PTA 253-Test 3 (CVA and TBI)

CVA (cardiovascular accident)

stroke

FAST

Face drooping, Arm weakness, Speech slurred, Time to call 911

age, genetics, gender, HTN, diabetes, obesity, cigarette smoking, high cholesterol, heart disease

risk factors for stroke for CVA patients (9)

1. maximum physical/psychological independence

2. maximize function

3. encourage active participation

4. "give life, not exercise"

goals of stroke rehab

better outcomes

early rehab results in __________

tactile cues, writing gestures, yes or no questions

ways to communicate with acute patients (3)

acute

typically people are doing things for the patient in this phase

work on bed mobility, sitting balance, early transfers, early gait, ROM, positioning, splinting, ADL training

acute phase PT interventions (8)

visual, perceptual

deficits common during acute phase

pt.abilities

interventions in acute PT rehab depends on this

acute rehab phase for CVA patients

starts in the acute care setting, when patient is stable (typically with in 72 hours of stroke)

early mobilization

may decrease learned non-use in CVA patients

first 72 hrs

when acute rehab starts

learned non-use

patient stops using hemiparetic limb because they are not forced to use it

subacute rehab phase

typically happens in the inpatient rehab facility

maximize function, prepare for discharge

goal for subacute rehab

3 hours of therapy, 2 disciplines, 5-6 days/week

minimum patient rehab facility qualifications for attending

return to living

chronic rehab phase goal for CVA patients

things started in the subacute phase

what interventions are done during chronic phase?

flexibility, strength, balance, endurance, progressing HEP

interventions for chronic phase CVA (5)

6 months

when chronic phase rehab starts after stroke

outpatient, home health

where interventions take place in chronic phase rehab

multidisciplinary approach for CVA patients

-PT, OT, ST, case management, doctors, nursing

motor learning

how each of us learn, by reorganizing, adaptation of the brain

the patient

who is at the center of the rehab process?

closed, open

motor learning environments

closed

in patients room; minimal distractions

open

other people around and things going on

task, goal, and learner

three components of motor learning

practice

key factor in learning with scheduled methods or orders

blocked, distributed, variable

3 types of practice

blocked

patient practices the exact same task over and over again for a certain amount of time, no variation of task, focuses on repetitions (we all learn this way)

distributed

patients rest more then they work or practice (1:5)

1:5

ratio of work to rest for distributed practice

variable

patient practice more then 1 task during a tx session- helps to reinforce performance and retention of skills

feedback

key factor in motor learning; intrinsic and extrinsic

extrinsic

external feedback, tactile cues, instructions, mirror, joint approximation, manual contact, tapping, vibration used

extrinsic

should direct to intrinsic info

intrinsic

feedback from within that comes naturally in response to movement

intrinsic

may not be able to pinpoint problem specifically but will in general

intrinsic, extrinsic

two types of feedback

huge

motor learning is a _______ deal in CVA patients

-FITT equation (frequency, intensity, time, type)

dose and progression for motor learning for CVA patients

FITT equation (frequency, intensity, time, type)

manipulating 1 or all of these can drastically change exercise,

FITT equation (frequency, intensity, time, type)

we must monitor patients when one of things are changed

motivation, self-management

work on this with all patient but especially L side stroke patients

feedback

is extremely important for confidence

confidence

picking doable exercises to do first and last in a session with help a pt. develop this

motivation, confidence

2 things a pt. needs to be successful in rehab

posture, balance

problems with these may be delayed, abnormal, or absent after stroke which increases fall risk

COG

posture and balance: release this with weight shifts in sitting and standing

affected leg

weight bearing though this increases sensory awareness, stability and strength

postural stability

is required before distal mobility

balance

assess static sitting and standing, if patient cannot sit unsupported start there, limits of stability (LOS),

posture

asses in sitting and standing, and symmetry

ankles

balance recovery strategies: mild perturbations, work on by standing on rocker board, used with small displacements

stepping

balance recovery strategies: apply very large displacements, use resistance to challenge the patient

hip

balance recovery strategies: larger displacements, larger perturbations, tandem-activities, larger weight shifts

Ipsilateral Pushing "Pusher Syndrome"

unconscious pushing toward the affected side, arms and legs

encourage active weight shift

the only way to correct ipsilateral pushing

shortening

doing this to an AD helps with pushers syndrome

passively correct

you cannot do this for pushers syndrome because they will push harder

orientation

pushers syndrome patients should be talk abut this so they can realize they are not straight and improve weight shift

posture, balance

is affected by contraversive pushing

task specific

used to increase speed and endurance during gait, variation of surfaces and direction to help with AD not fitting through the door, getting in the car, backing to the toilet, timing for community ambulation, work on dual task activity

FES

apply in gait during swing phase (DF most active), contracts anterior tibialis and then goes off during stance phase

swing phase

phase of gait when dorsiflexion is most active

FES

functional E-stim

interventions to improve activity: gait and locomotion (orthotics and wheelchairs)

-orthotics: AFO most common in stroke patients because their DF are weak

-can be set in 5 degrees DF for genu recurvatum to create flexion moment at knee

-can be set in 5 degrees PF for knee buckling to create more extension moment at the knee, helps knee stability during distance

-wheelchairs: hemi-hike seat is 2 inches lowers to allow bilateral LE to help patient ambulate better

upward/downward rotation, protraction, retraction

scapular movements to work on

positioning

used to get the affected limbs out of synergies

external rotation 90 degrees

when abducting shoulder, do this to avoid impingement

self assisted ROM

arm cradle, table top polishing, reaching to floor while seated, supine hand clasped behind head with elbows pressed into the mat (incorporate other things with this)

arm trough

used to protect the limb of CVA patients while they are sitting in a WC

spasticity

velocity dependent muscle tone with increased resistance to stretch

-modalities: prolonged cold (10-20 minutes), slow things down, massage to relax the muscles, ES to fatigue the muscles

-sustained stretching, positioning, (once things are done make sure the arm is extended, abducted, ER, wrist and fingers extended, while sitting and WB on these extremities-sustained stretching)

-if the spasticity has not been addressed the patient will not use the extremity

spasticity

faster and larger the stretch is applied the more resistance is created

descending motor pathways from cortex

what in the brainstem is injured to cause spasticity

upper motor lesions

common cause of spasticity

stimulation techniques

are used to stimulate sensory systems and generate a response

spontaneous movement

interventions to decrease this include WB, manual joint approximation, inflatable splints, joint mobs, ES, hot, cold

therapy ball

sitting on this is great for sensory function

learned non-use

adverse effect of sensory problems; the pt. doesn’t feel the limb or use it

as much as possible

how often should the unaffected side be used in exercise?

arm trough

used on patients Wheel Chair to support arm

arm trough

more appropriate position then the sling

flexion

which UE position is promoted by a sling and can promote contractures

slings

disadvantages: increases risk for contractures, increases flexor tone, teaches patient not to use extremity

slings

advantage: PTA is able to focus on patient rather then limb, reduces stretching the limb by supporting the weight

slings

used to prevent gravitational pull of GH joint, decreases pain and subluxation, protection during gait and transfers, reduces traction injuries

decreased balance and posture, cardiac disease, HTN

precautions for strengthening UE

isometric

watch the pt. carefullly during this exercise to make sure they do not hold their breath

grip problems

a glove can help stoke pt. with this impairment in exercise

subluxation, CRPS, shoulder impingement syndrome, adhesive capsulitis

very common shoulder issues in stroke patients (4)

subluxation

not painful initially with but over time it becomes very painful because all the structures are being pulled down and causing malalignment

shoulder impingement syndrome

happen when the soft tissues of the shoulder become impinged between the head of the humerus, typically when scapulohumeral rhythm is not normal

adhesive capsulitis

patients may develop this if they have spasticity, tightness in ligaments, soft tissue and joint capsule problems

CRPS

starts as intermittent pain in shoulder and progresses to extreme pain, 3 stages

3

how many stages of CRPS?

stage 3

which CRPS stage cannot be reversed?

CRPS stage 3

patients has progressive atrophy, significant osteoporosis, develop claw hand deformity (cannot be reversed)