Lecture 4 Flashcards
What percent of patients will walk post-stroke?
80%
98% of patients walked at 6 months with a (Functional Ambulatory Category Of 4+) IF….
Independent _______
LE strength of at-least ___ in _______
Independent sitting balance
LE strength of 1/5 in hip flexors, knee extensors, and ankle dorsiflexors in first THREE days
If the patient does not meet the criteria of:
Independent sitting balance
LE strength of atleast 1/5 in hip flexors, knee extensors, and ankle dorsiflexors in 3 days
What percent walked after 3 days with the criteria unmet?
What percent walked after 9 days of the criteria unmet?
27%
10%
Upon admission to inpatient rehab
If BERG balance scale is under 20 and the FIM-L is 1-2 (total or max assist)
This accurately predicted who will be __________ by __%
Accurately predicted who will be home bound 92% of the time (unable to leave home)
What are the main predictors of UE recovery in stroke?
AROM of shoulder and middle finger predicted the variance in UE function at 3 months
What did the AVERT study test?
(A very early rehabilitation trial)
The experiment group received 1st PT mobilization by first 24 hours
Sitting or standing, whatever they could tolerate
What did the AVERT study find?
No sig diff in death, adverse events, or falls
Sig diff in: Time in PT, Time to first mobilization, cost of care at 3 months, functional improvements
Overall the study showed early mobilization leads to better functional outcomes
What did the Winstein, Gardner, and McNeal Standing balance and gait study test?
One experimental group of patients received normal therapy and extra therapy on ONLY standing balance
Control group received only regular therapy
What were the conclusions of the Standing Balance and gait study
That there is no difference in outcome in patients who received extra standing balance training when it comes to walking
Standing balance does not improve gait training
Chronic stroke gait speed for unlimited household ambulation?
0.27m/s
Chronic stroke LIMITED community ambulation gait speed?
0.58m/s
Unlimited community ambulation speed in stroke survivors?
0.8m/s
Note: normal community ambulation in adults is 1.2m/s
How fast must you walk to cross a commercial street?
2m/s
What study categorized functional walking with chronic stroke patients according to gait speed
Perry at al.
How was gait proven as the 6th vital sign?
Studies compared survival using the combinations of
age, sex, gaitspeed
Age, sex, asssitive device,
Age, sex chronic conditions, smoking, BMI, Hospitalization
And found that gait can predict survival as effectively as the other predictors
How does supported treadmill ambulation help patients
Reduces gravity, postural instability, and protects against inadequate balance reactions
Helps motor learning w/ repetition that’s less asymmetrical than over ground
Allows PT to challenge patient in ways they can’t when they’re busy supporting the patient
Are these essential, important, or accessory for walking:
Muscle and peripheral nerves
Spinal cord pattern generators
Essential
Are these essential, important, or accessory for walking:
Ventrolateral and ventromedial spinal cord pathways
Medullary reticular formation
Essential
Are these essential, important, or accessory for walking:
Mesencephalic locomotor region
Subthalamic locomotor region
Essential
Are these essential, important, or accessory for walking:
Sensation, DCML
pontomedullary locomotor strip
Important
Are these essential, important, or accessory for walking:
Cerebellum, red nucleus, substantia Nigra, limbic cortex
Important
Are these essential, important, or accessory for walking:
Motor cerebral cortex
Pyramid tract
Accessory
Why is the medial medullary reticular formation essential for walking
Final integrative center for locomotion before the spinal cord
Driving center for locomotion in all animals
Provides drive to CPG in spinal cord
Interlink coordination that provides feedback to detect symmetry and asymmetry
How can PTs modify gait training to influence the medial medullary reticular formation more
Increasing the speed
Faster = more feedback provided to cerebellum via stretch sensitive muscle receptors
Why is the mesencephalic locomotor region essential for gait
Area may modulate speed of walking
May be involved in exploratory locomotion
Why is the subthalamic locomotor region essential to gait
Responsible for spontaneous goal directed gait
What do the “important” gait structures in the brain do?
Interact with regions that are essential to determine:
- Timing of swing/stance
- Detection of sensory gains during walking
- Coordination
- Motivation to walk
What part of the brain controls “motivation to walk”
Hippocampus
What might the cerebral cortex do to help with gait that makes it an accessory structure
May influence timing, initiation, transition of swing/ stance, and positioning of foot
Cortex may also interfere with walking if attention is required for another task
What are the three key inputs to central pattern generators
If these do not happen, walking does not happen!
Stretch of hip flexors
Unweighting of triceps surae (hamstrings)
Weight bearing to facilitate extensor tone in stance limb (muscle receptors in hamstring, pressure receptors in foot, and joint receptors)
What input resets the central pattern generator
Stretch of hip flexors
What input gives the leg permission to take a step in the CPG
unweighting of triceps surae
What phases of gait does hip extension occur in to trigger the swing phase via activation of the muscle spindles
What spinal cord segments are important for this?
Mid stance to heel off (AKA the key phase of gait)
L2 L3 L4
When walking, the COM is outside of the BOS what percent of the time?
80%
How can a patient progress on a lokomat
Increase speed, time
Decrease BW support, decrease guidance forces
Can adjust R and L sides independently
What is the max speed on the lokomat?
2mph
Manually assisted gait training can achieve higher speeds
Why is it important for the patient to wear as little as possible on the foot during gait training (no big heeled shoes)
So the patient gets tactile feedback from their feet about their gait mechanics
How fast should a patient move on a treadmill
How symmetrical should their limb movement be
As fast as possible
As symmetric as possible
How can learned nonuse of a limb occur
Overuse of other UE, compensation
May start with decreased sensation and motor abilities post stroke (initially )
How can CIMT help learned nonuse
Use dependent or treatment-induced cortical reorganization can occur with appropriate aggressive treatment
Cortical reorganization that helps learned nonuse comes from _______ practice and requires high ______
Massed practice - several hours every day
Requires high motivational drive and concentration
How does CIMT work?
Learned nonuse masked the recovery of limb
V
Increase patient motivation
V
Affected UE is used
V
Provide reinforcement
V
Further practice <-> user dependent cortical reorganization
V
Learned nonuse is reversed and UE is used in life situations permanently
What are the absolute requirements of candidates for CIMT treatment
Extent wrist 10-20 degrees
Extend atleast 2 fingers
Ability to understand and follow directions
What are the components of the CIMT protocol
Repetitive task training
Adherence enhancing behavioral strategies
Constrained use of less affected UE
How does CIMT achieve constrained use of less involved UE
mitt restraint with a sensor to document wearing time
What did Grotta JC et al test in their study on UE function post CVA
Intervention group has constraint of less affected UE and unilateral UE training
control group received bilateral therapy
Found that forced use works to improve motor function
What did the EXCITE trial test?
CIMT in stroke survivors
Significant improvement seen in
Wolf motor function test
Motor activity log
Stroke impact scale
What are drawbacks to robotic assisted locomotor training in adults
Time lost due to set up
Deconditioning
What did Lang C find with research into dosing and timing for plasticity and participation
Pt randomized into 100, 200, 300, or individualized max rep groups for UE task
All groups besides 200 reps saw significant improvement
Proved more is not always better
90% of patients saw meaningful change
Did not change use of UE at home
