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PT 642 DDxI Adult Neuro > PT Examination/Evaluation CVA > Flashcards

PT Examination/Evaluation CVA Flashcards

1
Q

how to assess for direct/primary impairments following stroke

A

neurological tests and measures
cognition/perception, sensation, CN testing, motor function/strength, postural control/balance, functional status, gait/locomotion, aerobic capacity/endurance, speech/language/swallowing, emotional status, bowel/bladder control

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2
Q

what are some examples of indirect impairments/complications following stroke

A
  • MSK: joint/soft tissue contracture, disuse atrophy, osteoporosis, decreased flexibility/increased risk of contracture formation
  • Neurological: seizures, hydrocephalus
  • Cardiopulmonary: DVT, changes in cardiac function, aspiration pneumonia
  • Integumentary: decreased skin integrity, loss of protective sensation, pressure ulcers
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3
Q

what does someone in inpatient rehab with mobility limitations need on their WC

A

custion

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4
Q

what needs to happen if pt is unable to weight shift

A
  • need improved seating system
  • turning schedule
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5
Q

what percent of pts will develop DVT/ PE secondary to bed rest/immbolization

A
  • 47% DVT
  • 10% PE
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6
Q

how to prevent and tx secondary DVT/PE development

A
  • prevent: early mobilization and OOB
  • Tx: anticoagulation therapy, activity limitation, elevation of limb for 3-5 days, TED stockings
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7
Q

what percent will develop decubitus ulcers and how do you prevent it

A
  • 14.5% over body prominences
  • prevent: frequent position changes, daily skin inspections, pressure-limiting devices
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8
Q

what test can be used to determine shoulder subluxation and what percent does this occur in

A

sulcus sign
70-84% of cases with MCA strokes

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9
Q

why is shoulder subluxation common in patients post stroke

A
  • lack of tone, muscle paralysis and proprioceptive impairments in early stages (flaccid)
  • changes in scapular position, tightness in joint support structures, and poor handling during synergy stages
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10
Q

what are the vasomotor signs and sx of reflex sympathetic dystrophy (RSD) or shoulder-hand syndrome (CRPS)

A

edema, hyperhydrosis, corsening of hair and nails, skin discoloration, extreme pain, loss of ROM, progressive atrophy of soft tissue
- may result in osteoporosis of UE bone, clawed hands

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11
Q

when is bowel and bladder indirect impairments most common

A

acute phase post stroke
29%

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12
Q

what can bowel and bladder dysfunction lead to

A

embarrassment, isolation, depression

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13
Q

what is a prognostic fact about b/b function following stroke

A

persistent incontinence of bowel/bladder is associated with poor long-term prognosis for functional recovery

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14
Q

what is neurogenic bladder caused by

A

due to hyper or hyporeflexia affecting sphincter control or sensory loss

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15
Q

how to compensate for neurogenic bladder dysfunction and other tx

A

put pt on toileting schedule
- may need medical intervention to prevent chronic UTI - medications or indwelling catheterization

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16
Q

bowel incontinence/constipation can lead to what and how is it treated

A
  • impaction
  • managed with stool softeners or dietary/fluid modifications and increased physical activity to promote mobility
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17
Q

what areas of cognitive status can be impaired after stroke

A

attention, memory, executive function, level of arousal, perseveration, poor judgement

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18
Q

speech and communication disorders following stroke

A

aphasia (expressive and/or receptive)
dysarthria (difficulty with speech - motor)
dysphagia (cannot swallow)

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19
Q

perceptual disorders following stroke

A

body schema, body image, spatial disorders, ipsilateral pushing, agnosia

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20
Q

what pseudobulbar affects can occur following stroke

A
  • emotional lability or emotional deregulation syndrome (cannot regulate emotions)
  • depression
  • behavioral hemispheric differences
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21
Q

describe sensory deficits following stroke

A

sensation often impaired but rarely absent on hemiplegic side

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22
Q

sensory deficits occur in about 53% of patients with what

A

cortical lesions to lateral hemisphere or thalamus (MCA)

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23
Q

where is the most common loss of sensation following stroke (55%)

A

face > UE > LE

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24
Q

direct impairments for pain following stroke

A

thalamic pain syndrome due to PCA infarct –> extreme neurogenic pain triggered by touch, pinprick, temp changes, loud noises, bright lights

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25
Q

indirect impairments for pain following stroke

A

muscle imbalances due to tonal changes –> shoulder-hand syndrome, knee hyperextension during gait, shoulder subluxation

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26
Q

sensory assessment

A
  • pain
  • superficial sensation
  • deep sensation (kinesthesia, proprioception, 2-point discrimination, vibration)
  • expect differences between UE/LE
  • use caution when comparing with uninvolved side - may also have loss due to aging, comorbidities
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27
Q

impairments to what cranial nerves would cause difficulty with facial movements

A

CN 5 and 7

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28
Q

oculomotor and visual deficits with lesions to MCA (________) or PCA (______)

A
  • optic radiations
  • visual cortices
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29
Q

list some visual deficits associated with stroke

A
  • strabismus, nystagmus, diploplia
  • hemianopsia
  • visual neglect, depth perception deficits
  • forced gaze deviation
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30
Q

hemispheric lesions cause eyes to look ________

A

away from hemiplegic side

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31
Q

brainstem lesions cause eyes to look

A

toward side of lesion

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32
Q

what can cause swallowing deficits

A

CN 9, 10 or brainstem via infarcts of MCA and PCA

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33
Q

delayed swallow reflexes, reduced pharyngeal peristalsis, reduced lingual control

A

dysphagia

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34
Q

penetration of food, liquid, or salivia into airway results in ~1/3 of patients with CVA due to decreased gag reflex

A

aspiration

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35
Q

what direction is nystagmus caused by UMN

A

purely vertical

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36
Q

what are the most common UE contractures

A

elbow, wrist, and finger flexion and FA pronation

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37
Q

what are the most common LE contractures

A

PF

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38
Q

how to treat PF contracture in bed

A

multi-podus boot

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39
Q

what is the most immediate tone in acute care episode following stroke

A

flaccidity

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40
Q

what occurs due to cerebral shock and can last days to weeks

A

flaccidity
no movement of limbs elicited

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41
Q

flaccidity may persist if

A

cerebellar lesions or primary motor cortices

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42
Q

what tone is present in cerebellar lesion

A

hypotonia

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43
Q

after initial flaccidity, what tonal changes often occur following stroke (90%)

A

spasticity, hyperreflexia, syngergies

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44
Q

what direction is trunk lateral flexion usually towards due to spasticity

A

hemiplegic side

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45
Q

synergies make it difficult to allow for

A

fractionation of movement (unable to isolate movements)

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46
Q

what muscles that are not in synergy but are hard to activate

A

teres major, latissimus dorsi, serratus anterior, finger extensors, ankle evertors

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47
Q

describe the UE flexor synergy

A
  • scapular retraction, elevation, or hyperextension
  • shoulder abd/ER
  • elbow flexion *
  • FA supination
  • Wrist/finger flexion
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48
Q

describe the UE extensor synergy

A
  • scapular protraction
  • shoulder add/Ir
  • elbow extension
  • FA pronation *
  • wrist/finger flexion
49
Q

describe the LE flexor synergy

A
  • hip flexion *, abd, ER
  • knee flexion
  • ankle DF and inversion
  • toe DF
50
Q

describe the LE extensor synergy

A
  • hip extension, add, IR
  • knee extension
  • ankle PF * and inversion
  • toe PF *
51
Q

describe Brunnstrom’s Stages of Recovery

A

1: flaccidity, no movement of limbs
2: spasticity beginning to develop, minimal voluntary movements, some associated movements
3: spasticity is further developing, may become severe
4: spasticity begins to decline, some out of synergy movement possible
5: isolated joint movements are more frequent and independent of synergy
6: near normal voluntary movement

52
Q

describe normal presentation of reflexes following stroke

A

initially hypo-reflexive (initial shock) –> hyperreflexia

53
Q

what will DTR’s demonstrate following stroke

A

clonus, clasp-knife, + babinski, + cutaneous, + CN reflexes

54
Q

what primitive/tonic reflexes often occur following stroke

A

STNR
ATNR
STLR
TLR

55
Q

unintentional involved limb movement resulting from intended action by the uninvolved limb

A

associated reactions

56
Q

resistance to abduction/adduction of either the UE or LE on the non-involved side produces overflow on the involved side

A

raimiste’s phenomenon

57
Q

fingers abduction and extend whenever the hemiplegic UE is lifted above horizontal with the elbow in extension

A

souque’s phenomenon

58
Q

mutual dependency between hemiplegic UE and LE - the UE flexes, the LE also flexes

A

homolateral limb synkinesis

59
Q

involuntary raising of the affected arm with yawning

A

parakinesia brachialis oscitans

60
Q

describe STNR (symmetric tonic neck reflex)

A

head/neck flexion - UE flex, LE ext
head/neck ext - UE ext, LE flex

61
Q

describe ATNR (asymmetric tonic neck reflex)

A

rotation of head to R results in R UE/LE extension and L UE/LE flexion
- most commonly seen

62
Q

describe STLR (symmetric tonic labryinthine reflex)

A

position the head in space affects limb posture
- supine: all limbs in full extension
- prone: all limbs in full flexion

63
Q

describe TLR (tonic lumbar reflex)

A
  • elicited by movement of the trunk on pelvis
  • rotation of the trunk to the hemiplegic side evokes flexion in hemiplegic UE and extension on hemiplegic LE
64
Q

describe positive support reaction

A

pressure on the bottom of the hemiplegic foot results in rigid extension of the limb (fixing)

65
Q

describe instinctive grasp reaction

A

stationary contact in the palm of the hand results in mass finger flexion (mass grasp) and inability to release

66
Q

what areas of the foot should be avoided if touching the patient’s feet

A

center between met heads, medial 1st met head, lateral 5th met head, heel

67
Q

reflex areas of the hand should be avoided to prevent elicit of reflex

A

central palm, thenar and hypothenar eminences, metacarpal heads

68
Q

what are inhibitory key points of contact - places to hold to avoid reflex

A

finger tips and dorsal side of the hand

69
Q

what percent of patients will have contralateral hemiparesis

A

80-90%

70
Q

how can ipsilateral weakness occur following stroke

A

from disuse

71
Q

are distal or proximal muscles more involved following stroke

A

distal

72
Q

what causes quadriparesis

A

brainstem CVA

73
Q

motor unit requirement may be diminished by as much as

A

50% 6 months after CVA

74
Q

will reaction times be faster or slower following stroke

A

slower and movement times prolonged

75
Q

which muscle fibers are more significantly loss following stroke

A

type II - difficulty initiating high-force movements

76
Q

incoordination is due to

A

lesions to cerebellum

77
Q

what does changes in muscle strength mean to patient

A
  • requires increased effort for normal movement
  • easily fatigued
  • complaints of weakness and pain
  • functional decline
78
Q

damage to which hemisphere causes motor apraxia

A

L hemisphere

79
Q

difficulty initiating and performing useful motor movement

A

motor apraxia

80
Q

movement is not possible on command but may be automatic, perservates

A

ideamotor apraxia

81
Q

purposeful movement is not possible on command or automatically, no idea how to do this movement

A

ideational apraxia

82
Q

damage to which hemisphere results in motor impersistence

A

R hemisphere

83
Q

inability to sustain motor behavior or posture

A

motor impersistence

84
Q

list some balance and postural deficits

A
  • impairments in steadiness, symmetry, and dynamic stability
  • most often maintain weight shift to non-involved side
  • ipsilateral pusher syndrome
  • increased postural sway in standing
  • often fall to involved side
85
Q

what tests and measures can be used to assess balance and postural deficits

A

Berg balance, functional reach, TUG, CTSIB, or stroke specific measure (FIST)

86
Q

active pushing with the stronger extremities toward the hemiplegic side and tend to fall towards the hemiplegic side

A

ipsilateral pusher syndrome

87
Q

ipsilateral pusher syndrome is caused by malalignment to what

A

visual-vestibular input

88
Q

is patient able to correct balance or correct to midline with ipsilateral pusher syndrome

A

no

89
Q

lesion where causes ipsilateral pusher syndrome

A

posterolateral thalamic CVA

90
Q

describe physiological walker

A

walks in home or parallel bars for exercise only

91
Q

describe household walker

A
  • limited: will rely on WC or some assistance
  • unlimited: no reliance on WC, difficulty with stairs or unlevel surfaces, may not be able to enter or leave house
  • gait speed: < 0.4 m/s
92
Q

describe limited community ambulator

A
  • can enter/leave house and perform curbs independently
  • independent walking in some community setting (restaurants)
  • gait speed: 0.4-0.8 m/s
93
Q

describe community ambulator

A
  • independent in home and all community
  • can walk in crowds and uneven surfaces
  • > 0.8 m/s
94
Q

what type of disease is stroke

A

cardiovascular disease – take Vitals before, during, and after tests/measures

95
Q

what are some parameters for modification to endurance activities

A
  • systolic > 250/ diastolic > 115
  • serious arrhythmias
  • greater than 2 mm changes in ST segments
96
Q

what test is commonly used in acute care and IRF and what do higher scores indicate

A

FIM
- higher scores: successful recovery, DC home, return to community

97
Q

define the acute phase of stroke rehab

A
  • rehab occurs within 72 hours of hospital
  • average length of stage about 5 days
  • focus on positioning, functional mobility, ADL’s, splinting, prep for rehab
98
Q

define the subacute phase of stroke rehab

A
  • acute IRF or SNF
  • more therapy is better
  • ability to go to rehab within 20 days of onset linked to better outcomes
  • focus on restoration, prevention, and compensation if needed (functional return home)
99
Q

define chronic phase of stroke rehab

A
  • > 6 months
  • done in outpatient or home (2-3x/week for 60-90 minutes)
  • continuing interventions from inpatient rehab
  • focus on restoration function as able, community reintegration, prevention of complications, and compensation if needed
100
Q

what is the mean length of stay in IRF and what must the patient be able to tolerate

A

14.6 days
tolerate 3 hours of multidisciplinary care 6 days/week for 5 day

101
Q

what is the mean length of stay in SNF and how much therapy is received

A

21-30 days
receive 1-2 hours of therapy/day 5 days a week

102
Q

when does most stroke recovery occur

A

first 3 months

103
Q

_____ deficits are 30 days are predictive of deficits at 6 months

A

motor

104
Q

list indicators of poor prognosis 20-30 days post stroke

A
  • no/min grip strength = no/min hand function later
  • no/min shoulder flexion = no/min hand function later
  • no hip flexion against gravity = not independent ambulator
  • assistance needed for sitting = not independent sitter later
105
Q

describe orpington prognostic scale (OPS)

A
  • performed within first 2 weeks post stroke
  • reliably predicts discharge setting
  • 4 domains: balance, cognition, motor, proprioception
  • scoring: <3.2 (mild-mod - high likelihood to return home), 3.2-5.2 (mod-severe - respond well to rehab), > 5.2 (severe = usually institionalized, dependent)
106
Q

PREP 2 Algorithm

A

Predict REcovery Potential - for UE function

107
Q

SAFE MRC meaning

A

shoulder abduction finger extension

108
Q

MEP meaning

A

Motor electrical potential

109
Q

early active control of shoulder abduction and finger extension predicts improved functional recovery of UE

A

PREP2

110
Q

used to show preseveration of internal capsule important for recovery

A

transcranial magnetic stimulation (TMS)

111
Q

what is the key tract for skilled movement

A

corticospinal tract

112
Q

what does lesion of corticospinal tract lead to

A
  • loss of functional motor units
  • loss of motor unit recruitment
  • reduced motor unit firing rate
  • lack of selective motor unit recruitment
  • reduced agonist recruitment
  • reduced force production and rate of force production
  • increased coactivation of antagonist
  • decreased ability to execute functional movement
113
Q

a form of MMT that can give a quick picture of strength/function used after CVA; allows for a quick screen for strength in patients with CVA

A

motricity index (MI)

114
Q

what movements are looked at for MI

A

UE: shoulder abduction, elbow flexion, pinch grip
LE: hip flexion, knee extension, ankle DF

115
Q

what is the max score for the affected arm/leg for MI and how to score

A

100 points
SUM (points for 3 movements) + 1

116
Q

what tests can be used to predict gait recovery

A
  • Trunk Control Test Sitting (TCT-s): can the patient sit unsupported for 30s y/n?
  • Motricity Leg Index: pt sitting 90/90 and assess DF, knee extension, and hip flexion
117
Q

when are gait precition tests performed

A

by day 3

118
Q

would you expect motor recovery in later stages of stroke recovery

A

no
- focus on increase functional activity

PT 642 DDxI Adult Neuro (15 decks)

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