CVA Impairments Part 1 Flashcards
list some common motor related CVA impairments
- weakness
- impaired motor control, limb synergies
- endurance and CV health
- ataxia, incoordination
- tone abnormalities, primitive reflex emergence
- Cranial nerve involvement
strength deficits from CVA are typically observed ________
contralaterally
except for when the cerebellum is damaged
T/F: CVA strength deficits are normally more proximal than distal
FALSE
observed more distally than proximally
what is the difference between hemiplegia and hemiparesis?
- hemiparesis → mild to moderate weakness on contralateral side
- hemiplegia → severe to profound weakness on contralateral side
- Dense hemiplegia → no active movement observed
T/F: strength deficits are always contralateral to the lesion
FALSE
mild ipsilateral weakness can also be seen
(10-25% of CST descend ipsilaterally → anterior CST)
list some primary neuromuscular impairments
- damage to descending cortical drive
- loss of force production
- loss of motor units
- asynchronous and abnormal motor firing
List some secondary neuromuscular impairments
- increased fatigability
- delayed reaction times
- prolonged movement times
- disuse muscular atrophy
- length-tension changes
It is common to see patterns of weakness between muscle pairs, give some examples
- UE and LE extensors > flexors
- Shoulder and hip ER > IR
- Hip ABD > ADD
- Ankle eversion > inversion
Facial weakness post stroke is due to damage to ________
contralateral corticobulblar (CN VII, XII pathways)
define motor control
- the process of initiating, directing, and grading purposeful voluntary movement
- plan → program → execute
- ability to regulate or direct mechanisms essential to movement
- creates movements that require minimal cognitive load
define motor plan
an idea or plan for purposeful movement that is made up of component motor programs
define motor program
an abstract representation that, when initiated, results in the production of a coordinated movement sequence
define motor learning
a set of internal processes associated with feedback or practice leading to relatively permanent changes in the capability for motor skill
define motor recovery
the reappearance of motor patterns present prior to CNS injury performed in the same manner as prior to injury
define motor compensation
the appearance of new motor patterns resulting from changes to CNS
→adaptation
→substitution
List the 6 stages of motor recovery post CVA
- initial flaccidty, no voluntary movement (cerebral shock)
- emergence of spasticity, hyerreflexia, and stereotypical synergies
- voluntary movement possible, but only in synergies, spasticity strong if present
- voluntary control in isolated joint movements emerging, corresponding decline of spasticity and synergies
- Increasing voluntary control out of synergy; coordination deficits present
- control and coordination near normal
what type of impairment is a synergy?
motor control impairment
most common patterns:
- flexor synergy (UE)
- scapula retraction and elevation, shoulder ABD and IR, elbow flexion and pronation, wrist and finger flexion
- extensor synergy (LE)
- hip extension, ADD and IR, knee extension, ankle PF and inversion, toe PF
define apraxia and specify some brain lesions that cause it
apraxia → inability to plan and execute purposeful movement that cannot be accounted for by any other reason
- Lesions
- premotor frontal cortex (either side)
- left inferior parietal lobe
- corpus callosum
what are the 2 types of apraxia?
- ideomotor
- inability to produce movement on command, but able to move automatically
- conceptualization of task remain intact
- ideational
- inability to produce movement both on command or automatically
- complete breakdown of conceptualization of task
List some methods for assessment of motor recovery post CVA
- Fugl-Meyer Assessment of Physical Performance
- 5 domains and lengthy
- Focus on Motor Domain → includes movement, coordination, and reflexes
- Rivermead Motor Assessment
- performance based measure w/3 sections (0-38 pts)
- gross motor (bed mobility, transfers, walking, stairs, etc)
- leg and trunk (rolling, bridging, standing w/toe taps, etc)
- arm (shoulder protraction, reaching, grip, ball bouncing, etc.)
- performance based measure w/3 sections (0-38 pts)
List some specific UE and LE outcome measures that can be used in the assessment of motor recovery post CVA
- UE
- 9 hole peg test
- action research arm test
- arm motor ability test
- box and blocks test
- motricity index
- LE
- 5 STS
- Motricity index
what is the impact of CVA on aerobic capacity?
- increased energy requirements 2/2 gross motor inefficiences and other related factors post CVA
- VO2 levels double w/household chores
- up to 3x normal VO2 levels w/ambulation on level ground
- leads to fatigue, mobility limitations, pain, emotional reactions, sleep disturbances, social isolation
- lower fitness levels associated w/higher mortality rates
What are the contributors to reduced endurance in CVA?
- Baseline CV health
- Primary CVA impairments
- Post-stroke deconditioning
what is chronotropic incompetence?
inability for HR to increase proportionally to metabolic demands of activity
related to baseline cardiac dysfunctions in most CVA patients
how do you test endurance in CVA populations?
- graded exercise testing if possible
- recommended + ECG monitoring before beginning exercise program post-CVA
- if unable to do graded exercise testing:
- light-to-moderate exercise recommended while monitoring pt response (HR, BP and RPE)
- keep it at the 3-6 range (of 0-10)
- Outcome measures:
- 6-min walk test
- 2-min walk test (acute CVA)
- light-to-moderate exercise recommended while monitoring pt response (HR, BP and RPE)
define coordination and ID its components
coordination → the ability to use different parts of the body together smoothly and efficiently
critical components:
- sequencing
- timing
- grading
incoordination is typically observed with damage to what brain regions?
- motor cortex
- basal ganglia
- cerebellum
- dorsal column/medial lemnsicus and assocaited structures
list and define several incoordination findings
- dysdiadochokinesia → impaired ability to perform rapid alternating movements
- Dysmetria → inability to judge distance or range of movement
- Dyssynergia → fragmented movement patterns
- Asynergia → loss of ability to associate muscles together for complex movements
- rebound phenomenon → inability to rapidly and sufficiently halt movement of a body part after a strong isometric force
- Tremor → unintentional, oscillatory movement
what is ataxia?
incoordination, results in difficulties w/fluidity/timing, accuracy, and speed of movements
two main types: cereballar and sensory
(other types: limb, truncal, and gait)
a CVA impacting the cerebellum, basal ganglia, or dorsal column will almost always have what exam findings?
- Trunk, limb, and/or gait ataxia
- dysmetria, dyssynergia, dysdiadochokinesia
- balance deficits
list some potential unique exam findings for CVAs impacting the cerebellum
IPSILATERAL
- oculomotor deficits
- lack of check reflex
- may see mild hypotonia
- intentional tremor
- slurred speech (dysarthria)
- sig difficulties w/motor learning
list some potential unique exam findings for CVA impacting the basal ganglia
CONTRALATERAL
- spasticity
- resting and intentional tremor
- difficulty initiating movements
- slowed movements, smaller movements
- considerable strength deficits
list some potential unique exam findings for CVA impacting the dorsal column
CONTRALATERAL
- abnormal sensory exam (particularly proprioception)
- unlikely to see tremor
Strokes primarily deal with spasticity with the exception of ___________
posturing (hypertonia)
two types: decorticate and decerebrate
Describe the 2 types of posturing
- Decorticate → UE flex, LE extension/IR/PF
- brainstem lesion above red nucleus
- Decerebrate → UE and LE extension
- brainstem lesion below red nucleus
T/F: Acute UMN injuries can result in hypotonia
TRUE
temporary and due to cerebral/spinal shock
how is spasticity measured?
Modified Ashworth Scale
describe the typical pattern of spasticity in UMN syndromes for the UEs
- Scapula → retracted, downward rotation
- Shoulder → ADD and IR, depression
- Elbow → flexion
- Forearm → pronation
- Wrist → flexion, ADD
- Hand → finger flexion, clenched fist thumn, ADD in palm
describe the typical pattern of spasticity in UMN syndromes for the LE
- Pelvis → retraction (hip hiking)
- Hip → ADD, IR, extension
- Knee → extension and flexion
- Foot and ankle → PF, inversion, equinovarus, toes claw, toes curl
- Hip and knee (prolonged sitting) → flexion and sacral sitting
- Trunk → lateral flexion w/concavity, rotation
- posture forward (prolonged sitting) → excessive forward flexion, forward head
List the primitive and tonic reflexes that are commonly seen post UMN
- Flexor withdrawl
- traction
- grasp
- tonic neck
- tonic labyrinthine
- positive support
- associated reactions
