All remaining lectures - except cognition not included Flashcards
some of the biggest challenges with working with pts with TBI is
permanent cognitive and behavior issues, emotional state, mood changes, communication
what does walking wounded mean
their motor function and physical states are ok, but cognitively and behaviorly they are not (TBI)
top 2 causes of TBI
transportation (ex: car, boat, plane)
falls
1 cause of TBI for pts 75 and up
falls
gunshot wound, stabbing, or skull fx would be an ex of what type of TBI
open
skull fx is an ___ TBI
open
___TBI’s result from acceleration or deceleration forces
closed
what is coup countercoup
closed TBI,
Coup injury: brain hitting front part of skul
lContracoup: brain hits front part then suboccipital region (axon shearing occurs)
not skull, but rather the brain itself….what part of the brain is effected in coup coutner coup
anterio-inferior temporal lobes and prefrontal cortex
4 classifications of TBI
- focal
- diffuse
- hypoxic
- hematoma
what is a focal TBI
a local one, can cause local swelling or hematomas
cause a mass shifting effect (swelling, blood collection, smushing ventricles and brain tissue)
what does DAI mean
diffuse axonal injury
FOCAL hematomas cause
a mass shifting effect (swelling, blood collection, smushing ventricles and brain tissue)
explain diffuse TBI
Shearing and retraction of axons
Can cause coma = poorer outcome
why is a diffuse TBI often a problem to dx
DAI may or may not show up on imaging! (there is just edema, no collection of blood)
this type of TBI is often caused by drowning, it is
Due to systemic hypotension, anoxia, vascular damage
Can lead to global damage
hypoxic, aka ischemic
3 main types of hematomas (TBI classification)
epidural
subdural
intracranial
this type of hematoma is located btwn your skull and dura mater
epidural
this type of hematoma is often arterial – quick developing
epidural
with a(an) _______hematoma there is usually a period of normal function, and then quickly there is N/V and UMN sx
epidural
hematomas are classified according to
where the bld collects
elders that are on blood thinners that fall and hit their head are prone to ___ hematomas
subdural
subdural hematomas effect what type of BV
venous
Venous
Develop slowly, over time
UMN signs and confusion
which type of hematoma
subdural
main form of secondary damage from a TBI
increased ICP
seizures typically occur when after a TBI
Tend to occur immediately after injury and 6 mo – 2 years after
normal ICP
Normal ICP = 4 – 15 mm HG
imaging that is best for TBI
MRI (CT’s don’t show the bleeds very well)
other testing for TBI
neuropsychological/cognitive
standard testing measurment for tx of TBI (not imaging, ut rather an OM)
glascow coma scale
a score less than ___ on the gloscow is indicative of poor long term prognosis
8
The most commonly used scale for pts in or coming out of a coma = predictive of longterm functional outcome
glascow coma scale
glascow ratings
3 – 8 = severe brain injury
9 – 12 = moderate brain injury
13 – 15 = mild brain injury
less than 8 not great
3 components of glascow
eye
verbal
motor
another common OM for TBI
rachos los amigos
based off of assistance needed
ranchos levels 1-3
I: No Response. Deep sleep. (true coma) (doesn’t even respond to px) Unresponsive to any stimuli.
II:Generalized Response. Reacts inconsistently and nonpurposely in a nonspecific manner. (they don’t change with you if you mix things up)
Respsonses are limited and the same regardless of stimuli.
III
Localized Response. Reacts specifically but inconsistently. Responses relate to the stimuli presented.
May follow simple commands.
goals for pts in level 1-3 of ranchos
Increase level of alertness and arousal
Prevent secondary impairments
Improve motor control
Facilitate normal muscle tone
Increase tolerance of positions and activities
Educate family members- to help arouse the pt
Coordinate care among all team members and family
il
decerberate posture is what
ext of upper and ext of lower
decorticate posture is what
flexed upper, extended lower
what is the significance of decerberate or decorticate in regards to tx
we want to position them opp of what the pattern is
when doing any form of sensory stimulation, always document what
what type of stimulation you are using, how the pt responded
what types of pt response will you document with sensory stimulation
vitals, eye opening, grimacing, arousal, head turning
types of sensory stimuli
tactile, olfactory, auditory, vestibular, gustation, kinesthesia (ROM)
Heightened state of activity. Bizzare and nonpurposeful activity. Unable to cooperate with treatment. Verbalization often incoherent and/or inappropriate. POOR attention
this is what Ranchos level
4 -aggitated and confused
what to be mindful of with ranchos level 4
dont overstimulate them, they are aggitated and confused.
calm down their surroundings
goals for ranchos level 4
Prevent outbursts of agitation
Assist patient in controling behavior
Patient’s safety is assured (and that of therapists and family)
Family members understand what to expect at this phase (it’s typically temporary)
Maintain (or increase) physical activity tolerance
Prevent secondary impairments
Coordinate care among all team members and family
frustrating aspect of level 4 ranchos
they have no carry over of the session - no memory recall. always have to start over
often times, pts in level 4 ranchos have to be monitored how often
24/7 (they may have to be restrained)
level 5 ranchos is what
confused, inappropriate
explain level 5 ranchos - Confused inappropriate
Able to respond to simple commands fairly consistently.
With complex commands, responses are non purposeful.
Highly distractible and poor attention!
Impaired memory!
explain level 6 (ranchos) - Confused appropriate
Needs external direction to complete tasks.
Follows simple directions well and has some carryover.
goal differences with levels 5/6 compared to the others
these pts are often mobile, so keeping them safe as they get around is an issue
goals of levels 5/6 ranchos
Increase function, balance, and ADL performance
Improve motor control
Improve impairments (strength, ROM)
Patient’s safety is assured
Family members understand what to expect at this phase
Increase physical activity tolerance
Coordinate care among all team members and family
with pts with 5/6 ranchos, is blocked or random practice better
do blocked and give them lots of breaks. there is still cognitive issues
level 6 is called (ranchos)
confused appropriate
level 7 is called (ranchos)
automatic appropriate
level 8 is called (ranchos)
purposeful appropriate
robot like is what ranchos level
automatic appropriate (7)
only Ranchos level that observes and responds to changing env
8
4 components of UE function
Locate target
Reach
Grasp
Manipulate
locate target, as a component of UE function, requires what 2 things
vision
eye head coordination
opening of the hand occurs in what component of UE function
reach, it is called aperature
role of arm in reach is
place hand in position for function; transportation
role of hand in grasp
interact with the env
2 types of grip
power -whole hand
precision- fingers
manipulation component of UE function is considered ___ mvmt
fractionated, well coordinated (independently working fingers)
posture/stability is most important in what component of UE function
reach
the key to successful UE function
variability
visual neglect and visual extinction are issues with what component of UE function
locating target
visual neglect and extinction usually occur dt lesion on what side of braint
more often associated with R hemisphere strokes
eye-head or eye/head/hand coordiation issues that occur with locating a target component of UE function, usually are due to ___ or ___ issues
cerebellar
vestibular
problems with reach include
timing (slower)
coordination (cerebellar dysmetria)
decomposition (they flex shoulder 1st then ext elbow - normally these should occur together)
involuntary movement of hemiplegic limb when other limb moves (problem with UE reach)
global synkinesis
Due to B excitation of cortex and reduced inhibition of opposite hemisphere
stroke spacticity (in regards to UE function issue) correlates to _
correlates to movement time and amplitude, but NOT interlimb coordination measures. Interlimb is cerebellar only.
the lack of coordination after stroke is the same as the lack of coordination with cerebellar issues (T or F)
F
inability to reach in space despite intact motor function, vision, and somatosensation. leads to poor grasp and
Poor visual control of hand
optic ataxia - issue with reach
Slowed reach and grasp
Smaller max aperture
Longer time to max aperture
Increased variability in aperture and scaling
Slower and less accurate movements
Poorly modulated fingertip forces
Scaling
Reduced ability to fractionate movement
Stroke vs PD in regards to grasp issues, which group is stroke and which is PD
Slowed reach and grasp
Smaller max aperture
Longer time to max aperture
Increased variability in aperture and scaling ——-PD
Slower and less accurate movements
Poorly modulated fingertip forces
Scaling
Reduced ability to fractionate movement —— stroke
ability to grasp is usually done within ___ days post stroke
recovery of - within 90 days
probs initiating mvmt in grasp is stroke or PD
PD
what effects release in stroke pts (UE function)
probs extending UE
with PD, release prob is
slowed
main probs with UE motor function dt stroke
Visual field deficits limit reach
Poor UE control leads to compensatory trunk motion
Synergistic movement leads to poor fractionation
Poor scaling of forces
main probs with UE motor function dt cerebellar issues
Problems with visual tracking and
Poor inter-limb coordination
main probs with UE motor function dt PD
Problems with speed and initiating movement affects quick reach/grasp
key consideration when tx pts with UE motor function issues
Train proximal and distal segments simultaneously
Don’t wait for proximal control to emerge before distal control
apraxia
inability to perform purposeful actions
inability to carry out skilled movement in the presence of intact sensation, movement and coordination
when tx pts with manipulation issues, start with ___ grip then move to ___ grip
start with power move to precision
ex of progressing from easier to harder with manipulation tasks/fractionation
items with friction or many points of contact to smaller, smoother surfaces
how would a stroke pt using a power grip release an object
flexing wrist
4 important aspects of CIMT
has a positive effect on neural plasticity
amount of practice is the key, not the restraint!
for patients with at least 10 degrees of wrist extension
Not recommended in first month post-stroke
loss or impairment of language skills in adults who have had a history of normal language skills. The loss or impairment is associated with recent
cerebral pathology or trauma.
aphasia
dysphagia
trouble swallowing
dysarthria
motor speech prob
Damage to the posterior superior left temporal lobe would cause ___ aphasia
wernicke (can't comprehend and integrate info) fluent aphasia (receptive aphasia)
Alexia: disorder of ___
Agraphia: disorder of ___
Acalculia: disorder of ___
alexia - reading
agraphia- writing
acalculia -math
non fluent aphasia characteristics
they comprehend what is coming in auditoriliy, but cannot form the words to speak properly
Broca’s aphasia is ___ (fluent or non)
non fluent (or expressive)
brocas aphasia is damage to the
(ant to the fissure) central sulcus
modalities of communication
input: reading and hearing
output: speaking gesturing, writing
wernickes is sometimes called ____
sensory aphasia (coming in is hard to interpret)
anomia
word retrieval issue (issue with Wernickes)
circumlocution
talking around something (issue with Wernickes)
substitutions of unintended sounds for
intended sounds in words
literal or phenomic paraphasia
a type of language output error commonly associated with aphasia, and characterized by the production of unintended syllables, words, or phrases during the effort to speak
paraphasia
Combination of consonants and vowels with
appropriate syllable structure and inflection to create new words
neologisms paraphasia
pt believes he’s speaking the correct way and doesn’t understand that others dont understant him
jargon paraphasia
occurs with Wernickes
word error, words chosen are semantically related
Ex: Pt wants to tell you he rode in a car to the clinic but he uses the word train instead (the words are related but not accurate)
verbal/semantic paraphasia
diet modifications for liquids include these
Thin Nectar- like Honey- like Spoon Thick Formerly “Pudding thick”
diet modifications for solids include (for dysphagia)
Solid Consistencies NDD1: Dysphagia Pureed NDD2: “ “- Mechanical Altered NDD3: “ “- Advanced Regular
what is perception
HOW brain understands what it see’s, feels, smells, tastes &; hears
State of responsiveness to sensory stimulation or excitability.
Terms: awake, alert, asleep, groggy, attending
arousal
Deficit in new learning; inability to recall information learned after brain
damage
anterograde amnesia
Ability to deploy mental resources for purposes of concentration
attention
perception comes from the ___ lobe which is often what is effected with pushers syndrome
pariatal
what are similarities btwn pushers and traditional stroke pts
motor function impairment matches other stroke pts., other stroke pts can have perceptual deficits also, the one thing that is different is the muscle activation on the non effected side (typically pts post stroke will lean to their “good” side not the “bad” side like pushers).
when will the pattern of pushing be at its greatest (what task)
when they are in standing (they push harder when they have more muscles working).
In addition, they resist any passive correction
pushers syndrome occurs typically with a ___ sided stroke
right sided stroke (so left body effected)
with severe hemiplegia (sensory and motor deficits)
explain the basics of what happens with pushers syndrome
a sense of imbalance causes the uninvolved limbs to push actively away from the uninvolved side (leaning towards the “bad” side), resulting in a loss of balance to the hemiparetic side
typical limb behavior of pushers syndrome (what position)
ext and abd of uneffected side
pushers is not an impairment of ____ or ____
not an impairment of cognition, visual/vertical (no impairments of perception from their visual world)
Patients with pusher syndrome perceive their body position to be, on average, ____ toward the ipsilesional side.
18 degrees towards the same side the stroke was on in the brain
3 characteristics that are listed in the scale to dx pushers syndrome
spontaneous body posture,
abd/ext,
resistance to passive correction of tilted posture
4 phases or goals of tx for pushers
4 phases of txgoal 1: help the pt recognize they are pushing
Goal 2. help them compare their posture to things around them so they know that they are off
Goal 3: help them correct the position
Goal 4: maintain the position during functional activity
to help correct pushers syndrome, what is a good plan of progression of tx
Start in seated postures, put hands in lap or in the air to prevent the abiity to push, or even constrain UE,
if you used a wall to tx/correct pushers syndrome, you would have them lean against the wall on their ___ side
have them lean against a wall on their “good” side (not impaired, bc you want them to feel it) – give them a target to lean to
way kirsten mentioned on how to correct/tx pushers on the mat
position them on their good elbow as they lean to the “good side” on the mat and this breaks up the pushing pattern
if you were doing wt shifting ex with pushers, you have them lean towards their ___ side and back to midline over and over (to correct)
towards good side then back up
early on transfers for pushers you would do ___
scoot transfers
in the clinic you would have them lean/transfer towards their “good” or unimpaired side, at home transfers you would have them transfer towards their impaired side
typical stroke pts, we have them transfer to their ___ side almost always
unimpaired
which aphasia presents with the patient talking Jargon or jibberish
wernicke’s
comprehending language
aphasia can be brought on by ____ (list)
suddenly-with a stroke gradual- tumor growth can occur with other disorders: Dysar thria Apraxia of Speech Cognitive Disorders Dysphagia
wernickes aphasia is caused by damage to what three areas of brain
Fissure of Rolando: posterior to central sulcus
Temporal lobe of the left hemisphere
Temporal- parietal lobes
where is wernickes area located
posterior superior left temporal lobe (damage causes fluent aphasia)
Anomia: word ret rieval/finding difficulties
Circumlocution: describe or talk around something
Paraphasias:
Literal/Phonemic
Verbal/Semantic
Neologisms:
Jargon
these are all issues with what type of aphasia
Wernickes
with wernickes aphasia, do pts have more trouble with propositional or non propositional language
propositional - novel (not automatic)
effortful, slower speech in indicative of what aphasia
non fluent
where is brocas area
directly in front of the motor cortex, left frontal lobe
global aphasia
Combo of fluent and Non Fluent aphasia
More severe form of aphasia
Usually caused by occlusion of the left MCA
Diffuse damage to the temporal, frontal, and parietal lobes
Severe impairment s of comprehension, integration, and
formulation of language
When using vision, aperature size is
barely larger than object size (much greater without vision)
without vision we don’t have precision of aperature
For UE dysfunction, Difficulties locating a target can occur due to problems with ___ and___
ision and impairments of eye-head-hand coordination
with stroke, cerebellar dysfunction and PD, what are the issues with reach
Stroke: compensation with trunk movement
Cerebellar: slowed reaction and movement times
PD: slower reaching times
how might a pt with cerebellar dysfunction compsensate their reach
Decomposition
Initially flex shoulder then extend elbow
With normal reach, shoulder and elbow joints move simultaneously and are well timed in respect to one another
hemiplegia vs hemiparisis
hemiplegia-paralisis on one side
hemiparisis- weakness on one side
alexia, agraphia, acalcula are associated with which apsasia type
Wernickes (fluent)
anomia, circumlocution, and paraphasias are associated with which type of aphasia
Wernickes
in summary, explain comparison btwn Wernickes and Brocas aphasia
Brocas - they are able to still communicate, and most of the time be understood, they just use simple words or phrases to get their point across.
Wernickes- they have more trouble. They often cannot be understood (bc of jibberish or jargon).
Global is a combo of both (it’s the worst kind)
an external device worn to restrict or assist motion or to transfer load from one area to another
orthosis
a member of the health care team who designs and fabricates orthotic devices, and evaluates patients for devices
orthotist
essential components to any task (each component can be altered somehow by an orthosis)
progression
stability
adaptability
how can progression be altered by an orthosis
PF can be restricted preventing push off
can can stability be altered by an orthosis
balance can be compromised
how can adaptabilty be altered with an orthosis
uneven surfaces can throw off a person’s ability to adapt
overall, what is the primary purpose of an AFO
control foot in saggital plane : prevent foot drop
the more anterior the trim line of the AFO, the more support/stability occurs ____
medial and laterally
prevents medial lateral translation
post stroke, do we want to prevent inversion or eversion
inversion (we don’t want that synergy pattern)
secondary aims/goals of AFO’s
prevent medial lateral translation of foot
support the knee
pros and cons of plastic AFOs
Benefits:
Interchangeable with different shoes
Relatively lightweight
Good motion control
Limitations:
Hot
Take up space in shoe
with plastic AFO’s, what must be a feature of the shoe
must have removable inserts
pros and cons of metal upright AFO’s
Benefits:
Accommodate changing limb volume
Cooler
Limitations:
Patient restricted to one pair of shoes
what would determine whether we recommend for the orthotist to lock the AFO in PF or DF
PF helps to support the knee bc it creates ext at the knee,
if the pt has weak quads, we want to keep knee extended = put in PF
Thin, narrow shell allows some motion at ankle
Stance: calf shell moves forward over footplate
Swing: calf shell “springs back” to facilitate foot clearance
allows for more motion at the ankle.
pts movement and body wt provide more flexible movement.
dorsiflexion assist can be built in to this one.
Less stable for pts with spaciticity (doesn’t control medial lateral movement)
this describes what AFO
post leaf spring (PLS)
PLS (post leaf spring) AFO prob not appropriate for what pts
highly spastic
better for lower tone
describe the articulating AFO, and how the joint functions or compensations that may occur
This has a PF stop (post stop limits PF) these pts have to bend their knee to compensate – which puts the pt at risk of buckling the knee
articulating AFO’s, 2 main features of the joints and what they assist or prevent
Screw to stop motion- stops PF
Spring to assist motion – aids DF
This AFO would be a good choice for a pt with ankle and knee weakness. This AFO has no joints, but it has the knee strap. This AFO provides: dorsi assist, and high trim lines in the medial part of foot to controls subtalar motion
non articulating
what features in an AFO would help prevent M/L translation of the foot
strap at the ankle, high ant trim lines around the foot,
How might a traditional AFO (solid or hinged) assist with knee control?
these aim to prevent knee buckling bc they are set in PF
AFO that is often used for children with CP and adults with spasticity.
Foot plate and upright put pressure on PF and ankle invertors to reduce tone
tone reducing AFO’s
what pts might you use a KAFO with
benefit for SCI pts, or pts with paralyisis of the LE
overall aim of a KAFO
prevent knee flexion (buckling)
main limitations of KAFO’s
bulky and heavy
typically, would pts post stroke be good candidates for KAFO
no, these require B upper body strength
explain the 2 locks of a KAFO
Drop lock puts knee in into extension
Bail lock allows them to back up to a chair and then it buckles so they can bend
hip, knee, ankle afo benefits/limitations
benefits: stability
limitation: not functional, to bulky
Type of HKAFO that allows for unilateral stepping
Posterior + lateral weight shift to one side advances opposite LE
reciprocating gait HKAFO
what should we take into consideration when recommending features of a device to an orthotist
Strengths/weaknesses, ROM, spacticity, muscle tone, sensation (dt skin break down)
hinge vs solid stop brace
Hinge brace is better for pts who’s quads are already strong, if quads are weak then solid stop.
inability to identify or recognize familiar objects & people,
visual system is intact;
parietal lobe damage
i.e. cannot find shoes in closet
visual agnosia
cannot ID familiar faces
prosopagnosia
R-L discrimination (don’t understand & use concepts of R and L)
bilateral problem assoc with L hemisphere damage
These pts ave difficulty following directions about how to get from one place to another
visual spacial perceptual deficit
extensive neglect syndrome
pt fails to recognize one’s paralyzed limbs as one’s own
anosognosia (they may even mention wanting it removed from their body)
Motor Planning Perception /praxis occurs where in brain
L hemisphere (parietal lobe)
ability to rapidly conceive of and plan motor acts in response to the environment
praxis
inability to carry out skilled movement in the presence of intact sensation, movement and coordination
apraxia
apraxia is the Disturbance of two basic functional cognitive processes that allow us to act in the world, what are these 2 processes
Planning – purpose (conceptual)
Execution – output (production)
explain what occurs (functionally) with apraxia
Generally patients spontaneously can use extremity for everyday tasks: Eating, shaving, opening door
However, when asked to pantomime or carry out a series of steps – performance is not correct or smooth in execution.
inability to attach meaning to somatosensory information
tactile agnosia
inability to identify objects by touch
asterognosis
explain sterognosis testing
occlude vision, use hands to identify common objects
4 phases of swallowing
Oral preparatory phase
Oral phase
Pharyngeal phase
Esophageal phase
what levels of ranchos scale would be appropriate for out pt
7 and 8
1-3 is acute
4-6 in patient
a type of language output error commonly associated with aphasia (usually Wernickes), and characterized by the production of unintended syllables, words, or phrases during the effort to speak, includes
Literal/Phonemic
Verbal/Semantic
Neologisms
paraphasia
with apraxia, do they have intact sensation, movement and coordination
yes, they can spontaneously perform tasks that utilize all of these components, they just cant pantomime or carry out a series of steps if asked to – their performance is not correct or smooth in execution.
reciting the ABCs is what type of speech (propositional or non propositional). Which type is the issue with Wernickes aphasia
ABC’s is non propositional, it’s automatic
Wernickes aphasia has issues with propositional -or needing to come up with conversation on their own
Broca’s aphasia is (fluent vs non) (expressive vs sensory/receptive)
BNE
Broca’s/non/expressive
SCI or paralysis, what type of orthotic device is best
KAFO
pt with high spacticity what AFO should you avoid and what ones would be good
Spasticity – need to do traditional plastic afo with high ant trim lines
Tone reducing AFO is good for spacticity
PLS (post leaf spring not good for spasticity)
Which AFO has a solid plastic frame with no joint at the ankle, they have high trim lines for M/L support = very stable
non articulating
