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Concorde Career College Physical Therapist Assistant. PTA 150: Fundamentals of Treatment II Day 9 & 10 CVA. Objectives. Describe the pathophysiology of a CVA Describe physical and neurological impairments associated with CVA - PowerPoint PPT Presentation
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Concorde Career CollegePhysical Therapist Assistant
PTA 150: Fundamentals of Treatment IIDay 9 & 10
CVA
Concorde Career College
Objectives
Describe the pathophysiology of a CVADescribe physical and neurological impairments
associated with CVADescribe physical therapy treatment interventions
for patients after a CVA
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Cerebrovascular Accident (CVA)
Sudden loss of neurological function caused by an interruption of the
blood flow to the brain
O’Sullivan, pg. 705
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CVA Epidemiology
The 3rd leading cause of death in the USTHE most common cause for disability in US
adultsIncidence of stroke 1.25 times greater for males
than femalesCompared to whites, African-Americans have 2x
the risk of first-ever stroke (higher also with Mexican-Americans, American Indians, and Alaska Natives)
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Definitions
CVA is used interchangeably with the term “stroke”Neurological deficits must remain for > 24 hours to
be classified as a strokeTransient Ischemic Attack (TIA)
Temporary interruption of blood flow to brainSymptoms resolve quickly (within 24 hours)Few if any permanent signs or symptomsPrecursor to strokeAbout 14% of persons surviving an initial stroke or
TIA will experience another one within a year
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Types of Strokes
Hemorrhagic StrokeBlood vessels rupture, blood leaks into the brain1˚ Cerebral Hemorrhage results from ruptured blood
vessels weakened by atherosclerosisResults in ↑ ICP and restricts blood flow to the brainSubarachnoid Hemorrhage (SAH) – bleeding b/w
arachnoid layer and pia mater• Common cause: aneurysm & AVM
Subdural Hemorrhage (SDH) – bleeding b/w dura mater and arachnoid layer• Common cause is trauma
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Types of Strokes
Ischemic StrokeMost common (~80%)A clot blocks or impairs blood flow to the brainCan result from a Thrombosis
• Results from platelet adhesions & aggregation on plaques• Cerebral Thrombosis: Blood clot forms in cerebral artery• Thrombi lead to ischemia = cerebral infarction
Can result from an Embolus• Dislodged matter; blood clot, plaque, fat, gas, air, tissue
that dislodges in the body and travels to the brain occluding cerebral circulation
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Impact
Severity and symptoms of stroke depend on Location of ischemic processSize of the ischemic areaNature & function of structures involvedAvailability of collateral flow
• O’Sullivan , page 708
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Anterior Cerebral Artery Syndrome
Middle Cerebral Artery Syndrome
Posterior Cerebral Artery Syndrome
Vertebrobasilar Artery Syndrome
Internal Carotid Artery Syndrome
Lacunar Syndrome
Vascular SyndromesConcorde Career College
Concorde Career College
Anterior Cerebral Artery (ACA)
Supplies medial part of the frontal and parietal lobe, basal ganglia and corpus callosum
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ACA Syndrome
Contralateral sensory & motor loss with LEs affected more than UEs
Urinary incontinenceMental impairment (confusion, amnesia)Apraxia affecting ability to imitate or perform
bimanual tasksAbulia (lack of desire to carry out an action),
slowness, delayed movements, lack of spontaneous movements
Behavioral changes
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Medial Cerebral Artery (MCA)
Supplies lateral cerebral hemispheres (incl. frontal, parietal and temporal lobes)
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MCA Syndrome
Contralateral hemiparesis of face and UE mainlyPure motor hemiplegia (lacunar stroke)Contralateral hemisensory loss of face & UE mainlySpeech impairment: Broca’s aphasia, Wernicke’s
aphasia, global aphasisPerceptual deficits: unilateral neglect, depth
perception difficulties, agnosiaApraxiaAtaxia of contralateral limbs (sensory ataxia)Contralateral hemianopsiaTable 18.2 (O’Sullivan)
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Posterior Cerebral Artery (PCA)
Supplies occipital lobe, medial and inferior temporal lobe, thalamus & brain
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PCA Syndrome
Contralateral sensory & motor loss (hemianesthesia)HemianopsiaVisual agnosia, prosopagnosia and cortical
blindnessOculomotor nerve palsyInvoluntary movement
Choreoathetosis, intention tremor, hemiballismusThalamic pain Pusher syndrome
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Hemiballismus - Video
http://www.bing.com/videos/search?q=hemiballismus&view=detail&mid=290D280B1B53C5E9CDEB290D280B1B53C5E9CDEB&first=0&FORM=LKVR
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Vertebrobasilar Artery
Vertebral artery arises from the subclavian artery, travels into the brain and then merge to form the basilar artery
Vertebral artery supplies the cerebellum and medulla
Basilar artery supplies the pons, internal ear, and cerebellum
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Vertebrobasilar Artery Syndrome
Wide variety of symptoms with ipsilateral and contralateral signs
Numerous cerebellar and cranial nerve abnormalities
Refer to Table 18.4 in O’Sullivan for details
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Internal Carotid Artery (ACA) Syndrome
Supplies both the MCA and ACAComplete occlusion leads to ↑↑ cerebral edema =
coma & possible deathIncomplete occlusion = mix of ACA & MCA
syndromes
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Lacunar Infarct
Caused by small vessel disease deep in cerebral white matter
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Lacunar Syndrome
Contralateral weaknessSensory lossDystonia/Involuntary movement
Choreoathetosis, hemiballismusAtaxia
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CVA – Major Risk Factors
AtherosclerosisHTNHeart diseaseDiabetesSmokingTIA
ObesityHypercholesteremiaPhysical Inactivity↑ Alcohol consumption
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Stroke Warning Signs
TIME IS BRAINSudden numbness or weakness of the face, arm
or leg, especially on one side of the bodySudden confusion, trouble speaking or
understandingSudden trouble seeing in one or both eyesSudden trouble walking, dizziness, loss of balance
or coordinationSudden, severe headache with no known cause
www.StrokeAssociation.org
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Imaging - CT
Frontal lobe stroke
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Imaging - MRI
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CVA Medical Management
Reestablish cerebral circulation and oxygenationControl blood pressureMaintain sufficient cardiac outputRestore/maintain fluid & electrolyte balanceMaintain blood glucose levelsControl ICPMaintain bladder function (possible use of
catheter)Maintain integrity of skin and joints
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Pharmacological Management
Anticoagulants (heparin, coumadin); to reduce clots and maintain profusion)
Antiplatelets (aspirin); used to decrease the risk of recurrent stroke
Antihypertensives
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Surgical Intervention
Endarterectomy – surgical removal of lining and plaque in an arteryUsed to prevent strokes (not treat them)
In the case of hemorrhage – surgery to repair rupture, prevent further bleeding evacuate the clot
Resection of unruptured AVM if found and risk is high
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Primary Impairments
Sensation Impairments↓ sensory perception & ability to process sensory
information• Touch, temperature, position, kinesthetic, pain• ASTEROGNOSIS
• The inability to identify an object by touch without visual input
PainCan experience severe headaches, neck or facial
painCentral post-stroke (thalamic) pain: constant, severe
burning with intermittent sharp painsConcorde Career College
Primary Impairments
Visual ImpairmentsEye movements (sluggish, reflexive, ataxic)Hemianopsia: Blindness in half of each eye’s visual
field (loss on the nasal side and half on temple side)Visual neglectDifficulties w/ depth perception & spatial
relationshipsForced gaze deviationBrainstem strokes may result in diplopia, oscillopsia
or visual distortions
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Primary Impairments
Motor Impairments – Stages of Motor Recovery
Stage 1 - FlaccidityStage 2 - Minimal voluntary movement; may see
synergies and spasticity developStage 3 – Voluntary control the movement
synergies; spasticity may ↑ further
(Continued)
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Primary Impairments
Motor Impairments – Stages of Motor Recovery
Stage 4 – movement combinations that do not follow the path of synergy are mastered; spasticity ↓
Stage 5 – Difficult movement combinations are learned
Stage 6 – disappearance of spasticity, individual joint movements become possible and coordination approaches normal
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Primary Impairments
Motor ImpairmentsWeakness (paresis)
• Occurs in 80-90% of all patients after stroke• Varies depending on location and size of stroke• Can result in complete paralysis/hemiparesis• Typically, more distal muscles exhibit greater weakness• May even see weakness on the “normal” side• Changes in muscle composition 2˚ weakness & disuse
• Atrophy, ↓ Fast twitch type II, ↑ slow twitch type I
• ↑ effort and fatigability
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Primary Impairments
Motor ImpairmentsChanges in tone
• Flaccidity – present immediately as a result of cerebral shock; usually short-lived but sometimes persists
• Spasticity/hypertonicity• Occurs in about 90% of patients after stroke
• Posturing of limbs is common with mod → severe spasticity
• Spasms (internal or external stimulation)
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Posturing
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Primary Impairments
Motor ImpairmentsAbnormal synergistic movement patterns
• Associated with spasticity, may ↓ with recovery• Review Table 18.5 in O’Sullivan
Impaired reflex responses (mild to severe)• Vary according to stage of recovery
• Hyporeflexia with flaccidity → hyperreflexia with spasticity
• ↑ stretch reflex – clonus, clasp-knife, (+) Babinski• ATNR• Associated reactions
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Primary Impairments
Motor ImpairmentsImpaired coordination responses
• Cerebellar strokes = ataxia & weakness• Basal Ganglia involvement = slow movements
(bradykinesia) & involuntary movements (choreoathetosis, hemiballismus)
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Video - Cerebellar Ataxia
http://www.bing.com/videos/search?q=cerebellar+ataxia&view=detail&mid=F8130C8EBA0E3DD338C5F8130C8EBA0E3DD338C5&first=1&FORM=LKVR3
http://www.bing.com/videos/search?q=cerebellar+ataxia&view=detail&mid=08E8A16F23E5E860EE9008E8A16F23E5E860EE90&first=21&FORM=LKVR18
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Primary Impairments
Motor ImpairmentsAltered motor programming
• Motor praxis• Ideational apraxia • Ideomotor apraxia
Diminished muscle performance for ADL• Strength, Power, Endurance
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Primary Impairments
Postural Control & Balance ImpairmentsMay experience difficulty with balance 2˚ to an
external force or during self-initiated exercises• Corrective responses to perturbations are often
inadequate = fallAsymmetry typically noted in posture
• Typically see falls to the same side as weaknessPusher Syndrome
• Active pushing of the uninvolved side offsets muscle control of the involved side (falls, leaning)
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Primary Impairments
Speech and Language ImpairmentsAphasia – an acquired communication disorder
caused by brain damage and is characterized by an impairment of language comprehension, formulation and use. (O’Sullivan, pg. 722)
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Primary Impairments
Speech and Language ImpairmentsReceptive Aphasia
• aka. Wernicke’s/Sensory/Fluent Aphasia • Auditory and reading comprehension impaired• Speech is functional
Expressive Aphasia• aka. Broca’s/Nonfluent Aphasia• Difficulty finding words to express ideas
Global Aphasia• Receptive and Expressive
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Primary Impairments
Speech and Language ImpairmentsDysarthria
• Nasal quality of speech, slurred wordsDysphonia
• Difficulty producing soundsDysphagia
• Difficulty in swallowing
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Primary Impairments
Altered PerceptionBody scheme – relationship of body parts to one
another as well as the body’s relationship to the environment
Body image – visual and mental image of one’s body may be altered following a stroke• Includes the individual’s feelings about this image
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Primary Impairments
Examples of body scheme/image impairments:Unilateral Neglect
• Visual recognition or attention on involved side• Limb neglect or attention on involved side
Anosognosia – denial, neglect or unawareness of one’s paralysis
Somatoagnosia – lack of awareness of one’s body structure and its relationship to the environment
Right-left discriminationFinger agnosia
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Primary Impairments
Altered PerceptionAgnosia - inability to recognize incoming information
despite intact sensory capabilities (O’Sullivan, pg 723)
• Visual object agnosia• Auditory agnosia• Tactile agnosia (astereoagnosia)Spatial relationship – difficulty determining the
relationship between the body and 2 or more objects in the environment
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Primary Impairments
Cognitive Impairments↓ alertness↓ attentionAltered orientationDiminished memoryImpaired executive function
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Primary Impairments
Cognitive Impairments – VocabularyConfabulationPerseverationMulti-infarct dementiaDelirium
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Primary Impairments
Alterations in AffectPseudobulbar Affect
• A.k.a. emotional dysregulation syndrome or emotional lability
• Emotional outbursts (crying, laughing)ApathyEuphoria↑ irritability or frustrationSocial inappropriatenessDepression
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Primary Impairments
Bladder and Bowel FunctionCommon during acute phaseOften implement a toileting scheduleUrinary retention controlled with catheterizationCan often lead to embarrassment, isolation or
depression
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Primary Impairments
Hemispheric Behavioral DifferencesLeft Hemispheric Damage
• Difficulties in communication• Difficulty with processing information• Cautious, anxious, disorganized• Often very aware of impairments
Right Hemispheric Damage• Difficulty in spatial-perceptual tasks• Difficulty with grasping overall idea of task or activity• Quick, impulsive• Overestimate their abilities, poor judgment
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General Characteristics of CVA
Right Hemisphere CVALeft side weakness or paralysisHemianopsiaDecreased awareness and judgmentMemory deficitsInattention and less reasoningEmotional labile Impulsive behaviors
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Characteristics of CVA
Left Hemisphere CVARight side weaknessAphasiaMotor ApraxiaDysphagiaHemianopsia
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Complications & 2˚ Impairments
MusculoskeletalLoss of ROM & ContracturesEdema & painDisuse atrophy & weaknessOsteoporosis
• Fall risk
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Complications & 2˚ Impairments
NeurologicalSeizuresHydrocephalus – an excessive accumulation of CSF
within the cranial cavity
CardiovascularThrombophlebitis/DVTImpaired Cardiac Function
• Impaired cardiac output, decompensation, rhythm disorders
• Can restrict exercise/activity toleranceConcorde Career College
Complications & 2˚ Impairments
PulmonaryDecreased lung volumeDecreased pulmonary perfusion & vital capacityAltered chest wall excursionGreater energy expenditureAspiration
IntegumentarySkin breakdown and decubitis ulcer
• Pressure, friction, shearingConcorde Career College
Rehabilitation after Stroke
The Role of the PT & PTA
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Acute Phase
Lo-intensity therapy can begin once stabilized medically.Early mobilization
Minimize deconditioningFunctional reorganization is promotedLearned nonuse is minimized
Reinforce a positive outlookDecreased incidence of depression, apathy and mental
deteriorationEarly presentation of rehabilitation planMonitor for potential medical emergencies!Average hospital stay is about 7 days
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Post-Acute Phase
TriageInpatient rehabilitation, TCU, SNF
What other services may be involved with the patient at this time?
Progression to home care, outpatient PTAssisting with return to work, recreation, social
activities
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PT Examination
Patient historyLevels of
ConsciousnessCommunicationCognitive, emotional
and behavioral statesCranial Nerve IntegritySensory IntegrityPerceptionTone/Reflexes
Joint Integrity & Mobility
Voluntary Movement patterns
StrengthPostural control &
balanceAmbulation &
Functional mobilityFunctional status
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Gait after a Stroke
The PTA AssessmentConcorde Career College
VIDEO
http://www.youtube.com/watch?v=YMzVywpbNes&feature=related
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Gait after Stroke
Important to look at movements occurring at the ankle, foot, knee, hip, pelvis, trunk and UEs.
Observe the different planes of motion Quantitative measures include distance, time,
cadence, velocity, and stride timesWhat type of AD may be necessary?May consider videotaping
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Trunk/Pelvis
Stance PhaseForward trunk 2˚
• Weak hip extension• Flexion contracture
Swing Phase↓ forward pelvic rotation 2˚
• Weak abdominal mmLeaning towards the stronger side to clear the
weaker side foot from the floor OR Backward leaning of trunk
• Both may be due to weak hip flexors
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Hip
Substitutions as a result of inadequate hip flexion:Hip hiking
• Weak abdominal mm and inadequate knee flexion may also contribute to this
Circumduction• ↑ extensor tone, ↑ PF tone or foot drop as well as
inadequate knee flexion may also contribute to thisExternal rotation/adduction
May see the opposite, exaggerated hip flexion• Flexor synergy
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Knee
Stance PhaseExcessive knee flexion 2˚
• Flaccid or weak LE, especially hip & knee extensors• Poor PPC• Flexion contracture• Ankle DF range past neutral
Hyperextension of knee 2˚• ↑ extensor tone of LE• Quadricep spasticity• Weakness of gluteus maximus, hamstrings and quads• PF contracture past 90˚• Impaired PPC
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Knee
Swing Phase↓ Knee flexion 2 ˚
• ↑ LE extensor tone, spastic quadriceps• Inadequate hip flexion and poor foot clearance• Circumduction or hiking pattern often seen as a result
Exaggerated, delayed knee flexion 2˚• Strong flexor synergy
Inadequate knee extension at initial stance 2˚• Spastic hamstrings• Sustained total flexor pattern• Weak knee extensors
Ankle/Foot
Stance PhaseEquinus gait – heel does not touch down
• Spastic or contracture of gastrocnemiusVarus foot – weight is on the lateral side of the foot
• Spastic tibialis anterior, posterior tibialis, toe flexors, soleus
Unequal step length• Hammer toes can cause pain with WB and prevent a full
step forward with opposite leg• Increased flexor tone in toe muscles
• Lack of DF ROM on affected side
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Ankle/Foot
Swing PhasePersistent equinus or varus or a combination of the 2
(equinovarus)• Weak dorsiflexors may contribute to this in addition to
spastic musclesExaggerated DF 2˚ strong flexor synergy pattern
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Intervention
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Strategies to Improve Sensory Function
Encourage use of the affected side!!Training should focus on functional tasksExamples:
Stroking skin with various fabricsDrawing shapes, letters onto the skin of affected sideApproximationInflatable pressure splints
Patient and family/caregivers must be educated on impairments as well as safety measures to protect the involved limbs
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Strategies to Improve Sensory Function
With unilateral neglect, incorporate strategies that encourage awareness and use of the body on the involved sideVisual scanningCueing (visual, verbal or motor cues)ImageryVisual focus on the affected arm or leg during activityBilateral tasksTactile input given by the therapist to the involved
limbPatient may require reorientation
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Strategies to Improve Flexibility and Joint Integrity
Early ROM dailyUE
PROM of shoulder important for reaching and overhead movements• Careful attention to mobilize the scapula on the thoracic
wall, maintain upward rotation and protractionMaintain full elbow extension, wrist and finger ROM
Self UE ROM may include arm cradling, table-top polishing, supine AAROM with intact UE clasping the affected UE
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Strategies to Improve Flexibility and Joint Integrity
Effective UE positioning is importantLap tray or arm trough5˚ shoulder ABD & FLEX, neutral rotation, 90˚elbow
FLEX & slightly forward, forearm pronated, functional hand position
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Strategies to Improve Flexibility and Joint Integrity
Volar resting (pan) splintFunctional20-30˚ wrist extension40-45˚ MP flexion10-20˚ IP flexionThumb opposition
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Strategies to Improve Flexibility & Joint Integrity
LE ROMOften see limited ankle DF
• Incorporate weight bearing encouraging DF by performing forward weight shifts or using adaptive equipment (tilt board, foot rocker)
Pay careful attention to hip flexor and knee flexion contraction with prolonged sitting in wheelchair
ROM in opposition to spasticity (if present) should also be performed daily
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Strategies to Improve Strength
<3/5 StrengthTherapist assisted exercisePowder boardSling suspensionAquatic Exercise
3/5 StrengthGravity resisted exercises
>3/5 StrengthFree weightsBandsMachines
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Strategies to ImproveStrength
Important to combine strengthening and functionWearing ankle weights while performing step ups or
stair climbingReaching exercises while wearing wrist weights
• Secondary postural stabilization occurs with this type of exercise
Resisted walking with Theraband taut at waist levelSit to stand with resistance given at shoulders by
therapist
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Strategies to ImproveStrength
Safe Exercise PrescriptionExercise is contraindicated with HTN & recent strokeWith HTN – avoid high-intensity & isometric
exercises• Concentric & eccentric exercises are less stressful for
the cardiovascular system• Sitting exercises less risk for increasing blood pressure
as compared to supine exercisesProper warm-up & cool down are important, better to
begin with LE exercises first
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Strategies to ImproveStrength
Need to carefully monitor:BPHRRate of Perceived Exertion (RPE)Breathing (avoid breath holding & Valsalva)
Patient needs to be educated to monitor HR and RPE as well as warning signs to stop exercises
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Strategies to Manage Spasticity
Early mobilizationProlonged stretchingExamples:
Rhythmic rotationSlow rocking movements over limb in an elongated,
weight bearing positionPNF upper trunk patterns can ↓ trunk tone
Activation of the antagonist muscles using slow & controlled movementsMay need to use facilitation techniques
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Strategies to Manage Spasticity
Modalities to reduce spasticityCold (ice wraps, ice packs)Estim to the antagonistVibration
May incorporate air splintsCan use soothing verbal commands/relaxation
techniques or imagery
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Strategies to Improve Initial Movement
Initially focus on normal postural alignment as well as control and functional use of extremities
Strategies should address dissociation and selective (out-of-synergy) movement patterns
Reinforce slow, controlled, “normal” movementsMay progress postures to optimize movements
Example: shoulder flexion in supine, sitting and then standing
Assistance may initially be provided but then progress to active, independent movements
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Strategies to ImproveInitial Movement Control
When addressing function, consider practicing eccentric contractions before concentricEccentric contraction are more efficient
Can gradually progress to a variety of activities that use all 3 types of contractions
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Strategies to ImproveMotor Learning
Strategy DevelopmentCritical tasks, goals and outcomes are identifiedBegin practice, may practice components of the task
before practice of the whole taskImportant to move towards whole task to allow for
transfer of learningPracticing with less affected side first may also assist
with transfer effectsClear, simple verbal instruction should be givenPatient needs to be active in problem solving
• i.e., Can the patient identify components performed incorrectly
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Strategies to ImproveMotor Learning
FeedbackCan be extrinsic or intrinsicDuring early motor learning, more likely to use
extrinsic feedback• Mirrors, verbal cues or manual cueing from therapist
Patient’s attention should be geared towards recognizing intrinsic and developed more as therapy progresses• Patient should “feel the movement”
Important to avoid bombardment of feedback and limit immediate feedback
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Strategies to ImproveMotor Learning
Practice, Practice and more PracticeMay initially be limited by enduranceNeed to encourage variable practice in order to
progressEnsure the environment is conducive to learning
• Eventually can progress to a more open, real-life environment
Motivation is important• Patient should be involved in goal setting• Treatment session should be positive• Therapist needs to be a support system, encouraging
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Strategies to Improve Postural Control & Functional Mobility
RollingPractice rolling to both sidesRolling to affected side more difficultClasp hands together to assist with momentum and
use of the affected UECan bend the LE’s to assist with pushing overSidelying on affected side promotes WB of the
affected UE
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Strategies to Improve Postural Control & Functional Mobility
Sit to Supine/Supine to SitImportant to practice towards both sidesWill likely be easier to perform from non-involved
sideTherapist may initially facilitate/assist movements
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Strategies to Improve Postural Control & Functional Mobility
SittingInitially looking for symmetrical posture with proper
spinal alignmentEarly sitting may involve therapist cueing (tactile &/or
verbal) May use UE’s initially to maintain sitting postureProgress to no UE support, weight shifting, truncal
motions, PNF patterns, reaching/dynamic activities, perturbations, scooting
Progression may then include these same activities while sitting on a ball
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Strategies to Improve Postural Control & Functional Mobility
BridgingDevelops hip and trunk extensor control as well as
LE selective control & early LE WBCan progress from performing the exercise, holding
the position and then performing dynamic activities within the posture
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Strategies to Improve Postural Control & Functional Mobility
Sit to Stand (STS)Focus on symmetrical WB, coordination & timing(Demonstration of proper sit to stand)Strategies to initiate STS:
• Clasp hands or reaching forward with UE’s• Place pt hands on ball while therapist stabilizes ball but
then move ball forward to promote anterior weight shift• Raise the mat height• Place stronger foot slightly behind the weaker
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Strategies to Improve Postural Control & Functional Mobility
Sit Down TransfersStrategies to promote controlled sit down include:
• Partial wall squats• Varying mat height• Lateral pelvic shifts to involved side and alternate
sit/stand
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Strategies to Improve Postural Control & Functional Mobility
Standing, Modified PlantigradeStanding with affected UE extended and in
weightbearing position, LE also extendedAssists with development of postural and extremity
controlVery stable positionCan progress from static standing to movement and
reaching activities
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Strategies to Improve Postural Control & Functional Mobility
StandingInitially standing can occur in parallel bars or at
bedside with assistProgression can include:
• 2 hand support → 1 hand support → free standing• Static standing → weight shift → dynamic (reaching,
stepping) → perturbations/rhythmic stabilizationFocus on proper alignment and symmetry
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Strategies to Improve Postural Control & Functional Mobility
TransfersNeed to practice transfers to both sidesImportant to support the weaker kneeVary surfaces and surface heightsMay progress from squat-pivot to stand-pivot
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Strategies to Improve Postural Control & Functional Mobility
Pusher SyndromeFocus is on the verticalCan use mirrors, the wall, a ball, or even the
therapist to assist with active, appropriate shifting rather than pushing
Ask the patient, “Which way are you leaning?”; “Which direction should you move to be vertical?”
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Strategies to Improve UE Function
UE as a Postural SupportExtended UE weightbearing promotes proximal
stabilization and counteracts flexion synergy, hypertonus
Approximation can stimulate shoulder girdle stabilization and elbow extensors
Can perform in sitting, modified plantigrade, standing and quadruped
Progress from holding the position to more dynamic activities
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Strategies to Improve UE Function
ReachingCan begin with positions which eliminate gravity
• Sidelying, tabletop assist, “dusting” with washcloth, reaching down to touch the floor
• May also need therapist assistProgress to anti-gravity activitesCombine with balance & functional activitiesVary height/distance to reach, weight of object
grasped, time to complete the taskAvoid substitution
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Strategies to Improve UE Function
Manipulation & DexterityInitial tasks usually involve more gross grasp and
releaseCan begin by using affected hand to stabilize while
performing a task with stronger handProgress to bilateral activities, emphasize
function/ADLsInclude reaching activitiesBuild-ups for items such as forks, toothbrush, pens
can improve independence and efficiency
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Strategies to Improve UE Function
Enhanced Training ActivitiesBilateral arm training w/ rhythmic auditory cueing
(BATRAC)http://www.youtube.com/watch?v=dy2qzvDa-Fc
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Strategies to Improve UE Function
Enhanced Training ActivitiesConstrain-Induced Movement Therapy (CIMT)Electromyographic Feeback (EMG-BFB)Neuromuscular Electrical Stimulation (NMES)
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Strategies to Improve UE Function
Management of Shoulder PainCommon complication post stroke In the case of flaccidity, arm needs support at all timesProper arm support is essential
Scapula/shoulder protracted, arm forward in slight ABD and neutral ROT
↓ subluxation – NMES, supportive devices↓ Pain, normalize tone – gentle stretching & mobilization,
cryotherapy, EMG BFB, relaxation trainingAdhesive capsulitis treated with mobilization, PROM and
ultrasoundAvoid trauma or traction injuries with functional mobility
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Strategies to Improve UE Function
Supportive DevicesSlings
Pros and Cons
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Strategies to Improve UE Function
Supportive Devices (Gillen)Consider using slings only with initial transfer and
gait trainingDetermine whether a sling that places the arm in
flexion is really necessary, if so consider wearing only for short periods of time
Selection of a sling is on an individual basisConsider alternatives: NMES, taping, hand in
pocket/belt, lap tray
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Strategies to ImproveLE Function
Necessary to prepare for appropriate gaitHelpful to start with improving pelvic control
Can practice forward pelvic rotation in sidelying, supine, hooklying, kneeling, sitting on ball, standing
Break synergistic patternsExample: hip extension is paired with knee flexion to
allow toe-off during terminal stance/pre-swingActivities to promote this include: bridging, supine
hip extension with knee flexed and heel pressing into the floor or standing and repeatedly practicing this phase of walking
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Strategies to ImproveLE Function
Avoiding hyperextension of the kneeActivities to promote this
control include: controlled heel slides in supine and sitting, partial wall squats, controlled flexion and extension of knee on leg press, terminal knee extension exercises with Theraband in standing
Concorde Career College
Strategies to ImproveLE Function
Important to progress activities by modifying postures
Example:Supine → Sitting → Kneeling → Standing
And… emphasize reduction of synergistic patterns
Concorde Career College
Strategies to ImproveBalance
Important to select appropriate exercises, challenging to the patient but does not compromise safety
Must first achieve postural alignment and static stability in upright postures
Can then progress to exploring limits of stabilityWeight shiftingEncouraging symmetrical weight bearingEncouraging weight bearing to more affected side
Concorde Career College
Strategies to ImproveBalance
Examples: Vary the BOSVary the support surfaceVary sensory inputsVary UE position/supportVary UE movementVary LE movementVary trunk movementsIncorporate dynamic functional activitiesIncorporate dual tasksChange the environment
Concorde Career College
Strategies to ImproveBalance
StrategiesAnkle
• Small A/P weight shifting or small perturbations• Standing on rocker board, foam roller, dynadisc
Hip • Larger A/P weight shifts or perturbations• Tandem stance promote medial-lateral strategies
• Standing on floor or foam roller
Stepping• Displacement of COM in all directions• Therapist can apply a band around waist• Step ups
Concorde Career College
Strategies to Improve Balance
Need full attention from patient (and therapist!)Provide well-timed feedbackMinimize hand supportEncourage active problem-solvingSafety education must be included
Concorde Career College
Strategies to Improve Locomotion
Gait trainingInitially parallel bars & assistive
devices can be used• Pros & Cons
Important to progress patient to least restrictive device or no device as able
Want to encourage even, longer step length and increased time• May use rhythmic auditory cues OR• Markers on the floor with tape
Concorde Career College
Strategies to ImproveLocomotion
Look at each phase of gaitStance Phase
• Initial weight acceptance• Midstance control• Forward weight advancement
Swing Phase• Knee and foot control for toe clearance• Foot placement
UE posturing
Concorde Career College
Strategies to Improve Locomotion
Vary the environmentCommunity walking, hiking trails, hills
Practice walking in all directionsForward, backward, sideways
Practice cross-steppingInclude stairs, curbs, step-over-stepInclude timing activities
Crossing the street, using escalators, elevators and automatic doors
Concorde Career College
Strategies to Improve Locomotion
Practice dual-task activitiesTalking, bouncing a ball, carrying a tray
Incorporate balance activitiesTandem walking, walking on foam/gravel/grass
Treadmills, cycle ergometersThese tools may assist with improving time and
reciprocity of the LEs
Concorde Career College
Strategies to ImproveLocomotion
Body weight support systems
Limb load monitorsNMES to improve ankle DF
Concorde Career College
Strategies to ImproveLocomotion
Orthotics AFO Knee Controls
Concorde Career College
Strategies to ImproveLocomotion
WheelchairsAppropriate positionTypes:
• Hemi-height wheelchair (Seat to floor height is 17.5”)• One arm drive chair• Power wheelchair
Training activities• Proper use, maintenance and safety• Methods of propulsion• Level and varied surfaces• Transfers
Concorde Career College
Strategies to ImproveAerobic Function
Initial Phase: functional activities are sufficientPost-Acute Phase: may progress to treadmill,
stationary bicycleCarefully monitor VS & symptoms of exertional
intolerance, impending stroke or heart attackChoose method based on patient’s interestSuggested frequency is 3X/week for 20-60 minutes
May be daily at lower intensitiesRecommend starting with intermittent training and
progressing to continuous 30 minutes of exerciseConcorde Career College
Questions
Concorde Career College