Competency Exam 2

Question 1

What is the incidence percentage for Ischemic strokes? Give brief description

Answer 1

• 87%
• Anoxia from lack of cerbral blood flow
  
  • Embolism (artery blockage)
  • Thrombosis (blood clot; atherosclerosis)

Question 2

What neurological deficits are common in R CVA?

Answer 2

L hemiparesis, visual field deficits or spatial neglect, poor insight and judgment, and or/ impulsive behavior.

Extremity: Left hemiplegia

Vision-Perception: Left visual field cut (left homonymous hemianopsia), neglect, gaze paresis; spatial awareness

Cognition: significant cognitive deficits, especially safety judgment; lack of insight and unawareness of deficits; Loss of prosody of speech and impaired pragmatics; attention deficits

Language: dysarthria (resulting from facial and tongue hemiparesis) usually no aphasia

Sensory: Left-sided sensory deficits

Praxis: constructional apraxia (usually right parietal)

Question 3

What neurological impairments are common in stokes?

Answer 3

**Hemiplegia, hemiparesis **

• impaired postural adaptation, bilateral integration; impaired mobility; decreased independence in any or all ADL, IADL Hemianopsia, other visual deficits
• Decreased awareness of environment; decreased ability to adapt to environment; impaired ability to read, write, navigate during mobility, recognize people and places, drive; can affect all ADL, IADL

Aphasia

• Impaired speech and comprehension of verbal or written language; inability to communicate, read, or comprehend signs or directions; Decreased social, community involvement; isolation

Dysarthria

• slurred speech, difficulty with oral motor functions such as eating, altered facial expressions

Somatosensory deficits

• increased risk of injury in insensitive areas

**Incontinence **

• loss of independence in toileting; increased risk of skin breakdown; decreased social, community involvement

Dysphagia

• at risk for aspiration; impaired ability to eat or drink by mouth

Apraxia

• decreased independence in any motor activity (ADL, speech, mobility), decreased ability to learn new tasks or skills

Cognitive deficits

• Decreased independence in ADL, IADL; decreased ability to learn new techniques; decreased social interactions Depression - decreased motivation, participation in activity; decreased social interaction

Question 4

If a client is given a 0 - Flaccid score on the Modified Ashworth Scale what would you document and what issues would you address in acute care treatment?

Answer 4

Documentation: Is the patient aware of arm? pain? sensation? PROM?Absence of tone?

Acute Care Treatment Issues:

• Splinting not yet indicated
• Arm positioning (family and nursing education)
• Arm up on pillow when seated or in bed
• Sling for ambulation only
• Elevation to prevent edema
• SROM/PROM program for the family, patient, or both
• Weight bearing incorporation into functional mobility tasks to increase proprioceptive input.
• Initiation of bilateral hand-over-hand tasks
• Initiation of weight-bearing strategies

Question 5

If a client scores a 1 - slight increase in tone at the end of range on the Modified Ashworth Scale, what would you document and what issues would you treat in acute care?

Answer 5

Documentation: Flexor or extensor; ability to bear weight with or without support at elbow and hand

Acute Care Treatment Issues:

• Splinting not usually indicated yet but if waking for 3 days with hand fisted,then may want to consider splinting. Consider using a resting mitt splint vs a resting hand splint, because it an more easily be adapted in later levels of the continuum of care

Question 6

If the client scores a 1+ - slight increase in tone at beginning of the range on the Modified Ashworth Scale what would you document and what issues would you treat in acute care?

Answer 6

Documentation: flexor or extensor; ability to bear weight with or without support at elbow and hand

Acute Care Treatment Issues:

• All strategies listed earlier
• Likely can begin gross assist with hand-over-hand tasks

Question 7

If client scores 2 - marked increase in tone through the entire ROM, but arm can easily be passively moved on the Modified Ashworth Scale what would you document and what issues would you treat in acute care?

Answer 7

Documentation: Flexor or extensor; document task patient is able to perform and not perform with affected hand

Acute Care Treatment Issues:

• Splinting usually indicated. Consider using a resting mitt splint vs a resting hand splint, because it can more easily be adapted at later levels of the continuum of care. A resting mitt splint places the patient in a reflex-inhibiting position with thumb abducted
• Reflex inhibiting positions would be helpful; that is, arm abducted and externally rotated on a pillow
• Keep a closer watch on skin protection, especially in the palm and axilla.
• Gross assist-level activities with increasing independence Grasp-and-release and reaching-tasks competent skills incorporated into such tasks as brushing teeth and obtaining toilet paper.

Question 8

If you client scores a 3 - on evident throughout all of ROM, an PROM is difficult on the Modified Ashworth Scale what would you document and what issues would you treat in acute care?

Answer 8

Documentation: Flexor and extensor

Acute Care Treatment Issues:

• Also see gross assist level
• May need to aggressively address ROM with either a mobility tech or the family or be integrated into nursing care
• Address pain
• reflex inhibiting positions recommended.

Question 9

If the client scores a 4 - rigid in flexion and extension on the modified ashworth scale what would you document and what issues would you treat in acute care?

Answer 9

Documentation: Flexor or extensor

Acute Care Treatment Issues:

• Splinting a must to prevent further permanent deformity
• Discuss with the physician use of anti-spasticity medications such as Baclofen or Zanaflex
• Focus all efforts on PROM and tone reduction to prevent joint changes such as heterotopic ossifications (especially in TBI)

Question 10

Describe the Babinski reflex

Answer 10

Stimulus: Performed by running a blunt object from heel to toes in an arc along the metatarsals

Normal Response: Flexion of all toes with plantar foot eversion

Abnormal Response: Extension of big toe and fanning of other toes; indicative of upper motor neuron damage

Question 11

Describe Romberg sign

Answer 11

Stimulus: Patient stands with feet together and eyes closed. Do not perform test if patient cannot maintain balance with eyes open.

Normal Response: Mild sway with no loss of balance

Abnormal Response: Inability to maintain balance, indicating a loss of position sense or reduction of peripheral sensation

Question 12

Describe the Hoffman’s sign reflex

Answer 12

Stimulus: Flick the middle-finger nail bed.

Normal Response: none

Abnormal response: extension of the distal interphalange with subsequent flexion of the thumb, fingers, or both. Usually present in pyramidal tract lesions

Question 13

Describe Doll’s eye reflex

Answer 13

stimulus: turn head manually while watching the eyes. May need to hod the eyes open.

Normal Response: While turning the head, the eyes should continue to look at the ceiling

Abnormal Response: If the eyes follow the movement of the head, this movement indicates brainstem involvement and a poor prognosis for survival

Question 14

Describe Decerebrate posturing reflex

Answer 14

Stimulus: observe patient’s position

Normal response: no abnormal tone

Abnormal response: jaw clenched, neck extended, and upper and lower limbs internally rotated and extended, indicating neurological impairment of the brainstem from the sub-thalamus to mid pons. Affects respiratory and cardiovascular centers located in the medulla. It is potentially life threatening, and decerebrate is more serious than decorticate. -Patients may progress or regress between decerebrate and decorticate. However, the regression into decerebrate posturing signifies a more life-threatening sequela

Question 15

Describe Decorticate posturing reflex

Answer 15

Stimulus: observe patient’s position

Normal Response: no abnormal tone

Abnormal Response: Upper limbs flex, but lower limbs extend with feet in plantar flexion. Indicates upper motor neuron lesion is above the level of the red nucleus

Question 16

What is a thrombotic ischemic stroke?

Answer 16

Grows to size sufficient to block artery where it lodges; usually results from atherosclerosis

Question 17

What is an embolic ischemic stroke?

Answer 17

Clot originates in a different site and lodges in a vessel that is too small, blocking arterial blood flow; usually results from atrial fibrillation

Question 18

What is a hemorrhagic stroke?

Answer 18

bleeding in the brain, as in an intracerebral hemorrhage or around the brain as in the case of subarachonoid hemorrhage

Question 19

What areas are assessed in stroke during an OT evalutation?

Answer 19

• early mobilization
• ADL evalutation
• Cognitive evaluation
• Swallow evaluation

More detail: roles, tasks, activities important to client, ADLs and IADLs, Postural adaptation, UE function, somatosensory assessment, mechanical and physiological components, voluntary movements, strength and endurance, functional performance, motor learning ability, visual function, speech and language, motor planning, cognition, psychosocial aspects

Question 20

What are the goal systolic and diastolic blood pressures for stroke patients (ischemic CVA, hemorrhagic)?

Answer 20

Ischemic CVA:

Systolic BP: 140-180 (possibly as high as 200-220)

Diastolic BP: < 130

Purpose and Complications: Compensatory vasodilation maintains adequate blood flow to protect the penumbra (the ischemic, but still viable brain tissue around the area of the stroke) and maintain perfusion

Hemorrhagic CVA:

• Systolic BP - Below 140-160
• Diastolic BP - Below 90
• Purpose and Complications: Untreated hypertension allows expansion of hemorrhage. Increased SBP causes enlargement of the CVA in 14% of cases. With a controlled BP of SBP < 160 and DBP 90, the rate of neurological degeneration is lower; as is the risk of rebleed.

Question 21

What aspects of care should an OT address during the initial session?

Answer 21

bed-chair position schedules, splinting needs, obtaining recommended patient equipment before discharge, and instructions for nurses and family regarding transfers, positioning, and feeding

Question 22

In what position should a motor evaluation be performed?

Answer 22

an upright position, because this position is optimal for function

Question 23

What issues should be addressed in a motor evalutation?

Answer 23

Functional ability : of the arms and legs during engagement in functional tasks

Self-protection of the arm: In all stages of UE recovery, the therapist should indicate whether the patient protects the arm appropriately.Lack of self-protection provides a goal for the evaluation and is appropriate for the acute care setting, because injury can cause further complications.

Skin integrity: (i.e, reddened area in axilla and palm because of abnormal synergistic tone)

Pain: location and severity

Tone: (MAS) hypotonic or hypertonic (note whether the tone is flexor or extensor synergistic patterning) Ataxia: (may have normal strength and full ROM but can’t control it effectively).

Finger-to-nose: instruct patient to move finger from his or her own nose to therapist’s finger. This motion allows the therapist to assess the quality of the velocity and amplitude of movement

Diadokinesis: Ability to perform rapidly alternating movement, most commonly evaluated via bilateral pronation or supination

Functional reach and grasp: Assess the patient’s ability to control strength and coordination using a styrofoam cup, and raise it up toward the mouth. Assess whether the patient can control the force on the cup as it is grasped and his or her coordination when reaching for and moving the cup. To assess response to treatment and initiate neuromuscular reeducation, incorporate 5 minutes of UE WB, then repeat the finger-to-nose test and a functional task such as reaching for and using a Styrofoam cup. If successful, then provide instruction to incorporate weight bearing into normal activities (e.g., leaning on the armrest of the chair). This task sets the stage for functional recovery in higher levels of the continuum of care.

Question 24

What would you consider for a ROM and strength evaluation?

Answer 24

• Assess premorbid biomechanical limitations such as arthritis, rotator cuff tear, or bursitis
• Assess proximal and distal ROM and MMT
• record ROM in terms of 0,.25,.50,.75, and full. The degrees may fluctuate significantly on the basis of fatigue, pain, or position. Look at the overall movement of each joint and average the function.
• **-DO NOT complete MMT on a patient with CVA or TBI unless the movement appears near normal.
• Provide education on PROM for the hemiplegic UE for supported shoulder flexion to 90 degrees and ER with scapular mobilization as needed. SROM for shoulder flexion and external rotation is not an advantageous therapeutic intervention. - to improve shoulder ROM, support the hemiplegic or weak arm by holding the humerus approx. 4 inches away from the axilla while maintaining ER. The thumb will also be pointing up. THis proximal hold produces greater pain-free flexion at the hemiplegic shoulder than does a distal hold.

Question 25

What precautions are there for ROM in neurological conditions?

Answer 25

• Client must have at least 45 degrees of ER before elevating arm.
• Shoulder should not be passively moved beyond 90 degrees of flexion and abduction unless the scapula is upwardly rotated and the humerus is externally rotated.
• ER to 45 degrees ultimately becomes the primary issue with the emergence of flexor synergistic patterning. Without 45 degrees of ER, the patient will not be able to lift the arm
• Do not use pulleys with unstable shoulders because it will contribute to shoulder tissue injury
• PROM training for families should include instructions of no PROM past 90 degrees to minimize painful pathologies as synergistic pattern emerges. Maintaining ER of at least 45 degrees is imperative for LT recovery. If time is available for only one exercise or stretch, choose ER.

Question 26

What type of reflexes do UMN and LMN lesions cause?

Answer 26

UMN : produce a hyperactive response (increased tone)

LMN : hypoactive

Question 27

What areas are an OT concerned with during an assessment of a neurological condition?

Answer 27

• Motor (functional ability, self-protection of arm, skin integrity, pain, tone, ataxia, finger-to-nose, diadokinesis, functional reach and grasp)
• ROM
• MMT
• Subluxation
• Neuroplasticity
• sensation
• pathological reflexes
• edema
• splinting
• cognition
• attention
• memory
• direction following
• safety judgment
• vision and perception
• occulomotor control
• visual field cuts
• gaze preference
• balance/functional mobility

Question 28

What are common impairments in sitting posture seen after stroke?

Answer 28

Head, neck:

• Normal: neutral
• Abnormal: forward, flexed to weak side, rotated away from weak side

Shoulders:

• Normal: Symmetrical height, Aligned over pelvis
• Abnormal: Uneven height, involved shoulder retracted

Spine, trunk:

• Normal: straight from posterior view, appropriate lateral curves, lateral trunk muscle lengths equal bilaterally
• Abnormal: Curved from posterior view, thoracic kyphosis, shortened lateral trunk muscles on one side, elongation on opposite side

Arms:

• Normal: not used to maintain static upright posture, relaxed
• Abnormal: use of stronger arm to maintain upright posture, increased or decreased muscle tone in involved arm

Pelvis:

• Normal: symmetrical weight bearing through both ischial tuberosities, neutral to slight anterior pelvic tilt, neutral rotation
• Abnormal: Asymmetrical weight bearing, posterior pelvic tilt, one hip retracted forward

Legs:

• Normal: hips at 90 degrees flexion, knees aligned with hips; hips in neutral adduction or abduction and internal or external rotation
• Abnormal: hips in more extension, hips adducted so that knees touch or involved hip externally rotated so that knees wide apart, feet in front of knees, feet not flat on floor, unable to bear weight

Question 29

What are the clinical manifestations of motor planning?

Answer 29

• failure to orient head or body correctly to a task
• failure to orient hand properly to objects and/or poor tool use
• Difficulty initiating or carrying out a sequence of movements
• movements characterized by hesitation and perseveration
• movements that can be performed only in context or in the presence of a familiar object or situation

Question 30

What precautions should you take in the care of a stroke patient?

Answer 30

• in the acute period after a stroke, ascertain the patient’s medical status and stability daily before treatment. know the symptoms of progressing or recurrent stroke
• determine whether cardiac or respiratory precautions apply for a particular patient and monitor accordingly, watching for signs of cardiac distress and blood pressure changes, including dizziness, breathing difficulties, chest pain, excessive fatigue, and altered heart rate or rhythm
• guard against falls by providing appropriate supervision and assistance during transfers and other transitional movements
• to avoid shoulder injury or pain, never pull or lift a patient by or under the weak arm during transfers or other transitional movements
• use appropriate precautions int he presence of insensitive skin, particularly if a patient also has visual field deficits and/or unilateral neglect
• ascertain a patient’s ability to swallow and follow recommended management techniques during feeding
• provide appropriate supervision for patients who demonstrate impulsive behavior and/or poor safety awareness
• teach the patient, family members and other health care workers about safety concerns for individual patient

Question 31

What treatments occur during the acute phase for a stroke survivor?

Answer 31

Early Mobilization

• the patient with acute stroke should be mobilized as soon after admission as is medically feasible. The patient should be encouraged to perform self-care as soon as medically feasible and, if necessary, should be offered compensatory training to overcome disabilities.
• Discharge planning should begin at the time of admission. Goals are to determine the need for rehabilitation, arrange the best possible living environment, and ensure continuity of care after d/c.

Question 32

What precautions should be taken during the acute phase after a stroke to lower the risk of secondary complications?

Answer 32

Skin care: use proper transfer and mobility tecniques to avoid undue skin friction; recommend appropriate positioning for bed and chair and participation in a scheduled position changes as needed; assist with w/c and seating selection and adaptation; teaching patient and caregiver precautions to avoid injury to insensitive skin and involved side of body; watching for signs of skin pressure or breakdown on a patient

Maintaining soft tissue length: risk factors include muscle paralysis, spasticity, and imbalance between agonist and antagonist groups; educate on bed positioning Fall prevention

Question 33

What is the proper bed supine positioning for patients with hemiplegia?

Answer 33

Supine positioning:

• head and neck slightly flexed -trunk straight and aligned
• involved upper extremity supported behind scapula and humerus with a small pillow or towel, shoulder protracted and slightly flexed and abducted with external rotation, elbow extended or slightly flexed, forearm neutral or supinated, wrist neutral with hand open
• involved lower limb with hip forward on pillow, nothing against soles of feet

Question 34

What is the proper side lying (on unaffected side) bed positioning for a patient with hemiplegia?

Answer 34

• Head and neck neutral and symmetrical
• trunk aligned -involved UE protracted with arm forward on pillow, elbow extended or slightly flexed, forearm and wrist neutral, and hand open -involved LE with hip and knee forward, flexed, and supported on pillows

Question 35

What is the proper side-lying (on affected side) bed positioning for a client with hemiplegia?

Answer 35

• head and neck neutral and symmetrical
• trunk aligned
• involved UE protracted forward and externally rotated with elbow extended or slightly flexed, forearm supinated, wrist neutral, and hand open
• involved LE with knee flexed
• uninvolved LE with knee flexed and supported on pillows

Question 36

What treatments occur during the rehabilitation stage of stroke recovery?

Answer 36

• Patients with persistent, non-remediable functional deficits should be taught compensatory methods for performing important tasks and activities, using the affected limb when possible and, when not, the unaffected limb.
• AE should be used only if other methods of performing the task are not available or cannot be learned. The device should have proven reliability and safety, and the patient and/or caregiver should be thoroughly trained in its proper use Treatment to improve component abilities -postural adaptation
• UE function
• somatosensory deficits
• mechanical and physiological components of movement
• voluntary movement and function
• Patients who have functional deficits and at least some voluntary control over movements of the involved arm or leg should be encouraged to use the limb in functional tasks and offered exercise and functional training directed at improving strength and motor control, relearning sensorimotor relationships, and improving functional performance
• task-specific and task-oriented interventions
• constraint-induced movement therapy
• motor learning ability
• visual dysfunction
• speech and language disorders
• motor planning deficits
• Cognitive deficits

Question 37

What is the proper way to handle a hemiparetic UE?

Answer 37

• teach the patient as early as possible to be responsible for the positioning of the arm during transfers, bed mobility, and other activities involving change of position.
• use gait belts or draw sheets, rather than the affected arm, to assist the patient in moving his or her body
• Avoid shoulder ROM beyond 90 degrees of flexion and abduction unless there is upward rotation of the scapula and external rotation of the humerus
• Avoid overhead pulley exercises as they appear to increase the frequency of pain in the shoulder because neither scapular nor humeral rotation occurs, and the force may be excessive

Question 38

Describe Level 1- No response: Total Assistance on the Rancho Los Amigos Cognitive Scale

Answer 38

• Complete absence of observable change in behavior when presented with visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli

Question 39

Describe Level 2 - Generalize response: Total assistance on the Rancho Los Amigos Cognitive Scale

Answer 39

• Demonstrates generalized reflex response to painful stimuli
• responds to repeated auditory stimuli with increased or decreased activity
• responds to external stimuli with physiological changes generalized, gross body movement, not-purposeful vocalization, or all of these
• responses noted above may be same regardless of type and location of stimulation
• -responses may be significantly delayed

Question 40

Describe Level 3 - Localized response: total assistance on the Rancho Los Amigos Cognitive Scale

Answer 40

• demonstrates withdrawal or vocalization to painful stimuli
• turns toward or away from auditory stimuli
• blinks when stron light crosses the visual field
• follows moving object passed within the visual field
• responds to discomfort by pulling tubes or restraints
• responds to inconsistently to simple commands
• responses directly related to type of stimulus
• may respond to some people (especially family and friends) but not to others

Question 41

Describe Level 4- Confused/agitated: maximal assistance on the Rancho Los Amigos Cognitive Scale

Answer 41

• alert and in heightened state of activity
• automatic responses to noxious stimuli incudes attempts to remove restraints or tubes
• may perform motor activities such as sitting, reaching and walking but without any apparent purpose or on another’s request
• very brief moments of attention to basic familiar persons or activites
• absent STM
• may cry out or scream out of proportion to stimulus even after its removal
• may exhibit aggressive or flight behavior
• mood may swing from euphoric to hostile with no apparent relationship to environmental events
• unable to cooperate with treatment efforts
• verbalizations are frequently incoherent, inappropriate to activity or environment, or both

Question 42

Describe Level 5 - Confused, inappropriate nonagitated: maximal assistance on the Rancho Los Amigos Cognitive Scale

Answer 42

• alert, not agitated, but may wander randomly or with a vague intention of going home
• may become agitated in response to external stimulation, lack of environmental structure, or both.
• may be oriented to self, but not to place or time
• frequent brief periods, nonpurposeful sustained attention
• severely impaired recent memory, with confusion of past and present in reaction to ongoing activity
• absent goal-directed, problem-solving, self-monitoring behavior
• Often demonstrates inappropriate use of objects without external direction
• may be able to perform previously learned tasks when structured and cues provided
• unable to learn new info -able to respond appropriately to simple commands fairly consistently with external structures and cues
• responses to simple commands without external structure and random and nonpurposeful in relation to command
• able to converse on a social, automatic level for brief periods of time when provided external structure and cues
• verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided

Question 43

Describe Level 6 - confused, appropriate: moderate assistance on the Rancho Los Amigos Cognitive Scale

Answer 43

• inconsistently oriented to person, time, and place
• able to attend to highly familiar tasks in nondistracting environment for 30 minutes with moderate redirection remote memory has more depth and detail than recent memory
• vague recognition of some staff
• able to use assistive memory aid with max A
• Emerging awareness of appropriate response to self, family, and basic needs
• moderate assist to problem-solve barriers to task completion
• shows carryover for relearned familiar tasks (e.g. self-care)
• emerging awareness of appropriate response to self, family, and basic needs
• shows carryover for relearned familiar tasks (e.g. self-care)
• max A for new learning with little or no carryover
• unaware of impairments, disabilities, and safety risks
• consistently follows simple direction
• verbal expressions are appropriate in highly familiar and structured situations

Question 44

Describe Level 7- automatic, appropriate: minimal assitance for daily living skills on the Rancho Los Amigos Cognitive Scale

Answer 44

• consistently oriented to person and place in highly familiar environments. Mod A for orientation to time
• able to attend to highly familiar tasks in a nondistracting environment for at least 30 mins with min A to complete tasks
• min Supervision for new learning
• demonstrates carryover of new learning
• initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he or she has been doing
• able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with min A

**note may go home with assistance**

• Superficial awareness of his or her condition but unaware of specific impairments and disabilities and the limits they place on his or her ability to safely, accurately, and completely carry out his or her household, community, work, and leisure ADLs
• minimal supervision for safety in routine home and community activities
• unrealistic planning for the future
• limited or absent ability to think about consequences of a decision or action
• overestimates abilities
• limited to absent ability to take others’ perspectives
• self-focused
• limited or absent ability to recognize inappropriate social interaction behavior

Question 45

Describe Level 8 - purposeful, appropriate: Stand-by Assistance on the Rancho Los Amigos Cognitive Scale

Answer 45

• consistently oriented to person, place, and time
• Independently attends to and completes familiar tasks for 1 hour in distracting environments
• Able to recall and integrate past and recent events
• Uses assistive memory devices to recall daily schedule and to-do lists and record critical information for later use with stand-by assistance.
• Initiates and carries out steps to complete familiar personal, household, community, work, and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance
• requires no assistance once new tasks and activities are learned
• aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action
• thinks about consequences of a decision or action with minimal assistance
• overestimates or underestimates abilities
• acknowledges others’ needs and feelings and responds appropriately with minimal assistance
• frequently prone to irritability and depression
• low frustration tolerance, easily angered
• impulsive and self-focused
• uncharacteristically dependent or independent
• able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance

**note may go home independently but would require daily supervison and routines**

Question 46

Describe Level 9 - Purposeful, appropriate: stand-by assistance on request on the Rancho Los Amigos Cognitive Scale.

Answer 46

• Independently shifts back and forth between tasks and completes them accurately for at least 2 consecutive hours
• uses assistive memory devices to recall daily schedule and to-do lists and record critical information for later use with assistance when requested
• initiates and carries out steps to complete familiar personal, household, work, and leisure tasks independently and unfamiliar personal, household, work, and leisure tasks with assistance when requested.
• aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action, but requires stand-by assistance to anticipate a problem before it occurs and take action to avoid it.
• able to think about consequences of decisions or actions with assistance when requested
• accurately estimates abilities but requires stand-by assistance to adjust to task demands
• acknowledges others’ needs and feelings and responds appropriately with stand-by assistance
• depression may continue
• may be easily irritable
• may have low frustration tolerance
• able to self-monitor appropriateness of social interaction with stand-by assitance

Question 47

Describe Level 10 - Purposeful, appropriate: modified independent on the Rancho Los Amigos Cognitive Scale.

Answer 47

• Able to handle multiple tasks simultaneously in all environments but may require periodic breaks
• able to independently procure, create, and maintain own assistive memory devices.
• independently intiates and carries out steps to complete familiar and unfamiliiar personal, household, community, work, and leisure tasks but may require more than usual amount of time or compensatory strategies to complete them
• anticipates impact of impairments and disabilities on ability to complete daily living tasks but takes action to avoid problems before they occur, but may require more than usual amount of time, compensatory strategies, or both
• able to independently think about consequences of diecsions or actions but may require more than usual amount of time or compensatory strategies to select appropriate decisions ora ction
• accurately estimates abilities and indepnedently adjusts to task demands
• able to recognize the needs and feelings of others and automatically respond in appropriate manner
• periodic periods of depression may occur
• irritability and low frustration tolerance when sick, fatigues, under emotional stress, or all of these
• social interaction behavior is consistently appropriate

Question 48

According to the Family guide to the Rancho Levels of Cognitive Functioning what can be expected at level 1?

Answer 48

Level 1 : No response: total assist

• respond to sounds, sights, touch, or movement

Question 49

According to the Family guide to the Rancho Levels of Cognitive Functioning what can be expected at level 2?

Answer 49

Level 2 - Generalized response: total assist

• to respond to sounds, sights, touch or movement
• respond slowly, inconsistently, or after a delay
• responds int eh same way to what he hears, seess, or feels. Responses may include chewing, sweating, breathing faster, moaning, moving, and/or increasing blood pressure

Question 50

According to the Family guide to the Rancho Levels of Cognitive Functioning what can be expected at level 3?

Answer 50

Level 3: Locailized response: Total assist

• be awake on and off during the day
• make more movements than before
• react more specifically to what he sees, hears, or feels. For example, he may turn twoards a sound, withdraw from pain, and attempt to watch a person move around the room
• react slowly and inconsistently
• begin to recognize family and friends
• follow some simple directions such as “Look at me” or “squeeze my hand”
• begin to respond inconsisently to simple questions with “yes” and “no” head nods

Question 51

According to the Family guide to the Rancho Levels of Cognitive Functioning what can family and friends do at levels 1, 2, & 3?

Answer 51

• explain to the individual what you are about to do. For example, “I’m going to move your leg.”
• talk in a normal tone of voice
• keep comments and questions short and simple. For example, instead of “can you turn your head towards me?, say “look at me.”
• tell the person who you are, where he is, why he is in the hospital, and what day it is
• limit the number fo visitors to 2-3 people at a time
• keep the room calm and quiet
• bring in favorite belongings and pictures of family members and close friends
• allow the person extra time to respond, but don’t expect responses to be correct
• sometimes the person may not respond at all
• give him rest periods. he will tire easily
• engage him in familiar activies, such as listenign to his favorite music, talking about the family and friends, reading out loud to him, watching TV, combing his hair, putting on lotion, etc
• He may understand parts of what you are saying. therefore, be careful what you say in front of the individual

Question 52

According to the Family guide to the Rancho Levels of Cognitive Functioning what can be expected at level 4?

Answer 52

Level 4: Confused/ agitated: max assist

• be very confused and frightened
• not understand what he feels or what is happening around him
• overreact to what he sees, hears, or feels by hitting, screaming, using abusive language, or thrashing about. This is because of the confusion
• be restrained so he doesn’t hurt himself
• be highly focused on his basic needs; ie., eating, relieving pain, going back to bed, going to the bathroom, or going home
• may not understand that people are trying to help him
• not pay attention or be able to concentrate for a few seconds
• have difficulty following directions
• recognize family/friends some of the time
• with help, be able to do simple routine activites such as feeding him, dressing or talking

Question 53

According to the Family guide to the Rancho Levels of Cognitive Functioning what can family and friends do at level 4?

Answer 53

• tell the person where he is and reassure him that he is safe
• bring in family pictures and personal items from home, to make him feel more comfortable
• allow him as much movement as is safe
• take him for rides in his wheelchair, with permission from nursing
• experiement to find familiar activities that are calming to him such as listening to music, eating, etc
• do not force him to do things. instead, listen to what he wants to do and follow his lead, within safety limits
• since he often becomes distracted, restless, or agitated, you may need to give him breaks and change activities frequently
• keep the room quiet and calm. for example, turn off the TV and radio, don’t talk too much and use a calm voice
• limit the number of visitors to 2-3 peopel at a time

Question 54

According to the Family guide to the Rancho Levels of Cognitive Functioning what can be expected at level 5?

Answer 54

Level 5: confused, inappropriate nonagitated: max assist

• be able to pay attention for only a few minutes
• be confused and have difficulty making sense of things outside himself
• not know the date, where he is or why he is in the hospital
• not be able to start or complete everday activites, sucha s brushing his teeth, even when physically able. He may need step-by-step instructions
• become overloaded and restless when tired or when there are too many people around; have a very poor memory, he will remember past events from before the accident better than his daily routine or information he has been told since the injury
• try to fill in gaps in memory by making things up; (confabulation)
• may get stuck on an idea or activity (perseveration) and need help switchign to the next part of the activity
• focus on basic needs such as eating, relieving pain, going back to bed, going to the bathroom, or going home

Question 55

According to the Family guide to the Rancho Levels of Cognitive Functioning what can familyor friends do at level 5?

Answer 55

• repeat things as needed. don’t assume that he will remember what you tell him
• tell him the day, date, name and location of th hospital, an why he is in the hospital when you first arrive and before you leave
• keep comments and questions short and simple
• help him organize and get started on an activity
• bring in family pictures and personal items from home
• limit the number of visitors to 2-3 people at a time
• give him frequent rest periords when he has problems paying attention

Question 56

According to the Family guide to the Rancho Levels of Cognitive Functioning what can be expected at level 6?

Answer 56

Level 6: confused, appropriate: mod assist

• be somewhat confused because of memory and thinking problems, he will remember teh main points form a conversation, but forget and confuse the details. For example, he may remember he had visitors in the morning, but forget what they talked about
• follow a schedule with some assistance, but becomes confused by changes in the routine
• know the month and year, unless there is a sever memory problem
• pay attention for about 30 mins, but has trouble concentrating when it is noisy or hwen the activity involves many steps. For example, at an intersection, he may be unable to step off the curb, watch for cars, watch the traffic light, walk , and talk at the same time
• brush his teeth, get dressed, feed himself etc., with help
• know when he needs to use the bathroom
• do or say things too fast, without thinking first
• know that he is hospitalized because of an injury, but will not understand all of the problems he is having
• be more aware of physical problems than thinking problems
• associate his problems with being in the hospital and think that he will be fine as soon as he goes home

Question 57

According to the Family guide to the Rancho Levels of Cognitive Functioning what can friends and family do at level 6?

Answer 57

• you will need to repeat things. discuss things that have happened during teh day to help the individual improve his memory
• he may need help starting and continuing activies.
• encourage the individual to participate in all therapises. he will not fully understand the extent of his propbles and the benefits of therapy

Question 58

According to the Family guide to the Rancho Levels of Cognitive Functioning what can be expected at level 7?

Answer 58

Level 7: automatic, appropirate: minmal assistance for daily living skills

• follow a set schedule
• be able to do routine self care without help, if physically able. For example, he can dress or feed himself independently; have propblems in new situations and may become frustrated or act without thinking first
• have problems planning, starting, and following through with activities
• have trouble paying attention in distracting or stressful situations. For example, family gatherings, work, school, church, or sports events
• not realize how his thinking and memory problems may affect future plans and goals. Therefore, he may expect to return to his previous lifestyle or work
• contintue to need supervision because of decreased safety awareness and judgment. He still does not fully understand the impact fo his physical or thinking problems
• think slower in stressful situations
• be inflexible or rigid, and he may seem stubborn. However, his behaviors are related to his brain injury
• be able to talk about doing something, but will have problems actually doing it

Question 59

According to the Family guide to the Rancho Levels of Cognitive Functioning what can be expected at level 8?

Answer 59

Level 8: puposeful, appropriate: stand-by assitance

• relaize taht he has a problem in his thinking and memory
• begin to compensate for his problems
• be more flexible and less rigid in his thinking. for example, he may be able to come up with several solutions to a problem
• be ready for driving or job training evaluation
• be able to learn new things at a slower rate
• still become overloaded with difficult stressful or emergency situations
• show poor judgment in new situations and may require assistance
• need some guidance to make decisions
• have thinking problems that ay not be noticeable to people who did not know the person before the injury

Question 60

According to the Family guide to the Rancho Levels of Cognitive Functioning what can family and friends do at levels 7 & 8?

Answer 60

• treat the person as an adult by providing guidance and assistance in decision making. his opinions should be respected
• talk with the individual as an adult. there is no need to try to use simple words or sentences
• be careful when joking or using slang, because the individual may misunderstand the meaning. also, be careful about teasing him
• help the individual in familiar activities so he can see some of the problems he has in thinking, problem solving, and memory. Talk to him about these problems without criticizing. reassure him that the problems are because of the brain injury
• strongly encourage the individual to continue with therapy to increase this thinking, memory and physical abilities. He may feel he is completely normal. However, he is still making progress and may possibly benefit from continued treatment
• be sure to check with the physician on the individual’s restirctions concerning, driving, working, and other activities. Do no just rely on him for information, since he may feel he is ready to go back to his previous lifestyle
• discourage him from drinking or using drugs, due to medical complications
• encourage him to use note taking as a way to help with his remaining memory problems
• encourage him to carry out his self-care as independently as possible
• discuss what kinds of situations make him angry and what he can do in these situations
• talk with him about his feelings
• learning to live with a brain injury can be difficult and it may take a long time for the infdividual and family to adjust. The social work and/or physcologist will provide the family/friends with information regarding counseling, resources, and/or support organizations.

Question 61

What is the percentage of incidence for a hemorrhagic stroke? Briefly describe.

Answer 61

• 13%
• bleeding directly into brain
  
  • aneurysm: vessel ruptures and bleeds

Question 62

What is a Transient Ischemic Attack (TIA)? Briefly describe.

Answer 62

• Atypical stroke
  
  • (small stroke deep in brain)

Question 63

What is the prevalence of strokes in the US and what is the percentage of recovery?

Answer 63

• 3rd leading cause of death in US
• Estimated 795,000 people sustain new or recurrent strokes

Disability:

• 50%-70% regain functional independence
• 15% - 30% sustain soem permanant disability

Depression affects approx 1/3 - cormorbidity that dampens volition for recovery and masks true cognitive ability

Question 64

What are some potential deficits resulting from CVA? What assessments might you use to evaluate?

Answer 64

Potential deficits:

• Aphasia
• hemineglect
• dysphagia
• paralysis
• sensory loss
• visual field
• balance
• muscle strength
• cognition
• coordination
• dressing apraxia
• depression

Assessments:

• line bisections/ cross out letters
• swallowing exam
• goniometer
• hot/cold
• berg balance
• MMT
• KTA
• Bor perceived rate of exertion
• Bedside eval for ADLs
• Depression scale
• functional test for hemiplegic/paretic UE (p 1019 in Radomski)

Question 65

What are potential neurological effects of a LCVA?

Answer 65

Left Sided Cerebral Injuries: Middle Cerebral Artery

• Weakness/paralysis/inoccordination R side (extremities, trunk & face)
• Impaired sensation R side
• Language deficts: aphasia
• Deficits in speech articulation
• Visual field deficit
• slow and cautious personality
• memory deficit
• learns better with demonstration instead of verbal instruction

Question 66

What are potential neurological effect of a RCVA?

Answer 66

Right Sided Cerebral Injuries: middle cerebral artery

• Weakness/paralysis/incoordination L side
• Impaired sensation L side
• Spatial and perceptual deficits
  
  • unilateral neglect, dressing apraxia, body scheme
• Vision deficits
• Cognitive deficits
  
  • impulsive behavior, short attention span, poor insight
• Usually has intact language, which may mask deficits
• Learns better with verbal instruction rather than demonstration

Question 67

What are the neurological effects associated with an anterior cerebral artery stroke?

Answer 67

• paralysis of the lower extremity
• sensation loss in toes, foot, and leg
• loss of bladder control
• balance deficits
• memory impairment & loss
  *

Question 68

What medications are use in the medical managment of CVA?

Answer 68

**baby aspirin, fish oil & vitamins = prevention ( as per conference)

• Antiplatelet Therapy - Aspirin (non-prescription); Plavix (prescription
• Anticoagulants - Coumadin or Warfarin
• Statins - Lipitor, Zocor, Pravachol
• Thrombolytic (t-PA) - 3 hr window, not for hemorrhagic stroke patients
• HBP reduction - Beta Blockers, Calcium Channel Blockers, Diuretics, ACE inhibitor

Question 69

Describe the Stroke Pathway (protocol)

Answer 69

Medical Workup

• neurological exam and stroke scale
• Noncontrast brain CT or brain MRI (usually performed in this order)
• Electrocardiogram
• Oxygen saturation
• lab work
  
  • blood glucose
  • serum electrolytes and renal function tests
  • markers of cardia ischemia
  • complete blood count, including platelet count
  • prothrombin time/ international normalized ratio
  • activated partial thromboplastin time

Medical managment of acute complications

• Airway maintenance
• blood pressure and heart rate control
• blood sugar control
• hemorrhagic conversion
• herniation
• increased intracranial pressure
• seizures

Ischemic stroke medication management

• t-PA (if no hemorrhage identified on CT and within 3 hr window from onset
• heparin- used to prevent another stroke from a cardioembolic source or coagulopathy. It is prevenatitve, not a therapy for the initial stroke
• Long-term anticoagulation if not a hemorrhagic stroke

Swallow evaluation (site dependent on sequence)

• screen by nursin. If no deficits are noted, then usually no further evaluation is ordered
• full swallow evaluation by either OT or SLP, either bedside or via modified barium swallow
• Initiation of nutrition and hydrationa nd medication via one of teh following methods
  
  • mouth with or without modifications to food and liquid consistency
  • Nasogastric tube through nose
  • percutaneous endoscopic gastrostomy tube through stomach
  • total parentteral nutrition (IV fluid)

Deep vein thrombosis, pulmonary embolism, infection prophylaxis

• foot or leg pumps
• compression hose
• universal precautions

Continued treatment of comorbidities

• other specialties are consulted such as cardiology, endocrinology, and pumonology, to magnage comorbid diseases

Evaluation by PT, OT, and SLP

• early mobilization
• ADL evaluation
• Cognitive eval
• Swallow eval

Discharge planning initiated

• determine appropriate discharge disposition

Question 70

What factors are associated with a poor prognosis in CVA?

Answer 70

• Coma ot onset
• decreased cognition
• severe hemiparesis
• prior CVA
• severe tone
• severe sensory disturbance
• apraxia
• neglect
• bowel and bladder incontinence

Question 71

What factors are associated with a good prognosis in CVA?

Answer 71

• Early return of muscle tone and motor function (w/i 2 wks)
• Good cognition
• intact sensation
• intact perception

Question 72

What are the general treatment precautions for a CVA?

Answer 72

• Cardiac precautions: may need to monitor HR, RR, blood pressure
  
  • look for dizziness, dyspnea, chest pain, fatigue
• fall risk
• aspiration
• amputation, burn, & other injury secondary to neglect and decreased sensation
• shoulder injury: frozen shoulder, subluxation, adhesive capsulitis

Question 73

Describe the Acute Phase of Stroke Intervention.

Answer 73

• Occurs as soon as client is medically stable
• may be seen bedside
• intervention
  
  • early mobilization
  • self-care
  • compensatory treatment: we can use the unaffected side but only for this acute phase! Position within Line of Vision, have it help as much as possible
  • skin care: positioning
    
    • OT develops positioning plan, skin breakdown can occur within 2 hrs
    • Create 24 hr schedule to reposition every 2 hrs
  • Contracture prevention: ROM
  • Fall Prevention
  • Patient/family education
  • Discharge planning
    
    • rehab candidate?

Question 74

Describe the Rehabilitation Phase of Stroke Intervention.

Answer 74

• Occurs as soon as client can
  
  • actively participate 3 hrs (minimum) of therapy/day
  • sit supported for an hr
• Settings
  
  • Inpatient
  • Skilled nursing facility
  • Outpatient
  • Home health
• Intervention
  
  • ADL and IADL
  • posture/balance
  • Motor control and motor planning
    
    • NDT, task oriented approach - limited to MOTOR performances only. Must blend with other approaches to address other deficits
  • Somatosensory Deficits
  • Vision and perception
  • Cognition
  • UE function
    
    • edema
    • functional voluntary movement
      
      • one hand use/ bilateral hand use
      • CIMT
    • Handling of hemiparetic UE
  • Client/family education
  • Discharge planning

Question 75

Describe the Community Reentry Phase of Stroke Intervention.

Answer 75

• occurs when client has reached level of independence and safety for setting
• consider caregivers and other resources
• Intervention
  
  • maintenance and transfer of skills
  • resumption of roles & occupations
    
    • IADL, work, leisure, education, social participation, driving
  • Client/caregiver education
  • Community resources:

Question 76

What movement control problems are experienced following a stroke?

Answer 76

• loss of postural control
• loss of selective movment control
  
  • weight shift
  • maintain body position against gravity
  • equilibrium resposne
• abnormal muscle tone
  
  • alteration in muscle tension and resistance to passive stretch
  • flaccidity, spasticity, associated reactions

Question 77

What is the basic premise of NDT?

Answer 77

• abnormal tone and reflexes interfere with normal movement and must be corrected
• treament designed to
  
  • decrease spasticity and abnormal movement patterns (synergies)
  • improve motor control and function
• based on analysis of “normal movement
• intervention strategy: NORMALIZE TONE

Question 78

What are the NDT Treatment Principles?

Answer 78

1. Treatment goal: retrain “normal” movement on hemiplegic side
   
   • Avoid any activities that increase spasticity or abnormal relfexes
2. Normalize tone by
   
   1. Inhibiting abnormal relfexes and associated reactions (high muscle tone)
   2. Using handling techniqeus and sensory facilitation (low muscle tone)
3. Treatment should result in a change in teh quality of movement and functional performance of the involved side
4. Treatment progresses in a cervico-caudal, proximo-distal pattern
5. Use of the hemiplegic side in all activites will improve symmetry and function

Question 79

What are inhibition techniques used for?

Answer 79

• decrease abnormal muscle tone that interferes with passive and active movement
• restore normal alightnment int eh trunk and extremities by lengthening spastic muscles
• stop unwanted movements and associated reactions from occuring
• teach methods for decreasing the abnormal posturing of the arm and leg during task performance

Question 80

What are facilitation techniques used for?

Answer 80

• Provide teh sensation of normal movement on teh hemiplegic side
• provide a system for relearning noraml movements of the trunk, arm, and leg
• stimulate muscles directly to contract isometrically, eccentrically, or isotonically
• Allow practicing movements while the therapist maintains some constraints
• Teach ways to incorporate the involved side into functional tasks and occupations

Question 81

What is the process for NDT Evaluation?

Answer 81

1. Interview
2. observation of client behavior: typical postures, preferred movement patterns, spontaneous use of hemiplegic side, asymmetry, neglect, abnormal tone, resposne to beign moved (usually at EOM)
   
   • Observation with handling provides sensory information about quality and strengthn of motion
   • Practical things to look for: Are their feet flat on floor? Are they WB symmetrically? Are they equal WB on pelvis (involved side tends to be hiked)? Is there a pelvis tilt (typically a posterior tilt)?
   • Observe statically and dynamically
   • Evaluation and treatment are mixed
3. Analysis of movement
   
   • Complete client’s performance to the typical
     
     • Core stability allows distal mobility
   • Begin with postural control then progress to selective control
     
     • example place and hold
   • Ask client to perform functional task: reach, sit, stand, move
   • segmental versus whole arm movement

Question 82

What treatment techniques are used in NDT?

Answer 82

• Handling
  
  • Facilitation or inhibition of movement
  • Establish normal alignment, decrease tone, reeducate normal patterns of movement
  • Sensory base to experience normal movement
  • Done slwoly to allow client to understand movements and organize resosne
  • Change pressure based on what you need:
    
    • firm: lengthen spastic muscles
    • soft: guide in normal movment pattern and elicit active movement
  • Decrease handling as patient gains more control
• Retrain functional tasks in patterns incorporating the involved side
  
  • bed mobility
  • weight shift
  • sit to stand and transfers
  • control of hemiplegic arm in weight bearing and non-weight bearing
  • gait training and balance
  • ADL and IADL using UE and avoiding patterns that increase spasticity

Question 83

What are Inhibition handling techniques?

Answer 83

• decrease abnormal muscle tone
• restore normal alignment
• decrease unwanted movements and associated reactions
• decrease abnormal posture

Question 84

What are Facilitation handling techniques?

Answer 84

• Provide sensation of normal movement
• Stimulate muscles to contract
• Incorporate involved side into functional tasks and occupations

Question 85

What are key points of control? Give some examples.

Answer 85

Best areas to control client’s movement (through handling)

• Proximal: Shoulder, pelvis, spine, ribcage
• Distal: hand, foot

Question 86

How do you inhibit spasticity?

Answer 86

• Reflex inhibiting movement patterns:
  
  • active movemnts that both inhibit abnormal tone and encourage or facilitate active movement responses
  • lengthen shortened muscles, decrease tone, correct alignment
• Trunk rotation
  
  • break up block pattern (difficulty segmenting movements)
  • perform in sitting, standing, lying down
  • increases awareness to hemi side
• Scapular protraction
  
  • Used for UE flexion synergy
  • Mobilize scapula before tyring to open spastic fingers (work proximal to distal)
• Weight bearing on affected side
  
  • most effective to inhibit spasticity
  • proprioceptive input
  • increased awareness
  • decrease neglect
  • prepare shoulder girdle first

Procedures for Practice

1. Position patient in sitting
2. Place hands on the hemiplegic arm using proximal and distal key points of control. Patients’s arm will be in a flexed, adducted position
3. Correct adduction of the humerus first, leaving teh elbow in flexion
4. Maintain teh humerus in neutral rotation by the side of teh body and use pressure ontop of teh ofrearm to extend teh elbow gradually. If teh forearm is supinated, pronate it first
5. When teh tension in teh biceps has decreased, slide your hand from teh top of the forearm to teh wrist and hand. Extend teh wrist to neutral first, leaving teh fingers flexed
6. When tension in teh wrist flexors has decreased open teh fingers, keepign teh wrist in neutral position
7. Maintain the arm in an extended position and proceed to weight bearing or guided movement

Question 87

What is compensatory training and how is it accomplished?

Answer 87

• Incorporating the involved arm
  
  • clasp hands
    
    • decreases neglect
    • protects from injury
    • maintains alignment of shoulder girdle and trunk
    • prepares arm for normal participation in tasks
    • prevents wrist flexion
    • keeps wrists in neutral to prepare for reaching
    • finger abduction decreases tone

Question 88

How do you use facilitation in NDT?

Answer 88

1. Restore alignment of teh segments to be moved usign key points of control
2. Assist teh desired movement using light hands
3. proceed slowly and feel for the patient’s response. The are will feel lighter and movement easier when the patient is assisting
4. repeat movements until patient can actively assist and you feel the patient is active
5. lighten messages of yoru hands so that the patient moves with less assistance. Give verbal feedback during this phase
6. gradually withdraw control. The patietn’s movement control may decline but shoudl not produce an abnormal response
7. Provide practice opportunities through use of activiteis (occuaption-as-means) or home exercises

Question 89

What is a phase shift?

Answer 89

Changes in preferred patterns of coordinated behavior to another

Question 90

What are control parameters?

Answer 90

variables that shift behavior from one form to another

Question 91

What is motor learning?

Answer 91

a set of processes associated with practice or experience leading to relatively permanent change in the capabilities of responding

Question 92

What is random practice?

Answer 92

repetitive practice of several tasks in varied sequence within a practice session

Question 93

What is block practice?

Answer 93

repetitive practice of the same task within a practice session

Question 94

What practices result in better motor learning?

Answer 94

• externally focused instructions
• self-controlled practice
• alternating between observation of a task with practice
• decreasing feedback to the learner over time

Question 95

What is the process of evalutating using the task-oriented approach and what are some of the standardized assessment that can be used?

Answer 95

1. Assess role performance (role checklist, OPH-II)
2. Assess occupational performance (COPM, AMPS)
3. Task selection and analysis (Fugl-Meyer Assessment)
4. Performance speculation assessments of client factors, performance skills, and performance patterns thought to be critical control parameters (A-ONE)
5. Evaluation of environment

Question 96

what are the treatment principles of the task-oriented approach?

Answer 96

1. Help patients adjust to role and task performance limits
2. create an environment that uses the common challenges of everyday life
3. practice functional tasks of close simulations to find effective and efficient strategies for performance
4. provide opportunities for practice outside of therapy time
5. use contemporary motor learning principles in training or retraining skills
6. minimize ineffective and inefficient movement patterns

Question 97

What are the 3 contemporary motor learning principles?

Answer 97

1. Use random and variable practice within natural context in treatment
2. Provide decreasing amounts of physical guidance and verbal feedback
3. Develop task analysis and problem-solving skills of patients so they can find their own solutions to occupational performance problems in home and community environments

Question 98

What brain structures are required for responsiveness?

Answer 98

At least one hemisphere and the RA need to be active

Question 99

What brain structures are active in a vegetative state?

Answer 99

RA is function (so they can wake up) but the cortex is damaged - not interacting with environment.

Question 100

What is the Glasgow Coma Scale?

Answer 100

It is a quick and easy tool, used in the immediate post-injury period to predict survival. You can have a score between 3 and 15. An initial score of <8 at 6 hours post injury - 50/50 chance of survival

score of less than or equal 8 = severe head injury

score of 9 - 12 = moderate head injury

score of 13 - 15 = mild head injury

Question 101

What is a decerebrate posture?

Answer 101

the arms are adducted adn extended, wrists are pronated and fingers flexed. Legs are stiffly extended with plantar flexion of the feet.

Question 102

What is a decorticate posture?

Answer 102

the arms are adducted and flexed wrists and fingers flexed on chest. Legs are stiffly extended and internally rotated with plantar flexion of the feet.

Question 103

What interventions should be addressed for a comatose patient?

Answer 103

• peform PROM, splinting, or both to reduce contractures
• educate the family on all interventiosn and rationale at their level of understanding. The family should also be trained on what reactions should be noted.
• Inform the patient before performing any intervention
• speak positively in the presence of the comatose patient
• perform sensory stimulation - sensory input using all five senses that should be performed daily. Families must be trained to perform a structured sensory stimulation program to augment the daily routines of the medical and therapy staff. These techniques are used sparingly in the acute care setting primarily because they have not been shown to be an efficacious and cost-effective treatment strategy and take an inordinate amount of time to administer and achieve results.

Question 104

What are examples of positive responses to sensory stimulation for a comatose patient?

Answer 104

• blinking
• calming effect
• crying
• direct response to the stimulus (pushing stimulus away or attending to it)
• eye opening
• following commands
• grimacing
• increased arousal
• increased movement
• increased muscle tone
• respiration rate increase, then decreases
• swallowing
• vocal utternaces (e.g. moaning)

Question 105

What are some examples of negative responses to sensory stimuli for a comatose patient?

Answer 105

• absense of any response
• agitation
• bite reflex or tightly pursed lips
• flushing
• increased salivation
• perspiration
• seiqure activity
• startle response followed by posturing
• sudden decrease in arousal
• sustained increase in HR, RR, and intracranial pressure

Question 106

What are some potential abnormal reflexes noted during a brain injury evaluation?

Answer 106

• position
  
  • decorticate or decerebrate postures
• reflexes
  
  • involuntary resposne to specific stimulus
  • indicative of severe brain damage
• grasp reflex
  
  • pressure in teh palm of the hand
  • finger flexion with strong grip that persists and resists removal of the object
  • may be viewed by family as voluntary
  • in reality impairs normal reaching, grasping, and releasing

Question 107

What is the procedure for testing sensory awareness with a TBI patient?

Answer 107

• Helps determine level of consciousness
• procedure
  
  • tell them what you are doing and what you expect
  • hold stimulus due to prolonged processing time
  • wait 15 - 30 seconds between each stimulus due to overstimulation
  • alternal stimulus on both sides of body
• Tactile stimulation
  
  • touch (light and firm)
  • chest rub (rub sternum with knuckles at the nipple line)
  • icing on forearm and upper arm (quick strokes, withdrawal response)
  • pressure to nail bed (cuticle level with thumb and forefinger
  • also observe client’s resposne to life support (pulling tubes)
• Auditory stimulation
  
  • turn head to sounds
  • changes in vital signs with familiar music
  • turn their head to opposite side and then call their name
  • ring bell 12 inches from their ear and see if they turn head
• Olfactory:
  
  • cotton ball saturated with odor under nostril
  • hold no longer than 10 seconds to avoid adaptation
  • Be alert to changes in level of consciousness, muscle tone, facial expression, verbalization, and reflexes
  • Sucking response to vanilla or banana may be adaptive
  • avoid noxious stimuli
• Visual
  
  • move a shiny object or penlight horizontally in front of them
  • fast moving object toward face
  • pictures of familiar people
• Gustatory/ oral motor
  
  • physician approval
  • popsicle, flavored toothettes

Question 108

What areas are evaluated during a brain injury evaluation?

Answer 108

• UE evaluation
  
  • AROM: get information through observation (spontatenous movement)
  • PROM
  • Tone (MAS)
• Cognition
  
  • Look for purposeful movement
  • Ability to follow verbal commands: open you eyes, stick out your tongue, squeeze my hand
  • Basic orientation
• As they improve and are able to follow commands begin evaluating
  
  • vision,
  • speech (verbal responses)
  • positioning (do they reposition)
  • ADLS (feeding, swallowing, bathing, etc)

Question 109

What ways can you involve the family early in TBI intervention?

Answer 109

• Educate them about TBI and what to expect
• support groups for family
• best way to communicate with client
• training: transfers, etc
• Give them a role
  
  • bringing in personal items from home
  • using memory book
  • stimulation to client
  • PROM

Question 110

How do you retrain cognition and perception in TBI?

Answer 110

• distraction free environment
  
  • then add stimuli
• compensatory techniques vs remediation
  
  • use a remedial approach until you think they have met their max potential and then use compensatory
• Multi-context treatment approach

Question 111

What treatment approach would you use to optimize cognition and perception?

Answer 111

• Cognitive retraining: remediation of deficits
  
  • Paper and pencil tasks, computer tasks
  • Need for practice
  • Assume one cognitive capcity may be treated in isolation from the othe cognitive capacities
  • Assume transfer of training to functional tasks
  • Little research to support efficacy
• Adaptive therapy: compensation for deficits
  
  • focus on cognitive skills that are intact
  • compensate for deficits by
    
    • changing the context
    • establishing routines
    • learning compensatory strategies

Question 112

What are the critical components of multi-context treatment approach?

Answer 112

• Train in muliple environments and change task components
• Identify criteria to transfer training to new tasks
  
  • from paper and pencil task to occupation
  • example: moving from playing “concentration” to remembering what to buy at the store
• Meta-cognitive training
  
  • awareness questioning
  • client’s ability to predict & estimate own performance
• Investigate and emphasize processing strategies
  
  • observe how client performs a task
  • ask questions about their strategy
• Use meaningful activities
  
  • incorporate strategies throughout task

Question 113

What is the difference between cognitive non-situational strategies and situational strategies?

Answer 113

Non-situational strategies

• planning
• self-questioning
• pacing
• checking work
• anticipating results

Situational strategies

• grouping
• association
• left to right scanning
• rehearsal
• elaboration

Question 114

What influences does PD have on Occupational Performance?

Answer 114

• Difficulty with coordination/manipulation (writing, fastners, using utensils)
• Decreased mobility
• Decreased performance with ADL/IADL
• Diffculty with eating/feeding
• Fatigue and cognitive problems affect activities
• sexual activity limitations
• sleep disturbances
• reduction in memory and attention
• vision impairments

Question 115

What are areas do you evaluate during a PD evaluation?

Answer 115

• PD is a diagnosis of exclusion and obtained by a careful history
• OT should evaluate:
  
  • occupational performance with mobility, safety, swallowing, fine motor coordination and dexterity
  • slowed movements, rigidity, depression, and limitations in activity

Question 116

What kidn of intervention would you design for a client with PD?

Answer 116

• Weighted utensils (client quickly habituates to these stick with built up handles)
• Conscious cognitive overrides for motor tasks; massed practice
• visual or auditory cueing to assist with initiation
• reduce cognitive memory and attentional demands
• use low vision strategies
• Treatment sessions should occure 45-90 mins after medications are taken for optimal performance

Interventions related to decreasing isolationa dn communication problems

• education about timing important activities to synchronize with medication regimen so that participation can occur when medications are at the height of effectiveness
• modification of leisure activites to encourage participation and decrease isolation
• info on support and advocacy groups
• caregiver training for modifying communication and social activities
• writing modifications, including enlarged felt-tip pen and writing when rested
• communication aids, including speed dial, large-key telephones, dictating devices, and remote control systems for lights, television, and otehr frequently used devices
• providing home exercise program to maintain facial movement and expression.

Interventions related to Safety

• INstruction in sit-to-stand techniques and bed mobility
• instruction to manage “freezing” while walking, includes avoiding crowds, narrow spaces, and room corners; reduce distractions such as not carrying items while walking; reduce clutter in pathway; doing one activity at a time; not hurrying to answer teh phone; focusing when changing directiosn; rhythmic beat or counting to maintain momentum
• Demonstration of equipment to increase independece and safety, such as a raised toilet seat, toilet grab bars, shower bench, sink chair, soap on a rope
• Prescribing walkign aids (walker for festinating gait)
• If required, a wheelchair having a proper seating system, scushion, and adjusted foot/legs rests and arm rests that is appropraite for transporting within the community
• good, uniform lighting, particularly in narrow spaces and at doorways
• providing home and group exercises to maintain mobilitiy, coordination, posture, and tolerance and reduce effects of festinating gait, bradykinesia, and postural instability
• home assessment and modifications that might include alternations to the bathroom (e.g., non-skid surfaces, bath bench/chair) and flooring (e.g., elimination throw rugs), horizontal strips on carpet where “freezing” episodes occur, and reducing furniture congestion

Interventions to maintain independence and participation

• modifying eating routine to include small portions, reduced distractions, more frequent meals that allow adequate time, and adapted equipment as required, such as non-slip surfaces for plates, built-up handles, and lids on cups
• instruction in using adult absorbent underwear if necessary
• demonstrating voice and facial exercise programs
• advising on modifying sexual routine, such as to occur after resting and urination
• instruction of energy effectiveness strategies in home, leisure, and work activities
• modifications to reduce or eliminate the need for fine motor control, such as clothing with minimal fastners or velcro closures
• to reduce impact of cognitive and perceptual limiations, use visual cues, rhythmic music, and a nondistracting environment; speak slowly and clearly; use simple insturction; provide one new concept at time; and practice and repetition
• home assessment

Question 117

What influence does ALS have on Occupational Performance?

Answer 117

• ADL’s
• IADL’s
• Strenght and ROM
• mobility
• participation
• work
• leisure
• feeding and eating
• a gradual decline in performance and participation of all occupations

Question 118

What areas do you evaluate when evaluating a client with ALS?

Answer 118

• Diagnosis of exclusion: must have UMN and LMN symptoms and accurate dx
• should be based on clearly defined levles of function
• early: focus on individual function
• Later: individual function, physical environment and social network
• ALS functional rating scale
• Re-evaluations should be done repeatedly as disease progresses

Question 119

How do you rehabilitate patients with ALS through the various stages?

Answer 119

Stage 1:

• characteristic clinical features: ambulatory, no problems with ADL, mild weakness
• Activites to maintain motor function: normal activites, moderate exercise in unaffected muscles, AROM
• equipment: None

Stage 2:

• characteristic clinical features: ambulatory, moderate weakness in certain muscles
• Activities to maintain motor function: modification in living; modest exercise; active, assisted ROM
• equipment: Assitive devices

Stage 3

• characteristic clinical features: ambulatory, severe weakness in certain muscles
• Activiies to maintain motor function: active life; active, assisted, PROM; joint pain managment
• Equipment: Assistive devices, adaptive devices, and home equipment

Stage 4

• Charactersitic clinical features: wheelchair-confined, almost independent, severe weakenss in legs
• Activities to maintain motor function: PROM, modest exercise in uninvolved muscles
• Equipment: Assistive devices, adaptive devices, wheelchair, home equipment

Stage 5

• Characteristic clinical features: wheelchair confined; depedent; pronounced weakness in legs, severe weakness in arms
• Activities to maintain motor function: PROM, pain managment, decubitus prevention
• Equipment: Adaptive devices, home equipment, wheelchair

Stage 6

• Characteristic clinical features: bedridden, no ADL, maximal assistance required
• Activities to maintain motor function: PROM, pain management, prevention of decubitus ulcers and venous thrombosis
• Equipment: Adaptive devices, home equipment

Question 120

What Intervention strategies do you provide in the early stages of ALS?

Answer 120

• ROM and moderate strengthening exercises
• Adaptive devices (dressing, bathing, etc)
• Home equipment
• splints and orthotics
• joint protection, energy concervation, pain management, work simplification

Question 121

What intervention strategies do you provide in the later stages of ALS?

Answer 121

• safety, positioning, skin integrity, transfers, edema control
• Augmentative communcation devices
• dysphagia management
• optimize social participation
• durable medical equipment
• environmental equipment

Question 122

What influences does MS have on Occupational Performance?

Answer 122

• ADL’s (dressing, feeding toileting, mobility, grooming/hygiene, bathing)
• IADL’s
• Memory, attention, safety judgment and impulsitivity
• Executive dysfunction
• decreased social participation
• work
• leisure
• visual deficits
• fall risk
• psychosocial factors
  
  • depression, anxiety, irritability, behavioral issues

Question 123

What areas would you evaluate during an MS evalutaion?

Answer 123

• diagnosis based on history, neurological exam and clinical picture
• expanded disability status scale
• MS functional composite
• fatigue assessment, such as modified fatigue impact scale and a qualitiative assessment
• 6-minute walk test to assess endurance and fatigue
• sleep history, questionnaire or diary
• cognitive screening such as the MACFIMS
• vision evaluation
• depression instruments sucha sthe BEck Depression inventory
• gait, bed mobility, and /or transfer assessmentsuch as the mobility section fo the FIM
• ADL, IADL, and dysphagia assessments
• Manual dexterity adn coordination tests, such as the nine-hole peg test or purdue pegboard
• sensory testing, including the weinstein and proprioception
• spasticity assessment using the MAS
• tremor and ataxia assessment
• trigger point evaluation for head, neck, and shoulder muscles
• vestibular evaluation

Question 124

What stategies would you implement in an intervention for an MS patient?

Answer 124

• adaptive devices
• energy conservation/ work simplification
• low vision strategies
• sensation: reduced temperatures, sensory precaution education
• self-catheterization
• time-saving strategies for ADL’s
• reduce environment distractors (fall risk)
• memory strategies
• gentle strengthening during remission periods
• stretching/ROM
• family education

Question 125

LOOK AT Table 6.23 in Smith - gabai

Answer 125

MS Theapeutic Intervention

• Motor
  
  • Symptoms
    
    • weakness
    • paralysis
    • spasticity
    • incoordination resulting from decreased proprioception adn weakness
    • tremors
  • Therapeutic intervention and precautions
    
    • Basic self-care, includign durable medical equipment and adaptive devices needed. Focus on:
      
      • Feeding – built-up utensils or u-cuffs
      • Dressing – reacher, sock aid, long shoehorn
      • Bathroom mobility – tub bench, 3-in-1 commode, versa frames
      • Bed mobility – bed rail
      • Bathing – long sponge brush, sitting vs standing
      • Grooming and hygiene – long brush or comb, seated with arms supported, electric toothbrush
    • Gentle strenthening once exacerbation period is completed
    • If spasticity is interfering with function, discuss antispasticity medications with physician
    • Balance for self-care
    • avoid fatigue
    • referral for rehab
• Sensory
  
  • Symptoms
    
    • Numbness
    • decreased proprioception
  • Therapeutic Interventions and precautions
    
    • sensory precaution education
    • reduce temperature of water to avoid burns
    • do not use moist heat for muscle pain
• Cognition
  
  • Symptoms
    
    • Memory
    • Attention
    • Safety judgment and impulsivity
    • Executive dysfunction
  • Therapeutic Intervention and precautions
    
    • ASsess safety judgment for home
    • Memory strategies such as writing down questions for health care professionals and the answers
    • May be impulsive
    • Fall risk
    • Reduction of environmental distractors
• Activity tolerance
  
  • Symptoms
    
    • fatigue
  • Therapeutic Interventions and precautions
    
    • energy conservation and work simplification strategies
    • avoid heat
    • reduce water temperature for shower
• Psychological
  
  • symptoms
    
    • depression
    • anxiety
    • irritability
    • behavioral issues
  • therapeutic interventions and strategies
    
    • education regardign teh disease especially if treating during the first exacerbation
    • referral for psycholgoy, psychiatry, or both
    • support group resoruces
    • time allowed for patient to discuss perceived life changes
    • family education

Question 126

What are the functional outcomes of a C1-3 SCI?

Answer 126

ventilator dependent

More detail:

• Preserved muslces and movements
  
  • face and neck muscles allowing the for neck movment and facial expressions, use of mouth
  • Sternocleidomastoid, cervical paraspinal, neck accessories
  • Neck flexion, extension, rotation
• Patterns of weakness
  
  • total paralysis (high level quadriplegia)
  • Total paralysis of trunk, upper extermities, lower extremities, dependent on ventilator
• Expected functional Outcomes
  
  • Dependent with all ADLs
  • Can use electronic activiation devices
• Therapeutic Intervention
  
  • Improve ability to use sip and puff with tasks such as blowign with a straw to push paper across the bedside table
  • Neck ROM if allowed by the physician; incorporate isometric exercises when feasible
  • Teach caregiver instruction methods
  • Move out of bed to chair using a lift (i.e. Hoyer, Invacare)
  • Monitor vital signs
  • Address DME needs
• Adaptive Devices
  
  • Hospital bed
  • ECU
  • Electric, tilt-in-space w/c with sip-and-puff control and portable respirator

Question 127

What are the functional outcomes of a C4 SCI?

Answer 127

• may require a ventilator
• scapular elevation

More detail

• Preserved Muscles and Movements
  
  • Neck movment, upper traps for scapular elevation, and diaphragm for respiration
  • Cervical paraspinal muscles
  • Neck flexion, extension, rotation, scappular elevation; inspiration
• Patterns of weakness
  
  • Paralysis of trunk and UEs and LEs and inability to cough
  • endurance adn spiratory reserve low secondary to paralysis of intercostals
• Expected Functional Outcomes
  
  • Dependent with all ADLs
  • may be able to breathe without respirator
• Theapeutic Intervention
  
  • Focus on scapular elevation to strengthen accessory muscles for repiration and vent weaning and isometrics
  • Quad coughing – after maximal inspiration, an assistant exerts pressre at the abdomen to increase the strength to cough
  • Teach caregiver instruction methods
  • Out of bed to chair using Hoyer lift
  • monitor vital signs
  • adress DME needs
• Adaptive Devices
  
  • ECU
  • Electric w/c
  • mouth stick
  • hospital bed

Question 128

what are the functional outcomes of a C5 SCI?

Answer 128

• shoulder movements, elbow flexion & supination
• No hand or wrist movements, no elbow extension

More detail:

• Preserved muscles and movements
  
  • Muscles spared: Biceps, brachialis, brachioradialis, deltoid, infraspinatus, rhomboid, supinator, serratus anterior
  • Preserved movment: elbow flexion, supination, external rotation, shoulder abduction to 90 degrees but limited shoulder flexion, extension, scapular adduction and abduction
• Patterns of weakness
  
  • No elbow extension
  • No hand function
  • Total paralysis of trunk and LEs
  • Patient at high risk for scapular hiking or winging
• Expected Functional Outcomes
  
  • Moderate to maximal assistance with functional mobility
  • Minimal to moderate assistance for setup, then able to perform BADLs with adaptive devices
  • Eating: Total assist for setup, then Independent eating with equipment
  • Dressing: LE total assist; UE some assist
• Therapeutic Intervention
  
  • Out of bed to chair. Monitor vital signs
  • Teach caregiver instruction methods
  • BADLs
  • Prevent elbow tightening resulting from lack of inhibitory action from elbow extnesors. Daily PROM is imparative
  • Address DME needs
• Adaptive Devices
  
  • Mobile arm supports
  • Adapted feeding devices (univeral cuff)
  • Hand splints
  • Manual wheelchair with hand-rim projections
  • Sliding board
  • Transfer tub bench or shower seat

Question 129

What are the functional outcomes of a C6 SCI?

Answer 129

• wrist extension (tenodesis)
• No elbow extension or hand movement

More details

• Preserved Muscles and Movements
  
  • Muscles spared: extensor carpi radialis, infraspinatus, latissimus dorsi, pectoralis major (clavicular portion), pronator teres, serratus anterior, teres minor
  • Preserved movement: Shoulder movement, scapular protraction, horizontal adduction, supination, radial wrist extension, tenodesis grasp
• Patterns of weakness
  
  • Wrist flexion
  • elbow extension
  • hand function with tenodesis spared
  • total paralysis from trunk to LEs
• Expected functional outcomes
  
  • Independent with BADLs with the following exceptions
    
    • cutting, shoetying, L/B dressing and bathing, uneven surface transfers
  • Eating: Independent with or without equipment except cutting
  • Dressing: Independent UE; some to total assist for LE
  • Bathing: U/B independent, L/B some to total assist
  • Homemaking: soem assist with light meal preparation; total assist for all other homemaking
• Therapeutic Intervention
  
  • Emphasize scaption depression with lower traps
  • Out of bed to chair
  • monitor vital signs
  • Teach the patient to provide effective caregiver instructions
  • BADLs
  • Especially focus on teh wrist to maximize the tenodesis grap
  • Address DME needs
• Adaptive Devices
  
  • Hosptial bed
  • Manual w/c with rim projections
  • Adaptive equipment for all BADLs

Question 130

What are the functional Outcomes of a C7-8 SCI?

Answer 130

• elbow extension, some finger movement
• limited grasp and dexterity

More Details:

• Preserved Muscles and Movements
  
  • Preserved muscles: all above muscles, triceps, pronator quadratus, extensor carpi ulnaris, flexor carpi radialis, flexor digitorum profundus and superficialis, extensor communis, thumb muscles, lumbricals (partially),
  • Preserved movement: elbow extension, strong wrist extension and flexion, finger flexion and extension; thumb flesion, extension, and abduction; good shoulder movement
• Patterns of weakness:
  
  • Paralysis of trunk and LEs (low-level quadriplegia)
  • Limited grasp and dexterity because of parital intrinsic muscle innervation
• Expected functional outcomes
  
  • Independent with all BADLs with adaptive equipment and DME
• Therapeutic Intervention
  
  • Out of bed to chair. Monitor vital signs
  • Teach caregiver instruction methods
  • BADLs
  • Intrinsic and muscle and shoulder strengthening
  • Balance tasks to prepare for safe sliding board transfers or depression transfers
  • Address DME needs
• Adaptive Devices
  
  • Manual wheelchair with hand rims
  • gloves
  • adaptive devices
  • tub seat
  • adapted seat for bowel program
  • hospital bed or standard bed
  • sliding board

Question 131

What are the functional outcomes for a T1-9 SCI?

Answer 131

• UE intact
• limited upper trunk and decreased endurance
• no LE movements

**NO LONGER REQUIRE PERSONAL CARE ASSISTANCE**

More detail

• Preserved Muscles and Movement
  
  • Preserved Muscles: Intrinsics, intercostals, erector spine
  • Preserved Movements: UEs intact, some patients may be ablet o ambulate with device
• Patterns of weakness
  
  • Limited trunk stability
  • paraplegia
• Expected Functional Outcomes
  
  • Independent with all ADLs
• Therapeutic Intervention
  
  • Out of bed to a chair. Monitor vital signs
  • Teach caregiver instruction methods
  • BADLs
  • Improve unsupported trunk stability adn balance durign task performance
  • Address DME needs
• Adaptive Device
  
  • W/c with hand rims
  • Standard bed

Question 132

What are the functional outcomes for a T10 - L1 SCI?

Answer 132

• full trunk stability
• LE paralysis

More details

• Preserved Muslces and Movements
  
  • Muscles: Intercostals, external obliques, rectus abdominus
  • Movements: good trunk stability
• Patterns of weakness
  
  • Weak LEs; may be able to ambulate
• Expected Functional Outcomes
  
  • Independent with all ADLs
• Therapeutic Intervention
  
  • Out of bed to chari. Watch vital signs
  • BADLs
  • Address DME need
• Adaptive Devices
  
  • May use w/c for distances
  • bilateral ankle foot orthoses
  • Standard bed

Question 133

What are the functional outcomes for a L2-S5 SCI?

Answer 133

Partial paralysis of LE

More details

• Preserved muscles and movement
  
  • muscles: all trunk muscles, depending on level, some hip, knee, and ankle movements
  • movements: good trunk stability, partial control on LEs
• Patterns of weakness
  
  • weak LEs, may be able to ambulate
• Expected Functional Outcome
  
  • Independent with all ADLs
  • May have bowel dysfunction but is independent with bowel program
• Therapeutic Intervention
  
  • Out of bed to a chair. Monitor vital signs
  • Teach caregiver instruction methods
  • BADLs
  • Address DME needs
• Adaptive Devices
  
  • W/c
  • standard bed
    *

Question 134

At what levels are tetraplegia and paraplegia demarcated?

Answer 134

C4 - tetraplegia

C6 - tetraplegia

T6 - paraplegia

L1 - Paraplegia

Question 135

How do you determine if someone has an incomplete SCI injury?

Answer 135

If the person has any voluntary anal contraction regardless of any other finding then the person by definition has an incomplete injury

Question 136

How do you determine the motor level of a SCI?

Answer 136

• Most nerve roots innervate more than one muscle; most muscles are innervated by more than one root
• If a muscle has at least a grade of 3 it is considered intact
• BUT ONLY IF the next most rostral (highest) muscle has a grade of 5
• Zone of Partial Preservation - complete injuries who have partial innervations in dermatomes below teh neurological level

Question 137

What is it mean to be an A on the ASIA impairment scale?

Answer 137

• Complete Injury
• absence of sensory and motor function in the lowest sacral segment
• Zone of Partial Preservation
  
  • used only with complete injuires
  • most caudal (lowest) dermatomes and myotomes below the neurological level that remain partial innervated

Question 138

What does it mean to be a B on the ASIA Scale?

Answer 138

• Incomplete
• sensory but no motor function is preserved belwo the neurological level and includes the sacral segments S4-S5

Question 139

What does it mean to be a C on the ASIA scale?

Answer 139

• Incomplete
• motor function is preserved below teh neurolgoical levle, and more than half of key muscles below the neruological level have a muscle grade of less than 3

Question 140

What does it mean to be a D on the ASIA scale?

Answer 140

• incomplete
• motor function is preserved below the neurolgoical level, and at least half of key muscles below the neurolgoical level have a muscle grade of 3 or more

Question 141

What does it mean to be an E on the ASIA scale?

Answer 141

• Normal
• motor and sensory function are normal

Question 142

Describe an UMN injury.

Answer 142

• reflex arc below the level of injury are intact, but no longer mediated by teh brain (brainstem)
• loss of voluntary function below the level of the injury
  
  • spastic paralysis
  • no muscle atrophy
  • hyperactive reflexes

Question 143

Describe a LMN injury.

Answer 143

• injury below the conus medullaris
• injury has affected the spinal nerves after they exit the cord
• reflex arc cannot occur because impulses can’t enter the cord to synapse
  
  • loss of voluntary function below the level of injury
  • flaccid paralysis
  • muscle atrophy
  • absence of reflexes

Question 144

What is the OT’s role in the acute care of SCI?

Answer 144

• prevent further damage to spinal cord
• reverse damage by stabilizing or decompressing damaged structures
• restore normal alignment
  
  • immobilization: halo or minerva throacic brace
  • surgery

Question 145

What is spinal shock?

Answer 145

• no reflex activity below level of injury (areflexia)
  
  • flaccid bladder and bowel
  • may need ventilator if interrupted innervation to diaphragm, abdominals, and intercostals
  • decreased HR and BP
• Lasts 1-6 weeks post injury
  
  • when it resolves, areas above the level of injury operate like they did prior to the injury
  • below, relex arc resumes if it is intact

Question 146

What is autonomic dysreflexia?

Answer 146

• Exaggerated response to ANS
  
  • Way of warning that something is wrong (but message can’t reach brain because of lesion)
  • Blood pression rises quickly
• Injuries above T4 to T6
• Causes:
  
  • Irritation of nerves below the level of injury
  • Examples: overful bladder, bowel, UTI, decubitus ulcer, ingrown toenail
• SIgns:
  
  • Sudden pounding headach, diaphoresis, flushing, goosebumps, tachycardia followed by bradycardia

Question 147

How should you respond to a client with autonomic dysreflexia?

Answer 147

• THIS IS A MEDICAL EMERGENCY *** RESPOND IMMEDIATELY***
• Find cause and alleviate immediately:
  
  • empty bladder, check for kinks in teh catheter tube, check for bowl impaction
• DO NOT lie them down - head needs to be elevated above the heart
  
  • Sit them upright adn remove anything restrictive such as binders and stocking to reduce BP
  • BP raises quickly, so may stroke and/or die if not treated
• may require medication if it happens frequently

Question 148

What is Orthostatic Hypotension?

Answer 148

• Decrease in BP
• usually occurs with cervical or thoracic SCI
• blood pools distally in teh LE’s secondary to decreased muscle tone in trunk and legs
• Occurs when person tries to sit up after lying for long periods
• Symptoms
  
  • lightheadedness, dizziness, pallor, sudden weakness, unresponsiveness
• Management
  
  • recline them quickly **this is different from autonomic dysreflexia)
  • usually diminishes as poeple can tolerate sitting for longer periods of time
• Prevention
  
  • TED hose, abdominal binders to assist circulation, assume upright position slowly, tilt in space wheelchair

Question 149

What respiratory complications are involved in a SCI?

Answer 149

• Above T12 respiration is compromised to some degree
  
  • decreased vital capacity cervical and high thoracic
  • trouble coughing, limited endurance (help practice coughing with external manuevers
• C4 and above require ventilator

Question 150

What is deep vein thrombosis?

Answer 150

• formation of a blood clot, most often in a LE or the abdomen or pelvic area
• Common secondary to reduced circulation caused by decreased tone, frequency of direct trauma to legs causing vascular damage (such as during transfers) prolonged bed rest
• Signs
  
  • LE swelling, localized redness, low-grade fever
• Prevention
  
  • TED hose, ROM

Question 151

What education should be provided on thermal regulation in SCI?

Answer 151

• Affects T6 or higher
• Blood vessels below the level of injury can’t constrict enough to conserve heat
  
  • body tends to assume temp of external environment
• Excessive sweating above level of injury but not below
  
  • leads to hyperthermia
• Avoid excessive temperatures
  
  • may lead to autonomic dysreflexia

Question 152

How common is spasticity in SCI and at what levels? What exacerbates spasticity?

Answer 152

• Spasms occur in
  
  • 100% of cervical injuries
  • 75% thoracic injuries
  • 58% lumbar injuries
  • 25% cauda equina injuries
• Spasticity is increased by
  
  • infections, positioning, pressure sores, UTIs, emotions
• Spasms can be used to maintain muscle bulk, circulation, bowel and bladder management
• Too much spasticiity
  
  • contractures, pain, difficulty performing ADLs
• common in elbow flexors and leg extensors

Question 153

What education should you provide on skin breakdown in SCI?

Answer 153

• pressure sores due to
  
  • prolonged sitting or lying on bony prominences
  • shearing forces
  • decreased circulation
• preventable
  
  • pressure relief every hour
  • visual inspections 2x day
  • good nutrition
• beware of burns and frostbite
• pressure relief every 15 mins and reposition every 30 mins
  
  • chair push-ups or bring person out of reclien and back down are examples of pressure relief
  • bed respositioning every 2 hrs
• Tilt in space w/c

Question 154

What is heterotopic ossification?

Answer 154

• abnormal formation of bone deposits on muscles, joints, and tendons
  
  • 20% of all SCI
  • Onset 1-4 months post injry
• Signs
  
  • Heat, pain, swelling, decreased A/PROM
• When bony joints change post SCI
• makes a crunchy noise
• Do ROM 2x a day to end of range - be careful not to over range

Question 155

How do you preserve tenodesis?

Answer 155

• want grip for tenodesis
• never put wrist and fingers in ext at the same time
• support proximal, extend wrist and flex fingers then flex wrist and extend fingers

Question 156

What parts of PROM are important in SCI?

Answer 156

Particularly address: shoulder ER, Abduction and flexion, elbow extension, forearm pronation and tenodesis

Question 157

What is anterior spinal cord syndrome?

Answer 157

Loss of all sensation (except proprioception) and motor function below the injury to the anterior spinal artery

Question 158

What is Brown-Sequard?

Answer 158

Lateral damage as a result of damage to only one side of the spinal cord, usually becasue of a stabbing or gunshot wound. The patient expereicnes motor paralysis and loss of proprioception on the ipsilateral side of the injury and loss of pain, temperature, and touch discrimination on the contralateral side of the injury

Question 159

What is Cauda equina syndrome?

Answer 159

Occurs with fractures belwo L2 with flaccid paralysis as teh primary feature

Question 160

What is Central cord syndrome?

Answer 160

Destruction of the central cord versus the periphery of the cord. Paralysis and sensory loss are greater in the UE than in the LE. Central cord syndrome is more common in older people because of the narrowing of the spinal cord.

Question 161

What is Complete SCI?

Answer 161

No muscle preservation at and below the level of the injury

Question 162

What is conus medullaris syndrome?

Answer 162

Injury to the sacral cord and lumbar nerve roots, resulting in the loss of bowel and bladder function and lower-extremity function.

Question 163

What is Incomplete SCI?

Answer 163

Preservation of some sensation or motor capabilities at or belwo the level of the injury.

Question 164

What is paraplegia?

Answer 164

Impaired movement in both lower extremities, but movement in teh UE is preserved. The trunk may also be impaired

Question 165

What is Quadriplegia (tetraplegia)?

Answer 165

Impaired movement in all four limbs

Question 166

What is Spinal cord Infarct?

Answer 166

Stroke within the spinal cord vascular distribution. The pattern of deficits is dependent on the level of the infarct

Question 167

What is transverse myelitis?

Answer 167

Inflammation across one level of teh spinal cord. The myelin sheath is attacked and causes paralysis below the level of the inflammation, which can progess over the couse of several weeks. One-third of patients recover fully, one-third recover partially but are left with significant deficits such as spasticity and bowel and bladder deficits, and one-third demonstrate no recovery at all. Patients are generally treated with corticosteroids and rehabilitation.

Question 168

What clinical interventions are used in SCI to address vital sign stability, blood pressure, respiration rate, heart rate and rhythm, and oxygen saturation?

Answer 168

• Occupational performance
  
  • Implement position chagnes (especially sitting) and task performance
• Clinical Interventions
  
  • Abdominal binder and thigh-high thromboembolic deterrent hose to maintain blood pressure. If these are not effective, then wrap the legs with elastic bandages
  • Expect a drop in BP the first several times teh patient is in an upright position. Do not sit patient completely upright the first several times. The patient will likely better tolerate gradual changes in the incline level
  • Implement a bed-chair position schedule with the nurses for at least 3 times/day for 15-30 minutes to augment and facilitate therapy efforts. Be sure weight shifts occur at least every 20 minutes. Do not use bed-chair position if spine is unstable; request clarification from physician, especially if spine stabilization surgery is being considered
  • Intitially use a hgih-back reclinging wheelchair unless a tilt-in-space wheelchair is available
  • Watch for autonomic dysreflexia symptoms

Question 169

What clinical interventions for SCI are used to address psychosocial adjustment to injury?

Answer 169

• Occupational performance
  
  • Assess
• Clinical Intervention
  
  • Encourage active participation
  • Begin education process because knowledge decrease fear of the unkown; take care to not give false hope for recovery
  • The patient may be grieving becasue of the significant loss of his or her body. Acutely, this may present as false hope or disinterest
  • include the family

Question 170

What clinical interventions for SCI are used to address discharge planning?

Answer 170

• Occupational performance
  
  • Assess current and previous level of function and psychosocial issues to determine appropriate recommendations
• Clinical intervention
  
  • Anticipate durable medical equipment and home environmental adaptations to allow teh family time to begin preparing for discharge. These adaptations may include home modifications such as buidlign a ramp, rearranging rooms for a bedroom on teh main levle, or oving if teh home is inacccessible (i.e., lives in second-story walk-up apartment)
  • continued thearpy recommendation options
    
    • Model SCI unit
    • Inpatient rehabilitation facility
    • Home health
    • Subacute rehabilitation
    • Nursing home
    • Long-term acute care (especially if vent weaning is possible)

Question 171

What clinical interventions for SCI are used to address BADLs?

Answer 171

• Occuaptional performance
  
  • Assess whether adaptive devices and positioning can be used to maximize function
• Clinical Intervention
  
  • Using room controls (e.g., call bell, TV remote, bed controls), obtain adaptive devices such as feather-light touch pad or fabricate them. Place it near the most effective movement such as the jaw or hand. See adapted quad bell
  • Feedign and drinking – long straw, universal cuff, built-up handle
  • Grooming and hygiene – u-cuff
  • Functional mobility – including log rolling for pressure relief, transfers, maintenance of upright balance

Question 172

What clinical interventions for SCI are used to address Bowel and bladder?

Answer 172

• Occupational performance
  
  • Assess
• Clinical Intervention
  
  • Generally, nursing staff address bowel an bladder maintenance in acute care
  • Educate patient on adaptive devices and options for self-catheterization adn bowel managment

Question 173

What clinical interventions for SCI are used to address P/AROM?

Answer 173

• Occupational Performance:
  
  • Assess and maintain. Must assess this area first before completing MMT
• Clinical Interventions
  
  • Joint mobility must be maintained to maximize recovery in the future
    
    • Exercises and stretchign: Include family education perform within parameters of ability and tolderance levles, and begin muscle reeducation efforts as appropriate
    • Scapulas: Prone position best if possible. Preserve scaption, prevent adhesions, and prevent overstretching and tearing of posterior shoulder ligaments or impingements. Necessary for preservation of teh accessory muscles for breathing, shoulders, elbows, and wrists
    • neck: Check with the physician before attempting. Especially important for paties with high quadriplegia
    • Shoulders: Horizontal abduction is important for pectoralis major stretch. Important to preserve maximum ribcage expansion for vent weaning. Perform internal and external rotation
    • Elbows, wrists, and hand: Flexion, extension, pronation and supination, and ulnar and radial deviation

Question 174

What clinical interventions for SCI are used to address Splinting?

Answer 174

• Occupational peformance
  
  • Assess on the basis of spasticity and level of injury
• Clinical Implications
  
  • Spasticity usually occurs in teh muscles below the level of injury. Muscles are not actually damaged but have no inhibitory influecnes from neurons abover teh injury. Careful observation must continue throughout actu hospitalization to prevent teh emergence of a nonfunctional spasticity. Initially, splint patients at night who have sustained a C1-C5 and possibly a C6-C7 injury with a static resting splint with fingers flexed halfway to prevent flattening of the palmar arch adn maintain functional hand range of motion and positioning. Judiciously apply the splints because they could inhibit the emergence of tenodesis. If tone increases in elbows, apply pillow extension splints

Question 175

What clinical interventions for SCI are used to address Positioning?

Answer 175

• Occupational Performance
  
  • Assess skin integrity and hemodynamics
• Clinical Intervention
  
  • Maintain skin integrity: keep heels off the bed at all times; avoid mulipodus boots because they can cause pressure ulcers ont eh balls of teh feet
  • sitting positioning: pelvis should be all the way back in the seat. Check to ensure proper positioning
  • improve hemodynamics (blood pressure) in the upright position
  • maximize respiratory function

Question 176

What clinical interventions for SCI are used to address pain?

Answer 176

• Occupational performance
  
  • Patients with C4-C7 injury frequently experience shoulder pain because of scapular immobilization
• Clinical Intervention
  
  • Request premedication before therapy
  • Increase joint mobility using traditional strategies
  • Undiagnosed fractures, shoulder dislocations, adn rotator cuff tears are common in the acute stages. If teh patient complains of severe pain, consult with the physician