Intervention for weakness.pdf

I N T E RV E N T I O N S FOR WEAKNESS PA RT 3 J.J. Mowder-Tinney PT, PhD, NCS Learning Objectives Compare and contrast differing strength training options Meet this beautiful 82-year young woman who had a hemorrhagic stroke 3 years ago. Biggest issue is weakness on the right side, not trusting the s...

I N T E RV E N T I O N S FOR WEAKNESS PA RT 3 J.J. Mowder-Tinney PT, PhD, NCS Learning Objectives Compare and contrast differing strength training options Meet this beautiful 82-year young woman who had a hemorrhagic stroke 3 years ago. Biggest issue is weakness on the right side, not trusting the strength she does have and ideomotor apraxia How can you PREPARE the person to get optimal output? NMES (Neuromuscular electrical stimulation) EMGBFB (Electromyographic Feedback) PNF PRE (Progressive Resistive Exercise) Isokinetic exercise Task-specific strength training Which one do you think would work better for our neurological population? Relative effort required during activities for young (mean age 22) versus old adults (mean age 74) Ascend Stairs was 54% versus 78% Descend stairs was 43% versus 88% Chair rise was 42% versus 80% Hortobágyi T, Mizelle C, Beam S, DeVita P. Old adults perform activities of daily living near their maximal capabilities. The of Gerontology Series A: Biological ScienceJournalss and Medical Sciences. 2003 May 1;58(5):M453-60. W H AT I S YO U R G OA L ? Overload Subacute and chronic stroke tolerated 80% 1RM Recommendations for 60-75% 1RM with 10-15 reps Maybe submax for early rehab Exercise Principles Specificity of training Type and speed of muscle contraction Length of muscle during training Cross-training - variability Muscle contraction Speed Reversibility Detraining effects unless strength is maintained How Intense to Strengthen? Don’t forget to educate about delayed onset muscle soreness! Like the cardiovascular system, skeletal muscle requires a workload of ~60% of maximum available strength (1RM) to increase in strength. There should be deterioration of form for last 2 reps 60% threshold = 15 reps at RPE 12-13 80% threshold = 10 reps at RPE 15-17 If more than 20 repetitions are completed with good form (no fatigue noted), resistance is below the 60% threshold Avers D and Brown M. J of Geriatric Phys Ther. 2009;32(4):148-52. Utilize different aspects of the exercise prescription to help you make sure you are accomplishing the person's goal! Type of Contraction Isometric Eccentric Initially, build forcegenerating capacity; increase strength in postural mm;Valsalva caution More efficient, require fewer MUs; effective in early strength training; caution in GBS, PPS, other neuromuscular disease Concentric Eccentric before concentric increases force of concentric; increase speed to focus on power Considerations for choices – Make sure you are focused on skilled therapy unless transitioning to home program NMES Very weak muscles Make functional if possible EMGBFB PRE Very weak muscles Focus on quality Focus on motor retraining Best for at least 3+/5 Isokinetic Aquatic Teach how to safely use for progressing to independent Supported movement Can offer resistance and input Finish task over ground Adjusting strength training for specific conditions is critical to know. There are some key ones in this chart you need to remember. Fell DW. LIFESPAN NEUROREHABILITATION. F. A. Davis Company; 2018. Page 737 Functional Task Oriented Training Addresses multiple system impairments and promotes transfer to functional skills Focus on the task or specific movements required for the task Think about manipulation of the 3 factors: Individual Task Environment 1. Focused on sit to stand to increase weightbearing on the more involved leg. Identify the priority for the patient and focus the home program 2. Asked them to stand up together and hold the glut squeeze for 5 seconds every time they stood up together. 3. Adjust the way they danced to facilitate more of a lower trunk weight shift. Until the next session AND change out some of the choices. Great work! Interventions for Weakness JILL SEALE, PT, P hD, NCS Acquired Brain Injury Variable impairments depending on focal or diffuse injury Weakness compounded by other injuries Could be unilateral or bilateral Primarily central neural activation deficits with impaired ability to active MUs May also have disuse atrophy Multiple Sclerosis Scattered axonal degeneration and reduced or blocked nerve conduction Disruption of supraspinal and/or spinal pathways to MU pool Weakness and muscle fatigue Reduced and slowed force production PD Less about weakness, more about initiation, timing, sequencing Impacted by changes in muscle tone Other Degenerative Diseases/Disorders GBS LMN presentation Distal to proximal weakness, fairly symmetrical ALS UMN and LMN presentation Often effects hand/trunk first, but overall can affect all muscles Myasthenia Gravis LMN presentation Affects high use muscles first/primarily Other Degenerative Diseases/Disorders Post-Polio Syndrome LMN presentation Prone to overuse Charcot Marie Tooth Hereditary, LMN presentation Progressive wasting Diagnosis Specific Strengthening and Rehab Strength Training Post Stroke Effective in improving strength, less robust evidence of link to improved function What makes for most transfer of increased strength to increased function? ◦ Specificity of training Modes: PRE, circuit training, isokinetic, functional/ task specific Low to high intensities Strength Training for Acquired BI Dependent on presentation Typically apply same strategies as with stroke Behavior and cognitive impairments may impact Strength Training in MS Strength plus aerobic training improved fitness, function, and QOL Carry over to function No increase in exacerbations, minimal risk of adverse side effects Resistive training at least 2x/wk at moderate intensity and task specific training – mild to moderate MS Strengthening to maintain strength and prevent decline in those with moderate to severe Strength Training in GBS While progressive, strength training is contraindicated Once stable/improving neurologically ◦ Progression from active assist to active to resistive ◦ Monitor closely for overuse and fatigue ◦ May still need energy conservation strategies Strength Training in ALS Training of muscles impacted by spasticity Submaximal strengthening for muscles not yet affected Muscles related to posture and respiration are key, so preventative strengthening while possible Strengthening for other DDs Myasthenia Gravis ◦ No strengthening during active crisis ◦ Maintenance in non-affected areas and strengthening post crisis (submax) ◦ Monitor for fatigue and over-use Post Polio Syndrome ◦ Muscles 4+-5: moderate to vigorous exercise (submax) ◦ Muscles 3+-4: exercised cautiously (submax) ◦ Muscles 3 or below: stretching/protection; no resistance training Charcot Marie Tooth ◦ No strengthening for affected muscles/joints ◦ Strengthening above affected area and compensations In Summary Strengthening is possible in most neurological diagnoses, AND can improve function (but not a direct cause/effect) Some strategies for strengthening may be specific to the diagnosis/disorder Task specificity and intensity are key (as usual) BUT, for those with degenerative or demyelination, caution is needed and monitoring for fatigue and overuse is crucial Interventions for Weakness JILL SEALE, PT, P hD, NCS Objectives Identify the effects of neurological pathology on muscle force generation Examine the efficacy of strength training across multiple neurological diagnoses Apply exercise science principles to persons with neurological diagnoses Design strength training programs for persons with neurological diagnoses Impaired Muscle Performance – The Neuro Spin Weakness is more than muscle atrophy There may be alterations in muscle tone Sensation may be impaired Cognition and/or communication may be impaired Strengthening in Neuromuscular Dysfunctions Strong support for efficacy of strength training in persons with neurological disorders ◦ Even in presence of spasticity ◦ Structural and neural Some debate in the evidence But what makes strengthening most effective? ◦ Task specificity ◦ Intensity It’s not about the muscle! Changes in cortical excitability Fewer motor neurons area activated post training due to enhanced efficacy of synapses Changes in motor unit recruitment and increases in neural drive IMPROVING MOTOR UNIT RECRUITMENT Longer treatment duration may be warranted ◦ Pak S, Patten C, Top Stroke Rehabil, 2008 Key Components Customized strengthening intervention ◦ Characteristics of patient (dx, age, co-morbidities, functional level, balance ability, level of motor control recovery or stage of disease progression) Ongoing evaluation and progression ◦ Continual challenge to neuromuscular system to adapt and facilitate optimal recovery Secondary Strength Impairments Due to reduced mobility and activity levels ◦ Atrophy ◦ Loss of ROM, contracture development ◦ Decreased endurance ◦ Decreased overall fitness Compound effects of weakness on function Preventable with exercise/education Diagnosis Specific Weakness Differences in “strength” presentation based on Practice Patterns 5D: nonprogressive disorders of CNS ◦ Directly related to specific site and severity of BI; correlate with functional status; remediation improves function 5E: Progressive disorders of the CNS ◦ Progressive decline in strength 5G: Acute or chronic polyneuropathies ◦ Weakness is primary clinical issue; careful recovery phase 5H: Nonprogressive disorders of the spinal cord ◦ Weakness or total paralysis that correlates with site and extent of damage; recovery depends on degree of sparing and neuroplasticity at SC Post Stroke Force production or impairment of motor control Weakness primarily on paretic side contralateral to lesion**with some ipsilateral weakness Primarily distal, flex/ext affected equally Reduced force generation plus slowness in force production, excessive sense of effort, rapid onset of fatigue Cause: central activation deficits, transsynaptic degeneration and secondary changes in muscle More Post Stroke Specifics Evidence suggests more struggle in shortened ROM, especially as velocity increases ◦ May encourage compensation by functioning in midrange ◦ Ada L, Canning C, Dwyer T, Clin Rehabil, 2000 More preservation of force during eccentric contractions, over isometric and concentric ◦ Unclear as to why ◦ Eccentric contraction not related to level of physical activity, concentric is ◦ Gray V, Rice DL, Garland SJ, Physiother Canada, 2012 Stroke Specific Motor Unit and Muscle Fiber Changes Fell text