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Sub-Acute (Theory) > W6: Stroke > Flashcards

W6: Stroke Flashcards

1
Q

Stroke is the …. leading cause of death in Australia.

In 2018 there will be ……

In 2017, ….. people living with the effects of stroke (predicted to increase to …. by 2050).

A

3rd leading cause of death in Australia.

In 2018 there will be 56,000 strokes

In 2017, 475,000 people living with the effects of stroke (predicted to increase to one million by 2050).

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2
Q

…..% of stroke survivors are < 65y/o

The financial cost of stroke is …./year.

A

30% of stroke survivors are < 65y/o

The financial cost of stroke is $5 billon/year

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3
Q

Indigenous vs Non-Indigenous
- …. x higher stroke rate
- …. x higher hospitalisation
- …. x higher death rate
- …. x more likely of dying/dependent at D/C

Other factors?

A
  • 1.7 x higher stroke rate
  • 2 x higher hospitalisation
  • 1.6x higher death rate
  • 3 x more likely of dying/dependent at D/C

Other factors: less likely to be treated in a stroke unit, delayed health assessments & greater

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4
Q

Percentages of ischemic & haemorrhagic stroke?

A

87% Ischemic
13% Haemorrhagic

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5
Q

Signs & symptoms of someone having a stroke?

A
  • FAST:
  • F: has their face drooped
  • A: can they lift both of their arms
  • S: is their speech slurred and do they understand you
  • T: Call 000 as TIME is critical
  • Other common symptoms:
  • Vertigo, headache, numbness in the face/half their body, sensitivity of the body, impaired speech & understanding
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6
Q

Prognosis after stroke after 5 years?

A

70% of stroke patients are either dead or disabled 5 years after the event

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7
Q

Prognosis: Predictors of survival at 3/12 and 12/12 post stroke

A
  • Age
  • Verbal component of the Glasgow coma scale (on admission)
  • Arm power (on admission)
  • Ability to walk (on admission)
  • Pre-stroke dependency
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8
Q

Prognosis: Disability percentage following stroke?

A
  • 40% of stroke survivors are disabled (Modified Rankin Scale score of 3–5).
  • 20% of these were disabled before the stroke
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9
Q

Prognosis: Walking after a stroke

What percentage of stroke patients will walk independently if they can independently sit for 30 seconds and visibly contract muscles in the legs within 72 hrs?

What percentage chance do they have of regaining walking if they can’t do the above?

A
  • 98% chance if (within 72 hours) a patient can
  • Independently sit for 30 seconds and
  • Visibly contract muscles in the legs (with or without movement)
  • Only 27% chance if patients could not do the above
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10
Q

Prognosis: Upper limb function

What percentage of stroke patients will regain upper limb function if they can exhibit some finger extension and shoulder abduction within 72 hrs?

What percentage do they have of regaining upper limb function if they can’t do the above?

A

Upper limb function
* 98% chance if (within 72 hours) a patient can
- Exhibit some finger extension
- Some shoulder abduction
* Only 25% if patients could not do the above

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11
Q

What is neuroplasticity?

Differentiate between adaptive and maladaptive plasticity? Provide an example of each.

A
  • Lifelong capacity of the brain to learn new ways of doing things based on new experiences and learning

Adaptive plasticity: Increased function/neural ability to perform a task. Example?

Maladaptive plasticity: Decreased function, impaired ability to perform tasks, learned non-use. Plasticity that is unhelpful (chronic pain, allodynia). Example?

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12
Q

List and describe 8 factors that influence neuroplasticity

A
  • Neuroplasticity is use dependent and specific
  • Repetition and intensity influence neuroplasticity
  • Neuroplasticity is time sensitive
  • Neuroplasticity is influenced by task-importance, motivation, feedback and attention
  • Strongly influenced by features of the environment
  • Neuroplasticity is influenced by adjunct therapies
  • Neuroplasticity is influenced by patient characteristics
  • Pharmacology influences neuroplasticity

SPIRT CAP
- S: Specificty and use-dependent
- P: Patient characteristics
- I: Intensity and repetition
- R: Relevance (task-importance, motivation, feedack & attention)
- T: Time sensitive
- C: Context/Environment
- A: Adjunct therapies
- P: Pharmacology

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13
Q

Factors that influence neuroplasticity.

  1. Explain: Neuroplasticity is use dependent and specific
A
  • Lack of use leads to a degrade in function and decrease size of cortical representations
  • Must activate specific networks during therapy to strengthen connections
  • Task specific rehabilitation –> increases these gains (boosts brain representation and leads to greater functional recovery)
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14
Q

Factors that influence neuroplasticity

  1. Explain: Repetition and intensity influence neuroplasticity
A
  • Repetition required for lasting neural changes must activate networks during therapy
  • Greater intensity shown to induce neuroplasticity
  • How many sets and reps? A lot more than you are used to!!
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15
Q

Factors that influence neuroplasticity

3: Explain Neuroplasticity is time sensitive

A
  • More amendable early following injury
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16
Q

Factors that influence neuroplasticity.

4: Explain neuroplasticity is influenced by task-importance, motivation, feedback and attention

A
  • More neuroplasticity when training relevant + important tasks
  • Appropriate feedback can increase therapy quality
  • Attention and focus during training influences the capacity to learn
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17
Q

Factors that influence neuroplasticity

5: Explain: Strongly influenced by features of the environment

A
  • Enhanced sensory, cognitive, motor and social stimulation facilitate increased neuroplasticity and learning (strengthens different neural pathways)
  • Ensure NOT competing for attention: To maximize neuroplasticity, it’s essential that sensory, cognitive, motor, and social stimuli aren’t competing for attention because the brain’s capacity to process multiple inputs at once is limited. When stimuli compete, attention is divided, reducing the focus and depth of engagement with each stimulus. This can weaken neural activation and hinder the formation of strong, lasting connections.
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18
Q

Factors that influence neuroplasticity

  1. Explain: Neuroplasticity is influenced by adjuvant or adjunct therapies
A
  • Priming can increase neuroplasticity: refers to techniques that prepare the brain to be more receptive to learning and adapt more efficiently to changes.
  • Priming can include motor imagery, mental practice, stimulation- based therapy or pharmacology
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19
Q

Factors that influence neuroplasticity

  1. Explain: Neuroplasticity is influenced by patient characteristics
A
  • Younger people greater/more efficient neuroplasticity than elderly
  • Stress can impair neuroplasticity
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20
Q

Factors that influence neuroplasticity

8: Pharmacology influences neuroplasticity

A
  • GABA receptor agonists (e.g. baclofen, benzodiazepine; used for anxiety, seizures, spasticity) reduce neuroplasticity
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21
Q

Differentiate between use-dependent and learning dependent plasticity

A

Use dependent plasticity
* Reorganisation of cortical regions as a result of motor practice
* Use it or lose it

Learning dependent plasticity
* Reorganisation of cortical regions as a result of skill acquisition
* Often involves task-specific training, goal-setting, active problem- solving, new skills
* Example from prep-work – Re-learning how to ride a bike

Summarised:
Use-dependent plasticity strengthens existing neural pathways through repetition of a task, enhancing efficiency without new skill acquisition (ie practicing a known skill)

Learning-dependent plasticity, however, involves creating new neural pathways by actively learning new skills or information (new skill)

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22
Q

Describe intensive task specific practice in the context of increasing neuroplasticity.

A

Training SHOULD be meaningful with real world relevance
- What’s the purpose of training this movement/task?
- Is this exercise/task/movement translatable to the task/movement I want to regain?

Set clear explicit short, medium and long term SMART goals
- Is it relevant for the patient? (Must ask) – set goals with the patient
- Be flexible

Practice intensity
- Increase active motor training. Increase reps & increase time (mins)
- Supervised, semi-supervised, independent
- Right level of difficulty

Practice specificity
- Task specific (part task or whole task)

Practice variability
- Modify task
- Modify environment
- Modifications should have relevance

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23
Q

Describe initial medical management if seen within:
- 0-4.5hrs
- 6-24 hrs
- 24 hrs

A
  • 0-4.5hrs: Administer tPA and candidate for thrombectomy
  • 6-24hrs: Should not receive tPA but is a candidate for thrombectomy
  • 24hrs+: should not receive tPA or thrombectomy
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24
Q

When is tPA used?
Who is it beneficial for?

Each 15m reduction of tPA was associated with?

A
  • Primary treatment <4.5hrs of symptom onset
  • Beneficial regardless of age or stroke severity

Note: - Each 15 min reduction in the time of tPA was associated with
- 4% ↑ in the odds of walking independently at discharge
- 3% ↑ in the likelihood of being discharged home rather than an institution
- 4% ↓ in the odds of death before discharge

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25
Q

Considerations for tPA?

A
  • Can only be performed within 4.5 hrs of lesion (ischemic!)
  • Routinely administered in emergency departments
  • Larger more proximal clots are more resistant to thrombolysis

Note: thrombolysis is the general process of breaking down blood clots. tPA (tissue plasminogen activator is one type of thrombolytic drug)

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26
Q

What is endovascular thrombectomy? When is it used? When is it indicated?

A

Used for proximal large artery occlusions.

Indicated within 6 hrs (10% of patients have proximal large artery occlusion and present within 6 hours)

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27
Q

Considerations for thrombectomy?

A
  • Can be performed up to 24 hrs after the lesion
  • Performed at limited sites in Sydney (RNSH, Westmead, PoW, Liverpool, RPA)
  • Can only be used in proximal occlusion sites
  • Must be an ‘infarct: ischemic penumbra’ mismatch to be effective after 6 hrs
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28
Q

Thrombectomy: evidence?

A
  • Every 100 patients treated with thrombectomy
  • 49 will have less disabled outcome
  • Of those, 36 will be functionally independent
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29
Q

What is a craniotomy?

A
  • A craniotomy may be performed to relieve pressure caused by bleeding in the brain, repair a damaged blood vessel, or remove a clot (hematoma) resulting from the bleed.
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30
Q

What are the 3 practice variables that influence motor skill acquisition?

A
  • Practice intensity
  • Practice specificity
  • Practice variability
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31
Q

What is practice intensity?

A
  • Learning a motor skills requires +++ repetitions
  • Neuroplasticity can take days, weeks, months and (perhaps) years.
32
Q

What strategies can you use to increase the amount of practice?

A
  • Set up patient for independent and semi-supervised practice
  • Provide exercise booklets
  • Train carers/family members
  • Group sessions/training with a partner
  • Minimal equipment if home-based
33
Q

What is practice specificity?

A
  • Movements should be similar and in the correct context while the skill is being practiced
  • Consider the action, task, skill and environmental context
34
Q

What are the two main considerations for task specific and environmental specific?

A

Practice needs to be task specific
* Consider senses used and attention load sensory/perceptual characteristics
- Use of vision, proprioception, tactile, attentional/cognitive demands ie talking while walking
* Consider muscle activation and joint movement while doing the task
- Muslce length/joint angle, type of contraction, velocity of muscle contraction, close or open chained, patient position

Practice needs to be environmental specific
* Moving or static
* Objects/equipment

35
Q

What is practice variability?

A
  • The variability in movement and context characteristics the learner experiences while practicing a skill
  • Seems to be a paradox
  • We want to be as specific as possible yet we want training to be variable.
  • Should be relevant variability
36
Q

Considerations for practice variability?

A
  • Considerations
  • Additional actions/task/skills
  • Consider inter-trial variability
  • Other task and environmental factors (same as practice specificity)
37
Q

What happens when you use exercises with high contextual interference?

A
  • Poorer performance and greater attention during practice
  • Better performance during retention and transfer tests after practice

BUT
- Higher contextual interference does not appear to enhance learning in children and people with low skill levels

38
Q

When do you use low vs high contextual interference?

A

Low = beginners
High = experts

39
Q

Differentiate between low and high contextual interference?

A

Low contextual: Non-repeated blocks of trials of each task variation

High contextual: random order of trials of all task variations

AI:
Low Contextual:

Definition: This involves presenting non-repeated blocks of trials for each task variation.

Explanation: In a low contextual setup, each task variation (e.g., a different exercise or task) is practiced in a separate block, and once the block is completed, it may not be repeated for a while. The task variations are typically practiced in isolation, one after another. This reduces the unpredictability or complexity of the task ordering. It is often referred to as “blocked practice.”

Example: If you are practicing three different exercises, in low contextual practice, you would do all repetitions of one exercise (say 20 squats) before moving on to the next task (e.g., 20 lunges), and so on, without mixing them together.

High Contextual:

Definition: This involves presenting trials in a random order with all task variations intermixed.

Explanation: In high contextual practice, different task variations are randomly mixed and practiced in an unpredictable sequence. This type of practice forces the learner to switch between tasks or variations frequently, introducing higher levels of complexity and requiring more cognitive effort and flexibility. This is often referred to as “random practice.”

Example: In high contextual practice, you would randomly alternate between squats, lunges, and other exercises, with no set order or repetition of any one task until all tasks have been cycled through.

Contextual Impact:
Low contextual practice is generally easier for learners in terms of task recall and performance consistency, as it provides a more predictable and structured sequence.

High contextual practice, while potentially more difficult, is often considered more beneficial for promoting skill retention, adaptability, and transfer of learning, especially for tasks that require versatility or real-world application, where unpredictable task switching is common.

40
Q

Considerations for providing instructions and demonstrations for stroke patients (Instructions)

A

Instructions

Types
- Short sentences eg shoulders forward. Non-verbal cues.

Frequency
- Depends on attentional capacity of the patient. Characteristics /interaction between task and patient

Timing
- Before and during practice

Other considerations
- Amount of info & what you are asking the patient to focus on (skills & environment)

41
Q

Considerations for providing instructions and demonstrations for stroke patients (demonstrations)

A

Demonstrations

Types
- Skill demonstration by experts
- Unskilled demonstrations by beginners
- Encourage more active problem solving

Frequency
- Several times

Timing
- Before and during practice

Other considerations
- Demonstrations are more effective with acquisition of a new pattern of movement rather than a new parameter of a well-learned movement pattern

42
Q

What are the 4 types of task-intrinsic feedback? With two examples.

A
  • Visual eg demonstrations/EMG biofeedback
  • Auditory eg instructions, metronome
  • Proprioception eg manual handling guidance, taping, orthoses
    -Tactile
43
Q

What is augmented feedback?

A

Feedback added to task-intrinsic feedback coming from a source external to the person performing a skill

44
Q

What is task intrinsic feedback?

A

Sensory feedback that is naturally available while performing a skill

45
Q

Differentiate between knowledge of performance and knowledge of results

A
  • Knowledge of results: Provides information about the outcome of performing a skill or about achieving the goal of the performance eg dynamometer, number of reps, ROM, walking speed, distance walked, etc
  • Knowledge of performance: Provides information about the movement characteristics leading to a performance outcome (ie how did you perform the task - refers to the process or technique). Examples: step length, knees behind toes in squat = technique/body alignment
46
Q

Differentiate between qualitative vs quantitative feedback

A
  • Qualitative: Augmented feedback that is descriptive in nature and indicates the quality of performance i.e. “Good” “Nice”
  • Quantitative: Augmented feedback that includes a numerical value related to the magnitude of a performance characteristic i.e. Speed of a baseball pitch
47
Q

Differentiate between internal vs external focus?

A
  • Internal attention focus: Instructions that direct attention to the movement themselves
  • i.e. Feel the muscle contracting when you perform the movement
  • External attention focus: Instructions that direct attention to the effect of movement on environment
  • i.e. Shift your weight toward the table
48
Q

Differentiate between intrinsic vs extrinsic focus?

A
  • Intrinsic feedback: Direct feedback that you get from an action. A patient may successfully execute a movement but realize they need to improve the process (through body and relative to body)
  • Extrinsic feedback: Feedback from a person or data such as a video or balance board device etc
49
Q

Discuss motivational strategies for increasing patient compliance/performance.

A
  • Ensure relevance of training exercises to the patients goal/motor skill.
  • Ensure goals (short- and long-term) are identifiable and specific
  • Remind patients of these goals
  • Provide encouraging feedback (don’t be patronising)
  • Assess outcome measures regularly
  • Consider reward systems and feedback
50
Q

When is EMG used? What type of patients are more suitable for EMG biofeedback over ES?

A

Electromyographic (EMG) biofeedback
* When is it used? Strengthening of grade 2 muscles (and above)
* Can be set-up for semi-supervised or independent practice
* Also provides visual and auditory feedback in the absence of a therapist

What type of patients are more suitable for EMG biofeedback over ES?
* Strengthening of muscles grade 2 and above. Must have a muscle contraction so the machine can get a reading of the level of activity - auditory or visual feedback

51
Q

Describe the aims of EMG biofeedback and electrical stimulation and the types of patients/conditions/impairments that these can be used for.

A

Aims of EMG biofeedback
* Increase muscle activity
- e.g. very weak muscles after stroke/MS/TBI/SCI or surgery
* Decrease muscle activity –> common to address spasticity/high tone
- e.g. Voluntary activity in stroke/MS/TBI/SCI, chronic musculoskeletal injuries
- Can’t be used in dystonia / involuntary mm activity
* To control muscle activity
- e.g. knee hyperextension in stroke/MS, patellofemoral pain syndrome

52
Q

Stroke foundation guidelines: Recommendation for EMG in those with reduced strength

A

Strong recommendation

53
Q

Stroke foundation guidelines: Recommendation for mental practice/ES/EMG/mirror therapy/bilateral training

A

Weak recommendation for stroke survivors with atleast some voluntary movement of the arm and hand, repetitive task-specific training may be used to improve arm and hand function

54
Q

Stroke foundation guidelines: Recommendation for ES for those with reduced strength and for upper limb activity

A

Weak recommendation for both weakness and upper limb activity

55
Q

Stroke foundation guidelines:
In stroke survivors who have persistent moderate to severe spasticity (ie spasticity that interferes with activity or personal care)

  • Botulinum toxin A should be trialled in conjunction with rehabilitation therapy which includes setting clear goals
  • Electrical stimulation and/or EMG biofeedback can be used
A

Weak recommendation: for stroke survivors with spasticity, adjunct therapies to Botulinum Toxin A, such as electrical stimulation, casting and taping may be used

55
Q

What are the consensus based recommendations for contractures?

A
  • For stroke survivors, serial casting may be trialled to reduce severe, persistent contracture when conventional therapy has failed
  • For stroke survivors at risk of developing contracture or who has developed contracture, active motor training or electrical stimulation to elicit muscle activity should be provided
56
Q

Strong recommendation guidelines on ES for shoulder subluxation?

A

Weak recommendation: for stroke survivors at risk of shoulder subluxation, electrical stimulation maybe used for the first six months after stroke to prevent or reduce subluxation (also weak for shoulder pain)

57
Q

What are the consensus based recommendations for swelling?

A

For stroke survivors with severe weakness who are at risk of developing swelling of the extremities, management may include the following:
* Dynamic pressure garments
* Electrical stimulation
* Elevation of the limb when resting.

For stroke survivors who have swelling of the hands or feet management may include the following:
* Dynamic pressure garments
* Electrical stimulation
* Continuous passive motion with elevation
* Elevation of the limb when resting.

57
Q

Explain the evidence for/against EMG biofeedback and electrical stimulation using the manuscripts Langhorne et al (2009) and de Souza et al (2018)

A

Langhorne (2009)
- Systematic review (Cochrane)
- 4 trials assessed arm function
- 3 trials assessed gait-walking speed
- Quality of study: Low to mod

Findings –> EMG was in favour of treatment

Souza Findings –>
The overall effect shows that the electrical stimulation is statistically better than the control at improving strength and the effect may or may not be clinically meaningful

57
Q

What does an MMT of 1 indicate?

A

Flicker or trace of contraction

58
Q

What does an MMT of 0 indicate?

A

0

59
Q

What does an MMT of -2 indicate?

A

Partial ROM with gravity eliminated, not full ROM

60
Q

What does an MMT of 2 indicate?

A

Full ROM with gravity eliminated

61
Q

What does an MMT of 2+ indicate?

A

< 50% of ROM available against gravity

62
Q

What does an MMT of 3 indicate?

A

Full ROM against gravity

62
Q

What does an MMT of -3 indicate?

A

> 50% of ROM available against gravity, but not full ROM

63
Q

What does an MMT of 3+ indicate?

A

Resist minimal force applied at < 50% of the available ROM

64
Q

What does an MMT of -4 indicate?

A

Resist minimal force for >50%, but not full ROM

65
Q

What does an MMT of 4 indicate?

A

Full ROM against gravity and against resistance

66
Q

What does an MMT of 4+ indicate?

A

Resist maximum resistance for some of the available ROM, but not full ROM

67
Q

What does an MMT of 5 indicate?

A

Full/Normal Strength

68
Q

What are the strategies to train weak muscles?

A
  • Train at mid-range
  • Train in gravity-eliminated position
  • Reduce friction
  • Reduce degrees of Freedom
  • Shorten lever
  • Manual guidance
  • Mental practice
  • Electrical stimulation (ES) and EMG biofeedback
69
Q

Do we train the skill or compensation? Why?

A
  • Early stage: Skill > compensation
  • Later stage: Skill < compensation

Why: * Neuroplasticity doesn’t stop after an injury. After a stroke/ABI the first 6 months are crucial (golden period for neuroplasticity to occur – people will improve regardless of the intervention, known as a period of spontaneous recovery! As a physio it’s our goal to boost that 6 month period to maximise outcomes.

NEUROPLASTICITY DOESN’T STOP AFTER 6mths IT JUST SLOWS DOWN!

70
Q

What is the aim of part-task training?

A

Increase ability to perform missing essential components

Decrease compensatory movements

Target impairments

71
Q

What is the aim of whole-task training?

A

Make the task physically easier

Make task cognitively easier

72
Q

What are some task factors that can be used to increase skill difficulty?

A
  • Increase reps, frequency & duration
  • Decrease manual guidance/assistance
  • Increase resistance
  • Increase distance/amplitude, speed, direction of movement
  • Increase degrees of freedom/joint involved
  • Part task –> Whole task
  • Body transport + object manipulation
  • Add cognitive task
73
Q

What are some environmental factors that can be used to increase skill difficulty?

A
  • Decrease base of support
  • Softer support
  • Increase attentional demands
  • Use a variety of real environments
  • Add extraneous conditions (weather, light, noise)

Sub-Acute (Theory) (10 decks)

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