Lecture CVA impairments Flashcards
brunnstom stages or recovery (7)*** (whether spasticity is increasing, decreasing, synergy patterns)
- Stage 1: Flaccidity, no movement
- Stage 2: Minimal voluntary movement, associated reactions; spasticity begins to develop
- Stage 3: Voluntary control of movement synergies; spasticity peaks in severity!
- Stage 4: Mastery of some movement combo outside of the synergies; spasticity begins to decline
- Stage 5: Difficult movement combo are learned; synergies lose their dominance
- Stage 6: Spasticity disappears, isolated joint movement & coordination achieved
- Stage 7: Normal movement
Flexion Synergy (UE)
I remember it as flexing my biceps
Strongest component in *
Scapular retraction/elevation Shoulder abduction/ER Elbow flexion* Forearm supination Wrist/finger flexion
Flexion Synergy (LE)
I remember it as about to stomp on a bug 45 degrees from me
Strongest component in *
Hip Flexion*/abd/ER
Knee flexion
Ankle DF/IV
Toe DF
Extension Synergy (UE)
Strongest component in *
Scapular protraction Shoulder adduction*/IR Elbow extension Forearm pronation* Wrist/finger flexion
Extension synergy (LE)
I remember it as doing a ballet backward kick
Strongest component in *
Hip extension, adduction, IR
Knee extension
Ankle PF*/IV
Toe PF
Typical “Hemi Arm Posture”***
Combination of flexion and extension patterns • Shoulder ADD (Extension) • Elbow flexion (Flexion) • Forearm pronation (Extension) • Wrist flexion (Flexion)
Typical “Hemi Leg Posture”***
Combination of flexion and extension patterns
• Hip flexion and adduction
• Knee extension
• Ankle plantarflexion
Typical Right Sided CVA deficits based on hemisphere
less aware of deficits left sided neglect agnosia visual spatial disorders poor judgement fluctuations in performance
Typical Left Sided CVA deficits based on hemisphere
Aphasia no neglect difficulty with verbal commands slow and cautious aware of impairments disorganised problem solving apraxia
Spasticity
Lack of inhibition from higher levels causes:
- An increase in stretch reflexes (especially in the antigravity muscles)
- Exaggerated flexor muscle response following noxious stimuli
- Flexor vs. Extensor spasticity
Spasticity
Symptoms
Hyperreflexia
Clonus
Spasms
Pain
Contractures: What is it
Shortening of Muscles, Tendons, Ligaments, Joint Capsule
Leads to restriction in ROM
Contractures: Secondary to:
Lack of muscle opposition
Hypertonicity
Lack of normal positioning
Bowel and Bladder Incontinence: What is more common than incontinence
Constipation and impaction more common than incontinence
Bowel and Bladder Incontinence
Assessment:
- Assess for dysuria
- Consider Foley catheter
- AVOID BACKWASHING
- Do not lift bag above level of bladder
- Bowel and bladder management and training
72% of individuals with stroke experience…. and it leads to….
shoulder pain
Leads to:
- Adhesive capsulitis
- Traction/compression neuropathy
- CRPS -complex regional pain syndrome
- Bursitis/tendonitis
- Rotator cuff tear
- HO
Aerobic Capacity
- Twice the O2 consumption/uptake seen in walking
- CAD comorbidity may by biggest factor in debility and reduced activity
tolerance - Inverse association between aerobic fitness and stroke mortality regardless of
other factors
Borg RPE
Very light
Hard
Very Hard
Exertion Scale
9
15
17
Cognition and arousal to determine
pt.’s present capabilities, ability to
contribute to POC, consents etc.
- Memory Deficits
- Attention Deficits
Dysarthria
Impairment of _____* secondary to ______
Impairment of speech production 2° damage to the CNS or PNS,
causing oral motor weakness, paralysis, or incoordination of the motor-speech system.
Dysarthria
Deficits in….
Lesions affecting CN… (2)
Caused by…
- Deficits in swallowing
- Lesions affecting CN IX (Glossopharyngeal N.) & CN X (Vagus N.)
- Causes:
Delayed triggering of swallow reflex
Decreased pharyngeal peristalsis
Decreased lingual control
Incoordination
Result of:
- Cerebellar or BG involvement
- Proprioceptive losses
- Motor weakness
- Ataxia, esp. with cerebellar disorders
- Impaired stretch reflex response that normally allows automatic adaptation of
mm. to postural/movement changes
Emotional lability:*
unstable or changeable emotional state,
characterized by a pathological rapid change from laughing to weeping with only slight provocation.
(R) CVA:
Difficulty with…
Described as…
Major Issue…
- Difficulty grasping the whole idea or the overall organization
of a pattern or activity - Described as: indifferent, quick, impulsive, euphoric, pt. overestimates their
ability while minimizing their problems. - Major Issue: SAFETY!!
(L) CVA:
Difficulty with…
Described as…
- difficulty with processing info in sequential/linear manner
- Described as: slower, negative, cautious, uncertain, depressed, anxious
Somatagnosia:
What is it?
Difficulty performing …
Lesion located at…
Somatagnosia: lack of awareness of the body structure & the relationship of body parts in oneself or in others.
Difficulty performing transfers; following directions re: arm position
Lesion: Dominant parietal lobe, or posterior temporal lobe
Unilateral Neglect (spatial neglect): What is it? Types: (2) Typically affects where in the body? Lesion located at...
Unilateral Neglect (spatial neglect): inability to register and to integrate stimuli & perceptions from one side of the body & the environment.
Types: Personal, peri-personal, & extrapersonal
Typically affects the left side of the body; sensory loss compounds the problem.
Lesion: non-dominant parieto-occipital area
Right-left discrimination:
What is it?
Lesion located at…
inability to identify the R or L side of one’s
own body or the examiner.
Lesion: parietal lobe of either hemisphere
Finger Agnosia:
What is it?
Lesion located at…
inability to identify the fingers of one’s own hand;
correlates highly with poor dexterity
Lesion: parietal lobe of either hemisphere
Anosognosia:
What is it?
Lesion located at…
severe condition including denial, neglect and lack of awareness of the presence or severity of one’ s paralysis.
Lesion: non-dominant parietal lobe
Figure -ground discrimination:
What is it?
Lesion located at…
inability to visually distinguish a figure
from the background in which it is embedded.
Lesion: non-dominant parietal lobe
Form Consistency:
What is it?
Lesion located at…
inability to perceive or to attend to subtle
differences in form and shape.
Lesion: non-dominant parieto-temporo-occipital region
Spatial Relations Deficit:
What is it?
Lesion located at…
inability to perceive the relationship of one
object in space to another object, or to oneself. Difficulty crossing midline. i.e. drawing a clock, setting a table
Lesion: non-dominant parietal lobe
Position in space:
What is it?
Lesion located at…
inability to perceive and to interpret spatial
concepts such as up, down, under, over, in, out, etc.
Lesion: non-dominant parietal lobe
Spatial Memory Deficit:
What is it?
Lesion located at
impaired memory of location of
objects/places (ie. Furniture in home)
Lesion: non-dominant parietal lobe
Topographical Disorientation:
What is it?
Lesion located at…
difficulty in understanding &
remembering the relationship of one location to another, unable to trace path/route
Lesion: non-dominant occipito-parietal lobe
Depth and Distance Perception:
What is it?
Lesion located at…
inaccurate judgment of direction,
distance and depth.
Lesion: non-dominant occipital lobe
Vertical Disorientation:
What is it?
Lesion located at…
distorted perception of what is vertical; causes
imbalance & distorted midline orientation
Lesion: non-dominant parietal lobe
Agnosia: What is it?
Agnosia
Inability to recognize familiar objects using one or more of the sensory
modalities, while often retaining the ability to recognize the same
object using other sensory modalities.
Three types of Agnosias and where the lesions are
Visual Agnosia: Lesion in occipito-temporo-parietal lobes of either
hemisphere
Auditory Agnosia: Lesion in dominant temporal lobe
Tactile Agnosia: Lesion in occipito-temporo-parietal lobes of either
hemisphere
Visual agnosias:
Visual Object Agnosia
inability to recognize & name common objects
brush, key, comb
Visual agnosias:
Simultanagnosia
inability to perceive the whole or the “big picture”,
only sees 1 element of an object at a time
decreased visual span - tubular vision
Visual agnosias:
Prosopagnosia
facial agnosia, inability to recognize familiar faces
Visual agnosias:
Color Agnosia
difficulty recognizing names of colors
Apraxia: What is it? Where it is seen in the brain? Often accompanied by? Lesion located at...
Disorder of voluntary learned movement; inability to perform purposeful movements.
Seen in L hemisphere lesions more than R; often accompanied by aphasia
Lesion: Premotor frontal cortex of either hemisphere, Left inferior
parietal lobe, corpus callosum
Types of Apraxia:
Ideomotor
Breakdown between concept & performance; movement is clumsy/slow
i.e. Ask a pt to brush his/her hair
(Can’t do on command)
Oral Apraxia
subtype of ideomotor apraxia in which buccofacial muscles cannot produce purposeful movement.
Types of Apraxia:
Ideational
Failure in the conceptualization of the task; incorrect tool
use
ie. Present pt with a toothbrush & toothpaste 🡪 “mouthing”
toothpaste
Apraxia
-Like syndromes (2)
Not true apraxias; more associated with R hemisphere lesions
Includes:
Constructional Apraxia
Dressing Apraxia
Constructional Apraxia:
Difficulty in recognizing parts to a whole
secondary to faulty spatial analysis & conceptualization of the task.
ie. Assembling a sandwich
Dressing Apraxia:
inability to dress oneself properly owing to a
disorder in body scheme or spatial relations.
Secondary Impairments
Psychological Problems:
more severe w/
includes…
more severe w/ (L) CVA
Frustration, anxiety, depression or denial.
Cognitive deficits influence behavior; pt irritable, inflexible, hypercritical, impatient, impulsive
Secondary Impairments
Decreased ROM/contractures/deformity
↓ flexibility, disuse atrophy, edema, pain
UE contractures: elbow, wrist, finger flexors & supinators/pronators
LE contractures: PF/IV; depends on dominant synergy
Alters alignment: ↑ energy expenditure & altered patterns of movement
Secondary Impairments
DVT/PE:
diagnosed by
Treated with
diagnosed by ultrasound
Treated with anticoagulants and antiplatelet agents
Secondary Impairments
Pain: Causes
Mm. imbalances Improper movement patterns Musculoskeletal strain Poor alignment Thalamic Syndrome: initial sensory loss on contralateral side, changes to severe burning pain.
Secondary Impairments
Shoulder subluxation: due to
paresis, loss of muscular tone & proprioception; Ligaments and capsule act as supporting structure
Secondary Impairments
CRPS:***
swelling and tenderness of the fingers, hand and shoulder
Sympathetic vasomotor changes: warm, red, glossy skin, trophic changes of fingernails
Later stages: contraction of hand in “intrinsic minus” position
Secondary Impairments
Deconditioning:
stroke as a result of cardiac disease requires diligent monitoring
Poor activity tolerance 2° cardiorespiratory system & musculoskeletal system
↓ CO, cardiac compensation and serious rhythm disorders
Sensory Assessment CVA Considerations
Superficial Sensation:
Deep Sensation:
Superficial Sensation: Light Touch Test intact before impaired Body part rather than dermatome Deep Sensation: Proprioception and Kinesthesia Test intact side first
Motor Assessment
- Minimize position changes. Complete all testing possible in each position - Initiate strength tests at level 3/5 - May document Motor Control description vs. MMT (or both)
