Neglect/ Pushing Flashcards
Vital inputs for standing
vision, vestibular, and somatosensory
stable position of standing
- impact of BOS on LOS - foot position matters, UE support matters
- LOS affected by feet support and UE support
the greater the balance dysfunction…
the lower the discharge functional scores are likely to be
what is postural control dependent on?
patient, environment, and task
what does postural control involve?
controlling the body’s position in space - including both orientation and stability
when working on postural control, what should you consider?
the ability to maintain COM within BOS
what might compromise ankle strategy?
tone, AFO, contracture, weakness
what might compromise hip strategy?
- weakness, tone, decreased trunk control, timing, initiation
what might compromise stepping strategy?
weakness, trunk control, tone
following neurologic incident patients may have:
problems in timing, motor activation, sensory input, cognitive processing, adaptation, sensory organization, learning
UE balance control
Monitor patient use of trying to grab furniture,
parallel bars- utilizing UE support for balance control which is not where we want to provide intervention
steady state control considerations
- Alignment
- Muscle tone
- Stability limits- sway strategies (motor control/coordination)
- Visual, vestibular, somatosensory inputs with integration
- Task-dependent weighting
What does anticipatory control require?
- Recognition of need for postural response
- APAs for movement
- UE, Trunk, LE –Strength, Isolation of muscle
activity, Timing - Sensory input to provide accurate information to
system
when should you focus on impairments?
- If they are interfering with balance or balance reactions
- prevent new impairments
when thinking about ankle strategy, what should you do?
consider ankle ROM
influence of impairments - strength
relationship of improving strength and its impact on balance is mixed
- a threshold of strength is needed for stability and movement components of balance and balance reactions
Interventions to improve strategies of postural control
facilitate development of sensory, motor, and cognitive strategies that are effective in balance control –> alignment –> sensory strategies –> cognitive strategies –> balance training
alignment
maintain COM within BOS, move COM within stable BOS, move COM in moving BOS
sensory strategies
learning to organize and select most appropriate sensory input
cognitive strategies
attentions need fro postural control, carry over of learning from one task to another
balance training
practice progressively challenging tasks that facilitate the development of postural control and behaviors
context of intervention
- predicable vs unpredictable
- simple or choice of reaction
- predictable vs unpredictable environment
neglect of body
◦ May not recognize parts of body as a part of them
◦ Reorient them to limbs on involved side
◦ Continual emphasis of attention to the limb
neglect of environment
◦ Decreased attention to side of environment
◦ Will not eat food if on side of neglect, may run into obstacles/doors on side of neglect
◦ Increased awareness to side of neglect, activities/cues to encourage attention to that side
neglect is primarily a disorder of what?
Primarily a disorder of attention where patient fails to orientate, report, or respond to simuli on
contralateral side
what is unilateral spatial neglect correlated with?
increased length of stay in inpatient rehabilitation facility, spending an average of 11 days longer
patients with unilateral neglect have a slower what?
progress and less functional improvement per day
compared to individuals following stroke with a similar admission status
when is recovery of neglect most rapid
over the first 10 days and plateaus around the 3 month mark with a majority of patients demonstrating recovery
what does neglect negatively affect?
disability one year post stroke and is a valid predictor for dependency but not of death one year post stroke
does neglect have to occur directly at midline?
nope
common interventions for neglect
Visual interventions
Prism Adaptation
Body Awareness
Mental Function
Movement interventions
Non-Invasive Brain Stimulation
Electrical Stimulation
Acupuncture
Reward
CPG for neglect
Clinicians should provide rehabilitation for neglect that enables people to meet their goals
Contraversive Pushing: Pusher Syndrome
- Perception of body posture in relation to
gravity is altered. - No disturbed processing of visual or vestibular
inputs determining visual vertical.
what is pusher syndrome typically associated with?
lesion to the posterolateral thalamus
Clinical Presentation of Contraversive Pushing Behaviors
◦ Perception of body as upright when actually tiled towards brain lesion
◦ Tendency to push with non-affected extremities into abduction and extension toward hemiparetic side
◦ Resistance to external correction
Are patients with pusher syndrome capable of reaching same functional outcomes
◦ Yes, can take up to 3.6 weeks longer
◦ Insurance and Medicare does not automatically give longer time in therapy to patients with
contraversive pushing, however level of assistance needed at admission, may impact
If given the same length of stay at those with stroke without pushing behavior?
◦ Poorer functional outcomes
◦ Increased caregiver burden
◦ More likely to discharge to SNF
Scale for Pushing Syndrome
Burke Lateropulsion Scale
5 Testing Positions
◦ Supine
◦ Sitting
◦ Standing
◦ Transfers
◦ Walking
0= no evidence of lateropulsion
17= maximum lateropulsion
Initial treatment for pusher syndrome
Initially help them realize their disturbed perception of erect body position
treatment for pusher syndrome in sitting
- permit contraversive body tilt within safety limits
- As they perceive the body tilt or fall ask patient to find a way to get upright again
◦ Support them if unable to return to upright.
What should you encourage for patents with pusher syndrome
- active exploration of visual surroundings.
- Have them align with visual vertical environmental cues
- Windows, pillars, pictures, mirror, door frames, therapist’s arm (vertical)
Progression
If pushing, the therapist may be able to subvert this
maladaptive action by having the patient perform an action toward the non-paretic side (reach for an object and use auditory cues to direct attention).
How to optimize pusher syndrome training:
- maintaining vertical while distracted or performing other activities
- Use conversation and/or head or arm movements while maintaining vertical.
what do most recent studies continue to emphasize for pusher syndrome?
visual feedback for orientation to vertical
