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Stroke Interventions Across Settings

Terms in this set (91)

CVA settings
1. Acute

2. sub-acute

3. post-acute
acute rehab
ICU

Monitored Bed ("Step-down Unit")

Unmonitored Bed (May be specialized unit)
sub-acute rehab
Inpatient Rehab Hospital

Transitional Care Unit

Skilled Nursing Facility
post-actue rehab
-home health

-outpt
Setting Considerations s/p CVA
pp 3
CVA: Acute Setting Treatment Standards: begins
Typically within 24-72 hours, often starts at bedside

Strong push to have early PT/other therapy
CVA: Acute Setting Treatment Standards: primary focus
Prevent/minimize harmful effects of deconditioning through early mob, increase LOC

Promote neuroplasticity through early stimulation of hemiparetic side

Minimize learned non-use of hemi side
CVA: Acute Setting Environment: personnel
MD/PAs

-RN

-PT, OT,

-SLP, RT,

-Nutrition,

-Case Manager
CVA: Acute Setting Environment: equipment
pp 5-9
CVA in Acute Setting: PT Interventions
Cardiopulmonary retraining

Positioning

PROM/AAROM/ AROM

Early fxn mobility (bed mobility & transfers, gait if possible)

Education (pt and caregivers)- very important!
Acute Setting Interventions: Cardiopulmonary-WHY
Significant cardiac & pulmonary co-morbidities

Diaphragmatic weakness

Generalized deconditioning

Decreased endurance/fatigue
Acute Setting Interventions: Cardiopulmonary- How
Diaphragmatic strengthening

Deep breathing

Incentive spirometry

Stretching
Acute Setting Interventions: Positioning- Why
Promote symmetry

Midline orientation

Promote protraction of scapula & pelvis

Decrease neglect and spasticity
Acute Setting Interventions: Positioning-How
Sitting
Supine
Sidelying
supine position
towel rolls/pillows w protract scapula & pelvis:

Invol UE: ER, Ext, Sup

Invol LE: hip/knee flex & DF or rest in ext
Side-lying on INVOLVED side:
Involved LE:
-Pelvis protracted
-Hip ext
- Knee flex

Involved UE:
-Shoulder protracted
-Elbow ext
-Forearm supinated
Side-lying on UNINVOLVED side:
Involved UE:
-Shoulder protracted
-Elbow extended
-Forearm neutral
-Wrist neutral

Involved LE:
-Pelvis protracted
-Hip/knee flexed
-DF

Trunk:
-Straight
Acute Setting: ROM Activities- most benefit
-scap mob

-low trunk rot

-hip/knee flex (AVOID PF response)

-DF

-Toe ext (AB toes and go into DF--> break up tone)
Acute Interventions: Mobility
pp 17
Acute Interventions: Neurofacilitation
-PNF

-NDT

-facilitation/inhibition

-air splint
acute setting pt need more mvt research
pp 21
prog: infaracts < 1cm
better
prog: younger age
better

(age affects later stages of fxn recovery)
prog: BP
High (>130 mmHg) & low (<90 mmHg) initial mean arterial pressure 10 days after stroke

--->associated w worse ST outcome
prog: functional independence
fxn independence declines annually for up to 5 years after stroke

--> w greatest fxn decline beginning to occur 3y after stroke

*decline independent of age or severity BUT greatest w medicaid or no health insurance*
prog: hemorrhagic
greater initial degrees of DISABILITY

-->hemorrhagic typically results in greater recovery of function vs. ischemic regardless of severity of disability on admission to rehab (when all other factors are equal)
prog: greatest recovery in
1st month:

natural process allow intact neurons to regain fxn:

--Reduction of edema
--Absorption of damaged tissue
--Improved local circulation/ cellular metabolism
prog: level of disability
3 months post stroke is strongest prognostic indicator of survival
acute care: avg days spent
5 days
acute care: implication of earlier dc
22-48% increase in serious medical complications in inpatient rehab or at home
----Cardiac arrhythmias, DVT, uncontrolled BP, 2nd CVA

cause transfer back to acute setting & delays in rehab process
timing for transfer to IP rehab
pp 28
acute setting dc plan
pp 29
IPR: enviroment- personnel
-Physiatrists

-RN

-PT, OT

-SLP

-Psych

-RT

-Nutritionist

-Case Manager/Social Services
IPR: time
3 hr a day expected
Inpatient Rehabilitation Goals
continue w acute BUT ADD:

Gait train (HIGT can start)

Posture/Midline Orientation/wt acceptance

Mobility of pelvis & scapulae

Balance

Endurance training

Equipment needs
Inpatient Rehabilitation Interventions: posture
sit/stand:

Symmetry

Trunk strength & mobility

Body awareness &
image

Decrease neglect
Inpatient Rehabilitation Interventions: pelvic mobility
-ant/post pelvic tilts

-PNF diagonals
Inpatient Rehabilitation Interventions: shoulder girdle mobility
-scap mob

-PNF diagonals
Inpatient Rehabilitation Interventions: balance
wt. shifting

Reaching

Protective reactions (sit) & balance reactions (stand)
Inpatient Rehabilitation Interventions: gait training
HIGT
Body Weight Support Treadmill Training/ Overground Training
pp 36
Inpatient Rehabilitation Interventions:
pp 37
IR: dc plan
avg LOS:

-mild=1w

-mod=2w

-sever=3w
Inpatient Rehabilitation Predictors of Function and LOS:
predicted by:

-BBS

-# of additional impairments

-aphasia

-family support
Inpatient Rehabilitation Predictors of Function and LOS: admission BBS
Higher admission BBS = HIGHER D/C FIM score

LOS DECREASED by 7.5 days for every 10 point increase in admission BBS score
Inpatient Rehabilitation Predictors of Function and LOS: impairment
LOS INCREASED by 1 day for each add. impairment
Inpatient Rehabilitation Predictors of Function and LOS: aphasia
LOS INCREASED by 1w if Receptive of Mixed aphasia
IR: dc plan, predictors for dc were
-good balance

-caregiver support

-absence of body neglect/cog issue
IR: dc plan, predictors for dc statistics
BBS= home
-every 10 pt increase, 10x more likely go home

Family support= 3x go home

+cog= go elsewhere

+body neglect= go elsewhere
Home Health- personnel
-PT, OT,

-SLP as needed

-RN/home health aide
Home Health-equipment
everyday items
HH: goals
-functional independence

Community reintegration

Recommend home modifications
Home Health Interventions
fxn mobility in home setting is primary concern (transfers on furniture)

TE

Endurance building

Address personal goals

SAFETY!
HH: gait train
-all level/surfaces

-w/wout shoes

-stairs (w/wout hand rails & shoes)
HH: aerobic endurance
Walking

Stationary bike

Standing activity/ADL
Home Health Referrals
Psychologist

Outpatient PT

Wellness options

Community Resources

Spasticity management
----physiatrist/ Neurologist
HH: dc plan
-acheive goals

-improve navigate community, no longer home bound

-refer outpt.

-utilize independence waivers/resources
CVA: Outpatient Rehabilitation- personnel
PT, OT, SLP, psychologist

PTA, COTA
CVA: outpt timeline
reffered during chronic phase

---can be 6m s/p CVA depend on severity
outpt goals
-HIGT

-exercise ideal
outpt: tx time
intensity varies:

-usually < inpt -60-90 minutes/visit 2-3 times per week
outpt: POC
fxn independence/ endurance

Quality of mvt

Community reintegration
outpt rehab interventions: mobility
-High intenity

-community mobility challenges addressed

-stretching & spasticity management
outpt rehab interventions: functional
-quality of transfers

-WC mob

-quality ambulation (energy efficieny, reduce fall risk, new strategies)
outpt rehab interventions: endurance
Stationary Bike:
Mobility
Dissociation
Motor planning

Wheelchair Training:

Treadmill Ambulation
w or w/out body-wt. support
outpt rehab interventions: community reintegration
Grocery shopping

Walking at park

Gym

Support groups

Return to work
Outpatient Rehabilitation Discharge Planning
Goal achievement

Plateau in progress

Resource depletion

Patient choice
Chronic CVA Survivors: Functional Potential
pp 57-58
Interventions for Sensory Function:
-sensory retrain

-sensory stimulation

-counteract learned nonuse
Interventions for Sensory Function: retraining
-Mirror therapy,

-bilateral activities,

-repetitive tasks
Interventions for Sensory Function: stimulation
Compression techniques:

----wt. bearing or pressure splints

-mobs

- e-stim
Interventions for Hemianopsia or Neglect: first step
education
Interventions for Hemianopsia or Neglect: room
-put items on involved side (NOT THE CALL BELL)

-involve family
Interventions for Hemianopsia or Neglect: visual reminders
-red ribbon on involved limb

-bilateral activities,

-midline crossing activities

-feedback

-imagery (lighthouse beam)
Interventions for Hemianopsia or Neglect: teach
compensate w head turn for hemianopsia
To Improve Joint Flexibility and Integrity
-PROM/AROM w terminal stretch

-positioning

-safe self ROM techniques

-splint/tone reduce devices
To Improve Joint Flexibility and Integrity: self ROM
-Arm Cradling

-Table Top Polishing

-seated lean
To Improve Strength: after stroke
PREs shown improve mm strength
To Improve Strength: combining
-resistance training w task oriented fxn activities enhances carryover in terms of improving function

*must watch BP with high intensity or iso ex*
To Manage Spasticity: early
-mob

-daily stretch

*rhythmic rot can be effective*
To Manage Spasticity:
Sustained stretch in length position, comb w wt bearing as able:
---Orthotics & air splints maintain mm in lengthened position

Active ex should focus on antagonist using slow, controlled movements
To Manage Spasticity: may be helpful
modalities
To Improve Movement Control: focus on
dissociation of diff body segments & selective (out of synergy) mvt patterns

--work on volitional control
To Improve Movement Control: imporant
task specific act.
To Improve Movement Control: other techniques
Constraint Induced mvt Therapy (CIMT) is effective for some patients

Therapist may need to guide mvt or use facilitation techniques, esp PNF
To Improve Postural Control/Balance
pp 67
To Improve Functional Mobility
pp 68
To Improve Gait and Locomotion
pp 69
To Improve Aerobic Capacity and Endurance: acute
fxn activity training is enough
To Improve Aerobic Capacity and Endurance: post acute
more challenge:

-stationary bike or treadmill
To Improve Aerobic Capacity and Endurance: intensity
40-70% Max VO2

*remember it is higher in locomotor CPG*
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