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DPT 670 - Multidisciplinary Care > Neuromuscular Care in the Acute Setting > Flashcards

Neuromuscular Care in the Acute Setting Flashcards

1
Q

Neuromuscular Care in the Acute Setting

Remeber, systems review = ?

A
  • Cardiovascular/pulmonary = HR, respiratory rate, blood pressure, edema, oxygen saturation
  • Integumentary = Pain, skin lesions, swelling, warmth, wound, reddish streaks
  • Musculoskeletal = Gross ROM, gross strength, height, weight
  • Neuromuscular = Gait, balance, coordination, tone, sensation, cognition
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2
Q

Neuromuscular Care in the Acute Setting

TIA/CVA = ?

A

TIA (Transient ischemic Attack):

  • Brief episode of neuro dysfunction (typically less than 24 hours)
  • Strong indicator of pending CVA (15% in 90 days)
  • Management: observation, treatment of risk factors, anticoagulation, carotid endarterectomy
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3
Q

Neuromuscular Care in the Acute Setting

CVA (stroke, brain attack) (ischemic, hemorrhagic, lacunar)

A
  • 4th leading cause of death in US
  • Sudden onset of focal neurologic deficits < 24 hours or imaging demonstrating ischemia or hemorrhage
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4
Q

Neuromuscular Care in the Acute Setting

CVA risk factors

A
  • Older age
  • African American or Hispanic
  • male gender
  • HTN
  • CAD
  • hyperlipidemia
  • a-fib
  • hypercoagulable state
  • DM
  • obesity
  • tobacco/alcohol abuse
  • sedentary lifestyle
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5
Q

Neuromuscular Care in the Acute Setting

CVA prevalence

A
  • 795,000 people suffering from stroke every year
  • 600,000 are first attacks and 195,000 are recurrent attacks
  • More than 140,000 people die from a stroke each year
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6
Q

Neuromuscular Care in the Acute Setting

Ischemic vs hemorrhagic stroke

What is a hemorrhagic stroke = ?

A

Intracerebral Hemorrhage (ICH):

  • 10-15% or all strokes
  • Occurs from rupture of cerebral vessels
  • Often as the result of high blood pressure exerting excessive pressure on arterial walls already damaged by atherosclerosis, aneurysm, or arteriovenous malformation (AVM)
  • Primary = (78-88%) - spontaneous rupture of small vessels damaged by chronic hypertension or amyloid angiopathy.
  • Secondary = Bleeding of cerebrovascular vascular abnormalities, tumors, or impaired coagulation.

hemorrhage = least occuring but most severe

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7
Q

Neuromuscular Care in the Acute Setting

AVM = ?

A

arteriovenous malformation (AVM)

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8
Q

Neuromuscular Care in the Acute Setting

ICH outcomes = ?

A

ICH outcomes:

  • ICH is associated with a higher risk of fatality compared with cerebral infarction
  • Hemorrhagic stroke not only damages brain cells but also may lead to increased pressure on the brain or spasms in the blood vessels
  • Approximately half of all patients with primary ICH die within the first month after the acute event

less dramatic but much more severe (most global)

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9
Q

Neuromuscular Care in the Acute Setting

Lacunar stroke = ?

A

Lacunar stroke

  • A subtype of ischemic strokes, accounting for 20–30% of ischemic strokes
  • Appropriately named given their propensity to form cavities (lacunes) = little dead cavities.
  • Subset of ischemic stroke
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10
Q

Neuromuscular Care in the Acute Setting

Ischemic vs hemorrhagic stroke

What is a Ischemic stroke = ?

A

Ischemic Strokes:

  • Ischemic strokes can present in pre-determined syndromes due to the effect of decreased blood flow to particular areas of the brain that correlate to exam findings.
  • This allows clinicians to be able to predict the area of the brain vasculature that can be affected.
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11
Q

Neuromuscular Care in the Acute Setting

Middle Cerebral Artery (MCA) Infarction = ?

A
  • The middle cerebral artery (MCA) is the most common artery involved in stroke.
  • Classical presentation of contralateral hemiparesis, facial paralysis, and sensory loss in the face and upper extremity.
  • The lower extremity may be involved, but upper extremity symptoms usually predominate.
  • Gaze preferences towards the side of the lesion may be seen.
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12
Q

Neuromuscular Care in the Acute Setting

MCA Syndrome = ?

A

MCA Syndrome:

  • Classical presentation of contralateral hemiparesis, facial paralysis, and sensory loss in the face and upper extremity
  • Neglect
  • Poor motivation
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13
Q

Neuromuscular Care in the Acute Setting

Anterior Cerebral Artery (ACA) Infarction = ?

A

Anterior Cerebral Artery (ACA) Infarction:

  • The ACA distribution involves the medial cerebral cortex.
  • The somatosensory cortex in that area comprises motor and sensory functions of the leg and foot.
  • The clinical presentation of an ACA infarction includes contralateral sensory and motor deficits in the lower extremity.
  • Left-sided lesions presented with more transcortical motor aphasia, in which patients have difficulty responding spontaneously with speech.
  • Right-sided lesions presented with a more acute confusional state and motor hemineglect (unilateral motor function is lost)
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14
Q

Neuromuscular Care in the Acute Setting

Posterior Cerebral Artery (PCA) Infarction = ?

A

Posterior Cerebral Artery (PCA) Infarction:

Peripheral (cortical):

  • homoymous hemianopia
  • memory deficits
  • perseveration (repeat response)
  • Several visual deficits (cortical blindness, lack of depth perception, hallucinations).

Central (penetrating):

  • Thalamus - contralateral sensory loss, spontaneous pain, mild hemi
  • Cerebral peduncle - CN 3 palsy with contralateral hemiplegia
  • Brain stem - CN palsies, nystagmus, pupillary abnormalities.
  • The superficial posterior cerebral artery (PCA) supplies the occipital lobe and the inferior portion of the temporal lobe, while the deep PCA supplies the thalamus and the posterior limb of the internal capsule, as well as other deep structures of the brain.
  • Superficial infarcts present with visual and somatosensory deficits, which can include impairment of stereognosis, tactile sensation, and proprioception.
  • Larger infarcts that involve the deep structures can lead to hemisensory loss and hemiparesis due to the involvement of the thalamus and the internal capsule.
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15
Q

Neuromuscular Care in the Acute Setting

Vertebrobasilar Infarction = ?

A

Vertebrobasilar Infarction:

  • The vertebrobasilar region of the brain is supplied by the vertebral arteries and the basilar arteries that originate within the spinal column and terminate at the Circle of Willis. These areas supply the cerebellum and brainstem.
  • The clinical presentation includes ataxia, vertigo, headache, vomiting, oropharyngeal dysfunction, visual-field deficits, and abnormal oculomotor findings.
  • Patterns of clinical presentation vary depending on the location and the infarction pattern of embolism or atherosclerosis.

Mid basilar artery = locked in syndrome

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16
Q

Neuromuscular Care in the Acute Setting

Cerebellar Infarction = ?

A

Cerebellar Infarction:

  • Patients may present with ataxia, nausea, vomiting, headache, dysarthria, and vertigo symptoms.
  • Edema and rapid clinical deterioration can complicate cerebellar infarction.
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17
Q

Neuromuscular Care in the Acute Setting

Spot a stroke, what should we look for?

A

Beyond B.E.F.A.S.T. = Other Symptoms You Should Know

  • Sudden NUMBNESS or weakness of face, arm, or leg, especially on one side of the body
  • Sudden CONFUSION, trouble speaking or understanding speech
  • Sudden TROUBLE SEEING in one or both eyes
  • Sudden TROUBLE WALKING, dizziness, loss of balance or coordination
  • Sudden SEVERE HEADACHE with no known cause
18
Q

Neuromuscular Care in the Acute Setting

Ischemic CVA management = ?

A

Cerebral Hypo-perfusion

  • Sclerotic intracranial arteries
  • Embolus

Medical management

  • BP control (normal to elevated range to ensure perfusion)
  • Treatment of risk factors
  • Anticoagulation
  • tPA-tissue plasminogen activator (clot buster drugs)
  • Blood glucose control
  • Carotid Endarterectomy (if indicated)

Prognosis

  • Ischemic CVA accounts for 85% of all stroke types
  • 13-23% mortality rate in 30 days
19
Q

Neuromuscular Care in the Acute Setting

Role of tPA in blood coagulation = ?

A
  • Accumulation of fibrin = clot
  • Plasmin is responsible for fibrinolysis
  • tPA: plasminogen (inactive) = plasmin (active)
  • American Heart Association in 2018 strongly recommend IV tissue plasminogen activator(tPA) within 4.5 hours of stroke symptoms onset for eligible patients.
  • tPA = Tissue plasminogen activator (tPA)
  • Contraindicated for hemmoragic stroke.
20
Q

Neuromuscular Care in the Acute Setting

A

Hemorrhagic CVA:

Hemorrhage

  • HTN, trauma, aneurysm rupture, hyper-coagulation

Medical Management

  • BP control (low to normal range)
  • Treatment of risk factors
  • Blood glucose control
  • Close monitoring/treatment of ICP
  • Possible surgical evacuation of hematoma

Prognosis

  • Poor prognosis compared to ischemic CVA
  • 30 day mortality rate of 35-50%
21
Q

Neuromuscular Care in the Acute Setting

Physical Therapy when dealing with a hemorrhagic stroke = ?

A

Hemorrhage

  • HTN, trauma, aneurysm rupture, hyper-coagulation

Medical Management

  • BP control (low to normal range)
  • Treatment of risk factors
  • Blood glucose control
  • Close monitoring/treatment of ICP
  • Possible surgical evacuation of hematoma

Prognosis

  • Poor prognosis compared to ischemic CVA
  • 30 day mortality rate of 35-50%
22
Q

Neuromuscular Care in the Acute Setting

National Institutes of Health Stroke Scale NIHSS

A
  • Assessment tool that systematically assesses and quantitatively measures stroke-related neurologic deficit
  • Can be performed by physician, RN, or PT
  • Valid for predicting lesion size and can help determine stroke severity
  • Predicts patient outcomes
  • Evaluator must complete training and competency testing
  • Requires 10 minutes to complete

Scoring

  • 0 = no deficits
  • 42 = worst deficits

NIHSS and Patient Outcomes:

  • Score is utilized from admission to months after CVA
  • Patients may have significant change in neuro status within minutes/hours/days

Severity of CVA:

  • Very Severe>25
  • Severe 15-24
  • Mild to moderately severe 5-14
  • Mild 1-5

Correlation of NIHSS score to Discharge Disposition:

  • <5: 80% discharged to home
  • 6-13: typically require acute inpatient rehabilitation
  • > 14 frequently require long-term skilled care
23
Q

Neuromuscular Care in the Acute Setting

Movement coordinator = ?

A

Cerebellum = Movement Coordinator

  • Considered part of the motor system because damage to the cerebellum is primarily manifested in motor dysfunction = Postural control, Equilibrium, Coordination
  • Upright posture in coordination with the vestibular system
  • Maintenance of muscle tone throughout the body
  • Sensory input by analyzing and integrating afferent and efferent messages
  • Responsible for movement synergy
24
Q

Neuromuscular Care in the Acute Setting

Conditions responsible for cerebellar damage include = ?

A
  • CVA
  • Head trauma
  • Alcoholism
  • Tumors
  • Toxins (chemotherapy, chemical weapons)
  • MS
  • Anything that causes oxygen deprivation
25
Q

Neuromuscular Care in the Acute Setting

Examples of global signs of cerebellar dysfunction include = ?

A

Ataxia - “without coordination”

  • Movements that lack smooth trajectory and fine motor control.

Tremor: Two types

  • Intentional
  • Postural (aka tremors at rest)

Dysarthria:

  • Poor control of word formation due to inability to coordinate the muscles and structures of speech.
26
Q

Neuromuscular Care in the Acute Setting

Coordination Tests and Measures:

  • UE tests include= ?
  • LE tests include = ?
A

UE Tests

  • RAM (rapid alternating movement tests) tests for dysdiadochokinesia (sup/pronate, flex/ext Bilateral 15 seconds)
  • Finger opposition (thumb to 5th digit then reverse)
  • Finger to nose (or chin)-arms at 90 degrees shoulder abd., alternate
  • Finger to clinician finger then back to nose (or chin)-move target finger

LE Tests

  • Heel to shin (supine or sit, heel to knee then slide down shin and return
  • Toe to clinician finger
  • RAM tests for dysdiadochokinesia
27
Q

Neuromuscular Care in the Acute Setting

State of physical equilibrium = ?

A

Balance = State of physical equilibrium

  • Maintenance and control of center of gravity
  • Combination of sensory input, sensorimotor integration and motor output
  • Frequently examined in all practice areas
28
Q

Neuromuscular Care in the Acute Setting

Joints, muscles, skin provide info regarding length, tension, pressure, pain, joint position = __ ? __ input

Sensory System

A

Somatosensory input = Joints, muscles, skin provide info regarding length, tension, pressure, pain, joint position.

  • Golgi tendon organs
  • mechano receptors

Outcome measure = Clinical Test of Sensory Interaction and Balance (CTSIB)

Sensory system asks: Where Am I? What is happening?

29
Q

Neuromuscular Care in the Acute Setting

Provides information regarding motion of objects/self, environmental orientation, postural sway, movements head/neck = __ ? __ input

Sensory System

A

Visual input = Provides information regarding motion of objects/self, environmental orientation, postural sway, movements head/neck

Sensory system asks: Where Am I? What is happening?

30
Q

Neuromuscular Care in the Acute Setting

Provides feedback regarding position, movement of head in relation to gravity
= __ ? __ input

Sensory System

A

Vestibular input = Provides feedback regarding position, movement of head in relation to gravity

Sensory system asks: Where Am I? What is happening?

31
Q

Neuromuscular Care in the Acute Setting

Central Nervous System processing of visual, somatosensory and vestibular input = ?

A

Sensorimotor Integration =
Central Nervous System processing of visual, somatosensory and vestibular input.

  • Occurs in the basal ganglia, cerebellum, vestibular cortex.
  • This is the brain’s decision-making process to tell the body what to do to maintain balance.

What does this mean to me? = What to do

32
Q

Neuromuscular Care in the Acute Setting

The action that occurs in response to the message from the brain = ?

A

Motor Output = The action that occurs in response to the message from the brain.

Impairments in any motor system can affect balance:

  • Strength
  • Range of motion
  • Pain
33
Q

Neuromuscular Care in the Acute Setting

Examples of balance examinations include = ?

A

Static Standing

  • Single leg stance (SLS)
  • Romberg test
  • Kansas University Sitting Balance Scale

Active standing

  • Functional reach test
  • Multi-dimensional reach
  • Tinetti
  • Berg balance scale
  • Dynamic Gait Index (DGI)
  • Timed up and go (TUG)
  • Kansas University Standing Balance Scale
34
Q

Neuromuscular Care in the Acute Setting

How can we improve our balance examination?

A

Multiple methods - Observation/descriptions

  • Level of assistance required
  • # times loss of balance with activities
  • Ability to attain/maintain midline
  • Duration of stance
  • Use of support with tasks
  • Direction of deviation of movement
  • Presence of postural control strategies, reactions (ankle, hip, knee, step)
35
Q

Neuromuscular Care in the Acute Setting

Normal cognition helps balance by ?

A

Normal cognition helps balance by:

  • Paying attention to surroundings
  • Making correct decisions about situations
  • Remembering dangerous situations, environments
36
Q

Neuromuscular Care in the Acute Setting

Patient with cognitive impairment usually decreased balance with increased risk of = ?

A

Patient with cognitive impairment usually decreased balance with increased risk of falls.

37
Q

Neuromuscular Care in the Acute Setting

Berg Balance Scale (BBS)

A

The Berg Balance Scale (BBS) is used to objectively determine a patient’s ability (or inability) to safely balance during a series of predetermined tasks.

It is a 14 item list with each item consisting of a five-point ordinal scale ranging from 0 to 4, with 0 indicating the lowest level of function and 4 the highest level of function and takes approximately 20 minutes to complete. It does not include the assessment of gait.

BERG

38
Q

Neuromuscular Care in the Acute Setting

Dynamic Gait Index (DGI)

A

The DGI tests the ability of the participant to maintain walking balance while responding to different task demands, through various dynamic conditions. It is a useful test in individuals with vestibular and balance problems and those at risk of falls.

Scoring:

  • A four-point ordinal scale, ranging from 0-3. “0” indicates the lowest level of function and “3” the highest level of function.
  • Total Score = 24
  • Interpretation < 19/24 = predictive of falls in the elderly, > 22/24 = safe ambulators
39
Q

Neuromuscular Care in the Acute Setting

Timed Up and Go test (TUG)

A

Purpose:
To assess mobility

Equipment:
A stopwatch

Directions:
Patients wear their regular footwear and
can use a walking aid, if needed.

Begin by having the
patient sit back in a standard arm chair and identify a
line 3 meters, or 10 feet away, on the floor.

40
Q

Neuromuscular Care in the Acute Setting

Four Square Step Test (FSST)

A

The Four Square Step Test (FSST) is used to assess dynamic stability and co-ordination. It looks at the ability of the subject to step over low objects forward, sideways, and backward.

Time to Administer = Less than five minutes

Cut-off scores

  • Older adults/geriatrics: > 15 seconds = increased risk of falls
  • Stroke: > 15 seconds or failed attempt = increased risk of falls
  • Parkinson’s: > 9.68 seconds = increased risk of falls
  • Vestibular Disorders: > 12 seconds = increased risk of falls
  • Limb Loss/Amputation: > 24 seconds = at risk for fall

DPT 670 - Multidisciplinary Care (11 decks)

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