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Revision - STROKE/ CEREBRAL PALSY / SPINAL CORD INJURY (Weeks 8-10) Exercise for Non-Progressive Neurological Conditions
Terms in this set (124)
Balance capacity, muscle endurance and strength, and spasticity of the limbs.
main factors that influence the mode of exercise prescribed for stroke clients!
monitoring of blood pressure responses is essential to reduce the likelihood of exercise-induced complications.
STROKE clients Exercise monitoring
primarily a consequence of cardiovascular disease
Diabetes, CAD, PAD, obesity, depression, osteoathritis
What comorbidities of stroke may need consideration
heterogeneous groups of disorders involving sudden, focal interruption of cerebral flow bold resulting in a neurological deficit/s lasting longer then 24-hrs. Cerebrovascular accident or 'brain attack'.
anoxic tissue damage downstream from the site of the origin possibly causing permanent impairments in brain function
-2nd largest cause of death.
-around 30% of stroke survivors are under 65 years of age
- Males at increased risk
Stroke statistics - AUS
65% of all stroke survivors suffer a disability that impedes their ability to carry out daily living activities unassisted.
Stroke disability outcomes
1. Ischemic (90% of all strokes)
Thrombotic (within brain "50% of strokes") and embolic (rest of the body)
2. Haemorrhagic (10% of all strokes)
- vessel rupture with blood leak inside brain
2 types of Stroke
Mini Stroke - usually warning sign of stroke, MEDICAL EMERGENCY
TIA - Transient Ischemic Attack
-age, prior stroke / TIA, HTN, AF, Fx, Dx CVD, DM, Cigarette, Alchohol, Obesity
Major Stroke Risk factors
Ischemic stroke ( surgery, med's)
Haemorrhagic stroke ( surgery to relieve intracranial pressure and insertion of stents to support weak vessels)
Tx for Stroke
-Warfarin - pts should avoid activities with high risk for trauma or injury.
-Rampil/ enalapril / Hydorchorrothiazide: decrase in resting and exercise BP
- Nimodipine=: increased exercise capacity in patients with angina
Medications and exercise effects and considerations
interconnection between the internal carotid arteries and basilar artery
Circel of Willis
Contralateral Weakness / hemiplegia. Sensory Impairment (temp, pain, touch). Spasticity, Contractures, Ataxia, Balance Impairement, Fatigue
deficit in attention to and awareness of one side of the field vision
inability to process sensory information
difficulty with motor planning / organisations
difficulty in making and coordinating the precise articulacy movements
Depression, anxiety, mood swings, impulse control, anger.
Behaivoural / Emotional Impairments
most recovery occurs in the first 6 months post-event. associated with physical conditioning
Recovery from Stroke
0- no symptoms
1- no sign. dissablity (able to carry ADL's)
2. slightly disability
3. moderate disability
4. mod-severe disability (unable to cater for themselves)
5. severe disability (constant nursing care)
The modified Ranking Scale (mRS)
1. commence physical conditioning exercises to support return to pre-stroke levels asap
2. Reduce the risk of recurrent stroke / CVD events
3. Improve Aerobic fitness within individual capacity
3 GOALS for Ex Rehab in Stroke
1. Major goal (aerobic functional capacity) avg. 14.4 whereas 20 is the minimum for independent living.
2. Aggressive rehab after 6mths can increase aerobic and sensory function
3. Aerobic ex. improves multi CVD risk factors
4. standard rehab not aerobic focused
4. KEY POINTS for Ex Rehab
Sign. reduction in muscular strength and endurance
2. Spasticity and loss of flexibility
Consideration for Stroke patients
Increase Vo2, mm, functional, balance, gait, work capacity, BMI
Benefits of Ex. Rehab
1. ESSA Adult Pre-Ex. Screen: risk factors for CVD and DM, resting ECG / stress test?
2. Mx - date Dx, Med's, complications, lifestyle issues,
3. Psychological state (depression is common) Referral recommendations
Pre-Exercise Screening and Assessment in Stroke Patients
Spasticity (Modified Ashworth Scale)
Pre-Exercise Screening and Assessment in Stroke Patients: CONSIDERATIONS
ABSOLUTE: due to high incidence of CVD with IS, assess unstable angina.
RELATIVE: Bz haemmorrhagic stroke is related HTN, assess resting pre-exercise BP <200mmHg and diastolic BP<110 mmHg.
Exercise in Stroke Patients: CONTRA-INDICATIONS
- Pt's have lower workloads, Associated with lower maximal HR and BP responses to ex. then controls
- Vo2 at given workload is higher in stroke patients
Exercise in Stroke Patients: Cardiovascular response
1. Cardiovascular - treadmill (self-paced 2% increase every 2min), cycle ergometry,
2. Strength (10RM) - free weights, exercise machines, dynamometry (handgrip). Done post Funct. Asses.
3. ROM - Goniometer, sit and reach (ROM in affected joints)
Exercise Testing Considerations - Stroke Patients
-TIMED STAIR CLIMB
-SHUTTLE WALKING TEST
FUNCTIONAL TESTING - (MILD) STROKE PATIENTS
-TIMED UP AND GO (TUG)
-SIT TO STAND
FUNCTIONAL TESTING - (MODERATE) STROKE PATIENTS
-TRANSFERS (NUMBER PER MINUTE)
-SIT TO STAND
FUNCTIONAL TESTING - (SEVERE) STROKE PATIENTS
-Treadmill walking, mimic daily tasks,
-handrail support / harness allow clients to walk.
-Ex. Intensity can be adjusted
BEST AEROBIC EXERCISE TRAINING = STROKE PATIENTS
- Ground / treadmill walking. Cycle ergometer, Seated stepper. Progress low to high intensity to longer duration.
-Frequency: 3-5 days /wk
-Intensity: 40-80% HRR
- Duration: 15-30min (interval training??)
AEROBIC EXERCISE PRESCRIPTION = STROKE PATIENTS
-Should include all major mm groups and functional exercises.
-May include: Weight machines, free weights, body weights, therabands,
-Frequency: 305 days/wk
-Intensity: Up to 80% 1RM
-Progression as tolerated.
Resistance Training EXERCISE PRESCRIPTION = STROKE PATIENTS
Goal: to improve ROM of involved extremities and prevent contractors
Frequency: 3-5 days/wk
Intensity: below point of discomfort
Emphasis on stretching mm on paretic side, in particular spasticity mm.
Flexibility PRESCRIPTION Prescription= STROKE PATIENTS
Knee/hip arthritis is common bas stroke clients are older.
Reduced motor control of legs may cause balance problems, compensation of uninvolved leg?
Closely monitor CVD related adverse events
Avoid isometrics and high-intensity exercises that will elevate SBP.
Special Consideration for Exercise= STROKE PATIENTS
a form of ABI involving damage to the brain caused by an external force to the head causing a tear, penetration, bruising, or swelling of the brain resulting in neurological injury.
Traumatic Brain Injury - TBI
-CLOSED: no penetration to the skull (e.g. falls, MVA, sporting injuries, assault, etc.)
OPEN - penetration to the skull. (e.g. bullet wounds, surgery, fractures, assault, etc.)
Mild TBI's account for 80% of injuries
25% of TBI discharge from hospital has some residual impairment hence post-injury service requirements
Traumatic Brain Injury - TBI STATISTICS
1. DIRECT INJURY
2. INDIRECT INJURY
3. PENETRATING INJURY
4. BLAST INJURY
Mechanisms of injury- TBI
-initial score on Glasgow Coma Scale.
-Duration of loss of consciousness
-length of post-traumatic amnesia.
SEVERITY ASSESSMENT - TBI
1. Mild= (PTA less than 1 hour) normal MRI
2. Moderate= (1-24 hours) = abnormal MRI
3. Severe = >24hrs, = abnormal MRI
Loss of consciousness- TBI
-INTENSIVE CARE (e.g ventilator, etc.)
-SURGERY (remove clots, bony fragments, etc)
-IMAGING (determine extent of injury)
-MEDICATIONS ( diuretics, anti-seizure, coma induced drugs.)
INITIAL TREATMENT - TBI
- increased mm tone and contractures,
- loss of mmm strength and endurance
- loss of ROM
- involuntary posturing
- fatigue (physical and mental)
- chronic pain
-loss of vision
TBI - SENSORYMOTOR IMPAIRMENTS
-Attention and concentration
TBI - COGNITIVE IMPAIRMENTS
Changes in personality
Loss of behavioural inhibitions
TBI - BEHAVIOURAL IMPAIRMENT
- GRIEF AND LOSS
TBI - EMOTION / PSYCHOSOCIAL IMPAIRMENTS
GP's, Psychologists, Social workers, Speech Pathologist, Physio's, EP's.
TBI - RECOVERY AND REHABILITATION
Seizures and depression
TBI - Long-term effect
1. Up-regulation of brain function
2. Increased physical / motor function
3. Improved mood
4. Reduced cognitive problems
TBI- Benefits of Exercise
Overall physical capacity is generally low after TBI. Vo2 max may be -50% of normal. Higher submit HR and BP response to workload. Fatigue faster.
TBI- response to Exercise
-Balance exercise may include:
Yoga, Pilates, Tai Chi, tandem stand / walk, standing on the unstable surface (i.e. BOSU ball, dura disc, wobble board, etc.)
-Intensity. Postural instability.
TBI- Neurmuscular Exercise
1. consider behavioural factors and supervision needs,
2. Depression and apathy are common
3. Communication issues related to cognitive impairment
4. Be aware of orthopaedic injuries
5. Avoid impact activities for 3-mths
TBI- Special Considerations for Exercise
occurs following physical impact
based on a combination of coma and PTA.
similar to STROKE EX. PRESCRIPTION
TBI Exercise guidelines
1. Multidisciplinary approach will provide best outcomes
2. Multimodal exercise approach
- Aerobic component
- Task related practice
- Strength component
EP in Stroke and ABI Rehab
Goal 1: Commence rehabilitation exercises asap to return to pre stroke or optimal recovery post stroke
Goal 2: Reduce the risk of recurrent stroke and CVD events.
Goal 3: Improve aerobic fitness within residual limits of capacity.
Goals for Stroke and ABI rehab
1. Time pressure/staffing resources make it hard to get enough practice and intensity of practice in stroke rehab
2. Moderate to severe stroke survivors movement deficits do not allow attainment of minimum CRF levels
3. Stroke rates increase with poor lifestyle choices - many survivors have low activity or no exercise history
4. Chronic stroke survivors are half as active as sedentary older adults
Challenges faced in exercising stroke and ABI clients
problems with spatial and perceptual abilities (eg. misjudge distances or be unable to guide their hands to pick up an object, button a shirt or tie their shoes)
Resting HR: 80bpm
10meter walk test: 2min 42sec (used quad stick)
TUG: 2min 50sec (used quad stick)
60sec STS: 7 (used quad stick)
6min arm crank: 414 (15W)
6min wheel chair push test: 210m
Modified Rivermead: 24/40
Berg Balance: 15/56
10RM leg press: 52.5kg
10RM Chest press: 18kg
10RM seated row: 34kg
STROKE patient case study, EG> assessment results
refers to a group of conditions that occur due to injury to the developing brain, which generally occurs either during pregnancy, birth or early infancy up to 2 years of age.
Cerebral palsy Aetiology
it largely affect movement, posture, and possibly speech, but may also involve cognitive impairment.
The consequences of Cerebral palsy
precise cause remains unknown (95%) .Although a number of risk factors have been identified. brain lesions may be congenital or acquired
Cerebral palsy causes
cannot be cured and requires lifelong management
Cerebral palsy - Management
age-related declines in gait, mobility, and functional ability
Cerebral palsy early age development
participation in physical activity and exercise is extremely important for both children and adults. it is been demonstrated to substantially improve their health outcomes and quality of life.
Cerebral palsy and Physical Activity
Cerebral palsy known as
Cerebral palsy Mechanism
1. Spastic (70-80%) damage to motor cerebral cortex, increased
2. Dyskinetic (20-30 % of cases) damage to basal ganglia. Impaired gait / postural control. Difficult speaking feeding, etc.
3. Ataxia (10%) damage to cerebellum. lack of coordination and balance. similar to PD not to be confused.
Types of Cerebral Palsy - MOVEMENT:
1. Hemiplegia, 2. Diplegia, 3. Qudraiplegia, 4. Atheoid, 5.Dystonic, 6.Ataxic.
Types of Cerebral Palsy - ANATOMICAL:
1. Pyramidal, 2. Extrapyramidal
damage to both is know as mixed cerebral palsy. both spastic and dyskinetic traits.
Types of Cerebral Palsy - PHYSIOLOGICAL:
INCRASED MM TONE IN PARTICULAR:
FLEXOR muscles of upper extremities: Biceps brachia, brachialias, pronator trees,
EXTENSOR muscle groups of the lower extremities: Quadriceps, triceps surae
(antagonistic mm of the hypertonic mm are usually weak)
MAIN AREAS OF Cerebral Palsy - SPASTICITY:
Epilepsy and Scoliosis. Visual and speech impairment common.
Cerebral Palsy - Associated conditions
Gross Motor Function Classfication System
LV1 - walks without limitations
Lv2-walks with limitations
Lv3- Walsking using hand held mobility device
Lv4-self-mobility with limitations, e.g powered mobility
Lv5 - transported in manual wheelchair
-Anti-seizure meds: common, S/E mental confusion, weight loss, dizziness, nausea, hyperactivity.
- Anti-spasmodic and muscle relaxants: used to decrease mm tone. S/E include drowsiness and lethargy. Poor balance / instability may also result.
- Botulinum Toxin (Botox) injections: can last 3-4 months, used in comb. with exercise
Cerebral Palsy Medications
1. Cardirespiratory endurance: improved aerobic capacity, improvement in HR, BP, vo2max.
2. Skeletal mm strength: improved functional strength, ADLs capacity
3. Skeletal endurance: improved mm endurance, decreased fatigue, improved work capacity.
4 Flexibility: increased ROM, improved coordinations and skill movement.
5. Body Composition: reduced BF, improved BMI.
Benefits of Exercise in Cerebral Palsy
ESSA pre-exercise screen: CVD risk?
Physical Exam: mm tone likely abnormal
reflexes (may be primitive).
Gait and posture assessment.
Pre-Exercise Screening and Assesment in Cerebral Palsy
intern. shoulder rotation, elbow flexion, forearm probation, wrist flexion, finger flexion, thumb in palm.
Hip flexion, hip abduction, knee flexion, ankle quoins, hind foot valgus and toe flexion.
Pre-Exercise Screening COMMON POSTURES in Cerebral Palsy
JUMP KNEE GAIT
Pre-Exercise Screening COMMON GAIT in Cerebral Palsy
-IMPROVE PHYSICAL FUNCTION
-PREVENTION OF SECONDARY CONDITIONS
Exercise TRAINING GOALS in Cerebral Palsy
-non-weight bearing, inc,swimming, hand cycling, stationary cycling, Schwinn Airdyne, Ergometers (upper and lower body)
-3 TO 5 DAYS / WEEK (INTERVAL TRANING?)
- MODERATE INTENSITY 40-50% VO2max
- 2-3 x 10min session, intermittent sessions with relief periods, 3x10min
-Slow progression with aim to increase Vo2 endurance. Use proper positioning and avoid prolonged sitting position. If Aquatic training, use skin care.
CARDO-VASCULAR Exercise PRESCRIPTION in Cerebral Palsy
free weights, elastic resistance bands, balance balls, exercise machines, or hydrotherapy. 2 d/wk. Intensity to fatigue, then lower resistance. 3x 8-12 Reps, Individual progression, TO IMPROVE MM STRENGTH.
RESISTANCE Exercise PRESCRIPTION in Cerebral Palsy
stretching, PNF, or active assistive stretching. 3 to 5 days / week, used as warm up or cooldown, 30-60 sec hold stretches, up to 20min for contracted mm, Aim to improve ROM directly related to ADL's. Check for LLI or Scoliosis, etc.
Flexibility Exercise PRESCRIPTION in Cerebral Palsy
Refers to damage to the neural elements of the spinal canal often resulting in permanent impairments in motor, sensory, and/or autonomic nervous system (ANS) function.
Spinal cord injury (SCI)
for functioning and disability affecting body systems, physical activities, and participation
Spinal cord injury (SCI) - Consequences
reduced health-related outcomes that increase morbidity and mortality.
Spinal cord injury (SCI) - associated
>15,000 Australians currently living with a SCI (0.07% of total population).
~80% of newly reported CSI cases are due to traumatic injury (20% non-traumatic).
More > 1 traumatic SCI occurs every day.
-Traumatic SCI occurrence is highest in 15-24 year olds (accounting for 30%) (av. 19 years).
-Traumatic SCI: 84% male and 16% female
Spinal Cord Injury Statistics
Spinal cord injury (SCI)
Monitor HR and BP for autonomic dysreflexia
Response To Exercise - SPINAL CORD INJURIES
-Conduct sensory information from PNS to brain.
-Conduct motor information from brain to PNS.
-Serve as a centre for sensory-motor integration and reflex production.
Spinal Cord Primary FUNCTIONS
1. Anterior cord syndrome. (Complete motor function, crude touch, pain and temperature sensation bilaterally. Fine touch and proprioception sense are preserved.
2. Brown-Sequard's syndrom(/ Hemicord lesion.Ipsilateral paralysis and loss of fine touch and proprioception.
3. Central cord syndrome. (Generally very rare.Results from compression by tumour or infarction of the posterior spinal artery)
4. Posterior cord syndrome.
(4) specific incomplete lesion syndromes:
Considered a medical emergency and must be recognised immediately.
-Monitor BP every 2-3 mins and seek medical attention
A blood clot in the legs primarily related to physical inactivity and immobility.
Deep vein thrombosis
May lead to pulmonary embolism that can be fatal.
Deep vein thrombosis S&S
high risk for the development of secondary conditions: Shoulder pain, chronic pain, depression, CVD, respiratory disease, obesity, Type 2 DM
"non-progressive persons require extensive on-going medical and health services".
Spinal Cord Injury Prognosis
CVD and stroke.
SCI is an independent risk factor
Proper exercise and physical activity reduces the prevalence of secondary complications and improve the quality of life for individuals with SCI.
Benefits Of Exercise In Spinal Cord Injury
-Reduce the risk secondary conditions such as CV disease, respiratory disease, diabetes, and hypertension.
-Reduce physical deconditioning and obesity.
-Increase functional ability and independence.
-Provide psychological benefits
Exercise can assist In Spinal Cord Injury
result from CV or respiratory disease
Deaths in persons with SCI
Assessment focus on the following:
CVD and PVD.
Circulatory hypokinesis leading to hypotensive responses.
Type 2 diabetes.
SCI - Pre-Screening And Assessment
It should be taken to facilitate the choice of exercise testing equipment, protocols, and adaptations:
-Upper and lower extremity involvement.
-Shoulder function and signs/symptoms of overuse in manual wheelchair users.
SCI - A pre-exercise functional assessment
1.Autonomic dysreflexia resulting from recent fracture: May precipitate spasms or increase the risk of fatty emboli, hypertensive crisis, or cerebrovascular events.
2.Orthostatic hypotension with the risk of syncope.
3. Recent deep vein thrombosis or pulmonary embolism.
4.Pressure ulcers which increase the risk of autonomic dysreflexia during exercise.
Absolute Contraindications For Exercise In Spinal Cord Injury
1. Active tendinitis (e.g., rotator cuff, elbow flexors, wrist flexors/extensors).
2. Chronic heterotopic ossification.
3. Peripheral neuropathy.
4. Pressure ulcers of grade 2 or less.
Relative Contraindications For Exercise In Spinal Cord Injury
1. Arm-crank ergometer.
2. Wheelchair ergometer.
3. Field or functional testing.
SCI - Cardiorespiratory Exercise Testing modes
Residual motor function.
Need for stabilization.
Accessibility of testing equipment.
No special considerations for the assessment of muscular strength. Evaluate mm strength and shoulder imbalances
SCI - Muscle Strength Testing CONSIDERATIONS
Strong focus on shoulder health and function
SCI - Goals for Exercise (wheelchair bound)
1. Aerobic exercise: Maintain cardiovascular health and prevent secondary disease.
2. Resistance training: Maintain function as well as preventing injury from muscle weakness or imbalance. Focus on ADLs: mobility, dressing, bathing, transfers, toileting, wheelchair propulsion, etc.
3. Flexibility training: Improve ROM to reduce spasticity and contractures.
SCI - Goals for Exercise
-Frequency: 2-3 days/week (never 2 consecutive days).
Intensity: As tolerated.
-Volume: Initially, 2 sets of 10 reps as tolerated and progress.
-Type: Focus on strength/endurance, maintaining muscular balance, and reducing repetitive strain around the shoulder:
Depressors (i.e., infraspinatus, subscapularis, pectoralis major, and latissimus dorsi). Scapular stabilisers (e.g., trapezius and rhomboids).
Internal and external rotators
Recommendations For Cardiorespiratory Exercise Programming
Sessions from a seated position in the wheelchair should be complemented with non-wheelchair exercise bouts to strengthen trunk stabilising muscles.
Recommendations For Cardiorespiratory Exercise Programming - CONSIDERATION
Frequency: 7 days/week; 1 session/day.
Intensity: Full ROM to the point of slight discomfort.
Time: Hold stretches for 20-30; 2-4 reps.
Type: Slow static stretches for all major muscle groups should be performed.
SCI - Recommendations For Flexibility And Joint ROM Exercise Programming (upper body function in wheelchair users)
Intensity: Full ROM for all major joints.
Time: Hold stretches for 30-60; 2-4 reps.
Type: Slow static stretches to point of resistance.
Caution: Consider care for those with osteopenia.
SCI - Recommendations For Flexibility And Joint ROM Exercise Programming (For joints with contracture or spasticity)
1. Monitor thermoregulation and signs of heat stress during cardiorespiratory exercise. 2. Potential risk areas for pressure sores should be checked on a regular basis. 3. Routinely assess shoulder pain and function.4. Evaluate ergonomics/movement patterns and minimise frequency of upper limb tasks where possible.5. Avoid extreme positions of the wrist (reduce risk of CTS).6. Avoid hand above the shoulder (RC impingement).
SCI - Special Considerations For Exercise
before exercising to reduce the risk of autonomic dysreflexia.
SCI - Empty bowels and bladder or urinary bag
Reduced dietary intake:
•Chewing or swallowing difficulties
•Difficulties shopping, preparing or cooking food
Causes of Malnutrition
•extra energy for tremors, some disease processes. Low energy (&food) requirements if low PA
•reduced energy budget but still need protein, vits, mins
Reduced absorption (disease process or meds)
Causes of Malnutrition - Increased requirements
•Undernutrition (stunting, wasting, vitamin and mineral deficiency)
•Over-nutrition (overweight, obesity or diet-related chronic disease)
Consequences of Malnutrition
If you see any clients with:
•Whole foods/food groups cut out of diet
•Changed preference to only eating soft foods
•Unintentional weight loss
Refer them to the dietitian for nutrition assessment
Must work with Speech Pathologist for assessment of swallowing.
Texture modified diets and Thickened fluids
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