Vascular Syndromes Flashcards
2 types of stroke
Ischemic Stroke and Hemorrhagic Stroke
Ischemic Stroke (most common)
Results from thrombosis (static clot) or embolism (traveling clot)
Hemorrhagic Stroke (most fatal)
Bleeding into the brain tissue. Can result from hypertension, aneurysm, or head injury.
Risk Factors for CVA
Age, Sex (men more likely), Race (African Americans more likely), HTN, High cholesterol, cigarette smoking, diabetes, prior stroke, obesity, heart disease
Define Thrombi
clots formed by plaque development in a vessel wall
Define Cerebral infarct
Death of a portion of the brain resulting from a thrombolytic CVA
Define Lacunar Infarct
Small clot located in the deep region of the brainstem and subcortical structures.
Result in less severe impairment.
Define Emboli
Clots that dislodge from their site of origin and travel to a cerebral blood vessel where they become trapped and interrupt blood flow.
Define Aneurysm
Bulge occurring in a blood vessel wall as a result of a clot formation.
Transient Ischemic Attack (TIA)
“mini stroke”
Focal ischemic cerebral incidents lasting for less than 24 hours
Signs and Symptoms of TIA
Numbness and mild weakness on one side of the body. Transient visual disturbances. Dizziness Falls Confusion with possible blackouts
Middle Cerebral Artery Supplies:
Lateral surfaces of the frontal, temporal, and parietal lobes.
Also, the inferior surface of the portions of the frontal and temporal lobes.
Most common artery occlusion resulting in CVA
Middle cerebral artery
Middle Cerebral Artery Left Hemisphere CVA S&S:
Contralateral Hemiplegia Contralateral Hemiparesthesia Aphasia Cognitive Involvement Affective Involvement (emotional lability and depression)
Middle Cerebral Artery Right Hemisphere CVA S&S:
Contralateral Hemiplegia Contralateral Hemiparesthesia Left neglect syndrome Apraxia cognitive involvement Euphoria
Posterior Cerebral Artery Supplies:
Medial and Inferior surfaces of temporal and occipital lobes.
Posterior Cerebral Artery CVA s&s:
Memory loss
Visual Perceptual Deficits
Visual Field Cuts
Anterior Cerebral Artery Supplies:
Superior, lateral, and medial aspects of the frontal and parietal lobs. Basal Ganglia and Corpus Callosum
Anterior Cerebral Artery CVA S&S:
Contralateral Hemiplegia Contralateral Hemiparesthesia Cognitive Involvement Frontal Lobe Involvement Apraxia Affective Involvement
Posterior Inferior Cerebellar Arterial Supplies:
Cerebellar peduncles and medulla
Posterior Inferior Cerebellar Arterial CVA S&S:
Ipsilateral hypertonicity
Ipsilateral Hyperactive Reflexes
Vertigo, Nausea, Nystagmus
Anterior Inferior Cerebellar and Superior Cerebellar Arterial Occlusion May Result in:
Ipsilateral ataxia ipsilateral hypotonicity hyporeflexia dysmetria adiadochokinesia movement decomposition asthenia rebound phenomenon staccato voice ataxic gait intention tremor incoordination facial sensory impairment dysphagia dysarthria Bell's Palsy Nystagmus, vertigo, nausea
Anterior Spinal Artery Supplies:
Medulla (pyramids, vestibular, hypoglossal, glossopharyngeal, and vagal nerve nuclei)
Anterior Spinal Artery CVA S&S:
contralateral hemiplegia (pyramids)
deviation of tongue to affected side (hypoglossal)
Dysphagia and loss of Gag Reflex (glossopharyngeal/vagus)
Nystagmus and Balance Disturbances (vestibular)
Vertebral Artery Supplies:
lateral aspect of the low medulla, including accessory nuclei
Vertebral artery CVA S&S:
dysphagia
Basilar Artery Supplies:
Pons( including corticospinal tract and the abducens, trigeminal, and facial nerve nuclei)
Basilar Artery CVA S&S:
contralateral hemiplegia (corticospinal tract)
medial/internal strabismus (abducens)
Loss of masseter and corneal reflex (trigeminal)
Bell’s Palsy and hyperacusis (facial)
Acute CVA Management
Monitor patient’s neurological function
prevent secondary complications
regulate: BP, cerebral perfusion, intracranial pressure
Flexor Synergy Pattern
Scapula elevation & retraction shoulder abduction & ER elbow flexion forearm supination wrist flexion and ulnar deviation fingers flexion and adduction thumb flexion and adduction hip flexion, ABD, and ER Knee flexion ankle DF and inversion toes DF
Extension Synergy Pattern
scapula protraction and depression shoulder horizontal ADD and IR elbow extension and pronation forearm pronation wrist extension fingers flexion and ADD thumb flexion and ADD hip extension, ADD, and IR knee extension ankle PF and Inversion Toes PF
Define Associated Reactions
Stereotyped movements in which effortless use of one extremity influences the posture and tone of another extremity.
What may have the strongest body of evidence of any therapy intervention for stroke
Constraint Induced Movement Therapy (CIMT)
Forced Use (in CIMT)
Wearing splint/mitt/sling on unaffected arm for 90% of waking hours
Shaping (in CIMT)
6 hours a day of progressive task-related practice
Minimum criteria for CIMT
10 degrees of active wrist extension, thumb abduction, and finger extension
Limitations of CIMT
Time (6 hours a day), personnel hours (6 hours a day), must have partial function intact in hand/wrist, difficult to maintain compliance with restraint schedule
Modified CIMT reduces what compared to regular CIMT?
Time needed (from 6 hours down to 2 hours)
One main potential problem with mental practice with motor imagery is ______ _______ _______.
limited cognitive function
Placing a block on a shelf, simulated drinking from a glass, and transferring a peg from a table to a hole underneath a shelf are examples of _______ ___ _______.
Bilateral Arm Therapy (BAT)
Seeing a loss in shoulder external rotation, followed by abduction and flexion would be indicative of _______ _______.
Adhesive capsulitis
The best mobilizations to improve adhesive capsulitis are what?
Posterior and inferior joint mobs
Treatment for subluxation may include what?
RTC muscle strengthening, shoulder girdle muscles and scapula muscle strengthening, taping, and NMES
Requirements of balance include:
Ability to maintain quiet stance.
Ability to move within base of support.
Ability to correct for unexpected perturbations.
Ability to walk on even surfaces with sufficient stability naturally.
Ability to navigate obstacles and environmental constraints.
To redistribute plantar flexion contractures that may arise from stroke is to insert what?
Heel lifts and/or shoe buildups
A “pusher” stroke patient would push towards what side?
Towards the involved side
T/F? Breaking the push in sitting will carry over to standing.
False, you must break the push in each position.
3 steps in treatment of pushing syndrome
Self awareness, active correction, translation
Sub-maximal measure of aerobic capacity that is targeted at people with at least moderately severe impairment
6-Minute Walk Test
Outcome measure that analyzes walking speed of preferred vs. fast
10 meter Walk Test
Four Subtests of the Action Research Arm Test
Grasp, Grip, Pinch, Gross Movement
Test for passive muscle tone with patient in supine
Ashworth
Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM. What is the Ashworth Grade?
1+
No increase in muscle tone. What is the Ashworth Grade?
0
What does PNF stand for? And what is it?
Proprioceptive Neuromuscular Facilitation, it is synergistic muscle contraction patters which are identified as components of normal movement
More marked increase in muscle tone through most of the ROM, but the affected part(s) easily moved. What is the Ashworth Grade?
2
14-tem scale designed to measure balance and fall risk of the older adult
Berg Balance Test
Test that is useful in identifying gait deviations and improvements as a result of treatment with excellent test and re-test results
Dynamic Gait Index
Measure of extremity impairment severity, measure more arm movement than leg, widely used quantitative measure of motor impairment
Fugl Myer Motor Performance
Describe Fugl Myer Motor Performance Scale from 0, 1, and 2
0 = cannot perform, 1 = performs partially, 2 = performs fully
True or False: Functional Reach Test allows the patient to reach as far they can with taking a step
False: Reach as far as patient can go without taking a step
Variation for functional reach test for individuals who are unable to stand
Modified Functional Reach Test, patient sitting with hips, knees, and ankles positioned at 90 degree of flexion with feet positioned on floor
Describe D2 Extension Pattern for PNF (lower body)
Extension, adduction, ER of hip, ankle PF and inversion
Test utilized within the first 3 months after a stroke has occurred yet can be used with anyone with suspected balance deficits. (High validity and reliability).
Postural Assessment Scale for Stroke Patients
59 item measure with 8 domains measured such as strength, hand function, ADL/IADL, mobility, communication, etc.
Stroke Impact Scale
Scale which quantifies muscle spasticity by assessing the response of the muscle to stretch applied at specified velocities
Tardieu Spasticity Scale
Hands-on problem solving approach which involves direct handling and guidance of patients to optimize function
NDT or Neurodevelopmental Treatment Approach
Main problem in patients with UMN lesions (2 answers)
abnormal coordination, abnormal postural tone
Aims or goals of NDT (2 answers)
selective movement patterns in preparation for functional skills, and reduction of spasticity
By moving the (1-blank) part of the body it is possible to influence and change movements of the (2-blank) parts
1- proximal, 2 - distal
What does PNF stand for? And what is it?
Proprioceptive Neuromuscular Facilitation, it is synergistic muscle contraction patters which are identified as components of normal movement
Describe D1 Flexion Pattern for PNF (upper body)
flexion, adduction, ER (shoulder), flexion of wrist and fingers. “driver reaching back for seatbelt”
Describe D1 Extension Pattern for PNF (upper body)
Extension, abduction, IR (of shoulder), extension of wrist and fingers, “driver buckling seatbelt”
Describe D1 Flexion Pattern for PNF (lower body)
Flexion, adduction, ER of hip, dorsiflexion and inversion of foot, “crossing soccer ball kick”
Describe D1 Extension Pattern for PNF (lower body)
Extension, abduction, IR of hip, plantarflexion (extension) and eversion of foot
Describe D2 Flexion Pattern for PNF (upper body)
Flexion, abduction, ER of shoulder, wrist and finger extension, “drawing sword/holding tray”
Describe D2 Extension Pattern for PNF (upper body)
Extension, adduction, IR of shoulder, wrist and finger flexion, “replacing sword”
Describe D2 Flexion Pattern for PNF (lower body)
flexion, abduction, IR of hip, ankle DF and eversion
Describe D2 Extension Pattern for PNF (lower body)
Extension, adduction, ER of hip, ankle PF and inversion
Pelvic Patterns (PNF): Describe what anterior and posterior movements of the hip and what phase of gait they correspond with
Anterior elevation: swing phase, posterior depression: heel strike/midstance
Typical adhesive capsulitis presentation
Loss of shoulder external rotation, followed by abduction and flexion
Treatment for adhesive capsulitis
Inferior portion of the capsule most damaged, as well as posterior joint tightness, so inferior and posterior glides are most important joint mobs to apply
Requirements for retraining balance
Ability to maintain quiet stance
Ability to move within base of support
Ability to correct for unexpected perturbations
Ability to walk on even surfaces with sufficient stability, mechanical energy, and foot clearance
Ability to navigate obstacles and environmental constraints
Balance Specific Assessment Tests for patients with a stroke
Trunk Impairment Scale: Sitting balance test
Berg Balance Test: Predicts falls in the SUBACUTE phase, and determines length of stay (>20 on the test=home)
Postural Assessment Scale for Stroke (PASS): includes sitting balance and transfers and can predict functional outcomes
Heel lifts to accomodate plantar flexion contractures works by:
Reducing spastic synergy
Reducing knee hyperextension
Improving ability to shift COG forward in BOS (for sit to stand)
Enables patient to relax which may allow for better passive stretching
Which LE muscles are often most weak in stroke patients?
Hip extensors and abductors.
Although, If knee buckles, address quadriceps first in strength training
Progression for TUG (Timed up and Go Test) in patients who need cognitive management
Cognitive= counting backwards by 3’s while performing TUG
Manual: Carrying a glass of water while performing TUG
Healthy adults are at an increased risk of falling if > 15 seconds on TUG
Pusher syndrome is usually when a patient pushes towards or away from the hemiparetic side?
Towards the hemi side
What lesion/area of the brain is most related to pushing syndrome?
lesion in the posterolateral thalamus, which is an area of the thalamus know to relay vestibular information to the cortex
What postural disorders should you differentiate pushers syndrome from?
Thalamic Astasia- Unable to sit up and fall to hemiplegic side, but do not resist correction
Cerebellar and brain stem lesions- tilt of subjective visual vertical ; Lateropulsion without resistance to correction
Vestibular cortex lesions- tilt of subjective visual vertical without pushing behavior
What are the three steps to treat pushers syndrome?
Self Awareness
Active Correction
Translation (sit on mat, bed, toilet…different environments)
Do you transfer a pusher patient to the strong side?
No- modified stand pivot to the hemiplegic side, but need to progress to being able to transfer with strong side as well.
