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DPT 620: Neuro > PT and the UE > Flashcards

PT and the UE Flashcards

1
Q

what are some fxnal activity and performance limitations with the UE following stroke?

A

carrying, moving, lifting and handling objects

fine hand use (grasp, manipulate, release)

hand and arm use (pull, push, reach, throw, catch, etc)

self care (washing, dressing, drinking, toileting, eating, looking after oneself)

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2
Q

what is the typical position of the scap following stroke?

A

abd and downward rotation

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3
Q

t/f: with the downward pull of the scap, there is nothing stopping the downward pull of the humerus except the muscles which stretch out very quickly

A

true

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4
Q

what are the UE changes w/hemiparesis?

A

losses of motor and sensory fxn

varying degrees of muscle tone

mal-alignment of the pelvis and trunk

PPT and upper trunk flexion

trunk shortening and lat flexion

inf displaced humerus

ant positioned humerus

downwardly rotated scap

laterally shifted/rotated scap

change in scapulohumeral rhythm

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5
Q

what are the primary risks and complications limiting recovery following stroke?

A

ROM losses

edema

shoulder subluxation

pain

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6
Q

where in the shoulder can there be ROM losses?

A

scapulothoracic

scapulohumeral

GH

hand/finger/wrist

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7
Q

what should we ALWAYS inspect for post stroke at the shoulder?

A

for pain and subluxation

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8
Q

t/f: biomechanical alignment is key in interventions post stroke

A

true

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9
Q

how do we provide biomechanical alignment?

A

start at the base

90 deg hip and knee flex

ant tilt/neutral pelvis

symmetrical WB

may use stool on ground and arm support

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10
Q

what are the SAFE requirements?

A

visible shoulder abduction and voluntary finger extension

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11
Q

what happens to the prognosis when a pt meets the SAFE requirements?

A

the prognosis is significantly better

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12
Q

if the pt meets the SAFE requirements within 2 days, what is the prognosis?

A

98% probability of return of UE fxn

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13
Q

if the pt meets the SAFE requirements in >12 days, what is the prognosis?

A

the prognosis goes way down if it takes this long

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14
Q

what complications in the shoulder can dramatically change recovery?

A

presence of shoulder pain and/or subluxation

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15
Q

what are the 4 categories of recovery for the UE?

A

(I) no muscles activity

(II) demonstrates active shoulder abduction

(III) demonstrates shoulder and finger extension

(IV) shoulder pain and subluxation

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16
Q

what interventions should we focus on for pts with no muscle activity?

A

ESTIM for motor recovery

motor imagery/mental practice

sensory training/sensory discrimination training

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17
Q

what are the interventions for pts with no muscle activity?

A

active assisted or PROM for hand edema

assess hand edema

instruct pt in compensation techniques for fxn

ESTIM for motor recovery

motor imagery/mental practice

sensory training/sensory discrimination training

avoiding hand splinting

pt and fam ed on passive protection and care of the UE

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18
Q

what are the key factors to consider about the UE in supine?

A

need to reduce the effects of gravity on the UE by supporting the arm in light WB

make sure the humerus and scap are in good position

avoid hand edema by elevating the extremity

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19
Q

what are the key factors to consider about the UE in SL on the affected side?

A

watch the scap and humerus

make sure the shoulder is protracted and the hand is supported in WB to promote recovery

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20
Q

what are the key factors to consider about the UE in SL on the unaffected side?

A

the shoulder has a tendency to retract, so get good protraction and support the UE

want as much ER as feasible

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21
Q

what are the key factors to consider for the UE in sitting?

A

use what you have available to support the UE

WB through the elbow and forearm

check the scap

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22
Q

for the preservation of fxning of the hand, we have to ensure maintanance of what two things?

A

1) the fxnal arch of the hand

2) ROM of the hand and fingers

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23
Q

t/f: sometimes, if spasticity is too high, the only way to manage it is w/really strong material/surface to keep them in a fxnal hand position

A

true

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24
Q

protective handling involves what 2 things?

A

protective, proper transfer technique

protection and maintenance of jt integrity

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25
Q

we want at least ___ degrees of wrist extension to be maintained

A

25

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26
Q

what do we mean by proper transfer techniques for protective handling post stroke?

A

avoid pulling or lifting on the affected limb during mobility or transfers (educate fam, staff, nursing)

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27
Q

how can we protect and maintain jt integrity?

A

ensuring good GH jt alignment and scap mobility on the thorax

avoiding passive or active shoulder flexion beyond 90 degrees

avoiding overhead pulleys

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28
Q

why should we avoid passive or active shoulder flexion beyond 90 degrees post stroke?

A

it can cause impingement and CRPS

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29
Q

when is the only time it may be acceptable to flex the shoulder beyond 90 degrees post stroke?

A

if the scap is gliding towards upward rotation and has sufficient ER available

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30
Q

how can we mobilize and protect the UE with transfers?

A

tuck the involved extremity into a pocket, gait belt, or under your arm

if higher level of fxn-can use uninvolved extremity to support the involved extremity (b/l clasp)

WB

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31
Q

how can we mobilize and protect the UE in gait?

A

WB on a moving cart or table (make sure the humeral head doesn’t move up)

can use urself as the AD and use your fingers for directional cues

b/l engagement

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32
Q

what is the problem with slings?

A

they promote non-use and assymetry of the trunk and extremity

they prevent normal mov’t from occuring

put the arm in a synergistic patterns

no sling does anything to realign the scap

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33
Q

t/f: slings are a tool to be used while gaining proximal stability and should not be used long term

A

true

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34
Q

what three types of slings support the GH jt?

A

Bobath sling

Give-Mohr sling

hook hemi harness

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35
Q

what is the Give-Mohr sling?

A

elastic fabric sling that has a hand device for the pt to hold onto

every mov’t gives input to the shoulder

leaves the arm free for normal mov’t in gait

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36
Q

what is the hook hemi harness?

A

intends to keep the humerus from downward subluxation

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37
Q

what is the problem with the Bobath, Give-Mohr, and hook hemi harness slings?

A

the pt can’t put them on independently

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38
Q

if a pt demonstrates active shoulder abduction WITHOUT finger extension, what interventions are appropriate?

A

motor imagery/mental practice

strength training

task specific training

ESTIM-NMES

mirror therapy

robot assisted training

video gaming

sensory retraining

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39
Q

if a pt demonstrates active shoulder abduction WITH finger extension, what interventions are appropriate?

A

modified CIMT

motor imagery/mental practice

sensory retraining

video gaming

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40
Q

when is there strong evidence for mental practice/imagery?

A

when used in conjunction with PT

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41
Q

t/f: there is good evidence for mental practice/imagery as an individual intervention

A

false

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42
Q

what are the 3 techniques for active recruitment and facilitation/strengthening of motor responses in the UE?

A

1) critical to maintain a proper scap and GH positioning

2) UT relaxation

3) facilitation of active response

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43
Q

what muscles are critical to keep the scap against the trunk?

A

rhomboids

MT

LT

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44
Q

why is UT relaxation important?

A

bc 90% of pts post stroke have their UT getting in the way of normal recruitment bc it becomes overused

45
Q

in the closed chain, we facilitate what activity?

A

tonic activity

46
Q

in the open chain, we facilitate what activity?

A

phasic activity

47
Q

how do we facilitate tonic activity?

A

with weight bearing (WB)

48
Q

how do we facilitate phasic activity?

A

with PNF and other techniques

49
Q

why do we do UE weight bearing?

A

bc it temporarily moves the head of the humerus back up into the glenoid fossa and assists in realignment of the jt

it fires/facilitates supportive musculature through stimulation of jt receptors for normal activation of shoulder muscles

50
Q

t/f: WB only provides temporary realignment of the jt and must be combined with other facilitation and protection strategies

A

true

51
Q

what are the indications for air splints?

A

increased ROM

reduction of hypertonicity (rest, mov’t)

stabilization

allow WB

52
Q

what are the mechanisms for how air splinting works?

A

neutral warmth

prolonged stretch

deep pressure

53
Q

t/f: air splints are a great option for when gait training and needing to control UE hypertonicity

A

true

54
Q

t/f: kinesiotaping should be used in conjunction with other techniques to be effective

A

true

55
Q

when used in conjunction with other techniques, what are the benefits of kinesiotaping?

A

facilitate/inhibit muscle fxn

support jt structure

reduce pain

provide proprioceptive feedback

achieve and maintain alignment

56
Q

t/f: mirror therapy is a promising treatment option for early after stroke

A

true

57
Q

what is mirror therapy?

A

stimulating the involved UE by using the uninvolved UE

58
Q

what are the benefits of MT (mirror therapy) early post stroke?

A

improves sensory awareness and recovery

improves attentional deficits

improves motor recovery in distal hemiplegic limb

59
Q

MT works well if ____ is available

A

abduction

60
Q

t/f: MT needs to be combined with conventional stroke rehab

A

true

61
Q

t/f: MT is a good option for someone early in recovery who is beginning to have shoulder pain

A

true

62
Q

what is the dosage for MT?

A

1/5 hours/day, 5 days/weeks for 4 weeks for improved motor performance and temp sense

63
Q

t/f: MT translates into ADLs like task specific interventions do

A

false

64
Q

what is involved in fxnal retraining?

A

motorized and ergonomic robotic arm

software which combines personalized, pt-specific exercises and games to engage and motivate

65
Q

what are the interventions for pts that demonstrate shoulder and finger extension?

A

modified CIMT

motor imagery/mental practice

sensory retraining

video gaming

virtual reality training

66
Q

what is a technique for encouraging the use of the affected arm?

A

CIMT

67
Q

what is involved in CIMT?

A

restricting use of the unaffected hand for several hours a day and performing tasks over and over w/the affected arm

68
Q

what technique involves “forced use” of the hand and fingers that causes the brain to reorganize to help move the hand?

A

CIMT

69
Q

what are the 3 procedures of CIMT?

A

1) massed practice of repetitive, structured, practice-intensive therapy in the use of the more affected arm

2) constraint (restraint) of the less affected arm 90% of waking hours

3) transfer program, which includes monitoring arm use in life situations and problem solving to overcome perceived barriers to using the extremity

70
Q

what is the 10x10x10 rule in CIMT?

A

to be considered a candidate for CIMT, they must have at least:

10 degrees active wrist extension
10 degrees active thumb abduction
10 degrees active extension of any other 2 digits on the affected hand

71
Q

other than the 10x10x10 rule, what other inclusion criteria must be met for CIMT?

A

pt must be able to walk relatively short distances w/o an AD

pt must have a high level of motivation and commitment

pt must have sufficient endurance

72
Q

what is the exclusion criteria for CIMT?

A

presence of chronic pain or co-morbidities that would limit participation

73
Q

what is involved in experience dependent cortical reorganization?

A

synapses that have potential for activation are recruited after the usually dominant system has failed

these neurons get set into constant use through repetition and practice

74
Q

what are the disadvantages of CIMT?

A

it requires a lot of labor from pts and medical staff

pts endure many hours of frustration

pts can suffer from muscle soreness resulting in stiffness and discomfort in the involved UE

acute CIMT can be harmful by increasing the size of the lesion

it is not beneficial to all pts with stroke/BI (typically for pts with higher level of fxn)

longer treatment=high cost (not reimbursed through insurance)

75
Q

what are the results of modified CIMT?

A

the results are consistent with more intense CIMT protocols

76
Q

what is the protocol for modified CIMT?

A

30 minutes of 1 on 1 therapy 3 days/week

5 hours/day in restraint (weekdays)

10 weeks

77
Q

what does neuromuscular electric stimulation do?

A

boosts arm and hand recovery through sensory electrical stimulation (SES)

specifically for hand closing/opening

it improves fxn, weakness, and spasticity

78
Q

t/f: virtual reality is task-specific training

A

true

79
Q

t/f: virtual reality is a beneficial intervention when used as an adjunct to usual care and when compared w/the same dose of conventional therapy

A

true

80
Q

virtual reality may be beneficial in improving what?

A

UE fxn and ADL fxn

81
Q

t/f: there is sufficient evidience of VR and interactive video gaming on grip strength, gait speed, or global motor fxn

A

false

82
Q

what are the interventions for a patient with shoulder pain and subluxation?

A

ed and training for the pt and family regarding UE care

gentle mobs for those w/decreased ROM or pain

ESTIM for subluxation

analgesic meds

avoid strapping

botox

83
Q

when a pt with shoulder pain and subluxation has ROM losses, what should we include?

A

gentle mobs

education and training for the pt and family

84
Q

when a pt with shoulder pain and subluxation has ROM losses, what should we avoid?

A

PROM/AROM of shoulder flexion greater than 90 degrees

overhead pulleys

85
Q

what is the incidence of pain in individuals with hemiplegia?

A

5-84%

86
Q

what are some causes of shoulder pain post stroke?

A

subluxation

impingement

87
Q

when the shoulder subluxes, what things can happen?

A

brachial plexus injury

structural tears (35%)

tendinopathies (53%)

88
Q

what results from impingement at the shoulder?

A

sub-acromial fluid collection

89
Q

what is the cause of hand pain post stroke?

A

pain syndrome-CRPS

90
Q

shoulder subluxation is the result of not only the effect of gravity but also the effect of ____ of the depressor muscles

A

spasticity

91
Q

how do we clinically rate subluxation at the shoulder?

A

measure the separation in terms of horizontal finger widths

92
Q

how do we manage shoulder subluxation?

A

active recruitment of the supraspinatus and deltoids

passive protection

93
Q

what 2 muscles are essential to maintain GH alignment?

A

the supraspinatus and deltoids

94
Q

t/f: the supraspinatus prevents the downward pull and subluxation of the humerus

A

true

95
Q

what is fxnal electrical stimulation (FES) effective and not effective for?

A

effective for prevention/reduction of subluxation but not for pain or motor recovery post-stroke

96
Q

several researchers have reported success w/management of shoulder subluxation with FES with what protocol?

A

gradually increasing stimulation times that ultimately reached 6-7 hours/day

on-off ratio typically 1:3

97
Q

who is Bioness implantable ESTIM for?

A

pts who respond well to ESTIM when it’s on, but gone when taken off

98
Q

what muscle does the Bioness implantable ESTIM target?

A

deltoids

99
Q

WC attachments result in a __mm reduction of subluxation

A

15

100
Q

slings with elbow flexion result in a __mm reduction in subluxation

A

10

101
Q

slings with elbow extension result in a __mm reduction in subluxation

A

4

102
Q

what is the best intervention for reduction of subluxation?

A

WB and ESTIM

103
Q

t/f: traditional passive tapping and strapping has strong evidence that it reduces subluxation

A

false, strapping should be avoided

104
Q

what is CRPS?

A

hyperactivity of somatosensory, autonomic, and motor systems resulting in regional pain, vascular, and trophic changes and atrophy

105
Q

the onset of CRPS is influenced by what things post stroke?

A

type of stroke

severity of motor loss, sensory loss, and spasticity

GH jt subluxation

106
Q

what is the EBP treatment consensus for CRPS?

A

medical and rehab combo is the best intervention

107
Q

what is involved in medical intervention for CRPS?

A

low doses of oral corticosteroids

nerve blocks

Botox

108
Q

what is involved in rehab of CRPS?

A

PROM to pain tolerance (with careful attention to the scap)

proper positioning in WB

neuromotor re-education to facilitate normal task specific use of the UE

mirror therapy

AVOID MODALITIES

109
Q

why should we avoid modalities in CRPS treatment?

A

bc they have abborant sensory processing and their pain is at the matrix level and is not a muscular pain

DPT 620: Neuro (12 decks)

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