PT Examination/Evaluation CVA Flashcards
how to assess for direct/primary impairments following stroke
neurological tests and measures
cognition/perception, sensation, CN testing, motor function/strength, postural control/balance, functional status, gait/locomotion, aerobic capacity/endurance, speech/language/swallowing, emotional status, bowel/bladder control
what are some examples of indirect impairments/complications following stroke
- MSK: joint/soft tissue contracture, disuse atrophy, osteoporosis, decreased flexibility/increased risk of contracture formation
- Neurological: seizures, hydrocephalus
- Cardiopulmonary: DVT, changes in cardiac function, aspiration pneumonia
- Integumentary: decreased skin integrity, loss of protective sensation, pressure ulcers
what does someone in inpatient rehab with mobility limitations need on their WC
custion
what needs to happen if pt is unable to weight shift
- need improved seating system
- turning schedule
what percent of pts will develop DVT/ PE secondary to bed rest/immbolization
- 47% DVT
- 10% PE
how to prevent and tx secondary DVT/PE development
- prevent: early mobilization and OOB
- Tx: anticoagulation therapy, activity limitation, elevation of limb for 3-5 days, TED stockings
what percent will develop decubitus ulcers and how do you prevent it
- 14.5% over body prominences
- prevent: frequent position changes, daily skin inspections, pressure-limiting devices
what test can be used to determine shoulder subluxation and what percent does this occur in
sulcus sign
70-84% of cases with MCA strokes
why is shoulder subluxation common in patients post stroke
- lack of tone, muscle paralysis and proprioceptive impairments in early stages (flaccid)
- changes in scapular position, tightness in joint support structures, and poor handling during synergy stages
what are the vasomotor signs and sx of reflex sympathetic dystrophy (RSD) or shoulder-hand syndrome (CRPS)
edema, hyperhydrosis, corsening of hair and nails, skin discoloration, extreme pain, loss of ROM, progressive atrophy of soft tissue
- may result in osteoporosis of UE bone, clawed hands
when is bowel and bladder indirect impairments most common
acute phase post stroke
29%
what can bowel and bladder dysfunction lead to
embarrassment, isolation, depression
what is a prognostic fact about b/b function following stroke
persistent incontinence of bowel/bladder is associated with poor long-term prognosis for functional recovery
what is neurogenic bladder caused by
due to hyper or hyporeflexia affecting sphincter control or sensory loss
how to compensate for neurogenic bladder dysfunction and other tx
put pt on toileting schedule
- may need medical intervention to prevent chronic UTI - medications or indwelling catheterization
bowel incontinence/constipation can lead to what and how is it treated
- impaction
- managed with stool softeners or dietary/fluid modifications and increased physical activity to promote mobility
what areas of cognitive status can be impaired after stroke
attention, memory, executive function, level of arousal, perseveration, poor judgement
speech and communication disorders following stroke
aphasia (expressive and/or receptive)
dysarthria (difficulty with speech - motor)
dysphagia (cannot swallow)
perceptual disorders following stroke
body schema, body image, spatial disorders, ipsilateral pushing, agnosia
what pseudobulbar affects can occur following stroke
- emotional lability or emotional deregulation syndrome (cannot regulate emotions)
- depression
- behavioral hemispheric differences
describe sensory deficits following stroke
sensation often impaired but rarely absent on hemiplegic side
sensory deficits occur in about 53% of patients with what
cortical lesions to lateral hemisphere or thalamus (MCA)
where is the most common loss of sensation following stroke (55%)
face > UE > LE
direct impairments for pain following stroke
thalamic pain syndrome due to PCA infarct –> extreme neurogenic pain triggered by touch, pinprick, temp changes, loud noises, bright lights
indirect impairments for pain following stroke
muscle imbalances due to tonal changes –> shoulder-hand syndrome, knee hyperextension during gait, shoulder subluxation
sensory assessment
- pain
- superficial sensation
- deep sensation (kinesthesia, proprioception, 2-point discrimination, vibration)
- expect differences between UE/LE
- use caution when comparing with uninvolved side - may also have loss due to aging, comorbidities
impairments to what cranial nerves would cause difficulty with facial movements
CN 5 and 7
oculomotor and visual deficits with lesions to MCA (________) or PCA (______)
- optic radiations
- visual cortices
list some visual deficits associated with stroke
- strabismus, nystagmus, diploplia
- hemianopsia
- visual neglect, depth perception deficits
- forced gaze deviation
hemispheric lesions cause eyes to look ________
away from hemiplegic side
brainstem lesions cause eyes to look
toward side of lesion
what can cause swallowing deficits
CN 9, 10 or brainstem via infarcts of MCA and PCA
delayed swallow reflexes, reduced pharyngeal peristalsis, reduced lingual control
dysphagia
penetration of food, liquid, or salivia into airway results in ~1/3 of patients with CVA due to decreased gag reflex
aspiration
what direction is nystagmus caused by UMN
purely vertical
what are the most common UE contractures
elbow, wrist, and finger flexion and FA pronation
what are the most common LE contractures
PF
how to treat PF contracture in bed
multi-podus boot
what is the most immediate tone in acute care episode following stroke
flaccidity
what occurs due to cerebral shock and can last days to weeks
flaccidity
no movement of limbs elicited
flaccidity may persist if
cerebellar lesions or primary motor cortices
what tone is present in cerebellar lesion
hypotonia
after initial flaccidity, what tonal changes often occur following stroke (90%)
spasticity, hyperreflexia, syngergies
what direction is trunk lateral flexion usually towards due to spasticity
hemiplegic side
synergies make it difficult to allow for
fractionation of movement (unable to isolate movements)
what muscles that are not in synergy but are hard to activate
teres major, latissimus dorsi, serratus anterior, finger extensors, ankle evertors
describe the UE flexor synergy
- scapular retraction, elevation, or hyperextension
- shoulder abd/ER
- elbow flexion *
- FA supination
- Wrist/finger flexion
describe the UE extensor synergy
- scapular protraction
- shoulder add/Ir
- elbow extension
- FA pronation *
- wrist/finger flexion
describe the LE flexor synergy
- hip flexion *, abd, ER
- knee flexion
- ankle DF and inversion
- toe DF
describe the LE extensor synergy
- hip extension, add, IR
- knee extension
- ankle PF * and inversion
- toe PF *
describe Brunnstrom’s Stages of Recovery
1: flaccidity, no movement of limbs
2: spasticity beginning to develop, minimal voluntary movements, some associated movements
3: spasticity is further developing, may become severe
4: spasticity begins to decline, some out of synergy movement possible
5: isolated joint movements are more frequent and independent of synergy
6: near normal voluntary movement
describe normal presentation of reflexes following stroke
initially hypo-reflexive (initial shock) –> hyperreflexia
what will DTR’s demonstrate following stroke
clonus, clasp-knife, + babinski, + cutaneous, + CN reflexes
what primitive/tonic reflexes often occur following stroke
STNR
ATNR
STLR
TLR
unintentional involved limb movement resulting from intended action by the uninvolved limb
associated reactions
resistance to abduction/adduction of either the UE or LE on the non-involved side produces overflow on the involved side
raimiste’s phenomenon
fingers abduction and extend whenever the hemiplegic UE is lifted above horizontal with the elbow in extension
souque’s phenomenon
mutual dependency between hemiplegic UE and LE - the UE flexes, the LE also flexes
homolateral limb synkinesis
involuntary raising of the affected arm with yawning
parakinesia brachialis oscitans
describe STNR (symmetric tonic neck reflex)
head/neck flexion - UE flex, LE ext
head/neck ext - UE ext, LE flex
describe ATNR (asymmetric tonic neck reflex)
rotation of head to R results in R UE/LE extension and L UE/LE flexion
- most commonly seen
describe STLR (symmetric tonic labryinthine reflex)
position the head in space affects limb posture
- supine: all limbs in full extension
- prone: all limbs in full flexion
describe TLR (tonic lumbar reflex)
- elicited by movement of the trunk on pelvis
- rotation of the trunk to the hemiplegic side evokes flexion in hemiplegic UE and extension on hemiplegic LE
describe positive support reaction
pressure on the bottom of the hemiplegic foot results in rigid extension of the limb (fixing)
describe instinctive grasp reaction
stationary contact in the palm of the hand results in mass finger flexion (mass grasp) and inability to release
what areas of the foot should be avoided if touching the patient’s feet
center between met heads, medial 1st met head, lateral 5th met head, heel
reflex areas of the hand should be avoided to prevent elicit of reflex
central palm, thenar and hypothenar eminences, metacarpal heads
what are inhibitory key points of contact - places to hold to avoid reflex
finger tips and dorsal side of the hand
what percent of patients will have contralateral hemiparesis
80-90%
how can ipsilateral weakness occur following stroke
from disuse
are distal or proximal muscles more involved following stroke
distal
what causes quadriparesis
brainstem CVA
motor unit requirement may be diminished by as much as
50% 6 months after CVA
will reaction times be faster or slower following stroke
slower and movement times prolonged
which muscle fibers are more significantly loss following stroke
type II - difficulty initiating high-force movements
incoordination is due to
lesions to cerebellum
what does changes in muscle strength mean to patient
- requires increased effort for normal movement
- easily fatigued
- complaints of weakness and pain
- functional decline
damage to which hemisphere causes motor apraxia
L hemisphere
difficulty initiating and performing useful motor movement
motor apraxia
movement is not possible on command but may be automatic, perservates
ideamotor apraxia
purposeful movement is not possible on command or automatically, no idea how to do this movement
ideational apraxia
damage to which hemisphere results in motor impersistence
R hemisphere
inability to sustain motor behavior or posture
motor impersistence
list some balance and postural deficits
- impairments in steadiness, symmetry, and dynamic stability
- most often maintain weight shift to non-involved side
- ipsilateral pusher syndrome
- increased postural sway in standing
- often fall to involved side
what tests and measures can be used to assess balance and postural deficits
Berg balance, functional reach, TUG, CTSIB, or stroke specific measure (FIST)
active pushing with the stronger extremities toward the hemiplegic side and tend to fall towards the hemiplegic side
ipsilateral pusher syndrome
ipsilateral pusher syndrome is caused by malalignment to what
visual-vestibular input
is patient able to correct balance or correct to midline with ipsilateral pusher syndrome
no
lesion where causes ipsilateral pusher syndrome
posterolateral thalamic CVA
describe physiological walker
walks in home or parallel bars for exercise only
describe household walker
- limited: will rely on WC or some assistance
- unlimited: no reliance on WC, difficulty with stairs or unlevel surfaces, may not be able to enter or leave house
- gait speed: < 0.4 m/s
describe limited community ambulator
- can enter/leave house and perform curbs independently
- independent walking in some community setting (restaurants)
- gait speed: 0.4-0.8 m/s
describe community ambulator
- independent in home and all community
- can walk in crowds and uneven surfaces
- > 0.8 m/s
what type of disease is stroke
cardiovascular disease – take Vitals before, during, and after tests/measures
what are some parameters for modification to endurance activities
- systolic > 250/ diastolic > 115
- serious arrhythmias
- greater than 2 mm changes in ST segments
what test is commonly used in acute care and IRF and what do higher scores indicate
FIM
- higher scores: successful recovery, DC home, return to community
define the acute phase of stroke rehab
- rehab occurs within 72 hours of hospital
- average length of stage about 5 days
- focus on positioning, functional mobility, ADL’s, splinting, prep for rehab
define the subacute phase of stroke rehab
- acute IRF or SNF
- more therapy is better
- ability to go to rehab within 20 days of onset linked to better outcomes
- focus on restoration, prevention, and compensation if needed (functional return home)
define chronic phase of stroke rehab
- > 6 months
- done in outpatient or home (2-3x/week for 60-90 minutes)
- continuing interventions from inpatient rehab
- focus on restoration function as able, community reintegration, prevention of complications, and compensation if needed
what is the mean length of stay in IRF and what must the patient be able to tolerate
14.6 days
tolerate 3 hours of multidisciplinary care 6 days/week for 5 day
what is the mean length of stay in SNF and how much therapy is received
21-30 days
receive 1-2 hours of therapy/day 5 days a week
when does most stroke recovery occur
first 3 months
_____ deficits are 30 days are predictive of deficits at 6 months
motor
list indicators of poor prognosis 20-30 days post stroke
- no/min grip strength = no/min hand function later
- no/min shoulder flexion = no/min hand function later
- no hip flexion against gravity = not independent ambulator
- assistance needed for sitting = not independent sitter later
describe orpington prognostic scale (OPS)
- performed within first 2 weeks post stroke
- reliably predicts discharge setting
- 4 domains: balance, cognition, motor, proprioception
- scoring: <3.2 (mild-mod - high likelihood to return home), 3.2-5.2 (mod-severe - respond well to rehab), > 5.2 (severe = usually institionalized, dependent)
PREP 2 Algorithm
Predict REcovery Potential - for UE function
SAFE MRC meaning
shoulder abduction finger extension
MEP meaning
Motor electrical potential
early active control of shoulder abduction and finger extension predicts improved functional recovery of UE
PREP2
used to show preseveration of internal capsule important for recovery
transcranial magnetic stimulation (TMS)
what is the key tract for skilled movement
corticospinal tract
what does lesion of corticospinal tract lead to
- loss of functional motor units
- loss of motor unit recruitment
- reduced motor unit firing rate
- lack of selective motor unit recruitment
- reduced agonist recruitment
- reduced force production and rate of force production
- increased coactivation of antagonist
- decreased ability to execute functional movement
a form of MMT that can give a quick picture of strength/function used after CVA; allows for a quick screen for strength in patients with CVA
motricity index (MI)
what movements are looked at for MI
UE: shoulder abduction, elbow flexion, pinch grip
LE: hip flexion, knee extension, ankle DF
what is the max score for the affected arm/leg for MI and how to score
100 points
SUM (points for 3 movements) + 1
what tests can be used to predict gait recovery
- Trunk Control Test Sitting (TCT-s): can the patient sit unsupported for 30s y/n?
- Motricity Leg Index: pt sitting 90/90 and assess DF, knee extension, and hip flexion
when are gait precition tests performed
by day 3
would you expect motor recovery in later stages of stroke recovery
no
- focus on increase functional activity
