Neuro Rehab - CVA & Neuroplasticity

A condition that affects the blood vessels supplying blood to the brain

Stroke

2 major types of stroke?

Ischemic and hemorrhagic

A clot blocks BF to an area of the brain

Ischemic stroke

Bleeding occurs inside or around the brain

Hemorrhagic stroke

3 hemorrhagic stroke types

Subdural, subarachnoid, and intracerebral

3 types of ischemic stroke

Thrombotic, embolic, and systemic hypoperfusion

What are factors may suggest a hemorrhagic stroke?

Age

What factors are associated with ischemic stroke?

CAD, prior CVA, and prior TIA

What is an important first step in emergent ischemic stroke management?

Early imaging, particularly CT, to help determine the type of stroke and guide treatment

What are key components of emergent ischemic CVA management?

Stroke awareness

EMS management

ER evaluation

Early CT imaging

Decision regarding thrombolysis

Acute Medical Management- Ischemic CVA

IV Thrombolysis

Endovascular procedures

Antiplatelet Therapy

BP management and supportive care

tPA to dissolve blood clots within ________ hours of symptom onset

3 - 4.5

If tPA admin, BP must be below ________

180/105 mm HG

Secondary Prevention & Long-term Medical Management - Ischemic CVA

Antithrombotic regimens

Vascular Risk factor control

Rehabilitation

Acute Medical Management - Hemorrhagic CVA

Blood pressure reduction

Reversal of anticoagulation

Surgical and procedural interventions

What is the typical acute-care length of stay after ischemic stroke?

5-7 days

What is the focus of acute care after stroke?

Medical stabilization, diagnosis of the type/severity of stroke, and planning for the next phase of care

What is the typical inpatient rehabilitation length of stay?

1-3 weeks, with an average of 12-16 days

What is the focus of inpatient rehabilitation?

Intensive therapy—at least 3 hours/day, 5-7 days/week

What is the typical SNF/subacute rehabilitation length of stay?

3-5 weeks, with an average of 30-32 days

Who may benefit from SNF/subacute rehabilitation?

Patients unable to tolerate intensive PT

What is the typical amount of therapy in SNF/subacute rehabilitation?

1-2 hours/day

What is the typical LTACH length of stay?

25 days or longer

What is the focus of LTACH?

Extended medical management and slow-paced rehabilitation for patients with severe medical complications or complex chronic needs

How long may outpatient/home health therapy continue?

Several weeks to months

What is the focus of outpatient/home health therapy?

Ongoing functional gains and community reintegration once home

Common Impairments Associated with CVA - UMN lesion S/S

Abnormal tone

Paresis

Reflexes - DTR's, ATNR, STNR

Decreased endurance

Altered mm activation patterns

Abnormal balance

Deficits in motor planning - apraxia

Impaired sensation

Decreased fractionation

Associated reactions

What is the general pattern of motor recovery after stroke?

Predictable sequential patterns

What happens to tone throughout typical stroke recovery?

Flaccidity initially → hypertonicity → normalized tone

What characterizes Stage 1 of Brunnstrom recovery?

Flaccidity with no active limb movement; cortical shock

What characterizes Stage 2?

Beginning of minimal voluntary movement, movement in synergy, associated reactions, and increased tone

What characterizes Stage 3?

Voluntary control of movement within synergy with maximal spasticity

What characterizes Stage 4?

Movement outside of synergy with decreased tone

What characterizes Stage 5?

Increased complex movement with further decreased tone

What characterizes Stage 6

Voluntary control of movement outside of synergy with further changes toward normalized tone

Synergy Patterns of the Extremities

Upper Extremity — Flexion Synergy

Scapular retraction + elevation OR hyperextension

Shoulder ABDuction, ER

Elbow flexion

Forearm supination

Wrist and finger flexion

Upper Extremity — Extension Synergy

Scapular protraction

Shoulder adduction + internal rotation

Elbow extension

Forearm pronation

Wrist and finger flexion

Lower Extremity — Flexion Synergy

Hip flexion + abduction + external rotation

Knee flexion

Ankle dorsiflexion + inversion

Toe dorsiflexion

Lower Extremity — Extension Synergy

Hip extension + adduction + internal rotation

Knee extension

Ankle plantarflexion + inversion

Toe plantarflexion

What are the 3 requirements for normal coordinated movement?

1. Proper muscles must be selected.

2. Selected muscles must be activated/inactivated in the proper sequence and at the correct time.

3. Muscles must be activated with the correct amount of tension

During a CVA exam, what is done first?

FMTA's

-Dep/Indep

-Static - ability to maintain symmetrical posture

-Dynamic - Ability to move out of the position

WS

Stability

Mobility

Dissociate

CVA exam - Strategy Assessment

Movement Continuum

Awareness/ ability to process sensory info

Adapt and change mov't/position

Motor Control strategies

Variance from normal

-Compensate

-Incorporate involved extremities

-Associate reax

During a CVA exam, what is done last?

Impairment Assessment - Any impairment that impacts strategy selection for an FMTA; Includes the neuro exam

When do you use compensation in PT intervention?

Permanent, unchanging impairments

Poor functional ability with little potential

Nature of the lesion - Dynamic (progressive) (e.g., ALS, MS, PD); Static (e.g., stroke, SCI)

Acute care setting limitations

When do you use recovery in PT intervention?

Temporary or changing impairments

Fair functional ability or has recovery potential

Nature of the lesion - Dynamic or Static

Rehab or subacute setting

Compensation examples

Toilet seat cushion

PROM

Sling use

Recovery examples

Swallowing/feeding

Walker

AROM

The tendency of the brain to shape itself according to experience; it is the potential to change

Neuroplasticity

The CNS can be thought of as a homeostatic balance between what two concepts?

Stability and plasticity

What is an example of stability?

Personality

What is an example of plasticity?

Learning, including motor learning

How does the adult brain differ from the developing brain?

Has greater stability and less capability for large-scale restructuring while the developing brain has less stability and greater ability for large-scale restructuring

What are the two major levels of plasticity?

Cellular level and systems level

What structures can change at the cellular level?

Neuronal structures such as dendrites and axons

What occurs at the systems level of plasticity?

Changes in neuronal network efficiency/flexibility and cortical representation

What can plasticity of the intact adult brain allow a person to do?

Learn new skills throughout life

What electrical properties can change during neural plasticity?

Excitability and synaptic efficacy

What can happen to synaptic efficacy?

It can increase through facilitation or decrease through inhibition/depression

What does long-term potentiation (LTP) do?

Enhances synapses that are repeatedly activated

What does long-term depression (LTD) do?

Diminishes synapses that are comparatively less active

What happens to synaptic effectiveness with practice?

Repeated activation improves synaptic effectiveness

What happens to the number of effective synapses with practice?

Inc

What can happen to silent synapses with practice?

Converge/become active synapses

What structural changes can occur as mechanisms of plasticity?

Changes in synapses, axon branches, dendritic branches, and new neurons

Where does new neurons occur?

Hippocampus and olfactory bulb

Representation of different body regions in organized areas of the CNS/cortex

Somatotopic Representation

Where is somatotopic representation found?

Throughout the CNS

Two examples of cortical somatotopic maps

Sensory and motor homunculi

Why do certain body parts have disproportionately large cortical representations?

Increased use is associated with increased cortical representation

What is cortical reorganization based on?

Use-dependent plasticity

What relationship exists between neural events and motor behavior?

It is a two-way street: structure and function influence each other

What happens to cortical representation when dexterity or sensory discrimination increases?

Greater dexterity or discrimination is associated with greater cortical representation

What happens when the CNS is damaged?

Primary cell death

Secondary cell death

-Transsynaptic degeneration

-Transneuronal degeneration

Edema

Glial cell reaction

Central core of ischemic area

Blood flow deficits, dec ATP, ionic disruption, metabolic failure

What mechanisms may contribute to active cell death in the penumbra?

Excitotoxicity, ionic imbalance, oxidative stress, apoptosis

Suppression of remote cortical tissue

Diaschisis

What neurotransmitter-related changes occur with diaschisis?

Alterations in neurotransmitter regulation, including GABA and glutamate

Cortical reorganization occurs in _____ hemispheres

BOTH

What may increase on the lesion side during cortical reorganization?

Dec excitability of MC

Dec map representation of affected parts

Inc MC, PMC, SMC activation Axonal sprouting

Synaptogenesis

Enlargement of motor map

Cortical reorganization non-lesion side

Inc MC, PMC, SMC activation

Use dependent dendritic overgrowth

Synaptogenesis

Pruning

(Interactive effect of lesion and postlesion behavior)

What is redundancy in the brain?

Enhances the brain's ability to adapt following injury

Several neuronal networks respond to the same information

Internal redundancy

Same function represented across distinct brain areas (parallel processing)

External redundancy

Recovery of networks that were temporarily disabled

Restoration

Use of internal and external redundancy.

Recruitment

Compensational use of new pathways

Retraining

10 Principles of Experience-Dependent Neuroplasticity: Principle 1

1. Use it or lose it

Failure to drive specific brain functions can lead to functional degradation.

Principle 2

2. Use it and improve it

Training that drives a specific brain function can lead to an enhancement of that function.

Principle 3

3. Specificity

The nature of the training experience dictates the nature of the plasticity.

Principle 4

4. Repetition matters

Induction of plasticity requires sufficient repetition.

Principle 5

5. Intensity matters

Induction of plasticity requires sufficient training intensity.

Principle 6

6. Time matters

Different forms of plasticity occur at different times during training.

Principle 7

7. Salience matters

The training experience must be sufficiently salient to induce plasticity.

Principle 8

8. Age matters

Training induced plasticity occurs more readily in younger brains.

Principle 9

9. Transference

Plasticity in response to one training experience can enhance the acquisition of similar behaviors.

Principle 10

10. Interference

Plasticity in response to one experience can interfere with the acquisition of other behaviors.