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282 Cards in this Set
- Front
- Back
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CVA's (cerebrovascular accident) /Strokes:
Definition-? |
A stroke happens when blood flow to a part of the brain is interrupted because a blood vessel in the brain is blocked or bursts open.
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CVA's (cerebrovascular accident) /Strokes:
what happens if blood flow stops for more than a few seconds? |
If blood flow is stopped for longer than a few seconds, the brain cannot get blood and oxygen. Brain cells can die, causing permanent damage
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CVA's (cerebrovascular accident) /Strokes:
how are motor deficits characterized? |
Motor deficits are characterized by paralysis (hemiplegia) or weakness (hemiparesis) on the side of the body opposite the side of the lesion
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CVA's (cerebrovascular accident) /Strokes:
factors affecting severity? |
The location and extent of the lesion, the nature of the structures involved, and the amount of collateral blood flow determine the severity of the neurologic deficits in an individual patient.
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CVA's (cerebrovascular accident) /Strokes:
Categories: by Etiology thrombus- main idea? |
: A clot may form in an artery that is already very narrow
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CVA's (cerebrovascular accident) /Strokes:
Categories: by Etiology embolus- main idea? |
A clot may break off from somewhere in the body and travel up to the brain to block a smaller artery
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CVA's (cerebrovascular accident) /Strokes:
Categories: by Etiology hemorrhage- main idea? |
abnormal bleeding due to blood vessel rupture. Some people have defects in the blood vessels of the brain that make this more likely. The flow of blood that occurs after the blood vessel ruptures damages brain cells.
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CVA's (cerebrovascular accident) /Strokes:
management TIA- main idea |
temporary interruption to blood flow to the brain. Deficits are temporary and do not last over 24 hours. It is a precursor to both cerebral infarction and MI. Caused by multiple factors including occlusive attacks, emboli, reduced cerebral perfusion due to hypotension, arrhythmia etc
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CVA's (cerebrovascular accident) /Strokes:
management minor stroke- main idea? |
Pt is stable and deficits are minor
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CVA's (cerebrovascular accident) /Strokes:
management major stroke- main idea? |
: Pt is stable but the deficits are severe
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Cerebral Infarcts
main idea |
Any pathologic process involving the vessels of the brain can cause a stroke. Cerebral.Infarcts are overwhelmingly the most common cause of a stroke.
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Cerebral Infarcts
what is an infarct? |
An infarct is a site of localized necrosis (cell death) precipitated by deprivation of blood (ischemia) and therefore oxygen to that tissue. Usually this is caused by complete occlusion of a cerebral vessel which causes ischemia and leads to cerebral infarct (this is not always true, not all vessel occlusions produce an infarct)
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Cerebral Infarcts
how many pathological processes? |
. Two pathological processes account for virtually all cerebral infarcts: thrombus and embolus. Hemorrhage occurs when a blood vessel ruptures, tissue death results from both the ischemia and the mechanical injuries.
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Cerebral Infarcts
risk factors? |
primarily same for athlerosclerosis
includes: - HTN - Diabetes Mellitus - hyperilipidemia - smoking - obesity - sedentary life style |
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Immediately after the trauma or infarct the patient will go through a varying period of cerebral shock and then recovery will begin. The amount of recovery is dependent on the...?
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... severity of the stroke and the amount of CNS reorganization
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Epidemiology
stroke is the X leading cause of death? |
stroke is the 3rd leading cause of death (behind heart disease and cancer) and the most common cause of adult disability in the US
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how many new stroke victims a year?
how many with recurrent stroke? |
around 610,000 new victims each year with an additional 185,000 with recurrent strok
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what % of people with stroke die in the ACUTE PHASE?
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30% die in the acute phase
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of those who survive a stroke, what % will be severely disabled?
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of the 70 % that survive, 30 - 40 % will be severely disabled
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what % of strokes happen before 65 years old?
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20%
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History and Physical with Stroke:
HISTORY main idea for collecting it? |
a complete history is performed on admission to help determine the cause of the stroke: i.e. an abrupt onset with a coma usually is indicative of a cerebral hemorrhage or a brainstem stroke. The history will be obtained from the Pt or family.
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History and Physical with Stroke:
PHYSICAL main idea, why collect it? |
physical: a complete physical will be performed including: VS, a cardiac and a neuro exam and neurovascular tests (palpation of the arteries, auscultation and pressures).
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History and Physical with Stroke:
DIAGNOSTIC TESTS main idea, why collect them? |
diagnostic tests: the Pt may also undergo some or all of the following diagnostic tests: CBC, urinalysis, blood sugars, test for syphillis, erythrocyte sedimentation rate, blood chemistry profile, cholesterol and lipid testing, chest x-ray, ECG, CAT, MRI, PET, and cerebral angiography.
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Clinical Manifestations
SENSATION how is loss of sensation associated with vascular lesion? |
the type and extent of sensory deficits is related to location and extent of the vascular lesion. Sensory deficits include any of the senses. Sensory deficits interfere with the acquisition of new motor skills.
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Classification of the sensory system:.
exteroreceptors main idea? |
sensory receptors responsible for the superficial sensations (skin and subcutaneous tissues)
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Classification of the sensory system:.
proprioceptors: main idea? |
sensory receptors responsible for deep sensations (muscles, tendons, ligaments, joints, fascia, and are responsible for position sense, movement sense (kinesthesia) and vibration.)
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Classification of the sensory system:.
cortical sensations main idea? |
a combination of exteroreceptors and proprioceptor input. Responsible for stereognosis (shape discrimination), 2 point discrimination, barognosis, graphesthesia, tactile localization, recognition of texture, and bilateral simultaneous stimulation.
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Classification of sensory receptors:
mechanoreceptors |
respond to mechanical deformation of the receptor or surrounding areas
-golgi tendon organs-reflexes -massage – Trigger point release |
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Classification of sensory receptors:
thermoreceptors |
respond to changes in temperature.
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Classification of sensory receptors:
nocioceptors |
respond to noxious stimuli and result in the perception of pain
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Classification of sensory receptors:
chemoreceptors: |
respond to chemical substances and are responsile for taste, smell, oxygen levels in arterial blood, C02 concentration, and body fluid osmolarity.
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Classification of sensory receptors:
photic |
(electromagnetic receptors): responds to light within the visible spectrum.
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It is important to remember that pain is not limited to stimulation received by the nocioceptors. High intensities of any stimulation to any type of receptor may be perceived as pain.
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It is important to remember that pain is not limited to stimulation received by the nocioceptors. High intensities of any stimulation to any type of receptor may be perceived as pain.
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Transmission of sensory signals
main idea |
receptors send signals into the spinal cord via the dorsal roots and carries it to the higher centers
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Transmission of sensory signals
Anterolateral Spinothalamic system |
responsible for cruder more primitive sensations (pain and touch)
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Transmission of sensory signals
Dorsal Column Medial Lemniscal system |
responsible for discriminate sensations such as kinesthesia, vibration etc.
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How is the sensory system evaluated
what kind of nerves do we test? |
dermatomes
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How is the sensory system evaluated
sharp/dull? temperatures? |
pin prick
- test tubes |
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How is the sensory system evaluated
light touch? pressure? |
-brush, tissue, finger pad, cotton ball
-must be deep enough td indent skin |
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How is the sensory system evaluated
kinesthesia? |
with pts eyes closed passively move their extremity through small ranges, Pt is to name the direction of the movement
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How is the sensory system evaluated
-position sense -vibration |
-with the pts eyes closed they name the position their limb is placed in.
-tested with a tuning fork |
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How is the sensory system evaluated
-stereognosis -tactile localization |
(object recognition) place familiar objects in a bag and see if the Pt can recognize them through touch (keys, pencils, coins etc)
-: recognition of the locality of touch |
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How is the sensory system evaluated
-2 point discrimination |
start with 2 points of stimulus at the exact same time decreasing the distance until they can only feel one point
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How is the sensory system evaluated
-bilateral simultaneous stimulation |
touch proximally and distally to the same extremity or bilateral extremities to see where they perceive the touch
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How is the sensory system evaluated
-barognosis |
recognition of weight, can be tested on one hand or bilaterally
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How is the sensory system evaluated
-graphesthesia |
recognition of letters, numbers or designs, traced on the palm
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How is the sensory system evaluated
-recognition of textures |
: place multiple textures in a bag to determine if the Pt can recognize
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Sequential recovery stages in hemiplegia
main idea? |
Motor recovery from a stroke occurs in stereotypical sequential stages. Variability in the clinical picture at each stage is possible and not all patient recovery fully. Patients may plateau at any stage depending upon the severity of their involvement and their capacity for adaptation. Rate of recovery also differs among patients.
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Brunnstroms' stages of recovery
Stage I |
Period of flaccidity immediately following the acute episode – slings for UE to decrease shoulder subluxation
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Brunnstroms' stages of recovery
Stage 2 |
as recovery begins, basic limb synergies may appear as associated reactions or minimal voluntary movement responses may be present. Spasticity begins to develop.
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Brunnstroms' stages of recovery
Stage 3 |
Patient gains voluntary control of the movement synergies, although the full range of synergies may not always develop. Spasticity has further increased and may become severe.
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Brunnstroms' stages of recovery
Stage 4 |
: Some movement patterns out of the synergy are developed and begin to be mastered. Spasticity begins to decline.
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Brunnstroms' stages of recovery
Stage 5 |
If progress continues, more difficult movement patterns are learned as the basic limb synergies lose their dominance over the motor acts.
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Brunnstroms' stages of recovery
Stage 6 |
Spasticity disappears and individual joint movements become possible and coordination approaches normal. Normal motor function is restored and recovery is complete.
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Alterations in tone versus Synergy patterns
main idea |
An important concept in managing a stroke Pt is the ability to recognize tonal changes and synergy movement patterns as separate and distinct clinical findings, and to recognize the relationship between the two. Flaccidity is present immediately and is usually short lived. Spasticity emerges in about 90 percent of cases and tends to occur in predictable muscle groups, commonly antigravity muscles. The effect of spasticity include restricted movement and static posturing of the limbs.
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Alterations in tone versus Synergy patterns
UE strong in what motions? |
strong in: -scapular retractors
-shoulder add, depressors and IR -elbow flexors -forearm pronators -wrist and finger flexors |
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Alterations in tone versus Synergy patterns
NECK and TRUNK strong in? |
strong in: side flexors causing slumping to the hemi side.
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Alterations in tone versus Synergy patterns
LE strong in what? |
-pelvic retractors
-hip add and IR -hip and knee ext -plantar flexors and supinators -toe flexors |
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Automatic postural tone
main idea |
automatic adjustment of muscle tension that occurs normally in preparation before and during a movement task may also be impaired. Thus pts with a stroke may lack the ability to stabilize proximal joints and the trunk.
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Synergy Patterns
main idea? |
Mass movement patterns associated with the presence of spasticity. May be elicited reflexively as associated reactions or voluntarily.
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basic synergy patterns
2 types |
flexion and extension:
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basic synergy patterns
UE FLEXION key points |
-scapular retraction / elevation or hyperextension
-shoulder abd and E -elbow flexion * -forearm supination -wrist and finger flexion |
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basic synergy patterns
LE FLEXION key points |
-hip flexion *, abd and ER
-knee flexion -ankle dorsiflexion and inversion (supination) -toe dorsiflexion |
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basic synergy patterns
UE EXTENSION key points |
-scapular protraction
-shoulder add * and IR -elbow extension -forearm pronation * -wrist and finger flexion |
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basic synergy patterns
LE EXTENSION key points |
hip extension, add * and IR
-knee ext* -ankle plantarflexion* and inversion (supination) -toe plantarflexion |
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Stroke and Reflexes:
during the flacid stage? |
- areflexia
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Stroke and Reflexes:
with spasticity what would present? |
-hyperreflexia
-clonus -clasp-knife -+Babinski -primitive reflexes re-emerge: - STNR and ATNR |
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Stroke and Reflexes:
with spasticity what ASSOCIATED REACTIONS may present? |
-Tonic lab supine = ext, prone = flex)
-Tonic lumbar reflex: rotation of the UE toward the hemi side results in flexed hemi UE and ext hemi LE, rotation toward the uninvolved side will have the opposite affect -Positive Support |
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Phenomenon with Stroke:
Souques' phenomenon: |
elevation of the hemiplegic arm above the horizontal may elicit extension and abd of the fingers.
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Phenomenon with Stroke:
-Raimiste's phenomenon |
: (overflow technique) resistance of abd or add in the UE or LE will produce a similar response to the opposite extremity
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Phenomenon with Stroke:
-Homolateral limb synkinesis: |
( associated reaction) describes the tendency for flexion of the hemiplegic arm to produce flexion in the hemi leg.
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Phenomenon with Stroke:
Higher level balance reactions...? |
...such as righting, equilibrium, and protective extension are frequently impaired or absent.
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Phenomenon with Stroke:
PARESIS |
: a common finding in stroke pts where they are unable to generate normal levels of force necessary for initiating and controlling movement or for maintaining posture. Specific changes occur in both the motor neuron and muscle. Not all muscle groups are affected equally
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Phenomenon with Stroke:
INCOORDINATION |
can result from cerebellar or basal ganglia involvement (vertebrobasiliar artery), from proprioceptive losses, or from motor weakness. Ataxia is common with cerebellar lesions. Coordination (ch 7) is the ability to execute smooth, accurate, controlled movements. Coordinated movements are characterized by appropriate speed, distance, direction, rhythm, and muscle tension.
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Examples of diagnosis that typically demonstrate coordination deficits
PARKINSONS |
- rigidity
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Examples of diagnosis that typically demonstrate coordination deficits
MS |
different areas of tightness and weakness
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Examples of diagnosis that typically demonstrate coordination deficits
Huntington's disease |
coordination deficits:
>30, 5-15 years post- death; tone, posture, dementia |
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Examples of diagnosis that typically demonstrate coordination deficits
CP |
increased or decreased tone
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Examples of diagnosis that typically demonstrate coordination deficits
Sydenham's choria |
- rheumatic fever- balance, gait, speech, cardiopulmonary
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Examples of diagnosis that typically demonstrate coordination deficits
cerebellar tumors |
– increased ataxia
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Examples of diagnosis that typically demonstrate coordination deficits
cerebellar strokes |
static ataxia
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Primary function of the cerebellum is coordination of motor activity,equilibrium and muscle tone. It works as an error-correcting mechanism by comparing the commands from the higher centers and the feedback from the periphery and it adjusts things as needed.
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Primary function of the cerebellum is coordination of motor activity,equilibrium and muscle tone. It works as an error-correcting mechanism by comparing the commands from the higher centers and the feedback from the periphery and it adjusts things as needed.
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Clinical Features of a Cerebellar dysfunction
dysmetria |
disturbance in the ability to judge the distance or range of movement
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Clinical Features of a Cerebellar dysfunction
dysdiadochokinesia |
impaired ability to perform rapid alternating movements
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Clinical Features of a Cerebellar dysfunction
tremor |
intention or static
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Clinical Features of a Cerebellar dysfunction
movement decomposition |
movements not performed as a single smooth activity, they are broken into component parts (ie finger to nose)
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Clinical Features of a Cerebellar dysfunction
ataxia |
jerky uncoordinated movements
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Clinical Features of a Cerebellar dysfunction
dysarthria |
disorder of the motor component of speech, inability to articulate
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Clinical Features of a Cerebellar dysfunction
nystagmus |
uncoordinated eye movement
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Clinical Features of a Cerebellar dysfunction
rebound phenomenon |
- inability to keep the limb in position after a resistance is released
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Clinical Features of a Basal Ganglia dysfunction
main condition? |
athetosis
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Changes in coordinated movements with age:
5 main points |
decreased strength
slowed reaction time loss of flexibility faulty posture impaired balance |
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How coordination is tested
nonequilibrium responses examples of? |
finger to nose (self and PT)
finger to finger alternating nose to finger finger opposition alternating pronation and supination rebound test (elbow flexion) foot and hand tapping heel to knee and toe heel to shin |
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How coordination is tested
equilibrium responses standing, examples of? |
feet together
- eyes closed - tandem - one foot - balance displaced |
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How coordination is tested
equilibrium responses gait, examples of? |
- balance beam
- heel-toe - sideways - backward - march - on heels / on toes |
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Motor programming deficits
with a LEFT CVA ability to initiate movement? |
difficulty initiating and performing sequences of movement
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Motor programming deficits
with a LEFT CVA time to learn task? |
take longer to learn a task
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Motor programming deficits
with a LEFT CVA speed of motion? |
slower overall movements, with more positioning errors
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Motor programming deficits
with a LEFT CVA APRAXIA... |
-inability to perform purposive movements although there is no sensory or motor impairment
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Motor programming deficits
with a LEFT CVA mental state? |
more realistic about problems
negative, anxious or depressed |
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Motor programming deficits
with a LEFT CVA defect only in affected side? |
can present with motor programming problems in both the involved and uninvolved sides
overall more likely to present with motor programming deficits |
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Motor programming deficits
with a RIGHT CVA MOTOR IMPERSISTENCE |
-inability to sustain a movement or posture
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Motor programming deficits
with a RIGHT CVA ability to pay attention? |
easily distracted and over stimulated
more perpetual deficits |
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Functional Abilities: are typically impaired or absent and vary considerably from patient to patient. The ability to perform functional tasks is influenced by motor and perceptual impairments, disorientation, communication disorders, sensory loss, and decreased cardiorespiratory endurance.
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Functional Abilities: are typically impaired or absent and vary considerably from patient to patient. The ability to perform functional tasks is influenced by motor and perceptual impairments, disorientation, communication disorders, sensory loss, and decreased cardiorespiratory endurance.
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Speech and Language disorders
pts with lesions involving the "X" of the dominant hemisphere (usually the left) demonstrate speech and language impairments. |
parietoccipital cortex
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Aphasia
main idea |
- is the general term used to describe an acquired communication disorder caused by brain damage and characterized by an impairment of language comprehension, formulation and use.
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fluent aphasia
main idea |
speech flows smoothly, with a variety of grammatical constructions and preserved melody of speech, nonsense words, misuse of words and word substitutions. Auditory comprehension is impaired. (receptive language, Wernicke’s)
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nonfluent aphasia
main idea |
the flow of speech is slow and hesitant, vocabulary is limited and syntax is impaired. Articulation may be labored. Comprehension is good. (expressive language, Broca’s)
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global aphasia
main idea |
severe aphasia characterized by marked impairments of the production and comprehension of language
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Dysarthria
main idea |
problems forming words, articulation
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Damage to Broca's Area
(Broca's aphasia) key points... can they produce speech, understand language, are words properly formed, rate of speech? |
Prevents a person from producing speech
Person can understand language Words are not properly formed Speech is slow and slurred. |
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Damage to Wernicke's Area
(Wernicke's aphasia) can they understand langauge, is their language clear? |
Loss of the ability to understand language
Person can speak clearly, but the words that are put together make no sense. This way of speaking has been called "word salad" because it appears that the words are all mixed up like the vegetables in a salad. |
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Perceptual deficits
where is the lesion, typically? |
lesions of the parietal lobe of the nondominant hemisphere usually right). ( anterior or middle cerebral artery).
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Perceptual deficits
what kind of clinical manifestation? |
These may include visuospatial distortions (inability to judge distance, size, position, rate of movement, form, or relation to parts as the whole ie: this pt will continuously run their wheelchair into the door frame), topographical disorientation (consistently get lost), disturbances in body image, and unilateral neglect.
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Cognitive and Behavioral changes
LEFT CVA ability to process information? typical mental state? |
difficulties processing information in a sequential, linear manner
negative, anxious, depressed |
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Cognitive and Behavioral changes
LEFT CVA assuredness? |
slower, more cautious, uncertain and insecure
hesitant in tasks and need more frequent feed back realistic in their appraisal of their existing problems |
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Cognitive and Behavioral changes
RIGHT CVA ability to see "big picture"? general mental attitude? |
difficulty in grasping the whole idea or the overall organization of a pattern or activity
indifferent, quick, impulsive, and euphoric |
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Cognitive and Behavioral changes
RIGHT CVA confidence in ability? attentiveness? |
they overestimate their abilities while minimizing or denying their problems (safety problems)
become distracted and overstimulated easily |
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LABILITY
main idea... |
they change from laughing to crying quickly and are unable to control their emotions
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How is attention span and memory impacted with a STROKE?
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The Pt with stroke typically has a short attention span, and immediate and short term memory is impaired. Long term memory remains intact
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STROKE pts may also exhibit irritability, confusion, restlessness, and sometimes psychosis, delusions or hallucinations. Dementia may occur with multiple brain infarcts. It is characterized by a general decline in higher brain functions such as faulty judgement, impaired consciousness, poor memory, diminished communication, and behavioral or mood alterations. Seizures occur in a small percentage of stroke patients.
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STROKE pts may also exhibit irritability, confusion, restlessness, and sometimes psychosis, delusions or hallucinations. Dementia may occur with multiple brain infarcts. It is characterized by a general decline in higher brain functions such as faulty judgement, impaired consciousness, poor memory, diminished communication, and behavioral or mood alterations. Seizures occur in a small percentage of stroke patients.
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Bladder and Bowel dysfunction with STROKE
main idea |
Urinary incontinence may require a catheter early on, but generally this resolves quickly. Pts are also frequently impacted requiring stool softeners and diet changes.
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Orofacial dysfunction with STROKE
dysphagia main idea |
- a swallowing dysfunction that is a common complication after stroke. Decreased nutritional intake may require a temporary NG tube. Swallow studies or special diets
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visual dysfunction with STROKE
homonymous hemianopsia main idea |
inability to see half the field of vision in one or both eyes- so either can’t see that side at all, or can’t see it well- Pusher Syndrome
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psychological problems with STROKE
common reaction include... |
frustrations in the changes in abilities. Common reactions include: anxiety, depression or denial. Additional their cognitive deficits play a role in their reactions. Depression is extremely common often needing pharmacological management.
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psychological problems with STROKE
which side (L or R) more commonly associated with secondary psych. issues? |
L CVA's more common than R CVA's and brainstem strokes.
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why are Decreasing ROM, Contracture and Deformity often associated with STROKE?
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may result from the loss of voluntary movement
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Deep Vein Thrombosis
often seen in stroke patients? |
DVT's and pulmonary embolism are potential complications for all immobilized patient
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Common signs of a DVT include...?
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calf pain or tenderness (+ Homan's sign), swelling and discoloration of the leg.
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treatments for DVT include...?
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Treatments include anticoagulants and antiplatelet agents, along with bed rest and elevation of the affected limb
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with a STROKE where might the patient have pain?
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Pain the Pt may have pain from muscle imbalances, improper movement patterns, musculoskeletal strain, and poor alignment
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pain with STROKE
thalamic syndrome |
from lesions affecting the thalamus resulting in contralateral sensory dysfunction.
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Shoulder dysfunction with STROKE
what shoulder condition is common (70-84%) with stroke patients? |
: Shoulder subluxation and pain is extremely common (70-84%) of patients post stroke. Adhesive capsulitis is often an eventual complication. Pain usually starts just during movement but if not addressed can eventually be at rest and extend into the arm and hand
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Reflex Sympathetic Dystrophy (RSD or shoulder-hand syndrome)
% that present with this, symptoms? |
also occurs in 12 - 25 % of the cases. The pt experiences swelling and tenderness in the hand and fingers along with shoulder pain. Sympathetic vasomotor changes including warm, red and glossy skin, along with trophic changes. In the latter stages increasing pain, followed by immobilization, stiffness, contractures and muscle atrophy. The skin is now cool, cyanotic and damp. The hand becomes contracted in MP extension and IP flexion. Early diagnosis is essential to prevent the latter deformities.
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Deconditioning with STROKE
cause? |
could be premorbid due to their age and cardiovascular status, prolonged bed rest as well as depression will impact their level of motivation as well as exercise tolerance.
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Recovery from stroke:
a. Mortality rates: what % at one month one year 5 years 10 years |
22 to 37 % at 1 month
25 - 50 % at 1 year 68 - 72 % at 5 years at 10 years only 35 % are still alive |
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when is the recovery from stroke fastest?
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fastest within the first few weeks after onset, with most (as high as 90%) of the neurologic recovery occurring by 3 months. Functional gain may continue for up to a year.
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Medical Management: includes the identification and control of stroke risk factors:
examples of stroke risk factors? |
regulation of BP
dietary adjustments smoking cessation platelet inhibiting therapy (aspirin) control of associated diseases (heart and DM) surgery (endarterectomy or angioplasty) Acute treatment includes returning the Pt to normal body activities. |
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Rehab Management of STROKE
when is rehab most optimal? |
early onset is optimal
timing of rehab should take into consideration: medical stability, motivation, Pt endurance, stage of recovery and the ability to learn |
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who are the members of the REHAB TEAM with a STROKE patient?
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physician
nurse Pt PT OT speech SW neurophyscologist Dietician |
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Assessment of STROKE PATIENT
sense abilities? |
mental status: cognitive function
communication ability sensation perception |
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Assessment of STROKE PATIENT
should you check joint mobility and skin condition? |
joint mobility include ROM, jt play and soft tissue compliance
skin and edema |
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Assessment of STROKE PATIENT
examples of things to look at with MOTOR CONTROL |
motor control: muscle tone, reflexes, reactions, strength, voluntary movement patterns, motor planning ability, coordination, and balance
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Assessment of STROKE PATIENT
examples of things to look at with functional mobility skills? |
Functional mobility skills: bed mobility, transfers, wheelchair mobility and gait
endurance / cardiorespiratory status |
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Acute stroke rehab
when should rehab begin? |
as soon as the Pt is stable (typically within 72 hours)
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Acute stroke rehab
goals with ROM |
promote ROM and prevent deformity
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Acute stroke rehab
goals use of involved side and trunk control? |
promote awareness, active movement, and use of the hemiplegic side
-improve trunk control, symmetry and balance |
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Acute stroke rehab
goals functional mobility? self care? |
improve functional mobility
-initiate self care activities |
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Acute stroke rehab
goals positioning? |
positioning:,-maximize the room to increase awareness of the hemiplegic side (hemi side to the door, family, TV etc) ** be careful to watch for signs of withdrawal in pts with unilateral neglect.
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how often should a STROKE pt be turned while in bed?
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-while spending significant time in bed should be on a 2 - 3 hour turning schedule
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when spending time in bed, a STROKE pt should avoid what kind of positioning?
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avoid: lateral side flexion of the head and trunk toward the affected side with head rotation toward the unaffected side; depression and retraction of the scapula, IR and Add of the arm, elbow flexion and forearm pronation, wrist and finger flexion; retraction and elevation of the hip, with hip and knee extension and hip add; or hip and knee flexion with hip abduction. Plantar flexion in either.
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should foot boards be used with a STROKE pt?
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avoid foot boards, objects in the hand and poor shoulder positions
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what kind of positioning should be promoted for a patient with STROKE while in bed?
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promote: lying in the supine position with head and trunk in midline or flexed slightly to the good side, a small pillow or towel under the scapula to promote protraction, the arm can rest on a pillow extended and in abd, with wrist and finger extension see 343-344 for lying on good side, affected side and sitting
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what is the HEMIPLEGIC ARM at risk for?
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the hemiplegic arm is at great risk for traction and subluxation injuries.
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HEMISLING
main idea and use? |
pads are between the elbow and wrist, these are effective to prevent subluxation but promote contractures in add and IR. They also may impair trunk mobility, balance reactions and a positive body image
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BOBATH SLING
main idea and use |
. Bobath slings are an alternative approach which is a humeral cuff maintained by a figure 8 harness. This avoids the internally rotated and flexed arm. A padded arm trough on the wheelchair is option. It is also good for controlling subluxation
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should slings be used with a STROKE pt with SPASTICITY?
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As spasticity emerges the use of slings are generally contraindicated; can use weight bearing, FES, approximation
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ROM after STROKE: usually ROM techniques with special attention to...
UE Focus |
UE ER and scapular movement (self ROM with overhead pulleys is generally contraindicated)
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ROM after STROKE: usually ROM techniques with special attention to...
LE Focus |
LE focus on the deficits; can use icing which can decrease spasticity, contract/ relax and decrease spasticity; increase tone by tapping, vibration and overflow technique
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functional mobility activities after STROKE
how should they be performed? |
should be practiced bilaterally, guided and AAROM provide a good base for early learning. The Pt should be given only as much assistance as needed and encouraged to move Indep as much as possible
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functional mobility with STROKE
examples of positions |
-bed mobility
-rolling -bridging -prone on elbows -quadruped -coming to sitting -sitting -kneeling -1/2 kneeling -modified plantigrade -standing -transfers -gt -other |
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Post Acute rehab with STROKE
what will pts be continuing with? |
pts will be continuing with the activities and goals initiated during the acute phase. It is important to remember to monitor cardiorespiratory endurance and avoid overexertion
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goals with post acute rehab
secondary complications? sensory and perceptual losses? |
prevent or minimize secondary complications
compensate for sensory and perceptual loss |
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goals with post acute rehab
movement control and posture? |
promote selective movement control and normalization of postural tone
improve postural control and balance |
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goals with post acute rehab
functional mobility and ADLs? |
develop independent functional mobility skills
develop independent ADL's |
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goals with post acute rehab
endurance? socialization? |
develop functional cardiorespiratory endurance
encourage socialization and motivation. |
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Motor control training
what kind of movement patterns? |
stress out of synergy movement patterns
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Motor control training
what kind of movement tasks should be emphasized? |
emphasize movement tasks that allow functional success (feeding, dressing, gt)
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Motor control training
as control develops, what should be tried? |
as control develops use more difficult postures
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Motor control training
what kind of resistance to movement? |
use minimal resistance to movement
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Motor control training
what kind of contractions will be easier? |
generally eccentric contractions will be easier than concentric, but all including isometrics should be practiced
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Motor control training
should spastic or weak muscles be activated first? |
weak muscles should be activated before spastic in unidirectional patterns followed by slow reversals. (balanced interaction is crucial for development of coordinated movement)
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Motor control training
what to do if pt is hypotonic? |
if patient is hypotonic, tone facilitation can be utilized with exteroreceptors, proprioceptors and reflex stimulation. There is a disagreement in theories whether or not to promote synergistic patterns. Can use tapping, quick bounce, stroking, cool pool
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Tone Reduction
when is spasticity typically seen in recovery? |
this spasticity is typically seen in the middle phases of recovery
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Tone Reduction
how should the positioning be? |
positioning out of reflex dependent postures
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Tone Reduction
what kind of movement patterns should be emphasized? |
reflex inhibiting movement patterns (encourages antagonists)
rhythmic rotation out of spastic patterns stimulate antagonists |
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Tone Reduction
what system do you want to activate? |
vestibular system
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Tone Reduction
what effect does prolonged icing have? |
prolonged icing to slow nerve conduction
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Sensory Compensation
which side to use? |
use affected side
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Sensory Compensation
what effect does repetition of sensory stimuli have? |
repetition of sensory stim helps with reorganization
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Sensory Compensation
what kinds of things can increase sensory input? |
stretch, stroking, superficial and deep pressure, and weight bearing will increase sensory input
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Sensory Compensation
where should attention be focused? |
focus attention directly on tasks
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Postural control and balance
why begin in static postures? |
begin in static postures to increase symmetrical weight bearing
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Postural control and balance
progress towards,,,? |
progress to controlled mobility activities
progress to dynamic surfaces |
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UE control with STROKE
begin with X and work X? |
begin with scapular activities and work distally
*reinforce OT guidlines* |
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LE control with STROKE
prepare for X? |
prepares for ambulation
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LE control with STROKE
incorporate X that are appropriate combinations for X? |
incorporate activities that are appropriate combinations for gt
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Gait training with stroke
when should gait training be initiated and why? |
is usually initiated early for motivation and minimize deconditioning. It should focus on attainment of movement control in selective patterns with appropriate timing
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Gait training with stroke
what should be done once deficiencies have been noted? |
Once deficiencies are noted it is important to bring the Pt down to the lower level activities to achieve the selective movement.
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how can persistent posturing of the upper extremity be controlled?
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by holding the hemiplegic. arm in extension and abd with the hand open
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what, if any, orthotic might be indicated with a stroke?
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the CVA pt will most likely need an AFO if any device, KAFO is rarely prescribed and rarely successful. The ankle position is usually utilized to control knee instability. Prescription will depend on the pts unique problems.
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Exercise conditioning
what kind of fitness program should be initiated? |
organized cardiovascular fitness program to increase endurance will be useful for all patients especially those with cardiac compromise. Careful monitoring during exercise is tantamount for success and safety.
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Patient and family education
how should information be conveyed? |
1.give accurate and factual information about the pts capabilities and limitations, avoid predicting the future.
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Patient and family education
how should interventions be structured? |
2.structure interventions carefully and do not overwhelm the Pt or family with information, be consistent and repeat information.
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Patient and family education
what kind of forum should be created? |
3.provide an open forum for communication and discussion
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Patient and family education
what kind of attitude should you have? |
4.be supportive, sensitive and maintain a hopeful manner.
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Patient and family education
role in problem solving with patients and families? |
5.assist pts and families in confronting alternatives and developing problem-solving abilities.
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Patient and family education
how should you impact the patients self esteem? |
6.motivate and provide positive reinforcement in therapy; enhance Pt satisfaction and self esteem.
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Patient and family education
what additional support in the community might you recommend to the patient? |
7.refer to support and self help groups.
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pts who generally do poor in rehab include:
what kinds of mental issues? |
decreased alertness, inattention, poor memory, and an inability to learn new tasks or follow simple commands
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pts who generally do poor in rehab include:
ANOSOGNOSIA definition |
denial of problem
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pts who generally do poor in rehab include:
what kinds of medical complications? |
-significant medical complications (falls, cardiac and DJD)
-serious language disturbances |
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TBI
50% are the result of...? |
Motor vehicle accidents
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TBI
which sex is usually more at risk |
males more than females
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TBI
typical age of a person with a TBI? |
15-24
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a major role of health professionals is education in the prevention of TBI, this includes...?
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use of passive restraints, helmets, responsible alcohol consumption, proper training in athletics and so on.
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Classification and Pathophysiology of TBI
how are TBIs assessed? |
a. mild, moderate or severe based on the Glascow coma scale (492)
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Classification and Pathophysiology of TBI
what determines if it is OPEN or CLOSED? |
depending on skull fracture
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Classification and Pathophysiology of TBI
velocity determinations? |
high velocity or low velocity
diffuse or focal |
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Factors that Influence outcome of a TBI include...?
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the preinjury status of the patient, the primary damage, the cumulative effect of secondary brain damage produced by systemic and intracranial mechanisms that occur after the initial injury
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Premorbid status of TBI include what 3 major categories?
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prior head injury
older adults intelligence and cognitive functioning |
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Primary damage with TBI
what does LOCAL BRAIN DAMAGE refer to? |
damage localized to the site of the impact
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Primary damage with TBI
what do the terms COUP and COUNTERCOUP INJURY refer to? |
under the site of impact as well as directly opposite the site of impact
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Primary damage
POLAR BRAIN DAMAGE refers to...? |
occurs when the head is subjected to acceleration and deceleration (ie head on collision) causes damage to the poles of the lobes due to the shift and abrupt stop, neurologic damage may not show up until 2 - 3 days later when swelling and shifting occur.
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Primary damage
DIFFUSE BRAIN INJURY anatomical picture |
diffuse axonal injury, refers to widely scattered shearing of subcortical axons within their myelin sheath, it can be isolated or also have localized or polar damage with it, it can also extend down into the midbrain and brainstem
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Primary damage
DIFFUSE BRAIN INJURY functional picture |
With this type of injury, the Pt is deeply comatose from the time of injury, has abnormal and autonomic dysfunction (control of involuntary bodily functions).
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Secondary injury
HyYPOXIC-ISCHEMIC INJURY anatomical picture |
vascular compromise due to shifting brain structures
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Secondary injury
HYPOXIC-ISCHEMIC INJURY anatomical picture |
vascular compromise due to shifting brain structures
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Secondary injury
HYPOXIC-ISCHEMIC INJURY injury picture |
. A more diffuse form of this would caused by arterial hypoxemia due to such things as airway obstruction and chest trauma.
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Secondary injury
INTRACRANIAL HEMATOMAS what are they associated with? |
often associated with the "talk and die" pts. This late appearing complication results from compression of the brain by the expanding hematoma.
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Secondary injury
INTRACRANIAL HEMATOMAS how are they usually classified? |
They are usually classified by their site (epidural, subdural or intracerebral) and by the time in which they develop after the injury: acute, subacute and chronic.
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Secondary injury
INTRACRANIAL PRESSURE what is this associated with? |
even mildly increased ICP is associated with increased morbidity.
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Secondary injury
INTRACRANIAL PRESSURE if severely increased? |
Severely increased ICP may result in herniation of the brain (uncal, central (transtentorial), and tonsillar (foramen magnum).
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Other causes to secondary brain damage include...?
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intracranial infection
-cerebral artery vasospasm -obstructive hydrocephalus -post traumatic epilepsy -neurochemical changes |
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Common clinical rating scales with TBI are used to...?
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used to standardize the description of patients who have sustained head injuries.
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The Glascow Coma Scale (GCS) is used to...?
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used to document level of consciousness and define severity of the injury (24-1) shown to be statistically reliable
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The GLASCOW COMA SCALE (GCS) has 4 stages, what are they?
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8 or less = severe
9 - 12 = moderate 13 -15=mild l5=normal |
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Ranchos Los Amigos level of cognitive functioning (LOCF) is...?
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descriptive scale that outlines a predictable sequence of cognitive and behavioral recovery seen in pts with TBI
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Ranchos Los Amigos level of cognitive functioning (LOCF)
is it certain and specific? |
No data on reliability and does not address specific cognitive deficits
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Ranchos Los Amigos level of cognitive functioning (LOCF)
general use with TBI |
It is useful for reporting general cognitive and or behavioral status. (24-3)
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Rappaport's Disability rating scale (DRS):
general use in TBIs? |
covers a wide range of A functional areas and is used to classify level of disability from none - to death. Statistical reliability is high. (24-4)
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Glascow Outcome Scale (GOS)
how different from the original and what is its use? |
original scale expanded to 8 categories, used for research to quantify outcomes. Statistically high reliability
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Diagnostics with TBI
electroencephalograms (EEC) what do they measure? |
measures CNS activity. One form of EEC is evoked potential where the EEC signals are averaged in response to stimuli and used to evaluate sensory function.
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Diagnostics with TBI
computed tomography (CT): what are they usefull for? |
useful for identifying hematomas, atrophy and ventricular enlargement. Not as sensitive as MRI.
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Diagnostics with TBI
magnetic resonance imaging (MRI): sensitivity? |
more sensitive than CT's especially to nonhemorrhagic lesions
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Diagnostics with TBI
cerebral blood flow mapping what does it use and what is its use? |
use PET scans (positron emissions tomography) to measure cerebral metabolism (only 60 worldwide) so limited clinical value. Their is a more common SPECT scan but it is not as sensitive.
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Deficits related to head injury
how does a decreased level of consciousness relate to accelration-deceleration injures? |
occurs consistently in acceleration-deceleration injuries as well as some focal injuries.
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Deficits related to head injury
what characterizes the coma: GCS <8 stage of a TBI? |
"not obeying commands, not uttering words and not opening the eyes", usually lasts only a few weeks at most
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Deficits related to head injury
persistent vegetative state (PVS) is characterized by what? |
postcomatose unawareness, may have a wide range of responses including eye opening and sleep - wake cycles , these may occur at subcortical levels. pts in PVS do not speak or produce any type of behavior that is purposeful or psychologically meaningful.
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Deficits related to head injury
post traumatic amnesia is characterized by what? |
: appear to be conscious, this describes the time between injury and the time when the Pt is able to remember ongoing events.
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Deficits related to head injury
cognitive deficits generally affect what abilities? |
most pts will have residual cognitive deficits. disorders of learning, memory and complex information processing
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Deficits related to head injury
cognitive deficits will generally manifest as? |
problems with selective attention to problems understanding a task, to problems planning a strategy for a solution.
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Deficits related to head injury
can communication be affected? |
deficits in communication: expressive as well as receptive
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Deficits related to head injury
behavioral defecits in what way are they the most disabling TBI defecits? |
these are the most socially disabling of all the TBI deficits. Long term changes in behavior such as sexual disinbibition, apathy, aggression, low frustration tolerance and depression often lead to a life of loneliness and seclusion.
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Deficits related to head injury
sensorimotor defecits general deconditioning due to? |
due to significant medical complications, effects of coma and other changes
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Deficits related to head injury
sensorimotor defecits what kinds of paresis? |
hemiparesis
bilateral hemiparesis |
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Deficits related to head injury
sensorimotor defecits how can they present? |
balance deficits
ataxia and incoordination (cerebellar or basal ganglia damage) |
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Deficits related to head injury
sensorimotor deficits what injuries are associated with this? |
fractures, peripheral nerve injuries and SCI
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Acute management of TBI
where is the focus, medically? |
: focuses on determination of the severity of the injury, preservation of life, and prevention of further damage. ICP may be monitored with a camino bolt (should remain below 20 mmHG
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Acute management of TBI
where is the focus for PT |
pulmonary hygiene, prevention of contractures (ROM, splinting; casting, passive weight bearing on the tilt table), and prevention of pressure sores. Functional mobility may begin when the Pt stabilizes. Always check with the nurse before initiating treatment in the NICU.
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Rehabilitative management with TBI
what is the #1 goal? |
prominent goal is to return the Pt to society at the highest possible level of functioning.
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Rehabilitative management with TBI
for low level patients (LOCF I-III), what does the treatment picture look like? |
these pts have little if any interaction with the environment. Goals of tx to prevent contractures, decubitus ulcers, and increase the level of interaction with the environment.
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Rehabilitative management with TBI
for low level patients (LOCF I-III) how should sensory stimulation be done? |
Sensory stimulation.should be done in short tx sessions (15 - 30 min). Be careful to only administer one stimulus at a time and not to overload.
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Rehabilitative management with TBI
for low level patients (LOCF I-III) how should they be monitored? |
should be closely monitored for response and the following should be noted: latency(time delay between stim and response), consistency (how many times out of a given number of stimulus does the Pt respond the same), intensity (is the response proportional to the stimulus), and duration (how long the response lasts).
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Rehabilitative management with TBI
with types of stimulation, how does the order of loss impact the return? |
Last to shut down is the first to start up
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Rehabilitative management with TBI
general ideas for AUDITORY STIMULATION? |
use normal tones, discuss meaningful topics to the Pt, intermittent use of the radio or television is ok, but discourage background noise during tx.
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Rehabilitative management with TBI
general ideas for VISUAL STIMULATION? |
use familiar objects and pictures, watch for attentiveness and tracking.
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Rehabilitative management with TBI
general ideas for OLFACTORY STIMULATION? |
place scents under pts nose for 10 -15 seconds (may not responds if trached) try and use favorite or familiar smells
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Rehabilitative management with TBI
general ideas for GUSTATORY STIMULATION? |
: watch out for swallowing precautions, use cotton swabs dipped in flavored solutions
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Rehabilitative management with TBI
general ideas for TACTILE STIMULATION? |
provided during functional activities such as turning and bathing, allow Pt to feel the motion of these activities
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Rehabilitative management with TBI
general ideas for VESTIBULAR STIMULATION? |
can be provided with neck ROM, rolling, rocking or WC rides.
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Rehabilitative management with TBI
what range typifies a MID LEVEL for cognitive function? |
mid level: (LOCF IV - VI)
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Rehabilitative management with TBI
what characterizes a MID LEVEL patient who is at LEVEL IV? |
level IV: these pts are in a confused and agitated state and require a tremendous amount of structure. Goals include maintenance or improvement of ROM, prevention of further deconditioning, improved response to simple commands, and prevention of agitated outbursts
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Rehabilitative management with TBI
when working with a MID LEVEL patient how should the treatment proceed? |
It is important to work at the pts physical level and strengthen instead of push to more challenging skills. Sometimes it is easier to use fun activities to get treatment goals
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Rehabilitative management with TBI
when working with a MID LEVEL patient is routine important? |
remember the pt is confused: see the Pt at the same time, same place and same person everyday. establish a routine, provide orientation do no test at this stage
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Rehabilitative management with TBI
when working with a MID LEVEL patient is it important to teach new skills? |
expect no carryover: teaching new skills is unrealistic. Use charts and graphs to help recall.
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Rehabilitative management with TBI
when working with a MID LEVEL patient what importance does your behavior have on them? |
model calm behavior: be calm and so will the Pt
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when working with MID LEVEL TBI patients, how should you accommodate low attention spans and how can you provide a sense of control to the patient?
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be prepared with numerous activities: low attention span requires numerous activities
-offer options: this gives the Pt a sense of control, be careful with the phrasing of your questions |
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when working with MID LEVEL TBI patients, is it beneficial to try and get the patient to understand other points of view?
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expect egocentricity: do not attempt to make the Pt understand other points of view
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Rehabilitative management for TBI
for patients at LEVEL V and VI, what are the common characteristics? |
at this level pts are confused but no longer agitated, they are able to follow simple commands fairly accurately and consistently, if overstressed their abilities will deteriorate
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Rehabilitative management for TBI
for patients at LEVEL V and VI, what should the goals focus on? |
While carryover is now present, new learning is limited. Goals should include increasing the patients participation in the program, increasing or maintaining ROM, increasing physical conditioning, and treating any focal motor defects
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Rehabilitative management for TBI
for patients at LEVEL V and VI, should the treatment schedule be fixed or fluid? |
maintain structure: keep their schedule
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Rehabilitative management for TBI
for patients at LEVEL V and VI, how should instructions be given? |
keep instructions to a minimum: speck slowly and allow for processing delays. Use familiar activities.
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Rehabilitative management for TBI
for patients at LEVEL V and VI, what is the benefit of using physical props? |
use physical props to improve compliance: use timers, charts, graphs. Videotaping may be useful for realism.
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Rehabilitative management for TBI
for HIGH LEVEL (LOCF VII & VIII), is the structure utilized early on still a priority? |
): it is at this level (late VII, early VIII) that pts are usually discharged home. It is important to wean them from the structure utilized early on
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Rehabilitative management for TBI
for HIGH LEVEL (LOCF VII & VIII), what role should decision making in the patient play? |
Pts should be involved in decision making, and reintegrated into their homes and communities. The focus is maintaining performance while decreasing structure and supervision.
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Rehabilitative management for TBI
for HIGH LEVEL (LOCF VII & VIII), what is a common residual problem? |
One residual problem in most brain injuries is some degree of sensorimotor integration dysfunction. Subtle problems with activities that require speed, flexibility, interlimb coordination, rhythm and timing.
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Rehabilitative management for TBI
for HIGH LEVEL (LOCF VII & VIII), what is ROBOT SYNDROME? |
robot like motion, excessive eating, and sedentary avocational activities. Pts at this level should be involved in pleasurable scheduled physical activity. pts who recover to level VIII will need vocational and driving services.
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Rehabilitative management for TBI
issues that cross all levels include the folowing facets in regards to ROM |
: often a combination of treatments is necessary: oral spasticity medications, nerve or motor point blocks, serial casting and positioning systems. If all conservative measures fail the Pt may undergo manipulation under anesthesia or surgical releases. most disabling of all is equines deformities. Use prophylactic casting, serial casting prior to surgery. short leg casts are also useful functionally for tone inhibition.
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Rehabilitative management for TBI
issues that cross all levels include the folowing facets in regards to MOBILITY |
use same techniques as discussed in CVA's but must keep the cognitive difficulties in mind. Improved mobility can result in improved cognitive function.
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Rehabilitative management for TBI
what should not be done if cognitive impairments cause safety issues? |
be careful not to document independence in activities if cognitive impairments cause safety issues.
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Rehabilitative management for TBI
in regards to goal setting and predictions, is there certainty in the projections? |
very Pt specific with outcome predictions very difficult due to the individuality of the injuries.
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