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S4- Neuro 1 > Week 2- Common Neurological Impairments 2 > Flashcards

Week 2- Common Neurological Impairments 2 Flashcards

1
Q

PART 1: CONSCIOUSNESS

A

PART 1: CONSCIOUSNESS

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2
Q

What are the (5) levels of consciousness and their definitions?

A

Full consciousness

Lethargy
-General slowing of cognitive & motor processes

Obtundation
-Dulled or blunted sensitivity, difficult to arouse

Stupor
-State of semi-consciousness, only arouses with intense stimulation

Coma
-Unconsciousness

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3
Q

What levels of consciousness do PTs play a role?

A

All 5 levels, degree of involvement changes based off of level.

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4
Q
  • What is the gold standard for measuring level of consciousness?
  • What 3 areas of consciousness does it measure?
  • Describe the grading scale.
A
  • Glascow Coma Scale (GCS)
  • eye opening, motor response, verbal response
  • Scores from 3-15
    • <8 = severe
    • 9-12 = moderate
    • 13-15 = mild
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5
Q

Post Stroke Considerations With the GCS:

  • Total GCS score found to predict acute mortality with __% accuracy.
  • _________ and __________ deficits common post CVA, concern for impacting verbal scores. Research suggests verbal component can be excluded when appropriate without loss of predictive value.
A
  • 88%

- cognition and communication

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6
Q

Arousal levels will often fluctuate post CVA, particularly in _____ stages, and levels of consciousness have many potential causes and influencers. What are some of these?

A

-acute stages

  • Course of injury/neuroanatomy injured
  • Medical interventions
  • Medications
  • Autonomic system dysfunction
  • Sleep/wake cycle disruption
  • Patient Positioning
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7
Q

What is the most typical structure injured post CVA that will cause impaired consciousness?

A

Reticular formation

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8
Q

What are some medications prescribed post stroke which can affect cognition?

A
  • narcotics- for pain, known to blunt consciousness

- BP medications- acute hypotension can blunt arousal levels

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9
Q

How does autonomic system dysfunction affect consciousness?

A

overactivation of parasympathetic can cause blunted arousal levels

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10
Q

How is patient positioning important for consciousness levels?

A

lying down in bed can contribute to state of arousal

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11
Q

PART 2: COGNITION

A

PART 2: COGNITION

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12
Q

What are the (6) basic components to a cognitive evaluation and what is tested with each?

A
  • Orientation (person, place, time, situation)
  • Attention (sustained, selective, divided, alternating)
  • Memory (immediate recall, short-term, long-term)
  • Executive Function (abstract thinking, problem-solving, judgment, reasoning, insight)
  • Communication (spontaneous speech, command following, repetitive and naming, articulation, fluency)
  • Behavior
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13
Q

Orientation:

  • Disorientation denotes general _________ dysfunction but can reflect difficulties with attention, memory.
  • Often requires increased ______, redirection, and encouragment.
A
  • intellectual

- cues

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14
Q

Attention:

  • ______ common cognitive deficit found post stroke.
  • Difficulty in processing and assimilating new information and techniques, _____ learning, ___ task.
  • Dysfunction correlated with ______ impairments leading to falls.
A
  • most
  • motor learning, dual task
  • balance
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15
Q

Memory:

  • Difficulty with _____-_____ of newly learned or retained tasks.
  • ____-_____ memory typically remains intact.
A
  • carry-over

- long-term

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16
Q

Executive Function:

  • __________ interactions, poor self-monitoring and self-correcting.
  • __________, inflexible thinking, decreased insight, impaired organization, sequencing and planning abilities, impaired judgement.
A
  • inappropriate

- impulsive

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17
Q

Where does communication deficits play a role in cognitive considerations post CVA?

A
  • Communication deficits can make cognitive evaluation extremely difficult.
  • The “why behind the what” becomes harder to judge.
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18
Q

With regards to behavioral changes, lesions to what areas can produce emotional changes? (3)

A
  • frontal lobe
  • hypothalamus
  • limbic system
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19
Q

Emotional changes can be both _______ and _________ sequela of a stroke.

A

direct and indirect

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20
Q
  • What is apathy?

- What is euphoria?

A
  • Apathy- shallow affect, blunted emotional response

- Euphoria- exaggerated feelings of well-being

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21
Q

What is pseudobulbar affect?

A

State of emotional liability due to neurological insult.

  • Emotional outbursts of uncontrolled or exaggerated laughing or crying.
  • Inconsistent with actual mood.
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22
Q

Depression is extremely common in this patient population throughout the continuum of the disease. Correlation found with left frontal and right parietal lesions but is more common just a ___________ _______ of the impact of the injury.

A

secondary sequelae

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23
Q

Behavioral Consideration Based on Hemispheric Involvement:

  • _____ sided strokes are very impulsive, quick, and they have little insight to their deficits and don’t know what’s going on. They are at fall risk because they wont consider safety or if they even have the capacity to do the task.
  • _____ sided strokes are more guarded and cautious. They tend to be compulsive and are also at risk for fall because of their fear of falling and tend to be more tense.
A
  • right

- left

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24
Q

PART 3: PERCEPTION

A

PART 3: PERCEPTION

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25
Q

What is perception?

A

Integration of sensory impressions into information that is physiologically meaningful.

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26
Q
  • What are the (4) perceptual deficits seen?

- 3 out of the 4 are involved with R hemisphere lesions, which is associated with L hemisphere lesions?

A
  • Body Scheme Impairements
  • Difficulties with Spatial Relationships
  • Agnosias
  • Apraxia

-Apraxia

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27
Q
  • What are the 2 types of apraxia?

- Apraxia and ________ often go hand in hand.

A
  • ideational and ideomotor

- aphasia

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28
Q

What are some body scheme impairments seen with R hemispheric lesions?

A
  • unilateral neglect
  • Pusher’s syndrome
  • anosognosia
  • somatagnosia
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29
Q

What is unilateral neglect?

A

Failure to orient toward, respond to, or report stimuli on the side contralateral to the lesion.
-Despite normal sensory, motor, and visual systems

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30
Q

Unilateral neglect mostly occurs with R ____________ junction, posterior ________ lesions.
-Also: dorsolateral frontal, cingulate gyrus, thalamic, putamen lesions.

A

-temporoparietal junction, posterior parietal lesions

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31
Q

We identify unilateral neglect by ________ or ______________.

A

Modality

  • Sensory (auditory, visual, or tactile)
  • Motor
  • Representational

Distribution

  • Personal
  • Spatial (peri-personal, extra-personal)
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32
Q

Stroke and Neglect:

  • __-__% of all stroke individuals
    • Reported in up to 2/3 of acute ____ hemispheric strokes with parietal involvement.
    • ____ infarcts most common.
  • Most common manifestations: _______ (“________”)
  • _____ prognostic indicator for functional recovery.
  • Improvement occurs in _______ stages of rehab.
A
  • 25-30%
    • right
    • MCA
  • Visual (‘visuospatial”)
  • Poor
  • early
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33
Q

What are some ways we examine for neglect?

A
  • Observation (mod-severe will have a full head rotation away from the side being neglected)
  • Double Simultaneous Stimulation Test
  • Clock drawing, picture copying, cross-out task, line bisection
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34
Q

With neglect, it is important to consider the presence of ____________ loss alongside neglect.

A

visual field loss

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35
Q

What is vertical disorientation?

A

Patient’s perception of vertical/midline are impaired.

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36
Q

What are 2 common presentations of vertical/midline disorientation?

A
  • Lateropulsion (fall towards sided of lesion/away from involved side)
  • Retropulsion
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37
Q

Pusher’s Syndrome:

  • Pusher’s syndrome is associated with lesions where?
  • What are some features associated with Pusher’s Syndrome? (3)
A

-R hemisphere centered in area of posterolateral thalamus.

  1. ) Contralateral tilted posture with sever imbalances (head able to correct with cues).
  2. ) Tendency to push strongly towards paretic side with nonaffected limbs.
  3. ) Resistance to external corrections.
38
Q

Pusher’s Syndrome and CVA:

Right Hemispheric CVA:

  • Majority (__-__%) of cases.
  • Commonly seen with left _________.
  • High association with left _______ and ______ neglect.

Left Hemispheric CVA:

  • Commonly seen with right __________.
  • High association with ________.
A

Right Hemispheric CVA:

  • 50-65%
  • hemiplegia
  • spatial and sensory

Left Hemispheric CVA:

  • hemiplegia
  • aphasia
39
Q

Pusher’s Syndrome ranges from __-__%. It can significantly hinder and/or delay functional recovery.

A

-10-63%

40
Q
  • What are some scales used to examine for Pusher’s Syndrome?
  • What is the issue with these scales?
A
  • Scale for Contraversive Pushing
  • Burke Lateropulsion Scale

-Minimal evidence behind scales

41
Q

How do we examine for Pusher’s Syndrome if outcome measures have minimal evidence?

A

Observation

  • sitting vs standing
  • exacerbating factors
  • response to corrections and cues
42
Q

PART 4: SPECIAL SENSES (VISION, VESTIBULAR, SOMATOSENSORY)

A

PART 4: SPECIAL SENSES (VISION, VESTIBULAR, SOMATOSENSORY)

43
Q

What are (3) things to ask with patient history for visual dysfunction?

A
  • Do you wear glasses? Contact lenses?
  • Do you notice anything different about vision?
  • Do you ever see double? (often post stroke)
44
Q

What are some common visual dysfunctions post CVA that involve CN II nuclei and associated CNS areas? Describe them.

A

Refractive Errors
-umbrella term for acute nearsightedness, farsightedness, or astigmatisms that were not present before stroke.

Impaired Accommodation
-ability to bring near objects into clear focus.

45
Q

What are some common visual dysfunctions post CVA that involve CN II and various regions of the visual tract, visual cortex? Describe them.

A

Visual Field Losses

-

46
Q

What are some common visual dysfunctions post CVA that involve the cerebellum? Describe them.

A

Impaired Pursuits and Saccades
-smooth movements of eyes

Diplopia
-double vision

47
Q

What are some common visual dysfunctions post CVA that involve CN III, IV, VI nuclei and associated CNS areas?Describe them.

A

Ptosis
-droopy eyelid

-

48
Q

Up to __% of strokes at the brainstem level hit CN III, IV, and VI nuclei and will result in ocular motility disturbances.

A

90%

49
Q

Potential Clinical Observations with Visual Dysfunction post Stroke:

  • Head _____/_____ during near tasks, or postural adjustments to task
  • Avoidance of _____ tasks
  • One eye appears to go in, out, up, or down
  • Vision shifts from eye to eye as indicated by head tilting
  • Seems to look _____ observer
  • Closes or covers one eye
  • Squints
  • During movement, bumps into walls or objects (either walking or in a wheelchair)
  • Appears to misjudge ________, Under-reaches or overreaches for objects
  • Has difficulty finding things
A
  • turn/tilt
  • near
  • past
  • distance
50
Q

Central Vestibular Dysfunction can come from damage to what (3) areas?

A
  • Cortical Vestibular Regions (PIVC, MST, VIR)
  • Brainstem Vestibular Regions (midbrain, pons)
  • Flocculonodular Lobe
51
Q

What is the most common complaint with vestibular dysfunction?

A

DIZZINESS

52
Q

Of all ED visits due to dizziness, __% found to have a TIA/CVA.

A

25%

53
Q
  • What are the most common sites of Transient Ischemic Attacks (TIAs)?
  • What are the symptoms?
A
  • Vertebrobasilar artery

- Vertigo, visual deficits tend to be VERY intense.

54
Q

When we have strokes, the more significant vestibular dysfunction is seen when the stroke involves what regions?

A

Brainstem and Cerebellar CVAs

55
Q

What are the 2 types/sites of strokes with Brainstem and Cerebellar CVAs?

A
  • Posterior Inferior Cerebellar Artery (PICA) Stroke (Wallenberg’s Syndrome)
  • Anterior Inferior Cerebellar Artery (AICA) Stroke
56
Q

What are the symptoms that both PICA and AICA strokes can present with?

A
  • vertigo
  • HA
  • facial pain (ipsilateral)
  • disequilibrium
  • N/V
  • ataxia (ipsilateral)
  • hiccups
  • contralateral limb burning pain/altered sensation of temp
57
Q

What is thee biggest difference between PICA and AICA stroke symptoms?

A

AICA will present with HEARING symptoms (unilateral sensory neural loss)

58
Q

Cortical CVA strokes involve ____/_____ territory infarcts.

A

MCA/PCA

59
Q

With cortical CVAs, ______ typically isn’t present and vestibular symptoms tend to be more _____ (disequilibrium, vertical disorientation).

A
  • vertigo

- mild

60
Q

VOR allows for _____ __________

A

Gaze Stabilization

-results in eye movements that equally counter head movements

61
Q

Post stroke VOR dysfunction:

  • Midbrain = ________ nucleus
  • Pons = ________ nucleus
A
  • oculomotor

- abducens

62
Q

Implications of CVA on Sensory Systems:

  • ___________ examination findings
  • _________ lesions: specific localized areas of dysfunction (parietal lobe)
  • __________ lesions: diffuse involvement
  • Frequency of reported impairments = __-__%
  • Which is affected more; light touch/proprioception OR temperature/pain
A
  • contralateral
  • cortical
  • thalamic
  • 50-80%
  • light touch/proprioception
63
Q

Sensory System dysfunction is linked to reduced ________ return, longer __________, learned ___-____, safety, and distal UE recovery

A

-functional, rehabilitation, non-use

64
Q

With sensory system involvement post CVA, _________ in particular is linked to poorer functional recovery

A

proprioception

65
Q

Describe these Terms:

  • Hypoesthesia
  • Hyperesthesia
  • Paresthesia
  • Dysesthesia
  • Allodynia
  • Analgesia
  • Hyperalgesia
  • Atopognosia
A
  • Hypoesthesia- decreased sensitivity to sensory stimuli
  • Hyperesthesia- increased sensitivity to sensory stimuli
  • Paresthesia- abnormal sensation such as numbness, prickling, or tingling
  • Dysesthesia- touch sensation experienced as pain
  • Allodynia- pain produced by non-noxious stimulus
  • Analgesia- complete loss of pain sensitivity
  • Hyperalgesia- increased sensitivity to pain
  • Atopognosia- inability to localize sensation
66
Q

Do we see loss or diminished/abnormal sensory more common post CVA?

A

diminished/abnormal

67
Q

PART 5: BALANCE

A

PART 5: BALANCE

68
Q

Fall Risk post CVA:

  • What is considered one of the greatest risk factors for falls among elderly people?
  • __-__% of individuals hospitalized for a stroke experience a fall during their hospitilization.
  • __% of individuals with stroke fall within 6 months of discharge from hospitals.
  • Individuals with stroke _x more likely to sustain hip fx after a fall.
A
  • stroke
  • 14-29%
  • 75%
  • 4x
69
Q

What are the most common predictors of fall risk post CVA? (3)

A
  • functional impairment
  • cognitive deficits
  • impaired balance
70
Q

What are the CVA impairments that can affect balance?

A
  • visual
  • vestibular
  • sensory loss
  • perceptual deficits
  • motor
  • reduced endurance
  • cognitive considerations
71
Q

CVA impairments that affect balance can lead to impairments in what (3) things?

A
  • steady state
  • anticipatory control
  • reactive responses
72
Q

Post stroke we often see more significant postural ____ with steady state.

A

sway

73
Q

Anticipatory control is often ________ post stroke.

A

delayed

74
Q

With patients post CVA, in regards to their reactive responses, they have more of a reliance on ________ strategy.

A

stepping

75
Q

What are some stroke specific outcome measures used for the examination of balance post CVA?

A
  • Postural Assessment Scale for Stroke Patients (PASS)
  • Trunk Impairment Scale (TIS)
  • Function in Sitting Test (FIST)
76
Q

What are some core outcome measures used for the examination of balance post CVA?

A
  • 6 Minute Walk Test
  • 10 Meter Walk Test
  • Berg Balance Scale (BBS)
  • Functional Gait Assessment (FGA)
  • Activities-Specific Balance -Confidence Scale (ABC)
  • 5 Times Sit to Stand Test
77
Q

PART 6: FATIGUE, PAIN

A

PART 6: FATIGUE, PAIN

78
Q

Post Stroke Fatigue:

  • Fatigue is a lack of _________ and _______ energy and occurs without specific exertion.
  • Up to ___% of individuals complain of fatigue post CVA. (__% #1 complaint).
  • Can manifest as problems related to ____-________, ________ instability, reduced _______ capacity, perceived reduction in energy.
  • Most closely associated with ________ post CVA.
A
  • physical and mental
  • 75%, (50%)
  • self-control, emotional, mental
  • depression
79
Q

Post stroke fatigue is independent of ________ or _______ of infarct.

A
  • location

- severity

80
Q

What are (2) scales to evaluate for presence of fatigue post CVA?

A
  • Fatigue Severity Scale
  • Fatigue Impact Scale

-no cut-offs or normative values

81
Q

What is the big difference between the Fatigue Severity Scale and the Fatigue Impact Scale?

A

The Fatigue Severity Scale has an added VAS for Fatigue.

82
Q
  • Central Post-Stroke Pain/ Thalamic Syndrome/ Neuropathic Pain is pain that arises as a direct consequence of lesion to central ____________ system.
  • What are the (3) areas involved?
  • Which area is the most common site?
A
  • somatosensory
  • cortex, thalamus, medulla
  • thalamus (VPL)
83
Q

Central Post-Stroke Pain/ Thalamic Syndrome/ Neuropathic Pain is present in ___% of CVAs.

A

10%

84
Q

Central Post-Stroke Pain/ Thalamic Syndrome/ Neuropathic Pain can range from _______ to _____ hemibody involvement and often begins _______ to ______ post initial insult.

A
  • focal to full

- weeks to months

85
Q

How is Central Post-Stroke Pain/ Thalamic Syndrome/ Neuropathic Pain described?

A

Severe, burning like pain.

-Sensory stimulation often produces exaggerated, prolonged, or painful response.

86
Q

Central Post-Stroke Pain/ Thalamic Syndrome/ Neuropathic Pain can be ________ or __________ and may have ________ such as mechanical stim, changes in temp, and stress.

A
  • intermittent or persistent

- triggers

87
Q
  • With Central Post-Stroke Pain/ Thalamic Syndrome/ Neuropathic Pain, ________ management can be tricky. A lot of the drugs wont do anything to neuropathic pain.
  • What types of drugs are better are better at managing neuropathic pain than analgesics?
  • What is one specific SSRI that helps?
A
  • medication
  • antidepressants (SSRIs)
  • Fluoxetine
88
Q

Fluoxetine has not only been effective in managing depression and neuropathic pain, but also enhances _________/_____________ after a brain injury.

A

neurorecovery/neuroplasticity

89
Q
  • What is the most common site of MSK pain post stroke?

- What is the second most common?

A
  • Shoulder

- Low Back

90
Q

About / of stroke survivors develop shoulder pain within the first 6 months of injury. __% of those develop to chronic.

A
  • 1/3

- 65%

91
Q

What are the causes of orthopedic pain?

A
  • Weakness (rotator cuff)
  • Impaired motor control (inappropriate muscle activation)
  • Chronic muscle shortening and contractures
  • Acute hypotonicity
  • Spasticity (direct vs indirect)
  • Positioning (effects of gravity on UE)
92
Q

Severe UE hemiplegia and/or shoulder subluxation within __ hours post CVA = significantly higher risk of developing shoulder pain within first __-__ weeks of CVA

A
  • 72 hours

- 8-10 weeks

S4- Neuro 1 (12 decks)

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