CVA Exercises

  • Course: PTA 265

  • Focus Area: Neurological Rehabilitation

  • Instructor: Taylor Lentz

PNF Exercises

  • Overview: Proprioceptive Neuromuscular Facilitation (PNF) is a technique used in rehabilitation to enhance both passive and active range of motion with the ultimate goal of improving functional mobility.

PNF Diagonal Patterns

  • Upper Extremity (UE): Involves diagonal movements across the body, targeting specific muscle groups to enhance coactivation and stability.

  • Lower Extremity (LE): Similar diagonal movements are used for the lower body, focusing on coordination and strength.

Techniques

  • Agonist Reversal (AR): Involves alternating muscle contraction and relaxation to promote functional movement.

  • Alternating Isometrics (AI): Utilizes isometric contractions of opposing muscle groups to improve stability.

  • Contract-Relax (CR): A technique that involves contracting a muscle group followed by relaxation and passive stretching.

  • Hold-Relax (HR): Similar to CR but incorporates an isometric hold.

  • Hold-Relax Active Movement (HRAM): Involves a combination of holding a contracted position followed by an active movement, achieving increased range.

  • Joint Distraction: Facilitating joint mobility through distraction techniques.

  • Normal Timing (NT): Movement sequences emphasized on timing to improve coordination.

  • Repeated Contractions (RC): Involves repetitively contracting a muscle to facilitate movement.

  • Resisted Progression (RP): Resistance is applied to enhance functional mobility during activities.

  • Rhythmic Initiation (RI): Gradually increasing speed of movement to facilitate coordination.

  • Rhythmic Stabilization (RS): Enhancing stabilization by alternating isometric contractions.

  • Rhythmic Rotation (RR): Facilitating mobility through rotational movements.

  • Slow Reversal (SR): Alternating from agonist to antagonist during movement execution.

  • Slow Reversal Hold (SRH): Incorporates a hold at the end of the range of movement.

  • Timing for Emphasis (TE): Highlighting specific movements through timing variations.

NDT Exercises

  • NDT (Neuro-Developmental Treatment): Focuses on facilitating normal movement patterns and decreasing abnormal tone.

Techniques to Promote Movement

  • Resistance: Building strength through applied resistance.

  • Quick Stretch: Utilizing a quick stretch to elicit a muscle response.

  • Tapping: Stimulating muscles through tapping to enhance proprioception.

  • Prolonged Stretch: Aimed at improving flexibility by maintaining a stretch.

  • Joint Approximation: Creating compression at the joint to enhance stability.

  • Overpressure: Applying additional pressure beyond normal range to assist in establishing movement.

Improve Flexibility

  • Weight Shifting: Can be performed in various positions to enhance balance and core stability.   - Sitting or Modified Plantigrade: Encouraging weight shifting through these positions.   - Standing for Lower Extremities: Guarding the patient while they practice weight shifting.   - Physioball Anterior Roll Outs: Utilizes a stability ball for support and movement.   - Protraction/Table Slides: Involves sliding motions that assist in flexibility and mobility.

Improve Strength

  • Exercises:   - Repeated Sit to Stand: Promotes lower extremity strength and function.   - Gripping: Strengthening hand function through repeated gripping exercises.   - Standing 4-Way Hip with Band: Offers resistance through multiple planes.   - Bilateral Resistance: Utilizing bands for total support exercises.

Improve Postural Control & Balance

  • Unsupported Sitting on Edge of Bed (EOB): Enhancing trunk stability in the sitting position.

  • Sitting on Physioball (PB): Promotes dynamic balance.

  • Perturbations: Using AI or RS for trunk stability.

  • Ball Tosses: Performing tosses on various surfaces to engage balance reactions.

  • Trunk Rotations: Implementing trunk rotations with a ball to work on core stability.

Balance Progressions

  • Romberg Test: Assesses static balance and stability.

  • Progressions in Standing:   - Even Surfaces: Eyes open (EO) and eyes closed (EC) for balance testing.   - Foam Surfaces: More challenging balance activities in EO and EC.   - Tandem Standing: Adopting tandem positions on various surfaces.   - Single-Leg Stands (SLS): Progressing from EO to EC.

Constraint-Induced Movement Therapy (CIMT)

  • Strategy: Promotes increased use of the affected Upper Extremity (UE) through focused activities.

  • Mechanism: The less affected UE is restrained to encourage the use of the more affected one.

  • Outcome: Leads to significant gains in motor function and a moderate reduction in disability levels.

Improve Fine Motor Skills

  • Resource: Teaching Mama offers various strategies for enhancing fine motor skills post-stroke.

Mobility and Range of Motion (ROM)

  • Key Activities:   - Sit-Stand Transfers: Teaching safe transitions between sitting and standing.   - Bed Mobility Transfers: Including chop and lift techniques.   - Lower Trunk Rotations (LTR): Assisting with transitions from supine to sidelying positions.   - Modified Plantigrade to Standing Transfers: Facilitating weight shifts to prepare for ambulation.

Pusher Syndrome

  • Definition: Characterized by patients who sit or stand asymmetrically with weight shifted towards the weaker side, causing instability and increased fall risk.

  • Management Strategies:   - Encourage Active Movements: To promote symmetrical posture.   - Visual Stimuli: Utilizing visual aids to direct focus.   - Environmental Prompts: Modifications within the environment to assist in positioning.   - Verbal and Tactile Cues: Using prompt cues to foster awareness and adjustment.

Gait Training

  • Importance: Guarding during ambulation to ensure safety during training.

  • Techniques:   - Starting in Parallel Bars: For safe ambulation learning.   - Step-Ups over Cones: Engaging functional movement practice.   - Blocking Affected LE: Assistance in mobility.   - Color-Coded Dots: Used for visual cues during walking.   - Ambulation with Orthotics: Encouraging safe walking patterns.   - Progression to Uneven Terrain: Enhancing adaptability.

Assistive Devices

  • Reported Devices:   - Rolling Walker (RW): Provides support during ambulation.   - Single Point Cane (SPC): Offers individual assistive guidance.   - Parallel Bars: Fundamental in rehabilitation for safe ambulation.   - Hemiwalker: Specialized device for those with hemiplegia.   - Wheelchair (W/C): Essential for mobility support.

Case Studies

Case #1: Right CVA

  • Profile: Felicia, 43 years old, suffering from left-sided neglect and other deficits.

  • Improvement: Notable progress over five weeks using HKAFO, walker, and cane.

  • Exercise Considerations:   - Goniometric Measurements: Identify deficitis.   - Manual Muscle Testing (MMT): Assess strength capabilities.   - Exercise Categories:     - Gait     - Strength     - Flexibility     - Posture   - Exercise Implementation: 2 exercises per category, with 4 including PNF or NDT.

Case #2: Left CVA

  • Profile: 68-year-old male with right-side hemiplegia and balance issues post stroke.

  • Exercise Planning: Utilize similar measurement and exercise structure as case #1.

Case #3: AVM Stroke

  • Profile: Barb Wiley endured a stroke after AVM; significant effects observed on the left side.

  • Rehabilitation Process: Home care followed by outpatient rehab after intensive rehabilitation.

  • Exercise Planning: Same structure as earlier cases.

Case #4: Young Adult Left CVA

  • Profile: Ryan, a 20-year-old active male, experienced severe hemiplegia post-stroke.

  • Exercise Consideration: Follow the same evaluation and exercise structure for his rehabilitation plan.

References

  • Primary Text: O’Sullivan, S.B. & Schmitz, T. (2014). Physical Rehabilitation (6th ed.). Philadelphia, PA: F. A. Davis.

  • Additional Resources:   - Flint Rehab Articles   - YouTube Videos   - Physioball Exercises   - Scholarly Articles and Blogs