CVARehabLinks - PowerPoint PPT Presentation

Title: CVARehabLinks


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CVA Rehab

• Michele Taft, OTD, CHT

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Hypertonicity
Sensorimotor   Intervention Combination of Rood, Brunstrom, PNF and NDT(Bobath) Occupation Based ideas
hypertonicity   Prolonged stretch   Compression     Firm pressure     Rocking rhythmically   Relaxation contract relax, hold relax Hold book open with affected hand Lean on affected extremity to sit up in bed before reaching for face cloth Encourage use of affected arm for reach with firm touch versus light tactile cue Sit is rocking chair   Squeeze face cloth then release
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Hypotonicity 
Sensorimotor   Intervention Combination of Rood, Brunstrom, PNF and NDT(Bobath) Occupation Based ideas
hypotonicity   Quick stretch   Resistance  Traction Light touch Vestibular stim Rhythmic initiation Patient perform a stretch with unaffected arm before an ADL Squeeze shampoo bottle  Grasp tub rail and lean back to prepare for transfer Light tactile cues during ADL Take elevator then practice transfer Therapist assist reach into closet for shirt, then patient grasp pants.
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Ataxia
Sensorimotor   Intervention Combination of Rood, Brunstrom, PNF and NDT(Bobath) Occupation Based ideas
ataxia   Weight bearing   Quadriped D1/D2 PNF Patterns Lean on affected arm while performing hygiene Spot clean carpet Put away groceries
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Contractures
Sensorimotor   Intervention Combination of Rood, Brunstrom, PNF and NDT(Bobath) Occupation Based ideas
contractures   Prolonged stretch   Splinting Positioning Weight-bearing hand during ADLs Use arm while in splint. Don or doff of splint Place hand to hold cup while pouring with be unaffected hand
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Balance/ Trunk Control
Sensorimotor   Intervention Combination of Rood, Brunstrom, PNF and NDT(Bobath) Occupation Based ideas
Balance/ trunk control   Weight shifting     Weight bearing in prone, sidelying then progress to sitting   Practice sit to stand/stand to sit Segmental rolling/trunk rotation   Pelvic tilt Prepare for wheelchair transfer by weight shifting to front of the seat Watch a movie on the wedge in prone or side lying, or in sitting rest arm on lap tray Toilet transfers In sidelying reach for clock In sitting reach for snacks forward and overhead in place in bowl elbow height
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Home Program

• https//www.youtube.com/watch?featureplayer_embed
  dedvxM3FH3onCPg

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Performance Area Technique Rationale
Eating              Self feeding Chin tuck to chew Head back to swallow Rotate head toward weak side Side bend toward stronger side Alternate bites of solids with sips of liquids Perform multiple swallows Built-up handles for utensils Prevents early swallow Assists clearing oral cavity Closes weaker side Encourages food to the stronger side Clear residue between bites  Same as above   Ease of grasp
Dressing Don garment on affected side first Use unaffected hand to position the affected arm Velcro closures Stabilize clothing with affected extremity Unaffected side has more flexibility Fosters independence and acknowledgment of affected extremity Limits need for fine motor coordination Fosters use and acknowledgment of affected extremity
Grooming Built-up handles for grooming Hold container in affected extremity Ease of grasp   Acknowledge affected extremity
Transfers Assist moving effected leg by hooking unaffected leg to prepare for transfer Fosters independence
Unable to engage in leisure activities Activity modification Grade activity to allow success
Lack of interest Occupational questionnaire Find what interests and motivates patient
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Cognition Affects Motor OutputMotor Apraxia
Motor Apraxia Impaired motor planning     Do the movements appeared to be clumsy? Can the patient adjust grasp according to altered requirements during object use? Are there problems sequencing of movement? Can patient move bolus (wad of food) with-in oral cavity. Can patient adjust grasp of a utensil, especially spoon? Difficulty scooping or stabbing food (not coordination or visual)? Can patient adjust their grasp of a shirt or sock?   Difficulty with buttons or fasteners yet has dexterity? Seems clumbsy. Can patient adjust their grasp of toothbrush, razor or comb? Is patient able to orient body in order to transfer?
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Ideational Apraxia
The patient does not know what to do in order to perform an activity.   Questions to ask yourself Does the patient have an idea what to do? Does the patient know which object to use? Does the patient know how to use the object? Does patient recognize utensil and its use such as knife to cut fork to eat? Does patient attempt to eat with inappropriate utensil, for example using a spoon to eat bread? Patient does not know what to do with shirt or pants or Misuses clothing i.e., may put leg in armhole or arm in a leg hole. May not know what to do with a washcloth May grasp washcloth and reach for toothpaste Attempts to turn on water from wrong places on faucet Tries to wet face cloth under faucet before turning on water Washes sink instead of face Uses tools inappropriately such as toothbrush for combing hair, rubbing toothpaste on face May misuse toothpaste or toothbrush May wet deodorant under running water Cannot take visual cues such as pointing to therapist mouth to indicate removing dentures May bite down on toothbrush when it is it is placed in their mouth. Gets trapped in sheets unable to untangle Turns the wrong direction getting into bed Unable to determine how to use a step stool Attempts to wheel wheelchair pushing on the armrest
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Unilateral Body Neglect
Failure to attend to the affected side of the body Questions to ask yourself Does the patient take care of and account for the paralyzed side? Does the patient use the extremity on the affected side? Does the patient account for the affected side during a transfer? Does not address affected side Stores food in affected side of mouth Spills liquid held ineffective hand.   Does not use affected arm during eating, may place it in the food. Does not tuck in shirt or pull down shirt on affected side Shirt gets stuck over affected shoulder without trying to fix it. Does not use affected hand during bilateral activities Attempts  to wash or shave only half the face   Walks into doorways on affected side When attempting sit to stand only moves affected side, leaving the affected side on the foot rests.
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Unilateral Spatial Neglect
Does not attend to person speaking from the affected side.  Keeps head rotated towards the unaffected side Does not eat food / drink on affected side or use utensils on unaffected side does not notice clothes placed on affected side Does not recognize handle of toothbrush if it is placed on the affected side May wheel and walls unaffected by this
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Spatial Relations Disorders
Unable to orient objects Unable to find armholes, leg holes or bottom of shirt Unable to differentiate front to back or insight from outside of clothing Attempts to correct but unable to correct tangled clothing Incorrectly matches buttons Puts hand through wrist cuff instead of shoulder on shirt or put foot into ankle of pants or arm through neck hole of shirt. Unable to learn one-handed tying with unaffected extremity Attempts to adjust shirt that has been placed on backwards without taking arms out of the sleeves Places foot in wrong leg hole Puts glasses on upside down Attempts to put dentures on upside down Overreaches Grab wrong object during ADL when 2 or more items are on the sink Difficulty orienting body to get out of bed may lean forward instead of backwards to assist getting out of bed May grab armrest instead of wheel of wheelchair
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Perseveration
Does patient repeat activity or part of activity over and over May keep stuffing food into mouth before swallowing without swallowing May continue to attempt eating soup when there's no soup on spoon, or use same utensil for all items including drinks May pull wrist of long sleeves all the way up past elbow Attempts to place more than one button in the same buttonhole May attempt to put the same arm through both sleeves Attempts to find ankle of sock at the toe side but persists in looking May wash face and then repeat activity over or may not stop washing face may not stop putting soap on washcloth May continue to wheel into things
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Organization sequencing
Places more food in the mouth before swallowing Attempts to eat food without cutting Dress the unaffected arm after instruction to address the effective arm first Does not complete fastening buttons or zippers Will stop in activity after each step Will put shoes on before socks. Does not turn water off after washing may leave electric razor on Does not ring out washcloth after rinsing Does not complete one task before going to the next Does not take glasses off to wash face Does not put brakes on before transferring Attempts to get out of bed before taking off blanket attempts
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Cognition Affects Motor OutputMotor Apraxia
Motor Apraxia Impaired motor planning     Do the movements appeared to be clumsy? Can the patient adjust grasp according to altered requirements during object use? Are there problems sequencing of movement? Can patient move bolus (wad of food) with-in oral cavity. Can patient adjust grasp of a utensil, especially spoon? Difficulty scooping or stabbing food (not coordination or visual)? Can patient adjust their grasp of a shirt or sock?   Difficulty with buttons or fasteners yet has dexterity? Seems clumbsy. Can patient adjust their grasp of toothbrush, razor or comb? Is patient able to orient body in order to transfer?
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Ideational Apraxia
The patient does not know what to do in order to perform an activity.   Questions to ask yourself Does the patient have an idea what to do? Does the patient know which object to use? Does the patient know how to use the object? Does patient recognize utensil and its use such as knife to cut fork to eat? Does patient attempt to eat with inappropriate utensil, for example using a spoon to eat bread? Patient does not know what to do with shirt or pants or Misuses clothing i.e., may put leg in armhole or arm in a leg hole. May not know what to do with a washcloth May grasp washcloth and reach for toothpaste Attempts to turn on water from wrong places on faucet Tries to wet face cloth under faucet before turning on water Washes sink instead of face Uses tools inappropriately such as toothbrush for combing hair, rubbing toothpaste on face May misuse toothpaste or toothbrush May wet deodorant under running water Cannot take visual cues such as pointing to therapist mouth to indicate removing dentures May bite down on toothbrush when it is it is placed in their mouth. Gets trapped in sheets unable to untangle Turns the wrong direction getting into bed Unable to determine how to use a step stool Attempts to wheel wheelchair pushing on the armrest
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Unilateral Body Neglect
Failure to attend to the affected side of the body Questions to ask yourself Does the patient take care of and account for the paralyzed side? Does the patient use the extremity on the affected side? Does the patient account for the affected side during a transfer? Does not address affected side Stores food in affected side of mouth Spills liquid held ineffective hand.   Does not use affected arm during eating, may place it in the food. Does not tuck in shirt or pull down shirt on affected side Shirt gets stuck over affected shoulder without trying to fix it. Does not use affected hand during bilateral activities Attempts  to wash or shave only half the face   Walks into doorways on affected side When attempting sit to stand only moves affected side, leaving the affected side on the foot rests.
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Unilateral Spatial Neglect
Does not attend to person speaking from the affected side.  Keeps head rotated towards the unaffected side Does not eat food / drink on affected side or use utensils on unaffected side does not notice clothes placed on affected side Does not recognize handle of toothbrush if it is placed on the affected side May wheel and walls unaffected by this
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Spatial Relations Disorders
Unable to orient objects Unable to find armholes, leg holes or bottom of shirt Unable to differentiate front to back or insight from outside of clothing Attempts to correct but unable to correct tangled clothing Incorrectly matches buttons Puts hand through wrist cuff instead of shoulder on shirt or put foot into ankle of pants or arm through neck hole of shirt. Unable to learn one-handed tying with unaffected extremity Attempts to adjust shirt that has been placed on backwards without taking arms out of the sleeves Places foot in wrong leg hole Puts glasses on upside down Attempts to put dentures on upside down Overreaches Grab wrong object during ADL when 2 or more items are on the sink Difficulty orienting body to get out of bed may lean forward instead of backwards to assist getting out of bed May grab armrest instead of wheel of wheelchair
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Perseveration
Does patient repeat activity or part of activity over and over May keep stuffing food into mouth before swallowing without swallowing May continue to attempt eating soup when there's no soup on spoon, or use same utensil for all items including drinks May pull wrist of long sleeves all the way up past elbow Attempts to place more than one button in the same buttonhole May attempt to put the same arm through both sleeves Attempts to find ankle of sock at the toe side but persists in looking May wash face and then repeat activity over or may not stop washing face may not stop putting soap on washcloth May continue to wheel into things
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Organization sequencing
Places more food in the mouth before swallowing Attempts to eat food without cutting Dress the unaffected arm after instruction to address the effective arm first Does not complete fastening buttons or zippers Will stop in activity after each step Will put shoes on before socks. Does not turn water off after washing may leave electric razor on Does not ring out washcloth after rinsing Does not complete one task before going to the next Does not take glasses off to wash face Does not put brakes on before transferring Attempts to get out of bed before taking off blanket attempts
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Impulsive
Swallows after brief chewing shovels food in mouth Does not test water before bathing Does not stand completely before transfer (when performing stand pivot), Does not lock W/C
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Impulsive
Swallows after brief chewing shovels food in mouth Does not test water before bathing Does not stand completely before transfer (when performing stand pivot), Does not lock W/C
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• https//www.youtube.com/watch?vbBQXvDQdRaEfeatur
  eplayer_embedded

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Additional Treatments

• Electrical Stimulation
• Technology
• Wii Hab
• Constraint Induced Movement Therapy
• Medical Assist
• Botox
• Surgical Release of tendon/muscle

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Electrical Stimulation

• Another method of muscle retraining is called
  neuromuscular electrical stimulation, or NMES.
  NMES involves sending a current into the nerve
  through electrodes placed on the skin, to trigger
  a muscle contraction. Placed strategically, an OT
  can use NMES to help a stroke patient perform
  such movements as making a fist or bending their
  elbow. NMES can also be used to retrain a
  dislocated shoulder to remain in its socket, a
  common problem in stroke patients. Other forms of
  NMES use specially fitted devices for the arm
  that can be timed, so the arm or hand can
  function with assistance during tasks and
  routines

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Technology

• Computer aided programs to motivate patients to
  perform use of the affected extremity.
• The Wii is one affordable way for them to
  continue it at home.

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Wii Hab

• https//www.youtube.com/watch?featureplayer_embed
  dedvSk53cBpZ_Ik

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Constrain Induced Movement Therapy

• Effect of Constraint-Induced Movement Therapy on
  Upper Extremity Function 3 to 9 Months After
  StrokeThe EXCITE Randomized Clinical Trial
• Steven L. Wolf, PhD, PT Carolee J. Winstein,
  PhD, PT J. Philip Miller, AB Edward Taub, PhD
  Gitendra Uswatte, PhD David Morris, PhD, PT
  Carol Giuliani, PhD, PT Kathye E. Light, PhD,
  PT Deborah Nichols-Larsen, PhD, PT for the
  EXCITE Investigators
• JAMA. 2006296(17)2095-2104.

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Constraint Induced Movement Therapy

• Context Single-site studies suggest that a 2-week
  program of constraint-induced movement therapy
  (CIMT) for patients more than 1 year after stroke
  who maintain some hand and wrist movement can
  improve upper extremity function that persists
  for at least 1 year.
• Objective To compare the effects of a 2-week
  multisite program of CIMT vs usual and customary
  care on improvement in upper extremity function
  among patients who had a first stroke within the
  previous 3 to 9 months.
• Design and Setting The Extremity Constraint
  Induced Therapy Evaluation (EXCITE) trial, a
  prospective, single-blind, randomized, multisite
  clinical trial conducted at 7 US academic
  institutions between January 2001 and January
  2003.
• Participants Two hundred twenty-two individuals
  with predominantly ischemic stroke.
• Interventions Participants were assigned to
  receive either CIMT (n 106 wearing a
  restraining mitt on the less-affected hand while
  engaging in repetitive task practice and
  behavioral shaping with the hemiplegic hand) or
  usual and customary care (n 116 ranging from
  no treatment after concluding formal
  rehabilitation to pharmacologic or
  physiotherapeutic interventions) patients were
  stratified by sex, prestroke dominant side, side
  of stroke, and level of paretic arm function.

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CIMT (cont.)

• Main Outcome Measures The Wolf Motor Function
  Test (WMFT), a measure of laboratory time and
  strength-based ability and quality of movement
  (functional ability), and the Motor Activity Log
  (MAL), a measure of how well and how often 30
  common daily activities are performed.
• Results From baseline to 12 months, the CIMT
  group showed greater improvements than the
  control group in both the WMFT Performance Time
  (decrease in mean time from 19.3 seconds to 9.3
  seconds 52 reduction vs from 24.0 seconds to
  17.7 seconds 26 reduction between-group
  difference, 34 95 confidence interval CI,
  12-51 Plt.001) and in the MAL Amount of Use
  (on a 0-5 scale, increase from 1.21 to 2.13 vs
  from 1.15 to 1.65 between-group difference, 0.43
  95 CI, 0.05-0.80 Plt.001) and MAL Quality of
  Movement (on a 0-5 scale, increase from 1.26 to
  2.23 vs 1.18 to 1.66 between-group difference,
  0.48 95 CI, 0.13-0.84 Plt.001). The CIMT group
  achieved a decrease of 19.5 in self-perceived
  hand function difficulty (Stroke Impact Scale
  hand domain) vs a decrease of 10.1 for the
  control group (between-group difference, 9.42
  95 CI, 0.27-18.57 P.05).
• Conclusion Among patients who had a stroke within
  the previous 3 to 9 months, CIMT produced
  statistically significant and clinically relevant
  improvements in arm motor function that persisted
  for at least 1 year.

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CIMT

• https//www.youtube.com/watch?vMMTh2hWvB2gfeatur
  eplayer_embedded

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Botox Assists Rehab for Spasticity

• https//www.youtube.com/watch?vkEchNz45Nq4featur
  eplayer_embedded

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• Not all patients can expect a functional
  recovery. The prognosis is dependent on the
  amount of brain damage.
• OT can give patients exposure to methods that
  will facilitate a happy productive life.