Neuro II Final Study Guide

Be able to create a problem list and associated goals for a patient.

• What is a problem list?

• Goals need to be what two things? Goals need to be based off of?

• Problem list: patient's current and past health concerns that are relevant to their care ➔ It's a living document that's updated as the patient's condition changes.

  • It's important to keep the problem list accurate, current, and consistent

  • Problems that are no longer relevant should be removed

  • Newly diagnosed chronic conditions should be added

  • Relate to functionality, PLOF, CLOF

• SMART goals (Specific, Measurable, Attainable, Realistic, Timely)

  • goals should be based off the pts limitation list (what are their functional limitations? PLOF compared to CLOF? etc.)

  • must have functional goals included in goals (goals need to be SMART and functional). Functional goals must:

    • State time frames (PLOF vs CLOF)

    • State who

    • Identify the behavior

    • Identify the conditions

    • Identify the degree specifically

    • Need to be stated in functional terms.

    • Ex: The patient will ambulate independently with straight cane on level surfaces 100 feet within one week.

Be familiar with SOAP Notes.

subjective

• hx of pt, PMHx, medications (side effects, MOA), PLOF, lifestyle/home, complications, complaints, goals, etc.

• past tx or any good/bad experiences from previous PT

objective

• hx taken from charts, numerical signs, vital signs, mental status, cognitive perceptual status, inspection of skin/edema, pain scale, cranial nerves, muscle tone, MMT, special tests, functional balance tests, gait, and any other measurements that are appropriate for this pt

assessment

• problem list, relation to goals and intervention

• LTGs and STGs (SMART):

  • must have time frames, state who, identify behaviors and conditions and the degree specifically, need to be stated in functional terms

  • ex. "pt will be able to ambulate independently with a straight cane on level surfaces 100ft within one week

  • must be pt focused, but may include caregiver/family education

  • rehab potential (always aim for good/excellent)

plan

• frequency, duration, tx interventions, discharge plans, education plans, referrals (OT, SLP, social work, etc.)

Describe the process for obtaining medical marijuana or CBD products in Florida (4 steps).

1) get diagnosed with a qualifying medical condition by a qualified physician

2) be entered into the medical marijuana use registry by their qualified physician

3) apply for a registry identification card (patients and their caregivers)

4) fill your order at a licensed medical marijuana treatment center

What diagnoses or conditions qualify for medical marijuana under Florida law?

• cancer

• epilepsy

• glaucoma

• HIV/AIDS

• PTSD

• amyotrophic lateral sclerosis (ALS)

• Crohn's disease

• Parkinson's disease

• multiple sclerosis (MS)

• terminal condition diagnosed by a physician other than their PCP

• medical conditions of the same kind or comparable to the others listed

• chronic nonmalignant pain caused by a qualifying medical condition, or that originates from a qualifying medical condition, and persists beyond the usual course of the qualifying condition

What are the implications for a physical therapist in relationship to medical marijuana?'

• Can we treat if the patient is high? Why or why not? How much should they take so its not an issue?

• What does it help with?

• You should educate patients on?

• Always ask if? What should you be looking out for?

• If the patient falls, the might do what? If they have comorbidities or a history of falling, what should you do if needed?

• Good for what type of management?

cannot treat if they are high bc they can't give reliable feedback!

• if they take as prescribed it should not be an issue (at the appropriate level)

  • helps with pain management which can optimize rehab time

  • educate your pts on appropriate use (tell them to listen to their MD)

• always ask if they use marijuana (look out for dizziness, loss of balance, cognition, mental status, etc.)

  • if they fall, they might blame you; if they have comorbidities or have a history of falling, maybe call the MD and adjust the dose if needed

• spasticity management

How can medical marijuana or CBD products help a patient?

pain management

What are some potential side effects and adverse reactions related to medical marijuana?

• CBD use during _______ is not recommended.

• May cause ______ damage.

• May interfere with?

• What type of side effects would be expected?

• Cannabis use disorder?

• Negative neurological effects?

• Cardiovascular risk?

• Respiratory risk?

• Physiological issues?

• CBD use during pregnancy is not recommended

• liver damage

• interference with other drugs you are taking (may lead to injury or serious side effects)

• Symptoms:

  • drowsiness or sleepiness-->driving: negatively affects skills required for safe driving

  • diarrhea or changes in appetite

  • changes in mood, such as irritability

  • unintentional poisoning

• cannabis use disorder: physical dependency and controlling their use

• negative neurological effects (brain health): memory, learning, attention, decision making, coordination, emotions, and reaction time (driving)

• cardiovascular risk (heart health): can make the heart beat faster and raise BP

  • can increase risk of MI and stroke--> importance of health history!

• respiratory risk (lung health): smoked cannabis, regardless of how it is smoked, can harm lung tissues and cause scarring and damage to small blood vessels

• psychosocial issues (mental health): linked to social anxiety, depression, and schizophrenia

Be able to describe methods of marijuana delivery (6)

• pill--> Marinol (FDA approved for N/V)

• topicals containing CBD (cannabidiol)

• vaping

• smoking

• sublingual spray

• edibles (tea--> instructions on how long to steam)

How do CBD products potentially relate to drug testing? Why are poppy seeds bad before a drug test?

they test for THC, not CBD

• make sure what you are taking does not have THC

• poppy seed could show up on urine tests as heroin!

What is the structure and function of the peripheral vestibular system?

• PVS are your what structures? They are responsible for?

• Where do the vestibular labyrinth lie? what movement sensors does it have?

• 3 primary functions of peripheral vestibular system? How does it do each?

PVS= inner ear structures--> sensory organ responsible for position of body/head; detects motion and proprioception

• the vestibular labyrinth lies within the temporal bone on each side of the skull

  • contains 2 types of movement sensors: semicircular canals and otoliths

3 primary functions of the Peripheral Vestibular System

1) visual clarity: ensuring that clarity is maintained despite changes in head position

• stabilization of visual images on the fovea of the retina during head movement to allow clear vision--> achieved through the VOR, which enables the eyes to move in the opposite direction of head motion

2) postural stability: maintaining postural stability, especially during head movement

• coordination muscle responses that help the body stay upright and balanced

3) spatial orientation: providing information used for spatial orientation

• provides continuous feedback about head position and movement relative to gravity, essential for navigating the environment and adjusting movements

Vestibular Subjective Exam

• If pt reports feeling dizzy what should you try to get them to do? Why?

• For vertigo, what are the two types and their differences?

• What other thing would you looks for during examination?

• What can be done to get a numerical/better idea of the patients dizziness?

If pt reports feeling dizzy, try to get them to explain what dizzy means to them; do they feel like their feet are unstable? Is the world spinning? Does it feel like they are spinning?

• “dizzy” does NOT tell us much

vertigo: nausea, room is spinning, throwing up (ask duration of s/s)

• neuritis: will last days to weeks

• BPPV: lasts about 10 minutes (if last weeks= NOT BPPV--> refer out!)

Other things to look out for:

• lightheadedness: feeling of passing out, orthostatic hypotension

• disequilibrium: losing balance, feeling like pt will fall

• oscillopsia: stationary objects appear to move, triggered by darkness because the eye is trying hard to adjust.

• duration and circumstances of s/s

What can be used to assess how dizzy:

• visual analog scale--> scale 1-10

• Dizziness Handicap Inventory

  • includes physical, functional, and emotional domains

  • very important because these pts have fear movements leading to anxiety or depression

• motion sensitivity quotient

What is the VOR and how is it tested?

• What is it mediated by? How?

• What is the relationship of eye velocity to head velocity is called? What does it mean? What does saccade mean? Eye position should arrive at?

• VOR is tested via what test and a positive finding means?

allows eyes to move at the same velocity but opposite direction as the head

• mediated by the SCC: hair cells deflected--> sends info to vestibular nuclei--> sends info to CNS nuclei of eyes

the relationship of eye velocity to head velocity is called the VOR gain

• as head moves in one direction, the eyes move in the opposite direction with equal velocity; saccade= difference in velocity where the eyes try to catch up

• eye position should arrive at a point in time that is equal with the opposite directed head position

tested via:

• head impulse test--> positive findings= saccades

What is the difference between a saccade and nystagmus?

• First, what are they both considered?

• For saccades: What is it and what is it used for? Not typically caused by what? What happens if someone has corrective saccades?

• For nystagmus: What is it and what is is composed of? What direction does the nystagmus move? When observing the eyes for resting nystagmus, what must you remember so the results are accurate and how can this be avoided?

  • What should you suspect if they don’t respond to treatment or the nystagmus does slow down?

  • If the nystagmus does slow down what should you suspect?

both are considered involuntary eye movements

saccades:

• normal rapid eye movements; used to reposition the eyes on a target of interest

• not typically caused by vestibular lesion

• corrective saccades (catch up)--> vestibular hypofunction--> vestibular involvement

nystagmus:

• eye movement due to a peripheral vestibular lesion

• composed by both slow and fast component eye movements

  • begins to slow down as the otoconia begins to settle (canal issue); if it continues to persist, it could be the cupula (very rare)

• the direction of the nystagmus is named by the direction of the fast movement: R side movement= R nystagmus

• when observing the eyes for resting nystagmus, remember that the pt may be able to suppress it in the light or if focusing on a target

  • tell the pt "look at my nose"; have them look beyond you, or do it in darkness

• if they don't respond to tx or nystagmus does not slow down= CUPULA involvement

• if nystagmus does slow down= crystals are settling= CANNALS are involved

How can a physical therapist differentiate between a central or peripheral vestibular lesion?

• CNS: What can cause injury to the CNS? Demyelinating diseases?

  • Nystagmus?

  • ________ and _____ _____ are indicative of a? What does this mean? When is this an emergency?

  • An ocular tilt reaction consists of what three things?

• What are the red flags of a central lesion? What should you do if suspected? What test would be positive?

CNS

• injury to the CNS: CVA, TIA, vertebral artery, vertebrobasilar insufficiency, TBI

• demyelinating diseases: MS

• nystagmus: pure vertical nystagmus may indicate central lesion

• lateropulsion and head tilt are indicative of a central lesion (pusher syndrome): pt tend to fall to one side (in the absence of a substance issue= WHOOP WHOOP!)

• an ocular tilt reaction consists of 3 key components:

1) ocular torsion: both eyes rotate (torsion) in the same direction

2) head tilt: the head tilts toward the AFFECTED side

3) skew deviation: one eye moves up while the other moves down

red flags of a central lesion

• REFER TO MD!

• diplopia that lasts >2 weeks after the onset of a peripheral vestibular loss

• persistent pure vertical positional nystagmus (bidirectional, HINTS)

• spontaneous up-beating nystagmus

- (+) test for skew deviation (vertical misalignment, HINTS)

What is the HINTS examination?

• Worrisome HINTS exam: What are the components and how does it work?

• Which patients do you perform the HINTS exam on?

test used to differentiate central (stroke) from peripheral (vestibular neuritis) causes of acute vertigo and nystagmus

• Worrisome HINTS exam: presence of ANY of the 3 components indicate a (+) finding (stroke or central pathology): a normal HIT, direction-changing nystagmus, OR skew deviation

3 components

1) head impulse test (HIT): ask the pt to fixate on a near target (PT's nose), grasp the pt's head, and apply a brief, small-amplitude (5-10°), and high-acceleration (3000-4000 deg/sec) head turn, first to one side and then to the other; when the head stops moving, the clinician looks to see it the eyes are still directed toward the target and watches for corrective saccades toward the target

• a normal HIT result means the eyes remain fixed on the target after head rotation, suggesting a central lesion (worrisome); an abnormal HIT result (catch-up saccade), may indicate VOR deficit

• abnormal finding is a GOOD finding; shows the person has a nerve problem (vestibular neuritis), not a brain problem

2) nystagmus: bidirectional nystagmus suggests a central cause (worrisome), which unidirectional nystagmus suggests peripheral

3) test of vertical skew: cover one eye then the other, observing if the eye moves medially and up/down

• vertical misalignment of the eyes (skew deviation) suggests a central lesion (worrisome)

Only perform exam on patient with hours or days of continuous, ongoing vertigo and spontaneous nystagmus

Side Note: Having normal HINTS and NOT experiencing continuous, ongoing vertigo and spontaneous nystagmus is OKAY! Now, if your patient has the vertigo and nystagmus but all the tests are “normal”, we get worried because it is not following vestibular diagnoses patterns which would usually cause these symptoms, hinting to something more serious like stroke.

Be able to provide testing and treatment for a patient with BPPV.

• What is it? Difference between Canalithiasis and Cupulolithiasisor? Which one do you test for first and and with what test? The ear going down is what side? What if its bilateral?

• Goals of treatment? What is canalith repositioning and liberatory maneuver?

CNS:

• What processes information from the PVS? This is why pts with stroke?

• Many vestibular reflexes are controlled by processes that exist primarily within the?

• Extensive connections between what structures?

• Vestibular pathways appear to terminate in? This suggests?

it is a disorder of the inner ear caused by dislodged otoconia; occurs when the otoconia from the otoliths fall into the canals, stimulating the hair cells

• canalithiasis: otoconia are free floating

• cupulolithiasisor: otoconia stick to the cupula

• examination: testing for canalithiasis first= Dix-Hallpike test and Log roll test

  • the ear going down is the side being tested; if bilateral, treat the worse side first

goals of tx:

• educate the pt about self-treatment-> Brandt-Daroff Exercises (HEP)

• replace the otoconia into the otoliths

  • Canalith Repositioning tx: movement of free-floating debris out of the involved SCC and into the vestibule (canalithiasis)

  • Liberatory (Semont) Maneuver: FAST; quickly shift the head to reposition the debris away from the cupula in the affected canal (cupulolithiasis)-> "S" in Semont= same side

• Decrease vertigo

• Increase balance

• Return to daily activity involving head motion

CNS

• the brain processes the information from the PVS

• this is why pts with strokes misinterpret of motion signals leading to perceptual problems

• many vestibular reflexes are controlled by processes that exist primarily within the brainstem (including VOR)

• extensive connections btwn the vestibular nuclei and the reticular formation, thalamus (sensory relay station), and cerebellum (balance and coordination)

• vestibular pathways appear to terminate in a unique cortical area, suggesting a distinct region in the brain dedicated to vestibular perception

How would a therapist know which side needed to be treated with bilateral BPPV?

treat the worst side FIRST

How would the treatment for a unilateral vestibular loss compare with a bilateral vestibular loss?

Bilateral Vestibular Lesion:

• Most common cause is? Primary complaints? no nausea or vertigo UNLESS it's?

• must use ________ of other mechanisms to try to gain ______ ______ because?

• Goals and outcomes?

• Physical therapy will heighten what two systems?

• BPPV is not a?

Unilateral vestibular loss:

• Most common cause is? Acutely, the patient will have? Prognosis?

• Start with what movements? Progress to what movements?

• Goals and outcomes?

• PT will address what three things?

Bilateral vestibular loss:

• the most common cause is ototoxicity (damage to the inner ear caused by certain medications or toxins)

• primary complaint is disequilibrium, oscillopsia, and gait ataxia (unique to BVH)

• no nausea or vertigo UNLESS it's asymmetrical (cannot be BPPV)

• must use substitution of other mechanisms to try to gain gaze stability bc the system will not grow back

• goals and outcomes:

  • reduce subjective complaints of gaze instability-> X1 exercises with your thumb (close eyes, shake head, open and refocus on the thumb in front of you), sequenced eye and head movements, imaginary targets (thumb out and close eyes, then open)

  • improve balance (static and dynamic)

  • instruct the pt in a HEP that includes walking: they are not moving bc they are scared but not moving will get them worse!

  • educating the pt in activities that may be difficult

  • increased safety awareness: fall prevention

• PT will heighten the visual and somatosensory systems!

• BPPV is NOT a bilateral vestibular lesion

Unilateral vestibular loss:

• Most common causes: viruses, trauma, vascular events

• Acutely, the patient will have: vertigo, nausea, resting nystagmus, oscillopsia with head movement, postural instability and disequilibrium (due to asymmetry)

  • → pt tells you they get dizzy when they unload the dishwasher

• Prognosis: The system has an amazing ability to recover since the nuclei “talk” to each other through interneurons.

• Start with L and R movements then progress to up and down exercises

Goals and outcomes:

• Improve stability of gaze during head movement through the VOR

  • Produce retinal slip so the system is “pushed” to recover: X1 exercises (move the head, x stays static) or X2 exercises (head and x go in opposite directions) if their neck is okay to do this

  • Make these harder by: standing, walking, being in busy gym environment

• Decrease motion sensitivity: provoking activities, habituation training,

  • Reaching down to ”unload the dishwasher” repeatedly

• Improve postural stability (static and dynamic = Dualtask Airex)

  • Use the alphabet on the floor or wall as they are standing and tell them to look for specific letters while standing still

• Establish a HEP that includes walking: They are not moving because they are scared but not moving will get them worse!

  • Dual tasking during walking, simulate people walking by, scanning the aisles at the grocery store

➔ PT will address the oscillopsia, postural instability and disequilibrium!

Be familiar with other diagnoses involving the vestibular system, such as Meniere's Disease or motion sickness

• Meniere's disease is caused by?

• Symptoms?

• Pts may be prescribed what?

• Physical therapy can be helpful once they?

• Motion sickness is caused by? Where should you look?

Meniere's disease

• caused by fluid buildup in the inner ear, increased endolymphatic pressure within the ear

• symptoms: ear fullness, vertigo, tinnitus, and hearing loss

• pts may be prescribes medication (such as diuretics) to control fluid buildup and alleviate symptoms

• physical therapy can be helpful once they are stable (MD clearance for PT), especially for balance dysfunction and other residual problems

motion sickness

• sensory conflict: your eyes (visual) are seeing something, your vestibular system is perceiving something else, your somatosensory is getting other information

• "look at the horizon" bc it doesn't move

Perilymphatic Fistulas?

Mal de Débarquement Syndrome?

Migraine Related Dizziness and cervicogenic Dizziness?

Perilymphatic Fistulas: Abnormal connection between the inner ear and middle ear, often requiring surgical intervention (Burst and require surgery: wait for MD clearance!)

• Physical therapy can be helpful once they are stable (MD clearance for PT), especially for balance dysfunction and other residual problems

Mal de Débarquement Syndrome: Individuals experience a persistent sensation of motion or rocking after being exposed to motion, such as a boat or airplane trip.

• ‘Land sickness’ in French = lasts for MONTHS

Migraine Related Dizziness and cervicogenic Dizziness

• Ask about what triggers the migraines and tell them to avoid them

• If they are having a migraine, don’t treat them! Wait until it is over, then continue treatment

• Help them identify triggers to avoid them

• Treat what you find (are they dizzy, are they losing balance?)

Contraindications for vestibular rehab?

• Not appropriate for what conditions? (4)

• Or if pt presents with?

• Once post op be observant for?

Not appropriate for:

• Unstable vestibular disorders: Menieres disease

• Uncontrolled migraine

• PLF

• Unrepaired superior semicircular canal dehiscence

Or if pt presents with:

• Sudden loss of hearing

• Increased feeling of pressure or fullness of ears

• Severe ringing

Once post-op:

• Be observant for discharge of fluid from ears or nose (CSF fluid)

• Pts with acute neck injuries may not be able to tolerate the CRM, or some of the GSE’s

How would you respond if a patient experienced a sudden hearing loss? If you see leakage what does that mean? What is contraindicated?

• immediate referral to the hospital! (could be a stroke)

• if you see leakage, could be CSF or a flare up of Meniere's

• PT CONTRAINDICATED!

What treatment would be appropriate for a patient with Vestibular Schwannoma (acoustic neuroma)?

• What is it? What nerves does it impact?

• PT is for pts experiencing? What is needed first?

  • Involves what exercises and helps compensate for what dysfunction?

tumor affecting CN VIII (vestibulocochlear) and VII (facial)

• PT for pts experiencing balance issues and dizziness due to the tumor or after surgery (MD clearance for PT)

  • involves gaze stabilization, habituation, and balance training exercises

  • helps compensate for vestibular dysfunction and improve overall function

What are the three systems involved in balance control?

• Of one of those systems, what are its three parts and wahc does each aprt do?

1) CNS integration

2) sensory systems: visual, vestibular, somatosensory

3) motor systems

For the sensory systems, what are its three parts and what does each part do?

• For the vestibular system, the primary motor functions of the vestibular system include what three things?

Sensory organization: visual system

• visual proprioception: orientation of the body parts with reference to the environment

  • relays information about the external environment

  • decreased visual acuity will have a negative impact on postural stability

Sensory Organization: Somatosensory Input

• somatosensory input: cutaneous and pressure sensations (surface information)

  • receptors detect relative orientation and movement of body parts, and orientation of the support surface

  • include stretch reflexes, flexor withdrawal, crossed extensor reflexes, automatic postural reactions

Sensory Organization: Vestibular System

• detects angular acceleration and deceleration forces acting on the head (SCC)

• detects linear acceleration and orientation of the head in reference to gravity (otolith organs- saccule and utricle)

• primary motor functions of the vestibular system include:

1) stabilization of gaze during head movements (VOR)

2) righting reactions of the head, trunk, and limbs (labyrinthine righting reactions)

3) regulation of muscle tone and postural muscle activation

Describe the motor strategies for balance recovery.

• This is one of the three main functions of what system?

• What is the ankle strategy?

• Weight shifting strategy?

• Hip strategy?

• Suspensory strategy?

• Stepping/Reaching strategy?

• Combination strategy?

• Standing vs sitting balance strategies?

• Reactive vs anticipatory strategies?

one of the 3 main functions of the vestibular system

1) ankle strategy

• used for small, slow perturbations on a firm surface (first line of defense)

• relies on distal-to-proximal muscle activation or orientation

2) weight-shifting strategy

• controls side to side weight shifts using the hips and trunk

• often used when adjusting foot position or reaching

3) hip strategy

• engaged when the ankle strategy is insufficient; larger, faster perturbations (on narrow or unstable surfaces)

• involves proximal-to distal muscle activation

4) suspensory strategy

• involves lowering the body by flexing the knees, hips, and ankles (lowering COM)

• used in dynamic balance tasks, especially during sports or uneven terrain

5) stepping/reaching strategy:

• used when other strategies fail, requiring a step or reach to prevent a fall (last resort)

6) combination strategies:

• real-world balance recovery is often not isolated to one strategy but a blend

7) standing vs. sitting balance strategies

• standing: requires more ankle, hip, and stepping strategies

• sitting: relies more on trunk control and weight shifts (important for neuro pts)

8) reactive vs. anticipatory postural strategies

• reactive: automatic responses after an external perturbation (slipping on ice)

• anticipatory: preemptive adjustments before movement (stabilizing the core before reaching for an object)

What is the muscle activation with these strategies?

• For ankle when being pushed forward? When pushed back?

• weight shifting?

• Hip when being pushed forward? When pushed back?

• suspensory?

• For stepping and for reaching?

ankle strategy

• pushed forward: gastrocnemius (PF)-> hamstrings-> paraspinals

• pushed backward: tibialis anterior (DF)-> quadriceps-> abdominals

weight-shifting strategy

• hip abductors (gluteus medius), adductors (adductor group), trunk muscles

hip strategy

• pushed forward: abdominals-> quadriceps

• pushed backward: paraspinals-> hamstrings

suspensory strategy

• quadriceps, hamstrings, gluteals, and core muscles

stepping/reaching strategy

• stepping: hip flexors, quadriceps, and dorsiflexors

• reaching: arm muscles (deltoid, triceps, biceps)

Be able to create a treatment plan related to the results of various balance and vestibular tests.

For the following outcome measure, what is the perfect score and what is the cutoff score?

• Berg balance test

• Tinetti performance - oriented mobility assessment

• Timed up and go test

• Four square step test

• Dynamic gat index

• Functional gait assessment

• Five times sit to stand test

• ABC scale

Be able to prescribe balance activities based on a case scenario.

For the following activities, what are the responses targeted and the progression of activity?

• Sit to stand to sit

• Stepping in all directions (forward, side, back)

• Step up and down

• Ankle, hip, and upper limb balance strategy practice

• Sideways reach task

• Ball games

• Card treasures hunt/sort into suits

How do safety considerations and environmental modifications relate to balance impairments?

• For instance what if someone is furniture walking?

• Have proper ______ if the visual is impaired

-if someone is furniture walking, don't take away the furniture!

-have proper lighting if the visual is impaired

What are the six conditions utilized on the Clinical Test for Sensory Interaction in Balance examination? Which conditions would suggest vestibular dysfunction?

• What are the three systems this tests? What does it always test?

• For each condition state how they a performed and what systems are involved in each

CTSIB tests: visual, somatosensory, vestibular (it ALWAYS tests vestibular!)

Condition 1: eyes open, firm surface. All three systems

Condition 2: eyes closed, firm surface. Somatosensory and vestibular reliance

Condition 3: eyes open, firm surface, visual conflict (dome). Somatosensory and vestibular reliance

Condition 4: eyes open, foam surface. Vison and vestibular reliance

Condition 5: eyes closed, foam surface. vestibular reliance

Condition 6: eyes open, foam surface + visual conflict (dome). vestibular reliance

When considering balance or other functional tests, what is the Minimally Clinically Important Difference (MCID)?

• Can be used to?

• It helps determine what?

MCID: the smallest change in a test score that is perceived as MEANINGFUL and indicates a significant improvement or decline in FUNCTION

• can be used to make goals

• it helps determine whether an intervention has a real impact on a pt's condition rather than just a statistically significant change

How can this value (MCID) be used in writing patient-centered functional goals?

• incorporating MCID into goal setting ensures alignment with best practices and provides objective justification for treatment efficacy

• when claims are denied, referencing MCID offers strong, evidence-based support for appeals, demonstrating the intervention's direct impact on the pt's functional improvement

  • ex: 6MWT; MCID is a 50-meter difference

Be able to prescribe adaptive equipment as related to balance/functional loss and safety training.

• Cane

• Walker (standing, rolling, four wheel)

• Hemi walker

• Forearm (Lofstrand) crutches

• Wheelchair

• Home safety and functional aids

cane: provides mild support for balance impairments; best for unilateral weakness, mild vestibular dysfunction, or early-stage balance loss

walker: provides more stability for moderate-to-severe balance issues

• standard walker: requires lifting, best for weight-bearing restrictions

• rolling walker (2WW): easier to advance, good for patients with limited endurance

• four-wheeled walker (4WW): includes a seat for rest, ideal for pts with fatigue or endurance issues

hemi walker: designed for unilateral weakness (post-stroke pts); provides more support than a can but is lighter than a standard walker

forearm (Lofstrand) crutches: used for long-term mobility support with more freedom than a walker; best for neuromuscular conditions (MS)

wheelchair: best for severe balance/motor impairments like ALS, SCI, advanced MS (power wheelchair)

home safety & functional aids: grab bars, raised toilet seat with handles, shower chair & non-slip mats

Given patient information, be able to perform differential diagnosis testing for a patient who complains of dizziness.

• What three questions should you be asking them/yourself?

• With vertigo, neurites will last how long? BPPV last how long?

• are they losing balance because they can't see (DM related) or is it truly vestibular?

• is it because they had a stroke and their depth perception has been thrown off?

• how long is it lasting?

  • with vertigo, neuritis will last days to weeks & BPPV lasts about 10 minutes

Review the Life After Stroke: A Guide for Patients and Caregivers.

resource to give to pts

No other info on Amandas or Ashley’s guide

Identify the risk factors for a stroke.

• Modifiable and Non modifiable

-modifiable: smoking, sedentary lifestyle, BP, cholesterol, diet

-non-modifiable: age

Promote prevention strategies for stroke.

• What two things are important when dealing with stroke? AHA spoke about the importance of those two things with what campaign?

• If someone has had a stroke, what is very important to prevent? Why?

-early recognition and prompt intervention ("brain attack" campaign by the AHA)

-think about preventing the SECOND stroke! (having one stroke increases the risk of having a second one)

What is (BE)FAST?

-B: BALANCE: SUDDEN LOSS OF BALANCE

-E: EYES: LOSS/CHANGE OF VISION IN ONE OR BOTH EYES

-F: FACE: FACE LOOKS UNEVEN (DROOPING)

-A: ARM: ARM/LEG WEAK/HANGING DOWN

-S: SPEECH: SPEECH SLURRED OR TROUBLE SPEAKING/SSEMS CONFUSED

-T: TIME: CALL 911 NOW!

Essentially how to identify a stroke is occurring

What is the pathology of a cerebrovascular accident?

• ischemic stroke

  • Has opportunity to be saved with?

  • More or less common?

  • What two things can cause it to occur?

  • Conditions that cause what can lead to this type of stroke?

  • During the stroke, your brain is being deprived of what 2 things?

  • Disrupts cellular ________ → ________ = _______ _______

    • What is the most common site of a ischemic stroke (What artery)?

• Hemorrhagic stroke

  • Better or worse outcomes?

  • What is it?

  • Occurs due to rupture of _____ ______ or what?

  • This causes what 3 things?

ischemic stroke

• has opportunity to be saved w/TPA

• more common

• thrombus or embolus blockage

• conditions that cause low systemic perfusion pressures (inadequate blood flow through the body's tissues due to reduced arterial pressure)

• deprives brain of oxygen and glucose

• disrupts cellular metabolism--> mitochondria= energy source

  • middle cerebral artery is the most common site for an ischemic stroke

hemorrhagic stroke

• more tragic-->WORST OUTCOME

• abnormal bleeding into the extravascular brain areas

• result of rupture of a cerebral vessel or trauma

• increased intracranial pressures, injury to brain tissues, and restriction to distal blood flow

What is the difference between a CVA and TIA?

TIA--> symptoms should resolve WITHIN 24 HRS

• vascular event, warning sign of a stroke to come

refer to MD for proper medication! regardless, always call 911 if someone is showing signs of a stroke bc you don't know if it is a TIA or a CVA

What is the medical management of an ischemic stroke?

• Acute

• Pharmacological

• Neurosurgical

acute management: make sure the pt doesn't die; stabilize them

pharmacological management:

• thrombolytics: break down the clot

• antiplatelet therapy: aspirin

• don't ignore stroke pain!

neurosurgical management:

• thrombectomy: physically removing the clot

• decompressive craniectomy

What is the medical management of a hemorrhagic stroke?

surgery ASAP to stop the bleed

Be familiar with the NIH Stroke Scale. How can this scale be clinically useful?

• First, what is the scale? For grading, what is the scoring like?

• Clinical importance?

• Levels of consciousness (What does each score mean from 0 to 3)

NIH Stroke Scale: numerical scale to determine stroke severity; health care providers record the person's performance in 11 categories and determine functional deficits

• Scoring is between a 0 - 3, and 3 is scored only if the person makes no movement (other than reflexive posturing) in response to noxious stimulation (if applicable to the part of the scale, as some sections only let you grade from 0 - 2)

clinical importance

• determines stroke severity

• guides treatment decisions

• tracks recovery & progression

• standardized communication: helps healthcare teams discuss pt status clearly

level of consciousness

0. alert; keenly responsive

1. not alert; but arousable by minor stimulation to obey, answer, or respond

2. not alert; repeated stimulation, obtunded-> requires strong or painful stimulation

3. responds only with reflex or is totally unresponsive, flaccid, and areflexic

What is the penumbra?

• How does tPA impact penumbra?

• the penumbra is the area of brain tissue surrounding the core infarct (irreversibly damaged tissue) in an ischemic stroke

• administration of tPA (tissue plasminogen activator) 3-4.5 hours of symptom onset protects the penumbra and can allow it to recover by breaking up the blood clot

  • the penumbra is functionally impaired but still salvageable

What is an ischemic cascade?

• What are the steps of it (9)

series of damaging cellular events triggered by reduced blood supply to the brain

steps of the ischemic cascade

1. decreased O2 & glucose supply

2. failure of ATP production

3. failure of ATP dependent ion pumps

4. disruption of ionic homeostasis-> sodium (Na+) and calcium (Ca2+) accumulate inside cells, causing cellular swelling (cytotoxic edema)

5. excess glutamate release-> leading to excitotoxicity

6. calcium overload-> activates enzymes that damage cell membranes, proteins, DNA

7. oxidative stress & free radicals-> further damages neurons

8. inflammatory response-> worsens brain injury and contributes to secondary damage

9. apoptosis (neuronal cell death)-> irreversible infarction if blood flow is not restored

Identify the different parts of the brain and the associated functions.

• For each of the following, say what it does in a healthy brain vs how its impacted in an injured brain

  • Frontal, parietal, occipital, temporal lobes

  • Cerebellum

  • Brainstem

Frontal lobe

— Healthy brain:

• Personality / emotions

• intelligence

• Attention / concentration

• Judgment

• Body movement

• Problem solving

• Speech (speak & write)

— Injured brain

• Loss of movement (paralysis)

• Repetition of a single thought

• Unable to focus on a task

• Mood swings, irritability, impulsiveness

• Changes in social behavior and personality

• Difficulty with problem solving

• Difficulty with language, can’t get the words out (aphasia)

Parietal lobe

— Healthy brain:

• Sense of touch, pain and temperature

• Distinguishing size, shape and color

• Spatial perception

• Visual perception

— Injured brain

• Difficulty distinguishing left from right

• Lack of awareness or neglect of certain body parts

• Difficulties with eye-hand coordination

• Problems with reading, writing, naming

• Difficulty with mathematics

Occipital lobe

— Healthy brain:

• Vision

— Injured brain

• Defects in vision or blind spots

• Blurred vision

• Visual illusions / hallucinations

• Difficulty reading and writing

Temporal lobe

— Healthy brain:

• Speech (understanding language)

• Memory

• Hearing

• Sequencing

• Organization

— Injured brain

• Difficulty understanding language and speaking (aphasia)

• Difficulty recognizing faces

• Difficulty identifying / naming objects

• Problems with short- and long-term memory

• Changes in sexual behavior

• Increased aggressive behavior

Cerebellum

— Healthy brain:

• Balance

• Coordination

— Injured brain

• Difficulty coordinating fine movements

• Difficulty walking

• Tremors

• Dizziness (vertigo)

• Slurred speech

Brainstem

— Healthy brain:

• Breathing

• Heart rate

• Alertness / consciousness

— Injured brain

• Changes in breathing

• Difficulty swallowing food and water

• Problems with balance and movement

• Dizziness and nausea (vertigo)

Identify the differences seen in patients with injury to the right or left hemisphere.

• right hemisphere injury: difficulty with executive function, spatial-perceptual tasks; quick, impulsive, overestimate their ability, L side neglect, R gaze preference

• left hemisphere injury: difficulty with communication, language, numbers, and reasoning; motor and visual deficits on the R, L gaze preference, anxious, disorganized

Identify major features of the different vascular syndromes, especially those discussed in class.

• ACA - What are the affected areas? Clinical features?

• MCA - What are the affected areas? Clinical features?

• ICA - What are the affected areas? Clinical features?

• PCA - What are the affected areas? Clinical features?

• Lacunar stroke - What are the affected areas? Clinical features?

• Cerebellum stroke - What are the affected areas? Clinical features?

• Vertebrobasilar artery syndrome- What are the affected areas? Clinical features?

  • Locked in syndrome - What are the affected areas? Clinical features?

anterior cerebral artery syndrome (ACA)

• affected area: medial frontal & parietal lobes

• clinical features: contralateral weakness & sensory loss (LE> UE), urinary incontinence (frontal lobe), personality changes, apathy, or impulsivity

middle cerebral artery syndrome (MCA)

• affected area: lateral frontal, temporal, & parietal lobes; basal ganglia

• clinical features: contralateral weakness & sensory loss (UE>LE), Broca's aphasia (if the dominant hemisphere is affected), contralateral homonymous hemianopia, neglect (if right hemisphere is involved), unilateral neglect, perceptual deficits

internal carotid artery syndrome (ICA)

• affected area: ACA and MCA territories (larger area of the brain)

• clinical features: severe motor/sensory deficits (both UE/LE), cortical blindness (if the PCA also affected), can lead to coma or death

• "I" for eyes; "internal"--> "in" everything (whole body)

posterior cerebral artery syndrome (PCA)

• affected area: occipital lobe, thalamus, & brainstem

• clinical features: contralateral homonymous hemianopia (visual loss), visual agnosia (can't recognize objects), prosopagnosia (can't recognize faces), memory loss, thalamic pain syndrome (severe/chronic pain)

Lacunar Strokes (Small Vessel Disease) •

• Affected Area: Small, deep brain structures (basal ganglia, thalamus, pons). •

• Clinical Features: pure motor stroke (internal capsule or pons), pure sensory stroke (thalamus), ataxic hemiparesis (cerebellar involvement), dysarthriaclumsy hand syndrome (pons), no cortical deficits (aphasia, neglect), multiinfarct dementia (multiple strokes lead to accumulation of deficits)

Cerebellum Stroke

• Affected Area: Cerebellum

• Clinical Features: dysmetria, scissoring gait, ataxia, dysdiadokinesia

Vertebrobasilar Artery Syndrome

• Affected Area: Brainstem, cerebellum, and occipital lobe.

• Clinical Features: Dizziness, vertigo, nausea/vomiting, diplopia, dysphagia, ataxia (lack of coordination)

Locked-In Syndrome

• Affected Area: Ventral pons (corticospinal and corticobulbar tracts).

• Clinical Features: Complete paralysis (except for eye movements, typically vertical gaze), no speech or limb movement, preserved cognition and sensation, communication is possible via eye movements or blinking.

Be familiar with pharmacological management following a CVA.

• Thrombolytics

• Anticoagulants

• Antiplatelets therapy

• Antihypertensive agents

• Angiotensin II receptor antagonists

• anticholesterol agents/statins

• antispasmodics/spasmolytics

• antispastics

• anticonvulsants

• antidepressants

• thrombolytics: dissolves blood clots

• anticoagulants (Warfarin [Coumadin], Heparin}: prevents clot formation

• antiplatelet therapy (Aspirin): prevents platelets from sticking together, reducing thrombus formation

• antihypertensive agents (ACE inhibitors, Beta-blockers, Calcium channel blockers): lowers BP to prevent stroke

• angiotensin II receptor antagonists (Losartan [Cozaar]): blocks angiotensin II to relax blood vessels and lowers BP

• anticholesterol agents/statins: lowers cholesterol, prevents atherosclerosis strokes

• antispasmodics/spasmolytics (Diazepam [Valium]): relaxes muscles and spasticity

• antispastics (Baclofen [Lioresal], Tizanidine [Zanaflex]): relaxes muscle and spasticity

• anticonvulsants (Clonazepam [Klonopin]): controls seizures, CNS depressant

• antidepressants (Fluoxetine [Prozac], Sertraline [Zoloft]): post-stroke depression

What would be the components of a comprehensive physical therapy examination for a patient with a stroke?

• cognition

• cardiopulmonary

• cranial nerve integrity

• sensation & vision

  • we need to do a better job on assessing vision!

• pain

• joint integrity & flexibility

• motor function

  • stages of motor recovery

  • obligatory synergy patterns (look at the strongest components***)

• tone: Modified Ashworth Scale

• reflexes: DTR, pathological (Babinski), tonic

• coordination

• motor planning

  • motor praxis: ability to plan & execute coordinated movement

• ipsilateral pushing --> Pusher syndrome

• muscle strength

  • do MMT on strong side but on involved, have them do STS or rolling in bed

  • hemiplegia/hemiparesis

  • presence of associated reactions: if R CVA (L weak), you resist R leg (L leg goes into a movement)

• postural control and balance/functional testing/status

• gait & locomotion

• integumentary integrity

• aerobic capacity & endurance

• stroke specific instruments

What are the neurological complications following stroke?

• altered consciousness

• aphasia

  • fluent aphasia (Wernicke's/receptive aphasia): difficulty with comprehension

  • nonfluent aphasia (Broca's/expressive aphasia): difficulty with speech

  • global aphasia: difficulty with both production and comprehension of language

• dysarthria: motor disorder preventing fluent speech (linked to dysphagia)

• dysphagia: risk of aspiration and nutritional needs

  • may need a MBS (Modified Barium Swallow) study to rule out

• cognitive dysfunction: attention (quiet, closed environment recommended), memory, executive function, multi-infarct dementia (multiple strokes lead to accumulation of deficits, Lacunar stroke), delirium (confusion, hallucinations)

  • delirium is transient (tends to go away when things calm down) and if sudden >dementia does not get better

• altered emotional state: pseudobulbar affect anxiety, irritability, frustration, depression (medications support groups)

• perceptual dysfunction: body scheme/body image (unilateral neglect), spatial relations, agnosia (not recognizing things, inability to process sensory input)

• seizures

• bladder and bowel dysfunction

• cardiovascular and pulmonary dysfunction: were not active before stroke

  • using an AFO forces you to be more active!

• DVT & PE: sedentary

• osteoporosis and fracture risk: sedentary

• sleep disturbances: insomnia, sleep apnea, sleep disturbances could lead to a stroke, good sleep wake cycle (circadian rhythm) is crucial!

Be able to assess and measure a patient's tone. Be able to use the Modified Ashworth Scale.

• What are the steps (3)?

• Grading scale?

1. position the pt comfortably in supine, ensuring the muscle being tested is relaxed

2. move the joint passively through its full available ROM at a consistent, moderate speed

• (technique: if muscle flexes, place in maximal flexion then move to full extension rapidly)

3. feel for resistance to passive movement and assign a score based on the MAS (velocity dependent)

grading scale

• 0 - no increase in muscle tone

• 1 - slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension

• 1+ - slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM

• 2 - more marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

• 3 - considerable increase in muscle tone, passive movement difficult

• 4 - affected part(s) rigid in flexion or extension

Identify synergistic flexion and extension patterns for the upper and lower extremity. Which components are strongest in each synergy?

UE synergies

1) flexion synergy

• scapular retraction/elevation

• shoulder ABD & ER

• elbow flexion (strongest)

• forearm supination

• wrist & finger flexion

2) extension synergy

• scapular protraction

• shoulder ADD & IR (strongest)

• elbow extension

• forearm pronation (strongest)

• wrist & finger flexion or extension

LE synergies

1) flexion synergy

• hip flexion (strongest)

• hip ABD & ER

• knee flexion

• ankle DF & IV

• toe extension

2) extensor synergy

• hip extension, ADD & IR (Hip extension and ADD strongest)

• knee extension (strongest)

• ankle PF & IV (ankle PF strongest)

• toe flexion

How can the patient's upper extremity be protected during movement and upright activities?

• Prevent what and promote what two things?

• How can subluxation be prevented? E stim should go on what muscles?

  • Why should you WBAT?

  • What can be used to stability and what can be used for support?

• prevent impingement promote scapular upward rotation and elevation

• prevent subluxation by elevating the arm with a GivMohr sling and KT tape; e-stim to medial and posterior deltoid/supraspinatus

  • WBAT for proprioception

  • air splint for stability, KT tape for support

Define the Stages of Motor Recovery. How can these help to guide treatment? (Identify each stage, what each stage entails, and what treatment can be done)

1) flaccidity: no voluntary movement or reflex activity

• tx focus= prevent contractures, maintain ROM, and use PROM

2) synergies, some spasticity: minimal voluntary movement-> early synergistic movements appear (involuntary, patterned muscle contractions)

• tx focus= encourage activation of weak muscles, initiate WB activities

3) marked spasticity: spasticity peaks, synergistic movements dominate

• tx focus= strengthen isolated movement, introduce AAROM, avoid reinforcing synergy patterns

4) out of synergy, less spasticity: some isolated movement-> voluntary movement begins outside of synergy patterns

• tx focus= improve coordination, emphasize functional tasks, work on isolated joint movements

5) selective control of movement: more control, less reliance on synergy patterns

• tx focus= strengthen individual muscle control, refine movement patterns, incorporate functional tasks

6) isolated, coordinated movement: isolated joint movements are smooth and controlled

• tx focus= fine motor coordination, balance, strength training

What is Pusher Syndrome? How can it be managed?

• Misperception of what, causing what?

• What activities can this be seen in?

• Key interventions? (What types of feedback can be used and how? What types of training are ideal for this syndrome?)

  • What side should you guard on?

ipsilateral pushing: neurological condition seen in pts with stroke or brain injury, where they actively push toward their weaker, hemiparetic side using their stronger limbs (causes lateral postural imbalance)

• misconception of vertical orientation, leading to postural imbalance

• seen in various postures and activities (sitting, standing, and walking)

key interventions

• visual & sensory feedback: use mirrors to help pts align with visual verticals; have them touch a stable surface (wall, chair) with a non-affected hand for reference

• weight shifting & postural training: encourage active midline orientation by shifting weight toward the stronger side

• task-specific training: lateral reaching tasks to promote midline awareness (guard on weaker side)

  • Guard on weaker side

Which is more effective for Pusher Syndrome, active or passive correction? Do not do what to patients with this syndrome and why? What are some cues you can used to help guide a patient?

active; DO NOT PASSIVELY MOVE THEM!! pt doesn't respond well to passive repositioning (being pushed into correct posture)

-"lean towards the wall"

-"lean towards me"

What would be appropriate treatment protocols for a patient with a flaccid UE or LE?

• Effective position of the pt in bed: Put a pillow under what and why? What should be offloaded and how? Put pillow where when sidelying?

• Bed mobility and transfers: Proper rolling towards the affected or unaffected side when at home or with nurses? What should be worked on at therapy?

effective position of the pt in bed:

• put a pillow under the affected UE while supine to promote extension

• offload the heels by putting a pillow under the calves

• put a pillow between the LE and the arm when side lying

bed mobility and transfers:

• proper rolling towards unaffected side at home or with nurses for safety

• work on the affected side in therapy to strengthen

How can spasticity be managed?

• What type of stretching is ideal and for how long? Why? What can help maintain muscle length?

  • What is autogenic inhibition and how does it work (mediated by what)?

• WB joints approximation for?

• Strengthen what muscles?

• Positioning techniques: What positions and why?

• E stim used for?

• Avoid spasticity triggers such as?

• What medication are used to treat spasticity?

• Straps should be used for? Are free weights open chain or machine closed chain better for spasticity?

• prolonged, slow stretching (hold for 30-60 sec)--> targets hypertonic muscles to reduce stiffness; splinting or orthotics may help maintain length

  • autogenic inhibition: neuromuscular reflex that causes a reduction in muscle activity following an excessive or sustained increase in tension, primarily mediated by Golgi tendon organs (GTOs)

• WB joint approximation for muscle recruitment

• strengthen antagonists (opposite muscles)--> ex. strengthen DF to reduce PF spasticity

• positioning techniques--> prevents contractures (side-lying, weight-bearing postures)

• e-stim (NMES, TENS)--> activates weak muscles or fatigues spastic ones

• avoiding spasticity triggers (fatigue, stress, infections)

• medications: Diazepam (Valium), Baclofen (Lioresal), Dantrolene Sodium (Dantrium), Botox injections to manage focal spasticity

• use straps for hands and feet, closed chain exercises and machines instead of free weights and open chain

Why is it important to avoid learned non-use?

when a pt neglects using a weaker limb due to difficulty or frustration, it leads to further loss of function (muscle atrophy and further weakness)

• if you don't use it, you'll lose it

When are compensatory strategies appropriate?

• You should encourage what first, then integrate compensatory strategies when needed to?

  • What are the two reasons to learn compensatory strategies

if not achieving full recovery

• encourage restorative therapy first, but integrate compensatory strategies when needed to maintain function (not likely to regain it)

  • 1) recovery is limited or unlikely (chronic stroke with severe deficits)

  • 2) pt has safety concerns (fall risk, difficulty holding objects securely)

Be able to prescribe activities for a patient with a stroke, based on a case scenario.

• To encourage engagement, the activities need to be?

• Use of feedback (what 2 types)

• Practice need to be physical and?

• Attention to? This relates to what framework?

• Monitor for what two things?

-patient engagement--> meaningful activities

-use of feedback (intrinsic and extrinsic)

-practice (physical and mental)

-attention to learning environment--> Gentile's Taxonomy

-monitor for physical and mental fatigue--> adjusting dose and progression

Be able to apply Gentile's Taxonomy to a patient scenario. Based upon a case scenario, design the appropriate treatment environment.

• What are the 4 sections?

• example case scenario: a post-stroke patient with R hemiparesis is working on improving STS transfers and ambulation with an AD:

  • Apply Gentiles Taxonomy and outline each of the 4 sections for this patient.

  • (^ For this, the example ashley gave makes no sense so forget what it says there, just follow what evelio told u)

1) stationary individual in stationary environment

2) moving individual in a stationary environment

3) stationary individual in a moving environment

4) moving individual in a moving environment

🔹 1. Stationary individual in stationary environment

• Body stability

• Stable, predictable environment

________________________________________

🔹 2. Moving individual in stationary environment

• Body transport introduced

• Environment still stable

________________________________________

🔹 3. Stationary individual in moving environment

• External environment becomes:

o Variable / unpredictable

________________________________________

🔹 4. Moving individual in moving environment (MOST COMPLEX)

• Body transport + environmental variability

________________________________________

How can mental practice (motor imagery) be applied during patient treatment?

• if the pt is cognitively aware, instruct them to run through the exercise in their head, so mental repetitions promote neuroplasticity

• Kinda like mental image training

How can neuroplasticity be promoted?

• What three things? For one of those things, what is it so important?

salience (important/significant) mental imagery, repetition, intensity

INTENSITY MATTERS BC IT PROMOTES NEUROPLASTCITY!--> Karvonen Formula: THR= [(HRmax-HRrest)x intensity] + HRrest

Be familiar with constraint induced therapy.

• What is it? Promotes what and prevents what? Must be _____ to the pt.

• Pts should be?

• Lasts up to how long and in intervals that are how long? Rests should be?

  • What other item is used to give visual feedback to the pt?

restrict the unaffected limb and perform intensive, repetitive tasks with the affected limb

• promotes neuroplasticity and prevents learned non-use; must be salient to the pt!

• pts should be cognitively aware

• lasts up to 15 minutes in 5-minute intervals with short rests

  • includes mirror therapy: artificial visual feedback makes it possible for the pt to "move" the affected limb

Apply strategies to improve sensory function based upon a case scenario.

? No info on Ashley’s or Amanda’s guide

How can mirror therapy be used to promote movement in a patient's hand? How does it work?

neuroplasticity activation

• the brain perceives the affected limb as moving, activating mirror neurons and motor pathways

  • tricks the brain into thinking that the involved limb is moving like normal

  • helps retrain the brain-body connection and improve voluntary movement

How can body weight support, virtual reality, and/or robotics be applied to patient care management?

• When would body weight support or the Lokomat be appropriate for a patient (robotic tech)? Describe the robotic assistance, therapist efficiency, and precautions.

• How does the Alter G treadmill work? This allows for what activities? Cons?

• How might gaming or virtual reality be incorporated into patient treatment? VR driving helps with what and music glove hand therapy helps with what?

When would body weight support or the Lokomat be appropriate for a patient (robotic tech):

• Works well with neurological patients, pediatric neuromuscular rehabilitation, severe muscle atrophy

  • Robotic Assistance: Lokomat is especially suitable for patients needing consistent, repetitive gait patterns → severe spasticity or poor motor control.

  • Therapist Efficiency: For patients requiring long-duration gait training that may be physically demanding for therapists to manually assist.

  • Precautions: check for pressure injuries. The harness lifts from the hips which may lead to femoral artery issues. Pts w/ cognitive deficiency might not be able to give feedback of level of comfort.

(2) How does the Alter G treadmill work?

• Reduced gravity

  • Works by using differential air pressure (DAP) technology to reduce the user's body weight, allowing for low-impact exercise and rehabilitation.

  • CON: Therapist cannot give physical cues because the patient is enclosed in the treadmill

(3) How might gaming or virtual reality be incorporated into patient treatment?

• Makes rehab engaging and interactive while promoting specific functional goals.

  • VR can simulate real-world challenges, such as navigating through crowds

  • Driving: attention, reaction time, visual scanning, and decision-making

  • Music Glove Hand Therapy: finger dexterity, strength, and coordination

What role does electrical stimulation play? Functional component? Spasticity management?

• Activates ____ muscles or fatigues ______ ones.

• FES uses what? What does this allow it to do?

  • Give an example of e stim on the LE being used to help functionally.

  • Give an example of e stim application on UE. What patient population would this help?

• spasticity--> activates weak muscles or fatigues spastic ones

• functional electrical stimulation (FES) use low-level electrical currents to activate/facilitate muscle contraction

  • e-stim activates DF during swing phase: a heel switch or motion sensor detects the walking cycle and triggers stimulation at the right time

  • UE applications: hand grasp & release- helps stroke or SCI pts with grasping objects

Be able to identify and prescribe treatment strategies for patients with cognitive-perceptual deficits.

• What approach is very important? What questions should you ask yourself about the patient? How can a social worker help?

• Visual impairments: Acuity? Oculomotor control? Intact visual fields? Diplopia? Homonymous hemianopsia (What type deficit)?

• Body scheme impairments: Unilateral neglect? Anosognosia? Somatoagnosia? Right-left discrimination? Finger agnosia?

use a team approach-> extremely important w/home arrangements & safety

• can they go home alone? will they set their house on fire? will they confuse a household item with food?

• have the social worker (supported by physician/OT/SLP) help find a home for them where they'll be SAFE

visual impairments

• acuity: Snellen chart, 20ft away smallest line person can read

• oculomotor control: smooth pursuits-> tx: bubbles, following object

• intact visual fields: cover one eye, check for peripheral vision

• diplopia: double vision-> tx: eye patching, sx, Botox, referrals

• homonymous hemianopsia: can only see one side; R/L

  • sensory deficit! 1 side gets cut out vs. neglect is a cognitive perceptual deficit

body scheme impairments

• unilateral neglect: unable to register stimuli on one side of body-> tx: work on getting the pt to address that side (stand on affected side, hot/cold, loud noise)

• anosognosia: denial that limb is paralyzed-> tx: getting pt to address the limb

• somatoagnosia: difficulty distinguishing body parts-> tx: pt or therapist stimulate the body part to bring awareness through sensation

• right-left discrimination: inability to discriminate between R/L side of body-> tx: colored stickers on extremities and point to the different colors

• finger agnosia: unable to identify fingers-> tx: rough textures for tactile/sensory input, identifying games

Be able to identify and prescribe treatment strategies for patients with cognitive-perceptual deficits. (continued)

• Spatial relations disorders: figure-ground discrimination? form discrimination? spatial relations? position in space? topographic disorientation? depth and distance perception? vertical disorientation?

• What is agnosia and what are the three types?

• What is apraxia? What are the two types?

spatial relations disorders

• figure-ground discrimination: inability to distinguish figures from an embedded background-> tx: practice identifying objects in threes and then introduce more

• form discrimination: confusion w/objects of similar shape-> tx: practice describing, identifying, demonstrating items (pencil-toothbrush)

• spatial relations: inability to perceive the relationship btwn objects, unable to tell when objects are too close/far apart/approximately lined up-> tx: "sit next to me", "lay down on the bed", activities that encourage crossing over midline

• position in space: difficult to interpret spatial concepts "up, down, over, under"-> tx: place 4 different items in a row, facing the same way and then add a 5th and have it upside down, ask pt to identify if there's an odd one out

• topographic disorientation: difficulty finding one's place to another (person gets lost in a familiar place)-> tx: verbal cues, give directions and see if they can find the end point

• depth and distance perception: judgment of depth is off, misjudge distance, difficulty navigating stairs/curbs-> tx: practice different depths and heights

• vertical disorientation: pts lean to the side (not in midline)-> tx: cueing, mirror (Pusher Syndrome)

agnosia

• inability to recognize/make sense of incoming information despite intact sensory capacities → visual object (don't recognize what they see), auditory (don't recognize what they hear), & tactile agnosia (don't recognize what they feel)

apraxia

• disorder of voluntary skilled learning movement

• ideomotor apraxia: able to carry out habitual tasks automatically, but unable to perform on command; often preservative

• ideational apraxia: failure in conceptualization; inability to perform a purposeful motor task at all; cannot verbally describe the process or functions of objects

What functional activities would be especially difficult for a patient lacking depth perception?

• pouring liquids

• grabbing objects (misjudging distance when reaching)

• using stairs or curbs (difficulty gaging step height)

• crossing the street (judging distance & speed of cars)

• cutting food or using knives (risk of injury)

• driving or parking (judging distance to cars, curbs, or pedestrians)

• catching or throwing a ball (hand-eye coordination issues)

What strategies would be helpful for a patient with unilateral neglect?

• First, what is it? Not due to? What side does it typically occur on?

• Treatment strategies: Sit on left or right? What if they are very inattentive? Give an example

• How can sensory input be used?

• What item can be used to help them see they have the other half of their body? What therapy can be used if their hand is not able to move?

Unilateral Neglect

• Unilateral neglect is the inability to register and integrate stimuli and perceptions from one side of the body (body neglect) and the environment or hemispace (spatial neglect)

• NOT DUE to sensory loss

• Typically seen on the left

Treatment Strategies

• Sit on the left. If they are really inattentive, start on the right and transition to the left.

  • Example: Dr Roberts had a patient that loved TV. She slowly (over weeks) started moving the TV to the left to promote that side (motivation)

• Use motivating factors!

• Use sensory input → tap on the left side, running water, hot & cold, etc.

• Use a mirror so they can see they have a body on the left

  • Mirror Box Therapy if the hand is not able to move

How does hemianopsia compare with unilateral neglect?

• Hemianopsia is what type of deficit? What about unilateral neglect?

• Which one is the patient aware of if they have it? Which is harder to treat?

hemianopsia: sensory deficit (visual)

• you could teach them how to fix it bc they are AWARE of it (they can only see one side)

• easier to treat compared to neglect

Unilateral neglect: cognitive perceptual deficit

• they cannot fix it bc they are NOT AWARE of it (cannot register stimuli on one side)

• more challenging than hemianopsia

Demonstrate knowledge about treatment strategies to promote motor control and functional abilities. For each of the following state what each treatment would entail

• Bed mobility - What movements? What patterns can be used?

• Wheelchair mobility

• Transfers

• Gait and balance

• ROM - What muscles should you focus on?

• Strength training

• Aerobic conditioning

• bed mobility: bridging, rolling (PNF patterns D1/D2 UE & LE), supine to sit via side lying (breaks the task into manageable steps for easier execution)

• wheelchair mobility: propulsion training, WC skills (turns, ramps, curbs, and uneven surfaces), weight shifts to prevent pressure injuries

• transfers: sliding boards, pivot transfers, stand pivot vs. squat pivot

• gait & balance: parallel bars, step-through patterns, cross-stepping, and dual-task walking, balance challenges (EO/EC, foam, perturbations)

• ROM: joint mobilization & stretching (focus on tight hip flexors, hamstrings, and PFs)

• strength training: task-specific (STS, step ups, reaching tasks), PNF strength techniques (repeated contractions & slow reversals)

• aerobic conditioning: seated UE ergometers, recumbent bikes, monitoring HR & BP

What are the parameters for high intensity training for a patient recovering from stroke or head injury?

? No info on Ashley’s or Amanda’s guide.

• Come back to this and use the value from neuro LAB ty evelio

What are the possible mechanisms of a traumatic brain injury (4)

-falls (32%)

-motor vehicle/traffic accidents (19%)

-struck by/against events (18%)

-assaults (10%)

What is a concussion? AKA mTBI

• Can be caused by what two things?

• If some gets a concussion, does that mean they will lose consciousness or not?

• Why should you take concussion seriously?

brain injury when the brain is shaken inside the skull (aka mTBI)

• can be caused by a direct force to the head or an indirect force

• they MAY OR MAY NOT lose consciousness (before if they did lose consciousness, it was not considered a concussion)

CONCUSSION IS A BRAIN INJURY, don't take it lightly!

How can the SCAT6 assist with concussion identification? What age group and population? What does it include? Determines if?

Sport Concussion Assessment Tool (SCAT) 6 for evaluating athletes aged 13 years and older

• list of steps that compiles objective and subjective findings

• determines if the person had a concussion and which functions are impacted

Are there red flags?

• If yes: Remove from play for immediate medical assessment or transport to hospital/medical Centre

• If no: Continue to next question

Positive observable signs?

• If yes: Remove from play for immediate medical assessment or transport to hospital/medical Centre

• If no: Continue to next question

Glasgow coma scale score < 15?

• If yes: Remove from play for immediate medical assessment or transport to hospital/medical Centre

• If no: Continue to next question

Neck pain, tenderness, or loss of ROM?

• If yes: Spinal immobilization and cervical collar AND remove from play for immediate medical assessment or transport to hospital/medical Centre

• If no: Continue to next question

Coordination or ocular/motor screen abnormalities?

• If yes: Remove from play for immediate medical assessment or transport to hospital/medical Centre

• If no: Continue to next question

Memory/Maddocks questions score <5?

• If yes: Remove from play for immediate medical assessment or transport to hospital/medical Centre

• If no: Continue with SCAT6 Administration

What is Chronic Traumatic Encephalopathy CTE?

• Commonly seen in what populations?

• S/S? These can lead to what?

CTE: progressive neurodegenerative disorder caused by repeated head trauma, such as concussions or sub concussive hits

• commonly seen in athletes (football, boxing), military personnel, and others exposed to repetitive brain injuries--> Like Tua

  • some athletes have committed suicide by shooting their heart and not their brain so that their brains could be studied

• s/s: memory problems, changes in emotion and personality → depression

Be able to recognize the signs and symptoms of concussion and CTE. Discuss issues of return to play and return to learn or work.

• Physical Symptoms Concussion

• Potential Longer Term Symptoms of Concussion

• Emotional Symptoms of Concussion

• Cognitive Symptoms of Concussion

physical symptoms concussion

• headaches & dizziness

• difficulty w/balance

• N/V

• fatigue

• difficulty w/sleeping

• double or blurred vision

• sensitivity to light/sound

• slurred speech

• glassy-eyed stare

potential longer-term symptoms of concussion

• loss of libido

• loss of menstruation

• growth problems (children)

• fatigue, exercise intolerance

• weight gain

• changes in BP and/or HR

• muscle weakness

• chronic headaches or dizziness

• muscle spasticity

• early dementia/chronic traumatic encephalopathy (brain disorder)

emotional symptoms of concussion

• irritability

• restlessness

• anxiety

• depression

• mood swings

• aggression

• decreased tolerance for stress

• change in personality/behavior

cognitive symptoms of concussion

• difficulty w/memory

• confusion

• slowed processing of information

• Feeling 'foggy'

• difficulty w/concentration

• decreased performance

WHOOP WHOOP

• deterioration of motor skills, memory (could indicate bleed)

Identify the neurological sequelae following a traumatic brain injury.

• Neuromuscular Impairments

• Cognitive Impairments

• Neurobehavioral Impairments

• Communication Impairments

• Swallowing

• Dysautonomia

• Disordered Sleep

• Post traumatic seizures

• Secondary Impairments and Medical Complications

  • Which one of them is getting the pt up important?

  • We want to do ROM, but not _______.

• neuromuscular impairments: paresis, impaired coordination and postural control, abnormal tone, abnormal gait, tremor and chorea (less common)

• cognitive impairments: arousal, concentration, memory, learning, executive functions (planning, cognitive flexibility, response inhibition)

• neurobehavioral impairments: agitation/aggression, disinhibition, apathy, mental inflexibility, impulsiveness, irritability

• communication impairments: disorganized oral or written communication, imprecise language, word retrieval difficulties, socially inappropriate language, difficulties in distracting environments, reading social cues

• swallowing: nutritional needs and aspiration risk

• dysautonomia: overactive sympathetic response-> increased HR, RR, and BP, diaphoresis, decerebrate/decorticate posturing, hypertonia, and teeth grinding

• disordered sleep: insomnia, hypersomnia, and sleep apnea (think of their circadian rhythm and natural light)

• post traumatic seizures: phenytoin (anticonvulsant)

• secondary impairments and medical conditions: due to the high potential of prolonged immobility and collateral injury:

Identify the changes in consciousness with traumatic brain injury.

• Coma

• Unresponsive wakefulness

• Minimally conscious state

• What are the 5 levels of consciousness?

• coma (different from a medically induced coma): no evidence of awareness

• unresponsive wakefulness (vegetative state): there is a sleep-wake cycle; eyes may be open, they might have reflexive squeezing, but they are not responsive

• minimally conscious state

5 levels of consciousness

• 1) alert: responds readily, may be confused

• 2) lethargic: drowsy

• 3) obtunded: difficult to arouse, cannot make complete sentences, repeated stimulation

• 4) stuporous: no verbal response, may moan, responds to pain by moving

• 5) comatose: no evidence of awareness

What is amnesia? Post traumatic amnesia?

• not being able to recall an event (the shorter it lasts, the better the prognosis)

• post-traumatic amnesia: length of time between the injury and the time at which the patient is able to consistently remember ongoing events’

  • the period after a brain injury until the patient can consistently remember ongoing events again.

  • after brain injury, the person is not yet reliably remembering what is happening right now / from moment to moment

What is the difference between declarative and procedural memory? Implicit Learning?

• declarative memory: the ability to recall facts and events from past experiences (remembering a pt's name or the steps of an exercise)

• procedural memory: the ability to remember how to perform a task, often referred to as muscle memory; involves practicing previously learned skills

• implicit learning: a form on non-cognitive learning that occurs without conscious awareness, like adapting to movement patterns without explicit instruction

What is the Glasgow Coma Scale and how is the score used in treatment?

• How does the scoring work and what is the ranges for severe, moderate, and mild?

Sections:

Eye Opening

• Spontaneous — 4

• To speech — 3

• To pain — 2

• No response — 1

Best Motor Response

• Follows motor commands — 6

• Localizes — 5

• Withdraws — 4

• Abnormal flexion — 3

• Extensor response — 2

• No response — 1

Verbal Response

• Oriented — 5

• Confused conversation — 4

• Inappropriate words — 3

• Incomprehensible sounds — 2

• No response — 1

the higher the score, the better the outcome

• 8 or less (severe)

• 9 to 12 (moderate)

• 13 to 15 (mild)

Be familiar with the Rancho Los Amigos Cognitive Functioning Scale. How might it guide therapeutic interactions and the treatment environment?

• Set realistic what?

• How can communication be modified?

• Tailor treatment activities: For lower levels 1 - 3, Mid levels 4 - 6, Higher levels 7 - 8)

people are not textbooks, but knowing the level they fall in this scale can help you be realistic with your treatment and make activities meaningful for the pt

• set realistic goals (a Level III won't be able to follow complex commands)

• modify communication: use simple cues for lower levels (I-III) and encourage problem-solving in higher levels (VII-VIII)

• tailor treatment activities

  • lower levels (I-III): sensory stimulation, positioning, passive ROM

  • mid levels (IV-VI): structured tasks, simple functional activities, redirection for agitation

  • higher levels (VII-VIII): community reintegration, memory aids

• optimize the environment: reduce distractions for confused pts (IV-V), introduce real-world challenges for more advanced levels (VII-VIII)

I. No Response
Patient appears to be in a deep sleep and is completely unresponsive to any stimuli.

II. Generalized Response
Patient reacts inconsistently and nonpurposefully to stimuli in a nonspecific manner. Responses are limited and often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and/or vocalization.

III. Localized Response
Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as closing eyes or squeezing hand in an inconsistent, delayed manner.

IV. Confused-Agitated
Patient is in a heightened state of activity. Behavior is bizarre and nonpurposeful relative to immediate environment. Does not discriminate among persons or objects; is unable to cooperate directly with treatment efforts. Verbalizations frequently are incoherent and/or inappropriate to the environment; confabulation may be present. Gross attention to environment is very brief; selective attention is often nonexistent. Patient lacks short- and long-term recall.

V. Confused-Inappropriate
Patient is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, responses are nonpurposeful, random, or fragmented. Demonstrates gross attention to the environment but is highly distractible and lacks ability to focus attention on a specific task. With structure, may be able to converse on a social automatic level for short periods of time. Verbalization is often inappropriate and confabulatory. Memory is severely impaired; often shows inappropriate use of objects; may perform previously learned tasks with structure but is unable to learn new information.

VI. Confused-Appropriate
Patient shows goal-directed behavior but is dependent on external input or direction. Follows simple directions consistently and shows carryover for relearned tasks such as self-care. Responses may be incorrect due to memory problems, but they are appropriate to the situation. Past memories show more depth and detail than recent memory.

VII. Automatic-Appropriate
Patient appears appropriate and oriented within the hospital and home settings; goes through daily routine automatically, but frequently robot-like. Patient shows minimal to no confusion and has shallow recall of activities. Shows carryover for new learning but at a decreased rate. With structure is able to initiate social or recreational activities; judgment remains impaired.

VIII. Purposeful-Appropriate
Patient is able to recall and integrate past and recent events and is aware of and responsive to environment. Shows carryover for new learning and needs no supervision once activities are learned. May continue to show a decreased ability relative to premorbid abilities, abstract reasoning, tolerance for stress, and judgment in emergencies or unusual circumstances

Describe the medical management following a TBI.

• When does medical management start? What is included in that management?

• Medical interventions include what?

  • Why would they use sugar or salt?

• What team approach is ideal?

• medical management starts at the scene: maintain blood flow and oxygen to the brain, stabilize the pt, treat other injuries, avoid elevation of intracranial pressure (pt positioned with head at 30°)

• medical interventions: medications, osmotherapy, hypothermia (aka target temperature management), surgical decompression

  • sugar or salt pull the fluid out of the brain (reduce risk of brain swelling)

• interdisciplinary team approach

What is heterotopic ossification and its relationship with TBI and SCI?

• What should you be careful about when doing as it can promote HO?

• Commonly occurs after (2)? For each, what area does it occur in?

abnormal formation of bone in soft tissues

• careful with aggressive stretching! (could promote HO)

-commonly occurs after TBI and SCI

*TBI-related HO: often affects hips, shoulder, elbow

*SCI-related HO: commonly occurs around the hips, shoulder, knee

What are the signs and symptoms of HO? How is it treated?

• What medications are used?

• What therapy is done?

• If its severe and functionally limiting then what can be done?

• What therapy can be done to prevent recurrence in some cases?

S/S: pain, decreased ROM, swelling and warmth around the area, joint stiffness

tx & management:

• medications: NSAIDs to decrease inflammation, bisphosphonates to slow bone growth

• physical therapy: ROM exercises to maintain mobility but avoid aggressive stretching

• surgical removal: if severe and functionally limited

• radiation therapy: in some cases, used to prevent recurrence

Outline the components of a physical therapy examination for a patient with TBI. Tip: Many of the same treatment procedures are utilized for a patient with TBI or stroke.

• Perform a through what? What should you make sure to include?

• Find out about the pts (4)?

  • For a good prognosis what is ideal? What might lead to a bad prognosis?

• Assess systems includes?

• Assess function includes?

• perform thorough history including history of injury, PMHx, results of CT scan/MRI

• find out about living situation, PLOF, work/school life, family

  • good prognosis-> active individual, younger age, no comorbidities

  • bad prognosis-> diffuse axonal injury (global TBI), decorticate/decerebrate positioning

assess systems:

• cognition/ability to follow commands

• spasticity/tone

• muscle function

• coordination

• sensation

• vital signs

• skin integrity

• ROM

• respiratory function

• CNs

assess function:

• bed mobility

• ambulation

• transfers

• balance

• stairs

• wheelchair mobility

Based on a case scenario, prescribe a physical therapy plan of care for a patient with TBI.

• What scale can help?

• What is the aerobic exercise recommendation for TBI? (Intensity, duration, frequency)

  • When can they start to do aerobic exercise after a CVA/TBI? They have to be medically ______, if not then?

• What is the strength exercise recommendation for TBI? (Intensity, duration, frequency)

• What is the Flexibility exercise recommendation for TBI? (Intensity, duration, frequency)

Rancho Los Amigos can help with this!

aerobic exercise recommendation for TBI

• intensity: 40-70% of VO2 peak

• duration: 20-60 minutes per session

• frequency: 3-5 times/wk

  • can start 8 to 21 days after CVA/TBI if medically stable

  • if unstable, PT contraindicated

strength exercise recommendation for TBI

• intensity: 3 sets of 8-12 reps

• duration: 1-2 sets

• frequency: 2-3 days/wk

flexibility exercise recommendation for TBI

• intensity: to tolerance

• duration: 30-60 second hold, 3 times for each muscle/joint

• frequency: 2 days/wk (before or after aerobic/strength)

How can spasticity be managed in a patient with a TBI?

• Stretching need to be? Hold for how long?

• Why WB joint approximation?

• Strengthen what muscles

• Positioning techniques include what? This prevents?

• E stim used for?

• Avoid spasticity triggers like?

• What should be used t the hands and feet and should you do closed chain exercises and machines or free weights and open chain exercise?

• prolonged, slow stretching (hold for 30-60 sec)

• WB joint approximation for muscle recruitment

• strengthen antagonists (opposite muscles)

• positioning techniques: prevents contractures (side-lying, weight-bearing postures)

• E-stim (NMES, TENS): stim the muscle opposite of the spastic muscle= reciprocal inhibition

• avoiding spasticity triggers (fatigue, stress, infections)

• use straps for hands and feet, closed chain exercises and machines instead of free weights and open chain (from lab)

What is serial casting?

• When is the cast changed? with each change what is increased? What should you make sure to check? If a cast is not appropriate then what can be used?

non-invasive method used to gradually increase joint mobility and reduce spasticity by applying a series of progressive casts--> a prolonged stretch

• the cast is changed every few days (2-5), increasing the stretch incrementally (CHECK FOR SKIN INTEGRITY!)

• could use a splint instead if casting is not appropriate

How would you modify the treatment environment to promote positive outcomes for a patient with TBI?

• use care NOT to overstimulate (monitor the pt's response)

Be able to apply PNF principles to TBI rehabilitation.

• bed mobility

• sitting balance

• gait training

• upper limb recovery

• bed mobility: D1 flexion/extension to facilitate rolling

• sitting balance: rhythmic stabilization for core control

• gait training: D1/D2 LE patterns to improve step initiation & weight shifting

• upper limb recovery: slow reversals in D1 flexion/extension for reaching tasks

How can neuroplasticity be promoted in a patient who sustained a TBI?

• INTENSITY AND SALIENCE (IMPORTANCE) MATTERS!