Central South Regional Stroke Network
Integrating Motor Learning Strategies in Task Oriented Stroke RehabSchedule (timing approximate) Slides will be posted after the sessionContact information: Vince DePaul, vincent.depaul@queensu.ca School of Rehabilitation Therapy, Queen’s University, Kingston ONTask: In small groups, you will work through these 2 cases. First work on Case 1 – and come back to the large group prepared to share your thoughts, ideas and discussion (we may ask you to share your screen – so assign a scribe to keep notes as you answer your questions. Part 1: Review CASE # 1: Mr. Sandeep Gill Mr. Sandeep Gill 77 years oldAdmitting Diagnosis: Right MCA infarctHPI: Mr. Gill was admitted to hospital after experiencing suddenonset left leg weakness and difficulty walking while grocery shopping.He also had involuntary movements of his left arm and hand forapproximately 30 minutes which felt like he “lost control”. Hiswife called EMS and he was brought to HGH. Mr. Gill spent the firstnight in the ED and then was transferred to the ward the next day.Imaging: CT Head showed evolution of small acute right ACA infarctPMHX: Rheumatic fever as a child, moderate mitral valve prolapse and regurgitation, atrial fibrillation, previous transient ischemic attack (TIA) x 2 (six and four years ago), ex-smokerMedications: Warfarin, Bisoprolol, Furosemide, Social History: Married; 3 adult children; retired accountant.Lives in a two-storey home with 16 stairs to the second (bedroom) levelOrders: Physiotherapy, Occupational Therapy, AATSubjectiveMr. Gill tells you that he feels a bit tired but otherwise does nothave any other complaints. He tells you that he has been sittingup in the bedside chair since breakfast. Mr. Gill asks you whenhe can go home and if he can “just exercsie at home”.Observation &VitalsPatient sitting up in bedside chair wearing own pajamas.On room air.Alert and oriented to person, place, and date. Flat affect. Speechfluent. Mr. Gill seemed unaware at times of any weakness withhis left leg.Heart rate (HR): 96 bpm BP: 123/78 mmHg SpO2: 97%Cranial N.NormalSensoryHypoesthesia to light touch, hypoesthesia to pin prick, and temperature throughout left upper and lower extremityAROM(L) Hip Flexion 95° Abduction 25°(L) Knee Flexion 100° Extension -10°(L) Ankle Plantarflexion 30° Dorsiflexion 10°ROM WNL in right LE and bilateral upper extremitiesMuscle ToneSome increase in tone in lower extremity extensors on rapid passive movement through range CoordinationHeel-to-shin: left leg slower compared to right legFinger-to-nose: no dysmetria or ataxiaFunctionalMobilityBed mobility: independent rolling without using bedrailTransfers: supervisionAmbulation: minimal assistance x 1 person to walk 50m using atwo-wheeled walker (previously independent no aids. You observe his left hand to periodically slip off grip of walker while walking.ADLBathing and dressing – lower body supervision, cueing, in sitting.Upper body/limb – some difficulty with sleeves and buttons, clumsy handFeeding/eating – supervision, cueing, clumsy with left hand for bilateral tasks (cutting, washing dishes)Intermittent coughing with eatingOutcomeMeasuresAlpha-FIM Score: 82Chedoke McMaster Stroke Assessment:? (L) Shoulder Pain: 7? Postural Control: 5Impairment Inventory: ? Arm= 6 Hand = 5 ? Leg= 5 Foot = 5Follow up information Based on the assessments of the inpatient PT and OT, Mr. Gill was deemed to be appropriate for discharge home from the Acute Stroke Unit on day 5 post-stroke. Mr Gill is unable to drive post-stroke, and his wife does not have her licence. He lives in Carlisle Ontario, just outside of Hamilton. The Stroke Team has referred Mr. Gill to be seen in his home by the Regional Community Stroke Rehabilitation Team (PT, OT, OTA/PTA, SLP). You are the therapist(s) seeing him in his home three days after discharge. On assessment, you note the following: Montreal Cognitive Assessment 27/30Motor ControlChedoke McMaster Stroke Assessment:Impairment Inventory: (Left) ? Arm= 6 Hand = 6 ? Leg= 6 Foot = 5Balance Berg Balance Scale = 43/56 Difficulty with standing with eyes closed, tandem stand, unipedal stance, alternate stepping, and turning 360. Observation of functional mobilitySit to stand – requires use of hands to stand up, able to perform without assistance however tends to bear weight mostly on right lower extremity Standing Posture: Stands independently - with slightly rounded shoulders, head forward posture. Tends to stand with weight shifted to right lower extremity. Walking – walking on level ground indoors with 2 wheeled walker with out assistance. Wife asks patient to wait for her before he gets up but he has been walking short distances independently over the last 24 hours with the walker.Stairs – able to walk up and down stairs with step-to gait pattern (leading with right going up and left going down) holding on to railing with one-person assistance to steady balance and give verbal cues for foot placement.Walking outdoors: Reduced speed, hesitant gait pattern - needs close supervision of wife when walking with walker over patio and grass in backyard Gait Gait speed – 0.5 m/s with walkerObservational Gait Analysis: Decreased stance time on left L/EDecreased step length bilaterally, left shorter than rightDecreased heel strike on left during initial contactDecreased right knee extension during mid stanceDecreased push-off on right during terminal stanceDecreased left foot clearance during swingGoal (Participation)“To improve my balance and walking so I can get out into my garden this summer without bugging my wife for help all the time.Take care of my own morning routine without help. Improve my hand so I can do my taxes on the computer the deadline.”Group Task and Questions: Review Case 1: Mr. Gill. Identify any information that you think will help with developing a motor learning-based treatment plan.Considering Mr. Gill’s Participation Goal - identify at least 2 activity goals that you will target with training and practice. Develop a detailed task-oriented treatment plan that integrates motor learning strategies discussed. Think about how you will organize a single treatment session, and what you may adjust over a number of treatment sessions. (use the questions in the table below to help you with your treatment plan development.After you answer question 3 After 3 weeks of home-based treatment, the COVID-19 pandemic forces you to discontinue all home visits for patients. What could you have Mr. Gill practice independently for the next week to allow him to keep moving forward with his recovery? How could he monitor his own performance and progress? Consider the following when developing your plan . Organizing practice:What will you have Mr. Gill practice during a supervised session?Will you use part-task or whole task practice? Describe:You know that variable task practice tends to promote better transfer of learned skills: How will you make practice variable? What will you vary? Order of task practice: In what order will you have Mr. Gill practice multiple tasks (or variations on a single task)? (ie. blocked, serial, random) Be specific – describe how you will implement this. Amount of practice: How will you promote abundant practice during and between therapy sessions? How will you measure and document amount of practice? Instructions, Feedback and Guidance: Focus of AttentionWhat would an external focus of attention instruction sound like for the task(s) you have selected for Mr. Gill to practice? What would an internal focus of attention instruction sound like? Practice giving the instructions out loud.Feedback:Will you provide knowledge of performance feedback? If yes, what aspects of movement performance are you trying to encourage, or correct?Will you provide knowledge of results feedback? If yes give a specific example.What feedback and guidance strategies will you use to promote active problem solving on the part of this patient? (Give some examples). Consider: Mode of feedback: (e.g. verbal, written, visual, tactile, haptic) Frequency/Timing: When will you give feedback? (Timing, relationship to patient performance, therapist vs patient regulated?)Will you provide any physical guidance/assistance to the patient during task practice? If yes, when? How could you organize the task to minimize need for physical guidance? How will you know if your treatment approach was effective? When will you assess motor learning?What will you do to assess and document learning?How will you measure transfer of learning?Autonomy and self-efficacyWhat aspects of your treatment plan will help promote patient autonomy and self-efficacy? What else could you do? What aspects of your treatment approach might limit self-efficacy? Try to be specific with your examples – be ready to demonstrateCASE 2: Barbara JamesRead through the following case – watch the video clip provided to get a visual picture of patient’s presentation. Discuss how you would adjust your treatment approach related to application of motor learning strategies based on this patient’s presentation. Barbara James 41 yr. old woman41 year-old woman with history of right hemorrhagic stroke (arteriovenous malformation rupture). Barb was out at mall when she had sudden severe headache, progressive left side weakness, and collapsed to ground in store. Store clerk called 911 – taken by ambulance to regional stroke centre. Spent 3 days in ICU, and 2 weeks on acute stroke unit. She was then transferred to the Regional Stroke Rehabilitation facility.Watch the following clip from beginning until 1:49. how Barb moves her arm and how she walks. For the next section – imagine you are the therapist working with Barb during this period after she arrives on the inpatient rehabilitation unit. Social HistoryLives with her husband and two teenage children. Has worked for 18 years in IT support. Much of this work involves communicating over the telephoneLives in 2 story house with 2 step access.Functional HistoryPreviously independent with mobility, ADLs, IADLsWalks 3 km with husband most nights. Enjoys baking and cooking. Patient GoalTo return to walking independently. Be able to help with cooking at home. Eventually return to work as an IT support person part-time Information from OT and PT assessment on entry to Stroke Rehabilitation UnitCognitive Assessment (OT)Mild disorientation to time and place.Attention span for up to 5 minutes on taskImmediate Number recall – able to recall 3 digits forward but only 2 digits backwardDifficulty with counting backwards by 3’s.Delayed word recall – 2 out of 5 words correct Montreal Cognitive Assessment (MoCA) score – 18/30Communication Dysarthria noted on assessment, husband notes that speech deteriorates throughout the day. Motor ControlCMSA – Arm = 4. Hand 3. Leg 4 Foot 4Able to use left arm and hand as a stabilizer when positioned in sitting. Able to pick up cup off table with left hand if right hand stabilizes cup on table. Can lift cup off table but spills water when attempts to bring to mouth (unable to keep cup level)Muscle ToneIncreased flexor tone in left upper extremity – worse with effortful activitiesIncreased plantar flexor and evertor tone - left ankleSensationIntact right and left Postural Control/BalanceBerg Balance Scale: 36.Gait and LocomotionLocomotion: Ambulates 30 m with 0.4 m/s using a quad cane and a temporary dorsiflexor assist and close supervision to contact guard of one person. Gait speed: 0.4 m/s (5 m walk test)Decreased step length bilaterally but right shorter than left, decreased clearance of the right foot during swing, decreased stance time on the stroke-affected leg. Lacks a loading response and push off on right. Lacks full dorsiflexion, some circumduction during right swing to clear leg. Stairs: Unable.EnduranceTolerates 3/4-hour treatment session with frequent rests.Questions:Review Case 2: Barbara James. Identify information relevant to developing a motor learning-based treatment plan for her during inpatient rehabilitation.Describe what an intervention session will look like with this patient compared to Mr. Gill. Use the same questions and cuesConsider how patient’s physical abilities and cognitive abilities will affect how you organize practice, and provide instructions, feedback and guidance during practice. Work through a specific task and develop a supervised practice session suitable to this patient. What would/could you leave this patient to safely practice outside of your treatment session to optimize motor learning? How can you set up the task and environment to maximize patient’s ability to perform he task without physical guidance.NOTE: Cases are modified versions previously developed cases created by V. DePaul & L. Coman for use in session with McMaster PT students May 2020 ................
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