CVA: Clinical Management & Locomotion CPG

What is the most common type of stroke?

MCA

Why is the most common type of stroke more prevalent?

MCA is more common due to anatomy; the angle of this artery is more straight than other arteries, therefore making it easier for plaque or clot to go in this artery

T or F: Anatomy of the brain vasculature predisposes patients to R vertebral artery stroke

False; MCA

What are modifiable and non-modifiable risk factors of a stroke?

modifiable

-sedentary life

-poor diet

-smoking

-living environment

-high BP

non-modifiable

-genetics

-fam hx

-previous stroke

-age, gender

-previous MI

What are the specific warning signs of a stroke?

SUDDEN...

-numbness or weakness of face, arm, leg (particularly one side)

-confusion, trouble speaking or understanding

-trouble seeing

-difficulty walking, dizziness, coordination

-severe headache

What is the quick acronym for stroke prevention? What does it stand for?

act FAST

F= face drooping

A = arm weakness

S = speech difficulty

T = time to call 911

What are the different types of brain vascular syndromes?

-MCA syndrome

-ACA syndrome

-PCA syndrome

-internal carotid artery syndrome

-vertebrobasilar artery syndrome

-lacunar syndrome

What are the precautions for a stroke during PT?

1. monitor vitals

2. prevent & reduce secondary impairments linked to mobility (musculoskeletal contractures/ROM; cardiopulm deconditioning / respiratory; integumentary breakdown)

3. prevent/ reduce fall risk

4. address cognitive / behavioral impairments (R vs L)

5. address speech/ language/ swallowing deficits

6. address visual &perceptual issues

7. screen for depression

What are cognitive / behavioral changes seen with R hemisphere stroke ?

-impulsivity

-poor judgement / insight

-difficulty with abstract reasoning & problem solving

-memory of spatial-perceptual info

-perception/ expression of emotions

-executive functions!!!

What are cognitive / behavioral changes seen with L hemisphere stroke?

-slow

-cautious behavior

-aware of disability

-disorganized

-highly distractable

-processing delays

-apraxia

-communication / language deficits

What are medical & pharma management of stroke?

-immediate CT testing to determine hemorrhage versus thrombotic/embolic infarct

-manage BP, electrolytes, glucose & bladder

-seizure prophylaxis

-pain management

-neurosurgical interventions as indicated

What is the medical prognosis for stroke recovery?

-non-linear pattern as a function of time

-largest improvements in performance typically occur within 6 months following a stroke

-late recovery of function has been demonstrated for pts with chronic stroke who undergo extensive functional training (function-induced plasticity)

T or F: It is unlikely that there will be any further recovery in function with a pt who is 1 year post stroke

False; can happen with extensive functional training

During what time frame will a stroke pt have the largest and most drastic improvement in function?

up to 6 months

What percentage of stroke pts fully recovery to pre-stroke status?

10%

The majority of stroke pts will have what level of disability?

50-60% of pts will have mod to severe disability

T or F: Despite label of "hemiplegia" pts have at least some bilateral dysfunction

True

Briefly describe the sequential motor recovery stages following stroke

stage 1: period of flaccidity

stage 2: limb synergies, minimal voluntary movement, spasticity develops

stage 3: voluntary control of synergies; increased spasticity

stage 4: other movement outside of synergy; spasticity declines

stage 5: difficult movements are learned; synergies lose dominance

stage 6: disappearance of spasticity; coordinated and individual limb movements possible

What is a positive indicator for medical prognosis for arm function recovery?

initial return of movement in the first 2 weeks

What is a negative indicator for medical prognosis of arm function recovery?

failure to recover grip strength before 24 days --> correlated to no recovery of arm function at 3 months

What are strong predictors of walking after a stroke?

-age

-severity of paresis

-leg power

What are the strongest clinical predictors of general stroke recovery?

motor function at baseline and age

In general, poor outcomes for stroke recovery are associated with what factors?

- advanced age & profound neuro impairments

- decreased alertness or attention or judgement

- severe visuospatial hemineglect

- persistent medical problems

- serious language disturbances

- less well-defined social & economic problems

What are the primary impairments following a CVA?

-sensory loss

-pain

-synergistic movements

-weakness

-tone alterations

-abnormal reflexes

-discoordination

-altered motor programming

-postural instability

-speech/language disordres

-altered perception & cog

-etc....

What are the secondary impairments following a CVA?

-loss of ROM

-contractures

-atrophy

-osteoporosis

-fall risk

-seizures

-cardiac abnormalities

-deconditioning

-decreased pulmonary funcitoning

-integumentary damage

What factor is a strong predictor of long-term independence following a stroke?

ambulation ability

What aspects should be incorporated in the activity level part of tests & measures?

-gait, mobility, balance

-aerobic capacity during activities

-self care & domestic life

-core outcome measures could be here too

T or F: R CVA has a 4x greater risk of fall within 6 months

False; L CVA

How should gait, mobility, and balance be assessed?

-use a battery of tests like OGA, FIM, stReAM, 5TSTS, 10meter walk test, BBS, FGA, etc.

-look at level of assistance, use devices, complex gait, etc.

-mobility: bed mobility, transfers, WC mobility

-postural control with sitting, standing, stepping; look at balance in steady state, anticipatory, reactive

How should aerobic capacity during activities be assessed?

-basic assessment would be tolerance of different positions (sitting, standing)

-other tests like 6MWT, 30s STS

-monitor vitals while on ergometer / treadmill

What are the core outcome measures?

ABC scale

5TSTS

BBS

10mWT

FGA

6MWT

What are impairment level aspects to assess during test & measures?

-mental function

-sensory integrity

-muscle performance

-ROM

-aerobic capacity

-motor function

-posture

-CN integrity

-pain

-assistive technology

How should participation level be assessed with tests & measures?

inquire with pt regarding work, school, community, environment, home, and other barriers

What aspects should be included in the systems review?

-neuromuscular

-musculoskeletal

-cardiovascular/pulm

-integumentary

-communication ability, affect, cognition, learning style

How should interventions be made for a pt s/p CVA?

-individualized approach!!!

-task specificity, intensity, and repetition should be considered with each

What are important areas to consider during interventions?

-monitor vitals & RPE

-task specificity****

-dosage and progression

-motor learning strategies(feedback, practice schedule)

-motivation

-systems approach (individual + task + environment)

How many reps should be done for UE task specific rehab? what about LE?

UE = 100s

LE = 1000s

T or F: Learning is promoted when pts receive reduced frequency of feedback and external focus of attention

True

Should challenging tasks be done earlier or later within a training session?

earlier

How do pts with visuospatial working memory deficits learn best?

with blocked practice instead of random practice

What should be avoided with the UE during interventions?

-PROM without adequate scapular mobilization

-pulling on UE during transfers

-using reciprocal pulleys

-CAUTION with slings (may consider taping, NMES, positioning instead)

What are important signs to look out for during aerobic conditioning that may indicate a pt's exertional intolerance?

-excessive fatigue

-dyspnea

-dizziness

-diaphoresis

-nausea

-vomiting

-chest pain

T or F: Current research support constraint-induced movement therapy

True

Should moderate to high intensity walking training be used for chronic stroke locomotion training?

YES! strong recommendation; 60-80% HRR or up to 85% maxHR

Should VR walking training be used for chronic stroke locomotion training?

YES! strong recommendation; helps improve walking speed and distance

Should strength training be used for chronic stroke locomotion training?

maybe...... weak evidence (so do other stuff first)

Should cycling interventions be used for chronic stroke locomotion training?

maybe.... weak evidence (so do other stuff first); could be initially good for those with safety concerns or fear of falling

Should circuit and combined training be used for chronic stroke locomotion training?

maybe.... weak evidence

Should balance training be used for chronic stroke locomotion training?

-DO NOT use sitting/standing balance training

-maybeeeee use static & dynamic balance with coupled VR or augmented visual feedback

When can balance training be used to help locomotion in those with chronic stroke?

when it is coupled with VR or augmented visual feedback

Should body weight support treadmill walking be used for chronic stroke locomotion training?

NO! strong evidence to not use this

Should robotic-assisted walking training be used for chronic stroke locomotion training?

NO! strong evidence to not use this

What SHOULD clinicians use for chronic stroke patients when targeting improvements in ambulation?

-moderate to high aerobic training

-walking training with VR

What should clinicians NOT USE for chronic stroke patients when targeting improvements in ambulation?

NOT

-static or dynamic activities

-BWSTT

-robot assisted gait training

What couldddd clinicians use for chronic stroke patients when targeting improvements in ambulation?

-strength training at 70% 1RM

-circuit training, cycling, stepping at 75-85%HRmax

-balance training with VR

Activity should not be done when the pt's resting HR is what?

>120bpm

Activity should be terminated if BP is at or above what value?

250/115mmHg