic phase of skin, muscle, and bone. Is not reversible
What treatment is indicated for CRPS?
Proper positioning and handling, PROM, grade 1/2 mobilizations, shoulder PROM with scapular mobilization, AROM, edema management
Once edema has resolved, what residual deformities can be seen in a pt with CRPS?
Wrist flexion, ulnar deviation, flattened palm, decreased arch definition, decreased web space, decreased MCP flexion, decreased finger adduction
What postures should be selected to enhance postural control and force production in pt’s following stroke?
Promote extended postures. High sitting with the hips above knees, standing, squatting
What muscle activation should be encouraged when selecting transitions?
Trunk activation, limb extensors and abductors
What is Pusher’s Syndrome?
Lateral postural imbalance caused by pushing with a stronger extremities toward the involved side. Will resist correction to midline
What brain structures are likely impacted with Pusher’s Syndrome?
Posterolateral thalamus, insula, operculum
Will a pt will Pusher’s Syndrome have intact vision and vestibular perception?
Yes
If a pt has Pusher’s Syndrome, how much is their perception off by in degrees?
Approximately 20 degrees off of true vertical
What are the three criteria needed to diagnose Pusher’s Syndrome?
- Spontaneous body posture with tilting toward the more paretic side
- Increased pushing by less involved limbs (increased abduction and extension)
- Resistance to passive correction of posture
Will a pt with Pusher’s Syndrome lean towards either affected or unaffected side?
Toward their affected side
What score on the Clinical Assessment Scale for Contraversive Pushing is indicative of Pusher’s Syndrome?
Score of 1 or higher for each of the three criteria
What is the Burke Lateropulsion Scale?
17 point scale that examines postural alignment and degree of resistance when moving pt passively in functional positions
What positions are assessed on the Burke Lateropulsion Scale?
Supine, sitting, standing, transfers, walking
Why would you use the Burke Lateropulsion Scale?
Assess for mild Pusher’s Syndrome because it is more sensitive to mild symptoms and more sensitive to change
What four activities will a pt with Pusher’s Syndrome typically have more difficulty with compared to a typical stroke pt?
Standing, walking, transfers, ADLs
Does a pt with Pusher’s Syndrome have a worse prognosis compared to a typical stroke pt?
No, their deficits can be corrected with proper identification and intervention training
What are the four treatment objectives for a pt with Pusher’s Syndrome?
- Assist pt to learn their perception of vertical is incorrect
- Direct pt to visually explore surroundings and look for visual verticals
- Encourage pt to reach, weight shift, and transfer to their less involved side
- Practice dual task
What are the appropriate conditions for performing standing weight shifts with a pt with Pusher’s Syndrome?
Active movement only and shifting toward the strong side
What intervention principles are important for a pt with ataxia following stroke?
Address active trunk control and stability, functional, progress by reducing their BOS and decrease reliance on UE
When initially addressing stability challenges with ataxia, what position should interventions be in?
Closed chain, mid-range movement
What are three considerations when progressing from closed chain activities to modified open chain activities?
Sensory feedback, grade recruitment, limit degrees of freedom
According to the CPG for locomotion in stroke patients, what interventions should be performed?
- Moderate to high intensity aerobic walking training at 70% HR max
- VR coupled with treadmill training
According to the CPG for locomotion in stroke patients, what interventions may be considered?
- Strength training of sets and 1 RM
- Circuit training
- Cycling
- VR with standing balance
According to the CPG for locomotion in stroke patients, what interventions should not be performed?
- Sitting and standing balance without augmented visual input
- Robot-assisted walking training
- BWSTT with therapist assistance
When will recovery from a stroke be the fastest?
First few weeks to months
How long will a pt be admitted to inpatient rehab following a stroke on average?
2 weeks
What factors are associated with a poorer outcome?
Advanced age, severe motor impairments, medical issues, impaired cognition, severe language issues, severe hemineglect, low SES
What % of patients will present with a decline in mobility at a 2 year follow-up, and what is the major risk factor associated with the decline?
12%, depression
