Study Guide- Subacute Assessment 2, Weeks 5 - Week 13 PDF

**Study Guide- Subacute Assessment 2, Weeks 5 -- Week 13** **Table of Contents** [***Case-based questions*** ***2***](#case-based-questions) [***Week 6 Masterclass - Stroke*** ***6***](#_heading=h.30j0zll) [***Week 6 Workshops -- Stroke -- Modalities + training weak muscles (also see required in...

**Study Guide- Subacute Assessment 2, Weeks 5 -- Week 13** **Table of Contents** [***Case-based questions*** ***2***](#case-based-questions) [***Week 6 Masterclass - Stroke*** ***6***](#_heading=h.30j0zll) [***Week 6 Workshops -- Stroke -- Modalities + training weak muscles (also see required information for case-based questions)*** ***12***](#week-6-workshops-stroke-modalities-training-weak-muscles-also-see-required-information-for-case-based-questions) [***Week 7 Workshops -- Stroke: Bed mobility, Sitting, STS, Standing and using equipment*** ***17***](#week-7-workshops-stroke-bed-mobility-sitting-sts-standing-and-using-equipment-slide-sheets-walk-belt-romedic-also-see-required-information-for-case-based-questions) [***Week 8 & 9 Masterclass -- Stroke: LL*** ***28***](#_heading=h.2et92p0) [***Week 8 Workshops -- Stroke: LL*** ***34***](#_heading=h.tyjcwt) [***Week 10 Masterclass -- Stroke: UL*** ***39***](#_heading=h.1t3h5sf) [***Week 10 Workshops -- Stroke: UL*** ***42***](#_heading=h.4d34og8) [***Week 11 Masterclass -- Parkinson's Disease*** ***46***](#week-11-masterclass-parkinsons-disease) [***Week 11 Workshops -- Parkinson's Disease*** ***53***](#week-11-workshops-parkinsons-disease) [***Week 12 Masterclass -- Multiple Sclerosis*** ***57***](#week-12-masterclass-multiple-sclerosis) [***Week 12 Workshop - Multiple Sclerosis*** ***64***](#week-12-workshop---multiple-sclerosis) [***Week 13 Masterclass + Workshops -- Life of a Rehabilitation Physio*** ***68***](#week-13-masterclass-workshops-life-of-a-rehabilitation-physio) [***Week 5 Online Module -- Secondary and non-motor impairments*** ***72***](#week-5-online-module-secondary-and-non-motor-impairments) [***Week 5 -- Workshop Using technology in Rehabilitation*** ***77***](#week-5-workshop-using-technology-in-rehabilitation) **Case-based questions** ======================== 1. See below 2. a. b. c. 3. d. i. ii. iii. e. f. g. 4. +-----------------------+-----------------------+-----------------------+ | **Activities** | **Essential | **Compensatory | | | components** | movements** | +=======================+=======================+=======================+ | **Bed mobility** | [Bridging to | - Wriggling instead | | | shifting] | of turning | | | | | | | - Flexion of hips | - Use of intact arm | | | | | | | - Flexion of knees | - Rotation and | | | | flexion of neck | | | - Dorsiflexion of | forward | | | ankles | | | | | - Excessive pushing | | | - Hip extension | up of intact arm | | | | | | | - Hip abduction or | - Hooks intact leg | | | adduction | under affected | | | | leg | | | [Rolling | | | | over] | - Falls backwards | | | | | | | - Rotation and | | | | flexion of neck | | | | | | | | - Flexion of neck | | | | and hip | | | | | | | | - Flexion and | | | | protraction of | | | | shoulder | | | | | | | | - Rotation of trunk | | | | | | | | [Side lying to | | | | sitting] | | | | | | | | - Lateral flexion | | | | of neck | | | | | | | | - Lateral flexion | | | | of trunk | | | | | | | | - Abduction of | | | | shoulder (lower | | | | arm) | | | | | | | | - Extension of | | | | elbow (lower arm) | | | | | | | | - Legs lifted and | | | | lowered over side | | | | of bed | | +-----------------------+-----------------------+-----------------------+ | **Sitting** | [Initial | - Wide base of | | | alignment]{.underline | support (e.g. | | | } | feet too far | | | | apart or hips | | | - 100% thigh | externally | | | support | rotated) | | | | | | | - Ankles | - Voluntary | | | plantargrade | restriction of | | | | movement (e.g. | | | - Feet shoulder/hip | patient holds | | | width apart | himself stiffly | | | | or holds his | | | - Even weight | breath) | | | distribution on | | | | both LL | - Uneven weight | | | | shift (shifts | | | - Flexion of knees | weight to the | | | | intact | | | - Flexion of hips | foot/buttock | | | | | | | - Extension of | - Shuffles feet | | | trunk | | | | | - Use of arms for | | | [Reaching in | balance, | | | sitting] | prematurely | | | | | | | - - - - - | - Lean forwards or | | | | backwards when | | | | asked to reach | | | | sideways | | | | | | | | - Avoids balance | | | | threats by | | | | reducing movement | | | | speed, and | | | | amplitude and/or | | | | holding stiffly | | | | and/or holding | | | | breath. | +-----------------------+-----------------------+-----------------------+ | **Sit to stand** | [Initial | Pre extension | | | alignment]{.underline | | | | } | - Weight shift onto | | | | intact | | | - \ - - - - [Stroke in Australian indigenous ] Compared to non-indigenous Australians - - - - - - Greater prevalence of risk factors - - Less likely to be treated in a stroke unit - Delayed health assessments - 2. [Risk factors] +-----------------------+-----------------------+-----------------------+ | **Type of stroke** | **Risk factors** | **Risk factors for | | | | both** | +=======================+=======================+=======================+ | **Ischemic (85-87%)** | - Previous TIA | - High blood | | | | pressure | | | - High cholesterol | | | | -- due to fatty | - Excessive alcohol | | | deposits on the | | | | arteries | - Family history | | | | | | | - Gender F\ M | - Smoking | | | | | | | - Arthrosclerosis | - Diabetes mellitus | | | | | | | - Atrial | - Physical | | | fibrillation | inactivity and | | | | obesity | | | - Blood disorders | | | | | - Illegal drug use | | | - Prior ischemic | | | | stroke | - Ethnicity | | | | | | | | - Age | +-----------------------+-----------------------+-----------------------+ | **Haemorrhagic | - Bleeding | | | (13-15%)** | disorders | | | | (haemophilia) | | | | | | | | - Vascular | | | | malformations | | | | | | | | - Dissection/tear | | | | | | | | - Gender: M | | | | | | | | - Use of | | | | anticoagulants | | +-----------------------+-----------------------+-----------------------+ 3. [Signs and symptoms of a stroke ] - Violation sensitivity the body - Violation speech and understanding - Vertigo a loss the balance - Violation sight - Numbness face and half the body - Strong headaches 25% in ischemic, 80% in haemorrhagic 4. - 70% of stroke patient are either dead or disabled 5 years after the event - *Mortality (death rate)* - - - *Predictors of survival at 3/12 and 12/12 post stroke* 1. 2. 3. 4. 5. - Disability - - - *Walking after stroke - evidence* - 98% chance if (within 72 hours) a patient can - - - Only 27% chance if patients could not do the above *Upper limb function- evidence* - 98% chance if (within 72 hours) a patient can - - - Only 25% if patients could not do the above 5. **Adaptive plasticity** a. **Maladaptive plasticity** b. c. d. [Neuroplasticity] 1. **Neuroplasticity is [use dependent] and specific** a. b. c. 2. **[Repetition and intensity] influence neuroplasticity** d. e. f. 3. **Neuroplasticity is [time sensitive]** g. 4. **Neuroplasticity is influenced by [task-importance, motivation, feedback and attention]** h. i. j. 5. **Strongly influenced by features of the [environment]** k. l. 6. **Neuroplasticity is influenced by [adjuvant or adjunct therapies]** m. n. 7. **Neuroplasticity is influenced by [patient characteristics]** o. p. 8. **[Pharmacology] influences neuroplasticity** q. r. s. t. e. 1. Use-dependent plasticity - - 2. Learning-dependent plasticity - - - f. - - - - 6. *What happens 24hr after a stroke??* - A person with stroke arrives to emergency \*time is of the essence - **0--4.5 hours** (last seen well) 🡪 Administer tPA and candidate for thrombectomy - **6--24 hours**🡪 Should not receive tPA but is a candidate for thrombectomy - **24 hours + 🡪** Should not receive tPA or thrombectomy g. [Medical treatment: Thrombolysis (tpA)] - Primary treatment \4 point on the [[NIHSS scale]](https://stroke.nih.gov/documents/NIH_Stroke_Scale.pdf)) - Risk is offset by later reduction in disability *Considerations: tpA* - Can only be performed within 4.5 hrs of lesion - Routinely administered in emergency departments - Larger more proximal clots are more resistant to thrombolysis h. [Medical treatment: Thrombectomy] - Mechanical retrieval of the clot using a catheter - Only effective on larger arteries - Used for proximal large artery occlusions - Does not work if tissue is dead... - Not effective after 24 hours - Indicated within 6 hours - - Only indicated from 6-24 hours if there is a mismatch between ischemic core (dead tissue) and penumbra **STUDY**🡪 - - - - *Considerations: Thrombectomy* - Can be performed up to 24 hrs after the lesion - Performed at limited sites in Sydney (RNSH, Westmead, PoW, Liverpool, RPA) - Can only be used in proximal occlusion sites (large artery) - Must be a 'dead zone: salvageable tissue' mismatch to be effective i. - Decompressive surgery (craniectomy) - - 7. j. k. l. +-----------------------+-----------------------+-----------------------+ | - - - | - - - | - - - | +-----------------------+-----------------------+-----------------------+ **Practice variable that influence motor skill acquisition** 1. 2. 3. 1. **Practice intensity** - - - - - - - - - - - *Strategies to increase the amount of practice:* - - - - - - - - 2. **Practice needs to be task specific** - - - - - - - - 3. **Practice variability** - - - - - - - Contextual inference  - - - **BUT** - 8. 1. **Instructions** - a. - - - - - - b. - - - - c. - - - - - - - - d. - - - - - - 2. **Demonstrations** - - a. - - - b. - c. - - - 9. **3. Feedback** - - - - - *Task-intrinsic feedback*; sensory feedback that is naturally available while performing a skill - *Augmented feedback:* feedback added to task-intrinsic feedback coming from a source external to the person performing a skill 10. *Augmented feedback:* feedback added to task-intrinsic feedback coming from a source external to the person performing a skill +-----------------------------------+-----------------------------------+ | *Vision* | - Demonstrations | | | | | | - EMG Biofeedback | | | | | | - Mirror | | | | | | - Videos (real-time and | | | playback) | | | | | | - Scales | | | | | | - Wii Fit | +===================================+===================================+ | *Auditory* | - Instructions | | | | | | - Metronome | | | | | | - Clapping | | | | | | - EMG biofeedback | | | | | | - iPhone circle timer | +-----------------------------------+-----------------------------------+ | *Proprioception and tactile* | - Manual handling/guidance | | | | | | - Lokomat | | | | | | - Taping | | | | | | - Compressive bandage | | | | | | - Orthoses | +-----------------------------------+-----------------------------------+ | *Knowledge of results* | Provides information about the | | | **outcome** of performing a skill | | | or about **achieving the goal of | | | the performance** | | | | | | e.g. dynamometer, number of reps, | | | walking speed, distance walked | +-----------------------------------+-----------------------------------+ | *Knowledge of performance* | Provides information about the | | | **movement characteristics | | | leading to a performance | | | outcome** | | | | | | e.g. force steadiness, amount of | | | sway -- gait | +-----------------------------------+-----------------------------------+ | *Intrinsic feedback* | Direct feedback that you get from | | | an action. A patient may | | | successfully execute a movement | | | but realize they need to improve | | | the process (through body and | | | relative to body) | +-----------------------------------+-----------------------------------+ | *Extrinsic feedback* | Feedback from a person or data | | | such as a video or balance board | | | device etc | +-----------------------------------+-----------------------------------+ | *Qualitative* | Augmented feedback that is | | | descriptive in nature and | | | indicates the quality of | | | performance i.e. "Good" "Nice" | +-----------------------------------+-----------------------------------+ | *Quantitative* | Augmented feedback that includes | | | a numerical value related to the | | | magnitude of a performance | | | characteristic i.e. Speed of a | | | baseball pitch | +-----------------------------------+-----------------------------------+ | *Internal attention focus* | Instructions that direct | | | attention to the movement | | | themselves i.e. Feel the muscle | | | contracting when | | | | | | you perform the movement | +-----------------------------------+-----------------------------------+ | *External attention focus* | Instructions that direct | | | attention to the effect of | | | movement on environment i.e. | | | Shift your weight toward the | | | table | +-----------------------------------+-----------------------------------+ 11. - - - - - - **Week 6 Workshops -- Stroke -- Modalities + training weak muscles (also see required information for case-based questions)** ============================================================================================================================= Understand the types of patients that are more suitable for EMG biofeedback over electrical stimulation Describe the aims of EMG biofeedback and electrical stimulation and the types of patients/conditions/impairments that these can be used for. +-----------------------+-----------------------+-----------------------+ | | **EMG Biofeedback** | **Electrical | | | | stimulation** | +=======================+=======================+=======================+ | *Overview:* | Measures the | Electrical | | | electrical output of | stimulation (ES) is | | | the muscle | the application of | | | | electrodes to muscles | | | Endurance exercise | to stimulate sensory | | | | nerves and motor | | | Neuromuscular control | nerves.
 | | | of muscle | | | | | ES refers to the | | | | stimulation of motor | | | | nerves. | | | | | | | | Motor ES is also | | | | termed neuromuscular | | | | electrical | | | | stimulation (NMES), | | | | functional electrical | | | | stimulation (FES). | | | | | | | | Stimulates a motor | | | | nerve which conveys | | | | nerve action | | | | potentials to | | | | stimulate muscle | | | | fibres in order to | | | | produce a muscle | | | | contraction. | +-----------------------+-----------------------+-----------------------+ | *Aim* | Increase muscle | Increase muscle | | | activity | strength | | | | | | | Decrease muscle | Increase joint ROM | | | activity | | | | | Increase muscle | | | Control muscle | endurance | | | activity (timing and | | | | co-ordination of | Prevent or treat | | | muscles) | conditions related to | | | | deceased muscle | | | | strength | +-----------------------+-----------------------+-----------------------+ | *Type of Patients* | Pt must have | Grade 0 or 1 or -2 | | | awareness of their | MMT | | | own muscle activity- | | | | the pt may | | | | consciously increase, | | | | decrease or control | | | | muscle activity. | | | | | | | | Targets specific | | | | muscles | | | | | | | | Not for a grade 0 or | | | | 1 MMT | | +-----------------------+-----------------------+-----------------------+ | *Conditions* | Stroke | | | | | | | | MS | | | | | | | | TBI | | | | | | | | SCI | | | | | | | | Chronic MSk injury | | | | | | | | Not suitable in | | | | voluntary muscle | | | | disorders such as | | | | apraxia or spacticity | | +-----------------------+-----------------------+-----------------------+ | *Evidence* | Research strongly | Weak recommendations | | | recommends the use of | for the use of ES to | | | EMG biofeedback for | improve weakness, | | | stroke survivors with | upper limb function, | | | reduced strength in | spasticity, | | | their arms or legs, | contracture, | | | strength training | subluxation, shoulder | | | should be provided | pain, swelling | | | | | | | \*\*\*not used in | | | | treatment for gait | | | | speed | | +-----------------------+-----------------------+-----------------------+ | *Machine | Set threshold by | | | parameters/settings* | doing a maximal | | | | contraction, 20% of | | | | max is the range. | | | | Functional range. | | | | | | | | WIDE = weak pts | | | | | | | | Dosage: 50-200 high | | | | volume | | +-----------------------+-----------------------+-----------------------+ Understand/apply the national Stroke foundation Guidelines for EMG biofeedback and electrical stimulation -  +-----------------------+-----------------------+-----------------------+ | | **EMG biofeedback** | **Electrical | | | | stimulation** | +=======================+=======================+=======================+ | ***Contraindications* | - - - | - - - - - - | | ** | | | +-----------------------+-----------------------+-----------------------+ | ***Precautions*** | - - | - - - - - - | | | | - | +-----------------------+-----------------------+-----------------------+ | ***Manage patient | - | - | | expectations*** | | | +-----------------------+-----------------------+-----------------------+ 1. For Against ----------------------- ---------------------------------------- --------------- EMG biofeedback Evidence to improve.... In stroke pts Electrical simulation Weak evidence 2. **Grade** **Meaning of grade (consider movement/ROM, gravity and/or resistance)** ----------- ------------------------------------------------------------------------- **0** **No contraction -** 1 Flicker or trace of contraction 2- 50-99% gravity eliminated, but not full ROM **2** **Full ROM with gravity eliminated** 2+ 0-50% of the range without gravity 3- 50-99% against gravity, but not full ROM **3** **Full ROM against gravity** 3+ 0-50% of the range against gravity + resistance 4- 50-99% of the range against gravity + mod resistance **4** **Full ROM against gravity and against resistance** 4+ *Max resistance through all* **5** **Normal strength** 3. **Impairment: reduced muscle strength (grade 0-2)** Strategies: - - - - - - - - - - - - - - - - - - - - 4. 5. [Principles of neurorehabilitation] **Early stage: skill \> compensation** **Later stage: skill\