Neurological impairments Flashcards
What happens to primitive reflexes with TBI
- Impaired righting reflexes with midbrain damange
- Absence of equilibrium rxs and protective extension with basal ganglia
The following are symptoms of what condition?
- Impaired righting reflexes
- Muscle weakness
- Decreased endurance
- Ataxia
- Postural deficits –> imbalance in muscle tone
- Limited joint motion
- Changes in sensation
TBI
Inpatient rehab phase of TBI focuses on…
- Provide intensive rehab for clients who can demonstrate stimulus specific responses. Generally at Rancho Level 5 and higher
- Optimize motor function (motor learning, skill acquisition, exercise. Occupation-based!)
- Optimize visual and visual perceptual function
- Optimize cognitive function
- Optimize speech and voice function
- Restore competence in self-maintenance tasks
- Contribute to behavioral and emotional adaptation
- Support family caregivers
How to address ataxia in inpatient rehab phase of TBI
-Intervention focused on compensatory strategies for control, including weighting of body parts or use of weighted utensils and cups
How to address apraxia in inpatient rehab phase of TBI
Hand over hand exercise to repair damaged neural pathways. Client may also compensate by following steps depicted in pictures or written on card
Acute phase of TBI
- Initial interventions occur in ICU and acute care units of hospitals. Involve both preventative and restorative approaches
- Positioning
- PROM to prevent development of secondary impairments
- Splinting and castings when spasticity interferes with functional movement or ADL performance
- Sensory stimulation
- Management of agitation
- Family and caregiver education
Splinting for TBI acute phase
- Splinting and casting when spasticity interferes with functional movement for ADL performance, when ROM deficiencies and when soft tissue contractures possible
- Resting or functional position splint when not involved in active movement or functional tasks. Alternate 2-hour periods. Frequent monitoring for skin breakdown
- Cone splints to keep fingers from digging into or damaging palmar surface
- Antispasticity splints to position hand and wrist in functional positions and abduct fingers, decreasing spasticity
- Elbow casts for loss of PROM in elbow flexors
Postacute rehab phase for TBI
- Rehab transitions from inpatient setting to postacute rehab e.g., home-based therapy, residential program, day tx program, OP community reentry
- Optimize cognitive function e.g., increase self awareness, environmental compensations
- Optimize visual and visual-perceptual function: environmental adaptations and strategies to compensate
- Restore competence in self-maintenance roles: self care and homemaking tasks: repetitive practice! e.g., errorless learning, fading cues, positive encouragement
- Restore competence in leisure and social participation: social skills training groups, role playing, behavior contracts, self reflection
- Restore competence in work: punctuality, respond to feedback, follow schedule, vocational rehab
- Contribute to behavioral and emotional adaptation: increase self awareness and coping skills
Postacute rehab phase TBI, strategies for cognitive function
- Several residual cognitive deficits remain, including memory and executive function
- Changing physical and social contexts and environment to compensate
- Increase client’s self awareness
Postacute rehab phase TBI strategies for visual and visual perceptual function
- Optimize function
- Focus on environmental adaptations and strategies to compensate for deficits that remain
Approaches of Acute phase of TBI
-Both preventative and restorative approaches
Postacute rehab phase TBI strategies for maintenance
- Interventions focus on self-care and homemaking if skills haven’t been fully acquired
- Emphasis on behavioral intervention with repetitive practice through errorless learning, fading cues, positive encouragement
- Strategies from inpatient may need to be adapted for community setting
- Once homemaking is achieved, focus on money management, shopping, community mobility
Postacute rehab phase TBI strategies for leisure and social participation
- Social skills training groups
- Behavior contracts, role-playing, self-reflection through video feedback and role modeling
- Guide client in identifying activities that are appropriate within client’s abilities
Postacute rehab phase TBI strategies for work
- After client competent in self maintenance
- Emphasize punctuality, ability to respond to feedback, follow work schedule
- Vocational rehab for skill development and ID work or volunteer settings
Initial stages of SCI
Spinal shock, may last between 24 hours and 6 weeks. Reflex activity ceases below the level of injury, resulting in spasticity
Purpose of rehab for SCI
to prevent further medical complications and to maximize client’s function
How can heterotopic ossification be controlled with SCI pts?
- Proper positioning in bed and WC
- Maintenance of joint ROM
- Regular monitoring of ROM to identify heterotpic ossification
Bowel and bladder function is affected for what level of SCI injuries?
All injuries at and above the S2-S5 level
Eval for SCI
- Top down approach
- Physical eval: medical precautions, UE ROM, strength, muscle tone, sensation, trunk balance, MMT
- Observation of endurance, fatigue, pain
- Hand and wrist function, grip strength, pinch strength
- Occupational performance eval through observation and standardized and nonstandardized assessments
Assessments included in SCI evals
- Spinal Cord Independence Measure: ADL performance, sphincter control, respiration, mobility
- Quadriplegia Index of Function: specific for clients with tetraplegia
- FIM: assess severity of disability and client function, not specific to SCI
- COPM: changes in client’s self perception
Intervention objectives for pts with SCI should be designed around…
Cooperative goals determined by client, family, OT, and other team members. Goals should be meaningful and realistic, centered around performance areas and underlying problems that hinder functional performance
What UE ROM movements should the OT focus on in an acute recovery phase for pt with SCI
- ROM movements involving scapular rotation, shoulder scaption, shoulder external rotation, elbow extension, and forearm pronation
- 80 degrees shoulder abduction, external rotation with scapular depression, and full elbow E. Forearm should be pronated to avoid risk for supination contractions
What grasp should be facilitated for clients with tetraplegia in an acute recovery phase of SCI
- Tenodesis grasp
- Dorsal and support wrist in E and thumb in opposition (preserve web space), allowing MCP and PIP joints to flex properly
C8 tetraplegia interventions should focus on…
Grasping objects with MCP joint E and PIP and DIP joint flexion
When should the psychosocial adaptation process begin with SCI recovery?
- Immediately, however most prominent during acute rehab phase.
- Positive coping skills development for clients with SCI should be emphasized throughout interventions
- Clients should be encouraged to solve their own problems, be involved in making decisions about their care, and be engaged in meaningful activities
- Group learning is particularly beneficial for people with SCI to allow them to learn from their peers
Transition rehab phase for SCI
- May involve OP occupational therapy services if client hasn’t been able to achieve optimal outcomes in acute rehab phase
- Max strength gains in first year postinjury
- Continued training in use of adaptive devices and consideration of use of other equipment important
- Access to support groups and interventions that enhance community integration should be focus
Motor and postural control impairments in CVA
- Motor dysfunction ranging from mild weakness to complete paralysis on side opposite of lesion
- Impairment in trunk and postural control that increases risk for falls, limits functional activity, and decreases independence in ADLs
- Impairment in standing activity that affects weight bearing, weight shifting, and stepping and increases risk for falls
Communication impairment in CVA that describes loss of all language ability
Global aphasia
Communication impairment in CVA that describes broken speech; slow, labored speech with frequent mispronunciations
Broca’s aphasia
Communication impairment in CVA that includes impaired auditory reception; speech may be fluent but is often meaningless or nonsensical
Wernicke’s aphasia or receptive aphasia
Communication impairment with CVA, difficulty finding words
Anomic aphasia
Often present with CVA; articulation disorder resulting from paralysis of the organs of speech
Dysarthria
Cognitive and perceptual impairments of CVA
- Spatial relations and positioning
- Spatial neglect (generally on contralateral side)
- Body neglect, generally on contralateral side
- Motor apraxia
- Ideational apraxia
- Organization and sequencing
- Attention
- Figure-ground
- Initiation
- Visual agnosia (difficulty recognizing objects)
- Problem solving
UE impairments with CVA
- Subluxation in glenohumeral joint
- Abnormal skeletan muscle involving inability to recruit and maintain muscular strength on the affected side, leading to:
- Edema, overstretching and damage of joint capsules and antagonist muscles that keep joints in place
- Shortening of muscle
- Damage to joints and soft tissues b/c lack of control and sensation
What are the three phases of recovery for CVA?
- Acute rehab phase immediately after stroke
- Rehab phase
- Community or continuing adjustment phase
Three phases of tx for SCI?
- Acute recovery phase/ acute phase: short sessions limited to 15 mins often in ICU
- Acute rehab phase/ active phase of intervention: provides education and support and help find meaningful activities to restore sense of self-efficacy and self-esteem
- Transitional rehab phase: may involve OP. Focus is to maximize strength gains in first year postinjury. Continued training in use of AD and other equipment considered. Support groups and interventions that enhance community integration
ADL assessments most commonly used with CVA
- Barthel index
- FIM
- COPM
- AMPS
- Stroke Impact Scale
- Arnadottir OT-ADL Neurobehavioral Eval (A-ONE)
Intake eval for CVA should include ?
- Client centered assessments that assess self-care such as by observing donning shirt
- Assess performance skills that measure postural adaptation, UE function, motor learning ability
Postural adaptation assessments for CVA
- Berg Balance Scale
- Functional Reach Test
- Observation with functional activities
UE function assessments for CVA
- Should include sensory, ROM, joint alignment, muscle tone, pain, motor control, strength and endurance, functional performance
- Functional Test for Hemiplegic/paretic UE
- Arm Motor Ability Test
- Wolf Motor Function Test
Why is motor learning ability for clients post stroke?
- The client’s ability to solve challenges of movement for mobility and UE use is critical for recovery from stroke
- Factors of visual function, speech and language, motor planning, cognition, and psychosocial function all integrate to influence performance abilities
Intervention for stroke recovery should focus on
- Focus on improving occupations through early ADL training using both compensatory and remedial approaches.
- Environmental and activity considerations are addressed using the task-oriented approach, which has shown significant effectiveness in stroke rehab compared with traditional therapy approaches
What tx approach has shown to be super effective in stroke recovery compared with traditional therapy approaches?
Task-oriented approach
- Tx environment should mimic reality as much as possible, including challenges
- Activity simulation should be as realistic as possible
- Opportunities should be available for client engagement and practice outside of therapy sessions
- Ineffective or inefficient movements should be eliminated
Specific methods to address performance skills and client factors for what population includes postural adaptation, use of UE, and inclusion of motor learning ability factors
Recovery from stroke
How can OT utilize motor learning ability to address communication difficulties when working with CVA client
- Active in facilitating communication for occupational performance by:
- Encourage gestures and visual cues e.g., have client communicate through demonstration
- Communicate in quiet, calm area
- Allow increased time for response
- Frame questions to allow yes or no responses
- Be concise
- Don’t be forceful
- Encourage speech through routine or familiar ADL performance
Why is transfer of learning important when working with CVA pts
Determines whether skills learned will be transfered from one task to another and from one environment to another
Brushing teeth, including positioning the toothbrush for toothpaste application on teeth is an example of…
Spatial relations and positioning
Searching for needed utensils in a silverware caddy addresses…
Spatial neglect
Brushing the neglected side of the mouth addresses
Body neglect
Opening kitchen supplies or preparing a small meal addresses this motor difficulty
Motor apraxia
Promoting the use of touch to identify objects is a strategy to address
Visual agnosia
