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155 Cards in this Set

  • Front
  • Back
What is one of the most frequently used treatments in neurological rehabilitation? ***
proprioceptive neuromuscular facilitation (PNF)
How can PNF help improve function? ***
by addressing
- strength
- flexibility
PNF is used to improve what functions in the neurological patient? ***
- 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)
Motor learning for neurological patients is enhanced through application of: ***
- 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
How does manual contact help the neurological patient? ***
- 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)
How should manual contact be carried out when administering PNF to a neurological patient? ***
- firmly
- generally in direction of muscle fibers
- placed on the skin overlying the target muscle groups if possible
- lumbrical grip (“puppet hand”) is preferable
Why is a lumbrical grip preferable when administering PNF? ***
- to avoid patient discomfort or excessive pressure
- to provide optimal control of the three-dimensional movements
What body positioning should the clinician use when administering PNF? ***
- 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
How does the clinician provide resistance when performing PNF? ***
- through clinician’s own body weight

- hands and arms remain relaxed
What is used to facilitate muscle activity when performing PNF? ***
the stretch reflex (usually quick stretch to elicit motor response)
What is the difference in muscular response between a quick stretch and a prolonged stretch? ***
- 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
What are the contraindications and precautions for quick stretch? ***
- joint hypermobility
- fracture
- pain

- spasticity
- pain (except that a little pain is actually good for a frozen shoulder, but never operate outside the patient’s tolerance)
In PNF, manual resistance is used for: ***
- 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
How is the appropriate level of resistance determined for PNF? ***
- 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
What is irradiation? ***
(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
What manipulations comprise joint facilitation? ***
- traction (a.k.a. distraction)

- approximation
How do traction and approximation maneuvers facilitate the joint? ***
- 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.)
What is the best method of approximation? ***
- 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,)
What are the important factors to remember concerning proper timing of movement in PNF? ***
- 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)
Smooth sequencing of muscle movement is necessary for…. ***
normal muscle action
Timing of most functional movements occurs in what direction? ***
distal to proximal
(e.g., hand is used to pick up pencil, then elbow and shoulder action position it for use)
Postural control proceeds in what direction? ***
proximal to distal (remember mobility, stability, controlled mobility, skill)
Why does PNF use diagonal patterns of movement? ***
- 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
Why are visual cues important during PNF? ***
- 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
What types of verbal input should be used during PNF? ***
verbal commands that
- are concise
- give directional cue (especially in patients with cognitive, auditory, or other deficits)
What are the three phases of verbal input for PNF? ***
- preparation
- action
- correction
How are voice volume and intonation used in PNF? ***
to either
- facilitate relaxation (e.g., soothing voice) or
- prompt greater effort (e.g., drill sergeant)
What items should the clinician ensure are carried out on the “PNF checklist”? ***
- 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
How are the PNF patterns named? ***
for the direction of movement in the proximal joint
Describe the scapular PNF patterns. ***
- 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
What is rhythmic initiation? ***
- 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)
What are alternating isometrics and for what are they used? ***
- isometric holding on one side of a joint, followed by alternate holding of the antagonist muscle groups

- used to promote strength, endurance, and stability
What are the positives of placing a patient in quadruped position? ***
- 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)
What is the typical progression for gait training? ***
- 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
Which interventions and clinician behaviors inhibit patient’s muscle tone/response? ***
- soothing voice
- heat (but can also be facilitory)
- massage

- prolonged stretch
- deep tendon pressure
- slow motion—rhythmic initiation, rolling slowly
Which interventions facilitate? ***
- loud voice
- heat (but can also be inhibitory)
- tapping

- quick stretch
- weight shifting
- resistance
- E-stim
Cerebrovascular accidents (CVA) are commonly referred to as a _________. ***
How many Americans are dealing with the sequelae of a stroke? ***
4.8 million, per the National Stroke Association
What is the annual incidence of CVA? ***
700,000 new CVAs annually
CVA is the ____ leading cause of death in the U.S. ***
What is a CVA? ***
the sudden onset of neurologic signs and symptoms resulting from a disturbance in the blood supply to the brain
Is loss of function from CVA temporary or permanent? ***
it may be either temporary or permanent
What are the two (three) major types of CVA? ***
- ischemic (thrombotic or embolic)

- hemorrhagic (subarachnoid or arteriovenous malformations)

(- Transient Ischemic Attack – TIA)
What is the predominant form of CVA? ***
- ischemic (70%)

- subtypes: thrombotic or embolic

- ischemia: hypoxia or decreased O2 to brain tissue due to poor blood supply
What is the typical cause of a thrombotic ischemic CVA? ***
- commonly due to atherosclerosis

- if atherosclerotic deposit occludes blood vessel the tissue supplied will die, i.e., cerebral infarct
What is the typical cause of an embolic ischemic CVA? *
- 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
What is an ischemic penumbra? ***
- 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
What are the characteristics of a hemorrhagic CVA? ***
- 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
What is a subarachnoid hemorrhage? ***
- 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
What is an arteriovenous malformation? ***
- 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
Describe a TIA and its presentation. ***
- transient ischemic attack
- resembles a stroke, but not a stroke
-cerebral vascular supply temporarily interrupted

- neurological dysfunction
- motor
- sensory
- speech function

- recurrent TIAs suggest thrombotic disease and indicate increased risk for stroke
What are the most common medical interventions for potential CVAs? ***
- 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
How long may it take to show the complete cerebral insult from a CVA via CAT scan? ***
up to 7 days
What acute care measures are taken with CVA patients? ***
- 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
Describe recovery from CVA. ***
- 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)
How important is the initial month following a CVA? ***
- 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)
What are the primary risk factors for CVA? ***
- 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
What should be done in the early stages if a CVA is suspected? ***
- 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
With what do clinical manifestations of stroke correspond? ***
- clinical manifestations vary but correspond to area of cerebral infarct

- neurologic impairments are closely related to area of the brain affected
(Review cerebral circulation!!)
Describe an anterior cerebral artery occlusion? ***
- 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
Describe a middle cerebral artery occlusion. ***
- 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
Describe a vertebrobasilar artery occlusion. ***
- 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
Describe a posterior artery occlusion. ***
- supplies occipital and temporal lobes
- 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
Describe a lacunar infarct. ***
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

- contralateral weakness and sensory loss
- ataxia
- dysarthria
What are some other CVA-associated syndromes? ***
- 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!
On what do the post-CVA functional capabilities of a patient depend? ***
- number of different impairments

functional capabilities dependent upon:
- nature of stroke
- amount of nervous tissue damaged
- preexisting medical conditions
- family support
- financial resources
What types of motor impairments might a patient experience post-CVA? ***
- 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
What is spasticity? ***
- 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
How is the Modified Ashworth Scale used to assess tone? ***
- 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
How is the Brunnstrom Stages of Recovery scale used? ***
- 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
What is synergy, per Brunnstrom’s synergy patterns? ***
defined group of muscles working together to produce patterns of movement
Describe a UE flexion synergy. ***
- scapular retraction and/or elevation
- shoulder external rotation
- shoulder abduction to 90 degrees

- elbow flexion
- forearm supination
- wrist and finger flexion
Describe a UE extension synergy. ***
- scapular protraction
- shoulder internal rotation
- shoulder adduction

- full elbow extension
- forearm pronation
- wrist extension with finger flexion
Describe a LE flexion synergy. ***
- hip flexion, abduction, and external rotation
- knee flexion to approximately 90 degrees
- ankle dorsiflexion and inversion
- toe extension
Describe a LE extension synergy. ***
- hip extension, adduction, and internal rotation
- knee extension
- ankle plantar flexion and inversion
- toe flexion
How does spasticity typically develop post-CVA? ***
- typically develops first in shoulder and pelvis
- spasticity usually develops proximally to distally

- reason for the characteristic synergy patterns
What other motor impairments may be noted post-CVA? ***
- muscle weakness
- paresis

- easily fatigued motor units
- atrophy of remaining muscle fibers

- CVA may also affect muscles on uninvolved side
How may motor planning deficits manifest post-CVA? ***
- 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)
What sensory impairments may be noted post-CVA? ***
- 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
What communication impairments may be noted post-CVA? ***
- 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
What orofacial deficits may be noted post-CVA? ***
- 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
What respiratory impairments may be noted post-CVA? ***
- 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
What reflex activity may be noted post-CVA? ***
- 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
What spinal (primitive) reflexes might be noted post-CVA? ***
- 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)
What spinal (tonic) reflexes might be noted post-CVA? ***
- 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 ???)
What associated reactions may be noted post-CVA? ***
- 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
What bladder and bowel dysfunctions may be seen post-CVA? ***
- 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
What are the keys to treatment planning for the post-CVA patient? ***
- 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
What is the Functional Independence Measure? ***
- 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)

- transfer bed*
- transfer toilet*
- tub/shower transfers*

- locomotion (walk/WC)*
- stairs*

communication and social cognition
- comprehension
- expression
- social interaction
- problem solving
- memory

* - typically what is done in rehab
What are some complications noted post-CVA? ***
- 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%)
What (general) early physical therapy interventions are carried out with post-CVA patients? ***
- diaphragm strengthening, blowing bubbles, stretching lateral trunk
- holding breath increases blood pressure; may need to monitor vitals depending on patient’s condition

- 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
How are facilitory and inhibitory activities carried out with post-CVA patients? ***
- 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
What functional activities are performed with the post-CVA patient? ***
- 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
What is a traumatic brain injury (TBI)? ***
- 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
What is the annual incidence and severity of brain injury. ***
- 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)
What is the most common cause of TBI? ***
motor vehicle accident (MVA)
Who are the most at-risk populations for TBI? ***
- infants and children
- those between 15-24
- those over 75 years of age
By what percentage can wear of a bicycle helmet reduce risk of TBI in children? ***
What are some factors that influence the outcome for patients following TBI? ***
- 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
What is the difference between an open and a closed/intracranial TBI? ***
- open injuries: penetrating wounds, gunshot, knife

- closed or intracranial injury: impact to head with injury, skull does not fracture, dura remains intact
List some subtypes of closed head injuries. ***
- concussion
- contusion
- hematoma
- locked-in syndrome and other acquired brain injuries
What is a concussion and what are its symptoms? ***
- momentary loss of consciousness and reflexes

- dizziness
- disorientation
- difficulty concentrating

- nausea
- HA
- blurred vision
- alterations in sleep patterns
- loss of balance
What is retrograde amnesia? ***
loss of memory of events prior to injury
What is post-traumatic amnesia? ***
inability to remember or learn new information
(duration is an indicator of severity of injury)
What is a contusion? ***
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
What is a coup lesion? A contrecoup lesion? ***
- same-side contusion: coup lesion

- contralateral contusion: contrecoup lesion (rebound—the brain bounces back to the opposite side)
What is a hematoma? ***
- 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
What is Locked-in syndrome? ***
rare, complete paralysis of all voluntary muscles except those that control eye movement
What is an acquired brain injury? ***
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)
What are some secondary problems of TBI? ***
- 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
What activities may increase ICP? ***
- activities that may increase ICP:
--- cervical flexion
--- percussion and vibration techniques
--- coughing
What are some signs and symptoms of ICP? ***
- 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)
What are anoxic injuries? ***
- caused by disruption of the oxygen supply to the brain

- damage is typically diffuse
- amnesia and movement disorders prevalent
What percentage of the body’s oxygen supply is used by the brain? ***
From what pathologies do anoxic injuries typically result? ***
they most often result from cardiac arrest
What disorders frequently accompany an anoxic injury? ***
- amnesia

- movement disorders
What is posttraumatic epilepsy? How common is it? ***
- an increased seizure risk post TBI

- 3,000 new cases annually occurring after TBI
With which type of head injury is posttraumatic epilepsy more common? ***
more common with open head injuries
What are some potential causes of posttraumatic epileptic seizures? ***
seizures may be triggered by:
- poor nutrition
- electrolyte imbalance
- missed medications
- drug use

- stress
- emotions
- infection
- fever
- vestibular stimulation
- flickering lights
For what is the Glasgow Coma Scale used? What does it evaluate? ***
- to assess arousal and function of the cerebral cortex

- eye-opening ability
- motor response
- verbal response
Describe the scoring/grading of the Glasgow Coma Scale. ***
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
What are the GCS scores and characteristics of a mild TBI? Moderate TBI? Severe TBI? ***
- 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
What is a MACE? ***
Military Acute Concussion Evaluation
What are some common problems with TBI? ***
- decreased level of consciousness
- cognitive impairments
- communication deficits
- behavioral changes

- motor or movement disorders
- sensory problems
- associated problems
What is arousal? ***
primitive state of being awake or alert (RAS function)
What is awareness? ***
conscious of internal and external environment
What is consciousness? ***
state of being aware
What is coma? ***
state of unconsciousness, no arousal (no sleep-wake cycle)
What is a vegetative state? ***
- brainstem reflexes and sleep-wake cycle have returned

- some periods of arousal, but remains unaware
What is persistent vegetative state? ***
vegetative state lasting longer than a year
What is stupor? ***
general unresponsiveness
What is obtundity? ***
- disinterest in environment

- slow response to sensory environment
What is delirium? ***
- patient is disoriented, fearful

- misperceives sensory stimuli
What is clouding of consciousness? ***
- confused, distracted

- poor memory
What are some cognitive deficits noted with TBI patients? ***
- disorientation
- poor attention span
- loss of memory

- poor organizational and reasoning skills
- poor problem-solving skills
- unable to control emotional responses
What are two abnormal postures noted with TBI patients? ***
What are two abnormal postures noted with TBI patients?  ***
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
What are some motor deficits noted with TBI patients? ***
- 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
What are some sensory deficits noted with TBI patients? ***
- 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
What are some behavioral deficits noted with TBI patients? ***
- may have personality and temperament change
- neuroses, psychoses
- sexual disinhibition, apathy

- irritability, agitation
- low frustration tolerance
- lack of emotional control
- lability, aggressive behavior
What are some other problems frequently associated with TBI? ***
40% of TBI patients also have other injuries
- orthopedic injuries
- fractures
- lacerations
What physical therapy interventions are conducted with TBI patients in the acute stage and when? ***
- increase arousal
- prevent secondary impairments
- improve function
- patient and family education

- PT as soon as patient is stable
How is TBI patient positioning important in the acute stage? ***
- 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
What are the levels of the Rancho Los Amigos Scale of Cognitive Functioning? ***
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
What issues will physical therapy address during inpatient rehabilitation? ***
- 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
How does the therapist help to increase patient awareness? ***
- even when patient is comatose, speak to them as if they hear and understand
- always explain procedures prior to treatment
- develop rapport
How is sensory stimulation used as an intervention? ***
- 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
What other positioning issues are important during inpatient rehabilitation? ***
- 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
What is the role of the therapist for wheelchair propulsion in inpatient rehabilitation? ***
- goal is Independence if possible
- PT or PTA may guide hand over hand
- ROM: prevent, treat contractures PRN, serial casting may be used
How is family education important to a TBI patient? ***
- 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
What must frequently be done before functional mobility training? How is this done? ***
often need to inhibit tone first,
- rhythmic initiation, rotation
- prolonged stretch
- weightbearing
- approximation
What are the goals of functional mobility training? ***
- 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
What sitting and transfer activities are carried out with the TBI patient and why? ***
- supine-to-sit transfer
- sit-pivot transfer
- standing unconscious patient/support in standing

- sitting and transferring may increase arousal
- challenge to postural alignment
What are some motor deficit interventions used for patients with a high physical level? ***
- 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
What physical and cognitive tasks are emphasized in inpatient therapy for TBI? ***
- throwing and catching
- obstacle course

- counting repetitions
- progressing toward independence in exercises

- field trips
What is involved in the discharge planning for a TBI patient? ***
- 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