Content for Exam 2 Flashcards
Scapular Patterns
In sidelying,
-Anterior elevation: 1 o clock
-Posterior elevation: 7 o clock
-Anterior depression: 5 o clock
-Posterior depression: 11 o clock
Anterior elevation – goes with D1 flexion – goes with protraction
Posterior depression – goes with D1 extension - goes with retraction
Pelvic Patterns
In sidelying,
-Anterior elevation: 1 o clock
-Posterior elevation: 11 o clock
-Anterior depression: 5 o clock
-Posterior depression: 7 o clock
Anterior elevation
“pull your pelvis up and fwd” – promotes pelvis protraction during preswing
Posterior depression
“sit back into my hands” – promotes trailing limb posture
PREP algorithm complete
potential to return to normal
or near-normal hand and arm function within 12 weeks
PREP algorithm notable
Potential to be using affected hand and arm in most activities of daily living within 12 weeks, though normal function is unlikely
PREP algorithm limited
Potential to have some movement in affected hand and arm within 12 weeks, but it is unlikely to be used functionally for activities of daily living
PREP algorithm none
minimal movement in affected hand and arm, with little improvement at 12 weeks
E-stim for inferior subluxation
suprapinatus and posterior deltoid
E-stim for anterior subluxation
supraspinatus and anterior deltoid
Berg Balance Scale cut off scores
A cut-off score of 12/56 is predictive of regaining unassisted ambulation (no physical assistance) by discharge.
A cut-off score of 29/56 is predictive of regaining community ambulation speed (>0.8 m/sec) by discharge*
What are the determinants of long-distance walking function
Balance is the main determinant in individuals with more severe gait deficits
Cardiovascular fitness is the main determinant in individuals with more mild deficits
Spasticity does NOT appear to be a major determinant of gait speed
What NIHSS scores predict good and bad outcomes
≥ 16 forecasts a high probability of death or severe debility, ≤ 6 forecasts good recovery
MCA syndrome
Contralateral weakness (UE and face)
Contralateral sensory impairment (UE and face)
Aphasia (L/dominant hemisphere) – expressive, receptive, global
Neglect (R/nondominant hemisphere)
ACA Syndrome
Sensory impairment in contralateral LE
Weakness in contralateral LE
Altered mental status - frontal lobe behavioral abnormalities (poor judgment, decreased attention, decreased motivation, difficulty registering emotions
Speech perseveration (aphasia)
Abulia (a lack of drive/will power)
Posterior Cerebral Artery
Contralateral homonymous hemianopsia
Contralateral limb weakness
Thalamic pain syndrome (abnormal sensations of temperature/proprioception/touch, tingling, paresthesia, intractable pain, allodynia)
Disruption of PCA anterior supply results in what?
apathy, amnesia
Disruption of PCA posterior supply results in what?
neglect (R hemisphere), aphasia
Visual agnosia, anomia
Lacunar Syndrome
Small infarcts at the end of deep penetrating arteries, often affecting white matter
Pure contralateral weakness, Pure contralateral sensory loss, Parkinsonism (basal ganglia), Large majority are asymptomatic
VertebroBasilar Artery Syndrome
Headache, D/N/V, diplopia, nystagmus, dysarthria, dysphagia
Ipsilateral ataxia (possibly due to double-crossing over of pathways), dysmetria, hemiparesis
Bilateral effects if trunk of basilar artery occluded
Locked-in syndrome
Superior Cerebellar Artery Syndrome
Headache, D/N/V, Nystagmus, diplopia, dysarthria
Dysmetria
Ipsilateral limb/gait ataxia
Ipsilateral Horner’s syndrome
Contralateral loss of touch/pain/temp in extremities, torso, and face, if any
Contralateral mild hemiparesis, if any
Anterior Inferior Cerebellar Artery
D/N/V, nystagmus, diplopia, dysarthria, dysmetria
Ipsilateral deafness
Ipsilateral ataxia, ipsilateral loss of balance
Ipsilateral Horner’s syndrome (decreased sweating on face, ptosis, constricted pupil)
Ipsilateral loss of touch/pain/temp and weakness in face
Contralateral loss of pain/temp and weakness in limbs, if any
Posterior Inferior Cerebellar Artery (PICA)
D/N/V, nystagmus, dysarthria, dysmetria
Ipsilateral ataxia, ipsilateral loss of balance
Ipsilateral Horner’s Syndrome
Dysphagia (CN nuclei IX, X)
Hoarseness of voice (CN nuclei IX, X)
Ipsilateral loss of touch/pain/temp on face (CN V nucleus)
Contralateral loss of pain/temp on body, if any
Spinal artery and vertebral arteries
Medial medullary syndrome,
paresis of contralateral U&LE
Contralateral loss of touch and proprioception
Ipsilateral tongue deviation (hypoglossal nucleus)
Suspect stroke If, ANY of the following with HINTS
HIT - Normal
Nystagmus - Direction-changing, vertical or purely torsional
Test of skew – positive with cover/uncover test
Suspect peripheral vestibular problem If, ALL of the following
HIT – Abnormal (showing corrective saccade)
Nystagmus - Direction-fixed and horizontal
Test of skew – negative with cover/uncover test
Pusher Syndrome
Stroke in R or L posterolateral thalamus, insular cortex, superior temporal gyrus, operculum, internal capsule
Pt posture tilted towards the affected hemi-side, actively pushes/leans towards the Hemi side, loses perception/sense of upright posture.
_____is the main determinant in individuals with more severe gait deficits
Balance
______is the main determinant in individuals with more mild deficits
Cardiovascular fitness
Slow-flexed walker characteristics
Excessive hip and knee flexion in midstance
Inadequate dorsiflexion in swing
Forward trunk lean
Slow-Extended Walker (Circumduction) characteristics
Quads too weak to support the knee during stance phase
Glut Max retracts femur into knee hyperextension to for stance limb support
Ankle PF spasticity
Hip hike and circumduction occur for foot clearance
Usually require an assistive device
Fast Walker characteristics
Lack of heel rise in terminal stance due to inadequate PF strength
Knee hyperextension in stance to compensate for lack of heel rise to allow the body to progress forward on the forefoot
Step length is compromised due to lack of transition of momentum from unaffected side
Moderate Walker characteristics
Increased weakness of plantarflexors
Weakness in hip extensors (glut max) and knee extensors (quads)
Greater knee flexion in mid stance
Independence in ADLs post-stroke is predicted by…
Age
Stroke severity (NIH stroke scale)
UE paresis
NIHStrokeScale
0
No stroke symptoms
1-4
Minor stroke
5-15
Moderate stroke
16-20
Moderate to severe stroke
21-42
Severe stroke
Orpington Prognostic Scale
Total score ranges from 1.6 – 6.8
Higher scores indicate a more severe stroke and a worse prognosis
Proportional Recovery model
Uses the Fugl-Meyer outcome measure for UE to predict UE recovery,
In 3 to 6 months, the majority of patients (recoverers) are estimated to recover a fixed proportion, between 0.55 and 0.85 (average ~ 70%), of their potential recovery. A minority of patients (non-recoverers) show only very moderate improvement, which cannot be linked to potential recovery
PREP model
Algorithm that predicts functional recovery of UE at 3 months. The algorithm is based on the evidence that sparing of descending white matter pathways is related to better recovery of upper limb function after stroke. It has good predictive value but requires the use of neurophysiological and neuroimaging assessment
PREP-2 algorithm
does not need MRI, instead uses NIHSS to predict UE recovery at 3 months post-stroke. If you do not have TMS score, you still can make some predictions.
If patient’s SAFE score is >5 when using PREP-2 algorithm…
you don’t need TMS to predict recovery
If patient’s SAFE score is < 5 when using PREP-2 algorithm…
if NIHSS is <7, then recovery could be good<>limited
If NIHSS is >7, then can be Good or poor, but you can lean more towards poor
IV tPA
IV tPA should be administered to all eligible acute stroke patients within 3 hours of last known normal . BP should be maintained <180/105 mm Hg for at least the first 24 hours after IV alteplase treatment.
Patients ≥18 years should undergo mechanical thrombectomy with a stent retriever if they:
Have minimal prestroke disability
Have a causative occlusion of the internal carotid artery or proximal middle cerebral artery
Have a National Institutes of Health stroke scale score of ≥6
Have a reassuring noncontrast head CT (ASPECT score of ≥6)
If they can be treated within 6 hours of last known normal. No perfusion imaging (CT-P or MR-P) is required in these patients.
Unilateral spatial neglect can occur with a lesion in any of the following areas:
Posterior parietal cortex
Frontal lobe
Cingulate gyrus
Striatum
Thalamus
Action-Intentional Disorders
Motor neglect,
Not a deficit of the motor pathway, but rather a failure or decreased ability to move in the contralesional space (space contralateral to the damaged hemisphere) despite being aware of a stimulus in that space.
Inattention unilateral spatial neglect
Sensory neglect,
Lack of awareness, or decreased awareness, of sensory stimulation in the contralesional hemispace.
This decreased sensory awareness occurs even though the sensory pathways and the primary sensory cortical areas are intact
Restitutive Approach for USN
aim to alter the underlying cognitive impairment. More often used in the early stage of the stroke pathway when plasticity is thought to be greatest
Compensatory Approach for USN
emphasis on coping with and finding ways of adapting to existing impairments. More often used in later stages of the stroke pathway
Top-Down Approach for USN
Requires awareness of the disorder.
Aim to train the person to voluntarily compensate for their neglect
Methods include training in scanning and usually provide feedback
Focus on the level of disability rather than impairment.
Bottom-Up Approach for USN
Do not require awareness of the disorder.
Aim to modify underlying factors, i.e. to alter the impaired representation of space.
Prism-wearing and prism adaptation training are popular recent examples of a bottom-up approach
Pusher Syndrome prognosis
Only 6 months after a stroke, pathological pushing behavior is rarely still evident.
Pusher syndrome thus has a good prognosis and does not seem to negatively influence the outcome of rehabilitation.
Pusher syndrome treatment ideas
perform treatments in upright position, do no correct passively instead use verbal and visual cues for patient to actively correct themselves. Focus on midline and verticality is key, patients need to see their deficits
King-Devick test
Developed to assess eye movement in children with reading difficulty, quantifies saccadic movements and has been proposed for both oculomotor assessment and acute diagnosis in patients with concussion.
Due to variability in performance, patients require a baseline measurement for valid post-injury comparison
Rancho Level I
No response, Dependent/Total Assist
Rancho level II
Generalized Response, Dependent/Total Assist
Rancho level III
Localized response, Dependent/Total Assist
Rancho level IV
Confused/Agitated, MAX A (mostly due to risky behavior)
Rancho level V
Confused, Inappropriate, Non-Agitated, MAX A
MST strategies for problem recognition
watching videos of someone else doing the task at hand, and demonstrating how they overcame their failures
MST strategies for problem solving
Self-reflection activities - self-prediction of performance prior to performance and self-evaluation following performance
MST strategies for decision making
allow for errors safely -> self-recognition of errors (if not happening, provide timely feedback) -> encourage to develop self correction strategies for future use -> practice with multiple reps -> generalize strategies for similar tasks
Rancho VI
Confused, Appropriate, MOD A
Rancho level VII
Automatic, Appropriate, MIN A
Rancho level VIII
Purposeful, Appropriate, SBA
