MOD 5 Management of Chronic Stroke Flashcards
What is a spasm?
persistent increased tension and shortness in a muscle or group muscles that cannot be released voluntarily.
When are pharmacologic interventions indicated for chronic stroke?
- an individual has significant hypertonicity/spasticity that is causing pain, discomfort, or negative impact on quality of life
- nonpharmacologic interventions have not worked
- to prevent secondary complications
What is the PT’s role in spasticity and hypertonicity?
- assist in decision making
- distinguish if there are other contributions to patient presentation
- determine whether medical solutions need to be explored
- inform team about effectiveness and adverse effects
What are the three modes of delivery for spasticity treatment?
- oral
- injections (muscle or nerve)
- intrathecal
What is intrathecal mode of delivery?
delivered by pump with catheter threaded into intrathecal area of the spinal cord
What are the common oral medications for hypertonicity?
- baclofen
- tizanidine (gxanoflex)
What are the common injection medications for hypertonicity?
- bo-tox
- phenol
What is the common intrathecal medication for hypertonicity?
baclofen
What are the actions of oral medications for hypertonicity?
- decrease excitation of alpha motor neuron in spinal cord
- inhibits mono- and polysynaptic spinal reflexes
What are the less commonly used oral medications for hypertonicity?
- diazepam
- dantrolene
- gabapentin
what does diazepam do?
depressant of the cns
What does dantrolene do?
inhibit calcium release in skeletal muscle
What does gabapentin do?
decreases pain
What are the adverse effects of baclofen and tizanidine?
- sedation
- fatigue
- may limit neuroplasticity
What are the adverse effects of diazepam?
- sedation
- confusion
- risk of dependence
- may limit neurologic recovery
What are the adverse effects of dantrolene?
- muscle weakness
- sedation
- hepatotoxicity
What are the actions of bo-tox injection for hypertonicity?
- inhibits acetylcholine release at neuromuscular junction resulting in muscle weakness
- effects degrade after 3-4 months
What are the adverse effects of botox injections for hypertonicity?
- possible effect on other muscles
- immunoresistance may develop
- pain with injections
- caution if person is on anticoagulants
- may not improve function
What is the PT’s role when it comes to botox injections?
- assess whether desired effect occured
- provide stretching within 1-2 weeks of injection
- strengthen muscles
What are the actions of a phenol injection?
- injection near nerve which will cause chemical neurolysis and paralysis of muscles innervated by nerve
- decrease mechanical stress on joints
What are the adverse effects of phenol injections?
- lasts for 6 months so could have negative effect
- making it the last option
What are the advantages of intrafecal baclofen pump?
- may help with severe bilateral LE spasticity and hypertonicity
- may eliminate need for oral baclofen
What are the adverse effects of infrafecal baclofen pump?
- CSF leak and infection
- pump requires periodic refills by needle and possible recalibration
- pump or tubing may malfunction
- may not improve function
What is the FIM?
functional independence measure
What is the PAI?
patient assessment instrument
How do you grade the GG section of the PAI?
1-6 assessment based on dependence level
What are the new additions to section GG of the PAI?
- resident refused
- not applicable
- did not attempt
What is the SIS?
stroke impact scale
self reported that evaluates disability and health related quality of life after stroke
What does the SIS assess?
- strength
- hand function
- ADL
- mobility
- communication
- emotion
- memory and thinking
What is the Fugl-Meyer assessment used for?
- post troke hemiplegic patients
What are the Brunnstrom Stages of Stroke Recovery?
- flaccidity stage
- spasticity appears
- increased spasticity
- decreased spasticity
- complex movement returns
- spasticity disappears
- normal function returns
What is the difference in scoring between the Fugl-Meyer LE and UE motor scales?
- UE = 66 points
LE = 34 points
LE has smaller MCID value
How many stroke survivors deal with gait dysfunction?`
2/3
What percentage of stroke survivors will be able to achieve normal gait speed?
30%
How many survivors of stroke with have another stroke within 5 years?
1/3
What are the 4 key components of walking?
- propulsion
- swing limb advancement
- stance control
- lateral and frontal stability
How do you implement high intensity gait training safely?
- vitals
- patient report
- borg RPE
- appraise the patient
What is the CPU for individuals 6 months post stroke?
- should use moderate to high intensity walking training to improve walking speed and distance
- should use VR with walking practice to improve walking speed and distance
According to the CPG, what should PTs NOT do for patients 6 months post stroke?
- perform sit to stand balance training
- should not perform body weight support treadmill training
- should not perform walking interventions with exoskeletal robotics on a treadmill
Why don’t non recommended interventions improve gait?
not working on gait
Before 6 months post stroke, what can you do for patients that need more support initially?
- physical assist
- body weight supported devices
- robotic assistance walking
What is the rationale behind body supported treadmill training?
- intensive task specifici training
- may facilitate cortical and subcortical reorganization
- minimize delay in gait training
What are the limitations of body weight supported treadmill training?
- equipment is needed
- cost
- often require 2 people assist
Who are the ideal candidates for body weight supported treadmill training?
- patients unable to walk independently
- <3 months in recovery with significant gait abnormalities
- nonfunctional ambulatory with goal of walking to improve CV function
What is the dosing of body weight supported training?
- provide title body weight support as needed
- target moderate to high intensity
- transition to overhead harness without body weight support as soon as possible
What are orthotics?
externally applied device to an existing body part that improves function
What is a neuroprosthetic?
- device which helps the subject’s own nervous system
example: NMES to stimulate deep fibular nerve to improve dorsiflexion during swing phase of gait and stop foot drop
Which diagnoses have evidence behind use of AFOs or functional electrical stimulation?
- MS
- spinal cord injury
- CVA (stroke)
When should you provide AFO/FES?
- improve quality of life
- improve gait speed
- improve walking endurance
- improve mobility
- improve dynamic balance
- improve muscle activation
When may you provide AFO/FES?
- to improve gait kinematics
- improve walking endurance (acute stroke)
When should you not provide AFO/FES?
improve plantarflexor spasticity
What is the process for PT eval to decide if a patient needs an AFO/FES?
- movement analysis
- impairment testing
- therapeutic alliance
- consider prognosis for functional mobility
- collab with orthotist
- reassess, reassess, reassess
What are the pros of the neofect AFO?
good for indoors
What are the pros of the saebo step AFO?
- less restrictive
- can adjust tension
- can don with multiple shoes
What are the pros of an ACE wrap as an AFO?
good for in clinic practice
What is a KAFO?
knee ankle foot orthosis
- adds knee control in extension
What are the advantages of KAFO?
- reduce gait abnormalities during stance phase
- prevents involuntary knee flexion or hyperextension
- improves foot positioning for initial contact
What are the disadvantages of KAFOs?
- can lead to gait deviation
- tend to be heavy
- high cost of energy expenditure
- low adherence
What are the FITT principles for chronic stroke intervention?
F - sufficient freq and appropriate progression to create functional change
I - high intensity to create functional change
T - appropriate interventions for acute vs chronic
T - activity specific and functional task practice
What percentage of stroke survivors have cardiac disease?
75%
What is the intensity that stroke patients should operate for aerobic exercise?
55-80% HR max
11-14 RPE
How long should stroke patients do aerobic exercise?
20-60 min sessions
How many days should a stroke patient do aerobic exercise?
3-5 days
For patients that were sedentary prior to stroke what should you consider?
consider smaller doses of 10-15 min for 3 times a week
What is the dosing for strength training for stroke patients?
- 2-3 days a week
- 30-50% and 50-80% 1RM
- 1 to 3 sets 10-15 reps
- large muscle groups
What should stroke patients use for strength training?
- weight machines
- free weights
- elastic bands
What are the 3 components of constraint induced movement therapy?
- restraint of less impaired UE using mitt
- repetitive task practice (>300 reps)
- use shaping which involves matching difficulty of tasks performed to the improvements of the patient made
What are the requirements for stroke patients for mCIMT?
- minimal sensory deficits
- minimal cognitive deficits
- must be Abel to demonstrate 20 deg of active wrist extension and 10 deg of active finger extension
What is the recommended freq of mCIMT?
30 minutes to 3 hours 2-10 weeks
What is sensory priming?
adjuvant therapists that modulated the central nervous system
What is the purpose of sensory priming?
initiate neural and behavioral change
How does 30 minutes of backward walking help stroke patients?
- improved forward and backward walking speed
What should be used to increase reactive balance?
provide perturbations
