Lecture: CVA PT Management Flashcards
Acute Care General PT Considerations
- Early Mobility
Early intervention is key! (Once medically cleared)
Prevent learned disuse - Prevent/minimize common secondary impairments
- Disposition planning
Skilled Nursing Facility (SNF)
Inpatient Rehabilitation Facility (IRF)
Home
What is the Drive to use compensatory techniques
Pressure to get patients to highest functional level
as quickly as possible in order for patient to go to
setting with lowest level of care ($$$)
Compensatory techniques use non-paretic limb exclusively to complete tasks:
- Eating and dressing using adaptive equipment to allow use
of only unimpaired side - Use of walking devices that promote minimal weight
bearing on paretic LE - Transfers with majority of weight on non-paretic LE
Early compensation has been shown to lead to
learned disuse
- Failure to recover the limb to its full potential
PT needs to find the balance between….
PTs are responsible to…
rehab for long-term benefit and speedy
return to function
to advocate for your
patient’s long-term rehab potential
Acute Care Goals (3)
Prevent complications
- Upright posture
- Frequent AROM/PROM.
Task-specific training
- Bed mobility
- Transfers
- Ambulation as appropriate (typically earliest is day 2)
Initiate forced use of paretic limbs
Inpatient Rehabilitation Admission Requirements
- Definable goals that can be achieved in a reasonable and relatively
predictable period of time - Able to tolerate 15 hours of therapy weekly
- Requires 24 hour rehabilitative nursing care
- Of sufficient medical complexity that requires frequent evaluations from a
physician with expertise in rehabilitation medicine - Requires at least two skilled therapy services
Goals of Rehab for CVA patients
Use of ROM, positioning, therex and modalities to:
• Increase function
• Increase mobility
• Limit Pain
Promote non-pathologic neuroplastic changes
• Changes in synaptic strength
• Circulating levels of neurotransmitters
• Axonal sprouting
• Formation of new synapses.
3 areas of the brain take over the role of damaged cells, and help form new tracts:
- Periinfarct cells
- Homologous contralateral regions of the infarcted zone
- Supplementary Motor Area
Constraint Induced Movement Therapy
(CIMT):
Theory
Learned non-use potentiates impairment
• Post-stroke, lack of use of the limb
makes it weaker and blocks
neurorecovery
Constraint Induced Movement Therapy
(CIMT):
EXCITE Trial:
• 2-week period of physical restraint
of the less involved UE
CIMT
Inclusion Criteria:***
- 10 degrees active wrist extension - 10 degrees active thumb abduction - 10 degrees extension of other two digits - Limited spasticity - Good PROM - Fairly good cognition - Good mobility
CIMT protocol
- Mitt and sling on unimpaired UE 90% of waking hours - 5+ hours of therapeutic exercise to paretic UE - 2 wk course
Forced Use Therapy
- Modified CIMT
- unilateral exercises using paretic side, positioning to promote weight
bearing on paretic limb, shoe wedge in unaffected side shoe to shift weight to paretic side during gait training….
DVT risk with Forced Use Therapy: What to do
- Move, move, move!
- Mobilize ASAP
- Use of Blood Thinners (Heparin)
- Risk of excessive bleeding
- Compression stockings
- Intermittent pneumatic compression
Spasticity and Contracture Intervention
- Prevent loss of ROM
- Sustained Positioning
- ↑ WB (• Common with the UE
- 1⁄2 kneeling common with with LE to promote dissociation between flexion and extension)
- modalities (ice)
- TENS/Biofeedback
Deep Pressure
• Used to increased joint awareness and
decrease spasticity
Pressure Sores
• Treatment
- PREVENTION
- Diligent skin care
- Pressure relief
- 15-20 minutes in w/c
- 2 hours in bed
- Positioning
- Proper w/c cushion and back
- Pressure mapping
- No aggressive ROM
- No sliding board
Osteoporosis and CVA
• Notes:
• Bone depletion is rapid post CVA
• Pattern of depletion:
- Distal to proximal LE
Osteoporosis: Treatment
• Medication • Weight bearing and muscle activation activities • Research Suggests that weight bearing without muscle activation is probably useless • Treatment with increase muscle activation appears to prevent osteoporosis • FES is a reasonable intervention
Locomotor CPG Recommendations
Clinicians MAY CONSIDER:
● Strength training at >/=70% 1 rep max
● Circuit training, cycling, or recumbent stepping at 75-85% HRmax.
- Do consider these interventions for Aerobic Capacity Intervention
Locomotor Training
• Split belt Treadmill Training
• Can be used to improve step length
symmetry overground
• Belt with intact LE set to self- selected fast walking pace, belt with impaired LE set to half that of the intact side and then increased over time
• Use harness and monitor vitals for safety
Locomotor Training: CPG Recommendations
How intense the walking training to have the most improvements in walking speed and distance?
Moderate- to high-intensity (60%-80% of heart rate reserve or up to 85% of heart rate
maximum) walking training was associated with the strongest evidence for improvements in
walking speed and distance.
Cognition deficits
MAP
• Memory Deficits
• Attention Deficits
• Procedural (Implicit) Learning
Treating Cognition in the Context of
Functional Mobility
- Dual Tasking
- Pathfinding
- Scavenger hunt
- Circuit training recall
- Patient-specific tasks (related to job, hobbies, other participation
level tasks)
Therapists, providers should be on alert as to stress on families and
patient and recognize signs:
- Personality change
- Cognitive loss
- Incontinence
The Many Forms of Neglect
Spatial neglect can occur in 3 dimensions of space
- Horizontal (R/L)
- Radial (peripersonal space/extrapersonal space)
- Vertical (up/down)
- Stimulus Centered
Evaluation of Neglect (4)
Sensitivity of these test is
Evaluation of Neglect
- Observation
- Line Bisection
- Drawing
- Reading/writing
Sensitivity of these test is very variable; NO GOLD STANDARD
Bell’s Test
• Ask pt to circle all bells in the
image
Ota Test
What is it and what does it test?
• Ask pt to put a circle around all complete circles, and an X through incomplete circles • Image is of extrapersonal neglect (when the person doesnt circle the circles that are away from him) • Stimulus centered neglect
Neglect vs Hemianopia
Hemianopia is not seeing from one side. Like one cannot see the left half of an image in Left Homonymous Hemianopia.
Neglect (cluttered scene) is not seeing half an image and the other half is blurry.
Neglect (uncluttered scene), image is blurry and various part s of the image is cut off
Most common to see L sided neglect with R sided lesions. Why?
• R hemisphere mediates attentional mechanisms directed in both
hemispheres
• L hemisphere is really only concerned with the R hemispace
• Therefore R sided neglect is less common because there’s back up
from the bilaterally supporting R hemisphere
• However, when R hemisphere is injured, L hemisphere doesn’t
support L sided perception
Neglect Prognosis
Recovery is variable! • Spontaneous neurological recovery shows a natural logistic curve up to 12-14 weeks post-stroke
Visual Scanning Therapy
What is it? What is special about it?
• Retraining patients to look toward the contralesional side with visual search, reading, and copying exercises • visual cues with red lines/anchor, bookmarks, red lights)
• Most prevalent treatment for neglect
Visual Scanning Training: What is it?
- Multimodal dynamic cueing to attend to neglected side - Visual: red anchor - Auditory: verbal cues from neglected side, clapping - Tactile: vibration, TENs (moderate evidence supports use as a supplement to visual scanning training)
Visual Scanning Training: Activities and what they include (3)
Paper/pencil activities
- Reading, writing, copying, target tracing
- Visual Attention iPad App
Tabletop activities
- Reaching for objects, ADL activities
- Start at midline, progress to neglected side
Functional activities
- Scanning during transfers
- Can use brightly colored tape on WC parts ( put tape on wheelchair for patient to look for)
Visual scanning combined with ____ may be effective
trunk rotation towards neglected
side
Visual Scanning Training: Lighthouse strategy
- Specific scanning protocol utilizing visual imagery
- I.e. find objects by illuminating with beams
Prism Adaptation
What does it do?
What does it help with the patient?
• Prisms cause a shift in subjective midline to ipsilesional hemispace • Helps improve ability to copy an image. • May cause a patient to mis-reach for item • With prisms off, may help patient adapt
Eye Patching
What are the glasses called?
What do they promote?
• Applied to the ipsilesional eye to
promote visual attention to
neglected side visual side
• Hemifield glasses (aka Bilateral
Hemi-Occlusion)
• Half field patching of ipsilateral
visual fields
Limb Activation
• Movement of the contralesional side may function as motor stimulus to activate involved hemisphere to improve neglect
Visual scanning environment during gait
- Narrated walk/ “I spy” game
- Obstacle course
- Topographical navigation, i.e. looking for room
- Compensatory strategies
- Head turning
- Visual anchors, i.e. door - visual anchor on door frame,
numbering corners (put the numbers on the corners and ask patient to find the numbers before they walk into the door), etc
What does Transcranial Magnetic Stimulation (TMS) does for the brain?
• Stimulate damaged R hemisphere, inhibit the hyperactive L
hemisphere, or both
• Magnetic pulses applied to unaffected side of the brain side→ disrupts
neural activity →disrupts post-stroke ipsilesional bias
• Induce neural plasticity when applied to affected side of brain
Interhemispheric Communication by TMS
After stroke, reduced inhibitory output from lesioned hemisphere causes increased excitation of non-lesioned side
Inhibitory TMS
may help restore
balance
Transcranial Direct Current Stimulation
What does it improve immediately?
Line bisection, figure cancellation improved immediately after TDCS
Contraversive Pushing
Aka Pusher Syndrome
- Caused by a mismatch between perception of visual and postural
vertical
Typical presentation:
- Pushed towards involved/hemiplegic side with uninvolved/sound
side
- Impaired sense of midline orientation/subjective postural vertical
- Extends and abducts UE and LE
- May resist therapist’s attempt to correct
Contraversive Pushing Interventions
- Feedback about loss of balance***
- Have patient self assess and problem solve to correct balance***
Contraversive Pushing Interventions
- Visual feedback
- Mirror, vertical references for midline orientation
- Computer based programs
Contraversive Pushing Interventions
Minimize pushing behavior
- Set up of environment/positioning
- Forearm for support rather than hand when sitting at edge of
mat - Can use wedge, stepstool, swiss ball
- Blocking foot: in a box/stool, on dycem
- WC positioning: full laptray, contoured back and cushion
- Wedge under pelvis on affected side
Contraversive Pushing Interventions
- Maintain midline in quiet sitting
- Can have pt place hand palm up on their thigh or place hand on
therapist’s shoulder or leg to gauge pushing
Contraversive Pushing Interventions
- Reaching toward unaffected side
- Requiring weight shifting toward the side they are pushing
from and correcting balance back to midline - Progress reaching and rotating toward involved side
Contraversive Pushing Interventions
- Progress to maintaining midline with distractions
- Goal of progressing towards automatic postural control
Contraversive Pushing Interventions
- Transfers
- May start with transfers away from pushing side, then progress
to both directions - Have patient hold object in unaffected hand or hold affected
side
Contraversive Pushing Interventions
- Progress to Standing
- Strand next to elevated mat with uninvolved forearm supported
or with uninvolved side next to wall - Practice quiet midline standing
- Practice weight shift toward uninvolved side and back to
midline - Reaching towards uninvolved side across mat
