Week 3 Flashcards
What are common hemiplegic gait abnormalities that lead to asymmetrical gait patterns?
spatial asymmetries
- decreased step and stride length
- variable step width
- decreased height in swing
temporal asymmetries
- decreased single-limb stance time
- increased double-limb stance time
- increased swing time
- decreased cadence
- decreased weight bearing and shift in stance
What gait speed is needed to be independent in ADL’s and less likely to have adverse event?
1 - 1.4 m/s
What gait speed constitutes dependent in ADL’s and is more likely to be hospitalized?
0-0.6 m/s
What is the gait speed cut off for interventions to reduce falls risk?
< 1 m/s
What is a patients gait speed if they are a household ambulator?
0-0.4 m/s
What is the patients gait speed if they are a limited community ambulator?
0.4-0.8 m/s
What is the patients gait speed if they are a community ambulator?
0.8-1.2 m/s
What is normal walking speed?
1.2-1.4 m/s
What is the cutoff gait speed for a patient to be discharged to a SNF vs home?
< 0.1 m/s - SNF
> 0.1 m/s - d/c to home more likely
What are common hemiplegic gait abnormalities seen in the upper extremities?
decreased or absent arm swing - due to hemiplegia
What are common hemiplegic gait abnormalities seen in the trunk?
- decreased rotation - due to asymmetrical arm swing
- ipsilateral lateral trunk lean - glut med weakness (Trendelenburg)
- forward trunk lean - glut max (extensors) weakness
What are common hemiplegic gait abnormalities seen in early stance phase (heel strike to midstance) at the pelvis/hip?
- decreased pelvic rotation
- decreased hip flexion
- increased hip IR
- increased hip adduction - Trendelenburg
What are common hemiplegic gait abnormalities seen in early stance phase (heel strike to midstance) at the knee?
- increased knee flexion (particularly at initial contact)
- peg leg - decreased knee flexion in early-stance followed by knee hyperextension in late-stance
- excessive knee hyperextension throughout stance
What are common hemiplegic gait abnormalities seen in early stance phase (heel strike to midstance) at the foot/ankle?
- decreased tibial progression
- decreased ankle DF
- lack of heel strike
- foot flat and foot slap at initial contact
- foot/ankle instability - inversion, supination
What are common hemiplegic gait abnormalities seen in late stance phase (midstance to terminal stance) at the pelvis/hip?
- decreased pelvic rotation
- decreased hip extension/terminal stance
- hip flexion during forward progression
What are common hemiplegic gait abnormalities seen in late stance phase (midstance to terminal stance) at the knee?
- decreased knee extension
- knee buckling
- delayed movement into knee flexion in preparation for swing phase
What are common hemiplegic gait abnormalities seen in late stance phase (midstance to terminal stance) at the foot/ankle?
- decreased tibial progression - step-to pattern
- decreased heel off at terminal stance
What are common hemiplegic gait abnormalities seen in early swing phase (push off to mid-swing) at the pelvis/hip?
- decreased hip flexion
- hip hiking
- circumduction
- increased compensatory ER
What are common hemiplegic gait abnormalities seen in early swing phase (push off to mid-swing) at the knee?
decreased knee flexion
What are common hemiplegic gait abnormalities seen in early swing phase (push off to mid-swing) at the foot/ankle?
- poor foot clearance
- toe drag
- decreased ankle DF
- increased inversion
What are common hemiplegic gait abnormalities seen in late swing (mid-swing to heel strike) at the pelvis/hip?
- decreased hip flexion
- hip hiking
- circumduction
- increased compensatory ER
What are common hemiplegic gait abnormalities seen in late swing (mid-swing to heel strike) at the knee?
decreased knee extension
What are common hemiplegic gait abnormalities seen in late swing (mid-swing to heel strike) at the foot/ankle?
- poor foot clearance
- toe drag
- decreased ankle DF
- increased inversion
How can spasticity abnormalities impact gait?
- stiff movements
- clonus will cause jerky movements
- UE spasticity patterns exacerbated during gait
- secondary muscle shortening can lead to further abnormalities
How can hypotonia abnormalities impact gait?
buckling LE
floppy UE
How can sensory impairments impact gait?
- variable foot placement
- variable joint positioning throughout gait cycle
- risk for ankle rolling
- often highly visually reliant
How can visual deficits impact gait?
- visual field cuts or loss of visual acuity - tripping, hitting walls/doors, decreased awareness of obstacles, veering while walking
- dysconjugate gaze - visual disruption, diplopia
How can coordination deficits impact gait? Cerebellar/sensory vs cerebellar only
cerebellar or sensory originates
- dyskinetic swing phase and arm swing
- slower movements
- variable foot placement
- trunk ataxia
Cerebellar only
- extraocular incoordination can lead to visual disruption
How can perceptual deficits impact gait?
- visuospatial neglect
- sensory neglect
- motor neglect
- Pusher’s syndrome - increased UE extension and LE in stance/lateral shift of CoG outside BoS, absent reactionary strategies can lead to falls
What are some common indications for AFO?
- weakness
- impaired proprioception
- spasticity
AFO precautions
- adequate ROM in braced joints - want neutral ankle DF
- be careful w/ sensory impairments
- consideration for cognitive, communication, and/or perceptual deficits
AFO exclusion criteria
- No ankle clonus
- No LE swelling
- No significant or poorly healing skin breakdown
Stirrup/Double Upright AFO indications and considerations
Indications
- Concern for skin integrity
- chronic edema
Considerations
- permanently attached to shoe
- heavy, clunky
- can be unlocked to allow for DF
Solid AFO indications and considerations
Indications
- Significant LE weakness or hypotonia requiring max stability
- alignment issues
Considerations
- rigid
- good support but limit mobility - non-ambulatory patients
- good for medial/lateral stability at ankle
- can include anterior shell for knee control
What does the patient lose with a solid AFO? What activities may be difficult?
- patient loses reciprocal gait pattern - can only do step-to gait pattern
- descending stairs and walking up ramp are limited due to limited DF
What is the primary brace for patients with diabetes and/or kidney issues who have edema issues?
stirrup/double upright AFO
What is the primary brace recommended for PF spasticity?
solid AFO
Pre-hinged AFO indications and considerations
Indications
- significant weakness but anticipate progressing toward hinged AFO
Considerations
- great option to allow brace to progress w/ patient
- can add a removable anterior plastic shell to help w/ knee buckling
Hinged/Articulated AFO indications and considerations
Indications
- need active ankle control (active DF and PF >3/5)
- need adequate knee control (quads > 3+/5)
Considerations
- provides adjustable ankle
- good medial/lateral stability
- allows for reciprocal gait pattern
What needs to be tested prior to the use of a hinged/articulated AFO? Why?
- test hamstring ROM
- if there is a knee contracture, it will be worsened with more DF ROM freedom
Which AFO allows for reciprocal gait pattern?
hinged/articulated AFO and up
What does a Ground Reactive AFO (GRAFO) do?
has anterior shell to push ground reaction force more anterior
Ground Reactive AFO (GRAFO) indications and considerations
Indications
- drop foot
- medial/lateral instability
- knee buckling in stance
Considerations
- creates knee extension to prevent buckling
- aids in foot clearance
- helpful w/ crouched gait pattern
What phase does Ground Reactive AFO (GRAFO) focus on?
stance phase
What does Posterior Leaf Spring (PLS) AFO help with? What phase does it assist in?
- solely helps w/ foot drop (DF weakness)
- swing phase orthoses
Posterior Leaf Spring (PLS) AFO indications and considerations
Indications
- drop foot w/ minimal to no medial/lateral instability
- absent knee buckling
Considerations
- allow for some AROM DF and PF
- minimal support
What does the evidence say about the utility of BWSTT? (LEAPS, STEPS, and CPG)
LEAPS - significant differences found in gait speed, balance confidence
STEPS - significant difference found in gait speed, endurance
CPG - little benefit of BWSTT on walking speed and distance compared w/ overground walking
What has BWSTT been shown to improve post-stroke?
improvements in gait speed, endurance, and fear of falling
What are the major indications and considerations for BWSTT?
- ambulatory patient w/ stable CV status
- gait goals in gait speed and/or reducing fall risk
- eliminate fall risk
- decreased physical load on therapist
What are some components of a BWSTT treatment protocol?
- allows for more steps per session
- be aware of CV status
- be cautious w/ behavior or cognitive deficits
How can BWSTT be progressed?
- increase speed
- reduce BWS
- reduce assist and facilitation
- add incline
- increase duration, lessen rest breaks
What should BWSTT look like?
- benefits at higher treadmill speeds
- BWS < 40% to remain functional
- always be followed by over ground ambulation to promote carryover
What type of patient is appropriate for NMES? How do treatment goals differ based on body part?
- UMN injury only
- UE - pain, subluxation, spasticity, strengthening
- LE - spasticity, strengthening
Acute treatment - functional training
Chronic treatment - neuroprosthesis
What are the precautions and contraindications for NMES?
Precautions
- impaired or absent sensory
Contraindications
- pacemaker, defibrillator, or any electrical/metallic implant
- open wounds, fractures, cancer near site
What tests can be used to determine visual field cut vs neglect?
Visual field cut
- Snellen
- visual fields
- extraocular motor - Big H
Neglect
- double simultaneous stimulation
- clock/house drawing test
- cancellation test
- line bisection test
- KF-NAF
What are anchors?
- external facilitation
- using target to visually seek on the neglected side
- ex: having patient follow tape to the end or therapist arm until they see the hand
What are guides?
- internal facilitation
- using object or finger to direct eyes toward neglect side
- ex: moving mirror towards neglected side so patient starts to look that way
What are the major prognostic indicators for CVA recovery?
- time to medical intervention
- type of medical intervention
- initial NHSS score
- age
- education level
- family support
- PLOF
- ambulatory on eval
How does prognosis differ between hemorrhagic and ischemic strokes?
hemorrhagic - high mortality rates acutely, but better prognosis long-term (less cell death)
Ischemic - low mortality rate but slower recovery
most to least disability prognosis by stroke type
1 - multiple vascular territories 2 - MCA (most common) 3 - ACA 4 - PCA 5 - Brainstem 6 - small vessel stroke 7 - cerebellar
What are the major acute prognostic indicators for UE recovery?
Finger extension and shoulder ABD on day 2 after CVA - most achieve some dexterity at 6 months
What is the PREP2 algorithm? What types of assessments and considerations are involved in this prognostic decision-making algorithm?
Combines Shoulder ABD MMT and Finger EXT MMT (total out of 10) and look at them 72 hours
- Considers age, MEPS (electrical diagnostic way for us to measure motor activity in extremities)
- MEPS – function that looks a brain activity during motor function
PREP2 excellent and treatment focus
potential to make complete recovery of UE function within 3 months
Treatment - promote normal function and minimise compensation
PREP2 good and treatment focus
potential to use affected hand and arm for most ADL’s within 3 months. May have some weakness, slowness, or clumsiness
Treatment - promote normal function and minimise compensation w/ affected limb
PREP2 limited and treatment focus
potential to regain movement in affected UE within 3 months, but daily activities are likely to require significant modification
Treatment - promote movement and reduce impairment by improving strength and ROM. Promote adaptation for ADL using affected limb
PREP2 poor and treatment focus
unlikely to regain useful movement of UE within 3 months
Treatment - prevent secondary complications such as pain, spasticity, and shoulder instability. teach compensation w/ other arm
What are available prognostic indicators for UE recovery in the subacute setting?
- early AROM finger EXT, grasp release, shoulder shrug, and shoulder ABD
- absence of somatosensory loss, visual field loss and/or neglect
- presence of grip strength or AROM shoulder FLEX
What are available prognostic indicators for return to ambulation post stroke?
- ambulation on eval
- balance scores on eval
- minimal loss of LE strength
- minimal perceptual visual or cognitive deficits
- healthy BMI
- younger age (<65)
How much recovery is seen at the chronic stage of CVA recovery?
- majority can walk short distances on flat surfaces w/ about 1/2 limited community ambulatory (0.4-0.8 gait speed)
- very few are unlimited ambulation (>1.2)
- majority have partially or completely dependent ADLs and most will regain functional independence
For the Stroke Impact Scale, describe the major function of the test and basic areas of examination and what it has been shown to correlate with.
- subjective questionnaire evaluating disability and health-related QoL after CVA
8 domains
- strength
- hand function
- ADL/IADL
- mobility
- communication
- emotion
- memory and thinking
- participation/role function
What does the Orpington Prognostic Scale evaluate? What are its cut-off scores?
measures
- motor deficits
- proprioception
- balance
- cognition
< 3.2 = likely return home
3.2-5.2 = respond better to rehab
> 5.2 = dependent w/ increased risk of instituionalism
want a low score
What type of patient is PASS test used for? What does it measure?
stroke specifc balance assessment
- sitting, standing, and dynamic balance
What type of patient is the TIS used for? What does it measure?
CVA, Parkinson’s, MS
- static and dynamic sitting and upper/lower trunk coordination
What type of patient is the FIST used for? What does it measure?
CVA and vestibular
- evaluates sensory, motor, anticipatory, reactive, and steady-state balance factor in SITTING
TUG-motor vs TUG-cog
motor - TUG w/ cup of water
cog - TUG and count backwards by 3 from 100 from randomly selected starting number
Why might you choose to utilize a TUG vs. TUG-Motor vs. TUG-Cog?
tug-motor and tug-cog are dual-task skills
What are some basic strategies to utilize when your patient demonstrates cognitive impairments that limit their participation in activities?
- simple directions
- establish a routine
- carry out activities in a consistent manner
- employ repetition as much as possible
- minimize distractions
- recognize when it is time to take a break
What are some basic strategies to utilize when your patient has aphasia?
- simple, short phrases
- give additional time
- be mindful of the volume of your voice
- simple yes/no questions
- gestures to facilitate understanding
What is berg balance cut off for community-level ambulation?
29/56
What is berg balance cutoff for unassisted ambulation?
12/56
_________________ is a strong overall predictor of both stroke severity and community ambulation status
self-selected walking speed
