Restoration vs. Compensation & CVA Outcomes Flashcards
Hyper-acute phase
0-24 hours: includes cell death
Acute phase 1-7
inflammation and scarring and endogenous plasticity
Subacute Phase
Early (7 days to 3 months post)
Late (3 to 6 months pos)
Chronic phase
more than 6 month
what is the Acute Phase
Setting: intensive care unit (ICU) or specialized stroke care unit
Therapist considerations: reviewing the medical record and communicating with the medical team
what are the goals for acute phase
-monitor changes in the patient’s status and promote early mobilization
-Early stimulation of the hemiparetic side to promote functional reorganization
-Encourage a positive outlook towards the rehabilitation process
-Interventions: bed mobility, sitting, transfers, locomotion, ADL training, ROM, splinting and positioning
-Provide instruction, education and training
What is the Subacute Phase
Setting: intensive inpatient rehabilitation, transitional care unit (TCU) within a skilled nursing facility
Therapist considerations: tolerance to daily rehabilitation
Goals: continuation of acute phase
What is the Chronic Phase?
Setting: outpatient rehabilitation (OP), community setting, or at home
what are chronic phase goals
Inpatient interventions plus CIMT, bilateral training, virtual reality (VR) training and electromechanical-assisted walking, etc.
OP: flexibility, strength, balance, locomotion, endurance and UE function; HEP prescription
Homecare: home environmental recommendations and adaptations
Community setting: recreational activities, community fitness programs and water-based activities
Recovery Timeline
Generally, fastest in the first weeks and months after onset, however, improvements can continue thereafter
Variability occurs based on the level of language and visuospatial function and impairment involvement
Variability also occurs based on stroke severity
what is intervention
The interaction between the PT with the patient/client and other individuals who may be involved in his/her care
what are intervention strategies
-Patient or client instruction
-Airway clearance techniques
-Assistive technology: prescription, application, and as appropriate fabrication or modification
-Biophysical agents
-Functional training in self-care and in domestic, education, work, community, social and civic life
-Integumentary repair and protection techniques
-Manual therapy techniques
-Motor function training
-Therapeutic exercise
what are intervention components
Environmental structure
Practice schedule
Feedback type and schedule
Intervention dosing
Program progression
Problem-solving, reflection, and self-management
What are body functions and structure level
Neuronal recovery of function is restored in the tissues that were initially lost after injury
what is neural plasticity
The factor that allows for the ability of the brain to modify in function and repair itself
what is mechanisms of neural plasticity
Neuroanatomical:
Neurochemical
Neuroreceptive
what are mechanisms of neural plasticity
-Neural regeneration (nerve growth)
-Activation of brain areas not previously active
-Nerve growth factors (trophic factors) that play a role in growth and repair processes
-Regenerative synaptogenesis (sprouting of the injured axons to innervate previously innervated synapses)
-Reactive synaptogenesis (collateral sprouting- reclaiming of synaptic sites of the injured axon by dendritic fibers from neighboring axons)
-Synaptic plasticity through neurotransmitter release and receptive sensitivity
-Long-term potential (LTP) changes synaptic strength
Principles of Experience-Dependent Neural Plasticity and Neurorehabilitation
Use it or lose it
Specificity matters
Repetition matters
Intensity matters
Timing matters
Age matters
Transference
Reinforce selection of important stimuli
Enhance attention feedback
Interference
Function-induced recovery (use-dependent cortical reorganization)
The ability of the nervous system to modify itself in response to changes in activity and new experiences
Task-oriented training
Use of repetitive task practice
Ex: CIMT and body weight support treadmill training (BWSTT)
Critical/sensitive period
The brain is most responsive to improvements from motor training
What is restorative interventions
-Directed toward remediating or improving the patient’s status in terms of impairments, activity limitations, participation restrictions, and recovery of function
-Targeted areas:
The involved extremities or trunk
-Assumed existing potential for change
Ex: a patient post-acute CVA
What is compensatory intervention
-Directed toward promoting optimal function using new motor patterns
what are two considerations of compensatory
-Adaptation: using the involved segments and adapting with remaining motor elements
-Substitution: functions are replaced or taken over by different body segments using different motor patterns
—Target: less involved or uninvolved extremities
-Adaptations of either the task, activity or environment can be considered
what are compensation intervention examples
-Use of intact limbs to compensate for those with weakness
-Use of sensory conservation and joint preservation techniques
-Use of environmental adaptations to optimize performance
Restorative & Compensatory/Substitution
Can be used together to maximize function
When restorative interventions are unrealistic or unsuccessful
What are preventative interventions
-Directed towards minimizing potential problems and maintaining health
-Therapist can help prevent things such as:
Decreased vital capacity and cardiovascular endurance
Disuse atrophy and weakness
Contractures
Decubitus ulcers
Deep vein thrombosis (DVT)
Renal calculi
Urinary tract infections
Pneumonia
Depression
what are intervention selection considerations
-Examination and evaluation of the patient
-Physical therapy diagnosis
Prognosis
-Goals and expected outcomes
what is restoration
the reappearance of motor patterns that were present before CNS injury”
what is compensation
the appearance of new motor patterns resulting from the adaptation of remaining motor elements or substitution of alternative motor strategies and body segments
what is substitution training
-The patient is made aware of movement deficiencies and the changes required to complete the functional task
-Alternate ways are proposed, broken down and adopted
-Requires patient practice to relearn the task
—Practice then needs to occur in the environment it is expected to occur
SUbstitution
-when functions are assumed, replaced, or substituted by different areas of the brain capable of becoming reprogrammed and engaging different efforts or body segments”
-Prior movement is performed in a new way
what are examples of substitution training
Post-CVA with hemiparesis: using the less-affected UE to dress
Post-CVA with unilateral neglect:
Color-coding shoes to dress
Extending and color-coding the w/c brake toggle to ease identification
what are concerns of utilizing substitution training
-Focusing on the less-involved segments may suppress recovery and contribute to learned nonuse of impaired segments
-Could lead to the development of splinter skills
-Splinter skills defined: “acquired in a manner inconsistent with skills the individual already processes”
-These skills cannot be generalized to task variations or other environments
When should I do what?
-Substitution Training:
-DO NOT: place a point of focus is there is potential for recovery
-DO: perform when recovery potential is limited
-DO: perform when the patient presents with significant comorbidities, impairments, and functional limitations with little or no expectation for additional recovery
What should I consider when designing a plan of care and selecting interventions?
Consider
-Patient variability
-Timeframe of injury/impairment onset
-Nature of the impairments
what are affects Recovery
-Motor and perceptual deficits have the greatest impact on functional performance
-Sensory loss, disorientation, communication disorders, and decreased cardiorespiratory endurance can also negatively affect recovery
-Positive factors might include:
*High motivation
*Stable and supportive family
*Financial resources
*Intensive training with repetitive practice
