Concorde Career College Physical Therapist Assistant

Concorde Career CollegePhysical Therapist Assistant

PTA 150: Fundamentals of Treatment IIDay 9 & 10

CVA

Concorde Career College

Objectives

Describe the pathophysiology of a CVADescribe physical and neurological impairments

associated with CVADescribe physical therapy treatment interventions

for patients after a CVA


Cerebrovascular Accident (CVA)

Sudden loss of neurological function caused by an interruption of the

blood flow to the brain

O’Sullivan, pg. 705


CVA Epidemiology

The 3rd leading cause of death in the USTHE most common cause for disability in US

adultsIncidence of stroke 1.25 times greater for males

than femalesCompared to whites, African-Americans have 2x

the risk of first-ever stroke (higher also with Mexican-Americans, American Indians, and Alaska Natives)


Definitions

CVA is used interchangeably with the term “stroke”Neurological deficits must remain for > 24 hours to

be classified as a strokeTransient Ischemic Attack (TIA)

Temporary interruption of blood flow to brainSymptoms resolve quickly (within 24 hours)Few if any permanent signs or symptomsPrecursor to strokeAbout 14% of persons surviving an initial stroke or

TIA will experience another one within a year


Types of Strokes

Hemorrhagic StrokeBlood vessels rupture, blood leaks into the brain1˚ Cerebral Hemorrhage results from ruptured blood

vessels weakened by atherosclerosisResults in ↑ ICP and restricts blood flow to the brainSubarachnoid Hemorrhage (SAH) – bleeding b/w

arachnoid layer and pia mater• Common cause: aneurysm & AVM

Subdural Hemorrhage (SDH) – bleeding b/w dura mater and arachnoid layer• Common cause is trauma


Types of Strokes

Ischemic StrokeMost common (~80%)A clot blocks or impairs blood flow to the brainCan result from a Thrombosis

• Results from platelet adhesions & aggregation on plaques• Cerebral Thrombosis: Blood clot forms in cerebral artery• Thrombi lead to ischemia = cerebral infarction

Can result from an Embolus• Dislodged matter; blood clot, plaque, fat, gas, air, tissue

that dislodges in the body and travels to the brain occluding cerebral circulation


Impact

Severity and symptoms of stroke depend on Location of ischemic processSize of the ischemic areaNature & function of structures involvedAvailability of collateral flow

• O’Sullivan , page 708


Anterior Cerebral Artery Syndrome

Middle Cerebral Artery Syndrome

Posterior Cerebral Artery Syndrome

Vertebrobasilar Artery Syndrome

Internal Carotid Artery Syndrome

Lacunar Syndrome

Vascular SyndromesConcorde Career College

Anterior Cerebral Artery (ACA)

Supplies medial part of the frontal and parietal lobe, basal ganglia and corpus callosum


ACA Syndrome

Contralateral sensory & motor loss with LEs affected more than UEs

Urinary incontinenceMental impairment (confusion, amnesia)Apraxia affecting ability to imitate or perform

bimanual tasksAbulia (lack of desire to carry out an action),

slowness, delayed movements, lack of spontaneous movements

Behavioral changes


Medial Cerebral Artery (MCA)

Supplies lateral cerebral hemispheres (incl. frontal, parietal and temporal lobes)


MCA Syndrome

Contralateral hemiparesis of face and UE mainlyPure motor hemiplegia (lacunar stroke)Contralateral hemisensory loss of face & UE mainlySpeech impairment: Broca’s aphasia, Wernicke’s

aphasia, global aphasisPerceptual deficits: unilateral neglect, depth

perception difficulties, agnosiaApraxiaAtaxia of contralateral limbs (sensory ataxia)Contralateral hemianopsiaTable 18.2 (O’Sullivan)


Posterior Cerebral Artery (PCA)

Supplies occipital lobe, medial and inferior temporal lobe, thalamus & brain


PCA Syndrome

Contralateral sensory & motor loss (hemianesthesia)HemianopsiaVisual agnosia, prosopagnosia and cortical

blindnessOculomotor nerve palsyInvoluntary movement

Choreoathetosis, intention tremor, hemiballismusThalamic pain Pusher syndrome


Hemiballismus - Video

http://www.bing.com/videos/search?q=hemiballismus&view=detail&mid=290D280B1B53C5E9CDEB290D280B1B53C5E9CDEB&first=0&FORM=LKVR


Vertebrobasilar Artery

Vertebral artery arises from the subclavian artery, travels into the brain and then merge to form the basilar artery

Vertebral artery supplies the cerebellum and medulla

Basilar artery supplies the pons, internal ear, and cerebellum


Vertebrobasilar Artery Syndrome

Wide variety of symptoms with ipsilateral and contralateral signs

Numerous cerebellar and cranial nerve abnormalities

Refer to Table 18.4 in O’Sullivan for details


Internal Carotid Artery (ACA) Syndrome

Supplies both the MCA and ACAComplete occlusion leads to ↑↑ cerebral edema =

coma & possible deathIncomplete occlusion = mix of ACA & MCA

syndromes


Lacunar Infarct

Caused by small vessel disease deep in cerebral white matter


Lacunar Syndrome

Contralateral weaknessSensory lossDystonia/Involuntary movement

Choreoathetosis, hemiballismusAtaxia


CVA – Major Risk Factors

AtherosclerosisHTNHeart diseaseDiabetesSmokingTIA

ObesityHypercholesteremiaPhysical Inactivity↑ Alcohol consumption


Stroke Warning Signs

TIME IS BRAINSudden numbness or weakness of the face, arm

or leg, especially on one side of the bodySudden confusion, trouble speaking or

understandingSudden trouble seeing in one or both eyesSudden trouble walking, dizziness, loss of balance

or coordinationSudden, severe headache with no known cause

www.StrokeAssociation.org


Imaging - CT

Frontal lobe stroke


Imaging - MRI


CVA Medical Management

Reestablish cerebral circulation and oxygenationControl blood pressureMaintain sufficient cardiac outputRestore/maintain fluid & electrolyte balanceMaintain blood glucose levelsControl ICPMaintain bladder function (possible use of

catheter)Maintain integrity of skin and joints


Pharmacological Management

Anticoagulants (heparin, coumadin); to reduce clots and maintain profusion)

Antiplatelets (aspirin); used to decrease the risk of recurrent stroke

Antihypertensives


Surgical Intervention

Endarterectomy – surgical removal of lining and plaque in an arteryUsed to prevent strokes (not treat them)

In the case of hemorrhage – surgery to repair rupture, prevent further bleeding evacuate the clot

Resection of unruptured AVM if found and risk is high


Primary Impairments

Sensation Impairments↓ sensory perception & ability to process sensory

information• Touch, temperature, position, kinesthetic, pain• ASTEROGNOSIS

• The inability to identify an object by touch without visual input

PainCan experience severe headaches, neck or facial

painCentral post-stroke (thalamic) pain: constant, severe

burning with intermittent sharp painsConcorde Career College

Primary Impairments

Visual ImpairmentsEye movements (sluggish, reflexive, ataxic)Hemianopsia: Blindness in half of each eye’s visual

field (loss on the nasal side and half on temple side)Visual neglectDifficulties w/ depth perception & spatial

relationshipsForced gaze deviationBrainstem strokes may result in diplopia, oscillopsia

or visual distortions


Primary Impairments

Motor Impairments – Stages of Motor Recovery

Stage 1 - FlaccidityStage 2 - Minimal voluntary movement; may see

synergies and spasticity developStage 3 – Voluntary control the movement

synergies; spasticity may ↑ further

(Continued)


Primary Impairments

Motor Impairments – Stages of Motor Recovery

Stage 4 – movement combinations that do not follow the path of synergy are mastered; spasticity ↓

Stage 5 – Difficult movement combinations are learned

Stage 6 – disappearance of spasticity, individual joint movements become possible and coordination approaches normal


Primary Impairments

Motor ImpairmentsWeakness (paresis)

• Occurs in 80-90% of all patients after stroke• Varies depending on location and size of stroke• Can result in complete paralysis/hemiparesis• Typically, more distal muscles exhibit greater weakness• May even see weakness on the “normal” side• Changes in muscle composition 2˚ weakness & disuse

• Atrophy, ↓ Fast twitch type II, ↑ slow twitch type I

• ↑ effort and fatigability


Primary Impairments

Motor ImpairmentsChanges in tone

• Flaccidity – present immediately as a result of cerebral shock; usually short-lived but sometimes persists

• Spasticity/hypertonicity• Occurs in about 90% of patients after stroke

• Posturing of limbs is common with mod → severe spasticity

• Spasms (internal or external stimulation)


Posturing


Primary Impairments

Motor ImpairmentsAbnormal synergistic movement patterns

• Associated with spasticity, may ↓ with recovery• Review Table 18.5 in O’Sullivan

Impaired reflex responses (mild to severe)• Vary according to stage of recovery

• Hyporeflexia with flaccidity → hyperreflexia with spasticity

• ↑ stretch reflex – clonus, clasp-knife, (+) Babinski• ATNR• Associated reactions


Primary Impairments

Motor ImpairmentsImpaired coordination responses

• Cerebellar strokes = ataxia & weakness• Basal Ganglia involvement = slow movements

(bradykinesia) & involuntary movements (choreoathetosis, hemiballismus)


Video - Cerebellar Ataxia

http://www.bing.com/videos/search?q=cerebellar+ataxia&view=detail&mid=F8130C8EBA0E3DD338C5F8130C8EBA0E3DD338C5&first=1&FORM=LKVR3

http://www.bing.com/videos/search?q=cerebellar+ataxia&view=detail&mid=08E8A16F23E5E860EE9008E8A16F23E5E860EE90&first=21&FORM=LKVR18


Primary Impairments

Motor ImpairmentsAltered motor programming

• Motor praxis• Ideational apraxia • Ideomotor apraxia

Diminished muscle performance for ADL• Strength, Power, Endurance


Primary Impairments

Postural Control & Balance ImpairmentsMay experience difficulty with balance 2˚ to an

external force or during self-initiated exercises• Corrective responses to perturbations are often

inadequate = fallAsymmetry typically noted in posture

• Typically see falls to the same side as weaknessPusher Syndrome

• Active pushing of the uninvolved side offsets muscle control of the involved side (falls, leaning)


Primary Impairments

Speech and Language ImpairmentsAphasia – an acquired communication disorder

caused by brain damage and is characterized by an impairment of language comprehension, formulation and use. (O’Sullivan, pg. 722)


Primary Impairments

Speech and Language ImpairmentsReceptive Aphasia

• aka. Wernicke’s/Sensory/Fluent Aphasia • Auditory and reading comprehension impaired• Speech is functional

Expressive Aphasia• aka. Broca’s/Nonfluent Aphasia• Difficulty finding words to express ideas

Global Aphasia• Receptive and Expressive


Primary Impairments

Speech and Language ImpairmentsDysarthria

• Nasal quality of speech, slurred wordsDysphonia

• Difficulty producing soundsDysphagia

• Difficulty in swallowing


Primary Impairments

Altered PerceptionBody scheme – relationship of body parts to one

another as well as the body’s relationship to the environment

Body image – visual and mental image of one’s body may be altered following a stroke• Includes the individual’s feelings about this image


Primary Impairments

Examples of body scheme/image impairments:Unilateral Neglect

• Visual recognition or attention on involved side• Limb neglect or attention on involved side

Anosognosia – denial, neglect or unawareness of one’s paralysis

Somatoagnosia – lack of awareness of one’s body structure and its relationship to the environment

Right-left discriminationFinger agnosia


Primary Impairments

Altered PerceptionAgnosia - inability to recognize incoming information

despite intact sensory capabilities (O’Sullivan, pg 723)

• Visual object agnosia• Auditory agnosia• Tactile agnosia (astereoagnosia)Spatial relationship – difficulty determining the

relationship between the body and 2 or more objects in the environment


Primary Impairments

Cognitive Impairments↓ alertness↓ attentionAltered orientationDiminished memoryImpaired executive function


Primary Impairments

Cognitive Impairments – VocabularyConfabulationPerseverationMulti-infarct dementiaDelirium


Primary Impairments

Alterations in AffectPseudobulbar Affect

• A.k.a. emotional dysregulation syndrome or emotional lability

• Emotional outbursts (crying, laughing)ApathyEuphoria↑ irritability or frustrationSocial inappropriatenessDepression


Primary Impairments

Bladder and Bowel FunctionCommon during acute phaseOften implement a toileting scheduleUrinary retention controlled with catheterizationCan often lead to embarrassment, isolation or

depression


Primary Impairments

Hemispheric Behavioral DifferencesLeft Hemispheric Damage

• Difficulties in communication• Difficulty with processing information• Cautious, anxious, disorganized• Often very aware of impairments

Right Hemispheric Damage• Difficulty in spatial-perceptual tasks• Difficulty with grasping overall idea of task or activity• Quick, impulsive• Overestimate their abilities, poor judgment


General Characteristics of CVA

Right Hemisphere CVALeft side weakness or paralysisHemianopsiaDecreased awareness and judgmentMemory deficitsInattention and less reasoningEmotional labile Impulsive behaviors


Characteristics of CVA

Left Hemisphere CVARight side weaknessAphasiaMotor ApraxiaDysphagiaHemianopsia


Complications & 2˚ Impairments

MusculoskeletalLoss of ROM & ContracturesEdema & painDisuse atrophy & weaknessOsteoporosis

• Fall risk



NeurologicalSeizuresHydrocephalus – an excessive accumulation of CSF

within the cranial cavity

CardiovascularThrombophlebitis/DVTImpaired Cardiac Function

• Impaired cardiac output, decompensation, rhythm disorders

• Can restrict exercise/activity toleranceConcorde Career College


PulmonaryDecreased lung volumeDecreased pulmonary perfusion & vital capacityAltered chest wall excursionGreater energy expenditureAspiration

IntegumentarySkin breakdown and decubitis ulcer

• Pressure, friction, shearingConcorde Career College

Rehabilitation after Stroke

The Role of the PT & PTA


Acute Phase

Lo-intensity therapy can begin once stabilized medically.Early mobilization

Minimize deconditioningFunctional reorganization is promotedLearned nonuse is minimized

Reinforce a positive outlookDecreased incidence of depression, apathy and mental

deteriorationEarly presentation of rehabilitation planMonitor for potential medical emergencies!Average hospital stay is about 7 days


Post-Acute Phase

TriageInpatient rehabilitation, TCU, SNF

What other services may be involved with the patient at this time?

Progression to home care, outpatient PTAssisting with return to work, recreation, social

activities


PT Examination

Patient historyLevels of

ConsciousnessCommunicationCognitive, emotional

and behavioral statesCranial Nerve IntegritySensory IntegrityPerceptionTone/Reflexes

Joint Integrity & Mobility

Voluntary Movement patterns

StrengthPostural control &

balanceAmbulation &

Functional mobilityFunctional status


Gait after a Stroke

The PTA AssessmentConcorde Career College

VIDEO

http://www.youtube.com/watch?v=YMzVywpbNes&feature=related


Gait after Stroke

Important to look at movements occurring at the ankle, foot, knee, hip, pelvis, trunk and UEs.

Observe the different planes of motion Quantitative measures include distance, time,

cadence, velocity, and stride timesWhat type of AD may be necessary?May consider videotaping


Trunk/Pelvis

Stance PhaseForward trunk 2˚

• Weak hip extension• Flexion contracture

Swing Phase↓ forward pelvic rotation 2˚

• Weak abdominal mmLeaning towards the stronger side to clear the

weaker side foot from the floor OR Backward leaning of trunk

• Both may be due to weak hip flexors


Hip

Substitutions as a result of inadequate hip flexion:Hip hiking

• Weak abdominal mm and inadequate knee flexion may also contribute to this

Circumduction• ↑ extensor tone, ↑ PF tone or foot drop as well as

inadequate knee flexion may also contribute to thisExternal rotation/adduction

May see the opposite, exaggerated hip flexion• Flexor synergy


Knee

Stance PhaseExcessive knee flexion 2˚

• Flaccid or weak LE, especially hip & knee extensors• Poor PPC• Flexion contracture• Ankle DF range past neutral

Hyperextension of knee 2˚• ↑ extensor tone of LE• Quadricep spasticity• Weakness of gluteus maximus, hamstrings and quads• PF contracture past 90˚• Impaired PPC


Knee

Swing Phase↓ Knee flexion 2 ˚

• ↑ LE extensor tone, spastic quadriceps• Inadequate hip flexion and poor foot clearance• Circumduction or hiking pattern often seen as a result

Exaggerated, delayed knee flexion 2˚• Strong flexor synergy

Inadequate knee extension at initial stance 2˚• Spastic hamstrings• Sustained total flexor pattern• Weak knee extensors

Ankle/Foot

Stance PhaseEquinus gait – heel does not touch down

• Spastic or contracture of gastrocnemiusVarus foot – weight is on the lateral side of the foot

• Spastic tibialis anterior, posterior tibialis, toe flexors, soleus

Unequal step length• Hammer toes can cause pain with WB and prevent a full

step forward with opposite leg• Increased flexor tone in toe muscles

• Lack of DF ROM on affected side


Ankle/Foot

Swing PhasePersistent equinus or varus or a combination of the 2

(equinovarus)• Weak dorsiflexors may contribute to this in addition to

spastic musclesExaggerated DF 2˚ strong flexor synergy pattern


Intervention


Strategies to Improve Sensory Function

Encourage use of the affected side!!Training should focus on functional tasksExamples:

Stroking skin with various fabricsDrawing shapes, letters onto the skin of affected sideApproximationInflatable pressure splints

Patient and family/caregivers must be educated on impairments as well as safety measures to protect the involved limbs


Strategies to Improve Sensory Function

With unilateral neglect, incorporate strategies that encourage awareness and use of the body on the involved sideVisual scanningCueing (visual, verbal or motor cues)ImageryVisual focus on the affected arm or leg during activityBilateral tasksTactile input given by the therapist to the involved

limbPatient may require reorientation


Strategies to Improve Flexibility and Joint Integrity

Early ROM dailyUE

PROM of shoulder important for reaching and overhead movements• Careful attention to mobilize the scapula on the thoracic

wall, maintain upward rotation and protractionMaintain full elbow extension, wrist and finger ROM

Self UE ROM may include arm cradling, table-top polishing, supine AAROM with intact UE clasping the affected UE



Effective UE positioning is importantLap tray or arm trough5˚ shoulder ABD & FLEX, neutral rotation, 90˚elbow

FLEX & slightly forward, forearm pronated, functional hand position



Volar resting (pan) splintFunctional20-30˚ wrist extension40-45˚ MP flexion10-20˚ IP flexionThumb opposition


Strategies to Improve Flexibility & Joint Integrity

LE ROMOften see limited ankle DF

• Incorporate weight bearing encouraging DF by performing forward weight shifts or using adaptive equipment (tilt board, foot rocker)

Pay careful attention to hip flexor and knee flexion contraction with prolonged sitting in wheelchair

ROM in opposition to spasticity (if present) should also be performed daily


Strategies to Improve Strength

<3/5 StrengthTherapist assisted exercisePowder boardSling suspensionAquatic Exercise

3/5 StrengthGravity resisted exercises

>3/5 StrengthFree weightsBandsMachines


Strategies to ImproveStrength

Important to combine strengthening and functionWearing ankle weights while performing step ups or

stair climbingReaching exercises while wearing wrist weights

• Secondary postural stabilization occurs with this type of exercise

Resisted walking with Theraband taut at waist levelSit to stand with resistance given at shoulders by

therapist



Safe Exercise PrescriptionExercise is contraindicated with HTN & recent strokeWith HTN – avoid high-intensity & isometric

exercises• Concentric & eccentric exercises are less stressful for

the cardiovascular system• Sitting exercises less risk for increasing blood pressure

as compared to supine exercisesProper warm-up & cool down are important, better to

begin with LE exercises first



Need to carefully monitor:BPHRRate of Perceived Exertion (RPE)Breathing (avoid breath holding & Valsalva)

Patient needs to be educated to monitor HR and RPE as well as warning signs to stop exercises


Strategies to Manage Spasticity

Early mobilizationProlonged stretchingExamples:

Rhythmic rotationSlow rocking movements over limb in an elongated,

weight bearing positionPNF upper trunk patterns can ↓ trunk tone

Activation of the antagonist muscles using slow & controlled movementsMay need to use facilitation techniques


Strategies to Manage Spasticity

Modalities to reduce spasticityCold (ice wraps, ice packs)Estim to the antagonistVibration

May incorporate air splintsCan use soothing verbal commands/relaxation

techniques or imagery


Strategies to Improve Initial Movement

Initially focus on normal postural alignment as well as control and functional use of extremities

Strategies should address dissociation and selective (out-of-synergy) movement patterns

Reinforce slow, controlled, “normal” movementsMay progress postures to optimize movements

Example: shoulder flexion in supine, sitting and then standing

Assistance may initially be provided but then progress to active, independent movements


Strategies to ImproveInitial Movement Control

When addressing function, consider practicing eccentric contractions before concentricEccentric contraction are more efficient

Can gradually progress to a variety of activities that use all 3 types of contractions


Strategies to ImproveMotor Learning

Strategy DevelopmentCritical tasks, goals and outcomes are identifiedBegin practice, may practice components of the task

before practice of the whole taskImportant to move towards whole task to allow for

transfer of learningPracticing with less affected side first may also assist

with transfer effectsClear, simple verbal instruction should be givenPatient needs to be active in problem solving

• i.e., Can the patient identify components performed incorrectly



FeedbackCan be extrinsic or intrinsicDuring early motor learning, more likely to use

extrinsic feedback• Mirrors, verbal cues or manual cueing from therapist

Patient’s attention should be geared towards recognizing intrinsic and developed more as therapy progresses• Patient should “feel the movement”

Important to avoid bombardment of feedback and limit immediate feedback



Practice, Practice and more PracticeMay initially be limited by enduranceNeed to encourage variable practice in order to

progressEnsure the environment is conducive to learning

• Eventually can progress to a more open, real-life environment

Motivation is important• Patient should be involved in goal setting• Treatment session should be positive• Therapist needs to be a support system, encouraging


Strategies to Improve Postural Control & Functional Mobility

RollingPractice rolling to both sidesRolling to affected side more difficultClasp hands together to assist with momentum and

use of the affected UECan bend the LE’s to assist with pushing overSidelying on affected side promotes WB of the

affected UE



Sit to Supine/Supine to SitImportant to practice towards both sidesWill likely be easier to perform from non-involved

sideTherapist may initially facilitate/assist movements



SittingInitially looking for symmetrical posture with proper

spinal alignmentEarly sitting may involve therapist cueing (tactile &/or

verbal) May use UE’s initially to maintain sitting postureProgress to no UE support, weight shifting, truncal

motions, PNF patterns, reaching/dynamic activities, perturbations, scooting

Progression may then include these same activities while sitting on a ball



BridgingDevelops hip and trunk extensor control as well as

LE selective control & early LE WBCan progress from performing the exercise, holding

the position and then performing dynamic activities within the posture



Sit to Stand (STS)Focus on symmetrical WB, coordination & timing(Demonstration of proper sit to stand)Strategies to initiate STS:

• Clasp hands or reaching forward with UE’s• Place pt hands on ball while therapist stabilizes ball but

then move ball forward to promote anterior weight shift• Raise the mat height• Place stronger foot slightly behind the weaker



Sit Down TransfersStrategies to promote controlled sit down include:

• Partial wall squats• Varying mat height• Lateral pelvic shifts to involved side and alternate

sit/stand



Standing, Modified PlantigradeStanding with affected UE extended and in

weightbearing position, LE also extendedAssists with development of postural and extremity

controlVery stable positionCan progress from static standing to movement and

reaching activities



StandingInitially standing can occur in parallel bars or at

bedside with assistProgression can include:

• 2 hand support → 1 hand support → free standing• Static standing → weight shift → dynamic (reaching,

stepping) → perturbations/rhythmic stabilizationFocus on proper alignment and symmetry



TransfersNeed to practice transfers to both sidesImportant to support the weaker kneeVary surfaces and surface heightsMay progress from squat-pivot to stand-pivot



Pusher SyndromeFocus is on the verticalCan use mirrors, the wall, a ball, or even the

therapist to assist with active, appropriate shifting rather than pushing

Ask the patient, “Which way are you leaning?”; “Which direction should you move to be vertical?”


Strategies to Improve UE Function

UE as a Postural SupportExtended UE weightbearing promotes proximal

stabilization and counteracts flexion synergy, hypertonus

Approximation can stimulate shoulder girdle stabilization and elbow extensors

Can perform in sitting, modified plantigrade, standing and quadruped

Progress from holding the position to more dynamic activities



ReachingCan begin with positions which eliminate gravity

• Sidelying, tabletop assist, “dusting” with washcloth, reaching down to touch the floor

• May also need therapist assistProgress to anti-gravity activitesCombine with balance & functional activitiesVary height/distance to reach, weight of object

grasped, time to complete the taskAvoid substitution



Manipulation & DexterityInitial tasks usually involve more gross grasp and

releaseCan begin by using affected hand to stabilize while

performing a task with stronger handProgress to bilateral activities, emphasize

function/ADLsInclude reaching activitiesBuild-ups for items such as forks, toothbrush, pens

can improve independence and efficiency



Enhanced Training ActivitiesBilateral arm training w/ rhythmic auditory cueing

(BATRAC)http://www.youtube.com/watch?v=dy2qzvDa-Fc



Enhanced Training ActivitiesConstrain-Induced Movement Therapy (CIMT)Electromyographic Feeback (EMG-BFB)Neuromuscular Electrical Stimulation (NMES)



Management of Shoulder PainCommon complication post stroke In the case of flaccidity, arm needs support at all timesProper arm support is essential

Scapula/shoulder protracted, arm forward in slight ABD and neutral ROT

↓ subluxation – NMES, supportive devices↓ Pain, normalize tone – gentle stretching & mobilization,

cryotherapy, EMG BFB, relaxation trainingAdhesive capsulitis treated with mobilization, PROM and

ultrasoundAvoid trauma or traction injuries with functional mobility



Supportive DevicesSlings

Pros and Cons



Supportive Devices (Gillen)Consider using slings only with initial transfer and

gait trainingDetermine whether a sling that places the arm in

flexion is really necessary, if so consider wearing only for short periods of time

Selection of a sling is on an individual basisConsider alternatives: NMES, taping, hand in

pocket/belt, lap tray


Strategies to ImproveLE Function

Necessary to prepare for appropriate gaitHelpful to start with improving pelvic control

Can practice forward pelvic rotation in sidelying, supine, hooklying, kneeling, sitting on ball, standing

Break synergistic patternsExample: hip extension is paired with knee flexion to

allow toe-off during terminal stance/pre-swingActivities to promote this include: bridging, supine

hip extension with knee flexed and heel pressing into the floor or standing and repeatedly practicing this phase of walking



Avoiding hyperextension of the kneeActivities to promote this

control include: controlled heel slides in supine and sitting, partial wall squats, controlled flexion and extension of knee on leg press, terminal knee extension exercises with Theraband in standing



Important to progress activities by modifying postures

Example:Supine → Sitting → Kneeling → Standing

And… emphasize reduction of synergistic patterns


Strategies to ImproveBalance

Important to select appropriate exercises, challenging to the patient but does not compromise safety

Must first achieve postural alignment and static stability in upright postures

Can then progress to exploring limits of stabilityWeight shiftingEncouraging symmetrical weight bearingEncouraging weight bearing to more affected side



Examples: Vary the BOSVary the support surfaceVary sensory inputsVary UE position/supportVary UE movementVary LE movementVary trunk movementsIncorporate dynamic functional activitiesIncorporate dual tasksChange the environment



StrategiesAnkle

• Small A/P weight shifting or small perturbations• Standing on rocker board, foam roller, dynadisc

Hip • Larger A/P weight shifts or perturbations• Tandem stance promote medial-lateral strategies

• Standing on floor or foam roller

Stepping• Displacement of COM in all directions• Therapist can apply a band around waist• Step ups


Strategies to Improve Balance

Need full attention from patient (and therapist!)Provide well-timed feedbackMinimize hand supportEncourage active problem-solvingSafety education must be included


Strategies to Improve Locomotion

Gait trainingInitially parallel bars & assistive

devices can be used• Pros & Cons

Important to progress patient to least restrictive device or no device as able

Want to encourage even, longer step length and increased time• May use rhythmic auditory cues OR• Markers on the floor with tape


Strategies to ImproveLocomotion

Look at each phase of gaitStance Phase

• Initial weight acceptance• Midstance control• Forward weight advancement

Swing Phase• Knee and foot control for toe clearance• Foot placement

UE posturing



Vary the environmentCommunity walking, hiking trails, hills

Practice walking in all directionsForward, backward, sideways

Practice cross-steppingInclude stairs, curbs, step-over-stepInclude timing activities

Crossing the street, using escalators, elevators and automatic doors



Practice dual-task activitiesTalking, bouncing a ball, carrying a tray

Incorporate balance activitiesTandem walking, walking on foam/gravel/grass

Treadmills, cycle ergometersThese tools may assist with improving time and

reciprocity of the LEs



Body weight support systems

Limb load monitorsNMES to improve ankle DF



Orthotics AFO Knee Controls



WheelchairsAppropriate positionTypes:

• Hemi-height wheelchair (Seat to floor height is 17.5”)• One arm drive chair• Power wheelchair

Training activities• Proper use, maintenance and safety• Methods of propulsion• Level and varied surfaces• Transfers


Strategies to ImproveAerobic Function

Initial Phase: functional activities are sufficientPost-Acute Phase: may progress to treadmill,

stationary bicycleCarefully monitor VS & symptoms of exertional

intolerance, impending stroke or heart attackChoose method based on patient’s interestSuggested frequency is 3X/week for 20-60 minutes

May be daily at lower intensitiesRecommend starting with intermittent training and

progressing to continuous 30 minutes of exerciseConcorde Career College

Questions


Concorde Career College Physical Therapist Assistant

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