Exam 2 Flashcards
What is a CVA?
Lack of O2 due to secondary ischemia or hemorrhage
What is ischemia?
Lack of blood flow due to blockage
What is hemorrhage?
Bleeding such as, ruptured blood vessel
What is TPA medication?
- Only ischemic CVA
- Breakdown clots and thins blood
- Would make hemorrhagic stroke worse
- Needs to be given during specific time frame
What are primary risk factors to CVA?
HTN, cardiac disease, DM, cigarette smoking, and TIA
What are secondary risk factors to CVA?
Obesity, high cholesterol, behaviors related to HTN, physical inactivity, and increased alcohol consumption
What is TIA?
Transient Ischemic Stroke - mini stroke
Commonly linked to athrosclerotic thrombosis and most often occurs in carotid and vertebrobasilar arteries
Pt presents with some symptoms and resolves within 48 hours
What is a completed stroke?
Total neurological deficits at the onset
What is a stroke in evolution?
Usually caused by thrombus and gradually progresses
Total neurological deficits are not seen for 1-2 hr post
Do not know stroke is coming
What is an ischemic stroke?
Loss of perfusion to a portion of the brain and within seconds there is irreversible infarction
What are the types of ischemic stroke?
Embolus and thrombus
What happens during an embolitic stroke?
Travels through bloodstream to cerebral arteries causing occlusion of BV
Most commonly comes from internal carotid
Occurs rapidly and presents with HA
Tissues distal to the infarct can sustain permanent damage
What happens during a thrombotic stroke?
Caused by arthrosclerotic plaque and occludes artery causing an infarct
Symptoms can appear in minutes or several days
Usually occurs during sleep or upon awakening after an MI or surgery
What are factors that cause hemorrhagic strokes?
HTN can cause rupture of an aneurysm
What are the characteristics of hemorrhagic stroke?
Severe HA Vomiting HTN Abrupt onset Bleeding and symptoms evolve in relation to speed of bleed
What are L hemisphere CVA characteristics?
Weakness, paralysis of the R side
Increased frustration
Decreased processing
Possible aphasia
Possible dysaphagia
Possible motor apraxia (ideomotor and ideational)
Decreased discrimination between L and R
R hemianopsia
What are R hemisphere CVA characteristics?
Weakness, paralysis of the L side
Decreased attention span
L hemianopsia
Decreased awareness and judgement
Memory deficit
L inattention
Decrease abstract reasoning
Emotional lability
Impulsive behaviors
Decreased spatial orientation
What are brainstem CVA characteristics?
Unstable vital signs
Decreased consciousness
Decreased ability to swallow
B weakness and paralysis
What are cerebellar CVA characteristics?
Decreased balance
Ataxia and nausea
Decreased coordination
Decreased ability for postural adjustment
Nystagmus
What is L sided neglect?
Do not recognize the L side of body
Important to draw pt attention to the L side
What is ideational apraxia?
Has no IDEA what the task requires
What is ideomotor apraxia?
Has an idea of what the task requires
Lost kinesthetic memory - no longer able to perform
IE. See pt combing earlier in the day and later when you ask the pt to perform the same task they do not know what to do
Intervention includes part task training
How soon does neuroplasticity become active?
During the first 3 months post stroke
What is Locked-In Syndrome?
Brain knows what to say or do, but cannot
What are synergy patterns?
Brain responsible for complex motor patterns and inhibition of massive gross motor patterns
Higher centers of the brain lose control
How body response when voluntary movement is initiated
Which synergy pattern is strongest in UE?
Flexor
What is the flexor synergy pattern?
Scapula = elevation and retraction
Shoulder = ABd and ER
Elbow = flex
Forearm = supination
Wrist = flex
Fingers = flexion with ADd
Thumb = Flex and ADd
Hip = ABd and ER
Knee = Flex
Ankle = DF with supination
Toes = Ext
What is the extensor synergy pattern?
Scapula = Depression and protraction
Shoulder = ADd and IR
Elbow = Ext
Forearm = Pronation
Wrist = Flexion with ADd
Thumb = Flex with ADd
Hip = Ext, IR, and ADd
Knee = Ext
Ankle = PF with inv
Toes = Flex and ADd
Which synergy pattern is strongest in the LE?
Extensors
What is NDT?
Slowing down or cessation of motor development and inhibition of righting reactions, equilibrium reactions, and automatic movements
Promote use of the involved body segments
Define facilitation
Elicit voluntary muscular contraction
Define inhibition
Decrease excessive tone or movement
Define key points of control
Specific handling of designated areas of the body will influence and facilitate posture, alignment, and control
Moves proximal to distal
Define placing in NDT
Act of moving an extremity into a position that the pt holds against gravity
Define reflex inhibiting posture in NDT
Certain designated static positions that Bobath found to inhibit abnormal tonal influences and reflexes
What are the basics of NDT?
ID constraints that limit pt’s ability to perform functional activities
Pt actively participates utilizing strengths and part to whole task training
Use developmental sequence
Proper form/control is a must
REPETITION
What is important about manual cues of NDT interventions?
Motor response are heavily influenced by pressure and direction of facilitation
Begin with light pressure and grade based on response
Focus on NOT on R
What are the key points of control of NDT intervention?
Placement of physical contact b/t clinician and pt body
Proximal key points
What are distal key points of NDT interventions?
Away from the source of the problem, usually at the UE and LE levels
Used to engage pt in activities with minimal control of the clinician
What is the Brunnstrom: Movement Therapy in Hemiplegia?
Created and defined synergy and encouraged the use of synergy patterns
7 stages
What are the 7 stages of Brunnstrom Movement Therapy?
No volitional movement initiated
Appearance of basic limb synergies - spasticity begins
Synergies are performed voluntarily - spasticity increases
Spasticity begins to decrease and movement patterns are not dictated solely by limb synergies
Further decrease in spasticity with independence from limb synergy
Isolated jt movement with coordination
Normal motor function is restored
Define associated reaction
Involuntary and automatic movement of a body part as a result of an intentional active or resistive movement in another body part
Define homolateral synkinesis
Flexion pattern of involved UE facilitates flexion of involved LE
What is Raimiste’s phenomenon?
Involved LE will ABd or ADd with applied R to the uninvolved LE in the same direction
What is Souque’s phenomenon?
Raising involved UE above 100-degrees with elbow ext will produce ext and ABd of fingers
What are the basic principles of PNF?
Stronger parts are used to strengthen weaker parts
Normal movement and posture is a balance b/t control of antagonist and agonist muscle groups
Development will follow the normal sequence through a component of motor learning
Manual contacts and correct handling are key
Methods promote or hasten the response of the neuromuscular mechanism through stimulation of proprioceptors
Where should manual contacts be in PNF?
Placement to stimulate pressure receptors and provides info to the pt about direction of movement
Placement over the Mm you want to activate in direction of desired movement
What is stretch good for in PNF?
Facilitate Mm
Place Mm in elongated position followed by quick stretch to facilitate movement
Why is PNF good for manual resistance?
Some decrease internal R while some strengthen
Changes in Mm function as it moves through range
Define chopping
Combo of B UE asymmetrical patterns performed as CKC activities
Define developmental sequence
Progression of motor skill acquisition where motor control stages are mobility, stability, controlled mobility, and skill
What is controlled mobility?
Ability to move within a WB position or rotate around a long axis
What are mass movement patterns?
Hip, knee, and ankle move into flex/ext simultaneously
Define overflow
Mm activation of an involved extremity due to intense action of uninvolved Mm
What are tips for successful PNF tx?
Learn diagonal patterns
Techniques MUST have accurate timing, specific commands, and correct hand placement
V/C are short and concise
Repetition is necessary
R given during the movement pattern is greater if goal is stability. R is less if goal was mobility
Utilize isometric and isotonic Mm contractions
Move through full movement and through all ranges
Developmental sequence used in conjunction with PNF techniques to increase agonists and antagonists
Utilized to increase strength or improve relaxations by enhanced overflow from stronger to weaker Mm
What are the 3 components of PNF diagonals?
Flex/ext
Motion towards/across midline
Rotation
What is joint facilitation?
Traction and approximation stim receptors w/in jt and structures
Traction = motion
Approximation = stability and WB
What are the mobility techniques of PNF patterns?
Rhythmic initiation Contract-relax Hold-relax Rhythmic rotation Hold-relax active movement Jt distraction Repeated contraction
What are the stability techniques of PNF patterns?
Rhythmic stabilization
Alt isometrics
Slow reversal
Slow reversal hold
What are the controlled mobility techniques of PNF?
Agonist reversal
Slow reversal
Slow reversal hold
What are the skill techniques of PNF patterns?
Agonist reversals Slow reversal Slow reversal hold Timing for emphasis Normal timing Resisted progression
What is rhythmic initiation?
Voluntary relaxation - clinician takes body part thru desired ROM
Isotonic contraction - pt helps move body part thru ROM (AAROM)
Resisted isotonic contraction - slightly resist pt thru ROM
What is rhythmic rotation?
Passive movement in rotational pattern
What are agonist reversals?
Concentric contraction of agonist resisted thru ROM - isometric hold at end - resisted eccentric contraction back to starting position - isometric hold at start
What is Rood?
Based on reflex stim model
Tx based on sensorimotor learning
Use developmental sequence to enhance motor control
Exercise only effective if response is correct and it provides sensory feedback that enhances motor learning of response - once response obtained then stim is withdrawn
What are the goals of Rood?
Obtain homeostasis in motor output
Activate Mm to perform a task independent of stim
Elicit desired reflex motor response
What are examples of facilitation in Rood?
Approximation Jt compression Icing Light touch Quick stretch R Tapping Traction
What are examples of inhibition in Rood?
Deep pressure
Prolonged stretch
Warmth
Prolonged cold
What is a high C-spine SCI?
C1-C5
What is a mid-level C-spine SCI?
C6
What is a low C-spine SCI?
C7-C8
Where does injury occur in a paraplegic?
Thoracic, lumbar, or sacral
What is an injury called at L1 or below?
Cauda equina injury (LMN)
What is spinal shock?
Physiologic response that occurs b/t 30-60 min after trauma to the spinal cord and can last up for several weeks
Define neurectomy
Surgical removal of a segment of nerve in order to decrease spasticity and improve function
Define myelotomy
Surgical procedure that severs certain tracts within SC to decrease spasticity and increase function
Define rhizotomy
Surgical resection of the sensory component of a spinal Nn to decrease spasticity and improve function
Define tenotomy
Surgical release of a tendon to decrease spasticity and improve function
What is a neurologic level SCI?
Most caudal segment of the SC with intact sensory and motor function on both sides
How is the neurologic level SCI measured?
Sensory - refers to normal sensation
Motor - MMT >/= 3/5
What is the skeletal level SCI?
Refers to level at which by x-ray/other imaging the greatest damage is found
Define zone of preservation
Poor or trace MMT or sensory function up to 3 levels below neurologic level of injury
Define sacral sparing
Incomplete lesion
Perianal sensation and/or voluntary control of rectal sphincter mm; movement of toe flexors
Sacral tracts run most medially within the SC
What are the categories of incomplete SCI?
Brown Sequard syndrome Posterior cord syndrome Anterior cord syndrome Central cord syndrome Cauda equina syndrome
What is a complete SCI?
No preserved motor or sensory function below the level of lesion
Results in tetraplegia
Completeness is not fully known until 6-8 weeks post injury because of spinal shock
What is Anterior Cord Syndrome?
Occurs to frontal part of SC
Results in loss of motor and sensation (p! and temp) below level of injury because fasciculus cuneatus and gracilis are injured
Can occur with disc herniations, tumors, and when the head is forced into flex
What is Brown Sequard Syndrome?
Occurs when 1/2 spinal cord is damaged
Results in IPSILATERAL paralysis and loss of vibratory and position sense.
Results in CONTRALATERAL loss of p! and temp
Usually caused by stab wound
What is cauda equina syndrome?
Injury at or below L1 (PNS - LMN injury)
Flaccidity, areflexia, and b/b dysfunction
What is a neurogenic nonreflexive (areflexic) bladder?
S2-4 injury; flaccid b/b; sacral reflex arc damaged
What is neurogenic reflexive bladder?
Hyperreflexic/spastic
Bladder empties reflexively for pt with injury above S2 (Scorebuilders states around T12)
Sacral reflex intact
What is a hyperreflexic b/b?
Have no voluntary control of b/b, but can still empty
Pt may have scheduled bathroom breaks
Greater risk for UTI
What spinal level controls b/b?
S2-S4
What is Central Cord Syndrome?
Most common
Central portion of SC is damaged typically from cerv hyperextension. Also caused from DJD and/or stenosis
Greater weakness in UE than LE
Greater motor deficits than sensory
What is Posterior Cord Syndrome?
Rare
D/t damage of posterior spinal Aa. IE. compression d/t tumor
Loss of proprioception, 2 point discrimination, vibration, and stereognosis
Motor function preserved
According to ASIA what is A classification of SCI?
Complete
No S/M function below level of injury
No sacral sparing (no preservation in S4-5)
According to ASIA what is B classification of SCI?
Sensory Incomplete
S (no M) function is preserved below neurologic level including S4-S5
According to ASIA what is C classification of SCI?
Motor Incomplete
M function is preserved below neurologic level, more than 1/2 of key Mm below neurologic level have <3/5 MMT
According to ASIA what is D classification of SCI?
M function is preserved below neurologic level and at least 1/2 of key Mm below neurologic level have strength of >/= 3/5
According to ASIA what is E classification of SCI?
Normal
S/M functions are normal
Define motor level in Standard Neurological Classification of Level of Injury
Most caudal
Mm have strength of >/= 3/5 with superior segment tested as normal
Define Motor Index Scoring on Standard Neurological Classification of Level of Injury
Test each key Mm using 0-5 score, total of 25 pt per extremity = 100 pt possible
Define Sensory Level on Standard Neurological Classification of Level of Injury
Determined by the most caudal dermatome with a normal score of 2/2 for PINPRICK and LIGHT TOUCH
Impaired does not necessarily mean they do not feel it. Could be hypersensitive
What muscles are involved with C4 SCI?
Cerv extensors and flexors/diaphragm/traps and LS
What Mm are involved with T6 SCI?
Accessory respiration Mm/upper back extensors
What Mm are involved with T12 SCI?
Thoracic abdominal and back Mm
Define spasticity
Velocity dependent
Define tonicity
Speed and velocity dependent
Can you strengthen motor loss that comes from a SCI?
You can strengthen, but not below the level of injury
What is motor loss from a SCI?
Motor loss below LOI may be complete or partial
Can be tested by MMT
What is sensory loss from a SCI?
Occurs in dermatomal pattern
ASIA test - light touch and pin prick
Graded normal, impaired, absent
What is spasticity from SCI?
Spinal shock occurs early after SCI (Mm are flaccid)
Mm spasms occur
The quicker the pt is out of spinal shock = better prognosis - contribute to neuroplasticity
Affect skeletal Mm, b/b, and sex organs
Can increase with pressure ulcers, full bladder or UTIs
What is b/b dysfunction after SCI?
Lose total or partial voluntary control of b/b
Can be reflexic above S2 or areflexic
Define hyperreflexic/spastic b/b dysfunction
Pressure inside b/b causes emptying
Define nonreflexic/flaccid b/b dysfunction
Sacral reflex is not intact so b/b require manual emptying
What are ways to void bladder without voluntary control?
Catheter
Intermittent catheter
Crede maneuver
What is a spastic bladder?
No control of urination
What is flaccid bladder?
Does not empty
What respiratory complications can occur with SCI?
Respiratory Mm (Intercostals T1-11 and C3-5) will be affected with injury above L1
Cough assist with high T
Functional cough T6
Normal cough T12
Forced vital capacity and inspiratory capacity increases as SCI level descends
What occurs to respiratory system when SCI is between C4 and T5?
Able to breathe on own, but intercostal Mm may be weak or paralyzed depending on level
C injury: breathing mainly by diaphragm
Need assisted cough to T6
What occurs to respiratory system when SCI is between T6 and T12?
Injury does not normally affect breathing. Cough may be impaired
Injuries below T12 have normal breathing and cough reflexes
What are sx/sx of DVT?
Dull ache, pain, calf tenderness, edema, and fever
Early - asymptomatic
What are tx options for DVT?
Acute - pt on bed rest until sx of inflammation have subsided, elevate extremity
Anticoagulant meds
Exercise contraindicated during acute phase
Amb permitted with stockings after local tenderness and swelling reslove
What are preventions/tx for DVT?
Elastic hose
Increase mobility
What is autonomic dysreflexia?
Syndrome of massive imbalanced reflex sympathetic dischage
ONLY occurs in pt with injury at or above T6
Lose ability to maintain homeostasis
What are the sx/sx of autonomic dysreflexia?
HTN Blurred vision Profuse sweating Goosebumps (below injury) Severe HA Stuffy nose Flushing of head and neck
MEDICAL EMERGENCY
What are the tx of autonomic dysreflexia?
Immediately - assist pt to sit or stand
Find and remove cause - check skin, bladder, and bowel
CHECK CATHETER, check tight clothing, look for undiagnosed pressure ulcer
Check BP
Call for help
What is ectopic bone?
Spontaneous formation of bone in soft tissue - common in hips and knees
What is the cause of ectopic bone?
Tissue hypoxia to abnormal Ca metabolism
What are the sx/sx of ectopic bone?
Edema, decreased ROM, and increased temp
What is the tx of ectopic bone?
Meds: diphosphates
PT and surgery
What is decreased bone marrow density?
Demineralization occurs within first year with peak at 4-6 months post injury due to NWB
Use stander and orthotics to prevent
What is orthostatic hypotension?
Decrease BP when you sit or stand
Can cause lightheadedness or fainting
What increases the likelihood of orthostatic hypotension?
T6 or above SCI
What are interventions of orthostatic hypotension?
Want to increase BP and get O2 back to brain
Tilt table helpful
What are the causes of orthostatic hypotension?
After SCI - BV do not decrease in size in smooth Mm around BV cannot vasoconstrict/dilate in response to changes in ANS
Cannot contract to get valves in veins to push blood back to heart - blood can pool
How do you prevent orthostatic hypotension?
Elastic hose and ab support and come to sitting/standing position gradually
What do you look for that can increase risk of pressure ulcers?
Thick, rough clothing, lumpy sheets, cushion covers or clothing, moisture, heat, burns, ill-fitting clothes, poor nutrition, orthopedic deformities
How do you prevent pressure sores?
Relief cushion and mattress
Periodic pressure release
- 15 sec every 15 min, 30 sec every 30 min, or 1 min for every hr
What causes spasticity in SCI?
Increased internal/external forces
Stress, ulcers, UTIs, b/b obstruction, temp changes, or touch
What are the sx/sx of spasticity in SCI?
Increased tonic stretch reflexes and exaggerated DTRs
What treatment is given for spastic SCI?
Meds, surgery, PT
What are sx/sx of UTI?
Fever, change in urine, sediment in urine, odor change, increase in tone
What are the 5 stages of grief?
Denial Anger Bargaining Depression Acceptance
What is MS pain of SCI?
Related to mechanical instability, inflammation, Mm spasm, and overuse of Mm and jt
What is neuropathic pain of SCI?
Sharp, stabbing, burning, or electrical pain associated with painful, hypersensitive response to normally non-noxious stimuli
What are components of acute SCI tx?
Positioning PROM/selective stretching Acclimation to vertical Strengthen spared Mm Improvement of respiratory fxn
What is acclimation to vertical?
Begin sitting activities ASAP
Watch for orthostatic hypotension - monitor VS
What are the components of SCI rehab?
Functional position Momentum rolling Sit to/from supine Protective ext Balance activities Transfer training W/C management and mobility Pressure relief and reposition in w/c Standing activities Gait activities Complete education and vocational counseling Sports and leisure education Community re-integration Home eval/modification
What kind of transfer is needed for SCI C5 or higher?
Dependent 2 person/1 person squat
What kind of transfer is needed for C5-C6?
Sliding board with/without A
No use of triceps
KEEP fingers flexed to keep tenodesis
What kind of transfer is needed for C7 SCI?
Use triceps with/without slide board
What kind of transfer is needed for C8-L2 SCI?
Most likely use footboard of w/c
What is jack knife?
Upper body and head forward of pelvis
Lose standing stability
Can use JK with intention to get back to upright position
