Stanbridge - T6 - Neuro2 - W3 - Interventions for CVA and CP

• Neuro Logic Interventions II PTA 1015 include:
  • Interventions for CVA (Cerebrovascular Accident) and CP (Cerebral Palsy)

Lecture Objectives

• Understand the etiology and clinical manifestations of stroke.
• Identify common implications seen in patients who have sustained Cerebrovascular Accidents.
• Describe appropriate treatment interventions for patients who have experienced strokes.
• Recognize the importance of functional training for patients who have had a stroke.
• Ischemic stroke is a thrombotic stroke.
• Frontal and parietal lobes are supplied with blood via the middle cerebral artery.
• Speech is "S" in the acronym F.A.S.T. when recognizing signs of a stroke.
• Midstance, quad weakness is the phase of gait where hyperextension thrust occurs and most likely cause.
• Contralateral hemiparesis and sensory loss in face and extremities, UE > LE is seen in a patient recovering from a left CVA due to MCA occlusion .
• Approximation is an NDT (Neuro-Developmental Treatment) technique to decrease spasticity.
• Broca's aphasia is also known as Expressive aphasia.
• Transference is the principle of neuroplasticity, when training one task may positively affect another similar task.

Cerebral Circulation Review

• The anterior cerebral artery supplies the superior border of the frontal and parietal lobes.
• The middle cerebral artery is the largest cerebral artery and is most often occluded, supplying blood to the lateral surface of the brain and deep portions of the frontal and parietal lobes.
• Vertebral Artery supplies of the brainstem and cerebellum.
• The Basilar Artery supplies the brain stem and the medial portion of the temporal and occipital lobes
• Posterior Cerebral Artery connects with the posterior communicating artery and both supply the midbrain, also the posterior cerebral artery also supplies occipital and temporal lobes
• Anterior and Posterior Communicating Arteries are interconnected at the base of the brain to form the Circle of Willis, providing a protective mechanism so that occlusion of one cerebral artery does not critically decrease blood flow to that region.
• Vascular Syndromes include:
  • Anterior Cerebral Artery (ACA) Occlusion.
  • Middle Cerebral Artery (MCA) Occlusion.
  • Vertebrobasilar Artery Occlusion.
  • Posterior Cerebral Artery Occlusion.
  • Cerebellar CVA (Cerebrovascular Accident).
    • Wallenberg Syndrome.
    • Lateral Pontine Syndrome.

Vertebrobasilar Artery Occlusion

• Supplies the cerebellum, medulla, pons, and internal ear.
• Complete occlusion results in death.
• Incomplete occlusion results in:
  • Diplopia, or double vision.
  • Dysphagia, or difficulty with swallowing.
  • Dysarthria, or difficulty forming words secondary to weakness.
  • Deafness, or inability to hear.
  • Vertigo, or spinning/dizziness.
  • Headaches.
  • Ataxia, or uncoordinated movements.
  • Dis-equilibrium.
  • Locked-in syndrome, the of inability to move or speak but being alert/oriented while only able to move eyes.
  • Contralateral Sensory Loss occurs with Posterior Cerebral Artery Occlusion
  • Thalamic Pain Syndrome may occur
  • Homonymous Hemianopia - Visual impairment with loss of vision in half the visual field for each eye.
  • Visual Agnosia – being unable to recognize objects or people
  • Cortical Blindness – being unable to process incoming visual information -Memory Deficits can occur

Wallenberg Syndrome

• Infarct caused in the posterior inferior cerebellar artery which supplies which supplies the cerebellum and medulla
• Occlusion results in:
  • Loss of pain and temperature on the contralateral side of the body and ipsilateral face.
  • Dizziness and vertigo.
  • Ataxia.
  • Diplopia.
  • Dysphagia.
  • Dysarthria.
  • Horner's syndrome
    • Miosis (pupil constriction).
    • Ptosis (eyelid droop).
    • Decreased sweating.

Cerebellar CVAs

• Lateral Pontine Syndrome may be the result of this
• Is an infarct of the anterior inferior cerebellar artery which supplies the cerebellum and CN VII and VIII.
• Occlusion may result in:
  • Ipsilateral ataxia.
  • Contralateral weakness.
  • Contralateral Loss of pain and temperature.
  • Dizziness And Vertigo.

Thalamic Pain syndrome

• Occurs following a stroke in the lateral thalamus, posterior limb of the internal capsule or parietal lobe.
• Characterized by:
  • Intolerable burning pain.
  • Sensory perseveration .
  • Sensation gets perceived as noxious and exaggerated.

Pusher syndrome

• Pusher Syndrome is also known as Contraversive Pushing.
• Occurs following a stroke in the posterolateral thalamus.
• 10-16% of stroke survivors experience it.
• Characterized by:
  • Using their non-paretic limb to push themselves towards their paretic side.
  • Meeting with efforts to passively correct when resistance occurs.
• Karnath et al. (2003) suggest that the initial rehabilitation:
  • Provides visual feedback of patient's altered body posture.
  • Uses vertical environmental cues such as door frames or vertical lines on a wall so the patient can reorient to the upright position.
  • Involves sitting or standing, asking patient if they see whether they are oriented upright.
  • Helps patients realize the disturbed perception of their altered body posture.
  • Ensures patients learn movements necessary to reach a vertical body position and can maintain this position while performing other activities
• Body-weight support treadmill training (BWSTT) and a mirror for visual feedback are recommended in more recent research.
• Lateral stepping with BWSTT & Robotic-assisted gait training can be helpful
• Standing frames can aid rehabilitation
• Other approaches include:
  • Positioning the therapist on the patient's unaffected side in sitting when possible and cueing the patient to lean into their hand.
  • Lowering the assistive device 1-2 levels.
  • Setting up an environment for controlled falling with visual cues.
  • Avoiding passive movement of the patient towards upright.
  • Having the patient slide hands slowly from hip to knee and progress gradually to lower leg (with guidance from therapist) when a fear of falling forward is present.

CVA Impairments Review

• Motor impairments
  • Abnormal Tone: flaccidity, spasticity, synergy, and contracture.
  • Paresis (muscle weakness).
    • Usually unilateral: hemiparesis.
  • Plegia (paralysis).
    • Usually unilateral: hemiplegia
  • Motor planning deficits: apraxia
  • Perceptual deficits
• Synergy, Sensory, Communication, Orofacial, Respiratory impairments all reviewed, and abnormal reflex activity of the spinal cord and brainstem and altered DTRS
• There maybe Bowel and bladder dysfunction

Synergy Patterns Information

• Synergy refers to a group of muscles that work together to provide patterns of movement.
• Results in the patient having poor motor control for isolating specific joint motions.
• Initially movement occurs in flexion or extension combinations.
• Synergies are produced as a result of a volitional movement or a reflex stimulus and typically arise after a period of flaccidity in a limb if the patient is recovering normally

UE Flexion Synergy

• UE Flexion synergy occurs when patient attempts to flex the shoulder of the affected UE.
• Scapular retraction with or without elevation.
• Shoulder ER/abduction to 90 deg.
• Elbow Flexion.
• Forearm supination.
• Wrist flexion.
• Finger and thumb flexion and adduction

UE Extension Synergy

• UE Extension synergy occurs when someone tries to extend the affected upper extremity.
• Scapular protraction.
• Shoulder IR/adduction.
• Elbow extension.
• Forearm pronation.
• Wrist extension.
• Finger and thumb flexion and adduction.

LE Flexion Synergy

• Occurs when someone attempts to flex the hip of the affected lower extremity.
• Hip Abduction and ER
• Knee Flexion to 90 deg
• Ankle DF and supination
• Great Toe Extension and other toes flex

LE Extension Synergy

• Found when patients attempts to extend the hip of the affected lower extremity.
• Hip adduction and IR
• Knee extension
• Ankle PF and inversion
• All toes flex and adduct

Brunnstrom Stages of Motor Recovery

• Devised by Brunnstrom to describe characteristic stages of motor recovery after a stroke and patients are assumed to pass through each of the stages towards recovery.
• The stages are;
  • I. Flaccidity – no volitional movement.
  • II. Spasticity begins to develop, and some synergy components appear
  • III. Spasticity increases and reaches its peak; the patient's voluntary movements are limited to synergy patterns.
  • IV. Spasticity begins to decrease; and deviations from synergy patterns begins
  • V. Spasticity continues to decrease; synergy patterns are drastically reduced
  • VI. Spasticity is essentially absent; isolated joint movements are performed with coordination, but complex and rapid movements may be difficult
  • VII. Return to normal function including fine motor skills
• Describes that patients move in synergies, a group of muscles that work together to provide patterns of movement; Brunnstrom also postulates the patient can plateau at any stage.

Interventions to Decrease Spasticity and Synergy

• Synergy post-CVA closely related to spasticity.
• Early mobilization, combined with daily stretching helps maintain length of spastic muscles.
• Weight-bearing exercises:
  • Seated WB through affected UE
  • Prone on elbows, quadruped, tall kneeling
  • Standing – weight shift in all directions
• PNF – rhythmic rotations, slow reversal, agonist reversal
• NMES/FES combined with functional training
• Botox injections to targeted muscles help relieve pain in UE or LE contributed by spasticity, especially in the ankle PF with excessive ankle PF and inversion that limit heel first IC.
• Regardless of intervention, principles of neuroplasticity must be considered.

CVA Motor Planning Deficits

• Apraxia is an acquired impairment acquired in the performance of purposeful movements that cannot be attributed to weakness, incoordination, sensory loss, poor language comprehension or inattention to commands.
• Patients will have difficulty mentally formulating a plan of action for a motor task:
  • Ideational Apraxia – failure to conceive or formulate & plan an action, either spontaneously or to command
  • Ideomotor Apraxia – the ability to know and remember planned action, but an inability to execute it
  • Constructional Apraxia – visual-spatial impairment that makes it difficult for people to copy, draw, or construct objective, even when they understand the task and are able to do it.
• PT and ST (Speech Therapy) interventions were evaluated in in patients with apraxia:
  • Transitive gesture training which involves gestures that are associated with use of objects.
  • Strategy Training uses of internal or external compensatory strategies to improve independence with an activity.
  • Transfer Training and Functional Approach included in the study:
    • Transfer training involves training a task with goal of it transferring to a similar task
    • Functional approach refers to repetitive practice of a particular task to improve independence

CVA Impairments Regarding Perceptual Deficit

• Agnosia – rare disorder where a person is unable to recognize and/or identify objects, persons, or sounds using one or more of their senses despite normal functional senses
• Anosognosia – denial or unawareness of one's illness that seen in patients with unilateral neglect
• Unilateral Neglect is often caused by a right-sided CVA.
• Is when patients are unable to attend to stimuli in patients left perceptual hemifield.
• Example: a patient with unilateral neglect may eat only from the right side of his or her plate or is not aware of their body position, image or parts, specifically their left side
• Majority of the rehabilitation tasks are compensatory so special adjustments to positioning may need to be made to improve body awareness and decrease the neglect.
• Rehab team and patient's family need to engage in activities and communication to reduce neglect; a patient’s items must be positioned within reach.
• Call button and water (if patient does not have fluid restrictions) should always be placed on the uninvolved side. Splints can improve positioning.
• Other therapy treatments include:
  • Visual scanning.
  • Trunk rotation to facilitate visual scanning.
  • Mirror therapy to patient to attend to affected side.
  • Viewing videos with moving objects to training eye tracking.
  • Virtual reality.
• Prism lenses: special lenses patients wear to increase their awareness of the affected side

Cerebral Palsy

• A disorder of posture and movement as a result of damage to the immature brain before, during, or after birth.
• Its Incidence is 3.1-3.6 cases per 1000 live births in the United States.
• Prematurity and lower birth weights in babies increase risk.
• Multiple causes occur, but not all are understood:
  • Any condition that produces anoxia, hemorrhage, or damage to the brain can result in CP -Causes can be;
    • prenatal
    • perinatal
    • postnatal
• A Cerebral Palsy Classification can be made in three ways: 1.Distribution of Involvement 2.Abnormal Muscle Tone and Movement 3. Severity
• Plegia = is a term used along with a prefix to determine how many limbs are affected by the paralysis as:
  • Quadraplegia = Quadriplegia/Tetraplegia which effects the entire body, causing UEs weaker than the LEs, difficulty developing head/trunk control and may or may not be able to ambulate with bilateral brain damage.
  • Diplegia effects primarily bilateral LE involvement and the trunk which is often related Premature birth (2 Months early) and is also know as the CP of Prematurity.
    • Hemiplegia = effects one sided UE and LE involvement and the trunk which shows similar presentation of someone with CVA
    • Athetoid is a tonal abnormalities that fluctuate from no tone to high tone with damage to Basal ganglia
    • Atonic babies are considered “Floppy infants” where Ttone is hypotonic, impeding to head and trunk control and interfering with breath pattern development
• Tonal change may be seen depending upon when the child’s changes their body relative to gravity and may occur differently across body parts for example hypertonic LE's and hypotonic trunk muscles. Spasticity:
  • Spasticity is a velocity dependent increased tone which is the most common tone found in the UE  (scap retractors, elbow>finger flexors) and also known as hypertonicity with muscles of the legs are hip flexors/abductors, knee flexors, ankle plantar flexors. it is usually present at birth but may show in older children as attempt to maintain withgravity
• Ataxia shows an unsteady stance to imbalance with cerebellar damage causing problems regarding low tone and coordination or a diplegic distribution where movements may be irregular.
• Balance impairments are seen in gait which is described as "Staggering" as well wider displacement which is allowed to compensate and use of UE

GMFCS

• GMFCS (functional mobility scale) helps determine motor impairment.
  • (read Figure 6-7 on p. 138-139): - Level I: walks without limitations. - Level II: walks with limitations and assistance - Level III: walks using a hand-held mobility device. - Level IV: is able to move independently but limited and may need self powered and mobility. - Level V: Manual wheelchair transportation.
• Diagnosing of Cerebral Palsy (CP) - not formally DX'd until 6 months of age but red flags should be noticed if.
  • Child may not be able to pull to stand at 9 months of age.
  • Hypotonic infants can be dx'd from 10-12 months old
  • Some research shows that a child can not be dx'd until 18 months old

Cerebral Palsy (CP) Deficits:

1. Feeding and speech impairments
2. Breathing inefficiency
3. Intellectual disability
4. Seizures
5. Visual impairments
6. Hearing, speech, and language impairments

• Athetoid type cerebral palsy is type of cerebral palsy presents with varying or fluctuating levels of tone*.

Spastic CP patients

• Move show and have trouble walking which is predictable in pattern
• PT needs to assess:
  • Head & trunk control
  • Assess Performance of movement transitions to assess ADLS
  • Mobility & the ability to maintain Ambulatory movement
  • Use of extremities for balance and reaching

CP Treatment

• During Cerebral Palsy (CP) treatment a Physical Therapy Examination will involve ICF which address:
  • Address Muscular structure/function : educate family regarding extensibility , delays and fine motoring , as oral activities . also help handling skill.
  • Address movement through standing, sitting and or self driven actions which will require attention and treatment against gravity

Influence of Tonic Reflexes

1. Tonic Labyrinthine Reflex (TLR) - supine may results may create ext Tonal changes while Proned positions will create Flexion
2. Asymmetric Tonic Neck Reflex (ATNR) -UE extension can develop on side of face and flexion of the UE on side of skeleton

• If persisted, asymmetry this cause unable to develop and bring UE together to develop movement for months
• • A child with with neck muscle or back should utilize symmetrical Tonic neck reflex**
    • In Quadrupled Positions
    • flex should be tested from arms flexion, and extend

Athetosis or Ataxia

• Lack postural stability
• Large uncompensated movements

General Treatment of Ideas Regarding Cerebral Palsy (CP)

• Child's that are showing Spasticity or tightness should utilize mobility in particular posture and stretching which with require assistance in supine position – Position trunk on a wedge and legs over the bolster with dangle items at eye level for play --- side Lying is best to dampen effect of most tonal changes because it’s natural Posture which allow effect flexion --- provide wight to extremities as able and stretching with help allow elongation. --- Sitting best promotes function as able to control head with upper andlower body control with righting and reaction control
  • Quadruple Position - allow extremity to fight against working Trunk -
  • Standing , promotes weight bearing and long holds on joints with heel chords and with working in alignment of gravity -- Focuses on stability in bearing during support and balance -- techniques include and should have approximation and weight bearing, utilize mirrors with support

Physical Therapy Examination involving ICF in Cerebral Palsy

• Helps with delays regarding gross and fine motor skills . will provide with more feeding ability that require teaching and practice
• Focus all treatment on slow gait coordination*

Examination should have the following:

• Post postural responses and balance issues which require treatment

CP Intervention during 4 stages

--Early and throughout will require action with parents
-- Parents act key parts - there input has legal right to effect treatment
-- handling and Position-
——supine allow movement mid line
— prone allow reach and grip access and motor support.
- ROMs - ROM gentel all limbs

• -- help promote sitting and handling with standing posture which help maintain motor control and prevent abnormal motion as able in proper standing program at ages of 12/16 while standing 4-5 times a week for around 60mins as appropriate. ---- Independent control includes movement within multiple places and posture -

Power Mobility helps allow independent control as ages of 17- 20 which allow help prevent motor issues

• Harness system can help promote movement. -- treatment will be needed with function Monitor for Orthosis for mobility, gait
• • the more ambundant orthotic used by CP patientis walking AFO
• ---PT should establish this product. -- Hinge AFO is normal movement -- Floor reaction AFO may help decrease knee flexion during spastic gait

Preschool years:

• Focus patient for social engagement.
• Monitor and ensure that the patient get support and treatment to facilitate walking through AFO with pt direction.
• ** Genu and decrease ankle support must maintain
• SMO if patient is having issue or would like active plant support or need stability* Use walker and equipment when and if needed
• *surgery may be needed to correct issues while medic can help control pains
• Schoolage and Adolescence
• Focus support , education and provide community outreach, promote activity and driving if possible.
• Adulthood allow them to work and function independently provide tools by PT***