Week 5 Stroke Treatment Strategies Flashcards
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How can I incorporate as many neuroplastic principles as possible when working with pts is something you have to consider.
Specificity – this is where task specific practice comes in
A lot of intervention questions on midterm– what is it most specific to what the problem is asking? If pt wants to improve walking – choose an answer with walking.
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Layer as many impairments as you can on impairments you want to address when choosing interventions – stairs address a lot of impairments like strength, flexibility (ROM to get through the motion), etc.
Self efficacy – if people aren’t confident in what they are doing, the performance suffers. Praise people when they do well. We want to promote self efficacy.
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PT interventions are centered around a meaningful salient goal with consideration of how to (1) structure the environment, (2) schedule practice, (3) provide feedback, (4) dose the intervention, (5) progress the program, and (6) encourage problem-solving, reflection, and self-management.
If pt doesn’t want to get better at walking don’t have to get on your soap box and make them walk.
Ask pts hey what do you want to work on today then see how you can address that.
Have to mix research, patient experience, and clinical knowledge to get the best outcomes. – referring to interventions
Setting up the environment – walking – do you have a place for them to sit when walking for a break? Is it in a closed environment where they aren’t distracted or are they walking in the streets of philly? It’s less about the intervention but more so what the environment has to offer.
If intervention doesn’t go as planned – was it that they took two steps, buckled, and didn’t have a chair near so everything went south? Did you not incorporate as much neuroplasticity as possible?
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Have to get peoples HR up, have to challenge people, and interventions should not be passive. Want pts to be actively involved.
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Muscle Weakness
“There is Level 1a evidence that progressive resistance training for the lower limbs (does not improve/improves) muscle strength, but there is conflicting Level 1b and Level 2 evidence as to whether it improves balance, gait, or endurance.”
What does this tell us? - There (is/is not) limited carryover to function.
How could you address weakness in the following muscles via functional activities?
Ankles
Knees
Hips
Weakness is the number one complaint ben gets.
If you strength train someone who has a stroke, they get stronger. It doesn’t mean it will help with their other functions.
If someone is complaining that their
ankles are weak – use more uneven surfaces which causes increased nm output than in a more static position. Sit to stand address ankle strength – tibias have to come forward in an eccentric manner to be able to stand. Walking on an incline – that gradient promotes eccentric control and strength of the gastrocs.
Knees are weak – think about stairs – they are single leg squats. Forcing leg to work hard and get it stronger.
Hips are weak – potentially using an obstacle course to step over things for hip flexors. A floor transfer – a lot of hip strength required to get off of the ground.
improves; is;
Metabolically they have to work (less/harder). Individuals who have a stroke have to pump out twice as much metabolically than a normal person when working. Have to address CV system because they are at risk of having a another stroke. If they continue to have htn, keep smoking, high blood glucose, cholesterol they’ll have a higher risk of having another stroke.
Medications – beta blockers (blunt the HR response),
If can’t rely on HR, (ABG/RPE) is the next thing you can look at to test how hard someone is working.
harder; RPE
Spasticity – UMN consequence where the muscle is hyperactive.
How to treat spasticity has some debate.
Overall the evidence is weak on what to do to manage spasticity.
If the muscle is overactive have to find ways to reduce it. Whether you do tens, exercise, etc. once you remove the stimulus the spasticity comes back. No expectation if you stretch 10 min a day 7x a week you’ll get rid of the spasticity long term. Spasticity is a passive phenomenon.
If you have a spastic gastroc and they can’t activate the gastroc we can teach them to rerecruit the muscle. If it doesn’t get recruited that is how spasticity can lead to their compensations but someone can power through and that is where we come in as therapists.
Reasons to address spasticity:
Spasticity can lead to a contracture (good luck getting rid of it once a contracture kicks in). So we are preventing a contracture. if a muscle is tight and not moving, blood will pool. If blood starts pooling a DVT can occur. So stretching may help prevent a blood clot. If you hold your biceps in contraction for hours on end it could potentially be sore or painful, the skin won’t be able to breathe – can get sore as the skin breaks down.
A common way to treat spasticity is stretching.
Optimal ways/positions to stretch – get them in a (NWB/WB) position. If gastrocs are tight – can do the typical lunge stretch, maybe standing on an incline.
No guarantee spasticity goes away, so have to compensate (potentially gait deviations) or learn to power through.
WB
Sensory Deficits
Use mirror to show the patient his/her more involved
Sensory stimulation:
(Static/Movement)!!
(NWB/Weight bearing)!! (consider barefoot during standing activities)
(Avoid compression/Compression)
Modalities: electrical stimulation, heat, cool
Evidence to support improvement in sensation as a result of these strategies is limited and inconsistent. - Likely won’t change the underlying impairment but can improve functional use and awareness
A lot of people are going to have sensory deficits.
If someone can’t feel what is going on at their leg you have to show them. A mirror is a great tool.
Movement is going to increase blood flow
WB – if someone is bearing weight on one leg it helps to address sensory deficits. Ability to feel foot on the ground is different barefoot than with sneakers.
Compression – get more stability and feel – compressing joint receptors.
Modalities – make sure to check on pts to make sure the skin is blanching – the blood refills after touching on them.
Most sensory deficits aren’t likely to get better. Have to make use of the sensations they do have.
Movement; Weight bearing; Compression;
Heart of what we are going to do as a therapist in neuro rehab
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An ideal post-stroke therapy scheme would include a ramped intensity (decrease/increase) over the first few weeks after stroke, (decreased/continued) high-intensity therapy for several weeks, and a transition to a program of similar intensity in the outpatient setting, supplemented by a home exercise program with measurable practice and outcomes.
If you don’t have intensity threated throughout their recovery they won’t get better.
increase; continued;
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NDT/Bobath – Neuromuscular development treatment – a style of therapy that encourages movement through facilitation. If you touch the hamstrings with your hand, you are asking the muscle to contract or work. There will be a physical dependence with this, they aren’t problem solving (they don’t have to be logged on so to speak), pt won’t be challenged because someone is moving them, wont promote a lot of neuroplasticity through intensity (not a lot of neural recruitment). This method works but there are draw backs as we discussed.
NDT therapists – certification attached to it.
Flavour of treatment is (low/high) intensity training. Treat stroke victims like (low/high) level athletes.
Slide – walk through history of where tx of gait started.
high; high
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Motor learning with thinking about the cues and/or environment you’re setting your patient up in will have a huge impact on their retention of a skill
- -Cognitive
- -associative
- -automatic
Mainly talking about Cerebral CVAs…..subcortical structures may not apply
Cognition – with stroke, there generally is a cognitive component that you have to take into account – even with those who have aphasia
Acuity verse chronicity – can be more setting dependent ; neuroplastic effects
Research – what does the newest research say? Does the research apply to your patient?
- -got us away from hot packs and ultrasound for LBP
- -APTA pushing use of CPGs to guide treatment
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Traditional interventions, which focus on correction of inappropriate movement patterns or error-reduction, can improve gait post-stroke;
however, emerging research has begun to suggest that the opposite approach, error augmentation, may also have a place in rehabilitation – Tyrell
conventional locomotor training on a treadmill has demonstrated improved gait speed, but no effect on interlimb symmetry
Based on motor learning principles of error-based practice and variability of practice
VIEWS trial talks about errors – also consistent with motor learning including error-based learning and variability of practice
Have to decide as a PT, are we going to help them or are we going to challenge them? If someone needs physical assistance with propulsion or limb swing, what can I do?
As assistance goes down, then you (shouldn’t/can and should) introduce error augmentation. Error augmentation – having someone make mistakes on purpose. Make them worse before they get better.
can and should
Impairment based strengthening is not enough.
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Due to conflicting findings, it is unclear whether strength and resistance training for the lower limbs improves motor function post stroke. As well, there was considerable heterogeneity in the type, duration, and intensity of strength/resistance interventions.
Winstein:
Used standing feedback trainer for 30-45min, 5x a week for 4 weeks
Visual feedback provided
Standing performance improved but locomotor performance did not compared to matched controls
If you do a specific task they’ll get better.
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Hands are the (worst/best) tools you can use. If you are going to physically help someone, should use hands first.
best
What would make someone choose one AD over the other? If someone needs stability, will choose an AD for stability.
Rolling walker with asterisk – requires Bilateral function – pt might not have use of both hands so a rolling walker won’t fly.
You as a therapist can choose to use one or more AD and if the goal is recovery, be mindful of if an AD is really necessary.
In a stroke population in the first 6 months barely use an AD unless that is there baseline.
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Gait Training Post Stroke
Whole Practice Gait Training:
Handling Techniques:
Side approach
Seated approach
Trunk/Pelvis -
Facilitate RETRACTION of the (impaired/intact) side and PROTRACTION of the (intact/impaired) side
Facilitate (shortening/elongation) of trunk with hand at lateral upper trunk
(Increase/Reduction) of pelvic ELEVATION associated with hip hiking
If someone needs help at the pelvis, can touch in order to get a better GAIT pattern. If someone is walking with hemiplegia and they are rotated might have to rotate them to get them squared up.
Think of how the trunk is elongated or shorted.
Pelvic elevation with hip hiking – can reduce by putting your hands on top of the iliac crest to facilitate it going down to potentially reduce that elevation. You could also have them add an obstacle to step over to increase the challenge. Have to figure out a different way to do it.
intact; impaired; elongation; Reduction;
Gait Training Post Stroke
Whole Practice Gait Training:
Handling Techniques
Upper Extremity-
NEVER hold onto the (uninvolved/hemiparetic) arm!
Placing hand on (upper lateral/lower medial) trunk or (anterior/posterior) shoulder helps to provide stability to trunk
Shoulder bracing?
NEVER EVER HOLD ONTO THE HEMIPARETIC ARM – more likely to dislocate. When muscles get weak after a stroke so you lose stability. Yanking on the arm will hurt or dislocate.
hemiparetic; upper lateral; anterior;
Gait Training Post Stroke
Participation Level Interventions
Current Evidence:
VARIABLE stepping training at HIGH intensities elicits (lesser/greater) gains in walking function and participation
(PREVENT/ALLOW) variability (errors!!)
Increase task DIFFICULTY in (SIMILAR/DIFFERENT) environments
(LOW/HIGH) intensity
Emphasis on task completion ONLY
Evidence supports that we need ^^
Variable stepping – lifting legs up to different heights, walking on different surfaces, changing directions when walking (sidesteps, backwards,). Walking Is not just a forward task. Can you do turns, can you side step, etc. these individuals need these challenges – forces them to make mistakes – error augmentation.
Take vitals and RPES at the start of every session – nonnegotiable.
greater; ALLOW; DIFFERENT; HIGH;
This article is from Hornby who is the leading researcher in stroke. He did a trial where he pushed people to walk walk walk walk who had strokes in the first 6 months. Other people did traditional therapy. When people just walked their gait speed and 6mwt got so much (worse/better). The berg balance got just as good as the other people who did traditional therapy. So if you work smarter and not harder you can get a lot better and just cut through the fluff.
better;
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Same thing in 2011 from Hornby – step step step step. 4000+ steps in a session compared to traditional therapy.
Take-home of this article and the other one - if you push task specificity and intensity they get better in therapy and in the real world.
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This strategy contrasts sharply from conventional clinical interventions, which focus on ameliorating impairments and provide practice of multiple functional tasks, performed at reduced cardiovascular intensity with attention toward normalizing movement patterns.
HAVE TO PUSH PATIENTS!!!!
20 years ago people who had strokes were treated like they were made of glass. Now the research says to treat them as high level athletes. Push intensity!
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There is some emerging research with TMS and Brain computer interfaces to influence gait that’s considered “top down.” however those will not be covered in this course.
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This review did not find, however, that improvements in walking speed and endurance may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations, or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory participants, but not in dependent walkers.
This review highlights improved walking speed….
People who don’t need physical assist should (be getting/not be getting) physical assist.
not be getting
VIDEO
Walking with FES – Takes a better left step.
Can use as a training tool so they know how proper activation should feel like.
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When errors occur (differences between the expected and actual movement), the internal model is updated, and motor output is modified to produce the correct movement. Over time, these errors drive learning of a new internal model for new limb dynamics or environment
Cerebellum – responsible for detecting errors and fixing them before you even know it.
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What this video shows us is the adaptability of the nervous system
Tied TheraBand around leg to make him worse. Has to work hard to pull the leg through. When you take the band away the walk is a lot cleaner. It only lasts for about 30 seconds.
This is what error augmentation looks like.
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Different ways to approach GAIT.
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Locomotor CPG
Interventions should be performed:
Aerobic (moderate to high/low to moderate) intensity walking training (intensities greater than _ % HR reserve or _% HR Max).
VR-coupled treadmill training
Interventions may be considered:
Strength training of multiple sets and repetitions at greater than _% 1RM
Circuit or combined training
Cycling training (particularly at higher intensities)
Interventions should not be performed:
Sitting and standing balance without augmented visual input
Robotic-assisted walking training
BWSTT with physical therapist assistance
Clinical Practice Guideline
Look at the chart for the midterm –
Promote intensity at ^^
Should not do sitting or standing balance without visual input
Robotic assisted – garbage
Body weight supported treadmill training – garbage
They are garbage because they are passive. If I have the physical ability to walk, don’t use passive approaches because they won’t have the great long term effects we want.
Chronicity of stroke 6 months or after – this CPG
VR-coupled standing balance training
moderate to high; 60; 70; 70;
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The SAFE score is the sum of the Medical Research Council grades for Shoulder Abduction and Finger Extension, out of 5 for MMT, for a total SAFE score out of 10.
Predicting recovery of the UE after stroke – look at shoulder (adduction/abduction) and (flexion/extension) of the finger
If someone had a cumulative total of 8 in MMTs they had a good complete recovery – get all their strength back
The weaker the arm the (stronger/weaker) the recovery was. Lower likelihood of recovery.
This algorithm predicts recovery pretty decently.
abduction; extension; weaker;
This algorithm helps predict recovery up to two years.
We in the academic community are doing better
If people are predicted to do better – we work hard as hell on the (compensation/recovery) function for the patient, if they have weaker strength and a worse predicted outcome, we have to alter tx.
recovery
FYI SLIDE – THINK TREE – don’t have to memorize this slide or the next
Can someone produce a lot of strength?
From left to right it is more compensatory
As someone starts to develop more strength > go into more task specific training
This slide – up in arms on what to do, this is a good start.
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FYI Slide II
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Learned non-use – it is a behaviour consequence – if the body starts to think the arm isn’t a viable body part to use it stops using it. Have to tell the pt the more you continue not to use the bad arm you aren’t setting yourself up for success.
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WON’T BE QUIZZED ON THIS ARTICLE!!!!!!
Within 72 hours poststroke, the nonfitters had signifi- cantly lower upper and lower extremity motor function scores, displayed more neurological deficits as measured with the NIHSS, were more often treated with rt-PA, and more often had total or partial anterior cerebral infarctions than lacunar anterior cerebral infarctions, in comparison with the fitters
Stroke in general – no therapy 50% of the people get better.
This article shows 78% of people spontaneously get better.
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GH Pain – subluxation that can occur due to (ligament/muscle) weakness. Gravity starts to weigh down on the shoulder and it translates inferiorly.
In order to get the muscle stronger have to overload the muscle. Have to push someone so by the 10th rep they fail. Strengthening needs to overload the muscle. Some pts cant actively recruit the muscle no longer how hard they try, which is where Estim can have some value.
muscle
We use e stim – turn the muscle on which helps neural recruitment especially if a pt is struggling with that.
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NMES for Shoulder Subluxation
Stimulation of the (supraspinatus/infraspinatus) and (anterior/posterior) deltoid
Pulls head of humerus back into the glenoid fossa
A lot of these individuals will have shoulders that can sublux . We’ll know this through the sulcus sign (that is how we know there is a subluxation).
Can use NMES to recruit those muscles – back of the humeral head and the supraspinatus. Turn those two e stim pads on to get the approximation and provide bony stability.
supraspinatus; posterior
E stim can be used in the spirit of FES. Using an FES bike that has pads placed on certain muscles and as this person pedals, those e stim pads turn on when the muscle should be turned on. It is a unique way to get muscle activation. It helps with spasticity reduction, recovery of the arm. Individuals can wear it to help the wrist extensors activate.
If someone is weak – can use FES/NMES to stimulate the muscle at the source instead of relying on the infarcted brain.
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Practice reach with different goals
Working on fine motor coordination – picking up rice with tweezers.
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Mirroring the task even though they can’t see the involved arm.
Ben has never used it.
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Constrain a limb in order for the other limb to improve
Pic – individual likely had a right sided stroke – using Left extremity and constrained the right extremity. Not allowing the compensation to happen, forcing the left hand to do the work.
GOT ITTT
Protocol is problematic in acute phase:
- -need to work on multiple function where protocol is based on one function
- -transfer package is designed for home/community not within the hospital (protocol would most likely be different in the hospital – more like to prevent non use )
- —-> lesion could enhance in the acute stage????
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Repetitive: 3-6hr per day depending on severity (10-15 days per protocol)
Shaping: task is performed in 10, 30second trials with feedback given - Behavior-based approach
Task practice: functional task completed for 15-20mins
Based on three things!
Repetitive task specific – individuals identify tasks they struggle with and work with task specific training. If struggle opening a jar, will work on that.
Shaping – forcing the use of their arm in whatever task it is.
Done for 6 hours a day > a lot of practice
Gpt ot
Use dependent – can help reorganize the cortex through motor learning and neuroplasticity.
For walking – if someone wants to get better at walking – have to modify peoples behaviours in some way shape or form.
Transfer package is the most important thing because you are modifying behaviour > next slide
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Focus on using impaired arm in more compensatory ways
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If arm is flaccid or spastic – have to maintain ROM so they don’t have contractures, skin issues, etc
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Pros – Easily accessible (cheap), safety (keeps arm tight to the body), easy to donn and doff
Cons –
Ability to move the arm is next to nothing
Potential hygiene and sores
Dependency
Potential brachial plexus compression
The arm usually extends and slides out, never positioned as nicely as this picture
No subluxation support
If someone has some strength, no need to constrain the arm. Not the sling for a person who has some motor function.
Basically would never use this sling.
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Pros –
If have distal use, not constraining the hands, it is free
Can passively reduce a subluxation
Cons –
Hard to put on
If someone has a weak left arm would be difficult to put on. Basically need a secondary caregiver to put this on.
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Dynamic support for the flaccid upper extremity. Arm is held in a functional position, with the elbow in 30° of flexion, the wrist in 30° of extension, and positions the shoulder in neutral rotation to reduce subluxation. Joint compression is applied through the wrist, elbow and shoulder to help facilitate neurological return. Easy to don/doff.
Pros –
Potential for mobility, arm can move fairly freely
Cons –
Cant use your hand, cant grip,
Pain in the ass to get on , straps get tangled all of the time, doesn’t always keep your shoulder int the best spot.
Not the best stability for the shoulder
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All of these are used to promote stability in the shoulder, maintain skin integrity, prevent contractures
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Kinesio taping – not that strong
Flaccid hand or finger – if gets tight, can limit ability to grip
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Conscious choice between recovery and compensation
The further you get away from the initial injury the (easier/harder) it becomes
Need a lot of practice !! Thousands of repetitions!! If want to get better with hand – use every opportunity to practice. Even if reaching for phone, every opportunity is a chance to practice.
Assistance – even if they need physical assistance, as they can start to move independently, can start to (remove/add) challenge.
harder; add
