OTA 103 Module 3

Cerebrovascular Accident (CVA)

Stroke

When does a stroke occur?

When there is a sudden death of brain cells due to lack of oxygen caused by disrupted blood flow to the brain.

Infarction

Dead tissue to the lack of adequate blood supply

Lesion

Injury

Neurological deficits affect

opposite side of the body to the hemisphere that was injured

Ischemic Stroke

Most common type of stroke, caused by blockage of artery that supplies blood to brain. Most common arteries affected: internal caotid arteries.

Ischemic Stroke

Is caused by Thrombosis & Embolism

Thrombosis

Blood supply may be blocked due to clot in one of the arteries

Embolism

Commonly a blood clot that breaks off and travels to the brain. Other sources of embolic material: fat globules, air bubbles, amniotic fluid, or septic emboli that contains bacteria and pus.

Hemorrhagic Stroke

Less common type of stroke, occurs when blood vessel breaks & causes a bleed in the brain. Caused by arteriovenous malformation (AVM) & aneurysm.

Aneursym

Ballooning of a blood vessel that causes walls of the vessel to become thin where ballooned & suspectible to rupture.

Arteriovenous Malformation (AVM)

Defect of the circulatory system. Occurs when there is lack of tiny cappillaries that connect directly to the ateries and veins. Causes nests of tangled arteries and veins that can weaken vessels and result in a rupture. Usually arises during fetal development.

Transient Ischemic Attack (TIA)

Temporary blockage of blood to the brain, results in temporary disturbance in function. Sudden onset of symptoms that’s consistent with having a stroke. Symptoms do not last longer than 24 hours lasting 2-30 minutes. Does not cause permanent damage. May be warning sign of potential stroke.

Symptoms of Transient Ischemic Attack

Confusion, Difficulty with vision with one or both eyes, Loss of balance with inability to walk, Numbness or weakness on one side of the body or face. Difficulty with speaking or understanding the spoken word.

Medical Management of Stroke

Surgery, Medications, Emergency treatment, Early treatment, Proper medical management.

Medical Complications of Stroke

Seizures, Deep Vein Thrombosis (DVT), Pulmonary embolism (PE), Urinary tract infection, Increased risk for lung infections & pneumonia, Subluxation of glenohumeral joint (shoulder), Aspiration/Dysphagia, and Skin breakdown & decubitus ulcers.

Deep Vein Thrombosis

Most common medical complication, blood clot forms in deep vein of thigh or lower leg

Pulmonary Embolism (PE)

Bloot Clot that to the lungs

Seizures

Increased risk for from the damage to brain tissue. Side effects form anti-seizure medications include drowsiness & impaired cognitive skills.

Shoulder Subluxation

Caused by weakness of rotator cuff muscles and/or spasticity of scapular muscles

Stroke has an Increased Risk for Lung Infections & PNA (Pneumonia)

Decreased mobility, Dysphagia, Weak respiratory muscles

Urinary Tract Infection

Due to incontinence or urinary retention. Use of diapers and/or poor perineal hygiene. Weakened or hypertonic urinary sphincter muscles.

Skin Breakdown & Decubitus Ulcers

Decrease in mobility & sensation.

Role of OTA with CVAs

Improve motor function. Integrate sensory-perceptual & cognitive functions. Facilitate maximum level of function independence. Encourage resumption of life roles. Promote health management & maintenance behaviors to prevent recurrent stroke.

Treatment Activities for Stroke patients

Level of difficulty in initial treatment activities should be established from the evaluation. Take into consideration client factors including: Age, symptoms from the stroke, Medical status, Existing medical Conditions

Major function of Central Nervous System

Recieve information from the body, which processes the information. Send a response to periphery.

Major function of the Peripheral Nervous System

Conducts information from the body to the CNS (afferent) & from the CNS to the body (efferent).

Parts of Peripheral Nervous System

Autonomic Nervous System & Somatic Nervous System

Autonomic Nervous System

Involuntary & unconscious, regulates the viscera (internal organs)

Somatic Nervous System

Voluntary & conscious. Regulates skeletal muscles & skin.

Myelination

Information transmitted along nerve fibers.

Myelin

Lipid-rich substance that wraps around axons of rapidly conducting nerve fibers. Increases velocity of impulses so information can travel significantly faster.

Motor Control

Process to achieve desired movement or set of actions

Normal postural medhanism allows for

stability, mobility, dynamic balance, & midline orientation.

Normal muscle tone

Muscles are in continuous state of mild preparedness or contraction. Small amount of involuntary resistanct to passive stretch.

Clonus

Repetitive muscle contraction in response to a quick stretch. Measured by # of beats (contractions)

Rigidity

Increase muscle tone of both against & antagonist muscle simultaneously. Results in resistance to passive movement in any direction throughtout the range of motion.

Isolated Control

When muscles more voluntary. Certain muscles can be stabilized while other muscles move into flexion & extension.

Hypertonic muscles

Flexor muscles of the upper extremity, extensor muscles of the lower extremity. Increase of tone from emotional stress, pain, fear, & cold.

Synergies

Mass pattern movement

Voluntary movement possible with

mass patterns of flexion/extension with inability to perform isolated movement of any one joint. Muscle grades not given synergistic movement.

Ataxia

Delayed initiation with problems in range, rate, force, and regularity of movement.

Adiadochokinesis

Decreased rapidly alternating movements

Dysmetria

Inability to estimate range of movement needed to reach a desire object.

Neurotherapeutic Approaches

Brunnstorm, Rood Approach, Proprioceptive Neuromuscular Facilitation (PNF), Neurodevelopemtal Approach (NDT)

Brunnstrom

Regresses to former patterns of movements from earlier life reappear. Uses motor patterns available to patient at any point in recovery process towards normal & complex movement patterns. Seven stages of recovery. Synergies intermediate stage for further recovery. Treatment begins by faclititating control of syngergies and then begin combine movements to deviate from synergy patterns.

Brunnstrom Treatment Strategies

Movement moves from flaccid, syngergies (spasticity), movement deviating from synergy (spasticity), movement deviating from synergy, isolated control. Associated reactions, facilitate movement on hemiplegic side. Recovery of movement proximal to distal. Can work on combined movements, facilitate synergy, management of posture and position, subluxation.

Associated movements

Involuntary control of hemiplegic side

Proprioceptive Neuromuscular Facilitation (PNF)

Herman Kabat , MD, Dorothy Voss, PT, & Margaret Knott, PT in early 50s.

PNF- Intervention Principles

Normal motor development proceeds in cephalocaudal & proximodistal direction. Early motor behavior dominated by reflex activity. Motor behavior is dominated by reflex actiivity. Motor behavior expressed in orderly sequence of total patterns of posture and movements. Growth of motor behavior has a rhytmic & cyclical trend, as evidenced by shifts between flexor & extensor dominance. Normal motor development orderly sequeence but lacks a step -by-step quality. Establishing balance between antagonists is a main objective of PNF. Improvement in motor ability depends on motor learning. Goal-directed activities coupled with techniques of facilitation are used to hasten learning of total patterns of walking & self-care activities.

PNF use of diagonal patterns.

Mass movement patterns observaed in most functional activities. Unilateral patterns are used. Challenge is recoginizing diagonal patterns in ADL. Bilateral Patterns. Developmental postures are called total patterns of movement & posture.

Bilateral patterns

Symmetric, Asymmetric, Ipsilateral, Contralateral, Diagonal reciprocal.

Reciprocal Bilateral Patterns

Use of UE to balance when walking on balance beam

Symmetric Bilateral Patterns

Reaching to lift large obeject off high shelf.

Asymmetric Bilateral Patterns

Putting on left earring using both hands

Ipsilateral Bilateral Patterns

Same side of body

Contralateral Bilateral Patterns

Oppositie side of body

Diagonal reiprocal Bilateral Patterns

Crossing midline, trunk rotation, total pattern can use stronger muscles to help weaker muscles.

Procedures to Faciltate Movement for Proprioceptive Neuromuscular Facilititation (PNF)

visual cues, manual contacts, verbal commands, stretches, traction, approximation, rhythmic initiation, approximation, rhythmic initiation, relaxation techniques.

Rood Approach

Margret Rood approach use of sensory stimulation in the 1940s. Controlled sensory positions & activities that follow normal ontogenic motor development, to produce purposeful muscular responses.

Basic assumptions of the Rood Approaches

Normal muscle prerequisite for movement. Treatment begins at developmental level of functioning. Motiviation enhances purposeful movement. Repetition is necessary for the reeducation of muscular responses.

Principles of Rood approaches.

Reflexes assist or retard effects of sensory stimulation. Sensory stimulation of receptors can produce predictable responses. Muscles have different duties. Heavy-work, stabilizers. Light-work, mobilizers. Heavy work before light work.

Sequence of Motor Development occurs through 8 Ontogenic Motor Patterns

Reciprocal Inhibition (relax one to contract), Co-contraction (same time contraction), Heavy-work (stability), Skill (both stability & mobility)

Rood: Treatment Techniques- Inhibitory Stimulation

Neutral warmth, slow rhythmic rocking. Manual stroking of the spine. Manual stroking of the spine. Manual pressure on upper lip, soles of the feet & hand. Manual pressure to the tendinous insertion of a muscle. Light compression. Positioning spastic muscles in an elongated position.

Rood: Treatment Techniques- Facilitatory Stimulation

Quick stretch of a muscle. Tapping over a muscle belly. Fast brushing over a muscle belly. Vibration over the muscle. Icing, thermal stimulus can have unpredictable results. Heavy joint compression to faclitiate joint co-contraction.

Neurodevelopemtnal Approach (NDT)

Developed by Bertha Bobath (PT) & husband Karel (neurologist). Normal movement patterns are emphasixed in approach. Symmetry & alignment of the trunk & pelvis are important.

Common impairments with hemiplegia

Muscle tone in affected side moves from being flaccid to having mixed tone with both flaccidity and spasticity. Most common problem, & compromises function. Sensory loss, visual-perceptual problems, diminished weight bearing on the hemiplegic side, & apraxia also affect functional abilities.

NDT Intervention Goals

Normalize tone. Inhibit primitive movement patterns. Facilitate normal movement. Quality over quantity of movement.

NDT: Treatment Techniques to Normalize Tone

Weight bearing over the affected side. promotes sensory input & awareness to hemiplegic side. UE weight bearing procedures: start with scapular mobilization. If sitting, hand should be several inches from the hip. Humerus should be external rotation with elbow in extension.

Treatment Techniques for NDT

Trunk rotation (dissociation of upper & lower trunk). Activities incorporate trunk rotation in either sitting or standing. Aids in trunk stability. Promos weight shifting to the hemiplegic side. Increases sensory input & awareness of the hemiplegic side.

NDT Scapular protraction

Helpful for patients with UE flexor. Protract scapula before moving hemiplegic arm or opening the hand.

NDT Anterior pelvic tilt

Optimal sitting position. Provides proper alignment. Promotes more effective reaching patterns.

Important parts of NDT techniques for treatment.

Proper positioning, incorporate involved UE into activities, Facilitation of slow, controlled movements.

Positioning techniques

Minimizes effect of abnormal tone, promote normal alignment, prevent contracture & skin breakdown. Alternate position every 2-4 hours is reccomend in bed. Symmetrical and erect trunk in sitting.

Hemiparesis

Milder weakness or partial paralysis

Hemiplegia

significant weakness or total paralysis

Spasticity is

velocity dependent, described as minimal, moderate, or severe. May fluctuate daily and increases with stressful body changes.

Motor skill deficits

Absence of voluntary control. Return of function is usually proximal to distal.

OT Treatment for Motor Symptoms

Passive and active ROM, Management of hemiplegic shoulder/subluxation. Motor retraining. Influencing muscle tone. Strengthening & endurance. Edema management. Compensatory techinques.

Passive & Active ROM

Full mobility of scapula, clavicle, and humerus is required for pain-free ROM. Twice daily ROM. AAROM used with minimal active movement.

Management of Hemiplegic Shoulder

Never help a patient to move or scoot in bed or w/c by pulling shoulder. Hemiplegic shoulder for any reason. Ensure movement of the scapula when you provide passive range of motion to shoulder movements. Keep joint mobile as lack of movement & tightness can contribute to pain.

Treatment of Shoulder Subluxation

Avoid overhead pulley exercises & slings. Prevents pain through positioning, PROM exercise, education, taping, and proper handling. ROM program to maintain joint mobility. Educate on attending to & managing their own extremity.

Task-oriented approach

Bilateral training, constraint induced movement therapy. Functionally based approaches that is client driven & occupation based.

Constraint Induced Movement Therapy (CIMT)

Restrains use of functional extermity to force use of affected extremity through participation in an intensive program. Goal to facilitate use of the affected UE.

Bilateral Training

Uses both UE to complete functional tasks simultaneously. Progression of affected arm with motor return is described as stabilizer, gross assist, partial assist, and functional .

Training muscle tone with strengthening & endurance

Use with caution if spasticity is present. Strengthening of unaffected side only if spasticity is not increased on affected side. Endurance training graded to each client’s needs. Incorporate functional, occupation-focused task.

OT treatments to reduce edema

Positioning in elevation. Contrast baths. Retrograde massage, beings at fingertips & move towards the elbow. Pressure garment.

Compensatory Techniques of Hemiplegia/Hemiparesis

Hand dominance retraining. Teaching one-handed techniques. Use of adaptive equipment. Functional positioning.

Homonymous Hemianopsia

Visual loss of one part of the visual field in both eyes. Affects opposite side of lesion in the brain. Difficulty with smooth movement of the eyes. Double vision (diplopia) can also occur.

OT Treatment that is Restorative Approach for Homonymous Hemianopsia

Teaching how to visually scan, Placing commonly placed used objects, Playing games where client use visual search strategies. Practice worksheets where the client must find items on the sheet. Approach client from side of visual loss.

OT Treatment that is Adaptive/Compensatory Approach for Homonymous Hemianopsia

Placing, approaching intact side. Edcuation of safety concerns. Using external anchoring techniques.

Emotional Lability

Emotional response that is inappropriate or out of proportion. Episodes of crying easily or laughing at inappropriate times. Person often feels out of control of their emotional response & embrassed by it.

Agnosia

Inability to process sensory information.

Visual agnosia

Misuse common objects because they do not recognize them

Prosopagnosia

Inability to recognize famillar people by their faces.

Somatognosia

Lack awareness of body structure & has diffculty recognizing body parts in relation to each other.

Treatment for Apraxia

Familar activities. Breaking a task down into many steps & using only verbal commands may make the problem worse. Prior to a task, use proprioceptive & tactile input for required motion of the task. Tactile guiding & verbalizing tasks.

Left CVA conditions

Apraxia, Ideomotor & Apraxia of Speech. Aphasia.

Right CVA

Behavioral Problems, Communication Problems, Dressing Apraxia, Unilateral Neglect, Visual Perceptual Deficits

Aphasia

Loss of ability to use language.