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Physical Therapist Assistant
PTA 150: Fundamentals of Treatment II
Day 9 & 10
CVA
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Objectives
 Describe the pathophysiology of a CVA
 Describe physical and neurological impairments
associated with CVA
 Describe physical therapy treatment interventions
for patients after a CVA
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Cerebrovascular Accident
(CVA)
Sudden loss of neurological
function caused by an
interruption of the blood flow to
the brain
O’Sullivan, pg. 705
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CVA Epidemiology
 The 3rd leading cause of death in the US
 THE most common cause for disability in US
adults
 Incidence of stroke 1.25 times greater for males
than females
 Compared to whites, African-Americans have 2x
the risk of first-ever stroke (higher also with
Mexican-Americans, American Indians, and Alaska
Natives)
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Definitions
 CVA is used interchangeably with the term “stroke”
 Neurological deficits must remain for > 24 hours to
be classified as a stroke
 Transient Ischemic Attack (TIA)
 Temporary interruption of blood flow to brain
 Symptoms resolve quickly (within 24 hours)
 Few if any permanent signs or symptoms
 Precursor to stroke
 About 14% of persons surviving an initial stroke or
TIA will experience another one within a year
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Types of Strokes
 Hemorrhagic Stroke
 Blood vessels rupture, blood leaks into the brain
 1˚ Cerebral Hemorrhage results from ruptured blood
vessels weakened by atherosclerosis
 Results in ↑ ICP and restricts blood flow to the brain
 Subarachnoid Hemorrhage (SAH) – bleeding b/w
arachnoid layer and pia mater
• Common cause: aneurysm & AVM
 Subdural Hemorrhage (SDH) – bleeding b/w dura
mater and arachnoid layer
• Common cause is trauma
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Types of Strokes
 Ischemic Stroke
 Most common (~80%)
 A clot blocks or impairs blood flow to the brain
 Can result from a Thrombosis
• Results from platelet adhesions & aggregation on plaques
• Cerebral Thrombosis: Blood clot forms in cerebral artery
• Thrombi lead to ischemia = cerebral infarction
 Can result from an Embolus
• Dislodged matter; blood clot, plaque, fat, gas, air, tissue
that dislodges in the body and travels to the brain
occluding cerebral circulation
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Impact
 Severity and symptoms of stroke depend on
 Location of ischemic process
 Size of the ischemic area
 Nature & function of structures involved
 Availability of collateral flow
• O’Sullivan , page 708
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Anterior Cerebral Artery Syndrome
Middle Cerebral Artery Syndrome
Posterior Cerebral Artery Syndrome
Vertebrobasilar Artery Syndrome
Internal Carotid Artery Syndrome
Lacunar Syndrome
Vascular Syndromes
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Anterior Cerebral Artery (ACA)
 Supplies medial part of the frontal and parietal
lobe, basal ganglia and corpus callosum
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ACA Syndrome
 Contralateral sensory & motor loss with LEs affected





more than UEs
Urinary incontinence
Mental impairment (confusion, amnesia)
Apraxia affecting ability to imitate or perform
bimanual tasks
Abulia (lack of desire to carry out an action),
slowness, delayed movements, lack of spontaneous
movements
Behavioral changes
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Medial Cerebral Artery (MCA)
 Supplies lateral cerebral hemispheres (incl. frontal,
parietal and temporal lobes)
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MCA Syndrome
 Contralateral hemiparesis of face and UE mainly
 Pure motor hemiplegia (lacunar stroke)
 Contralateral hemisensory loss of face & UE mainly
 Speech impairment: Broca’s aphasia, Wernicke’s





aphasia, global aphasis
Perceptual deficits: unilateral neglect, depth
perception difficulties, agnosia
Apraxia
Ataxia of contralateral limbs (sensory ataxia)
Contralateral hemianopsia
Table 18.2 (O’Sullivan)
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Posterior Cerebral Artery (PCA)
 Supplies occipital lobe, medial and inferior
temporal lobe, thalamus & brain
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PCA Syndrome
 Contralateral sensory & motor loss (hemianesthesia)
 Hemianopsia
 Visual agnosia, prosopagnosia and cortical blindness
 Oculomotor nerve palsy
 Involuntary movement
 Choreoathetosis, intention tremor, hemiballismus
 Thalamic pain
 Pusher syndrome
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Hemiballismus - Video
http://www.bing.com/videos/search?q=hemiballismus
&view=detail&mid=290D280B1B53C5E9CDEB290
D280B1B53C5E9CDEB&first=0&FORM=LKVR
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Vertebrobasilar Artery
 Vertebral artery arises from the
subclavian artery, travels into
the brain and then merge to
form the basilar artery
 Vertebral artery supplies the
cerebellum and medulla
 Basilar artery supplies the
pons, internal ear, and
cerebellum
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Vertebrobasilar Artery Syndrome
 Wide variety of symptoms with ipsilateral and
contralateral signs
 Numerous cerebellar and cranial nerve
abnormalities
 Refer to Table 18.4 in O’Sullivan for details
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Internal Carotid Artery (ACA)
Syndrome
 Supplies both the MCA and ACA
 Complete occlusion leads to ↑↑ cerebral edema =
coma & possible death
 Incomplete occlusion = mix of ACA & MCA
syndromes
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Lacunar Infarct
 Caused by small vessel disease deep in cerebral
white matter
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Lacunar Syndrome
 Contralateral weakness
 Sensory loss
 Dystonia/Involuntary movement
 Choreoathetosis, hemiballismus
 Ataxia
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CVA – Major Risk Factors
Primary
Secondary
 Atherosclerosis
 Obesity
 HTN
 Hypercholesteremia
 Heart disease
 Physical Inactivity
 Diabetes
 ↑ Alcohol consumption
 Smoking
 TIA
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Stroke Warning Signs
TIME IS BRAIN
 Sudden numbness or weakness of the face, arm or
leg, especially on one side of the body
 Sudden confusion, trouble speaking or
understanding
 Sudden trouble seeing in one or both eyes
 Sudden trouble walking, dizziness, loss of balance
or coordination
 Sudden, severe headache with no known cause
www.StrokeAssociation.org
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Imaging - CT
 Frontal lobe stroke
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Imaging - MRI
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CVA Medical Management
 Reestablish cerebral circulation and oxygenation
 Control blood pressure
 Maintain sufficient cardiac output
 Restore/maintain fluid & electrolyte balance
 Maintain blood glucose levels
 Control ICP
 Maintain bladder function (possible use of
catheter)
 Maintain integrity of skin and joints
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Pharmacological Management
 Anticoagulants (heparin, coumadin); to reduce
clots and maintain profusion)
 Antiplatelets (aspirin); used to decrease the risk of
recurrent stroke
 Antihypertensives
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Surgical Intervention
 Endarterectomy – surgical removal of lining and
plaque in an artery
 Used to prevent strokes (not treat them)
 In the case of hemorrhage – surgery to repair
rupture, prevent further bleeding evacuate the clot
 Resection of unruptured AVM if found and risk is
high
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Primary Impairments
 Sensation Impairments
 ↓ sensory perception & ability to process sensory
information
• Touch, temperature, position, kinesthetic, pain
• ASTEROGNOSIS
• The inability to identify an object by touch without visual input
 Pain
 Can experience severe headaches, neck or facial
pain
 Central post-stroke (thalamic) pain: constant, severe
burning with intermittent sharp pains
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Primary Impairments
 Visual Impairments
 Eye movements (sluggish, reflexive, ataxic)
 Hemianopsia: Blindness in half of each eye’s visual
field (loss on the nasal side and half on temple side)
 Visual neglect
 Difficulties w/ depth perception & spatial relationships
 Forced gaze deviation
 Brainstem strokes may result in diplopia, oscillopsia
or visual distortions
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Primary Impairments
Motor Impairments – Stages of Motor Recovery
 Stage 1 - Flaccidity
 Stage 2 - Minimal voluntary movement; may see
synergies and spasticity develop
 Stage 3 – Voluntary control the movement
synergies; spasticity may ↑ further
 (Continued)
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Primary Impairments
Motor Impairments – Stages of Motor Recovery
 Stage 4 – movement combinations that do not
follow the path of synergy are mastered;
spasticity ↓
 Stage 5 – Difficult movement combinations are
learned
 Stage 6 – disappearance of spasticity, individual
joint movements become possible and
coordination approaches normal
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Primary Impairments
 Motor Impairments
 Weakness (paresis)
• Occurs in 80-90% of all patients after stroke
• Varies depending on location and size of stroke
• Can result in complete paralysis/hemiparesis
• Typically, more distal muscles exhibit greater weakness
• May even see weakness on the “normal” side
• Changes in muscle composition 2˚ weakness & disuse
• Atrophy, ↓ Fast twitch type II, ↑ slow twitch type I
• ↑ effort and fatigability
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Primary Impairments
 Motor Impairments
 Changes in tone
• Flaccidity – present immediately as a result of cerebral
shock; usually short-lived but sometimes persists
• Spasticity/hypertonicity
• Occurs in about 90% of patients after stroke
• Posturing of limbs is common with mod → severe spasticity
• Spasms (internal or external stimulation)
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Posturing
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Primary Impairments
 Motor Impairments
 Abnormal synergistic movement patterns
• Associated with spasticity, may ↓ with recovery
• Review Table 18.5 in O’Sullivan
 Impaired reflex responses (mild to severe)
• Vary according to stage of recovery
• Hyporeflexia with flaccidity → hyperreflexia with spasticity
• ↑ stretch reflex – clonus, clasp-knife, (+) Babinski
• ATNR
• Associated reactions
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Primary Impairments
 Motor Impairments
 Impaired coordination responses
• Cerebellar strokes = ataxia & weakness
• Basal Ganglia involvement = slow movements
(bradykinesia) & involuntary movements
(choreoathetosis, hemiballismus)
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Video - Cerebellar Ataxia
 http://www.bing.com/videos/search?q=cerebellar+a
taxia&view=detail&mid=F8130C8EBA0E3DD338C
5F8130C8EBA0E3DD338C5&first=1&FORM=LKV
R3
 http://www.bing.com/videos/search?q=cerebellar+a
taxia&view=detail&mid=08E8A16F23E5E860EE90
08E8A16F23E5E860EE90&first=21&FORM=LKVR
18
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Primary Impairments
 Motor Impairments
 Altered motor programming
• Motor praxis
• Ideational apraxia
• Ideomotor apraxia
 Diminished muscle performance for ADL
• Strength, Power, Endurance
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Primary Impairments
 Postural Control & Balance Impairments
 May experience difficulty with balance 2˚ to an
external force or during self-initiated exercises
• Corrective responses to perturbations are often
inadequate = fall
 Asymmetry typically noted in posture
• Typically see falls to the same side as weakness
 Pusher Syndrome
• Active pushing of the uninvolved side offsets muscle
control of the involved side (falls, leaning)
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Primary Impairments
 Speech and Language Impairments
 Aphasia – an acquired communication disorder
caused by brain damage and is characterized by an
impairment of language comprehension, formulation
and use. (O’Sullivan, pg. 722)
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Primary Impairments
 Speech and Language Impairments
 Receptive Aphasia
• aka. Wernicke’s/Sensory/Fluent Aphasia
• Auditory and reading comprehension impaired
• Speech is functional
 Expressive Aphasia
• aka. Broca’s/Nonfluent Aphasia
• Difficulty finding words to express ideas
 Global Aphasia
• Receptive and Expressive
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Primary Impairments
 Speech and Language Impairments
 Dysarthria
• Nasal quality of speech, slurred words
 Dysphonia
• Difficulty producing sounds
 Dysphagia
• Difficulty in swallowing
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Primary Impairments
 Altered Perception
 Body scheme – relationship of body parts to one
another as well as the body’s relationship to the
environment
 Body image – visual and mental image of one’s body
may be altered following a stroke
• Includes the individual’s feelings about this image
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Primary Impairments
 Examples of body scheme/image impairments:
 Unilateral Neglect
• Visual recognition or attention on involved side
• Limb neglect or attention on involved side
 Anosognosia – denial, neglect or unawareness of
one’s paralysis
 Somatoagnosia – lack of awareness of one’s body
structure and its relationship to the environment
 Right-left discrimination
 Finger agnosia
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Primary Impairments
 Altered Perception
 Agnosia - inability to recognize incoming information
despite intact sensory capabilities (O’Sullivan, pg 723)
• Visual object agnosia
• Auditory agnosia
• Tactile agnosia (astereoagnosia)
 Spatial relationship – difficulty determining the relationship
between the body and 2 or more objects in the
environment
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Primary Impairments
 Cognitive Impairments
 ↓ alertness
 ↓ attention
 Altered orientation
 Diminished memory
 Impaired executive function
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Primary Impairments
 Cognitive Impairments – Vocabulary
 Confabulation
 Perseveration
 Multi-infarct dementia
 Delirium
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Primary Impairments
 Alterations in Affect
 Pseudobulbar Affect
• A.k.a. emotional dysregulation syndrome or emotional
lability
• Emotional outbursts (crying, laughing)
 Apathy
 Euphoria
 ↑ irritability or frustration
 Social inappropriateness
 Depression
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Primary Impairments
 Bladder and Bowel Function
 Common during acute phase
 Often implement a toileting schedule
 Urinary retention controlled with catheterization
 Can often lead to embarrassment, isolation or
depression
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Primary Impairments
 Hemispheric Behavioral Differences
 Left Hemispheric Damage
• Difficulties in communication
• Difficulty with processing information
• Cautious, anxious, disorganized
• Often very aware of impairments
 Right Hemispheric Damage
• Difficulty in spatial-perceptual tasks
• Difficulty with grasping overall idea of task or activity
• Quick, impulsive
• Overestimate their abilities, poor judgment
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General Characteristics of CVA
 Right Hemisphere CVA
 Left side weakness or paralysis
 Hemianopsia
 Decreased awareness and judgment
 Memory deficits
 Inattention and less reasoning
 Emotional labile
 Impulsive behaviors
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Characteristics of CVA
 Left Hemisphere CVA
 Right side weakness
 Aphasia
 Motor Apraxia
 Dysphagia
 Hemianopsia
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Complications &
2˚ Impairments
 Musculoskeletal
 Loss of ROM & Contractures
 Edema & pain
 Disuse atrophy & weakness
 Osteoporosis
• Fall risk
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Complications &
2˚ Impairments
 Neurological
 Seizures
 Hydrocephalus – an excessive accumulation of CSF
within the cranial cavity
 Cardiovascular
 Thrombophlebitis/DVT
 Impaired Cardiac Function
• Impaired cardiac output, decompensation, rhythm
disorders
• Can restrict exercise/activity tolerance
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Complications &
2˚ Impairments
 Pulmonary
 Decreased lung volume
 Decreased pulmonary perfusion & vital capacity
 Altered chest wall excursion
 Greater energy expenditure
 Aspiration
 Integumentary
 Skin breakdown and decubitis ulcer
• Pressure, friction, shearing
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Rehabilitation after
Stroke
The Role of the PT & PTA
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Acute Phase
 Lo-intensity therapy can begin once stabilized medically.
 Early mobilization
 Minimize deconditioning
 Functional reorganization is promoted
 Learned nonuse is minimized
 Reinforce a positive outlook
 Decreased incidence of depression, apathy and mental
deterioration
 Early presentation of rehabilitation plan
 Monitor for potential medical emergencies!
 Average hospital stay is about 7 days
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Post-Acute Phase
 Triage
 Inpatient rehabilitation, TCU, SNF
 What other services may be involved with the
patient at this time?
 Progression to home care, outpatient PT
 Assisting with return to work, recreation, social
activities
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PT Examination
 Patient history
 Joint Integrity &
 Levels of
Mobility
 Voluntary Movement
patterns
 Strength
 Postural control &
balance
 Ambulation &
Functional mobility
 Functional status
Consciousness
 Communication
 Cognitive, emotional
and behavioral states
 Cranial Nerve Integrity
 Sensory Integrity
 Perception
 Tone/Reflexes
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Gait after a Stroke
The PTA Assessment
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VIDEO
 http://www.youtube.com/watch?v=YMzVywpbNes&
feature=related
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Gait after Stroke
 Important to look at movements occurring at the
ankle, foot, knee, hip, pelvis, trunk and UEs.
 Observe the different planes of motion
 Quantitative measures include distance, time,
cadence, velocity, and stride times
 What type of AD may be necessary?
 May consider videotaping
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Trunk/Pelvis
 Stance Phase
 Forward trunk 2˚
• Weak hip extension
• Flexion contracture
 Swing Phase
 ↓ forward pelvic rotation 2˚
• Weak abdominal mm
 Leaning towards the stronger side to clear the
weaker side foot from the floor OR
 Backward leaning of trunk
• Both may be due to weak hip flexors
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Hip
 Substitutions as a result of inadequate hip flexion:
 Hip hiking
• Weak abdominal mm and inadequate knee flexion may
also contribute to this
 Circumduction
• ↑ extensor tone, ↑ PF tone or foot drop as well as
inadequate knee flexion may also contribute to this
 External rotation/adduction
 May see the opposite, exaggerated hip flexion
• Flexor synergy
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Knee
 Stance Phase
 Excessive knee flexion 2˚
•
•
•
•
Flaccid or weak LE, especially hip & knee extensors
Poor PPC
Flexion contracture
Ankle DF range past neutral
 Hyperextension of knee 2˚
• ↑ extensor tone of LE
• Quadricep spasticity
• Weakness of gluteus maximus, hamstrings and quads
• PF contracture past 90˚
• Impaired PPC
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Knee
 Swing Phase
 ↓ Knee flexion 2 ˚
• ↑ LE extensor tone, spastic quadriceps
• Inadequate hip flexion and poor foot clearance
• Circumduction or hiking pattern often seen as a result
 Exaggerated, delayed knee flexion 2˚
• Strong flexor synergy
 Inadequate knee extension at initial stance 2˚
• Spastic hamstrings
• Sustained total flexor pattern
• Weak knee extensors
Ankle/Foot
 Stance Phase
 Equinus gait – heel does not touch down
• Spastic or contracture of gastrocnemius
 Varus foot – weight is on the lateral side of the foot
• Spastic tibialis anterior, posterior tibialis, toe flexors,
soleus
 Unequal step length
• Hammer toes can cause pain with WB and prevent a full
step forward with opposite leg
• Increased flexor tone in toe muscles
• Lack of DF ROM on affected side
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Ankle/Foot
 Swing Phase
 Persistent equinus or varus or a combination of the 2
(equinovarus)
• Weak dorsiflexors may contribute to this in addition to
spastic muscles
 Exaggerated DF 2˚ strong flexor synergy pattern
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Intervention
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Strategies to Improve
Sensory Function
 Encourage use of the affected side!!
 Training should focus on functional tasks
 Examples:
 Stroking skin with various fabrics
 Drawing shapes, letters onto the skin of affected side
 Approximation
 Inflatable pressure splints
 Patient and family/caregivers must be educated on
impairments as well as safety measures to protect
the involved limbs
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Strategies to Improve
Sensory Function
 With unilateral neglect, incorporate strategies that
encourage awareness and use of the body on the
involved side
 Visual scanning
 Cueing (visual, verbal or motor cues)
 Imagery
 Visual focus on the affected arm or leg during activity
 Bilateral tasks
 Tactile input given by the therapist to the involved
limb
 Patient may require reorientation
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Strategies to Improve
Flexibility and Joint Integrity
 Early ROM daily
 UE
 PROM of shoulder important for reaching and
overhead movements
• Careful attention to mobilize the scapula on the thoracic
wall, maintain upward rotation and protraction
 Maintain full elbow extension, wrist and finger ROM
 Self UE ROM may include arm cradling, table-top
polishing, supine AAROM with intact UE clasping
the affected UE
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Strategies to Improve
Flexibility and Joint Integrity
 Effective UE positioning is important
 Lap tray or arm trough
 5˚ shoulder ABD & FLEX, neutral rotation, 90˚elbow
FLEX & slightly forward, forearm pronated,
functional hand position
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Strategies to Improve
Flexibility and Joint Integrity
 Volar resting (pan) splint
 Functional
 20-30˚ wrist extension
 40-45˚ MP flexion
 10-20˚ IP flexion
 Thumb opposition
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Strategies to Improve
Flexibility & Joint Integrity
 LE ROM
 Often see limited ankle DF
• Incorporate weight bearing encouraging DF by
performing forward weight shifts or using adaptive
equipment (tilt board, foot rocker)
 Pay careful attention to hip flexor and knee flexion
contraction with prolonged sitting in wheelchair
 ROM in opposition to spasticity (if present) should
also be performed daily
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Strategies to Improve
Strength
 <3/5 Strength
 Therapist assisted exercise
 Powder board
 Sling suspension
 Aquatic Exercise
 3/5 Strength
 Gravity resisted exercises
 >3/5 Strength
 Free weights
 Bands
 Machines
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Strategies to Improve
Strength
 Important to combine strengthening and function
 Wearing ankle weights while performing step ups or
stair climbing
 Reaching exercises while wearing wrist weights
• Secondary postural stabilization occurs with this type of
exercise
 Resisted walking with Theraband taut at waist level
 Sit to stand with resistance given at shoulders by
therapist
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Strategies to Improve
Strength
 Safe Exercise Prescription
 Exercise is contraindicated with HTN & recent stroke
 With HTN – avoid high-intensity & isometric
exercises
• Concentric & eccentric exercises are less stressful for
the cardiovascular system
• Sitting exercises less risk for increasing blood pressure
as compared to supine exercises
 Proper warm-up & cool down are important, better to
begin with LE exercises first
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Strategies to Improve
Strength
 Need to carefully monitor:
 BP
 HR
 Rate of Perceived Exertion (RPE)
 Breathing (avoid breath holding & Valsalva)
 Patient needs to be educated to monitor HR and
RPE as well as warning signs to stop exercises
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Strategies to Manage Spasticity
 Early mobilization
 Prolonged stretching
 Examples:
 Rhythmic rotation
 Slow rocking movements over limb in an elongated,
weight bearing position
 PNF upper trunk patterns can ↓ trunk tone
 Activation of the antagonist muscles using slow &
controlled movements
 May need to use facilitation techniques
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Strategies to Manage Spasticity
 Modalities to reduce spasticity
 Cold (ice wraps, ice packs)
 Estim to the antagonist
 Vibration
 May incorporate air splints
 Can use soothing verbal commands/relaxation
techniques or imagery
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Strategies to Improve
Initial Movement
 Initially focus on normal postural alignment as well
as control and functional use of extremities
 Strategies should address dissociation and
selective (out-of-synergy) movement patterns
 Reinforce slow, controlled, “normal” movements
 May progress postures to optimize movements
 Example: shoulder flexion in supine, sitting and then
standing
 Assistance may initially be provided but then
progress to active, independent movements
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Strategies to Improve
Initial Movement Control
 When addressing function, consider practicing
eccentric contractions before concentric
 Eccentric contraction are more efficient
 Can gradually progress to a variety of activities that
use all 3 types of contractions
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Strategies to Improve
Motor Learning
 Strategy Development
 Critical tasks, goals and outcomes are identified
 Begin practice, may practice components of the task
before practice of the whole task
 Important to move towards whole task to allow for
transfer of learning
 Practicing with less affected side first may also assist
with transfer effects
 Clear, simple verbal instruction should be given
 Patient needs to be active in problem solving
• i.e., Can the patient identify components performed
incorrectly
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Strategies to Improve
Motor Learning
 Feedback
 Can be extrinsic or intrinsic
 During early motor learning, more likely to use
extrinsic feedback
• Mirrors, verbal cues or manual cueing from therapist
 Patient’s attention should be geared towards
recognizing intrinsic and developed more as therapy
progresses
• Patient should “feel the movement”
 Important to avoid bombardment of feedback and
limit immediate feedback
Concorde Career College
Strategies to Improve
Motor Learning
 Practice, Practice and more Practice
 May initially be limited by endurance
 Need to encourage variable practice in order to
progress
 Ensure the environment is conducive to learning
• Eventually can progress to a more open, real-life
environment
 Motivation is important
• Patient should be involved in goal setting
• Treatment session should be positive
• Therapist needs to be a support system, encouraging
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Rolling
 Practice rolling to both sides
 Rolling to affected side more difficult
 Clasp hands together to assist with momentum and
use of the affected UE
 Can bend the LE’s to assist with pushing over
 Sidelying on affected side promotes WB of the
affected UE
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Sit to Supine/Supine to Sit
 Important to practice towards both sides
 Will likely be easier to perform from non-involved
side
 Therapist may initially facilitate/assist movements
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Sitting
 Initially looking for symmetrical posture with proper
spinal alignment
 Early sitting may involve therapist cueing (tactile &/or
verbal)
 May use UE’s initially to maintain sitting posture
 Progress to no UE support, weight shifting, truncal
motions, PNF patterns, reaching/dynamic activities,
perturbations, scooting
 Progression may then include these same activities
while sitting on a ball
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Bridging
 Develops hip and trunk extensor control as well as
LE selective control & early LE WB
 Can progress from performing the exercise, holding
the position and then performing dynamic activities
within the posture
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Sit to Stand (STS)
 Focus on symmetrical WB, coordination & timing
 (Demonstration of proper sit to stand)
 Strategies to initiate STS:
• Clasp hands or reaching forward with UE’s
• Place pt hands on ball while therapist stabilizes ball but
then move ball forward to promote anterior weight shift
• Raise the mat height
• Place stronger foot slightly behind the weaker
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Sit Down Transfers
 Strategies to promote controlled sit down include:
• Partial wall squats
• Varying mat height
• Lateral pelvic shifts to involved side and alternate
sit/stand
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Standing, Modified Plantigrade
 Standing with affected UE extended and in
weightbearing position, LE also extended
 Assists with development of postural and extremity
control
 Very stable position
 Can progress from static standing to movement and
reaching activities
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Standing
 Initially standing can occur in parallel bars or at
bedside with assist
 Progression can include:
• 2 hand support → 1 hand support → free standing
• Static standing → weight shift → dynamic (reaching,
stepping) → perturbations/rhythmic stabilization
 Focus on proper alignment and symmetry
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Transfers
 Need to practice transfers to both sides
 Important to support the weaker knee
 Vary surfaces and surface heights
 May progress from squat-pivot to stand-pivot
Concorde Career College
Strategies to Improve Postural
Control & Functional Mobility
 Pusher Syndrome
 Focus is on the vertical
 Can use mirrors, the wall, a ball, or even the
therapist to assist with active, appropriate shifting
rather than pushing
 Ask the patient, “Which way are you leaning?”;
“Which direction should you move to be vertical?”
Concorde Career College
Strategies to Improve
UE Function
 UE as a Postural Support
 Extended UE weightbearing promotes proximal
stabilization and counteracts flexion synergy,
hypertonus
 Approximation can stimulate shoulder girdle
stabilization and elbow extensors
 Can perform in sitting, modified plantigrade, standing
and quadruped
 Progress from holding the position to more dynamic
activities
Concorde Career College
Strategies to Improve
UE Function
 Reaching
 Can begin with positions which eliminate gravity
• Sidelying, tabletop assist, “dusting” with washcloth,
reaching down to touch the floor
• May also need therapist assist
 Progress to anti-gravity activites
 Combine with balance & functional activities
 Vary height/distance to reach, weight of object
grasped, time to complete the task
 Avoid substitution
Concorde Career College
Strategies to Improve
UE Function
 Manipulation & Dexterity
 Initial tasks usually involve more gross grasp and
release
 Can begin by using affected hand to stabilize while
performing a task with stronger hand
 Progress to bilateral activities, emphasize
function/ADLs
 Include reaching activities
 Build-ups for items such as forks, toothbrush, pens
can improve independence and efficiency
Concorde Career College
Strategies to Improve
UE Function
 Enhanced Training Activities
 Bilateral arm training w/ rhythmic auditory cueing
(BATRAC)
 http://www.youtube.com/watch?v=dy2qzvDa-Fc
Concorde Career College
Strategies to Improve
UE Function
 Enhanced Training Activities
 Constrain-Induced Movement Therapy (CIMT)
 Electromyographic Feeback (EMG-BFB)
 Neuromuscular Electrical Stimulation (NMES)
Concorde Career College
Strategies to Improve
UE Function
 Management of Shoulder Pain
 Common complication post stroke
 In the case of flaccidity, arm needs support at all times
 Proper arm support is essential
 Scapula/shoulder protracted, arm forward in slight ABD and neutral ROT
 ↓ subluxation – NMES, supportive devices
 ↓ Pain, normalize tone – gentle stretching & mobilization,
cryotherapy, EMG BFB, relaxation training
 Adhesive capsulitis treated with mobilization, PROM and
ultrasound
 Avoid trauma or traction injuries with functional mobility
Concorde Career College
Strategies to Improve
UE Function
 Supportive Devices
 Slings
 Pros and Cons
Concorde Career College
Strategies to Improve
UE Function
 Supportive Devices (Gillen)
 Consider using slings only with initial transfer and
gait training
 Determine whether a sling that places the arm in
flexion is really necessary, if so consider wearing
only for short periods of time
 Selection of a sling is on an individual basis
 Consider alternatives: NMES, taping, hand in
pocket/belt, lap tray
Concorde Career College
Strategies to Improve
LE Function
 Necessary to prepare for appropriate gait
 Helpful to start with improving pelvic control
 Can practice forward pelvic rotation in sidelying,
supine, hooklying, kneeling, sitting on ball, standing
 Break synergistic patterns
 Example: hip extension is paired with knee flexion to
allow toe-off during terminal stance/pre-swing
 Activities to promote this include: bridging, supine hip
extension with knee flexed and heel pressing into the
floor or standing and repeatedly practicing this phase
of walking
Concorde Career College
Strategies to Improve
LE Function
 Avoiding hyperextension of the
knee
 Activities to promote this
control include: controlled heel
slides in supine and sitting,
partial wall squats, controlled
flexion and extension of knee
on leg press, terminal knee
extension exercises with
Theraband in standing
Concorde Career College
Strategies to Improve
LE Function
 Important to progress activities by modifying
postures
 Example:
 Supine → Sitting → Kneeling → Standing
 And… emphasize reduction of synergistic patterns
Concorde Career College
Strategies to Improve
Balance
 Important to select appropriate exercises,
challenging to the patient but does not compromise
safety
 Must first achieve postural alignment and static
stability in upright postures
 Can then progress to exploring limits of stability
 Weight shifting
 Encouraging symmetrical weight bearing
 Encouraging weight bearing to more affected side
Concorde Career College
Strategies to Improve
Balance
 Examples:
 Vary the BOS
 Vary the support surface
 Vary sensory inputs
 Vary UE position/support
 Vary UE movement
 Vary LE movement
 Vary trunk movements
 Incorporate dynamic functional activities
 Incorporate dual tasks
 Change the environment
Concorde Career College
Strategies to Improve
Balance
 Strategies
 Ankle
• Small A/P weight shifting or small perturbations
• Standing on rocker board, foam roller, dynadisc
 Hip
• Larger A/P weight shifts or perturbations
• Tandem stance promote medial-lateral strategies
• Standing on floor or foam roller
 Stepping
• Displacement of COM in all directions
• Therapist can apply a band around waist
• Step ups
Concorde Career College
Strategies to Improve
Balance
 Need full attention from patient (and therapist!)
 Provide well-timed feedback
 Minimize hand support
 Encourage active problem-solving
 Safety education must be included
Concorde Career College
Strategies to Improve
Locomotion
 Gait training
 Initially parallel bars & assistive
devices can be used
• Pros & Cons
 Important to progress patient to least
restrictive device or no device as
able
 Want to encourage even, longer step
length and increased time
• May use rhythmic auditory cues OR
• Markers on the floor with tape
Concorde Career College
Strategies to Improve
Locomotion
 Look at each phase of gait
 Stance Phase
• Initial weight acceptance
• Midstance control
• Forward weight advancement
 Swing Phase
• Knee and foot control for toe clearance
• Foot placement
 UE posturing
Concorde Career College
Strategies to Improve
Locomotion
 Vary the environment
 Community walking, hiking trails, hills
 Practice walking in all directions
 Forward, backward, sideways
 Practice cross-stepping
 Include stairs, curbs, step-over-step
 Include timing activities
 Crossing the street, using escalators, elevators and
automatic doors
Concorde Career College
Strategies to Improve
Locomotion
 Practice dual-task activities
 Talking, bouncing a ball, carrying a tray
 Incorporate balance activities
 Tandem walking, walking on foam/gravel/grass
 Treadmills, cycle ergometers
 These tools may assist with improving time and
reciprocity of the LEs
Concorde Career College
Strategies to Improve
Locomotion
 Body weight support systems
 Limb load monitors
 NMES to improve ankle DF
Concorde Career College
Strategies to Improve
Locomotion
 Orthotics
AFO
Knee Controls
Concorde Career College
Strategies to Improve
Locomotion
 Wheelchairs
 Appropriate position
 Types:
• Hemi-height wheelchair (Seat to floor height is 17.5”)
• One arm drive chair
• Power wheelchair
 Training activities
• Proper use, maintenance and safety
• Methods of propulsion
• Level and varied surfaces
• Transfers
Concorde Career College
Strategies to Improve
Aerobic Function
 Initial Phase: functional activities are sufficient
 Post-Acute Phase: may progress to treadmill,
stationary bicycle
 Carefully monitor VS & symptoms of exertional
intolerance, impending stroke or heart attack
 Choose method based on patient’s interest
 Suggested frequency is 3X/week for 20-60 minutes
 May be daily at lower intensities
 Recommend starting with intermittent training and
progressing to continuous 30 minutes of exercise
Concorde Career College
Questions
Concorde Career College