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76 Cards in this Set
- Front
- Back
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- types of stroke:
- Ischemic CVA |
̈ Hypoxia due to poor blood supply
̈ Thrombosis due to atherosclerosis ̈ Embolus due to CVD, a-fib, MI or valvular disease ̈ Excess glutamate and damage extends beyond original infarct *obstruction |
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-types of stroke:
- Hemorrhagic |
̈ Intracerebral, subarachnoid, arteriovenous malformation (congenital; berry aneurysm)
̈ Underlying causes HTN, aging, spontaneous hemorrhage ̈ Higher mortality rate vs. ischemic ̈ AVM, SH/SAH *bleed |
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-types of stroke:
- Transient Ischemic Attack (TIA) |
̈ Temporary interruption with transient symptoms which resolve < 24 hours
̈ Indicates thrombotic disease with increased risk for CVA |
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Risk Factors
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HTN
HD Arrhythmia/ a-fib DM CHF PAD High cholesterol Rheumatic HD/Valve Endocarditis ESRD Sleep Apnea Early menopause Use of estrogen/progestin Smoking, inactivity, obesity, poor diet Family Hx, gender, age, race |
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Diagnosis
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Physical examination
MRI/MRA CT Scan ̈ Imaging results may not be conclusive until days later Doppler |
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Acute Management
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-Control BP, support cerebral perfusion, monitor
ICP -Heparin, diuretics, calcium channel blockers, thrombolytics (within 3 hours), neuro protective agents to improve blood flow & minimize damage by controlling glutamate release or recover from calcium overload -Surgery: metal clipping of aneurysm, remove vessel, evacuate hematoma, endarterectomy |
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Recovery & Prevention
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First 3 months are key; 2-3 years following
Follow the heart... same risk factors but it is a Brain Attack! Overall outcomes are fair with 15% mortality, 10% LTC, 40% mod to severe impairment, 25% mild impairment & 10% nearly full recovery |
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Right CVA
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Left hemiplegia
Left neglect, body image disturbance Quick, impulsive behavior Unaware of limits Poor judgment Safety risk Rigid thoughts Difficult abstract reasoning Difficulty with perception of emotion and expression of negative emotion Difficult processing visual cues Memory impairment |
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Left CVA
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Right hemiplegia
Speech & language- Broca, Wernicke, global Difficulty planning & sequence movement Slow, cautious Disorganized problem solving Aware of limits Anxious about performance Difficulty expressing positive emotion Difficulty processing verbal cues Memory impaired |
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Syndromes
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ACA (anterior)
MCA (middle) Vertebrobasilar PCA Lacunar Infarcts Thalamic Pain Syndrome Pusher Syndrome |
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ACA (anterior)
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Uncommon; due to embolus
Contralateral hemiparesis & sensory loss primarily in Lower extremities, incontinence, apraxia, aphasia, memory and behavior deficits *homunculous lower extremity area |
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MCA (middle)
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Most common
Contralateral spastic hemiparesis, sensory loss in face & UE, less involvement of LE, homonymous hemianopsia, loss of conjugate eye gaze, motor speech *homunculous outer part of cortex by hands & face |
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Speech Deficits
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-Broca's : motor
-Wernicke's : receptive -Global : both |
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Vertebrobasilar Artery Occlusion
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Often fatal
CN involvement = diplopia, dysphagia, dysarthria, deafness, vertigo, ataxia Locked-in syndrome- alert & oriented, unable to move or speak, eye movements are possible *knows what is going on but can not do anything except blink |
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PCA
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Contralateral loss of sensation, thalamic pain syndrome, homonymous hemianopsia (only one field of vision) , visual agnosia, cortical blindness
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Lacunar Infarcts
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Deep regions including internal capsule, thalamus, basal ganglia, pons (cortical spinal tract)
Cystic cavity or “hole” remains Common with DM, HTN & small vessel arteriolar disease Contralateral weakness, sensory loss, ataxia, dysarthria or pure motor, pure sensory loss |
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Thalamic Pain Syndrome
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Lateral thalamus, posterior limb of internal capsule, parietal lobe
Intolerable burning pain and sensory perseveration Sensation is noxious and exaggerated *sensory relay, given sedatives, massive pain |
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Pusher Syndrome
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-Right CVA involves posterolateral thalamus
-Active push with strong side toward hemi side -Cervical rotation and lateral flexion to the right -absent or significant impaired tactile & kinesthetic awareness *trunk work in side lying- PNF, Chop/ lift *nothing passive *pushes to bad side. |
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Pusher Syndrome (continued)
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-visual deficits
-truncal asymmetries; increased WB on LEFT during sitting & resistance to equal WB attempts -difficulty with transfers due to pushing backward & to involved side *trunk work in side lying- PNF, Chop/ lift *nothing passive*pushes to bad side. |
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Cognitive Deficits
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Attention, memory
Confabulation Confusion Perseveration Impaired judgment Impulsiven inflexible Lack flexibility/abstract thought Impaired organization, sequencing, planning Dementia Delirium MMSE or SLUM |
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Motor Impairments
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Paresis: muscle weakness
Motor planning deficits: apraxia (difficulty performing purposeful movement), may have motor capability but unable to determine steps to achieve movement goal; evident in self care activities ̈ Ideational vs. ideomotor |
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Assessment of Tone
(Modified Ashworthscale) (Spasticity) |
-upper motor *0 is no increase in muscle tone *1 is slight increase in muscle tone; catching and releasing or minimal resistance at the end of ROM when part is moved in flexion or extension *1+ is slight increase in muscle tone; catching followed by minimal resistance throughout the remaining ROM |
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Assessment of Tone
(Modified Ashworthscale) (continued) |
*2 is more marked increase through most of ROM but affected part is moved easily
*3 is considerable increase, passive movement is difficult *4 when the affected part is in rigid flexion or extension |
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Brunnstrom Stages of Motor Recovery:
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-characteristic pattern of muscle tone development and recovery
-initially flaccid replaced by developing spasticity -synergistic movement develops in flexion and extension that are stereotypical and primitive elicited reflexively or as volitional movement response -later stages indicated by spasticity subsiding -plateau can occur at any stage, stages are sequential |
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Brunnstrom Stages 1and 2
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Stage I: no voluntary or reflex activity present in involved extremity
Stage II: synergy patterns begin to develop; may appear as associated reactions |
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Brunnstrom Stages 3 and 4
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Stage III: movement synergies can be performed voluntarily Stage
IV: deviation from movement synergy is possible; limited combinations of movement are possible |
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Brunnstrom Stages 5, 6, & 7
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Stage V: movement synergies are less dominant; more complex combinations of movement are possible
Stage VI: isolated movements and combinations of movements are evident; coordination deficits may be present with rapid activity Stage VII: return of fine motor skills |
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Brunnstroms Synergy Patterns
upper extremity Flexion: |
scapular retraction and/or elevation, shoulder external rotation, abduction to 90 degrees, elbow flexion, forearm supination, wrist and finger flexion
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Brunnstroms Synergy Patterns
upper extremity Extension: |
scapular protraction, shoulder internal rotation, adduction, full elbow extension, forearm pronation, wrist extension with finger flexion
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Brunnstroms Synergy Patterns
lower extremity flexion: |
hip flexion, abduction and external rotation, knee flexion to about 90 degrees, ankle dorsiflexion and inversion, toe extension
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Brunnstroms Synergy Patterns
lower extremity extension: |
hip extension, adduction andinternal rotation, knee extension, ankle plantar flexion and inversion, toe flexion
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Deep tendon reflexes:
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0 is no response
1 is minimal response 2 is normal response 3 is hyperactive response 4 is clonus (tendon is tapped or stretched and seen as alternating periods of muscle contractions and relaxation, frequently seen in ankle or wrist in response to a quick stretch) |
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Brainstem Reflexes:
Symmetric tonic neck reflex: |
flexion of neck results in flexion of arms and extension of legs, extension of neck results in extension of arms and flexion of legs
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Brainstem Reflexes:
Asymmetric tonic neck reflex: |
rotation of head to left causes extension of left arm and leg and flexion of right arm and leg; rotation of head to right causes extension of right arm and leg and flexion of left arm and leg
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Brainstem Reflexes:
Tonic labyrinthine reflex: |
prone position facilitates flexion, supine position facilitates extension
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Associated Reactions:
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automatic movements occur as a result of active or resisted movement in another part of the body
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Associated Reactions:
Souques phenomenon: |
flexion of involved arm above 150 degrees facilitates extension and abduction of fingers
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Associated Reactions:
Raimistes phenomenon: |
resistance applied to the hip abductors or adductors of uninvolved LE causes a similar response in involved LE
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Associated Reactions:
Homolateral limb synkinesis: |
flexion of involved UE elicits flexion of involved LE
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Communication Impairments
Aphasias- |
language comprehension, oral expression and use of symbols to communicate ideas
Brocas: expressive Wernickes: receptive Global: expressive and receptive |
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Communication Impairments
Dysarthria: |
difficulty articulating words due to weakness and inability to control muscles involved in speech production (coord)
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Communication Impairments
Emotional lability: |
usually in patients with right hemisphere CVA; laugh or cry inappropriately without cause (RCVA)
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Sensory impairments
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̈ Proprioception: loss of position sense; interferes with sitting, standing, weight shifting, sequencing motor responses and eye-hand coordination
̈ Partial to total sensory loss ̈ Interferes with function |
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Respiratory impairments
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̈ Decreased lung expansion due to muscle weakness, especially diaphragm
̈ Complications include pneumonia, atelectasis ̈ Decreased lung volumes, fatigue ̈ Contributes to fatigue, decreased endurance, exercise tolerance |
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Orofacial deficits: facial asymmetry impairments
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̈ Dysphagia: difficulty or inability to swallow; at risk for aspiration (brainstem level)
̈ Asymmetry, weakness, ptosis of eye ̈ Eating & breathing coordination = aspiration risk |
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B&B dysfunction impairments
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̈ incontinence
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Functional Limitations
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̈ ADL ̈ Motor & sensory deficits contribute
̈ Spasticity difficult to overcome ̈ Emphasize function eg: increase DF vs demonstrate DF at heel strike during gait |
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Impairments
Neglect: |
disregard for involved side of body; impaired perception of vertical, visual, spatial relationships; motor perseveration
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Impairments
Perseveration: |
involuntary persistence of same verbal or motor response regardless of stimulus; difficult to redirect to new idea or activity
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Bowel & Bladder dysfunction:
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̈ incontinence due to muscle paralysis or inadequate sensation; early weight bearing (bridging or standing) can assist regaining control
*bridging, scooting, standing exercises |
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Homonymous Hemianopsia
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One half of visual field and nasal portion of the other
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Posture Deficits
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-Pelvis- post tilt in sitting, retracted in standing
-Trunk- decreased lordosis, increased kyphosis; lateral flexion -Shoulders- shoulder depression, winging & downward rotation -Head/neck- lateral flexion with rotation away form affected side -UE- flexed, adducted, pronated -LE- abduct & ER in sitting; adduct & IR in standing; uneven WB |
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Gait: typical deficits
hip: |
-retracted, flexed; trendelenburg limp ( weak abductors), scissoring (spasticadductors), insufficient pelvic rotation during swing
- weak hip flexors during swing may cause circumduction, external rotation with adduction, backward leaning of trunk, exaggerated flexion synergy |
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Gait: typical deficits
knee: |
weak extensors result in locking of knee, spastic quadriceps also contribute to hyperextended knee
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Gait: typical deficits
ankle: |
foot drop, equinus gait, varus foot, or equinovarus position
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Gait: typical deficits
unequal step length: |
-hemi leg does not advance
-decreased cadence, uneven timing |
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Complications
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Abnormal postures & positioning
̈ Contractures interfere with function, hygiene, limit gait ̈ Spasticity may be reduced via medication Botulinum; dantrolne sodium Shoulder pain; subluxation Respiratory Integumentary |
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Complications (continued)
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CRPS: pain, edema, temperature changes, trophic changes
Increased risk of trauma and falls increased risk of thrombophlebitis pain psychological problems; anxiety, depression, denial |
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Plan of Care
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Functional Assessments
̈ FIM, Fugl-Meyer Functional goals addressing bed mobility, transfers, ambulation, stairs, WC, safety, patient & family ed., discharge planning |
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Goals and Interventions
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̈ prevent or minimize indirect impairments/secondary complications
maintain ROM, prevent deformityn maintain skin integrity avoid traction injuries to arm ̈ Sensory- mirror, thermal, compression ̈ teach compensation strategies for sensory andperceptual losses |
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Goals and Interventions (continued)
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̈ promote awareness, active movement, and use of hemiplegic side
promote normalization of tone through tone reducing activities promote selective movement control of involved extremities, emphasize functional patterns ofmovement |
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Goals and Interventions (continued)
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̈ improve postural control, symmetry and balance
̈ task specific training promote active problem solving independence focus on goal directed tasks, functional mobility skills: rolling, transfers, wheelchair mobility, ambulation focus on adapting movements to specific environmental demands organize feedback inputs (knowledge of results, knowledge of performance) and practice schedules to facilitate learning |
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Goals and Interventions (continued)
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̈ promote independence in ADLs/self care;compensatory training as appropriate
̈ improve respiratory and oromotor function; promote cardiorespiratory endurance improve chest expansion oromotor training exercise conditioning |
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Guidelines to promote learning in the patient with CVA
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left hemisphere lesions (right hemiplegia)
̈ develop an appropriate communication base, words, gestures, pantomime, assess level of understanding ̈ give frequent feedback and support ̈ do not under estimate ability to learn |
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Guidelines to promote learning in the patient with CVA
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*min attention spans right hemisphere lesions (left hemiplegia) ̈ use verbal cues; patient is often confused by gestures and demonstrations due to visuospatial deficits ̈ give frequent feedback, focus on slowing downand controlling movement ̈ focus on safety ̈ avoid environmental/spatial clutter ̈ do not overestimate ability to learn |
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Motor Learning Strategies
Cognitive stage... |
̈ Demonstrate & practice
̈ Part practice vs. whole ̈ Simple cues ̈ Mental practice ̈ Visualization ̈ Self-evaluation ̈ Assist with problem solving *get pt involved! |
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Motor Learning Strategies
Feedback |
̈ Intrinsic
̈ Extrinsic ̈ Visual input ̈ Proprioceptive/WB feedback ̈ EMG |
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Motor Learning Strategies
Practice |
̈ Repetition or blocked practice improves early performance and motivation
̈ Variable practice-performance vs better retention |
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Compensatory Approach
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Indications
̈ to offset or adapt to residual impairments and disabilities Focus is on early resumption of functional independence with reliance on uninvolved segments for function, e.g.: functional training with an individual with complete SCI |
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Compensation
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Changes made in patients overall approach to tasks
̈ patient is made aware of movement deficiencies and provided with alternate ways to accomplish tasks ̈ patient relearns functional patterns and habitual ways of moving ̈ patient practices functional skills in a variety of environments |
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Issues with compensation approach
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focus on uninvolved segments to accomplish daily tasks may suppress recovery and contribute to learned non-use of impaired parts
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Issues
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focus on task specific learning may lead to development of splinter skills in patient with brain damage, skills can't be easily generalized to other tasks or environments
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Issues
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may be only possible approach if:
̈ no additional recovery is anticipated ̈ severe motor deficits are present or is sensorimotor recovery plateaus ̈ patient exhibits extensive co-morbidities |
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Strategies with compensation approach
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simplify the activity
establish new functional patterns; identify key task elements, residual segments valuable for control of movements repeated practice; work toward consistency and efficiency |
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Strategies
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energy conservation and activity pacing techniques are important to ensure completion of all daily movement requirements
adapt environmental to facilitate relearning skills, ease of movement ̈ simplify, set up for optimal performance ̈ use environmental adaptations to enhance performance; color code system, grab bars,etc... |
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Orthotics & AD
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* orthotics are a type of compensation AFO- posterior leaf, solid ankle, hinged ankle; DF limits knee extension; PF limits flexion moment and gives stability WC- hemi height, one-arm drive |
