Physiotherapy Stroke Team

PHYSIOTHERAPY STROKE EDUCATION WORKBOOK

Name: PHYSIO STROKE EDUCATION WORKBOOK

ACKNOWLEDGMENTS

This workbook was designed by a team of St George’s Hospital physiotherapists to help both students and rotational staff develop skills and knowledge in the management of stroke patients.

Contributors

Aimee Pinto

Rachael Speirs Sarah Hilton Jo Barker Isabel Cary Hilary Myall Ruth Carr Sara Gawned Claire Salisbury Chris Davis Hannah Bevan Dawn Foster Kris Mikstacki Kerry Carter Jaide Pascal Ella Wright

Reproduction / modification is authorised only when the source is acknowledged. Permission to reproduce / modify must be obtained prior to use from the SLCSN via [email protected].

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CONTENTS

Basic neuroanatomy……………………………………………………………………………………………………………………...... 5 Stroke background...... 8 Medical management of stroke…………………………………………………………………………………………………………….10 Investigations………………………………………………………………………………………………………………………………….12 The multidisciplinary team………………………………………………………………………………………………………………… 18 Guidelines and national initiatives………………………………………………………………………………………………………..19 Organisation of stroke care in South London…………………………………………………………………………………………. 20 Neurological assessment…………………………………………………………………………………………………………………...21 Respiratory and cardiovascular assessment……………………………………………………………………………………………26 Generating a problem list………………………………….………………………………………………………………………………..27 Outcome measures…………………………………………………………………………………………………………………………..31 Handling a stroke patient……………………………………………………………………………………………………………………32 Equipment……………………………………………………………………………………………………………………………………..34 Early mobilisation of the stroke patient…………………………………………………………………………………………………..37 Treatment and management of the upper limb………………………………………………………………………………………….38 Gait………………………………………………………………………………………………………………………………………………40 Tone – assessment and management……………………………………………………………………..……………………………..42 Walking aids…………………………………………………………………………………………………………………………………...45 Orthotics………………………………………………………………………………………………………………………………………..46 Treadmill training……………………………………………………………………………………………………………………………. 48 Electrical stimulation………………………………………………………………………………………………………………………...49 Ataxia……………………………………………………………………………………………………………………………………………51 Glossary………………………………………………………………………………………………………………………………………..55 Resources……………………………………………………………………………………………………………………………………...61

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INSTRUCTIONS

As you work through the book, there will be different activities to complete relating to different aspects of stroke care.

The book is designed to allow you to work at your own pace but you may set some targets for completion with your clinical educator or senior.

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GUIDANCE FOR COMPLETION

Students: In your initial objective setting session with your clinical educator, it may be useful to plan which sections of the workbook you want to look at different stages of your placement. This will differ according to the length of your placement and your previous experience or knowledge.

Week 1:

Week 2:

Week 3:

Week 4:

Week 5:

Week 6:

Rotational staff:

You may want to work through at your own pace or set yourself targets for your rotation.

Month 1:

Month 2:

Month 3:

Month 4:

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BASIC NEUROANATOMY

What does this diagram show?

Can you label it?

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What are the basic functions of each part of the brain?

Frontal lobe: Label the parts of the brain:

Parietal lobe:

Temporal lobe:

Occipital lobe:

Brainstem:

Cerebellum:

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What do these diagrams represent? On this diagrammatic representation of the brain, shade in the distribution of the ACA, MCA and posterior circulation:

What is the difference between the two and can you name each one?

Cerebrum

Cerebellum

If a patient had an ACA7 infarct, would they be likely to have greater deficits in the upper limb or lower limb and why?

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STROKE BACKGROUND What are the definitions of the terms below? 1. Stroke:

2. TIA (Transient Ischaemic Attack):

3. Cerebral infarct:

4. Cerebral haemorrhage:

What percentage of strokes are ischaemic?

What proportion of all strokes are fatal?

What proportion of TIAs will go on to have a stroke within five years?

Does a cerebral embolus or a cerebral thrombus have a better outcome and why?

What type of stroke is more fatal, ischaemic or haemorrhagic?

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What are the main risk factors for the causes of stroke and why are they a risk factor?

1. …………………………………………………………………………………………………………………………………………………...

2. ……………………………………………………………………………………………………………………………………………………

3. ……………………………………………………………………………………………………………………………………………………

4. ……………………………………………………………………………………………………………………………………………………

5. ……………………………………………………………………………………………………………………………………………………

6. ……………………………………………………………………………………………………………………………………………………

7. ……………………………………………………………………………………………………………………………………………………

8. ……………………………………………………………………………………………………………………………………………………

9. …………………………………………………………………………………………………………………………………………………… Can you work out what type of stroke these patients may have had?

Example 1: Example 2: Example 3 • Right sided weakness affecting the • A 65 year old right handed • Altered vision leg more than the arm gentleman • Reduced balance • Right sided paraesthesia • Right sided weakness and • Reduced coordination of the right • Urinary and faecally incontinent parasthesia affecting the arm more and left lower limbs • Inappropriate social behaviour than the leg • Hemianopia • Dysphasia

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MEDICAL MANAGEMENT OF STROKE

A selection of medications are commonly used in early post stroke management including the following : – Antiplatelet therapy – Anticoagulants – Antihypertensives – Statins

What is the main purpose in the use of these medications post stroke?

What do antiplatelets do?

Can you name 3 commonly used antiplatelet medications?

How do anticoagulants work?

Can you name 3 commonly used anticoagulants?

What is the difference between anticoagulants and thrombolysis?

What is thrombolysis?

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What type of stroke is thrombolysis used in?

How does thrombolysis work?

In what time frame can thrombolysis be used?

When will thrombolysis not be used in a acute stroke?

What is the main benefit of thrombolysis?

What are the implications to the therapists following thrombolysis?

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INVESTIGATIONS

Different types of scans will be used following CVA including CT and MRI which are covered in the next section of the workbook. A diffusion weighted MRI can also be used if an infarct cannot be identified on CT or MRI. A new infarct will show up like a light bulb on the scan in the early stages (see picture).

Why would an MRA/CTA (Angiography) and carotid doppler be carried out?

What is a carotid endarterectomy?

Can you name two cardiac investigations that may be completed and why?

A chest X-ray is also carried out. There are two reasons for this, can you think of them?

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CT AND MRI SCANS

A (CT) scan, uses to take pictures of the head from many different angles. The pictures provide a detailed, view of specific areas of the brain. MRI) uses and magnets to produce detailed pictures of the brain’s structure. CT scans are usually performed before an MRI scan. Can you think of three reasons for this?

3) Below is an image of a CT scan and an MRI scan. Can you look at the differences between the two images and work out what colour bone, fluid and soft tissue would appear as on each image? CT scan: MRI scan:

Bone – Bone –

Fluid – Fluid –

Soft tissue – Soft tissue – 13

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Haemoglobin contains iron. Iron is a mineral which is MRI measures the way hydrogen atoms absorb and give off dense like bone, therefore a bleed (haemorrhage) will electromagnetic energy. Bodies are 60% hydrogen atoms. Water show up as white on a CT scan. An ischaemic infarct and fat contains lots of hydrogen atoms. Tissues that have the will lead to a lack of oxygen supplying the brain tissue least hydrogen atoms appear darkest on MRI. Therefore bone will and will cause the tissue around the lesion to become appear dark and fat will appear white. Blood contains some necrotic. This will therefore show up darker on a CT hydrogen atoms so it will therefore appear as a grey like colour. scan. However MRIs can be a bit more complicated as the colour of the structures can vary depending on whether how the scan is On the 2 images below draw a circle around the area weighted. of the lesion and label it an infarct or a haemorrhage. Can you identify the infarct on this MRI?

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These are 10 images of CT scans at different cross sections. On each CT scan there is an area highlighted. Can you identify the structure that is highlighted and label each image with the correct letter to match the structure?

a. Spinal cord f. Posterior limb of internal capsule b. Sylvian fissure g. Corona radiata c. Cerebellar hemisphere h. Anterior horn of lateral ventricle d. Body of caudate nucleus i. Sulci 15 e. Midbrain j. Thalamus PHYSIO STROKE EDUCATION WORKBOOK

You should now be a little more confident with how the different types of strokes show up on a CT scan and where the different structures within the brain are located.

Identify whether the following CT scans show an image of an infarct or a haemorrhage and describe the area in which the lesion is located and the circulation involved i.e. ACA, MCA or posterior circulation.

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This is a CT scan of a patient who has had a stroke.

Answer the following true or false questions: a) The area affected is in the patient’s left cortical hemisphere. b) The patient has a had a brain haemorrhage. c) The artery involved is the anterior cerebral artery. d) The patient is most likely to have greater neurological deficits in the right upper limb as opposed to the right lower limb but both may be affected. e) The area of damage is in the frontal region.

f) The patient is likely to have some degree of sensory impairment. g) The patient may have problems with communication - Broca’s and Wernicke’s areas are usually located on the left side of the brain.

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THE MULTIDISCIPLINARY TEAM Fill in the members of the MDT:

The MDT

During your time on the Acute Stroke Unit arrange a joint session with two other member of the MDT and reflect on your experience. Date: MDT member: Date: MDT member: Main learning points: Main learning points:

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GUIDELINES AND NATIONAL INITIATIVES

What is the FAST campaign?

Which guideline was developed for stroke care in London based on the National Stroke Strategy?

From this strategy, complete the following sentences: • All Londoners should be no more than from a specialist stroke unit. • On arrival at a HASU, a stroke patient should have a CT scan and access to thrombolysis (if appropriate) within . • 100% of patients admitted to a stroke unit should receive a physiotherapy assessment within of admission. • of patients should have face to face sessions of PT, OT and SLT per week as necessary. • of patients should have appropriate seating, posture and positioning within of admission to the unit.

What is the National Sentinel Stroke Audit?

The Workforce Planning Document (Department of Health, 2008) provides a consensus statement on physiotherapy intervention after stroke. It recommends of physiotherapy plus of physiotherapy assistant treatment per day in the acute stage of stroke and of physiotherapy plus of physiotherapy assistant treatment per day in the sub-acute stage of stroke.

What does the Physiotherapy Concise Guide for Stroke (2008) say about: • When a stroke patient should be mobilised?

• Aerobic training after stroke?

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ORGANISATION OF STROKE CARE WITHIN SOUTH LONDON

What is a HASU and which government guideline outlined the need for them?

How many HASUs are there in London and where are they located?

What is a clinical network?

When were the South London Cardiac and Stroke Networks formed?

Which PCTs does the network include?

Which hospitals house the HASUs in the South London Cardiac and Stroke Network? (This includes South East and South West.)

Where are the other stroke units in this network?

If you want to know a patient’s local stroke unit, you can look it up on the London stroke unit lookup ( www.londonsulookup.nhs.uk). Find out which stroke unit the following patients would come under: SW12 0PG – CR0 6SY – SW17 0AD – SE16 6HP – SM4 6RB – SE11 4TJ – BR5 2NJ – 20 PHYSIO STROKE EDUCATION WORKBOOK

NEUROLOGICAL ASSESSMENT

A good assessment will give you a baseline from which to work, allow accurate identification of the patient’s problems and what is causing them, allow effective establishment of patient-centred goals and allow you to develop a comprehensive treatment plan. What might you want to find out in the subjective and objective assessments?

SUBJECTIVE OBJECTIVE

What is the difference between upper motor neurones (UMN) and lower motor neurones (LMN)?

What are the positive and negative features of the UMN syndrome? POSITIVE NEGATIVE

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Neurological observations: What are the three sections of the Glasgow Coma Scale (GCS)?

What score on the GCS is classed as a coma?

What other neurological observation will be recorded on the obs chart and why?

Initial physical observations: What can you gain from looking at the patient from the end of the bed?

Range of movement and tone: How would you assess tone?

What is the difference between hypertonia and spasticity?

What is an associated reaction?

When do you need to be particularly careful to assess and monitor range of movement?

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Voluntary Movement: What are you looking for when watching a patient move?

Muscle strength: How do we assess muscle strength in stroke patients?

Sensation: How do we assess sensation in stroke patients?

Proprioception: How do we assess proprioception in stroke patients?

Coordination: How do we assess coordination in stroke patients?

You also may want to go and investigate how to assess balance, inattention/neglect and orientation/cognition.

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What kind of cognitive or communication problems might mean we have to adapt our assessment strategy?

PROBLEMS THAT MAY AFFECT ASSESSMENT

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In general, for patients with cognitive and/or communication difficulties, the assessment will have to be more basic and may need to be more functional (i.e. movement analysis and observation of impairments through a functional task). The level of adaptation will depend on the level of impairment.

Some ideas for adaptation of assessment:

Communication difficulties:

1. Keep sentences s _ _ _ _ and s _ _ _ _ _.

2. Use g ______and d _ m ______when asking a patient to do something.

3. You may need to try w _ _t _ _ _ or d ______words or actions.

4. If a patient cannot say “yes” and “no” you could use t _ _ _ _ _ u _ / t _ _ _ _ _ d _ _ _ , n _ _ / s _ _ k _ , w _ _ _ _ _ g , b _ _ _k _ _ _ or p ______t _ _ _ e w _ _ _ _.

Cognitive difficulties:

1. Explain w _ _ _ y _ _ a _ _ g _ _ _ _ t _ d _ and w _ _ to help with i ______and a _ _ _ _ _ y.

2. Remind the patient w _ _ _ _ t _ _ _ a _ _ and w _ _ t _ _ _ a _ _ t _ _ _ _ to improve _ r ______.

3. Keep commands _ _ _ _ _ e – only o _ _ s _ _ _ _ at a time.

4. Keep sessions s _ _ _ _ and have r ______b _ _ _k _ if the patient is having difficulty ______g.

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RESPIRATORY AND CARDIOVASCULAR ASSESSMENT What would you include in a respiratory assessment?

What would you include in a cardiovascular assessment?

What is the ischaemic penumbra? Suggested reading: Turton, A. and Pomeroy, V. (2002) When should upper limb function be trained after stroke? Evidence for and against early intervention. NeuroRehabilitation 17 pp215-224

Why is it important that a stroke patient is given supplementary oxygen post stroke? Suggested link http://www.so2s.co.uk/protocol.shtml

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GENERATING A PROBLEM LIST When producing a problem list for a patient once you have completed their assessment, try to think logically about the order in which you write things down in order to ensure that you don’t miss anything. Be as descriptive as possible as another therapist should be able to get an accurate picture of the patient from your problem list. What sort of things might you put under the following headings? Impairments: 1. Voluntary activity – Do they have any? Is it recruited normally but just weak or can they only recruit in certain patterns of activity? Try to be specific about muscle groups. 2. Muscle tone – Do they present with any changes in tone? If so, where? Is it high, low or a mixture of both? Do the have any associated reactions with effort, yawning, coughing etc? (You can group 1 and 2 together to describe a limb eg: Predominantly low tone throughout right upper limb with evidence of flickers of activity around shoulder with weight bearing tasks but no voluntary movement throughout rest of UL). 3. Range of movement - Are there any limitations to movement? Are you able to identify why? Is it due to changes in muscle or joint? Could it be due to a premorbid problem or is it new? 4. Sensation - Are there any sensory changes and to which modalities? i.e. light touch, pain, temp, proprioception. 5. Pain - Is the patient reporting pain or producing a pain behaviour in response to any kind of stimulus? 6. Coordination - Are there any difficulties with coordination? Are there any signs of ataxia – dysmetria, tremor, dysdiadochokinesia 7. Perception / spatial awareness - What is the patients perception of midline like? Do they have any signs of hemianopia, inattention or neglect? 8. Cognition - Are there any problems with orientation, memory, concentration, insight or motivation? 9. Motor planning - Are there any difficulties in putting movements together to form a complete task i.e. doing things in the wrong order or missing out components (ideomotor apraxia)? Do the use objects inappropriately i.e. combing hair with toothbrush (ideational apraxia)?27 PHYSIO STROKE EDUCATION WORKBOOK

Activities: 1. Bed mobility - How much assistance does the patient need with rolling, lying to sitting, moving up and down the bed (independent with ……strategy, prompting, asst x 1, asst x 2)?

2. Sitting balance - How much assistance does the patient need to maintain balance? Are they able to be dynamic in sitting (i.e. reach, put on shoes, etc.)?

3. Sit to stand - How much assistance does the patient need with sit to stand (independent with strategy, prompting, asst x 1, asst x 2, an aid)?

4. Transfers - What method and assistance does the patient require with transfers? Does this differ between in therapy and with the nurses? Does this differ with the type of transfer i.e. bed to chair versus chair to toilet?

5. Walking - What method and assistance does the patient require with walking? Does this differ between in therapy and with the nurses? 6. High level balance tasks - Is the patient limited in their ability with TUSS, TUSS tog, TUSS tan, turning, picking things up form the floor? 7. Upper limb function - Describe any limitations to functional use of the upper limb. Other: Are there any other impairments that might influence your treatment but you will not directly be trying to affect? 1. Speech - Does the patient have any aphasia receptive or expressive or dysarthria? Is English their first language? 2. Swallowing - Does the patient have any dysphagia? 3. Vision / hearing- Does the patient have any visual impairment or hearing deficit? 4. Skin / continence - Are there any problems which might impact on your treatment? 28 PHYSIO STROKE EDUCATION WORKBOOK

Have a go at formulating a hypothetical problem list for the following patient: Impairments:

Picture to be added once consent obtained.

Activities:

Other:

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Have a go at formulating a hypothetical problem list for the following patient: Impairments:

Activities:

Other:

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OUTCOME MEASURES

Match up the outcome measures with what they are measuring:

Ashworth Scale Muscle strength

Oxford Scale Dynamic standing balance

Timed 10 metre walk

Upper limb function Berg

MRMI Muscle Tone (two)

Tardieu Scale Standing Balance

TUSStan / TUSStog General level of function

ARAT Gait 31 PHYSIO STROKE EDUCATION WORKBOOK

HANDLING A STROKE PATIENT Identify any risks or things you would need to consider before handling this patient:

Picture of acute stroke patient in bed to be added once consent obtained

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What four factors need to be considered prior to assisting a patient to move?

1. 2. 3. 4.

What variable factors may impact on the ability of a patient to carry out the transfer from one day to the next?

Bearing this in mind, what measures should you put in place to minimise the risk to the patient, yourself and other members of the team?

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EQUIPMENT

The tables on the next two pages cover various manual and therapeutic handling equipment. Can you fill in the pros and cons for each one and in the “treatment ideas” column, think about when and how you might use each one.

Equipment Pros Cons Treatment ideas

Hoist

Tilt table

Sliding board

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Equipment Pros Cons Treatment ideas

Arjo

Samhall turner / rotastand

Body weight support treadmill (more in later slide)

Electric standing frame

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Case 1: • Independent sitting balance • Power in lower limb 3/5 (R) and 5/5 (L) • Power in upper limb 0/5 (R) and 5/5 (L) • Sensory deficit in (R) lower limb: altered sensation, not absent • BP and HR stable What methods could you use to transfer this patient and why?

1) 2) 3) 4)

Case 2: • Assistance of 1 for sitting balance • Perceptual deficit – unable to maintain midline alignment in sitting • Inattention/ neglect to the (R) with sensory deficit • Power (R) lower limb 1-2/5 and (L) lower limb 5/5 • Power (R) upper limb 0/5 and 5/5 (L) lower limb • Cognitive impairment – limited to one step commands with poor attention and recall

What methods could you use to transfer this patient and why? 1)

3) 36 PHYSIO STROKE EDUCATION WORKBOOK

EARLY MOBILISATION OF THE STROKE PATIENT

What does early mobilisation mean?

What are the benefits of early mobilisation for a stroke patient?

What needs to be checked prior to mobilisation?

What is the name of the large multi-centre trial looking at very early rehabilitation? Briefly describe the study. Suggested reading: A very early rehabilitation trial for stroke (AVERT) Julie Bernhardt, Helen Dewey, Amanda Thrift, Janice Collier and Geoffrey Donnan. Stroke 2008;39;390-396; originally published online Jan 3, 2008.

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TREATMENT AND MANAGEMENT OF THE UPPER LIMB

The shoulder is a complex joint and is especially vulnerable if it has been affected by a stroke. It is a shallow ball and socket joint that is dependent on muscle activity for primary stability – rather than bony configuration.

Name the major active stabilisers of the shoulder joint:

Weakness, abnormal tone and impaired coordination of movement can lead to subluxation of the shoulder joint. Label the types of subluxation below and indicate whether high or low tone would lead to that type of subluxation.

Unopposed Unopposed Unopposed gravitational pull on pull of internal pull of arm rotators elevators

is the most common type seen in stroke patients. It can be identified visually (externally or on xray) or by palpation - by a dip where humeral head has dropped down. It can be measured in fingers for severity of subluxation.

Write down 3 complications of a subluxed shoulder: SUBLUXATION WILL NOT RECOVER 1. …………………………………………………………….. 2. …………………………………………………………….. UNLESS THE MUSCLES RECOVER and 3. …………………………………………………………….. NEEDS TO BE MANAGED CAREFULLY

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Put an X by the things that you SHOULD NOT do with a hemiplegic arm and a √ by the things you SHOULD do: Make sure the patient is not lying directly on the affected shoulder Pull a patient up by their affected arm Pull on the arm when moving a patient in bed Place a pillow under the affected arm (right up under the shoulder) Let the arm hang over the edge of the chair Use the hand as the point of contact when moving a low tone arm with no activity at the shoulder Support the arm under the elbow when moving/positioning the patient Careful positioning of the upper limb is very important. What prolonged positions should you avoid? Why is it important to position the upper limb?

List possible treatment options for the hemiplegic arm: •……………………………………………………………………………………………. •……………………………………………………………………………………………. •……………………………………………………………………………………………. •……………………………………………………………………………………………. •……………………………………………………………………………………………. •……………………………………………………………………………………………. •……………………………………………………………………………………………. •……………………………………………………………………………………………. 39 PHYSIO STROKE EDUCATION WORKBOOK

GAIT What would you look for when analysing gait? A B C D E F G H Head:

Shoulders:

______

What are the 2 main phases of a normal gait cycle? Trunk: (Label diagram) Name the components that make up the two phases (A-H on the diagram): Arms: A……………………………………………………… B……………………………………………………… C……………………………………………………… Pelvis: D……………………………………………………… E……………………………………………………… F……………………………………………………… Hips: G……………………………………………………… H……………………………………………………… Define the following terms: Knees: Step length:

Stride length: Feet:

Cadence: 40 PHYSIO STROKE EDUCATION WORKBOOK

Watch the GAIT VIDEO (8.5 MB) and then answer Reflect on a patient you have treated with gait the following questions: impairment: Type of stroke: Key impairments: Key impairments:

Pick one treatment idea and explain your clinical reasoning: Pick one treatment idea and explain your clinical reasoning:

Produce evidence for the treatment chosen: Produce evidence for the treatment chosen:

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TONE – ASSESSMENT AND MANAGEMENT Tone is the state of of a muscle.

It is the continuous in muscles that helps to maintain posture.

It ……………... throughout the day and in response to different situations which is normal and does not indicate a problem.

Can you list things that normally increase or decrease a persons muscle tone which we can influence as a therapist:

Increase muscle tone Decrease muscle tone

Can you highlight on the diagram where the neural and the non-neural components of hypertonia are: CNS Reflex hyper-excitability LESION

Altered muscle function HYPERTONIA

Non-CNS factors Altered passive (eg immobilisation) mechanical properties 42 PHYSIO STROKE EDUCATION WORKBOOK

Find the following definitions of spasticity:

Lance (1980)

Pandyan (2005)

Complete the following table showing the features of both Upper Motor Neurone (UMN) and Lower Motor Neurone (LMN) lesions:

UMN Lesion LMN Lesion

Positive features Negative features

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Look at the following paragraphs and work out which structure or system contributing to the maintainance of normal muscle tone is being described:

A = ...... The………A………..is a small fusiform structure lying parallel to the extrafusal muscle fibres. It consists of a stretch receptor inside a skeletal muscle sensitive to the length of the muscle. It contains specialised cells called intrafusal fibres that have nerve endings wrapped around their central regions. Stretch of the muscle stretches this central region and activates the …………A……..… Ia afferents. One large muscle may have several dozen …………A………. endings in it.

B = …………………………………………..

The most important local reflex is the …. ……B………..….. This is also known as the tendon jerk or myotactic reflex. It is called a….. …B…….….. because there is a direct connection between the afferent and efferent nerve cells. Only the muscle spindle afferents make a ….. ………B…………….

C = …………………………………………..

The …………C……….…. is the second major proprioceptor in muscle. It is found in musculotendinous junctions. It is activated by muscle tension (not length). Both the spindle and …………C…………. are activated when a muscle is passively stretched but the spindle is switched off if the muscle shortens back to its original length. The ………C……..…… is active during passive stretch and also active contraction. The …………C……. is said to be in series with the muscle and detects tension. It’s main role is to protect muscle against excess load.

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WALKING AIDS Useful tip: You may wish to have the walking aim higher than normal as it will generally be used primarily for balance rather than weight-bearing. Fill the boxes in, pros on the left, cons on the right:

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ORTHOTICS

Recommended reading: Neurological Physiotherapy – Susan Edwards (Chapter 8) What is an orthotic?

List some reasons why you would use an orthotic: Orthoses are classified in relation to the parts of the body over which they act. Fill in the following names:

1. F……….. O……….. 2. A...... F……….. O……….. or AFO 3. K...... A...... F………. O………. or KAFO 4. H…………K...... A...... F……… O………... or HKAFO

What do you need to consider before providing an orthotic and why?

Orthotics vary in their rigidity and the amount of support they require, when might you need a more rigid orthotic?

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Name the following orthotics and match them with their use:

Maintains the foot in neutral position at the ankle, so that the foot can be cleared during swing phase. Can be used with patient with increased tone in the posterior compartment.

The same as a full foot AFO, but can be useful for patients who walk longer distances outside, or go up and down stairs. Patient needs to have enough quadriceps control to maintain knee extension.

Helps with foot clearance in swing phase whilst assisting some active plantarflexion for push off.

Provides support medially, and sensory and proprioceptive feedback. Patient needs to have active dorsiflexion to clear toes. Used for patients with lack of medial/lateral stability.

The patient should have some active dorsiflexion (but this can be weak and fatiguable) and no tonal issues.

Maintains dorsiflexion range whilst the patient is in bed.

Maintains the knee in extension and ankle in neutral, to allow effective standing and weight-bearing. It is used when there is not enough quadriceps control to maintain an extended knee in standing.

For patients with complex tonal patterns and/or alignment issues, a bespoke AFO may be required. For this referral to an ort47hotist is needed. They will then take a cast and provide a custom-made AFO. PHYSIO STROKE EDUCATION WORKBOOK

TREADMILL TRAINING

…………………………..

……………………………… ……………………..……….. …………………………...

WHAT ARE THE BENEFITS ……..…………………..... OF BODY WEIGHT SUPPORT TREATMILL TRAINING? ………………………….… ………………………..………..

……………………………… …………………………..…

…………………………..… ………………………….……….. ……………………………………..

What did the Cochrane Review on treadmill training in stroke find?

48 PHYSIO STROKE EDUCATION WORKBOOK

ELECTRICAL STIMULATION What does FES stand for and what does it do?

What can FES be used for?

When is FES not effective?

What type of FES machine is this?

Complete the missing words: (see picture for clues)

FES can correct ……………foot in…………..motor neurone conditions. Skin surface electrodes are placed over the……………………..nerve as it passes over the head of the…………..and the motor point of……………….....…. Stimulation produces ……….……. and ………..….which will improve the quality of a patients gait pattern (retraining swing phase)

What else apart from foot drop could FES be used for in stroke patients? 49 PHYSIO STROKE EDUCATION WORKBOOK

What do the NICE guidelines say about FES?

What function would a patient with drop foot need in order to use the FES?

Useful references: • Burridge JH, Swain ID, Taylor PN. (1998). Functional electrical stimulation: a review of the literature published on common peroneal nerve stimulation for the correction of dropped foot. Reviews in Clinical Gerontology 8; 155-161 • Burridge, J, Taylor P, Hagan S, Wood D, Swain I (1997) The effects of common peroneal nerve stimulation on the effort and speed of walking. A randomised controlled clinical trial with chronic hemiplegic patients. Clinical Rehabilitation, 11.201-210. • Baker LL, Yeh C, Wilson D, Waters RL. Electrical stimulation of wrist and fingers for hemiplegic patients, Physical Therapy, 1979; 59 (12) 1495-1499 • Kraft GH, Fitts SS & Hammond MC. Techniques to improve function of the arm and hand in chronic hemiplegia. Archives of Physical Medical Rehabilitation, 1992; 73; 220-227. • Taylor PN, Burridge JH, Wood DE, Norton J, Dunkerly A, Singleton, C, Swain ID. (1999) Clinical use of the Odstock Drop Foot Stimulator - its effect on the speed and effort of walking. Arch Phys Med Rehabil 80: 1577-1583,. • Taylor PN, Burridge JH, Dunkerley AL, Lamb A, Wood DE, Norton JA, Swain ID. (1999) Patient's Perceptions of the Odstock Dropped Foot Stimulator (ODFS). Clin. Rehabil 13: 333-340 50 PHYSIO STROKE EDUCATION WORKBOOK

ATAXIA

Find the words relating to ataxia in the word search. What do they mean and how do they relate to ataxia?

Proprioceptive – F H G V R O M E R T N O I T N E T N I

O D Y S D I A D O C H O K I N E S I A Vestibular- S G A E E D C A H C A E F H S R J F S I B N N A Y H I A D J E B D U F J W Y Cerebellar – D E G S J S S I A D G E F S M O C A N Coordination – E N S O E C M I F F Y V S R G A D B E N O A R B H D K R G W G S C A C Y W R Balance – T I C Y V R H O M B E R G S T E S T G O T H A E O D G P K B S R K S R M V Y Dysmetria – K A I H S N R H A H A H F E Y E E S A Dysarthria – R N L S T O F G T I L A D R N B T D I I I A A I M D Y R J A R G R S E R F M Nystagmus – S D R G B E E H Y J N O E Y H L I H E T R Y I U T T V C E C N J B F L A A E Asynergy – D O R G L R E I J X E H L P Q A V N D Dysdiadochokinesia – F O E S A I G S A D S A R A V R W N H S C H S R A R S J F W H D I W O N A W Romberg’s Test – S F Y D A W N Y O R D S D H R U T H W D D S P R O P R I O C E P T I V E S G Dyschronometria –

51 PHYSIO STROKE EDUCATION WORKBOOK

VESTIBULAR ATAXIA:

Affects vestibular nuclei and connections with vestibular system, particularly common with medullary strokes.

What are the common symptoms of vestibular ataxia?

OCULOMOTOR ASSESSMENT TREATMENT OPTIONS Describe how you would test the following: Cawthorne Cooksey exercises: Participants are Smooth pursuit - maintains fixation on a moving object encouraged to move into positions that provoke symptoms, with repeated stimulus the participant will eventually tolerate the position without symptoms – Habituation. Vestibular ocular reflex (VOR) - Stabilises retinal image Gaze stabilisation: Exercises to decrease visual stimuli during head and body movement. and visual compensations, using patterned cards to complete the above oculormotor movements, subjects need to be able to do this for 2 minutes to improve.

Balance work: Any exercises to challenge balance- wobble board, wobble cushion, foam mat, balance without Saccades - Changes fixation to new area of interest. visual input.

Postural control: Pilates based exercises to improve stability

52 PHYSIO STROKE EDUCATION WORKBOOK

SENSORY ATAXIA:

Dysfunction of spinal dorsal columns leading to a loss of proprioceptive and cutaneous input.

What are the common symptoms of sensory ataxia?

SENSORY ASSESSMENT TREATMENT OPTIONS What sensory modalities would you assess? Sensory re-education: expose the patient to varying different types of cutaneous input. Trial different textures (smooth, rough), temperatures (hot, warm, cold) and pressure (light, deep).

Compensation strategies: patients will become more What additional assessment would you carry out? reliant on visual and vestibular input to maintain balance in the absence of reliable sensory and proprioceptive information. It is important to allow the patient to experience movement in different postural sets in order to practice maintaining balance using the information available to them.

53 PHYSIO STROKE EDUCATION WORKBOOK

CEREBELLAR ATAXIA:

Dysfunction of the cerebellum leading to oculomotor abnormalities, dysarthria, reduced co-ordination of limb movements, reduced balance, reduced motor learning and possible cognitive deficits.

Cerebellar ataxia can be divided into sporadic onset (80%) and hereditary (20%). Can you name a hereditary condition causing cerebellar ataxia?

Which main blood vessels leading to the brain, if affected, could lead to cerebellar ataxia?

CO-ORDINATION AND BALANCE ASSESSMENT TREATMENT OPTIONS See earlier section on neurological assessment. Seating/postural support: To ensure safety. Would Rhomberg’s test be positive or negative with cerebellar ataxia? Weights: May improve stabilisation through increased proprioceptive feedback. Can use velcro weights on distal end of limbs or can attach to walking aids.

Lycra garments: Improves posture and smoothness of movement. However, need to consider cost of garment and compliance can be an issue.

Balance re-education: Remember to vary the tasks to get the best results.

54 PHYSIO STROKE EDUCATION WORKBOOK

GLOSSARY

IMPAIRMENTS

Define the following terms:

Agnosia –

Agraphia –

Akinesia –

Alexia –

Anosognosia –

Apraxia –

Aphasia –

Receptive aphasia –

Expressive aphasia –

55 PHYSIO STROKE EDUCATION WORKBOOK

Ataxia –

Bradykinesia –

Clonus –

Confabulation –

Dysarthria –

Dysdiadochokinesia –

Dysgraphia –

Dysphagia –

Dysmetria -

Dysphonia –

Dyslexia –

Dyspraxia – 56 PHYSIO STROKE EDUCATION WORKBOOK

Dystonia –

Echolalia –

Emotional lability –

Hemianopia –

Hypertonicity –

Hypotonicity –

Ischaemic cascade –

Ischaemic penumbra –

Neglect –

57 PHYSIO STROKE EDUCATION WORKBOOK

Nystagmus –

Rigidity –

Spasticity –

Stereognosis -

MEDICAL DISORDERS AND INVESTIGATIONS:

Describe the following terms:

Atrial fibrillation (AF) –

CADASIL -

58 PHYSIO STROKE EDUCATION WORKBOOK

Carotid sinus syndrome –

Carotid endarterectomy (CEA) –

Carotid Doppler Ultrasound –

Decompressive craniectomy –

Epilepsy –

Haemorrhagic transformation –

Moyamoya disease –

Postural hypotension –

Thrombolysis –

Todd’s paralysis -

59 PHYSIO STROKE EDUCATION WORKBOOK

Lacunar infarct -

MEDICATIONS: What are the main uses for these drugs?

Drug name Main use

Amitriptyline

Aspirin

Gabapentin

Dantrolene

Baclofen

Tizanadine

Alteplase

Metocoplramide, promethazine

Betahistine

Diazepam

60 PHYSIO STROKE EDUCATION WORKBOOK

RESOURCES

South London Cardiac and Stroke Network – www.slcsn.nhs.uk

Evidence/Research

. http://www.cochrane.org/reviews/en/ab002840.html

. http://www.library.nhs.uk/default.aspx (requires athens login)

. http://www.evidence.nhs.uk/default.aspx

. http://www.improvement.nhs.uk/stroke/

Guidelines

. http://www.healthcareforlondon.nhs.uk/

. http://www.nice.org.uk/

. www.rcplondon.ac.uk/

. National clinical guideline for stroke (RCP)

61 PHYSIO STROKE EDUCATION WORKBOOK

Organisations

. http://www.stroke.org.uk/

. http://www.strokecare.co.uk/

. http://www.headway.org.uk

. http://www.brainandspine.org.uk

. http://www.differentstrokes.co.uk/