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PHTY302 > Sensori-motor impairments after a stroke > Flashcards

Sensori-motor impairments after a stroke Flashcards

1
Q

What are positive impairments after a stroke?

A

additional features.
Spasticity
Increased tendon reflexes

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2
Q

What are negative impairments after a stroke?

A

Loss of pre-existing function

Loss of strength
Loss of co-ordination
Loss of sensation

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3
Q

What is spasticity?

A

Hyperexcitability of the stretch reflex
Velocity dependent
Often referred to as increased tone

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4
Q

What is tone?

A

Resistance to passive movement

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5
Q

What can increased tone be due to

A

Contracture, spasticity, excessive muscle activity

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6
Q

Why is spasticity not just increased tone?

A

Spasticity is velocity dependent

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7
Q

What are some secondary impairments following a stroke?

A 
Loss of fitness
Contracture
Learned non-use
Swelling
Shoulder pain
Shoulder subluxaion
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8
Q

Which impairments have the greatest impact on activity?

A

Historically, was thought positive features, particularly spasticity. However, it was later learnt that weak agonist muscles were more of a problem than excessive antagonist muscles.

Negative impairments - loss of strength has the strongest and most consistent relationships with activity limitation.

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9
Q

How is spasticity measured?

A

Ashford vs Tardieu

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10
Q

What is the ashford scale?

A

Measures “tone” - resistance to passive movement

grades 0-4 represent “no increase in tone” to “limb rigid in flexion or extension”

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11
Q

What is the Tardieu scale?

A

Measures velocity dependent - resistance to passive movement.
Limb moved at 3 speeds v1, v2, v3
Quality of muscle reaction is graded
Grades 0-4 represent “no resistance” to “unfatiguable clonus”

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12
Q

GPP for spasticity

A

Interventions to decrease spasticity other than an early comprehensive therapy program should NOT be routinely provided for people who have mild to moderate spasticity (i.e. spasticity that does not interfere with stroke survivor’s activity or personal care

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13
Q

Stroke guidelines for people with moderate to severe spasticity

A

B :botox with reha

C: e stim and/or emg biofeedback

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14
Q

What is the relationship between strength and activity

A

curvilinear
Weak populations: very strong relationship between strength and activity
In strong/normal population - no relationship between strength and activity

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15
Q

What are the assumptions about the distribution of loss of strength after a stroke? are they correct?

A

Assumption distal muscles affected more, UL extensors more affected than flexors, LL flexors more affected than extensors

These are NOT supported by evidence
Assess each patient and se what their problems are!!

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16
Q

What are the causes of loss of strength after a stroke?

A

neural and peripheral canges

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17
Q

What are the neural changes that cause loss of strength after a stroke?

A
  • Loss of upper motor neurons as direct result of the stroke
  • Loss of lower motor neurons due to trans-synaptic degeneration
  • Decreased excitability of motor neurons
  • Loss of orderly recruitment of motor units

These neural changes result in activation failure

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18
Q

Activation capacity =

A

proportion of muscle force that can be voluntarily activated

19
Q

Activation failure =

A

proportion of muscle force not activated voluntarily

20
Q

What peripheral changes cause loss of strength after a stroke?

A

-Loss of muscle mass
- Loss of motor units (some suggestion more Type 2 motor units lost)
Remodelling of motor units
- collateral sprouting
-Increased innervation ratio, less orderly recruitment

21
Q

What is collateral sprouting

A

Motor neurons supplying muscle fibres that didn’t have input

22
Q

What are the characteristics of loss of strength after a stroke?

A

Inner range of muscles is more severely affected
Difficulty sustaining muscle contractions
Difficulty producing force rapidly.

23
Q

What are the options for increasing strength after stroke?

A

Devices:
E stim
EMG triggered ES
EMG biofeedback

Active exercise
- Isolated movements
Task specific

Mental practice
Robotics
Mirror therapy

24
Q

How do the principles of strengthening differ in grade 0-2 ?

A

Unable to move against resistance.
Need low load/high reps

Use functional positions e.g. modified sit to stand, modified standing, modified walking - i.e treadmill and bodyweight

25
Q

What is the aim of training grade 0-2 muscles?

A

Increase central drive to muscles
Improve activation capacity

Need to structure the training that allows for lots of repetitions to be acheived.

26
Q

What can be used in severe pareises

A

Smart arm

Robotics

27
Q

Techniques to elicit movement in very weak muscles

A 
Eliminate gravity
Eliminate friction
Different parts of range
Eccentric/isometric/ concentric contractions
Shorten/minimise impact of the lever arm
Reduce the degrees of freedom
28
Q

How should mental practice be done?

A

Practice session
What is being visualised - movements, activities
How many reps
Record pracitce

29
Q

Strengthening interventions grade 0/1

A 
Eliciting muscle activity:
Mid-range
Gravity eliminated
Decrease friction
Shorten lever arm

Devices: EMG biofeedback
E stim
EMG triggered ES

Mental practice
Modified task related training

30
Q

Strengthening interventions grade 2

A 
Exercises:
full range
inner range
Sustained contraction
Increased speed
Resistance to mid-ramge

Devices: EMG biofeedback
E stim
EMG triggered ES

Mental practice
Modified task related training

31
Q

Strengthening interventions grade 3/4

A

Incorporate
More co-ordination training/modified task practice
Strengthening in shortened range of muscle
Sustained contractions
Increased speed of contractions

Used closed chain weight-bearing positions for extensor muscles
Used bodyweight to increase resistance to movement
Principles of PRE - dosages

32
Q

What is loss of skillful co-ordination after stroke?

A

The loss of skillful co-ordination of voluntary muscle activity to meet enviromental demands due to loss of UMN after stroke

33
Q

What are the characteristics of loss of co-ordination after stroke?

A

Loss of spatial accuracy
Loss of temporal accuracy
Jerky movement trajectories
Excessive muscle activty/co-contraction

34
Q

Co-ordination training after stroke

A

Reproduce timing and spatial demands of the task in context of
part practice
Modified whole task practice

Intensity of practice is vital i.e repetitions ++++++++++

Practice must be structured to allow semi-supervised and independent practice

35
Q

What sensory modalities are retrained after a stroke?

A

Tactile localisation
Texture discrimination
Joint position
object recognition

Anticipation and attentive exploration are integral to the training
Calibration: using vision and comparison to intact side

36
Q

Is sensation training effective after stroke?

A

Emerging evidence that sensation training is effective for the upper limb

Insufficient evidence to state that sensation training is effective for the lower limb

It is unclear whether improvement in sensation leads to improved performance at level of activity

37
Q

Cueing a patient with sensory loss

A

Patients with sensory loss or perceptual impairments may not be able to use intrinsic feedback to guide their performance

They may be more reliant on augmented feedback to improve performance

Cue patients to attend to relevant sensory information to improve awareness of the sensory information they are getting

38
Q

Types of augmented feedback

A 
Visual 
Auditory
Somatosensory (tactile and proprioceptive)
Kinematic
EMG
39
Q

Impairment: Strength
Yes/no
Level of evidence
Comment

A

Impairment
Yes/no: Yes
Level of evidence: Grade B
Comment: PRT, e stim

40
Q

Impairment: Co-ordination
Yes/no:
Level of evidence:
Comment:

A

Impairment
Yes/no: yes
Level of evidence: Grade A
Comment: Task specific training

41
Q

Impairment: sensation
Yes/no:
Level of evidence:
Comment:

A

Impairment
Yes/no: ???
Level of evidence: Grade C
Comment: Sensory specific training

42
Q

Impairment: spasticity - mild
Yes/no:
Level of evidence:
Comment:

A

Impairment
Yes/no: No
Level of evidence: GPP
Comment: No intervention

43
Q

Impairment: spasticity mod to sev
Yes/no:
Level of evidence:
Comment:

A

Impairment
Yes/no: Yes
Level of evidence: Grade B
Comment: Botox + rehab

PHTY302 (9 decks)

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