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)
