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155 Cards in this Set
- Front
- Back
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What is one of the most frequently used treatments in neurological rehabilitation? ***
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proprioceptive neuromuscular facilitation (PNF)
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How can PNF help improve function? ***
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by addressing
- strength - flexibility - ROM |
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PNF is used to improve what functions in the neurological patient? ***
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- establish head and trunk control
- control pelvis and trunk during movement of extremities - initiate and sustain movement (patient follows hand) - controls shifts in the center of gravity (head, shoulders, hips) |
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Motor learning for neurological patients is enhanced through application of: ***
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- manual contacts (hands on patients, especially patients with cognitive issues)
- manual resistance - verbal input - visual cues (often forgotten--body follows head, head follows eyes) - body position and body mechanics - joint facilitation - stretch (quick-stretch facilitates) - irradiation (overflow) - timing of movement - patterns of movement |
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How does manual contact help the neurological patient? ***
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- touch to the skin stimulates pressure receptors and
- sends information to the patient about desired direction of movement (where you want the patient to move) |
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How should manual contact be carried out when administering PNF to a neurological patient? ***
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- firmly
- generally in direction of muscle fibers - placed on the skin overlying the target muscle groups if possible - lumbrical grip (“puppet hand”) is preferable |
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Why is a lumbrical grip preferable when administering PNF? ***
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- to avoid patient discomfort or excessive pressure
- to provide optimal control of the three-dimensional movements |
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What body positioning should the clinician use when administering PNF? ***
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- pelvis, shoulders, arms, and hands should be in line with movement (visualize the diagonal)
- if not possible, arms and hands should be in alignment with movement - clinician movement should mirror desired patient movement |
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How does the clinician provide resistance when performing PNF? ***
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- through clinician’s own body weight
- hands and arms remain relaxed |
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What is used to facilitate muscle activity when performing PNF? ***
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the stretch reflex (usually quick stretch to elicit motor response)
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What is the difference in muscular response between a quick stretch and a prolonged stretch? ***
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- quick stretch facilitates the elongated muscle as well as synergistic muscles and the same joint
- quick stretch elicits motor response - prolonged stretch elicits decreased muscle activity |
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What are the contraindications and precautions for quick stretch? ***
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contraindications
- joint hypermobility - fracture - pain precautions - spasticity - pain (except that a little pain is actually good for a frozen shoulder, but never operate outside the patient’s tolerance) |
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In PNF, manual resistance is used for: ***
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- influencing movement initiation (irradiation—patient senses the muscle and tells it to move)
- timing of functional movement patterns - motor learning - postural stability - endurance - muscle mass |
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How is the appropriate level of resistance determined for PNF? ***
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- the appropriate resistance is determined based on purpose of intervention (this got a foot stomp)
- for mobility: the greatest amount of resistance tolerated with patient still able to perform movement smoothly - for stability: the greatest amount of resistance that still allows patient to isometrically maintain a designated position |
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What is irradiation? ***
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(a.k.a. overflow, reinforcement)
- spread of muscle activity in response to resistance - magnitude increases in proportion to increased stimulus - examples: --- resistance to trunk flexion produces overflow into hip flexors and ankle dorsiflexors --- resistance to trunk extension produces overflow into the hip and knee extensors --- resistance to hip flexion, adduction, and external rotation produces overflow into the dorsiflexors |
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What manipulations comprise joint facilitation? ***
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- traction (a.k.a. distraction)
- approximation |
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How do traction and approximation maneuvers facilitate the joint? ***
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- they stimulate receptors in the joint
- traction creates elongation of a body segment and may be used to alleviate pain, especially that from edema (any joint can be distracted; take particular care with elbow) - approximation produces compression and is used to promote stability and weight bearing (weight bearing is approximation; better than manual; quadruped is good; against wall, on a plinth for UEs, etc.) |
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What is the best method of approximation? ***
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- weight bearing of the patient’s own body weight is better than any manual approximation
- promotes stability (quadruped is good; against wall, on a plinth for UEs, etc,) |
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What are the important factors to remember concerning proper timing of movement in PNF? ***
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- smooth sequencing of muscle is necessary for normal muscle action
- timing of most functional movements occurs in a distal to proximal direction (e.g., hand is used to pick up pencil, then elbow and shoulder action position it for use) - postural control proceeds proximal to distal or cephalocaudal (remember mobility, stability, controlled mobility, skill) |
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Smooth sequencing of muscle movement is necessary for…. ***
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normal muscle action
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Timing of most functional movements occurs in what direction? ***
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distal to proximal
(e.g., hand is used to pick up pencil, then elbow and shoulder action position it for use) |
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Postural control proceeds in what direction? ***
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proximal to distal (remember mobility, stability, controlled mobility, skill)
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Why does PNF use diagonal patterns of movement? ***
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- most functional movement is triplanar, not uniplanar (be sure to consider this in your treatment approach)
- PNF patterns are based on muscles working synergistically in functional contexts |
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Why are visual cues important during PNF? ***
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- they help with correct body position and motion (mirrors are outstanding in this capacity!)
- eye movement influences both head and body position (stand off to side; head follows eyes) feedback from visual system may be used to - promote stronger muscle contraction - facilitate proper alignment of body parts (photograph of patient posture can be very helpful) - induce postural reactions |
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What types of verbal input should be used during PNF? ***
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verbal commands that
- are concise - give directional cue (especially in patients with cognitive, auditory, or other deficits) |
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What are the three phases of verbal input for PNF? ***
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- preparation
- action - correction |
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How are voice volume and intonation used in PNF? ***
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to either
- facilitate relaxation (e.g., soothing voice) or - prompt greater effort (e.g., drill sergeant) |
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What items should the clinician ensure are carried out on the “PNF checklist”? ***
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- proper patient position
- proper clinician position (in line with movement, mirror movement, lumbrical grip) - proper body mechanics of clinician (use of body weight, not arm strength) - proper manual contacts (lumbrical grip, over affected muscles, in direction of fibers) - proper stretch (quick) - proper resistance (based on purpose or desired response—for mobility/for stability) - proper verbal command (concise, directional, soothing/energizing) - desired movement |
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How are the PNF patterns named? ***
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for the direction of movement in the proximal joint
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Describe the scapular PNF patterns. ***
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- scapular clock: 12:00 head, 6:00 feet
- First Diagonal pattern --- Scapular Anterior Elevation --- Scapular Posterior Depression - Second Diagonal pattern --- Scapular posterior elevation --- Scapular anterior depression |
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What is rhythmic initiation? ***
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- focus on improving mobility
- used to begin patterns of moving - can begin as passive rhythmic movement, then patient instructed to actively move limb (e.g., rolling) |
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What are alternating isometrics and for what are they used? ***
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- isometric holding on one side of a joint, followed by alternate holding of the antagonist muscle groups
- used to promote strength, endurance, and stability |
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What are the positives of placing a patient in quadruped position? ***
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- first posture in developmental sequence with COG significant distance from supporting surface (requires balance)
- multiple options from this position to work on strengthening, range of motion, balance, coordination and endurance (unfortunately, family members often object to this “humiliating” position) |
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What is the typical progression for gait training? ***
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- approximation and stability exercises in standing with feet symmetrically placed
- approximation and stability exercises in midstance and then with weight shifted forward onto front limb - resistance applied to pelvis of advancing limb as patient steps forward (prep for walking; facilitates overflow; work where they are weak) - repetitive stepping forward and backward with one limb - reciprocal gait with manual contacts at pelvis - resisted reciprocal gait |
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Which interventions and clinician behaviors inhibit patient’s muscle tone/response? ***
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- soothing voice
- heat (but can also be facilitory) - massage - prolonged stretch - deep tendon pressure - slow motion—rhythmic initiation, rolling slowly |
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Which interventions facilitate? ***
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- loud voice
- heat (but can also be inhibitory) - tapping - quick stretch - weight shifting - resistance - E-stim |
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Cerebrovascular accidents (CVA) are commonly referred to as a _________. ***
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stroke
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How many Americans are dealing with the sequelae of a stroke? ***
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4.8 million, per the National Stroke Association
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What is the annual incidence of CVA? ***
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700,000 new CVAs annually
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CVA is the ____ leading cause of death in the U.S. ***
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third
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What is a CVA? ***
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the sudden onset of neurologic signs and symptoms resulting from a disturbance in the blood supply to the brain
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Is loss of function from CVA temporary or permanent? ***
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it may be either temporary or permanent
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What are the two (three) major types of CVA? ***
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- ischemic (thrombotic or embolic)
- hemorrhagic (subarachnoid or arteriovenous malformations) (- Transient Ischemic Attack – TIA) |
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What is the predominant form of CVA? ***
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- ischemic (70%)
- subtypes: thrombotic or embolic - ischemia: hypoxia or decreased O2 to brain tissue due to poor blood supply |
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What is the typical cause of a thrombotic ischemic CVA? ***
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- commonly due to atherosclerosis
- if atherosclerotic deposit occludes blood vessel the tissue supplied will die, i.e., cerebral infarct |
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What is the typical cause of an embolic ischemic CVA? *
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- associated with cardiovascular disease
- blood clot breaks away from intima and is carried to the brain - embolus can lodge in cerebral blood vessel, occlude vessel, cause cerebral infarct - once neuronal death occurs, no regeneration |
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What is an ischemic penumbra? ***
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- area surrounding dead cerebral tissue
- vulnerable due to decreased blood supply by 20 to 50% - changes to NTs causes further damage - increased glutamate over stimulation of postsynaptic receptors - facilitates entry of calcium ions into cells - neurotoxic byproducts cause death of additional cells - thus brain injury extends beyond initial site of infarction |
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What are the characteristics of a hemorrhagic CVA? ***
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- 20% of all strokes
- causes include, vessel malformation, loss of vessel integrity due to hypertension, aging - result from abnormal bleeding; ruptured blood vessel - risk increases after age 65 |
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What is a subarachnoid hemorrhage? ***
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- bleeding into subarachnoid space
- primary causes are aneurysm (ballooning of a vessel wall), vascular malformation - 90% due to berry aneurysms: congenital defect of a cerebral artery, vessel is abnormally dilated at a bifurcation |
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What is an arteriovenous malformation? ***
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- congenital anomaly affecting circulation in the brain
- arteries and veins communicate directly, no capillaries for exchange - blood vessels dilate and form masses within the brain - weakens blood vessel walls, in time can rupture causing CVA |
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Describe a TIA and its presentation. ***
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- transient ischemic attack
- resembles a stroke, but not a stroke -cerebral vascular supply temporarily interrupted presentation: - neurological dysfunction - motor - sensory - speech function - recurrent TIAs suggest thrombotic disease and indicate increased risk for stroke |
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What are the most common medical interventions for potential CVAs? ***
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- hospitalization
- attempt to determine etiology - neuroimaging to determine cause (CAT or MRI) - on CAT may take 7 days to show complete insult, MRI can diagnose within 2-6 hours of initial event - physical exam to evaluate: motor, sensory, speech, reflex function |
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How long may it take to show the complete cerebral insult from a CVA via CAT scan? ***
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up to 7 days
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What acute care measures are taken with CVA patients? ***
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- monitoring of neurologic function
- prevention of secondary complications - pharmacologic interventions may include: Heparin, diuretics, calcium channel blockers, thrombolytic and neuroprotective agents - tPA: tissue plasminogen activator, can decrease the effects of neurologic damage when given within 3 hours of onset, however only 3 to 5% of patients arrive in time (as it is a “clot buster” use is only for ischemic stroke, obviously) surgical intervention: - metal clip at base of an aneurysm - removal of an abnormal vessel - evacuation of a hematoma |
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Describe recovery from CVA. ***
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- many survivors sustain permanent neurologic disability
- most significant neurological recovery occurs in 1 to 3 months - movement patterns may improve up to 2 years after initial injury - 10% recover completely - 24% mild impairments - 40% moderate to severe - 10% require LTC - 15% die shortly afterward - patients with 28 days of rehabilitation following CVA show greatest improvement in walking, transfers, self-care, and sphincter control (Functional Independence Measure) |
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How important is the initial month following a CVA? ***
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- most significant neurological recovery occurs in 1 to 3 months
- patients with 28 days of rehabilitation following CVA show greatest improvement in walking, transfers, self-care, and sphincter control (Functional Independence Measure) |
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What are the primary risk factors for CVA? ***
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- primary risk factors: hypertension and heart disease
- hypertension increases risk 4-6 times other risk factors: - diabetes mellitus - smoking - prior CVA or TIAs - obesity - age - physical inactivity - family history - treat medical conditions that are predisposing factors |
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What should be done in the early stages if a CVA is suspected? ***
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- in an effort to increase public awareness and educate: “Brain attack” (so people will take it as seriously as a heart attack)
- outcomes improved with earlier medical intervention - the average person waits 12 hours from onset prior to seeking medical attention |
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With what do clinical manifestations of stroke correspond? ***
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- clinical manifestations vary but correspond to area of cerebral infarct
- neurologic impairments are closely related to area of the brain affected (Review cerebral circulation!!) |
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Describe an anterior cerebral artery occlusion? ***
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- uncommon
- most commonly caused by embolus - anterior cerebral artery supplies superior border of frontal and parietal lobes typical deficits: - contralateral weakness and sensory loss, primarily LEs - incontinence - aphasia - memory and behavioral deficits |
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Describe a middle cerebral artery occlusion. ***
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- most common type of CVA
- middle cerebral artery supplies surface of cerebral hemispheres and the deep frontal and parietal lobes typical deficits: - contralateral sensory loss and weakness in the face and UE, less involvement in the LE - homonymous hemianopia: visual field loss in temporal half of one, and visual field loss in nasal portion of the other |
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Describe a vertebrobasilar artery occlusion. ***
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- complete occlusion usually fatal
- supplies the brain stem and cerebellum typical deficits if cranial nerve involvement - diplopia - dysphagia - deafness - vertigo - ataxia - locked-in syndrome - patient alert and oriented, but unable to move or speak - eye movements are only possible active movement and become patient’s primary means of communication |
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Describe a posterior artery occlusion. ***
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- supplies occipital and temporal lobes
deficits: - contralateral sensory loss - pain - memory deficits - homonymous hemianopia - visual agnosia: inability to recognize familiar objects - cortical blindness: inability to process incoming visual info even though optic nerve intact |
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Describe a lacunar infarct. ***
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most often occur in deep brain
- internal capsule - thalamus - basal ganglia - pons - lacuna: cystic cavity after infarcted tissue removed; common in patients with diabetes and hypertension deficits: - contralateral weakness and sensory loss - ataxia - dysarthria |
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What are some other CVA-associated syndromes? ***
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- neurologic impairments related to area of brain affected
CVA parietal lobe - neglect - impaired vertical, visual, spatial relationships - perseveration Thalamic Pain Syndrome - lesion to lateral thalamus, posterior limb of internal capsule, or parietal lobe - patient experiences burning pain and sensory perseveration Pusher Syndrome - right-sided CVA of posterolateral thalamus - patient actively leans toward hemiplegic side - efforts to passively correct are met with resistance - need to ensure these patients have a seatbelt on! |
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On what do the post-CVA functional capabilities of a patient depend? ***
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- number of different impairments
functional capabilities dependent upon: - nature of stroke - amount of nervous tissue damaged - preexisting medical conditions - family support - financial resources |
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What types of motor impairments might a patient experience post-CVA? ***
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- damage to motor cortex leads to multiple motor problems
- flaccidity (hypotonicity) – muscles lack ability to initiate movement or contract, usually only temporary - spasticity (hypertonicity) – exaggerated deep tendon reflexes, synergy patterns present |
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What is spasticity? ***
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- classic theory: response to UMN lesion, hyperexcitability of monosynaptic stretch reflex
--- increased output from muscle spindle afferents controls alpha motor neuron activity in gray matter of spinal cord --- uninterrupted activity of gamma efferent or motor system is believed to account for continuous activation of the afferent system by maintaining the muscle spindle’s sensitivity to stretch - current theory: stretch reflex is not strong enough to control all alpha motor neuron activity --- hypertonicity develops from abnormal processing of the afferent (sensory) input after the stimulus reaches the spinal cord --- defect in inhibitory modulation from higher cortical centers and spinal interneuron pathways leads to presence of spasticity |
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How is the Modified Ashworth Scale used to assess tone? ***
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- clinical tool to assess presence of abnormal tone (0 – 4 scale)
0 – no increase in muscle tone 1 – slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of ROM when the affected part is moved in flexion or extension 1+ - slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM 2 – more marked increase in muscle tone through most of the ROM, but affected part easily moved 3- considerable increase in muscle tone, passive movement difficult 4 – affected part rigid in flexion or extension synergy |
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How is the Brunnstrom Stages of Recovery scale used? ***
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- describes characteristics of stages of motor recovery after CVA
I – flaccidity – no voluntary or reflex activity is present in the involved extremity II – spasticity begins to develop – synergy patterns begin to develop; some of the synergy components may appear as associated reactions III – spasticity increases and reaches its peak – movement synergies of the involved UE or LE can be performed voluntarily IV – spasticity begins to decrease – deviation from the movement synergies is possible; limited combinations of movement may be evident V – spasticity continues to decrease – movement synergies are less dominant; more complex combinations of movements are possible VI – spasticity is essentially absent – isolated movements and combinations of movements are evident; coordination deficits may be present with rapid activities VII – return to normal function – return of fine motor skills |
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What is synergy, per Brunnstrom’s synergy patterns? ***
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defined group of muscles working together to produce patterns of movement
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Describe a UE flexion synergy. ***
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- scapular retraction and/or elevation
- shoulder external rotation - shoulder abduction to 90 degrees - elbow flexion - forearm supination - wrist and finger flexion |
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Describe a UE extension synergy. ***
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- scapular protraction
- shoulder internal rotation - shoulder adduction - full elbow extension - forearm pronation - wrist extension with finger flexion |
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Describe a LE flexion synergy. ***
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- hip flexion, abduction, and external rotation
- knee flexion to approximately 90 degrees - ankle dorsiflexion and inversion - toe extension |
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Describe a LE extension synergy. ***
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- hip extension, adduction, and internal rotation
- knee extension - ankle plantar flexion and inversion - toe flexion |
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How does spasticity typically develop post-CVA? ***
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- typically develops first in shoulder and pelvis
- spasticity usually develops proximally to distally - reason for the characteristic synergy patterns |
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What other motor impairments may be noted post-CVA? ***
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- muscle weakness
- paresis - easily fatigued motor units - atrophy of remaining muscle fibers - CVA may also affect muscles on uninvolved side |
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How may motor planning deficits manifest post-CVA? ***
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- most common with left hemisphere involvement
- difficulty performing purposeful movement even though patient may have no sensory or motor impairments - apraxia: have motor capability to perform specific movement, but patient unable to remember how to perform the task (e.g., unable to remember motions to complete or correct order for sit-to-stand) |
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What sensory impairments may be noted post-CVA? ***
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- parietal lobe involvement
- may lose tactile or proprioception --- evaluation of proprioception: joint moved quickly in specific direction with patient’s eyes closed; patient asked to identify direction of movement --- patients tend to have partial impairment rather than complete --- impairments may affect ability to maintain upright posture |
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What communication impairments may be noted post-CVA? ***
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- 30% of CVAs with frontal or temporal lobe involvement experience communication deficits
- Aphasia: communication disorder caused by brain damage – impaired language comprehension, oral expression, and use of symbols to communicate ideas --- Broca’s Aphasia: expressive disorder --- Wernicke’s Aphasia: receptive aphasia --- Global Aphasia: both expressive and receptive - important to establish some form of communication—talk to the SLP - dysarthria: difficulty forming words and a result of weakened musculature - emotional lability: difficulty controlling emotions; may laugh or cry suddenly for no apparent reason |
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What orofacial deficits may be noted post-CVA? ***
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- usually due to cranial nerve involvement
- facial assymetries - dysphagia (food pockets) – check cheeks before putting these patients on their backs on a mat!! - poor coordination with eating and breathing – may lead to aspiration |
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What respiratory impairments may be noted post-CVA? ***
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- decreased lung expansion, decreased control of muscles of respiration
- diaphragm may be affected - decreased vital capacity - decreased activity contributes to decreased respiratory function - patients often complain of fatigue post-CVA |
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What reflex activity may be noted post-CVA? ***
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- primitive reflexes may appear
- spinal level reflexes occur at the spinal cord level if noxious stimulus - patient and family education needed to ensure they know it is not a sign of volitional movement |
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What spinal (primitive) reflexes might be noted post-CVA? ***
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- flexor withdrawal to noxious stimulus applied to bottom of foot – causes:
--- hip and knee flexion --- ankle dorsiflexion --- toe extension - cross extension to noxious stimulus applied to the ball of foot with LE prepositioned in extension – causes flexion and then extension of the opposite LE - startle reflex to sudden loud noise – causes extension and abduction of UEs - grasp reflex to pressure applied to ball of foot or palm of hand – causes flexion of the toes or fingers, respectively (all the above are primitive reflexes—spinal cord level, present at 28 weeks’ gestation and integrated by 1-2, 1-2, 4-6, and 9 months respectively) |
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What spinal (tonic) reflexes might be noted post-CVA? ***
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- ATNR – rotation of head to left causes extension of left arm and leg, flexion of right arm and leg; and vice versa
- STNR – flexion of neck and arms, extension of legs; extension of neck and arms, flexion of legs - TLR – prone position facilitates flexion; supine position facilitates extension tonic thumb reflex – when involved extremity is elevated above the horizontal, thumb extension is facilitated with forearm supination (all the above are postural tonic reflexes—brainstem level, present at birth, 4-6 months, birth-2 months, and ???; integrated by 4-6 months, 8-12 months, persists, and ???) |
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What associated reactions may be noted post-CVA? ***
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- Souques’ phenomenon – flexion of involved arm above 150 degrees facilitates extension and abduction of fingers
- Raimiste’s phenomenon – resistance applied to hip abduction or adduction of the uninvolved LE causes a similar response in the involved LE - Homolateral limb synkinesis – flexion of the involved UE elicits flexion of the involved LE |
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What bladder and bowel dysfunctions may be seen post-CVA? ***
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- incontinence due to muscle paralysis or inadequate sensory stimulation to the bladder
- early weightbearing through bridging or standing assists with regaining bladder control - rehab team works together to assist patient with regaining this ADL; documentation important |
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What are the keys to treatment planning for the post-CVA patient? ***
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- PT will develop the treatment plan based on patient’s prior level of functioning (PLOF)
- patient and family should actively participate - interventions selected by PT should be directly related to specific functional tasks |
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What is the Functional Independence Measure? ***
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- developed in early 1980s as national data system
- measures physical, psychological, and social function - specific items include: self-care, transfers, locomotion, communication, and cognition - uses 7 point ordinal scale - PT completes FIM at intial eval - PTA completes and reports progress to rehab team 0 – not done by patient or helper 1 – total assist (or requires 2 people to assist) patient performs < 25% 2 – maximum assist, patient performs 25-49% of task (or 1 of 3 tasks) 3 –moderate assist, patient performs 50-74% of task (or 2 of 3) 4 – minimum assistance contact guard or steadying assist, patient > 75% of task 5 – supervision only, no touch, set up, verbal cueing 6 – modified independence, assistive device, more time, safety 7 – independent and safe - measures level of patient independence in several categories: ---- self-care ---- sphincter control ---- transfers ---- locomotion (locomotion scale includes steps, level vs. uneven, distance, and amount of assistance required) ---- communication, and ---- social cognition self care - eating - grooming - bathing - dressing UE - dressing LE* sphincter control - toileting (pull down, wipe, pull up)* - bladder (level and frequency of accidents) - bowel (level and frequency of accidents) transfers - transfer bed* - transfer toilet* - tub/shower transfers* locomotion - locomotion (walk/WC)* - stairs* communication and social cognition - comprehension - expression - social interaction - problem solving - memory * - typically what is done in rehab |
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What are some complications noted post-CVA? ***
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- flexion contractures due to spasticity
- unable to open fist to wash palm or trim nails - shoulder pain, subluxation - Complex Regional Pain Syndrome (previously RSD or shoulder/hand syndrome) may develop --- pain, ANS S & S: edema, atrophy, temp changes, sweating, mottled skin, thin brittle nails, extreme sensitivity --- progresses in three stages --- management but no cure - increased risk of trauma, falls - increased risk of thrombophlebitis - pain - depression (30 to 60%) |
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What (general) early physical therapy interventions are carried out with post-CVA patients? ***
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cardiopulmonary
- diaphragm strengthening, blowing bubbles, stretching lateral trunk - holding breath increases blood pressure; may need to monitor vitals depending on patient’s condition positioning - should be started immediately, continue though all stages of recovery, and is everyone’s responsibility - position out of typical synergy pattern, avoiding potential pressure points - alternate between back, involved side, uninvolved side -shoulder and pelvis first to be addressed --- frequently rhomboids and gluteus maximus become tight --- position in slight protraction - when leaving patient room leave needed items within reach - place objects near involved side to discourage neglect common bad ideas - soft object, ball, wash cloth in spastic hand—may facilitate palmar grasp reflex and increase spasticity - footboard intended to prevent gastroc tightness—opposite effect due to constant pushing against by patient |
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How are facilitory and inhibitory activities carried out with post-CVA patients? ***
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- eliciting primitive reflexes during PT treatment should be avoided (flexor withdrawal, cross extension, startle/Moro, grasp)
- only utilize tonic reflexes if all else fails - perform quick stretch only until patient is able to actively recruit muscle - tapping, vibration, approximation, weight bearing are facilitory --- applied from muscle insertion to origin (tapping and vibration) - inhibition --- slow, rhythmic rotation beginning proximally - ice may be used with caution |
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What functional activities are performed with the post-CVA patient? ***
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- rolling to begin immediately
--- toward involved side easier --- toward uninvolved harder - bed mobility - scooting - movement transitions --- supine –to –sit --- WC to bed/mat --- bed to commode - positioning - bridging and bridging with approximation - hip extension over edge of mat or bed - SLR with HS co-contraction - lower trunk rotation and LTR with bridging - hip flexor retraining - hip and knee extension with ankle DF - UE elevation - functional activities |
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What is a traumatic brain injury (TBI)? ***
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- an insult to the brain, not of a degenerative or congenital nature, but caused by an external physical force, that may produce a diminished or altered state of consciousness, resulting in an impairment of cognitive abilities or physical functioning
- can also result in the disturbance of behavioral or emotional function - these impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment |
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What is the annual incidence and severity of brain injury. ***
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- 1.5 million Americans are brain injured annually
- 230,000 experience mild to moderate TBI - 80,000 long-term disability - < 50,000 die (CDC 2004) |
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What is the most common cause of TBI? ***
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motor vehicle accident (MVA)
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Who are the most at-risk populations for TBI? ***
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- infants and children
- those between 15-24 - those over 75 years of age |
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By what percentage can wear of a bicycle helmet reduce risk of TBI in children? ***
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88%
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What are some factors that influence the outcome for patients following TBI? ***
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- amount of immediate damage from injury
- cumulative effects of secondary brain injury - pre-morbid cognitive characteristics - presence or absence of substance abuse - pre-injury personality and work history |
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What is the difference between an open and a closed/intracranial TBI? ***
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- open injuries: penetrating wounds, gunshot, knife
- closed or intracranial injury: impact to head with injury, skull does not fracture, dura remains intact |
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List some subtypes of closed head injuries. ***
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- concussion
- contusion - hematoma - locked-in syndrome and other acquired brain injuries |
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What is a concussion and what are its symptoms? ***
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- momentary loss of consciousness and reflexes
symptoms: - dizziness - disorientation - difficulty concentrating - nausea - HA - blurred vision - alterations in sleep patterns - loss of balance |
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What is retrograde amnesia? ***
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loss of memory of events prior to injury
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What is post-traumatic amnesia? ***
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inability to remember or learn new information
(duration is an indicator of severity of injury) |
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What is a contusion? ***
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bruising on surface of the brain sustained at the time of impact
- small vessels hemorrhage - same-side contusion: coup lesion - contralateral contusion: contrecoup lesion (rebound) - extent of injury dependent upon depth of tissue damage |
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What is a coup lesion? A contrecoup lesion? ***
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- same-side contusion: coup lesion
- contralateral contusion: contrecoup lesion (rebound—the brain bounces back to the opposite side) |
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What is a hematoma? ***
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- localized swelling that is filled with blood caused by a break in the wall of a blood vessel
- the blood is usually clotted or partially clotted - vascular hemorrhage with hematoma formation - epidural hematomas : between dura mater and skull - subdural hematoma: acute venous hemorrhage rupture of cortical bridging veins; bleeding between the dura and the brain itself |
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What is Locked-in syndrome? ***
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rare, complete paralysis of all voluntary muscles except those that control eye movement
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What is an acquired brain injury? ***
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brain pathology that occurs at the cellular level and affects cells throughout the entire brain; primarily due to disruption of oxygen to brain tissue
(e.g., airway obstruction, near-drowning, toxin exposure, MI, CVA, electrical shock) |
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What are some secondary problems of TBI? ***
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- damage may occur within the hour or several months later
- increased intracranial pressure is common post TBI (70%) --- normal ICP 5 – 10 mm Hg (>20 mm HG is abnormal and dangerous) --- ICP typically develops in first week |
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What activities may increase ICP? ***
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- activities that may increase ICP:
--- cervical flexion --- percussion and vibration techniques --- coughing |
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What are some signs and symptoms of ICP? ***
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- decreased responsiveness
- impaired consciousness - irritability - severe headache - vomiting - changes in vitals, increased BP, decreased HR - papilledema (edema and inflammation of optic nerve at entrance to retina) |
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What are anoxic injuries? ***
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- caused by disruption of the oxygen supply to the brain
- damage is typically diffuse - amnesia and movement disorders prevalent |
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What percentage of the body’s oxygen supply is used by the brain? ***
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20%
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From what pathologies do anoxic injuries typically result? ***
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they most often result from cardiac arrest
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What disorders frequently accompany an anoxic injury? ***
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- amnesia
- movement disorders |
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What is posttraumatic epilepsy? How common is it? ***
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- an increased seizure risk post TBI
- 3,000 new cases annually occurring after TBI |
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With which type of head injury is posttraumatic epilepsy more common? ***
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more common with open head injuries
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What are some potential causes of posttraumatic epileptic seizures? ***
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seizures may be triggered by:
- poor nutrition - electrolyte imbalance - missed medications - drug use - stress - emotions - infection - fever - vestibular stimulation - flickering lights |
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For what is the Glasgow Coma Scale used? What does it evaluate? ***
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- to assess arousal and function of the cerebral cortex
evaluates - eye-opening ability - motor response - verbal response |
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Describe the scoring/grading of the Glasgow Coma Scale. ***
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scores range from 3 to 15
- mild TBI: GCS 13 or more; loss of consciousness < 20 mins., normal CAT scan - moderate TBI: GCS 9 -12; may have permanent deficits - severe TBI: GCS 3-8; in a coma, most have permanent impairment eye opening 1 – no respone 2 – in response to pain 3 – in response to speech 4 – spontaneous motor response 1 – no response 2 – decerebrate posturing 3 – decorticate posturing 4 – withdraws to pain 5 – localized 6 – obeys verbal command verbal response 1 – no response 2 – incomprehensible sounds 3 – use of inappropriate words 4 – conversation confused 5 - oriented |
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What are the GCS scores and characteristics of a mild TBI? Moderate TBI? Severe TBI? ***
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- mild TBI: GCS 13 or more; loss of consciousness < 20 mins., normal CAT scan
- moderate TBI: GCS 9 -12; may have permanent deficits - severe TBI: GCS 3-8; in a coma, most have permanent impairment |
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What is a MACE? ***
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Military Acute Concussion Evaluation
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What are some common problems with TBI? ***
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- decreased level of consciousness
- cognitive impairments - communication deficits - behavioral changes - motor or movement disorders - sensory problems - associated problems |
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What is arousal? ***
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primitive state of being awake or alert (RAS function)
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What is awareness? ***
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conscious of internal and external environment
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What is consciousness? ***
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state of being aware
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What is coma? ***
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state of unconsciousness, no arousal (no sleep-wake cycle)
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What is a vegetative state? ***
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- brainstem reflexes and sleep-wake cycle have returned
- some periods of arousal, but remains unaware |
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What is persistent vegetative state? ***
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vegetative state lasting longer than a year
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What is stupor? ***
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general unresponsiveness
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What is obtundity? ***
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- disinterest in environment
- slow response to sensory environment |
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What is delirium? ***
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- patient is disoriented, fearful
- misperceives sensory stimuli |
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What is clouding of consciousness? ***
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- confused, distracted
- poor memory |
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What are some cognitive deficits noted with TBI patients? ***
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- disorientation
- poor attention span - loss of memory - poor organizational and reasoning skills - poor problem-solving skills - unable to control emotional responses |
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What are two abnormal postures noted with TBI patients? ***
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decerebrate rigidity:
- LE: extension, hips IR, ADD, knees extended, ankles PF and feet supinated - UE: IR and extended shlds, extended elbows, pronated forearms, flexed wrists and fingers decorticate rigidity: - LE: extension - UE: shlds IR, ADD, elbow flex, pronated forearms,wrist flexion |
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What are some motor deficits noted with TBI patients? ***
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- generalized weakness
- disorders of muscle tone - cardiovascular issues - motor sequencing issues, ataxia - decreased balance - primitive and/or tonic reflexes - may have good motor skills but poor cognitive abilities - environment is important – may need quiet/solitude in order to focus/perform |
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What are some sensory deficits noted with TBI patients? ***
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- sense of smell may be diminished or absent
- cutaneous sensation may be impaired or absent - visual, perceptual, and proprioceptive deficits - deficit depends on area of brain damage |
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What are some behavioral deficits noted with TBI patients? ***
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- may have personality and temperament change
- neuroses, psychoses - sexual disinhibition, apathy - irritability, agitation - low frustration tolerance - lack of emotional control - lability, aggressive behavior |
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What are some other problems frequently associated with TBI? ***
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40% of TBI patients also have other injuries
- orthopedic injuries - fractures - lacerations - SCI |
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What physical therapy interventions are conducted with TBI patients in the acute stage and when? ***
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interventions/goals:
- increase arousal - prevent secondary impairments - improve function - patient and family education - PT as soon as patient is stable |
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How is TBI patient positioning important in the acute stage? ***
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- patients are often positioned supine for ease of care, however
- supine greatest impact of tonic labyrinth reflexes and extensor tone domination - side-lying and semiprone positions reduce influence of these reflexes - prone, with UE in slight abduction and external rotation inhibits abnormal tone |
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What are the levels of the Rancho Los Amigos Scale of Cognitive Functioning? ***
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Level I – no response; total assistance
Level II – generalized response; total assistance Level III – localized response; total assistance Level IV – confused/agitated; maximal assistance Level V – confused, inappropriate nonagitated; maximal assistance Level VI – confused, appropriate; moderate assistance Level VII – automatic, appropriate; minimal assistance for daily living skills Level VIII – purposeful, appropriate; standby assistance Level IX – purposeful, appropriate; standby assistance on request Level X – purposeful,, appropriate; modified independent |
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What issues will physical therapy address during inpatient rehabilitation? ***
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- abnormal posturing, muscle tone
- presence of primitive reflexes - decreased ROM, potential for contractures - decreased endurance - decreased awareness and responsiveness - decreased sensory awareness - communication - knowledge of condition |
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How does the therapist help to increase patient awareness? ***
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- even when patient is comatose, speak to them as if they hear and understand
- always explain procedures prior to treatment - develop rapport |
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How is sensory stimulation used as an intervention? ***
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- while its use is debatable as intervention
- used to determine level of arousal - if used, limit exposure, so you’re able to determine which stimulus caused response - leave adequate time for response after application of stimulus - response may be: heart rate, BP, muscle tone, grimacing, eye movement, vocal |
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What other positioning issues are important during inpatient rehabilitation? ***
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- changed every 2 hours to prevent DU
- respiratory hygiene - prevent orthostatic hypotension - tilt-in-space WC for those unable to maintain head and neck/trunk control - standard WC for those with fair head and trunk control |
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What is the role of the therapist for wheelchair propulsion in inpatient rehabilitation? ***
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- goal is Independence if possible
- PT or PTA may guide hand over hand - ROM: prevent, treat contractures PRN, serial casting may be used |
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How is family education important to a TBI patient? ***
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- teaching them ways to assist is important: via pictures, music, etc.
- ensure family members are careful not to overstimulate - family members should be encouraged to assist with patient positioning, bed mobility, transfers, body mechanics - clinician should provide education on potentially unusual behavior - family should know there are support services available |
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What must frequently be done before functional mobility training? How is this done? ***
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often need to inhibit tone first,
- rhythmic initiation, rotation - prolonged stretch - weightbearing - approximation |
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What are the goals of functional mobility training? ***
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- focus on development of postural control
- interventions in prone are useful for head and neck control (e.g., stability ball) - contraindicated for seizure disorders or increased ICP - commonplace tasks may be more easily learned (ADLs are more meaningful to patient) - use of hand-over-hand guidance techniques |
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What sitting and transfer activities are carried out with the TBI patient and why? ***
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- supine-to-sit transfer
- sit-pivot transfer - standing unconscious patient/support in standing - sitting and transferring may increase arousal - challenge to postural alignment |
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What are some motor deficit interventions used for patients with a high physical level? ***
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- maintaining balance
- raising arms overhead - PNF diagonals - trunk rotation or lateral bend - reciprocal arm movements - anterior/posterior pelvic tilts - marching - bouncing in a circle - moving sit-to-supine, sit-to-prone |
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What physical and cognitive tasks are emphasized in inpatient therapy for TBI? ***
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- throwing and catching
- obstacle course - counting repetitions - progressing toward independence in exercises - field trips |
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What is involved in the discharge planning for a TBI patient? ***
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- may require follow up home care
- may need placement in long-term care facility - may need outpatient PT - team approach to discharge planning: family, patient, PT, PTA, OT, SLP, physician, social work services |
