2.5- Stroke III: Impairments Flashcards
When does a stroke patient experience flaccid paralysis?
very early due to cerebral shock (systems shut down)
What happens to muscles during flaccid paralysis?
- they can’t contract or initiate movement
* no reflex activity, atrophy of muscle, some fasciculation
How long does the period of low tone last?
It is very transient- lasts minutes to weeks. (48 hours is fairly common)
- longer it lasts the worse the prognosis
T or F: A PT should start therapy as soon as a patient goes into flaccid paralysis.
False.
Generally doesn’t pay to start PT until shock is over (can only position, can’t do much else)
First sign of flaccid paralysis recovery occurs _______ and works its way ______.
Tone increases first in ____________.
proximally to distally
shoulder and hip
What occurs as cerebral shock dissipates?
Spastic Paralysis
Spastic paralysis is characterized by __________.
exaggerated deep tendon reflexes and increased muscle tone
Normal reflexes becomes hyperreflexive _______>______. What causes this?
proximal > distal
loss of upper motor neuron influence (no more upper motor neuron inhibition) and abnormal processing of sensory info
Spastic paralysis clinical findings:
- increased resistance to _________
- _________ of deep tendon reflex
- Posturing of extremities into _______
- May eventually develop true ____ as a result
- passive stretch
- hyperreflexia
- synergies (muscles, specifically antigravity muscles, increase tone in characteristic patterns)
- contractures
Upper Extremity Flexion Synergy~
a. develops initially in _____ with _____ and ______ of ________
b. elbow _____, forearm _____, wrist and finger _____
a. develops initially in shoulder girdle with adduction and downward rotation of scapula
b. elbow flexion, forearm pronation, wrist and finger flexion
Lower Extremity Extensor Synergy~
a. pelvis ______, hip ______ and ______
b. knee ______, ankle ______, toes _____
a. pelvis retracts, hip adduction and IR
b. knee extension, ankle PF with supination, toes flex
What is the Ashworth Scale?
a clinical tool used to assess the presence of abnormal tone
What is the Brunstrom’s Stages of Recovery?
stages to describe the characteristic pattern of development of muscle tone and recovery
Brunstrom’s Stages of Recovery~
a. she believed that each patient passes through each stage but you don’t _____________
b. can get ________ and patient will not ______
a. don’t always see them
b. can get stuck in any stage and patient will not improve further
What is Paresis?
muscle weakness
What is Apraxia?
have motor capability to do a specific movement combination, but unable to put steps together (ex. ambulation, dressing)
What is:
force production on involved side decreases making initiation and control of movement, maintaining posture difficult
motor units atrophy and are easily fatigued
Parasis
T or F: The opposite side of the stroke is not affected.
False.
Opposite side of the stroke (“good side”) is also affected and becomes weaker from inactivity
Motor Planning Deficits~
a. difficulty __________________
b. most often with _______ hemisphere stroke (motor area)
a. difficulty sequencing movement properly
b. most often with left hemisphere stroke
What happens if Apraxia occurs in right hemisphere strokes? (most often in left hemisphere)
problems dressing because the right hemisphere has body image
What is proprioception?
affects posture and perception of being upright
Proprioception causes problems with ________ and ______. It also causes problems perceiving _______ (also affects weightbearing).
problems with balance and ADL’s
problems perceiving upright posture
What is Aphasia?
difficulty with language comprehension, oral expression, and use of symbols
Communication Problems: Aphasia
a. Broca’s - _______ communication
b. Wernicke’s - ___________ communication
c. Global - _____________ communication
a. Broca’s- expressive
b. Wernicke’s- receptive
c. Global- both types of communication
________ - difficulty articulating words due to weakness and incoordination of speech muscles.
Dysarthria
Flaccid dysarthria - _______ voice
Spastic dysarthria - ________ voice
Flaccid- “breathy” voice
Spastic- irregular voice
Facial deficits are often associated with _____________.
cranial nerve involvement
What causes facial asymmetries?
weakness of facial muscles, eye muscles, and muscles around the mouth
Facial asymmetries limits ability to ________ and may cause ________ or ___________.
limits ability to make facial expressions (social problem) and may cause drooling (social problem) or food to pocket in cheeks.
What is Dysphagia?
inability to swallow
- may aspirate into lungs with any food or drink
Lower motor Cranial Nerve VII involvement~
a. can’t protect ___________
b. lack of ___________ - can cause infection
a. can’t protect eye by closing
b. lack of tearing and closing
Cardiopulmonary~
a _________% decrease in lung capacity due to decrease in __________, _______, & _______
30-40% decrease due to decrease in chest expansion, decreased function of diaphragm, and fatigue
- reduced vital capacity- must increase respiratory rate to compensate
- shallow breathing can lead to pneumonia
Why do stroke patients have decreased cardiac function?
because of a reduced activity level
**significant fatigue with patients
Reflexes~
- Primitive reflexes-
- Deep tendon reflexes-
- Spinal level reflexes (withdrawal)-
- Primitive- lost soon after birth may return
- Deep tendon- decreased during flaccid stage, exaggerated during spasticity
- Spinal level- function may remain (even in flaccid limbs) but not purposeful
How can a patient regain control of incontinence?
early weightbearing (bridging, standing)
Neglect- CVA in _________ lobe
parietal
- don’t recognize impaired side of body
- impaired perception of vertical
______________ - involuntary persistence of the same motor response regardless of stimulation or its duration
* may repeat same action over and over
Motor preservation
_______________________ - right CVA
*actively lean and push towards affected side
*___________ & _____________ to the right
*absences of _______________
*______________ deficits
Pusher Syndrome
cervical rotation and lateral flexion
tactile awareness
visual
What happens if you try to redistribute weight on a patient with Pusher Syndrome? What side of the body has increased weightbearing?
they will resist
they have increased weightbearing on the left
Patients with Pusher Syndrome have problems with ______ - they push back and away with uninvolved extremities.
transfers
Where does a stroke happen to cause intolerable burning pain, often long after stimulus has been removed?
in the Thalamus
called Thalamus Pain Syndrome
What are the two traditional treatment approaches?
- Neurodevelopmental Theory (NDT)
2. Proprioceptive Neuromuscular Facilitation (PNF)
Name a non-traditional approach to therapy treatment.
Constraint Induced Movement Therapy (Forced non-use)
What is Constraint Induced Movement Therapy?
forcing the use of the involved side by taking away use of uninvolved side
*uninvolved extremity (most often UE) is restrained 90% of the day for 10-14 days
What is “Shaping”?
repetitive actions gradually made harder as improvements occur
T or F: Constraint Induced Movement Therapy and Shaping are the same thing.
False.
They are different but can be used together
Constraint Induced Movement Therapy~
research finds increased _____ and _____ of movement and increased use in _______
increased quality and skill of movement and increased use in real life
What are the 2 theories on why Constraint Induced Movement Therapy works?
- overcome learned non-use after stroke
2. use dependent cortical reorganization (theory is to force area of cortex to take over damaged area of cortex)
How might dependent cortical reorganization work? (3 ways)
a. remaining connections are strengthened
b. silent pathways are unmasked (thru repetition)
c. increased axonal sprouting to overcome gaps
Why might the Constraint Induced Movement Therapy positive results exist?
research had very inclusive criteria
- must have some ROM of hand/wrist
- no excessive spasticity
- no serious cognitive deficits
- willing to be compliant
TPA is still the gold standard but what 3 methods were discussed to increase the rate of perfusion to the affected stroke area.
- mechanical clot retrieval (go up, grab it, pull it out)
- suction devices
- intra-arterial ultrasound (to bust the clot up_
____________________ - designed to limit the natural cascade that occurs after an injury
Neuroprotective therapies
Neuroprotective therapies~
- limit the over-aggressive actions of the ____ cells
- some of these drugs are delivered ____, some are inserted via ____ right into the area of the brain which has been damaged
- glial cells
* some delivered IV, some inserted via catheter
