Week 2- Common Neurological Impairments 1 Flashcards
PART 1: STRENGTH
PART 1: STRENGTH
- __-__% of stroke survivors experience some degree of contralateral weakness.
- What is the exception to this rule?
- 80-90%
- Most descending drive from the cerebellum descends ipsilaterally.
Why can we also see mild ipsilateral weakness in patients with a CVA?
10-25% of CST (corticospinal tract) descend ipsilaterally. (anterior CST)
Do we see extremity involvement or trunk involvement more and why?
Extremity, trunk gets bilateral innervation.
The degree of primary weakness related to a stroke is based off the ________ and ______ of the stroke.
- location
- size
- What is the difference between hemiparesis and hemiplegia?
- What is “Dense Hemiplegia”?
- Hemiparesis is mild to moderate weakness on the contralateral side, while hemiplegia is severe to profound weakness on contralateral side.
- Dense Hemiplegia = no active movement observed.
With weakness after a stroke there are _________ and __________ effects of the stroke.
primary and secondary
Primary Neuromuscular Impairments:
- Damage to descending _________ drive
- Type I __, Type II __ leading to a loss of force production.
- Loss of ______ units
- Asynchronous and abnormal motor unit firing.
- cortical
- Type I ↑, Type II ↓
- motor units
Secondary Neuromuscular Impairments:
- Increased ___________
- Delayed _________ times
- Prolonged movement times
- Disuse muscular _________
- Length tension changes
- fatigability
- reaction
- atrophy
Do we as PTs treat primary or secondary impairments?
Both
- With strokes, do we see proximal or distal involvement more often? Why?
- Does distal or proximal involvement return quicker?
- DISTAL, the corticospinal tract is involved with more fine movements of distal extremities.
- proximal
What are some common patterns of weakness and time to recover between muscle pairs?
- Shoulder extensors > flexors
- Shoulder ER > IR
- Elbow extensors > flexors
- Finger extensors > flexors
- Hip extensors > flexors
- Hip ER > IR
- Hip abductors > adductors
- Knee flexors > extensors
- Ankle DF > PF
- Ankle eversion > inversion
Facial weakness is resulting from damage to contralateral _______ (CN__ and ___) pathways
corticobulbar (CNVII and CNVIII)
The __________ is often spared in strokes affecting facial muscles.
forehead
PART 2: MOTOR CONTROL
PART 2: MOTOR CONTROL
_____________ is the ability of the brain to use what it has.
Motor control
Match the definitions below to either motor control, plan, program, learning, recovery, or compensation.
- ) An abstract representation that, when initiated, results in the production of a coordinated movement sequence.
- ) A set of internal processes associated with feedback or practice leading to relatively permanent changes in the capability for motor skill.
- ) The appearance of new motor patterns resulting from changes to CNS.
- ) The reappearance of motor patterns present prior to CNS injury performed in the same manner as prior to injury.
- ) The underlying substrates of neural, physical, and behavioral aspects of movement.
- ) An idea or plan for purposeful movement that is made up of component motor programs.
- ) Motor program
- ) Motor learning
- ) Motor compensation
- ) Motor recovery
- ) Motor control
- ) Motor plan
What IS motor control?
“The process of initiating, directing, and grading purposeful voluntary movement”
How many stages of motor recovery are there post CVA?
6
What are the first (3) stages of motor recovery post CVA?
Stage I
- Initial flaccidity, no voluntary movement (cerebral shock)
Stage 2
-Emergence of spasticity, hyperreflexia, and emergence of stereotypical synergies (mass patterns of movement)
Stage 3
-Voluntary movement possible, but only in synergies, spasticity strong if present
Synergies are a ___________ impairment.
motor control
What are the most common synergy patterns?
- Flexor Synergy (UE)
- Extensor Synergy (LE)
- Describe a Flexor Synergy (UE).
- Describe a Extensor Synergy (LE).
Flexor Synergy (UE) -Scapula retraction and elevation, shoulder abduction and ER, elbow flexion*, supination, wrist and finger flexion
Extensor Synergy (LE) -Hip extension, adduction*, and IR, knee extension*, ankle PF and inversion, toe PF
Can synergy patterns be reversed?
Yes, can have UE Extensor Synergy and LE Flexor Synergy
With synergistic movements, patients lack the ability to _________ muscles.
isolate
What are the last (3) stages of motor recovery post CVA?
Stage 4
-Voluntary control in isolated joint movements emerging, corresponding decline of spasticity and synergies
Stage 5
-Increasing voluntary control out of synergy; coordination deficits present
Stage 6
-Control and coordination near normal
The last 3 stages of motor recovery progression involves further emergence of __________ and _________ control of movement.
voluntary and accurate
What is motor praxis?
The ability to plan and execute coordinated movements.
What is apraxia?
Inability to plan and execute purposeful movements that cannot be accounted for by any other reason.
Lesions in what areas can causes apraxia?
- Premotor frontal cortex (either side)
- Left inferior parietal lobe
- Corpus callosum
What is the difference between ideomotor apraxia and ideational apraxia?
- Ideomotor Apraxia- Inability to produce movement on command, but able to move automatically
- Ideational Apraxia- Inability to produce movement both on command or automatically.
With ____________ apraxia the conceptualization of the task remains intact.
ideomotor
How do we assess Motor Recovery post CVA? (Strength vs Motor Control)
MMT
It is often very difficult for patients to ________ specific movements post CVA. How do we document strength deficits then?
- isolate
- Examine and document strength deficits through functional observation (Functional Strength Testing).
What are 2 assessments used for Motor Recovery post CVA?
- Fugl-Meyer Assessment of Physical Performance
- Rivermead Motor Assessment
- What is the main flaw of the Fugl-Meyer Assessment of Physical Performance?
- How do we instead use this assessment?
- 155 items meaning it will take about 45 minutes to complete.
- Focus on just the motor domain.
The motor domain of the Fugl-Meyer Assessment of Physical Performance includes what 3 things?
- movement
- coordination
- reflexes
- What is the Fugl-Meyer Assessment of Physical Performance MDC for UE and LE?
- What is the Fugl-Meyer Assessment of Physical Performance MCID for UE and LE?
MDC -5.4 points (UE) -5 points (LE) MCID -10 points (UE) -10 points (LE)
If we want to consider how motor control is impacting mobility, what test would we use?
Rivermead Motor Assessment
What are the 3 sections of the Rivermead Motor Assessment?
- Gross Motor
- Leg and Trunk
- Arm
- How is the Rivermead Motor Assessment scored?
- What is the MCID?
- If the patient can do the task they get a point, if they can’t do the task they don’t get a point and the test stops.
- 3 points
List some UE Outcome Measures used to assess motor recovery post CVA.
- 9 Hole Peg Test
- Action Research Arm Test
- Arm Motor Ability Test
- Box and Blocks Test
- Motricity Index
List some LE Outcome Measures used to assess motor recovery post CVA.
- Five Time Sit to Stand Test
- Motricity Index
PART 3: ENDURANCE
PART 3: ENDURANCE
Are endurance and activity tolerance the same thing?
Yes
Why do we look at endurance when addressing patient post CVA?
All of a sudden, easy tasks become exhausting to these patients. It is highly common post stroke.
When addressing Endurance/Activity Tolerance we are looking at ________ capacity. What is the main way to measure this?
- aerobic
- Functional Reserve (VO2) (O2 consumption/min)
What is functional reserve?
The remaining capacity of cardiovascular/respiratory/neuromuscular systems to respond to metabolic changes.
Functional Reserve is a product of what 2 things?
- workload
- energy expenditure
With low fitness levels, small tasks require increased energy expenditure. How does this affect functional reserve?
Substantially reduces reserve.
After a stroke:
- It is _x the work to do ADLs.
- It is _x the work to walk short distances over level ground.
- 2x
- 3x
Its also been found that post stroke individuals are more __________ to minor reductions in functional reserve.
sensitive
What are the (3) contributors to reduced endurance in CVA?
- Baseline Cardiovascular Health
- Primary CVA Impairments
- Post-stroke Deconditioning
Baseline Cardiovascular Health:
- Up to 80% have ______.
- 20-40% of patients have ______ ________ _______.
- What are some common pre-morbid findings in the post-stroke populations?
- Cardiac dysfunction contributes to a lower aerobic capacity via what 2 principle mechanisms?
- HTN
- silent cardiac ischemia
-decreased cardiac output, widespread atherosclerosis, cardiac decomposition, rhythmic disorders
- Ischemia-induced reductions in ejection fraction (EF) and stroke volume (SV)
- Inability for HR to increase proportionally to metabolic demands (chronotropic incompetence)
Primary CVA Impairments:
-What are some primary CVA impairments that can increase energy expenditure, even with simple low-intensity tasks?
- Weakness (primary and secondary)
- Impaired motor control
- Cognitive and perceptual deficits
- Balance
- Pain
- Fatigue
Post-Stroke Deconditioning:
- Result of _____ illness, ________, and limited activity levels
- How does deconditioning affect each of the following systems; Neurological, Cardiovascular, Pulmonary, Musculoskeletal, Behavioral
-acute illness, bedrest
- Neurological: degradation of neural circuits due to loss of active engagement
- Cardiovascular: decreased cardiac output and HRmax, increase in resting and exercise BP
- Pulmonary: decreased lung volume, pulmonary perfusion and vital capacity as well as altered chest wall excursion
- Musculoskeletal: decreased muscle mass, bone mass, and flexibility
- Behavioral: depression, anxiety, fear
For patients post-stroke, it is recommended that they undergo _______ exercise testing with ECG monitoring before beginning an exercise program. Why?
- Graded Exercise Testing
- due to lack of CVA guidance
- What is the problem with graded exercise testing?
- What do we do if we are unable to do graded exercise testing?
- Expensive and not commonly in clinic, hard to do a treadmill test on post CVA patients.
- Light-to-moderate exercise recommended while monitoring pt response.
With graded exercise testing, monitor ___ and ___ closely. May need to use the __________ scale to assess.
- HR and BP
- Borg RPE (below 6)
What are two graded exercise testing outcome measures used?
- 6MWT
- 2MWT (acute CVA)
PART 4: COORDINATION
PART 4: COORDINATION
- What is coordination?
- What is incoordination?
- The ability to use different body parts of the body together smoothly and efficiently.
- Movements that are awkward, uneven, and inaccurate.
What are the (3) critical components of coordination?
- Sequencing
- Timing
- Grading
Incoordination is found with __________, _______, and _______ lesions.
-motor cortex, basal ganglia, and cerebellar lesions
What are the big potential findings with a coordination examination?
- Dysdiadochokinesia
- Dysmetria
- Dyssynergia
- Asynergia
- Rebound phenomenon
- Tremor
What is dysdiadochokinesia?
Impaired ability to perform rapid alternating movements.
What is dysmetria?
Inability to judge distance or range of movement. (hypometria or hypermetria)
What is dyssynergia?
Fragmented movement patterns.
What is asynergia?
Loss of ability to associate muscles together for complex movements.
What is rebound phenomenon (check reflex)?
Inability to rapidly and sufficiently halt movement of a body part after a strong isometric force.
What is tremor?
Unintentional, oscillatory movement. (resting or intentional)
- What is ataxia?
- What are the 2 types of ataxia?
- Impaired balance or coordination.
- Cerebellar ataxia (due to damage of cerebellum), Sensory ataxia (due to proprioceptive deficits).
Ataxia results in difficulties with _______/______,________, and _______ of movements.
fluidity/timing, accuracy, and speed
When we have coordination deficits, what are the (3) areas the deficits can come from?
- cerebellar pathology
- basal ganglia pathology
- disruption of DCML and associated structures
- The __________ is the coordination hub.
- The _____________ is important in the initiation and execution of movement.
- The __________ plays a role in coordination by gathering info from peripheral somatosensory receptors that hold crucial info to the status of the environment, body, and how they are interacting.
- cerebellum
- basal ganglia
- DCML
Damage to the cerebellum, basal ganglia, and DCML pathway can all result in what (3) same exam findings?
- Trunk, limb, and/or gait ataxia.
- Dysmetria, dyssynergia, and dysdiadochokinesia.
- Balance deficits.
- Cerebellum = ipsilateral or contralateral?
- Basal ganglia = ipsilateral or contralateral?
- DCML = ipsilateral or contralateral?
- Cerebellum = ipsilateral
- Basal ganglia = contralateral
- DCML = contralateral
Cerebellum Unique Exam Findings:
- __________ deficits
- lack of _______ reflex
- may see mild _________
- ________ tremor
- slurred speech (__________)
- significant difficulties with ____________
- oculomotor
- check
- hypotonia
- intentional
- dysarthria
- motor learning
Basal Ganglia Unique Exam Findings:
- __________ (if non-CVA pathology, may see rigidity)
- _______ and _________ tremor
- difficulty _________ movement
- slowed and smaller movements
- considerable ________ deficits
- spasticity
- resting and intentional
- initiating
- strength
DCML Unique Exam Findings:
- abnormal sensory exam (particularly ____________)
- unlikely to see _________
- proprioception
- tremor
What are some common post-stroke impairments that can impact coordination?
- Weakness
- Motor control
- Sensory loss
- Cognition and communication deficits
- Vision (diplopia)
PART 5: TONE ABNORMALITIES AND REFLEXES
PART 5: TONE ABNORMALITIES AND REFLEXES
- What is tone?
- Is a certain amount of muscle tone normal?
- Muscle’s resistance to passive stretch.
- Yes
Flaccidity is on the end of _____tonicity, rigidity is on the end of _____tonicity.
- hypotonicity
- hypertonicity
- LMN = ______tonicity
- UMN = ______tonicity
- LMN = hypotonicity
- UMN = hypertonicity
- Spasticity = velocity ___________
- Hypertonicity = velocity __________
- dependent
- independent
With strokes, do we see spasticity or hypertonicity? Why?
-Spasticity, it is usually a result of damage to pyramidal or extrapyramidal tracts, which are often impacted with strokes.
__________ is a form of hypertonia that presents with specific resting positioning, seen with severe brain injury or stroke.
Posturing
What are the 2 types of posturing, how do they present, and where is their location of injury?
Decorticate (UE flexion, LE extension/IR/PF)
-brainstem lesions ABOVE red nucleus
Decerebrate (UE and LE extension)
-brainstem lesions BELOW red nucleus
- With acute UMN injuries, we can see temporary _________.
- What is the cause?
- What is the duration?
- hypotonia
- cerebral or spinal shock
- highly variable (days to weeks)
With Subacute → Chronic UMN injuries we have a development of ____________. Tone gets worse before it gets better.
spasticity
A reduction in spasticity is needed for an improvement in ______________.
motor control
- What is the main scale used to assess tone?
- It measures ___________, and that alone.
- Modified Ashworth Scale
- spasticity
Describe the grading scale of the Modified Ashworth Scale.
0 = No increase in muscle tone. 1 = Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end range of motion when the affected part/s is/are moved in flexion. 1+ = Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than 1/2) of the ROM. 2 = More marked increase in muscle tone through most of the ROM, but affected part(s) are easily moved. 3 = Considerable increase in muscle tone, passive movement difficult. 4 = Affected part(s) rigid in flexion or extension.
Typical Patterns of Spasticity in UMN Syndromes:
- Scapula =
- Shoulder =
- Elbow =
- Forearm =
- Wrist =
- Hand =
- Pelvis =
- Hip =
- Knee =
- Foot and Ankle =
- Hip and Knee =
- Trunk =
Posture forward (prolonged sitting posture) =
- Scapula = retraction, downward rotation
- Shoulder = adduction and IR, depression
- Elbow = flexion
- Forearm = pronation
- Wrist = flexion, adduction
- Hand = finger flexion, clenched fist thumb, adducted in palm
- Pelvis = retraction (hip hiking)
- Hip = adduction (scissoring), IR, extension
- Knee = extension and flexion
- Foot and Ankle = PF, inversion, equinovarus, toes claw, toes curl
- Hip and Knee = flexion, sacral sitting
- Trunk = lateral flexion with concavity, rotation
Posture forward (prolonged sitting posture) = excessive forward flexion, forward head
What are DTRs?
Deep Tendon Reflexes
-“Involuntary, predictable, and specific response to stimulus that is dependent on an intact reflex arc”
What is the grading for DTRs?
0 = absent, no response 1+ = low normal, diminished response 2+ = normal 3+ = brisker or more reflexive than normal 4+ = very brisk, non-sustained clonus 5+ = sustained clonus
After a stroke we can see a return of ________ or _______ reflexes.
primitive or tonic
PART 5 (2): CRANIAL NERVE DYSFUNCTION
PART 5 (2): CRANIAL NERVE DYSFUNCTION
__________ strokes require in in-depth CN examination.
Brainstem
How are each of the 12 cranial nerves typically affected with damage?
- I = rarely involved, typically skipped
- II = field cuts/visual loss, reduced visual acuity (blurry)
- III, IV, VI = gaze palsies → double vision (diplopia), ptosis
- V = loss of facial sensory input, asymmetrical jaw movement and strength, loss of mastication → choking risk → aspiration risk
- VII = facial weakness, loss of sensory tongue, impairment of salivary glands → choking risk → aspiration risk, impairment of lacrimal glands → impaired vision
- VIII = hearing loss, vestibular dysfunction → vertigo, balance deficits
- IX = dysphagia, reduced taste and sensation of tongue, loss of gag reflex → choking risk → aspiration risk, ANS: cardiovascular dysfunction (HR, BP)
- X = pharyngeal and laryngeal weakness, loss of gag reflex → choking risk → aspiration risk, ANS: abnormalities of esophageal motility, gastric acid secretion, gallbladder emptying, cardiovascular dysfunction (HR)
- XI = UTrap and SCM weakness → inability to rotate head/shrug shoulders
- XII = tongue weakness → choking risk → aspiration risk
