Neurological Flashcards
What pathophysiological mechanisms underpin Ischemic Stroke (Specifically PACI) and the associated pain response?
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blood supply to an area of brain tissue is reduced, resulting in tissue hypoperfusion. There are several potential mechanisms which can result in an ischaemic stroke including:
* Embolism: an embolus originating somewhere else in the body (e.g. the heart) causes obstruction of a cerebral vessel.
* Thrombosis: A blood clot forms locally within a cerebral vessel (e.g. due to atheroma rupture) which travels to the brain.
* Systemic hypoperfusion: blood supply to the entire brain is reduced secondary to systemic hypotension (e.g. cardiac arrest).
* Cerebral venous sinus thrombosis: blood clots form in the veins that drain the brain, resulting in venous congestion and tissue hypoxia.
PACI
* A PACI (Partial Anterior Circulatory Infarct) is just one classification of stroke that affects part of the anterior circulation supplying one side of the brain (Tu et al, 2018). See the Bamford Stroke Classification >
* This could be an obstruction that occurs in an anterior or middle cerebral artery. However, the middle cerebral artery (MCA) is the typical culprit in acute stroke. See the Circle of Willis >
* The MCA supplies blood to part of the frontal, temporal, and parietal lobes; as well as the curate nucleus and thalamus. In PACIs, the severity of the stroke may be limited due to the Circle of Willis allowing for possible collateral circulation.
PAIN
* Pain after stroke is often undiagnosed and undertreated. It can be difficult to recognise due to the effects of stroke such as aphasia, dementia, fatigue, mood disorders and depression.
* Shoulder pain is common post-stroke and likely to be stimulated by peripheral nociceptors in the shoulder joint stimulating the lateral spinothalamic pathway (9)
* Post-stroke headache affects 6-44% of the ischemic stroke population (10). The mechanism is unclear and is possibly due to nociception activation by traction or mechanical forces, chemical stimulation of nociceptors or electrical events causing depolarisation of pathways.
What are the 4 Bamford stroke classifications?
- Total Anterior Circulation Stroke (TACS): A large cortical stroke affecting the areas of the brain supplied by both the middle and anterior cerebral arteries.
- A less severe form of TACS, in which only part of the anterior circulation has been compromised. Higher cerebral dysfunction alone is also classified as PACS.
- Posterior Circulation Syndrome (POCS) involves damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem).
- Lacunar Stroke (LACS): A subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions (e.g. dysphasia).
What pathophysiological mechanisms underpin Heamoragic Stroke?
Haemorrhagic strokes occur secondary to the rupture of a blood vessel or abnormal vascular structure within the brain. There are two subtypes of haemorrhagic stroke known as intracerebral haemorrhage and subarachnoid haemorrhage.
* Intracerebral haemorrhage involves bleeding within the brain secondary to a ruptured blood vessel. Intracerebral haemorrhages can be intraparenchymal (within the brain tissue) and/or intraventricular (within the ventricles).
* Subarachnoid haemorrhage is a type of stroke caused by bleeding outside of the brain tissue, between the pia mater and arachnoid mater.
Consider by area of brain affected
What are the predominant patient-reported dysfunctions for stroke?
With Clinical Physio Flashcard
Depends on the area of the brain affected, but may include:
* Unilateral/Ipsilateral motor impairments
* Unilateral/Ipsilateral sensory deficits
* Impaired vision
* Impaired speech
* Weakness
* Facial Droop
* Difficulty mobilising
* Shoulder weakness & stiffness
* Sleep Disturbances
* Headache: Post-stroke headache affects 6-44% of ischemic stroke population
What dysfunctions may be found during an objective assessment for stroke?
Depends on the area of the brain affected, but may include:
* Receptive and/or expressive dysphasia
* Unilateral/Ipsilateral weakness
* Hemiparesis
* Hypoesthesia
* Shoulder pain & weakness: Occurs in 25-50% of stroke patients. This can be caused byfrozen shoulder or shoulder subluxation due to weakness of muscles supporting the glenohumeral joint
What modifiable and non-modifiable risk factors influence Stroke?
Non-modifiable
* Atherosclerosis
* Carotid Artery Stenosis
* Age
* Sex
Modifiable
* Obesity
* High Blood Cholesterol
* Smoking
* Physical Inactivity
* Stress
* Low fruit and vegetable intake
What is the prognosis for Stroke?
- Varies significantly between patients, and is influenced by the size of the stroke, location of the stroke, lifestyle, and psychosocial factors. Thus, a prognosis is difficult to determine.
- Some research has indicated that a lessened severity of neurological deficits in the early post-stroke phase, and younger age is associated with better outcomes (13).
- Most recovery occurs in the first few months. However, further improvements, adaptations, and behavioural changes can take many years and it may take weeks, to years for a new baseline to be established
What are the psychometric properties of the Modified Ashworth Scale (with reference(s) & critical analysis)?
- Validity: Adequate content validity (SCC = 0.5) when compared to biceps T-reflex, excellent construct validity when compared to other clinical measures (r = ≥0.83).
- Reliability: Adequate intra-rata (57.5-85%), poor inter-rata (42.5-50%).
- Responsiveness: Very responsive of both upper (SRM = 0.99) and lower (SRM = 0.82) extremity muscles.
- Feasibility: Excellent. Already a prevalently used tool in neurological assessment, easy to integrate into practice and requires no special training or equipment unlike alternatives.
Saleh et al (2022) - Meta-Analysis (Acute stroke)
What are the psychometric properties of the 4AT (with reference(s) & critical analysis)?
- Validity: Pooled SN: 88%, SP: 88%
Tieges et al, (2021) - Meta-Analysis
What are the 3 key treatments for Stroke Rehab (with references)?
- RTT (NICE Stroke Rehab Guidelines, 2013; Thomas et al, 2016)
- Early Mobilisation & Intervention (Morreale, 2016; Hordacre, 2021)
- Core Strengthening (Gamble et al, 2021)
What were the key findings/recommendations of the NICE Stroke Rehab Guidelines of 2013 (with critical appraisal)?
- Offer patients repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving, and manipulating objects in functional tasks) and lower limb weakness (such as sit-to-stand transfers, walking and using stairs).
- Recommend the inclusion of progressive strength training, this may include: bodyweight activities (such as sit-to-stand repetitions), progressive resistance exercise, or the use of ergometers. Maier et al (2019) recommends these exercises should be functional and meaningful to the patient.
Critical Appraisal
Clinical Guidlines
What were the key findings/recommendations of the NICE Stroke Rehab Guidelines of 2013 (with critical appraisal)?
- Offer patients repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving, and manipulating objects in functional tasks) and lower limb weakness (such as sit-to-stand transfers, walking and using stairs).
- Recommend the inclusion of progressive strength training, this may include: bodyweight activities (such as sit-to-stand repetitions), progressive resistance exercise, or the use of ergometers. Maier et al (2019) recommends these exercises should be functional and meaningful to the patient.
Critical Appraisal
Clinical Guidelines
What were the key findings/recommendations of Thomas et al (2016) regarding RTT (with critical appraisal)?
Patients who receive RTT may be more likely to improve upper and lower limb function after treatment and sustain these improvements ≤6 months after treatment than patients receiving usual care.
Critical Appraisal
* Journal: Stroke (IF = 7.2)
* Design: SR
What were the key findings/recommendations of Gamble et al (2021) regarding core strengthening in stroke patients (with critical appraisal)?
Determined that the addition of core stability exercises improves trunk control and dynamic balance, thus they should be incorporated into rehabilitation planning.
Critical Appraisal
* Journal: Archives of Physical Medicine & Rehabilitation (IF = 4)
* Design: SR
What were the key findings/recommendations of Morreale et al (2016) regarding early mobilisation for stroke patients (with critical appraisal)?
Early mobilisation is reported to produce greater improvements in ambulation and general function at 12 months post-stroke
Critical Appraisal
* Journal: European Journal of Physical and Rehabilitation Medicine (IF = 5.3)
* Design: RTC
What does a subjective neurological assessment involve?
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Consider what applies to Connie in each scenario
What does a Obective Neuro Assessment Entail?
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- Vital Signs (Sats/HR/BP/BR)
- Vision Ax (Acuity / Fields / Depth / Oculomotor) - only if indicated in ESD
- Sensation (only if indicated in ESD) / Propioception
- PROM / Tone
- AROM / Coordination / Strength (incl. grip)
- Functional Ax (Gait, Balance, ADLs)
What are the clinical features of Bell’s Palsy
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What are the clinical features of Dysphasia?
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What are the clinical features of Cerebral Palsy?
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What are the clinical features of Guillan-Barré Syndrome?
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