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246 Cards in this Set
- Front
- Back
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Does a stroke cause more than motor dysfunction?
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yes- sensory issues, etc
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Initial Impairments after a stroke
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motor
cognitive sensory communication perceptual |
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Secondary impairments/conditions post stroke
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mm shortening, contractures, pain, subluxation, DVT, edema, seizures, bowel/bladder dysfunction, sexual dysfunction, dysphagia, depression
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What is the first step in establishing a hypothesis about impairments and subsequent dysfunction associated with stroke?
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understanding cortical function. If you can recognize symptoms, you can tell where the stroke was and vice versa
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Where do 80-85% of strokes occur?
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Middle Cerebral Artery (cause of arm dysfunction, Broca's)
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Frontal Lobe
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Primary Motor Area- hemiparesis: arm usually involved more than leg
Pre-motor area-motor planning Motor association Area Executive cognitive skills (judgment, reasoning) Personality (emotion, motivation, inhibition) Expressive Speech |
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Parietal Lobe
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"where system"
Primary sensory areas Sensory association areas Left brain- r/l discrimination, praxis **problems with neglect Right brain- visuospatial orientation |
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Temporal Lobe
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"what system"
auditory info, memory Left brain- language, interpretation Right brain- sounds, rhythm, music, visual performance, affective expression *recognize objects, process info |
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Aphasia
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Wernicke's- receptive
Broca's- expressive **aphasia is always a result of LEFT brain damage |
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Occipital Lobe
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synthesis and integration of visual info
visual memory formation of visuospatial relationships visual reception -L brain- right field only -R brain- left and right fields |
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Are outcomes poorer with L or R damage?
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right hemisphere
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Left Brain dysfunction
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right hemiparesis
right sensory loss aphasia with decreased reading, writing apraxia/motor planning left/right confusion compulsiveness slowness |
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Right brain dysfunction
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left hemiparesis
left sensory loss visuospatial impairment poor body scheme poor attention neglect syndrome memory problems time disorientation problem solving poor awareness impulsiveness/safety concrete thinking |
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Why is R brain damage more detrimental than L
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people who have impaired ability to think. process and use information; problem solve; knowledge of performance and results have difficulty learning new strategies, poorer outcomes, and are more dependent on others for completion of day to day tasks
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Steps in clinical decision making
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1. initial data collection (lesion site, severity, cause)
2. pre-morbid info (interview, pt centered goals) 3. skilled observation of task performance 4. establish hypothesis 5. determine additional info needed (tests) |
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Advantages of Top-down approach
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streamlines the evaluation
helps to focus on specific problems focuses on how intervention will impact the disability and functional limitation insures a functional outcome |
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Advantages and limitations of bottom up approach
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helpful when difficult to determine a particular deficit
assess all impairments in a standardized way context one must infer the meaning of the impairment to function |
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What type of test should start stroke assessment?
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start with tests that require observation of FUNCTIONAL TASK to determine what tests of impairment are necessary. Do not exclusively use tests of impairment
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Acute care/hospitalization for adults with stroke
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rehab goals secondary to medical stability
detailed eval rare due to time limitations include motor, cognition, balance, vision, exec fxn ADL, meaningful activity predictive outcome measures for referral & d/c limited |
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LTAC for people with strokes
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medically unstable, more than 100 days
assessment like acute with emphasis on observation prevent physical and mental deterioration |
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SNF for people with strokes
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hospital or nursing based
also called transitional care and extended care -100 day extension of hospitalization -comprehensive assessment -goals to go to inpatient rehab or home with OT |
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Inpatient rehab for people with stroke
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medically stable, ready for intense therapy
3 hrs of therapy daily comprehensive assessment to resume previous roles preparing for home and community important to address psychological impact of stroke |
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Stroke assessments for inpatient rehab
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IRF-PAI at admission
FIM |
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Home health for people with strokes
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next step toward community reintegration
progress expected to continue assessments should center around task important to pt caregiver has a significant role *work with person and family on environment and function |
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Stroke assessments for home health
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OASIS
quality of life measures other measures that provide quantifiable understanding of impact of stroke |
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Outpatient rehab for people with stroke
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1860.00 cap
maximum independence comprehensive assessment centered on activity, responsibility, roles (COPM) task analysis |
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Three scenarios for stroke intervention
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1) Remediate/Correct impairments that may correct the disability or functional limitation- restorative/remedial design
2) Remediate/Correct the disability of functional limitation itself by using existing strengths- can be restorative & compensatory 3) Compensatory/Adaptive approach- using alternative methods to overcome the disability of functional limitation; assistive technology and environmental modifications |
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Broca's aphasia
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expressive
lesion of left prefrontal motor cortex/frontal lobe speech takes effort and is slow may perseverate may use habitual responses "thank you" |
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Wernicke's aphasia
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receptive
lesion of left temporal lobe no auditory feedback, can't comprehend language shift order of intended words or sounds jargon, neologisms, etc *usually unaware of language errors |
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Conduction aphasia
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results when arcuate fasciculus(connective pathway) is involved
-preserved speech production and auditory comprehension -difficulty repeating sentences, impaired ability to select words - inability to find correct word in speech or writing -talk around things to communicate |
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Global aphasia
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extensive involvement of frontal and temporal areas
nearly complete loss of receptive and expressive some automatic expressions may be intact |
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Intervention for communication disorders
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approach and treat pt as an adult
provide quiet environment with minimal distraction don't talk louder or more slowly use eye contact don't assume pt cannot understand short, precise statements |
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NeuroMUSCULAR disorders affecting communication
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Dysarthria
Apraxia |
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Behavioral techniques for bladder problems after stroke
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bladder training
habit training timed voiding prompted voiding pelvic floor exercises |
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Managing sexual dysfunction after stroke
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*sex is not contraindicated
stress effective communication, adaptive strategies, positioning, etc |
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PLISSIT model
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Permission
Limited Information Specific Suggestions Intensive Therapy |
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Most common causes of death in the US
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1. cardiovascular disease
2. cancer 3. stroke |
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Modifiable Risk factors for stroke
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hypertension
smoking obesity elevated serum fibrinogen (clotting factor) diabetes sedentary lifestyle contraceptives with high estrogen level systolic hypertension cardiac disease atrial fibrillation alcohol abuse |
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Non modifiable risks for stroke
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age (esp after 75)
gender (male) race (African American, hispanic) heredity |
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Ischemic stroke types
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88% of all strokes
-TIAs -thrombosis -embolism -lacunar stroke **can be modified |
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Hemorrhagic stroke types
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12% of all strokes
-hypertensive -aneurysm |
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Ischemic strokes
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arterial supply to the brain is blocked
caused by narrowing of arteries atherosclerosis can lead to thrombotic of embolic stroke also caused by blood clots moving from heart. can occur d/t afib |
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TIAs
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precursors of stroke, 35% will progress to stroke within 5 yrs
brief, focal loss of function full recovery within 24 hrs probably due to ischemia |
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Treatment for TIA
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endarterectomy or angioplasty can stop progression
medication to thin blood, monitor BP, diet, exercise |
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Thrombosis
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50% of all strokes
develops in minutes, hours, or days frequently occurs where arteries branch and plaque may have narrowed arteries for years exacerbated by high blood pressure 60% occur during sleep usually have hypertension, diabetes, or vascular disease *strokes in progress *around area of anoxia, transitional area of brain has decreased blood flow-reversible effects here! |
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How long does a pt have to get treatment during a stroke?
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3 hours
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Intervention for thrombosis
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medication- within 3 hours, drs must first be sure stroke is not hemmorrhagic
anticoagulant drugs |
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Immediately following a strokes medical management period attempts to...
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-stop progression of the lesion
-reduce cerebral edema -decrease the risk of hydrocephalus -treat seizures -reduce secondary complications |
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Embolism
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38% of all strokes
embolism IMMEDIATELY clogs the artery effects are immediate usually get caught in the heart before reaching the brain usually no warning signs damage depends on what artery clot is in hard to do surgery without causing damage from surgery itself |
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Other intervention for thrombotic or embolic stroke
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1. neuroprotective agent- alter the course of metabolic events
2. Cooling therapy- medical coma induction to limit brain injury 3. Endarterectomy- primarily with TIA |
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Lacunar stroke
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occur in smaller penetraring "end" arteries
patients make remarkable recoveries frequent in people with multiple medical dx |
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CT Scan after stroke
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R is L, L is R
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Completed Stroke
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deficits persist more than 1 day
deficits are stable *can do more with these patients |
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Progressive or Extending Stroke
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ischemic stroke w/ deficits that increase over time
repeated emboli developing thrombus *unstable. therapy is mild. hour to hour changes. read charts carefully |
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Hemmorrhagic Strokes
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(hypertensive or aneurysm)
12% of strokes worst kind to have usually d/t congenital malformation of arteries, can be caused by head injury bleeding in brain produces oval shaped clot that resolves slowly Tx includes lowering BP, surgery, medically induced coma |
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Ischemic vs Hemorrhagic Stroke
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Ischemic- a clot blocks blood flow to an area of the brain
Hemorrhagic- bleeding occurs inside or around brain tissue |
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Subdural hematoma
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bleeding below the dura mater
effects similar to stroke |
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Aneurysm
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like a balloon coming from artery- pops and bleeds into brain
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Four major hemorrhagic hypertensive sites (don't need to memorize)
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Putamen- most common
Thalamic pontine- usually fatal cerebellar- ataxia, other cerebellar symptoms |
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Where do 80% of all strokes occur?
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Middle Cerebral Artery
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MCA Stroke
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80%
contralateral paralysis- UE Contralateral sensory loss- UE hemianopia- field cut limb-kinetic apraxia (usually lt hemisphere) |
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Anterior Cerebral Artery Stroke
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10%
contralateral paralyis- LE contralateral sensory loss- LE grasp reflex, sucking reflex lack of spontaneous behavior, motor inattention, perseveration, and amnesia frontal lobe problems: memory, limbic, personality |
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Post Cerebral Artery Stroke
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7%
cortical blindness- contralateral visual field memory deficit ataxia can have contralateral hemiparesis involved thalamas can cause sensory loss |
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Why is blood flow to brain so important?
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brain does not store O2 or glucose effectively
damage occurs within 2-3 min |
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Predictors of stroke recovery
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return of arm mvmt w/in 2 wks=possible recovery
no grip at 24 days= no UE fxn at 3 mos |
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Spontaneous stroke recovery
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majority of recovery in first 6 mos (this is SSR)
nothing we can physically to encourage. change environment to encourage SSR |
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5 parts of Spontaneous Stroke Recovery
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1. Functional or adaptive recovery
2. recovery of post-stroke edema 3. reperfusion of ischemia 4. diaschisis 5. CNS reorganization |
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Functional or Adaptive Recovery
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can be defined as neurological or functional
functional recovery results from pt learning to do previous tasks Amt of func recovery inversely proportional to degree of damage *in the beginning, focus on the weak side. Focus on compensation just before d/c |
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Recovery of post-stroke edema
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secondary edema disrupts neuronal functioning
some early recovery d/t edema resolution |
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Reperfusion of ischemia
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ischemia insult consists of:
-area of infarct -surrounded by area of moderate blood flow -non-functioning neurons can resume function *we can't impact this. Drugs can help |
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Recovery of Diaschisis
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diaschisis- state of low reactivity after stroke where neuronal connections lie.
*recovery of strong side of the brain can impact weak side of body because it helps get synapses back to the other side |
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CNS Reorganization
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Synaptogenesis- forming new synapses is enhanced through practice of new and learned skills
-reflection of the demands we place on our patients -alter task and environment! Consider person *practice must be challenging enough to force learning! *always work a level ahead of what pt can do! |
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UE impairments
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pain
contractures superimposed orthopedic conditions learned non-use loss of biomechanical alignment weakness tone |
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Effects of UE impairment..
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inability to weight bear during ADL, mobility
inability to move objects using grasp inability to reach and manipulate, poor arm trajectory |
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Who will recover arm function?
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grade above 3 on finger extension scale after day 7=arm fxn return
presence of shoulder shrug after day 11=hand fxn return shoulder abduction after day 11= hand mvmt synergistic hand mvmt after day 11= good hand mvmt hand sensation, age, gender not significant |
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Does the problem of upper extremity mm weakness begin proximally or distally?
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proximally
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Seating for good lumbar spine position (PEAK)
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Pelvis in neutral
Equal weight on both buttocks Angles (90 deg) Knees facing forward **in order to have good thoracic spine, must have good lumbar spine! |
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The Shoulder Rules
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Position of the Thoracic Spine
Position of Scapula on thorax Function of Rotator cuff |
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What mm become shortened with overall kyphosis and side bending?
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rectus abdominis
obliques (both on same side) *keep ability to rotate |
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What mm become elongated and weak with spinal flexion and lateral flexion?
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Latissimus dorsi
Gluteus maximus Back extensors *important to use as quickly as possible. Strengthen |
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Position of scapula on thorax after stroke
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weight of flaccid arm causes downward rotation
weakness in serratus ant causes winging, tipping |
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How to determine if scapula is downward rotated?
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Measurement between spine and side vs between spine and inf angle
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What will happen if you move arm on downward rotated scapula?
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IMPINGEMENT!!
this is why we work on scapula first! |
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Downward scapular rotation(with winging and tipping) causes...
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-disorientation of glenoid fossa (instability)
-weak serratus ant and lower trap -tight levator scapulae and rhomboid *sometimes have to stretch before we can strengthen |
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Rotator cuff weakness after stroke causes...
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GH joint instability (entire rot cuff)
inability to initiate abduction (supraspinatus) no downward glide of HOH (ITS) no ext rot to avoid impingement (infra, teres minor) **using deltoid without rot cuff WILL cause impingement. Always work on rotator cuff! E-stim good |
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What happens to mm when we hold injured arms in front of us?
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internal rotators (pec major, lats) become tight. Infraspinatus, teres minor become stretched
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What 3 structures are involved with impingement?
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supraspinatus tendon
long head of the biceps subacromial bursa |
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Anterior subluxation after stroke
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can happen with lap trays if you don't put a stop behind the elbow
Elbow should NOT be behind the shoulder puts pressure on short head of biceps- can cause bicipital tendinitis *pt's relieve pressure by shortening biceps *sulcus sign |
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Superior subluxation after stroke
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weakness in infraspinatus, subscap, teres minor
can happen with weight bearing through improperly positioned arm *if pt weight bears on outstretched arm or elbow, trunk MUST be activated |
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Most to least common subluxations after stroke
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1. Inferior
2. Anterior 3. Superior |
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Superior impingement
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inf ligament may be stretched or torn
usually require joint mob in inf direction joint mob must be followed by retraining infraspinatus, teres minor, and subscap to cause downward glide |
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What is the goal in minimizing mm weakness?
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work from proximal to distal in EVERY session!
minimize faulty biomechanics functional activity that is relevant and meaningful forced use of RW increases strength & func outcome *walker forces pts to attend to weak side neuromuscular stimulation for reduction of subluxation & promotion of early return peripheral sensory stimulation alone and paired with motor cortical stimulation improves neural plasticity forcing pt to use unaffected side increased synapses patients can get pain relief through TENS |
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How do we measure inferior subluxation?
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-Radiographs are most objective. Costly, expose pts to radiation and give delayed feedback
-Palpation by finger width most widely used -arm length discrepancy -clinical observation |
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Does subluxation cause pain?
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NO, but it clearly puts the muscles, tendons and ligaments at a biomechanical disadvantage and can contribute to orthopedic and neurologic injuries.
Subluxation is directly associated with poor limb function making prevention and intervention important! |
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What are the causes of shoulder pain after stroke?
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Spasticity of internal rotators
stretching associated with mm shortening limited range causing contractures & frozen shoulder impingement |
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Is subluxation reversible? Does it affect rehab outcomes?
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over time, without tx, tension on joint capsule will result in irreversible overstretching of superior capsule
*protect limb during acute flaccid stages b/c it is pulling **bottom line: we appear to have more impact acutely, but we can't tie this to better outcomes functionally |
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What are the rules of thumb for using humeral supports?
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ALWAYS EVALUATE:
-application of force and how that impacts the shoulder girdle and subluxation -how the support moves with the patient as they access the environment -necessity for reducing the subluxation vs the negative impact of abnormal tone and posture -comfort, cosmesis, pain control -how does the support keep the humerus in the glenoid fossa? How does it impact the scapula on the trunk? -impact on function -supports should not be used universally -used as early preventative measure- "think ortho" -horizontal and vertical measurements |
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Pros and cons of using positioning devices as humeral supports (lap tray, arm rest, pillow, foam cushion)
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Pros:
-low tech/inexpensive -horizontal msmt -easy to apply and teach -can be applied quickly in sitting or laying cons: -don't move with your body; fall w/ mvmt -over/undercorrection in inf subluxation -can put arm in poor position if pt slides in chair |
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Pusher syndrome
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push hard to involved side
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Bobath Sling
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allows arm to rest at side of body
support through axilla to minimize vertical displacement straps support axilla against thorax debate: horizontal displacement, circulation compromise |
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When NOT to use a Bobath sling
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do not use for moderate subluxations (2-3 fingers). Use with minimal subluxations and some mm tone support
**must have good sensation |
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Harris Hemi-sling
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vertical support to minimize inferior subluxation
displaces weight of arm over both shoulders places shoulder in adduction/int rot minimizes arm swing and use *poor impact on tone; arm not in ER, elbow not extended. Does nothing to prevent mm shortening, will create shortening over time. No horizontal displacement! |
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Single strap hemi-sling
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upward vertical support to minimize internal subluzation
single strap over opposite shoulder *use for short periods of time to control weight of arm |
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Roylan humeral cuff sling
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-intends to pull humerus vertically with force enveloping the humerus and pulling superiorly
-force transmitted to opposite trunk *allows elbow extension. Can be worn for long periods of time. Can be worn under clothing. |
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Pros of prescribing a sling
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protects from injury during transfer
allows therapist freedom to control trunk & LE may prevent soft tissue stretching prevents prolonged dangling of extremity may relieve pressure on nm bundle supports weight of arm |
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cons of prescribing a sling
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may contribute to neglect of body scheme disorders
may contribute to learned nonuse may hold UE in a shortened position fosters dependence on passive positioning may initiate shoulder-hand syndrome shortened internal rotators scapula and trunk not affected no arm swing while walking blocks sensory input no motor demands on UE |
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Bottom line on using slings
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*use as a preventative measure when UE is flaccid, to prevent stretching of the joint capsule when supraspinatus is not active
*no lasting impact on existing subluxation *do not address scapular or trunk alignment that is the primary cause of subluxation ***weigh advatages of minimizing subluxation with the possible advantages/disadvantages of position, function, circulation, tone changes, pain relief, and gait changes. Evaluate every time you see client! |
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Role of e-stim in humeral support
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in clients with neurological disorders, we use e-stim early in recovery to:
prevent or retard mm atrophy muscle re-education (with functional tasks) |
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NMES contraindications/precautions
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pacemaker
avoid anterior neck, head active cancer ____________ abnormal sensation pregnancy |
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Where should NMES electrodes be placed for inferior subluxation
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supraspinatus and post deltoid
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timing for e-stim
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to prevent/decrease subluxation:
on- no more than 10 sec (avoid fatigue) off- 50 sec moving to 30 sec as mm strengthen On:off ratio 1:5 to avoid fatigue To use as orthotic aid while decreasing subluxation: duty cycle should be increased from 1:5 ratio of ON to OFF to 1:1 ratio wearing time increased to 6 hrs/day use 4-6 weeks for prevention |
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General e-stim info
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-should see increases in motor recruitment
-should see improvement within 2 weeks -combine voluntary conscious effort with stimulation -e-stim improves recovery RATE, not func outcomes -consider transitioning with home units |
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Bottom line on e-stim
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*for those at risk with subluxation, start nmes early for mm reeducation and to prevent subluxation
*for those with chronic subluxation and pain, consider use for 2 weeks to decrease pain *carefully assess impact on spasticity and function with standardized tests |
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Goals of taping for humeral support
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-inhibition of overactive mm synergies
-facilitation of underactive mm synergies -optimal joint alignment -offloading or irritable neural tissue; direct or indirect pain relief -largely compensatory, immediate effects *best when combined with sling |
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Intervention to prevent and treat subluxation
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*proper positioning into maximal ext rotation helps prevent subluxation
*teach proper handling to pt and caregivers *avoid over aggressive therapy including pulleys and ROM *use NMES early with functional tasks and mental practice for mm reeducation to facilitate recovery, prevent subluxation *slings are best method to support flaccid UE during standing, transfers, but no one sling is better than any other. Add taping *use additional methods for pain reduction (aromatherapy, accupressure) |
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Positive symptoms vs negative symptoms
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positive symptoms hinder or mask normal movement
decreasing positive symptoms does not increase function negative symptoms are those a patient lacks after insult (strength, sensation, coordination) improving negative symptoms DOES increase function |
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Tone after CNS insult
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we cannot fix tone
positive symptom we need to intervene with tone if: 1. tone limits PROM 2. it is compromising skin integrity or causing pain 3. it limits functional mobility or activity |
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What scale do we use for tone
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Modified Ashworth Scale
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How does tone manifest itself? (progression)
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1. initial tone..usually begins after initial flaccidity
fingers curl, elbow flex, elbow ext 2. flexion synergy with volitional mvmt within the synergy only scapular retraction, scapular elevation, GH joint abduction, elbow flex, elbow ext, forearm supination *happens voluntarily or any time you ask pt to do something that causes them to concentrate 3. ability to freely mix the synergies 4. more isolated movement patterns |
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Hand functional levels
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1. mass flexion
2. mass extension 3. digital finger grasp 4. thumb adduction grasp 5. thumb to index finger grasp 6. cylindrical grasp 7. spherical grasp *many get stuck at 1. try to work a level ahead |
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Scale used to identify levels of recovery in the hand
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Chedoke McMaster Stroke Impairment Inventory
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Stages of motor recovery of the Chedoke McMaster Stroke Impairment Inventory
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stage 1: flaccid paralysis
stage 2: spasticity is present but no voluntary mvmt stage 3: marked spasticity, synergistic voluntary mvmt stage 4: spasticity present, mvmt can occur in opposite synergy stage 5: spasticity wanes, but evident with rapid mvmt and at end of range stage 6: mvmt near normal except for complex tasks stage 7: normal **compensate before stage 4, functional at stage 4 |
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Consensus recommendations for UE intervention post stroke
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-remedial intervention will not be successful unless pt has experienced some recovery
-at least stage 4 of Chedoke -if not stage 4, compensatory approach -any additional intervention will not result in any significant change |
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Compensatory approach to UE after stroke
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maintain a comfortable, pain free, mobile arm and hand
-proper positioning while at rest -careful handling during functional activities -instruction to provide appropriate self-ROM exercises -humeral supports for first 2 stages during xfers, mobility (taping, estim) -teach compensatory strategies |
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Function based Restorative approach to UE after stroke
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task oriented, results in motor learning and cortical reorganization
intervention techniques: -visual demonstration -verbal instruction -manual guidance -appropriate feedback -consistent and repetitive practice |
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problems with visual regard after stroke
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cannot keep eyes fixed on something while head or body is moving. Work on this!
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Assessing visual regard after stroke
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1. can pt locate and maintain eye gaze on fixed or moving target in central or peripheral field? (head still, move eyes)
2. can pt locate and stabilize on target in far periphery? (keep eyes on target while head is moving) 3. eye-head-trunk mvmt to find object in far periphery (turn head and trunk in all directions, walking, sitting,standing) 4. Does pt have blurred, dizzy, double vision? |
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Problems with visual regard after stroke
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visual field cut
visual neglect breaking visual fixation slowed reaction time |
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Evaluating reach after stroke
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can observe during functional task
tasks that require different end hand positions contralateral/ipsilateral reach in central & periphery bilateral/unilateral reach high and low accuracy demands *start with something they are good at, then hard, then easy again |
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Problems with reaching (transportation phase)
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delayed mvmt timing for stable and moving objects
disruptions in interjoint coordination undershooting or overshooting object abnormal motor activation sensory issues affecting reach |
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Interventions for reaching (transportation phase)
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vary fast/slow tasks
work with pts on accuracy force pts to alter tasks, heights, shape, distance ipsilateral, midline, and contralateral |
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Problems with reaching (hand shaping)
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absence of anticipatory hand shaping
inappropriate closing too late or too soon inability to alter hand shape larger or smaller pre-grip formation inaccurate recognition of object & its use |
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Interventions for hand shaping
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*highly driven by sensory and visual input. Remind pt to plan ahead before trying the task
-what is object's size, shape, or weight and how should I use it? -What type of grip is needed for lifting, throwing, or carrying this object? -Remember to open hand prior to reaching the object |
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Grip Assessment
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-functional observation
-standardized testing Ask yourself 1. does grip vary according to size, wt, shape of object 2. can they show anticipatory control or adapt accordingly 3. are they using visual systems to guide grip |
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Problems seen in grip phase
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-may take pt longer time to contact object before lifting it (sensory issue)
-pt may not be able to adjust force. Overcompensation is typical. -pt lacks variety of grasps needed for function -the greater the visual issues, the more impaired the grip |
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Interventions for grip phase
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-gripping objects of different size, shape, weight
-grip stationary and moving objects -power grip first- then precision **all practice needs to occur within the context of functional and meaningful activity |
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Assessments for the manipulation phase
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-Stabilization: can the pt perform isometric finger forces sufficient to hold the object in hand during transport
-Manipulation: can the pt control mvmt of the object through space? -Can the pt release object when and where desired? -Can pt use tools in manner intended **work on stabilization before manipulation! |
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Standardized assessments for manipulation phase
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Purdue pegboard
minnesota rate of manipulation peabody fine motor scales Bruinicks-oseretsky motor development |
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Problems with manipulation
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-in-hand manipulation problems
-slower release or inability to release |
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Interventions for manipuation
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-in-hand manipulation activities (graded for size, shape)
-release on supported (holding object in other hand), then unsupported surfaces, into a container and stacking |
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Which deficits cause functional limitations?
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Positive Symptoms: exaggerations or excess mvmt
-spasticity -spasms -abnormal tone -Babinski response Negative Symptoms: deficits or losses of mvmt -weakness -loss of fine/gross coordination -poor mm endurance |
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Minimizing ROM restrictions
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-increase capsule extensibility (joint mob, modalities, splinting)
-maximize mm resting length (manual therapy, modalities, splinting/casting) -minimize edema -minimize tone |
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UE joint mob after stroke
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*because the hand and wrist are so often positioned in flexion, joint mob to encourage ext is particularly important
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Minimizing pain after stroke
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TENS unit-prevents pain from reaching cortex
resolve any orthopedic issues remember to assess neural tension and treat as needed |
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Teaching patients to be responsible for affected arm
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-make sure arm does not fall off wc or get caught
-check temp of objects before touching -follow splint schedules -complete exercise and functional programs -make a CONSISTENT effort |
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Causes of edema
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-lack of mm contraction acting as a vascular pump
-entrapment/impingement due to postural change after a stroke -sympathetic nerve response to hemiplegia -blood clot/DVT -sleeping incorrectly |
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Controlling edema
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-sleep or rest with arm in at least 30 deg elevation
-compression wraps -splints -activity and exercise -modalities: cryotherapy, estim, contrast baths -retrograde if done gently |
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Sensory re-education
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-Discriminatory: incorporate sensory requirements for all tasks (ex: pick up corduroy shirt and silk pants)
-Protective: educate client in how to protect limb from stimuli that pt cannot safely detect |
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Maximizing fine motor coordination after stroke
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-fine motor coordination is often sensory based
-intervention should be task specific -understand key components of fine motor coordination |
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key components of fine motor coordination
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isolated finger control
thumb opposition stability of wrist and thumb maintaining hand arches demanding in-hand manipulation |
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UE function is facilitated by attention to all of these aspects of motor control..
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sensory
visual cognition strength coordination ...within the context of meaningful activity through conscious practice techniques |
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Shoulder/hand syndrome
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Also called complex regional pain syndrome or reflex sympathetic dystrophy
-caused by sympathetic nerve system overflow -causes hypersensitivity to pain and of mechanoreceptors -lack of active/passive ROM -loss of ability to stand weight bearing 3 stages |
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Stage 1 of Shoulder/Hand Syndrome
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-diffuse aching in shoulder, arm and hand
-swollen tender hand and wrist -shiny dry skin -increase in hair and nail growth -passive ROM to hand and wrist causes sharp and SEVERE pain **easily intervened at this stage |
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Treatment for Stage 1
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-treat cause of pain if possible
-elevate hand and arm to decrease swelling -maintain ROM as possible -check body alignment, biomechanics, hand and arm care -touching, rubbing, massage -TENS for pain -WEIGHT BEARING- in a biomechanically appropriate position |
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Stage 2 of Shoulder/Hand Syndrome
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-MARKED decrease in ROM
-pain is severe and diffuse -hair is scant, nails become brittle and crack -skin gets more shiny, cold, flaky, and swollen |
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Intervention for Stage 2 Shoulder/Hand Syndrome
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-joint mob as needed
-TENS -connective tissue mobilization -gradual but consistent increase in weight bearing |
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Stage 3 Shoulder/hand syndrome
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-severe tissue deformity
-joint contractures -out of the realm of OT -IRREVERSIBLE |
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What happens after stroke?
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weakness
spasticity coordination issues sensory problems cognitive and perceptual problems loss of function |
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After stroke, weakness is a result of...
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-insufficient recruitment of motor neurons from cortical areas
-secondary changes in the mm fibers **not a lot you can do except work with neuroplasticity |
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What mm are active during sit to stand?
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hip extensors, knee extensors, and plantar flexors concentrically
*same mm active eccentrically during stand to sit *important to work in mid ranges to combat weakness |
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Weakness in plantar and dorsi flexors after stroke
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plantar flexors produce 85% of forward propulsion during gait
dorsi-flexor weakness leads to foot drop |
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Quadriceps weakness after stroke
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-quads are important for loading and stance during walking, and for standing control and balance
-compensation is usually knee hyperextension (which will damage ligaments)/ forward trunk lean *quads are also one of the first to become weak in muscular dystrophy *ACL most prone to damage |
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Moving the line of gravity anterior to the knee joint after stoke..
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*a forward trunk lean moves the gravity's line anterior to the knee joint, causing knee hyperextension
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How can we assist in facilitating cortical changes in our patients after a stroke?
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1. enrich the environment
-variety of sensory and motor experiences 2. use functional "task oriented" training -plethora of practice opportunities 3. e-stim, treadmill training, mental practice 4. strength, power, endurance training 5. flexibility 6. remember they still have the same joints, mm-they just need to be trained 7. sensory training 8. balance training |
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Feeding vs eating
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feeding- getting food to the mouth
eating- feeding plus deglutition |
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Dysphagia
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difficulty swallowing
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Direct vs indirect intervention for swallowing
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direct- stroking faucial arch
indirect- exercise |
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Neuromuscular responses to swallowing
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-veleopharyngeal closure= 'k' sound
-pharyngeal peristalsis -airway protection -cricopharyngeal sphincter relaxation |
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Things to look for (eating) in physical exam
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poor speech
gurgling speech=food sitting on vocal cord poor ROM facial droop drooling, pocketing food |
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Dysphagia evaluation
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-skilled observation of signs of dysphagia
-bedside assessment -videoflouroscopic modified barium swallow *assess cough- should be strong *do you often cough right after drinking something? *level of consciousness *check denture alignment |
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residue filling cavity high vs low
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high= valecula
low= piriformis |
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when can aspiration occur?
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before, during, or after swallow
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5 primary reasons people cannot feed themselves
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poor strength
poor ROM incoordination decreased cognition impaired vision |
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Oral preparatory phase
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*voluntary
lip closure buccal tension rotary jaw movement rotary, lateral lingual movement anterior bulging of the soft palate |
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oral phase
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*voluntary
pushing bolus to back of tongue |
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pharyngeal phase
|
'k' sound
triggering of the swallow reflex |
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4 neuromuscular responses to triggering the swallow
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1. velopharyngeal closure
2. pharyngeal peristalsis 3. airway protection (anatomically bottom up) 4. cricopharyngeal sphincter relaxation |
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Esophogeal phase
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pharyngeal structures return to resting state
cricopharyngeal sphincter contracts peristaltic wave continues secondary tertiary wave |
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Receptive components of visual perception
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*the anterior visual pathway
-lesions occurring anywhere from the retina, optic nerve, optic chiasm to the lateral geniculate of the thalamus affect reception **basis is acuity, visual field, oculomotor control *this is the reception- visual component |
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cognitive components of visual perception
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visual cognitive components- the posterior visual pathway
-lesions occurring anywhere from the thalamus to the primary visual cortex in the occipital lobe, to the parietal, temporal and frontal lobe result in problems with perception **reception is the visual component. Perception is the cognitive component in the occipital lobe. Perception is important as it relates to getting around and moving objects in space |
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What are the 3 foundations for visual perception
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visual acuity
visual field occulomotor control |
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visual field
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visual field cut can occur with lesions to either side of the brain
may have some inattention depending on severity, but can quickly learn and compensate **difference with field cut and neglect is that people with field cut will compensate by turning head to look in that direction |
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Common visual field cuts
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hemianopia- loss of vision in one half in one eye (temporal or nasal)
homonymous- loss of field (R or L) that is the same in both eyes Bilateral hemianopia- loss of the same half of vision in both eyes Homonymous hemianopia- loss of nasal field in one eye and temporal field in the other resulting in the loss of an entire visual field |
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Hemineglect
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impaired ability to react or process sensory stimuli presented in the hemispace contralateral to a lesion of the R or L cerebral hemisphere
*accompanied by losses in: visual field, body awareness, hemiparesis, somatosensation, spatial awareness **poor rehab outcome. Work on this aggressively!!! |
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Somatagnosia
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inability to recognize body parts
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anosognosia
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denial or lack of awareness of paralysis; particularly hemiparetic arm
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right/left discrimination
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difficulty determining left from right or discriminating left vs right side of body
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unilateral body neglect
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failure to orient to stimulus to involved side
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Where do body scheme/awareness issues occur
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with R parietal lobe lesions. Coupled with unilateral spatial neglect
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Spatial Relations
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relationship of space between objects, and space between self and objects.
-depth perception, figure ground, position in space, form constancy, topographical orientation, spatial attention *usually a deficit in one area means a deficit in all |
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Where do lesions involving spatial relations occur?
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R inferior parietal hemisphere
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Characteristics of hemineglect
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-asymmetry of attention and shift away from left events
-frame of reference shift -distortion of mental representation in space -impaired sense of pain -deviation of posture -contralateral gaze avoidance -visual spatial disorders and visual sensory deficit |
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Which parietal lobe attends to which visual field
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right attends both left and right
left only attends to the right |
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Right hemisphere damage may result in (vision)...
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-decreased arousal and attention
-difficulty sharing attention -deficits in the internal spatial representation |
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Lesions in the frontal lobe cause...
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Cognitive deficits:
1. executive function-problem solving 2. basic cognitiion- orientation, attention, memory |
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Skilled observation as visual assessment
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person's behavior
informal/formal observation of task strengths and limitations |
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How do you determine what assessment to use?
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can the person participate?
is the assessment relevant for the person? what additional info do I want to know? Does that assessment cover the areas I want? Is it in line with the correct model guiding my intervention? Do I need a sensitive assessment? Does it measure change over time? Am I qualified to perform it? |
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Types of approach for perception and cognition
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1. remedial/restorative- intervention for the cause of the dysfunction with expected transfer of training; practice and repetition of underlying processing skills
2. functional/adaptive- compensatory intervention to improve the dysfunction through repetitive practice and feedback 3. Combined approach- task oriented approach to challenge development of underlying process skills. Recognizes the complexity of everyday tasks |
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What is the most favorable evidence based intervention for neglect?
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contralateral limb activation. Hand over hand using your hand over their involved hand
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Evidence based interventions for neglect
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contralateral limb activation
CIMT mental imagery prism glasses eye patching caloric stimulation optokinetic stimulation neck vibration trunk rotation |
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Task oriented interventions for sensory perceptual cognitive impairments
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activity processing
behavior modification group treatment multicontextual approach Affolter approach- hand over hand |
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Tips for working with cognitive impairment
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Keep it simple!
avoid frustration use multiple, simple cues decrease environmental stimuli slow down provide basic instruction goal-directed engaging activities frequent practice motor learning |
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At what stage on the Chedoke stroke scale do you begin remedial intervention for recovery?
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stage 4
before stage 4, compensatory approach |
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Stages of Motor Recovery of the Chedoke McMaster Stroke Impairment Inventory
|
1: flaccid paralysis
2: spasticity present, no voluntary movement 3: marked spasticity, voluntary mvmt is synergistic 4: spasticity present, mvmt can occur in opposite synergy(ex: can open and close hand) 5: spasticity wanes, but evident with rapid mvmt and extremes of range 6: mvmt near normal except for complex tasks |
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Compensatory approach for stroke
|
Maintain a comfortable, pain free, mobile arm and hand
-proper positioning while at rest -careful handling during activity -instruct on self ROM exercise -humeral supports for first 2 stages during xfers and mobility -teach compensatory strategies (one handedness) |
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Restorative approach: Function based
(post-stroke) |
Task oriented approach results in motor learning and creates cortical reorganization
Intervention techniques: -visual demonstration -verbal instructions -manual guidance -appropriate feedback -consistent and repetitive practice |
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Restorative intervention: impairment based
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results in improvement in impairments, but not function
NDT, Brunnstrom, PNF neurorestorative intervention to address positive signs are no more effective than any other impairment based intervention |
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Evidence based restorative intervention (EBRI)
|
Bilateral arm training-
-practice same task with both hands simultaneously -theory-activate damaged hemisphere via corpus callosum |
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Neural basis behind mental practice
|
reorganization of motor cortex
cortical and muscular representations show impulses in same areas as with actual movement |
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Uses for mental practice
|
increase performance of elite athletes
strength without mm activation reducing falls and social skills training studies with people who had strokes showed effective combined with physical practice mirror therapy |
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Limitations of mental practice
|
-dependent on pt ability to consistently practice
-depends on pt ability to accurately imagine -unclear how often and how long -unclear whether effects endure -may or may not change pt perception of performance |
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Assets of mental practice
|
cost effective
conserves energy allows imaginer to gain insights into movement allowing person to develop strategies and correct errors |
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EBRI: robot aided motor training
|
mechanical devise designed to train arm mvmts through intensive practice of repetitive and stereotyped movements
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Assets of robotics
|
can aide with PROM
can help maintain flexibility can assist when pt has active but non-functional movements can be used with higher level pts who with to increase strength by providing resistance during mvmt |
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When are robotics most useful (according to research)
|
in more severely impaired patients during the acute phases when experiencing spontaneous recovery
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Using robotics
|
rely on repetition of specific movements to improve functional outcomes
focus on retraining of UE best when movement is self-initiated Myomo (my own movement) |
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Limitations of robotics
|
-do not improve outcomes of wrist and hand
-restrains other movements (trunk-arm, wrist-hand) -no long-term maintenance of improvements |
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Bioness
|
splint that gives pt stimulation every time they make a certain movement
-early on= mm reeducation -later= may be purely compensatory |
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Take home message for UE intervention for Chronic stroke
|
-try anything if pt has at least stage 4 motor recovery
-set functional goals -engage person in their intervention -use motor learning concepts -intense, frequent, repetitive -try for 2 weeks; d/c with compensatory strategies if no gains |
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Learned non-use
|
during the period in which the pt learns non-use, potential motor recovery is limited by learned over reliance on the unaffected limb
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Shaping
|
use for CIMT. Stay right with the pt. Praise for positive attempts
Reward for using the involved arm |
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Typical CIMT inclusion criteria
|
initially in pts were in a period of chronic stroke- post stroke >1 yr
EXCITE trial used 3-9 mos post stroke *doesn't work in acute -no balance problems (or in wc) -understand purpose of the restraint -no excessive spasticity or pain -no serious or uncontrolled medical issues |
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potential side effects of CIMT
|
-uninvolved arm= stiffness, cramping, numbness
-involved arm= fatigue, painful over-use -frustration -compromised safety -increased stroke lesion volume may occur if tx is introduced immediately after stroke |
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Lower extremity training- evidence for...
|
-early task-specific gait training
-partial body weight supported treadmill training -robotic-assisted gait training -weight training/ endurance training programs -estim |
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how much body weight to support during partial weight gait
|
some say 40-60%
some say 10-20% of body weight support **bottom line: do what it takes to allow person to have a normal gait pattern |
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|
What kind of patients can use partial weight training for neuro rehab
|
SCI
TBI stroke CP |
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Contraindications to partial weight training for gait
|
lightheadedness
confusion dyspnea angina excessive BP changes bradycardia |
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Advantages to PBW training
|
-increase pt confidence, tend to walk longer
-safer for pt and therapist -allows therapist to walk pts who couldn't -allows therapist to evaluate gait pattern |
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Disadvantages of PBW training
|
not task oriented
harness can be uncomfortable |
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Idea of PNF
|
apply resistance to the diagonals of movement
|
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Positive argument for compensation
|
early resumption of functional independence using uninvolved or less involved segments
environmental adaptation practice of new skills |
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Arguments against compensation
|
promote learned non-use of impaired segments
develop splinter skills: skills which cannot be easily generalized to other environments or variations of same task |
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Argument for remediation
|
-exercise to reduce sensorimotor deficits and promote motor recovery and improved fxn of impaired segments
-requires some degree of voluntary movement -training focuses on remediation of impairment |
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Argument against remediation
|
-delay of functional independence
-require significant hands on approach and are labor intensive and prolonged evidence supporting use of specific techniques is poor |
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Functional/Task oriented training
|
Best of both worlds
P-E-O mechanisms behind aquiring new skills and practice complex mvmt broken down into discrete task shift is away from impairments individualized hands-on approach evidence to support good practice |
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Rhythmic initiation in PNF
|
employs phases of voluntary relaxation, passive mvmt and repeated dynamic contractions of major mm groups involved in agonistic pattern of mvmt
-therapist can use to work from PROM into more AROM -therapist can thus use to improve flexibility and begin motor learning |
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Slow rehearsals in PNF
|
involves slow dynamic contraction of antagonist followed smoothly by slow contraction of agonist
ex: biceps, then triceps |
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Slow reversal hold in PNF
|
same as slow reversals except add isometric contraction at the extremes or anywhere there is weakness
|
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Rhythmic stabilization in PNF
|
isometric contraction of the antagonist, followed by isometric contraction of the agonist
|
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Hold relax (contract relax) in PNF
|
most used. hold tight against therpist for 20 sec. relax. apply stretch.
*be careful not to over stretch |
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Hold-relax-swing/bounce
|
very risky
|
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Timing in PNF
|
distal to proximal!
expect the distal component to be completed by halfway through the pattern. THIS IS KEY!!! |
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Where should therapist hands be in PNF?
|
over the agonist
"push into me" |
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Traction in PNF
|
slight traction at beginning of pattern
traction through joints facilitates movement |
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Approximation in PNF
|
gentle compression of joint surfaces. Done manually or through weight bearing. Feeds info about position into the joint receptors.
-facilitates stability through a joint. Used for wt bearing joints |
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mm used in movement patterns and mvmt patterns in notes!
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...
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