Week 3 Flashcards
What is diaschisis
sudden inhibition of function secondary to neurophysiological changes that occur distant to the focal brain lesion
What is tPA stand for
tissue plasminogen activator
what is the penumbra
moderately ischaemic tissue that surrounds the ischaemic core
is viable for up to 6 hours
What is the leading treatment for ischaemic stroke
tPA: thrombolysis
What is the time frame that tPA can be delivered in
up to 4.5 hours post symptom onset
neurointervention involves
intra-arterial thrombolysis and mechanical clot removal
Antithrombotic therapy involves
ingestion of aspirin orally/NGT/suppository within 48 hours after onset of stroke
-only if imaging excludes haemorrhage
If patients have received thrombolysis, how long do they have to wait until they can take aspirin
should be deferred for 24 hours and only prescribed if follow up imaging has excluded haemorrhage
Acute phase blood pressure lowering therapy can be used in ischaemic stroke id
BP is >220/120
no reductions past 10-20%
in acute primary intracerebral haemorrhage, with severe hypertension observed, Acute phase BP lowering therapy can be used
to maintain SBP <180mmHg
If the patient is already on antihypertensive therapy, what should you do
continue provided there is no symptomatic hypotension or any other reason to withhold
What are the current recommendations for patients with large MCA infarcts in terms of cerebral oedema
patients should urgently referred for consideration of decompressive hemicranectomy, due to the increased intra cranial pressure
Are corticosteroids recommended for management of brain oedema and raised ICP
no
Main focus of management in intracerebral haemorrhage management
rapid assessment
routine investigations
prevention of complications
Current recommendations in intracerebral haemorrhage management include
haemostatic drug treatment with rFVlla is experimental and not recommended for use
for patients receiving anticoagulation therapy prior to stroke and who have elevated INR, therapy to reverse anticoagulation should be initiated rapidly
surgical evacuation may be undertaken for cerebellar hemisphere haematomas >3cm in selected patients
Current recommendations involving physiological monitoring include
check of neurological status (GCS), Vital signs (HR, BP, Temp, Spo2, and glucose levels) and respiratory pattern monitored and documented regularly during the acute phase
frequency of observations should be determined by the patient’s status
Current recommendations for oxygen therapy includes
patients who are hypoxic (<95% oxygens sats) should be given supplemental oxygen
The routine use of supplemental oxygen is not recommended in acute stroke patients who are not hypoxic
prevalence of hyperglycemia in patients following stroke is
1/3
Current recommendations for glycaemic control includes
blood glucose monitoring (on admission) and appropriate glycaemic therapy instituted
Pyrexia is
“fancy word for fever” increased body temperature
pyrexia is associated with
poorer outcomes after stroke
common causes of pyrexia include
Respiratory or urinary infections
Current recommendations for pyrexia
antipyretic therapy, comprising regular paracetamol and / or physical cooling measures should be used routinely where fever occurs
Current recommendations for seizure management are
anticonvulsant meds to be used for patients with recurrent seizures post stroke
What is spasticity
motor disorder characterised by a velocity dependant increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks resulting from hyper-excitability of the stretch reflex as one component of the upper motor neurone syndrome
When should interventions to reduce spasticity be undertaken
when the level of spasticity interferes with activity or the ability to care to the patient
what can be used as an intervention to decrease level of spasticity
botulinum toxin A - should be trialled in conjunction with rehab
electrical stimualtion and or EMG biofeedback can be used
What is a contracture
shortening of soft tissue that results in reduced joint ROM due to impairments (weakness or spasticity)
What can be used to prevent contracture
conventional therapy for those at risk of contracture `
the routine use of splints or prolonged positioning of muscles in lengthened positions is not recommended
Usual position of hemiplegic limbs following ABI
Upper limb -Shx : abd/IR Elb, Wrx and fingers : F Forearm : pronation Thumb : adduction
Lower limb - Supine Hip: ER Knee: E Ankle: PF
Sitting position
Hip : F/ER
Knee : F
Ankle : slight PF
Conventional therapy for contracture includes
Encouraging active movement
target muscles most at risk of shortening
Implement a positioning program for UL/LL between therapy times and during rest periods
Joints at risk of contracture should be positioned >20-30 minutes in outer range
Passive positioning should be routine ward protocol
Aim to keep humerus in the plane of the scapula
Teach patients to attend to their own arm
Subluxation definition
partial or incomplete dislocation that usually stems from changes in the mechanical integrity of the joint
head of humerus is lowered relative to the glenoid cavity (anterior and inferior)
What causes subluxation
Weakness (especially supraspinatus and deltoid)
Overextensibility of capsular structures
Spasticity
When is a subluxation most likely to happen
in the first three weeks
subluxation can be associated with
poor upper limb function
shoulder pain
reflex sympathetic dystrophy (now CRPS)
Management of patients with severe weakness who are at risk of developing a subluxed shoulder includes
electrical stimulation
firm support devices (hemiplegic sling, collar and cuff, wheelchair attachments
Education and training for the patient, family/carer and clinical staff on correct handling and positioning
Management for patients who have a subluxed shoulder includes
firm support devices
Evidence behind the functional electrical stimulation
Evidence supports use in early management of stroke (<2/12) for the prevention of subluxation
Recommended to commence within 48 hours of stroke for patients with a MAS score of <4 for UL items
Applied to posterior deltoid and supraspinatus
Parameters for the functional electrical stimulation
30 Hz
Daily - commence 1 hour/day - 6hours /day
commence with 1: 3 on/off cycle and gradually increase duration of on cycle and decrease duration of off cycle
Cease once the MAS score for UL items is 4
Indications for shoulder strapping
reduce shoulder pain
reduce glenohumeral subluxation (most effective when applied with slings)
Facilitate appropriate glenohumeral and scapulothoracic alignment
facilitate or inhibit muscle activity
Disadvantages of shoulder strapping
skin irritation
needs to be applied by someone with experience
requires regular application (aim for 1-2x per week to reduce skin irritation)
What is central post stroke pain (CPSP)
superficial and unpleasant burning, lancinating or prickling sensation, often made worse by touch, water or movement
refer to neurologist or specialist
Swelling of the extremities can happen when
patients are immobile with limbs in dependant positions
- swelling of hands and feet
Prevention strategies for swelling of the extremities
dynamic pressure garments
electrical stimulation
limb elevation whilst resting
management of swelling of the extremities
dynamic pressure garments
electrical stimulation
limb elevation whilst resting
continuous passive motion with elevation
Why does loss of cardiorespiratory fitness occur
deconditioning occurs as a result of the immobility imposed early after stroke
rehab should include interventions aimed at increasing cardiorespiratory fitness once patients have sufficient strength in the large LL muscle groups
Patients should be encouraged to undertake regular ongoing fitness training
Define fatigue
abnormal or pathological fatigue characterised by weakness unrelated to previous exertion levels and is usually not ameliorated by rest
Prevalence of fatigue in long term
16-70%
When should therapy for patients experiencing fatigue be done
periods of the day when they are most alert
management strategies for fatigue
exercise
establishing good sleep patterns
avoidance of sedatives
avoidance of excessive alcohol
Incontinence
dysfunction of the bladder or bowel may be caused by a combination of stroke related impairments ( eg. weakness, cognitive or perceptual impairments)
pelvic floor exercises
Pressure care is used for
pressure ulcers are areas of localised damage to the skin and underlying tissue due to pressure, shear or friction
who should get pressure care
all stroke survivors are at risk therefore they should have pressure care risk assessment and regular evaluation
all high risk patients should be provided with appropriate pressure relieving aids and strategies including a pressure relieving mattress
Main strategies for treatment (pressure care)
local treatment of wound (dressings, topical applications)
Pressure relief (beds, mattresses, cushions, patient repositioning)
Treatment of concurrent conditions which may delay healing (poor nutrition, infection )
EStim(electromagnetic, US, Laser)
prevalence of falls in inpatients
79% at risk
do balance and mobility predict falls
no
what should intervention target to reduce falls risk
stroke specific problems such as difficulty standing
when should falls risk assessment be undertaken
on admission to hospital
ICF analysis includes
environmental factors
personal factors
functioning factors
physical impairments
treatment plans include
SMART goals
specific treatment strategies for each problem
identify resting positions (bed/chair)
Identify handling/assistance requirements for health pros or family/carer during bed mobility, transfers, sitting, standing and mobility
identify mobility level
identify practice that can be carried out independently by patient or with assistance from family/carer
Functional activity retraining is centred around
bed mobility, sitting balance, sit to stand, standing balance, transfers, gait, UL function, outdoor/community mobility and high level balance
Strengthening is centred around
targeted areas of weakness with consideration of optimisation for neuroplasticity
flexibility treatment is centred around
management and prevention
What types of specific impairments might need to be considered as part of any treatment plan
respiratory dysfunction pain oedema subluxation joint stiffness vestibular dysfunction
Ways to maximise sensory feedback to ensure optimal motor performance
visual feedback : mirrors, video, targets, scales
Auditory feedback : verbal, biofeedback
Sensory feedback : handling, tactile facilitation, strapping, compression (bandaging/tubigrip)
What are the aims of physiotherapy following stroke
prevent/manage secondary complications optimise cardiorespiratory function optimise motor performance increase physical fitness and strength inspire interest and motivation promote mental and physical vigour
what are some benefits of physiotherapy in stroke cases
prevention of complications such as contracture, subluxation, swelling of extremities, pressure ulcers, falls
fatigue
loss of cardiorespiratory fitness
improved positioning and handling by health professionals and the family/carer
overcoming learned non-use or compensations through positive movement experiences
management of impairments such as weakness, sensory loss, flexibility, tone and spasticity
How much?
rehab should be structured to provide as much practice as possible within the first 6 m after stroke
minimum PT 1h/day 5x/week
task specific circuit classes/video self modelling can increase amount of practice
pts should be encouraged to practice skills learnt in therapy throughout the remainder of the day
Timing
patients should be mobilised as early and as frequently as possible
upper limb training should commence early
acutely, commence as soon as possible with frequent short sessions out of bed
Weakness
most common impairment
most significant contributor to reduced function
one or more interventions used
- progressive resistance exercises
Estim
EMB biofeedback in conjunction with conventional therapy
loss of sensation
sensory specific training can be provided to stroke survivors who have sensory loss
sensory training designed to facilitate transfer can also be provided to stroke survivors who have sensory loss
visual loss
patients who appear to have difficulty with recognising objects or people should be screened using specific assessment tools and if a deficit is found, referred for comprehensive assessment by relevant health professional
Sitting
practising reaching beyond arm’s length while sitting with supervision/assistance should be undertaken by people who have difficulty sitting
Practice should ideally be integrated into everyday tasks (eg. reaching for a cup)
Standing up
practicing standing up should be undertaken by people who have difficulty in standing up from a chair
repetitive task specific training
Standing
task specific standing practice with feedback can be provided for people who have difficulty standing
no intervention approach is superior to another
minimal evidence to support significant differences in standing balance with regards to postural sway or outcome measures
Walking
people with difficulty walking should be given the opportunity to undertake tailored, repetitive practice of walking/components of as much as possible
extra interventions that can be including with walking are
cueing of cadence
mechanically assisted gait (treadmill/robotic device)
joint position feedback
virtual reality training
ankle foot orthoses, individually fit, can be used for people with persistent foot drop
high intensity resistance training has shown what outcomes
improved gait speed and functional outcomes
fitness training has what effect on walking
significant positive effect
what is limb apraxia
impaired planning and sequencing of movement that is not due to weakness, incoordination or sensory loss
what is agnosia
inability to recognise sounds, smells, objects or body parts despite having no primary sensory deficits
- disabling and dangerous
the presence of agnosia should be assessed by appropriately trained personnel and communicated to the stroke team
What is neglect
failure to attend to sensory or visual stimuli on or to make movements towards one side of the environment
typically left side due to lesions in the right hemisphere
Deleterious effects on all aspects of ADL’s and is a predictor of functional outcome
interventions that can be trialled on patients presenting with neglect
simple cues to draw attention to affected side
visual scanning training in addition to sensory stimulation
Prism adaptation
eye patching
mental imagery training or structured feedback
Treatment planning includes
prioritising functional limitations analysing each functional limitation with consideration of the task and ICF -Task analysis - movement dysfunction ICF analysis - environmental factors -Personal Factors - Functional factors -Physical impairments
comprehensive treatment plans include
SMART goals
specific treatment strategies for each problem
identify resting positions
identify handling/assistance requirements for health professionals or family/carer during bed mobility, transfers, sitting, standing, mobility
identify mobility level
identify practice that can be carried out independently by patient or with assistance from family/carer
how to maximise feedback during treatment sessions
visual feedback: mirrors, video, targets, scales
Auditory feedback : verbal, biofeedback
Sensory feedback: handling, tactile facilitation, strapping, compression (bandaging/tubigrip)
Interventions must be
goal directed with measurable outcomes
functional tasks or components of functional tasks
distance achieved, time to perform, number of reps, number of errors to make it measurable
