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PMR 01 - Stroke > Day 5 - Flash Cards (Stroke Rehab + Dysphagia) > Flashcards

Day 5 - Flash Cards (Stroke Rehab + Dysphagia)

1
Q

List 8 causes of intracerebral hemorrhage

A
  1. HTN (hypertension).
  2. CAA (cerebral amyloid angiopathy).
  3. anticoagulant use (warfarin).
  4. bleeding diathesis (thrombocytopenia).
  5. trauma.
  6. vasculitis.
  7. hemorrhage from tumour
  8. hemorrhagic transformation of stroke.
  9. Infection
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2
Q

List 3 locations where the hypertensive intracerebral hemorrhages occur.

A
  1. putamen.
  2. thalamus.
  3. cerebellum.

Hint: Inferior part of the brain.

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3
Q

List 8 causes of shoulder pain post stroke. 🔑🔑

A

SOFT TISSUE:

  1. adhesive capsulitis.
  2. impingement syndrome.
  3. rotator cuff injury.
  4. bicipital tendinopathy.
  5. soft tissue contracture.
  6. myofascial pain.

BONY:

  1. GH subluxation/dislocation.
  2. humeral fracture.
  3. AVN.
  4. osteoarthritis.
  5. Heterotopic ossification.

NEURO:

  1. CRPS type 1.
  2. brachial plexopathy.
  3. axillary neuropathy.
  4. suprascapular neuropathy.
  5. spasticity.
  6. central thalamic pain.

OTHER:

  1. tumour.
  2. referred pain (neck, visceral, intra-abdominal).

Ref: Braddom pg 1200; EBRSR module 11 pg 5.

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4
Q

What is the most effective initial treatment for post-stroke shoulder subluxation?🔑

A

POSITION (L4: consensus opinion).

SLING (L2: limited evidence).

EXERCISES:

Gentle ROM,

Avoid beyond 90 degrees of flexion/abd

Avoid over-head pullies

Static positional stretches daily increase pain and decrease ROM

MODALITIES: (FES)

MEDS: Oral NSAID less pain, improved ROM and improved functional recovery

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5
Q

What is the definition of shoulder subluxation?

A

Shoulder subluxation is best defined as changes in the mechanical integrity of the glenohumeral joint causing a palpable gap between the acromion and humeral head.

Ref: EBRSR module 11 pg 5.

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6
Q

In hemiplegic shoulder pain and spasticity, what 2 muscles are likely involved?

A
  1. Subscapularis (most important).
  2. Pectoralis major.

Ref: EBRSR Module 11 pg 4.

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7
Q

Name 2 types of recovery after stroke

A
  1. Neurological (intrinsic) recovery.
  2. Functional (adaptive) recovery.

Ref: EBRSR module 3 pg 5.

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8
Q

What is the difference between remedial and compensatory rehabilitation?

A
  • Remedial focuses on improving the neurological impairment.
  • Compensatory focuses on improving function irrespective of neurological impairment.

EBRSR

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9
Q

List 4 non-pharmacologic interventions to manage hypertension.

A
  1. Exercise: moderate intensity accumulative 30-60 minutes/day x 4-7 days/week (Grade D)
  2. Weight loss (D)
  3. Reduce alcohol consumption (low risk drinking guidelines - <14/week for men, <9/week for women) (B)
  4. Dietary changes (DASH diet): emphasize fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources reduced in saturated fat and cholesterol (B)
  5. Controlled sodium: 1500mg/day = 50yo, 1300mg/day 51-70yo, 1200mg/day >70yo (B)
  6. Stress management: individualized cognitive behavioural interventions and relaxation techniques (B)

Ref: 2013 CHEP guidelines for HTN

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10
Q

Name 2 indications of warfarin after stroke.

A
  1. cardiac arrhythmia (atrial fibrillation).
  2. clot/thrombosis (PE or DVT).
  3. mechanical heart valve.

Ref: medscape website.

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11
Q

What is the BP goal during first 24 hrs post stroke?

A

If patient is receiving tPA → goal is 185/110 mmHg

If not → treat ≥ 220/120 mmHg by reducing 15% gradually during 24 hour

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12
Q

Name 2 predictors of motor recovery after stroke.

A
  1. age
  2. initial severity of stroke (eg. Lesion size).

Ref: EBRSR module 3 pg 11.

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13
Q

What are the indications/requirements for tPA to be administered?

A
  • CLOCK: 3 hours from stroke onset.
  • CLINICAL: deficits measurable on NIH stroke scale.
  • CT head: no hemorrhage or non-stroke cause of deficits.
  • CONSENT: informed consent obtained from patient age 18 yo
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14
Q

What are the contraindications of tPA?

A

ABSOLUTE CONTRAINDICATIONS:

  1. TBI/stroke/spinal trauma within 3 months
  2. SAH symptoms
  3. arterial puncture (noncompressible site, within 7 days)
  4. ICH history
  5. Intracranial neoplasm/AVM/aneurysm
  6. recent OR (intracranial/intraspinal surgery)
  7. HTN (SBP>185, DBP>110)
  8. active internal bleeding
  9. acute bleeding diathesis (plt < 100,000, heparin with incr PTT, INR >1.7 from anticoagulant, etc.)
  10. hypoglycemia (<2.7 or >22.2)
  11. multilobar infarct on CT/MRI (>1/3 MCA hemisphere, ASPECTS >5)

Ref: 2013 – AHA guidelines – early management of acute ischemic stroke pg 29.

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15
Q

What is the ABCD2 score? What is it used for?

A

It is a tool to triage patients with a TIA. It is one part of the process to determine how quickly a patient needs to be worked up for stroke.

A: age > 60

B: blood pressure > 140/90

C: clinical signs.

Unilateral weakness (2 points);

just aphasia, no weakness (1 point)

D: duration of symptoms:

60 minutes (2 points),

10-59 minutes (1 point)

D: diabetes

total score: 7

2 DAY STROKE RISK BASED ON SCORE:

0-3: 1%.

4-5: 4%.

6-7: 8%.

Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S. (2007) Lancet, 369, 283-292.

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16
Q

What are some hypercoagulable states that can increase the risk of stroke? List 4

A
  1. increased hematocrit, RBC, fibrinogen
  2. protein C and S deficiencies
  3. Cancer
  4. sickle cell anemia
  5. antiphospholipid syndrome (APL).
  6. factor 5 leiden deficiency.
  7. antithrombin 3 deficiency.

Ref: Stroke recovery and rehab textbook pg 657, 382.

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17
Q

List 6 differential diagnoses mistaken for stroke (stroke mimickers).

A
  • Seizure (17%)
  • Systemic infection (17%)
  • Brain tumor (15%)
  • Metabolic disorders, such as hyponatremia and hypoglycemia (13%)
  • Positional vertigo (6%)
  • Conversion disorder

Medscape.com

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18
Q

List 4 rehabilitation methods for motor deficits.

A
  1. Traditional exercise program
  2. Brunnstrom: uses primitive synergistic patterns in training
  3. CIMT (Constraint induced movement therapy)
  4. Robotic devices
  5. EMG-biofeedback
  6. FES (functional electrical stimulation)

Ref: Cuccurullo pg 27-28, EBRSR Executive Summary

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19
Q

List 3 classes of medications that can be used to aid in motor recovery after stroke.

A

Elevate seratonin and dopamine on top of stimulant:

amphetamines (conflicting evidence).

levadopa (conflicting evidence).

SSRI (strong evidence = single dose; moderate evidence 90 day course).

NARI (strong evidence = single dose, dexterity in hand short term).

Ref: EBRSR executive summary pg 19.

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20
Q

What benefit is there for the use of FES in hemiplegic shoulder pain and shoulder subluxation? (Functional electrical stimulation).

A
  1. FES does not reduce hemiplegic shoulder pain (strong evidence).
  2. FES does prevent shoulder subluxation (strong evidence).

EBRSR executive summary pg 20.

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21
Q

What are 4 risk factors for post-stroke depression?

A

Female

Phx depression or psych illness

functional limitations/physical disability (severity of injury)

cognitive impairment

social isolation/living alone

aphasia/dysphasia.

Ref: EBRSR module 18 pg 8.

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22
Q

List 2 management strategies of post-stroke depression.

A
  1. SSRI: Fluoxetine (Prozac)
  2. Methylphenidate (CNS Stimulant)
  3. Combined therapy
  4. Repetitive transcranial magnetic stimulation - tMS (1a)

EBRSR module 18 pg 80-82

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23
Q

A patient with TIA, what are three investigations to perform within 24 hours?

A
  1. CT head: rule out hemorrhage.
  2. carotid Ix: U/S or CT angiogram.
  3. ECG: rule out atrial fibrillation.
  4. ECHO: rule out cardiac cause.
  5. holter: rule out atrial fibrillation.
  6. Bloodwork: CBC, electrolytes, creatinine, glucose, PTT/INR, fasting glucose, lipid profile.

Ref: 2009 – APSS – secondary stroke prevention pg 11.

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24
Q

What is apraxia?

A

Apraxia is a disorder of voluntary movement where one cannot execute a purposeful activity despite the presence of adequate mobility, strength, sensation, coordination, and comprehension.

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25
Q

What is the difference between ideomotor apraxia and ideational apraxia?

A

Motor or Ideomotor

Can automatically perform a movement but cannot carry it out on command

i.e. Can’t answer the phone, but he might pick it up automatically.

Ideational

Can perform separate movements but cannot coordinate all steps into an integrated sequence

i.e. Can’t write letter or prep sandwich, but he can the steps alone.

Stroke Rehabilitation Clinician Handbook

26
Q

Constructional apraxia: definition and site of lesion.

A

Inability or difficulty to build, assemble, or draw objects.

Site: Parietal lobe (R > L).

27
Q

Dressing apraxia: definition and site of lesion.

A

Inability to dress oneselve despite adequate motor ability.

Site: Right > Left hemisphere

28
Q

Deference between dysdiadochokinesis and dysmetria

A

Dysdiadochokinesis: difficulty with rapid alternating movements

Dysmetria: difficulty with placement of body part during active movement resulting in undershooting (HYPOMETRIA) or overshooting (HYPERMETRIA) of the target.

29
Q

List 2 cerebral locations involved in apraxia, and define its type.

A

Left MCA (parietal): ideomotor apraxia

Right MCA (parietal): constructional apraxia

Left ACA (frontal): left arm apraxia

Bilateral ACA (frontal): gait apraxia

Ref: Stroke Rehabilitation textbook pg 91; Ferro article; EBRSR module 2 pg 11.

ERABI: common in L MCA strokes, especially frontal/parietal lobes.

Ref: http://www.abiebr.com/set/1-47-year-old-single-male-vehicle-collision-rla-4-and-combative/15-apraxias

30
Q

What are 4 strategies to help a patient with short term memory?

A
  1. computer based training.
  2. imagery based training
  3. notebook (write things down)
  4. homework
  5. repetition

Ref: EBRSR module 12 pg 39.

31
Q

Neglect – what artery and lobe is typically affected? What interventions have a positive effect on neglect?

A

Right MCA territory – parietal lobe.

POSITIVE EFFECT:

  1. Prism Adaptation
  2. Visual scanning
  3. Limb activation
  4. Eye Patching
  5. Mirror Therapy
  6. Ref: EBRSR module 13.
32
Q

What are the 4 main arteries supplying the cerebral cortex?

A

Anterior circulation:

  1. Internal carotid arteries.
  2. Middle cerebral artery.
  3. Anterior communicating artery.
  4. Anterior cerebral artery.
33
Q

What are the 3 main arteries supplying the cerebellum?

A
  1. superior cerebellar artery (SCA)
  2. anterior and inferior cerebellar artery (AICA)
  3. posterior and inferior cerebellar artery (PICA).
34
Q

Name the cranial nerve involved:

  1. Left visual field
  2. Left tongue deviation
  3. Right mastication
  4. Right head rotation
  5. Inward and downward movement of L eye
A
  1. Left visual field: Right CN 2. (Optic tract or Optic radiation)
  2. Left tongue deviation: Left CN 12.
  3. Right mastication: Right CN 5.
  4. Right head rotation: left SCM - left CN 11.
  5. Inward and downward movement of L eye: Left CN 4.

Ref: general anatomy.

35
Q

How can apraxia of speech be distinguished from dysarthria?

A

APRAXIA

Non-speech movements intact; breathing and phonation not involved; inconsistent errors.

DYSARTHRIA

All movements of mouth affected; consistent errors.

Ref: Delisa pg 415.

36
Q

List 4 types of dysarthria

A

Pyramidal

  • SPASTIC: UMN (eg pseudobulbar palsy).
  • FLACCID: LMN (eg bulbar palsy).
  • MIXED: (eg ALS, MS, Wilsons disease).

ExtraPyramidal

HYPOKINETIC: extra-pyramidal (eg. Parkinsonism).

HYPERKINETIC: Extra-pyramidal (basal ganglia).

a. Quick: chorea, myoclonus, tourettes.
b. Slow: athetosis, dyskinesias, dystonia.
c. Tremors: organic voice tremor.

Cerebellum

  • ATAXIC: cerebellum (eg. Cerebellar ataxia).

Ref: Delisa pg 415.

37
Q

Define these terms:

Paraphasias (semantic and phonemic)

Neologism

Telegraphic

Echolalia

Circumlocution

A

PARAPHASIAS: errors of speech where words are substituted incorrectly:

a. Semantic: same-class substitution (“chair” instead of “table”). aka nominal paraphasia
b. Phonemic: sound or syllable substitution (“flair” instead of “chair”).

NEOLOGISM: incomprehensible words – may be partially recognizable or new words.

TELEGRAPHIC: similar to telegram – mostly nouns and verbs “2-3 word sentence”

ECHOLALIA: Accurate repetition of preceding utterance when repetition is not required.

CIRCUMLOCUTION: Circumlocution is a phrase that circles around a specific idea with multiple words rather than directly evoking it with fewer and after words.

Ref: Delisa pg 420.

38
Q

What is the risk of developing a stroke in a patient with TIA that is untreated?

A
  1. 10-20% will have a stroke within first 90 days.
  2. 50% of these strokes occur within first 2 days (48 hours).

Ref: 2009 – APSS – secondary stroke prevention document pg 5.

39
Q

What are some methods to prevent shoulder pain in a stroke patient with a flail arm?

A
  1. Protection/immobilization ( Sling/brace Lapboard in wheelchair)
  2. Education on how to safely mobilize arm (Sling/brace, or no traction)
  3. Proper positioning of limb at/above level of heart (venous return).
  4. Functional Electrical Stimulation (FES)

Ref: Stroke recovery and rehab textbook pg 518-519; first principles.

40
Q

What is the difference between neurological recovery and functional recovery?

A

NEUROLOGICAL RECOVERY (intrinsic, spontaneous):

  • Recovery of neurological impairments as result of brain recovery/reorganization
  • Influenced by rehabilitation

FUNCTIONAL RECOVERY (adaptive):

  • Improvement in mobility and activities of daily living.
  • Influence by neurological recovery, rehabilitation and motivation

Ref: EBRSR module 3 pg 5-6.

41
Q

Describe the three bands of stroke severity

A
  1. Upper band = milder strokes (FIM > 80) → Doesn’t require in patient rehabilitation
  2. Middle band = moderate strokes (FIM = 40-80) → Require in patient rehabilitation
  3. Lower band = severe strokes (FIM <40)

Ref: EBRSR Module B; EBRSR Module B; Garraway et al, 1981, 1985 articles – referenced from Teasell’s workshop in winnipeg “rehabilitation of severe stroke survivors”.

42
Q

Types of aphasia

A
43
Q

Give 4 reasons why a patient with a right MCA infarct may not be able to drive

A
  1. Constructional apraxia
  2. Left hemineglect
  3. Left Hemiparesis/plegia.
  4. Hemianopsia
  5. Poor perceptual skill – spatial perception
  6. Poor insight
  7. Poor judgment
  8. Seizure disorder.

Ref: first principles.

44
Q

List 4 contraindications to warfarin for primary stroke prevention.

When you can’t give anticoagulant medication?

A
  1. severe/active bleeding diathesis.
  2. non-adherence to medication & INR monitoring.
  3. pregnancy (1st trimester and at least 4 weeks before delivery).
  4. allergy/intolerance to warfarin.
  5. active bleeding.
  6. patient refusal.
45
Q

Constraint-induced movement therapy. List 2 criteria needed to be met in upper extremity for pt to receive Rx.

A

INCLUSION CRITERIA FOR STUDY (lower functioning participants):

  1. stroke in previous 3-9m.
  2. at least 10 degrees active wrist extension.
  3. at least 10 degrees active thumb abduction/extension.
  4. at least 10 degrees active extension of two other digits

Ref: EXCITE trial CIMT 2006 – JAMA, November 1, 2006—Vol 296, No. 17.

MEMORY AID: spiderman’s hands during web-shooting to recall motions needed for inclusion.

46
Q

What is pseudobulbar palsy?

What is the localization?

List 4 clinical features.

List 2 causes.

A

ANATOMY

  • UMN Lesion to corticobulbar tracts

CLINICAL: ALL “Ds” + Emotion

  • Dysarthria
  • Dysphagia
  • Dysphonia
  • Emotional lability
  • Small, stiff and spastic tongue
  • Brisk jaw jerk

Causes:

  • Brain trauma
  • multiple bilateral lacunar infarcts.
  • Amyotrophic lateral sclerosis.
  • Multiple sclerosis
  • Parkinson’s disease.

Ref: wikipedia.

47
Q

4 Treatments for venous insufficiency.

A

CONSERVATIVE:

  1. Elevate legs/feet 20 cm
  2. External compression stockings (30-40 mmHg).
  3. Intermittent pneumatic compression stockings
  4. weight loss.
48
Q

Anosognosia vs Agnosia

A

Anosognosia

Patient is unaware of their own mental health condition or that they can’t perceive their condition accurately.

Agnosia

Patient is unable to recognize and identify objects, persons, or sounds despite normally functioning senses.

49
Q

Which cranial nerves are important for eating and swallowing?

A

CN V, VII, IX, X, XI, XII

Ref: Review Notes 2012

50
Q

What is the innervation of salivation?

A

Salivary secretion mediated by PSNS.

CN 9: Parotid gland

CN 7: the rest of the glands (submandibular, sublingual)

Ref: wikipedia.

51
Q

Define Penetration vs Aspiration 🔑

A

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

52
Q

What are the 3 phases of swallowing? Which phase is aspiration most likely to occur in?

A
  1. ORAL (a. Preparatory b. Propulsion)
  • food manipulation and mastication
  • voluntary phase, when tongue propels food posteriorly until swallowing reflex triggered
  1. PHARYNGEAL: reflexive swallow carries bolus through pharynx
    * Aspiration most likely to occur in pharyngeal phase.
  2. ESOPHAGEAL: peristalsis carries bolus through cervical and thoracic esophagus into stomach

Ref: Review notes 2012

53
Q

What are some symptoms/signs of aspiration for each phase of swallowing?🔑

A

ORAL: drooling, pocketing food

PHARYNGEAL: food sticking, choking/coughing, wet/gurgling voice

ESOPHAGEAL: heartburn, food sticking

54
Q

What are risk factors for dysphagia and aspiration?🔑

A

Think from up to bottom, from LOC to aspiration and infection.

  • unable to feed self/distraction while eating
  • difficulty swallowing secretions, wet voice, weak voice, weak cough, etc.
  • poor cognition/decreased LOC.
  • ascultatory evidence of lower lobe conslidation
  • improper food consistency.
  • improper positioning (eg. Unable to sit upright).
  • coughing/throat clearing or wet, gurgly voice quality after swallowing water
  • choking more than once while drinking 50mL water
  • weak voice and cough
  • wet-hoarse voice quality
  • recurrent lower resp infections
  • low-grade fever or leukocytosis
  • severe cognitive and cognition disorders

Ref: EBRSR module 15 pg 5, ABIEBR Module 5 p15

55
Q

What are independent predictors of pneumonia following stroke?

A
  1. Age > 65 years
  2. Dysarthria or no speech due to aphasia
  3. Failure on water swallow test
  4. Modified Rankin Scale score ≥ 4
  5. Abbreviated Mental Test score <8

Presence of ≥2 these risk factors = 90.9% sensitivity and 75.6% specificity for development of pneumonia.

Ref: EBRSR module 15 pg 10.

56
Q

List 5 compensatory strategies during swallowing for management of dysphagia.

A
  1. Chin tuck: Delayed initiation of pharyngeal swallow.
  2. lateral Head tilt: towards strong side.
  3. Head turn: towards side of weakness.
  4. Supraglottic swallow: breath holding before and after swallow.
  5. Super supraglottic swallow: valsalva plus breath holding.
  6. Mendolsohn Maneuver: hold larynx up with muscles or hand.
  7. Double swallow
  8. Masako maneuver (pt protrudes tongue and then swallows).
  9. Effortful / hard swallow: Reduced tongue base retraction, pharyngeal weakness (Improve bolus flow through pharynx)

EBRSR module 15 pg 36; Stroke rehab textbook pg 194-195.

57
Q

List 2 complications of severe dysphagia in stroke patient and 2 potential treatments.

A

COMPLICATIONS:

  • Aspiration pneumonitis.
  • Aspiration pneumonia.
  • Dehydration.
  • Malnourishment.

Braddom pg 592.

TREATMENTS:

  • NPO until properly assessed.
  • Changes in posture and head position.
  • Elevation of head in bed.
  • Feeding in upright position.
  • Chin tuck with swallowing.
  • head rotation (Turn head to paretic side with swallowing).
  • Diet modifications (e.g. thickened fluids, pureed, soft foods in small boluses).
  • electrical stimulation (conflicting evidence).
  • tMS (1a).
  • nifedipine (1b).
  • black pepper oil (1b).

Ref: EBRSR module 15; ABC.

58
Q

List 4 signs or symptoms of dysphagia.

“Dysphagia is the medical term for swallowing difficulties.”

A
  • choking on food.
  • coughing during meals.
  • drooling.
  • loss of food from mouth.
  • pocketing of food in cheeks.
  • slow, effortful eating.
  • difficulty swallowing pills.
  • avoiding food or fluids.
  • complaining of food stuck in throat.
  • problems swallowing.
  • reflux.
  • heartburn.
  • nasal regurgitation
  • wet voice
  • abnormal gag reflex (Cuccurullo – debatable).

Ref: EBRSR – module 15, pg 4; Cuccurullo pg 35-36.

59
Q

What are the indications for a PEG or an RIG tube insertion?

A

When patient have complication from dysphagia:

  • Aspiration pneumonia
  • Under-eating: loss of >10% body weight
  • Malnutrition: impaired QoL due to time required to maintain nutrition orally

Note: RIG = radiologically inserted gastrostomy.

Ref: DeLisa, pg 731.

60
Q

What are the contraindications to using an NG feeding tube?

You are inserting silicon tube through his nose, passing the mucosal wall which has arteries.

A
  1. Basal skull fractures.
  2. Facial fractures.
  3. Esophageal strictures
  4. esophageal varices
  5. bleeding diatheses

Ref:uptodate article – NG and nasoenteric tubes.

PMR 01 - Stroke (8 decks)

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