The Evaluation of Persons with Brain Injury Flashcards
the pt presentation with CVA can vary based on what factors?
cause of stroke
area of infarct
setting
what are the 2 types of stroke?
ischemic and hemorrhagic
which stroke is more common?
ischemic stroke
what is the most common area of infarct?
MCA (middle cerebral artery)
a stroke of the cerebellum will result in what deficits?
coordination deficits
what is the focus of acute/subacute CVA care?
medical stability (hemodynamics, respiratory fxn)
in acute/subacute stroke rehab, which is more common, flaccid or spastic hemiplegia?
flaccid hemiplegia
what are the characteristics of chronic CVA care?
stable but CV impaired
spastic hemiplegia
loss of fractionated movement
what is normal CBF?
60
what is the threshold for synaptic transmission for CBF?
20
what is the CBF levels indicative of irreversible damage?
12
what is the CBF range for reversible damage/suboptimal fxn?
12-20
what is the CBF range for adequate function?
20-60
why will a pt’s BP be kept high post CVA?
to increase perfusion
what is the penumbra?
the area of vulnerability around the dead tissue post CVA that is silent, not dead from a lack of blood flow
with adequate restoration of perfusion, it can be reversed
what are the characteristics of a left hemisphere lesion?
difficulty communicating
difficulty processing info in a sequential, linear manner
cautious, anxious, and disorganized when trying new tasks
realistic in appraisal of problems
what are the characteristics of a right hemisphere lesion?
difficulty in spatial-perceptual tasks
overestimation of their abilities (decreased awareness of limitations)
may have L neglect and even pusher
geographically challenged
what are common s/s following a stroke?
impaired motor control (flaccidity vs spasticity, decreased activation on the involved side, decreased contralateral strength)
impaired sensation and proprioception
limited ability to ambulate
limited postural stability
limited fxnal mobility
limited ability to perform self-care and ADLs
what are some less common, lesion-specific s/s following a stroke?
impaired language and communication
dysphagia (deep and posterior, more severe)
impaired cognition/memory
impaired behavioral control and judgement
visual/perceptual deficits ; unilateral neglect
apraxia (sequencing issue)-premotor injury
limbic: fear, emotional lability, depression
impaired B/B control
pain (MSK, neuro)
sleep disturbances
is the issue post CVA more so strength or activation of muscles?
activation of muscles
what is the first step in treatment post CVA?
postural alignment!!!
what are the primary impairments in CVA?
changes in muscle tone, muscle activation, muscle strength, and sensation
what are the muscle tones that can result from CVA?
flaccidity, hypotonicity, and spasticity
what are the deficits in muscle activation that can result from CVA?
poor initiation, muscle sequencing, timing, or firing
what are the deficits in muscle strength that can result from CVA?
flaccid paralysis or weakness, contralateral weakness
what are the deficits in sensation that can result from CVA?
varying degrees of light touch, nociception, static, and dynamic position sense
what secondary impairments can result from CVA?
changes in postural alignment, stability, and/or mobility
atypical movement synergies
clinical hypertonicity
changes in muscle and soft tissue length
pain, edema, skin integrity, vascular integrity (DVT)
what is clinical hypertonicity?
not spasticity, but movement related phenomenon where more movement and effort leads to increased tone
what are composite impairments that can result from CVA?
functional movement deficits
undesirable functional compensations and learned non-use
pain
in the hours to days following CVA, what happens?
flaccid hemiplegia
electrical silence
when does the most significant recovery occur post CVA?
the 1st 6 months
what are the key components of interventions post-CVA?
make the interventions skilled, task-specific, goal directed
how long post CVA can pts generally make improvements?
2-3 years
t/f: interventions have to be salient to the pt
true
what % recover to near complete fxning?
10%
what % recover fxnally with mild impairment?
25%
what % experience moderate to severe impairments?
40%
what % require placement and 24 hrs care?
10%
what % die as a result of CVA?
15%
t/f: early intervention yields more potent results
true
what is one of the main determinants of synaptogenesis?
training, specifically experience-induced or fxn-induced cortical reorganization
t/f: the cortex has the capacity to change structure and fxn during training and enriched environments
true
t/f: the anatomy of the damage, time since damage, age of pt, and amount of therapy received influences changes that can be made
true
t/f: the secondary motor areas become more fxnally relevant w/damage to the primary motor cortex, but can’t fully compensate
true
what is involved in acute care d/c planning?
chart review, labs/imaging/meds/social hx, MD orders, nursing report, AIDET, systems review, and fxnal assessment
what is involved in d/c planning for chronic CVA?
observation, AIDET, interviewing, HPI/imaging, meds, social/PLOF, ROS, systems review, examination
what do we want to know in acute CVA care?
date, type, location
current med stability, parameters
initial presenting symptoms and severity
timing of medical intervention
hx of management to date
trajectory of recovery
presence of complications
current vs previous status, prognosis
optimal d/c setting given status and supports
what do we want to know in chronic CVA care?
date, type, and location
current presenting symptoms and severity; summary of progression
medical interventions, w/complications
what type of Rx (medical, PT, OT, SLP) has pt received
desired goals
limiting factors
what social info is critical to obtain or ask for?
social hx and level of function
what are the screenings in acute CVA care?
medical stability
alertness
cognition and ability to follow commands
communication
perception
sensory and motor fxn
postural control and functional status
if a pt has HTN (>165/95mmHg) what is their risk for stroke?
6x increased risk
if a pt has heart disease, what is their risk for stroke?
2-6x increased risk
if a pt has A-fib, what is their risk for stroke?
increased risk of ischemic stroke, DVT, edema
what is the risk for a pt that has HF w/ or w/o reduced ejection fraction (EF)?
reduced exercise tolerance
if a pt has DM, what is their risk for stroke?
3-6x increased risk
what are the 5 components of metabolic syndrome?
increased waist circumference, increased BP, decreased HDL, increased triglycerides, increased fasting glucose
if a pt with metabolic syndrome has all 5 components present, what is their stroke risk?
5 fold stroke risk
what CV conditions increase risk for stroke?
HTN, heart disease, A-fib, HF
what endocrine disorders increase stroke risk?
DM, metabolic syndrome, obesity, and hypothyroidism
what neurologic conditions increase stroke risk?
hx of stroke, TIA, tumor, or brain injury
sleep fxns
cognitive decline (is dementia)
behavioral/psychological changes
what pulmonary conditions increase stroke risk?
smoking
what are precautions for CVA in acute care?
b4 seeing the pts, obtain and follow the physician’s orders regarding bed rest, activity, and vital signs parameters
pre-plan your sequence and equipment, assistance needs, and safety plan
monitor vital signs for all individuals
implement fall precautions
monitor pt’s pain and fatigue
plan ahead in regards to neglect and impulsivity
monitor for PT vulnerability (potential abuse)
pts with flaccid hemiplegia may be at risk for what?
shoulder pain and dysfunction
what critical evaluation limitations can greatly impact your eval?
beginning postural alignment
alertness, cognition, communication
behavior, attention, judgement, motivation
perception, neglect
motor sequencing and planning issues (apraxia)
what should be done at the start of a CVA intervention?
postural adjustments (esp the pelvis)
what is included in the neuro section of the systems review?
signs of seizures or hydrocephalus
screen of CNs
swallowing fxns
mentation
communication
behavior
motor fxns
executive fxns
what are the 5 breathing patterns to be aware of?
eupnea
bradypnea
biot’s respirations
cheyne-strokes respirations
apnea
what is eupnea?
normal respiration w/ equal rate and depth
12-20 breaths/min
what is bradypnea?
slow respirations
<10 breaths/min
what are Biot’s respirations?
irregular respiration of variable depth (usually shallow), alternating w/periods of apnea
what are Cheyne-Strokes respirations?
gradual increase in depth of respiration followed by gradual decrease and then a periods of apnea
what is apnea?
absence of breathing
why does hemorrhagic CVA pose concern for respiration?
the bleed can expand and shift structures and put pressure on the BS (respiratory and vital fxns)
why would acute CVA BP be higher?
doctors often set it higher to increase perfusion
anyone with dysphagia should have what vital sign monitored?
temperature
what are s/s to watch for aspiration and swallowing dysfunction?
excessive drooling, wet/gurgly voice, frequent coughing/choking
poor oral food management, pocketing of food
what are the interventions for aspiration/swallowing dysfunctions?
referral to SLP
positioning for meals
precautions pertaining to oral intake should be implemented where indicated
monitor and inform
what is the primary auditory cortex responsible for?
auditory discrimination
what is the secondary auditory cortex responsible for?
classification of sounds (language vs other sounds)
what is wernicke’s area responsible for?
auditory comprehension, vocabulary
what is the role of the subcortical connections?
to connect broca’s and wernicke’s area
what is broca’s area responsible for?
instructions for language output
what is the oral and throat region of the sensorimotor cortex responsible for?
cortical output to speech muscles
what are strategies for Broca’s aphasia?
allow for supplemental time
if you know what they’re talking about, provide the 1st letter of the word or a sentence completion cue
ask the pt to DESCRIBE the object they’re unable to think of (look, fxn, location)
ask pt to gesture the sue of the object
reading aloud may be fluent
songs and automatic language
what aphasia can understand but can’t communicate?
Broca’s
t/f: pts with broca’s aphasia tend to get frustrated
true
what are strategies for wernicke’s aphasia?
limit verbal commands
avoid open ended ?s
ask the pt to GESTURE the use of the object
reading/writing are not going to be effective
which aphasia will the pt not understand what you’re saying, speak in gibberish, and pretent that they understand you?
Wernicke’s aphasia
what are strategies for dysarthria?
proximal stability for controlled mobility
proper breathing support
increased volume of speech
decreased rate of speech
hard articulatory contacts
increased oral cavity opening
short phrasing
allow supplemental time
what are strategies for verbal apraxia?
focus on improved motor production
repeating sounds and practicing the correct mouth movements
encourage the pt to speak slowly ‘‘silent rehearsal
rest breaks
visual model
allow supplemental time
more severe=AAC
encourage use of hand gestures, writing, pointing to letters/pictures, and a computer
what are commonalities in aphasia strategies?
short phrases
speak slowly
avoid complex commands and questions
repeat as needed
modeling
visual cues
decreased external stimuli
allow supplemental time
difficulty understanding what they’ve read
what is included in a functional assessment?
changing and maintaining body position (transfers, bed mobility, bending, squatting, sitting, standing)
walking and moving (short, long, terrain change, stairs, obstacles, etc)
what should be considered in assessing levels of assistance?
how much of the tasks can the pt complete themselves
what makes the pt successful (time, facilitation, cues, sequencing, assitance)
ind, sup v, CG, min A, mod A, Max A, dep
% performed
what predicts d/c during acute hospitalization?
AM-PAC “6 click”
t/f: the AM-PAC “6 click” is done like the Berg Balance, asking the patient to perform each task
false, it is done based on observations during the visit
what does the AM-PAC “6 click” evaluate?
mobility and independence w/mobility
are unilateral or BL ADs better post-stroke?
BL
what is wrong with using a hemiwalker post stroke?
it tends to promote asymmetry and non use of the involved side
t/f: a walker is often used post-stroke and can have a platform to position the hand in a way that doesn’t promote increased tone
true
what is taken into account for prescription of assistive technology?
motor fxn, prognosis, and ambulatory status
when a pt is d/c home, home health, or outpatient, do we prescribe ADs?
yes
when a pt is d/c to IFR to home or subacute to home, do we prescribe ADs?
sometimes
when a pt is d/c to ECF and/or are non-ambulatory, do we prescribe ADs?
nope!
how do we leave pts when we finish the bedside eval?
symmetrical (if possible upright) and with the call bell in reach
communicate how you leave the pt
in acute care, what is the exam/screening of mental functions consisting of?
A and O x4, commands, observation for other signs of impaired mental fxns [Mini cog]
in chronic care, what is the exam/screening of mental functions consisting of?
systems review (A and O x4, commands), MoCA
what are some orientation deficit strategies?
introduce and explain why you are there (point to your name badge)
ask about the circumstances of their injury and fill in as needed (once they can tell you about their stroke, you don’t have to focus on cognition anymore bc you have it)
make eye contact to ensure you have their attention
what are some executive function deficit strategies?
may need to help them “get started” or to keep them going
may need to re-direct if impulsive or perseverative (repetative words, actions, etc)
break things down to assist them w/sequencing or organizing their thoughts and actions
may be unaware of their errors/safety issues, so provide concrete feedback
what are some attention deficits strategies?
decrease extraneous noise/stimuli as much as possible
say pt’s name prior to providing verbal info
make and ensure eye contact when speaking
keep questions and instructions simple
change activity as appropriate
one activity/step at a time
forced choices
rest breaks
incorporate problem solving
pt/caregiver education for carryover
when using attention deficit strategies, what do you document?
document the time the pt can attend to the type of task
if cues are provided, count the # of cues/time
what are some memory deficit strategies?
realize they may not be able to recall case hx info or even personal info (check to rule out confabulation)
face to face communication
use less words (declarative) and more procedural
repetition
rehearsal
write important info down
set timers/alarms
set schedule
pt/caregiver education for carryover
break things down into smaller units and repeat, repeat, repeat
what is confabulation?
when a pt fills in the void when they can’t remember a story
what should be documented with memory deficit strategies?
of cues, % content remembered
what is hemi-spatial neglect?
pt can’t tell where their body is in space
what CVA would cause hemi-spatial neglect?
R parietal lobe lesion
what is hemi-body neglect?
pt can’t feel one side of their body
what spatial relations may be present post-stroke?
difficulty in perceiving the relationship bw self and objects in the environment
what are agnosias?
inability to recognize incoming info despite in tact sensory capacities
what is anosognisia?
pt is unaware of their illness
what is somatognosia?
pt is unaware of one’s own body
if you move towards a pt’s neglectful side and they track you, is it mild or severe?
more likely mild
if you move towards a pt’s neglectful side and they can’t track you, is it mild or severe?
more likely severe
what should be documented with neglect?
what resting neglect is
what it takes to improve it and much it improves
how long attention is maintained
t/f: for a pt with neglect, position yourself in the L visual field if possible, or position where the pt can remain engaged visually
true
what are some problem-solving strategies?
have the pt verbalize possible solutions to a given activity
have the pt verbalize appropriate solutions to a given activity
immediately bring unsafe/inappropriate actions to the pts attention
ask the pt what the safest and most effective solution
pt/caregiver education for carryover
what should be documented for problem-solving strategies?
the # of cues or % of the task the pt can complete w/ or w/o cues
what are strategies for poor safety awareness. impulsivity, anosognosia, and somatognosia?
think it through b4 you act (you and the pt)
ask the pt what their deficits are
ask pt what has happened to them; point out deficits as needed
ask pt why they need to use an AD
incorporate problem solving
ask pt to verbalize the steps they intend to do b4 doing them
ask pt to perform each step slowly; even consider counting or verbalizing through the activity
engage pt in an activity (to a certain extent) if they’re insistent, they can perform despite deficits so that they may see they’re unable
pt/caregiver education for carryover
what is the role of the BG in movement?
makes the efferent copy of the movement
what is the role of the cerebellum in movement?
revision of movement
which stroke subgroup experiences impulsivity and difficulty with problem solving?
R MCA or BS
what population would benefit from sequencing strategies?
pts with impulsivity
what are some sequencing strategies?
break down the whole task into parts
have PT verbalize steps to an activity prior to performing it
generate written steps
immediately point out incorrect steps
incorporate problem solving
pt/caregiver education for carryover
what should be documented with sequencing strategies?
of cues in a given activity prep, initiation, or execution
what are some motor planning and motor sequencing strategies for the pre-motor cortex?
breakdown whole tasks into parts
provide proximal stability for distal mobility
include stability as part of the movement sequence
what are some motor planning and motor sequencing strategies for the SMA?
break down whole tasks into parts
use bi-manual activities
use demonstration, hand-over-hand, repetition
have pt ID movement sequence errors
incorporate problem solving
what is the Yerkes-Dodson inverted-U principle?
bell curve that shows appropriate levels of arousal allowing for optimal motor performance
high/low arousal or limbic levels can deteriorate motor performance and limit ability to motor learn
how can you examine for levels of arousal/limbic levels?
ANS responses of homeostatic state including HR, BP, RR, pupil dilation, and sweating
determination of pt reactivity, including degree and rate of response to stimulation (touch, sound, light, smell)
what are some emotional-limbic effects of stroke?
apathy
euphoria
increased irritability/frustration
depression
social inappropriateness
pseudo-bulbar affect
what is apathy?
shallow affect and blunted emotional responses
what CVA would cause apathy?
L or frontal lobe injury
t/f: euphoria is a common effect of stroke
false
what CVA would result in increased irritability/frustration?
L CVA (R hemiplegia)
t/f: depression is an extremely common effect of stroke
true
what kind of depression is caused by stroke?
neurogenic depression
t/f: there is a greater fxnal impairment at both admission and d/c with depression post-stroke
true
t/f: pts with stroke and depression have a lower level of participation in the rehab process
true
t/f: pts with stroke and depression experience similar gains over a the course of rehab
true
t/f: pts with stroke and depression experience spontaneous resolution w/in several months of onset
true
what is pseudobulbar affect?
emotional lability, emotional dysregulation, uncontrolled emotional outbursts that are random and obstructive
can PBA be medically managed?
yes
who can help with emotional-limbic effects of stroke?
neuropsychologist
in the outpatient setting, what makes up the eval?
observation, AIDET, interview (HPI/imaging), meds, social/PLOF, ROS, systems review, exam
does inpatient or outpatient use more evaluative functions?
outpatient
what is evaluated in outpatient?
motor fxn, praxis (sequencing), strength, postural control and fxnal status, outcomes measures
is inpatient or outpatient more focused on fxnal improvement?
outpatient
what does the standard fxnal examination include?
movt assessment
levels of assistance
documentation
what should be documented in the standard fxnal assessment
time, facilitation, cues, sequencing, assistance
what levels of assistance may be documented?
indep, sup v, CG, min A, mod A, max A, dep
what is the FIM?
fxnal independence measure
t/f: the FIM takes into account the assisstance and time
true
what measure is great for non-ambulatory patient?
the FIM
on the FIM what scores show the largest gains in function?
admission FIM >37-72/126
t/f: D/C deposition and FIM score on admission are significantly correlated
true
a FIM score of <40/126 is likely to d/c where?
to LTC facility
a FIM score of >80/126 is likely to d/c where?
home
movement system dx is the impaired movement or motor control related to…
movement pattern coordination deficits
force production deficit
fractionated movement deficit
postural vertical deficit
sensory selection and weighting deficit
sensory detection deficit
hypokinesia
dysmetria
cognitive deficits
______ performance discriminates the effects of stroke and is related to the potential for recovery
gait velocity
t/f: when 10m gait velocity measured are stratefied into clinically meaningful fxnal ambulation classes, changes in velocity are clinically meaningful
true
what is household ambulation gait velocity?
<0.4m/s
what is limited community ambulation gait velocity?
0.4-0.8 m/s
what is full community ambulation gait velocity?
> or =0.8 m/s
t/f: transitioning to a higher class of ambulation is associated with substantially better fxn, QOL, mobility, and community participation
true
why should we make gait training a priority?
bc very early mobilization after stroke fast tracks return to walking
what is the ICF domain of the OPS?
body fxn
what is the Orpington Prognostic Indicator (OPS)?
an assessment of stroke severity based on motor performance, proprioception, balance, and cognition
OPS scores range from ___ to ____
1.6-6.8
do higher OPS scores indicate greater or lesser deficit?
greater deficit
each section of the OPS is graded from ____ to ____
0-1.2
what is a 0 on the OPS?
normal performance
the motor performance of the OPS is based upon what?
the Medical Research Council Grading for Power
the cognitive component of the OPS is based on what?
the Hodkin’s Mental test
what is mild to moderate OPS score?
<3.2
what is moderate to moderately severe OPS score?
3.2-5.2
what is severe to major OPS score?
> 5.2
for OPS scores <3.2, what does it indicate?
high likelihood of returning home
for OPS scores that fall bw 3.2-5.2, they generally respond better to what?
rehab
for OPS scores >5.2, pts are typically dependent or independent?
dependent
t/f: there is no MDC, MCID, or SEM established for the OPS
true
what are the postural deviations of the pelvis
asymmetrical weight bearing with majority of the weight on the stronger side
in sitting, posterior pelvic tilt
in standing, unilateral retraction and elevation on the more affected side
what are the postural deviations of the trunk?
with sacral sitting (post pelvic tilt) a flattened lumbar curve with exaggerated thoracic curve and forward head
lateral flexion with trunk shortening on the more affected side
what are the postural deviations of the shoulders?
unequal height with more effected shoulder depressed
humeral subluxation with scapular downward rotation and lateral flexion of the trunk
scapular instability (winging) may be present
what are the postural deviations of the head/neck?
protraction with lateral trunk flexion
lateral flexion of the head with rotation away from the more affected side
what are the postural deviations of the UEs?
more affected UE typically held in a flexed adduction position, with IR and elbow flexion, forearm pronation, wrist and fingers flexion, and limb is NWB
stronger UE used for postural support
what are the postural deviations of the LEs?
in sitting: more affected LE typically held in hip abduction and ER with hip and knee flexion (flexion synergy pattern)
in standing: more affected LE typically held in hip and knee extension with adduction and IR (scissoring pattern); ankle PF
unequal WB on feet, similar to pelvis in sitting
when a pt is on what medication, will it change the BP parameters allowed by the physician within acute care?
thrombolytics like rt-PA
what medication can mask a pt’s HR during exercise?
anti-hypertensives like ace-inhibitors, ɑ-blockers, ß-
blockers, CA++ channel blockers,
vasodilators, and diuretics
