Stanbridge - T5 - Neuro1 - W2 - Intro to CVA Part 2, Pelvic PNF Patterns

• CVA Part II concerns intervention for neurologic conditions
• PTA 1012 addresses Lecture Objectives

Lecture Objectives in CVA Treatment

• Physical therapist assistant (PTA) addresses role in stroke patients treatment
• Describe treatment interventions for patients who have experienced strokes
• Acknowledge the importance of functional training for stroke rehabilitation

Acute Medical Management of Cerebrovascular Accidents

• Regulation of blood pressure is needed and to be reduced primarily after a hemorrhagic CVA
• Cerebral perfusion and increased blood flow (tPA or medical procedures) are vital
• Intracranial pressure should be monitored (possible shunting or craniotomy after a hemorrhagic CVA)

Acute Medical Management for Ischemic CVA

• Treatment for ischemic CVA or TIA includes medications and procedures
• Tissue plasminogen activator (tPA) is a thrombolytic medication and the main treatment for ischemic CVA
• Must be given within 3 hours after the beginning of CVA symptoms, remember FAST
• Used to decrease the effects of neurologic damage
• If tPA is not an option, MD may prescribe anticoagulant or antiplatelet medication

Blood Clot Reduction for Ischemic CVA

• Anticoagulants like Heparin (Lovenox) or Warfarin (Coumadin) reduce the coagulation (clotting) of blood
• Antiplatelet reduces platelet formation (aspirin)
• Individuals may need a procedure to open arteries and restore cerebral perfusion

Thrombectomy Procedure

• Thrombectomy removes a clot from a blood vessel
• A surgeon will inset catheter in the femoral artery to the blocked artery in the brain or neck

Angioplasty and Stenting

• This procedure uses a thin tube to insert a balloon or mesh that expands vessels
• A stent retriever is a wire mesh in the catheter that traps and pulls out blood clots through a tube

Acute Medical Management for Hemorrhagic CVA

• Hemorrhagic CVA can have a sudden onset and worsen quickly
• The fastest treatment possible results in a greater recovery
• The treatment approach depends on the location of the hemorrhage
• Anticoagulant medication is stopped for patients whose CVA results from hemorrhage

Medical Procedures for Hemorrhagic CVA

• Available medical procedures include:
  • Aneurysm clipping
  • Blood Transfusion
  • Coil embolization
  • VP shunting
  • Craniotomy
  • Surgery or radiation to reduce or remove AVM
  • Surgery to remove excess blood only if shows signs of getting worse

Pharmaceutical Interventions for Spasticity

• Baclofen acts on the CNS and reduces muscle spasms, tightness, and pain, which improves range of motion -Confusion or hallucination is a known side effect that will slightly sedate -Coordination, loss of muscle tone, and weakness is also a side effect in unaffected muscles
• Zanaflex reduces spasticity by resisting nerve impulses without reduced muscle strength -It is best used when you need it for relief or need to complete certain activities because of its short activity life. -Low blood pressure, sleepiness, and dry mouth are key side effects. -Valium and Klonopin act on the CNS to relax muscles and decrease Brief spasticity. -Side effects include mental impairment, dependence drowsiness, and muscle weakness.
• Dantrolene is a medication that prevents contraction-inducing signals resulting reduced muscle tone. -Side effects: include: liver failure, diarrhea, dizziness, vomiting, nausea, drowsiness, weakness, and depression

Impairments Related to Cerebrovascular Accidents

(Continued from PPT #1)

• Motor impairments include abnormal tone, paresis, and plegia
• Deficits in motor planning may occur following a CVA
• Sensory and/or communication, orofacial, respiratory impairments can result from a CVA
• Reflex reactivity may be abnormal within the spinal cord and brainstem
• Bowel and bladder dysfunction is possible, along with altered DTRs

Communication Deficits

• Aphasia is caused by UMN injury
  • Broca's aphasia is expressive or non-fluent
  • Wernicke's aphasia is receptive or fluent
  • Global aphasia is non-fluent
• Dysarthria creates difficulty articulating words because of weakness in muscles associated with production of speech (caused by LMN injury)
• Emotional lability creates difficulty controlling emotions, which is common in R CVA’s from UMN injury

Orofacial Deficits

• Facial asymmetries exist from weakness in muscles of the face, eye, and mouth
• Can result in difficulty making facial expressions, difficulty controlling fluids and saliva and trouble closing the eye
• PTAs have to be aware of fluid and/or dietary restrictions

Respiratory Impairments

• Decreased lung expansion and diaphragm engagement occurs
• Respiratory rate increases while vital capacity decreases, resulting in shallow breathing
• All cause of in effective cough
• Decrease in cardiovascular conditioning occurs, results in fatigue
• Treatment:
  • Performing activities that improve general condition -Diaphragmatic strengthening, light aerobics, -Cardiopulmonary Training -Deep breathing exercises (PLB) -Monitor vitals, stretch trunk to reduce wall tightness and lateral chest expansion

Shoulder Impingement

• With rotator cuff muscle plegia or paresis, humeral head elevates superiorly during arm elevation
• Causes supraspinatus tendon impingement between head and acromion
• Poor scapular muscle control may contribute a lack of upward scapula rotation causing impingement during overhead movements
• Treatment:
  • Utilize proper positioning and handle the affected arm with care -Electrostimulation to affected shoulder, review electrotherapy PTA 1013 notes -Do not perform overhead pulleys on flaccid limbs
  • During PROM of the shoulder (flaccid), do not exceed 90 degrees of abduction /flexion, and ensure the humerus is externally rotated and the scapula is upwardly rotated
• PROM of the flaccid shoulder during internal and external rotation should be done in an adducted position

Bowel and Bladder Dysfunction

• Incontinence may occur secondary to muscle paralysis or sensory compromise
• This issue can be embarrassing for patients
• Treatment: -Perform synergistic muscle activation, pelvic floor activation: -Train TrA, and gluteal muscles -Weight bearing -Utilize timed voiding

Functional Limitations

• Limitations may occur with ADL’s bathing, toileting, dressing, hygiene/grooming, and feeding
• Limitations of mobility exist, concerning transition, transfers, and ambulation
• Limitations can occur with higher level activities such as work, return to sport, or hobbies

Complex Regional Pain Syndrome

• Aka RSD, shoulder/hand syndrome
• Can have unknown etiology
• Results in stocking/glove presentation
• Characterized by movement disorders, weakness, atrophy, pain alongside autonomic sign/symptoms and edema
• Management focuses on prevention through encouragement, active and functional hand use in rehabilitation early stages

Further CVA Complications

• Increased risk of trauma and/ or falls
• Increased risk of DVT's
• Depression

Inpatient Acute Care Following Cerebrovascular Accidents

• IP hospitalization average lengths post stroke are 2-4 days
• Moderate to severe CVA patients who need further hospital care may be directed to Acute Rehabilitation or a Skilled Nursing Facility (SNF) for continued Rehab
• Patient will be directed to attend home-based/out-patient therapy once medically stable

Importance of Stroke Rehabilitation Positioning

• Early interventions to manage motor impairment, like spasticity, resulting in contractures should be a focus
• Positioning is the rehab team's and patient's responsibility
• Proper positioning assists in maintaining normal ROM in joints, decreases musculoskeletal impairments, improves respiratory function, and increases sensory awareness

Early Intervention Involving Positioning (Supine)

• Place trunk midline with the head and neck slight flexion
• Place a pillow under the involved UE and scapula for support and protraction
• Position the involved UE in shoulder abduction (30-45 deg)/extension/ER, elbow extension, fingers extended, thumb abducted
• Positioning on the LE: ankle dorsiflexion, knee extension, and hip neutral rotation
• Prevent hyperextension under the involved knee with a shallow towel

Positioning in The Uninvolved Side (Early Intervention)

• Put or keep head/neck in neutral
• Support the UE with scapula protracted, shoulder flexed (45-90deg), thumb abducted, wrist slightly extended, elbow extended, fingers extended
• The UE should be in patient’s view, insert a pillow between the knees with both hips and knees slightly flexed

Positioning on the Involved Side (Early Intervention)

• Match position on the uninvolved side, EXCEPT without a pillow under involved UE
• A good way to improve weight bearing and proprioception through effected side
• This is a great way to reduce spasticity in scapular retractors, while emphasizing protraction and weight bearing on shoulder

Utilizing Wheelchairs

• Use Wheelchair Seating for Early Intervention Positioning
• LE, Head/neck, and Truck should maintain Midline Orientation
• 90/90 degree rules for Lower Extremities
• Lumbar roll/tray is to provide added encouragement with postural/seating support

Splinting/Orthoses for UE

• UE Shoulder subluxation can be prevented through with splinting
• Different names and methods are -Shoulder cuff -Elbow Orthosis -Wrist Hand orthosis -Elbow Wrist Hand Orthosis

Splint and orthoses for LE

• Decreased tone, improved positioning, and enhanced functional alignment in and out of function are goals with LE spliting during early intervention
• Various methods can be utilized or combined
• HKAO: Hip/Knee/Ankle/Foot Orthosis
• KAFO: Knee/Ankle/Foot Orthosis
• AFO: Ankle/Foot Orthosis

Lower Extremity Early Intervention (Treatment)

• Mobility Training Can Include
  • Bridging which encourages weight bearing with approximation
  • Lower Trunk Rotation: allows for increased trunk control,
• PROM/AAROM/AROM to areas at risk for contractures
• STM to reduce Spasming
• Resistive Training w/ FES

Upper Extremity Early Intervention (Treatment)

• PROM/AROM/AAROM to upper Extremity or Shoulder
• Scapula joint / mobilization
• Facilitate NMES/FES with PNF techniques
• Wand exercises

Stages of Motor Control

• Hierarchic Model Review

Important Terms

• Mobility
• Stability
• Controlled Mobility
• Skilled Movement
• Functional Transition = NDT ( Early, Mid, Late Intervention)

Motor Activation ( NDTA/ PNF) Early (Mid and Late Intervention)

• Scooting
• Rolling
• Supine -sit
• Bed- chair

Stroke Rehabilitation

• Seated Activities facilitate proper alignment, dynamic seated activities to improve balance for seating Activities: Utilize the NDT and or PNF techniques

WB = Hand

• Utilize facilitation towards trunk

Gait

• Goal = Repetition Specificity increase Motor planning

Standing Alignment

• Encourage Maintain Trunk

Post hemiplegic Patients

• Exhibit Deviations During gait
• Need Assistance with Weight Shifting
• Facilitate Proper Alignment