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DM Neuro 1 > CVA Impairments Part 3 > Flashcards

CVA Impairments Part 3 Flashcards

1
Q

What types of asymmetries are seen w/Hemiplegic gait?

A
  1. Spatial asymmetries
    • decreased step length
  2. Temporal asymmetries
    • decreased single-limb stance time
    • increased swing time
    • intra-limb ratio of swing: stance time
  3. additional
    • decreased WB in stance
    • decreased weight shift in stance
    • decreased step height in swing
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2
Q

how does the temporal features of hemiplegic gait impact overall gait?

A

decreased gait speed

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3
Q

List some other common features (not including the LE) of hemiplegic gait

A
  1. UE
    • decreased or absent arm swing
  2. Trunk
    • ipsilateral lateral trunk lean
    • forward trunk lean
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4
Q

T/F: the ipsilateral lateral trunk lean that may be observed in hemiplegic gait is due to trunk weakness

A

FALSE
the trunk is often spared

the weakness may be coming from the hip (glute med weakness pulling the trunk down)

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5
Q

Impact of Hemiplegic Gait on the pelvis/hip

heel strike → mid-stance

A
  1. ↓ pelvic rotation
  2. ↓ hip flexion
  3. ↑ hip IR
  4. ↑ hip adduction
  5. Trendelenberg
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6
Q

Impact of Hemiplegic gait on the knee

heel strike → mid-stance

A

3 common knee patterns:

  1. Increased knee flexion (particularly at IC)
  2. decreased knee flexion during early stance phase, followed by knee hyperextension in mid to late stance
  3. Excessive knee hyperextension throughout most of the stance phase
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7
Q

Impact of Hemiplegic gait on the foot/ankle

heel strike → mid-stance

A
  1. ↓ tibial progression
  2. ↓ ankle DF
  3. Lack of heel strike
  4. Foot flat initial contact
  5. Foot slap after initial contact
  6. Instability at foot/ankle complex à inversion, supination
  7. Pes planus
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8
Q

Impact of Hemiplegic gait on the pelvis/hip

mid-stance → terminal stance

A
  1. decreased pelvic rotation
  2. decreased hip extension/terminal stance
  3. hip flexion during forward progression
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9
Q

Impact of Hemiplegic gait on the knee

mid-stance → terminal stance

A
  1. decreased knee extension
  2. knee buckling
  3. delayed movement into knee flexion in prep for swing phase
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10
Q

Impact of Hemiplegic gait on foot/ankle

mid-stance → terminal stance

A
  1. May still see decreased tibial progression (step-to pattern)
  2. decreased heel off at terminal stance
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11
Q

Impact of Hemiplegic gait on pelvis/hip

Initial swing → terminal swing

A
  1. decreased hip flexion
  2. hip hiking
  3. circumduction
  4. increased compensatory ER
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12
Q

Impact of Hemiplegic gait on the knee

initial swing → terminal swing

A
  1. initial swing → mid-swing = decreased knee flexion
  2. mid-swing → terminal swing = decreased knee extension
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13
Q

Impact of Hemiplegic gait on foot/ankle

Initial swing → terminal swing

A
  1. poor foot clearance
  2. toe drag
  3. decreased ankle DF
  4. increased inversion
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14
Q

What are some additional considerations w/post stroke gait? (i.e other factors that influence it)

A
  1. Tone abnormalities
  2. Somatosensory deficits
  3. Vision deficits
  4. Coordination deficits
  5. Perceptual deficits
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15
Q

how can tone abnormalities influence post-stroke gait?

A
  1. Spasiticity
    • movements might appear stiff, en-block movements
    • clonus will cause jerky movements at joints
    • UE spasticity patterns commonly exacerbate during gait
  2. Hypotonia
    • buckling LE
    • Floppy UE
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16
Q

how can somatosensory deficits influence post-stroke gait?

A
  1. variable foot placement at IC
  2. risk for ankle rolling
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17
Q

how can vision deficits influence post-stroke gait?

A
  1. Visual field losses or loss of visual acuity
    • tripping over obstacles on floor
    • hitting door frames, walls
    • decreased awareness of oncoming obstacles
    • veering while walking
  2. Dysconjugate gaze
    • visual disruption → LOB
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18
Q

how can coordination deficits influence post-stroke gait?

A
  1. Cerebellar or Sensory originates
    • fractionated, dyskinetic swing phase
    • fractionated, dyskinetic arm swing
    • slower movements
    • variable foot placement
    • trunk ataxia → LOB
    • cerebellar only: EOM incoordination → visual disruption → LOB
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19
Q

how can perceptual deficits influence post-stroke gait?

A
  1. Visuospatial neglect
    • visual → veering, curved trajectory of gait path
    • decreased awareness of oncoming obstacles
    • difficulty following directions involving neglected side
  2. Sensory neglect
    • similar to somatosensory deficits, though often more severe
  3. Motor neglect
    • involved hemibody often “left behind”
  4. Pusher’s syndrome
    • increased extension in uninvolved UE (if holding AD) and LE in stance
      • lateral shift of COG outside BOS leading to falls
    • absent reactionary strategies → falls
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20
Q

define orthosis

A

device worn to restrict or assist motion, or to transfer stress from one area of the body to another (brace)

21
Q

what is the difference between a splint and an orthosis?

A

splints are temporary orthoses

22
Q

what is the difference between an orthotist and a pedorthist?

A

orthotist → designs, fabricates, fits orthoses for limbs and trunk

pedorthist → designs, fabricates, fits shoes and foot orthoses

23
Q

List some potential goals for Orthotic Rx

A
  1. improve alignment
  2. minimize influence of abnormal tone
  3. increase stability at a joint or segment
  4. prevent contractures or deformity
  5. facilitate weak muscles
  6. stimulate an eccentric or concentric muscle contraction
  7. limit or facilitate motion
  8. provide proprioceptive feedback
  9. position a body part for optimum function
24
Q

what is the main goal for foot orthoses?

A

redistribute forces on foot

  • transfer WBing stresses to pressure-tolerant sites
  • protect painful areas from contact w/shoe
  • correct alignment
  • accomodation for fixed deformity
25
Q

what is the main goal for ankle-foot orthoses (AFO)?

A

affect motion and stability at proximal joints

most common indications:

  1. ankle weakness ≤ 4/5
  2. impaired or absent proprioception at ankle and/or knee
  3. ankle PF spasticity
26
Q

List the general inclusion criteria for an orthosis

A
  1. Observed limitations in functional mobility
    • most common gait abnormalities preceding decision for orthotic eval:
      1. foot drop
      2. poor foot clearance in swing
      3. ankle instability in stance
      4. knee buckling in stance
      5. hyperextension in stance
    • most common transfer abnormalities preceding decision for orthotic eval:
      1. ankle instability in stance
      2. knee buckling in stance
27
Q

List precautions and exclusion criteria for Orthoses

A
  1. NO ankle clonus
  2. NO LE swelling or skin breakdown
  3. adequate ROM in joints to be braced
  4. be careful w/sensory impairments
    • specifically light touch, pressure
  5. considerations for cognitive, communication, and/or perceptual deficits
28
Q

List different types of AFOs from most to least supportive

A
  1. Stirrup/Double Upright
  2. Solid
  3. Pre-hinged
  4. Hinged/Articulated
  5. Posterior leaf spring
29
Q

List indications and considerations for stirrup/double upright AFOs

A
  1. Indications
    • increased concern for skin integrity
    • chronic edema issues
  2. Considerations
    • permanently attached to shoe
    • heavy, clunky
    • can be unlocked to allow for DF

**this is THE ONLY option for folks w/chronic edema

30
Q

List indications and considerations for Solid AFOs

A
  1. Indications
    • sig LE weakness or hypotonia requiring max stability
      • primary brace recommended for PF spasticity
    • alignment issues
  2. Considerations
    • rigid plastic, minimal pliability
    • provides good support but limited mobility (mostly recommended for nonambulatory pts)
    • good for M/L stability at ankle
    • can include anterior shell for knee control
31
Q

List indications and considerations for Pre-hinged AFOs

A
  1. Indications
    • sig weakness but anticipate continued motor return and potential to progress to articulated AFO
  2. Considerations
    • great option to allow brace to progress with pt
    • can add a removable anterior plastic shell to help w/knee buckling
32
Q

List indications and considerations for Hinged AFOs

A
  1. Indications
    • active DF and PF (ideally ≥3/5)
    • adequate knee control (quadriceps ≥3+/5)
  2. Considerations
    • provides adjustable ankle control
      • can be fabricated w/DF assist or PF stop if needed
    • good M/L stability
    • allows for reciprocal gait pattern
33
Q

List indications and considerations for Ground Reactive AFOs

A
  1. Indications
    • Drop foot
    • M/L ankle instability
    • knee buckling in stance (primary goal)
  2. Considerations
    • creates knee extension moment to prevent buckling
    • aids in foot clearance
    • helpful w/crouched gait pattern
34
Q

List indications and considerations for Posterior-Leaf Spring AFOs (PLS)

A
  1. Indications
    • drop foot w/minimal to no M/L instability
    • absent knee buckling, may see knee hyperextension
    • goal = limit PF from a drop foot, no knee or hip issues
  2. Considerations
    • allows for some active DF and PF (also provides counter moment to both)
    • otherwise minimal support, will not aid w/knee buckling (“swing phase AFO”)
35
Q

List indications and considerations for KAFO (knee-ankle-foot orthoses)

A
  1. Indications
    • most commonly used for paraplegia
    • can be used w/hemiplegia
      • severe knee hyperextension
      • M/L instability at knee
  2. Considerations
    • most can be progressed to solid AFO
    • knee joint can be locked to provide max sagittal plane support during standing/walking tasks (unlocked for sitting)
    • VERY heavy and clunky
      • high reliance on hip muscles to move forward
36
Q

What are some considerations for Orthoses in general

A
  1. each AFO will have a dif impact on function
  2. Goal for choosing a brace
    • least restrictive orthoses
    • brace selection most reflective on both pt presentation and prognosis for recovery
  3. When to brace? (Not immediately)
  4. Insurance coverage
    • 1 brace/3-5 years unless sig change in function
    • out of pocket - $60-1200
37
Q

What are some things to consider with mangement of Orthoses?

A
  1. Must always be worn w/closed toed-shoes
  2. Ideally should not be donned against bare skin
  3. Wear schedules
  4. Skin checks
38
Q

List some indications and considerations for UE splints/orthotics

A
  1. Indications
    • management or prevention of contraction at fingers, wrist or elbow
    • hypotonia, hypertonia
    • often used as “resting splints”
  2. Considerations
    • when donned, eliminates functional use from splinted joints
    • Skin checks important
    • RN, pt edu
39
Q

What are some modalities for Post-stroke gait training?

A
  1. BWSTT (body weight supported treadmill training)
  2. NMES
  3. FES
  4. EMG biofeedback
  5. Other:
    • Partial BW supported overground ambulation
    • Aquatic therapy
    • Neurologic Music therapy
    • Robotics
    • VR
    • Mental imagery
40
Q

What are some benefits to BWSTT? Risks?

A
  1. Benefits
    • increase stride length
    • increase step length
    • improved symmetry
    • improved activity tolerance
    • improved gait speed
  2. Risks (w/o harness system) ⇒ falls
    • harness system removes this risk and has an unloading effect allowing pts to particiapte even faster in this type of training
41
Q

T/F: BWSTT improves all aspects of gait

A

FALSE
improvements in speed, reduced fear of falling and endurance but NOT in the overall quality of gait

42
Q

T/F: better to have a slow speed w/BWSTT

A

FALSE

the faster the better (to a certain point)

43
Q

List some indications for NMES

A
  1. UMN injuries only
  2. UE: pain, subluxation, spasticity (short-term effects), strengthening
  3. LE: spasticity, strengthening
44
Q

List some precautions and contraindications for NMES

A
  1. Precautions
    • impaired or absent sensation to area being stimulated
  2. Contraindications
    • internal pacemaker, defibrillator, or any electrical/metalic implant
    • Open wounds, fractures, cancerous lesions near site of stim
45
Q

What is FES and what are some indications for it?

A

Functional Electrical Stimulation → use of NMES to promote specific functional activity

  1. Indications:
    • UMN injuries only
    • Acute
      • UE: functional training - reaching, grasping, carrying
      • LE: cycling, ambulation
    • Chronic
      • Neuroprosthesis
46
Q

What does EMG biofeedback require? What are some limitations for this modality?

A

requires some active movement of targeted muscle groups

Limitations → no standarized recommendations for trx prescription

insufficient evidence to suggest superiority over other forms of trx in UE

47
Q

List some Outcome measures we may incorporate with stroke pts

A
  1. Stroke Impact scale → subj questionnaire evaluating disability and health-related QOL after stroke
  2. Functional Independence Measure (FIM)
  3. Orpington Prognostic Scale → scored 1.6-6.8 and scores place pts into mild-moderate, moderate-severe, and severe or major deficits categories
48
Q

Describe the cut off scores for the Oprington Prognostic Scale

A
  • Scores <3.2 high likelihood of returning home
  • Scores between 3.2-5.2 generally respond better to rehab (good prognosis)
  • Score >5.2 typically dependent w/increased risk of institutionalism

DM Neuro 1 (16 decks)

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