NM IV Unit 1: Diagnosis-specific Considerations (acquired and traumatic brain injury)

what is pusher syndrome

a motor deficit/behavior characterized by pushing through the non-affected UE and LE toward the hemiplegic side resulting in tilting of posture to the affected side

what CVA typically experiences pusher syndrome more

right CVA is more common than left

what is associated with pusher syndrome

a stroke affecting the posterolateral thalamus

what occurs in pusher syndrome

there is altered perception of the body orientation resulting in perceived vertical orientation when the body is tilted at least 20 degrees to the affected side of the body

what are the proposed hypothesis that cause lateropulsion (2)

disturbance of the visual-vestibular system

subjective postural vertical disturbance

what is the impact on function of pusher syndrome (2)

sitting balance and transfers are impacted

poor standing balance resulting in increased fall risk

what is seen with fear in standing with pusher syndrome

pts do not fear falling to the affected side and resist any correction but they fear falling towards the stronger side

what is the major indicator of pusher syndrome

resistance to correction

what is wallenbergs sydrome

lean to the strong side without any pushing due to a lesion on the medulla

what is thalamic astasia

backward or contralateral lean without pushing due to a posterolateral thalamus lesion

what is seen in a vestibular cortex stroke

lean or loss of balance contralaterally (towards weak side) without pushing due to a posterior insula lesion

what is the gold standard outcome measure for lateropulsion

the Burke lateropulsion scale (BLS)

what side do you transfer pts with pusher syndrome

to the unaffected side unless there is safety concern

what is the timeline for resolving pusher syndrome

the signs will be resolved after 6 months after stroke

what side should a AD be placed when walking with pusher syndrome

on the strong side to overcome the resistance

how often is CIMT used

for 3 hrs/day 5x/wk over 2-3 weeks performing shaping tasks and functional tasks

what are shaping tasks

using small successive steps to make task more difficult

when is CIMT used

in the chronic stage of recovery >1 year

what is FES

e-stim delivered to the peripheral nerve and muscle during a functional task

what type of intervention is FES

augmented coupled with restorative task specific practice

when can FES be used as a compensatory intervention

when the extent of neural damage is too extensive and it is used to promote safety and independence with functional mobility

what are the benefits of FES in the UE (3)

hand dexterity and function

motor function/ADLs

shoulder muscle tone, pain, and sublux reduction

what are the benefits of FES for the LE (4)

motor function

walking speed/efficiency

functional ambulation

physiological cost index improvement

when are improvements from FES in the UE seen the most

in the acute and subacute phases rather than the chronic phase

when are improvements from FES seen the most in the LE

in the acute and chronic stages

how does FES provide benefits

there is a positive effect on brain plasticity given the high level sensory motor input to the CNS

what should be used to improve quality of life for pts with foot drop due to chronic stroke hemiplegia

an AFO or FES

what should be used for pts with decreased LE motor control due to acute or chronic post stroke hemiplegia to improve gait speed or other mobility

an AFO or FES

what should be used to improve dynamic balance post stroke

an AFO or FES

what should be done to improve walking endurance for pts post stroke

you may use an AFO or FES

what should be done if a pt has PF spasticity post stroke during treatment

you should not use an AFO or FES

what should be done to improve muscle activation in the anterior tib and gastroc post stroke

you may use an AFO and you should use FES

what ae the benefits of locomotor training on a treadmill without a harness for acute stroke pts

improved max gait speed and step width but no significant improvement in comfortable gait speed

what are the benefits of body weight support treadmill training

improved gait speef and distance

when should body weight support treadmill training be performed

it should be performed early

what is the most important factor of body weight support treadmill training

intensity

what was seen at follow up after locomotor training

if the pt wasn't already walking they did not retain their gains in walking speed and distance

what are the benefits of unilateral locomotor training

it improves wt acceptance on the affected limb while the unaffected limb is forces to take a longer step

what is mirror therapy

a form of motor imagery involving a mirror placed in the pts midsagittal plane with the unaffected limb in front of the mirror and the affected limb on the other side of the mirror and the pt observes unaffected limb movements with progression to attempting to move the affected limb behind the mirror

what is the goal of mirror therapy (3)

improved attention to the paretic side

improved motor function

reduced pain if the pt presents

what pts are appropriate for mirror therapy (4)

pts with motivation to commit to treatment

ability to follow instructions

hemispatial neglect

low level motor functioning

what pts are least appropriate for mirror therapy (5)

cognitive and attention deficits

aphasia

dementia

severe hemispatial neglect with head turn limitations

high level motor function

what are the benefits of mirror therapy for the UE (5)

ADL performance

motor function

spatial neglect

cortical reorganization

reduce shoulder pain

what are the benefits for mirror therapy in the LE (2)

improved motor recovery

improved gait

what is the Via Therapy app

an app that guides clinicians through an algorithm for UE interventions post stroke

what model does the Via therapy app

the SAFE model which stands for shoulder abduction and finger extension

what does the SAFE model state

if pts who are 2 days post stroke have the ability to produce voluntary shoulder abduction and finger extension they have a 98% probability of achieving UE function

what phases post stroke benefit from CIMT

subacute and chronic phases

what are the 4 elements of the CIMT protocol

repetitive and intense task specific training of paretic UE over multiple days

shaping

transfer package

restraint of non paretic UE via safety mitt

what is the most important element of the CIMT protocol

repetitive ad intense task specific practice

how often is repetitive task specific training of the paretic UE done for CIMT

3 hrs a day 5x/wk for 2-3 weeks

what tasks are performed with task specific practice in CIMT

shaping and functional task practice

during CIMT treatment what should the pt do at home

15-30 min a day performing specific repetitive UE tasks

following completion of CIMT what should the pt do at home

3 individualized repetitive tasks 15-30 min a day and 7 selected ADLs using the affected UE only

what is the goal of repetitive and intense task specific training in CIMT

to overcome learned non use and promote neuroplastic changes

what is shaping

performing small successive steps to make the task more difficult with the goal of meeting the motor objective

how can tasks be modified to perform shaping (4)

modify the time

adjust the size of objects

reach distance

reps

what movements should b focused on when performing shaping during CIMT

joint movements that have the most pronounced deficits along with the greatest potential for improvement

what feedback should be provided during shaping tasks

immediate feedback with knowledge of results

what is the transfer package of CIMT

the pts ability to transfer their gains from the clinical or research world to the real world

what are the most consistent predictors of adherence to exercise

self efficacy and overcoming barriers

what are the 4 specific interventions in the transfer package

monitoring through a motor activity log (MAL)

problem solving interventions

behavioral contract

social support

what are problem solving interventions

developing a partnership between the PT and pt to identify potential barriers and instruct and equip the pt on how to overcome them

what is a behavioral contract

a form of formal written agreement between the PT and pt that specifies the activities the pt will use the paretic UE and specify the condition of the mitt outside the sessions

what is the most important aspect of CIMT

safety as it may not be safe to wear the mitt during certain activities

what is a motor activity log

a 6 point scale that has pts rate how much and how well they used the paretic UE on 30 ADLs

when is a motor activity log completed with CIMT

first day of treatment

each day of treatment

immediately after treatment

once a week for the first month after the treatment program

what is the goal if the physical restraint in CIMT

forced use of the UE by preventing the urge to use the unaffected UE

how often in the CIMT mitt worn

90% of waking hours

what is required to start CIMT

shoulder flexion and abduction more than 45 degrees

elbow ext more than 20 degrees from 90

wrist ext more than 10 degrees starting from flexion

finger ext more than 10 degrees in at least 2 digits

what is seen on functional MRIs after CIMT

there is a shift in the motor cortical activation toward the ipsilateral areas along the contralateral hemisphere

what is the Wolf Motor Function Test

an outcome measure used for CIMT that scores functional skills 0-5 including griping, lifting arm to box with wrist weights, and straightening the elbow with weights and 3 times trials of tasks including lifting a pencil, folding a towel, stacking checkers, and flipping cards

what is the modified CIMT protocol

30 minutes of shaping and functional task practice in therapy 3 days/wk for 10 weeks with the use of a contraint mitt for 5 hrs/day for 5 days/wk

what is contraversive pushing

active pushing with the stronger extremities toward the hemiparetic side after a stroke with increased resistance to manual aligment

how is pushing syndrome diagnosed

with the scale for contraversive pushing (SCP)

what is the 3 variables measured in the SCP

spontaneous body posture

extension: increase of pushing force by spreading of the non paretic extremities from the body

resistance to passive correction of posture

each is assessed in sitting and standing

how is spontaneous body posture scored

1= severe contraversive tilt with falling to the side contralateral to the brain lesion

.75- severe contraversive tilt without fall

.25- mild contraversive tilt without fall

0- no tilt/upright

how is extension scored on the SCP

1- performed in rest

.5- performed not until position is changed when scooting forward

0- no extension

how is resistance scored on the SCP

1- resistance shown

0- no reisstance

what is required to be considered to have contraversive pushing on the SCP

a positive score on each item

what is the gold standard outcome measure for contraversive pushing

Burke lateropulsion scale

what are the 5 test positions of the burke lateropulsion scale

supine rolling

sitting

transferring

standing

walking

what does the Burke lateropulsion scale assess

it assesses resistance in the 5 functional positions

what indicates contraversive pushing on the burke lateropulsion scale

more than 2/17

what is the overall prognosis of pusher syndrome

most pts show resolution after 3 months and almost all pts resolve by 6

what is the impact of pusher syndrome on stroker recovery

most pts take 3-4 weeks longer to attain the same functional outcome levels as a stroke survivor without pushing

what is the first step of treatment for pusher syndrome

make the pt aware of the lean througn visual cues such as tape, mirror, or a pole

once a pt with pusher syndrome is aligned upright what is done

the pt should lean to the uninvolved side first by reaching forward and eventually laterally

how is a forward reach initiated when treating a pt with pusher syndrome

the pt strokes their own thigh then progress to stroking the thigh down to the shin to create more trunk lean

what is done once a pt can lean forward with decreased pushing behavior

they are encouraged to reach away from the body to the unaffected side

what side should a pt with pusher syndrome be transfered

toward their strong side since it is harder and will promote more recovery

what is essential for arm function

proper alignemnt

what can create shoulder pain as a result of neurological impairments

shoulder muscle weakness can impair the scapulohumeral rhythm leading to impingement

what should be avoided when handling a hypotonic shoulder post stroke (5)

lifting under axilla

traction

repositioning with hands under axilla

slings

painful ROM

why should slings not be sued post stroke

it provides no opportunity for functional UE motion with the potential to increase a synergistic patten and contributes to inferior sublux

what is a Giv-Mohr sling

a sling hat allows for wt bearing through the UE and attempts to correct sublux and maintains the UE in a more neutral alignment

what are the benefits of forearm WB (7)

support for the flaccid/spastic arm

proprioceptive activation for GH approximation

activates musculature

scap stability

decreased tone

decrease degrees of freedom

increased ease when inhibiting a fisted hand

what are the benefits with extended arm WB (5)

increase UE stability

functional transitions

thoracic extension

scapular muscle strength

progression from forearm WB

what are the three extended arm WB positions

hands anterior to hips

hands in line with hips

hands posterior to hips

what does the extended arm hands anterior to hips allow

increased WB to the UE to promote function with decreased reliance on trunk stability