Evaluation of Patient with Stroke

Question 1

When evaluating a stroke patient describe how the time and pattern of onset describe the type of stroke.

Answer 1

Exact time and pattern of symptom onset

• abrupt onset with worsening symptoms (cerebral hemorrhage)
• sever headache (subarachnoid hemorrhage)
• Embolus occurs rapidly with no warning (associated with heart disease)
• Thrombus onset is often more variable and uneven

Question 2

What is the most common imaging used for stroke patients?

Answer 2

CT scan

• allows for identification of large arteries and veiens
• poor sensitivity for detecting small infarcts
• acute bleeding is visible

Question 3

What is the backup imaging system if CT doesn’t get the job done or is unavailable?

Answer 3

MRI
-more sensitive in diagnosis of acute strokes, can detect cerebral ischemia in as early as 30 min after vascular occlusion

Question 4

What type of imaging is used to examine the posterior circulation of the brain and carotid arteries?

Answer 4

Doppler Ultrasound

Question 5

What are some goals in the medical management of a stroke?

Answer 5

Improve cerebral perfusion (reestablish circulation)
Maintain adequate BP and CO
Restore/maintain fluid/electrolyte balance
Maintain blood glucose levels
Control seizures and infection
Control edema, and pressure
Maintain bowel/bladder function, may require catheter
Maintain skin integrity
Decrease risk of complications such as DVT, aspiration, ulcers, etc

Question 6

What are some common pharmacological management techniques?

Answer 6

Thrombolytics (tPA)
Anticoagulants (Warfarin, heparin)
Antiplatelet Therapy (aspirin, plavix)
Antihypertensive agents
Antispastics
Anticonvulsants
Antidepressants

Question 7

What is the framework of rehabilitation for stroke?

Answer 7

Reduce disability and promote independence
Reduce or prevent complications and improve quality of life
Coordinated interdisciplinary team makes a comprehensive plan of care
Interdisciplinary communication is critical

Question 8

What type of activities are done in the acute phase for rehab of a stroke?

Answer 8

Early mobilization (prevent harmful effects of bed rest)
Communicate with team
Continually monitor status during treatment
Increase patient’s level of consciousness and foster independence
Early stimulation and use of hemiparetic side

Question 9

What are some common things to test for in a PT examination of a stroke patient?

Answer 9

Cranial nerve integrity
Sensation
Flexibility and joint ROM (joint misalignment problems are common)

Question 10

What are some common contracture sites after a stroke

Answer 10

Elbow flexors
Wrist and finger flexors
Forearm pronators
Plantarflexion

Question 11

What does examination of muscle tone consist of?

Answer 11

Initial observation of resting posture

Passive motion testing (modified ashworth scale)

Question 12

What is the 1st stage for motor recovery following a stroke?

Answer 12

Stage 1: period of flaccidity immediately following acute episode (no movement of limbs)

Question 13

What is the 2nd stage for motor recovery following a stroke?

Answer 13

Stage 2: Basic synergies begin to appear (minimal voluntary movement), Spasticity begins to develop

Question 14

What is the 3rd stage for motor recovery following a stroke?

Answer 14

Stage 3: Gains voluntary control of the movement synergies. Full range may not develop. Spasticity has further increased and may become severe

Question 15

What is the 4th stage for motor recovery following a stroke?

Answer 15

Some movement combinations that do not follow the paths of either synergy are mastered, spasticity begins to decline

Question 16

What is the 5th stage for motor recovery following a stroke?

Answer 16

If progress continues, basic limb synergies lose their dominance over motor acts

Question 17

What is the 6th stage for motor recovery following a stroke?

Answer 17

Disappearance of spasticity, individual joint movements become possible and coordination approaches normal. Normal motor function is restored

Question 18

Which stages do most stroke patients plateau at?

Answer 18

Stages 3 and 4

Question 19

When is a patient experience flaccidity in their muscles after a stroke?

Answer 19

First few days primarily due to cerebral shock

Question 20

Which muscles are mostly affected by spasticity?

Answer 20

UE: scap retractors, shoulder adductors, depressors and internal rotators, elbow flexors, forearm pronators and wrist and finger flexors
LE: Pelvic retractors, hip adductors and IR, Hip and knee extensors, plantarflexors, supinators, and toe flexors

Question 21

How can a therapists intensify resistance, initial catch, with first stretch?

Answer 21

Increasing the speed of moving the limb.

Question 22

What is clonus?

Answer 22

A phasic stretch response

Question 23

What are the levels of the Modified Ashworth Scale?

Answer 23

0 - No increase in muscle tone
1 - slight increase in tone manifested by catch and release (at end range)
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

Question 24

Describe what a synergy pattern is?

Answer 24

Patient is unable to isolate voluntary movement of a single limb segment without movement of remainder of the limb

Question 25

How do reflexes progress in patients after a stroke?

Answer 25

Initially hyporeflexia with flaccidity

Then hyperreflexia when spasticity and synergy patterns emerge

Question 26

What is apraxia?

Answer 26

Difficulty planning and executing purposeful movements that can’t be accounted for any other reason (more evident with left hemisphere damage)

Question 27

What are the 2 types of apraxia?

Answer 27

Ideational - inability of patient to produce movement either on command or automatically (complete breakdown in the conceptualization of the task
Ideomotor - Patient is unable to produce a movement on command but is able to move automatically

Question 28

Which direction do patients with hemiplegia typically fall ?

Answer 28

Direction of weakness

Question 29

Name some common functional performance measures for balance that can be used.

Answer 29

BERG
POMA, Tinetti
Functional Reach Test
TUG
BESTest

Question 30

What are some stroke-specific tests of postural control and balance?

Answer 30

PASS
Trunk Impairment Scale
Function in Sitting Test
ABC scale

Question 31

What is pusher syndrome?

Answer 31

Characterized by active pushing with stronger extremities toward the hemipareteic side with a lateral postural imbalance

Question 32

What can pusher syndrome lead to during rehabilitation?

Answer 32

Poorer rehabilitation outcomes with longer hospital stays

Question 33

What are some functional walking categories?

Answer 33

Physiological Walker - Walks for exercise at home or in parallel bars only
Household Walker - Limited (relies on walking to some extent but also uses wheelchair), Unlimited (able to use walking for all household activities but difficulty with stairs)
Community Walker - Most limited (can enter and leave home independently) Least limited (independent with stair management, independent walking for at least 2 community activities), Community (Independently walks for all home and community activities, can deal with crowds and eleven terrain)

Question 34

Name some Stroke-Specific Outcome measures

Answer 34

StrokEdge - Recommended for entry-level education
Fugl-Meyer Assessment - Good construct validity and high reliability (gold standard instrument)
Stroke Impact Scale - self report measure developed to assess function
Stroke Specific Quality of Life Scale - 49 items assessed on 5-point scale