Test 2: Stroke rehab pt. 3 Flashcards
types of intervention selection for PT in stroke rehab
Remediation: when there is potential for structure and behavior plasticity
compensation
prevention
what factors affect whether the intervention is geared towards restoration, compensation, or prevention
stage of recovery
task/environment specific factors
pt resources- family, PLOF vs CLOF
attainable goals/DC plan
important PT considerations for evidence based practice
evidence based interventions dont define the scope of PT
focus on exercise that improves movement/motor learning/control
gaps in literature still exist- much of what we do is not in researches extensively yet
All strokes are different- not 1 optimal intervention
early mobilization is supported universally
best interventions are multimodal
factors to take into account when choosing stroke intervention
phase of recovery
severity
pt age
comorbidities
cognitive abilities
communication status
affective status
social and financial resources
potential DC planb
difference between rote exercise vs task specific
task specific = functional task where pt reaches goal in environment
rote = doesn’t have function directly tied to exercise
rationale for task specific training
salient goals
enhanced sensory experience
motor control is goal based
pts have varying abilities - more freedom in achieving task
what is neuro IFRAH
IFRAH = integrative functional rehabilitation and habitation
whole person approach
RESTORE FUNCTION not movement lost
habitation = process of helping those with disabilities attain, keep, or improve skills and functioning for daily living
functional mobility includes
bed mobility
transfers
sitting
standing
why have stroke pts “find midline”
pts with acute neuro disorders often haev misalignment of midline (“inattention”)
use verbal and tactile cues as well as mirror visual feedback
importance of dual task posture activities
better outcomes with dual tasks
enhanced feedback with dual task manipulation of object, overall sensory experience, and meaningfulness of a purposeful activity enhances subject performance
types of visual biofeedback
force platform with screen visual feedback
VR/video games
benefits of visual feedback for postural control and why
reduced sway
improved posture symmetry
improved dynamic stability
movement control is organized around achieving posture control and real time feedback allows for internal cuing to self correct
what is pusher syndrome and possible interventions
pt sits/stands asymmetrically with most weight shifted toward weaker side
have pt look at posture in mirror
pt can lean non affected side toward wall/therapist and keep it there while performing exercise
uses environmental prompts to improve perceptual and visuospatial awareness of body
when to use physical activity vs aerobic training
aerobic = more strenuous; not appropriate in acute stage
physical activity = appropriate in acute; early mobilization
rationale for aerobic training in stroke rehab
CVD and CVA go hand in hand
post stroke deconditioning/pts predisposed to a sedentary lifestyle
- increase fall risk
- decline in ambulation ability
- low level CV exercise is difficult, thus further harming CV system
- inactivity = secondary complications
challenges of aerobic training with stroke patients
many are nonambulatory
poor self efficacy
poor baseline of activity
aerobic training for subacute phase
walking
treadmill
cycle ergometry
seated stepper
non ambulatory aerobic training
UBE
recumbent bike
nu step
aquatic therapy
ambulatory treatment options with support
BWSTT
robotic assisted treatment training
aquatic therapy
aerobic training leads to
improved O2 consumption
improved workload tolerance
decreased fatiguability
improved VS at submax workloads
improved self concept
improved functional activities
what is progressive resistive strength training and its benefits
application of external load in addition to gravity during repetitive movements to overload the muscles generating the movement
improves strength
no evidence for increase in spascticity or decrease in ROM
increases function in the presence of significant weakness
rationale for resistive training
increased strength is correlated with improved motor function in stroke survivors (i.e. standind, posture control, gait, etc)
strength training counteracts hemiplegia
concerns/limits with resistive training
strength does not equal function
strength alone cant overcome functional limits
inconsistent findings of benefits in research
precautions with resistive training
hemiplegia affects grasp
impaired sensation = increase injury
place pts with posture deficits should be positioned to prevent falls
avoid valsalva for pts with unstable BP
start with submax protocols
what types of UE treatments are best for stroke pts
focus on restoration and prevention of further MSK complication
close collaboration with OT
PT should focus on posture and mobility aspects
OTs should focuse on ADL aspects
recovery of skilled upper limb use includes
managing MSK impairments
sensory and perceptual retraining
motor strengthening
improvement of selective capacity/fractionation
evidence for upper limb interventions
passive positioning/WBing strategies (PROM)
PNF patterns (AAROM)
CIMT (forced use AROM) - evidence based
slings/sublux prevention (nonuse/compensation)
what is assisted stabilization WBing
pt performs WBing through affected extremity with assisted stabilization and positioning from therapist and performs weight shifting
full elbow ext important
intervention protocol for UE WBing
hand WBing at pt side
shoulder extended, abducted, and ER with elbow, wrist, and fingers extended
maintain position performing weight shifting loading for several minutes
rationale for UE WBing
sustained stretching include relaxation through mechanisms of autogenic inhibition
slow rocking movements can be added to increase relaxation effects from influences of slow vestibualr stimulation
increased proprioceptove awareness through approximation of joints
what is PNF
uses facilitation of total patterns of movement to promote motor learninf in synergistic patterns
emphasis on patterns to promote recovery of function
rationale for PNF
active assisted hands on treatment to facilitate active movement patterns
challenge of PNF
reliance on therapist to perform movement
not related to functional task
active movements needs to occur outside of synergy pattern
what is CIMT
specific protocol that involves 2 week period of timed interval training where the unaffected limb is constrained by sling or mitt and affected limb is challenged through therapeutic task training
rationale for CIMT
counteract learned nonuse
massed practive thought to induce cortical reorganization (neuroplastic changes)
research = maintained use of UE with 2 year follow up retention studies
challenge of CIMT
concerns regarding performance of therapy too soon after stroke may create frustration and overuse syndromes creating neuroplastic changes
(timing matters)
prevalence of shoulder sublux with stroke
malalignment of glenohumeral joint where humeral head displaces downward
56-82% occurance with stroke hemiplegia
67% of pts report incidence of shoulder hand pain syndrome post stroke
intervention for shoulder sublux
slings = controversial
no evidence that slings can prevent sublux
some evidence for electrotherapy like NMES
positives of sling use post stroke
support weight of arm and protect pt
can assist with shoulder approximation and prevent sublux (Giv Mohr Sling)
frees up therapist to attend to postural/trunk control during activitie s
negatives of sling use post stroke
can cause contracture with prolonged use
contributes to body scheme disorders and body neglect
use blocks spontaneous use of UE and contribute to learned non use
affects postural stability and use of UE to weight shift with LOB
what is EMGBF
uses surface electrodes to record muscle actuion potentials and present information in a visual and auditory manner
what is NMES
neuromuscular electrical stimulation shourt term intervention for regaining muscle force, motor control, and reduce spasticity
what is FES
functional electrical stimulation
motor level ES used to substitute for voluntary activation when the peripheral nerve supply to the muscle remains intact during functional activity
rationale for EMGBF
timely and proportional info about muscle activation provided to pt
allows them to increase control over muscel force and activation
main 2 functions of NMES/FES
improve force generation - more motor units firing
reduce spasticity - stimulation of antagonist muscle results in reciprocal inhibition of agonist and relaxes its tone
what areas of the body is NMES/FES most supported
ankle
knee
wrist
what is overground locomotor (gait) training
PT facilitateds gait training in reciprocal stepping pattern while advancing toward end goal
most common for stroke pts
considerations for PT with gait training
must meet pre-gait dynamic posture stability first
need proximal stability in standing and good posture awareness
keep physical assistance to minimum and fade as quickly as possible
what are some overground gait training progressions
functional movements (different directions, surfaces, steps, etc)
task specific skills (walking in home or community environment)
activities that involve coincident timing
dual task
what does research say about the type of gait training and the phase of stroke recovery
chronic - can improve walking distance and ability but not balance
subacute- can improve balance and walking ability but not distance
acute - no improvement in walking, too many degrees of freedom
PT considerations for body weight supported TT (BWSTT)
PT can provide manual assist
closed loop training
can introduce gait earlier and safer
harness provides safety, lowered weight, no need for AD
can transition away from harness to reduce BW incrementally
BWSTT has been shown to specifically improve
walking velocity and walking distance
what is robotic assisted gait training
electromechanical
uses exoskeleton or auto ambulator systems
no difference in outcomes compared to conventional training
