Quiz 3 Flashcards
Cerebrovascular Accident
sudden loss of blood supply resulting in loss of oxygen supply to the brain
damages kills brain cells
neurological deficits related to areas affected
affects opposite side of the body to the hemisphere of the brain affected
Ischemic stroke
87%
caused by thrombus- blood clot or embolus traveling blood clot
Hemorrhagic stroke- 10%
caused by rupture of blood vessel with bleeding into the brain
blood is leaked into adjacent brain tissue
often more severe than ischemic strokes
anurism is a type
usually die of complications if live after stroke
Risk Factors for CVA
Risk Factors: controllable: hypertension cigarette smoking excessive alcohol intake high cholesterol intake obesity
uncontrollable: increasing age male sex black race history of DM previous CVA or TIA family history
Effects
mental functions sensory functions neuromuscular movement-related functions voice speech functions
Dysfunction:
flaccid paralysis or hypotonicity absent or reduced reflexes impaired posture sensory deficits visual impairments perceptual dysfunction cognitive dysfunction behavioral and personality changes impaired speech and language skills
Early Treatment:-Warning Signs
warning signs:
early treatment can reduce progression and residual effects if within 4 hours of start treatment
use of clot buster drugs
FAST- face, arm, speech, time
Medical management:
emergency treatment: open airway, establish fluid balance, and treat medical problems
give medicine
surgery may be indicated
*Hemispheric Lateralization:
Left cerebral hemisphere- Right hemipharesis
responsible for language, time concept, and analytic thinking
often have aphasia- partial or total loss of language communication and apraxia- motor planning problems
Right cerebral hemisphere- left hemipharesis
controls visual-perceptual function and perception of the whole
neglect/inattention more common
may retain good verbal but poor functional performance- dysarthria
Cerebellum Stroke:
abnormal reflexes of the head and torso
coordination and balance problems
ataxia
dizziness
problems with swallowing and articulation
cranial nerve deficits- vertigo, nausea, vomitting, headaches, nystagmus, slurred speech
Brainstem Stroke
controls primary functions- breathing, heart rate, blood pressure and arousal
dizziness
problems with swallowing and articulation
cranial nerve deficits
paralysis
likely to be critically ill- to need mechanical ventilation
MCA- Middle Cerebral Artery
most common
largest vessel branching off the internal carotid artery
most common cerebral occlusion site
feeds- femoral, temporal, parietal lobes of brain and basal ganglia and internal capsule
MCA- Effects
Effects of complete MCA CVA
facial asymmetry, arm weakness, and speech deficits
hemiplegia or hemiparesis of contralateral side
affecting lower part of face arm and hand
sensory loss in same areas
homonymous hemianopsia- visual field deficits affecting the same half of the visual field in both eyes
ACA- Anterior Cerebral Artery
least common- frontal and parietal lobes classic signs: contralateral leg weakness and sensory loss behavioral abnormalities incontinence may occur
PCA- Posterior Cerebral Artery
feeds the medial occipital lobe and inferior and medial temporal lobes
vision- contralateral homonymous hemianopsia
larger strokes- aphasia and neglect
Cognitive Dysfunction:
Inatention and memory deficits attention and concentration deficits disorientation insight deficits judgement and safety awareness deficits
Transient Ischemic Attack: TIA’s
incomplete stroke with symptoms lasting from a few minutes to 24 hours
Role of OT: Tx of CVA
improve motor function
integrate sensory-perceptual and cognitive functions
facilitate maximum level of functional independence
encourage resumption of life roles
promote health management and maintanence behaviors to prevent recurrent stroke
Grading of treatment:
increase length and complexity of activity
consider time for completetiong, extend of steps, number of steps, amount of physical assistance, verbal cues used and adaptive equipment
Remedial vs Compensatory Treatment:
remediation- restoring function
compensation- adaptation of task or environment
usually use a combination of both
Abnormal Reflexes/ Postural Mechanism post CVA
delayed righting, equilibrium, and protective response
address balance and trunk control of head and trunk-normal postural mechanisms
Positioning Techniques:
reduce abnormal tone promote alignment prevent contracture & skin breakdown Bed-- alternative positions AE use as needed prevent decupitus ulcers affected arm is supported resting hand splint in functional position
Balance Impairments:
poor automatic & postural adjustments against gravity
decreased weight bearing on affected side
Positioning Treatment
NDT- handling techniques- plevis, shoulders, chest & head) use wedges for anterior pelvic tilt encourage crossing midline co-treat with PT for balance sit on PB to improve righting reactions
Sensoriomotor Interventions-
Occupation-based Treatment Ideas
Weight shifting —- prepare for wheelchair transfer by weight shifting to front of seat
Weight bearing prone, side lying, then progress to sitting— watch a movie or read a book on a wedge in prone or side lying, in sitting rest arm on lap tray
Practice sit<>stand transfers - toilet transfers
segmental rolling/trunk rotation- in side lying, reach for clock
pelvic tilt- in sitting reach for snacks forward and overhead and place in bowl at elbow height
Abnormal Muscle Tone:
Flaccid paralysis: often replaced by spastic paralysis
more affective
synergies- want to break out to prevent contractors choose activities move away from synergies
Spasticity is described as minimal, moderate, or severe
can fluctuate through out the day
Motor Control Deficits:
Voluntary muscle control absent immediately after stroke function returns in stages and may stop at any stage return proximal to distal
Common motor problems:
movement dominated by synergy patterns
impairment of coordination, including ataxia
fine motor- last to recover
Motor Control Treatment:
PROM/AROM: full mobility of scapula, clavicle, and humerus is required for pain-free ROM
2 x a day ROM
AROM: used with minimal active movement
Treatment of shoulder subluxation and pain:
avoid overhead pulley and pain
pain prevented by positioning PROM
proper handling
sling use- givmohr
Motor Retraining
sensorimotor, task-oriented, or functionally based approaches
CIMT-usedful with learned disuse
robotic-assisted therapy may be used for retaining movement
Influence muscle tone:
hypotonic muscles are stimulated through sensation
hypertonic muscles are inhibited through positioning and handling
bilateral integration
important to start early, progression of the affected arm with motor return
strength and endurance
used with caution is spasticity is presents
strengthening of unaffected side only if spasticity is no increased on affected side
endurance training graded to each clients needs
Elevation and retrograde massage:
severe edema may be early sign of complex pain syndrome- RSD
treatment includes elevation, AROM, retrograde massage, compression wraps, and pneumatic compression devices
Compensatory techniques
possible hard dominance retraining
teaching one handed techniques
Hypotonicity:
Sensorimotor intervention————Occupation Based treatment-
quick stretch- patient performs a stretch with unaffected arm before ADL
resistance- squeezing shampoo bottle
traction- grasp tub grab bar and lean back to prepare for transfer
light touch- tactile cues during ADL
vestibular stimulation- take elevator to treatment room and then perform transfers
rhythmic initiation- therapist assists reach into closet for shirt, then pt reaches for pants
Hypertonicity:
Sensorimotor intervention————Occupation Based treatment-
prolonged stretch - hold book open with affected hand
compression- lean on affected extremity to sit up in bed before reaching for face cloth
firm pressure- encourage use of affected arm for reach with firm touch vs light tactile cues
rocking rhythmically- sit in rocking chair
relaxation- contract relax, hold relax- squeeze face cloth then release
Contracture:
Sensorimotor intervention————Occupation Based treatment
prolonged stretch- weight bearing through hand during ADL
splinting - use arm while in splint- don/dof splint
positioning- place hand to hold cup while pouring with unaffected hand
Ataxia:
Sensorimotor intervention————Occupation Based treatment-
weight bearing- lean on affected arm while performing hygiene tasks
quadruped- spot clean carpet
D1/D2- putting away groceries
visual deficits
may affect distance vision, peripheral awareness, or accommodations or may cause diplopia
auditory deficits
usually from normal aging
should not be misinterpreted as confusion
Tactile deficits:
changes in touch, pain, pressure, temperature, vibration and proprioception
Olfactory and gustatory deficits:
may have a dulled sense of smell and taste
Visual Perceptual Dysfunction:
remediation of visual- perceptual deficits
focuses on the restoration of skills
compensatory strategies for visual-
perceptual and perceptual motor impairment
intact skills compensate for deficits
repetitive practice may be needed to learn a strategy- Safety
Visual Perceptual Treatments
Treatment Ideas: pen/paper tasks, visual scanning cancellation tasks reading, using anchor line alphabet/number board on wall with post its, reaching and crossing midline to locate sequential characters to promote visual scanning scavenger hunt in room/hallway
Spatial Relations Deficits:
clients may have difficulty with shape recognition, depth perception, figure-ground distinction, and vertical or horizontal orientation
Functional Manifestation
Dressing difficulties: unable to orient clothing, locate armholes, leg holes or bottom of shirt
May put glasses on upside down
attempts to put dentures in upside down
difficulty orienting body to get out of bed
OT Treatment Spatial Relations:
use repetition and practice monitor amount & type of cueing required set up environment/task the same way every time use pictures/written instructions use mirror for visual feedback
Unilateral Body Neglect:
inability to interpret perceptual messages from the hemiplegic side of the body
functional manifestations
pt does not use involved extremity for ADL or position it correctly for transfers
Unilateral Spatial Neglect:
functional manifestation:
does not attend to person speaking on affected side
keeps head rotated towards affected side
does not use items on affected sides
Treatment: for Spatial Neglect
constant cueing- visual, verbal, and tactile
set up activities the same way; repetitions
set up environment to ensure safety
provide stimulation from involved side
promote head turning toward involved side
Ideomotor Apraxia
impaired motor planning functional manifestations: pt may appear clumsy, unable to adjust self to task pt may have problems sequencing task difficulty moving bolus poor coordination with utensils difficulty fasteners
Ideational Apraxia
inability to plan motor acts
functional manifestations:
pt does not know what to di in order to perform an activity
does the pt attempt to use items incorrectly
may perform task incorrectly
Treatment for Apraxia:
verbal and tactile cues positioning garmet in same position each time bottom up to top pull over clothes hand over hand assistance perform same way each time
Cognitive Dysfunction:
initiation and motivation deficits
- difficulty starting and finishing a task
- decrease in intrinsic motivation
Attention and concentration deficits
- deficits in ability to attend and maintain focus
- tx: adjust environment, remove distractions
Disorientation and confusing
- awareness of person, place, time and situation
- retain personal information the longest
- forget situational information first
* Tx: provide visual cues for place, date, situation: reinforce orientation but be careful about making pt frustrated or belligerent
Memory deficits
- CVA affects reception, integration, and retrieval of information
- Tx: use external memory aides, repetition, and visual cues
Sequencing and organization
- affects understanding of time and space
- may stop activity after each step of an activity
- use familiar environment
Insight deficits
- unable to recognize deficits
- Tx: frequency re-education into current status/stimulation occasionally may allow pt to fail at certain tasks to promote awareness of deficits
Judgement and safety
- impaired ability to understand the consequences of behavior
- may be resistive to feedback
- Tx: discuss consequences of actions, allow pt to fail at task and review why and what could have been done differently.
Generalization and learning deficits:
client should perform task in various context
Cognitive fatigue
build rest periods into treatment sessions
Behavior Manifestations: Impulsivity
- decreased insight can lead to impulsivity
- functional manifestations: shovels food in mouth and swallows without chewing
- does not test water temperature before showering
- does not completely stand before transfer
- does not lock w/c breaks
* Treatment:
* use clear instructions to ensure safety
* setup environment to ensure pt safety
Behavior Manifestation: Perseveration
- Perseveration:
* meaningless, non-purposeful repetition of an action
* Functional manifestations:
* pt repeats activity or part of activity over and over - Treatment:
* use verbal cues to break up repetition
Dysarthria:
- oral-motor dysfunction resulting in difficulty in pronouncing sounds or combinations of sounds
* Tx: oral motor exercises
Aphasia:
- acquired language disorder- range of deficits
- broca- aphasia: expressive aphasia
- wernicks aphasia: receptive aphasia
- global aphasia: loss of expressive and receptive skills
- anomia- word finding difficulty
Dysphagia:
- difficulty swallowing because of weakness
- clinical signs- drooling, pocketing of food, coughing, or gurgling
- high risk for aspiration
- Treatment:
- involves feeding program and modified diet- levels of food
Treatment of Unilateral Neglect:
reinforce attention to involved side with visual and tactile cues
use of mirror during ADL’s tasks
encourage use of involved side in all task as mush as possible
reinforce safety and setup with functional transfers
