Neuromuscular II Exam 1 Review PDF

Neuromuscular II Exam 1 Review Dr. Kumar reviews Unit 1: Clinical Decision Making & Neuromotor Training 1. ICF framework: identification of components within a patient case ○ Health condition→ disorder or disease CVA, TKE, OA, Lumbar laminectomy, CP, etc. ○ Bod...

Neuromuscular II Exam 1 Review Dr. Kumar reviews Unit 1: Clinical Decision Making & Neuromotor Training 1. ICF framework: identification of components within a patient case ○ Health condition→ disorder or disease CVA, TKE, OA, Lumbar laminectomy, CP, etc. ○ Body structures & functions→ impairments Strength, balance, tone, proprioception, sensation, ROM, etc. ○ Activity limitations→ ADLs, functional activities Sit to stand, gait, stair climbing, reaching, crawling, fall recovery, etc. ○ Participation restrictions→ society Social situations, activities within the home, hobbies, housework, yardwork, etc. ○ Environmental factors→ living, community ○ Personal factors→ age, gender, job, insurance 2. Principles / Terms associated with Neuroplasticity ○ Principles of Neuroplasticity: HOW AND WHY- age, time, PLOF, cognition and sensation Use it or lose it → motor memory Use it & Improve it → expand mvmts Specificity → training must reflect outcome/goal Repetition matters → how much Intensity matters → mass vs. distributed HIGH INTENSITY = best tx for pt Time Matters → sooner = better than later (90 days-6 months) Salience matters → meaningful to pt Age matters Transference → “carry over” / transfer to other activities Interference → repetition of compensatory skills can interfere w/ development of optimal performance Unlearn bad habits ○ Terms used: Massed vs. Distributed Massed→ more practice time vs rest ○ Motivation & skill level is high; good endurance & attention; used later in rehab as skills are being mastered Distributed→ more rest time vs practice ○ Easily fatigued or distracted; typically used early when skills training is being initiated Constant vs. Variable Constant→ task is practiced in same way w/ no variation Variable→ task is practiced in variable conditions & parameters Blocked vs. Random Blocked→ same task repeated throughout whole practice time ○ Repetition of 1 task Random→ variety of tasks are practiced during practice time ○ Practice sequence is random (better for long term effects) Part vs. Whole Part→ learning individual components of the task  Whole→ progressing from arts of the tasks to completing the whole task at once ○ Feedback: Immediate → given immediately after task Delayed→ brief time delay allowed before giving feedback Summary→ feedback after a set # of trials Faded→ feedback given less frequent w/ ongoing practice Bandwidth→ feedback given if performance falls outside normal (wacky performance) ○ Stages of Motor Learning: Cognitive Stage→ novice (developing understanding) Associative Stage → starts to become more self aware / self correction Autonomous Stage→ expert (capacity to self correct) 3. Application of Neuroplasticity: characteristics ideal for recovery ○ Sub-acute stroke pts→ BEST PTS FOR NEUROPLASTICITY ○ H&Y stage 1-3 (acute phases) → NEUROPLASTICITY 4. Treatment Framework: Restorative, Augmented, Compensatory approaches (how to apply each) ○ Restorative Interventions (AROM) Focus on targeted mvmt deficiencies Activity based/task specific exercises motor learning strategies neuroplasticity 3 main qualities: Repetitive & intense practice Strategies that enhance active motor learning Strategies that encourage use of the more involved extremity & limit use of less involved side Resolve primary impairments & limit secondary impairments Apply effective task-specific strategies to the retraining of functional activities Adapt strategies to changing task & environmental conditions Help with recovery and go back to previous activity level ○ Augmented Interventions (AAROM) acute injuries Aspects of guided mvmt → promotes voluntary control or neuroplasticity An intensive HANDS ON approach & neuromuscular sensory stimulation technique used to “jump-start” recovery & promote early mvmt Activity/ Function Based Approach Neurofacilitation approaches PNF NDT Bridge gap btw absent or severely disordered mvmts & more active, controlled mvmts ***Discontinue when pt develops adequate voluntary control Indicated for pts whom: Lack voluntary mvmt control Demonstrate insufficient motor recovery Difficulty initiating or sustaining mvmt Contraindicated for pts whom: Demonstrate sufficient active mvmt control PNF Concepts: Existing potential → pt prognosis  Resistance → facilitates mvmt Positive reinforcement Achieve highest level of function NDT concepts: Idea of disinhibition Alignment Handling Placing and Practice ○ Compensatory Interventions: CHRONIC (1 yr post stroke) Resumption of functional task through substitution or adaptation Substitution→ change to the individual’s overall approach to a functional task ○ Add/New strategy ○ ex) R CVA = learning to tie your shoe w/ only R hand Adaptation→ modification of the environment to relearn the mvmt Adaptation=Alternative (A/A) ○ Use alternative ways to perform ADLs ○ ex) sit to stand recliner ○ ex) R CVA = use of a R hemi walker for gait 1 year post stroke pt ○ When to use which Intervention? Condition / pathophysiology (do they have potential for neuroplasticity?) Complete SCI vs acute CVA Current level of function / Independence Capacity to motor learn (cognitive, sensory status) Age of pt Time since injury PLOF / independence Safety Use of a blended approach Personal factors Insurance / length of stay Social support Unit 2: Role of Outcome Measures; FIM & CARES tool 1. Components of FIM (define levels of assistance in terminology & numeric scores); CARES Tool  ○ Functional Independence Measure (FIM) IMPORTANT Most common outcome measure used in acute rehab Assesses caregiver burden w/ “levels” associated w/ specific tasks (18 different)” Multidisciplinary tool Commonly used at eval, re-eval, & d/c At d/c → will determine overall functional improvement Measures→ level of assistance needed Scoring: Can My Silly Mini Model Meet Tom Today? (7-0) 7→ Complete Independence (no assistance, no DME, no extra time needed) 6→ Modified Independence (use of AD, requires extra time) 5→ Supervision (verbal cues or supervision for safety is required) 4→ Minimal Assistance (25% assistance required. Pt able to perform 75%) 3→ Moderate Assistance (50 assistance required. Pt able to perform 50%) 2→ Max Assistance (50-75% assistance is required. Pt able to perform 25%) 1→ Total Assistance (>75% assistance is required, or used of >1 person) 0→ Task does not occur CGA/SBA =Both fall under min A ○ CGA = hand on pt (on gait belt) ○ SBA = 0 hands on pt Know the progression of different diseases and how they would go through the different stages ○ CARES Tool (inpatient) - KNOW 1-6 and their definitions 6–independent 5–setup or clean up assist 4–supervision/touch assist 3–partial/mod A 2– substantial/max A 1–dependent 2. Apply FIM into case scenarios (identify and progress plan based on FIM) Outcome Measures: 1. Review components of OM and what OM is actually measuring ○ OM→ standardized tests, measures, or instruments that allow for an objective measure of health status ○ Variables to Consider when choosing a test:  Dimension→ ICF model label Format Performance based Conducted via self-reports Reliability Ability to which test is reproducible or consistency to which it is utilized Inter = btw multiple ppl Intra = PT (1 person) (A1 steak sauce) Validity Ability of tool to measure what it is supposed to measure Responsiveness Ability to detect change ○ MDC→ smallest amount of change in an OM that is NOT attributable to error ○ MCID→ smallest amount of change that is perceived as beneficial to pt/PT Feasibility Choose test that is ○ NOT time consuming ○ Easy to score ○ Least amount of equipment to use 2. Application of outcome measure within a POC (all OMs) ○ Romberg Static standing balance assessment ICF: body structures/function Lacking reliability/validity ○ Sharpened Romberg Static Standing Balance -- Tandem stance ICF: body structures/function Lacking reliability/validity ○ BERG Balance Scale Static/Dynamic Standing Balance/Functional Mobility 14 Tasks Lower Score = ↓ Balance Floor & Ceiling Effects (too difficult--too easy) Ex: don’t do BERG for someone who may struggle with sitting balance for example bc they would score low for this so it would be a floor effect ICF: activity (VOPP) (Kumar said Body structures & function) ○ Tinetti static/dynamic balance + gait screen 2 categories: Balance (9items) & Gait (7 items) Lower score = ↓ balance, fall risk (gait) ICF: gait = activity; balance = body structures and functions ○ Functional reach Quick standing balance screen Max distance reached while in static position Modified for sitting Highly recommended for stroke, PD--recommended for MS ICF: activity (VOPP) (Kumar said body structures & function)  ○ TUG Quick screen of dynamic balance & mobility (gait) in elderly Falls ICF: activity ○ 6MWT Measures functional endurance/activity tolerance ICF: activity ○ 10MWT AD may be used Assist may be given Functional mobility / speed ICF: activity ○ DGI/FGA Assess higher level functional mobility (gait) Ambulate while changing speeds, moving head, & ambulating over objects ICF: activity 3. Effective progression of outcome measure (how to apply functionally/clinically) - all OMs 4. Review cut off scores and implications of scoring: Berg, TUG, DGI/FGA, 10 Meter Walk, Tinetti, PASS, Functional Reach - T’s = AD’s NO numbers for MCID OR MCD - know that you would use long/short term goals ○ Berg Balance Score: /= 15 s = increased fall risk Gait: >13.5 s = increased fall risk ○ DGI Score: 20° (starting @ 90° flex) ○ Wrist ext > 10° (starting from full flexion) ○ Finger extension > 10° in @ least 2 digits 4. Shaping vs Functional Exercises KNOW THIS ○ Shaping - KNOW DIFFERENCE BTW FLEXION/EXTENSION Flipping cards → open doors Use large ball at beginning for gripping → move to smaller ball once motor control achieved To improve flexion→ use large ball then work towards a smaller ball (gripping) To improve extension→ start with smaller ball and work towards larger ball (gripping) ○ Functional Exercises eating, folding towels Unit 9: Improving Motor Function of the UE and LE Post Stroke 1. Outcome Measures to Predict UE/LE Motor Recovery Post Stroke (Fugl Meyer; Chedoke) ○ Fugl Meyer (Assessment of Motor Recovery after Stroke) Impairment based Evaluates & measures recovery in post-stroke hemiplegic pts One of the most widely used quantitative measures of motor impairment 5 Domains: Motor Function (UE & LE) Sensory Function Balance Joint ROM Joint Pain ○ Chedoke McMaster Stroke Assessment - KNOW THIS  Impairment Based--presence of spasticity 1→ Flaccid, no reflex 2→ Spasticity present, no voluntary mvmt 3→ Marked spasticity, synergy full & voluntary 4→ ↓ spasticity, synergy begin to reserve 5→ spasticity wanes, synergy can be reversed. Mvmt environmentally specific 6→ Coordination of mvmt near normal when NS stressed 7→ Normal 2. Interventions to Facilitate Motor Recovery ○ Recovery/Restorative (AROM) Motor learning, task specific Motor control ○ Augmented -- more acute (AAROM) Sensory function Strength Flexibility & jt integrity PNF NDT ○ Compensation -- more chronic - long term management and AD Spasticity management Assistive devices ○ RECOVERY = PROXIMAL → DISTAL 3. Mirror Box / FES Evidence: Recommendations ○ Mirror Therapy→ useful early on (acute stages)--restorative tx Used to convey visual info to the damaged portion of the brain thru observing the affected portion of the body as it executes mvmt Tricks brain into thinking affected (unaffected) arm is moving via reflection Most Appropriate for: Pts w/ motivation to commit to tx Ability to follow instructions Hemispatial neglect may benefit Not Appropriate for: Recent alcohol abuse, severe depression, or claustrophobia Cognitive disorders, aphasia, dementia, mental health problems or attention deficit Severe hemispatial neglect w/ limitations in turning the head Evidence to Support: need to know UE/LE (not in too much detail), most support of treatments UE→ good/high evidence ○ Several HIGH RCTs (random control trials) ○ Improved: ADL performance Motor activity, function, recovery Spatial neglect ○ Cortical reorganization--chronic ○ Use in combo--rTMS, FES, NDT, CIMT LE→ not a lot of evidence ○ Very few studies ○ Postural stability ○ Recommended use in combo w/ rTMS ○ Functional Electrical Stimulation (FES) → compensatory tx & augmented Augmented therapy Shoulder subluxation benefits Strengthen muscle contraction & improve motor control in that extremity Apply FES w/in function  Evidence to support: need to know UE/LE (not in too much detail), most support of treatments UE ○ mod→ high Level RCTs ○ Improved: hand/dexterity function Motor function & ADL use Sh. muscle tone, EMG, pain, subluxation ○ acute/subacute > chronic LE ○ mod→ high level RCTs ○ Improved: Motor function Walking speed/efficiency Peroneal nerve stim Functional ambulation ROM ○ Combo--exercise, cycling, KTape, standard PT 4. Treadmill Training: Benefits, Type of Exercise, Evidence ○ Task specific training ○ Repetitive task specific practice Ambulatory & non-ambulatory ○ Benefits: Improve functional mobility & speed, temporal aspects of gait Improve functional independence BWS vs Non-BWS (body weight support) Harness (safety & support % of weight) Facilitation vs none Steady state Mxm walking speed (progression/regression capacity) Incline (resistance training) Split belt Unilateral training ○ Type of Exercise: Endurance Training ○ Evidence to Support: Effective for: LE strength Self efficacy Sit to stand Trunk motor impairment Gait speed & ST parameters Endurance Motor activation Stairs NOT effective for: Balance Falls  Quality of life measures ○ Treadmill training = traditional overground therapies for improving gait ○ Not found superior to other interventions ○ May enhance gait speed & endurance ○ Clinical Decision Making to Use Treadmill: Medically stable Able to sit EOB w/ independence Does NOT need to have a current capacity to stand Unit 10: Physical Therapy management of neglect and visual perceptual problems Remedial Approach → retraining, recovery of underlying skills, recovery and reorganization of the CNS, Bottom up approach (foundational) Compensatory/ adaptive approach → direct training of functional skills, top down approach (starting with function) 1. Treatment Strategies for Apraxia (Ideomotor vs Ideational) ○ Ideomotor: disconnect between the idea of a movement and its motor execution Guide mvmt Can do mvmt via not on command ○ Ideational: failure in the conceptualization of the task (ie mermaid brushing hair with a fork) Go thru step by step ○ Remedial approach: One command at a time and allow time for pt to complete Break tasks down into their components Guiding Repetition Perform tasks in a normal environment ○ Compensatory approach: Strategy training (ie use of picture sequences) 2. Treatment Strategies for Agnosia ○ Agnosia: the inability to recognize or make sense of incoming information despite intact sensory capabilities ○ Remedial approach: Photographic drills to discriminate objects and faces The easy street environment ○ Compensatory approach: Encourage patient to use other sensory modalities like touch 3. Treatment Strategies for Neglect ○ Neglect = NOT sensory issue PERCEPTION PROBLEM (pts ignore side) Use vision to help w/ recovery Forced to do activities on neglected side ○ Remedial approach: Simple verbal instructions Use of shapes to stimulate the right brain (most ppl ignore L side of body due to lesion on R) Minimize letters and numbers to avoid stimulating to the left L = Letters Encourage client to turn their head of trunk and head to side of neglect Encourage motor activities on the left Eye patching, prism glasses, optokinetic stimulation, neck vibration  ○ Compensatory approach: External cues to draw attention to left side Arrange the environment for success such as objects on the less affected side (right) Mirror to draw attention to that side 4. Identifying Cognitive vs Perceptual Deficits Cognition Deficits Impairments Attention deficits Sustained attention, selective attention, divided attention, alternating attention Memory impairments Immediate recall, STM, LTM Impaired executive function (higher order cognition) Volition, planning, purposive action, effective performance Perception Deficit Impairments Body schema/body image Unilateral neglect, anosogosia, R-L discrimination, finger agnosia Spatial relation impairments Figure ground discrimination (pull things out of background), spatial relations, position in space, topographical disorientation, depth and distance perception, vertical disorientation Agnosias Visual object, auditory, tactile agnosia Apraxia Ideomotor, ideational 5. Conditions leading to Cognitive / Perceptual Deficits (why) ○ Cognition→ frontal lobe (prefrontal) ○ Perception→ non-dominant hemisphere (R) temporal-parietal association area ○ Brain injury Traumatic (cognitive) vs atraumatic (cognitive + perceptual) ○ CVA R hemisphere→ neglect (perceptual) L hemisphere→ not as many perceptual issues Lesion or artery damaged -- MCA most common MCA→ perceptual (feeds parietal/temporal lobes = perception) ACA→ cognitive (feeds frontal lobe = cognition) ○ Parkinsons Prefrontal circuitry → cognitive problems (later PD) Not much perceptual damage Motor problem 4 channels → motor, limbic, oculomotor and prefrontal circuitry ○ Multiple sclerosis Lesion site dependent Cognitive issues with memory and planning Unit 10: Pusher's Syndrome 1. Burke Lateropulsion Scale vs Scale for Contraversive Pushing: Features / Use of Each ○ Main diagnostic feature→ Resistance to correction ○ Burke Lateropulsion Scale (resistance to correction scale) -- Burke from Greys (more than 2 seasons out of 17) 5 testing positions Supine rolling (resistance to passive rolling) Sitting (resistance to passive postural correction based on the degree of tilt) Transferring (resistance and assistance during transferring) Standing (resistance to passive postural correction based on degree of tilt, past midline) Walking (resistance and assistance during walking) Max score: 17 points >2/17 = diagnostic for contraversive pushing BLS is more sensitive at detecting mild pusher behavior and more responsive to small changes than the SCP **GOLD STANDARD** ○ Scale for Contraversive Pushing (SCP) ** there are knowledge check questions in the BB powerpoints ** 6 points 3 things: L-P-R Spontaneous body posture→ leaning ABDuction & EXT of nonparetic extremities→ pushing Resistance to passive correction of titled posture→ resistance*** CP = > 0 in each of the 3 categories 2. Treatment for Pushers based on stage of Pushers KNOW THIS 1. Pt needs to become aware of lateral lean ○ Allow push/lean to occur ○ Do not push against ○ Visual cues = vertical objects (door frames, tape on wall) 2. Initiation of reach ○ Stroke thigh 3. Progression of reach ○ Stroke down thigh onto shin 4. Active reaching to uninvolved side ○ Lean forward, lean to unaffected side ○ #1 Realize the disturbed perception of the body position and visual exploration Avoid “passive” correction Hands-off approach Allow pathological pushing to occur Make pt visually aware of their tilted body position Mirrors, use of tape line Assistance for active correction including support with non-paretic hand on the paretic side or a shift of the non-paretic arm and thus the COG towards the non-paretic side Visually explore the surroundings and the bodys relation to the surroundings Ensure the pt see whether he/she is oriented upright  Work in a room containing vertical structures -- such as door frames, windows, pillars, or pictures Also beneficial to use visual aids that give the pts feedback about their orientation ○ #2 Reaching a vertical body position actively Show an object on the non-paretic side and ask to reach the object with the hand by shifting their weight toward this side (able to desist from pushing temporarily) Therapist may demonstrate the movement Acoustic signals (knocking on the bed frame) ○ Prevent Pushing Raise mat table up to prevent non-paretic LE pushing Use unstable surfaces under nonparetic LE PT on STRONG side of patient ○ Transfers Easier to transfer toward paretic side (already wanting to lean that way) Work towards both directions 3. Prognosis ○ GOOD ○ Transient behavior for most → FULL RECOVERY ○ Pushing resolved in 6 weeks in 62% of pt (2/3rds) and 3 mos in 79% of pts ○ 90% resolution in 6 months - KNOW THIS AND 6 WKS ○ 6 mos after a CVA, pathological pushing is rarely still present ○ R CVA and pushing→ predicts slower recovery ○ Neglect and pushing→ predicts slower recovery ○ Pts who push take longer to recover functional mobility LOS is increased by 3.6 weeks ○ Prolonged recovery Pt with pushing behavior and only motor impairment recover the QUICKEST as measured by BLS Pts with motor, neglect and proprioceptive impairment take the longest to recover (37% recover in 27 days) Left CVA recovers faster than Right CVA Left CVA → right hemiparesis ○ Older age and severe motor deficits products slower recovery >27 days Right CVA → left hemiparesis ○ Older age, imparied proprioception and impaired cognitive deficits (including depression) predicts slower recovery > 27 days ○ Presence of visuo-spatial neglect does not seem to predict prolonged recovery Unit 11: Strength Training 1. Training Forms: Cross Training, Power, Concentric, Eccentric - when to utilize each ○ Eccentric Training Eccentric = preserved post-stroke this more of a potent training stimulus Unique activation strategy may increase cortical activation Promoting more neuroplasticity Cross transfer to non-paretic, untrained leg  No superior benefit over other training modes have been demonstrated yet but carry over to function looks promising Increased power & gait speed ○ Power training→ explosive resistance training Fast concentric phase, slow eccentric Use of a shuttle or keiser air leg press machine Fall prevention, gait speed/forward progression Increase gait, power, & speed Weight bearing/function based exercise, shuttle, and pneumatic keiser devices Weighted vests (start at 2% of body weight and add 1-2% as able and threshold) ○ Functional training Repeated standing up and sitting down Lower seat height, bias weaker extremity +/- use of the UEs for different phases of movement Step ups (conc)/downs (ecc)/lateral Raise step height Heel raises, lunges, squats/mini squats Walking against resistance -- place tubing around the pelvis Part of task practice Ex trailing leg position with threshold Limited research on functional progressive repetitive training No difference in strength with the acute stroke population ** acutely the type of intervention may not matter and we may see more benefits of progessive functional training in the chronic stage of recovery (>6 mos post stroke) ○ Cross Training Used to strengthen the paretic side by strengthening the non-paretic side Dragert and zehr 2013 Reported a 31% increase in torque in the paretic untrained DF and 35% increase in the nonparetic trained DF after isometric training Other considerations for the SEVERELY WEAK Open chain exercises (closed 1st) Eccentric training (preserved so stronger) E-stim (w or w/out voluntary contraction) (help recruitment more muscles) Biofeedback Mental imagery Mirror box 2. Prescribing Cross Training, Power, Concentric, Eccentric - differentiate between ○ Strengthening Prescription 1-3 days/week START w/ 1 set of 10-15 reps of 8-10 exercises (whole body) Progress to 2-3 sets 50-80% of 1 RM Start at 50% Chronic stroke goal = 70-80% 1 RM Start early!! Medical screen for precautions Remember that stroke is a cardiovascular issue = vitals pre, during, post  ○ Capacity to recover Risks are nearly non-existent (falls, Valsalva, DOMS) ○ Eccentric Training Fernadez- Gonzalo (RCT -- 2014/2016) 4 sets of 7 reps (2 min contractile activity) 2x/wk for 12 wks Increased power, force, size, balance and TUG Clark and pattern (RCT -- 2013) 3x/wk for 5 weeks + gait training Hip, knee, and ankle at 30-120 d/s Increased power and gait speed ○ Power training Start @ lower intensity (20-40% of 1 RM) progress to 60-70% Must develop a base 1st then increase speed 8-15 reps, 1-3 sets 2-3x/wk Morgan, single group design (2015) 3x/wk for 8 wks, 2-3 sets of 8-15 reps Unilateral leg press, calf raises and jumping shuttle MVP, +walking practice at 125% of self selected walking speed (SSWS) ○ Significant increased strength, power and gait speed 3. Training Intensity Rx / Recommendations based on stage of stroke ○ AHA/ASA Recommendations for Stroke Survivors At least 1 set of 10-15 reps of 8-10 exercises (torso, upper and lower extremities) 50-80% of 1 RM MUST START AT 50% 1 RM CHRONIC STROKE | 70-80% 1 RM = GOAL 2-3 days/week Progress to 2-3 sets Programs should be developed and trained professionals and should be offered early after stroke ○ CDC- older adult recommendations NOT supervised (HEP) >/= 2 days a week >/= 1 set of 8-12 reps (more benefit with 2-3 sets) Rest 2-3 min between sets Begin with no weight and re-assess bi-weekly If you can lift the wt >12 times with good form its time to increase the weight If you can't do >/= 8 reps then you should reduce the weight Work all major muscle groups (program online) Legs, hips, back, chest, abs, shoulders and arms Warm-up 5-10 min Cool down with stretching (30-60 s for older adult) 4. Strength Training - what does the literature say ○ Perform passive stretching to prevent stiffness ○ Strengthen paretic muscles over short lengths ○ Harness eccentric strength preservation More efficient and higher force production  ○ Incorporate exercises that increase speed of contraction for power ○ Address the non-paretic or less affected limb to prevent weakness bilaterally 5. Establishing a resistance for training based on RM coefficient --- QUIZ QUESTION ○ Given RM coefficient #’s x %RM coefficient Then multiple the RPE % they want to achieve ○ NO CALCULATOR :( Unit 11: Cardiovascular Training 1. Precautions / Contraindications ○ ***Contraindications: quiz Medical instability of diabetes, angina, arrhythmias Uncontrolled HRrest, >100bpm or < 50 bpm Resting systolic BP = 200 mmHg or < 90mmHg Resting diastolic BP >110mmHg Oxygen saturation < 90% ○ Precautions Pts on Beta Blockers -- use RPE to measure intensity and monitor 2. Training Intensity Rx / Recommendations based on stage of stroke ○ AHA/ASA CV Guideline--Stroke 20-60 min/session (multiple 10 min sessions) @ 40-70% of HRrest--3-5x/wk ○ Dosage: Low Intensity (< 40%) 60min, 2-3 days/wk All pts should at least be getting low intensity Mod Intensity (40-59%) 30 min, 5 days/wk Vigorous Intensity (60-84%) 20 min, 3 days/wk Multiple short sessions Min 10 min bouts ○ Intensity leads to greater production of Brain Derived Neurotrophic Factors (BDNF) Involved in: Neuroplasticity 30 min @ 60% MaxHR = Increased BDNF 3. CV Training - what does the literature say ○ Evidence Supports CV Exercise: Mod intensity steady state aerobic exercise HIIT protocols Feasibility/safety Neuro protection ○ Evidence: Chronicity Specific ACUTE → early mobilization Begin physical activity w/in 24 hrs post stroke Improved functional outcomes 3 months post SUBACUTE → aerobic Ex training 40-59% HRR, mod  Robot assisted, cycle ergometer Varying time frames of duration/fx, dependent on LOS CHRONIC Consider HIIT Add resistance training Minimum: 8 weeks, 3x/wk, 20 min ○ Evidence supports CV training at all levels of recovery ○ Recommendations: Subacute = 30 min / day, 3x/wk @ mod intensity Chronic = HIIT, 20min/day, 3x/week, 8 weeks @ high intensity WILL BE ON EXAM: PSEUDOBULBAR: affects where they go through different mood swings - emotional outbursts; uncontrolled laughing, crying, secondary to CVA, seen in Amyotrophic Lateral Sclerosis treatment→ be positive, support Redirection to positive tasks Impairments→ Depression, apathy, aphasia How does it affect functioning? From the book p.606: - Stroke cognitive affect (pseudobulbar affect) PBA - Emotional lability or emotional dysregulation syndrome - Emotional outburst of uncontrolled or exaggerated laughing or crying that are inconsistent w/ mood - Pt unable to control episodes Apathy: - Shallow affect & blunted emotional responses - Misconstrued as depression or poor motivation