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PMR 01 - Stroke > Day 3 - Spasticity & Neuro Rehab > Flashcards

Day 3 - Spasticity & Neuro Rehab Flashcards

1
Q

Treatment of Central Pain Post Stroke 🔑

A

First Line

  1. Amitriptyline (75mg/d)
  2. Gabapentin (Neurontin) 900mg/d

Others

  1. Pregabalin (Lyrica) 150mg/d
  2. Naloxone (8mg)
  3. I.V. Lidocaine → short-term (45 min) pain relief only
  4. Morphine infusion (9-30mg)
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2
Q

Pathophysiology of Thalamic/Central Pain States Post Stroke (CPSP)

A

Damage to spino-thalamic pathway → impaired temperature (hot, cold) and pain (pinprick)

→ hyperalgesia +/or allodynia

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3
Q

Risk factors for Post-Stroke Fatigue (PSF)

A
  • Depression
  • Chronic pain
  • Sleep disorders
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4
Q

Treatment of Post-Stroke Fatigue (PSF)

A
  • Modafinil 200mg/d
  • Cognitive Therapy/Graded Activity Training
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5
Q

List 2 screening tools for depression 🔑

A
  1. Patient Health Questionnaire (PHQ)-9
  2. Hospital Anxiety and Depression Scale (HADS)
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6
Q

List 4 Risk Factors for Depression post stroke

A
  • Female sex (especially those with severe depression)
  • Previous history of depression
  • Stroke severity, functional limitations or need for assistance with activities of daily living
  • Cognitive impairment
  • Social factors (living alone, divorced or living in a nursing home)
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7
Q

List 2 Pharmacological & 2 Non-Pharmacological Management for Depression Post-Stroke

A

Non-Pharmacological Management

  1. Exercise
  2. Cognitive-Behavioural Therapy (CBT)

Pharmacological

  1. TCA → Amitriptyline 10-25mg
  2. SSRI → Escitalopram (Cipralex) 5mg Fluoxetine (Prozac) 10mg
  3. CNS Stiumlant → Methylphenidate (Ritalin) 5mg
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8
Q

Explain brain lobes and their clinical relation.

A

Frontal lobe

  • Laterally separated from the temporal lobes by the Sylvian fissure.
  • Primary motor cortex → voluntary movement → Weakness
  • Problem solving, thinking and planning → Apraxia
  • Behavior & personality

Parietal lobe

  • Primary somatosensory cortex → Perception → Neglect

Temporal

  • Primary auditory cortex → Language → Aphasia
  • Memory, Object and face recognition

Occipital

  • Primary visual cortex → Vision and orientation
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9
Q

List 5 descending tracts.

A
  1. Corticospinal
  2. Vestibulospinal
  3. Rubrospial
  4. Olivospinal
  5. Reticulospinal
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10
Q

Mini-Mental State Examination (MMSE) ORAL.C.

A

Orientation

  • D/M/Y, Season and Time
  • Location From country to Ward

Registration

  • 3 Objects

Attentions

  • 100 minus 7 five times

Language

  • Name 2 object
  • Give 3 order command
  • Read command
  • Write sentence

Copy

  • Pentagon
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11
Q

Main challenges in bladder for stroke patient.

A
  1. Incontinence → areflexia
  2. Aphasia → communication
  3. Impaired mobility → WC
  4. Neurogenic Bladder → neurodynamic study
  5. Repeated UTI

Cuccurollo

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12
Q

How do you manage bladder dysfunction in stroke patient?

A

Failure to store

Antimuscarinic agents

  • MOA: Prevent acetylcholine release from parasympathetic nerves by binding to receptors on the detrusor muscle, thus assisting in bladder storage.
  • Drugs: Solifenacin (Vesicare) or Oxybutynin (Ditropan)
  • Side effects: dry mouth, blurry vision, and constipation

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)

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13
Q

List 2 investigation you would like to do before treating bladder dysfunction?

A
  1. Urodynamics evaluation
  2. Post void residuals (PVRs)
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14
Q

List 2 pharmacological and 2 nonpharmacological treatments for stress incontinence.

A

Pharmacological

  1. Adrenergic agonists
  2. Oxybutynin (Ditropan)

NonPharmacological

  1. Take fiber to avoid constipation
  2. Avoid jumping or running
  3. Pelvic floor muscle exercises
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15
Q

Stroke patient with diarrhea, how do you manage?

A
  1. Treat underlying causes (e.g., bowel infection, diarrhea)
  2. Timed toileting schedule
  3. Training in toilet transfer
  4. Communication skills
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16
Q

Stroke patient with constipation, how do you manage?

A
  1. Adequate fluid intake/hydration
  2. Diet modification (e.g., increase dietary fiber),
  3. Bowel management (stool softeners, stool stimulants, suppositories 3-2-1 program)
17
Q

Decreased sexual activity post-stroke attributed to:

A
  • Inability to discuss sexuality with spouse
  • Unwillingness to participate in sexual activity
  • Reduced body image and self-esteem
  • Positioning problems due to disability and spasticity or muscle weakness
18
Q

Treatment of sexual dysfunction post-stroke

A
  1. Emotional support
  2. Psychotherapy
  3. Medical consultation (urology)
  4. PDE5 inhibitor
  5. Treat underlying spasticity/weakness/contracture
19
Q

Define Spasticity & Modified Ashworth Scale

A

A motor disorder characterized by an abnormal, velocity-dependent increase in the tonic stretch reflexes (muscle tone) with exaggerated phasic stretch reflexes (tendon jerks, clonus) resulting from hyperexcitability of the stretch reflex. It is a component of the UMNS.

Modified Ashworth Scale:

0 No increase in tone

1 Slight increase in muscle tone, manifested by a catch and release or minimal resistance at the end of the ROM when the affected part(s) is moved in flexion and extension

1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM

2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

3 Considerable increase in muscle tone, passive movement difficult

4 Affected part(s) rigid in flexion or extension

20
Q

List 5 management options for spasticity.

A

Prevention first (non-pharmacological)

  • Remove factors or noxious stimuli that may increase spasticity (UTI, etc).
  • Exercises: positioning, stretching/ROM.
  • Bracing: splinting (static vs dynamic), Serial casting.
  • Modalities: cold, electrical stim, FES

Treating second (pharmacological)

  • oral medications → Baclofen
  • focal treatments → BotoX
  • intrathecal baclofen.
  • surgical options (selective dorsal rhizotomy)..

Ref: http://www.abiebr.com/set/case-study-2/27-spasticity-post-abi

21
Q

What is the mechanism of botulinum toxin? 1 Mark

A

Inhibition of acetylcholine release at the neuromuscular junction

22
Q

What is the mechanism of botulinum toxin? 1 Mark

A

Inhibition of acetylcholine release at the neuromuscular junction

23
Q

Postural abnormalities in upper limb and where to inject.

A
24
Q

Postural abnormalities in wrist and where to inject.

A
25
Q

Postural abnormalities in hip & knee and where to inject.

A
26
Q

Postural abnormalities in ankle and where to inject.

A
27
Q

How much Botox will you inject per muscle and per session? What is the effectiveness timeline of Botox?

A
  • Usual dosage of onabotulinumtoxinA (Botox) is 25 to 200 units per muscle
  • Initial safe dose for first treatment is likely 400 units total or 6 units per kg for an adult.
  • Reinjections should occur after 3 months

“3 days for initial effect, 3 weeks for peak effect, and 3 months duration.”

Cuccurollo

28
Q

List 4 side effects of Botox.

A
  1. Pain/soreness
  2. Nerve trauma
  3. Hematoma/bruising/local erythema or swelling
  4. Flu-like syndrome with headache, nausea, fatigue, general malaise
  5. Dysphagia may occur from cervical injection (short-lived)
  6. Unwanted weakness in injected or adjacent muscles (localized)
29
Q

List 6 side effects of baclofen.

A
  1. Brain : Depression - Confusion - Headache - Hallucinations
  2. Cerebellum : Coordination disorder - Tremor - Ataxia - Nystagmus
  3. Basal Ganglia : Dystonia
  4. Brainstem : Blurred vision - Slurred speech - Tinnitus - Diplopia - Dysarthria
  5. Cardiorespiratory : Hypotension - Dyspnea - Palpitation - Chest pain - Syncope.
  6. Gastrointestinal : Nausea - Constipation
  7. Genitourinary: Urinary retention - Inability to ejaculate
30
Q

List 4 signs of abrupt drug withdrawal of baclofen

A
  1. Increased spasticity.
  2. Agitation
  3. Confusion
  4. Hallucinations
  5. Seizures
  6. Psychosis
  7. Dyskinesia
31
Q

List 10 surgical operations for treatment of spasticity.

A

Tendon: Release, Transfer, Lengthening

Muscle: Myotomy

Nerve: Peripheral neurectomy → Cordectomy → Dorsal Rhizotomy → Myelotomy

Devices: ITB Pump, Deep brain stimulator

32
Q

List 4 positive effect of spasticity.

A
  • Hemp in ambulation, standing, or transfers (e.g., stand pivot transfers)
  • Maintaining muscle bulk due to muscular contraction
  • Preventing deep vein thrombosis (DVT) by providing improved venous flow secondary to muscle contractions
  • Preventing osteoporosis
  • Can serve as a “diagnostic tool” (spasticity can be a sign of exposure to a noxious stimuli : infection, bowel impaction, urinary retention, etc.)

Cuccurollo

33
Q

List 4 negative effect of spasticity.

A
  • Interferes with function
  • Can cause extreme discomfort/pain
  • Interferes with hygiene and nursing care
  • Contractures and disfigurement
  • Increased risk for development of decubitus ulcers
  • Bone fractures
  • Joint subluxation/dislocation
  • Increased risk of heterotopic ossification (HO)
  • Acquired peripheral/entrapment neuropathy

Cuccurollo

34
Q

List 4 triggers of spasticity.

A
35
Q

List 4 reasons for poor outcome of Botox.

A
  1. Inactive medication
  2. Incorrect dose
  3. Incorrect diagnosis
  4. Incorrect muscle selection
  5. Unrealistic goals
  6. Disease condition

PMR 01 - Stroke (8 decks)

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