Exam II Flashcards
what does EDGE stand for in regards to outcome measures? what is the role that EDGE plays?
(1) Evidence Database to Guide Effectiveness
(2) committees of experts review outcome measures and rank them for different neurological health conditions (PD, stroke, MS, TBI, SCI, and vestibular)
what is the EDGE scoring system?
4 - highly recommended
3 - recommended
2 - reasonable to use, but limited study in target group
1 - not recommended
what outcome measures are recommended for assessing body structures and functions in PD patients? (2)
(1) MDS-UPDRS revision - part 3
(2) MDS-UPDRS - part 1
what outcome measures are recommended for assessing activity limitations in PD patients that are specific to PD? (1) which ones are non-specific to PD? (3)
- PD Specific
(1) MDS-UPDRS - part 2 - Non-Specific
(1) 6 minute walk
(2) 10 meter walk
(3) Mini BESTest
what outcome measures are recommended for assessing participation restrictions in PD patients? (2)
PD Questionnaire
(1) PDQ-8
(2) PDQ-39
what does the outcome measure MDS-UPDRS stand for? what is considered a good score?
(1) Movement Disorder Society - Unified PD Rating Scale
(2) the lower the score the better
what is the gold standard OM for looking at the progression of PD overtime?
MDS-UPDRS
what does Part I of the MDS-UPDRS assess?
(1) non-motor aspects of ADL’s
(2) such as: cognition, depression, apathy, sleep, urinary, constipation, orthostatic symptoms
what does Part II of the MDS-UPDRS assess?
(1) motor aspect of ADL’s
(2) such as: speech, swallowing, eating, dressing, hygiene, handwriting, bed mobility, tremor, STS, walking, balance and freezing
what does Part III of the MDS-UPDRS assess?
(1) motor examination (of impairments)
(2) tremors, rigidity, bradykinesia, STS, balance, gait, freezing
what are the dimensions assessed in the PDQ outcome measure? (8) what is considered a good score?
(1) mobility
(2) ADL
(3) emotional well-being
(4) stigma
(5) social support
(6) cognition
(7) communication
(8) bodily discomfort
- Lower the score the better
what does the current model of care for PD look like? what is the ideal model of care for PD?
(1) Current: Reactive (PT referral after an event has occurred, such as falling, not before)
(2) Ideal: Proactive (preventative PT with ongoing assessment over the course of disease)
what are some non-motor impairments to consider when working with PD patients?
(1) postural hypotension
(2) bladder urgency and frequency
(3) sleep disturbances
(4) psychosis
(5) depression, anxiety, apathy
(6) medication side effects (ex. on/off phenomenon)
(7) dysphagia
what is festination anteropulsion? what triggers this gait pattern?
COM falls too far anterior during gait
Triggers:
(1) wheeled walkers without hand breaks
(2) forcing through a freeze
(3) being pulled on during a freeze
what is festination retropulsion? what triggers this gait pattern?
COM falls too far posterior during gait (could be due to under scaled balance reaction)
Triggers:
(1) backing up
(2) reaching overhead
(3) opening a door
(4) carrying items too close to their body
what triggers an akinetic gait pattern (freezing gait)?
(1) tight / narrow spaces (doorways or elevators)
(2) cluttered areas
(3) crowds
(4) anxiety / stress / rushing
(5) turning / pivoting
(6) change in floor patterns
what are the 4 S’s to overcome freezing and festinating gait patterns in PD patients?
(1) STOP: don’t force way through a freeze
(2) STAND Tall: COG over BOS
(3) SWAY: side to side
(4) STEP Long
when should patients stop a festinating gait pattern?
STOP as soon as festination occurs; educate patients on this
what are a couple visual cues than can be used to correct frozen gait?
(1) caregiver places foot perpendicular to pt.’s foot and has them try to step over
(2) laser pointers or laser canes project a line so pt. can attempt to step over laser
what type of walker is ideal for PD patients? how do they work?
(1) U-Step walkers
(2) very heavy walkers for multi directional instability; they essentially have gas pedals where brakes would be, so in order to move, the gas pedal must be squeezed
when would you give a PD patient a walker without handbrakes?
NEVER (causes festination)
how can colored tape be used to increase step length and step speed? how should these be measured?
(1) colored parallel lines placed perpendicular to the walking path that look like train tracks (can implement throughout home)
(2) length between each strip should be about 150% of initial step length (on average between 24-28 inches apart)
(3) goal is to achieve normal step length by having patient walk over the lines
how can rhythmic auditory cues be used to increase step length and step speed? what are some ways this can be implemented?
(1) moving to rhythmic music
(2) metronome (set 25% faster than baseline cadence or between 100 and 125 steps/minute)
(3) counting out loud 1,2,1,2,1,2
(4) caregiver snapping or clapping to provide a beat
how does sensory cueing to improve gait work from a physiological standpoint in PD patients?
bypassing the damaged internal automatic control mechanism (basal ganglia) and use the cortex for conscious control of gait
does dual tasking work when implementing external sensory cues to improve gait in PD patients?
no; cueing requires focused attention because gait is no longer automatic
what are some cues to improve sit to stand and stand to sit in patients with PD?
(1) scoot to edge (for sit to stand)
(2) widen BOS
(3) keep COG forwards over BOS (controlled lowering to prevent leg collapse)
when a PD patient has a tendency to go into retropulsion, what is a strategy to prevent this when backing up to a chair to sit down?
have the patient side step in an arch shape (side stepping in a U shape to the chair) instead of walking straight back to the chair
what are ways we can help PD patients with bed mobility?
(1) focus on neck and trunk rotation and axial mobility using large amplitude movements
(2) silk sheets and PJs (help reduce friction)
(3) sheet bar (prevents feet from getting tangled in sheets)
how does a stooped posture observed in PD patients present?
(1) flexion of neck and trunk
(2) shoulder rounded and IR
(3) flexion of hips and knees
how does a camptocormia posture observed in PD patients present?
(1) extreme involuntary forward flexion of thoracolumbar spine in standing and walking (bent over looking at the ground)
(2) subsides in recumbent positions (not structural issue; more related to dystonia and excessive contraction of abdominals)
how does pisa syndrome posture observed in PD patients present?
(1) increased lateral flexion (looks like scoliosis)
(2) subsides with passive correction in recumbent positions
from an exercise standpoint, what should the focus be to correct posture for PD patients? what manual therapy techniques might help posture in this population?
(1) strengthen extensor muscles (quads, hip extensors, back extensors, etc.) and core
(2) stretch flexors (pecs, trunk rotation stretches, chin tucks) both active as passive stretching
(3) manual therapy: spine and shoulders (due to hypomobility)
what PNF patterns promotes spinal extension and can be beneficial for PD patients?
bilateral UE D2 flexion
what should be encouraged for bed positioning in PD patients?
(1) lying as flat as possible and minimize pillows because they promote a flexed posture
(2) prone and prone on elbows would be more ideal
what benefits may cardiovascular training lead to in PD patients?
(1) neuroplasticity increases
(2) slow or reverse neurodegeneration
(3) increased blood flow leading to increased nutrition and growth factors which is thought to stimulate neuroplasticity
what is the goal for cardiovascular training in patients with PD?
(1) 150 minutes per week at moderate intensity (30 minutes 5x/week)
(2) high intensity has been shown even better in PD patients
why is it important to monitor BP and HR in PD patients?
they’re at a risk for hypotension
how should a PT assess balance and fall interventions for PD patients?
(1) ask about falls each visit
(2) perform annual or semi annual risk assessment
(3) consider all contributions to falls (ex: sensory, dynamic, mobility, strength, orthostatic issues) and work on areas that need improvement
what type of cycling has been shown effective in PD patients? what parameter should this cycling be performed at?
(1) tandem cycling: PT and patient are on a tandem bike and the PT sets the cadence for the patient
(2) 80-90 RPMs
what are the 4 treatment concepts of LSVT BIG (a continuing education PD Treatment)?
(1) Amplitude
(2) Sensory re-calibration
(3) Intensive standardized exercise program (1hr / 4x/week for 4 weeks)
(4) Empowerment
what are the most important elements for success in treating patients with PD?
(1) high repetition
(2) high intensity
(3) dynamic movement
(4) patient enjoyment
what stages of Hoehn and Yahr are patients most successful with dynamic exercise treatments for PD?
Hoehn and Yahr 1-3
what is the most common form of MS (affects 85% of MS patients)?
Relapsing-remitting MS
what is the overall goal for MS patients at the time of diagnosis?
(1) patient education
(2) baseline evaluation
what is the overall goal for MS patients following an acute exacerbation?
return to baseline
what is the overall goal for MS patients undergoing the progressive disease without remission?
(1) support, avoid deconditioning, maintain safety, maximize heath and independent function
(2) assessment of current and future mobility aids
what is the overall goal for advanced or late stage MS patients?
(1) PT focused on seated positioning, transfers, strength, respiratory function, and equipment needs
(2) use of standing devices and wheelchairs
what classifies a relapse or exacerbation in regards to MS?
new and/or recurrent MS symptoms lasting >24 hours
what factors affect MS relapses?
(1) stress (minor or major)
(2) affective disorders (ex. depression)
(3) disease of major organ systems
(4) viral or bacterial infection
(5) psuedoexacerbation: temporary worsening of symptoms <24 hours (ex. Utoff’s symptom)
what is Utoff’s symptom?
(1) adverse reaction to heat (internal or external); effects are usually immediate leading to deceased function and increased fatigue
(2) psuedoexacerbation lasting less than 24 hours
what effects can exercise have on MS patients?
(1) psychological: improve mood
(2) improved outcomes for balance, endurance, strength, core stability, power, and aerobic fitness
(3) improved activity: gait, ADLs, bed mobility
(4) improved participation: improved QOL
what time of day is optimal to exercise MS patients?
morning; fatigue hasn’t set in yet and it’s typically cooler
how frequent should rest intervals be given to patients with MS? why?
frequently; prevent over heating
how should the exercise intensity be prescribed for MS patients?
challenging but NEVER a struggle; slower progression
what are two exercise contraindications in MS patients?
(1) exercising to fatigue
(2) patients with relapse-remitting MS during an exacerbation should NOT exercise until relapse has passed
what temperature should the water be set at for aquatic exercise when working with MS patients?
<85 degrees
what is the importance of energy effectiveness strategies (EES) in MS patients? what are 3 of these strategies that can be utilized in this population?
(1) important for managing fatigue
(a) activity diary: record sleep, activities, and aggravating factors and symptoms
(b) energy conservation techniques (ex. use of motorized scooter in community to conserve energy)
(c) activity pacing: balance activity with interspersed rest periods
what is learned non-use of the paretic UE (in stroke patients)? what is the downside to this?
(1) when patient switches to non-paretic side for all tasks as a compensation
(2) paretic arm becomes more impaired due to disuse
what are the 4 main elements of CIMT?
(1) repetitive and intense training of paretic UE over multiple days
(2) shaping
(3) transfer package
(4) physical restraint (mitt) of uninvolved limb
what is the dosage for CIMT?
3 hours per day
5 days per week
2-3 weeks
what is the difference between a shaping task and a functional task?
(1) shaping: tasks that aren’t salient (flipping cards, twisting nuts and bolts, etc)
(2) functional: ADLs (eating, folding clothes, etc.)
what are the goals of CIMT?
(1) reverse learned non-use
(2) increased use of paretic UE
(3) promote long lasting neural plasticity
what is shaping in regards to CIMT?
behavioral training technique in which motor objectives are achieved in small successive steps making the task more difficult overtime
what is important for the use of shaping with CIMT to be successful?
positive reinforcement and motivation (avoid patient frustration)
what are ways shaping can be progressed?
(1) alter time to complete a given task
(2) change height / reaching / distance / reps
what is the transfer package in regards to CIMT? what are some ways this is reinforced?
(1) techniques used to transfer gains in the clinic to gains in the real world
(2) home assignments
(a) home skill assignment: 10 ADLs performed within 30 minutes
(b) home practice: repetitive tasks for 15-30 minutes
what is the motor activity log that is used during the transfer package?
self administered tool to asses how well they use the paretic arm on 30 different ADLs (using a 6-point scale)
what is the behavioral contract associated with the transfer package?
formal written contract signed by the patient to facilitate adherence
how often should the physical restraint (mitt) of the non-paretic arm be used during CIMT?
90% of waking hours
when during a patient’s recovery does research suggest is an optimal time to start CIMT?
chronic stage of recovery (>1 year)
what are the minimum active ROM requirements for a patient to be eligible for CIMT?
(1) shoulder flexion and abduction >=45
(2) elbow extension >=20
(3) wrist extension >=10
(4) finger extension >=10 (at least 2 digits)
what is the most common outcome measure used pre- and post- CIMT?
Wold Motor Functional Test
what are the treatment parameters for modified CIMT (mCIMT)?
- 30 minutes of shaping and functional practice
- 3 days per week
- 10 weeks
- Restraint worn 5 hours a day x 5 days per week
what is contraversive pushing?
(1) pushing towards the paretic side following stroke (or away from the side of the brain the lesion occurred)
(2) this occurs when the non-paretic arm and leg are used to push the body towards the paretic side
what are some other names used to describe contraversive pushing?
(1) contraversive lateropulsion
(2) pusher syndrome
(3) pusher behavior
how common is contraversive pushing in stroke patients? does a right or left CVA result in a higher prevalence of contraversive pushing?
(1) ~10%
(2) R CVA this condition is much more common
what two scales can be used to determine if a patient has contraversive pushing and not just severe weakness?
(1) Scale for Contraversive Pushing (SCP)
2) Burke Lateropulsion Scale (BLS
what are the 3 categories of the Scale for Contraversive Pushing?
(1) spontaneous body posture
(2) abduction and extension of non-paretic side
(3) resistance to passive correction of tilted posture
- Scale is out of 6 points
what is the hallmark characteristic of patients with contraversive pushing?
resistance to passive correction of their tilted posture
what scale is considered the gold standard for diagnosing contraversive pushing?
Burke Lateropulsion Scale (BLS)
what are the 5 testing positions when using the Burke Lateropulsion Scale (BLS)?
(1) supine rolling
(2) sitting
(3) transferring
(4) standing
(5) walking
> 2/17 is diagnostic for contraversive pushing
what are other main characteristics of patients with contraversive pushing? (3)
(1) severe hemiparesis / plegia
(2) severe sensory deficit
(3) neglect
what is thought to cause contraversive pushing?
(1) gravi-ceptive impairment (vestibular and visual are normal)
(2) mismatch between the sensory systems resulting in contra-lesional tilt and pushing behavior
what is the prognosis for patients with contraversive pushing?
(1) very good, most patients it’s transient behavior
2) 79% of patients recover within 3 months (after 6 months pushing is rarely still present
what two factors predict slower recovery from contraversive pushing?
(1) R CVA
(2) neglect
where are common lesion locations in patients with contraversive pushing?
posterolateral thalamus of parietal lobe (thalamus is sensory relay center)
should the treatment for patients with contraversive pushing be primarily active or passive?
(1) active (mirrors, use of tape lines, etc.)
(2) the goal is to have the patient actively move back to midline
where should weight bearing be encouraged in patients with contraversive pushing?
non-paretic side (because they favor the paretic side)
what should always be addressed first when treating patients with contraversive pushing?
alignment
which side is easier to transfer a patient with contraversive pushing? which side SHOULD you transfer this patient towards?
(1) easier to transfer to paretic side (because they lean towards that side)
(2) from a PT standpoint you will work on transfers to both sides, but transfers should be more geared towards the non-paretic side to facilitate proper alignment
how should gait training be started in patients with contraversive pushing?
gait training with the patient’s non-paretic side against a wall or a raised mat (they tend to be less fearful of fall and reduce pushing when sturdy surface is on non-paretic side)
what are 4 goals for therapy in patients with contraversive pushing?
(1) early on let the patient fall safely towards paretic side (teaches them leaning towards paretic side isn’t safe)
(2) use visual vertical cues, tactile and verbal cues to align patient
(3) promote active alignment by reaching past midline for objects on non-paretic side
(4) promote automatic postural control (ex. distracting environments and dual tasking)
