Clinical Decision Making + Interventions for People with Neurologic Disorders

what are 3 TYPES of INTERVENTIONS

1. direct interventions

2. coordination, communication + documentation

3. patient/client-related instructions

what are 8 STEPS for an EFFECTIVE TREATMENT INTERVENTION

1. careful examination + evaluation

2. identify patient problems

3. develop a prioritized problem list

4. identify impairments + functional limitations leading to problems

5. identify impairments/functional which would respond to PT intervention

6. develop a treatment plan with appropriate interventions

7. reassess, reassess, reassess

8. change interventions appropriately

what are 3 TYPES of PATIENT EXAMINATION

1. history

2. systems review

3. tests + measures

what are the 4 COMPONENTS of IDENTIFYING PATIENT PROBLEMS + MOVEMENT SYSTEM DIAGNOSIS

1. health condition (disease/disorder)

2. body structure + function (impairment)

3. activities (functional limitations)

4. movement system diagnosis

what are 3 TYPES of BODY STRUCTURE FUNCTION (Impairments)

1. primary impairment

2. secondary impairment

3. composite impairment

what are 3 TYPES of PRIMARY IMPAIRMENTS

1. tone

2. strength

3. sensation

what are 4 TYPES of SECONDARY IMPAIRMENTS

1. contracture

2. pain

3. edema

4. alignment

what are 6 TYPES of COMPOSITE IMPAIRMENTS

1. movement deficits

2. atypical movements

3. compensations

4. balance

5. posture

6. endurance

what IMPAIRMENT is associated with NEUROLOGIC PROBLEMS

primary impairments

what leads to COMPOSITE IMPAIRMENTS

primary + secondary impairments

what are 4 CATEGORIES of ACTIVITIES (Functional Limitations)

1. gait/stairs

2. ADLs

3. bed mobility

4. transfers

what are 2 FACTORS that affect PARTICIPATION (Disability)

1. life role: age + gender

2. environment (family support, accessibility, economics)

what can PATIENTS with the SAME IMPAIRMENTS + FUNCTIONAL LIMITATIONS have

different degrees of disability

what are 5 QUESTIONS to consider when DEVELOPING a TREATMENT PLAN

1. what are my expected goals?

2. what problems are limiting this patient the most (prioritize, can't treat everything)?

3. how can I treat these problems + get the most out of my treatment?

4. how will I order my treatment?

5. how will I progress the patient?

what are 5 GENERAL TREATMENT CONSIDERATIONS for a neuro patient

1. address KEY IMPAIRMENTS in strength, power, ROM, endurance, posture, balance as needed

2. task-specific functional training of sufficient intensity

3. educate patient

4. provide assistive, adaptive devices as needed

5. promote long-term wellness

what are 3 QUESTIONS to consider when CHOOSING a SPECIFIC INTERVENTION

1. will it help patient accomplish goals?

2. is there scientific evidence to support the intervention?

3. exactly how will I perform the intervention: time, reps, position, force, speed + intensity?

what are 5 SPECIFIC EVIDENCE-BASED NEUROLOGICAL INTERVENTIONS

1. intensive task-oriented/functional training

2. functional electrical stimulation

3. strength training

4. endurance training

5. flexibility/ROM

what is an INTENSIVE TASK-ORIENTED ACTIVITY

is an activity organized around the accomplishment of a task that provides the maximal stimulus for functional improvement

what 5 COMPONENTS does an INTENSIVE TASK-ORIENTED ACTIVITY involve

1. increased time

2. frequency

3. repetitions of an activity

4. increased attention/problems solving

5. increase in physiologic effort

how is PHYSIOLOGIC EFFORT measured

through HR/RPE

is INTENSITY considered RELATIVE/NOT RELATIVE

relative

what are 3 EXAMPLES of INTENSIVE TASK-ORIENTED TRAINING

1. intensive gait + balance training

2. Constraint Induced Movement Therapy (CIMT) + Forced Use Therapy

3. intensive functional circuit training, independent practice, group practice

what 2 ANPT GUIDELINES SHOULD be implemented to improve locomotor function following chronic stroke, incomplete spinal cord injury + brain injury

SHOULD USE:

1. moderate to high intensity walking training

2. virtual reality training interventions coupled with walking practice

what 4 ANPT GUIDELINE SHOULD NOT be used to improve locomotor function following chronic stroke, incomplete spinal cord injury + brain injury

SHOULD NOT:

1. perform sitting/standing balance training

2. use sitting/standing balance training with additional vibratory stimuli

3. body weight-support treadmill training

4. perform walking interventions with exoskeletal robotics on a treadmill/elliptical devices

what are 5 IMPORTANT ASPECTS of HIGH INTENSITY LOCOMOTOR + BALANCE TRAINING RESEARCH*

1. no magic in harness support

2. most benefit noted in protocols that progressively + systematically increased treadmill speed

3. similar benefits to treadmill training alone

4. may be most appropriate for lower level patients to initiate walking/as a protection for higher level patient

5. no better than aggressive brace assisted walking

what are 7 PRACTICAL TRAINING CONSIDERATIONS based on HIGH INTENSITY LOCOMOTOR + BALANCE TRAINING EVIDENCE

1. use minimum amount of BWS to achieve desired result

2. do NOT EXCEED 40-50% BWS during ambulation (preferably <30%)

- higher levels of unloading may be okay for standing activities

3. adjust treadmill speed to optimize quality of gait paying attention to equal step length

4. use principles of progressive interval training for increasing gait speed

5. use principles of aerobic endurance training + monitor vitals of HR max (60-80%)

6. combine auditory + visual cues as needed (virtual reality training)

7. combine with E-stim as needed

what is CONSTRAINT-INDUCED MOVEMENT THERAPY

is behavioral therapy that restricts the use of functional limb to encourage use of the impaired limb

what is the GOAL of CONSTRAINT-INDUCED MOVEMENT THERAPY

attempt to overcome 'learned nonuse'

what is the MINIMUM MOTOR REQUIREMENT for CONSTRAINT-INDUCED MOVEMENT THERAPY

20 degrees wrist extension + 10 degrees extension of all digits

what EXTREMITY is RESTRAINED in CONSTRAINT-INDUCED MOVEMENT THERAPY

less affected upper extremity

regarding E-STIM is there generally more benefit in LOWER/UPPER EXTREMITY

lower extremity

what does E-STIM reduce

shoulder subluxation but no effect on pain

when is it RECOMMENDED to use E-STIM

during functional activities

when is it NOT RECOMMENDED to use E-STIM

during isolation activities

what are 7 BASIC CONSIDERATIONS for STRENGTH TRAINING

1. make strength training functional when possible

(specificity of training)

2. give appropriate resistance (60-80% 1 rep max)

3. 2-3 sets of 8-12 reps 2-3 days/week

4. when considering speed of movement + type of contraction, consider functional task muscle will be used for

5. use eccentrics with very weak muscles

6. remember to progress patient, change exercises periodically + work on power

7. monitor vitals

what is the APPROPRIATE RESISTANCE for STRENGTH TRAINING

60-80% 1 rep max

what is the RECOMMENDED FREQUENCY for STRENGTH TRAINING

2-3 days/week

what is the RECOMMENDED SETS + REPS for STRENGTH TRAINING

Sets: 2-3 sets

Reps: 8-12 reps

regarding STRENGTH TRAINING, what should be considered when considering SPEED of MOVEMENT + TYPE of CONTRACTION

consider the functional task muscle that will be used

should ECCENTRICS/CONCENTRICS be used with very WEAK MUSCLES

eccentrics

what are 2 WAYS to progress a patient in STRENGTH TRAINING

1. change exercises periodically

2. work on power

what are 5 GENERAL CONSIDERATIONS for ENDURANCE TRAINING

1. monitor vitals

2. exercise at 60-80% age predicted max HR or 50-70% heart rate reserve

3. if patient on meds that blunt HR use perceived exertion scales

4. progress to 20-60 minutes of exercise sessions

5. start with frequent brief sessions

what are 2 RECOMMENDED INTENSITIES for ENDURANCE TRIANING

1. 60-80% age predicted max HR

OR

2. 50-70% heart rate reserve

regarding ENDURANCE TRAINING, what should be used if a patients is on MEDICATIONS that BLUNT HEART RATE

perceived exertion scales

what 2 DISORDERS have ABNORMAL HR RESPONSE

1. multiple sclerosis

2. parkinson's disease

what is the INTENSITY LEVEL for DETRAINED

40-50%

what is the INTENSITY LEVEL for LOW FIT

50-60%

what is the INTENSITY LEVEL for AVERAGE FIT

60-75%

what is the INTENSITY LEVEL for an ATHLETE

75-85%

what are the 3 MOST IMPORTANT LOWER EXTREMITY FLEXIBILITY EXERCISES

1. ankle dorsiflexion (with knee extension)

2. hip extension

3. knee extension

what are 2 MOST IMPORTANT UPPER EXTREMITY FLEXIBILITY EXERCISES

1. shoulder external rotation

2. combined wrist/elbow/finger extension (exception SCI)

what are 2 MOST IMPORTANT TURNK FLEXIBILITY EXERCISES

1. extension

2. rotation

what is the ORDERING of INTERVENTIONS within a session (3)

1. significant impairment that need to be addressed prior to functional training (contracture, tone)

2. functional training + function-based strength, balance + endurance

3. supplemental strength, balance + endurance

what are 5 GUIDELINES for NEURO REHAB

1. neuro rehab should be task-oriented + intensive

2. take into account concepts of motor learning

3. neuro rehab should include strength, aerobic + flexibility training

4. techniques (functional electrical stimulation, auditory/visual cueing + forced use) should be used when appropriate

5. patient should be encouraged to practice on their own both physical + mentally