Exam II Flashcards
Stroke recurrence
25-35% of acute stroke patients
Within 5 yrs post stroke recurrence risk is 40% (24% for women and 42% for men)
Increased risk with thrombotic stroke
S/S of stroke
- muscle weakness (typically on 1 side of the body)
- disorganized speech
- tingling or sensation deficit
- altered mental status
- increaSed confusion
Stroke demographics
African American>Hispanic>Caucasian
Socioeconomic and geographic connections
Stroke risk factors
- HTN (biggest)
- high serum cholesterol
- obesity
- heavy alcohol use
- cocaine use
- smoking
- diabetes
- heart disease
Thrombotic stroke
Ischemic-area deprived of blood
Blood clot blocks flow of blood in brain
Embolic stroke
Ischemic-area deprived of blood
Fatty plaque or blood clot breaks away and flows to brain where it blocks the artery
Cerebral hemorrhage
“Bleed”
Break in blood vessel (aneurysm)–> recover quickly once blood is reabsorbed
TPA
Tissue plasminogen activator
Given within 2 hours post stroke will reverse the symptoms
Thrombotic CVA factors
Causes by ASCHD and HTN "Stroke in progress" TIAs -indicative of thrombolytic -possible vasospasm -transient systemic arterial hypotension
Mercy procedure
Go in and remove clot
Kind of like a heart stent
Follow arteries to the brain
Thrombotic CVA and TIA medical management
- prevention
- improve circulation ASAP
- pharmaceuticals
- T-PA
- anticoagulants
- antiplatelets
- surgery (thromboendaeterectomy) for carotid and subclavian blockages
Embolic CVA Facts
- signs of cardiac disease
- originate from
- heart
- internal carotid artery
- carotid sinus
- branches of MCA are commonly affected (poorer outcomes)
Embolic CVA Management
- prevention
- long term anticoagulant therapy
- surgery
Hemorrhagic CVA Facts
- Causes
- HTN
- ruptured saccular aneurysm (berry)
- AV malformation (age 10-35 most common)
- bleeding displaces midline structures
- blood re-absorbed over 6-8 months
What space are the arteries found in?
Subarachnoid
Hemorrhagic CVA Management
- hypertensives
- prevention
- HTN management
- Ruptured aneurysm
- surgery
- Post surgical HOB restrictions, 4-6 wk limited activity, anti seizure meds
Review blood supply
see drawing
Left sided brain damage
- R sided hemiplegia
- don’t worry as much about these patients
- cautious and slow
- possible sensory dysfunction, visual field defect, cognitive impairment
Right sided brain damage
- L sided hemiplegia
- more dangerous
- severe denial of deficits
- impulsive
- perceptual and memory deficits
- possible sensory dysfunction, visual field defect, cognitive impairment
Medical Management of Impairments
- spasticity
- seizures
- respiratory dysfunction
- trauma
- DVT
- CRPS
- Pain
CVA Movement Dysfunction
- decrease force production
- abnormal synergistic mvt
- altered muscle contractions and timing
- decreased force regulation
- delyaed responses
- abnormal muscle tone
Abnormal synergistic mvt
- usually happens later after stroke
- “associated reaction”=UE, ask them to do something and they flex their arm
CVA sensory dysfunction
- awareness
- interpretation
- any modality may be affected
- visual disturbances
- decreased awarenes, decreased attention, inablity to be right here right now, distractable
- double vision
- blurry vision
CVA Secondary impairments
- change in alignment
- change in mobility
- change in muscle and soft tissue length
- pain
- edema (secondary to decrease ms pump)
Composite impairments
- mvt deficits
- atypical mvts
- undesirable compensation
OPS
- Orpington Prognostic Scale
- specific to stroke
- looking at motor deficit (using MMT), proprioception, balance, cognition
- used during initial eval
<3.2=minor problem
3.2-5.2=moderate problem
.5.2=major problem
Other OPS facts
- should not be used for acute prognosis
- only used when neurologically stable
- optimal predictive power is at 2 wks post stroke
- scores range from 1.6-6.8
OPS Scores
90% of pts who scored 3-5 were eventually D/C
>.5.2 required long term care
Framingham Heart Study
- only 1 CVA=good chance of full functional recovery
- rehab is effective in improving functional ability
- age is not a detriment
Recovery from stroke
- initial functional gains
- reduced cerebral edema
- absorption of damaged tissue
- improved vascular flow
- Follow by neurplasticity
- negative
- positive
Predictors of motor function recovery
- recovery may extend for years
- initial return of UE mvt in 1st 2 wks=predictive of full UE recovery
- failure to recover grip strength by 24 days=predictive of no UE recovery at 3 months
- 30% of pts have no UE recovery
Functional recovery
86% of recovery is predictable at 1 month
- Long term
- 58% regain independence in ADLs
- 82% learn to walk
Special considerations post CVA
- Monitor vitals
- > 200, 110 resting DBP
- > 10 or 50 HR
- elevated INR
- DVT=3–75% after stroke
- LOE=loss of energy 9moderate)
- respiratory insufficiency >90%
Common problems post CVA
- seizures (10% after ischemic, 34% after hemorrhagic)
- cognitive problems
- dysphagia
- visuospatial and perceptual disturbances
- language deficits
- if dom hemisphere is affect–language deficits
Compensatory strategies for dysphagia
- thickening liquids
- pudding-honey-nectar-thin
- chin tuck during swallowing
- small sips
Treatment of dysphagia
- VitalStim NMES
- biofeedback with mirror
- posture/environmental setup
Visuospatial and perceptual disorders
- attention deficits and distractibility
- homonymous hemianopsia and other visual field cuts
- body scheme and body image disorders
- depth, distance or visual perceptual deficits
Agnosia
The inability to recognize familiar objects using one or more sensory modalities, while retaining the ability to recognize the same object using other sensory modalities
Anosognosia
The severe denial, neglect, and lack of awareness of the presence or severity of one’s deficits
very common with L hemis and patients with cerebellar disorders
Dysarthria
- muscle dysfunction leads to impaired verbal communication.
- may affect respiration, phonation, articulation, resonance
- Treatment–tongue and oral motor exercises, functional speaking practice, posture
Aphasia
- dominant hemisphere injury
- impairs expression and/or understanding of language
Broca’s aphasia
- Expressive
- sometimes they can still write
- frustrating
- slow, trying to find the right word
- understand you completely
- depression is common
- can teach them hand signs to communicate (like thumbs up, thumbs down)
Wernicke’s Aphasia
- Receptive
- can’tn understand you
- may respond and act like they understand you
- word salad
- give them simple and work toward more complex commands to test understanding
- guide using your hands “pantamime”
Global aphasia
- cant receive or say anything
- makes for a very quick eval
- have to use functional activities to test for strength
Apraxia
- loss of ability to execute or carry out skilled movements and gestures, despite having the desire and the physical ability to perform them.
- instructions are understood
- mild form=dyspraxia
- found with parietal lobe injury
- types can occur alone or in combo
Buccofacial/orofacial apraxia
- most common form
- inability to carry out facial mvt on command
ex. licking licks, blowing bubbles, whistling, coughing, winking
Limb-Kinetic Apraxia
-inability to make fine, precise movement with an arm or leg
Ideomotor Apraxia
inability to make proper mvt in response to a verbal command
ex. tell a patient to walk across the room and they can’t, but ask them to go get coffee (which is on the other side of the room) and they do it.
Ideational Apraxia
inability to coordinate activities with multiple, sequential movements
ex. dressing, eating, bathing
- can’t sequence properly
Verbal apraxia
difficulty coordinating mouth and speech movements on command
Constructional apraxia
inability to copy, draw, or construct simple figures
Occulomotor apraxia
difficulty moving eyes on command
Neglect
- dense (0/5) L hemi
- flaccidity
- poor trunk control–flexion and post pelvic tilt
- homonymous hemianopsia
- absent sensation
- perceptual deficit
Pusher
- may or may not have mid-mod hemiparesis
- normal tone to mild/mod hypertonicity
- inaccurate perception of midline
- impaired to intact sensation
- impaired judgement/safety awarenses
Modified ashworth scale
Test in supine-1x quick, 1x slow
0=no increased tone
1=slight increase tone at end of ROM
1+=slight increase tone for less than 1/2 ROM
2=increase tone through most of ROM
3=considerable increase in tone, PROM is difficult
4=rigid
Action research arm test pt population
- stroke
- MS
- TBI
Action research arm test facts
- 19 tasks
- evaluates subscales of grasp, grip, pinch, and gross motor mvt both proximally and distally
action research arm test scoring
0-57
-increase score=increase ability
-scored on a 4 pt scale
3=task performed w/i 5 sec with appropriate posture and movement
2=great difficulty or greater than 5 sec
1=task partially completed w/i 60 sec
0-subject unable to complete any part within 60 seconds
Fugl-Meyer Population
stroke
Fugl-Meyer Facts
- UE and LE assessment
- reflexes
- flexor/ext synergies
- mvt out of synergies
- sensory
- balance
- PROM
- pain with PROM
Fugl-Meyer Scoring
0-226
0-can’t do
2-does independently
increase score=better
PASS pt population
Postural assessment scale for stroke
-1st 3 months post stroke
PASS scoring
0-36 12x4 pt items -grade performance in situations of varying difficulty in maintaing or changing a lying, sitting, or standing posture 0=unable 3=normal increase score=better
Stroke Impact Scale Facts
- strength
- hand function
- ADL/IADL
- mobility
- communication
- emotion
- memory and thinking
- participation/role function
Stroke Impact Scale scoring
59Qs-self report
5 pt likert scale
0-100
increase score=better
Tardieu spasticity scale pt population
- CP
- adults with TBI
- stroke
- adults with intellectual and multiple disabilities
Tardieu Scoring
-sitting for UE
-supine for LEs
3 speeds-
1. slow as possible
2. speed of gravity
3. fast as posible
0=no resistance
5=immobile
increase score=increase tone
rd. acute stroke management guidelines
review
Hemiplegic UE
- tx must be a team approach unless the team prioritizes 1 member
- communication is key
- PAIN is NOT NORMAL!
- pain occurs in 70-845 of pts with stroke
- typically present with movement, but may evolve to be present at rest
Inferior subluxation
- lack of active mvt
- downward rotation of the scapula with the glenoid foss moving vertical to downward
- loss of passive locking mechanisms
- stretching of soft tissue and jt capsule
Anterior subluxation
- new control is unbalanced
- side bending of the head toward the affected side
- downwardly rotated scapula is pulled superiorly
- see extension of humerus with IR
Superior subluxation
TONE
- flexion synergy of UE
- elevation of shoulder
- scapula elevated and abducted
- head of humerus becomes pressed up against acromion
- distinct lack of isolated humerus vs. scapula mvt
- may lead to impingement
Impingement
- marked spasticity
- superior sublux
- muscle imbalance
- loss of scapulohumeral rhythm
Passive mgt w/ 0/5 strength, hyptonia/flaccidity, 2 cm inf. sublux
- use a sling in standing
- Giv Mohr
- Bobath
- neither sling keeps elbow flexed or humerus IR, both provide more support to shoulder and scapula
Tx for 0/5 strength, 2 cm inf sublux
- use e-stim to help reduce subluxation (see document with instructions)
- teach awareness of UE with bed mobility
- PROM with massage–all joints, shoulder flex limited to 90 degrees
- WB
- use UE to stabilize objects (hold down a piece of paper while writing, etc)
tx of 1-2/5 strength with 2 cm inf sublux
- PNF scapular patterns
- fluidotherapy with physical and mental practice
- WB (isometric)
- sling for standing
- e-stim
tx for 2-3/5 prox>distal strength, normal tone, no sublux
- pt uses arm for EVERYTHING
- distal UE–self ROM, massage, isometrics
- proximal UE–arom, theraband
- PNF patterns
- WB
- functional tasks
- constraint induced PT
tx for 1-2/5 prox>distal, MAS=2, 1 cm ant sublux
- e-stim for subluxation
- AAROM using other UE
- WB isometrically distally
- PNF
- WB prone on elbows/quadriped
- FES
- aggressive PROM to capsule
- manual support and guidance
- bi-manual activities
- use arm for stabilizing activities
3-4/5 prox>distal strength, MAS-2, P with shoulder flex/abd AROM >120
- don’t push through pain
- enforce shoulder ER
- PRE
- shoulder ER and depression
- scap add and retraction
- try scapular taping
tx for 0-1/5 prox strength, MAS=4, unable to isolate ms groups
- PROM to maintain shoulder extension
- WB with inhibition to biceps and facilitation to triceps
- rhythmic rotation
- POE WB
- scap retraction
- e-stim to triceps
Shoulder hand syndrome S/S
12-25% of pts with UE P!
- 1st S/S=hand edema and tenderness
- then w/ localized tenderness to shoulder during ROM
- pain is primarily with movement
- pt begins guarding the UE more, tightness in FL, add and IR develops
Later stages of shoulder-hand syndrome
- sympathetic vasomotor changes–warmth, redness, glossy skin
- trophic changes in fingers
- more atrophy and contraccture
- skin changes–cool, cyanotic, damp
- marked atrophy of thenar and hypothenar muscles
Shoulder-Hand synrome tx
- osteoporotic changes occur
- few pts experience recovery at this stage
- prevention is KEY
- prevent microtrauma
- if any P! or edema develops–address immediately
- NEVER push through P!
Stage I Shoulder-Hand Syndrome
- limited shoulder ROM
- swelling of dorsum of hand
- skin becomes shiny
- limited ROM of finger flexion
- hypersensitive to touch, pressure, variations in mvt
- P! in wrist extension
- can last several weeks
Stage II Shoulder-Hand Syndrome
- shoulder P! subsides and ROM increases
- limitation less P!
- edema subsides, but fingers become stiffer–in ext of MP jts specifically
- sensitivity decreases
- osteoporosis seen on x-ray
Stage III Shoulder-Hand Syndrome
- cannot reverse here
- progressive atrophy of bones, skin, muscles
- lmitation of hands, wrists and fingers increases leaving hand painless, but useless, atrophied and clawed
Possible causes of shoulder-hand syndrome
- if in improper sling
- failure of pumps in shoulder/hand
reduce edema
- elevation
- ice slush or contrast baths (3-5 sec) up to wrist
- retrograde massage
- string wrap or coband wrap
Maintain or increase ROM of MCP, PIP, DIPs
- PROM without force
- AROM
- facilitationof gross grasp (do NOT facilitate a spastic grasp)
Maintain wrist in slight ext (no more than 30 degrees)
- simple cock up splint allows for MCP flexion, put on with ace wrap instead of straps
- use a W/C lap board with towel or foam wedge
Encourage movement of involved shoulder
- ask pt to move arm in forward flexion only to pt of discomfort
- check to make sure scapula is gliding before ROM
- PROM only to point of pt discomfort
- in supine, have affected arm remain at side and move body against the arm
Bed positioning
- pt positioned on hemi side
- check to make sure scapula is protracted
- pt should not be on GH jt
- pt may stay as long as no discomfort or skin intolerance
AVOID
- any device that puts arm in flex, add, IR
- holding onto arm during repositioning
- any device which keeps MCP in ext
Classification of ambulators
- physiologic-therapeutic not functional (50 ft)
- limited household, low endurance (150ft)
- unlimited household
- limited community–limited by endurance or speed
- community
Velocity of household ambulator
0.4m/s
To be a community ambulator need ability to…
- navigate change sin surface levels and terrain
- avoid obstacles
- endure distance
- manage lighting changes
- manage distraction
- manage load carrying
- handle weather changes
- walk with sufficient velocity
Velocity of limited community ambulator
0.4-0.8m/s
Velocity of a community ambulator
1.2-1.4 m/s
Velocity to cross street at stoplight
1.2m/s for 13-27 m
ability to negotiate a 7-8 inch curb independently
