Hello, in This Audio Recording I Will Be Discussing CVA Interventions

Hello, in this audio recording I will be discussing CVA interventions.

A cva is commonly referred to as a stroke and can be ischemic or hemorrhagic.

An Ischemic CVA is when there is a blocked blood vessel whereas a hemorrhagic cva is a burst blood vessel or leak. TIA or transient ischemic attack is Mild, isolated or repetitive neurological symptoms that are similar to a CVA and develop suddenly lasting from a few mins to several hours but<24 hrs and clear completely Strokes vary depending on which area of the brain is affected. Right brain stroke affects the left side of the body is characterized by a deficit in visual-spatial skills, impulsivity, short attention span, poor body awareness (reach for object while falling seem unaware), unilateral neglect, emotional lability Left brain stroke affects the right side of the body and is characterized by deficits with language, logic, sequencing, overly cautious behavior so may need more positive reinforcement

When evaluating our client with a CVA, we will be assessing their ability to perform adl and functional mobility tasks, cognition (including orientation and attention span), upper extremity function (including ROM, strength, sensation, tone), postural control (including trunk control/balance sitting and standing), edema and pain, coordination, language (looking out for language disorders such as aphasia and apraxia), visual and perceptual impairments, behavioral impairments such as impulsivity, emotional lability defined as rapid changes in emotion such as going from laughing to crying. Secondary complications we may also address include subluxation of the affected shoulder joint, joint contractures, and edema.

Interventions:  Common seen deficit is loss of trunk and postural control  Impairment in trunk control may lead to o Dysfunction in limb control, increased risk for falls, impaired ability to interact with the environment, visual dysfunction secondary to resultant head and neck misalignment, symptoms of dysphagia due to malalignment, and decreased ADLs o We always want to establish a neutral yet active starting alignment. Patient should . Feet flat on floor and weight bearing . Equal weight bearing through ischial tuberosities (buttocks bones) . Neutral to slight ant pelvic tilt . Erect spine . Head over shoulders and shoulders over hips o External cues such as mirror, verbal/tactile, and environmental cues can be helpful in establishing the patient’s ability to maintain their trunk in midline. o We want to maintain trunk ROM through w/c and armchair positioning ensuring the trunk is in proper alignment . Exercise program focused on trunk ROM may include Hands on techniques as needed for mobilization o Prescribe dynamic weight shifting activities to allow practice of weight shifts through the pelvis . Have occupations to reach beyond span of limits of stability . Adjust posture o Strengthening the trunk is best achieved by using tasks that require the client to control the trunk against gravity . Bridge the hips in the supine position is a great way to strengthen the back extensors o We may use compensatory strategies and environmental adaptations when trunk control does not improve to a sufficient level and puts client at risk. . AE (reachers, long handles); w/c seating systems, lumbar rolls, lateral supports, cushion  Occupations in Standing Treatment strategies  Establish symmetrical BOS and proper alignment to prepare to engage in occupations o Used hands on support as needed o Feet approx hip width apart o Equal weight bearing through the feet o Neutral pelvis o Knees slightly bent o Aligned and symmetrical trunk  We want the client to have the ability to bear weight and shift weight through more affected LE  We want to encourage dynamic reaching activities in multiple environments to develop task specific weight shifting abilities  Use the environment to grade task difficulty and provide external support  Training upright control within the context of functional tasks are graded  Inability to use language  Aphasia is a language disorder that results from neurological impairment  Global aphasia is characterized by a loss of all language skills. They are unable to understand what is being said or written by others and are unable to express themselves to others  Broca’s aphasia: also known as expressive aphasia – inability to express themselves through speech  Wernicke’s aphasia or receptive aphasia is characterized by impaired auditory comprehension and feedback, with fluent, well articulated paraphasic speech,

 Inability for UE use o Could be due to pain, contracture, motor control loss, weakness, learned nonuse o We want Integration of it use o Eval should focus primarily on assessing the client’s ability to integrate UE into their performance of functional tasks- in other words, to use the affected UE to support performance o Interventions to improve UE function include: early mobilization and positioning ---- positioning their arm by their side supported by pillows when they are lying on their back, or when patient is lying on the affected side, supporting the involved extremity ensure patient is not lying directly on their shoulder joint but instead the scapular – to ensure this they must have the arm extended out to 90 degrees and place pillows between the knees with the involved leg extended. PROM, AAROM, Active ROM exercises and activities (if the client does not have scapular rotation or external rotation of humerus, make sure ROM exercises do not move the shoulderabove 90 degrees of flexion and abduction if there is a deficit with the scapular rotation), Weight bearing, incorporate task oriented training o Choosing activities appropriate for motor control level .Examples include stabilizing paper with involved extremity while writing with non-involved extremity, GM assist: throwing a ball, washing a table using both UE FM assist would be having the involved side assist with shoe tying or buttoning, when it is the dominant one being used practicing different grasps such as brushing teeth or screwing nuts and bolts, computer tasks, handwriting. o Using CIMT which is restraining the non-involved UE in order to force the patient to use their involved UE during their every day activities o PAMS electrical stimulation o Complications o Subluxation. Which is malalignment caused by instability of the GH joint due to the weakened muscles around the joint and is a common occurrence after stroke. Interentions include stability and strengthening exercises to shoulder/scapular area, positioning education, avoid overhead activities, pams used may include ultrasound, electric stimulation. o Tonicity o Low tone right after stroke o GH joint and wrist are susceptible to damage o Clients with low tone also have unstable wrist o Splinting o Common uses for splints during the low tone stage are maintaining joint alignment, protecting the tissues from shortening or overstretching, preventing injury to the extremity, and adjunctive tx for edema control. Resting hand splint may be helpful for client with flaccid to mild tone. Spasticity splint for moderate to high tone. o May be need support for palmer support for palmar arch and maintain neutral wrist deviation and neutral position of the wrist between flexion and extension. o Positioning is key in order to prevent contractures, reduce the effects of spasticity, and to protect the involved UE

1. In order to prevent edema, we want to have the client complete AROM, elevate the hand above heart level, retrograde massage distally to proximally, and compression garments. Arm trough may be used to position and support a flaccid UE and prevent edema through elevation.

Unilateral neglect can occur from a stroke. This is the client who may leave half of their food on the plate or continually bump into objects on the side affected by the stroke. Interventions would include approaching the client on the neglected side, having family members position themselves on the affected side, placing objects such as the TV , telephone on the affected side ( would not want to place call button or anything that they may need in an emergency for safety and cueing them to look to that side use that affected extremity using hand over hand guidance and verbal cues.

When instructing caregivers in how to assist clients with their functional mobility it’s important that they understand when assisting person with transfers they want to avoid pulling on the involved arm but instead use a transfer or gait belt to assist the person with standing and transfers. They should not hold onto the patient’s arm when assisting them with ambulation and once again hold onto the transfer belt with their body positioned on the patient’s involved side. If the client is unable to ambulate but is able to transfer, it is important to first transfer towards the client’s stronger side, blocking the involved knee to prevent buckling. You want to make sure you keep your base of support close to client, maintaining proper body mechanics and that the client is not pulling on your neck. Remedial vs compensatory Initially with CVA we want to focus on remedial approach vs compensatory – regaining their function and attempting to have our client return to their prior level of function, repetition of completing task. If we are working with a patient who had their cva several years ago, we will be focusing on compensatory approaches. An example of a remedial approach is having the client use their involved extremity while completing self care tasks. A compensatory approach would be using one handed techniques and adaptive equipment such as button hook in order to complete ADLs. Some strategies we may teach our client are ways to increase ease of adl tasks such as donning the involved extremity first so when patient is putting on a shirt, they would put the involved arm in first, same with pants and underwear. Adaptive equipment that may be used : Self feeding – rocker knife, built up or angled utensils, universal cuff, high sided dish, cup with a lid to decrease spillage, mobile arm support Dressing – button hook, elastic shoe laces, Velcro in place of buttons, front opening/closing bra Bathing and toileting – drop arm commode, grab bars, handheld shower, nonskid mat Mobility: hemi-walker, single point cane or quad cane, arm trough, hemi-wheelchair