STROKE

Epidemiology
Etiology
1. ATHEROSCLEROSIS
  1. major contributory factor in CV disease
2. Ischemic Strokes
S & S
1. Early Warning Signs
  1. Sudden numbness/weakness face, arm, leg, esp on 1 side of body
  2. Sudden confusion, trouble speaking/understanding
  3. Sudden trouble seeing in 1 or both eyes
  4. Sudden trouble walking, dizziness, loss balance/coordination
  5. Sudden severe idiopathic headaches
  6. Sudden nausea, fever (not viral)
  7. Brief LOC or a pd of decreased consciousness
Risk Factors & Stroke Prevention
1. HBP
2. Heart Disease
3. Diabetes
4. Modifiable
  1. Smoking
  2. Obesity
  3. Lack of Exercise
  4. Diet
  5. Excess Alcohol
5. Nonmodifiable
  1. Age (> 55)
  2. Gender (W>M)
  3. Race (Af Am)
  4. Family Hx
6. Early CT to differentiate btwn atherothrombotic & Hemorrhagic stroke
  1. Atherothrombotic-give t-PA, urokinase, or prourokinase to dissolve clot
    1. t-PA can't be given w/hemorrhagic stroke
Pathophysiology
1. Mgmt Categories
2. Vascular Syndromes
Classification
1. Extracranial blood supply to brain
  1. • Extracranial blood supply to brain = provided by R & L ICAs & R & L vertebral arteries • I internal carotid artery begins at bifurcation of common carotid artery & ascends and the deep portions of neck two carotid canal • Turns rosteromedially & ascends into cranial cavity • Then pierces Dura mater & gives off ophthalmic & anterior choroidal arteries b4 bifurcating into middle & anterior cerebral arteries • Anterior communicating artery communicates with anterior cerebral arteries of either side, giving rise to the rostral portion of circle of Willis • Vertebral artery arises as branch off subclavian artery & enters ventral foramen of v-bra C6 & travels through foramina of TVP of upper 6 C-v-bra to foramen Magnum & into brain • Travels and posterior cranial fossa ventrally & medially & unites with vertebral artery from other side to form basilar artery at upper border of Medulla • At upper border of pons, basilar a. bifurcates to form posterior cerebral arteries & posterior portion of a circle of Willis • Posterior communicating arteries connect the posterior cerebral arteries with internal carotid arteries & complete the circle of Willis
2. Etiology (3)
3. Location
  1. ACA Syndrome
    1. supplies medial aspect of cerebral hemisphere & subcortical structures
    2. b/c anterior communicating a. allows perfusion of prox ACA from either side, occlusion proximal to this=min deficit
    3. Common characteristics: contralateral hemiparesis & sensory loss w/greater involvement of LE b/c the somatotopic org of the medial aspect of the cortex inclds the fnxal area for LE. P. 710 table 18.1
    4. LE INVOLVEMENT
  2. MCA Syndrome
    1. supplies entire lateral aspect of cerebral hemisphere & subcortical structures
    2. Occlusion of proximal MCA=extensive neurological damage w/signif cerebral edema
    3. Common characteristics: Contralateral spastic hemiparesis & sensory loss of face, UE, & LE, w/face & UE > LE; Table 18.2 p. 712
    4. Lesions:
      1. Parieto-occipital cortex of dominant hemisphere (L hem) typically produce Aphasia
      2. R Parietal Lobe of nondominant Hemisphere (R hem) typically produce perceptual deficits: unilat neglect, anosognosia, apraxia, spatial disorg
    5. Homonymous Hemianopsia=common
    6. MOST COMMON SITE OF OCCLUSION IN STROKE
    7. UE INVOLVEMENT
  3. PCA Syndrome
    1. each of the 2 supply the corresponding occipital love; supplies upper brainstem, midbrain, posterior diencephalon
    2. Occlusion proximal to posterior communicating a. typically results in min deficit owing to collateral blood supply from posterior communicating a (sim to ACA syndrome)
    3. Occlusion of thalamic branches may produce hemianesthesia (contralat sensory loss) or central post-stroke (thalamic) pain
    4. Occipital infarction=Homonymous Hemianopsia, visual agnosia, Prosopagnosia or if bilat, cortical blindness
    5. Temporal lobe ischemia=amnesia; Subthalmic branches involvement=wide variety deficits;
    6. Contralat Hemiplegia occurs w/involvement of cerebral peduncle
  4. Internal Carotid Artery Syndrome
    1. supplies both MCA & ACA
    2. Occlusion typically produces massive infarction in region of brain supplied by MCA
    3. Common: signif edema w/possible uncal herniation, coma, & death
  5. Lacunar Syndromes
    1. caused by small vessel disease deep in cerebral white matter
    2. strongly assoc w/hypertensive hemorrhage & diabetic microvascular disease
      1. hypertensive hemorrhage affecting thalamus can produce central post-stroke pain
    3. Specific to anatomic sites:
      1. Pure Motor Lacunar Stroke
      2. involvement of posterior limb of internal capsule, pons & pyramids
      3. Pure Sensory Lacunar Stroke
      4. involvement of ventrolateral thalamus or thalamocortical projections
      5. Dysarthrial Clumsy Hand Syndrome
      6. Ataxic Hemiparesis
      7. Sensory/Motor Stroke
      8. Dystonial/Involuntary movements
    4. Deficits in consciousness, lang, or visual fields aren't seen here as higher cortical areas are preserved
  6. Vertebrobasilar Artery Syndrome
    1. vertebral aa: supply the cerebellum and medulla
    2. basilar a: supplies the pons, internal ear, & cerebellum
      1. Locked-in Syndrome-occurs w/basilar a. thrombosis & bilat infarction of ventral pons p.713
      2. pt. can't move or speak but remains alert & oriented; horizontal eye movements=impaired but vertical eye movements & blinking=intact
    3. Occlusions of this syst =wide variety of sx w/ipsilat & contralat signs
    4. numerous cerebellar & CN abnormalities are present Table 18.4 p. 714-715
4. Management
  1. TIA
    1. Precursor to susceptibility for both cerebral infarction & myocardial infarction
  2. Minor or Major Stroke
    1. Major: in presence of stable, usually severe, impairments
  3. Deteriorating Stroke
    1. Pt whose neurological stat is deteriorating after admission to hosp; may be due to cerebral or systemic causes
  4. Young Stroke
    1. stroke affected ppl younger than 45
Medical Dx
1. Hx & Exam
  1. Medical exam
  2. Neurological exam
    1. Neurovascular tests
      1. Neck Flexion
      2. Palpation of Arteries
      3. Auscultation of heart & blood vessels
      4. Ophthalmic Pressures
  3. Neurovascular tests
    1. Neck Flexion
    2. Palpation of Arteries
    3. Auscultation of heart & blood vessels
    4. Ophthalmic Pressures
  4. Vitals & signs of cardiac decompensation
2. Test & Measures
  1. Urinalysis
  2. Blood analysis
  3. Fasting blood glucose level
  4. Blood chemistry profile
  5. Blood cholesterol & lipid profile
  6. Thyroid function tests
  7. Full cardiac eval
  8. EEG
  9. Lumbar puncture
3. Imaging
  1. CT
  2. MRI
  3. PET
  4. Transcranial & Carotid Doppler
  5. Cerebral Angiography
Medical Mgmt
1. Medical Mgmt
2. Pharmacological Interventions
  1. Anticoagulant Therapy
    1. Heparin, Coumadin
  2. Antiplatelet Therapy
    1. Aspirin
  3. Antihypertensive Agents
3. Neurosurgical Intervention
  1. Endarterectomy
  2. Surgery
Primary Impairments
1. Sensation
  1. specific localized areas of dysfnx=common w/cortical lesions
  2. diffuse involvement throughout 1 side of body=deeper lesions involving thalamus & adj structures
  3. Pain
    1. PCA lesions involving the ventral posterolateral thalamus & spinothalamic syst -->central post-stroke (thalmic pain): constant, severe burning pain w/intermittent sharp pains
  4. Visual
    1. Homonymous Hemianopsia
      1. lesions of optic radiation in internal capsule or primary visual cortex
      2. loss of vision in contralat 1/2 of each visual field: the nasal half of 1 eye & temporal 1/2 of other eye corresponding to hemiplegic side
    2. Visual Neglect/visual inattention
    3. Forced gaze deviation
2. Motor Fnx
  1. Stages of Motor Recovery
  2. Weakness
  3. Alterations in Tone
    1. Flaccidity
      1. immediately after stroke due to effects of cerebral shock
      2. lasts a few days or weeks
      3. lesions restricted to primary motor cortex or cerebellum then flaccidity persists
    2. Spasticity
      1. 90% cases
      2. in UMN syndrome occur predom in antigravity mm.
      3. UE: scapular retractors; shoulder add, dep, & IR; elbow flexors & forearm pronators; wrist & finger flexors; neck & trunk-->increased lat flx to hemiplegic side
      4. LE: pelvic retractors, hip add & IR,; hip & knee extensors, PFs & Supinators; toe flexors
  4. Abnormal Synergy Patterns "Obligatory Synergies"
    1. pt unable to perform an isolated mvmt of limb segment w/o producing mvmts in in the remainder of the limb
      1. ie: bending elbow also results in shoulder flx, abd & ER
    2. Flexion Synergy Components
      1. UE: Scap retraction/elevation or hyperextension; Shoulder abd, ER; Elbow flx; Forearm Sup; Wrist & finger Flx
      2. LE: Hip flx, abd, ER; Knee flx; Ankle DF, IV, Toe DF
    3. Extension Synergy Components
      1. UE: Scap protract; Shoulder ADD, IR; Elbow Ext; Forearm Pronation; Wrist & Finger Flx
      2. LE: Hip Ext, Add, IR; Knee Ext; Ankle PF, IV; Toe PF
  5. Abnormal Reflexes
    1. Stretch reflexes: hyperactive & pts=clonus, clasp-knife response, & +Babinski
  6. Altered Coordination
    1. Cerebellum involvement=cerebellar ataxia (lateral medullary syndrome, basilar artery syndrome, pontine syndromes) & motor weakness
    2. Basal Ganglia involvement (posterior cerebral artery syndrome)=bradykinesia or involuntary movements
  7. Altered Motor Programming
    1. Motor Praxis:
      1. def: ability to plan & execute coordinated movement
    2. Apraxia
      1. caused by lesions of premotor frontal cortex, left inferior parietal lobe , & corpus callosum
      2. more evident in L hemisphere damage than right & commonly seen w/aphasia
      3. difficulty planning & executing purposeful mvmts that can't be accounted for by any other reason
      4. 2 MAIN TYPES
      5. Ideational Apraxia
      6. inability of pt to produce mvmt either on command or automatically & reps a complete breakdown in conceptualization of the task
      7. has no idea how to do the mvmt
      8. Ideomotor Apraxia
      9. inability to produce a mvmt on command BUT is able to move automatically
3. Postural Control & Bal
  1. Ipsilateral Pushing/Pusher Syndrome/Contraversive Pushing
    1. an unusual motor behavior characterized by active pushing w/stronger extremities toward hemiparetic side, leading to lateral postural imbalance
    2. end result = tendency to fall toward the hemiparetic side
4. Speech, Lang & Swallowing
  1. lesions involving cortex of dominant hemisphere (typically L hemisphere)=speech & lang impairments
  2. Aphasia
    1. acq'd communication disorder caused by brain damage; characterized by an impairment of lang comprehension, formulation & use
    2. MAJOR Classification Categories:
      1. Fluent (Wernicke's/Sensory/Receptive) Aphasia
      2. speech flows smoothly w/a variety of grammatical constructions & preserved melody of speech; auditory comprehension=impaired
      3. difficulty comprehending spoken lang & following commands
      4. Lesion=in auditory association cortex in L lateral temporal lobe
      5. Nonfluent (Broca's/Expressive) Aphasia
      6. speech flows is slow & hesitant, vocab is limited & syntax is impaired
      7. speech production=labored or lost completely; comprehension=good
      8. Lesion=in premotor area of L frontal lobe
      9. Global Aphasia
      10. Severe; characterized by marked production & comprehension of lang impairments
      11. often an indication of extensive brain damage
  3. Dysarthria
    1. a category of motor speech disorders caused by lesion in parts of the CNS or PNS that mediate speech production
    2. volitional & automatic actions are impaired resulting in slurred speech
    3. Lesion=may be in Primary motor cortex in frontal lobe, Primary sensory cortex in parietal lobe, or Cerebllum
  4. Dysphagia
    1. swallowing difficulty
    2. Lesions=affecting medullary brainstem (CN IV & X), Large vessel Pontine lesions, Acute hemispheric Lesions (esp. MCA & PCA infarcts)
5. Perception & Cognition
  1. Visual-Perceptual Deficits
    1. freq. result of lesions in R parietal cortex & seen more w/L hemiplegia than R
    2. Body scheme
      1. postural model of body including relationship of body parts to ea other & relationship of body to the environment
    3. Body Image
      1. visual & mental image of one's body that includes feelings about one's body
    4. Specific impairments of Body Scheme/Body Image incld: Unilateral neglect; Anosognosia; Somatoagnosia, R-L Discrimination; Finger Agnosia
    5. Spatial Relations
      1. a constellation of impairments that have in common a difficulty in perceiving the relationship btwn the self & 2 or more objects in the environment
      2. Specific Impairments in: Figure-ground Discrimination; Form Discrimination; Spatial Relations; Position in Space; Topographical Disorientation
    6. Agnosias
      1. inability to recognize incoming info despite intact sensory capacities
      2. can incld: Visual object, Auditory, or Tactile (astereognosis) Agnosia
  2. Cognitive Deficits
    1. Alertness
    2. Attention
      1. Lesion: Prefrontal cortex & Reticular Formation
    3. Orientation
    4. Memory
      1. Immediate Recall
      2. STM
      3. Lesions: Limbic Syst, Limbic Association Cortex (Orbitofrontal areas), or Temporal Lobes
      4. LTM
      5. Lesions: Hippocampus of Limbic Syst
    5. Confabulation
      1. memory gaps are filled w/inappropriate words or fabricated stories
      2. Lesion: Prefrontal Cortex
    6. Confusion
      1. Disruption to: Prefrontal Cortex & occurs w/diffuse bilateral lesion
    7. Perseveration
      1. the con't'd repetition of words, thoughts, or acts not related to current context
      2. pt. gets stuck & repeats words or acts w/o much success stopping
      3. Lesions: Premotor &/or Prefrontal Cortex
    8. Executive Fnxs
      1. those capacities that enable person to engage in purposeful behaviors: volition, planning, purposeful action & effective performance
      2. Lesions: Prefrontal Cortex=impulsiveness, inflexible thinking, lack of abstract thinking, impaired org & seq, decreased insight, impaired planning ability & judgment
    9. Dementia
      1. can result from multi small infarcts of brain=Multi-Infarct Dementia
      2. progressive impairments in memory & cognition
    10. Delirium/Acute Confusional State
      1. clouding of consciousness or dulling of cognitive processes & impaired alertness
6. Emotional Stat
  1. Lesions: Frontal Lobe; Hypothalamus; Limbic Syst=Emotional Changes
  2. Pseudobulbar Affect
    1. emotional outbursts of uncontrolled/exaggerated laughing or crying that's inconsistent w/mood
  3. Apathy
    1. shallow affect & blunted emotional responses
  4. Euphoria
    1. exaggerated feelings of well-being
  5. Increased Irritability or frustration & social inappropriateness
  6. Depression
    1. Lesions: L Frontal Lobe (Acute Stage); in R Parietal Lobes (Subacute Stage)
7. Hemispheric Behavioral Differences
  1. L Hemisphere Damage (R Hemiplegia)
    1. "SPEECH"
    2. difficulty in communication, processing info in sequential, linear manner
    3. "cautious, anxious & disorganized"
      1. thus need more feedback & support
    4. Realistic in their appraisal of their existing probs
    5. Nonfluent (Broca's) Aphasia; Fluent (Wernicke's) Aphasia; Global Aphasia
    6. difficulty planning & seq mvmts
    7. Apraxia: ideational, Ideomotor
    8. Disorganized problem-solving; difficulty w/processing delays
    9. Difficulty w/expression of Pos emotions
    10. Difficulty processing verbal cues & commands; memory impairment typically related to language
  2. R Hemisphere Damage (L Hemiplegia)
    1. "VISION"
    2. difficulty in spatial-perceptual tasks & in grasping the whole idea of a task
    3. "quick & impulsive"
      1. need mad feedback
    4. Overestimate their abilities while acting unaware of their deficits
      1. SAFETY is an issue
    5. Visual-Perceptual Impairments
      1. Left side unilat neglect; Agnosia; Visuospatial & Body scheme/image impairments
    6. Difficulty sustaining a movement
    7. Difficulty w/perception of emotions, expression of Negative Emotions
    8. Rigidity of thought; difficult w/abstract reasoning; unable to self-correct; poor judgment; difficulty grasping overall org or pattern, problem-solving & synthesizing info
8. Bladder & Bowel Fnx
  1. Urinary Incontinence
  2. Diarrhea
  3. Constipation
  4. Impaction
Complications & Indirect Impairments
1. Musculoskeletal
  1. Contractures; Disuse Atrophy & Muscle Weakness; Osteoporosis
2. Neurological
  1. Seizures
    1. right after stroke during acute phase; late onset seizures=several months post stroke
    2. Anticovulsant: Dilantin, Tegretol, Solfoton
  2. Hydrocephalus
3. Cardiovascular/Pulmonary
  1. DVT
    1. dangers are high acute phase
    2. Anticoagulant Therapy; Prophylactice use of Low-dose Heparin or Low-Molecular Weight Heparin
    3. Limb Elevation; Intermittent Pneumatic Compression & Compression Stockings
  2. Cardiac Fnx
    1. pts suffer CVA due to underlying CAD=may: impaired cardiac output, cardiac decompensation & serious rhythm disorders
  3. Pulmonary Fnx
    1. Decreased lung vol, perfusion & vital capacity & altered chest wall excursion
      1. Pt.: increased fatigue & decreased endurance
    2. Aspiration
4. Integumentary
  1. Skin breakdown & Decubitus Ulcers due to ischemia & necrosis
    1. Friction, Shearing, and/or Maceration
      1. Maceration-by excess moisture ie urinary incontinence
Recovery & Prognosis
1. Recovery is gen fastest in 1st few wks after onset w/measurable neurological & fnxal recovery occurring in the 1st mo post stroke
2. Late recovery of fnx =demonstrated w/pts w/chronic stroke (>1 yr post stroke) who undergo extensive functional training
3. Initial grade of paresis measured on initial hospital admission=important predictor of motor recovery
  1. Motor fnx often improves after the 1st few days
  2. w/Complete Paralysis at hosp admission, motor recovery occurs in <15% pts.
4. Acute Stroke:
  1. 70-80%=ambulation mobility probs while 6mos-1yr later only 20% needed help indep walking
  2. 67-88%=partial or complete dependence in Basic ADLs 1 yr later only 31% req'd partial or total assist
Physical Rehabilitation
1. Acute Phase
  1. Once medically stabilized (~72 hrs) begin low-intensity rehab
2. Post-Acute Phase
  1. Pts=referred to inpatient rehab if can't tolerate an intensity of services of 2-2+ rehab disciplines, 5 days/wk for min 3 hrs of active rehab/day
  2. if pt req less intensive services (1 hr of tx 2-3x/day to daily, short sessions)=transferred to TCU
  3. Rehab during chronic phase (>6mo) post stroke=outpatient rehab or @ home
3. Examination
  1. Basic Components:
    1. Pt. Hx
    2. Systems Review
      1. Neuromuscular; Musculoskeletal; Cardiopulmonary; Integumentary
    3. Tests & Measures
      1. Level of Consciousness; Emotional Stat; Behavioral Style; Communication & Lang; Ventilation & Respiration; Anthropomerics; Integumentary Integrity; Pain; CN & PN & sensory integrity; Perceptual fnx; Jt integrity & mobility; Posture; Motor Function; Muscle Performance; Postural control & bal; Gait & locomotion;W/C mgmt & mobility; Aerobic capacity & endurance; orthotics; Fnxal stat & activity level; Work/Community/Leisure activities
  2. Hx
  3. Levels of Consciousness
    1. Normal, Lethargy, Obtundation, Stupor, Coma
  4. Communication
  5. Cognitive, Emotional & Behavioral States
    1. Orientation: Person, Place, Time
    2. Attention: Selective, Sustained, Alternating, Divided
    3. Memory: Immediate, STM, LTM
    4. Ability to follow commands: 1, 2, & 3 level commands
    5. To assess higher cortical fnx:
      1. tests of simple arithmetic & abstract reasoning
    6. Mini-Mental Status Examination (MMSE)
      1. valid & reliable quick screen of cognitive fnx
    7. The Beck Depression Inventory
      1. 21 statements; scored on scale 0-3; short version=13 questions; 5 mins to complete
  6. CN & Sensory Integrity; Jt Integrity & Mobility
  7. Perception
    1. Body scheme/image; Apraxia; Agnosia, Spatial Relations; Unilateral Neglect etc
  8. Tone/Reflexes
    1. Modified Ashworth Scale
  9. Voluntary Movement Patterns
    1. Abnormal; Obligatory Synergies etc
    2. Coordination Tests to examine Control
      1. focus: speed/rate control, steadiness, response orientation, RT & MT
    3. Fine motor control & dexterity
  10. Strength
    1. if pt's spasticity doesn't pose validity issues: MMT, handheld or isokinetic dynamometry etc
  11. Postural Control & Balance
    1. in sitting & standing
    2. Reactive Postural Control & Anticipatory Postural Control
    3. Performance Based Tests
      1. BBS
      2. • 14 functional tasks scored using a 5 point ordinal scale • Examines unsupported sitting & standing, transfers, functional reach, picking objects off floor, turning, single leg stance & stepping • Score4 = independent function while a score 0 = unable to perform • Max score 56 • High intrarater & interrater reliability
      3. Fugl-Meyer Test
      4. • For acute stroke patients • Includes items of unsupported sitting, standing (with & without support), parachute reactions to both sides, & single limb stance both sides • Scored using 3 point ordinal scale
      5. Postural Assessment Scale for Stroke Patients (PASS)
      6. • Examines postural abilities of acute stroke patients • 12 items examines sitting & standing without support, standing on paretic LE, & changing posture (supine to affected side, supine to unaffected side, supine to sitting, sitting to standing, & standing at taking a pencil off floor) • Scored using ordinal scale with descriptors ranging from can’t perform to perform with little help, to perform without help • Good construct validity; high intrarater & interrater reliability
      7. Others:
      8. Functional Reach Test; Performance-Oriented Mobility Assessment--Tinetti (POMA), Timed Up & Go Test, Clinical Test of SEnsory Interaction & Balance; Dynamic Posturography: LOS Test
  12. Ambulation & Functional Mobility
    1. Observational Gait Analysis
    2. Performance-Based Gait Tests=determine gait fnx following stroke incld:
      1. 10 Meter Walk Test
      2. 6-Minute Walk Test
      3. Energy Expenditure
      4. Emory Functional Ambulation Profile
      5. Walkie-Talkie Test
  13. Functional Status
    1. Instruments incld item to examine: Functional Mobility Skills; Basic ADL & IADL skills
    2. The Barthel Index
    3. Functional Independence Measure (FIM)
  14. Disability-Specific Instruments
    1. Fugl-Meyer Assessment of Physical Performance (FMA)
      1. • An impairment-based test with items organized by sequential recovery stages • Three point ordinal scale measuring impairments of volitional movement with grades ranging from 0 – 2 • Subtests exist for UE & LE fnx, Bal, Sensation, ROM, & Pain • Total = 226 • Good construct validity & high reliability for determining motor function & balance • 30-40 mins to administer'
    2. National Institute of Health Stroke Scale (NIHSS)
      1. • For initial & serial exam of impairments following acute stroke11 item impairment-based test; uses a variable ordinal scale • Some items scored 0 – 2 or 0 – 3 (level of consciousness, best gaze, visual fields, facial palsy, limb ataxia, sensory, best language, dysarthria, extinction, &inattention) other items scored 0 – 4 (motor arm & motor leg)
    3. Stroke Rehabilitation Assessment of Movement (STREAM)
      1. • Clinical measure of voluntary movements & basic mobility following stroke • 30 items distributed equally among 3 subscales: UL mvmts, LL mvmt & basic mobility items voluntary movement items explored out of synergy control & scored using 3 point ordinal scale (unable to perform, partial performance, complete performance) • Basic mobility includes variety of items (rolling, bridging, sit to stand, standing, stepping, walking & spares) & scored using 4 point ordinal scale (unable, partial, complete/with aid, complete/no eight) • Maximum = 70 w/ea limb subscore worth 20 & fnxal mobility subscore worth 30 pts • Good construct validity & high reliability • Been used to dock motor recovery over time & predict discharge destination following stroke
    4. Motor Assessment Scale (MAS)
      1. • Examines functional mobility skills following stroke • 6 point ordinal scale with descriptors • 8 items of motor function including the movement transitions (supine to sideline, supine to sit, sit to stand), balanced sitting, walking, upper arm function, hand movements & advanced hand function • The 9th item = impairment item examining muscle tone • High reliability & high concurrent validity w/FMA • Can be used to document motor recovery over time
4. Goals & Outcomes
PT Interventions
1. Framework for Intervention
  1. Neurophysiological/Neurodevelopmental Approaches:
    1. Neurodevelopmental Treatment (NDT)
    2. PNF
    3. Movement Therapy in Hemiplegia--Brunnstrom Approach
    4. Sensory Stimulation Techniques
2. Strats to Improve Sensory Fnx
  1. Pt. may have impaired/absent spontaneous movement
  2. Sensory Stimulation=very important for recovery and focuses on restoring sensitivity of more affected extremities & reqs some residual sensory fnx
  3. Repeated sensory stimuli stims tactile, mechanoreceptors & muscle receptors:
    1. Stroking; Stretching; Superficial & Deep Pressure; Approximation
  4. IMPORTANT:
    1. Teach active visual scanning movements thru turning head & axial trunk rot to involved side
    2. UE exercises involving crossing midline toward hemiparetic side
    3. Functional activities w/bilat interaction
      1. ie: pour a drink, drink it; pick up object w/involved hand & place in other hand; dust tabletop w/both hands
    4. Max Pt's attn by providing visual, tactile or proprioceptive stimuli to involved side:
      1. Stroking; Brushing; Icing, Vibrating
  5. ie: Put red tape on floor & have pt follow; Place red ribbon on hemiparetic wrist & have pt keep ribbon in sight
3. Strats to Improve Motor Fnx
  1. Improve Flexibility & Jt Integrity
    1. Soft Tissue/Jt Mob
    2. AROM & PROM w/terminal stretch-all motions daily
      1. UE PROM:
      2. scapula must be mobilized on thoracic wall w/emphasis on upward rot & protraction to prevent subacromial impingement during overhead mvmts & prepare for fwd reach patterns
  2. Improve Strength
    1. Exercise Modalities:
      1. Free weights, Therabands; Machines (PRE, Isokinetics)
    2. Lifting free wts or using Therabands during functional activities places added demand for postural stability=important element of training to improve postural control
    3. Concentric or Eccentric exercises can be used
      1. Eccentric =less cardiovascular stress than concentric
      2. Eccentric=greater risk of muscle injury
  3. Manage Spasticity
    1. Interventions:
      1. Early mobilization combo w/elongation of spatic muscles
      2. Sustained Stretch through positioning
      3. ie: shoulder ext, abd, ER ; Elbow, wrist & fingers Ext; positioned in WB 5-10 mins
      4. prolonged pressure on; Slow rocking movements=increase inhibitory effects thru adding influences of slow vestibular stimulation
      5. ie: WB in kneeling/quadruped for quad spasticity
      6. Rhythmic Rotation-to gain initial range
      7. Rhythmic Initiation combo w/trunk rot
      8. PNF upper trunk patterns emphasizing trunk rot
      9. Splinting; Ice wraps/packs; E-stim to antag; Vibration; Soothing verbal commands & Cognitive relaxation techniques
    2. Training Strats:
      1. Activation of Antag mm. using slow & controlled movements
  4. Improve Initial movement Control
    1. Primary Focus:
      1. Activities that promote normal postural alignment & control & fnxal use of extremities
    2. PT should focus on Dissociation of diff body segments (ability to move diff parts of body/limbs separately) & Selective (out-of-synergy) mvmt patterns
    3. If pt's motor responses=weak/unable to activate-->Direct Facilitation to assist initiation of movement
      1. ie: if lack adequate elbow ext control, place in siting w/UE WB & tap over triceps to facilitate holding in Ext
    4. Weak mm. should be activated first in unidirectional movements then progress to slow active reciprocal contractions of agonist & antag
      1. Balanced interaction of both agonist & antag-crucial for normal corodination & fnx
      2. ie: PNF patterns using reversal of antags & proprioceptive loading through light, tracking resistance=ideal for this
  5. Improve Motor Learning
    1. Focus on the brain's capacity for recovery through reorg & adaptation & encourages active particpation
    2. Optimal Motor Learning Factors:
      1. Strategy Development
      2. ID task elements & Successful Goals & Outcomes
      3. Demonstrate; Practice (bimanual task practice, mental practice etc)
      4. Ask pt. to self-exam performance & ID probs
      5. Feedback
      6. Direct Pt.'s attn to naturally occurring intrinsic feedback
      7. Visual Feedback=crucial in early stages
      8. ie: use a mirror
      9. Proprioceptive Input=in later learning
      10. important for mvmt refinement
      11. by reinforced WB (approximation) on involved side during upright activities
      12. ie: Manual Contacts, Tapping; Stretching; Tracking Resistance; Antigravity Postures; Vibration
      13. Augmented Feedback via EMG
      14. Exteroceptive Inputs:
      15. ie: Light rubbing & Stroking esp where disortions of proprioception exist
      16. Practice
      17. Distributed Practice for hospitalized pts-->Block practice
      18. to improve initial performance & motivation
      19. Variable practice: Serial or Random Practice Orders
      20. ASAP: improves performance & results in better retention of learned skills, adaptability, & generalizability to diff environments
      21. Closed Environment-->Contextual Interference/Open Environment
      22. Begin & End tx session on a pos note & a task the pt is successful in
  6. Improve Postural Control & Functional Mobility
    1. Initial Tx Strat Focus:
      1. Trunk symmetry & use of both sides of body
    2. Functional Training Activity Options:
      1. Rolling
      2. ie: have pt clasp hands together in prayer pos (to not leave involved side lagging behind) & have involved LE assit in rolling by pushing off from a flexed & ADD, hooklying pos.
      3. ie: Roll onto involved side & into sidelying-on-elbow pos=important to promote early WB & elongates lateral trunk flexors (may be spastic)
      4. Supine-to-Sit & Sit-to-Supine
      5. do so from both sides & emphasize rising form involved side
      6. Practice controlled lowering
      7. Sitting
      8. In early sitting: have pt. use UEs for Bilat support on table/TherEx ball
      9. Sitting on TherEx ball
      10. promote pelvic alignment & mobility (pelvic rotations) & trunk upright alignment (gentle bouncing)
      11. Sitting control: Stability-->Dynamic Stability-->Dynamic Challenges: Reaching
      12. Incorp PNF patterns
      13. promote trunk rot; Bilat UE activity & crossing midline=important for unilateral neglect
      14. Practice Scooting in sitting "Butt Walking"
      15. to ensure mobility for dressing (putting pants on)
      16. Bridging
      17. Benefits/Purpose
      18. develop trunk & hip ext control=important for bedpan, pressure relief, initial bed mobility (scooting) & sit-to-stand transfers
      19. Develops adv LE out-of-synergy control (hip ext w/knee flx) & stims early WB through foot
      20. Bridge & lift uninvolved foot off surface & place on small ball while maintaining pelvis level
      21. this increases demands on involved side
      22. vary position of UEs
      23. Sit-to Stand & Sit-Down Transfers
      24. STS
      25. STS Focus
      26. Symmetrical WB, Coordinated muscular responses & adequate timing
      27. Flexion-Momentum Phase: Encourage fwd weight shift
      28. focus pt's eyes on visual target directly in front @ eye level & use verbal cues to facilitate the desired moveents
      29. have pt. swing both hands fwd or reach fwd w/both UEs; clasp hands together
      30. both hands on TherEx ball while PT stabilizes & moves ball forward in time w/fwd weight shift
      31. Extension Phase: of hips & knees to stand
      32. Alter height of seat: elevated (to decrease extensor force reqd)-->depressed/standard Ht
      33. WB on involved (strong foot behind weak when standing)-->uninvolved
      34. Prayer Hand pos. reduces UE push-off (push-off=ineffective in fwd wt shift)
      35. Sitting Down
      36. Practice eccentric mvmts w/back against wall doing partial wall squats
      37. Standing, Modified Plantigrade
      38. ideal early standing posture to develop postural & extremity control
      39. Involved UE is WB in ext (out of synergy posture) & involved LE is holding in Ext (out of synergy pattern of hip flx w/knee ext)
      40. Fwd trunk pos=creates ext moment @ knee, thus assisting weak knee extensors
      41. Holding posture--moving in posture/wt shift-->reaching tasks
      42. Standing
      43. can apply gentle PNF tech of Rhythmic Stabilization
      44. Early WB on involved limb can be done via using a half-sitting pos
      45. Transfers
      46. Pt. w/Pusher Syndrome
      47. PT's effort to passive correct pt's tilted posture-->Pt. pushing Stronger
      48. training needs to emphasize vertical positions w/active mvmt shifts to stronger side
      49. PT can sit next to stronger side and tell pt to "lean over to me"
      50. Can have pt. positioned w/stronger side next to a wall & instruct "lean towards the wall"
      51. If pt. uses a cane it can be shortened to encourage wt shift to stronger side
  7. Improve UE Fnx
    1. Activities to retrain UE postural support, Reaching, & Manip=essential
    2. UE As Postural Support
      1. promotes proximal stabilization & counteracts effects of excess flexor hypertonus & dominant flexion synergy
    3. Reaching
      1. Pt. w/min voluntary control: practice reaching fwd in sidelying where Pt's UE is supported by PT in shoulder flx w/elbow ext. UE is mobilized fwd & Pt. is asked to hold pos.
      2. Pt. in sitting w/hand resting on table & slide hand fwd to recruit shoulder flexors, scap protractors & elbow extensors; Practice polishing table to decrease friction
      3. Substitutions =not allowed
      4. trunk or head lateral movements; excessive shoulder elevation
    4. Manipulation & Dexterity
      1. Voluntary release is gen more difficult to achieve than voluntary grasp, & stretching/positioning and inhibitory techniqs may be necessary to facilitate ext mvmts
      2. ie: Pt. uses involved hand to stabilize (a book, a paper, food) while uninvolved side writes, & cuts the food
    5. Enhanced Training Activities:
      1. Constraint-Induced movement Therapy
      2. assoc w/changes in brain org & include apparent shift in motor cortical activation toward other ipsilat areas & contralesional hemisphere
      3. Bilateral Arm Training With Rhythmic Auditory Cueing (BATRAC)
      4. Chronic Stroke: Repetitive training program utilizing customized bilat arm trainer where pt holds onto T-bar handles & moves them fwd.
      5. Bilat mvmts are timed to an auditory metronome
      6. Signif improvements in fnxal motor performance of weaker UE=sustained 2 mos after training
      7. EMG Biofeedback
      8. allows pts to alter motor unit activity based on augmented audio & visual feedback info
      9. can focus on voluntary inhibition of spastic mm. or on increasing kinesthetic awareness & recruitment of motor units in weak, hypoactive mm.
      10. Best for pts. in chronic stage; results=greatest when used as adjunct to task-specific training
      11. NMES
      12. used to reduce spasticity, improve sensory awareness & volitional limb movements
    6. Mgmt of Hemiplegic Shoulder Pain (HSP)
      1. FLACCID STAGE
      2. reduced support & normal seating action of rotator cuff mm (supraspinatus) causing ligs to be sole supporters
      3. w/o proper support, stability decreases & causes subluxation; mal scapulohumeral rhythm
      4. ***ARM SHOULD BE SUPPORTED @ ALL TIMES
      5. In supine & sitting: scapula/shoulder should be Protracted w/arm Forward in Slight Abd & neutral rot
      6. SPASTIC STAGE
      7. may lead to poor scapular position & contrib to subluxation & restricted mvmt
      8. Activities that traumatize the shoulder:
      9. PROM w/o adequate scap mobilization; Pulling on UE during transfer; Using Reciprocal Pulleys
      10. Chronic Regional Pain Syndrome/Reflex Sympathetic Dystrophy
      11. Diffuse pain onset: aching throughout limb; 3 Stages p. 753
      12. INTERVENTIONS:
      13. To Reduce Subluxation:
      14. NMES & use of supportive devices
      15. To Normalize tone & Reduce Pain:
      16. Mobs (grade 1-2), Gentle Stretching, Cryotherapy, EMG Biofeedback, Relaxation Training
      17. For Adhesive Capsulitis
      18. Mobs, PROM techniqs & US
      19. Pharmacotherapy
    7. Supportive Devices:
      1. Slings:
      2. • (+) prevent soft tissue stretching & relieve pressure on neurovascular bundle • (+) appropriate for initial transfer & gait training but overall use should be minimized during rehab • (-) Do little to reduce subluxation or improve sure function • (-) positions arm close to body in ADD, IR & elbow flexion • (-) prolonged use = contractures & increased flexor tone • (-) impaired trunk mobility, balance, sensory input & body image & may increase the body neglect • (-) block spontaneous use of the UE & contribute to learned nonuse
      3. Types:
      4. Pouch Sling or Single Strap Hemisling
      5. w/2 cuffs that support elbow & wrist; Provides min mechanical support of humerus
      6. Humeral Cuff Sling
      7. Provides humeral support w/slight ER while allowing elbow ext & may provide some reduction of subluxation
      8. Alternatives to Slings:
      9. Taping/strapping
      10. to facilitate or inhibit musculature surrounding scapula
      11. NMES
      12. Hand positioned in a garment pocket
      13. Pts. in w/c
      14. Arm board/lap tray; lateral elbow guard &/or straps
  8. Improve LE Fnx
    1. Activities to break up obligatory synergy patterns:
      1. PNF LE D1 ext pattern; holding against theraband around upper thighs in supine/standing; Standing, lateral side-steps
    2. Activities that stress Hip Adduction during flexion moments of the hip & knee:
      1. Supine, PNF LE D1 flexion pattern; Sitting, crossing & uncrossing involved LE over uninvolved; Standing, Step-Ups
    3. Activities to promote Knee Flexion w/Hip Ext needed for toe-off @ end of stance:
      1. Bridging; Supine Hip Ext w/Knee Flx over side of mat pushing down thru heel; Standing, Posterior Foot rises
    4. Activities for Pelvic Control:
      1. Promoted thru lower trunk rotation activities that emphasize forward pelvic rotation (protraction)
      2. Practice rotation in sidelying; Supine, modified hooklying; Kneeling; or Standing; Sitting on TheEx Ball
    5. For Poor Knee Control: pt. hyperextends when standing
      1. Reciprocal action (smooth reversals of flexion & ext mvmts); First in supine (foot slides in hooklying)-->Sitting (foot slides under chair)-->Partial sitting or partial wall squats in standing
  9. Improve Balance
    1. Ways to increase difficulty by manipulating:
      1. BOS: sitting, LEs uncrossed-->crossed; Standing wide-->narrow-->tandem pos; Standing on 1 LE
      2. Support Surface
      3. Sensory Inputs
      4. UE pos/support: light touch down support; UEs extended out to side -->UEs across chest
      5. UE movements: single UE raise-->Bilat UE raises; reaching; picking objects off table/stool/floor
      6. LE movements: single LE raises, Stepping (fwd-backward, side; step-ups); Marching in place; Foot on ball, moving ball
      7. Trunk Mvmts: head & trunk rotations; Looking up @ ceiling or down to floor
      8. Destabilizing functional activities: Sit-to-stand, sit-down, turning, floor-to-stand
      9. Dual Task Training: standing while catching or kicking ball; Standing while talking; standing while hold tray w/glass of H20
      10. Environmental conditions: closed-->open environments
    2. Postural Strategy Training
      1. Ankle Strategies Promoted via:
      2. small range ant-post shifts or applying small perturbations @ hips (fwd-backward)
      3. standing on half-foam roller or wobble board
      4. Hip Strategies Promoted via:
      5. larger ant-post shifts or stronger perturbations
      6. Med-Lat hip strats promoted through TANDEM stance (on floor/foam roller)
      7. Stepping Strategies Promoted via:
      8. increased displacements of COM outside BOS
      9. apply Theraband around hips, offer resistance to fwd lean; Once pt achieves desired lean, quickly release resistance =necessitates a step to control balance
      10. Practice Step-Ups (small step to large; foam surface)
    3. Enhanced Training Activities:
      1. Force Platform Biofeedback
      2. biofeedback provided to pt. while standing on computerized force-plate syst ; Pt. practices voluntary mvmt shifts in response to computer generated visual feedback; can also practice responding to unexpected platform tilts (perturbations) to improve reactive bal control
      3. Improvements have been found in steadiness (reduced sway), **Postural Symmetry & **Dynamic Stability ; thus improvements in balance
      4. Limited evidence of carryover of improve bal during functional skills, specifically transfer skills & endurance, functional reach & measures of ADL & mobility
  10. Improve Locomotion
    1. Locomotor Training
      1. walking=primarily a brainstem & spinal cord fnx
      2. ie: locomotor Central Pattern Generators (CPG)=ID'd as existing in the Ventral Spinal Cord while Integrating Command Centers=ID'd in the Medial Medullary Reticular Formation
      3. CNS is responsive to Training-Induced Plastic Changes in locomotor fnx & recovery
      4. Using BWSS & TM
      5. Sullivan et al: TM training @ fast speeds (0.98 m/sec) was more effective @ improving speeds of overground walking than training at slow (0.22 m/sec) or variable speeds
      6. Functional speeds req'd for community ambulation= ~2.8 mph (1.3 m/sec)
      7. Training: 30 mins/day 5 days/wk for 6-12 wks
    2. Gait Training
      1. Gait practice w/overhead harness & PBWS provides least interference w/balance & walking
      2. Encouraged to take even steps
      3. facilitated by use of Rhythmic auditory cues (verbal cues, metronome) & foot markers placed on floor
      4. Critical areas of stance phase control to be addressed:
      5. Initial wt acceptance, Midstance control & Fwd wt advancement during stance on involved limb
      6. During swing: control of knee & foot for toe clearance & foot placement=key reqs
      7. Address persistent posturing of UE in flx & Add
      8. facilitate via positioning
      9. Practice functional, task-specific locomotor skills:
      10. Walking fwd, backward, sideward & crossed stepping; Elevation activities: step-up/step-down; Lateral step-ups; Stair climbing, Step-over-Step & community activities: ramps curbs uneven terrain; crossing streets, automatic doors, escalators etc
    3. Enhanced Training Activities
      1. Limb Load Monitors
      2. provide biofeedback about amt of loading/WB on hemiparetic limb & effective in improving stance & gait
      3. pt. demonstrate more symmetrical WB & increased stance times on involved LE w/increased swing times on uninvolved LE
      4. NMES
      5. Multichannel FES
      6. uses a program developed from individ profiles of EMG & anthropometrics to stim antag groups of mm.
    4. Orthotics
      1. may be req'd when probs prevent safe ambulation:
      2. inadequate ankle DF during swing; Mediolateral ankle instability; Insufficient push-off during late stance
      3. Foot-Ankle Controls
      4. AFO
      5. to control impaired ankle/foot fnx
      6. Knee Controls
      7. AFO
      8. to control knee instability: adjust pos of ankle: set at 5 deg DF limits knee hyperext whereas set at 5 deg PF decreases flexor moment & stabilizes knee during midstance
      9. pt. w/knee hperext w/o foot/ankle instab:
      10. Swedish Knee Cage to protect knee
      11. KAFO=rarely indicated or successful
4. Strats to Improve Aerobic Fnx
  1. Pts. benefit from endurance/aerobic training to improve cardiovascular fnx
  2. Early stages: overground walking
  3. Postacute stage: TM walking or stationary cycling
  4. Pts w/bal impairments: TM training or overground walking w/safety harness or recumbent cycle ergometer
  5. Intensity: 40-70% Max O2 uptake
  6. 3x/wk for 20-60 mins; can upgrade to daily if lower intensities are used
  7. begin w/intermittent training protocols but can be progressed to 30 mins of continuous exercise
5. Strats to Improve Feeding & Swallowing
  1. Oral Exercises
  2. Cheek Exercises
  3. Food Presentation: height, distance, w/in visual field
  4. Adapted utensils
  5. Stroking neck=stim swallowing; Massing cheek=clearing cheek of bolus; Resisted sucking exercises
6. Pt/Client-Related Instruction
Discharge Planning
1. indication of attainment of a fnxal ceiling=considered when lack of evidence of progress @ 2 successive evals over a 2 wk pd