CVA Flashcards
Types of CVA
Ischemia
- 80%
- Risk factors: Hypertension, cardiac disease, diabetes, smoking, alcohol or drug use, lifestyle
Hemorrhage
- 20%
- Due to trauma, hypertension, aneurysm, drug interactions
TIA - Transient Ischemic Attacks
- Atherosclerosis
- Precursor to CVA
- No permanent damage, no change in MRI
ACA stroke impairments
Contralateral Hemiparesis-greater in leg
Contralateral Motor and Sensory loss-greater in leg
Speech Impact-Aphasia
Mental and Behavioral Changes
Agraphia/Acalculia or Dysgraphia/Dyscalculia
Apraxia
MCA stroke impairments
Contralateral hemiparesis
Contralateral homonymous hemianopia
Visual spatial impairment
Behavioral and emotional issues
Apraxia
Lack of judgement
Apathy
Lability
Depression
PCA stroke impairments
Contralateral Hemiparesis
Visual issues-Cortical Blindness
Dysphagia
Memory issues
Loss of laterality
Dyslexia
All visual perceptual issues
Vertebral-basilar artery system stroke impairments
Contralateral hemiplegia (in most cases)
Depending on area may have ipsilateral impact to the tongue or eye
Balance issues
Coordination issues
Vertigo
Can require ventilator (for some)
Right side stroke symptoms
Left side motor and sensory impairment
Visual field deficits
Spatial neglect
Poor insight and judgment
Impulsive
Attention span
Initiating activities
Drawing
Remembering visual objects
Recognition of faces
Emotional stability
Left side stroke symptoms
Right side motor impairment
Aphasia
Apraxia
Motor speech
Expressive speech
Emotional control
Understanding math
Writing
Proprioception
Reading numbers and letters
Recognizing objects
Remembering written information
Functional limitations commonly seen after stroke at the base
Assess seating and posture
Inability to cross or maintain midline
Multi directional trunk weakness
Pelvic tilt – often posterior for stability
Inability to move segmental
Decreased weight shift - poor weight bearing on effected side
Lateral trunk flexion on affected side is common
Functional limitations commonly seen after stroke in upper limb
Decreased strength
Edema
Decreased muscle activity
Subluxation
Spasticity: increased tone
Decreased segmental movement
Decreased sensation and increase in associated
movement
Methods of spasticity assessment
Physiologic measures
Passive activity measures
Voluntary activity measure
Functional measures
Quality of life measures
Language after stroke
Aphasia
- Broca’s
- Wernicke’s
- Anomic
- Global
- Dystarthria
Broca’s aphasia
Non-fluent
Slow, broken, effortful
Comprehension intact
Repetition is poor
Wernicke’s aphasia
Fluent
Fast talker
May invent new words or sounds
Comprehension and repetition are poor
Anomic aphasia
Fluent
Word finding issues
Comprehension and repetition are good
Global aphasia
Non fluent
Combo of all aphasia symptoms
Dysarthria
Biomechanical issues
Weakness, decreased ROM
Not really aphasia
Cognition and behavior in vision after stroke
Visual problems
- Homonymous hemianopsia: effects ½ the visual field of both eyes a patient with left hemianopsia will have visual loss on the nasal field of the right eye and the ear side of the left eye
Unilateral neglect
Perceptual issues
Cognition
Psychosocial/Behavioral
- Depression
- Anxiety
- Altered sex drive
- Altered appetite
- Avoidance of social
- Personality changes
CVA assessment
We often get these folks very early in the process-2-7 days after!
- Initial Assessment in Field (FAST)
- Degree of the CVA (see NIHSS on Canvas)
It is the worst it will be
Not a progressive disorder, but can get worse if they just sit
Typical recovery
- 3-6 months to return
- Lifetime to improve
Functional Assessment Scale
Assessing CVA clients with top down approach
Functional
ADL Assessment
Environmental assessment
Assessing CVA clients with bottom up approach
Balance and Mobility
- Berg
- Tinetti
- Timed Get up and Go
- Functional Reach
- Wheelchair Skills
Upper Limb
- ROM
- Subluxation
- MMT
- Tone assessment
- Box and Blocks
- 9-hole peg test
- Perdue
Modified Ashworth Scale
Upper limb assessment
More Top Down in Nature
- Action Reach Arm Test
- The hand function test
Bottom up
- 9-hole peg test – precision, tip pinch, manipulation
- Perdue peg board - precision, tip pinch, manipulation
- Minnesota Dexterity test – more precise gross dexterity
- Box and Blocks - originally used to assess median nerve damage, but also looks at gross dexterity; least precise gross dexterity
- Range of motion
- Strength
- Sensory function: pain, temp, light touch, moving/constant, touch localization, stereognosis
- Tone
Cognitive/Vision and Psychosocial Assessments
Fugle-Meyer
ADL Assessments
Cognitive Assessments
- Orientation
- Kolman or Cognitive Assessment
Vision
- Perceptual tests
- Acuity
Specific Issue
- Executive Function Performance Test
- Grocery Shopping Assessment
- Others
Treatment options for stroke
Rehabilitative/Remedial
Compensatory and adaptive
or both
Timeline after stroke
- Stroke occurs
- Hyperacute - first 24 hours
- Acute - 1-7 days
- Early subacute - 1 week - 3 months
- Late subacute - 3-6 months
- Chronic - 6+ months
Acute stage of stroke
Positioning
Dysphagia management
Fall preventions and safety
- Teaching transfers
- Very basic ADLS
Early mobilization and function
Preparing the client for rehab
Rehabilitation stage of stroke
Goal is restorative
- By remediation or adaptation
ADL training and equipment
- Motor learning
- Addressing safety
Task oriented training
CIMT - Constraint Induced Movement therapy
Combined with cognitive strategies
- Mental practice (MP)
- Mirror therapy (MT)
- Virtual reality
- Action observation (AO)
- Strengthening and exercises and functional tasks
* Grading and adapting
* NMES
Special issues with CVAs
Once they have active movement, you don’t have to worry about subluxation.
Spasticity and hemiplegic shoulder pain
Limited evidence that slings prevent subluxation
Aggressive ROM results in increased incidence of painful shoulder, gentle ROM is preferred
Ultrasounds not helpful, use NSAIDs
Functional e-stim may help reduce or prevent subluxation, but doesn’t appear to reduce pain
Deinnervation of subscapularis may reduce shoulder pain and improve PROM
Some evidence that massage aromatherapy and acupressure can reduce shoulder pain
Oral corticosteroids appear to improve shoulder-hand syndrome for at least the first 4 weeks
Mirror therapy can reduce pain associated with shoulder hand syndrome.
General stroke safety
Medical status
Cardiac and respiratory precautions
Fall risk
Subluxation
Skin
Swallowing
Impulsive - don’t trust them
Handling upper limb after stroke
Teach patient as early as possible proper positioning
Use gait belt or draw sheet instead of pulling on arm
Orthotics as needed
Avoid motions above 90 degrees unless there is scapular mobility
- No overhead pulleys
Encourage touching and handling of the extremity by the patient
- Self range
Use the limb
Bed position to avoid subluxation after stroke
