Restoration vs. Compensation & CVA Outcomes

Question 1

Hyper-acute phase

Answer 1

0-24 hours: includes cell death

Question 2

Acute phase 1-7

Answer 2

inflammation and scarring and endogenous plasticity

Question 3

Subacute Phase

Answer 3

Early (7 days to 3 months post)
Late (3 to 6 months pos)

Question 4

Chronic phase

Answer 4

more than 6 month

Question 5

what is the Acute Phase

Answer 5

Setting: intensive care unit (ICU) or specialized stroke care unit

Therapist considerations: reviewing the medical record and communicating with the medical team

Question 6

what are the goals for acute phase

Answer 6

-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

Question 7

What is the Subacute Phase

Answer 7

Setting: intensive inpatient rehabilitation, transitional care unit (TCU) within a skilled nursing facility

Therapist considerations: tolerance to daily rehabilitation

Goals: continuation of acute phase

Question 8

What is the Chronic Phase?

Answer 8

Setting: outpatient rehabilitation (OP), community setting, or at home

Question 9

what are chronic phase goals

Answer 9

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

Question 10

Recovery Timeline

Answer 10

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

Question 11

what is intervention

Answer 11

The interaction between the PT with the patient/client and other individuals who may be involved in his/her care

Question 12

what are intervention strategies

Answer 12

-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

Question 13

what are intervention components

Answer 13

Environmental structure
Practice schedule
Feedback type and schedule
Intervention dosing
Program progression
Problem-solving, reflection, and self-management

Question 14

What are body functions and structure level

Answer 14

Neuronal recovery of function is restored in the tissues that were initially lost after injury

Question 15

what is neural plasticity

Answer 15

The factor that allows for the ability of the brain to modify in function and repair itself

Question 16

what is mechanisms of neural plasticity

Answer 16

Neuroanatomical:
Neurochemical
Neuroreceptive

Question 17

what are mechanisms of neural plasticity

Answer 17

-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

Question 18

Principles of Experience-Dependent Neural Plasticity and Neurorehabilitation

Answer 18

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

Question 19

Function-induced recovery (use-dependent cortical reorganization)

Answer 19

The ability of the nervous system to modify itself in response to changes in activity and new experiences

Question 20

Task-oriented training

Answer 20

Use of repetitive task practice

Ex: CIMT and body weight support treadmill training (BWSTT)

Question 21

Critical/sensitive period

Answer 21

The brain is most responsive to improvements from motor training

Question 22

What is restorative interventions

Answer 22

-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

Question 23

What is compensatory intervention

Answer 23

-Directed toward promoting optimal function using new motor patterns

Question 24

what are two considerations of compensatory

Answer 24

-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

Question 25

what are compensation intervention examples

Answer 25

-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

Question 26

Restorative & Compensatory/Substitution

Answer 26

Can be used together to maximize function

When restorative interventions are unrealistic or unsuccessful

Question 27

What are preventative interventions

Answer 27

-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

Question 28

what are intervention selection considerations

Answer 28

-Examination and evaluation of the patient

-Physical therapy diagnosis
Prognosis

-Goals and expected outcomes

Question 29

what is restoration

Answer 29

the reappearance of motor patterns that were present before CNS injury”

Question 30

what is compensation

Answer 30

the appearance of new motor patterns resulting from the adaptation of remaining motor elements or substitution of alternative motor strategies and body segments

Question 31

what is substitution training

Answer 31

-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

Question 32

SUbstitution

Answer 32

-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

Question 33

what are examples of substitution training

Answer 33

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

Question 34

what are concerns of utilizing substitution training

Answer 34

-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

Question 35

When should I do what?

Answer 35

-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

Question 36

What should I consider when designing a plan of care and selecting interventions?

Answer 36

Consider
-Patient variability
-Timeframe of injury/impairment onset
-Nature of the impairments

Question 37

what are affects Recovery

Answer 37

-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