CVA Flashcards
Def: Sudden loss of neurological function, caused by sudden interruption of blood flow to the brain; resultant impaired neurological function
CVA- Cerebrovascular accident or stroke
Def: Temporary interruption of blood flow, transient symptoms (<24hrs), Susceptible to CVA or MI. Without treatment 1/3 will have a CVA within one year
TIA- Transient ischemic attack
2 types of stroke:
Which is more common?
Ischemic and Hemorrhagic
~80-87% are Ischemic
- Ischemic = cerebral thrombosis, cerebral embolus
- Hemorrhagic (bleeding causing disfunction) = Intracerebral, subarachnoid, arteriovenous, malformation (AVM)
Name some potentially modifiable risk factors for CVA:
What are some NON-modifiable factors?
Modifiable: HTN, Atrial Fib, Diabetes, Stress, Smoking, Obesity/diet, Alcohol consumption
NON-modifiable: Gender, Race, Family hx of CVA, Age, Prior CVA
What does “BE FAST” stand for when spotting a stroke?
B: Balance
E: Eyes
F: Face drooping
A: Arm weakness
S: Speech difficulty
T: Time to call 911
Def: Paralysis on one side of body.
Contralateral side in stroke pt.
Hemiplegia
Def: Weakness on one side of body
Hemiparesis
Def: Loss of ability to understand or express speech
Aphasia
Def: Bleeding occurs from a broken blood vessel within the brain. Some things that increase your risk for this kind of hemorrhage are high blood pressure, heavy alcohol use, advanced age, and the use of cocaine or amphetamines
Intracerebral Hemmorrhage
Def: bleeding from a damaged blood vessel causes blood to accumulate at the surface of the brain. Blood fills a portion of the space between the brain & the skull & it mixes with the CSF. As blood flows into the CSF it increases pressure on the brain, which causes an immediate headache. Can lead to artery spasms which cause brain damage.
Subarachnoid hemorrhage
How do you determine/measure amount of subluxation at shoulder joint?
Measure in fingerbreadths; gap from acromion to head of humerus
Symptoms of a CVA depend on:
- Area of brain involved
- Size of ischemic area
- Nature and functions of structures involved
- Availability of collateral blood flow
- How rapid occlusion occurs
- How quickly reperfusion occurs
Middle cerebral artery (MCA, stroke syndrome) infarcts are the most common type of stroke and can result in contralateral sensory loss and weakness in the ___ and ____ extremity. Infarction of the dominant hemisphere can lead to global ___.
Face and upper extremity
Global aphasia
Hemispheric differences:
Difficulty with visual cues, impulsive, Unrealistic, inability to perceive emotional/social cues, difficulty synthesizing information, spatial-perceptual deficits
RIGHT Hemispheric Lesion causing LEFT Hemiplegia
Hemispheric differences:
Speech/language impairment, difficulty processing verbal cues, slow/cautious behavior, highly distractible, perseverates (repeats things), apraxia (Difficulty planning and sequencing movements)
LEFT Hemispheric Lesion causing RIGHT hemiplegia
____ ___ Syndrome: Tetraplegia, bulbar palsy (CN V-XII). Patient must communicate with vertical on movements and eye blinking
Locked In Syndrome
____ _____ Syndrome: Once initial stroke symptoms (numbness and tingling) dissipate, replace with intolerable burning pain and hypersensitivity. “Allodynia” - pain from a stimulus that would normally not cause pain
Thalamic Pain Syndrome
____ Syndrome: Patient unable to determine vertical and pushes towards hemiparetic side. Resists passive correction.
Pusher Syndrome
Stages of the motor recovery (6):
I. Flaccidity II. Synergies, Some spasticity III. Marked spasticity IV. Out of synergy, less spasticity V. Selective control of movement VI. Isolated/coordinated movement
Synergy Patterns:
____ synergy dominates in upper limb and ___ synergy dominates in lower limb.
Muscles are neurophysiologically linked and cannot act alone or perform all of their functions. Unable to perform isolated movements.
Flexor synergy dominates upper limb
Extensor synergy dominates lower limb
Upper extremity flexion Synergy components:
Scapula: retraction and elevation
Shoulder: ABduction and external rotation
Elbow: Flexion
Forearm: Supination
Wrist: Flexion
Fingers: Flexion
Dominant elbow flexion
Weakest rotation: Shoulder AB and ER
Lower Extremity Extensor Synergy Components:
Hip: Extension, ADDuction & IR
Knee: Extension
Ankle: Plantarflexion and inversion
Toes: Flexion
Dominant: Hip ADD, knee ext., and ankle plantar flexion
Weakest: Hip ext and IR
Def: Non-fluent form of aphasia in which the person knows what they want to say but is unable to produce the words or sentence. Speak in short phrase. Affects frontal lobe of brain. (Usually left frontal)
Broca’s aphasia
Def: “Fluent” type of aphasia where person may speak in long, complete sentences that have no meaning, adding unnecessary words and even creating made-up words. Comprehension of written and spoken word is impaired.
Damage to temporal lobe (usually left temporal lobe/parietal lobe junction)
Wernicke’s aphasia
Poor positioning can lead to:
- Pain
- ## Joint ____
- skin tears
- Poor interaction with ___
- ____ from a w/c or ambulation level
Joint tightness
Pressure ulcers
Poor interaction with environment
Immobility from a w/c or ambulation level
Def: no movement of muscles
Flaccid
Spasticity/hypertonicity =
Increased tone
When setting up a pt’s room, visitors should approach or sit/stand by [non-affected or hemiplegic?] side?
Why?
Have staff, family, and visitors place patient’s bed side table on the ____ side, especially with meal tray set up with supervision and cueing to locate items.
Sit on hemiplegic side. To facilitate turning his/her head, make eye contact during conversation and to help patient learn to cross midline.
On hemiplegic side
Advantages of proper positioning of UE:
- Prevention of shoulder subluxation
- Prevention of pain
- Prevent loss of ROM
- Improvement in functional outcome to assist in ADL’s
Procedure for UE positioning:
- ____ arm at all times
- Avoid lifting through ___ or ____ arm to move pt.
- Use ____, _____, lap trays, air splints, thermoplastic splints or casting
- Slings should be worn during ____ or ____. Remove when ___ or _____.
- In sitting, position shoulder in slight ___, ___ and ____ rotation; forearm in ____ and hand in ___ weight bearing position.
Support
Avoid axilla or pulling on arm
Pillows, slings
Transfers or ambulation; remove when sitting or in bed
Position shoulder in slight flexion, ABduction, and ER; forearm in pronation and hand in open WB position.
Advantages of lying on UNAFFECTED side:
- Promote ____ and prevent or decrease ___ and muscle ____
Promote relaxation and prevent or decrease pain and muscle tightness
Procedure for lying on UNAFFECTED side:
- Flat pillow under head
- Pillow under affected arm for support. Affected shoulder is slightly ___ with hand supported and wrist ___.
- Affected leg supported ENTIRELY by a pillow, hip slightly ____, hip and knee ___. Make sure ankle is ____ and not bent toward bed.
- Pillow behind back if needed
- Affected side should be rolled ____ slightly.
Slightly forward and wrist straight
Hip slightly forward, hip and knee bent; ankle is supported
Affected side rolled forward slightly
Advantages of Lying on AFFECTED side:
- Promote ___ of affected side
- Promote relaxation and prevent or decrease pain and ____
- Provide ____ of and ___ input on affected (hemiplegic) side
- Allows patient to use unaffected hand to assist with ____ and ___ as needed.
Promote stretching
Decrease tightness
Provide awareness of and sensory input on hemiplegic side
Covers and pillow
Procedure for lying on AFFECTED side:
- Affected shoulder ____
- Pillow under head
- Palm of hand turned ___ with entire arm supported
- Affected hip should be ___ with knee slightly ___
- Pillow under unaffected leg for support
Affected shoulder forward (abduct scapula)
Palm of hand turned up (supinated)
Affected hip straight with knee slightly bent
Procedure for lying Supine:
- Pillow under head with head ___ or slightly turned toward side
- Body should be ____ in bed
- Place pillows under entire ____ arm, including ___ ___ , with palm facing ___. Keep elbow, wrist, and fingers ____.
- Lift ___ with small towel rolls under ankles to prevent ____ on heels.
- Keep affected hip in ___ position with toes and knees pointed up toward ceiling.
- DO NOT place pillows under ____. May cause contractures or increase reflex activity.
Head straight
Body straight
Pillows under entire affected arm, including under shoulder blade with palm facing up. Keep elbow, wrist, fingers straight
Lift heels to prevent pressure on heels
Keep hip in neutral position
NO PILLOWS UNDER KNEES
Advantages of sitting up in chair/wheelchair:
- To encourage ____
- Increase ____ and patient’s level of _____
- Decrease effects of prolonged ___ ___ and deconditioning.
- Foster return to _____
Encourage mobility
Alertness and level of consciousness
Decr effects of prolonged bed rest
Return to independence
Procedure for Wheelchair Positioning:
- Ensure patient is seated and ____ in center of wc
- Ensure hips and knees form a ____ degree angle when placed on foot rests
- Position affected arm slightly ___ at a 90 degree angle with palm facing ___ and fingers ____
- Support arm using ____ or appropriate arm/hand splints, lap tray or arm trough
Aligned in center
Hips/knees at 90 degree angle
Affected arm slightly forward, palm down, fingers extended
Support arm using pillows
Most common postural deficits are:
- Alignment
- Stability
- Symmetry
- Static and dynamic balance
Pelvic postural alignment DEFICITS:
- Asymmetrical WB with shifting of weight onto ____ side
- Fear of weight shifting onto ___
- ____ pelvic tilt posture and ____ of pelvis on affected side
They shift weight onto stronger side
Fear of shifting onto affected side
Posterior pelvic tilt and retraction
Trunk DEFICITS:
- Loss of lumbar ____, increased ___ curve (rounded posture) and ____ head
- ____ flexion of trunk
- ____ rotation or retraction
Loss of Lumbar lordosis, increased thoracic curve and forward head
Lateral Flexion of trunk
Posterior rotation
Shoulder DEFICITS:
- Shoulders have ____ height with affected side shoulder ____
- Humeral _____ with downward rotation of scapula
- Scapular instability (winging)
Unequal height, affected shoulder depressed
Humeral subluxation
Advantages of UE WB:
- Promotes proximal ____
- Inhibits abnormal ___
- Facilitates increased ____ movement and control
Stabilization
Abnormal tone
Active movement
Def: Area of salvageable brain tissue beyond the blood starved infarct. Zone that is still viable- can be salvaged if flow of blood and oxygen restored.
If blood flow is restored there is a resolution of the ____ and subsequent spontaneous recovery for 3-6 months due to plasticity which may continue for years.
The Penumbra
_____ ____ Is recommended for selected patients who may be treated within __ hours of onset of ischemic stroke.
It should be administered to eligible patients who can be treated in the time period of __-___ hours after stroke. This treatment option is only for ____ strokes.
Intravenous rtPA (aka clot buster)
3 hours
3-4.5 hours
Ischemic
What is MERCI? What does it stand for?
Mechanical embolus removal in cerebral ischemia
It is mechanical thrombectomy, goal is to restore blood flow. Can be used within 8 hours of onset.
What are Solitaire and Trevo?
Thrombectomy used within 6 hours of Onset. Can be used on patient outside the window for using tPA and have a good outcomes
Neuroplasticity is the ability of the brain to form and re-organize synaptic connections, especially in response to learning or experience or following injury. Plasticity may continue for years post CVA. Goal of rehab can change from compensation to restoration of function. How we spend our treatment minutes in rehab should change to focus on ______.
Restoration
Stroke patients are _____ in flaccid stage and _____ in spastic and synergistic stages.
Hyporeflexive
Hyperreflexive
*clonus wrist or ankle, clasp-knife response,
+ Babinski
Def: Type of reflex that involves movement of head or position of body eliciting an obligatory change in Resting tone or movement of extremities
Tonic reflexes
*ATNR is most common
Def: Unintentional movements of the stroke limb caused by voluntary action of another limb. Can be elicited when a patient coughs, sneezes, yawns or when performing and exertional movement on uninvolved side
Associated reactions
Def: Loss of half of the visual field on the same side and both eyes. Damage to the right side of the posterior portion of the brain or right optic tract can cause a loss of the left field of view in both eyes
Homonymous hemianopsia
Def: Muscles are neurophysiologically linked and cannot act alone or perform all of their functions. Unable to perform isolated movements.
Synergy patterns
Interventions for abnormal tone:
Flaccidity (hypotonicity)
- WB/ Approximation
- Brisk rubbing
- Tapping
- Quick stretch
- Associated reactions
- Vibration
Interventions for abnormal tone:
Spasticity (hypertonicity)
- Positioning
- Slow stretch, rhythmic rotation
- WB
- Biofeedback, mental imagery, relaxation techniques
- Cold (10-20 min application), short lived effect
- Dynamic orthosis- slow sustained stretch
- Air splints
- Deep pressure over tendon
- Pharmacology- Botox, Baclofen
Def: Type of aphasia where the person can speak normally and understand speech but cannot identify written words or pictures
Anomic Aphasia
Def: Type of aphasia where the person has severe impairment of production, comprehension, and repetition of language; poor prognosis.
Difficulty with articulation of words.
Due to large infarct involving Wernicke and Broca areas.
Global aphasia
Patients with ___ hemisphere damage can still sometimes swear and use emotional words. They can even sometimes sing what they can’t speak.
Left
*bc Right hemisphere= emotion, music
Dysphagia/Aspiration precautions:
- changing ___ position/posture
- Elevation of _____
- Feeding in ____ position
- Using ___ ____ technique
- Diet modification (mechanical soft diet, thickened liquids)
- ____/____ exercises- Speech therapist
Head
Head of bed
Upright position
Chin tuck
Oral/motor
Def: Most commonly is a result of a CVA in the R cerebral hemisphere resulting in visual neglect of the left side of the body/world.
Hemispatial Neglect
25% of hemiplegic patients have non-functional arm long term.
This results in ____ ____ ____.
Interventions include:
Hemiplegic shoulder pain
-Early positioning, proper handling techniques, establish scapular mobility before addressing glenohumeral motion, estim to rotator cuff muscles/trapezius/serratus interior, sling to minimize subluxation, taping, weight-bearing exercise
Common Gait Deviations seen in patients with stroke:
Hip:
Knee:
Ankle:
Hip: Retraction, hiking, circumduction, inadequate hip flexion
Knee: Decreased knee flexion during swing, excessive flexion during stance, hyper extension during stance, or instability during stance
Ankle: Foot drop, ankle inversion or eversion, toe clawing
Def: Repetitive, intense use of affected extremity for two weeks with non-paretic UE constrained in a sling; positive results in acute and chronic stroke patients
Constraint Induced Movement Therapy
There’s a strong evidence for PT interventions favoring intensive high ____ task-oriented and task-specific training in all phases post stroke.
Early ____ within 24 hrs post stroke, over ground walking, group circuit training, ___ ___ of motor performance, and CIMT(Constraint induced Movement therapy) were all found to be beneficial.
Repetitive
Mobilization
Mental imaging
*Also PBWS (Partial body weight supported) treadmill training
The goal of managing a patient with ischemic stroke is to achieve Cerebral ___ and _____ further strokes.
Cerebral reperfusion
Prevent further strokes
Acute care of strokes:
___ used for the emergent care of ischemic strokes. Used to break down fibrin clots in the cerebral arteries. Must be administered within 3 to 4 1/2 hours post onset of CVA symptoms. Significant neurological improvement due to the potential to salvage penumbral tissue.
*what is the full name?
rtPA - Recombinant Tissue Plasminogen Activator
*Potential complications: risk of cerebral bleed or secondary embolization caused by thrombus fragmentation. Often used in conjunction with mechanical embolus removal.
Pharmacology for strokes:
______-Used to decrease risk of MI and CVA following MI. Also used in acute care management of stroke if the patient does not receive thrombolysis. ____ is the most commonly used in the stroke population.
Side effects include increased risk of G.I. bleeding
Antiplatelets
Aspirin (ASA)
Anticoagulants- _____ is used prophylactically against DVT and PE.
____ (Coumadin) effective in prevention of strokes due to atrial fibrillation.
Side effects: Bleeding therefore not for use with ____ strokes.
Heparin
Warfarin
Not for hemorrhagic strokes!
Basic principles of PNF:
- ___ Movement Patterns
- ____ and _____ patterns
- __ diagonal motions for each major body part
- Muscles move from fully _____ to fully _____ position
- Incorporates _____, ______, and _____ muscle contractions
- May be passive, active ____, active or ____ in nature
Mass
Spiral and diagonal patterns
2 diagonal motions
Fully lengthened to fully shortened
Isometric, concentric, and eccentric
Active assistive; resistive
Essential components of PNF:
- ____ contacts
- Body ___ and body ____
- ______
- Manual ____
- Irradiation
- Joint _____
- Timing of movement
- Patterns of movement
- Visual cues
- ____ commands
Manual
Body position and mechanics
Stretch
Manual resistance
Joint facilitation
Verbal commands
PNF Techniques- Mobility
- Rhythmic _____: Teach a pattern and improve mobility (PROM)
- Rhythmic ____: Decrease tone, relaxation, increase ROM (Ex. Pt. hook-lying, therapist gently pushes legs back and forth)
- Hold Relax/Contract Relax: Improve mobility
Rhythmic Initiation
Rhythmic Rotation
PNF Techniques- Stability
- Alternating ____: Promotes stability (hook lying, push on each side of legs, hold it don’t let me move it-pelvic stability)
-Rhythmic _____: Stability
(Pt. sitting, therapist simultaneously pushes back on one shoulder and forward on other)
Alternating Isometrics
Rhythmic Stabilization
PNF Techniques: Controlled Mobility/Skill
- ____ Reversal: Improve mobility and coordination (PNF patterns we practiced)
- ____ Reversal: Controlled mobility, stability, and skilled movement (Resistance at pelvis during bridging)
- Resisted Progression: Skilled ambulation/ crawling
Slow reversal
Agonist reversal
Developmental sequence:
- Head control
- _____
From
Prone
- Prone on \_\_\_\_
- Prone on \_\_\_\_
- \_\_\_\_\_\_\_
- \_\_\_\_\_\_\_
- \_\_\_\_\_\_\_
- Standing
From
Supine
- Hook lying
- \_\_\_\_ lying
- Side sitting
- \_\_\_\_\_\_
- Standing
Rolling
On elbows On hands Quadruped Kneeling Half kneeling
Side-lying
Sitting
D1 Flexion:
- Shoulder ____ and ____
- Forearm ____
- Wrist ____ ____
- Finger ____
D1 Extension:
- Shoulder ____ and ____
- Forearm _____
- Wrist ___ ____
- Finger ____
D1 flexion:
Sho ADD and ER
Forearm supination
Wrist radial dev.
Finger flexion
D1 Extension:
Sho AB and IR
Forearm pronation
Wrist ulnar dev.
Finger extension
D2 flexion: Shoulder \_\_\_\_ and \_\_\_\_ Forearm \_\_\_\_\_ Wrist \_\_\_\_ \_\_\_\_ Finger \_\_\_\_
D2 extension: Shoulder \_\_\_ and \_\_\_ Forearm \_\_\_\_ Wrist \_\_\_\_ Finger \_\_\_
D2 Flexion: Sho AB and ER Forearm supination Wrist radial dev Finger extension
D2 Extension: Sho ADD and IR Forearm pronation Wrist ulnar dev Finger flexion
LE D1 flexion:
Hip ____ and ___
Knee ____
Ankle ____ and ____
Toes ____
LE D1 Extension:
Hip ___ and ___
Knee ___
Ankle ____ and ___
Toes ___
D1 flexion: Hip ADD and ER Knee flexion Ankle dorsiflexion and inversion Toes extended *man crossing leg while sitting
D1 extension: Hip AB and IR Knee extension Ankle plantar flexion and eversion Toes flexed *karate kick girl, ballerina
LE D2 flexion:
Hip ____ and ___
Knee ____
Ankle ____ and ____
Toes ____
LE D2 extension:
Hip ___ and ____
Knee ____
Ankle ___ and ____
Toes ____
LE D2 flexion:
Hip AB and ER
Knee flexion
Ankle dorsiflexion and eversion
Toes extended
*looks like how a dog pees or swimmer doing butterfly kick
LE D2 extension:
Hip ADD and IR
Knee extension
Ankle plantar flexion and inversion
Toes flexed
*baseball player pic
Why do stroke patients need to learn to bridge?
Bed mobility, bedpan use, pressure relief
Bridge positioning:
- Have pt. put legs into _____ position. Assist hemi side as needed.
- Have pt. _____ hemi leg with ______
- Facilitate movement by putting hand on distal femur with a “____ and ____” movement and other hand under hip/ butt with ____ movement
- Have pt move pelvis laterally
- Have pt. flex head and neck to activate core
*PTA should be by the knees facing toward patient’s head rather than facing the bed/their legs
Hook lying
Stabilize hemi leg with strong leg’s foot
Forward and downward; other hand pushes upward
Def. Ipsilateral pushing that occurs in pt’s with CVA in posteriolateral thalamus. Their perception of vertical was approximately 20° toward hemiparetic side
Pusher syndrome
Type of CVA most fatal in acute stage:
Hemorrhagic
2 types of CVA that account for majority of CVAs:
Embolic and Thrombotic
Def: Difficulty articulating words due to oral motor weakness s/p CVA
Dysarthria
