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)
Indication for VMBS Studies.
- Follow-up of previous positive VMBS study
- Brainstem stroke.
- Obvious signs of choking or wet, hoarse voice after drinking.
- Problems maintaining adequate nutrition and hydration.
- Recurrent respiratory infections.
Assessment of Swallowing Post Stroke at Time of Admission.
List 6 Compensatory Strategies.
- Chin tuck
- Chin up
- Head rotation
- Head tilt
- Supraglottic swallow
- Super supraglottic swallow
- Mendelsohn maneuver
List 6 Low-Risk Feeding Strategies
- Make sure its the correct type of food
- Minimize distractions
- Bed at 90 degrees, neck slightly flexed
- Mouth care before eating to remove bacteria
- Use metal teaspoons, do not use plastic!
- Slow rate of feeding
- Make sure to fully swallow the bolus
- Preform mouth care and remove all food debris
- Observe for 30mins to check for any signs and symptoms
- Keep him upright to clear esophagus and reduce reflux
- Document his food and liquid intake also if any issue raises
Define aphasia
Aphasia is inability to communicate. It affects all aspects of language: speaking, reading, writing, and understanding language.
Define aphasia
Aphasia is inability to communicate. It affects all aspects of language: speaking, reading, writing, and understanding language.
Anatomic Localization of Wernicke’s Aphasia
Anatomic Localization of Broca’s Aphasia
Anatomic Localization of Global Aphasia
Anatomic Localization of Anomic Aphasia
Anatomic Localization of Conduction Aphasia
Anatomic Localization of Transcortical Motor Aphasia
Anatomic Localization of Transcortical Sensory Aphasia
Types of aphasia
List 4 FLUENT APHASIA
- Transcortical sensory
- Wernicke’s
- Conduction
- Anomia
List 4 NONFLUENT APHASIA
- Broca’s
- Transcortical motor
- Global
- Mixed transcortical
Paraphasias - Anomia - Echolalia
Paraphasias: Incorrect substitution of words or parts of words
Echolalia: Repetition (“echoing”) of words or vocalizations made by another person
Anomia: Difficulty recalling words; word-finding difficulty
List 4 things to check prior to driving for stroke patient. 🔑
- Visual field deficit.
- Neglect
- Hemiplegia or hemiparesis.
- Apraxias.
- Cognitive deficits (problem solving).
- Language difficulties (receptive aphasia).
Advice for stroke patient returning to driving.
- Driving in an unfamiliar area.
- Driving at night.
- Driving when tired (includes long distances).
- Parallel parking.
- Driving in rush hour, particularly in a large city.
- Driving on busy multilane high speed expressways.
Advice for stroke patient returning to driving.
- Driving in an unfamiliar area.
- Driving at night.
- Driving when tired (includes long distances).
- Parallel parking.
- Driving in rush hour, particularly in a large city.
- Driving on busy multilane high speed expressways.
You were consulted for shifting stoke patient, what would be your criteria for admission?
Criteria for Admission to a Comprehensive Rehabilitation Program For Stroke Patient:
- Stable neurologic status
- Significant persisting neurologic deficit
- Sufficient cognitive function to learn
- Sufficient communicative ability to engage with the therapists
- Physical ability to tolerate the active program (at least 3 h/d)
- Achievable therapeutic goals
DeLisa Chapter 44
Good prognostic factors for motor recovery 🔑
- Active finger extension (98% will have some dexterity, 60% of them full recovery)
- Shoulder abduction
Evidence-Based Review of Stroke Rehabilitation
Poor prognostic factors for motor recovery 🔑
Regular old patient, on wheelchair and shoulder sling, poor hand grip.
- Dense hemiplegia
- Spasticity
- Prolonged flaccidity period
- No grasp by 4 weeks
Canadian Notes
Poor prognostic factors for motor recovery 🔑
Regular old patient, on wheelchair and shoulder sling, poor hand grip.
- Dense hemiplegia
- Spasticity
- Prolonged flaccidity period
- No grasp by 4 weeks
Canadian Notes
Patient is unhappy about his rehab progression post-stroke, what do you replay?
- 70% improvement within 6 months as natural process
- Depends on integrity of corticospinal tract, more damage = less recovery.
- Proportion is unaffected by rehabilitation therapies
- It’s more driven by adaptive or compensatory learning strategy.
- High motivation related to better functional outcomes
Evidence-Based Review of Stroke Rehabilitation
List 6 Treatment for CRPS. “Neuropathic Pain”
Nonpharmacological
- Exercise: Gentle ROM exercise
- Modalities: TENS & US
Pharmacological
- Corticosteroids (systemic): prednisone in doses up to 100 to 200 mg/d or 1 mg/ kg, and tapered over 2 weeks.
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Amytriptyline and lamotrigine have support as first-line agents (IIaB).
- Pregabalin, gabapentin may be considered as second-line agents (IIbB).
- Topical capsaicin
Surgical
- Intra-articular corticosteroid injections
- Sympathetic stellate ganglion blocks
List 4 interventions used for mobility rehabilitation post stroke
- Lower limb strength exercise
- Static and dynamic balance
- Orthosis or walking aid.
- Treadmill Training (Manual or robotic)
Evidence-Based Review of Stroke Rehabilitation
List 4 treatment methods for Hemiplegic Side
- Task-Specific Training
- Constraint-Induced Movement Therapy (CIMT)
- Strength Training
- Functional Electrical Stimulation (FES)
- Robotics
- Bilateral Arm Training
- Virtual Reality
Evidence-Based Review of Stroke Rehabilitation
Mention two types of hand orthosis and list 4 benefits.
Types
- Static/passive (volar splint)
- Dynamic/active (Saeboflex)
Aims are:
- Reduction in spasticity
- Reduction in pain
- Improvement in functional outcome
- Prevention of contracture
- Prevention of edema
Mention two types of hand orthosis and list 4 benefits.
Types
- Static/passive (volar splint)
- Dynamic/active (Saeboflex)
Aims are:
- Reduction in spasticity
- Reduction in pain
- Improvement in functional outcome
- Prevention of contracture
- Prevention of edema
10 DDx for shoulder pain in stroke patient.
Muscle
- Myofascial pain
- Soft tissue contracture
Tendon
- Impingement syndrome
- Rotator cuff injury
- Bicipital tendonitis
Joint
- Capsulitis
- Subluxation
Neuro
- CRPS type 1
- Brachial plexopathy
- Axillary neuropathy
- Suprascapular neuropathy
- Spasticity
2 most common causes of Hemiplegic Shoulder Pain (HSP) 🔑
- Spasticity (subscapularis + pectoralis major)
- Frozen shoulder
Canadian Notes
Brachial Plexus/Peripheral Nerve Injury Treatment and Prognosis
Treatment
You have traction injury, protect the plexus but be aware of contraction.
- Proper bed positioning, avoid traction
- 45 shoulder abduction sling for nighttime positioning
- Sling for ambulation to prevent traction by gravity
- Armrest in wheelchair
- ROM to prevent contracture
Prognosis
- 8 to 12 months for reinnervation.
List 4 Treatment for Hemiplegic Shoulder Pain (HSP) 🔑
- Sling
- NSAIDs
- ROM exercises
- Suprascapular nerve block
List 3 xray views for assessing shoulder subluxation.
- AP
- Scapular Y
- Axillary
Is sling enough to manage shoulder subluxation?
Remember we have weak muscle → loose stability “We are just resting the joint”
- Shoulder sling use is controversial
- Indicated for patient ambulation to support extremity & prevents hand edema
- May encourage contractures in shoulder adduction/internal rotation or elbow flexion (flexor synergy pattern).
TREATMENT
- FES → early reactivation of shoulder musculature
- Arm board, arm trough, lapboard
Cuccurollo
List 4 Treatment approach to prevent skin breakdown and limit ulcers. 🔑
- Turning position every 2 hours
- Air Mattress
- Weight shift 2-3 minutes every 15 minutes
- Wheelchair cushion
- Skin hygiene maintenance
- Nutrition assessment (prevent malnutrition)
Plan your rehab plan for mobility of stroke patient 🔑
- Start with balance training (standing & sitting, static & dynamic)
- Strength (leg press, FES) & aerobic (cycling) training
- Orthosis in case of foot drop or planterflexion deformity or cane for support
- Gait training either manual +/- support or robotic.
Evidence-Based Review of Stroke Rehabilitation
Stroke patient with hyper extended knees, how do you manage him?
- Weak Hamstring → Swedish Knee Brace or Brace with dial lock + strength exercises
- Spastic quadriceps → Botox
- Drop foot → AFO to increase ankle dorsiflexion leading to knee flexion moment arm.
- Tight Achillis Tendon → Body weighted stretch, cryotherapy
Clinical complications of Spastic Equinovarus
- Pain on weight bearing
- Ankle instability
- Abnormal base of support
- Unstable gait , impaired balance
- Interference with transfers
- Genu recurvatum
Evidence-Based Review of Stroke Rehabilitation
Clinical complications of Spastic Equinovarus
- Pain on weight bearing
- Ankle instability
- Abnormal base of support
- Unstable gait , impaired balance
- Interference with transfers
- Genu recurvatum
Evidence-Based Review of Stroke Rehabilitation
