CVA Flashcards
Function of the lobes: Frontal lobe (6)
- Judgement
- Emotion
- Motivation
- Memory
- Pre-motor cortex (plans mvmt, including speech)
* Broca’s area - Motor cortex (execute mvmt skills, including speech)
Function of the lobes: Parietal lobe (4)
- Sensory cortex
- Receive & appreciate info from the senses
- Provides sensory context (compare new info w/ past experiences)
- Understand symbolic language
Function of the lobes: Temporal lobe (3)
- Auditory cortex - receive “raw data”
- Wernicke’s area (understand auditory info, compares w/ past experiences)
- Visual-object recognition (persons, colors, etc.)
Function of the lobes: Occipital lobe (2)
- Visual cortex - receive “raw data”
2. Functions w/ parietal & temporal lobes to understand what is being seen
Function of the limbic system (7)
Functions with all other cortices for memory circuits, motivation olfaction, emotion, visceral tone, fear/frustration, anger, behavior
Progression/Recovery from CVA (typical first 6 mos - 4 stages)
Recovery dependent on extent of damage
0-2 wks: flaccidity
2-4 wks: incr. motor control, spasticity, focus on bilateral mvmts
2-4 mos: recovery slows, but still regaining function
4-6 mos: limited changes, abnormal mvmt becomes habitual
What is Constraint-Induced Mvmt Treatment (CIMT)?
Intensive program focused on using affected side. Restrain unaffected side. 5-6hrs/day. Use of incremental, repetitive tasks. Task-oriented approach
Deficits resulting from CVA lesions: Frontal lobe (12)
- Lack judgement
- Flat affect
- Possible memory deficits
- Spastic hemiparesis
- Loss of voluntary eye mvmt patterns
- Motor apraxia
- Expressive aphasia
- Personality changes
- Difficulty sequencing
- Perseveration
- Difficulty prob-solving
- Uncontrollable emotions
Deficits resulting from CVA lesions: Parietal lobe (9)
- Difficulty w/ academics (eg dyslexias)
- Difficulty naming objects
- R/L confusiom
- Impaired processing of tactile info
- Inability to focus visual attention
- Difficulty w/ eye-hand coordination
- Lack of awareness of body parts
- Impaired spatial orientation
- Dressing or constructional apraxia
Deficits resulting from CVA lesions: Temporal lobe (12)
- Receptive aphasia
- Disturbance of selective attention
- Difficulty identifying/categorizing objects
- Prosopagnosia (difficulty recognizing faces)
- STM loss
- Changes in sexuality
- Persistent talking
- Increased aggressive behavior
- Cortical deafness
- Visual-object agnosia or neglect
- Hallucinations or auras
- Possible seizures
Deficits resulting from CVA lesions: Occipital lobe (10)
- Vision defects
- Difficulty visually locating objects
- Difficulty identifying colors
- Hallucinations & visual distortions
- Word blindness
- Inability to recognize object mvmt
- Difficulty reading & writing
- Poor processing of visual stimuli
- Visual-object neglect
- Prosopagnosia
What arteries supply the frontal lobe?
Anterior cerebral artery
Middle cerebral artery
What arteries supply the temporal lobe?
Posterior cerebral artery
Middle cerebral artery
What arteries supply the parietal lobe?
Anterior cerebral artery
Middle cerebral artery
What arteries supply the occipital lobe?
Posterior cerebral artery
Two categories of CVA - What are they? Prevalence?
Ischemic - blocked oxygen supply - 80% of CVA
Hemorrhagic - bleeding in brain - 20% of CVA
What are the types of ischemic CVA? (4)
- Atheroma
- Thrombosis
- Embolus
- Steal
What’s an atheroma CVA?
Build up of plaque to restrict/occlude vessel (cholesterol & lipids)
What’s a thrombosis CVA?
Blood material collects on arterial wall - obstruction
What’s an embolus CVA?
“glob” from atheroma or thrombosis breaks off, migrates, then blocks blood flow
What’s a steal CVA?
Shunts blood from another artery due to low pressure (occurs @ circle of willis)
What’s an aneurysm CVA?
Weakness in blood vessel breaks
What’s an arteriovenous malformation (AVM) CVA?
capillary bed all tangled - poor integrity, leaks
Deficits resulting from CVA lesions: Cerebellum (7)
- Impaired gross & fine motor coordination
- Lost ambulation
- Poor postural control
- Inability to make rapid mvmts
- Impaired control of eye mvmts
- Tremors or dizziness
- Slurred speech
Deficits resulting from CVA lesions: Brain stem (5)
- Impaired regulation of temp, heart rate, respiration
- Difficulty swallowing
- Difficulty w/ balance & mvmt
- Nausea & dizziness
- Impaired arousal & sleep regulation
Effects of Stroke - Involvement of: Internal Carotid Artery (3 primary, 5 dominant (L), 6 non-dominant (R)
Contralateral hemiplegia Contralateral hemianesthesia Homonymous hemianopsia LEFT SIDE Aphasia Agraphia/dysgraphia Acalculia/Dyscalculia R/L confusion Finger agnosia RIGHT SIDE Perceptual dysfunction Unilateral neglect Anosognosia Constructional/dressing apraxia Attention deficits Loss of topographic memory
Effects of Stroke - Involvement of: Middle Cerebral Artery (4 primary, 1 dominant (L), 5 non-dominant (R)
*MOST COMMON Contralateral hemiplegia - greater involvement of arm, face, & tongue Sensory deficits Homonymous hemianopsia Deviation of head/neck toward affected side DOMINANT HEMISPHERE (L) Aphasia NON-DOMINANT HEMISPHERE (R) Anosognosia Unilateral neglect impaired vertical perception Visual spatial deficits Perseveration
Effects of Stroke - Involvement of: Anterior Cerebral Artery (1 primary, 5 possibilities)
Contralateral LE weakness more severe than arm POSSIBLE: Apraxia Mental changes Primitive Reflexes Incontinence Severe confusion/intellectual changes
Effects of Stroke - Involvement of: Posterior Cerebral Artery (12 possibilities)
Affects are potentially broad & varied since this artery supplies the upper brainstem, temporal, & occipital lobes POSSIBILITIES: Sensory deficits Motor deficits Involuntary mvmt disorders Memory loss Alexia Astereognosis Dysesthesia Akinesthesia Homonymous hemianopsia or quadrantanopia Amonia Topographic disorientation Visual agnosia
Effects of Stroke - Involvement of: Cerebellar Artery System (7)
Ipsilateral ataxia Contralateral loss of pain & temp sensitivity Ipsilateral facial analgesia Dysphagia Dysarthria Nystagmus Contralateral hemiparesis
What’s analgesia?
Inability to feel pain
Effects of Stroke - Involvement of: Vertbrobasilar Artery System (4)
Affects brainstem functions
Bilateral or crossed sensory & motor abnormalities
e.g. loss of proprioception, hemiplegia, quadriplegia, involvement of cranial nerves 3-7
OT Evaluation of Ct w/ CVA:
- Review medical records
- Knowing affected area helps focus eval process
- Apply deficits to occupational profile
- Ct-centered assessment (e.g. COPM)
- Observation of functional tasks
- Standardized assessments
Recovery from stroke: Timeframe of greatest improvement
The first 3-6 mos is the most crucial time period for recovery
Adaptations for cts with CVA: Dressing
- One-handed dressing techniques
- Wear clothing with looser fit
- AE e.g. reacher
Adaptations for cts with CVA: Shopping
- Powered mobility
- Ankle-foot orthotic & cane
- The internet
Core Concepts for a Ct-Centered Eval (7)
- Ct’s are uniquely qualified to make decisions re: their occupational functioning
- Offer ct active role in defining goals & outcomes
- Ct-therapist relationships = interdependent
- OTs help enable ct’s to meet their own goals
- Eval/intervention focusing on contexts in which the ct lives, role, interests, & culture
- Ct is “prob-definer” for transition into “prob-solver”
- Allow ct to eval their own perf & set personal goals
Standardized Tools to use with CVA (only some of the possibilities) (13)
- The Arnadottir OT Neurobehavioral Eval (A-ONE)
- The Assessment of Motor & Process Skills (AMPS)
- The Canadian Occupational Performance Measure (COPM)
- The NIH Stroke Scale
- Canadian Neurological Scale
- Rankin Scale
- Barthel Index
- Kohlm Eval of Living Skills (KELS)
- Functional Independence Measure (FIM)
- Berg Balance Scale
- Stroke Impact Scale
- Tinetti Test
- Motricity Index
What does The Arnadottir OT Neurobehavioral Eval (A-ONE) measure? AKA?
Objectively documents the way that dysfunction of ct factors (e.g. left-sided neglect, apraxia, & spatial dysfunction) affects self-care & mobility tasks.
AKA ASL-focused Occupation-based Neurobrhavioral Eval
What does The Assessment of Motor & Process Skills (AMPS) measure?
Uses IADLs to evaluate underlying perf skills related to the completion of various IADLs (e.g. reaching, grasping, & posture) & process skill dysfunction (e.g. using items & searching & locating)
What does Kohlm Eval of Living Skills (KELS) measure?
Living skills eval that includes ratings of 17 tasks (e.g. safety awareness, money mgmt, phone book use, meds mgmt)
What does Functional Independence Measure (FIM) measure?
Measure of disability in performing BADLs that includes 18 items scored on a 7-pt scale; includes subscores for motor & cognitive function; perf areas include self-care, sphincter control, mobility, locomotion, cognition, & socialization
What does Barthel Index measure?
Measure of disability in performing BADL (0-100), includes 10 items: bowels, bladder, feeding, grooming, dressing, transfer, toileting, mobility, stairs & bathing
What does Rankin Scale measure?
Global disability scale w/ 6 grades indicating disability
0 = no symptoms, 6 = dead
What does Tinetti Test measure?
Balance & gait in older adults
What does Motricity Index measure?
Measures impairments in limb strength
What approaches does evidence-based treatment support?
Use of functional activities as the therapeutic change agent (e.g. task-oriented approaches). Use of task-oriented approaches have better functional outcomes as well as overall health-related quality of life.
Principles of task-oriented approaches (5)
- Help ct’s adjust to role & task perf limitations by exploring new roles & tasks
- Create an enviro that includes the common challenges of everyday life
- Practice functional tasks identified as important by the ct to find effective & efficient strategies for performance
- Provide opportunities to practice outside of therapy time (e.g. homework assignments)
- Minimize ineffective & inefficient mvmt patterns
Functional limitations commonly observed post CVA: impairment secondary to poor trunk control (6)
- Dysfunction of limb control
- Increased risk for falls
- Impaired ability to interact with the enviro
- Dysphagia
- Decreased ind. w ADLs
Tx interventions post CVA to increase ct’s ability to perform seated tasks(7)
- Est. neutral yet active starting alignment *neutral to slight anterior pelvic tilt
- Reaching activities from active posture
- Use external cues (eg verbal tactile physical) to maintain posture
- Maintain trunk ROM via proper positioning & exercises
- Practice dynamic weight shifts *reaching tasks beyond arms length
- Activities that strengthen the trunk
- Compensatory strategies & enviro adaptations when necessary
Examples of interventions for wheelchair sitting post CVA w: poor trunk stability (4)
- Lateral supports
- Lumbar rolls
- Chest straps
- Tilt in space frames
Adaptive equipment post CVA with poor trunk stability (2)
- Reachers
2. Long-handled equipment
Functional limitations commonly observed post CVA: impairment secondary to inability to perform tasks while standing (4)
- Increased fall risk
- Poor functional outcomes
- Difficulties in ADL, IADL, work & leisure
Factors contributing to poor standing post CVA (4)
- Fear of falling/knee buckling
- Weakness in LE
- Spasticity impeding proper alignment (eg plantar flexion spasticity)
- Perceptual dysfunction
Specific factors that contribute to poor standing post CVA (4)
- Ankles - weakness, ROM, & proprioception deficits
- Hips - poor ability to restore equilibrium
- Stepping - widened stance
- Loss of postural reactions
- Inability to weight bear/shift
Tx strategies to improve ct ability to perform chosen tasks while in standing (5)
- Est. symmetrical base of support & proper alignment
- Est. ability to weight bear & weight shift through the affected LE (grade as needed, eg sit on high stool 1st)
- Encourage dynamic reaching activities to develop task specific weight shifting
- Use the enviro to grade task difficulty & provide support
- Use of graded functional tasks - duration, speed, difficulty
Functional limitations commonly observed post CVA: impairment secondary to deficits in communication (2)
- Aphasia
2. Dysarthria
Tx strategies used with language impairment post CVA (9)
- Encourage speech
- Reassure ct it’s a common part of the disability
- Let one person talk at a time
- Give extra time for ct response
- Phrase Q’s so they’re easy to respond to (yes/no, either/or)
- Use visual cues & gestures
- Never force a response
- Be concise
- Don’t rush communication.
Functional limitations commonly observed post CVA: impairment secondary to deficits in neurobehavioral or cognitive-perceptual (11)
- Deficits in spatial relations
- Spatial neglect
- Body neglect
- Motor apraxia
- Ideation all apraxia
- Organization & sequencing
- Attention
- Figure ground
- Initiation
- Visual agnosia
- Problem solving
Tx approaches for neurobehavioral deficits post CVA: compensatory & adaptive approach (10)
- Repetition of tasks
- Top-down
- Emphasize intact skill training
- Use enviro or task modification to support optimal perf
- Emphasize modification
- Choice of avidity driven by perf challenges, not by component deficits
- Stress symptoms not cause
- Ct-driven compensatory strategies
- Caregiver-therapist enviro adaptations
- Task specific & not generalizable
Tx approaches for neurobehavioral deficits post CVA: restorative & remedial approach (8)
- Restoration of component skills
- Bottom- up approach
- Deficit specific
- Targets cause of symptoms & emphasizes components
- Assumes transfer of training will occur
- Assumes improved component perf will result in increased skill
- Choice of activity driven by component deficits
- Research demonstrates short-term results with skills generalizable to very similar tasks
Tx approaches for neurobehavioral deficits post CVA: combo approach (4)
- Rejects dichotomy btwn compensatory & restorative approaches
- Uses optimally relevant occupations & enviro as tx modality to challenge components
- Choice of tx driven by tasks relevant to ct needs
- Rejects use of contrived activities
Functional limitations commonly observed post CVA: inability to perform tasks secondary to UE dysfunction (9)
- Pain
- Contracture & deformity
- Loss of selective motor control
- Weakness
- Superimposed orthopedic limitations
- Loss of postural control to support UE control
- Learned nonuse
- Loss of biomechanical alignment
- Inefficient & ineffective mvmt patterns
What should the primary focus be on re: UE limitations post CVA?
Eval & intervention should focus on ct’s ability to integrate UE into the performance of functional tasks
Ways to use UE during functional performance (8)
- Weight bearing through hand/forearm during ADLs & mobility tasks - can be used as postural support, as an aid during transitional mvmts, & for preventing falls
- Moving objects across a surface with a static grasp (e.g. ironing, polishing furniture, open/close drawer) - strengthens muscles needed to reach in space
- Reach & manipulation
- Use objects of different sizes/shapes to encourage control of the hand during reach & manipulation
- Choose activities that are appropriate to the ct’s level of motor control
- Use constraint-induced mvmt techniques
- Specific training the arm to be used in weight bearing, reach, & manipulation within contexts of ADLs/mobility
- Grade tasks appropriately (# degrees of freedom, level of antigravity control, & resistance required)
UE Complications/Interventions Post CVA (9)
- Subluxation
- Abnormal skeletal muscle activity
a. Flaccidity
b. Spasticity - Prevent pain syndrome & contracture
- Protect unstable joints
- Maintain soft tissue length
- Positioning programs
- Soft tissue elongation
- Splinting
- Ct education
Precautions to take with shoulder subluxation (2) & focus of tx
- Support flail shoulder in bed, wheelchair (use pillows to maintain alignment)
- Support while standing (hands in pockets or taped)
- Focus of tx = achieving trunk alignment & scapula stability in position of upward rotation
Complications secondary to abnormal skeletal muscle activity after stroke (flaccidity stage) (5)
- Edema
- Overstretch of the glenohumeral joint capsule
- Shortening of muscles due to positioning in shortened positioned (e.g. resting hand in lap)
- Over-stretching of antagonist muscle (related to #3)
- Risk of joint & soft tissue injury during ADLs & mobility tasks
Complications secondary to abnormal skeletal muscle activity after stroke (spasticity stage) (6)
- Deformity
- Maceration of palm tissue (softening)
- Possible masking of underlying selective motor control
- Pain syndromes
- Impaired ability to manage BADLs (dressing, bathing)
- Loss of reciprocal arm swing during gait
What is low-load prolonged stretch? (LLPS)
Tx if soft tissue shortening/lengthening-associated changes have already occurred. Involves placing the soft tissues in question on submaximal stretch for prolonged periods. May include splinting, casting, & positioning programs.
Main uses of splints post CVA during low-tone stage (4)
- Maintaining joint alignment
- Protecting the tissues from shortening/stretching
- Preventing injury to the extremity
- Adjunct to help control edema
What specific structures is splinting used for post CVA?
- Palmar arch support
- Maintain neutral wrist deviation
- Maintain neutral wrist between flex/ext
* In most cases, the fingers do not require splinting
Ct education for low-tone stage (2) & high-tone stage (1)
LOW TONE:
1. Teach ct’s & caregivers/family to protect the joints
2. & maintain full ROM
HIGH TONE:
1. Teach positioning that will provide elongated of overactive muscles & prevent contracture
How to protect unstable joints post CVA (what to protect against, 2 motions to beware of)
Protect against subluxation & impingement
Main concern is upward rotation of the scapula & external rotation of the shoulder
Examples of positions that may be prescribed during leisure or self-care activities to protect unstable joints & maintain ROM (6)
- Weight bearing on extended arm
- In supine, hands behind head while allowing elbows to drop toward bed (stretches internal rotators)
- In supine, pillow protracting the scapula & under the elbow to promote glenohumeral alignment
- Lying on a protracted scapula to maintain stretch of retractors & scapulothoracic mobility
- Support involved wrist with more functional hand & reach toward floor with both hands (to elongate muscles that tent to shorten)
- Cradling the affected arm with the stronger arm, lifting it to chest level, & gently raising & lowering, & adducting & abducting
Interventions for visual impairments secondary to stroke (5) & adaptations (5)
INTERVENTIONS 1. Eye calisthenics 2. Fixations 3. Scanning 4. Visual motor techniques 5. Bilateral integration ADAPTATIONS 1. Use of prisms 2. Driving adaptations 3. Reading adaptations 4. Changes in lighting 5. Enlarged print
Strategies used by OTs for psychosocial support post CVA (6)
- Foster internal locus of control related to recovery
- Use therapeutic activities to improve self-efficacy or confidence in the performance of specific activities
- Promoting the use of adaptive coping strategies such as seeking social support, info seeking, positive reframing, & acceptance
- Promote success in chosen occupations to promote success
- Encourage social support/support groups
- Use occupations to promote social participation
Tx goals for someone with cerebellar dysfunction (3)
- Strengthen proximal muscles
- Improve postural responses
- Increase stability
