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NMR II > Exam 3: Stroke Intervention > Flashcards

Exam 3: Stroke Intervention Flashcards

1
Q

What are the four facilitation models we can combine to create evidence based practice?

A
  1. Brunnstrom’s
  2. Rood’s
  3. Bobath or NDT
  4. PNF
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2
Q

What are the two task oriented model approaches we can combine to create evidence based practice?

A
  1. MRP
  2. Constraint-Induced Movement Therapy
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3
Q

What theory is Brunnstrom’s Movement Therapy in Hemiplegia based on?

A

Hierarchical model

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4
Q

What are the two main components of Brunnstrom’s Movement Therapy?

A
  1. Synergies
  2. Stages of motor recovery
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5
Q

What would treatment look like via Brunnstrom’s Movement Therapy?

A

Early stages reinforce synergies, and do not practice movements that deviate from synergies until stage 4 of motor recovery

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6
Q

Does evidence support or refute encouraging movements within synergies as a form of treatment?

A

Refute – current evidence does not support reinforcing synergy as once it is established, these primitive patterns are difficulty to change

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7
Q

What is the definition of associated reaction?

A

An involuntary automatic movement in involved limb with active or resisted movement of another body part

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8
Q

What is the definition of homolateral synkinesis?

A

A flexion pattern of the involved UE facilitates flexion of the involved LE

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9
Q

What is Ramiste’s phenomenon?

A

Involved LE will abduction or adduction with applied resistance to the uninvolved LE in the same direction

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10
Q

What is Souque’s phenomenon?

A

Raising involved UE above 100 degrees with elbow extension will produce extension and abduction of the fingers

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11
Q

What is the Rood Sensory Motor Approach?

A

Use of sensory stimulation to facilitate and inhibit motor responses. Believed that exercise must provide sensory feedback in order to be therapeutic

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12
Q

What facilitation techniques are used with the Rood Sensory Motor Approach?

A

Approximation, joint compression, icing, light touch, quick stretch, resistance, tapping, traction

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13
Q

What inhibition techniques are used with the Rood Sensory Motor Approach?

A

Deep pressure, prolonged stretch, neutral warmth, prolonged cold

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14
Q

What is NDT?

A

Individualized intervention that seeks to promote normal movement patterns via key points of control, facilitation, and inhibition

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15
Q

What are the four stages of NDT treatment?

A

Preparation, progression, simulation, and function

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16
Q

What is considered when choosing the correct theoretical approach for intervention in stroke patients?

A

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

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17
Q

What are general considerations when planning interventions for patients with stroke?

A

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

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18
Q

What are the risks of mobilizing patients in acute care following stroke?

A

Adverse events, increased inflammation, expansion of ischemic lesion, worse functional outcome

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19
Q

What are the benefits of mobilizing patients in acute care following stroke?

A

Use it or lose it, release BDNF and promote neurogenesis, promote neuroplasticity and functional mobility, reduce secondary complications associated with bed rest

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20
Q

What is the grade A evidence recommendation from the CPG when considering patients following acute stroke?

A

It is recommended that early rehabilitation for hospitalized stroke patients be provided in environments with organized interprofessional stroke care

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21
Q

What treatment is most harmful according to the CPG for acute stroke care?

A

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

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22
Q

True or False: High-dose early mobilization less than 24 hours post stroke is contraindicated

A

True

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23
Q

When is a lower dose, early mobilization program indicated following stroke, and what are the benefits?

A

24-72 hours post stroke. No increased adverse events and improved outcomes

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24
Q

How frequently should a pt be repositioned to maintain ROM?

A

Every two hours

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25
Q

When should you do PROM with terminal stretch daily?

A

Early intervention to prevent loss of ROM

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26
Q

When should you do PROM with terminal stretch at least twice a day?

A

If a contracture starts to develop

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27
Q

What are two other considerations in order to achieve full ROM?

A

Edema and tone management

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28
Q

What are ROM precautions for working with the UE?

A

Need ER and distraction paired with a mobile scapula if the shoulder is flexed above 90

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29
Q

Should you use overhead pulleys to achieve ROM with a stroke patient?

A

No - they are contraindicated because they do not have a mobile scapula or normal GH rhythm

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30
Q

What are examples of safe self-ROM that can be taught early?

A

Arm cradling, table top polishing, reach to floor in sitting, lying on the beach if scapulohumeral rhythm is intact

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31
Q

What are examples of interventions to improve spasticity?

A

Optimal positioning, early mobilization, daily stretching, position in lengthened position with weight-bearing, slow rocking, modalities

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32
Q

What modalities can be used to decreased spasticity?

A

10-15 minutes of cold to decrease nerve conductivity, massage, e-stim to antagonist for reciprocal inhibition, botox

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33
Q

What are the results of progressive resistive strength training in stroke patients?

A

Improve strength, spasticity does not increase, ROM is not limited

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34
Q

What are two key principles for strength training in patients following a stroke?

A
  1. Specificity of training
  2. Combine with task specific training
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35
Q

What are the parameters for strength training in patients following a stroke?

A

3 sets of 8-12 reps
2-3x per week

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36
Q

What are three precautions for strength training in patients following a stroke?

A

Hand function, impaired sensation, risk of falls

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37
Q

What interventions should you avoid when doing strength training with stroke patients who also have hypertension or cardiac disease?

A

High intensity sustained max, isometrics, valsalva, supine exercises

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38
Q

What are examples of sensory retraining programs?

A

Mirror therapy, repetitive sensory discrimination, bilateral simultaneous movements, task practice

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39
Q

What are examples of sensory integrative treatment?

A

Normalize tone, augment cues, practice function

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40
Q

What are examples of sensory stimulation intervention?

A

Compression, weightbearing, mobilization, e-stim, thermal stimulation

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41
Q

What are interventions for hemianopsia and unilateral neglect?

A

Teach visual scanning, direct attention to involved side with cuing, encourage active movement of involved limbs

42
Q

Following an acute stroke, what intervention is recommended to work on aerobic capacity?

A

Minimize bed rest with early mobilization (following 24 hrs). Can follow with traditional training as time passes

43
Q

What are exercise precautions for interventions targeting aerobic capacity?

A

Monitor HR and PRE, avoid holding breath or valsalva, be aware of medications that can decrease cardiac output

44
Q

What screening is recommended with the CPG for aerobic exercise in stroke patients?

A

Screen for CVA and TIA. Can use submax stress test

45
Q

What are the parameters for aerobic exercise in stroke patients according to the CPG?

A

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

46
Q

How should aerobic exercise be progressed according to the CPG for stroke patients?

A

Increase duration by 5-10 minutes every 1-2 weeks. Increase intensity by 5-10% every 1-4 weeks.

47
Q

What are the 6 general considerations for interventions to improve UE function?

A
  1. Maintain pain free ROM
  2. Maintain or restore normal shoulder mechanics
  3. Encourage active functional movements with the hand and arm involved
  4. Maintain and re-train the sensory system
  5. Avoid trauma
  6. Educate pt and family
48
Q

What is the SAFE Model?

A

Tool to predict UE function at 6 months within the first 72 hrs following a stroke

49
Q

What motions are examined with the SAFE Model?

A

Shoulder abduction and finger extension

50
Q

How will a pt present if they have a 98% probability of regaining arm dexterity at 6 months according to the SAFE Model?

A

Some voluntary finger extension and shoulder abduction

51
Q

How will a pt present if they have a 25% probability of regaining arm dexterity at 6 months according to the SAFE Model?

A

No voluntary finger extension and shoulder abduction

52
Q

If a pt is considered to have recovered arm dexterity, what would the ARAT cutoff score be?

A

At least 10

53
Q

What are examples of interventions if a pt does not have voluntary movement following a stroke?

A

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

54
Q

What are examples of interventions if a pt does have voluntary movement following a stroke?

A

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

55
Q

What are examples of interventions if a pt is able to perform shoulder abduction against gravity following a stroke?

A

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

56
Q

What are examples of interventions if a pt is able to perform finger extension following a stroke?

A

Sensory retraining, motor imagery, mirror therapy, trunk restraint, task-specific training, video games, strength training, CIMT

57
Q

What are examples of interventions for pt who have or are at risk of shoulder pain following a stroke?

A

Education, gentle mobilization, e-stim for subluxation, analgesia, team prevention, avoid strapping, botox

58
Q

What are strategies to reduce the risk of shoulder subluxation?

A

Position in supportive position with arm board of lap tray with lateral elbow guard, NMES, biofeedback, taping

59
Q

What are benefits of using a sling following a stroke?

A

Protect from traction injury to soft tissue, nerves, and vasculature. Therapists are then free to help with mobility

60
Q

What are the cons for using a sling following a stroke?

A

Little reduction of subluxation, arm position can increased flexor tone and contractures, increase neglect and learned non-use

61
Q

What are the recommended guidelines for using a sling following a stroke?

A

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

62
Q

What are the four main categories of shoulder pain?

A
  1. Flaccid presentation
  2. Shoulder impingement
  3. Adhesive capsulitis
  4. Complex regional pain syndrome
63
Q

How will a pt present who is in the flaccid category in terms of shoulder pain?

A

Lack of tone, proprioception, and muscle activation. Subluxation that is not initially painful, traction, chronic pain

64
Q

How will a pt present who is in the shoulder impingement category in terms of shoulder pain?

A

Impingement symptoms occur with flexion and abduction when there is not normal GH rhythm

65
Q

How will a pt present who is in the adhesive capsulitis category in terms of shoulder pain?

A

Hypertonia will restrict movement. Secondary tightness of ligaments, tendons, and joint capsule. Intrascapular inflammation can also occur

66
Q

Why might a pt experience complex regional pain syndrome following a stroke?

A

Changes to the ANS

67
Q

What activities should be avoided when a pt has shoulder pain following a stroke?

A

Avoid PROM without adequate scapular mobility, traction, pulling on UE during transfers, overhead pulleys

68
Q

What interventions should be considered for a pt with shoulder pain following a stroke?

A

Mobilizing the scapular in sidelying, work towards approximation of the humerus in the glenoid fossa, establish normal scapula and GH rhythm, reduce subluxation

69
Q

What does CRPS stand for?

A

Complex Regional Pain Syndrome

70
Q

How will a pt present in Stage 1 of CRPS?

A

Pink discoloration, cool, hypersensitivity, guarded movement. Is highly reversible

71
Q

How will a pt present in Stage 2 of CRPS?

A

Decreased pain, dystrophic changes, early osteoporosis. Has a variable prognosis

72
Q

How will a pt present in Stage 3 of CRPS?

A

Atrophic phase of skin, muscle, and bone. Is not reversible

73
Q

What treatment is indicated for CRPS?

A

Proper positioning and handling, PROM, grade 1/2 mobilizations, shoulder PROM with scapular mobilization, AROM, edema management

74
Q

Once edema has resolved, what residual deformities can be seen in a pt with CRPS?

A

Wrist flexion, ulnar deviation, flattened palm, decreased arch definition, decreased web space, decreased MCP flexion, decreased finger adduction

75
Q

What postures should be selected to enhance postural control and force production in pt’s following stroke?

A

Promote extended postures. High sitting with the hips above knees, standing, squatting

76
Q

What muscle activation should be encouraged when selecting transitions?

A

Trunk activation, limb extensors and abductors

77
Q

What is Pusher’s Syndrome?

A

Lateral postural imbalance caused by pushing with a stronger extremities toward the involved side. Will resist correction to midline

78
Q

What brain structures are likely impacted with Pusher’s Syndrome?

A

Posterolateral thalamus, insula, operculum

79
Q

Will a pt will Pusher’s Syndrome have intact vision and vestibular perception?

A

Yes

80
Q

If a pt has Pusher’s Syndrome, how much is their perception off by in degrees?

A

Approximately 20 degrees off of true vertical

81
Q

What are the three criteria needed to diagnose Pusher’s Syndrome?

A
  1. Spontaneous body posture with tilting toward the more paretic side
  2. Increased pushing by less involved limbs (increased abduction and extension)
  3. Resistance to passive correction of posture
82
Q

Will a pt with Pusher’s Syndrome lean towards either affected or unaffected side?

A

Toward their affected side

83
Q

What score on the Clinical Assessment Scale for Contraversive Pushing is indicative of Pusher’s Syndrome?

A

Score of 1 or higher for each of the three criteria

84
Q

What is the Burke Lateropulsion Scale?

A

17 point scale that examines postural alignment and degree of resistance when moving pt passively in functional positions

85
Q

What positions are assessed on the Burke Lateropulsion Scale?

A

Supine, sitting, standing, transfers, walking

86
Q

Why would you use the Burke Lateropulsion Scale?

A

Assess for mild Pusher’s Syndrome because it is more sensitive to mild symptoms and more sensitive to change

87
Q

What four activities will a pt with Pusher’s Syndrome typically have more difficulty with compared to a typical stroke pt?

A

Standing, walking, transfers, ADLs

88
Q

Does a pt with Pusher’s Syndrome have a worse prognosis compared to a typical stroke pt?

A

No, their deficits can be corrected with proper identification and intervention training

89
Q

What are the four treatment objectives for a pt with Pusher’s Syndrome?

A
  1. Assist pt to learn their perception of vertical is incorrect
  2. Direct pt to visually explore surroundings and look for visual verticals
  3. Encourage pt to reach, weight shift, and transfer to their less involved side
  4. Practice dual task
90
Q

What are the appropriate conditions for performing standing weight shifts with a pt with Pusher’s Syndrome?

A

Active movement only and shifting toward the strong side

91
Q

What intervention principles are important for a pt with ataxia following stroke?

A

Address active trunk control and stability, functional, progress by reducing their BOS and decrease reliance on UE

92
Q

When initially addressing stability challenges with ataxia, what position should interventions be in?

A

Closed chain, mid-range movement

93
Q

What are three considerations when progressing from closed chain activities to modified open chain activities?

A

Sensory feedback, grade recruitment, limit degrees of freedom

94
Q

According to the CPG for locomotion in stroke patients, what interventions should be performed?

A
  1. Moderate to high intensity aerobic walking training at 70% HR max
  2. VR coupled with treadmill training
95
Q

According to the CPG for locomotion in stroke patients, what interventions may be considered?

A
  1. Strength training of sets and 1 RM
  2. Circuit training
  3. Cycling
  4. VR with standing balance
96
Q

According to the CPG for locomotion in stroke patients, what interventions should not be performed?

A
  1. Sitting and standing balance without augmented visual input
  2. Robot-assisted walking training
  3. BWSTT with therapist assistance
97
Q

When will recovery from a stroke be the fastest?

A

First few weeks to months

98
Q

How long will a pt be admitted to inpatient rehab following a stroke on average?

A

2 weeks

99
Q

What factors are associated with a poorer outcome?

A

Advanced age, severe motor impairments, medical issues, impaired cognition, severe language issues, severe hemineglect, low SES

100
Q

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?

A

12%, depression

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