Lecture 6: Stroke management 2025 Flashcards
NOTE:
Home health = does not set multiple disciplines
Inpatient = multiple disciplines
* PT, OT, Speech
Stroke Time frames
Acute - Recovery (medical), early mobilization, prevent learned nonuse, education
* however, dont want to do too much too soon - brain needs time, can make things worse
Subacute - rehab setting?
Chronic - typically more than 6 months post stroke, varies, 3-6 months
* this is a hard pt because if deficits are already ingrained they’re harder to turn around
w/ stroke you can have so many deficits
pseudobulbar effect = when they laugh/cry inappropraitely
Brunstrom stages are for what?
motor recovery following stroke
Stage 1 brunstrom
Extremeitites flaccid. Typically occurs immediately following lesion, and typically persists hours to days
* would not do modified ashworth here
Stage 2 brustrom
Minimal volitional motions are possible and associated reactions are seen in synergistic patterns. Spasticity begins to develop
Stage 3 brunstrom
Voluntary control of the synergies is possible through partial range. spasticity will peak at this stage
Stage 4 brunstrome
Limited motions combining the synergistic movements are possible. Spasticity begins to decline
Stage 5 brunstrome
More advanced movement combinations are possible as spasticity continues to diminish
* so start getting better movement
Stage 6 brunstrome
Isolated movements are possible with near normal coordination. Spasticity has declined and amy only be evident w/ increased speed of movement
synergy patterns
pt has lesion to R hemisphere
* what is is hemiplegia/paresis?
* What side is sensory loss?
L sided hemiplegia/paresis
L sided sensory Loss
What side of the brain does the lesion have to be in for the pt to be quick and impulsive
R brain lesion = quick and impulsive
* poor judgement / unrealistic
* unable to self correct w/ cueing
What side is the lesion on if the pt has poor insight, awareness of impairments, denial of disability (increased safety risk)
Right
What side is the lesion on if the pt has neglect?
most likely R sided lesion (left side unilatearl neglect) - ignoring that side
Lesion on what side of the brain leads to issues with perception/knowing where they are at
R side
What side is the brain lesion on if the pt has difficulty w/ abstract reasoning / problem solving?
R
What side is the lesion on if the pt has a difficult time grasping the whole idea
R
What side of the brain is the lesion likely on if they have memory problems?
R
What side of the brain is the lesion on if the pt has difficulty w/ the ability to percieve emotions
R
What side of the brain is the lesion on if the pt has difficulty w/ expression of negative emotions?
R
KNOW: w/ R sided brain lesion they’ll have fluctuations in task performance
Know w/ Left sided lesion
* Right side hemiplegia/paresis
* Right side sensory loss
w/ right sided lesions we see more visual-perceptual impairments, while w/ L sided we see more speech and language impairments
What 3 kinds of aphasia do we see w/ left sided lesions?
Nonfluent (broca’s) aphasia
Fluent (Wernicke’s) aphasia
Global - both
aphasia defintion
a language disorder that affects a person’s ability to communicate effectively
A lesion on what side of the brain would lead to the pt having difficulty processing verbal cues / verbal commands?
Left
A lesion on what side of the brain leads to the pt having slow, cautious behavior style?
L (exact opposite of the impulsivity w/ R lesion)
A lesion to what side of the brain leads to the pt being disorganized?
L
A lesion to what side of the brain leads to the pt being very awayre of impairments and the extent of disability?
L (exact opposite of right)
Which side of the brain is the lesion in if the pt is having memory impaorments associated w/ language?
L (makes sense, this is the side w/ all the aphasias)
A lesion to what side of the brain leads to perseveration?
L
NOTE: will also have
* Disorganized problem solving
* Difficulty initaiting tasks, processing delays highly distractible
Which side of the brain is the lesion in the the pt has difficulty w/ expression of positive emotions?
L
* opposite of R
Apraxia defintion
a neurological disorder that affects the ability to plan and execute purposeful movements
* difficulty planning and sequencing movements
motor planning is impacted
A lesion to what side of the brain leaads to apraxia?
L
* ideational
* Ideomotor
deficits common w/ L and R brain lesions (can be either)
* Visual field defects: homonymous hemianopsia
* Emotional abnoramlities: Labilty, apthy, irritability, low frustration levels, anxiety, depression
* Cognitive deficits: confusion, short attention spasn, loss of memory, executive functions
A pt has a lesion on what side of the brain if they are impulsive, have poor judgement, and this leads to an increased safety risk
R
PASS = can use in any of the 3 settings, but best for acute/in patient
Functional reach test = any of the 3 settings
the below shows what settings you can use different tests
NOTE: not just talking about stroke w/ this table
DGI = okay for out pt
ashworth any setting but don’t do w/o tone or super rigid and know that already
PT interventions: - stroke - remember to check vital signs because may have had a hypertensive issue leading to this
Restorative
* think restoring function of arm post stroke
Preventative
* ROM = to prevent contratcutes w/ stroke
Compensatory
* compensating for something thats actually lost
* Think a wheel chair for leg loss
* think more assistive devices / things changing mobility
because strokes can present so differently
Rehab bridges the gap between maladaptive behavior and independent function
* we stop maldaptive behavior
Explain a remedial apprach (stroke intervention)
Bottom up appraoch
Focused on the pts deficits and retraining behaviors
Recovery of underlying skills (bottom) to generalize these skills to function
So start w/ the most basic things and build to a goal essentialy
* more focused on impairments
* think getting back strength / Rom focused at gaining ambulation
Explain the adaptive/compensatory stroke intervention approaches
Top down apprach
Direct training in the functional deficit
not targeting directly the impairments - basically ignoring the imapirments focusing on function
* neuro is more fucntion focused - so i guess you would use this one more - no right or wrong answer here
Which appraoch focuses more on deficits the remedial or adaptive approach?
Remedial
DGI and Pass fall where on ICF table?
Activity
The perception, attention, thinking, and memory
* act of knowing
Cognition
Integration of sensory impressions into psychologically meaningful information
* Cognition and visual subsets
Perception
look under cognition and see what deficits they could potentailly have if cognitiion is impacted
* same thing w/ perception
perception deficits = agnosias = not perceving body as they did before
* spastial realtions = discrimitive tasks - think losing depth perception
types of attention fall under cognition (the act of knowing) what kind of attention is this: easily distracted by any activity in the environment: responds to background noise: difficulty attending to therapists directions while in a croweded therapy clinic
Selective
types of attention fall under cognition (the act of knowing) what kind of attention is this: Difficulty with details; stops a task midway; stops doing exercises after six reps when asked to do 15
Sustained
types of attention fall under cognition (the act of knowing) what kind of attention is this: unable to do two things at one time: complete dressing and answer questions about weekend plans
Divided
types of attention fall under cognition (the act of knowing) what kind of attention is this: unable to return to original task if interrupted: during cooking activity, therapist stops patient to correct use of mobility device; patient requires cue to resume cooking task
alternating
Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: Skills learned for one task can generalize to others
Retraining
so maybe breaking a task down and working on a walking peice and then we want to generalize it to longer distance walking. Breaking something down.
Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: Promote normal CNS processing of sensory information to elicit specific desired motor responses
Sensory integrative
do more sensory retraining (she doesnt do sessions like this)
Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: Practice every activity in its true context in order to recover function
Neurofunctional
Not always easy to do depending on ur pts level of assist. more working functional i guess
Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: direct repetitive practice of specific functional skills that are impaired
Rehabilitative/compesatory (functonal)
more functional - kind of like blocked practice - keep doing sit to stands etc…
Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: training individuals with brain injury to structure and organize information
Cognitive rehab/quadraphonic
more cognitive practice
What are our 4 kinds of attention deficits?
* damage to these 4 areas in the brain can lead to deficits w/ these?
Types
1) sustained
2) Focused/selective
3) Alternating
4) Divided
Lesion area
* Reticular formation
* Sensory systems
* Limbic system
* Frontal lobe
Memory impairments can be immediate recall, short-term memory, or long term memory
* what 5 areas can the lesion be in to have memory problems?
Lesion area:
* Frontal
* Parietal
* Temporal
* Occipital
* limbic
so like everything lmfao
some thigns that could help pts w/ memory impairments
* getting info in smaller chunks (not overhwleming them w/ too mcuh verbage)
* routine
* real life activities to understand a concept (so releate it to them)
* store items into the same lcoation
* go back over stuff you went over in session
* Whole list on next slide
Executive function impairments
Volition, planning, purposive action, effective performance
Lesion area =
lesion = frontal and prefrontal cortex, subcortical structires
vision test if they can’t register one side of body = do visual field tests
* note not somethign wrong w/ eyes but sensory perception
The inability to recognize or make sense of information despite intact sensory capabilities
Agnosia
* visual
* aduitory
* Tactile/asterognosis
What is a visual agnosia?
Difficulty recognizing an object (even though they can see it fine, they just can’t recognize it)
* think seeing someones face but not being able to recognize what it is
* the perception is damaged, not the sensory
Explain auditory agnosia
Can hear it (have sensory) but not understand
* so they cant make meaning out of sensory environment - sensory is intact
Explain tactile/astereognsis agnosia
Can feel something but don’t know what it is
Inability to perform purposeful movement despite intact abilities
Apraxia
What is ideomotor apraxia?
Unable to perform on command, but can at other times
* so sometimes they can do the motor, just not when you need them to
* “ask them to stand up” and they can’t do it. But other times they will be able to stand
What is ideational apraxia?
Does not understand the concept (ex - brushing teeth)
* they might put the toothbrush in hair
* doesnt understand the concept of the motor movement
The inability to register and integrate stimuli and perceptions from one side of the body or environment, awareness impaired
Neglect
they are very teachable - can teach them to constantly look at that side
Complete lack of awanress, or denial, of a paretic extremity as belonging to the person, or a lack of insight concerning, or denial of, paralysis and disability
Anosognosia
so i guess worse than neglect - they dont even register it / deny whats going on
* difference is that they’re denying that that side is even involved
Since they are denying that its even going on these pts are very unteachable - these pts are harder to rehab
where is the lesion for apraxia?
Frontal and parietal lobe
What are our 3 kinds of aphasia?
1) Brocas/non fluent/expressive - meaning speech is choppy - maybe one word - not speaking normally - expressive ebcause they’re having a hard time talking and physically expressing themselves
2) Wernikckes/fluent/receptive - talking a ton. (fluent) but doesnt make any sense
3) global - mix of both
What is dysarthria?
Difficulty speaking
* think dys articulatiuon
What is dysphagia?
Difficult swalling
Type of aphasia that is fluent / receptive
Wernickes
Type of aphasia that is non-fluent/expressive
Brocas
type of aphasia that is both receptive and expressive
Aphasia
which kind of aphasia has loss of auditory comprehension with fluent speech and word substiutions; where reading and writing are impaired
Wernicke
* know: this is lesions in posterior portion of temporal gyrus
* considerd fluent
so not going to give this pt something to read - going to have to give them a gesture.
Which kind of aphasia has intact comprehension of oral and written language with difficulty producing speech, articulating, naming, and writing; limited vocab.
Broca aphasia
* considered non fluent
* Lesions are anterior lesions, third frontal convolution (left hemisphere)
so you can write things to these pts if wanted
* want it to be a Y/N answer because they’ll have a hard time responding
Which kind of aphasia describes a severe aphasia that involves loss of production and comprehesnion of language including writing; usually results from a large MCA infarct
Globa aphasia
* considered non fluent
Which kind of aphasia has fluent speech with difficulty naming, repeating words while retaining written and oral comprehension
Conduction Aphasia
can be fluent or non fluent
This is for dysarthria (different than aphasia)
* difficulty physically speaking
* Adequate lighting, take advatngae of visual cues - you want to be able to hear the pt
* dont want to communicate for 30 minutes straight w/ them - would be too taxing on them
* maybe communicate w/ other methods like writing
* encourage pt to take their time when they’re talking
Knowledge check: Type of aphasia w/ fluent speech but not inteligable
* Wernicikes, receptive (need to know the receptive part)
* so know both names because she tested here on it
NOTE: That visual aphasia is not a visual field cut, its a perception issue
however, you can teach both to do visual scanning etc… just need to learn that they arent aware of one side of their body
parietal lobe?
Spatial relations disorder = where person recieves their body in space
* people often have a hard time recignizing they have a problem when they have perceptual deficits like this
Figure-ground discrimination, form discrimination, spatial relations, position in space, topographical disorientation, depth and distance perception, vertical disorientattion
Lesion area: Parietal, occipital, temporal
man putting on shirt below
* all those areas in the brain have to be active to put the shirt on
* which i guess is kind of a spatial relations thing
deficit in sensory processing = simple tasks become hard
Depth perception: ability to judge the distance between objects or between objects and self
Figure ground: distinguishing objects in the foreground from pattern in the background
* think finding an object thats in a junk drawer / purse
Spatial relations: Ability to interpret where objects are in space and how they releate to self and to other objects
* where objects are in space and how they relate to self/other objects
* “Where am I in relation to walker”
Right/L discrimination: Ability to understand and apply concepts of right and left personal: left and right as they releate to own body parts extrapersonal: how left and right are interpreted in the environment
She emailed us a different verson of this slide
named for vision field thats lost
* If I have left hemonimouys hemiansopsia I cannot see the left visual field
different than neglect because they litteraly dont even sense it
visual scanning
neglect = awareness issue
* dont know they have it a lot of the time
Visual field loss = processing issue
* easier to treat - use scanning in direction of loss
* are aware they have this
Can help w/ visual scanning by:
* Visual search board
* Visual scan on wall/door
* Technology
* Scavenger hunt- grocery store, cabinets
* Card games, word search
* walking
can also do oculomotor exercises
Field expanders/prisms - equipment that helps shift images from the cut field
Prism glasses (for tx of diplopia)
* Refract light and focus it on the same place in both the retinas
* Helps the brain to produce a single image leading to clearer vision
* Changes the way light enters the eye and brain, therefore affecting the NS
* Can start w/ tape on glasses before getting prism glasses
Is neglect an awareness of perception problem?
* Tx?
Awareness - the sensory is intact, the just don’t know what they’re seeing (which is why its an awarness problem)
Treatment: Scanning to increase attention
* 1) - present all information on involved side
* 2) Present all information on involved or neglected side
* When to use each appraoch? - if it just happened use option 1 to make them functional. Eventually want to challenging them and teach them to scan to be more attentitve
Moving involved side arm/leg within neglected environment
Image: left neglect, right
Is this right or left neglect?
* meaning which side of the brain is impacted
Left neglect, right brain damage
differeniate neglect from visual field cut questions
Both will look like they’re having visual field loss because they’re unaware of that side
neglect = tyicallu L side because its on the R side of brain
Strategies to maximize interactions when treating pt w/ unilateral neglect (left sided)
* Improve comprehension of information by having the pt read along using his/her infex finger a guide
* During transfers and mobility, cue the pt to locate and safely position the left limb before movement
* Anchor the left side of the pts environment by placement of a brightly colored item or border. Ask the pt to look to the left until the border is seen
* Utilize functional, meaningful activities when addressing issues of neglect. This assists in generalization of skills
* Conduct therapeutic activities in natural settings
* Improve the pts awareness of deficits by providing direct feedback during activities
Visual field cut is a problem w/ awareness or information processing?
Visual field processing
* don’t have the sensory at all
Neglect is a problem w/ awareness or information processing?
Awareness
* they’re processing the sensory and just not doing anything w/ it
tx for visual field cut and neglect = scanning (compensatory tx)
Strategies to structure clinical communication interactions
Altering the presentation of information for pts w/ attention deficits
* Establish and maintain eye contact w/ your pt before presenting directions
* Offer instructions in small chunks
* Slow the rate of presentation by asking the pt to repeat (in their own words) or demonstrate understanding of instructions before providing additional information
* When family is present or when you are participating in a cotreatment, avoid interruptions and designate one person to dl all the instructing
* Incorporate short breaks into tx that involve a high level of attention in order to manage fatigue
* Avoid interrupting the pt in the middle of a task. Limit unncessary converstations
* Stop the pt to provide additional information during natural breaks between steps
knowledge check: in which deficit does the pt experience denial of the deficits
Agnosagnosia
Locked in syndrome:
* acute hemiparesis rapidly progressing to tetraplegia and lower bulbar paralysis - the pt cannot move or speak but remains alert and oriented
* what imaired horizontal or vertical eye movements
* occulsion of what system causes this
* does this pt have the potential to recover
horizontal eye movements are impaired but vertical eye movements and blinking remain intact
Occlusion of the vertebrobasilar system - so vertebrobaslar stroke
Patient can demonstrate some improvements over time
w/ Pusher syndrome
* know: its a behavior phenomenon
* leaning and active pushing toward the hemiplegic side or nonhemiplegic side?
* do they have resistance to any attempot at possive correction of posture towards midline or across the body toward the nonaffected side
Typically R or L brain?
* is recovery process fast or slow?
Leaning and active pushing toward the hemiplegic side in all positions using the nonparetic arm and leg
* they are pushing toward the hemiplegic (impacted) side - so toward more involved side / weaker side
Resistance to any attempt at passive correction of posture towards midline or across the body toward the nonaffected side
* so you can’t just push them back to center
Also called ipsilatearl pushing, contraversive pushing, pusher behavior
Research:
* 80% R brain lesions
* “Graviceptive” neglect - she didnt know why this word was used
* Involvement of thalamus? - they arent sure so dont memorize
* recovery process is low
think of it like not having any muscles on the weak side so the ones that are actually firing drag us over there
note: they are pushing w/ their stronger side toward weaker side (falls)
Pusher syndrome patient observation
* sits or stands asymmetrically
* Most of the weight shited toward the weaker side
* Uses the stronger UE or LE to push over to the weaker side leads to instability and falls
Considerations EXAM
* pt will push more forcefully if therapist tries to passively correct posture - she said this is on exam
* training needs to emphasize upright with active movement shifts toward stronger side (opposite way they’re shifted)
* environmental prompts
* Use visual cues and cognitive strategies
Considerations - Tx
EXAM
Typical stroke
* Treat from hemi side - so target weaker side w/ tx
* Stabilize hemi leg
* Tone management and wt bearing
* Forced use
Hemineglect
* treat from front and progress to hemi side - because they litteraly cant see if you if you’re on the impacred side - teach them to be aware of that side
* Use of mirrors to engage hemi side
* Stabilize hemi leg
* Tone management and wt bearing
* Forced use
Pusher syndrome
* Treat from front - cant pick a side, thats a safety concern - EXAM
* Stabilizing force from front, back, or circumferentially - NOT ON THE SIDE!!!!!
* Use of vertical cue (wall, door frame)
* Use of physical cue (wall, person)
* remove pushing ability or use it to your advantage (self tone management) - if they’re pushing to weaker side you can work on joint approximation by utilizing this already done movement
Cerebellar damage = ipsilateral
Cerebellar damage
* can come from a cerebellar stroke, spinocerebellar ataxia, lesions, infectious disease complications
* Dizziness/vertigo, nausea.vomiting, ipsilateral ataxia and hypotonia, nystagmus, impaired balance, incoordinated gait and speech
* Symptoms are ipsilateral (same side as damage)
* Strength is not normally the issue, its movement coordination
Remember theres speech deficits w/ this as well dysarthria
NOTE: these pts are very high fall risks
for post stroke
CIMT = constraint induced movement therapy
not going to post specific questions on gait
* must knwo normal gait to recignize abnormal gait
estem for fibular/personeal nerve?
outcomes less sucessful for pts w/
* advanced age
* Severe motor impairments
* Persistent medical problems
* Impaired cognitive function
* Severe langauge disturbances
* Severe visospatal neglect
* lower SES
Depression: Single major risk factor for mobility decline
knowledge check: hemineglect (neglect to one side) should be treated from which side initally?
Treat from the front
