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Implementing Task Repetition in a CVA Patient

Implementing Task Repetition in a CVA Patient. Ross M. Haley, PT, DPT Geriatric Resident October 4th, 2010. Initial Evaluation – 6/18/10. Subjective information Script: PT 3x/week for 6-8 weeks; patient with significant ataxia, persistent, s/p CVA 49 y/o old female CVA on March 5 th 2010

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Implementing Task Repetition in a CVA Patient

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  1. Implementing Task Repetition in a CVA Patient Ross M. Haley, PT, DPT Geriatric Resident October 4th, 2010

  2. Initial Evaluation – 6/18/10 • Subjective information • Script: PT 3x/week for 6-8 weeks; patient with significant ataxia, persistent, s/p CVA • 49 y/o old female • CVA on March 5th 2010 • Occupation: chief custodian at Red Clay school district; currently on disability • Patient was previously going to a local PT facility but was discharged 2 weeks ago 2o lack of improvement

  3. What else do you want to know?

  4. Additional Subjective Reports • Chief Complaint – significant weakness in right upper and lower extremity • Secondary complaints: intermittent complaints of vertigo with spinning that lasts 2-3 minutes; difficulty with balance with ~2-3 LOB/week, no falls • Specific functional limitations: inability to drive and work; inability to use right arm to cook dinner and lift 5 pounds, decreased standing tolerance and walking distance • Assistive device: SPC at all times when walking • Home Situation: 1 floor home with 6 STE (hand rail available); lives with 16 y/o daughter, who is currently doing all house cleaning and shopping • Past MHx: brain tumor removal March 2007, HTN, high cholesterol, thyroid imbalance, depression • Medications: Plavix, Topamax, Cymbalta, Atenolol, levothyroxine, Lipitor, Ambien, Neurontin, Claritin, Naprosyn • Goals: increase standing time, return to work as custodian, increase strength in right UE to return to using right arm to cook dinner • Patient received 17 visits from other PT facility

  5. Question 1-What class of drug is Atenolol? • Beta Blocker • Diuretic • Ace Inhibitor • Antiplatelet

  6. Objective Information • What do you want to look at?

  7. Initial Evaluation • Objective information • Clonus: 2 beats at right wrist and 2 beats at right ankle • Muscle Tone: slightly increased in right UE • Motor Control • LE: able to isolate knee flexion with hip extended; unable to fully extend right knee actively • UE: unable to isolate wrist flexion with elbow extension; limited active wrist extension and flexion • Standing Tolerance: ~ 1 minute • Transfers: sitstand with supervision and minimal use of UE • Gait: full step length B, foot flat on right at heel strike, right UE stays flexed and doesn’t swing, right pelvis slightly retracted and less mobile during gait, ambulates with SPC in L hand, occasional crossovers with right LE, but able to self correct balance • Gait Speed: .75m/s self-selected; 1 m/s fast speed

  8. Question 2-Clonus is mostly associated with? • Upper Motor Neuron lesion • Lower Motor Neuron lesion • Muscle tightness • Adverse drug reaction

  9. Initial Evaluation • Additional Objective Information • Stairs: ascending 1 step at a time, slow, using 1 hand rail, supervision; descendingsideways with right leading, 1 step at a time, supervision • 9 hole peg test: Left24.59 secs Right53.47 seconds, difficulty with pinch grip and accuracy with placement • TUG: 16.2 secs avg without cane • 6MWT: 363 ft with cane, supervision, needing 3 standing rest breaks

  10. Question 3-What is the fall risk cut-off time for the Time Up and Go Test? • 10.5 seconds • 12.5 seconds • 13.5 seconds • 15.5 seconds

  11. PT Diagnosis/Assessment • What is your PT diagnosis/assessment? • Assessment: Patient presents with ataxia s/p L CVA that is currently impairing her ADL’s and IADL’s. Pt demonstrates decreased self-selected gait speed and significantly decreased 6MW distance which is affecting her ability to ambulate in the community; in addition, her current TUG time puts her in the fall risk category. Her subjective reports and results of 9 hole peg test suggest that she has decreased functional use of the right UE. She will benefit from skilled physical therapy to improve her balance, gait and endurance, and functional use of her right UE.

  12. The Kicker • Since the patient already had 17 visits at another facility, billing staff marks only 7 visits left on the chart!! • Her impairments • UE control • Balance • Gait and endurance • Standing tolerance • What should we work on in 7 visits?? What will be very important for this patient, given this predicament?

  13. Current Research on Neuroplasticity • Lang et al (2009) • The amount of task-specific practice that occurs during typical neuro-rehabilitation is far below that which animal models suggest would be needed to promote neuroplasticity • To see neuroplastic changes in animal models, it requires the animals to perform hundreds of repetitions of movement practice daily • Upper Extremity: 400-600 repetitions • Gait: not studied as much • In spinal cord injured animals, 1000-2000 steps during daily, 30 min treadmill sessions to improve hindlimb stepping • Average repetition in PT (PT session duration: avg. 36 mins, excluding rest breaks) • Functional UE control: 32 • Gait: 357 steps

  14. Research Continued • Moore et al (2009) • Preliminary estimates suggest an average of ~4000 steps performed during 1 hour sessions required for clinical and physiological changes • Birkenmeier et al (2010) • Determined it was feasible to perform high repetition intervention (> 300 reps) for upper extremity control in 1 hour sessions. • There were no adverse events, patient attendance was high (97%) and scores on the Action Research Arm Test improved by an average of 8 points after 18 sessions

  15. Question 4-What is the cut-off score for safe independent ambulation using Berg Scale? • 19 • 45 • 40 • 35

  16. Treatment Day #1 • Subjective: “I’m working on getting a case manager to get more visits.” • Objective • Berg Balance Scale: 34/56 • Treatment • Endurance • UBE x 6 minutes • UE Control • Sorting Silverware Exercise (appendix of Birkenmeier article) • Patient was seated at the counter with utensils placed on affected side and sorter placed on unaffected side. Patient was instructed to pick up one utensil at a time and place in correct slot • 1 repetition = reach, grasp, and release of 1 utensil into sorter • Patient was able to perform 150 repetitions, with complaints of fatigue at 60th repetition; increased shoulder shrug, excessive trunk lean to achieve task

  17. Treatment Day #1 • Patient Education • Education that she will need to practice sorting silverware at home with goal of 300 repetitions/day. Patient was given a log to keep track of her daily repetitions. • Encouraged patient to use her right UE more with cooking/kitchen duties

  18. Treatment Day #2-5 • Subjective Reports • Day 2: Still trying to reach case manager. Compliant with HEP, but did not count repetitions. Patient also started crochetting daily. Patient does not have access to or financial capabilities to join a gym • Education on counting repetitions • Day 3: “I started using a spice rack to place spices in and out of the cabinet when I’m standing at the kitchen counter.” Pt is able to perform 150 repetitions before fatiguing. She is performing 300 repetitions of silverware exercise. • Progression of silverware • Day 5: Patient excited about progress and reported performing 10 mins of standing activities including 300 repetitions of moving spices in/out of cabinet. She thinks the cane is getting in her way of walking.

  19. Treatment Day #2-5 • Treatment • Endurance • UBE x 8-10 minutes • Treadmill with harness system • Day 2: fatigued at 10 mins Day 4: fatigued at 15 mins • Recumbant bike • Day 3: fatigued at 11 minutes Day 5: fatigued at 15 minutes • Standing Tolerance with UE control: Lifting cones to/from counter to first cabinet shelf • Progressed to 1# dumbbell by treatment day 5 • By day 3, she was able to stand for 11 minutes without needing to sit down

  20. Treatment Day #2-5 Treatment Continued: • Balance activities: picked 2 exercises a day such as narrow stance, tandem stance and performed 1-2 sets of 10 repetitions of each • Sitstands without UE support • Practiced floor transfers – why? • Supervision • Overground walking with and without cane • Weight-bearing on cane

  21. Treatment Day #2-5 • Additional Education • Discharged cane at home by treatment 4, but still use for community ambulation • Decrease the amount of weight bearing through cane. • Gave her pedometer to borrow to assess number of steps/day. • Adult population should be taking 10,000 steps/day • Pedometer will assist with walking program at home.

  22. Re-Evaluation/Treatment Day #6 • Patient completed ¾ short term goals and ¼ long term goals • Treatment: • Dynamic Balance Activities • Backwards, lateral, and diagonal stepping around cones without cane • Obstacle course with patient holding hockey stick and simulating sweeping motion of broom • Why do this? • This is the 7th visit, but there is good news… • Her insurance approved an additional 10 visits!

  23. What major patient goal have we not addressed yet? • Return to work! • New Goals Created • STG • Pt will discontinue use of cane when walking community distances in 2-3 visits • Pt will take a 30lb trash bag from can to dumpster 50 ft away independently in 3-4 visits • Pt will walk with a dust mop >1000ft independently with no LOB in 3-4 visits

  24. What is the cut-off score for fall risk in older adults for the DGI? • 15 • 17 • 19 • 21

  25. Treatment Day #7-9 • Focused on return to work activities • Education on proper lifting mechanics • Carrying boxes and trash bags • 20-31.5 lbs carrying up to 300 ft with supervision only • Simulating walking with dust mop – forwards, backwards, side-stepping • Total distance of 700 ft with supervision only • Carrying crates through obstacle course to simulate unlevel ground • Assessed DGI to determine ability to discharge cane • 22/24 • Discharged cane completely

  26. Treatment Day #7-9 • Additional Treatment • Bike for endurance: 26 minutes total • Patient was cleared by neurologist to drive • Performed driving step test to determine appropriate reaction time • Completed 24 steps in 10 seconds • Patient bought her own pedometer and is keeping track of her daily stepping

  27. Treatment Day #9 Continued • Plan: Follow-up in 1 month to assess ability to maintain and/or improve functional gains before return to work

  28. Follow-up • Patient was too busy to follow-up for one last visit • She has been working 10-12 hour days at work without limitations, even training two people. • Reports no falls • Currently averaging ~21,000 steps per day • Still completing HEP whenever she can

  29. Ending Thoughts • Empower your patients! • This patient already had the motivation to get better; all she needed was direction • A home exercise program (and COMPLIANCE!) is a very important part of your treatment and is one of the main contributors why she was so successful • Especially when limited on visits and multiple impairments to address • Repetition, intensity and task-specificity are critical features of motor practice for promoting neuroplasticity and motor learning (Nudo et al. 1996a; Nudo et al. 1996b; Shepherd 2001; Kleim and Jones 2008)

  30. Questions?

  31. References • Birkenmeier RL, Prager EM, Lang CE (2010) Translating Animal Doses of Task-Specific Training to People With Chronic Stroke in 1-Hour Therapy Sessions: A Proof-of-Concept Study. Neurorehabil Neural Repair • Kleim JA, Jones TA (2008) Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res 51: S225-239 • Lang CE, Macdonald JR, Reisman DS, Boyd L, Jacobson Kimberley T, Schindler-Ivens SM, Hornby TG, Ross SA, Scheets PL (2009) Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil 90: 1692-1698 • Moore JL, Roth EJ, Killian C, Hornby TG (2009) Locomotor Training Improves Daily Stepping Activity and Gait Efficiency in Individuals Poststroke Who Have Reached a "Plateau" in Recovery. Stroke • Nudo RJ, Milliken GW, Jenkins WM, Merzenich MM (1996a) Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. J Neurosci 16: 785-807 • Nudo RJ, Wise BM, SiFuentes F, Milliken GW (1996b) Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science 272: 1791-1794 • Shepherd RB (2001) Exercise and training to optimize functional motor performance in stroke: driving neural reorganization? Neural Plast 8: 121-129

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