Day 2 - MSK Rehab & Functional Outcome Flashcards
Brunnstrom stages of motor recovery
Stage 1
- No activation of the limb.
Stage 2
- Spasticity appears, and weak basic flexor and extensor synergies are present.
Stage 3
- Spasticity is prominent; the patient voluntarily moves the limb, but muscle activation is all within the synergy patterns.
Stage 4
- The patient begins to activate muscles selectively outside the flexor and extensor synergies.
Stage 5
- Spasticity decreases; most muscle activation is selective and independent from the limb synergies.
Stage 6
- Isolated movements are performed in a smooth, phasic, well-coordinated manner
List 4 methods for motor rehabilitation in stroke.
Gait:
- Body-weight-support treadmill training
- Robotic Gait
U&L Limb
- Constraint-induced movement therapy (CIMT)
- Functional electrical stimulation (FES)
- Bilateral arm training
- Mirror therapy
- Robotic hand
Cuccurollo Chapter 1
List 3 stages of CRPS.
Stage 1 (acute)
- Burning pain, diffuse swelling/edema, hyperpathia or allodynia
Stage 2 (dystrophic)
- Pain becomes more intense and spreads proximally, decreased ROM
Stage 3 (atrophic)
- Muscular weakness/atrophy, contractures/flexion deformities of shoulder/hand
- Cuccurollo Chapter 1*
Which CRPS type is seen in stroke patient?
- CRPS type I is formerly known as reflex sympathetic dystrophy (RSD), shoulder-hand syndrome.
- CRPS type I follows an injury without nerve injury in the affected limb, whereas CRPS type II develops following a peripheral nerve injury to the affected limb.
How do you diagnose CRPS? “Shoulder-Hand syndrome”
- Clinical exam: Shoulder/hand pain preceded by rapid ROM loss
- X-rays: periarticular osteopenia
- Triple phase bone scan
- Skeletal scintigraphy (bone scan)
Gold standard for diagnosis of sympathetically mediated CRPS type I?
Stellate ganglion block
Stroke patient asks you: why I my shoulder is downward position? is it dislocated?
The supraspinatus muscle is flaccid during the initial phase of hemiplegia. The weight of the unsupported arm can cause the humeral head to sublux downward in the glenoid fossa.
List 2 Clinical manifestations of shoulder subluxation in stroke patient?
- Palpable gap between the acromion and humeral head
- Decrease in arm external rotation
- Shoulder pain (Conflicting evidence)
How do you manage shoulder subluxation in stroke patient?
- Shoulder sling as support in ambulation and reduce edema
- Functional Electrical Stimulation (FES)
- Arm board, arm trough, lapboard
What medication would like to prescribe in order to have better recovery 🔑
Better mentality → high levels of serotonin, dopamine & CNS Stimulant
- Fluoxetine (Prozac) → SSRI
- Levodopa
- Amphetamines
Canadian Notes
Complication of wearing shoulder sling for too much time?
Contractures in shoulder adduction/internal rotation or elbow flexion (flexor synergy pattern).
Explain Yergason’s test.
With the elbow flexed at 90°, and while the forearm is pronated
Patient supinates the forearm, flexes the elbow, and externally rotates the humerus
Examiner resists these movements and pulls downward on the elbow.
The test result is positive if the patient experiences pain over the bicipital groove
List 4 Treatments for Brachial Plexus/Peripheral Nerve Injury
- Avoid traction of the shoulder
- Sling for ambulation to prevent traction by gravity
- ROM to prevent contracture while traction avoided
- 45° shoulder abduction sling for nighttime positioning
List 4 ways to manage dependent edema
- Compression glove
- Foam wedge
- Retrograde massage
- Arm elevation
List 4 spasticity management in stroke patient.
- Stretching
- Splints/orthosis, serial casting
- Botulinum toxin
- Intrathecal baclofen (ITB) pump
Although widely done in clinical practice, the use of medications (e.g., benzodiazepines, baclofen, dantrolene, clonidine, tizanidine) in stroke patients still lacks scientific evidence to support efficacy. These drugs appear to have modest effects on the hypertonicity and posturing associated with stroke; side effects limit their usefulness.
How to tell if stroke patient is Malnourished? What are the complications?
Body Mass Index (BMI) value less than 18.5 is considered to be underweight.
- Decreased response to physiotherapy. (Low therapy adherence)
- Increased length of stay. (Always on bed, now he developed bed sore)
- Greater risk of bedsores and UTIs.
- Lower Barthel Index scores at 1-4 months. (Poor outcome)
List 4 diagnostic tools for DVT 🔑
- Ultrasonography: A positive venous ultrasound at two or more sites proximal veins is needed for a positive diagnosis of a DVT.
- Impedance plethysmography
- Contrast venography:
- D-dimer assays
How do you manage bladder dysfunction in stroke patient?
Failure to pass
Adrenergic antagonists
MOA: Inhibit smooth muscle activity in the prostate and at the bladder neck
Side effects: Postural hypotension, abnormal ejaculation, and nasal congestion
Spastic Bladder (Hyperactive)
Baclofen, tizanidine, diazepam, and dantrolene sodium
Botulinum toxin type A
Underactive Bladder
Intermittent catheterization (IC)
What are the investigation you would like to do before treating bladder dysfunction?
- Urodynamics evaluation
- Post void residuals (PVRs)
List 2 pharmacological and 2 nonpharmacological treatments for stress incontinence.
Pharmacological
- Adrenergic agonists
- Oxybutynin (Ditropan)
NonPharmacological
- Take fiber to avoid constipation
- Avoid jumping or running
- Pelvic floor muscle exercises
Phases of swallowing & problem seen with each phase
- Oral Preparatory Phase → Drooling and pocketing
- Oral Propulsive Phase → Drooling and pocketing
- Pharyngeal Phase → Aspiration
- Esophageal Phase → heartburn and food sticking
List 3 diagnostic tools for dysphagia
- Bedside swallowing evaluation
- Videofluorographic swallowing evaluation (VFSS)/Modified barium swallow (MBS)
- Fiberoptic endoscopic evaluation of swallowing (FEES)
Define Penetration vs Aspiration
Penetration
Entry of material into the larynx but not below the true vocal cords.
Aspiration
Entry of material into airway below level of true vocal cords
Predictors of aspiration on bedside swallowing exam
- Abnormal gag reflex
- Cough after swallow
- Dysphonia
- Voice change after swallow (wet voice)
Risk factors for development of pneumonia secondary to aspiration include
Think of bed ridden patient on multi devices and tissue under his chin:
- Decreased level of consciousness
- Tracheostomy
- Emesis
- Reflux
- Nasogastric tube (NGT) feeding
- Dysphagia
Signs and Symptoms of Dysphagia 🔑
Dysphagia is the medical term for swallowing difficulties:
- Slow effortful eating
- Drooling
- Pocketing
- Chocking
- Coughing after meal
- Hurt burn
- Food and liquid avoidance
List 3 clinical screening tests for dysphagia
- Impaired pharyngeal sensation
- Failure on 50 ml water test
- IDDSI (International Dysphagia Diet Standardisation Initiative)