Stroke Flashcards
CVA definition
Disruption in cerebral circulation causing loss of neurons and neurological function
Types of stroke
Ischemic (roughly 80% of all strokes)
-thrombus (1st common) or embolus (2nd)
- low systemic perfusion
Hemorrhage
- aneurysm, artery or AVM
- increases mortality rate
- intracerebral (future or leak in brain) subarachnoid (due to an AVM)
- increase pressure causes compression and cellular death
TIA
Ischemia without tissue death. Symptom resolve in less than 24 hrs
Ischemia penumbra
Area surrounding ischemic event
- one of the main priorities is to save the penumbra area
Ateriovenvous malfomation
A congenital defect causing a tangle
Progresses dilation with age
50% of AVMs will burst
Major risk factors of stroke for woman
Early meno
Estrogen suppl
Preeclampsia
Pregnancy, birth, 6 weeks post birth
Warning sign
Face
Arms
Speech
Time to emergency services
Vascular syndromes
Anterior cerebral artery (ACA)
Middle MCA
Internal ICA
Posterior PCA
Vertebrobasilar artery syndrome
Lacunar
ACA
Frontal and parietal lobses, basal ganglia, anterior fronix, corpus callosum
Contra lateral patterns
LL affected
Urinary incontinence
Abulia (inability for will power)
A kinetic mutism
Apraxia
Broca’s aphasia
MCA
Most common
Lateral aspects (Frontal, temporal, parietal lobes) (internal capsule, corona radiata etc)
Extensive neurological damage
UL
Contralateral
Wernickes aphasia
Broca aphasia
Global aphasia
Perceptual deficits (neglect, agonsognosia, apraxia, depth perception/ disorganization)
Hemianopia
Loss of visual field on one side of midline
Homonymous
Loss on same side of both eyes
ICA
Supplies both MCA and ACA
Large obstruction of area supplied by MCA
uncal herniation
PCA
Occipital lobe, medial/inferior temporal lobe, upper brain stem, mid brain,
Peripheral territory: Homonymous hemianopia, visual agnosia, prosopagnosia, dyslexia
Central territory: central post stroke (thalamic) pain, hemianesthesia, sensory impairments, contra lateral hemiplegia, oculomotor nerve palsy
Vertebrobasilar artery syndrome
Cerebellum and medulla. Pons, internal ear, and cerebellum
Ipsilateral, contralateral S&S
Locked in syndrome
Aware and awake but has complete paralysis
Sudden onset
There is preserved consciousness and sensation
When the eyes are paralyzed as well, the syndrome is known as total locked in syndrome
Lacunar syndrome
Caused by occlusion of small penetrating arteries supplying the brains deep structures
20 of all strikes
Associated with hypertension and diabetes
Could be silent
Dysarthria
Motor speech disorder (lip tongue etc)
Speech may be slow
Aphasia
Impairment of language (written and spoken) affecting comprehension and/or production
Receptive/ Wernickes
- difficulty with comprehension of language
- can speak normal cadence but is random
Expressive/ Brocas
- difficulty with speech production
- flow is slow and hesitant, limited vocabulary, and impaired syntax
Global
- difficulty with language comprehension and production
- indicative of extensive brain damage
-limits patients ability to learn, therefore affects outcomes of rehab
DysphaGia
Difficulty swallowing
Aspiration occurs in 1/3 of patients
Can cause respiratory distress, aspirations pneumonia, and possibly even death
Nothing per oral (NPO) precautions are given
Cognitive Dysfunctions
Impairments in alterness, orientation, attention, memory or executive fxns
memory
Perseveration
- repeating a word or act over and over again
Altered emotional status
Pseudobulbar affect- random outbursts of emotions
Apathy- blunted emotional response
Euphoria- exaggerated feelings
Depression- feelings of sadness
Hemispheric behavioral differences- left
Slow, cautious, anxious
Hesitant for new tasks
Aware of deficits
Difficulty with communication and info processing
Hemispheric behavioral differences- right
They are almost reckless presenting
Unaware of their deficits
Increased safety risk
Perceptual dysfunction
Dysfunction of Body scheme and body image
Agnosia (inability to processes any sensory information)
Unilateral neglect
Lack of awareness of own body on one side
No reaction to sensory stimulation on one side
Almost always seen in right hemisphere lesion
Spatial relations syndrome
Difficulty perceiving relationships b/w self and objects in space
Agnosia
Interpreting sensory info
Visual, auditory, and tactile (asterognosis)
What is the stages of motor recovery
Twitches and Brunnstrom
Stage 1-6
1- flaccid paralysis
6- disappearance of spacitiy
Why are people initiallly flaccid immediately afte stroke
Cerebral shock
What UMN responses may you expect in strokes
DTR: hyperreflexia, clonus, babinski, clasp knifed response
Flexion synergy- stand outs
Elbow flexion
Extensor synergy- standouts
Shoulder adduction an wrist pronation
Choreoathetosis
Twisting or wringing type mvmts of the wrist
Hemiballismus
Sudden uncontrolled mvmts
Apraxia (Motor programming)
A problem of doing and planning the task.
No primary motor impairments
Ideational apraxia (Motor programming)
Inability to produce purposeful mvmts on command or automatically
No idea how to do the mvmt
Ideomotor apraxia
Inability to do purposeful mvmts on command, but can automatically.
Often perseverates
Which side to the usually fall?
Towards the hemispheric side
Pusher syndrome
A disorder of postural control- pushes weight to weaker hemiparetic side
Altered sense of verticality
Scale for contraversive pushing
1- tilting toward paretic side often
2- abduction and extension of unaffected limbs
3- resistance to passive correction
PT implications for push’s syndrome
Avoid transfers to pare tic side
Avoid gait aids
Be aware of where and how you position patients
Interventions
Preventative
- minimize potential complaications and secondary impairments (essentially move them)
restorative
- aimed at improving impairments and limitations
Compensatory
- aimed at modifying the task, activity or environment to improve function and participation
How to: improve sensory fxn
Sensory retraining/ stimulation approach
- mirror therapy
- sensory discrimination activities (different textures)
- compression techniques (ie weight bearing)
- electrical stimulations
- thermal stimulation
Saftey education (improve awareness of impairments and protection of anesthetic limb)
How to: Improve hemianopia or unilateral neglect
Encourage awareness and use of environment and hemipaetic side
Active visual scannning mvmts
Cueing
UE exercises involving crossing midline toward hempareti side
Functional activities involving bilateral interactions
Prism glasses
How to: improve flexibility and joint integrity
PROM and AROM (if possible) should be performed daily in all motions
Postioning to maintain soft tissue length and encourage proper joint alignment
Use protective devices (eg wrist splint)
Side lying of affected shoulder
Benefits- allows patient to become more aware of affected side
Weight bearing on weaker side will regulate abnormal muscle tone
Inhibits abnormal postures
How to: improve strength
Progressive resistive strength training
Combine resistance with functional activities
Exercise precautions
- specifically designed gloves with Velcro to help hand functions
- increase risk with postural or sensations impairments
- hypertension and cardiac disease is high in stroke patients
How to: improve mvmt control and UE fxn
Focus on dissociation of segments and selective out of energy mvmt patterns
Aim for the mvmts to be normal- should be meaningful
Contrain-induced movement therapies
Promotes increase use of affected UE. Used in 90% of waking hours
shoulder pain (hemiplegic shoulder)
Flaccid stage (supraspinatus dis function)
- inferior subluxations
Spastic stage
- poor scapula positioning may lead to mvmt restrictions and subluxations
- frozen shoulder is common
How to: manage shoulder pain (hemiplegic shoulder)
Arm supported at all times (positioning, handling, use of tray, arm sling when transferring, strapping / taping)
Gentle guided exercises
PROM an gentle mobs
Functional electrical stimulation FES/ NMES
Don’t pull on arm or let it hang unsupported
How to: improve functional status
Bed mobility
STS transfers
Sitting
Standing
And other transfers
Improve balance and postural control
Train active mvmts shift toward strong side
Encourage patient to problem solve
Visual cues or stimuli
Verbal cues or stimuli
Tactile cues or stimuli
Improve gait an locomotion
BWS and motorized treadmills (gradually reduce to improve independence)
Functional electrical simulation
Orthsis and assistive devices
Wheelchairs (hemi-height, one arm driving, power wheelchair
Different gait patterns
Circumduction
-Foot flap or drop foot
Hypertension of knee
- weak quads or poor motor control of quads
Decrease stance time on the affected limb
- pain or weakness
Left Hemisphere lesions
slow, anxious, cautious, disorganized
Right hemisphere lesions
quick, implusive, poor judgement
