Hot Topics in Stroke Rehab - 2018 Rehab Summit: Las Vegas · HOT TOPICS IN STROKE ... Learning...

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HOT TOPICS IN STROKE REHABILITATION Turning Evidence-Based Practice into Everyday Practice J.J. Mowder-Tinney PT, PhD, NCS, CSRS, CEEAA, C/NDT

[email protected]

Learning Objectives •  Identify standardized tests appropriate for specific patient

presentations • Contrast differing areas of the scientific literature in a case

based format • Differentiate options for individualization of interventions

for common patient case scenarios for a variety of settings

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What Will I Do in 2 Hours? • I will review three case studies focused on different aspects of problems to discuss a variety of treatments

• This will be simplified therefore I will not… • Go into depth regarding outcome measure testing

• Review the specifics of evaluation testing • Review specific research articles

Visions • APTA 2020

• Transforming society by optimizing movement to improve the human experience.

• AOTA 2025 • Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living.

Motivation

Observation

Evaluation

Investigation

INTERVENTION DESIGN

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Mot

ivat

ion What will

improve quality of

life?

LISTEN Obs

erva

tion

Functional Activities

All

Movement Eval

uatio

n

Posture Strength Aerobic Capacity Balance In

vest

igat

ion

Review the Literature

Translate the Knowledge

These…

…lead you to your INTERVENTION

Reminder - MONITOR • Make sure to monitor during all activities • Always get baseline measurements

• Blood Pressure • Heart Rate • Rate of Perceived Exertion

Fairly Light

Somewhat Hard

Hard

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CASE #1

Jackson is a 27-year-old male who sustained a anoxic brain injury in

12/2014. Has history of concussions from falls and depression prior to

injury.

Lives at home with mother in 2 story house with fully accessible basement. Uses power wheelchair with Roho or

pushed in a manual wheelchair depending on transportation.

Primary goal of patient is to walk and for mom is to improve transfers.

Interests in sports, physical fitness and weight lifting.

MOTIVATION

• What are the top five things you want to work on during therapy?

• What do you wish you could get back to doing?

• How would you like things to be different?

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Increase control in sitting, improve transfers, stand

straighter, and walk.

VIDEO OBSERVATION

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Case #1 Video Observation

Reflection on Current Practice

Based on your observation take 30 seconds and write down what measures you would perform.

What Will Make The Biggest Impact?

If you could wave a magic wand….

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•  Breathing •  FIST

•  Hip abduction •  Hip extensors •  Core

•  Occiput to wall sitting

•  Thomas test •  DF range

Posture Strength

Aerobic Capacity Balance

Impairment/Body Structure

Function Outcome Measure Jackson’s Eval

Scores Norms

Posture

Occiput to Wall Distance ** in chair ____ cm 0 cm

Ankle Passive DF -15° Right/ -7° Left Neutral

Thomas Test Neutral Neutral

Muscle Performance:

Strength

Hip abduction 1/5 bilateral 5/5

Supine Hip Extensor Unable to isolate with knee/hip extended 5/5

Cardiovascular Endurance

N/T N/T N/T

Balance FIST 14/56 N/A

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Case #1 Video Evaluation

Outcome Measures

Most reference Norms were taken from Rehabmeasures.org comparing community dwelling

and the associated age range. Additional references are below.

Function in Sitting Test - http://www.samuelmerritt.edu/fist

1.  Landers MR, Oscar S, Sasaoka J, Vaughn K. Balance confidence and fear of falling avoidance behavior are most predictive of falling in older adults: prospective analysis. Physical therapy. 2016 Apr 1;96(4):433-42.

2.  Rikli, R. E. and Jones, C. J. (2013). "Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years." The Gerontologist 53(2): 255-267.

3.  Peeler J, Anderson JE. Reliability of the Thomas test for assessing range of motion about the hip. Phys Ther Sport. 8(1):14-21;2007

INVESTIGATION KNOWLEDGE TRANSLATION

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Reflection References • Wainwright SF, Shepard KF, Harman LB, Stephens J.

Novice and experienced physical therapist clinicians: a comparison of how reflection is used to inform the clinical decision-making process. Physical Therapy. 2010 Jan 1;90(1):75-88.

• Donaghy ME, Morss K. Guided reflection: A framework to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice. 2000 Jan 1;16(1):3-14.

• Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using the International Classification of Functioning, Disability and Health (ICF) framework and patient management model. Physical therapy. 2011 Mar 1;91(3):416-30.

Investigation Highlights Posture 1.  Lee JH, Cynn HS, Yoon TL, Ko CH, Choi WJ, Choi SA, Choi BS. The effect of

scapular posterior tilt exercise, pectoralis minor stretching, and shoulder brace on scapular alignment and muscles activity in subjects with round-shoulder posture. Journal of Electromyography and Kinesiology. 2015 Feb 28;25(1):107-14.

2.  Lomas-Vega R, Garrido-Jaut MV, Rus A, del-Pino-Casado R. Effectiveness of Global Postural Re-education for Treatment of Spinal Disorders: A Meta-analysis. American Journal of Physical Medicine & Rehabilitation. 2016 Jul 6.

3.  Kim KY, Chun SP, Kang TG, Kim GD. Effects of Core Stability Training on Postural Control Ability and Respiratory Function in Chronic Stroke Patients. In Current Research on Healthcare and Nursing, Advanced Science and Technology Letters. 2015;.88:181-186.

4.  Haruyama K, Kawakami M, Otsuka T. Effect of Core Stability Training on Trunk Function, Standing Balance, and Mobility in Stroke Patients: A Randomized Controlled Trial. Neurorehabilitation and neural repair. 2017 Mar 1:1545968316675431.

5.  Oh D, Kim G, Lee W, Shin MM. Effects of inspiratory muscle training on balance ability and abdominal muscle thickness in chronic stroke patients. Journal of physical therapy science. 2016;28(1):107-11.

6.  Park BS, Noh JW, Kim MY, Lee LK, Yang SM, Lee WD, Shin YS, Kim JH, Lee JU, Hwang BY, Kim J. Randomized Controlled Pilot Trial of Truncal Exercises after Stroke to Improve Gait and Muscle Activity. Neuroscience and Medicine. 2016 Nov 2;7(04):149.

Investigation Highlights Strengthening

•  Kim CY, Lee JS, Kim HD, Kim JS. The effect of progressive task-oriented training on a supplementary tilt table on lower extremity muscle strength and gait recovery in patients with hemiplegic stroke. Gait & posture. 2015 Feb 28;41(2):425-30.

•  Ada L, Dorsch S, Canning CG. Strengthening interventions increase strength and improve activity after stroke: a systematic review. Australian Journal of Physiotherapy. 2006 Dec 31;52(4):241-8.

•  Wist S, Clivaz J, Sattelmayer M. Muscle strengthening for hemiparesis after stroke: A meta-analysis. Annals of physical and rehabilitation medicine. 2016 Apr 30;59(2):114-24.

•  Fernandes B, Ferreira MJ, Batista F, Evangelista I, Prates L, Silveira-Sérgio J. Task-oriented training and lower limb strengthening to improve balance and function after stroke: A pilot study. The European Journal of Physiotherapy. 2015 Apr 3;17(2):74-80.

•  Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy. 2013 Feb;43(2):54-64.

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Reflection Based on the motivations, observations, and

evaluations take 30 seconds and write down what interventions you would perform.

INTERVENTIONS

Breathing Exercises •  Inspiratory muscle trainer •  Breathing exercises – breath in for 2, hold for 2, blow

out for 4.

Supine/Sidelying •  Supine extensor activation •  Initiation of rolling •  Clam shells – with resistance •  Bridging – push heels into the mat (glut focus)- slight ER

Sitting •  Kinesiotaping for cervical extension •  Resistance with theraband, Pushing •  Facilitate error with wedge •  Wheelchair tilted back for stretching, breathing and exc

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•  Park BS, Noh JW, Kim MY, Lee LK, Yang SM, Lee WD, Shin YS, Kim JH, Lee JU, Hwang BY, Kim J. Randomized Controlled Pilot Trial of Truncal Exercises after Stroke to Improve Gait and Muscle Activity. Neuroscience and Medicine. 2016 Nov 2;7(04):149.

Tilt Table • Passive stretch of ankles, trunk alignment, hip stretch, extensor activation with legs straight, abdominals

• Pulling theraband quick with one arm to get opposite extensors

Kim CY, Lee JS, Kim HD, Kim JS. The effect of progressive task-oriented training on a supplementary tilt table on lower extremity muscle strength and gait recovery in patients with hemiplegic stroke. Gait & posture. 2015

Feb 28;41(2):425-30.

Case #1 Video Intervention

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How Do You Adjust Your Intervention?

Intervention Adjustment

Adjust

Observe

Reflect

Motor Learning Intensity

Feedback

Knowledge of Results

Self Efficacy

External Cues

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Progression/Challenges** • Eyes closed

• Speed Changes (Slow/fast) • Visual distracters • Dual task training with challenges – cognitive, visual,

manual, auditory (singing, words start with K, reading, dialing a phone, etc).

• Challenges – carrying heavy objects, pushing heavy objects

Reference the Progression/Challenges slide for adjustment with

ANY of the cases

Home Exercise Program • Don’t under estimate the power of

a focused home activity – emphasize this to them

• Supine Hip Extension activation in supine

•  Tilt wheelchair stretching of pecs

•  In this case I would focus on head and trunk position and stretching

TRY Part Task Training with lower level patient Henry KD, Rosemond C, Eckert LB. Effect of number of home

exercises on compliance and performance in adults over 65 years of age. Physical Therapy. 1999 Mar 1;79(3):270.

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CASE #2

Fred is a 66 year-old male with a subarachnoid hemorrhage in 2013. He had two seizures prior to hemorrhage and 3 seizures since. Has fallen three

times in the last month.

Lives with wife was a special ed teacher. Buffalo Bills fan. Lives in a

ranch style house with no stairs. He is Independent in bed mobility with rail, mod A without. Ambulates with quad

cane throughout the house.

Scared of falling again. Enjoys visiting son who has two stairs to enter without a railing. Wants to get in and out of car

and walking through doors that automatically close and open.

Increasing strength, stand straighter, and improve balance to

prevent falls.

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VIDEO OBSERVATION


Reflection on Current Practice

Based on your observation take 30 seconds and write down what measures you would perform.

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•  6MWT •  TUG •  ABC Scale

•  Sit to stand •  Hip extensors •  Hip abd/Knee

flexors

•  Occiput to wall difference

•  Thomas test

Posture Strength



Function Outcome Measure Bill’s Eval Scores Norms

Posture

Occiput to Wall Distance 0 cm 0 cm

Thomas Test Neutral

Muscle Performance:

Strength

30 Second Sit to Stand

2 with UE support and rocking 16 reps

Hip abductors/Knee Flexors

1/5 **unable to isolate movement 5/5

Supine Hip Extensor 1/5 5/5


6MWT 291 feet 1876 feet

Balance TUG 58 secs 14 secs

ABC Scale 24% >67%

____

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Gait Speed

•  I didn’t put gait speed in these charts because I always measure gait speed if the person is ambulatory because of correlation with safety. • Not always used as a goal (ie. Ataxia)

•  This information gives me ammunition for patient feedback (knowledge of results) as well as insurance companies.

Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. Journal of aging and physical activity. 2015 Apr;23(2):314-22.


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Investigation Highlights Trunk Flexibility 1.  Büssing A, Ostermann T, Lüdtke R, Michalsen A. Effects of yoga interventions on pain and

pain-associated disability: a meta-analysis. The Journal of Pain. 2012 Jan 31;13(1):1-9. 2.  Hirose D, Ishida K, Nagano Y, Takahashi T, Yamamoto H. Posture of the trunk in the sagittal

plane is associated with gait in community-dwelling elderly population. Clinical Biomechanics. 2004 Jan 31;19(1):57-63.

Muscle Performance 1.  Shishov N, Melzer I, Bar-Haim S. Parameters and measures in assessment of motor

learning in neurorehabilitation; a systematic review of the literature. Frontiers in human neuroscience. 2017;11.

2.  Arvin M, van Dieën JH, Faber GS, Pijnappels M, Hoozemans MJ, Verschueren SM. Hip abductor neuromuscular capacity: A limiting factor in mediolateral balance control in older adults?. Clinical Biomechanics. 2016 Aug 31;37:27-33.

3.  Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy. 2013 Feb;43(2):54-64.

Investigation Highlights Aerobic Conditioning •  Boyne P, Dunning K, Carl D, Gerson M, Khoury J, Rockwell B, Keeton G, Westover J,

Williams A, McCarthy M, Kissela B. High-Intensity Interval Training and Moderate-Intensity Continuous Training in Ambulatory Chronic Stroke: A Feasibility Study. Physical Therapy. 2016 Apr 21.

•  Dean CM, Richards CL, Malouin F. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Archives of physical medicine and rehabilitation. 2000 Apr 30;81(4):409-17.

•  Wevers L, Van De Port I, Vermue M, Mead G, Kwakkel G. Effects of Task-Oriented Circuit Class Training on Walking Competency After Stroke A Systematic Review. Stroke. 2009 Jul 1;40(7):2450-9.

•  Askim T, Dahl AE, Aamot IL, Hokstad A, Helbostad J, Indredavik B. High Intensity Aerobic Interval Training for Patients 3–9 Months After Stroke. A Feasibility Study. Physiotherapy Research International. 2014 Sep 1;19(3):129-39.

•  Prout EC, Mansfield A, McIlroy WE, Brooks D. Physiotherapists’ perspectives on aerobic exercise early after stroke: A preliminary study. Physiotherapy Theory and Practice. 2016 Jul 27:1-9.

•  Billinger SA, Boyne P, Coughenour E, Dunning K, Mattlage A. Does aerobic exercise and the FITT principle fit into stroke recovery?. Current neurology and neuroscience reports. 2015 Feb 1;15(2):1-8.

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INTERVENTIONS

Hip Abductor Strengthening • Hip abductor muscles

play an important role in mediolateral balance control. Accurate balance performance appears limited by lower hip abductor strength when explicit visual information on balance reduces the need for hip abductor proprioception

Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy. 2013 Feb;43(2):54-64.

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Case #2 Video Interventions

Alternate Facilitation for Higher Level

External Cues • Counting number of steps to improve step symmetry

•  Let’s start with a goal of increasing stride length. An internal cue would be to ask your patient to “take a bigger step”. To switch this to become more automatic and have an external focus, count how many steps they took in a certain distance (ie. 25feet). If it took them 28 steps to complete that distance, have them do it again but with less steps.

• Practice getting in and out of car in the clinic •  Use the environment to set up and mimic a car •  Remember to facilitate a posterior pelvic tilt when lifting up leg over

lip

• Don’t forget to focus on using a curb

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Mimic Getting In and Out of Car

Aerobic Conditioning

Circuit

•  Evidence for the efficacy of a task-related circuit class at improving locomotor function in chronic stroke.

•  The use of task-oriented circuit class training to improve gait and gait-related activities in patients with chronic stroke.

HIIT

• High Intensity Interval Training (HIIT) • Repeated bouts of high intensity followed by recovery periods (no

single formula) • Allows greater stress to system •  Improved muscle metabolic function • Trains aerobic and anaerobic system • Build base first


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Adjust

Observe

Reflect


Feedback


Self Efficacy

External Cues

Enhance Error • Add weights to legs during retraining

• Add weighted vest

• Add theraband resistance IN direction of error

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Home Exercise Program

• Don’t under estimate the power of a focused home activity – emphasize this to them

•  In this case I would focus on visual tracking, rotations and/or proximal stability

CASE #3

Tim is a 66 year-old male diagnosed with R CVA 2/2015. PMHx includes right lumbar lami in 2013 requiring

right AFO for foot drop and bilateral hip replacements (2009,2016).

Lives with significant other in a 2 story home with 3 steps to enter with bilateral

railings. Right sided railing to access basement. Ambulates using straight

cane.

Pt was a professor of toxicology and biology prior to stroke. Goals to

improve walking speed and fluidity and balance

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Improve walking speed and balance.

VIDEO OBSERVATION


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Reflection on Current Practice Based on your observation take 30 seconds and write

down what measures you would perform.



•  6MWT •  Four Square Step Test

•  ABC Scale

•  Sit to stand •  Hip abductors •  Hip extensors •  PF

Strengthening

•  Occiput to wall difference

•  Thomas test

Posture Strength

*Isolate Mvmt*


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Function Outcome Measure Bill’s Eval Scores Norms

Posture

Occiput to Wall Distance 2 cm 0 cm

Thomas Test Right WNLs/ Left stiff iliopsoas and Rectus Neutral

Muscle Performance:

Strength

30 Second Sit to Stand 6 with UE support 11 reps

Hip abductor 2/5 5/5

Plantarflexion Strength Bilateral 1/5 5/5

Supine Hip Extensor 5/5


6MWT 363 feet 1368 feet

Balance

Four Square Step Test 28 seconds – needs to look at floor 15 secs

ABC Scale 61% >67%

DGI 15/24 **Turns 19/24

____



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Investigation Highlights Balance and Motor Learning •  Winstein C, Lewthwaite R, Blanton SR, Wolf LB, Wishart L. Infusing

motor learning research into neurorehabilitation practice: a historical perspective with case exemplar from the accelerated skill acquisition program. Journal of Neurologic Physical Therapy. 2014 Jul 1;38(3):190-200.

•  Winstein CJ, Kay DB. Translating the science into practice: shaping rehabilitation practice to enhance recovery after brain damage. Progress in brain research. 2015 Dec 31;218:331-60.

•  Winstein C, Lewthwaite R, Blanton SR, Wolf LB, Wishart L. Infusing motor learning research into neurorehabilitation practice: a historical perspective with case exemplar from the accelerated skill acquisition program. Journal of Neurologic Physical Therapy. 2014 Jul 1;38(3):190-200.

•  Fisher, Beth E., Susanne M. Morton, and Catherine E. Lang. "From motor learning to physical therapy and back again: the state of the art and science of motor learning rehabilitation research." (2014): 149-150.

Investigation Highlights Balance and Motor Learning •  Pollock CL, Boyd LA, Hunt MA, Garland SJ. Use of the challenge

point framework to guide motor learning of stepping reactions for improved balance control in people with stroke: a case series. Physical therapy. 2014 Apr 1;94(4):562.

•  Beauchamp MK, Janaudis-Ferreira T, Parreira V, Romano JM, Woon L, Goldstein RS, Brooks D. A randomized controlled trial of balance training during pulmonary rehabilitation for individuals with COPD. CHEST Journal. 2013 Dec 1;144(6):1803-10.

•  Mansfield A, Wong JS, Bryce J, Knorr S, Patterson KK. Does perturbation-based balance training prevent falls? Systematic review and meta-analysis of preliminary randomized controlled trials. Physical therapy. 2015 May 1;95(5):700-9.

•  Yungher DA, Morgia J, Bair WN, Inacio M, Beamer BA, Prettyman MG, Rogers MW. Short-term changes in protective stepping for lateral balance recovery in older adults. Clinical biomechanics. 2012 Feb 29;27(2):151-7.

Investigation Highlights Balance and Motor Learning •  Mansfield A, Inness EL, Komar J, Biasin L, Brunton K, Lakhani B, McIlroy WE.

Training rapid stepping responses in an individual with stroke. Physical therapy. 2011 Jun 1;91(6):958-69.

•  Kleynen M, Moser A, Haarsma FA, Beurskens AJ, Braun SM. Physiotherapists use a great variety of motor learning options in neurological rehabilitation, from which they choose through an iterative process: a retrospective think-aloud study. Disability and Rehabilitation. 2016 Jul 11:1-9.

•  Reisman DS, Bastian AJ, Morton SM. Neurophysiologic and rehabilitation insights from the split-belt and other locomotor adaptation paradigms. Physical Therapy. 2010 Feb 1;90(2):187.

•  Pai YC, Bhatt TS. Repeated-slip training: an emerging paradigm for prevention of slip-related falls among older adults. Physical therapy. 2007 Nov;87(11):1478.

•  Merlo AR, etal. Participants perspectives on the feasibility of a novel, intensive, task-specific intervention for individuals with chronic stroke: A qualitative analysis. Phys Ther. 2013;93:147-157.

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INTERVENTIONS

Strengthen • Practice retraining ability to isolate movements but FOCUS on priority functional movements •  Motivators

• Need to be able to turn on and turn off muscles •  Can use theraband wrap to take away

gravity to assist with isolation

• Estim plantarflexors for knee control

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Strength and balance exercises reduce falls while walking training alone could

increase them.

85% of balance comes from proximal strategies (hip abd, add, trunk) and 15%

from the ankle

Reactive Balance •  Train stepping on the good side.

•  Reactive stepping: Side stepping, backward stepping, forward stepping

• Start with just stepping out. Go in all directions.

• On ramp • Resisted stepping • Slip trainer

•  http://rehabharness.com/product_list.php?listing=1

Reactive Balance - Fishing

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Case #3 Video Intervention



Adjust

Observe

Reflect

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Feedback


Self Efficacy

External Cues

External Cues • Utilization of an external cue

• Adjustment of increasing awareness of surroundings through eyes closed or external cues

Home Exercise Program • Don’t under estimate the

power of a focused home activity – emphasize this to them

•  In this case I would focus on plantarflexor strengthening or increased lower extremity strengthening (stepping up and down)

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Ataxia Intervention Video

Don’t get stuck in the mud

Facility Consultations Available

Hot Topics in Stroke Rehab - 2018 Rehab Summit: Las Vegas · HOT TOPICS IN STROKE ... Learning...

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Transcript of Hot Topics in Stroke Rehab - 2018 Rehab Summit: Las Vegas · HOT TOPICS IN STROKE ... Learning...