Stroke and TBI Flashcards
Rest @ the end, NOT IN THE MIDDLE!!!
Rest when you ARE FINISHED!!!!
CVA- 2 Types
Ischemic
- Blood flow obstructed
Hemorrhagic
- Ruptured blood vessel leaks blood INTO brain
Vascular Syndromes:
Anterior Cerebral Artery (ACA)
2 BIG things to remember w/ LOSS
- C/L motor and sensory loss: LE>UE
- Sensory loss: LE>UE
Vascular syndromes:
ACA
ALL things: get the jist
- C/L M & S loss: LE>UE
- Sensory loss: LE>UE
- Memory/Behavioral impairs d/t Frontal lobe involve (A.CEO)
- Urinary incont
- Probs w/ imitation, Bimanual tasks, aPraxia
Vascular Syndromes:
Middle Cerebral Artery
What about MCA?
MOST AFFECTED ARTERY!!!
aka most common loc. for ischemic stroke
Vascular Syndromes:
MCA
- C/L M & S loss involving UE and face
- UE>LE
- C/L homonymous hemianopsia
Dominant Side (Left stroke): Aphasia
NONdominant Side (Right stroke): Perceptual problems
- U/L neglect, depth perception, spatial relations, aGnosia, aPraxia
Depth perception Ex. step ups and knowing how much effort to use
Vascular Syndromes:
Posterior Cerebral Artery
Think VISION!!!
memory
thalamic pain
Vascular Syndromes:
PCA
- C/L Homonymous hemianopsia
- Memory deficits
- Visual aGnosia (recoGnizing)
- ProsopaGnosia** diff naming people on site/recoGnize faces
- Central poststroke (Thalamic) pain**
Practice!
53yo male had stroke affected his ACA. Which presentation?
C/L hemiparesis of LE, urinary incont, aPraxia (planning prob), C/L hemisensory LE
Homonymous Hemianopsia (MCA, PCA) vs Hemineglect (R stroke, MCA, perceptual prob)
Homonymous Hemianopsia
- Visual Field defect
- actively have pt look that way where cut is
Hemineglect
- perceptual deficit
- NOT paying attn to that side
see pics
Spatial-Perceptual Dysfunction
R. stroke, MCA, NONdom side
- incorrect perception of self & illness (this is where they dont realize they have deficits)
- incorrect perception of self in space–> may neglect ALL Input from affected side
- AGnosia (come back to this)
- APraxia (come back to this)
Spatial-Perceptual Dysfunction
R. stroke, MCA, NONdom side
AGnosia
INability to recoGNize an obj by sight, touch, hearing
Spatial-Perceptual Dysfunction
R. stroke, MCA, NONdom side
aPraxia
Talk about 2 types also… Ideational vs Ideomotor
INability to carry out learned/purposeful, sequential mvmts on command
aPraxia-motor Planning prob
- Ideational: Lost ability to recognize & what obj used for–> EX. think Toothbrush is for writing
- Ideomotor: Lose ability to do purposeful tasks on command–> Ex. Dr. Cohens pt in waiting room “stand up.” Ex. Brush your teeth–> cannot, even tho they brushed their teeth earlier in day
Practice!
PT commands pt to pick a pen amongst straws, unable to complete d/t inability to FIND pen. MOST APPROP dx?
Form Discrimination
aka cannot “discriminate” bw pens and straws
Figure-Ground Discrim–background makes diff to find figure
Types of Aphasia:
In terms of Comprehension
- Pt does not comprehend speech==Wernicke’s==Fluent
- Pt does not comprehend speech==Global aphasia==NON-fluent
- Pt DOES comprehend speech==Broca’s==NON-fluent
Fluent speech aphasia
Wernicke’s
- Pt does NOT comprehend (comprehension prob)
- receptive
NON-fluent speech aphasias
Broca’s
- Pt comprehends
- BEN has Broca’s–> Broca’s, Expressive, Non-fluent; Broken syntax
Global aphasia (s/s both Wernicke’s/Broca’s)
- Pt DOES NOT comprehend speech
Fluent (WernIcke’s/Sensory/Receptive) Aphasia
What artery and S/S?
INF MCA
- Lesion=> Auditory assoc. cortex L. Lat Temporal Lobe
- Speech flows smoothly w/ variety of grammatical constructs and preserved melody of speech
- Comprehension impaired
- Pt demos diff in comprehending lang and in following commands
remember Temporal lobe is hearing and COMPREHENDING what we hear!
NON-fluent aphasia (Broca’s/Expressive aphasia)
What artery and S/S?
NOTE: Comprehension is OK
SUP MCA
- Premotor area of L. Frontal lobe
- FLOW of speech slow, hesitant, vocab limtd, syntax impaired
- COMPREHESION GOOD
- Speech production labored or lost completely
Side Specific Sx’s
Right CVA
Think “baby in a Rocker
Impulsive makes decisions too quickly–> Baby in a Rocker
- LEFT side weak/paralysis
- Left neglect, spatial-perceptual probs
- IMPULSIVE!
- Short attn, STM loss
- Communication probs—weak facial mm’s
- Cog probs
Gait belt! NEVER leave pt alone! IMPULSIVE!
Side Specific Sx’s
Left CVA
Think “OLD person”
CAUTIOUS in making judgements; act like OLD person
- RIGHT side weak/paralysis
- Aphasias–> Dmg’d Brocas (frontal) or Wernickes (temporal)
- Personality changes– Cautious (opp to R side), disorganized
- Diff w/ NEW info–> dec memory, diff generalizing or conceptualizing
MOTIVATE YOUR Pt!!! d/t slow, cautious, unmotivated
Practice!
Pt w/ recent R sided CVA has perceptual deficits and poor awareness of impairments. Which strategies to use?
- more verbal cues/commands
- Supine pos–> L scapula should be protracted and shoulder slightly abd’d
- L S/L- L. hip should be extended and knee flexed and supported by pillows
Visual cues not good bc they hve perceptual problems!
Positive and Negative Features of Upper Motor Neuron Syndrome
see chart
Reflexes
DTRs vs Pathologic
DTRs
- Asymmetry
- UMN: HypERreflex
- LMN: HypOreflex
Pathologic
- Babinksi–> Clear UMN sign
Practice!
New pt w/ LEFT CVA. Initial exam, what s/s most likely present?
OLD lady! slow cautious, R motor and sensory loss, R weakness, language defs aphasias, personality changes, decd memory,
Clonus of gastroc mm R. lower limp (abnorm reflexes)
NOT rigidity! Spasticity in CVA present
Abnormal Synergy Patterns
Just memorize which ones are more predominant in UE (flexion)/LE (extension)
This way if you remember the more common ones, the LESS common are just the OPPOSITE!!! So only remember 1 for ea!
UE abnorm synergy: FLEX more common
LE abnorm synergy: EXT more common
Abnormal Synergy Patterns
UE: more common and entails?
Inc tone, multi jts
Unable to move jt individually
no isolated mvmts
FLEXION synergy more common
- Scapular retraction, elevation, hyperext
- Shoulder ABD, ER
- Elbow Flex
- Forearm SUP
- Wrist and finger Flex
AND THEN YOU KNOW THAT EXT IS OPP OF ALL OF THESE!
Abnormal Synergy Patterns
LE: More common and entails what?
EXTENSION synergy more common
- Hip EXT, ADD, IR
- Knee EXT
- Ankle PF, INversion
- Toe Ext
Now you know w/ Flexion LE synergy it is just the OPP
Circumducted gait bc LE “longer”
Brunnstrom Stages of Recovery (Cohen)
Stage I: Flaccidity
- Flaccidity of involved limbs
- NO reflex OR voluntary mvmts
Brunnstrom Stages of Recovery (Cohen)
Stage II: Beginning of MIN voluntary mvmt
- Min. voluntary mvmt or assocd reactions
- Mvmts in partial or whole synergy patterns
- Spasticity BEGINS to develop
Assocd reactions– contraction elsewhere in body causes contract where observing
Brunnstroms Stages of Recovery (Cohen)
Stage III: Voluntary control of mvmt synergy (splints, RIPs)
Diff stage bc spasticity @ PEAK
- Voluntary control of mvmt synergies
- Mvmt may NOT be full ROM
- Spasticity @ peak–HypERtonia (severe)
Brunnstroms Stages of Recovery (Cohen)
Stage IV: Dec Tone
- SOME mvmts OUT of synergy
- Spasticity DEC, but observable
**- Indiv can: ** place hand behind body, elevate arm to forward horz pos (flex), PRO/SUP w/ elbow @ 90deg
Brunnstrom Stages of Recovery (Cohen)
Stage V: Declining spasticity
- Declining spasticity**
- INC in complex mvmt; able to perform more diff mvmts OUT of synergy
- Ind can: abduct arm, flex arm and OH, Pro/Sup w/ elbow ext’d
Brunnstroms Stages of Recovery (Cohen)
Stage VI: Indiv, isolated jt mvmts
- Indiv jt mvmt, coord’d mvmt (nearly norm)
- NO spasticity!
- Ind can: hand from lap to chin, hand from lap to opp knee (MAJOR PROGRESS d/t isolating elbow is diff)
Brunnstroms Stages of Recovery (Cohen)
Stage VII: Normal motor function
Normal motor function
Brunnstrom’s Stages of Recovery
See pics and note the INC in spasticity to DEC and moving from synergies to controlling synergies to isolated mvmts!
Practice!
PT eval’ing 86yo w/ R CVA due to MCA infarct 4 wks ago. Classic s/s MCA CVA. Reflex testing. What should PT expect?
L. sided hypERreflex and + Babinski (toes fan out)
Positioning Strategies to Reduce Common Malalignments
UE or LE, what is the basic jist/point of positioning? What do we want to do/achieve?
Want to BREAK OUT of all synergies!
Put them in pos’s OPP of synergies!
Positioning Strategies to Reduce Common Malalignments
Supine position
Head, Neck, and if more affected UE (remember FLEX synergy more common)
LE other card
HOW TO SET THEM UP:
Head/Neck: Neutral and symmetrical; support on pillow
Trunk: Aligned @ midline
More affected UE (flexor syn common): Scapular protracted; Shoulder forwrd/slight abd’d; arm supported on pillow; Elbow ext’d w/ hand resting on pillow; Wrist neutral; Fingers ext’d; Thumb abd’d
Pos’ing Strategies to Reduce Common Malaligns
Supine position
Head, Neck–> you did prev card
If more affected LE (remember EXT synergy more common)
HOW TO SET THEM UP:
More affected LE (EXT synergy more common)
- Hip forward (pelvis PROtracted); Knee on small pillow or towel roll to prevent hyperEXT; NOTHING against soles of feet.
- *If persisten PF, splint can be used to pos. foot/ankle in neutral pos.
Positioning Strategies to Reduce Common Malalignments
S/L on MORE Affected Side
Head/Neck, Trunk, More affected UE (Flexion synergy common)
Head/Neck: Neutral/Symmetrical
Trunk: Alignment in midline
More affectedUE (Flexion common): Scapular protracted; Shoulder forward; Arm in slight ABD/ER; Elbow Extd; Forearm sup; Wrist neutral Fingers extd; Thumb abd’d
Positioning Strategies to Reduce Common Malalignments
S/L on MORE Affected Side
Head/Neck, Trunk, More affected LE (EXT synergy common)
Head/neck–see prev
Trunk–see prev
More affected LE (EXT synergy): Hip extd and knee flexed and supported by pillows. ALTERNATIVE pos–> Slight hip and knee flexion w/ pelvic rotation
Positioning Strategies to Reduce Common Malalignments
S/L on LESS AFFECTED Side
Head/Neck, Trunk, More affected UE (Flexion synergy common)
Head/Neck: Neutral and Symmetrical
Trunk: Aligned in MIDLINE; small pillow or towel can be placed under rib cage to elongate the hemiplegic side.
More affected UE (flexion more common): Scapular protracted, Shoulder forward; Arm on a supporting pillow w/ Elbow Extd, Wrist neutral, Fingers extd, Thumb abd’d
Positioning Strategies to Reduce Common Malalignments
Sitting in Armchair or W/C
Head/Neck, Trunk, Pelvis, More affected UE, Both LEs
Head/neck: Neutral/Symmetrical; head directly above pelvis
Trunk: Spine EXT
Pelvis: Aligned in neutral w/ WB on buttocks
More affected UE: Shoulder protracted and forwrd; Elbow supported on arm trough or lapboard; Forearm/wrist neutral, Fingers extd, Thumb abd’d (resting splint prn)
BOTH LEs: Hips flexed to 90/90, pos’d in neutral w/ respect to rotation.
Practice!
82yo suffered R. stroke (L affected) a week ago. PT educating him on various pos strategies. MOST approp for S/L on LEFT side (affected side?
Head/Neck: neutral
L. scapular protracted
L arm in sligh ABD/ER
Elbow EXTd
Forearm sup’d
Wrist neutral
Fingers EXTd
Thumb ABD’d
Practice!
82yo suffered R. stroke (L affected) a week ago. PT educating him on various pos strategies. MOST approp for S/L on LEFT side (affected side?
Head/Neck: neutral
L. scapular protracted
L arm in sligh ABD/ER
Elbow EXTd
Forearm sup’d
Wrist neutral
Fingers EXTd
Thumb ABD’d
Pusher Syndrome aka
Contraversive pushing
- Push ONTO WEAK side–> using STRONG side to push to weak side
Tx’s:
- Have pt push/lean onto you AWAY from weaker side
- Mirror tx
- Have strong side next to wall and ask them to lean onto wall
Stroke- Interventions using Neurodevelopmental Techniques (NDT)
Kickstand
Tactile cueing on quads w/ clasped hands
PNF
UE PNF Patterns
Chart, but you KNOW THESE!!!
SEE PICS
PNF: UE D1 Flex/Ext
Flex think Eating
Ext think Pushing away
HEAD MUST FOLLOW ARM/HAND TO BE PNF!!!
D1 Flex:
- Shoulder: Flex, Add, ER
- Forearm: Sup
- Wrist: Radially flexed
- “Eating”
D1 Ext:
- Shoulder: Ext, ABD, IR
- Forearm: PRO
- Wrist: Ulnarly ext’d
- “Pushing away”
PNF: UE D2 Flex/Ext
HEAD MUST FOLLOW ARM/HAND TO BE PNF!!!
D2 Flex:
- Shoulder: Flex, Abd, ER
- Wrist: Radially Extd
- Drawing a sword
D2 Ext:
- Shoulder: Ext, ADD, IR
- Wrist: Ulnarly flexed
- Putting sword BACK
Implementing PNF into HEP
Head/neck and Trunk Chop
Think Chop DOWN: D1 Flex into D1 Ext
Lead arm (weak arm) BEGINS D1 flex and moves into D1 ext
*use Opp arm (strong) arm to assist (opp arm moving in D2 patterns–dont memorize this)
Head, neck, and trunk must all go WITH WRIST/HAND
Implementing PNF into HEP
Head/neck and Trunk Lift
Think Lift UP: D2 Ext into D2 Flex
Lead arm (weak arm) BEGINS D2 EXT and moves into D2 FLEX
Upper trunk, head and neck extend/rotate TOWARD lead hand–MUST FOLLOW
UE PNF- Thrust Pattern aka Boxing!
Thrust Pattern
see pics
LE PNF Patterns- Overview
LE/D1– FAdER; EABIR
LE/D2– FABIR; EAdER
D1 LE-Flex/Ext
D1 Flex: put pants on or socks, cross
D1 Ext: getting out of car
LE D1 Flexion
- Hip flex, add, ER
- Knee flex or ext
- Ankle DF, Inv
- Toe ext
- “Putting pants on or socks, cross”
LE D1 Extension
- Hip ext, abd, IR
- Knee flex or ext
- Ankle PF, EV
- Toe flex
- “Getting out of car”
D2: LE Flex/Ext
D2 Flex: Moving over in seat- very AWK
SAME POS @ KNEE FOR ALL**
LE D2 Flexion:
- Hip flex, abd, IR
- Knee flex or ext
- Ankle DF, EVersion
- Toe flexion
LE D2 Extension
- Hip ext, add, ER
- Knee flex or ext (SAME @ KNEE FOR ALL)
- Ankle PF, INV
- Toe flexion
Practice!
Pt w/ PD exhibits forward stooped posture. Which PNF pattern MOST approp for posture?
B/L D2 Flexion
Draw 2 swords!!!
TBI’s
Coup and Contrecoup
see pics
Glasgow Coma Scale (EMV)
LESS than _ == COMA
Eye: 1-4; Motor: 1-6; Verbal: 1-5
< 8
Glasgow Coma Scale (EMV)
What is it/How scored?
Score interpretations?
Obj way to describe pts Lvl of Consciousness
- Eye: 1 (never)-4(spont.)
- Motor: 1(none)-6(obeys commands)
- Verbal: 1(none)-5(Oriented)
Scores:
- 3-8= SEVERELY ABNORMAL
- 9-12= MOD abnorm
- 13-14= Mild abnorm
- 15= MILD TBI
Glasgow Coma Scale
Eye Opening: 1-4
4: Spontaneous
3: To sound
2: To pain
1: Never
Glasgow Coma Scale
Motor Response: 1-6
6: Obeys commands
5: Localizes pain
4: Normal flexion (w/drawal)
3: ABnormal flexion
2: Extension
1: None
Glasgow Coma Scale
Verbal Response: 1-5
5: Oriented
4: Confused conversation
3: Inapprop words
2: Incomprehensible sounds
1: None
TBI- Tone abnorms
Decorticate posturing vs Decerebrate (all the E’s)
Decorticate== FLEXION one in UEs
Decerebrate (all the E’s)== EXT one!
Practice!
Pt dx w/ TBI. Pt opens eyes to speech, makes convo w/ inapprop words, w/drawals from touch and rolls eyes. Lvl of severity?
Opens to speech= 3
inapprop words= 4
w/drawals= 4
=11= Mildly abnorm
Rancho Los Amigos: Lvl of Cog Functioning
Lvl you HAVE TO KNOW
Lvl 4: Confused-Agitated– Needs MAX ASSIST
RLA: Lvl of Cog Functioning
Break it down by Lvl, Response, Assist
This will help you get it organized!!!
Lvl I: NO response: TOTAL assist
Lvl II: Generalized response: TOTAL assist
Lvl III: Localized response: TOTAL assist
Lvl IV: Confused-Agitated: MAX assist (problem lvl)
Lvl V: Confused-Inapprop: MAX assist (angry stage)
Lvl VI: Confused-Approp: MOD assist
Lvl VII: Automatic-Approp: MIN assist
Lvl VIII: Purpose-Approp: Stand-By assist
Rancho Lvl IV
KNOW THIS ONE!!!!
RLA IV
Confused-Agitated
- Alert, INCd state of activity
- Aggressive or flight behavior
- absent STM
- UNable to cooperate w/ tx
Set up the environment!!!–more on this
Rancho Lvl IV
Set up Environment
THE ONE TO KNOW!
Set up environment + other deets:
- Quiet room, Remove distractions, Remove objs that could be thrown or used aggressively
- Simple instructions w/ process time
- Watch frustration–know when to stop/change acts.
- Safe choices–allows pt to feel they have control over situation
Interventions?–next cards
Rancho Lvl IV: Interventions
- NOTE: give control to pt when SAFE and APPROP. Control given while maint. focus on therap. goals by phrasing questions as, “would you rather play ball or go fora walk? PREVENTS situations where the pt chooses an undesirable or unrealistic activity if asked “What would you like to do?” Or case where pt simply answers “NO” when asked “Would you like to…?”
Motor probs:
- Prepare MULT. acts
- Give pt choices (No y/n ?’s)
Behavioral probs:
- Be calm, Be consistent (SAME tx time, PT, loc)
- Provide orientation
- Know when to stop/change acts.
Rancho Lvl IV: Interventions
- NOTE: give control to pt when SAFE and APPROP. Control given while maint. focus on therap. goals by phrasing questions as, “would you rather play ball or go fora walk? PREVENTS situations where the pt chooses an undesirable or unrealistic activity if asked “What would you like to do?” Or case where pt simply answers “NO” when asked “Would you like to…?”
Motor probs:
- Prepare MULT. acts
- Give pt choices (No y/n ?’s)
Behavioral probs:
- Be calm, Be consistent (SAME tx time, PT, loc)
- Provide orientation
- Know when to stop/change acts.
Rancho Lvl V:
Confused-INapprop, NON-AGITATED
Deets:
- Unable to learn new info
- Freq brief pds, NON-purposeful sustained attn
- Consist approp resp to SIMPLE commands in structured environ
- Demos INapprop use of objs w/out ext. direction
Interventions? next cards
Rancho Lvl V:
Confused-INapprop, NON-AGITATED
Interventions:
- Quiet environment, HIGHLY structured functional tasks, Give control to pt when safe/approp
- Give options
- Use cues/ext. direction
- Use Assistive devices
- Tx plans– include using daily planner
Rancho Lvl VI:
Confused-Approp
Deets
- LITTLE carry-over for new learning
- MAX A for new learning w/ little or no carry over
- Consistently follows SIMPLE directions
- Unaware of impairs, disabilities and safety risks (KNOW THIS ONE!)
INTERVENTIONS? NEXT CARDS
Rancho Lvl VI:
Confused-Approp
Interventions:
- HIGHLY structured functional tasks
- DECREASE: use of cues/ext direction, use of ADs (opp of RLA V: Confused-INapprop)
- INC: speed and complexity of tasks as able
Practice!
TBI pt. Confused-Agitated (RLA IV). Memory impairs (esp STM), unable to recall day/loc or acts performed in prev sessions. All approp recommendations?
- Establish daily routine, orient pt place and time freq, use chart/whiteboard in pts room to doc progress
DO NOT: challenge pt to provide loc/date—they have STM loss and you’ll piss them off even more!!!
Rancho Lvl VII:
Automoatic-Approp
Deets
- MIN supervision for NEW learning, w/ carry-over (into other tasks)
- Initiation AND follow thru of basic ADLs
- MIN supervision for safety in home-routine/commun acts
- **Able to attend to HIGHLY familiar tasks in non-distract environ for @ least 30mins w/ MIN-A to complete tasks
Interventions? next cards
Rancho Lvl VII:
Automoatic-Approp
Interventions:
Motor probs
- STRUCTURED functional tasks
- INC complexity of tasks
- Work on coord/fine motor
With intervention guidelines
Moving from RLA IV (confused-agitated) to RLA V (confused INapprop), VI (Confused-approp), and VII (Automatic-Approp)
RLA IV–FOCUSED, structured
RLA V, VI, VII– MOVE from structured to more complex environment
