CVA Impairments Part 1

Question 1

list some common motor related CVA impairments

Answer 1

1. weakness
2. impaired motor control, limb synergies
3. endurance and CV health
4. ataxia, incoordination
5. tone abnormalities, primitive reflex emergence
6. Cranial nerve involvement

Question 2

strength deficits from CVA are typically observed ________

Answer 2

contralaterally

except for when the cerebellum is damaged

Question 3

T/F: CVA strength deficits are normally more proximal than distal

Answer 3

FALSE
observed more distally than proximally

Question 4

what is the difference between hemiplegia and hemiparesis?

Answer 4

1. hemiparesis → mild to moderate weakness on contralateral side
2. hemiplegia → severe to profound weakness on contralateral side
3. Dense hemiplegia → no active movement observed

Question 5

T/F: strength deficits are always contralateral to the lesion

Answer 5

FALSE

mild ipsilateral weakness can also be seen

(10-25% of CST descend ipsilaterally → anterior CST)

Question 6

list some primary neuromuscular impairments

Answer 6

1. damage to descending cortical drive
2. loss of force production
3. loss of motor units
4. asynchronous and abnormal motor firing

Question 7

List some secondary neuromuscular impairments

Answer 7

1. increased fatigability
2. delayed reaction times
3. prolonged movement times
4. disuse muscular atrophy
5. length-tension changes

Question 8

It is common to see patterns of weakness between muscle pairs, give some examples

Answer 8

1. UE and LE extensors > flexors
2. Shoulder and hip ER > IR
3. Hip ABD > ADD
4. Ankle eversion > inversion

Question 9

Facial weakness post stroke is due to damage to ________

Answer 9

contralateral corticobulblar (CN VII, XII pathways)

Question 10

define motor control

Answer 10

• 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

Question 11

define motor plan

Answer 11

an idea or plan for purposeful movement that is made up of component motor programs

Question 12

define motor program

Answer 12

an abstract representation that, when initiated, results in the production of a coordinated movement sequence

Question 13

define motor learning

Answer 13

a set of internal processes associated with feedback or practice leading to relatively permanent changes in the capability for motor skill

Question 14

define motor recovery

Answer 14

the reappearance of motor patterns present prior to CNS injury performed in the same manner as prior to injury

Question 15

define motor compensation

Answer 15

the appearance of new motor patterns resulting from changes to CNS

→adaptation

→substitution

Question 16

List the 6 stages of motor recovery post CVA

Answer 16

1. initial flaccidty, no voluntary movement (cerebral shock)
2. emergence of spasticity, hyerreflexia, and stereotypical synergies
3. voluntary movement possible, but only in synergies, spasticity strong if present
4. voluntary control in isolated joint movements emerging, corresponding decline of spasticity and synergies
5. Increasing voluntary control out of synergy; coordination deficits present
6. control and coordination near normal

Question 17

what type of impairment is a synergy?

Answer 17

motor control impairment

most common patterns:

1. flexor synergy (UE)
   
   • scapula retraction and elevation, shoulder ABD and IR, elbow flexion and pronation, wrist and finger flexion
2. extensor synergy (LE)
   
   • hip extension, ADD and IR, knee extension, ankle PF and inversion, toe PF

Question 18

define apraxia and specify some brain lesions that cause it

Answer 18

apraxia → inability to plan and execute purposeful movement that cannot be accounted for by any other reason

1. Lesions
   
   • premotor frontal cortex (either side)
   • left inferior parietal lobe
   • corpus callosum

Question 19

what are the 2 types of apraxia?

Answer 19

1. ideomotor
   
   • inability to produce movement on command, but able to move automatically
   • conceptualization of task remain intact
2. ideational
   
   • inability to produce movement both on command or automatically
   • complete breakdown of conceptualization of task

Question 20

List some methods for assessment of motor recovery post CVA

Answer 20

1. Fugl-Meyer Assessment of Physical Performance
   
   • 5 domains and lengthy
   • Focus on Motor Domain → includes movement, coordination, and reflexes
2. 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.)

Question 21

List some specific UE and LE outcome measures that can be used in the assessment of motor recovery post CVA

Answer 21

1. UE
   
   • 9 hole peg test
   • action research arm test
   • arm motor ability test
   • box and blocks test
   • motricity index
2. LE
   
   • 5 STS
   • Motricity index

Question 22

what is the impact of CVA on aerobic capacity?

Answer 22

1. 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
2. leads to fatigue, mobility limitations, pain, emotional reactions, sleep disturbances, social isolation
3. lower fitness levels associated w/higher mortality rates

Question 23

What are the contributors to reduced endurance in CVA?

Answer 23

1. Baseline CV health
2. Primary CVA impairments
3. Post-stroke deconditioning

Question 24

what is chronotropic incompetence?

Answer 24

inability for HR to increase proportionally to metabolic demands of activity

related to baseline cardiac dysfunctions in most CVA patients

Question 25

how do you test endurance in CVA populations?

Answer 25

1. graded exercise testing if possible * recommended + ECG monitoring before beginning exercise program post-CVA 2. 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)

Question 26

define coordination and ID its components

Answer 26

coordination → the ability to use different parts of the body together smoothly and efficiently critical components: 1. sequencing 2. timing 3. grading

Question 27

incoordination is typically observed with damage to what brain regions?

Answer 27

1. motor cortex 2. basal ganglia 3. cerebellum 4. dorsal column/medial lemnsicus and assocaited structures

Question 28

list and define several incoordination findings

Answer 28

1. dysdiadochokinesia → impaired ability to perform rapid alternating movements 2. Dysmetria → inability to judge distance or range of movement 3. Dyssynergia → fragmented movement patterns 4. Asynergia → loss of ability to associate muscles together for complex movements 5. rebound phenomenon → inability to rapidly and sufficiently halt movement of a body part after a strong isometric force 6. Tremor → unintentional, oscillatory movement

Question 29

what is ataxia?

Answer 29

incoordination, results in difficulties w/fluidity/timing, accuracy, and speed of movements two main types: cereballar and sensory (other types: limb, truncal, and gait)

Question 30

a CVA impacting the cerebellum, basal ganglia, or dorsal column will almost always have what exam findings?

Answer 30

1. Trunk, limb, and/or gait ataxia 2. dysmetria, dyssynergia, dysdiadochokinesia 3. balance deficits

Question 31

list some potential unique exam findings for CVAs impacting the cerebellum

Answer 31

IPSILATERAL 1. oculomotor deficits 2. lack of check reflex 3. may see mild hypotonia 4. intentional tremor 5. slurred speech (dysarthria) 6. sig difficulties w/motor learning

Question 32

list some potential unique exam findings for CVA impacting the basal ganglia

Answer 32

CONTRALATERAL 1. spasticity 2. resting and intentional tremor 3. difficulty initiating movements 4. slowed movements, smaller movements 5. considerable strength deficits

Question 33

list some potential unique exam findings for CVA impacting the dorsal column

Answer 33

CONTRALATERAL 1. abnormal sensory exam (particularly proprioception) 2. unlikely to see tremor

Question 34

Strokes primarily deal with spasticity with the exception of \_\_\_\_\_\_\_\_\_\_\_

Answer 34

posturing (hypertonia) two types: decorticate and decerebrate

Question 35

Describe the 2 types of posturing

Answer 35

1. Decorticate → UE flex, LE extension/IR/PF * brainstem lesion above red nucleus 2. Decerebrate → UE and LE extension * brainstem lesion below red nucleus

Question 36

T/F: Acute UMN injuries can result in hypotonia

Answer 36

TRUE temporary and due to cerebral/spinal shock

Question 37

how is spasticity measured?

Answer 37

Modified Ashworth Scale

Question 38

describe the typical pattern of spasticity in UMN syndromes for the UEs

Answer 38

1. Scapula → retracted, downward rotation 2. Shoulder → ADD and IR, depression 3. Elbow → flexion 4. Forearm → pronation 5. Wrist → flexion, ADD 6. Hand → finger flexion, clenched fist thumn, ADD in palm

Question 39

describe the typical pattern of spasticity in UMN syndromes for the LE

Answer 39

1. Pelvis → retraction (hip hiking) 2. Hip → ADD, IR, extension 3. Knee → extension and flexion 4. Foot and ankle → PF, inversion, equinovarus, toes claw, toes curl 5. Hip and knee (prolonged sitting) → flexion and sacral sitting 6. Trunk → lateral flexion w/concavity, rotation 7. posture forward (prolonged sitting) → excessive forward flexion, forward head

Question 40

List the primitive and tonic reflexes that are commonly seen post UMN

Answer 40

1. Flexor withdrawl 2. traction 3. grasp 4. tonic neck 5. tonic labyrinthine 6. positive support 7. associated reactions