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’s Stages of Recovery
See pics and note the INC in spasticity to DEC and moving from synergies to controlling synergies to isolated mvmts!
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.
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
TBI’s
Coup and Contrecoup
see pics
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
TBI- Tone abnorms
Decorticate posturing vs Decerebrate (all the E’s)
Decorticate== FLEXION one in UEs
Decerebrate (all the E’s)== EXT one!
Rancho Los Amigos: Lvl of Cog Functioning
Lvl you HAVE TO KNOW
Lvl 4: Confused-Agitated– Needs MAX ASSIST
