Subacute Rehab Flashcards
List what you would include in upper limb neurological assessment?
- Observation
- AROM
- PROM/Tone
- Strength
- Coordination
- Sensation
- Function
What problems might neuro patients have with their upper limb?
- Weakness/low tone
- High tone or rigidity
- Contractures
- Loss of function
- Pain
- Change of sensation
- Loss of coordination
- Tremors
Reasons for limited upper limb recovery following CVA and TBI?
- Cognition
- Severity of paresis
- Low mood/ depression/ anxiety limiting rehab engagement
- Poor Sensation/ limiting sensory recovery
- Visual inattention
- Flaccidity and spasticity
Problems associated with increased tone in UL
- Typical pattern of spasticity in UL:
- Shoulder med. Rot. / adduction
- Elbow flexion / pronation
- Wrist / fingers flexed
- Tends to develop over time
- Worse on effort
- Feels stiff and static
- Patient may be embarrassed
- Secondary changes:
- Soft tissue shortening
- Joint stiffness
- Skin changes
- Pain
- Loss of function
What techniques can be used to manage increased tone?
- Passive and Active stretching (PNF)
- Massage – including soft tissue mobilisation
- Passive movements
- Positioning
- Active movement/strengthening/function
- Heat therapy
- Medication
- Hydrotherapy
Clinical messages:
- Discourage activities which strongly provoke increased tone
- Prevention of secondary complications
What are the recognised sub-acute UL treatment options
Continuation from early rehab:
- Motor Imagery/Mental Practice
- Care of Upper limb
- Supportive devices
- Hand oedema – AROM and PROM
- Mirror therapy
- CPM
Sub-acute:
- Electrical stimulation - FES
- CIMT (Control Induced Movement Therapy)
- Botox for spasticity/spasticity management
- Strength training/Task specific
- Other treatment options - Robot assisted therapy, Video Gaming, Saeboflex
Prognostic indicators of UL recovery post-CVA/TBI
- Some voluntary finger extension and shoulder abduction on day 2 = high probability of regaining some dexterity at 6 months
- Recovery of upper limb post-CVA is 5 – 50%
- 5 - 85% of patients have UL problems following CVA
Most important positive indicators
- Early UL strength
- spasticity
Most important negative indicators
- Severity of paresis
- Flaccidity
- Visual inattention
What is FES
Functional Electrical Stimulation (FES) is the “process of pairing the stimulation simultaneously or intermittently with a functional task”
What are the indications for FES
In the national guidelines for stroke FES is recommended for use:
- In the correction of foot drop in MS and CVA patients
- In the reduction of hemiplegic shoulder pain
How does FES work
Low level electrical impulses generate stimulation to the nerve fibres which causes firing and therefore mimicking neural innervation to produce muscle contraction
What are the uses of electrical stimulation?
- Foot drop
- Hemiplegic Shoulder
- Paraplegia: standing, cycling, walking
- Exercising: decrease spasticity, increase circulation, decreased adhesions,
- Prepare for active exercise
Contraindications to use of FES
- Patients who do not comprehend the physiotherapist’s instructions or who are unable to co-operate
- Electrode placement, not:
- Over trunk/pelvis in first 12 weeks of pregnancy*
- Over pregnant uterus at any stage in pregnancy*
- Over the eyes
- Epiphyseal regions in children
- Patients with pacemakers
- Skin allergies to electrodes, gel or tape
- Dermatological conditions – dermatitis, broken skin, eczema
- Area of tumour or suspected malignancy
What is the indications for Constraint Induced Movement therapy (CIMT)
Consider for people with stroke who have 10 degrees of wrist extension and 10 degrees finger extension (NICE, 2013)
How and why would the unaffected limb be constrained in CIMT?
- The purpose is to facilitate functional tasks and adaptive task practice with the affected limb.
- To encourage use of affected arm, to give increased sensory stimulation to affected arm, to stop compensations in affected arm, with a glove
- The non- affected limb is recommended to be constrained for 90.% of waking hours.
- More than 7 hours of specific training of the affected limb is required per day.
What are the considerations in using CIMT
Therapy considerations:
- Specific task training that is patient orientated is referred to as functional task practice
- Requires commitment of both patient and carers
- Appropriate consideration of candidates and informed consent
- Therapy planning of programme and timetable
