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Current Evidence Based Protocols in Stroke Rehabilitation

Profession: Physical Therapists/Assistants,Occupational Therapists/Assistants,Doctors of Chiropractic
Topic: Clinical
CEU: 1.5 unit
Contact Hours: 15 hours

States Approved:
- Physical Therapists/Assistants : California, Colorado, Hawaii, Indiana, Maine, Massachusetts, Michigan, Nevada, New York, Rhode Island, South Dakota, Utah, Vermont, Wyoming
- Occupational Therapists/Assistants : Ohio
- Doctors of Chiropractic : Iowa, Nebraska, New Jersey

Skill Level: Beginner


 

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Course Description:

The book was developed to assist facilities to put in place a stroke rehabilitation protocol that is evidence based, designed to achieve maximum functionality and improve patient quality of life. This will guide clinicians to determine the best interventions for their patients, better stratify stroke patients, reduce readmission, and optimize healthcare utilization.

The primary goals of rehabilitation are to prevent complications, minimize impairments, maximize function, and prevent stroke recurrence. Early assessment and intervention are critical to optimize rehabilitation. Standardized evaluations and valid assessment tools are essential to development of a comprehensive treatment plan. Evidence-based interventions should be based on functional goals. In stroke rehabilitation, a number of restorative therapies currently exist and others are in various stages of development. Approaches advocated for improving arm motor function including constraint-induced movement therapy, antispasticity medications, exercise, functional electrical stimulation and robotic therapy.

A recent review of randomized controlled trials indicates that restorative therapies provide improvement in function when compared to no treatment. Superiority of one type of therapy over another could not be distinguished, and therefore the specific choice of therapy was difficult to justify over another type of treatment. Consequently, there are reservations in the medical community concerning the benefit of various types of restorative therapies.

Despite evidence suggesting that rehabilitation may be useful in brain restoration and in the therapy of patients with stroke, there is little information available describing the precise nature of interventions provided by rehabilitation therapists. Identifying interventions that can improve motor function remains a priority. This book will provide an overview of the current understanding of modern rehabilitation therapies and the effects on plasticity and recovery of motor function in stroke. The book concludes with describing how the patient and the patient’s family members are essential members of the rehabilitation team. Patient and family involvement are described in detail.

Course objectives:

  1. Identify the cause of cerebrovascular accident
  2. Implement interventions that are evidence-based which would help in promoting recovery in patients with stroke
  3. Choose the best outcome measure based on side of stroke, time since stroke, age of the patient and current ambulatory status
  4. Create treatment programs that would include balance retraining and other device based therapies
  5. Review other restorative therapies to improve cognition such as mental practice and non-invasive brain stimulation.

Table of Contents

CHAPTER 1: CEREBROVASCULAR ACCIDENT 1
What Causes Stroke? 2
Ischemia/reperfusion injury 3
Brain plasticity 4
Spontaneous Behavioral Recovery After Stroke 5
Molecular and Physiological Events 6
Stroke Complications 6
-- Skin Breakdown  
-- Deep Vein Thrombosis  
-- Recurrence of Stroke  
-- Dysphagia  
-- Bowel and Bladder Incontinence  
-- Malnutrition  
-- Cognitive and Communication Impairments  
-- Social Deterioration  
-- Shoulder Pain  
-- Mood Disturbance: Depression and Emotionalism  
-- Visual and Spatial Neglect  
Stroke Rehabilitation: Is it Effective? 16
Recommendations 21
CHAPTER 2: OUTCOME MEASURES 23
Action Research Arm Test (ARAT) 26
Barthel Index (BI) 27
Beck Depression Inventory (BDI) 29
Behavioral Inattention Test (BIT) 31
Berg Balance Scale (BBS) 33
Box and Block Test (BBT) 34
Canadian Neurological Scale (CNS) 35
Canadian Occupational Performance Measure (COPM) 36
Chedoke Arm and Hand Activity Inventory (CAHAI) 39
Chedoke-McMaster Stroke Assessment Scale (CMSA) 41
Clinical Outcome Variables (COVS) 42
Clock Drawing Test (CDT) 44
EuroQol Quality of Life Scale (EQ5D) 46
Frenchay Activities Index (FAI) 47
Frenchay Aphasia Screening Test (FAST) 50
Functional Ambulation Categories (FAC) 51
Functional Independence Measure (FIM) 53
Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA) 58
General Health Questionnaire-28 (GHQ-28) 59
Geriatric Depression Scale (GDS) 61
Hospital Anxiety and Depression Scale 62
Line Bisection Test (LBT) 64
London Handicap Scale (LHS) 65
Medical Outcomes Study Short Form 36 (SF-36) 66
Mini-Mental State Examination (MMSE) 69
Modified Ashworth Scale (MAS) 71
Modified Rankin Handicap Scale (MRS) 72
Montreal Cognitive Assessment (MoCA) 75
Motor Assessment Scale (MAS) 75
Motor-free Visual Perception Test (MVPT) 77
National Institutes of Health Stroke Scale (NIHSS) 78
Nine-hole Peg Test (NHPT) 80
Nottingham Health Profile (NHP) 81
Orpington Prognostic Scale (OPS) 83
Reintegration to Normal Living Index (RNLI) 85
Rivermead Mobility Index (RMI) 87
Stroke-Adapted Sickness Impact Profile (SA) 87
Stroke Impact Scale (SIS) 89
Stroke Specific Quality of Life Scale) 91
Stroke Therapy Assessment of Movement (STREAM) 92
Timed “Up & Go” Test (TUG) 93
Wolf Motor Function Test (WMFT) 95
Recommendations 98
CHAPTER 3: REHABILITATION INTERVENTIONS 102
Adaptive Equipment 104
Work Conditioning 105
Patient/Family Education 105
Dysphagia Treatment 106
Recovery of Communication 106
Motor Functioning-Strengthening 107
Neurodevelopmental Training for Motor Retraining 107
Spasticity Control 108
Cognitive Training 109
Constraint-Induced Movement Therapy 113
Combined Botulinum Toxin Type A and Modified constraint-induced movement therapy in Upper Limb Spasticity 119
Approaches to Reducing Visual Neglect 121
CHAPTER 4: IMPROVING BALANCE AND PROPRIOCEPTION 123
Gait Deviations and Causes 125
Limb Loading 127
Partial Body Weight Support for Treadmill Training 129
CHAPTER 5: DEVICE BASED THERAPIES 131
Functional or Neuromuscular Electrical Stimulation 131
Biofeedback 132
Repetitive Task Practice and Robotic Therapy 133
Non-Invasive Brain Stimulation 135
CHAPTER 6: CONCLUSION 138
Patient and Caregiver Involvement 138
Time Window for Restorative Therapies 141
REFERENCES 143
APPENDIX 160
Examination 160
Exam questions 161

Needs Assessment (Based on AOTA manual)

Rehabsurge is NOT an AOTA accredited continuing education provider

Category 1: DOMAIN

  • Areas of Occupation
    • Activities of Daily Living (ADL)
    • Social Participation
  • Client Factors
    • Body Structures
  • Activity Demands
    • Required Body Functions
    • Required Body Structures
  • Performance Skills
    • Sensory Perceptual Skills
    • Motor and Praxis Skills

Category 2: PROCESS

  • Intervention
    • Develop intervention plan & approaches (create/promote, establish/restore, maintain, modify, prevent)
    • Implementation of intervention (therapeutic use of self, therapeutic use of occupations/activities, consultation process, education process, advocacy)
  • Outcomes
    • Health & wellness
    • Prevention
  • Research
    • Research outcomes
  • Contemporary Issues and Trends
    • Evidence-based practice

Target Audience:

  • Physical Therapists
  • Physical Therapy Assistants
  • Occupational Therapists
  • Occupational Therapy Assistants
  • Doctors of Chiropractic

To purchase the online exam and e-book, simply hit the "click to proceed" button above. This option allows you to print your certificate instantly after passing the exam. (A score of 70% is required to pass the exam.)

To buy the paperback version from Amazon click below.

About the Author

Caroline Joy Co, PT, DPT, CHT, CSFA, is a licensed physical therapist and certified hand therapist whose clinical experience includes acute, subacute, home health and outpatient settings. Her background includes Community Based Therapy designed to assist people with disabilities access therapy in their communities using predominantly local resources. She is the President and CEO of PTSponsor.com, an online resource for U.S. hospitals and clinics that seek to sponsor and hire foreign-trained physical therapists. She specializes in hand therapy through an integrated approach that includes education, counsel and exercise. She is also certified in functional assessment for work hardening and work conditioning.

She is also the President of Rehabsurge, Inc. Rehabsurge, Inc. is a continuing education company and a contracting agency. Her past affiliations include Long Beach Medical Center, Horizon Health and Subacute Center, and Grandell Therapy and Nursing Center. She was a professional speaker for Summit Professional Education, Cross Country Education and Dogwood Institute for Hand therapy courses; myofascial release and nerve mobilization courses; and coding, billing, documentation and ethics. She received her transitional doctorate from A.T. Still University and her BS in Physical Therapy from University of the Philippines- College of Allied Medical Professions. She is licensed in California, Nevada and New York.

Terms

Rehabsurge, Inc.’s mission is to support health care and education professionals to continue their educational and professional development. Rehabsurge is committed to identifying, promoting, and implementing innovative continuing education activity which can increase and impart professional knowledge and skills through books, audiobooks or digital e-books based on sound scientific and clinically derived research. The first Rehabsurge continuing education book was published in July 2009. As a sponsor of Continuing Education (CE) seminars and workshops we enable professionals to enhance their skills, pursue professional interests and redefine their specialties within their respective disciplines while earning CEUs, CE credits or Contact Hours. Offerings include CE books, audiobooks and digital e-books focused on the latest treatment and assessment approaches, as well as discussions of alternative and state-of-the art therapies.

Rehabsurge, Inc. exists to provide the latest treatment and assessment approaches to the practicing clinician. The basic proposition of our business is simple, solid, and timeless. When we bring the latest knowledge and skill to our clients, then we successfully nurture and protect our brand- Rehabsurge, Inc. That is the key to fulfilling our ultimate obligation to provide consistently attractive books, audiobooks and digital e-books.

DISABILITY POLICY:

Rehabsurge, Inc. seeks to ensure that all students have access to its activities. To that end, it is committed to providing support services and assistance required for equal access for learners with disabilities. Rehabsurge, Inc. has a firm commitment to meeting the guidelines of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973. Rehabsurge, Inc. will provide support services and assistance for students with disabilities, including reasonable accommodations, modifications, and appropriate services to all learners with documented disabilities.

Full Disclosure

To comply with professional boards/associations standards, all planners, speakers and reviewers involved in the development of continuing education content are required to disclose their relevant financial relationships. An individual has a relevant financial relationship if he or she has a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in their presentation content over which the individual has control. Relevant financial relationships must be disclosed to the audience.

As part of its accreditation with boards/associations, Rehabsurge, Inc. is required to resolve any reported conflicts of interest prior to the educational activity. The presentation will be scientifically balanced and free of commercial bias or influence.

To comply with professional boards/associations standards:

I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all Planners involved do not have any financial relationship.

Caroline Joy Co, PT, DPT, CHT, CSFA

Accreditation

CA sealPhysical Therapists/Assistants :  California, Colorado, Hawaii, Indiana, Maine, Massachusetts, Michigan, New York, Rhode Island, South Dakota, Utah, Vermont, Wyoming

Occupational Therapists/Assistants: Ohio

Doctors of Chiropractic: Iowa, Nebraska, New Jersey

Course Description:

The book was developed to assist facilities to put in place a stroke rehabilitation protocol that is evidence based, designed to achieve maximum functionality and improve patient quality of life. This will guide clinicians to determine the best interventions for their patients, better stratify stroke patients, reduce readmission, and optimize healthcare utilization.

The primary goals of rehabilitation are to prevent complications, minimize impairments, maximize function, and prevent stroke recurrence. Early assessment and intervention are critical to optimize rehabilitation. Standardized evaluations and valid assessment tools are essential to development of a comprehensive treatment plan. Evidence-based interventions should be based on functional goals. In stroke rehabilitation, a number of restorative therapies currently exist and others are in various stages of development. Approaches advocated for improving arm motor function including constraint-induced movement therapy, antispasticity medications, exercise, functional electrical stimulation and robotic therapy.

A recent review of randomized controlled trials indicates that restorative therapies provide improvement in function when compared to no treatment. Superiority of one type of therapy over another could not be distinguished, and therefore the specific choice of therapy was difficult to justify over another type of treatment. Consequently, there are reservations in the medical community concerning the benefit of various types of restorative therapies.

Despite evidence suggesting that rehabilitation may be useful in brain restoration and in the therapy of patients with stroke, there is little information available describing the precise nature of interventions provided by rehabilitation therapists. Identifying interventions that can improve motor function remains a priority. This book will provide an overview of the current understanding of modern rehabilitation therapies and the effects on plasticity and recovery of motor function in stroke. The book concludes with describing how the patient and the patient’s family members are essential members of the rehabilitation team. Patient and family involvement are described in detail.

Course objectives:

  1. Identify the cause of cerebrovascular accident
  2. Implement interventions that are evidence-based which would help in promoting recovery in patients with stroke
  3. Choose the best outcome measure based on side of stroke, time since stroke, age of the patient and current ambulatory status
  4. Create treatment programs that would include balance retraining and other device based therapies
  5. Review other restorative therapies to improve cognition such as mental practice and non-invasive brain stimulation.

Table of Contents

CHAPTER 1: CEREBROVASCULAR ACCIDENT 1
What Causes Stroke? 2
Ischemia/reperfusion injury 3
Brain plasticity 4
Spontaneous Behavioral Recovery After Stroke 5
Molecular and Physiological Events 6
Stroke Complications 6
-- Skin Breakdown  
-- Deep Vein Thrombosis  
-- Recurrence of Stroke  
-- Dysphagia  
-- Bowel and Bladder Incontinence  
-- Malnutrition  
-- Cognitive and Communication Impairments  
-- Social Deterioration  
-- Shoulder Pain  
-- Mood Disturbance: Depression and Emotionalism  
-- Visual and Spatial Neglect  
Stroke Rehabilitation: Is it Effective? 16
Recommendations 21
CHAPTER 2: OUTCOME MEASURES 23
Action Research Arm Test (ARAT) 26
Barthel Index (BI) 27
Beck Depression Inventory (BDI) 29
Behavioral Inattention Test (BIT) 31
Berg Balance Scale (BBS) 33
Box and Block Test (BBT) 34
Canadian Neurological Scale (CNS) 35
Canadian Occupational Performance Measure (COPM) 36
Chedoke Arm and Hand Activity Inventory (CAHAI) 39
Chedoke-McMaster Stroke Assessment Scale (CMSA) 41
Clinical Outcome Variables (COVS) 42
Clock Drawing Test (CDT) 44
EuroQol Quality of Life Scale (EQ5D) 46
Frenchay Activities Index (FAI) 47
Frenchay Aphasia Screening Test (FAST) 50
Functional Ambulation Categories (FAC) 51
Functional Independence Measure (FIM) 53
Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA) 58
General Health Questionnaire-28 (GHQ-28) 59
Geriatric Depression Scale (GDS) 61
Hospital Anxiety and Depression Scale 62
Line Bisection Test (LBT) 64
London Handicap Scale (LHS) 65
Medical Outcomes Study Short Form 36 (SF-36) 66
Mini-Mental State Examination (MMSE) 69
Modified Ashworth Scale (MAS) 71
Modified Rankin Handicap Scale (MRS) 72
Montreal Cognitive Assessment (MoCA) 75
Motor Assessment Scale (MAS) 75
Motor-free Visual Perception Test (MVPT) 77
National Institutes of Health Stroke Scale (NIHSS) 78
Nine-hole Peg Test (NHPT) 80
Nottingham Health Profile (NHP) 81
Orpington Prognostic Scale (OPS) 83
Reintegration to Normal Living Index (RNLI) 85
Rivermead Mobility Index (RMI) 87
Stroke-Adapted Sickness Impact Profile (SA) 87
Stroke Impact Scale (SIS) 89
Stroke Specific Quality of Life Scale) 91
Stroke Therapy Assessment of Movement (STREAM) 92
Timed “Up & Go” Test (TUG) 93
Wolf Motor Function Test (WMFT) 95
Recommendations 98
CHAPTER 3: REHABILITATION INTERVENTIONS 102
Adaptive Equipment 104
Work Conditioning 105
Patient/Family Education 105
Dysphagia Treatment 106
Recovery of Communication 106
Motor Functioning-Strengthening 107
Neurodevelopmental Training for Motor Retraining 107
Spasticity Control 108
Cognitive Training 109
Constraint-Induced Movement Therapy 113
Combined Botulinum Toxin Type A and Modified constraint-induced movement therapy in Upper Limb Spasticity 119
Approaches to Reducing Visual Neglect 121
CHAPTER 4: IMPROVING BALANCE AND PROPRIOCEPTION 123
Gait Deviations and Causes 125
Limb Loading 127
Partial Body Weight Support for Treadmill Training 129
CHAPTER 5: DEVICE BASED THERAPIES 131
Functional or Neuromuscular Electrical Stimulation 131
Biofeedback 132
Repetitive Task Practice and Robotic Therapy 133
Non-Invasive Brain Stimulation 135
CHAPTER 6: CONCLUSION 138
Patient and Caregiver Involvement 138
Time Window for Restorative Therapies 141
REFERENCES 143
APPENDIX 160
Examination 160
Exam questions 161

Needs Assessment (Based on AOTA manual)

Rehabsurge is NOT an AOTA accredited continuing education provider

Category 1: DOMAIN

  • Areas of Occupation
    • Activities of Daily Living (ADL)
    • Social Participation
  • Client Factors
    • Body Structures
  • Activity Demands
    • Required Body Functions
    • Required Body Structures
  • Performance Skills
    • Sensory Perceptual Skills
    • Motor and Praxis Skills

Category 2: PROCESS

  • Intervention
    • Develop intervention plan & approaches (create/promote, establish/restore, maintain, modify, prevent)
    • Implementation of intervention (therapeutic use of self, therapeutic use of occupations/activities, consultation process, education process, advocacy)
  • Outcomes
    • Health & wellness
    • Prevention
  • Research
    • Research outcomes
  • Contemporary Issues and Trends
    • Evidence-based practice

Target Audience:

  • Physical Therapists
  • Physical Therapy Assistants
  • Occupational Therapists
  • Occupational Therapy Assistants
  • Doctors of Chiropractic

About the Author

Caroline Joy Co, PT, DPT, CHT, CSFA, is a licensed physical therapist and certified hand therapist whose clinical experience includes acute, subacute, home health and outpatient settings. Her background includes Community Based Therapy designed to assist people with disabilities access therapy in their communities using predominantly local resources. She is the President and CEO of PTSponsor.com, an online resource for U.S. hospitals and clinics that seek to sponsor and hire foreign-trained physical therapists. She specializes in hand therapy through an integrated approach that includes education, counsel and exercise. She is also certified in functional assessment for work hardening and work conditioning.

She is also the President of Rehabsurge, Inc. Rehabsurge, Inc. is a continuing education company and a contracting agency. Her past affiliations include Long Beach Medical Center, Horizon Health and Subacute Center, and Grandell Therapy and Nursing Center. She was a professional speaker for Summit Professional Education, Cross Country Education and Dogwood Institute for Hand therapy courses; myofascial release and nerve mobilization courses; and coding, billing, documentation and ethics. She received her transitional doctorate from A.T. Still University and her BS in Physical Therapy from University of the Philippines- College of Allied Medical Professions. She is licensed in California, Nevada and New York.

Terms

Rehabsurge, Inc.’s mission is to support health care and education professionals to continue their educational and professional development. Rehabsurge is committed to identifying, promoting, and implementing innovative continuing education activity which can increase and impart professional knowledge and skills through books, audiobooks or digital e-books based on sound scientific and clinically derived research. The first Rehabsurge continuing education book was published in July 2009. As a sponsor of Continuing Education (CE) seminars and workshops we enable professionals to enhance their skills, pursue professional interests and redefine their specialties within their respective disciplines while earning CEUs, CE credits or Contact Hours. Offerings include CE books, audiobooks and digital e-books focused on the latest treatment and assessment approaches, as well as discussions of alternative and state-of-the art therapies.

Rehabsurge, Inc. exists to provide the latest treatment and assessment approaches to the practicing clinician. The basic proposition of our business is simple, solid, and timeless. When we bring the latest knowledge and skill to our clients, then we successfully nurture and protect our brand- Rehabsurge, Inc. That is the key to fulfilling our ultimate obligation to provide consistently attractive books, audiobooks and digital e-books.

DISABILITY POLICY:

Rehabsurge, Inc. seeks to ensure that all students have access to its activities. To that end, it is committed to providing support services and assistance required for equal access for learners with disabilities. Rehabsurge, Inc. has a firm commitment to meeting the guidelines of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973. Rehabsurge, Inc. will provide support services and assistance for students with disabilities, including reasonable accommodations, modifications, and appropriate services to all learners with documented disabilities.

Full Disclosure

To comply with professional boards/associations standards, all planners, speakers and reviewers involved in the development of continuing education content are required to disclose their relevant financial relationships. An individual has a relevant financial relationship if he or she has a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in their presentation content over which the individual has control. Relevant financial relationships must be disclosed to the audience.

As part of its accreditation with boards/associations, Rehabsurge, Inc. is required to resolve any reported conflicts of interest prior to the educational activity. The presentation will be scientifically balanced and free of commercial bias or influence.

To comply with professional boards/associations standards:

I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all Planners involved do not have any financial relationship.

Caroline Joy Co, PT, DPT, CHT, CSFA

Accreditation

CA sealPhysical Therapists/Assistants :  California, Colorado, Hawaii, Indiana, Maine, Massachusetts, Michigan, New York, Rhode Island, South Dakota, Utah, Vermont, Wyoming

Occupational Therapists/Assistants: Ohio

Doctors of Chiropractic: Iowa, Nebraska, New Jersey