CVA Flashcards by Andrea Smith

Def: Sudden loss of neurological function, caused by sudden interruption of blood flow to the brain; resultant impaired neurological function

CVA- Cerebrovascular accident or stroke

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Def: Temporary interruption of blood flow, transient symptoms (<24hrs), Susceptible to CVA or MI. Without treatment 1/3 will have a CVA within one year

TIA- Transient ischemic attack

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2 types of stroke:

Which is more common?

Ischemic and Hemorrhagic

~80-87% are Ischemic

Ischemic = cerebral thrombosis, cerebral embolus
Hemorrhagic (bleeding causing disfunction) = Intracerebral, subarachnoid, arteriovenous, malformation (AVM)

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Name some potentially modifiable risk factors for CVA:

What are some NON-modifiable factors?

Modifiable: HTN, Atrial Fib, Diabetes, Stress, Smoking, Obesity/diet, Alcohol consumption

NON-modifiable: Gender, Race, Family hx of CVA, Age, Prior CVA

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What does “BE FAST” stand for when spotting a stroke?

B: Balance
E: Eyes

F: Face drooping
A: Arm weakness
S: Speech difficulty
T: Time to call 911

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Def: Paralysis on one side of body.

Contralateral side in stroke pt.

Hemiplegia

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Def: Weakness on one side of body

Hemiparesis

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Def: Loss of ability to understand or express speech

Aphasia

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Def: Bleeding occurs from a broken blood vessel within the brain. Some things that increase your risk for this kind of hemorrhage are high blood pressure, heavy alcohol use, advanced age, and the use of cocaine or amphetamines

Intracerebral Hemmorrhage

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Def: bleeding from a damaged blood vessel causes blood to accumulate at the surface of the brain. Blood fills a portion of the space between the brain & the skull & it mixes with the CSF. As blood flows into the CSF it increases pressure on the brain, which causes an immediate headache. Can lead to artery spasms which cause brain damage.

Subarachnoid hemorrhage

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How do you determine/measure amount of subluxation at shoulder joint?

Measure in fingerbreadths; gap from acromion to head of humerus

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Symptoms of a CVA depend on:

Area of brain involved
Size of ischemic area
Nature and functions of structures involved
Availability of collateral blood flow
How rapid occlusion occurs
How quickly reperfusion occurs

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Middle cerebral artery (MCA, stroke syndrome) infarcts are the most common type of stroke and can result in contralateral sensory loss and weakness in the ___ and ____ extremity. Infarction of the dominant hemisphere can lead to global ___.

Face and upper extremity

Global aphasia

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Hemispheric differences:

Difficulty with visual cues, impulsive, Unrealistic, inability to perceive emotional/social cues, difficulty synthesizing information, spatial-perceptual deficits

RIGHT Hemispheric Lesion causing LEFT Hemiplegia

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Hemispheric differences:

Speech/language impairment, difficulty processing verbal cues, slow/cautious behavior, highly distractible, perseverates (repeats things), apraxia (Difficulty planning and sequencing movements)

LEFT Hemispheric Lesion causing RIGHT hemiplegia

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____ ___ Syndrome: Tetraplegia, bulbar palsy (CN V-XII). Patient must communicate with vertical on movements and eye blinking

Locked In Syndrome

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____ _____ Syndrome: Once initial stroke symptoms (numbness and tingling) dissipate, replace with intolerable burning pain and hypersensitivity. “Allodynia” - pain from a stimulus that would normally not cause pain

Thalamic Pain Syndrome

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____ Syndrome: Patient unable to determine vertical and pushes towards hemiparetic side. Resists passive correction.

Pusher Syndrome

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Stages of the motor recovery (6):

I. Flaccidity
II. Synergies, Some spasticity 
III. Marked spasticity 
IV. Out of synergy, less spasticity 
V. Selective control of movement 
VI. Isolated/coordinated movement

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Synergy Patterns:

____ synergy dominates in upper limb and ___ synergy dominates in lower limb.
Muscles are neurophysiologically linked and cannot act alone or perform all of their functions. Unable to perform isolated movements.

Flexor synergy dominates upper limb

Extensor synergy dominates lower limb

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Upper extremity flexion Synergy components:

Scapula: retraction and elevation

Shoulder: ABduction and external rotation

Elbow: Flexion

Forearm: Supination

Wrist: Flexion

Fingers: Flexion

Dominant elbow flexion

Weakest rotation: Shoulder AB and ER

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Lower Extremity Extensor Synergy Components:

Hip: Extension, ADDuction & IR

Knee: Extension

Ankle: Plantarflexion and inversion

Toes: Flexion

Dominant: Hip ADD, knee ext., and ankle plantar flexion

Weakest: Hip ext and IR

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Def: Non-fluent form of aphasia in which the person knows what they want to say but is unable to produce the words or sentence. Speak in short phrase. Affects frontal lobe of brain. (Usually left frontal)

Broca’s aphasia

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Def: “Fluent” type of aphasia where person may speak in long, complete sentences that have no meaning, adding unnecessary words and even creating made-up words. Comprehension of written and spoken word is impaired.
Damage to temporal lobe (usually left temporal lobe/parietal lobe junction)

Wernicke’s aphasia

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Poor positioning can lead to: - Pain - Joint ____ - - skin tears - Poor interaction with ___ - ____ from a w/c or ambulation level

Joint tightness Pressure ulcers Poor interaction with environment Immobility from a w/c or ambulation level

Def: no movement of muscles

Flaccid

Spasticity/hypertonicity =

Increased tone

When setting up a pt’s room, visitors should approach or sit/stand by [non-affected or hemiplegic?] side? Why? Have staff, family, and visitors place patient’s bed side table on the ____ side, especially with meal tray set up with supervision and cueing to locate items.

Sit on hemiplegic side. To facilitate turning his/her head, make eye contact during conversation and to help patient learn to cross midline. On hemiplegic side

Advantages of proper positioning of UE:

- Prevention of shoulder subluxation - Prevention of pain - Prevent loss of ROM - Improvement in functional outcome to assist in ADL’s

Procedure for UE positioning: - ____ arm at all times - Avoid lifting through ___ or ____ arm to move pt. - Use ____, _____, lap trays, air splints, thermoplastic splints or casting - Slings should be worn during ____ or ____. Remove when ___ or _____. - In sitting, position shoulder in slight ___, ___ and ____ rotation; forearm in ____ and hand in ___ weight bearing position.

Support Avoid axilla or pulling on arm Pillows, slings Transfers or ambulation; remove when sitting or in bed Position shoulder in slight flexion, ABduction, and ER; forearm in pronation and hand in open WB position.

Advantages of lying on UNAFFECTED side: - Promote ____ and prevent or decrease ___ and muscle ____

Promote relaxation and prevent or decrease pain and muscle tightness

Procedure for lying on UNAFFECTED side: - Flat pillow under head - Pillow under affected arm for support. Affected shoulder is slightly ___ with hand supported and wrist ___. - Affected leg supported ENTIRELY by a pillow, hip slightly ____, hip and knee ___. Make sure ankle is ____ and not bent toward bed. - Pillow behind back if needed - Affected side should be rolled ____ slightly.

Slightly forward and wrist straight Hip slightly forward, hip and knee bent; ankle is supported Affected side rolled forward slightly

Advantages of Lying on AFFECTED side: - Promote ___ of affected side - Promote relaxation and prevent or decrease pain and ____ - Provide ____ of and ___ input on affected (hemiplegic) side - Allows patient to use unaffected hand to assist with ____ and ___ as needed.

Promote stretching Decrease tightness Provide awareness of and sensory input on hemiplegic side Covers and pillow

Procedure for lying on AFFECTED side: - Affected shoulder ____ - Pillow under head - Palm of hand turned ___ with entire arm supported - Affected hip should be ___ with knee slightly ___ - Pillow under unaffected leg for support

Affected shoulder forward (abduct scapula) Palm of hand turned up (supinated) Affected hip straight with knee slightly bent

Procedure for lying Supine: - Pillow under head with head ___ or slightly turned toward side - Body should be ____ in bed - Place pillows under entire ____ arm, including ___ ___ , with palm facing ___. Keep elbow, wrist, and fingers ____. - Lift ___ with small towel rolls under ankles to prevent ____ on heels. - Keep affected hip in ___ position with toes and knees pointed up toward ceiling. - DO NOT place pillows under ____. May cause contractures or increase reflex activity.

Head straight Body straight Pillows under entire affected arm, including under shoulder blade with palm facing up. Keep elbow, wrist, fingers straight Lift heels to prevent pressure on heels Keep hip in neutral position NO PILLOWS UNDER KNEES

Advantages of sitting up in chair/wheelchair: - To encourage ____ - Increase ____ and patient’s level of _____ - Decrease effects of prolonged ___ ___ and deconditioning. - Foster return to _____

Encourage mobility Alertness and level of consciousness Decr effects of prolonged bed rest Return to independence

Procedure for Wheelchair Positioning: - Ensure patient is seated and ____ in center of wc - Ensure hips and knees form a ____ degree angle when placed on foot rests - Position affected arm slightly ___ at a 90 degree angle with palm facing ___ and fingers ____ - Support arm using ____ or appropriate arm/hand splints, lap tray or arm trough

Aligned in center Hips/knees at 90 degree angle Affected arm slightly forward, palm down, fingers extended Support arm using pillows

Most common postural deficits are:

- Alignment - Stability - Symmetry - Static and dynamic balance

Pelvic postural alignment DEFICITS: - Asymmetrical WB with shifting of weight onto ____ side - Fear of weight shifting onto ___ - ____ pelvic tilt posture and ____ of pelvis on affected side

They shift weight onto stronger side Fear of shifting onto affected side Posterior pelvic tilt and retraction

Trunk DEFICITS: - Loss of lumbar ____, increased ___ curve (rounded posture) and ____ head - ____ flexion of trunk - ____ rotation or retraction

Loss of Lumbar lordosis, increased thoracic curve and forward head Lateral Flexion of trunk Posterior rotation

Shoulder DEFICITS: - Shoulders have ____ height with affected side shoulder ____ - Humeral _____ with downward rotation of scapula - Scapular instability (winging)

Unequal height, affected shoulder depressed Humeral subluxation

Advantages of UE WB: - Promotes proximal ____ - Inhibits abnormal ___ - Facilitates increased ____ movement and control

Stabilization Abnormal tone Active movement

Def: Area of salvageable brain tissue beyond the blood starved infarct. Zone that is still viable- can be salvaged if flow of blood and oxygen restored. If blood flow is restored there is a resolution of the ____ and subsequent spontaneous recovery for 3-6 months due to plasticity which may continue for years.

The Penumbra

_____ ____ Is recommended for selected patients who may be treated within __ hours of onset of ischemic stroke. It should be administered to eligible patients who can be treated in the time period of __-___ hours after stroke. This treatment option is only for ____ strokes.

Intravenous rtPA (aka clot buster) 3 hours 3-4.5 hours Ischemic

What is MERCI? What does it stand for?

Mechanical embolus removal in cerebral ischemia It is mechanical thrombectomy, goal is to restore blood flow. Can be used within 8 hours of onset.

What are Solitaire and Trevo?

Thrombectomy used within 6 hours of Onset. Can be used on patient outside the window for using tPA and have a good outcomes

Neuroplasticity is the ability of the brain to form and re-organize synaptic connections, especially in response to learning or experience or following injury. Plasticity may continue for years post CVA. Goal of rehab can change from compensation to restoration of function. How we spend our treatment minutes in rehab should change to focus on ______.

Restoration

Stroke patients are _____ in flaccid stage and _____ in spastic and synergistic stages.

Hyporeflexive Hyperreflexive *clonus wrist or ankle, clasp-knife response, + Babinski

Def: Type of reflex that involves movement of head or position of body eliciting an obligatory change in Resting tone or movement of extremities

Tonic reflexes *ATNR is most common

Def: Unintentional movements of the stroke limb caused by voluntary action of another limb. Can be elicited when a patient coughs, sneezes, yawns or when performing and exertional movement on uninvolved side

Associated reactions

Def: Loss of half of the visual field on the same side and both eyes. Damage to the right side of the posterior portion of the brain or right optic tract can cause a loss of the left field of view in both eyes

Homonymous hemianopsia

Def: Muscles are neurophysiologically linked and cannot act alone or perform all of their functions. Unable to perform isolated movements.

Synergy patterns

Interventions for abnormal tone: Flaccidity (hypotonicity)

- WB/ Approximation - Brisk rubbing - Tapping - Quick stretch - Associated reactions - Vibration

Interventions for abnormal tone: Spasticity (hypertonicity)

- Positioning - Slow stretch, rhythmic rotation - WB - Biofeedback, mental imagery, relaxation techniques - Cold (10-20 min application), short lived effect - Dynamic orthosis- slow sustained stretch - Air splints - Deep pressure over tendon - Pharmacology- Botox, Baclofen

Def: Type of aphasia where the person can speak normally and understand speech but cannot identify written words or pictures

Anomic Aphasia

Def: Type of aphasia where the person has severe impairment of production, comprehension, and repetition of language; poor prognosis. Difficulty with articulation of words. Due to large infarct involving Wernicke and Broca areas.

Global aphasia

Patients with ___ hemisphere damage can still sometimes swear and use emotional words. They can even sometimes sing what they can’t speak.

Left *bc Right hemisphere= emotion, music

Dysphagia/Aspiration precautions: - changing ___ position/posture - Elevation of _____ - Feeding in ____ position - Using ___ ____ technique - Diet modification (mechanical soft diet, thickened liquids) - ____/____ exercises- Speech therapist

Head Head of bed Upright position Chin tuck Oral/motor

Def: Most commonly is a result of a CVA in the R cerebral hemisphere resulting in visual neglect of the left side of the body/world.

Hemispatial Neglect

25% of hemiplegic patients have non-functional arm long term. This results in ____ ____ ____. Interventions include:

Hemiplegic shoulder pain -Early positioning, proper handling techniques, establish scapular mobility before addressing glenohumeral motion, estim to rotator cuff muscles/trapezius/serratus interior, sling to minimize subluxation, taping, weight-bearing exercise

Common Gait Deviations seen in patients with stroke: Hip: Knee: Ankle:

Hip: Retraction, hiking, circumduction, inadequate hip flexion Knee: Decreased knee flexion during swing, excessive flexion during stance, hyper extension during stance, or instability during stance Ankle: Foot drop, ankle inversion or eversion, toe clawing

Def: Repetitive, intense use of affected extremity for two weeks with non-paretic UE constrained in a sling; positive results in acute and chronic stroke patients

Constraint Induced Movement Therapy

There’s a strong evidence for PT interventions favoring intensive high ____ task-oriented and task-specific training in all phases post stroke. Early ____ within 24 hrs post stroke, over ground walking, group circuit training, ___ ___ of motor performance, and CIMT(Constraint induced Movement therapy) were all found to be beneficial.

Repetitive Mobilization Mental imaging *Also PBWS (Partial body weight supported) treadmill training

The goal of managing a patient with ischemic stroke is to achieve Cerebral ___ and _____ further strokes.

Cerebral reperfusion Prevent further strokes

Acute care of strokes: ___ used for the emergent care of ischemic strokes. Used to break down fibrin clots in the cerebral arteries. Must be administered within 3 to 4 1/2 hours post onset of CVA symptoms. Significant neurological improvement due to the potential to salvage penumbral tissue. *what is the full name?

rtPA - Recombinant Tissue Plasminogen Activator *Potential complications: risk of cerebral bleed or secondary embolization caused by thrombus fragmentation. Often used in conjunction with mechanical embolus removal.

Pharmacology for strokes: ______-Used to decrease risk of MI and CVA following MI. Also used in acute care management of stroke if the patient does not receive thrombolysis. ____ is the most commonly used in the stroke population. Side effects include increased risk of G.I. bleeding

Antiplatelets Aspirin (ASA)

Anticoagulants- _____ is used prophylactically against DVT and PE. ____ (Coumadin) effective in prevention of strokes due to atrial fibrillation. Side effects: Bleeding therefore not for use with ____ strokes.

Heparin Warfarin Not for hemorrhagic strokes!

Basic principles of PNF: - ___ Movement Patterns - ____ and _____ patterns - __ diagonal motions for each major body part - Muscles move from fully _____ to fully _____ position - Incorporates _____, ______, and _____ muscle contractions - May be passive, active ____, active or ____ in nature

Mass Spiral and diagonal patterns 2 diagonal motions Fully lengthened to fully shortened Isometric, concentric, and eccentric Active assistive; resistive

Essential components of PNF: - ____ contacts - Body ___ and body ____ - ______ - Manual ____ - Irradiation - Joint _____ - Timing of movement - Patterns of movement - Visual cues - ____ commands

Manual Body position and mechanics Stretch Manual resistance Joint facilitation Verbal commands

PNF Techniques- Mobility - Rhythmic _____: Teach a pattern and improve mobility (PROM) - Rhythmic ____: Decrease tone, relaxation, increase ROM (Ex. Pt. hook-lying, therapist gently pushes legs back and forth) - Hold Relax/Contract Relax: Improve mobility

Rhythmic Initiation Rhythmic Rotation

PNF Techniques- Stability - Alternating ____: Promotes stability (hook lying, push on each side of legs, hold it don’t let me move it-pelvic stability) -Rhythmic _____: Stability (Pt. sitting, therapist simultaneously pushes back on one shoulder and forward on other)

Alternating Isometrics Rhythmic Stabilization

PNF Techniques: Controlled Mobility/Skill - ____ Reversal: Improve mobility and coordination (PNF patterns we practiced) - ____ Reversal: Controlled mobility, stability, and skilled movement (Resistance at pelvis during bridging) - Resisted Progression: Skilled ambulation/ crawling

Slow reversal Agonist reversal

Developmental sequence: - Head control - _____ ``` From Prone - Prone on ____ - Prone on ____ - _______ - _______ - _______ - Standing ``` ``` From Supine - Hook lying - ____ lying - Side sitting - ______ - Standing ```

Rolling ``` On elbows On hands Quadruped Kneeling Half kneeling ``` Side-lying Sitting

D1 Flexion: - Shoulder ____ and ____ - Forearm ____ - Wrist ____ ____ - Finger ____ D1 Extension: - Shoulder ____ and ____ - Forearm _____ - Wrist ___ ____ - Finger ____

D1 flexion: Sho ADD and ER Forearm supination Wrist radial dev. Finger flexion D1 Extension: Sho AB and IR Forearm pronation Wrist ulnar dev. Finger extension

``` D2 flexion: Shoulder ____ and ____ Forearm _____ Wrist ____ ____ Finger ____ ``` ``` D2 extension: Shoulder ___ and ___ Forearm ____ Wrist ____ Finger ___ ```

``` D2 Flexion: Sho AB and ER Forearm supination Wrist radial dev Finger extension ``` ``` D2 Extension: Sho ADD and IR Forearm pronation Wrist ulnar dev Finger flexion ```

LE D1 flexion: Hip ____ and ___ Knee ____ Ankle ____ and ____ Toes ____ LE D1 Extension: Hip ___ and ___ Knee ___ Ankle ____ and ___ Toes ___

``` D1 flexion: Hip ADD and ER Knee flexion Ankle dorsiflexion and inversion Toes extended *man crossing leg while sitting ``` ``` D1 extension: Hip AB and IR Knee extension Ankle plantar flexion and eversion Toes flexed *karate kick girl, ballerina ```

LE D2 flexion: Hip ____ and ___ Knee ____ Ankle ____ and ____ Toes ____ LE D2 extension: Hip ___ and ____ Knee ____ Ankle ___ and ____ Toes ____

LE D2 flexion: Hip AB and ER Knee flexion Ankle dorsiflexion and eversion Toes extended *looks like how a dog pees or swimmer doing butterfly kick LE D2 extension: Hip ADD and IR Knee extension Ankle plantar flexion and inversion Toes flexed *baseball player pic

Why do stroke patients need to learn to bridge?

Bed mobility, bedpan use, pressure relief

Bridge positioning: - Have pt. put legs into _____ position. Assist hemi side as needed. - Have pt. _____ hemi leg with ______ - Facilitate movement by putting hand on distal femur with a “____ and ____” movement and other hand under hip/ butt with ____ movement - Have pt move pelvis laterally - Have pt. flex head and neck to activate core *PTA should be by the knees facing toward patient’s head rather than facing the bed/their legs

Hook lying Stabilize hemi leg with strong leg’s foot Forward and downward; other hand pushes upward

Def. Ipsilateral pushing that occurs in pt’s with CVA in posteriolateral thalamus. Their perception of vertical was approximately 20° toward hemiparetic side

Pusher syndrome

Type of CVA most fatal in acute stage:

Hemorrhagic

2 types of CVA that account for majority of CVAs:

Embolic and Thrombotic

Def: Difficulty articulating words due to oral motor weakness s/p CVA

Dysarthria