Stroke Part 2 Flashcards
What are the prognostic indicators for shoulder pain?
- Low stage of motor recovery (stage 1 & 2)
- Scapular mal-alignment
- Loss of shoulder movement (flex & ABD <90, ER <60)
T/F: It is okay to force shoulder ROM in order to see their full range
False
If scapular mobility or shoulder ER is absent what movements should not be performed by patient?
No abduction or flexion >90 degrees
What are some ways to test voluntary movements in regards to synergy dominance?
- Fugl-Meyer Assessment of Physical Performance
- Chedoke- McMaster Stroke Assessment - Impairment Inventory
- Isolated, active movement against gravity
Why is MMT not valid during early stages of stroke recovery? What should be used instead? What is used when they are in late stages?
- In presence of strong spasticity, reflex & synergy dominance
- Use functional strength training instead
- Once they are in stage 5, MMT, handheld dynamometer can be used
What motions of the trunk should be examined?
- APT + Lumbar extension
- PPT + Lumbar flexion
- Lumbar lateral flexion (both directions)
In the early stages of recovery why may trunk motion be limited? What about late?
- Early: impaired motor recruitment
- Late: Impaired motor recruitment, ROM restriction
In regards to the NIH Stroke Scale is a lower score better or worse? What is severity scale?
- Lower score = better
- 25-42 very severe
- 15-24 severe
- 5-14 moderate
- 1-5 mild
What are some facilitation model approach for intervention?
- Brunnstrom’s Movement Therapy in Hemiplegia
- Rood’s Sensory Motor approach
- Bobath or Neuro-developmental Treatment (NDT)
- Proprioceptive Neuromuscular Facilitation (PNF)
What are some task oriented model approaches for intervention?
- Carr and Shepherd’s Motor Relearning Program for stroke
- Constraint - induced movement therapy
What is an associated reaction?
An involuntary automatic movement in involved limb with active or resisted movement of another body part
What is a homolateral synkinesis?
A flexion pattern of the involved UE facilitates flexion of the involved LE
What is Ramiste’s Phenomenon?
involved LE will ABD or ADD with applied resistance to the uninvolved LE in the same direction
What is Souques’ phenomenon?
Raising involved UE above 100 degrees (flexion/ abd with ER) with elbow extension will produce extension & abudction of the fingers
What is the principle of Brunnstrom: Movement Therapy in Hemiplegia?
- based on hierarchical model
- Early stage reinforced synergies
- No movement practiced that deviated from synergies until stage 4 of motor recovery
How is Rood Sensory Motor Approach done?
- Use of sensory stimulation to facilitate & inhibit motor response
- Believed that exercise must provide proper sensory feedback in order to be therapeutic
What techniques facilitate according to Rood Sensory Motor Approach?
- Approximation
- Joint compression
- Icing
- Light touch
- Quick stretch
- resistance
- tapping
- Traction
What techniques inhibit according to Rood Sensory Motor Approach?
- Deep pressure
- prolonged stretch
- Neutral warmth
- Prolonged cold
What is the order of motor control demands from least to most?
- Least: Closed chain
- Modified open chain
- Most: Open chain
What is the main idea of NDT?
- Individualized intervention that seeks to promote normal movement patterns
- Proximal control in progressively challenging positions to work towards skill
When choosing intervention strategies for patient post stroke when may facilitation be beneficial?
When motor control is limited
When choosing intervention strategies for patient post stroke what is required for task training & CIMT to be beneficial?
active control
When choosing intervention strategies for patient post stroke when may compensation be indicated?
if needed to achieve functional goals
What are the general considerations for intervention strategies for patients post stroke?
- Sequence of activities
- Stage of motor control
- Sensory & motor functions are interrelated
- Management of muscle tone is important to maximally participate in intervention & function
- Functional - task - oriented
- Specificity of training
- High intensity of practice both in and out therapy session
When considering intervention strategies for patients post stroke what is required for function?
- active control in all 3 place of movement is essential for function
- Function required asymmetrical, symmetrical, unilateral, bilateral & reciprocal movements
What are the risks of mobilizing patients too early?
- Adverse events
- Increase inflammation
- Expansion of ischemic lesion
- Worse functional outcome
What are the benefits of mobilizing patients in the acute phase?
- Use it or lose it
- Release BDNF & promote neurogenesis
- promote neuroplasticiy & functional mobility
- Reduce secondary complications associated with bed rest
What is contraindicated when deciding when to mobilize patients post stroke?
High - dose, very early mobilization (<24 hour) post stroke mobilization is contraindicated
What mobilization protocol should be implemented for the acute phase of patients post stroke?
Lower-dose, early mobilizations programs initiated 24-72 hours post-stroke ICH & SAH
What are some example of interventions that target ROM?
- Positioning strategies to reduce common malalignments
- Soft tissue/joint mobilization
- PROM w/ terminal stretch
- Edema & tone management
T/F: Overhead pulleys are contraindicated for patients post - stroke
True
When addressing ROM of the UE what is the precaution?
ER + distraction with mobile scapula over 90 degrees shoulder flexion
What are some safe self - ROM strategies that should be taught?
- Arm cradling
- Table top polishing
- Reach to floor in sitting
Name some interventions for spasticity
- Optimal positioning
- Early mobilization
- Daily stretching
- Position in lengthened position with WB
- Slow rocking
- modalities
What are the results of progressive resistive strength training?
- Improve strength
- No increase spasticity or decrease in ROM
What are the principles of progressive resistive strength training?
- Specificity of training
- Combine with task specific training
- Free weight, tubing/bands, machines
- 3x 8-12, 2-3x/week
What are some precaution for strengthening interventions?
- Hand function
- Impaired sensation
- Risk of falls
- Comorbidities
Name some intervention to improve sensory function
- Encourage use of affected side
- Sensory retraining programs
- Sensory integrative treatment
- Sensory stimulation intervention
- Education for safety
What are some sensory retraining programs?
- mirror therapy
- Repetitive sensory discrimination
- Bilateral simultaneous movement
- task practice
What are some sensory integrative treatment?
- Normalize tone
- augment cues
- Practice function
What are some sensory stimulation interventions?
- Compression
- Weightbearing
- mobilization
- E- stim
- Thermal stimulation
What are some interventions for hemianopsia & unilateral neglect?
- Teach visual scanning
- Direct attention to involved side with cues
- Encourage active movement of involved limbs
During the acute phase what is the intervention for aerobic capacity?
minimize bed rest with early mobilization
During post-acute phase what is the intervention for aerobic capacity?
traditional training
What are exercise precaution when performing interventions for aerobic capacity?
- Monitor HR & RPE
- Avoid breath holding/ Valsalva
- Medication decrease cardiac output (monitor RPE)
What are the general considerations for managing the UE in individual post- stroke?
- Maintain pain free ROM
- Maintain/ restore normal shoulder girdle mechanics
- Encourage active functional movements. Keep the arm & hand involved in functional activities
- Maintain & retrain the sensory system
- Avoid trauma
- Educate patient & family
What can the SAFE Model predict?
- Upper limb function at 6 months within 72 hours of stroke by examining shoulder abduction & finger extension
- Probability of regaining arm dexterity at 6 months based on SAFE score on day 2 CVA
What are the pros of slings?
- Protect from traction injury to soft tissue, nerves & vasculature
- Therapist hands are free to help with mobility
What are the cons of slings?
- Little reduction of subluxation
- Position of arm in ADD/IR + elbow flexion increase flexor tone & contracture which increase neglect & learned non-use
What are the guidelines for using slings?
- Minimize use
- Select appropriate sling for the individual
- Consider alternatives
What is a flaccid presentation of shoulder pain?
- Lack of tone, proprioception & muscle activation
- Subluxation, traction, chronic pain
How does shoulder impingement syndrome occur?
With flexion/ abduction without normal glenohumeral rhythm
How can adhesive capsulitis occur post stroke?
- Hypertonia restricts movement
- Secondary tightness of ligaments, tendons & join capsule
- Intracapsular inflammation can occur
If a patient has a painful shoulder what activities should they avoid?
- PROM without adequate scapular mobility
- Traction & pulling on UE during transfers
- No overhead pulleys
When treating a painful shoulder what activities should be selected?
- Mobilize scapula in side lying
- Work towards approximation of the head of the humorous in glenoid fossa in good alignment
- Maintain/establish normal scapulohumeral rhythm
- Consider intervention to reduce sublimation
Describe stage 1 of Complex Regional Pain Syndrome (CRPS) and is it reversible in this stage?
- Discoloration (pink)
- Cool
- Hypersensitive
- Guarded movement
- Highly reversible
Describe stage 2 of CRPS and what is the prognosis?
- Pain subsides
- Dystrophic changes
- Early osteoporosis
- Variable prognosis
Describe stage 3 of CRPS and is it reversible in this stage?
- Atrophic phase (skin, muscle, bone)
- Largely irreversible
How should CRPS be treated?
- proper positioning & handling
- PROM, grade 1 & 2 mobilizations
- shoulder PROM only with scapular mobilizations, limit to 90 degrees flexion or abduction or point of pain
- AROM (therapy ball on table in standing)
- Edema management
name some residual deformities you may see while a patient recovers from CRPS
- Wrist flexion
- Ulnar deviation
- Flattened palm, decreased definition of the arches
- Decreased web space
- Decreased MCP flexion
- Decreased finger adduction
When selecting interventions to enhance postural control & force production what postures should be selected?
- That put patients into more extended postures
- High sitting (hip above knees)
- Standing
- Squatting
name some transitions to bias involved trunk, limb extensors & abductors
- Lateral weight shift in high sit
- Lift off
- Scooting
- Sit to stand
- Stand
- Stand & step less involved limb
What is the order for progression of interventions to enhance postural control & force production?
- Closed Kinetic chain (static stability, body on stable limb)
- Modified open kinetic chain (body & limb move together, limb moves on stable body)
- Open kinetic chain
What is pusher’s syndrome?
- Lateral postural imbalance caused by pushing with the stronger extremities toward the involved side
- Resist correction to midline
- Altered perception of body’s orientation (misperception of vertical 20 degrees)
Pusher’s syndrome is common in strokes involving what?
- posterolateral thalamus
- insula
- operculum
T/F: Pusher’s syndrome can not be corrected
False
- Can be corrected with proper identification and intervention training
What tasks do patients with pusher syndrome have difficulty with?
- Standing
- Walking
- Transfers
- ADLs
What are the treatment objectives when treating pusher’s syndrome?
- Assist patient to learn their perception of vertical is incorrect
- DIrect patient to visually explore surroundings and look for visual verticals
- Encourage patient to reach, weight shift, & transfer to the less involved side
- Practice to make more automatic (dual task)
- Do not forget to treat the more involved side too
In treatment of pusher syndrome emphasize (passive or active) weight shifts toward (stronger or weaker side)
Emphasize active weight shifts towards the stronger side
Name some intervention strategies for pusher syndrome
- Visual stimuli
- Can help to position therapist/ wall on stronger side/ stand pt In corner
- Focus on unilateral support with weaker UE
- Disadvantage less involved limbs to discourage pushing
- Shorten cane or change support
- Motor learning strategies very effective
- Body weight support treadmill training
What are intervention principles to treat ataxia?
- Address active trunk control & stability
- Use task specific, functional practice
- Progress challenge by: reducing BOS & decreasing reliance on UE
Patients with ataxia initially have a challenge in stability with limbs in closed kinetic chain. How should this be addressed?
- Joints mid range to avoid passive propping
- Work on graded recruitment
- Gradually increase the range of movement
- Gradually decrease the amount of support through UE
In treating patients with ataxia, after they master closed kinetic chain activities where should they progress? How is this done?
- Modified open chain activities
- Sensory feedback
- Grade recruitment
- Limit degrees of freedom
In treating patients with ataxia, after they master modified open kinetic chain activities where should they progress?
- Open kinetic chain
- Initially use object in hand to provide feedback
- Select object or task with consequence
What do positioning strategies reduce?
Malalignments
How often should PROM (or AROM) with terminal stretch be implemented? How often if contracture is developing?
- Daily
- Twice daily
What are some modalities that can be used to decrease spasticity?
- Cold
- Massage
- E-stim to antagonist (reciprocal)
- Botox
What should be avoided when strengthening patients with comorbidities post- stroke?
- Acute: High intensity sustained max
- Avoid isometric & Valsalva
What protocol should be used when strengthening patients post-stroke?
Submaximal protocol 30-50% MVC w/ gradual progression
Name some interventions for those without voluntary movement according to algorithm for selecting Upper Limb Interventions
- Maintain PROM
- Prevent/manage edem
- Sensory retraining
- Manage spasticity
- Positioning
- Patient education
- Motor Imagery
- Mirror therapy
- E Stim
- Supportive device
- Avoid splinting
- Compensatory techniques
Name some interventions for those with some voluntary movement according to algorithm for selecting Upper Limb Interventions
- Sensory retraining
- Manage spasticity
- Positioning
- Patient education
- Motor Imagery
- Mirror therapy
- E Stim
- Supportive device
- Maintain PROM/ AAROM
- Robot assisted therapy*
- Bilateral arm training *
- Trunk restraint*
Name some interventions for those with shoulder abduction against gravity according to algorithm for selecting Upper Limb Interventions
- Motor Imagery
- Sensory retraining
- Mirror therapy
- E Stim, EMG triggered E-stim
- Robot assisted therapy
- Bilateral arm training
- Trunk restraint
- TST*
- Video gaming *
Name some interventions for those with finger extension according to algorithm for selecting Upper Limb Interventions
- Motor Imagery
- Sensory retraining
- Mirror therapy
- Trunk restraint
- TST
- Video gaming
- Strength training*
- Mod- CIMT or CIMT*
Name some interventions for those with/at risk for shoulder pain according to algorithm for selecting Upper Limb Intervention
- Education
- Gentle mobilization
- E-stim for subluxation
- Analgesia
- Team prevention
- Avoid strapping
- Botulinum toxin for spasticity
What are some strategies to reduce subluxation?
- Supportive positions
- NMES
- Biofeedback
- Taping
T/F: Recovery from CRPS is a fast process
False - Slow
What does CRPS stand for?
Complex regional pain syndrome
What are some treatment options for gait?
- Treadmill training (w or w/o harness)
- Robotic- assisted locomotor training
- Functional electrical stimulation (FES)
- Virtual reality
- Motor imagery
- Rhythmic Auditory Cueing
- Orthotics & devices
When is recovery for stroke the fastest?
First weeks to months
How long can functional gains be made?
months to years
