Week 2 Flashcards
What is an essential aspect of stroke care and should be a priority in redesign efforts?
The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration
What are the recommended rehab interventions for stroke patients?
Receive rehab at an intensity commensurate with anticipated benefit and tolerance
Differences in the amount of practice performed
during therapy were NOT correlated with: ___
- Patient age
- Patient’s current level of function
- Therapists level of experience
What are some inconsistent approaches to rehabilitation?
• Lack of evidence based intervention
- Have evidence, not consistently applying
• Lack of consistency in approach
- Various camps/approaches
• Use of approaches that don’t focus on motor
learning/neuroplasticity
The key to recovery of a neuro dysfunction is ____
- Intensity of practice
- Enriched environment
- Task specificity
When do we use augmented interventions?
When normal rehab strategies are not possible due to limited motor function
What is neuromuscular facilitation?
Use of facilitation techniques - Enhanced capacity to initiate movement response through increased neuronal activity and altered synaptic potential
What is activation as found under neuromuscular facilitation?
Actual production of movement response; reaching critical threshold for neuronal firing
What kind of technique does neuromuscular facilitation include?
Includes techniques used for inhibition of unwanted motor
activity – decreased capacity to initiate movement response through altered synaptic potential
What is an additive facilitative technique?
Inputs applied simultaneously often combined (ie PNF); collectively produce desired motor response
• Spatial summation: input from multiple presynaptic cells…
sums to get action potential
What is another way that facilitative technique works?
Repeated stimulation may produce desired response
• Temporal summation: repeated input from single neuron
What are some neuromuscular facilitation techniques?
- Resistance
- Quick Stretch
- Tapping/repeated quick stretch
- Prolonged stretch
- Joint approximation
- Joint traction
What population was the neurodevelopmental treatment (NDT) created for?
Persons with stroke and cerebral palsy
What does neurodevelopmental treatment (NDT) center around?
Specialized handling that inhibited spastic and reflex
patterns and promoted normal postural control and
movements
Neurodevelopmental treatment (NDT) was initially based on ____
Hierarchical theory of motor control
____ is foundation for skilled learning
Postural control
What are the characteristics of Neurodevelopmental treatment (NDT)?
• Control of posture and movement in progressively more challenging postures and activities
• Use of therapeutic handling techniques- facilitation and inhibition
• Manual contacts guide and direct movement
• Key points of control: optimal body part(s) for control of inhibiting or
facilitating movement
• Avoids compensatory movements
• Taught in continuing education courses
• Not supported by evidence as being superior over other approaches
Sensory stimulation technique are things that involve __
Touch, visual, auditory, olfactory
What are sensory stimulation techniques used to do?
- Increase alertness, attention, arousal
- Sensory discrimination
- Initiation of movements
- Used to augment task specific/activity training
- Sensory stimulation in those with low arousal
- Watch for increased sensitivity to sensory stimulation in some persons
What are the sensory stimulation techniques?
- Sensory Retraining
- Biofeedback
- Neuromuscular Electrical Stimulation
- Functional Electrical Stimulation
What is the sensory retraining sensory stimulation technique?
Sensory re-education, tactile kinesthetic guiding, repetitive sensory practice, desensitization
What is the biofeedback sensory stimulation technique used for?
Used with severe motor weakness; must be part of activity-based, task oriented training
What is the neuromuscular electrical stimulation sensory stimulation technique used for?
Muscle re-education, improve ROM, reduce spasticity, decrease edema, manage disuse atrophy
What is the functional electrical stimulation sensory stimulation technique used for?
Recruits muscles in synergistic sequence for purpose of functional movement
What is the Brunnstrom method?
Recovery from stroke in stages from no movement
to synergistic movement to out of synergy; encouraged
synergistic movements
What is the Rood method?
Facilitation and inhibition; focused on cutaneous stimulation; joint compression/distraction, use of
stretch/resistance/reflexes; stroking, brushing, icing, warmth,
pressure and vibration
What is continuum of care?
Provision of care from the entry of the patient into the
healthcare system until care is no longer needed
What are the requirements of an inpatient rehab facility?
Patient has to be able to tolerate a minimum of 3 hours of rehab
What are the keys to coordination?
- Need a team and the patient/caregiver are the center of this team
- Need EARLY investigation of options and prognostication of future need
- Education, Education, Education
- Good communication with hand-off to next facility
What is the 1st step in the acute management of stroke?
Rapid diagnosis – Ischemic v Hemorrhagic
What are the components of the rapid diagnosis of a stroke?
- CT scan preferred
- Candidate for tPA?
- Endovascular intervention
What are the acute management options for a stroke?
- Platelet antiaggregants
- Treatment of fever
- BP management
- Continuation of statins
What are the acute management thing to do for an hemorrhagic stroke?
- Control bleeding
* Reducing pressure
What kind of situations is supportive care needed?
If there is a small bleed
What type of surgical treatment options for a stroke?
- Repair of vessel
* Removal of AVM
What are the acute management options for a TBI?
• Establish severity – GCS
• Stabilization
• Prevention of intracranial hypertension
• Adequate and stable cerebral perfusion pressure
• Optimization of cerebral hemodynamic and
oxygenation
• Avoidance of secondary insults
• Mechanical ventilation
• Seizure medication
What are the things that can increase Intracranial Pressure?
Edema, abnormal fluid dynamics or hematomas
What is normal ICP?
4-15 mmHg
What can a severe increase in ICP result in?
Brain herniation
What is an increased ICP associated with?
Increased mortality and
poorer outcomes
In what kind of cases is a drug induced paralysis done?
In cases with increasing ICP
What are the kinds of drugs used to induce paralysis and in what cases are they used?
• Pentobarbitol: strong barbituate; acts on smooth and
skeletal mm; need careful monitoring of cardio resp
status
• Pavulon: blocks impulse at NMJ; affects skeletal mm
only
What are the management options for an unstable ICP management?
• Ventriculostomy open to drain
• Hyperventilation - decreases PCO2 = vascular constriction = decreased space taken up in cranium = decreased pressure (ICP)
• Osmotherapy with Diuretics/Mannitol - decreases
edema only in areas with intact cells and vasculature = decreased edematous pressure = decreased ICP
What are the parameters for early and safe mobilization for acute patients?
- Monitoring
- Upright tolerance
- Out of bed to chair
- Ther ex
- Sitting, standing, gait
What are the management in the field and ER?
- Saving the life is the priority
- Stabilizing the spine to minimize damage
- Preserve neurologic function and minimize secondary damage and complications
What are the life saving ABCs to always check incase of a spinal cord injury?
Airways
Breathing
Circulation
When should a possible spinal injury be assumed?
- Spinal pain/tenderness
- Motor or sensory loss
- Paresthesias
- Altered mental status
- Intoxication
- Other painful injury that could mask spinal pain
What are the acute medical management of a SCI?
• Stabilized medically - ABCs - Necessary diagnostics - High doses of methylprednisolone (within first 8 hours) - Enhancing arterial blood pressure • Stabilized orthopedically - Stabilization of spine - Necessary diagnostics - Fracture management
What are the fracture management for a C spine injury if surgery won’t be done right away?
• Traction for the C-Spine - Halo - Tongs • Positioning - Conservative mgmt of thoracic and lumbar • Orthoses • Surgery • Combo of above
When should surgery for a SCI be done?
- When fracture unstable
- Non-reducible
- Gross misalignment
- Continued cord compression
- Worsening neuro status
What are the types of surgery done for an SCI?
- ORIF
* Decompression
Is early or late surgery better for an SCI?
Early
What are the implications of a spinal fusion?
- Hypomobility
- Hypermobility above and below the level
- Respiration, swallowing, and speech if surgery is done anteriorly
- Scapular precautions if surgery was done posteriorly
What are the functions of a spinal orthoses?
- Promotes fusion
- Limits mobility
- Prevents deformity
- Reduces pain
- Protects neural tissue
- Unloading
What are the medical management options for a bladder dysfunction?
Indwelling vs intermittent catherization
What are the medical management options for a GI dysfunction?
Nasogastric tubes, Bowel program
What are the medical management options for a GI dysfunction?
Equipment, positioning, education
What are the medical management options for a respiratory dysfunction?
Ventilation, CPT, positioning, assisted cough
What are the medical management options for a cardiovascular dysfunction?
Bradycardia, orthostatic hypotension, AD, DVT, CAD
What are the DVT treatments?
- Pharmacological anticoagulant
- Compression stockings
- IVC Filter
- Mobilization
What type of regulation does the insula and hypothalamus contribute to?
The autonomic system
What are medullary neurons responsible for?
For maintaining the peripheral vascular tone and the arterial blood pressure
What do medullary neurons innervate?
The spinal sympathetic preganglionic neurons that are located in the lateral horns of the spinal gray matter of the thoracic and upper spinal segments
What do medullary neurons synapse with?
The post ganglionic neurons that send axons to innervate target organs as well as heart and blood vessels
What does the vagus nerve synapse with?
The pericardium
What is orthostatic hypotension?
Sustained drop in BP > 20 mmHG systolic, or >10 mmHG diastolic within 3 minutes of supine to upright
What are the causes of orthostatic hypotension?
- Decreased vasoconstriction
- Decreased venous return
- Dehydration
What are the presentation of orthostatic hypotension?
- Pale
- Dizziness
- Nausea
- Light headed
- Blurry vision
- Shortness of breath
What are the differential diagnosis or thing that orthostatic hypotension can present as?
- Low BP
- Vestibular Dysfunction
- Low Oxygen Saturation
- Stress/anxiety
What are the management options of orthostatic hypotension?
- Abdominal binder
- TEDS, ACE Wraps, Tubigrip
- Meds
- Initial mobilization to w/c
- Tilt table
- Hydration
What is an acute condition that will need to be addressed in a person with SCI?
Bowel and Bladder dysfunction
What are the characteristics of a bowel and bladder dysfunction?
- Serious medical complication
- Impact on participation
- Self-esteem/psychosocial issues
- Can be very limiting
What are some MSK complications that can come with an SCI?
- Osteoporsis
- Hetertopic ossification
- Pain
- Spasticity/spasms
- Post traumatic Cystic Myelopathy (syringomyelia)
What are the implications of osteoporosis in a person with an SCI?
Ambulation, prolonged standing, e-stim
What are the implications of hetertopic ossification in a person with an SCI?
ROM, NSAIDs, acetic acid ionto, surgery
What type of pain can be seen in a person with an SCI?
Neurogenic or musculoskeletal
What are common pharmacological interventions for dysfunctions associated with a SCI?
• GI system - Bowel management - Prevention of ulcers • Neuromuscular - Control spasticity - Manage pain • Cardiovascular - DVT prophylaxis - Regulate BP - AD
What are the effects of positioning as a PT intervention in a SCI?
- To prevent skin breakdown
- Improve respiratory function
- Improve flexibility and prevent contractures
- Normalize posture/biomechanics
- Normalize BP
- Manage spasticity
What are the effects of upright tolerance as a PT intervention in a SCI?
- Bed
- Recliner
- Upright chair
- Tilt table
What are the things to monitor in a patient with aa SCI?
Vitals, eyes, color, subjective
What are the types of aids used in a patient with a SCI?
TED hose, abdominal binder, any muscle activity
What are the components of skin management in a patient with a SCI?
- Education if KEY
- Monitor skin
- Proper bed
- Positioning program
- Cleanliness
- Cushion selection
- Training in pressure relief
- w/c selection to promote pressure relief
What are the components of functional flexibility in a patient with a SCI?
- Early intervention
- Multi-person intervention
- Establish a routine
- Use hyper and hypo-flexibility to patient’s advantage
What are the characteristics of the selective flexibility needed in a patient with a SCI?
- Low back: mild tightness of extensors
- Shoulders: excessive extension and ER
- Elbows: full ext
- Wrist: full flex and ext
- Hands: tight long finger flexors
- Hamstrings: 110-120°
- Hips: neutral to full ext
- Ankles: neutral to full
What are the respiratory components to evaluate in a person with a SCI?
- Respiratory muscle strength
- Breathing pattern
- Cough
- Chest mobility
- Postural Alignment
- Breath support for speech
What are the components of strengthening as a PT intervention in a patient with a SCI?
- Contraindications
- Maximize/protect what is intact
- Establish stability
- Creative ways to allow pt to exercise the little movement remaining
- Para focus: shoulder depressors and elbow extensors
- Tetra focus: shoulder flex/ext, horizontal adductors, elbow flex/ext, wrist ext
What are the components of education for a patient with a SCI?
- Needs to begin day one
- All about empowering the patient
- Explain all the whys
- Allow patient to choose
- Hot topics
What are the hot topics to educate a patient with a SCI on?
- Skin inspection
- Pressure relief
- AD
- PROM
- Proper positioning
What are the components of early mobility seen in a person with a SCI?
• Bed mobility
- Log vs segmental rolling
- Prop on elbows
- Supine>
During what stage after a stroke is there a time limited window of heightened plasticity?
Early after stroke
What kind of factors does a stroke trigger?
Factors that create heightened conditions of axonal growth and synaptic proliferation
____ intervention is the best for any neuro dysfunction
EARLY intervention is the best for any neuro dysfunction
Can recovery of a neuro dysfunction be done in the chronic stage?
- Evidence of substantial motor improvements > 1 year post stroke
- Improvement despite previous diagnosis of “plateau”
- Seen with participation in novel, task-specific, repetitive motor practice
What are the 2 phases of learning?
- Fast phase
* Slow phase
What is included in the fast phase of learning?
- Initial, fast improvements
- Seen in single session or first few sessions
- Activation of striatum and cerebellum
What is included in the slow phase of learning?
- Slow, evolving
- Moderate gains, progressing across multiple sessions
- Motor cortex
- Increase in number of synapses
What is a plateau?
- Common in all areas of neuromuscular performance
- Achieving an adaptive state
- Stable training stimulus = stabilization of max performance
- Not indication of diminished capacity for motor improvement
What can we do when patient plateaus?
oExpect recovery
oPeriodization
➢Adjust exercise delivery so that positive adaptations continue
➢ Modify intensity, session duration, changing routine, etc…
➢Task specific, repeated practice protocols
➢CHALLENGING exercise regimens
