Neuromuscular 2 Unit 4 Dx Specific Interventions: CVA, Pusher Flashcards
Stoke OM
With the 5x Sit to Stand OM, where does this fall in the ICF category?
Activity
Stoke OM
With the Fugle Meyer Assessment OM, where does this fall in the ICF category?
Body Structure/Function
Stoke OM
With the Stroke Impact Scale OM, where does this fall in the ICF category?
Participation
Stoke OM
With the 10 M walk test OM, where does this fall in the ICF category?
Activity
Stoke OM
With the STREAM OM, where does this fall in the ICF category?
Body Function and Activity
Stoke OM
With the Chedoke McMaster Stroke Assessment OM, where does this fall in the ICF category?
Body Function and Activity
Stoke OM
With the Postural Assessment Scale for Stroke (PASS) OM, where does this fall in the ICF category?
Activity
Stoke OM
With the SF-36 OM, where does this fall in the ICF category?
Participation
Stoke OM
With the Functional Gait Assessment (FGA) OM, where does this fall in the ICF category?
Activity
What is the Chedoke McMaster Stroke Assessment (Sequence of Motor recovery)?
This OM is expanded upon the Brunnstrome stages
- This can help us establish a baseline of motor function, track changes over time and It can predict motor recovery (Prognostic implications). This can aid in goal setting.
How is the Fugl Meyer OM relevant with Motor Recovery?
- The Fugle Meyer Motor Scale aids in capturing information specific to the stages of motor recovery, by identifying the movement pattern out of synergy as they progress and it can also aid in determining what stage of recovery the pt is currently in, track those changes over time and aid in determining prognosis
What are some Prognostic Indicators for the CVA population?
- Preservation of function (lesser degree of impairment = better recovery)
- Severity of neuronal damage
- Advanced age
- Persistent medical problems
- Impaired cognition
What are some tools that can help prognosis be further predicted?
- Orpington Prognostic Scale (OPS)
- Corticospinal Track Integrity
- Motor Evoked Potentials (MEPs)
- NIH Stroke Scale
Prognostic Indicators
What is the Orpington Prognostic Scale (OPS)?
This is typically assessed 2 weeks post stroke to aid in determining appropriate discharge setting for the pt. and will ultimately guide the intensity of of therapy that the pt will receive
Prognostic Indicators
What is the Corticospinal Track Integrity?
This can guide us and give us info about how much recovery is possible for this patient
Prognostic Indicators
What is the Motor Evoked Potentials (MEPs)?
(Via Transcranial Magnetic Stimulation), this is predictive in UE function. If there is a presence of a motor envoked potential that indicative of a better prognosis for that individual. It also provides information about how that pt will respond to treatment
Prognostic Indicators
What is the NIH Stroke Scale?
This is used to assess stroke severity and aid in permitting the severity guide the prognosis, this can give us out patients potential to recovery
Post-Stroke its important to have to patient perform Cardiovascular and Strength Training. What types of Training does this include?
High evidence supports the use of muscle strength and aerobic training post-stroke
- Eccentric Training
- Cross Education Training
- Power Training
Post-Stroke, why should we do Power Training? What does it have implications for?
It has Implications for Fall Prevention and improved Gait speed
- This type of training has a fast concentric phase followed by a slow eccentric phase
- By training this burst of fast concentric activation, we provide opportunity for the pt to react quickly in the event of a loss of balance, followed by control in order to reduce the risk of falls and walk more safely at a faster pace
Post-Stroke, what does the Power Training Dosage look like?
Power Training should start at about 20-40% of 1-rep max and then progress over time to 60-70%
- Develop strength base, then increase speed of the contraction
- 8-12 reps, 1-3 sets
- 2-3x per week
With Post-Stroke interventions, what is Functional Electrical Stimulation (FES)?
This is electrical stimulation delivered to the peripheral nerve and muscle during a functional task
- This is considered an Augmented Intervention and is coupled with restorative tasks specific practice
- FES has been utilized to promote both UE and LE recovery post-stroke
- The electrodes are placed on the desired muscles of activation and the stimulation is timed during a certain movement
What is the goal for FES?
(Functional Electrical Stimulation)
To promote increased recruitment of muscle activation for normal motor function, faciliate functional recovery by means of augmentation
- In certain situations, when recovery of motor function does not occur (neuronal damage is too extensive) FES can be used as a compensatory means to promote safety and independence with functional mobility
How can FES benefit the UE?
- It can help improve hand dexterity function and motor function for ADL
- FES can be used in the management of the flaccid UE and hypotonic shoulder that is predisposed to subluxation. FES can aid in prevention of subluxation by aiding increased muscle tone in the muscles surrounding the glenohumeral joint, reduce pain and even potential reduction of a subluxation that has occurred.
- This is more often seen in the Acute/Subacute phases Rather than Chronic
How can FES benefit the LE?
- Improvement in motor function in the LE, walking speed and efficiency when administered to the peroneal (fibular) and anterial tibialis in both acute and chronic stroke
- A reduction in the physiological cost index is also observed with use of FES in the LE.
According to the CPG, when should FES and an AFO be used for Post-stroke patients?
For individuals with Acute and/or Chronic post stroke Hemiplegia
With Post-Stroke interventions, what is Locomotor Training?
Locomotor training is a task orientated approach can take many forms including:
-Overground training
-Treadmill with and without harness
-Body Weight Supported Treadmill Training (BWSTT)
-Robotic Assisted training
-High intensity stepping
-Motor Imagery
-VR
- The majority of these ARE contemporary approaches with the exception of overground training.
With Locomotor Training, what is the evidence for Treadmill Training in CVA populations without the use of a harness? What are the considerations to do this type of intervention?
- There was improved maximum gait speed and step width across all phases of post stroke rehab.
- However there were no significant improvements in comfortable gait speed
Considerations:
- The Patient has walking ability and is safe to walk on a treadmill
With Post-Stroke Interventions, What is the Body Weight Support Treadmill Test (BWSTT)?
- The patient is placed in a harness that has capacity to unweight the patient while they are positioned over a treadmill.
- Therapists can provide assistance for weight shifting and appropriate pelvic rotation along with foot placement. Depending on the level of involvement of the patient, this can take from 1-4 additional therapists and assistants to perform.
- Progression can include progressive lowering of the body weight support for increased limb loading
With the BWSTT, How can this intervention benefit the patient? What are the conderations for this interventions?
- This intervention has been shown to result in improvements in gait speed and distance.
- It is also found that early intervention may improve functional walking ability
- However there is no significant evidence that shows it is superior to other forms of physical therapy interventions.
- What matters most is intensity.
Conderations:
- As long as the patient is medically stable, and you can get them up into standing and walking, even if they do not have the ability to walk currently.
With Locomotor Training, what are additional variations of Treadmill use that we may see? What is the goal of these variations?
- Split Belt Training
- Unilateral Training
The goal would be to forward weight acceptance on the affected limb, while the unaffected limb is forced to take a longer step
With Locomotor Training, what variables can you manipulate on the treadmill?
- Speed
- Incline
- Amount of assist
- Amount of body weight support (if doing BWSTT)
- Should be followed up with task specific gait overground
–As the clinician, you will need to be sure of which parameters are best for your patient’s current status and consult the literature for guidance as well.
With Locomotor Training, what should be followed up with Treadmill training?
If safe and feasible, it is also recommended that all bouts on the treadmill should be followed up with overground stepping for carryover of task as the dynamics of the treadmill are different than overground and at the end of the day, our patient need to be able to walk overground.
With Post-Stroke Interventions, what is Mirror Therapy?
Another Type of Contemporary Approach
- This has been used to address deficits in both UE and LE post-stroke
- Also been studied for use in the treatment of phantom limb pain for those with amputations and in chronic regional pain syndrome
What are the step of performing Mirror Therapy?
- A mirror is placed in the patient’s midsagittal plane.
- The unaffected limb is placed in front of the mirror so that it’s
reflection can be seen in the mirror. The affected limb is placed behind the mirror and out of sight. - The patient then performs movement with the unaffected UE and observes these movements in the mirror with an eventual progression to attempting to move the unaffected limb behind the mirror.
- This will create an illusion that the affected limb is moving, thus tricking the brain into believing the affected limb is moving.
What are the goals of Mirror Therapy?
The goal of mirror therapy in the post stroke population can includes improved attention to the paretic limb, improved motor function and reduction of pain.
Who is most appropriate for Mirror Therapy?
- Patients with motivation to commit to treatment
- Ability to follow instructions
- Hemispatial neglect may benefit
- Low level motor functionin g
Who is NOT appropriate for Mirror Therapy?
- Not recommended for those cognitive and attention deficitsl aphasia, dementia
- Severe hemispatial neglect with limitations in turn the head may not benefit
- High level motor functioning
How can Mirror Therapy benefit the UE?
- Demonstrates effectiveness in ADL performance, Motor activity, Function and recovery
- Improvements in spatial neglect and cortical reorganization
- May increase activation of the hemisphere, including the primary motor cortex
- Reduction of pain, including shoulder pain are also reported
This type of intervention is recommended in conjunction with other therapies
How can Mirror Therapy benefit the LE?
- Improved motor recovery, specifically in ankle dorsiflexion
- Improved mobility and gait in subacute and chronic stroke
With Post-Stroke Interventions, what is the Via Therapy App?
Another Contemporary tool
- This is a tool with a goal to improve UE function in individuals post-stroke
- This app helps guide clinicians through an algorithm for upper limb interventions post-stroke
- This is based on a model called SAFE (which stands for Shoulder Abduction and Finger Extension)
With Post-Stroke Therapy, what is VR therapy?
Another Contemporary approach
- This has implications of both UE and LE
- In the LE there is emerging evidence to support its use on a treadmill for improvements in gait speed in both subacute and chronic stroke; this is an area of rapid development
- In the UE, VR has been shown to enhance use of the upper limb and also included in the via therapy app
With Post-stroke Interventions, what is CIMT?
Constraint Induced Movement Therapy
- This was designed to address the more affected UE in individuals post-stroke
- The CIMT protocol was ultimately birthed as a response to the learned non-use in order promote behavior change and ultimately recovery of the affected limb. Since the birth of
CIMT, numerous studies have explored the efficacy of CIMT with positive finding in both the subacute and chronic phases post stroke.
With CIMT, what are the 4 elements of the CIMT protocol?
- Repeatative and intense task specific training of paretic UE over multiple days
- Shaping
- Transfer package, to real world environment
- Restraint of non-paretic UE via safety mitt
- Repetitive and intense task specific practice is considered the most imperative element of these four in facilitating recovery. Conversely, the physical restraint is believed to be the least significant.
With the 1st element of CIMT (Repetitive and Intense Task Speficic and training of paretic UE over Multiple days), What is the Premis behind this Element?
The premise is behavior change and is facilitated by:
- Repetitive training under Supervised Therapy
-For 3 hrs a day, 5 consecutive days a week for 2-3 weeks
-With this the patient will also perform shaping and functional task practice
- Home Program
-15-30 minutes a day on specific assigned repetitive UE tasks
-Once the patient has completed the program, a home program is individualized for 3 specific repetitive tasks
15-30 minutes a day and 7 selected ADL’s using the affected UE indefinitely
What is the overall goal with the 1st element of CIMT (Repetitive and Intense Task Speficic and training of paretic UE over Multiple days)?
To overcome learned non- use and promote neuroplastic change
With the 2nd element of CIMT (Shaping), What is the Premis behind this Element?
Shaping is based on principles of behavioral training
and ultimately described as small successive steps to make the task more difficult all with the goal of meeting the motor objective.
- When selecting which movements to work on, the recommendation is to focus on joints movements that have the most pronounced deficits along with the greatest potential for
improvement.
For exapmle, let’s say the patient needs to improve in their ability to perform elbow extension, which would be the motor objective. The therapist can facilitate training of a task that promotes repetitive elbow extension by having the patient perform a task that required a small amount of elbow
extension and the target is positioned near the patient. Then, in order to shape the task, the therapist can position the target gradually further away from the patient. The number of reps can also be increased along with reducing the time permitted for the task.
With the 2nd element of CIMT (Shaping), What should ther be an emphasis on?
On positive reinforcement, all with the intent of promoting behavior change.
- Immediate feedback (KR: # reps completed in 30 sec)
- Coach the patient
- Modeling the task (demonstration)
- Encouragement - verbal rewards
With the 3rd element of CIMT (Transfer package), What is the Premis behind this Element?
This refers to the patient’s ability to transfer their gains from the clinical or research world to the realworld environment. Within the transfer package a number of strategies are employed to hold the patient accountable for adherence to the program.
- All are employed to assist in promoting self-efficacy and overcoming perceived barriers, both of which are the two strongest and most consistent predictors of adherence to exercise.
With the 3rd element of CIMT (Transfer package), What are 4 interventions to promote adherence?
- Monitoring, in which the participant uses a measure to track activity called the motor activity log.
- Problem solving interventions are also employed by developing a partnership between the therapist and participant in order to identify potential barriers and instruct and equip the participant on how best to overcome them
- Behavioral Contract in the form of a formal written agreement between the therapist and participant is also established. This contract specifies the activities in which the participant will use the paretic UE and also specify the condition of the mitt outside of the sessions
-
Social support is also addressed by recruiting the caregiver and educating on the appropriate amount of
support for the participant. There may be a caregiver contract as well
With the 3rd element of CIMT (Transfer package), What is the Motor Activity Log (MAL)? When is the MAL administered?
- The motor activity log is a valid and reliable measure. Its a 6-point Rating Scale. It’s purpose is to track progress during the treatment by asking the participant to rate how much and how well they used the paretic UE during certain ADL’s.
- These ADL’s are actually a standardized list of 30 specific ADL’s
- This MAL is administered on the first day of treatment, each day of treatment, immediately after the treatment program and once a week for the first month after treatment
With the 4th element of CIMT (Physical Restraint (Mitt)), What is the Premis behind this Element? What is the recommended goal for this protocol?
- The ultimate premise behind wearing the mitt is to promote forced use of the UE by preventing the urge to using the unaffected UE.
- The recommended goal of the protocol is for the patient that has mild to moderate motor deficits to wear for 90% of waking hours
- Ultimately the purpose of having this mitt is to serve as a reminder to not use the unaffected UE. In doing so, this can help reduce the amount of verbal cues required by the therapist or caregiver to remind the patient to use the affected UE.
this mitt is not the magic ingredient of the CIMT protocol, the repetitive and intensive forced use of the paretic UE is most significant
KNOW
What are the Minimum Active ROM requirements when deciding if your patient is appropriate for CIMT?
- Shoulder Flexion and Abduction ≥ 45°
- Elbow Extension ≥ 20° (Starting from 90° flex on table)
- Wrist Extension ≥ 10° (Starting from full flexion)
- Finger Extension ≥ 10° in a least 2 digits
What are the overall goals for CIMT?
- Overcome learned non- use and promote use dependent cortical plasticity
- Increase speed and efficiency of movement
- Increased use
-New movement strategies (not pre-stroke movement patterns of coordination)
With CIMT, What is the Wolf Motor Function Test (Outcome Measure)?
This is the most commonly used outcome measure pre and
post CIMT and is referenced a great deal in the literature, along with the MAL.
- The Wolf Motor Function test is composed of 2 components, Strength and Functional task items:
-The strength component can include grip strength assessment and amount of weight the extremity can lift during a movement.
-The functional task component includes timed trials are used to assess the average the amount of time required to perform a movement (3 times trials)
What is the Modified CIMT (mCIMT)?
A modification for improved clinical feasibility
- 30 minutes of shaping and functional task practice in therapy, 3 days a week for 10 weeks.
- The restraint is to be worn 5 hours a day for 5 days a week, as opposed to the 90% of waking hours in the original protocol
- While the timeframes are different, the home exercise component and behavioral contract still remain the same. This creates opporunity to deliver this modified protocol in an outpatient setting.
What is Contraversive Pushing?
This is Peculiar behavior
- This is when a patient post-stroke will lean/tilt towards the paretic side
- The non-paretic arm/leg (unaffected) are used to “push” away from the non-paretic side in sitting/standing
- This does create postural instability/falls/fear of falling
- This can be either L or R CVA (however more often with R)
The fear of falling is comes when you ask them to move back to midline
What would happen if you (the PT) try to align the patient with Contaversive Pushing?
They would resist this motion and push more, which then increases their instability and falls
What is the Scale of Contraversive Pushing (SCP)?
This can help the clinician determine if the patient has Contaversive pushing
- This as a max score of 6 points
- Contraversive Pushing is diagnosed when there is >0 in each of the 3 categories
With the Scale of Contraversive Pushing (SCP), what are the 3 categories tested?
- Spontaneous Body Posture
- Abduction and Extension of the Non-Paretic Extremities
- Resistance to passive correction of tilted posture (This is the HALLMARK characteristic of people with CP)
With Scale of Contraversive Pushing (SCP), What does the value 1 mean for the Spontaneous Body Posture?
Value 1 = Severe contaversive tilt with falling to that side
With Scale of Contraversive Pushing (SCP), What does the value 0.75 mean for the Spontaneous Body Posture?
Value 0.75 = Severe contaversive tilt without falling
With Scale of Contraversive Pushing (SCP), What does the value 0.25 mean for the Spontaneous Body Posture?
Value 0.25 = Mild contraversive tilt without falling
With Scale of Contraversive Pushing (SCP), What does the value 0 mean for the Spontaneous Body Posture?
0 = Inconspicuous
With Scale of Contraversive Pushing (SCP), What does the value 1 mean for the Abduction and extension of the non-paretic extremities?
Value 1 = Performed spontaneously, already when at rest
With Scale of Contraversive Pushing (SCP), What does the value 0.5 mean for the Abduction and extension of the non-paretic extremities?
Value 0.5 = Performed only on changing position (e.g., on transferring from bed to wheelchair)
With Scale of Contraversive Pushing (SCP), What does the value 0 mean for the Abduction and extension of the non-paretic extremities?
Value 0 = Inconsipicuous
With Scale of Contraversive Pushing (SCP), What does the value 1 mean for the Resistance to passive correction of tilted posture?
Value 1 = Resistance occurs
With Scale of Contraversive Pushing (SCP), What does the value 0 mean for the Resistance to passive correction of tilted posture?
0 = Resistance does not occur
What is Burke Lateropulsion Scale (BlS)?
- This has been advocated as being superior to the scale for contraversive pushing.
- This has been shown to be much more sensitive at detecting mild pusher behavior when compared to the scale for contraversive pushing.
-
More importantly it is more responsive to small changes
(that’s critical when you’re trying to show progress and recovery of pusher behavior in response to your PT interventions) - This is considered Gold standard cause its more sensitive
How is the Burk Lateropulsion Scale (BLS) scored?
There are 5 Testing positions:
1. Supine Rolling (resistive to passive rolling)
2. Sitting (Resistance to passive postural correction based on degree of tilt)
3. Transferring (resistance and assistance during transferring)
4. Standing (resistance to postural correction based on degree of tilt, past midline)
5. Walking (resistance and assistance during walking)
- Max Score = 17 points
- > 2 / 17 is diagnostic for contraversive pushing
What are other characteristics that go along with Contraversive Pushing?
- Severe hemiparesis
- Severe Sensory deficit
- Neglect
These patient have a higher incidence of pushing behavior
There is also a higher incidence of pushing in those with R CVA than L
What are Causes of Contraceptive Pushing?
- Gravi-ceptive impairment
-Vestibular and Visual input likely normal - Mis-match between sensory systems results in contra-lateral tilt and pushing behavior
What is the Prognosis for those patients with Contraversive Pushing?
Prognosis is good
- Transient behavior for most
- Pushing resolved in 6 weeks in 62% of patients, and 3 months in 79% of patinets
- R CVA and pushing predicts slower recovery
- Neglect and pushing predicts slower recovery
- Patient who push take LONGER TO RECOVER functional mobility
-Longer length of stay by 3.6 weeks
Contraversive Pushing
What is a common lesion location for people who push?
The Posterolateral Thalamus, and Parietal Lobe
- The Thalamus is involved in our control of upright posture
What should be the Treatment Approach for Contraversive Pushing?
- Avoid “Passive” correction
-Hand-off approach - Make patient visually aware of their tilted body position
-Mirrors, use of tape line - “Actively” regain midline in sitting and standing
-Reaching activites with the non-paretic extremities are carries out
-Acoustic signals (clapping, knocking on the bed frame) - PREVENT pushing
-Raise table may up to prevent non-paretic LE pushing
-Use unstable surface under nonparetic LE - Promote alignment with vision using vertical structures
-Door and window frames,pillars, picture frames, broom handle, yard stick, your arm, mirror & shirt with vertical tape line, etc. - Provide feedback about their body orientation
- Promote weight bearing on the nonparetic side followed by the paretic side
How do we transfer a patient with contraversive pushing from the bed to wheelchair?
- Firstly work on alignment
- Prevent falling and minimize therapist effort
- Begin by reducing fear of falling while flexing forward
- Utilize visual vertical cues throughout the transfer
- Prevent LE pushing/abduction by blocking knee
- Prevent UE pushing/abduction
- Squat pivot transfer, not stand pivot
Which direction do you think it is easier to
transfer a patient from bed to wheelchair if
they have contraversive pushing?
A) Towards the paretic side
B) Towards the nonparetic side
A) Towards the Paretic side
- At the beginning of rehab it is easier to transfer toward the
paretic side, since pts tend to push in this direction
- In the early days patients DO NOT want to move towards the nonparetic side, as it induces a fear of falling and they will therefore resist and push against you if you try to transfer towards the nonparetic side. This pushing makes the transfer more difficult.
- HOWEVER, from a therapeutic stand-point you should begin immediate training of transfers to the nonparetic side
As PTs we will need to work on both directions,
- use visual verticals is critical especially when transferring towards the non-paretic side
What should be done with Gait Training with patients with Contraversive Pushing?
- Begin gait training with the patient’s non-paretic side against a wall or a raised mat
-Pt tend to be less fearful of falling and tend to reduce pushing when there is a sturdy surface on the nnparetic side
-Work on nonparetic weight bearing (standing sequence, parteic foot up on 1’’ step, etc) - “Glue your shoulder on the wall”
- Use a mirror and visual verticals
What are the Goals for Therapy for those patients with Contraversive Pushing?
- Early on let the patient “fall” safely towards the paretic side
-Trial and error learning
-Teaches the patient that leaning to the paretic side is NOT a safe position to assume - Use vertical visual cues, tactile cues, and auditor cues to align patient to midline
- Promote active alignment via reaching past midline for objects on nonparetic side
-Reduces fear of falling when the body moves towards nonparetic side - Promote auromatic postural control by adding:
-Distracting environments
-Dual Tasking (Cognitive and Motor)
